Prescribing Medications for Alcohol Dependence

Prescribing Medications for Alcohol Dependence

Three oral medications (naltrexone, acamprosate, and disulfiram) and one injectable medication (extended-release injectable naltrexone) are currently approved for treating alcohol dependence. Topiramate, an oral medication used to treat epilepsy and migraine, has recently been shown to be effective in treating alcohol dependence, although it is not approved by the FDA for this indication. All of these medications have been shown to help patients reduce drinking, avoid relapse to heavy drinking, achieve and maintain abstinence, or gain a combination of these effects. As is true in treating any chronic illness, addressing patient adherence systematically will maximize the effectiveness of these medications (see "Supporting Patients Who Take Medications for Alcohol Dependence").

When should medications be considered for treating an alcohol use disorder?

The drugs noted above have been shown to be effective adjuncts to the treatment of alcohol dependence. Thus, consider adding a medication whenever you're treating someone with active alcohol dependence or someone who has stopped drinking in the past few months but is experiencing problems such as craving or "slips." Patients who previously failed to respond to psychosocial approaches alone are particularly strong candidates for medication treatment.

Must patients agree to abstain?

No matter which alcohol dependence medication is used, patients who have a goal of abstinence, or who can abstain even for a few days prior to starting the medication, are likely to have better outcomes. Still, it's best to determine individual goals with each patient. Some patients may not be willing to endorse abstinence as a goal, especially at first. If a patient with alcohol dependence agrees to reduce drinking substantially, it's best to engage him or her in that goal while continuing to note that abstinence remains the optimal outcome.

A patient's willingness to abstain has important implications for the choice of medication. Most studies on effectiveness have required patients to abstain before starting treatment. A notable exception is topiramate, which was prescribed to study volunteers

who were still drinking.1 Both oral and extended-release injection naltrexone also may be helpful in reducing heavy drinking and encouraging abstinence in patients who are still drinking.2,3 However, its efficacy is much higher in patients who can abstain for 4 to 7 days before initiating treatment. Acamprosate, too, is only approved for use in patients who are abstinent at the start of treatment, and patients should be fully withdrawn before starting. Disulfiram is contraindicated in patients who wish to continue to drink, because a disulfiramalcohol reaction occurs with any alcohol intake at all.

Which of the medications should be prescribed?

Which medication to use will depend on clinical judgment and patient preference. Each has a different mechanism of action. Some patients may respond better to one type of medication than another. (See chart on pages 89 for prescribing information.)

Naltrexone

Mechanism: Naltrexone blocks opioid receptors that are involved in the rewarding effects of drinking alcohol and the craving for alcohol. It's available in two forms: oral (Depade, ReVia), with once-daily dosing, and extended-release injectable (Vivitrol), given as once-monthly injections.

Efficacy: Oral naltrexone reduces relapse to heavy drinking, defined as 4 or more drinks per day for women and 5 or more for men.4,5 It cuts the relapse risk during the first 3 months by about 36 percent (about 28 percent of patients taking naltrexone relapse versus about 43 percent of those taking a placebo).5 Thus, it is especially helpful for curbing consumption in patients who have drinking "slips." It is less effective in maintaining abstinence.4,5 In the single study available when this Guide update was published, extended-release injectable naltrexone resulted in a 25 percent reduction in the proportion of heavy drinking days compared with a placebo, with a higher rate of response in males and those with lead-in abstinence.3

Topiramate

Mechanism: The precise mechanism of action is unclear. Topiramate is thought to work by increasing inhibitory (GABA) neurotransmission and reducing stimulatory (glutamate) neurotransmission. It is available in oral form and requires a slow upward titration of dose to minimize side effects.

Efficacy: Topiramate has been shown in two randomized controlled trials to significantly improve multiple drinking outcomes, compared with placebo.1,6 Over the course of a 14-week trial, topiramate significantly increased the proportion of volunteers with 28 consecutive days of abstinence or non-heavy drinking.1 In both studies, the differences between topiramate and placebo groups were still diverging at the end of the trial, suggesting that the maximum effect may not have been reached. The magnitude of topiramate's effect may be larger than that for naltrexone or acamprosate. Importantly, efficacy was established in volunteers who were drinking at the time of starting the medication.

Acamprosate

Mechanism: Acamprosate (Campral) acts on the GABA and glutamate neurotransmitter systems and is thought to reduce symptoms of protracted abstinence such as insomnia, anxiety, restlessness, and dysphoria. It's available in oral form (three times daily dosing).

