RESUMO
Although single-center and cross-sectional studies have suggested a modest impact of liver donation on donor psychological well-being, few studies have assessed these outcomes prospectively among a large cohort. We conducted one of the largest, prospective, multicenter studies of psychological outcomes in living liver donors within the Adult-to-Adult Living Donor Liver Transplantation Cohort Study2 (A2ALL-2) consortium. In total, 271 (91%) of 297 eligible donors were interviewed at least once before donation and at 3, 6, 12, and 24 mo after donation using validated measures. We found that living liver donors reported low rates of major depressive (0-3%), alcohol abuse (2-5%), and anxiety syndromes (2-3%) at any given assessment in their first 2 years after donation. Between 4.7% and 9.6% of donors reported impaired mental well-being at various time points. We identified significant predictors for donors' perceptions of being better people and experiencing psychological growth following donation, including age, sex, relationship to recipient, ambivalence and motivation regarding donation, and feeling that donation would make life more worthwhile. Our results highlight the need for close psychosocial monitoring for those donors whose recipients died (n=27); some of those donors experienced guilt and concerns about responsibility. Careful screening and targeted, data-driven follow-up hold promise for optimizing psychological outcomes following this procedure for potentially vulnerable donors.
Assuntos
Transtorno Depressivo Maior/psicologia , Transplante de Fígado/psicologia , Doadores Vivos/psicologia , Qualidade de Vida , Adulto , Estudos Transversais , Transtorno Depressivo Maior/epidemiologia , Feminino , Seguimentos , Sobrevivência de Enxerto , Humanos , Masculino , Prognóstico , Estudos Prospectivos , Inquéritos e QuestionáriosRESUMO
Because results from single-center (mostly kidney) donor studies demonstrate interpersonal relationship and financial strains for some donors, we conducted a liver donor study involving nine centers within the Adult-to-Adult Living Donor Liver Transplantation Cohort Study 2 (A2ALL-2) consortium. Among other initiatives, A2ALL-2 examined the nature of these outcomes following donation. Using validated measures, donors were prospectively surveyed before donation and at 3, 6, 12, and 24 mo after donation. Repeated-measures regression models were used to examine social relationship and financial outcomes over time and to identify relevant predictors. Of 297 eligible donors, 271 (91%) consented and were interviewed at least once. Relationship changes were positive overall across postdonation time points, with nearly one-third reporting improved donor family and spousal or partner relationships and >50% reporting improved recipient relationships. The majority of donors, however, reported cumulative out-of-pocket medical and nonmedical expenses, which were judged burdensome by 44% of donors. Lower income predicted burdensome donation costs. Those who anticipated financial concerns and who held nonprofessional positions before donation were more likely to experience adverse financial outcomes. These data support the need for initiatives to reduce financial burden.
Assuntos
Transplante de Fígado , Doadores Vivos/psicologia , Fatores Socioeconômicos , Obtenção de Tecidos e Órgãos/economia , Adulto , Feminino , Humanos , Relações Interpessoais , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Qualidade de Vida , Apoio Social , Inquéritos e QuestionáriosRESUMO
Research efforts accelerated in the 1990s to define the presentation of common psychiatric disorders in primary care settings. Two diagnostic instruments, the DSM-IV-PC and the PRIME-MD, were introduced in 1994, and a self-report form of the PRIME-MD, the PHQ, was published in 1999. These tools have streamlined the larger, often cumbersome psychiatric nomenclature of the DSM-III and DSM-IV and appear to be more useful in general medical settings. It still is not practical to use either instrument in its entirety for all patients in a busy primary care practice. Studies have suggested an efficient and effective, two-step method of screening primary care patients for psychiatric disorders, however. In this approach, a limited number of probing questions extracted from the PRIME-MD or PHQ (or DSM-IV-PC) are posed to patients, either in person or by a written self-report (i.e., a general health update or review of systems). Then a follow-up evaluation is done to confirm or refute positive screening results. Short, simple questionnaires that address specific topics (e.g., CAGE for alcohol screening or the GDS for mood disorders in older adults) complete and complement this approach. This method has the advantage of being easy to incorporate into routine office practice using minimal physician or office staff time, while showing acceptable sensitivity and specificity in studies to date. More research, particularly prospective studies, is needed to confirm the effectiveness of this approach and expand it beyond the few available studies that have focused mostly on depressive disorders.
