Barriers to Implementation of Treatment Guidelines for ADHD in Adults With Substance Use Disorder

Objective: Attention deficit hyperactivity disorder (ADHD) is common among adult patients with a substance use disorder, yet often goes undetected. This is a qualitative study to explore implementation barriers to a guideline developed in Belgium for the recognition and treatment of ADHD in adult patients with substance use disorder and to gain a better understanding of the strategies to overcome these barriers.

Methods: Focus groups were conducted with caregivers and patients to explore experiences with comorbid substance use disorder and ADHD. The barriers reported in these focus groups became the subject of further study in focus groups with addiction professionals (physicians, psychiatrists, and psychologists) who had tried the guideline and with psychiatrists specializing in addiction but without experience with ADHD.

Results: Our analysis revealed a number of barriers to the implementation of this guideline, including lack of information from the family, pressure from patients and caregivers to make an ADHD diagnosis, and the potential for abuse of ADHD medication. Furthermore, diagnostic instruments for ADHD have not been validated in people with substance use disorder. Although patients with ADHD are usually treated in an outpatient setting, patients with ADHD comorbid with substance use disorder are difficult to identify in an outpatient setting for various reasons. Finally, there is a lack of specific ADHD expertise in substance use treatment organizations.

Conclusions: Despite the availability of an approved guideline for recognizing and treating adult ADHD in patients with a substance use disorder, underdiagnosis and inadequate treatment still persist. As in general substance use treatment, medication only plays a supportive role in the treatment of substance use disorder with comorbid ADHD. An integrated approach and further improvements in the competence of practitioners may help to reduce the resistance to diagnosing ADHD in substance use treatment centers. Practitioners who specialize in addiction medicine and therapists without medical education view the problem from different perspectives and therefore each group needs specific information and training. Targeted interventions need to be developed to keep these patients in treatment.     

Positive Drinking Consequences Are Associated With Alcohol Use and Alcohol-Related Problems Among Veterans Seeking Treatment for Alcohol Use Disorder

Background: Military service is associated with increased rates of heavy drinking. Widely used clinical practices (e.g., motivational interviewing) indicate that addressing both negative and positive drinking consequences is essential to effective treatment. However, research on effectively assessing positive drinking consequences in a clinical population is absent. Aims: The current study (1) evaluated the utility of the Positive Drinking Consequences Questionnaire (PDCQ), a measure previously validated in an undergraduate sample, for use with treatment-seeking veterans, and (2) evaluated relationships between positive drinking consequences and alcohol expectancies, pre-treatment alcohol use, and alcohol-related problems. Method: Ninety-seven veterans seeking treatment for alcohol problems completed an anonymous survey (97.9% male; mean age = 49.76[11.40], 67.0% Caucasian). Results: The PDCQ evidenced a single factor latent structure and internal consistency (Cronbach's alpha = .90). Positive drinking consequences and expectancies were related yet distinct constructs. After controlling for demographic factors, experiencing more positive drinking consequences at program intake was associated with heavier pretreatment drinking (η_p² = .10, p = .003) and alcohol-related problems (η_p² = .18, p < .001). Further, PDCQ scores evidenced incremental validity in accounting for pretreatment alcohol use (η_p² = .12, p = .002) and alcohol-related problems (η_p² = .11, p = .003) when expectancies also were included in the model. Conclusion: Positive drinking consequences are assessed reliably by the PDCQ in a clinical sample and appear to play an important role in the drinking behavior of veterans seeking alcohol treatment.     

Cognitive Control Network Function in Alcohol Use Disorder Before and During Treatment With Lorazepam

Individuals with alcohol use disorders (AUDs) have deficits in cognitive control, but how they change with treatment is unclear. Seven patients with AUD and anxiety from an open-label trial of disulfiram plus lorazepam performed a multisensory Stroop task during fMRI (both pre and post initiation of treatment), and were compared to nine healthy controls (HCs) (n = 16; Albuquerque, NM; years 2009–2012). Evoked BOLD signal and resting state functional connectivity were compared (HC vs. AUD; Scan 1 vs. Scan 2). AUD demonstrated hyperactivity and altered connectivity in the cognitive control network compared to HC, but treatment did not normalize function.     

