Efficacy of extended-release naltrexone in alcohol-dependent patients who are abstinent before treatment.

Extended-release naltrexone (XR-NTX) is a once-a-month injectable formulation that is Food and Drug Administration-approved for the treatment of alcohol dependence in patients able to abstain from alcohol before treatment initiation.

This paper presents the results of an analysis of efficacy data from a subgroup of patients with 4 days or more of voluntary abstinence before treatment initiation (n = 82) on a wide range of drinking-related outcomes.

In these patients, all of whom received counseling, the rate of abstinence was severalfold higher for XR-NTX 380 mg compared with placebo:

• median time to first drink was 41 days versus 12 days, respectively;
• rate of continuous abstinence at end of the study was 32% versus 11% (P = 0.02).

Extended-release naltrexone 380 mg, compared with placebo, substantially increased time to first heavy drinking event (>180 days vs 20 days; P = 0.04) and decreased the median number of any drinking days per month by 90% (0.7 vs 7.2; P = 0.005) and heavy drinking days per month by 93% (0.2 days vs 2.9 days; P = 0.007).

The XR-NTX 380 mg group also had more than twice as many responders compared with placebo (70% vs 30%; P = 0.006; responder defined as having no more than 2 heavy drinking days in any consecutive 28-day period) and experienced greater improvement in gamma-glutamyl transpeptidase levels (P = 0.03).

Outcomes for XR-NTX 190 mg (n = 26) were generally intermediate, demonstrating a dose-response effect.

In conclusion, XR-NTX 380 mg prolonged abstinence and reduced the number of heavy drinking days and drinking days in patients who were abstinent for as few as 4 days before treatment initiation.

Research report; O’Malley SS, Garbutt JC, Gastfriend DR, Dong Q, Kranzler HR. J Clin Psychopharmacol. 2007 Oct;27(5):507-12. Efficacy of extended-release naltrexone in alcohol-dependent patients who are abstinent before treatment.

Twelve Step Facilitation as adjunctive therapy may be used with Naltrexone.

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Variety of AA Groups Reflects a Diverse Fellowship

Alcoholics Anonymous is known for the diversity of its membership, with A.A. members from every walk of life sitting side by side in the approximately 60,000 A.A. groups in the United States and Canada. Over the years, though, professionals-doctors, lawyers, airplane pilots, and others-have established a few A.A. groups for those in their field.

Given their common concerns and issues, these members have found A.A. meetings with peers useful. Such groups, which are autonomous along with every other A.A. group, are usually found in large metropolitan areas. They function as any other A.A. meeting.

Among their other purposes, these groups can allay the fears of new A.A. members who may feel more comfortable in a meeting of their peers. The preamble read at “Birds of a Feather” A.A. meetings, which are attended by airline cockpit crew members, refers to the “occupational sensitivity of its members.”

One of the hurdles facing those seeking help in A.A. may be fear of exposure or the shameful sense that their problem is unique to them. Local A.A. offices-called central offices or intergroups- sometimes have lists of A.A. members willing to talk one-on-one with a person seeking information about Alcoholics Anonymous. On these lists are representatives of many professions who will be able to reassure a prospective A.A. member that they are not alone.

There are also A.A. groups for women, men, gays, lesbians, and young people, among others. Information on where to find these groups or any other local meetings is available at A.A. offices around the country.

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Al-Anon offers new life to families of alcoholics

Alcoholism touched every aspect of Brenda’s family life. She lost a father to alcoholism, and her brother developed the disease. She also married a problem drinker. They had a large family, and her husband left the job of parenting to her.

"I had out-of-control children at home," she says. "There was no structure–no rules, no bedtime schedules. It was just chaos." Brenda tried to structure the household but found that she couldn’t do it alone. Some of her children developed behavior problems at school and eventually abused alcohol themselves.

For nearly a decade, Brenda searched for support. She went to parent meetings at school. She went to marriage counseling. She went to churches and Bible study groups. Finally, a therapist suggested Al-Anon.

"I remember listening to people at my very first Al-Anon meeting and thinking, this is where I belong,"

"I remember listening to people at my very first Al-Anon meeting and thinking, this is where I belong," Brenda recalls. "The stories I was hearing there were about the very kinds of things happening in my life."

Al-Anon offers free and confidential support for anyone affected by an alcoholic or problem drinker. This includes parents, grandparents, spouses, partners, coworkers, and friends. Alateen, a part of Al-Anon, is a recovery program for young people impacted by a loved one’s alcoholism.

