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A cohort study of male subjects attending an Alcoholics Anonymous program in India: One-year follow-up for sobriety.

A cohort of subjects in India who completed detoxification treatment and a de-addiction program based on the Alcoholics Anonymous (AA) model were followed-up at 1 year to investigate the factors associated with complete abstinence.

Patients (N = 187 men) who were admitted consecutively to an addiction facility and fulfilled Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for alcohol dependence were recruited for the study.

Patients with major psychopathology were excluded. The final outcome at 1 year was determined by visiting the patients and talking to the families and members of the local AA group.

Of the 187 men initially recruited, 5 were excluded because of major psychopathology, 1 committed suicide, and 7 could not be traced.

Of the 174 patients available for follow-up, 58 (33.3%) remained sober (complete abstinence for the past year) at 1 year.

Patients coming from distant places and those with follow-up workers in their localities fared better than those from the local area and those from towns where there was no one to motivate them to continue with AA meetings.

These variables were significantly associated with sobriety even after adjustment for other confounders using multivariate techniques. A third of the cohort remained sober at 1-year follow-up.

The patients’ initial motivation and continued support once they returned to their communities were associated with sobriety at follow-up.

Research report; Kuruvilla PK; Vijayakumar N; Jacob KS. A cohort study of male subjects attending an Alcoholics Anonymous program in India: One-year follow-up for sobriety. Journal of Studies on Alcohol 65(4):546-549, July 2004.

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Acquired brain injury refers to any brain damage that happens after birth. Alcohol is one of the many causes of acquired brain injury. The injury inflicted by alcohol abuse is referred to as alcohol related brain injury (ARBI). Just how much damage is done depends on a number of factors. These include individual differences, as well as the person’s age, gender, nutrition and their overall pattern of alcohol consumption.

A person with ARBI might experience problems with memory, cognitive abilities and physical coordination. A younger person has a better chance of recovery because of their greater powers of recuperation. However, the effects of alcohol related brain injury can be permanent for some.

Alcohol and brain injury

Brain injury can be caused by alcohol because it:

• Has a toxic effect on the central nervous system.
• Results in changes to metabolism, heart functioning and blood supply.
• Interferes with the absorption of vitamin B1 (thiamine), which is an important brain nutrient.
• May be associated with poor nutrition.
• Can cause dehydration, which may lead to wastage of brain cells.
• Can lead to falls and accidents that injure the brain.
• Can lead to motor vehicle and other accidents

Alcohol consumption and ARBI

Alcohol consumption ranges from light (social drinkers) to heavy consumption. Decline in thinking and brain functioning is gradual, and depends upon the amount of alcohol consumed and for how long.

Alcohol related brain injury is more likely to occur if a person drinks heavily on a regular basis over many years. It is possible to develop ARBI over a short period of time, if the drinking is heavy enough. This can be known as ’binge drinking’, which means drinking more than six drinks at a time. Safe levels of alcohol consumption include:

For men - a maximum of four standard alcoholic drinks per day with at least two alcohol free days every week.

For women - a maximum of two standard alcoholic drinks per day with at least two alcohol free days every week.

Disorders associated with ARBI

• ARBI is associated with changes in cognition (memory and thinking abilities), difficulties with balance and coordination, and a range medical and neurological disorders. Some alcohol related disorders include:
• Cerebellar atrophy - the cerebellum is the part of the brain responsible for muscle coordination. Damage results in difficulties with balance and walking, which is called ’ataxia’.
• Frontal lobe dysfunction - the brain’s frontal lobes are involved in abstract thinking and planning. Damage results in cognitive difficulties.
• Hepatic encephalopathy - many people with alcohol related liver disease develop particular psychiatric symptoms, such as mood changes, confusion and hallucinations.
• Korsakoff’s amnesic syndrome - a loss of short term memory.
• Peripheral neuropathy - the extremities are affected by numbness, pain, pins and needles.
• Wernicke’s encephalopathy - a disorder caused by a severe deficiency of vitamin B1. Some of the symptoms include ataxia, confusion and problems with vision.

