A full and thankful heart: writings about gratitude by Alcoholics Anonymous co-founder,Bill Wilson

Abstract

Background: A robust literature on gratitude has accumulated in recent years as a result of the positive psychology movement. Gratitude is a prominent theme in the 12 step program Alcoholics Anonymous (AA), and yet there is little empirical research on the role of gratitude in addiction recovery, and less still on the role of gratitude in AA.

Method: Thematic analysis and grounded theory methodology were employed to produce a framework of AA co-founder Wilson’s conceptualization of gratitude in AA. In the AA text, As Bill Sees It, 17 pages are indexed to the topic “gratitude.” The content of these pages served as data for the current study.

Results: The resulting conceptual framework depicts three themes which describe a circular process: (1) benefactors exist in the form of God and other people, the benefactors (2) provide “gifts,” most notably the AA program and recovery from alcoholism, and (3) these gifts are reciprocated.

Conclusions: The findings closely map to psychological and philosophical depictions of gratitude as something that involves the aid of a benefactor in the provision of gifts that are unearned and cannot be repaid but which motivate reciprocation. The conceptual framework reveals constructs related to gratitude such as humility, arrogance, relationship to God, and interpersonal social support. These constructs can be examined as phenomena that co-occur with gratitude or as mechanisms of the effect of gratitude on recovery in future research.     

Trajectories of alcohol use in the UK military and associations with mental health

IntroductionThere are higher levels of alcohol misuse in the military compared to the general population. Yet there is a dearth of research in military populations on the longitudinal patterns of alcohol use. This study aims to identify group trajectories of alcohol consumption in the UK military and to identify associations with childhood adversity, deployment history and mental disorder.MethodsData on weekly alcohol consumption across an eight year period and three phases of a UK military cohort study (n = 667) were examined using growth mixture modelling.ResultsFive alcohol trajectory classes were identified: mid-average drinkers (55%), abstainers (4%), low level drinkers (19%), decreasing drinkers (3%) and heavy drinkers (19%). Alcohol consumption remained stable over the three periods in all classes, other than in the small decreasing trajectory class. Individuals in the heavy drinking class were more likely to have deployed to Iraq. Abstainers and heavy drinkers were more likely to report post-traumatic stress disorders at baseline compared to average drinkers.ConclusionsHeavy drinkers in the UK military did not change their drinking pattern over a period of eight years. This highlights the need to develop effective preventive programmes to lessen the physical and psychological consequences of long-term heavy alcohol use. Individuals with a mental health problem appeared more likely to either be drinking at a high level or to be abstaining from use.     

Statins worsen glycemic control of T2DM in target LDL-c level and LDL-c reduction dependent manners: a meta-analysis

Objective: Recent studies demonstrated that a low target low-density lipoprotein cholesterol (LDL-c) level, high LDL-c reduction and high dose of statin therapy increased incident diabetes. This study aimed to explore how statin therapy influences glycemic control in type 2 diabetes mellitus (T2DM).

Methods: Medline, Embase, and Cochrane Central were searched for randomized control trials inT2DM. Trials with target LDL-c levels of ≤2.6 mmol/L or LDL-c reduction of ≥30% were analyzed. Then, we calculated mean differences in glycosylated hemoglobin (HbA1c) and fasting blood glucose via stratified LDL-c level, relative LDL-c reduction and statin dose.

Results: In total, trials involving 6,875 participants (3,619 statins, 3,256 controls) were included. Meta-analysis showed that detrimental effect of intensive LDL-c lowering statin therapy on HbA1c (SMD 0.10%; 95% CI 0.05, 0.15; p = 0.000) was more severe than all statin trials analyzed together (SMD 0.07%; 95% CI 0.02, 0.12; p = 0.005). Stratified analyses revealed that the effects on HbA1c became increasingly significant as target LDL-c level decreased and LDL-c reduction increased. Low baseline LDL-c and endpoint LDL-c levels were risk factors involved in increasing HbA1c level during statin therapy.

Conclusions: Statin therapy worsens the glycemic control of T2DM in target LDL-c level and LDL-c reduction dependent manners.     

