Developments in the treatment of alcoholism

The treatment of alcoholism has changed during the past 2 decades. Notable developments have occurred in pharmacotherapy, psychotherapy, and health-care delivery. A better understanding of the biologic basis for addiction has led to clinical trials of medications that target neuroreceptors. One such medication is the opiate antagonist naltrexone, which decreases the craving for alcohol. Psychosocial interventions continue to be the mainstay of alcohol treatment programs. The efficacy of three different therapies was demonstrated in a study called Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity). This study, however, did not prove the patient-treatment "matching" hypothesis. In addition to therapies provided by addiction specialists, interest is growing in the use of brief motivational techniques in primary-care settings. As the field of addiction responds to an unfolding health-care delivery system, a broader range of treatment options in conjunction with a greater opportunity to individualize patient care is evolving.     

Recent developments in the pharmacotherapy of alcohol dependence.

The effectiveness of a treatment for alcohol dependence can be appropriately determined only after controlling for the usual clinical course of alcoholism, subgroups of alcohol-dependent individuals, and placebo effects. The results of appropriate treatment trials must also be interpreted in light of the side effects and costs, and there must be assurances that the overall improvement in functioning observed with the drug is significant enough to outweigh the liabilities. In addition, medications are almost always used in combination with education, counseling, and behavioral therapies, and the impact of these additional treatments must be considered. Viewed from this perspective, 3 medications are quite promising regarding their potential future impact in the alcohol field, including naltrexone, the medication with the most available data in the United States. There are additional data regarding buspirone and acamprosate. Intriguing results have also been generated regarding medications that affect serotonin and dopamine brain activity and with alcohol-sensitizing drugs such as disulfiram. However, none of these medications has been proven to be clinically effective in the routine treatment of the average alcoholic… (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Oral treatment schedules for onychomycosis: a study of patient preference

BACKGROUND: An improved understanding of patients' attitudes to medication may help promote compliance with oral medications for onychomycosis. This study was performed to assess patients' preference between continuous and intermittent oral treatment schedules for onychomycosis and to determine the reasons underlying the selections made. METHODS: Patients were eligible for inclusion if they had current onychomycosis and were willing to take oral medication for this condition. In a 30-min, face-to-face interview, each patient answered questions about four possible treatment schedules for onychomycosis; regimen 1--continuous (daily regular intake) for 12 weeks; regimen 2--intermittent 1 week/month for 3 months (last week of therapy is week 9); regimen 3--intermittent once weekly for 21 weeks; regimen 4--intermittent 1 week/month for 4 months (last week of therapy is week 13). RESULTS: A total of 102 patients from Germany and Spain participated in the study. When asked to choose between regimens 1, 2, and 3, 46% of patients favored the 9-week intermittent schedule, 42% selected the 12-week continuous schedule, and 12% preferred the 21-week intermittent schedule. The preference for the 9-week intermittent schedule was more notable among younger patients (< 45 years), possibly because they are less used to taking regular medication, and among Spanish patients, an effect that could not be attributed to age because the average age of patients was similar in the participating countries (Germany 47.2 years; Spain 48.0 years). When the patients who preferred regimen 2 were asked to choose between regimens 1, 3, and 4 (both intermittent schedules longer than the continuous schedule), most (57%) favored the shortest treatment schedule (regimen 2). CONCLUSIONS: Overall, patients favored an intermittent schedule lasting 9 weeks. Treatment duration is the critical factor in determining patients' preference for treatment schedules for onychomycosis.     

Body adaptation to the action of ecological factors at the cellular and subcellular levels

While poor drug compliance is a significant impediment to the effective treatment of hypertension, knowledge of what patients wish to know about their medications in order to improve compliance is very limited. To develop a preliminary understanding of patients' medication requirements and expectations, a simple 30-item questionnaire was developed and administered to 66 patients who were either taking antihypertensive drugs, or about to commence antihypertensive drug treatment. Ninety percent of patients wanted to know about all possible side effects of medications as well as the most likely side effects. Ninety-six percent wanted to know if their drug treatment would keep them well. In addition, most patients wanted to avoid multiple medications, were concerned about the prospect of life-long treatment, and were worried about potential drug interactions. Effects of the drugs on their lifestyles as well as any lifestyle changes required to augment drug therapy were other issues of concern. The elderly were less interested in many of these issues. A strong desire for further knowledge about their disease was noted in most subjects (82%). If compliance with medication therapy is to be improved, a better understanding of patients' concerns and fears about medications is required, particularly in a relatively asymptomatic disease like hypertension.     

