Thomas G. Brown

Effect of Chronic Alcohol Consumption on the Activity of the Hypothalamic-Pituitary-Adrenal Axis and Pituitary β-Endorphin as a Function of Alcohol Intake, Age, and Gender

BACKGROUNDnExperimental evidence indicates that components of the hypothalamic-pituitary-adrenal (HPA) axis and of the endogenous opioid system, such as beta-endorphin (beta-END), influence alcohol consumption, whereas chronic alcohol abuse alters the activity of both systems. Furthermore, gender and age differences have been reported in the activity of the HPA axis under basal conditions, in response to stress and acute alcohol challenge. The objective of the present studies was to investigate the hypothesis that chronic alcohol consumption alters the activity of the HPA axis and pituitary beta-END as a function of severity of alcohol abuse, gender, and age.nnnMETHODSnThree age groups of each gender (18-29, 30-44, and 45-60 years old) were recruited. Each age and gender group included four subgroups: (a) nondrinkers, (b) light drinkers, (c) heavy drinkers, and (d) alcoholics in treatment. Demographic characteristics, alcohol consumption, and presence of alcohol dependence were recorded by using a structured interview. Blood samples were taken on the day of the interview. The levels of plasma adrenal corticotropic hormone (ACTH), cortisol, and beta-END were estimated as an index of the activity of the HPA-axis and pituitary beta-END.nnnRESULTSnPlasma ACTH and beta-END levels were significantly lower in females than males of all age and drinking category groups. Plasma cortisol levels were higher in 18- to 29-year-old female subjects compared with the 18- to 29-year-old male subjects. The plasma ACTH and beta-END levels were lower whereas plasma cortisol levels were higher in heavy drinkers than nondrinkers. This decrease in plasma ACTH and beta-END levels with heavy drinking was more pronounced in female than male subjects of the 30-44 and 45-60 age groups.nnnCONCLUSIONSnChronic drinking, gender, and age influence the activity of the HPA-axis and pituitary beta-END, which in turn may influence drinking behavior.

Matching substance abuse aftercare treatments to client characteristics.

This study investigated matching client attributes to different aftercare treatments. A naturalistic sample of adults entering substance abuse treatment was randomized into either Structured Relapse Prevention (RP, n=61) or a 12-Step Facilitation (TSF, n=72) aftercare program. Four patient attributes were matched to treatment: age, gender, substance abuse profile, and psychological status. Substance use outcomes were assessed 3 and 6 months posttreatment. At 6 months, four significant matches were uncovered. Females and individuals with a multiple substance abuse profile reported better alcohol outcomes with TSF aftercare than their cohorts exposed to RP aftercare. Individuals with high psychological distress at treatment entry were able to maintain longer periods of posttreatment abstinence with TSF aftercare compared to their cohorts exposed to RP. Inversely, RP was found to maintain abstinence significantly longer for individuals reporting low distress compared to those with high distress. Finally, better outcomes were achieved when random assignment to aftercare was consistent with participant preference. Overall, an Alcoholics Anonymous approach to aftercare appears to provide the most favorable substance use outcomes for most groups of substance abusers. RP may be most suitable for clients whose psychological distress is low, especially where maintenance of abstinence is targeted. Where choice in aftercare program is possible, matching client preference with type of aftercare program can improve outcome.

The incidence and characteristics of violent men in substance abuse treatment

Linkage between marital violence and substance abuse has been noted in men seeking treatment for substance-use disorders. The present study examined (1) the incidence of family violence in men admitted into substance abuse treatment; (2) the psychosocial characteristics associated with marital violence; and (3) the comparability of violent substance abusers to their treatment cohorts. Fifty-nine men in substance abuse treatment involved in a significant relationship in the past year were assessed for substance abuse, family violence, psychosocial functioning, and personality attributes. Fifty-eight percent of men reported at least one incident of physical familial violence in the past year, while 100% of the men reported having engaged in psychological abuse in the past year. Additionally, greater violence was associated with interpersonal insensitivity, hostile outbursts, and poorer overall functioning independent of substance abuse. Finally, violent male substance abusers reported significantly more hostility, suspiciousness, projection of blame, and interpersonal inadequacy than did the less violent substance abusers. These findings suggest that, in drug-treatment settings, systematic objective screening for family violence is routinely called for.

Brief Motivational Interviewing for DWI Recidivists Who Abuse Alcohol and Are Not Participating in DWI Intervention: A Randomized Controlled Trial

