Library Watch - On Clinical Issues

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...on Clinical Issues

www.ProjectCork.org

Winter 2008

The Jailbreak Health Project. Incorporating a unique radio programme for prisoners.

Minc A; Butler T; Gahan G. International Journal of Drug Policy 18(5): 444-446, 2007. (1 refs.)
Several studies in NSW have identified prisoners to be at high risk for blood borne viruses. The prevalence of hepatitis C among men in NSW correctional centres is 40% and over 60% among women. It is even higher among those with histories of injecting drug use. As part of the state's strategy to minimise the spread of blood borne viruses and promote healthy lifestyles among prisoners, the Community Restorative Centre broadcasts a weekly half hour radio programme to prisoners and the community. The project is funded through the NSW Health Department and aims to provide support to prisoners, ex-prisoners and their families. Jailbreak's success hinges on the participation of the very people [prisoners] the show wishes to target. The radio show is aimed specifically at broadcasting health promotion and harm-minimisation messages to prisoners and their supporters although this is not obvious. When you tune in to Jailbreak you will hear a diverse range of opinion, music and poetry from people caught up in the criminal justice system. Nevertheless at the heart of this exciting and challenging project is the delivery of engaging, relevant and clear health messages to prison inmates, ex-inmates and families in relation to HIV, hepatitis and sexual health. Since 2002, valuable health information, often in the form of personal stories, vignettes and quiz questions, can be heard in and around Sydney on 2SER 107.3 FM or online at http: www.2ser.com. Jailbreak has not been without controversy and has to balance the security focus of correctional authorities and the illegality of substance use in correctional centres with the need to convey messages to prisoners in relation to harm-minimisation.

Adult outcomes of binge drinking in adolescence: Findings from a UK national birth cohort.

Viner RM; Taylor B. Journal of Epidemiology and Community Health 61(10): article 902, 2007. (37 refs.)
Aims: The aim of the study was to determine outcomes in adult life of binge drinking in adolescence in a national birth cohort. Design and setting: Longitudinal birth cohort: 1970 British Birth Cohort Study surveys at 16 years (1986) and 30 years (2000). Participants: A total of 11 622 subjects participated at age 16 years and 11 261 subjects participated at age 30 years. Measurements: At the age of 16 years, data on binge drinking (defined as two or more episodes of drinking four or more drinks in a row in the previous 2 weeks) and frequency of habitual drinking in the previous year were collected. Thirty-year outcomes recorded were alcohol dependence/ abuse (CAGE questionnaire), regular weekly alcohol consumption (number of units), illicit drug use, psychological morbidity (Malaise Inventory) and educational, vocational and social history. Findings: 17.7% of participants reported binge drinking in the previous 2 weeks at the age of 16 years. Adolescent binge drinking predicted an increased risk of adult alcohol dependence (OR 1.6, 95% CI 1.3 to 2.0), excessive regular consumption (OR 1.7, 95% CI 1.4 to 2.1), illicit drug use (OR 1.4, 95% CI 1.1 to 1.8), psychiatric morbidity (OR 1.4, 95% CI 1.1 to 1.9), homelessness (OR 1.6, 95% CI 1.1 to 2.4), convictions (1.9, 95% CI 1.4 to 2.5), school exclusion (OR 3.9, 95% CI 1.9 to 8.2), lack of qualifications (OR 1.3, 95% CI 1.1 to 1.6), accidents (OR 1.4, 95% CI 1.1 to 1.6) and lower adult social class, after adjustment for adolescent socioeconomic status and adolescent baseline status of the outcome under study. These findings were largely unchanged in models including both adolescent binge drinking and habitual frequent drinking as main effects. Conclusions: Adolescent binge drinking is a risk behaviour associated with significant later adversity and social exclusion. These associations appear to be distinct from those associated with habitual frequent alcohol use. Binge drinking may contribute to the development of health and social inequalities during the transition from adolescence to adulthood.

Alcohol and tobacco cessation in alcohol-dependent smokers: Analysis of real-time reports.

