Superior outcome of females over males after brief treatment for the reduction of heavy drinking

Duration of therapy - Does it matter?: A systematic review and meta-regression of the duration of psychosocial treatments for alcohol use disorder

BACKGROUND

The recommendations in clinical guidelines for duration of therapy for alcohol use disorder (AUD) are based on consensus decisions. In reality, we do not know the optimal duration of an alcohol treatment course.

METHODS

A systematic review and meta-regression of randomized controlled trials of psychosocial treatment in alcohol outpatient treatment centers. The population consisted of adults suffering from AUD, treated in an outpatient facility with at least two sessions of therapy. Meta-regression analysis was performed with treatment outcome as a function of duration of therapy across studies. Treatment outcome was defined as long-term alcohol use measured in percentage of days abstinent (PDA), percentage of heavy days drinking (PHD), and/or proportion of participants abstinent (ABS).

RESULTS

48 studies encompassing 8984 participants. Mean planned duration of therapy: 18 (8-82) weeks and 14 (2-36) sessions. Mean actual attended sessions: 9 (1-26). Mean follow-up time: 43 (8-104) weeks with a mean of 6 (2-18) research assessments. Neither planned weeks, duration of sessions, frequency of sessions per week, nor actual attended sessions were associated with long-term alcohol use outcomes. However, frequency of research assessments was positively associated with PDA and PHD.

CONCLUSION

No associations between long-term alcohol use outcomes and planned or actual attended duration of psychosocial treatment in outpatient care. Research assessments and, accordingly, the research project in itself may influence outcome in studies of psychosocial treatment for alcohol use disorder.

Kontrolliertes Trinken bei Alkoholkonsumstörungen: Eine systematische Übersicht

Hintergrund: Verhaltenstherapeutische Behandlungen zum selbstkontrollierten Trinken (KT) wurden in den letzten 50 Jahren vielfältig erforscht. Eine aktuelle Übersicht über den gegenwärtigen Status dieses Ansatzes liegt nicht vor. Fragestellung: Es wird ein systematischer Überblick über die Konzept- und Forschungsgeschichte des KT (Definition, theoretische Wurzeln, Behandlungsmethoden), Wirksamkeit von KT-Behandlung (inkl. Prognosefaktoren) sowie Implementierung von KT in das Behandlungssystem (Akzeptanz und Verbreitung) vorgenommen. Methodik: Gemäß den PRISMA Richtlinien wurde in den Datenbanken PsycINFO, Medline und Psyndex nach psychologischen Behandlungen zum selbstkontrollierten Alkoholkonsum bei Menschen mit klinisch relevanten Alkoholproblemen recherchiert und 676 einschlägige Beiträge identifiziert. Ergebnisse: KT wird als regelgeleitet-planvoller Alkoholkonsum definiert. Seine theoretischen Wurzeln reichen von Lerntheorien bis zur Psychologie der Selbstregulation. In der Behandlung haben Behavioral Self-Control Trainings frühere Methoden (z. B. aversive Konditionierung, Kontingenzmanagement und Reizexposition) abgelöst. Einzel und Gruppenbehandlungen sowie Selbsthilfemanuale zum KT erweisen sich über das gesamte Spektrum des problematischen Alkoholkonsums als kurz- und langfristig wirksam zur Reduktion des Alkoholkonsums und alkoholassoziierter Probleme wie auch zur Förderung des Übergangs zur Abstinenz. Prognostisch bedeutsam sind v. a. der Zielentscheid des Patienten pro KT und seine Zuversicht in die Realisierbarkeit von KT. Akzeptanz und Verbreitung von KT haben in den letzten Jahrzehnten zugenommen und variieren u. a. länderspezifisch. Schlussfolgerungen: Angesichts der Wirksamkeit von KT-Behandlungen sowie gesundheitspolitischer, ethischer, therapeutischer und ökonomischer Überlegungen sollten Reduktionsbehandlungen gleichrangig neben Abstinenzbehandlungen in ein zieloffen ausgerichtetes Behandlungssystem integriert werden.

A research agenda for gender and substance use disorders in the emergency department

For many years, gender differences have been recognized as important factors in the etiology, pathophysiology, comorbidities, and treatment needs and outcomes associated with the use of alcohol, drugs, and tobacco. However, little is known about how these gender-specific differences affect ED utilization; responses to ED-based interventions; needs for substance use treatment and barriers to accessing care among patients in the ED; or outcomes after an alcohol-, drug-, or tobacco-related visit. As part of the 2014 Academic Emergency Medicine consensus conference on "Gender-Specific Research in Emergency Care: Investigate, Understand and Translate How Gender Affects Patient Outcomes," a breakout group convened to generate a research agenda on priority questions related to substance use disorders.

Impact of gender on patient preferences for technology-based behavioral interventions

Introduction:

Technology-based interventions offer an opportunity to address high-risk behaviors in the emergency department (ED). Prior studies suggest behavioral health strategies are more effective when gender differences are considered. However, the role of gender in ED patient preferences for technology-based interventions has not been examined. The objective was to assess whether patient preferences for technology-based interventions varies by gender.

Methods:

This was a secondary analysis of data from a systematic survey of adult (≥18 years of age), English-speaking patients in a large urban academic ED. Subjects were randomly selected during a purposive sample of shifts. The iPad survey included questions on access to technology, preferences for receiving health information, and demographics. We defined “technology-based” as web, text message, e-mail, social networking, or DVD; “non-technology-based” was defined as in-person, written materials, or landline. We calculated descriptive statistics and used univariate tests to compare men and women. Gender-stratified multivariable logistic regression models were used to examine associations between other demographic factors (age, race, ethnicity, income) and technology-based preferences for information on specific risky behaviors.

