Long-term effects of pharmacotherapy on relapse prevention in alcohol dependence.
Background: There is growing evidence that pharmacological treatment with two of the best validated anticraving medications, acamprosate and naltrexone, is efficacious in promoting abstinence in recently detoxified alcohol-dependent subjects.
Objective: The stability of effects after termination of treatment remains to be answered, especially when combining both the drugs.
Method: After detoxification, 160 alcohol-dependent subjects participated in a randomized, double-blind, placebo-controlled trial. Patients received naltrexone or acamprosate or a combination of naltrexone and acamprosate or placebo for 12 weeks. Patients were assessed weekly by interview, self-report, questionnaires and laboratory screening. Additionally, follow-up evaluation based on telephone interview of participants, general practitioners and relatives was conducted 12 weeks after terminating the medication.
Results: At week 12, the proportion of subjects relapsing to heavy drinking was significantly lower in the group with combined medication compared with both placebo and acamprosate (P < 0.05).
No difference was detectable between acamprosate and naltrexone, both of which were superior to placebo (P < 0.05).
12 Week Relapse rates were;
- 28% (combined medication),
- 35% (naltrexone),
- 50% (acamprosate) and
- 75% (placebo).
After follow-up (week 24), combined medication led to relapse rates significantly lower than placebo, but not lower than acamprosate.
Again, both naltrexone and acamprosate were superior to placebo.
24 Week Relapse rates were
- 80% (placebo),
- 54% (acamprosate),
- 53% (naltrexone) and
- 34% (combined medication).
Conclusions:
The results of this study highlight the stability of effects of pharmacotherapy on relapse prevention in alcohol dependence.
Research; Kiefer F; Andersohn F; Otte C; Wolf K; Jahn H; Wiedemann K. (2004), Long-term effects of pharmacotherapy on relapse prevention in alcohol dependence. Acta Neuropsychiatrica, October 2004, vol. 16, no. 5, pp. 233-238(6)
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Researchers Identify Five Alcoholism Subtypes
Analyses of a national sample of individuals with alcohol dependence (alcoholism) reveal five distinct subtypes of the disease, according to a new study by scientists at the National Institute on Alcohol Abuse and Alcoholism (NIAAA), part of the National Institutes of Health (NIH).
“Our findings should help dispel the popular notion of the typical alcoholic, notes first author Howard B. Moss, M.D., NIAAA Associate Director for Clinical and Translational Research. “We find that young adults comprise the largest group of alcoholics in this country, and nearly 20 percent of alcoholics are highly functional and well-educated with good incomes. More than half of the alcoholics in the United States have no multigenerational family history of the disease, suggesting that their form of alcoholism was unlikely to have genetic causes.
Clinicians have long recognized diverse manifestations of alcoholism, adds NIAAA Director Ting-Kai Li, M.D, “and researchers have tried to understand why some alcoholics improve with specific medications and psychotherapies while others do not. The classification system described in this study will have broad application in both clinical and research settings. A report of the study is now available online in the journal Drug and Alcohol Dependence.
Previous efforts to identify alcoholism subtypes focused primarily on individuals who were hospitalized or otherwise receiving treatment for their alcoholism. However, recent reports from NIAAA’s National Epidemiological Survey on Alcohol and Related Conditions (NESARC), a nationally representative epidemiological study of alcohol, drug, and mental disorders in the United States, suggest that only about one-fourth of individuals with alcoholism have ever received treatment. Thus, a substantial proportion of people with alcoholism were not represented in the samples previously used to define subtypes of this disease.
In the current study, Dr. Moss and colleagues applied advanced statistical methods to data from the NESARC. Their analyses focused on the 1,484 NESARC survey respondents who met diagnostic criteria for alcohol dependence, and included individuals in treatment as well as those not seeking treatment. The researchers identified unique subtypes of alcoholism based on respondents’ family history of alcoholism, age of onset of regular drinking and alcohol problems, symptom patterns of alcohol dependence and abuse, and the presence of additional substance abuse and mental disorders:
Young Adult subtype: 31.5 percent of U.S. alcoholics. Young adult drinkers, with relatively low rates of co-occurring substance abuse and other mental disorders, a low rate of family alcoholism, and who rarely seek any kind of help for their drinking.