Cooney NL; Litt MD; Cooney JL; Pilkey sDT; Steinberg HR; Oncken CA et al. Psychology of Addictive Behaviors 21(3): 277-286, 2007. (49 refs.)
Alcohol-tobacco interactions and relapse precipitants were examined among alcohol-dependent smokers in a trial of concurrent alcohol and tobacco treatment. After discharge from treatment, participants completed 14 days of electronic diary assessments of mood, self-efficacy, urges to drink or smoke, and drinking and smoking behavior. Electronic diary data revealed an increase in frequency of alcohol urges after smoking episodes. Drinking relapse episodes were predicted by prior Electronic diary ratings of low self-efficacy to resist drinking and high urge to smoke. Smoking relapse episodes were predicted by high urge to smoke and high negative, high arousal mood. Results support a cross-substance cue reactivity model of multiple substance use and a limited-strength model, but not a cross-substance coping model.

An investigation of stigma in individuals receiving treatment for substance abuse.

Luoma JB; Twohig MP; Waltz T; Hayes SC; Roget N; Padilla M; Fisher G. Addictive Behaviors 32(7): 1331-1346, 2007. (37 refs.)
This study examined the impact of stigma on patients in substance abuse treatment. Patients (N= 197) from fifteen residential and outpatient substance abuse treatment facilities completed a survey focused on their experiences with stigma as well as other measures of drug use and functioning. Participants reported experiencing fairly high levels of enacted, perceived, and self-stigma. Data supported the idea that the current treatment system may actually stigmatize people in recovery in that people with more prior episodes of treatment reported a greater frequency of stigma-related rejection, even after controlling for current functioning and demographic variables. Intravenous drug users, compared to non-IV users, reported more perceived stigma as well as more often using secrecy as a method of coping. Those who were involved with the legal system reported less stigma than those without legal troubles. Higher levels of secrecy coping were associated with a number of indicators of poor functioning as well as recent employment problems. Finally, the patterns of findings supported the idea that perceived stigma, enacted stigma, and self-stigma are conceptually distinct dimensions.

Buprenorphine 101: Treating opioid dependence with buprenorphine in an office-based setting.

Torrington M; Domier CP; Hillhouse M; Ling W. Journal of Addictive Diseases 26(3): 93-99, 2007. (16 refs.)
This clinical observation provides a first look at differences between two patient subgroups, prescription opiate (PO) abusers and heroin abusers, presenting for office-based buprenorphine treatment. Medical and drug use histories, medication dose, treatment outcome, and demographic information were collected from the first 101 opiate-dependent adults entering treatment. The results indicate that prescription opiate abusers (n = 42) and heroin abusers (n = 59) differed in several demographic characteristics, drug use history, and treatment outcome. Physicians may benefit from this information by using it to tailor comprehensive treatment and medical care plans for opioid-dependent patients taking buprenorphine.

Changes in the prevalence of non-medical prescription drug use and drug use disorders in the United States: 1991-1992 and 2001-2002.

Blanco C; Alderson D; Ogburn E; Grant BE; Nunes EV; Hatzenbuehler ML; Hasin DS. Drug and Alcohol Dependence 90(2/3): 252-260, 2007. (39 refs.)
Objective: To examine changes in the prevalence of non-medical prescription drug use and DSM-IV non-medical prescription abuse and dependence in the United States between 1991-1992 and 2001-2002. Method: Comparison of the prevalence of past-year non-medical prescription drug use and drug use disorders in the total sample and among lifetime non-medical users in two large national surveys conducted 10 years apart. Results: From 1991-1992 to 2001-2002, the prevalence of DSM-IV non-medical prescription drug use increased by 53%, from 1.5% to 2.3% (p < 0.001), and the prevalence of drug use disorders increased by 67% from 0.3% to 0.5% (p < 0.001). The conditional prevalence of a disorder among users increased numerically from 19.9% to 23.6%, but this increase was not statistically significant (p = 0.15). Conclusions: There have been substantial increases in the prevalence of prescription drug non-medical use and prescription drug use disorders in the United States. Given the clinical utility of prescription drugs, urgent action is needed to find approaches that balance the need for access to these medications among those who need them, against their potential for abuse and dependence in subgroups of vulnerable individuals.

Crack cocaine trajectories among users in a midwestern American city.

