By Kathleen T. Brady, M.D., Ph.D., and Susan C. Sonne, Pharm.D.

Addiction to alcohol or other drugs (AODs) is a complex problem determined by multiple factors, including psychological and physiological components. Stress is considered a major contributor to the initiation and continuation of AOD use as well as to relapse.

Many studies that have demonstrated an association between AOD use and stress have been unable to establish a causal relationship between the two. However, stress and the body’s response to it most likely play a role in the vulnerability to initial AOD use, initiation of AOD abuse treatment, and relapse in recovering AOD users.

This relationship probably is mediated, at least in part, by common neurochemical systems, such as the serotonin, dopamine, and opiate peptide systems, as well as the hypothalamic-pituitary-adrenal (HPA) axis. Further exploration of these connections should lead to important pharmacological developments in the prevention and treatment of AOD abuse.

Studies indicate that treatment techniques which foster coping skills, problem solving skills, and social support play a pivotal role in successful treatment.

In the future, individualized treatment approaches that emphasize stress management strategies in those patients in whom a clear connection between stress and relapse exists will become particularly important.

Alcohol Research & Health, Vol. 23, No. 4, 1999

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Despite the increasing incidence of alcohol misuse and the costs it incurs, British society continues to hold equivocal and ambiguous attitudes towards drinking, and understanding of the nature of alcohol dependence and related issues is limited.

This qualitative study aimed to investigate the experiences of individuals with alcohol dependence to enhance understanding of the illness, identify key issues and common themes and provide insight into the experiences of the participants during their alcohol dependent period and recovery.

A qualitative approach, using narrative method, was used.

Eight participants, all members of Alcoholics Anonymous (AA), were interviewed by the researchers.

Using a grounded theory approach and content analysis, the in-depth narratives of the eight participants were systematically analysed.

While participants continued to deny the existence of a problem to those around them, their behaviours indicated that they were aware of the problem but were afraid to admit it openly through fear of other people’s reactions.

Participants generally regarded GPs as helpful but other health professionals less so, especially nurses and Accident and Emergency staff.

Participants considered that the success of treatment depended on their own motivation and willingness to engage in radical behaviour change.

They considered that reaching this stage represented a turning point in their illness. The point at which this stage was reached appeared to be different for each participant.

This systematic analysis of a small sample of alcohol dependent individuals gives insight into their experiences during alcohol dependency and the journey to recovery.

The findings suggest that denial of the problem to the outside world occurs simultaneously with individuals being aware of their problem.

Participants felt the illness carries a stigma and their negative experiences of health professionals other than GPs suggests that nurses and other health workers need to revise their understanding of alcohol dependence and their approach to it.

AA was a significant factor in recovery for these participants.

Research; Dyson J. Experiences of alcohol dependence: a qualitative study. J Fam Health Care. 2007;17(6):211-4.

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Women live longer than men, and this is usually true even among those infected with hepatitis C. But female heavy drinkers die at about the same age as men who abuse alcohol and have the disease, the Psychiatric Times reported Jan. 25.

Both men and women who drank heavily and had hepatitis C died, on average, a decade sooner than they should have, compared to those who drank moderately or abstained from alcohol use. Researchers noted that the study demonstrates that alcohol has different effects on men and women with hepatitis C and that drinking speeds up the fatal progression of the disease.

The mean death age for female heavy drinkers with hepatitis C was 49.1 years, compared to 61 among the light drinkers and nondrinkers. Among men, the mean death rate was 50 for heavy drinkers, compared to 55.1 for the moderate drinkers and abstainers.

"While [hepatitis C infection] alone showed a disproportionate effect on premature death in males, heavy alcohol use presented a stronger effect in females, resulting in a ’catching-up’ effect that diminished the gender difference in age of [hepatitis] death," the study authors wrote.

Study author Chiung M. Chen and colleagues examined more than 7 million mortality records to reach their conclusions.

The study appears in the February 2007 issue of the journal Alcoholism: Clinical and Experimental Research.

