Echocardiographic evaluation of intracardiac venous gas emboli following in-water recompression.

Decompression sickness is a potentially fatal illness. Optimal treatment is dry recompression with hyperbaric oxygen. In-water recompression (IWR) offers expedited treatment but has insufficient evidence to recommend it as a treatment option. This trial compares IWR to standard surface oxygen treatment using 2D echocardiography as the semi-quantitative measurement for inert gas loading. Divers were randomly assigned to either IWR or normobaric oxygen (NBO2). A provocative dive profile to 33.5 meters for 25 minutes was used to stimulate bubble formation. After 60 minutes on the surface, bubble scoring was obtained using 2D echocardiography. Divers underwent either the IWR or NBO2 treatment for 82 minutes. Echocardiography was then repeated. Pre-treatment mean bubble counts were 28.1 bpf (bubbles per echo frame), [+/- 13.2 to 43.0 95% CI] for IWR, and 18.3 bpf [+/- 0.0 to 39.6 95% CI] for NBO2. After treatment, mean bubble score dropped to 0.1 bpf [+/- 0.0 to 0.2 95% CI] (p < 0.01) and 1.8 bpf [0.0 to 3.8 95% CI] (p = 0.103) respectively. IWR vs. NBO2 reduction of bubble counts was 99.7% vs. 90.1%; however, this was not found to be statistically significant. IWR reduced the central VGE load compared to NBO2, suggesting that IWR is a viable emergency treatment when a recompression chamber is unavailable.

Cross-cultural evaluation of two drinking assessment instruments: alcohol timeline followback and inventory of drinking situations.

This article describes the psychometric characteristics of two major assessment instruments used in a World Health Organization (WHO) clinical trial: (a) Alcohol Timeline Followback (TLFB, which assesses daily drinking patterns), and (b) Inventory of Drinking Situations (IDS, which assesses antecedents to "heavy" drinking). Clients (N = 308) were outpatient alcohol abusers from four countries (Australia, Canada, Mexico, and Sweden). Generally, the Alcohol TLFB and IDS were shown to be reliable and valid with outpatient alcohol abusers in four countries, and in three languages. These results suggest that the Alcohol TLFB and the IDS can be used in clinical and research settings with Swedish-, Spanish-, and English-speaking alcohol abusers.

Gender in relation to relapse crisis situations, coping, and outcome among treated alcoholics.

Relapse crisis situations resulting in successful coping (i.e., abstinence) and unsuccessful coping (i.e., relapse) were examined in 90 male and 35 female alcohol clients over the first 12 weeks following treatment discharge. More similarities than differences were observed between the genders in the relapse crisis situations encountered, the number and type of coping strategies used, and the drinking outcome results. A similar proportion of males and females successfully abstained in the first 12 weeks posttreatment; a combination of cognitive and behavioral coping was most frequently used by both genders, and negative emotional states constituted the most commonly reported relapse crisis situation. Survival of a relapse crisis was strongly associated with the number of coping strategies used by both men and women. There was a nonsignificant trend for females to relapse more frequently in negative affect situations (i.e., negative emotions, conflict with others) and males in the presence of other drinkers. Further studies employing larger sample sizes are needed to examine gender differences in the process of relapse.

Development and validation of the drug-taking confidence questionnaire: a measure of coping self-efficacy.

The Drug-Taking Confidence Questionnaire (DTCQ; Annis & Martin, 1985) is a 50-item self-report questionnaire developed to assess situation-specific coping self-efficacy for use of a particular substance of abuse (e.g., cocaine, heroin, alcohol, cannabis, etc.). Results from exploratory and confirmatory factor analyses of the DTCQ on 713 clients seeking treatment at an addiction treatment facility provided strong evidence for the situation-specificity of efficacy beliefs. An 8-factor first-order model, based on the eight high-risk categories for relapse identified by G.A. Marlatt (Marlatt & Gordon, 1980) and a 3-factor second-order model (i.e., negative situations, positive situations, and temptation situations) provided the best fit to the data. All eight subscales of the DTCQ were shown to have good reliability (alphas .79 to .95). Extensive convergent and discriminant validity analyses for the DTCQ and its subscales in relation to ADS, DAST, OES, DRIE, SCQ, SCL-90R, BDI, HS, and SOCRATES substantiate that the DTCQ is a promising tool for further research and clinical application.

Measurement of antecedents to drug and alcohol use: psychometric properties of the Inventory of Drug-Taking Situations (IDTS).

