Reductions in physical pain predict lower risk of relapse following alcohol treatment.

OBJECTIVE: Physical pain is considered a potential predictor of relapse in alcohol-dependent individuals after treatment. The aim of this study was to evaluate whether reductions in pain level during the follow-up period after treatment were associated with lower relapse risk. METHOD: A sample of 366 participants was recruited from alcohol treatment centers in Warsaw, Poland. At baseline, information was obtained about pain level, demographics, childhood abuse, impulsivity, depressive symptoms, severity of alcohol and sleep problems. After finishing the alcohol treatment program, patients were followed for 12 months and alcohol drinking (relapse) as well as pain severity were evaluated. RESULTS: In the followed-up group, 29.5% of patients confirmed that they drank any alcohol during past 4 weeks. Comparing follow-up to baseline pain, 48.6% of subjects reported an increased severity of pain, 28.8% reported the same level of pain, 22.6% reported decreased level of pain. There was a significant association between the decrease in level of pain and the lower risk of relapse. Other factors associated with relapse during 4 weeks prior to the follow-up were baseline severity of depressive symptoms, low baseline social support and number of drinking days during 4 weeks prior to entering treatment. In multivariate analysis, a decrease in pain level was associated with a lower likelihood of relapse (OR=0.159; 95%CI:0.04-0.62; p=0.008) even when controlled for other factors associated with relapse. CONCLUSIONS: Decreases in pain level following treatment for alcohol dependence are associated with, and may contribute to, a lower risk of alcohol relapse.

History of sexual abuse and suicide attempts in alcohol-dependent patients.

History of child abuse is considered one of the important risk factors of suicide attempt in general population. At the same time it has been shown that suicide attempts appear significantly more frequently in alcoholics than in healthy individuals. The objective of this study was to investigate associations between history of childhood sexual abuse and suicide attempts in a sample of Polish alcohol dependent patients. A sample of 364 alcohol-dependent subjects was recruited in alcohol treatment centers in Warsaw, Poland. Information was obtained about demographics, family history of psychiatric problems, history of suicide attempts, sexual and physical abuse during childhood and adulthood and severity of alcohol problems. When analyzed by gender, 7.4% of male and 39.2% of female patients had a lifetime history of sexual abuse; 31.9% of the study group reported at least one suicide attempt during their lifetime. Patients who reported suicide attempts were significantly younger (p=0.0008), had greater severity of alcohol dependence (p=0.0002), lower social support (p=0.003), and worse economic status (p=0.002). Moreover, there was a significant association between history of suicide attempts and family history of psychiatric problems (p=0.00025), suicide attempts in the family (p=0.0073), childhood history of sexual abuse (p=0.009) as well as childhood history of physical abuse (p=0.002). When entered into linear regression analysis with other dependent variables history of childhood sexual abuse remained a significant predictor of suicide attempt (OR=2.52; p=0.035). Lifetime experience of sexual abuse is a significant and independent risk factor of suicide attempts in alcohol-dependent individuals.

Explaining unexpected gender differences in hostility among persons seeking treatment for substance use disorders.

OBJECTIVE: Gender differences in depression and anxiety are found among patients seeking treatment for substance use disorders, but few data exist on differences in hostility. As part of a larger study describing substance abuse treatment seekers, analyses investigated whether women would be more depressed and anxious than men, but less hostile. METHOD: Data were collected at baseline from 336 outpatients (62% men) at an addiction treatment agency. Most of the outpatients (81%) had DSM-IV chart diagnoses of alcohol dependence or abuse. RESULTS: On the depression, anxiety and hostility subscales of the Brief Symptom Inventory, women had significantly higher scores than did men. When scores were converted to gender-keyed T scores standardized on a normal sample, differences in depression and anxiety were no longer significant. However, differences in hostility remained. A regression analysis indicated that hostility scores were explained not by gender, but by greater severity of adverse consequences from substance use, insomnia, lack of social support, and being married. A childhood history of physical or sexual abuse, although more common in women than men, did not explain gender differences in hostility after controlling for other variables. CONCLUSIONS: The women in this study did not appear to be more anxious and depressed than did the men after controlling for gendered population norms. However, the women were more hostile than the men. Women's greater hostility was explained not by gender per se, but by personal and social factors that were differentially distributed across genders. Treatment implications are reviewed.

Alcohol's effects on sleep in alcoholics.

