Does it matter how we refer to individuals with substance-related conditions? A randomized study of two commonly used terms

ObjectiveStigma is a frequently cited barrier to help-seeking for many with substance-related conditions. Common ways of describing individuals with such problems may perpetuate or diminish stigmatizing attitudes yet little research exists to inform this debate. We sought to determine whether referring to an individual as “a substance abuser” vs. “having a substance use disorder” evokes different judgments about behavioral self-regulation, social threat, and treatment vs. punishment.MethodA randomized, between-subjects, cross-sectional design was utilized. Participants were asked to read a vignette containing one of the two terms and to rate their agreement with a number of related statements. Clinicians (N = 516) attending two mental health conferences (63% female, 81% white, M age 51; 65% doctoral-level) completed the study (71% response rate). A Likert-scaled questionnaire with three subscales [“perpetrator-punishment” (α = .80); “social threat” (α = .86); “victim-treatment” (α = .64)] assessed the perceived causes of the problem, whether the character was a social threat, able to regulate substance use, and should receive therapeutic vs. punitive action.ResultsNo differences were detected between groups on the social threat or victim-treatment subscales. However, a difference was detected on the perpetrator-punishment scale. Compared to those in the “substance use disorder” condition, those in the “substance abuser” condition agreed more with the notion that the character was personally culpable and that punitive measures should be taken.ConclusionsEven among highly trained mental health professionals, exposure to these two commonly used terms evokes systematically different judgments. The commonly used “substance abuser” term may perpetuate stigmatizing attitudes.     

Identifying “Hitting Bottom” Among Individuals with Alcohol Problems: Development and Evaluation of the Noteworthy Aspects of Drinking Important to Recovery (NADIR)

Background: Alcohol use disorder (AUD) is a costly public health concern; yet, many individuals with AUD never receive formal treatment. Prior studies have identified that “hitting bottom” may be an important factor in seeking treatment for AUD) and the notion that “hitting bottom” is necessary for recovery is commonly portrayed in the popular media. Yet, “hitting bottom” has never been formally operationalized. Objectives: The present article aimed to operationalize “hitting bottom.” Methods: A multiphase process was used to develop a measure of hitting bottom among individuals experiencing alcohol problems: The Noteworthy Aspects of Drinking Important to Recovery (NADIR). Psychometric evaluation of the measure was conducted using online data collected from individuals who identified as moderate to heavy drinkers (N = 597). Results: The NADIR included five lower-order dimensions and one higher-order dimension (“hitting bottom”), had strong concurrent validity with measures of alcohol use severity and alcohol-related problems, and was found to have excellent internal consistency reliability (α > 0.90). An overall summary score on the NADIR of 50+ (factor scores>0) differentiated individuals who had previously sought treatment for AUD and reported more excessive alcohol use compared to those with no treatment history and lower levels of alcohol use. Thus, the NADIR with a cutoff of 50 may be a good starting point for future researchers to test as a method to identify individuals who have hit bottom. Conclusions/Importance: The NADIR provides a viable operational definition of hitting bottom. Future research should evaluate the predictive validity of the NADIR.     

The Rapid Recovery Progression Measure: A Brief Assessment of Biopsychosocial Functioning During Substance Use Disorder Recovery

Background: There is debate in the literature around how to measure outcomes in treatment and recovery from substance use disorder (SUD). Various constructs have been suggested as appropriate including “recovery capital” and “treatment progression.” To contribute to this debate, the construct of “recovery progression” has been suggested by the authors, and a psychometric assessment, the Recovery Progression Measure (RPM). Although published psychometrics data have demonstrated the RPM to be reliable, at 36-item long, it may be too lengthy to complete in clinic environments. Therefore, a shorter version has been developed, the Rapid RPM. Objectives: To examine reliability, validity, sensitivity and specificity of the Rapid RPM via data from 9208 service users. Methods: Data were collected from service users accessing the Breaking Free Online (BFO) treatment and recovery program, which has within its baseline assessment the six-item, 11-point Likert scale Rapid RPM. Psychometric properties were examined. Results: Internal reliability of the Rapid RPM was excellent, α =.92. The Rapid RPM also had good concurrent and predictive validity, with baseline scores, and changes in scores to follow-up, being significantly associated with scores on standardized measures of common mental health sequela, severity of substance dependence and quality of life, and changes in self-reported substance use. The Rapid RPM was also able to differentiate between participants scoring above thresholds on these measures for clinically relevant substance dependence and mental health difficulties. Conclusions: This study provides data to support reliability, validity, sensitivity and specificity of the Rapid RPM, indicating potential as a clinical tool.     

