Acupuncture? Nicotine patches? Telephone therapy? Antidepressants? Cognitive behavioural therapy?

Which work? Which have no effect? Which are dangerous? Confused?

Over 40 Cochrane reviews analyse the evidence.

For example, one systematic review (CD000146) shows how nicotine patches can double the odds of successful quitting. Another (CD000031) concludes that the antidepressants bupropion and nortriptyline aid long-term smoking cessation, but selective serotonin reuptake inhibitors (e.g. fluoxetine) do not. Yet another (CD006103) revealed that varenicline (recently approved in the UK by NICE), increased the odds of successful long-term smoking cessation more than threefold compared with pharmacologically unassisted quit attempts.

Ever since Sir Richard Doll and others used careful analysis to show that smoking was a key cause of cancer, there has been pressure to find ways of reducing dependency on tobacco. Richard Doll’s work also showed the importance of putting critical analysis and high quality research at the heart of good decision making.

“With changes in the law providing fresh impetus for smokers to quit, the catalogue of reviews in The Cochrane Library is a great source of the knowledge needed by people wanting to make well informed decisions. The reviews provide reliable evidence on the strengths and weaknesses of many different types of therapy. They should help guide policy-makers who are looking for ways to increase the chances that people who want to stop smoking succeed in putting their cigarettes down for good,” says Director of the UK Cochrane Centre, Professor Mike Clarke from the University of Oxford.

They can all be found at http://www.thecochranelibrary.com or visit http://www.eurekalert.org/images/release_graphics/pdf/Cochrane_Smoking_Cessation_Reviews.pdf

Smoking Cessation Therapies — Cochrane Reviews:

A summary of all treatments designed to help people stop smoking that have been reviewed by The Cochrane Library. Simply click on the URL under the review title to see the abstract and if you wish to see the full review.

Also; Nicotine Anonymous: The Book

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Washington residents are dying from unintended drug poisoning in numbers beginning to approach deaths in car crashes, and overdose deaths blamed on legal drugs now exceed fatal overdoses caused by illicit drugs, the Spokane Spokesman-Review reported Feb. 4th 2008.

Prescription-drug overdoses have increased 800 percent in Washington between 1995, when 45 overdose deaths were reported, to 2004, when 411 state residents died from overdoses on drugs like hydrocodone and methadone. “Prescription drug overdose deaths have been climbing through the roof,” said Jennifer Sabel, an epidemiologist at the Washington Department of Health. “Even doctors don’t really realize the magnitude of the deaths.”

In nearby Idaho, drug poisonings rose from 32 in 2000 to 62 in 2004. Some victims died because they misused patches containing powerful painkillers like Fentanyl, while others suffered from a toxic mix of prescription painkillers and alcohol or over-the-counter medications like Benadryl. “Users may be lulled into thinking prescription medications are safe as opposed to ‘street drugs,’ ” said Spokane County Medical Examiner Sally Aiken.

Overall opiate-related deaths in Washington rose from 260 in 1995 to 555 in 2004; auto crashes kill about 650 residents in the state each year. Mentions of prescription opiates on death certificates has risen even as involvement of illicit drugs like heroin have fallen by a third during the same period.

The trend is echoed by research conducted by the federal Centers for Disease Control and Prevention (CDC), which found that mentions of narcotic painkillers on death certificates rose 91 percent between 1999 and 2002. “This is a national problem,” said Dr. Gary Franklin, medical director for Washington’s Department of Labor and Industries.

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BACKGROUND: Most formal treatment programs recommend Alcoholics Anonymous (AA) attendance during treatment and as a form of adjunctive aftercare, but we know very little about treatment seekers’ patterns of AA involvement over time and how these relate to abstinence.

METHOD: This paper applies latent class growth curve modeling to longitudinal data from 349 dependent drinkers recruited when they were entering treatment and were re-interviewed at one or more follow-up interviews one, three and five years later, and who reported having attended AA at least once.

