Kate Johnson

Healthy female babies might not make such healthy adults, at least when it comes to rheumatoid arthritis, according to a group of British researchers.

Exposure to infection in early childhood may help protect women from developing rheumatoid arthritis (RA), reported Dr. C.J. Edwards and colleagues from the University of Southampton and the Southampton General Hospital, United Kingdom.

“It appears that a developing immune system exposed to fewer infectious microorganisms through improved standards of hygiene may be more likely to produce [rheumatoid factor] and perhaps begin the pathological process that leads to [rheumatoid arthritis],” reported Dr. Edwards and colleagues (Ann. Rheum. Dis. 2006;65:401–4).

The researchers' study measured rheumatoid factor (RF) levels in 675 men and 668 women aged 61–69 years and investigated the association of RF with markers of exposure to childhood infection. These markers included sharing a bedroom during childhood, social class, and birth order.

“Reduced exposure to microorganisms is thought to result from higher social class, fewer siblings, having your own bedroom during childhood, and living in an urban environment,” the authors reported.

A positive RF level—defined as 6 IU/ml or higher—was present in 16.6% of the men and 11.8% of the women in the study.

Although no significant relationship was found between markers of childhood infection and the presence of RF in men, women who shared a bedroom during childhood had a significantly lower risk of being RF positive (odds ratio 0.48), they noted.

There also was a trend that associated lower birth order and lower social class with a reduced likelihood of RF positivity in women.

The presence of RF has been shown to confer a risk of developing RA—although RF may be present for up to 10 years before clinical disease onset, the authors noted.

Up to 80% of people with RA also have RF; however, 10% of the normal population tests positive for RF, and prevalence increases with age. It is not clear why the association of RF positivity and increased childhood exposure to infection was found in women and not in men.

The epidemiology of RA, however, is markedly different for the two groups, noted the authors. “Women are three times more likely to have RA than men and have a peak incidence in middle age. In contrast, men have an increasing incidence that becomes equal to that of women later in life.”

The authors noted a parallel between the “hygiene hypothesis” linking decreased infectious exposure and allergy.

“Epidemiological evidence has now shown that autoimmune diseases such as type 1 diabetes are more likely in subjects exposed to a 'cleaner' environment during childhood and that atopy has an increased incidence in subjects with autoimmune diseases, including RA,” Dr. Edwards and colleagues noted.

Healthy female babies might not make such healthy adults, at least when it comes to rheumatoid arthritis, according to a group of British researchers.

Exposure to infection in early childhood may help protect women from developing rheumatoid arthritis (RA), reported Dr. C.J. Edwards and colleagues from the University of Southampton and the Southampton General Hospital, United Kingdom.

“It appears that a developing immune system exposed to fewer infectious microorganisms through improved standards of hygiene may be more likely to produce [rheumatoid factor] and perhaps begin the pathological process that leads to [rheumatoid arthritis],” reported Dr. Edwards and colleagues (Ann. Rheum. Dis. 2006;65:401–4).

The researchers' study measured rheumatoid factor (RF) levels in 675 men and 668 women aged 61–69 years and investigated the association of RF with markers of exposure to childhood infection. These markers included sharing a bedroom during childhood, social class, and birth order.

“Reduced exposure to microorganisms is thought to result from higher social class, fewer siblings, having your own bedroom during childhood, and living in an urban environment,” the authors reported.

A positive RF level—defined as 6 IU/ml or higher—was present in 16.6% of the men and 11.8% of the women in the study.

Although no significant relationship was found between markers of childhood infection and the presence of RF in men, women who shared a bedroom during childhood had a significantly lower risk of being RF positive (odds ratio 0.48), they noted.

There also was a trend that associated lower birth order and lower social class with a reduced likelihood of RF positivity in women.

The presence of RF has been shown to confer a risk of developing RA—although RF may be present for up to 10 years before clinical disease onset, the authors noted.

Up to 80% of people with RA also have RF; however, 10% of the normal population tests positive for RF, and prevalence increases with age. It is not clear why the association of RF positivity and increased childhood exposure to infection was found in women and not in men.

The epidemiology of RA, however, is markedly different for the two groups, noted the authors. “Women are three times more likely to have RA than men and have a peak incidence in middle age. In contrast, men have an increasing incidence that becomes equal to that of women later in life.”

The authors noted a parallel between the “hygiene hypothesis” linking decreased infectious exposure and allergy.

“Epidemiological evidence has now shown that autoimmune diseases such as type 1 diabetes are more likely in subjects exposed to a 'cleaner' environment during childhood and that atopy has an increased incidence in subjects with autoimmune diseases, including RA,” Dr. Edwards and colleagues noted.

Healthy female babies might not make such healthy adults, at least when it comes to rheumatoid arthritis, according to a group of British researchers.

Exposure to infection in early childhood may help protect women from developing rheumatoid arthritis (RA), reported Dr. C.J. Edwards and colleagues from the University of Southampton and the Southampton General Hospital, United Kingdom.

“It appears that a developing immune system exposed to fewer infectious microorganisms through improved standards of hygiene may be more likely to produce [rheumatoid factor] and perhaps begin the pathological process that leads to [rheumatoid arthritis],” reported Dr. Edwards and colleagues (Ann. Rheum. Dis. 2006;65:401–4).

The researchers' study measured rheumatoid factor (RF) levels in 675 men and 668 women aged 61–69 years and investigated the association of RF with markers of exposure to childhood infection. These markers included sharing a bedroom during childhood, social class, and birth order.

“Reduced exposure to microorganisms is thought to result from higher social class, fewer siblings, having your own bedroom during childhood, and living in an urban environment,” the authors reported.

A positive RF level—defined as 6 IU/ml or higher—was present in 16.6% of the men and 11.8% of the women in the study.

Although no significant relationship was found between markers of childhood infection and the presence of RF in men, women who shared a bedroom during childhood had a significantly lower risk of being RF positive (odds ratio 0.48), they noted.

There also was a trend that associated lower birth order and lower social class with a reduced likelihood of RF positivity in women.

The presence of RF has been shown to confer a risk of developing RA—although RF may be present for up to 10 years before clinical disease onset, the authors noted.

Up to 80% of people with RA also have RF; however, 10% of the normal population tests positive for RF, and prevalence increases with age. It is not clear why the association of RF positivity and increased childhood exposure to infection was found in women and not in men.

The epidemiology of RA, however, is markedly different for the two groups, noted the authors. “Women are three times more likely to have RA than men and have a peak incidence in middle age. In contrast, men have an increasing incidence that becomes equal to that of women later in life.”

The authors noted a parallel between the “hygiene hypothesis” linking decreased infectious exposure and allergy.

“Epidemiological evidence has now shown that autoimmune diseases such as type 1 diabetes are more likely in subjects exposed to a 'cleaner' environment during childhood and that atopy has an increased incidence in subjects with autoimmune diseases, including RA,” Dr. Edwards and colleagues noted.

Minor physical anomalies are not increased in infants born to women with systemic lupus erythematosus, according to the results of a new study that examined 30 babies of women with SLE.

The incidence of minor physical anomalies was 43% “consistent with the incidence in the general population,” said Dr. Phyllis N. Bonaminio of Northwestern University, Chicago, and her colleagues (Ann. Rheum. Dis. 2006;65:246–8).

The minor physical anomalies included flat nasal bridge (five), hypoplastic nose (four), long philtrum (three), high-arched palate (three), and thin vermillion, posterior-rotated ears, low-set ears, and protruding ears in one infant each. Limb anomalies included syndactyly and polydactyly in one infant each, and length discrepancies in the second and third toes of two infants.

Flat nasal bridge, hypoplastic nose, and long philtrum are associated with fetal alcohol exposure and were found in some of the infants of the 10 women who reported substance abuse during pregnancy, the authors noted.

Neither prednisone (reported by 50%), nor aspirin (reported by 20%), nor maternal disease flare were associated with minor physical anomalies, reported the authors.

