CRACK COCAINE,ALCOHOL, AND OTHER DRUG USE PATTERNS AMONG HOMELESS PERSONS WITH OTHER MENTAL DISORDERS

This study examined the co-occurrence of cocaine, alcohol, marijuana, and other drug use among treatment seeking homeless persons to determine whether alcohol use predicted cocaine use differently than marijuana and other drugs predicted cocaine use. Participants were 141 homeless persons with substance use and other nonpsychotic mental disorders seeking drug treatment at a metropolitan health care agency for homeless persons. They were 72.3% male, 27.7% female, 82.7% African American, 17.3% Caucasian, with an average age of 37.7 (SD 7.1) years and had 13.1 (SD 2.4) average years of education. Results supported the assertion that cocaine use was strongly associated with extent of alcohol use and that the association between cocaine and alcohol was stronger than the association between cocaine and other drug use, including marijuana. Participants with cocaine plus alcohol disorders were retained longer in treatment than disorders of cocaine only with no differences in abstinence outcome. The findings should drive further research into the use of alcohol as a trigger or predictor of cocaine use, the deleterious effects of the combined use of cocaine and alcohol, and specialized treatments for polysubstance users.     

Polydrug Use in an Inpatient Treatment Sample of Problem Drinkers

Over the past 30 years in the United States, there have been marked secular increases in polydrug use. Alcohol and other substance use disorders are highly comorbid. Yet, little research has characterized patterns of polydrug use in persons with alcohol dependence. In particular, little is known about this population's use of alcohol and other drugs in combination or on the same day, which is termed simultaneous polydrug use (SPU). This research assessed patterns of SPU in 212 problem drinkers who participated in an alcohol treatment outcome study. Subjects were given a Time-Line Follow-Back interview that assessed the use of alcohol and nine other drug classes for each day of the 120 days before treatment entry. A majority of subjects (61%) reported SPU during this assessment interval. Subjects who reported SPU were disproportionately younger, male, and unmarried, compared with those who did not report SPU. The most common alcohol/drug combinations were alcohol with cocaine (60% of subjects who reported SPU), alcohol with marijuana (51 % of SPU subjects), and alcohol with sedatives (31 % of SPU subjects). The most common three-drug combination was alcohol, cocaine, and marijuana (23% of SPU subjects). Alcohol use and drug use were associated at the event level, significantly more than association predicted by the base rates of the individual behaviors. Time-Line Follow-Back data correlated highly with a questionnaire measure of SPU. Results indicate that polydrug use is an important focus for assessment and intervention in alcohol treatment programs.     

Initiation and Progression of Alcohol,Marijuana, and Cocaine Use Among Adolescent Abusers

Adolescent alcohol and drug use are associated with many negative consequences. Understanding factors in initiation and patterns of use could aid in treatment and prevention. Sixty-four adolescents calling a cocaine hotline received structured telephone interviews. Mean age was 16.7 years. Two-thirds of the adolescents were young men. Sixty-six percent used alcohol; 60.9%, marijuana; 60.9%, cocaine; mean onset was at 13.57, 13.28, and 14.64 years, respectively. Daily use of alcohol was reported by 25.8%; marijuana, 36.9%; and cocaine, 41.3%. Eighty-four percent tried drugs because of peer pressure. Multiple alcohol/drug use commonly started in early adolescence. Peer use and pressure were major reasons for initiation. Early interventions can incorporate and make use of these factors.     

DSM-III-R nicotine dependence in young adults: prevalence, correlates and associated psychiatric disorders

We describe the epidemiology of nicotine dependence and Us association with other substance use and psychiatric disorders. Data came from a random sample of young adults, 21–30 years of age, in the Detroit, Michigan metropolitan area. The NIMH Diagnostic Interview Schedule was used to ascertain DSM-III-R disorders. Lifetime prevalence of nicotine dependence was 20%. Higher rates were observed in whites, persons with low education and persons who were separated or divorced. Males and females with nicotine dependence had significantly increased odds for alcohol and illicit drug disorders, major depression and one or more anxiety disorder, as compared to non-dependent smokers and non-smokers combined. Among smokers, lifetime prevalence of illicit drug disorders other than marijuana alone, major depression and any anxiety disorder were significantly higher in dependent than non-dependent people. Major depression was associated specifically with nicotine dependence, an association explained in part by neuroticism. This finding suggests that the personality trait of neuroticism might constitute a common predisposition for major depression and nicotine dependence.     