Naltrexone and alcohol dependence. Role of subject compliance

BACKGROUND: Two previous double-blind, placebo-controlled studies demonstrated that naltrexone (50 mg/d) reduces alcohol drinking in alcohol-dependent subjects. In both studies, treatment compliance was excellent. However, a robust treatment effect size for naltrexone relative to placebo has been shown for compliant subjects but not for subjects who missed research visits. The goal of this study was to determine the effectiveness of naltrexone in subjects who received psychosocial treatment in a more naturalistic setting with respect to the role of treatment attendance and medication compliance. METHODS: Ninety-seven alcohol-dependent subjects were randomly assigned to receive either naltrexone (n = 48) or matching placebo (n = 49) for 12 weeks. All subjects received individual counseling (twice per week for the first month followed by once per week). RESULTS: Overall, naltrexone showed only modest effects in reducing alcohol drinking for the 12 weeks of treatment. However, naltrexone treatment efficacy improved across a variety of outcome measures for subjects who completed treatment and were highly compliant with taking medication. CONCLUSIONS: Naltrexone is clinically effective relative to placebo in individuals who comply with the treatment protocol and take medication. The modest treatment effects in the entire sample suggest that the clinical efficacy of naltrexone could be improved by enhancing treatment compliance.     

Understanding attitudes toward use of medication in substance abuse treatment: A multilevel approach.

Individual and organizational variables influence attitudes toward use of naltrexone, methadone, and buprenorphine for the treatment of alcohol and drug disorders. Previous research has not considered both sets of influences simultaneously. Hierarchical linear modeling tested the contribution of individual and organizational variables with data from the National Drug Abuse Treatment Clinical Trials Network treatment unit and workforce surveys (n = 2,269 staff nested within 247 treatment units). Individual-level variables consistently had more influence on attitudes, but a unique blend of variables existed for each medication. One predictor, support for psychiatric medications, influenced attitudes across all medications. Staff attitudes toward addiction medications varied significantly between treatment units. Implications for increasing the appropriate use of addiction medications are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Contingency management to enhance naltrexone treatment of opioid dependence: A randomized clinical trial of reinforcement magnitude.

Fifty-five detoxified opioid-dependent individuals were randomly assigned to 1 of 3 treatments delivered over 12 weeks: standard naltrexone maintenance, standard naltrexone plus low-value contingency management (CM), or standard naltrexone plus high-value CM. Results suggest that (a) assignment to either CM condition was associated with significant reductions in opioid use over time compared with standard naltrexone treatment; (b) contrasts of high- versus low-value reinforcement magnitude were not significant, suggesting no relative benefit of higher over lower value incentives in this population; (c) participants assigned to either CM group reported significant reductions in readiness to change compared with participants assigned to standard naltrexone treatment. These findings suggest that targeted behavioral therapies can play a substantial role in broadening the utility of available pharmacotherapies. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Repeated doses of combined oral lysine acetylsalicylate and metoclopramide in the acute treatment of migraine

The combination of lysine acetylsalicylate and metoclopramide is effective in the treatment of migraine attacks. It was unknown whether repeated doses could improve efficacy. The aim of this open trial was to evaluate the effects of a second, and eventually a third dose of lysine acetylsalicylate and metoclopramide when a first dose of the treatment was ineffective. Patients were asked to take a second dose 2 hours after a first dose when they thought that the first dose was ineffective. They were allowed to take a third dose or their rescue medication 2 hours after the second dose when they judged that the treatment remained ineffective. Two hundred ninety-two patients were included in the study; 262 of the 292 patients treated 517 attacks. Headache relief (reduction in headache severity from grade 3 or 2 to grade 1 or 0) was observed in 54.8% of attacks after one dose, in 48.1% of attacks after a second dose, and in 40.3% of attacks after a third dose. Complete headache relief without recurrence and without use of a rescue medication was reported in 37% of the total attacks. The patients judged their treatment as good or excellent in 78% of attacks treated with one dose, in 41% of those treated with two doses, and in 19% of those treated with three doses. Tolerance, as judged by the patients, was considered good in 92% of treated attacks. Minor side effects occurred in 6% of attacks after a first dose, in 4.5% of attacks after a second dose, in 1.5% of attacks after a third dose, in 2% after unspecified delay, and in 14% overall. In conclusion, the efficacy of lysine acetylsalicylate and metoclopramide in the treatment of migraine attacks can be improved by repeated doses. It is well tolerated.     