Reference: Chen, C.M., Yoon, Y.H., Yi, H.Y., Lucas, D.L. (2007) Alcohol and Hepatitis C Mortality Among Males and Females in the United States: A Life Table Analysis. Alcoholism: Clinical and Experimental Research, 31(2): 285-292; doi: 10.1111/j.1530-0277.2006.00304.x.

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• Alteration in the function of cerebral neurotransmitter receptors during the establishment of alcohol dependence: neurochemical aspects.

In this review;

• First we evaluate evidence on the role of the neurobiological alterations induced by chronic ethanol consumption in the development of ethanol tolerance, dependence and withdrawal.
• Secondly, we describe the neuropathological consequences of chronic ethanol on cognitive functions and on brain structures.

Chronic alcohol consumption can induce alterations in the function and morphology of most if not all brain systems and structures.

While tolerance mechanisms are unlikely to contribute to the neuroadaptive changes associated with ethanol dependence, it is otherwise clear that repeated high, intoxicating doses of ethanol trigger those neuroadaptive processes that lead to dependence and contribute to the manifestation of the abstinence syndrome upon withdrawal.

An unbalance between inhibitory and excitatory neurotransmission is the most prominent neuroadaptive process induced by chronic ethanol consumption.

Due to the diffuse glutamatergic innervation to all brain structures, the neuroadaptive alterations in excitatory neurotransmission can affect the function of most if not all of neurotransmitter systems.

The expression of the withdrawal syndrome is the major causal factor for the onset and development of the neuropathological alterations.

This suggests a link between the neuroadaptive mechanisms underlying the development of ethanol dependence and those underlying the functional and structural alterations induced by chronic ethanol.

In animals and humans, specific alterations occur in the function and morphology of the diencephalon, medial temporal lobe structures, basal forebrain, frontal cortex and cerebellum, while other subcortical structures, such as the caudate nucleus, seem to be relatively spared.

The neuropathological alterations in the function of mesencephalic and cortical structures are correlated with impairments in cognitive processes.

In the brain of alcoholics, the prefrontal cortex and its subterritories seem particularly vulnerable to chronic ethanol, whether Korsakoff’s syndrome is present or not.

Due to the role of these cortical structures in cognitive functions and in the control of motivated behavior, functional alterations in this brain area may play an important role in the onset and development of alcoholism.

Research; Fadda F, Rossetti ZL. Chronic ethanol consumption: from neuroadaptation to neurodegeneration. Prog Neurobiol. 1998 Nov;56(4):385-431.

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The relation between alcohol and jealousy is a deeply rooted belief within the general population as well as in the medical, and particularly psychiatric, environment.

Furthermore, in recent years there has been a growing interest on the forensic aspects of pathological jealousy, since they are a frequent cause of severe violence, homicide and suicide.

Some authors have described a high prevalence of pathological jealousy in alcoholic patients, even awarding it a specific value in alcoholism.

Nevertheless, recent studies do not completely support this relation, and draw attention to other factors.

Results from the various studies contain several definitions and classifications of pathological jealousy, and although most of them highlight the prevalence of jealousy in alcoholic patients, they question its specific quality.

Also, the presence of pathological jealousy in subjects with psychiatric disorders other than alcoholism is suggested, indicating the existence of predisposing and triggering factors which could explain the development of pathological jealousy.

Yet, the important methodological difficulties in the published articles and the shortage of studies do not allow the confirmation of the alcoholic etiology in pathological jealousy; this is the reason why considering alcoholic jealousy as a separate entity is debatable.

In this sense, the best diagnosis in these patients would be paranoid disorder combined with alcoholic dependence, hence, a dual diagnosis.

Research; Jiménez-Arriero MA, Hernández B, Mearin Manrique I, Rodríguez-Jiménez R, Jiménez Giménez M, Ponce Alfaro G. Alcoholic jealousy: an old and current dilemma. Adicciones 2007; 19(3): 267-72

Emotional Wellness: Transforming Fear, Anger, and Jealousy into Creative Energy

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Groundbreaking research from the University of Melbourne has shed new light on why long term drug users find it hard to say no, despite dire consequences to their health.

