Organizational Readiness to Implement System Changes in an Alaskan Tribal Dental Care Organization

INTRODUCTION

Tribal health care systems are striving to implement internal changes to improve dental care access and delivery and reduce health inequities for American Indian and Alaska Native children. Within similar systems, organizational readiness to implement change has been associated with adoption of system-level changes and affected by organizational factors, including culture, resources, and structure.

OBJECTIVES

The objectives of this study were to assess organizational readiness to implement changes related to delivery of evidence-based dental care within a tribal health care organization and determine workforce- and perceived work environment-related factors associated with readiness.

METHODS

A 92-item questionnaire was completed online by 78 employees, including dental providers, dental assistants, and support staff (88% response rate). The questionnaire queried readiness for implementation (Organizational Readiness for Implementing Change), organizational context and resources, workforce issues, organizational functioning, and demographics.

RESULTS

Average scores for the change commitment and change efficacy domains (readiness for implementation) were 3.93 (SD = .75) and 3.85 (SD = .80), respectively, where the maximum best score was 5. Perceived quality of management, a facet of organizational functioning, was the only significant predictor of readiness to implement change (B = .727, SE = .181, P < .0002) when all other variables were accounted for.

CONCLUSION

Results suggest that when staff members (including dentists, dental therapists, hygienists, assistants, and support staff) from a tribal health care organization perceive management to be high quality, they are more supportive of organizational changes that promote evidence-based practices. Readiness-for-change scores indicate an organization capable of institutional adoption of new policies and procedures. In this case, use of more effective management strategies may be one of the changes most critical for enhancing institutional behaviors to improve population health and reduce health inequities.

KNOWLEDGE TRANSFER STATEMENT

The results of this study can be used by clinicians and other leaders implementing changes within dental care organizations. To promote organizational readiness for change and, ultimately, more expedient and efficient adoption of system-level changes by stakeholders, consideration should be given to organizational functioning generally and quality of management practices specifically.

Provider and community perspectives of dental therapists in Alaska's Yukon-Kuskokwim Delta: A qualitative programme evaluation

OBJECTIVES

Dental therapists deliver preventive and basic restorative care and have been practicing since 2006 in Alaska's Yukon-Kuskokwim (YK) Delta. In this qualitative programme evaluation, we documented health providers' and community members' experiences with dental therapy. The goal of the evaluation was to develop a conceptual model of dental care delivery in Alaska Native Communities centred on dental therapists.

METHODS

We developed semi-structured interview scripts and used snowball sampling to recruit 16 health providers with experience providing care in the YK Delta and 125 community members from six YK Delta Communities in 2017 and 2018. The six communities were a stratified convenience sample based on community-level exposure to dental therapists (high, medium and no exposure). Interview data were digitally recorded, transcribed, verified for accuracy and coded inductively into conceptual domains using content analytic methods.

RESULTS

Providers believed individuals living in the YK Delta have benefited from clinic-based restorative care and community-based education provided by dental therapists. The restricted scope of dental therapy practice limits the complexity of care that may be offered to patients. However, community members expressed high satisfaction with the quality of care provided by dental therapists. Community members noted more widespread knowledge and evolving norms about oral health and believed dental therapists are helping to prevent disease and improve quality of life. Participants believed access to dental care for children has improved over the years, but felt that many adults in the YK Delta continue to have unmet needs. A potential barrier to sustained programme effectiveness is low retention of dental therapists in the region, driven primarily by reports that dental therapists feel overworked, stressed and geographically isolated.

CONCLUSIONS

Dental therapists have contributed to the dental care delivery system in Alaska's YK Delta. Future opportunities remain within the system to address the needs of adults, develop strategies to retain dental therapists in the region and incorporate evidence-based, prevention-oriented strategies to improve oral health behaviours and reduce oral diseases.

Alaska Native Children Do Not Prefer Sugar-Sweetened Fruit Drinks to Sugar-Free Fruit Drinks

BACKGROUND

Alaska Native children, including children of Yup'ik descent, consume large volumes of sugar-sweetened fruit drinks, which contain added sugars that contribute to obesity, diabetes, and dental caries. To date, taste preference evaluations have not been conducted on commercially available sugar-free fruit drinks.

OBJECTIVE

The study tested the hypothesis that children would have equal preference for sugar-free and sugar-sweetened fruit drinks.