Founded in 1951 by the wives of two Alcoholics Anonymous members, Al-Anon is based on AA’s Twelve Steps. There are no dues and no fees. Rather than relying on mental health professionals, members lead self-help meetings in a spirit of mutual help. The purpose is to share their hope, strength, and experience in dealing with an alcoholic loved one.

It works. Today more than 26,000 Al-Anon groups exist in 115 countries.

Al-Anon begins with the principle that alcoholism is a family disease. And those who care most about the alcoholic are affected the most.

Al-Anon literature compares life with an alcoholic to a drama where people develop stereotyped, almost scripted, roles. Their behaviors center on the alcoholic and are dominated by:

• Obsession–going to great lengths to stop the alcoholic’s drinking, such as searching the house for hidden stashes of liquor, secretly pouring drinks down the drain, or listening continually for the sound of opening beer cans.
• Anxiety–worrying constantly about the effects of the alcoholic’s drinking on the children, the bills, and the family’s future.
• Anger–feelings of resentment that result from being repeatedly deceived and hurt by the alcoholic.
• Denial–ignoring, making excuses for, or actively hiding the facts about the alcoholic’s behavior.
• Guilt–family members’ belief that they are somehow to blame for the alcoholic’s behavior.
• Insanity–defined in Al-Anon as "doing the same thing over and over and expecting different results."

With help from their peers, Al-Anon members learn an alternative–detachment with love. This happens when family members admit that they did not cause their loved one’s alcoholism; nor can they control or cure it. Sanity returns to family life when members focus on taking care of themselves, changing the things that they can, and letting go of the rest.

As a result, alcoholic family members are no longer shielded from the consequences of their own behavior. This, more than anything else, can help them face the facts about their addiction and admit their need for help.

"Since I’ve been in Al-Anon, my life has totally changed," says Brenda. "I filed for divorce and set up my own household. Now my children are getting a lot more of their needs met with a lot more stability in their lives, and I’m a much happier parent. Since I moved out, my son has been on the honor roll at school and my daughter has had the best two years of her life."

To learn more about Al-Anon go online to http://www.al-anon-alateen.org/. A basic text, "How Al-Anon Works for Families and Friends of Alcoholics," explains the Al-Anon program in detail.

Alive & Free is a health column that provides information to help prevent substance abuse problems and address such problems. It is created by Hazelden, a nonprofit agency based in Center City, Minn. "Copyright © 2003 Hazelden Foundation. All rights reserved."

How Al-Anon Works for Families & Friends of Alcoholics

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Recovering alcoholics can benefit from Al-Anon

R.J. has been clean and sober and an active member of Alcoholics Anonymous for 20 years. He lives the Twelve Step program each day, one day at a time. He attends AA meetings faithfully, reads the literature, meditates, and asks his Higher Power for guidance. He has told his story many times and listened with loving acceptance to the stories of others, as AA members are encouraged to do. He thought nothing about addiction could surprise him at this point in his life and recovery.

Then he discovered his 20-year old son had a drug and alcohol problem. "I felt so stupid," he said. "I know this stuff, and it never entered my mind that my son was using. He was the good boy, the one who got straight A’s. He knows I’m a recovering alcoholic and that his mother (my ex-wife) is a practicing one. I thought knowing about us would keep him sober. But he got to a point where he seemed paralyzed; he couldn’t stay on track. One day I said, sort of in passing, ‘You act like you’re on drugs.’ He said, ‘I am.’ When I asked what kind and he said he’d tried ‘just about everything,’ I was stunned. I didn’t know what to do."

Not knowing what to do, R.J. did nothing the night of his son’s revelation except listen. "I told him I wouldn’t preach or yell, but I asked him if I could tell him when I heard him giving me the ‘standard’ addict’s lines like, ‘I have it under control.’ He said I could, and we talked until 4 a.m."

Next, R.J. sought help from others. His first impulse was to issue an edict telling his son not to come around until he got straight, but a counselor at work cautioned that things could get worse if his son felt abandoned, with no safe places or safe people to turn to. "She suggested I establish clear rules so he wouldn’t come here high or use here, but let him know that I love him and I’d do whatever it takes to help him when he’s ready."

When a long-time friend (also a recovering alcoholic) suggested going to Al-Anon, R.J. said he was "blown away" by the idea. Like many recovering alcoholics, he had always viewed Al-Anon as a Twelve Step mutual-help group for "them"–the family and friends of the alcoholic–and AA as the Twelve Step group for "us"–the alcoholics who affected their lives.

R.J. and his friend went to an Al-Anon meeting where they were the only men. He confessed that he was very nervous at first but said the familiar Twelve-Step meeting structure eased his anxiety. "Then I said, ‘I’m an alcoholic–the reason you’re here–but now I need help.’ It broke the ice, and they welcomed us with so much warmth and generosity."

