Assessment of the Short Grit Scale in patients with substance use disorder: Psychometric properties and patient characteristics

Background: Recovery from substance use disorder requires sustained effort and perseverance. Hence, the resilience factor of grit may be important for people in recovery. Little research has been conducted on grit in patients with substance use disorder (SUD), especially in a large and varied sample.Objectives: To analyze the psychometric properties of the Short Grit Scale (Grit-S) in patients with SUD and to use demographic and clinical characteristics to predict variance in Grit-S scores.Methods: Participants completed the Grit-S and other self-report measures. Psychometric properties of the Grit-S were assessed in outpatients (N = 94, 77.7% male) and a hierarchical regression predicted Grit-S variance in inpatients (N = 1238, 65.0% male).Results: The Grit-S demonstrated good internal consistency (α=.75) and strong test-retest reliability (adjusted r = .79, p < .001). Mean Grit-S score was 3.15, lower than other clinical samples reported in the literature. Regression modeling indicated a moderate, statistically significant association between demographic and clinical characteristics and Grit-S scores (R2 = 15.5%, p < .001). Of particular interest, the positive factor of recovery protection showed the strongest association with Grit-S of all variables assessed (β=.185 vs. β = .052-.175 for the remaining significant independent variables).Conclusion: The psychometric properties of the Grit-S in patients with SUD support its use in this population. Moreover, the particularly low grit scores among inpatients with SUDs and the association of grit scores with substance use risk and recovery factors suggest that grit could be useful as a treatment target in this population.

Correlates of optimism among patients in substance use disorder inpatient treatment

BACKGROUND AND OBJECTIVES

Early recovery from substance use disorder (SUD) is often characterized by hopelessness and despair about the future. Optimism, or the expectation that good things will happen, may provide a buffer against despair, and motivate adaptive goal engagement and coping. Study objectives were to (1) compare levels of optimism among individuals in substance use disorder inpatient treatment to other populations and (2) examine correlates of optimism.

METHODS

This exploratory study utilized a cross-sectional survey design. Participants (n = 355) completed self-report measures assessing sociodemographic and clinical characteristics. The main variable of interest, optimism, was assessed by Life Orientation Test-Revised scores. Multivariate regression was used to examine the association among sociodemographic and clinical variables and optimism.

RESULTS

Our sample (n = 342) scored lower on optimism (mean = 11.7) than general population and SUD patients reported in the literature (range = 13.0-18.5). Optimism was higher for SUD inpatients who were college-educated and those with higher scores on the recovery protection factor, while greater anxiety severity was associated with lower optimism scores.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

This study contributes to emerging research on the association between optimism and SUDs. Optimism has not been previously studied among patients in acute, short-term inpatient SUD treatment and doing so may be clinically useful in addressing low optimism as an obstacle to motivation for treatment. Bolstering optimism may be a promising target for intervention and future research.

Suicidal motivations among opioid overdose survivors: Replication and extension

BACKGROUND

Several studies suggest suicidal motivation may contribute to opioid overdose fatalities in people with opioid use disorder. In this study, we sought to replicate and extend prior findings suggesting that a desire to die is common prior to nonfatal opioid overdose in people with opioid use disorder.

METHODS

Adults receiving inpatient detoxification and stabilization who reported a history of opioid overdose (N = 60) completed questions about suicidal cognition prior to their most recent overdose.

RESULTS

Approximately 45% reported some desire to die prior to their most recent overdose, with 20% reporting they had some intention to die. The correlation between these ratings was of a moderate magnitude (ρ = 0.58). Almost 40% of the sample perceived no risk of overdose prior to their most recent overdose event, suggesting a significant underestimation of risk in this population.

CONCLUSIONS

Desire to die was common in adults with opioid use disorder prior to nonfatal opioid overdose events, and 1 in 5 people with a history of opioid overdose reported intention to die prior to their most recent opioid overdose. Careful assessment of suicidal cognition in this population may improve prevention of opioid overdose deaths.

Do people with opioid use disorder and posttraumatic stress disorder benefit from dding Individual opioid Drug Counseling to buprenorphine?

BACKGROUND AND PURPOSE

Large randomized trials have found that behavioral therapy for opioid use disorder (e.g., Individual Drug Counseling, Cognitive Behavioral Therapy for Opioid Use Disorder) does not improve buprenorphine maintenance outcomes, on average, for individuals with opioid use disorder. However, recent studies indicate that certain subgroups of patients may benefit from the addition of behavioral therapy to buprenorphine. In particular, people with more complex and severe psychosocial needs may benefit from the addition of behavioral therapy for opioid use disorder.

METHODS

In this study, we conducted a secondary analysis of a large, multi-site randomized trial (N = 357) of buprenorphine maintenance with and without individual Opioid Drug Counseling (ODC) for the treatment of opioid use disorder. We hypothesized that participants with posttraumatic stress disorder (PTSD) would benefit from the addition of ODC.

RESULTS

Logistic regression models indicated a significant PTSD by treatment condition interaction. Specifically, 67% of those with PTSD had a successful opioid use disorder treatment outcome when they were assigned to receive both ODC and buprenorphine, compared to a 36% response rate among those who received buprenorphine alone.

CONCLUSIONS

Although these results require replication, our findings provide initial indication that ODC is an important complement to buprenorphine maintenance treatment for people with co-occurring PTSD and opioid use disorder.

Psychometric properties of the Anxiety Sensitivity Index-3 in adults with substance use disorders

Anxiety sensitivity, or the fear of anxiety-related sensations, has demonstrated relevance to a broad range of psychiatric conditions, including substance use disorders (SUDs). Anxiety sensitivity is typically measured through self-report instruments, most commonly the Anxiety Sensitivity Index-3 (ASI-3). Despite the widespread use of the ASI-3 in studies of SUDs, little is known about its psychometric properties within this population. Patients on an inpatient detoxification unit seeking treatment for SUDs (N = 1248) completed a battery of self-report measures, including the ASI-3. Psychometric properties of the ASI-3 were examined. An exploratory factor analysis with half of the sample (n = 624) supported a 3-factor structure corresponding to the ASI-3 subscales (Social Concerns, Cognitive Concerns, Physical Concerns). Confirmatory factor analysis was used to validate this 3-dimensional structure in a separate subsample (n = 624), resulting in adequate fit when testing a second-order hierarchical model. Internal consistency and convergent and discriminant validity results also supported the use of the ASI-3 in people with SUDs. Despite its widespread use in SUD research, this is the first psychometric investigation of the ASI-3 among individuals seeking treatment for SUDs.

Validation of the craving scale in a large sample of adults with substance use disorders

Valid and reliable measures of craving are essential for both clinical practice and research. Brief measures are particularly valuable for clinical and research settings in which assessment burden needs to be minimized. The Craving Scale is a 3-item measure of craving that has been previously validated in cocaine-dependent samples. This brief measure has also demonstrated predictive validity in both alcohol and opioid use disorder; however, its psychometric properties in these disorders are not well characterized. The aim of this paper was to extend prior psychometric analyses of the Craving Scale to a large sample of adults seeking treatment for substance use disorders (N = 1,283). Analyses of readability indicated that the Craving Scale was written between a 7-8th grade reading level and had minimal grammatical complexity. The Craving Scale demonstrated strong internal consistency reliability (omega = 0.81), a single-factor latent structure, and adequate concurrent and discriminant validity. Importantly, results were similar when analyses were run separately for alcohol and opioid craving and in men and women, supporting measure invariance across these key groups. Our results provide further support for the reliability and validity of the Craving Scale for use in people with substance use disorders.

Associations between Childhood Abuse and Chronic Pain in Adults with Substance Use Disorders

Both childhood abuse and chronic pain are common in people with substance use disorders (SUDs). Studies have found that exposure to childhood abuse is associated with chronic pain in adulthood; however, few studies have examined this association in people with SUDs. Objectives: This study aimed to characterize the association between childhood abuse and chronic pain presence and severity in adults with SUDs. Methods: Data were obtained from 672 treatment-seeking participants with SUDs on an inpatient detoxification unit. Regression models evaluated whether childhood physical or sexual abuse was associated with the likelihood of chronic pain and severity of several pain-related characteristics: pain catastrophizing, pain severity, and pain interference. Results: Childhood physical and sexual abuse were significantly associated with a greater likelihood of chronic pain in adulthood. In the adjusted analyses, childhood physical abuse was associated with worse pain severity, whereas childhood sexual abuse was associated with greater pain catastrophizing and worse pain interference. Conclusions: Childhood physical and sexual abuse were associated with a greater likelihood of chronic pain in adults with SUDs. Among those with chronic pain, exposure to childhood abuse was associated with a more severe symptom profile, characterized by greater pain severity, more catastrophic interpretations of pain, and more pain-related interference with daily life. People with SUDs and a history of childhood abuse may benefit from screening for pain and interventions to reduce pain catastrophizing. These findings highlight the importance of longitudinal research to understand mechanisms linking childhood abuse exposure to later pain and substance misuse.

