Training primary care nurses to conduct alcohol screening and brief interventions in South Africa.

Although progress has been made in developing a scientific basis for alcohol screening and brief intervention (SBI), training packages are necessary for its widespread dissemination in primary care settings in developing societies. Using a training package developed by the World Health Organisation 121 nurses from one rural site (29 clinics in Vhembe District) and one urban site (3 clinics and 6 mobile clinics in Polokwane/ Seshego) in South Africa were compared before and after SBI training regarding knowledge and attitudes, and the subsequent practice of SBI in routine clinical practice. Although the training effects were at times moderate, all changes were in a direction more conducive to implementing SBI. Health care providers significantly increased in knowledge, confidence in SBI and higher self-efficacy in implementing SBI at follow-up after 9 months after receiving the training. When delivered in the context of a comprehensive SBI implementation programme, this training is effective in changing providers' knowledge, attitudes, and practice of SBI for at-risk drinking.

Marijuana consumption and tolerance to physiological and subjective effects.

The relation between marijuana consumption and the development of tolerance was investigated during a 31-day study. Volunteers with a history of moderate or heavy marijuana use were given access to one-gram (2.1% delta9 tetrahydrocannabinol [THC]) marijuana cigarettes during a 21-day smoking period. Both groups tended to increase consumption during this time. Heavy users averaged 5.7 cigarettes per day and indicated a progressive decline in ratings of intoxication and duration of pulse rate effect. Moderate users averaged 3.2 cigarettes per day but showed no changes in either of these reactions during this time. Results suggested that tolerance does not develop to the two most reliable indexes of marijuana intoxication unless heavy doses of delta9 THC are self-administered repeatedly. Also, the tendency to increase consumption during this time is not necessarily associated with the development of tolerance.

Types of alcoholics, II. Application of an empirically derived typology to treatment matching.

Data from 79 male alcoholics who were randomly assigned to either coping skills training or interactional group psychotherapy were used to replicate a multidimensional, empirically derived typology and to evaluate the typology's usefulness in matching patients to treatment. Consistent with previous cluster analysis research, indicators of risk for alcoholism, alcohol dependence, drinking history, and psychopathological impairment distinguished alcoholics along two broad dimensions of vulnerability and severity, with one subtype (type B alcoholics) manifesting an earlier onset of problem drinking, more familial alcoholism, greater dependence on alcohol, and more symptoms of antisocial personality than the other subtype (type A alcoholics). Analyses of outcome indicated that type A alcoholics fared better in interactional treatment and more poorly with coping skills training. Conversely, type B alcoholics had better outcomes with the coping skills treatment and worse outcomes with interactional therapy. Differences in treatment response were maintained for 2 years from the beginning of aftercare treatment.

Psychopathology as a predictor of treatment outcome in alcoholics.

We performed a one-year follow-up study of 266 alcoholics who had received extensive psychiatric assessment, including diagnosis with the National Institute of Mental Health Diagnostic Interview Schedule and DSM-III criteria, during their index treatment episode. The aims were to evaluate the relationship between additional DSM-III diagnoses in alcoholics and outcome at follow-up, assess the relative prognostic power of different ways of measuring psychopathology by comparing categorical DSM-III diagnoses and a global symptom severity measure, and assess whether ratings of psychopathology add to the prognostic power of an alcohol-dependence measure. While coexistent psychiatric diagnoses generally predicted poorer treatment outcome, there were significant interactions in the relationship between diagnoses and treatment outcome for men and women. For men, having an additional diagnosis of major depression, antisocial personality, or drug abuse was associated with poorer outcome. For women, having major depression was associated with a better outcome in drinking-related measures, while antisocial personality and drug abuse were associated with poorer prognosis. The value of determining psychiatric diagnosis was supported by covariance analyses that suggested that prognostic significance of specific disorders was not accounted for by general psychopathology or general dependence dimensions.

Behavioral and social effects of heroin self-administration and withdrawal.

Behavioral and social reactions to intravenously administered heroin were studied during a 33-day experimental addiction cycle. Three groups of four subject volunteers were allowed to self-administer heroin for a ten-day period as part of a longer study of oplate antagonists. Data relevant to sleep patterns, energy expenditure, social interaction, and other observable behaviors were collected during hourly observations. Comparison of behavioral differences before and after drug administration indicated few significant acute reactions. Reactions to long-term heroin self-administration were most pronounced in the areas of sleep behavior and social interaction. Subjects tended to sleep less, especially during the initial period of acquisition, and to withdraw more from social contact. No changes were noted in energy expenditure during waking hours. The results were interpreted in terms of physiological tolerance, central nervous system arousal, and sleep deprivation.

Buspirone treatment of anxious alcoholics. A placebo-controlled trial.