Falck RS; Wang JC; Carlson RG. Addiction102(9): 1421-1431, 2007. (62 refs.)
00 Aims: Although crack cocaine first appeared in cities in the United States in the mid-1980s, little is known about its use over long periods of time. This study identified crack cocaine user groups on the basis of long-term trajectories. Design: Following a natural history approach, data were collected periodically from 1996 to 2005. Group-based modeling assessed the probability of a crack smoker becoming abstinent during the observation period. Settings: A targeted sampling plan guided the recruitment of a community sample of crack cocaine users in Dayton, Ohio. Participants: Crack smokers (n = 430) 18 years or older whose urine tested positive for cocaine metabolites at the baseline interview. Measurements Interviewer-administered and audio computer self-administered, structured questionnaires were used to collect data on a range of variables, including frequency of crack use. Abstinence was defined as not having used crack for at least 6 consecutive months during the study. Findings: Three trajectory-based groups were identified: (1) No Change, characterized by a very low probability of abstinence; (2) Some Change, characterized by a low to moderate probability of abstinence; and (3) Dramatic Change, characterized by a high probability of abstinence. African Americans and men were significantly less likely to become abstinent. For the majority of the people (63.6%), crack use was uninterrupted by extended periods of abstinence during the study. Conclusion: Crack cocaine use that persists for a decade or longer may well be the norm for a large proportion of people who have experience with the drug.

An exploration of recent club drug use among rave attendees.

Yacoubian GS; Peters RJ. Journal of Drug Education 37(2): 145-161, 2007. (80 refs.)
Raves are characterized by large numbers of youth dancing for long periods of time and by the use of "club drugs," such as 3, 4-methylenedioxymetham-phetamine (MDMA or "ecstasy"). While a small body of research has explored the use of ecstasy and other club drugs (EOCD) among club rave attendees in the United States, we are aware of no studies that have investigated the relationship between EOCD use and high-risk sexual behaviors among members of this population. We explored the association between EOCD use and high-risk sexual behaviors among a sample of 283 club rave attendees interviewed during the spring and summer of 2005. Data were collected at 13 rave events in two different clubs along the Baltimore-Washington corridor between March 17 and September 3, 2005. Potential respondents were conveniently sampled and approached between 12 a.m. and 5 a.m. as they exited the clubs. Only 12% reported using ecstasy within the two days preceding the interview, findings considerably lower than our earlier studies of club rave attendees. Moreover, no significant relationship was discerned between recent MDMA use and high-risk sexual behavior. These findings suggest that the use of EOCD among rave attendees has diminished and that the allocation of significant resources to combat their proliferation, among this and other populations at risk for EOCD use, may be premature.

Determinants of physician discussion regarding tobacco and alcohol abuse.

Bertakis KD; Azari R. Journal of Health Communication 12(6): 513-525, 2007. (49 refs.)
The U.S. Preventive Services Task Force recommends that clinicians screen adults for tobacco and alcohol abuse and provide appropriate interventions. This study employed direct observation and interactional analysis of medical visits to investigate factors associated with physician discussion of tobacco and alcohol use with patients. New adult patients were randomly assigned to primary care at a university medical center. Videotapes of the visits were analyzed using the Davis observation code. Regression equations related discussions of substance use (alcohol and other substances), smoking, and health promotion to patient health status, depression, age, education, income, gender, alcohol abuse, and current smoking. Patients reporting better physical health were more likely to have their physicians employ a practice style emphasizing addiction behaviors (p = .0186). Substance use (p = .0117) and health promotion counseling (p = .0130) occurred more frequently with younger patients. Physicians discussed substance use (p =< .0001) and addiction (p < .0001) more often with male patients. Problem drinkers were more likely to have physicians address their substance use (p =. 0069) and focus on addiction behaviors (p = .0017). Physicians adopted an addiction-oriented practice style (p < .0001), addressing substance use (p = .0009) and smoking (p < .0001), more often with patients who smoked. Physicians appear more apt to discuss these behavioral risk factors with healthier, younger, male patients who abuse tobacco and alcohol.

Depressive symptoms and subsequent alcohol use and problems: A prospective study of medical inpatients with unhealthy alcohol use.

