Childhood trauma among individuals with co-morbid substance use and post traumatic stress disorder

Increased Prevalence of Childhood Complex Trauma in Comorbid Posttraumatic Stress Disorder and Substance Use Disorders Compared to Either Disorder Alone: A Systematic Review

OBJECTIVE

Childhood complex trauma (CCT) prevalence among individuals with comorbid posttraumatic stress disorder (PTSD) and substance use disorder (SUD) is unknown. We conducted a meta-analysis to compare CCT prevalence in samples of PTSD alone, SUD alone and comorbid PTSD+SUD.

METHOD

A systematic review of PTSD, CCT and SUD literature was conducted using online databases. Binary outcome meta-analytic models were fitted comparing CCT prevalence in comorbid PTSD + SUD to PTSD and SUD only.

RESULTS

Seven studies were included, and estimates for CCT prevalence were higher, on average, among individuals with comorbid PTSD+SUD (35%-78%) compared to PTSD alone (4%-70%) and SUD alone (2%-65%). A meta-analysis of four studies indicated individuals with comorbid PTSD+SUD were 18% more likely to have experienced CCT compared to individuals with PTSD only (RR = 1.18, 95% CI [1.13, 1.25]) and 24% more likely compared to individuals with SUD only (RR = 1.24, 95% CI [1.20, 1.29]).

CONCLUSIONS

Further research is needed to establish a more accurate prevalence rate for individuals with comorbid PTSD and SUD. Evidence of greater CCT prevalence will inform research study design and clinical targets during treatment for individuals with comorbid PTSD and SUD.

Co-occurring experiences of traumatic events and substance use among young people

OBJECTIVE

Harmful substance use among young people is concerningly prevalent. Substance use disorder (SUD) and post-traumatic stress disorder (PTSD) frequently co-occur in treatment settings and are well researched among adults but lacking among young community cohorts. The aim of this study was to explore the prevalence and relationship between substance use, SUD, trauma, and PTSD among a community sample of young people in Australia.

METHOD

A cross-sectional examination of data collected from participants (n = 1007, 48.9 % male) aged 18-22 years (M = 20 years, SD = 0.44), who took part in the 7-year follow-up of a cluster RCT of school-based substance use prevention interventions: The Climate and Preventure (CAP) study. A series of regressions were conducted to examine the relationship between trauma-related variables and substance use outcomes.

RESULTS

48.3 % experienced a traumatic event (median = 2, range = 1-11) and of those 10.9 % met a probable PTSD diagnosis. Median age of first trauma exposure was 14 years (range = 0-21). 89.9 % used substances; 73.1 % reported binge drinking, and 35.6 % met a probable diagnosis of SUD (alcohol/cannabis). Those who experienced any traumatic event had almost 1.5 times greater odds of binge drinking. Cannabis use was significantly associated with most trauma-related variables. Sexual trauma exposure was the only trauma type significantly associated with all substance use variables.

CONCLUSIONS

This study demonstrated that substance use/SUD and experiences of trauma/PTSD are prevalent among a community sample of young people. Importantly, substance use among young people is associated with experiencing a traumatic event, particularly sexual and physical types of traumatic events, and developing PTSD.

Responding to the HIV Health Literacy Needs of Clients in Substance Use Treatment: The Role of Universal PrEP Education in HIV Health and Prevention

Health literacy, particularly HIV health literacy, is a key social determinant of health and can be significantly improved through targeted health education. This paper explores the often-overlooked potential of pre-exposure prophylaxis (PrEP) education as a powerful tool to enhance HIV health literacy among people with substance use disorders (PWSUD), a population notably susceptible to HIV. Given the syndemic interplay of substance use disorders (SUDs) and HIV, health professionals, especially substance use counselors, are uniquely positioned to bolster HIV health literacy and positively influence health outcomes. This article offers a brief introduction to PrEP, delineates potential barriers and facilitators to its use and education, and proposes strategies for effective PrEP education, implementation, and adherence. By equipping substance use counselors with essential knowledge and skills, we aim to encourage and promote the integration of PrEP education into substance use treatment. The overarching objective is to empower counselors to proactively engage in HIV prevention efforts, thereby fulfilling pressing health literacy needs and contributing to improved health outcomes among PWSUD.

Patterns and Sociodemographic Characteristics of Substance Abuse Among the Adult Population in Makkah City, Saudi Arabia: A Cross-Sectional Study

BACKGROUND

Substance abuse is a term that refers to the harmful or hazardous use of psychoactive substances, including alcohol and illicit drugs. One of the key impacts of illicit drug use on society is the negative health consequences experienced by its members.

OBJECTIVE

This study recorded the pattern of substance abuse and the sociodemographic characteristics of adult substance abusers in Makkah City.

METHODS

An online self-administered survey was provided to the general population through social media platforms between March 2023 and August 2023. Males and females living in Makkah over the age of 18 were included in it. The participants who refused to take part or those who were younger than 18 were not included in the study.

RESULTS

The number of participants in this study was 720; 73.5% were under the age of 30 and 424 were females (58.9%). The significant variables between substance abuse and sociodemographic data were gender (P=0.001), depression (P≤0.000), anxiety (P≤0.000), stress (P=0.025), and bad/shocking experience during childhood (P=0.004).

CONCLUSION

Substance abuse positively correlates with sociodemographic data, with males having a higher risk, and psychiatric neurosis is associated with childhood trauma and anxiety.

Screening for adverse childhood experiences among young people using drugs in Vietnam: related factors and clinical implications

BACKGROUND

Research evidence shows a strong association between adverse childhood experiences (ACEs) and later-life substance use. But little is known about the prevalence and impact of ACEs among young people using drugs (YPUD) in Vietnam.

METHOD

A cross-sectional study using respondent-driven sampling and peer recruitment methods was conducted among YPUD aged 16-24 in three cities in Vietnam. Eligible participants were screened for ACEs using the ACE-IQ, tested for HIV and hepatitis C, and assessed for sociodemographic and behavioral characteristics.

RESULTS

Data were collected on 553 individuals whose median age was 20: 79% were male, 18.3% women and 2.7% transgender. Methamphetamine use was reported by 75.8% of participants. 85.5% reported at least one ACE and 27.5% had four ACEs or more. An ACE score of 4 or higher was associated with female and transgender, lower educational level, methamphetamine use, buying sex, depression, psychotic symptoms and expressed need for mental health support.

CONCLUSIONS

ACEs were found to be very common among YPUD in Vietnam. It is therefore strongly recommended that these young people should be provided with a comprehensive and secure assessment and care that includes not only essential harm reduction and addiction treatment needs but also addresses their mental health needs.

Noninvasive Vagal Nerve Stimulation for Opioid Use Disorder

Background

Opioid Use Disorder (OUD) is an escalating public health problem with over 100,000 drug overdose-related deaths last year most of them related to opioid overdose, yet treatment options remain limited. Non-invasive Vagal Nerve Stimulation (nVNS) can be delivered via the ear or the neck and is a non-medication alternative to treatment of opioid withdrawal and OUD with potentially widespread applications.

