Divalproex sodium in alcohol withdrawal: a randomized double-blind placebo-controlled clinical trial.

BACKGROUND: Divalproex sodium, an anticonvulsant and antikindling agent and gamma-aminobutyric acid enhancer, has been proposed as an alternative to benzodiazepines for treating alcohol withdrawal. This study reports on a randomized, double-blind, placebo-controlled trial of divalproex sodium in acute alcohol withdrawal. METHODS: Thirty-six hospitalized patients experiencing moderate alcohol withdrawal as measured by a score of at least 10 on the revised Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar) were randomized to receive either divalproex sodium 500 mg three times per day for 7 days or matched placebo in a double-blind manner. All subjects received a baseline dose of oxazepam and had additional oxazepam available as a rescue medication in accordance with a standard, symptom-triggered detoxification protocol. Mean total milligrams of oxazepam received, progression of withdrawal symptoms, psychological distress as measured by the Symptom Checklist-90, side effects, and adverse outcomes were compared between groups. RESULTS: Use of divalproex sodium resulted in less use of oxazepam (p < 0.033). Group differences seemed primarily driven by those subjects who experienced symptoms above threshold level (CIWA-Ar >or=10) after 12 hr. The progression in severity of withdrawal symptoms (increase in CIWA-Ar above baseline) was also significantly greater in the placebo group (p < 0.05). CONCLUSIONS: This placebo-controlled pilot study suggests that divalproex sodium significantly affects the course of acute alcohol withdrawal and reduces the need for treatment with a benzodiazepine. A more aggressive loading dose strategy may demonstrate a more robust or earlier response.

Brief intervention for heavy-drinking college students: 4-year follow-up and natural history.

OBJECTIVES: This study examined long-term response to an individual preventive intervention for high-risk college drinkers relative to the natural history of college drinking. METHODS: A single-session, individualized preventive intervention was evaluated within a randomized controlled trial with college freshmen who reported drinking heavily while in high school. An additional group randomly selected from the entire screening pool provided a normative comparison. Participant self-report was assessed annually for 4 years. RESULTS: High-risk controls showed secular trends for reduced drinking quantity and negative consequences without changes in drinking frequency. Those receiving the brief preventive intervention reported significant additional reductions, particularly with respect to negative consequences. Categorical individual change analyses show that remission is normative, and they suggest that participants receiving the brief intervention are more likely to improve and less likely to worsen regarding negative drinking consequences. CONCLUSIONS: Brief individual preventive interventions for high-risk college drinkers can achieve long-term benefits even in the context of maturational trends.

The problem of college drinking: insights from a developmental perspective.

This article represents the proceedings of a symposium at the 2000 RSA Meeting in Denver, Colorado. John Schulenberg and Jennifer L. Maggs were Organizers. Stephen W. Long was Chair and provided opening remarks. The presentations were: (1) I'm not a drunk, just a college student: Binge drinking during college as a developmental disturbance, by John Schulenberg; (2) Course of alcohol use disorders during college, by Kenneth J. Sher; (3) How do students experience alcohol and its effects? Positive versus negative expectancies and consequences, by Jennifer L. Maggs; and (4) Brief intervention in the context of developmental trends in college drinking, by G. Alan Marlatt. Critique and commentary were provided by Robert A. Zucker.

Individual drinking changes following a brief intervention among college students: clinical significance in an indicated preventive context.

This study investigated the clinical significance of previously reported statistically significant mean reductions in drinking and related problems among college students in a randomized trial of a brief indicated preventive intervention (G. A. Marlatt et al., 1998). Data were analyzed over a 2-year follow-up for participants from a high-risk intervention group (n = 153), a high-risk control group (n = 160), and a functional comparison group (n = 77). A risk cutpoint for each dependent measure was based on the functional comparison group distribution. Compared with the high-risk controls, more individuals in the high-risk intervention group improved and fewer worsened, especially on alcohol-related problems and, to a lesser extent, on drinking pattern variables. These data from a prevention context clarify the magnitude and direction of individual change obscured by group means.

An individual in context: predictors of alcohol use and drinking problems among Greek and residence hall students.

Fraternity, sorority, and residence hall residents were compared on drinking rates and patterns, drinking-related problems, family history of alcohol problems, alcohol outcome expectancies, and high school drinking patterns. Results indicated residence in a fraternity was related to more frequent alcohol consumption and greater negative consequences even after accounting for family history, expectancies, and high school drinking rates. Family history of alcohol problems was only related to negative consequences for men. Only high school drinking rates were related to amount of alcohol consumed per occasion, for both men and women. Fraternity residence was found to be related to more negative consequences even after accounting for current drinking habits. However, sorority residence was found to moderate the relationship between current drinking and negative consequences. Both high and low drinkers in sororities indicated similar rates of alcohol-related negative consequences, whereas high frequency female drinkers in the residence hall sample reported significantly more problems.

