Substance Abuse, General Principles

The Evidence for SBIRT in Adolescents

The need for mental health services, and substance use treatment in particular, among deployed military personnel is well known and can hardly be debated 1-4. However, the need of the children in families with deployed parents is relatively poorly understood and remains a critically important and largely unaddressed public health issue in the United States 5-7. This is why the manuscript by Acion and colleagues 6 is both timely and important, as it examines the increased risk of alcohol and drug use among children from deployed families. The findings, while descriptive in nature, clearly demonstrate higher levels of current alcohol use, heavy alcohol use, current marijuana use, current illegal drug use and current prescription drug misuse among children in deployed families versus children in other families. This issue is particularly troubling given that the United States has had a substantial increase in deployed military personnel in recent years and a corresponding increase in the number of children who have had their parents deployed. An emerging literature outlines a range of psychosocial issues among children in military-connected families 5, 8. The issue of increased substance use among the children in military families appears to be troubling, in particular because substance use may exacerbate many of the other issues these children and youth are facing 5. It has been well documented that alcohol and substance misuse is a pervasive problem among military personnel and veterans that extends to their families 3, 4, 8, 9. Recent findings indicate that half the substance abuse treatment admissions among veterans aged 21–39 years involve alcohol as the primary substance of abuse 10. Additionally, research concerning army soldiers examined shortly after returning from deployment show that 27% met criteria for alcohol abuse 1. As such, it is not surprising that alcohol misuse is a critically important problem not only for those serving in the military, but also for their family members. However, data on substance use among family members, particularly the children, are lacking 5-7. While most attention has been given to the deployed family member, less attention has been given to the children of the deployed family members. These children may be vulnerable to a host of issues that also include mobility and disruption of care and social networks 5. Several new strategies have been proposed 11, and recent initiatives have been launched to understand more clearly and address the broader issues of family functioning in this population 12, 13. For example, in 2010 the National Institute of Drug Abuse and the Department of Veteran Affairs launched a program to support research on substance abuse among US military personnel, veterans and their families 1. However, it is not yet clear how these initiatives will address the growing needs of at-risk children in military families specifically and what the outcomes may be pertaining to prevention and intervention initiatives, including screening and treatment services. The paper by Acion and colleagues 6 suggest that schools and health-care providers conduct screening for early substance use and facilitate access to services among youth at heightened risk for substance use. Similarly, the American Academy of Pediatrics recommends that pediatricians screen and evaluate youth routinely for substance use and provide office interventions and referrals for patients who are using alcohol or other substances 14. While this policy does not address military-connected families specifically, if the policy were implemented fully, with particular attention to youth whose parents are deployed, substance use issues in this population could be addressed more promptly and thoroughly, and then evaluated in future research. Additionally, the National Institute of Alcohol Abuse and Alcoholism has disseminated the recently developed Alcohol Screening and Brief Intervention for Youth: A Practitioner's Guide [15], which will greatly streamline interaction with youth and provide guidance to practitioners on this important topic. In addition to these new tools and initiatives, it will be important to establish future research priorities regarding substance use among the children in military-connected families 5. It is particularly important to identify strategies to reduce and delay alcohol use in this population and seek to prevent the consequences of early alcohol and substance use 16, 17. Additionally, providing reassurance to the impacted communities will also be important by implementing additional protection to these youth to offset the hardship their families have faced. To conclude, military-connected youth have substantially higher levels of substance use than other youth for a number of reasons and, as such, it should be considered an important health disparity. This issue, as do other disparities, merits commensurate increased attention and provision of resources to these affected children and youth. Unfortunately, lack of action to address this issue more deliberately raises important questions about our capacity, commitment and willingness to provide the support services that many of these children need and deserve. None.

Letter to editor

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

Adaptation of the Drug and Drug Problems Perception Questionnaire to assess healthcare provider attitudes toward adolescent substance use.