Methods

This paper reviews the neurobiology of opioid withdrawal and OUD and the emerging literature of nVNS for the application of OUD. Literature databases for Pubmed, Psychinfo, and Medline were queried for these topics for 1982-present.

Results

Opioid withdrawal in the context of OUD is associated with activation of peripheral sympathetic and inflammatory systems as well as alterations in central brain regions including anterior cingulate, basal ganglia, and amygdala. NVNS has the potential to reduce sympathetic and inflammatory activation and counter the effects of opioid withdrawal in initial pilot studies. Preliminary studies show that it is potentially effective at acting through sympathetic pathways to reduce the effects of opioid withdrawal, in addition to reducing pain and distress.

Conclusions

NVNS shows promise as a non-medication approach to OUD, both in terms of its known effect on neurobiology as well as pilot data showing a reduction in withdrawal symptoms as well as physiological manifestations of opioid withdrawal.

Role of positive emotion regulation strategies in the association between childhood trauma and posttraumatic stress disorder among trauma-exposed individuals who use substances

BACKGROUND

The co-occurrence of childhood trauma and posttraumatic stress disorder (PTSD) is highly prevalent and clinically significant. Existing research emphasizes the role of emotion regulation in the relation between childhood trauma and PTSD. Yet, research in this area has almost exclusively examined the influence of strategies aimed at regulating negative emotions, such as anger and sadness.

OBJECTIVE

To extend existing research, the current study examined underlying roles of strategies for regulating positive emotions (i.e., self- and emotion-focused positive rumination and positive dampening) in the association between childhood trauma severity and PTSD symptoms.

PARTICIPANTS AND SETTING

Participants were 320 trauma-exposed community individuals who reported past 30-day substance use (Mage = 35.78, 50.3% men, 81.6% white).

METHOD

Analyses examined whether childhood trauma severity was indirectly related to PTSD symptoms through self-focused positive rumination, emotion-focused positive rumination, and positive dampening.

RESULTS

Positive dampening, but not positive self- and emotion-focused positive rumination, indirectly explained associations between childhood trauma severity and PTSD symptoms (B = .17, SE = .03, 95% CI [.12, .24]).

CONCLUSIONS

These findings highlight the potential utility of targeting positive dampening in the treatment of PTSD symptoms among individuals who use substances with a history of childhood trauma.

Promoting Social Participation and Recovery with Virtual Reality Based Interventions among people with Mental Health and Substance Use disorders: A Qualitative study (Preprint)

BACKGROUND

People with mental health disorders (MHDs) and substance use disorders (SUDs) are a highly vulnerable group, particularly affected by social exclusion, marginalization, and disconnectedness. Virtual reality technology holds a potential for simulating social environments and interactions to mitigate the social barriers and marginalization faced by people recovering from MHDs and SUDs. However, it is still unclear how we can harness the greater ecological validity of virtual reality-based interventions targeting social and functional impairments in individuals with MHDs and SUDs.

OBJECTIVE

The aim of this paper was to explore how service providers in community-based MHD and SUD health care services perceive the barriers to social participation among adults recovering from MHDs and SUDs to provide a broader understanding of how learning experiences can be modeled to promote social participation in virtual reality environments.

METHODS

Two semistructured, open-ended, and dual-moderator focus group interviews were conducted with participants representing different community-based MHD and SUD health care services. Service providers were recruited from their MHD and SUD services in our collaborating municipality in Eastern Norway. We recruited the first participant group at a municipal MHD and SUD assisted living facility for service users with ongoing excessive substance use and severe social dysfunctionality. We recruited the second participant group at a community-based follow-up care service aimed at clients with a broad range of MHDs and SUDs and various levels of social functioning. The qualitative data extracted in the interviews were analyzed, using reflexive thematic analysis.

RESULTS

The analysis of the service providers' perceptions of the barriers to social participation among clients with MHDs and SUDs revealed the following five main themes: challenging or lacking social connections, impaired cognitive functions, negative self-perception, impaired personal functioning, and insufficient social security. The barriers identified are interrelated in a cluster of cognitive, socioemotional, and functional impairments, leading to a severe and diverse complex of barriers to social participation.

CONCLUSIONS

Social participation relies on people's capability to use their present social opportunities. Promoting basic human functioning is key to promoting social participation among people with MHDs and SUDs. The findings in this study indicate a need to address cognitive functioning, socioemotional learning, instrumental skills, and complex social functions to meet the complexity and diversity of the identified barriers to social functioning in our target group. Virtual reality-based interventions for promoting social participation should be sequenced into distinct scenarios dedicated to specific learning goals to build complex learning in a step-by-step process based on successively more complex levels of human and social functioning.

Associations Between Traumatic Stress, Brain Volumes and Post-traumatic Stress Disorder Symptoms in Children: Data from the ABCD Study

Reduced volumes in brain regions of interest (ROIs), primarily from adult samples, are associated with posttraumatic stress disorder (PTSD). We extended this work to children using data from the Adolescent Brain Cognitive Development (ABCD) Study® (N = 11,848; Mage = 9.92). Structural equation modeling and an elastic-net (EN) machine-learning approach were used to identify potential effects of traumatic events (TEs) on PTSD symptoms (PTSDsx) directly, and indirectly via the volumes 300 subcortical and cortical ROIs. We then estimated the genetic and environmental variation in the phenotypes. TEs were directly associated with PTSDsx (r = 0.92) in children, but their indirect effects (r < 0.0004)-via the volumes of EN-identified subcortical and cortical ROIs-were negligible at this age. Additive genetic factors explained a modest proportion of the variance in TEs (23.4%) and PTSDsx (21.3%), and accounted for most of the variance of EN-identified volumes of four of the five subcortical (52.4-61.8%) three of the nine cortical ROIs (46.4-53.3%) and cerebral white matter in the left hemisphere (57.4%). Environmental factors explained most of the variance in TEs (C = 61.6%, E = 15.1%), PTSDsx (residual-C = 18.4%, residual-E = 21.8%), right lateral ventricle (C = 15.2%, E = 43.1%) and six of the nine EN-identified cortical ROIs (C = 4.0-13.6%, E = 56.7-74.8%). There is negligible evidence that the volumes of brain ROIs are associated with the indirect effects of TEs on PTSDsx at this age. Overall, environmental factors accounted for more of the variation in TEs and PTSDsx. Whereas additive genetic factors accounted for most of the variability in the volumes of a minority of cortical and in most of subcortical ROIs.

Treatment of post-traumatic stress disorder and substance use disorder in adults with a history of adverse childhood experiences: A systematic review of psychological interventions

Background

Adverse childhood experiences (ACEs) have long-term effects on adult health, including unresolved trauma and substance use disorder (SUD). There are hypotheses of a mediating role of emotion regulation. This systematic literature review and narrative synthesis assessed the effectiveness of psychological interventions on emotion regulation, PTSD and SUD symptoms.

Methods

Searches were conducted using the Cochrane Handbook for Systematic Reviews methodology. Eligible studies were randomised controlled trials (RCTs) and quasi-experimental psychological interventions published between 2009 and 2019. Study characteristics, results and methodological quality were systematically analysed.

