Getting a Grip on Drinking Behavior Training Working Memory to Reduce Alcohol Abuse

Alcohol abuse disrupts core executive functions, including working memory (WM)—the ability to maintain and manipulate goal-relevant information. When executive functions like WM are weakened, drinking behavior gets out of control and is guided more strongly by automatic impulses. 

This study investigated whether training WM restores control over drinking behavior. 

Forty-eight problem drinkers performed WM training tasks or control tasks during 25 sessions over at least 25 days. Before and after training, we measured WM and drinking behavior. 

Training WM improved WM and reduced alcohol intake for more than 1 month after the training.

Further, the indirect effect of training on alcohol use through improved WM was moderated by participants’ levels of automatic impulses: Increased WM reduced alcohol consumption in participants with relatively strong automatic preferences for alcohol. 

These findings are consistent with the theoretical framework and demonstrate that training WM may be an effective strategy to reduce alcohol use by increasing control over automatic impulses to drink alcohol. 

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Request Reprint E-Mail:  : k.houben@maastrichtuniversity.nl  

Contingency management for alcohol use reduction: A pilot study using a transdermal alcohol sensor

Contingency management (CM) has not been thoroughly evaluated as a treatment for alcohol abuse or dependence, in part because verification of alcohol use reduction requires frequent in-person breath tests. Transdermal alcohol sensors detect alcohol regularly throughout the day, providing remote monitoring and allowing for rapid reinforcement of reductions in use.

The purpose of this study was to evaluate the efficacy of CM for reduction in alcohol use, using a transdermal alcohol sensor to provide a continuous measure of alcohol use. 

Participants were 13 heavy drinking adults who wore the Secure Continuous Remote Alcohol Monitoring (SCRAM) bracelet for three weeks and provided reports of alcohol and drug use using daily web-based surveys. In Week 1, participants were asked to drink as usual; in Weeks 2 and 3, they were reinforced on an escalating schedule with values ranging from $5 to $17 per day on days when alcohol use was not reported or detected by the SCRAM.

Self-reports of percent days abstinent and drinks per week, and transdermal measures of average and peak transdermal alcohol concentration and area under the curve declined significantly in Weeks 2–3. A nonsignificant but large effect size for reduction in days of tobacco use also was found. An adjustment to the SCRAM criteria for detecting alcohol use provided an accurate but less conservative method for use with non-mandated clients.

Results support the efficacy of CM for alcohol use reductions and the feasibility of using transdermal monitoring of alcohol use for clinical purposes.

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Request Reprint E-Mail:  Nancy_Barnett@brown.edu 

   

National Prevention Strategy America’s Plan for Better Health and Wellness June

The National Prevention Strategy aims to guide our nation in the most effective and achievable means for improving health and well-being. 

The Strategy prioritizes prevention by integrating recommendations and actions across multiple settings to improve health and save lives.

• pg. 31   Preventing Drug Abuse and Excessive Alcohol Use 

Preventing drug abuse and excessive alcohol use increases people’s chances of living long, healthy, and productive lives. Excessive alcohol use includes binge drinking (i.e., five or more drinks during a single occasion for men, four or more drinks during a single occasion for women), underage drinking, drinking while pregnant, and alcohol impaired driving.  Drug abuse includes any inappropriate use of pharmaceuticals (both prescription and over-the counter drugs) and any use of illicit drugs.

Alcohol and other drug use can impede judgment and lead to harmful risk-taking behavior. Preventing drug abuse and excessive alcohol use improves quality of life, academic performance, workplace productivity, and military preparedness; reduces crime and criminal justice expenses; reduces motor vehicle crashes and fatalities; and lowers health care costs for acute and chronic conditions.


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Combined Pre- and Postnatal Ethanol Exposure in Rats Disturbs the Myelination of Optic Axons

To analyse myelination and outgrowth of the optic axons in relation to the neuro-ophthalmological manifestations of ethanol (EtOH) abuse during pregnancy.  

An experimental model of chronic EtOH exposure was developed in rats and their offspring by subjecting the dams to a liquid diet (35% of the daily total calories as either EtOH or maltose-dextrose nutritional controls (Con). Eyeballs and optic nerves were obtained at key developmental stages and processed for morphologic, immunocytochemical and immunoblotting procedures, using alternatively antibodies against myelin basic protein (MBP) or neurofilament (NF) protein, and image analysing.  

A significant delay in onset of optic axons myelination, as well as a significant reduction in optic nerve size (P < 0.001), optic axons number (P < 0.001), myelinated axons density (P < 0.001), number of myelin lamellae linked to axon diameter (P < 0.001) and optic axon cross-sectional area (P < 0.001) were detected in the global morphometric assessment of the EtOH nerves with respect to the Con. Expression of MBP and NF was noticeably reduced in the EtOH optic nerves when compared with the Con.  

