Marker or mediator? The effects of adolescent substance use on young adult educational attainment

AIMS: We tested the effects of adolescent substance use on college attendance and completion by young adulthood in the context of the behavioral and familial risk factors that influence substance use. DESIGN, SETTING AND PARTICIPANTS: Longitudinal data were collected from a community sample of children of alcoholics (248) and matched controls (206) at three adolescent assessments (micro(age) = 13-15) and a long-term follow-up in young adulthood (micro(age) = 25). MEASUREMENTS: College attendance and degree completion by age 25 were self-reported in young adulthood. During adolescence, self-reports of alcohol and drug use were assessed with log-transformed quantity/frequency measures; substance use risk factors [e.g. parental monitoring, externalizing and internalizing symptoms and Diagnostic and Statistical Manual version III (DSM-III) diagnosis of parental alcoholism] were assessed by both self- and parent-report, and adolescent reading achievement was assessed using a standardized assessment of reading achievement (Wide Range Achievement Test). FINDINGS: Using growth curve modeling, we found that mean levels and growth in adolescent substance use mark, or identify, those adolescents who are at risk for reduced odds of attending and completing college. Moreover, adolescent substance use was not merely a marker of risk, in that growth in drug use (but not alcohol use) significantly mediated the effects of parental alcoholism and early externalizing behavior on later college completion, partially explaining the effects of these risk factors on college completion. CONCLUSIONS: The current study provides evidence for both the marker and the mediator hypotheses, and identifies multiple pathways to higher educational attainment. The findings point to the importance of studying the effects of adolescent substance use in a broader developmental context of its correlated risk factors to specify more effectively the key pathways to later developmental outcomes.     

Comparison of Objective Screening and Self-Report for Alcohol and Drug Use in Traumatically Injured Patients

Alcohol and drug use is prevalent in trauma patients. Concerns over the validity of self-reporting drug use could make nonlaboratory screening problematic. This study sought to validate patient self-report of substance use against objective screening to determine the reliability of self-report in trauma patients. Patients admitted to either the Trauma or Burn services who were at least age 18 were screened for alcohol and drug use with validated screening tools. Exclusion criteria were altered mental status, non English speaking, inability to answer questions for other reasons, under police custody, or admission for <24 hours. Results from admission blood alcohol concentration (BAC) and urine drug screen (UDS) were also collected and compared to self-reported use to determine its reliability. Alcohol use was queried in 128 patients, 101 of whom had a BAC drawn. Of those 101, 34 (33.7%) had a BAC ≥ 0 mg%. Alcohol Use Disorder Identification Test creening revealed 13 (12.9%) patients who were self-reported non drinkers, none of which had a BAC > 0 mg%. Drug use was queried in 133 patients, 93 of whom had a UDS. A positive was found in 26 (28.0%) of the patients, only 12 (46.2%) of whom reported drug use in the past year. Although substance use in trauma patients is prevalent, self-report screening techniques for drugs may be inadequate at determining those patients whom could benefit from brief interventions while in the hospital. Further investigation is needed to determine the discrepancy between alcohol and drug use screening in trauma patients and more acceptable means of drug use discussion.     

Mindfulness impairments in individuals seeking treatment for substance use disorders

Background: Mindfulness training may be an effective treatment for substance use disorders (SUDs). Little research has been done, however, on baseline levels of mindfulness in the substance using population. Objectives/Methods: We investigated mindfulness levels using the Mindful Attention Awareness Scale (MAAS) in individuals presenting for substance use treatment, and compared polydrug vs. monodrug users, as well as investigated for differences between groups based on substance used, predicting that group means would fall below the mean obtained from a large national adult sample, that the different drug groups would have comparable scores, and that the polydrug users would have a significantly lower score than do monodrug users. Results: We found that the means of most drug groups were below the national mean, and that the polydrug users had a lower score on the MAAS than did monodrug users (4 vs. 3.6, p = 0.04). We were also surprised to find that opiate users had a significantly higher score (4.31) than did users of other substances (p = 0.02). Conclusion/Significance: These results suggest that mindfulness deficits may be common in the substance using population, that there may be sub-groups in which these deficits are more pronounced, and that they may be a suitable focus of SUD treatment. These findings lend support to the ongoing development of mindfulness-based treatments for SUDs, and suggest that particular sub-groups may benefit more than others. Future research can aim at clarifying these deficits, and at elucidating their clinical relevance.     