BACKGROUNDnDriving while impaired (DWI) recidivists with unresolved alcohol use problems pose an ongoing risk for traffic safety. Following conviction, many do not participate in mandated alcohol evaluation and intervention programs, or continue to drink problematically after being relicensed. This study investigated if, in DWI recidivists with alcohol problems and not currently involved in DWI intervention, Brief Motivational Interviewing (BMI) produced greater reductions in risky drinking at 6- and 12-month follow-up compared to an information-advice control condition. Additional analyses explored whether BMI was associated with greater readiness to change, subsequent substance abuse treatment service utilization, and satisfaction compared to the control condition.nnnMETHODSnMale and female recidivists with drinking problems and not currently engaged in DWI intervention were recruited, evaluated, and then randomly assigned to receive 1 of 2 manualized interventions: 30-minute BMI session or information-advice. Participants, interviewers, researchers, and statisticians were blind to assignment. Outcomes were changed in: percent of risky drinking days (i.e., > or =3 standard drinks/d for males; > or =2 for females) in the previous 6 months derived from the Timeline Followback, biomarkers of alcohol abuse (GGT, AST, ALT, MCV) by blood assay, and alcohol abuse-related behaviors using the MMPI-Mac scale. Data from the Readiness to Change Questionnaire, a substance abuse service utilization questionnaire, and the Client Satisfaction Scale were also collected.nnnRESULTSnAnalyses revealed significant declines in risky drinking with both interventions. BMI (n = 92) resulted in a 25% reduction in risky drinking days at 12-month follow-up, which compared to the control intervention (n = 92) represented a significant decline from 6-month levels. Exposure to BMI also produced significantly greater improvement at 6-month follow-up in a biomarker of alcohol abuse and a behavioral measure related to recidivism risk. Exploration of readiness to change, substance abuse service utilization, and satisfaction with intervention indicated a perception of BMI being more useful in coping with problems.nnnCONCLUSIONSnBrief MI approaches warrant further implementation and effectiveness research as an opportunistic DWI intervention strategy to reduce risks associated with alcohol use outside of clinical and DWI relicensing settings.

Violent substance abusers in domestic violence treatment.

Although substance abuse is frequently encountered in men receiving services in violence treatment settings, systematic study of these ‘dual-problem’ men has lagged. This study had two main objectives: (1) the characterization of psychoactive substance abuse disorders in a naturalistic sample of men in domestic violence treatment; and (2) clarification of the role of substance abuse on the sociodemographic, personality, psychosocial, and abuse characteristics of dual-problem men. Fifty-three adult men who were attending domestic violence treatment were recruited. They were administered the Addiction Severity Index, the Conflicts Tactics Scale, Structured Clinical Diagnostic Interview, the 16PF and the Symptoms Checklist-90. Partners, when available, were asked to provide corroboration. Sixty-three percent of the men had a current diagnosis of psychoactive substance abuse or dependence, while 92.5% had a lifetime diagnosis. Of the former, the majority was diagnosed as multiply dependent on alcohol and other drugs. As the severity of the substance abuse increased, so too did the dangerousness and frequency of abusive behaviors. Moreover, dual-problem men reported more hostility, apprehension, frustration and suspiciousness and past arrests than did their violence-only cohorts as well as a history of multiple (unsuccessful) treatments for substance abuse. These findings suggest that the trend toward multiple drug complaints seen in other clinical milieus is also being confronted in conjugal violence settings. In addition to the greater therapeutic challenge such dual-problem men present, these findings speak to the need to investigate integrated treatment approaches to improve the outlook of men grappling with both conjugal violence and multiple substance abuse problems.

Strategies to increase research-based practice: interplay with unit culture.

Purpose: A major focus of clinical nurse specialist nursing practice is the integration of research findings into practice. The purpose of this study was to describe strategies used to facilitate research utilization (RU) by nurses in a practice setting. Design: This multiple-case study identified the strategies that clinical nurse specialists and masters degree-prepared nurse educators, working collaboratively, used to facilitate RU. Setting/Sample: The setting included 8 units in 4 sites of a university hospital with all willing nurses participating. Methods: Open-ended focus groups and individual interviews and observational sessions were conducted using investigator-designed interview guides. Comprehensive qualitative analysis led to identification of categories and themes related to RU and the unit culture that supported it. Findings: Findings demonstrated that strategies to facilitate RU by staff at the unit level included conducting original research, supporting nurses participating in research, assessing and meeting staff learning needs, promoting staff attendance at conferences, stimulating goal-setting for presentations and publications, encouraging and responding to new ideas, questioning practice and stimulating inquiry, capitalizing on expertise in research knowledge and skills, and generating information and material resources. Characteristics of unit culture were linked to varying degrees of success with these strategies. The interplay of strategies with unit culture and research-based practice is described. Conclusion: A wide repertoire of strategies is needed to facilitate RU, and the outcome of these strategies is influenced by the unit culture. Implications for Practice: Consideration of the findings and the scope of the strategies used by nurses in the study can help clinical nurse specialist and other nursing leaders facilitate the building of practice on research.

Motivational interviewing and clinical psychiatry.

