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...on Clinical Issues
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www.ProjectCork.org
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Fall 2008
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Attendance at Narcotics Anonymous and Alcoholics Anonymous meetings, frequency of attendance and substance use outcomes after residential treatment for drug dependence: a 5-year follow-up study.
Gossop M; Stewart D; Marsden J. Addiction 103(1): 119-125, 2008. (44 refs.)
Aims This study investigates the relationship between frequency of attendance at Narcotics Anonymous and Alcoholics Anonymous (NA/AA) meetings and substance use outcomes after residential treatment of drug dependence. It was predicted that post-treatment NA/AA attendance would be related to improved substance use outcomes. Methods Using a longitudinal, prospective cohort design, interviews were conducted with drug-dependent clients (n = 142) at intake to residential treatment, and at 1 year, 2 years and 4-5 years follow-up. Data were collected by structured interviews. All follow-up interviews were carried out by independent professional interviewers. Findings Abstinence from opiates was increased throughout the 5-year follow-up period compared to pre-treatment levels. Clients who attended NA/AA after treatment were more likely to be abstinent from opiates at follow-up. Abstinence from stimulants increased at follow-up but (except at 1-year follow-up) no additional benefit was found for NA/AA attendance. There was no overall change in alcohol abstinence after treatment but clients who attended NA/AA were more likely to be abstinent from alcohol at all follow-up points. More frequent NA/AA attenders were more likely to be abstinent from opiates and alcohol when compared both to non-attenders and to infrequent (less than weekly) attenders. Conclusions: NA/AA can support and supplement residential addiction treatment as an aftercare resource. In view of the generally poor alcohol use outcomes achieved by drug-dependent patients after treatment, the improved alcohol outcomes of NA/AA attenders suggests that the effectiveness of existing treatment services may be improved by initiatives that lead to increased involvement and engagement with such groups. Copyright 2008, Society for the Study of Addiction to Alcohol and Other Drugs.
Brief alcohol intervention in the emergency department: Moderators of effectiveness.
Walton MA; Goldstein AL; Chermack ST; McCammon RJ; Cunningham RM; Barry KL et al. Journal of Studies on Alcohol and Drugs 69(4): 550-560, 2008. (66 refs.)
Objective: Prior research supports the effectiveness of brief interventions for reducing alcohol misuse among patients in the emergency department (ED). However, limited information is available regarding the mechanisms of change, which could assist clinicians in streamlining or amplifying these interventions. This article examines moderators of outcomes among ED patients, ages 19 and older, who participated in a randomized controlled trial of a brief intervention for alcohol misuse. Method: Injured patients (N = 4,476) completed a computerized survey; 575 at-risk drinkers were randomly assigned to one of four brief intervention conditions, and 85% were interviewed again at 3-month and 12-month follow-ups. Results: Regression models using the generalized estimating equations approach examined interaction effects between intervention condition (advice/no advice) and hypothesized moderator variables (stage of change, self-efficacy, acute alcohol use, attribution of injury to alcohol) on alcohol outcomes over time. Overall, participants who reported higher levels of self-efficacy had lower weekly consumption and consequences, whereas those with higher readiness to change had greater weekly consumption and consequences. Furthermore, individuals who attributed their injury to alcohol and received advice had significantly lower levels of average weekly alcohol consumption and less frequent heavy drinking from baseline to 12-month follow-up compared with those who attributed their injury to alcohol but did not receive advice. Conclusions: This study provides novel data regarding attribution for alcohol-related injury as an important moderator of change and suggests that highlighting the alcohol/injury connection in brief, ED-based alcohol interventions can augment their effectiveness. Copyright 2008, Alcohol Research Documentation.
Brief family treatment intervention to promote aftercare among substance abusing patients in inpatient detoxification: Transferring a research intervention to clinical practice.
O'Farrell TJ; Murphy M; Alter J; Fals-Stewart W. Addictive Behaviors 33(3): 464-471, 2008. (11 refs.)
