Attempted suicide among entrants to three treatment modalities for heroin dependence in the Australian Treatment Outcome Study (ATOS): prevalence and risk factors

AIMS: To determine the lifetime and recent histories of attempted suicide among entrants to treatment for heroin dependence in three treatment modalities and a non-treatment comparison group; and to ascertain factors associated with a recent history of attempted suicide. DESIGN: Cross-sectional structured interview. SETTING: Sydney, Australia. PARTICIPANTS: Six hundred and fifteen current heroin users: 201 entering methadone/buprenorphine maintenance (MT), 201 entering detoxification (DTX), 133 entering drug free residential rehabilitation (RR) and 80 not in treatment (NT). FINDINGS: A lifetime history of attempted suicide was reported by 34% of subjects, 13% had attempted suicide in the preceding year and 5% had done so in the preceding month. Females were more likely to have lifetime (44% versus 28%) and 12 month (21% versus 9%) suicide attempt histories. The 12 month prevalence of attempted suicide among treatment groups ranged between 11% (MT, NT) and 17% (RR). Factors associated with recent suicide attempts were: being an RR entrant, female gender, younger age, less education, more extensive polydrug use, benzodiazepine use, recent heroin overdose, Major Depression, current suicidal ideation, Borderline Personality Disorder (BPD)and Post-Traumatic Stress Disorder. CONCLUSIONS: Recent suicidal behaviour is a major clinical problem for heroin users, and for females and RR entrants in particular. An essential adjunct to treatment for heroin dependence is routine screening for depression and suicidal ideation, with the provision of appropriate treatment where needed.     

Conduct disorder, antisocial personality disorder and substance use disorders in schizophrenia and major affective disorders

OBJECTIVE: To examine the relationships between childhood conduct disorder (CD), antisocial personality disorder (ASPD) and substance use disorders (substance abuse or substance dependence) in psychiatric patients with severe mental illness. METHOD: Substance use-related problems on screening instruments, lifetime and recent prevalence of substance use disorders, and family history of substance use disorder were evaluated in four groups of 293 patients with mainly schizophrenia-spectrum and major affective disorders: No ASPD/CD, CD Only, Adult ASPD Only, Full ASPD. RESULTS: Full ASPD was strongly related to all measures of substance use problems and disorders, as well as fathers' history of substance use disorder. The odds ratios for Full ASPD and substance use disorders ranged between 3.96 (lifetime cannabis use disorder) to 11.35 (recent cocaine use disorder). To a lesser extent, patients with CD Only or Adult ASPD Only were also at increased risk for having substance use disorders compared to the No ASPD/CD patients. CONCLUSIONS: Childhood CD and adult ASPD represent significant risk factors for substance use disorders in patients with schizophrenia-spectrum and major affective disorders. Considering other research indicating that CD and ASPD have a higher prevalence in patients with severe mental illness, the present findings suggest that CD and ASPD could reflect a common factor that independently increases patients' vulnerability to both psychiatric and substance use disorders.     

Are non-fatal opioid overdoses misclassified suicide attempts? Comparing the associated correlates

This paper aimed to determine whether non-fatal opioid overdose and suicide attempts are distinct behaviours by examining the histories of 1500 opioid-dependent individuals. This paper utilised data collected as part of a large retrospective case-control study. Unintentional non-fatal opioid overdoses were more common than suicide attempts (58% vs. 32%). Overall, the correlates associated with a history of attempted suicide only and non-fatal opioid overdose only were different. Drug-related risk behaviours (including high impulsivity, injection of opioids, sedative dependence) were associated with non-fatal opioid overdose; and a history of mental disorders (depression, anxiety disorder, and screening positive for borderline personality disorder (BPD+) were associated with suicide attempts. Additionally, those who reported a history of both behaviours had a more severe clinical profile including excessive drug use, psychological disorders and childhood trauma. The study concluded that non-fatal opioid overdose and attempted suicide are distinct clinically significant problems that require different approaches for prevention. Additionally, if both behaviours are reported a thorough assessment of underlying comorbid problems should be initiated by treatment services.     

