Outpatient Alcohol Research Articles

Validation of the Christo Inventory for Substance-misuse Services (CISS): a simple outcome evaluation tool

The Christo Inventory for Substance-misuse Services (CISS) was developed as a single page outcome evaluation tool completed by drug/alcohol service workers either from direct client interviews or from personal experience of their client supplemented by existing assessment notes. Its 0–20 unidimensional scale consists of 10 items reflecting clients’ problems with social functioning, general health, sexual/injecting risk behaviour, psychological functioning, occupation, criminal involvement, drug/alcohol use, ongoing support, compliance, and working relationships. Comparison scores indicating low, average or high problem severity were produced by 243 drug users attending a harm minimisation out patient service and 102 alcohol users at an outpatient alcohol service. Means and cut-off scores for abstinence oriented treatments were derived from a 6-month follow-up of 90 treated drug users. Sub sets of the harm minimisation sample were used to derive item alpha, test-retest and inter-rater reliability coefficients of 0.74, 0.82 and 0.82, respectively. The inter-rater coefficient increased to 0.91 when retests were conducted the same day. Among the abstinence oriented treatment sample the CISS produced correlations ranging from 0.43 to 0.99 with the Opiate Treatment Index and measures of trait anxiety, unpleasant life events, poor quality of life and low self-esteem. The simplicity, flexibility and brevity of the CISS make it a useful tool allowing comparison of clients within and between many different service settings.

THE IMPACT OF BRIEF MOTIVATIONAL INTERVENTION AT THE START OF AN OUTPATIENT DAY PROGRAMME FOR ALCOHOL DEPENDENCE

Motivational intervention, a strategy to increase motivation for change, was tested as an addition to treatment at the start of an outpatient programme for alcohol dependence. Admissions to the programme were randomly allocated to either a motivational or educational procedure. The three motivational constructs of the SOCRATES-8A Readiness to Change questionnaire (Ambivalence about change, Recognition of problems, Taking Steps to change) were used as measures of motivation for change. At one week post-intervention, motivational participants reported significantly greater levels of problem recognition. The motivational group's post-intervention scores were significantly higher on the Taking Steps scale and significantly lower on the Ambivalence scale. There was no difference on measures of engagement in treatment or drop-out from the outpatient treatment programme. For the population as a whole, a relatively low pre-intervention score on the Ambivalence scale was predictive of drop-out. Results support the efficacy of motivational intervention for decreasing self-reported levels of ambivalence about change and for increasing problem recognition and taking steps towards change. More detailed research with a longer follow-up period is needed to determine whether this has any impact on other vectors of motivation for change, including participation in treatment, outcome expectancy and drinking behaviour.

Ambulatory detoxification of alcoholic patients--evaluation of a model project

We present the concept and first catamnestic results of a model project "outpatient alcohol detoxification" which was initiated in 1998. To date 48 patients (18 female, 29 male, mean age 44.5 years, mean duration of alcohol dependence 10.2 years) entered treatment, 43 (92%) patients could be successfully detoxified. In only 21 (44%) patients a medication was necessary. To avoid drugs with abuse potential, doxepine (34%) and clonidine (19%) were predominantly used. No severe medical complications were observed. A follow-up examination after 6 months showed that 26 (55%) patients were abstinent and still in outpatient treatment. Further implications of this project are discussed.

Alcohol treatment, changes in coping skills, self-efficacy, and levels of alcohol use and related problems 1 year following treatment initiation.

The relationships among alcohol treatment, coping skills, and self-efficacy in predicting alcohol use and related consequences following treatment initiation were investigated. The participants were 77 men and 65 women who were entering either inpatient or outpatient alcohol treatment. The analyses confirmed predictions that treatment, coping skills, and self-efficacy each contributed significantly to the prediction of 12-month alcohol consumption beyond the variance accounted for by participant control variables. Only self-efficacy explained significant additional variance in the consequences outcome. Mediation analyses of the alcohol consumption variables suggested that treatment effects were not mediated by either coping skills or self-efficacy and that the effects of coping skills were not mediated by self-efficacy. The findings are interpreted as providing partial support for social learning theory approaches. Suggestions for future research are discussed.

Factor replicability and validity of the Temperament and Character Inventory in substance-dependent patients.