Results

Thirteen studies, including nine RCTs, were selected. Integrated SUD and PTSD treatments consisted of Seeking Safety, exposure-based treatment, Trauma Recovery and Empowerment Model, and integrated cognitive behavioural therapy. Two studies reported emotion regulation. Five studies found a small to medium positive effect size of psychological interventions on PTSD outcomes. Two studies had a small positive effect size on SUD outcomes and two a small negative effect size. Attrition was high across most studies. Characteristics likely to affect the applicability of the review were described.

Conclusion

The review found some evidence of a small inconsistent positive effect of psychological interventions on PTSD outcomes, and no evidence of effect on SUD outcomes. The range of theoretical models was narrow. Overall quality was low with high clinical heterogeneity and missing key information, particularly on emotion regulation, an important transdiagnostic feature. Further research is required to establish interventions that can treat these multiple conditions with a focus on effectiveness, acceptability, and implementation in real life clinical practice.

Moderators for the Relationship between Post-Traumatic Stress Disorder and Opioid Use Disorder

Objective: Post-traumatic stress disorder (PTSD) is a common risk factor for opioid use disorder (OUD). However, not all individuals with PTSD develop OUD when exposed to opioids. As the underlying moderators remain unexplored, this analysis aimed to determine if non-traumatic adverse experiences and stressors prior to the age of 18 moderate the relationship between PTSD and OUD. Methods: In a matched dataset (n = 830) of individuals with or without PTSD who reported lifetime use of opioids, the following non-traumatic adverse experiences and stressors were assessed: emotional abuse, emotional neglect and physical neglect, parents' adverse experiences, and number of days jailed before the age of 18. Using the PROCESS macro in SAS for each factor, the conditional effects were estimated through simple slopes. Moderation was inferred through significant interaction effects. Results: The matched data were similar on age, gender, ethnicity, education, being born in the US, living with, or losing biological parents before age 18, and family history of depression, anxiety, and substance use disorder. Significantly more individuals in the preexisting PTSD group had preexisting psychiatric disorders, and preexisting substance use and schizotypal personality disorder. Childhood emotional abuse and neglect and physical neglect (effect: 0.03; 95%CI: 0.001-0.056; p = .039), and more than one event of adversity experienced by parents (effect: 0.34; 95%CI: 0.07-0.61; p = .013) significantly interacted with PTSD to lead to OUD. Conclusion: The conditional effect of PTSD on the development of OUD after exposure to opioids was dependent on the frequency and severity of childhood non-traumatic adverse experiences. To identify individuals with PTSD who are at a high risk of developing OUD, programs may focus on non-traumatic adverse childhood experiences that are not commonly explored. Future steps may include focusing on educational schemes to mitigate this higher risk of developing OUD in at-risk individuals, for example, by discussing the risks when prescribing opioids.

Does Childhood Adversity Lead to Drug Addiction in Adulthood? A Study of Serial Mediators Based on Resilience and Depression

Drug addiction is a common problem worldwide. Research has shown adverse childhood experiences (ACEs) to be an important factor related to drug addiction. However, there are few studies on how ACEs lead to drug addiction and the role of resilience and depression in this process. Thus, the main purposes of the study were to determine the proportion of those with adverse childhood experiences who take drugs in adulthood and how resilience and depression affect this relationship. The results showed that (1) greater severity of ACEs made individuals more likely to take drugs; (2) ACEs were positively correlated with depression, and resilience was negatively correlated with ACEs and depression; and (3) ACEs not only affected drug addiction through resilience or depression alone but also through the combined action of resilience and depression, indicating that depression led to drug addiction while resilience weakened the effect of ACEs on depression and drug addiction. Furthermore, in the serial mediation model, abuse, neglect, and family dysfunction were significant predictors of drug addiction. Our results are encouraging in that they provide guidance in understanding the complex relationships among ACEs, resilience, depression, and drug addiction.

Adverse childhood experiences among females in substance use treatment and their children: A pilot study

Women with substance use disorder (SUD) often have experienced adverse childhood experiences (ACEs). The intergenerational nature of ACEs also put their children at risk for experiencing ACEs. However, no research has explored the prevalence of ACEs in children whose mothers have SUD. This study assessed ACE scores in mothers with SUD and their children and compared them with non-SUD participants. Females with SUD were recruited from a treatment center (n = 50) and compared to females without SUD from the same area (n = 50). The ACE scores of the participants and their children were measured as well as sociodemographic variables. ANOVA and Fisher's Exact tests were used to examine univariate differences. Multivariate regression models assessed the difference in ACE scores between the groups and their children and the relationship between maternal and child ACE scores while including sociodemographic confounders. The mean ACE score was significantly higher in SUD participants (4.9, SD = 2.9) when compared to non-SUD participants (1.9, SD = 2.0) after controlling for sociodemographic variables (p < .01). Children of treatment participants also had significantly higher mean ACE scores (3.9, SD = 2.3) than children of comparison participants (1.3, SD = 2.0, p < .01). Maternal ACE score was positively related to children's ACE score after controlling for sociodemographic variables. Given the intergenerational nature of ACEs and their high burden in both mothers and children in substance use treatment, these preliminary findings suggest that mother-child trauma-informed interventions may be appropriate for this population.

Integrated Trauma-Focused Psychotherapy for Traumatic Stress and Substance Use: Two Adolescent Case Studies

Post-traumatic stress disorder (PTSD) and substance use disorder (SUD) occur frequently as comorbid diagnoses among adolescents. Historically, these conditions have been treated using a sequential model; however, emerging evidence suggests that an integrated treatment model may be most effective. This article presents two de-identified clinical case studies from an ongoing randomised controlled trial examining the efficacy of an integrated, exposure-based, cognitive-behavioral psychotherapy (CBT) for PTSD and SUD among adolescents (COPE-A), relative to a supportive counselling control condition (person-centred therapy). In both case studies, participants were randomised to receive the COPE-A integrated treatment, which incorporates prolonged exposure (PE) including imaginal and in vivo exposure as a core treatment component alongside CBT for PTSD and SUD. The clinical profile and treatment response of each participant is discussed. Promising results were found in both cases, with substantially reduced traumatic stress symptoms and decreased or stable levels of substance use by the end of treatment. Clinical implications of these early findings are discussed.

Early childhood trauma, substance use and complex concurrent disorders among adolescents

PURPOSE OF REVIEW

To highlight the interdependence between early childhood trauma, substance use and complex concurrent disorders among adolescents and discuss the delayed response and gaps in the healthcare system.

RECENT FINDINGS

High-risk behavior such as suicidality, self-harm and hazardous substance use including overdose and the use of psychotropic substances for self-medication of mental health challenges is a growing concern. These symptoms are often related to early childhood trauma, substance use and complex concurrent disorders. Most countries do not have a youth mental healthcare system, there are no specific guidelines and only few programs addressing high-risk substance use are in place.

