ABSTRACT – Aims: The study investigates severity of alcohol dependence among drug misusers. Specifically, it investigates the inter-relationship of alcohol and drug dependence and associations with alcohol consumption, drug consumption and substance-related problems.

Design, setting, participants: The sample comprised 735 people seeking treatment for drug misuse problems, who were current (last 90 days) drinkers.

Measurements: Data were collected by structured face-to-face interviews. Dependence upon illicit drugs and upon alcohol was measured by the Severity of Dependence Scale (SDS).

Findings: Three groups of drinkers were identified: non-alcohol-dependent drug misusers (63%); low-dependence (19%); and high-dependence (18%). Many drug misusers were drinking excessively and alcohol dependence was related to patterns of alcohol and drug consumption. High-dependence drinkers were more likely to drink extra-strength beer; they were less frequent users of heroin and crack cocaine but more frequent users of benzodiazepines, amphetamines and cocaine powder; they reported more psychological and physical health problems. The SDS was found to have good reliability and validity as a measure of alcohol dependence. SDS scores for alcohol and drug dependence were unrelated.

Conclusions: Alcohol use is an important and under-rated problem in the treatment of drug misusers. A comprehensive assessment of alcohol use among drug misusers should include separate assessments of alcohol consumption, alcohol-related problems and severity of alcohol dependence.

Research; Gossop, Michael; Marsden, John; Stewart, Duncan. Dual dependence: assessment of dependence upon alcohol and illicit drugs, and the relationship of alcohol dependence among drug misusers to patterns of drinking, illicit drug use and health problems. Addiction; Volume 97(2), February 2002, p 169-178.

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Dr Harry M. Tiebout

One of the first psychiatrists to describe alcoholism as a disease rather than a moral failing or criminal activity.

Harry M. Tiebout was also one of the first to wholeheartedly endorse Alcoholics Anonymous as an effective force in the struggle against compulsive drinking.

This volume brings together, for the first time, some of Tiebout’s most influential writings. Many of these pieces–from explorations of the therapeutic approach to alcoholism to instructive discussions of the act of surrender so crucial to recovery–are seminal documents in the history, treatment, and understanding of alcoholism.

Together, they represent the significant contribution of one man to the countless lives shaken by alcoholism and steadied with the help of Alcoholics Anonymous, psychiatric intervention, and the foresight and commitment of doctors like Harry Tiebout.

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Harry Tiebout Buy Now!

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It is not known, however, whether such pain increases the risk of relapse following periods of abstinence.

Researchers assessed data on pain and substance use in 397 adults who, as part of a larger randomized trial, had been interviewed periodically in the 24 months after their discharge from an urban, residential alcohol and drug detoxification unit.

Pain was measured with the pain item on the SF-36 Health Survey. Analyses were adjusted for potential confounders (e.g., demographics, addiction severity, depressive symptoms).

• Sixteen percent of subjects reported persistent pain (moderate-to-higher levels of pain at all available interviews) in the 24 months after detoxification.
• Subjects reporting persistent pain were significantly more likely than those with mild or no pain to have used the following in the past 30 days at the 24-month follow-up:
• heroin/opioids not prescribed for pain (odds ratio, 5.4);
• heavy amounts of alcohol* (odds ratio, 2.2).

Comments: Persistent pain is common among alcohol and drug users who have undergone residential detoxification and increases the likelihood of relapse. This study suggests that clinicians must be careful to screen for pain symptoms in patients with substance dependence. When persistent pain is present, thoughtful management is required to minimize risks associated with undertreatment while not fostering opioid analgesic abuse.

Research References:Larson MJ, Paasche-Orlow M, Cheng DM, et al. Persistent pain is associated with substance use after detoxification: a prospective cohort analysis. Addiction. 2007.

The Mindbody Prescription: Healing the Body, Healing the Pain by John E. Sarno Read more about this title…

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Domestic violence

Intimate partner violence against women is prevalent and is associated with poor health outcomes.

Understanding indicators of exposure to intimate partner violence can assist health care professionals to identify and respond to abused women. This study was undertaken to determine the strength of association between selected evidence-based risk indicators and exposure to intimate partner violence.

In this cross-sectional study of 768 women aged 18-64 years who presented to 2 emergency departments in Ontario, Canada, participants answered questions about risk indicators and completed the Composite Abuse Scale to determine their exposure to intimate partner violence in the past year.

Results: Intimate partner violence was significantly associated with

• being separated,
• in a common-law relationship or
• single
• depression
• somatic symptoms
• having a male partner who was employed less than part time, or
• having a partner with an alcohol or
• drug problem

Each unit increase in the number of indicators corresponded to a four-fold increase in the risk of intimate partner violence; women with 3 or more indicators had a greater than 50% probability of a positive score on the Composite Abuse Scale.

Intimate partner violence was not associated with pregnancy status.