Disturbed myelination of optic axons, caused by EtOH abuse, strongly disrupts the optic nerve development and the establishment of definitive retinal and optic nerve targets, and subsequently the visual patterns.

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Request Reprint E-Mail:   pons_she@gva.es

Recent Heavy Alcohol Consumption at Death Certified as Ischaemic Heart Disease: Correcting Mortality Data from Kaunas (Lithuania)

To assess the proportion of deaths assigned to ischaemic heart disease (IHD) which in fact were caused by the toxic effects of alcohol, and how this may affect the official statistics of mortality from IHD in Lithuania. 

Using the IHD register in Kaunas, Lithuania, and verifying underlying causes of death using standard international methodology, 3061 cases were found in Kaunas city who had died from IHD at age 25–64 during 1993–2007. Out-of-hospital sudden deaths accounted for 2467 cases (81%), including 1498 where forensic autopsy was conducted and post-mortem concentration of alcohol in blood and urine was available. 

In total, 78.4% of all initial IHD diagnoses were verified, while in 8.7% of deaths the underlying cause of death was corrected into an alcohol-related cause and in 12.9% to other diseases. Alcohol was found in about half (50.3%) of out-of-hospital death cases subjected to autopsy. In 18.0% of cases, the alcohol concentration was 3.5% or higher. Alcohol was more likely to be present in winter months and at weekends. 

A significant number of alcohol-attributable deaths in Lithuania were misclassified as coronary deaths, accounting for almost one-tenth of officially registered deaths from IHD in ages 25–64. A high prevalence of positive post-mortem blood or urine alcohol tests suggests that the proportion of alcohol-related deaths among out-of-hospital IHD deaths may be actually even higher. A similar situation may be present in some other countries where high levels of alcohol consumption and binge drinking patterns are observed. 

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Request Reprint E-Mail:   ricaradi@itc.kmu.lt 

A guiding framework and approach for implementation research in substance use disorders treatment.

This paper introduces readers to the concepts of implementation science, implementation theory, and implementation frameworks and models.

A wide range of models has been published in the literature related to implementation. 

The paper will present an overview of the Consolidated Framework for Implementation Research (CFIR), which is a comprehensive typology that unifies and consolidates the array of constructs that influence implementation from the perspective of these models. 

The CFIR is then used to evaluate implementation models used in studies of substance use disorder (SUD) treatments. Implementation research is scarce, with few prospective studies of theory-driven implementation. 

We assert that future research in SUD needs to meet three overarching objectives to promote wider implementation of evidence-based practices: (a) differentiation of core versus adaptable components of evidence-based interventions need; (b) development of methods to design implementation strategies, effectively adapted to the broad context; and (c) design and testing of predictive models to assess likelihood of effective implementation and prospects for sustainability while taking into account salient contextual factors.

A recommended strategy for accomplishing these objectives is described.

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Request Reprint E-Mail:  : laura.damschroder@va.gov   

Implementing evidence-based psychosocial treatment in specialty substance use disorder care.

Implementing evidence-based psychosocial or behavioral treatments for clients with substance use disorders (SUDs) presents significant challenges. 

In this article, we first identify the treatments for which there is some consensus that sufficient empirical support exists to designate them as “evidence-based,” and then briefly consider the nature of that evidence. Following that, we review data from a Substance Abuse and Mental Health Services Administration survey on the extent to which these evidence-based treatments (EBTs) are used in SUD treatment in the United States. 

The main focus of the article is a review of 21 studies attempting to implement EBTs from which we glean information on factors associated with more and less successful implementation. 

We conclude that more conceptually driven, organizationally focused (not just individual-provider-focused) approaches to implementation are needed and that, at least with some providers in some organizational contexts, it may be more effective to implement evidence-based practices or processes (EBPs) rather than EBTs.

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Request Reprint E-Mail:  jennifer.manuel@ucsf.edu

The role of college students' use of protective behavioral strategies in the relation between binge drinking and alcohol-related problems.

Previous research has examined protective behavioral strategies (PBS), or cognitive-behavioral strategies that may be employed when using alcohol to reduce consumption and related problems, as an important predictor of alcohol use and alcohol-related problems. 

More recently, studies have explored the mediating and moderating role of PBS on the relationships between key alcohol-related risk factors (i.e., drinking motives, depressive symptoms, binge drinking) and alcohol problems; however, current research examining PBS as a moderator of the relationship between alcohol use and related problems has methodological limitations. 

The purpose of the present study was to extend previous literature to examine the moderating effect of PBS on the relationship between binge drinking and alcohol-related problems. 

Data were collected and analyzed from 4,154 students at 13 midwestern universities. 

Findings indicated that PBS moderated the binge drinking-alcohol problems relationship for each of the four measures of binge drinking. However, effects were strongest when binge drinking was measured dichotomously versus continuously.