Efficacy: Acamprosate increases the proportion of dependent drinkers who maintain abstinence for several weeks to months, a result demonstrated in multiple European studies and confirmed by a meta-analysis of 17 clinical trials.7 The meta-analysis reported that 36 percent of patients taking acamprosate were continuously abstinent at 6 months, compared with 23 percent of those taking a placebo.

More recently, two large U.S. trials failed to confirm the efficacy of acamprosate,8,9 although secondary analyses in one of the studies suggested possible efficacy in patients who had a baseline goal of abstinence.9 A reason for the discrepancy between European and U.S. findings may be that patients in European trials had more severe dependence than patients in U.S. trials,7,8 a factor consistent with preclinical studies showing that acamprosate has a greater effect in animals with a prolonged history of dependence.10 In addition, before starting medication, most patients in European trials had been abstinent longer than patients in U.S. trials.11

Disulfiram

Mechanism: Disulfiram (Antabuse) interferes with degradation of alcohol, resulting in accumulation of acetaldehyde, which, in turn, produces a very unpleasant reaction including flushing, nausea, and palpitations if the patient drinks alcohol. It's available in oral form (once-daily dosing).

Efficacy: The utility and effectiveness of disulfiram are considered limited because compliance is generally poor when patients are given it to take at their own discretion.12 It is most effective when given in a monitored fashion, such as in a clinic or by a spouse.13 (If a spouse or other family member is the monitor, instruct both monitor and patient that the monitor should simply observe the patient taking the medication and call you if the patient stops taking it for 2 days.) Some patients will respond to self-administered disulfiram, however, especially if they're highly motivated to abstain. Others may use it episodically for high-risk situations, such as social occasions where alcohol is present.

How long should medications be maintained?

The risk for relapse to alcohol dependence is very high in the first 6 to 12 months after initiating abstinence and gradually diminishes over several years. Therefore, a minimum initial period of 3 months of pharmacotherapy is recommended. Although an optimal

treatment duration hasn't been established, it is reasonable to continue treatment for a year or longer if the patient responds to medication during this time when the risk of relapse is highest. After patients discontinue medications, they may need to be followed more closely and have pharmacotherapy reinstated if relapse occurs.

If one medication doesn't work, should another be prescribed?

If there's no response to the first medication selected, you may wish to consider a second. This sequential approach appears to be common clinical practice, but currently there are no published studies examining its effectiveness. Similarly, there is not yet enough evidence to recommend a specific ordering of medications.

Is there any benefit to combining medications?

A large U.S. trial found no benefit to combining acamprosate and naltrexone.8 Naltrexone, disulfiram, and both in combination were compared with placebo in the treatment of alcohol dependence in patients with coexisting Axis I psychiatric disorders.14 Equivalently better outcomes were obtained with either medication, but combining them did not have any additional effect. At this time, there is no evidence supporting the combination of medications, but the number of studies examining this question is limited.

Should patients receiving medications also receive specialized alcohol counseling or a referral to mutual help groups?

Offering the full range of effective treatments will maximize patient choice and outcomes, as no single approach is universally successful or appealing to patients. The different approachesmedications for alcohol dependence, professional counseling, and mutual help groupsare complementary. They share the same goals while addressing different aspects of alcohol dependence: neurobiological, psychological, and social. The medications aren't prone to abuse, so they don't pose a conflict with other support strategies that emphasize abstinence.

Almost all studies of medications for alcohol dependence have included some type of counseling, and it's recommended that all patients taking these medications receive at least brief medical counseling. Evidence is accumulating that weekly or biweekly brief (i.e., 1520 minutes) counseling by a health professional combined with prescribing a medication is an effective treatment for many patients during early recovery.1,6,8,15 Medical counseling focuses on encouraging abstinence, adherence to the medication, and participation in community support groups. (For more information, see "Supporting Patients Who Take Medications for Alcohol Dependence" on page 5 and "Should I recommend any particular behavioral therapy for patients with alcohol use disorders?" in the full Guide on page 31.)

Supporting Patients Who Take Medications for Alcohol Dependence

Pharmacotherapy for alcohol dependence is most effective when combined with some behavioral support, but this doesn't need to be specialized, intensive alcohol counseling. Nurses and physicians in general medical and mental health settings, as well as counselors, can offer brief but effective behavioral support that promotes recovery. Applying this medication management approach in such settings would greatly expand access to effective treatment, given that many patients with alcohol dependence either don't have access to specialty treatment or refuse a referral.

How can general medical and mental health clinicians support patients who take medication for alcohol dependence?

