Craving for alcohol and drugs in animals and humans: biology and behavior

Research studies indicate that sites and pathways for appetitive drive states, that are located in the limbic system, appear to be responsible for normal and pathological craving for alcohol and other addicting drugs. Pathological craving for alcohol and drugs in humans has been substantiated by animal studies, which have identified neurosubstrates and neurotransmitters associated with behavioral models of addiction. Repetitive administration of alcohol and drugs appears to affect hedonic homeostasis of the appetitive drives leading to the hedonic alleostasis where negative reinforcement exceeds positive returns despite continued drug use. Neuroimaging studies have concentrated on areas in the brain related to reward or reinforcement of alcohol/drug use, but the technique can be employed to find support for a neurosubstrate to distinguish normal craving or "liking" from pathological craving or "wanting" a drug. Identifying the neurobasis of "wanting" a drug long after not "liking it" is central to understanding pathological craving and loss of control over drug use in addiction in humans. Neuroimaging is currently the only method to directly visualize sites for craving in the brain in humans. Neuroimaging techniques will provide methods, which are not possible in animals, for studying addictive disease in humans.

Genetic comparison of seizure control by norepinephrine and neuropeptide Y

Epilepsy is a disease of neuronal hyperexcitability, and pharmacological and genetic studies have identified norepinephrine (NE) and neuropeptide Y (NPY) as important endogenous regulators of neuronal excitability. Both transmitters signal through G-protein-coupled receptors, are expressed either together or separately, and are abundant in brain regions implicated in seizure generation. NPY knock-out (NPY KO) and dopamine beta-hydroxylase knock-out (DBH KO) mice that lack NE are susceptible to seizures, and agonists of NE and NPY receptors protect against seizures. To examine the relative contributions of NE and NPY to neuronal excitability, we tested Dbh;Npy double knock-out (DKO) mice for seizure sensitivity. In general, DBH KO mice were much more seizure-sensitive than NPY KO mice and had normal NPY expression, demonstrating that an NPY deficiency did not contribute to the DBH KO seizure phenotype. DKO mice were only slightly more sensitive than DBH KO mice to seizures induced by kainic acid, pentylenetetrazole, or flurothyl, although DKO mice were uniquely prone to handling-induced seizures. NPY contributed to the seizure phenotype of DKO mice at high doses of convulsant agents and advanced stages of seizures. These data suggest that NE is a more potent endogenous anticonvulsant than NPY, and that NPY has the greatest contribution under conditions of extreme neuronal excitability.

Alpha(1) and beta(2) adrenoreceptor agonists inhibit pentylenetetrazole-induced seizures in mice lacking norepinephrine

It has been known for many years that norepinephrine (NE) is a potent endogenous anticonvulsant, yet there is confusion as to which receptor(s) mediate this effect. This is probably due to multiple factors, including the importance of distinct signaling pathways for different seizure paradigms, a lack of comprehensive pharmacological studies, and difficulty in interpreting existing pharmacological results due to the presence of endogenous NE. We sought to circumvent these problems by testing the anticonvulsant activity of selective agonists for most known adrenoreceptors (ARs) in dopamine beta-hydroxylase knockout (Dbh -/-) mice that lack endogenous NE. Dbh -/- mice are hypersensitive to pentylenetetrazole (PTZ)-induced seizures, demonstrating that endogenous NE inhibits PTZ-induced seizures in the wild type. Pretreatment of Dbh -/- mice with an alpha(1)AR or beta(2)AR, but not an alpha(2)AR or beta(1)AR agonist significantly protected against PTZ-induced seizures. In contrast, only the beta(2)AR agonist showed anticonvulsant activity in heterozygous controls. Furthermore, an alpha(1)AR antagonist exacerbated PTZ-induced seizures in control mice, whereas a beta(2)AR antagonist had no effect. We conclude that activation of the alpha(1)AR is primarily responsible for the anticonvulsant activity of endogenous NE in the murine PTZ model of epilepsy. Endogenous NE probably does not activate the beta(2)AR under these conditions, but exogenous activation of the beta(2)AR produces an anticonvulsant effect.

Why physicians are unprepared to treat patients who have alcohol- and drug-related disorders

Most primary care physicians do not feel competent to treat alcohol- and drug-related disorders. Physicians generally do not like to work with patients with these disorders and do not find treating them rewarding. Despite large numbers of such patients, the diagnosis and treatment of alcohol- and drug-related disorders are generally considered peripheral to or outside medical matters and ultimately outside medical education. There is substantial evidence that physicians fail even to identify a large percentage of patients with these disorders. Essential role models are lacking for future physicians to develop the attitudes and training they need to adequately approach addiction as a treatable medical illness. Faculty development programs in addictive disorders are needed to overcome the stigma, poor attitudes, and deficient skills among physicians who provide education and leadership for medical students and residents. The lack of parity with other medical disorders gives reimbursement and education for addiction disorders low priority. Medical students and physicians can also be consumers and patients with addiction problems. Their attitudes and abilities to learn about alcohol- and drug-related disorders are impaired without interventions. Curricula lack sufficient instruction and experiences in addiction medicine throughout all years of medical education. Programs that have successfully changed students' attitudes and skills for treatment of addicted patients continue to be exceptional and limited in focus rather than the general practice in U.S. medical schools. The authors review the findings of the literature on these problems, discuss the barriers to educational reform, and propose recommendations for developing an effective medical school curriculum about alcohol- and drug-related disorders.

