Showing papers in "Addiction in 2003"

The validity of self-reports of alcohol consumption: state of the science and challenges for research.

Abstract: Aims To review three topics pertaining to the validity of alcohol self-reports: factors that influence response accuracy; the relative merits of different self-report approaches; and the utility of using alternative measures to confirm verbal reports. Findings Response behavior is influenced by the interaction of social context factors, respondent characteristics, and task attributes. Although research has advanced our knowledge about self-report methods, many questions remain unanswered. In particular, there is a need to investigate how task demands interact with different patterns of drinking behavior to affect response accuracy. There is also a continuing need to use multiple data sources to examine the extent of self-report response bias, and to determine whether it varies as a function of respondent characteristics or assessment timing. Conclusion Self-report methods offer a reliable and valid approach to measuring alcohol consumption. The accuracy of such methods, however, can be improved by research directed at understanding the processes involved in response behavior.

The relationship of average volume of alcohol consumption and patterns of drinking to burden of disease: an overview.

Abstract: Aims As part of a larger study to estimate the global burden of disease attributable to alcohol: • to quantify the relationships between average volume of alcohol consumption, patterns of drinking and disease and injury outcomes, and • to combine exposure and risk estimates to determine regional and global alcohol-attributable fractions (AAFs) for major disease and injury categories. Design, methods, setting Systematic literature reviews were used to select diseases related to alcohol consumption. Meta-analyses of the relationship between alcohol consumption and disease and multi-level analyses of aggregate data to fill alcohol–disease relationships not currently covered by individual-level data were used to determine the risk relationships between alcohol and disease. AAFs were estimated as a function of prevalence of exposure and relative risk, or from combining the aggregate multi-level analyses with prevalence data. Findings Average volume of alcohol consumption was found to increase risk for the following major chronic diseases: mouth and oropharyngeal cancer; oesophageal cancer; liver cancer; breast cancer; unipolar major depression; epilepsy; alcohol use disorders; hypertensive disease; hemorrhagic stroke; and cirrhosis of the liver. Coronary heart disease (CHD), unintentional and intentional injuries were found to depend on patterns of drinking in addition to average volume of alcohol consumption. Most effects of alcohol on disease were detrimental, but for certain patterns of drinking, a beneficial influence on CHD, stroke and diabetes mellitus was observed. Conclusions Alcohol is related to many major disease outcomes, mainly in a detrimental fashion. While average volume of consumption was related to all disease and injury categories under consideration, pattern of drinking was found to be an additional influencing factor for CHD and injury. The influence of patterns of drinking may be underestimated because pattern measures have not been included in many epidemiologic studies. Generalizability of the results is limited by methodological problems of the underlying studies used in the present analyses. Future studies need to address these methodological issues in order to obtain more accurate risk estimates.

Peers and adolescent smoking.

Abstract: There is a considerable body of empirical research that has identified adolescent peer relationships as a primary factor involved in adolescent cigarette smoking. Despite this large research base, many questions remain unanswered about the mechanisms by which peers affect youths’ smoking behavior. Understanding these processes of influence is key to the development of prevention and intervention programs designed to address adolescent smoking as a significant public health concern. In this paper, theoretical frameworks and empirical findings are reviewed critically which inform the current state of knowledge regarding peer influences on teenage smoking. Specifically, social learning theory, primary socialization theory, social identity theory and social network theory are discussed. Empirical findings regarding peer influence and selection, as well as multiple reference points in adolescent friendships, including best friendships, romantic relationships, peer groups and social crowds, are also reviewed. Review of this work reveals the contribution that peers have in adolescents’ use of tobacco, in some cases promoting use, and in other cases deterring it. This review also suggests that peer influences on smoking are more subtle than commonly thought and need to be examined more carefully, including consideration of larger social contexts, e.g. the family, neighborhood, and media. Recommendations for future investigations are made, as well as suggestions for specific methodological approaches that offer promise for advancing our knowledge of the contribution of peers on adolescent tobacco use.

Exploring the association between cannabis use and depression

Abstract: Aim To examine the evidence on the association between cannabis and depression and evaluate competing explanations of the association. Methods A search of Medline, Psychinfo and EMBASE databases was conducted. All references in which the terms 'cannabis', 'marijuana' or 'cannabinoid', and in which the words 'depression/depressive disorder/depressed', 'mood', 'mood disorder' or 'dysthymia' were collected. Only research studies were reviewed. Case reports are not discussed. Results There was a modest association between heavy or problematic cannabis use and depression in cohort studies and well-designed cross-sectional studies in the general population. Little evidence was found for an association between depression and infrequent cannabis use. A number of studies found a modest association between early-onset, regular cannabis use and later depression, which persisted after controlling for potential confounding variables. There was little evidence of an increased risk of later cannabis use among people with depression and hence little support for the self-medication hypothesis. There have been a limited number of studies that have controlled for potential confounding variables in the association between heavy cannabis use and depression. These have found that the risk is much reduced by statistical control but a modest relationship remains. Conclusions Heavy cannabis use and depression are associated and evidence from longitudinal studies suggests that heavy cannabis use may increase depressive symptoms among some users. It is still too early, however, to rule out the hypothesis that the association is due to common social, family and contextual factors that increase risks of both heavy cannabis use and depression. Longitudinal studies and studies of twins discordant for heavy cannabis use and depression are needed to rule out common causes. If the relationship is causal, then on current patterns of cannabis use in the most developed societies cannabis use makes, at most, a modest contribution to the population prevalence of depression.

