Going to the doctor with enhancement in mind – An ethnographic study of university students’ use of prescription stimulants and their moral ambivalence

Aims: The aim of this qualitative research is to show how the alcohol socialization process – i.e. the ways children and young people get acquainted with alcohol – can generate very diverse experiences and meanings in different cultural contexts.

Method: A total of 16 focus groups were conducted in Italy and Finland, divided by age (4 groups), gender and socio-cultural level. A total of 190 participants took part in the study.

Findings: The findings support the hypothesis that the alcohol socialization process takes place in very different ways and assumes diverse meaning in the two countries involved in the study. In Italy the relationship with alcohol takes place as part of a gradual process and participants’ first memories of drinking alcohol are connected to positive values. In Finland, on the other hand, often the first experiences of drinking overlap with the first experiences of intoxication and alcohol images reflect an ambiguous relation with this substance, closely related to its intoxicating effects.

Conclusions: Results show that the alcohol socialization process can take very different forms and meanings according to a specific drinking cultures. Thus, further comparative research should take into more consideration the implication of these substantial differences.     

Are educational aspirations associated with the risk of alcohol use and alcohol use-related problems among adolescents?

OBJECTIVE: Using prospective data, we hypothesized that public middle school students with high educational aspirations would report less alcohol use, and alcohol use-related problems in the subsequent year. METHODS: The participants for these analyses included students, ages 11 to 14 years old, participating in a longitudinal study in an urban sample of public schools (n = 1229). As part of the prospective annual assessments of the students, in 1992 (to) and 1993 (t1), data on educational aspirations and on alcohol use, and alcohol use-related problems were gathered. Latent variable modeling was used to assess the relationship between educational aspirations at baseline (to) and subsequent year drinking behavior (t1) in two separate models, one to examine the relationship of educational aspirations with self-reported alcohol use (model 1), and another to examine the association with alcohol use-related problems (model 2). Potential confounding by age, sex, race-ethnicity, alcohol use by peers, self-reported school performance, and neighborhood environment was held constant in each model. In addition, each model took into account the prior year report of alcohol use and alcohol use-related problems, respectively. RESULTS: The evidence indicated that students with high aspirations were no more nor less likely to report subsequent alcohol use [beta = 0.15, 95% confidence interval (CI) = -0.19, 0.49; p = 0.38] nor alcohol use-related problems (beta = -0.009, CI = -0.07, 0.06; p = 0.80). Other characteristics were associated with alcohol use at follow-up and included race-ethnicity (being non-Black), neighborhood environment, and having friends who drink alcohol. Characteristics associated with alcohol use-related problems at the time of the follow-up interview also included race-ethnicity, peer drinking, neighborhood environment, as well as older age. CONCLUSIONS: Findings from the current study do not support the hypothesis that educational aspirations have significant influences on alcohol consumption or drinking problems in this study population of urban, predominantly Black students. As such, this work helps to advance our understanding of suspected relationships between educational aspirations, as well as factors associated with resilience to alcohol use and the occurrence of alcohol use-related problems.     

Iboga interactions with psychomotor stimulants: panacea in the paradox?

Currently, no effective therapy has been approved for the treatment of addiction to stimulant drugs (e.g., cocaine, amphetamine and its methylated derivatives). However, preclinical studies indicate that the naturally-occurring indole alkaloid, ibogaine, and a synthetic iboga alkaloid congener, 18-methoxycoronaridine (18-MC), attenuate stimulant self-administration in laboratory animals. The in vivo pharmacological interactions between iboga agents and stimulant drugs are unclear. Ibogaine enhances the increase in accumbal dopamine produced by the acute administration of stimulant drugs. Consistent with these data, both ibogaine and 18-MC potentiate the expression of stimulant-induced motor behaviors in acute and chronic stimulant-treated animals. To account for the paradox between their effects on self-administration and motor behavior, we proposed that iboga agents interfere with stimulant self-administration by increasing sensitivity to their psychomotor-activating effects. However, this interpretation is contradicted by very recent observations that 18-MC is without effect on the dopamine response to acute cocaine and that both ibogaine and 18-MC block the expression of sensitized levels of dopamine in the nucleus accumbens produced by chronic cocaine administration. Thus, a positive relationship exists between the effects of iboga pretreatment on stimulant-induced dopamine sensitization and stimulant self-administration behavior. These data indicate that iboga agents might attenuate stimulant self-administration by reversing the neuroadaptations theoretically implicated in drug craving and compulsive drug-seeking behavior.     

