Addiction

Historically, addiction treatments have been delivered and evaluated under an acute‐care format. Fixed amounts or durations of treatment have been provided and their effects evaluated 6–12 months after completion of care. The explicit expectation of treatment has been enduring reductions in substance use, improved personal health and social function, generally referred to as ‘recovery’. In contrast, treatments for chronic illnesses such as diabetes, hypertension and asthma have been provided for indeterminate periods and their effects evaluated during the course of those treatments. Here the expectations are for most of the same results, but only during the course of continuing care and monitoring. The many similarities between addiction and mainstream chronic illnesses stand in contrast to the differences in the ways addiction is conceptualized, treated and evaluated. This paper builds upon established methods of during‐treatment evaluation developed for the treatment of other chronic illnesses and suggests a parallel evaluation system for out‐patient, continuing‐care forms of addiction treatment. The suggested system retains traditional patient‐level, behavioral outcome measures of recovery, but suggests that these outcomes should be collected and reported immediately and regularly by clinicians at the beginning of addiction treatment sessions, as a way of evaluating recovery progress and making decisions about continuing care. We refer to this paradigm as ‘concurrent recovery monitoring’ and discuss its potential for producing more timely, efficient, clinically relevant and accountable evaluations.

Background  In the past two decades, a number of studies investigating the role of the therapeutic alliance in drug treatment have been published and it is timely that their findings are brought together in a comprehensive review.

Aims  This paper has two principal aims: (1) to assess the degree to which the relationship between drug user and counsellor predicts treatment outcome and (2) to examine critically the evidence on determinants of the quality of the alliance.

Methods  Peer‐reviewed research located through the literature databases Medline, PsycInfo and Ovid Full Text Mental Health Journals using predefined search‐terms and published in the past 20 years is considered. Further papers were identified from the bibliographies of relevant publications.

Findings  A key finding is that the early therapeutic alliance appears to be a consistent predictor of engagement and retention in drug treatment. With regard to other treatment outcomes, the early alliance appears to influence early improvements during treatment, but it is an inconsistent predictor of post‐treatment outcomes. There is relatively little research on the determinants of the alliance. In studies that are available, clients’ demographic or diagnostic pre‐treatment characteristics did not appear to predict the therapeutic alliance, whereas modest but consistent relationships were reported for motivation, treatment readiness and positive previous treatment experiences.

Conclusions  The therapeutic alliance plays an important role in predicting drug treatment process outcomes, but too little is known about what determines the quality of the relationship between drug users and counsellors.

Aims  To explore differences in alcohol consumption and negative nightlife experiences between young people who drink prior to attending city nightlife venues and those who do not drink until reaching bars and nightclubs.

Design, setting and participants  A cross‐sectional survey of 380 young people (aged 18–35 years) in bars and nightclubs in a large city centre in the North‐west of England.

Measurements  An anonymous questionnaire explored participants' basic demographics; frequency of utilizing nightlife; quantities of alcohol consumed prior to and during a typical night out in the city; and negative experiences in the city's nightlife in the previous year [fighting, being verbally abused, being sexually molested (e.g. groped) and being too drunk to walk].

Findings  Participants who reported drinking prior to attending nightlife (e.g. at their own or a friend's home) reported significantly higher total alcohol consumption over a night out than those not drinking until reaching bars and nightclubs. Over a quarter (26.5%) of female and 15.4% of male alcohol consumption over a night out occurred prior to attending nightlife. Individuals who drink before going out were over four times more likely to report drinking >20 units on a usual night out and 2.5 times more likely to have been involved in a fight in the city's nightlife during the previous 12 months.

Conclusions  Measures to tackle drunkenness and alcohol‐related violence in nightlife should expand beyond those targeted solely at nightlife environments. Continued disparities in pricing and policing of alcohol between on‐ and off‐licensed premises may increase at‐home drinking prior to nights out and alcohol‐related problems in residential areas.

Aims  Reducing alcohol‐related harm in young people is a major priority across Europe. Much alcohol use and associated harm in young people occurs in public drinking environments. This review aims to identity environmental factors in drinking establishements that are associated with increased alcohol consumption and associated harm and to understand the extent of study in this area across Europe.

