Medical Treatment of Alcohol Dependence: A Systematic Review

To summarize published data on pharmacologic treatments for alcohol dependence alone and in combination with brief psychosocial therapies that may be feasible for primary care and specialty medical settings.

We conducted electronic searches of published original research articles and reviews in MEDLINE, SCOPUS, CINAHL, Embase, and PsychINFO. In addition, hand searches of reference lists of review articles, supplemental searches of internet references and contacts with experts in the field were conducted. Randomized controlled studies published between January 1960 and August 2010 that met our inclusion/exclusion criteria were included.

A total of 85 studies, representing 18,937 subjects, met our criteria for inclusion. The evidence base for oral naltrexone (6% more days abstinent than placebo in the largest study) and topiramate (prescribed off-label) (e.g., 26.2% more days abstinent than placebo in a recent study) is positive but modest. Acamprosate shows modest efficacy with recently abstinent patients, with European studies showing better results than U.S. ones. The evidence-base for disulfiram is equivocal. Depot naltrexone shows efficacy (25% greater reduction in rate of heavy drinking vs. placebo, in one of the largest studies) in a limited number of studies. Some studies suggest that patients do better with extensive psychosocial treatments added to medications while others show that brief support can be equally effective.

Although treatment effects are modest, medications for alcohol dependence, in conjunction with either brief support or more extensive psychosocial therapy, can be effective in primary and specialty care medical settings.


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Why should I comply? Sellers' accounts for (non-)compliance with legal age limits for alcohol sales.

Availability is an important predictor of early and excessive alcohol consumption by adolescents. Many countries have implemented age limits to prevent underage purchases of alcohol. However, shop-floor compliance with these age limits appears to be problematic. This study addresses the issue of non-compliance with age limits. Which measures do vendors take to avoid underage alcohol sales, and what do they report as important reasons to comply or not with age limits for alcohol sales?

Open-ended telephone interviews were conducted with store managers selling alcohol (N=106). Prior to the interviews, all outlets were visited by an underage mystery shopper in order to measure compliance with the legal age limits on alcohol sales. The interview results are compared against actual compliance rates.

Several measures have been taken to prevent underage sales, but the compliance level is low. Furthermore, open coding resulted in 19 themes, representing both valid and invalid arguments, that vendors mentioned as relevant to their decisions of whether to comply with the law. Compliance with age limits is dependent on the knowledge of the rules and the ability and motivation to follow the rules. The ability aspect in particular seems to be problematic, but in many cases, the motivation to actively comply with the age limits is lacking.

To enhance compliance, it is important to raise the awareness of the importance of age limits and to connect possible violations of the regulations to negative consequences.

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Wine and Health: A Review

As indicated by epidemiological studies, regular and moderate wine consumption, particularly red wine, has been associated with health benefits. Clinical studies and work performed with animal models indicate that wine may protect against cardiovascular disease, atherosclerosis, hypertension, certain types of cancer, type 2 diabetes, neurological disorders, and metabolic syndrome.

The mechanism of action has been attributed to antioxidant, lipid regulating, and anti-inflammatory effects. A variety of wine constituents have been studied in various disease models. Both the alcoholic and polyphenolic components of wine are believed to contribute to these beneficial effects.

As wine is a complex mixture, it is likely that a multitude of chemical constituents, as well as their metabolites, work synergistically to impact human health. In sum, although wine drinking may be contraindicated in certain individuals, in healthy people, regular consumption of moderate amounts of wine may protect against certain chronic health conditions


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APHA 140th Annual Meeting and Exposition San Francisco, CA • October 27-31, 2012

2012 Annual Meeting Call for Abstracts Now Open

The American Public Health Association is announcing the Call for Abstracts for the 2012 Annual Meeting to be held October 27-31 in San Francisco, CA. The theme is Prevention and Wellness Across the Lifespan.

We encourage abstracts in all areas of public health and are also interested in abstracts that focus on the Annual Meeting theme. All abstracts must be submitted online. An easy to use online form will walk you through the process step-by-step. The deadlines for submission of abstracts range from Feburary 6-10, 2012 depending on the Section, SPIG, Caucus or Forum to which you wish to submit your abstract. All submissions will end at 11:59 pm Pacific Standard Time on the due date listed on the Call for Abstracts. No late submissions will be accepted.