RESULTS: Four classes of AA "careers" of meeting attendance emerged:

The low AA group mainly just attended AA during the 12 months following treatment entry.

The medium and high AA groups were characterized by stable attendance at the second and third follow-ups-at about 60 meetings a year for the medium group and over 200 meetings per year for the high group, followed by slight increases for the medium group and slight decreases for the high group by year five.

The declining AA group doubled its meeting attendance post baseline, to almost 200 meetings during the year following treatment entry, but by year five they were only attending about six meetings on average.

Decreases in AA meetings did not necessarily signal disengagement from AA; at the five-year follow-up, a third of the low AA group and over half of the declining AA group said they felt like a member of AA. Activities other than meeting attendance, such as having a sponsor, otherwise paralleled the meeting careers, but social networks were similar by year five.

Rates of abstinence by year five (for the past 30 days) were

• 43% for the low AA group,
• 73% for the medium group,
• 79% for the high group and
• 61% for the declining group.

Rates of dependence symptoms and social consequences of drinking did not differ between the groups at year five.

CONCLUSIONS: The prototypical AA careers derived empirically are consistent with anecdotal data about AA meetings: some never connect; some connect but briefly; and others maintain stable (and sometimes quite high) rates of AA attendance. However, contrary to AA lore, many who connect only for a while do well afterwards.

Research; Kaskutas LA, Ammon L, Delucchi K, Room R, Bond J, Weisner C. Alcoholics anonymous careers: patterns of AA involvement five years after treatment entry. Alcohol Clin Exp Res. 2005 Nov;29(11):1983-90.

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OBJECTIVE: The purpose of this study is to examine how helping activities and spirituality–perhaps key influences on sobriety–change over alcoholism recovery.

The study also explores interrelations among Alcoholics Anonymous (AA), helping and spirituality.

METHOD: Questionnaires were administered to recovering alcoholics (118 men, 80 women) recruited at AA and Women for Sobriety meetings, treatment programs and through personal connections. A helping scale measured Recovery Helping (8-item alpha = 0.78), Life Helping (12-item alpha = 0.62), and Community Helping (6-item alpha = 0.60). The Daily Spiritual Experiences scale assessed two components of spirituality identified by factor analysis: Theism and Self-Transcendence. Two components of an AA scale, Involvement and Achievement, were also treated separately on the basis of factor analysis.

RESULTS: Structural equation modeling revealed that

• longer sobriety predicted significantly more time spent on Community Helping,
• less time spent on Recovery Helping and
• higher levels of Theism, Self-Transcendence and AA Achievement.
• Model covariances revealed that both AA components were related to more Recovery Helping and higher Theism.
• Both spirituality components related to all forms of helping, with one exception.

CONCLUSIONS: The findings highlight important changes in helping with length of sobriety.

• As their sobriety accumulates, recovering alcoholics seem to devote less time to informal helping and more time to organized community projects–perhaps indicating evolving needs and abilities.
• The results also suggest roles for AA and spirituality in encouraging helping, and they indicate that some forms of spirituality relate to AA affiliation.

Future work might establish whether and when helping in different domains contributes to the maintenance of abstinence and to other drinking-related outcomes.

Research Report; Zemore SE, Kaskutas LA. J Stud Alcohol. 2004 May;65(3):383-91. Helping, spirituality and Alcoholics Anonymous in recovery.

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Extended-Release Naltrexone Works Particularly Well for Abstinent Patients with Dependence

Many patients with alcohol dependence do not receive the full benefits of treatment because they do not adhere to it. In part to address issues with adherence, extended-release (ER) naltrexone, which is released over a month after one injection, was developed. Pharmacotherapy researchers assessed ER-naltrexone efficacy in a subgroup of 82 subjects in a larger clinical trial who had ?4 days of abstinence.

