Adolescent alcohol use: risks and consequences.

AIMS: The aim of the study was to summarize results of recent epidemiological research on adolescent alcohol use and its consequences, to outline the risk factors for drinking in adolescents and to consider effective treatment and preventative interventions. METHODS: A literature review of relevant studies on adolescent alcohol use. RESULTS: Alcohol use and other risk-taking behaviours such as smoking, substance use and risky sexual behaviour emerge in adolescence and tend to cluster together. Heavy alcohol consumption in late adolescence appears to persist into adulthood and is associated with alcohol problems, including dependence, premature death and diminished work capacity. Early identification of adolescent risk factors may be helpful in preventing and/or attenuating risk. CONCLUSION: There is a need for high-quality long-term prospective cohort studies to investigate the long-term consequences of adolescent drinking and further work is needed to identify the most effective intervention strategies.

Time to act on the inadequate management of Wernicke's encephalopathy in the UK.

Wernicke's encephalopathy (WE) is a serious medical emergency whose pathogenesis is well understood and reviewed in this paper. Summarizing the evidence for its prophylaxis and management, the authors suggest that, in the UK, there is evidence that many patients identified as being at risk of WE currently do not receive appropriate treatment, despite the availability (not universal) of guidelines and protocols.

The evolution and treatment of Korsakoff's syndrome: out of sight, out of mind?

Wernicke's Encephalopathy is an acute neuro-psychiatric condition caused by an insufficient supply of thiamine (Vitamin B1) to the brain. If undiagnosed or inadequately treated, it is likely to proceed to Korsakoff's Syndrome. Wernicke's Encephalopathy can result from dietary deficiency alone and this form is usually successfully treated, with little chance of Korsakoff's Syndrome supervening. On the other hand, thiamine deficiency associated with alcohol misuse/dependence may require up to 1 gram of thiamine IV in the first 24 hours to be treated successfully. The reasons for this difference in treatment will be discussed. Thiamine diphosphate acts as a co-factor for a number of thiamine-dependent enzymes. Thiamine deficiency leads to a reduction in the activity of these enzymes, and this leads to alterations in mitochondrial activity, impairment of oxidative metabolism, decreased energy status and eventually selective neuronal death. The damage caused by the combination of thiamine deficiency and alcohol metabolism probably interferes with adequate thiamine transport at a number of sites in the body, including the blood-brain barrier, as well as causing damage to the apoenzymes which then require higher concentrations of thiamine to work normally. The accumulated damage is likely to render the use of oral thiamine therapeutically inadequate since the body is unable to produce high enough concentrations of thiamine in the blood to traverse the blood-brain barrier. Some individuals are probably genetically predisposed to develop Wernicke's. Long before individuals with alcohol misuse or dependence develop Wernicke's Encephalopathy the neurons and other cells of the body are functioning sub-optimally because of the inadequate supply of thiamine and the neurotoxic effect of alcohol. This relative deficiency initiates a series of pathological changes which accumulate and further interfere with the supply of thiamine and its utilisation at a time when the requirements are increased. The best treatment for Korsakoff's Syndrome is timely recognition of Wernicke's Encephalopathy and appropriate intervention and prevention.

Rates of undiagnosed attention deficit hyperactivity disorder in London drug and alcohol detoxification units.

BACKGROUND: ADHD is a common childhood onset mental health disorder that persists into adulthood in two-thirds of cases. One of the most prevalent and impairing comorbidities of ADHD in adults are substance use disorders. We estimate rates of ADHD in patients with substance abuse disorders and delineate impairment in the co-morbid group. METHOD: Screening for ADHD followed by a research diagnostic interview in people attending in-patient drug and alcohol detoxification units. RESULTS: We estimated prevalence of undiagnosed ADHD within substance use disorder in-patients in South London around 12%. Those individuals with substance use disorders and ADHD had significantly higher self-rated impairments across several domains of daily life; and higher rates of substance abuse and alcohol consumption, suicide attempts, and depression recorded in their case records. CONCLUSIONS: This study demonstrates the high rates of untreated ADHD within substance use disorder populations and the association of ADHD in such patients with greater levels of impairment. These are likely to be a source of additional impairment to patients and represent an increased burden on clinical services.

The Korsakoff syndrome: clinical aspects, psychology and treatment.

