Changing perspectives on alcohol and drug problems

An outline is presented of the extent of the drug and alcohol problem in Australian today and the relative contribution of legal and illicit drugs is discussed. The impact of these problems on clinical practice is highlighted and the importance of detection and benefit of intervention emphasised. The different perspectives with which health professionals approach these problems are presented in an historical overview, and modern concepts of drug (and alcohol) “dependence” and related “disabilities” are described.     

Journey through the K-hole: phenomenological aspects of ketamine use

Although recreational use of the dissociative anaesthetic drug ketamine is currently increasing, little is known about the phenomenological aspects of its use. We therefore designed a structured interview to examine initiation experiences, positive and negative effects of ketamine use, and concerns about the drug and its long-term effects. Ninety participants (30 frequent users, 30 infrequent ‘recreational’ users and 30 ex-users who had abstained from use for at least 3 months) were interviewed and reported drug use was verified by hair sample analysis. The most appealing aspects of ketamine for two-thirds of users were “melting into the surrounding”, “visual hallucinations”, “out-of-body experiences” and “giggliness”. Unappealing effects for half of users were “memory loss” and “decreased sociability”. Frequent ketamine users expressed more concerns than other groups about long-term effects on physical health problems, especially K-cramps and cystitis, whereas ex-users were more concerned about mental health problems. Addictive/dependent patterns of behaviour were also a concern: the majority of frequent users reported using the drug without stopping until supplies ran out and the mean increase in dosage in this group was six-fold from initiation to current use. We have identified specific health issues which seem uniquely related to ketamine use. Additionally, the dependence on ketamine frequently reported by users may be a cause for concern as its popularity grows and substance misuse services should be made aware of this when clients present in the future.     

Motivation for change and psychological distress in homeless substance abusers

This study explores the treatment needs of homeless individuals participating in a large urban day shelter program. Alcohol and drug use, psychological distress, and stage of change were assessed in 100 participants presenting for services. The associations among substance use, risk perception, and readiness to change were examined for alcohol and drugs separately. Participants had high levels of psychological distress compared to “non-patient” samples. Eighty percent had used alcohol in the past 6 months, with 65% of those drinking at higher-risk levels; 60% had used drugs, with 82% in the higher-risk levels. While the majority felt that they drank and/or used drugs “too much”, most were in precontemplation or contemplation stages of change. Intervention efforts for this population should focus on motivation, facilitation through the stages, and the associations between psychiatric symptoms and substance use.     

Outcomes,performance, and quality-What's the difference?

Calls for greater accountability within the addiction treatment field have led to a wide range of efforts designed to improve treatment performance, quality, and outcomes. However, efforts with conceptually and methodologically different approaches have used the same umbrella terms such as “quality,” “performance indicators,” and “outcome domains,” causing substantial confusion among providers and policymakers. This article provides operational definitions of the terms used in discussing quality, performance, and outcomes, as well as a discussion of ways to integrate efforts to measure treatment system performance and quality during treatment with patient outcomes during and following treatment. This article thus helps build a common understanding about how these efforts to bring greater accountability can be combined and integrated to improve the attractiveness and effectiveness of addiction treatments.     

Changes concurrent with intiation of abstinence from cocaine abuse

In an exploration of changes that occur with initiation of cocaine abstinence, this study examined treatment outcomes in four domains—behavior (cocaine use), affect (depression), cognition (schematic self-representations), and psychophysiology (reactivity to drug cues). Nineteen patients initially entered this 8-week outpatient psychopharmacotherapy trial for the treatment of cocaine dependence. Thirteen completed treatment, and eleven maintained abstinence during the last four weeks of the study. In addition to a demonstrated change in their cocaine-using behavior, these “abstainers” reported reduced depression, increased congruency with “ideal” self-schemas, increased discrepancy with “addict” self-schemas, and generally more positive self-representations. In addition, “abstainers” reported reduced posttreatment craving in the presence of cocaine cues, but evidenced no change in physiological reactivity. Implications of these findings for research and treatment are discussed.     

Effective Services for Homeless Substance Abusers

A heterogeneous and representative sample of 323 homeless individuals in the metropolitan-Denver area with alcohol or other substance abuse problems received a comprehensive array of substance-abuse treatment services. Following treatment, these individuals showed dramatic improvement on average in their (a) levels of alcohol and drug use, (b) housing status, (c) physical and mental health, (d) employment, and (e) quality of life. Those who received more service improved more than those who received less service. These improvements are attributable, at least partly, to the treatment rather than to alternative hypotheses such as spontaneous remission. However, the rate of improvement generally slowed during the six-month follow-up period. A random half of the clients received intensive case management in addition to the other services. Case management marginally increased client's contacts with addiction counselors, but had little effect on the level of other services received or on the tailoring of services to client needs. As a result, case management also had little, if any, effect on outcomes.     

Drugs and the media

“Drugs” are extremely newsworthy: each year they are the subject of literally thousands of items produced by the Australian media. Most of these items are repetitious, stereotypical and narrowly focused on crime, deviance and rectification. Illegal drug consumption by individuals and the efforts of medical and social welfare professionals to eradicate the “problem” so defined are the twin foci of the press and television. Legal substances (including tobacco and alcohol) are interpreted much more ambiguously, and are relatively infrequently the subject of journalistic analysis.