Initial Development and Psychometric Properties of a New Measure of Substance Use Disorder “Recovery Progression”: The Recovery Progression Measure (RPM)

There is a growing literature around substance use disorder treatment outcomes measures. Various constructs have been suggested as being appropriate for measuring recovery outcomes, including “recovery capital” and “treatment progression.” However, these previously proposed constructs do not measure changes in psychosocial functioning during the recovery process. Therefore, a new psychometric assessment, the “Recovery Progression Measure” (RPM), has been developed to measure this recovery oriented psychosocial change. Aims: The aims of this study were to evaluate the reliability and factor structure of the RPM via data collected from 2218 service users being treated for their substance dependence. Method: Data were collected from service users accessing the Breaking Free Online (BFO) substance use disorder treatment and recovery program, which has within its baseline assessment a 36-item psychometric measure previously developed by the authors to assess the six areas of functioning described in the RPM. Reliability analyses and exploratory factor analyses (EFA) were conducted to examine the underlying factor structure of the RPM measure. Results: Internal reliability of the RPM measure was found to be excellent (α > .70) with the overall assessment to have reliability α = .89, with item-total correlations revealing moderate–excellent reliability of individual items. EFA revealed the RPM to contain an underlying factor structure of eight components. Discussion: This study provides initial data to support the reliability of the RPM as a recovery measure. Further work is now underway to extend these findings, including convergent and predictive validity analyses.     

Developmental pathways of adolescent cannabis use: Risk factors,outcomes and sex-specific differences

Background: Characterizing patterns of adolescent cannabis use (CU), as well as risk factors and outcomes uniquely associated with these pathways is essential for informing treatment and prevention efforts. Yet, few studies have examined these issues among youth at-risk of engaging in problematic cannabis use. Further, research accounting for use of other substances or sex differences in patterns of CU remains exceedingly sparse. Methods: Trajectory-based modeling was used to identify underlying CU pathways among a predominantly Hispanic (90%) sample of at-risk youth (n?=?401; 46% female) across adolescence (ages～14–18), controlling for baseline substance use and participant demographics. Adolescent psychopathology (i.e., conduct disorder, attention deficit hyperactivity disorder, anxiety, and depression) was examined as a predictor and outcome of CU. Results: Three trajectories of adolescent CU were identified, with most youth (74%) engaging in relatively “low” levels of use, followed by ～12% exhibiting an early-initiating “chronic” course, and 14% “escalating” in use. Although boys and girls both experienced increased levels of CU across adolescence, boys were more likely to exhibit escalating and chronic patterns of use. Findings revealed unique associations between adolescent CU pathways and facets of psychopathology; most notably, the relatively robust and bidirectional association between CU trajectories and conduct problem symptoms. Conclusions: Specific facets of psychopathology may confer unique associations with CU across development, including the initiation and exacerbation of CU during adolescence.     

Construct Validity for Alcohol Dependence as Indicated by the SUDDS-IV

Objective.?This study considers the diagnostic construct validity of the DSM-IV (Diagnostic and Statistical Manual-IV) for “alcohol dependence”. Previous reports have indicated that “dependence” constitutes a more distinct and pronounced syndrome than “alcohol abuse”. Method.?Data were collected in 2000–2001 on 1340 male and female inmates evaluated for “substance use disorders” using the SUDDS-IV, a detailed structured diagnostic interview, to collect data on all of the DSM-IV diagnostic criteria for “abuse” and “dependence”. Results.?Dependent individuals tended to produce distinct and extensive symptom profiles that distinguished them from individuals without a diagnosis or those meeting abuse criteria. Conclusions.?Alcohol dependence as defined by the DSM-IV appears to be quite distinct from abuse and can be identified unequivocally for the majority of dependent cases.     

The Role of Individual and Contextual Factors in Differentiating Substance Use Profiles among Adolescents

Background: Adolescent substance use is a significant public health concern due to its prevalence and associated negative consequences. Although many adolescents use substances, there is substantial heterogeneity in their use patterns. Identifying risk and protective factors that differentiate adolescents with different substance use profiles is important for preventing negative consequences for those at risk. Objective: This study identified distinct latent profiles of substance use by considering adolescents' involvement in multiple common and illicit substances as well as related problems and examined the extent to which individual and contextual factors in the family, peer, school, and neighborhood environments were related to adolescents' membership of substance use profiles. Method: Data came from 9,155 high school students (51% female; 74% European American) who completed electronic surveys in the 2009 Dane County Youth Assessment (DCYA). Latent class analysis (LCA) was conducted to identify profiles of adolescent substance involvement and related problems. Multinomial logistic regression was conducted to examine associations between individual and contextual factors and latent class membership. Results: LCA identified four distinct profiles of adolescent substance use characterized by both licit and illicit substance use and related problems: Abstainers (56.3%), Alcohol-only users (25.6%), Alcohol-cigarette-marijuana users (13.8%), and Problem polysubstance users (4.3%). Controlling for demographics, individual and contextual factors were associated with adolescents' likelihoods of membership in substance use profiles; notably, the associations varied to some extent across substance use profiles. Conclusions: Substance use is heterogeneous among adolescents. Effects of risk and protective factors on substance use vary depending on adolescents' substance use patterns.     