Because it is not unusual to have more than one problem drinker in a family, it makes sense that recovering alcoholics can also be affected by another’s alcohol or drug use, and that they could benefit from the fellowship and support of Al-Anon. Except for one word in Step Twelve where Al-Anon has substituted the word "others" for AA’s word "alcoholics," the Steps of the two groups are identical.

"At AA we learn that we’re powerless over alcohol. At Al-Anon you discover that you’re powerless over others," explained R.J. He thought the Al-Anon members he met also gained by meeting two recovering alcoholics who embrace the same Twelve Step philosophy they do.

R.J. said it was a profound experience to view addiction "from the other side of the fence" at Al-Anon. "It struck such a chord when a woman there told me I’ve got my story, but my son is still writing his. I can tell him about my path and show him a path exists, but I can’t walk it for him."

Al-Anon meetings are held in 115 countries, and there are over 24,000 Al-Anon groups worldwide. For more information visit http://www.al-anon.alateen.org/.

Alive & Free is a health column that provides information to help prevent substance abuse problems and address such problems. It is created by Hazelden, a nonprofit agency based in Center City, Minn. "Copyright © 2003 Hazelden Foundation. All rights reserved." Any other use of the Web site or the information contained here is strictly prohibited.

At Amazon; How Al-Anon Works for Families & Friends of Alcoholics

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Bringing Up the Touchy Subject of a Patient’s Drinking

Broaching the subject of alcohol with a patient or client who shows signs of a drinking problem can be awkward. Drinkers often feel ashamed of their problem, at the same time that they downplay its seriousness. Directly confronting them may do no more than provoke a flat denial. For these reasons professionals very often steer clear of the matter. But to wait for that patient or client to bring up the subject amounts to giving up on the issue, according to some with first-hand experience in the matter.

“In 30 years of practice it almost never happens that someone comes in and announces that they have a problem with alcohol,” says Carvel Taylor-Valentine, a licensed clinical social worker.

“Patients would rather that their problems are about anything other than alcohol or drugs. They would rather admit to some kind of mental illness, even schizophrenia, than to call themselves an alcoholic.”

The reason for this, says Ms. Taylor-Valentine, who is a certified addictions counselor, is simple: “They don’t want to stop drinking. Alcohol is a feel-good substance, and they are afraid of giving it up.”

Marsha Epstein, M.D., medical director, Tucker Health Center, a unit of the Los Angeles Department of Public Health, agrees.

“No one is quick to admit to current problems with alcohol or drugs. When I was in private practice years ago, I saw about 2,000 patients over four and a half years and none ever admitted current heavy drinking.”

Dr. Epstein, who also has a master’s degree in public health, remembers a phone call from the daughter of a woman patient disclosing that the mother drank alcoholically. “I believed the daughter, but I never brought up any problem with alcohol to her mother. I did not know how.”

Both Dr. Epstein and Ms. Taylor-Valentine have found that the information forms filled out by new patients are the best place to introduce questions about drinking problems, especially if the questions are about alcohol abuse in a patient’s family.

“It was at a medical conference that I was introduced to a woman who was a member of Al-Anon and who told me about that program,” says Dr. Epstein. [Al-Anon is a Twelve Step program for those who have problem drinkers in their lives.] “When I returned from that conference, I added a question about drinking problems among family members to the medical history forms filled out by patients.”

Happy to Discuss Anyone Else’s Drinking

Whereas practically no patient would talk about their drinking problem, “lots admitted that they had family members who drank too much,” says Dr. Epstein. Nowadays, when the conversations get to a patient’s drinking, Dr. Epstein says, “instead of asking if someone has a problem with alcohol, I ask when was the last time they overdid it. Not asking specific questions is a mistake.”

When a patient opens up about their alcohol abuse, Dr. Epstein steers them to Alcoholics Anonymous. “Here’s the number for A.A. meetings – just go. You don’t have to say anything, and you can sit in the back.”

Back in her time in private practice, Dr. Epstein also made use of Al-Anon. “If they checked ‘yes’ on that question about a family drinking history, I would suggest they go to an Al-Anon meeting and come back and tell me how it was.”

What Dr. Epstein discovered was that some of her patients found their way to Alcoholics Anonymous through Al-Anon.

“Over the course of a few years, five patients who had gone to Al-Anon returned to tell me that they discovered in that program that they had a problem with alcohol. I suspect there were many others who got to A.A. through Al-Anon. It never occurred to me that it would work this way.”

