Loosening the Grip: a handbook of Alcohol Information 9th

Chapter 9: Evaluation and Treatment Overview

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Chapter 9: Evaluation and Treatment Overview

Allen JP, Litten RZ, Fertig JB, Babor T. A review of research on the Alcohol Use Disorders Identification Test (AUDIT). Alcoholism: Clinical and Experimental Research 21(4): 613–619, 1997. (31 refs)

Research on the core version of the Alcohol Use Disorders Identification Test (AUDIT) is reviewed. Sensitivities and specificities of the AUDIT for criteria of current hazardous use and, to a slightly lesser extent, lifetime alcohol dependence are high. In general, AUDIT scores are at least moderately related to other self-report alcohol screening tests. Several studies also show them as correlated with biochemical measures of drinking. Results of the AUDIT have also been associated with more distal indicators of problematic drinking. Indices of internal consistency, including Cronbach's alpha and item-total correlations, are generally in the 0.80's. Future directions for research on the AUDIT are suggested. Copyright 1997, Research Society on Alcoholism

Allen JP, Wilson VB, eds. Assessing Alcohol Problems. A Guide for Clinicians and Researchers, 2nd ed. Bethesda, MD: NIAAA, 2003. (chapter refs)

This resource intended for clinicians and researchers is an update of an earlier (1996) volume.There are nine chapters which include a review of the assessment provess along with a quick reference to the available instruments; screening through self-report and use of biomarkers of heavy drinking; the diagnostic process and criteria for diagnosis; assessemnt in terms of consumption, assessment of adults, and assessment among adolescents with attention to both alcohol and other drug use, and as a means of informing treatment planning; and concludes with a discussion of treatment outcome. (Copyright 2003, Project Cork)

Cunningham JA, Humphreys K, Koski-Jannes A. Providing personalized assessment feedback for problem drinking on the Internet: A pilot project. Journal of Studies on Alcohol 61(6): 794–798, 2000. (25 refs.)

Objective: This project developed an Internet program that conducts a brief assessment of an individual's drinking habits and then provides normative feedback comparing the user's drinking to that of others of the same gender and age group. The Internet program, "Try Our Free Drinking Evaluation," was based at the Addiction Research Foundation Internet web site (now at http://notes.camh.net/efeed.nsf/newform). Method: A voluntary survey linked to the participant's feedback summary collected respondents' impressions of the program. Results: During the trial period, the site received approximately 500 hits per month. While the feedback was generally well received, the weekly summary format was less credible to those individuals who drink less than once per week or whose consumption varies a great deal over time. Conclusions: Given these pilot results indicating that there is an audience for Internet-based interventions, the next step is to evaluate whether receiving such personalized feedback materials on the Internet lends to any change in drinking behavior by participants. Copyright 2000, Alcohol Research Documentation, Inc.

Ewing JA. Detecting alcoholism, the CAGE questionnaire. Journal of the American Medical Association 252(14): 1905–1907, 1984.

Four clinical interview questions, the CAGE questions, have proved useful in helping to make a diagnosis of alcoholism. The questions focus on Cutting down, Annoyance by criticism, Guilty feeling, and Eye-openers. The acronym "CAGE" helps the physician to recall the questions. How these questions were identified and their use in clinical and research studies are described.

Rosenberg SD, Drake RE, Wolford GL, Mueser KT, Oxman TE, Vidaver RM, et al. Dartmouth Assessment of Lifestyle Instrument (DALI): A substance use disorder screen for people with severe mental illness. American Journal of Psychiatry 155(2): 232–238, 1998. (48 refs.)

Objective: Despite high rates of co-occurring substance use disorder In people with severe mental illness, substance use disorder is often undetected in acute-care psychiatric settings. Because under detection is related to the failure of traditional screening instruments with this population, the authors developed a new screen for detection of substance use disorder in people with severe mental Illness. Method: On the basis of criterion ("gold standard") diagnoses of substance use disorder for 247 patients admitted to a state hospital, the authors used logistic regression to select the best items from 10 current screening instruments and constructed a new instrument. They then tested the validity of the new instrument, compared with other screens, on an independent group of 73 admitted patients. Results: The new screening instrument, the Dartmouth Assessment of lifestyle Instrument (DALI), is brief, is easy to use, and exhibits high classification accuracy for both alcohol and drug (cannabis and cocaine) we disorders. Receiver operating characteristic curves showed that the DALI functioned significantly better than traditional instruments for both alcohol and drug use disorders. Conclusions: Initial findings suggest the DALI may be useful for detecting substance use disorder in acutely ill psychiatric patients. Further research is needed to validate the DALI in other settings and with other groups of psychiatric patients. Copyright 1998, American Psychiatric Association

Schorling JB, Buchsbaum DG. Screening for alcohol and drug abuse (review). Medical Clinics of North America 81(4): 845–865, 1997. (97 refs.)

This article reviews the current status of screening for substance use disorders in health care settings. First, the epidemiology of alcohol and other drug abuse is briefly reviewed, followed by a discussion of the principles underlying whether or not screening is warranted. Different screening instruments and strategies are then described. Finally, current recommendations for screening for alcohol and other drug abuse are discussed. Copyright 1997, W B Saunders

Selzer M. The Michigan Alcoholism Screening Test: The quest for a new diagnostic instrument. American Journal of Psychiatry 127(12): 1653–1658, 1971.

Sillanaukee P, Massot N, Jousilahti P, Vartiainen E, Sundvall J, Olsson U, et al. Dose response of laboratory markers to alcohol consumption in a general population. American Journal of Epidemiology 152(8): 747–751, 2000. (23 refs)
The dose response to alcohol use of carbohydrate-deficient transferrin (CDT), gamma-glutamyltransferase (GGT), and their combination (gamma-CDT) was studied in an age- and gender-stratified, random sample from Finland in 1997. A linear association with a threshold between alcohol consumption and the three markers was observed. Body mass index was negatively associated with CDT and positively with GGT. Age was positively associated with GGT and gamma- CDT. In conclusion, CDT appears to be an early phase marker of alcohol consumption. The combined marker, gamma-CDT was less associated with factors such as body mass index but more strongly correlated with alcohol consumption than were the two markers separately.

