The Myth of "Cross-Addiction" Debunked

For decades, the conventional wisdom and clinical lore in rehab facilities and recovery communities has warned against the risks of so-called "cross-addiction". "Be careful," they say, "you're at-risk of picking up a new addiction now that you've kicked one habit." Heroin addicts are warned against developing an addiction to alcohol, and cocaine addicts are warned against developing an addiction to opiates, Cross-addiction can even occur to things like exercise or sugar, according to pamphlets and even therapists who have worked in the field for years and years.

But is it even true? Is the notion of cross-addiction supported by empirical evidence - or does it fall on its face under scientific scrutiny?

According to a new report, published September 10 in JAMA Psychiatry, the answer is a resounding, "No."

The study, "Testing the Drug Substitution Switching-Addictions Hypothesis," analyzed data from the National Epidemiological Study on Alcohol and Related Conditions (NESARC) to investigate whether participants developed new-onset substance use disorders (SUD) after remission from a previous SUD. These data were then compared against people with a SUD who did not achieve remission but also developed a new-onset SUD.

The authors discovered that, "As compared with those who do not remit from an SUD, remitters have less than half the risk of developing a new SUD. Contrary to clinical lore, achieving remission does not typically lead to drug substitution but rather is associated with a lower risk of new SUD onsets."

This is probably the best evidence to-date that addresses the concept of cross-addiction. Will counselors and agencies begin to pull back from this concept - or will clients still be subjected to homework assignments and lectures warning against it?

Here's the abstract from JAMA Psychiatry (found here: http://archpsyc.jamanetwork.com/article.aspx?articleid=1901525):

Importance  Adults who remit from a substance use disorder (SUD) are often thought to be at increased risk for developing another SUD. A greater understanding of the prevalence and risk factors for drug substitution would inform clinical monitoring and management.

Objective  To determine whether remission from an SUD increases the risk of onset of a new SUD after a 3-year follow-up compared with lack of remission from an SUD and whether sociodemographic characteristics and psychiatric disorders, including personality disorders, independently predict a new-onset SUD.

Design, Setting, and Participants  A prospective cohort study where data were drawn from a nationally representative sample of 34 653 adults from the National Epidemiologic Survey on Alcohol and Related Conditions. Participants were interviewed twice, 3 years apart (wave 1, 2001–2002; wave 2, 2004–2005).

Main Outcomes and Measures  We compared new-onset SUDs among individuals with at least 1 current SUD at wave 1 who did not remit from any SUDs at wave 2 (n = 3275) and among individuals with at least 1 current SUD at wave 1 who remitted at wave 2 (n = 2741).

Results  Approximately one-fifth (n = 2741) of the total sample had developed a new-onset SUD at the wave 2 assessment. Individuals who remitted from 1 SUD during this period were significantly less likely than those who did not remit to develop a new SUD (13.1% vs 27.2%, P < .001). Results were robust to sample specification. An exception was that remission from a drug use disorder increased the odds of a new SUD (odds ratio [OR] = 1.46; 95% CI, 1.11-1.92). However, after adjusting for the number of SUDs at baseline, remission from drug use disorders decreased the odds of a new-onset SUD (OR = 0.66; 95% CI, 0.46-0.95) whereas the number of baseline SUDs increased those odds (OR=1.68; 95% CI, 1.43-1.98). Being male, younger in age, never married, having an earlier age at substance use onset, and psychiatric comorbidity significantly increased the odds of a new-onset SUD during the follow-up period.

Conclusions and Relevance  As compared with those who do not remit from an SUD, remitters have less than half the risk of developing a new SUD. Contrary to clinical lore, achieving remission does not typically lead to drug substitution but rather is associated with a lower risk of new SUD onsets.

Computerized Vs In-Person Brief Intervention for Drug Misuse: RCT

We have written much about the challenges of widespread implementation of SBIRT in the US. Well, authors of a new study, published online this month in the journal, Addiction, have suggested a novel tool which they believe could help ensure that scores of additional patients are being screened: computerized brief intervention. And according to their study, it works as well and the in-person version:

Abstract

Background and aims

Several studies have found that brief interventions (BIs) for drug misuse have superior effectiveness to no-treatment controls. However, many health centers do not provide BIs for drug use consistently due to insufficient behavioral health staff capacity. Computerized BIs for drug use are a promising approach, but their effectiveness compared with in-person BIs has not been established. This study compared the effectiveness of a computerized brief intervention (CBI) to an in-person brief intervention (IBI) delivered by a behavioral health counselor.