A case of cutaneous ulcerative alternariosis: rare association with diabetes mellitus and unusual failure of itraconazole treatment

Alternaria species are ubiquitous dematiaceous fungi that are increasingly recognized as pathogens in immunocompromised patients or those with significant underlying disease, but they are also pathogens in otherwise healthy hosts. We describe a case of dermal cutaneous ulcerative alternariosis in a frail 83-year-old patient with diet-controlled diabetes mellitus. Histological analysis revealed hyphal morphology in tissue sections that was initially confused with that of a zygomycetous fungus, and multiple positive culture results were necessary to identify the organism. Treatment with oral itraconazole and surgical debridement were ineffective; clinical improvement was achieved by means of treatment with intravenous amphotericin B lipid complex. We review the literature regarding the role of diabetes mellitus in cutaneous alternariosis and regarding the efficacy of treatment with itraconazole, which has been used very successfully. To our knowledge, this is only the second case report noting diabetes mellitus uncomplicated by steroid administration as a possible predisposing factor for cutaneous infection.

Ethanol-associated behaviors of mice lacking norepinephrine

Although norepinephrine (NE) has been implicated in animal models of ethanol consumption for many years, the exact nature of its influence is not clear. Lesioning and pharmacological studies examining the role of NE in ethanol consumption have yielded conflicting results. We took a genetic approach to determine the effect of NE depletion on ethanol-mediated behaviors by using dopamine beta-hydroxylase knockout (Dbh -/-) mice that specifically lack the ability to synthesize NE. Dbh -/- males have reduced ethanol preference in a two-bottle choice paradigm and show a delay in extinguishing an ethanol-conditioned taste aversion, suggesting that they drink less ethanol in part because they find its effects more aversive. Both male and female Dbh -/- mice are hypersensitive to the sedative and hypothermic effects of systemic ethanol administration, and the sedation phenotype can be rescued pharmacologically by acute replacement of central NE. Neither the decreased body temperature nor changes in ethanol metabolism can explain the differences in consumption and sedation. These results demonstrate a significant role for NE in modulating ethanol-related behaviors and physiological responses.

Effectiveness of coerced addiction treatment (alternative consequences): a review of the clinical research

Of central importance is that our clinical experience and treatment outcome studies to date strongly suggest that coercion is fundamental to addiction treatment and favorable outcomes from therapeutic interventions. Often the alcoholic/drug abuser must be given an opportunity to feel, face, or experience the "consequences" of their alcohol and drug addiction before the denial of their illness can be penetrated and motivation for treatment to recover from addictive illness can be developed. Continued use of alcohol and drugs is an unhealthy and dangerous state for those who are addicted and for others who are affected by their addictive illnesses. Effective therapeutic interventions and long-term recovery are more likely to succeed if avoiding "alternative consequences" are contingent on continued compliance with addiction treatment by those who suffer from addictive illnesses.

Prediction of treatment outcomes: lifetime depression versus the continuum of care

We sought to determine the impact of a lifetime diagnosis of major depression on addiction treatment outcome. Structured interviews were conducted upon admission, and consecutive structured interviews were conducted prospectively for treatment outcome at 6 and 12 month follow-up periods. A multisite evaluation study of patients undergoing addiction treatment for alcohol and drug dependence was conducted in private outpatient facilities. Two thousand twenty-nine subjects from 33 independent programs were enrolled in a national registry for addiction treatment outcomes. The patients received abstinence-based addiction treatment with referral to a 12-step recovery program, often Alcoholics Anonymous, and continuing care in the treatment programs. The outcome areas measured were treatment completion, posttreatment substance use, exposure to psychosocial relapse risk factors, involvement with continuing care (formal aftercare and peer support groups), and posttreatment vocational functioning, health care utilization, and legal involvement. The prevalence rate of depressive symptoms over at least a 2-week period (major depression) in our sample was 28%. Multivariate analysis with stepwise multiple regression indicated that the most powerful predictors (relatively) of posttreatment alcohol/drug use were peer support group attendance and program continuing care involvement. Lifetime depression by itself and in interaction with each of these factors accounted for less than 2% of the variance in outcome. Logistic regression yielded similar results in the prediction of abstinence versus relapse. Posttreatment more than pretreatment factors appear to be more decisive in predicting risk for relapse.

Structural and functional neuroimaging findings in substance-related disorders

Intoxication with alcohol results in depressed global glucose metabolism that continues into the stages of withdrawal and abstinence. The decrease in metabolism, however, is not equal across the brain, with certain regions more affected than others. Such a pattern of disturbance suggests that the effect of alcohol on the brain cannot simply be a nonspecific depressant effect secondary to decreased blood flow or glucose transport into the cells but may be related to the dysfunction of the various neurotransmitter systems. Different authors have suggested the dysfunction to be related to the GABAergic, cholinergic, and dopaminergic systems. Long-term alcoholism is associated with atrophy of several brain regions. The frontal lobes and limbic structures seem to be most vulnerable. The data are encouraging with regard to the normalization in brain metabolism and in size of vulnerable brain regions with continued abstinence. In addition to findings of improvement in cognitive functioning and many health parameters, these findings arm clinicians with further data on the benefits of abstinence in the struggle to aid patients in maintaining their sobriety. Several areas remain to be addressed. In particular, clinicians are in need of data, neuroimaging and otherwise, that serve as prognostic indicators, thus allowing patients at higher risk for relapse to be identified and provided with more intensive treatment. A similar need exists for indicators of diagnostic heterogeneity that would guide the development of more highly tailored treatment regimens for identified subgroups of patients. Currently, we have rudimentary knowledge of the gender differences of the effects of alcohol and cocaine on the brain.