Managing the care of patients who take medication for alcohol dependence is similar to other disease management strategies, such as initiating insulin therapy in patients with diabetes mellitus. In the recent Combining Medications and Behavioral Interventions (COMBINE) clinical trial, physicians, nurses, and other health care professionals in outpatient settings delivered a series of brief behavioral support sessions for patients taking medications for alcohol dependence.8 The sessions promoted recovery by increasing adherence to the medication and supporting abstinence through education and referral to support groups.8 (For a set of how-to templates outlining this program, see pages 1922 in the full Guide.) It was designed for easy implementation in nonspecialty settings, in keeping with the national trend toward integrating the treatment of substance use disorders into medical practice.

What are the components of medication management support?

Medication management support consists of brief, structured outpatient sessions conducted by a health care professional. The initial session starts by reviewing with the patient the medical evaluation results as well as the negative consequences of drinking. This information frames a discussion about the diagnosis of alcohol dependence, the recommendation for abstinence, and the rationale for medication. The clinician then provides information on the medication itself and adherence strategies and encourages participation in a mutual support group such as Alcoholics Anonymous (AA).

In subsequent visits, the clinician assesses the patient's drinking, overall functioning, medication adherence, and any side effects from the medication. Session structure varies according to the patient's drinking status and treatment compliance, as outlined on page 22 in the full Guide. When a patient doesn't adhere to the medication regimen, it's important to evaluate the reasons and help the patient devise plans to address them. A helpful summary of strategies for handling nonadherence is provided in the "Medical Management Treatment Manual" from Project COMBINE, available online at www.niaaa.nih.gov/guide.

As conducted in the COMBINE trial, the program consisted of an initial session of about 45 minutes followed by eight 20-minute sessions during weeks 1, 2, 4, 6, 8, 10, 12, and

16. General medical or mental health practices may not follow this particular schedule, but it's offered along with the templates as a starting point for developing a program that works for your practice and your patients.

Can medication management support be used with patients who don't endorse a goal of abstinence?

This medication management program has been tested only in patients for whom abstinence was recommended, as is true with most pharmacotherapy studies. It's not known whether it would also work if the patient's goal is to cut back instead of abstain. Even when patients do endorse abstinence as a goal, they often cut back without quitting. You're encouraged to continue working with those patients who are working toward recovery but haven't yet met the optimal goals of abstinence or reduced drinking with full remission of dependence symptoms. You also may find many of the techniques used in medication management supportsuch as linking symptoms and laboratory results with heavy alcohol useto be helpful for managing alcohol-dependent patients in general.

A Clinician's Guide U.S. Department of Health and Human Services National Institutes of Health National Institute on Alcohol Abuse and Alcoholism NIH Publication 073769 www.niaaa.nih.gov/guide October 2008 Update

References

1. Johnson BA, Rosenthal N, Capece JA, et al. Topiramate for Alcoholism Advisory Board and the Topiramate for Alcoholism Study Group. Topiramate for treating alcohol dependence: A randomized controlled trial. JAMA: The Journal of the American Medical Association. 298(14):16411651, 2007.

2. Kranzler HR, Armeli S, Tennen H, et al. Targeted naltrexone for early problem drinkers. J Clin Psychopharmacol. 23(3):294304, 2003.

3. Garbutt JC, Kranzler HR, O'Malley SS, et al. Efficacy and tolerability of long-acting injectable naltrexone for alcohol dependence: A randomized controlled trial. JAMA: The Journal of the American Medical Association. 293(13):16171625, 2005.

4. Bouza C, Angeles M, Munoz A, Amate JM. Efficacy and safety of naltrexone and acamprosate in the treatment of alcohol dependence: A systematic review. Addiction. 99(7):811828, 2004.

5. Srisurapanont M, Jarusuraisin N. Naltrexone for the treatment of alcoholism: A metaanalysis of randomized controlled trials. Int J Neuropsychopharmacol. 8(2):267280, 2005.

6. Johnson BA, Ait-Daoud N, Bowden C, et al. Oral topiramate for treatment of alcohol dependence: A randomised controlled trial. The Lancet 361(9370):16771685, 2003.

7. Mann K, Lehert P, Morgan MY. The efficacy of acamprosate in the maintenance of abstinence in alcohol-dependent individuals: Results of a metaanalysis. Alcohol Clin Exp Res. 28(1):5163, 2004.

8. Anton RF, O'Malley SS, Ciraulo DA, et al., for the COMBINE Study Research Group. Combined pharmacotherapies and behavioral interventions for alcohol dependence: The COMBINE study: A randomized controlled trial. JAMA: The Journal of the American Medical Association. 295(17):20032017, 2006.

