Prevalence of substance abuse in a psychiatric evaluation unit.

The prevalence of substance abuse and psychiatric illness was studied in a Psychiatric Evaluations Unit. Twenty-six percent of the subjects received a psychiatric diagnosis only with no concomitant substance use disorder. Thirty-four percent were diagnosed with a substance use disorder but with no other psychiatric disorders. Thirty-nine percent of the subjects had a history of both psychiatric and substance use disorder; 62% of these substance abusers with a psychiatric illness reported using drugs (including alcohol) the week before the interview; 56% used illicit drugs while 44% used alcohol only. Differences among substance abusers with a psychiatric illness, those with a substance abuse diagnosis alone, and those with a psychiatric diagnosis alone are presented.     

Psychological distress and return to substance use two years following treatment

This study examined client background characteristics, substance use severity, and psychological distress in relation to return to alcohol and drug use among men and women 2 years following substance user treatment. Participants (n = 180) completed a baseline interview within their first month of substance user treatment (conducted in 1995/1996) and follow-up interview 2 years following the baseline interview (conducted in 1997/1998). Structural equation modeling analyses were used to examine the relationship among client background characteristics and problem severity indicators, measured during treatment, in relation to alcohol and illicit drug use 2 years posttreatment. Psychological distress directly predicted alcohol and illicit drug use during follow-up and appeared to mediate the relationship between client background characteristics (such as gender, race, and marital status) and substance use consequences on posttreatment substance use. Income directly predicted alcohol use and age directly predicted illicit drug use, regardless of problem severity (including psychological distress and substance use consequences). Results support long-term clinical monitoring of psychological distress as a marker for return to drug or alcohol use.     

Estazolam treatment of insomnia in generalized anxiety disorder: a placebo-controlled study

Estazolam, a triazolobenzodiazepine with an intermediate elimination half-life, has been shown previously to be an effective and safe hypnotic in insomniacs without concomitant psychiatric illness. Our study of the efficacy of estazolam in patients with insomnia associated with generalized anxiety disorder began when 108 patients meeting criteria for generalized anxiety disorder (mean total score of Hamilton Rating Scale for Anxiety [HAM-A] = 22.0 +/- 3.1 [SD]) and insomnia were given single-blind placebo for 7 nights. Nine patients whose anxiety and/or insomnia improved were dropped as placebo responders. The remaining 99 patients were randomly allocated (1:1) to double-blind treatment with either estazolam 2.0 mg or matching placebo for 7 nights. Hypnotic efficacy, as determined by patient-completed sleep questionnaires, was statistically significant for estazolam 2.0 mg versus placebo for all sleep indices (p less than 0.01). Patients treated with estazolam 2.0 mg showed significantly greater improvement in anxiety than those receiving placebo on the mean total score of HAM-A ([placebo, -3.4; estazolam, -7.1; p less than 0.001] and without the insomnia item [placebo, -2.7; estazolam, -5.5; p less than 0.001]). Anxiety scores on the State-Trait Anxiety Inventory showed greater improvement in the estazolam group, but without statistical significance (p = 0.237). Estazolam 2.0 mg is an effective hypnotic in patients with generalized anxiety disorder and appears to have a favorable anxiolytic action.     

Influence of language abilities and alcohol expectancies on the persistence of heavy drinking in youth

OBJECTIVE: It has been suggested that neuropsychological functioning and cognitive factors influence substance use and treatment outcomes in youth. This study examined a model in which language skills moderate the extent to which expectancies about the positive effects of alcohol predict the persistence of alcohol involvement in youth over an 8-year period. METHOD: Participants were substance use disordered adolescents recruited from inpatient alcohol and drug treatment centers (N = 139). Exclusion criteria included major head trauma, neurological illness and psychiatric disorders. Participants were administered neuropsychological tests, expectancy questionnaires and substance involvement interviews that spanned an 8-year period from ages 16 to 24 on average. Substance involvement was assessed by self-report, collateral reports and urine toxicology screens. RESULTS: Using latent class growth analysis of alcohol use over 8 years, participants were classified as abstainers, infrequent users, worse with time or frequent users. Language x Expectancy interactions were significant at all time points (p range .05 to .0001, effect size eta2 range 0.03 to 0.20). This interaction significantly predicted 8-year alcohol dependence symptoms over and above effects accounted for by covariates or main effects (F = 2.98, 5/100 df, p < .05; R2delta = 4%, beta = 0.21, p <.05). CONCLUSIONS: For youths with above average language skills, positivealcohol expectancies predicted alcohol use frequency and dependence symptoms in the 8 years following treatment; expectancies were less related to outcomes for youths with poorer language scores. Results suggest that verbal skills may magnify the relationship between alcohol expectancies and drinking behavior.     