Young Antisocial subtype: 21 percent of U.S. alcoholics. Tend to be in their mid-twenties, had early onset of regular drinking, and alcohol problems. More than half come from families with alcoholism, and about half have a psychiatric diagnosis of Antisocial Personality Disorder. Many have major depression, bipolar disorder, and anxiety problems. More than 75 percent smoked cigarettes and marijuana, and many also had cocaine and opiate addictions. More than one-third of these alcoholics seek help for their drinking.
Functional subtype: 19.5 percent of U.S. alcoholics. Typically middle-aged, well-educated, with stable jobs and families. About one-third have a multigenerational family history of alcoholism, about one-quarter had major depressive illness sometime in their lives, and nearly 50 percent were smokers.
Intermediate Familial subtype: 19 percent of U.S. alcoholics. Middle-aged, with about 50 percent from families with multigenerational alcoholism. Almost half have had clinical depression, and 20 percent have had bipolar disorder. Most of these individuals smoked cigarettes, and nearly one in five had problems with cocaine and marijuana use. Only 25 percent ever sought treatment for their problem drinking.
Chronic Severe subtype: 9 percent of U.S. alcoholics. Comprised mostly of middle-aged individuals who had early onset of drinking and alcohol problems, with high rates of Antisocial Personality Disorder and criminality. Almost 80 percent come from families with multigenerational alcoholism. They have the highest rates of other psychiatric disorders including depression, bipolar disorder, and anxiety disorders as well as high rates of smoking, and marijuana, cocaine, and opiate dependence. Two-thirds of these alcoholics seek help for their drinking problems, making them the most prevalent type of alcoholic in treatment.
The authors also report that co-occurring psychiatric and other substance abuse problems are associated with severity of alcoholism and entering into treatment. Attending Alcoholics Anonymous and other 12-step programs is the most common form of help-seeking for drinking problems, but help-seeking remains relatively rare.
Other co-authors of the study include Chiung M. Chen, M.A. and Hsiao-Ye Yi, Ph.D., of the Alcohol Epidemiologic Data System at CSR Inc., in Arlington, Virginia.
The National Institute on Alcohol Abuse and Alcoholism, part of the National Institutes of Health, is the primary U.S. agency for conducting and supporting research on the causes, consequences, prevention, and treatment of alcohol abuse, alcoholism, and alcohol problems and disseminates research findings to general, professional, and academic audiences. Additional alcohol research information and publications are available at www.niaaa.nih.gov.
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The interplay between help seeking and alcohol related outcomes: divergent processes for professional treatment and self-help groups.
Summary:
This study examined the influence of self-selection on the duration of professional treatment and participation in Alcoholics Anonymous (AA) and the influence of social causation on alcohol-related outcomes.
A sample of alcoholics was surveyed at baseline and 1, 3, and 8 years later. Participants completed an inventory at each survey that assessed participation in treatment and AA since the last assessment and alcohol-related functioning.
There were divergent processes of self-selection and social causation with respect to the duration of participation in professional treatment and AA.
Individuals with more severe alcohol-related problems obtained longer episodes of professional treatment, but this self-selection process was much less evident for AA.
Longer participation in professional treatment in the first year predicted better alcohol-related outcomes, but the duration of subsequent treatment was not associated with better subsequent outcomes.
In contrast, longer participation in AA consistently predicted better subsequent alcohol-related outcomes.
The findings are consistent with a need-based model of professional treatment, in which more treatment is selected by and allocated to individuals with more severe problems, and an egalitarian model of self-help, in which needs play little or no role in continued participation.
Rudolf H. Moos and Bernice S. Moos. The interplay between help-seeking and alcohol-related outcomes: divergent processes for professional treatment and self-help groups. Drug and Alcohol Dependence 75(2):155-164, August 2004.
Cirrhosis, Drinking and AA participation.
The authors tested the hypotheses that cirrhosis mortality rates are positively associated with per capita alcohol consumption and negatively associated with the 12-Step fellowship Alcoholics Anonymous (AA) membership rates, using data from the province of Ontario, Canada, for 1968 to 1989. Time-series analyses with auto-regressive integrated moving average (ARIMA) modeling were applied to male and female cirrhosis mortality rates in three age groups: 15-44, 45-64 and e65 years. Missing AA membership data were interpolated using two methods: linear splines and cubic splines.