Prevalence of nonpsychotic mental disorders does not affect treatment outcome in a homeless cocaine-dependent sample

This study presents the prevalence and treatment outcome of DUAL diagnoses (psychoactive substance use disorders [PSUD] plus other nonpsychotic mental disorders) among a population of homeless persons participating in a behavioral day treatment and contingency management drug abuse treatment program. Participants were 128 persons: 76.6% male, 23.4% female; 82.2% African-American, 17.2% Caucasian. There were 46 (35.9%) PSUDs and 82 (64.1%) DUAL participants. Cocaine (96.9%) and alcohol disorders (57.8%) were most prevalent overall, and 60.2% of participants had two or more psychoactive substance use disorders. DUAL participants had significantly more alcohol disorders than PSUDs (62.2% versus 50.0%). The most prevalent mental disorders (other than substance use) for the total and DUAL samples were, respectively, mood (51.6% and 80.5%) and anxiety (35.9% and 56.1%), and 31.3% and 48.8% had more than two mental disorders. The DUAL group had more severe problems than the PSUD group at baseline in alcohol, medical condition, employment/support, and psychiatric status areas on the ASI. Both groups showed treatment improvements at 6-months follow-up with the DUAL group showing greater mean changes than the PSUD group in five of the seven ASI areas. These findings are discussed in terms of effect of dual diagnoses on treatment outcome and study limitations related to a retrospective design and select sample of nonpsychotic mental disorders.     

Violent victimization and drug involvement among Mexican middle school students

Aims To answer the following research questions: (a) is there an association between violent victimization and exposure to opportunities to use marijuana, inhalants and cocaine and (b) is there an association between violent victimization and actual drug use among youth with drug‐using opportunities? Design Cross‐sectional survey. Setting Two middle schools located in the Historic Downtown area of Mexico City. Participants The entire body of students (n = 767; mean age 13.8 years, 52% males). Measurements Qualitative research was used to develop questions on drug exposure opportunities and violent victimization. Standardized questions on life‐time alcohol, tobacco, marijuana, inhalant drugs and cocaine use were also included, as well as questions on violent victimization and other covariates. Findings One‐quarter (25%) of students had an opportunity to try marijuana, inhalant drugs or cocaine; 35% who had an opportunity actually used at least one drug. In this sample, 59% had been victimized violently. Youth who had been victimized had greater odds of opportunities to use drugs compared to those who had not been victimized [adjusted odds ratio (OR) = 3.8; 95% confidence interval (CI), 2.4, 6.1]. Once exposure opportunity is taken into consideration, no association was evident between violent victimization and actual drug use (adjusted OR = 0.9; 95% CI, 0.4, 2.1). Conclusions It is possible to trace back the association between violent victimization and drug use to differences in exposure to opportunities. Limitations considered, this study suggests interventions to improve micro and macro contexts, such as families, schools and communities, so young people can have better places to live and develop.     

Implicit cognition and dissocative experiences as predictors of adolescent substance use

The present study evaluated the mediating role of implicit cognitive processes in the prediction of alcohol and marijuana use and examined the relationships between dissociative experiences, implicit processes, and sensation seeking in models of drug use and problem experiences. Participants were 467 diverse at-risk adolescents in California. Results from latent variable models revealed that implicit cognition independently predicted alcohol and marijuana use and mediated the predictive effects of sensation seeking on drug use. Dissociative experiences did not predict implicit cognition or drug use in this sample, though this factor was a significant predictor of problem experiences and was positively correlated with sensation seeking. This research provides further evidence suggesting that implicit, associative memory processes are influential in drug-use motivation.     

Does substance use compromise depression treatment in persons with HIV? Findings from a randomized controlled trial†

Depression and substance use are significant obstacles to effective HIV care. Using data derived from a randomized controlled trial of persons with HIV who are homeless or marginally housed, this study assesses the utility of antidepressant treatment among persons with HIV, depression, and active substance use. Participants were diagnosed with depressive disorders and randomly assigned to receive directly observed therapy with fluoxetine or a referral to community mental health treatment. Assessments, conducted at baseline and every 3 months over a 9-month period, included the Hamilton Rating Scale for Depression, the Beck Depression Inventory II, and self-report of alcohol, crack, cocaine, heroin, or methamphetamine use in the past 90 days. To investigate the effect of antidepressant treatment in the setting of active substance use, the authors fit mixed-effects linear regression models to estimate the effect of directly observed fluoxetine on depressive symptom severity after stratifying by any alcohol use or any illicit drug use. To investigate whether alcohol use or illicit drug use moderated the antidepressant treatment response, the authors examined the interaction terms. The effect of directly observed fluoxetine treatment on depression symptom severity was statistically significant irrespective of alcohol use status. When stratified by illicit drug use status, the effect of directly observed fluoxetine treatment on depression symptom severity was statistically significant only among persons who did not use illicit drugs. The interaction terms were not statistically significant. This study found a benefit of antidepressant treatment in persons with HIV, depression, and alcohol use. In addition, this study found no evidence that either alcohol use or illicit drug use moderates the antidepressant treatment response. Altogether, these findings support the use of antidepressant medication in this population. The public health impact of research in this area is significant given the known adverse effects of depression on HIV-related health outcomes. ClinicalTrials.gov Identifier: NCT00338767.     