Sex differences in benzodiazepine misuse among adults with substance use disorders

Women are more likely than men to be diagnosed with anxiety disorders and to be prescribed benzodiazepines. People with substance use disorders are at a heightened risk for the misuse of benzodiazepines, yet little is known about sex differences in the prevalence, correlates or patterns of benzodiazepine misuse in this population. The aim of this study was to characterize sex differences in benzodiazepine misuse in a sample of adults receiving substance use disorder treatment (N = 352). Almost half of the sample had been prescribed a benzodiazepine and more than 40% had misused a benzodiazepine. Women were more likely to have a lifetime prescription than men, but were not more likely to report misuse or regular misuse. Consistent with data for other substances, women were more likely to report misusing benzodiazepines to cope and reported greater anxiety sensitivity. The vast majority (97%) of participants reported co-use of benzodiazepines with other substances and 65% of women reporting misusing benzodiazepines via a non-oral route of administration (e.g., intranasal). Although benzodiazepine misuse prevalence was not substantively different between men and women, several sex differences in clinical characteristics and patterns of use were identified. Further research on the nature of sex differences in benzodiazepine misuse is needed to inform targeted treatment for both men and women with substance use disorders.

Anxiety sensitivity and grit as mediators between childhood abuse and relapse risk for substance use

BACKGROUND

Childhood abuse is prevalent in those with substance use disorders (SUDs), and can lead to adverse consequences, including relapse to substance use following treatment.

OBJECTIVE

To determine whether anxiety sensitivity (AS) and grit mediate associations between childhood abuse and substance use relapse risk.

PARTICIPANTS AND SETTING

Patients on an inpatient detoxification and stabilization unit seeking treatment for SUDs (N = 702).

METHODS

Participants were administered self-report measures assessing childhood physical and sexual abuse (CPA/CSA), AS, grit, and relapse risk. A parallel mediation model was used to investigate the association between childhood abuse and relapse risk as mediated by AS and grit.

RESULTS

Anxiety sensitivity was associated with greater relapse risk (β = 0.29, t = 8.24, p < 0.001). Indirect effects of CPA and CSA on relapse risk through AS were statistically significant (CPA: β = 0.05, 95 % C.I. = 0.02-0.08; CSA: β = 0.04, 95 % C.I. = 0.01-0.07), indicating AS significantly mediated effects of both CPA and CSA on relapse risk. Grit was not a mediator, however, higher grit score was significantly associated with decreased relapse risk (β = -0.17, t = -4.90, p < 0.001).

CONCLUSIONS

Anxiety sensitivity may be an important construct linking child abuse to relapse risk. Although grit may not mediate the effect of child abuse on relapse risk, it may be clinically relevant to relapse risk. As this sample consisted of treatment-seeking adults, the generalizability of results to other populations is uncertain. Future studies should investigate interventions targeting these constructs in this population.

Benzodiazepine misuse in adults with alcohol use disorder: Prevalence, motives and patterns of use

OBJECTIVE

Benzodiazepines are among the most commonly misused drugs. Despite the known risks of combining benzodiazepines and alcohol, little is known about misuse among people with alcohol use disorder (AUD). Our aim was to characterize the prevalence, correlates, and patterns of misuse of benzodiazepines in adults with AUD.

METHOD

Adults receiving treatment for AUD (N = 258) completed a battery of questionnaires. We used descriptive statistics to characterize the prevalence and patterns of misuse and we used logistic regression models to identify correlates of misuse.

RESULTS

Almost half of the sample reported a history of benzodiazepine prescription and 30% reported a history of misuse. Younger age, female sex, anxiety, and other substance use were associated with misuse. Coping was the most commonly reported reason for misuse. All participants who had misused a benzodiazepine in the past year used concurrently with another substance.

CONCLUSIONS

Benzodiazepine misuse was common in this study, and risky patterns of use, such a co-use with other substances, were prevalent. Coping was the most common reason for misusing benzodiazepines, suggesting that un- or under-treated psychiatric symptoms may contribute to misuse.

Depression history as a predictor of outcomes during buprenorphine-naloxone treatment of prescription opioid use disorder

BACKGROUND

In the multi-site Prescription Opioid Addiction Treatment Study (POATS), the best predictor of successful opioid use outcome was lifetime diagnosis of major depressive disorder. The primary aim of this secondary analysis of data from POATS was to empirically assess two explanations for this counterintuitive finding.

METHODS

The POATS study was a national, 10-site randomized controlled trial (N = 360 enrolled in the 12-week buprenorphine-naloxone maintenance treatment phase) sponsored by the NIDA Clinical Trials Network. We evaluated how the presence of a history of depression influences opioid use outcome (negative urine drug assays). Using adjusted logistic regression models, we tested the hypotheses that 1) a reduction in depressive symptoms and 2) greater motivation and engagement in treatment account for the association between depression history and good treatment outcome.

RESULTS

Although depressive symptoms decreased significantly throughout treatment (p <.001), this improvement was not associated with opioid outcomes (aOR = 0.98, ns). Reporting a goal of opioid abstinence at treatment entry was also not associated with outcomes (aOR = 1.39, ns); however, mutual-help group participation was associated with good treatment outcomes (aOR = 1.67, p <.05). In each of these models, lifetime major depressive disorder remained associated with good outcomes (aORs = 1.63-1.82, ps = .01-.055).

CONCLUSIONS

Findings are consistent with the premise that greater engagement in treatment is associated with good opioid outcomes. Nevertheless, depression history continues to be associated with good opioid outcomes in adjusted models. More research is needed to understand how these factors could improve treatment outcomes for those with opioid use disorder.

Pain interference and catastrophizing are not associated with polysubstance use among treatment-seeking patients with substance use disorders and chronic pain

Background: People with substance use disorders (SUD) and co-occurring chronic pain report the use of myriad substances, which is concerning due to the heightened risk of overdose associated with polysubstance use. Identifying malleable factors associated with polysubstance use in this population can inform interventions. In this study, we examined whether two pain processes - pain interference and pain catastrophizing - were associated with polysubstance use. Objectives: We examined the cross-sectional associations among self-reported pain interference and catastrophizing and polysubstance use. We also determined if sex and primary SUD moderated these associations. Methods: Participants were 236 (36% female) adults receiving inpatient treatment for SUD (58% alcohol use disorder, 42% opioid use disorder) who met criteria for chronic pain. We utilized negative binomial regression to examine associations between pain interference and catastrophizing (focal independent variables) and the number of substances used in the month before treatment (i.e., polysubstance use; outcome). Results: Participants used three substances, on average, in the month prior to treatment. Neither pain interference (IRR = 1.05, p = .06) nor pain catastrophizing (IRR = 1.00, p = .37) were associated with polysubstance use. The association between pain interference and polysubstance use was moderated by sex and primary SUD (ps<0.01), such that these variables were positively related in men and those with alcohol use disorder. Conclusion: Pain interference and catastrophizing were not uniformly associated with polysubstance use, underscoring the need to examine other factors associated with polysubstance use in this population. However, men and those with alcohol use disorder might benefit from interventions targeting pain interference to reduce polysubstance use.