DESIGN

This was an experimental two-alternative forced-choice paired preference test.

PARTICIPANTS/SETTING

The study focused on a convenience sample of Yup'ik children, aged 7 to 10 years, recruited and enrolled from the Yukon-Kuskokwim Health Corporation dental clinic in Bethel, AK (N=89).

INTERVENTION

Children evaluated four different commercially available sugar-free fruit drinks paired with the sugar-sweetened versions of each flavor. Order of flavor pair presentation was alternated across children, and order of presentation within each of the four pairs was randomized across pairs.

MAIN OUTCOME MEASURES

The outcome was taste preference for the sugar-free versus the sugar-sweetened version of a fruit drink.

STATISTICAL ANALYSES PERFORMED

A test of equivalence was run across all four flavors and separately for each flavor using two one-sided tests.

RESULTS

The data failed to demonstrate equivalence of the sugar-free and sugar-sweetened fruit drinks across all four flavors (P=0.51) or separately for each flavor. However, this was not because of a preference for sugar-sweetened drinks. The preference for sugar-free drinks overall and for each flavor was >50%. Although the lower bounds of the 90% CIs were within the range of equivalence (40% to 60%), the upper bounds were outside the range of equivalence (>60%). According to post hoc analyses, similar preferences were observed for Yup'ik and non-Yup'ik children, boys and girls, and children of different ages.

CONCLUSIONS

Taste preference findings suggest that sugar-free fruit drinks may be a well-tolerated alternative to sugar-sweetened fruit drinks for Yup'ik children in Alaska Native communities.

Assessment of pain-related fear in individuals with chronic painful conditions

Background

Heightened fear and anxiety related to pain may result in emotional and behavioral avoidance responses causing disability, distress, and depression. Fear and anxiety associated with pain can potentially change the course of the pain experience. It is plausible that fear and anxiety related to pain affect the duration and frequency of pain experienced by the patient.

Aim

The study aimed to examine the applicability of the Fear of Pain Questionnaire-III (FPQ-III) in identifying who are likely to report longer duration and greater frequency of pain experience.

Methods

To test this hypothesis, a cross-sectional study was conducted with 579 individuals from a community-based sample living with chronic pain. The factor structure and validity of FPQ-III in the community-based sample were also tested.

Results

The findings suggest higher fear of severe pain but lower fear of medical pain, associated with longer duration and more frequent pain experience. The analysis also confirmed the three-factor structure of FPQ-III, demonstrating good internal consistency for fear of severe pain (0.71) and fear of medical pain (0.73) and acceptable range for fear of minor pain (0.65).

Conclusion

These findings suggest that the FPQ-III can be potentially applied to identify individuals at risk for prolonged continuous pain and as a screening tool to measure fear and anxiety related to pain.

Influence of Fear of Pain and Coping Strategies on Health-Related Quality of Life and Patient-Anticipated Outcomes in Patients With Chronic Pain: Cross-Sectional Study Protocol

Background

Fear of pain and coping strategies are emotional-behavioral responses to pain and are known to play an important role in the development and maintenance of pain. It is highly likely that fear of pain and coping strategies influence each other, potentially affecting the course of chronic pain. To our knowledge, the relationship between pain, fear of pain and coping strategies, and how they influence patient-anticipated outcomes and health-related quality of life, have not been investigated.

Objective

The aims of this study are to test (1) if both fear of pain and/or coping strategies are sufficient causes for maintaining pain; and (2) whether fear of pain influences coping strategies and pain intensity. The study will also examine the impact of fear of pain and coping strategies on health-related quality of life and patient-anticipated outcomes.

Methods

The cross-sectional study will be conducted using an online survey. The Fear of Pain Questionnaire-III (FPQ-III), the Brief Coping Inventory (COPE), and EuroQoL-5d (EQ-5D) validated questionnaires will be used to collect data. Information pertaining to demographic factors, pain-related factors, and patient-anticipated outcomes will also be collected. The study has ethics approval from the Human Research Ethics Committee of the University of Adelaide. Study participants will be individuals aged 18 years and above who are experiencing chronic pain (ie, pain lasting more than 6 months). Effect measure modification technique (EMMM) will be used to examine if fear of pain acts as a moderator or mediator between coping strategies and pain. Simple and multinomial logistic regression analysis will be used to examine the effect of fear of pain and coping strategies on health-related quality of life and patient-anticipated outcomes.

