To Approach or Avoid Alcohol? Automatic and Self‐Reported Motivational Tendencies in Alcohol Dependence

Background: Motivational conflict is central to alcohol dependence, with patients reporting motivation to limit their drinking at the same time as urges to drink alcohol. In addition, dual process models of addiction emphasise the power of automatic cognitive processes, particularly automatic approach responses elicited by alcohol‐related cues, as determinants of drinking behavior. We aimed to examine the strength of automatic and self‐reported alcohol approach and avoidance tendencies among alcohol‐dependent inpatients relative to matched controls. Methods:enbsp; A total of 63 alcohol‐dependent patients undergoing detoxification and 64 light‐drinking controls completed a stimulus‐response compatibility (SRC) task, which assesses the speed of categorization of alcohol‐related pictures by making symbolic approach and avoidance movements. We also included modified versions of the SRC task to assess automatic motivational conflict, that is, strong approach and avoidance tendencies elicited simultaneously by alcohol‐related cues. Results: There were no differences between alcohol‐dependent patients and controls on the SRC task, although individual differences in the quantity of alcohol consumed before entering treatment were significantly positively correlated with the strength of approach (but not avoidance) tendencies elicited by alcohol‐related cues. Automatic approach tendencies were also positively correlated with self‐reported “approach” inclinations and negatively correlated with self‐reported “avoidance” inclinations. Conclusions: Although alcohol‐dependent patients and matched controls did not differ on automatic approach and avoidance tendencies elicited by alcohol‐related cues, individual differences in the quantity of alcohol consumed before entering treatment were associated with the strength of automatic approach tendencies elicited by alcohol cues.     

Is the Strength of Implicit Alcohol Associations Correlated with Alcohol‐induced Heart‐rate Acceleration?

BACKGROUND: Heart rate (HR) acceleration during the ascending limb of the blood alcohol curve has proven to be a reliable measure of the sensitivity to the activating effects of alcohol. In this study, we investigated the correlation between an ethanol-induced cardiac change and the strength of implicit alcohol-related arousal and approach associations and attentional bias for alcohol-related stimuli in heavy drinkers. These 3 types of implicit alcohol-related cognitions have been proposed to reflect the strength of incentive sensitization that is experienced after repeated alcohol use. METHODS: Forty-eight heavy drinking men performed a modified version of the Implicit Association Test (IAT) to measure their implicit alcohol arousal and approach-avoidance associations. A modified version of the emotional Stroop was used to measure attentional bias for alcohol-related stimuli (blocked and unblocked). Next, a high dose of alcohol (1.0 mL/kg body weight 95% USP alcohol) was administered in a short period of time. Resting baseline HR, blood alcohol concentrations, mood, and craving for alcohol were assessed before alcohol administration and for 2 hours post-alcohol consumption. RESULTS: Contrary to our hypothesis, a negative association was found between implicit arousal associations and alcohol-induced HR change. This indicates that strong arousal associations were correlated with a decrease in alcohol-induced HR. Approach associations and attentional bias were not correlated with alcohol-induced HR change, but both were correlated positively with each other. CONCLUSIONS: Alcohol-arousal associations and other implicit cognitions (attentional bias, approach associations) are not positively related to individual differences in the sensitivity to alcohol's activating effects, at least not in the present sample consisting primarily of family history-negative heavy drinkers.     

No evidence or no alternative? Taking responsibility for off‐label prescribing

Recombinant activated factor VII (rFVIIa) is registered for patients with rare haematological disorders, but is used 'off-label' in many other situations, including intracranial haemorrhage, cardiac surgery, trauma, transplantation and prostatectomy. Lack of systematic evidence to support these off-label uses has not slowed the growth of off-label prescribing of rFVIIa. We use the case of rFVIIa to illustrate the issues raised by off-label prescribing, and the kind of impasse that can arise when views about evidence, expertise and clinical necessity are in conflict. We argue that clinicians, hospital drug committees and regulators all need to acknowledge the complexity of prescribing decisions, and ensure that decisions to prescribe off-label are sufficiently justified.     

Should DSM‐V Include Dimensional Diagnostic Criteria for Alcohol Use Disorders?