Assuntos
Transtornos de Ansiedade/diagnóstico , Transtornos Cognitivos/diagnóstico , Transtorno Depressivo/diagnóstico , Programas de Rastreamento/métodos , Atenção Primária à Saúde/métodos , Escalas de Graduação Psiquiátrica , Transtornos Relacionados ao Uso de Substâncias/diagnóstico , Inquéritos e Questionários , Adulto , Distribuição por Idade , Fatores Etários , Idoso , Algoritmos , Transtornos de Ansiedade/epidemiologia , Transtornos Cognitivos/epidemiologia , Transtorno Depressivo/epidemiologia , Humanos , Medicina Interna/métodos , Programas de Rastreamento/normas , Anamnese/métodos , Anamnese/normas , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Pesquisa , Fatores de Risco , Sensibilidade e Especificidade , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Estados Unidos/epidemiologiaRESUMO
The DSM-IV work groups are the first to be given the opportunity to document carefully all stages of deliberations and make decisions based on carefully constructed and data-based criteria. The 5-year process has encouraged the use of detailed literature reviews and allowed members of the working groups to generate data from both MacArthur analyses and field trials to make the most appropriate decisions possible. The Substance Use Disorders Work Group was faced with a potentially infinite number of questions that could be asked. The guidelines presented at the beginning of this article, especially the focus on areas in which data are already available or might potentially be generated from a field trial, allowed our Work Group to focus on a limited number of questions. With rare exceptions, each of these areas was evaluated by the thorough literature reviews that have formed the chapters that make up this section of the Sourcebook. Our goals are relatively straightforward. It is important that clinicians, researchers, administrators, and those who will work the DSM-IV process have full access to the state of the literature that existed in the late 1980s and early 1990s, and the decision-making process that was used to address the issues that affected the DSM-IV. It is hoped that this article will not only help readers to understand both how and why the DSM-IV Substance Use Disorders Work Group made the relevant decisions, but will also encourage active research to answer more fully the potentially important questions raised in these reviews.
Assuntos
Transtornos Relacionados ao Uso de Substâncias/diagnóstico , Humanos , Manuais como Assunto , Psiquiatria , Índice de Gravidade de Doença , Sociedades Médicas , Estados UnidosRESUMO
A 4-week, double-blind, placebo-controlled trial of amantadine was conducted in 61 cocaine dependent outpatients. Subjects received 100 mg of amantadine 3 times daily. A follow-up visit was conducted at week 8. There were no significant differences between groups in treatment retention, or in the number of benzoylecgonine positive urine samples. Self-reported drug and alcohol use declined in both groups. At week 8 follow-up, self-reported drug use was significantly lower in the placebo group. Amantadine was not effective, and discontinuation of it may have been associated with an increase in cocaine use.
