Substance misuse trends in South Africa

This paper, the first in a series related to the Joint European South African Research Network in Anxiety Disorders programme, examines substance use trends in South Africa. Alcohol remains the substance with the greatest burden of harm. Yet, trends vary by region, with for example methamphetamine being a major driver of psychiatric and substance abuse treatment demand in the Western Cape province. Heroin use is increasing in several provinces, where rapid intervention is required to avoid an epidemic. In particular, the state (the main funder of drug services) urgently needs to provide opioid substitution treatment. Apart from an inadequate number of treatment services, barriers to treatment are high. Barriers are predominantly cost, transport and resource related. Services are also impacted by a small and inadequately trained workforce and poor integration with mental health services. To adequately intervene with substance use disorders, South Africa needs an evidence-based policy and service planning framework that forges linkages with the mental health service system.     

A Randomized,Double-Blind,Placebo-Controlled,Trial of Lamotrigine Therapy in Bipolar Disorder,Depressed or Mixed Phase and Cocaine Dependence

Bipolar disorder is associated with very high rates of substance dependence. Cocaine use is particularly common. However, limited data are available on the treatment of this population. A 10-week, randomized, double-blind, placebo-controlled trial of lamotrigine was conducted in 120 outpatients with bipolar disorder, depressed or mixed mood state, and cocaine dependence. Other substance use was not exclusionary. Cocaine use was quantified weekly by urine drug screens and participant report using the timeline follow-back method. Mood was assessed with the Hamilton rating scale for depression, quick inventory of depressive symptomatology self-report, and young mania rating scale. Cocaine craving was assessed with the cocaine-craving questionnaire. Data were analyzed using a random regression analysis that used all available data from participants with at least one postbaseline assessment (n=112). Lamotrigine and placebo groups were similar demographically (age 45.1±7.3 vs 43.5±10.0 years, 41.8% vs 38.6% women). Urine drug screens (primary outcome measure) and mood symptoms were not significantly different between groups. However, dollars spent on cocaine showed a significant initial (baseline to week 1, p=0.01) and by-week (weeks 1–10, p=0.05) decrease in dollars spent on cocaine, favoring lamotrigine. Few positive trials of medications for cocaine use, other than stimulant replacement, have been reported, and none have been reported for bipolar disorder. Reduction in amount of cocaine use by self-report with lamotrigine suggests that a standard treatment for bipolar disorder may reduce cocaine use. A study limitation was weekly assessment of urine drug screens that decreased the ability to detect between-group differences.     

An estimation of the prevalence of opioid dependence in New Zealand

Background

An accurate prevalence estimate for opioid dependence in New Zealand, and hence the extent of unmet treatment need, is lacking.

Methods

Opioid users were recruited via snowball sampling, with participants initially recruited from opioid substitution treatment (OST) services and dedicated needle exchanges in Auckland, Tauranga and Christchurch. Participants estimated the number of people they knew personally who were receiving OST and who were not receiving OST, but were using opioids daily or almost daily. From these estimates a multiplier of the ratio between these two groups was derived and applied to the known number receiving OST in New Zealand to arrive at the total population estimate.

Results

The mean multiplier estimate, weighted for treatment site, for 84 recruited participants was 2.015. The multiplier was higher for Christchurch. Initial recruitment source did not influence the value of the multiplier estimate. When the multiplier was applied to the known size of the New Zealand OST treatment population the total opioid dependent population was estimated to be 9142 (95% CI: 8248-10036), of whom half were not receiving OST.

Conclusion

This figure was lower than for previous less robust estimates, but still represents a substantial level of unmet need. Greater effort needs to be made to close this treatment gap.     

