Severe Alcohol Problems Research Articles

Participant Selection Biases in a Randomized Clinical Trial of Alcoholism Treatment Settings and Intensities

Eligible participants and decliners in a randomized study of inpatient, intense outpatient, and standard outpatient treatments for alcoholics were compared and contrasted on a series of demographic, social stability, psychological, legal, drug use, problem severity, and treatment history variables. Among 302 individuals meeting eligibility requirements, those agreeing to participate, compared with decliners, were more likely to be unemployed, be residentially less stable, have legal problems, use other drugs, have a more severe alcohol problem, have a recent treatment history, and were less likely to have problems with violence. Participants also were more likely to be male and non-white, although gender and racial effects were not significant when other variables were controlled for. The implications of these findings for generalizing the results of inpatient-outpatient studies are discussed, and the need for routine reporting of decliner characteristics in research reports is stressed.

Quality of life measures in alcohol dependent subjects and changes with abstinence and continued heavy drinking.

This study evaluates the quality of life status of 39 male and 21 female Caucasian subjects admitted to a voluntary sector community alcohol detoxification unit. Baseline data including socio-demographics, severity of alcohol dependence and alcohol problems were collected 4-5 days following admission. In addition, the following measures were obtained: Rotterdam Symptoms Checklist, the Beck Depression Inventory, the General Health Questionnaire 12, Chubon's Life Situation Survey and the Nottingham Health Profile. Subjects were followed up at 12 weeks, and subdivided into two groups: relapsers and non-relapsers. A relapse was defined as drinking 21 or more units per week for men and 14 units or more per week for women over 7 consecutive days (1 unit is the equivalent of 8-10 g of absolute ethanol). Fifty-eight (97%) subjects were successfully followed-up, with 36 (62%) of the group relapsing to heavy drinking within 12 weeks. The results show that alcohol dependence is associated with a poor quality of life. Subjects rated poorly on the standardized questionnaires compared with the normative values for their reference populations. Relapsers and non-relapsers differed significantly in their life situation, depression, physical and psychological symptom total scores and the Nottingham Health Profile sub-score energy at 12 weeks compared with baseline, and these changes were investigated for each group. Within the relapse group a linear regression showed no association between any of the quality of life measures and time to relapse. Individual sub-score analysis of the Nottingham Health Profile results point to the importance of sleep, social isolation, pain, physical mobility and anergia in alcohol dependency. There was little change as a result of either not remitting or returning to heavy drinking and overall these findings confirm that alcohol dependent subjects have a poor quality of life.

Remission of substance use disorder among psychiatric inpatients with mental illness.

The authors assessed the nature and stability of remission of substance use disorder among persons with severe mental illness at index hospitalization and at 1-year follow-up. Consecutively admitted inpatients with severe mental illness completed the Structured Clinical Interview for DSM-III-R, Quality of Life Interview, and Addiction Severity Index at admission and 1 year later. Of the 268 patients, 70 were classified as past substance abusers in remission at baseline. Baseline characteristics and 1-year outcomes of this group were compared with those of the 109 current substance abusers and the 89 patients who were not substance abusers. The past abusers were significantly more likely to be women, and they consistently differed significantly from the current abusers in variables involving frequency of drug and alcohol use at baseline. During the follow-up period, the patients with current abuse at baseline were significantly more likely to have recurrences of substance use disorders and to use substance abuse services, and they had significantly more months of alcohol use and alcohol use to excess during follow-up than did the past abusers. Baseline and follow-up assessments suggested that a substantial proportion of severely mentally ill patients with past substance use disorders are in stable remission.

Expressed emotion and relapse in alcoholic patients.

Although family members' expressed emotion (EE) predicts patients' elevated relapse rates in schizophrenia and mood disorders, little is known about the relationship between EE and relapse in alcoholism. For 86 alcoholic patients (78 men, 8 women), the association between the spouse's EE and the alcoholic patient's subsequent relapse status in the 12 months after the couple began an outpatient behavioral marital therapy (BMT) program for alcoholism was examined. Alcoholic patients with high EE spouses, when compared with their counterparts with low EE spouses, were more likely to relapse, had a shorter time to relapse, and drank on a greater percentage of days in the 12 months after starting BMT. EE continued to be associated with relapse after patients' age, education, and alcohol problem severity were taken into account. Greater use of Antabuse and more sessions of BMT were associated with reduced relapse for alcoholic patients with high EE spouses.

