Relapse triggers—full moon, full wallet, or foolhardy?

Any physician who has spent even a short period of time caring for patients in an emergency department recognizes how common substance abuse is among these patients. This phenomenon has been documented in the emergency medicine literature for both psychiatric and medical problems (1). For some patients the substance use is ongoing, and the cumulative exposure to alcohol or other drugs reaches a threshold at which symptomatic disease precipitates presentation. For others, increased use or relapse from recovery delivers the insult that results in clinical problems. Comparison of the rates of clinical events or death in the beginning of a month to those at the end of the preceding month has recently yielded some intriguing insights. Using computerized data from all death certificates in the United States between 1973 and 1988, Phillips et al (2) found significant increases in the number of deaths in the first week of the month from many causes, including substance abuse. Other investigators have documented an increase in cocaine use and hospital admissions at the beginning of the month, after receipt of disability payments, among a small sample of veterans with schizophrenia (3). This purported “check effect” was found during a 4-year period in California, during which psychiatric emergencies (n 5 35,500) were increased in the first part of the month (4). Of interest, these authors did not find a reduction in this check effect in the period when benefits to persons with drug and alcohol-related disabilities were discontinued. By examining the timing of presentations to an emergency department and the “check effect,” Halpern and Mechem (5) in this issue of The Green Journal pursue further understanding about the medical and public health responses to substance abuse. Their results may be useful in addressing two broad questions: what are the environmental precipitants of relapse among those who have achieved recovery (or exacerbating factors among those not in recovery); and what interventions are effective in decreasing the medical and psychiatric burden of patients with alcohol and drug abuse (5). This study focused on more severely affected patients who presented to an emergency department for psychiatric reasons and who were given primary substance abuse or other psychiatric diagnoses. Although the majority of complications and costs of substance abuse problems accrue from patients who are less severely affected than those described by these authors (6), it is nonetheless of great interest to find effective means of minimizing the consequences of alcohol and drug use among the group of patients who were described. Brief interventions by primary care providers in patients with risky alcohol consumption decrease drinking, medical consequences, and utilization of health care services (7–9). Such interventions for hazardous drinkers are now being examined in other medical care settings, such as the emergency department and inpatient medical services. The Halpern and Mechem article provides insights about relapse prevention (10). Approaches to preventing relapse among primary care patients who are in recovery from alcohol and drug use have been considered from a clinician’s perspective (11). Supporting a patient’s recovery is an important goal for the clinician, particularly as this is the status of the majority of patients who have a lifetime history of alcohol problems (12). Research about the check effect enables thinking more broadly about how to prevent relapse and disease exacerbations among substance abusers (3,4). This work raised the possibility of new ways to minimize the harmful consequences of substance use by addressing a potential relapse trigger or exacerbating factor, the monthly federal check. These authors examined whether the timing of federal disbursements of welfare, disability, and military benefits was associated with the pattern of psychiatric presentations to an emergency department, reflecting an exacerbation or relapse of substance abuse. In this casecontrol study of patients seen at a single urban emergency department for psychiatric reasons during a 7-year period, patients with a primary diagnosis from billing records of substance abuse displayed a significantly different pattern of psychiatric presentations compared with control patients who had a primary diagnosis of another psychiatric illness. The greater rate of psychiatric presentation at the beginning of each month for substance abusers was demonstrated by calculation of a “boundary effect” that reflects the number of presentations during the first week of the month divided by number of presentations during the last week of the preceding month (2). The finding of a significantly greater boundary effect Am J Med. 2001;110:406 – 407. From the Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Boston Medical Center and Boston University Schools of Medicine and Public Health, Boston, Massachusetts. Requests for reprints should be addressed to Jeffrey Samet, MD, MA, MPH, Clinical Addiction Research and Education (CARE) Unit, Boston Medical Center, 91 East Concord Street, Suite 200, Boston, Massachusetts 02118.