Sleep problems, which can have significant clinical and economic consequences, are more common among alcoholics than among nonalcoholics. During both drinking periods and withdrawal, alcoholics commonly experience problems falling asleep and decreased total sleep time. Other measures of sleep are also disturbed. Even alcoholics who have been abstinent for short periods of time (i.e., several weeks) or extended periods of time (i.e., several years) may experience persistent sleep abnormalities. Researchers also found that alcoholics are more likely to suffer from certain sleep disorders, such as sleep apnea. Conversely, sleep problems may predispose some people to developing alcohol problems. Furthermore, sleep problems may increase the risk of relapse among abstinent alcoholics.

Effects of age and alcoholism on sleep: a controlled study.

OBJECTIVE: Sleep problems are common, costly and potentially fatal in older adults. Sleep problems are also commonly associated with alcoholism. Yet few studies have examined the combined effects of alcoholism and aging on sleep. The purpose of this study was to investigate the main and interactive effects on sleep of diagnostic group and age group. METHOD: Alcohol dependent patients (n = 139; 118 men) and nonalcoholic controls (n = 87; 57 men) completed full-montage polysomnography, structured psychiatric diagnostic interviews, validated rating scales and alcohol histories at the University of Michigan between 1989 and 1996. The sample was divided for analytic purposes into older (aged 55+ years) and younger (aged <55 years) subgroups. RESULTS: After controlling for gender, race, body mass index and psychiatric-related sleep symptoms, alcoholics and older adults had significantly decreased total sleep time, and increased Stage 1 sleep percentage, respiratory distress and periodic limb movements. Older adults also had decreased delta sleep percentage and shorter rapid eye movement sleep latencies. Significant interactions were found between alcoholism and age group for Stage 1 sleep percentage, sleep-disordered breathing and periodic limb movements, with older alcoholics having the most disturbances. Older alcoholics had the highest mean values for sleep latency and the lowest mean values for sleep efficiency and delta sleep percentage when compared with the other three groups. CONCLUSIONS: Older alcoholics have increased sleep disturbances when compared with younger alcoholics and with nonalcoholics of both age groups. Care providers should screen for sleep problems among older adults with alcohol problems.

Insomnia, self-medication, and relapse to alcoholism.

OBJECTIVE: This study was an investigation of the frequencies of insomnia and its self-medication with alcohol in a group of alcoholic patients, as well as the relationship of these variables to alcoholic relapse. METHOD: The subjects were 172 men and women receiving treatment for alcohol dependence. They completed a sleep questionnaire, measures of alcohol problem severity and depression severity, and polysomnography after at least 2 weeks of abstinence. RESULTS: On the basis of eight items from the Sleep Disorders Questionnaire, 61% of the subjects were classified as having symptomatic insomnia during the 6 months before treatment entry. Compared to patients without insomnia, patients with insomnia were more likely to report frequent alcohol use for sleep (55% versus 28%), had significantly worse polysomnographic measures of sleep continuity, and had more severe alcohol dependence and depression. Among 74 alcoholics who were followed a mean of 5 months after treatment, 60% with baseline insomnia versus 30% without baseline insomnia relapsed to any use of alcohol, a significant difference. Insomnia remained a robust predictor of relapse after application of logistic regression analysis to control for other variables. A history of self-medicating insomnia with alcohol did not significantly predict subsequent relapse. CONCLUSIONS: The majority of alcoholic patients entering treatment reported insomnia symptoms. Given the potential link between insomnia and relapse, routine questions about sleep in clinical and research settings are warranted.

Modifying residents' professional attitudes about substance abuse treatment and training.

Some physicians have negative attitudes and beliefs towards patients with addiction. Moreover, few residents are inclined towards a subspecialty fellowship in addiction psychiatry. We aimed to determine if a one-day educational conference could facilitate attitudinal change among 52 general psychiatry residents. Significant changes (p < 0.05) in attitudes were reported following the conference, including enhanced beliefs that physicians can motivate their addicted patients to seek treatment and increased physician interest in pursuing advanced addiction training. A one-day educational intervention may be effective in improving professional attitudes toward addiction treatment by reinforcing previously acquired medical education. The duration of these changes remains to be determined.

Sociopathy, gender, and treatment outcome among outpatient substance abusers.

Antisocial personality disorder (ASPD) may predict poor prognosis but gender/sociopathy relationships to prognosis remain unclear. This study investigated the effects of ASPD upon psychiatric and substance-related outcomes among 235 addiction treatment center outpatients. Prevalence rates for ASPD were similar for males (16%) and females (22%). At baseline, women and ASPD patients displayed greater substance-related and psychiatric severity. At 6-month follow-up, ASPD patients had greater severity on both measures than did patients without ASPD, but women now had equivalent psychiatric severity to men. After controlling for initial severity, ASPD was related to worse substance-related outcomes, but not to worse psychiatric outcomes.