In that subgroup, 380 mg of ER-naltrexone in 28 subjects versus placebo in 28 subjects

• increased the time to first drink (median days, 41 versus 12);
• increased continuous abstinence over 6 months (32% versus 11%);
• increased time to first heavy drinking (>180 versus 20 days);
• decreased days with any drinking (median days per month, 0.7 versus 7.2);
• decreased days with heavy drinking (median days per month, 0.2 versus 2.9).

Smaller benefits, which were not always statistically significant, were found among 28 subjects treated with 190 mg of ER-naltrexone.

Comments by Michael Levy, PhD:
In this industry-sponsored secondary analysis of a small subgroup of subjects who had achieved just 4 or more days of abstinence before entering treatment, those who received ER-naltrexone in conjunction with psychosocial treatment had better treatment outcomes than those who received placebo. Medications with proven benefit for the treatment of alcohol dependence tend to be underutilized in general. This study suggests that ER-naltrexone is another treatment option for clients with alcohol dependence who have achieved even a short duration of abstinence.

Research Reference: O’Malley SS, Garbutt JC, Gastfriend DR, et al. Efficacy of extended-release naltrexone in alcohol-dependent patients who are abstinent before treatment. J Clin Psychopharm. 2007;27(5):507–512.

From; Join Together Online

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Sleep disturbances commonly appear in the context of both posttraumatic stress disorder (PTSD) and alcohol use disorders.

Sleep symptoms typically reported among clinical populations include;

• delayed sleep onset,
• poor sleep continuity,
• early morning awakening, and
• disturbed sleep architecture.

The aim of the present study was to examine multiple forms of sleep disturbances among individuals with comorbid PTSD and alcohol dependence, PTSD only, alcohol dependence only, and a control group.

Both PTSD and alcohol dependence diagnoses were associated with multiple forms of sleep disturbance, but comorbidity of the two disorders did not appear to increase the risk over and above either single disorder for reporting any of the sleep difficulties examined.

As PTSD symptom severity increased, so did

• sleep latency,
• mid-sleep wakening, and
• early morning wakening.

However, contrary to our hypothesis, no significant direct relationship between severity of alcohol use and sleep disturbances was revealed.

These findings suggest a need for thorough assessment of sleep symptoms in patients presenting with PTSD or alcohol dependence.

Sleep disturbances associated with posttraumatic stress disorder and alcohol dependence. Addict Behav. 2007 Sep 29. Waldrop AE, Back SE, Sensei A, Brady KT.

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A deficiency in the essential nutrient thiamine resulting from chronic alcohol consumption is one factor underlying alcohol-induced brain damage.

Thiamine is a helper molecule (i.e., a cofactor) required by three enzymes involved in two pathways of carbohydrate metabolism.

Because intermediate products of these pathways are needed for the generation of other essential molecules in the cells (e.g., building blocks of proteins and DNA as well as brain chemicals), a reduction in thiamine can interfere with numerous cellular functions, leading to serious brain disorders, including Wernicke-Korsakoff syndrome, which is found predominantly in alcoholics.

Chronic alcohol consumption can result in thiamine deficiency by causing inadequate nutritional thiamine intake, decreased absorption of thiamine from the gastrointestinal tract, and impaired thiamine utilization in the cells.

People differ in their susceptibility to thiamine deficiency, however, and different brain regions also may be more or less sensitive to this condition.

Research; The Role of Thiamine Deficiency in Alcoholic Brain Disease, Peter R. Martin, M.D., Charles K. Singleton, Ph.D., and Susanne Hiller-Sturmhöfel, Ph.D. Alcohol Research & Health; Vol. 27, No. 2, 2003

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A synopsis of the pharmacological rationale, properties and therapeutic effects of depot preparations of naltrexone for treating alcohol dependence.

Although oral naltrexone has been shown to diminish alcohol reinforcement, its limitations as a medication include its small treatment effect size, plasma level fluctuation and adverse events.

The pharmacokinetic profile of naltrexone could be optimised by intramuscular administration, sustaining its release over several weeks.