Is Baclofen a Revolutionary Medication in Alcohol Addiction Management? Review and Recent Updates

ABSTRACT

Baclofen, a γ-aminobutyric acid (GABA)-B receptor agonist, represents a promising drug in alcohol addiction management. Animal models have shown its action at various stages of the process of alcohol addiction. Moreover, initial open and randomized controlled trials have shown the efficacy of 30 mg/day baclofen on alcohol craving, intake, and relapse prevention. It may also decrease alcohol withdrawal symptoms. However, these initial studies were conducted by the same Italian team; 2 American studies, using a different methodology, did not confirm these effects. Following recent reports by an alcohol-dependent French physician who treated himself with high doses (120–270 mg/day), claiming prolonged suppression of alcohol craving and absence of dependence symptoms, baclofen has since received wide media exposure in France where it has been called “the treatment for alcoholism.” An open-label French study supports these findings. In addition, baclofen seems to be particularly interesting because of its safety and tolerance, even in patients with cirrhosis. Thus, baclofen should benefit from further studies of its biobehavioral mechanisms, dose-response effect, and indications in various alcoholic patient profiles.     

Knowledge and utilization of technology-based interventions for substance use disorders: an exploratory study among health professionals in the European Union

Abstract

Background: Little is known about the knowledge and use of technology-based interventions (TBIs) by health personnel working in the addiction field across Europe.

Methods: An online questionnaire was designed using SurveyMonkey^® in order to determine the level of knowledge, use and perceived efficacy of TBIs in substance use disorders (SUDs), among health professionals across six EU Member States: Germany, Italy, UK, France, Poland and the Netherlands. The survey was sent to a convenience sample of 1200 addiction experts.

Results: Surveyed participants (311, response rate 26%), had a mean professional addiction experience of 17 years; 23% stated to have good knowledge of TBIs, while 12% use them in their clinical practice. Forty-six percent consider TBIs useful in the treatment of addiction, and 44% foresee a significant increase of them in the future. TBIs were considered important for people facing barriers to accessing treatment (63%) and for providing support outside the formal care settings (60%). Lack of technical support (48%), poor infrastructure and equipment (42%), and lack of digital literacy among health workers (38%) were identified as the main obstacles in the diffusion of TBIs.

Conclusions: Knowledge and utilisation of TBIs among health workers in drug addiction field is low. Nevertheless, TBIs are perceived as a possible means of facilitation in providing access to treatment, and as therapeutic tools which will become more important in the future. The need to improve training policies, awareness and attitudes towards TBIs among EU health professionals, working in the field of addiction is paramount.     

From substances to food: an examination of addiction shift in individuals undergoing residential treatment for substance use

Background: Addiction shift (also known as “Cross,” “Transfer,” or “Substitute” addiction) is a common theme that emerges in the literature on recovery from substance use disorders. Some research has suggested that those who recover from one substance use disorder are at increased risk of developing another. Despite existing research in this area, little is known about how individuals may be at risk of developing an addiction to food as they recover from a substance use disorder.

Methods: The current study sought to examine addiction shift, specifically from substances to food in 44 participants undergoing residential treatment for substance use disorders. It was hypothesized that drug and/or alcohol use cravings would go down from pre (at intake to residential treatment) to post (at discharge from residential treatment), while food addiction and/or food craving would increase.

Results: Significant changes were observed from pre to post for mean body mass index, and scores from measures assessing alcohol cravings, impulsive behaviors, distress tolerance, depression, and anxiety. No significant differences from pre to post were observed for scores measuring food addiction or food cravings.

Conclusions: Changes in pre to post measures indicated that drug and/or alcohol use cravings decreased. Contrary to original hypotheses, food addiction and food craving was relatively low at baseline and did not change from pre to post. Exploratory post-hoc analyses of psychological factors suggested that impulsivity, distress tolerance, depression, and anxiety went down from pre to post. Short follow-up timeframe and competition theory are likely important factors in these findings.     

Reducing sexual risk behaviors: secondary analyses from a randomized controlled trial of a brief web-based alcohol intervention for underage,heavy episodic drinking college women

Background: Alcohol use and sexual risk behaviors (SRBs) are significant problems on college campuses. College women are at particularly high risk for negative consequences associated with sexually transmitted infections (STIs) and unwanted pregnancy.

Methods: The current study (n?=?160) examined the effect of a brief, web-based alcohol intervention (n?=?53) for college women on reducing SRBs compared to an assessment only control (n?=?107) with a randomized controlled trial. Outcome measures included condom use assertiveness and number of vaginal sex partners and data were collected at baseline and three-month follow-up.

