Study: Are Drug Screens Sufficient for Adolescent Treatment?

Could it be that we are missing something when it comes to treating adolescents with a substance use disorder? According to a study in the most recent edition of the Journal of Studies on Alcohol Drugs, if you aren't using drug screens when treating this population, the answer is likely "Yes".
In the article, Schuler, et al. looked at data from SAMHSA's CSAT 2007 adolescent treatment database, which tracks outcomes for CSAT-sponsored providers. The total sample consisted of 5,186 adolescents who received either Motivational Enhancement Therapy/Cognitive Behavioral Therapy5 (MET/CBT5) - with or without biological drug screen (BDS) - or were part of the BDS-only or No-Treatment groups within another study. Below is a breakdown of the subjects:

All participants responded to the GAIN structured clinical interview, so scores on the Substance Use Frequency Scale and Substance Problem Scale were the primary outcomes measured. Propensity score methods were used to adjust for baseline differences among youth in the four groups, given the non-randomized nature of the data. The results are striking:

The BDS-only condition seemed to outperform all groups at baseline, 3-, 6- and 12-months on Substance Problem Scale scores and at 6- and 12-months on Substance Frequency Scale scores.
What could account for the significant differences? The authors point out that many adolescents who are involved in treatment and/or the criminal justice system may earn rewards for negative drug screens - or face significant consequences for positive screens. Therefore, the self-report nature of the data could skew the results. That would not necessarily explain the consistent differences across groups, however.

What do you think about these results? If you work with adolescents, does this surprise you? Could evidence like this impact the interventions you use?

SAMHSA Releases State and National Behavioral Health Barometer

The federal Substance Abuse and Mental Health Services Administration recently released its yearly report on the general state of behavioral health needs and services in the US. Based on population and treatment-facility data sets from state to state, the Behavioral Health Barometer is a sweeping, in-depth look into adolescent and adult drug use, treatment and mental health service utilization.

Among the highlights:
- Nationally, youth and young adult use of nonmedical pain relievers is declining in general.
- Past-month cigarette use among teens nationally and locally is declining, although Minnesota saw a small increase in 2011-2012
-Over 50% of Minnesota adolescents, and over 60% of adolescents nationally, did not receive treatment for their past-year depressive episode.
-In Minnesota, only 6.6% of people with past-year alcohol dependence received treatment. For illicit drugs, the number is 14.6%
-In Minnesota, while the number of people receiving methadone treatment has increased by nearly 1000 people since 2008, the number of people receiving buprenorphine has actually decreased in that time (owing to a sharp drop from 2008-2009.

The national report is here:
http://www.samhsa.gov/data/StatesInBrief/2K14/National_BHBarometer.pdf

Read the MN report here:
http://store.samhsa.gov/shin/content/SMA13-4796/SMA13-4796MN.pdf

And find your state here:
http://store.samhsa.gov/product/Behavioral-Health-Barometer-2013/SMA13-4796

Do Adverse Childhood Experiences Make Amphetamine More Pleasurable?

In a fascinating new study, researchers from the University of Maryland and Johns Hopkins University observed the way amphetamine affects the brain, comparing subjects who reported adverse childhood experiences (ACE) with those who did not. They found significant differences between groups in the way the drug impacted the dopamine (DA) neurotransmitter in the ventral striatal (VS) region of the brain, finding a significant positive correlation between early childhood trauma and VS DA release.

The results, published online in the journal, Psychopharmacology, suggest that adverse childhood experiences may enhance vulnerability to amphetamine-use disorders later in life by changing the way the brain transmits dopamine. Interestingly, a positive association between childhood trauma and amphetamine-induced pleasure was suggested for men, but vice versa for women.

Here's the abstract via SpringerLink, and an interesting image from the article:

Abstract

Rationale

Childhood exposure to severe or chronic trauma is an important risk factor for the later development of adult mental health problems, such as substance abuse. Even in nonclinical samples of healthy adults, persons with a history of significant childhood adversity seem to experience greater psychological distress than those without this history. Evidence from rodent studies suggests that early life stress may impair dopamine function in ways that increase risks for drug abuse. However, the degree to which these findings translate to other species remains unclear.

Objectives

This study was conducted to examine associations between childhood adversity and dopamine and subjective responses to amphetamine in humans.

Methods

Following intake assessment, 28 healthy male and female adults, aged 18–29 years, underwent two consecutive 90-min positron emission tomography studies with high specific activity [11C]raclopride. The first scan was preceded by intravenous saline; the second by amphetamine (AMPH 0.3 mg/kg).

Results

Consistent with prior literature, findings showed positive associations between childhood trauma and current levels of perceived stress. Moreover, greater number of traumatic events and higher levels of perceived stress were each associated with higher ventral striatal dopamine responses to AMPH. Findings of mediation analyses further showed that a portion of the relationship between childhood trauma and dopamine release may be mediated by perceived stress.

Conclusions

Overall, results are consistent with preclinical findings suggesting that early trauma may lead to enhanced sensitivity to psychostimulants and that this mechanism may underlie increased vulnerability for drug abuse.

http://link.springer.com/article/10.1007%2Fs00213-013-3407-z

If You Build It, They Will Drink

If there were lingering doubts about the effect of alcohol availability on alcohol consumption, a host of new studies seem to lead the reader to the same conclusion: that increases in availability are correlated to increases in consumption. In other words: if you build it (bar, liquor store, etc), we will drink. What's more, in many cases, it's not just drinking that will happen. So-called alcohol outlet density has been linked to interpersonal and intimate partner violence, adolescent consumption and beliefs about alcohol, and even alcohol-attributable deaths. On the other hand, raising the minimum prices or implementing taxes on alcohol sales seems to go a long way in reducing these potential harms.