Clinical Correlates of Smoking Status in Men and Women with Opioid Use Disorder

Background: Smoking is highly prevalent in people with opioid use disorder (OUD) and is a significant contributor to morbidity and mortality in this population. However, little is known about the differences between those with OUD who do and do not smoke cigarettes. Objectives: Our aim was to investigate differences between treatment-seeking adults with OUD who did and did not smoke. Methods: Participants (N = 568; 30% female) completed a battery of self-report questionnaires including measures of current smoking status and number of cigarettes smoked per day as well as measures of clinical characteristics (e.g. craving, anxiety). Results: Of the total sample, 77% were current smokers. Multivariable logistic regression identified heroin use (OR = 2.20, 95% CI = 1.38, 3.53) and younger age (OR = 0.97, 95% CI = 0.95, 0.997) as strong correlates of smoking status; other characteristics were not significant. Older age and opioid craving were associated with more cigarettes smoked per day. Notably, these patterns differed for males and females; opioid craving (B = 0.62, SE_B = 0.24) was associated with the number of cigarettes smoked among men, and anxiety (B = 0.39, SE_B = 0.19) was associated with the number of cigarettes smoked among women. Conclusion: Adults with OUD who used heroin in the past month were more likely to be current smokers. No sex differences were observed in likelihood of smoking; however, the predictors of smoking status and severity differed between men and women.

Long-term naturalistic follow-up of chronic pain in adults with prescription opioid use disorder

BACKGROUND

Chronic pain is common in patients with prescription opioid use disorder (OUD), and pain severity has been shown to predict opioid use for those with chronic pain. However, recent research suggests that focusing on pain status (i.e., the presence or absence of chronic pain) at treatment initiation may not reflect the clinical significance of pain over the long-term course of OUD. Reports of variability in chronic pain and its clinical significance over time have yet to be investigated in patients with prescription OUD. The present study examined variability in chronic pain status from entry into prescription OUD treatment through 3.5-year follow-up. Additionally, we examined the association between concurrent chronic pain and opioid use at three follow-up time points.

METHODS

This secondary analysis (N = 309) of a national, randomized, controlled trial of prescription OUD treatment used generalized estimating equations to assess variability in the prevalence of chronic pain from study entry to 3.5-year follow-up, and the association between chronic pain status and concurrent opioid use.

RESULTS

Fifty-three percent of participants reported variability in chronic pain status over time. The prevalence of chronic pain decreased from study entry through follow-up (aOR = 0.47, p < 0.001). Chronic pain was associated with increased opioid use at each follow-up assessment (aOR = 3.56, p < 0.001).

CONCLUSIONS

Chronic pain status may vary over time in those with prescription OUD, and chronic pain appears to be associated with concurrent opioid use. The present findings highlight the importance of assessing chronic pain throughout the course of prescription OUD.

Associations among interpretation bias, craving, and abstinence self-efficacy in adults with substance use disorders

OBJECTIVE

Interpretation bias is a crucial therapeutic target in emotional disorders. However, few studies have examined the role of interpretation bias in substance use disorders (SUDs). Our specific aims were: (1) to examine whether interpretation bias was associated with craving and abstinence self-efficacy, and (2) explore potential moderators of these associations, including anxiety severity, sex, and substance type.

METHODS

Adults attending an inpatient SUD treatment program (N = 224; mean age = 38.95; 67% male/33% female; 68% primary alcohol use disorder/29% primary opioid use disorder) completed the Word-Sentence Association Paradigm (WSAP) with ambiguous situations related to general anxiety domains (e.g., daily stress, health, relationships), as well as measures of craving (Craving Scale), abstinence self-efficacy (Brief Situational Confidence Scale), and anxiety symptoms (Overall Anxiety Severity and Impairment Scale [OASIS] and Anxiety Sensitivity Index-3).

RESULTS

Negative interpretation bias was modestly associated with more craving (r = .23, p =  .001) and less confidence to resist using substances (r = -0.23, p =  .001). In multiple linear regression models that included the anxiety measures, interpretation bias was the most robust predictor of craving and abstinence self-efficacy. Sex (N = 224) and substance type (opioid vs. alcohol; n = 219) did not moderate these relationships.

CONCLUSIONS

These findings suggest that interpretation bias might be an important individual difference within SUD populations.

Correlates of Opioid Abstinence in a 42-Month Posttreatment Naturalistic Follow-Up Study of Prescription Opioid Dependence

OBJECTIVE

The natural course of prescription opioid use disorder has not been examined in longitudinal studies. The current study examined correlates of opioid abstinence over time after completion of a treatment trial for prescription opioid dependence.

METHODS

The multisite Prescription Opioid Addiction Treatment Study examined different durations of buprenorphine-naloxone treatment and different intensities of counseling to treat prescription opioid dependence, as assessed by DSM-IV; following the clinical trial, a longitudinal study was conducted from March 2009-January 2013. At 18, 30, and 42 months after treatment entry, telephone interviews were conducted (N = 375). In this exploratory, naturalistic study, logistic regression analyses examined the association between treatment modality (including formal treatment and mutual help) and opioid abstinence rates at the follow-up assessments.

RESULTS

At the 3 follow-up assessments, approximately half of the participants reported engaging in current substance use disorder treatment (47%-50%). The most common treatments were buprenorphine maintenance (27%-35%) and mutual-help group attendance (27%-30%), followed by outpatient counseling (18%-23%) and methadone maintenance (4%). In adjusted analyses, current opioid agonist treatment showed the strongest association with current opioid abstinence (odds ratios [ORs] = 5.4, 4.6, and 2.8 at the 3 assessments), followed by current mutual-help attendance (ORs = 2.2, 2.7, and 1.9); current outpatient counseling was not significantly associated with abstinence in the adjusted models.

CONCLUSIONS

While opioid agonist treatment was most strongly associated with opioid abstinence among patients with prescription opioid dependence over time, mutual-help group attendance was independently associated with opioid abstinence. Clinicians should consider recommending both of these interventions to patients with opioid use disorder.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT00316277​.

Nonmedical benzodiazepine use in adults with alcohol use disorder: The role of anxiety sensitivity and polysubstance use

BACKGROUND AND OBJECTIVES

The nonmedical use of benzodiazepines-defined as use without a prescription or at a dose or frequency higher than prescribed-is increasing among adults in substance use disorder treatment and is associated with risk for overdose. The aim of the current study was to characterize the prevalence of nonmedical benzodiazepine use among adults seeking treatment for alcohol use disorder and to examine whether nonmedical benzodiazepine use was associated with: (1) polysubstance use and (2) greater anxiety sensitivity.

METHODS

A sample of 461 treatment-seeking adults with alcohol use disorder who were recruited for a cross-sectional study were included in this analysis.

RESULTS

A total of 89 participants (19%) reported nonmedical benzodiazepine use in the previous 30 days. Results of a logistic regression indicated that polysubstance use (number of substances used in the past month) was associated with nonmedical benzodiazepine use. The association between anxiety sensitivity and nonmedical benzodiazepine misuse was moderated by gender; anxiety sensitivity was associated with benzodiazepine use among women, but not men.

DISCUSSION AND CONCLUSIONS

These results replicate findings from research on opioid use disorder suggesting that anxiety sensitivity is associated with nonmedical benzodiazepine use in women and not men.

SCIENTIFIC SIGNIFICANCE

Targeted intervention to those with polysubstance use-including education on overdose risk when benzodiazepines are combined with other substances-is indicated in men and women with alcohol use disorder. Anxiety sensitivity may be a potential therapeutic target to reduce nonmedical benzodiazepine use among women with alcohol use disorder. (Am J Addict 2018;27:485-490).

Religious coping in patients with severe substance use disorders receiving acute inpatient detoxification

BACKGROUND AND OBJECTIVES

Religious coping, one of the most widely studied components of spirituality among psychiatric populations, has rarely been addressed in patients with severe substance use disorders (SUD). The aim of our study was to elucidate whether religious coping is related to symptom expression and mutual-help participation.

METHODS

Self-reported religious coping was assessed in individuals sequentially admitted to a private psychiatric hospital for inpatient detoxification. Target symptoms of SUD included severity of substance use prior to admission and craving during detoxification. Three hundred thirty-one patients (68.6% male) participated in the survey; mean age was 38.0 years, and primary presenting diagnosis was most commonly alcohol use disorder (n = 202; 61%), followed by opioid use disorder (n = 119; 36%).

RESULTS

Positive religious coping was associated with significantly greater mutual-help participation, fewer days of drug use prior to admission, and was modestly, yet significantly associated with lower drug craving. Negative religious coping was associated with lower confidence in the ability to remain abstinent post-discharge and higher drug craving.

CONCLUSIONS

Consistent with hypotheses, greater positive religious coping was associated with greater mutual-help participation, lower severity of pre-admission drug use, and lower substance craving during detoxification. Use of positive religious coping may modify the course of SUD recovery by promoting engagement in mutual-help activities.

