Exploring longitudinal course and treatment-baseline severity interactions in secondary outcomes of smoking cessation treatment in individuals with attention-deficit hyperactivity disorder

Background: A double blind, placebo-controlled randomized trial (NCT00253747) evaluating osmotic-release oral system methylphenidate (OROS-MPH) for smoking-cessation revealed a significant interaction effect in which participants with higher baseline ADHD severity had better abstinence outcomes with OROS-MPH while participants with lower baseline ADHD severity had worse outcomes. Objectives: This current report examines secondary outcomes that might bear on the mechanism for this differential treatment effect. Methods: Longitudinal analyses were conducted to evaluate the effect of OROS-MPH on three secondary outcomes (ADHD symptom severity, nicotine craving, and withdrawal) in the total sample (N = 255, 56% Male), and in the high (N = 134) and low (N = 121) baseline ADHD severity groups. Results: OROS-MPH significantly improved ADHD symptoms and nicotine withdrawal symptoms in the total sample, and exploratory analyses showed that in both higher and lower baseline severity groups, OROS-MPH statistically significantly improved these two outcomes. No effect on craving overall was detected, though exploratory analyses showed statistically significantly decreased craving in the high ADHD severity participants on OROS-MPH. No treatment by ADHD baseline severity interaction was detected for the outcomes. Conclusions: Methylphenidate improved secondary outcomes during smoking cessation independent of baseline ADHD severity, with no evident treatment-baseline severity interaction. Our results suggest divergent responses to smoking cessation treatment in the higher and lower severity groups cannot be explained by concordant divergence in craving, withdrawal and ADHD symptom severity, and alternative hypotheses may need to be identified.     

Clinical predictors of treatment reduction in hypertensive patients

Objective:To demonstrate that some hypertensive patients under good blood pressure (BP) control can reduce medications, and to identify predictors of successful reduction. Design:Observational study with 11-month follow-up. Setting:Outpatient hypertension clinic at the Seattle Veterans Administration Hospital. Patients:59 males (51% of those eligible) with diastolic BP<95 mm Hg for ≥6 months; 57 patients (97%) completed the study. Intervention:Gradual reduction of medications unless diastolic BP rose above 95 mm Hg. Measurements and main results:Intensity of treatment with BP medications was assessed using a scale of their comparative “vigors.” 35 patients (59%) reduced medications successfully. By the end of the study, systolic BP had risen by 8.2±12.3 mm Hg (mean±SD) in successful patients, while diastolic BP did not change significantly. Two predictors of treatment reduction were statistically significant in both univariate and multivariate analyses: successful patients had been treated more intensively (2.7±1.7 vs. 1.3±0.5 “vigor units,” p=0.0001), and they had been enrolled in the clinic longer (5.5±3.0 vs. 3.1±2.3 years, p=0.003). Lower systolic BP, higher urinary sodium excretion, lower compliance, and younger age were significant predictors of treatment reduction on univariate analysis only. Age≤65 years had the highest sensitivity (86%) for treatment reduction, while treatment with two or more “vigor units” had the highest specificity (79%) and likelihood ratio (3.3). Conclusions:Treatment reduction is feasible in many well-controlled hypertensives, though systolic BP rises. Patients with high intensity and long duration of treatment are most likely to reduce medications successfully. Presented in part at the annual meeting of the Society of General Internal Medicine, Arlington, Virginia, April 1988, and the annual meeting of the Robert Wood Johnson Clinical Scholars Program, Miami, Florida, October 1988. This study was conducted while Dr. Steiner was a Robert Wood Johnson Clinical Scholar at the University of Washington. Support was provided by the Northwest Health Services Research and Development Program of the Veterans Administration. The opinions, conclusions, and proposals in this paper are those of the authors, and do not necessarily represent the views of the Robert Wood Johnson Foundation or the Veterans Administration.     