Pharmacotherapy for postacute traumatic brain injury: A literature review for guidance in psychological practice.

Objectives: The purpose of this review is to educate and guide the actions of rehabilitation psychologists by providing a summary of the current literature on pharmacotherapies and treatment effectiveness for the chronic sequelae associated with severe traumatic brain injury (TBI). A number of medications are reviewed for use in treating deficits in arousal, cognition, function, and other problems associated with TBI. Findings for their use in this population are summarized. Cautions, limitations, and directions for future research are discussed. Conclusions: Pharmacological management of chronic symptoms of TBI is commonplace in rehabilitation practice. Clear clinical guidelines for the use of pharmacotherapy in TBI are lacking, however, because of the few conclusive findings regarding the effectiveness of any particular agent. Rehabilitation psychologists frequently encounter patients treated with numerous medications and, therefore, need to be aware of potential effects on cognitive and functional abilities. Additionally, rehabilitation psychologists should be aware of available and empirically supported pharmacotherapies as they are in a position to comprehensively assess the patient and provide requested consultation to the treating physician concerning the patient's need for and likelihood of benefiting from various pharmacological agents. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Behavioral family counseling and naltrexone for male opioid-dependent patients.

Men (N=124) entering treatment for opioid dependence who were living with a family member were randomly assigned to one of two 24-week treatments: (a) behavioral family counseling (BFC) plus individual treatment (patients had both individual and family sessions and took naltrexone daily in presence of family member) or (b) individual-based treatment only (IBT; patients were given naltrexone and were asked in counseling sessions about their compliance, but there was no family involvement). BFC patients, compared with their IBT counterparts, ingested more doses of naltrexone, attended more scheduled treatment sessions, had more days abstinent from opioids and other drugs during treatment and during the year after treatment, and had fewer drug-related, legal, and family problems at 1-year follow-up. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Fluoxetine in depressed alcoholics. A double-blind, placebo-controlled trial

BACKGROUND: The selective serotonergic medication fluoxetine has demonstrated efficacy in the treatment of major depression and has suggested efficacy in the treatment of alcoholism. However, no completed trials with any selective serotonergic medication have been reported in patients who display both major depression and alcoholism, despite previous observations that both depression and alcoholism are associated with low serotonergic functioning. METHODS: Fifty-one patients diagnosed as having comorbid major depressive disorder and alcohol dependence were randomized to receive fluoxetine (n = 25) or placebo (n = 26) in a 12-week, double-blind, parallel-group trial. Weekly ratings of depression and alcohol consumption were obtained throughout the 12-week course of the study. RESULTS: The improvement in depressive symptoms during the medication trial was significantly greater in the fluoxetine group than in the placebo group. Total alcohol consumption during the trial was significantly lower in the fluoxetine group than in the placebo group. CONCLUSIONS: Fluoxetine is effective in reducing the depressive symptoms and the alcohol consumption of patients with comorbid major depressive disorder and alcohol dependence. It is unknown whether these results generalize to the treatment of less depressed and less suicidal alcoholics.     