From; About AA; A newsletter for professionals, Spring 2007. www.AA.org

Dilemma of the Alcoholic Marriage

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A Few Basic Facts About AA

Alcoholics Anonymous is well-known as an organization for people who want to stop drinking. At the same time, there are some points about A.A. that may be unclear to the general public and even to professionals working to help problem drinkers.

Founded in the United States in 1935, when one alcoholic discovered he could stay sober by helping another alcoholic, Alcoholics Anonymous now has more than two million members in some 180 countries.

Bill W. and Dr Bob – cofounders of AA

A.A.’s sole purpose is helping people recover from the disease of alcoholism, and it has no affiliation with any other group or organization. Members anywhere in the world can come together to form an A.A. group, of which there are an estimated 106,000 worldwide.

Among other facts about Alcoholics Anonymous are:

Membership is free. A.A. groups usually pass a basket around at meetings to cover the cost of renting the meeting room and for other incidental expenses, such as coffee.

A.A. is not a religious organization; it is not allied with any religious organization, and requires no religious belief as a condition of membership. Members include Catholics, Protestants, Jews, Muslims, Hindus, agnostics, and atheists.

A.A. does no recruiting. The only requirement for membership is a desire to stop drinking. There are no other requirements to be met, no initiation fees to be paid, and no forms to be filled out. It is completely up to anyone considering joining A.A. to determine if they have a problem with alcohol and whether they will deal with it in Alcoholics Anonymous. A person becomes a member of A.A. simply by deciding they want to be a member.

A.A. groups are autonomous and run by the members themselves.

A.A. is not a temperance society. Members acknowledge their inability to drink safely but have nothing to say about the drinking of others. It is a principle of A.A. that it has no opinion on what are termed outside issues.

A.A. is not affiliated with any hospital or rehab, or any other such facility. No professional services of any kind are offered or performed under A.A. sponsorship.

A.A. meetings take several forms, but at any meeting there will be alcoholics talking about how drinking affected their lives and what life as a sober member of A.A. is like.

Anonymity is respected. Newcomers can turn to A.A. with the assurance that their attendance at meetings will be kept private.

“Open” Meetings of A.A. are meetings which anyone may attend to observe how A.A. works. “Closed” meetings are reserved for those with a drinking problem.

Contacting A.A. Information on how to find local A.A. meetings can be found in telephone directories and at numerous Internet sites, including www.aa.org.

From; About AA; A newsletter for professionals, Spring 2007.

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The AA Recovery Program

The relative success of the A.A. program seems to be due to the fact that an alcoholic who no longer drinks has an exceptional faculty for “reaching” and helping an uncontrolled drinker.

In simplest form, the A.A. program operates when a recovered alcoholic passes along the story of his or her own problem drinking, describes the sobriety he or she has found in A.A., and invites the newcomer to join the informal Fellowship.

The heart of the suggested program of personal recovery is contained in Twelve Steps describing the experience of the earliest members of the Society:

1. We admitted we were powerless over alcohol – that our lives had become unmanageable.
2. Came to believe that a Power greater than ourselves could restore us to sanity.
3. Made a decision to turn our will and our lives over to the care of God as we understood Him.
4. Made a searching and fearless moral inventory of ourselves.
5. Admitted to God, to ourselves and to another human being the exact nature of our wrongs.
6. Were entirely ready to have God remove all these defects of character.
7. Humbly asked Him to remove our shortcomings.
8. Made a list of all persons we had harmed, and became willing to make amends to them all.
9. Made direct amends to such people wherever possible, except when to do so would injure them or others.
10. Continued to take personal inventory and when we were wrong promptly admitted it.
11. Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.
12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics and to practice these principles in all our affairs.

Newcomers are not required to accept or follow these Twelve Steps in their entirety if they feel unwilling or unable to do so.

They will usually be asked to keep an open mind, to attend meetings at which recovered alcoholics describe their personal experiences in achieving sobriety, and to read A.A. literature describing and interpreting the A.A. program.

A.A. members will usually emphasize to newcomers that only problem drinkers themselves, individually, can determine whether or not they are in fact alcoholics.

At the same time, it will be pointed out that all available medical testimony indicates that alcoholism is a progressive illness, that it cannot be cured in the ordinary sense of the term, but that it can be arrested through total abstinence from alcohol in any form.

From the AA FACT FILE. This document also is available on G.S.O.’s A.A. Web site: www.aa.org

Alcoholics Anonymous: The Story of How Many Thousands of Men and Women Have Recovered from Alcoholism

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Principles of management of substance-abuse disorders

With empathy and positive management, many alcohol and drug dependent people can be liberated from their addictions.

