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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Research Sources: McLellan, T.A. 2002; Miller,W.R. 2002; National Institute on Drug Abuse. 1999; Project MATCH Research Group. 1997.

Active participation in a support group can contribute to long-term recovery.

Project MATCH and other studies in the 1990s definitively proved that AA can be an active ingredient of treatment both during a professional intervention and afterward, depending on the patient’s type of therapy.

Patients who joined the AA fellowship or who had an AA sponsor after receiving twelve step facilitation therapy had better abstinence records than those who received an intervention but did not continue their AA participation upon completion.

Other research indicates AA participation may be less effective for patients who receive cognitive behavior therapy because the programs have different goals that may confuse patients.

What researchers still don’t understand, however, are the precise mechanisms of AA participation.

While AA affiliation is associated with self-efficacy, motivation and coping efforts, all significant predictors of good outcome following a professional intervention, some studies have shown that patients who adopt more of the fellowship’s basic tenets – such as acknowledging that alcoholism is a disease, admission of their powerlessness over alcohol and working the twelve steps of the program – relapse at the same rates as patients who adopt very few.

This suggests that the active ingredient may be less about AA per se than continuing participation in support groups that promote a lifestyle inconsistent with the problematic use of alcohol and other drugs.

From; www.ensuringsolutions.org

Brief-TSF is designed to support active participation in Alcoholics Anonymous.

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Estimated Alcoholics Anonymous Membership 1991-1992

• New members during past year – 0.9 million
• On-going members – 1.5 million
• Total membership – 2.4 million

Continuation Rate in Alcoholics Anonymous

In 1991-1992 4.8 million respondents reported ever attending an Alcoholics Anonymous (AA) meeting, for reasons related to their drinking, prior to the last 12 months and 31% reported continued AA attendance during the last 12 months.

Rate of continued AA attendance was associated with years since first AA meeting

• 1-4 years since first AA meeting – 36% remained
• 5-9 years since first AA meeting – 30% remained
• 10-19 years since first AA meeting – 29% remained
• 20 years or more since first AA meeting – 32% remained

Comparison of Past Year Drinking Status – Dropouts and Continuing AA Members

Dropouts:

• Abstinent 33%
• Low risk drinking 14%
• High risk drinking 53%

Continued AA attendance:

• Abstinent 62%
• Low risk drinking 9%
• High risk drinking 29%

1. low risk drinking = never exceed 4 drinks per day(male) or 3 drinks per day (female)
2. high risk drinking = exceeds 4 drinks per day (male) or 3 drinks per day (female)

Research Source: NIAAA 1991-1992 National Longitudinal Alcohol Epidemiologic Survey (NLAES). Data Brief – National Longitudinal Alcohol Epidemiologic Survey (NLAES) Findings on Alcoholics Anonymous Membership by Loran Archer.

Thus, 36% remain attending A.A. at the end of one year and 32% are still attending at the end of 20 years.

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Four patterns of AA attendance emerged:

• low (mainly during the year following treatment entry);
• medium (about 60 meetings per year with a slight increase by year 5);
• high (over 200 meetings per year with a slight decrease by year 5); and
• declining (almost 200 meetings the year following treatment entry and about 6 meetings in year 5).

Abstinence (past 30 days) in year 5 significantly differed across groups:

• 79 percent of patients with high attendance reported abstinence, followed by
• 73 percent with medium attendance,
• 61 percent with declining attendance, and
• 43 percent with low attendance.

Patients with medium or high attendance had the largest social networks of people who supported patient abstinence or decreased alcohol use.

Patients across the groups had similar numbers of dependence symptoms and social consequences of drinking.

Patients who attend AA after treatment can be characterized as those who never connect, those who connect briefly, and those who maintain stable (and sometimes quite high) attendance. Even those who connect for a short while appear to benefit years later, though higher attendance was associated with a greater likelihood of long-term abstinence. Providers should reinforce AA attendance as part of a comprehensive effort to improve long-term abstinence.

Research Reference: Kaskutas LA, Ammon L, Delucchi K, et al. Alcoholics Anonymous careers: patterns of AA involvement five years after treatment entry. Alcohol Clin Exp Res. 2005:29(11);1983–1990.

Reprinted with permission from Alcohol and Health: Current Evidence.

From Jointogether

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Abstinence Resolves Most Brain Cognitive Problems Caused by Drinking

A study of alcoholics who have abstained from drinking for between six months and 13 years concludes that sobriety can counteract most of the brain and thinking damage caused by heavy drinking, News Today reported Aug. 29.

