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Disclaimer: CME certification for these activities has expired. All information is pertinent to the timeframe in which it was released.


New Developments in the Pharmacologic Treatment of Alcoholism


GOAL
For participants to understand the biologic basis of alcohol dependence and become familiar with the available pharmacologic treatment options and their role in a holistic treatment approach.

TARGET AUDIENCE
This educational activity was designed for nurses, physicians, program directors and administrators, counselors, social workers, and other healthcare workers directly involved in the treatment of alcoholism. No prerequisites required.

LEARNING OBJECTIVES
The Institute for Johns Hopkins Nursing and The Johns Hopkins University School of Medicine take responsibility for the content, quality, and scientific integrity of this CE activity. At the conclusion of this activity, participants should be able to:

  • Understand the neurochemical abnormalities that are thought to play a role in alcohol dependence.
  • Review the currently available and emerging medications for the pharmacologic treatment of alcoholism.
  • Examine the clinical evidence for the use of pharmacologic treatment options for alcoholism.
  • Establish protocols that incorporate pharmacologic therapies into a holistic approach to the treatment of alcohol dependence.

ACCREDITATION STATEMENTS
The Institute for Johns Hopkins Nursing is accredited as a provider of continuing education in nursing by the American Nurses Credentialing Center's Commission on Accreditation.

The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

CREDIT DESIGNATION STATEMENT
The Institute for Johns Hopkins Nursing designates this activity for a maximum of 2 contact hours. The Johns Hopkins University School of Medicine designates this educational activity for a maximum of 2 category 1 credits toward the AMA Physician's Recognition Award. Each participant should claim only those hours that he/she actually spent in the activity.

The estimated time to complete this educational activity: 2 hours.

Release date: April 15, 2004. Expiration date: April 15, 2006.

DISCLAIMER STATEMENT
The opinions and recommendations expressed by faculty and other experts whose input is included in this program are their own. This enduring material is produced for educational purposes only. Use of The Institute for Johns Hopkins Nursing and the Johns Hopkins University School of Medicine names implies review of educational format, design, and approach. Please review the complete prescribing information of specific drugs or combinations of drugs, including indications, contraindications, warnings, and adverse effects, before administering pharmacologic therapy to patients.

Supported by an unrestricted education grant from Ortho-McNeil Pharmaceutical, Inc.

Full Disclosure Policy Affecting CE Activities:
As sponsors accredited by the American Nurses Credentialing Center (ANCC) and the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of The Institute for Johns Hopkins Nursing and the Johns Hopkins School of Medicine to require the disclosure of the existence of any significant financial interest or any other relationship a faculty member or a sponsor has with the manufacturer(s) of any commercial product(s) discussed in an educational presentation. The Program Directors and Participating Faculty reported the following:

PROGRAM DIRECTORS

    Bankole A. Johnson, MD, PhD
    Wurzbach Distinguished Professor
    Departments of Psychiatry and Pharmacology
    Deputy Chairman for Research
    Chief, Division of Drug and Alcohol Addiction
    University of Texas Health Science Center
    San Antonio, Texas
    Dr Johnson reports serving as a consultant to Ortho-McNeil Pharmaceutical, Inc.

    Joan Kub, PhD, APRN, BC
    Assistant Professor
    Johns Hopkins University School of Nursing
    Baltimore, Maryland
    Dr Kub reports having no financial or advisory relationships with corporate organizations related to this activity.

PARTICIPATING FACULTY

    Louise Epperson, MSN, CRNP
    Director
    Detoxification and Primary Care Services
    Treatment Research Center
    University of Pennsylvania
    Philadelphia, Pennsylvania
    Ms Epperson reports receiving honoraria from Ortho-McNeil Pharmaceutical, Inc.

    Mary E. McCaul, PhD
    Professor
    Department of Psychiatry and Behavioral Sciences
    Johns Hopkins UniversitySchool of Medicine
    Director, Johns Hopkins Hospital
      Program for Alcoholism and Other
      Drug Dependencies
    Baltimore, Maryland
    Dr McCaul reports receiving grants and/or research support from Alkermes, Inc, and Drug Abuse Sciences, Inc.

Notice:
The audience is advised that one or more articles in this continuing education activity may contain reference(s) to unlabeled or unapproved uses of drugs or devices. The following faculty members have indicated that they have referenced unlabeled/unapproved uses of drugs or devices:

Dr Johnson – acamprosate, buspirone, fluoxetine, nalmefene, naloxone, topiramate
Dr McCaul – acamprosate, buspirone

All other faculty have indicated that they have not referenced unlabeled/unapproved uses of drugs or devices.