AIMS: The Korsakoff syndrome is a preventable memory disorder that usually emerges (although not always) in the aftermath of an episode of Wernicke's encephalopathy. The present paper reviews the clinical and scientific literature on this disorder. METHODS: A systematic review of the clinical and scientific literature on Wernicke's encephalopathy and the alcoholic Korsakoff syndrome. RESULTS: The Korsakoff syndrome is most commonly associated with chronic alcohol misuse, and some heavy drinkers may have a genetic predisposition to developing the syndrome. The characteristic neuropathology includes neuronal loss, micro-haemorrhages and gliosis in the paraventricular and peri-aqueductal grey matter. Lesions in the mammillary bodies, the mammillo-thalamic tract and the anterior thalamus may be more important to memory dysfunction than lesions in the medial dorsal nucleus of the thalamus. Episodic memory is severely affected in the Korsakoff syndrome, and the learning of new semantic memories is variably affected. 'Implicit' aspects of memory are preserved. These patients are often first encountered in general hospital settings where they can occupy acute medical beds for lengthy periods. Abstinence is the cornerstone of any rehabilitation programme. Korsakoff patients are capable of new learning, particularly if they live in a calm and well-structured environment and if new information is cued. There are few long-term follow-up studies, but these patients are reported to have a normal life expectancy if they remain abstinent from alcohol. CONCLUSIONS: Although we now have substantial knowledge about the nature of this disorder, scientific questions (e.g. regarding the underlying genetics) remain. More particularly, there is a dearth of appropriate long-term care facilities for these patients, given that empirical research has shown that good practice has beneficial effects.

The role of AA sponsors: a pilot study.

AIMS: The aim of this study was to explore the roles of Alcoholics Anonymous (AA) sponsors and to describe the characteristics of a sample of sponsors. METHODS: Twenty-eight AA sponsors, recruited using a purposive sampling method, were administered an unstructured qualitative interview and standardized questionnaires. The measurements included: a content analysis of sponsors' responses; Severity of Alcohol Dependence Questionnaire-Community version (SADQ-C) and Alcoholics Anonymous Affiliation Scale (AAAS). RESULTS: Sample characteristics were as follows: the median length of AA attendance was 9.5 years (range 5-28); the median length of sobriety was 11 years (range 4.5-28); the median number of sponsees per sponsor was 1 but there was a wide range (0-17, interquartile range 3.75); and the sponsors were highly affiliated to AA (median AAAS score 8.75, range 5.5-8.75, maximum possible score 9). Past alcohol dependence scores were surprisingly low: 5 (18%) sponsors had mild, 14 (50%) moderate and 9 (32%) severe dependence according to the SADQ-C (median 26.5, range 11-56). Sponsorship roles were as follows: 16 roles were identified through the initial content analysis. These were distilled into three super-ordinate roles through a thematic analysis: (1) encouraging sponsees to work the programme of AA (doing the 12 steps and engaging in AA activity); (2) support (regular contact, emotional support and practical support); and (3) carrying the message of AA (sharing sponsor's personal experience of recovery with sponsees). CONCLUSIONS: The roles identified broadly corresponded with the AA literature delineating the duties of a sponsor. This non-random sample of sponsors was highly engaged in AA activity but only had a past history of moderate alcohol dependence.

Follow-up of provision of inpatient treatment for UK Healthcare Professionals with alcohol dependence: snapshot of a pilot specialist National Health Service.

Alcohol dependent healthcare professionals (AHCPs) entering a specialized National Health Service (NHS) inpatient treatment facility in southeast London, UK, were investigated. A retrospective case-note analysis was conducted, supplemented with a postal questionnaire. Twenty-three mature (mean age 46.7 years; 13 male) AHCPs, 82% of admissions, with a mean duration of alcohol dependence of 16.5 years were followed-up at an average of 26 months postdischarge. Half of the sample met criteria for lifetime psychiatric disorder. Physical illness was also a prominent problem. At follow-up, six professionals reported continuous abstinence since discharge. For those who continued drinking, there was a significant reduction in daily quantity consumed. This study suggests that the absence of an adequate treatment infrastructure and administrative resources have a major impact on access to treatment services and outcomes for addicted healthcare professionals. There is a need for supported and dedicated services for this group within the UK National Health Service. The study's limitations are noted.

Wernicke's encephalopathy revisited. Translation of the case history section of the original manuscript by Carl Wernicke 'Lehrbuch der Gehirnkrankheiten fur Aerzte and Studirende' (1881) with a commentary.