The role of antisocial and borderline personality features in substance dependence among incarcerated females

This study examined the association of borderline personality disorder (BPD) and antisocial personality disorder (ASPD) with substance dependence among incarcerated females (N=105) as well as the influence of the co-occurrence of BPD and ASPD on psychosocial functioning in substance-dependent participants. The severity of BPD and ASPD both were associated with drug dependence, but BPD was not associated with alcohol dependence. After controlling for ASPD severity, BPD severity was no longer associated with drug dependence. The ASPD features of criminal activity and recklessness were most uniquely associated with drug and alcohol dependence (respectively). None of the BPD features was uniquely associated with alcohol or drug dependence after controlling for ASPD. A co-occurring BPD diagnosis was associated with mood disturbance and experiential avoidance among substance-dependent participants. An ASPD diagnosis was associated with an earlier age at first arrest, along with greater childhood abuse and severity of alcohol dependence. These findings have important implications for further understanding and developing ways to help substance-dependent incarcerated females.     

Possible role of a dysregulation of the endogenous opioid system in antisocial personality disorder

Around half the inmates in prison institutions have antisocial personality disorder (ASPD). A recent theory has proposed that a dysfunction of the endogenous opioid system (EOS) underlies the neurobiology of borderline personality disorder (BPD). In the present theoretical paper, based on a comprehensive database and hand search of the relevant literature, this hypothesis is extended to ASPD, which may be the predominant expression of EOS dysfunction in men, while the same pathology underlies BPD in women. According to evidence from human and animal studies, the problematic behaviours of persons with antisocial, callous, or psychopathic traits may be seen as desperate, unconscious attempts to stimulate their deficient EOS, which plays a key role in brain reward circuits. If the needs of this system are not being met, the affected persons experience dysphoric mood, discomfort, or irritability, and strive to increase binding of endogenous opioids to receptors by using the rewarding effects of aggression by exertion of physical or manipulative power on others, by abusing alcohol or substances that have the reward system as target, by creating an “endorphin rush” by self‐harm, by increasing the frequency of their sexual contacts, or by impulsive actions and sensation seeking. Symptoms associated with ASPD can be treated with opioid antagonists like naltrexone, naloxone, or nalmefene. Copyright © 2015 John Wiley & Sons, Ltd.     

Antisocial personality disorder, HIV risk behavior and retention in methadone maintenance therapy

In a sample of 55 consecutive methadone maintenance admissions to our clinic, 42% were diagnosed with antisocial personality disorder (ASPD) using the National Institute of Mental Health Diagnostic Interview Schedule NIMH DIS. Individuals with ASPD exhibited greater risk for HIV infection as defined by more sexual contacts, needle use and equipment sharing. Data at 1 year follow-up were obtained on this group of patients. The objective was to compare the ASPD and non-ASPD groups with regards to demographics, drug abuse history, outcome and retention in treatment. There were no significant differences between the groups on any demographic or treatment outcome variables. Survival analysis indicated that there were no group differences in treatment retention. In conclusion, although there were no differences in treatment outcome between ASPD and non-ASPD groups it is possible that ASPD patients who drop out of treatment will be at higher risk for contracting and spreading HIV within the IV drug using population. These data also suggest that in this population the diagnosis of ASPD using primarily behavioral traits as measured in the NIMH-DIS-III, has little utility in predicting treatment outcome.     

Anti-social personality disorder and response to methadone maintenance treatment

A sample of 183 current methadone maintenance patients were interviewed on their drug use history, criminal history, current drug use, and symptoms of Anti-social Personality Disorder (ASPD). Thirty-nine percent of patients met the DSM-III-R criteria for a diagnosis of ASPD. ASPD patients had an earlier onset of drug use, drug injecting, heroin use, had wider polydrug using histories and had been arrested earlier and more frequently than other patients. Despite the different pretreatment histories of ASPD and other patients, there were no differences between the two groups in retention in treatment, methadone dosage or heroin use. It is concluded that heroin-dependent ASPD patients can be successfully retained in methadone treatment, on similar methadone doses and with similar in-treatment drug use patterns as those of non-ASPD heroin dependent patients.     

Patterns of Mood and Personality Factors and Associations With STI/HIV-Related Drug and Sex Risk Among African American Male Inmates

Background: Research on the association between antisocial personality disorder (ASPD) with comorbid mental disorders and sexually transmitted infection (STI)/HIV risk among inmates is scant despite the high prevalence of psychopathology and of STI/HIV in this population. Methods: We used baseline data from Project DISRUPT, a cohort study conducted among incarcerated African American men (n = 207), to measure associations between ASPD and STI/HIV risk. We also conducted latent class analyses (LCAs) to identify subgroups defined by ASPD with comorbid stress, depression, and borderline personality disorder symptoms and measured associations between latent class membership and STI/HIV risk. Results: Approximately 15% had ASPD and 39% reported depression. Controlling for sociodemographics, stress, and depression, ASPD was independently associated with illicit [AOR = 3.23, 95% confidence interval (CI): 1.18–8.87] and injection drug use (AOR: 5.49, 95% CI: 1.23–24.42) but not with sexual risk. LCAs suggested that those at high risk of ASPD were likely to experience co-morbid mental disorders. ASPD comorbid with these disorders was linked to drug and sex risk. Conclusions: STI/HIV prevention for inmates should incorporate diagnosis and treatment of ASPD and comorbid disorders, and interventions to address ASPD-related factors (e.g., impulsivity) that drive STI/HIV risk.     