Association of Alcohol Use Biomarkers and Cognitive Performance in Veterans With Problematic Alcohol Use and Posttraumatic Stress Disorder: Data From the Mind Your Heart Study

The authors conducted a study of alcohol use biomarkers and cognitive performance among 85 veterans with problematic alcohol use and posttraumatic stress disorder (PTSD). All analyses were adjusted for demographics, depression, anxiety, and PTSD symptoms. Elevated levels of aspartate aminotransferase were associated with worse performance on the Trail Making Test Part A and Hopkins Verbal Learning Test. Two other biomarkers were not associated with any neurocognitive measures. Indirect alcohol use biomarkers (e.g., aspartate aminotransferase) may have a specific role in identifying veterans with problematic alcohol use and PTSD who show a change in psychomotor speed and immediate verbal memory performance.     

Predicting an Alcohol Use Disorder in Urban American Indian Youths

This study examines predictors of alcohol use disorders (AUDs) among an urban American Indian cohort who were followed from approximately age 11 to age 20. Approximately 27% of the sample had a lifetime diagnosis of alcohol abuse or dependence. The results indicated that externalizing, but not internalizing, behaviors, family conflict, and school liking served as significant predictors of an AUD. Neither having an alcoholic mother nor an alcoholic father was found to be significantly predictive of an alcohol use disorder at ages 19 and 20. Finally, early alcohol initiation was a substantial predictor of an AUD and acted as a partial mediator.     

可靠性和有效性的检验与评价

可靠性检验及有效性评价应用于医学研究的重要性在于提高研究设计及研究结果的质量。本文着重介绍了可靠性检验及有效性评价的方法及线索,四种常用的可靠性检验方法是:重复检验法、替代检验法、分段检验法及内部连续性检验法,组内相关分析及Cronbach氏α值的计算构成了可靠性检验的核心内容。标准有效性、内容有效性、构思有效性是有效性评价的三个主要线索。     

Bipolar Disorder in a Population of Adolescents with Alcohol Use Disorders

ABSTRACT

Objectives: The objective of this paper is to present the prevalence of Bipolar Disorder (BPD) in a population of adolescents and young adults with alcohol use disorders (AUD) and to compare salient alcohol use, mood, and diagnostic variables between adolescents with BPD, those with Major Depressive Disorder (MDD), and those with AUD without a mood disorder.

Methods: The subjects were 452 adolescents and young adults, age 12.9 to 28.3 years, who met DSM-IV criteria for a lifetime history of either alcohol abuse or alcohol dependence. DSM-IV psychiatric and AUD diagnoses were obtained by semi-structure interviews (K-SADS and SCID) to discern the possible effect of comorbid BPD on alcohol and other drug variables, we compared adolescents or young adults who met DSM-IV criteria for concurrent BPD and AUD with adolescents with MDD plus AUD and those with AUD and no mood disorder. Following one-way ANOVA comparing across the 3 groups, we proceeded with post hoc analysis comparing the BPD+AUD group with either the MDD + AUD or AUD only group.

Results: 6.4% of the subjects met criteria for BPD. While there were no differences between groups on the alcohol consumption variables, subjects with BPD had a significantly earlier onset of an AUD diagnosis than either the MDD group or the AUD only group. The BPD + AUD group had a significantly greater percentage of subjects meeting criteria for alcohol dependence than the AUD only group.

Conclusions: Comorbid mood disorders, particularly Bipolar Disorder, may have an important effect on alcohol and substance use variables and diagnosis. More research is needed to determine the effect of treatments for mood disorder on both mood and substance use variables.     