Assuntos
Amantadina/uso terapêutico , Cocaína , Dopaminérgicos/uso terapêutico , Transtornos Relacionados ao Uso de Opioides/reabilitação , Adulto , Alcoolismo/diagnóstico , Alcoolismo/psicologia , Alcoolismo/reabilitação , Comorbidade , Relação Dose-Resposta a Droga , Método Duplo-Cego , Esquema de Medicação , Feminino , Seguimentos , Humanos , Masculino , Transtornos Relacionados ao Uso de Opioides/diagnóstico , Transtornos Relacionados ao Uso de Opioides/psicologia , Detecção do Abuso de Substâncias , Resultado do TratamentoRESUMO
This article exemplifies the major difficulties inherent in carrying out and interpreting human drug research. The information available about the long-term consequences of opiate use remains unclear. In fact, an overall summary of the persistent cognitive effects of long term drug use yields vague and tentative information (Table 2). An explanation of some of the methodologic constructs that have led to the majority of unclear conclusions may be helpful. 1. Baseline. One such important factor in providing an accurate assessment of the possible effects of long-term drug use is to have knowledge of the user's cognitive capacity before exposure to drugs. Such baseline information might be available from school records. 2. Repeated testing. Additionally, it is essential to have control groups and conditions, whereby the groups receive nearly identical testing on repeated occasions to assess whether findings remain consistent. 3. Observed Subjects. In choosing the subjects, polysubstance users are probably the most convenient group of individuals to study because of ease of availability, but very little about the effects of one specific drug class compared to another will be learned. Users do have decided drug preferences and ideally researchers should observe a user over a period of time with repeated urine testing to determine the pattern of use and as much information as possible about the dose. An adequate age range in both drug users and control subjects is helpful. 4. Age Range. One must control for the effects of aging, but if all of the subjects are very young, subtle cognitive deficits may be missed. If, however, subjects are too old, acute or chronic physical conditions that cause cognitive deficits may be impossible to differentiate from long-term drug effects. 5. Choice of Test. It is essential to match the appropriate test to the dependent variables being assessed. 6. Length of abstinence. For valid testing, subjects should be drug free confirmed by toxicology. The best studies have the longest periods of abstinence in a protected environment where drugs are not available. Recovery of function may occur weeks or months after last exposure to drugs. These standards are difficult to achieve, but many studies that have failed to attend to these issues have involved large expenditures of effort with little or no new knowledge as the outcome.
Assuntos
Fármacos do Sistema Nervoso Central/efeitos adversos , Transtornos Cognitivos/etiologia , Transtornos Relacionados ao Uso de Substâncias/complicações , Animais , Transtornos Cognitivos/induzido quimicamente , Humanos , Desempenho Psicomotor/efeitos dos fármacosRESUMO
This study evaluated the ability of cocaine withdrawal symptoms, measured by the Cocaine Selective Severity Assessment (CSSA) and initial urine toxicology results, to predict treatment attrition among 128 cocaine dependent veterans participating in a 4-week day hospital treatment program. The CSSA was administered and a urine toxicology screen was obtained at intake and at the start of the day hospital (about 1 week later). The combination of a positive urine toxicology screen and a high CSSA score at intake predicted failure to complete treatment. Urine toxicology results at the start of the day hospital, but not at intake, predicted failure to complete treatment. Among participants without other psychiatric illness, high CSSA scores at intake predicted failure to complete treatment. The presence of cocaine withdrawal symptoms and a positive urine toxicology screen are clinically useful predictors of treatment attrition.
Assuntos
Transtornos Relacionados ao Uso de Cocaína/reabilitação , Pacientes Desistentes do Tratamento/estatística & dados numéricos , Síndrome de Abstinência a Substâncias , Adulto , Transtornos Relacionados ao Uso de Cocaína/urina , Feminino , Previsões , Humanos , Masculino , Modelos Teóricos , Philadelphia , Estudos Prospectivos , Curva ROC , RiscoRESUMO
This article assesses the reliability and validity of the Cocaine Selective Severity Assessment (CSSA), a measure of cocaine abstinence signs and symptoms. Interrater reliability and scale internal consistency were high. Initial CSSA scores were significantly higher in cocaine-dependent subjects than in alcohol-dependent subjects. Initial CSSA scores were highly correlated with recent cocaine use and with severity measures from the Addiction Severity Index (ASI) including the interviewer severity rating and composite score in the drug section. Among cocaine-dependent subjects, initial CSSA scores were higher for those who failed to achieve abstinence or who subsequently dropped out of treatment. Further, CSSA scores showed consistent and marked declines over time for subjects who continued in treatment and remained abstinent. The CSSA appears to be a reliable and valid measure of cocaine abstinence symptoms and a useful predictor of negative outcomes in cocaine dependence treatment.