Specific characteristics of male partners, relationships and women’s mental health are significantly related to exposure to intimate partner violence in the past year. Identification of these indicators has implications for the clinical care of women who present to health care settings. (Source: Open Medicine

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Alcohol is the most widely used and abused drug among working adults. Over 80 percent of problem drinkers are employed full-time. Unhealthy drinking patterns contribute to a host of preventable problems including increased workers’ compensation and disability claims, hospital costs and job turnover. In addition, 20 percent of employees have been injured by, had to cover for, or worked harder because of a colleague’s drinking. Alcohol abuse and dependency cause employees to miss more work days, have lower productivity, and higher medical costs than those without active drinking problems.

Screening for alcohol problems can motivate some to temper their drinking while others—whose drinking may be dangerous or disruptive—may seek treatment, recovery and success. Business leaders willing to invest in screening and brief interventions (SBI) for alcohol problems can realize a return on investment of at least 215% by making interventions available for problem drinkers. To reap these rewards, employers need to first make screening available and accessible.

Tools for Screening

Alcohol screenings are usually completed in 5-10 minutes. Two frequently used screening instruments are the 4-question CAGE and the 10-question AUDIT. Both tools focus on quantity and frequency of alcohol intake. The AUDIT also assesses binge drinking, addictive symptoms and negative consequences.

In the Workplace

Many employers support activities and offer benefits that facilitate employee alcohol screening. Employee assistance programs that offer screening are linked to reductions in healthcare costs and increased productivity.7 New staff orientations are opportune events to inform employees about alcohol abuse and dependency resources. Company health fairs, and workplace wellness programs—when led by clinicians equipped to perform confidential alcohol screening—are also key events to identify and help problem drinkers.

In Healthcare Settings

Alcohol screening enables healthcare providers to address problem drinking before it becomes life-altering. By ensuring that health plans cover alcohol SBI, employers provide the necessary healthcare tools for employees to monitor their drinking. Screening can take place in the primary care setting as part of routine health exams. It can also be offered to women as part of their pregnancy-preparedness and prenatal care. Physicians’ offices, hospitals, emergency rooms, urgent care centers and behavioral health clinics are all safe environments to assess addictive behaviors.

In the Home

Online resources are also available for employees and their families to assess their own problem drinking and seek help independent of workplace resources. Websites like AlcoholScreening.org provide validated screening tools, recommended actions and local resources for those seeking treatment and further information.

After Screening

Alcohol screening tests are similar in accuracy as tests for diabetes and high blood pressure. While screening does not provide a specific diagnosis, it does help identify people who may benefit from a comprehensive assessment by a trained professional. There are two possible courses of action for someone who screens positive for alcohol problems:

If the person exhibits signs of dependency, a referral to a treatment program more equipped to handle and assess addiction is appropriate (e.g., inpatient treatment), or

If the person’s behavior is more associated with problem drinking, a brief intervention of low intensity and short duration can be conducted.

Brief-TSF utilizes the CAGE and AUDIT and concentrates on breaking down denial and then referral to Alcoholics Anonymous.

From Ensuring Solutions

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In our continuing editorial series with experts from the National Institute on Alcohol Abuse and Alcoholism (NIAAA), Coalitions Online interviewed Ricardo Brown, Ph. D., Health Science Administrator and Minority Health and Health Disparities Coordinator.

Here, in recognition of Black History Month, Dr. Brown discusses the disparities in alcohol use and treatment among minorities and stresses the need for greater minority participation in clinical studies.

Q: What are the major differences in alcohol use among minorities?

Among Asian Americans, Chinese Americans have higher rates of abstinence from alcohol, while Japanese Americans report higher rates of heavy drinking. With respect to adolescent drinking, African American teens drink less than non-Hispanic white and Latino teens.

Q: How do the health effects and mortality rates of alcohol use differ among minorities?

Despite having higher abstinence rates, alcohol-related deaths are higher among African-American males than white males. Alcohol-related mortality rates for white Hispanic Latino men is double that for non-Hispanic white men. Among Native Americans, the leading cause of death is alcohol-related.

Q: What are some of factors that might influence these varying rates?

Genes and environmental factors, and their interaction, play an important role.

Environment can play a part in shaping use, treatment and prevention, and some people have a genetic predisposition to alcohol drinking.

Some examples of environmental factors are location and insurance coverage. For example, minority patients who enter treatment programs generally have success rates that are equal to those of white patients. However, depending on where they live and the resources of their neighborhood, they may not have access to treatment.

Hispanics/Latinos and African Americans are also less likely to have insurance coverage for treatment. However, we need to conduct more studies to determine the exact multi-dimensional factors that influence use of alcohol. Getting more minorities to participate in clinical trials is a challenge we’re facing now and one way to address the disparities is by getting increased participation by minority groups so we can understand the underlying mechanisms responsible for disparities between groups of people.

Q: What is the role of the community in helping to address these disparities?