Treatment

A person with suspected alcohol related brain injury needs to be assessed by a neuropsychologist. Treatment depends on the individual and the type of brain damage sustained.

Helping people with ARBI

People with impaired brain function can be helped, if the demands placed on them are reduced. A predictable routine, which covers all daily activities, can also be a great help. Carers might like to consider the following points when communicating with people with ARBI:

• Break down information and present one idea at a time
• Tackle one problem at a time
• Allow the person time to work at their own pace
• Minimise distractions
• Avoid stress
• Allow for frequent breaks and rest periods.
• Where to get help
• Your doctor
• Neuropsychologist
• Acquired brain injury associations
• Support groups for alcoholism.

Things to remember

• Alcohol has a toxic effect on the central nervous system and can cause significant brain injury.
• Alcohol related brain injury is more likely in people who drink heavily over a long period of time, but aggressive binge drinkers are also at risk.
• The symptoms depend on which part of the brain has been damaged, but can include problems with coordination, thinking, planning, organisation, memory and perception.

Researchers say that the reward center in an adolescent’s brain isn’t as fully developed or responsive as an adult’s, which could explain why teens tend to engage in risky behaviors such as consuming alcohol, using drugs, or having unsafe sex, Health Day News reported Feb. 26.

Using magnetic resonance imaging (MRI), researchers scanned the brains of 12 teens aged 12 to 17 and 12 young adults aged 22 to 28. During the scan, participants played a game that involved monetary risk and reward.

In comparing the scans, the researchers found that the ventral stratium, the section of the brain known as the reward center, showed increased activity as the reward increased for both groups. However, the right ventral stratium, which is responsible for motivation, showed more activation in adult participants than in the teens.

“That region of the brain controls how much an organism is willing to work to get a reward,” Bjork said. “The data show that adolescents are just as happy and excited at the prospect of winning as adults, but they differed in the expenditure of effort for that reward.”

The researchers concluded that adolescents are more likely to engage in risky behaviors, such as alcohol and other drug use, because they involve little effort but provide a greater reward in return.

The research also may explain why teens sometimes seem unmotivated to adults. “Adults have readily active motivation in the brain,” said study co-author James Bjork, a research fellow in the Laboratory of Clinical Studies at the National Institute on Alcohol Abuse and Alcoholism. “But it may take exceptionally strong incentives to get kids jazzed up.”

The study’s findings are published in the Feb. 25 issue of the Journal of Neuroscience.

Creative Interventions for Troubled Children & Youth by Liana Lowenstein Read more about this title…

Spirituality and Alcoholics Anonymous.

What can be confidently said about AA in general and about the role of spirituality in AA in particular?

• First, there is convincing evidence that alcoholism severity predicts later AA attendance.
• Second, atheists are less likely to attend AA, relative to individuals who already hold spiritual and/or religious beliefs. However, belief in God or a Higher Power before AA attendance does not offer any advantage in AA-related benefits, and atheists, once involved, are at no apparent disadvantage in deriving AA-related benefits.
• Third, the spiritually-based principles of AA appear to be endorsed in AA meetings regardless of the perceived social dynamics or climate of a particular meeting, eg, highly cohesive or aggressive.
• Fourth, significant increases in spiritual and religious beliefs and practices seem to occur among AA-exposed individuals.
• Fifth, in spite of much discussion to the contrary there is little evidence that spirituality directly accounts for later abstinence. We are finding, however, that spirituality has an important indirect effect in predicting later drinking reductions.

Specifically, in the past 20 years a number of effective methods have been developed to facilitate initial AA attendance (AA dropout is high, with some estimates ranging as high as 80%). Interventions that lead to initial increases in spirituality appear to lead to sustained AA affiliation, which, in turn, produces sustained recovery over time.

TSF and Brief-TSF are designed from studies such as this to facilitate AA attendance.

Research; Tonigan JS. Spirituality and alcoholics anonymous. South Med J. 2007 Apr;100(4):437-40.

