Alcohol and other drug use disorders among homeless people in Australia

This paper describes alcohol and drug-use disorders among 210 homeless people in Australia, and compares the Australian findings with the international literature. While the prevalence of alcohol-use disorders among people who are homeless in Australia is comparable with other international studies, drug-use disorders appear to be more prevalent among Australian homeless than comparable international studies. Reasons for this difference are explored.     

Mortality among injecting drug users in Melbourne: a 16-year follow-up of the Victorian Injecting Cohort Study (VICS)

Multiple factors affect injecting drug-related mortality, many of which will vary over time and between jurisdictions. There are relatively few studies of mortality among injecting drug users (IDU) in Australia. We aimed to provide data comparable to those reported internationally on the rate of mortality among IDU in Australia. We retrospectively examined mortality among participants (N=220) from the first Australian cohort study of IDU by linking coded personal identifier records with a national death register. The overall mortality rate among those followed-up was 0.83 per 100 PY (95% CI, 0.56-1.21 per 100 PY). This rate is lower than those reported internationally but comparable to the limited Australian data from other cohorts of IDU. Mortality was higher among males, most common among those aged in their early thirties and drug-related mortality occurred typically after substantial injecting careers. Extensive experience of incarceration (>or=3 times) was associated with increased risk of mortality. These results suggest that rates of mortality among Australian IDU may be lower than those reported internationally, with low HIV prevalence and Australia's long-held harm reduction framework potentially contributing to this result. Further studies using defined cohorts followed over time are needed to examine long-term outcomes among IDU in Australia.     

The influence of co-occurring axis I disorders on treatment utilization and outcome in homeless patients with substance use disorders

The current study examined the relationship between co-occurring substance use and Axis I psychiatric disorders and treatment utilization and outcome among homeless individuals (N=365) who participated in an episode of intensive outpatient substance use treatment. Compared to patients without a co-occurring diagnosis, homeless patients with a diagnosis of major depressive disorder or PTSD participated in more substance use treatment. Diagnostic status did not predict 12-month alcohol or drug treatment outcome. Substance use treatment programs appear to successfully engage homeless individuals with major depressive disorder and PTSD in treatment. Such individuals appear to achieve similar benefits from standard substance use treatment as do homeless individuals without such disorders.     

A cross-national study on Mexico-US migration, substance use and substance use disorders

Background

Epidemiologic research has consistently found lower prevalence of alcohol and drug use disorders among Hispanic immigrants to the US than among US-born Hispanics. Recent research has begun to examine how this change occurs in the process of assimilation in the US. We aimed to study immigration, US nativity, and return migration as risk factors for alcohol and drug use among people of Mexican origin in both the US and Mexico.

Methods

Data come from nationally representative surveys in the United States (2001-2003; n = 1208) and Mexico (2001-2002; n = 5782). We used discrete time event history models to account for time-varying and time-invariant characteristics.

Results

We found no evidence that current Mexican immigrants in the US have higher risk for alcohol or alcohol use disorders than Mexicans living in Mexico, but current immigrants were at higher risk for drug use and drug use disorders. Current Mexican immigrants were at lower risk for drug use and drug disorders than US-born Mexican-Americans. US nativity, regardless of parent nativity, is the main factor associated with increasing use of alcohol and drugs. Among families of migrants and among return migrants we found increased risk for alcohol use, drug use and alcohol and drug use disorders. Evidence of selective migration and return of immigrants with disorders was found regarding alcohol use disorders only.

Conclusions

Research efforts that combine populations from sending and receiving countries are needed. This effort will require much more complex research designs that will call for true international collaboration.     

Commentary: Harm reduction,managed alcohol programs and doing the right thing

In this commentary to the special issue on managed alcohol programs, the necessity of working from a harm reduction orientation when supporting people who experience homelessness is explored. While not all people who experience homelessness have substance use disorders, many respond to experiences of trauma and exclusion through the use of substances, and in many cases this leads to problematic use. In a context where people who are homeless regularly experience the control and regulation of their lives through emergency services, harm reduction approaches provide a welcomed alternative through humane, respectful, effective and client centred approaches to addressing substance use disorders. The articles in this volume demonstrate the value of managed alcohol programs to support people whose consumption of alcohol is problematic. The emerging evidence base for managed alcohol programs has important implications for policy and practice.     

What have population surveys revealed about substance use disorders and their co-morbidity with other mental disorders?

