Showing posts with label Alcholism. Show all posts
Showing posts with label Alcholism. Show all posts
Wednesday, October 13, 2010
International Society of Addiction Medicine Awards Ceremony
The International Society of Addiction Medicine, 12th Annual Meeting in Milan Italy held it's awards ceremony in the Auditorium of Milan. It was a gala evening. Opera solo with piano gave us a dozen or more of Opera's classics in the finest black tie performance including Figaro. Following that thanks and awards were given. The organizers especially deserved praise as this was a conference celebrated for the high level of science in the friendliest of atmospheres. The University of Bicocca setting Milan was terrific. Next year the conference will be in Oslo, Norway.
Abstinence versus Controlled Drinking
Dr. K.F. Mann, Professor and Chair of Addiction Medicine, Heidelberg University, Germany, at the 12th Annual International Society of Addiction Medicine conference, Milan, Italy, 2010, presented on Abstinence versus Controlled Drinking. It was a most informative and enlightened presentation by a brilliant researcher and teacher.
He looked at the types of evidence available to study this question. He reported on the studies of the stability of drinking patterns outcomes in 5, 10 and 16 year follow up studies. These clearly showed that those abstinent after five years were most likely to be abstinent at 10 and 16 years. The other groups were separated into improved and unimproved. The unimproved showed stable unimprovement. At first the 10 year follow up of the 'improved' had shown what appeared to be good results however continued follow up showed that half of these were dead a few years later. This pointed indeed to the benefits associated with abstinence.
PROJECT MATCH study showed that those who sought abstinence were mostly likely to achieve abstinence and if they didn't were most likely to have improvement. In contrast those who thought only to "control" their drinking didn't have as good outcomes.
The UKATT study he quoted was most interesting in that it showed clearly that 1 pound spent on prevention and treatment resulted in 5-6 pounds of financial savings.
PREDICT Study (Mann et al, 2009) showed that people who believed and aimed for abstinence had better outcomes with the use of Naltrexone.
The NESARC study was interesting in that it did show that a large group of people with alcohol problems but not alcohol dependence could get out of their alcohol problems without the need of professional help.
Dr. Mann discussed the Sobell & Sobell study of 1976 that had caused such confusion and misinterpretation. It was a controlled drinking study but what it really showed was that those who were going for abstinence did better.
The Current Standard of Knowledge therefore was that
1. Severely dependent persons show go for abstinence
2. There are those who are low risk drinkers who may be treated differently. This is the conclusion of Sobell in Paris in 2010
The DSMV aims to help such people where the main role is for moderation goals.
Dr. Mann said that one of the major problems surrounded the term "controlled drinking". The WHO has long identified three distinct categories. High Risk, Moderate Risk and Low Risk. It is clear from the research that the High Risk need to be separated from the Low Risk. The Severely addicted are a distinctly different population from the less severely affected. This distinction is significant because each of the different categories can be shown to have distinctly different presentation in regards to risk and influence of drug and alcohol abuse on such diseases as cancer and heart disease.
The European Medicine Agency recognizes that there is a need for Full Abstinence in addiction and that Intermediate harm reduction may be a goal towards that.
Not surprisingly patients preference on first visit separates into 54% wanting abstinence and 46% wanting non abstinence. Those wanting abstinence are mostly female, unemployed and have more alcohol related problems.
Dr. Mann reported that while there was wide exceptance of 'controlled drinking' throughout European care givers it was interesting how this divided. More psychologists than physicians favored 'controlled drinking'. Psychiatrists versus physical doctors had the greatest acceptance of 'controlled' drinking. Acceptance of controlled drinking was greatest in inpatient versus outpatient care givers.
Patient characteristics that influenced the choice of controlled drinking versus abstinence were a) that it was the patient choice b) there was an absence of previous relapses c) the patient had significant social stability d) there was low severity of dependence.
