Library Watch - On Clinical Issues

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...on Clinical Issues

www.ProjectCork.org

Summer 2010

Responding to the risks associated with the relapse of recovering staff members within addiction services.

Adams PJ; Warren H. Substance Use & Misuse 45(6): 951-967, 2009. (20 refs.) Practitioners working within addiction services who are recovering from their own addiction issues contribute positively to the strength of service interventions, but their recovery also poses risks, particularly those associated with the possibility of relapse. Little has been published on this issue despite its significant impact on the relapsing practitioners, their clients and colleagues, and the services themselves. This "point-of-view" article divides the various impacts of a practitioner's relapse into four phases and examines how services might develop early and late response strategies. It argues that formal monitoring processes can assist in both preventing and responding to the harms associated with these relapses.

Familial drinking in Italy: Harmful or protective factors?

Strunin L; Lindeman K; Tempesta E; Ascani P; Anav S; Parisi L. Addiction Research & Theory 18(3): 344-358, 2010. (49 refs.) Methods: We conducted ethnographic interviews of 80 adolescent (ages 16-18) and 80 young adult (ages 25-30) regular and heavy drinkers in two regions (Abruzzo and Umbria). All 20 Italian regions produce wine. Abruzzo has a high ratio of heavy drinkers while Umbria has a high ratio of regular drinkers. We used the AUDIT to determine eligibility. We queried age at first drink, first 5+, first drunk, context of drinking, drinking with family during meals, availability of alcohol at home, parent's relationship to, attitudes about and discussion about alcohol. Results: Half of regular and heavy drinkers were allowed alcohol in a family setting while growing up. Those allowed alcohol with meals when growing up consumed less on their first drink occasion and were more likely to never drink 5+ or get drunk than those not allowed. They also had reduced or delayed 5+ or drunk occasions. Conclusions: In Italy the tradition of incorporating alcohol with meals in a family setting may protect against harmful drinking. Other qualitative research should explore family, other adult and peer relationships to clarify alcohol use and risk-related behaviors. Research in countries with similar and different early age introduction would increase knowledge about the protective aspect of drinking in a family setting.

*Estimating risk of alcohol dependence using alcohol screening scores.

Rubinsky AD; Kivlahan DR; Volk RJ; Maynard C; Bradley KA. Drug and Alcohol Dependence 108(1-2): 29-36, 2010. (47 refs.) Brief alcohol counseling interventions can reduce alcohol consumption and related morbidity among non-dependent risky drinkers, but more intensive alcohol treatment is recommended for persons with alcohol dependence. This study evaluated whether scores on common alcohol screening tests could identify patients likely to have current alcohol dependence so that more appropriate follow-up assessment and/or intervention could be offered. This cross-sectional study used secondary data from 392 male and 927 female adult family medicine outpatients (1993-1994). Likelihood ratios were used to empirically identify and evaluate ranges of scores of the AUDIT, the AUDIT-C, two single-item questions about frequency of binge drinking, and the CAGE questionnaire for detecting DSM-IV past-year alcohol dependence. Based on the prevalence of past-year alcohol dependence in this sample (men: 12.2%; women: 5.8%), zones of the AUDIT and AUDIT-C identified wide variability in the post-screening risk of alcohol dependence in men and women, even among those who screened positive for alcohol misuse. Among men, AUDIT zones 5-10, 11-14 and 15-40 were associated with post-screening probabilities of past-year alcohol dependence ranging from 18 to 87%, and AUDIT-C zones 5-6,7-9 and 10-12 were associated with probabilities ranging from 22 to 75%. Among women, AUDIT zones 3-4, 5-8, 9-12 and 13-40 were associated with post-screening probabilities of past-year alcohol dependence ranging from 6 to 94%, and AUDIT-C zones 3, 4-6, 7-9 and 10-12 were associated with probabilities ranging from 9 to 88%. AUDIT or AUDIT-C scores could be used to estimate the probability of past-year alcohol dependence among patients who screen positive for alcohol misuse and inform clinical decision-making.