Palfai TP; Cheng DM; Samet JH; Kraemer KL; Roberts MS; Saitz R. Journal of Studies on Alcohol and Drugs 68(5): 673-680, 2007. (70 refs.)
Objective: We sought to determine whether depressive symptoms assessed during hospitalization predicted alcohol use and alcohol-related problems during the subsequent year among medically ill patients. Method: The study sample was a cohort of hospitalized medical patients with unhealthy alcohol use who participated in a randomized controlled trial of an alcohol brief intervention. Depressive symptoms at baseline, assessed with the Center for Epidemiologic Studies-Depression Scale (CES-D), were used to predict alcohol use and problems at 3 and 12 months. Results: Of the 341 patients enrolled, 90% (men = 220; women = 88) provided data on at least one follow-up time point during the subsequent year. Gender-stratified longitudinal Poisson regression models were fit for each alcohol outcome, adjusting for baseline values of age, physical symptoms, randomization group, alcohol outcome, cocaine use, and socioeconomic indicators. Depressive symptoms were significantly associated with drinks per day (men: incidence rate ratio [IRR] = 1. 17 per 10-unit increase in CES-D, p <.0 1; women: IRR = 1.00 per 10-unit increase in CES-D, p =.98) and alcohol-related problems (men: IRR = 1.22 per 10-unit increase in CES-D, p <.001; women: IRR = 1.05 per 10-unit increase in CES-D, p =.39) for men but not for women. They were not significantly associated with the number of days abstinent in men or women. Conclusions: In hospitalized medical patients with unhealthy alcohol use, depressive symptoms predict subsequent drinks per day and alcohol-related problems among men. These findings suggest that symptoms of depression may be important to consider in treatment planning for male medical patients with unhealthy patterns of drinking.

Do individuals with a severe mental illness experience greater alcohol and drug-related problems? A test of the supersensitivity hypothesis.

Gonzalez VM; Bradizza CM; Vincent PC; Stasiewicz PR; Paas ND. Addictive Behaviors 32(3): 477-490, 2007. (38 refs.)
The supersensitivity hypothesis posits that individuals with a severe mental illness (i.e., schizophrenia and bipolar disorder; SMI) are more likely to be diagnosed with a substance abuse as opposed to a substance dependence diagnosis, and experience greater negative consequences associated with substance use at lower levels of consumption, as compared with non-SMI substance abusers. This is the first known study to test this hypothesis with a control group of non-SMI substance abusing individuals. Forty-two individuals with only a substance use disorder (SUD-only) and 53 dually diagnosed individuals (DD) were compared on measures of substance use, alcohol and drug dependence, negative consequences, substance use outcome expectancies, and motivation for change. A third group of SMI-only individuals (i.e., no SUD; n=35) were also recruited and all three groups were compared on psychological symptoms. Substance use, negative consequences, substance use outcome expectancies, motivation for change, and severity of alcohol and drug dependence were not found to differ significantly between the DD and SUD-only groups. However, the DD group had significantly greater levels of psychological symptoms, as compared with the SMI-only and SUD-only groups. Overall, this study does not provide support for the supersensitivity hypothesis.

Follow-up services after an emergency department visit for substance abuse.

Breton AR; Taira DA; Burns E; O'Leary J; Chung RS. American Journal of Managed Care 13(9): 497-505, 2007. (39 refs.)
Objective: The recent introduction of substance abuse treatment measures to the Health Plan Employer and Data Information Set (HEDIS) highlights the importance of this area for managed care organizations (MCOs). Particularly challenging are members first diagnosed in an emergency department (ED). Study Design: Retrospective claims analysis. Methods: Claims were abstracted for all members who used an ED in 2004 for a diagnosis of substance abuse in a large commercial MCO. General linear models were used to estimate the association between receiving follow-up care within 14 and 60 days and sex, age, type of primary diagnosis, substance abused, and level of use. Results: Of the 1235 patients who visited an ED with a diagnosis of substance abuse, 13% received follow-up substance abuse services within 14 days of their ED visit. An additional 36% of patients had an outpatient service that did not code a substance abuse diagnosis within 2 weeks of an ED visit. The diagnosis breakdown of patients' primary diagnoses was 28% substance use, 13% mental health issues, and 59% noripsychiatric (medical) disorders. The multivariable regression analyses revealed having a nonpsychiatric (medical) primary diagnosis was the strongest predictor of not receiving follow-up care (relative risk = 0,51) at 14 days compared with patients who had a mental health diagnosis. Conclusions: Training ED staff and nonbehavioral health outpatient providers in treatment follow-up for substance abuse may improve the quality of care for patients. Encouraging providers to code for substance abuse when treatment or counseling is delivered would improve health plan HEDIS scores. Interventions may be needed for frequent ED users with substance abuse.