This paper reviews the epidemiology of alcohol and drug abuse and dependence as revealed in recent US general population surveys of the prevalence and correlates of mental disorders, the Epidemiologic Catchment Area (ECA) studies, and the National Comorbidity Study (NCS). These surveys indicate that mental disorders affect between a third and a half of people at some time in their lives, and around one in four in any year. Among the most common forms of mental disorder are phobias, alcohol use disorders, affective disorders and drug use disorders. There are marked gender differences in the prevalence of these disorders: substance use disorders and anti-social personality disorders predominate in men while affective and anxiety disorders predominate in women. The co-occurrence of substance use and other mental disorders is less common in the community than in the clinic because the presence of other mental disorders increases the chances of people with substance use disorders receiving specialist treatment. Only a minority of those with substance use and other mental disorders in the community are treated, with the more severe cases with multiple co-morbid mental disorders and manifest distress the most likely to be treated.     

Living With Dual Diagnosis and Homelessness: Marginalized Within a Marginalized Group

Objective: Concurrent mental and substance use disorders or dual diagnosis are highly prevalent among individuals experiencing homelessness. Studies have indicated that dual diagnosis leads to poorer health outcomes and higher health service utilization among those affected. This study aims to estimate the prevalence of dual diagnoses among homeless populations in British Columbia (BC), Canada, and understand their characteristics and specific factors associated with dual diagnoses. Methods: The BC Health of the Homeless Survey is a cross-sectional study involving the homeless population of three cities in BC. The survey assessed addiction and concurrent disorders with standardized interviews—the Mini-International Neuropsychiatric Interview Plus, the Maudsley Addiction Profile, and the Brief Symptom Inventory—in a sample of 500 individuals who are homeless living in shelters or on the street. We characterized individuals after categorizing them into four groups: those without any current mental disorder, those with substance use disorders only, those with mental disorders only, and those with concurrent substance use and mental disorders. Focusing on the concurrent disorder group, we completed a multivariate analysis comparing individuals with dual diagnosis to those without concurrent disorders. Results: Consistent with previous studies, we found that individuals with dual diagnoses report more severe physical and psychological symptoms. Among the homeless, they were more likely to be Aboriginal and younger and more likely to not make it into a shelter. They also reported substantially more difficulties in getting the health care service that they need. Conclusions: Within this marginalized group, individuals with dual diagnosis were more likely to be from groups considered to be more vulnerable with more complex needs. They were having more problems accessing even basic support, such as shelters and health care. Without a systematic approach in providing appropriate care to individuals with dual diagnosis, the most vulnerable clients are not only the ones likely to suffer the most but also the ones having the most problems meeting their basic needs.     

Deriving costs of service use among an urban homeless population

The purpose of this study was to describe a novel approach to calculating service use costs across multiple domains of service for homeless populations. A randomly-selected sample of homeless persons was interviewed in St. Louis, MO and followed for 2 years. Service- and cost-related data were collected from homeless individuals and from the agencies serving them. Detailed interviews of study participants and of agency personnel in specific domains of service (medical, psychiatric, substance abuse, homeless maintenance, and homeless amelioration services) were conducted using a standardized approach. Service utilization data were obtained from agency records. Standardized service-related costs were derived and aggregated across multiple domains from agency-reported data. Housing status was not found to be significantly associated with costs. Although labor intensive, this approach to cost estimation allows costs to be accurately compared across domains. These methods could potentially be applied to other populations.     

The DrugCheck Problem List: a new screen for substance use disorders in people with psychosis

Despite considerable recent interest in the issue of comorbid substance use disorders in people with serious mental illness, there remains a need to refine approaches to screening. This paper describes the development and testing of a new screen for substance-related comorbidity, the 12-item DrugCheck Problem List (PL). Exploratory factor analysis with inpatient samples suggested a single-factor structure, although confirmatory factor analysis in a further sample found similar fit from a two-factor model. Sensitivity and specificity in detecting DSM-IV substance use disorders were both high and comparable to performances of the Severity of Dependence Scale and Alcohol Use Disorders Identification Test (Australian version). The list of problem areas provided by the PL has utility in driving further assessment and treatment planning, and offers suggested foci for motivational interviewing. While further testing is indicated, these data provide strong initial support for its use.     