Methods  A systematic literature search identified studies that had explored associations between physical, staffing and social factors in drinking environments and increased alcohol use or alcohol‐related harm.

Results  Fifty‐three papers were identified, covering 34 studies implemented in nine countries. Most studies had been implemented in non‐European countries and many had collected data more than a decade prior to the review. The majority had used observational research techniques. Throughout the studies, a wide range of physical, staffing and social factors had been associated with higher levels of alcohol use and related harm in drinking environments. Factors that appeared particularly important in contributing to alcohol‐related problems included a permissive environment, cheap alcohol availability, poor cleanliness, crowding, loud music, a focus on dancing and poor staff practice. However, findings were not always consistent across studies.

Conclusions  Drinking establishments, their management and the behaviours of the young people who use them vary widely across Europe. While international research shows that environmental factors in drinking settings can have an important influence on alcohol‐related harm, there is currently a scarcity of knowledge on the relevance and impacts of such factors in modern European settings. Developing this knowledge will support the implementation of strategies to create drinking environments in Europe that are less conducive to risky drinking and alcohol‐related harm.

Aim  To compare alternative survey methods for estimating (a) levels of at risk alcohol consumption and (b) total volume of alcohol consumed per capita in comparison with estimates from sales data and to investigate reasons for under‐reporting.

Setting  The homes of respondents who were eligible and willing to participate.

Participants  A total of 21 674 Australians aged 14 years and older.

Design  A 2001 national household survey of drug use, experiences and attitudes with weights applied for age, sex, geographic location and day of week of interview.

Measures  Self‐completion questionnaire using quantity–frequency (QF) and graduated–frequency (GF) methods plus two questions about consumption ‘yesterday’: one in standard drinks, another with empirically based estimates of drink size and strength.

Results  The highest estimate of age 14 + per capita consumption of 7.00 l of alcohol derived from recall of consumption ‘yesterday’ or 76.8% of the official estimate. The lowest was QF with 49.8%. When amount consumed ‘yesterday’ was recalled in standard drinks this estimate was 5.27 l. GF questions yielded higher estimates than did QF questions both for total volume (5.25 versus 4.54 l) and also for the proportion of the population at risk of long‐term alcohol‐related harm (10.6%versus 8.1%). With the detailed ‘yesterday’ method 61% of all consumption was on high risk drinking days.

Conclusions  Questions about typical quantities of alcohol consumed can lead to underestimates, as do questions about drinking ‘standard drinks’ of alcohol. Recent recall methods encourage fuller reporting of volumes plus more accurate estimates of unrecorded consumption and the proportion of total alcohol consumption that places drinkers at risk of harm. However, they do not capture longer‐term drinking patterns. It is recommended that both recent recall and measures of longer‐term drinking patterns are included in national surveys.

Objective  To describe the relapse curve and rate of long‐term prolonged abstinence among smokers who try to quit without treatment.

Method  Systematic literature review.

Data sources  Cochrane Reviews, Dissertation Abstracts, Excerpt Medica, Medline, Psych Abstracts and US Center for Disease Control databases plus bibliographies of articles and requests of scientists.

Study selection  Prospective studies of self‐quitters or studies that included a no‐treatment control group.

Data extraction  Two reviewers independently extracted data in a non‐blind manner.

Data synthesis  The number of studies was too small and the data too heterogeneous for meta‐analysis or other statistical techniques.

Results  There is a paucity of studies reporting relapse curves of self‐quitters. The existing eight relapse curves from two studies of self‐quitters and five no‐treatment control groups indicate most relapse occurs in the first 8 days. These relapse curves were heterogeneous even when the final outcome was made similar. In terms of prolonged abstinence rates, a prior summary of 10 self‐quitting studies, two other studies of self‐quitters and three no‐treatment control groups indicate 3–5% of self‐quitters achieve prolonged abstinence for 6–12 month after a given quit attempt.

Conclusions  More reports of relapse curves of self‐quitters are needed. Smoking cessation interventions should focus on the first week of abstinence. Interventions that produce abstinence rates of 5–10% may be effective. Cessation studies should report relapse curves.

