Point prevalence of alcoholism in hospitalized patients: continuing challenges of detection, assessment, and diagnosis.

OBJECTIVE: To measure a 1-day point prevalence of alcohol dependence among hospitalized patients and to assess practices of detection, evaluation, and diagnosis of alcohol problems. PATIENTS AND METHODS: On April 27, 1994, a total of 795 adult inpatients at 2 midwestern teaching hospitals were asked to complete a survey that included the Self-administered Alcoholism Screening Test (SAAST). The records of SAAST-positive patients were reviewed to determine the numbers of patients receiving laboratory screening for alcoholism, addiction consultative services, and a discharge diagnosis of alcoholism. RESULTS: The survey response rate was 84% (667/795). Of the 569 patients who provided SAAST information, 42 (7.4%) had a positive SAAST score and thus were identified as alcohol dependent. Thirteen (31%) of the 42 alcoholic patients received addiction or psychiatric consultative services during their hospitalization. Serum gamma-glutamyltransferase was measured in 4 (11%) of the 38 actively drinking alcoholic patients. Three (7%) of 42 alcoholic patients received a discharge diagnosis of alcohol abuse or dependence. CONCLUSIONS: The alcoholism prevalence rate was lower than those observed in several other US hospitals. Laboratory testing may be underutilized in identifying hospitalized patients who may be addicted to alcohol. Physician use of consultative services and diagnosis of alcohol dependence had not improved from similar observations more than 20 years earlier. These findings may indicate persistent problems in physician detection, assessment, and diagnosis of alcoholism.

Effect of current tobacco use and history of an alcohol problem on health status in hospitalized patients.

This prospective study assessed the relationship between current tobacco use and history of an alcohol problem to health status in hospitalized patients. Factors associated with current tobacco use and history of an alcohol problem were also evaluated. Data were collected using a self-administered survey distributed by nursing staff to adult inpatients registered on April 27, 1994 at the Mayo Clinic, Rochester, Minnesota affiliated hospitals. Respondents (N = 589, 45% female) were classified into 4 subgroups based on current tobacco use status and history of an alcohol problem: (a) current tobacco use only (n = 94, 16%); (b) history of an alcohol problem only (n = 30, 5%); (c) both (n = 27, 5%); or (d) neither (n = 438, 74%). Patients with both current tobacco use and an alcohol problem history reported markedly lower scores on health status measures of general and mental health compared to the other three subgroups. Moreover, current tobacco use and history of an alcohol problem were each associated with increased psychological distress. Current tobacco use was predictive of a history of an alcohol problem and vice versa.

Comparison study for identifying promoter allelic polymorphism in interleukin 10 and tumor necrosis factor alpha genes.

Cytokines such as tumor necrosis factor (TNF)-alpha and Interleukin (IL)-10 play significant roles in autoimmunity and transplantation tolerance. Allelic polymorphisms that occur in the regulatory regions of these cytokine genes are closely associated with acute and chronic transplant rejection. The presence of a G-to-A polymorphism at position -308 in the promoter region of the TNF-alpha gene can increase transcription six- to sevenfold. Likewise, the G-A polymorphism at position -1082 of the IL-10 promoter results in lower levels of IL-10 protein. Accordingly, a genotype that dictates the production of high levels of TNF-alpha with low IL-10 capabilities is most likely to generate an inflammatory environment that is less receptive to the transplant. The potential for determining a patient's haplotype before transplantation may be an effective way of monitoring the post-transplant status of such patients. A variety of methodologies that address the detection of mutations have been used both in research and clinical diagnostic tests. This study analyzes the genetic variations in cytokines using two methodologies: the traditional allele-specific oligonucleotide (ASO) polymerase chain reaction (PCR) and the newer and more flexible Invader technology. The sensitivity and specificity of the Invader assay for simultaneous investigation of multiple targets makes it a useful tool in such analyses.

Management of patients with bipolar mood disorder and substance dependence.

