Nonmedical use and abuse of scheduled medications prescribed for pain,pain-related symptoms,and psychiatric disorders: Patterns,user characteristics,and management options

The nonmedical use of scheduled medications commonly prescribed for pain, pain-related symptoms, and psychiatric disorders began rising in the mid-1990s. Physicians are confronted with the dilemma of how to minimize the abuse and diversion potential of these products without compromising access for patients with a legitimate medical need. Using data from the National Survey on Drug Use and Health, we describe the scope of nonmedical use of opioids, stimulants, and tranquilizers; characteristics of nonmedical users; and options available to reduce abuse liability. In 2003, lifetime prevalence estimates of nonmedical use were 31.2 million for opioids, 20.7 million for stimulants, and 20.2 million for tranquilizers. Nonmedical users of psychotherapeutics were more likely to be Caucasian; use alcohol, cocaine, or heroin; and to use needles to inject drugs than those who reported using illicit drugs only. Sources of diversion are enumerated, and options for minimizing the abuse liability associated with these medications are described.     

Prevalence, correlates, and comorbidity of DSM-IV antisocial personality syndromes and alcohol and specific drug use disorders in the United States: results from the national epidemiologic survey on alcohol and related conditions

OBJECTIVE: The purpose of this study was to provide nationally representative data on the prevalence, sociodemographic correlates, and comorbidity of antisocial syndromes across alcohol and 8 specific drug use disorders, including sedative, tranquilizer, opiate, stimulant, hallucinogen, cannabis, cocaine, and inhalant/solvent abuse and dependence. METHOD: This study is based on a nationally representative sample of adults. Lifetime prevalences of antisocial syndromes were estimated and logistic regression analyses were used to examine associations between antisocial syndromes and sociodemographic characteristics and substance use disorders. Diagnoses were made according to the criteria of the DSM-IV using the National Institute on Alcohol Abuse and Alcoholism Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV Version. RESULTS: The lifetime prevalences of antisocial personality disorder (APD), conduct disorder, and adult antisocial behavior were 3.6%, 1.1%, and 12.3%, respectively. Prevalences of alcohol use disorders and drug use disorders were 30.3% and 10.3%, respectively. In general, men and individuals who were younger, widowed/separated/divorced, of lower socioeconomic status, and living in urban areas or in the West were more likely to have antisocial syndromes. Native Americans were more likely and Asians and Hispanics were less likely to have APD and adult antisocial behavior. Virtually all of the associations between APD and adult antisocial behavior and specific substance use disorders were positive and statistically significant (p < .05). Significant associations between conduct disorder and substance use disorders were concentrated among women. CONCLUSION: Comorbidity of specific substance disorders with antisocial syndromes is very common in the U.S. population. Further work in many directions is indicated by the results of this study, including the factors that give rise to the associations and the treatment and prevention implications of these conditions when comorbid.     

Prevalence, correlates, disability, and comorbidity of DSM-IV drug abuse and dependence in the United States: results from the national epidemiologic survey on alcohol and related conditions

