Cognitive functioning in substance abuse and dependence: a population-based study of young adults

Aims   To investigate whether substance use disorders (SUDs) are associated with verbal intellectual ability, psychomotor processing speed, verbal and visual working memory, executive function and verbal learning in young adults, and to study the associations of SUD characteristics with cognitive performance.
Participants   A population-based sample ( n  = 466) of young Finnish adults aged 21–35 years.
Measurements   Diagnostic assessment was based on all available information from a structured psychiatric interview (SCID-I) and in- and out-patient medical records. Established neuropsychological tests were used in the cognitive assessment. Confounding factors included in the analyses were comorbid psychiatric disorders and risk factors for SUDs, representing behavioural and affective factors, parental factors, early initiation of substance use and education-related factors.
Findings   Adjusted for age and gender, life-time DSM-IV SUD was associated with poorer verbal intellectual ability, as measured with the Wechsler Adult Intelligence Scale–Revised (WAIS-R) vocabulary subtest, and slower psychomotor processing, as measured with the WAIS-R digit symbol subtest. Poorer verbal intellectual ability was accounted for by parental and own low basic education, whereas the association with slower psychomotor processing remained after adjustment for SUD risk factors. Poorer verbal intellectual ability was related to substance abuse rather than dependence. Other SUD characteristics were not associated with cognition.
Conclusions   Poorer verbal intellectual ability and less efficient psychomotor processing are associated with life-time alcohol and other substance use disorders in young adulthood. Poorer verbal intellectual ability seems to be related to parental and own low basic education, whereas slower psychomotor processing is associated with SUD independently of risk factors.     

Association of tobacco dependence and quit attempt duration with Rasch-modeled withdrawal sensitivity using retrospective measures

Aim   To examine whether Rasch modeling would yield a unidimensional withdrawal sensitivity measure correlating with factors associated with successful smoking cessation.
Design   The psychometric Rasch modeling approach was applied to estimate an underlying latent construct (withdrawal sensitivity) in retrospective responses from 1644 smokers who reported quitting for 3 or more months at least once.
Setting   Web-based, passcode-controlled self-administered computerized questionnaire.
Participants   Randomly selected convenience sample of 1644 adult members of an e-mail invitation-only web panel drawn from consumer databases.
Measurements   Lifetime Tobacco Use Questionnaire, assessing tobacco use across the life-span, including demographics and respondent ratings of the severity of withdrawal symptoms experienced in respondents' first and most recent quit attempts lasting 3 or more months.
Findings   Rasch-modeled withdrawal sensitivity was generally unidimensional and was associated with longer periods of smoking cessation. One latent variable accounted for 74% of the variability in symptom scores. Rasch modeling with a single latent factor fitted withdrawal symptoms well, except for increased appetite, for which the fit was marginal. Demographic variables of education, gender and ethnicity were not related to changes in sensitivity. Correlates of greater withdrawal sensitivity in cessation attempts of at least 3 months included younger age at first quit attempt and indicators of tobacco dependence.
Conclusion   The relationship between tobacco dependence symptoms and Rasch-model withdrawal sensitivity defines further the relationship between sensitivity and dependence. The findings demonstrate the utility of modeling to create an individual-specific sensitivity measure as a tool for exploring the relationships among sensitivity, dependence and cessation.     

A survey of tobacco dependence treatment guidelines in 31 countries

Aims The Framework Convention on Tobacco Control (FCTC) asks countries to develop and disseminate comprehensive evidence‐based guidelines and promote adequate treatment for tobacco dependence, yet to date no summary of the content of existing guidelines exists. This paper describes the national tobacco dependence treatment guidelines of 31 countries. Design, setting, participants A questionnaire on tobacco dependence treatment guidelines was sent by e‐mail to a convenience sample of contacts working in tobacco control in 31 countries in 2007. Completed questionnaires were received from respondents in all 31 countries. During the course of these enquiries we also made contact with people in 14 countries that did not have treatment guidelines and sent them a short questionnaire asking about their plans to produce guidelines. Measurements The survey instrument was a 17‐item questionnaire asking the following key questions: do the guidelines recommend brief interventions, intensive behavioural support, medications; which medications; do the guidelines apply to the whole health‐care system and all professionals; do they refer explicitly to the Cochrane database; are they based on another country's guidelines; are they national or more local; are they endorsed formally by government; did they undergo peer review; who funded them; where were they published; do they include evidence on cost effectiveness of treatment? Findings According to respondents, all their countries' guidelines recommended brief advice, intensive behavioural support and nicotine replacement therapy (NRT); 84% recommended bupropion; 19% recommended varenicline; and 35% recommended telephone quitlines. Nearly half (48%) included cost‐effectiveness evidence. Seventy‐one per cent were supported formally by their government and 65% were supported financially by the government. Most (84%) used the Cochrane reviews as a source of evidence, 84% underwent a peer review process and 55% were based on the guidelines of other countries, most often the United States and England. Conclusion Overall, the guidelines reviewed followed the evidence base closely, recommending brief interventions, intensive behavioural support and NRT, and most recommended bupropion. Varenicline was not on the market in most of the countries in this survey when their guidelines were written, illustrating the need for guidelines to be updated periodically. None recommended interventions not proven to be effective, and some recommended explicitly against specific interventions (for lack of evidence). Most were peer‐reviewed, many through lengthy and rigorous procedures, and most were endorsed or supported formally by their governments. Some countries that did not have guidelines expressed a need for technical support, emphasizing the need for countries to share experience, something the FCTC process is well placed to support.     