9. Mason BJ, Goodman AM, Chabac S, Lehert P. Effect of oral acamprosate on abstinence in patients with alcohol dependence in a double-blind, placebo-controlled trial: The role of patient motivation. J Psychiatr Res. 40(5):383393, 2006.

10. Rimondini R, Arlinde C, Sommer W, Heilig M. Longlasting increase in voluntary ethanol consumption and transcriptional regulation in the rat brain after intermittent exposure to alcohol. FASEB J. 16(1):2735, 2002.

11. Mason BJ, Ownby RL. Acamprosate for the treatment of alcohol dependence: A review of double-blind, placebo-controlled trials. CNS Spectrums. 5:5869, 2000.

12. Fuller RK, Gordis E. Does disulfiram have a role in alcoholism treatment today? Addiction. 99(1):2124, 2004

13. Allen JP, Litten RZ. Techniques to enhance compliance with disulfiram. Alcohol Clin Exp Res. 16(6):10351041, 1992.

14. Petrakis L, Poling L, Levinson C, et al., Naltrexone and disulfiram in patients with alcohol dependence and comorbid psychiatric disorders. Biological Psychiatry. 57(10):11281137, 2005.

15. O'Malley SS, Rounsaville BJ, Farren C., et al., Initial and maintenance naltrexone treatment for alcohol dependence using primary care vs. specialty care: A nested sequence of 3 randomized trials. Archives of Internal Medicine. 163(14):16951704, 2003.

0

Uses and Abuses of Racist Jokes

by Philip Yaffe

I love racist jokes.

If you are shocked by this declaration, you shouldn't be because what I mean by the term is not those disgusting, brutal and generally false observations designed to cause offense and injury. These do not qualify as jokes, because there is nothing funny about putting people in degrading pigeonholes.

What I mean by racist jokes are those well-crafted stories that deftly ridicule racist and ethnic stereotypes by taking them to their logical but absurd extremes. You know, the kind of racist stories that the Irish as being dullards, the French as being rude snobs, Americans as being loud-mouthed braggarts, Jews as being hook-nosed money-grubbers, Germans as being humorless machines and Belgians as being . . . well, Belgians.

While all of these stereotypes may contain a grain of truth, it is never more than a grain, but some people like to portray them as a bumper crop in order to degrade and demean the objects of their pet prejudices. True racist jokes work to counteract this dangerous venom.

I recall a major event that took place in the United States in 1971. This was the first showing of the sitcom titled "All in the Family." It centered around a dysfunctional family composed of a truly racist family headed by a virulent racist father (Archie Bunker), his loyal but long-suffering wife (Edith), and their free-spirited daughter Gloria, and her equally "hippy" husband (Michael). It was the U.S. adaptation of a British sitcom called "Till Death Do Us Part."

What I remember most about the program (other than it was hysterically funny) was how people reacted to it. I was part of a small group that began watching it together. For the first few episodes, we were all very entertained by Archie's demented rantings about Germans, Poles, blacks, homosexuals, women's libbers, etc., considering it all to be good fun. However, when the storyline turned in our direction, the reaction was quite different. "They can't say that! They can't broadcast such prejudiced garbage on television!" Yes, they could. And they continued doing so for several years.

I think a key lesson learned by these early episodes, by those who were capable of learning, was that racist, ethnic, social and political stereotypes that seem to be just harmless fun when aimed at someone else become seriously injurious when aimed at you.

A modern version of this lesson is currently being taught in Britain by the overwhelming success of Henning Wehn. Wehn is a German stand-up comedian (yes, there are such things) who emigrated to Britain in 2003. Since arriving there, he has made quite a name for himself by playing on the German stereotype, and deftly deflecting stereotypical barbs launched by his colleagues on panel shows. Among his other devices, he often appears on stage wearing a stopwatch around his neck to lampoon the supposed genetically impelled German obsession for efficiency and punctuality.

Okay, if you are now convinced that racist and other sorts of stereotypical jokes can and do serve a serious social purpose, I would like to offer you a few of my favorites that debunk the stereotypes that they are ostensibly promoting by taking them to their ridiculously logical conclusion.

Dutch frugality

Question: How can a pilot recognize that he is flying over the Netherlands?

Answer: Easy, by observing the lines of toilet paper drying in the sun.

Scots Frugality

Two Scots, a father and son, visit London for the first time. They are staying in a hotel on the edge of the city. The son decides he wants to see the sights in the center. When he returns that evening, he proudly announces to his father, "Instead of taking the bus into town, I noted which bus was going there. Instead of getting on, I ran behind it. It led me straight to the center and I saved 50 pence!" The father slaps his forehead in disgust. "Ay, you idiot. Why didn't you run behind a taxi? You could have save five pound!