Assuntos
Transtornos Relacionados ao Uso de Cocaína/diagnóstico , Cocaína/efeitos adversos , Cocaína Crack/efeitos adversos , Determinação da Personalidade/estatística & dados numéricos , Síndrome de Abstinência a Substâncias/diagnóstico , Delirium por Abstinência Alcoólica/diagnóstico , Delirium por Abstinência Alcoólica/psicologia , Delirium por Abstinência Alcoólica/reabilitação , Alcoolismo/diagnóstico , Alcoolismo/psicologia , Alcoolismo/reabilitação , Transtornos Relacionados ao Uso de Cocaína/psicologia , Transtornos Relacionados ao Uso de Cocaína/reabilitação , Estudos de Coortes , Comorbidade , Humanos , Variações Dependentes do Observador , Psicometria , Reprodutibilidade dos Testes , Síndrome de Abstinência a Substâncias/psicologia , Síndrome de Abstinência a Substâncias/reabilitação , Resultado do TratamentoRESUMO
Alcohol misuse is the second most common indication for liver transplantation in the United States. Our post-transplant alcoholism treatment trial suggested that current interventions might not be transferable to liver transplantees. We sought to identify differences between patients awaiting liver transplantation and alcoholics entering treatment without severe liver disease. Thirty transplant patients were compared to thirty naltrexone study patients on medical status, alcohol and drug use, alcohol craving, motivation for treatment, psychiatric symptoms, and psychosocial problems. Lifetime alcohol consumption was greater for transplant patients compared to naltrexone patients. In contrast to the naltrexone group, transplant patients denied craving for alcohol and showed little motivation for alcoholism treatment. Groups did not differ on other psychosocial measures. Liver transplant patients differ from patients in alcoholism treatment trials on measures of alcohol consumption, alcohol craving and motivation for treatment. Alcoholism interventions should accommodate their medical condition and boost motivation for continued abstinence.
Assuntos
Alcoolismo/epidemiologia , Alcoolismo/reabilitação , Transplante de Fígado/psicologia , Motivação , Naltrexona/uso terapêutico , Antagonistas de Entorpecentes/uso terapêutico , Aceitação pelo Paciente de Cuidados de Saúde/psicologia , Adulto , Albuminas/metabolismo , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Naltrexona/administração & dosagem , Antagonistas de Entorpecentes/administração & dosagemRESUMO
Alcoholic liver disease is an important cause of cirrhosis, liver-associated death, and need for liver transplant. Up to 50% of recipients use some alcohol, and perhaps 10% drink addictively. Careful evaluation by an addiction medicine specialist is the best predictive instrument before transplant surgery, whereas the 6-month rule lacks sensitivity and specificity. Addictive drinking, but not minor slips, is associated with increased mortality. There is no standard therapy for alcoholism in alcoholics waiting for a transplant or for those who have undergone a transplant. Stably abstinent, methadone-maintained opiate-dependent patients should continue methadone; are generally good candidates for liver transplant; and show low relapse rates. Pre- and post-transplant smoking rates are high and cause significant morbidity and mortality. Transplant teams should encourage smoking cessation treatments. Marijuana use in liver transplant recipients is common, although risks associated with this practice are unknown.
Assuntos
Alcoolismo/terapia , Sobrevivência de Enxerto , Hepatopatias Alcoólicas/cirurgia , Hepatopatias/cirurgia , Transplante de Fígado , Transtornos Relacionados ao Uso de Substâncias/complicações , Analgésicos Opioides/efeitos adversos , Analgésicos Opioides/uso terapêutico , Humanos , Hepatopatias/etiologia , Hepatopatias/mortalidade , Hepatopatias Alcoólicas/mortalidade , Transplante de Fígado/efeitos adversos , Transplante de Fígado/mortalidade , Fumar Maconha/efeitos adversos , Transtornos Relacionados ao Uso de Opioides/complicações , Transtornos Relacionados ao Uso de Opioides/cirurgia , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/prevenção & controle , Seleção de Pacientes , Recidiva , Medição de Risco , Fatores de Risco , Abandono do Hábito de Fumar , Transtornos Relacionados ao Uso de Substâncias/mortalidade , Transtornos Relacionados ao Uso de Substâncias/reabilitação , Transtornos Relacionados ao Uso de Substâncias/cirurgia , Fatores de Tempo , Resultado do TratamentoRESUMO
Alcoholism affects nearly 12.5 million Americans and is responsible for annual costs of over $130 billion from loss of job productivity, deleterious health effects, and direct treatment expenses. Research on treating alcoholism from the standpoint of relapse prevention using psychosocial interventions alone has produced only modest results. Studies on the efficacy of adjunctive medications using multiple medications in placebo-controlled and open trials combined with psychosocial interventions have shown mixed results. Recently, a safe and well-tolerated opiate antagonist, naltrexone, was approved by the Food and Drug Administration (FDA) for the adjunctive treatment of alcoholism. This review describes the pertinent preclinical and clinical research that led to the FDA's approval. Details are provided describing the subjects, methods, and results of the two pivotal human studies that led to the FDA review for this indication. Clinical therapeutic guidelines, appropriate patient selection, and future directions are also elucidated.