Minor physical anomalies are not increased in infants born to women with systemic lupus erythematosus, according to the results of a new study that examined 30 babies of women with SLE.

The incidence of minor physical anomalies was 43% “consistent with the incidence in the general population,” said Dr. Phyllis N. Bonaminio of Northwestern University, Chicago, and her colleagues (Ann. Rheum. Dis. 2006;65:246–8).

The minor physical anomalies included flat nasal bridge (five), hypoplastic nose (four), long philtrum (three), high-arched palate (three), and thin vermillion, posterior-rotated ears, low-set ears, and protruding ears in one infant each. Limb anomalies included syndactyly and polydactyly in one infant each, and length discrepancies in the second and third toes of two infants.

Flat nasal bridge, hypoplastic nose, and long philtrum are associated with fetal alcohol exposure and were found in some of the infants of the 10 women who reported substance abuse during pregnancy, the authors noted.

Neither prednisone (reported by 50%), nor aspirin (reported by 20%), nor maternal disease flare were associated with minor physical anomalies, reported the authors.

Minor physical anomalies are not increased in infants born to women with systemic lupus erythematosus, according to the results of a new study that examined 30 babies of women with SLE.

The incidence of minor physical anomalies was 43% “consistent with the incidence in the general population,” said Dr. Phyllis N. Bonaminio of Northwestern University, Chicago, and her colleagues (Ann. Rheum. Dis. 2006;65:246–8).

The minor physical anomalies included flat nasal bridge (five), hypoplastic nose (four), long philtrum (three), high-arched palate (three), and thin vermillion, posterior-rotated ears, low-set ears, and protruding ears in one infant each. Limb anomalies included syndactyly and polydactyly in one infant each, and length discrepancies in the second and third toes of two infants.

Flat nasal bridge, hypoplastic nose, and long philtrum are associated with fetal alcohol exposure and were found in some of the infants of the 10 women who reported substance abuse during pregnancy, the authors noted.

Neither prednisone (reported by 50%), nor aspirin (reported by 20%), nor maternal disease flare were associated with minor physical anomalies, reported the authors.

Community health centers are currently clinically understaffed and will likely face increasing shortages that may limit their expansion, according to a study by the rural health research centers of both the University of Washington, Seattle, and the University of South Carolina, Columbia, and by the National Association of Community Health Centers (JAMA 2006;295:1042–9).

The study surveyed 846 federally funded community health centers (CHCs) in the 50 states and the District of Columbia. Mailed questionnaires and telephone surveys asked CHC chief executive officers about staffing and recruiting patterns, use of federal and state recruitment programs, and perceived barriers to recruitment, reported Dr. Roger A. Rosenblatt from the University of Washington, and his colleagues.

Responses were obtained from 79% of the population and revealed that funded clinical staff vacancies are common. The data show that the average CHC has 13% of its family physician full-time equivalent (FTE) positions unfilled. Rural CHCs reported a significantly higher proportion of these vacancies, as well as recruiting difficulties, compared with their urban counterparts, with more than one-third of rural CHCs reporting that they had been trying to recruit a family physician for more than 7 months. “It would require more than 400 FTE family physicians to fill all the vacancies,” noted the authors.

Some of the greatest recruitment difficulties were reported for obstetrician/gynecologists and psychiatrists; rural locations reported more than 20% of funded positions vacant. Dentists' vacancies also were indicated, with more than half of rural CHCs reporting a vacant position for 7 months or longer. Less difficulty was reported in recruiting nurse-practitioners and physician assistants, with no significant rural-urban differences.

When asked to indicate perceived barriers to recruitment and retention of both rural and urban CHC physicians and nurses, respondents consistently noted the inability to offer competitive compensation packages.

“The lack of spousal employment opportunities, lack of cultural activities and opportunities, lack of adequate housing, and poor-quality schools were perceived as disproportionately greater barriers for rural centers,” noted the authors. Survey respondents suggested three potential interventions to address these perceived barriers: better capacity to provide annual salary increases, more National Health Service Corps loan repayment incentives, and greater visibility of CHCs as desirable practice opportunities during training.

“The clinical role of CHCs is dependent on primary care clinicians, both physicians and nonphysician clinicians,” the authors wrote, noting that the declining production of family physicians from residency programs “may lead to serious workforce shortages, particularly in rural CHCs.”

Roughly 66% of the responding CHCs indicated their plans to expand as part of a federal 5-year initiative to increase spending on CHCs by at least $2.2 billion through fiscal year 2006. However, the decline in “physicians choosing generalist careers may be the rate-limiting step in the nation's ability to staff CHCs,” they wrote.

The authors made several suggestions, including the following, for federal and state governments, as well as for CHCs:

▸ Bolstering elements of the Health Professions Educational Assistance Act of 1976, the only federal program aimed at encouraging primary care clinicians who are likely to practice in underserved areas.

▸ Increasing the use of nurse-practitioners and physician assistants.

▸ Creating new alliances between CHCs and primary care training programs.

▸ Expanding the National Health Service Corps and related programs that provide financial incentives to attract health care clinicians to underserved areas.

▸ Developing new approaches to loan repayment plans.

▸ Creating additional incentives for rural areas.

Community health centers are currently clinically understaffed and will likely face increasing shortages that may limit their expansion, according to a study by the rural health research centers of both the University of Washington, Seattle, and the University of South Carolina, Columbia, and by the National Association of Community Health Centers (JAMA 2006;295:1042–9).

The study surveyed 846 federally funded community health centers (CHCs) in the 50 states and the District of Columbia. Mailed questionnaires and telephone surveys asked CHC chief executive officers about staffing and recruiting patterns, use of federal and state recruitment programs, and perceived barriers to recruitment, reported Dr. Roger A. Rosenblatt from the University of Washington, and his colleagues.

Responses were obtained from 79% of the population and revealed that funded clinical staff vacancies are common. The data show that the average CHC has 13% of its family physician full-time equivalent (FTE) positions unfilled. Rural CHCs reported a significantly higher proportion of these vacancies, as well as recruiting difficulties, compared with their urban counterparts, with more than one-third of rural CHCs reporting that they had been trying to recruit a family physician for more than 7 months. “It would require more than 400 FTE family physicians to fill all the vacancies,” noted the authors.

Some of the greatest recruitment difficulties were reported for obstetrician/gynecologists and psychiatrists; rural locations reported more than 20% of funded positions vacant. Dentists' vacancies also were indicated, with more than half of rural CHCs reporting a vacant position for 7 months or longer. Less difficulty was reported in recruiting nurse-practitioners and physician assistants, with no significant rural-urban differences.

When asked to indicate perceived barriers to recruitment and retention of both rural and urban CHC physicians and nurses, respondents consistently noted the inability to offer competitive compensation packages.

“The lack of spousal employment opportunities, lack of cultural activities and opportunities, lack of adequate housing, and poor-quality schools were perceived as disproportionately greater barriers for rural centers,” noted the authors. Survey respondents suggested three potential interventions to address these perceived barriers: better capacity to provide annual salary increases, more National Health Service Corps loan repayment incentives, and greater visibility of CHCs as desirable practice opportunities during training.

“The clinical role of CHCs is dependent on primary care clinicians, both physicians and nonphysician clinicians,” the authors wrote, noting that the declining production of family physicians from residency programs “may lead to serious workforce shortages, particularly in rural CHCs.”

Roughly 66% of the responding CHCs indicated their plans to expand as part of a federal 5-year initiative to increase spending on CHCs by at least $2.2 billion through fiscal year 2006. However, the decline in “physicians choosing generalist careers may be the rate-limiting step in the nation's ability to staff CHCs,” they wrote.

The authors made several suggestions, including the following, for federal and state governments, as well as for CHCs:

▸ Bolstering elements of the Health Professions Educational Assistance Act of 1976, the only federal program aimed at encouraging primary care clinicians who are likely to practice in underserved areas.