The role of the physician in addiction prevention and treatment

With increasing pressure on general physicians by managed care organizations and the public to treat and advocate for drug and alcohol addicted patients, it is more necessary than ever that physicians have the knowledge and skills to appropriately address this segment of the population. Specifically, physicians need a better understanding of the prevalence of alcohol and drug dependence in a variety of populations, along with increased awareness of the economic impact of addictive illnesses on our society. Routine screening questions should be incorporated into patient encounters, and physicians should be able to identify environments that may pose a risk for the development of addiction. Physicians need training and practice in referring patients to treatment teams, monitoring patients in recovery, and providing interventions that will eliminate or reduce substance abuse before it becomes addiction. The treatment outcomes in abstinence-based programs, particularly those combined with referral to AA, have been encouraging, demonstrating that addiction is a treatable illness and not a character defect. In addition, several studies provide evidence that addiction treatment is cost-beneficial, resulting in reduced medical costs, lowered absenteeism, and increased productivity. Despite these encouraging results, there is still room for improvement. Treatment is not always effective, and it is not sufficiently available to everyone who needs it. Addicted individuals are both stigmatized and marginalized, and many are too ill to advocate for themselves. Widespread recognition in the medical community of addiction as a treatable illness will contribute to a greater understanding of addictive disorders and reduce the stigma attached to the diagnosis and treatment of addiction. For this to occur, better training for physicians in the recognition and management of addictive disorders, starting at the medical school level, is necessary. The approval of addiction medicine as a clinical specialty by the American Medical Association also has helped to advance the legitimacy of addiction as a treatable illness, and provides a focal point for the synthesis and integration of clinical, teaching, and research activities central to addiction medicine. The combination of knowledge, skills, and attitudes outlined in the article will go a long way toward increasing physicians' abilities to assist their patients with recovery from addiction.

Mortality risks in alcoholism and effects of abstinence and addiction treatment

The mortality rate from alcoholism and related comorbidities is high. Studies show multiple causes of premature death from alcoholism. Several studies showed that abstinence had a positive effective on the overall survival of alcoholics. Alcoholics who abstained from alcohol, particularly continuously, showed reduced mortality rates and increased years of longevity than alcoholics who relapsed to alcohol consumption. The sources of the findings tend to be derived from treatment populations, in which abstinence is expected to occur in higher rates than in the general population.

Paecilomyces lilacinus fungemia in an adult bone marrow transplant recipient

Paecilomyces lilacinus is a rare fungal pathogen in humans. We report a case of fungemia caused by P. lilacinus in a non-neutropenic adult, 120 days after bone marrow transplant. The patient's primary risk factor was the presence of an indwelling vascular catheter. Her initial clinical course was characterized by fever, chills, and rigors. Blood cultures from the central line and peripheral veins were positive, as was a peripheral specimen drawn after removal of the catheter. Two initial peripheral specimens were positive for P. lilacinus only by blind subculture and/or sustained incubation. She developed peripheral pulmonary nodules following the fungemia, thus raising the possibility of disseminated disease, but definitive diagnosis was confounded by Pseudomonas bacteremia. The nodules cleared and she recovered following removal of the central line and treatment with amphotericin B and 5-fluorocytosine, despite in vitro resistance to these antifungal drugs. This case underscores the increasing importance of P. lilacinus as a human pathogen capable of producing disease in immunocompetent, as well as in immunocompromised hosts. Also of note is that blood culture systems may require extended incubation or subcultures in order to detect fungi.

Management of withdrawal syndromes and relapse prevention in drug and alcohol dependence

The primary care physician is in a good position to diagnose, manage and intervene with patients who are undergoing the process of treatment and recovery from alcohol and drug disorders. Medications such as benzodiazepines are effective in the treatment of withdrawal syndromes, and naltrexone and disulfiram can be used to augment relapse prevention. Patients may also participate in psychosocial methods of addiction treatment that can reduce the risk of relapse and improve their psychosocial, health, legal and employment status.

Comorbid cigarette and alcohol addiction: epidemiology and treatment

The close association of nicotine addiction and alcoholism is well established. As many as 80% of alcoholics smoke, and 30% of smokers are alcoholics. The mortality from cigarette smoking and alcoholism individually is very high, as an estimated 400,000 deaths from tobacco and 100,000 deaths from alcoholism are reported annually. Cigarettes and alcohol interact to cause certain cancers, e.g., head and neck. Only recently has attention been focused on the role of tobacco in abstinent alcoholics. An important study found high rates of mortality from tobacco in abstinent alcoholics in recovery. However, the mortality rates from alcoholism were high and predominant. Of great importance is that studies show that abstinence from alcohol essentially eliminates the premature deaths or increased mortality rates from active alcoholism. Similar studies showing a reduction in mortality from abstinence in nicotine addiction have not been forthcoming. The importance of treating nicotine addiction, however, is clear to reduce the high mortality rates from tobacco smoking in active or abstinent alcoholics.

Integration of generalized vulnerability to drug and alcohol addiction

The vulnerability to develop addiction to alcohol has been well established in familial and genetic studies. Similar familial and genetic studies have supported a vulnerability to drug addiction. The co-occurrence of alcohol and drug addiction in the same individuals is highly prevalent in clinical populations. Common putative neurochemical mechanisms underlie addiction to both alcohol and drugs, namely, in the mesolimbic pathway and the locus ceruleus in the brain. Treatment strategies are directed at both alcohol and multiple drug addictions in patient populations. The formulation of a generalized vulnerability that extends to both alcohol and drug addiction is not only possible but necessary to explain the substantial numbers of individuals who develop both alcohol and drug addictions. Future research that is pertinent and relevant may depend on the understanding of a generalized vulnerability to develop alcohol and drug addiction and its application in diagnostic strategies and treatment models.

