Social Change through Legislation

D A T A The Brown University

Digest of Addiction

Theory and Application

August 2007 Vol. 26, No. 8 • ISSN 1040-6328

Online ISSN 1556-7559

Highlights… Researchers from Stanford University

recently examined whether improved

outcomes and lower health costs

associated with involvement in a self-help

group were sustained at 2-year follow-up.

Our other page one story looks at data

showing an increase in abuse of

prescription drugs in college students.

� � �

In This Issue… Study: Men oscillate between cocaine use

and abstinence more often than women

See page 2

Spiritual growth linked to less heavy

drinking among alcoholics in recovery

See page 3

Parents of adult children with drug use

problems at risk for ill health

See page 4

Study investigates psychophysiologial

responses in pathological gamblers

See page 5

From the Field Dangerous liaisons: Alcohol’s role in injury

occurrence — by Michael J. Mello, M.D.

See page 8

Treatment Outcomes

Promoting self-help group involvement improves long-term recovery and lowers health costs

Actively promoting self-help group

involvement appears to improve post-

treatment outcomes while reducing the

costs of continuing care, according to

findings published in Alcoholism: Clinical

& Experimental Research.

Researchers Keith Humphreys and

Rudolf H. Moos from the Veterans Affairs

and Stanford University Medical Centers,

Palo Alto, reached this conclusion after

examining whether positive clinical out-

comes and reduced health care costs evi-

dent 1 year after treatment among sub-

stance-dependent patients who were

strongly encouraged to attend 12-Step

self-help groups were sustained at 2-year

follow-up.

Participants were low-income male

veterans treated in either 12-Step-based

(N=887) or cognitive-behavioral (N=887)

treatment programs who were matched

on their history of mental health utiliza-

tion. The treatment programs comprised

5 12-Step-oriented programs and 5 CB

inpatient programs participating in the

Dept. of Veterans Affairs nationwide mul-

tisite substance abuse treatment out-

come study. These programs treated sub-

stance-dependent patients on an inpa-

tient basis for 21 to 28 days and offered

outpatient continuing care after dis-

charge. The 12-Step-based programs

placed substantially more emphasis on

12-Step ideas, had more staff members in

recovery, had a more spiritually focused

treatment environment, and promoted

self-help group involvement much more

Prescription Drugs

Survey reveals increase in non-medical use of prescription drugs in U.S. colleges

Non-medical use of prescription drugs

(NMPD) among U.S. college students

increased steadily between 1993 and

2001, according to findings published in

the journal Addiction.

Researcher Sean Esteban McCabe of

the University of Michigan, Ann Arbor,

and colleagues reached this conclusion

after examining the prevalence and

trends of NMPD among US college stu-

dents between 1993 and 2001. McCabe

and his team also sought to explore

whether college-level characteristics

explained the variation in college-level

prevalence trajectories over time.

Data for the study were collected via

the College Alcohol Study (CAS) from 119

4-year colleges and universities between

1993 and 2001. The representative sam-

ples included all respondents from the

same 119 institutions in 1993 (N=15,282),

1997 (N=14,428), 1999 (N=13,953) and

2001 (N=10,904). The demographic char-

acteristics of students were generally sim-

ilar in all 4 survey years. The mean age of

the sample was around 21 years for each

survey year. The proportion of women

responding increased over time (57% in

1993, 59% in 1997, 61% in 1999 and 64%

in 2001), while the proportion of white

students responding decreased over time

(82% in 1993, 78% in 1997, 77% in 1999

and 76% in 2001).

See Prescription Drugs, page 7…

See Self-help Group Involvement, page 6…

Published online in Wiley InterScience (www.interscience.wiley.com) • DOI: 10.1002/data.20049

The Brown University Digest of Addiction Theory and Application August 2007

6

extensively than did the CB programs.

Patients completed a self-adminis-

tered survey at baseline, 1-year, and 2-

year follow-up. The 2-year follow-up

assessed patients’ substance use, psychi-

atric functioning, self-help group affilia-

tion (AA, CA, and NA), and mental health

care utilization costs. The national VA

database was used to calculate the num-

ber of mental health outpatient visits and

inpatient days for each patient from 1 to 2

years posttreatment. Mental health care

was defined as that provided for patients’

substance use disorder and any psychi-

atric comorbidities. Costs were calculated

using VA budgets at $85 per outpatient

visit and $750 per day for inpatient care.

Results Of the 1,774 veterans followed up at 1

year, 86% (N=1,528) were followed up

again at 2 years. Their clinical outcomes

and mutual help group affiliations consti-

tute this report. Findings revealed a

slightly higher follow-up rate for patients

treated in CB than in 12-Step programs

(88% vs. 84%, respectively). As VA health

care data are available on all patients, fol-

low-up rate for the cost and utilization

outcomes was 100%.