Coping and alcohol use and abuse disorder

One hundred and forty-one (141) heroin users were interviewed at the time of their most recent overdose of which 34% returned for in-depth interviews within seven days. Subjects were predominantly male (77%), aged between 18 and 29 (53%), highly dependent, and unlikely to be (8%) or to have ever been (68%) in MMT. Poly-drug use was prevalent (54%) at the time of overdose despite most subjects' awareness of the association between poly-drug use and overdose. Subjects consumed other drugs with heroin in order to increase the pleasurable effects of drug use rather than to medicate symptoms of withdrawal or depression. The overdose did not appear to change subjects' low level of concern about overdosing - only a minority (11 %) said they would seek treatment following overdose. Experience of overdose therefore does not appear to be a motivating factor for entry into treatment. A variety of harm reduction initiatives needs to be supported in order to reduce the frequency and hazards of overdose.     

The characteristics of heroin users entering treatment: findings from the Australian treatment outcome study (ATOS)

The current study aimed to describe the characteristics (demographics, drug use, mental and physical health) of entrants to treatment for heroin dependence in three treatment modalities; and to compare these characteristics with heroin users not in or seeking treatment. Participants were 825 current heroin users recruited from Sydney, Adelaide and Melbourne: 277 entering methadone/buprenorphine maintenance treatment (MT), 288 entering detoxification (DTX), 180 entering drug-free residential rehabilitation (RR) and 80 not in treatment (NT). Treatment entrants were generally long-term heroin users with previous treatment experience. The majority of the sample (55%) were criminally active in the month preceding interview. Injection-related health problems (74%) and a history of heroin overdose (58%) were commonly reported. There were high degrees of psychiatric co-morbidity, with 49% reporting severe psychological distress, 28% having current major depression, 37% having attempted suicide and 42% having a lifetime history of post-traumatic stress disorder. Personality disorders were also prevalent, with 72% meeting criteria for antisocial personality disorder and 47% screening positive for borderline personality disorder. Striking similarities were noted between the non-treatment and treatment groups in length of heroin use career, drug use and treatment histories. [Ross J, Teesson M, Darke S, Lynskey M, Ali R, Ritter A, Cooke R. The characteristics of heroin users entering treatment: findings from the Australian Treatment Outcome Study (ATOS). Drug Alcohol Rev 2005;24:411-418]     

Non-injecting routes of administration among entrants to three treatment modalities for heroin dependence

A sample of 535 entrants to opioid dependence treatments across three treatment modalities were administered a structured interview to ascertain the prevalence of non-injecting heroin use. Ten per cent of participants had used heroin primarily by smoking/inhaling in the month preceding interview, and 9% had used heroin and other drugs exclusively by non-injecting routes. Non-injectors were younger (25.3 vs. 29.5 years), had higher levels of education (10.6 vs. 10.0 years), were more likely to be employed (33 vs. 18%) and had lower levels of recent crime (31 vs. 56%). They also had shorter heroin using careers (5.1 vs. 9.9 years), fewer symptoms of dependence (5.1 vs. 5.6), had been enrolled in fewer previous treatment episodes (3.3 vs. 11.5) and had less extensive lifetime (8.0 vs. 9.1 drug classes) and recent (3.6 vs. 4.9) polydrug use. Non-injectors were substantially less likely to report lifetime (13% vs. 58%) or recent (2% vs. 29%) heroin overdoses. There were no differences between the general physical and psychological health of the two groups. While non-injectors had a lower level of post-traumatic stress disorder (29% vs. 34%), there were no differences in levels of major depression, attempted suicide, antisocial personality disorder, or borderline personality disorder. A substantial minority of Australian treatment entrants are now using heroin exclusively by non-injecting routes. While this group is younger, and has substantially reduced risk of overdose and blood borne virus transmission, the physical and psychological health of non-injectors mirrors that of injectors.     