Results: Regression analyses revealed that the alcohol intervention was associated with higher levels of condom use assertiveness at a three-month follow-up. Additionally, more alcohol use was associated with less condom use assertiveness for those with more significant sexual assault histories.

Conclusions: These findings suggest that alcohol interventions may impact college women’s beliefs but not behavior, and future interventions should more explicitly target both alcohol and sexual risk to decrease risky behaviors.     

The efficacy and safety of adding either vildagliptin or glimepiride to ongoing metformin therapy in patients with type 2 diabetes mellitus

Objective: To compare the effects of either vildagliptin or glimepiride on glycemic variability, oxidative stress, and endothelial parameters in patients with type 2 diabetes mellitus (T2DM) inadequately controlled with metformin alone.

Methods: In this randomized, open-label, parallel study, 34 patients with T2DM being treated with metformin having an HbA1c of 7.0–10.0% were allocated into either the vildagliptin or glimepiride group. A mixed-meal tolerance test and 72-hour continuous glucose monitoring were conducted, and urinary 8-iso-prostaglandinF_2α (PGF_2α) and endothelial-dependent flow-mediated dilatation (FMD) were evaluated at baseline and after 12 weeks of treatment.

Results: Similar significant improvements in HbA1c level were shown in both vildagliptin (?0.8%) and glimepiride (?0.9%) groups after treatment (Ps<0.001). The mean amplitude of glycemic excursions (MAGE) and the mean of daily differences (MODD) were significantly decreased by vildagliptin (P = 0.044 and P = 0.031, respectively) but not by glimepiride. Glimepiride was significantly associated with a higher incidence of hypoglycemia than vildagliptin (P = 0.005). There were no significant differences in urinary 8-iso-PGF_2α or FMD between the two groups.

Conclusions: Vildagliptin effectively improved glucose level with a significantly greater reduction in glycemic variability and hypoglycemia than glimepiride in patients with T2DM ongoing metformin therapy. The two drugs showed no significant differences in urinary 8-iso-PGF_2α and FMD.

Trial registration: NCT01404676     

Late-onset alcohol dependence: patient-reported problems

Introduction: Elderly alcohol dependent patients can be discriminated based on the age of onset of alcohol use. This is relevant for their clinical problem presentation and for the course of treatment.

Materials and methods: In this paper, problems of elderly patients are presented at intake in an addiction treatment center, based on the most recent, almost nationwide applied intake instrument in The Netherlands: the MATE. Prevalences are analyzed for substance use, psychiatric and somatic co-morbidity, level and severity of dependence, limitations in daily functioning, craving, and perceived levels of depression, anxiety and stress. Among a total of 1942 alcohol dependent patients, four subpopulations were compared in the analyses: adults (24–55 years), elderly patients (≥?55 years) with early (early-onset alcohol dependence (EOAD),??45 years) onset alcohol dependence.

Results: Results show that LOAD has less problem severity in almost all assessment areas than adults. They do however use 3.5 times more often medication for physical illnesses, and suffer more often from confusion and somatic diseases. LOAD is not different from EOAD and MOAD.

Conclusion: The results show that LOAD in a relatively short time period developed an alcohol dependence and alcohol related problems that are similar to that of their peers who used alcohol for a much longer time.     

Predictors of Membership in Alcoholics Anonymous in a Sample of Successfully Remitted Alcoholics

Abstract

This study identifies factors associated with Alcoholics Anonymous (AA) membership in a sample of 81 persons who have achieved at least one year of total abstinence from alcohol and other drugs. Forty-four were AA members, 37 were not. Logistic regression was used to test the cross-sectional associations of baseline demographic, substance-related, spiritual and religious, and personality variables with AA membership. Significant variables from the bivariate analyses were included in a multivariate model controlling for previous AA involvement. Having more positive views of God and more negative consequences of drinking were significantly associated with AA membership. This information can be used by clinicians to identify clients for whom AA might be a good fit, and can help others overcome obstacles to AA or explore alternative forms of abstinence support.     