▸ Increasing the use of nurse-practitioners and physician assistants.

▸ Creating new alliances between CHCs and primary care training programs.

▸ Expanding the National Health Service Corps and related programs that provide financial incentives to attract health care clinicians to underserved areas.

▸ Developing new approaches to loan repayment plans.

▸ Creating additional incentives for rural areas.

Community health centers are currently clinically understaffed and will likely face increasing shortages that may limit their expansion, according to a study by the rural health research centers of both the University of Washington, Seattle, and the University of South Carolina, Columbia, and by the National Association of Community Health Centers (JAMA 2006;295:1042–9).

The study surveyed 846 federally funded community health centers (CHCs) in the 50 states and the District of Columbia. Mailed questionnaires and telephone surveys asked CHC chief executive officers about staffing and recruiting patterns, use of federal and state recruitment programs, and perceived barriers to recruitment, reported Dr. Roger A. Rosenblatt from the University of Washington, and his colleagues.

Responses were obtained from 79% of the population and revealed that funded clinical staff vacancies are common. The data show that the average CHC has 13% of its family physician full-time equivalent (FTE) positions unfilled. Rural CHCs reported a significantly higher proportion of these vacancies, as well as recruiting difficulties, compared with their urban counterparts, with more than one-third of rural CHCs reporting that they had been trying to recruit a family physician for more than 7 months. “It would require more than 400 FTE family physicians to fill all the vacancies,” noted the authors.

Some of the greatest recruitment difficulties were reported for obstetrician/gynecologists and psychiatrists; rural locations reported more than 20% of funded positions vacant. Dentists' vacancies also were indicated, with more than half of rural CHCs reporting a vacant position for 7 months or longer. Less difficulty was reported in recruiting nurse-practitioners and physician assistants, with no significant rural-urban differences.

When asked to indicate perceived barriers to recruitment and retention of both rural and urban CHC physicians and nurses, respondents consistently noted the inability to offer competitive compensation packages.

“The lack of spousal employment opportunities, lack of cultural activities and opportunities, lack of adequate housing, and poor-quality schools were perceived as disproportionately greater barriers for rural centers,” noted the authors. Survey respondents suggested three potential interventions to address these perceived barriers: better capacity to provide annual salary increases, more National Health Service Corps loan repayment incentives, and greater visibility of CHCs as desirable practice opportunities during training.

“The clinical role of CHCs is dependent on primary care clinicians, both physicians and nonphysician clinicians,” the authors wrote, noting that the declining production of family physicians from residency programs “may lead to serious workforce shortages, particularly in rural CHCs.”

Roughly 66% of the responding CHCs indicated their plans to expand as part of a federal 5-year initiative to increase spending on CHCs by at least $2.2 billion through fiscal year 2006. However, the decline in “physicians choosing generalist careers may be the rate-limiting step in the nation's ability to staff CHCs,” they wrote.

The authors made several suggestions, including the following, for federal and state governments, as well as for CHCs:

▸ Bolstering elements of the Health Professions Educational Assistance Act of 1976, the only federal program aimed at encouraging primary care clinicians who are likely to practice in underserved areas.

▸ Increasing the use of nurse-practitioners and physician assistants.

▸ Creating new alliances between CHCs and primary care training programs.

▸ Expanding the National Health Service Corps and related programs that provide financial incentives to attract health care clinicians to underserved areas.

▸ Developing new approaches to loan repayment plans.

▸ Creating additional incentives for rural areas.

COLORADO SPRINGS – All addictions, whether chemical or behavioral, should be viewed as different manifestations of an underlying addiction syndrome–and addiction recovery programs will fail to achieve optimal outcomes until their protocols reflect this view, Howard J. Shaffer, Ph.D., said at a symposium on addictive disorders sponsored by Psychotherapy Associates.

“We need this different way of viewing and assessing the nature of addiction so that we can do better in treating it,” he said in an interview.

Between 80% and 90% of individuals recovering from addiction will relapse within the first year, possibly because their treatment is too narrowly focused on a single substance or behavior, rather than on their general susceptibility to addiction, said Dr. Shaffer of Harvard Medical School and director of the division on addictions at the Cambridge (Massachusetts) Health Alliance.

“The existing focus on addictive substances does not adequately capture the origin, nature and processes of addiction,” he wrote in his initial description of the syndrome model of addiction (Harv. Rev. Psychiatry 2004;12:367–74).

Dr. Shaffer outlined the way in which psychoactive drugs and addictive behaviors such as gambling or shopping are neurobiologically similar in that they stimulate the brain's reward system.

Individuals with a genetic predisposition to addiction might find themselves susceptible to one or another psychoactive substance or behavior, depending on which ones they have been exposed to, have access to, and what their psychosocial risk factors are, he suggested.

“Genetic predisposition to addiction is not drug specific,” he said, pointing to the phenomenon of addiction “hopping” as an example.

This phenomenon is commonly seen in addiction recovery programs, when the addiction that is being treated–alcoholism, for example–is replaced by another previously unrecognized addiction, such as exercise or disordered eating, said Dr. Shaffer, who has published extensively on gambling treatment programs and addiction.

In an ongoing study of 508 subjects with multiple drunk-driving offenses, Dr. Shaffer has found a high rate of coexisting addictions. These include alcohol abuse/dependence in 98%, substance abuse/dependence in 42%, nicotine dependence in 17%, and pathological gambling in 2%.

In addition, he found comorbid mental disorders in the group, including alcohol/substance abuse/gambling disorder in 99%, generalized anxiety disorder/depression or dysthymia in 20%, conduct disorder in 22%, posttraumatic stress disorder in 14%, and mania in 9%.

His study has not yet explored treatment strategies for these patients, Dr. Shaffer said. But effective treatment for such individuals must address their comorbidities rather than simply focus on their offense.

“Believe me, they know they are not supposed to drink and drive,” he said.

Adapting current treatment strategies to reflect the syndromic nature of addiction will require clinicians to take a broader view of the problem, Dr. Shaffer said.

“When you discover your substance abuse patient has a gambling problem, don't farm them out to another provider,” he said.

“Now there's a tendency to move people out of one program and into another–to take care of these problems separately rather than together in an integrated treatment plan.”

But just identifying comorbid addictions and psychiatric disorders will prove challenging to many clinicians, he suggested.

“Most [comorbidities] are being missed, and so that's the next issue. We have to do a really rigorous evaluation,” Dr. Shaffer said. He noted that his study represents the first time multiple offenders have been evaluated in this way anywhere.

Dr. Shaffer said his findings will be used to form the foundation of a computerized evaluation tool that his group is developing.

The computerized tool is aimed at guiding clinicians through a detailed interview with patients.

“The computer will yield a diagnostic evaluation across the DSM categories, mental health as well as the substance use disorders, and this will also cover ICD-10–the International Classification of Diseases,” Dr. Shaffer said.

“Then better treatment matching can begin.”

COLORADO SPRINGS – All addictions, whether chemical or behavioral, should be viewed as different manifestations of an underlying addiction syndrome–and addiction recovery programs will fail to achieve optimal outcomes until their protocols reflect this view, Howard J. Shaffer, Ph.D., said at a symposium on addictive disorders sponsored by Psychotherapy Associates.

“We need this different way of viewing and assessing the nature of addiction so that we can do better in treating it,” he said in an interview.

Between 80% and 90% of individuals recovering from addiction will relapse within the first year, possibly because their treatment is too narrowly focused on a single substance or behavior, rather than on their general susceptibility to addiction, said Dr. Shaffer of Harvard Medical School and director of the division on addictions at the Cambridge (Massachusetts) Health Alliance.

“The existing focus on addictive substances does not adequately capture the origin, nature and processes of addiction,” he wrote in his initial description of the syndrome model of addiction (Harv. Rev. Psychiatry 2004;12:367–74).