The factor structure and validity of the Temperament and Character Inventory (TCI; Cloninger, Svrakic, Przybeck, & Wetzel, 1994) were evaluated in 357 inpatient and outpatient alcohol, cocaine, and opioid dependent individuals. A Procrustes rotation of principal components did not fully replicate the TCI's original factor structure in either this clinical sample or in a community sample of 183 individuals who did not abuse substances. These analyses suggested 4 reliable factors that were associated with conceptually related personality dimensions in predictable ways. Higher Novelty Seeking (or low constraint) and Harm Avoidance (or low vigor) were associated with several substance use and psychopathology indicators. Self-Transcendence and a factor we labeled Sociability (Reward Dependence and Cooperativeness) were related to fewer indicators.

General and alcohol-specific social support following treatment

Both general and alcohol-specific support have been shown, albeit inconsistently, to affect drinking behavior. The discrepant findings may be clarified by examining how they work together. In exploratory analysis of clients following private outpatient alcoholism treatment, we found that the two variables add uniquely to the explanation of the variance in proportion of days abstinent (PDA). Both contribute significantly in the short term (3 months posttreatment), but only alcohol-specific support helps to explain variance over the longer term (15 months posttreatment), and alcohol-specific support explains more of the variance in PDA than general support at both time periods. More complex relationships are operating when short-term treatment effects have diminished. Alcohol-specific support mediates the relationship between general support and PDA, and both general social support and alcohol-specific support are moderators of one another in their relationships to PDA. Knowing how different types of social support affect drinking behavior at different intervals following treatment may help treatment providers to better prepare their clients for the posttreatment social environment.

The relationship of cognitive functioning to amount of recent and lifetime alcohol consumption in outpatient alcoholics

Previous investigations of the relationship between drinking patterns and cognitive functioning have generally studied severely alcoholic patients, in whom the neurocognitive effects of alcohol consumption can be obscured by other medical or psychosocial factors. In the present study, cognitive functioning was examined after a minimum of 4 days of abstinence in 69 mildly to moderately alcohol-dependent outpatients without comorbid psychiatric, neurologic, or systemic medical illness. Circumscribed decrements in reaction time and verbal memory were associated with higher amounts of alcohol consumption in the 90 days prior to enrollment in the study, and amount of recent consumption was correlated with scores on numerous cognitive tests. In contrast, longer drinking history was not associated with poorer performance on any neuropsychological measures. Thus, in this group of high-functioning, mildly to moderately alcohol-dependent outpatients, mild cognitive deficits were related to the amount of recent, but not lifetime, alcohol consumption. Published by Elsevier Science Ltd

Alcohol abusers who want to quit smoking: Implications for clinical treatment

Although most alcohol abusers are dependent on nicotine, studies of such individuals have been scarce. Consequently, little information is available for advising clients who wish to consider resolving both problems. Clients entering an outpatient alcohol treatment program who were also current smokers were asked about their temporal preferences for changing their alcohol and cigarette use. Over three-quarters of alcohol abusers who were also smokers when asked said they would be willing to consider stopping smoking during or after treatment for an alcohol problem. Individuals who were interested in quitting smoking cigarettes while in treatment for an alcohol problem were different from those who did not want to stop smoking, and such differences may influence their ability to successfully address both problems together. Compared to those who preferred to change their drinking first then address their smoking, those who said they would be willing to address both problems (i.e. smoking and drinking) together in treatment were not only considerably more likely to think that quitting smoking would affect quitting drinking, but also more likely to be planning to quit smoking in the next six months. These results suggest that some individuals whose alcohol problems are not severe and who also smoke cigarettes will be more receptive to a dual recovery approach than others. In the absence of research findings, health care practitioners who encounter individuals who drink heavily and smoke cigarettes should at a minimum explore the option of dual cessation with their clients. The clinical and research implications of the present results are discussed.

Factor replicability and validity of the Temperament and Character Inventory in substance-dependent patients.

The factor structure and validity of the Temperament and Character Inventory (TCI; Cloninger, Svrakic, Przybeck, & Wetzel, 1994) were evaluated in 357 inpatient and outpatient alcohol, cocaine, and opioid dependent individuals. A Procrustes rotation of principal components did not fully replicate the TCI's original factor structure in either this clinical sample or in a community sample of 183 individuals who did not abuse substances. These analyses suggested 4 reliable factors that were associated with conceptually related personality dimensions in predictable ways. Higher Novelty Seeking (or low constraint) and Harm Avoidance (or low vigor) were associated with several substance use and psychopathology indicators. Self-Transcendence and a factor we labeled Sociability (Reward Dependence and Cooperativeness) were related to fewer indicators.