Implications and future directions are discussed.



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Request Reprint E-Mail:   lcnpc@mizzou.edu  

Strategies to implement alcohol screening and brief intervention in primary care settings: A structured literature review.

Although alcohol screening and brief intervention (SBI) reduces drinking in primary care patients with unhealthy alcohol use, incorporating SBI into clinical settings has been challenging. 

We systematically reviewed the literature on implementation studies of alcohol SBI using a broad conceptual model of implementation, the Consolidated Framework for Implementation Research (CFIR), to identify domains addressed by programs that achieved high rates of screening and/or brief intervention (BI). Seventeen articles from 8 implementation programs were included; studies were conducted in 9 countries and represented 533,903 patients (127,304 patients screened), 2,001 providers, and 1,805 clinics.

Rates of SBI varied across articles (2–93% for screening and 0.9–73.1% for BI). Implementation programs described use of 7–25 of the 39 CFIR elements. 

Most programs used strategies that spanned all 5 domains of the CFIR with varying emphases on particular domains and sub-domains. 

Comparison of SBI rates was limited by most studies' being conducted by 2 implementation programs and by different outcome measures, scopes, and durations. 

However, one implementation program reported a high rate of screening relative to other programs (93%) and could be distinguished by its use of strategies that related to the Inner Setting, Outer Setting, and Process of Implementation domains of the CFIR. 

Future studies could assess whether focusing on Inner Setting, Outer Setting, and Process of Implementation elements of the CFIR during implementation is associated with successful implementation of alcohol screening, as well as which elements may be associated with successful, sustained implementation of BI. 


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Request Reprint E-Mail: Emily.Williams3@va.gov
  

Ethanol Alters BDNF-Induced Rho GTPase Activation in Axonal Growth Cones

The effects of ethanol on development of postmitotic neurons include altered neurite outgrowth and differentiation, which may contribute to neuropathology associated with fetal alcohol spectrum disorders. We previously reported that ethanol exposure alters axon growth dynamics in dissociated cultures of rat hippocampal pyramidal neurons. Given the important regulatory role of small Rho guanosine triphosphatases (GTPases) in cytoskeletal reorganization associated with axon growth, and reports that ethanol alters whole cell Rho GTPase activity in other cell types, this study explored the hypothesis that ethanol alters Rho GTPase activity specifically in axonal growth cones.

Fetal rat hippocampal pyramidal neurons were maintained in dissociated cultures for 1 day in control medium or medium containing 11 to 43 mM ethanol. Some cultures were also treated with brain-derived neurotrophic factor (BDNF), an activator of Rac1 and Cdc42 GTPases that promotes axon extension. Levels of active Rho GTPases in growth cones were measured using in situ binding assays for GTP-bound Rac1, Cdc42, and RhoA. Axon length, growth cone area, and growth cone surface expression of tyrosine kinase B (TrkB), the receptor for BDNF, were assessed by digital morphometry and immunocytochemistry.

Although ethanol increased the surface area of growth cones, the levels of active Rho GTPases in axonal growth cones were not affected in the absence of exogenous BDNF. In contrast, ethanol exposure inhibited BDNF-induced Rac1/Cdc42 activation in a dose-dependent manner and increased RhoA activation at the highest concentration tested. Similar TrkB expression was observed on the surface of axonal growth cones of control and ethanol-treated neurons.

These results reveal an inhibitory effect of ethanol on growth cone signaling via small Rho GTPases during early stages of hippocampal development in vitro, and suggest a mechanism whereby ethanol may disrupt neurotrophic factor regulation of axon growth and guidance.


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Request Reprint E-Mail:  lindslt@mail.amc.edu   

Analysis and Interpretation of Specific Ethanol Metabolites, Ethyl Sulfate, and Ethyl Glucuronide in Sewage Effluent for the Quantitative Measurement of Regional Alcohol Consumption

The quantitative measurement of urinary metabolites in sewage streams and the subsequent estimation of consumption rates of the parent compounds have previously been demonstrated for pharmaceuticals and narcotics. Ethyl sulfate and ethyl glucuronide are excreted in urine following the ingestion of alcohol, and are useful biomarkers for the identification of acute alcohol consumption. This study reports a novel ion-exchange-mediated chromatographic method for the quantitative measurement of ethyl sulfate and ethyl glucuronide in sewage effluent, and presents a novel calculation method for the purposes of relating the resulting sewage concentrations with rates of alcohol consumption in the region.

A total of 100 sewage samples covering a 25-day period were collected from a treatment plant servicing approximately 500,000 people, and analyzed for levels of ethyl sulfate and ethyl glucuronide. The resulting data were then used to estimate combined alcohol consumption rates for the region, and the results were compared with alcohol related sales statistics for the same region.