BACKGROUND: Symptoms of anxiety are common in alcoholics and may contribute to relapse following initiation of abstinence. Buspirone hydrochloride, a serotonin1A partial agonist, has a pharmacologic profile that may be particularly suited to the treatment of anxious alcoholics. METHODS: We conducted a randomized, 12-week, placebo-controlled trial of buspirone in 61 anxious alcoholics, all of whom also received weekly relapse prevention psychotherapy. Outcomes were measured at the end of treatment and at a 6-month follow-up evaluation. RESULTS: Buspirone therapy was associated with greater retention in the 12-week treatment trial, reduced anxiety, a slower return to heavy alcohol consumption, and fewer drinking days during the follow-up period. CONCLUSIONS: Buspirone appears to have a useful role in the treatment of anxious alcoholics. Further research is needed to clarify which patient characteristics and concomitant treatments result in optimal response to buspirone therapy.

The Composite International Diagnostic Interview. An epidemiologic Instrument suitable for use in conjunction with different diagnostic systems and in different cultures.

The Composite International Diagnostic Interview (CIDI), written at the request of the World Health Organization/US Alcohol, Drug Abuse, and Mental Health Administration Task Force on Psychiatric Assessment Instruments, combines questions from the Diagnostic Interview Schedule with questions designed to elicit Present State Examination items. It is fully structured to allow administration by lay interviewers and scoring of diagnoses by computer. A special Substance Abuse Module covers tobacco, alcohol, and other drug abuse in considerable detail, allowing the assessment of the quality and severity of dependence and its course. This article describes the design and development of the CIDI and the current field testing of a slightly reduced "core" version. The field test is being conducted in 19 centers around the world to assess the interviews' reliability and its acceptability to clinicians and the general populace in different cultures and to provide data on which to base revisions that may be found necessary. In addition, questions to assess International Classification of Diseases, ninth revision, and the revised DSM-III diagnoses are being written. If all goes well, the CIDI will allow investigators reliably to assess mental disorders according to the most widely accepted nomenclatures in many different populations and cultures.

SCAN. Schedules for Clinical Assessment in Neuropsychiatry.

After more than 12 years of development, the ninth edition of the Present State Examination (PSE-9) was published, together with associated instruments and computer algorithm, in 1974. The system has now been expanded, in the framework of the World Health Organization/Alcohol, Drug Abuse, and Mental Health Administration Joint Project on Standardization of Diagnosis and Classification, and is being tested with the aim of developing a comprehensive procedure for clinical examination that is also capable of generating many of the categories of the International Classification of Diseases, 10th edition, and the Diagnostic and Statistical Manual of Mental Disorders, revised third edition. The new system is known as SCAN (Schedules for Clinical Assessment in Neuropsychiatry). It includes the 10th edition of the PSE as one of its core schedules, preliminary tests of which have suggested that reliability is similar to that of PSE-9. SCAN is being field tested in 20 centers in 11 countries. A final version is expected to be available in January 1990.

Types of alcoholics, I. Evidence for an empirically derived typology based on indicators of vulnerability and severity.

An empirical clustering technique was applied to data obtained from 321 male and female alcoholics to identify homogeneous subtypes having discriminative and predictive validity. The clustering solution identified two "types" of alcoholics who differed consistently across 17 defining characteristics in the male and female samples. One group, designated type A alcoholics, is characterized by later onset, fewer childhood risk factors, less severe dependence, fewer alcohol-related problems, and less psychopathological dysfunction. The other group, termed type B alcoholics, is characterized by childhood risk factors, familial alcoholism, early onset of alcohol-related problems, greater severity of dependence, polydrug use, a more chronic treatment history (despite their younger age), greater psychopathological dysfunction, and more life stress. The two types also differed with respect to treatment outcome assessed prospectively at 12 and 36 months. The results are consistent with historical and contemporary typological theories that have postulated similar subgroups of alcoholics. The findings suggest that an empirically derived, multivariate typology of alcoholism has theoretical implications for explaining the heterogeneity among alcoholics and may provide a useful basis for predicting course and estimating treatment response.

Marihuana and human physical activity.

Adult male volunteers with a prior history of either moderate (N = 12) or heavy (N = 14) marihuana use were systematically observed before, during and after a 21-day period of free access to 1 g 2% delta-9 THC marihuana cigarettes. A matched sample of casual alcohol drinkers (N = 11) served as a control group. Sleep and other molar behaviors were observed hourly to obtain a representative sample of daily activity. Both moderate and heavy users were less active immediately after marihuana use and slept more on days following heavier consumption. Heavy users reduced their waking activity on days following heavier consumption, as well as during the entire period of marihuana availability. These reactions did not persist beyond the period of availability for either group. The findings suggest a dose-related delayed reaction to heavy marihuana consumption which disappears following the cessation of regular use. However, changes in activity following single doses of marihuana may be related more to the social circumstances of its use than to its pharmacological action.