• Establish a working/therapeutic relationship
• Identify the patient’s current level of drug use (drug type, daily dose, frequency of use); check for multiple drug use
• Determine the patient’s “readiness for change”
• Help the patient weigh up the costs (and benefits) of their continued drug use (affordability, health effects, legal consequences, effects on relationships, job, family)
• Contrast with the benefits of a drug-free lifestyle
• Establish an “environment of safety”
• Encourage the patient to cut down or stop using drugs
• Negotiate appropriate (and attainable) goals with the patient
• Discuss strategies to achieve these goals
• Identify the situations in which the patient is likely to use drugs and the factors that will make it difficult to change the pattern of use
• Provide positive reinforcement for goals achieved and arrange appropriate social supports
• Discuss HOW to cease substance use (i.e., detoxification)
• Inform the patient of the symptoms that are likely to occur and discuss strategies for ameliorating them
• Facilitate working through grieving for the losses sustained due to former lifestyle choices
• Discuss strategies for coping without drugs, including involvement with self-help groups
• Remember that relapse is common
• Identify any gains made during the previous attempt and encourage the patient to try again
• Examine the factors that led to the relapse and discuss strategies to deal with them
• Discover why the substance-oriented lifestyle developed (optional)

Research extract from; Tobie L Sacks and Nicholas A Keks. Alcohol and drug dependence: diagnosis and management. Medical Journal of Australia Practice Essentials #14.

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Alcohol and drug dependence approach

Synopsis – diagnosis and management

An empathetic and non-judgemental attitude to the patient is required when managing drug dependence problems.

Careful assessment to establish the nature and extent of drug use must precede any attempts at management (more than one consultation is likely to be necessary).

The active cooperation of the patient in any management plan is essential, as the patient’s readiness for change will be a powerful influence on the success of any intervention.

Goals for stopping or reducing drug use must be agreed with the patient and must be attainable. Abstinence from drugs will not be every patient’s goal; harm reduction (through education to avoid collateral risks or efforts to cut down on drug consumption) is a worthwhile objective.

Detoxification is only part of the process. Many lifestyle adjustments are required to maintain a drug-free existence, and these changes may require social support and/or psychological therapies.

Relapse is common but can be used as a learning experience. Patients who relapse into drug use should be encouraged to try again.

With empathy and positive management, many drug dependent people can be liberated from their addictions.

Research extract from; Tobie L Sacks and Nicholas A Keks. Alcohol and drug dependence: diagnosis and management. Medical Journal of Australia Practice Essentials #14.

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Dual dependence

An assessment of dependence upon alcohol and illicit drugs, and the relationship of alcohol dependence among drug misusers to patterns of drinking, illicit drug use and health problems.

Aims: The study investigates severity of alcohol dependence among drug misusers. Specifically, it investigates the inter-relationship of alcohol and drug dependence and associations with alcohol consumption, drug consumption and substance-related problems.

Design, setting, participants: The sample comprised 735 people seeking treatment for drug misuse problems, who were current (last 90 days) drinkers.

Measurements: Data were collected by structured face-to-face interviews. Dependence upon illicit drugs and upon alcohol was measured by the Severity of Dependence Scale (SDS).

Findings: Three groups of drinkers were identified:

• non-alcohol-dependent drug misusers (63%);
• low-dependence (19%); and
• high-dependence (18%).

Many drug misusers were drinking excessively and alcohol dependence was related to patterns of alcohol and drug consumption.

Alcohol use is an important and under-rated problem in the treatment of drug misusers.

High-dependence drinkers were more likely to drink extra-strength beer; they were less frequent users of heroin and crack cocaine but more frequent users of benzodiazepines, amphetamines and cocaine powder; they reported more psychological and physical health problems. The SDS was found to have good reliability and validity as a measure of alcohol dependence. SDS scores for alcohol and drug dependence were unrelated.

Conclusions: Alcohol use is an important and under-rated problem in the treatment of drug misusers. A comprehensive assessment of alcohol use among drug misusers should include separate assessments of alcohol consumption, alcohol-related problems and severity of alcohol dependence.

Research report; Gossop, Michael; Marsden, John; Stewart, Duncan. Dual dependence: assessment of dependence upon alcohol and illicit drugs, and the relationship of alcohol dependence among drug misusers to patterns of drinking, illicit drug use and health problems. Addiction, Volume 97(2) February 2002 p 169-178 [Research Reports]

The Dual Diagnosis Recovery Sourcebook : A Physical, Mental, and Spiritual Approach to Addiction with an Emotional Disorder

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