The Effect of Drinking Intensity and Frequency on Serum Carbohydrate‐Deficient Transferrin and γ‐ Glutamyl Transferase Levels in Outpatient Alcoholics

Whereas heavy alcohol consumption is known to elevate serum carbohydrate-deficient transferrin (CDT) and gamma-glutamyl transferase (GGT) levels, the contribution of drinking pattern to these effects is not completely understood. We present data on 423 men and 146 women evaluated 1 year after treatment in a large-scale alcoholism treatment study (Project MATCH). Relationships between drinking frequency (number of days drinking), intensity (drinks per drinking day), and blood levels of CDT and GGT were analyzed by using response surface regression models and thin-plate spline-smoothing techniques. Both models indicated differences between CDT- and GGT-drinking pattern relationships in men and, also, a difference between men and women in CDT drinking-pattern relationships. For men, CDT levels appeared to respond primarily to frequency of drinking, whereas GGT was influenced primarily by drinking intensity. For women, both CDT and GGT were influenced more by drinks per drinking day (intensity) than by number of days drinking (frequency). The data confirm both the independent nature of these biological markers of alcohol consumption and gender differences in alcohol-induced CDT response reported previously.

Female alcoholic outpatients and female college students: a correlational study of self-reported alcohol consumption and carbohydrate-deficient transferrin levels.

We sought to test the efficacy of two biochemical markers of alcohol consumption, gamma glutamyl transpeptidase and carbohydrate deficient transferrin, as indicators of heavy alcohol consumption in a female population. Using a sample of female outpatient alcoholics (n = 36) and a comparison group of female college students (n = 50), alcohol intake was monitored by self-report at approximately 90-day intervals over a period of 12 months. Gamma glutamyl transpeptidase (GGTP) and carbohydrate-deficient transferrin (CDT) values were determined for each sampling period. The criterion for heavy alcohol consumption was set at 140 g/alcohol/week for a 90-day period. Receiver operating characteristic (ROC) curves were plotted, area under the curve (Az) computed, and sensitivity and specificity calculated for both CDT and GGTP. ROC curves provide a graphical illustration of the association between the specificity and sensitivity of any diagnostic test over all possible cutpoint values. A significant, positive correlation between the amount of alcohol consumed and GGTP activity was recorded for the outpatient alcoholic group. Among the college students, there was a significant, positive correlation between CDT levels and alcohol consumed for the second reporting period. The sensitivity of the individual biochemical markers was low but, when used in combination, sensitivity was 66% and specificity, 80%. When a more stringent criterion for heavy alcohol consumption was applied (420 g/alcohol/week), the sensitivity of CDT actually decreased. CDT, used alone, is a poor indicator of heavy alcohol consumption in female subjects. When GGTP measures are used in conjunction with CDT, detection of heavy alcohol consumption may be enhanced to useful levels.

Injured Intoxicated Drivers: Citation, Conviction, Referral, and Recidivism Rates

Study objectives: Several studies have suggested that legally intoxicated drivers who are injured when involved in a motor vehicle crash are unlikely to be cited or prosecuted for driving under the influence (DUI). The purpose of this study was to determine (1) the rates of citation and prosecution of legally intoxicated drivers who are injured in a motor vehicle crash and hospitalized in a Level I trauma center, (2) the rates of previous and subsequent alcohol-related citation in this population, and (3) the rate of referral for treatment of alcohol-related problems made during the hospital stay. Methods: In a retrospective review of trauma registry and Cleveland Municipal Court records from January 1993 through April 1995, we examined the records of all drivers injured in a motor vehicle crash who were transported to a Level I urban trauma center, admitted to the trauma service, and determined to have a blood alcohol content (BAC) of .10 gm% or higher at the time of admission to the emergency department. Results: Seventy drivers admitted after a motor vehicle crash had a BAC of .10 gm% or higher. This represented 33% of the drivers older than 16 years of age who were admitted to the trauma service. Twenty-three drivers (32.8%) were cited for DUI, and 15 (21%) of the 70 were successfully prosecuted and convicted. Four of 23 cited drivers had previous citations; another 5 incurred subsequent citations during the study period. Eight of the 70 drivers who were admitted with a high BAC were referred for outpatient alcohol counseling after discharge. None were offered counseling as inpatients. Conclusion: Citation and prosecution rates of legally intoxicated drivers injured in motor vehicle crashes and hospitalized in our trauma center were low. Recognition of alcoholism and inpatient counseling were rare. Multiple alcohol-related citations were common among drivers cited for DUI. [Cydulka RK, Harmody MR, Barnoski A, Fallon W, Emerman CL: Injured intoxicated drivers: Citation, conviction, referral, and recidivism rates. Ann Emerg Med September 1998;32:349-352.]