These commentaries [1,2] as well as the Engberg & Morral [3] paper, raise important and thought-provoking questions concerning the role of adolescent substance use in academic outcomes. Godley [1] makes the point that, regardless of the nature of the relation between academic achievement and substance use, schools are an important potential intervention environment for adolescents who are at risk for substance use problems. Indeed, our own findings and those of Engberg & Morral [3] suggest that adolescent drug use is related to reductions in sustained engagement in academic pursuits, which implies that interventions outlined by Godley [1] could improve school engagement and attendance. Engberg & Morral's data are particularly compelling, as they demonstrate that reducing substance use through a treatment program increases school attendance among heavy drug-using adolescents. Taken together, the results of both empirical studies suggest that decreasing drug use will produce improvements in academic outcomes. Results of both studies [3,4] underscore the importance of clarifying the mechanisms by which substance use influences academic outcomes. Research suggests at least two potential mechanisms. First, substance use itself may impair cognitive development which, in turn, reduces academic achievement and disrupts academic progression. Recent studies have shown that heavy adolescent substance use can lead to problems with working memory and attention due to changes in adolescent brain activity [5]. In turn, these memory and attention problems may lead to decreases in academic performance and engagement in school, and ultimately increase risk for school problems and dropout. However, these findings have been reported with heavy drinking and drug-using adolescents (similar to the clinical sample used by Engberg & Morral), and it is unclear whether such effects would emerge at lower levels of use. Moreover, the magnitude and permanence of these effects are unclear in terms of whether they extend to impair academic functioning. For example, studies [6,7] suggest that withdrawal is an important predictor of the neurocognitive deficits associated with adolescent drinking, but it is not clear whether prolonged periods of abstinence rectifies these deficits or whether they are permanent. Alternatively, it could be that drug and alcohol use during adolescence leads to association with antisocial peer groups, which in turn diminishes school engagement and increases other behavioral and social problems. Indeed, as Godley and the current studies support, substance use is related to many school-related outcomes that have a strong behavioral and social component. That is, outcomes such as school grades, attendance, school completion and dropout are influenced not only by intellectual functioning, but also by motivation, organizational skills and social/behavioral skills. In other words, the effects of substance use on academic outcomes may have motivational, social and behavioral components in addition to any effects on cognition and cognitive development. Thus, negative academic outcomes may be due to both the direct effect of substance use on cognitive skills as well as the constellation of motivational, social and behavioral risk factors associated with substance use in adolescence. Interestingly, the findings from the current studies suggest that the mechanism by which substance use influences academic performance may differ depending on the nature of the adolescent sample (clinical versus community) and the developmental outcome that is studied (high school attendance versus academic achievement and college completion). Specifically, the substance use of heavy drug-using adolescents may directly impair academic (cognitive) abilities which limits academic performance in adolescence. For most adolescents who use drugs at a lower level, however, adolescent drug use may serve as a maturational ‘snare’ that keeps some adolescents engaged in deviant peer groups as others move on to more normative groups, thus having a long-term direct effect on educational attainment. Other studies [8–10] have discussed similar processes, in which differential pathways to problematic outcomes are determined, in part, by the level of multiple risk behaviors. If we believe that multiple mechanisms are operating, then it follows that preventive interventions aimed at improving academic engagement should broaden their focus beyond drug use in adolescence. We echo Godley's [1] suggestion that community and family risk factors should also be targets of intervention. Our findings showed that drug use in adolescence partially mediated the effect of adolescent externalizing behaviors on college completion; adolescent externalizing also had direct effects on both adolescent reading achievement and on degree completion [3]. This implies that a powerful target of intervention would be externalizing behaviors, especially for adolescents who have not yet developed heavy or problematic levels of alcohol and/or drug use. This commentary was supported by Grant AA16213 from the National Institute an Alcohol Abuse and Alcoholism to Laurie Chassin and a National Research Service Award from the National Institute on Drug Abuse to Kevin M. King, Grant DA019753.