Advanced Studies in Nursing provides disclosure information from contributing authors, lead presenters, and participating faculty.  Advanced Studies in Nursing does not provide disclosure information from authors of abstracts an poster presentations. The reader shall be advised that these contributors may or may not maintain financial relationships with pharmaceutical companies.

America's Alcohol Problem
Joan Kub, PhD, APRN, BC*

Findings from the 2002 National Survey on Drug Use and Health reveal that more than one half of Americans (120 million) aged 12 years and older report being current drinkers of alcohol, meaning they had at least 1 drink in the 30 days prior to the survey. Of these individuals, 22.9% participated in binge drinking (>=5 drinks on one occasion) at least once in the 30 days prior to the survey (54 million individuals), and 6.7% of Americans (approximately 16 million) admit to heavy drinking, defined as 5 or more drinks on the same occasion at least 5 different days in the past 30 days.1 Although the highest prevalence of alcohol use is among persons 21 years of age (70.9% of whom report drinking), binge drinking and heavy drinking are most common in young adults aged 18 to 25 years and occur in children as young as 12 years old. Level of alcohol use is also strongly associated with illicit drug use (32.6% of heavy drinkers were also users of illegal drugs), and 1 in 7 Americans (33.5 million) have admitted to driving under the influence of alcohol at least once in the 12 months prior to being interviewed.1 These numbers have increased from the time this survey was conducted in 2000 to 2001.

These statistics point to alcohol as a serious issue for individuals, their friends and families, and society. More than one half of American adults have a close friend or family member who is or has been alcohol dependent, and approximately 1 in 4 children younger than 18 years is exposed to alcohol abuse or dependence in the family.2 The 1992 National Longitudinal Alcohol Epidemiologic Survey found that 14 million Americans (7.4% of the population) met the criteria for alcohol abuse or dependence; the most recent (2002) National Survey on Drug Use and Health found that the number had increased to 14.9 million Americans. 1,3-5

PHYSICAL AND ECONOMIC IMPACT OF ALCOHOLISM
Alcohol exerts its effects most commonly in the gastrointestinal, nervous, cardiac, skeletal, and immune systems. Chronic heavy drinking is associated with cirrhosis of the liver, gastritis, pancreatitis, peripheral neuropathy, brain damage and dementia, cardiomyopathy, arrhyth-mias, hypertension, stroke, certain cancers, and fetal abnormalities. In addition to morbidity, significant mortality is associated with alcohol abuse, which is responsible for 105 000 deaths annually.4,6

Alcohol can also have psychologic and cognitive effects; alcohol abuse and alcoholism rank among the top 3 psychiatric disorders in the United States.4,7 Individuals who suffer psychologic distress and rely on alcohol to relieve that stress are more likely to develop alcohol abuse and dependence, and those who are alcoholics have a higher incidence of mental disorders. Furthermore, strong relationships exist between heavy alcohol consumption and cognitive impairments.

From a psychosocial and societal perspective, alcohol-related problems include economic loss related to time off from work, disruption of family and social relationships, emotional problems, violence and aggression, and legal problems. According to data collected and calculated by the US Department of Health and Human Services in 2000, the total cost is approximately $185 billion annually, representing a 25% increase from figures compiled just 6 years earlier.8 Alcohol use is associated with risk of injury and death in a wide variety of circumstances, including automobile accidents, falls, violence, and fires.

TREATMENT OF ALCOHOLISM
According to the 1993 National Drug and Alcoholism Treatment Unit Survey, more than 700 000 people daily in the United States receive treatment for alcoholism in either inpatient or outpatient settings: 13.5% in a hospital or residential setting and 86.5% in an out-patient facility.9 The most recent (2002) National Survey on Drug use and Health found that 2.2 million persons received treatment fro alcoholism during the past year.1 The process begins with detoxification, with or without pharmacotherapy. Detoxification is accompanied by various types of psychosocial or behavioral therapies, which may include cognitive behavioral therapy, motivational enhancement, or 12-step programs. Project MATCH analyzed these various types of programs in a large-scale study of 1700 subjects randomly assigned to one of these types of interventions.10 The findings indicated a reduction in the percentage of drinking days from 75% to 20% during the year following a 3-month course of therapy for only about half of the patients regardless of the specific type of intervention they received. Although psychosocial therapies have helped many alcohol-dependent patients, 40% to 70% resume drinking within 1 year of treatment. Clearly, there is much room for improvement.