You do not need to be an APHA member to submit an abstract. However, if your abstract is accepted for presentation, the presenting author MUST become an APHA Individual member and MUST register for the Annual Meeting by the September advance registration deadline. Submission of an abstract implies a commitment to make the presentation at the annual meeting, therefore please make sure you understand what is required of you before submitting.

START YOUR ABSTRACT SUBMISSION

A prospective study of mortality up to eight years after starting treatment for alcohol and drug problems in Stockholm County: 2000–2008 Read More:

Research indicates an association between substance use and premature death and that misuse of illicit drugs is more closely linked to mortality than alcohol misuse. Given that these studies often are based on homogeneous treatment populations, we sought to analyse long-term mortality among both alcohol and drug misusers in a representative treatment system sample by examining: (1) excess death ratios (SMR, standardised mortality ratio) in comparison with the general population and (2) risk factors for mortality within the sample.

Prospective study (N = 1659; 28% women) interviewed when starting treatment in Stockholm County, 2000–2002, and followed-up with regard to mortality up to 8 years after baseline. Analyses were based on death certificates and intake interview data (demographics, social situation/support, ICD-10 alcohol/drug dependence, treatment experiences). The strength of the study is the prospective design, that we have been able to link mortality to interview data, and to reach a heterogeneous treatment population.

(1) SMR was 5.7 (no sex difference). (2) Logistic regression showed that being older, male, retired and having reported living with a substance misuser were identified as risk factors for mortality within the sample. Housing organised by authorities and no dependence on alcohol/drugs were protective factors. The mortality risk did not differ between alcohol and drug-dependent cases. Neither was homelessness, living situation (3 years) nor education predictive of mortality.

No difference regarding mortality risk between treated alcohol and drug-dependent patients in Sweden is found when controlling for age.

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Request Reprint E-Mail: jessica.storbjork@sorad.su.se

FASD News - 3/2012

Medical News Today - No Safe Level Of Alcohol During Pregnancy

The authors of a study published online on Tuesday that was designed to overcome the difficulties of obtaining accurate and reliable data in Fetal Alcohol Syndrome research, say their findings reinforce the warning that there is no safe level of alcohol consumption during pregnancy.

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Edmonton Journal (Canada) - Justice system struggles to deal with fetal alcohol disorder

Since the Alberta government launched its 10-year plan on FASD five years ago — a strategy with heavy emphasis on screening and education — more offenders are coming to court already diagnosed with FASD, and the justice system is struggling to find the most effective ways to deal with them.

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Daily Mail - Mothers warned drinking during seventh to 12th week of pregnancy puts unborn babies at highest risk of foetal alcohol syndrome

Drinking regularly during pregnancy is known to increase the odds of having children with foetal alcohol syndrome. However, scientists have now found that the risk to a woman's baby is highest if they consume alcohol in the seventh to 12th week.

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AngolaPress (Angola) - Sociologist warns about alcohol consumption during pregnancy

The sociologist Maria Fernanda Nguenda, on Tuesday here criticised pregnant women that consume alcoholic drinks, putting at risk their own health and their babies, ANGOP has learnt.

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MyHealthNewsDaily (Denmark) - 1-2 Drinks a Week Can Raise Miscarriage Risk

Drinking even a small amount of alcohol could increase the risk of miscarriage during the first four months of pregnancy, a new study from Denmark suggests.

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MedicalXpress (USA) - SDSU researchers develop an assessment tool to identify birth defects

Researchers with the National Children’s Study at South Dakota State University, in collaboration with Dr. H. Eugene Hoyme, chief academic officer at Sanford Health and president and senior scientist for Sanford Research/University of South Dakota, are working to develop a standardized assessment tool that would be used to identify birth defects in infants.

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MATERIALS and BLOGS

Empowering Front-Line Staff and Families Through a Collection of Lived Experiences

NAT member Anne Guarasci and colleagues at the College of New Caledonia have developed a resource for front-line workers who work with women who have FASD or FASD behaviours and characteristics.

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POPFASD - 2 New eLearning Videos featuring Kim Barthel

There are two new eLearning videos available on the POPFASD website. In the first video, Kim Barthel speaks about the "Brain and FASD" and in the second video, she discusses the "Theory of Attachment". The videos are excerpts from the 2009 POPFASD District Partner Meeting in Richmond, B.C.