UNLABELLED: Nine patients with bipolar mood disorder and concurrent substance dependence were treated in an 18-bed inpatient addiction unit over a 3-month period. A multidisciplinary team approach used a medicalized Minnesota model and stressed the establishment of a positive diagnosis and individualization of management strategies for each patient. Clinically significant affective symptoms that required acute psychiatric intervention developed in several patients during hospitalization. Manic symptoms developed in three patients during sedative withdrawal, requiring the team to differentiate manic symptoms from physiologic withdrawal; and two patients became severely depressed, requiring pharmacologic management and suicide-prevention strategies. SUMMARY: Our experience with the patients in this case series supports the contention that there is no simple, uniform approach to the substance-dependent patient with bipolar disorder. Treatment teams must be prepared to differentiate complex syndromes and to manage manic, depressive, and addictive behaviors.

The Virginia generalist initiative: lessons learned in a statewide consortium.

In response to Virginia's need for an increased supply of generalist physicians, the state's three medical schools--Eastern Virginia Medical School, Virginia Commonwealth University School of Medicine, and the University of Virginia School of Medicine--have formed a partnership with key governmental stakeholders in the Virginia Generalist Initiative funded by The Robert Wood Johnson Foundation's Generalist Physician Initiative. These state-supported medical schools historically have functioned independently, with little cooperative effort. This paper describes the consortium, its activities, its successes, and its unmet objectives, and uses a series of cases in point to illustrate relevant lessons learned. Some of these lessons are that (1) stakeholders must be involved from the beginning of planning to identify mutual goals and establish consortium protocols; (2) all partners must share a philosophical commitment to the consortium's mission, as well as the time and resources needed; (3) an atmosphere that enables risk-taking behavior must be created; (4) stakeholders must be willing to revise goals and sustain an environment conductive to change; and (5) trust is essential and must be vigilantly maintained. The paper concludes that the Virginia Generalist Initiative has dramatically altered the goals, objectives and programs of the three schools and has succeeded in aligning the schools' strategic objectives with the state's priorities.

Developments in the treatment of alcoholism.

The treatment of alcoholism has changed during the past 2 decades. Notable developments have occurred in pharmacotherapy, psychotherapy, and health-care delivery. A better understanding of the biologic basis for addiction has led to clinical trials of medications that target neuroreceptors. One such medication is the opiate antagonist naltrexone, which decreases the craving for alcohol. Psychosocial interventions continue to be the mainstay of alcohol treatment programs. The efficacy of three different therapies was demonstrated in a study called Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity). This study, however, did not prove the patient-treatment "matching" hypothesis. In addition to therapies provided by addiction specialists, interest is growing in the use of brief motivational techniques in primary-care settings. As the field of addiction responds to an unfolding health-care delivery system, a broader range of treatment options in conjunction with a greater opportunity to individualize patient care is evolving.

Gender differences in factor structure of the Self-Administered Alcoholism Screening Test.

Recent studies have revealed differences between men and women alcoholics in symptoms, consequences, and help-seeking behavior related to alcohol usage. Based on these findings, it was hypothesized that gender differences also would appear on alcohol screening instruments. The Self-Administered Alcoholism Screening Test (Colligan, Davis, & Morse, 1988: SAAST: Swenson & Morse, 1975) of 1,920 men and 1,775 women was subjected to a within-gender, principle-components, factor analysis with a varimax rotation. Gender differences at the component level were revealed. Men endorsed the "help-seeking for alcohol-related problems" component while women endorsed the "help-seeking for emotional problems" component. In addition, men expressed concern about receiving a psychiatric label while women expressed concern about receiving a drinker label. The results suggest that different items need to be used in screening women for alcohol-related problems.

Optical properties of deep ice at the South Pole: absorption.