Skinner HA: The Drug Abuse Screening Test. Addictive Behaviors 7(4): 363–371, 1982.

The Drug Abuse Screening Test (DAST) was designed to provide a brief instrument for clinical screening and treatment evaluation research. The 28 self-report items tap various consequences that are combined in a total DAST score to yield a quantitative index of problems related to drug misuse. Measurement properties of the DAST were evaluated using a clinical sample of 256 drug/alcohol abuse clients. The internal consistency reliability estimate was substantial at .92, and a factor analysis of item intercorrelations suggested an unidimensional scale. With respect to response style biases, the DAST was only moderately correlated with social desirability and denial. Concurrent validity was examined by correlating the DAST with background variables, frequency of drug use during the past 12 months, and indices of psychopathology. Although these findings support the usefulness of the DAST for quantifying the extent of drug involvement within a help-seeking population, further validation work is needed in other populations and settings.

Chapter 10:  Treatment Techniques and Approaches

A.A. World Services. Alcoholics Anonymous 2004 Membership Survey. New York: A.A. World Services, 2005

Available online.< www.alcoholics-anonymous.org/en_media_resources.cfm?PageID=75>

Aguilar TE, Munson WW: Leisure education and counseling as intervention components in drug and alcohol treatment for adolescents, Journal of Alcohol and Drug Education 37(3): 23–34, 1992. (52 refs)

The purpose of this paper is to illustrate the association between substance abuse and leisure experiences and to present a rationale for leisure interventions designed to remediate this social and behavioral problem. Leisure education and counseling is suggested for inclusion in broad-based prevention or intervention strategies for substance abuse. Recommendations are provided for strengthening leisure education and counseling programs by including suggestions for theory, content, format and duration. Copyright 1992, Alcohol and Drug Problems Association of North America.

Bouza C; Angeles M; Ana M; Maria AJ. Efficacy and safety of naltrexone and acamprosate in the treatment of alcohol dependence: A systematic review. Addiction 99(7): 811-828, 2004. (75 refs.)

Aims: To ascertain the efficacy and safety of naltrexone and acamprosate in the treatment of alcohol dependence. Methods: Systematic review of the literature (1990-2002) and meta-analysis of full published randomized and controlled clinical trials assessing acamprosate or naltrexone therapy in alcohol dependence. Estimates of effect were calculated according to the fixed-effects model. Measurements: Relapse and abstinence rates, cumulative abstinence duration and treatment compliance were considered as primary outcomes. Findings: Thirty-three studies met the inclusion criteria. Acamprosate was associated with a significant improvement in abstinence rate [odds ratio (OR): 1.88 (1.57, 2.25), P < 0.001] and days of cumulative abstinence [WMD: 26.55 (17.56, 36.54]. Short-term administration of naltrexone reduced the relapse rate significantly [OR: 0.62 (0.52, 0.75), P < 0.001], but was not associated with a significant modification in the abstinence rate [OR: 1.26 (0.97,1.64), P = 0.08]. There were insufficient data to ascertain naltrexone's efficacy over more prolonged periods. Acamprosate had a good safety pattern and was associated with a significant improvement in treatment compliance [OR: 1.29 (1.13,1.47), P < 0.001]. Naltrexone's side effects were more numerous, yet the drug was nevertheless tolerated acceptably without being associated with a lower adherence to treatment (OR: 0.94 (0.80, 1.1), P = 0.5). However, overall compliance was relatively low with both medications. Conclusions: Both acamprosate and naltrexone are effective as adjuvant therapies for alcohol dependence in adults. Acamprosate appears to be especially useful in a therapeutic approach targeted at achieving abstinence, whereas naltrexone seems more indicated in programmes geared to controlled consumption. Both drugs are safe and acceptably tolerated but issues of compliance need to be addressed adequately to assure their usefulness in clinical practice. (Copyright 2004, Society for the Study of Addiction to Alcohol and Other Drugs)

Brewer C; Meyers RJ; Johnsen J. Does disulfiram help to prevent relapse in alcohol abuse? CNS Drugs 14(5): 329-341, 2000. (62 refs.)

When taken in an adequate dose, disulfiram usually deters the drinking of alcohol by the threat or experience of an unpleasant reaction. However, unless its consumption is carefully supervised by a third party as part of the formal or implied therapeutic contract, it is usually discontinued and the deterrent effect is therefore lost. In most studies, disulfiram administration has not been supervised and most reviews fail to stress the crucial importance of supervision. Unsupervised disulfiram has little or no specific effect. We have therefore reviewed all published clinical studies in which there was evidence that attempts had been made to ensure that disulfiram administration was directly supervised at least once a week. We found 13 controlled and 5 uncontrolled studies. All but one study reported positive findings, which were usually both statistically and clinically significant in controlled evaluations. In the sole exception, involving 'skid-row alcoholics', it seems that adequate supervision was not achieved. In general, the better the supervision, the better the outcome. Provided that attention is paid to the details of supervision and that supervisors are given appropriate training, supervised disulfiram is a simple and effective addition to psychosocial treatment programmes. Compared with unsupervised disulfiram or no disulfiram control groups, it reduces drinking, prolongs remissions, improves treatment retention and facilitates compliance with psychosocial interventions such as community reinforcement, marital and network therapies. The supervisor may be a health professional, workmate, probation officer or hostel worker but is usually a family member. Treatment should probably continue for a minimum of 12 months. Supervised disulfiram appears to be more effective than supervised naltrexone and may be more effective than unsupervised acamprosate. The crucial importance of supervising the consumption of disulfiram has been overlooked or minimised by many reviewers. Copyright 2000, Adis International Ltd.

Bryant-Jefferies R. Counselling the Person Beyond the Alcohol Problem. Abingdon UK: Radcliffe Medical Press, 2006. (8 refs.)

This volume in a series that uses primarily clinical diaglogue to explicate the therapeutic process, is based on Carl Roger's person-centered approach. The focus of this book is to demonstrate how this technique can support those who are engaged in the recovery process, those who are working to create and sustain a non-alcohol focused life. It demonstrates the use of the clinician-client relationship to provide enpowerment. In the process it also depicts the health problems which are attributable to alcohol use and the impact of alcohol dependency on family life, the differences that are related to age, the steps involved in enabling people to use available support systems, and how to prevent relapse, as well as coping with it. There are case illustrations. (Copyright 2006, Project Cork)

Cook CCH. Addiction and spirituality. Addiction 99(6) 539-551, 2004. (31 refs.)