A meta-analysis of estimated genetic and environmental effects on smoking behavior in male and female adult twins.

Abstract: Background Numerous twin studies on smoking behavior have shown that genetic and environmental factors play significant and approximately equal roles in the determination of smoking initiation (SI) and smoking persistence (SP). However, estimates of heritability (h2), shared (c2) and unique environmental effects (e2) from the literature display considerable variability for SI and SP, due most probably to differences in statistical analysis models, age, gender, sample size, origin of cohorts and measurement of smoking behavior. Methods A systematic literature search identified six studies for SI and 10 studies for SP. Data from these studies were obtained and re-analysed by meta-analytical techniques. Results For SI, our results indicate that the parameters h2, c2 and e2 are (mean +/- SEM): 0.37 +/- 0.04, 0.49 +/- 0.04 and 0.17 +/- 0.03 in male adults, and 0.55 +/- 0.04, 0.24 +/- 0.06 and 0.16 +/- 0.01 in female adults, respectively. These values were weighted by a combination of original estimates of variance from studies reporting variances plus estimated variances from studies where variances were not reported (called the combined variance method). Using the same approach for SP, we found that the parameters h2, c2 and e2 weighted by the combined variance method for the phenotype are (mean +/- SEM): 0.59 +/- 0.02, 0.08 +/- 0.04 and 0.37 +/- 0.03 in male adults, and 0.46 +/- 0.12, 0.28 +/- 0.08 and 0.24 +/- 0.07 in female adults, respectively. Conclusions Our results indicate that genetic factors play a more significant role for SI but a less significant role for SP in female adults compared to male adults. Significant gender difference was also detected in shared environmental factors for SI and SP. However, no significant gender difference was detected for e2 for either phenotype. These findings suggest that genetic and environmental factors may contribute differently to the determination of smoking initiation and persistence in male and female smokers.

Eye movements to smoking-related pictures in smokers: relationship between attentional biases and implicit and explicit measures of stimulus valence

Abstract: Aims To investigate biases in overt orienting of attention to smoking-related cues in cigarette smokers, and to examine the relationship between measures of visual orienting and the affective and motivational valence of smoking cues. Design Smokers and non-smokers took part in a single session in which their attentional and evaluative responses to smoking-related and matched control pictures were recorded. Participants Twenty smokers and 25 non-smokers. Measurements Direction and duration of gaze was measured while participants completed a visual probe task. Subjective and cognitive-experimental measures of the motivational and affective valence of the stimuli were recorded. Findings Smokers, but not non-smokers, maintained their gaze for longer on smoking-related pictures than control pictures. They were also faster to detect probes that replaced smoking-related than control pictures, consistent with an attentional bias for smoking-related cues. Furthermore, smokers showed greater preferences for smoking-related than control pictures, compared with non-smokers, on both the subjective (explicit) and cognitive-experimental (implicit) indices of stimulus valence. Within smokers, longer initial fixations of gaze on smoking-related pictures were associated with a bias to rate the smoking pictures more positively, with greater approach tendencies for smoking pictures on the cognitive-experimental task, and with a greater urge to smoke. Conclusions These results demonstrate that smokers show biased attentional orientating to smoking cues, which is related to craving and the affective and motivational valence of the stimuli.

Longer-term primary prevention for alcohol misuse in young people: a systematic review

Abstract: Objective To identify and summarize rigorous evaluations of psychosocial and educational interventions aimed at the primary prevention of alcohol misuse by young people aged up to 25 years, especially over the longer term (>3 years) Methods Cochrane Collaboration Systematic Review Data sources A comprehensive search of 22 databases and recursive checking of bibliographies for randomized and non-randomized controlled trials and interrupted time-series studies Main outcome measures Objective or self-report measures of alcohol use and misuse Results Fifty-six studies were selected for inclusion in the systematic review Twenty of the 56 studies showed evidence of ineffectiveness No firm conclusions about the effectiveness of prevention interventions in the short- and medium term were possible Over the longer term (>3 years), the Strengthening Families Programme (SFP) showed promise as an effective prevention intervention The Number Needed to Treat (NNT) for the SFP over 4 years for three alcohol initiation behaviours (alcohol use, alcohol use without permission and first drunkenness) was 9 (for all three behaviours) One study also highlighted the potential value of culturally focused skills training over the longer-term (NNT = 17 over 35 years for 4+ drinks in the last week) Conclusions (1) Research into important outcome variables needs to be undertaken; (2) the methodology of evaluations needs to be improved; (3) the SFP needs to be evaluated on a larger scale and in different settings; (4) culturally focused interventions require further development and rigorous evaluation; and (5) an international register of alcohol and drug misuse prevention interventions should be established and criteria agreed for rating prevention interventions in terms of safety, efficacy and effectiveness