Results

Recruitment began July 2017 and it is anticipated that data collection will be completed by October 2017. Findings from this study will help to extend our understanding of fear of pain and coping strategies, their interaction, and their impact on health-related quality of life and patient-anticipated outcomes.

Conclusions

Fear of pain and coping strategies have significant influence on the experience of chronic pain and its course. This study will help enhance our understanding of the relationship between fear of pain and coping strategies, which may help in developing patient-centered care practices.

Motivational Interviewing as an Adjunct to Cognitive Behavior Therapy for Anxiety Disorders: A Critical Review of the Literature

Cognitive behavior therapy (CBT) is efficaciously and effectively used in the treatment of anxiety disorders; however, as CBT for anxiety routinely utilizes exposure components, clients often experience ambivalence about treatment and their clinicians often must deal with resistance. Motivational Interviewing (MI) is a therapeutic strategy that addresses ambivalence about change in clinical interventions. MI has been applied as an adjunct for treatments such as CBT in order to increase motivation for and commitment to the intervention, especially when components of the treatment may be challenging (e.g., exposure, cognitive restructuring). Though researchers have commented specifically on the use of MI as a supplement to CBT for anxiety disorders, no comprehensive review has systematically assessed the strengths and limitations of extant literature on the topic, nor across anxiety disorders. Findings are summarized from 6 case studies and uncontrolled trials and 11 randomized controlled trials published through March 2016. An integrated critique of this literature also is offered. Limitations and the preliminary nature of the work in this area notwithstanding, it appears that it is feasible to supplement or integrate CBT with MI and that doing so has the potential to improve treatment initiation and engagement, as well as clinical outcomes. A number of directions for future research are addressed, such as determining which MI approaches to implement, with whom, when, and in what contexts.

Fear of Pain Mediates the Association between MC1R Genotype and Dental Fear

Fear of pain is experienced in acute and chronic pain populations, as well as in the general population, and it affects numerous aspects of the orofacial pain experience, including pain intensity, pain-related disability, and pain behavior (e.g., avoidance). A related but separate construct-dental fear-is also experienced in the general population, and it influences dental treatment-seeking behavior and oral and systemic health. Minimal work has addressed the role of genetics in the etiologies of fear of pain and dental fear. Limited available data suggest that variants of the melanocortin 1 receptor (MC1R) gene may predict greater levels of dental fear. The MC1R gene also may be etiologically important for fear of pain. This study aimed to replicate the finding that MC1R variant status predicts dental fear and to determine, for the first time, whether MC1R variant status predicts fear of pain. Participants were 817 Caucasian participants (62.5% female; mean ± SD age: 34.7 ± 8.7 y) taking part in a cross-sectional project that identified determinants of oral diseases at the community, family, and individual levels. Participants were genotyped for single-nucleotide polymorphisms on MC1R and completed self-report measures of fear of pain and dental fear. Presence of MC1R variant alleles predicted higher levels of dental fear and fear of pain. Importantly, fear of pain mediated the relation between MC1R variant status and dental fear (B = 1.60, 95% confidence interval: 0.281 to 3.056). MC1R variants may influence orofacial pain perception and, in turn, predispose individuals to develop fears about pain. Such fears influence the pain experience and associated pain behaviors, as well as fears about dental treatment. This study provides support for genetic contributions to the development/maintenance of fear of pain and dental fear, and it offers directions for future research to identify potential targets for intervention in the treatment of fear of pain and dental fear.