Results:

Of 417 participants, 45.1% were male. There were no significant demographic differences between men and women. Women were more likely to use computers (90.8% versus 81.9%; p=0.03), Internet (66.8% versus 59.0%; p=0.03), and social networks (53.3% versus 42.6%; p=0.01). 89% of men and 90% of women preferred technology-based formats for at least type of health information; interest in technology-based for individual health topics did not vary by gender. Concern about confidentiality was the most common barrier to technology-based use for both genders. Multivariate analysis showed that for smoking, depression, drug/alcohol use, and injury prevention, gender modified the relationship between other demographic factors and preference for technology-based health information; e.g., older age decreases interest in technology-based information for smoking cessation in women but not in men (aOR 0.96, 95% CI 0.93-0.99 versus aOR 1.00, 95% CI 0.97-1.03).

Conclusion:

Our findings suggest ED patients' gender may affect technology preferences. Receptivity to technology-based interventions may be a complex interaction between gender and other demographic factors. Considering gender may help target ED patient populations most likely to be receptive to technology-based interventions.

Reduced-risk drinking as a viable treatment goal in problematic alcohol use and alcohol dependence

This review describes and discusses studies related to reduced-risk drinking as an additional treatment option for patients with problematic alcohol use and alcohol dependence. The review provides some empirical support for the following statements: (a) reduced-risk drinking is a viable option for at least some problem and dependent drinkers; (b) abstinence and non-abstinence-based treatments appear to be equally effective; (c) allowing patients to choose their treatment goal increases the success rate. The relatively short follow-up period (1-2 years) of the studies hampers a proper evaluation of the added value of the reduced-risk drinking approach.

Advancing sex and gender competency in medicine: sex & gender women's health collaborative

Research conducted to date has deepened our understanding of sex and gender differences in the etiology, diagnosis, treatment, and outcomes for many conditions that affect both women and men. The Sex and Gender Women’s Health Collaborative (SGWHC) is supported by the coordinated efforts of our founding partners: the American Medical Women’s Association, the American College of Women’s Health Physicians and Society for Women’s Health Research to address the gaps in medical education with regard to sex and gender competency in the care of women. The SGWHC initiated and continues to build a novel digital resource library of sex and gender specific materials to be adopted and adapted into medical education and clinical practice, residing @ http://www.sgwhc.org. This article presents a case for the inclusion of sex and gender focused content into medical curricula and describes a means for students, faculty, and practitioners to access a centralized, interactive repository for these resources.

Effectiveness of a Feedback-Based Brief Intervention to Reduce Alcohol Use in Community Substance Use Disorders

Feedback brief interventions for alcohol use problems have been highly effective with undergraduate populations. However, there has been little research on the effectiveness of administering feedback alone to community treatment populations. The goal of the current study was to assess the effectiveness of a feedback brief intervention in a community treatment setting with patients characterized largely by dependence on alcohol and drugs, ethnic diversity, and low socioeconomic status. It was hypothesized that pre-treatment brief individualized feedback would reduce alcohol consumption and increase participation in subsequent treatment for a substance use disorder (SUD). Participants were recruited from a public hospital's SUD clinic. After the intake but prior to entry into the treatment as usual, 121 participants were randomized to receive personalized feedback or a condition without feedback. Eighty-seven participants completed post-intervention follow-up interviews and were included in the final analyses. Repeated measures ANOVAs and MANCOVAs were used to examine variables obtained from the Addiction Severity Index (ASI; McLellan et al., 1992) of drinking quantity and frequency, and motivation for treatment. Results indicated that personalized feedback delivered no benefit beyond that of pre-treatment assessment procedures (phone screening and intake interview) alone. Intervention conditions did not differ on other outcomes at follow-up, including days of heavy drinking, motivation for treatment, or drug use frequency. Therefore, feedback-based brief interventions may be not helpful in reducing the drinking frequency and intensity of individuals presenting to community-based substance use treatment.

Focusing a gender lens on emergency medicine research: 2012 update

The influence of sex and gender on patient care is just being recognized in emergency medicine (EM). Providers are realizing the need to improve outcomes for both men and women by incorporating sex- and gender-specific science into clinical practice, while EM researchers are now beginning to study novel sex- and gender-specific perspectives in the areas of acute care research. This article serves as an update on the sex differences in a variety of acute clinical care topics within the field of EM and showcases opportunities for improving patient care outcomes and expanding research to advance the science of gender-specific emergency care.

Gender, violence and brief interventions for alcohol in the emergency department

BACKGROUND

The impact of gender and violence on brief interventions (BIs) for alcohol use in the emergency department (ED) has not been studied. Our objective was to examine the effectiveness of alcohol BIs in an ED population stratified by gender and violence.

METHODS

This was a secondary analysis of datasets pooled from three ED-based randomized controlled studies of alcohol BIs. AUDIT-C was the primary outcome measure; secondary outcomes were binge drinking and achievement of NIAAA safe drinking levels. We conducted univariate comparisons and developed generalized linear models (GLM) for the primary outcome and generalized estimating equation (GEE) models for secondary outcomes to examine the intervention effect on the whole study group, gender-stratified subgroups, and gender- and violence-stratified subgroups.

RESULTS

Of 1219 participants enrolled, 30% were female; 31% of women and 42% of men reported violence involvement at baseline. In univariate analysis, no differences in outcomes were found between intervention and control groups for any subgroup. However, in multivariable models, men demonstrated an intervention effect for likelihood of safe drinking limits. Stratifying further by violence, only men without violence involvement demonstrated a positive intervention effect for safe drinking limits. There was no evidence of an intervention effect on women.

CONCLUSIONS

Analyzing the overall effect of ED-based BI may mask its ability to improve alcohol-related outcomes in a subset of the population. Alternatively, interventions may need to be significantly improved in subsets of the ED population, e.g., in women and in men with involvement in violence.

