Why do controlled-drinking outcomes vary by investigator, by country and by era? Cultural conceptions of release and remission in alcoholism

Variations in the reported rates of controlled drinking by former alcoholics are notable, at times startling. Reports of such outcomes (which in some cases involved a large percentage of subjects) were common for a brief period ending in the mid- to late 1970s. By the early 1980s, a consensus had emerged in the United States that severely alcoholic subjects and patients could not resume moderate drinking. Yet--at a point in the mid-1980s when the rejection of the possibility of a return to controlled drinking appeared to be unanimous--a new burst of studies reported resumption of controlled drinking was quite plausible and did not depend on the initial severity of alcoholics' drinking problems. Variations in controlled-drinking outcomes--and in views about the possibility of such outcomes--involve changes in the scientific climate and differences in individual and cultural outlooks. These cultural factors have clinical implications as well as contributing to the power of scientific models of recovery from alcoholism.     

Practical Issues in Selecting and Using Treatment Goals With Severely Dependent Alcohol Abusers

Practical issues in considering abstinence or moderation drinking goals for severely dependent alcoholics are discussed from three different perspectives: (1) factors associated with the client; (2) therapist considerations; and (3) factors stemming from the service-providing institution's policies and concerns. Distinctions are made between moderate drinking defined as: a goal choice, a treatment training procedure, and short-term drinking outcome, and a stable outcome pattern over a long term. While current studies show that moderate drinking is a relatively rare stable outcome pattern in severely dependent alcoholics, a sizable minority of alcoholics in treatment express a preference for moderation as a goal choice. Potential benefits and risks of moderation as a planned goal are presented. Guidelines for selecting appropriate candidates for a sanctioned moderate drinking goal are discussed.     

Over-reports of recent alcohol consumption in a clinical population: A validity study

Decisions concerning appropriate treatment in alcoholism programs are often based on the self-reports of the clients. However, few programs have incorporated validation procedures (such as breath tests) since it is generally assumed that alcoholics will deny the extent of their drinking and their subsequent alcohol problems.The self-reports of recent alcohol consumption of sixty-five new entrants to an alcoholism treatment program were validated with breath tests. Five estimates of blood alcohol concentrations were derived by varying elimination rates. For all five estimates, over-reporters comprised a substantial proportion of the total sample (23%–57%) and exceeded the percentage of consistent reporters for those people who had a positive breath test. Correlations between self-reports and breath tests were not significant which indicates that the amount of alcohol consumed does not necessarily relate to reporting behavior.It is concluded that despite the widely held notion that alcoholics deny the extent of their drinking, errors in the direction of over-reporting should be taken seriously and examined more closely. On an individual level, overpresentation of a client's condition may be related to subsequent behavior in a treatment program; on an aggregate level, over-reports may bias the findings of evaluation studies by inflating success rates.     

A double-blind, placebo-controlled pilot trial of quetiapine for the treatment of Type A and Type B alcoholism

BACKGROUND: Atypical antipsychotics may be useful in the treatment of alcohol dependence. Human trials suggest that atypical antipsychotics may reduce alcohol craving and consumption, especially among patients with comorbid psychopathology. Therefore, these medications may be more useful for treating more severely affected alcoholics, such as patients with Type B alcoholism. Type B alcoholics are characterized by an early age of onset of problem drinking, high severity of alcohol dependence, increased psychopathology, and treatment-resistance. Quetiapine is an atypical antipsychotic with a favorable side effect profile, and may be a promising medication for the treatment of alcohol dependence, particularly Type B alcoholism. METHODS: Male and female alcoholics (33 Type A and 28 Type B) were included in a 12-week, double-blind, placebo-controlled trial. After detoxification, patients were randomized to receive quetiapine (n = 29), 400 mg/d at bedtime, or placebo (n = 32). The primary outcome measure was the quantity and frequency of alcohol consumption, measured by the timeline follow back. RESULTS: Forty-seven patients (77%) completed the trial, with no significant between-group differences in treatment retention. Nine quetiapine-treated patients (31%) maintained complete abstinence compared with 2 placebo-treated patients (6%) (chi(2) = 6.3, P = 0.012). There was a significant interaction between quetiapine and alcoholic subtype. As predicted, quetiapine- versus placebo-treated Type B alcoholics had significantly fewer days of drinking and fewer days of heavy drinking. Alcohol craving was also significantly reduced in quetiapine-treated compared with placebo-treated Type B alcoholics. Among Type A alcoholics, quetiapine provided no advantage over placebo in improving drinking outcomes. CONCLUSIONS: Quetiapine may be effective for the treatment of alcohol dependence, particularly in the more complicated Type B, early-onset alcoholics.     