Jewish Logic

Moshe, an 85-year-old orthodox Jew, is lying on his deathbed in a New York apparently. He comes out of his comma and asked, "Sarah, Sarah, my wife of 55 years, are you here with me?" "Yes, Moshe, yes I am here." "Sarah, I want you should do something for me. I want you should put on your coat, I want you should go downstairs, I want you should go to the corner to St. Patrick's Cathedral, I want you should find a priest, and I want you should bring him back here." "What! You want I should go get a priest and bring him back here. Why?" "I want to convert. I want to become a Christian." "Moshe, Moshe. You have been an orthodox Jew for 85 years, you entire life. Now in your final hours, you want to convert. You want to become a Christian. You crazy!" Moshe sits bolt upright in the bed and points his finger to his head. "Crazy like a fox. Better one of them should die than one of us!"

Texan Superiority

Everything about Texas is supposed to be bigger and better than anywhere else. A Texan is visiting in Italy and he is trying to impress an Italian by how big Texas is. He first tells him how big it is in square miles, but the Italian does not seem to be properly impressed. So he translates everything into square kilometers. The Italian still is not properly impressed, so he translates everything into acres. Still not the proper reaction, so he translates everything into hectares. Same problem. In desperation, the Texan say, "Look, Luigi. I can get on a train at 8 o'clock in the morning. That train is going to travel all day and all night, and at 8 o'clock the next morning, it's still goin' to be in Texas." Finally, the Italian responds. "Hey, you know, we also gotta trains like that here in Italy, but we don't brag about them."

Since everything in Texas is bigger and better than anywhere else, here is a second joke. This one is called "The Ultimate Texas Dilemma."

A group of four Texans are standing in a group in the Dallas railway station when a train pulls in. A fellow gets off the train wearing a conservative brown suit, narrow lapels, Homburg hat, and carrying an umbrella. One of the Texans leaves to the group and goes over to talk to the newcomer. After a couple of minutes he returns to the group and says, "Hey, fellas, you gotta help me. I'm having a problem. That there is my cousin from Boston and we're talking about midgets. Should I say we've go the tallest or the smallest?" And believe me, there just isn't any good answer to that.

Irish Dullness

O'Reily is walking along the River Shannon when he sees his friend O'Malley fishing. He goes up to greet him and says, "Hey, O'Malley, if I guess how many fish you got in your basket, will you give me one of them?" "O'Reily, if you guess how many fish I got in my basket, I'll give you both of them." So O'Reily guesses four. And O'Malley doubles over with laughter. "Ay you fool, you missed it by three."

A Very Special Telephone

This joke is about the United States and Israel, but its humor is universal. To my mind, it is the best joke in the world. It takes a while to get to the punch line, but it is well worth it.

Benyamin Netanyahou, the Prime Minister of Israel, is on a visit to Barak Obama in Washington. Obama is giving him a tour of the White House. At a certain moment, Obama stops him and says, "Mr. Prime Minister, you see that telephone over there? It is a very special telephone. It is a direct line to God." "Really!" "Absolutely. Try it. Try it." Netanyahou goes over to the telephone, picks up the receiver, talks for two or three minutes, then returns. "A direct line to God. Mr. President, I am indeed impressed." They finish the tour and Netanyahou is at the front door preparing to return to Jerusalem when Obama pulls a piece of paper out of his coat pocket. "Mr. Prime Minister, the bill for the telephone call." Netanyahou looks at it. "$3,460. For two minutes. Well, it was a direct line to God." He pays the bill and returns to Jerusalem.

Six months later, Obama is visiting Netanyahou in Jerusalem. Netanyahou is giving Obama a tour of the Knesset, the Israeli Parliament. At a certain moment, Netanyahou stops him and says, "Mr. President, you see that telephone over there? It is a very special telephone. We too now have a direct line to God." "Really!" "Absolutely. Try it. Try it." Obama goes over to the telephone, picks up the receiver, talks for two or three minutes, then returns. "A direct line to God. Mr. Prime Minister, I am indeed impressed." They finish the tour and Obama is at the front door preparing to return to Washington when Netanyahou pulls a piece of paper out of his coat pocket. "Mr. President, the bill for the telephone call." Obama looks at it. "$1.23. One dollar and twenty-three cents!" "Mr. President," Netanyahou says, "you must understand. For us, this is a local call.

You may be wondering about the reference to Belgians at the beginning of this article. Belgium is a small country, about the size of Maryland, sandwiched between German, France, Luxembourg, and the Netherlands. Although Brussels, the Belgian capital, is also the capital of the European Union, the country itself has a very indifferent reputation, as to its people.