Understanding polydrug use: review of heroin and cocaine co-use

Abstract: The use of cocaine by heroin-dependent individuals, or by patients in methadone or buprenorphine maintenance treatment, is substantial and has negative consequences on health, social adjustment and outcome of opioid-addiction treatment. The pharmacological reasons for cocaine use in opioid-dependent individuals, however, are poorly understood and little is known about the patterns of heroin and cocaine co-use. We reviewed anecdotal evidence suggesting that cocaine is co-used with opioid drugs in a variety of different patterns, to achieve different goals. Clinical and preclinical experimental evidence indicates that the simultaneous administration of cocaine and heroin (i.e. ‘speedball’) does not induce a novel set of subjective effects, nor is it more reinforcing than either drug alone, especially when the doses of heroin and cocaine are high. There is mixed evidence that the subjective effects of cocaine are enhanced in individuals dependent on opioids, although it is clear that cocaine can alleviate the severity of symptoms of withdrawal from opioids. We also reviewed preclinical studies investigating possible neurobiological interactions between opioids and cocaine, but the results of these studies have been difficult to interpret mainly because the neurochemical mechanisms mediating the motivational effects of cocaine are modified by dependence on, and withdrawal from, opioid drugs. Our analysis encourages further systematic investigation of cocaine use patterns among opioid-dependent individuals and in laboratory animals. Once clearly identified, pharmacological and neuroanatomical methods can be employed in self-administering laboratory animals to uncover the neurobiological correlates of specific patterns of co-use.

The National Treatment Outcome Research Study (NTORS): 4-5 year follow-up results.

Abstract: Aims The National Treatment Outcome Research Study (NTORS) is the first prospective national study of treatment outcome among drug misusers in the United Kingdom. NTORS investigates outcomes for drug misusers treated in existing services in residential and community settings. Design, setting and participants The study used a longitudinal, prospective cohort design. Data were collected by structured interviews at intake to treatment, 1 year, 2 years and at 4–5 years. The sample comprised 418 patients from 54 agencies and four treatment modalities. Measurements Measures were taken of illicit drug use, injecting and sharing injecting equipment, alcohol use, psychological health and crime. Findings Rates of abstinence from illicit drugs increased after treatment among patients from both residential and community (methadone) programmes. Reductions were found for frequency of use of heroin, non-prescribed methadone, benzodiazepines, injecting and sharing of injecting equipment. For most variables, reductions were evident at 1 year with outcomes remaining at about the 1 year level or with further reductions. Crack cocaine and alcohol outcomes at 4–5 years were not significantly different from intake. Conclusions Substantial reductions across a range of problem behaviours were found 4–5 years after patients were admitted to national treatment programmes delivered under day-to-day conditions. The less satisfactory outcomes for heavy drinking and use of crack cocaine suggest the need for services to be modified to tackle these problems more effectively. Despite differences between the United Kingdom and the United States in patient populations and in treatment programmes, there are many similarities between the two countries in outcomes from large-scale, multi-site studies.

Familial influences on adolescent smoking.

Abstract: The family unit is the primary source of transmission of basic social, cultural, genetic, and biological factors that may underlie individual differences in smoking. Existing information on the role of familial factors in tobacco use is characterized by two separate, but somewhat overlapping, lines of research: genetic epidemiological studies and risk-factor research. The present paper summarizes and evaluates studies assessing the association between adolescent smoking and parent and sibling smoking behaviors. A review of 87 studies reveals that methods are limited by a lack of standardized instruments, failure to measure important confounding and mediating factors, reliance on cross-sectional designs and the use of inconsistent definitions of tobacco-related behavior and assessment procedures. Moreover, there are no systematic family studies of the acquisition and continuation of smoking that have employed contemporary methodological standards for examining familial aggregation of tobacco behaviors among adolescents. Findings across studies show weak and inconsistent associations between parent and adolescent smoking; inconsistent findings may be attributed to methodological issues or associated factors that may complicate the relation between parent and adolescent smoking. Sibling and peer smoking show greater associations with adolescent smoking. Suggestions for future research include contemporary family studies that delineate meaningful phenotypes of tobacco use and prospective work on the later stages of tobacco use and the timing of the influence and valence of parent and family factors. Integration of the risk factor approach within the family study design may enrich both approaches to elucidate familial influences on smoking.

Opiates, cocaine and alcohol combinations in accidental drug overdose deaths in New York City, 1990-98.

Abstract: Aims Accidental drug overdose contributes substantially to mortality among drug users. Multi-drug use has been documented as a key risk factor in overdose and overdose mortality in several studies. This study investigated the contribution of multiple drug combinations to overdose mortality trends. Design We collected data on all overdose deaths in New York City between 1990 and 1998 using records from the Office of the Chief Medical Examiner (OCME). We standardized yearly overdose death rates by age, sex and race to the 1990 census population for NYC to enable comparability between years relevant to this analysis. Findings Opiates, cocaine and alcohol were the three drugs most commonly attributed as the cause of accidental overdose death by the OCME, accounting for 97.6% of all deaths; 57.8% of those deaths were attributed to two or more of these three drugs in combination. Accidental overdose deaths increased in 1990‐93 and subsequently declined slightly in 1993‐98. Changes in the rate of multi-drug combination deaths accounted for most of the change in overdose death rates, whereas single drug overdose death rates remained relatively stable. Trends in accidental overdose death rates within gender and racial/ethnic strata varied by drug combination suggesting different patterns of multi-drug use among different subpopulations. Conclusions These data suggest that interventions to prevent accidental overdose mortality should address the use of drugs such as heroin, cocaine and alcohol in combination.

Gender and ethnic differences in smoking, drinking and illicit drug use among American 8th, 10th and 12th grade students, 1976-2000.