Development of dosing guidelines for reaching selected target breath alcohol concentrations.

OBJECTIVE: This study evaluated gender-specific ethanol dosing protocols that were designed to result in one of two peak breath alcohol concentrations (BrACs)--0.07 or 0.10 g/2101. Inter- and intrasubject variability in BrAC were assessed and several possible methods for reducing variability in BrAC were evaluated. METHOD: Subjects (16 women, 16 men, ages 21-30 years) were studied after low (women 0.49 g/kg, men 0.53 g/kg consumed over 10 minutes) and high (women 0.81 g/kg, men 0.89 g/kg consumed over 20 minutes) ethanol doses, consumed following a 4-hour fast. All subjects were regular drinkers. RESULTS: Mean (+/-SD) peak BrACs actually achieved were 0.069+/-0.011 g/2101 after the low dose, and 0.105+/-0.014 g/2101 after the high dose. Mean values for peak BrAC, time to peak BrAC and area under the curve were not statistically significantly different between genders at either dose. BrACs varied by as much as twofold between subjects after equivalent gender and body weight adjusted doses. There was some reproducibility of ethanol pharmacokinetic parameters over dose and time in men, but not in women. CONCLUSIONS: The doses used resulted in equivalent mean ethanol exposures for women and men at each dose, with mean peak BrACs that closely approached the targets, but there was substantial inter- and intrasubject variability in ethanol pharmacokinetics.

Integrating skills training and motivational therapies. Implications for the treatment of substance dependence.

Two well-articulated models of substance abuse treatment, skills training and motivational enhancement, have received considerable research attention in recent years. Skills training treatments operate on the underlying rationale of correcting skills deficits, whereas motivational strategies are based on affecting clients' willingness to use skills they already possess. Skills training and motivational enhancement are typically described as distinct treatments and have recently been constructed as different treatments within a large multisite trial in the United States (Project MATCH). This article explores how treatments for substance abuse can draw from and integrate skills training and motivational strategies. Recovery from addictive patterns of behavior often requires learning over time and typically involves slips, relapses, and multiple quit attempts. Therapeutic support for change in addictive behavior, in particular attempting to prevent and minimize relapse, requires assessment and support of both why one might pursue change (motivation) and how one can best be successful (skills).

College alcohol use: a full or empty glass?

Data from the Harvard School of Public Health College Alcohol Study (1993) were used to describe weekly alcohol consumption and its associated problems among a representative national sample of college students. The median number of drinks consumed/week by all students, regardless of drinking status, was 1.5. When students were divided by drinking pattern, the median number of drinks/week was 0.7 for those who did not binge drink and 3.7 for those who did so infrequently. For frequent binge drinkers, the median was considerably higher: 14.5 drinks/week. Nationally, 1 in 5 five college students is a frequent binge drinker. Binge drinkers consumed 68% of all the alcohol that students reported drinking, and they accounted for the majority of alcohol-related problems. The data indicate that behavioral norms for alcohol consumption vary widely among students and across colleges. Therefore, it may not be possible to design an effective "one size fits all" approach to address college alcohol use.

Screening and brief intervention for high-risk college student drinkers: results from a 2-year follow-up assessment.

This randomized controlled trial evaluated the efficacy of a brief intervention designed to reduce the harmful consequences of heavy drinking among high-risk college students. Students screened for risk while in their senior year of high school (188 women and 160 men) were randomly assigned to receive an individualized motivational brief intervention in their freshman year of college or to a no-treatment control condition. A normative group selected from the entire screening pool provided a natural history comparison. Follow-up assessments over a 2-year period showed significant reductions in both drinking rates and harmful consequences, favoring students receiving the intervention. Although high-risk students continued to experience more alcohol problems than the natural history comparison group over the 2-year period, most showed a decline in problems over time, suggesting a developmental maturational effect.

Prenatal alcohol exposure and family history of alcoholism in the etiology of adolescent alcohol problems.