Use of treatment strategies in a moderated drinking program for women

Little is known about the extent to which individuals participating in drinking reduction interventions use the drinking reduction strategies presented during treatment. In consideration of this issue, we advanced hypotheses about the impact of baseline drinking patterns on strategy use and the relationship of strategy use to drinking patterns over time. One hundred forty-four women who participated in a 10-week drinking reduction program were monitored over an 18-month posttreatment follow-up period. Results indicated that the frequency of baseline heavy drinking days and the frequency of baseline abstinent/light drinking days negatively predicted drinking reduction strategy use during treatment. Over the follow-up period, strategy use decreased; however, participants who received booster sessions had higher strategy use during the initial phase of follow-up. Although cross-lagged panel analysis revealed that strategy use during treatment predicted abstinent/light days at the 6-month follow-up assessment, this effect was moderated by baseline drinking patterns. These data indicated that the use of drinking reduction strategies is predictive of subsequent reduced drinking only in the early posttreatment period and only for baseline heavier drinkers. Future research is needed to further specify the interplay of strategy use and drinking outcomes and to develop interventions designed to encourage the continued use of strategies over extended periods of time.

Sex differences in alcohol misuse and estimated blood alcohol concentrations among emergency department patients: implications for brief interventions

OBJECTIVES

The objective was to assess the relationship between alcohol use and misuse and patient sex among emergency department (ED) patients by comparing self-reported estimates of quantity and frequency of alcohol use, estimated blood alcohol concentrations (eBACs) when typically drinking and during heavy episodic drinking (binging), and alcohol misuse severity, to understand sex differences in alcohol use and misuse for this population.

METHODS

The authors surveyed a random sample of nonintoxicated, subcritically ill or injured, 18- to 64-year-old English- or Spanish-speaking patients on randomly selected dates and times at two EDs during July 2009 and August 2009. Participants self-administered a questionnaire about their self-reported alcohol use during a typical month within the past 12 months and the Alcohol Use Disorders Identification Test (AUDIT). Using the formulae by Matthews and Miller, sex-specific eBACs were calculated for participants according to their reported weight and the number of reported alcoholic drinks consumed on days when typically drinking and on days of heavy episodic (binge) drinking (five or more drinks/occasion for men, four or more drinks for women). Sex-specific alcohol misuse severity levels (low-risk, harmful, hazardous, and dependence) were calculated using AUDIT scores. Wilcoxon rank-sum and Pearson's chi-square tests were used to compare outcomes by sex. Negative binomial regression was used to assess the relationship between sex and the number of drinks consumed on a typical day, the number of days spent drinking and binging, and estimated AUDIT scores. Logistic regression was used to assess the outcome of the presence of binging according to sex. Multinomial logistic regression was used to compare by sex the percentage of days spent drinking and binging in 1 month, eBACs when typically drinking and when binging, and AUDIT at-risk drinking levels. Incidence rate ratios (IRRs) and adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were estimated. All models were adjusted for patient demographic characteristics.

RESULTS

Of the 513 participants, 52.1% were women, 55.8% were white non-Hispanic, and their median age was 34 years (interquartile range [IQR] = 25 to 46 years). Men reported greater mean alcohol consumption than women when typically drinking (4.3 vs. 3.3 drinks/day; p < 0.001) and during heavy episodic drinking (8.6 vs. 5.3 drinks/occasion; p < 0.001). Men spent more days drinking (IRR = 1.41, 95% CI = 1.19 to 1.65) and engaging in heavy episodic drinking (IRR = 1.68, 95% CI = 1.31 to 2.17) than women. Additionally, men were more likely to engage in heavy episodic drinking (AOR = 1.72, 95% CI = 1.16 to 2.56) than women. However, the mean eBACs for men and women were similar when typically drinking (0.05 vs. 0.06; p < 0.13) and during heavy episodic drinking (0.13 vs. 0.12; p < 0.13). Mean AUDIT scores were greater for men than women (7.5 vs. 5.3; p < 0.001), although alcohol misuse severity levels were similar between men and women (24.4% vs. 26.6% for hazardous, 2.8% vs. 2.2% for harmful, and 6.5% vs. 3.4% for dependence; p < 0.38).

CONCLUSIONS

Although men drink more than women, women have similar eBACs with comparable levels of alcohol misuse. Women may benefit from recognizing that they are reaching similar levels of intoxication compared to men. Addressing these differences and possible health implications in future ED brief interventions may induce changes in problematic alcohol use among women.

Prevention of fetal alcohol spectrum disorders

Alcohol use among women of childbearing age is a leading, preventable cause of birth defects and developmental disabilities in the United States. Although most women reduce their alcohol use upon pregnancy recognition, some women report drinking during pregnancy and others may continue to drink prior to realizing they are pregnant. These findings emphasize the need for effective prevention strategies for both pregnant and nonpregnant women who might be at risk for an alcohol-exposed pregnancy (AEP). This report reviews evidence supporting alcohol screening and brief intervention as an effective approach to reducing problem drinking and AEPs that can lead to fetal alcohol spectrum disorders. In addition, this article highlights a recent report of the National Task Force on Fetal Alcohol Syndrome and Fetal Alcohol Effect that describes effective interventions to reduce alcohol use and AEPs, and outlines recommendations on promoting and improving these strategies. Utilizing evidence-based alcohol screening tools and brief counseling for women at risk for an AEP and other effective population-based strategies can help achieve future alcohol-free pregnancies.

