Outpatient alcohol detoxification: Implementation efficacy and outcome effectiveness of a model project

Background: The aim of the study was to examine the practicability and implementation efficacy of an alcohol outpatient detoxification model and the concomitant `motivational' psychotherapeutic approach. Method: This was an open prospective study to examine the implementation efficacy, practicability and medical safety of a novel psychotherapy-based, integrated outpatient detoxification model in alcohol-dependent patients. Patients were carefully screened for relevant neuropsychiatric disorders and other exclusion criteria and then seen on a daily outpatient basis for 5 - 7 days. Patients received psychotropic or other medication, if necessary (CIWA-A score >16). Beside management of withdrawal symptoms, psychotherapeutic interventions were conducted to motivate the patient for further alcohol therapy. Results: Of 557 patients screened 331 entered the program. For medical reasons 226 patients had to be admitted for inpatient detoxification, 122 patients in a special alcohol unit, 101 patients in a general hospital. 198 (60%) of the outpatients received psychotropic medication during treatment. 312 (94%) of these patients successfully completed treatment. 301 (91% of the initial sample) patients entered a consecutive 3-month motivational phase of a two-phase alcohol treatment program. 139 (46%) patients successfully completed the 1-year consecutive outpatient treatment. Conclusions: Outpatient detoxification, at least in a highly structured frame, can be considered as a safe and efficient therapeutic approach. The data of this study also indicate that psychotherapeutic interventions and motivation for further abstinence and treatment may work in alcohol-dependent patients on an outpatient basis. Further controlled trials are necessary to compare the effects of outpatient versus inpatient withdrawal. Copyright (C) 2004 S. Karger AG, Basel

Transition From Full Mu Opioid Agonists to Buprenorphine in Opioid Dependent Patients-A Critical Review

Methadone, a full opioid agonist at the mu-, kappa-, and delta-receptor, and buprenorphine, a partial agonist at the mu receptor, are first-line medications in opioid maintenance treatment. Transition from methadone to buprenorphine may precipitate withdrawal, and no accepted algorithm for this procedure has been developed. Current treatment strategies recommend transfer from methadone to buprenorphine predominantly in patients at low doses of methadone (30–40 mg/day). There are some reports indicating that transition from higher doses of methadone may be possible. A number of dosing strategies have been proposed to soften withdrawal symptoms and facilitate transfer including use of other opioids or medications and especially microdosing techniques for buprenorphine. The case series and studies available thus far are reviewed

Chronological relationship between antisocial personality disorder and alcohol dependence

Personality disorders, and particularly antisocial personality disorder (ASPD), frequently co-occur with alcohol dependence. ASPD is considered to be an important cofactor in the pathogenesis and clinical course of alcohol dependence. The chronological relationship between the onset of symptoms of ASPD and alcohol-dependence characteristics has not yet been studied in great detail and the role of ASID in classification schemes of alcohol dependence as suggested by Cloninger and Schuckit has yet to be determined. We studied 55 alcohol-dependent patients to assess the prevalence and age at manifestation of ASPD, conduct disorder characteristics as well as alcohol dependence by employing the Semi-Structured Assessment for the Genetics of Alcoholism and the Structured Clinical Interview for DSM-IIIR. Results indicate that the onset of ASPD characteristics precede that of alcohol dependence by some 4 years. This finding suggests that in patients with ASPD, alcohol dependence might be a secondary syndrome as suggested by previous research. Copyright (C) 2002 S. Karger AG, Basel

Alcohol use disorders in opioid maintenance therapy: Prevalence, clinical correlates and treatment

Maintenance therapy with methadone or buprenorphine is an established and first-line treatment for opioid dependence. Clinical studies indicate that about a third of patients in opioid maintenance therapy show increased alcohol consumption and alcohol use disorders. Comorbid alcohol use disorders have been identified as a risk factor for clinical outcome and can cause poor physical and mental health, including liver disorders, noncompliance, social deterioration and increased mortality risk. The effects of opioid maintenance therapy on alcohol consumption are controversial and no clear pattern has emerged. Most studies have not found a change in alcohol use after initiation of maintenance therapy. Methadone and buprenorphine appear to carry little risk of liver toxicity, but further research on this topic is required. Recent data indicate that brief intervention strategies may help reduce alcohol intake, but the existing evidence is still limited. This review discusses further clinical implications of alcohol use disorders in opioid dependence