Background: Spirituality is a topic of increasing interest to clinicians and researchers interested in addiction. Aims:  To clarify the way(s) in which the concept of spirituality is understood and employed in practice by clinicians and researchers who publish papers on addiction and spirituality, and to develop a definition or description of spirituality which might receive widespread assent within the field. Design:  A descriptive study of 265 published books and papers on spirituality and addiction. Findings:  The study revealed a diversity and lack of clarity of understanding of the concept of spirituality. However, it was possible to identify 13 conceptual components of spirituality which recurred within the literature. Among these conceptual components of spirituality, 'relatedness' and 'transcendence' were encountered most frequently. 'Meaning/purpose', 'wholeness (non-)religiousness' and 'consciousness' were encountered less frequently in the papers on addiction and spirituality than in an unsystematically ascertained sample of papers concerned with spirituality in relation to other areas of psychology and medicine. However, biases in the literature are notable. For example, the great majority of publications are from North America and the field is dominated by interest in Twelve-Step and Christian spirituality. Conclusion:  Spirituality, as understood within the addiction field, is currently poorly defined. Thirteen conceptual components of spirituality which are employed in this field are identified provisionally and a working definition is proposed as a basis for future research. (Copyright 2004, Society for the Study of Addiction to Alcohol and Other Drugs)

Copello AG; Velleman RD; Templeton LJ. Family interventions in the treatment of alcohol and drug problems (review). Drug and Alcohol Review 24(4): 369-385, 2005 (166 refs.)

Alcohol and drug problems affect not only those using these substances but also family members of the substance user. In this review evidence of the negative impacts substance misuse may have upon families are examined, following which family-focused interventions are reviewed. Several family-focused interventions have been developed. They can be broadly grouped into three types: (1) working with family members to promote the entry and engagement of substance misusers into treatment; (2) joint involvement of family members and substance misusing relatives in the treatment of the latter; and (3) interventions responding to the needs of the family members in their own right. The evidence base for each of the three types is reviewed. Despite methodological weaknesses in this area, a number of conclusions can be advanced that support wider use of family focused interventions in routine practice. Future research needs to focus on (1) pragmatic trials that are more representative of routine clinical settings; (2) cost-effectiveness analyses, in terms of treatment costs and the impact of interventions on costs to society; (3) explore treatment process; and (4) make use of qualitative methods. In addition, there is a need to define more clearly the conceptual underpinnings of the family intervention under study. (Copyright 2005, Australian Medical and Professional Society on Alcohol and Other Drugs)

Cunningham JA; Humphreys K; Koski-Jannes A. Providing personalized assessment feedback for problem drinking on the Internet: A pilot project. Journal of Studies on Alcohol 61(6): 794-798, 2000. (25 refs.)

Objective: This project developed an Internet program that conducts a brief assessment of an individual's drinking habits and then provides normative feedback comparing the user's drinking to that of others of the same gender and age group. The Internet program, "Try Our Free Drinking Evaluation," was based at the Addiction Research Foundation Internet web site (now at http://notes.camh.net/efeed.nsf/newform). Method: A voluntary survey linked to the participant's feedback summary collected respondents' impressions of the program. Results: During the trial period, the site received approximately 500 hits per month. While the feedback was generally well received, the weekly summary format was less credible to those individuals who drink less than once per week or whose consumption varies a great deal over time. Conclusions: Given these pilot results indicating that there is an audience for Internet-based interventions, the next step is to evaluate whether receiving such personalized feedback materials on the Internet lends to any change in drinking behavior by participants. Copyright 2000, Alcohol Research Documentation, Inc.

Fals-Stewart W; Birchler GR. A national survey of the use of couples therapy in substance abuse treatment. Journal of Substance Abuse Treatment 20(4): 277-283, 2001. (22 refs.)

Although results from multiple studies conducted over the last two decades indicate that Behavioral Couples Therapy (BCT) is an effective treatment for married or cohabiting alcohol- and drug- abusing patients, both in terms of reduced substance use and improved relationship satisfaction, it is unclear whether BCT or other types of couples-based interventions are used in community-based substance abuse treatment programs. In the present study, program administrators (e.g., executive directors, clinical directors, staff physicians) from 398 randomly selected community-based outpatient substance abuse treatment programs in the U.S. were interviewed regarding use of different family- and couples-based therapies in their programs. According to the program administrators, 27% of the programs provided some type of couples-based treatment. However, less than 5% of the agencies used behaviorally oriented couples therapy and none used BCT specifically. Recommendations for researchers and clinicians to increase the use of BCT in community-based treatment programs are provided. Copyright 2001, Pergamon Press

Fernandez AC, Begley EA, Marlatt GA. Family and peer interventions for adults: Past approaches and future directions. Psychology of Addictive Behaviors 20(2): 207-213, 2006. (51 refs.)

Through the use of published literature and empirical research, the authors explore the differing conceptual frameworks, techniques, and effectiveness of various family interventions for change-resistant, substance-abusing adults. The 2 dominant programs in place to help families and friends deal with the addiction of an adult loved one are the Johnson Intervention and Al-Anon. Research on these 2 programs is presented, followed by an outline of promising alternative approaches. These include A Relational Intervention Sequence for Engagement, Community Reinforcement Training, Community Reinforcement and Family Training, Unilateral Family Therapy, and Pressures to Change. The effectiveness and appropriateness of these approaches in different situations are discussed. In addition. areas in need of further study are pointed out. (Copyright 2006, American Psychological Association)

Flores PJ, Georgi JM. Substance Abuse Treatment: Group Therapy. Treatment Improvement Protocol (TIP) Series 41. Rockville MD: Center for Substance Abuse Treatment, 2005. (218 refs.)