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Yasir Abbasi and Ruta Rele suggest services for health professionals

In the United Kingdom about one third of the population is addicted to nicotine, while 6% are addicted to alcohol. The public is usually influenced by the media, which mainly concentrates on hard core illegal drugs such as heroin, cocaine, and sometimes cannabis. Other substances, which are also of growing concern, get overlooked. These can be volatile substances (such as glue or aerosols), stimulants, hallucinogens, benzodiazepines, prescribed opioid analgesics, and non-prescribed methadone.

Health professionals, like everyone else, are susceptible to addiction. Yet few of us are aware of facilities available to doctors with substance misuse problems. These services respect vital issues like confidentiality and patient care.

Full stort at; BMJ Career Focus 2007;335:163

TSF for Dual Diagnosis

The role of 12-step programs and 12-step-oriented treatments for dually diagnosed individuals (DDI) remains unclear. Here are presented the results of a pilot study in a target population of 10 seriously mentally ill patients received an adjunctive modified 12-step facilitation (TSF) therapy emphasizing engagement of DDI in a specialized 12-step program for DDI.

Participants significantly increased their 12-step attendance and decreased their substance use during the 12 weeks of treatment.

Larger and longer-term studies are needed to assess the efficacy of modified TSF for DDI relative to other treatments, and to determine what forms of TSF are most effective in this population.

Research; Bogenschutz MP. Tucker NE Specialized 12-step programs and 12-step facilitation for the dually diagnosed. Community Ment Health J. 2005 Feb;41(1):7-20.

Brief-TSF can be adapted to serve these people.

Helping, spirituality and Alcoholics Anonymous

OBJECTIVE: The purpose of this study is to examine how helping activities and spirituality–perhaps key influences on sobriety–change over alcoholism recovery.

The study also explores interrelations among Alcoholics Anonymous (AA), helping and spirituality.

METHOD: Questionnaires were administered to recovering alcoholics (118 men, 80 women) recruited at AA and Women for Sobriety meetings, treatment programs and through personal connections. A helping scale measured Recovery Helping (8-item alpha = 0.78), Life Helping (12-item alpha = 0.62), and Community Helping (6-item alpha = 0.60). The Daily Spiritual Experiences scale assessed two components of spirituality identified by factor analysis: Theism and Self-Transcendence. Two components of an AA scale, Involvement and Achievement, were also treated separately on the basis of factor analysis.

RESULTS: Structural equation modeling revealed that

• longer sobriety predicted significantly more time spent on Community Helping,
• less time spent on Recovery Helping and
• higher levels of Theism, Self-Transcendence and AA Achievement.
• Model covariances revealed that both AA components were related to more Recovery Helping and higher Theism.
• Both spirituality components related to all forms of helping, with one exception.

CONCLUSIONS: The findings highlight important changes in helping with length of sobriety.

• As their sobriety accumulates, recovering alcoholics seem to devote less time to informal helping and more time to organized community projects–perhaps indicating evolving needs and abilities.
• The results also suggest roles for AA and spirituality in encouraging helping, and they indicate that some forms of spirituality relate to AA affiliation.

Future work might establish whether and when helping in different domains contributes to the maintenance of abstinence and to other drinking-related outcomes.

Research Report; Zemore SE, Kaskutas LA. J Stud Alcohol. 2004 May;65(3):383-91. Helping, spirituality and Alcoholics Anonymous in recovery.

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A synopsis of the pharmacological rationale, properties and therapeutic effects of depot preparations of naltrexone for treating alcohol dependence.

Although oral naltrexone has been shown to diminish alcohol reinforcement, its limitations as a medication include its small treatment effect size, plasma level fluctuation and adverse events.

The pharmacokinetic profile of naltrexone could be optimised by intramuscular administration, sustaining its release over several weeks.

As a result, plasma levels would remain relatively constant; high enough to reduce drinking, low enough to minimise side effects.