Use of Mental Health and Substance Abuse Treatment Services by Female Injection Drug Users

This article examines whether female injection drug users (IDUs) who have a history of using mental health services (i.e., one or more psychiatric hospitalizations or counseling) enter types of drug treatment different from those of female IDUs who do not have a history of using mental health services. Data used for this exploration originate from a statewide drug-treatment database covering all women who entered drug treatment in the state of Massachusetts from 1996 to 2001. A total of 7776 women were included in the study. Through the use of logistic regression analysis, the study determined that those female IDUs who had a mental health service history, compared with female IDUs who had no such history, were about two-thirds more likely to enter substance abuse treatment other than detoxification only. Specifically, women with a mental health service history were about 66% more likely to enter substance abuse treatment modalities such as drug-free outpatient counseling, methadone maintenance, and/or long-term residential services rather than detoxification alone. This is a positive result, indicating that female IDUs who have mental health problems and therefore have high needs for effective substance abuse treatment are entering the more intensive and/or longer term modalities likely to lead to better outcomes. Possible factors accounting for this, including the referral process within detoxification centers, the role of community referral agents, and the experience women gain as a consequence of receiving services in more than one service system, are discussed.

Risky use of alcohol, drugs and cigarettes in a psychosis unit: a 1 1/2 year follow-up of stability and changes after initial screening

BACKGROUND

Co-morbidity with substance use disorders negatively influences overall functioning in patients with psychosis. However, frequencies and courses of risky use of alcohol, drugs and cigarettes are rarely investigated in patients at psychosis units. The purpose of this study is to describe the use of alcohol, drugs and cigarettes in patients at a psychosis unit over a 1 1/2 year period after them having taken part in a screening investigation including a feed-back of the results to personnel. Relationships with sex and age are also described.

METHODS

The patients' use of the substances was examined at baseline and at follow-up using three self-reporting instruments: Alcohol Use Disorders Identification Test (AUDIT), Drug Use Disorders Identification Test (DUDIT) and Fagerstrom Test for Nicotine Dependence (FTND).

RESULTS

One hundred and eighty-six patients out of 238 at baseline (78 percent) took part in the follow-up. Total AUDIT score decreased in women. Older men more often developed a risky alcohol use. Older women tended to reduce their risky drug habits. On a group level the habits mostly were stable, but 11 percent changed their alcohol habits and 15 percent changed their smoking habits from risky to no/low risky use, or vice versa. Nine percent changed their drug habits, predominantly from risky to no/low risky use.

CONCLUSION

A more active approach towards alcohol, drug and smoking habits in psychosis units would probably be beneficial.

Substance abuse treatment entry, retention, and outcome in women: a review of the literature

This paper reviews the literature examining characteristics associated with treatment outcome in women with substance use disorders. A search of the English language literature from 1975 to 2005 using Medline and PsycInfo databases found 280 relevant articles. Ninety percent of the studies investigating gender differences in substance abuse treatment outcomes were published since 1990, and of those, over 40% were published since the year 2000. Only 11.8% of these studies were randomized clinical trials. A convergence of evidence suggests that women with substance use disorders are less likely, over the lifetime, to enter treatment compared to their male counterparts. Once in treatment, however, gender is not a significant predictor of treatment retention, completion, or outcome. Gender-specific predictors of outcome do exist, however, and individual characteristics and treatment approaches can differentially affect outcomes by gender. While women-only treatment is not necessarily more effective than mixed-gender treatment, some greater effectiveness has been demonstrated by treatments that address problems more common to substance-abusing women or that are designed for specific subgroups of this population. There is a need to develop and test effective treatments for specific subgroups such as older women with substance use disorders, as well as those with co-occurring substance use and psychiatric disorders such as eating disorders. Future research on effectiveness and cost-effectiveness of gender-specific versus standard treatments, as well as identification of the characteristics of women and men who can benefit from mixed-gender versus single-gender treatments, would advance the field.

Learning sobriety together: A randomized clinical trial examining behavioral couples therapy with alcoholic female patients

Married or cohabiting female alcoholic patients (n = 138) and their non-substance-abusing male partners were randomly assigned to 1 of 3 equally intensive interventions: (a) behavioral couples therapy plus individual-based treatment (BCT; n = 46), (b) individual-based treatment only (IBT; n = 46), or (c) psychoeducational attention control treatment (PACT; n = 46). During treatment, participants in BCT showed significantly greater improvement in dyadic adjustment than those in IBT or PACT; drinking frequency was not significantly different among participants in the different conditions. During the 1-year posttreatment follow-up, compared with participants who received IBT or PACT, participants who received BCT reported (a) fewer days of drinking, (b) fewer drinking-related negative consequences, (c) higher dyadic adjustment, and (d) reduced partner violence.

Experiences of harm reduction among women with alcohol use problems

This paper explores women's choice of controlled drinking or abstinence goals in harm reduction treatment programs for alcohol use problems. Situated within debates about controlled or abstinence goals for alcohol use, this research project provides a specific focus on women's treatment needs. We explore evidence which reveals that women in treatment for alcohol problems often hold deeply internalized dominant social ideologies on addiction. Results demonstrate that while offered the choice of abstinence or controlled use goals, most women defined themselves as "addicts," adopted a disease metaphor of "addiction," and chose abstinence. The findings here raise questions about whether or not clients receive sufficient education about harm reduction and controlled drinking and make adequately informed choices.