Most importantly, Dr. Mann said that 'controlled drinking' could be seen as a 'stage' towards abstinence. This was most beneficial in Motivational Interviewing where controlled drinking could be a first choice which was great if it worked but if it didn't then the therapist was in a strong position to say, 'well we tried it that way, now what about trying it this way."
Dr. Mann reported that he had changed his own opinions over his years of practice based on reflecting on the evidence of research, seeing that there was a need as with other disease categories to offers options to patients, and consider at what stage a person's disease was by careful assessment.
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He looked at the types of evidence available to study this question. He reported on the studies of the stability of drinking patterns outcomes in 5, 10 and 16 year follow up studies. These clearly showed that those abstinent after five years were most likely to be abstinent at 10 and 16 years. The other groups were separated into improved and unimproved. The unimproved showed stable unimprovement. At first the 10 year follow up of the 'improved' had shown what appeared to be good results however continued follow up showed that half of these were dead a few years later. This pointed indeed to the benefits associated with abstinence.
PROJECT MATCH study showed that those who sought abstinence were mostly likely to achieve abstinence and if they didn't were most likely to have improvement. In contrast those who thought only to "control" their drinking didn't have as good outcomes.
The UKATT study he quoted was most interesting in that it showed clearly that 1 pound spent on prevention and treatment resulted in 5-6 pounds of financial savings.
PREDICT Study (Mann et al, 2009) showed that people who believed and aimed for abstinence had better outcomes with the use of Naltrexone.
The NESARC study was interesting in that it did show that a large group of people with alcohol problems but not alcohol dependence could get out of their alcohol problems without the need of professional help.
Dr. Mann discussed the Sobell & Sobell study of 1976 that had caused such confusion and misinterpretation. It was a controlled drinking study but what it really showed was that those who were going for abstinence did better.
The Current Standard of Knowledge therefore was that
1. Severely dependent persons show go for abstinence
2. There are those who are low risk drinkers who may be treated differently. This is the conclusion of Sobell in Paris in 2010
The DSMV aims to help such people where the main role is for moderation goals.
Dr. Mann said that one of the major problems surrounded the term "controlled drinking". The WHO has long identified three distinct categories. High Risk, Moderate Risk and Low Risk. It is clear from the research that the High Risk need to be separated from the Low Risk. The Severely addicted are a distinctly different population from the less severely affected. This distinction is significant because each of the different categories can be shown to have distinctly different presentation in regards to risk and influence of drug and alcohol abuse on such diseases as cancer and heart disease.
The European Medicine Agency recognizes that there is a need for Full Abstinence in addiction and that Intermediate harm reduction may be a goal towards that.
Not surprisingly patients preference on first visit separates into 54% wanting abstinence and 46% wanting non abstinence. Those wanting abstinence are mostly female, unemployed and have more alcohol related problems.
Dr. Mann reported that while there was wide exceptance of 'controlled drinking' throughout European care givers it was interesting how this divided. More psychologists than physicians favored 'controlled drinking'. Psychiatrists versus physical doctors had the greatest acceptance of 'controlled' drinking. Acceptance of controlled drinking was greatest in inpatient versus outpatient care givers.
Patient characteristics that influenced the choice of controlled drinking versus abstinence were a) that it was the patient choice b) there was an absence of previous relapses c) the patient had significant social stability d) there was low severity of dependence.
Most importantly, Dr. Mann said that 'controlled drinking' could be seen as a 'stage' towards abstinence. This was most beneficial in Motivational Interviewing where controlled drinking could be a first choice which was great if it worked but if it didn't then the therapist was in a strong position to say, 'well we tried it that way, now what about trying it this way."
Dr. Mann reported that he had changed his own opinions over his years of practice based on reflecting on the evidence of research, seeing that there was a need as with other disease categories to offers options to patients, and consider at what stage a person's disease was by careful assessment.