Psychopharmacotherapy for addictive and comorbid disorders: current studies

Proper diagnosis of comorbid disorders is crucial in treatment planning for the dually diagnosed. Since psychoactive substance use can obfuscate the diagnosis, special care must be taken to exclude organically based syndromes. Adequate periods of abstinence should first be achieved and subsequently the patient re-examined for residual symptoms compatible with a nonaddictive, nonsubstance-induced psychiatric disorder. The integration of concurrent treatment of both the mental and the addictive disorders appears to be the best approach for treatment of comorbid psychiatric and addictive disorders. An abstinence-based model that typically utilizes a 12-step group therapy is often employed for the addictive illnesses. Other forms of psychosocial therapies such as case managers are being used as well. Presently, physicians' prescribing practices for comorbid addicted patients are based on traditional approaches to use of medications in psychiatric patients, and their attitudes towards addictive disorders may play a significant role in determining the overall success of treatment.

Lifetime diagnosis of major depression as a multivariate predictor of treatment outcome for inpatients with substance use disorders from abstinence-based programs

A multisite, longitudinal study of patients undergoing inpatient alcohol and drug dependence treatment was conducted in private inpatient facilities, consisting of 4339 subjects from 38 independent programs enrolled in a national addiction treatment outcomes registry. Structured interviews were conducted upon admission, including documentation of current alcohol/drug disorder (DSM-III-R) and lifetime diagnosis of major depressive syndrome; structured interviews were conducted prospectively at 6- and 12-month follow-up periods. The prevalence rate of lifetime diagnosis of major depression in the sample was 39%. Comorbidity varied according to gender and substance of choice. Lifetime depressive symptoms did not correlate with differential length-of-stay, treatment completion, or follow-up consent and, at best, were very weakly associated with follow-up contact. Patients diagnosed with lifetime depression showed the same frequency of participation in posttreatment continuing care: they also showed statistically significant reductions in job absenteeism, inpatient hospitalizations, and arrest rates pre- vs. posttreatment comparable to those of patients without lifetime depression diagnosis. Lifetime major depressive syndrome was not a predictor of outcome in response to abstinence-based treatment. Involvement in posttreatment continuing care accounted for far greater outcome variance. Posttreatment vs. pretreatment factors may be more decisive in influencing risk for relapse.

Integration in education for addiction medicine

Addiction to alcohol and other drugs is a serious public health problem that is one of the most common disorders seen in medical practice. Although it is an extremely common disorder, it is poorly diagnosed and treated by physicians. In order to begin to develop an integrated approach to education and addiction, one must define the many roles of the physician working with addicted patients. Training about addictions must begin early in the medical student's career, and continue in a vertically integrated way throughout medical school. The notion of addiction as a disease process must be introduced and integrated into course materials in the preclinical years. Careful attention must be paid to the development of positive views toward working with addicted patients, and students must be indoctrinated early with the idea that physicians have a responsibility to diagnose and manage addicted patients. Students should be given multiple opportunities to learn and use screening interviews for addiction in preclinical interviewing courses, and while on the clerkships. Residency education and continuing medical education in addictions are also important, so that faculty may become good role models for students in this critical area.

Integration of treatment and posttreatment variables in predicting results of abstinence-based outpatient treatment after one year

A multi-site, longitudinal study of patients undergoing outpatient alcohol and drug dependence treatment was conducted in private outpatient facilities, consisting of 2,029 subjects from 33 independent programs enrolled in a national addiction treatment outcomes registry. Pretreatment demographic and substance variables, treatment utilization variables, and post-treatment continuum of care variables were examined simultaneously in a multivariate prediction context for association with outcome. Upon admission patients provided history information to treatment staff trained in the collection of data for the evaluation efforts. Trained interviewers conducted consecutive structured interviews prospectively for treatment outcome at six- and 12-month follow-up periods. Multivariate analysis with stepwise multiple regression indicated that, relatively speaking, the most powerful predictors of treatment outcome were posttreatment variables: namely, support group attendance and involvement in a continuing care program. Pretreatment and treatment variables contributed proportionately little to the prediction of outcome. Additional sequential-stage analysis showed that the incremental contribution to prediction by posttreatment attendance at Alcoholics Anonymous and involvement in a treatment program following discharge far exceeded the initial predictive validity of the 14 pretreatment and treatment variables examined. Participation in posttreatment continuing care correlated with statistically significant reductions in job absenteeism, inpatient hospitalizations, and arrest rates. Posttreatment more than pretreatment factors may be decisive in influencing risk for relapse.

The integration of pharmacological therapy for comorbid psychiatric and addictive disorders

The integration of pharmacological therapies for comorbid disorders requires an acceptance of independence and interactions of respective addictive and psychiatric disorders. At the same time, alcohol and other drugs induce psychiatric states that are indistinguishable from psychiatric disorders. On the other hand, while psychiatric disorders do not induce addictive use of alcohol and drugs, they do pose vulnerabilities to the development of addictive disorders. Generally, the treatment of comorbid disorders begins with abstinence and evaluation of the effects of alcohol and other drugs in contributing to the psychiatric picture. In the case of comorbid disorders, stabilization and standard treatments can be employed with certain cautions, namely, to avoid the use of addicting medications such as benzodiazepines and opiates beyond the detoxification stage. High potency neuroleptics and antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs) can be used to treat continuing psychiatric states after the exclusionary criteria in DSM-IV for substance-related disorders have been applied to the clinical case. If the psychiatric symptoms clear with sustained abstinence, little or no medications may be required. Specific treatment of the addictive disorders will often determine the extent that addictive disorders are responsible for psychiatric symptomatology. Alternatively, treatment of the psychiatric disorder will enhance compliance with addiction treatment.