Two earlier studies showed that a brief family treatment (BFT) intervention for substance abusing patients in inpatient detoxification increased aftercare treatment post-detox. BFT consisted of meeting with the patient and a family member with whom the patient lived to review aftercare plans for the patient. A phone conference was used when logistics prevented an in-person family meeting. Based on the earlier research results, we trained a newly hired staff person to continue providing BFT. We monitored key process benchmarks derived from the earlier research studies to ensure ongoing fidelity in delivering BFT. This method proved successful in transferring BFT from delivery in a research study to ongoing delivery in routine clinical practice after the research ended. It also ensured that a high proportion of patients had their families contacted and included in. planning the patients' aftercare. Copyright 2008, Elsevier Science.
Cannabis potency and contamination: A review of the literature. (review).
McLaren J; Swift W; Dillon P; Allsop S. Addiction 103(7): 1100-1109, 2008. (82 refs.)
Aims: Increased potency and contamination of cannabis have been linked in the public domain to adverse mental health outcomes. This paper reviews the available international evidence on patterns of cannabis potency and contamination and potential associated harms, and discusses their implications for prevention and harm reduction measures. Methods: A systematic literature search on cannabis potency and contamination was conducted. Results Cannabis samples tested in the United States, the Netherlands, United Kingdom and Italy have shown increases in potency over the last 10 years. Some countries have not shown significant increases in potency, while other countries have not monitored potency over time. While there are some grounds to be concerned about potential contaminants in cannabis, there has been no systematic monitoring. Conclusion: Increased potency has been observed in some countries, but there is enormous variation between samples, meaning that cannabis users may be exposed to greater variation in a single year than over years or decades. Claims made in the public domain about a 20- or 30-fold increase in cannabis potency and about the adverse mental health effects of cannabis contamination are not supported currently by the evidence. Systematic scientific testing of cannabis is needed to monitor current and ongoing trends in cannabis potency, and to determine whether cannabis is contaminated. Additionally, more research is needed to determine whether increased potency and contamination translates to harm for users, who need to be provided with accurate and credible information to prevent and reduce harms associated with cannabis use. Copyright 2008, Society for the Study of Addiction to Alcohol and Other Drugs.
Client matching: A severity-treatment intensity paradigm.
De Leon G; Melnick G; Cleland CM. Journal of Addictive Diseases 27(3): 99-113, 2008. (34 refs.)
Despite considerable effort to develop matching strategies and client placement protocols, research studies fail to yield compelling results regarding the benefits of matching to treatment. The most consistent findings suggest a matching paradigm, which defines a successful placement as the least treatment intensity required addressing the severity of the disorder. The purpose of the present study is to provide further empirical support for the validity of a severity-intensity paradigm utilizing data from the Drug Abuse Treatment Outcome Studies. A "passive match" approach employed the Client Matching Protocol decision algorithm, which recommended clients to long-term residential or outpatient drug-free treatment. One-year outcomes for clients matched to long-term residential treatment were better on all outcome variables compared to those undertreated in outpatient drug-free treatment. Findings supported the validity of the severity-intensity paradigm in that undertreated clients showed less improvement compared to matched and overtreated clients. Copyright 2008, Haworth Press.
Clinician perceptions of factors influencing referrals to a smoking cessation program.
Holtrop JS; Malouin R; Weismantel D; Wadland WC. BMC Family Practice article 9, 2008. (27 refs.)
Background: Referral of patients to smoking cessation telephone counseling (i.e., quitline) is an underutilized resource by primary care physicians. Previously, we conducted a randomized trial to determine the effectiveness of benchmarked feedback on clinician referrals to a quitline. Subsequently, we sought to understand the successful practices used by the high-referring clinicians, and the perceptions of the barriers of referring patients to a quitline among both high and non-referring clinicians in the trial. Methods: We conducted a qualitative sub-study with subjects from the randomized trial, comparing high-and non-referring clinicians. Structured interviews were conducted and two investigators employed a thematic analysis of the transcribed data. Themes and included categories were organized into a thematic framework to represent the main response sets. Results: As compared to non-referring clinicians, high-referring clinicians more often reported use of the quitline as a primary source of referral, an appreciation of the quitline as an additional resource, reduced barriers to use of the quitline referral process, and a greater personal motivation related to tobacco cessation. Time and competing demands were critical barriers to initiating smoking cessation treatment with patients for all clinicians. Clinicians reported that having one referral source, a referral coordinator, and reimbursement for tobacco counseling (as a billable code) would aid referral. Conclusion: Further research is needed to test the effectiveness of new approaches in improving the connection of patients with smoking cessation resources. Copyright 2008, BioMed Central Ltd.