SCIENTIFIC SIGNIFICANCE

The findings of this study suggest that positive and negative religious coping are linked with several key SUD recovery variables. Further research to replicate this finding and to assess mechanisms within this potential association is warranted. (Am J Addict 2017;26:744-750).

Perceived barriers to smoking cessation among adults with substance use disorders

The majority of adults seeking substance use disorder treatment also smoke. Smoking is associated with greater substance use disorder severity, poorer treatment outcome, and increased mortality among those with substance use disorders. Yet, engaging this population in smoking cessation treatment is a significant challenge. The aim of this study was to examine perceived barriers to smoking cessation among treatment-seeking adults with alcohol or opioid use disorder. Additionally, we examined whether anxiety sensitivity - a known risk factor for barriers to smoking cessation in the general population - was associated with more barriers to smoking cessation in this sample. A sample of 208 adults was recruited for a one-time study and completed self-report measures of anxiety sensitivity and perceived barriers to smoking cessation. Results indicated that the most common barriers were anxiety (82% of the sample), tension/irritability (76%), and concerns about the ability to maintain sobriety from their primary substance of abuse (64%). Those who reported more barriers also reported lower confidence in the ability to change their smoking behavior. Higher anxiety sensitivity was associated with more perceived barriers to smoking cessation, even when controlling for cigarette dependence severity. These results suggest that there are several perceived barriers to smoking cessation among treatment-seeking adults with substance use disorders. In addition to psychoeducational interventions aimed to modify negative beliefs about smoking cessation, anxiety sensitivity may be a promising therapeutic target in this population.

Grit in patients with substance use disorders

BACKGROUND AND OBJECTIVES

Grit is an emerging concept in positive psychology, defined as the ability to be persistent and focused in pursuit of long-term goals. This concept has received a great deal of interest recently because of its robust ability to predict success and well-being across a wide variety of domains. The study aim was to examine the clinical relevance of the construct of grit among patients with substance use disorders.

METHODS

Inpatients on a detoxification unit were enrolled from September 2013 to August 2015 (N = 673). Psychometric properties of the Short Grit Scale (Grit-S) were reported. We then examined sociodemographic and clinical variables that might be associated with grit in this population.

RESULTS

In this sample of patients with substance use disorders, the total Grit-S demonstrated strong psychometric properties. Grit-S scores were higher among older patients and those who were employed; scores were lower among those never married, diagnosed with a co-occurring psychiatric disorder, or who had used heroin during the past month, according to bivariate analyses. Grit-S scores remained associated with age, employment, and presence of a co-occurring psychiatric disorder in adjusted analysis.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

This study provides initial support for the utility of the Grit-S among those with substance use disorders; this novel measure has not been previously reported in clinical populations. Research examining grit prospectively is needed to determine whether the links between grit and outcomes observed in other populations apply to patients with substance use disorders. (Am J Addict 2016;25:652-658).

Delay discounting in opioid use disorder: Differences between heroin and prescription opioid users

BACKGROUND

Among those with opioid use disorder, heroin use is associated with poorer prognosis relative to use of prescription opioids alone. However, relatively little is known about distinguishing features between those who use heroin relative to those who use prescription opioids. In the present study we evaluated differences in delay discounting in those with opioid use disorder based on primary opioid of use. Delay discounting is associated with a range of negative outcomes and is an important therapeutic target in this population.

METHODS

Treatment-seeking adults with opioid dependence completed self-report measures including past-month opioid use and the Monetary Choice Questionnaire (Kirby and Marakovic, 1996; Kirby et al., 1999), a measure of delay discounting. Participants were divided into two groups based on whether they used any heroin in the past 30days or only prescription opioids, and delay discounting scores were compared between the groups. Group differences in sociodemographic or clinical variables were included in the analysis as covariates.

RESULTS

Results from a forward stepwise linear regression indicated that heroin use was associated with significantly higher delay discounting (B=-0.99, SE_B=0.34, t=-2.88, p=0.005), even when considering covariates.

CONCLUSIONS

Adults with opioid dependence who exclusively used prescription opioids had lower delay discounting relative to those who used heroin. This finding contributes further to the literature suggesting that heroin use is associated with greater clinical severity among those with opioid use disorder.

Prevalence of restless legs syndrome during detoxification from alcohol and opioids

BACKGROUND AND AIMS

Restless legs syndrome (RLS) is a movement disorder associated with adverse health outcomes and decreased quality of life. Small case series suggest that symptoms of RLS occur during opioid withdrawal. However, the prevalence is unknown.

METHODS

We conducted an observational study to determine the prevalence of RLS among inpatients patients receiving buprenorphine detoxification from opioids. To assess the specificity of RLS to opioid detoxification, we also evaluated patients receiving detoxification from alcohol as a comparison group. The diagnosis of RLS was established using a validated questionnaire.

RESULTS

The sample consisted of 124 adults with primary opioid use disorder and 180 with primary alcohol use disorder. In the total sample, 33.6% met a likely RLS diagnosis: 50.8% of those with opioid use disorder and 21.7% of those with alcohol use disorder (χ² = 27.96[1,304] p < .001). In the logistic regression analysis controlling for socio-demographic and clinical variables, diagnosis of opioid use disorder was associated with more than twice the likelihood of RLS diagnosis (OR=2.05, 95% CI 1.09-3.88) relative to diagnosis of alcohol use disorder.

CONCLUSIONS

Approximately half of patients undergoing inpatient opioid detoxification exhibited the symptoms characteristic of RLS. We believe that these data support the existence of a secondary form of RLS associated with opioid withdrawal.

Longitudinal association between pain severity and subsequent opioid use in prescription opioid dependent patients with chronic pain

BACKGROUND

Patients with prescription opioid use disorder commonly report relief of chronic pain as the chief reason for first opioid use; indeed, the prevalence of chronic pain is high in this population. Understanding the association between pain severity and subsequent opioid use is crucial for understanding how to manage these conditions simultaneously and has not been examined in this population. The aim of this analysis was to examine the proximal effect of pain severity on opioid use during 12 weeks of buprenorphine-naloxone therapy for patients with chronic pain and prescription opioid use disorder.

METHODS

This study is a secondary analysis of a national, randomized, controlled trial of buprenorphine-naloxone plus counseling for prescription opioid dependent patients. The association between past-week pain severity and opioid use in the subsequent week was examined in 148 patients presenting with chronic pain at baseline.

RESULTS

Results from a multivariable logistic regression model showed that greater pain severity in a given week was significantly associated with increased odds of opioid use in the following week over the 12-week treatment, even after adjusting for covariates associated with opioid use (aOR=1.15, p<0.001).

CONCLUSIONS

Despite previous reports of no association between baseline pain and subsequent opioid use, our findings suggest that patients who experience flare-ups of pain during treatment are prone to relapse to opioid use. Future studies may identify those who are at risk to use opioids by carefully monitoring patterns of their pain intensity over time.

Association between a brief alcohol craving measure and drinking in the following week

BACKGROUND AND AIMS

Craving for alcohol is thought to be a predictor of alcohol use, particularly in the near future. The assessment of craving in clinical practice requires brief, simple measures that can be implemented routinely. This study tested whether greater alcohol craving was associated with a higher likelihood of alcohol use in the subsequent week.

DESIGN

The COMBINE Study (Combining Medications and Behavioral Interventions for Alcohol Dependence) was a large, multi-site clinical trial of treatment for alcohol dependence. Participants were randomized (stratified by site) to one of nine treatment conditions involving combinations of pharmacotherapy and psychotherapy. Craving was assessed every other week throughout the treatment period.

SETTING

Substance use disorder treatment settings at 11 academic sites across the United States.

PARTICIPANTS

Participants from the COMBINE Study (n = 1370) with available craving data.

MEASUREMENTS

Craving was assessed using the three-item self-report Craving Scale. Drinking was assessed using the Timeline Followback method, and was defined as alcohol use in each study week.

FINDINGS

There was an average of 5.8 (of a possible seven) observation pairs per participant. Craving was associated strongly with alcohol use in the following week [B = 0.27, standard error (SEB ) = 0.06, Wald χ(2)  = 43.34, odds ratio (OR) = 1.31, 95% confidence interval (CI) = 1.16, 1.47, P < 0.001]. For each 1-unit increase in the Craving Scale, the likelihood of drinking in the next week was 31% higher.