Aims  This study examined whether voucher‐based reinforcement therapy (VBRT) contingent upon smoking abstinence during pregnancy is an effective method for decreasing maternal smoking during pregnancy and improving fetal growth.

Design, setting and participants  A two‐condition, parallel‐groups, randomized controlled trial was conducted in a university‐based research clinic. A total of 82 smokers entering prenatal care participated in the trial.

Intervention  Participants were assigned randomly to either contingent or non‐contingent voucher conditions. Vouchers exchangeable for retail items were available during pregnancy and for 12 weeks postpartum. In the contingent condition, vouchers were earned for biochemically verified smoking abstinence; in the non‐contingent condition, vouchers were earned independent of smoking status.

Measurements  Smoking outcomes were evaluated using urine‐toxicology testing and self‐report. Fetal growth outcomes were evaluated using serial ultrasound examinations performed during the third trimester.

Findings  Contingent vouchers significantly increased point‐prevalence abstinence at the end‐of‐pregnancy (41% versus 10%) and at the 12‐week postpartum assessment (24% versus 3%). Serial ultrasound examinations indicated significantly greater growth in terms of estimated fetal weight, femur length and abdominal circumference in the contingent compared to the non‐contingent conditions.

Conclusions  These results provide further evidence that VBRT has a substantive contribution to make to efforts to decrease maternal smoking during pregnancy and provide new evidence of positive effects on fetal health.

Mục tiêu  Đánh giá những thay đổi về cấu trúc, hóa học và chuyển hóa trong não, đặc biệt là những thay đổi trong hạch nền (basal ganglia), ở những người sử dụng methamphetamine, cũng như ở trẻ em phơi nhiễm methamphetamine từ thời kỳ trước khi sinh.

Phương pháp  Các nghiên cứu sử dụng chụp cộng hưởng từ (MRI) và chụp cắt lớp phát xạ positron (PET) đánh giá các thay đổi cấu trúc, hóa học và chuyển hóa trong não bộ của đối tượng methamphetamine, hoặc trẻ em phơi nhiễm methamphetamine từ trước khi sinh, đã được xem xét và tóm tắt. Các nghiên cứu tiền lâm sàng liên quan cung cấp những hiểu biết sâu sắc cho việc diễn giải các nghiên cứu hình ảnh này cũng đã được xem xét.

Kết quả  Ở người lớn sử dụng methamphetamine, MRI cho thấy khối lượng thể vân (striatal volumes) tăng, trong khi phổ cộng hưởng từ cho thấy nồng độ của dấu hiệu thần kinh N‐acetylasparate và creatine toàn phần giảm trong hạch nền. Ngược lại, trẻ em phơi nhiễm methamphetamine trước sinh cho thấy cấu trúc thể vân nhỏ hơn và creatine toàn phần cao hơn. Hơn nữa, các nghiên cứu PET liên tục cho thấy mật độ chất vận chuyển dopamine (DAT) giảm và số lượng thụ thể dopamine D₂ giảm trong thể vân ở đối tượng methamphetamine. Các nghiên cứu PET cũng phát hiện mức độ thấp hơn của mật độ chất vận chuyển serotonergic và chất vận chuyển monoamine trong túi (VMAT2) trên toàn các vùng phụ thể vân, cũng như sự thay đổi chuyển hóa glucose não tương quan với mức độ nghiêm trọng của các triệu chứng tâm thần ở vùng limbic và orbitofrontal.

Kết luận  Các nghiên cứu hình ảnh não bộ chứng minh rõ ràng những bất thường trong cấu trúc và hóa học não ở những cá nhân sử dụng methamphetamine và trẻ em phơi nhiễm methamphetamine từ trước khi sinh, đặc biệt là trong thể vân. Tuy nhiên, vẫn còn nhiều câu hỏi quan trọng cần giải đáp và cần có kích thước mẫu lớn hơn để xác nhận những quan sát sơ bộ này. Thêm vào đó, cần có các nghiên cứu dọc để đánh giá hiệu quả của điều trị và tình trạng kiêng cữ đối với những thay đổi này trong não, cũng như xác định liệu các chỉ số hình ảnh, và có thể là di truyền, có thể được sử dụng để dự đoán kết quả điều trị hoặc tái phát hay không.