Focus on secondary prevention: implications of a study on intervention in social networks

Screening and brief intervention (SBI) as a method within secondary prevention of alcohol use-related problems has experienced enormous attention and interest over the past 20 years. Initial results were very promising and great effort was put into designing screening instruments and developing different kinds of interventions. However, at the same time, the approach has generated problems in its own right. Some of these problems relate to standardization of instruments and some to criteria of inclusion into samples; others relate to the focus on the individual drinking style independent from social influences. In light of these problems, it is necessary to elaborate on the theoretical foundation, as well as on the methods used in SBI. This article introduces a method for intervening in social networks with important implications for SBI. By putting emphasis on the motivational part of SBI and including social networks in the field of intervention, it may be assumed that the approach will produce better results than heretofore. The results from a Danish qualitative study on intervening into the social network of social drinkers are presented. This study was carried out between 1991 and 1999 and involved 13 adult Danes between 35 and 45 years of age. They all had a weekly alcohol consumption of 120 to 360 g of pure alcohol and they all considered themselves to be social drinkers. The results of this study show that enhanced awareness of the person's own drinking, as well as that of peers, may influence decisions about specific drinking situations. These findings and the perspectives for SBI are discussed. Recommendations for further research are also presented.

Gender differences in outcomes in an HMO-based substance abuse treatment program

This study examined gender differences in treatment outcomes and outcomes predictors among 155 men and 81 women attending a gender-sensitive substance abuse treatment program. Bivariate analyses indicated women improved more than men in social/family and daily functioning domains, but differences disappeared after controlling for baseline characteristics. Multivariate models predicting treatment outcomes revealed that, across Addiction Severity Index domains, outcomes for men were predicted primarily by mental health and medical conditions, severity of the substance abuse problem, and treatment com- pletion. For women, in addition to treatment completion, outcomes were more likely to be predicted by social, socio-demographic, and life-history characteristics. For abstinence outcomes, women who completed treatment were 9 times as likely to be abstinent at 7-month follow-up as other women; men who completed were 3 times more likely to be abstinent than other men. Women with more severe psychiatric status and those who felt their life was out of control were less likely to be abstinent, as were men who lived alone. Clinicians targeting such factors differentially for men and women may enhance the effectiveness of treatment.

Alcohol misuse by women

Alcohol misuse among women is an important and growing problem. There is epidemiological and metabolic evidence that risk factors for and consequences of alcohol misuse are significantly different for women than for men. Understanding these differences is imperative if effective preventative and treatment interventions are to be undertaken. This article reviews the epidemiology of alcohol misuse by women, effects of alcohol misuse on women, fetuses, and relationships, and assessment and treatment strategies. We then suggest directions for future research in this field.

Short-term treatment for alcohol-related problems: four-session guided self-change versus one session of advice--a randomized, controlled trial

The aim of this study was to compare two short-term treatments for alcohol-related problems. The study was performed at an outpatient clinic for substance misuse, and subjects (65 men and 28 women) were recruited through advertisements in the local newspaper. The subjects were randomized to either a four-session guided self-change group or a one-session advice group. Alcohol consumption, degree of alcohol dependence, negative consequences of drinking, and health-related quality of life were measured or assessed, respectively, by using the timeline follow-back technique, the Short Alcohol Dependence Data (SADD) questionnaire, The Drinker Inventory of Consequences questionnaire, and the Nottingham Health Profile questionnaire. Biological markers for high alcohol consumption [carbohydrate-deficient transferrin (CDT) and gamma-glutamyl transferase (gamma-GT) levels] were analyzed. All assessments were made at baseline and at 9- and 23-month follow-up periods after treatment. Self-reported alcohol consumption was significantly reduced (P <.0001) in both treatment groups at the 23-month follow-up period, as were measures of alcohol dependence, negative consequences of drinking, and health-related quality of life, whereas no corresponding reduction was found in CDT or gamma-GT values. No statistically significant differences in self-reported alcohol consumption were found between the two groups. Patient satisfaction was significantly higher with the four-session guided self-change treatment than with the one session of advice. This finding seems to indicate that individuals, although suffering from alcohol-related problems of relatively low severity, appreciate more time with a therapist.

Brief interventions for problem drinking and women

Early identification and intervention among problem drinking women may avert the more severe, adverse consequences of alcohol abuse and dependence. Screening and brief interventions, while generally effective, have not been adequately examined among subgroups, such as women. The purpose of this review article is to examine the efficacy of brief interventions for the population of women in need of some alcohol treatment. Representative studies with random assignment to treatment conditions and either substantial numbers of women, or a special focus on women, were included. Findings suggest brief interventions are not consistently helpful to women drinkers.

Behavioral couples therapy for female substance-abusing patients: effects on substance use and relationship adjustment

Married or cohabiting female drug-abusing patients (N = 75) were randomly assigned to either a behavioral couples therapy condition (BCT; n = 37), which consisted of group, individual, and behavioral couples therapy sessions, or to an equally intensive individual-based treatment condition (IBT; n = 38), which consisted of group and individual counseling. During most of the 1-year follow-up, compared with participants who received IBT, those who received BCT reported (a) fewer days of substance use, (b) longer periods of continuous abstinence, (c) lower levels of alcohol, drug, and family problems, and (d) higher relationship satisfaction. However, differences in relationship satisfaction and number of days of substance use dissipated over the course of the posttreatment follow-up period and were not significantly different by the end of 1 year.

Brief interventions for alcohol problems: a meta-analytic review of controlled investigations in treatment-seeking and non-treatment-seeking populations

Brief interventions for alcohol use disorders have been the focus of considerable research. In this meta-analytic review, we considered studies comparing brief interventions with either control or extended treatment conditions. We calculated the effect sizes for multiple drinking-related outcomes at multiple follow-up points, and took into account the critical distinction between treatment-seeking and non-treatment-seeking samples. Most investigations fell into one of two types: those comparing brief interventions with control conditions in non-treatment-seeking samples (n = 34) and those comparing brief interventions with extended treatment in treatment-seeking samples (n = 20). For studies of the first type, small to medium aggregate effect sizes in favor of brief interventions emerged across different follow-up points. At follow-up after > 3-6 months, the effect for brief interventions compared to control conditions was significantly larger when individuals with more severe alcohol problems were excluded. For studies of the second type, the effect sizes were largely not significantly different from zero. This review summarizes additional positive evidence for brief interventions compared to control conditions typically delivered by health-care professionals to non-treatment-seeking samples. The results concur with previous reviews that found little difference between brief and extended treatment conditions. Because the evidence regarding brief interventions comes from different types of investigation with different samples, generalizations should be restricted to the populations, treatment characteristics and contexts represented in those studies.

