Cost-Effectiveness of Home Visits in the Outpatient Treatment of Patients with Alcohol Dependence

The purpose of this study was to compare the cost-effectiveness of conventional outpatient treatment for alcoholic patients (CT) with this same conventional treatment plus home visits (HV), a new proposal for intervention within the Brazilian outpatient treatment system.

A cost-effectiveness evaluation alongside a 12-week randomized clinical trial was performed. We identified the resources utilized by each intervention, as well as the cost according to National Health System (SUS), Brazilian Medical Association (AMB) tables of fees, and others based on 2005 data. The incremental cost-effectiveness ratio (ICER) was estimated as the main outcome measure – abstinent cases at the end of treatment.

• There were 51.8% abstinent cases for HV and 43.1% for CT, a clinically relevant finding.
• Other outcome measures, such as quality of life, also showed significant improvements that favored HV.

The baseline scenario presented an ICER of USD 1,852. Sensitivity analysis showed an ICER of USD 689 (scenario favoring HV) and USD 2,334 (scenario favoring CT).

The HV treatment was found to be cost-effective according to the WHO Commission on Macroeconomics and Health.

Research; Edilaine Moraesa, Geraldo M. Camposa, Neliana B. Figliea, Ronaldo Laranjeiraa, Marcos B. Ferrazb. Eur Addict Res 2010;16:69-77 (DOI: 10.1159/000268107)

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Biomarkers in Alcohol Misuse: Their Role in the Prevention and Detection of Thiamine Deficiency

In Western countries alcohol misuse is the most frequent cause of thiamine (vitamin B1) deficiency (TD) and consequent neuro-impairment.

Studies have demonstrated that between 30 and 80% of alcoholics are thiamine deficient, and this puts them at risk of developing the Wernicke–Korsakoff (WK) syndrome.

The relative roles of alcohol and TD in causing brain damage remain controversial and it is important to try to determine the role played by each factor.

Animal studies support an additive effect of alcohol exposure and TD, and indicate the potential for interaction between alcohol and TD in human alcohol-related brain damage.

Early diagnosis of alcohol-related TD is therefore an important aspect of effective intervention and treatment.

Alcohol biomarkers provide a direct and indirect way of estimating the amount of alcohol being consumed, the duration of ingestion and the harmful effects that long-term alcohol use has on body functions.

Appropriate use of these markers is very helpful when considering a diagnosis of alcohol-related TD.

Research report; Rosanna Mancinelli, and Mauro Ceccanti. Biomarkers in Alcohol Misuse: Their Role in the Prevention and Detection of Thiamine Deficiency. Alcohol and Alcoholism 2009 44(2):177-182;

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I’ll Quit Tomorrow: A Practical Guide to Alcoholism Treatment

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BACKGROUND: The Alcohol Use Disorders Identification Test (AUDIT) is an international screening instrument extensively employed in adult target groups. However, there is scarce information on screening with the AUDIT in adolescent populations.

The purpose of this study was to determine the cut-off point for hazardous, harmful, and dependent alcohol use through the validation of the AUDIT in a Chilean adolescent sample.

METHODS: The original English version of the AUDIT was translated into Spanish, using the procedure recommended by the World Health Organization. The text was then back-translated and sent to one of the original authors (Thomas Babor), who approved the translation. Students attending public schools in Santiago, Chile, self-administered the AUDIT, and those older than 15 years completed the

Composite International Diagnostic Interview-Substance Abuse Module (CIDI-SAM), which served as a gold standard. Between 1 and 4 weeks after the CIDI-SAM, participants answered a second AUDIT.

RESULTS:

• A total of 42 female and 53 male adolescents (mean age: 15.9 [SD=1.2]) completed the AUDIT, with a mean score of 4.3.
• Reliability according to Cronbach’s alpha was 0.83.
• Test-retest correlation was also satisfactory (intra-class correlation 0.81 [95% CI 0.73-0.87]).
• Analysis of the receiver operating characteristic (ROC) curve yielded cut-off points for hazardous, harmful, and dependent alcohol use of 3, 5, and 7 points, respectively.

CONCLUSIONS: The Chilean version of the AUDIT is a valid and reliable tool for identifying adolescents with hazardous, harmful, and dependent alcohol use. The suggested cut-off points make screening with the AUDIT more accurate for adolescent populations.