This program calls attention to the upcoming timetable for the revision of the Diagnostic and Statistical Manual (DSM)-IV and the publication of DSM-V. It is vitally important for Research Society of Alcoholism members to be aware of the current discussions of the important scientific questions related to the next DSM revision and to use the opportunity for input. The title of the symposium highlights 1 key question, i.e., whether the DSM definitions should remain strictly categorical as in the past or whether a dimensional component should be included in this revision. Two substantive and 1 conceptual paper are included in this portion of the symposium. The fourth and final presentation detailing the revision timetable and the opportunities for input is by Dr. Darrel Regier. Dr. Regier is the director of American Psychiatric Institute for Research and Education the research and education branch of the American Psychiatric Association and the organization within the APA that will oversee the DSM revision. The discussion is by Marc Schuckit, who was chair of the Substance Use disorders (SUD) Committee for DSM-IV and cochair of the international group of experts reviewing the SUD definitions for DSM-V.     

Does Effect Size in Naltrexone Trials for Alcohol Dependence Differ for Single‐Site vs. Multi‐Center Studies?

BACKGROUND: The opioid antagonist naltrexone was first shown in single-site trials to be efficacious in the treatment of alcohol dependence. Recent clinical trials of the medication have used multi-center designs, which permit greater generalization and increased statistical power. We compared effect sizes for these two kinds of trial design on the hypothesis that multi-center trials introduce sources of variation that reduce the observed effect size. METHODS: A meta-analysis of data from 19 placebo-controlled trials of the efficacy of naltrexone (7 multi-center and 12 single-site studies) was performed. Effect size estimates for these two study designs were compared using two outcomes: percentage of days drinking and percentage of subjects relapsing to heavy drinking. RESULTS: Compared with single-site studies, multi-center studies were estimated to yield a nonsignificantly smaller effect on the percentage of days drinking (Cohen's d = 0.20 vs. 0.33, respectively) and a significantly smaller effect on the percentage of subjects relapsing to heavy drinking (Cohen's d = 0.17 vs. 0.41, respectively; p = 0.014). Earlier studies showed a larger effect size than later studies. CONCLUSION: The smaller effect size seen with multi-center studies may reflect random error due to heterogeneity among the sites. However, because multi-center studies were, in general, conducted more recently than single-site studies, it was not possible conclusively to disentangle the moderating impact of study type and year of publication on effect size. Further research on factors that moderate effect size can contribute to the development of medications to treat alcohol dependence.     

Is Heavy Alcohol Consumption an Attributable Factor for Cancer‐Related Deaths Among Japanese Men?

BACKGROUND: Over the past four decades, per capita alcohol consumption in Japan has increased 4-fold. Age-adjusted cirrhosis mortality rates for men have also increased, whereas the rates for women have declined gradually. This widening difference in mortality could be due to a decreasing prevalence of viral hepatitis infection for both sexes and to differences in alcohol consumption between the sexes. Difficulties in estimating the impact of increased alcohol consumption on mortality rates in Japan also arise from changes in the prevalence of non-alcohol-related risk factors. METHODS: To measure the relative contribution of alcohol to death from cirrhosis, liver cancer, esophageal cancer, and head and neck cancer among Japanese men, we used the mortality rate for Japanese women as the standard because alcohol consumption for women has been low. We used published vital statistics data from 1992 to 1996 to calculate the attributable risk percent (ARP) in 5-year cohorts of Japanese men age 20 and older. RESULTS: Among Japanese men, heavy alcohol consumption accounted for 70.7% of deaths due to cirrhosis, 76.8% of liver cancer deaths, 88.5% of esophageal cancer deaths, and 87.4% of head and neck cancer deaths. When we examined ARPs by age group, ARPs for these four diseases were approximately 80% in the middle age groups. However, for older groups, the ARPs for cirrhosis and liver cancer were much lower than those for esophageal cancer and head and neck cancer. The prevalence of previous hepatitis C virus infection, considered to be the major cause of cirrhosis and liver cancer, increased with age. CONCLUSIONS: The results support previous epidemiologic studies conducted in Japan. Heavy alcohol consumption is a major public health problem among younger Japanese men, accounting for approximately 80% of the deaths for the four diseases examined.