Role of aggressivity on reactivity and craving before and after cue exposure in recently detoxified alcoholics: Results from an experimental study

The role of aggressivity and cue exposure in induction of craving were investigated in a clinical setting. Thirty abstinent alcoholic patients were divided into a low and a high aggressive group based on scores on the physical aggression subscale of the Buss-Durkee Hostility Inventory and exposed to alcohol cues. Craving was measured by means of the Alcohol Craving Questionnaire (ACQ) and Visual Analogue Scales (VAS). Important findings are: (1) main effects of aggressivity on `emotionality', `purposefulness' and `expectancy' of ACQ were very significant; (2) on `drinking intention' and `craving for alcohol' of VAS, aggressivity and cue exposure showed a significant interaction; (3) the main effect of cue exposure on heart rate also reached a significance level of 0.007. The results were discussed in the context of the Classical, Operant Conditioning Theory, the Cognitive Craving Theory of Tiffany, Gilbert's STAR Model, and the Self-Medication Hypothesis Copyright (C) 2001 S. Karger AG, Basel

Effects of irritability on craving before and after cue exposure in abstinent alcoholic inpatients: Experimental data on subjective response and heart rate

Objective: Irritability is often linked with problem drinking. The aim of this study is to examine the possible influence of irritability on craving induced by a cue-exposure paradigm. Methods: 30 male abstinent alcoholic inpatients of the Psychiatric Hospital of Munich University, Germany gave answers to a series of personality questionnaires. Results of this study concerning the impact of aggressivity on craving for alcohol has recently been published. In this study, the subjects were subdivided into a low- and a high-irritable group based on their scores on the irritability subscale of the Buss-Durkee Hostility Inventory and were exposed to alcohol cues. Craving was measured by means of the Alcohol Craving Questionnaire (ACQ) and Visual Analogue Scales (VAS). The heart rate was also assessed throughout the whole process. ANCOVA for repeated measurement was employed to evaluate the data - irritability disposition as the between-subject factor and the experimental manipulation (absence vs. presence of alcohol cues) as the within-subject factor. Results: Major findings are: (1) main effects of irritability on `emotionality', `purposefulness', and `expectancy' of the ACQ as well as on `craving for alcohol' of the VAS were significant; (2) cue exposure also exerted a significant main effect on I craving for alcohol' of the VAS and on the heart rate after the presentation of alcohol cues; (3) on `compulsivity' of the ACQ and `intention to alcohol intake' of the VAS; there was a significant interaction between irritability and cue exposure. The high-irritable alcoholics, compared with their statements in the baseline, tended to report a higher control over alcohol intake and a lower intention to alcohol use after cue exposure. However, after confrontation with alcohol stimuli, their low-irritable counterparts reported a much lower control and a slightly higher intention than they did in the baseline. Conclusions: The results of this study indicate that induced craving in hospitalized alcohol addicts probably varies with the magnitude of their irritability; it might make patients more aware of their vulnerability to alcohol, help them develop more differential coping strategies and improve medical therapy against alcohol craving. Copyright (C) 2002 S. Karger AG, Basel

Effects of haloperidol and atypical neuroleptics on psychomotor performance and driving ability in schizophrenic patients - Results from an experimental study

