Findings were presented from a study that asked whether early identification of patients with comorbid depression and subsequent enrollment in an enhanced psychiatric case management (PCM) intervention would be an effective way to engage depressed substance abuse patients from a community treatment program into psychiatric treatment. Patients were screened for depression using the Global Appraisal of Individual Needs (GAIN) and a DSM-IV checklist. Those patients, positive for depression on both evaluations, were assigned to PCM (n=10) or to no case management, treatment as usual (TAU) (n=10). The mean age of the sample (N = 20) was 33.2 (SD = 9.362) years, 55% were females, 50% were Caucasian, 35% African American, and 15% were other. The patients were given a written explanation of the research study and asked to provide written informed consent. All interview sessions were conducted face-to-face, in private, at the facility from which the sample was recruited. Evaluations were conducted by either the Principal Investigator or an experienced drug treatment counselor who was specifically trained on the procedures. Training procedures included review of the case management manual of the Arkansas/Aspen Primary Care intervention for depression study. Outcomes during the first six weeks revealed significantly more patients in the PCM group (p = .016) scheduled an appointment with a mental health professional, received new referrals to mental health professionals (p = .003), and kept at least one appointment with a physician (p = .016). Although this study was not primarily designed to examine barriers to care, it is worthwhile to comment on them here. For each person barriers to any activity or behavior are different and can be described as "internal" (i.e., perceived) barriers, and "external" barriers which are outside the individual. Self-reported barriers to care among patients in the PCM group were examined prospectively. The most frequently reported were various internal barriers, in particular those dimensions related to fear. These were fears of antidepressant drugs, medicines not working, continued use of medications, prescription use, over-sleeping, "old issues," and diagnosis. The conclusion is that PCM services are feasible and appear to be effective in encouraging psychiatric referral by depressed substance abusers. The study demonstrated the efficacy of the psychiatric case management intervention in increasing psychiatric treatment referral and engagement for persons undergoing substance abuse treatment who have symptoms of major depression. Given these promising results with a small sample, a full-scale study is currently being planned.

More work is needed to define the rates of alcohol dependence and utilization of addiction treatment among Asian Americans and Pacific Islanders (AA/PI). Review of the literature reveals a debate about the accuracy and generalizability of epidemiological data on alcohol use among Asian Americans. A common limitation of initial reports is that their samples were often drawn from treatment centers, and rates of alcoholism among Asian Americans in the general population were then extrapolated from these results. We hypothesized that AA/PI, in general, have relatively low rates of alcohol dependence, but those AA/PI with alcohol dependence tend to utilize addiction treatment services less frequently than Caucasians. There have been some studies conducted that suggest there is under utilization of mental health services by Asian Americans. These studies support the hypothesis that Asian Americans with alcohol dependence utilize treatment services less frequently than the general population. We examined data from the 1998 National Household Survey on Drug Abuse, which contains criteria for alcohol dependence and variables for treatment utilization. Of the 800 Asians and Pacific Islanders interviewed for the 1998 National Household Survey on Drug Abuse, only 3.25% met criteria for alcohol dependence within the previous year. Multiple regression analysis revealed that Asian race was predictive of no alcohol dependence, independent of age, gender, marital status, and education. Among those AA/PI with alcohol dependence, only 7.7% had previously been in treatment for addiction. Despite this low value, Asian race was not predictive of previous treatment independent of age, gender, marital status, and education. We conclude that AA/PI have relatively low rates of alcohol dependence and few AA/PI with alcohol dependence have previously had treatment. But, utilization of treatment services by AA/PI was not found to be significantly different than among Caucasians. Despite starting with a sample of 800 AA/PI, because of low rates of alcohol dependence, we had a relatively small sample with which to test treatment utilization. Rigorous tests with larger sample sizes of the hypothesis that Asian Americans are less likely than the general population to seek treatment for addictions and other mental health issues, are needed. As national surveys begin to include identifiers for Asian and Pacific Islanders it will become possible to monitor use patterns among these groups. In addition, it will be possible to test the hypothesis that has been presented but never rigorously tested.

Rhabdomyolysis is a serious and often unrecognized complication of alcohol and other substance use. The occurrence of rhabdomyolysis has been linked with a number of substances, including recreational drugs such as cocaine, heroin, ethanol, and isopropyl alcohol. The failure to recognize the potential for this complication could have serious consequences as severe as renal impairment or even acute renal failure (ARF). The nature of rhabdomyolysis was discussed beginning with a case report of a 45-year-old male patient without any active medical problems who experienced rhabdomyolysis following an episode of uncomplicated binge drinking. The patient had recently completed a 6-month period of sobriety. During the week prior to admission, the patient admitted to consuming large amounts of alcohol daily—the equivalent of one to two pints of hard liquor daily, as well as multiple six-packs of beer. His creatine kinase, initially ~3200, decreased following initial screening and vigorous hydration each day. The mechanisms that induce rhabdomyolysis were examined with particular attention to the acute and chronic role of various drugs with a particular focus on the acute and chronic role of alcohol. In one cohort, up to 26% of patients undergoing alcohol withdrawal have been noted to meet criteria for rhabdomyolysis. Although renal impairment is believed to occur in 30% of rhabdomyolysis, ARF is a very serious and unrecognized consequence of rhabdomyolysis. Ten percent of all cases of ARF are due to non traumatic rhabdomyolysis. Unfortunately, due to poor recognition of rhabdomyolysis, it is often too late for conventional treatments needed to promote renal function. Once a renal specialist is involved, dialysis is often necessitated. Although non-traumatic rhabdomyolysis in the modern emergency department is most commonly seen in association with drugs of abuse, it does not appear to carry the estimated 50% mortality rate secondary to ARF due to traumatic rhabdomyolysis. Nonetheless, it represents a potentially significant cause of morbidity and mortality, which may be easily prevented. The paper concluded with an emphasis on early recognition, diagnosis, and treatment benefits, with particular emphasis on the role of early creatine kinase screening in patients suspected of using drugs of abuse. The direct myotoxicity of some drugs of abuse was reviewed, as well as the accentuation of other related predisposing factors, such as hypovolemia, hypoglycemia, psychosis, neuroleptic usage, and prolonged immobility.