Exploring the Factor Structure of a Recovery Assessment Measure among Substance-Abusing Youth

Abstract

To date, the measurement of recovery in the field of substance abuse is limited. Youth recovery from substance abuse is an important area to consider, given the complexities of such issues. The Recovery Assessment Scale (RAS) has been validated with mental health patient populations; however, its measurement characteristics have not been examined for individuals in substance abuse treatment. The current study explored the factor structure of the RAS with a sample of 80 substance-abusing youth who participated in a pilot aftercare study (M_age 20.5, SD = 3.5; 71.3% male). Reliability analysis showed an internal consistency of α = .90 for the entire RAS measure among the youth sample. Results of exploratory factor analysis identified the following four factors: personal determination, skills for recovery, self-control in recovery, and social support/moving beyond recovery among the substance-abusing youth sample. The RAS also demonstrated sound convergent and divergent validity in comparison to other validated measures of functioning, sobriety, and well-being. Collectively, results support that the RAS has adequate psychometric properties for measuring recovery among substance-abusing youth.     

Understanding How People with Mental Health Difficulties Experience Substance Use

Background: Quantitative studies dominate research exploring reasons for substance use and experiences of substance use by people with mental health difficulties. This limits the depth of understanding which can be gained about these experiences. Objectives: In the present article, we synthesized current qualitative research in this area to provide enhanced theoretical knowledge of these experiences. Methods: Following a systematic literature search, we identified 12 studies which explored how people with mental health difficulties experienced using substances, and which met additional inclusion criterion. We used Noblit and Hare's metaethnographic approach to qualitatively synthesize these studies. Results: Synthesis led to the development of two themes; “substance use mediates acceptance and social inclusion” and “substance use provides perceived opportunities for control and power.” Conclusions/Importance: The findings suggest that in the studies reviewed people's motivation for substance use was embedded in social and psychological contexts. It indicated that substance use could provide perceived benefits such as mediating the impact of mental health stigma, enabling the development of alternative identities, increasing their sense of power and providing opportunities for social inclusion. Mental health and substance use workers should therefore aim to develop alternative opportunities for people with co-occurring disorders to gain such benefits, and seek to challenge mental health stigma.     

Development and evaluation of pictograms on medication labels for patients with limited literacy skills in a culturally diverse multiethnic population

BackgroundMuch of the migrant workforce in Qatar is of low literacy level and does not understand Arabic or English, presenting a significant challenge to health care professionals. Medicine labels are typically in Arabic and English and are therefore poorly understood by these migrant workers.ObjectiveTo develop pictograms illustrating selected medicine label instructions and to evaluate comprehension of the pictograms or conventional text supported with verbal instructions in foreign workers with low literacy skills.MethodsA range of common labeling instructions were identified and pictograms depicting these were developed using visual concepts and ideas from the literature. The process involved a consultative approach with input from the researchers, a local graphic artist, and members of the target population. The final set was evaluated for comprehension in participants who were randomized to one of three study groups: text plus verbal instructions, pictogram-only label, and pictogram with verbal instructions. One-way ANOVA and Chi-square tests were used to assess differences between group variables. Statistical significance was set at P ≤ 0.05.ResultsOf 23 label instructions screened, 11 were selected for the study. A total of 123 participants took part in this study. Pictogram plus verbal instructions group achieved better results in interpreting the majority of the label instructions (P ≤ 0.05). The best interpreted pictograms with verbal instructions included: “Take two tablets three times a day,” “Take one tablet in the morning and one tablet at night,” and “Instill one drop in the eye.” The worst interpreted pictograms with verbal instructions were: “Do not take with dairy products” and “Do not use by mouth.” Some pictograms were difficult to interpret even when accompanied with verbal instructions, suggesting the need to thoroughly pilot them among users prior to implementation.ConclusionMedication labels consisting of simple pictorials supported by verbal instructions were better comprehended by individuals with low literacy skills than labels with written plus verbal instructions in a language that the individual did not understand. Further, pictogram-only labels were the least comprehended types of medicine labels among the participants.     

