Alcohol-related emergency department attendances after the introduction of the Sale and Supply of Alcohol Act 2012.

AIM: To measure changes in alcohol-related emergency department (ED) attendances after introduction of the Sale and Supply of Alcohol Act 2012. METHODS: Cross-sectional survey of Christchurch ED attendees in three-week sampling periods in 2013 and 2017. Participants had consumed alcohol within four hours, or their drinking had directly contributed to the attendance. The quantity of alcohol consumed and places of purchase and consumption for the index drinking episode were recorded. RESULTS: From 2013 to 2017 there was a non-significant (p=.41) reduction in the proportion of ED attendees eligible for the study, from 253/3400 (7.4%) to 258/3721 (6.9%). Among participants (n=169 in 2013, n=139 in 2017), liquor store purchasing increased from 41.7% in 2013 to 56.1% in 2017 (p<.01) but there was no significant change in quantity consumed in the index episode; last drink location; percentage of participants with an injury-related attendance; or pre-drinking. In both waves, most participants had purchased alcohol from off-licence venues and consumed their last drink at a private location. CONCLUSION: Alcohol-related ED attendances remained common after the Sale and Supply of Alcohol Act 2012 was introduced, and they mainly occurred in people who sourced alcohol from off-licence outlets and had their last drink at private locations.

Personality Predictors of Drinking Outcomes in Depressed Alcohol-Dependent Patients.

AIM: To evaluate the role of personality dimensions as predictors of drinking outcomes in depressed alcohol-dependent patients. METHODS: Temperament and character inventory (TCI) scores were obtained at baseline in a 24-week study of 127 depressed alcohol-dependent patients who received open-label naltrexone and were randomized to citalopram or placebo. The association between TCI personality dimensions and alcohol outcomes during follow-up was examined using general linear mixed models. RESULTS: Low novelty seeking, high self-directedness and high cooperativeness predicted less alcohol consumption on drinking days during follow-up. Temperament and character variables had no effect on the percentage of days abstinent from alcohol. Depression mediated the effects of self-directedness and cooperativeness on alcohol outcomes while the effect of novelty seeking remained after adjusting for depression scores in follow-up. CONCLUSION: Identifying personality characteristics at baseline predicts drinking outcomes in depressed, alcohol-dependent patients. In particular patients with high novelty seeking drank more heavily on drinking days and they may therefore need more intensive intervention to achieve good treatment outcomes.

A randomized trial of combined citalopram and naltrexone for nonabstinent outpatients with co-occurring alcohol dependence and major depression.

Despite the high rate of co-occurrence of major depression and alcohol dependence, the role of pharmacotherapy in their treatment remains unclear. In the new era of naltrexone for alcohol dependence, it is notable that only 1 study to date has examined the efficacy of antidepressant medication prescribed concurrently with naltrexone. We aimed to determine whether combining naltrexone with citalopram produced better treatment outcomes than naltrexone alone in patients with co-occurring alcohol dependence and depression, and to investigate whether either sex or depression type (independent or substance-induced depression) moderated treatment response. Participants were 138 depressed alcohol-dependent adults who were not required to be abstinent at the commencement of the trial. They were randomized to 12 weeks of citalopram or placebo, plus naltrexone and clinical case management. Treatment was well attended, and medications were reasonably well tolerated with high adherence rates. Substantial improvements in both mood and drinking occurred in both groups, with no significant differences between groups on any of the mood or drinking outcome measures, whether or not other variables were controlled for. No interaction effect was found for independent/substance-induced depression status, whereas there was a marginal effect found by sex, with greater improvement in 1 drinking outcome measure (percent days abstinent) in women taking citalopram. These findings suggest that citalopram is not a clinically useful addition to naltrexone and clinical case management in this treatment population. Independent/substance-induced depression status did not predict treatment response. Findings for sex were equivocal.

OPRM1 genotype and naltrexone response in depressed alcohol-dependent patients.