Functional and adaptive significance of primate pads and claws: evidence from New World anthropoids

To address the recent rise in asthma morbidity and mortality in Russia, an intervention study was conducted to improve asthma diagnosis, treatment and prevention. US recommendations for asthma management were adapted for use in educating Moscow families with children with asthma. Two hundred and fifty-two children with asthma aged 4-14 years receiving health care in eight Moscow public health clinics together with their parents were enrolled in the study to see whether US teaching manuals for asthma management would be acceptable and effective in Russia. Children at four of the clinics with recent asthma attacks were randomly assigned to either the education or control group to test if patient education and guided asthma care would improve outcomes for patients. Modern medications were made available to both groups to see if training in the US guidelines was necessary to get physicians to use the medications. Children with recent asthma attacks at the other four clinics were defined as comparison group 1 to control for the possible effect of medication availability. All children at the eight clinics who had no asthma attacks composed comparison group 2 to see if the outcomes for these children would change over time. One-year follow-up results showed significant improvement in asthma self-management skills of children and parents, in terms of asthma treatment, only among those in the education group. Significant increases were observed in the subgroup of children in the education group using anti-inflammatory drugs for asthma control. Children in the education group had markedly increased peak flow rates and reduced daily peak flow variability as compared to control and comparison groups. There was a significantly greater reduction in doctor visits by the education group of children compared to control. Presumably, changes in parents' and children's behaviour in terms of asthma treatment and prevention skills, proper treatment of the disease and access to medications could be responsible for reducing asthma morbidity in children.     

The disease controversy and psychotherapy with alcoholics

This article discusses conducting psychotherapy with alcoholics in light of the controversy about whether alcoholism is a disease. The belief that alcoholism is a disease forces many clinicians to offer abstinence from alcohol as the only option for alcoholics who seek treatment. From this perspective, the alcoholic must be helped to accept the idea that he or she has a disease and that to recover from this problem, drinking must stop. Others maintain that alcoholism may not be a disease and view alcoholic drinking as maladaptive behavior. From this vantage point, helping the patient to control or to moderate drinking might be considered. These two distinct paradigms lead to divergent treatment goals, which leaves the clinician in a quandary about how best to treat an individual who experiences a drinking problem. To resolve this dilemma, it is suggested that the clinician who works with alcoholics entertain a multiplicity of perspectives and should not be blinded by any one paradigm. While control of alcohol intake must take place if such patients are to improve their functioning, the author argues that recovery can occur either by abstinence or through moderating drinking.     

Pharmacotherapies for alcohol abuse. Withdrawal and treatment

Pharmacologic management of alcoholism is only one part of the management of both alcohol dependence and withdrawal, which also includes the provision of a calm, quiet environment; reassurance; ongoing reassessment; attention to fluid and electrolyte disorders; treatment of coexisting addictions and common medical, surgical, and psychiatric comorbidities; and referral for ongoing psychosocial and medical treatment. For further discussion of these topics, the reader is referred to previously published sources. A survey of alcoholism treatment programs revealed that although benzodiazepines were the most commonly used drugs, standardized monitoring of patients' withdrawal severity was not common practice, and a significant minority of clinicians were using a variety of other drugs, some not known to prevent or treat the complications of withdrawal. Treatment should be based on the available evidence (Working Group on Pharmacological Management of Alcohol Withdrawal: American Society of Addiction Medicine Committee on Practice Guidelines: Pharmacological management of alcohol withdrawal: An evidence-based practice guideline. Unpublished draft, 1997). Patients with significant symptoms, patients with complications such as seizures or delirium tremens, and patients at higher risk for complications of alcohol withdrawal should receive benzodiazepines, particularly chlordiazepoxide, diazepam, or lorazepam, because of their safety and documented efficacy in preventing and treating the most serious complications of alcohol withdrawal. These drugs may be dosed on a fixed schedule for a predetermined number of doses on a tapering schedule over several days, or they may be administered by front-loading. An alternative approach for selected patients without seizures or acute comorbidity is symptom-triggered therapy, which individualizes treatment and decreases the duration and dose of medication administration. With either of the regimens, patients should have their withdrawal severity monitored until symptoms are resolving. Once withdrawal from alcohol is safely completed, the focus should turn to helping to prevent relapse. Disulfiram may be useful in highly motivated subsets of patients and when compliance-enhancing strategies are used. Naltrexone is useful in the broader population of patients entering treatment for alcohol dependence. These pharmacologic interventions should be given in the context of ongoing psychosocial support. There is substantial evidence that pharmacologic management of alcohol abuse and dependence is effective. As would be predicted from alcohol's myriad cellular effects, no panacea exists for alcoholism. For alcohol withdrawal, however, although treatment regimens have only recently been refined, evidence for effective treatment of symptoms and prevention of complications with benzodiazepines has been available for decades. Within the last decade, effective treatments, including naltrexone, have been shown to reduce alcohol intake in alcohol-dependent persons. Given the prevalence and cost of alcohol-related problems, all effective therapies (including pharmacologic treatments) should be considered to treat alcohol abuse and dependence.     