Differences in access to zidovudine (AZT) among symptomatic HIV-infected persons

Object:To evaluate socioeconomic factors that determine whether symptomatic HIV-infected persons are offered zidovudine (AZT). Design:Cross-sectional survey conducted as part of the Robert Wood Johnson Foundation’s AIDS Health Services Program. Setting:Public hospital clinics and community-based AIDS organizations in nine American cities. Patients:880 HIV-seropositive outpatients interviewed between October 1988 and May 1989. Main results:Males were more likely to have been offered AZT than were females (adjusted odds ratio 2.99; 95% confidence interval 1.67 to 5.36), those with insurance were more likely to have been offered AZT than were those without (adjusted odds ratio 2.00; 95% confidence interval 1.25 to 3.21), and whites more likely to have been offered AZT than were non-whites (adjusted odds ratio 1.73; 95% confidence interval 1.11 to 2.69). Intravenous drug users were less likely to have been offered AZT than were non-drug users (adjusted odds ratio 0.44; 95% confidence interval 0.28 to 0.69). Persons who had had an episode of Pneumocystis cariniipneumonia were more likely to have been offered AZT than were persons who had AIDS and had not had Pneumocystis cariniipneumonia (adjusted odds ratio 2.95; 95% confidence interval 1.71 to 5.11). Conclusion:The authors conclude that traditionally dis-advantaged groups have less access to AZT, the only antiretroviral agent demonstrated to increase survival of patients who have symptomatic HIV infection. Presented in part at the annual meeting of the Society of General Internal Medicine, Arlington, Virginia, May 2–4, 1990. Supported in part by a grant from the Robert Wood Johnson Foundation (12044).     

The effects of carbamazepine and lorazepam on single versus multiple previous alcohol withdrawals in an outpatient randomized trial

OBJECTIVE: Benzodiazepines are the mainstay of treatment for mild-to-moderate alcohol withdrawal in outpatient settings, but they can interact with alcohol, cause motor incoordination, or be abused. This study compared the therapeutic responses of the benzodiazepine lorazepam and the anticonvulsant carbamazepine for the outpatient treatment of acute alcohol withdrawal in terms of patients’ previous detoxification histories, and compared the effects of these 2 medications on drinking behaviors in the immediate postdetoxification period. DESIGN: This was a randomized double-blind trial comparing patient responses to carbamazepine and lorazepam across 2 levels of detoxification histories (0–1 or ≥2 previous medicated detoxifications). SETTING: A university medical center substance abuse clinic in Charleston, SC. PATIENTS: One hundred thirty-six patients in moderate alcohol withdrawal were randomized. Major exclusions were significant hepatic or hematologic abnormalities and use of medications that could alter withdrawal symptoms. INTERVENTIONS: Patients received 600–800 mg of carbamazepine or 6–8 mg of lorazepam in divided doses on day 1 tapering to 200 mg of carbamazepine or 2 mg of lorazepam. MAIN OUTCOME MEASURES: The Clinical Institute Withdrawal Assessment for Alcohol-Revised was used to assess alcohol withdrawal symptoms on days 1 through 5 and postmedication at days 7 and 12. Daily drinking was measured by patient report using a daily drinking log and a breath alcohol level with each visit. Side effects were recorded daily. RESULTS: Carbamazepine and lorazepam were equally effective at decreasing the symptoms of alcohol withdrawal. In the post-treatment period, 89 patients drank on at least 1 day; on average, carbamazepine patients drank less than 1 drink per drinking day and lorazepam patients drank almost 3 drinks per drinking day (P=.003). Among those with multiple past detoxifications, the carbamazepine group drank less than 1 drink per day on average and the lorazepam group drank about 5 drinks per day on average (P=.033). Lorazepam-treated patients had a significant rebound of alcohol withdrawal symptoms post-treatment (P=.007) and the risk of having a first drink was 3 times greater (P=.04) than for carbamazepine-treated patients. Twenty percent of lorazepam-treated patients had dizziness, motor incoordination, or ataxia and did not recognize their impairment. Twenty percent of carbamazepine-treated patients reported pruritus but no rash. CONCLUSIONS: Carbamazepine and lorazepam were both effective in decreasing the symptoms of alcohol withdrawal in relatively healthy, middle-aged outpatients. Carbamazepine, however, was superior to lorazepam in preventing rebound withdrawal symptoms and reducing post-treatment drinking, especially for those with a history of multiple treated withdrawals. This research was supported by the National Institutes of Health National Institute on Alcohol Abuse and Alcoholism Center Grant no. AA10761.     