CONCLUSIONS

Craving for alcohol is associated strongly with alcohol use in the following week. Clinicians can measure alcohol craving effectively using a brief self-report craving scale.

Long-term outcomes from the National Drug Abuse Treatment Clinical Trials Network Prescription Opioid Addiction Treatment Study

BACKGROUND

Despite the growing prevalence of prescription opioid dependence, longitudinal studies have not examined long-term treatment response. The current study examined outcomes over 42 months in the Prescription Opioid Addiction Treatment Study (POATS).

METHODS

POATS was a multi-site clinical trial lasting up to 9 months, examining different durations of buprenorphine-naloxone plus standard medical management for prescription opioid dependence, with participants randomized to receive or not receive additional opioid drug counseling. A subset of participants (N=375 of 653) enrolled in a follow-up study. Telephone interviews were administered approximately 18, 30, and 42 months after main-trial enrollment. Comparison of baseline characteristics by follow-up participation suggested few differences.

RESULTS

At Month 42, much improvement was seen: 31.7% were abstinent from opioids and not on agonist therapy; 29.4% were receiving opioid agonist therapy, but met no symptom criteria for current opioid dependence; 7.5% were using illicit opioids while on agonist therapy; and the remaining 31.4% were using opioids without agonist therapy. Participants reporting a lifetime history of heroin use at baseline were more likely to meet DSM-IV criteria for opioid dependence at Month 42 (OR=4.56, 95% CI=1.29-16.04, p<.05). Engagement in agonist therapy was associated with a greater likelihood of illicit-opioid abstinence. Eight percent (n=27/338) used heroin for the first time during follow-up; 10.1% reported first-time injection heroin use.

CONCLUSIONS

Long-term outcomes for those dependent on prescription opioids demonstrated clear improvement from baseline. However, a subset exhibited a worsening course, by initiating heroin use and/or injection opioid use.

Health-related quality of life among prescription opioid-dependent patients: Results from a multi-site study

BACKGROUND

Although prescription opioid use disorder has recently increased sharply in the United States, relatively little is known about the general well-being of this population. Assessment of quality of life in patients with substance use disorders has been recommended to improve clinical care.

OBJECTIVES

Health-related quality of life was examined in prescription opioid-dependent patients at entry to a national multi-site clinical trial, to compare quality of life scores in the study sample to other populations; further, background variables associated with quality of life in the literature were examined.

METHODS

Prescription opioid-dependent patients (N = 653) were compared to general populations on the Medical Outcome Study Short Form-36 (SF-36) quality of life measure; and the association between patient background variables and quality of life was examined.

RESULTS

Compared to a general population, the current sample of prescription opioid-dependent patients had worse physical (-1.7 points, p < .001) and mental quality of life (-12.3 points, p < .001) as measured by the SF-36, similar to other opioid-use disorder populations. Within our sample, women showed more impairment than men in mental quality of life (-4.3 points, p < .001); older patients scored worse on physical (-5.2 points, p < .001), but not mental, quality of life. Chronic pain was associated with poorer physical quality of life (-9.0 points, p < .001).

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

The growing focus on wellness underscores the importance of measuring quality of life in addition to substance use outcomes. Routine assessment of health-related quality of life can add an important dimension to overall evaluation of patients' treatment response.

Initial response as a predictor of 12-week buprenorphine-naloxone treatment response in a prescription opioid-dependent population

OBJECTIVE

Initial medication response has been shown to predict treatment outcome across a variety of substance use disorders, but no studies have examined the predictive power of initial response to buprenorphine-naloxone in the treatment of prescription opioid dependence. We therefore conducted a secondary analysis of data from the Prescription Opioid Addiction Treatment Study to determine whether initial response to buprenorphine-naloxone predicted 12-week treatment outcome in a prescription opioid-dependent population.

METHOD

Using data from a multisite, randomized controlled trial of buprenorphine-naloxone plus counseling for DSM-IV prescription opioid dependence (June 2006-July 2009), we conducted a secondary analysis to investigate the relationship between initial medication response and 12-week treatment outcome to establish how soon the efficacy of buprenorphine-naloxone could be predicted (N = 360). Outcomes were determined from the Substance Use Report, a self-report measure of substance use, and confirmatory urinalysis. Predictive values were calculated to determine the importance of abstinence versus use at various time points within the first month of treatment (week 1, weeks 1-2, 1-3, or 1-4) in predicting successful versus unsuccessful treatment outcome (based on abstinence or near-abstinence from opioids) in the last 4 weeks of buprenorphine-naloxone treatment (weeks 9-12).

RESULTS

Outcome was best predicted by medication response after 2 weeks of treatment. Two weeks of initial abstinence was moderately predictive of treatment success (positive predictive value = 71%), while opioid use in both of the first 2 weeks was strongly predictive of unsuccessful treatment outcome (negative predictive value [NPV] = 84%), especially when successful outcome was defined as total abstinence from opioids in weeks 9-12 (NPV = 94%).

CONCLUSIONS

Evaluating prescription opioid-dependent patients after 2 weeks of buprenorphine-naloxone treatment may help determine the likelihood of successful outcome at completion of the current treatment regimen.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT00316277.

Denial of urinalysis-confirmed opioid use in prescription opioid dependence

Although research has generally supported the validity of substance use self-reports, some patients deny urine-verified substance use. We examined the prevalence and patterns of denying urinalysis-confirmed opioid use in a sample of prescription opioid dependent patients. We also identified characteristics associated with denial in this population of increasing public health concern. Opioid use self-reports were compared with weekly urinalysis results in a 12-week multi-site treatment study for prescription opioid dependence. Among those who used opioids during the trial (n=246/360), 44.3% (n=109) denied urinalysis-confirmed opioid use, although usually only once (78%). Overall, 22.9% of opioid-positive urine tests (149/650) were denied on self-report. Multivariable analysis found that initially using opioids to relieve pain was associated with denying opioid use. These findings support the use of both self-reports and urine testing in treating prescription opioid dependence.

Who benefits from additional drug counseling among prescription opioid-dependent patients receiving buprenorphine-naloxone and standard medical management?

BACKGROUND

In the multi-site Prescription Opioid Addiction Treatment Study (POATS), conducted within the National Drug Abuse Clinical Trials Network, participants randomly assigned to receive individual drug counseling in addition to buprenorphine-naloxone and medical management did not have superior opioid use outcomes. However, research with other substance-dependent populations shows that subgroups of participants may benefit from a treatment although the entire population does not.

METHOD

We conducted a secondary analysis of POATS data to determine whether a subgroup of participants benefited from drug counseling in addition to buprenorphine-naloxone and medical management, either due to greater problem severity or more exposure to counseling as a result of greater treatment adherence. Problem severity was measured by a history of heroin use, higher Addiction Severity Index drug composite score, and chronic pain. Adequate treatment adherence was defined a priori as attending at least 60% of all offered sessions.

RESULTS

Patients who had ever used heroin and received drug counseling were more likely to be successful (i.e., abstinent or nearly abstinent from opioids) than heroin users who received medical management alone, but only if they were adherent to treatment and thus received adequate exposure to counseling (OR=3.7, 95% CI=1.1-11.8, p=0.03). The association between severity and outcome did not vary by treatment condition for chronic pain or ASI drug severity score.

CONCLUSIONS

These findings emphasize the importance of treatment adherence, and suggest that patients with prescription opioid dependence are a heterogeneous group, with different optimal treatment strategies for different subgroups.

Reasons for opioid use among patients with dependence on prescription opioids: the role of chronic pain

The number of individuals seeking treatment for prescription opioid dependence has increased dramatically, fostering a need for research on this population. The aim of this study was to examine reasons for prescription opioid use among 653 participants with and without chronic pain, enrolled in the Prescription Opioid Addiction Treatment Study, a randomized controlled trial of treatment for prescription opioid dependence. Participants identified initial and current reasons for opioid use. Participants with chronic pain were more likely to report pain as their primary initial reason for use; avoiding withdrawal was rated as the most important reason for current use in both groups. Participants with chronic pain rated using opioids to cope with physical pain as more important, and using opioids in response to social interactions and craving as less important, than those without chronic pain. Results highlight the importance of physical pain as a reason for opioid use among patients with chronic pain.