In general, cirrhosis mortality rates were positively associated with alcohol consumption and negatively associated with AA membership. These effects were not statistically significant for some age and gender combinations. Limitations of this study include restrictions in the length of series available and in the ability to infer causality. Nevertheless, the findings are consistent with previous research demonstrating that per capita consumption is a strong determinant of cirrhosis mortality and that higher levels of AA membership can reduce cirrhosis mortality.
Research report; Robert E. Mann, Reginald G. Smart, Brian R. Rush, Rosely Flam Zalcman, and Helen Suurvali. Cirrhosis mortality in Ontario: Effects of alcohol consumption and Alcoholics Anonymous participation. Addiction 100(11):1669-1679, November 2005.
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TSF for Dual Diagnosis
The role of 12-step programs and 12-step-oriented treatments for dually diagnosed individuals (DDI) remains unclear. Here are presented the results of a pilot study in a target population of 10 seriously mentally ill patients received an adjunctive modified 12-step facilitation (TSF) therapy emphasizing engagement of DDI in a specialized 12-step program for DDI.
Participants significantly increased their 12-step attendance and decreased their substance use during the 12 weeks of treatment.
Larger and longer-term studies are needed to assess the efficacy of modified TSF for DDI relative to other treatments, and to determine what forms of TSF are most effective in this population.
Research; Bogenschutz MP. Tucker NE Specialized 12-step programs and 12-step facilitation for the dually diagnosed. Community Ment Health J. 2005 Feb;41(1):7-20.
Brief-TSF can be adapted to serve these people.
Women and the Twelve Steps of Alcoholics Anonymous: A Gendered Narrative
This paper examines how women “work†the twelve steps of Alcoholics Anonymous (AA) from a gendered perspective.
Feminist critics of AA have
- challenged the language of AA’s Twelve Steps,
- the spiritual nature of the steps, and
- the male-dominated culture of the Twelve-Step program.
This paper offers insight into how women in AA approach, interpret, and utilize the Twelve Steps to recover from alcoholism.
Through survey and narrative data, findings suggests
- that women working AA’s Twelve Steps become empowered and
- change for the better in spite of the male-dominated culture and language of the Twelve Steps and
- regardless of the difficulty they may have encountered in completing these steps.
In particular, the first three steps-the “surrender stepsâ€-
- encourage women to let go of their alcoholic obsession and
- begin a spiritual path of recovery.
Steps Four through Nine require
- women to “clean house†and
- get rid of old self-destructive ways so that they may develop a new and stronger sense of self.
Finally, on completing Steps Ten through Twelve, women
- experience a spiritual awakening and
- then, in turn, “pass on†what they have learned from the Twelve Steps to other women in the program.
Woven throughout these women’s experiences is
- an acknowledgment of gender and
- the role it plays in how they work the Twelve Steps.
In the end, these women express a sense of personal empowerment that is particular to a gender-specific orientation to the Twelve Steps of AA.
Research; Jolene M. Sanders, Women and the Twelve Steps of Alcoholics Anonymous: A Gendered Narrative. Alcoholism Treatment Quarterly, Volume: 24 Issue: 3, 2006
Al-anon, Adult Children of Alcoholics, Gambler Anonymous, Narcotics Anonymous,
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Alcoholism Is Not Just A Mans Disease Anymore
A new examination of data on similarly aged groups, compared across decades, has found substantial increases in drinking and alcohol dependence among women.
Increases were particularly notable among white and Hispanic women beginning with those born in the United States after World War II.
Cross-sectional studies, which collect information at a single point in time, generally find that young Americans report having more lifetime alcohol problems than older Americans, despite having had less time to develop these problems. But these studies are hampered by the fact that people of different ages may remember or report problems to different degrees. A new examination of data, collected on similarly aged groups one decade apart, has found substantial increases in drinking and alcohol dependence among women “ particularly white and Hispanic women“ beginning with those born in the United States after World War II.
Results are published in the May issue of Alcoholism: Clinical & Experimental Research.