Temporal patterns of veterans' psychiatric service utilization, disability payments, and cocaine use

This study examined temporal patterns of service utilization, disability benefits, and substance use. Specifically, it investigated whether the first day of the first week of each month (when disability payments are disbursed) was associated with increased emergency room (ER) use and more frequent cocaine use among psychiatric patients. All 1993 psychiatric ER presentations (n=1,448) at a Veterans Administration hospital were reviewed in order by the week of each month in which they occurred. A random subsample of only those admitted to an inpatient psychiatric service (n=143) was further assessed for amount of disability payments received and recent cocaine use. This study found that for the total population of patients utilizing the ER, most ER visits occurred during the first week, followed by weeks two, three, and four respectively. The highest percentage (49%) of patients who used cocaine were those admitted during the first week of the month, followed by week two (39%), week four (28%) and week three (25%). For the subsample of patients admitted to inpatient services, patients hospitalized during the fourth week of the month were those receiving the highest disability payments. This study found that cocaine users have the most ER visits during the first week of the month following receipt of benefits. Current data, if confirmed, would suggest public policy changes, such as payment of entitlement money to cocaine users through a third-party payee and stipulated treatment for psychiatric patients with substance use disorders as a condition of payment. Ethical and political issues, including confidentiality and patient autonomy, would need to be considered in any such policy changes.

Integration of health care economics for addiction treatment in clinic care

Over the past decade, radical changes have occurred in the availability and funding of treatment services for individuals with addictive disorders. Traditional inpatient and residential treatments have been replaced by outpatient settings. "Standard" addiction treatments, such as 28-day inpatient hospitalizations, are largely a thing of the past. The process of treatment planning has also changed. Treatment decisions now depend on third-party coverage rather than severity of illness. The procedures for determining eligibility and obtaining authorization for treatment are often ponderous and impersonal and determined through administrative procedures that are external to the treatment facility. The criteria used to determine the type of treatment seem arbitrary rather than clinically based.

A mouse model of Borrelia meningitis after intradermal injection

Both young and adult C3H/HeN mice developed meningitis within 3 weeks of intradermal inoculation with a newly identified uncultivable Borrelia species, an agent of human relapsing fever. Meningoencephalitis with perivascular infiltrates and plexitis developed at approximately 25 days after inoculation. Infiltrates were composed of B and plasma cells and monocytes. This model recreated the meningitis associated with spirochetal infections through an intradermal route of infection.

A new Borrelia species isolated from patients with relapsing fever in Spain

BACKGROUND

Lyme disease and tick-borne relapsing fever are worldwide systemic borrelioses caused by several Borrelia species transmitted by hard ticks (family Ixodidae) and soft ticks (family Argasidae), respectively. A previous seroepidemiological study of Lyme borreliosis showed several serologically reactive patients with clinically atypical presentations, and this discovery led to the hypothesis that some of the cases of Lyme borreliosis had been caused by another borrelia organism.

METHODS

Blood from patients in southern Spain who had suspected Lyme disease or relapsing-fever borreliosis was cultured before treatment began. Isolates of Borrelia spp were inoculated into several strains of mice of different ages. The 16S rRNA and flagellin in genes of Borrelia spp were sequenced by PCR and assessed by phylogenetic analyses.

FINDINGS

We isolated a species of Borrelia from three patients with relapsing fever and from Ornithodorus spp ticks in southern Spain. This organism (refractory to in-vitro cultivation) caused a relapsing spirochaetaemia with multiple organ involvement in laboratory mice that recreated the human disease. Phylogenetic analysis showed that this organism is a previously unrecognised species.

INTERPRETATION

We have discovered a new borrelia pathogen that is closely related to the other tick-borne agents of relapsing fever in Europe and Africa, and which causes a relapsing systemic disease with serological similarities to Lyme borreliosis.

Prevalence of depression and alcohol and other drug dependence in addictions treatment populations

The diagnosis of depression has been viewed as an important factor in the treatment response for those who have alcohol and other drug dependence. The objective of the study was to examine the prevalence of a lifetime history of major depression in inpatients with a substance use disorder in addictions treatment. An evaluation study of 6,355 patients was conducted in inpatient and outpatient addictions treatment programs from 41 sites. Subjects were required to have a substance use disorder and to be evaluated for a lifetime diagnosis of major depression according to DSM-III-R criteria. The rate of a lifetime diagnosis of major depression was 43.7%. The most common diagnosis was alcohol dependence, followed by cocaine dependence, and cannabis dependence). Depression was associated in significantly greater numbers with diagnoses involving drugs other than alcohol, in females greater than in males, with number and frequency of use, and in inpatient programs more than outpatient programs. The rates for continuous abstinence at one year did not differ between those with and without a lifetime history of depression.

Treatment outcome for impoverished alcoholics in an abstinence-based program

Positive patient characteristics have been assumed important in determining treatment outcome for the abstinence-based method of addiction treatment. Thus far, controlled and uncontrolled studies of the abstinence-based method have examined predominantly employed, White, and married populations of alcoholics. We present a treatment outcome study of the abstinence-based method of treatment in unemployed, Black, and unmarried population of alcoholics. The negative patient characteristics of our study did not predict an unfavorable outcome in comparison to those in other studies that included positive patient characteristics.

Pharmacotherapy in alcoholism

This review categorizes five main uses of pharmacologic agents in the treatment of alcoholism: reversing the active pharmacologic effects of alcohol; controlling withdrawal symptoms; blocking the desire for alcohol use; treating psychiatric symptoms induced by alcohol and other drugs; and treating independent, but concurrent, psychopathologic conditions. No medication, including stimulants such as caffeine, has been found to actually reverse the action of alcohol. Because of their cross-tolerance and dependence with alcohol, benzodiazepines--especially intermediate acting preparations such as chlordiazepoxide and diazepam--are the mainstay in treating alcohol withdrawal, including convulsions and delirium tremens. Studies suggest that serotonin uptake inhibitors such as zimelidine, citalopram, viqualine, and fluoxetine may reduce alcohol consumption and that is not an antidepressant effect. Naltrexone, an opioid antagonist, also may be effective in reducing the urge to drink. The major aversive agent to alcohol in clinical use is disulfiram. When an independent psychiatric disorder accompanies alcoholism or drug addiction, it may require treatment, including pharmacotherapy, as the addiction is also being treated with nonpharmacologic methods such as abstinence-based treatment programs.