药物成瘾患者创伤后应激障碍、抑郁、焦虑症状的调查

目的:调查了解药物成瘾者的创伤后应激障碍(PTSD)及焦虑抑郁的共病症状,为寻找更有效的治疗提供理论基础。方法:采用自编问卷、DSM-IV、初级PTSD筛查量表(PC-PTSD)、医院焦虑与抑郁量表(HADS)对年龄和性别相匹配的100例药物成瘾者和98例无任何物质成瘾史的被试测量成瘾状况,PTSD情况以及焦虑抑郁状况,并采用t检验和χ2检验比较成瘾组和对照组在抑郁、焦虑和PTSD得分的差异。结果:成瘾组和对照组在焦虑、抑郁(t=7.17,P<0.001;t=3.01,P<0.01)和PTSD量表(t=-3.39,P<0.001)的得分差异有统计学意义。成瘾组中有抑郁(P<0.01)和焦虑(P<0.01)的人数显著多于对照组;17例(17%)呈现PTSD阳性症状,同时还伴有抑郁、焦虑状况,对照组则有10%的人呈PTSD阳性症状并同时伴有抑郁、焦虑,两组差异没有统计学意义P>0.05)。结论:物质成瘾者PTSD症状及抑郁、焦虑共病症状较为严重,提示对药物成瘾需采用多元治疗方法,对多种不同症状同时进行治疗,才可能有好的治疗效果。     

HANS治疗仪对男性戒断期酒依赖患者心理渴求的作用

目的:评价HANS治疗仪对男性酒依赖患者戒断期心理渴求的影响。方法:将92例符合ICD-10中酒依赖诊断标准的戒断期男性患者随机分成两组:HANS组(治疗组)45例,给予2/100 Hz经皮穴位电刺激(HANS);Mock-HANS组(对照组)47例,给予模拟经皮穴位电刺激(Mock-HANS),为期15 d。比较两组酒精心理渴求评分(视觉模拟标尺,VAS)、谷氨酰转肽酶(GGT)和心率及血压变化。结果:(1)HANS组心理渴求分值(VAS)在治疗后d10(0.98±s 0.85 vs.1.6±s 1.35,P<0.05)和d15差异有显著性(0.67±s 0.76 vs.1.6±s 1.35,P<0.001),Mock-HANS组的下降差异无显著性;在治疗15 d时HANS组较Mock-HANS组的VAS分值差异有极显著性(0.67±s0.76 vs.1.84±s 0.87,P<0.001);(2)HANS组的GGT在治疗后下降差异有显著性(88.5±s 70.0 vs.198.1±s83.2,P<0.05),同时也低于Mock-HANS组的治疗后GGT的平均值(88.5±s 70.0 vs.144.0±s 85.2,P<0.05);(3)经治疗15 d后HANS组的收缩压和舒张压较治疗前下降明显(103.9±s 6.1 vs.126.7±s 14.1;68.7±s 6.0 vs.81.6±s 8.6,P均<0.05),而Mock-HANS组差异无显著性;(4)HANS组的心率在治疗15 d后下降差异有显著(70.5±s 2.8 vs.83.6±s 4.4,P<0.05),Mock-HANS组治疗后的心率变化差异无显著性。结獉论獉:HANS治疗仪能减轻戒断期酒依赖者的心理渴求程度,辅助改善血中GGT指标,降低酒依赖患者的心率、血压,对酒依赖患者的戒断期有一定的辅助治疗作用。     

Cue-induced craving and physiological reactions in recently and long-abstinent heroin-dependent patients

Objective

To understand the different patterns of cue-induced craving and physiological reactions among recently abstinent and long-abstinent heroin-dependent patients.

Method

26 healthy adult controls (HC), 29 long-abstinent (more than 1 year, LA), and 26 recently abstinent (less than 1 month, RA) heroin-dependent individuals were exposed to heroin-related and neutral video cues, one video per session, on different days in random order. Self-reported heroin craving by a 10-point visual analog scale (VAS), physiological reactions [skin conductance (SC), muscle electromyography (MEG), skin temperature (TEMP)] and cardiovascular arousal [heart rates (HR), systolic blood pressure (HBP) and diastolic blood pressure (LBP)] were assessed at baseline and after exposure.

Results

Both heroin-abstinent groups showed increased heroin craving, SC, MEG, HR, SBP and LBP after exposure to heroin-related video, compared to the control group and compared to exposure to the neutral video. Except the RA group showed more HR changes, changes of heroin craving, SC, MEG, HR, SBP and LBP after exposure to the heroin cue video were not different between the LA and RA groups.

Conclusions

Abstinent heroin-dependent patients had elevated craving and physiological reactions after exposure to videos containing heroin-related cues and the cue induced responses still occurred in long-abstinent patients. This phenomenon should be addressed in treatment and recovery services for heroin dependence.     

Ways of problem solving as predictors of relapse in alcohol dependent male inpatients

Aim

The purpose of this study was to identify how remitters and relapsers view their everyday problem solving strategies.

