A call for papers. Substance abuse: innovations in primary care.

Substance use disorders in pregnancy: clinical, ethical, and research imperatives of the opioid epidemic: a report of a joint workshop of the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine

Perceived Effectiveness of Medications Among Mental Health Service Users With and Without Alcohol Dependence

501: The use of protease inhibitors (PI) during pregnancy and the risk for intrauterine growth restriction in human immunodeficiency virus (HIV) positive women

Worldwide, alcohol use accounts for approximately 2.5 million deaths annually1 and in the United States is estimated to account for economic costs exceeding $200 billion per year.2 According to the 2011 National Survey on Drug Use Health, 52% of Americans aged 12 years or older reported alcohol use, nearly 25% reported binge drinking (≥5 drinks on 1 occasion), and 6% reported heavy drinking (binge drinking on ≥5 occasions) over the past 30 days.3 The harmful effects of alcohol on health involve nearly every organ system as well as psychiatric and social comorbidity. While less prevalent, illicit drug use is also associated with health problems (such as human immunodeficiency virus infection and overdose) and substantial health care expenditures. The 2011 National Survey on Drug Use Health estimates that approximately 9% of Americans aged 12 years or older—an estimated 22.5 million individuals—used illicit drugs during the past 30 days in the United States.3 Because individuals who use alcohol and other drugs may have substantial health problems, they interact frequently with primary care, emergency departments, and other health care settings. Although some have questioned the “disease model” of addiction, asserting that substance use is a chosen behavior andnotadisease,4 there isnodoubt thatalcoholandotherdrug use disorders are prototypical chronic diseases and should be approached as such by the health care system.5 Substanceusedisorders, likediabetes, cardiovascular disease, and other chronic diseases, are characterized by a prolongedduration, intermittent acute and chronic exacerbations, and substantial morbidity and mortality. These disorders also are influenced by genetic and environmental factors, are related tospecificpathophysiologicphenomenon,and have major psychosocial components. Like other chronic diseases, substance use disorders are also treatable. Evidence for the effectiveness of treatment for improving outcomes among hazardous and harmful drinkers and among those with alcohol or drug dependence has increased considerably in the past 50 years. Screening, brief intervention, and referral to treatment (SBIRT) has been advocated for both alcoholand drug-using medical patients.6 Systematic reviews strongly support pharmacologicmanagement of alcohol withdrawal7 and also support the use of brief interventions inprimary care tomodestly decreasedrinking.8 Similarly, evidenceexists supporting theeffectivenessofpharmacotherapy suchasnaltrexone toprevent relapse in alcoholdependent individuals, althoughtheeffect size isalsomodest.9 Pharmacological approaches to opioid dependence such as buprenorphine10 have demonstrated efficacy, and buprenorphine is available in primary care. The availability of effective treatments for substance use disorders is a prerequisite for a systematic approach to treatmentandfollow-upknownaschroniccaremanagement (CCM). Chronic caremanagement is designed to improve the quality of health care and reduce health care costs for patients with chronic diseases such as diabetes,11 cardiovascular disease,12 and comorbidmedical andpsychiatric disease.13 Chronic care management also appears to be effective in increasing smoking abstinence.14 However, CCMhas not been studiedwidely in individuals with alcohol or drug dependence. Thus, the study in this issue of JAMA by Saitz and colleagues15 evaluatingCCMvsusualprimarycare for the treatment of patientswithdependence on alcohol andother drugs (opioids or stimulants) is an important addition to the literature. The authors randomly assigned 563 individuals to the 2 treatment strategies andassessed theprimaryoutcomes—selfreported abstinence fromheavydrinking, opioids, and stimulants—at baseline and 3, 6, and 12 months along with a series of secondary outcomes including other substance use measures, hospitalization, emergency department use, and substance use–related biomarkers. In comparisonwith usual primary care,CCMhadnosignificant effect onanyof theprimary outcomes. At 12months, 44% of patients assigned to CCM reported past-30-day abstinence from heavy drinking, opioids, andstimulants comparedwith42%ofpatients in theusualprimary care group. Similarly, there were virtually no differences in the other substance use–related measures and biomarkers, quality-of-life scores, or hospital and emergency department utilization. The only exception was that CCMtreated alcohol-dependent patientswere slightly less likely to experience alcohol problems, but this difference is probably clinically unimportant. Even though the patients in the CCM group were more likely to receive addiction treatment and medications, there was no improvement in outcomes vs primary care. For clinicians who believe that CCM should have a role in substancedependence treatment, these results are likely tobe disappointing.Methodologically, thiswasanexceedinglywelldesigned study in a “real-world” group of substancedependent patients using a comprehensive CCM model that was compared with usual primary care. The outcomes were well chosen and included both substance use–specific and broader measures. The 12-month follow-up rate (98% had Related article page 1156 Opinion