Profile of a sample of subjects admitted to an acute care psychiatric facility with manic symptoms.

A prospective survey was conducted on 155 consecutive subjects with manic symptoms admitted to an inpatient psychiatric facility to identify possible reasons for rehospitalization. Approximately one third were previously hospitalized at the same facility within the past month. Over half (57%) of the sample were admitted because of aggressive episodes. On admission, 80 percent were receiving carbamazepine or lithium for a mood disorder, and 52.3 percent were receiving multiple medications, of which antipsychotics accounted for over half. Forty-four percent of the sample had comorbid substance use on admission, with marijuana and stimulants accounting for the majority of illicit drug use. Medication noncompliance in 64 percent, and identifiable psychosocial stressors in 55 percent, were also likely contributors to rehospitalization. The data highlights specific treatment issues in the care of patients with a manic component to their illness, and suggests the need for individualized discharge planning with careful followup and continual patient education to assist in the transition from inpatient to society.     

Illicit peyote use among American Indian adolescents in substance abuse treatment: a preliminary investigation

Few studies to date have addressed illicit (i.e., nonceremonial) peyote use among American Indians (AIs). Participants were 89 AI adolescents admitted to a tribally operated residential substance abuse treatment program (RSATP) between 1998 and 2001. The RSATP is designed to provide specialized treatment of patients with substance use and other comorbid psychiatric disorders and is infused with a culturally sensitive approach to treatment. The participants completed a series of interviews that collected information on psychiatric diagnostic status, history of substance use, and ethnic identity. The majority of participants were male (65%), did not come from a two-parent household (75%), reported a mean use of 5.4 substances, and met full criteria for a median of 2.9 substance use disorders. Of 89 clients, 10 (11.2%) reported illicit use of peyote. The vast majority of these youth (n = 8) reported using peyote only once or twice in their lifetime. Illicit peyote users did not differ from nonusers in terms of age, gender, other substance use, prevalence of either other substance abuse/dependence or other nonsubstance use psychiatric disorders. However, illicit peyote users were more likely to report low levels of social support, low levels of self-esteem, and low identification with AI culture yet comparable involvement in AI traditional practices. The results of this exploratory study suggest that illicit peyote use is uncommon among AI adolescents with serious substance abuse problems.     

Partner violence impacts the psychosocial and psychiatric status of pregnant, drug-dependent women

The present study compared pregnant, drug-dependent women reporting current partner abuse (n=26) or no partner abuse (n=76) at treatment enrollment on initial psychosocial and psychiatric functioning. Abused pregnant women presented with more severe alcohol and family/social problems and greater rates of psychiatric problems and comorbidity than nonabused women did. The abused women reported that their partners had greater rates of alcohol and illicit drug use, relative to the partners of the nonabused women. Results suggest that treatment should address the women's relationships with their partners, especially when substance abuse and violence issues are present.     