I live in Belgium and know differently. They are generally a very nice, sophisticated accommodating, people. My favorite Belgian joke reflects this.

Question: How can you recognize a Belgian on a North Sea oil platform?

Answer: It's very easy. He's the one throwing bread crumbs to the helicopter.

I'm not sure why, but I find this really sweet.

------------------------

Philip Yaffe, a former reporter/feature writer with The Wall Street Journal, is the author of the following books available from Amazon and other online vendors:

The Gettysburg Approach to Writing & Speaking like a Professional

The Gettysburg Collection:

A comprehensive companion to The Gettysburg Approach to Writing & Speaking like a Professional

Actual English: English grammar as native speakers really use it

Gentle French: French grammar as native speakers really use it

What'd You Say? / Que Dites-Vous?

Fun with homophones, proverbs, expressions, false friends, and other linguistic oddities in English and French

The Little Book of BIG Mistakes

Things we "know" that just aren't so.

Contact: phil.yaffe@yahoo.com,phil.yaffe@gmail.com

0

Award-Winning Author Bertrice Small

Background of Bertrice Small

Bertrice Small is an award-winning American novelist who was born in Manhattan and has lived on eastern Long Island for 35 years. The New York Times bestselling author has written 50 novels, among which most of them belong to the genre of historical romance. Small has also written several well-received novels in the genres of fantasy romance and erotic contemporary.

The outstanding and talented author has also received many awards for her novels, such as Outstanding Historical Romance Series, Best Historical Romance and Career Achievement for Historical Fantasy. Recently, in 2008, Small was recognized as a Pioneer of Romance by ROMANTIC TIMES magazine for her significant literary works and contributions to the genre. A few years earlier in 2004, she received the Lifetime Achievement Award by ROMANTIC TIMES magazine.

Besides achieving great success in the literary world with her outstanding novels, Bertrice Small is also highly recognised in the community as a member of various literary organizations, such as The Authors Guild and Romance Writers of America.

Popular and Bestselling Novels

Small has written numerous novel series that have clinched spots in bestselling novel lists. Her first novel series was "Leslie Family Saga Series" which was published in 1978. Subsequently, Small also wrote many popular novel series like the "O'Malley Family Saga Series", "Skye's Legacy Series" and the "Friarsgate Inheritance Saga Series". The "O'Malley Family Saga Series" has captivated the hearts of many fans, telling the tales of the fascinating adventures of the Irish protagonist Skye O'Malley and her involvement in royal conflicts, passionate pursuits and bold encounters. Readers will truly enjoy this novel as they flip page after page, relishing the excitement in the novel.

In 2010, Small has released new titles for her novel series, such as "Passionate Pleasures" (Book 5 of "Channel Pleasures Series"), "The Border Vixen" (Book 5 of "The Border Chronicles") and "Crown of Destiny" (Book 6 of "World of Hetar" Series).

Small has also written single titles, each with a unique concept, plot and storyline, such as "The Kadin", "Love Wild and Fair" and "A Moment in Time", which are also popular among fans.

Besides working on her own individual novels and series, Small has collaborated with other authors to produce several anthologies as well.

Upcoming books

Small will be releasing new titles in late 2011, "Guilty Pleasures" (Book 6 of "Channel Pleasures Series") and "Bond of Passion" (Book 6 of "The Border Chronicles").

0

The Right Way to Admit You Made a Mistake in Business

This isn't my typical "how to" marketing communications article; but it does have to do with business communication and it happens to be especially relevant to me at the moment. Mistakes: we all make them - right? Yet who hasn't run across people in business who find it impossible to admit when they DO make a mistake by deflecting blame elsewhere; don't know how to properly apologize and offer assurances that they will work on the issue that caused the mistake; or simply out and out lie in order to avoid taking responsibility? I know I certainly have. In fact, I once "fired" a customer that was in the liar category. She not only lied when things went wrong - she pointed the finger at my company and its employees. Life is just too short to lose sleep over people like that...

I was recently reminded of the RIGHT way to handle a personal business mistake when I had ads that went out with uncorrected errors for a client. The uncorrected errors were the result of both my own and my graphic designer's carelessness. For me personally, it was a case of too many deadlines crashing in at once (I was about to leave on vacation), too much distraction (children visiting from out of the country), and relying too heavily on my graphic designer to get it right. I'm not blaming my graphic designer. I'm the account executive and art director; I'm the one directing the designer; and I'm the one who should ensure that every communication that goes out for my clients are exactly what they expect.