Experimental analysis of the 'happy hour": effects of purchase price on alcohol consumption.

An experimental analogue of a discount drink policy known as the "happy hour" was used to study the effects of purchase price on drinking behavior. Male volunteers with a prior history of either casual (N=20) or heavy (N=14) drinking were given free access to beverage alcohol during a 20-day period. Approximately half the subjects could purchase alcohol under a single-price condition (50 cents/drink), while a matched group was given a price reduction daily (25 cents/drink) during a three-hour period in the afternoon. The results demonstrated that the afternoon price reduction significantly increased alcohol consumption in both casual and heavy drinkers. Reinstatement of the standard purchase price effectively suppressed drinking in both groups. The findings are discussed in terms of the theoretical and research implications of environmental influences on drinking.

Alcohol, affect, and the disinhibition of verbal behavior.

A study was conducted to investigate the effects of acute alcohol administration on affective states and verbal behavior during the ascending and descending limbs of the blood alcohol curve. Sixteen male social drinkers were given alcohol (1.0 g/kg) or placebo in a double-blind crossover research design. Subjects tested while blood alcohol levels (BAL) were ascending close to peak concentration (0.11 g%) described themselves as more elated, friendly, and vigorous than when tested under placebo conditions. As BAL declined, subjects described themselves as more angry, depressed, and fatigued. Cognitive confusion, hostile verbal interaction, and aggressive thematic content were also greater during alcohol intoxication, but these measures were unrelated to direction of change in the BAL curve. It was concluded that (1) the effects of alcohol on affect are biphasic and are closely related to direction of change in the BAL curve, (2) the disinhibition of certain types of verbal behavior is related neither to affective state or to direction of the BAL curve, and (3) the perception of cognitive disorientation may mediate the effects of alcohol on those behaviors normally suppressed by various controlling influences.

Opiates, catecholamines, behavior, and mood.

Indirect evidence has linked opioid reinforcement with changes in noradrenergic metabolism secondary to drug administration. Methodological precedents for biobehavioral correlations in depressive illness have suggested an important association between changes in mood and biogenic amine excretion patterns in the urines of patients during depression and recovery. This paper presents preliminary data on the possible relationship between changes in catecholamine excretion that were observed and the changes in behavior, mood, psychiatric status, and cardiorespiratory physiology secondary to heroin administration and methadone-assisted withdrawal. This study focuses on the urinary excretion of MHPG, since an appreciable fraction of this metabolite is probably derived from norepinephrine originating in the brain. The subjective changes in mood associated with heroin use, the decrease in respiratory rate, and the behavioral and mental status effects associated with opiate intoxication were observed only in the individuals whose MHPG excretion increased during the period of opiate administration.

The type A/type B distinction. Subtyping alcoholics according to indicators of vulnerability and severity.

Multidimensional typologies of alcoholics are reviewed, including Cloninger's neurobiological learning model, Morey and Skinner's hybrid model, and Zucker's developmental model. The more recent Type A/Type B typology proposed by Babor and colleagues is reviewed in more depth, as is a previous replication and extension by Litt and colleagues. Both the original study and the replication indicate this typology is a useful tool in classifying alcoholic inpatients into two groups and in matching alcoholics to the most suitable treatment. The present study replicates the typology using outpatient samples of male alcoholics. The resulting two clusters are very similar to those identified by the two earlier studies. As expected, the relative proportion of Type A alcoholics is higher in the outpatient samples than in the previously studied inpatient samples. Preliminary analysis of the typology's clinical efficiency suggests that the variables used to classify subjects might be appreciably reduced, thus effecting a considerable time savings in assessment. A discriminant function analysis indicates that using only 5 of the original 16 clustering variables results in a correct classification rate of almost 95%. Future research directions are addressed.

Issues in the definition and diagnosis of alcoholism: implications for a reformulation.

This paper examines definitions of alcoholism from theoretical and historical points of view. It begins with a review of definitions of alcoholism from the 19th century to the present, giving particular attention to medical approaches, psychiatric formulations, behavioral concepts, and definitions proposed by the American Psychiatric Association and the World Health Organization. It is concluded that current definitions differ widely in scope, the meanings attached to words like disease and disorder, the criteria for including signs and symptoms as essential characteristics, and the potential uses of the definitions. Based on these considerations, the practical issues of developing and applying clinically useful diagnostic procedures are discussed. The paper concludes with a discussion of diagnostic issues that should be considered in any effort to improve clinical identification, treatment planning and international communication.

The nature of alcoholism in patients with different family histories for alcoholism.