SUMMARY

In addition to the significance of traumatic experience for high-risk substance use and addiction, most parts of the system of care ignore the trauma aspect in treatment of substance use and focus on abstinence. There are hardly any early intervention programs, broader prevention strategies or evidence-based or target-group-oriented treatment offers.

The Developmental Origins of Opioid Use Disorder and Its Comorbidities

Opioid use disorder (OUD) rarely presents as a unitary psychiatric condition, and the comorbid symptoms likely depend upon the diverse risk factors and mechanisms by which OUD can arise. These factors are heterogeneous and include genetic predisposition, exposure to prescription opioids, and environmental risks. Crucially, one key environmental risk factor for OUD is early life adversity (ELA). OUD and other substance use disorders are widely considered to derive in part from abnormal reward circuit function, which is likely also implicated in comorbid mental illnesses such as depression, bipolar disorder, and schizophrenia. ELA may disrupt reward circuit development and function in a manner predisposing to these disorders. Here, we describe new findings addressing the effects of ELA on reward circuitry that lead to OUD and comorbid disorders, potentially via shared neural mechanisms. We discuss some of these OUD-related problems in both humans and animals. We also highlight the increasingly apparent, crucial contribution of biological sex in mediating the range of ELA-induced disruptions of reward circuitry which may confer risk for the development of OUD and comorbid neuropsychiatric disorders.

Trajectories of Posttraumatic Stress in Youths After Natural Disasters

IMPORTANCE

Disaster exposure is associated with the development of posttraumatic stress (PTS) symptoms in youths. However, little is known about how to predict which youths will develop chronic PTS symptoms after disaster exposure.

OBJECTIVE

To evaluate PTS symptom trajectories among youths after 4 major US hurricanes and assess factors associated with those trajectories.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used integrative data analysis to combine data from 4 studies of youths' responses to natural disasters (hurricanes Andrew [1992], Charley [2004], Ike [2005], and Katrina [2008]) at time points ranging from 3 to 26 months after the disasters. Those studies recruited and surveyed youths aged 6 to 16 years at schools via convenience sampling of schools near the path of destruction for each hurricane. This study was conducted from August 2017 to August 2020, and pooled data were analyzed from February 2019 to October 2020.

EXPOSURE

Experience of a natural disaster during the ages of 6 to 16 years.

MAIN OUTCOMES AND MEASURES

Posttraumatic stress symptoms were assessed using the University of California, Los Angeles, Posttraumatic Stress Disorder Reaction Index (UCLA PTSD-RI) and the UCLA PTSD-RI-Revised. Latent class growth analyses were used to evaluate the youths' PTS symptom trajectories and associated factors.

RESULTS

Among 1707 youths included in the study, the mean (SD) age was 9.61 (1.60) years, 922 (54%) were female, and 785 (46%) self-identified as White non-Hispanic. Four PTS symptom trajectories were identified: chronic (171 participants [10%]), recovery (393 [23%]), moderate-stable (563 [33%]), and low-decreasing (580 [34%]). Older youths were less likely to be in the chronic group; compared with the chronic group, each 1-year increase in age was associated with increased odds of being in the other groups (recovery: odds ratio [OR], 1.78 [95% CI, 1.29-2.48]; moderate-stable: OR, 1.94 [95% CI, 1.43-2.62]; and low-decreasing: OR, 2.71 [95% CI, 1.99-3.71]). Compared with males, females had higher odds of being in the chronic group than in any other group (recovery group: OR, 0.48 [95% CI, 0.26-0.91]; moderate-stable group: OR, 0.37 [95% CI, 0.21-0.64]; and low-decreasing group: OR, 0.25 [95% CI, 0.14-0.44]).

CONCLUSIONS AND RELEVANCE

In this cohort study, few youths reported chronic distress, and trajectories among most youths reflected recovery or low-decreasing PTS symptoms. Older age and identification as male were factors associated with decreased odds of a chronic trajectory. Youths with chronic or moderate-stable trajectories may benefit from intervention.

Randomised controlled trial of integrated trauma-focused psychotherapy for traumatic stress and substance use among adolescents: trial protocol

INTRODUCTION

Post-traumatic stress disorder (PTSD) and substance use disorder frequently co-occur and tend to have their onset during adolescence. Although research has highlighted the importance of treating these disorders in an integrated fashion, there is a dearth of empirically validated integrated treatment options for adolescents with this comorbidity. This paper describes the study protocol for a randomised controlled trial (RCT) examining the efficacy of an integrated trauma-focused cognitive-behavioural treatment for traumatic stress and substance use among adolescents (Concurrent Treatment of PTSD and Substance Use Using Prolonged Exposure - Adolescent (COPE-A)), relative to a supportive counselling control condition (Person-Centred Therapy (PCT)).

METHODS AND ANALYSIS

A two-arm, parallel, single-blind RCT with blinded follow-up at 4 and 12 months poststudy entry will be conducted in Sydney, Australia. Participants (n~100 adolescents aged 12-18 years) and their caregivers (caregiver participation is optional) will be allocated to undergo either COPE-A or PCT (allocation ratio 1:1) using minimisation. Both therapies will be delivered individually by project psychologists over a maximum of 16 sessions of 60-90 min duration and will include provision of up to four 30 min optional caregiver sessions. The primary outcome will be between-group differences in change in the severity of PTSD symptoms from baseline to 4-month follow-up, as measured by the Clinician-Administered PTSD Scale for Children and Adolescents for DSM-5.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the human research ethics committees of the Sydney Children's Hospital Network (HREC/17/SCHN/306) and the University of Sydney (HREC 2018/863). Findings will be published in peer-reviewed journals and presented at scientific conferences.

TRIAL REGISTRATION NUMBER

ACTRN12618000785202; Pre-reults.

PROTOCOL VERSION

Version 1, 31 July 2017.

The impact of trauma characteristics on post-traumatic stress disorder and substance use disorder outcomes across integrated and substance use treatments

Proponents of complex post-traumatic stress disorder (PTSD) constructs suggest that specific trauma characteristics, such as earlier age of first trauma (trauma age) and higher number of traumas (trauma count), may obstruct PTSD symptom reduction in treatment. PTSD and substance use disorders (SUD) commonly co-occur, but the impact of trauma age and count on PTSD treatment responses in a comorbid PTSD and SUD sample is unclear. Further, no studies have examined the impact of trauma characteristics on SUD treatment outcomes or whether their impact on either PTSD or SUD outcomes varies if PTSD is directly addressed. A secondary analysis of a randomized controlled trial was conducted to examine: (1) whether trauma age and count influence comorbid PTSD and SUD (PTSD+SUD) responses during and following treatment; and (2) whether these effects differed across an exposure-based, integrated PTSD+SUD treatment (Concurrent Treatment of PTSD and Substance Use Disorders using Prolonged Exposure; COPE) and a SUD-only focused treatment (Relapse Prevention Therapy; RPT). Individuals with PTSD+SUD randomized to COPE (n = 39) or RPT (n = 43) provided weekly measurements of PTSD and SUD. Across COPE and RPT, earlier trauma age predicted reduced SUD improvement (B = -0.01, standard error = 0.00). Trauma count did not predict changes in PTSD or SUD during or following treatment. These findings suggest that excluding individuals from exposure-based, integrated treatments on the basis of trauma characteristics is not empirically supported. However, individuals with earlier trauma ages may require additional or unique clinical attention to improve their SUD outcomes.