I knew before the magazines hit the streets that the ads contained errors. There's always that moment when you realize you've made a mistake and this is the moral turning point. It's the time when you either pull up your big girl (or boy) panties and proactively address the situation; start looking around for a scape goat; start working on the cover up lie; or just plain stick your head in the sand and hope nobody discovers what happened. (Of course, I chose to take the proactive approach.)

Regardless of whom the mistake affected (customer; your employer; co-worker, vendor, etc.) or what the consequences were as a result of the mistake, here are some steps to follow the next time YOU screw up royally in business.

Act quickly. An apology seems forced when your mistake becomes known to the entire world. Take the high road - as soon as you realize the mistake, communicate with those who will be affected by it.

When possible, apologize in person. Someone very wise encouraged me to do this many years ago when I was in a similar situation. It's a lot harder than sending an email; but it will speak volumes about the sincerity of your apology and the strength of your character. When the people you need to apologize to are not within close proximity, a phone call is better than email. However, if you need to apologize to a large group, sometimes email really is the best solution.

Explain what happened without blaming others. The full explanation is important, because we can't make positive change unless we understand what truly happened. Try to stick to the facts, especially where other people are concerned. Sometimes the actions of others play into a situation that was ultimately your fault. Accept full responsibility and resist the temptation to point fingers.

Make assurances that you are taking steps to prevent the mistake from happening again. No Mistake is a bad thing if we learn from it and it brings about positive change or growth. If safeguards or systems need to be put into place to minimize the risk of re-occurrence, explain that you have recognized this and are taking action.

Apologize! This seems to be the hardest part for some people. They can explain their mistake and take action to prevent it from happening again, but saying "I'm sorry" is taking off the armor and opening up to... what? What is the worst thing that can happen? Why is it so hard for some people to admit they're not perfect, when everyone knows that NOBODY is perfect? Just say it: I screwed up. I'm so sorry. Please accept my apology. Will you please forgive me? However you choose to say it, you must make yourself vulnerable. I have found that most (not all, but most) people respond graciously to a sincere apology.

If appropriate, make restitution. This is especially important if your mistake affected a customer. You may have personal relationships with long-time customers, but your relationship is still based on doing business together. Perhaps you can't afford to fully recompense your customer the way you would like to; but any gesture is better than none at all.

Ultimately, the act of apologizing - whether in your personal life, or in business - is a healthy dose of self-awareness: awareness of your actions and the effect of those actions on other people. When you can be honest in your assessment of what you did and the undesired effect it had, you will naturally be much less likely to repeat the mistake. Abandon the need to be all knowing and infallible, and you make yourself more available for more genuine relationships and communication with the people you do business with.

Kerry O'Malley is President and founder of Marketects, an industrial marketing communications agency based in Houston, TX. For over a decade Marketects has worked with numerous small to mid size manufacturing and industrial service companies and helped them increase brand recognition, move into new markets, and obtain new prospects through creative and targeted marketing communications. Prior to founding Marketects, Ms. O'Malley had a proven track record managing marketing communications in actual manufacturing and industrial service companies. Because of her work on "the other side of the desk" Ms. O'Malley has a no-nonsense approach to marketing and believes she can offer creative solutions to industrial companies, regardless of budget. Her specialties include industrial advertising and P/R campaign management; trade show strategies and display development; web site content development; brand identity consulting and development; and industrial so cial media marketing management.