The relationship of pre-treatment Alcoholics Anonymous affiliation with problem severity, social resources and treatment history

Little research has examined the relationship of substance abuse patients' prior Alcoholics Anonymous (AA) affiliation to important treatment-related variables. This study of 927 individuals seeking treatment in public, health maintenance organization (HMO) and private-for-profit medical programs, found that 82.8% of patients presented at treatment with a history of AA affiliation. Degree of prior AA affiliation was significantly associated with more extensive prior utilization of formal and informal helping resources, current seeking of treatment in the public sector, having low income, being divorced/separated and having more severe alcohol, employment/support and psychiatric problems. Implications for service delivery and future research are discussed.

Alcohol and secure hospital patients: I. An examination of the nature and prevalence of alcohol problems in secure hospital patients

The extent and severity of alcohol problems experienced by mentally disordered patients admitted to maximum security hospitals, whilst not included in the criteria for admission, is undoubtedly of relevance and importance in planning the treatment and future disposal of these patients. The study to be described attempts to address such concerns by means of applying an extensive assessment approach with a substantial patient population drawn from three of the four Secure Hospitals within the United Kingdom (n=211). Measures utilised included semi-structured interview, standardised questionnaires and clinical reports contained in case records. Detailed information is provided on weekly consumption levels, problems related to drinking, severity of dependence on alcohol, and use of alcohol at the time of offences. Results highlighted not only the high prevalence, but the extreme severity of alcohol difficulties evident amongst the patient sample, as well as substantial use of alcohol at the time of offences. Future papers will explore further the characteristics of patients with a history of problem drinking and the possible relationship between alcohol and offending. This study represents the first major, detailed and comprehensive assessment of alcohol problems in an extensive sample of secure hospital patients. The implications of these findings for the development of therapeutic services and the future disposal of these patients is emphasised.

Recognizing and responding to alcohol abuse in the armed forces ‐ a case study

The theme of the work is the personal experience in the Royal Navy of an individual with severe alcohol problems. Based on material supplied to the authors, the piece is essentially a case of “Peter”, a former naval rating. Describes his pre‐Navy alcoholic career, his later heavy drinking aboard ship and on shore, and his eventual departure from the Navy. Shows how, in a culture of heavy drinking ‐ some of it hallowed by tradition ‐ the alcoholic can go unnoticed and unstopped; indeed, cultural pressures may even be exerted on him or her to increase consumption of alcohol. It notes that “Peter’s” drinking was apparently only ever tackled at a disciplinary level, never at a therapeutic/counselling one. Controversially, “Peter” contends that his former employer was (and remains) effectively indifferent to alcohol abuse among its workforce. Looks at some of the reasons for a heavy drinking culture, at how it impacts on vulnerable individuals and why it might be difficult to change at an organizational level.

Planned duration of residential drug abuse treatment: efficacy versus effectiveness

Two randomized controlled trials of residential drug abuse treatment programs found the programs to be equally effective, based on outcomes among those assigned to the treatments. This study aimed to compare the relative efficacy of the programs, based on outcomes among those who received the specific treatment program as planned. Secondary analyses of data from two concurrent randomized controlled trials, with stratification by actual length of stay. Two residential drug abuse treatment facilities in the United States. Six hundred and twenty-eight clients were enrolled over a 2-year period, representing 85% of all clients admitted, 91% of all eligible clients, and 95% of those asked to participate. At one facility, clients were randomized to 3-month or 6-month versions of a traditional therapeutic community program. At the second facility, clients were randomized to 3-month or 6-month versions of a modified therapeutic community program that emphasized relapse prevention and health education. Time from admission to first drug use (except alcohol); and Addiction Severity Index (ASI) composite scores for severity of drug, alcohol, legal, and employment problems. Five hundred and thirty-nine clients (86%) completed a follow-up interview at least 16.5 months after admission. In the relapse prevention trial, benefits of the 6-month program were generally limited to those who stayed at least 40 days. In the therapeutic community trial, among those who stayed at least 171 days, the 12-month program had a beneficial effect on employment. Otherwise, there were inconsistent differences between the 6- and 12-month programs. On average, clients who stayed in treatment at least 80 days benefited from continuing in treatment for up to 6 months, but not beyond. Conversely, those admitted to programs of longer planned duration who dropped out of treatment early had worse outcomes than those who dropped out of shorter programs. Thus, although longer planned duration of treatment may be efficacious, it is not effective.