Arousal in Alcoholics and Social Drinkers Progressing through a Drinking Sequence

Physiological and self-report reactions of 11 nonabstinent, nonhospital-ized alcoholics and 11 social drinkers were monitored before, during, and after consumption of two supposedly alcoholic beverages. Unlike previous reports that alcoholics experience increased anxiety/arousal prior to drinking, no such evidence was observed in the present study. Both alcoholics and social drinkers, however evidenced reduced pulse rates during and following drinking. It is suggested that previous investigations may have found predrinking anxiety increases because of their use of hospitalized (and often abstinent) alcoholics and/or their use of procedures which highlighted the negative aspects/consequences of drinking.     

Family history and antisocial traits moderate naltrexone's effects on heavy drinking in alcoholics

Naltrexone's (NAL) effects on alcohol consumption are generally modest, so identifying patients likely to benefit would improve treatment utility. Several studies indicate that potentially significant moderators of NAL's effects might include family history of alcohol problems (FH), age of onset of alcohol problems, degree of antisocial traits, and comorbid drug use. Data from 128 alcoholic patients enrolled in a 12-week NAL treatment study (50 mg/day) were reanalyzed to determine the role of FH, age of onset, antisocial traits, and comorbid drug use in NAL's treatment effects on heavy drinking days. Dichotomized FH, age of onset of alcohol problems, and comorbid cocaine or marijuana use had no interaction effect with medication. Percentage of relatives with problem drinking (family history percentage [FHP]) moderated the effects of NAL on drinking such that NAL resulted in lower drinking rates only for patients with higher FHP. Antisocial traits also moderated the effects of medication on drinking for patients compliant with =70% of medication. Patients with more antisocial traits had less heavy drinking on NAL than on placebo, whereas patients low on antisocial traits had no benefit from NAL. Covarying antisociality in regressions of drinking outcome on FHP showed that the effects of FHP were not attributable to antisociality. Thus, NAL may selectively benefit alcoholics with antisocial traits or 20% or more relatives with problem drinking.     

Drinking in alcoholics following an alcohol challenge research protocol

OBJECTIVE: The present study examined the impact of participating in an alcohol administration study on the subsequent drinking behavior of 25 non-treatment-seeking alcoholics. METHOD: Subjects attended two assessment sessions, followed by a week-long regimen on one of three pharmacological agents (naltrexone, nalmefene, or placebo), a day-long laboratory assessment including a standardized alcohol administration procedure, and a debriefing session consisting of individualized feedback and alcohol counseling. Follow-up consisted of a telephone interview 6 weeks after the alcohol challenge session. RESULTS: At the follow-up interview, subjects reported significant reductions in drinking quantity and frequency from the prestudy period, and no subjects reported increased drinking following study participation. CONCLUSIONS: These findings suggest that alcohol administration research procedures may not be detrimental to the poststudy drinking behavior of alcoholics. The use of such procedures could be cautiously expanded to improve the generalizability of findings for alcoholic populations of interest.     

The validity of self-reports in alcoholism research

It is often assumed that many alcoholics underreport their drinking and behavioral problems. Nonetheless, previous studies using official records and collateral reports suggest that self-reports of concrete drinking problems are not biased, and that overreports equal or exceed underreports. New data are presented, based on collateral reports and blood alcohol measures for 632 alcoholics interviewed four years after treatment. Results indicate that the subjects accurately reported abstention and major alcohol-related events, such as jail terms and hospitalization. Compared with estimates from blood alcohol measures, 35% of recent drinkers underreported their consumption during the 24 hours before the interview, and 24% underreported their consumption during the previous month. However, an overall outcome classification based on a combination of consumption and other measures was not substantially affected by errors in consumption reports. These findings indicate that most types of self-reports are valid, and that broadly based outcome measures are not likely to be significantly biased by underreporting errors.     