Decreased alcohol consumption in outpatient drinkers is associated with improved quality of life and fewer alcohol-related consequences

This study’s objective was to determine whether changes in alcohol consumption are associated with changes in quality of life and alcohol-related consequences in an outpatient sample of drinkers. Two hundred thirteen subjects completed the Short Form 36-item (SF-36) Health Survey and the Short Inventory of Problems at baseline, 6 months, and 12 months. Subjects who sustained a 30% or greater decrease in drinks per month reported improvement in SF-36 Physical Component Summary (P=.058) and Mental Component Summary (P=.037) scores and had fewer alcohol-related consequences (P<.001) when compared to those with a <30% decrease. These findings suggest another benefit of alcohol screening and intervention in the primary care setting. This research was supported by grant AA1029 from the National Institute on Alcohol Abuse and Alcoholism (NIAAA). Dr. Kraemer is supported by a Mentored Career Development Award from NIAAA (K23 AA00235). Dr. Conigliaro is supported by an Advanced Career Development Award from the Department of Veterans Affairs HSR&D Service (CD-97324-A) and a Robert Wood Johnson Foundation Generalist Physician Faculty Scholar Award (no. 031500).     

Visual impairment and cognitive dysfunction in Alzheimer’s disease

Objective:To determine whether impaired visual acuity is associated with dementia and cognitive dysfunction in older adults. Design:Paired case-control comparisons of the relative frequencies of visual impairment in demented cases and nondemented controls. Cohort analyses of correlation between visual acuity and cognitive functioning in demented cases. Setting:Internal medicine clinics at two academically affiliated medical centers. Participants:Eighty-seven consecutively selected patients ≥65 years of age with mild-to-moderate, clinically diagnosed Alzheimer’s disease (cases) and 87 nondemented controls matched to the cases by age, sex, and education. Measurements and main results:The prevalence of visual impairment was higher in cases than in controls [unadjusted odds ratio for near-vision impairment =2.7 (95% CI=1.4, 5.2); unadjusted odds ratio for far-vision impairment =2.1 (95% CI=1.02, 4.3); odds ratios adjusted for family history of dementia, depression, number of medications, and hearing loss were 2.5 (95% CI=1.1, 10.5) for near-vision impairment and 1.9 (95% CI=0.8, 4.6) for far-vision impairment]. When further stratified by quartiles of visual acuity, no statistically significant “dose-response” relationship between vision impairment and dementia risk was observed. Among cases, the degree of visual impairment was significantly correlated with the severity of cognitive dysfunction for both near and far vision (adjusted ps<0.001). Conclusions:Visual impairment is associated with both an increased risk and an increased clinical severity of Alzheimer’s disease, but the increased risk may not be consistent with a progressive dose-response relationship. Further studies are needed to determine whether visual impairment unmasks and exacerbates the symptoms of dementia or is a marker of disease severity. Supported by the Robert Wood Johnson Foundation Research and Development Program to Improve Patient Functional Status, the University of Washington Alzheimer’s Disease Research Center (National Institutes of Health grant No. AG 05136) and Alzheimer’s Disease Patient Registry (National Institutes of Health grant No. AG 06781), and National Institute on Aging Academic Award No. K08 AG00265 (Dr. Uhlmann). The views expressed here are not necessarily those of the Robert Wood Johnson Foundation.     

Alcohol withdrawal

OBJECTIVE: To describe current practices employed in the inpatient treatment for alcohol withdrawal. DESIGN: Survey. SETTING: Inpatient alcoholism treatment programs in the United States. PARTICIPANTS: Medical directors of 176 (69%) of 257 eligible programs randomly selected from a national listing. RESULTS: The medical directors estimated that of all inpatients treated for alcohol withdrawal at the programs, 68% received one of the following medications. Benzodiazepines, including the long-acting chlordiazepoxide (33%) and diazepam (16%), and less frequently the short-acting oxazepam (7%) and lorazepam (4%), were the most commonly used agents. Barbiturates (11%), phenytoin (10%), clonidine (7%), (5-blockers (3%), carbamazepine (1%), and antipsychotics (1%) were less frequently given. Drug was most often given on a fixed dosing schedule with additional medication “as needed” (52% of the programs). Only 31% of the programs routinely used a standardized withdrawal severity scale to monitor patients. Mean duration of sedative treatment was three days; inpatient treatment, four days. Use of fixed-schedule regimens was associated with longer sedative treatment (mean four vs three days, p<0.01). Northeast census region location and psychiatrist program director were significantly associated with longer sedative and inpatient treatment duration. CONCLUSIONS: The most commonly reported regimen for alcohol withdrawal included three days of long-acting benzodiazepines on a fixed schedule with additional medication “as needed.” Standardized monitoring of the severity of withdrawal was not common practice. The directors reported using a variety of other regimens, some not known to prevent the major complications of withdrawal. Although geographic location and director specialty were significantly associated with treatment duration, much of the variation in treatment for alcohol withdrawal remains unexplained. Dr. Saitz was a Fellow in General Internal Medicine at the Veterans Affairs Medical Center, Manchester, New Hampshire, the New England Deaconess Hospital, and Harvard Medical School when the study was conducted. Presented at the annual meeting of the Association for Medical Education and Research in Substance Abuse, Bethesda, Maryland, November 20, 1993.     

