A commentary on the proposed changes in DSM-III concept of alcohol dependence

This paper discusses changes in the DSM-III diagnosis of alcohol dependence as proposed by Rounsaville, Spitzer and Williams (Am. J. Psychiatry 143 (1986) 463). The discussion covers the following issues: the changes in the concept of alcohol abuse and the expansion of the concept of alcohol dependence, the withdrawal of indicators of social and occupational impairment, the phraseology used in the new indicators, the lack of a time frame to evaluate the indicators as present, and the relationship of the new diagnosis with compulsive behaviors and with the Alcohol Dependence Syndrome of the International Classification of Diseases-9th Revision.     

Low alcohol alternatives: a promising strategy for reducing alcohol related harm

BackgroundLess than 1% of the beer market in British Columbia comprises beers with an alcohol content below 4%, despite the success of low alcohol beers in other countries, e.g. Australia. A small experimental study is described in which male students were given either unmarked low alcohol beer (3.8%) or regular strength beer (5.3%) to investigate their enjoyment and subjective intoxication.MethodsThirty-four male students who reported drinking 5 or more beers in 1 day at least once in the last month volunteered for the study. In each drinking session, small groups of between 6 and 10 students consumed two servings of beer while playing dominoes. Each subject was his own control in the experiment by attending two group-drinking sessions, drinking a different beverage each time. The different beers were given in balanced order with half the subjects in each group drinking each type of beer. Standard measures of subjective intoxication and enjoyment were used. Blood alcohol levels were tested before, during and after drinking.ResultsAlthough significantly higher blood alcohol levels were obtained with the higher strength beer (means of 0.026 versus 0.033 mg/100 ml at the end of the study, p < 0.001), (i) most participants reported enjoying the two sessions equally or preferred the low alcohol beer session, (ii) most did not report feeling different between the two sessions and (iii) only about half correctly guessed which was the higher alcohol content beer. There was a preference, however, for the taste of the stronger beer.ConclusionWe conclude beer drinkers cannot readily distinguish low and regular strength beers and can enjoy socializing equally with either. We recommend taxation strategies to create incentives for the manufacture, marketing and consumption of low alcohol alternatives.     

The potential of contribution analysis to alcohol and drug policy strategy evaluation: an applied example from Wales

Abstract

Contribution analysis (CA) is being increasingly favoured as a policy evaluation tool. This includes application to evaluate alcohol and drug policies. This paper reflects on one such example and begins by providing a brief overview of CA as an evaluative research method. It then describes the way in which CA was applied to evaluate alcohol and drug policy in Wales, one of the constituent countries of the UK. This paper reports on two issues. First, how the theory of CA was translated into practice. Second, the key learning points for us as evaluators that arose out of the utilisation of this method. The article highlights that our use of CA enabled a rich exploration of programmes within their contextual setting, and had a range of limitations and considerable challenges associated with identifying and explaining causalities. Within these methodological discussions, we also illustrate how the policy was more successful in elements closer to its nomenclature framing; i.e. harm reduction, than it was to other incorporated aims. The analysis presented in this paper will be useful across a range of jurisdictions where the need to evaluate drug and alcohol policy and practice initiatives may arise.     

Bisphenol A and immunotoxic potential: A commentary

Bisphenol A (BPA) is used in the manufacture of polycarbonate and epoxy resin plastics. There has been interest in the possibility that BPA has immunotoxic properties, and a variety of investigations have explored this. Among the approaches taken have been human observational and cross-sectional studies, investigations using experimental animals, and in vitro studies, some of which have been reviewed previously by the European Food Safety Authority (EFSA).This commentary aims to provide a focused review of data regarding the ability of BPA to perturb the immune system, including the developing immune system, and to cause related adverse health effects. The objective is to complement the evaluations conducted by EFSA, with a focus on the ability of BPA to impair immune function, to promote respiratory allergy and airway inflammation, and to compromise immunological tolerance to dietary proteins.The conclusion drawn is that there is currently no persuasive evidence that BPA has significant immunotoxic potential. This is, in part, due to some of the data reviewed being apparently contradictory or inconsistent, and the investigations from which those data were derived having limitations with regard to experimental design.The conclusion drawn here is that presently there is no clear evidence that BPA has the potential to cause immunotoxicity resulting in adverse health effects.     

The VALUE trial: a commentary.

The Valsartan Antihypertensive Long-Term Use Evaluation (VALUE) Trial compared coronary heart disease outcome in two anti-hypertensive treatment strategies based on either an angiotensin receptor blocker, valsartan, or a calcium channel blocker (CCB), amlodipine. In both patient groups a diuretic was added, if necessary, in an attempt to achieve blood pressure (BP) goals. Follow-up of over 15,000 patients was maintained for 4.2 years. There were no differences in the primary composite endpoint of cardiac morbidity and mortality (which included interventional procedures, hospitalised heart failure, non-fatal myocardial infarction and fatal coronary heart disease, however myocardial infarction and stroke events occurred less commonly on amlodipine than on valsartan the former achieving statistical significance [p=0.02 and p=0.08 respectively]). There was a non-significant excess of hospitalised heart failure on amlodipine (p=0.012). However, lower BPs early in the trial probably accounted for most of the observed benefits in favour of the CCB. The angiotensin receptor blocker arm was associated with less new onset diabetes. The results of VALUE add further support to the evidence that blood pressure control is the major determinant in outcome in trials of antihypertensive therapy.     