The influence of antipsychotic treatment on the neuropsychological and psychomotor performance of schizophrenic patients is still a subject of investigation. The present study was designed to evaluate the effects of atypical neuroleptics in comparison with a conventional dopamine antagonist neuroleptic (haloperidol) on several dimensions of psychomotor performance (visual perception, attention, reaction time, and sensorimotor performance) considered to be of relevance in evaluating driving fitness. Psychomotor performance was assessed by means of the ART 90, a computerized Act and React Test which is generally used in diagnosis of psychomotor performance. The 49 participating patients were examined at discharge following psychopathological stabilisation; 20 received haloperidol, 29 received an atypical neuroleptic. Our findings demonstrate a remarkably reduced psychomotor performance in the haloperidol-treated group of schizophrenic patients compared with patients treated with atypical neuroleptics. Only 1 (5%) subject passed all subtests without major failures and could be regarded as competent to drive. Among patients with atypical neuroleptics, 7 patients (24%) passed all test parameters without major failures. Copyright (C) 2003 S. Karger AG, Basel

Outpatient alcoholism treatment-24-month outcome and predictors of outcome

Objectives: To study the value of demographic and alcohol-related variables for predicting 24-month treatment outcome in an outpatient setting. Methods: Prospective observational study with 92 alcohol-dependent patients. Assessments were made by personal interviews at the beginning and end of therapy, and at the 24-month follow-up. Univariate and logistic regression analyses were performed. Results: The mean age was 46.0 (SD = 9.9) years. There were 58 males (65.2%) and 31 females (34.8%). Of the 67 patients interviewed at 2-year follow-up, 58% were abstinent and 79% improved. Differences between abstainers and non-abstainers were found for number of previous detoxifications, and number of patients attempted suicides. In addition, female gender and a higher number of prior treatments predicted negative treatment outcome. Conclusion: Matching patients to different types of treatment by means of empirically based characteristics may help to improve outcome but research has failed to establish reliable predictors in that area. Data from this follow-up study confirm the role of certain clinical outcome predictors. Additionally, results give further evidence for outpatient treatment as an effective setting for alcohol-dependent patients as indicated by a favourable retention rate (84%) and outcome (minimum abstinence rate 44%)

Impulsive traits and 5-HT2A receptor promoter polymorphism in alcohol dependents: Possible association but no influence of personality disorders

Objective: Impulsive behavior in alcoholics puts them at serious risk of severer course of disease and has been related to the serotonergic neurotransmission dysfunction. The aim of this study is to investigate the association between impulsive aggression in alcohol dependents with regard to the G-1438A polymorphism in the promoter region of the 5-HT2A receptor gene. Furthermore, we investigated the statistical interaction between 5-HT2A alleles, antisocial personality disorder (APD) and impulsive aggression in alcohol dependents. Alcohol dependents were investigated because these personality disorders and impulsive behavior are very frequent in alcohol dependence anf of clinical relevance. Methods: One hundred and thirty-five patients of German descent meeting DSM-IV criteria of alcohol dependence were recruited. Blood samples were taken from alcohol dependents to determine 5-HT2A promoter polymorphisms using PCR (polymerase chain reaction) of lymphocyte DNA. Impulsive aggression was assessed using a German version of the Barratt Impulsiveness Scale which was translated and backtranslated. Alcohol dependents were subdivided into low- or high-impulsivity groups using a median split of the Barratt score. APD and borderline personality disorder (BPD) were assessed using the SCID-II interview. Results: The low-impulsivity group was slightly older and showed a later age at alcoholism onset than the highly impulsive group. Alcohol dependents with high impulsive traits showed a significant association with 5-HT2A 1438 A alleles. After excluding alcohol dependents with APD or BPD from the analysis, this association remained significant. Furthermore, no association between APD, BPD and 5-HT2A alleles was noted. Conclusions: Inpatient alcohol dependents showed a significant association between 5-HT2A A alleles and impulsive traits, independent of the presence of APD or BPD. No association was noted between personality disorders and the polymorphism. This is the first report about an association of 5-HT2A promoter polymorphism and impulsive behavior in alcohol dependents. This finding may refer only to impulsive traits and may be independent of personality disorders in this sample. These results have to be confirmed in larger samples and in healthy control subjects to determine whether this association is of general validity. Copyright (C) 2001 S. Karger AG, Basel