The association between DSM-III-R alcohol dependence, psychological distress and drug use

This paper examines the association between DSM-III-R alcohol dependence, psychological distress and the frequency of drug use in a sample of 219 men and 162 women consecutively admitted to nine alcohol treatment programs in a Northern California county. Results show that psychological distress is higher among men who are more severely dependent on alcohol and among those who have lower education; women who are less alcohol dependent and women who are younger have higher scores in psychological distress than other women. With regard to drug use, about 65% of the men and 64% of the women report using a drug other than alcohol at least once a week during the 12 months prior to admission into treatment. Among both men and women, the drugs most frequently used are crack/cocaine, marijuana and methamphetamine. Among men, regression analysis shows that drug use is associated with being younger. Among women results show that the predictors of drug use are being younger, being unemployed, having a higher income, being a heavier drinker and having fewer symptoms of alcohol dependence. These results show a complex pattern of association across alcohol dependence, drug use and psychological distress. Knowledge of this pattern is necessary for tailoring effective clinical interventions to clients with different kinds of comorbidity.     

Predictors of treatment contact among individuals with cannabis dependence

Epidemiological studies have repeatedly shown that cannabis is the most commonly used illegal drug in the United States. Furthermore, individuals with cannabis dependence have high rates of comorbid substance use disorders and depression. A significant proportion of individuals with addictive disorders develop withdrawal symptoms, cannot control their drug use despite substantial adverse psychosocial consequences, and frequently have a coexisting psychiatric disorder. Nevertheless, only a minority of persons with cannabis dependence ever seek treatment. We were unable to locate epidemiological reports regarding treatment seeking behavior among persons with cannabis dependence. Epidemiological studies of populations with substance disorders have observed that employment, higher educational level, previous use of treatment, major depression, and a co-occurring substance dependency increased the probability of seeking treatment for alcohol dependence. Thus we hypothesized that the same variables would predict service use among persons with cannabis dependence. The main findings of this study were that persons with cannabis dependence were more likely to contact a professional during the past year if they previously sought treatment and had alcohol dependence with major depression. Prospective, longitudinal studies of adolescents would increase our understanding of the processes by which individuals identify themselves as having problems related to their habitual use of marijuana, and why some seek help while others do not.     

Onset of alcohol and tobacco use and transition to other drug use among students from Morelos, Mexico

OBJECTIVE: To estimate the cumulative probability of occurrence of first use of alcohol and tobacco, and the risk of transition to illegal drugs (marijuana, cocaine, and heroine, among others), in adolescents and young adults, in Morelos State, Mexico. MATERIAL AND METHODS: A cross-sectional study was conducted during schoolyear 1998-1999, among 13 293 students aged 11-24 years, selected from public schools by probabilistic multistage sampling. Data were collected on sociodemographic, health status, and substance abuse variables, using a validated self-applied questionnaire. Data were restructured to assemble a synthetic cohort for discrete time survival analysis. Associations were assessed with hazard rates and 95% confidence intervals obtained by means of multivariate Cox regression models. RESULTS: Sixty percent of males started drinking alcohol at 17 years of age, and smoking tobacco at 18 years of age, on average. Women started using alcohol and tobacco one year after men. Utilization of illicit drugs occurred at 19 years of age on average in 5% of women and 13% of men. Nine out of every 100 illicit drug users started directly using illicit drugs without previous use of alcohol and/or tobacco. In general, alcohol or tobacco users were at greater risk of starting drug use than nonusers (RR=6.72; 95 % confidence interval [CI]=4.13-10.93). CONCLUSIONS: Study findings suggest that interventions to decrease drug abuse should go together with efforts to delay initiation of alcohol and tobacco use. The innovative method used in this study yields epidemiologic evidence relating early use of alcohol and tobacco with initiation of illegal drugs in Mexican students.     

Substance abuse history predicts depression and relapse status among cocaine abusers

This study examined the relationships between lifetime years of cocaine, alcohol, and marijuana use prior to entry into residential treatment for primary cocaine dependence and (a) intake depression levels, and (b) levels of cocaine use in the six months after completing treatment. Years of education, age, and lifetime years of cocaine and alcohol use contributed significantly to predicting depression levels. Lifetime years of alcohol use alone predicted cocaine use during the six months post-treatment.     

