Mental health impact of the war on drugs.

Further to the publication by the London School of Economics and Political Science of the report Ending the Drug Wars, this editorial focuses on the mental health impact of the 'war on drugs' and on the need to end such policies in favour of evidence-based interventions to manage drug dependence as a health condition.

Randomized controlled trial in alcohol relapse prevention: role of atenolol, alcohol craving, and treatment adherence.

Previous studies suggest that beta-adrenergic blockers reduce craving levels during acute alcohol withdrawal. We conducted a new study to assess whether the daily use of atenolol by the abstinent alcoholic could maintain a blunted craving for alcohol and result in a decreased rate of relapse for alcohol abuse. The study was designed as a randomized, controlled, double-blind clinical trial. Among all 100 patients (50 atenolol, 50 placebo), only 15 stayed in the trial and remained fully abstinent for 1 year (7 atenolol, 8 placebo). Of the remaining 85 patients, 30 withdrew early while still abstinent (17 atenolol, 13 placebo). In the 57 high-risk patients who reported craving for alcohol at baseline, the treatment failure rates were 90% for patients receiving placebo, and was reduced to 65% in those who received atenolol (risk reduction = 28%, 95% confidence interval, -3% to 49%). The data from this trial also support the observation that poorer levels of treatment adherence are strongly associated with adverse outcomes for alcoholics during follow-up. This relationship was present both for patients who received atenolol and for those who received placebo.

The impact of gender on clinical characteristics and outcome in alcohol withdrawal.

Few studies have compared the social and clinical features of alcoholism for women and men, and none has focused on patients entering treatment for withdrawal. We investigated the role of gender by analyzing the data for 179 patients (34 women, 145 men) who underwent outpatient withdrawal. Our analysis focused on two questions: 1) How do women and men compare in terms of baseline social and clinical features? and 2) Do women and men have similar treatment outcomes in alcohol withdrawal? Baseline sociodemographic features revealed that women were more likely to be poor (90% vs. 71%, p = .03) but less likely to be uninsured (32% vs. 51%, p = .05), homeless (6% vs. 20%, p = .05), or have legal problems (29% vs. 54%, p = .02). Surprisingly, women and men reported a similar mean daily alcohol intake (240 g vs. 243 g). Women reported a shorter duration of alcohol abuse prior to entering treatment (16.1 y vs. 19.1 y). Although women experienced a higher treatment failure rate (53% vs. 43%), this difference is not significant. Our analysis highlights gender similarities and differences among patients entering treatment for withdrawal. We conclude that women and men have similar treatment outcomes in the management of alcohol withdrawal.

Social and clinical features as predictors of outcome in outpatient alcohol withdrawal.

OBJECTIVE: To identify patient features--both social and clinical--that may be associated with treatment failure in outpatient alcohol withdrawal. DESIGN: A prospective observational cohort study of patients who underwent outpatient management of the alcohol withdrawal syndrome. SETTING: Community hospital-based outpatient alcohol treatment program. PATIENTS: The 179 patients who were eligible for and participated in a clinical trial of drug therapy for outpatient management of the alcohol withdrawal syndrome. MAIN RESULTS: Treatment failure occurred for 45% (80/179) of the patients. Failure rating did not vary according to diverse sociodemographic features such as age, level of education, income, medical insurance status, and marital status. Persons who were homeless did as well as those who were not. In contrast, two clinical features of withdrawal were associated with significantly higher rates of treatment failure: craving and withdrawal symptom severity. High cravers had a treatment failure rate of 56% (22/39), compared with 36% (41/115) for those with lower scores (p less than 0.03). Among those with moderate-to-high withdrawal symptom severity, 49% (74/151) represented treatment failures, compared with 22% (6/27) of those in the low-symptom group (p less than 0.01). CONCLUSIONS: While these data do not confirm that socially disadvantaged persons are at increased risk for withdrawal treatment failure, two clinical features--craving and withdrawal symptom severity--may help identify high-risk patients.

The efficacy of atenolol in the outpatient management of the alcohol withdrawal syndrome. Results of a randomized clinical trial.

We conducted a randomized, double-blind, clinical trial of atenolol compared with placebo in the outpatient management of patients with the alcohol withdrawal syndrome. In addition to receiving customary therapy, 88 patients were randomly assigned to receive atenolol and 92 to receive placebo. Outcome during the next 14 days was assessed using two main measures: the patient's clinical course as assessed by an alcohol withdrawal severity index; and the occurrence of treatment failure (composite measure including return to drinking, dropouts, and withdrawal lasting longer than 5 days). In addition, levels of craving for alcohol were assessed as an associated response variable. Overall, treatment failure occurred for 37% of the patients receiving atenolol and 52% of those receiving placebo. Among patients who had withdrawal symptoms at baseline, vital signs became normal more rapidly in the patients receiving atenolol, and their abnormal behavioral characteristics also resolved more rapidly. Levels of craving for alcohol were strongly associated with treatment failure; the group of patients who received atenolol included significantly fewer who reported high levels of craving 24 hours after treatment began (7% of patients receiving atenolol and 20% of those receiving placebo). We conclude that the outpatient management and treatment outcomes of the alcohol withdrawal syndrome are improved in patients who receive atenolol, and that the beneficial effects are associated with reduced levels of craving for alcohol. If these results are confirmed by other investigators, atenolol may prove to play an important role in the outpatient management of the alcohol withdrawal syndrome.

Randomized clinical trial of atenolol in patients with alcohol withdrawal.

We conducted a randomized, double-blind clinical trial of atenolol as compared with placebo in the treatment of patients hospitalized with the alcohol withdrawal syndrome. In addition to receiving customary therapy, 61 patients were randomly assigned to receive atenolol, and 59 to receive placebo. Outcome was assessed daily by the measurement of nine features in three categories: vital signs, clinical signs (e.g., tremor), and behavioral signs (e.g., agitation and anxiety). Compared with placebo patients, atenolol patients had a significant reduction in the mean length of hospital stay (four as compared with five days, P less than 0.02). On each treatment day, significantly fewer patients receiving atenolol required concomitant benzodiazepines, and patients receiving placebo required a significantly higher mean daily dose of benzodiazepines. Among patients who had withdrawal symptoms at base line, vital signs became normal more rapidly in the patients receiving atenolol, and their abnormal behavior and clinical characteristics also resolved more rapidly. We conclude that atenolol is helpful in the treatment of patients with the alcohol withdrawal syndrome.