Attitudes of house officers toward the autopsy

Study Objective:To assess the attitudes of house officers in internal medicine and pathology about the value and use of the autopsy. Design:Self-administered multiple-choice questionnaire. Setting:Two New York City urban teaching hospitals. Subjects:112 internal medicine and 37 pathology house officers who were on site during the survey period. Main results:Most internal medicine house officers (86%) felt that the autopsy rate was too low and needed to be increased. The most common reason the residents cited for the low rate was the reluctance of families to grant permission. A majority of medicine housestaff (78%) felt they needed more instruction on how to ask for an autopsy, and 34% had never received feedback from the pathology department on autopsy results. Most pathology residents (94%) felt the autopsy rate was too low; the most common reasons they cited for the low rate were reluctance of clinicians to request permission and clinicians’ fears of being sued for malpractice. Conclusions:House officers in internal medicine and pathology agreed that autopsies should be performed more frequently, and identified problems in obtaining autopsies that should be addressed by educational, organizational, and regulatory strategies. Supported in part by a grant from the Robert Wood Johnson Foundation. The opinions and conclusions herein are those of the authors and do not necessarily represent the views of the Robert Wood Johnson Foundation.     

Ability of primary care physicians to diagnose and managePneumocystis carinii pneumonia

This study assesses the ability of primary care physicians to diagnose and managePneumocystis carinii pneumonia (PCP) in a standardized patient (SP) with unidentified HIV infection. One hundred thirty-four primary care physicians from five Northwest states saw an SP with unidentified HIV infection who presented with symptoms, chest radiograph, and arterial blood gas results classic for PCP. Seventy-seven percent of the physicians included PCP in their differential diagnoses and 71% identified the SP’s HIV risk. However, only a minority of the physicians indicated that they would initiate an appropriate diagnostic evaluation or appropriate therapy: 47% ordered a diagnostic test for PCP, 31% initiated an antibiotic appropriate for PCP, and 12% initiated an adequate dose of trimethoprim— sulfamethoxazole. Only 6% of the physicians initiated adjunctive prednisone therapy, even though prednisone was indicated because of the blood gas result. These findings suggest significant delay in diagnosis and treatment had these physicians been treating an actual patient with PCP. Presented at the International Conference on AIDS, Berlin, Germany, June 6 –11, 1993. Supported by grant number HS 06454-03 from the Agency for Health Care Policy and Research. Dr. Curtis is funded by the Robert Wood Johnson Clinical Scholars Program. The views expressed herein are those of the authors and are not necessarily the views of the Agency for Health Care Policy and Research or the Robert Wood Johnson Foundation.     

Primary care and receipt of preventive services

OBJECTIVE: To examine whether health insurance, a regular place of care, and optimal primary care are independently associated with receiving preventive care services. DESIGN: A cross-sectional telephone survey. SETTING: Population based. PARTICIPANTS: Probability sample of 3,846 English-speaking and Spanish-speaking women between the ages of 18 and 64 in urban California. INTERVENTIONS: Women were asked about their demographic characteristics, financial status, health insurance status, need for ongoing care, regular place of care, and receipt of blood pressure screening, clinical breast examinations, mammograms, and Pap smears. Women who reported a regular place of care were asked about four components of primary care: availability, continuity, comprehensiveness, and communication. MEASUREMENTS AND MAIN RESULTS: In multivariate analyses that controlled for differences in demographics, financial status, and need for ongoing care, having a regular place of care was the most important factor associated with receiving preventive care services (p<.0001). Having health insurance (p<.001) and receiving optimal primary care from the regular place of care (p<.01) further significantly increased the likelihood of receiving preventive care services. CONCLUSION: A regular source of care is the single most important factor associated with the receipt of preventive services, but optimal primary care from a regular place increases the likelihood that women will receive preventive care. Supported by Robert Wood Johnson Foundation grant 22907 and Agency for Health Care Policy Research (AHCPR) grant HSO7373. Dr. Bindman and Dr. Grumbach are Robert Wood Johnson Foundation Generalist Physician Faculty Scholars.     