Results indicated that the pattern of

findings at the 1-year follow-up largely

persisted at 2 years, except for the absti-

nence rate, which was substantially high-

er among 12-Step patients than among

CB patients (49.5% vs. 37%, respectively).

Group differences in help-seeking pat-

terns were also similar to those found at the

1-year follow-up, with patients treated in

12-Step programs demonstrating signifi-

cantly higher rates of self-help group

involvement at 2 years. Specifically, among

12-Step patients, the rate of attending 10

self-help treatment meetings in the past 3

months was about 50% greater (36% vs.

24% in CB) and the rate of talking to a spon-

sor once or twice a month or more was

almost 100% greater (25% vs. 14% in CB).

Analyses of treatment utilization and

cost revealed that from 1-year to 2-year

follow-up, 12-Step patients had fewer

inpatient days (7 vs. 10 in CB) and outpa-

tient visits (7 vs. 10 in CB). These findings,

according to the study, translate to about

30% lower average per patient costs in the

12-Step condition ($5,638) than in the CB

condition ($8,078).

Study limits This study was not a randomized trial.

Patients in each condition did not differ

at baseline on any measured variable.

Additionally, these findings must be con-

sidered in light of the impressive size of

12-Step mutual help organizations in the

U.S. An addicted individual can find an

AA or NA meeting in most U.S. cities and

towns, and at most hours of the day.

Finally, the authors note that these results

do not suggest that professional treat-

ment services be cut back in lieu of pro-

moting self-help group therapy. They

note that each patient in this study

received an intensive professional inter-

vention, and many received outpatient

continuing care afterwards.

Authors’ conclusions These results indicate that actively pro-

moting self-help group involvement is a

useful method for maximizing the benefits

of treatment while lowering its ongoing

Continued from page 5…

Self-help Group Involvement From page 1

Study sample

N = 1,774 veterans

25% were employed

20% were married

20% had comorbid Axis I psychiatric disorder

Average mental health costs in year prior to intake = $3,313

adequate decision making in real life.

Whether somatic markers and psy-

chophysiological responses to positive

and negative consequences can be

“trained”, for example through biofeed-

back, or whether these phenomena are

nonremediable remains an open ques-

tion, according to the authors. They note

that an applicable intervention might

involve psycho-education aimed at absti-

nence for pathological gamblers with low-

ered psychophysiological risk sensitivity.

� � �

Goudriaan AE, Oosterlaan J, de Beurs E, et al.:

Psychophysiological determinants and concomi-

tants of deficient decision making in pathological

gamblers. Drug Alcoh Dep 2006; 84:231-239. E-mail:

[email protected]; [email protected].

Suggested reading:

Blaszczynski A, Nower L: A pathways model of

problem and pathological gambling. Addiction 2002;

97:487-499.

positive and negative consequences in

the pathological gambling group.

Study limits The pathological gambling group in

this study excluded persons with co-mor-

bid alcohol or substance abuse or

dependence, thereby limiting generaliza-

tion of the results to a general pathologi-

cal gambling population.

Authors’ conclusions The disadvantageous decision making

by pathological gamblers on the IGT, com-

bined with a pattern of both abnormal

anticipatory SCR and HR reactivity, sug-

gests that deficiencies in developing psy-

chophysiological reactions to behavior

with negative consequences could play a

role in the development and/or continua-

tion of pathological gambling. The authors

posit that the diminished risk sensitivity in

pathological gamblers may interfere with

the number of cards picked from advan-

tageous decks. Control participants

showed a larger decrease in HR before

selecting from the disadvantageous decks

compared to when they selected from

advantageous decks, while this effect was

in the opposite direction for pathological

gamblers.

Controls also showed stronger antici-

patory SCRs before selecting from a dis-

advantageous deck, whereas no such dif-

ferences were present for the PG group.

Further, HR increased in controls after

rewards, while HR decreased after wins in

the PG group.

No significant differences were

observed between pathological gamblers

and controls when dividing the groups in

high and low BIS/BAS scores. However

pathological gamblers did score higher

on both BIS and BAS measures, suggest-

ing a higher sensitivity for immediate

The Brown University Digest of Addiction Theory and Application August 2007

7

Measures The measures in the CAS survey

assessed demographic characteristics,

alcohol use, illicit drug use and NMPD

for all 4 study years. NMPD was meas-

ured by asking students how often, if

ever, they had used any of the following

drugs in the absence of a doctor’s order:

(a) opiate-type drugs (controlled sub-

stances such as codeine, Demerol, Perco-

dan); (b) tranquilizers (drugs such as Val-

ium, Librium); (c) barbiturates (sleeping

pills such as Quaaludes, downs, Yellow

Jackets); and (d) amphetamines (stimu-

lants such as speed, uppers, ups). To

reflect the changing prominence of spe-

cific drugs, the lists of examples for the 3

classes of prescription medications were

updated in 2001 as follows: (a) opiate-

type drugs (codeine, morphine,

Demerol, Percodan, Percocet, Vicodin,

Darvon, Darvocet); (b) tranquilizers

(drugs such as Valium, Librium, Xanax,

Ativan, Klonopin); and (c) barbiturates

(sleeping pills such as Seconal, Nembu-

tal, downs or Yellow Jackets). Students

rated their responses as (1) never used,

(2) used, but not in the past 12 months,

(3) used, but not in the past 30 days and

(4) used in the past 30 days.