Ethyl glucuronide was found to be unstable in sewage effluent. Ethyl sulfate was stable and measurable in all samples at concentrations ranging from 16 to 246 nM. The highest concentrations of the alcohol biomarker were observed during weekend periods. Sixty one percent of the total mass of ethyl sulfate in sewage effluent corresponds to alcohol consumption on Friday and Saturday. Sales statistics for alcohol show that consumption in the region is approximately 6,750 kg/d. The quantity of ethyl sulfate passing through the sewage system is consistent with consumption of 4,900 to 7,800 kg/d.

Sewage epidemiology assessments of ethyl sulfate can provide accurate estimates of community alcohol consumption, and detailed examination of the kinetics of this biomarker in sewage streams can also identify time-dependent trends in alcohol consumption patterns.


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malcolm.reid@niva.no

Alcohol-Binding Sites in Distinct Brain Proteins: The Quest for Atomic Level Resolution

Defining the sites of action of ethanol on brain proteins is a major prerequisite to understanding the molecular pharmacology of this drug. The main barrier to reaching an atomic-level understanding of alcohol action is the low potency of alcohols, ethanol in particular, which is a reflection of transient, low-affinity interactions with their targets. These mechanisms are difficult or impossible to study with traditional techniques such as radioligand binding or spectroscopy. However, there has been considerable recent progress in combining X-ray crystallography, structural modeling, and site-directed mutagenesis to define the sites and mechanisms of action of ethanol and related alcohols on key brain proteins. 

We review such insights for several diverse classes of proteins including inwardly rectifying potassium, transient receptor potential, and neurotransmitter-gated ion channels, as well as protein kinase C epsilon.

Some common themes are beginning to emerge from these proteins, including hydrogen bonding of the hydroxyl group and van der Waals interactions of the methylene groups of ethanol with specific amino acid residues. The resulting binding energy is proposed to facilitate or stabilize low-energy state transitions in the bound proteins, allowing ethanol to act as a “molecular lubricant” for protein 

function. 

We discuss evidence for characteristic, discrete alcohol-binding sites on protein targets, as well as evidence that binding to some proteins is better characterized by an interaction region that can accommodate multiple molecules of ethanol.

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Request Reprint E-Mail: reba@mail.utexas.edu  

Synergistic Effect of Alcohol Consumption and Body Mass on Serum Concentrations of Cytokeratin-18

Cytokeratin-18 is an essential component of the cytoskeleton of epithelial cells (including hepatocytes). Serum concentrations of cytokeratin-18 (tissue polypeptide-specific antigen [TPS]) are used as a marker of epithelial neoplasms. Here, we investigated the potential interaction between alcohol and obesity in relation to serum TPS concentrations.

 

Alcohol consumption, body mass index, and components of metabolic syndrome were measured in a random sample (n = 420) of the adult population (aged 18 to 92 years, 45% men) from a single municipality. Regular alcohol intake of >20 g/d (women) or >30 g/d (men) was considered risky drinking. Serum TPS was measured with a commercial immunoassay.

 

Risky drinking was associated with increased serum concentrations of TPS, which was particularly evident among obese individuals. Among individuals without risky drinking, TPS concentrations were similar for all levels of body mass. Conversely, among risky drinkers, serum TPS concentrations increased in parallel with body mass (p = 0.002). The odds ratio of a high (>100 U/l) TPS concentration for the combination of risky drinking and obesity was greater than the additive effect of the 2 separate factors, after adjusting for age and sex. A similar interaction was observed between risky drinking and abdominal adiposity, a major component of the metabolic syndrome. Serum TPS concentrations were correlated with markers of liver damage. Serum TPS was not superior to standard markers (gamma-glutamyl transferase and red blood cell mean volume) for the detection of risky drinking.

There is a synergism between risky alcohol consumption and common metabolic disorders (particularly obesity) in relation to serum concentrations of cytokeratin-18 (TPS), which probably reflect liver disease.


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Request Reprint E-Mail:  arturo.gonzalez.quintela@usc.es 

Differential Effects of Ethanol on Spectral Binding and Inhibition of Cytochrome P450 3A4 with Eight Protease Inhibitors Antiretroviral Drugs

Cytochrome P450 3A4 (CYP3A4) is the most abundant CYP enzyme in the liver, which metabolizes approximately 50% of the marketed drugs including antiretroviral agents. CYP3A4 induction by ethanol and its impact on drug metabolism and toxicity is known. However, CYP3A4–ethanol physical interaction and its impact on drug binding, inhibition, or metabolism is not known, except that we have recently shown that ethanol facilitates the binding of a protease inhibitor (PI), nelfinavir, with CYP3A4. The current study was designed to examine the effect of ethanol on spectral binding and inhibition of CYP3A4 with all currently used PIs that differ in physicochemical properties.

