Psychiatric care management for chronic addictive disorders: conceptual framework

Coexisting mental and addictive disorders are common, and service systems are not well configured to treat them. Psychiatrists frequently feel lacking in skills to address both the addictive disorder and the mental illness. Although programs for treating "dual disordered" patients have been under development, specialized programs are likely to provide treatment for only a minority of patients. Furthermore, many patients either do not respond to them or simply refuse to participate. This article describes care management, a clinical approach that can be applied to coexisting disorders by any practitioner. Care management complements rehabilitation treatment and completes the continuum of care.

Improving the quality of VA care for patients with substance-use disorders: the Quality Enhancement Research Initiative (QUERI) substance abuse module

Substance-use disorders are costly in both human and economic terms and are highly prevalent among patients in the VA Health Care System. The Quality Enhancement Research Initiative (QUERI) Substance Abuse Module (SAM) seeks to enhance identification and management of patients with substance-use disorders seen in primary care and other medical settings; bolster specialized substance-abuse treatment practices; improve care for patients with multiple comorbidities; and strengthen treatment for high-risk and underserved substance-abuse patient subgroups. This article describes how the SAM will achieve these aims by following the QUERI process steps and conducting an integrated set of research projects that incorporates literature reviews and meta-analyses, naturalistic and randomized controlled trials of promising treatments, studies of barriers to guideline implementation, and outcome-oriented evaluations of the implementation of practice guidelines.

Alcohol home delivery services: a source of alcohol for underage drinkers

OBJECTIVE

This study describes the use of alcohol home delivery services by underage drinkers, and characteristics of grocery and liquor stores that deliver alcohol. The availability of alcohol home delivery services across the United States is also described.

METHOD

Individuals surveyed were from 15 small- and medium-sized midwestern communities. Of all enrolled 12th graders, 83.5% (N = 4,487) responded, and of a randomly selected cohort of 18- to 20-year-olds, 93.9% (N = 1,721) responded. All grocery stores that sold alcohol and liquor stores in the corresponding communities were invited to participate in the study and 124 (92.5%) of those businesses completed surveys regarding outlet characteristics and practices. Data for the surveys were based on a nested cross-sectional design with individual respondents nested within the 15 communities.

RESULTS

Purchases of delivered alcohol were made by 10% of 12th graders and 7.3% of 18- to 20-year-olds within the past year; 20.2% of outlets delivered alcohol. Using bivariate analyses, purchasing delivered alcohol was associated with male gender, high-risk drinking (drinking five or more drinks on an occasion), more recent and more frequent drinking. Providing delivery services was more common among outlets selling keg beer and/or single servings. Multivariate analyses revealed positive associations between purchasing delivered alcohol and male gender for the 12th graders, and high risk and more recent drinking for both the 12th graders and 18- to 20-year-olds. For outlets, selling keg beer was positively associated with providing delivery services. A separate survey indicated that home delivery services appear to be available in many areas of the country.

CONCLUSIONS

Home delivery is a previously unidentified source of alcohol for underage drinkers that could be curtailed with effective alcohol policies.

A randomized trial of integrated outpatient treatment for medically ill alcoholic men

BACKGROUND

Medically ill alcoholics often do not respond to conventional alcoholism treatment or decline physician referrals. Integrated outpatient treatment (IOT), a new treatment specifically designed for this population, combines comprehensive medical care with alcoholism interventions.

OBJECTIVE

To compare the efficacy of IOT with that of standard treatment approaches.

METHODS

One hundred five male veterans with severe medical complications caused by alcoholism and recent drinking were randomly assigned to receive IOT or referral to standard alcoholism and medical treatment and were evaluated over 2 years. Integrated outpatient treatment patients received medical care and alcoholism interventions once or twice monthly. Patients in the control group were referred for alcoholism treatment, but few accepted. However, patients in the control group did engage in outpatient medical care.

RESULTS

At baseline, the mean +/- SD age of the control group was 57.2 + 10.0 years, compared with 52.8 +/- 11.5 years in the IOT group (P= .04). The groups were well matched in other respects. The mean +/- SD number of visits over 2 years for the IOT patients was 42.2 +/- 29.1, compared with 17.4 +/- 15.6 for the control patients (P<.001); the frequency of hospital use was similar in both groups. After 2 years, 28 (74%) of 38 surviving IOT patients and 17 (47%) of 36 control patients were abstinent (P=.02). Nearly twice as many control patients (30% [n = 16]) as IOT patients (18% [n= 9]) died, but the results of Cox survival analysis were not significant. There were no differences in symptoms of alcohol dependence, quality of life, or life problems. The incremental cost of IOT was approximately $1100 per patient per year.