Using the same response scale, the

study measured illicit drug use by asking

students how often, if ever, they had used

marijuana, crack cocaine, other forms of

cocaine, heroin, LSD, or other psyche-

delics. College-level variables included

geographic region, admissions selectivity,

private/public status, commuter status,

co-educational status, size of student

enrollment, urbanization, and historical-

ly black school status.

Results Findings indicated that lifetime and

12-month prevalence of non-medical use

of several prescription drugs increased

between 1993 and 2001. Analyses showed

the estimated 12-month prevalence of

any NMPD (tranquilizer/ anxiolytic, opi-

oid, sedative/sleeping medication)

increased at a steady rate from about 4%

in 1993 to 6% in 1997, to 7% in 1999 and to

10% in 2001. In contrast, results showed

the 12-month prevalence of illicit drug

use other than marijuana experienced a

significant increase between 1993 and

1997, followed by decreases in 1999 and

2001. Despite the increasing rates of any

NMPD relative to illicit drug use other

than marijuana, the study showed the 12-

month prevalence of any NMPD was

lower than illicit drug use other than mar-

ijuana in 3 of the 4 survey years.

Analyses of college-level trends

showed that historically black college and

university (HBCU) status was significant-

ly associated with NMPD in 1993, 1999

and 2001. In the 1993 survey, an estimat-

ed 2% of students at these institutions

reported NMPD in the past year, com-

pared to 4% of students at non-HBCUs;

larger differences between the 2 groups

were detected in 1999 and 2001. Addi-

tionally, findings revealed that commuter

status was significantly associated with

NMPD in 1997, 1999 and 2001. In the

1997 survey, an estimated 6% of students

at non-commuter schools reported

NMPD in the past year, compared to 4%

of students at commuter schools. Addi-

tional analyses indicated that both col-

lege-level marijuana use status and illicit

drug use status in 1993 were significantly

associated with NMPD in each of the 4

survey years.

Hierarchical linear models assessing

between-college variation in prevalence

trends over time revealed increasing

trends in any NMPD prevalence across all

4 study years, and significant between-

college variance in terms of the preva-

lence trends. In particular, these results

suggest illicit drug use status in 1993 may

have explained higher levels of NMPD

use during this time period.

Study limits This study represented secondary

analyses. As such, the survey items in the

original questionnaires limited the scope

of what could be examined. Additionally,

student-level inference about trends in

NMPD over time was not possible, as the

study data were cross-sectional and not

collected from the same students over

time. Finally, response rates were low at

some colleges, resulting in small samples

in some cases.

Authors’ conclusions These findings emphasize a need for

continued monitoring of NMPD and illic-

it drug use among college students.

Results suggest that prevention and inter-

vention efforts aimed at reducing mari-

juana and other illicit drug use should

also include multi-faced efforts to reduce

NMPD simultaneously. Results also sug-

gest that prevention and policy efforts to

reduce NMPD be targeted at non-HBCU

and non-commuter schools.

CAS data were collected under grants

from the Robert Wood Johnson Founda-

tion. Manuscript development was sup-

ported by a grant from the National Insti-

tute on Drug Abuse, National Institutes

of Health.

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McCabe S, West B, Wechsler H: Trends and

college-level characteristics associated with the

non-medical use of prescription drugs among US

college students from 1993 to 2001. Addiction

2006; 102:455-465. E-mail: [email protected].

Suggested reading:

Mohler-Kuo M, Lee J E, Wechsler H: Trends in

marijuana and other illicit drug use among college

students: results from 4 Harvard School of Public

Health College Alcohol Study surveys: 1993–2001.

J Am Coll Health 2003; 52:17–24.

costs. Although the difference in cost is

smaller in proportion (30% vs. 40% at 1

year) and in size ($2,440 per patient vs.

$5,735 at 1 year) at 2 years, it is still a sub-

stantial savings, particularly in a time of

reduced resources for addiction treatment.

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Humphreys K, Moos RH: Encouraging posttreat-

ment self-help group involvement to reduce

demand for continuing care services: Two-year

clinical and utilization outcomes. Alc Clin Exp Res

2007; 31(1):64-68. E-mail: [email protected].

Suggested reading:

Humphreys K, Moos RH: Can encouraging sub-

stance abuse inpatients to participate in self-help

groups reduce demand for health care?: A quasi-

experimental study. Alc Clin Exp Res 2001;

2:711–716.

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Prescription Drugs From page1