A Placebo-Controlled Trial of Dextromethorphan as an Adjunct in Opioid-Dependent Patients Undergoing Methadone Maintenance Treatment

Background:

Low-dose dextromethorphan (DM) might have anti-inflammatory and neurotrophic effects mechanistically remote from an NMDA receptor. In a randomized, double-blind, controlled 12 week study, we investigated whether add-on dextromethorphan reduced cytokine levels and benefitted opioid-dependent patients undergoing methadone maintenance therapy (MMT).

Methods:

Patients were randomly assigned to a group: DM60 (60mg/day dextromethorphan; n = 65), DM120 (120mg/day dextromethorphan; n = 65), or placebo (n = 66). Primary outcomes were the methadone dose required, plasma morphine level, and retention in treatment. Plasma tumor necrosis factor (TNF)-α, C-reactive protein, interleukin (IL)-6, IL-8, transforming growth factor–β1, and brain-derived neurotrophic factor (BDNF) levels were examined during weeks 0, 1, 4, 8, and 12. Multiple linear regressions with generalized estimating equation methods were used to examine the therapeutic effect.

Results:

After 12 weeks, the DM60 group had significantly longer treatment retention and lower plasma morphine levels than did the placebo group. Plasma TNF-α was significantly decreased in the DM60 group compared to the placebo group. However, changes in plasma cytokine levels, BDNF levels, and the methadone dose required in the three groups were not significantly different.

Conclusions:

We provide evidence—decreased concomitant heroin use—of low-dose add-on DM’s efficacy for treating opioid-dependent patients undergoing MMT.     

The Role of Topiramate in the Management of Cocaine Addiction: A Possible Therapeutic Option

Topiramate (TPM) is an antiepileptic drug able to play a role in both neurological and psychiatric disorders. TPM facilitates gamma-aminobutyric acid (GABA) transmission and inhibits glutamatergic transmission (i.e. AMPA/kainate receptors).Several studies reported that the modulation of GABAergic and glutamatergic synaptic transmission may reduce cocaine reinforcement. Therefore, TPM could be used in the management of cocaine dependence.     

A cross-sectional survey of factors associated with the uptake of smoking cessation aids among smokers and ex-smokers

Background: A cross-sectional survey was conducted in Germany via the online panel PsyWeb with the aim of assessing factors associated with the uptake of smoking cessation aids among smokers and ex-smokers.

Methods: Of the 10,000 panel members invited to participate in the survey, 624 took part.

Main Outcome Measures: Outcomes were measured via questionnaires to assess the uptake of smoking cessation aids, health literacy, readiness to change smoking behavior, and the Fagerström Test for Nicotine Dependence.

Results: There was no association between gender or educational status and use of smoking cessation aids according to chi-square tests of independence. Logistic regression showed that health literacy, degree of tobacco dependence, and readiness to change were significantly associated with the uptake of smoking cessation aids. Smokers with a high degree of nicotine dependence, high readiness to change, and low health literacy were more likely to use aids.

Conclusion: The survey results can be used to develop psychological approaches and interventions to promote smoking cessation, e.g., interventions to increase readiness to change among smokers may increase the uptake of aids. Moreover, the results may help to improve patient care by disseminating information on effective aids and thereby promoting smoking cessation among relevant patient groups.     

Management of ventilator-associated pneumonia: Need for a personalized approach

Introduction: Optimizing management of ventilator-associated pneumonia (VAP) should focus on the accurate identification of true lung infection, determination of the etiological agent, and early institution of adequate empirical therapy and de-escalation. Local adaptation of the standard guidelines leads to favorable outcome in the management of VAP

Areas covered: In this review, we present the concepts of early adequate therapy and the key considerations such as patient characters, clinical and etiological diagnosis, and assessment of patients for de-escalation that favor optimization of therapy. We highlight the issues that need a personalized approach in the management of VAP emphasizing on various patient categories for reassessment and tailoring the therapy.

Expert commentary: Rapid diagnostic techniques and non-invasive metabolomics will identify phenotypes which will shift the traditional paradigm based on conventional cultures. A personalized approach taking into account baseline resistance epidemiology, underlying disease (and comorbidities), duration of hospitalization, and prior antimicrobial exposure should guide targeted therapy.     

Opioid Use Disorder: Challenges During Acute Hospitalization

Opioid use is a major public health concern increasing the volume of need for medical care and the national tragedy of accidental overdose deaths. Patients with opioid use disorders have higher numbers of emergency department visits, acute hospitalizations, and complications secondary to opioid use. Acute care nurse practitioners are challenged to manage increasingly complicated patient encounters related to opioid use. This article addresses effective strategies for inpatient management of opioid use disorder including identification and the use of measurement-based tools, as well as providing supportive care.