Researchers looked at a wide range of problem areas for alcoholics, including abstraction/cognitive flexibility, attention, auditory working memory, immediate memory, delayed memory, psychomotor function, reaction time, spatial processing, and verbal skills.

They found that all but spatial processing recovered with sustained sobriety, noting that even alcoholics in long-term recovery may have lingering problems with tasks like map-reading or assembling things.

“Alcoholics may have periods of abstinence, during which time they give their nervous system time for repair,” according to researcher Edith Sullivan of the Stanford University School of Medicine. “Thus, longitudinal studies of alcoholics are critical for identifying functional areas that are targeted by alcoholism, those that are relatively spared, and those that can recover with sobriety.”

The research was published in the September 2006 issue of Alcoholism: Clinical & Experimental Research.  

Reference: Fein, G. et al. (September 2006). Cognitive Performance in Long-Term Abstinent Alcoholic Individuals. Alcoholism: Clinical & Experimental Research, 30,: 1538. 

From; Join Together Online

Alcoholics Anonymous has the most consistent and well known global recovery record.

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The recovery process in Alcoholics Anonymous includes several general phases that people may pass through. These are not time related but are usually dependent on the persons particular circumstances.

Initial Sobriety

• Surrenders to alcohol – accepts alcoholism
• Begins humble search for self
• Restoration of physical health begins
• Restoration of memory begins
• Restoration of mental functions begins
• Begins to practice self-honesty
• Is pre-occupied with sobriety
• Growth of open-mindedness
• Lessening of needless guilt
• Freely discusses alcohol and its problems
• Mild depression and anxiety lessens
• Mental functions are more alert

Learning Sobriety

• Accepts and owns their alcoholism
• Loss of freedom acknowledged and accepted
• Alibis replaced by sound reasons for sobriety
• Social pressures to quit, lessen – threats replaced by encouragement
• Grandiose behaviour begins to be replaced by the give and take of real personal relations
• Aggressive behaviour begins to be replaced by willingness to learn
• Persistent remorse disappears, peace initiated
• Abstinence graduates into sobriety
• Pattern of thinking begins to change
• Regains friends
• Job prospects improve
• Sobriety-centred behaviour improves
• Regains outside interests
• Acceptance of friends
• Sense of humour starts to replace self-pity
• Acceptance of environment improves
• Begins to regain family faith
• Resentment of others begins to be replaced by acceptance of others
• Loyalty and protection of family interests begins
• Sex relations improve
• Greater understanding of life partner
• Learns to enjoy a good breakfast

Accepting Sobriety

• Surrenders to life – accepts life on its terms
• Loss of desire to drink becomes profane and lasting
• Improved ethical and moral perception
• Improved thinking
• Improved feeling
• Keeps company with people one can respect of help
• Emotional ‘dips’ become fewer and shallower
• Emotions become easier to manage

Creative sobriety

• Loss of desire to drink becomes deeper and almost permanent
• Fears, anxieties and depressions are understood and managed in interpersonal relations
• Appreciates deeply freedom from alcohol
• Explores new freedom to use it in other activities without fear
• Single-minded sobriety; defines assurances that there is no compromise with sobriety
• Genuine spiritual desires centred on new way of life
• Alibi system replaced by deepening quality of intelligent sobriety
• Appreciates need for help, both for sobriety and as a guard against drinking in daily life

Pleasurable Sobriety

• Self-unity, at peace with oneself, knows serenity
• Socialises easily, at one with the world
• Little or no emotional hang-overs
• Rewards clearly exceed tough times
• Feels well, enjoys sobriety
• Anxiety, shyness, etc., disappear in genuine interpersonal relations

Adapted from Stewart DA. Thirst For Freedom. Hazeldene; Minnesota

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METHODS: In association with a national study of drug use among US dental students, a questionnaire was translated from English into Dutch and administered to dental students at two dental schools in The Netherlands. Students received an anonymous 115-item questionnaire in the fall of 1996.

RESULTS: Alcohol was the students’ drug of choice for

• lifetime (95%),
• past year (94%) and
• past month (88%) use.

No significant correlations were found between alcohol use and gender, schools, and years in dental education.

In the past month,

• 58% of students reported drinking on 5 or more days;
• 53% had 5 or more drinks on the same occasion,
• 20% had 5 or more drinks on the same occasion on 5 or more days; and
• 17% reported getting drunk at least monthly.