Abstract: Aims This paper examines ethnic differences in licit and illicit drug use among American 8th, 10th and 12th grade students, with a particular focus on girls. Design The study uses cross-sectional data from large, ethnically diverse, nationally representative samples of 8th, 10th and 12th grade girls. Setting Data were collected through questionnaires administered in schools. Participants A total of 40 416 8th grade girls and 37 977 8th grade boys, 35 451 10th grade girls and 33 188 10th grade boys, and 33 588 12th grade girls and 31 014 12th grade boys took part in the study. Findings Across ethnic groups, drug use is highest among Native American girls and lowest among black and Asian American girls. Trend data suggest that there have been important changes in girls’ drug use over time and that girls’ and boys’ drug use patterns are converging. Conclusions Drug use is widespread among American adolescent girls. Future research should examine further girls’ drug use and seek to identify whether risk and protective factors identified in past research, based on predominantly white samples, are also important predictors for drug use among non-white girls.

Abuse and dependence potential for the non-benzodiazepine hypnotics zolpidem and zopiclone: a review of case reports and epidemiological data.

Abstract: Aims The non-benzodiazepine hypnotics zolpidem and zopiclone, which are indicated for short-term treatment of insomnia, were considered originally by physicians as almost devoid of abuse and dependence potential. Several recent publications, however, have suggested that both agents carry a significant risk of abuse. To substantiate and re-evaluate this situation, the world literature was reviewed for cases of dependence of both agents; these cases were analysed in order to identify certain underlying patterns, if evident. Methods A systematic review based on a Medline literature search was conducted including the years 1966–2002 to assemble all available clinical case reports that were analysed for typical features of abuse and dependence according to prespecified criteria. Only case reports were of interest, and clinical studies were excluded. No limitations as to language or publication year were applied. The terms ‘zolpidem’, ‘zopiclone’ and ‘abuse’, ‘dependence’, ‘addiction’, ‘withdrawal’ and ‘intoxication’ were used to identify relevant publications. Potentially relevant citations were retrieved and assessed for inclusion independently by two authors. Results A total of 36 cases for zolpidem were identified, most of them reported in recent years, and 22 cases for zopiclone. Both sexes were involved to a similar extent; and cases were reported in all age groups. In extreme cases, dose increases reached a factor of 30–120 above the recommended doses. The majority of patients had a history of former drug or alcohol abuse and/or other psychiatric conditions. Conclusion On the basis of world-wide prescription numbers, which are approximately twofold higher for zolpidem (1 338 774 000 tablets from June 2001 to June 2002 in Europe, Japan and United States) than for zopiclone (664 897 000 tablets during the same period in Europe and Japan), the relative incidence of reported dependence similar for both drugs and remarkably lower than that of benzodiazepines used for the treatment of disturbed sleep. The findings offer the conclusion that zolpidem and zopiclone are relatively safe drugs. However, as both drugs are psychotropic drugs, patients with a history of abuse or dependence and those with psychiatric diseases seem to be at increased risk of abuse of these agents.

Role of the media in influencing trajectories of youth smoking

Abstract: This paper summarizes results of empirical studies on cigarette advertising and promotions, antismoking advertising, product placement in movies, on television and in music media and news coverage about smoking. In addition, we provide an overview of some of the theoretical literature relevant to the study of media uses and effects. Finally, we discuss empirical findings in the context of these theories to draw some conclusions about media influences on smoking and identify issues for further research. We conclude that (a) the media both shape and reflect social values about smoking; (b) the media provide new information about smoking directly to audiences; (c) the media act as a source of observational learning by providing models which teenagers may seek to emulate; (d) exposure to media messages about smoking also provides direct reinforcement for smoking or not smoking; (e) the media promote interpersonal discussion about smoking; (f) the media can influence ‘intervening’ behaviors that may make teenage smoking less likely; and (g) antismoking media messages can also set the agenda for other change at the community, state or national level. We outline priorities for further research which emphasize the need for longitudinal studies, multi-level studies, an awareness of the probably dynamic relationship between tobacco advertising and antismoking advertising, the importance of determining appraisal of tobacco industry youth smoking prevention efforts and the dearth of research on news coverage about smoking.

Cannabis and educational achievement

Abstract: AIMS: To examine the relationship between cannabis use in adolescence/young adulthood and levels of educational attainment. DESIGN: Data were gathered over the course of a 25-year longitudinal study of a birth cohort of 1265 New Zealand children. MEASUREMENTS: Measures analysed included (a) frequency of cannabis use in adolescence and young adulthood (15-25 years); (b) levels of educational achievement to age 25 years; and (c) social, family and individual characteristics assessed prior to age 16. FINDINGS: Increasing cannabis use was associated with increasing risks of leaving school without qualifications, failure to enter university and failure to obtain a university degree. The association between cannabis use and leaving school without qualifications persisted after control for confounding factors. When due allowance was made for pre-existing levels of cannabis use there was no evidence to suggest the presence of reverse causal pathways in which lower educational achievement led to increased cannabis use. CONCLUSIONS: Findings support the view that cannabis use may act to decrease educational achievement in young people. It is likely that this reflects the effects of the social context within which cannabis is used rather than any direct effect of cannabis on cognitive ability or motivation. Language: en

Buprenorphine versus methadone maintenance therapy: a randomized double-blind trial with 405 opioid-dependent patients.