A functional polymorphism rs1799971 (A118G) in the µ-opioid receptor gene (OPRM1) produces an amino acid substitution Asn40Asp, which is believed to influence naltrexone response in nondepressed alcohol-dependent patients. In this study, patients with alcohol dependence and major depression (n=108) received open-label naltrexone and clinical case management for 12 weeks, and were randomized to citalopram or placebo. General linear mixed models examined the effect of the OPRM1 A118G genotype on alcohol outcomes during treatment. There was no evidence of any difference in the percentage of days abstinent, drinks per drinking day or percentage of heavy drinking days between Asp40 carriers and noncarriers during treatment. This study therefore failed to replicate the previous positive findings for this single nucleotide polymorphism in relation to naltrexone response, possibly indicating that the effect is not present in depressed patients.

Depression outcome in alcohol dependent patients: an evaluation of the role of independent and substance-induced depression and other predictors.

BACKGROUND: Depression commonly co-occurs with alcohol use disorders but predictors of depression treatment outcome in patients with both conditions are not well established. METHODS: Outpatients with alcohol dependence and major depression (n=138) were prescribed naltrexone and randomized to citalopram or placebo for 12 weeks, followed by a 12-week naturalistic outcome phase. General linear mixed models examined predictors of Montgomery Asberg Depression Rating Scale (MADRS) score over 24 weeks. Predictors included whether depression was independent or substance-induced, and demographic, alcohol use, and personality variables (Temperament and Character Inventory subscales). RESULTS: Most improvement in drinking and depression occurred between baseline and week 3. During follow-up, patients with substance-induced depression reduced their drinking more and they had better depression outcomes than those with independent depression. However, greater reduction in drinking was associated with better depression outcomes for both independent and substance-induced groups, while antidepressant therapy had no effect for either group. Baseline demographic and alcohol use variables did not predict depression outcomes. Among personality variables, high self-directedness was a strong predictor of better depression outcomes. LIMITATIONS: Subjects were not abstinent at baseline. The influence of naltrexone on depression outcomes could not be tested. CONCLUSION: Alcohol dependent patients with substance-induced depression have better short term depression outcomes than those with independent depression, but this is largely because they reduce their drinking more during treatment.

Opioid substitution treatment in New Zealand: a 40 year perspective.

We provide an overview of the history and philosophy of the treatment for opioid dependence, which has been dominated by methadone substitution treatment for the past 40 years in New Zealand. Although changes in approach have occurred over this time, influenced by various sociopolitical events and changing ideologies, opioid substitution treatment has still "not come of age". It remains undermined by stigma and risk concerns associated with methadone and has struggled to be accessible and attractive to illicit opioid drug users, comprehensive and integrated into mainstream health care. However, the introduction in 2012 of Pharmac-subsidised buprenorphine combined with naloxone (Suboxone) in the context of an emerging trend towards a broader recovery and well-being orientation could signal a new era in treatment. The availability of buprenorphine-naloxone may also facilitate a further shift in treatment from primarily siloed specialist addiction services to integrated primary care services. This shift will help reduce stigma, promote patient self-management and community integration and align opioid substitution treatment with treatment for other chronic health conditions such as diabetes and asthma.

Current clinical practices in Aphasia Therapy in Finland: challenges in moving towards national best practice.

AIMS: The objective of this article is to discover and document the state of clinical practices for aphasia therapy in Finland and to gather information for developing national best practice. METHODS: Two surveys were administered in Finland that explored current clinical practices in aphasia rehabilitation and the resources available to speech and language therapists (SLTs). We integrated and compared the results of these surveys. The results are based on the responses of the 88 (45 + 43) returned questionnaires from SLTs. RESULTS: Four principle themes were identified: planning the aphasia therapy, measures and assessment methods, current therapy service provision, and development suggestions and barriers to change. The results of this study showed considerable consistency in clinical practices among the respondents to the surveys. However, we noticed that there are some discrepancies between the recent research findings and present clinical practices. CONCLUSIONS: The findings from this study indicate that there are many challenges in clinical decision-making at the moment in Finland. The article helps clinicians to evaluate the practices they use and to execute justified modifications in order to implement more effective models of practice. It is evident that national best practice guidelines for aphasia therapy would support SLTs in clinical decision-making.