Prevalence rates for past month use of tobacco was 24% and marijuana, 4%.

Male students smoked twice as much as females, with significant differences found for all three periods of use (X2>19.00, P<0.01).

When asked whether their schools offered policies and education programs on alcohol and other drugs, 52% of students reported that these were not available.

CONCLUSIONS: Dental schools should develop effective programmes to educate students about responsible use of alcohol and other licit and illicit drugs. Schools should also inform students about their susceptibilities to substance abuse and dependency.

Community Dent Oral Epidemiol. 2001 Feb;29(1):48-54. Substance use among Dutch dental students. Plasschaert AJ, Hoogstraten J, van Emmerik BJ, Webster DB, Clayton RR.

See also;

• Brief-TSF can assist people cease alcohol consumption.
• Twelve-Step Programs as an Adjunct to Psychotherapy and Psychopharmacology
• Subscribe to Twelve Step Facilitation by e-Mail

Counseling for Relapse Prevention by Terence T. Gorski, Merlene Miller Read more about this title…

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“A recovering alcoholic can help alcoholics who are still suffering from the disease, because the patients relate to them,” said Dr. Richard D. Blondell, an addiction-medicine specialist at the University of Louisville School of Medicine in Kentucky. “The patients credit the visitor as the main thing that motivated them.”

The study included 140 patients who were hospitalized for alcohol-related incidents. One group received standard medical care, a second group received medical care plus a 15-minute intervention by a trained addiction specialist, and the third group received medical care, intervention, and an in-depth talk with a recovering alcoholic.

Researchers found that 59 percent of those who met with recovering alcoholics abstained from drinking for six months after the incident, compared to 44 percent of those who received addiction counseling alone, and one-third of those who only received medical care.

In addition, half the patients who met with recovering alcoholics had entered some form of treatment, compared with only 15 percent of those who received medical treatment and counseling by an addiction specialist.

The study is published in the May issue of the Journal of Family Practice.

From; Jointogether

Brief-TSF is based on these principles.

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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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An AA sponsor is a close 1-on-1 collaboration between an older sober member and a relative newcomer to sobriety. Its a two way helping relationship – the sponsor affirms their own sobriety and the sponsee gains new insights.

AIMS: The aim of this study was to explore the roles of Alcoholics Anonymous (AA) sponsors and to describe the characteristics of a sample of sponsors.

METHODS: Twenty-eight AA sponsors, recruited using a purposive sampling method, were administered an unstructured qualitative interview and standardized questionnaires. The measurements included: a content analysis of sponsors’ responses; Severity of Alcohol Dependence Questionnaire-Community version (SADQ-C) and Alcoholics Anonymous Affiliation Scale (AAAS).

RESULTS: Sample characteristics were as follows:

• the median length of AA attendance was 9.5 years (range 5-28);
• the median length of sobriety was 11 years (range 4.5-28);
• the median number of sponsees per sponsor was 1 but there was a wide range (0-17, interquartile range 3.75); and
• the sponsors were highly affiliated to AA (median AAAS score 8.75, range 5.5-8.75, maximum possible score 9).

Past alcohol dependence scores were surprisingly low:

• 5 (18%) sponsors had mild,
• 14 (50%) moderate and
• 9 (32%) severe dependence according to the SADQ-C (median 26.5, range 11-56).

Sponsorship roles were as follows: 16 roles were identified through the initial content analysis. These were distilled into three super-ordinate roles through a thematic analysis:

1. encouraging sponsees to work the programme of AA (doing the 12 steps and engaging in AA activity);
2. support (regular contact, emotional support and practical support); and
3. carrying the message of AA (sharing sponsor’s personal experience of recovery with sponsees).

CONCLUSIONS: The roles identified broadly corresponded with the AA literature delineating the duties of a sponsor. This non-random sample of sponsors was highly engaged in AA activity but only had a past history of moderate alcohol dependence.

Research; The role of AA sponsors: a pilot study. Whelan PJ, Marshall EJ, Ball DM, Humphreys K. Alcohol Alcohol. 2009 Jul-Aug;44(4):416-22. Epub 2009 Mar 18.

• See also;
• 12 Step Sponsor

The Twelve-Step Facilitation Handbook: A Systematic Approach to Early Recovery from Alcoholism and Addiction by Joseph Nowinski

The Twelve Steps Of Alcoholics Anonymous: Interpreted By The Hazelden Foundation by Hazelden Foundation

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