Topiramate as add-on therapy in non-respondent alcohol dependant patients: a 12 month follow-up study.

INTRODUCTION: Topiramate is a neuromodulator drug with different action mechanisms that could be implicated in alcohol dependence. It has been studied in open and double-blind studies.

METHOD: In a group of patients (n = 64) undergoing standard treatment for alcohol dependence (according to ICD-10 criteria) with poor outcomes, a 12 month observational, prospective and multicenter study was conducted to assess the usefulness and tolerability of topiramate as addon therapy.

Outcome measures were retention rate, alcohol consumption (days of drinking per month and number of Standard Drink Units [SDU] per day, and results of Alcohol Dependence Intensity Scale [ADIS]), craving and priming visual scales and serum transaminase levels.

RESULTS: In these patients, adding topiramate medication leads to a significant decrease (p<0.001) in all the variables studied, including those derived from the craving and priming visual scales, the ADIS as well as the number of drinks/day and SDU/day consumed, the MCV and GGT values.

Mean topiramate dose was almost 200 mg/day. Only three patients dropped out due to adverse reactions.

CONCLUSIONS: Topiramate showed positive results for alcohol dependence in real clinical practice, with a significant decrease in

• craving-priming and
• dependence intensity scales,
• number of drinking days per month reported and
• transaminase levels.

Topiramate seems to be a useful and well-tolerated pharmacological aid for patients with bad evolution in their alcohol dependence treatment.

Research; Fernandez Miranda JJ, Marina Gonzalez PA, Montes Perez M, Diaz Gonzalez T, Gutierrez Cienfuegos E, Antuna Diaz MJ, Bobes Garcia J. Topiramate as add-on therapy in non-respondent alcohol dependant patients: a 12 month follow-up study. Actas Esp Psiquiatr. 2007 Jul-Aug;35(4):236-42.

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Paths of entry into Alcoholics Anonymous: Consequences for participation and remission.

Three groups of individuals with alcohol use disorders who, in the first year after initiating help-seeking were compared:

• those who entered Alcoholics Anonymous (AA) only,
• those who entered professional treatment and AA together, and
• those who entered professional treatment only.

A sample of initially untreated individuals (N = 362) was surveyed at baseline and 1 year, 3 years, 8 years, and 16 years later.

At each contact point, participants described their participation in AA and treatment and their current alcohol-related functioning. They also described their reasons for entering AA and/or treatment and the perceived benefits of these sources of help.

• Compared with individuals who initially participated only in treatment but later entered AA, those who entered treatment and AA together participated in AA longer and more frequently and were more likely to achieve remission.
• Among individuals who initially participated only in AA, those who later entered treatment had poorer remission outcomes than those who did not enter treatment.
• Longer duration of participation in AA was associated with a higher likelihood of remission at all four follow-ups;
• individuals who dropped out of AA were more likely to relapse or remain nonremitted.

those who entered treatment and AA together participated in AA longer and more frequently and were more likely to achieve remission.

In conclusion, compared with individuals who participated only in professional treatment in the first year after they initiated help-seeking, individuals who participated in both treatment and AA were more likely to achieve remission.

Individuals who entered treatment but delayed participation in AA did not appear to obtain any additional benefit from AA.

Moos, Rudolf H. and Moos, Bernice S.  Paths of entry into Alcoholics Anonymous: Consequences for participation and remission.  Alcoholism: Clinical & Experimental Research 29(10):1858-1868, October 2005.

Brief-TSF is designed as adjunctive therapy with AA.

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Some women in the U.S. and U.K. are choosing to skip dinner and drink alcohol instead in hopes of losing weight, but the strategy is flawed because of the high caloric content of alcohol, the Telegraph reported March 19.

In a practice dubbed “drunkorexia,” women may drink a glass or two of wine rather than eating a meal in a pattern that seems to combine two dangerous behaviors: binge drinking and eating disorders.

“They get fully hooked, it is an extremely noxious thing,” said Janet Treasure, head of the eating-disorders unit at the Institute of Psychiatry in London. “It is more common with bulimia than anorexia but you get the combination of empty calories with no nutritional value and the risky behavior that goes with being drunk.”

“You are more likely to be binge drinking,” added Susan Price of the British Dietetic Association. “What you should do is eat a healthy balanced diet and choose low calorie mixers and non-alcohol low calorie soft drinks.”