Older adult treatment outcome following elder-specific inpatient alcoholism treatment.

This study examined multidimensional 6-month outcomes of elder-specific inpatient alcoholism treatment for 90 participants over the age of 55. At baseline, physical health functioning was similar to that reported by seriously medically ill inpatients in other studies while psychosocial functioning was worse, and nearly one third of the sample had comorbid psychiatric disorders. Based on 6-month outcomes, participants were classified into the following groups: Abstainers, Non-Binge Drinkers, and Binge Drinkers. The groups did not differ on any baseline measures (demographics, drinking history, alcohol symptoms and age of onset, comorbidity, or length of treatment). General health improved between baseline and follow-up for all groups. Psychological distress decreased for Abstainers and Non-Binge Drinkers, but did not change for Binge Drinkers. Results suggest that a large percentage of older adults who receive elder-specific treatment attain positive outcomes across a range of outcome measures.

Sleep-disordered breathing in alcoholics.

Sleep apnea and related disorders contribute to disturbed sleep in abstinent alcoholics. In an earlier report from our group, sleep-disordered breathing was common and increased with age in a cohort of 75 abstinent alcoholics. We now report an extension of the previous work that includes studies of an additional 103 abstinent alcoholics undergoing treatment for alcoholism (total sample = 188) and a comparison group of 87 normal subjects. The presence and severity of sleep-disordered breathing was assessed with polysomnography. Among the alcoholics, sleep-disordered breathing (defined as 10 or more apneas plus hypopneas per hour of sleep) was present in 3% of 91 subjects under age 40, 17% of 83 subjects age 40 to 59, and 50% of 14 subjects age 60 or over. Subjects with sleep-disordered breathing were more likely to be male and had more severe sleep disruption and nocturnal hypoxemia and more complaints related to daytime sleepiness than subjects without sleep-disordered breathing. In a multiple linear regression analysis, age and body mass index were significant predictors of the presence of sleep-disordered breathing, whereas smoking history and duration of heavy drinking were not predictors after controlling for the effects of age and body mass index. Our findings suggest that sleep-disordered breathing contributes significantly to sleep disturbance in a substantial proportion of older alcoholics and that symptomatic sleep-disordered breathing increases with age in alcoholics. Sleep-disordered breathing, when combined with existing cardiovascular risk factors, may contribute to adverse health consequences in alcoholics.

Polysomnographic and subjective sleep predictors of alcoholic relapse.

Previous studies indicate that subjectively reported and objectively measured sleep abnormalities at baseline can increase the risk of relapse in treated alcoholics. However, previous studies did not include both subjective and objective sleep measures in the same group of patients. We utilized polysomnography and the Sleep Disorders Questionnaire to determine if baseline polysomnography increased the ability to predict relapse beyond the prediction with subjective measures alone, after controlling for nonsleep variables that were associated with relapse. We followed 74 patients with a DSM-III-R diagnosis of alcohol dependence, of whom 36 relapsed to at least some drinking during an average follow-up interval of 5 months. Univariate analyses revealed that relapsed patients did not differ from abstinent patients at baseline in demographics or psychiatric co-morbidity, but they had more prior treatment episodes for alcoholism, more difficulty falling asleep, more complaints of abnormal sleep, and, on polysomnography, longer sleep latencies, shorter rapid eye movement sleep latencies, and less stage 4 sleep percentage than abstinent patients. With a series of logistic regression analyses, which controlled for age and gender, we demonstrated that sleep measures improved the prediction model compared with nonsleep variables alone, and that polysomnography-measured sleep latency was the most significant predictor variable. We conclude that subjective and objective measures of baseline sleep are predictors of relapse in treated alcoholic patients. These data also suggest that neurophysiological dysfunction contributes strongly to the etiology of relapse. Finally, sleep disturbance warrants clinical attention as a target of alcoholism treatment.

Anabolic-androgenic steroid abuse and performance-enhancing drugs among adolescents.

Adolescents use a wide variety of drugs and supplements, including anabolic steroids, to improve their sports performance and physical appearance. Prevalence rates for steroid use generally range between 4% and 12% among male adolescents and between 0.5% and 2% for female adolescents. Although the short-term health effects of anabolic steroids such as effects on the liver, serum lipids, reproductive and cardiovascular systems, and moods and behavior have been increasingly studied, the long-term health effects are not well known. Steroid users are more likely to be boys, participate in strength-related sports, and use other illicit drugs. The effects of many other potential risk factors have not been fully elucidated, however. Assessment of anabolic steroid abuse includes physical and mental status and laboratory examinations. Steroid cessation, supportive therapy, and adjunctive pharmacotherapies are all employed in treating steroid abuse and dependence.