CONCLUSIONS

Standard medical care alone was surprisingly effective in inducing abstinence in surviving medically ill alcoholics. Integrated outpatient treatment significantly increased both engagement and abstinence for a modest annual cost. Further refinement and testing of IOT is indicated.

Prevention and Treatment of Hypertension Study (PATHS): effects of an alcohol treatment program on blood pressure

OBJECTIVE

To determine whether blood pressure is reduced for at least 6 months with an intervention to lower alcohol intake in moderate to heavy drinkers with above optimal to slightly elevated diastolic blood pressure, and whether reduction of alcohol intake can be maintained for 2 years.

DESIGN

A randomized controlled trial.

METHODS

Six hundred forty-one outpatient veterans with an average intake of 3 or more alcoholic drinks per day in the 6 months before entry into the study and with diastolic blood pressure 80 to 99 mm Hg were randomly assigned to a cognitive-behavioral alcohol reduction intervention program or a control observation group for 15 to 24 months. The goal of the intervention was the lower of 2 or fewer drinks daily or a 50% reduction in intake. A subgroup with hypertension was defined as having a diastolic blood pressure of 90 to 99 mm Hg, or 80 to 99 mm Hg if recently taking medication for hypertension.

RESULTS

Reduction in average weekly self-reported alcohol intake was significantly greater (P<.001) at every assessment from 3 to 24 months in the intervention group vs the control group: levels declined from 432 g/wk at baseline by 202 g/wk in the intervention group and from 445 g/wk by 78 g/wk in the control group in the first 6 months, with similar reductions after 24 months. The intervention group had a 1.2/0.7-mm Hg greater reduction in blood pressure than the control group (for each, P = .17 and P = .18) for the 6-month primary end point; for the hypertensive stratum the difference was 0.9/0.7 mm Hg (for each, P = .58 and P = .44).

CONCLUSIONS

The 1.3 drinks per day average difference between changes in self-reported alcohol intake observed in this trial produced only small nonsignificant effects on blood pressure. The results from the Prevention and Treatment of Hypertension Study (PATHS) do not provide strong support for reducing alcohol consumption in nondependent moderate drinkers as a sole method for the prevention or treatment of hypertension.

A clinical tool for rating response to civil commitment for substance abuse treatment

OBJECTIVE

The objectives of this study were to develop a measure to assess patients' response to civil commitment, to test this measure on two groups of dually diagnosed patients (medically ill alcoholics and patients with dual mental and substance use disorders), and to identify patient characteristics associated with a positive response to commitment.

METHODS

The outcome of 38 male veterans civilly committed to inpatient substance abuse treatment for an average of six months was rated by their treating clinicians. Raters used the Commitment Response Form (CRF), a scale anchored to behavioral descriptions that was developed for the study and that measures outcome in five areas: patients' attitude toward recovery, substance use, medical condition, engagement in substance abuse treatment, and independence of functioning. Each patient's medical records were reviewed by two clinical staff members who made independent retrospective ratings and a joint rating using the CRF. They also made independent and joint dichotomous ratings of whether the patient was a positive responder or a nonresponder to civil commitment.

RESULTS

The CRF showed superior reliability when compared with the dichotomous rating of outcome. The scale demonstrated reasonable psychometric properties. Mean scale scores did not differ significantly by patient group; slightly more than half were rated as having a good to excellent overall response. Better outcome was associated with longer periods of previous abstinence from alcohol and a higher level of education.

CONCLUSIONS

Use of a scale anchored to behavioral descriptions improved reliability of outcome determinations by clinical staff. Civil commitment resulted in good to excellent outcome in many but not all committed patients.

The use of alcohol home delivery services by male problem drinkers: a preliminary report

Alcohol home delivery services (AHDS) provide convenient and confidential access to alcohol, yet little is known about their use. The purpose of this report is to present preliminary data describing the use of AHDS by problem drinkers. We surveyed 174 males regarding social and demographic characteristics, alcohol use history, and use of AHDS. Use of AHDS was most common among problem drinkers. When statistically controlling for the effects of demographic and social characteristics, regular drinkers without a history of alcohol problems were significantly less likely to have had alcohol delivered than problem drinkers, p = .0036. Contrary to expectation, medically ill alcoholics with advanced and disabling medical complications of heavy drinking were not more likely than other problem drinkers to have alcohol delivered. Living in an urban area and not having a vehicle available were associated with the use of AHDS. The public health and safety considerations of alcohol availability via home delivery are discussed.