Dental Care-Related Fear and Anxiety: Distress Tolerance as a Possible Mechanism

Distress tolerance, the degree to which one is able to cope with and endure negative emotional states, has been broadly applied to understand and treat a variety of health (including behavioral) problems, but little is known about its role in oral health care and specifically dental care-related fear and anxiety, making it a novel construct in the oral health care literature. This cross-sectional study examined distress tolerance as a possible predictor of dental fear and anxiety among a sample of adults with and without diagnoses of dental phobia, investigated possible differences in levels of distress tolerance between adults with and without dental phobia, and determined possible associations between distress tolerance and fear of pain, anxiety sensitivity, and depression. Using 52 volunteers (n = 31, dental phobia group; n = 21, healthy comparison group), this investigation used self-report measures of distress tolerance, fear of pain, anxiety sensitivity, dental fear, and depression. The Anxiety Disorders Interview Schedule, a semi-structured interview, was used to assess for dental phobia and other psychological disorders. Distress tolerance significantly predicted dental fear and anxiety, even after controlling for age, sex, fear of pain, anxiety sensitivity, and depression. In addition, the dental phobia group had lower distress tolerance than the healthy comparison group. Distress tolerance was significantly associated with fear of pain, anxiety sensitivity, and depression. Findings indicate that low distress tolerance plays a unique and distinct role as a possible mechanism in the genesis of dental care-related fear and anxiety and phobia and may exacerbate the experience of other states, including fear of pain and anxiety sensitivity. Knowledge Transfer Statement: Results indicate that patients who have a lower ability to tolerate emotional and physical distress may have higher levels of dental care-related fear and anxiety and even dental phobia, as well as associated sequelae (e.g., avoidance of dental care). Treatment of highly fearful dental patients may helpfully include a focus on increasing distress tolerance.

Toward a genetic understanding of dental fear: evidence of heritability

OBJECTIVES

Dental fear is a prevalent problem that impacts dental treatment-seeking behavior and thus oral, systemic, and psychological health. Among other important predictors, fear of pain has been shown to be a critical component of dental fear. While learning history (id est, past experience) is known to shape development and maintenance of dental fear and fear of pain, minimal work has addressed genetic etiological variables for these healthcare-related anxieties. With the aim of coming to a more complete conceptualization of dental fear, this study assessed the heritability of dental fear and fear of pain and elucidated the role of genetics in the relation between the constructs.

METHODS

Participants (n = 1370; 827 female), aged 11-74 years (M = 29.2, SD = 12.2), in a family-based cohort study completed measures of dental fear and fear of pain. Heritability and genetic correlation were estimated using likelihood-based methods under the variance components framework.

RESULTS

Dental fear was 30% heritable (P < 0.001) and fear of pain was 34% heritable (P < 0.001). Notably, there was substantial genetic correlation between dental fear and fear of pain, ρ_G = 0.67, suggesting they are genetically related, but likely are distinct phenotypes.

CONCLUSIONS

It is clear that, in addition to environmental factors, genetic influences are important in the etiology of dental fear and anxiety and should be considered in future studies of fear and anxiety associated with dental treatment and, potentially, interventions aimed at reducing distress that is a barrier to dental treatment utilization.

Depression and Rural Environment are Associated With Poor Oral Health Among Pregnant Women in Northern Appalachia

Both oral health problems and depression among pregnant women contribute to maternal-infant health outcomes. Little is known, however, about the potential effects of clinically significant depression on the oral health status of pregnant women. The purpose of the present study was to determine the influence of clinically significant depression and rural- or urban-dwelling status on oral health outcomes among pregnant women. Pregnant women (N = 685) in rural (i.e., West Virginia) and urban (i.e., Pittsburgh, PA) areas of northern Appalachia were assessed by calibrated examiners regarding gingivitis, oral hygiene, and DMFT (decayed, missing, and filled teeth), completed the Center for Epidemiologic Studies-Depression Scale (CES-D) and provided demographics. Participants were categorized based on clinically significant depressive symptoms (CES-D ≥ 16) and rural/urban domicile. Women with depression and those living in rural areas had worse oral health on all three indices than their non-depressed and urban counterparts. Depression, particularly among women in rural areas, affects certain oral health indices and represents a modifiable target for intervention. Moreover, treatments designed specifically for rural populations may be of particular utility. Women who are pregnant or planning to become pregnant may benefit from regular depression screenings from their dental and medical health care providers.

Collecting psychosocial self-report data in oral health research: impact of literacy level and computerised administration

OBJECTIVES

In oral and other health research, participant literacy levels may impact the quality of data obtained through self-report (e.g., degree of data missingness). This study addressed whether computerized administration of a battery of psychosocial instruments used in an oral health disparities research protocol yielded more complete data than paper-and-pencil administration and aimed to determine the role of general literacy in differences in data missingness between administration types.