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Daysofwanderandgrace - O’Malley on ADHD in FASD

Chapter 4 of Kieran O’Malley’s ADHD and Fetal Alcohol Spectrum Disorders is the most comprehensive research-based discussion I’ve found about the unique challenges ADHD poses in FASD. It was published in 2007, so there is more recent research than O’Malley reviews here.

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Urban Servant - FASD: Not Diagnosed and Identified to The Legal System......

Yesterday at the Legal Aspects of FASD seminar Hon. Anthony P. Wartnick quoted these two sources... There is a fundamental principle of juvenile and adult criminal law which is this. "The treatment of criminal offenders as rational, autonomous and choosing agents is a fundamental organizing principle of our criminal law."

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RESEARCH

Alcoholism - Prenatal Alcohol Exposure Patterns and Alcohol-Related Birth Defects and Growth Deficiencies: A Prospective Study

The physical features of fetal alcohol syndrome include smooth philtrum, thin vermillion border, short palpebral fissures, microcephaly, and growth deficiencies on weight and height. However, little is known about the specific quantities of alcohol exposure, pattern of drinking, timing of exposure, and magnitude of risk for each of these features.

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Alcohol and Alcoholism - Placental Hypoxia and Foetal Development Versus Alcohol Exposure in Pregnancy

To examine the causes of variability in the effect of maternal drinking on the foetus, with particular reference to the pattern, frequency and duration of the period of drinking, differences in maternal, foetal and placental metabolism of ethanol/acetaldehyde, and genetic factors.

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International Journal of Epidemiology - Moderate alcohol intake during pregnancy and risk of fetal death

Even low amounts of alcohol consumption during early pregnancy increased the risk of spontaneous abortion substantially. The results indicate that the fetus is particularly susceptible to alcohol exposure early in pregnancy.

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The American Journal of Occupational Therapy - Neurocognitive Habilitation Therapy for Children With Fetal Alcohol Spectrum Disorders: An Adaptation of the Alert Program

The authors carried out a neurocognitive habilitation group therapy with the goal of increasing self-regulation in kids with FASD. The therapy consisted of a 12 week program using techniques adapted from the Alert Program, in which children learn to identify their state of regulation by recognizing when they are over-aroused (their engine is running “too high”), under-aroused (their engine is running “too low”), or at an optimal state of alertness (their engine is running “just right”).

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IN OTHER LANGUAGES

AGI - Agenzia Giornalistica Italia (Italy) - Alcol: dopo 7 settimane di gravidanza a rischio feto

Bere regolarmente durante la gravidanza aumenta le probabilita' di avere figli con sindrome feto-alcolica. Tuttavia, un gruppo di scienziati statunitensi ha ora dimostrato che il rischio per il bambino aumenta se la mamma consuma alcool dalla settima alla dodicesima settimana.

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Healthylives (Netherlands) - Ook een beetje alcohol slecht tijdens de zwangerschap

Dat het drinken van alcohol tijdens de zwangerschap ernstige gevolgen kan hebben voor je ongeboren baby is bekend. Toch denken sommige zwangere vrouwen dat het drinken van af en toe een glaasje alcohol geen kwaad kan.

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A Retrospective Analysis of the Nature, Extent and Cost of Alcohol-Related Emergency Calls to the Ambulance Service in an English Region

To measure the prevalence, pattern and associated financial cost of alcohol-related ambulance call outs in the North East of England using routinely collected data from the North East Ambulance Service (NEAS).

A retrospective cohort study over a 1-year time period (1 April 2009 to 31 March 2010) using NEAS patient record forms.

In the North East, 10% of ambulance call outs were alcohol-related. Males were 2.5 times more likely than females to be attended by an ambulance on the street rather than at home. People aged 10–19 had the highest relative risk ratio (3.4) of an ambulance pick up being on the street compare with those aged over 60. These call outs and subsequent accident and emergency (A&E) attendances cost over £9 million in a 1-year period. When extrapolated to the whole country the cost could be as much as £152 million per year.