Dr. Shaffer outlined the way in which psychoactive drugs and addictive behaviors such as gambling or shopping are neurobiologically similar in that they stimulate the brain's reward system.

Individuals with a genetic predisposition to addiction might find themselves susceptible to one or another psychoactive substance or behavior, depending on which ones they have been exposed to, have access to, and what their psychosocial risk factors are, he suggested.

“Genetic predisposition to addiction is not drug specific,” he said, pointing to the phenomenon of addiction “hopping” as an example.

This phenomenon is commonly seen in addiction recovery programs, when the addiction that is being treated–alcoholism, for example–is replaced by another previously unrecognized addiction, such as exercise or disordered eating, said Dr. Shaffer, who has published extensively on gambling treatment programs and addiction.

In an ongoing study of 508 subjects with multiple drunk-driving offenses, Dr. Shaffer has found a high rate of coexisting addictions. These include alcohol abuse/dependence in 98%, substance abuse/dependence in 42%, nicotine dependence in 17%, and pathological gambling in 2%.

In addition, he found comorbid mental disorders in the group, including alcohol/substance abuse/gambling disorder in 99%, generalized anxiety disorder/depression or dysthymia in 20%, conduct disorder in 22%, posttraumatic stress disorder in 14%, and mania in 9%.

His study has not yet explored treatment strategies for these patients, Dr. Shaffer said. But effective treatment for such individuals must address their comorbidities rather than simply focus on their offense.

“Believe me, they know they are not supposed to drink and drive,” he said.

Adapting current treatment strategies to reflect the syndromic nature of addiction will require clinicians to take a broader view of the problem, Dr. Shaffer said.

“When you discover your substance abuse patient has a gambling problem, don't farm them out to another provider,” he said.

“Now there's a tendency to move people out of one program and into another–to take care of these problems separately rather than together in an integrated treatment plan.”

But just identifying comorbid addictions and psychiatric disorders will prove challenging to many clinicians, he suggested.

“Most [comorbidities] are being missed, and so that's the next issue. We have to do a really rigorous evaluation,” Dr. Shaffer said. He noted that his study represents the first time multiple offenders have been evaluated in this way anywhere.

Dr. Shaffer said his findings will be used to form the foundation of a computerized evaluation tool that his group is developing.

The computerized tool is aimed at guiding clinicians through a detailed interview with patients.

“The computer will yield a diagnostic evaluation across the DSM categories, mental health as well as the substance use disorders, and this will also cover ICD-10–the International Classification of Diseases,” Dr. Shaffer said.

“Then better treatment matching can begin.”

COLORADO SPRINGS – All addictions, whether chemical or behavioral, should be viewed as different manifestations of an underlying addiction syndrome–and addiction recovery programs will fail to achieve optimal outcomes until their protocols reflect this view, Howard J. Shaffer, Ph.D., said at a symposium on addictive disorders sponsored by Psychotherapy Associates.

“We need this different way of viewing and assessing the nature of addiction so that we can do better in treating it,” he said in an interview.

Between 80% and 90% of individuals recovering from addiction will relapse within the first year, possibly because their treatment is too narrowly focused on a single substance or behavior, rather than on their general susceptibility to addiction, said Dr. Shaffer of Harvard Medical School and director of the division on addictions at the Cambridge (Massachusetts) Health Alliance.

“The existing focus on addictive substances does not adequately capture the origin, nature and processes of addiction,” he wrote in his initial description of the syndrome model of addiction (Harv. Rev. Psychiatry 2004;12:367–74).

Dr. Shaffer outlined the way in which psychoactive drugs and addictive behaviors such as gambling or shopping are neurobiologically similar in that they stimulate the brain's reward system.

Individuals with a genetic predisposition to addiction might find themselves susceptible to one or another psychoactive substance or behavior, depending on which ones they have been exposed to, have access to, and what their psychosocial risk factors are, he suggested.

“Genetic predisposition to addiction is not drug specific,” he said, pointing to the phenomenon of addiction “hopping” as an example.

This phenomenon is commonly seen in addiction recovery programs, when the addiction that is being treated–alcoholism, for example–is replaced by another previously unrecognized addiction, such as exercise or disordered eating, said Dr. Shaffer, who has published extensively on gambling treatment programs and addiction.

In an ongoing study of 508 subjects with multiple drunk-driving offenses, Dr. Shaffer has found a high rate of coexisting addictions. These include alcohol abuse/dependence in 98%, substance abuse/dependence in 42%, nicotine dependence in 17%, and pathological gambling in 2%.

In addition, he found comorbid mental disorders in the group, including alcohol/substance abuse/gambling disorder in 99%, generalized anxiety disorder/depression or dysthymia in 20%, conduct disorder in 22%, posttraumatic stress disorder in 14%, and mania in 9%.

His study has not yet explored treatment strategies for these patients, Dr. Shaffer said. But effective treatment for such individuals must address their comorbidities rather than simply focus on their offense.

“Believe me, they know they are not supposed to drink and drive,” he said.

Adapting current treatment strategies to reflect the syndromic nature of addiction will require clinicians to take a broader view of the problem, Dr. Shaffer said.

“When you discover your substance abuse patient has a gambling problem, don't farm them out to another provider,” he said.

“Now there's a tendency to move people out of one program and into another–to take care of these problems separately rather than together in an integrated treatment plan.”

But just identifying comorbid addictions and psychiatric disorders will prove challenging to many clinicians, he suggested.

“Most [comorbidities] are being missed, and so that's the next issue. We have to do a really rigorous evaluation,” Dr. Shaffer said. He noted that his study represents the first time multiple offenders have been evaluated in this way anywhere.

Dr. Shaffer said his findings will be used to form the foundation of a computerized evaluation tool that his group is developing.

The computerized tool is aimed at guiding clinicians through a detailed interview with patients.

“The computer will yield a diagnostic evaluation across the DSM categories, mental health as well as the substance use disorders, and this will also cover ICD-10–the International Classification of Diseases,” Dr. Shaffer said.

“Then better treatment matching can begin.”

COLORADO SPRINGS – Smoking defeats the purpose of drug and alcohol addiction recovery programs and therefore should be banned, said Dr. Elizabeth B. Stuyt, medical director of Circle Program at the Colorado Mental Health Institute in Pueblo, Colo.

Nicotine inhibits new learning in the brain and thus hinders recovery from other chemical dependencies, said Dr. Stuyt, a psychiatrist.

“I don't know how patients can possibly heal while they are smoking, given the neurobiology,” she said in an interview.

At a conference on addictive disorders and behavioral health, Dr. Stuyt said her 90-day inpatient recovery program for patients with comorbid chemical dependencies and psychiatric disorders has banned smoking for the past 5 years. The decision was based partly on the results of her study, which found significantly higher 12-month alcohol and drug addiction recovery rates among nonsmoking participants (50%), compared with those who smoke (14%) (Am. J. Addiction 1997;6:159–67).

Dr. Stuyt says all addictive drugs, including nicotine, have been shown to reduce hippocampal neurogenesis and thus decrease the brain's ability to adapt to new information. Since one of the goals of drug recovery programs is to teach participants how to resist their cravings, allowing them to smoke is counterproductive. Not only does smoking lower the brain's ability to learn this new skill; it also reverses the learned resistance to cravings.

In addition, she said, tobacco is often regarded as a “gateway drug” to other drugs, and smoking relapses in recovering drug and alcohol addicts are considered red flags because they often precede a full relapse.

In a recent study of 440 patients treated in her program between January 2001 and December 2003, she found that those who had been smokers and who planned to return to smoking were less likely to successfully complete the program (54%), compared with nonsmokers (74%).

To help her patients kick their tobacco habit, Dr. Stuyt also recommends auricular acupuncture, which she says is an effective aid in decreasing all cravings. This technique, which is promoted by National Acupuncture Detoxification Association, has almost doubled the number of patients completing her program, she said.