Illicit Peyote Use Among American Indian Adolescents in Substance Abuse Treatment: A Preliminary Investigation

Few studies to date have addressed illicit (i.e., nonceremonial) peyote use among American Indians (AIs). Participants were 89 AI adolescents admitted to a tribally operated residential substance abuse treatment program (RSATP) between 1998 and 2001. The RSATP is designed to provide specialized treatment of patients with substance use and other comorbid psychiatric disorders and is infused with a culturally sensitive approach to treatment. The participants completed a series of interviews that collected information on psychiatric diagnostic status, history of substance use, and ethnic identity. The majority of participants were male (65%), did not come from a two-parent household (75%), reported a mean use of 5.4 substances, and met full criteria for a median of 2.9 substance use disorders. Of 89 clients, 10 (11.2%) reported illicit use of peyote. The vast majority of these youth (n = 8) reported using peyote only once or twice in their lifetime. Illicit peyote users did not differ from nonusers in terms of age, gender, other substance use, prevalence of either other substance abuse/dependence or other nonsubstance use psychiatric disorders. However, illicit peyote users were more likely to report low levels of social support, low levels of self-esteem, and low identification with AI culture yet comparable involvement in AI traditional practices. The results of this exploratory study suggest that illicit peyote use is uncommon among AI adolescents with serious substance abuse problems.     

Reliability and validity of the German version of the European Addiction Severity Index (EuropASI)

OBJECTIVE: This study provides data on the psychometric characteristics of the German version of the European Addiction Severity Index (EuropASI). The ASI is a frequently used clinical and research instrument that measures problem severity among people with substance dependence. METHOD: The German ASI was used in a sample of 112 consecutively admitted male psychiatric inpatients seeking treatment for severe alcohol problems. The conceptual structure of the German ASI subscales was investigated by analyzing the intercorrelations of the severity ratings and composite scores. Internal consistency, interrater reliability and concurrent validity in terms of correlations with other assessment instruments were evaluated. RESULTS: The German ASI subscales proved to be independent or moderately correlated (-0.17 < r < 0.34). Each correlation coefficient between corresponding severity ratings and composite scores was significant (p < .0005), ranging from r = 0.47 to r = 0.93. Reliability measures indicated moderate to good internal consistency (Cronbach's alpha: 0.69-0.92) and moderate to excellent interrater reliability (intraclass correlation coefficient: 0.62-0.99). Validity was supported by significantly higher ratings in the alcohol section in alcohol dependent patients compared to patients without dependence (t = 2.99, 108 df, p = .004). Significant correlations (p < .001) were found between the alcohol use section and the Michigan Alcoholism Screening Test (r = 0.34 composite score and r = 0.44 severity rating) and between psychiatric status and the Symptom Checklist-90-revised (r = 0.55/0.51), supporting concurrent validity. CONCLUSIONS: The German version presented evidence of acceptable psychometric properties and its applicability in German-speaking countries could be confirmed.     

Quality of care for substance use disorders in patients with serious mental illness

We assessed the quality of care for substance use disorders (SUDs) among 8,083 patients diagnosed with serious mental illness from the VA mid-Atlantic region. Using data from the National Patient Care Database (2001-2002), we assessed the percentage of patients receiving a diagnosis of SUD, percentage beginning SUD treatment 14 days or earlier after diagnosis, and percentage receiving continued SUD care 30 days or less. Overall, 1,559 (19.3%) were diagnosed with an SUD. Of the 1,559, 966 (62.0%) initiated treatment and 847 (54.3%) received continued care. Although patients diagnosed with bipolar disorder were more likely to receive a diagnosis of SUD than those diagnosed with schizophrenia or schizoaffective disorder (22.7%, 18.9%, and 17.7%, respectively; chi(2) = 26.02, df = 2, p < .001), they were less likely to initiate (49.1%, 70.7%, and 68.6%, respectively; chi(2) = 59.29, df = 2, p < .001) or continue treatment (39.9%, 63.2%, and 62.2%, respectively; chi(2) = 72.25, df = 2, p <. 001). Greater efforts are needed to diagnose and treat SUDs in patients with serious mental illness, particularly for those with bipolar disorder.     