The journal, Addiction, has published several of these studies online in the past few weeks. Gruenewald and colleagues analyzed survey data from 50 California cities with populations between 50,000 - 500,000. They found "greater on-premise outlet densities were related to greater drinking frequencies and volumes, and use of on-premise drinking places" (like bars and restaurants).  The researchers concluded that, in addition to characteristics of the individual drinkers (e.g. "impulsivity, risky driving), alcohol availability is correlated with consumption and related problems.

Also in-press at Addiction, Paschall and colleagues analyzed the same sample, but instead focused on adolescent drinking. Some 1478 California youths, aged 13-17, responded to survey questions about past-year alcohol consumption, perceived availability, and questions related to underage enforcement and parental views toward drinking. The answers to these questions were then compared against alcohol outlet (bar) density, public policy, law enforcement activity and city demographics. The authors found that adolescent behaviors and attitudes were significantly affected by their environments. For example, past-year alcohol use was positively correlated to bar density and inversely correlated to "the comprehensiveness and stringency of local alcohol policies". In addition, higher rates of adult drinking were associated with greater increases of past-year adolescent drinking over the three-year study period.

Over in Alcohol and Alcoholism, Grubesic and colleagues studied the association between outlet density in Philadelphia and violent crime. Once again, the researchers found consistent association between the two. Here is a pair of maps, the first showing assault density, the second showing outlet density:

Contrary to the popular belief, no association was found between assault density and "transportation nodes and risky retailers". However, alcohol expenditures and general commercial activity were "positively and significantly" associated with assault density. 

The connection between intimate partner violence (IPV) and alcohol outlet density seems to be well established. In 2012, Conradi and colleagues reported that the density of bars in California was positively associated with IPV-related emergency department visits between 2005-2008. Then, earlier this year, Waller and colleagues found alcohol outlet density to be positively correlated to male-to-female physical - but not sexual - IPV among a national sample. Finally, in March, Zhao and colleagues showed that alcohol outlet density was associated with an increase in alcohol-attributable deaths in British Columbia between 2002-2009. In fact, they calculated that a 10% increase in private liquor stores was associated with a 2.45%, 2.36% and 1.99% increase in acute, chronic and total alcohol-associated (AA) mortality rates.

Interestingly, the single policy that seemed to have the biggest impact in turning these numbers around: raising the minimum price for alcohol. A 10% increase in the minimum price was associated with a 31.72% reduction in "wholly AA deaths". Pretty big numbers. As Dr W observed recently, "raising taxes on alcohol would do more for public health than all the treatment in the world." 

What do you think?

Sunday Alcohol Blue Laws: Keeping consumption in-check?

In a brand new paper by SUNY economist Bans Yoruk, the author analyzes alcohol consumption rates in five states which recently repealed laws banning the sale of alcohol on Sundays. The findings, published online this month in the journal Addiction, show that in three of the five states, per capita alcohol consumption rose significantly in the years following the repeals. Beer seems to be the type of alcohol responsible for most of the increase across the states, with wine and spirits seeing small, if any, changes in demand.

The five states studied were Delaware, which repealed its law against Sunday alcohol sales in 2003, as did Massachusetts and Pennsylvania; Rhode Island, which repealed in 2004; and New Mexico, where the law was changed in 1995. The three states whose per capita consumption increased were Delaware (from 4% pre-repeal to 4.7% post-repeal), Pennsylvania (4% to 4.6%), and New Mexico (6.5% to 7.1%). The increase in Rhode Island was “small and statistically insignificant,” and there was no change in Massachusetts. (Interestingly, the demand for beer seemed to drive the up-tick in sales – all three states where the overall demand rose saw beer consumption increase by about a full percentage point.) The five states were then compared to control states, like our beautiful Minnesota, where alcohol Blue Laws remain in effect. 

Here's the graph from the paper:

Professor Yoruk's analysis falls on the heels of another study which tracked the effects of, among other variables, perceived alcohol availability and bar density on adolescent alcohol consumption. Paschall, et al. found such environmental factors contributed significantly to higher rates of past-year alcohol use. Could it be that an archaic and puritanical relic could actually be saving some lives? Will be interesting to see what readers think about the issue…

Sources:

        Paschall, M. J., Lipperman‐Kreda, S., & Grube, J. W. (2013). Effects of the Local Alcohol Environment on Adolescents’ Drinking Behaviors and Beliefs.Addiction.

        Yörük, B. K. (2013). Legalization of Sunday alcohol sales and alcohol consumption in the United States. Addiction.

UMN Researchers: Brief Intervention Effective with Adolescent Substance Users

Some promising results out of the University of Minnesota’s Center for Adolescent Substance Abuse Research: brief interventions can help students aged 12-18 dramatically reduce their substance use – in as few as 2 sessions. The team, led by clinical psychologist Ken Winters, PhD, Tamara Fahnhorst, MPH, and Andria Botzet, M Ed., implemented a randomized controlled trial in an urban public school system, delivering one of two treatment conditions, plus a control. The first, student-only condition delivered two one-hour therapy sessions in a two-week period; the second added a session with the parent(s) of the student. The results are impressive: while 37% of the control group reported avoiding cannabis during the last three months at the 6-month follow-up, 63% of the parent-group and over 50% of the student-only group reported the same.

See a complete rundown at Drug and Alcohol Findings or check the Journal of Substance Abuse Treatment for the abstract.