Anticipated versus actual alcohol consumption during 21st birthday celebrations.

Brister HA; Wetherill RR; Fromme K. Journal of Studies on Alcohol and Drugs 71(2): 180-183, 2010. (15 refs.) Objective: The 21st birthday celebration is often associated with excessive alcohol consumption. The current study examined whether individuals consume more alcohol than anticipated during their celebration and whether situational factors contribute to prediction errors. Method: College students (N = 150; 50% female) who planned to drink during their 21st birthday celebration were contacted by telephone 1 week before their celebrations and asked about their birthday plans, including anticipated alcohol consumption. The week after the celebration, in-person semi-structured interviews and self-report measures were administered to obtain information about the 21st birthday celebration, including type and amount of alcohol consumed, pace of drinking, influential peer involvement, and engagement in 21st birthday traditions. Results: The majority of 21st birthday celebrants consumed more alcohol than they anticipated, with men showing greater prediction error than women. Situational factors were positively associated with the discrepancy between anticipated and actual alcohol consumption. Conclusions: Drinking shots, drinking at a fast pace, celebrating with influential peers, and engaging in 21st birthday traditions were associated with drinking more alcohol than anticipated during 21st birthday celebrations. Findings suggest future interventions that target situational factors could reduce excessive 21st birthday drinking.

Case studies in cannabis vaporization.

Earleywine M; Van Dam NT. Addiction Research & Theory 18(3): 243-249, 2010. (12 refs.) Cannabis remains the world's most popular illicit drug despite its documented contribution to respiratory problems. The vaporizer heats cannabis without igniting it. Previous work suggests that vaporizers have the potential to minimize respiratory irritation, but it has not been used as an intervention yet. We sought to establish the feasibility of the vaporizer as an intervention for cannabis smokers with respiratory problems. Four cannabis users who reported respiratory symptoms (including two tobacco smokers) agreed to stop smoking cannabis and use the vaporizer for 1 month. The vaporizer appeared to be a practical and acceptable method for the administration of cannabis in users with respiratory problems. After 1 month of vaporizer use, self-reported respiratory symptoms improved dramatically. Measures of lung function (forced expiratory volume (FEV1) and forced vital capacity (FVC)) showed more modest improvements. Vaporizing proved reactive for tobacco smokers, leading them to decrease cigarette smoking and confounding interpretations of improvement. Nevertheless, those who smoked cannabis exclusively also benefited from the vaporizer. We attempted a reversal design where participants would then return to smoking but all refused. These results suggest that the cannabis vaporizer is acceptable to users, and has the potential to decrease cannabis-related respiratory problems. The device may increase awareness about respiratory health in cannabis users who also smoke cigarettes. Randomized control trials with large samples of users and longer durations of vaporizing appear warranted. Given the reactive effect of the vaporizer on tobacco use, such trials may have to focus initially on those who smoke cannabis but not tobacco.

Cognitive functioning in children prenatally exposed to alcohol and psychotropic drugs.

Dalen K; Bruaroy S; Wentzel-Larsen T; Laegreid LM. Neuropediatrics 40(4): 162-167, 2009. (37 refs.) Cognitive functioning was compared in 29 children diagnosed with fetal alcohol syndrome (FAS), 35 children with fetal alcohol effects (FAE), and 66 psychotropic drugs-exposed (PDE) children using Wechsler tests and the neuropsychological test battery NEPSY. In the FAS group, verbal IQ (VIQ = 78), performance IQ (PIQ = 77), and full scale IQ (FSIQ = 75) were significantly lower as compared to the FAE and PDE groups. In the PDE group VIQ and FSIQ were significantly higher than in the FAE group. In the FAS group, processing speed (PS) was significantly lower than the other three factors. In the FAE group, perceptual organization (PO) was significantly higher, whereas PS was significantly lower than the other factors. In the PDE group, verbal comprehension (VC) was significantly higher than the other factors. Attention subscales on the NEPSY were significantly lower in all the three groups. Prenatal alcohol exposure affects IQ levels more than exposure to psychotropic drugs. Attentional problems were found in all children when tested with the NEPSY in all groups.