Drinking trajectories following an initial lapse.
Witkiewitz K; Masyn KE. Psychology of Addictive Behaviors 22(2): 157-167, 2008. (71 refs.)
Relapse following alcohol treatment is a major problem for individuals who are alcohol dependent, yet little is known about the course of drinking after the initial lapse. In the current study, discrete-time survival analysis and latent growth mixture modeling were used to evaluate the time to first lapse and the trajectories of postlapse drinking in a sample of 563 individuals who received community alcohol treatment. Results showed a decreasing risk of lapsing over time. After the initial lapse, 3 trajectory subgroups provided a parsimonious representation of the heterogeneity in postlapse drinking frequency and quantity, with the majority of individuals reporting light, infrequent drinking. Covariate analyses incorporating demographics, distal risk factors, time to first lapse, and coping behavior as predictors of time to lapse and postlapse drinking trajectories indicated that alcohol dependence and coping behavior were the strongest predictors of lapsing and postlapse drinking behavior. Copyright 2008, American Psychological Association.
Empirically supported substance abuse treatment approaches: A survey of treatment providers' perspectives and practices.
Herbeck DA; Hser YI; Teruya C. Addictive Behaviors 33(5): 699-712, 2008. (36 refs.)
To better understand the extent that empirically supported and promising substance abuse treatment approaches are implemented in community settings, treatment providers were surveyed regarding their perceptions and use of several psychosocial and pharmacological treatment interventions. Program directors (n=30) and staff members (n=331) from diverse community settings rated the effectiveness and extent of use of various treatment interventions, and provided information on program and workforce characteristics via self-administered questionnaires. On average, program directors and staff rated the psychosocial treatment interventions as effective, with the exception of vouchers/motivational incentives. About half of the treatment providers did not know the effectiveness of certain pharmacological treatments, including buprenorphine and naltrexone. Respondents from the majority of programs (55%-80%) reported using Motivational Enhancement Therapy, Community Reinforcement Approach, and Supportive Expressive Psychotherapy. The extent that programs used several of the treatment interventions was related to organizational training and information resources. The study findings provide important information regarding training and research dissemination efforts. Copyright 2008, Elsevier Science.
Extending residential care through telephone counseling: Initial results from the Betty Ford Center Focused Continuing Care protocol.
Cacciola JS; Camilleri AC; Carise D; Rikoon SH; Mckay JR; McLellan AT et al. Addictive Behaviors 33(9): 1208-1216, 2008. (30 refs.)
There is increasing evidence that a chronic care model may be effective when treating substance use disorders. In 1996, the Betty Ford Center (BFC) began implementing a telephone-based continuing care intervention now called Focused Continuing Care (FCC) to assist and support patients in their transition from residential treatment to longer-term recovery in the "real world". This article reports on patient utilization and outcomes of FCC. FCC staff placed clinically directed telephone calls to patients (N=4094) throughout the first year after discharge. During each call, a short survey was administered to gauge patient recovery and guide the session. Patients completed an average of 5.5 (40%) of 14 scheduled calls, 58% completed 5 or more calls, and 85% were participating in FCC two months post-discharge or later. There was preliminary evidence that greater participation in FCC yielded more positive outcomes and that early post-discharge behaviors predict subsequent outcomes. FCC appears to be a feasible therapeutic option. Efforts to revise FCC to enhance its clinical and administrative value are described. Copyright 2008, Elsevier Science.
FASD: What types of intervention and rehabilitation are useful? (review).
Kalberg WO; Buckley D. Neuroscience and Biobehavioral Reviews 31(2): 278-285, 2007. (27 refs.)