Do stimulants improve functioning in adults with ADHD?: A review of the literature

ADHD is prevalent in adulthood and stimulant pharmacotherapy is the primary treatment for uncomplicated presentations. ADHD is associated with significant functional impairment in major life roles. Measurement of the efficacy of stimulant treatment for adult ADHD therefore should include assessment of improvement in role function. A literature search was conducted to identify studies that measured change in function with stimulant treatment in adult ADHD using measures other than global clinical impression or global assessment of function ratings. Five studies were identified that met our search criteria. Evidence of functional improvement with stimulant treatment was found with the following validated self-report measures of functional wellbeing employed across these studies: the Medical Outcome Study 36-item Short Form Health Survey; ADHD Impact Module for Adults; Quality of Life Enjoyment and Satisfaction scale—Short Form; Sheehan Disability Scale, and Social Adjustment Scale—Self-Report. We conclude that investigations using self-report scales provide evidence that stimulant treatment translates into measurable improvement in daily function for adults with ADHD. Further investigation could better characterize the mediators and moderators of individual improvement, an important step towards the personalization of treatment for ADHD in adulthood.     

The Trouble with Training: substance misuse education in British medical schools revisited. What are the issues?

My 1987 survey of substance misuse education in British medical schools highlighted inadequacies in the quality of undergraduatesubstance misuse training. The continuing difficulty in engaging generalists in the care of substance misusers suggested it was time to revisit the issue. Deans, Heads of Departmentsof Psychiatry and 13 other specialities in 23 medical schools were surveyed. The response rate from Deans and Heads of Psychiatry was 70%. Psychiatry provided a mean of 6.7 (range 2-14) hours formal training (lectures/seminars),excluding one model department which provided 30 hours and co-ordinated an additional 30 hours of undergraduate substance misuse education. In 10 (45.5%) schools training is very limited, while 10 (45.5%) schools provide average (three) or above average (seven) training hours. Average or above average undergraduate training was found in schools with an academic department of addiction behaviour. These centres were associated with the most comprehensiveservices and the most postgraduate substance misuse training opportunities. These findings may partially explain why most doctors are ill-equipped to deal with substance problems. Since 1987, psychiatry has doubled input, but this is offset by diminished input from other departments. The establishment of academic departments of addiction studies in medical schools would influence decision making within university and services, promote scientific credibility and benefit communities.     

The Trouble with Training: substance misuse education in British medical schools revisited. What are the issues?

My 1987 survey of substance misuse education in British medical schools highlighted inadequacies in the quality of undergraduatesubstance misuse training. The continuing difficulty in engaging generalists in the care of substance misusers suggested it was time to revisit the issue. Deans, Heads of Departmentsof Psychiatry and 13 other specialities in 23 medical schools were surveyed. The response rate from Deans and Heads of Psychiatry was 70%. Psychiatry provided a mean of 6.7 (range 2-14) hours formal training (lectures/seminars),excluding one model department which provided 30 hours and co-ordinated an additional 30 hours of undergraduate substance misuse education. In 10 (45.5%) schools training is very limited, while 10 (45.5%) schools provide average (three) or above average (seven) training hours. Average or above average undergraduate training was found in schools with an academic department of addiction behaviour. These centres were associated with the most comprehensiveservices and the most postgraduate substance misuse training opportunities. These findings may partially explain why most doctors are ill-equipped to deal with substance problems. Since 1987, psychiatry has doubled input, but this is offset by diminished input from other departments. The establishment of academic departments of addiction studies in medical schools would influence decision making within university and services, promote scientific credibility and benefit communities.     