Cannabis and psychosis in acute psychiatric admissions

This study assessed the duration of admission and time to relapse in 62 acute psychiatric in-patients who had urinary drug screens performed because of suspicion of illicit drug use. Some 51% of those with psychosis (n = 45) and 29% of those with non-psychotic illness (n = 17) were THC-positive although this was not significant. In those with recurrent admissions for psychosis tetrahydrocannabinol (THC)-positive subjects were significantly younger. The duration of admission was 7 days shorter in the THC-positive group but this was not significant. Their duration since last admission (rapidity of relapse) was 10 months versus 33 months which was significant. [Grace RF, Shenfield G, Tennant C. Cannabis and Psychosis in acute psychiatric admissions. Drug Alcohol Rev 2000;19:287-290]     

Psychological Distress and Return to Substance Use Two Years Following Treatment

This study examined client background characteristics, substance use severity, and psychological distress in relation to return to alcohol and drug use among men and women 2 years following substance user treatment. Participants (n = 180) completed a baseline interview within their first month of substance user treatment (conducted in 1995/1996) and follow-up interview 2 years following the baseline interview (conducted in 1997/1998). Structural equation modeling analyses were used to examine the relationship among client background characteristics and problem severity indicators, measured during treatment, in relation to alcohol and illicit drug use 2 years posttreatment. Psychological distress directly predicted alcohol and illicit drug use during follow-up and appeared to mediate the relationship between client background characteristics (such as gender, race, and marital status) and substance use consequences on posttreatment substance use. Income directly predicted alcohol use and age directly predicted illicit drug use, regardless of problem severity (including psychological distress and substance use consequences). Results support long-term clinical monitoring of psychological distress as a marker for return to drug or alcohol use.     

Non-medical use, abuse and dependence on sedatives and tranquilizers among U.S. adults: psychiatric and socio-demographic correlates

BACKGROUND: Non-medical use of sedatives and tranquilizers carries risks including development of abuse/dependence. Such use may correlate with psychiatric symptoms. METHODS: Cross-sectional survey, the 2002-2004 National Survey on Drug Use and Health. Respondents 18 years and older (n=92,020). Bivariate and multivariable associations were investigated. RESULTS: The prevalence of past-year non-medical use of sedatives or tranquilizers was 2.3%. Of those with non-medical use, 9.8% met criteria for abuse/dependence. On multivariable analysis, panic symptoms and elevated serious mental illness scores were associated with past-year non-medical use. Also, the following past-year socio-demographic and substance use covariates were associated with past-year non-medical sedative or tranquilizer use: female sex, white/hispanic/other ethnicity, criminal arrest, uninsurance, unemployment, alcohol abuse or dependence, cigarette use, illicit drug use, younger age of initiating illicit substance use, and any history of IV drug use. Among those with sedative or tranquilizer use, those with abuse/dependence were more likely to have agoraphobic symptoms. In addition, they were more likely to be older, unmarried, have a low education level and have been arrested. CONCLUSIONS: Non-medical use of sedatives and tranquilizers is common. Furthermore, nearly 10% of those with non-medical use meet criteria for abuse/dependence. Anxiety symptoms associated with non-medical use (panic symptoms) and abuse/dependence (agoraphobia) should alert clinicians to screen for these problems and consider alternate treatment or referral.     

Characteristics of older opioid maintenance patients

The aging "baby boomer" population has higher rates of substance use than previous cohorts and is predicted to put increased demands on substance abuse treatment services; however, little is known about older illicit drug abusers. This study compared 41 older (age 50-66 years) and 26 younger (age 25-34 years) opioid maintenance patients on psychiatric, substance use, medical, general health, demographic, and psychosocial characteristics using standardized instruments. The health of both groups was compared to age and sex-matched U.S. population norms. Both groups had high rates of lifetime psychiatric and substance abuse/dependence diagnoses, and poor general health compared to population norms. The older group began using illicit substances significantly later in life, and had significantly more medical problems and worse general health than the younger group. The inevitable increasing medical morbidity and physical limitations of an increasingly large older population with substance use problems will challenge treatment providers and planners. Low rates of positive urine opioid tests occurred for both older and younger patients without age-specific services.     