Trends and age-related characteristics of substance use in the hospitalized homeless population

We aimed to examine trends and characteristics of substance use (opioid, cocaine, marijuana, and heroin) among hospitalized homeless patients in comparison with other hospitalized patients in 3 states.This was a cross-sectional study, based on the 2007 to 2015 State Inpatient Data of Arizona, Florida, and Washington (n = 32,162,939). Use of opioid, cocaine, marijuana, heroin, respectively, was identified by the International Classification of Diseases, 9th Revision. Multi-level multivariable regressions were performed to estimate relative risk (RR) and 95% confidence intervals (CI). Dependent variables were the use of substances (opioid, cocaine, marijuana, and heroin), respectively. The main independent variable was homeless status. The subgroup analysis by age group was also conducted.Homeless patients were associated with more use of opioid (RR [CI]), 1.23 [1.20–1.26], cocaine 2.55 [2.50–2.60], marijuana 1.43 [1.40–1.46], and heroin 1.57 [1.29–1.91] compared to other hospitalized patients. All hospitalized patients including those who were homeless increased substance use except the use of cocaine (RR [CI]), 0.57 [0.55–0.58] for other patients and 0.60 [0.50–0.74] for homeless patients. In all age subgroups, homeless patients 60 years old or older were more likely to be hospitalized with all 4 types of substance use, especially, cocaine (RR [CI]), 6.33 [5.81–6.90] and heroin 5.86 [2.08–16.52] in comparison with other hospitalized patients.Homeless status is associated with high risks of substance use among hospitalized patients. Homeless elderly are particularly vulnerable to use of hard drugs including cocaine and heroin during the opioid epidemics.     

Pilot feasibility study of Heart2HAART: a smartphone application to assist with adherence among substance users living with HIV

Background: Smartphones with programmable apps may offer innovative interactive interventions for improving adherence among people living with HIV with substance use problems. Methods: This pilot randomized controlled trial sought to primarily determine the usability and feasibility of using a smartphone-based intervention called Heart2HAART as an adjunct to directly observed treatment with adherence counseling compared to directly observed treatment with adherence counseling alone among those with HIV and a history of substance use over a three-month time frame. Participants in the Heart2HAART condition completed an additional survey on usability and acceptability. Adherence was measured using unannounced pill counts assessed via a phone call. Results: Twenty-eight participants were randomized to receive Heart2HAART (n?=?19) or control (n?=?9). All were receiving either weekly (n?=?9) or daily (n?=?19) observed treatment. Among those randomized to Heart2HAART, 63.2% reported no difficulty using the Heart2HAART smartphone application and 94.7% responded that the medication reminders did not interfere negatively with their activities. On average participants used Heart2HAART application 56.8 times over the three-month trial. In analyses adjusting for age, there was no difference in adherence to HAART medication between the Heart2HAART and control group as evaluated by the random pill count assessment (P?=?.29). Conclusions: Heart2HAART was feasible to use during a three-month pilot trial. Future studies may evaluate a more tailored approach, with more robust contingency management.     

Not all non-drinkers with HIV are equal: demographic and clinical comparisons among current non-drinkers with and without a history of prior alcohol use disorders*

Studies of persons living with HIV (PLWH) have compared current non-drinkers to at-risk drinkers without differentiating whether current non-drinkers had a prior alcohol use disorder (AUD). The purpose of this study was to compare current non-drinkers with and without a prior AUD on demographic and clinical characteristics to understand the impact of combining them. We included data from six sites across the US from 1/2013 to 3/2015. Patients completed tablet-based clinical assessments at routine clinic appointments using the most recent assessment. Current non-drinkers were identified by AUDIT-C scores of 0. We identified a prior probable AUD by a prior AUD diagnosis in the electronic medical record (EMR) or a report of attendance at alcohol treatment in the clinical assessment. We used multivariate logistic regression to examine factors associated with prior AUD. Among 2235 PLWH who were current non-drinkers, 36% had a prior AUD with more patients with an AUD identified by the clinical assessment than the EMR. Higher proportions with a prior AUD were male, depressed, and reported current drug use compared to non-drinkers without a prior AUD. Former cocaine/crack (70% vs. 25%), methamphetamine/crystal (49% vs. 16%), and opioid/heroin use (35% vs. 7%) were more commonly reported by those with a prior AUD. In adjusted analyses, male sex, past methamphetamine/crystal use, past marijuana use, past opioid/heroin use, past and current cocaine/crack use, and cigarette use were associated with a prior AUD. In conclusion, this study found that among non-drinking PLWH in routine clinical care, 36% had a prior AUD. We found key differences between those with and without prior AUD in demographic and clinical characteristics, including drug use and depression. These results suggest that non-drinkers are heterogeneous and need further differentiation in studies and that prior alcohol misuse (including alcohol treatment) should be included in behavioural health assessments as part of clinical care.     