“By looking at two different cross-sectional surveys that asked the same questions in the same manner, but were conducted 10 years apart, we were able to compare, for example, 30 – 40 year olds in 2001 with 30 – 40 year olds in 1991, explained Richard A. Grucza, an epidemiologist at Washington University School of Medicine and the studys corresponding author. Essentially, this allowed us to correct for the effects of age on reporting. When we did this, we found that the tendency for young people to have higher levels of lifetime alcohol dependence clearly remained for women, although it disappeared for men.
Furthermore, added Shelly F. Greenfield, associate clinical director of the Alcohol and Drug Abuse Treatment Program at McLean Hospital, prevalence surveys are inclusive. “Epidemiologic surveys document the prevalence of an illness such as alcohol dependence in the entire population rather than just one segment of the population, such as those seeking treatment,†she said. “This allows us to track trends in illnesses – including whether certain people are more vulnerable for a particular disease, at what age they manifest symptoms, and how quickly the illness progresses.â€
For this study, researchers examined two large, national surveys: the National Longitudinal Alcohol Epidemiologic Survey (NLAES), conducted in 1991 and 1992; and the National Epidemiological Survey on Alcohol and Related Conditions (NESARC), conducted in 2001 and 2002. They compared lifetime prevalence rates from the same age groups and demographics, while simultaneously controlling for age-related factors.
“We found that for women born after World War II, there are lower levels of abstaining from alcohol, and higher levels of alcohol dependence, even when looking only at women who drank,†said Grucza. “However, we didn’t see any significant tendency for more recently born men to have lower levels of abstention, or higher levels of alcohol dependence.†He added that these results shed more light on a “closing gender-gap in alcoholism,†showing that it is probably due to higher levels of problems among women, while men have been more or less steady in their levels of dependence.
Greenfield concurred. “This is an excellent study that adds important information to the accumulating evidence that the gender gap between women and men in the prevalence of alcohol dependence is narrowing,†she said. “One possible explanation is that between 1934 and 1964, the social acceptability of women’s drinking increased. As it was more socially acceptable for women to drink, a greater number of them became drinkers. Because women have a heightened vulnerability to the effects of alcohol – that is, greater blood alcohol levels at similar ‘doses’ of alcohol – we may therefore see a concomitant rise in alcohol dependence among those who ever drank.â€
Grucza drew an analogy between women’s drinking habits and culture and immigration. “Clearly there were many changes in the cultural environment for women born in the 40s, 50s and 60s compared to women born earlier,†he said. “Women entered the work force, were more likely to go to college, were less hampered by gender stereotypes, and had more purchasing power. They were freer to engage in a range of behaviors that were culturally or practically off-limits, and these behaviors probably would have included excessive drinking and alcohol problems.â€
He noted that U.S. immigrants from cultures with conservative values vis-Ã -vis drinking tend to adhere to their own cultural norms, while their children are likely to adopt U.S. norms, which are comparatively lax regarding alcohol.
“We can think of U.S. culture as having been traditionally dominated by white men,†added Grucza. “As women have ‘immigrated’ into this culture, they have become ‘acculturated’ with regard to alcohol use. But Black women – who still have the lowest rates of drinking among the demographic groups we looked at – have a second barrier between them and the dominant U.S. culture, namely, their race, that may be keeping them from adopting the standards of the dominant culture with respect to alcohol use.â€
Greenfield suggested that specially designed prevention programs that target female drinkers might help to lower drinking rates, and also delay the age of drinking initiation, which could help prevent later alcohol problems. “It would also be helpful to educate women about the gender differences in metabolism of alcohol, and the associated heightened female vulnerability to alcohol’s adverse health consequences at lower doses than men,†she said.
Grucza agreed that interventions for women need further investigation. “Whenever we see change in a disorder in the population, there is an opportunity to take a closer look at which risk factors for the disorder might be changing at the same time,†he said. “The classic example of this would be the rise in lung cancer in the late 20th century, a time in which sales of commercially produced cigarettes also skyrocketed. In this case, we obviously wouldn’t want to change the progress made by women over the last 50 – 60 years, but we can look at specific changes in their drinking behavior and start to speculate about what interventions might work.â€
Richard A. Grucza, Kathleen K. Bucholz, John P. Rice, Laura J. Bierut. (May 2008). Secular trends in the lifetime prevalence of alcohol dependence in the United States: a re-evaluation. Alcoholism: Clinical and Experimental Research (ACER). 32(5): 763–770.