Husbands' SUD is associated with higher levels of co-occurring but not non-co-occurring psychiatric disorders among their wives

OBJECTIVE: Substance use among husbands has been shown to be associated with higher rates of substance use and of psychiatric symptoms among their wives. However, substance use disorders (SUD) and psychiatric disorders (as opposed to substance use or psychiatric symptoms) are rarely rigorously assessed among large samples of couples, so it is unclear whether SUD among husbands are associated with SUD among their wives, and whether the wives also display a higher prevalence of co-occurring or non-co-occurring psychiatric disorders. We compared the level of SUD, of co-occurring (with SUD) psychiatric disorders, and of non-co-occurring psychiatric diagnoses among the wives of males with SUDs vs among the wives of males without SUDs. We hypothesized that the presence of SUDs among males would be associated with a higher level of SUDs, of co-occurring psychiatric disorders, and of non-co-occurring psychiatric disorders in their wives. METHOD: The subjects in this study were the spouses of adult men with a lifetime history of an SUD (SUD+ husbands, N=342) vs those with no lifetime history of an SUD (SUD- husbands, N=350). These subjects were recruited for participation in a longitudinal project designed to elucidate the etiology of substance use disorders. RESULTS: Co-occurring SUDs were five times more common among the spouses of SUD+ husbands than among the spouses of SUD- husbands (10.2% vs 2.0%, chi-square=19.7, p=0.000). SUD/depressive disorder and SUD/anxiety disorder were both seven times more common among the spouses of SUD+ husbands than among the spouses of SUD- husbands (19.4% vs 4.7%, chi-square=45.8, p=0.000; 14.3% vs 2.0%, chi-square=34.5, p=0.000). In contrast, non-co-occurring depressive disorders and non-co-occurring anxiety disorders were not more common among the wives of the SUD+ husbands than among the SUD- husbands. CONCLUSIONS: These findings demonstrate that SUD and co-occurring psychiatric disorders (with SUD) are more common among the spouses of SUD+ husbands than among the spouses of SUD- husbands, but non-co-occurring ("pure") psychiatric disorders are not more common among the spouses of the SUD+ husbands.     

The association of alcohol dependence with general practice attendance

Introduction and Aims . This study was designed to examine the relationship between alcohol dependence and general practitioner (GP) service attendance in Australia. Design and Methods . Data were analysed from the 1997 Australian National Survey of Mental Health and Wellbeing. In this survey, a representative sample of the Australian population was interviewed to ascertain past 12 month psychiatric diagnoses for all major mental disorders as well as the use of primary and other health services (n = 10 641, 79% response rate). Results . People with alcohol dependence comorbid with other psychiatric disorders have higher rates of service usage than those without such disorders. Discussion and Conclusions . Alcohol dependence comorbid with mental disorders has a significant impact on GP service in Australia. High rates of service use by individuals with such comorbidities were a considerable burden for GP services.[Proudfoot H, Teesson M. The association of alcohol dependence with general practice attendance. Drug Alcohol Rev 2009]     

Comparing the dynamic course of heroin, cocaine, and methamphetamine use over 10 years

To examine dynamic changes in drug-use trajectories over time we analyzed episode types and predictors of quitting use over the 10 years following drug-use initiation for 1797 heroin, cocaine, and methamphetamine (meth) users. Most episodes reflected high use and incarceration, however these events occurred more frequently among heroin and meth users. Quitting was predicted by current treatment and self-help participation among meth (RR 2.57, 1.79–3.70; 2.57, 1.80–3.67) and cocaine (RR 2.00, 1.42–2.81; 2.10, 1.63–2.72) users, and by a history of quitting for meth users (RR 1.11, 1.06–1.17). Quitting was less likely among all users under legal supervision (RR 0.55–0.69) and among heroin (RR 0.66, 0.45–0.97) and meth users (RR 0.73, 0.60–0.89) with an early drug-use onset. Relative to cocaine or meth use, heroin use was characterized by persistent use at a high-level which was often only interrupted by incarceration. While quitting drug use can be facilitated by treatment and/or self-help participation, few people had these experiences in the 10 years following first use.     

Psychedelic-assisted therapies: The past,and the need to move forward responsibly

Recent clinical studies illustrate that psychedelics such as LSD and psilocybin may represent much-needed new treatment options for mood disorders and alcohol and other drug use disorders. More clinical studies are required to confirm the safety and efficacy of psychedelic-assisted therapies, but the cultural stigma that has surrounded psychedelics since the 1960s has hindered research. This problem is amplified in Australia. There has been a complete absence of research into psychedelic therapies, and Australian-based research advocates claim to have encountered a number of barriers. In this commentary, we provide a brief account of the historical stigma associated with psychedelics, and an overview of the contemporary context of research into psychedelic-assisted therapies, including the purported barriers to research in Australia. In light of the complex history of psychedelics, we identify a number of pressing questions relating to the social and legal context that need to be addressed so that clinical studies can proceed. Research is needed to address such questions so that the nature and extent of purported barriers to clinical studies with psychedelics can be properly elucidated, and strategies developed – with practitioners, patients, families and other stakeholders – to responsibly address these barriers. This is important because it will enable Australian researchers to contribute robust evidence about the possible efficacy and safety of psychedelic therapies, and to facilitate local expertise needed to implement psychedelic-assisted therapies, should they prove efficacious.     