Methods

Two-arm randomized clinical trial, conducted in two health centers in New Mexico, USA. Participants were 360 adult primary care patients with moderate-risk drug scores on the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) who were randomly assigned on a 1:1 basis to a computerized brief intervention (CBI) or to an in-person brief intervention (IBI) delivered by a behavioral health counselor. Assessments were conducted at baseline and 3-month follow-up, and included the ASSIST and drug testing on hair samples.

Results

The IBI and CBI conditions did not differ at 3 months on global ASSIST drug scores (b=-1.79; 95% CI=-4.37,-0.80) or drug-positive hair tests (OR=.97; 95% CI= 0.47,1.94). There was a statistically significant advantage of CBI over IBI in substance-specific ASSIST scores for marijuana (b=-1.73; 95% CI= -2.91,-0.55; Cohen's d=.26; p=.004) and cocaine (b= -4.48; 95% CI= -8.26,-0.71; Cohen's d=.50; p=.037) at 3 months.

Conclusions

Computerized brief intervention can be an effective alternative to in-person brief intervention for addressing moderate drug use in primary care.

What do you think - could computerized brief interventions be the key to widespread SBIRT implementation?

Source: http://onlinelibrary.wiley.com/doi/10.1111/add.12502/abstract 

Gaps in Clinical Prevention and Treatment for Alcohol Use Disorders

Dr W's article, "Gaps in Clinical Prevention and Treatment for Alcohol Use Disorders" was published this month online in the journal Alcohol Research: Current Reviews. Here's the abstract:

Abstract

Heavy drinking causes significant morbidity, premature mortality, and other social and economic burdens on society, prompting numerous prevention and treatment efforts to avoid or ameliorate the prevalence of heavy drinking and its consequences. However, the impact on public health of current selective (i.e., clinical) prevention and treatment strategies is unclear. Screening and brief counseling for at-risk drinkers in ambulatory primary care has the strongest evidence for efficacy, and some evidence indicates this approach is cost-effective and reduces excess morbidity and dysfunction. Widespread implementation of screening and brief counseling of nondependent heavy drinkers outside of the medical context has the potential to have a large public health impact. For people with functional dependence, no appropriate treatment and prevention approaches currently exist, although such strategies might be able to prevent or reduce the morbidity and other harmful consequences associated with the condition before its eventual natural resolution. For people with alcohol use disorders, particularly severe and recurrent dependence, treatment studies have shown improvement in the short term. However, there is no compelling evidence that treatment of alcohol use disorders has resulted in reductions in overall disease burden. More research is needed on ways to address functional alcohol dependence as well as severe and recurrent alcohol dependence.

And check out the full piece here:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3908715/

Study: Burden of Disease Associated with Alcohol-use Disorders Higher Than Previously Thought

In a paper published online last week in the journal, Alcoholism: Clinical and Experimental Research, a group of international researchers have brought fresh eyes to a familiar data set: the NIAAA's NESARC. Whereas past studies have estimated the alcohol-attributable global burden of disease, or rates of alcohol-attributable deaths and years of life lost, no study has focused specifically on the burden of disease in the United States associated with alcohol-use disorders (AUD). This is important, the authors note, because alcohol-use disorders (including "abuse" and "dependence" from DSM or "the harmful use of alcohol" from ICD) "were identified as the largest disease category contributing to the alcohol-attributable global burden of disease for the year 2004, making up approximately one-third of this burden." By using US-specific data, including population and death statistics as well as Waves 1 and 2 of the NESARC, the authors were able to estimate the burden of disease from AUD in the US in 2005.