Psychosocial intervention utilization and substance abuse treatment outcomes in a multisite sample of individuals who use opioids

BACKGROUND

There are several relatively safe and effective FDA-approved medications for Opioid Use Disorder (OUD). Despite the existence of these medications, the rate of returning to opioid use after treatment is relatively high, underscoring the need for continued enhancement of treatments. Adjunctive psychosocial interventions paired with medication have been shown to improve OUD treatment outcomes. However, studies have yet to conclusively examine the distinct effects of the most widely utilized psychosocial treatment modalities. The current study will investigate the relationship between individual counseling, group therapy, and 12-Step participation and illicit opioid abstinence at the end of treatment, 1 and 3 months after treatment.

METHOD

A secondary analysis was conducted with data from a sample of 570 individuals diagnosed with OUD who were recruited from eight substance abuse treatment centers in the United States. Participants were enrolled in a two-group randomized, controlled trial testing buprenorphine-naloxone versus extended-release naltrexone for OUD. A two-level hierarchical linear growth model was used to examine the effects of individual counseling, group therapy, and 12-Step participation on illicit opioid abstinence (urinanalyses) 1- and 3-months post-treatment.

RESULTS

Hours of individual counseling and 12-Step participation significantly predicted abstinence at follow-up (p < .001, b = -0.59, 95% CI [0.42, 0.74]; p < .01, b = -0.05, 95% CI [0.92, 0.98]). There was a significant interaction between individual counseling and 12-Step participation (p < .01, b = -0.06, 95% CI [1.02, 1.10]). Additionally, participant age and employment status were significant predictors of illicit opioid abstinence (p < .01, b = -0.02, 95% CI [0.97, 0.99]; p < .01, b = -0.38, 95% CI [0.52, 0.90]). Hours of group therapy was not found to significantly predict illicit opioid abstinence.

CONCLUSIONS

Findings suggest that greater levels of individual therapy and 12-Step participation may be beneficial for individuals receiving medication treatment for OUD.

Service provider perspectives on treating adolescents with co-occurring PTSD and substance use: challenges and rewards

Purpose

Post-traumatic stress disorder (PTSD) and substance use disorder (SUD) frequently co-occur (PTSD+SUD). The onset of these disorders often occurs during adolescence. There is limited understanding of the perspectives of service providers working with this population. The purpose of this paper is to identify the practices, attitudes, experiences and training needs of Australian service providers treating adolescents with PTSD+SUD.

Design/methodology/approach

Service providers in Australia were invited to complete an anonymous online survey regarding their experiences working with adolescents who have PTSD+SUD. Ninety participants completed the 48-item survey that comprised multiple choice and open-ended questions.

Findings

Service providers estimated that up to 60 per cent of their adolescent clients with PTSD also have SUD. They identified case management, engaging with caregivers and difficult client emotions as specific challenges associated with working with this population. Despite this, providers rated treating PTSD+SUD as highly gratifying for reasons such as teaching new coping skills, developing expertise and assisting clients to achieve their goals. There were mixed perspectives on how to best treat adolescents with PTSD+SUD, and all participants identified a need for evidence-based resources specific to this population.

Originality/value

This is the first survey of Australian service providers working with adolescents who experience PTSD+SUD. The findings improve our understanding of the challenges and rewards associated with working with this population, and provide valuable information that can enhance clinical training and guide the development of new treatment approaches for this common and debilitating comorbidity.

Persistence and Subtype Stability of ADHD Among Substance Use Disorder Treatment Seekers

Objective: To examine ADHD symptom persistence and subtype stability among substance use disorder (SUD) treatment seekers. Method: In all, 1,276 adult SUD treatment seekers were assessed for childhood and adult ADHD using Conners' Adult ADHD Diagnostic Interview for Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; CAADID). A total of 290 (22.7%) participants met CAADID criteria for childhood ADHD and comprise the current study sample. Results: Childhood ADHD persisted into adulthood in 72.8% (n = 211) of cases. ADHD persistence was significantly associated with a family history of ADHD, and the presence of conduct disorder and antisocial personality disorder. The combined subtype was the most stable into adulthood (78.6%) and this stability was significantly associated with conduct disorder and past treatment of ADHD. Conclusion: ADHD is highly prevalent and persistent among SUD treatment seekers and is associated with the more severe phenotype that is also less likely to remit. Routine screening and follow-up assessment for ADHD is indicated to enhance treatment management and outcomes.

Exploration of Associations Between Early Maladaptive Schemas, Impaired Emotional Regulation, Coping Strategies and Resilience in Opioid Dependent Poly-Drug Users

BACKGROUND

Early Maladaptive Schema (EMS) are self-beliefs regarding oneself, others and the world, developed in childhood as the result of cumulative negative experiences (Young, 1993). High levels of EMS are present in the opioid using population along with high levels of emotional dysregulation and maladaptive coping alongside traits of resilience.

OBJECTIVES

The study explored the associations between EMS in relation to emotional dysregulation, maladaptive coping, adaptive coping and resilience between a clinical group composed of opioid dependent polydrug users attending a facility for opioid substitution treatment (n = 52) and a healthy comparison group (n = 70).

METHODS

A cross-sectional design was used to compare group differences using MANOVAs, and multiple regression analysis identified associations between EMS and emotional dysregulation, coping and resilience.

RESULTS

The groups significantly differed in relation to emotional dysregulation, maladaptive coping, adaptive coping and resilience. Specific EMS were significant independent predictors in regards to high emotional dysregulation, maladaptive coping, adaptive coping and resilience.

CONCLUSION

EMS appear to have a significant impact on emotional dysregulation, coping and resilience. Clinical implications suggest that EMS should be addressed when treating opioid dependent polydrug users.

Sex Specific Alterations in α4*Nicotinic Receptor Expression in the Nucleus Accumbens

Background: The mechanisms leading from traumatic stress to social, emotional and cognitive impairment and the development of mental illnesses are still undetermined and consequently there remains a critical need to develop therapies for preventing the adverse consequences of traumatic stress. Research indicates nicotinic acetylcholine receptors containing α4 subunits (α4*nAChRs) are both impacted by stress and capable of modulating the stress response. In this study, we investigated whether varenicline, a partial α4β2*nAChR agonist which reduces nicotine, alcohol and sucrose consumption, can reduce stress, a driving factor in substance use disorders. We also examined the effect of stress on nucleus accumbens (NAc) α4*nAChR expression. Methods: Transgenic mice with fluorescent tags attached to α4*nAChRs were administered varenicline and/or yohimbine (a pharmacological stressor) and plasma corticosterone and NAc α4*nAChR expression were measured. A separated group of mice were exposed to maternal separation (MS) during post-natal day (P) 2–14, then restraint stressed (30 min) at six weeks of age. Body weight, anxiety-like behaviours (elevated plus maze), plasma corticosterone and NAc α4*nAChR levels were measured. Results: Varenicline attenuated yohimbine-induced plasma corticosterone increases with no effect on NAc α4*nAChR expression. MS reduced unrestrained plasma corticosterone levels in both sexes. In females, MS increased body weight and NAc α4*nAChR expression, whereas, in males, MS and restraint caused a greater change in anxiety-like behaviours and plasma corticosterone levels. Restraint altered NAc α4*nAChR expression in both male and female MS mice. Conclusions: The effects of stress on NAc α4*nAChR are sex-dependent. While varenicline attenuated acute stress-induced rises in corticosterone levels, future studies are required to determine whether varenicline is effective for relieving the effects of stress.