HIV screening among substance-abusing veterans in care

Calls for screening for HIV infection among individuals with substance use disorders, including alcohol use, are increasing. We investigated HIV screening and its predictors in the Veterans Health Administration (VA) system among such individuals in care. Our primary outcome was retrospective evidence of screening for HIV infection, adjusting for patient demographics and important comorbid disease. Of the 371,749 sample patients with histories of substance use disorders using VA services, 20% had evidence of HIV screening. Screening was lowest among those with alcohol use disorders alone (11%) and highest among those treated in substance use programs (28%) or receiving inpatient care (28%). The findings suggest a low recognition of substance use disorders (especially alcohol use) as risk factors for HIV. Quality improvement initiatives to increase risk factor recognition and screening among patients with substance use disorders will yield benefits in the fight against HIV.     

Cigarette Smoking in Youths With Mental Health and Substance Use Problems: Prevalence,Patterns, and Potential for Intervention

Mental health symptoms and substance use disorders are clear risk factors for cigarette smoking and nicotine dependence among young people, yet research on cigarette smoking among youths with concurrent mental health and substance use disorders (“dual diagnosis”) is considerably lacking. We examined smoking history and perspectives regarding smoking, cessation, and mental health and substance use in 97 adolescents and emerging adults (ages 14 to 24) referred to a program for youths with concurrent mental health and substance use disorders in Canada. Results show high rates of cigarette smoking, and modest interest in quitting but little interest in attending formalized programs to assist with cessation. Many participants reported smoking more when mental health was worse; most reported that they frequently smoke cigarettes and use drugs or alcohol concurrently. Current smokers perceived more benefits from cigarette smoking in regulating emotions and ameliorating their mental health symptoms than former smokers. In contrast, perceived detrimental effects of smoking were unrelated to current smoking status. Results suggest a need for integrated treatment that incorporates emotion regulation as part of cessation approaches. Integrating smoking cessation approaches into existing mental health and substance use treatments may be more palatable to adolescents and emerging adults than stand-alone smoking cessation programs.     

The relationship between early maladaptive schemas and eating-disorder symptomatology among individuals seeking treatment for substance dependence

Numerous studies have examined early maladaptive schemas (EMS) and their relationship to psychological disorders, including eating disorders (EDs) and substance use disorders (SUDs). However, to date, there are no empirical investigations that have examined the relationship between EMS and EDs among individuals seeking treatment for substance use. In an attempt to further elucidate this relationship, the purpose of the current, exploratory study was to examine the relationship between EMS, ED symptomatology (i.e. bulimia and binge-eating but not anorexia) and substance use and to directly compare EMS among individuals with and without a probable ED diagnosis. Participants were 387 men and 132 women seeking residential treatment for substance use. Results demonstrated that 11 of the 18 EMS were significantly associated with ED. Moreover, patients with a probable ED scored significantly higher than patients without a probable ED on 8 of the 18 EMS. Results suggest that EMS are prevalent among individuals with ED pathology seeking treatment for substance use. Thus, treatment programs could potentially benefit from the assessment and treatment of EMS among dually diagnosed patients. Given the exploratory and preliminary nature of the study, continued research is needed to further examine the relationship between EMS, EDs and substance use.     

Does Availability of Illicit Drugs Mediate the Association between Mental Illness and Substance Use?

This study investigated the association between presence of mental illness, detected by an increased level of Kessler Psychological Distress Scale score, and prevalence of exposure to opportunity to obtain illicit drugs among adolescents and young adults aged 12–24 years using data collected by the 2007 Australian National Drug Strategy Household Survey (N = 2,663). Adolescents and young adults with mental illness have increased prevalence of exposure to drug use opportunity. Higher exposure to opportunity to obtain illicit drugs among people with pre-existing mental illness may further contribute to the co-existence of drug dependence and other mental disorders that are frequently reported in the literature.