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Drug and Alcohol Practice, Policies and Research in Europe, ISAM, 2010
Dr. Uchtenhagen, at the 12th Annual International Society of Addiction Medicine Conference, Milan, Italy 2010, presented on the Drug and Alcohol Practice Polices and Research in Europe. He made a strong point that the history of Europe had resulted in progressive and humanistic laws in this regard. There was no unified drug legislation across Europe though most nations conformed with UN conventions. Possession was sanctioned with only fines in 6 countries and admonished in another 7 countries. 25 to 90% of countries didn't have sanctions.
The EU Drug Strategy 2005-2012 set frameworks for Drug Action Plans aiming at reduction in the prevalence, harm and availability. When these were evaluated there was increasing focus on harm reduction. There was also noted a gap between public policy and public behaviour and a knowledge gap regarding drug supply. The EU Drug Action Plan 2009 to 2012 had specific actions encouraging support groups such as European Citizens Alliance on Drugs and specific action 21 which systematically aimed to provide access and improve coverage of harm reduction strategies.
The EMCDDA 2006 showed no single format on drug strategy in EU. The trend was to shift from substance use to addressing the consequence of substance use. There was further shift from abstinence only to moderate use options. The diversified treatment models included opioid replacement which clearly showed prevention of blood borne infection. Evaluation showed 27 members have diversification. The recommendations were for drug free treatment as well as appropriate substitution treatment. Opioid substitution showed overall coverage as very diverse across Europe from 5% to 83% with available substitution even lower in prison populations. Further there was further divergence around availability of syringes and condom and availability at most in 18 states. Supervised consumption rooms developing in 1986 at the height of the Aids epidemic showed 62 rooms in 36 European cities.
In 2007 it was noted that harm reduction as a concept was accepted now as part of a balanced approach. Follow up studies of harm reduction showed that they lead to decrease in AIDS in users and no harm to greater community. Opiod Substitution Treatments were shown by the WHO 2004 and 2008 to reduce mortality and morbidity and be most cost effective.
Peer approach interventions were part of the Harm Reduction programs IRETREA was such an example.
The Seventh Framework Program (FP7) was a key pillar for European Research Area and had an open call for research in the area of drug and alcohol abuse and treatment.
Dr. Uchtenhagen has published his ethical perspectives in Intern. Rev. Psych 22, 2010
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The EU Drug Strategy 2005-2012 set frameworks for Drug Action Plans aiming at reduction in the prevalence, harm and availability. When these were evaluated there was increasing focus on harm reduction. There was also noted a gap between public policy and public behaviour and a knowledge gap regarding drug supply. The EU Drug Action Plan 2009 to 2012 had specific actions encouraging support groups such as European Citizens Alliance on Drugs and specific action 21 which systematically aimed to provide access and improve coverage of harm reduction strategies.
The EMCDDA 2006 showed no single format on drug strategy in EU. The trend was to shift from substance use to addressing the consequence of substance use. There was further shift from abstinence only to moderate use options. The diversified treatment models included opioid replacement which clearly showed prevention of blood borne infection. Evaluation showed 27 members have diversification. The recommendations were for drug free treatment as well as appropriate substitution treatment. Opioid substitution showed overall coverage as very diverse across Europe from 5% to 83% with available substitution even lower in prison populations. Further there was further divergence around availability of syringes and condom and availability at most in 18 states. Supervised consumption rooms developing in 1986 at the height of the Aids epidemic showed 62 rooms in 36 European cities.
In 2007 it was noted that harm reduction as a concept was accepted now as part of a balanced approach. Follow up studies of harm reduction showed that they lead to decrease in AIDS in users and no harm to greater community. Opiod Substitution Treatments were shown by the WHO 2004 and 2008 to reduce mortality and morbidity and be most cost effective.
Peer approach interventions were part of the Harm Reduction programs IRETREA was such an example.
The Seventh Framework Program (FP7) was a key pillar for European Research Area and had an open call for research in the area of drug and alcohol abuse and treatment.
Dr. Uchtenhagen has published his ethical perspectives in Intern. Rev. Psych 22, 2010
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Does Underage Drinking Cause Brain Damage?