The Self-Rating of the Effects of Alcohol (SRE) form as a retrospective measure of the risk for alcoholism

Aims. A low level of response (LR) to alcohol is a characteristic of sons of alcoholics and predicts an elevated future alcoholism risk. A 12-question Self-Rating of the Effects (SRE) of alcohol form has been shown to correlate cross-sectionally with a designation of a low LR determined by alcohol challenges. Design. his study evaluates the potential usefulness of the SRE as a retrospective measure of both the response to alcohol and of subsequent alcoholism in two samples. Setting. All subjects were studied in the United States, most in California. Participants. First, 94 sons of alcoholics and controls completed the SRE 15 years after an alcohol challenge, and SRE values were compared to their prior LR results and their alcoholic outcomes. Secondly, the relationship between SRE results and alcoholic status was determined in 551 men and women alcoholics, their relatives, and controls. Measurements. Subjects were evaluated with face-to-face interviews. Findings. Despite the interval of 15 years, the correlation between the SRE and the subjective high feelings on the alcohol challenge was between -0.3 and -0.4. For those 94 subjects the full SRE correlated with a diagnosis of alcohol dependence at 0.5, a figure that remained at 0.3 even when only the estimates related to the earliest drinking experiences were considered. For the 551 men and women, the correlation between the SRE and alcohol dependence diagnoses was 0.6, including 0.3 for the estimates of the first five times of drinking. All major findings in both samples remained robust when the recent drinking history or the number of items endorsed was considered, or when the most severe alcohol problem, passing out, was deleted from the analysis. Conclusions. When alcohol challenges are not possible, these retrospective reports indicate that the SRE is a potentially useful surrogate for determining a subgroup of people who might carry a low level of response to alcohol and a subsequent elevated risk for alcoholism.

The Self‐Rating of the Effects of Alcohol (SRE) form as a retrospective measure of the risk for alcoholism

A low level of response (LR) to alcohol is a characteristic of sons of alcoholics and predicts an elevated future alcoholism risk. A 12-question Self-Rating of the Effects (SRE) of alcohol form has been shown to correlate cross-sectionally with a designation of a low LR determined by alcohol challenges. This study evaluates the potential usefulness of the SRE as a retrospective measure of both the response to alcohol and of subsequent alcoholism in two samples. All subjects were studied in the United States, most in California. First, 94 sons of alcoholics and controls completed the SRE 15 years after an alcohol challenge, and SRE values were compared to their prior LR results and their alcoholic outcomes. Secondly, the relationship between SRE results and alcoholic status was determined in 551 men and women alcoholics, their relatives, and controls. Subjects were evaluated with face-to-face interviews. Despite the interval of 15 years, the correlation between the SRE and the subjective high feelings on the alcohol challenge was between -0.3 and -0.4. For those 94 subjects the full SRE correlated with a diagnosis of alcohol dependence at 0.5, a figure that remained at 0.3 even when only the estimates related to the earliest drinking experiences were considered. For the 551 men and women, the correlation between the SRE and alcohol dependence diagnoses was 0.6, including 0.3 for the estimates of the first five times of drinking. All major findings in both samples remained robust when the recent drinking history or the number of items endorsed was considered, or when the most severe alcohol problem, passing out, was deleted from the analysis. When alcohol challenges are not possible, these retrospective reports indicate that the SRE is a potentially useful surrogate for determining a subgroup of people who might carry a low level of response to alcohol and a subsequent elevated risk for alcoholism.

The Emergence of an Alcohol Policy Reform Agenda in the United States: A Don Cahalan Legacy

During the last two decades our society has experienced a fundamental shift in its understanding of and response to alcohol problems. These developments occurred on several fronts: the formation of the anti-drunk driving movement; the government’s increased attention to prevention policy; the creation of various national coalitions of health, safety and consumer groups seeking governmental regulations of alcohol industry marketing practices; and increased attention among alcohol researchers to social, economic, and political factors that contribute to the incidence and severity of alcohol problems. Today, an intense political drama is occurring at all levels of governmentlocal, state and federalregarding alcohol policy. The alcohol industry and its allies are using their enormous financial resources and political clout to forestall the increasing pressure from citizen action groups, governmental agencies, and scholars for meaningful changes in the role of alcohol in our society. This essay examines the theoretical, philosophical and political underpinnings of these shifts in societal understanding of alcohol, alcohol problems, and alcohol policy. It first analyzes the shifts that occurred in alcohol research in the late 1960s and early 1970s,

Drinking goal selection in behavioral self-management treatment of chronic alcoholics

The relationship between individuals' choice of abstinence or moderate drinking during outpatient behavioral management treatment and outcome over 12 months' posttreatment was examined. At the initial assessment, 46% of 106 chronic alcoholic subjects chose abstinence, 44% chose moderate drinking, and 9% were unsure. Over the course of treatment, subjects were more likely to move from moderation to abstinence goals, and after the first 4 weeks of treatment, two-thirds chose abstinence. These subjects were older, had more severe alcohol problems (i.e., higher MAST scores), and were more likely to maintain their weekly alcohol consumption goals during the 16-week treatment period. Moreover, these subjects reported less alcohol use in the 12 month follow-up period, and a greater proportion were judged as having successful outcomes. The implications of these findings are discussed.