Diets that focus on limiting daily food intake may unintentionally encourage the problem, but experts note that alcohol has more calories on a gram-for-gram basis than carbohydrates or protein. A 250 ml glass of wine, a standard large pour in pubs, contains more calories than a light lunch, for example. Some beers contain 250 calories per pint.

From Join Together Online

See also;

• Brief-TSF can assist people cease alcohol consumption.
• ‘Drunkorexics’

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Bupropion and nicotine patch as smoking cessation aids in alcoholics

This is a double-blind placebo-controlled study of sustained-release bupropion as a smoking cessation aid in alcoholics undergoing treatment for their alcoholism.

Participants (N=58) were enrolled within 1 week of entry into alcohol treatment from community and Veterans Affairs Substance Use Disorder programs.

All participants received nicotine patch and were invited to attend a smoking cessation lecture and group. Cigarette smoking and alcohol outcomes were measured at 6 months.

Bupropion when added to nicotine patch did not improve smoking outcomes.

One third of participants on bupropion reported discontinuing the drug during weeks 1-4.

Participants reported cigarette outcomes with nicotine patch that are similar to those seen in the general population.

All study participants significantly reduced cigarette use.

Comorbid affective disorder or antipersonality disorder did not affect outcomes.

Alcohol outcomes were improved in those who discontinued cigarettes.

Research; Grant KM, Kelley SS, Smith LM, Agrawal S, Meyer JR, Romberger DJ. Bupropion and nicotine patch as smoking cessation aids in alcoholics Alcohol. 2007 Aug;41(5):381-391.

The Easy Way to Stop Smoking: Join the Millions Who Have Become Nonsmokers Using the Easyway Method by Allen Carr Read more about this title…

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Concise Alcoholics Anonymous and TSF Research Summary

All the elements of TSF have moderate to strong research support, most of which has been replicated.

NB: AA does not participate in research but individual members do. The huge volume of peripheral research supports a strong case for recommending AA participation by alcoholics. Additionally, testimony of the effectiveness of AA are the two million current sober members of Alcoholics Anonymous.

We know: -

• that Twelve Step Facilitation reduces alcohol abuse, improves related consequences, and improves employment prospects.
• that Alcoholics Anonymous has good efficacy, and that Peer Sponsoring/social support is an essential element in AA’s success.
• that recovering people who help recovering people maintain better sobriety and have greater involvement in the general community.
• that men, women, adolescence, African-Americans, Hispanics and gay men benefit from AA. That all socio-demographic groups are represented.
• that AA is also suitable for head trauma victims, and methadone patients.
• that AA has wide acceptance and is readily available in almost all communities. The current global membership of AA is approximately 2.06 million.
• that participation in Alcoholics Anonymous improves medication compliance for mental health patients, improves psychological functioning, Improves coping, reduces child abuse and domestic violence, reduces healthcare usage, reduces hospitalization, reduces medical symptoms, reduces subsequent treatment demand, reduces mortality, and reduces associated costs.
• that healthcare workers have good success rates for substance abuse treatment and recovery from alcoholism that can be improved with AA participation.
• that alcoholics with social networks supportive of drinking have better outcomes if they initiate AA attendance while in treatment.
• that affiliation with AA is enhanced if prospects gain an awareness of the culture and methods used by AA and that sobriety is better than drinking prior to attending AA.
• that 80% of Australian, 87% of USA, and 65% of UK doctors believe that Alcoholics Anonymous is the treatment of choice for alcoholism, but overall they do not understand how AA works.
• that more than 80% of specialist alcohol and drug treatment staff support Alcoholics Anonymous treatment referral and 92% of another specialist A & D service requested training in 12 Step approaches.
• that AA Peer Sponsor contact at the healthcare worker office/institution increases initiation and sustained attendance at AA meetings.
• that active and regular AA participation is one of the more effective ways to effect lifestyle changes for alcoholics.
• that routinely engaging patients in continuing outpatient care is likely to yield better outcomes..
• that most people in the early stages of alcoholism seek help from GP’s or Community Health Centers.
• that individuals with substance abuse medical conditions benefit from integrated medical and substance abuse treatment, and approaches such as TSF can be cost-effective.
• that for every $1.00 invested in intervention with alcoholics $4.30 is saved in future healthcare costs.