Baseline characteristics and treatment outcomes in prescription opioid dependent patients with and without co-occurring psychiatric disorder

BACKGROUND

Given the growing prevalence of prescription opioid dependence and the considerable rates of additional psychopathology in drug dependence, we examined the association between the presence of a co-occurring Axis I psychiatric disorder and sociodemographic and clinical characteristics in this secondary analysis of patients entering a treatment study for dependence on prescription opioids. Treatment outcomes were also compared.

METHODS

Patients dependent on prescription opioids participated in a multi-site, two-phase, randomized, controlled trial to assess different lengths of buprenorphine-naloxone pharmacotherapy and different intensities of counseling (Clinicaltrials.gov identifier: NCT00316277). Among the 653 participants entering the first phase of the trial, 360 entered the second phase, receiving 12 weeks of buprenorphine-naloxone treatment; they are reported here. Half of those participants (180/360) had a current co-occurring psychiatric disorder in addition to substance dependence.

RESULTS

Sociodemographic characteristics were similar overall between those with and without a co-occurring psychiatric disorder, but women were 1.6 times more likely than men to have a co-occurring disorder. On several clinical indicators at baseline, participants with a co-occurring disorder had greater impairment. However, they had better opioid use outcomes at the conclusion of 12 weeks of buprenorphine-naloxone stabilization than did participants without a co-occurring disorder.

CONCLUSIONS

Prescription opioid-dependent patients with a co-occurring psychiatric disorder had a better response to buprenorphine-naloxone treatment despite demonstrating greater impairment at baseline. Additional research is needed to determine the mechanism of this finding and to adapt treatments to address this population.

Association of cannabis use with opioid outcomes among opioid-dependent youth

OBJECTIVE

Cannabis use is common among opioid-dependent patients, but studies of its association with treatment outcome are mixed. In this secondary analysis, the association of cannabis use with opioid treatment outcome is assessed.

METHODS

In the main study, participants (n=152) aged 15-21 years were randomized to receive psychosocial treatments and either a 12-week course of buprenorphine-naloxone with a dose taper to zero in weeks 9-12, or a 2-week detoxification with buprenorphine-naloxone. Drug use was assessed by self-report and urine drug screen at baseline and during study weeks 1-12. The association between cannabis and opioid use at weeks 4, 8, and 12 was examined using logistic regression models.

RESULTS

Participants reported a median of 3.0 days (range=0-30) cannabis use in the past month; half (50.3%; n=77) reported occasional use, one-third reported no use (33.1%; n=50), and one-sixth reported daily cannabis use (16.6%; n=25). Median lifetime cannabis use was 4.0 years (range=0-11) and median age of initiation of use was 15.0 years (range 9-21). Neither past cannabis use (age of initiation and use in the month prior to baseline) nor concurrent use was associated with level of opioid use.

CONCLUSIONS

Overall, cannabis use had no association with opioid use over 12 weeks in this sample of opioid-dependent youth. While cannabis use remains potentially harmful, it was not a predictor of poor opioid treatment outcome.

Concurrent substance abuse is associated with sexual risk behavior among adults seeking treatment for prescription opioid dependence

BACKGROUND

Increasingly, new HIV infections among people who use drugs are attributed to sexual risk behavior. However, HIV prevention research targeting persons with opioid dependence continues to focus on drug injection practices. Moreover, despite the rising prevalence of prescription opioid dependence in the United States, little is known about HIV risk in this population.

METHODS

This study examined the prevalence of sexual risk behavior among patients with opioid dependence who primarily use prescription opioids for non-medical purposes. As part of a multi-site clinical trial, participants (N = 653) completed a baseline assessment that included the Risk Behavior Survey.

RESULTS

In the past month, 74% were sexually active. Of these, most had opposite sex partners (97.3%) and vaginal intercourse (97.1%); anal intercourse was uncommon (3.1%). The majority reported unprotected intercourse (76.5%), but few had multiple partners (11.3%). Unprotected intercourse was associated with history of other substance dependence (adjusted odds ratio [AOR] = 1.73), and having multiple partners was associated with concurrent cocaine use (AOR = 2.54). Injection drug use in the past month was rare (2.5%).

CONCLUSIONS

While the majority of sexually active participants engaged in unprotected intercourse, the proportion with multiple sex partners was low relative to other samples of persons who use illicit drugs. Among persons with non-medical prescription opioid dependence, those who concurrently use other substances may be at elevated risk for HIV infection. Comprehensive assessment of substance abuse history among individuals dependent upon prescription opioids is critical for identifying patients who may require additional clinical interventions to reduce HIV sexual risk behavior.

Patient characteristics associated with buprenorphine/naloxone treatment outcome for prescription opioid dependence: Results from a multisite study

BACKGROUND

Prescription opioid dependence is a growing problem, but little research exists on its treatment, including patient characteristics that predict treatment outcome.

METHODS

A secondary analysis of data from a large multisite, randomized clinical trial, the National Drug Abuse Treatment Clinical Trials Network Prescription Opioid Addiction Treatment Study (POATS) was undertaken to examine baseline patient characteristics (N=360) associated with success during 12-week buprenorphine/naloxone treatment for prescription opioid dependence. Baseline predictor variables included self-reported demographic and opioid use history information, diagnoses assessed via the Composite International Diagnostic Interview, and historical opioid use and related information from the Pain And Opiate Analgesic Use History.

RESULTS

In bivariate analyses, pre-treatment characteristics associated with successful opioid use outcome included older age, past-year or lifetime diagnosis of major depressive disorder, initially obtaining opioids with a medical prescription to relieve pain, having only used opioids by swallowing or sublingual administration, never having used heroin, using an opioid other than extended-release oxycodone most frequently, and no prior opioid dependence treatment. In multivariate analysis, age, lifetime major depressive disorder, having only used opioids by swallowing or sublingual administration, and receiving no prior opioid dependence treatment remained as significant predictors of successful outcome.

CONCLUSIONS

This is the first study to examine characteristics associated with treatment outcome in patients dependent exclusively on prescription opioids. Characteristics associated with successful outcome after 12 weeks of buprenorphine/naloxone treatment include some that have previously been found to predict heroin-dependent patients' response to methadone treatment and some specific to prescription opioid-dependent patients receiving buprenorphine/naloxone.

Clinician beliefs and attitudes about buprenorphine/naloxone diversion

BACKGROUND AND OBJECTIVES

Concern about diversion of buprenorphine/naloxone (B/N) in the United States may affect prescribing patterns and policy decisions. This study examines addiction treatment clinician beliefs and attitudes regarding B/N diversion.

METHODS

Participants (n = 369) completed a 34-item survey in 2010 during two national symposia on opioid dependence. We conducted multivariable regression, examining the relationship of perceived danger from B/N diversion with clinician characteristics and their beliefs about B/N treatment and diversion. We compared causal beliefs about diversion among clinicians with and without B/N treatment experience.

RESULTS

Forty percent of clinicians believed that B/N diversion is a dangerous problem. The belief that B/N diversion increases accidental overdoses in the community was strongly associated with perceived danger from B/N diversion.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

Attitudes and beliefs, not education level, were associated with clinician's perceived danger from B/N diversion. Clinicians with greater B/N patient experience were more likely to believe treatment access barriers are the major cause of B/N diversion.

Poor sleep at baseline predicts worse mood outcomes in patients with co-occurring bipolar disorder and substance dependence

BACKGROUND

Sleep problems are common in patients with bipolar disorder and have been shown to predict subsequent mood symptoms. Sleep problems have also been shown to lead to worse substance use outcomes in individuals with substance use disorder. However, the relationship between sleep and clinical outcomes in a population with co-occurring bipolar disorder and substance use disorder is unclear.

METHOD

This secondary analysis included 60 outpatients (mean age = 38.1 years; recruited via advertisements, fliers, clinician referrals, and hospital treatment programs) who met DSM-IV criteria for both bipolar disorder and substance use disorder (assessed with the Structured Clinical Interview for DSM-IV Axis I Disorders) and who participated in a randomized clinical trial comparing integrated group therapy for bipolar disorder and substance use disorder to group drug counseling for substance use disorder alone. A 12-week treatment period preceded a 24-week follow-up. Poor sleep was assessed with the Pittsburgh Sleep Quality Index, which provides 7 component subscores and an overall sleep score. Data were collected from August 2003 through April 2007.