Group therapy has long been considered a key ingredient of substance abuse treatment. This volume provides a consensus- evidenced based discussion of group work. Chapter 1 provides an overview of the role of groups in substance abuse treatment. Chapter 2 provides a discussion of the type of groups that are most commonly used: psychoeducational groups, to educate clients about substance abuse; kills development groups, to cultivate the skills needed to attain and sustain abstinence; cognitive-behavioral groups, to alter thoughts and actions that lead to and evoke continued substance use; support groups, that buoy members and provide a forum to share information about maintaining abstinence and managing issues of daily living; and Interpersonal process groups, which delve into psychosocial developmental issues that contribute to addiction and can interfere with recovery. Chapter 3 discusses criteria for the placement of clients in groups. Chapter 4 considers discusses group development and processes, and phase-specific tasks. Chapter 5 considers the states of treatment. Chapter 6 addresses group leadership and leadership skills, and Chapter 7 deals with the need for training and supervision of group therapists and different approaches to these. There are a series of 8 appendices, which among other things set forth clinical guidelines, a sample group agreement, and discussion of cultural competency and diversity issues. (Public Domain) Available online.

Frances RJ; Miller SI; Mack AH, eds. Clinical Textbook of Addictive Disorders, 3rd edition. New York: Guilford Press, 2005. (684 pp.)

This is the third edition of a major reference work in the field of addiction medicine, which was created by the founders of the American Academy of Addiction Psychiatry (AAAP) It is organized into five major sections, with a total of 28 chapters and 51 contributors. This volume provides historical background, diagnostic process and assessment, diagnostic tools, substance specific discussions of the major drug classes, covers the full range of treatment approaches and how these can be adapted to the needs and characteristics of special populations. It also discusses other "behavioral" addictions such as gambling disorders. Section I deals with the foundations of addiction medicine, the neurobiology of substance dependence and the historical and social context of psychoactive substance use disorders. Section II is directed to assessment, both psychological evaluation in adolescents and adults, and laboratory testing. Section III deals with major drug classes: alcohol, nicotine, opiates, marijuana, hallucinogens, and club drugs, cocaine and stimulants, and sedative/hypnotics and benzodiazepines. Section IV considers special populations and special issues: comorbidity, polysubstance abuse; women; the elderly; the workplace; HIV/AIDS; pain; pathological gambling and other "behavioral" disorders. The final section is directed to treatment: individual psychodynamic psychotherapy; cognitive therapy, group therapy; self-help; family-therapy; adolescent treatment; and treatment matching. (Copyright 2005, Project Cork)

Galanter M; Brook D. Network therapy for addiction: Bringing family and peer support into office practice. International Journal of Group Psychotherapy 51(1): 101-122, 2001. (67 refs.)

Network therapy was developed as a specialized type of combined individual and group therapy to ensure greater success in the office- based treatment of addicted patients by using both psychodynamic and cognitive-behavioral approaches to individual therapy while engaging the patient in a group support network composed of family members and peers. This article outlines the role of group cohesiveness as a vehicle for engaging patients in this treatment; the patient's family and peers are used as a therapeutic net-work joining the patient and therapist at intervals in therapy sessions. This network is managed by the therapist to provide cohesiveness and support, to undermine denial, and to promote compliance with treatment. The author presents applications of the network technique designed to sustain abstinence and describes means of stabilizing the patient's involvement. Some specific techniques discussed include ambulatory detoxification, disulfiram and naltrexone administration, relapse prevention, and contingency contracting Also discussed are recent research on the use of psychiatric residents and counselors for treatment, and use of the Internet in dissemination. Copyright 2001, American Group Psychotherapy Association, Inc.

Gossop M; Harris J; Best D; Man LH; Manning V; Marshall J; Strang. Is attendance at Alcoholics Anonymous meetings after inpatient treatment related to improved outcomes? A 6-month follow-up study. Alcohol and Alcoholism 38(3): 421-426, 2003. (43 refs.)

Aims: This study investigates the relationship between attendance at Alcoholics Anonymous (AA) meetings prior to, during, and after leaving treatment, and changes in clinical outcome following inpatient alcohol treatment. Methods: A longitudinal design was used in which participants were interviewed at admission (within 5 days of entry), and 6 months following departure. The sample comprised 150 patients in an inpatient alcohol treatment programme who met ICD-10 criteria for alcohol dependence. The full sample was interviewed at admission to treatment. Six months after departure from treatment, 120 (80%) were re-interviewed. Results: Significant improvements in drinking behaviours (frequency, quantity and reported problems), psychological problems and quality of life were reported. Frequent AA attenders had superior drinking outcomes to non-AA attenders and infrequent attenders. Those who attended AA on a weekly or more frequent basis after treatment reported greater reductions in alcohol consumption and more abstinent days. This relationship was sustained after controlling for potential confounding variables. Frequent AA attendance related only to improved drinking outcomes. Despite the improved outcomes, many of the sample had alcohol and psychiatric problems at follow-up. Conclusions: The importance of aftercare has long been acknowledged. Despite this, adequate aftercare services are often lacking. The findings support the role of Alcoholics Anonymous as a useful aftercare resource. (Copyright 2006, Oxford Press)

Humphreys K; Moos R. Can encouraging substance abuse patients to participate in self-help groups reduce demand for health care? A quasi-experimental study. Alcoholism: Clinical and Experimental Research 25(5): 711-716, 2001. (19 refs.)