Abstract: Aims To assess the efficacy of buprenorphine compared with methadone maintenance therapy for opioid dependence in a large sample using a flexible dosing regime and the marketed buprenorphine tablet. Design Patients were randomized to receive buprenorphine or methadone over a 13-week treatment period in a double-blind, double-dummy trial. Setting Three methadone clinics in Australia. Participants Four hundred and five opioid-dependent patients seeking treatment. Intervention Patients received buprenorphine or methadone as indicated clinically using a flexible dosage regime. During weeks 1‐6, patients were dosed daily. From weeks 7‐13, buprenorphine patients received double their week 6 dose on alternate days. Measurements Retention in treatment, and illicit opioid use as determined by urinalysis. Self-reported drug use, psychological functioning, HIV-risk behaviour, general health and subjective ratings were secondary outcomes. Findings Intention-to-treat analyses revealed no significant difference in completion rates at 13 weeks. Methadone was superior to buprenorphine in time to termination over the 13-week period (Wald c 2 = 4.371, df = 1, P = 0.037), but not separately for the single-day or alternate-day dosing phases. There were no significant between-group differences in morphine-positive urines, or in selfreported heroin or other illicit drug use. The majority (85%) of the buprenorphine patients transferred to alternate-day dosing were maintained in alternate-day dosing. Conclusions Buprenorphine did not differ from methadone in its ability to suppress heroin use, but retained approximately 10% fewer patients. This poorer retention was due possibly to too-slow induction onto buprenorphine. For the majority of patients, buprenorphine can be administered on alternate days.

Does retention matter? Treatment duration and improvement in drug use.

Abstract: Aim This study examines whether there is a minimum threshold, continuous or non-linear relationship between the duration of addiction treatment and improvements in drug use. Design Longitudinal cohort study of 62 drug treatment units and 4005 clients in the US National Treatment Improvement Evaluation Study, fielded from 1993 to 1995. Subjects Baseline and 1-year follow-up interviews with clients in methadone maintenance, out-patient non-methadone, short-term residential and long-term residential treatment programs. Measures Improvement in drug use is the difference between the client-reported peak frequency of drug use (in days per month) in the year prior to the baseline interview minus the peak frequency in the year after discharge. Primary drug, and overall use of the major illicit drugs (heroin, cocaine powder, crack cocaine, and marijuana) are considered separately. Results Controlling for multiple factors, treatment duration had a positive linear relationship with primary drug use improvement among methadone clients and an inverted-U-shaped relationship with overall and primary drug use improvements among out-patient and long-term residential clients. Improvement with longer duration is greatest for long-term residential clients. Conclusions Contrary to previous arguments for a sharp retention threshold for onset of treatment effects, we find smooth curves relating treatment duration to drug use improvements in methadone maintenance, out-patient non-methadone and long-term residential modalities. These relationships are effectively linear for durations typically observed in single treatment episodes, but unusually long retention in out-patient non-methadone and long-term residential units appear steadily less predictive of improvement.

Traditional markers of excessive alcohol use.

Abstract: Aims The blood tests used traditionally as markers of excessive drinking are the liver enzymes, gamma glutamyltransferase (GGT), aspartate aminotransferase (AST) and alanine aminotransferase (ALT), and the red blood cell volume (mean corpuscular volume; MCV). Here we review the nature of these markers’ association with alcohol use, their practical application in detecting, assessing or monitoring drinking and increases in understanding of these markers in the past 10 years. Design Articles were identified via Medline search and perusal of bibliographies. Findings The conventional markers have imperfect sensitivity and specificity, but have an added clinical role in the detection of complications of drinking, and of comorbid conditions that may increase risk of drinking. GGT may in part be a marker of the oxidative stress associated with ethanol metabolism. Markers are more likely to be elevated in those aged more than 30 years and in regular drinkers with a longer drinking history. The markers may be useful in opportunistic case finding, in motivating patients to change drinking and in monitoring treatment response. Increased prevalence of obesity and hepatitis C must be considered in interpretation of liver enzyme results. The liver enzymes are prognostic indicators for several medical conditions and for mortality. Conclusions These conventional tests are widely available and relatively inexpensive. While having limited sensitivity and specificity in detection of excessive drinking, they also provide valuable data on complications of drinking, comorbid conditions that may be affected by drinking and, in some cases, prognosis.

A 60-year follow-up of alcoholic men

Abstract: Aims To study the course of male alcohol abuse from age 20 to age 70–80 years. Design A prospective multi-disciplinary follow-up of two community cohorts of adolescent males from 1940 until the present. Setting and participants Two hundred and sixty-eight former Harvard undergraduates (college sample) and 456 non-delinquent, socially disadvantaged Boston adolescents (core city sample). Measurements Since adolescence these cohorts have been followed by repeated interview, questionnaires and physical examination. The college cohort has been followed until age 80 and the younger core city cohort until age 70. DSM-III criteria were used to ascertain alcohol abuse and alcohol dependence. At some point during their lives, 54 (20%) of the college men and 140 (31%) of the core city men met criteria for alcohol abuse. Outcome categories were mortality, continued alcohol abuse and stable remission. Findings and conclusions These socially divergent cohorts resembled each other in four respects. First, by age 70 chronic alcohol dependence was rare; this was due both to death and to stable abstinence. By age 70, 54% of the 72 successfully followed alcohol-dependent core city men had died, 32% were abstinent, 1% were controlled drinkers and only 12% were known to be still abusing alcohol. By age 70, 58% of the 19 successfully followed college alcohol-dependent men had died, 21% were abstinent, 10.5% were controlled drinkers and only 10.5% were known to be still abusing alcohol. Secondly, in both samples alcohol abuse could persist for decades without remission, death or progression to dependence. Thirdly, among both samples prior alcohol dependence and AA attendance were the two best predictors of sustained abstinence. Fourthly, few life-time symptoms of alcohol abuse were the best predictor of sustained return to controlled-drinking.