End-of-life decision making

OBJECTIVE: To identify the desired features of end-of-life medical decision making from the perspective of elderly individuals. DESIGN: Qualitative study using in-depth interviews and analysis from a phenomenologic perspective. SETTING: A senior center and a multilevel retirement community in Los Angeles. PARTICIPANTS: Twenty-one elderly informants (mean age 83 years) representing a spectrum of functional status and prior experiences with end-of-life decision making. MAIN RESULTS: Informants were concerned primarily with the outcomes of serious illness rather than the medical interventions that might be used, and defined treatments as desirable to the extent they could return the patient to his or her valued life activities. Advanced age was a relevant consideration in decision making, guided by concerns about personal losses and the meaning of having lived a “full life.” Decisionmaking authority was granted both to physicians (for their technical expertise) and family members (for their concern for the patient’s interests), and shifted from physician to family as the patient’s prognosis for functional recovery became grim. Expressions of care, both by patients and family members, were often important contributors to end-of-life treatment decisions. CONCLUSIONS: These findings suggest that advance directives and physician-patient discussions that focus on acceptable health states and valued life activities may be better suited to patients’ end-of-life care goals than those that focus on specific medical interventions, such as cardiopulmonary resuscitation. We propose a model of collaborative surrogate decision making by families and physicians that encourages physicians to assume responsibility for recommending treatment plans, including the provision or withholding of specific life-sustaining treatments, when such recommendations are consistent with patients’ and families’ goals for care. This research was partially funded by the Robert Wood Johnson Clinical Scholars Program. The views expressed above are those of the authors and do not necessarily reflect those of the Robert Wood Johnson Foundation.     

Prior capacity of patients lacking decision making ability early in hospitalization

Objective: To investigate the appropriateness of hospitalization as the time to elicit patients’ medical care preferences, the authors evaluated the capability of seriously ill patients to participate in decision making early in hospitalization and their decision making capacity two weeks before hospital entry. Design: Cross-sectional study with retrospective evaluation of preadmission decision making capacity. Setting: Five acute care teaching hospitals. Patients: Four thousand three hundred one acutely ill hospitalized adults meeting predetermined severity of illness criteria in nine specific disease categories. Measurements: Surrogate decision makers’ estimates of the prior mental capacities of patients unable to be interviewed early in hospitalization about care preferences due to intubation, coma, or cognitive impairment. Comparison of the demographics, degrees of sickness at admission, and outcomes of interviewable vs noninterviewable patients. Main results: Forty percent of the patients were not interviewable concerning preferences. Of these, 83% could have participated in treatment decisions two weeks prior to hospitalization. The patients who were not interviewable were more acutely ill, had less chronic disease, and were more likely to die during hospitalization than the interviewable patients. Conclusions: Many acutely ill patients likely to die in the hospital lost their ability to make medical care decisions around the time of hospital admission. Preferences for care and advance directives should be discussed in the outpatient setting or very early in hospital admission. Presented at the annual meeting of the Society of General Internal Medicine, April 29–May 1, 1992, Washington, DC. Funding for SUPPORT is provided by the Robert Wood Johnson Foundation.     

Evaluation of the appropriate use of a CIWA-Ar alcohol withdrawal protocol in the general hospital setting

Background: The Clinical Institute Withdrawal Assessment-Alcohol, Revised (CIWA-Ar) is an assessment tool used to quantify alcohol withdrawal syndrome (AWS) severity and inform benzodiazepine treatment for alcohol withdrawal. Objectives: To evaluate the prescribing patterns and appropriate use of the CIWA-Ar protocol in a general hospital setting, as determined by the presence or absence of documented AWS risk factors, patients’ ability to communicate, and provider awareness of the CIWA-Ar order. Methods: This retrospective chart review included 118 encounters of hospitalized patients placed on a CIWA-Ar protocol during one year. The following data were collected for each encounter: patient demographics, admitting diagnosis, ability to communicate, and admission blood alcohol level; and medical specialty of the clinician ordering CIWA-Ar, documentation of the presence or absence of established AWS risk factors, specific parameters of the protocol ordered, service admitted to, provider documentation of awareness of the active protocol within 48 h of initial order, total benzodiazepine dose equivalents administered and associated adverse events. Results: 57% of patients who started on a CIWA-Ar protocol had either zero or one documented risk factor for AWS (19% and 38% respectively). 20% had no documentation of recent alcohol use. 14% were unable to communicate. 19% of medical records lacked documentation of provider awareness of the ordered protocol. Benzodiazepine associated adverse events were documented in 15% of encounters. Conclusions: The judicious use of CIWA-Ar protocols in general hospitals requires mechanisms to ensure assessment of validated alcohol withdrawal risk factors, exclusion of patients who cannot communicate, and continuity of care during transitions.     