Background: Twelve-step-oriented inpatient treatment programs emphasize 12-step treatment approaches and the importance of ongoing attendance at 12-step self-help groups more than do cognitive- behavioral (CB) inpatient treatment programs. This study evaluated whether this difference in therapeutic approach leads patients who are treated in 12-step programs to rely less on professionally provided services and more on self-help groups after discharge, thereby reducing long-term health care costs. Methods: A prospective, quasi-experimental comparison of 12-step- based (N = 5) and cognitive-behavioral (n = 5) inpatient treatment programs was conducted. These treatments were compared on the degree to which their patients participated in self-help groups, used outpatient and inpatient mental health services, and experienced positive outcomes (e,g., abstinence) in the year following discharge. Using a larger sample from an ongoing research project, 887 male substance-dependent patients from each type of treatment program were matched on pre-intake health care costs (N = 1774). Al baseline and 1- year follow-up, patients' involvement in self-help groups (e.g., Alcoholics Anonymous), utilization and costs of mental health services, and clinical outcomes were assessed. Results: Compared with patients treated in CB programs, patients treated in 12-step programs had significantly greater involvement in self-help groups at follow-up. In contrast, patients treated in CB programs averaged almost twice as many outpatient continuing care visits after discharge (22.5 visits) as patients treated in 12-step treatment programs (13.1 visits), and also received significantly more days of inpatient care (17.0 days in CB versus 10.5 in 12-step), resulting in 64% higher annual costs in CB programs ($4729/patient, p < 0.001). Psychiatric and substance abuse outcomes were comparable across treatments, except that 12-step patients had higher rates of abstinence at follow-up (45.7% versus 36.2% for patients from CB programs, p < 0.001). Conclusions: professional treatment programs that emphasize self-help approaches increase their patients' reliance on cost-free self-help groups and thereby lower subsequent health care costs. Such programs therefore represent a cost-effective approach to promoting recovery from substance abuse. Copyright 2001, Research Society on Alcoholism.

Humphreys K; Wing S; McCartry D; Chappel J; Gallant L; Haberle B; et al. Self-help organizations for alcohol and drug problems: Toward evidence-based practice and policy. Journal of Substance Abuse Treatment 26: 151-158, 2004. ( 25 refs.)

This expert consensus statement reviews evidence on the effectiveness of drug and alcohol self-help groups and presents potential implications for clinicians, treatment program managers and policymakers. Because longitudinal studies associate self-help group involvement with reduced substance use, improved psychosocial functioning, and lessened health care costs, there are humane and practical reasons to develop self-help group supportive policies. Policies described here that could be implemented by clinicians and program managers include making greater use of empirically-validated self-help group referral methods in both specialty and non-specialty treatment settings and developing a menu of locally available self-help group options that are responsive to client's needs, preferences, and cultural background. The workgroup also offered possible self-help supportive policy options (e.g., supporting self-help clearinghouses) for state and federal decision makers. Implementing such policies Could strengthen alcohol and drug self-help organizations, and thereby enhance the national response to the serious public health problem of Substance abuse. Copyright 2004, Elsevier Science

International Journal of Group Psychotherapy 51(1): 1-122 (entire issue), 2001.
This special issue on group therapy and substance abuse has seven articles on different aspects of group work.

Kaskutas LA; Turk N; Bond J; Weisner C. The role of religion, spirituality and Alcoholics Anonymous in sustained sobriety Alcoholism Treatment Quarterly 21(1): 1-16, 2003 (26 refs.)

Spirituality or belief in a higher being is an integral part of Alcoholics Anonymous (AA). This study examines the role of religiosity in AA involvement and long-term sobriety in a representative sample of 587 men and women (ages 30 to 44 yrs) interviewed upon entering treatment and re-interviewed 1 and 3 years later. Religiosity is defined as spiritual, religious, secular (atheist or agnostic) and unsure, using the Religious Beliefs and Practices Scale employed in Project MATCH. Similar proportions within each religiosity group reported prior 12-month AA exposure at baseline; and over 40% of the unsure, spiritual and religious respondents and 25% of the secular respondents reported having gone to at least one AA meeting in the 12 months before the year 3 interview. Those who reported a spiritual awakening at year 3 were at the highest odds of continuous sobriety for the last year; religious self-definition was not associated with a significantly higher odds of sobriety at year 3 after controlling for other influences. An increase in AA activities, other than AA meetings, between baseline and the year 1 follow-up was also associated with a higher odds of sobriety, highlighting the importance of increased AA involvement in the period immediately following treatment episodes. (Copyright 2003, Haworth Press)

Klaw E; Humphreys K. Life stories of moderation management mutual help group members. Contemporary Drug Problems 27(4): 779-804, 2000. (31 refs.)

This study analyzed life story themes of 30 Moderation Management (MM) members. MM is the only mutual help organization in the US that supports problem drinkers who wish to moderate their alcohol consumption. Qualitative interview data indicated that MM involvement was often precipitated by a conscious rejection of the 12-step philosophy espoused in Alcoholics Anonymous and in many professional treatment programs. In particular, MM members did not believe that their problem drinking was a disease manageable only through abstinence or that they needed to surrender control to a spiritual "higher power for recovery. In contrast, the MM world view which emphasizes self-control and choice, seemed to better match the experience, values and preferred self-narratives of this high-functioning sample of white, middle-class, well-educated Americans. Copyright 2000, Federal Legal Publications, Inc.

Lobdell JC. This Strange Illness: Alcoholism and Bill W. New York: Walter de Gruyter, Inc.,, 2004.

This work considers the impact of Bill Wilson in the formation of Alcoholics Anonymous and its conceptualiztion of the disesase as an illness of the mind, body, and spirit. It considers the evolving definitions of alcoholism, including theoretical formulations, statistically derived typologies and the changing definitions used by the medical community. The first chapters set forth the historical context and a historical perspective of AA, tracing its origins through Bill Wilson. and Dr Bob Smith. Several chapters are devoted to providing a biological and genetic perspective of alcoholism, presenting studies related to behavioral genetic, biochemical and genetic aspects of alcoholism. The final chapters endeavor to integrate the psychology and biology of alcoholism with the philosophy, theology and traditions of AA to provide a unified paradigm to support future research. Copyright 2005, Project Cork

Mann K. Pharmacotherapy of alcohol dependence: A review of the clinical data. (review). CNS Drugs 18(8): 485-504, 2004. (118 refs.)