DESIGN

Oral health data were obtained from 1,652 adolescent and adult participants who were administered a large questionnaire battery via either paper-and-pencil or tablet personal computer. Number of unanswered items for each participant was compared across administration mode. For a subset of 171 participants who were randomized to one of the administration modes, general literacy and satisfaction with the questionnaire experience also were assessed.

RESULTS

Participants assigned to complete the oral health questionnaire battery via tablet PC were significantly more likely than those assigned to the paper-and-pencil condition to have missing data for at least one item (p < .001); however, for participants who had at least one missing item, paper-and-pencil administration was associated with a greater number of items missed than was tablet PC administration (p < .001). Across administration modes, participants with higher literacy level completed the questionnaire battery more rapidly than their lower literacy counterparts (p < .001). Participant satisfaction was similar for both modes of questionnaire administration (p ≥ .29).

CONCLUSIONS

These results suggest that a certain type of data missingness may be decreased through the use of a tablet computer for questionnaire administration.

Patternable nanowire sensors for electrochemical recording of dopamine

Spatially resolved electrochemical recording of neurochemicals is difficult due to the challenges associated with producing nanometer-scale patternable and integrated sensors. We describe the lithographic fabrication and characterization of patternable gold (Au) nanowire (NW) based sensors for the electrochemical recording of dopamine (DA). We demonstrate a straightforward NW-size-independent approach to align contact pads to NWs. Sensors, with NW widths as small as 30 nm, exhibited considerable insensitivity to scan rates during cyclic voltammetry, a nonlinear increase in oxidation current with increasing NW width, and the selectivity to measure submaximal synaptic concentrations of DA in the presence of interfering ascorbic acid. The electrochemical sensitivity of Au NW electrode sensors was much larger than that of Au thin-film electrodes. In chronoamperometric measurements, the NW sensors were found to be sensitive for submicromolar concentration of DA. Hence, the patternable NW sensors represent an attractive platform for electrochemical sensing and recording.

Only male mice show sensitization of handling-induced convulsions across repeated ethanol withdrawal cycles

BACKGROUND

Alcohol abuse, especially when experienced in multiple cycles of chronic abuse and withdrawal, leads to a sensitization of central nervous system hyperexcitability that may culminate in overt expression of seizures. In spite of the growing prevalence of alcohol abuse and dependence in females shown in recent epidemiologic studies, evidence of sexual dimorphism in the expression of alcohol withdrawal-induced seizures and the development of seizure sensitization following multiple cycles of ethanol (EtOH) exposure and withdrawal has not been examined in either animal models or in clinical reports.

METHODS

Subjects in these experiments were male and female C3H/Hecr mice. The female mice were intact or ovariectomized, with ovariectomized mice receiving 17-beta-estradiol or placebo pellets. All mice were exposed to 4 cycles of exposure to 16-hour EtOH vapor, separated by 8-hour withdrawal periods. During each 8-hour withdrawal, hourly assessment of seizure propensity was assessed as handling-induced convulsions. Additional assessments were taken up to 72 hours after the final EtOH withdrawal cycle.

RESULTS

Male and female mice showed similar seizure propensity during an initial withdrawal from chronic EtOH. Across subsequent withdrawal cycles, however, male mice exhibited a robust increase in seizure severity beginning with the third withdrawal cycle. In marked contrast, female mice failed to demonstrate sensitization of seizure severity. The lack of seizure sensitization following up to 4 cycles of alcohol exposure and withdrawal could not be explained by hormonal status (presence or absence of estrogen) or by sex differences in blood alcohol levels.

CONCLUSIONS

Male and female mice exposed to the same number of cycles of EtOH withdrawal demonstrate differences in expression of seizures. Males show the typical sensitization of seizures, or kindling response, which has been reported clinically as well as in animal models, but females do not. The reason for the lack of seizure sensitization in female mice remains to be elucidated, but may be related to sex differences in alcohol effects on excitatory/inhibitory neurotransmission, rather than to hormonal or blood alcohol level differences.