Two injectable naltrexone depot preparations, Vivitrex and Naltrel, have been tested as pharmacotherapy for alcohol dependence.

Their adverse-event profiles seem to be mild compared with oral naltrexone.

Vivitrex has shown efficacy at reducing heavy drinking significantly among alcohol-dependent men.

Naltrel helped reduce relapse and promote abstinence in two samples of alcohol-dependent individuals. Additional efficacy studies are warranted.

Johnson BA. Expert Opin Pharmacother. 2006 Jun;7(8):1065-73. A synopsis of the pharmacological rationale, properties and therapeutic effects of depot preparations of naltrexone for treating alcohol dependence.

Pharmacotherapy Principles & Practice by Marie A. Chisholm-Burns, Barbara G. Wells, Terry L. Schwinghammer, Patrick M. Malone, Jill M. Kolesar, John C. Rotschafer, Joseph T. DiPiro Read more about this title…

A qualitative study of Alcoholics Anonymous members and South Asian men.

The spiritual aspect of recovery for people with drinking problems was explored in a comparative analysis of South Asian men recovering from drink problems and white members of Alcoholics Anonymous (AA).

In-depth semi-structured interviews were carried out with participants to explore significant factors that assisted recovery. Interviews were analyzed using grounded theory. Ten participants in total were interviewed; 5 were South Asian men receiving individual and/or group counseling with South Asian therapists either in an NHS or non-statutory specialist alcohol treatment service, and 5 were white members of AA.

Models of recovery for the two groups were developed and are presented.

Spirituality and religion played an important role in the experiences of recovery described by AA and South Asian participants respectively.

For AA participants their experiences reflected those described in AA’s Big Book although concepts such as that of a Higher Power were complex and multilayered, with spirituality just one, albeit significant, aspect.

South Asian participants generally underwent a re-affirmation of existing beliefs rather than the conversion type of experience described by AA participants.

The findings are discussed in relation to implications for service delivery and development and directions for future research.

Morjaria, A.; Orford, J. Role of religion and spirituality in recovery from drink problems: A qualitative study of alcoholics anonymous members and South Asian men. Addiction Research and Theory, 10(3):225-256, 2002.

The Spirituality of Imperfection: Storytelling and the Search for Meaning by Ernest Kurtz, Katherine Ketcham Read more about this title…

A popular aid is the Just for Today card that AA and Al-anon members carry in their pocket or purse and refer to when thinking of a drink or they are disturbed by a life event.

• Just for today I will try to live through this day only, and not tackle all my problems at once. I can do something for twelve hours that would appall me if I felt that I had to keep it up for a lifetime.
• Just for today I will be happy. This assumes to be true what Abraham Lincoln said, that most folks are as happy as they make up their minds to be.
• Just for today I will adjust myself to what is, and not try to adjust everything to my own desires. I will take my luck as it comes, and fit myself to it.
• Just for today I will try to strengthen my mind. I will study. I will learn something useful. I will not be a mental loafer. I will read something that requires effort, thought and concentration.
• Just for today I will exercise my soul in three ways: I will do somebody a good turn, and not get found out; if anybody knows of it, it will not count. I will do at least two things I don’t want to do just for exercise. I will not show anyone that my feelings are hurt; they may be hurt, but today I will not show it.
• Just for today I will be agreeable. I will look as well as I can, dress becomingly, keep my voice low, be courteous, criticize not one bit. I won’t find fault with anything, nor try to improve or regulate anybody but myself.
• Just for today I will have a program. I may not follow it exactly, but I will have it. I will save myself from two pests: hurry and indecision.
• Just for today I will have a quiet half hour all by myself and relax. During this half hour, sometime, I will try to get a better perspective of my life.
• Just for today I will be unafraid. Especially I will not be afraid to enjoy what is beautiful and to believe that as I give to the world, so the world will give to me.

A pocket sized version of this is available at most 12-Step meetings such as Alcoholics Anonymous or Al-Anon

Download a PDF copy to printout and give to your patients.

Attached Files:

• just-for-today.pdf (21 KB)