The NEEDNT Food List: non-essential, energy-dense, nutritionally-deficient foods.

AIM: To provide a list of non-essential, energy-dense, nutritionally-deficient foods in New Zealand (NEEDNT foods) which are usually high in calories and either bereft of nutritional benefits or easily replaced with lower calorie, more nutritious alternatives. METHODS: The List was compiled using the National Heart Foundation and Diabetes New Zealand "Foods to Avoid", "Stop Eating" and "Optional Foods" lists and the Canterbury District Health Board "Supermarket Shopping Guide". Foods and beverages were included if they contained alcohol, saturated fat, added sugar, were prepared using a high fat cooking method or contained a large amount of energy relative to their essential nutrient value. As it has no energy value, salt was not a criterion for inclusion on the List. RESULTS: Over 50 potential foods or groups of foods were identified that contained alcohol, saturated fat, added sugar, were prepared using a high fat cooking method or contained a large amount of energy relative to their essential nutrient value. Fifty foods/groups of foods were included on the final list (Table 1). CONCLUSIONS: The NEEDNT Food List will be a useful tool for medical practitioners and other health professionals working with people wanting to lose weight [corrected].

An estimation of the prevalence of opioid dependence in New Zealand.

BACKGROUND: An accurate prevalence estimate for opioid dependence in New Zealand, and hence the extent of unmet treatment need, is lacking. METHODS: Opioid users were recruited via snowball sampling, with participants initially recruited from opioid substitution treatment (OST) services and dedicated needle exchanges in Auckland, Tauranga and Christchurch. Participants estimated the number of people they knew personally who were receiving OST and who were not receiving OST, but were using opioids daily or almost daily. From these estimates a multiplier of the ratio between these two groups was derived and applied to the known number receiving OST in New Zealand to arrive at the total population estimate. RESULTS: The mean multiplier estimate, weighted for treatment site, for 84 recruited participants was 2.015. The multiplier was higher for Christchurch. Initial recruitment source did not influence the value of the multiplier estimate. When the multiplier was applied to the known size of the New Zealand OST treatment population the total opioid dependent population was estimated to be 9142 (95% CI: 8248-10036), of whom half were not receiving OST. CONCLUSION: This figure was lower than for previous less robust estimates, but still represents a substantial level of unmet need. Greater effort needs to be made to close this treatment gap.

Consumer and treatment provider perspectives on reducing barriers to opioid substitution treatment and improving treatment attractiveness.

In New Zealand approximately 4600 people receive opioid substitution treatment (OST) for opioid dependence, primarily methadone maintenance treatment. This study explored ways in which OST could be improved, given the significant waiting times for treatment. Two parallel surveys were conducted: 1) peer interviews with 85 regular daily or almost daily opioid drug users (51.8% receiving OST, 18.8% not currently receiving OST, and 29.4% never received OST) and; 2) a census of all 18 specialist OST service providers. When asked how OST might be improved, the four categories most commonly cited by the opioid users were 'better treatment by staff', 'more flexibility', 'better takeaway arrangements', and 'decreased waiting time'. Both opioid users and specialist services rated 'restricted takeaways' and 'having to go on a waiting list' in the top three perceived barriers to OST. Almost all services reported significant resource issues and barriers to the transfer of stable clients from specialist services to continuing treatment in primary care. The findings from this study indicate how OST can be made more accessible and attractive and thus achieve better uptake and retention.

An improved brief measure of cannabis misuse: the Cannabis Use Disorders Identification Test-Revised (CUDIT-R).