OBJECTIVE: To examine the relative importance of prenatal alcohol exposure and family history of alcoholism for the prediction of adolescent alcohol problems. METHOD: In 1974-75, a population-based, longitudinal prospective study of alcohol and pregnancy began with self-report of alcohol use by pregnant women. In a 14-year follow-up, 439 parents provided information on the family history of alcohol problems for these adolescent offspring. The 14-year-old adolescents provided information on the frequency and quantity of their own alcohol consumption within the past month, on the consequences of their drinking over the past 3 years, and on their age at first intoxication. Additional covariates were assessed prenatally and at follow-up. RESULTS: Prenatal alcohol exposure was more predictive of adolescent alcohol use and its negative consequences than was family history of alcohol problems. Prenatal exposure retained a significant predictive effect even after adjustment for family history and other prenatal and environmental covariates. By contrast, the nominally significant correlation of family history with adolescent drinking is weaker after adjustment for prenatal alcohol exposure and disappears entirely after adjustment for other relevant covariates. We observed no evidence for an interactive effect of fetal exposure and family history in predicting adolescent alcohol use. CONCLUSIONS: Fetal alcohol exposure is a risk factor for adolescent alcohol involvement and alcohol-related problems and may account for variance in prediction of problems otherwise attributed to family history of alcoholism. Studies of alcoholism etiology and family history need to include consideration of even modest levels of fetal alcohol exposure.

Variability of ethanol absorption and breath concentrations during a large-scale alcohol administration study.

Ethanol disposition was evaluated in 77 female and 97 male college seniors during an alcohol challenge study. All were regular drinkers who exceeded legal intoxication levels at least twice a month by history. A standard ethanol dose (females, 0.43 g/kg; males, 0.51 g/kg) was administered over 10 min, after a 4-hr fast, and breath alcohol concentrations (BrACs) were measured for 2 hr. Intersubject variability in BrACs was greatest early in the study, during ethanol absorption; the coefficient of variation decreased from 39% at 14 min to 14% at 125 min after the start of drinking. The time to peak BrAC varied from 10 to 91 min after the start of drinking (mean 39.6 min). Mean BrACs were significantly lower in females than males; mean peak BrACs were 0.054 g/210 liters in females and 0.058 g/210 liters in males (p = 0.031). The beta- and r-values for both genders were higher than those typically used in ethanol dose calculation formulas. Data are discussed to direct future research. The constants used in Widmark's formula need to be revised differentially for males and females in this population to reach specific target BrACs. Furthermore, substantial variability in absorption rates must be accounted for when assessing rising versus falling limb BrAC phenomena.

Task persistence after alcohol consumption among children of alcoholics.

Two studies examined task persistence after alcohol consumption among young adult offspring of alcoholics [children of alcoholics (COAs)] and young adult offspring of nonalcoholics (NonCOAs). In study I, heavy drinking college seniors (n = 294) participated in a laboratory alcohol challenge in the context of a baseline assessment for a longitudinal study. Subjects completed a computerized administration of the Matching Familiar Figures Test in two halves: the first half sober, and the second half approximately 50 min after consuming a 0.8 ml/kg body weight dose of ethanol. COAs demonstrated significantly greater acceleration of response latencies after consumption of alcohol compared with NonCOAs. In study II, moderate-to-heavy drinking volunteers (n = 149) were recruited for a one-time laboratory alcohol challenge, and completed a circle-tracing task three times approximately 50 min after consuming a 0.8 ml/kg body weight dose of ethanol. COAs displayed significantly less persistence on the second and third circle-tracing trials compared with NonCOAs. Data are discussed in relation to models of impulsivity and differential alcohol sensitivity among COAs.

High-risk drinking across the transition from high school to college.

Alcohol use and related problems were studied from the senior year in high school to the first autumn in college for 366 heavy drinking students. Four risk factors-subject sex, family history of drinking problems, prior conduct problems, and type of college residence-were evaluated as predictors of: (1) differential changes in drinking rates, (2) differential changes in alcohol-related problems, and (3) alcohol dependence symptoms during the first college term. Results suggest that both dispositional and environmental factors are associated with changes in drinking rates and the existence of dependence symptoms. Increases in the frequency of drinking were specifically and strongly associated with residence in a fraternity (men) or sorority (women). Three risk factors were associated with increased quantity of drinking: male gender, residence in a fraternity or sorority, and a history of conduct problems. Prior conduct problems were also consistently associated with dependence symptoms during the first term in college. A family history of alcohol problems was not consistently related to changes in use rates or problems, although some analyses suggest interactive effects. Early interventions on college campuses should target individuals using additive risk profiles.

The Alcohol Skills Training Program: a group intervention for young adult drinkers.