Functional and Psychiatric Correlates of Comorbid Post-Traumatic Stress Disorder and Alcohol Use Disorder

Post-traumatic stress disorder (PTSD) and alcohol use disorder (AUD) are common comorbid conditions that affect large segments of the population. Individuals with comorbid PTSD/AUD face greater clinical and functional stressors than those with diagnoses of either PTSD or AUD alone. The purpose of this article is to review the phenomenology and functional associations of PTSD/AUD and address the common social, occupational, and psychological concerns associated with both disorders. Given the increased problems associated with comorbid PTSD/AUD, clinical and research efforts should focus on targeting functional and psychosocial problems in conjunction with psychiatric symptoms.

Effects of Assault Type on Cognitive Behaviour Therapy for Coexisting Depression and Alcohol Misuse

Although assault exposure is common in mental health and substance misusing populations, screening for assaults in treatment settings is frequently overlooked. This secondary analysis explored the effects of past sexual (SA) and physical (PA) assault on depression, alcohol misuse, global functioning and attrition in the Depression and Alcohol Integrated and Single focussed Intervention (DAISI) project, whose participants (N = 278) received cognitive behaviour therapy (CBT) for their depression and/or alcohol misuse. Of the 278 DAISI participants, 220 consented to screening for past assault (either by a stranger or non-stranger) at baseline. Depression, alcohol, and global functioning assessments were administered at baseline and 3, 12, 24, and 36 months post baseline. A between-group analysis was used to assess differences between SA and No SA, and PA and No PA groupings, on adjusted mean treatment outcomes across all assessment periods. SA and PA participants had similar mean symptom reductions compared to No SA and No PA participants except for lower depression and global functioning change scores at the 12-month follow-up. People with coexisting depression and alcohol misuse reporting SA or PA can respond well to CBT for depression and alcohol misuse. However, follow-up is recommended in order to monitor fluctuations in outcomes.

Mental health among clients of the Sydney Medically Supervised Injecting Centre (MSIC)

The Sydney Medically Supervised Injecting Centre (MSIC) is a supervised injecting facility (SIF) where people who inject drugs (PWID) can do so legally, under health professional supervision. The majority of clients have low levels of education and employment, high rates of incarceration and unstable housing and poor social networks, and 70 % do not access local health services. These factors increase the risk of poor mental health, and it has been documented that PWID have elevated rates of mood, anxiety, personality and psychotic disorders; post-traumatic stress disorder (PTSD); and higher rates of trauma exposure, suicidality and self-harm. The current study is the first to investigate the mental health among clients of a SIF. Validated instruments to examine clients' mental health, social networks and trauma histories were administered to 50 frequently attending clients by a mental health nurse. The majority of respondents were unemployed, homeless and had a history of incarceration, and 82 % report they had been diagnosed with a mental health problem, but only 24 % report they were receiving treatment. Respondents had poor social networks, had poorer mental health symptoms compared to US inpatients and had experienced multiple traumatic events, and a high number of respondents had scores indicative of PTSD. These results highlight the need for mental health clinicians to be employed in SIFs and other drug consumption rooms (DCRs) to assist clients to address their mental health and psychosocial needs, particularly in light of the fact that these services are often the only places these PWID engage with in an ongoing way.

The Influence of Parental Emotional Neglect on Assault Victims Seeking Treatment for Depressed Mood and Alcohol Misuse: A Pilot Study

This study explores the relationship between reported parental emotional neglect when a child, assault type experienced, posttraumatic stress symptoms (PTSS), depression, and alcohol consumption in treatment seekers for comorbid depressive symptoms and alcohol misuse. Participants (n = 220) with concurrent depression and alcohol misuse were recruited from the DAISI (Depression and Alcohol Integrated and Single-focussed Interventions) project. Assault type and PTSS were retrospectively assessed by the Posttraumatic Stress Diagnostic Scale. The Measure of Parenting Style is a self-report measure that retrospectively assessed emotional neglect experienced as a child. An exploratory factor analysis using the tetrachoric correlation matrix (applying principal factor extraction with a varimax rotation) identified the two assault factors of sexual assault (SA) and physical assault (PA). A path analysis revealed that Maternal Emotional Neglect increased the impact of PTSS and depression. Paternal Emotional Neglect increased the impact of PA on PTSS and alcohol dependence symptoms. There appears to be differential effects of assault type and Maternal/Paternal emotional neglect on depression and alcohol misuse, suggesting that parenting roles serve distinct protective functions.

Substance use to regulate intense posttraumatic shame in individuals with childhood abuse and neglect

Childhood abuse and neglect (CAN) is considered as a risk factor for substance use disorder (SUD). Based on the drinking to cope model, this study investigated the association of two trauma-relevant emotions (shame and sadness) and substance use. Using ecological momentary assessment we compared real-time emotion regulation in situations with high and low intensity of shame and sadness in currently abstinent patients with CAN and lifetime SUD (traumaSUD group), healthy controls with CAN (traumaHC group), and without CAN (nontraumaHC group). Multilevel analysis showed a positive linear relationship between high intensity of both emotions and substance use for all groups. The traumaSUD group showed heightened substance use in low, as well as in high, intensity of shame and sadness. In addition, we found an interaction between type of emotion, intensity, and group: the traumaHC group exhibited a fourfold increased risk for substance use in high intense shame situations relative to the traumaSUD group. Our findings provide evidence for the drinking to cope model. The traumaSUD group showed a reduced distress tolerance for variable intensity of negative emotions. The differential effect of intense shame for the traumaHC group emphazises its potential role in the development of SUD following CAN. In addition, shame can be considered a relevant focus for therapeutic preinterventions and interventions for SUD after CAN.

Psychological therapies for post-traumatic stress disorder and comorbid substance use disorder

BACKGROUND

Post-traumatic stress disorder (PTSD) is a debilitating mental health disorder that may develop after exposure to traumatic events. Substance use disorder (SUD) is a behavioural disorder in which the use of one or more substances is associated with heightened levels of distress, clinically significant impairment of functioning, or both. PTSD and SUD frequently occur together. The comorbidity is widely recognised as being difficult to treat and is associated with poorer treatment completion and poorer outcomes than for either condition alone. Several psychological therapies have been developed to treat the comorbidity, however there is no consensus about which therapies are most effective.