Back to table of contents Previous article Next article Clinical and Research NewsFull AccessNearly 10% of U.S. Employees Report Substance Use DisorderMary Brophy MarcusMary Brophy MarcusPublished Online:4 Jun 2015https://doi.org/10.1176/appi.pn.2015.6a1AbstractThe findings of the Substance Abuse and Mental Health Services Administration survey of full-time employees point to challenges of heavy alcohol and illicit drug use facing the accommodation and food services sector.Nearly 1 in 10 full-time employees in the United States has a substance use disorder, according to a report by the Substance Abuse and Mental Health Services Administration (SAMHSA). The findings, which document the industries hit hardest by alcohol and illicit drug use, highlight the importance of employee awareness and treatment programs.For the report, researchers combined data from the National Survey on Drug Use and Health (NSDUH)—which tracks alcohol and drug use in U.S. populations—from 2008 to 2012. The responses of full-time employees aged 18 to 64 were then compared across 19 job categories. These results were then compared with the results of the NSDUH conducted between 2003 and 2007.According to the report, 9.5 percent of full-time workers in the United States were dependent on or abused alcohol or illicit drugs in the past year. A total of 8.7 percent of full-time workers reported heavy drinking (defined as consuming five or more drinks on the same occasion on five or more days over a 30-day period), and 8.6 percent reported illicit drug use in the past month.Drug and alcohol problems can lead to a variety of factors that prove costly for employers, including lost productivity, accidents and injuries, employee absenteeism, dips in morale, and overall health issues, Peter Delany, Ph.D., L.C.S.W.-C., the director of SAMHSA's Center for Behavioral Health Statistics and Quality, told Psychiatric News. "It is estimated that U.S. companies lose billions of dollars a year as a result of problems related to alcohol and drug abuse," he said. By combining five years of data from the NSDUH, researchers can "more clearly identify the variations in substance use across different industries," Delany explained. The highest rates of past-month heavy alcohol use were found in employees of the mining (17.5 percent) and construction (16.5 percent) industries; the lowest rates were found in health care and social assistant workers (4.4 percent). The highest rates of past-month illicit drug use were found in accommodations and food service industry workers (19.1 percent); the lowest rates were found in public administration employees (4.3 percent). Accommodations and food service industry employees also had the highest rates of past-year abuse of any substance (16.9 percent); those in the educational services sector had the lowest (5.5 percent)."Substance abuse, both alcohol and drug use, continues to be a major problem in our workforce," said Petros Levounis, M.D., M.A., chair of the Department of Psychiatry at Rutgers New Jersey Medical School.By comparing the combined results of the 2008-2012 surveys with a study published in 2007, researchers found that accommodations and food service industry workers' past month use of illicit drugs increased from 16.9 percent in 2003-2007 to 19.1 percent in 2008-2012—a factor Levounis said might be driven by "a culture of stimulant use" in the industry where employees often work late into the evening. Construction workers, in contrast, experienced dips in workers' past-month use of illicit drugs—from 13.9 percent in 2003-2007 to 11.6 percent in 2008-2012."What we are seeing here reflects a public health problem that is beyond the scope of anything psychiatrists can directly address in their day-to-day practices," Andrew Saxon, M.D., a professor of psychiatry at the University of Washington, told Psychiatric News. "What psychiatrists can do is to be alert for and comfortable with diagnosing and treating substance use problems in the patients that they do see since a large number of people with psychiatric disorders also have co-occurring substance use disorders."The NSDUH report highlights the opportunity for alcohol and drug awareness programs in the workplace to address the needs of employees, explained Frederick Goggans, M.D., the medical director at McLean Borden Cottage, a residential alcohol and drug treatment facility in Camden, Maine. "Over my career, which spans 35 years, I've noticed that those businesses that have employee assistance programs to identify workplace alcohol and drug abuse are practicing smarter business than those who don't have programs," Goggans told Psychiatric News. "Communicating to people where they can go for help, providing affordable care, and reducing discrimination against those with substance use and mental disorders can do a lot to reduce the level of alcohol and drug use," Delany said. ■"Substance Use and Substance Use Disorder by Industry" can be accessed here. ISSUES NewArchived