We performed type I and type II spectral binding with CYP3A4 at 0 and 20 mM ethanol and varying PIs’ concentrations. We also performed CYP3A4 inhibition using 7-benzyloxy-4-trifluoromethylcoumarin substrate and NADPH at varying concentrations of PIs and ethanol.

Atazanavir, lopinavir, saquinavir, and tipranavir showed type I spectral binding, whereas indinavir and ritonavir showed type II. However, amprenavir and darunavir did not show spectral binding with CYP3A4. Ethanol at 20 mM decreased the maximum spectral change (δA_max) with type I lopinavir and saquinavir, but it did not alter δA_max with other PIs. Ethanol did not alter spectral binding affinity (K_D) and inhibition constant (IC₅₀) of type I PIs. However, ethanol significantly decreased the IC₅₀ of type II PIs, indinavir and ritonavir, and markedly increased the IC₅₀ of amprenavir and darunavir.

Overall, our results suggest that ethanol differentially alters the binding and inhibition of CYP3A4 with the PIs that have different physicochemical properties. This study has clinical relevance because alcohol has been shown to alter the response to antiretroviral drugs, including PIs, in HIV-1-infected individuals.


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Request Reprint E-Mail: kumarsa@umkc.edu   

Use and Correlates of Protective Drinking Behaviors During the Transition to College: Analysis of a National Sample

This study examined patterns and correlates of protective drinking behaviors among incoming first-year college students

Incoming first-year students (N = 76,882) from 258 colleges across the U.S. provided baseline data on demographics, drinking practices, and protective behaviors as part of a web-based alcohol education program. Across the several colleges, responses to protective behavior questions were collected from seven weeks before the start of the school year to five weeks after.

Factor analysis identified three protective behavior sub-factors: Limit Drinking, Avoid Drinking and Driving, and Intent to Get Drunk. Both Limit Drinking and Avoid Drinking and Driving generally declined over the course of the data collection period while Intent to Get Drunk and peak blood alcohol concentration increased immediately after the start of school. In multiple regression analyses, the number of heavy drinking episodes in the past two weeks had a strong negative association with a Total Protective Behavior Score and the Limit Drinking Score, and a positive association with the Intent to Get Drunk Score. With the exception of the Intent to Get Drunk Score, women were more likely to use protective behaviors than men. Underage drinkers used protective behaviors less often than their of-age peers, though the effect was small. Race/ethnicity, time to matriculation, and intent to join/membership in a fraternity/sorority had negligible effects on protective behavior scores.

College students increase risky drinking after the start of school while progressively using fewer behaviors that might mitigate the consequences of drinking.


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Request Reprint E-Mail:  scott.walters@utsouthwestern.edu 

Summary of Preventing Alcohol, Tobacco, and Other Substance-exposed Pregnancies: A Community Affair - September 23-24, 2008, Rockville, MD

On September 23 and 24, 2008, the Work Group on Women, Drinking, and Pregnancy of the Interagency Coordinating Committee on Fetal Alcohol Syndrome (ICCFAS), the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the American Legacy Foundation (Legacy), a nonprofit health organization dedicated to building a world where young people reject tobacco and anyone can quit, collaborated and hosted a symposium to explore best approaches to disseminating the message about the potential harm caused by risky drinking, tobacco, and other substance use during the childbearing years and, in particular, the importance of abstaining from any and all drinking and smoking during pregnancy. 

The joint objective was to initiate a national effort to change the common perception that the use of alcohol and tobacco during pregnancy is safe. Approximately 103 addiction prevention and treatment professionals, health policymakers, health communications and marketing professionals, addiction researchers, community activists, Federal agency representatives, and others participated in the symposium.  

Twenty-two presentations were organized into eight general topic areas:

• Historical Background
• Epidemiology and Impact of Prenatal Substance Use on Birth Outcomes in the U.S.
• Federal Agency Activities to Address Substance Misuse Among Women of Childbearing Age
• Intervening with Women in the Preconception Period and During Pregnancy
• Reaching Out to Special Populations
• Measuring the Cost-Effectiveness of Interventions for Substance Misuse among Women of Childbearing Age
• Marketing the Message: “Alcohol, Tobacco, and other Substance Use and Pregnancy Do Not Mix”
• Future Directions for Preventing Alcohol, Tobacco, and other Substance-exposed Pregnancies: Framing an Action Agenda 

 
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Never Mind the Bottle. Archaeobotanical Evidence of Beer-brewing in Mediterranean France and the Consumption of Alcoholic Beverages During the 5th Century BC

This article reports on an example of early archaeobotanical evidence for beer-making in Iron Age South-Eastern France. 

