Frequency of serum low-density lipoprotein cholesterol measurement and frequency of results < or=100 mg/dl among patients who had coronary events (Northwest VA Network Study).

This population-based, cross-sectional analysis targeted all veterans with coronary heart disease (CHD) who were active patients in primary care or cardiology clinics in the Veterans Health Administration Northwest Network from July 1998 to June 1999. We report guideline compliance rates, including whether low-density lipoprotein (LDL) was measured, and if measured, whether the LDL was < or=100 mg/dl. In addition, we utilized multivariate logistic regression to determine patient characteristics associated with LDL measurements and levels. Of 13,891 active patients with CHD, 5,552 (40.0%) did not have a current LDL measurement. Of those with LDL measurements, 39.1% were at the LDL goal of < or =100 mg/dl, whereas 26.5% had LDL > or =130 mg/dl. Male gender, younger age, history of angioplasty or coronary artery bypass grafting, current hypertension, diabetes mellitus, and angina pectoris were associated with increased likelihood of LDL measurement. Older age and current diabetes and angina were associated with increased likelihood of LDL being < or =100 mg/dl, if measured. Although these rates of guideline adherence in the CHD population compare well to previously published results, they continue to be unacceptably low for optimal clinical outcomes. Attention to both LDL measurement and treatment (if elevated) is warranted.

Divalproex sodium in alcohol withdrawal: a randomized double-blind placebo-controlled clinical trial.

BACKGROUND: Divalproex sodium, an anticonvulsant and antikindling agent and gamma-aminobutyric acid enhancer, has been proposed as an alternative to benzodiazepines for treating alcohol withdrawal. This study reports on a randomized, double-blind, placebo-controlled trial of divalproex sodium in acute alcohol withdrawal. METHODS: Thirty-six hospitalized patients experiencing moderate alcohol withdrawal as measured by a score of at least 10 on the revised Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar) were randomized to receive either divalproex sodium 500 mg three times per day for 7 days or matched placebo in a double-blind manner. All subjects received a baseline dose of oxazepam and had additional oxazepam available as a rescue medication in accordance with a standard, symptom-triggered detoxification protocol. Mean total milligrams of oxazepam received, progression of withdrawal symptoms, psychological distress as measured by the Symptom Checklist-90, side effects, and adverse outcomes were compared between groups. RESULTS: Use of divalproex sodium resulted in less use of oxazepam (p < 0.033). Group differences seemed primarily driven by those subjects who experienced symptoms above threshold level (CIWA-Ar >or=10) after 12 hr. The progression in severity of withdrawal symptoms (increase in CIWA-Ar above baseline) was also significantly greater in the placebo group (p < 0.05). CONCLUSIONS: This placebo-controlled pilot study suggests that divalproex sodium significantly affects the course of acute alcohol withdrawal and reduces the need for treatment with a benzodiazepine. A more aggressive loading dose strategy may demonstrate a more robust or earlier response.

Attrition prevention with individuals awaiting publicly funded drug treatment.

AIMS: To evaluate the effectiveness of a motivational intervention to reduce attrition from a waiting list for substance abusers seeking publicly funded treatment. DESIGN: Randomized clinical trial comparing an "attrition prevention" condition to standard care while awaiting treatment admission. SETTING: A centralized substance abuse assessment and referral center in Seattle, Washington. PARTICIPANTS: Substance abusers (n = 654) eligible for publicly funded drug abuse treatment. MEASUREMENTS: Alcohol and drug use, substance-related negative consequences, areas in need of help, perceived need for help, emotional status, readiness to change, reasons for seeking and perceived barriers to entering treatment. FINDINGS: Overall, approximately 70% of clients entered treatment, and of these approximately 70% completed their assigned treatment. Those who entered treatment showed significant reductions in substance use and improved psychosocial function at a short-term 3-month follow-up. However, the attrition prevention intervention had no differential effect on treatment entry, completion or outcome compared to the standard waiting list. Further, there were no differences across therapists on these outcome measures. CONCLUSIONS: A motivational attrition prevention intervention did not enhance treatment entry, completion or outcome among treatment-seeking substance abusers. It is suggested that alternative strategies, such as contingency management and case management, may help facilitate treatment entry for individuals seeking publicly funded treatment.

Trauma, symptoms of posttraumatic stress disorder, and associated problems among incarcerated veterans.

OBJECTIVE: To help improve treatment for incarcerated veterans, the study examined exposure to trauma, symptoms of posttraumatic stress disorder (PTSD), functional status, and treatment history in a group of incarcerated veterans. METHODS: A convenience sample of 129 jailed veterans who agreed to receive outreach contact completed the Life Event History Questionnaire, the PTSD Checklist-Civilian Version (PCL-C), and the Addiction Severity Index. Participants who had scores of 50 or above on the PCL-C, designated as screening positive for PTSD, were compared with those whose scores were below 50, designated as screening negative for PTSD. RESULTS: Some 112 veterans (87 percent) reported traumatic experiences. A total of 51 veterans (39 percent) screened positive for PTSD, and 78 veterans (60 percent) screened negative. Compared with veterans who screened negative for PTSD, those who screened positive reported a greater variety of traumas; more serious current legal problems; a higher lifetime use of alcohol, cocaine, and heroin; higher recent expenditures on drugs; more psychiatric symptoms; and worse general health despite more previous psychiatric and medical treatment as well as treatment for substance abuse. CONCLUSIONS: The findings encourage the development of an improved treatment model to keep jailed veterans with PTSD from repeated incarceration.