Trajectories of retention in opioid agonist therapy in a Canadian setting

BackgroundLong-term engagement in opioid agonist therapy (OAT) has been consistently associated with reduced risk for morbidity and mortality in people with opioid use disorder (OUD). However, the dynamic nature of engagement/disengagement in OUD care for over time is poorly captured by traditional metrics. We characterized long-term longitudinal trajectories of engagement in OAT in Vancouver, Canada, between 2005 and 2018.MethodsData were derived from two community-recruited prospective cohorts of people who use drugs. Retention in OAT was defined as self-reported enrolment in OAT for two consecutive follow-up periods (an approximately six-month retention interval). We used latent class growth analysis to identify OAT engagement trajectories during the first five years after OAT initiation and multivariable logistic regression to evaluate predictors of trajectory group membership.ResultsWe identified four OAT retention trajectories among 438 OAT initiators: “consistently high” (36%), “consistently low” (23%), “increasing” (23%), and “decreasing” (15%). Employment was a significant cross-cutting predictor of membership of all sub-optimal OAT engagement patterns compared to consistently high trajectories. We also found that initiating OAT after 2014 (when regulatory changes to the provincial OAT program were introduced) was associated with the “consistently low” engagement group relative to others.ConclusionsWe identified four distinct OAT engagement trajectories in Vancouver, Canada, with employment being a common predictor of sub-optimal care trajectories, suggesting the need to explore alternative OAT models to address employment-related barriers. Care trajectory analysis could help inform tailored interventions to specific populations of people with OUD at specific time points to improve engagement in OAT, and decrease opioid-related morbidity and mortality.     

Perspectives of alcohol treatment providers and users on alcohol addiction and its facilitating factors in Uganda and Belgium

Background: Although conceptualisation of addiction varies with time and culture, literature on intercultural studies between high and low income countries is scarce. This article uses Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 guidelines on diagnosis of Alcohol Use Disorder (AUD) and the Capability Opportunity Motivation – Behaviour (COM-B) model to explore perspectives on alcohol addiction and its facilitating factors in Uganda and Belgium.

Method: Sixty qualitative interviews (40 with service providers and 20 service users) were administered in four alcohol treatment centres, two in Uganda and two in Belgium. Interviews were transcribed and analysed thematically using Nvivo software.

Result: While addiction was primarily regarded as a disease enabled by capability factors (affordability and the absence of life and social skills) by Belgian respondents, many Ugandans viewed it as a moral or criminal issue; motivated by the varied roles of informal alcohol use amidst weak restrictions. Opportunity-related factors including; acceptability, availability, media influence, cultural/religious beliefs and practices and peer influence were recognised as facilitating factors in both countries, while stigma was equally prevalent.

Conclusion: Interventions in Uganda could explore strengthening legislation and research on utilisation of the well-entrenched religious and cultural institutions to encourage alternatives to alcohol use. In Belgium, promotion of life and social skills, alcohol regulation in educational institutions and other demand reduction strategies seem essential to delay the onset of (mis)use. In both societies; general reduction of opportunities for access, early intervention, programmes for young persons and prevention of stigma through awareness-raising can be explored for mitigation of AUD.     

Integration of generalized vulnerability to drug and alcohol addiction

Summary

The vulnerability to develop addiction to alcohol has been well established in familial and genetic studies. Similar familial and genetic studies have supported a vulnerability to drug addiction. The co‐occurrence of alcohol and drug addiction in the same individuals is highly prevalent in clinical populations. Common putative neurochemical mechanisms underlie addiction to both alcohol and drugs, namely, in the mesolimbic pathway and the locus ceruleus in the brain. Treatment strategies are directed at both alcohol and multiple drug addictions in patient populations. The formulation of a generalized vulnerability that extends to both alcohol and drug addiction is not only possible but necessary to explain the substantial numbers of individuals who develop both alcohol and drug addictions. Future research that is pertinent and relevant may depend on the understanding of a generalized vulnerability to develop alcohol and drug addiction and its application in diagnostic strategies and treatment models.     

Comparison between insulin degludec/liraglutide treatment and insulin glargine/lixisenatide treatment in type 2 diabetes: a systematic review and meta-analysis

Aim: To evaluate the efficacy and adverse effects of IDegLira and IGlarLixi treatment and to perform a comparison between two strategies.

Methods: The registration number is CRD42017053952. Randomized controlled trials of IGlarLixi treatment or IDegLira treatment compared with placebo or active hypoglycemic agents in type 2 diabetes were included.