Over the last 20 years, the role of adjuvant pharmacotherapy in optimising outcome in rehabilitation programmes for alcohol-dependent patients has become increasingly evident. New avenues for rational drug treatment have arisen from better understanding of the neurobiological substrates of alcohol dependence, including adaptive changes in amino acid neurotransmitter systems, stimulation of dopamine and opioid peptide systems, and, possibly, changes in serotonergic activity. Disulfiram, naltrexone and acamprosate are currently the only treatments approved for the management of alcohol dependence. However, there is still no unequivocal evidence from randomised controlled clinical trials that disulfiram improves abstinence rates over the long term. Aversive therapy with disulfiram is not without risk for certain patients, and should be closely supervised. Both naltrexone and acamprosate improve outcome in rehabilitation of alcohol-dependent patients, but seem to act on different aspects of drinking pathology. Naltrexone is thought to decrease relapse to heavy drinking by attenuating the rewarding effects of alcohol. However, data from the naltrexone clinical trial programme are somewhat inconsistent, with several large studies being negative. Acamprosate is believed to maintain abstinence by blocking the negative craving that alcohol-dependent patients experience in the absence of alcohol. The clinical development programme has involved a large number of patients and studies, of which the vast majority have shown a beneficial effect of acamprosate on increasing abstinence rates. Both drugs are generally well tolerated; nausea is reported by around 10% of patients treated with naltrexone, while the most frequent adverse effect reported with acamprosate is diarrhoea. Another opioid receptor antagonist, nalmefene, has shown promising activity in pilot studies, and may have a similar profile to naltrexone. Data from studies of SSRIs in alcohol dependence are somewhat heterogeneous, but it appears that these drugs may indirectly improve outcome by treating underlying depression rather than affecting drinking behaviour per se. Similarly, the anxiolytic buspirone may act by ameliorating underlying psychiatric pathology. Dopaminergic neuroleptics, benzodiazepines and antimanic drugs have not yet demonstrated evidence of activity in large controlled clinical trials. Trials with drugs acting at serotonin receptors have yielded disappointing results, with the possible exception of ondansetron. Because the biological basis of alcohol dependence appears to be multifactorial, the future of management of alcoholism may be combination therapy, using drugs acting on different neuronal pathways, such as acamprosate and naltrexone. Pharmacotherapy should be used in association with appropriate psychosocial support and specific treatment provided for my underlying psychiatric comorbidities. (Copyright 2004, Adis International Ltd.)

Meyers RJ; Miller WR, eds. A Community Reinforcement Approach to Addiction Treatment. Cambridge: Cambridge University Press, 2006. (191 pp.)

This edited work, organized into nine chapters and with 10 contributors, is a revision of a previous volume. It presents the Community Reinforcement Approach (CRA), a broad-spectrum cognitive-behavioral treatment for substance use disorders. At the core of CRA is the belief that an individual's environment can play a powerful role in encouraging or discouraging drinking and drug use. Consequently, it attempts to rearrange contingencies so that sober behavior is more rewarding than substance-abusing behavior. Originally tested in the early 1970s with a small sample of alcohol-dependent inpatients, it has repeatedly proven to be successful over the years with larger, diverse populations. The initial chapters deal with the development of the CRA approach, the early Azrin studies demonstrating its efficacy, also provide a detailed description of the treatment approach, including basic guidelines for clinicians, communication skills, problem-solving and drink-refusal strategies. CRA is then compared to other forms of treatment with a new chapter devoted to the finding from a controlled trial of CRA and traditional treatment. The final chapters discuss the application to special populations: the homeless, those with cocaine and opiate dependencies, and its application to family members [Community Reinforcement and Family Training (CRAFT)] followed by a summary chapter. (Copyright 2006, Project Cork)

Miller WR; Carroll KM, eds. Rethinking Substance Abuse: What the Science Shows, and What We Should Do about It. New York: Guilford Press, 2006.

Several years ago one author lamented that the research being conducted on "change" within the substance abuse field was 'mis-directed.' The core problem he stated was not a lack of understanding about how clients change, but the absence of knowledge about how clinicians change, i.e. and what will enable them to adopt best practices. This volume is intended to deal with the conundrum. This book has the goal of describing what treatment and prevention would look like were they based on the best science available. It presents key information from the current substance abuse research in a practical fashion to promote better clinical care. This volume, organized into 18 chapter with 28 contributors, is organized into five section. The first section deals with the field's failure to utilize best practices, the increasing understanding of essentially complex phenomenon related to drug use/abuse, and outlines the goals for the book. Section II considers the neurobiology of addiction, the insights provided by brain imaging in respect to risk factors and relapse, as well as the genetic factors related to substance use and abuse. Section III considers psychological factors. It includes examination of the phenomenon of natural change, change in the absence of treatment. It reviews the relationship of substance use and co-occurring psychological problems. Another chapter also summarizes the insights into developmental factors that play a role in the development of substance abuse problems. Section IV turns to examination of social factors. The domains considered are the presence of race and gender differences, the impact of family and close relationships, the impact of social context, as well as the insights provided by ethnographic and anthropological studies. Section V is devoted to intervention. Beyond consideration of specific modalities, such as behavior therapies and drug therapies, a domain less discussed, religion and spirituality is also examined. In this section the limitations of the current treatment system are also considered. The concluding chapter sets forth ten principles and ten recommendations. (Copyright 2006, Project Cork)

Moak DH. Assessing the efficacy of medical treatments for alcohol use disorders. (review). Expert Opinion on Pharmacotherapy 5(10): 2075 -2089, 2004. (132 refs.)

Alcohol use disorders (AUDs) are common health problems that have a significant impact on society as a whole. There is a need for more effective treatments. In the last two decades, evidence for the efficacy of pharmacological approaches to treatment has increased. Although it has long been clear that medications are needed for the treatment of the alcohol withdrawal syndrome, the important role of medications in the longer-term treatment of AUDs has only recently been appreciated. In particular, naltrexone, acamprosate and topiramate appear to be efficacious treatments, especially when combined with psychosocial interventions that emphasise compliance with medication and encourage treatment retention. The goal of this review is to bring together the existing literature supporting the usefulness of pharmacological treatments for the alcohol withdrawal syndrome, for longer-term treatment of AUDs, and for comorbid AUDs and other psychiatric disorders. In addition, opportunities for future research will be identified. (Copyright 2004, Ashley Publications Ltd.)

Moos RH; Moos BS. Long-term influence of duration and frequency of participation in Alcoholics Anonymous on individuals with alcohol use disorders. Journal of Consulting and Clinical Psychology. 72(1): 81-90, 2004. (46 refs.)