Male drugs-related deaths in the fortnight after release from prison: Scotland, 1996-99.

Abstract: Aims to assess if 15–35-year-old males released after 14 + days’ imprisonment in Scotland, 1996–99, had a higher drugs-related death rate in 2 weeks after release than during subsequent 10 weeks; higher than expected death rate from other causes; and if drugs-related deaths in the first fortnight were three times as many as prison suicides. Confidential linkage of ex-prisoner database against deaths. Scotland's male prisons and young offenders’ institutions during July to December 1996–99; 19 486 index releases after 14+ days’ incarceration. Relative risk of drugs-related death in the first 2 weeks after release (34 deaths) versus subsequent 10 weeks (23). Other causes of death (21) relative to expectation. Drugs-related deaths in first 2 weeks after release relative to suicides in prison (12). Drugs-related mortality in 1996–99 was seven times higher (95% CI: 3.3–16.3) in the 2 weeks after release than at other times at liberty and 2.8 times higher than prison suicides (95% CI: 1.5–3.5) by males aged 15–35 years who had been incarcerated for 14+ days. We estimated one drugs-related death in the 2 weeks after release per 200 adult male injectors released from 14 + days’ incarceration. Non-drugs-related deaths in the 12 weeks after release were 4.9 times (95% CI: 2.8–7.0) the 4.3 deaths expected. Investment in, and evaluation of, prison-based interventions is needed to reduce substantially recently released drugs-related deaths.

A hierarchy of gambling disorders in the community.

Abstract: Aims To help refine the definition and diagnosis of gambling disorders, we investigated the distribution among US gamblers of the 10 DSM-IV criteria for Pathological Gambling. Design We drew data from two stratified random surveys (n = 2417, n= 530) of gambling behavior and consequences among community-based samples of US adults. A fully structured questionnaire, administered by trained lay interviewers, screened for the life-time prevalence of problem and Pathological Gambling. Per DSM-IV definitions, anyone meeting five or more of 10 itemized criteria was considered a pathological gambler. We analyzed these criteria among all gamblers who met one or more criteria (n = 399). Findings Most gamblers who met only one or two criteria reported ‘chasing their losses’. At subclinical levels (three to four criteria), gamblers also reported elevated rates of gambling-related fantasy: lying, gambling to escape and preoccupation. Pathological gamblers with five to seven criteria reported marked elevations of loss of control, withdrawal symptoms and tolerance (internalizing dimensions of dependence); risking their social relationships and needing to be bailed out financially (externalizing dimensions). Most of the highest-level pathological gamblers (eight to 10 criteria) reported committing illegal acts to support gambling. Conclusion Dependence in a biobehavioral sense appears to be a hallmark of Pathological Gambling, but it marks only one threshold in a qualitative hierarchy of disorders beginning with a common subclinical behavior, ‘chasing’. Epidemiological assessments and future DSM revisions might consider explicit recognition of a problem gambling disorder, identifying people presenting some cognitive symptoms of Pathological Gambling but not clear signs of dependence. Pathological gamblers in turn appear to have two distinct levels of severity.

How important is treatment? One‐year outcomes of treated and untreated alcohol‐dependent individuals

Abstract: Aims To compare representative treatment and untreated samples of alcohol-dependent individuals in rates of abstinence and non-problematic use at 1-year follow-up. Participants and design A total of 482 alcohol-dependent adults in a northern California county identified through a probability survey of problem drinkers in the general population (n = 111) or a survey of consecutive admissions to public and private substance abuse programs (n = 371) were interviewed in person at baseline and by telephone at 1 year. Measurements Logistic regression models were used to predict 30-day abstinence and 12-month non-problematic alcohol use. Results At follow-up, alcohol-dependent individuals in the treatment sample had higher abstinence rates and non-problematic use outcomes than those in the untreated general population sample. In logistic regression models of the merged samples, being in the treatment sample was related strongly and positively to abstinence and non-problematic use. Having more drug users and heavy drinkers in one's social network, higher psychiatric comorbidity, and more social consequences were inversely related to abstinence and non-problematic use in the treatment sample. The number of drug users and heavy drinkers in one's social network was also inversely related to abstinence in both the treatment and untreated general population samples. Results predicting non-problematic use were similar. Conclusions These results are consistent with other studies that examine treatment effectiveness in the absence of a controlled trial. Although natural recovery also occurs, alcohol-dependent individuals benefit from treatment. Co-occurring psychiatric problems continue to be major barriers to treatment effectiveness. An emphasis on changing social networks to be conducive to recovery could heighten both clinical effectiveness and prevention efforts within communities.

Socioeconomic status and drinking patterns in young adults.