Fetal alcohol spectrum disorders (FASD) occurs worldwide when children are prenatally exposed to alcohol. This paper discusses recent findings regarding the neuropsychological and behavioral effects of prenatal alcohol exposure and how it impacts the developmental and functional abilities of children with FASD. Specifically, recent research focus has concentrated on studies to elucidate a neurobehavioral phenotype for the alcohol-exposed population. As a result, the FASD field has learned what types of neurobehavioral issues occur most frequently with these children. This paper discusses how that information can be used to inform school assessment, intervention planning, and support. Strategies for functional assessment, individualized planning, structured teaching, and developments in cognitive-behavioral methods are described. Copyright 2007, Elsevier Science.
Fentanyl epidemic in Chicago, Illinois and surrounding Cook County.
Schumann H; Erickson T; Thompson TM; Zautcke JL; Denton JS. Clinical Toxicology 46(6): 501-506, 2008. (28 refs.)
Introduction. Epidemics related to illicit fentanyl abuse have been reported and the potential exists for a national epidemic associated with high mortality. This report describes emergency department visits for opioid toxicity and a recent outbreak of illicit fentanyl fatalities in Chicago, Illinois and surrounding Cook County. Methods. Retrospective chart review of opioid-related overdoses seen in our emergency department and a retrospective review of data from the Cook County Medical Examiner's Office Fentanyl Fatality Database from April 2005 through December 2006. Results. Our emergency department treated 43 patients with a total of 55 emergency department visits during this time. Paramedic transport was utilized for 83.6% of the emergency department visits and naloxone was administered during 80.4% of transports. Naloxone was administered during 47.3% of emergency department visits witwh total doses ranging from 0.4 mg to 12 mg. Eighty percent of cases were treated and discharged from the emergency department. During this same time frame, the Medical Examiner's office identified 342 fentanyl-related fatalities. In 2006, illicit fentanyl fatalities represented 6.9% of all Medical Examiner cases for that year. Approximately 80% of deaths occurred in Chicago. A peak in fentanyl-related deaths occurred in the spring of 2006 and again in the fall of 2006 while the number of emergency department visits peaked during May of 2006. Conclusion. Chicago and surrounding Cook County experienced an outbreak of 342 fentanyl-related deaths between April 2005 and December 2006. The experience demonstrated a clear need for an interdisciplinary approach to identifying, communicating, and managing an outbreak. Copyright 2008, Informa Healthcare.
Five-year outcomes of alcohol-dependent persons treated with motivational enhancement.
Adamson SJ; Sellman JD. Journal of Studies on Alcohol and Drugs 69(4): 589-593, 2008. (16 refs.)
Objective: The purpose of this study was to determine whether the superior treatment effect of motivational enhancement therapy (MET) previously demonstrated at 6 months was sustained at a 5-year posttreatment follow-up. Method: Patients with mild to moderate alcohol dependence had completed a trial in which all patients were assessed, attended a brief feedback session, and were randomized to four sessions of MET, nondirective reflective listening, or no further counseling. The primary drinking outcome was unequivocal heavy drinking (UHD), defined as drinking 10 or more standard drinks on six or more occasions over a 6-month period. At the 6-month follow-up, 108 of 122 patients agreed to a further follow-up interview. Results: Seventy-seven patients were successfully followed for a mean (SD) of 58 (14) months after the completion of treatment. Although the group as a whole had continued to improve, with rates of UHD reduced from 51% at 6 months to 25% at 5 years, there was no difference by treatment group in drinking for UHD or a range of lower drinking thresholds. Conclusions: Although 5-year outcomes were indistinguishable among the three treatment groups, this was the result of patients in the comparison conditions catching up to the drinking gains of MET patients rather than a deterioration in drinking for MET patients. Individuals allocated to receive MET achieved a greater reduction sooner than either of the comparison treatment conditions. Copyright 2008, Alcohol Research Documentation.
Journey through the K-hole: Phenomenological aspects of ketamine use.
Muetzelfeldt L; Kamboj SK; Rees H; Taylor J; Morgan CJA; Curran HV. Drug and Alcohol Dependence 95(3): 219-229, 2008. (24 refs.)