BACKGROUND: Current and comprehensive information on the epidemiology of DSM-IV 12-month and lifetime drug use disorders in the United States has not been available. OBJECTIVES: To present detailed information on drug abuse and dependence prevalence, correlates, and comorbidity with other Axis I and II disorders. Design, Setting, and PARTICIPANTS: Face-to-face interviews using the Alcohol Use Disorder and Associated Disabilities Interview Schedule of the National Institute on Alcohol Abuse and Alcoholism in a large representative sample of US adults (N=43093). MAIN OUTCOME MEASURES: Twelve-month and lifetime prevalence of drug abuse and dependence and the associated correlates, treatment rates, disability, and comorbidity with other Axis I and II disorders. RESULTS: Prevalences of 12-month and lifetime drug abuse (1.4% and 7.7%, respectively) exceeded rates of drug dependence (0.6% and 2.6%, respectively). Rates of abuse and dependence were generally greater among men, Native Americans, respondents aged 18 to 44 years, those of lower socioeconomic status, those residing in the West, and those who were never married or widowed, separated, or divorced (all P<.05). Associations of drug use disorders with other substance use disorders and antisocial personality disorder were diminished but remained strong when we controlled for psychiatric disorders. Dependence associations with most mood disorders and generalized anxiety disorder also remained significant. Lifetime treatment- or help-seeking behavior was uncommon (8.1%, abuse; 37.9%, dependence) and was not associated with sociodemographic characteristics but was associated with psychiatric comorbidity. CONCLUSIONS: Most individuals with drug use disorders have never been treated, and treatment disparities exist among those at high risk, despite substantial disability and comorbidity. Comorbidity of drug use disorders with other substance use disorders and antisocial personality disorder, as well as dependence with mood disorders and generalized anxiety disorder, appears to be due in part to unique factors underlying each pair of these disorders studied. The persistence of low treatment rates despite the availability of effective treatments indicates the need for vigorous educational efforts for the public and professionals.     

Race-ethnicity and the prevalence and co-occurrence of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, alcohol and drug use disorders and Axis I and II disorders: United States, 2001 to 2002

The objective of this study was to compare the current prevalence and co-occurrence of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, alcohol and drug use disorders and mood, anxiety, and personality disorders among whites, blacks, Native Americans, Asians, and Hispanics in a large representative sample of the US population. Striking mental health disparities were observed in the prevalences of psychiatric disorders, especially among Native Americans. Disparities in psychiatric comorbidity differed from those associated with prevalence. Most significantly, the association between alcohol disorders and personality disorders was significantly greater among Asians relative to whites, blacks, and Native Americans, despite lower prevalences of these disorders among Asians. Taken together, the results of this study highlight the need of future studies that help unravel the risk factors underlying the disparities in both prevalence and comorbidity of psychiatric disorders observed among race-ethnic groups in the United States.     

Lifetime comorbidity of DSM-IV mood and anxiety disorders and specific drug use disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions

OBJECTIVE: To present nationally representative data on the lifetime prevalence and comorbidity of 8 specific drug use disorders, separately for abuse and dependence, and mood and anxiety disorders. METHOD: Data come from a representative sample (N=43,093) of the United States civilian, noninstitutional population 18 years and older. Diagnoses of mood, anxiety, and drug use disorders were based upon face-to-face personal interviews using the Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV Version (AUDADIS-IV). RESULTS: Associations between specific mood and anxiety disorders and specific drug use disorders were virtually all positive and statistically significant (p<.05). In general, associations were greater for dependence than abuse, greater for mood than anxiety disorders, and in some instances stronger among women than men (p<.05). Large odds ratios also were observed for individuals with comorbid mood and anxiety disorders. CONCLUSION: The comorbidity between specific mood and anxiety disorders and specific drug use disorders is pervasive in the U.S. population. Findings suggest that comorbid psychiatric disorders may increase the risk of greater involvement in more serious illicit drug use disorders and that the greater comorbidity between mood and anxiety and drug use disorders among women may reflect greater deviance and psychopathology among drug-using women than men. Findings also suggest that drug abuse prevention and intervention efforts should address other psychiatric conditions. Further, definitions of drug use disorder phenotypes should give careful consideration to other psychiatric conditions as meaningful characteristics of case heterogeneity.     

Prevalence, correlates, disability, and comorbidity of DSM-IV alcohol abuse and dependence in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions

CONTEXT: Epidemiologic information is important to inform etiological research and service delivery planning. However, current information on the epidemiology of alcohol use disorders in the United States is lacking. OBJECTIVES: To present nationally representative findings on the prevalence, correlates, psychiatric comorbidity, and treatment of DSM-IV alcohol abuse and dependence. Design, Setting, and PARTICIPANTS: Face-to-face interviews with a representative US adult sample (N = 43 093). MAIN OUTCOME MEASURES: Lifetime and 12-month DSM-IV alcohol abuse and dependence. RESULTS: Prevalence of lifetime and 12-month alcohol abuse was 17.8% and 4.7%; prevalence of lifetime and 12-month alcohol dependence was 12.5% and 3.8%. Alcohol dependence was significantly more prevalent among men, whites, Native Americans, younger and unmarried adults, and those with lower incomes. Current alcohol abuse was more prevalent among men, whites, and younger and unmarried individuals while lifetime rates were highest among middle-aged Americans. Significant disability was particularly associated with alcohol dependence. Only 24.1% of those with alcohol dependence were ever treated, slightly less than the treatment rate found 10 years earlier. Strong associations between other substance use disorders and alcohol use disorders (odds ratios, 2.0-18.7) were lower but remained strong and significant (odds ratios, 1.8-7.5) when controlling for other comorbidity. Significant associations between mood, anxiety, and personality disorders and alcohol dependence (odds ratios, 2.1-4.8) were reduced in number and magnitude (odds ratios, 1.5-2.0) when controlling for other comorbidity. CONCLUSIONS: Alcohol abuse and dependence remain highly prevalent and disabling. Comorbidity of alcohol dependence with other substance disorders appears due in part to unique factors underlying etiology for each pair of disorders studied while comorbidity of alcohol dependence with mood, anxiety, and personality disorders appears more attributable to factors shared among these other disorders. Persistent low treatment rates given the availability of effective treatments indicate the need for vigorous education efforts for the public and professionals.     

Substance use disorders in patients with posttraumatic stress disorder: a review of the literature

OBJECTIVE: Alcohol use disorders and other substance use disorders are extremely common among patients with posttraumatic stress disorder (PTSD). This article reviews studies pertaining to the epidemiology, clinical phenomenology, and pathophysiology of comorbid PTSD and substance use disorders. METHOD: Studies were identified by means of computerized and manual searches. The review of research on the pathophysiology of PTSD and substance use disorders was focused on studies of the hypothalamic-pituitary-adrenal axis and the noradrenergic system. RESULTS: High rates of comorbidity suggest that PTSD and substance use disorders are functionally related to one another. Most published data support a pathway whereby PTSD precedes substance abuse or dependence. Substances are initially used to modify PTSD symptoms. With the development of dependence, physiologic arousal resulting from substance withdrawal may exacerbate PTSD symptoms, thereby contributing to a relapse of substance use. Preclinical work has led to the proposal that in PTSD, corticotropin-releasing hormone and noradrenergic systems may interact such that the stress response is progressively augmented. Patients may use sedatives, hypnotics, or alcohol in an effort to interrupt this progressive augmentation. CONCLUSIONS: Vigorous control of withdrawal and PTSD-related arousal symptoms should be sought during detoxification of patients with comorbid PTSD and substance use disorders. Inclusion of patients with comorbid PTSD and substance use disorders in neurobiologic research and in clinical trials will be critical for development of effective treatments for this severely symptomatic patient population.     

Major depression and comorbid substance use disorders

PURPOSE OF REVIEW: The presentation of major depressive disorder is often complicated by the co-occurrence of substance use disorders, such as alcohol and illicit drug abuse or dependence. The article reviews the recent systematic research on the distinguishing baseline characteristics including demographic characteristics and the influence of family history, and clinical features such as depressive symptomatology and suicidal ideation, and the outcome of treatment for depression in patients with comorbid major depressive disorder and substance use disorders. The review also addresses the possible explanations cited in the literature as to why these two disorders tend to co-occur and the implications of the comorbidity of these illnesses on treatment. RECENT FINDINGS: Nearly one-third of patients with major depressive disorder also have substance use disorders, and the comorbidity yields higher risk of suicide and greater social and personal impairment as well as other psychiatric conditions. Although the treatment of comorbid major depressive disorder and substance use disorders with medication is likely effective, the differential treatment effects based on substance use disorder comorbidity have been understudied. SUMMARY: Emerging results of recent studies comparing the outcome of major depressive disorder patients with comorbid major depressive disorder and substance use disorders suggest that there are fewer differential effects based on comorbidity than previously anticipated by older assumptions from smaller, less methodologically rigorous studies.     