The development, factor structure, and validity of the Inventory of Drug-Taking Situations (IDTS) is described. This 50-item self-report questionnaire, which is an extension of the Inventory of Drinking Situations (Annis, 1982. Inventory of drinking situations; Annis, Graham & Davis, 1987, Inventory of drinking situations (IDS): User's guide), is designed to assess the situational antecedents to use of a wide range of drugs of abuse. The IDTS consists of 8 subscales that measure a client's substance use in the 8 situations identified in the work of Marlatt (1978, Alcoholism: New directions in behavioral research and treatment): Unpleasant Emotions, Physical Discomfort, Pleasant Emotions, Testing Personal Control, Urges and Temptations to Use, Conflict with Others, Social Pressure to Use, and Pleasant Times with Others. Reliability, factor structure and validity of the IDTS were assessed on 699 clients admitted to the Addiction Research Foundation's treatment facility in Toronto. The IDTS was shown to have reliable subscales. The IDTS total score correlated with self-ratings of the severity of the clients' substance use problem, and with retrospective reports of frequency of use (drugs) and quantity of use (alcohol), years of usage, and severity of dependence. Confirmatory factor analysis was used to test the fit of the data to Marlatt's model of substance use situations, as well as to several alternative models. The goodness-of-fit indicators suggested that the best fit for the data was an 8-factor model corresponding to the 8 subscales based on the Marlatt categories. Evidence was presented that the 8 subscales can be further grouped into 3 second-order factors: (1) negative situations, (2) positive situations, and (3) temptation situations. The negative situation subscales of Unpleasant Emotions, Conflict with Others and Physical Discomfort were found to be correlated with the SCL-90R Depression scale. Interpersonal Sensitivity scale and Somatization scale respectively. The positive social situation subscales of Pleasant Times with Others and Social Pressure to Use were found to be negatively correlated with percentage of time using alone, and positively correlated with pressure from friends and family to use. On the States of Change Readiness and Treatment Eagerness Scales (SOCRATES), clients at the precontemplation stage of change had relatively flat, undifferentiated IDTS profiles (i.e. little scatter of subscale scores), whereas clients in the determination stage had the most differentiation in their IDTS subscale scores. Excellent comparability was found for alcohol clients between the IDS and the IDTS. Evidence was also presented for adequate comparability between the computer and paper and pencil administrative formats of the IDTS.

Drinking-related assessment instruments: cross-cultural studies.

In recent years a number of drinking-related assessment instruments have undergone extensive developmental work and are in widespread use. These include measures that are designed to assess: 1) patterns of alcohol consumption. Timeline Followback Method (TLFB); and 2) antecedents to alcohol use, Inventory of Drinking Situations (IDS)-two constructs that would be expected to be sensitive to cross-cultural variability in drinking practices. These assessment tools present opportunities for the study of cross-cultural differences in drinking patterns and the circumstances under which drinking occurs. A World Health Organization project utilizing these assessment tools is currently underway in five countries (Australia, Canada, Mexico, Poland, and Sweden). This project focuses on the identification of profile differ.

The role of coping in relapse crisis outcome: a prospective study of treated alcoholics.

This study investigates the influence of coping on the outcome of a relapse crisis for a sample of 125 treated alcoholics during the first 12 weeks following treatment completion. Both number and type of coping responses were examined. Results indicated that survival of a relapse crisis was most strongly related to the number of coping strategies used. Termination of a drinking episode was also related to number of coping responses. In addition, the type of coping strategy influenced survival, with the exclusive use of active coping strategies significantly associated with abstinence outcome compared with the exclusive use of avoidant strategies. Combining active and avoidant strategies appeared to be most effective for terminating a drinking episode. Results are discussed in the context of the cognitive-behavioral model of relapse, the general literature on coping behavior and the findings of other relapse studies.

A controlled field trial of group versus individual cognitive-behavioural training for relapse prevention.

Results are presented of a randomized field trial comparing two aftercare regimes, namely individual versus group delivery of a structured relapse prevention approach. Two addictions treatment programs (one a 12-Step 26-day residential program, the other an evening group counselling program) implemented structured relapse prevention in either group or individual format as part of the first three months of aftercare. Process measures (e.g. attendance, client satisfaction) indicated that both group and individual formats were delivered very successfully at both sites. Follow-up rate at 12 months across both programs was 74%, and drinking and drug use at the 12-month follow-up was substantially less than use at entry into treatment. However, there were no significant differences in outcomes between individual and group delivery on any of the alcohol or drug use measures. Only one psychosocial outcome measure (social support from friends at 12-month follow-up) showed a significant difference for format and it favored the group format. These findings suggest some important directions for future research.