Although recreational use of the dissociative anaesthetic drug ketamine is currently increasing, little is known about the phenomenological aspects of its use. We therefore designed a structured interview to examine initiation experiences, positive and negative effects of ketamine use, and concerns about the drug and its long-term effects. Ninety participants (30 frequent users, 30 infrequent 'recreational' users and 30 ex-users who had abstained from use for at least 3 months) were interviewed and reported drug use was verified by hair sample analysis. The most appealing aspects of ketamine for two-thirds of users were "melting into the surrounding", "visual hallucinations", "out-of-body experiences" and "giggliness". Unappealing effects for half of users were "memory loss" and "decreased sociability". Frequent ketamine users expressed more concerns than other groups about long-term effects on physical health problems, especially K-cramps and cystitis, whereas ex-users were more concerned about mental health problems. Addictive/dependent patterns of behaviour were also a concern: the majority of frequent users reported using the drug without stopping until supplies ran out and the mean increase in dosage in this group was six-fold from initiation to current use. We have identified specific health issues which seem uniquely related to ketamine use. Additionally, the dependence on ketamine frequently reported by users may be a cause for concern as its popularity grows and substance misuse services should be made aware of this when clients present in the future. Copyright 2008, Elsevier Science.
Long-term effects of heroin-assisted treatment in Germany.
Verthein U; Bonorden-Kleij K; Degkwitz P; Dilg C; Koehler WK; Passie T et al. Addiction 103(6): 960-966, 2008. (19 refs.)
Aims: Trials in Switzerland, the Netherlands and Spain have found that heroin-assisted treatment (HAT) as maintenance treatment for opioid-dependent patients reduces illicit drug use. A German trial also found diamorphine treatment to be superior to methadone treatment. The present study describes the association between 2 years of heroin treatment and improvements in health and social stabilization, as well as illicit drug use. Design A prospective cohort study design. Participants A total of 515 patients were assigned to diamorphine treatment; 278 patients remained in the study treatment for the entire period of 24 months (54.8%). Measurements The results on physical (Opiate Treatment Index Health Symptoms Scale) and mental (Symptom Checklist 90-Revised Global Severity Index) health and illicit drug use (number of days with drug use within the last month-European Addiction Severity Index) were examined by repeated-measures analyses. Findings: Symptoms of physical (Pillai's trace = 0.837, df = 4, P < 0.001) and mental health (Pillai's trace = 0.450, df = 4, P < 0.001) improved during treatment. Street heroin use declined rapidly (Pillai's trace = 0.836, df = 4, P < 0.001), as did cocaine use (Pillai's trace = 0.280, df = 4, P < 0.001). Conclusions: Heroin-assisted treatment is associated with improvements in mental and physical health in the long term. Copyright 2008, Society for the Study of Addiction to Alcohol and Other Drugs.
Parental illicit drug use and family life: Reports from those who sought help.
Cattapan O; Grimwade J. Australian and New Zealand Journal of Family Therapy 29(2): 77-87, 2008. (23 refs.)
Family histories of abuse and neglect are common among persons with substance addictions. Clearly such family backgrounds impact on future lifestyle choices. How this early life experience then impacts on the substance user as a parent and on their children has not been considered in the literature in any detail. Clients of local community drug services were invited to participate in a study evaluating the family life of parents who were dependent on illicit substances. Fifteen parents participated in a qualitative, longitudinal study about their family life, treatment and drug of choice. Four aspects of parental perception of family life were examined: the perceived impact of the family of origin on the parent drug user, self-perception, the impact of parental illicit drug use on the family environment, the impact of parental illicit drug use on children. For parents struggling with a substance addiction, it would seem that recovery has much to do with differentiation and gaining a sense of agency. Copyright 2008, Australian Academic Press.
Quality of web-based information on cocaine addiction.
Khazaal Y; Chatton A; Cochand S; Zullino D. Patient Education and Counseling 72(2): 336-341, 2008. (30 refs.)