OBJECTIVES

To determine the efficacy of psychological therapies aimed at treating traumatic stress symptoms, substance misuse symptoms, or both in people with comorbid PTSD and SUD in comparison with control conditions (usual care, waiting-list conditions, and no treatment) and other psychological therapies.

SEARCH METHODS

We searched the Cochrane Depression, Anxiety and Neurosis Group's Specialised Register (CCDANCTR) all years to 11 March 2015. This register contains relevant randomised controlled trials from the Cochrane Library (all years), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date). We also searched the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov, contacted experts, searched bibliographies of included studies, and performed citation searches of identified articles.

SELECTION CRITERIA

Randomised controlled trials of individual or group psychological therapies delivered to individuals with PTSD and comorbid substance use, compared with waiting-list conditions, usual care, or minimal intervention or to other psychological therapies.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 14 studies with 1506 participants, of which 13 studies were included in the quantitative synthesis. Most studies involved adult populations. Studies were conducted in a variety of settings. We performed four comparisons investigating the effects of psychological therapies with a trauma-focused component and non-trauma-focused interventions against treatment as usual/minimal intervention and other active psychological therapies. Comparisons were stratified for individual- or group-based therapies. All active interventions were based on cognitive behavioural therapy. Our main findings were as follows.Individual-based psychological therapies with a trauma-focused component plus adjunctive SUD intervention was more effective than treatment as usual (TAU)/minimal intervention for PTSD severity post-treatment (standardised mean difference (SMD) -0.41; 95% confidence interval (CI) -0.72 to -0.10; 4 studies; n = 405; very low-quality evidence) and at 3 to 4 and 5 to 7 months' follow-up. There was no evidence of an effect for level of drug/alcohol use post-treatment (SMD -0.13; 95% CI -0.41 to 0.15; 3 studies; n = 388; very low-quality evidence), but there was a small effect in favour of individual psychological therapy at 5 to 7 months (SMD -0.28; 95% CI -0.48 to -0.07; 3 studies; n = 388) when compared against TAU. Fewer participants completed trauma-focused therapy than TAU (risk ratio (RR) 0.78; 95% CI 0.64 to 0.96; 3 studies; n = 316; low-quality evidence).Individual-based psychological therapy with a trauma-focused component did not perform better than psychological therapy for SUD only for PTSD severity (mean difference (MD) -3.91; 95% CI -19.16 to 11.34; 1 study; n = 46; low-quality evidence) or drug/alcohol use (MD -1.27; 95% CI -5.76 to 3.22; 1 study; n = 46; low-quality evidence). Findings were based on one small study. No effects were observed for rates of therapy completion (RR 1.00; 95% CI 0.74 to 1.36; 1 study; n = 62; low-quality evidence).Non-trauma-focused psychological therapies did not perform better than TAU/minimal intervention for PTSD severity when delivered on an individual (SMD -0.22; 95% CI -0.83 to 0.39; 1 study; n = 44; low-quality evidence) or group basis (SMD -0.02; 95% CI -0.19 to 0.16; 4 studies; n = 513; low-quality evidence). There were no data on the effects on drug/alcohol use for individual therapy. There was no evidence of an effect on the level of drug/alcohol use for group-based therapy (SMD -0.03; 95% CI -0.37 to 0.31; 4 studies; n = 414; very low-quality evidence). A post-hoc analysis for full dose of a widely established group therapy called Seeking Safety showed reduced drug/alcohol use post-treatment (SMD -0.67; 95% CI -1.14 to -0.19; 2 studies; n = 111), but not at subsequent follow-ups. Data on the number of participants completing therapy were not for individual-based therapy. No effects were observed for rates of therapy completion for group-based therapy (RR 1.13; 95% CI 0.88 to 1.45; 2 studies; n = 217; low-quality evidence).Non-trauma-focused psychological therapy did not perform better than psychological therapy for SUD only for PTSD severity (SMD -0.26; 95% CI -1.29 to 0.77; 2 studies; n = 128; very low-quality evidence) or drug/alcohol use (SMD 0.22; 95% CI -0.13 to 0.57; 2 studies; n = 128; low-quality evidence). No effects were observed for rates of therapy completion (RR 0.91; 95% CI 0.68 to 1.20; 2 studies; n = 128; very low-quality evidence).Several studies reported on adverse events. There were no differences between rates of such events in any comparison. We rated several studies as being at 'high' or 'unclear' risk of bias in multiple domains, including for detection bias and attrition bias.

AUTHORS' CONCLUSIONS

We assessed the evidence in this review as mostly low to very low quality. Evidence showed that individual trauma-focused psychological therapy delivered alongside SUD therapy did better than TAU/minimal intervention in reducing PTSD severity post-treatment and at long-term follow-up, but only reduced SUD at long-term follow-up. All effects were small, and follow-up periods were generally quite short. There was evidence that fewer participants receiving trauma-focused therapy completed treatment. There was very little evidence to support use of non-trauma-focused individual- or group-based integrated therapies. Individuals with more severe and complex presentations (e.g. serious mental illness, individuals with cognitive impairment, and suicidal individuals) were excluded from most studies in this review, and so the findings from this review are not generalisable to such individuals. Some studies suffered from significant methodological problems and some were underpowered, limiting the conclusions that can be drawn. Further research is needed in this area.

Childhood Maltreatment and PTSD: Spiritual Well-Being and Intimate Partner Violence as Mediators

Childhood maltreatment places individuals, including African American women who are undereducated and economically disadvantaged, at risk for developing posttraumatic stress disorder (PTSD) symptoms. Participants were 192 African American women with a history in the prior year of both a suicide attempt and intimate partner violence (IPV) exposure. They were recruited from a public hospital that provides medical and mental health treatment to mostly low-income patients. A simple mediator model was used to examine if (1) existential well-being (sense of purpose) and/or religious well-being (relationship with God) mediated the link between childhood maltreatment and adult PTSD symptoms. Sequential multiple mediator models determined if physical and nonphysical IPV enhanced our understanding of the mediational association among the aforementioned variables. Findings suggest that existential well-being mediated the association between childhood maltreatment and adult PTSD symptoms in a simple mediator model, and existential well-being and recent nonphysical IPV served as sequential multiple mediators of this link. However, religious well-being and physical IPV were not significant mediators. Findings underscore the importance of enhancing existential well-being in the treatment of suicidal African American women with a history of childhood maltreatment and IPV.

Delivery of a mainstreaming treatment model towards co-existing difficulties: a brief exploration of practitioners’ understanding, views and reported experiences

Purpose

– The purpose of this paper is to describe the delivery of a mainstreaming model within a public sector, mental health (National Health Service (NHS)) organisation. The model promotes the inclusivity of a spectrum of presentations from co-existing moderate anxiety and depression to severe mental disorder (psychosis) and problematic substance and alcohol use.