As a result, plasma levels would remain relatively constant; high enough to reduce drinking, low enough to minimise side effects.

Two injectable naltrexone depot preparations, Vivitrex and Naltrel, have been tested as pharmacotherapy for alcohol dependence.

Their adverse-event profiles seem to be mild compared with oral naltrexone.

Vivitrex has shown efficacy at reducing heavy drinking significantly among alcohol-dependent men.

Naltrel helped reduce relapse and promote abstinence in two samples of alcohol-dependent individuals. Additional efficacy studies are warranted.

Johnson BA. Expert Opin Pharmacother. 2006 Jun;7(8):1065-73. A synopsis of the pharmacological rationale, properties and therapeutic effects of depot preparations of naltrexone for treating alcohol dependence.

Pharmacotherapy Principles & Practice by Marie A. Chisholm-Burns, Barbara G. Wells, Terry L. Schwinghammer, Patrick M. Malone, Jill M. Kolesar, John C. Rotschafer, Joseph T. DiPiro Read more about this title…

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The prominence of Twelve-Step programs has led to increased attention on the putative role of spirituality in recovery from addictive disorders.

We developed a 6-item Spirituality Self-Rating Scale designed to reflect a global measure of spiritual orientation to life, and we demonstrated here its internal consistency reliability in substance abusers on treatment and in nonsubstance abusers.

This scale and the measures related to recovery from addiction and treatment response were applied in three diverse treatment settings: a general hospital inpatient psychiatry service, a residential therapeutic community, and methadone maintenance programs.

Findings on these patient groups were compared to responses given by undergraduate college students, medical students, addiction faculty, and chaplaincy trainees.

These suggest that, for certain patients, spiritual orientation is an important aspect of their recovery.

Furthermore, the relevance of this issue may be underestimated in the way treatment is framed in a range of clinical facilities.

Research; Galanter M, Dermatis H, Bunt G, Williams C, Trujillo M, Steinke P. Assessment of spirituality and its relevance to addiction treatment. J Subst Abuse Treat. 2007 Oct;33(3):257-64.

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One in every two pregnant Australian woman still consume alcohol during pregnancy, according to a study in the Australian and New Zealand Journal of Obstetrics and Gynaecology. The responsibility of providing accurate information about the harmful effects of alcohol and its lifelong effects on the child falls on obstetricians and other health professionals.

And yet, almost half of the obstetricians interviewed said they did not routinely ask about alcohol consumption in pregnancy.

An editorial by Professor Elizabeth Elliot from the University of Sydney titled “Alcohol and Pregnancy: the Pivotal Role of the Obstetrician”, discusses the state of awareness about the adverse effects of alcohol consumption during pregnancy and the obstetricians’ participation in educating against maternal drinking.

Only 16% of the obstetricians routinely provided information about the consequences of alcohol in pregnancy, while only 5% gave advice which were consistent with the latest guidelines of The National Health and Medical Research Council of Australia (NHMRC) – which states that, for pregnant women, ‘no drinking is the safest option’.

Professor Elliot says, “Failure to provide information about the dangers of alcohol consumption in the antenatal consultation represents a lost opportunity. Accurate recording of antenatal alcohol exposure will help identify children who require pediatric assessment, since the effects of alcohol may not be obvious at birth.”

“More importantly, identifying the women who are unable to stop drinking provides an important opening for the management of problem drinking and prevention of exposure to alcohol in future pregnancies,” added Professor Elliot.

Alcohol consumption during pregnancy has been associated with increased risks of miscarriage, stillbirth, intrauterine growth restriction, pre-term birth and low birth-weight. However, the best known adverse effect of alcohol exposure on the fetus is the fetal alcohol syndrome (FAS) – which is associated with a wide range of birth defects and ongoing educational, behavioral and psychological problems.

This paper is published in the June 2008 issue of Australian and New Zealand Journal of Obstetrics and Gynaecology (Vol. 48, Issue 3, 2008).

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