In a 1-year period, we estimated that over 31,000 ambulance call outs were alcohol-related. A large discrepancy was found between manual and electronic recording of alcohol-related ambulance attendances to A&E. The workload and cost of alcohol-related call outs is high and mostly preventable. Ambulance visits may present a teachable moment for brief intervention to reduce alcohol-related risk and harm.

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Mapping the Maintenance Stage of Recovery: A Qualitative Study among Treated and Non-treated Former Alcohol Dependents in Poland

The study provides an in-depth qualitative understanding of the maintenance stage when recovering from alcohol dependence with a focus on the broader social context of change of addictive behaviour. It explores the recovery as a subjective process within the abstinence-oriented Polish treatment system organized on the basis of the Minnesota model and is probes for group differences between treated and non-treated populations.

The study is based on qualitative data from a media-recruited sample of 29 treated and non-treated former alcohol dependents (ICD-10) in Warsaw/Poland 2006/2007. They reported a recovery time of at least 2 years (M_recovery = 11, SD = 9). In-depth, semi-structured interviews were analysed according to the problem-centred interview method using ATLAS.ti software.

A wide range of maintenance strategies potentially contributing to the stabilization of recovery from alcohol dependence was identified. However, from the respondents' point of view, the change process is contingent upon the subjective weighing of specific maintenance factors and the importance attributed to their interplay. This includes time management as well as one's ability to invest available resources and strengths in shaping and pursuing personal goals.

More commonalities than differences can be observed between groups during the maintenance stage, regardless of respondents' type of the pathway out of addiction. However, when confronting professional concepts of recovery with subjective accounts, only a subgroup conforms to the invasive, potentially normative definitions of recovery, while others do not link their recovery with identity transformation.



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Request Reprint E-Mail: zulewska@ipin.edu.pl

Interactive Influences of Neighborhood and Individual Socioeconomic Status on Alcohol Consumption and Problems

To assess cross-level interactions between neighborhood and individual socioeconomic status (SES) on alcohol consumption and problems, and investigate three possible explanations for such interactions, including the double jeopardy, status inconsistency and relative deprivation hypotheses.

Data from the 2000 and 2005 US National Alcohol Surveys were linked to the 2000 US Census to define respondent census tracts as disadvantaged, middle-class and advantaged. Risk drinking (consumption exceeding national guidelines), monthly drunkenness and alcohol problems were examined among low-, middle- and high-SES past-year drinkers (n = 8728). Gender-stratified, multiple logistic regression models were employed, and for outcomes with a significant omnibus F-test, linear contrasts were used to interpret interactions.

Cross-level SES interactions observed for men indicated that residence in advantaged neighborhoods was associated with markedly elevated odds of risk drinking and drunkenness for low-SES men. Linear contrasts further revealed a nearly 5-fold increased risk for alcohol problems among these men, relative to middle-SES and high-SES men also living in advantaged neighborhoods. Among women, neighborhood disadvantage was related to increased risk for alcohol problems, but there were no significant SES interactions. These findings did not support theories of double jeopardy and status inconsistency.

Consistent with the relative deprivation hypothesis, findings highlight alcohol-related health risks among low-SES men living in affluent neighborhoods. Future research should assess whether this pattern extends to other health risk behaviors, investigate causal mechanisms and consider how gender may influence these.


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Request Reprint E-Mail: nmulia@arg.org

The relationship between naloxone-induced cortisol and delta opioid receptor availability in mesolimbic structures is disrupted in alcohol-dependent s

Hypothalamic-pituitary-adrenal (HPA) axis responses following naloxone administration have been assumed to provide a measure of opioid receptor activity. Employing positron emission tomography (PET) using the mu opioid receptor (MOR) selective ligand [¹¹C] carfentanil (CFN), we demonstrated that cortisol responses to naloxone administration were negatively correlated with MOR availability.

In this study, we examined whether naloxone-induced cortisol and adrenocorticotropin (ACTH) responses in 15 healthy control and 20 recently detoxified alcohol-dependent subjects correlated with delta opioid receptor (DOR) availability in 15 brain regions using the DOR-selective ligand [¹¹C] methyl-naltrindole (MeNTL) and PET imaging.

The day after the scan, cortisol responses to cumulative doses of naloxone were determined.

