Effects of using recommended coping strategies on drinking outcome following a brief intervention.

AIMS: To explore the unique contribution to outcome drinking of clients' use of six strategies for moderating drinking, after statistically accounting for variance explained by some client and intervention variables. DESIGN: An exploratory hierarchical regression analysis assessed the contributions to variance in drinking outcome of pre-intervention (client characteristics, baseline drinking), assignment (level of assessment, therapist experience) and early follow-up variables. Data came from an experimental trial which evaluated the effect of adding assessment to provision of a self-help book to heavy drinkers. SETTING: Diverse Ontario communities. PARTICIPANTS: Heavy drinkers (99 males, 56 females) were selected from 185 media-recruited applicants who were screened by telephone to exclude cases with severe alcohol-related problems. Their mean (+/- SD) pre-admission weekly quantity of alcohol consumed was 22 +/- 15 drinks. Follow-up rates at 3 and 12 months were 92% and 88%. MEASUREMENTS: Regressed onto weekly quantity at follow-up were: client characteristics, previous measures of weekly quantity, experimental condition and use of the menu of strategies (setting goals for drinking, keeping track of drinking, pacing drinking, planning ahead to avoid heavy drinking, developing free-time activities and coping with problems without drinking). FINDINGS: At 3 months the variables predicting lower weekly quantity were: pre-intervention weekly quantity, developing free-time activities, setting goals for drinking and condition. Lower weekly quantity at 12 months was predicted by lower 3-month and pre-intervention weekly quantity, and regular use of: coping with problems without drinking, setting goals for drinking and keeping track of drinking. CONCLUSIONS: This descriptive study revealed a positive association between level of use of recommended coping strategies at follow-up and drinking outcome. Controlled studies of the effects of strategy use on drinking outcome are therefore warranted.

Screening for problem drinking and counseling by the primary care physician-nurse team.

Present methods to screen for alcohol abuse are generally obtrusive and result in referral to services that deal mainly with alcoholics. These factors deter physicians from identifying alcohol abuse patients at an early stage. In the present study, 81% of all primary care physicians of a single city evaluated (i) the efficiency and the acceptability of a nonobtrusive screening method for the identification of problem drinkers and (ii) the effectiveness of brief cognitive behavioral counseling given by a nurse in a lifestyle context. Patients (n = 15,686) attending the private practices of 42 primary-care physicians were asked four alcohol-neutral trauma questions in the reception area. Physicians asked about alcohol use and alcohol-related problems only to patients with previous trauma. Problem drinkers by defined criteria were offered an appointment with a nurse who, by random assignment, gave either 3-hr of cognitive behavioral counseling over 1 year or simply advised patients to reduce their alcohol intake. The screening method identified 62-85% of expected number of problem drinkers in this population. Following the application of exclusion criteria, 105 problem drinkers were entered in the intervention part of the study. After 1 year, patients who received counseling showed significant reductions in reported alcohol consumption (-70%; p < 0.001), psychosocial problems (-85%; p < 0.001) and serum gamma glutamyl transferase (-32% to -58%; p < 0.02). Physician visits were reduced (-34%; p < 0.02) following counseling. Patients receiving only advice showed neither reductions in psychosocial problems nor in serum gamma glutamyl transferase or physician visits, but reported a 46% reduction (p < 0.01) in alcohol consumption. Data indicate that asking patients about recent trauma is efficient and is well accepted as the first screening instrument in the identification of the problem drinker. Cost of screening per patient is under one dollar. Counseling of 3 hr given by a nurse is markedly superior (p < 0.05) to simple advice in reducing alcohol consumption, objective indicators of alcohol-related morbidity, and the frequency of physician visits.

A self-help approach for high-risk drinking: effect of an initial assessment.

A self-help book was offered to persons wanting to quit or cut down on their alcohol use. Study participants (99 men, 56 women) were recruited through advertisements, screened by telephone, and randomly assigned to 1 of 2 conditions. Book by mail or Assessment + Book (30-min telephone motivational interview plus book by mail). At 3-month follow-up, significantly more participants qualified as moderate drinkers in the Assessment + Book condition (65% vs. 43%), by this criterion: < or = 12 drinks/week and < or = 10% heavy drinking days (5 + drinks if male and 4 + drinks if female; 13.6 g of ethanol per drink). At 12 months there was no effect of condition, but significantly more women than men were rated as moderate drinkers (71% vs. 52%). Collateral informants corroborated the participants' reports of drinking.

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.

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.

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.