Sleep problems in early childhood and early onset of alcohol and other drug use in adolescence

BACKGROUND: No prospective studies exist on the relationship between sleep problems early in life and subsequent alcohol use. Stimulated by the adult literature linking sleep problems to the subsequent onset of alcohol use disorders in some adults, we examined whether sleep problems in early childhood predicted the onset of alcohol and other drug use in adolescence and whether such a relationship was mediated by other known predictors of this relationship, namely, attention problems, anxiety/depression, and aggression in late childhood. METHODS: This study is part of an ongoing longitudinal study of the development of risk for alcohol and other substance use disorders. Study participants were 257 boys from a community-recruited sample of high-risk families. RESULTS: Mothers' ratings of their children's sleep problems at ages 3 to 5 years significantly predicted an early onset of any use of alcohol, marijuana, and illicit drugs, as well as an early onset of occasional or regular use of cigarettes by age 12 to 14. Additionally, although sleep problems in early childhood also predicted attention problems and anxiety/depression in later childhood, these problems did not mediate the relationship between sleep problems and onset of alcohol and other drug use. CONCLUSIONS: This is, to our knowledge, the first study that prospectively examines the relationship between sleep problems and early onset of alcohol use, a marker of increased risk for later alcohol problems and alcohol use disorders. Moreover, early childhood sleep problems seem to be a robust marker for use of drugs other than alcohol. Implications for the prevention of early alcohol and other drug use are discussed.     

Concurrent and Sequential Use of Drugs and Alcohol: Patterns,Characteristics of Users,and Implications for Treatment and Prevention

A treatment population of 1,544 drug/alcohol abusers at 10 combined treatment centers was studied to determine the various patterns of sequential use and their corresponding policy implications. Most of the persons who began their substance abuse with alcohol continued to use only alcohol. Alcoholics who did use another substance, either sequentially or concurrently, tended to select a drug other than opiates or marijuana. Although a majority of opiate users eventually became concurrent or sequential users of another substance, a sizable number remained mono-users. A miniscule number of the opiate users moved on to alcohol or marijuana. Most of the users initiated into regular use with marijuana eventually began to use a nonopiate, nonalcoholic substance. A majority of the users who started with a nonalcohol, nonopiate, nonmaryuana substance eventually used marijuana. Sequential and concurrent users in general were more similar to each other than to mono-users. The implications of the development of drug use typologies for direct treatment are discussed. Having identified target groups, the author then suggests policies for controlling substance abuse indirectly, such as those dealing with employment.     

Concurrent and sequential use of drugs and alcohol: patterns, characteristics of users, and implications for treatment and prevention

A treatment population of 1,544 drug/alcohol abusers at 10 combined treatment centers was studied to determine the various patterns of sequential use and their corresponding policy implications. Most of the persons who began their substance abuse with alcohol continued to use only alcohol. Alcoholics who did use another substance, either sequentially or concurrently, tended to select a drug other than opiates or marijuana. Although a majority of opiate users eventually became concurrent or sequential users of another substance, a sizable number remained mono-users. A miniscule number of the opiate users moved on to alcohol or marijuana. Most of the users initiated into regular use with marijuana eventually began to use a nonopiate, nonalcoholic substance. A majority of the users who started with a nonalcohol, nonopiate, nonmarijuana substance eventually used marijuana. Sequential and concurrent users in general were more similar to each other than to mono-users. The implications of the development of drug use typologies for direct treatment are discussed. Having identified target groups, the author then suggests policies for controlling substance abuse indirectly, such as those dealing with employment.     

Chapter 10: Substance Abuse Prevention for High-Risk Youth

SUMMARY

This pilot study explores issues of culture and alcohol and other drug use in relation to substance abuse prevention with high-risk youth, with a particular interest in Latinos/as and acculturation. Many of the prominent prevention studies are school based, missing some of the youth at very highest risk for alcohol and drug use and abuse. Consequently, this study was conducted in community settings with youth from high-risk neighborhoods and environmental conditions including a homeless youth shelter, an alternative learning setting, and a low-income community program. The data indicated a high lifetime prevalence of drug use (over 80% for Whites and Latinos for beer, wine, liquor, and marijuana), with consistently lower prevalence rates observed among African-Americans. In addition, the study found significant ethnic differences in substance use (last 30 days) in the sample (median age = 16), with African-Americans reporting significantly lower incidence of marijuana and cocaine use (p < .05) than other youth. Implications for prevention, intervention and future research are discussed.     