Method

A total of 128 male alcohol dependent male inpatients who were hospitalized at the Ankara University Psychiatry Clinic, Alcohol and Substance Abuse Treatment Unit were recruited for the study. Subjects demographic status and alcohol use histories were assessed by a self-report questionnaire. Also, patients were evaluated with The Coopersmith Self-esteem Inventory (CSI), The Spielberger State-Trait Anxiety Scale (STAI-I-II), and The Problem Solving Inventory (PSI). Patients were followed for six months with monthly intervals after hospital discharge. Drinking status was assessed in terms of abstinence and relapse. Data were assessed with Student t-test, and univariate and multivariate analyses. In the logistic regression analysis, age, marital status, employment status and PSI subscores were taken as the independent variables and drinking state at the end of six months as the dependent variable.

Results

There were significant differences in reflective and avoidant styles, and monitoring style of problem solving between abstainers and relapses. It was found that subjects who perceived their problem solving style as less avoidant and less reflective were at greater risk to relapse.

Conclusions

The findings demonstrated that active engagement in problem solving like utilizing avoidant and reflective styles of problem solving enhances abstinence. In treatment, expanding the behavior repertoire and increasing the variety of ways of problem solving ways that can be utilized in daily life should be one of the major goals of the treatment program.     

Associations between behavioral disinhibition and cocaine use history in individuals with cocaine dependence

Background

Behavioral disinhibition has been suggested as both a cause and consequence of substance use disorders. Many studies examining associations between behavioral disinhibition and substance use history have focused on individuals with alcohol dependence or non-dependent college students. In the present study, the relationship between behavioral disinhibition and cocaine use history in individuals with cocaine dependence is examined.

Methods

Forty-six non-treatment-seeking cocaine-dependent men and women completed impulsivity (Barratt Impulsiveness Scale; BIS) and novelty seeking (Temperament and Character Inventory; TCI) questionnaires at the baseline visit of an ongoing study. Unadjusted, and adjusted for gender and age, Pearson correlations were calculated between BIS, TCI, and cocaine use variables from the Structured Clinical Interview for DSM-IV and Timeline Follow-back (age of onset, quantity/frequency of past 30 day cocaine use).

Results

As expected, elevated motor impulsivity and novelty seeking were each associated with younger age of dependence onset. Also, individuals with lower levels of persistence on the TCI reported more days of cocaine use over the previous month. Unexpectedly, increased novelty seeking and attentional impulsivity were associated with fewer days of cocaine use and less money spent on cocaine, respectively. Controlling for age and gender did not substantially change the pattern of observed associations.

Conclusions

The present study provides preliminary evidence for associations between behavioral disinhibition and cocaine use history in cocaine-dependent individuals. Given our relatively small sample size and the correlational nature of our findings, further research is needed to replicate and extend our results.     

Predictors of attrition with buprenorphine/naloxone treatment in opioid dependent youth

Background

In opioid dependent youth there is substantial attrition from medication-assisted treatment. If youth at risk for attrition can be identified at treatment entry or early in treatment, they can be targeted for interventions to help retain them in treatment.

Methods

Opioid dependent adolescents and young adults (n = 152), aged 15–21, were randomized to 12 weeks (BUP, n = 74) or 2 weeks of detoxification (DETOX, n = 78) with buprenorphine/naloxone (Bup/Nal), both in combination with 12 weeks of psychosocial treatment. Baseline and early treatment related predictors of treatment attrition were identified in each group using bivariate and multivariate logistic regression.

Results

In the DETOX group 36% left between weeks 2 and 4, at the end of the dose taper, while in the BUP group only 8% left by week 4. In the BUP group, early adherence to Bup/Nal, early opioid negative urines, use of any medications in the month prior to treatment entry, and lifetime non-heroin opioid use were associated with retention while prior 30-day hallucinogen use was associated with attrition. In the DETOX group, only use of sleep medications was associated with retention although not an independent predictor. A broad range of other pre-treatment characteristics was unrelated to attrition.

Conclusions

Prompt attention to those with early non-adherence to medication or an early opioid positive urine, markers available in the first 2 weeks of treatment, may improve treatment retention. Extended Bup/Nal treatment appeared effective in improving treatment retention for youth with opioid dependence across a wide range of demographics, and pre-treatment clinical characteristics.