We discuss recent measurements of the wavelength-dependent absorption coefficients in deep South Pole ice. The method uses transit-time distributions of pulses from a variable-frequency laser sent between emitters and receivers embedded in the ice. At depths of 800-1000 m scattering is dominated by residual air bubbles, whereas absorption occurs both in ice itself and in insoluble impurities. The absorption coefficient increases approximately exponentially with wavelength in the measured interval 410-610 nm. At the shortest wavelength our value is approximately a factor 20 below previous values obtained for laboratory ice and lake ice; with increasing wavelength the discrepancy with previous measurements decreases. At ~415 to ~500 nm the experimental uncertainties are small enough for us to resolve an extrinsic contribution to absorption in ice: submicrometer dust particles contribute by an amount that increases with depth and corresponds well with the expected increase seen near the Last Glacial Maximum in Vostok and Dome C ice cores. The laser pulse method allows remote mapping of gross structure in dust concentration as a function of depth in glacial ice.

The University of Virginia health promotion and disease prevention program.

INTRODUCTION: Proof of effectiveness now exists for many health promotion and disease prevention practices, yet the importance of this knowledge is not widely appreciated, and a large percentage of the population does not receive this care. Universities with comprehensive academic medical centers are particularly appropriate places for providing health promotion programs. The University of Virginia began a health promotion and disease prevention program for employees in 1990. METHODS: Periodic health risk appraisal, with follow-up and selected interventions, is offered to approximately 14,000 employees as a cost-free fringe benefit. Health risks are assessed with a modification of the Carter Center Health Risk Appraisal. Results are given to participants in group sessions; referrals are made for clinical preventive services and interventions, as needed. RESULTS: During the first three years, 29% of the employee population participated in the program. Participants were more likely to be young, female and not African American. Nearly 96% had one or more risk factors, with an average of 3.6 risk factors overall. Participants on average had 1.8 risk factors for cardiovascular disease; 0.3 for cancer; 0.6 for injury; 0.1 for alcohol abuse; and 0.7 for mental health. Nonparticipants were not receiving similar comprehensive health risk appraisal elsewhere. CONCLUSIONS: University of Virginia employees have multiple health risks, not detected through their usual health care, for which effective interventions are available. This population probably reflects conditions throughout the state and nation. Academic medical centers should place high priority on establishing health promotion programs as part of their responsibilities to society.

Mortality following inpatient addictions treatment. Role of tobacco use in a community-based cohort.

OBJECTIVE: To determine the impact of tobacco- and alcohol-related deaths on overall mortality following inpatient treatment for alcoholism and other nonnicotine drugs of dependence. DESIGN: Population-based retrospective cohort study. SETTING: Olmsted County, Minnesota (the Rochester Epidemiology Project), and the Inpatient Addiction Program (IAP) at Mayo Clinic, Rochester. PATIENTS: All 845 Olmsted County residents admitted to an inpatient addiction program for treatment of alcoholism and other nonnicotine drugs of dependence during the period 1972 through 1983. METHODS: Patients were followed up through the medical record linkage system of the Rochester Epidemiology Project through December 1994 to obtain vital status, and death certificates were obtained for those who died. The underlying cause of death was classified as alcohol related, tobacco related, both, or neither based on the classification from the Centers for Disease Control and Prevention. The observed number of deaths by underlying cause were compared with the expected number using cause-specific 1987 death rates for the white population of the United States. All-cause mortality was also compared with that expected for persons in the West North Central Region of the United States of like age, sex, and year of birth. Univariate and multivariate assessments were made to identify predictors of all-cause mortality from baseline demographic information. RESULTS: At admission, the mean (SD) age of the 845 patients was 41.4 (14.5) years, and 35% were women. Altogether, 78% had alcohol as their only nonnicotine drug of dependence and 18% had alcohol and other nonnicotine drugs of dependence, while 4% were classified as having a nonalcohol, nonnicotine drug dependence alone. At admission, 75% were current and 8% former cigarette smokers, 3% were current cigar or pipe smokers, and 2% were current users of smokeless tobacco. Follow-up after the index IAP admission totaled 8913 person-years (mean [SD] of 10.5 [5.6] years per patient). Death certificates were obtained for 96% (214) of the 222 patients who died. Of these 214 deaths, 50.9% (109) had a tobacco-related and 34.1% (73) had an alcohol-related underlying cause (P<.001). The cumulative mortality significantly exceeded that expected (P<.001); at 20 years, the observed mortality was 48.1% vs an expected 18.5%. Multivariate predictors of mortality, even after adjusting for expected mortality, were older age at admission (P<.001) and male sex (P<.001). CONCLUSIONS: Patients previously treated for alcoholism and/or other nonnicotine drug dependence had an increased cumulative mortality that was due more to tobacco-related than to alcohol-related causes. Nicotine dependence treatment is imperative in such high-risk patients.