An archaeological sample from a fifth century BC house at the site of Roquepertuse produced a concentration of carbonized barley (Hordeum vulgare) grains. The sample was taken from the floor of the dwelling, close to a hearth and an oven. The barley grains are predominantly sprouted and we argue that the assemblage represents the remains of deliberate malting. Malt was most likely related to beer-brewing. The neighboring oven could have been used to stop the germination process at the desired level by drying or roasting the grain. 

Beer-making evidence in Roquepertuse is discussed in the context of the consumption of alcoholic beverages in the Iron Age Western Mediterranean using archaeological and historical data. 


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Request Reprint E-Mail:   laurent.bouby@univ-montp2.fr

Impact of Motivational Changes on Drinking Outcomes in Pharmacobehavioral Treatment for Alcohol Dependence

Psychological factors such as motivation to change and self-efficacy influence drinking outcomes in alcohol-dependent individuals who are enrolled in pharmacobehavioral studies. Previous results from our research clinic indicated that initial stage of change of heavy drinkers enrolled in a pharmacobehavioral trial was significantly associated with alcohol consumption. However, overall empirical findings regarding the consistency and extent of the connection between motivational factors and behavior are mixed. This may be in part because of the impact of changes in motivation over the course of treatment and/or characteristics of the individuals receiving the intervention. 

Our goal in the present study was to examine the extent to which levels of motivation and self-efficacy changed during the treatment phase of a pharmacobehavioral treatment trial, and the extent to which these variables affected drinking behavior in subsets of alcohol-dependent individuals.

We conducted an exploratory evaluation of changes in motivation, temptation to drink, confidence to abstain, and drinking behavior over time during the treatment phase of a pharmacobehavioral study involving 321 alcohol-dependent individuals. We also examined the extent to which individual variables such as initial drinking severity, onset of alcohol dependence, and medication status influenced changes in motivation, self-efficacy, and drinking behavior.

Participants reported improvements in motivation to change, self-efficacy for change, and drinking behaviors over the course of treatment. As hypothesized, motivation to change and self-efficacy for change were related to specific dimensions of posttreatment drinking. Heavy drinkers reported more improvement in drinking behaviors than did nonheavy drinkers. Early-onset drinkers who were on medication reduced their drinking more than those on placebo, and these drinking changes appear to be partially mediated by reductions in temptation.

Reductions in drinking occur and are predicted by increased motivation to change, reduced temptation to drink, and increased confidence to abstain in this population of alcoholic-dependent individuals. Early and late onset and heavy drinkers and those taking medications displayed differential changes in drinking behavior, some of which were explained by the mediating effects of self-efficacy. This is a first step in understanding more about which alcoholic individuals respond best to treatment and what mechanisms may be involved in the changes in drinking and drinking-specific changes in frequency and intensity of drinking.


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Request Reprint E-Mail:    jkp2n@virginia.edu

Alcohol Dependence in Men: Reliability and Heritability

The assessment of a Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV) life-time history of alcohol dependence (LTH-AD) has been found to be moderately reliable and substantially heritable. However, in studies of the heritability of LTH-AD, measurement error could not be discriminated from the true unique environmental effects. 

The aims of this study were to: (i) estimate the reliability of LTH-AD in a population based sample, (ii) identify characteristics of LTH-AD predicting a reliable diagnosis, (iii) investigate the heritability of LTH-AD as a function of diagnostic confidence, and (iv) to estimate the genetic and environmental influences on LTH-AD correcting for measurement error.

An unselected sample of 4,203 male twins was interviewed twice approximately 1-year apart assessing DSM-IV LTH-AD over the same period of life. Logistic regression was used to identify clinical features that predict a reliable diagnosis LTH-AD. Genetic and environmental influences on reliable LTH-AD were examined using structural equation models.

Reliability of the diagnosis of LTH-AD was moderate (κ = 0.54) and was predicted by the number of AD symptoms, treatment seeking, duration of most severe episode, and a great deal of time spent to obtain, use, or recover from alcohol use (DSM-IV AD criterion #5). Using an index of caseness, heritability of LTH-AD increased as a function of diagnostic confidence. Accounting for errors of measurement in a multivariate twin model, the heritability of LTH-AD increased from 55 to 71%.

Reliably diagnosed LTH-AD can be predicted by characteristics relevant to the disorder. LTH-AD appears to be a moderately reliable disorder of high heritability.


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Request Reprint E-Mail:    eivind.ystrom@fhi.no

Inebria bulletin 6: Brief interventions terminology explored, pharmacy settings and Boston conference

The Inebria Bulletin nº6 has been released by the International Network on Brief Interventions for Alcohol Problems (INEBRIA). 

It includes information on the next Conference in Boston, which will take place on the 22-23^rd of September 2011, conclusions from a debate about appropriate EIBI terminology, a digest from 2010 conference on evidence and experience of delivering brief interventions in the pharmacy setting and further announcements. Past bulletins are also available on the Inebria website.   > > >   Read More

Alcohol use, heavy episodic drinking, and subsequent problems among adolescents in 23 European countries: does the prevention paradox apply?