A study into the frontal cortex, the key region of the brain involved in decision making, has shown that drug users have to place much greater demand on the brain to control impulses.

The two year study was conducted by researchers Dr Murat Yücel and Dr Dan Lubman of the ORYGEN Research Centre and the Melbourne Neuropsychiatry Centre, based at the University of Melbourne and was recently published in the July edition of the prestigious international journal Molecular Psychiatry.

“Drugs can capture and hijack some parts of the brain,” said Dr Murat Yücel a lead researcher in the study.

“In this study we found the frontal cortex, an area that is essential for exercising control over thoughts and behaviours, was working inefficiently.”

“These findings may help explain why it takes addicted individuals enormous effort to exercise control over their drug-taking behaviour in the face of adverse consequences, and why they are vulnerable to relapse back into uncontrolled, compulsive patterns of use.”

The studies involved brain-imaging technology to probe the physiological and biochemical properties of a key region of the brain, the frontal cortex.

Participants were asked to complete a test of self-control in which they had to overcome an automatic response in favour of a more controlled alternative response, thus requiring them to control their impulsive tendencies.

They researchers discovered two important differences between the opiate-using group and a group who have never used heroin.

Firstly, the opiate-using group needed to activate more of their brain by placing greater physiological demand on it to avoid making an error on a test of self control.

At the same time, brain cells in the frontal region were revealed to be less healthy than the non opiate-using group.

“What people don’t tend to understand about long term drug users is that this is not a matter of choice. They have a reduced level of biological resources and find it hard to stop.”

Dr Dan Lubman, an addiction psychiatrist and a senior investigator on the project, says this new evidence is likely to lead to the development of innovative strategies for the treatment of addiction

“These findings tell us that we need to provide a combination of pharmaceutical and psychological treatments that will help bolster the efficiency of the frontal cortex and hence the individual’s ability to stop their urge to use drugs.” Dr Lubman said.

“To improve treatments for long term drug users we need to understand at what stage these brain deficits occur. The next question we need to ask is are these latest research findings a consequence of addiction or do they explain people’s vulnerability to problematic drug use?” he said.

In future, the researchers would like to examine whether these processes recover with abstinence.

From a press release of the University of Melbourne, Australia.

Brain Damage, Brain Repair by James W. Fawcett, Anne E. Rosser, Stephen B. Dunnett Read more about this title…

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Predictors of 4 year outcome of community residential treatment for patients with substance use disorders.

Aims This study examined systematically how predictors of substance use disorder (SUD) treatment outcome worked together over time and identified mediators and moderators of outcome.

Design The MacArthur model was applied in this naturalistic study to identify how baseline, discharge and 1-year follow-up factors worked together to predict 4-year improvement in substance-related problems.

Setting Eighty-eight community residential facilities were selected based on geographic representativeness, number of patient referrals and type of treatment orientation.

Participants Of 2796 male patients who completed intake assessments, 2324 were assessed at the 1-year follow-up and 2023 at the 4-year follow-up.

Measurements Self-report measures of

• symptom severity,
• functioning,
• social resources and coping,
• treatment and
• involvement in Alcoholics Anonymous (AA) were collected at baseline and at 1- and 4-year follow-ups.

Provider-rated treatment participation measures were obtained at discharge.

Findings

• Greater substance use severity,
• more psychiatric symptoms,
• more prior arrests and
• stronger belief in AA-related philosophy at treatment entry

predicted improvement significantly in substance-related problems 4 years later.

At the 1-year follow-up,

• being employed and
• greater use of AA-related coping
• predicted outcome significantly.

AA-related coping at 1 year mediated the relationship partially between belief in AA philosophy at treatment entry and 4-year outcome.

Conclusions

The findings highlight the unique and positive impact of AA involvement on long-term SUD treatment outcome and extend understanding of why AA is beneficial for patients.

Research report; Predictors of 4 year outcome of community residential treatment for patients with substance use disorders. Addiction. 2008 Apr;103(4):671-80. Laffaye C, McKellar JD, Ilgen MA, Moos RH.