Abstract: Aims To investigate the relationship between several indicators ofsocioeconomic status and drinking patterns in young adulthood. Design Data collected in a longitudinal study of young adults was analysed usingrepeated-measures models to examine the relationship between income, occupationalactivity and educational achievement and patterns of drinking. Setting These data were collected as part of a longitudinal study ofa birth cohort of New Zealanders. They were interviewed for themost part in a central location using a face-to-face methodand a computer-assisted alcohol interview. Participants The participants were members of the Dunedin Multidisciplinary Healthand Development study aged 18, 21 and 26 years. Nine hundred andsixty-nine study members contributed to the analysis. Study membershave been found to be broadly representative of the New Zealandpopulation and cross national studies suggest findings are generalizableto other similar market economies. Measurements Three indicators of socioeconomic status were used; educationalachievement, occupational activity and income. The educational achievementindicator at age 18 had three levels that ranged from no school qualificationsto higher school qualifications. For age 21 two additional categoriesof tertiary educational achievement were included to make five categories andfor age 26 higher tertiary degrees were included in the measureto make six categories. Five categories of occupational activitywere used. Income data was also used. Two measures of alcohol consumptionwere used. These were the frequency of drinking and the typicalquantity of alcohol consumed per drinking occasion in the past year. Findings Frequency of drinking increased over these early adult yearsand the quantities consumed peaked at age 21 and decreased thereafterfor both males and females. Frequency of drinking was influencedby income with the higher income respondents drinking more oftenand this was persistent overtime. Quantity of drinking was mostinfluenced by educational achievement. The less well-educated youngadult drank significantly more during a drinking occasion and atall ages. There was also a relationship between educational achievement andfrequency of drinking for males at age 18 and a relationship between women’soccupational activity and the quantities they consumed. Conclusions The finding that the dimensions of drinking operate differently explainsthe lack of consistency in previous research, which has investigated socioeconomicstatus and the volumes of alcohol consumed. The findings of higherquantities consumed among those of lower social status may explain someof the reduced life expectancy found among those with lower socioeconomicstatus.

A comparison of treatment‐seeking pathological gamblers based on preferred gambling activity

Abstract: Aims To compare and contrast gamblers with different forms of problematic gambling activities. Design, setting and measurements Pathological gamblers completed the Addiction Severity Index (ASI) and gambling questionnaires when initiating out-patient treatment. Participants Participants (n = 347) were categorized by their most problematic form of gambling activity: sports, horse/dog-races, cards, slots and scratch/lottery tickets. Differences in demographics, gambling variables, and ASI composite scores were compared across groups. Findings After controlling for demographic variables, the types of gamblers differed in severity of gambling, alcohol and psychiatric problems. Horse/dog-race gamblers were generally older, male and less educated; they began gambling regularly at a young age and spent relatively high amounts of money gambling. Sports gamblers were young males and had intermediary gambling problems; they had relatively high rates of current substance use but few psychiatric problems. Card players spent low to moderate amounts of time and money gambling, and they generally reported few alcohol problems and little psychiatric distress. Slot machine players were older and more likely to be female. Slot gamblers began gambling later in life, had high rates of bankruptcy and reported psychiatric difficulties. Scratch/lottery gamblers spent the least amount of money gambling, but they gambled the most frequently and had relatively severe alcohol and psychiatric symptoms. Conclusions Gambling patterns and severity of psychosocial problems vary by form of problematic gambling, and these differences may influence treatment recommendations and outcomes.

Sex differences in the effects of stressful life events on changes in smoking status.

Abstract: Aims Stressful life events known to be associated with substance use were examined to determine if there were sex-specific responses to stress resulting in changes in smoking status. Participants and measurements A community-based sample of ever smokers from the Americans’ Changing Lives study (n = 1512, 45% female based on sample weights) was used to examine the interactive effects of sex and stressful life events on the likelihood of two outcomes; relapse among former smokers and failure to quit among current smokers. Logistic regression procedures were used to calculate odds ratios. Factors known to be associated with smoking status (e.g. depression, self-esteem, social support) were assessed as control variables. Findings In the sample of former smokers (n = 729) interpersonal loss events were associated with continued abstinence, whereas change of residence and adverse financial events were associated with increased occurrence of relapse. Women were more likely than men to relapse in response to a financial event. In the sample of current smokers (n = 783), financial events were associated with continued smoking, whereas health events were associated with increased likelihood of quitting. Women were more likely than men to continue smoking in the presence of an adverse financial event and less likely than men to quit in response to an adverse health event. Conclusions Overall, stressful life events appear to have a greater deleterious effect on continued abstinence and the ability to quit smoking for women when compared to men. In particular, health and financial events are important risk factors for women and tobacco use.

Ethyl glucuronide—the direct ethanol metabolite on the threshold from science to routine use

Abstract: Aims Current biological state markers remain suboptimal with regard to sensitivity and specificity for monitoring recent alcohol consumption in various settings. Furthermore, these biomarkers can be influenced by age, gender and a variety of substances and non-alcohol-associated diseases and do not cover fully the time axis for alcohol intake. Ethyl glucuronide (EtG) is a non-volatile, watersoluble, stable, direct metabolite of ethanol that can be detected in various body fluids, tissues and hair. Shortly after the consumption even of small amounts of ethanol, EtG becomes positive. It can detect ethanol intake up to 80 hours after the complete elimination of alcohol from the body, covering a unique and important time spectrum for recent alcohol use. EtG seems to meet the need for a sensitive and specific marker to elucidate alcohol use not detected by standard testing. Design, setting, participants, methods and findings The literature was reviewed with a focus on possible diagnostic and therapeutic applications, currently available methods and future perspectives. To date, more than 4000 samples of body fluids, tissues and hair from approximately 1500 individuals have been assessed. Conclusions The data suggest that EtG is a useful tool in numerous settings, including alcohol and drug treatment (to detect lapse/relapse and for motivational feedback), in safety sensitive work settings where use is dangerous or in other settings where alcohol use may be risky (e.g. such as driving, work-place, pregnancy or monitoring physicians or other professionals who are in recovery and working) or for resolving forensic questions. If the question of recent alcohol consumption has to be answered in a binary way (yes/no), such as for determining lapses, the use of EtG in urine is among the preferred tests. The use of this marker alone and complementary with other biological state markers and self-reports is expected to lead to significant improvement in treatment outcome, therapy efficacy and cost reduction.