Association between psychiatric disorders and the progression of tobacco use behaviors

OBJECTIVE: To examine the progression of tobacco use and the patterns of comorbidity of tobacco use and psychiatric disorders. METHOD: The authors conducted analyses of prospective and retrospective reports, collected from 1988 to 1998, of a sample of high- and low-risk youths identified on the basis of the presence or absence of a parental history of substance abuse or dependence. RESULTS: A parental history of substance use disorders was associated with regular tobacco use and nicotine dependence, but not with experimentation for all youths. Individual and composite psychiatric diagnoses were strongly associated with nicotine dependence, but not with regular use or experimentation. While the presence of an affective disorder and drug abuse/dependence generally increased the risk for co-occurring nicotine dependence, analyses based on the temporal onset of disorders showed that it was the initiation of alcohol or drug use that predicted the progression to nicotine dependence. For low-risk youths, oppositional defiant disorder was the single psychiatric risk factor that predicted the transition to nicotine dependence. CONCLUSIONS: This study adds to the accumulating evidence that has implicated comorbid psychiatric disorders in the etiology and subsequent course of nicotine dependence. In addition, family history may represent an important indicator of an increased risk for nicotine dependence.     

Inhalant use, abuse, and dependence among adolescent patients: commonly comorbid problems

OBJECTIVE: Little is known about adolescents with DSM-IV-defined inhalant abuse and dependence. The aim of this study was to compare comorbidity among (1) adolescents with inhalant use disorders, (2) adolescents who reported using inhalants without inhalant use disorder, and (3) other adolescent patients drawn from an adolescent drug and alcohol treatment program. METHOD: The authors examined 847 admissions of patients who had completed structured diagnostic assessments. The three groups were compared for noninhalant substance use disorders, posttraumatic stress disorder, conduct disorder, major depression, previous suicide attempts, and physical/sexual abuse and neglect. RESULTS: Adolescents with inhalant abuse or dependence (group 1; n = 28) were significantly more likely to meet lifetime criteria for abuse or dependence on alcohol, hallucinogens, nicotine, cocaine, and amphetamines, to have had major depression, and to have attempted suicide compared with other adolescent patients who reported never using inhalants (group 3); adolescents with inhalant use disorders also reported significantly more abuse and neglect. Adolescents with inhalant abuse or dependence (group 1) did not differ significantly on any measure compared with adolescents who reported using inhalants without an inhalant use disorder (group 2). CONCLUSIONS: Adolescent patients with a history of inhalant use, abuse, or dependence entering treatment should be carefully screened for noninhalant substance use disorders, major depression, suicidality, and abuse and neglect.     

Severe mental illness and substance use disorders among former Supplemental Security Income beneficiaries for drug addiction and alcoholism

BACKGROUND: Recently enacted federal legislation targeted at curbing perceived abuses of cash benefits for former Supplemental Security Income beneficiaries for drug addiction and/or alcoholism (DA&A) may be creating a residual population that is too seriously impaired to work owing to psychiatric and substance use disorders. METHOD: Data in this report were derived from 1-year follow-up interviews of 204 randomly selected DA&A beneficiaries in Chicago who were initially interviewed between January 1997 and March 1997, immediately following their termination in the Supplemental Security Income DA&A program. Information on subjects' work and benefits status were collected along with DSM-III-R psychiatric and substance use disorder diagnostic information. Urine specimens were also collected and tested for recent use of marijuana, cocaine, opiates, phencyclidine, amphetamines, and methadone. RESULTS: Twenty-six percent had a past-year severe mental illness while 34% met the DSM-III-R criteria for drug dependence. Illegal drug use was also prevalent with about 50% of the sample testing positive for marijuana, cocaine, or opiates. Compared with those working and earning at least $500 a month, unemployed or underemployed subjects who had lost all federal benefits had a much greater likelihood of being dependent on drugs (odds ratio, 5.0; P<.005; 95% confidence interval, 1.6-15.7) and of having 2 or more comorbid psychiatric disorders (odds ratio, 6.9; P<.005; 95% confidence interval, 1.9-24.7). CONCLUSIONS: Those who have lost DA&A disability benefits and who continue to be unemployed or underemployed have elevated rates of drug dependence and psychiatric comorbidities; consequently, helping these cases make the transition from government assistance to sustained employment is increasingly difficult.     