Risk factors for anabolic-androgenic steroid use in men.

The illicit use of anabolic steroids to enhance athletic performance and physical appearance can cause numerous psychiatric and other adverse effects. In order to prevent steroid use and its negative consequences, knowledge of risk factors is needed. We conducted an anonymous survey of 404 male weight lifters from community gymnasiums who completed a 20-min, self-administered questionnaire. The sample for this study included all 35 men who were thinking about using steroids ("high-risk" nonusers), 50 randomly selected nonusers who were not thinking about using steroids ("low-risk" nonusers) and all 49 steroid users. The three groups differed in age, training characteristics, other performance-enhancers tried, body image, acquaintance with steroid users, and perception of negative consequences. When groups were compared along a continuum from low risk to high risk and from high risk to actual use, we found increasing amounts of competitive bodybuilding, performance-enhancers tried, and steroid-using acquaintances. Groups did not differ in their use of addictive substances. Nearly three-fourths of the high-risk group felt "not big enough," compared to 21% of the low-risk group and 38% of the steroid users (p < .001). These data suggest that steroids do work to increase satisfaction with body size, and that dissatisfaction with body size may contribute to the risk of using steroids.

Treatment of alprazolam withdrawal with chlordiazepoxide substitution and taper.

We describe the first case series (n = 6) of using chlordiazepoxide to accomplish a rapid, well-tolerated withdrawal from alprazolam. After abruptly discontinuing alprazolam, we substituted a 50-mg dose of chlordiazepoxide for each 1 mg of alprazolam (except for one elderly patient where we substituted 25 mg) and gave additional chlordiazepoxide doses (25-50 mg every 4-6 hours) as needed for the first 1-2 days of hospitalization. With this approach, the mean "substitution ratio" of chlordiazepoxide to alprazolam was 86 to 1. We then tapered chlordiazepoxide by an average of 10% each day over a 7- to 14-day period according to the symptoms manifested and tolerated by individual patients. No seizures or other serious side effects occurred. Incomplete cross-dependence, as described elsewhere in the literature, was not observed. The rapidity and familiarity of the method are advantages for inpatient units, but careful titration of dosage, diagnostic clarity, and extended follow-ups are necessary when applying this approach.

Treatment outcome of alcoholics with and without cocaine disorders.

The treatment outcome literature suggests that alcoholics with coexisting drug dependence have worse prognoses. We compared three groups of inpatients treated on the same hospital unit for disorders of alcohol only (n = 51), cocaine only (n = 27), or both disorders (dual group, n = 27). At follow-up, we contacted 105 (81%) of 129 patients at a mean of 13.4 +/- 4.1 months after discharge. The three groups significantly and equivalently decreased their consumption of substances at follow-up, and they also had equivalent improvements in employment and in medical and psychiatric well-being. A nonsignificant trend existed for greater abstinence in the alcohol group (53%) than in the dual group (35%), and with regression analysis diagnostic group and stable residence predicted abstinence in the past 30 days. Elapsed time before using alcohol was equivalent for the two alcohol groups, and relapse to alcohol preceded relapse to cocaine by 1 month on average. In sum, outcomes were more similar than different for the three groups. Although specific treatments to enhance abstinence for cocaine users are indicated, clinicians should approach cocaine-using alcoholics with equal optimism for improvement as with other alcoholics.

Severity and treatment of alcohol withdrawal in elderly versus younger patients.

We conducted a retrospective chart review of older (n = 48; mean age = 69) and younger (n = 36; mean age = 30) patients who were admitted to residential/inpatient treatment for alcohol withdrawal and dependence. Although the two age groups did not differ in terms of recent drinking history, the elderly group had significantly more withdrawal symptoms for a longer duration than the younger group. The elderly group also had more symptoms of cognitive impairment, daytime sleepiness, weakness, and high blood pressure. Finally, no significant differences were found between age groups in either the dosage or number of days of detoxification medication, although a trend was found for more days of medication in the elderly. We conclude that alcohol withdrawal may be more severe in elderly than in younger persons. Accordingly, treatment may take longer and should target the specific profile of symptoms that characterize alcohol withdrawal in the elderly.