Alcohol-related discussions during general medicine appointments of male VA patients who screen positive for at-risk drinking

OBJECTIVE: This study describes primary care discussions with patients who screened positive for at-risk drinking. In addition, discussions about alcohol use from 2 clinic firms, one with a provider-prompting intervention, are compared. DESIGN: Cross-sectional analyses of audiotaped appointments collected over 6 months. PARTICIPANTS AND SETTING: Male patients in a VA general medicine clinic were eligible if they screened positive for at-risk drinking and had a general medicine appointment with a consenting provider during the study period. Participating patients (N=47) and providers (N=17) were enrolled in 1 of 2 firms in the clinic (Intervention or Control) and were blinded to the study focus. INTERVENTION: Intervention providers received patient-specific results of positive alcohol-screening tests at each visit. MEASURES AND MAIN RESULTS: Of 68 visits taped, 39 (57.4%) included any mention of alcohol. Patient and provider utterances during discussions about alcohol use were coded using Motivational Interviewing Skills Codes. Providers contributed 58% of utterances during alcohol-related discussions with most coded as questions (24%), information giving (23%), or facilitation (34%). Advice, reflective listening, and supportive or affirming statements occurred infrequently (5%, 3%, and 5%, of provider utterances respectively). Providers offered alcohol-related advice during 21% of visits. Sixteen percent of patient utterances reflected “resistance” to change and 12% reflected readiness to change. On average, Intervention providers were more likely to discuss alcohol use than Control providers (82.4% vs 39.6% of visits; P=.026). CONCLUSIONS: During discussions about alcohol, general medicine providers asked questions and offered information, but usually did not give explicit alcohol-related advice. Discussions about alcohol occurred more often when providers were prompted. This research was supported by grants from the University of Washington Royalty Research Fund, and the Department of Veterans Affairs, Health Services Research and Development Service (SDR 96-002). Dr. Bradley is an investigator at the VA Puget Sound Health Care System, and is currently supported by National Institute of Alcohol Abuse and Alcoholism grant no. K23AA00313) and is a Robert Wood Johnson Foundation Generalist Physician Faculty Scholar. Views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs, the University of Washington, the National Institute of Alcohol Abuse and Alcoholism, or the Robert Wood Johnson Foundation.     

Nicotine dependence is associated with compulsive alcohol craving

Aims To investigate a possible association of nicotine dependence and alcohol craving. Design A prospective cross‐sectional study on patients diagnosed with alcohol dependence. Setting Detoxification unit of a regional psychiatric hospital. Participants A total of 127 smoking male patients were included in the study at admission for detoxification from alcohol. Measurements The Fagerström Test for Nicotine Dependence (FTND) was used to assess the severity of nicotine dependence while the Obsessive Compulsive Craving Scale (OCDS) was used to measure alcohol craving. The OCDS was assessed at admission and after 7 days of withdrawal treatment, distinguishing the total score, the obsessive and the compulsive subscale. Findings Spearman’s correlation revealed a significant association between the extent of alcohol craving and the FTND score (day 0, n = 127: OCDS total score r = 0.238, P = 0.007; OCDS compulsive score r = 0.280, P = 0.001; day 7; n = 94: OCDS total score r = 0.212, P = 0.040; OCDS compulsive score r = 0.225, P = 0.029). Conclusions The severity of nicotine dependence is associated with higher craving in alcohol‐dependent patients. These results point towards shared pathophysiological mechanisms in alcohol craving and nicotine addiction.     