Letter to editor

The associations between socioeconomic status (SES) and tobacco use, alcohol consumption and drug use are poorly understood in the Islamic Republic of Iran. To measure education- and wealth-related inequalities in cigarette smoking, hookah smoking, illicit drug use and alcohol consumption in Kermanshah Province, Islamic Republic of Iran. We used baseline data from the Ravansar Noncommunicable Disease (RaNCD) study. The study collected information on socioeconomic and demographic characteristics, cigarette and hookah smoking, alcohol consumption and illicit drug use of 10 015 adults aged ≥ 35 years between 2014 and 2016. The relative concentration index and absolute concentration index were used to measure education- and wealth-related inequalities in cigarette smoking, hookah smoking, illicit drug use and alcohol consumption. Cigarette smoking was concentrated among less-educated and less-wealthy men and women. Similarly, illicit drug use was concentrated among lower-SES men. In contrast, hookah smoking and alcohol consumption were more prevalent among higher-SES men. There were education- and wealth-related inequalities in tobacco, alcohol and illicit drug use in the west of the Republic of Iran. Future studies should aim to identify the main socioeconomic determinants of these inequalities in Kermanshah Province and generally in the Islamic Republic of Iran.

Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: Comparison at intake and 6 months later

Emerging research suggests that some bariatric surgery patients are at a heightened risk for developing substance use problems, especially alcohol use problems. An exhaustive literature review was conducted in January 2015 to investigate all articles published that included data on postoperative alcohol use, alcohol use disorders, and illicit drug use among bariatric surgery patients. Twenty-three studies reported on alcohol and/or substance use among bariatric patients. Six studies longitudinally assessed alcohol use behaviors; 3 of these studies found an increase in alcohol use following surgery. Six studies were cross-sectional, and 2 studies assessed medical records. Five studies investigated the prevalence of admissions to substance abuse treatment, and 3 studies combined alcohol and drug use data in a single index. Six studies reported on illicit drug use and reported low-postoperative use. The studies' samples were primarily non-Hispanic white females in their upper 40s, and only 11 of the 23 studies utilized validated assessment instruments. Studies employing longitudinal designs and large sample sizes indicate that bariatric patients who had the gastric bypass procedure are at an elevated risk for alcohol use problems postoperatively. Research also indicates that bariatric surgery patients might be overrepresented in substance abuse treatment facilities. Risk factors for problematic postoperative alcohol use include regular or problematic alcohol use presurgery, male gender, younger age, tobacco use, and symptoms of attention deficient and hyperactivity disorder. As a whole, however, studies indicate bariatric surgery patients demonstrate a low prevalence of problematic alcohol use, and studies about gastric bypass patients are not entirely conclusive. Prospective, longitudinal studies are needed, utilizing standardized and validated alcohol assessment instruments that follow postoperative bariatric patients well beyond 2 years, and account for types of bariatric procedure. Finally, study samples with greater racial/ethnic diversity and wider age ranges are needed.

This study was designed to assess trends in cigarette, illicit drug, and heavy alcohol use among active-duty military personnel from 1980 to 2005 and to examine the influence of socio-demographic changes within the military on patterns of substance use. Substance use prevalence rates were estimated from cross-sectional data obtained from nine self-report surveys administered to more than 150 000 active-duty service members world-wide over a 25-year period. Direct standardization was used to adjust for socio-demographic changes. Measures included self-reported cigarette use, illicit drug use and heavy alcohol use in the 30 days prior to the survey. Heavy alcohol use was defined as drinking five or more drinks per typical drinking occasion at least once a week in the past 30 days. Cigarette and illicit drug use among military personnel declined sharply and significantly from 1980 to 1998. Heavy alcohol use decreased in the mid-1980s but was stable from 1988 to 1998. Both cigarette smoking and heavy alcohol use increased significantly between 1998 and 2002 and remained at those levels in 2005. Illicit drug use remained low. Logistic regression analyses indicated that trends were influenced by other factors besides socio-demographic changes across survey years. The military has made notable progress in decreasing cigarette smoking and illicit drug use, but has made less progress in reducing heavy alcohol use. Additional emphasis should be placed on understanding recent increases in substance use and on planning effective interventions and prevention programs to reduce use in this high-risk population.

Outcomes in patients with acute myocardial infarction and a history of illicit drug use