Negative Affect Mediates the Association between Posttraumatic Cognitions and Craving in Veterans with Posttraumatic Stress Disorder and Alcohol Use Disorder

Abstract

Objective: The co-occurrence of posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) is common. Individuals with PTSD/AUD commonly drink to cope with PTSD symptoms, which maintains PTSD/AUD, and may result in increased craving for alcohol. Negative affect is implicated in negative reinforcement models of craving. Further, Emotional Processing Theory posits that posttraumatic cognitions lead to the experience of negative affect, which may result in increased craving in PTSD/AUD. The current study aims to advance the understanding of craving in PTSD/AUD by evaluating if specific posttraumatic cognitions (e.g., cognitions about the self, world, and self-blame) are associated with increased negative affect, and whether higher negative affect is associated with heightened craving. Methods: Three separate simple mediation models were utilized to test if negative affect mediated the relationship between each specific posttraumatic cognition type and craving among 136 treatment-seeking veterans with PTSD/AUD. Results: We found that negative affect mediated the association between all posttraumatic cognition types and craving. Specifically, viewing oneself as being unable to handle PTSD-related distress, viewing the world as very dangerous, and blaming oneself for one’s role in a traumatic event were all associated with increased negative affect, which was related to higher craving. Conclusions: Given that posttraumatic cognitions improve via trauma-focused treatment for PTSD, future work should evaluate whether improvements in posttraumatic cognitions via trauma-focused treatment lead to decreased negative affect and craving in PTSD/AUD.     

Life Goals Increase Self-regulation among Male Patients with Alcohol Use Disorder

Background: Alcohol use disorder (AUD) has been conceptualized as a chronic self-regulation failure. Objectives: The aim of this study was to examine the most probable pathways related to self-regulation among patients with AUD. In this study, a hypothetical model was proposed that focused on the relationship between risk factors (extrinsic life goals, emotion dysregulation) and protective factors (intrinsic life goals, self-control, and abstinence self-efficacy). Methods: Male patients with AUD (N = 188) were recruited from alcohol centers of four psychiatric hospitals between March 2015 and September 2015. All participants completed psychological assessments, including the Future Oriented Goals Scale (FOGS), the Alcohol Abstinence Self-Efficacy Scale (AASE), the Brief Self-Control Scale (BSCS), and the Difficulties in Emotion Regulation Scale (DERS) as well as sociodemographic characteristics. Results: The final model was found to be a good fit to data. In testing indirect effects, it was shown that intrinsic life goals via emotion dysregulation, self-control, and alcohol abstinence self-efficacy decreased alcohol self-regulation failure. On the other hand, extrinsic life goals via these factors increased alcohol self-regulation failure. Conclusions/Importance: These results suggest that intrinsic goals might indirectly be the important and protective factors for AUD. Moreover, the findings implicate that self-regulation through goal setting may be necessary to alleviate symptoms and improve function among patients with AUD.     

Smoking Cessation and Alcohol Consumption in Individuals in Treatment for Alcohol Use Disorders

Abstract

Most individuals with alcohol use disorders are dependent on both alcohol and nicotine, and combined use of both substances is more damaging to health than use of either alone. Although research indicates that alcoholics can quit smoking, discrepant results have been reported regarding whether smoking cessation is associated with increased risk of alcohol relapse. The purpose of this paper was to examine the relationship between smoking cessation and alcohol consumption using data from Project MATCH. Of the 1,307 participants who smoked at any point during the study, 160 (12%) quit. Quitters consumed less alcohol than those who continued smoking. In addition, quitters demonstrated a significant reduction in alcohol consumption at the time of smoking cessation, which was sustained for six months post-cessation. These findings suggest that individuals in treatment for alcohol use disorders who are motivated to stop smoking can safely be encouraged to do so without jeopardizing their sobriety.     