Results: Eight trials were included. The absolute HbA1c change relative to baseline after IGlarLixi treatment was ?1.50% with significance (95% CI, ?1.89% to ?1.12%, p < 0.01); the absolute HbA1c change after IDegLira treatment was ?1.89% with significance (95% CI, ?2.04% to ?1.73%, p < 0.01). Comparisons between IGlarLixi treatment and IDegLira treatment indicated no significant differences between groups. The absolute weight change after IGlarLixi treatment significantly decreased (weighted mean difference (WMD), ?0.62 kg; 95% CI, ?0.93 to ?0.31 kg, p = < 0.01), but the absolute weight change after IDegLira treatment was not significantly changed (WMD, ?0.81 kg; 95% CI, ?3.26 to 1.65 kg, p = 0.52). There were no significant differences between groups.

Conclusion: Glucose control of IGlarLixi treatment or IDegLira treatment was significantly lower than that at baseline. Comparisons between the two treatment groups indicated no significant differences between groups in absolute HbA1c changes or body weight changes relative to baseline.     

Family income trajectory during childhood is associated with adolescent cigarette smoking and alcohol use

Background

Although childhood socioeconomic disadvantage has been linked with adolescent tobacco and alcohol use in cross-sectional research, less is known about the influence of changes in socioeconomic status during childhood. Upward socioeconomic mobility may attenuate the negative influence of earlier socioeconomic disadvantage on health, while downward mobility may counter the health benefits of earlier socioeconomic advantage. This study evaluated the influence of common trajectories of family income during childhood on smoking and alcohol use during adolescence.

Methods

Data utilized were part of the 15-year longitudinal Study of Early Child Care and Youth Development. A 5-class trajectory model (two stable, one downward, and two upward income trajectories) was developed previously with this sample (N = 1356). Logistic regression analyses were conducted to determine whether children of the more disadvantaged income trajectories were more likely to engage in tobacco and alcohol use at age 15 relative to those of the most advantaged trajectory.

Results

Family income trajectory was significantly associated with ever-smoking (p = .02) and past-year alcohol use at age 15 years (p = .008). Children from the less advantaged trajectories were more likely to have ever-smoked than children of the most advantaged trajectory (all p's < .05). Children of the downwardly mobile trajectory were more likely to have used alcohol within the past year than children of the most advantaged trajectories as well as the most disadvantaged trajectory (all p's < .05).

Conclusions

Findings indicate that childhood socioeconomic disadvantage influences adolescent smoking, while downward socioeconomic mobility influences adolescent alcohol use.     

Quality of web-based information on alcohol dependence

Aims: To evaluate the quality of web-based information on alcohol dependence and to assess particular content quality indicators.

Methods: Three keywords, ‘alcohol addiction’, ‘alcohol dependence’ and ‘alcohol abuse’ were entered into three popular World Wide Web search engines. Websites were assessed with a standardized proforma designed to rate sites on the basis of accountability, presentation, interactivity, readability and content quality. ‘Health on the Net’ (HON) quality label, and DISCERN scale scores aimed to assist persons without content expertise to assess quality of written health publication and were used to verify their efficiency as quality indicators.

Results: Of the 180 websites identified, 104 were included. Based on outcome measures, the overall quality of the sites turned-out to be poor. The global scores appeared as good content quality indicators.

Conclusions: While alcohol education web sites for patients are widespread, their educational material highly varies in quality and content.     

Pain management in opioid maintenance treatment

ABSTRACT

Introduction: Opioid addiction is a worldwide disease with a significant impact. A multitude of physical and mental comorbidities are associated with opioid addiction, pain being one of the most relevant. Insufficient pain management may lead to a disruption in medical treatment, self-medication, and subsequent harm to patients.

Areas covered: In this review, the authors provide a general overview of opioid addiction. A literature search for pain management and opioid maintenance treatment was conducted. Different settings of acute or chronic pain and situations specific to patients addicted to opioids are described. Pain management therapy in addiction is also addressed with an emphasis on treatment strategies such as the optimization of methadone and buprenorphine medication, additional opioid analgesia, and multimodal pain management.

Expert opinion: Opioid addiction is a growing global health concern, and maintenance therapy remains an effective and lifesaving treatment option. However, there remains uncertainty on the appropriate pain management for this patient group. The backbone of pain management in opiate-addicted patients remains maintenance therapy while adjunctive treatment such as regional analgesia, non-opioid analgesia, antidepressants, steps to improve sleep, acceptance and commitment therapy, biofeedback, and hypnosis should be considered. Additional opioid medication is possible as well.     