Paroxetine for social anxiety and alcohol use in dual-diagnosed patients

The objective of this study was to compare the efficacy and tolerability of paroxetine to matched placebo in adults with co-occurring social anxiety disorder and alcohol use disorder. Outcome measures included standardized indices of social anxiety and alcohol use. Fifteen individuals meeting DSM-IV criteria for both social anxiety disorder and alcohol use disorder were randomized to treatment. Paroxetine (n = 6) or placebo (n = 9) was given in a double-blind format for 8 weeks using a flexible dosing schedule. Dosing began at 20 mg/d and increased to a target dose of 60 mg/d. There was a significant effect of treatment group on social anxiety symptoms, where patients treated with paroxetine improved more than those treated with placebo on both the Clinical Global Index (CGI) and the Liebowitz Social Anxiety Scale (Ps < or = 0.05). On alcohol use, there was not a significant effect of treatment on quantity/frequency measures of drinking, but there was for the CGI ratings (50% paroxetine patients versus 11% placebo patients were improvers on drinking, P < or = 0.05). This pilot study suggests that paroxetine is an effective treatment for social anxiety disorder in individuals with comorbid alcohol problems, and positive treatment effects can be seen in as little as 8 weeks. Further study is warranted to investigate its utility in helping affected individuals reduce alcohol use.

Alcohol and pregnancy: highlights from three decades of research

The detrimental effects of alcohol on offspring have been alluded to for centuries, although only in the past few decades has the relationship between alcohol and birth defects been shown conclusively. This review article begins with a historical overview of the understanding of alcohol's effects on the offspring, followed by a description of the first clinical reports of fetal alcohol syndrome. The contribution of animal models is highlighted and some possible mechanisms of alcohol's teratogenicity are discussed. Challenges and opportunities for future research are offered.

Gender comparison in alcoholics with concurrent social phobia: implications for alcoholism treatment

The present study compares male and female alcoholics with concurrent social phobia (N = 110) enrolled in an alcohol treatment study. Groups were compared using demographics, social phobia symptoms and severity, and psychiatric variables. Results showed that females reported higher fear ratings than males on some social phobia measures, although for the most part, the genders were more similar than different on social phobia symptoms and severity. There was a high occurrence of psychiatric comorbidity, especially for females. Females also reported more distress than males in family and social functioning. The results are discussed in terms of their implications for treatment for individuals with concurrent alcoholism and social phobia.

Concurrent alcoholism and social anxiety disorder: a first step toward developing effective treatments

BACKGROUND

Social anxiety disorder (also called social phobia) is an anxiety disorder in which affected individuals fear the scrutiny of others. Clinical reports suggest that individuals with social anxiety disorder often use alcohol to alleviate anxiety symptoms, a practice that leads to alcohol abuse and/or dependence in approximately 20% of affected individuals. The present study investigated whether simultaneous treatment of social phobia and alcoholism, compared with treatment of alcoholism alone, improved alcohol use and social anxiety for clients with dual diagnoses of social anxiety disorder and alcohol dependence.

METHODS

The design was a two-group, randomized clinical trial that used 12 weeks of individual cognitive behavioral therapy for alcoholism only (n = 44) or concurrent treatment for both alcohol and social anxiety problems (n = 49). Outcome data were collected at the end of 12 weeks of treatment and at 3 months after the end of treatment.

RESULTS

Results with intent-to-treat analyses showed that both groups improved on alcohol-related outcomes and social anxiety after treatment. With baseline scores covaried, there was a significant effect of treatment group on several drinking measures. Counter to the hypothesis, the group treated for both alcohol and social anxiety problems had worse outcomes on three of the four alcohol use indices. No treatment group effects were observed on social anxiety indices.

CONCLUSIONS

Implications for the staging of treatments for coexisting social phobia and alcoholism are discussed, as well as ways that modality of treatments might impact outcomes.

Cognitive behavioral therapy delays relapse in female socially phobic alcoholics

The present study was conducted to test the hypothesis that socially phobic alcoholics treated with Cognitive Behavioral therapy (CBT) will have better drinking outcomes than those treated with Twelve-Step Facilitation therapy (TSF). Three hundred ninety-seven treatment-seeking alcoholics with concurrent social phobia were compared retrospectively to a matched sample of 397 alcoholics without social phobia. Treatment was delivered in an outpatient setting, and patients were randomized to either CBT, TSF, or Motivational Enhancement therapy (MET). The groups were compared on self-reported drinking measures (e.g., quantity and frequency of drinking, and time-to-event measures) during treatment period and monthly for 1 year following treatment. Survival analyses revealed that female outpatients with social phobia showed delayed relapse to drinking when treated with CBT rather than TSF; the reverse was true for female outpatients without social phobia. Survival analyses in male outpatients with and without social phobia revealed an opposite trend, though it was not statistically significant. These data suggest that Cognitive Behavioral therapy is superior to Twelve-Step Facilitation therapy for the treatment of alcohol problems in specific populations. namely socially phobic women seeking outpatient treatment.