Victimization and perpetration of intimate partner violence and substance use disorders in a nationally representative sample

ABSTRACT: The aim of this study was to examine the relationship between perpetration and victimization of physical and sexual intimate partner violence (IPV) in the past year and substance use disorders (SUDs) in the past year, including alcohol, sedatives/tranquilizers, cocaine, cannabis, and nicotine stratified according to sex. Data were from the National Epidemiologic Survey on Alcohol and Related Conditions. A series of adjusted logistic regression models were conducted. Among men and women, all types of SUDs were associated with increased odds of IPV perpetration (odds ranging from 1.4 to 8.5 adjusting for sociodemographic variables). IPV victimization increased the odds of having all types of SUDs for male and female victims, with the exception of sedatives/tranquilizer abuse/dependence among women (odds ranging from 1.5 to 6.0 adjusting for sociodemographic variables). Substances that had the most robust relationship with perpetration and victimization of IPV included alcohol and cannabis, after adjusting for sociodemographic variables, mood disorders, anxiety disorders, personality disorders, and mutual violence.     

Substance use,substance use disorders,and comorbidity patterns in a representative sample of incarcerated male Dutch adolescents

The aim of this study was to investigate the prevalence of substance use and substance use disorders (SUDs) among incarcerated boys, and comorbidity patterns and the relationship between SUDs and violent offending and criminal recidivism. The presence of SUDs and other psychiatric disorders was assessed in a representative sample of 204 incarcerated boys aged 12 to 18 years using the Diagnostic Interview Schedule for Children (DISC). Ninety-two percent had used alcohol, 86% had used cannabis, and 33% had used other substances. The 6-month prevalence of SUDs was 55%, and 22% reported polysubstance abuse or dependence. SUDs were positively associated with comorbid externalizing and psychotic disorders. Substance dependence was negatively associated with violent offending but not with criminal recidivism. These high prevalence rates call for more attention to diagnosis and management of SUDs among incarcerated male adolescents. The negative association between substance dependence and the violent nature of the index offense needs further investigation.     

Psychiatric comorbidity in pathological gamblers seeking treatment

OBJECTIVE: The authors' goal was to determine the frequency of psychiatric comorbidity among treatment-seeking pathological gamblers, compare the severity of gambling and psychological problems in gamblers with and without comorbid disorders, and investigate differences between gamblers with and without comorbid disorders in the dopamine D(2) receptor gene (DRD(2)). METHOD: Sixty-nine pathological gamblers who consecutively applied to a specialized outpatient treatment program were evaluated with structured interviews, self-report questionnaires, and psychological scales and were genotyped for a DRD(2) polymorphism. RESULTS: A comorbid psychiatric disorder was present in 43 (62.3%) of the gamblers. The most frequent diagnoses were personality disorders (N=29 [42.0%]), alcohol abuse or dependence (N=23 [33.3%]), and adjustment disorders (N=12 [17.4%]). Gamblers with comorbid psychiatric disorders had gambling scores and psychological scale scores indicating greater severity of gambling and psychopathology. Significant differences in DRD(2) allele distribution were found in gamblers with and without comorbid disorders. CONCLUSIONS: Psychiatric comorbidity is common among pathological gamblers and is associated with greater severity of clinical problems. The DRD(2) gene could be a liability genetic factor for psychiatric comorbidity in pathological gambling.