Clients Entering Drug Abuse Day Treatment: 18-Month Outcomes

Clients who entered and remained in day treatment for at least 2 weeks (N = 66) were interviewed using the Addiction Severity Index and other measures, and were reinterviewed at 6, 12, and 18 months after baseline. Follow-up rates for each time point ranged from 58% to 68%, and 30 clients (45%) were interviewed at every time point. Those who were consistently followed (N = 30) did not differ from those who were not consistently followed (N = 36) on demographics or on outcome variables measured at baseline. Comparison of mean outcome scores across time using MANOVA indicated significant changes from baseline to 6 months in the areas of alcohol, drug, legal, and social problem severity, and these changes were maintained up to 18 months postadmission. Outcomes reflecting psychiatric symptoms and employment also changed over time, but exhibited different patterns of change. Results are confounded by treatment received, since many respondents also participated in residential treatment during follow-up. Day treatment can serve clients having a range of substance abuse problems, and can act as a bridge to traditional residential treatment. Randomized clinical trials, where clients receive only one or the other type of treatment, are needed to assess the effectiveness of day treatment alone.

Predictors of HIV-related risk behaviors among heterosexuals in alcoholism treatment.

To determine which measures of alcohol and drug use are associated with HIV-related sexual risk and protective behaviors. Entrants (N = 743, 72% male) to alcoholism treatment clinics underwent a structured interview including an assessment of demographics, substance abuse characteristics and sexual behaviors. Associations were examined between alcohol- and drug-related behaviors, and demographic variables, with the prevalence of high-risk sexual behaviors. Those more likely to use alcohol or drugs when having sex, and those who expect to have high-risk sex when they drink alcohol, were more likely to engage in high-risk sexual behavior. Measures of severity of alcohol or drug problems alone were not consistently related to high-risk or protective behaviors. Several other concurrently used measures (such as the Addition Severity Index and alcohol expectancies) showed more consistent association with high-risk behaviors. There was no apparent reduction in the likelihood of practicing risk-reducing behaviors among those more severely addicted and those who combined alcohol and/or drugs with sex. This study suggests that sexual risk and protective behaviors are not consistently associated with severity of addiction problems. Some measures of alcohol and drug use (i.e., the ASI Drug Composite Score and the Enhanced Risk subscale of the alcohol expectancy measure) were more consistently related to the specific risk behaviors measured than were others (e.g., the ASI Alcohol Composite Score), while most measures showed little or no association with protective behaviors.

Assessing alcohol problems in female DWI offenders.

The severity of alcohol problems in a sample of 812 women driving while intoxicated (DWI) offenders enrolled in a Drinking Driver Program in New York State was assessed through the use of multiple measures. These women voluntarily provided information through a self-administered questionnaire completed at the beginning of the program. Classification of alcohol problems based on DSM-III-R criteria was compared with classification based on the use of alcohol-specific and nonalcohol-specific measures of alcohol-related problems. Greater hostility and a larger number of drinks ever consumed accounted for nearly 12% of the variance between no diagnosis and alcohol abuse women, whereas these two variables plus age, race, depression, and having a relative with alcohol problems accounted for nearly 41% of the variance between alcohol abuse and dependent women. A subsample of women within each DSM-III-R diagnostic group showed high risk for later, more severe alcohol problems. Multiple measures of alcohol problems help to elucidate subtle differences in alcohol problems within each of the broad categories specified by the DSM, and should facilitate more appropriate intervention and treatment plans for women DWI offenders with alcohol-related problems.

Personality disorders and treatment outcome in methadone maintenance patients.