Intoxicated motor vehicle passengers warrant screening and treatment similar to intoxicated drivers

BACKGROUND

Alcohol interventions decrease alcohol consumption and recurrent injury. The study hypotheses are (1) intoxicated passengers are similar to intoxicated drivers in crashes and driving under the influence of alcohol (DUI), and (2) DUI conviction rates after injury are low.

METHODS

Intoxicated motor vehicle occupants hospitalized for injury in 1996-1998 were matched to the state traffic database for crashes and DUI. Drivers and passengers were compared for crashes and DUI in the 2 years preceding and 1 year after admission. Driver DUI citation at the time of admission was also recorded. A logistic regression model for crash and DUI probability was constructed.

RESULTS

Six hundred seventy-four patients met inclusion criteria. In the 2 years preceding admission, passengers and drivers were equally cited for crashes (14.7% vs 19.3%, p = 0.12). In 1 year after admission, they were also equally cited (7.1% vs 7.7%, p = 0.92). Driver/passenger status was not a predictor by logistic regression; 13.4% of intoxicated drivers were convicted of DUI for the admitting crash.

CONCLUSION

Intoxicated passengers and drivers are equally likely to be cited for crashes and DUI before and after admission for injury. Few admitted intoxicated drivers are convicted of DUI. Screening and intervention for all intoxicated crash occupants is warranted.

Reducing alcohol consumption among heavily drinking women: evaluating the contributions of life-skills training and booster sessions

Problem-drinking women (N = 144) without histories of severe physical dependence on alcohol received drinking-reduction training and were assigned to receive (or not receive) 2 treatment enhancements: life-skills training and booster sessions. The design resulted in 4 treatment conditions: drinking-reduction treatment (DRT) plus life-skills training, DRT plus booster sessions, DRT plus life-skills training and booster sessions, or DRT only. The interventions entailed 13 hr of DRT, 7 hr devoted to the life-skills training or to a no-life-skills training educational module, plus 8 hr of booster sessions for those receiving them. Participants evidenced significant reductions in alcohol use during the 18 months after treatment. Those with greater pretreatment drinking evidenced differential response to the experimental manipulations: The treatment enhancements (life skills and booster sessions) led to significantly improved drinking outcomes among women who were heavier drinkers at pretreatment. There were no significant effects of the treatment enhancements among lighter drinkers at pretreatment. The results provide support for use of treatment enhancements in interventions designed to moderate women problem drinkers' alcohol use.

Use of SELF-HELP MANUALS to Treat Problem Drinkers

In spite of research findings indicating that alcohol abusers may benefit from self-help manuals, health care providers have been slow to recognize their potential usefulness. As self-care strategies grow more popular and funding for traditional forms of alcohol treatment diminish, health care providers need to look more seriously at these materials. They also need to be aware of new innovations such as self-help materials that can be purchased on diskette. It may not be long before computerized materials sit next to printed manuals on bookstore shelves, and nurses need to know which materials to recommend.

A study of minimal interventions for problem drinkers in acute care settings

This article reports an investigation of three minimal interventions for potential problem drinkers in general hospital wards. The interventions were: (a) brief advice; (b) the provision of health education literature; (c) a combination of both the advice and literature. One year after recruitment the mean levels of alcohol consumption and the number of alcohol-related problems reported by the cohort was significantly reduced. These reductions were supported by reductions in the mean levels of GGT and AST, but not in mean MCV. No statistically significant treatment effects were found. The results are presented and implications for nursing are discussed.

Minimal interventions for problem drinkers: a review of the literature

There is an increasing body of literature concerning the role in health promotion for nurses working in many health care settings. It has been argued that this role should include identifying those individuals whose life-style increases their risk of developing health problems, as well as providing appropriate advice and information. Life-style factors which may contribute to ill-health include problem drinking. This literature review presents a critique of studies of brief, or minimal, interventions for problem drinkers which have been conducted in both primary care and acute settings. The concept of minimal interventions is explored and the potential for nurses to assume a role in delivering such interventions is discussed.

Alcohol treatment outcome methodology: state of the art 1989-1993

This article reviews the 61 alcohol treatment outcome studies published from 1989-1993 with respect to methodology. Although better assessment of subjects' pretreatment characteristics was noted, a minority of studies met even the basic requirements of experimental studies. Further, some reversals of methodological progress were observed in several areas, particularly in collecting outcome data from multiple sources. It is suggested that funding agencies and journal editors require that submissions meet minimum standards for adequate outcome evaluation.

A cross-national trial of brief interventions with heavy drinkers. WHO Brief Intervention Study Group

OBJECTIVES

The relative effects of simple advice and brief counseling were evaluated with heavy drinkers identified in primary care and other health settings in eight countries.

METHODS

Subjects (1260 men, 299 women) with no prior history of alcohol dependence were selected if they consumed alcohol with sufficient frequency or intensity to be considered at risk of alcohol-related problems. Subjects were randomly assigned to a control group, a simple advice group, or a group receiving brief counseling. Seventy-five percent of subjects were evaluated 9 months later.

RESULTS

Male patients exposed to the interventions reported approximately 17% lower average daily alcohol consumption than those in the control group. Reductions in the intensity of drinking were approximately 10%. For women, significant reductions were observed in both the control and the intervention groups. Five minutes of simple advice were as effective as 20 minutes of brief counseling.