Relationships Between Experiences of Parental Violence During Childhood and Women's Psychiatric Symptomatology

Data were collected from 472 women between the ages of 18 and 45 drawn from five sources: outpatient alcoholism treatment, DWI education programs, a shelter for battered women, outpatient mental health treatment, and randomly from the community. To control for alcohol problems and help-seeking behavior, respondents were classified into three groups: women with alcohol problems and in treatment, women without alcohol problems and in treatment, and women in the random sample. Controlling for respondents' (a) help-seeking behavior, alcohol problems, race, childhood socioeconomic status, and parental alcohol problems, (b) experiences of father-to-daughter verbal aggression and violence, and (c) level of severity of father-to-daughter abuse were found to predict adulthood psychiatric symptomatology. However, experiences of mother-to-daughter verbal aggression and violence, as well as level of severity of mother-to-daughter abuse were found unrelated to adulthood psychiatric symptomatology in the multivariate analyses. Explanations for the greater effect of father verbal abuse and violence are discussed.

The origins and evolution of the disease concept of treatment.

The disease concept of treatment (DCT) has been the dominant treatment model for alcoholism in the United States for the last 30 years. This article sheds light on this treatment model by tracing its historical origins and its evolution in institutions. Accounts from the published literature on Alcoholics Anonymous (AA) and early alcoholism treatment programs were culled for insights regarding the development of DCT. Early examples of AA facilities, state mental hospital alcoholism units, detoxification units, and outpatient alcoholism clinics are described as they evolved. The important role of AA in this process is detailed. Accounts are given of the interaction between professionals and alcoholism counselors during the period in which DCT was developed in these institutions. It was found that all of the current types of alcoholism treatment programs had their origins in early, informal AA facilities except for outpatient alcoholism clinics. DCT evolved concurrently in AA facilities, state mental hospitals and detoxification units. The historical accounts summarized here suggest that DCT was primarily a structured and didactic presentation of AA principles that incorporated some additional treatment elements, notably, the confrontation group. Thus, it can be argued that most alcoholism treatment today (i.e., DCT) derives from the original AA model. It is suggested that studies be undertaken to distinguish the degree to which AA recovery principles are different from DCT methods by researching the clinical beliefs and practices of alcoholism counselors and comparing them with those of AA members.

Sexual adjustment of male alcoholics: changes from before to after receiving alcoholism counseling with and without marital therapy

Married male alcoholics ( N = 36), who had recently begun individual outpatient alcoholism counseling, were randomly assigned to a no-marital-treatment control group or to 10 weekly sessions of either a behavioral marital therapy (BMT) or an interactional couples therapy group. Impotence decreased from before to after counseling irrespective of whether the alcoholic patients received additional marital therapy. Husbands who received BMT reported increased frequency of wives’ orgasm during intercourse and greater increases in satisfaction with the privacy and context of their sexual activities than did couples in the other two treatment groups. These findings support a biopsychosocial formulation of alcoholics’ sexual problems that implicates the physical effects of acute and chronic alcohol intake as most relevant to the elevated rates of impotence and marital conflict as a major contributing factor to most sexual problems of alcoholics. The improvement observed in sexual adjustment was rather limited. Despite the improvements in impotence, the alcoholics still experienced over twice the rate of impotence reported by demographically similar nonalcoholics. In terms of sexual satisfaction, BMT produced only modest gains as viewed by husbands and no gains from the wives’ perspective. Perhaps sexual adjustment is one of the last areas of the alcoholic’s marriage to improve after treatment. The limited time frame of the present study may have precluded observing further improvements in sexual adjustment that would emerge later after a longer period of recovery.