A neuroimmunological model of antisocial and borderline personality disorders

The neurobiology of the dramatic personality disorders (DSM-IV—Cluster B) has remained somewhat elusive, with the consequence that pharmacological treatment of these disorders is far from satisfactory. The clinical feature that characterizes the borderline personality disorder (BPD) is repeated acts of self-mutilation, whereas those with an antisocial personality disorder (ASPD) are disposed to repeated acts of criminality. While the antisocial group are inevitably incarcerated in penal institutions, the borderline patient, despite their acute psychological suffering, is often refused hospitalization primarily due to the absence of effective interventions. In this paper it will be hypothesized that both these disorders are due to a primary dysregulation of interferon-gamma (IFN-γ), neuropeptide Y (NPY), β-endorphin and insulin. A gender bias has also been observed in relation to these two conditions with females being predisposed to developing a BPD and males an ASPD—a gender bias that can be directly attributed to β-endorphin. Other perplexing features of these disorders are the self-injurious behaviour (SIB) and frequent ammenorhoea of the BPD, a complete lack of morality often combined with heightened cognition and the ‘low serotonin syndrome’ (low serotonin, low LDL (low density lipoprotein) cholesterol and mild hypoglycaemia) of the ASPD. A neuroimmunological explanation of this curious constellation of symptoms will be advanced in this paper. © 1997 John Wiley & Sons, Ltd.     

Increased impulsivity in cocaine dependent subjects independent of antisocial personality disorder and aggression

Several previous studies show a relationship between impulsivity and substance abuse; however, it is unclear whether the increased impulsivity seen in substance dependent groups is specifically related to substance abuse, or if it is due to concomitant antisocial personality disorder (ASPD) or aggression. The issue of whether impulsivity is specifically related to substance abuse is important since it has a bearing on risk factors for development of substance abuse. To determine whether cocaine dependent subjects show increased impulsivity independent of ASPD, the Barratt impulsiveness scale (BIS-11), a delayed reward laboratory measure of impulsivity, and the life history of aggression scale were administered to 49 cocaine dependent subjects and 25 controls. Results showed that cocaine dependent subjects with ASPD were more impulsive and aggressive than controls, but cocaine dependent subjects without ASPD were also more impulsive compared to controls. Controlling for aggression history, cocaine dependent subjects without ASPD continued to have elevated impulsivity as measured by the BIS-11, but not the delayed reward task. This study supports the hypothesis that the increased impulsivity as measured by the BIS-11 in cocaine dependent individuals is not exclusively due to concomitant increases in aggression or ASPD.     

The relationship of conduct disorder to attempted suicide and drug use history among methadone maintenance patients

In order to examine the effects of a diagnosis of childhood conduct disorder (CD) on history of attempted suicide and drug use, unconfounded by early onset heroin use, 181 methadone maintenance patients who commenced heroin use after the age of 15 were interviewed. CD was diagnosed in 54% of patients. Compared to other patients, CD patients were younger and less educated. The onset of drug use, injecting drug use and heroin use occurred, on average, 2 years earlier than in other patients, and they had broader histories of injecting polydrug use. CD patients were more likely to have attempted suicide and to have been hospitalized after an attempt, and to have attempted suicide while enrolled in their current treatment. The current study indicates that a history of CD increases the risk of attempted suicide over and above the higher risks associated with injecting drug use per se. [Darke S, Ross J, Lynskey M. The relationship of conduct disorder to attempted suicide and drug use history among methadone maintenance patients. Drug Alcohol Rev 2003;22:21 - 25]     

The relationship between age and risky injecting behaviours among a sample of Australian people who inject drugs

Background

Limited evidence suggests that younger people who inject drugs (PWID) engage in high-risk injecting behaviours. This study aims to better understand the relationships between age and risky injecting behaviours.

Methods

Data were taken from 11 years of a repeat cross-sectional study of sentinel samples of regular PWID (The Australian Illicit Drug Reporting System, 2001–2011). Multivariable Poisson regression was used to explore the relationship between age and four outcomes of interest: last drug injection occurred in public, receptive needle sharing (past month), experiencing injecting-related problems (e.g. abscess, dirty hit; past month), and non-fatal heroin overdose (past six months).