Daily marijuana users with past alcohol problems increase alcohol consumption during marijuana abstinence.

Peters EN; Hughes JR. Drug and Alcohol Dependence 106(2): 111-118, 2010. (68 refs.) Drug abuse treatment programs typically recommend complete abstinence because of a fear that clients who stop use of one drug will substitute another. A within-subjects study investigated whether consumption of alcohol and other substances changes during marijuana abstinence. Twenty-eight daily marijuana users who were not trying to stop or reduce their marijuana consumption completed an 8-day baseline period in which they used marijuana and other drugs as usual, a 13-day marijuana abstinence period, and a 7-day return-to-baseline period. Participants provided self-report of substance use daily and submitted Urine samples twice weekly to verify marijuana abstinence. A diagnosis of past alcohol abuse or dependence significantly moderated the alcohol increase from baseline to marijuana abstinence (p < 0.01), such that individuals with this diagnosis significantly increased alcohol use (52% increase) but those without this history did not (3% increase). Increases in marijuana withdrawal discomfort scores and alcohol craving scores from baseline to marijuana abstinence significantly and positively correlated with increases in alcohol use. Increases in cigarettes, caffeine, and non-marijuana illicit drugs did not occur. This study provides empirical validation of drug substitution in a subgroup of daily marijuana users, but results need to be replicated in individuals who seek treatment for marijuana problems.

Deaths with transdermal fentanyl patches.

Jumbelic MI. American Journal of Forensic Medicine and Pathology 31(1): 18-21, 2010. (19 refs.) Fentanyl is a potent Schedule II narcotic analgesic recommended for use in the management of unremitting pain not controlled by morphine or other opiate/opioid drugs. The danger inherent to fentanyl is its potency (greater than 50-100 times that of morphine) and rapidity of action, causing respiratory depression within minutes of administration. Advisories have been issued on a state and national level to health care providers and through manufacturers' package inserts for patients. Still, as will be demonstrated in this case review, the use of only a single transdermal patch taken as prescribed for the first time can prove fatal. A drug that requires such extensive warnings-that if unheeded lead to death because of its narrow therapeutic/toxic window, should have strict criteria and limited outpatient use. Initial medical observation and documentation for determining tolerance might be required before issuing a prescription. There has been a rise in the popularity of this drug evidenced by increased deaths among drug abusers and more prescriptions written. In the year 2006, the Center for Forensic Sciences in Onondaga County had 8 cases where fentanyl was considered the cause of death, often with other drugs detected in therapeutic concentrations. This number was a marked increase from the 1 to 2 cases occurring annually from 2002 to 2005. All of these 2006 overdoses because of fentanyl involved the transdermal formulation. The investigative data, blood and liver fentanyl levels, and autopsy findings will be presented.

Efficacy of psychostimulant drugs for cocaine dependence. (review).