COLORADO SPRINGS – Smoking defeats the purpose of drug and alcohol addiction recovery programs and therefore should be banned, said Dr. Elizabeth B. Stuyt, medical director of Circle Program at the Colorado Mental Health Institute in Pueblo, Colo.

Nicotine inhibits new learning in the brain and thus hinders recovery from other chemical dependencies, said Dr. Stuyt, a psychiatrist.

“I don't know how patients can possibly heal while they are smoking, given the neurobiology,” she said in an interview.

At a conference on addictive disorders and behavioral health, Dr. Stuyt said her 90-day inpatient recovery program for patients with comorbid chemical dependencies and psychiatric disorders has banned smoking for the past 5 years. The decision was based partly on the results of her study, which found significantly higher 12-month alcohol and drug addiction recovery rates among nonsmoking participants (50%), compared with those who smoke (14%) (Am. J. Addiction 1997;6:159–67).

Dr. Stuyt says all addictive drugs, including nicotine, have been shown to reduce hippocampal neurogenesis and thus decrease the brain's ability to adapt to new information. Since one of the goals of drug recovery programs is to teach participants how to resist their cravings, allowing them to smoke is counterproductive. Not only does smoking lower the brain's ability to learn this new skill; it also reverses the learned resistance to cravings.

In addition, she said, tobacco is often regarded as a “gateway drug” to other drugs, and smoking relapses in recovering drug and alcohol addicts are considered red flags because they often precede a full relapse.

In a recent study of 440 patients treated in her program between January 2001 and December 2003, she found that those who had been smokers and who planned to return to smoking were less likely to successfully complete the program (54%), compared with nonsmokers (74%).

To help her patients kick their tobacco habit, Dr. Stuyt also recommends auricular acupuncture, which she says is an effective aid in decreasing all cravings. This technique, which is promoted by National Acupuncture Detoxification Association, has almost doubled the number of patients completing her program, she said.

COLORADO SPRINGS – Smoking defeats the purpose of drug and alcohol addiction recovery programs and therefore should be banned, said Dr. Elizabeth B. Stuyt, medical director of Circle Program at the Colorado Mental Health Institute in Pueblo, Colo.

Nicotine inhibits new learning in the brain and thus hinders recovery from other chemical dependencies, said Dr. Stuyt, a psychiatrist.

“I don't know how patients can possibly heal while they are smoking, given the neurobiology,” she said in an interview.

At a conference on addictive disorders and behavioral health, Dr. Stuyt said her 90-day inpatient recovery program for patients with comorbid chemical dependencies and psychiatric disorders has banned smoking for the past 5 years. The decision was based partly on the results of her study, which found significantly higher 12-month alcohol and drug addiction recovery rates among nonsmoking participants (50%), compared with those who smoke (14%) (Am. J. Addiction 1997;6:159–67).

Dr. Stuyt says all addictive drugs, including nicotine, have been shown to reduce hippocampal neurogenesis and thus decrease the brain's ability to adapt to new information. Since one of the goals of drug recovery programs is to teach participants how to resist their cravings, allowing them to smoke is counterproductive. Not only does smoking lower the brain's ability to learn this new skill; it also reverses the learned resistance to cravings.

In addition, she said, tobacco is often regarded as a “gateway drug” to other drugs, and smoking relapses in recovering drug and alcohol addicts are considered red flags because they often precede a full relapse.

In a recent study of 440 patients treated in her program between January 2001 and December 2003, she found that those who had been smokers and who planned to return to smoking were less likely to successfully complete the program (54%), compared with nonsmokers (74%).

To help her patients kick their tobacco habit, Dr. Stuyt also recommends auricular acupuncture, which she says is an effective aid in decreasing all cravings. This technique, which is promoted by National Acupuncture Detoxification Association, has almost doubled the number of patients completing her program, she said.

ORLANDO – Up to 39% of geriatric patients are taking potentially inappropriate medications, and this trend is associated with increased drug-related problems and health care costs, according to a recent study.

The findings should encourage physicians to be more critical in their prescribing decisions, said Diane M. Spokus, one of the authors of the study, which was presented as a poster at the annual meeting of the Gerontological Society of America.

The retrospective examination of medication use among 17, 971 managed-care patients aged 65 or older found that 6,875 (39%) were using at least one potentially inappropriate medication (PIM), including 13% who were using two or more PIMs.

PIMs were defined by the revised Beers criteria (Arch. Intern. Med. 2003;163:2716–24) as either “medications or medication classes that should generally be avoided in persons 65 years or older because they are either ineffective, or they pose unnecessarily high risk for older persons, and a safer alternative is available.”

The finding of a 39% rate of PIM prescriptions is higher than what has been previously reported, “but we attributed that to the fact that we included oral estrogen as a PIM, and that accounted for almost 10%,” Ms. Spokus said in an interview. After estrogen, the two most commonly prescribed PIMs were propoxyphene and combination products, as well as short-acting benzodiazepines (7% each), followed by digoxin (4.7%) and long-term, nonsteroidal anti-inflammatories (4.6%).

By using principal and secondary discharge diagnoses occurring within 30 days of the medication prescription, the study found a nearly threefold higher rate of drug-related problems among patients taking at least one PIM, compared with those not taking such medications (14% vs. 5%).

The most common drug-related problems were syncope (3.6%), malaise and fatigue (3.5%), dehydration (1.8%), sleep disturbances (1.5%), and any cognitive impairment (1.5%). PIMs were associated with increased costs, including facility-paid, provider-paid, and prescription costs (about $2,250 per patient over 6 months), compared with patients who were not taking the medications (about $1,000), with patients taking more than one PIM accounting for the highest costs.

A larger, prospective study is needed to determine which drugs are associated with the most problems, Ms. Spokus said. The researchers also noted that their measures were limited in their ability to infer causality–something that might be achieved in a prospective study.

ORLANDO – Up to 39% of geriatric patients are taking potentially inappropriate medications, and this trend is associated with increased drug-related problems and health care costs, according to a recent study.

The findings should encourage physicians to be more critical in their prescribing decisions, said Diane M. Spokus, one of the authors of the study, which was presented as a poster at the annual meeting of the Gerontological Society of America.

The retrospective examination of medication use among 17, 971 managed-care patients aged 65 or older found that 6,875 (39%) were using at least one potentially inappropriate medication (PIM), including 13% who were using two or more PIMs.

PIMs were defined by the revised Beers criteria (Arch. Intern. Med. 2003;163:2716–24) as either “medications or medication classes that should generally be avoided in persons 65 years or older because they are either ineffective, or they pose unnecessarily high risk for older persons, and a safer alternative is available.”

The finding of a 39% rate of PIM prescriptions is higher than what has been previously reported, “but we attributed that to the fact that we included oral estrogen as a PIM, and that accounted for almost 10%,” Ms. Spokus said in an interview. After estrogen, the two most commonly prescribed PIMs were propoxyphene and combination products, as well as short-acting benzodiazepines (7% each), followed by digoxin (4.7%) and long-term, nonsteroidal anti-inflammatories (4.6%).

By using principal and secondary discharge diagnoses occurring within 30 days of the medication prescription, the study found a nearly threefold higher rate of drug-related problems among patients taking at least one PIM, compared with those not taking such medications (14% vs. 5%).

The most common drug-related problems were syncope (3.6%), malaise and fatigue (3.5%), dehydration (1.8%), sleep disturbances (1.5%), and any cognitive impairment (1.5%). PIMs were associated with increased costs, including facility-paid, provider-paid, and prescription costs (about $2,250 per patient over 6 months), compared with patients who were not taking the medications (about $1,000), with patients taking more than one PIM accounting for the highest costs.

A larger, prospective study is needed to determine which drugs are associated with the most problems, Ms. Spokus said. The researchers also noted that their measures were limited in their ability to infer causality–something that might be achieved in a prospective study.