Craving is associated with amygdala volumes in adolescent marijuana users during abstinence

Background: Amygdala volume abnormalities have been reported in relation to craving in substance-dependent adults, but it remains unclear if these effects are seen in adolescent marijuana (MJ) users, particularly following abstinence. Objectives: The aim of this study was to examine the relationship between amygdala volume and craving during 28 days of abstinence in adolescent MJ users. Methods: MJ-using adolescents (n?=?22) aged 16–19 were recruited as part of a larger study on brain function in teen drug users. Craving measures were collected twice per week throughout a 28-day abstinence period. High-resolution anatomical magnetic resonance imaging data were collected at the end of the 28 days of confirmed abstinence. Left and right amygdala volumes were traced by hand (ICC?>?0.86). Composite scores for self-reported craving and withdrawal symptoms throughout the 28-day abstinence period were calculated to provide four composite measures of total craving, mood, sleep, and somatic complaints. Results: Results revealed that greater craving during abstinence was significantly associated with smaller left and right amygdala volumes, after controlling for age and gender. Other measures of withdrawal, including mood, somatic complaints and sleep problems, were not related to amygdala morphometry. Conclusion: These results are consistent with previous findings in adult alcohol- and cocaine-dependent individuals, who demonstrated a relationship between reduced amygdala volumes and increased craving. Future studies are needed to determine if these brain-behavior relationships are attributable to MJ use or predate the onset of substance use.     

Differences in end-of-life decision making among black and white ambulatory cancer patients

OBJECTIVE: African-American (black) and white individuals have been shown to differ in their desire for life-sustaining treatments and their use of living wills for end-of-life care, but the reasons for these differences are unclear. This study-was designed to test the hypothesis that these ethnic differences exist because black patients trust the health care system less, fear inadequate medical treatment more, and feel less confident that living wills can give them more control over their terminal care. DESIGN: Cross-sectional, in-person survey conducted from November 1993 to June 1994. SETTING: Two medical oncology clinics with 40% to 50% black patient representation. PARTICIPANTS: Ambulatory cancer patients, 92 black and 114 white, who were awaiting their physician visits and agreed to participate (76% of those eligible). Patients were excluded if they were under age 40 or if they had nonmelanoma skin cancer only. MEASUREMENTS AND MAIN RESULTS: Black ambulatory cancer patients wanted more life-sustaining treatments (odds ratio [OR] 2.8; 95% confidence interval [CI] 1.4–5.3), and were less likely to want to complete a living will at some time in the future (OR 0.36; 95% CI 0.17–0.75) than were white patients after controlling for socioeconomic variables. However, these differences were not related to lack of trust or fear of inadequate medical treatment in this study population. Both groups of patients trusted the health care system and felt that physicians treated patients equally well. Neither group feared inadequate or excessive medical care, and the majority of both groups agreed that living wills would help them keep control over their terminal care. CONCLUSIONS: Black and white cancer patients make different end-of-life choices, even after adjusting for likely explanatory variables. The other factors that influence decision making remain unclear and need to be further explored if physicians are to understand and help their patients make choices for end-of-life care. Abstract presented at the Robert Wood Johnson Clinical Scholars Program National Meeting, November 1994. Funded by Robert Wood Johnson Clinical Scholars Program while Dr. McKinley was a Clinical Scholar (July 1992–June 1994).     

A Double-Blind Trial of Gabapentin Versus Lorazepam in the Treatment of Alcohol Withdrawal

Introduction: Some anticonvulsants ameliorate signs and symptoms of alcohol withdrawal, but have an unacceptable side effect burden. Among the advantages of using anticonvulsant agents in this capacity is their purported lack of interaction with alcohol that could increase psychomotor deficits, increase cognitive impairment, or increase intoxication. The aim of this study was to evaluate alcohol use and symptom reduction of gabapentin when compared with lorazepam in the treatment of alcohol withdrawal in a double‐blinded randomized clinical trial. Methods: One hundred individuals seeking outpatient treatment of alcohol withdrawal with Clinical Institute Withdrawal Assessment for Alcohol–Revised (CIWA‐Ar) ratings ≥10 were randomized to double‐blind treatment with 2 doses of gabapentin (900 mg tapering to 600 mg or 1200 tapering to 800 mg) or lorazepam (6 mg tapering to 4 mg) for 4 days. Severity of alcohol withdrawal was measured by the CIWA‐Ar on days 1 to 4 of treatment and on days 5, 7, and 12 post‐treatment and alcohol use monitored by verbal report and breath alcohol levels. Results: CIWA‐Ar scores decreased over time in all groups; high‐dose gabapentin was statistically superior but clinically similar to lorazepam (p = 0.009). During treatment, lorazepam‐treated participants had higher probabilities of drinking on the first day of dose decrease (day 2) and the second day off medication (day 6) compared to gabapentin‐treated participants (p = 0.0002). Post‐treatment, gabapentin‐treated participants had less probability of drinking during the follow‐up post‐treatment period (p = 0.2 for 900 mg and p = 0.3 for 1200 mg) compared to the lorazepam‐treated participants (p = 0.55). The gabapentin groups also had less craving, anxiety, and sedation compared to lorazepam. Conclusions: Gabapentin was well tolerated and effectively diminished the symptoms of alcohol withdrawal in our population especially at the higher target dose (1200 mg) used in this study. Gabapentin reduced the probability of drinking during alcohol withdrawal and in the immediate postwithdrawal week compared to lorazepam.     