Dr. Howard Moss, US NIAAA Assistant Director of Clinical Research, presented , "Does Underage Drinking Cause Brain Damage - Convergent Evidence from Imaging Research" to a packed audience at the 12th Annual International Society of Addiction Medicine Conference, University of Bicocca, Milan, Italy, 2010.
He noted first that there was a distinct phase of development distinguishing Adult from Adolescent and that this was in agreement with other mammalian research.
This phase was typified by 1. Engagement in disproportionate amount of risk taking behaviour 2. Increased Appetitive Drive 3. Emotional Volatility 4. Greater autonomic and neuroendrocrine reactivity to stress. 5. Greater cognitive disruption during stress (eg. impulsive responding) 6. Decreased sensitivity to behavioral effects of psychosomatic substances (Note, paradoxically, Decreased not increased) 7. Decreased sleep drive and phase delay
Adolescent brain development was studied and reviewed by Tapert and Schwienburg. There was first increased growth, especially in the preadolescent period followed by pruning which resulted in synaptic refinement. Synaptic pruning: there are many connections between neurons and those not used get pruned away and this results in improvement in attention. By end of adolescence half of the synapses have been pruned. Grey matter is replaced by white matter. 1% of the brain's gray matter is pruned per year during teen years. Glutaminergic neurons are replaced.
Adolescence is the highest risk period for initiation of regular drug use in the US. Cigarettes, for instance have their peak initiation by age 16.
Drug use prevalences in 8th grade show 17 % use alcohol, 8% use illicit drugs, 8% use cigarettes. By 12th grade 45% use alcohol, 21% use illicit drugs and 22% use cigarettes.
Adolescent drinking is less frequent than adults but adolescent drinking is associated with high dose, they drink to get drunk. Adults drink more frequently at a lower dose.
Morphometry studies of the brains of adolescents comparing heavy drinkers with controls show that heavy drinkers have smaller hippocampus. The hippocampus is associated with memory and learning. Morphometry studies also show that heavy drinkers have smaller prefrontal cortexes. The prefrontal cortex is what makes homo sapiens different from other species in planning, goal direction etc. Mylenization studies, using Defusioin Tensor Imaging ( D.L. Thatcher, S. Pajtec, D.B. Clark, 2010) show that the brains of adolescents in the substance abuse samples show decreased myelinization and brains which don't function in a synchronous way. The Fractional Anisotrophy studies show the region of impairment most in the Superior Longitudinal Fasciularis. Heavy drinking adolescents have deficits in large white matter areas.
P Magnetic Resonance Spectroscopy studies brain metabolism showing the energy use of the brain by following phospholipid turnover. The studies of adolescents with alcohol, conduct disorder and Substance Abuse Disorders show that their synapses are not be pruned which explains well the attentional problems and executive function failure seen behaviorally.
Functional MRI studies show regional changes in Oxygen use and can identify areas involved in a task. The Spatial Memory Task changes rapidly in pre adolescents. Heavy drinking adolescents actually did better on this test but the MRI studies showed that they had to use many more areas of their brain to accomplish the task.(Tapert et al, 2004). However after 4-5 years of heavy drinking Spatial Memory Tasks evidence decreased performance, and less activation in superior or inferior parietal areas. Heavy drinkers showed less memory retrieval and poor spatial memory while heavy marijuania users showed decreased learning of tasks, decreased sequencing and increased error. Heavy drinkers showed decreased hippocampus and decreased prefrontal development and decreased white matter integrity. f MRI studies showed decreased performance.
Dr. Moss in conclusion said that the evidence collectively points to negative brain changes as a consequence of alcohol and drug abuse. These negative brain changes constitute brain damage. The question he said that the studies didn't show was whether this was delayed development which could potentially 'catch up' or more permanent deficits. The other question the research did not answer as yet was whether these changes were precursors to later dependence. However he said the epidemiological evidence to date shows very clearly that the heavier the drinking in early adolescence the greater the likelihood of later dependence. What was further not shown was how these changes impacted on other psychopathology. The conclusion remained though that these changes associated with alcohol and drug abuse looked like brain damage.