According to theprevention paradox a majority of alcohol-related problemsin a population can be attributed to low to moderate drinkers simply because they are more numerous than heavy drinkers, who have a higher individual risk of adverseoutcomes. We examined the prevention paradox in annual alcohol consumption, heavy episodic drinking (HED), and alcohol-related problems among adolescents in 23 European countries.

Survey data from the 2007 European School Survey Project on Alcohol and Drugs (ESPAD) among 16-year-old students were analysed.

A total of 38 370 alcohol-consuming adolescents (19 936 boys and 18 434 girls) from 23 European countries were included.

The upper 10% and the bottom 90% of drinkers by annual alcohol intake, with or without HED, and frequency of HED, were compared for the distribution of 10 different alcohol-related problems.

Although the mean levels of consumption and alcohol-related problems varied largely between genders and countries, in almost all countries the heavy episodic drinkers in the bottom 90% of consumers by volume accounted for most alcohol-related problems, irrespective of severity of problem. However, adolescents with three or more occasions of HED a month accounted for a majority of problems.

The prevention paradox, based on measures of annual consumption and heavy episodic drinking seems valid for adolescent European boys and girls. However, a minority with frequent heavy episodic drinking accounted for a large part of all problems, illustrating limitations of the concept. As heavy episodic drinking is common among adolescents, our results support general prevention initiatives, combined with targeted interventions.


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The Örebro prevention program revisited: A cluster-randomized effectiveness trial of program effects on youth drinking

This study aimed to assess the effectiveness of the Örebro prevention program (ÖPP), an alcohol misuse prevention programme that aims to reduce youth drinking by changing parental behaviour.

Cluster-randomized trial, with schools randomly assigned to the ÖPP or no intervention.

Forty municipal schools in 13 counties in Sweden.

1752 students in the 7th grade and 1314 parents were assessed at baseline. Students' follow-up rates in the 8th and 9th grades were 92.1% and 88.4% respectively.

Classroom questionnaires to students and postal questionnaires to parents were administered before randomization and 12 and 30 months post-baseline.

Two-level logistic regression models, under four different methods of addressing the problem of loss to follow up, revealed a statistically significant programme effect for only one out of three drinking outcomes under one loss-to-follow-up method, and that effect was only observed at the 12-month follow up.

The Örebro prevention programme as currently delivered in Sweden does not appear to reduce or delay youth drunkenness.


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Request Reprint E-Mail:  maria.bodin@ki.se,   

Young people, alcohol and influences

This study differs from other research: it develops evidence of how different domains of influence work together, understanding their relative importance in tackling different patterns of drinking among different groups.

The study involved a survey of 5,700 teenagers aged 13–14 (Year 9) and 15–16 (Year 11) in schools in England and data was statistically modelled to highlight the strongest influences on and predictors of young people’s drinking.

The report:

• examines circumstances surrounding young people's first time drinking, their current drinking patterns (including levels of consumption), and their experiences of drunkenness; and
• develops our understanding of what really influences young people's drinking patterns by identifying the domains and indicators that have the strongest relationship with their behaviour.

   
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Eurocare and Active Press Release: Better alcohol control policy means less injuries, more safety and money saved

The European Union is the heaviest drinking region in the world. Therefore, in Europe we suffer from the highest alcohol related problems. It is estimated that 58 million adults in the EU drink at risky levels, and 23 million are alcohol addicted. 

Alcohol constitutes the primary risk factor for accidents, injuries and violence. Approximately half of the deaths attributable to alcohol are from injuries.
 
This issue is being addressed at the 3rd European injury prevention conference, organised by EuroSafe in cooperation with the Hungarian Presidency of the European Council. Today stakeholders in the prevention of accidents and injuries from Europe and other continents meet in Budapest to exchange, debate and discuss the latest results in injury research, policies and practices. > > > >

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The Alcohol Concern Smart Recovery Pilot Project final evaluation report

Austerity plus recovery plus curtailed treatment equals more mutual aid is the formula for ways out of dependence in the post-credit crunch 2010s. But with only 12-step groups, the offer is limited. What will it take for a cognitive-behavioural alternative to flourish in England was the question for this pilot project.

Summary The SMART Recovery pilot project was funded by the English Department of Health for two years from April 2008. SMART is an acronym for 'Self Management and Recovery Training'. As applied to drinking, it offers a recovery and relapse prevention aid which like Alcoholics Anonymous (AA) relies on mutual support in small groups of people recovering from drink problems, but instead of being based on the 12 steps, sees addiction as a learned behaviour which it seeks to unlearn using cognitive-behavioural principles. The US-originated system focuses on:
• building and maintaining motivation to abstain;
• coping with urges;
• managing thoughts, feelings and behaviour; and
• balancing momentary and enduring satisfactions.