A large body of research has identified peer exposure as a key factor driving adolescent substance use. However, findings on the role of sex partners are less robust and mixed. This study aims to fill this gap by examining the independent contribution of close friends' and sex partners' alcohol and marijuana use on adolescents' use of these substances. A secondary data analysis of social network data collected in 2000-2002 from a household sample of African American youth (14-19years old) in the Bayview and Hunter's Point neighborhoods of San Francisco was conducted. Index participants and their nominated close friends and romantic sex partners (N = 104 triads) self-reported recent alcohol and marijuana use (defined as any use in the past 3months). Generalized estimated equations were used to estimate the independent association between adolescent's recent substance use and their friend's and sex partner's use. Adolescents with a marijuana-using romantic sex partner had a nearly six-fold higher odds of using marijuana compared to adolescents with a non-using partner, controlling for close friend's marijuana use and other confounders [OR:5.69, 95%CI: 1.94, 16.7]; no association with close friend's marijuana use was found. A similar pattern was observed for alcohol use. Adolescents with an alcohol-using romantic sex partner had increased odds of using alcohol compared to adolescents with a non-using partner, controlling for close friend's alcohol use and other confounders [OR:2.40, 95%CI: 1.02, 5.63]; no association with close friend's alcohol use was found. Romantic sex partners may play a unique and significant role in adolescent substance use. Peer-focused interventions may be more effective if they consider romantic sex partners. Future research should consider the role of romantic sex partners in changing social context related to substance use from adolescence to young adulthood.

Concurrent substance use among adolescents has been associated with an increase in physical and mental health problems. These outcomes tend to be exacerbated among adolescents of color in underserved urban settings. The purpose of this study was to understand alcohol and concurrent drug use patterns among adolescents in an underserved urban community to provide targeted prevention and treatment recommendations. This study examined data among adolescents in an underserved urban community (N = 1789; 56.90% female; 70.86% Hispanic/Latino/a; meanage = 15.96 ± 1.56). Using latent class analysis (LCA) and multinomial logistic regression modeling, analyses identified independent correlates of latent class membership. Five latent classes (LC) were identified including LC group 1: Predominant alcohol use and limited to no concurrent-drug use (n = 213; 11.9%); LC group 2: Concurrent drug and alcohol use including methamphetamine, marijuana and synthetic marijuana use, and alcohol use (n = 74; 4.2%); LC group 3: Concurrent drug and alcohol use, with no marijuana use (n = 204; 11.39%); LC group 4: High Concurrent drug use and alcohol use (n = 204; 11.40%); and LC group 5: Concurrent drug use without alcohol use (n = 1101; 61.52%). Significant between group differences were noted between latent class groups and sociodemographic characteristics. Multinomial logistic regression models identified the associations between sociodemographic characteristics and corollary clinical features of substance use on latent class groupings of alcohol and concurrent drug use. Understanding concurrent substance use LC groups among adolescents is essential to providing targeted interventions and treatment programs, as well as early intervention programs that may help reduce substance use during adolescence.

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

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

Antisocial behavior is a known risk factor for substance use in adolescence, but the combined effects of antisocial and prosocial behaviors are unknown. This study examined whether five types of anti- and prosocial behaviors are associated with subsequent alcohol and substance use. A prospective longitudinal cohort study of 3817 adolescents (55.3% females) aged 15 at baseline (T1) and 17 at follow-up (T2). Self-reports at T1 measured antisocial behaviors (criminal behavior, conduct problems) and prosocial behaviors (global prosociality, general trust, institutional trust). T2 measures included alcohol use (hazardous use, alcohol use disorder), drug use, and nicotine use. Antisocial behaviors positively predicted all types of substance use (X2=5.79 to 59.07, p<0.001), while prosocial behaviors negatively predicted most substance use measures (X2=-5.64 to 86.14, p=0.862 to<0.001). After adjusting for covariance between antisociality and prosociality, it was found that conduct problems (X2=5.54 to 32.22, p=0.005 to<0.001), criminal behavior (X2=3.61 to 33.77, p=0.007 to<0.001), and institutional trust (X2=-3.92 to 27.56, p=0.262 to<0.001), were the most important predictors. Antisocial behaviors and deficits in institutional trust at age 15 are strong and unique predictors of substance use and alcohol use disorder by age 17. This specific spectrum of social behaviors during the critical phase of adolescence is of relevance from a prevention perspective to minimize the risk of later development of substance abuse.