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

UNLABELLED: 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 treatment for alcohol dependence: level of dependence and treatment outcome.

The relationship between level of alcohol dependence and treatment outcome was examined by comparing the success rates of severely dependent and not severely dependent males treated briefly in Toronto and Brazil. Treatment involved three 1-hour sessions of training in methods for achieving abstinence or moderate drinking. During the year following treatment, the severely dependent clients were more frequently rated as "successful"--56% of them achieved abstinence or moderate drinking, compared to about 30% of those who were not severely dependent. Although this difference is not statistically significant, the finding is clearly of clinical relevance.

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.

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

UNLABELLED: Problem drinkers (52 males, 38 females) recruited through advertisements were randomly assigned to one of three treatments: GUIDELINES: three sessions of advice using a pamphlet outlining basic steps for achieving abstinence or moderate drinking. Manual: three sessions of instruction in the use of a 'self-help' manual presenting a step-by-step approach for attaining abstinence or moderate drinking. Therapist: six or more sessions of instruction in the methods outlined in the 'self-help' manual. At 3, 6 and 12 months follow-up, no significant differences were found among the groups in reduction of heavy drinking days (i.e. days when consumption exceeded four drinks, each containing 13.6 g/ethanol). Overall, the number of heavy days were reduced from an average of 43 at intake, to 20 over the 1-year follow-up period. Females, however, had significantly greater reductions than males (75% versus 35%). Three months after treatment the rate of successful moderate drinkers was significantly higher for females than males in the GUIDELINES (60% versus 33%) and the Manual condition (63% versus 18%), but not in the Therapist condition (25% versus 35%). At 1-year follow-up, females were more successful than males in all conditions. Mean changes in GGT and MCV levels lended support to the change in drinking status (from heavy drinker at intake to moderate drinker at follow-up), based on clients' self-reports.

Drug deprivation and reinforcement by diazepam in a dependent population.

Individuals who were using therapeutic doses (approximately 15 mg diazepam or its equivalent daily) of a benzodiazepine persistently and wished to attempt to stop were recruited into a study offering a medically supported outpatient behavioral treatment with a goal of abstinence. All subjects received the same behavioral treatment that emphasized the development of strategies for coping with abstinence and alternatives to benzodiazepines as a coping mechanism. The goal of abstinence was to be achieved within approximately 8 weeks by means of gradual tapering of the daily dose. Some subjects (Group D, n = 23) were randomly assigned to a condition in which their dose was to be tapered on a regime of active diazepam. Others (Group P, n = 19) were switched to placebo at the first treatment session and "tapered" from this pharmacologically inert substitute for diazepam. Supplies of tablets of each preparation were provided by the experimenters, and subjects were specifically requested to use only those tablets. The principal dependent variable was "supplementation", or use of a benzodiazepine other than that specifically authorized by the therapist. Supplementation was detected by measures of plasma benzodiazepine levels as compared to levels predicted if there had been strict compliance with the therapeutic regime. These comparisons were made by two expert judges who were blind to the subjects' experimental assignment. Self-report of supplementation was also obtained. Plasma level determinations indicated a significantly greater frequency of supplementation (84% versus 33% of subjects) for subjects in Group P.(ABSTRACT TRUNCATED AT 250 WORDS)

Withdrawal reaction after long-term therapeutic use of benzodiazepines.

We conducted a double-blind, placebo-controlled trail in which 40 patients who had undergone long-term therapy with benzodiazepines were switched to placebo or to diazepam in a dose approximately equivalent to their usual dose of the benzodiazepine; the dose of diazepam was then tapered during an eight-week period. Patients were assessed clinically and psychologically and had weekly sessions of behavioral therapy. The subjects who received placebo had more symptoms, assessed their symptoms as more severe, and stopped taking the study drug at a higher rate than those receiving the tapering doses of diazepam. The subjects in the placebo group also had symptoms shortly after being switched to placebo, whereas those in the diazepam group had symptoms much later. Some withdrawal symptoms were distinct from those of anxiety (e.g., tinnitus, involuntary movement, and perceptual changes). Withdrawal symptoms occurred earlier in patients who had received short-acting benzodiazepines than in those who had received long-acting benzodiazepines. Symptoms gradually disappeared over a four-week period in both the placebo and the diazepam groups. Serial determination of plasma benzodiazepine concentrations was a useful way to assess compliance, treatment outcome, and relapse during withdrawal. We conclude that a clinically important, mild, but distinct withdrawal syndrome occurs after discontinuation of long-term therapeutic use of benzodiazepines.