甲基苯丙胺渴求量表在戒毒人员中应用的信效度

目的:探讨修订版甲基苯丙胺渴求量表(MA craving scale)在甲基苯丙胺成瘾戒毒人员中的适用性.方法:以460名甲基苯丙胺类成瘾的戒毒人员为施测对象,对数据进行项目分析、探索性因素分析和验证性因素分析.结果:修订版甲基苯丙胺渴求量表共包含5个因子,总量表与分量表的内部一致性系数0.62～0.73之间,重测信度...     

Patient,Program, and System Barriers and Facilitators to Detoxification Services in the U.S. Veterans Health Administration: A Qualitative Study of Provider Perspectives

Background: Because substance use disorder (SUD) treatment is expanding, and detoxification (detox) is often the entry point to SUD treatment, it is critical to provide ready access to detox services. Objectives: The purpose of the current study was to examine patient, program, and system barriers or facilitators to detox access within an integrated health care system with variable rates of detox utilization across facilities. Methods: Inpatient and outpatient providers from 31 different U.S. Veterans Health Administration detox programs were interviewed. Results: Qualitative analyses identified six facilitators and 11 barriers to detox access. Facilitators included program staff and program characteristics such as encouragement and immediate access, as well as systemic cooperation and patient circumstances. Barriers to detox included programmatic and systemic problems, including lack of available detox services, program rules or admission requirements, funding shortages, stigma related to a SUD diagnosis or receiving detox services, and a deficiency of education and training. Other major barriers pertained to patients' lack of motivation and competing responsibilities. Conclusions/Importance: To improve detox access, health care settings should consider enhancing supportive relationships by emphasizing outreach, engagement, and rapport-building with patients, improving systemic communication and teamwork, educating patients on available detox services and the detox process, and addressing patient centered barriers such as resistance to detox or competing responsibilities. In addition, programs should consider open-door and immediate-admission policies. These approaches may improve detox access, which is important for increasing the likelihood of transitioning patients to SUD treatment, thus improving outcomes and reducing utilization of high-cost services.     

Associations of Father's Lifetime Cannabis Use Disorder with Child's Initiation of Cannabis Use,Alcohol Use,and Sexual Intercourse by Child Gender

Background: Early initiation of alcohol use, cannabis use, and sexual intercourse among adolescents is an important public health concern in the United States. Parents' history of substance use disorder is an important contributing factor for children's problem behaviors. Objectives: The associations of fathers' lifetime cannabis use disorder with children's initiation of cannabis use, alcohol use, and sexual intercourse were examined. In addition, child's gender was considered as a moderator of each association. Methods: Data from two companion longitudinal studies was utilized, the Rochester Youth Developmental Study and its intergenerational extension, the Rochester Intergenerational Study. Multiple linear regression analyses were conducted to examine the associations of the father's lifetime cannabis use disorder with the child's initiation of cannabis use, alcohol use, and sexual intercourse. To test gender differences in the associations, the study sample was stratified by child's gender. Results: The average age of first cannabis use (b = –3.71, p < .05), alcohol use (b = –3.65, p < .05), and sexual intercourse (b = –2.94, p < .05) among daughters of fathers with a lifetime cannabis use disorder was lower than that of their counterparts after adjusting for all other control variables, whereas no significant differences were detected in a father–son relationship. Conclusions: Homotypic continuity of cannabis use, as well as heterotypic continuity from the father's cannabis use to the child's alcohol use and sexual intercourse existed in a father–daughter relationship. These findings suggest that family-based interventions for female adolescents whose father has suffered from a cannabis use disorder be developed to prevent better adolescents' early substance use and sexual intercourse.     