Getting into ecstasy: Comparing moderate and heavy young adult users.

Sterk CE; Theall KP; Elifson KW. Journal of Psychoactive Drugs 39(2): 103-113, 2007. (50 refs.)
In this article, the authors examine factors associated with initial and present Ecstasy use among young adults. Face-to-face structured interviews were conducted in Atlanta, Georgia among 261 active Ecstasy users. The median age at which respondents first heard of Ecstasy was 16 years, whereas the median age of first Ecstasy use was 18 years. Initial Ecstasy use frequently involved polydrug use, including alcohol (50.4%). In terms of their current use, 47.5% of respondents were considered heavy Ecstasy users (using on 10 or more separate occasions in the last 90 days). White respondents, those who used more than one pill during their initial use, and those who used again within one month after their initial use were more likely to be current heavy Ecstasy users. Women, those who waited a longer time between initial and subsequent Ecstasy use, and those who considered themselves in the upper SES bracket were less likely to be current heavy Ecstasy users. A better understanding of initial and current Ecstasy use patterns, including polydrug use, is essential for effective prevention and intervention efforts.

Khat use and mental illness: A critical review. (review).

Warfa N; Klein A; Bhui K; Leavey G; Craig T; Stansfeld SA. Social Science & Medicine 65(2): 309-318, 2007. (51 refs.)
Khat has been used as a stimulant plant in many parts of Africa and the Arabian Peninsula for centuries. Its current use among particular migrant communities in Europe and elsewhere has caused alarm among policy makers and health care professionals. In the United Kingdom, the debate over the psychiatric and social implications of khat use has led to a demand for stricter legal control of this stimulant plant. This paper (a) provides a historical overview of khat use, and (b) reviews the evidence for the existence of a causal link between khat use and mental illness. To do so, we undertook a detailed search of social and medical science databases for case reports, qualitative and quantitative articles on khat use and mental illness from 1945 to 2006. The validity and reliability of the studies that met our inclusion criteria were examined. Lastly, although highlighting health concerns about khat use we suggest that the debate about this popular drug in migrant populations carries elements of a 'moral panic'. There is a need for improved research on khat use and its possible association with psychiatric disorders.

Prescription drug abuse among prisoners in rural southwestern Virginia.

Wunsch MJ; Nakamoto K; Goswami A; Schnoll SH. Journal of Addictive Diseases 26(4): 15-22, 2007. (24 refs.)
Non-medical-use of prescription medications is on the rise across the U.S., particularly in rural areas. In this study of 233 prisoners and probationers in southwestern Virginia, we add to an emerging profile of individuals abusing prescription medications. In this retrospective review of 2000-2004 augmented Addiction Severity Index data, those abusing prescription medications reported increased illicit drug and alcohol abuse, poly-drug abuse, psychiatric problems, and arrests for property crimes. Forty percent reported abuse of OxyContin((R)), a drug implicated in a number of deaths in this region. Compared to non-users, OxyContino((R)) users were younger, more likely to be female, and more likely to abuse benzodiazepines, methadone, cocaine, and heroin. Longevity of abuse of these other drugs belies suggestions that OxyContino was acting as a "gateway" drug leading naive users into addiction and risk of death.

Rural, suburban, and urban variations in alcohol consumption in the United States: Findings from the National Epidemiologic Survey on Alcohol and Related Conditions.

Borders TF; Booth BM. Journal of Rural Health 23(4): 314-321, 2007. (26 refs.)
Context: Alcohol consumption is a major public health problem nationally, but little research has investigated drinking patterns by rurality of residence. Purpose: To describe the prevalence of abstinence, alcohol use disorders, and risky drinking in rural, suburban, and urban areas of the United States. Methods: Analyses of the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) were conducted to estimate prevalence rates for abstinence, a current alcohol use disorder, and exceeding recommended daily and weekly drinking limits. Logistic regression analyses were conducted to test for rural and urban versus suburban differences after adjusting for potential confounders. Additional analyses were stratified by Census Region. Findings: Nationally, the odds of abstinence and, among drinkers, the odds of a current alcohol disorder and exceeding daily limits were higher in rural than suburban areas. Stratified analyses revealed differences in the associations between rurality of residence and drinking across Census Regions. Rural residents of the Northeast, Midwest, and South and urban residents of the Northeast had higher odds of abstinence than their suburban peers. Among drinkers, rural and urban residents of the Midwest had higher odds of a current alcohol disorder and exceeding daily limits; urban residents of the Midwest had higher odds of exceeding weekly limits. Conclusions: Abstinence is particularly common in the rural South, whereas alcohol disorders and excessive drinking are more problematic in the urban and rural Midwest. Health policies and interventions should be further targeted toward those places with higher risks of problem drinking.