Clinical diagnosis of substance use disorders in private psychiatric populations

The clinical diagnoses of comorbid substance use and psychiatric disorders by psychiatrists in a private psychiatric inpatient setting were analyzed. Two hundred patients consecutively discharged from a private university-affiliated psychiatric service by clinical psychiatrists were examined for concomitant substance use and psychiatric disorders according to DSM-III-R criteria for Axis I and Axis II disorders. Fifty-nine patients (30%) were diagnosed with a comorbid substance use and psychiatric disorder on Axis I, supporting findings of previous studies. Comorbid diagnosis patients were more likely to be male (54%, 32) than were psychiatric only (noncomorbid diagnosis) patients (males 37%, 51). There were no differences between comorbid (dual diagnosis) and noncomorbid diagnoses in age, mean length of stay, or discharge type. Of the 59 patients with comorbid disorders, 83% had Axis I diagnoses, and 64% had Axis II diagnoses. Polysubstance use disorder was the most common dual diagnosis, cooccurring with an Axis I diagnosis in 47% of patients with an Axis II diagnosis in 45%. Psychiatrists in clinical psychiatric inpatient settings diagnose substance use disorders in rates similar to public settings despite absence of specific addiction treatment.

Criminal activity and crack addiction

The association of crack and criminal activity is commonly believed but not well documented or characterized in any systematic studies of crack addicts. In this survey of 200 crack addicts, daily use of crack correlated more with illicit, criminal activities to obtain a supply of crack than to demographic features. Correspondingly, felony and cocaine dealing was associated with total dollars spent on cocaine but not to other demographic features such as level of property or affluence. Moreover, the majority of crack addicts in this sample used cocaine intranasally before starting crack use. The mean age from onset of crack use to seeking help for cocaine addiction is less than 3 years. Severity of crack use and addiction as measured by daily use was associated with psychosocial consequences more than other demographic features.

Dissociation of "conscious desire" (craving) from and relapse in alcohol and cocaine dependence

Treatment of withdrawal and postabstinence craving has yielded mixed results in eliminating drug and alcohol use, improving outcomes, and reducing relapse in those patients addicted to alcohol and drugs. To assess the role of "conscious desire" (or craving) for drugs/alcohol during abstinence and withdrawal in continued addictive drug and alcohol use, we analyzed data from 1626 patients voluntarily admitted to a primary rehabilitation center in Minnesota. Eighty-one percent and 71% of all patients completed surveys at 6 and 12 months following discharge. Forty-two percent were diagnosed as alcohol dependent (AD) alone, 28% as alcohol and drug dependent (ADD) other than cocaine, and 25% as cocaine dependent (CD). At 6 months following discharge, the CD group had the lowest abstinence rate for drugs, at 83%, compared to the AD group, at 99%, and for alcohol, at 76%, compared to the AD group, at 75%. The AD group had the best outcomes and the least slippage from 6 to 12 months for drugs and alcohol. In all groups craving was not a major self-reported cause of relapse. For the CD subgroup, impulsive action with no known cause was the most common reason for relapse, while the AD group cited depression. These data agree with other reports in the literature suggesting that relapse is not commonly related to conscious craving. Our experience suggests that craving is rarely the first reason given for relapse. Drug seeking and use are such highly ritualized, automatic behaviors that the addict may appear not to require the intervention of conscious thoughts or distinct craving states to use.(ABSTRACT TRUNCATED AT 250 WORDS)

The epidemiology of the comorbidity of psychiatric and addictive disorders: a critical review

Assessing the prevalence of the comorbidity of psychiatric and addictive disease using epidemiologic methods results in artifactually high rates. Use of a clinical sample will yield falsely high rates, because substance use is associated with exacerbation of mental illness. Cross sectional design will inflate rates of psychiatric comorbidity in addicts, who attribute substance use to psychological symptoms until well into recovery. Application of exclusionary criteria for independent diagnosis is subject to investigator bias, particularly about the unproven yet popular "self-medication" hypothesis. The psychiatric symptoms which are common in active addiction generally clear within weeks to months of treatment for addiction but do not respond to standard psychopharmacologic treatment for primary mental illness. When lengthy follow up periods are employed, substance induced psychiatric syndromes typically resolve. We conclude that while patients treated in psychiatric settings often have comorbid and independent addictive illness, patients treated in addiction settings uncommonly have comorbid psychiatric illness despite common psychiatric symptoms.

Comorbidity of psychiatric and alcohol/drug disorders: interactions and independent status

Dual diagnosis as interpreted in clinical psychiatric practice is often not what the term means-two independent disorders. Commonly, addiction disorders are attributed to self medicating of "underlying" psychiatric disorders, there by, a contingency status. However, studies and clinical addiction practice show that drug and alcohol addiction must be afforded an independent status before accurate assessment and assignment of interactions in dual diagnosis can be made in clinical conditions. Studies also show rates for psychiatric comorbidity are low in addiction populations and rates for addictive disorders are high in psychiatric populations. If the common denominator is taken as addiction, then the perspective of the setting and examiner become crucial in determining prevalence rates for both disorders. Most importantly, effective treatment of either disorder will not occur unless an agreement on an independent status is accepted for both addictive and psychiatric disorders in any patient population setting.