Epigenetic Regulation of GABAergic Neurotransmission and Neurosteroid Biosynthesis in Alcohol Use Disorder

BackgroundAlcohol use disorder (AUD) is a chronic relapsing brain disorder. GABA_A receptor (GABA_AR) subunits are a target for the pharmacological effects of alcohol. Neurosteroids play an important role in the fine-tuning of GABA_AR function in the brain. Recently, we have shown that AUD is associated with changes in DNA methylation mechanisms. However, the role of DNA methylation in the regulation of neurosteroid biosynthesis and GABAergic neurotransmission in AUD patients remains under-investigated.MethodsIn a cohort of postmortem brains from 20 male controls and AUD patients, we investigated the expression of GABA_AR subunits and neurosteroid biosynthetic enzymes and their regulation by DNA methylation mechanisms. Neurosteroid levels were quantified by gas chromatography-mass spectrometry.ResultsThe α ₂ subunit expression was reduced due to increased DNA methylation at the gene promoter region in the cerebellum of AUD patients, a brain area particularly sensitive to the effects of alcohol. Alcohol-induced alteration in GABA_AR subunits was also observed in the prefrontal cortex. Neurosteroid biosynthesis was also affected with reduced cerebellar expression of the 18kDa translocator protein and 3α-hydroxysteroid dehydrogenase mRNAs. Notably, increased DNA methylation levels were observed at the promoter region of 3α-hydroxysteroid dehydrogenase. These changes were associated with markedly reduced levels of allopregnanolone and pregnanolone in the cerebellum.ConclusionGiven the key role of neurosteroids in modulating the strength of GABA_AR-mediated inhibition, our data suggest that alcohol-induced impairments in GABAergic neurotransmission might be profoundly impacted by reduced neurosteroid biosynthesis most likely via DNA hypermethylation.     

Alcohol Use Disorders Among Afghan Migrants in Germany

ABSTRACT

Little is known about the effect of acculturation on patterns of alcohol use for migrants from Islamic countries. In a field study of Afghan migrants to Germany, participants who drink alcohol were screened with respect to alcohol use problems and then interviewed concerning patterns of use, mental health, and sociodemographic variables. Snowball sampling was used until 50 Afghan migrants with alcohol use disorders could be interviewed. A significant correlation was found between acculturation stress and mental distress, as well as between mental distress and severity of alcohol use. These correlations did not differ with respect to whether alcohol had been used prior to migration. The findings support the hypothesis of the effect of acculturation on problematic alcohol use. Acculturation needs to be focused on in the treatment of alcohol use disorders.     

Depression and Anxiety Subgroups Across Alcohol Use Disorder and Substance Use in a National Epidemiologic Study

Abstract

Objective: The high prevalence of alcohol/substance use among individuals with psychiatric disorders elucidates the import of investigations into associations between types and severity of psychiatric symptoms and alcohol/substance use. This study examined the likelihood of alcohol use disorder and substance use among individuals with varying depression and anxiety symptoms and severity thereof. Differences across sex were also examined.

Methods: Using data from the National Epidemiological Survey on Alcohol and Related Conditions, a nationally representative sample from the United States (N?=?43,093), separate logistic regressions estimated the odds of lifetime alcohol use disorder, depressant, stimulant, hallucinogen, and comorbid substance use across psychiatric symptom clusters controlling for age, sex, and ethnicity.

Results: Symptom severity was a more important correlate of alcohol use disorder and substance use than symptom type. In particular, the odds ratio of lifetime use of depressants, stimulants, hallucinogens, or any combination of these types of substances were higher for individuals with either severe depression or severe depression and anxiety relative to a healthy control. Moreover, the odds of having a diagnosis of lifetime alcohol use disorder were higher for individuals with severe symptoms of depression, anxiety, and both depression and anxiety, relative to healthy individuals. Those with mild depression were more likely to engage in substance use than individuals with anxiety alone. Patterns of association among males and females were highly consistent.

Conclusions: The findings highlight an enhanced risk of alcohol and substance use among individuals with severe depression and/or anxiety symptoms above what is seen among individuals with less severe symptomatology. In addition, this study shows a unique risk posed by the presence of depression on substance use. This study offers a framework for future studies to examine the causal mechanisms explaining the connection between psychiatric symptoms and alcohol/substance use.