AIMS: A translation into English of the case history section of Carl Wernicke's original manuscript of 1881, with a discussion on its relevance for clinicians today. METHODS: A copy of Carl Wernicke's original German text was obtained by one of the authors (CCHC) and translated into English from the old German by a professional translator. RESULTS: The translation was subsequently agreed by native German speaking referees, and minor changes made. CONCLUSIONS: The authors studied the translation in detail and concluded that Wernicke's description had stood the test of time. The diagnosis of Wernicke's Encephalopathy remains a clinical one.

Wernicke's encephalopathy: 'Plus ça change, plus c'est la même chose'.

AIMS: To develop clinical guidelines to identify individuals who misuse alcohol and are at risk of developing Wernicke's Encephalopathy (WE). METHOD: Non-systematic literature review of studies which includes a careful clinical record of the development of signs and symptoms of thiamine deficiency and in which the diagnosis of WE has been confirmed at autopsy. RESULTS: The review of the clinical findings in cases of WE, diagnosed at autopsy, shows a consistent pattern of signs and symptoms. The pattern appears to be similar regardless of whether the thiamine deficiency is related to nutritional problems alone or associated with alcohol misuse. CONCLUSIONS: The assessment of the degree of thiamine deficiency and the diagnosis of WE remain a clinical evaluation, and guidelines are suggested to help the clinician. Since neurotoxicity due to the metabolism of excessive alcohol in patients with chronic and severe alcohol dependence may be an important factor in determining long-term outcome of treatment, this must form part of the overall evaluation.

Doctors' health and fitness to practise: treating addicted doctors.

The literature describing the diagnostic process in the addicted doctor is scant. Figures from North America indicate that the prevalence of alcohol problems in doctors may be no higher than in the population as a whole, whereas high rates of prescription drug use have been recognized. This practice of self-treatment with controlled drugs is a 'unique concern' for doctors. The development of substance misuse problems in doctors cannot be reduced to a single factor: Anxiety and depression, personality problems, stress at work, family stress, bereavement, an injury or accident at work, pain and a non-specific drift into drinking have been implicated. Early diagnosis is critical because doctors are often reluctant to seek help and colleagues reluctant to intervene. Medical schools and continuing medical education programmes must give greater emphasis to addiction and substance misuse in doctors with a view to reducing the incidence of 'impaired physicians' and promoting and encouraging early treatment and rehabilitation. The relationship between the addiction psychiatrist and the occupational physician is key given that these problems occur at the interface between occupational health and regulatory systems. The need for individually tailored back to work programmes requires careful coordination and monitoring and may be difficult to implement without their involvement. Generally, the prognosis for doctors' recovery is good and it is possible to predict which doctors will 'make it'.

Griffith Edwards' work on the life course of alcohol dependence.

In 1976 Edwards & Gross proposed the concept of the alcohol dependence syndrome, based on the clinical observation that heavy drinkers manifested an inter-related clustering of signs and symptoms. That this modest 'provisional description' turned out to be so significant and influential is perhaps unsurprising when the context in which it was made is appreciated. Griffith Edwards and his colleagues at the Maudsley Hospital had undergone a rigorous 3-year training in clinical psychiatry, during which they had been taught to think critically and were grounded in the art of clinical observation. As he assessed patients for various alcohol research studies he realized that there was a clustering of certain elements. Thus clinical observation and an appreciation of the patient's drinking history contributed to the genesis of the concept. This paper reflects on the integration of his rigorous training at the Maudsley, his enquiring mind and encyclopaedic knowledge of the historical and research literature which enabled him to formulate a testable hypothesis about the alcohol dependence syndrome.

Information processing deficits in withdrawing alcoholics.

Prepulse inhibition (PPI) of the acoustic startle response (a reduction in response to an intense, startling stimulus (the pulse) if preceded by 30-150 ms by a weaker, non-startling stimulus) is an established model to index information processing deficits in thought-disordered schizophrenic patients. The present study aimed to investigate the influence of alcohol withdrawal on the PPI effect. Eight withdrawing alcoholic patients underwent testing for PPI of the acoustic startle response (defined as percentage reduction of the response over pulse-alone stimulus; prepulses 15 dB above the background) on three occasions (1, 3 and 7 days following the last drink). The results demonstrated remarkably low levels of PPI on days 1 and 3, with this being very robust in three patients who had a history of delirium tremens; there was a trend towards normalization of PPI on day 7. This study, although preliminary, suggests strongly that there is a deficit in the filtering of sensory information in alcohol-dependent patients undergoing alcohol withdrawal. This was most apparent in those with a history of delirium tremens. Further studies are needed to define the cause and chronicity of these deficits.