Integrated outpatients treatment for medically ill alcoholic men: results from a quasi-experimental study

OBJECTIVE

This report documents the findings of a quasi-experimental study of a new approach to treating medically ill alcoholics. The intervention, the Alcohol Related Disorders (ARD) Clinic, consists of concurrent alcohol treatment and medical care delivered by an interdisciplinary team in an outpatient medical clinic at the Minneapolis Veterans Affairs Medical Center (MVAMC).

METHOD

We compared 50 ARD patients with 50 patients who met eligibility for the clinic, but had to be referred elsewhere because the clinic was full at the time (referred patients). Referred patients received medical care in other MVAMC clinics or in the community.

RESULTS

During the 2-year follow-up period, ARD patients returned for outpatient visits over three times as often as referred patients (p < .001). More referred patients received no follow-up care at MVAMC (p < .01). ARD patients had more frequent (p < .05) but briefer (p < .01) hospitalizations. Almost twice as many referred (32%) as ARD patients (18%) died during the follow-up period. Referred patients ranged from 1.18 times less likely to 5.03 times more likely to die during follow-up than those in the ARD group (p = .11). ARD patients lived for an average of 82 days longer than referred patients, and each ARD clinic visit in the second follow-up year predicted an additional 3.5 days lived (p < .01).

CONCLUSIONS

Integrated outpatient treatment for medically ill alcoholics appears to improve outpatients follow-up and alter patterns of hospitalization when compared with standard approaches. Two-year mortality may have been reduced as a result.

A comparison of the Alcohol Dependence Scale and clinical diagnosis of alcohol dependence in male medical outpatients

The Alcohol Dependence Scale (ADS) is a brief self-report instrument designed to assess the alcohol dependence syndrome. Although previous studies have reported its validity, it has only been studied in populations who were presenting for assessment or treatment of alcohol problems, and recent studies have shown lower mean scores than would be expected. To assess its utility in a primary medical setting, we retrospectively examined our experience in two groups of medical outpatients: an early intervention group and a group of medically ill alcoholics. We administered the ADS to 61 male veterans being referred to a special clinic for alcohol-related medical problems. Subjects were also assessed for alcohol dependence by experienced clinicians using a DSM-III-R checklist. ADS scores overall were much lower than would be expected, especially in the medically ill alcoholics. When subjects were dichotomized into dependent or nondependent, there was poor agreement between the two methods. The correlation between the scores was significant, however, and lowering the cut-point on the ADS from 13/14 to 2/3 improved agreement. Medically ill alcoholics who are not presenting for assessment or treatment of alcohol problems may either lack insight into their drinking habits or may be reluctant to disclose them. Although conclusions from this study are tentative until more formal studies are done, it may be most prudent to use other instruments, such as the Michigan Alcoholism Screening Test, in medical outpatients. If the ADS is used, lowering the cut-score to 2/3 may reduce false negatives. Further research on the use of the ADS in different settings and with different populations is clearly needed.

Characteristics of male medical patients referred for alcoholism treatment

PURPOSE

Medically ill alcoholics are frequently encountered in medical practice, yet little is known about this subgroup of alcoholics. Anecdotal evidence suggests that current treatment methods may be ineffective in some of these patients, and that many of them resist referral to treatment programs. In this pilot study, we sought to characterize this group, in order to determine whether further research was indicated.

BASIC PROCEDURES

In the Minneapolis VA Medical Center, we conducted a retrospective chart review of 61 alcoholics from 3 groups of alcohol-dependent patients: medical inpatients who accepted transfer to treatment, medical inpatients who refused transfer, and ambulatory patients requesting treatment. The groups were compared on demographic, physical, psychological, and laboratory characteristics, and on compliance with medical appointments. Most Important Findings: As might be expected, inpatients were older and sicker than ambulatory patients, but also demonstrated fewer nonmedical complications of alcoholism. On psychological testing, those who transferred were more likely to exhibit anxiety and depression, while the ambulatory patients were more antisocial. Inpatients who transferred differed from those who refused in having fewer previous treatments and less severe medical illness and in showing more compliance with medical recommendations in general.

PRINCIPAL CONCLUSIONS

These findings raise the possibility that these groups may significantly differ from one another, and suggest that further research on the characteristics of medically ill alcoholics is indicated. Improved characterization could potentially lead to more effective treatment approaches.