Research; Drug Alcohol Depend. 2009 Aug 1;103(3):155-8. Epub 2009 May 6. The Alcohol Use Disorders Identification Test (AUDIT) as a screening instrument for adolescents. Santis R, Garmendia ML, Acuña G, Alvarado ME, Arteaga O.

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Youth With Alcohol and Drug Addiction: Escape from Bondage (Helping Youth With Mental, Physical, and Social Challenges) by Kenneth McIntosh

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Aims; The helper therapy principle suggests that, within mutual-help groups, those who help others help themselves. The current study examines whether clients in treatment for alcohol and drug problems benefit from helping others, and how helping relates to 12-step involvement. Design Longitudinal treatment outcome.

Participants; An ethnically diverse community sample of 279 alcohol- and/or drug-dependent individuals (162 males, 117 females) was recruited through advertisement and treatment referral from Northern California Bay Area communities. Participants were treated at one of four day-treatment programs.

Measurements; A helping checklist measured the amount of time participants spent, during treatment, helping others by sharing experiences, explaining how to get help and giving advice on housing and employment. Measures of 12-step involvement and substance use outcomes were administered at baseline and a 6 month follow-up.

Findings; Helping and 12-step involvement emerged as important and related predictors of treatment outcomes. In the general sample, total abstinence at follow-up was strongly and positively predicted by 12-step involvement at followup, but not by helping during treatment; still, helping positively predicted subsequent 12-step involvement. Among individuals still drinking at follow-up, helping during treatment predicted a lower probability of binge drinking, whereas effects for 12-step involvement proved inconsistent.

Conclusions; Findings support the helper therapy principle and clarify the process of 12-step affiliation.

Research report; Sarah E. Zemore, Lee Ann Kaskutas & Lyndsay N. Ammon, In 12-step groups, helping helps the helper. Addiction; March 2004

Peer Support in Action: From Bystanding to Standing By

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Episodes of intimate partner violence are associated with alcohol consumption. To explore this relationship further, researchers interviewed a random sample of heterosexual couples at baseline and 5 years later. They assessed alcohol use and related problems, and the incidence (new cases) and recurrence (cases at both follow-up and baseline) of male-to-female partner violence and female-to-male partner violence. Analyses included 1136 couples who were cohabitating and/or married at both baseline and follow-up. Partner violence was defined as a range of violent behaviors, such as slapping, kicking, forcing sex, and threatening with a gun or knife.

• At follow-up, the incidence of both female-to-male and male-to-female partner violence was only 6 percent. However, recurrence was more common (female-to-male violence 44 percent, male-to-female violence 39 percent).
• In unadjusted analyses, incidence and/or recurrence of partner violence was significantly associated with greater mean consumption by male perpetrators; heavy drinking (at least 5 drinks on an occasion in the past year) by male and female perpetrators; and/or alcohol problems among male and female perpetrators.
• Among these alcohol indicators, only mean consumption (among both female perpetrators and male victims) remained significantly associated with new or recurrent cases of female-to-male partner violence when analyses were adjusted for potential confounders.

Comments by Joseph Conigliaro, MD, MPH: Female-to-male partner violence was as common as male-to-female partner violence in this population-based sample, whereas male perpetration of partner violence is often the norm in clinical samples. Nevertheless, heavy episodic drinking, alcohol problems, and higher average alcohol consumption should be considered risk factors for partner violence and addressed in prevention efforts.

Reference: Caetano R, McGrath C, Ramisetty-Mikler S, et al. Drinking, alcohol problems and the five-year recurrence and incidence of male to female and female to male partner violence. Alcohol Clin Exp Res. 2005;29(1):98-106.

Reprinted with permission from “Alcohol and Health: Current Evidence”.

Healing the Trauma of Domestic Violence: A Workbook for Women (New Harbinger Self-Help Workbook) by Edward S., Ph.D. Kubany, Mari A. McCaig, Janet R. Laconsay Read more about this title…

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Bipolar Patients with Comorbid Substance Use Disorders; Diagnostic and Treatment Considerations:

Comorbidity of bipolar disorder (BD) and alcoholism and substance use disorders (SUDs) represents a serious public health problem and a major challenge to treatment systems.

Bipolar disorder is among the top causes of disabilities worldwide, and reportedly the fourth leading mental illness as a source of disease burden in established market economies. Large epidemiologic surveys in the United States have consistently confirmed a high association between bipolar disorder and SUDs. The Epidemiological Catchments Area Study reported bipolar I and bipolar II disorders as having the highest association with SUDs when compared with any other major psychiatric disorder.