Capella D. Cochrane Database of Systematic Reviews 2(CD007380), 2010. (104 refs.) Background: Cocaine dependence is an increasingly prevalent disorder for which no medication is approved yet. Likewise opioid for heroin dependence, replacement therapy with psychostimulant could be efficacious for cocaine dependence. Objectives: To ascertain the efficacy of psychostimulants for cocaine dependence on cocaine use, sustained cocaine abstinence and retention in treatment. The influence of type of drug, comorbid disorders and clinical trial reporting quality over psychostimulants efficacy has also been studied. Search strategy MEDLINE, EMBASE, PsycINFO, CENTRAL, references of obtained articles and experts in the field. Selection criteria: Randomized parallel group controlled clinical trials comparing the efficacy of a psychostimulant against placebo have been included. Data collection and analysis Two authors evaluated and extracted data. The Relative Risk (RR) was used to assess dichotomous outcomes except for adverse event (AE) induced dropouts for which the risk difference (RD) was preferred. The Standardized Mean Difference (SMD) was used to assess continuous outcomes. To determine the influence of moderating variables, a stratified analysis was conducted. Funnel plots were drawn to investigate the possibility of publication bias. Main results: Sixteen studies have been included, which have enrolled 1,345 patients. Seven drugs with psychostimulant effect or metabolized to a psychostimulant have been investigated: bupropion, dexamphetamine, methylphenidate, modafinil, mazindol, methamphetamine and selegiline. Psychostimulants did not reduce cocaine use ( SMD 0.11, 95% CI: -0.07 to 0.29), showed a statistical trend over improving sustained cocaine abstinence ( RR 1.41, 95% CI: 0.98 to 2.02, p=0.07) and did not improve retention in treatment ( RR 0.97, 95% CI: 0.89 to 1.05). The proportion of AE induced dropouts was similar for psychostimulants and placebo (RD 0.01, 95% CI: -0.02 to 0.03). When the type of drug was included as a moderating variable, it was shown that the proportion of patients achieving sustained cocaine abstinence was higher with bupropion and dextroamphetamine, and also with modafinil, at a statistical trend of significance, than with placebo. Nevertheless, no studied drug was efficacious on any of the remaining outcomes. Besides, psychostimulants appeared to increase the proportion of patients achieving sustained cocaine and heroin abstinence amongst methadone maintained dual heroin-cocaine addicts. The main findings did not seem to be influenced by clinical trial reporting quality. No evidence of publication bias was found. Authors' conclusions: This review found mixed results, therefore evidence of the efficacy of psychostimulants for cocaine dependence is inconclusive. Nevertheless promising results exist for methadone maintained dual heroin-cocaine addicts and for some specific drugs such as dexamphetamine and bupropion.

Inhalant use, inhalant-use disorders, and antisocial behavior: Findings: from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC).

Howard MO; Perron BE; Vaughn MG; Bender KA; Garland E. Journal of Studies on Alcohol and Drugs 71(2): 201-209, 2010. (21 refs.) Objective: Few studies have explored the topography of antisocial behavior in a nationally representative sample of inhalant users. We examined (a) the lifetime prevalence of 20 childhood and adult antisocial behaviors in inhalant users with inhalant-use disorders (IUD+) and without IUDs (IUD); (b) the nature and strength of associations between inhalant use, IUDs, and specific antisocial behaviors in multivariate analyses; and (c) the relationships between inhalant use, IUDs, and antisocial behaviors in a national sample of adults with antisocial personality disorder. Method: The National Epidemiologic Survey on Alcohol and Related Conditions was a multistage national survey of 43,093 U.S. residents. Respondents completed a structured psychiatric interview. Results: IUD+ and IUD respondents were significantly younger and more likely to be unemployed, to be male, to have never married, and to report family and personal histories of alcohol and drug problems than inhalant nonusers. Family histories of alcohol problems and personal histories of drug problems were significantly more prevalent among IUD+ respondents, compared with IUD respondents. In bivariate analyses, IUD+ and IUD respondents evidenced significantly higher lifetime levels of all childhood and adult antisocial behaviors than inhalant nonusers. IUD+ respondents were significantly more likely than their IUD counterparts to report bullying behavior, starting physical fights, using dangerous weapons, physical cruelty to people, staying out all night without permission, running away, and frequent truancy in childhood, as well as greater deceitfulness, impulsivity, irritability/aggressiveness, recklessness, and irresponsibility in adulthood. Multivariate analyses indicated that IUD+ respondents had a significantly elevated risk for childhood and adult antisocial behaviors, compared with inhalant nonusers, with the strongest effects for using dangerous weapons, physical cruelty to animals, and physical cruelty to people. Similarly, IUD+ respondents differed significantly from their IUD counterparts primarily across measures of interpersonal violence. Among persons with antisocial personality disorder, inhalant use and IUDs were associated with greater antisocial behavior, albeit with fewer and weaker effects. Conclusions: Respondents with IUDs had pervasively elevated levels of antisocial conduct, including diverse forms of early-onset and interpersonally violent behavior.

Matching to sufficient treatment: Some characteristics of undertreated (Mismatched) clients.