Sexual dysfunction and psychological distress in methadone maintenance

We administered the Derogatis Sexual Functioning Inventory to 25 methadone maintenance patients who had been on a stable dose of methadone for at least 2 months, and obtained ratings of depression and anxiety, levels of sex hormones, and liver function tests. Five subjects with significantly lower Global Sexual Satisfaction Index scores (p < .0001) had more psychological symptoms, higher methadone doses, poorer body image, and less sexual drive and satisfaction, but normal fund of sexual information and lifetime experience. Sexual dysfunction among methadone maintenance patients may be due to coexisting psychiatric problems rather than caused by opiates. Methadone patients presenting with sexual dysfunction should receive psychiatric evaluation.

Beneficial effects of treatment of nicotine dependence during an inpatient substance abuse treatment program

The Minneapolis Department of Veterans Affairs Medical Center began an intervention for tobacco use in its inpatient substance dependency treatment program on June 19, 1988, including an institutional smoke-free policy and a smoking cessation program. Sequential substance-dependent patients admitted before institution of the policy (n = 455) were compared with patients admitted after institution of the policy (n = 457). Patients completed self-administered questionnaires regarding smoking practices and attitudes. Seventy-six percent of patients were current cigarette smokers. Fifty-eight percent of patients after institution of the policy described themselves as "not smoking regularly," compared with 19% of patients admitted before the institution of the policy. Similar proportions of patients admitted before and after the institution of the policy believed that quitting smoking would threaten recovery. Forty-one percent of patients hospitalized after institution of the policy abstained from smoking for more than 1 week during their hospital stay. Rates of early termination of treatment did not change. We conclude that concurrent intervention for nicotine addiction during inpatient treatment of substance dependence is associated with a temporary reduction in smoking and increased motivation to quit smoking.

Thyrotropin and prolactin response to thyrotropin-releasing hormone in depressed and nondepressed alcoholic men

Thyrotropin-releasing hormone (TRH) stimulation tests were performed on 81 alcoholic men after at least 3 weeks of abstinence. Subjects were given 500 micrograms of TRH intravenously, and thyroid-stimulating hormone (TSH) and prolactin (PRL) were measured at baseline, and then 15 and 30 min later. Comparisons were made among alcoholics with (n = 27) and without (n = 54) a lifetime history of depression as determined by the Diagnostic Interview Schedule. Nine nondepressed, nonalcoholic subjects served as controls. Alcoholics with or without a depression history did not differ from each other or from control in TSH or PRL response area under the curve. Blunted TSH responses were present in 10 (12%) of the alcoholics and none of the controls when blunting was defined as a delta max TSH less than 5 microU/ml. When blunting was defined as a delta max TSH less than 7 microU/ml, 18 (22%) of the alcoholics and 1 (1%) of the controls were blunted. Conversely, 2 (2.5%) of the alcoholics had a delta max TSH greater than 32 microU/ml. All subjects were clinically euthyroid. Contrary to expectation, depressed subjects were slightly less likely to show blunted responses than nondepressed subjects. No relationship was found between neuroendocrine measurements and several measurements of alcoholism or depression. Some alcoholic subjects show a blunted TSH response to TRH injection, which may be a function primarily of the alcoholism itself. The precise mechanism remains unknown.

Psychoneuroendocrine effects of methadone maintenance

A variety of neuroendocrine and psychiatric dysfunctions have been demonstrated in humans maintained on opiates, but both have not previously been examined in the same population. We performed a series of neuroendocrine challenge tests in men participating in a methadone maintenance clinic and in normal controls. Psychiatric diagnoses were made with DSM-III Criteria, using the Diagnostic Interview Schedule, and subjects also completed the Symptom Checklist. Our results in the methadone group suggest (a) near-maximal stimulation of prolactin secretion, with a blunted prolactin response to insulin hypoglycemia, (b) mild suppression of cortisol levels, but an exaggerated cortisol response to stimulation, (c) a delayed and inhibited insulin response to food ingestion with resulting mild hyperglycemia, (d) low body weight, but elevated calorie ingestion, and (e) inability to concentrate urine when dehydrated, which was partially corrected by administration of arginine vasopressin. Phobic disorder was associated with a lower prolactin response to both inhibitory and stimulatory challenges. Depression did not appear to be related to the increased cortisol response to stimulation. These results suggest several potentially fruitful areas for future investigation, including the prolactin system and anxiety disorders, nutrient ingestion and metabolism, and posterior pituitary function.