RESULTS

When analyses were controlled for baseline mood, substance use, and treatment condition, baseline sleep score predicted mood over the course of the 12-week treatment (β = 0.28; P < .05) and 24-week follow-up (β = 0.46; P < .01): worse sleep was associated with worse mood outcomes. Sleep was not associated with substance use outcomes.

CONCLUSIONS

Impaired sleep is a prognostic factor for mood outcomes in patients with co-occurring bipolar and substance use disorders. Further investigation is warranted into the long-term clinical outcomes of poor sleep in this population with co-occurring bipolar disorder and substance use disorder so that appropriate interventions can be developed.

Adjunctive counseling during brief and extended buprenorphine-naloxone treatment for prescription opioid dependence: a 2-phase randomized controlled trial

CONTEXT

No randomized trials have examined treatments for prescription opioid dependence, despite its increasing prevalence.

OBJECTIVE

To evaluate the efficacy of brief and extended buprenorphine hydrochloride-naloxone hydrochloride treatment, with different counseling intensities, for patients dependent on prescription opioids.

DESIGN

Multisite, randomized clinical trial using a 2-phase adaptive treatment research design. Brief treatment (phase 1) included 2-week buprenorphine-naloxone stabilization, 2-week taper, and 8-week postmedication follow-up. Patients with successful opioid use outcomes exited the study; unsuccessful patients entered phase 2: extended (12-week) buprenorphine-naloxone treatment, 4-week taper, and 8-week postmedication follow-up.

SETTING

Ten US sites. Patients A total of 653 treatment-seeking outpatients dependent on prescription opioids.

INTERVENTIONS

In both phases, patients were randomized to standard medical management (SMM) or SMM plus opioid dependence counseling; all received buprenorphine-naloxone.

MAIN OUTCOME MEASURES

Predefined "successful outcome" in each phase: composite measures indicating minimal or no opioid use based on urine test-confirmed self-reports.

RESULTS

During phase 1, only 6.6% (43 of 653) of patients had successful outcomes, with no difference between SMM and SMM plus opioid dependence counseling. In contrast, 49.2% (177 of 360) attained successful outcomes in phase 2 during extended buprenorphine-naloxone treatment (week 12), with no difference between counseling conditions. Success rates 8 weeks after completing the buprenorphine-naloxone taper (phase 2, week 24) dropped to 8.6% (31 of 360), again with no counseling difference. In secondary analyses, successful phase 2 outcomes were more common while taking buprenorphine-naloxone than 8 weeks after taper (49.2% [177 of 360] vs 8.6% [31 of 360], P < .001). Chronic pain did not affect opioid use outcomes; a history of ever using heroin was associated with lower phase 2 success rates while taking buprenorphine-naloxone.

CONCLUSIONS

Prescription opioid-dependent patients are most likely to reduce opioid use during buprenorphine-naloxone treatment; if tapered off buprenorphine-naloxone, even after 12 weeks of treatment, the likelihood of an unsuccessful outcome is high, even in patients receiving counseling in addition to SMM.

The relationship of manic episodes and drug abuse to sexual risk behavior in patients with co-occurring bipolar and substance use disorders: a 15-month prospective analysis

Risky sexual behavior is common among individuals with bipolar and substance use disorders. This 15-month prospective study examined the effects of between-subject differences and within-subject changes in mood symptoms and drug use on sexual risk behavior among 61 patients with both disorders. Participants completed five post-treatment follow-up assessments at 3-month intervals. Using a multivariate mixed-effects model analysis, more average weeks of mania (between-subject difference) was associated with greater sexual risk, but change in weeks of mania (within-subject change) was not; depression was unrelated to sexual risk. In addition, within-subject increases in days of cocaine use predicted increases in sexual risk. Results underscore the importance of substance abuse treatment and suggest that bipolar patients with active and/or recurrent mania are in need of targeted HIV prevention services. Further research is needed to test whether individual differences in impulsivity may explain the association between mania and sexual risk.

The impact of drug use in social networks of patients with substance use and bipolar disorders

In this exploratory analysis, we assessed the effect of drug use among social-network members on recovery from drug dependence in patients with co-occurring bipolar disorder. Patients (n = 57) enrolled in a group therapy study completed assessments over 15 months. Patients with zero to one drug users in their social networks at intake had few days of drug use during treatment and follow-up, whereas those with ≥ 2 drug users had significantly more days of drug use. Multivariate analysis showed that patients who consistently named multiple drug users in their social networks had a marked increase in drug use over 15 months, while those who never or occasionally named multiple drug users had a small decline in drug use over time. Multiple drug users in social networks of treatment-seeking drug-dependent patients with co-occurring bipolar disorder may indicate poor drug use outcomes; efforts to reduce the association with drug users may be useful. This clinical trial has been registered in a public trials registry at clinicaltrials.gov (identifier is NCT00227838). 

Predicting long-term outcomes for women physically abused in childhood: contribution of abuse severity versus family environment

OBJECTIVE

Child physical abuse (CPA) has been associated with adverse adult psychosocial outcomes, although some reports describe minimal long-term effects. The search for the explanation for heterogeneous outcomes in women with CPA has led to an examination of a range of CPA-related factors, from the severity of CPA incidents to the childhood family environment. This study compares several models for predicting adult outcomes: a multidimensional CPA severity scale, the presence or absence of CPA, family environment, and childhood stresses.

METHODS

The effect of CPA on adult outcomes was examined among 290 community-dwelling women raised in 2-parent families. Standardized measures and a focused interview were used to collect data, with siblings as collateral informants.

RESULTS

Comparison of a multidimensional CPA severity scale to a dichotomous measure of the presence or absence of CPA showed that the severity scale did not have greater predictive value for adult outcomes than the dichotomous measure. Childhood family environment scales considerably attenuated the predictive value of the dichotomous measure of CPA, exerting a greater mediating effect on outcomes than did childhood stresses.

CONCLUSIONS

The specific characteristics of a CPA experience may be less important than the occurrence of CPA and the woman's childhood family environment for predicting long-term psychosocial outcomes.

PRACTICE IMPLICATIONS

The presence of child physical abuse is substantial and continues to increase, but the clinical significance of abuse on adult outcomes is unclear. The findings of the current study lend credence to the idea that family stresses and resources other than CPA may be crucial in understanding long-term effects in women. Hence treatment and support for victims of CPA might benefit from clinicians' exploration of the family environment.

Predictors of buprenorphine-naloxone dosing in a 12-week treatment trial for opioid-dependent youth: secondary analyses from a NIDA Clinical Trials Network study

INTRODUCTION

The present investigation examines baseline patient characteristics to predict dosing of buprenorphine-naloxone, a promising treatment for opioid addiction in youths.

METHODS

This study of 69 opioid-dependent youths is a secondary analysis of data collected during a National Institute on Drug Abuse (NIDA) Clinical Trials Network study. Outpatients aged 15-21 were randomized to a 12-week buprenorphine-naloxone dosing condition (including 4 weeks of taper). Predictors of dosing included sociodemographic characteristics (gender, race, age, and education), substance use (alcohol, cannabis, cocaine, and nicotine use), and clinical characteristics (pain and withdrawal severity).

RESULTS

Most (75.4%) reported having either "some" (n=40, 58.0%) or "extreme" (n=12, 17.4%) pain on enrollment. Maximum daily dose of buprenorphine-naloxone (19.7 mg) received by patients reporting "extreme" pain at baseline was significantly higher than the dose received by patients reporting "some" pain (15.0mg) and those without pain (12.8 mg). In the adjusted analysis, only severity of pain and withdrawal significantly predicted dose. During the dosing period, there were no significant differences in opioid use, as measured by urinalysis, by level of pain.

CONCLUSION

These data suggest that the presence of pain predicts buprenorphine-naloxone dose levels in opioid-dependent youth, and that patients with pain have comparable opioid use outcomes to those without pain, but require higher buprenorphine-naloxone doses.