De Leon G; Melnick G; Cleland CM. Journal of Addictive Diseases 29(1): 59-67, 2010. (24 refs.) A previous study by the investigative team using Drug Abuse Outcome Study data supported the validity of a sufficient treatment matching paradigm, which defines successful placement as the least treatment intensity required to address the severity of a disorder. The least favorable outcomes were obtained in the under-treated clients who received insufficient treatment intensity. The purpose of the current study was to further clarify characteristics of the undertreated clients. Four groups, those matched and mismatched to long-term residential (LTR) and drug-free outpatient (ODF) treatment, were compared on several baseline variables. Results indicated that the severity levels of drug use, social and psychological problems, and motivation for those mismatched to ODF (undertreated) were significantly lower than the clients matched to LTR but generally higher than the clients matched to ODF and those mismatched to LTR (overtreated). These findings underscore the importance of identifying clients at risk for under-treatment and facilitating their entry into treatments of sufficient intensity. More generally, they highlight the need to develop a range of treatment options of sufficient intensity to meet severity differences among clients.

Pharmacotherapy of alcohol use disorders in the Veterans Health Administration.

Harris AHS; Kivlahan DR; Bowe T; Humphreys KN. Psychiatric Services 61(4): 392-398, 2010. (32 refs.) Objective: Acamprosate, oral and long-acting injectable naltrexone, and disulfiram are approved for treatment of alcohol dependence. Their availability and consideration of their use in treatment are now standards of high-quality care. This study determined rates of medication initiation among Veterans Health Administration (VHA) patients. Methods: VHA pharmacy and administrative data were used to identify patients with alcohol use disorder diagnoses in fiscal years (FY) 2006 and 2007 and the proportion (nationally and by facility) who received each medication. Patient characteristics associated with receipt were also examined. Results: Among more than a quarter-million patients with alcohol use disorder diagnoses, the percentage receiving any of the medications increased from 2.8% in FY 2006 to 3.0% in FY 2007. Receipt of these medications was more likely among patients who received specialty addiction care, those with alcohol dependence (compared with abuse), those younger than 55 years, and females. In the patient subgroups examined, the largest proportion to receive any of the medications was 11.6%. Across 128 VHA facilities, rates of use among patients in the sample who had received past-year specialty addiction treatment ranged from 0% to 20.5%; rates ranged from 0% to 4.3% among those with no specialty treatment. Patient preferences and medical contraindications could not be determined from the data. Conclusions: Findings suggest the need to better understand systemwide variation in use of these medications and their use as a rough proxy for availability and consideration of pharmacotherapy-a standard of care with strong organizational support.

Social desirability biases in self-reported alcohol consumption and harms.

Davis CG; Thake J; Vilhena N. Addictive Behaviors 35(4): 302-311, 2010. (47 refs.) Aims: Self-reports remain the most common means of assessing alcohol consumption despite concern for their validity. The objective of this research is to assess the extent to which social desirability biases relate to self-reported consumption, hazardous use, and harms. Methods: In each of two studies presented, undergraduate students (N = 391 and N = 177) who reported that they had consumed alcohol in the past year completed online confidential surveys. Results: Both studies show consistent associations between impression management bias and self-reported consumption such that high impression managers report 20 to 33% less consumption and are about 50% less likely to report risky drinking. No significant correlations involving consumption were found for self-deception bias. Study 2 also indicated that high impression managers report 30-50% fewer acute harms following a drinking episode, and that these effects are maintained after controlling statistically for trait impulsivity/constraint. Conclusions: Impression management bias represents a significant threat to the validity of self-reported alcohol use and harms. Such bias may lead to misspecification of models and under-estimates of harmful or hazardous use.

The Cannabis Use Problems Identification Test (CUPIT): Development, reliability, concurrent and predictive validity among adolescents and adults.