Barriers to help-seeking for change in drinking: a gender-focused review of the literature.

Women with drinking problems are less likely than men to utilize alcohol-specific treatment services; they are comparatively more likely to seek help in general health and mental health care settings. These patterns in service utilization may be attributable, in part, to gender differences in barriers or disincentives to seeking and receiving care for alcohol abuse. In this paper we provide a gender-focused review of research on barriers to help-seeking for addictions behavior change. Two major categories of barrier, involving client and treatment program characteristics, appear to have a greater impact on service utilization of women than men. Insights gained from barriers literature provide valuable direction for future research and suggest applications in clinical service provision and treatment planning.

The use of calcium carbimide in relapse prevention counselling: results of a randomized controlled trial.

The effect of combining relapse prevention counselling with use of an alcohol-sensitizing drug was examined. Fifty-six alcoholic subjects who participated in a clinical trial of the short-acting alcohol sensitizing drug, citrated calcium carbimide, were randomly assigned to: (i) a Physician Advice condition in which subjects took the drug within a context designed to reinforce the medical management of their drinking problem; and (ii) a Relapse Prevention condition in which subjects were instructed to pair use of the drug with planned entry into high risk drinking situations and to gradually reduce reliance on the drug by developing alternative coping behaviour patterns. As predicted, subjects receiving carbimide in conjunction with relapse prevention counselling showed significant growth in internal attribution for change; whereas those receiving carbimide under more traditional medical management showed no movement toward internality. On measurement of alcohol consumption at 6, 12 and 18 months follow-up, there was some indication of superior maintenance of treatment gains at 18 months post-treatment for subjects who had received relapse prevention counselling, although the effect did not reach a conventional level of significance (F = 2.82; P less than 0.06). The findings are interpreted as consistent with a cognitive social-learning analysis of the maintenance of behaviour change.

A cognitive-social learning approach to relapse: pharmacotherapy and relapse prevention counselling.

A cognitive-social learning model of relapse prevention, specifically Albert Bandura's theory of self-efficacy, is one of the most influential theoretical frameworks that has been applied to the problem of relapse in the substance abuse field. Theory and research within this approach are reviewed and future directions for research are suggested. It is proposed that the critical distinction drawn between treatment strategies aimed at "initiation" versus "maintenance" of behaviour change provides a theoretical framework for the use of pharmacological agents in the treatment of alcohol problems. Pharmacological agents can be powerful in initiating a change in consumption, but if patients externally attribute to the drug the cause of their improvement, maintenance of improvement following withdrawal of the drug is likely to be poor. Relapse prevention counselling procedures, on the other hand, have been designed to provide self-attribution for change in drinking behaviour on the part of patients to promote maintenance of treatment effects. A combined approach using pharmacological agents (aimed at initiating a change in drinking) in conjunction with relapse prevention counselling procedures (aimed at fostering internal attribution and maintenance of change) should improve long-term outcome results. Available empirical evidence is presented.

Outcome and efficacy expectancy in the prediction of post-treatment drinking behaviour.

A recent controversy in research on self-efficacy theory has been directed at the role of outcome and efficacy expectancies in the prediction of behaviour. While Bandura maintains that outcome expectancies add little information to prediction beyond that explained by efficacy expectations, others disagree. The present study explored the efficacy-outcome expectancy relationship in a population of alcoholic clients as they moved through a traditional treatment program and were contacted following a three-month aftercare period. Results indicated that outcome expectancies (defined as the costs and benefits expected to result from a change in drinking) did not predict consumption at follow-up. However, self-efficacy (defined as confidence in being able to resist the urge to drink heavily) assessed at intake of treatment, was strongly associated with the level of consumption on drinking occasions at follow-up. These findings are discussed in relation to the relevance of self-efficacy theory to research and treatment of alcoholic patients.

Relapse to substance abuse: empirical findings within a cognitive-social learning approach.

A cognitive-social learning model of relapse prevention, specifically Albert Bandura's theory of self-efficacy, is one of the most influential theoretical frameworks that has been applied to the problem of relapse in the substance abuse field. Theory and related empirical findings within this approach are reviewed, including the following: the assessment of a client's high-risk situations for relapse; the development of an individualized treatment plan; the distinction between treatment strategies aimed at "initiation" versus "maintenance" of behavior change; the importance of growth in client self-efficacy; the difference between the process of lapse versus relapse; the use of drugs in relapse prevention counseling; and the role of client-treatment matching. On the basis of the empirical evidence reviewed, it is concluded that a cognitive-social learning approach to relapse prevention is showing promise. Future directions for research are suggested.

