Addiction, culture and family therapy strategies.

Τhis update reviews the empirical evidence supporting the use of couple and family therapies in managing families affected by addiction, both adolescent and adult populations. A particular focus of the paper is the need for a "culturally competent" strategy in assessing and treating target families.

Homogenizing alcoholism treatment across Europe.

UNLABELLED: Alcohol treatment ideologies and goals vary in different countries of Europe and have been influenced by cultures and drinking patterns. From the traditional high-consumption wine countries of Southern Europe to the spirit drinking North European countries. However, due to the natural course of alcoholism, long-term alcohol dependent patients share common features independent from initial drinking patterns and cultural influences. This makes populations' characteristics and the result of treatment comparable within Europe, even though treatment approaches and selection of patients vary in different countries. Clinical trials using common measures for outcome of intervention have been performed in the last ten years in several countries of Europe. Outcome has been measured not only with the traditional definition of abstinence (or other drinking end-points), but also in terms of the subjective impact of disease and treatments on patients' lives. The discovery that different types of supportive therapies (alone or in combination with medications) do have positive influences on the progress of the alcoholic disease, improving the patients' quality of life (QoL) in all countries of Europe, shed a light of optimism on what, until recently, was considered an untreatable disease. SUMMARY: From the age when alcohol treatment outcomes were incorrectly measured and barely comparable because of different populations (especially from the USA), scarce description of intervention and goals of treatment, a great progress has been reached, in recent years, with new methodologies applied in Europe in clinical trials dealing with populations of alcoholics. Therapies do work in improving their well-being status and life expectancy in all countries of Europe.

The role of gamma-hydroxybutyric acid in the treatment of alcoholism: from animal to clinical studies.

Since its discovery nearly 40 years ago, gamma-hydroxybutyric acid (GHB) has attracted several waves of scientific interest due to new developments in the knowledge of its mechanisms of action and ideas for its potential use in clinical practice. Its effects have been claimed to treat different psychiatric conditions, but over time its use has become limited to a few specific situations (e.g. sedating patients in non-painful surgical procedures and narcolepsy). New interest in the drug derives from its potential use in the treatment of alcoholism. Recent studies demonstrated a marked effect of the substance in suppressing ethanol (ETOH) withdrawal symptoms and in reducing craving for alcohol, compared to other available drugs. However, GHB has to be given under very careful supervision because of its side-effects, including the risk of abuse and dependence and possible interference with the metabolic pathways of endogenous GHB and ETOH. This short review discusses these and related issues and we hope that it will stimulate further interest in GHB.

Alcohol and criminal behaviour.

Substance abuse is a factor in some but not all incidents of crime: more than half of murders are committed when the killer is intoxicated. Males are more likely than females to be violent when consuming alcohol, and a past history of violence is predictive of future crime. The risk of violent behaviour is greater in subjects with dual diagnosis (e.g. alcohol dependence and psychiatric disorders). Offenders with an intellectual disability are overrepresented in prison and court populations, and more than 50% of them have a problem with alcohol. Since these subjects, in addition to intellectual disability and alcohol use, have psychiatric and behavioural problems, early recognition, in an effort to prevent future crimes, is an appropriate goal. Specific programmes have to address their particular needs.

Integration of pharmacotherapies in the existing programs for the treatment of alcoholics: an international perspective.

This review examines current therapies of alcoholism and addresses the difficulties encountered in evaluating the result of integrating pharmaco- and psychosocial treatment of alcoholics. A variety of treatment modalities and goals, and factors influencing admission of alcoholics, exist in different countries creating problems of comparability. Recognition of alcoholism as a separate entity from associated psychiatric co-morbidity coupled with the introduction of specific pharmacotherapies represent a major advance in the treatment of alcoholism. Combining psychosocial and pharmacological treatments appears to be the most effective approach in the treatment of alcoholics. In the future, rational therapy with appropriate choice of treatment strategies will decrease the necessity for hospital treatment of alcoholic patients.

Acamprosate treatment in a long-term community-based alcohol rehabilitation programme.