Salivary cortisol measurements during a medically assisted alcohol withdrawal.

Previous studies using plasma cortisol estimations have suggested that hypothalmo-pituitary-axis (HPA) activation occurs in alcohol-dependent patients during alcohol withdrawal. The present study set out to confirm this finding using salivary cortisol assays, which are a better indicator of plasma free cortisol, the fraction which exerts its physiological effects. Nine alcohol dependent patients provided four saliva samples (at 10 a.m., 2 p.m., 6 p.m. and 10 p.m.) on days 1, 3 and 7 of a medically assisted alcohol withdrawal (corresponding to 1, 3 and 7 days following the last drink, respectively).Withdrawal symptom severity, craving and mood disturbance were also measured. A group of non-alcohol-dependent individuals, without psychiatric or medical disorder, gave four samples at the same times on one day only. Mean daily cortisol levels in our alcohol-dependent population, as calculated by the area under the curve (AUC), decreased significantly over time (mean AUC (nmol/l/hour) on day 1 = 149, on day 7 = 85.7, p = 0.009) and were significantly higher than controls on each day (mean AUC in controls = 28.3, p = 0.001). The cortisol response showed a similar temporal trend to withdrawal symptom severity and mood disturbance. This is consistent with previous studies measuring plasma cortisol in alcohol withdrawal. However, the magnitude of the effect in our study was greater, and in contrast to some previous studies, levels were far from normal by day 7. The comparatively low cortisol response in our one mildly dependent patient suggests that there may be a relationship between dependence severity and the size of the cortisol response to withdrawal. Salivary cortisol sampling could prove to be a useful prognostic tool, with implications for subsequent withdrawal symptom severity, mood disturbances, risk of relapse and alcohol-related cognitive decline. There are implications for developing new treatments for alcohol withdrawal but more studies are needed.

Hepatitis B and C in alcohol-dependent patients admitted to a UK alcohol inpatient treatment unit.

The prevalence of hepatitis B and C infection was studied in a sample of alcohol-dependent patients admitted to a specialist alcohol inpatient unit to identify factors associated with hepatitis B and C infection. Laboratory, clinical and socio-demographic data were collected from 277 admissions over a 3-year period who were tested routinely for markers of hepatitis B and C infection. Of the 275 subjects tested for hepatitis C, 27 (9.8%) were positive to the hepatitis anti-HCV IgG antibody. Of the 275 subjects tested for hepatitis B, 30 (10.9%) were positive to the hepatitis anti-HBc IgG antibody. Few differences were found between hepatitis B positive and negative subjects. Hepatitis C positive individuals were more likely than Hepatitis C negative patients to have also been infected with the hepatitis B virus (p < 0.001), to have an unplanned discharge (p < 0.005) and to have ever used cannabis (p < 0.005), cocaine (p < 0.001), amphetamines (p < 0.001) or heroin (p < 0.001). They were also more likely to have a co-morbid antisocial personality disorder (p < 0.001), a lifetime diagnosis of opiate dependence (p < 0.001) and cocaine dependence (p < 0.005), higher serum gamma glutamyl transferase (GGT) levels (p < 0.05) and a lower platelet count (p < 0.05). These findings may help clinicians to identify those alcohol dependent patients with risk factors for hepatitis virus infection.

Randomised controlled trial of a brief alcohol intervention in a general hospital setting.