See also;
- 12-Step Treatment More Effective than Alternative
- AA Offers Recovery Not Religion
- Brief-TSF ASSESSMENT
- Subscribe to Twelve Step Facilitation by e-Mail
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Counseling The Alcoholic Woman by Joseph F. Perez |
Despite decades of using a chronic disease metaphor for alcoholism and, more recently, drug addiction, we continue to provide treatment based on an acute model of care.
Is it time to shift to a chronic care approach similar to disease management models?
To explore this question, a recent study analyzed data demonstrating the chronic nature of addiction.
- Over 50% of people who resolve drug problems following treatment receive multiple episodes of care, usually over several years.
- Data from 2003 from programs receiving public funds revealed that 64% of people were readmissions to treatment and 19% had more than four admissions.
- In a study of 448 persons following treatment, 82% transitioned at least once between relapse, treatment re-entry, incarceration, and periods of abstinence over a 2-year period.
- Alarming results of a study from 23 states revealed that only 17% of persons discharged from intensive treatment were transitioned to outpatient continuing care.
Several emerging practices for a chronic care model and their results were also reviewed, revealing the following:
- telephonic follow-up resulted in fewer positive cocaine urine tests;
- assertive continuing care for adolescents demonstrated greater access to and participation in continuing care as well as greater abstinence;
- recovery management check-ups at 90-day intervals combined with motivational interventions for those who had relapsed provided a faster return to, and greater participation in, treatment as well as a lesser need for treatment at 2-year follow-up.
The authors discuss the need for substantial system changes required across all elements of the addiction treatment system if a chronic care model is to be implemented.
Comments by Michael Boyle, PhD:
Providers do what they are paid to deliver. If we want to change to a potentially more effective model of addiction treatment, the funding bodies must implement new billing codes and rates for continuing recovery management. Providers need to strive to remove any sense of failure, shame, or guilt persons may have regarding their return to use and need for additional assistance.
Reference:
Dennis M, Scott CK. Managing addiction as a chronic condition. Addict Sci Clin Pract. 2007;4(1):45-55.
From; Join Together Online
Related Reading:
The Role of Uncontrollable Trauma in the Development of PTSD and Alcohol Addiction
By Joseph Volpicelli, M.D., Ph.D.; Geetha Balaraman; Julie Hahn; Heather Wallace, M.A.; and Donald Bux, Ph.D.
After a traumatic event, people often report using alcohol to relieve their symptoms of anxiety, irritability, and depression.
Alcohol may relieve these symptoms because drinking compensates for deficiencies in endorphin activity following a traumatic experience. Within minutes of exposure to a traumatic event there is an increase in the level of endorphins in the brain.
During the time of the trauma, endorphin levels remain elevated and help numb the emotional and physical pain of the trauma.
However, after the trauma is over, endorphin levels gradually decrease and this may lead to a period of endorphin withdrawal that can last from hours to days. This period of endorphin withdrawal may produce emotional distress and contribute to other symptoms of posttraumatic stress disorder (PTSD).
Because alcohol use increases endorphin activity, drinking following trauma may be used to compensate this endorphin withdrawal and thus avoid the associated emotional distress. This model has important implications for the treatment of PTSD and alcoholism.
Alcohol Research & Health, Vol. 23, No. 4, 1999
Related Reading:
AA works with bipolar disorder
A follow up study on alcoholics with and without coexisting affective disorder Three-hundred male alcoholics were selected from consecutive admissions to hospital. They were divided into three target populations:
- primary alcoholics;
- alcoholics with unipolar affective disorder; and
- alcoholics with bipolar affective disorder.
After three follow-up interviews over a 2-year period after hospital discharge, the three sub- groups reported differences in frequency of mood change, amount of treatment received, and hospital attendance, although there were no clear-cut differences in items associated with their alcoholism.
There were, however, some indications that bipolar patients functioned at a better level during the follow-up period, particularly those who were older, had a previous history of longer periods of abstinence, and maintained more frequent contact with Alcoholics Anonymous (AA) and their family doctor.
K O’Sullivan, C Rynne, J Miller, S O’Sullivan, V Fitzpatrick, M Hux, J Cooney and A Clare. (1998), A follow up study on alcoholics with and without coexisting affective disorder. The British Journal of Psychiatry 152: 813-819 (1988)
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