Assuntos
Alcoolismo/reabilitação , Naltrexona/uso terapêutico , Antagonistas de Entorpecentes/uso terapêutico , Método Duplo-Cego , Aprovação de Drogas , Feminino , Humanos , Masculino , Naltrexona/efeitos adversos , Antagonistas de Entorpecentes/efeitos adversos , Ensaios Clínicos Controlados Aleatórios como Assunto , Resultado do Tratamento , Estados Unidos , United States Food and Drug AdministrationRESUMO
Few studies have examined the value of treating alcohol addiction either before or after liver transplantation. Nevertheless, most liver transplant programs and many insurance companies require 6 months to 1 year of abstinence from alcohol as a condition of eligibility for liver transplantation (the 6-month rule). We believe there are potentially harsh clinical consequences to the implementation of this rule. For example, the natural history of alcohol use disorders often involves brief fallbacks to drinking ("slips"), but when alcoholic liver transplant candidates slip, most are removed from consideration for transplantation or are required to accrue another 6 months of sobriety. Because there is no alternative treatment to liver transplantation for most patients with end-stage liver disease, the 6-month rule could be lethal in some circumstances. In this review, we survey the literature concerning the ability of the 6-month rule to predict drinking by alcoholic patients who undergo liver transplantation and examine its impact on the health consequences of drinking before and after liver transplantation. We believe that fostering candor between the alcoholic patient and the transplant team is the key to recovery from alcoholism. We conclude that it is unethical to force alcoholic liver patients who have resumed alcohol use while waiting for or after transplantation to choose between hiding their drinking to remain suitable candidates for transplantation or risk death by asking for treatment of alcoholism. Consequently, we advocate a flexible approach to clinical decision making for the transplant professional caring for an alcoholic patient who has resumed drinking and provide specific guidelines for patient management.
Assuntos
Consumo de Bebidas Alcoólicas/prevenção & controle , Transplante de Fígado , Cuidados Pós-Operatórios/métodos , Cuidados Pré-Operatórios/métodos , Consumo de Bebidas Alcoólicas/efeitos adversos , Consumo de Bebidas Alcoólicas/epidemiologia , Humanos , Incidência , Hepatopatias Alcoólicas/epidemiologia , Hepatopatias Alcoólicas/etiologia , Hepatopatias Alcoólicas/cirurgia , Prognóstico , Estados Unidos/epidemiologiaRESUMO
Alcoholic liver disease is the second most common indication for liver transplantation in the United States. The lack of alcoholism treatment studies led us to study motivational enhancement therapy (MET) plus naltrexone after transplant. The authors could not complete this study. Sixty alcoholic patients were to receive MET plus naltrexone or placebo for 6 months. Fifty men and 5 women were screened. Nine died and 15 were not approached. Of 31 approached, 20 were ineligible, 11 refused, and 5 entered but dropped out before completion. Barriers to posttransplant alcoholism included infirmity, intensive medical management, and denial for alcoholism treatment. Because 30%-50% of alcoholic patients drink after transplant, the authors suggest using MET alone pretransplant.