Pain Interference in Individuals in Driver Intervention Programs for Driving Under the Influence Offenders

Pain-related problems among individuals in court-mandated Driver Intervention Programs (DIPs) for “driving under the influence” (DUI) offenders have not been well studied. This project examines 3,189 individuals from a DIP in Dayton, Ohio. Over 11% of participants reported significant pain-related interference in the past 4 weeks. Pain was significantly more likely in those with depression, more childhood conduct problems, and recent use of multiple illicit drugs. Many individuals seen in court-mandated DIP programs for DUI offenders also report difficulties with pain. DIP programming should address pain in relation to substance use and mental health issues.     

Deliberate Self-Harm,Substance Use,and Negative Affect in Nonclinical Samples: A Systematic Review

ABSTRACT

Background and Method: A systematic literature review was conducted to examine associations between self-harm, substance use, and negative affect in nonclinical samples. Results: Forty-two articles describing 36 studies were identified that met the inclusion criteria. Findings indicated that individuals who engage in substance use are significantly more likely to engage in self-harm. It was also found that negative affective states such as depression and anxiety are consistently associated with self-harm. Conclusions: These findings provide some guidance in identifying those who are at increased risk of self-harm. Reducing these risk factors could be an important strategy in preventing self-harm behavior in the general population.     

Assessing the association between the strength of state policies on school drug prevention and substance use disorders

Background: Adolescent substance use has been linked to numerous adverse health, social, and educational outcomes. While there have been intensive resources placed in school-based prevention programs, the association of these policies on prevention outcomes is still unclear. State variation in policies provides an opportunity to assess the influence of school-based prevention programs. Objectives: To examine the association between the strength of state high school-based prevention programing and the prevalence of substance use disorders among adolescents ages 14–17 in the United States. Methods: National Survey on Drug Use and Health (NSDUH) data with state-level identifiers were merged with National Association of State Boards of Education (NASBE) information on school-based prevention policy strength, categorized into “required,” “recommended,” and “no policy.” Unadjusted comparisons and multilevel random intercept linear regression models were estimated to assess the change in rates of substance abuse or dependence from pre- to post- policy implementation, accounting for the nesting of individuals within states. Results: Rates of alcohol and tobacco abuse/dependence were significantly lower in states that required an alcohol prevention curriculum. After covariate adjustment, rates of alcohol abuse/dependence remained significantly lower in those states. Conclusions: Reinforcing alcohol prevention messaging in school appears to have a modest association with decreased rates of adolescent alcohol use disorders, possibly in part due to a different approach to the curriculum. For other substances, policy requirements appear to be less effective in reducing the prevalence of adolescent substance use disorders, suggesting that more targeted messaging with higher-risk students may be required.     

Emerging consensus on measuring addiction recovery: Findings from a multi-stakeholder consultation exercise

Aim: To identify indicators that diverse stakeholders believe are important when measuring recovery from addiction. Methods: Our previous work with service users had generated 28 indicators of recovery. Using Delphi group methodology (three rounds), we assessed the extent to which stakeholders working in the addictions field agreed that the 28 indicators were important on a scale of 1–10. Participants included 146 individuals with diverse job roles in 124 organisations across the British Isles. Findings: Round 1 scores were high. There was evidence of greater scoring consensus in Round 2, but this trend was less certain in Round 3. Participants scored 27/28 indicators ≥7/10 in Round 3, so confirming their importance. The only Round 3 indicator with a mean score <7 was “experiencing cravings”. There were statistical differences between the Round 3 indicator scores of some sub-groups of participants, but absolute differences were small (never more than 1 point for any indicator). Conclusions: We have identified 27 recovery indicators that stakeholders working within the addiction field in the British Isles consistently ranked as important. Replicating our methods in other countries, and with additional stakeholder groups, will provide greater clarity on the term “recovery”, its relevance and value, and how it can best be measured.     

Characteristics of transgender individuals entering substance abuse treatment

Little is known about the needs or characteristics of transgender individuals in substance abuse treatment settings. Transgender (n = 199) and non-transgender (cisgender, n = 13,440) individuals were compared on psychosocial factors related to treatment, health risk behaviors, medical and mental health status and utilization, and substance use behaviors within a database that documented individuals entering substance abuse treatment in San Francisco, CA from 2007 to 2009 using logistic and linear regression analyses (run separately by identified gender). Transgender men (assigned birth sex of female) differed from cisgender men across many psychosocial factors, including having more recent employment, less legal system involvement, greater incidence of living with a substance abuser, and greater family conflict, while transgender women (assigned birth sex of male) were less likely to have minor children than cisgender women. Transgender women reported greater needle use, and HIV testing rates were greater among transgender women. Transgender men and women reported higher rates of physical health problems, mental health diagnoses, and psychiatric medications, but there were no differences in service utilization. There were no differences in substance use behaviors except that transgender women were more likely to endorse primary methamphetamine use. Transgender individuals evidence unique strengths and challenges that could inform targeted services in substance abuse treatment.