ORLANDO – Up to 39% of geriatric patients are taking potentially inappropriate medications, and this trend is associated with increased drug-related problems and health care costs, according to a recent study.

The findings should encourage physicians to be more critical in their prescribing decisions, said Diane M. Spokus, one of the authors of the study, which was presented as a poster at the annual meeting of the Gerontological Society of America.

The retrospective examination of medication use among 17, 971 managed-care patients aged 65 or older found that 6,875 (39%) were using at least one potentially inappropriate medication (PIM), including 13% who were using two or more PIMs.

PIMs were defined by the revised Beers criteria (Arch. Intern. Med. 2003;163:2716–24) as either “medications or medication classes that should generally be avoided in persons 65 years or older because they are either ineffective, or they pose unnecessarily high risk for older persons, and a safer alternative is available.”

The finding of a 39% rate of PIM prescriptions is higher than what has been previously reported, “but we attributed that to the fact that we included oral estrogen as a PIM, and that accounted for almost 10%,” Ms. Spokus said in an interview. After estrogen, the two most commonly prescribed PIMs were propoxyphene and combination products, as well as short-acting benzodiazepines (7% each), followed by digoxin (4.7%) and long-term, nonsteroidal anti-inflammatories (4.6%).

By using principal and secondary discharge diagnoses occurring within 30 days of the medication prescription, the study found a nearly threefold higher rate of drug-related problems among patients taking at least one PIM, compared with those not taking such medications (14% vs. 5%).

The most common drug-related problems were syncope (3.6%), malaise and fatigue (3.5%), dehydration (1.8%), sleep disturbances (1.5%), and any cognitive impairment (1.5%). PIMs were associated with increased costs, including facility-paid, provider-paid, and prescription costs (about $2,250 per patient over 6 months), compared with patients who were not taking the medications (about $1,000), with patients taking more than one PIM accounting for the highest costs.

A larger, prospective study is needed to determine which drugs are associated with the most problems, Ms. Spokus said. The researchers also noted that their measures were limited in their ability to infer causality–something that might be achieved in a prospective study.

MONTREAL — Fluid reduction is not a common coping strategy among people with urinary incontinence, although many practitioners believe it is, according to Australian researchers.

“Anecdotally, as continence advisers, we have the perception that the majority of our patients actually reduce their fluids in order to cope with their urinary symptoms, but surprisingly only a third of people actually do,” said Charmaine Bryant, a clinical nurse consultant at Prince of Wales Hospital in Randwick, Australia.

In a study she presented at the annual meeting of the International Continence Society, Ms. Bryant administered a questionnaire to 356 consecutive adult patients presenting with urinary incontinence and/or overactive bladder symptoms. The patients were seen at community health/hospital continence clinics.

The results on fluid intake (last 24 hours), 5-year history of change in fluid intake, personal demographics, and quality of life were compared with answers given from 353 age- and sex-matched control subjects drawn from the local community.

There were three groups of patients: those seeking treatment for bladder problems, control subjects who reported no bladder problems, and controls who reported some bladder problems but were not seeking treatment.

The study found that among patients seeking treatment, only 34% had reduced their fluid intake over the past 5 years while the remaining 66% had either increased or not changed it. Among controls who reported bladder problems but were not seeking treatment, only 20% had reduced their fluid intake, while 30% had increased it, and 49% reported no change.

By comparison, 7% of asymptomatic controls had reduced their fluid intake over the past 5 years (largely because of caffeine or alcohol problems), 24% had increased it, and 69% reported no change.

In the two groups reporting bladder problems, the decision to reduce fluids was largely self-directed rather than medically directed—and the method of reduction consisted primarily of reducing fluids before going out and before going to bed, Ms. Bryant said.

Another surprising finding was the total amount of fluids that subjects consumed.

“The mean was well over 2 liters a day, whereas I thought that the mean would probably be somewhere around 1.5 liters a day,” she said in an interview.

“Significant numbers reported moderate intake levels of between 2 and 3 liters, and high levels of more than 3 liters, suggesting that intake levels among people with continence-related dysfunction are typically quite high,” she added. A significant minority reported very high intake levels of up to 9 liters a day.

The information should be useful to practitioners as they counsel patients on fluid manipulation, she commented.

MONTREAL — Fluid reduction is not a common coping strategy among people with urinary incontinence, although many practitioners believe it is, according to Australian researchers.

“Anecdotally, as continence advisers, we have the perception that the majority of our patients actually reduce their fluids in order to cope with their urinary symptoms, but surprisingly only a third of people actually do,” said Charmaine Bryant, a clinical nurse consultant at Prince of Wales Hospital in Randwick, Australia.

In a study she presented at the annual meeting of the International Continence Society, Ms. Bryant administered a questionnaire to 356 consecutive adult patients presenting with urinary incontinence and/or overactive bladder symptoms. The patients were seen at community health/hospital continence clinics.

The results on fluid intake (last 24 hours), 5-year history of change in fluid intake, personal demographics, and quality of life were compared with answers given from 353 age- and sex-matched control subjects drawn from the local community.

There were three groups of patients: those seeking treatment for bladder problems, control subjects who reported no bladder problems, and controls who reported some bladder problems but were not seeking treatment.

The study found that among patients seeking treatment, only 34% had reduced their fluid intake over the past 5 years while the remaining 66% had either increased or not changed it. Among controls who reported bladder problems but were not seeking treatment, only 20% had reduced their fluid intake, while 30% had increased it, and 49% reported no change.

By comparison, 7% of asymptomatic controls had reduced their fluid intake over the past 5 years (largely because of caffeine or alcohol problems), 24% had increased it, and 69% reported no change.

In the two groups reporting bladder problems, the decision to reduce fluids was largely self-directed rather than medically directed—and the method of reduction consisted primarily of reducing fluids before going out and before going to bed, Ms. Bryant said.

Another surprising finding was the total amount of fluids that subjects consumed.

“The mean was well over 2 liters a day, whereas I thought that the mean would probably be somewhere around 1.5 liters a day,” she said in an interview.

“Significant numbers reported moderate intake levels of between 2 and 3 liters, and high levels of more than 3 liters, suggesting that intake levels among people with continence-related dysfunction are typically quite high,” she added. A significant minority reported very high intake levels of up to 9 liters a day.

The information should be useful to practitioners as they counsel patients on fluid manipulation, she commented.

MONTREAL — Fluid reduction is not a common coping strategy among people with urinary incontinence, although many practitioners believe it is, according to Australian researchers.

“Anecdotally, as continence advisers, we have the perception that the majority of our patients actually reduce their fluids in order to cope with their urinary symptoms, but surprisingly only a third of people actually do,” said Charmaine Bryant, a clinical nurse consultant at Prince of Wales Hospital in Randwick, Australia.

In a study she presented at the annual meeting of the International Continence Society, Ms. Bryant administered a questionnaire to 356 consecutive adult patients presenting with urinary incontinence and/or overactive bladder symptoms. The patients were seen at community health/hospital continence clinics.

The results on fluid intake (last 24 hours), 5-year history of change in fluid intake, personal demographics, and quality of life were compared with answers given from 353 age- and sex-matched control subjects drawn from the local community.

There were three groups of patients: those seeking treatment for bladder problems, control subjects who reported no bladder problems, and controls who reported some bladder problems but were not seeking treatment.

The study found that among patients seeking treatment, only 34% had reduced their fluid intake over the past 5 years while the remaining 66% had either increased or not changed it. Among controls who reported bladder problems but were not seeking treatment, only 20% had reduced their fluid intake, while 30% had increased it, and 49% reported no change.

By comparison, 7% of asymptomatic controls had reduced their fluid intake over the past 5 years (largely because of caffeine or alcohol problems), 24% had increased it, and 69% reported no change.

In the two groups reporting bladder problems, the decision to reduce fluids was largely self-directed rather than medically directed—and the method of reduction consisted primarily of reducing fluids before going out and before going to bed, Ms. Bryant said.