Alcohol mixed with energy drinks: Are there associated negative consequences beyond hazardous drinking in college students?

Objective

The consumption of alcohol mixed with energy drinks (AmED) is prevalent among college students as is hazardous drinking, a drinking pattern that places one at risk for alcohol-related harm. The present study, therefore, examined associations between AmED use, hazardous drinking, and alcohol-related consequences in college students.

Methods

Based on a probability sample conducted in 2010, participants were 606 undergraduate students aged 18–25. AmED consumption included lifetime and past year use. Hazardous drinking and alcohol-related consequences were measured during the past year. Point prevalence was used to estimate rates of AmED use, and chi-square, ANOVA, and logistic regression were used to examine associations between AmED use, hazardous drinking, and alcohol-related consequences.

Results

Lifetime and past year AmED use prevalence rates were 75.2% and 64.7%, respectively. Hazardous drinkers who engaged in AmED use were significantly more likely than past year hazardous drinkers who did not engage in AmED use to have had unprotected sex (OR = 2.35, CI 1.27–4.32).

Conclusions

AmED use appears to be highly prevalent among college students, and AmED use may confer additional risk for unprotected sex beyond hazardous drinking. Unprotected sex has implications for public health, and students who drink hazardously and consume AmED may be at greater risk.     

Are stimulants effective in the treatment of executive function deficits? Results from a randomized double blind study of OROS-methylphenidate in adults with ADHD

The objective of this study was to evaluate the association between executive function deficits (EFDs) and response to methylphenidate treatment in ADHD in adults. We conducted a 6-week, parallel design, randomized, placebo controlled study in adults with DSM-IV ADHD. Our psychometric index of executive function used standardized neuropsychological testing. We assessed behaviors reflective of EFDs using the Behavior Rating Inventory of Executive Function — Adult Version (BRIEF-A). Subjects with available measures of executive functioning (OROS-MPH N = 40; Placebo N = 47) were included for analysis. There was no difference in the percent of subjects completing the 6-week acute efficacy Phase I of the trial (100% (N = 40) vs. 98% (N = 46), p = 0.4). The mean daily dose at Phase I endpoint was 84.6 ± 31.6 mg (1.04 ± 0.29 mg/kg) OROS-MPH and 100.5 ± 21.9 mg (1.20 ± 0.11 mg/kg) placebo (p = 0.0007). Based on the neuropsychological testing at the baseline assessment, 40% of the ADHD subjects (N = 35/87) were considered to have EFDs but 93% (N = 81) of subjects had ≥ 2 BRIEF-A clinical scale T-scores > 65. Regardless of the definition used, however, EFDs did not impact the clinical response to OROS-MPH. This randomized clinical trial showed that executive function deficits do not moderate the response to methylphenidate and measures of executive function deficits are not associated with response to OROS-MPH.     

Are proton pump inhibitors associated with the development of community-acquired pneumonia? A meta-analysis