Topical versus peribulbar anesthesia in cataract surgery

PURPOSE: To compare the use of topical anesthesia with that of peribulbar anesthesia in cataract surgery. SETTING: Quinze-Vingts Hospital, Paris, France. METHODS: This prospective study comprised 45 patients who had phacoemulsification and intraocular lens implantation in both eyes with 1 to 9 months between surgeries. Each patient had peribulbar anesthesia for one surgery and topical anesthesia for the other. The anesthesia method for the first eye was randomly selected. After surgery, patients were asked to rate their pain and whether they preferred one anesthesia technique over the other. RESULTS: When topical anesthesia was given, 82.2% of patients required no intravenous medications. Overall, 62.2% preferred topical over peribulbar anesthesia, with most patients citing the lack of periocular injection as the reason. CONCLUSION: Despite the increased technical difficulty, topical anesthesia proved an effective alternative to peribulbar anesthesia for cataract surgery that avoids the risks of periocular injection and reduces the need for intravenous medications.     

Migraine preventive medications: a reappraisal

Newer acute care migraine medications demonstrate improved rapidity of action, consistent effectiveness, excellent safety profiles, and rarely cause rebound headaches. Their use could decrease the need for migraine-preventive medication. The present analysis derives a formula that can be used by practitioners to determine the cost-effectiveness of various migraine-preventive medications relative to selected acute-care medications. We propose a measure called the cost-equivalent number (CEN), the number of headaches per month at which the cost of the preventive medication equals the cost savings in acute-care treatment realized by using the preventive medication. The use of the CEN individualizes the decision of whether to use a migraine-preventive medication, weighing both the efficacy and cost of the preventive medication against the cost of the acute-care medication. A CEN lower than the migraine frequency suggests that use of a preventive medication will be cost-effective.     

Dental care of the polymedication patient

With increasing frequency, ambulatory patients maintained on multiple medications are seeking dental care. Because new medications are approved for use each year and new interactions and side effects are regularly exposed for existing medications, it is important to keep current in this area. With the availability of regularly updated computer programs to help analyze accurate patient medication lists, the treatment of the polymedication patient has become much easier. The close, careful attention to patient medications should help prevent medical problems as well as reveal much about the patient's ability to withstand dental procedures.     

Bio-dissolution of spent nickel-cadmium batteries using Thiobacillus ferrooxidans

BACKGROUND: To evaluate the magnitude, nature and chronicity of the use of medications on the part of non-institutionalized elderly individuals as well as the complexity of their treatment routine. METHOD: Cross-section study through door-to-door survey of all individuals age 65 or above. Municipality of Villanueva de los Castillejos (Huelva). The surveyor asked the person to show him/her all of the medications he/she was using without overlooking any, recorded the brand name, dosage and frequency with which the medication in question was taken, and the approximate length of time, in months or in years, over which said medication had been taken. Measurement methods were included for the purpose of assessing the complexity of the treatment routine. RESULTS: Information was gathered from 362 subjects (83.8% of the actual population). Of all those surveyed, 83.1% was taking one or more medications daily, for an average (standard deviation) of 2.6 (2.0). Those used most were antihypertensive drugs (41.8%), peripheral vasodilators for circulation to the brain (21.3%), benzodiazepine derivatives (17.4%) and nonsteroid antiinflammatory drugs (14.1%). 91.3% and 46.1% of the subjects who were taking medication daily, had been taking one or more drugs for at least 1 and 5 years, respectively. The medication in question was taken on the average of one to two times a day. Approximately 20% of the population surveyed was taking medication solely when certain symptoms arose, and 7.3% of the drugs were prescribed regularly, but not daily. CONCLUSIONS: The quantity and chronicity of the consumption of medications is high, although comparable to that of other Spanish studies conducted employing similar means and methods. The routine prescribed seems simple for seniors.