SMART Recovery UK (see web site) and the national charity Alcohol Concern joined together to establish the SMART Recovery project to pilot the model at six sites in England. It aimed to test whether non 12-step mutual aid can flourish and become self-sustaining with a view to facilitating take-up by areas across England. Such a development would in particular redress the lack of aftercare following formal treatment for patients uncomfortable with AA, but might also offer a recovery and relapse prevention option in its own right.

The featured evaluation report (for full report click title of this entry; for summary click here) was one of the project's outputs. It was not intended to quantify drinking outcomes but to determine whether the project's methods had proved a feasible way to establish new mutual aid groups of these kinds in the six areas, and whether these developments were acceptable to alcohol treatment/help services and potential group members. The researchers relied largely on analysing documents related to the project, observing its work, and on the views of those involved, gathered via interviews, focus groups, and questionnaires.
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Warring Cultural Icons? Addiction and Mental Illness as Brain Diseases

The two primary (New York) intellectual organs, the New York Review of Books and New York Times, have recently featured two powerful cultural icons saying exactly opposite things about prescription pharmaceuticals and “brain disease.”

In an ongoing two-part series in the NYRB (part 1 is in the June 23rd issue), Marcia Angell, the first woman editor-in-chief of the New England Journal of Medicine and now at the Harvard Medical School, argues against the firmly ensconced American view that mental illness can be–it has been–resolved to brain functioning. The Times, for its part, once again supports the slightly-more-come-lately view of addiction as a brain disease with a profile of Nora Volkow, the visionary director of the National Institute on Drug Abuse (NIDA).  > > > >   Read More

Prevention of Alcohol Dependence: Strategies for Selective, Indicated, and Universal Prevention

Study of the chronology of criteria of dependence in alcohol dependence syndrome (ADS) can enable us to design strategies for the prevention for ADS, which takes into account primary prevention (indicated, selective, and universal prevention) approaches and aims at reducing the occurrence of ADS. 

The objective of this work is to study the age-wise and order-wise chronologies of International Classification of Diseases Tenth Revision Diagnostic Criteria for Research (ICD-10 DCR) dependence criteria in individuals with ADS. 

Consecutively admitted and consenting inpatients with ICD-10 DCR diagnosis of ADS were evaluated in a structured interview after detoxification using Semi-Structured Assessment for the Genetics of Alcoholism (SSAGA)-II. The total sample size was 81. The mean ages at the first onset of alcohol use, development of the first criterion, and ICD-10 dependence was 18.72 years (SD: 6.84), 24.33 years (SD: 9.21), and 27.51 years (SD: 9.28), respectively. 

In age-wise chronology, tolerance, loss of control, and craving were present in 97.53%, 80.24%, and 79%, respectively, of our study sample. In order-wise chronology, either craving (16%) or tolerance (71.6%) was present as the first criterion and the presence of craving (16%), tolerance (21%), or loss of control (18.5%) was observed as the first criterion in 55.5% of the subjects. 

Indicated prevention may be attempted by enquiring about craving, tolerance, and loss of control and use of anticraving medications or behavioral strategies. 

Selective prevention by using naltrexone for those genetically inclined and universal prevention by use of “clinical” labeling on alcoholic beverages can also be attempted.

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Levels of explanation in psychiatric and substance use disorders: implications for the development of an etiologically based nosology

The soft medical model for psychiatric illness, which was operationalized in DSM-III, defines psychiatric disorders as syndromes with shared symptoms, signs, course of illness and response to treatment. Many in our field want to move to a hard medical model based on etiological mechanisms. 

This essay explores the feasibility of this move and asks whether psychiatric disorders have the needed single clear level of explanation for an etiologically based nosology.

I propose seven criteria for a good explanation: (i) strength, (ii) causal confidence, (iii) generalizability, (iv) specificity, (v) manipulability, (vi) proximity and (vii) generativity. 

Applying them to cystic fibrosis, a gene-level approach to etiology performs well across the board. By contrast, a detailed review of alcohol dependence and a briefer review of major depression suggests that psychiatric disorders have multiple explanatory perspectives no one of which can be privileged over others using scientific data alone.

Therefore, a move toward an etiologically based diagnostic system cannot assume that one level of explanation will stand out as the obvious candidate on which to base the nosology. 

This leaves two options. Either a hard medical model will be implemented that will require a consensus about a preferred level of explanation which must reflect value judgments as well as science.

To take this approach, we need to agree on what we most want from our explanations. 

Alternatively, we will need to move away from the traditional hard medical model that requires that we ground our diagnoses in single biological essences, and focus instead on fuzzy, cross-level mechanisms, which may more realistically capture the true nature of psychiatric disorders.

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Request Reprint E-Mail:   kendler@hsc.vcu.edu.