Tobacco use by university students, Lebanon, 2001

Abstract: Aims The objective was to determine the prevalence of smoking [cigarettes and/or narghile (i.e. water-pipe)] among university students and to examine multiple correlates. Design Cross-sectional. Setting Beirut, Lebanon. Participants A proportionate random sample of 1964 students from public and private universities in Beirut, Lebanon. Measurements Participants completed a self-administered anonymous questionnaire that included demographic and scholastic items and health behavioral aspects, including smoking, alcohol, physical activity, weight control measures and seat belt use. Findings The overall prevalence of smoking was 40% (21.1%, 7.6% and 11.3% of the students were smoking only narghile, only cigarettes and both cigarettes and narghile, respectively). Regression analyses showed that males, those of non-Lebanese origin, pursuing undergraduate degrees, performing risky weight control measures and drinking excessive amounts of alcohol had increased odds of smoking cigarettes. Also, age, high level of paternal education and field of study were significant predictors. Narghile smoking was significantly higher among males who drank excessive alcohol. Conclusions The authors advocate a collaborative effort to alleviate the consequences of smoking among university students.

Direct measurement of alcohol and its metabolites.

Abstract: Background Ethanol can be easily and accurately measured in body fluids or vapours by several chemical and enzymatic methods. However, the persistence of ethanol in the body is short lived and ethanol's metabolism and distribution within the body are extremely complex. Aim This article discusses the complex pharmacokinetics of ethanol and how pharmacokinetics can affect measured ethanol concentrations when ethanol is sampled across different individuals or from different body fluids or vapors, such as whole blood, plasma, breath, urine, saliva, or transdermal ethanol. Findings Several physical methods for the quantification of ethanol concentrations are described, including gas chromatography, electrochemical detection, infrared detection and enzymatic methods, along with their advantages and limitations. Also discussed, is the utility of the measurement of several immediate metabolites of ethanol, including acetaldehyde, acetate, and fatty acid ethyl esters. Conclusions The complex distribution and metabolism of ethanol and its metabolites can obscure the relationship between the ethanol concentration that is measured in body fluids or vapours and the amount of ethanol that is actually taken into the body.

Supply control and harm reduction: lessons from the Australian heroin 'drought'.

Abstract: AIMS: To examine the effects of supply-side drug law enforcement on the dynamics of the Australian heroin market and the harms associated with heroin. SETTING: Around Christmas 2000, heroin users in Sydney and other large capital cities in Australia began reporting sudden and significant reductions in the availability of heroin. The changes, which appear to have been caused at least in part by drug law enforcement, provided a rare opportunity to examine the potential impact of such enforcement on the harm associated with heroin. DESIGN: Data were drawn from a survey of 165 heroin users in South-Western Sydney, Australia; from the Drug Use Monitoring in Australia (DUMA) project; from NSW Health records of heroin overdoses; and from the Computerized Operational Policing System (COPS) database. FINDINGS: Heroin price increased, while purity, consumption and expenditure on the drug decreased as a result of the shortage. The fall in overall heroin use was accompanied by a significant reduction in the rate of overdose in NSW. However, the health benefits associated with the fall in overdose may have been offset by an increase in the use of other drugs (mainly cocaine) since the onset of the heroin shortage. There does not appear to have been any enduring impact on crime rates as a result of the heroin 'drought'. CONCLUSION: Supply control has an important part to play in harm reduction; however, proponents of supply-side drug law enforcement need to be mindful of the unintended adverse consequences that might flow from successfully disrupting the market for a particular illegal drug. Language: en

Attentional shifts to smoking cues in smokers.

Abstract: Aims Many theories of addiction assume that responses to drug cues maintain drug use and precipitate relapse. There is evidence that measures derived from experimental cognitive psychology yield important information about cue reactivity. We used a pictorial version of the visual probe task to evaluate: (i) whether minimally deprived smokers attend differentially to smoking cues (attentional bias); (ii) whether this bias is related to self-reported craving and dependence; and (iii) whether it predicted outcome in a subsequent cessation attempt. Design Participants took part in a structured smoking cessation program. Each participant completed the visual probe task roughly 2 weeks before quitting while non-deprived. Setting A research smoking cessation clinic. Participants 141 heavy smokers seeking treatment for smoking cessation. Measurements The computerized attentional bias measure and self-reported urge were taken in a laboratory session. Participants also monitored their smoking and craving on electronic diaries both when smoking ad libitum and for up to 6 weeks post-cessation. Findings Participants were faster and more accurate in responding to a visual probe that replaced a smoking picture than to a neutral picture, indicating that they showed attentional bias towards the smoking cues. Attentional bias on the first half of the task correlated with pre-task craving, indicating that the bias may tap motivational processes, but it did not predict outcome in smoking cessation. Conclusions The visual probe task can add useful information about attentional responses to drug cues. Further work is required to uncover the theoretical significance and utility of this measure.