AIMS: To evaluate the efficacy of acamprosate in maintaining abstinence in weaned alcohol-dependent patients. DESIGN: A multicentre, double-blind, randomized control trial. Patients were individually randomly allocated to active or placebo conditions. Abstinence was assessed during a 6-month treatment period and after a 6-month follow-up period. SETTING: A community-based, outpatient alcohol rehabilitation programme. PARTICIPANTS: Two hundred and forty-six alcohol-dependent patients between the ages of 18 and 65 years were recruited immediately following acute, inpatient withdrawal treatment. MEASUREMENTS: The primary outcome measure was self-reported abstinence from alcohol since the previous sessions at 3, 6, 9 and 12 months following the start of treatment, with treatment taking place for a period of 6 months. FINDINGS: A significantly higher proportion of patients in the acamprosate group were abstinent after 3 months and 6 months of treatment. The percentage of patients with continuous abstinence at the end of the treatment period was almost double for the acamprosate group than for the placebo group (40.7% vs. 20.8%, respectively). Acamprosate significantly increased the retention of patients in the treatment programme. Six months after drug treatment ceased, the criterion of abstinence since the previous visit was reached by significantly more patients from the acamprosate group (43.4%) than from the placebo group (29.8%), but this difference was not statistically significant at the 3-month point after cessation of study medication. CONCLUSIONS: Acamprosate may be a useful pharmacological compound for the long-term treatment of alcohol-dependence when applied in a community-based rehabilitation programme.

Alcoholism. The cost of illness in the Federal Republic of Germany.

The purpose of this study was to estimate the direct and indirect costs of alcoholism in the Federal Republic of Germany. Direct costs comprised treatment costs, while indirect costs consisted mainly of costs incurred as a result of work time lost, as well as costs related to premature retirement and premature mortality. The costs of alcoholism were estimated using the aggregated statistics of several social security organisations and official statistics. For the purposes of this study, alcoholism was defined as alcohol dependence syndrome [9th revision of the International Classification of Diseases code (ICD) 303], alcoholic chronic liver disease and cirrhosis (ICD 571.0 to 571.3), and alcoholic psychoses (ICD 291). The reference period consisted of the years 1985 to 1991. All statistics and all analyses were limited to the so-called old states of Germany, within the boundaries as they were before 3rd October 1990. The overall monetary burden (in 1990 Deutschemarks) of alcoholism in the western part of Germany in 1990 was estimated to be DM5975 million. Alcoholism is associated with considerably more indirect costs (DM4422 million) than direct costs (DM1553 million). The predominance of indirect costs is mainly the result of the very high premature mortality of patients with alcoholism. Thus, the cost of premature mortality makes up more than half of the indirect costs of alcoholism (DM2284 million), while about a quarter of the indirect costs (DM1150 million) are associated with inability to work. Early retirement accounts for a similar amount (DM988 million). The majority of direct costs is accounted for by treatment in acute hospitals (DM869 million). Costs incurred as a result of rehabilitation treatment (DM373 million) and ambulatory care (DM331 million) are also considerable.

Towards a multi-functional diagnostic and evaluation instrument for international comparative research into the quality of the treatment of alcohol problems.

An evaluative survey, actualized until june 1991 is presented of instruments measuring alcohol problems. It is argued that in international comparative studies into the quality of alcohol treatment, scientists must agree on using identical measuring instruments and procedures.

Mortality studies in the long-term evaluation of treatment of alcoholics.

Mortality studies demonstrate that, in all the Countries evaluated, alcoholics die twenty years earlier than expected. Causes of death vary according to drinking patterns. Though mortality data seem crude, they can detect changes due to clinical intervention. Alcoholism studies should benefit by improvement of research methodologies as already applied to other chronic diseases.

Stroke-cirrhosis relationship: an autopsy study in a heavy drinking population.