Bashford J; Flett R; Copeland J. Addiction 105(4): 615-625, 2010. (68 refs.) Aims: To describe the empirical construction and initial validation of the Cannabis Use Problems Identification Test (CUPIT), a brief self-report screening instrument for detection of currently and potentially problematic cannabis use. Design: In a three-phase prospective design an item pool of candidate questions was generated from a literature review and extensive expert consultation. The CUPIT internal structure, cross-sectional and longitudinal psychometric properties were then systematically tested among heterogeneous past-year users. Participants: Volunteer participants were 212 high-risk adolescents (n = 138) and adults (n = 74) aged 13-61 years from multiple community settings. Measurements: The comprehensive assessment battery included several established measures of cannabis-related pathology for CUPIT validation, with DSM-IV/ICD-10 diagnoses of cannabis use disorders as criterion standard. Findings: Sixteen items loading highly on two subscales derived from principal components analysis exhibited good to excellent test-retest (0.89-0.99) and internal consistency reliability (0.92, 0.83), and highly significant ability to discriminate diagnostic subgroups along the severity continuum (non-problematic, risky, problematic use). Twelve months later, baseline CUPIT scores demonstrated highly significant longitudinal predictive utility for respondents' follow-up diagnostic group membership. Receiver operating characteristic (ROC) analysis identified a CUPIT score of 12 to be the optimal cut-point for maximizing sensitivity for both currently diagnosable cannabis use disorder and those at risk of meeting diagnostic criteria in the following 12 months. Conclusions: The CUPIT is a brief cannabis screener that is reliable, valid and acceptable for use across diverse community settings and consumers of all ages. The CUPIT has clear potential to assist with achievement of public health goals to reduce cannabis-related harms in the community.

The Psychostimulant Check-Up: A pilot study of a brief intervention to reduce illicit stimulant use.

mout MF; Longo M; Harrison S; Minniti R; Cahill S; Wickes W et al. Drug and Alcohol Review 29(2): 169-176, 2010. (37 refs.) Introduction and Aims. This study is to test the acceptability of a single-session 'check-up' intervention for psychostimulant users and document participants' subsequent progress in reducing psychostimulant use and related harms. Design and Methods. The design was pre-experimental single-group repeated measures. Eighty participants received the Psychostimulant Check-Up, with 62% completing a 3 month follow up. Results. Participants were predominantly young adult methamphetamine users. The majority indicated that the Check-Up answered their questions, increased their awareness of services, and they would recommend it to their friends. At follow up, there was a significant reduction in self-reported methamphetamine use, the number of self-reported psychostimulant-related negative consequences experienced in the previous month and rates of injecting: 62% self-reported at least a 1 g reduction in methamphetamine use. Discussion and Conclusions. The intervention was well accepted and the majority of those who received it subsequently made meaningful reductions in psychostimulant use and related harm. The intervention offers sufficient promise to warrant a randomised trial to establish whether improvements were specific to the intervention.

Is ecstasy a drug of dependence? (review).

Degenhardt L; Bruno R; Topp L. Drug and Alcohol Dependence 107(1): 1-10, 2010. (105 refs.) This paper examines the evidence for an MDMA or "ecstasy" dependence syndrome. Animal evidence suggests that MDMA may be a less potent reinforcer than other drugs, but that it does have dependence potential. This suggests that (a) ecstasy dependence might be less likely than dependence upon other drugs; and (b) factors related to the behavioural and psychological aspects of reward and dependence may make a relatively greater contribution for ecstasy than for other drugs, where physically centred (and better understood) features of dependence may be more salient. Human evidence supports this proposition. Some people report problems with their use, but the literature suggests that physical features play a more limited role than psychological ones. Tolerance is apparent, and withdrawal is self-reported, but it is unclear whether these reports distinguish sub-acute effects of ecstasy intoxication from symptoms reflective of neuroadaptive processes underlying a "true" withdrawal syndrome. Studies examining the structure of dependence upon ecstasy suggest it may be different from drugs such as alcohol, methamphetamine and opioids. Consistent with studies of hallucinogens, a two-factor structure has been identified with factors suggestive of "compulsive use" and "escalating use". Regardless of the nature of any dependence syndrome, however, there is evidence to suggest that a minority of ecstasy users become concerned about their use and seek treatment. Further controlled studies are required to investigate this phenomenon.