Another surprising finding was the total amount of fluids that subjects consumed.

“The mean was well over 2 liters a day, whereas I thought that the mean would probably be somewhere around 1.5 liters a day,” she said in an interview.

“Significant numbers reported moderate intake levels of between 2 and 3 liters, and high levels of more than 3 liters, suggesting that intake levels among people with continence-related dysfunction are typically quite high,” she added. A significant minority reported very high intake levels of up to 9 liters a day.

The information should be useful to practitioners as they counsel patients on fluid manipulation, she commented.

British physicians are being warned by their country's medical authorities about new risks associated with atomoxetine in the treatment of attention-deficit hyperactivity disorder.

The new risks of seizures and abnormal heart rhythm (QT interval prolongation) were identified by the Medicines and Healthcare Products Regulatory Agency (MHRA), the U.K. equivalent of the Food and Drug Administration (FDA), after a Europewide review of atomoxetine, which is marketed in the United Kingdom and United States as Strattera.

The FDA has not issued similar warnings, although it is evaluating the U.K. data and “will make any necessary label changes as appropriate,” said spokesperson Crystal Rice.

The MHRA initiated its Europewide review of Strattera last fall, after new warnings were issued about the drug's potential to cause suicidal thoughts and behavior. Changes were made to the product's label at that time in the United Kingdom and the United States. The British review concluded that “the overall balance of risks and benefits of Strattera remains positive in the treatment of ADHD in children of 6 years and older and in adolescents.”

However the MHRA's letter to health care physicians says the product's label is being updated to reflect the new risks, and it offers the following new advice to prescribers:

▸ Seizures are a potential risk with Strattera and therefore it should be introduced with caution in patients with a history of seizure. Discontinuation of Strattera should be considered in any patient developing seizures or if there is an increase in seizure frequency.

▸ Reports of QT interval prolongation have been received in association with Strattera. Therefore it should be used with caution in those with congenital or acquired long QT or a family history of QT prolongation. This risk may be increased if Strattera is used concomitantly with other drugs that produce QT prolongation, drugs that can cause electrolyte disturbances, and those that inhibit cytochrome P450 2D6.

The new evidence comes on the heels of a recent FDA panel meeting in which reports of sudden death and nonfatal cardiovascular events in connection with ADHD drugs were discussed. Last month, the panel advised that ADHD drugs carry a black box warning about these potential adverse events.

British physicians are being warned by their country's medical authorities about new risks associated with atomoxetine in the treatment of attention-deficit hyperactivity disorder.

The new risks of seizures and abnormal heart rhythm (QT interval prolongation) were identified by the Medicines and Healthcare Products Regulatory Agency (MHRA), the U.K. equivalent of the Food and Drug Administration (FDA), after a Europewide review of atomoxetine, which is marketed in the United Kingdom and United States as Strattera.

The FDA has not issued similar warnings, although it is evaluating the U.K. data and “will make any necessary label changes as appropriate,” said spokesperson Crystal Rice.

The MHRA initiated its Europewide review of Strattera last fall, after new warnings were issued about the drug's potential to cause suicidal thoughts and behavior. Changes were made to the product's label at that time in the United Kingdom and the United States. The British review concluded that “the overall balance of risks and benefits of Strattera remains positive in the treatment of ADHD in children of 6 years and older and in adolescents.”

However the MHRA's letter to health care physicians says the product's label is being updated to reflect the new risks, and it offers the following new advice to prescribers:

▸ Seizures are a potential risk with Strattera and therefore it should be introduced with caution in patients with a history of seizure. Discontinuation of Strattera should be considered in any patient developing seizures or if there is an increase in seizure frequency.

▸ Reports of QT interval prolongation have been received in association with Strattera. Therefore it should be used with caution in those with congenital or acquired long QT or a family history of QT prolongation. This risk may be increased if Strattera is used concomitantly with other drugs that produce QT prolongation, drugs that can cause electrolyte disturbances, and those that inhibit cytochrome P450 2D6.

The new evidence comes on the heels of a recent FDA panel meeting in which reports of sudden death and nonfatal cardiovascular events in connection with ADHD drugs were discussed. Last month, the panel advised that ADHD drugs carry a black box warning about these potential adverse events.

British physicians are being warned by their country's medical authorities about new risks associated with atomoxetine in the treatment of attention-deficit hyperactivity disorder.

The new risks of seizures and abnormal heart rhythm (QT interval prolongation) were identified by the Medicines and Healthcare Products Regulatory Agency (MHRA), the U.K. equivalent of the Food and Drug Administration (FDA), after a Europewide review of atomoxetine, which is marketed in the United Kingdom and United States as Strattera.

The FDA has not issued similar warnings, although it is evaluating the U.K. data and “will make any necessary label changes as appropriate,” said spokesperson Crystal Rice.

The MHRA initiated its Europewide review of Strattera last fall, after new warnings were issued about the drug's potential to cause suicidal thoughts and behavior. Changes were made to the product's label at that time in the United Kingdom and the United States. The British review concluded that “the overall balance of risks and benefits of Strattera remains positive in the treatment of ADHD in children of 6 years and older and in adolescents.”

However the MHRA's letter to health care physicians says the product's label is being updated to reflect the new risks, and it offers the following new advice to prescribers:

▸ Seizures are a potential risk with Strattera and therefore it should be introduced with caution in patients with a history of seizure. Discontinuation of Strattera should be considered in any patient developing seizures or if there is an increase in seizure frequency.

▸ Reports of QT interval prolongation have been received in association with Strattera. Therefore it should be used with caution in those with congenital or acquired long QT or a family history of QT prolongation. This risk may be increased if Strattera is used concomitantly with other drugs that produce QT prolongation, drugs that can cause electrolyte disturbances, and those that inhibit cytochrome P450 2D6.

The new evidence comes on the heels of a recent FDA panel meeting in which reports of sudden death and nonfatal cardiovascular events in connection with ADHD drugs were discussed. Last month, the panel advised that ADHD drugs carry a black box warning about these potential adverse events.

A rapid test to detect human infection with avian influenza provides preliminary results in just 4 hours instead of the standard 2–3 days, according to officials with the Food and Drug Administration and the Centers for Disease Control and Prevention.

The test is being made available to the World Health Organization and individual countries in addition to its distribution throughout the United States.

The test, developed by the CDC and rushed through the FDA approval process, is intended to detect H5 viral strains from respiratory secretions in patients suspected of being infected. Further testing is then required to identify specific subtypes such as the H5N1 subtype, which so far has been responsible for 166 human infections and 88 deaths worldwide.

“This provides a presumptive positive result, not a definitive result,” Dr. Steve Gutman of the FDA said in a teleconference sponsored by that agency. “And a negative result does not conclusively rule out infection.” He said the test is not intended as a screening tool but rather to investigate signs and symptoms of avian influenza in people who have possibly been exposed to the virus.

Within the United States, the test, which is known as the Influenza A/H5 (Asian Lineage) Virus Real-Time RT-PCR Primer and Probe Set, is being distributed to about 140 designated laboratories in the Laboratory Response Network. About 87% of the country's population lives within 1 hour of such a lab, said the CDC's Steve Monroe, Ph.D. Physicians wishing to test a patient should send their samples directly to the closest Laboratory Response Network lab.

The availability of the test provides a powerful tool for the timely detection of avian influenza, Dr. Gutman said.

A rapid test to detect human infection with avian influenza provides preliminary results in just 4 hours instead of the standard 2–3 days, according to officials with the Food and Drug Administration and the Centers for Disease Control and Prevention.

The test is being made available to the World Health Organization and individual countries in addition to its distribution throughout the United States.

The test, developed by the CDC and rushed through the FDA approval process, is intended to detect H5 viral strains from respiratory secretions in patients suspected of being infected. Further testing is then required to identify specific subtypes such as the H5N1 subtype, which so far has been responsible for 166 human infections and 88 deaths worldwide.

