The Co-Occurring Center for Excellence. Addressing mental disorders and alcoholism, addiction co-occurring.

The Co-Occurring Center for Excellence (COCE) was created by SAMHSA in 2003 to provide information and a range of services to mental health and substance abuse administrators and policymakers at state and local levels, their counterparts in tribal and Native populations, clinical providers, other providers, and all other agencies and systems through which clients may enter the treatment system.

COCE provides state-of-the-art and sustainable technical assistance, training, information and resources, and links to other resources that serve persons with co-occurring disorders.

http://www.coce.samhsa.gov/

See also;

• Double Trouble in Recovery
• Dual Diagnosis Anonymous
• Double Trouble in Recovery for Alcoholics
• 12-Step Treatment More Effective than Alternative

The Dual Diagnosis Recovery Sourcebook : A Physical, Mental, and Spiritual Approach to Addiction with an Emotional Disorder by Dennis Ortman Read more about this title…

Study Examines Link Between Stress Relapse

A new animal study finds that a stress-related gene and brain chemical may play a role in addiction relapse, according to the National Institute on Alcohol Abuse and Alcoholism (NIAAA).

Researchers from NIAAA and Camerino University in Italy found that rats that showed a preference for alcohol were more sensitive to stress. Those more prone to relapse under stress were examined for genetic patterns that might offer clues to this trait. Researchers found that these rats had higher expression levels of Crhr1, a gene that encodes the stress-related corticotropin-releasing hormone receptor 1 (CRH-R1).

“Our findings demonstrate that the Crhr1 genotype and its expression interact with environmental stress to reinstate alcohol-seeking behavior in this animal model of excessive drinking,” said study leader Anita Hansson, Ph.D., a fellow at NIAAA’s Laboratory of Clinical and Translational Studies.

“This finding helps untangle the complex interplay of genetic and environmental factors that influence relapse,” added NIAAA Director T-K Li, M.D. “It also points to potential approaches for treating individuals at risk for relapse.”

The research appears in the online edition of the Proceedings of the National Academy of Sciences. Research Reference: Hansson, A.C., et al. (2006) Variation at the rat Crhr1 locus and sensitivity to relapse into alcohol seeking induced by environmental stress. Proc. Natl. Acad. Sci.

From Join Together

Brief-TSF addresses relapse prevention as stress relief.

“I’ll never touch it again, doctor!” – harmful drinking after liver transplantation.

Alcohol relapse can negatively influence the outcome after liver transplantation (LT).

The aim of our study was to identify factors that could be associated with the recurrence of harmful alcohol consumption after LT.

A total of 387 consecutive patients (23.8% women) who underwent LT for alcoholic cirrhosis in Geneva, Switzerland, and Lyon, France, between 1989 and 2005 were evaluated.

• Mean +/- SD age was 51.3 +/-7.5 years. Follow-up time was 61.2 +/- 47.5 months.

Alcohol consumption relapse and potential factors associated with it were studied.

• The relapse rate of harmful alcohol consumption after LT was 11.9%.

In univariate analysis, alcohol relapse was significantly associated with

• age greater than 50 years,
• year of LT 1995 or earlier,
• duration of abstinence less than 6 months,
• presence of psychiatric comorbidities,
• presence of a life partner, and
• a high score on the High-Risk Alcoholism Relapse (HRAR) scale.

Multivariate logistic regression disclosed the following independent factors of relapse:

• duration of abstinence of less than 6 months;
• presence of psychiatric comorbidities; and
• HRAR score higher than 3.

In patients with none of these factors, alcohol relapse was 5%, while the presence of 1, 2, or 3 factors was associated with relapse rates of 18%, 64%, and 100% of the patients, respectively.

In a large cohort of patients undergoing LT for alcoholic cirrhosis,

• a duration of abstinence of less than 6 months before wait-listing for LT,
• the presence of psychiatric comorbidities, or
• an HRAR score higher than 3

was associated with relapse into harmful drinking.

The presence of more than 1 factor dramatically increased this risk over 50%.

In the pre-LT evaluation in this setting, these factors should be accurately determined.

Research; Haber PS, McCaughan GW. “I’ll never touch it again, doctor!” – harmful drinking after liver transplantation. Hepatology. 2007 Sep 25;46(4):1302-1304.