Outcomes for older trauma patients in the emergency department screening positive for alcohol,cocaine, or marijuana use

Background: Substance use among older adults is an increasing concern, with the prevalence of substance use in older populations expected to double in the next decade. Drug and alcohol use is associated with trauma risk and outcomes, but little is known about the specific risk for older trauma patients. Objectives: To evaluate the association between drug and alcohol use and trauma outcomes among adults aged 55 years and older. Methods: This retrospective observational study included older adults from the Illinois Trauma Registry between 1999 and 2009. Exclusion criteria were age younger than 55 years or absent date of birth, ethanol level, or urine drug screen (UDS). Alcohol intoxication was defined as ethanol level greater than 80?mg/dL. UDS was used to screen cocaine and marijuana use. Analyses, for both the alcohol and the marijuana/cocaine groups, compared outcomes for patients with negative vs. positive screens. Results: 21?320 patients were included in the alcohol analysis and 17?077 in the drug analysis. Compared to non-intoxicated patients, alcohol-intoxicated patients had significantly (p?0.001) lower in-hospital mortality, decreased ICU admission, decreased intubation rate, and shorter hospital length of stay. Patients screening positive for cocaine or marijuana had significantly longer lengths of stay with increased ICU admission compared with those who screened negative. Conclusion: Among older trauma patients, this study shows significant associations with multiple trauma outcomes, including one between elevated ethanol concentrations and improved outcomes. Future research into the causes of these findings could inform the care of older trauma patients and aid in prevention of injuries.     

Crack users show high rates of antisocial personality disorder, engagement in illegal activities and other psychosocial problems

The aim of this study was to compare three groups of Brazilian psychoactive substance (PAS) abuse patients (crack cocaine users, cocaine snorters, and non-cocaine PAS users) in terms of psychiatric comorbidities and severity of psychosocial problems. A cross-sectional, multi-center study was conducted at five Brazilian research centers. A total of 738 current PAS abusers seeking specialized treatment (outpatient and inpatient clinics) were assessed using the sixth version of the Addiction Severity Index (ASI-6): 293 patients using crack cocaine were compared with 126 using powder cocaine and 319 using non-cocaine PAS (mostly alcohol and marijuana). Psychiatric comorbidities were assessed in a smaller sample (290 cases), originating from three of the centers, using the Mini International Neuropsychiatric Interview Plus (MINI-Plus). Crack and powder cocaine users were significantly younger than non-cocaine PAS users (31.1 ± 8.1 and 32.9 ± 8.8 vs. 42.4 ± 12, respectively; p < .001). Crack users presented a higher rate of antisocial personality disorder (25%) than powder cocaine (9%) and non-cocaine PAS users (9%), even when adjusted for confounding factors (Pr = 2.6; 95% CI 1.10-6.40). According to ASI-6 summary scores, crack users presented a significantly higher rate of occupational, family, and legal problems and reported more illegal and violent activities such as burglary and theft (23%) and threatening or assaulting (32%) than non-cocaine PAS users. Our findings, combined with the recent increase observed in the prevalence of crack use in Brazil, highlight the severity of psychiatric symptoms and psychosocial problems related to this powerful drug and corroborate the already suggested association between crack/cocaine, violence, and legal problems. Treatment programs for crack users should routinely consider the possibility of associated psychiatric comorbidities, such as antisocial personality disorder, which may affect treatment outcomes.     

Predictors of marijuana use and uptake among teenagers in Sydney, Australia

Information on drug-related behaviors was obtained from a random sample of teenagers aged 14 to 19 years in Sydney, Australia, interviewed in their homes in 1985 (N = 996) and 1986 (N = 756). The 1985 prevalence of current marijuana use was 10%. The predictors of marijuana use were: male sex; heavier, more frequent alcohol use; use of drugs other than alcohol, tobacco, or marijuana; marijuana use by siblings, friends, and other acquaintances; attitudes and beliefs favoring drug use; the attitude that possession of marijuana should not be a criminal offense; and the attitude that marijuana is not an important drug issue. In the 756 reinterviewed respondents, prevalence of marijuana use rose from 7% in 1985 to 9% in 1986. The rate of uptake was 6% and peaked at 12% at age 17. The predictors of uptake were: age; male sex; heavier, more frequent alcohol use; tobacco smoking; attitudes and beliefs favoring drugs use; and the attitude that marijuana smoking should be legal. Strategies to prevent marijuana use need to take into account the strong association between heavy drinking and marijuana use, the influence of drug users in the social network, and attitudes and beliefs about drugs.