Measuring principal substance of abuse in comorbid patients for clinical research

Few individuals with substance use disorders limit their intake to one substance of abuse; however, many studies focus on a single substance. Unfortunately, the optimal method to determine the principal substance is unclear. In particular, this issue is problematic in patients with co-occurring psychiatric illness, who commonly use multiple substances. Hence we compared three methods for assessing the principal substance of abuse in 150 subjects with bipolar disorder and substance dependence: 1) the Addiction Severity Index interview, 2) a self-administered questionnaire, and 3) the most frequently used substance. While most subjects were concordant on the interview and the other two methods, we found substantial disagreement (9.3% between the interview and the questionnaire, and 12.7% between the interview and the most frequently used substance) and partial agreement (14.0%). These findings from a comorbid population demonstrate that different methods to assess principal substance of abuse could lead to different conclusions about treatment outcomes. Hence studies of comorbid patients may benefit from 1) using more than one method to assess principal substance and 2) reporting use of all substances as well as a targeted substance.

A prospective study examining the effects of gender and sexual/physical abuse on mood outcomes in patients with co-occurring bipolar I and substance use disorders

OBJECTIVES

Prior research suggests possible gender differences in the longitudinal course of bipolar disorder. This study prospectively examined gender differences in mood outcomes and tested the effects of sexual/physical abuse and posttraumatic stress disorder (PTSD).

METHODS

Participants (49 men, 41 women) with co-occurring bipolar I and substance use disorders (92% alcohol, 42% drug) were enrolled in a group treatment trial. They were followed for eight months, with monthly assessments, yielding 32 weeks of data. Primary outcome measures were number of weeks in each mood state, recurrences of depression or mania, and polarity shifts from depression to mania or vice versa. Negative binomial regression was used to examine the effects of gender, lifetime abuse, and PTSD on these outcomes.

RESULTS

Participants met syndromal criteria for a mood episode on a mean of 27% of 32 weeks, with depression occurring most frequently. Compared to men, women reported significantly more weeks of mixed mania [relative rate (RR) = 8.53], fewer weeks of euthymia (RR = 0.58), more recurrences of mania (RR = 1.96), and more direct polarity shifts (RR = 1.49) (all p < 0.05). Women also reported significantly higher rates of lifetime sexual or physical abuse (68% versus 33%), which partially explained the relationships between gender and mixed mania and direct polarity shifts.

CONCLUSIONS

Participants experienced persistent mood symptoms over time. Women consistently reported poorer mood outcomes, and lifetime abuse may help explain observed gender differences in mood outcomes. Further research is necessary to better understand the treatment implications of these findings.

Depression precipitated by alcohol use in patients with co-occurring bipolar and substance use disorders

OBJECTIVE

Bipolar disorder and substance use disorder frequently co-occur. However, little is known about the near-term effects of substance use on bipolar disorder. Thus, the present study tests whether alcohol use precipitates depression among patients with co-occurring bipolar disorder and substance use disorder.

METHOD

This study uses data collected as part of 2 clinical trials (the first study was conducted from March 1999 through March 2004 and the second study was conducted from August 2003 through May 2007) of a manualized group therapy for patients with co-occurring bipolar disorder and substance dependence. One hundred fifteen participants were assessed at baseline and each month through month 8. Baseline diagnoses were made using the Structured Clinical Interview for DSM-IV, and monthly substance use and mood data were collected using the Longitudinal Interval Follow-Up Evaluation and the Addiction Severity Index. Generalized estimating equation methodology was used to analyze these longitudinal data.

RESULTS

Our primary hypotheses were supported: days of alcohol use and an increase in days of alcohol use each significantly predicted the presence of a depressive episode in the subsequent month when controlling for current depression and current drug use.

CONCLUSION

These data suggest that alcohol use in patients with bipolar disorder and substance dependence increases the risk of a depressive episode in the near term.

TRIAL REGISTRATION

This study draws on data generated during 2 clinical trials. One was exempt from trial registration; clinicaltrials.gov Identifier for other trial: NCT00227838.

Sibling agreement on retrospective reports of parental alcoholism and other childhood events

Studies have used siblings to verify subject reports of retrospective data and examined variables influencing subject-sibling agreement, but questions remain. From 1998 to 2000, we examined a community sample of women (N = 143) in a metropolitan area, aged 21-60, balanced by race, parental alcoholism, and social class, as well as their siblings, using standardized, self-administered questionnaires and an interview.

RESEARCH QUESTIONS

Do subject and sibling reports agree? Do reports vary by subject characteristics, or the type of childhood experience? Descriptive statistics showed that agreement was strong for measures of parental alcoholism and psychiatric problems, weaker for family environment, and varied little by subject characteristics. Study limitations and implications are noted, and future research suggested.

Predictors of dropout from group therapy among patients with bipolar and substance use disorders

OBJECTIVE

Bipolar and substance use disorders frequently co-occur. Integrated treatment for these disorders has been shown to be effective at reducing substance use, but no study has examined attrition from dual diagnosis group therapy. The current study identified baseline demographic and clinical characteristics that predict treatment dropout among patients with co-occurring bipolar and substance use disorders.

METHOD

Using binary and multivariate analyses, baseline data were analyzed as part of a randomized controlled trial of integrated group therapy for bipolar and substance use disorders.

RESULTS

Cigarette smoking, recent mood episode, and lack of a college education were strong predictors of dropout after controlling for demographic and substance use variables.

CONCLUSIONS

Given the strength of smoking as a predictor of dropout as well as the high rate of smoking among this population, a greater focus on the relationship between smoking and bipolar disorder is warranted.

Assessment of depressive symptom severity among patients with co-occurring bipolar disorder and substance dependence

BACKGROUND

We examined a modified version of the Hamilton Depression Rating Scale (HDRS) among treatment-seeking patients with co-occurring bipolar disorder and substance dependence in order to elucidate key features of depression in this specific population of patients.

METHODS

Patients with current bipolar disorder and substance dependence who were prescribed mood stabilizers (n=105) completed a 27-item version of the HDRS that was subjected to item and principal components analyses. Preliminary validity analysis consisted of comparing the derived total and component scores to the depressed mood indicators from the Addiction Severity Index (ASI).

RESULTS

Eleven items representing two related components labeled "melancholia" and "anxiety" were retained. The 11-item HDRS total and component scores were higher for those who reported serious depression, serious anxiety, cognitive problems, and suicidal ideation on the ASI than for those who did not report these problems.

LIMITATIONS

We conducted the analyses with a relatively small sample of patients who were primarily white and were diagnosed with bipolar I disorder, thus limiting the generalizability of findings. Moreover, we obtained limited data regarding construct validity of the 11-item scale.

CONCLUSIONS

Our psychometric evaluation of the HDRS led us to retain 11 items representing primarily melancholic and neurovegetative symptoms of depression. These findings suggest that sample-specific item characteristics of the HDRS need to be evaluated prior to using this scale to assess depressive symptom severity among patients with complex diagnostic and treatment characteristics.

Assessing negative consequences in patients with substance use and bipolar disorders: psychometric properties of the short inventory of problems (SIP)

The Short Inventory of Problems (SIP), a questionnaire that measures negative consequences of alcohol use, has not been validated among substance users with co-occurring psychiatric illness. This study examined the psychometric properties of the SIP in 57 outpatients diagnosed with substance use disorder and bipolar disorder. We modified the items to assess drugs in addition to alcohol and, further, we added corresponding items to assess consequences of bipolar disorder. This modified version of the SIP was psychometrically sound, and may be useful in patients with both disorders. A greater understanding of perceived negative consequences may enhance outcome assessment in dually diagnosed populations.

HIV risk behavior among patients with co-occurring bipolar and substance use disorders: associations with mania and drug abuse

BACKGROUND

Bipolar and substance use disorders frequently co-occur, and both are associated with impulsivity, impaired judgment, and risk-taking.

OBJECTIVES

This study aimed to: (1) describe the rates of HIV sexual and drug risk behaviors among patients with co-occurring bipolar and substance use disorders, (2) test whether acute mania, psychiatric severity, and drug severity independently predict HIV risk, and (3) examine the relationship between specific substance dependencies and sexual risk behaviors.

METHOD

Participants (N=101) were assessed for psychiatric diagnoses, substance abuse, and HIV risk behavior using structured clinical interviews and self-report questionnaires.

RESULTS

The majority (75%) were sexually active in the past 6 months and reported high rates of sexual risk behaviors, including unprotected intercourse (69%), multiple partners (39%), sex with prostitutes (24%, men only), and sex trading (10%). In a multivariate linear regression model, recent manic episode, lower psychiatric severity, and greater drug severity were independent predictors of total HIV risk. Cocaine dependence was associated with increased risk of sex trading.

CONCLUSIONS

Results underscore the importance of HIV prevention for this population.