Results

"In the United States in 2005, 65,000 deaths, 1,152,000 years of life lost due to premature mortality (YLL), 2,443,000 years of life lost due to disability (YLD), and 3,595,000 disability-adjusted life years (DALYs) lost were associated with AUD. For individuals 18 years of age and older, AUD were associated with 3% of all deaths (5% for men and 1% for women), and 5% of all YLL (7% for men and 2% for women). The majority of the burden of disease associated with AUD stemmed from YLD, which accounted for 68% of DALYs associated with AUD (66% for men and 74% for women). The youngest age group had the largest proportion of DALYs associated with AUD stemming from YLD."

Some figures from the article:

Prevalence of alcohol use disorders by category, sex, and age in 2005. 

And:

Proportion of all deaths associated with alcohol use disorders in 2005, by sex and age


You can read the abstract of the paper by Rehm, et al. here:

http://onlinelibrary.wiley.com/doi/10.1111/acer.12331/abstract

Would love to hear readers reactions to these numbers. 

Overcoming Addictions, a web-based application, & SMART Recovery: Outcomes of a randomized clinical trial

This week's entry comes from Dr Reid K Hester, PhD. He is Director of the Research Division at Behavior Therapy Associates, LLC, where they have been conducting some exciting new research using a web-based application, Overcoming Addictions. Thank you, Dr Hester, for the guest post:

Overcoming Addictions, a web-based application, & SMART Recovery: Outcomes of a 

randomized clinical trial

My research staff and I recently published the early outcomes of a new web app, Overcoming Addictions in the Journal of Medical Internet Research (http://www.jmir.org/2013/7/e134). Overcoming Addictions (OA, www.overcomingaddictions.net) is an abstinence-oriented, cognitive behavioral program based on the protocol of SMART Recovery. SMART Recovery (www.smartrecovery.org) is an organization that has adapted empirically supported treatment strategies for use in a mutual help framework with in-person meetings, online meetings, a forum and other resources.

A firm believer of “In God we trust, everyone else has to show their data,” we evaluated the effectiveness of OA and SMART Recovery (SR) with problem drinkers in a randomized clinical trial. We recruited 189 heavy problem drinkers primarily through SMART Recovery’s web site and their online and in-person meetings. We randomly assigned them to: (1) OA alone, (2) OA+ attend SMART Recovery meetings (OA +SR), or to (3) attend SMART Recovery meetings (SR) only. Outcome measures included self-reported percent days abstinent, mean drinks per day when they did drink , and alcohol/drug related consequences. We also interviewed significant others to corroborate the participant’s self-report.

We predicted that: (1) All groups would reduce their drinking and alcohol/drug related consequences at follow-up compared to their baseline levels; (2) the OA groups would reduce their drinking and alcohol/drug related consequences more than the control group (SR).

There were several striking features of our participants. First, 60% of them were female. While this is consistent with the clinical trials of our other web applications like the Drinker’s Check-up (www.drinkerscheckup.com) and Moderate Drinking (www.moderatedrinking.com), it is significantly more than what one would predict given the prevalence of problem drinking in women versus men (35 vs. 65% respectively) in the epidemiological data. Second, this was a highly educated group with an average of 16 years of education. Third, while these folks were not seeking formal treatment, they had a level of alcohol problems comparable to the outpatient arm of Project MATCH.

At the 3 month follow-up both the intent-to-treat analyses and the actual use analyses showed highly significant improvement from baseline to follow-ups.  Mean within-subject effect sizes were large (d > .8) overall. There were, however, no significant differences between groups. Participants in all groups significantly increased their percent days abstinent from 44% to 72% (P<.001), decreased their mean drinks per drinking day from 8.0 to 4.6 (P<.001), and decreased their alcohol/drug-related problems (P<.001) by about 50%. These are clinically meaningful improvements in outcomes.

These outcomes indicate that both our Overcoming Addictions web app and attending SMART Recovery meetings and using their resources online (www.smartrecovery.org) were effective in helping people recover from their problem drinking.

These graphs reflect outcomes of the actual use analyses.

NIDA/NIAAA Merger Called Off!

This morning, Francis Collins, MD, PhD, the Director of the National Institutes of Health announced that he had decided to reverse his earlier decision to proceed with the merger of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the National Institute on Drug Abuse (NIDA). This is a cause for celebration, as the merger was a solution in search of a problem right from the start.