Attitudes toward nicotine dependence among chemical dependence unit staff--before and after a smoking cessation trial.

As a part of a prospective study to assess the effect of nicotine dependence treatment among smokers undergoing inpatient treatment for other addictions, we surveyed the treatment staff about their attitudes toward smoking. The study was carried out in the Alcoholism and Drug Dependence Unit (ADDU), an inpatient addictions' treatment unit at Mayo Clinic. The subjects for this report were the ADDU staff. The attitude survey used was modified from that of Bobo and Gilchrist, and the survey was conducted for all staff before and after the prospective intervention study. Compared with the pre-study survey, the post-study survey indicated more staff thought nicotine dependence treatment should be provided to all smokers (p = 0.025). The percentage who thought that nicotine dependence treatment should be encouraged at the time of admission to the unit also increased (p = 0.005). Overall, staff attitudes toward nicotine dependence treatment changed toward more acceptance. While the intervention trial likely had an effect, other factors could also have played a role in this apparent change in staff attitude.

Self-administered Nicotine-Dependence Scale (SANDS): item selection, reliability estimation, and initial validation.

The Self-Administered Nicotine-Dependence Scale (SANDS) is a questionnaire to assist in the determination of the most appropriate intervention for the nicotine-dependent individual. Six content domains included are: (1) self-efficacy; (2) social skills deficit; (3) loss of control; (4) consequences of use; (5) social support for smoking; and (6) concern for healthy life-style. A preliminary set of 79 items was reduced to a 32-item scale, which, in turn, was divided into two non-overlapping subscales of 16 items each. Logistic regression analyses of an additional sample of subjects indicated that the SANDS added predictive power to knowledge of sex and transdermal-patch status for predictions of smoking status 6 months later.

Nicotine dependence treatment during inpatient treatment for other addictions: a prospective intervention trial.

This study assessed the effect of treating nicotine dependence in smokers undergoing inpatient treatment for other addictions. It was a prospective, nonrandomized, controlled trial with a 1-year outcome. The subjects were smoking patients (50 controls, 51 in intervention group) in an inpatient addictions treatment unit in a medical center. The enrollment of subjects was sequential: controls were enrolled first; after a 6-week washout period, intervention subjects were enrolled. Controls received usual care, and the intervention group received nicotine dependence treatment consisting of a consultation, 10 intervention sessions, and a structured relapse prevention program. Smoking cessation rate and abstinence from alcohol or other drug use were the main outcome measures. The confirmed smoking cessation rate at 1 year was 11.8% in the intervention group and 0.0% in the control group (p = 0.027). Nicotine dependence intervention did not seen to interfere with abstinence from alcohol or other drugs (1-year relapse rate was 31.4% in the intervention group and 34.0% in controls). In this study, nicotine dependence treatment provided as part of addictive disorders treatment enhanced smoking cessation and did not have a substantial adverse effect on abstinence from the nonnicotine drug of dependence.

The Common Alcohol Logistic-Revised scale (CAL-R): a revised alcoholism scale for the MMPI and MMPI-2.

The Common Alcohol Logistic-Revised (CAL-R) scale was developed for use with MMPI or MMPI-2 with medical patients. It was derived from the Common Alcohol Logistic (CAL) scale and developed by (1) dropping the six CAL items deleted from the MMPI during construction of the MMPI-2 and recomputing item weights (using logistic regression); (2) calculating norms; and (3) repeating the validation procedure used in developing CAL. We used the same criterion group (1,221 alcoholics) and same contrast sample (7,621 nonalcoholic medical patients) used for CAL. Comparison of receiver operating characteristic curves, positive predictive value, and negative predictive value for CAL and CAL-R indicates that the latter has the same favorable ability to screen medical patients for alcoholism as the former.