Results

Data from 6795 first-time study participants were analysed (median age: 33 years, interquartile range [IQR]: 27–40; median duration of injecting: 13 years [IQR: 7–20]). After adjusting for factors including duration of injecting, each five year increase in age was associated with significant reductions in public injecting (adjusted incidence rate ratio [AIRR]: 0.90, 95% confidence interval [CI]: 0.88–0.92), needle sharing (AIRR: 0.84, 95% CI: 0.79–0.89) and injecting-related problems (AIRR: 0.96, 95% CI: 0.95–0.97). Among those who had injected heroin in the six months preceding interview, each five year increase in age was associated with an average 10% reduction in the risk of heroin overdose (AIRR: 0.90, 95% CI: 0.85–0.96).

Conclusions

Older PWID report significantly lower levels of high-risk injecting practices than younger PWID. Although they make up a small proportion of the current PWID population, younger PWID remain an important group for prevention and harm reduction.     

The interactive effects of antisocial personality disorder and court-mandated status on substance abuse treatment dropout

The present study sought to examine the interactive effects of court-mandated (CM) treatment and antisocial personality disorder (ASPD) on treatment dropout among 236 inner-city male substance users receiving residential substance abuse treatment. Of the 236 participants, 39.4% (n = 93) met criteria for ASPD and 72.5% (n = 171) were mandated to treatment through a pretrial release-to-treatment program. Results indicated a significant interaction between ASPD and CM status, such that patients with ASPD who were voluntarily receiving treatment were significantly more likely to drop out of treatment than each of the other groups. Subsequent discrete time survival analyses to predict days until dropout, using Cox proportional hazards regression, indicated similar findings, with patients with ASPD who were voluntarily receiving treatment completing fewer days of treatment than each of the other groups. These findings suggest the effectiveness of the court system in retaining patients with ASPD, as well as the role of ASPD in predicting treatment dropout for individuals who are in treatment voluntarily. Implications, including the potential value of the early implementation of specialized interventions aimed at improving adherence for patients with ASPD who are receiving treatment voluntarily, are discussed.     

Bystander resuscitation attempts at heroin overdose: does it improve outcomes?

STUDY OBJECTIVE: To document the characteristics and effectiveness of cardiopulmonary resuscitation (CPR) at non-fatal heroin overdose events in Melbourne, Australia. METHODS: A retrospective analysis of a computerised database of ambulance attendance records at non-fatal heroin overdose cases for the period 1/12/1998 to 31/7/2000 was undertaken. MAIN OUTCOME MEASURES: The main outcome measure was the rate of patient hospitalisation. The rate of CPR administration at heroin overdose cases was also examined, along with characteristics of the attendance, such as the age and sex of the overdose case, the relationship of person providing CPR to the overdose case as well as the location, time and date of the event. RESULTS: CPR was administered prior to ambulance arrival in 579 heroin overdose cases (9.4% of total heroin overdose cases attended) between 1/12/98 and 31/7/2000. A greater proportion of female overdose cases were administered CPR than males and CPR administrations were evenly distributed across attendances occurring in private and public locations. Bystander administration of CPR prior to ambulance attendance resulted in a significantly lower rate of heroin user hospitalisation (14.5%) compared to cases where bystander CPR was not administered (18.8%). CONCLUSIONS: While CPR administration prior to ambulance attendance at heroin overdose events is relatively uncommon (especially compared to out-of-hospital cardiac arrest), such administration was associated with a statistically significant improvement in clinical outcomes in cases of non-fatal heroin overdose. These findings suggest that the provision of CPR training to people likely to come into contact with heroin overdose events may be an effective strategy at minimising consequent overdose-related harm.     

Adolescent alcohol use disorders predict adult borderline personality

BACKGROUND: This study investigated adolescent alcohol use disorders (AUDs) and other characteristics as predictors of adult borderline personality disorder (BPD) symptoms. METHODS: Adolescents with AUDs (n = 355) were recruited from clinical treatment sources and adolescents without AUDs (n = 169) were recruited from the community. During an adolescent assessment (age 16+/-1.3), childhood physical and/or sexual abuse history, AUDs and associated psychiatric disorders were measured via semi-structured interviews. Symptoms of BPD were measured in a young adult follow-up assessment (age 22+/-2.4). Latent class analysis was utilized to classify individuals into four categories based upon BPD symptom profiles. RESULTS: Multinomial regression models indicated that adolescent AUDs and other psychiatric disorders mediated the relationship between child physical and/or sexual abuse and adult BPD latent class. CONCLUSIONS: Results were consistent with a developmental conceptualization of BPD, with AUDs and other adolescent psychopathology antecedents representing developmentally relevant forms of dysregulation, and in their more severe forms culminating in borderline symptomatology.