For most of us at NIAAA (this process started when I was still there) it always looked like a simple power grab by NIDA and a relatively small but influential group of researchers and policymakers closely affiliated with it. The White House Office of Drug Control Policy (ONDCP; the Drug Czar), former NIDA Director Alan Leschner (who coveted NIAAA when he was at NIDA,) and current NIDA Director Nora Volkow all pushed very hard to make this happen. The "problem" it was supposed to solve were "missed opportunities" to pursue research involving both alcohol and drug disorders, but that's actually never been a problem in reality. The two institutes collaborate on multiple initiatives, and both alcohol and other drug disorders are frequently studied together, if only because they often occur together. But few of us involved with this ever thought there was a problem with the two institutes.

At any rate, without getting into details right now, I think this is very good news indeed.

MW

Implementing the NIAAA Guide in Primary Care Clinics

After two years, it finally feels like things are coming together. Allina Health continues to be a great place to try out new ideas for addressing alcohol and pain, across hospitals and clinics. I've been able to recruit up to three primary care clinics in the SBIRT+ project, which is focused on addressing alcohol in primary care. (SBIRT+ stands for Screening, Brief Intervention and Referral to Treatment, Plus Point of Service Care. Point of service care reflects treatment for alcohol dependence (not just at-risk drinking) in primary care. The NIAAA Clinician's Guide uses this model.) Allina is also developing a collaborative care model at a pilot clinic and I expect to be involved in that effort, which is focused on coordination of care and reduction in preventable hospitalization for patients with complex chronic illnesses. Heavy drinking is common among people with chronic diseases who demonstrate high cost and poor outcomes. To reach the goals of reducing costs and improving outcomes requires addressing drinking and other co-morbidities such as depression in addition to improving care for their other chronic medical conditions.

This is a very ripe time for new ideas. Health care clinicians are disillusioned with the time-limited rehab system, where there is only one option that doesn't change even after repeatedly showing lack of effectiveness. They want guidance on what to do next. They are intrigued by the NIAAA Guide's clear guidelines for addressing heavy drinking across the spectrum of severity (from risk drinking to functional dependence to severe recurrent dependence) and by medical treatment options, especially anti-relapse medications. Contrary to what many in the addiction treatment field believe, doctors and other primary care clinicians want very much to help but have pretty much been told to "leave it to the addiction experts," which for the most part means counselors alone, and for relatively short periods. However, the patients spend much more time in primary care than they do in any treatment programs.

In the last week, I've presented SBIRT+ at two primary care clinics, and in the next week I'll be talking to two or three more. I'll fill you in as I go.

MW

NIH Funding Success Rate at Historic Low

As expected, recent figures release by the National Institutes of Health (NIH) show a dismal 17.4% success rate for scientists applying for research funding. NIH is the largest funder of biomedical research in the world, and has two institutes devoted to addiction: The National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the National Institute on Drug Abuse (NIDA.) It's only through NIH supported research that progress is made on understanding addiction and improving treatment outcomes. Yes, we need more access to treatment but we also need better treatments, and that can only come through scientific research. Anyone who care about addiction and its treatment needs to contact their representatives and let them know we support and need research on addiction. Advocacy matters! Why do you think research funding for breast cancer, HIV/AIDS, and autism has gone up so much! Advocacy! Please support research and urge others to as well. MW NIH Grants Funding Drops; The success rate of the government agency’s grant applications has hit an all-time low. By Jef Akst TheScientist.com Oct. 17, 2011 Grant proposals submitted to the National Institutes of Health (NIH) are less likely to be funded than ever before, according to a sneak peak at this year’s success rates obtained by ScienceInsider last week. According to the new estimate put out by the NIH’s Office of Extramural Research (OER), the fiscal year that ended on September 30 saw the funding of just 17.4 percent of research grant applications—a historic low, according to a comment from NIH Director Francis Collins. The numbers are still “preliminary,” and may rebound slightly in the final release of the data next month, OER chief Sally Rockey told ScienceInsider. Still, it’s a significant drop from the 32 percent of grants the agency was funding around the turn of the millennium, and the first time in NIH history that the success rate has dipped below 20 percent. And the drop in grant funding could get even worse: just last month, the Senate approved a 1 percent drop in the NIH budget. If finalized, it would mark only the second time since 1970 that the agency’s budget has gone down instead of up.