Peak cortisol and ACTH levels and area under the cortisol and ACTH curve did not differ by group. There were negative relationships between cortisol area under curve to naloxone and [¹¹C] MeNTL-binding potential (BP_ND) in the ventral striatum, anterior cingulate, fusiform cortices, temporal cortex, putamen and a trend in the hypothalamus of healthy control subjects.

However, in alcohol-dependent subjects, cortisol responses did not correlate with [¹¹C]MeNTL BP_ND in any brain region. Plasma ACTH levels did not correlate with [¹¹C]MeNTL BP_ND in either group.

The study demonstrates that naloxone provides information about individual differences in DOR availability in several mesolimbic structures.

The data also show that the HPA axis is intimately connected with mesolimbic stress pathways through opioidergic neurotransmission in healthy subjects but this relationship is disrupted during early abstinence in alcohol-dependent subjects.

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gwand@jhmi.edu

Widespread and sustained cognitive deficits in alcoholism: a meta-analysis

The cognitive repercussions of alcohol dependence are well documented. However, the literature remains somewhat ambiguous with respect to which distinct cognitive functions are more susceptible to impairment in alcoholism and to how duration of abstinence affects cognitive recovery.

Some theories claim alcohol negatively affects specific cognitive functions, while others assert that deficits are more diffuse in nature.

This is the first meta-analysis to examine cognition in alcohol abuse/dependence and the duration of abstinence necessary to achieve cognitive recovery. A literature search yielded 62 studies that assessed cognitive dysfunction among alcoholics. Effect size estimates were calculated using the Comprehensive Meta-Analysis V2, for the following 12 cognitive domains: intelligence quotient, verbal fluency/language, speed of processing, working memory, attention, problem solving/executive functions, inhibition/impulsivity, verbal learning, verbal memory, visual learning, visual memory and visuospatial abilities.

Within these 12 domains, three effect size estimates were calculated based on abstinence duration. The three groups were partitioned into short- (<1 month), intermediate- (2 to 12 months) and long- (>1 year) term abstinence.

Findings revealed moderate impairment across 11 cognitive domains during short-term abstinence, with moderate impairment across 10 domains during intermediate term abstinence. Small effect size estimates were found for long-term abstinence.

These results suggest significant impairment across multiple cognitive functions remains stable during the first year of abstinence from alcohol. Generally, dysfunction abates by 1 year of sobriety.

These findings support the diffuse brain hypothesis and suggest that cognitive dysfunction may linger for up to an average of 1 year post-detoxification from alcohol.

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Request Reprint E-Mail: stephane.potvin@umontreal.ca

Alcohol administration attenuates hypothalamic–pituitary–adrenal (HPA) activity in healthy men at low genetic risk for alcoholism, but not in high-ris

Acute alcohol challenge studies in rodents and naturalistic observations in drinking alcoholics suggest that alcohol stimulates the hypothalamic–pituitary–adrenal (HPA) system.

The literature on respective studies in healthy volunteers is more inconsistent, suggesting differential alcohol effects depending on dosage, recent drinking history, family history of alcoholism and alcohol-induced side effects.

These papers and the putative pharmacologic mechanisms underlying alcohol effects on the HPA system are reviewed here and compared with a new study, in which we investigated how secretion of adrenocorticotrophin (ACTH) and cortisol is affected by ingestion of 0.6 g/kg ethanol in 33 young healthy socially drinking males with a paternal history of alcoholism (PHP) versus 30 family history negative (FHN) males.

Alcohol and placebo were administered in a 2-day, double-blind, placebo controlled crossover design with randomized administration sequence

After administration of placebo, ACTH and cortisol decreased steadily over 130 minutes. In FHN subjects, secretion of both hormones was even more attenuated after alcohol, resulting in significantly lower levels compared with placebo. In PHP subjects, no alcohol effect on hormone secretion could be detected. The ratio of cortisol to ACTH secretion, each expressed as area under the secretion curve, was significantly increased by alcohol in FHN and PHP participants.

These results argue against HPA stimulation being a mechanism that promotes the transition from moderate to dependent drinking. The fact that alcohol-induced HPA suppression was not detected in PHP males is consistent with the general concept that subjects at high risk for alcoholism exhibit less-pronounced alcohol effects.

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ulrich.zimmermann@uniklinikum-dresden.de