Evaluation and acute management of psychotic symptomatology in alcohol and drug addictions

The practical clinical evaluation of patients manifesting psychotic symptomatology and addictive illness is approached in diverse and contradictory ways. While addiction specialists may not recognize the existence of Axis I disorders that prevent the utilization of treatment in the system, trained mental health professionals are traditionally prone to deny or minimize the addictive process and its capacity to produce psychiatric symptoms. This may result in premature diagnosis, and in a poor response to psychiatric treatment. The purpose of this paper is to describe a pragmatic model, based on clinically observable conditions, for the evaluation and acute management of major psychiatric symptomatology associated with diagnosed drug and alcohol addiction. Before describing the model, psychotic illness and symptoms in the general population versus the drug and alcohol addicted will be examined. The model will be applied to a few discrete syndromes based on common clinical presentations.

A neurochemical basis for alcohol and other drug addiction

There are major clinical observations in alcohol and other drug addicts and neurochemical studies in animals and humans that support the hypothesis for a common neurochemical basis for alcohol and other drug addiction. The common occurrence of concurrent alcohol and multiple drug dependence in clinical and general populations, family history and genetic studies, and basic and clinical research in the neurochemistry of addictive behavior provide evidence for a common genealogical vulnerability to combined alcohol and other drug addiction. Clinical neurochemical models for addictive behaviors can be derived from neurochemical pathways for the initiation and sustenance of addictive disorders. The role of tolerance and dependence is not specific to addiction but indicates a homeostatic response of the brain to the presence of a foreign substance. Animal and human studies are analyzed for clinical synthesis of a neurochemical basis for addictive disorders.

Perspectives of effective treatment for alcohol and drug disorders

Of the 1918 patients in the follow-up sample used for illustration, 63% reported total abstinence for the year after treatment, and an additional 24% reported at least 6 months of abstinence out of 12. Most relapses occurred during the first 6-month interval; 88% of patients who were abstinent the first 6 months maintained this status for the full year. Patients abusing drugs other than alcohol had much poorer outcomes than those abusing alcohol only, and this finding held up even when drug choice was controlled for sex and age of patients. Intravenous drug use was an important predictor of relapse, as was a history of antisocial behavior. A strong relationship to outcome was seen for patient participation in an aftercare program, and for weekly attendance at peer support group meetings. Emotional distress, relationship difficulties and family problems, financial difficulties, craving, and being around others who use alcohol and drugs are all seen as making the commitment to abstinence more difficult. There is clear evidence also that increased difficulty in these areas is predictive of later relapse. Comparisons of pretreatment and posttreatment measures of patient functioning revealed a decreased need for expensive health care services, such as hospitalization and emergency room care. The motor vehicle accident rate, traffic arrest rate, and criminal offense arrest rate all showed posttreatment declines. On-the-job problems also decreased dramatically following treatment. Posttreatment difficulties were disproportionately higher among patients who had returned to substance use than among patients who remained abstinent, documenting that successful treatment can have an affect in many areas that improve the quality of life for patients themselves (along with their families and communities) as well as reduce the high economic costs associated with alcohol and drug abuse in our society. Cost offsets for chemical dependency treatment are substantial and of broad scope; they also are related directly to the recovery rate. In general, the findings for outpatient programs tend to parallel those of the inpatients. Initial chemical severity and range of other clinical problems are lower, but significant reductions are noted. For both inpatients and outpatients monitored by CATOR, the posttreatment improvement in health care utilizations, reductions in work-related problems, and fewer arrests are related directly to recovery status. That is to say that recovering patients show significantly better improvement than relapsed patients. This means that treatment efficacy must be considered as a key element in estimating treatment benefits.

Current epidemiology of comorbidity of psychiatric and addictive disorders

Some major epidemiologic studies have assumed that treatment of the psychiatric symptoms will result in a lowered morbidity and mortality from the addictive disorders or, more specifically, that the addictive disorders are dependent on the psychiatric disorders and etiologically linked to them as an effect or secondary consequence. There is little systematic evidence beyond anecdotal and intuitive supposition to support this popular and only hypothetic position. The consequence is that to insist on the priority of the psychiatric disorder in diagnosis and treatment is to perpetuate artifactual prevalence rates for psychiatric comorbidity in addictive disorders, and to preclude the definitive treatment to reduce the psychiatric morbidity and mortality caused by addictive disorders.

A hypothesis for a common neurochemical basis for alcohol and drug disorders

Research findings clearly support a uniform theory for a neurochemical basis of drug and alcohol addiction. Data are available that document final common pathways for addictive behaviors in the limbic system in which neurotransmitters modulate the drive states, mood, and instinctual behaviors. The specific areas in the brain implicated in the loss of control inherent in the addictive use of multiple drugs and alcohol are the ventral tegmentum, nucleus accumbens, locus ceruleus, dorsal raphe nuclei, and the periaquaductal grey area. These sites contain cell bodies and receptors for dopamine, norepinephrine, serotonin, and endogenous opiates respectively, where multiple drugs and alcohol can often produce their effects. The acquired drive of addiction that arises spontaneously, repetitively, and relentlessly is manifested in the addictive behaviors of preoccupation, compulsivity, and relapse to drugs and alcohol.

Treatment of khat addiction

The authors present two cases of khat addiction that were successfully treated with bromocriptine. Khat is a bush cultivated in the Mid East because of its highly stimulant effects. Its leaves contain a variety of sympathomimetics. While khat is rarely found in the U.S., American soldiers stationed in the Arabian peninsula may be exposed to it. Because of an alcohol interdiction during the current Persian Gulf crisis, these troops may be tempted to use this plant as an alternative recreational drug.