.
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V
He noted first that there was a distinct phase of development distinguishing Adult from Adolescent and that this was in agreement with other mammalian research.
This phase was typified by 1. Engagement in disproportionate amount of risk taking behaviour 2. Increased Appetitive Drive 3. Emotional Volatility 4. Greater autonomic and neuroendrocrine reactivity to stress. 5. Greater cognitive disruption during stress (eg. impulsive responding) 6. Decreased sensitivity to behavioral effects of psychosomatic substances (Note, paradoxically, Decreased not increased) 7. Decreased sleep drive and phase delay
Adolescent brain development was studied and reviewed by Tapert and Schwienburg. There was first increased growth, especially in the preadolescent period followed by pruning which resulted in synaptic refinement. Synaptic pruning: there are many connections between neurons and those not used get pruned away and this results in improvement in attention. By end of adolescence half of the synapses have been pruned. Grey matter is replaced by white matter. 1% of the brain's gray matter is pruned per year during teen years. Glutaminergic neurons are replaced.
Adolescence is the highest risk period for initiation of regular drug use in the US. Cigarettes, for instance have their peak initiation by age 16.
Drug use prevalences in 8th grade show 17 % use alcohol, 8% use illicit drugs, 8% use cigarettes. By 12th grade 45% use alcohol, 21% use illicit drugs and 22% use cigarettes.
Adolescent drinking is less frequent than adults but adolescent drinking is associated with high dose, they drink to get drunk. Adults drink more frequently at a lower dose.
Morphometry studies of the brains of adolescents comparing heavy drinkers with controls show that heavy drinkers have smaller hippocampus. The hippocampus is associated with memory and learning. Morphometry studies also show that heavy drinkers have smaller prefrontal cortexes. The prefrontal cortex is what makes homo sapiens different from other species in planning, goal direction etc. Mylenization studies, using Defusioin Tensor Imaging ( D.L. Thatcher, S. Pajtec, D.B. Clark, 2010) show that the brains of adolescents in the substance abuse samples show decreased myelinization and brains which don't function in a synchronous way. The Fractional Anisotrophy studies show the region of impairment most in the Superior Longitudinal Fasciularis. Heavy drinking adolescents have deficits in large white matter areas.
P Magnetic Resonance Spectroscopy studies brain metabolism showing the energy use of the brain by following phospholipid turnover. The studies of adolescents with alcohol, conduct disorder and Substance Abuse Disorders show that their synapses are not be pruned which explains well the attentional problems and executive function failure seen behaviorally.
Functional MRI studies show regional changes in Oxygen use and can identify areas involved in a task. The Spatial Memory Task changes rapidly in pre adolescents. Heavy drinking adolescents actually did better on this test but the MRI studies showed that they had to use many more areas of their brain to accomplish the task.(Tapert et al, 2004). However after 4-5 years of heavy drinking Spatial Memory Tasks evidence decreased performance, and less activation in superior or inferior parietal areas. Heavy drinkers showed less memory retrieval and poor spatial memory while heavy marijuania users showed decreased learning of tasks, decreased sequencing and increased error. Heavy drinkers showed decreased hippocampus and decreased prefrontal development and decreased white matter integrity. f MRI studies showed decreased performance.
Dr. Moss in conclusion said that the evidence collectively points to negative brain changes as a consequence of alcohol and drug abuse. These negative brain changes constitute brain damage. The question he said that the studies didn't show was whether this was delayed development which could potentially 'catch up' or more permanent deficits. The other question the research did not answer as yet was whether these changes were precursors to later dependence. However he said the epidemiological evidence to date shows very clearly that the heavier the drinking in early adolescence the greater the likelihood of later dependence. What was further not shown was how these changes impacted on other psychopathology. The conclusion remained though that these changes associated with alcohol and drug abuse looked like brain damage.
.
- Posted using BlogPress from my iPa
V
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