“This provides a presumptive positive result, not a definitive result,” Dr. Steve Gutman of the FDA said in a teleconference sponsored by that agency. “And a negative result does not conclusively rule out infection.” He said the test is not intended as a screening tool but rather to investigate signs and symptoms of avian influenza in people who have possibly been exposed to the virus.

Within the United States, the test, which is known as the Influenza A/H5 (Asian Lineage) Virus Real-Time RT-PCR Primer and Probe Set, is being distributed to about 140 designated laboratories in the Laboratory Response Network. About 87% of the country's population lives within 1 hour of such a lab, said the CDC's Steve Monroe, Ph.D. Physicians wishing to test a patient should send their samples directly to the closest Laboratory Response Network lab.

The availability of the test provides a powerful tool for the timely detection of avian influenza, Dr. Gutman said.

A rapid test to detect human infection with avian influenza provides preliminary results in just 4 hours instead of the standard 2–3 days, according to officials with the Food and Drug Administration and the Centers for Disease Control and Prevention.

The test is being made available to the World Health Organization and individual countries in addition to its distribution throughout the United States.

The test, developed by the CDC and rushed through the FDA approval process, is intended to detect H5 viral strains from respiratory secretions in patients suspected of being infected. Further testing is then required to identify specific subtypes such as the H5N1 subtype, which so far has been responsible for 166 human infections and 88 deaths worldwide.

“This provides a presumptive positive result, not a definitive result,” Dr. Steve Gutman of the FDA said in a teleconference sponsored by that agency. “And a negative result does not conclusively rule out infection.” He said the test is not intended as a screening tool but rather to investigate signs and symptoms of avian influenza in people who have possibly been exposed to the virus.

Within the United States, the test, which is known as the Influenza A/H5 (Asian Lineage) Virus Real-Time RT-PCR Primer and Probe Set, is being distributed to about 140 designated laboratories in the Laboratory Response Network. About 87% of the country's population lives within 1 hour of such a lab, said the CDC's Steve Monroe, Ph.D. Physicians wishing to test a patient should send their samples directly to the closest Laboratory Response Network lab.

The availability of the test provides a powerful tool for the timely detection of avian influenza, Dr. Gutman said.

COLORADO SPRINGS — All addictions, whether chemical or behavioral, should be viewed as different manifestations of an underlying addiction syndrome—and addiction recovery programs will fail to achieve optimal outcomes until their protocols reflect this view, Howard J. Shaffer, Ph.D., said at a symposium on addictive disorders sponsored by Psychotherapy Associates.

“We need this different way of viewing and assessing the nature of addiction so that we can do better in treating it,” he said in an interview.

Between 80% and 90% of individuals recovering from addiction will relapse within the first year, possibly because their treatment is too narrowly focused on a single substance or behavior, rather than on their general susceptibility to addiction, said Dr. Shaffer of Harvard Medical School and director of the division on addictions at the Cambridge (Massachusetts) Health Alliance. “The existing focus on addictive substances does not adequately capture the origin, nature and processes of addiction,” he wrote in his initial description of the syndrome model of addiction (Harv. Rev. Psychiatry 2004;12:367–74).

“Genetic predisposition to addiction is not drug specific,” he said, pointing to the phenomenon of addiction “hopping” as an example. This phenomenon is commonly seen in addiction recovery programs, when the addiction that is being treated—alcoholism, for example—is replaced by another previously unrecognized addiction, such as exercise or disordered eating, he said.

Indeed, in an ongoing study of 508 subjects with multiple drunk driving offenses, Dr. Shaffer has found a high rate of coexisting addictions. These include alcohol abuse/dependence in 98%, substance abuse/dependence in 42%, nicotine dependence in 17%, and pathological gambling in 2%.

In addition, he found comorbid mental disorders in the group, including alcohol/substance abuse/gambling disorder in 99%, generalized anxiety disorder/depression or dysthymia in 20%, conduct disorder in 22%, posttraumatic stress disorder in 14%, and mania in 9%.

“Most [comorbidities] are being missed, and so that's the next issue. We have to do a really rigorous evaluation,” Dr. Shaffer said.

COLORADO SPRINGS — All addictions, whether chemical or behavioral, should be viewed as different manifestations of an underlying addiction syndrome—and addiction recovery programs will fail to achieve optimal outcomes until their protocols reflect this view, Howard J. Shaffer, Ph.D., said at a symposium on addictive disorders sponsored by Psychotherapy Associates.

“We need this different way of viewing and assessing the nature of addiction so that we can do better in treating it,” he said in an interview.

Between 80% and 90% of individuals recovering from addiction will relapse within the first year, possibly because their treatment is too narrowly focused on a single substance or behavior, rather than on their general susceptibility to addiction, said Dr. Shaffer of Harvard Medical School and director of the division on addictions at the Cambridge (Massachusetts) Health Alliance. “The existing focus on addictive substances does not adequately capture the origin, nature and processes of addiction,” he wrote in his initial description of the syndrome model of addiction (Harv. Rev. Psychiatry 2004;12:367–74).

“Genetic predisposition to addiction is not drug specific,” he said, pointing to the phenomenon of addiction “hopping” as an example. This phenomenon is commonly seen in addiction recovery programs, when the addiction that is being treated—alcoholism, for example—is replaced by another previously unrecognized addiction, such as exercise or disordered eating, he said.

Indeed, in an ongoing study of 508 subjects with multiple drunk driving offenses, Dr. Shaffer has found a high rate of coexisting addictions. These include alcohol abuse/dependence in 98%, substance abuse/dependence in 42%, nicotine dependence in 17%, and pathological gambling in 2%.

In addition, he found comorbid mental disorders in the group, including alcohol/substance abuse/gambling disorder in 99%, generalized anxiety disorder/depression or dysthymia in 20%, conduct disorder in 22%, posttraumatic stress disorder in 14%, and mania in 9%.

“Most [comorbidities] are being missed, and so that's the next issue. We have to do a really rigorous evaluation,” Dr. Shaffer said.

COLORADO SPRINGS — All addictions, whether chemical or behavioral, should be viewed as different manifestations of an underlying addiction syndrome—and addiction recovery programs will fail to achieve optimal outcomes until their protocols reflect this view, Howard J. Shaffer, Ph.D., said at a symposium on addictive disorders sponsored by Psychotherapy Associates.

“We need this different way of viewing and assessing the nature of addiction so that we can do better in treating it,” he said in an interview.

Between 80% and 90% of individuals recovering from addiction will relapse within the first year, possibly because their treatment is too narrowly focused on a single substance or behavior, rather than on their general susceptibility to addiction, said Dr. Shaffer of Harvard Medical School and director of the division on addictions at the Cambridge (Massachusetts) Health Alliance. “The existing focus on addictive substances does not adequately capture the origin, nature and processes of addiction,” he wrote in his initial description of the syndrome model of addiction (Harv. Rev. Psychiatry 2004;12:367–74).

“Genetic predisposition to addiction is not drug specific,” he said, pointing to the phenomenon of addiction “hopping” as an example. This phenomenon is commonly seen in addiction recovery programs, when the addiction that is being treated—alcoholism, for example—is replaced by another previously unrecognized addiction, such as exercise or disordered eating, he said.

Indeed, in an ongoing study of 508 subjects with multiple drunk driving offenses, Dr. Shaffer has found a high rate of coexisting addictions. These include alcohol abuse/dependence in 98%, substance abuse/dependence in 42%, nicotine dependence in 17%, and pathological gambling in 2%.

In addition, he found comorbid mental disorders in the group, including alcohol/substance abuse/gambling disorder in 99%, generalized anxiety disorder/depression or dysthymia in 20%, conduct disorder in 22%, posttraumatic stress disorder in 14%, and mania in 9%.

“Most [comorbidities] are being missed, and so that's the next issue. We have to do a really rigorous evaluation,” Dr. Shaffer said.