‘Breaking the Cycle’ of maternal substance use through relationships: a comparison of integrated approaches

Background: To compare a novel relationship-focused intervention (RFI) for maternal substance use, offered through ‘Breaking the Cycle (BTC)’, to standard integrated treatment (SIT). Although SIT focuses on the mother–child relationship tangentially by providing basic parenting information, RFI involves a central focus on promoting healthy maternal relationships with a particular emphasis on fostering mother–child interactions.

Method: Measures in the domains of addiction, relationship capacity, and mental health were administered to 65 women receiving RFI and 25 receiving SIT, at intake (T1) and one year later (T2).

Results: While both groups of mothers improved in addiction severity, women receiving RFI also improved in mental health functioning and relationship capacity. Improvements in relationship capacity predicted addiction severity, over and above improvements in abstinence self-efficacy, social support, and mental health.

Conclusions: Findings highlight the importance of a relationship-focus in assisting mothers to make broad changes that support addiction recovery. Implications and future directions are discussed.     

Trajectories of initiation for the heroin-based drug whoonga – qualitative evidence from South Africa

BackgroundWhoonga is a smoked heroin-based street drug that first emerged in South Africa a decade ago. While previous scientific reports suggest that use is growing and youth are particularly vulnerable, trajectories of initiation are not well characterized.MethodsIn 2015, 30 men undergoing residential addiction treatment for this smoked heroin drug in KwaZulu-Natal, South Africa participated in semi-structured interviews about their experiences using the drug. Interview data were coded using qualitative content analysis.ResultsParticipant trajectories to initiating smoked heroin were “vertical” in the context of marijuana use or “horizontal” in the context of other hard drug use. Participants reporting vertical trajectories began smoking heroin as youth at school or in other settings where people were smoking marijuana. Several participants with horizontal trajectories started smoking heroin to address symptoms of other drug or alcohol addiction. Social influences on initiation emerged as an overarching theme. Members of participants’ social networks who were smoking or distributing heroin figured prominently in initiation narratives. Surprisingly, references to injection drug use were absent from initiation narratives. Participants reported people who smoke heroin differ from those who inject heroin by race.ConclusionConsistent with theories implicating social and structural influences on substance use initiation, people who started smoking heroin had social contacts who smoked heroin and frequented places where substance use was common. Smoked heroin initiation for several participants with horizontal trajectories may have been averted if they accessed evidence-based treatments for stimulant or alcohol use disorders. With increasing reports of heroin use across Africa, a coordinated approach to address this growing epidemic is needed. However, because smoked heroin and injection heroin use occur in distinct risk environments, interventions tailored to people who use smoked heroin will be needed to prevent smoked heroin use, prevent transition to injection use, and mitigate other social harms.     

Drinking patterns and harm of unrecorded alcohol in Russia: a qualitative interview study

Background: Consumption of unrecorded alcohol (alcohol, consumed as a beverage, but not reflected in official statistics) has been linked to heavy drinking and alcohol-related mortality in Russia, with different studies looking for possible toxic components or other explanations. This study explores self-reported drinking behaviors of people diagnosed with alcohol dependence to elicit the perspectives of consumers of unrecorded alcohol.

Methods: Semi-structured in-depth expert interviews were conducted with patients (n?=?25) of state-run addiction treatment centers of two Russian cities. Interviews were analyzed using thematic content analysis.

Results: A strict hierarchy between different types of unrecorded alcohol products, their ascribed quality, and the subjective harm caused by their consumption was found, with home-made spirits for own consumption at the top and technical fluids at the bottom. The ranking order correlated with product price, social status of associated consumers, and severity of their alcohol dependence. Binge drinking was the prevailing drinking pattern and shifts from recorded to unrecorded consumption within a single binge or a zapoi (continuous drinking for at least two days) were typical. Consumption of low-quality unrecorded alcohol was associated with stronger hang-overs, zapois, alcohol psychoses and poisonings, and other indicators of alcohol attributable harm, while no such connection was found for spirits for own consumption.

Conclusions: In the dominant explanation patterns of the consumers, the experienced alcohol-induced harm is attributed to alcohol quality, while a thorough analysis of their reported drinking behaviors cannot exclude specific drinking patterns linked to the severity of alcohol dependence as the main determinants of the described health detriments.