Objectives: Our objectives were as follows: 1) to survey the literature on motivational interviewing (MI), “a client-centered yet directive method for enhancing intrinsic motivation to change by exploring and resolving client ambivalence” and a well-established method of brief intervention, especially in the field of addictions treatment; 2) to review hypotheses about its mode of action; and 3) to discuss its possible impact on clinical psychiatry, in particular, on teaching communications skills. Method: Literature reviews and metaanalyses of numerous clinical trials of MI for addictions treatment have already been published and are briefly summarized. So far, no literature survey exists for MI applied to psychiatric patients. This review is limited to a synthesis of the articles relevant to psychiatry and to comments based on our teams experiences with MI. Results: There is no evidence that MI achieves better results than other established techniques for treating addictions; it may simply work faster. The explanation for the methods rapid effectiveness remains speculative. Outcomes concerning the application of MI to psychiatric patients, although preliminary, are promising. Methods of assessing the integrity of MI treatment are more developed than in most psychotherapies, which permits the learning progress of trainees to be measured. Conclusions: MI offers a complement to usual psychiatric procedures. It may be worthwhile to teach it, not only for addictions but also for other broad treatment issues, such as enhancing patients medication compliance and professionals communication skills. Questions remain concerning MIs feasibility in psychiatry settings.

Alcohol and cocaine abusers 6 months after traditional treatment: do they fare as well as problem drinkers?

Problem drinkers (N = 49) and individuals presenting with both alcohol and cocaine problems (N = 51) admitted to a traditional 28-day alcoholism treatment milieu were compared on their psychosocial, psychological, neuropsychological functioning and substance abuse at admission as well as at six months posttreatment follow-up. On admission, alcohol and cocaine patients were younger, more likely to live alone or with their family of origin, to report having started using alcohol at an earlier age, to have fewer alcohol-related problems and to have fewer years of but more diversity in their substance abuse than the alcohol-only patients. Otherwise both groups were more similar than different on psychosocial, psychological and neuropsychological dimensions. At six-months posttreatment, both groups showed similar improvement on most dimensions of functioning measured. However, a significantly greater proportion of the alcohol and cocaine abusers admitted to having relapsed in the previous six months, reported significantly fewer average days of abstinence than the alcohol group since terminating treatment, and were more likely to present urine specimens indicative of recent substance abuse at the six-month follow-up interview. Thus, traditional approaches to alcoholism treatment may be less effective in establishing abstinence for individuals with both alcohol and cocaine problems. Adaptations to treatment to reduce the risk for relapse faced by alcohol and cocaine abusers in such milieu are discussed.

Alcoholics also dependent on cocaine in treatment: Do they differ from “pure” alcoholics?☆

Although individuals who exhibit both alcohol and cocaine dependency are seen increasingly in traditional alcoholism rehabilitation settings, their comparability with pure alcoholics is unclear. Sociodemographic, psychological, cognitive, and substance abuse status were, therefore, monitored in a group of alcoholics (n = 64) versus a group of cocaine dependent alcoholics (n = 82) on admission and just prior to discharge from 28-day multimodal treatment settings. At admission, cocaine-dependent alcoholics were younger, more likely to be unmarried, have more extensive substance use histories as well as more frequent prior treatments than pure alcoholics. Additionally, members of both groups exhibited abnormalities on psychological indices. Both psychological and cognitive indices revealed significant between-group differences which subsequent analyses found to be a confound of the marked age discrepancy between groups. From admission to discharge, scores on both psychological and cognitive indices declined significantly in both groups. Urine assay data revealed a greater tendency for cocaine-dependent alcoholics to relapse during treatment. While the psychological and cognitive data largely argue for the comparability of groups of patients classified as pure alcoholics with those who are dependent on both alcohol and cocaine, the latter group may have more difficulty in achieving abstinence during treatment. The interpretability of behavioral indices gathered only at treatment admission is questioned.

Levels and circadian rhythmicity of plasma ACTH, cortisol, and β-endorphin as a function of family history of alcoholism

RationaleIndividuals with a family history of alcoholism may present a dysfunction in the activity of the hypothalamic–pituitary–adrenal (HPA) axis that predates the development of alcoholism.ObjectiveThe present study investigated the hypothesis that this HPA-axis dysfunction is associated with alterations in the pattern of the circadian (24xa0h) secretions of adrenal corticotropic hormone (ACTH), cortisol, and β-endorphin.MethodsMen with [high risk (HR)] or without [low risk (LR)] family history of alcoholism participated in the study. Blood samples were drawn every 30xa0min for 24xa0h for estimation of the plasma hormone levels. Participants ingested meals at predetermined intervals and filled out mood questionnaires prior to the placement of the catheter and 1xa0h after each meal.ResultsThe circadian peaks for β-endorphin, ACTH, and cortisol occurred between 0800 and 0830 hours in both LR and HR participants. The plasma ACTH and β-endorphin concentrations were lower in HR than LR participants, while the plasma cortisol concentrations were similar between HR and LR participants. For each hormone, the total 24-h secretion was estimated from the area under the 24-h time–concentration curve (AUC). For ACTH and β-endorphin, but not the cortisol, AUC were lower in HR than LR participants. LR participants reported being more nervous than HR participants. For the LR participants, but not HR participants, the initial mood ratings of “nervous” were positively correlated with the initial plasma cortisol and β-endorphin concentrations as well as with the cortisol and β-endorphin AUC.ConclusionsHR participants presented lower plasma concentrations as well as lower AUC for β-endorphin and ACTH but not for cortisol. This suggests a dysfunction of the HPA-axis in HR participants that predates the development of alcoholism and a dissociation between plasma ACTH and cortisol levels as a function of family history of alcoholism.