Design/methodology/approach

– This paper introduces the delivery of three collective approaches, termed the “three essential elements” to support a mainstreaming treatment model, facilitated by a “Dual Diagnosis Lead”. The model encompasses; a “direct access” referral pathway, joint collaboration with practitioners and the delivery of a “Dual Diagnosis” training programme. An independent evaluation was commissioned to explore eight mental health and substance misuse practitioners’ views and experiences in relation to the impact of the mainstreaming model. This paper also considers feedback from 230 course participants attending a one day “Dual Diagnosis” training programme.

Findings

– This paper suggests that practitioners may benefit from the implementation of the mainstreaming approach and the delivery of this approach could be moving “Dual Diagnosis” interventions closer to mainstream practice.

Research limitations/implications

– The limitations of the mainstreaming model are acknowledged in relation to the generalisation of practitioners’ views and reported experiences.

Originality/value

– This paper offers a description of the delivery of a mainstreaming model involving the “three essential elements”. The model provides a useful insight and demonstrates the possibilities which may be achieved when attempting to implement a mainstreaming treatment approach within mainstream mental health and drug and alcohol services.

Risk and protective factors associated with substance use disorders in adolescents with first-episode mania

OBJECTIVE

Adolescents with bipolar disorder (BD) are more likely to develop substance use disorders (SUDs) than adolescents without psychiatric disorders; however, to our knowledge, specific risk factors underlying this relationship have not been prospectively examined. The purpose of this study was to identify predictors of developing SUDs after a first manic episode.

METHOD

Participants aged 12 to 20 years and hospitalized with their first manic episode associated with bipolar I disorder (BP-I) were recruited as part of the University of Cincinnati First-Episode Mania Study and prospectively evaluated for patterns of substance use. Follow-up ranged between 17 and 283 weeks (mean = 113 weeks, SD = 71.9 weeks). Demographic and clinical variables were compared between adolescents with and without SUDs.

RESULTS

Of the 103 adolescents with BD, 49 (48%) either had a SUD at baseline or developed one during follow-up. Of the 71 participants who did not have a SUD at study entry, 17 (24%) developed one during follow-up (median = 40 weeks). Later onset of BD, manic (versus mixed) mood episode, and comorbid disruptive behavior disorders were associated with an increased risk of developing a SUD in univariate analyses. Adolescents treated with psychostimulant treatment before their first manic episode were significantly less likely to develop a SUD independent of attention-deficit/hyperactivity disorder (ADHD) diagnosis. Comorbid posttraumatic stress disorder (PTSD) and psychotic symptoms were the strongest predictors of SUD development.

CONCLUSION

Our results confirm high rates of SUD in adolescents with BD. In addition, our findings identify potential risk factors associated with SUDs in adolescents with BD. These data are preliminary in nature and should be explored further in future studies.

Stress increases voluntary alcohol intake, but does not alter established drinking habits in a rat model of posttraumatic stress disorder

BACKGROUND

Life-altering anxiety disorders, such as posttraumatic stress disorder (PTSD), can co-occur at high rates with substance use disorders. Alcoholism, compared with other substance use disorders, is particularly common. Rodent studies of acute stress effects on alcohol consumption show that stress can alter ethanol (EtOH) consumption. This study examined voluntary EtOH consumption in male Long-Evans rats that had undergone a stress-enhanced fear learning (SEFL) procedure.

METHODS

Adult Long-Evans rats were exposed to a stress that consisted of 15 inescapable foot-shocks (1 mA, 1 second) known to cause a long-lasting nonassociative enhancement of subsequent fear learning. Control animals received no shock. One day later, animals were placed in a novel and very different context and received a single foot-shock. On day 3, animals were returned to the single shock context and freezing was used as a measure of learned fear. The intermittent access 2-bottle choice (2BC) regimen consisted of 1 bottle of water and 1 bottle of experimental solution, either 19% EtOH or 28.4% sucrose-0.08% quinine, for a 24-hour period, 3 days a week, and all other times 2 water bottles. This regimen lasted until stable levels of experimental solution drinking were reached, at which point the experimental solution was removed for 40 days and then returned to measure the resumption of consumption.

RESULTS

Rats that received stress prior to EtOH consumed significantly more EtOH than control rats before and after reinstatement. Rats that received stress after drinking was established did not consume significantly more EtOH when the drug was returned. Stress had no significant effect on sucrose-quinine drinking, our calorie and taste control for EtOH.

CONCLUSIONS

A single traumatic event sufficient to produce long-lasting enhancement of fear learning increases voluntary EtOH consumption, but does not alter previously acquired EtOH drinking habits or alter the consumption of a calorically equivalent sweet-bitter-tasting solution.

Childhood sexual abuse and risk for initiating injection drug use: a prospective cohort study

OBJECTIVE

This study examined whether childhood sexual abuse predicts initiation of injection drug use in a prospective cohort of youth.

METHOD

From October 2005 to November 2010, data were collected from the At Risk Youth Study (ARYS), a prospective cohort study of street-involved youth in Vancouver, Canada. Inclusion criteria were age 14-26 years, no lifetime drug injection, and non-injection drug use in the month preceding enrollment. Participants were interviewed at baseline and semiannually thereafter. Cox regression was employed to identify risk factors for initiating injection.

RESULTS

Among 395 injection-naïve youth, 81 (20.5%) reported childhood sexual abuse. During a median follow-up of 15.9 months (total follow-up 606.6 person-years), 45 (11.4%) youth initiated injection drug use, resulting in an incidence density of 7.4 per 100 person-years. In univariate analyses, childhood sexual abuse was associated with increased risk of initiating injection (unadjusted hazard ratio [HR], 2.38; 95% confidence interval [CI], 1.29-4.38; p=0.006), an effect that persisted in multivariate analysis despite adjustment for gender, age, aboriginal ancestry and recent non-injection drug use (adjusted HR, 2.71; 95% CI, 1.42-5.20; p=0.003).

CONCLUSION

Childhood sexual abuse places drug users at risk for initiating injection. Addiction treatment programs should incorporate services for survivors of childhood maltreatment.

Exposição a trauma e transtorno de estresse pós-traumático em usuárias de crack

OBJETIVO: Verificar a ocorrência de trauma e transtorno de estresse pós-traumático (TEPT) em uma amostra de mulheres dependentes de cocaína tipo crack. MÉTODO: A amostra foi composta por 99 mulheres, entre 18 e 52 anos, internadas em uma unidade de desintoxicação e extensamente avaliadas por meio da SCID-I e a ASI-6. RESULTADOS: Verificou-se uma taxa de exposição a trauma de 86,9% entre mulheres dependentes de cocaína tipo crack. A taxa de TEPT na amostra foi de 15,1%. Os clusters de revivescência e hiperexcitabilidade foram os mais frequentes - 24,4% e 20,9% respectivamente. Entre os tipos de eventos relatados, os mais frequentes foram sofrer agressão/abuso físico e ser testemunha de violência a outros. CONCLUSÃO: Os resultados sugerem uma frequente exposição a eventos traumáticos. Com relação à idade da experiência traumática, sugere-se que as usuárias expostas a trauma durante a infância e adolescência apresentam um início do uso de drogas em idades mais precoces que aquelas cujo trauma ocorreu na vida adulta.