Longitudinal associations between outpatient medical care use and substance use among rural stimulant users

Background: Negative views toward substance use treatment among some rural substance users and limited treatment resources in rural areas likely affect substance use utilization. It is therefore important to determine whether accessing healthcare options other than substance use treatment, specifically outpatient medical care (OMC), is associated with reductions in substance use. Objectives: We examined whether use of OMC was associated with reductions in substance use among rural substance users over a three-year period. We also explored whether substance user characteristics, including substance-use severity and related-problems, moderated this potential relationship. Methods: Data were collected from an observational study of 710 (61% male) stimulant users using respondent-driven sampling. Participants were recruited from rural counties of Arkansas, Kentucky, and Ohio. Results: We found a significant main effect of having at least one OMC visit (relative to none) on fewer days of alcohol, crack cocaine, and methamphetamine use over time. Fewer days of alcohol, crack cocaine, and methamphetamine use were reported in participants with at least one OMC visit (relative to those with none) among those reporting higher Addiction Severity Index employment and psychiatric severity scores, and low education, respectively. Conclusion: Our findings extend the results from prior studies with urban substance users to show that contact with an outpatient medical care clinic is associated with reductions in substance use over time among rural substance users with especially poorer functioning. These findings highlight the potential importance of OMCs in addressing unhealthy substance use in rural communities.     

Does stress mediate the development of substance use disorders among youth transitioning to young adulthood?

Background: Stress is a well-documented factor in the development of addiction. However, no longitudinal studies to date have assessed the role of stress in mediating the development of substance use disorders (SUD). Our previous results have demonstrated that a measure called Transmissible Liability Index (TLI) assessed during pre-adolescent years serves as a significant predictor of risk for substance use disorder among young adults. However, it remains unclear whether life stress mediates the relationship between TLI and SUD, or whether stress predicts SUD. Methods: We conducted a longitudinal study involving 191 male subjects to assess whether life stress mediates the relationship between TLI as assessed at age 10–12 and subsequent development of SUD at age 22, after controlling for other relevant factors. Results: Logistic regression demonstrated that the development of SUD at age 22 was associated with stress at age 19. A path analysis demonstrated that stress at age 19 significantly predicted SUD at age 22. However, stress did not mediate the relationship between the TLI assessed at age 10–12 and SUD in young adulthood. Conclusions and scientific significance: These findings confirm that stress plays a role in the development of SUD, but also shows that stress does not mediate the development of SUD. Further studies are warranted to clarify the role of stress in the etiology of SUD.     

Adult liver transplant survey: policies towards eligibility criteria in Canada and the United States 2007

Goals: To assess the current practice patterns of liver transplant centres in Canada and the USA regarding transplant eligibility. Background: Liver transplantation is an evolving field and today remains the only life‐sustaining treatment for end‐stage liver disease. Issues of allocation and transplant eligibility are important factors in the ethical practice of medicine. Study: Questionnaires were mailed to liver transplant programme directors in Canada and the USA inquiring about current practices regarding recipient eligibility. Results: This study demonstrates that there is consensus in the use of other eligibility criteria, including non‐compliance, social status, abstinence from alcohol and methadone and cocaine use. Interestingly, literature is lacking to support the use of these parameters as eligibility criteria with the exception of alcohol. There is a lack in consensus regarding marijuana use, human immunodeficiency virus status, ability to accept blood transfusions and prisoner status. The literature suggests that liver transplantation in select patients who refuse blood transfusions results in good outcomes. Conclusions: Important decisions regarding transplant eligibility still have to be made empirically in the absence of scientific literature about various social issues. While consensus among transplant programmes is useful, it is important that we continue to use the evidence in the literature to revise these eligibility criteria, keeping in mind ethical principles applied to the access and allocation of a scarce resource.     

Does “High = High Risk”? An Event-Based Analysis of the Relationship Between Substance Use and Unprotected Anal Sex Among Gay and Bisexual Men

This study examined the relationship between substance use and condom use using a study design that remedied some of the methodological problems noted in prior research. A community sample of 147 gay men completed daily diaries in which they reported their substance use and sexual behaviors for 8 weeks. This method helped ensure the contiguity of substance use and sexual behaviors, established the temporal relationships between them, and controlled for confounding individual differences that could cause both substance use and sexual risktaking. A within-subjects analysis showed no significant relationships between condom use and alcohol and/or drug use consumed within 4 hr of having anal sex. Condoms were more likely to be used with casual than with steady partners and were more likely to be used by HIV– men. These results suggest that the relationships found in prior studies could be due to measurement differences or confounding personality or situational factors.