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The Symptoms of Alcohol Dependence or Alcoholism

What symptoms of alcoholism does adjunctive Brief-TSF address?

Brief-TSF and the symptoms of alcohol abuse.

Medical, psychosocial and spiritual professional healthcare workers are regularly presented with symptoms of alcohol abuse that are readily assessed or which may be masked by other symptoms; or denied.

The Brief-TSF course explores the signs and symptoms of alcohol abuse and dependence and provides screening and assessment tools along with best practice evidence based application of their use.

Medical symptoms of alcoholism.

The medical symptoms of alcoholism are; Hangovers, blackouts, injuries, lethargy, weight gain or loss, poor coordination, high blood pressure, impotence, vomiting, nausea, cirrhosis of the liver, pancreatic disease, brain damage, peripheral neuropathy and tolerance to alcohol.

Psychological signs of alcohol dependence.

The psychological symptoms of alcohol dependence are; Poor concentration, sleep problems, cloudy thinking, depression, anxiety/stress, aggression, loss of control of drinking, denial of effects of alcohol.

Social aspects of alcohol abuse

The social aspects of alcohol abuse are; Difficulties and arguments with family or friends, difficulties performing at work or home, unemployment, withdrawal from friends and social activities, legal problems, financially insecure.

Spiritual affect of alcohol addiction.

The spiritual affect of alcohol addiction are; Dysthymia or mild chronic depressed, ‘restless, irritable and discontent’ (Alcoholics Anonymous, 1976 p Page xxviii), self-centered, insecure, self-pitying, resentful, fearful and feeling useless.

Healthcare workers such as nurses, doctors, psychologists, social workers, faith based workers (pastors, Rabbis, priests, ministers, other clergy), counselors and trained volunteers will recognize these symptoms and be able to address them after completion of the Brief-TSF training course.

Brief-TSF incorporates screening, assessment, disturbing denial, identifying loss of control of alcohol, taking an alcohol abuse and treatment history, assessing effects of alcohol and drugs, relapse prevention, psychological aspects and an overview of Alcoholics Anonymous (AA).

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Stages of Affiliation with Alcoholics Anonymous

 How do alcoholics get to AA?¹

AA has grown to over 100,000 groups with more than two million members simply on word-of-mouth recommendation. Often the recommendation has come from friends, family, employers, healthcare workers or law courts.

People progress through stages of affiliation with others and with Alcoholics Anonymous in pursuit of solutions to their problems. Two paths are identified; Direct Affiliation and Facilitated Affiliation².

The stages are not necessarily discrete where a person moves in clear progression from one stage to the next. A person is more likely to move up and down, sometimes jumping a stage in regression or progression. However, AA reports that 51% of current members stayed sober from their first meeting.

Facilitation plays a significant part in the process of AA affiliation as approximately 60%³ of AA members seek help from the helping professions prior to attending AA.

These stages of affiliation generally follow Prochaska and DiClemente Stages of Change model and are;

• Pre-contemplation,
• Contemplation,
• Preparation,
• Non-affiliation,
• Affiliation,
• Misaffiliation,
• Affiliation-mandated,
• Supra-affiliation,
• Altruistic affiliation,
• Ambivalent affiliation,
• Disaffiliation,
• Re-affiliation.

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Designed By Professionals for Professionals

Brief-TSF is a professionally written continuing professional education program for healthcare workers.

All disciplines of the helping profession who come in contact with patients may benefit from Brief-TSF training for alcoholism.

The professions included are nurses, doctors, psychiatrists, psychologists, social workers, faith based workers (pastors, priests, ministers, Rabbis, and other clergy) and counselors.

Brief-TSF may also be used by trained and supervised volunteers.

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Avoidance of alcohol-related stimuli in alcohol-dependent inpatients

BACKGROUND: Previous research has shown an attentional bias toward drug-related stimuli in heavy social drinkers.

Attentional orientation to drug-related cues may lead to increased craving and preoccupation with the drug and impaired ability to focus attention on nondrug-related activities, resulting in renewed drug taking or relapse from drug abstinence.

OBJECTIVE: The aim of this study was to investigate whether alcohol-dependent inpatients would differ in their selective attention toward alcohol-related stimuli in comparison with a group of social drinking controls.