Calcium carbimide in alcoholism treatment. Part 2: Medical findings of a short-term, placebo-controlled, double-blind clinical trial.

Drug-induced toxicity in chronic alcoholics who participated in a 4-month placebo (Pl)--controlled clinical trial of the efficacy of calcium carbimide (CC) is reported. Daily monitoring of patients' compliance indicated that 85% of study medications were taken, and very little drinking took place during the study. Patients did not report more symptoms or experience more medical problems during CC administration than during placebo administration. There was no evidence of hepatotoxicity, or behavioural toxicity. Mean white blood cell count was slightly increased during CC treatment, and returned to baseline values when CC was stopped. Thyroid function was not affected by CC in patients with normal pretreatment function. However one patient with pretreatment reduced thyroid function became hypothyroid after CC administration, which indicates a need for systematic monitoring. We conclude that CC is safe for use in alcoholics with normal thyroid function, and may be the preferred alcohol-sensitizing drug in some situations.

Calcium carbimide in alcoholism treatment. Part 1: A placebo-controlled, double-blind clinical trial of short-term efficacy.

A randomized, double-blind, placebo-controlled single cross-over study of the alcohol sensitizing drug, calcium carbimide (CC), was conducted in 128 patients with alcohol dependence. Seventy-one (55%) completed the 4-month study. Patients reported drinking and pill-taking behaviour, and submitted urines (for analysis of alcohol and the tablet marker riboflavin) on 97%, and 91% of treatment days, respectively. All of the 69 analyzable completers were abstinent on at least 85% of days, and 58% (40) were alcohol-free during the study. Medications were taken on at least 85% of days. Symptoms and adverse clinical findings were not increased in frequency during CC, compared to placebo. Seventy-eight per cent of the patients believed they had received CC throughout the study, suggesting that CC exerts a strong psychological deterrent effect. Alcohol consumption was significantly reduced to the same extent with CC and placebo, compared to pre-treatment levels.

The reactive effects of follow-up assessment procedures: an experimental study.

A four group randomized control study designed to investigate the reactive effects of follow-up interviews and self-monitoring procedures on the self-reported drinking patterns of treated alcoholics failed to demonstrate any such effects. However, problems were experienced in gaining participation in frequent follow-up interviews and with the use of daily self-monitoring procedures. Limitations on the conclusions that can be drawn are discussed.

Maturational changes in Canadian adolescents' cognitive attitudinal structure concerning marijuana.

Thirty-four items concerning marijuana use were administered three times to a cohort of Canadian high school students between Grades 11 and 13, in 1977 (n = 439), 1978 (n = 419), and 1979 (n = 167). These items were designed to measure four distinct constructs: attitude, perceived peer approval or disapproval, concern about risks, and symbolic protest against conventional society. A cross-sectional factor analysis of the Grade 13 data supported the hypothesized factor structure, as had earlier work with college students. However, analogous analyses on the Grade 11 and Grade 12 data contradicted the hypothesized factor structure. Most notably, separate factors for positive and negative attitude appeared in the Grade 11 and 12 analyses. The data were interpreted primarily in terms of maturational changes, largely through elimination of alternative interpretations by internal analyses and previous findings. Implications were discussed for adolescent cognitive-attitudinal development, attitude theory, and analysis of panel data.

Is inpatient rehabilitation of the alcoholic cost effective? Con position.

Across all sectors of the health care system there is pressure to increase the cost-effectiveness of service delivery. In recent years, a number of official reports in the alcoholism field have called for the establishment of alternatives to traditional inpatient hospitalization for alcoholics. This paper briefly reviews five bodies of scientific evidence that bear on this recommendation. It is concluded that: inhospital alcoholism programmes of a few weeks to a few months duration show no higher success rates than periods of brief hospitalization of a few days; the great majority of alcoholics seeking treatment for alcohol withdrawal can be safely detoxified without pharmacotherapy and in nonhospital-based units--detoxification with pharmacotherapy on an ambulatory basis has also been shown to be a safe alternative at one-tenth the cost; "partial hospitalization" (day treatment) programmes have been found to have equal or superior results to inpatient hospitalization at one-half to one-third the cost; well-controlled trials have also demonstrated that outpatient programmes can produce comparable results to inpatient programmes--one estimate places the cost saving at $3700 per patient compared with the typical course of inpatient treatment; and a growing body of evidence suggests that if patients could be matched on clinically significant dimensions to a range of treatment alternatives, much higher overall improvement rates in the alcoholism treatment field would be observed. The question that should guide future investigation is "What treatments are most effective for what types of alcoholics?"