Drug-use behavior and correlates in people with schizophrenia

This study examined how illicit drugs were accessed, reasons for drug use, prevalence of emotional, physical, and sexual abuse, psychiatric symptomatology, level of functioning, and the relationship of these factors to substance use in 25 schizophrenia outpatients. To identify unique substance-use behaviors or correlates, this information was compared to 25 substance-abusing outpatients with major affective disorders, and 30 people with schizophrenia alone. Patients largely financed their drug habits with money given by immediate family members, and reported using drugs primarily for social reasons. While all three groups reported high levels of physical, sexual, and emotional abuse, a relationship between emotional abuse and substance use was observed only for people with schizophrenia. There were no differences between the two schizophrenia groups in psychiatric symptoms or level of functioning. The treatment implications of these findings are discussed.     

The Epidemiology of the Comorbidity of Psychiatric and Addictive Disorders:

Assessing the prevalence of the comorbidity of psychiatric and addictive disease using epidemiologic methods results in artifactually high rates. Use of a clinical sample will yield falsely high rates, because substance use is associated with exacerbation of mental illness. Cross sectional design will inflate rates of psychiatric comorbidity in addicts, who attribute substance use to psychological symptoms until well into recovery. Application of exclusionary criteria for independent diagnosis is subject to investigator bias, particularly about the unproven yet popular "self-medication" hypothesis. The psychiatric symptoms which are common in active addiction generally clear within weeks to months of treatment for addiction but do not respond to standard psychopharmacologic treatment for primary mental illness. When lengthy follow up periods are employed, substance induced psychiatric syndromes typically resolve. We conclude that while patients treated in psychiatric settins often have comorbid and independent addictive illness, patients treated in addiction settings uncommonly have comorbid psychiatric illness despite common psychiatric symptoms.     

High Dose versus Moderate Dose Methadone Maintenance: Is There a Better Outcome?

ABSTRACT

Methadone dosing has been an issue of controversy among clinicians for a long time. Few recent studies reported that doses above 100 mg daily seem promising in better control of illicit opiate use for some patients, but more research is needed to support that notion. A retrospective chart review for patients maintained on methadone at Atlanta Veterans Affairs Medical Center was conducted. Patients were categorized into two groups: patients on a methadone dose of 60 to 100 mg daily (n = 34) and patients on a methadone dose greater than 100 mg daily (n = 25). Those charts were compared for urine drug screens for opiates and cocaine (first four from admission and most recent four screens), retention or drop out from the program, and Addiction Severity Index (ASI) composite score at admission and most recent score. The results of the first and last four urine drug screens for opiates showed that the moderate dose group was positive 23% and 17%, respectively. However, the high dose group was positive 14% and 8%, respectively. These results showed statistical significance (Chi-Square = 8.04, df = 3 and p =.03). ASI scores for drugs did not show statistically significant improvement for the moderate dose group (p =.19) but showed statistically significant improvement for the high dose group (p =.0002) when the result of the first and last ASI scores among each group were compared. The ASI scores for family problems showed statistically significant improvement for the moderate dose group (p =.03). High doses of methadone greater than100 mg daily may provide a better outcome for illicit opiate use among some patients who would not respond to moderate doses.     

Incidence of next-day anterograde amnesia caused by flurazepam hydrochloride and triazolam

The incidence of next-day anterograde amnesia was evaluated in hospitalized patients who received flurazepam hydrochloride or triazolam. A blinded observer assessed memory and daytime drowsiness in 154 patients after the bedtime ingestion of flurazepam hydrochloride (n = 54), triazolam (n = 49), or no hypnotic drug (n = 51). The hypnotic agents were administered before midnight. At approximately 0800 the next morning, the patients were shown a picture of an object on colored construction paper and asked to remember it as well as the color of the background. Both the observer and patient assessed drowsiness using the Stanford Sleepiness Scale. The observer also made a note of the items on the patient's breakfast tray. Patients were then revisited at 1100 and asked to recall the object in the picture, the color of the background, and at least three items from their breakfast tray. Ten of the 54 patients in the flurazepam group failed to recall all three items compared with only two in the triazolam group and two in the control group. The 14 patients who experienced memory impairment were significantly more drowsy at 0800 than those who were able to recall the items. Next-day anterograde amnesia occurred more frequently in patients who received flurazepam hydrochloride than in those who received triazolam or no hypnotic drug. This effect may be related to the next-day drowsiness caused by flurazepam and its slowly eliminated active metabolite.