The prevalence of lifetime alcohol abuse or dependence in persons with bipolar I disorder and bipolar II disorders were found to be 46%, and 39.2% respectively.

Similarly, the National Comorbidity Survey reported respondents with mania to be 8 to 9 times more likely to have an additional lifetime disorder of drug or alcohol dependence compared with the general population. The most recent and largest epidemiologic survey of more than 42,000 respondents in the United States, the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), reported that mania and hypomania were associated with very high rates of SUDs. Those with mania were 6 times more likely to have alcohol dependence and 14 times more likely to have drug dependence over the past 12 months.

Research from; Psychiatric Annals, Volume 38 · Number 11, NOVEMBER 2008

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This study was designed to examine aggression in a group of socially well-adapted recovered alcoholics.

The question addressed was whether the treatment, together with long-term abstinence from alcohol, could reduce aggression and hostility in recovered alcoholics.

Sixty four male stable alcoholics with at least 3 years sobriety were compared with 69 non-alcoholics. Neither group had any other psychological problems.

Both groups were given a questionnaire on general characteristics as well as aggressive and hostility traits.

After a 3-year abstinence, men from the recovering alcoholics group displayed greater signs of hostility and covert aggression. They were different from non-alcoholics on measures for indirect aggression, irritability, negativism, suspicion, resentment, and guilt.

Research report; Ziherl S, Cebasek Travnik Z, Kores Plesnicar B, Tomori M, Zalar B. Trait aggression and hostility in recovered alcoholics. Eur Addict Res 2007; 13(2): 89-93.

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Brief-TSF may be utilised in combination with supportive pharmacotherapy; for example, craving reduction medications.

While recognising the existence of multiple problems of adjustment in most problem drinkers (e.g., marital conflict, family dysfunction), Brief-TSF advocates pursuing the goal of early recovery as primary, delaying most other therapies if necessary, until the client has achieved approximately 6 months of sobriety.

The primary exceptions to this recommendation would be emergency or incapacitating medical treatment, debilitating depression or other major affective disorder, or a psychotic disorder, which would take precedence over Brief-TSF.

Brief-TSF is not compatible with treatments based on notions of controlled use.

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While the war on drugs continues to attract world attention, it is often overlooked that alcoholism remains a major worldwide health concern. No matter what your expertise, the Handbook of Alcoholism can help you acquire the necessary skills to treat problem drinkers and alcohol-dependent patients. In three sections;

• Patient Care,
• Research, and
• Useful Data and Definitions

this comprehensive handbook not only addresses the underlying psychological problems of alcoholism, but helps you to better diagnose and treat the non-psychiatric medical disorders caused by the disease.

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Handbook of Alcoholism Treatment Approaches (3rd Edition) by Reid K. Hester, William R. Miller Read more about this title…

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Alcoholics and addicts can attest to their countless attempts to stop or cut back on their drinking or drugging. They learn but cannot really accept that they have no power over alcohol or drugs.

The following research of the 1970’s began to explore this phenomenon and in the process confirming a basic tenet of Alcoholics Anonymous.

We alcoholics are men and women who have lost the ability to control our drinking. We know that no real alcoholic ever recovers control. All of us felt at times that we were regaining control, but such intervals – usually brief – were inevitably followed by still less control, which led in time to pitiful and incomprehensible demoralization. We are convinced to a man that alcoholics of our type are in the grip of a progressive illness. Over any considerable period we get worse, never better. Alcoholics Anonymous, pp 30.

Abstract of research report; This study evaluates the ability of alcoholics to regulate their blood alcohol levels (BAL) within a designated range by relying primarily on interoceptive (internal) cues. Forty male alcoholics and 20 control subjects were exposed to an initial training session in which they received sufficient ethanol to maintain them within a designated BAL range over a 2 1/2-hour period.

They were then exposed to two experimental sessions, one providing "overfeedback" and one "underfeedback." During each session, subjects had ten drinking decisions to make with respect to regulation of their BAL.

The results indicated that alcoholics displayed greater "loss-of-control" than control subjects.

This finding supported the hypothesis that alcoholics may possess a neurophysiologic feedback dysfunction that contributes to their relative inability to regulate ethanol intake.

A. M. Ludwig, F. Bendfeldt, A. Wikler and R. B. Cain. Loss of control in alcoholics. Archives of General Psychiatry. Vol. 35 No. 3, March 1978.

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