BACKGROUND: The evidence suggests that brief alcohol-focused interventions, directed at hazardous and harmful drinkers in non-specialist settings such as primary care are effective in reducing alcohol consumption. However, there is a need for further research in the hospital setting. This is a randomised controlled trial to investigate the effectiveness of a 10-minute brief intervention amongst 'at risk' drinkers admitted to general hospital wards. Unlike some previous trials, this trial is randomised, used blinded assessors, includes an intention-to-treat analysis, included female subjects and excluded people with alcohol dependence. METHODS: A total of 250 'at risk' drinkers admitted to King's College Hospital were identified using the Alcohol Use Disorders Identification Test (AUDIT). Some 154 subjects entered the study and were randomly allocated to the control and intervention groups. Subjects in the control group received no advice about their drinking whilst subjects in the intervention group received 10 minutes of simple advice on reducing alcohol consumption. Recruitment took place between 1995 and 1997. The primary outcome was the AUDIT questionnaire at 12 months. Secondary outcomes were a previous week's Drinks Diary, questionnaires (General Health Questionnaire, Alcohol Problems Questionnaire and the Severity of Alcohol Dependence Questionnaire) and laboratory blood tests (gamma glutamyl transferase, mean cell volume and haemoglobin). RESULTS: At 3-month and 12-month follow-up, all participants were included in the intention-to-treat analysis. At both time points there was no evidence of an intervention effect that could be attributed to the brief intervention. Both the intervention and control groups had an improved AUDIT score and reduced levels of alcohol consumption as measured by a subjective Drinks Diary at 3 months which was maintained at 12 months. CONCLUSIONS: This study has added further evidence on brief interventions in the hospital setting. In contrast to the recent Cochrane review by McQueen et al., the results of this study do not support the effectiveness of a brief alcohol intervention in general hospital wards. However our study was underpowered and there were flaws in the statistical analyses, and these limitations temper the strength of our conclusions.

Persistence of heroin use despite methadone treatment: poor coping self-efficacy predicts continued heroin use.

AIM: To evaluate the association between coping self-efficacy and persistent use of heroin by patients enrolled in a methadone treatment program. DESIGN AND METHODS: Cross-sectional survey. One hundred and ninety-one patients attending outpatient methadone clinics in South-East England, United Kingdom. Validated questionnaires were used to assess drug use (Maudsley Addiction Profile), alcohol use (Alcohol Use Disorders Identification Test), mental health (Hospital Anxiety and Depression Scale) and coping self-efficacy (brief 8-item Drug Taking Confidence Questionnaire). RESULTS: Half of the participants (95/191) reported heroin use in the preceding 14-day period. Heroin use during methadone treatment was associated with financial problems (P = 0.008), spending time with other drug users (P < 0.001), cocaine use (P = 0.002), low mood (P = 0.002) and dissatisfaction with the daily methadone dose (P = 0.014). Compared with 'Heroin-abstinent' patients, the 'Heroin' group reported significantly lower mean coping self-efficacy scores (t = 9.8, d.f. = 182, P < 0.001, effect size 1.17). After correcting for the effects of co-variants in a logistic regression model, the main determinants of persistent heroin use were 'coping self-efficacy' [B -0.05; standard error (SE) 0.008; Wald 36.6; odds ratio (OR) 0.95, 95% confidence interval (CI) 0.94, 0.97; P < 0.001] and 'dissatisfaction with methadone dose' (B 0.93; SE 0.46; Wald 4.1; OR 2.5, 95% CI 1.03, 6.25; P = 0.042). Satisfaction with methadone dose showed no association with self-efficacy. DISCUSSION AND CONCLUSIONS; While heroin use during methadone treatment can partly be explained by inadequate dosing, our data suggest a more complex picture with significant contribution from poor coping self-efficacy. Efforts aimed at enhancing and maintaining the patients' self-efficacy and social skills are likely to improve heroin and other drug use outcomes with added benefits for treatment completion rates and the throughput of methadone programs.

The treatment of patients at risk of developing Wernicke's encephalopathy in the community.

AIM: To review the process of identifying alcohol-dependent patients at risk of developing Wernicke's encephalopathy (WE) in the community, and prophylactic treatment options. METHODS: Non-systematic literature review of the diagnosis of thiamine deficiency and of its treatment in the community. The role of supplementation of beer and bread with thiamine was evaluated. RESULTS: The diagnosis of thiamine deficiency is not always made, and treatment apparently may sometimes be inadequate. CONCLUSIONS: Alcohol-dependent patients in the community who are at risk of developing WE should be given thiamine 250 mg, intramuscularly, daily for 3-5 days as part of a community detoxification programme. Further work is essential to determine the optimum dose of thiamine required to prevent permanent brain damage (Korsakoff's Psychosis). Neurotoxicity, due to the metabolism of excessive alcohol in patients with chronic and severe alcohol dependence, must be considered as an important factor in determining the long-term outcome of treatment.