0

Top 10 Tourist Attractions in Limerick

The second largest city in Ireland is known for more than just this! Yes, it is one of the most beautiful cities in the country and boasts of an ancient charm as well as a contemporary magnetism, both in the same breadth. A major contributing factor of increasing visitors to this place is played by the tourist attractions housed here. This article on the top 10 tourist attractions in Limerick will capture for you the most essential attractions housed in the city that you could visit while on yours tours here. Also, these Limerick attractions will enable you to an insight into the culture and heritage of the place in a major way. The top 10 tourist attractions in <a rel="nofollow" onclick="javascript:_gaq.push(['_trackPageview', '/outgoing/article_exit_link/1153041']);" href="http://www.ebookireland.com/limerick.htm">Limerick Ireland</a> are: Franciscan Abbey This grand medieval church is more than just a place of worship. Its beautiful interiors and exquisite ext eriors make it one of the most visited tourist attractions in the city! St. Marys Cathedral Choir Stalls the St. Marys Cathedral is one of the most revered places in the entire country. The oak choir stalls are a feature of much fascination not just for the visitor but are also considered special by the natives here. The Hunt Museum Guests interested in art and antiques can especially visit the Hunt Muesum that houses a rare and exclusive collection of art pieces, collected over time. Once a private collection, the artifacts housed here also comprise of the works of Da Vinci and Yeats. Plassey O Malley Sculpture Collection Housed within the Hunt Museum, the Plassey collection is a wonderful depiction of the artistic talents of Helen O Malley who has created over 350 heads and figures that are spectacularly housed here. King Johns Castle The setting is perfect and the ambiance is just enough to inspire a medieval feel for the onlookers of King Johns Castle. Built around the 13th century, this castle is nestled comfortably in the heart of the Limerick city. Adding beauty to the entire ambiance is the Shannon River that flows just outside the huge ramparts of the castle. Interesting walking tours around the castle can be undertaken by the history and adventure lovers. Foynes Flying Boat Museum Ireland houses a number of museums and galleries that sketch a wonderful picture of the history and culture of the place in a grand way. The Flying boat Museum is just one of them. Lough Gur Visitor Centre The agricultural connection of Ireland is very wonderfully preserved and treasured in the Lough Gur Visitor Center that tells tales of the ancient farmers and their ways of life in this mystic valley. The ancient tools, the dwellings, the customs and rituals of the framers and even a number of other possessions that have been housed here; help capture a wonderful picture of those times. Boat Tours across river Shannon This longest river in Ireland is also one of the oldest witnesses to the history of the place. Boat tours are organized for guests that are also enjoyed by the natives here; as this place vouches for picnic and outings for the entire family. Uni Golf Club For all golf lovers, this is the place to be. With an 18-hole course, what less could one expect? And the best place to be in while visiting these places are the <a rel="nofollow" onclick="javascript:_gaq.push(['_trackPageview', '/outgoing/article_exit_link/1153041']);" href="http://limerickhotels.ebookireland.com/">Limerick hotels</a> that play your perfect host in the city. Besides these they also enable you to taste a slice of the traditional Irish hospitality, here in Ireland!

The second largest city in Ireland is known for more than just this! Yes, it is one of the most beautiful cities in the country and boasts of an ancient charm as well as a contemporary magnetism, both in the same breadth. A major contributing factor of increasing visitors to this place is played by the tourist attractions housed here. This article on the top 10 tourist attractions in Limerick will capture for you the most essential attractions housed in the city that you could visit while on yours tours here. Also, these Limerick attractions will enable you to an insight into the culture and heritage of the place in a major way.

The top 10 tourist attractions in Limerick Ireland are:

- Franciscan Abbey This grand medieval church is more than just a place of worship. Its beautiful interiors and exquisite exteriors make it one of the most visited tourist at tractions in the city!

- St. Marys Cathedral Choir Stalls the St. Marys Cathedral is one of the most revered places in the entire country. The oak choir stalls are a feature of much fascination not just for the visitor but are also considered special by the natives here.

- The Hunt Museum Guests interested in art and antiques can especially visit the Hunt Muesum that houses a rare and exclusive collection of art pieces, collected over time. Once a private collection, the artifacts housed here also comprise of the works of Da Vinci and Yeats.

- Plassey O Malley Sculpture Collection Housed within the Hunt Museum, the Plassey collection is a wonderful depiction of the artistic talents of Helen O Malley who has created over 350 heads and figures that are spectacularly housed here.

- King Johns Castle The setting is perfect and the ambiance is just enough to inspire a medieval feel for the onlookers of King Johns Castle. Built around the 13th century, this castle is nestled comfortably in the heart of the Limerick city. Adding beauty to the entire ambiance is the Shannon River that flows just outside the huge ramparts of the castle. Interesting walking tours around the castle can be undertaken by the history and adventure lovers.

- Foynes Flying Boat Museum Ireland houses a number of museums and galleries that sketch a wonderful picture of the history and culture of the place in a grand way. The Flying boat Museum is just one of them.

- Lough Gur Visitor Centre The agricultural connection of Ireland is very wonderfully preserved and treasured in the Lough Gur Visitor Center that tells tales of the ancient farmers and their ways of life in this mystic valley. The ancient tools, the dwellings, the customs and rituals of the framers and even a number of other possessions that have been housed here; help capture a wonderful picture of those times.

- Boat Tours across river Shannon This longest river in Ireland is also one of the oldest witnesses to the history of the place. Boat tours are organized for guests that are also enjoyed by the natives here; as this place vouches for picnic and outings for the entire family.

- Uni Golf Club For all golf lovers, this is the place to be. With an 18-hole course, what less could one expect?

And the best place to be in while visiting these places are the Limerick hotels that play your perfect host in the city. Besides these they also enable you to taste a slice of the traditional Irish hospitality, here in Ireland!

0