Aims: This study examined the influence of the duration and intensity of the first episode of treatment for previously untreated individuals with alcohol use disorders on short-term and long-term outcomes, and the effect of additional treatment and delayed treatment on outcomes. Design, setting, participants: A sample of alcoholic individuals (n = 473) was recruited at alcoholism information and referral centers and detoxification units and was surveyed at baseline and 1 year, 3 years and 8 years later. Measurements: At each contact point, participants completed an inventory that assessed their treatment utilization since the last assessment and their current alcohol-related, psychological and social problems. Findings: Compared with individuals who remained untreated, individuals who entered treatment relatively quickly and who obtained a longer duration of treatment had better short-and long-term alcohol-related outcomes and better short-term social functioning. Individuals who obtained a longer duration of additional treatment had better alcohol-related outcomes than individuals who obtained no additional treatment but, among individuals who delayed treatment entry. the duration of treatment was not associated with treatment outcomes. In general, the intensity of treatment was not related to better outcomes. Conclusions: Rapid entry into treatment and the duration of treatment for alcohol use disorders may be more important than the intensity of treatment. Treatment providers should consider structuring their programs to emphasize continuity, rather than intensity of care. (Copyright 2003, Society for the Study of Addiction to Alcohol and Other Drugs)

Moos RH. Iatrogenic effects of psychosocial interventions for substance use disorders Prevalence, predictors, prevention, Addiction, 100(8): 595–604, 2005. (96 refs.)

Aims: To examine the prevalence and personal and intervention-related predictors of potential iatrogenic effects associated with psychosocial interventions for substance use disorders and provide a conceptual framework to guide further research on such effects. Method: A review of relevant studies focuses on the prevalence and predictors of potential iatrogenic effects of psychosocial treatment and prevention programs for substance use disorders. Results: Between 7% and 15% of patients who participate in psychosocial treatment for substance use disorders may be worse off subsequent to treatment than before. In addition, several controlled trials of substance use prevention have shown some apparent iatrogenic effects, including more positive expectations about substance use and a rise in alcohol use and alcohol-related problems. Probable person-related predictors of deterioration associated with treatment include younger age and unmarried status, more serious current diagnoses and substance use problems and more psychiatric and interpersonal problems. Probable intervention-related predictors of deterioration include lack of bonding; lack of monitoring; confrontation, criticism and high emotional arousal; deviancy modeling; and stigma, low or inappropriate expectations and lack of challenge. Conclusion: A significant minority of individuals with substance use problems appear to deteriorate during or shortly after participation in treatment or prevention programs. Safety standards and monitoring procedures are needed to routinely identify potential adverse consequences of intervention programs; research is needed to clarify whether deterioration is due to iatrogenic effects of interventions and to identify new approaches to counteract any such effects. (Copyright 2005, Society for the Study of Addiction to Alcohol and Other Drugs)

Myrick H; Brady KT; Malcolm R. New developments in the pharmacotherapy of alcohol dependence. American Journal on Addictions 10(Supplement): 3-15, 2001. (82 refs.)

Neuroscientific underpinnings and pharmacotherapeutic treatments of substance use disorders are rapidly developing areas of study. In particular, there have been exciting new developments in our understanding of the involvement of excitatory amino acid neurotransmitter systems and the opiate and serotonin systems in the pathophysiology of alcohol withdrawal, alcohol dependence, and in subtypes of individuals with alcoholism. In this article, new developments in the pharmacotherapy of alcohol dependence will be reviewed. In particular, anticonvulsants in alcohol withdrawal and protracted abstinence syndromes will be discussed. New data on opiate antagonists and acamprosate, an agent that exerts actions through excitatory amino acid systems in relapse prevention, will be reviewed. Finally, there will be a review of new data concerning the use of serotonin reuptake inhibitors in subtypes of alcoholism and the use of combination pharmacotherapy. Copyright 2001, American Academy of Psychiatrists in Alcoholism and Addictions

O'Farrell TJ; Fals-Stewart W. Behavioral couples therapy for alcoholism and drug abuse. Journal of Substance Abuse Treatment 18(1): 51-54, 2000. (22 refs.)

Behavioral couples therapy (BCT) sees the substance-abusing patient with the spouse to arrange a daily "sobriety contract" in which the patient states his or her intent not to drink or use drugs and the spouse expresses support for the patient's efforts to stay abstinent. BCT also teaches communication and increases positive activities. Research supports three conclusions. First, BCT for both alcoholism and drug abuse produces more abstinence and fewer substance-related problems, happier relationships, fewer couple separations and lower risk of divorce than does individual-based treatment. Second, domestic violence is substantially reduced after BCT for both alcoholism and drug abuse. Third, cost outcomes after BCT are very favorable for both alcoholism and drug abuse, and are superior to. individual-based treatment for drug abuse. The Institute of Medicine (1998) documented a large gap between research and practice in substance abuse treatment. BCT is one example of this gap. BCT has relatively strong research support, but it has not yet become widely used. Copyright 2000, Pergamon Press

Overman GP; Teter CJ; Guthrie SK. Acamprosate for the adjunctive treatment of alcohol dependence. Annals of Pharmacotherapy 37(7/8): 1090-1099, 2003. (62 refs.)

Literature related to the treatment of alcohol dependence with acamprosate (calcium acetylhomotaurinate) was reviewed. Acamprosate is a synthetic derivative of homotaurine, a naturally occurring analogue of gamma-aminobutyric acid. Primary literature and review articles published from 1966 to June 2003 were identified by MEDLINE search, and abstracts from recent meetings were also reviewed. Acamprosate has been marketed in 24 countries. Although the precise mechanism of its action in the treatment of alcohol-dependent patients is unclear, it may restore the balance between inhibitory and excitatory neurotransmission in the central nervous system disrupted by chronic alcohol consumption. Trials in Europe have shown consistent increases in abstinence rates compared with placebo when acamprosate treatment was paired with appropriate psychosocial and behavioral therapies. Decreased direct and indirect health care costs associated with acamprosate treatment have also been reported. It was concluded that acamprosate is a promising medication for the treatment of alcohol dependence in the United States. Copyright 2003, Harvey Whitney Books Co.

Panasa L; Caspib Y; Fournierc E; McCarty D. Performance measures for outpatient substance abuse services: Group versus individual counseling. Journal of Substance Abuse Treatment 25(4): 271-278, 2003. (46 refs.)

