Craving and Approaching – Avoidance

A Step Essential to the Understanding of Craving

By Mary Jo Breiner M.S., Werner G. K. Stritzke, Ph.D., and Alan R. Lang, Ph.D.

Craving is only one component of the mental processes that influence drinking behavior.

Alcohol-related cues (ARCs) can set in motion a dynamic competition between inclinations to approach drinking and inclinations to avoid drinking. Craving can thus be integrated into a comprehensive model of decision making in which ambivalence or conflict is a key element.

The relative strength of each component of the ARC reaction can fluctuate over time as well as in response to both subjective states and environmental circumstances.

Simultaneously and independently evaluating these opposing responses puts clinicians in a better position to influence the relative weight that the patient assigns to the positive and negative outcomes of alcohol consumption.

Alcohol Research & Health Vol. 23, No. 3, 1999

Extended-Release Naltrexone Works Particularly Well for Abstinent Patients with Dependence

Many patients with alcohol dependence do not receive the full benefits of treatment because they do not adhere to it. In part to address issues with adherence, extended-release (ER) naltrexone, which is released over a month after one injection, was developed. Pharmacotherapy researchers assessed ER-naltrexone efficacy in a subgroup of 82 subjects in a larger clinical trial who had ?4 days of abstinence.

In that subgroup, 380 mg of ER-naltrexone in 28 subjects versus placebo in 28 subjects

• increased the time to first drink (median days, 41 versus 12);
• increased continuous abstinence over 6 months (32% versus 11%);
• increased time to first heavy drinking (>180 versus 20 days);
• decreased days with any drinking (median days per month, 0.7 versus 7.2);
• decreased days with heavy drinking (median days per month, 0.2 versus 2.9).

Smaller benefits, which were not always statistically significant, were found among 28 subjects treated with 190 mg of ER-naltrexone.

Comments by Michael Levy, PhD:
In this industry-sponsored secondary analysis of a small subgroup of subjects who had achieved just 4 or more days of abstinence before entering treatment, those who received ER-naltrexone in conjunction with psychosocial treatment had better treatment outcomes than those who received placebo. Medications with proven benefit for the treatment of alcohol dependence tend to be underutilized in general. This study suggests that ER-naltrexone is another treatment option for clients with alcohol dependence who have achieved even a short duration of abstinence.

Research Reference: O’Malley SS, Garbutt JC, Gastfriend DR, et al. Efficacy of extended-release naltrexone in alcohol-dependent patients who are abstinent before treatment. J Clin Psychopharm. 2007;27(5):507–512.

From; Join Together Online

Brief-TSF is designed to as adjunctive therapy for anti-craving medication.

The prominence of Twelve-Step programs has led to increased attention on the putative role of spirituality in recovery from addictive disorders.

We developed a 6-item Spirituality Self-Rating Scale designed to reflect a global measure of spiritual orientation to life, and we demonstrated here its internal consistency reliability in substance abusers on treatment and in nonsubstance abusers.

This scale and the measures related to recovery from addiction and treatment response were applied in three diverse treatment settings: a general hospital inpatient psychiatry service, a residential therapeutic community, and methadone maintenance programs.

Findings on these patient groups were compared to responses given by undergraduate college students, medical students, addiction faculty, and chaplaincy trainees.

These suggest that, for certain patients, spiritual orientation is an important aspect of their recovery.

Furthermore, the relevance of this issue may be underestimated in the way treatment is framed in a range of clinical facilities.

Research; Galanter M, Dermatis H, Bunt G, Williams C, Trujillo M, Steinke P. Assessment of spirituality and its relevance to addiction treatment. J Subst Abuse Treat. 2007 Oct;33(3):257-64.

See also;

• The Most Effective Form of Harm Reduction
• What About This Spiritual Awakening Thing?

“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…

DEVELOPING A WILLINGNESS TO CHANGE: TREATMENT-SEEKING PROCESSES FOR PEOPLE WITH ALCOHOL PROBLEMS.

The study explores treatment-seeking processes in men and women with alcohol problems, focusing on promoting and hindering factors.

Open interviews were held with five women and seven men within a month of their first voluntary treatment for alcohol problems. The interview protocols were analysed consecutively in accordance with grounded theory methodology.

Developing a willingness to change was found to be the basic psychosocial process that lead to treatment seeking.

Categories that constituted sub-processes and supported willingness to change were:

• actuating inner forces;
• dealing with conflicting feelings and thoughts; and
• hoping to turn the situation around.

These processes were continuously assisted by demanding and caring support from partners, friends or professionals.

The processes that precede treatment-seeking were highly complex, and both internal and external factors promoted and hindered treatment entry.

The social significance of alcohol and the grief related to thoughts of abstaining were the most striking hindering factors.

Such feelings need to be considered when motivating people to seek treatment for alcohol problems.

Jakobsson A, Hensing G, Spak F. DEVELOPING A WILLINGNESS TO CHANGE: TREATMENT-SEEKING PROCESSES FOR PEOPLE WITH ALCOHOL PROBLEMS. Alcohol Alcohol. 2004 Dec 6;

Difference in medical history classified by ICD-10 between male and female alcoholics.

The drinking history and current medical history of patients with alcohol dependence were surveyed in Japan and they were analyzed by demographics; gender, age and changes with time (2 stages).

The results showed that in the course of continued habitual drinking by patients with alcohol dependence, a wide range of physical complications occurred.

The main complications

• in men were gastrointestinal diseases and
• in women were mental and behavioral disorders, showing a gender difference in the medical history.

This result suggested that there is a high possibility that this will contribute to early discovery and early measures against alcohol related problems in women, which are difficult to bring out into the open.

Better alcohol education including mental health is important from an early age.

Nihon Arukoru Yakubutsu Igakkai Zasshi. 2008 Feb;43(1):25-34. Difference in medical history classified by ICD-10 between male and female alcoholics. Shinoda R, Mizukami Y, Nakagawa Y, Maruyama K.

See also;

• Brief-TSF is designed to address these issues.
• 12-Step Treatment More Effective than Alternative
• Subscribe to BriefTSF by e-Mail

Counseling the Culturally Diverse: Theory and Practice by Derald Wing Sue, David Sue Read more about this title…

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

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

Influence of outpatient treatment and 12-step group involvement on one-year substance abuse treatment outcomes.

We examined whether substance abuse patients self-selecting into 1 of 3 aftercare groups (outpatient treatment only, 12-step groups only, and outpatient treatment and 12-step groups) and patients who did not participate in aftercare differed on 1-yr substance use and psychosocial outcomes.

A total of 3,018 male patients filled out a questionnaire at intake and 1 yr following discharge from treatment.

Patients were classified into aftercare groups at follow-up using information from VA databases and self-reports.

Results;

• Patients who participated in both outpatient treatment and 12-step groups fared the best on 1-yr outcomes.
• Patients who did not obtain aftercare had the poorest outcomes.
• In terms of the amount of intervention received, patients who had more outpatient mental health treatment, who more frequently attended 12-step groups or were more involved in 12-step activities had better 1-yr outcomes.
• In addition, patients who kept regular outpatient appointments over a longer time period fared better than those who did not.

Research report; Ouimette, Page Crosby; Moos, Rudolf H; Finney, John W. Influence of outpatient treatment and 12-step group involvement on one-year substance abuse treatment outcomes. Journal of Studies on Alcohol. Vol 59(5), Sep 1998, 513-522.