Relationships Between Experiences of Parental Violence During Childhood and Women's Self-Esteem

The interrelationships between experience of parental verbal aggression and physical violence during childhood and the development of low self-esteem during adulthood were explored separately for the father-daughter and mother-daughter relationships. Data were collected from 472 women between the ages of 18 and 45 during in-depth interviews drawn from five sources: outpatient alcoholism treatment, DWI (Driving While Intoxicated) education programs, shelter for battered women, outpatient mental health treatment, and randomly from the community. Control variables included respondents' alcohol problems and help-seeking behavior, parental alcohol problems, number of changes in childhood family (e.g., divorce), and respondents' race and social class. Controlling for these variables, experiences of father-to-daughter verbal aggression, moderate violence, and severe violence were found related to lower self-esteem in adulthood for women. Conversely, controlling for these variables, experiences of mother-to-daughter verbal aggression, moderate violence, and severe violence were not found related to lower self-esteem in adulthood for women.

Personality disorder and dimension differences between type A and type B substance abusers.

Substance abuse subtype differences in DSM-IV personality disorders and normal personality dimensions were evaluated in 370 inpatient and outpatient alcohol, cocaine, and opiate abusers. The Type A/Type B distinction was replicated, with Type B substance abusers exhibiting more premorbid risk factors, more severe substance abuse, and greater psychosocial impairment. As predicted, compared to Type A, Type B were more commonly diagnosed with, and had more severe symptoms of, all personality disorders except Schizoid. With regard to normal personality dimensions, Type B scored higher on neuroticism, novelty seeking, and harm avoidance; Type A scored higher on agreeableness, conscientiousness, cooperativeness, and self-directedness. These subtype differences remained after controlling for the effects of antisocial personality and psychiatric symptoms.

Evaluation of the readiness to change questionnaire with problem drinkers in treatment.

Prochaska and DiClemente's (1982, 1983) readiness to change model proposes that people resolve health-related concerns by working through a qualitative progression of distinct motivational stages. The present study examined the responses of 66 (44 males, 22 females) mildly dependent outpatient alcohol abusers to the Readiness to Change Questionnaire, a scale developed to classify individuals according to their motivational stage. It has been suggested that the RTCQ may have applicability to problem drinkers in treatment. Reliability analyses conducted on the questionnaire's three subscales resulted in alpha coefficients of .30 for the Precontemplation subscale, .52 for the Contemplation subscale, and .76 for the Action subscale. The low internal reliability for the first two subscales does not support the use of this questionnaire in a treatment context at this time. Further studies are needed to refine the subscales. A psychometrically sound measure, once developed, would provide guidance in treatment matching.

The Transition Group

SUMMARY This article describes a transition group developed for inner city residents receiving inpatient alcoholism rehabilitation in a hospital-based alcoholism facility. The goal of the group was to facilitate clients' transition from inpatient to outpatient alcoholism treatment. First, the paper will suggest reasons why clients do not continue in care, and it will review prior efforts to help people connect with continuing outpatient treatment. Then, the theoretical framework that guided the group's design will be described. Next, it will outline the intervention's components. Finally, it will discuss the group's effectiveness and implications for clinical practice with adults who experience alcohol problems.

Acamprosate treatment in a long‐term community‐based alcohol rehabilitation programme

To evaluate the efficacy of acamprosate in maintaining abstinence in weaned alcohol-dependent patients. A multicentre, double-blind, randomized control trial. Patients were individually randomly allocated to active or placebo conditions. Abstinence was assessed during a 6-month treatment period and after a 6-month follow-up period. A community-based, outpatient alcohol rehabilitation programme. Two hundred and forty-six alcohol-dependent patients between the ages of 18 and 65 years were recruited immediately following acute, inpatient withdrawal treatment. The primary outcome measure was self-reported abstinence from alcohol since the previous sessions at 3, 6, 9 and 12 months following the start of treatment, with treatment taking place for a period of 6 months. A significantly higher proportion of patients in the acamprosate group were abstinent after 3 months and 6 months of treatment. The percentage of patients with continuous abstinence at the end of the treatment period was almost double for the acamprosate group than for the placebo group (40.7% vs. 20.8%, respectively). Acamprosate significantly increased the retention of patients in the treatment programme. Six months after drug treatment ceased, the criterion of abstinence since the previous visit was reached by significantly more patients from the acamprosate group (43.4%) than from the placebo group (29.8%), but this difference was not statistically significant at the 3-month point after cessation of study medication. Acamprosate may be a useful pharmacological compound for the long-term treatment of alcohol-dependence when applied in a community-based rehabilitation programme.