Simplifying alcohol assessment: Two questions to identify alcohol use disorders.

Vinson DC; Kruse RL; Seale JP. Alcoholism: Clinical and Experimental Research 31(8): 1392-1398, 2007. (43 refs.)
Background: Previous work has validated a single question to screen for hazardous or harmful drinking, but identifying those patients who have an alcohol use disorder (AUD) among those who screen positive is still time consuming. We therefore sought to develop and validate a brief assessment instrument using DSM-IV criteria for use in primary care medical practice. Methods: Four cross-sectional surveys of past-year drinkers. The developmental sample included patients presenting to emergency departments with an acute injury. The second sample, from the same study, was recruited by random-digit dialing. The third sample was recruited in 5 family medicine practices in Georgia. The fourth sample was the National Epidemiologic Survey on Alcohol and Related Conditions. Interviews with the first 3 samples used the Diagnostic Interview Schedule. The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) used the Alcohol Use Disorder and Associated Disabilities Interview Schedule. Results: Two constructs with promising test characteristics were identified: recurrent drinking in hazardous situations and drinking more than intended. Among those who screened positive with the single question in the developmental sample (N=959), if either of the 2 items was positive, the sensitivity for current AUD was 95% and the specificity was 77%. In the second (N=494) and third (N=280) samples, the sensitivity was 94 and 95% and the specificity was 62 and 66%, respectively, among those with a positive screen. In the NESARC sample, including those with at least 1 occasion in the past year of drinking 5 or more drinks (N=7,890), the sensitivity and specificity were 77 and 86%, respectively. Conclusions: The sensitivity and specificity of these 2 items across 4 samples suggest that they could be formulated into 2 questions, potentially providing busy primary care clinicians with an efficient, reasonably accurate assessment instrument to identify AUD among those patients who screen positive with the single screening question.

Six-month changes in spirituality, religiousness, and heavy drinking in a treatment-seeking sample.

Robinson EAR; Cranford JA; Webb JR; Brower KJ. Journal of Studies on Alcohol and Drugs 68(2): 282-290, 2007. (51 refs.)
Objective: This descriptive and exploratory study investigated change in alcoholics' spirituality and/or religiousness (S/R) from treatment entry to 6 months later and whether those changes were associated with drinking outcomes. Method: Longitudinal survey data were collected from 123 outpatients with alcohol use disorders (66% male; mean age = 39; 83% white) on 10 measures of S/R, covering behaviors, beliefs, and experiences, including the Daily Spiritual Experiences and Purpose in Life scales. Drinking behaviors were assessed with the Timeline Followback interview. Alcoholics Anonymous (AA) participation and attendance were also measured. Results: Over 6 months, there were statistically significant increases in half of the S/R measures, specifically the Daily Spiritual Experiences scale, the Purpose in Life scale, S/R practices scale, Forgiveness scale, and the Positive Religious Coping scale. There were also clinically and statistically significant decreases in alcohol use. Multiple logistic regression analyses showed that increases in Daily Spiritual Experiences and in Purpose in Life scores were associated with increased odds of no heavy drinking at 6 months, even after controlling for AA involvement and gender. Conclusions: In the first 6 months of recovery, many dimensions of S/R increased, particularly those associated with behaviors and experiences. Values, beliefs, self-assessed religiousness, perceptions of God, and the use of negative religious coping did not change. Increases in day-to-day experiences of spirituality and sense of purpose/meaning in life were associated with absence of heavy drinking at 6 months, regardless of gender and AA involvement. The results of this descriptive study support the perspective of many clinicians and recovering individuals that changes in alcoholics' S/R occur in recovery and that such changes are important to sobriety.