Organic mental disorders associated with heavy drinking and alcohol dependence

Wernicke and Korsakoff first described their respective syndromes in the late nineteenth century, and they were linked to each other and to thiamine deficiency by the 1940s. Korsakoff's syndrome (alcohol amnestic disorder) became almost synonymous with alcohol-related organic mental disorder because of the apparent simplicity of its manifestations and pathology, while other, more diffuse cerebral dysfunction was relegated to the poorly defined term alcoholic dementia. Work in neuropsychology, pathology, and imaging studies during the last 15 years has resulted in a new understanding of the interactions of heavy drinking, nutritional deficiency states, premorbid factors, and associated medical pathology, such as head trauma. Heavy drinking appears to result in cortical deficits and mild to moderate amnesia (intermediate brain syndrome) through an interaction of direct neurotoxicity and premorbid and associated factors. Alcohol amnestic disorder seems to result from the synergistic combination of drinking, malnutrition, and genetic vulnerability to thiamine deficiency. Dementia associated with alcoholism is most likely a combination of intermediate brain syndrome and alcohol amnestic disorder.

Alcoholism screening in the elderly

Alcoholism in the elderly is often underidentified because of the differences in the presentation and symptom patterns compared to younger individuals. One way to address this problem is through routine use of screening instruments, but up to this time, none of the instruments used to identify alcoholism in younger populations have been shown to be valid in the elderly. We studied the validity of the Michigan Alcoholism Screening Test, scored both with weighted (MAST) and unit scoring (UMAST), and two short versions: the Brief MAST (BMAST) and Short MAST (SMAST) in 52 hospitalized elderly male alcoholics and 33 nonalcoholic controls. The MAST and UMAST showed excellent sensitivity and specificity, while the SMAST was less specific, and the BMAST less sensitive and less specific. Factor structure of the two brief versions was similar to that found in younger alcoholics, suggesting that symptom constellation is not necessarily different in the elderly. We recommend the use of the MAST or UMAST for screening for alcoholism in the elderly.

Measurement of depression in alcoholics

Estimates of the prevalence of depression among alcoholics vary widely, partly because of different methods used to define depression. To assess the specificity, sensitivity, change over time and agreement of several common methods, 52 men alcoholics were studied. Using DSM-III diagnosis by clinical interview as the standard, the Hamilton Depression Scale (Ham-D) showed high sensitivity, high specificity and good agreement with DSM-III. The Beck Depression Inventory and the Depression Scale of the Minnesota Multiphasic Personality Inventory were not sensitive enough for screening purposes. Both self-report measures correlated more highly with the Ham-D and clinical interview than with each other. The dexamethasone suppression test had both low sensitivity and low specificity. All measures showed significant improvement over three weeks. More attention should be paid to using DSM-III criteria or the Ham-D instead of self-report scales in screening for depression among alcoholics.

Differences in cerebral asymmetries related to drinking history and ethnicity. A computerized axial tomography (CAT) scan study

Normal computerized axial tomography scans of 179 American Indian, black, and white subjects were examined for cerebral asymmetry patterns. Information concerning the drinking history of each subject was also obtained. Results indicated that alcohol use history was associated with differences in asymmetry patterns, above and beyond differences associated with ethnicity. In subjects without a history of alcohol use, more whites were more likely to have left asymmetry of both occipital length and width, as compared to American Indians and blacks. In subjects with a history of alcohol use, all subjects closely resembled one another, regardless of ethnicity. In the total sample, alcohol users were more likely to show greater right occipital width.

Adrenocortical hyperactivity in newly admitted alcoholics: prevalence, course and associated variables

After initial screening of 269 consecutive Psychiatry Service admissions suggested adrenal stimulation in alcoholics, 52 consecutive newly-admitted alcoholics were intensively studied in order to determine the extent of adrenal hyperactivity, how quickly it resolved and the factors associated with it. While 21% failed to show suppression of cortisol at either 0800 or 1600 hr the day following administration of dexamethasone (1 mg) at 2300 hr, no patient showed both clinical and biochemical evidence of alcoholic pseudo-Cushing's syndrome, and all patients suppressed normally eight days later. Analysis of a variety of variables, including several measures of recent alcohol consumption, alcohol withdrawal and depression failed to show significant association with nonsuppression. The DST should be interpreted cautiously in alcohol abusers during the first 10-14 days following admission. Persistent nonsuppression, however, is probably not due to alcohol abuse.