They can be a stronger force in encouraging people from all walks of life to participate in clinical and epidemiological studies, so that the outcomes of those studies can be applicable to all groups. It’s also important for any local community or university-based group to be involved in their local alcohol research center, which are located throughout the country.

Q: What efforts does the NIAAA do to address these disparities?

Our Director Dr. Ting-Kai Li is aware of these disparities and he’s working closely with the National Center for Minority Health Disparities and other organizations to address them. He is also developing mechanisms for increasing enrolment of African-Americans and other ethnic minorities in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC).

Dr. Ricardo Brown is NIAAA’s Health Science Administrator and Minority Health and Health Disparities Coordinator. For more information about the NIAAA and its programs, visit www.niaaa.nih.gov.

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SPIRITUALITY AND HEALTH

Many people use prayer, and some studies have shown a positive association between prayer and improved health outcomes. This article explores four possible mechanisms by which prayer may lead to improved health.

While acknowledging the efficacy of prayer and recognizing the needs of patients, prayer, being a personal spiritual practice, cannot be prescribed, nor should it be used in place of medical care.

The spiritual search for meaning and hope in life is integral to human existence. This is particularly evident during times of personal stress and crisis. Recent census findings indicate that 74% of Australians and 96% of Americans believe in a higher power, and similar percentages claim some form of religious affiliation.1,2 Evidence also suggests that certain spiritual beliefs and the practice of prayer are associated with improved coping and better health outcomes.3-6 Although North Americans have been the predominant participants in most of the research available, the findings are relevant to the Australian experience, as they reflect a basic human desire for supernatural involvement in matters of health and wellbeing.

Research; Marek Jantos and Hosen Kiat. Medical Journal of Australia, 2007; 186: S51-S53

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A Systematic Review

Background; Primary care physicians can play a unique role in recognizing and treating patients with alcohol problems.

Objective; To evaluate the accuracy of screening methods for alcohol problems in primary care.

Methods; We performed a search of MEDLINE for years 1966 through 1998. We included studies that were in English, were performed in primary care, and reported the performance characteristics of screening methods for alcohol problems against a criterion standard. Two reviewers appraised all articles for methodological content and results.

Results; Thirty-eight studies were identified. Eleven screened for at-risk, hazardous, or harmful drinking; 27 screened for alcohol abuse and dependence. A variety of screening methods were evaluated.

The Alcohol Use Disorders Identification Test (AUDIT) was most effective in identifying subjects with at-risk, hazardous, or harmful drinking (sensitivity, 51%-97%; specificity, 78%-96%).

The CAGE questions proved superior for detecting alcohol abuse and dependence (sensitivity, 43%-94%; specificity, 70%-97%).

These 2 formal screening instruments consistently performed better than other methods, including quantity-frequency questions.

The studies inconsistently adhered to methodological standards for diagnostic test research: 3 provided a full description of patient spectrum (demographics and comorbidity), 30 avoided workup bias, 12 avoided review bias, and 21 performed an analysis in pertinent clinical subgroups.

Conclusions; Despite methodological limitations, the literature supports the use of formal screening instruments over other clinical measures to increase the recognition of alcohol problems in primary care.

Research; David A. Fiellin, M. Carrington Reid, Patrick G. O’Connor. Screening for Alcohol Problems in Primary Care; A Systematic Review. Arch Intern Med. 2000;160:1977-1989.

Brief-TSF includes both the AUDIT and CAGE questionnaires.

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BACKGROUND: Most formal treatment programs recommend Alcoholics Anonymous (AA) attendance during treatment and as a form of 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.

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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The purpose of the study was to examine the rates and inter-relationships among violence receipt, alcohol use problems, and depression in women seeking prenatal care.

While waiting for their prenatal care appointment, women (n = 1054) completed measures of past year partner and non-partner violence receipt, alcohol misuse (using the TWEAK and quantity and frequency of alcohol use in past year), and depression (using the Center for Epidemiological Studies Depression Scale – CESD and prior history of depression).

Over 30% of women reported either violence receipt, alcohol use problems or depression risk.

Significant inter-relationships among all measured risk variables were found.

Violence receipt was significantly related to

• alcohol misuse,
• cigarette use,
• less education, and
• scoring above the cutoff on the CESD (? 16).

Practitioners can be well-equipped to provide assessment, interventions, or referrals as needed to the high numbers of women encountered in prenatal care settings experiencing psychosocial and behavioral problems that may affect their pregnancy.

Research; H. A. Flynn, M. A. Walton, S. T. Chermack, R. M. Cunningham and S. M. Marcus. Brief detection and co-occurrence of violence, depression and alcohol risk in prenatal care settings. Archives of Women’s Mental Health, 1434-1816 (Print) 1435-1102 (Online), Volume 10, Number 4 / August, 2007

Brief-TSF provides guidelines and strategies for using the TWEAK.

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