A positive association between alcohol consumption and stroke incidence has been clearly established. The present study evaluated the frequency of stroke in a sample of 500 autopsied patients affected by liver cirrhosis mainly due to chronic alcohol abuse as confirmed by the histologic pattern mostly of mixed and micronodular types. Frequency of stroke was compared to that of 4,741 non-cirrhotic patients autopsied in the same period. Our findings demonstrate that stroke frequency, especially when due to thromboembolism, decreased significantly in cirrhotics. Therefore, hepatopathy is a crucial event in alcoholic patients. Nevertheless the concomitant presence of liver cirrhosis, in studies dealing with this subject, is not being currently evaluated.

Personality disorders and alcoholism treatment outcome.

The relationship existing between personality disorders (classified according to DSM III) and alcohol treatment outcome was evaluated in 404 alcoholics admitted to the Psychiatric Clinic of the University of Trieste, Italy. One quarter of the subjects had personality disorders, mainly of the 'antisocial', 'dependent', and 'borderline' subtypes. Alcohol abuse was specifically related to 'antisocial' personalities. Marked differences in treatment outcome among personality disorders were found. Group therapy for alcoholism was not beneficial to 'antisocial' personalities; it was most useful among 'dependent' subjects.

1,4-Butanediol and ethanol compete for degradation in rat brain and liver in vitro.

We examined the enzymatic reaction responsible for the conversion of 1,4 butanediol to gamma-hydroxybutyric acid and the interaction of ethanol with this conversion in brain and liver. The enzyme responsible for this reaction in liver appears to be alcohol dehydrogenase. However, in both tissues, there was a competitive inhibition by ethanol of the conversion of 1,4 butanediol to gamma-hydroxybutyric acid with an apparent Ki of 6.5 X 10(-3) M in brain and 2.7 X 10(-3) M in liver. These findings may explain the potentiation of the behavioral effects of ethanol by 1,4 butanediol.

Attitudes toward alcoholism among Italian future teachers and health professionals.

Attitudes toward alcoholism were investigated in an Italian population of 401 future teachers and health professionals. The results were compared to data obtained from comparable individuals (students) previously interviewed in the United States and in Australia. In Italy, alcoholism is mainly considered a 'medical illness' caused by 'moral weakness'. The data suggest that attitudes of Italian students are strongly influenced by cultural patterning. University attendance had minor effects in changing students' attitudes.

Ethanol potentiates the toxic effects of 1,4-butanediol.

The simultaneous administration of ethanol increases the mortality rate and tissue damage observed in rats after 1,4-butanediol (1,4-BD). A related increase in tissue 1,4-BD concentration supported the hypothesis of an in vivo competition of the two substances for alcohol dehydrogenase. The clinical implications of the results, in light of the recent discovery of the presence of endogenous 1,4-BD in humans are discussed.

1,4 Butanediol, gamma-hydroxybutyric acid and ethanol: relationships and interactions.

We have investigated the interaction of 1,4 butanediol (1,4 BD) with ethanol and the involvement of the major metabolite of 1,4 BD, gamma-hydroxybutyric acid (GHB) in the ability of 1,4 BD to produce behavioral and EEG changes in rat as well as the toxic side effects of 1,4 BD. Behavioral, electrical, and biochemical studies in rats suggest that the effects of 1,4 BD are indeed mediated by GHB. Further, ethanol appears to block conversion of 1,4 BD to GHB. 1,4 BD however potentiates some of the behavioral effects of ethanol perhaps by a mechanism of action similar to that of other alcohols. Thus 1,4 BD appears to have two types of pharmacologic actions, one attributable to its conversion to GHB and the other an inherent property of the diol itself.

Effect of ethanol and acetaldehyde on gamma-hydroxybutyric acid in rat brain and liver.

We examined the effect of acute and chronic ethanol administration on brain and liver gamma-hydroxybutyric acid (GHB), the effect of pyrazole on the ethanol-GHB interaction, and the effect of acetaldehyde on brain and liver GHB. Ethanol produced a marked increase in liver GHB but had no effect on GHB in brain. The ethanol effect in liver was not blocked by pyrazole. Acetaldehyde had no effect in brain or liver on GHB.