CONCLUSIONS

Brief interventions are consistently robust across health care settings and sociocultural groups and can make a significant contribution to the secondary prevention of alcohol-related problems if they are widely used in primary care.

How to have a high success rate in treatment: advice for evaluators of alcoholism programs

Two seasoned alcohol treatment researchers offer tongue-in-cheek advice to novice program evaluators faced with increasing pressure to show high success rates. Based on published examples, they advise: (1) choose only good prognosis cases to evaluate; (2) keep follow-up periods as short as possible; (3) avoid control and comparison groups; (4) choose measures carefully; (5) focus only on alcohol outcomes; (6) use liberal definitions of success; (7) rely solely upon self-report and (8) always declare victory regardless of findings.

Barriers to help-seeking for change in drinking: a gender-focused review of the literature

Women with drinking problems are less likely than men to utilize alcohol-specific treatment services; they are comparatively more likely to seek help in general health and mental health care settings. These patterns in service utilization may be attributable, in part, to gender differences in barriers or disincentives to seeking and receiving care for alcohol abuse. In this paper we provide a gender-focused review of research on barriers to help-seeking for addictions behavior change. Two major categories of barrier, involving client and treatment program characteristics, appear to have a greater impact on service utilization of women than men. Insights gained from barriers literature provide valuable direction for future research and suggest applications in clinical service provision and treatment planning.

Empirically based guidelines for moderate drinking: 1-year results from three studies with problem drinkers

OBJECTIVES

The study was conducted to refine guidelines on moderate drinking for problem drinkers, persons whose alcohol use is hazardous or harmful. Information on levels of alcohol intake unlikely to cause problems is useful for health professionals, educators, and policymakers.

METHODS

Based on their reports of alcohol-related problems, participants in three studies assessing interventions to reduce heavy drinking (114 men, 91 women) were categorized as "problem-free" or "problem" drinkers at follow-up. Drinking measures were examined to identify patterns separating these outcome categories.

RESULTS

Analyses using 95% confidence intervals for means on drinking measures showed that guidelines should be sex-specific. Based on analyses of positive and negative predictive value, sensitivity, and specificity, it is recommended that men consume no more than 4 standard drinks in any day and 16 drinks in any week, and that women consume no more than 3 drinks in any day and 12 drinks in any week.

CONCLUSIONS

These guidelines are consistent with those from several official bodies and should be useful for advising problem drinkers when moderation is a valid treatment goal. Their applicability to the general population is unevaluated.

Alcohol and polysubstance abuse among women

A review of the literature in this relatively new field highlights the legitimacy of gender-specific research on substance abuse in women. Consistent findings compared to men include a higher physical vulnerability to alcohol, a higher risk of assortative mating, the reported association of traumatic events with the onset of substance abuse, a higher psychiatric comorbidity and a shorter interval between first problem and first treatment episode. Intravenous drug use remains the major source of growth of HIV infection among women. Family assessment and treatment as well as the involvement of female role models are critical to the recovery process. Gender-specific services may be recruiting women who might not otherwise have sought treatment for their substance abuse. Further investigation is required in order to distinguish the relative significance of the genetic versus environmental vulnerability of women, the impact of rapidly changing social mores on the onset, pattern and course of substance abuse, possible gender-specific alcohol typologies, the validity of the recall of traumatic events as well as the program variables required in reaching out and engaging women on the path to recovery.

Assisting problem drinkers to change on their own: effect of specific and non-specific advice

Problem drinkers (99 males, 41 females) wishing to quit or cut down without professional help received a 60-minute session during which they were assessed and given at random one of these materials: Guidelines, a two-page pamphlet outlining specific methods for achieving abstinence or moderate drinking; Manual, a 30-page booklet describing the methods in the Guidelines; or General Information, a package about alcohol effects. At 12 months follow-up, subjects in the Guidelines and Manual conditions showed significantly greater reductions of heavy days (of 5+ drinks) than subjects in General Information (70% vs. 24%); in addition, significantly fewer subjects in the Guidelines and the Manual conditions expressed need for professional assistance with their drinking (25% vs. 46% in General Information). No main effect of condition or gender was observed on rates of moderate drinkers. At 12 months follow-up, 31% of the men and 43% of the women were rated as moderate drinkers. It was concluded that drinkers intending to cut down on their own derive greater benefit (in terms of their alcohol use) from materials containing specific instructions to develop moderate drinking than from those providing general information on alcohol effects. Clinical and research implications of the findings are discussed.

Carbohydrate-deficient transferrin as an alcohol marker among female heavy drinkers: a population-based study

Carbohydrate-deficient transferrin (CDT) has previously been reported to be an excellent marker of male alcoholics. Less is known of its efficiency among women and especially of early-phase alcohol abuse in nonselected populations. The present population-based study examined the diagnostic value of CDT among consecutive women, including 13 teetotallers, 135 social drinkers (mean alcohol consumption 45 +/- 34 g/week), and 57 nonalcoholic heavy drinkers (197 +/- 97 g/week). Sixty-two women with a well-documented history of chronic alcoholism (942 +/- 191 g/week) were also studied, as well as 36 pregnant women used as a reference group. Two weeks of abstinence among 11 alcoholics was followed. The CDT (containing part of isotransferrin with pI = 5.7, 5.8, and 5.9) was separated by anion exchange chromatography and assayed by radioimmunoassay. In the whole material, CDT correlated significantly with alcohol consumption (r = 0.43, p < 0.001) but not with conventional markers (gamma-glutamyltransferase, AST, ALT, and mean corpuscular volume). The CDT values of alcoholics (34 +/- 20 units/liter) were significantly (p < 0.001) higher than those of teetotallers (19 +/- 6 units/liter), social drinkers (20 +/- 6 units/liter), or pregnant women (16 +/- 3 units/liter). Heavy drinkers also had higher values (25 +/- 13 units/liter), but the difference did not reach statistic significance. The specificity of CDT was on the level of conventional markers when the cut-off value was increased from 26 to 29 units/liter. At a specificity of 95%, CDT found 19% of the heavy drinkers and 52% of the alcoholics; the best traditional marker, AST, with a specificity of 97%, found 7% and 56%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Hidden alcohol abuse among women