Most substance abuse treatment programs employ various models of group therapy. Empirical evidence, however, of the benefits of group vs. individual treatment is scarce. This study examined the impact of type of treatment, defined as individual or group counseling, on treatment performance, as measured by treatment completion and goal achievement. Data on clients treated in publicly funded substance abuse outpatient treatment programs were drawn from the Massachusetts Substance Abuse Information System. A larger proportion of group to individual therapy was strongly and positively associated with increased likelihood for improved measures of treatment performance. State data systems can provide useful insights into the development and application of performance measurement. (Copyright 2003, Elsevier Science)

Pardini DA; Plante TG; Sherman A; Stump JE. Religious faith and spirituality in substance abuse recovery: Determining the mental health benefits. Journal of Substance Abuse Treatment 19(4): 347-354, 2000. (50 refs.)

Recently mental health professionals have begun examining the potential value of religious faith and spirituality in the lives of individuals suffering from a variety of acute and chronic illnesses. This study explored the relation between religious faith, spirituality, and mental health outcomes in 236 individuals recovering from substance abuse. We found that recovering individuals tend to report high levels of religious faith and religious affiliation, but choose to rate themselves as being more spiritual than religious. Results also indicate that among recovering individuals, higher levels of religious faith and spirituality were associated with a more optimistic life orientation, greater perceived social support, higher resilience to stress, and lower levels of anxiety. This represents the largest self-report study to date examining the relation between religious faith, spirituality, and mental health outcomes among individuals recovering from substance abuse. Copyright 2000, Pergamon Press

Rhule DM. Take care to do no harm: Harmful Interventions for youth problem behavior. Professional Psychology: Research and Practice 36(6): 618-625, 2005. (45 refs.)

Youth conduct problems, delinquency, and substance abuse pose serious consequences for the youth themselves, their victims and families, and the broader society. The widespread impact of these problem behaviors highlights the importance of preventing and treating them effectively. Despite this need, an emerging literature has demonstrated that certain intervention programs for these problem behaviors, particularly those that have used group-delivery formats, have produced iatrogenic effects. The potential for intervention to produce negative outcomes raises several ethical implications and dilemmas. In this article, the author provides illustrative examples of iatrogenic effects of interventions that target youth conduct problems, delinquency, and substance abuse; discusses the relevant ethical implications raised by these outcomes; and suggests recommendations to prevent, detect, and respond to their occurrence. Copyright 2005, American Psychological Association

Taskforce of College on Problems of Drug Dependence; Stitzer ML; Owen PL; Hall SM; Rawson RA; Petry NM. Standards for drug abuse treatment providers. Drug and Alcohol Dependence 71(2): 213-125, 2003. [Note: This policy statement was adopted in the wake of discussion of funding faith-based programs. The issue for the College is not the sponsorship of treatment by religious organizations, but the need, in all settings, for evidence-based clinical approaches to assure that quality care is provided.]

This policy statement of The College on Problems of Drug Dependence (CPDD) was developed in response to efforts by the Federal Executive Office to fund faith-based organizations to provide substance abuse treatments. Of concern to The College was not whether treatment providers are or are not religious organizations. Rather the predominant concern was that any treatment provided be evaluated for effectiveness if there is to be quality of care. This policy statement discusses the current status of standards for drug abuse treatment delivery and provides recommendations that may help to shape future policy in this area. Specifically, it is recommended that evaluation standards should be focused on objective patient outcomes using assessment domains including treatment retention and urinalysis evidence of drug abstinence that have been effectively used for many years in treatment outcome research. (Copyright 2003, Elsevier Scientific Publishers Ireland, Ltd)

Tiebout HM: Surrender versus compliance in therapy, with special reference to alcoholism. Quarterly Journal of Studies on Alcohol 14:58–68, 1953.

Note: This article is available as a monograph through the National Council on Alcohol and Other Drug Dependencies.

Velleman RDB, Templeton LJ, Copello AG. The role of the family in preventing and intervening with substance use and misuse: A comprehensive review of family interventions, with a focus on young people. (review). Drug and Alcohol Review 24(2): 93-109, 2005. (154 refs.)

The family plays a key part in both preventing and intervening with substance use and misuse, both through inducing risk, and/ or encouraging and promoting protection and resilience. This review examines a number of family processes and structures that have been associated with young people commencing substance use and later misuse, and concludes that there is significant evidence for family involvement in young people's taking up, and later misusing, substances. Given this family involvement, the review explores and appraises interventions aimed at using the family to prevent substance use and misuse amongst young people. The review concludes that there is a dearth of methodologically highly sound research in this area, but the research that has been conducted does suggest strongly that the family can have a central role in preventing substance use and later misuse amongst young people. (Copyright 2005, Australian Medical and Professional Society on Alcohol and Other Drugs)

Zemore SE; Kaskutas LA; Ammon LN. In 12-step groups, helping helps the helper. Addiction 99(8): 1015-1023, 2004. (46 refs.)

Aims: The helper therapy principle suggests that, within mutual-help groups, those who help others help themselves. The current study examines whether clients in treatment for alcohol and drug problems benefit from helping others, and how helping relates to 12-step involvement. Design: Longitudinal treatment outcome. Participants: An ethnically diverse community sample of 279 alcohol- and/or drug-dependent individuals (162 males, 117 females) was recruited through advertisement and treatment referral from Northern California Bay Area communities. Participants were treated at one of four day-treatment programs. Measurements: A helping checklist measured the amount of time participants spent, during treatment, helping others by sharing experiences, explaining how to get help and giving advice on housing and employment. Measures of 1.2-step involvement and substance use outcomes were administered at baseline and a 6 month follow-up. Findings: Helping and 12-step involvement emerged as important and related predictors of treatment outcomes. In the general sample, total abstinence at follow-up was strongly and positively predicted by 12-step involvement at follow-up, but not by helping during treatment; still, helping positively predicted subsequent 12-step involvement. Among individuals still drinking at follow-up, helping during treatment predicted a lower probability of binge drinking, whereas effects for 12-step involvement proved inconsistent. Conclusions: Findings support the helper therapy principle and clarify the process of 12-step affiliation. (Copyright 2004, Society for the Study of Addiction to Alcohol and Other Drugs)

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