Cocaine dependence: alcohol and other drug dependence and withdrawal characteristics

In this study, a cocaine abstinence syndrome is confirmed. Moreover, the cocaine withdrawal syndrome was found to be medically and psychiatrically benign and required no medication for detoxification in this inpatient setting. The 150 patients who underwent cocaine withdrawal did not show the three distinct phases of the abstinence symptomatology previously described. No patients required pharmacological intervention for cocaine withdrawal, and the dropout rate was 8% of the 150 cocaine dependents. The common symptoms of acute cessation of cocaine were transient craving, hyperactivity, slight tremor, insomnia and apprehension. The diagnosis of cocaine dependence alone without an additional drug or alcohol diagnosis was unusual in this study at 5%, as is the solitary use of cocaine also uncommon according to other studies. Studies clearly document that the concurrent and simultaneous use and dependence on multiple drugs and alcohol is present in the majority of treatment populations and common in the general population. As many as 54% of cocaine dependents qualified for alcohol dependence in this study, and many were dependent on alcohol prior to their cocaine dependence. Cocaine dependence appears to be yet another diagnosis in the spectrum of the multiple drug and alcohol dependent.

Cocaine-associated violence and relationship to route of administration

The relationship between route of cocaine administration, that is, free base/crack smoking (FB), intravenous injection (IV), and nasal insufflation (NS) and level of violence was studied. The authors hypothesized that the route that produced the most intense effects (i.e., FB > IV > NS) would produce the highest level of violence. Over a 12-month period, 194 cocaine users were screened. After excluding polydrug users, 101 patients of both sexes participated in this study for the evaluation of expressions of violence. Evaluations were conducted by a structured questionnaire. The order of level of increased violence matched that of the most "intense" route of administration for some measures only. FB and IV use generally produced the same level of violence for most measurements. Both FB and IV routes produced more violence than NS. Violent actions requiring sustained activity (e.g., rape, burglary, and armed robbery) showed no relationship to route. The difference in levels in violence between males and females varied according to circumstance, not route of administration.

Suicide risk associated with drug and alcohol addiction

The association of alcohol and drugs with suicidal thinking and behavior is both causal and conducive. The subjective state of hopelessness is key to the disposition to actual suicide. Alcohol and drugs are influential in providing a feeling of hopelessness by their toxic effects, by disruption of interpersonal relationships and social supports, and, possibly, by manipulating neurotransmitters responsible for mood and judgment. Because alcoholism and drug addiction are leading risk factors for suicide and suicidal behavior, any alcoholic or drug addict should be assessed for suicide, especially if actively using alcohol or drugs.

Stimulation of rat alveolar macrophage fibronectin release in a cadmium chloride model of lung injury and fibrosis

Rats were exposed to saline or cadmium chloride (CdCl2) at 25, 100, or 400 micrograms/kg body weight by intratracheal instillation. At 3, 7, 14, and 28 days after exposure five animals/treatment were euthanized, the lungs were lavaged, and bronchoalveolar lavage fluid (BALF) was analyzed for lactate dehydrogenase (LDH), total protein, N-acetylglucosamindase (NAG), and cell number, type, and viability. Lung hydroxyproline concentration was characterized as a marker of lung collagen. Alveolar macrophages (AM) obtained in BALF were cultured and the release of fibronectin and TNF was determined. Lung tissue was examined microscopically at 28 and 90 days after exposure. Exposure to CdCl2 resulted in lung injury and inflammation demonstrated by increases in BALF LDH, total protein, NAG, and inflammatory cells. AM TNF release was not significantly changed by CdCl2 treatment. All doses of CdCl2 stimulated AM fibronectin secretion, a response which persisted throughout the 28-day postexposure period examined. Pulmonary fibrosis was demonstrated biochemically and/or histologically (trichrome staining tissue) at all CdCl2 dose levels. The association of CdCl2-induced AM fibronectin release with lung fibrosis confirms and extends previous observations relating AM-derived fibronectin to the development of interstitial lung disease and provides further evidence that the persistent increase in AM fibronectin release represents an early indicator of fibrosis.

Nicotine dependence: diagnosis, pharmacology and treatment

Nicotine dependence has been clearly documented as an addiction to nicotine. The development of tolerance and dependence to nicotine has been documented as well in studies in animals and humans. The morbidity and mortality from nicotine dependence continues to be widespread and significant in spite of some reduction in the prevalence of use. Various modalities of pharmacological and nonpharmacological treatments have been developed in recent years. These treatment methods may be used singularly or in combination. Although some success has been claimed with each form of treatment, more studies are needed to confirm their full efficacy.

Measurement of histamine in rat bronchoalveolar lavage fluid by high-performance cation-exchange chromatography coupled with post-column derivatization to o-phthaldialdehyde

To better define involvement of mast cell derived mediators in the pulmonary response to fibrogenic dusts, a rapid and accurate method was required to analyze samples of bronchoalveolar lavage fluid for histamine. Samples of rat lung lavage were analyzed for histamine via high-performance cation-exchange chromatography coupled with post-column derivatization with o-phthaldialdehyde. The fluorescent derivative could be detected to ca. 1 ng/ml of lavage. Recoveries averaged 94.2% with an average relative standard deviation of +/- 5.3%. There were no correlations between amount or fibrogenicity of inhaled dust and subsequent release of histamine into lavage fluid.

Violent behaviors associated with cocaine use: possible pharmacological mechanisms

Violent behaviors are increasingly noted in clinical practice to be associated with cocaine use; however, few studies actually characterize these behaviors. Cocaine addicts who made self-inquiries for themselves to obtain information about the effects, diagnosis, and treatment of cocaine dependence were interviewed. The study examined in a structured telephone interview their violent behaviors associated with cocaine use. The types of violent behavior reported by these cocaine addicts ranged from minor psychological aggressions to major physical acts that included murder and rape. The pharmacological mechanisms underlying the induction of cocaine-associated violence may involve known neurotransmitter systems affected by cocaine. A possible explanation may be that cocaine acts in those areas of the brain, particularly the limbic system, that subserve aggressive and violent behaviors.