Neurobehavioral effects of prenatal alcohol: Part I. Research strategy

This paper, Part I of a three-part series, reviews the literature on the neurobehavioral effects of prenatal alcohol exposure and describes a large group of tests assembled to assess neurobehavioral outcomes of alcohol teratogenesis in 7-year-old children. This paper presents the distribution of these test scores for our sample and discusses their relationships with an alcohol binge score and with full-scale IQ. This group of tests is suitable for children with a wide range of abilities and provides a broad assessment of neurobehavioral deficits. Part II of this series describes a new method of statistical analysis, Partial Least Squares (PLS), which is particularly well suited to complex multivariate data sets such as these, and with its aid, examines the effects of prenatal alcohol exposure on IQ, achievement, vigilance and classroom behavior, a total of 43 outcome scores. Part III examines prenatal alcohol effects on outcomes from the broad group of 164 scores deriving from 17 neuropsychologic tests, using the Partial Least Squares methodology, and summarizes the implications of our findings for the behavioral teratology of alcohol.     

Trichloroethylene risk assessment: A review and commentary

Trichloroethylene (TCE) is a widespread environmental contaminant that is carcinogenic when given in high, chronic doses to certain strains of mice and rats. The capacity of TCE to cause cancer in humans is less clear. The current maximum contaminant level (MCL) of 5 ppb (μg/L) is based on an US Environment Protection Agency (USEPA) policy decision rather than the underlying science. In view of major advances in understanding the etiology and mechanisms of chemically induced cancer, USEPA began in the late 1990s to revise its guidelines for cancer risk assessment. TCE was chosen as the pilot chemical. The final guidelines emphasized a “weight-of-evidence” approach with consideration of dose-response relationships, modes of action, and metabolic/toxicokinetic processes. Where adequate data are available to support reversible binding of the carcinogenic moiety to biological receptors as the initiating event (i.e., a threshold exists), a nonlinear approach is to be used. Otherwise, the default assumption of a linear (i.e., nonthreshold) dose-response is utilized. When validated physiologically based pharmacokinetic (PBPK) models are available, they are to be used to predict internal dosimetry as the basis for species and dose extrapolations. The present article reviews pertinent literature and discusses areas where research may resolve some outstanding issues and facilitate the reassessment process. Key research needs are proposed, including role of dichloroacetic acid (DCA) in TCE-induced liver tumorigenesis in humans; extension of current PBPK models to predict target organ deposition of trichloroacetic acid (TCA) and DCA in humans ingesting TCE in drinking water; use of human hepatocytes to ascertain metabolic rate constants for use in PBPK models that incorporate variability in metabolism of TCE by potentially sensitive subpopulations; measurement of the efficiency of first-pass elimination of trace levels of TCE in drinking water; and assessment of exogenous factors’ (e.g., alcohol, drugs) ability to alter metabolic activation and risks at such low-level exposure.     

Obstacles to the adoption of low risk drinking goals in the treatment of alcohol problems in the United States: A commentary

Although moderation and harm reduction approaches to the treatment of alcohol problems are accepted in many parts of the world, they continue to be rare in the US. A major reason for this state of affairs has to do with the way alcohol treatment services in the US developed, and in particular the creation of a group of paraprofessional counselors many of whom attributed their recovery to the 12-step philosophy. While it is unlikely that these counselors will offer moderation services, the provision of services to problem drinkers in primary care medical settings presents a promising alternative.     

Adolescents in transition: The role of workplace alcohol and other drug policies as a prevention strategy

Aims: To assess (1) the alcohol and other drug (AOD) consumption patterns of adolescent new entrants to the Australian workforce and (2) the association between these consumption patterns and workplace factors.

Methods: A cross-sectional survey of 300 first-year apprentices (aged 15-22 years) employed in South Australian workplaces was conducted.

Findings: More than 40% of apprentices surveyed reported cannabis and alcohol consumption patterns that placed them at risk of potential harm. In addition, 19% reported drinking alcohol and 6.7% reported using cannabis during work-related hours. Workplace alcohol availability and the existence of workplace AOD policies were significantly associated with apprentices' consumption patterns. Apprentices employed in workplaces where alcohol was available used alcohol more often than those reporting no alcohol availability at work. Apprentices reporting an alcohol policy at their workplace reported less alcohol use compared to apprentices reporting no policy. Apprentices reporting a drug policy at their workplace reported lower levels of cannabis and alcohol use compared to those reporting no policy.

Conclusions: Workplace factors, in particular workplace AOD policies, were significantly associated with adolescent AOD use both at and away from the workplace. These findings indicate that the workplace has potential as a setting for prevention strategies design to minimize AOD-related harms.     

The onset and progression of alcohol use disorders: A qualitative study from Goa,India

Quantitative evidence about the burden of alcohol use disorders (AUDs) needs to be complemented with a nuanced qualitative understanding of explanatory models to help supplement public health strategies that are too often steeped uncritically in biomedical models. The aim of this study was to identify the role of various factors in the onset and persistence of AUD and recovery from AUD. This was a qualitative study nested in a population cohort from Goa, India. In-depth interviews of men with incident, recovered, and persistent AUD covered topics such as changes in drinking habits over time, perceptions and experiences about starting/stopping drinking, and so on. Data were analyzed using thematic analysis. Reasons to begin drinking included social drinking, functional use of alcohol, stress, and boredom. Progression to problematic drinking patterns was characterized by drinking alone, alternating between abstinent and heavy drinking periods, and drinking based on the availability of finances. Some enablers to reduce/stop drinking included consequences of drinking lifestyle and personal resolve; some barriers included availability of alcohol at social events and stress. Some reasons for persisting heavy use of alcohol included lack of family support, physical withdrawal symptoms, peer pressure, stress, and easy availability. This article offers a strong conceptualization and nuanced understanding of AUD across a spectrum of developmental courses. This adds to the limited literature on explanatory models of AUD in India and identifies potential targets for prevention and treatment strategies for AUD in low- and middle-income country settings.