BACKGROUND: Cannabis is widely used and significant problems are associated with heavier consumption. When a cannabis misuse screening tool, the CUDIT, was originally published it was noted that although it performed well there was concern about individual items. METHODS: 144 patients enrolled in a clinical trial for concurrent depression and substance misuse were administered an expanded CUDIT, containing the original 10 items and 11 candidate replacement items. All patients were assessed for a current cannabis use disorder with the SCID. RESULTS: A revised CUDIT-R was developed containing 8 items, two each from the domains of consumption, cannabis problems (abuse), dependence, and psychological features. Although the psychometric adequacy of the original CUDIT was confirmed, the CUDIT-R was shorter and had equivalent or superior psychometric properties. High sensitivity (91%) and specificity (90%) were achieved. CONCLUSIONS: The 8-item CUDIT-R has improved performance over the original scale and appears well suited to the task of screening for problematic cannabis use. It may also have potential as a brief routine outcome measure.

Should ethanol be scheduled as a drug of high risk to public health?

Six criteria described in the New Zealand Misuse of Drugs Act and used by the Expert Advisory Committee on Drugs (EACD) for determining the risk of a drug to public health were examined in relation to ethanol, using gamma-hydroxybutyric acid (GHB) as a comparator drug. GHB is an ideal candidate for use as a comparator because it is a sedative substance very similar to ethanol and has been previously investigated by the EACD using these six criteria. GHB was subsequently classified as a Class B1 drug under the Misuse of Drugs Act, that is, as a prohibited drug of high risk to public health. The dangerousness level of ethanol was found to be at least similar to that of GHB in this analysis. This highlights a major discrepancy in public policy.

Development of a brief treatment instrument for routine clinical use with methadone maintenance treatment clients: the methadone treatment index.

Routine measurement of treatment outcome between clinician and client in alcohol and drug user treatment services is an important quality improvement initiative. It is particularly important for clients receiving long-term treatment such as methadone maintenance treatment, as fluctuations in substance use, functioning, and health are to be expected. Although there are a number of standardized alcohol and drug user treatment outcome instruments available for research and clinical use, a key challenge is to develop clinical instruments that will actually be used routinely in busy practice settings by a range of staff. Such instruments need to be brief, acceptable to staff and clients, easy to use, provide immediate feedback, and meet adequate psychometric requirements. This report describes development work undertaken in three studies of the Methadone Treatment Index (MTI). The MTI is a brief instrument comprising measures of recent substance use, aspects of social and behavioral functioning, and physical and psychological health. The MTI was designed in consultation with clinicians and clients for use in monitoring treatment progress with clients receiving methadone maintenance treatment. Key findings were that the MTI was acceptable to clients, produced clinically relevant information, and has satisfactory psychometric properties, although it was not used to measure change in this study. Further evaluation of the MTI on a longitudinal basis is supported.

Five-year outcomes of alcohol-dependent persons treated with motivational enhancement.

OBJECTIVE: The purpose of this study was to determine whether the superior treatment effect of motivational enhancement therapy (MET) previously demonstrated at 6 months was sustained at a 5-year posttreatment follow-up. METHOD: Patients with mild to moderate alcohol dependence had completed a trial in which all patients were assessed, attended a brief feedback session, and were randomized to four sessions of MET, nondirective reflective listening, or no further counseling. The primary drinking outcome was unequivocal heavy drinking (UHD), defined as drinking 10 or more standard drinks on six or more occasions over a 6-month period. At the 6-month follow-up, 108 of 122 patients agreed to a further follow-up interview. RESULTS: Seventy-seven patients were successfully followed for a mean (SD) of 58 (14) months after the completion of treatment. Although the group as a whole had continued to improve, with rates of UHD reduced from 51 % at 6 months to 25% at 5 years, there was no difference by treatment group in drinking for UHD or a range of lower drinking thresholds. CONCLUSIONS: Although 5-year outcomes were indistinguishable among the three treatment groups, this was the result of patients in the comparison conditions catching up to the drinking gains of MET patients rather than a deterioration in drinking for MET patients. Individuals allocated to receive MET achieved a greater reduction sooner than either of the comparison treatment conditions.