The influences of ethanol and other factors on the excretion of urinary salsolinol in social drinkers

Salsolinol, a substance that may participate in the development of alcoholism, has been identified in urine and other biological samples from alcoholics. Differentials have been observed between alcoholics and controls. Salsolinol forms when dopamine reacts with acetaldehyde, which may exist in higher concentrations in the blood of alcoholics after alcohol ingestion. Hence, it was postulated that there is a relationship between level of social drinking and the elaboration of salsolinol. Salsolinol is also found in certain food and beverage products. Eighty volunteers, balanced for gender, social drinking level, ethanol dose administered and experimental diet provided urine samples 90 minutes and three hours after ethanol was consumed. Salsolinol levels were analysed in urine using high performance liquid chromatography. A 24 hour carryover effect was observed. Diet, ethanol dose and social drinking level had main and interactive effects on excreted quantities of salsolinol. Gender, situational stress and cigarette smoking had minor if any influence on salsolinol excretion. While there was no evident difference in amounts of salsolinol excreted by light and heavy drinkers in the absence of external sources of salsolinol, heavy social drinkers excreted less salsolinol than did light drinkers after consuming a "salsolinol-enriched" diet, suggesting that they differ in some aspect of absorption, distribution, or metabolism of salsolinol after drinking ethanol. Accordingly, studies that attempt to determine whether salsolinol has any relationship to drinking behaviour in humans should be particularly concerned with salsolinol that occurs in exogenous sources.     

Exploring psychological benefits associated with moderate alcohol use: a necessary corrective to assessments of drinking outcomes?

The aim of this paper is to identify positive psychological concomitants of moderate alcohol consumption. Current research and public-health perspectives on alcohol emphasize harms disproportionately relative to benefits. The major exception is research establishing beneficial effects of moderate drinking on cardiovascular health and overall mortality. In addition, much observational and experiential data suggest the widespread prevalence of positive drinking experiences. This paper is one of the first attempts since 1985 to codify such benefits in epidemiological terms. Methodological difficulties in accomplishing this include defining moderate drinking, controlling for confounding variables, and establishing causality. Nonetheless, evidence of psychological benefits has been found in experimental, observational, interview, self-report, correlational, and some prospective research. These positive findings are in the areas of subjective health, mood enhancement, stress reduction, sociability, social integration, mental health, long-term cognitive functioning, and work income/disability. Problem drinkers and alcoholics also seek mood and other benefits from alcohol, but are more likely to drink to counteract negative feelings and to support their egos than are social drinkers. It is as yet impossible to determine to what extent moderate alcohol consumption causes positive psychological outcomes and to what extent it is part of a complex pattern of mutually reinforcing variables.     

Structure of the MAST with an Australian sample of alcoholics

The dimensionality of the Michigan Alcoholism Screening Test (MAST) was examined utilizing an Australian sample (n = 196) of alcoholics. This study was specifically designed to overcome some of the problems with sampling and analytic techniques used in previous studies. Three moderately intercorrelated factors were revealed which covered (a) alcohol-related disabilities; (b) help-seeking behaviour and (c) recognition of a drinking problem. These factors were found to be internally consistent as shown by moderate to high alpha coefficients. Results indicate that the additive system of scoring all 24 items may result in an underestimation of the information afforded by the MAST.     

Can Stanton Peele's opinions be taken seriously? A reply to Peele

In an article in the October-December 1988 issue of the Journal of Psychoactive Drugs, Stanton Peele expressed a number of opinions against alcoholism treatment and in favor of controlled drinking as a treatment goal for alcoholics. These opinions are examined critically and found to be contradicted by recent studies, empirical observations, and reinterpretations of earlier studies. It is concluded that marginal scholarship, partial and/or inaccurate representations of research, and inappropriate generalizations do not constitute the basis for drawing reliable and valid conclusions about alcoholism treatment or about controlled drinking as a feasible treatment goal for alcoholics.     

Drinking, drinking styles and drug use in children of alcoholics, depressives and controls

Adolescent children of alcoholic, depressive and normal control fathers were assessed with a variety of alcohol and drug use measures. Children of alcoholics were quite similar to the other two groups with regard to alcohol consumption, reasons for drinking, attitudes toward temperate and intemperate use of alcohol, and the typical drinking context. However, children of alcoholics, both male and female, were more likely to report drug use than children of depressives or children of normal controls. These findings suggest that although children of alcoholics are at risk for the development of alcoholism, deviant drinking practices may not be discernible in adolescence.     

Effects of alcoholics' expectation of a drink.

The expectation of receiving alcohol influenced the drinking behavior of alcoholics and social drinkers resulting in increases in the amount of placebo consumed and higher estimates by both alcoholics and social drinkers of the percentage of alcohol in the placebo.     