The media systematically ignore the historical, economic and industrial aspects of drug production and consumption.

“Drugs”, although habitually construed as the cause of “human” and “social” problems (and hence as necessitating administrative attention), seem strangely divorced from real political economic determinations. They serve as inexhaustabled pretexts for the proliferation of television current affairs items and newspaper features which seldom resist the image of the confessing, suffering victim. “Hard” news is preoccupied with reiterating the ritual drama of drug seizures and exposes of “organised” crime. Both the press and television educate their audiences to a resigned, alienated passivity.     

What is Controlled Drinking?

Different terms have been utilized to define the drinking dispositions of problem drinkers which are neither total abstinence nor overtly harmful. The main terms that have been used are “normal drinking”, “controlled drinking”, “non-problem drinking” and “attenuated drinking”. Each concept is considered and criticized and it is concluded that clinicians and researchers need to be very aware of the overlap that exists between the different definitions. It is concluded that the greatest value that has been achieved from the advent of controlled drinking treatment and the ensuing debate is not that another treatment option has been developed, but that the perception of alcohol related problems has been changed to encompass the drinking of the population as a whole.     

Characterizing “Nonresponsive” Methadone Patients

A review of records at a large urban methadone clinic revealed a substantial group of patients with treatment tenures of at least 6 months whose urinalysis results indicated continued regular use of opiates. In an attempt to characterize these “nonresponsive” patients and to identify their specific treatment needs, we compared them to a group of patients with comparable treatment tenures but whose urinalysis results indicated little or no recent illicit opiate use. Contrary to expectations, opiate use itself was virtually the only feature that clearly distinguished the two groups. “Responders” and “nonresponders” did not differ significantly on measures of psychosocial problem severity in any other area, nor did they differ in their treatment service utilization. Moreover, examination of admission data indicated that the two groups showed similar rates of improvement in the severity of their psychosocial problems in all seven measured areas. The implications of these results for treatment and clinic administration are discussed.     

Effectiveness of Making Alcoholics Anonymous Easier: A group format 12-step facilitation approach

Most treatment programs recommend clients attend 12-step groups, but many drop out posttreatment. The effectiveness of Making Alcoholics Anonymous [AA] Easier (MAAEZ ), a manual-guided intervention designed to help clients connect with individuals encountered in AA, was tested using an “OFF/ON” design (n = 508). MAAEZ effectiveness was determined by comparing abstinence rates of participants recruited during ON and OFF conditions and by studying the effect of the number of MAAEZ sessions attended. At 12 months, more clients in the ON condition (vs. OFF) reported past 30-day abstinence from alcohol (p = .012), drugs (p = .009), and both alcohol and drugs (p = .045). In multivariate analyses, ON condition participants had significantly increased odds of abstinence from alcohol (odds ratio [OR] = 1.85) and from drugs (OR = 2.21); abstinence odds also increased significantly for each additional MAAEZ session received. MAAEZ appeared especially effective for those with more prior AA exposure, severe psychiatric problems, and atheists/agnostics. MAAEZ represents an evidence-based intervention that is easily implemented in existing treatment programs.     

On "Gradualism" and the building of the harm reduction-abstinence continuum

This paper makes the case that a perspective called “Gradualism” could serve as a foundation for building a therapeutic continuum between the harm reduction and abstinence-oriented treatment worlds. In contrast to other integrationist writers (Denning, 2001; Marlatt, Blume, & Parks, 2001), this paper argues for the incorporation of abstinence into harm reduction approaches. The goal is to build on the strengths of both perspectives while reducing their weaknesses, and examples of each are provided. Lastly, with the frequent occurrence of relapse among addicted patients, building a continuum could also serve to provide a therapeutic “safety net” for those in need.     

Family-centred practice in the interface between child welfare and the alcohol and drug field

Recently publicized cases of child abuse and neglect ahve highlighted the complexity of interaction between professionals in the alcohol and drug field and those in the child welfare field. Despite exhortations to practitioners in both fields to see their clients from a “family-centred perspective”, a range of psychological, ethical, conceptual, professional and organizational factors mean that this often remains an elusive goal. In this paper the obstacles to adopting a family-centred approach which cuts across different professions and fields of service are identified. These factors interact in complex ways and although workers feel the tensions, it is difficult for them to perceive the set of constraints as a whole from the vantage point of an actor in the process. By identifying and analysing these obstacles workers in both fields may be better able to collaborate in maximizing the opportunities which also exist for family-centred practice.     

Outcome of a unique youth drug abuse program: A follow-up study of clients of Straight, Inc.

A unique feature of the 12-hour per day Straight, Inc., program is temporary placement of the client with the family of a client who has progressed further in the program. Eighty-five (85) percent of the clients reported that their drug use was less at follow-up than when they started in the program. Follow-up reports by parents indicated their impression of a statistically significant decrease in the proportion of clients who were still involved in substance use. Statistically significant improvement at follow-up was also reported by the clients on seven of eight other selected outcome criteria (e.g., suicidal thoughts, physical violence, number of arrests, etc.). The majority of the clients reported that they were “satisfied” with the program (70%), that the program “helped” them (74%), and, specifically, that the program helped them with their relationship with their parents (69%).     