Objective: To evaluate the quality of web-based information on cocaine use and addiction and to investigate potential content quality indicators. Methods: Three keywords: cocaine, cocaine addiction and cocaine dependence were entered into two popular World Wide Web search engines. Websites were assessed with a standardized proforma designed to rate sites on the basis of accountability, presentation, interactivity, readability and content quality. "Health on the Net" (HON) quality label, and DISCERN scale scores aiding people without content expertise to assess quality of written health publication were used to verify their efficiency as quality indicators. Results: Of the 120 websites identified, 61 were included. Most were commercial sites. The results of the study indicate low scores on each of the measures including content quality. A global score (the sum of accountability, interactivity, content quality and aesthetic criteria) appeared as a good content quality indicator. Conclusions: While cocaine education websites for patients are widespread, their global quality is poor. There is a need for better evidence-based information about cocaine use and addiction on the web. Practice implications: The poor and variable quality of web-based information and its possible impact on physician-patient relationship argue for a serious provider for patient talk about the health information found on Internet. Internet sites could improve their content using the global score as a quality indicator. Copyright 2008, Elsevier Science.
Survey of alcohol use in the US Army.
Lande RG; Marin BA; Chang AS; Lande GR. Journal of Addictive Diseases 27(3): 115-121, 2008. (18 refs.)
The objective of this study was to collect data that would provide information about the frequency, attitudes, and consequences of alcohol use in the U.S. Army. A questionnaire was used to assess the frequency of alcohol consumption, attitudes related to the use of alcohol, and adverse consequences experienced with alcohol use. The survey was conducted at Walter Reed Army Medical Center in Washington, D.C. Survey participants included both military employees working at Walter Reed Army Medical Center and military patients. No attempt was made to identify the medical status of the participants. The investigators distributed 1,200 questionnaires. Following distribution, the investigators received 1,010 completed questionnaires, resulting in an 84% return rate. Thirty-four percent of the survey participants (n = 335) were deployed to an area of combat operations. There was a significant difference in binge drinking between military personnel assigned to an area of combat operations and those not assigned to an area of combat operations (p = 0.023). Multiple regression results showed that age, marital status, and deployment status were correlated with four or more drinks at one time (p < 0.001). In other words, binge drinking is more likely to occur among military personnel who are younger, experiencing marital problems, and recently returned from an area of combat operations. Significant differences between the two groups also emerged in terms of other specific consequences associated with consumption. Deployment to an area of combat operations seems to influence consumption patterns, alcohol related attitudes, and behaviors. This could be a consequence of wartime experiences. This study should help guide the clinical screening of alcohol use disorders, which may complicate emotional recovery from traumatic experiences if undetected. Copyright 2008, Haworth Press.
The methamphetamine home: Psychologyogical impact on preschoolers in rural Tennessee.
Asanbe CB; Hall C; Bolden CD. Journal of Rural Health 24(3): 229-235, 2008. (22 refs.)
Context: A growing number of children reside with methamphetamine-abusing parents in homes where the illicit drug is produced. Yet, the effects of a methamphetamine environment on psychological child outcome are still unknown. Purpose: To examine whether preschoolers who lived in methamphetamine-producing homes are at increased risk for developing psychological problems. Methods: The participants were 58 white children between the ages of 4 and 5 years; 31 with a history of living in methamphetamine-producing homes and 27 children who live in non-methamphetamine producing homes in rural Tennessee. The groups were similar in age, gender, and socioeconomic background. The groups were compared for behavioral and emotional adjustment using the behavior assessment system for children-parent rating scale-preschool (BASC-PRS-P) form. Biological or custodian parents completed a rating on their preschoolers that provided information about the children's pattern of behavior and feelings. Findings: Preschoolers from the methamphetamine-producing homes showed more externalizing problems than their peers, but were comparable on internalizing problems. On specific behaviors, the data indicate that preschoolers in the methamphetamine group showed higher aggression symptoms than their peers from non-methamphetamine-producing homes. Conclusions: These findings, if replicated, point to the need for mental health screening when a child is removed from a methamphetamine-producing home. Copyright 2008, Blackwell Publishing.
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