Primary care-based ambulatory opioid detoxification

OBJECTIVE: To determine the feasibility of primary care-based ambulatory opioid detoxification (AOD) using two protocols: clonidine and clonidine plus naltrexone. SETTING: The Central Medical Unit (CMU)—a freestanding primary care medical clinic staffed by physicians and nurse practitioners. PATIENTS: Injection drug users (IDUs) seeking substance abuse treatment between the ages of 18 and 50 years who were addicted to opioids (e.g., heroin) and not currently in drug treatment. INTERVENTIONS: In the clonidine protocol, clonidine was administered every 4 hours “as needed” for up to 12 days. In the clonidine plus naltrexone protocol, clonidine was administered and naltrexone was administered in increasing doses over five days. Both protocols included “adjuvant” medications for muscle cramps, insomnia, and vomiting. Successfully detoxified patients were referred to ongoing drug treatment. DESIGN: A prospective nonrandomized clinical trial. MEASUREMENTS AND MAIN RESULTS: One hundred forty opioid-addicted IDUs were referred to the medical clinic for AOD. Among the 125 patients who enrolled in the study, 57 selected clonidine and 68 selected clonidine/naltrexone. The treatment groups (clonidine vs clonidine/naltrexone) were similar at baseline with respect to: age at first heroin use (21 years vs 23 years), mean admission opioid craving score (45/100 vs 49/100), and withdrawal symptom score (19/72 vs 18/72). Overall, 70% (88/125) of the AODs were successful, including 42% (24/57) for clonidine and 94% (64/68) for clonidine/naltrexone (p<0.001). CONCLUSIONS: This study suggests that primary care-based AOD can be safely and effectively carried out by primary care providers and that clonidine/naltrexone may be more effective in this setting than is clonidine alone. Ambulatory opioid detoxification can give internists a larger role in initiating drug treatment for IDUs who are addicted to opioids.     

Improving patient quality of life with feedback to physicians about functional status

OBJECTIVE: To improve functional status among primary care patients. INTERVENTION: 1) Computer-generated feedback to physicians about the patient’s functional status, the patient’s self-reported “chief complaint,” and problem-specific resource and management suggestions; and 2) two brief interactive educational sessions for physicians. DESIGN: Randomized controlled trial. SETTING: University primary care clinic. PARTICIPANTS: All 73 internal medicine houseofficers and 557 of their new primary care patients. MEASURES: 1) Change in patient functional status from enrollment until six months later, using the Functional Status Questionnaire (FSQ); 2) management plans and additional information about functional status abstracted from the medical record; and 3) physician attitude about whether internists should address functional status problems. RESULTS: Emotional well-being scores improved significantly for the patients of the experimental group physicians compared with those of the control group physicians (p<0.03). Limitations in social activities indicated as “due to health” decreased among the elderly (>70 years of age) individuals in the experimental group compared with the control group (p<0.03). The experimental group physicians diagnosed more symptoms of stress or anxiety than did the control group physicians (p<0.001) and took more actions recommended by the feedback form (p<0.02). CONCLUSIONS: Computer-generated feedback of functional status screening results accompanied by resource and management suggestions can increase physician diagnoses of impaired emotional well-being, can influence physician management of functional status problems, and can assist physicians in improving emotional well-being and social functioning among their patients. Supported by the Robert Wood Johnson Foundation. The opinions and conclusions herein are those of the authors and do not necessarily represent the views of the Sepulveda VA, UCLA, CSUF, Rand, or the Robert Wood Johnson Foundation.