1. The course and consequences of alcohol abuse were examined in male and female patients being treated for alcoholism. 2. Demographic characteristics, family history for alcoholism, psychopathology, drinking history and social and physical consequences of alcohol abuse were assessed. 3. Probands with alcoholism on both the maternal and paternal sides of their pedigree experience greater psychosocial and physical consequences of alcohol abuse than other alcoholic patients. 4. Sex of the proband and type of family pedigree for alcoholism were found not to be interactive but to contribute separate additive effects.

Overview: demography, epidemiology and psychopharmacology--making sense of the connections.

This overview discusses the five papers covering demographic and prevalence issues in terms of the commonalities and differences across psychoactive substances, particularly as they pertain to the relationship between demographic factors and the prevalence of substance abuse. This overview also concerns itself with gaps in knowledge, methodological issues and future directions for research. It begins with some basic definitions and fundamental questions. A brief review of the salient points of each paper is then provided, followed by a more synthetic discussion of methodological and theoretical issues. It closes with some speculative ideas about the meaning of demographic variables for an understanding of substance abuse.

Ethical, scientific and clinical issues in ethanol administration research involving alcoholics as human subjects.

Research involving the administration of ethanol to human subjects has been conducted with some regularity since the 1960s. The purpose of this paper is to provide a broader discussion of the ethical and clinical issues pertaining to the administration of ethanol to subjects with a history of alcohol dependence and to assess the potential benefits and risks of ethanol administration research. Three kinds of investigation are reviewed: (1) basic scientific research on alcohol dependence and related disabilities; (2) clinical research that involves ethanol administration as part of the treatment; and (3) studies that have evaluated the short- and long-term effects of ethanol administration on the health and wellbeing of alcoholic research participants. It is concluded that ethanol administration research has not only contributed to the fund of knowledge about basic mechanisms of alcohol dependence; it has also advanced the scientific understanding of treatment. Moreover there is no compelling evidence that participation in ethanol administration research per se has adverse effects on alcoholic research subjects. In the interests of developing a practical approach to the ethical dilemmas posed by ethanol administration research, an ethical review process is suggested that takes into account the principles of respect for people, beneficence, and justice by tailoring the risk/benefit analysis to four types of research subjects: alcoholics recruited directly from the community, subjects recruited from residential treatment settings, recovering alcoholics, and alcoholics in outpatient treatment.

Alcohol screening and brief intervention: dissemination strategies for medical practice and public health.

This paper introduces the concept of risky drinking and considers the potential of alcohol screening and brief intervention (SBI) to reduce alcohol-related problems in medical practice and in organized systems of health care. The research evidence behind this approach is reviewed. Potential strategies for the dissemination of SBI to systems of health care are then discussed within the context of a public health model of clinical preventive services. There is an emerging consensus that SBI should be promoted in general healthcare settings, but further research is needed to determine the best ways to achieve widespread dissemination. In an attempt to provide an integrative model that is relevant to SBI, dissemination strategies are discussed for three target groups: (1) individual patients and practitioners; (2) health care settings and health systems; and (3) the communities and the general population. Dissemination strategies are considered from the fields of social change, social science, commercial marketing and education in terms of their potential for translating SBI innovations into routine clinical practice. One overarching strategy implicit in the approaches reviewed in this article is to embed alcohol SBI in the more general context of preventive health services, the utility of which is becoming increasingly recognized as a critical supplement to more traditional clinical medicine.

Cross system agreement for substance use disorders: DSM-III-R, DSM-IV and ICD-10.

This report presents results of a field trial of Substance Use Disorders as defined by DSM-III-R, DSM-IV (proposed) and ICD-10. Diagnoses based on the three systems were derived from interviews using the Composite International Diagnostic Interview (CIDI) in a heterogeneous sample of 521 adults drawn from clinical and community settings. Two issues are addressed: (1) cross system agreement; and (2) syndrome coherence of proposed criterion sets for Substance Dependence in each of the three systems. Findings were as follows: (1) Cross system agreement for Dependence was generally high, especially between DSM-III-R and DSM-IV. (2) Cross system agreement was lower for DSM-III-R and DSM-IV Abuse and very low for DSM-IV Abuse and ICD-10 Harmful Use. (3) Agreement varied across drug categories with lowest DSM-III-R/DSM-IV agreement for alcohol abuse and DSM-IV/ICD-10 agreement for marijuana use disorders. (4) Overall prevalence differed for the three systems with DSM-IV yielding highest rates followed by DSM-III-R and ICD-10 in that order. (5) Factor analysis of Dependence criteria showed high loadings of all items on a single factor across the three diagnostic systems and for all categories of drugs. Implications for validity of the dependence syndrome construct and for revisions in DSM-IV are discussed.