Progesterone and prostaglandin H synthase-2 involvement in alcohol-induced preterm birth in mice

BACKGROUND

Recently, an association between alcohol consumption during pregnancy and shortened gestational length has been reported, but the underlying mechanisms remain unknown. Progesterone (P4) and prostaglandins have been shown to play important roles in parturition in both human and animal models. Recently, it has been suggested that prostaglandin H synthase-2 (PGHS-2) is responsible for prostaglandin changes associated with term and preterm labor. It is possible that alcohol induces preterm birth by altering P4 or PGHS-2 levels. These studies were designed to determine the role of P4 and PGHS-2 in alcohol-induced preterm labor in mice.

METHODS

Experiment 1: Pregnant dams treated with either vehicle or alcohol (6 g/kg, intragastrically) on gestational day (GD) 16 were killed at various times in gestation up to the time of delivery. Plasma P4 levels were measured by radioimmunoassay and uterine PGHS-2 mRNA expression was measured by Ribonuclease Protection Assay. Results indicated that alcohol treatment was associated with an earlier decline in plasma P4 levels and an earlier rise in uterine PGHS-2 mRNA levels during gestation. Experiment 2: Pregnant C57BL/6J females were treated with either P4 (2.0 mg, subcutaneously) or vehicle (sesame oil) 2 hr before receiving either 6 g/kg alcohol (intragastrically) or vehicle (isocaloric sucrose) on gestational day (GD) 16. Results indicate that P4 pretreatment effectively antagonized alcohol-induced preterm delivery. Experiment 3: On GD16, pregnant dams received either 100 mg/kg nimesulide (a specific PGHS-2 inhibitor) or vehicle (saline) subcutaneously, 2 hr before treatment with either 6 g/kg alcohol (given intragastrically) or isocaloric sucrose. Nimesulide was effective in antagonizing alcohol-induced preterm labor.

CONCLUSIONS

Together, these data suggest that both P4 and PGHS-2 may play roles in alcohol-induced preterm birth.

Alcohol plus cocaine prenatally is more deleterious than either drug alone

A C57BL/6J mouse model was used to examine the coteratology of alcohol and cocaine. Plugged female mice were assigned to one of four treatment groups: control, cocaine only, alcohol only, or alcohol-cocaine. Experimental animals were treated from gestation day (GD) 6-18 and were killed the morning of GD 19. Alcohol was administered in a liquid diet containing 25% ethanol-derived calories (25% EDC), and cocaine was administered daily in subcutaneous injections of 60 mg/kg. All groups were pair-fed to the alcohol-cocaine group. The results showed that the cocaine-only and the alcohol-cocaine group had fewer successful pregnancies. The alcohol-only group had the lowest maternal weight gain from GD 1-19. There were no treatment group effects on litter size, sex ratio, or prenatal mortality. Importantly, fetuses in the alcohol-cocaine group weighed less than all other groups and had the greatest occurrence of fetal anomalies. These data confirm the teratogenic effects of alcohol and cocaine and suggest that the combination of the two drugs, if administered chronically, is more deleterious to pregnancy and fetal outcome than either drug alone.

Alcoholics with and without social phobia: a comparison of substance use and psychiatric variables

OBJECTIVE

While alcoholics with social phobia comprise a substantial portion of the alcoholic population, little is known about how they differ from alcoholics without social phobia in their substance use and psychiatric health. The present study was conducted to examine baseline differences between alcoholics with and without social phobia on substance use and psychiatric variables.

METHOD

Alcoholics without social phobia (n = 397) were chosen to match those with social phobia (n = 397) on several variables, including age and gender. All subjects were participants in Project MATCH, a large clinical client-treatment matching study.

RESULTS

Exploratory/Confirmatory analyses revealed that alcoholics with social phobia had higher scores on the alcohol dependence scale and endorsed more dependence symptoms on the SCID, although they did not drink greater amounts or more often than alcoholics without social phobia. They also reported drinking in order to improve sociability and enhance functioning more than did the comparison group. Alcoholics with social phobia were more likely to conform to social norms than alcoholics without social phobia. They also had more symptoms of depression as indicated by higher scores on the Beck Depression Inventory and higher incidence of a major depressive episode from the C-DIS.