Detecting bipolar disorder among treatment-seeking substance abusers.

Bipolar disorder is increasingly recognized to have frequent comorbidity with substance use disorders, but may be difficult to diagnose among patients with active substance use. The purpose of this paper is to describe a brief, self-report form for the efficient detection of bipolar disorder. The 19-item form was piloted in 373 consecutive applicants for substance abuse treatment at an urban Veterans Affairs (VA) medical center. Results show reasonable internal consistency (alpha = .850) and high rates of manic symptomatology (36%), previous bipolar diagnosis (30%, 51% of whom report prior psychiatric hospitalization), and exposure to mood stabilizers (20%, 66% of whom reported therapeutic benefit). Comparison of nine different scoring algorithms with chart diagnosis as the validating criterion found that self-report of bipolar diagnosis was optimally sensitive. Either self-report of bipolar diagnosis with hospitalization or self-report of exposure to mood stabilizers with therapeutic response was optimally specific. Symptom self-report items had significantly poorer sensitivity and specificity (F = 7.60, p < .01). We conclude that questions pertaining to diagnostic and treatment history (especially hospitalization or therapeutic medication response) are considerably superior to symptom-based screening for clinically diagnosed bipolar disorder. Further work using structured interview as the diagnostic criterion is under way to validate this instrument.

Substance abuse and psychiatric illness: treatment experience.

The purpose of this paper is to describe an outpatient dual-diagnosis treatment program and 1-year clinical outcome and hospital utilization data. Subjects were 118 consecutive admissions to the Seattle Veterans Affairs (VA) Medical Center's Dual Disorders program over the period from June 1, 1992, to August 31, 1994. Program eligibility requirements included having a current substance use disorder and an active non-substance-related major Axis I disorder (typically major depression, post-traumatic stress disorder [PTSD], bipolar disorder, or schizoaffective disorder). The treatment frame involved group-based programming (including support, medications management, and psychoeducation), routine urine drug screening, and crisis interventions. Results showed that subjects averaged 1.5 non-substance-related Axis I psychiatric disorders (54% involving psychotic symptoms) and 1.8 active substance use disorders. Patients stayed engaged in treatment for a median of 217 days, with 60% of patients having no positive drug screens, and the overall sample having a 40% reduction in the number of inpatient bed days in the year after intake. Conclusions were that, for a number of patients with comorbid disorders, psychiatric stabilization and cessation of substance use can be accomplished within an outpatient treatment frame that averages two completed clinical contacts per week.

Disulfiram use in patients with abnormal liver function test results.

BACKGROUND: Concern about the precipitation of severe hepatitis by disulfiram often causes clinicians to avoid using this effective treatment in patients who have elevated baseline transaminase levels, even though no empirical evidence has so far shown severe hepatotoxicity to be related to such laboratory abnormalities. This study examines the effects of disulfiram in alcohol-dependent patients with elevated liver function test results and/or serologic evidence of hepatitis C virus (HCV) infection. METHOD: Hepatitis serologies and baseline transaminase levels were obtained for 57 male alcoholics starting treatment with disulfiram. Sequential liver function test results were obtained for up to 12 weeks while subjects took disulfiram. RESULTS: Although subjects with elevated baseline transaminase levels and serologic evidence of HCV infection were the most likely to evidence marked elevations in transaminase levels while taking disulfiram, most subjects took disulfiram without other adverse consequences. In only 1 subject did elevations appear directly related to disulfiram. CONCLUSION: Monitoring of liver function test results is warranted for patients taking disulfiram and permits most patients with moderately elevated transaminase levels to take it safely.

Clinical issues related to the costs of alcoholism.

Alcohol (ethanol) use disorders are prevalent in many countries and are associated with significant social and health costs. Little is known, however, about the comparative cost effectiveness of treatments for alcoholism. Pharmacoeconomic evaluations are largely (if not wholly) absent from the alcoholism treatment outcome database. We discuss pharmacological approaches to the treatment of alcohol withdrawal and dependence, describing agents that ameliorate withdrawal symptoms, deter alcohol consumption, reduce alcohol craving and produce conditioned alcohol aversion. Cost-relevant clinical considerations are elucidated and recommendations for cost-conscious pharmacological treatment of alcohol dependence are proffered.

The relation of the kinetics of pirmenol to its antiarrhythmic efficacy.

In a single-blind study the multiple oral dose kinetics of pirmenol were related to its efficacy in eight patients with frequent (mean, 631; range, 167-1374 beats/hour) premature ventricular contractions (PVC). Oral pirmenol was started at 100 mg bid for 48 hours and increased to 150 mg bid in six patients to obtain more than 70% suppression of PVC counts. Efficacy was achieved without side effects. Pirmenol decreased heart rate but not PR interval, QRS duration, or QTc interval. Peak plasma levels after the first 100-mg dose occurred at 1 to 3 hours and ranged from 0.6 to 1.9 micrograms/mL. Plasma elimination half-life ranged from 9.7 to 31 hours (mean, 18.3). From 67.4 to 171.3 mg pirmenol (mean, 102.3 mg) were recovered in the urine in 48 hours after the last dose. Cumulative excretion in divided urine collections was consistent with a mean elimination half-life of 15 to 20 hours. The pharmacokinetics of pirmenol support oral twice-daily administration. The minimum PVC suppressing plasma level is between 0.5 and 1.5 micrograms/mL.