Stressful life events and alcohol misuse in women: a critical review

The literature on stressful life events and alcohol misuse in women is critically reviewed. Many researchers have suggested that women begin to misuse alcohol in response to stress linked to precipitating circumstances or life events. Middle-aged women are felt to be especially at risk because of the nature of the events that they are likely to experience, e.g., divorce, bereavement and departure of children from the home. Evidence for these views has been collected by asking patients to recall particular events in their past that they considered may have caused their heavy drinking. This approach has several methodological problems, most notably the failure to deal with the possibility that heavy drinking produced an increased frequency of stressful life events rather than vice versa. It has been speculated that women are more likely to attribute their heavy drinking to causes that are more likely to elicit sympathy than condemnation. None of the studies discussed has considered the possibility that the link between life events and heavy drinking reflects the activities of a sizable subgroup of women described as "sociopathic" alcoholics, the disturbance producing an excess of both events and excessive alcohol consumption. Considerable criticism has been leveled at the use of poorly validated concepts such as "mid-life crisis" and the tendency to use terms such as "menopausal syndrome" as an explanation for almost any difficulty experienced by women in middle age. It is concluded that the hypothesis that stressful life events cause excessive drinking remains to be empirically demonstrated.     

Cue-Exposure Interventions for Alcohol Relapse Prevention: Need for a Memory Modification Component

The ability of cue-conditioned responses (CCRs) to predict relapse in problem drinkers across a wide variety of situations is better appreciated when one considers that encoded alcohol-related stimuli can be retrieved from memory and, consequently, serve as symbolic cues. By decreasing retrieval strength to such cues one might: (1) decrease the possibility that such cues elicit alcohol-related CCRs (urges), which may lead to drinking, and (2) decrease the possibility of relapse resulting directly from thinking about drinking. A memory modification approach, as compared to cue exposure, may be relatively effective with old versus young alcoholics.     

Women alcoholics. A review of social and psychological studies.

Research on social-history variables, personality characteristics, social roles and role confusion, and possible treatment methods for women alcoholics is reviewed. Suggestions for additional studies involving factors motivating drinking in women, theories of personality, new treatment methods, and differentiation between subgroups of women alcoholics are discussed.     

Analysis of lipoprotein metabolism in alcoholics]

High density lipoprotein (HDL) is increased by exercise and drinking and is well known as a negative risk factor of coronary heart disease. We analyzed serum lipids of alcoholics from the view points of biochemical examination, remnant like particle (RLP) and particle size of lipoprotein for the purpose of estimated effect of serum lipids, especially HDL quality in alcoholics. Serum levels of total cholesterol, free glycerol, RLP-C and RLP-TG were significantly decreased after hospitalization. The condition of RLP-C/RLP-TG on admission revealed cholesterol-rich composition. In case of HDL-C, the longer period from last drinking to hospitalization affected its decrease. From analytical study of particle size of lipoprotein, quantities of HDL-C in very large size and large size were significantly decreased after hospitalization which means that HDL composition at hospitalization is cholesterol-rich. So, it is speculated that increased serum level of HDL in alcoholics may be caused by expanded cholesterol ester and its quality may be different from that of healthy people. In this meaning, the study of arteriosclerosis in alcoholics will be necessary in relation to high level of serum HDL-C.     

Drug Addiction and Responsibility for the Health Care of Drug Addicts

The existing literature on drinking patterns of Black alcoholics is relatively limited; however, most of the data suggest that drinking behavior of Blacks may be different from that of Whites. A summary of recent studies in this area is presented in Table 1. Robins et al. (1968) indicated that heavy drinking is a common pattern among Black urban males and that drinking behavior usually resulted in objective difficulties and personal worry. Maddox and Williams (1968) reported that drinking is twice as common in urban Black men as in urban White men of similar socioeconomic class origins. King et al. (1969), in a study of the social problems of Black men, demonstrated the significance of alcohol abuse in the Black urban ghetto and how this related to broken homes, delinquency, sexual and reproductive irresponsibility, and underemployment.     

Dose-related effects of alcohol among male alcoholics, problem drinkers and nonproblem drinkers

Cognitive variables, such as expectancies regarding the usefulness of alcohol, have been receiving increased attention in recent years because these expected effects can influence decisions to drink and mediate responses to alcohol. In the present study, alcohol expectancies were assessed using the Alcohol Beliefs Scale, a measure that yields dose-related data on expected effects of alcohol. The subjects were male alcoholics, problem drinkers and nonproblem drinkers. The central finding was that drinker group membership and rated dose level interacted in predicting subjects' estimates of the usefulness of alcohol for them. On the "useful for feeling better" factor, the greatest benefit was expected from a moderate dose, particularly among alcoholics. On the "useful for relieving emotional distress" factor, usefulness ratings increased with dose, with alcoholics expecting the greatest rate of increase. A similar pattern was found for the "useful for feeling in charge" factor, except that the ratings for problem drinkers and alcoholics paralleled each other. These findings have implications for our efforts to understand drinkers' motivations to initiate and continue drinking.