Background: The co-occurrence of mental and substance use disorders (SUDs) poses major public health challenges. Understanding their prevalence and risk factors is critical for developing targeted interventions. Aim: To estimate the prevalence of substance use and risk of co-occurring common mental disorders in three South African provinces (Western Cape, Eastern Cape [EC] and North West [NW]). Setting: The study was conducted in three provinces in South Africa (Madibeng district in NW province, King Sabata Dalindyebo [KSD] in the EC and Khayelitsha in the Western Cape). Methods: A stratified multistage random household survey was conducted using the 9-item Patient Health Questionnaire (PHQ-9), 7-item Generalised Anxiety Disorder Assessment (GAD-7) and Primary Care PTSD Screen (PC-PTSD-5) to assess mental disorders. Alcohol and substance use were measured with the Alcohol Use Disorders Identification Test (AUDIT) and Drug Use Disorders Identification Test (DUDIT). Weighted prevalence estimates were calculated, and Rao–Scott adjusted Chi-square tests accounted for the complex survey design. Unweighted Chi-square tests explored demographic associations. Results: Of 1597 participants, 64.9% screened positive for at least one mental disorder. The prevalence of alcohol use disorder (AUD) was 31.9% and SUD 7.4%. Co-occurrence of AUD and SUD was 6.3%. Alcohol use disorder was significantly associated with depression, anxiety and posttraumatic stress disorder (PTSD), whereas SUD (excluding alcohol) showed no significant associations. Conclusion: Psychiatric comorbidity was partly associated with substance use. The findings highlight a substantial burden of co-occurring alcohol use and mental disorders among South African men, underscoring the need for integrated, trauma-informed primary healthcare services. Contribution: The study provides population-based evidence to inform service delivery and policy for under-resourced settings.

Screening, Brief Intervention and Referral to Treatment (SBIRT) programs have been effective for moderate reductions of alcohol use among participants in universal settings. However, there has been limited evidence of effectiveness in referring individuals to specialty care, and the literature now often refers to screening and brief intervention (SBI). This study examines documentation of substance use disorder (SUD) diagnoses in a low-income Medicaid population to evaluate the effect of universal SBIRT on healthcare system recognition of SUDs, a first step to obtaining a referral to treatment (RT) for individuals with SUDs. SBI patient data from Wisconsin's Initiative to Promote Healthy Lifestyles (WIPHL) were linked to Wisconsin Medicaid claims data. A comparison group of Medicaid beneficiaries was identified from a matched sample of non-SBIRT clinics (total study N = 14,856). Hierarchical generalized linear modeling was used to assess rates of SUD diagnosis in the 12 months following receipt of SBIRT in WIPHL clinics compared with rates in non-SBIRT clinics. Analysis controlled for clinic, individual patient's health status, demographics, and baseline substance use diagnoses. SBIRT was associated with greater odds of being diagnosed with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), alcohol abuse or dependence as well as drug abuse or dependence over the 12 months subsequent to receipt of the screen. The overall diagnostic rate for any DSM-IV substance abuse or dependence was 9.9% at baseline and 12.2% during the follow-up year. SBIRT patients had 42% (p = .003) greater odds of being diagnosed with a substance use disorder within 12 months relative to comparison clinic patients. However, there were very few claims for specialty SUD services. The presence of SBIRT in a primary care clinic appears to increase the awareness and recognition of patients with SUDs and a greater willingness of healthcare providers to diagnose patients with an alcohol or drug use disorder on Medicaid claims. Further research is needed to determine if this increase in diagnosis reflects integrated care for SUDs or if it leads to improved access to specialty care, in which case abandonment of the RT component of SBIRT may be premature.

When you see it, let it be: Urgency, mindfulness and adolescent substance use

Differential typologies of current substance use among Black and White high-school adolescents: A latent class analysis