Objective To study the New York City area population after the September 11, 2001, 9/11 attacks, focusing on tobacco and drug use and drug use disorders. An abundance of research has identified the important mental health sequelae stemming from exposure to disasters, especially vulnerability to the development of posttraumatic stress disorder (PTSD) and major depressive disorder (MDD). There also is a body of literature on the association of disaster exposure with alcohol use/misuse, but far less research on tobacco and other drug use/disorders. Methods A terrorism-affected sample (N = 379) was assessed nearly 3 years after the attacks using structured diagnostic interviews, providing predisaster and postdisaster prevalence and incidence of tobacco and drug use, changes in tobacco and drug use, and predisaster and postdisaster prevalence and incidence of drug use disorders in relation to the 9/11 attacks. DSM-IV criteria were fully assessed using structured diagnostic interviews for psychiatric disorders including PTSD, MDD, panic disorder, generalized anxiety disorder, and alcohol and drug use disorders. Results Tobacco use did not increase significantly, and no predictors of increased tobacco use could be found for any subgroups, including disaster trauma exposures. Drug use (largely cannabis) increased initially but decreased by 3 years after the attacks. Drug use disorders, which were associated with other psychiatric disorders, were rare and primarily began prior to 9/11. Conclusions The overall lack of increase of tobacco use or predictors of increased use found after the disaster and the low rates of new drug use disorders suggest that universal screening for increased tobacco use and new drug use disorders by clinicians may have very low yield. Regardless, postdisaster settings provide suitable circumstances for general discussions about self-care including concern for increased tobacco use, avoiding drug use, and guidance on healthier means of managing stress than through substances. Additionally, because existing tobacco and drug use are endemic in populations, the postdisaster setting can serve as a reminder for clinicians to assess these problems generally and provide appropriate referrals when needed. Postdisaster circumstances offer opportunities to disseminate and promote public health messages and address issues of substance use and misuse.

Drug misuse in India: Where do we stand & where to go from here?

ImportanceIllicit and nonmedical (use in ways other than instructed) drug use is common in adolescents and young adults and increases the risk of harmful outcomes such as injuries, violence, and poorer academic performance.ObjectiveTo review the benefits and harms of interventions to prevent illicit and nonmedical drug use in children, adolescents, and young adults to inform the US Preventive Services Task Force.Data SourcesMEDLINE, PubMED, PsycINFO, and the Cochrane Central Register of Controlled Trials (January 1, 2013, to January 31, 2019 [children and adolescents]; January 1, 1992, to January 31, 2019 [young adults <25 years]); surveillance through March 20, 2020.Study SelectionClinical trials of behavioral counseling interventions to prevent initiation of illicit and nonmedical drug use among young people.Data Extraction and SynthesisCritical appraisal was completed independently by 2 investigators. Data were extracted by 1 reviewer and checked by a second. Random-effects meta-analysis was used to estimate the effect sizes associated with the interventions.Main Outcomes and MeasuresNumber of times illicit drugs were used; any illicit drug or any cannabis use.ResultsTwenty-nine trials (N = 18 353) met inclusion criteria. Health, social, or legal outcomes such as mental health symptoms, family functioning, consequences of drug use, and arrests were reported in 19 trials and most showed no group differences. The effects on illicit drug use in 26 trials among nonpregnant youth (n = 17 811) were highly variable; the pooled result did not show a clinically important or statistically significant association with illicit drug use (standardized mean difference, −0.08 [95% CI, −0.16 to 0.001]; 24 effects [from 23 studies]; n = 12 801; I2 = 57.0%). The percentage of participants using illicit drugs ranged from 2.3% to 38.6% in the control groups and 2.4% to 33.7% in the intervention groups at 3 to 32 months’ follow-up. The median absolute risk difference between groups was –2.8%, favoring the intervention group (range, –11.5% to 14.8%). The remaining 3 trials provided a perinatal home-visiting intervention to pregnant Native American youth. One trial (n=322) found a reduction in illicit drug use at 38 months (eg, cannabis use in the previous month, 10.7% in the intervention group and 15.6% in the control group) but not at earlier follow-up assessments. Across all 29 trials, only 1 trial reported on harms and found no statistically significant group differences.Conclusions and RelevanceThe evidence for behavioral counseling interventions to prevent initiation of illicit and nonmedical drug use among adolescents and young adults was inconsistent and imprecise, with some interventions associated with reduction in use and others associated with no benefit or increased use. Health, social, and legal outcomes were sparsely reported, and few showed improvements.

To explore the use of tobacco, alcohol, and illicit drugs and its associated factors among Chinese immigrants living in Spain. A mixed-method design, using surveys and semi-structured interviews. A total of 133 Chinese immigrants and stakeholders were assessed in the quantitative study and 7 stakeholders were interviewed in the qualitative study. The use of tobacco and alcohol was higher than the use of illicit drugs in Chinese immigrants. The prevalence of daily smokers was greater in men than in women (37.3% vs. 2.5%, p<.001). Men consumed more alcohol (76% vs. 50.6%, p=.004) and more frequently (21.6% daily vs. 2.4%, p=.024) than women. The use of illicit drugs was low and Cannabis was the most illicit drug consumed (4%). Qualitative data revealed that due to a great workload, the workers tended to avoid behaviors of illicit drug consumption, but not of alcohol and tobacco, in which the consumption is associated with business meetings and leisure. This study found that Chinese immigrants in Spain consume more alcohol and tobacco than illicit drugs and that men have a high consumption compared to women. These findings reveal important cultural differences that should be addressed by public health managers in order to develop strategies that consider the characteristics of this population.