Development, content, and evaluation of the Alcohol Skills Training Program (ASTP) is described. Patterned after strategies for relapse prevention, the ASTP is a cognitive behavioral approach to the secondary prevention of alcohol problems. Format and context of the six group sessions are detailed, and process considerations are discussed. Results are summarized for two controlled investigations of the ASTP with young adult drinkers. The psychoeducational approach of the ASTP is recommended as an effective means for changing drinking patterns among young adults who are at risk for alcohol-related problems.

Biases in the perceptions of the consequences of alcohol use among college students.

Previous studies have shown that college students' perceptions of the quantity and frequency of peer alcohol consumption are biased. Most students report that their social referents drink more than they themselves do. In the current study members of two fraternities and two sororities (N = 252) were asked to make two types of ratings of alcohol-related consequences across four target individuals. The ratings were: (1) the frequency of occurrence of predefined alcohol-related negative consequences and (2) the degree to which certain alcohol-related consequences are considered "problems." The targets were: themselves, their best friend, a typical member of their fraternity or sorority and a typical student at the university. Estimates of frequency of problem behaviors for typical member of the residence and typical student at the university were significantly higher than ratings for self (p < .001). Data from ratings of behavioral definitions of alcohol problems for the same four targets replicated the bias, although to a lesser degree. Correlational analyses suggest that biased perceptions of problems were unrelated to personal levels of alcohol consumption. Results are discussed in terms of the cognitive and motivational factors that could result in this misrepresentation of peer behavior.

An experimental test of three methods of alcohol risk reduction with young adults.

This study tested 3 forms of alcohol risk reduction programming for young adults. Volunteers were randomly assigned to receive a 6-week class and discussion group, a 6-unit self-help manual, or a single 1-hr feedback and advice session with professional staff. Results reveal significant reductions in self-reported drinking at the end of the intervention phase and maintenance of drinking changes throughout a 2-year follow-up period. Comparable drinking reductions were rated across treatments; however, noncompliance with the self-help reading program suggested limited utility. Treatment response was related to subject age, as subjects showed increased drinking during the year they reached legal drinking status. The efficacy of brief motivational interventions and client matching in prevention programs is discussed.

Maintenance of smoking cessation.

Relapse is a frequently encountered problem in smoking cessation. With a cognitive-behavioral model of the relapse process, we can describe high-risk situations where smoking first recurs, the process by which people end up in these situations, and typical responses to violations of abstinence. The model posits that individuals are actively coping with situation-specific urges to smoke that result from prior conditioning. Individuals' beliefs in their ability to cope with urges are critical. Clinical strategies based on the model include assessment of risk profiles, understanding and anticipating high-risk situations, debriefing and reinterpreting lapses in abstinence, and limiting risk through lifestyle changes. These strategies can be incorporated into brief medical office visits. Recommended procedures include systematic but brief assessment, encouragement, goal setting, planning for risk, reinterpreting lapses, recommendations for lifestyle changes, and follow-up appointments.

Biases in the perception of drinking norms among college students.

Individual drinking patterns and the perceived typical drinking patterns of close friends and reference groups were assessed in two different studies with college students. In both studies virtually all students reported that their friends drank more than they did. These effects were found across different levels of individual drinking, within different types of samples, across gender of subjects and with different types of questionnaire assessment. In addition, students' estimates of typical or average drinking within their own social living groups were significantly higher than average drinking within the group estimated from self-reports. Because of the consistent, asymmetrical pattern of reports of self and other drinking, it was interpreted that reports of others' drinking were exaggerated. These biases were particularly evident within organized social groups (i.e., fraternities and sororities) but were minimal in reference to "students in general" or "people in general." Results are discussed in terms of cognitive and motivational factors that potentially could promote or excuse excessive drinking practices among college students.

Prediction of smoking relapse: analyses of temptations and transgressions after initial cessation.

Different types of "relapse crises" and associated coping responses were associated with the resumption of smoking using a prospective design. One hundred and two previously heavy smokers (M = 23.9 cigarettes a day) who achieved initial abstinence through a smoking cessation program were interviewed by telephone at 1, 2, and 3 months posttreatment. At each assessment, subjects described relapse crises, situations in which they were tempted to smoke or actually smoked but resumed abstinence (lapsed). Prospective analyses indicated that any smoking lapse is strongly related to subsequent relapse. Situational characteristics of relapse crises and the number of cognitive and behavioral coping responses reported during crises were only modestly consistent over time and were unrelated to later relapse. Confidence ratings and situational attributions about the relapse crises were also not prospectively associated with eventual relapse. Subanalyses suggested that lapses associated with urges and emotional (guilt) responses and lapses occurring in frequent situations are more likely to result in relapse.