Potential associations among genetic markers in the serotonergic system and the antisocial alcoholism subtype.

Alcoholism is transmitted in families. The complexity and heterogeneity of this disorder has made it difficult to identify specific genetic correlates. One design with the potential to do so is the family-based association study, in which the frequencies of genetic polymorphisms are compared between affected and nonaffected members. Reduced central serotonin neurotransmission is associated with features of an antisocial subtype of alcoholism, although a primary deficit has not been traced to a particular component. Genetic markers related to the sertonergic system have been identified, located, and cloned. If associations can be discovered, the development process for pharmacotherapy could be facilitated. In this review, the evidence for the involvement of the serotonergic system in antisocial alcoholism is examined, and the potential for family-based association studies to identify specific components that may be involved is discussed.

Treatment of alprazolam withdrawal with chlordiazepoxide substitution and taper.

We describe the first case series (n = 6) of using chlordiazepoxide to accomplish a rapid, well-tolerated withdrawal from alprazolam. After abruptly discontinuing alprazolam, we substituted a 50-mg dose of chlordiazepoxide for each 1 mg of alprazolam (except for one elderly patient where we substituted 25 mg) and gave additional chlordiazepoxide doses (25-50 mg every 4-6 hours) as needed for the first 1-2 days of hospitalization. With this approach, the mean "substitution ratio" of chlordiazepoxide to alprazolam was 86 to 1. We then tapered chlordiazepoxide by an average of 10% each day over a 7- to 14-day period according to the symptoms manifested and tolerated by individual patients. No seizures or other serious side effects occurred. Incomplete cross-dependence, as described elsewhere in the literature, was not observed. The rapidity and familiarity of the method are advantages for inpatient units, but careful titration of dosage, diagnostic clarity, and extended follow-ups are necessary when applying this approach.

Recent advances in addictive disorders. Special populations. Women, ethnic minorities, and the elderly.

The term special populations in the field of substance abuse refers to groups of patients who have unique treatment needs or who are underserved. This article reviews recent advances in substance abuse among three special population groups: women, ethnic minorities, and the elderly. The prevalence, problems with identification, issues in treatment, and treatment outcomes of substance abuse are discussed separately for each group. Finally, the heterogeneity of characteristics within each special population group is emphasized.

Alcohol and cocaine abuse. A comparison of epidemiology and clinical characteristics.

Increasing numbers of persons presenting for substance abuse treatment are multiple-substance users and their predominant drugs of choice are cocaine and alcohol. There are similarities in the treatment of alcohol and cocaine abuse, but important clinical differences need to be acknowledged. This chapter compares and contrasts the most recent epidemiology and clinical characteristics of both alcohol and cocaine abusers. First, use and abuse trends in the United States for both substances are described. The clinical characteristics of dependence on either substance are contrasted in detail, and finally, treatments are briefly described. Treatment for both disorders can be accomplished in the same setting if important demographic and pharmacological differences are addressed. In either disorder, comorbid psychopathology is frequent and appropriate treatment matching based on diagnosis is imperative.

Benzodiazepines and the elderly. A review of potential problems.

This article reviews the literature describing the extent of benzodiazepine use and abuse in the elderly and specific problems attendant upon this use, Unrecognized, undocumented use and abuse of psychoactive drugs is frequent in this population and can lead to serious problems with untreated dependence and withdrawal. The elderly appear to be more sensitive to the effects of benzodiazepines, both because of changed pharmacokinetics and pharmacodynamics with aging and because of altered postreceptor cerebral response. All problems identified with benzodiazepines such as dependence, withdrawal, and cognitive and psychomotor impairment are proportionally greater among the elderly, who can least afford these risks. Review of the literature leads to the conclusion that benzodiazepine prescribing for the elderly should be undertaken with the greatest caution and only with the recognition of all potentially disastrous effects.