Seven years ago the authors examined 64 consecutive female out-patients with macrocytosis (erythrocyte mean cell volume > or = 100 fl). The cause remained undetermined in 23 (35.9%). Their patient histories were evaluated in 1992, and the new highly specific alcohol marker, serum carbohydrate-deficient transferrin, from the frozen sera taken during the initial study was examined. It was elevated in 6 of the 23 women. Furthermore, four of these six had visited the health centre after 1985 and they all had clinical records indicative of alcohol problems. Because early intervention has proved to be effective, information about the risks of alcohol abuse (intervention) should be given to women with suspect alcohol-induced symptoms or signs.

Drinking habits and detection of heavy drinking among middle-aged women

Little is known about alcohol consumption and the efficiency of alcohol questionnaires among women. In the present study 40-year-old (n = 90) and 45-year-old (n = 75) women participating in a health screening gave a self-report about their alcohol consumption and filled out the Malmö modified Michigan Alcoholism Screening Test (Mm-MAST) and the CAGE questionnaires. Teetotallers comprised 11% of the 40-year-old group and 8% of the 45-year-old women. CAGE, but not Mm-MAST worked with the traditional cut-off point of two recommended for men. When the criterion for heavy drinking was a self-reported consumption > or = 140 g of absolute alcohol per week or a positive (> or = 2) finding in the CAGE or > or = 4 'yes' answers in the Mm-MAST, 20% of the 40-year-old and 17% of the 45-year-old group (together 19%) proved positive. Neither of the two questionnaires nor self-report alone worked perfectly for identifying the heavy drinker group (n = 31) screened. Using the three above criteria; of the heavy drinkers 52% were detected by self-report, 55% by CAGE, and 45% by Mm-MAST. CAGE in combination with self-report detected 90% and this combination, being short and simple, can be recommended for clinical practice.

Physician detection of drinking problems in patients attending a general medicine practice

OBJECTIVE

To assess the patient and physician characteristics that influence physicians' detection of problem drinking in their medical patients.

SETTING

The outpatient medical clinic at an urban university teaching hospital staffed by interns and residents.

DESIGN

Cross-sectional study of a randomly chosen subsample of consecutive patients.

MEASUREMENT

Univariate and multivariate analysis with calculated adjusted odds ratios of factors associated with physician detection of drinking problems. A problem was diagnosed according to the patient's results on the alcohol module of the Diagnostic Interview Schedule (DIS).

RESULTS

Physicians detected 22% of 189 presumably inactive problems and 49% of 92 current problems, i.e., those that have occurred within the preceding year. Multivariate correlates of detection of active problems included male patient gender, presence of gastrointestinal complications of excessive drinking, number of concurrent medical disorders, and previous medical record reference to alcohol (p less than 0.05). Physician gender and year of training were not associated with detection.

CONCLUSION

Our physicians appear to rely on specific patient characteristics as well as the patient's medical record to detect drinking problems in their ambulatory patients. Their reliance upon these factors may hinder their detection of drinking problems in women patients and less seriously impaired individuals.

Implications of gender for alcohol treatment research: a quantitative and qualitative review

Previous reviews of alcohol treatment research have indicated that in the majority of studies there are no sex differences in treatment outcome. The current meta-analysis was used to measure the magnitude and direction of trends of sex difference in treatment outcome. The results indicated that women had better treatment outcomes than men in the first 12 months after treatment while men showed greater improvement than women in follow-ups after 12 months. However, the estimated differences were small and derived from a heterogeneous sample of studies. Evidence from the studies in the meta-analysis is used to highlight the importance of gender-related factors which may impact on the processes and outcomes of treatment. In particular, sex differences in physiological responses to alcohol, in social norms for alcohol, and in socio-cultural experiences are considered important areas for future investigation in alcohol treatment research.

Superior outcome of females over males after brief treatment for the reduction of heavy drinking: replication and report of therapist effects

The procedures and findings of a previous study were replicated. Sixty-one men and 35 women were randomized to one of three treatments: Manual: three sessions of instructions in use of a manual describing a step-by-step method for attaining abstinence or moderate drinking.

GUIDELINES

three sessions of advice using a pamphlet summarizing the contents of the manual. Therapist: application of the step-by-step method in an indefinite number of sessions. At 3-month follow-up, the number of Moderate drinkers was again significantly higher among women than men in the GUIDELINES (77% versus 24%) and Manual conditions (75% versus 33%), but not in the Therapist condition (50% versus 53%). Again, at 1-year more women than men were Moderate drinkers in all conditions (69% versus 31% overall). Changes from baseline in GGT, MCV, and the Digit Symbol Test corroborated the clients' reports of drinking. In this study the more experienced therapists had significantly lower rates of client dropout than the less experienced. Clinical and research implications of the findings are discussed.

Brief didactic treatment for alcohol and drug-related problems: an approach based on client choice

The conceptual and empirical basis of a treatment programme for the prevention of severe alcohol or drug-related problems is described. The approach rests on the assumption that clients are capable of self-control and of taking responsibility for much of their treatment. We also believe that offering clients choices, particularly about the goal of treatment, is conducive to better outcome. The treatment involves cognitive and behavioural techniques which have been gradually refined in outcome studies with clients of diverse characteristics, and with abstinence or moderation as goals. It is proposed that the treatment model is suitable as a true self-help procedure, or as a brief intervention for primary care health professionals.