This study examined the relationship between personality disorder (PDs) and 7-month treatment outcome in 197 men admitted to methadone maintenance. Subjects reported pervasive improvement, and the amount of improvement did not significantly differ for those subjects with and without PDs. PD subjects entered treatment with more severe self-reported drug, alcohol, psychiatric, and legal problems, and despite progress, remained more problematic in those areas relative to subjects without PDs. Subjects with antisocial PD had admission and 7-month problem status similar to subjects with other PDs. The 7-month urinalysis results for opiates and cocaine showed no significant differences between subjects with and without PDs. Fewer PD subjects stayed in treatment continuously for the 7-month period. Several cluster B PDs-borderline, antisocial, and histrionic-predicted poorest overall outcomes. Methadone-maintained patients with PDs may warrant additional treatment services if they are to approach the functional level of patients without PDs.

Older adult controlled drinkers and abstainers.

Little is known about the lifetime course of alcohol problems, especially during late adulthood. Many individuals with a history of alcohol problems achieve remission of their symptoms through abstinence or controlled drinking. This study examined 135 older adults with a prior history of alcohol diagnoses who were symptom free for at least the past year. Two groups were identified based on their alcohol consumption within the past year: abstinent individuals (n = 92) and controlled drinkers (n = 43). The groups did not differ in age, racial composition, education, income, or years since their last alcohol-related symptom, but they did differ in gender composition, indices of alcoholism severity, history of formal and informal treatment, as well as lifetime alcohol consumption patterns. Abstinent individuals had more severe alcohol problems, consumed higher amounts of alcohol on drinking days, had more years of heavy alcohol consumption, and were more likely to have attended alcohol treatment and Alcoholics Anonymous (AA). The controlled drinkers had a longer history of moderate social drinking, and their current consumption habits appeared to be similar to symptom-free older adult drinkers. The results suggest that gender, alcoholism severity, history of formal and informal treatment, and past consumption patterns are associated with whether older adults with histories of alcoholism attain successful outcomes through abstinence or controlled drinking.

Other evidence for at least two alcoholisms II: Life course variation in antisociality and heterogeneity of alcoholic outcome

AbstractWithin the framework of a cumulation/nesting theory for the emergence of adult psychopathology, a typing structure for alcoholism based upon variations in life course continuity of antisocial behavior over childhood and adulthood was examined for its ability to differentiate symptomatic and life history variations among alcoholic and nonalcoholic men accessed by way of a population-based recruitment strategy. Results supported the theory and identified two alcoholic types, one high on lifetime antisociality (antisocial alcoholic = AAL), the other low (nonantisocial alcoholic = NAAL), and a third nonalcoholic type with low lifetime antisociality. Types differed in age of onset, severity, number, and life course of alcohol problems, measures of social adaptation, amount and severity of other psychopathology, and salience of family history load of alcoholism. Antisociality and alcoholism tended to be nested characteristics.

Women and alcohol: Current Australian research

Over the past decade research on women and alcohol has been gaining momentum with evidence of an accumulating data base and a growing section of the drug and alcohol literature specifically addressing this area of interest. Despite the gains made in gender sensitive research on substance use, a review of the literature reveals that many of the articulated concerns are similar to those identified over the preceding 20 years.This paper reports on the findings of an Australian wide survey investigating the current level of research on women and alcohol. The survey was used in conjunction with a critical analysis of the literature to identify gaps in research activity in the area of women and alcohol. Identified research gaps result, in part, from the disproportionate focus on women with severe alcohol problems within treatment facilities. There is a lack of qualitative and quantitative research on women's drinking, whether it be usual use or problematic use, within the general population as a way of bridging the gap between population surveys and clinical studies. In addition, there is a need for longitudinal research to provide information on the context of women's drinking over a several year period, giving insight into the many factors which could be influencing women's drinking behaviour. Finally, the relative lack of commitment to prevention as a research agenda for women needs to be addressed.

Trends in the treatment of alcohol problems in the US general population, 1979 through 1990.

The purpose of this study was to conduct a comprehensive analysis of alcohol-treatment service utilization trends in the general population during the 1980s. Three national surveys of the US household population (1979, 1984, and 1990) were used for trend analysis of treatment utilization. Trends in demographic characteristics of persons with lifetime treatment rates and particular types of treatment were examined by means of logistic regression analysis, controlling for alcohol problem severity and other variables. Substantial increases in the numbers reporting treatment were found. In all surveys, Alcoholics Anonymous was the treatment used most frequently and its use increased most, especially for women. Men were more likely than women (odds ratio [OR] = 2.01, 95% confidence interval [CI] = 1.20, 5.39) and unmarried persons were twice as likely as married persons to have been treated [corrected]. Social consequences carried more predictive power than dependence symptoms. From a general population perspective, while overall treatment capacity has increased, the structural changes in the public/private balance of services have not positively affected the representation of women or other characteristics of the treatment population.