Personality variables in cocaine- and marijuana-dependent patients.

Khantzian (1985) hypothesized that the drug of choice of patients with substance-dependence disorders reflects an attempt at self-medication. Cocaine- and marijuana-dependent inpatients were compared using the MMPI to test this hypothesis. These two groups of patients did not differ on the standard validity and clinical scales of the MMPI, and their scores were basically similar to a group of alcohol-dependent inpatients and a group of psychiatric patients of similar age. There was no single MMPI code type that was characteristic of either group of substance-dependent patients. It appears that drug of choice had little effect on the MMPI scores of these two groups of substance-dependent patients. These results are not consistent with the theory of self-medication.

Learning and memory impairment in older, detoxified, benzodiazepine-dependent patients.

The effects of benzodiazepine dependence on the ability to learn and remember new material (determined with the Auditory-Verbal Learning Test) were studied in 20 detoxified, benzodiazepine-dependent patients who were 55 years of age or older and in a drug-dependence rehabilitation program. The patients were matched approximately for age, sex, and IQ with 20 detoxified, alcohol-dependent patients in the same rehabilitation program and 22 control subjects from a community sample. Neuropsychologic testing was performed a mean of 6 to 10 days after the patients had been completely detoxified from the addicting substance. The benzodiazepine-dependent patients had more difficulty with tests of learning and short-term and delayed recall than did the alcohol-dependent or control group. The difference between the benzodiazepine-dependent patients and the control group was statistically significant. The results suggest that benzodiazepine dependence in older people can cause memory impairment that persists into the early drug-free period.

The definition of alcoholism. The Joint Committee of the National Council on Alcoholism and Drug Dependence and the American Society of Addiction Medicine to Study the Definition and Criteria for the Diagnosis of Alcoholism.

To establish a more precise use of the term alcoholism, a 23-member multidisciplinary committee of the National Council on Alcoholism and Drug Dependence and the American Society of Addiction Medicine conducted a 2-year study of the definition of alcoholism in the light of current concepts. The goals of the committee were to create by consensus a revised definition that is (1) scientifically valid, (2) clinically useful, and (3) understandable by the general public. Therefore, the committee agreed to define alcoholism as a primary, chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. The disease is often progressive and fatal. It is characterized by impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking, most notably denial. Each of these symptoms may be continuous or periodic.

Substance use disorder diagnostic schedule (SUDDS): the equivalence and validity of a computer-administered and an interviewer-administered format.

In order to evaluate the equivalence of interviewer-administered and computer-administered forms of the substance use disorder diagnostic schedule (SUDDS), both forms were presented to 100 substance-dependent inpatients. An additional 101 psychiatric outpatients were administered one form or the other. For patients who received both forms of the SUDDS, the percentage agreement ranged from 96% for the classification of a lifetime diagnosis of alcohol abuse/dependence to 88% for the classification of current diagnosis of alcohol abuse/dependence (kappa coefficients ranged from 0.709 to 0.865). Overall agreement with a clinician diagnosis (validity) and the two forms of administration varied from 100% for computer-generated diagnosis of current alcohol abuse/dependence to 71% for computer-generated lifetime diagnosis of drug abuse/dependence, when stratified by number of symptoms reported. No consistent differences were found in the performances of the two forms of the SUDDS, and we conclude that they may be used interchangeably.

Disulfiram treatment of patients with both alcohol dependence and other psychiatric disorders: a review.

In treatment of alcohol dependence, disulfiram is most useful in conjunction with a structured, supervised, aftercare program. However, it has been reported to cause psychiatric side effects and to interact with various psychiatric medications. Many patients with alcohol dependence suffer from other psychiatric disorders and are treated with such psychiatric medications. This paper reviews the pertinent clinical pharmacology of disulfiram and the literature on potential psychiatric complications and drug interactions of disulfiram. At the usual dosage, about 250 mg/day, disulfiram does not appear to increase significantly the risk of psychiatric complications or of psychiatric drug interactions. Therefore, it can be considered a treatment option for patients with alcohol dependence and other psychiatric disorders.