 
Alcohol Abuse

A. Maladaptive pattern of alcohol use leading to clinically significant impairment or distress, as manifested by 1 or more of the following occurring within a 12-mo period:

  • Recurrent use resulting in failure to fulfill major obligations
  • Recurrent use when physically hazardous
  • Recurrent alcohol-related legal problems
  • Continued use despite persistent or recurrent social or interper- sonal problems caused or exacerbated by the effects of alcohol

B. Symptoms have never met criteria for dependence

Alcohol Dependence

Maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 3 or more of the following occurring within a 12-mo period:

  • Tolerance, as defined by:
    • need for markedly increased amounts to achieve intoxication or desired effect
    • markedly diminished effect with continued use of the same amount
  • Withdrawal, as manifested by:
    • characteristics of withdrawal syndrome for alcohol
    • the same (or closely related) substance is used to relieve or avoid withdrawal symptoms
  • Large amounts over a longer period than intended
  • Persistent desire or 1 or more unsuccessful efforts to cut down
  • Much time spent in activities to obtain/use alcohol or recover from its effects
  • Reduction/cessation of social, occupational, or recreational activities
  • Continued use despite knowledge of persistent or recurrent physical or psychological problems caused or exacerbated by alcohol use

Data from the American Psychiatric Association.5

 

PHARMACOLOGIC TREATMENT OF ALCOHOL DEPENDENCE
The development of new medications has initiated a new era in alcoholism treatment. Until 1995, the only pharmacologic treatment approved in the United States for the treatment of alcohol abuse was disulfiram. Since then, there has been much advancement in the knowledge of the biology of alcoholism. This increase in knowledge has resulted in the development of promising medications specifically targeted to various receptors in the brain with the goal of reducing the desire to drink as well as promoting abstinence.

This issue of Advanced Studies in Nursing, based on presentations given at the 2003 Southeastern Conference of Alcohol and Drug Addiction, December 3, 2003, reviews currently available medications as well as emerging developments in the pharmacologic treatment of alcoholism. The specific focus is on the available clinical evidence for the use of pharmacologic treatments as well as methods for incorporating these therapies into a holistic approach to the treatment of alcohol dependence. To understand how these various pharmacothera-pies may be useful adjuncts to traditional 12-step help programs and psychotherapeutic approaches, it is first necessary to gain a basic understanding of the biologic and neurochemical aberrations underlying alcoholism as we understand them today.

REFERENCES
1. Department of Health and Human Services Substance Abuse and Mental Health Services Administration. Results from the 2002 National Survey on Drug Use and Health: National Findings. Rockville, Md: Office of Applied Studies; 2003. Publication SMA 03-3836. Available at: http://www.samh-sa.gov/oas/NHSDA/2k2NSDUH/Results/2k2results.htm#cha p3. Accessed January 9, 2004.
2. Grant BF. Estimates of US children exposed to alcohol abuse and dependence in the family. Am J Public Health.
2000;90(1):112-115.
3. Grant BF. Alcohol consumption, alcohol abuse and alcohol dependence. The United States as an example. Addiction. 1994;89(11):1357-1365.
4. Volpicelli JR. Alcohol abuse and alcoholism: an overview. J Clin Psychiatry. 2001;62(suppl 20):4-10.
5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (Text Revision), Fourth Edition. Washington, DC: American Psychiatric Association; 2002.
6. McGinnis JM, Foege WH. Mortality and morbidity attributable to use of addictive substances in the United States. Proc Assoc Am Physicians. 1999;111(2):109-118.
7. Kessler RC, McGonagle KA, Zhao S, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: results from the National Comorbidity Survey. Arch Gen Psychiatry. 1994;51(1):8-19.
8. Harwood H. Updating Estimates of the Economic Costs of Alcohol Abuse in the United States: Estimates, Update Methods, and Data. Rockville, Md: National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, US Department of Health and Human Services; 2000. Available at: http://www.niaaa.nih.gov/publications/economic-2000/printing.htm. Accessed February 25, 2004.
9. Fuller RK, Hiller-Sturmhofel S. Alcoholism treatment in the United States: an overview. Alcohol Res Health. 1999; 23(2):69-77.
10. Project MATCH Research Group. Matching alcoholism treatments to client heterogeneity: treatment main effects and matching effects on drinking during treatment. J Stud Alcohol.
1998;59(6):631-639.





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