Liver Transplantation & the Alcoholic Patient: Medical, Surgical and Psychosocial Issues by Michael R. Lucey, Robert M. Merion, Thomas P. Beresford Read more about this title…

Does Drinking Reduce Stress?

By Michael A. Sayette, Ph.D.

For centuries, people have used alcohol to relieve stress-that is, the interpretation of an event as signaling harm, loss, or threat. The person usually responds to stress with a variety of behavioral, biological, and cognitive changes. Alcohol consumption can result in a stress response dampening (SRD) effect, which can be assessed using various measures.

Numerous individual differences and situational factors help determine the extent to which a person experiences SRD after consuming alcohol.

Individual differences include

• a family history of alcoholism,
• personality traits,
• extent of self-consciousness,
• cognitive functioning, and
• gender.
• Situational factors influencing alcohol’s SRD effect include
• distractions during a stressful situation and
• the timing of drinking and stress.

The attention-allocation model and the appraisal disruption model have been advanced to explain the influence of those situational factors.

Alcohol Research & Health, Vol. 23, No. 4, 1999

This project gathered survey information from physicians, physician assistants, dentists and pharmacists in Arizona who, while enrolled or following a completion of a monitored aftercare program, had relapsed back to active chemical dependency.

In general, survey respondents were male, averaged 52 years of age, had relapsed several times and started abusing illicit drugs and alcohol in high school or college.

The findings suggest several subjective factors that contributed to the subjects’ relapse included;

• dishonesty to self,
• not working a 12 step program, and
• denial of the problem.

Factors reported to be helpful for future relapse prevention were

• abstinence from substance use,
• working a 12 step program, and
• having spiritual beliefs.

By identifying the specific causes of relapse, future studies may attempt to decrease the percentage of health care providers who relapse by recognizing signs of problematic behavior before they occur.

Long MW, Cassidy BA, Sucher M, Stoehr JD. Prevention of relapse in the recovery of Arizona health care providers. J Addict Dis. 2006;25(1):65-72.

A Sponsorship Guide for 12-Step Programs by M. T. Read more about this title…

Dual Disorders – Third Edition

Depression. Schizophrenia. Post-traumatic stress disorder. Bipolar disorder.

Millions of individuals diagnosed with psychiatric or emotional disorders must battle an equally menacing and powerful disease–chemical dependency–alcoholism, drug addiction, medication addiction.

First published in 1993, Dual Disorders is the leading text on the biological and psychological relationship between mental illness and addiction.

The third edition of this Hazelden best-seller has been updated to include the latest research, information about new medications, and an explanation of new diagnostic criteria.

Key features and benefits

• outlines the relationship between chemical dependency and psychiatric disorders
• contains important resources for chemically dependent individuals and their families
• presents practical relapse prevention strategies
• pharmacotherapy

Dual Disorders – Buy 3rd Ed today!

Predictors of 4 year outcome of community residential treatment for patients with substance use disorders.

Aims This study examined systematically how predictors of substance use disorder (SUD) treatment outcome worked together over time and identified mediators and moderators of outcome.

Design The MacArthur model was applied in this naturalistic study to identify how baseline, discharge and 1-year follow-up factors worked together to predict 4-year improvement in substance-related problems.

Setting Eighty-eight community residential facilities were selected based on geographic representativeness, number of patient referrals and type of treatment orientation.

Participants Of 2796 male patients who completed intake assessments, 2324 were assessed at the 1-year follow-up and 2023 at the 4-year follow-up.

Measurements Self-report measures of

• symptom severity,
• functioning,
• social resources and coping,
• treatment and
• involvement in Alcoholics Anonymous (AA) were collected at baseline and at 1- and 4-year follow-ups.

Provider-rated treatment participation measures were obtained at discharge.

Findings

• Greater substance use severity,
• more psychiatric symptoms,
• more prior arrests and
• stronger belief in AA-related philosophy at treatment entry

predicted improvement significantly in substance-related problems 4 years later.

At the 1-year follow-up,

• being employed and
• greater use of AA-related coping
• predicted outcome significantly.

AA-related coping at 1 year mediated the relationship partially between belief in AA philosophy at treatment entry and 4-year outcome.

Conclusions

The findings highlight the unique and positive impact of AA involvement on long-term SUD treatment outcome and extend understanding of why AA is beneficial for patients.