METHOD: Thirty-five alcohol-dependent inpatients were compared with a group of 39 social drinking controls matched for age, sex, and verbal IQ.

Attentional bias was assessed using alcohol-related pictures in a dot probe detection task.

Questionnaires were used to examine outcome expectancies after alcohol consumption, anxiety, mood, and craving.

RESULTS: The alcoholic inpatients showed a bias away from the alcohol-related stimuli, scored higher on alcohol outcome expectancies, and on anxiety measures (both state and trait).

They also presented with more negative mood compared with the control group.

Craving was higher in the alcoholic group for the factor “loss of control over drinking.”

CONCLUSIONS: Alcoholic inpatients undergoing treatment based on the 12-step treatment of Alcoholics Anonymous (Minnesota model), which includes counseling, and intensive group, individual, and family psychotherapy, show an avoidance for drug-related stimuli and a perception of loss of control over drinking.

We suggest that their increased perception of loss of control over drinking produces the avoidance from the drug-related stimuli.

Research report; Townshend JM, Duka T. Avoidance of alcohol-related stimuli in alcohol-dependent inpatients. Alcohol Clin Exp Res. 2007 Aug;31(8):1349-57.

The Annotated AA Handbook : A Companion to the Big Book by Frank Dwyer Read more about this title…

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Craving Reduction Medications

What medications are used in the direct treatment of alcoholism?

Anti-craving drugs and Brief-TSF, a good combination.

The process of Brief-TSF supports the use of anti-craving medications to aid in alcoholic relapse prevention. Most prescribing authorities require that alcohol craving medications be accompanied with counseling. Evidence based best practice guidelines recommend the use of craving reduction drugs where appropriate

Alcoholics Anonymous has a clear policy on the use of medications to help restore health. As always AA makes suggestions to its members;

• During their drinking days, many alcoholics made their problems worse by mixing liquor with sedatives, tranquilizers, marijuana, or other drugs. They may cling to the pill or drug habit even after they stop drinking. It will probably also be wise if you encourage the alcoholic to seek medical advice from a physician knowledgeable about the special problems recovering alcoholics experience. Using medications or discontinuing their use without proper professional guidance may be dangerous, and either course may lead a sober alcoholic back to the first drink.

(The pamphlet "The A.A. Member – Medications and Other Drugs" discusses the problem in detail.) (AA, 1976).

’Alcoholics Anonymous and the Use of Medications to Prevent Relapse’.

This study did not find any strong or widespread negative attitudes toward medication for preventing relapse among AA members. Most of those who experienced unfavorable pressure continued taking their health medication (Rychtarik et al, 2000).

Two Craving Reduction Medications

There are two alcohol anti-craving drugs recommended for alcoholism or alcohol dependence. These are; acamprosate tablets (Campralâ„¢) and naltrexone tablets (Reviaâ„¢).

A new formulation – long-acting Injectable naltrexone – is currently under development. May 2007 – Now available in the USA.

Naltrexone Tablets (ReViaâ„¢)

A Cochrane Review of 29 studies from around the world concluded that naltrexone provides real help to people trying to moderate their drinking and "should be accepted as a treatment for alcoholism.”

This study reported that in comparison to placebo, a short-term treatment of naltrexone (ReViaâ„¢) significantly decreased relapse by as much as 36% over and above normal rates, and significantly reduced withdrawal symptoms.

Naltrexone and intensive psychosocial treatment, such as counseling or attending AA meetings, was superior in the medium-term. (Srisurapanont et al, 2005).

Acamprosate (Campralâ„¢) Tablets

Seventeen randomized, placebo-controlled trials of acamprosate (Campralâ„¢) were reviewed covering 4087 alcoholics. Continuous abstinence rates at 6 months were significantly (54%) higher in the acamprosate-treated patients compared to placebo patients. Acamprosate also had a modest but significant beneficial effect on retention in treatment (Mann et al, 2004).

Overall, patients treated with acamprosate (Campralâ„¢) exhibited a significantly greater rate of treatment completion, time to first drink, abstinence rate, and/or cumulative abstinence duration than patients treated with placebo. The drug’s reliable effect on prolonging abstinence, in conjunction with an excellent safety profile, suggests that acamprosate may be useful for a broad range of patients with alcohol dependence (Mason, 2001).

Drinking and craving alcohol must be addressed first

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