This study was presented at the American College of Chest Physicians meeting in Pittsburgh (PA, USA) in October 2011. The study objective was to evaluate the association of proton pump inhibitors (PPIs) and community-acquired pneumonia (CAP). The design was a meta-analysis of nine case-controlled and cohort studies. 120,863 pneumonia cases from 1987 to 2006 were included in the meta-analysis. PubMed and Ovid Medline were searched from inception through May 2011 by two investigators independently using keywords: PPI, pneumonia, CAP, anti-ulcer, antacid, omeprazole, esomeprazole, lansoprazole, pantoprazole and rabeprazole. This meta-analysis only included case-controlled and cohort studies that were published in full in English and evaluated PPI use and CAP incidence. Studies were excluded if they included the following patients: pediatric, Helicobacter pylori treatment and critically ill. Bibliographies of recent review articles and systematic reviews were hand-searched. Quality of studies was assessed using the Newcastle-Ottawa Quality Assessment Scale. Two investigators independently extracted data into standardized data collection forms that were confirmed by a third investigator. Data were analyzed based on current use of PPIs, duration of PPI use (<30 days or >180 days) and PPI dose (high vs low). Overall association of PPI and CAP was analyzed using the random effects model (Comprehensive Meta analysis(?) Version 2.0). Nine studies met all criteria for the primary outcome. Newcastle-Ottawa Quality Assessment Scale scores ranged from 4 to 8 out of 9. Current use of PPIs (odds ratio [OR]: 1.39; 95% CI: 1.09-1.76), PPI use <30 days (OR: 1.65; 95% CI: 1.25-2.19), PPI high dose (OR: 1.50; 95% CI: 1.33-1.68) and PPI low dose (OR: 1.17; 95% CI: 1.11-1.24) were significantly associated with CAP. There was no association between CAP and PPI use >180 days (OR: 1.10; 95% CI: 1.00-1.21). In conclusion, patients currently receiving PPIs, particularly <30 days or high dose, showed an association with CAP. Practitioners need to be vigilant about adverse effects of PPIs and consider alternative therapies.     

Drinking patterns among older people in the community: hidden from medical attention?

AIMS: To determine patterns of alcohol use and misuse among community-dwelling people aged 65 years and over in Christchurch and to assess how often this comes to medical attention. METHODS: A cross-sectional survey of alcohol use and misuse was conducted followed by a self-administered postal survey among non- respondents. General practitioners (GPs) of the respondents completed a self-administered questionnaire on patients' alcohol use and misuse. RESULTS: The response rate was 58% (141/243). The prevalence of hazardous alcohol consumption in the past twelve months (AUDIT cut-off score 8 or more) was 9.9% (95% CI = 4.9-14.9) and the prevalence of lifetime alcohol dependence using DSM-IV diagnostic criteria was 24.8% (95% CI = 17.6-32.0). Men were more likely than women to report lifetime dependency and current hazardous patterns. The response rate among GPs was 77.7% (108/139). None of the GPs identified or diagnosed alcohol problems in the past twelve months among this group and reported a history of alcohol problems in only four (4.0%) patients. Those with current hazardous patterns of alcohol use were twice as likely to be admitted to hospital (RR=2.4; 95% CI 1.2-5.1) but significantly less likely to visit their GPs in the previous twelve months (RR=0.55; 95% CI 0.7-1.1). CONCLUSION: A significant proportion of community-dwelling elderly people reported patterns of alcohol consumption that put them at risk of future damage to physical or mental health. Hazardous drinkers were less likely to visit their GPs and only in a few cases, were GPs aware of such potential problems.     

Adherence to and persistence with non-vitamin K-antagonist oral anticoagulants: does the number of pills per day matter?

Once daily dosing schedule is associated with increased adherence to and persistence with cardiovascular therapies. Such feature has been claimed responsible for the significantly lower (both temporary and permanent) discontinuation of oral anticoagulation with rivaroxaban (which is given once daily) compared to dabigatran (which is given twice daily) in a large, real-world dataset of patients with atrial fibrillation (AF) in the United States. While a cause-effect relationship between dosing schedule and adherence and persistence could not be established, the above finding supports nonetheless the preferential selection of the non vitamin-K-antagonists oral anticoagulant (NOAC) with the easiest and most convenient regimen. Given however, the differences in efficacy and safety observed with the various NOACs compared to warfarin in the phase III clinical trials in non-valvular AF, careful individualization of treatment should be pursued, being dosing schedule only one of the variables to be taken into account. Maximal effort instead, should be put in implementing measures to enhance patient's adherence to and persistence with treatment.