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Correlates of alcohol use among methadone-maintained adults

This prospective study (n = 190) examined correlates of alcohol use from baseline data of a longitudinal trial conducted among moderate and heavy alcohol users receiving methadone maintenance therapy (MMT).

The sample included MMT clients who were 18–55 years of age, and were receiving MMT from five large methadone maintenance clinics in the Los Angeles area.

Half of the sample was heavy drinkers and nearly half (46%) reported heroin use. Using a structured questionnaire, correlates of heavy alcohol use included White and Hispanic ethnicity, and fair or poor physical health combined with older age (?50 years). We also found that MMT clients who were younger than 50 years, regardless of health status, were more likely to be heavy drinkers.

Compared with moderate alcohol consumers, a greater number of heavy alcohol users also experienced recent victimization.

To optimize MMT, alcohol screening should be part of routine assessment and alcohol treatment should be made available within MMT programs.

Moreover, special consideration should be provided to the most vulnerable clients, such as the younger user, those with a long-term and current history of heavy drug use, and those victimized and reporting fair or poor health. In addition, promoting attention to general physical and mental health problems within MMT programs may be beneficial in enhancing health outcomes of this population.

Research report; Adeline Nyamathi, Allan Cohen, Mary Marfisee, Steven Shoptaw, Barbara Greengold, Viviane de Castro, Daniel George and Barbara Leake. Drug and Alcohol Dependence. Volume 101, Issues 1-2, 1 April 2009, Pages 124-127. Correlates of alcohol use among methadone-maintained adults

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This article first explains the conceptual framework and plan of a naturalistic, multisite evaluation of Department of Veterans Affairs (VA) substance abuse treatment programs. It then examines the effectiveness of an index episode of inpatient treatment and the effectiveness of continuing outpatient care and participation in self-help groups.

The study was conducted among 3018 patients from 15 VA programs that emphasized 12-Step, cognitive-behavioral (CB), or eclectic treatment.

Casemix-adjusted 1-year outcomes showed that patients in 12-Step programs were the most likely to be abstinent, free of substance abuse problems, and employed at the 1-year follow-up.

Patients who obtained more regular and more intensive outpatient mental health care, and those who participated more in 12-Step self-help groups, were more likely to be abstinent and free of substance use problems at the 1-year follow-up.

These findings support the effectiveness of 12-Step treatment and show that patients with substance use disorders who become more involved in outpatient care and self-help groups tend to experience better short-term substance use outcomes.

Moos RH, Finney JW, Ouimette PC, Suchinsky RT. A comparative evaluation of substance abuse treatment. Alcohol Clin Exp Res. 1999 Mar;23(3):529-36.

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By Melody Beattie

Review By Neal J. Pollock (VA USA)

While I have not read Melody Beattie’s other works, I thought this a very valuable book in and of itself. It sheds much light on the topic and helped me to become sensitized to the obvious signs of codependency in people. By doing this, it enabled me to avoid situations where I could become codependent in a relationship.

I think that, as in the Diagnostic and Statistical Manual, there are levels of psychological situations and/or problems. Thus, there may be people inherently inclined towards codependency, but there may also be people who are thrust into it due to the demands of others. The latter may find this book incredibly helpful in avoiding such relationships and in helping their dependent person seek real help vs. codependency from another person. There are also a number of great quotes by the author in this book. A few are:

p. 70: “It’s hard to feel compassion for someone while that person is using or victimizing us.”

p. 71: “If everything looks black, we’ve probably got our eyes shut.”

p. 164: “Who we’re in a relationship with says as much about us as it does about them.” Earnie Tucker (quoted by Melody Beattie)

Codependency is not something to make light of, it’s as much (if not more) the codependent’s problem as the dependent’s. As Caroline Casey humorously noted in “Making the Gods Work for You” (Harmony Books NY 1998), on page 72:
“What do codependents see when they die? Someone else’s life flashes before their eyes.”

This is literally a life-changing book for codependents.

Reviewer: A reader

Once Melody Beattie’s Codependent No More has been “digested”, Beyond Codependency helps to move the recovering codependent past the hurt and on to the business of literally changing behaviors and making a better life. I absolutely recommend this book above any others to recovering codependents.

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