Research report; Predictors of 4 year outcome of community residential treatment for patients with substance use disorders. Addiction. 2008 Apr;103(4):671-80. Laffaye C, McKellar JD, Ilgen MA, Moos RH.

See also;

• Brief-TSF is designed to as adjunctive therapy for anti-craving medication.
• Twelve Step Facilitation

This study analyzed the Alcoholics Anonymous (AA) participation of 55 patients during the 3 months after their discharge from structured treatment, when dropout is high.

Three levels of meeting attendance were discerned:

• low,
• mid-level, and
• “90 meetings in 90 days.”

Of greatest interest, the mid-level group showed mixed interest in AA practices despite substantial meeting attendance, that is,

• they admitted powerlessness over alcohol, but had less enthusiasm for the higher power concept, and relapsed significantly;
• they were likely to have a sponsor, but were less involved with other AA members; and
• they reported working the 12 Steps, but were less interested in the AA literature.

Findings suggest that individuals who are attending AA but having difficulty embracing key aspects of the program need professional assistance that focuses more on AA practices and tenets and meeting attendance.

Barriers to affiliation can also serve as opportunities for furthering both counselling goals and affiliation.

Research; Paul Elliott Caldwell and Henry S.G. Cutter. Journal of Substance Abuse Treatment. Volume 15, Issue 3, May-June 1998, Pages 221-228

• See also:
• Twelve Step Facilitation
• Brief-TSF Description
• AA and Treatment Work Better Together
• Alcohol Related Brain Injury
• THE TWELVE REWARDS OF RECOVERY

The Role of Stress in Alcohol Use, Alcoholism Treatment, and Relapse

By Kathleen T. Brady, M.D., Ph.D., and Susan C. Sonne, Pharm.D.

Addiction to alcohol or other drugs (AODs) is a complex problem determined by multiple factors, including psychological and physiological components. Stress is considered a major contributor to the initiation and continuation of AOD use as well as to relapse.

Many studies that have demonstrated an association between AOD use and stress have been unable to establish a causal relationship between the two. However, stress and the body’s response to it most likely play a role in the vulnerability to initial AOD use, initiation of AOD abuse treatment, and relapse in recovering AOD users.

This relationship probably is mediated, at least in part, by common neurochemical systems, such as the serotonin, dopamine, and opiate peptide systems, as well as the hypothalamic-pituitary-adrenal (HPA) axis. Further exploration of these connections should lead to important pharmacological developments in the prevention and treatment of AOD abuse.

Studies indicate that treatment techniques which foster coping skills, problem solving skills, and social support play a pivotal role in successful treatment.

In the future, individualized treatment approaches that emphasize stress management strategies in those patients in whom a clear connection between stress and relapse exists will become particularly important.

Alcohol Research & Health, Vol. 23, No. 4, 1999

Due to their high prevalence in the general population, alcohol use and abuse can be associated with hepatitis B and C virus infections and it has been demonstrated that alcohol plays a role as a co-morbid factor in the development of liver disease.

There is evidence that alcohol abuse accelerates the progression of liver fibrosis and affects the survival of patients with chronic hepatitis C. The mechanism by which alcohol worsens hepatitis C virus-related liver disease has not been fully clarified, but enhanced viral replication, increased oxidative stress, cytotoxicity and impairment of immune response could play a relevant role.

Alcohol abuse also seems to reduce both sensitivity to interferon and adherence to treatment.

It sounds reasonable to presume that the mechanisms enhancing liver damage in patients affected by hepatitis B are similar to those involved in hepatitis C virus infection.

However, more studies are warranted to improve our knowledge about the interaction between alcohol intake and hepatitis B virus infection.

In conclusion alcohol abuse is associated with an accelerated progression of liver injury, leading to an earlier development of cirrhosis, higher incidence of hepatocellular carcinoma, and higher mortality.

Abstinence from alcohol could reverse some of these deleterious effects.

Research report; Gitto S, Micco L, Conti F, Andreone P, Bernardi M. Alcohol and viral hepatitis: a mini-review. Dig Liver Dis. 2009 Jan;41(1):67-70. Epub 2008 Jul 3.

See also;

• Helping an Alcoholic is Possible in Right Circumstances
• Hep C Factsheet
• Hepatitis B
• If you have healthcare training this manual may help.

The Alcoholic