Clinical and Reliable Change in an Australian Residential Substance Use Program Using the Addiction Severity Index

Although the Addiction Severity Index (ASI) is one of the most frequently used measures in alcohol and other drug research, it has rarely been used to assess clinical and reliable change. This study assessed clients’ clinical and reliable change at The Salvation Army residential substance abuse treatment centers in Australia. A total of 296 clients completed ASI interviews on admission to treatment and 3 months after discharge from treatment. Clients demonstrated significant improvement on all seven ASI composites. The range of reliable change for each ASI composite varied from 30% to 70%. More than two-thirds of clients experienced clinically significant improvement for alcohol and drug problems. Psychiatric distress was clinically reduced in 44% of clients. This research indicates that residential substance abuse treatment can make important differences in client's lives at a clinical and functional level. However, the research highlights the challenge of effectively targeting psychiatric comorbidity within alcohol and other drug abuse populations.     

Measuring alcohol and drug dependence with New York City ADAM data

The Arrestee Drug Abuse Monitoring (ADAM) Program collects self-report survey information and urine specimens from adult arrestees in 35 cities nationwide. In 2000, a new survey instrument was fielded that includes questions about alcohol and other drug (AOD) abuse and dependence. Despite high levels of drug use among national arrestee populations, no studies have examined need for AOD treatment among ADAM arrestees. To address this limitation, a secondary analysis was undertaken with New York City ADAM data collected in 2000. Thirty-seven percent of the arrestees were diagnosed in need of drug treatment, while 19% were diagnosed in need of alcohol treatment. Compared to those arrestees who were diagnosed as not needing AOD treatment, arrestees who met the criteria for ADAM abuse/dependence were more likely to be male, older, and to have tested positive by urinalysis for at least one illicit drug. Because “need for treatment” was operationalized as a diagnosis of abuse or dependence, the current results should be viewed as liberal estimates of treatment need. Implications for the delivery of drug treatment to criminal populations are discussed.     

Extreme discordant phenotype methodology: an intuitive approach to clinical pharmacogenetics

Pharmacogenetics represents “the study of variability in drug response due to heredity”. Of the more than six dozen pharmacogenetic differences described in the medical literature, the majority of these variations occurs in drug-metabolizing enzyme genes and others in drug receptor and drug transporter genes, whereas many others have not yet been explained on a molecular basis. It is clear that “drug efficacy” or “drug toxicity” represents a multiplex phenotype, i.e. interaction between the drug (or its metabolites) and the gene products (enzymes, receptors, other targets) of two, and usually many more than two, genes. Because there is a gradient in these phenotypes (efficacy or toxicity), it is extremely important to select patients having the most unequivocal phenotype possible—if one wishes to find the gene(s) responsible for the trait. The method of “extreme discordant phenotype” (EDP) is therefore highly recommended. Using EDP methodology, DNA sequence variants (genotype) can be unconditionally correlated with drug efficacy or toxicity (phenotype). EDP methodology is mathematically intuitive and, in essence, has been used in a number of previous clinical pharmacogenetic studies. This EDP approach should be applicable to virtually any pharmaceutical agent in patient populations.     

Alcohol controls and Aboriginal society: The effects of the Northern Territory restricted areas legislation

The “restricted areas” provisions of the Northern Territory Liquor Act constitute a preventative policy aimed at reducing the effects of alcohol abuse, particularly on Aboriginal communities. Under the provisions, communities can apply to be declared “dry” or semi-restricted with respect to liquor. Since their inception in 1979, the provisions have given rise to continuing controversy. This paper addresses some of the issues associated with the controversy. Patterns of alcohol consumption on “dry”, semi-restricted and unrestricted communities are compared, and the incidence of apprehension for public drunkenness before and after restricted area declarations is examined. The paper also discusses the provisions under which vehicles implicated in acts of illicit “grog-running” are forfeited to the NT Government. It is concluded that the restricted area provisions are associated with reduced levels of alcohol consumption and apprehensions for drunkenness, and are therefore beneficial in outcome. However, it is also argued that at present the provisions are flawed in that, while some aspects serve to promote community control over alcohol consumption, other elements have the effect of undermining community control and responsibility.     

Cantharidin poisoning due to “Blister beetle” ingestion

Cantharidin, the active ingredient of “Spanish Fly”, is contained in a number of insects collectively called blister beetles and is a well known toxin and vesicant. We report on a case of ingestion of Mylabris dicincta (“Blister beetle”) in Zimbabwe by a 4 year old girl. The ingested beetles were probably mistaken for the edible Eulepida mashona. She presented with many of the classic signs and symptoms of cantharidin poisoning including haematuria and abdominal pains. This was recognised only after consultation with the drug information centre. She was managed conservatively, recovered and was discharged after 9 days. A overview of the clinical effects of cantharidin toxicity and its treatment is presented.