CONCLUSIONS

Alcoholics with social phobia enter treatment with some problems that are more severe than those expressed by alcoholics without social phobia. Whether these problems affect treatment efficacy is an important area for future research.

Gender differences in substance use disorders

Despite the fact that the rate of substance abuse and dependence is higher among men than it is among women, the prevalence rates, especially the more recent ones, indicate that a diagnosis of substance abuse is not gender specific. From the emerging literature on gender differences over the past 25 years, male and female substance abusers are clearly not the same. Women typically begin using substances later than do men, are strongly influenced by spouses or boyfriends to use, report different reasons for maintaining the use of the substances, and enter treatment earlier in the course of their illnesses than do men. Importantly, women also have a significantly higher prevalence of comorbid psychiatric disorders, such as depression and anxiety, than do men, and these disorders typically predate the onset of substance-abuse problems. For women, substances such as alcohol may be used to self-medicate mood disturbances, whereas for men, this may not be true. Although these comorbid disorders might complicate treatment for women, women are, in fact, responsive to treatment and do as well as men in follow-up. Gender differences and similarities have significant treatment implications. This is especially true for the telescoping phenomenon, in which the window for intervention between progressive landmarks is shorter for women than for men. This is also true for the gender differences in physical and sexual abuse, as well as other psychiatric comorbidity that is evident in female substance abusers seeking treatment. The barriers to treatment for women are being addressed in many treatment settings to encourage more women to enter treatment, and family and couples therapy are standard therapeutic interventions. Negative consequences associated with substance abuse are different for men and women, and gender-sensitive rating instruments must be used to measure not only the severity of the problem but also to evaluate treatment efficacy. To determine whether gender differences observed over the past 25 years become less demarcated in comparisons of younger cohorts of substance abusers in the future will be interesting. Changing societal roles and attitudes toward women, the increase in women entering the workplace, in general, and into previously male-dominated sports and professions, in particular, may influence not only opportunities to drink but also drinking culture. Some gender differences likely will remain, but other gender differences will probably also emerge. The comparison of male and female substance abusers promises to be a fruitful one for researchers. The translation if the research findings to the treatment community to improve treatment outcome for both sexes will be an equally exciting challenge for the field.

Telescoping of landmark events associated with drinking: a gender comparison

OBJECTIVE

The literature suggests that women exhibit "telescoped" development of (i.e., faster progression to) alcoholism, with fewer years drinking than men. The purpose of this study was to use data gathered in the course of a large clinical trial to further examine this issue.

METHOD

Subjects in this retrospective study were from a pool of 1,307 men and 419 women enrolled in Project MATCH, a multisite alcohol treatment matching study. MATCH subjects were recruited from both outpatient and aftercare settings over a 2-year period. Age-of-onset for landmark events in the development of alcoholism were determined from self-report and clinical interviews given at baseline entry into the study. Gender differences in age-of-onset variables were assessed within both outpatient and aftercare settings. Gender differences in progression times between successive landmarks were also examined. Differences were tested with both multivariate and univariate ANOVA techniques.

RESULTS

Women generally began getting drunk regularly at a later average age than men (26.6 versus 22.7 years, p< or =.001), began experiencing their first drinking problems at a later average age than men (27.5 versus 25.0 years, p< or =.001) and exhibited loss of control over their drinking at a later average age than men (29.8 versus 27.2 years, p< or =.001). However, these gender differences were most pronounced for older individuals and attenuated for younger subjects. Women also progressed faster than men, on average, between first getting drunk regularly and first encountering drinking problems (0.9 versus 2.3 years, p< or =.001) and between first loss of drinking control and onset of worst drinking problems (5.5 versus 7.8 years, p< or =.001). Women also exhibited shorter average progression times between first getting drunk regularly and first seeking treatment (11.6 versus 15.8 years, p< or =.001), although this effect was negligible for younger subjects.

CONCLUSIONS

Telescoping is a relatively robust phenomenon in treatment-seeking alcoholics and indicates that women are more likely to progress faster through the landmark events in the development of alcoholism than are men.