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PubMed1995

Mental health care practices and educational needs of general practitioners.

OBJECTIVES: To describe current mental health care practices of general practitioners and to identify their educational priorities and training preferences. METHOD: Self-administered questionnaire to a stratified random sample of New South Wales general practitioners. SUBJECTS: 721 full-time general practitioners, of whom 534 (74%) responded. RESULTS: Mental health problems recognised by general practitioners at least once per week were psychosomatic (93%), emotional (89%), addiction (79%), social/economic (71%) and family (69%). At least two-thirds recognised sexual problems, sexual abuse and major psychiatric problems less frequently than once per week. Sixty-four per cent of general practitioners reported that patients felt uncomfortable about being referred to psychiatrists; 53% that referral service waiting lists were too long; 51% that there were insufficient local mental health services; and 25% that communication difficulties between referring general practitioners and mental health specialists obstructed optimal care. Educational priorities were diagnostic and counselling skills, with particular emphasis on crisis, family, individual and marital counselling and strategies to prevent general practitioner burn-out. CONCLUSIONS: General practitioners are interested in improving their mental health counselling and diagnostic skills but barriers remain. Both structural and educational initiatives are essential to enhance the quality of mental health care in general practice.

Adolescent↗

PubMed2005

Alcohol misuse, abuse, and addiction in young and middle adulthood.

This chapter reviews research on alcohol misuse, abuse, and addiction in young and middle adulthood. Young adulthood is defined as ages 21 to 35 and middle adulthood as ages 36 to 65. The authors searched the Cumulative Index of Nursing and Allied Health Literature (CINAHL) and other databases for the years 1992 through 2004 using the terms alcohol abuse, alcoholism, and alcohol dependence, then hand-searched for the inclusion of age as a variable. The search was limited to research and English-language publications. Unpublished dissertation studies were excluded, as were topics that were reviewed in other chapters of this volume. When possible, articles for review were limited to alcohol only, as compared with other drugs of abuse. Research articles were selected for review if they contained the variables alcohol misuse, abuse, or alcohol addiction or dependence and age. The review included both nurse- and non-nurse-investigators and was comprised of 50 studies. The results are in four content areas across the global area of alcohol misuse, abuse, and dependence in young and middle adulthood: incidence and prevalence, developmental changes, the work setting, and the family setting. Few articles used a developmental framework, although in some studies, the framework was implicit. Nurse-investigators were more likely to produce qualitative studies, although the studies varied dramatically in size of sample, research design, and variables. Overall, there was greater breadth than depth. The use of adult developmental theory was limited despite its potential explanatory potential in this field. There is a need for more nurse-researchers to explore adult developmental theory and pay increased attention to age and developmental stage as explanatory variables.

Adult↗

PubMed2003

Baclofen does not alter the reinforcing, subject-rated or cardiovascular effects of intranasal cocaine in humans.

RATIONALE: There is evidence from research in animals and humans that the gamma-aminobutyric acid B receptor subtype (GABA(B)) agonist baclofen may have promise as a pharmacotherapy for cocaine addiction. OBJECTIVES: In the present study, the ability of baclofen to modify the reinforcing, subject-rated and cardiovascular effects of intranasal cocaine in humans was determined. METHODS: Non-treatment-seeking volunteers ( n=7) with recent histories of cocaine use were recruited to participate in this placebo-controlled, double-blind study. Baclofen (0, 10, 20 and 30 mg) was administered orally, followed approximately 1.5 h later by intranasal cocaine (4 mg [placebo] and 45 mg). Subject-rated and cardiovascular measures were taken prior to baclofen administration and then at regular intervals after cocaine was administered. The reinforcing effects of cocaine and cocaine-baclofen combinations were assessed using the Multiple-Choice Procedure. RESULTS: Intranasal cocaine significantly increased the crossover point on the Multiple-Choice Procedure relative to placebo, suggesting that this cocaine dose functioned as a reinforcer. This dose of intranasal cocaine also produced increases in subject-rated effects typical of psychostimulants and elevated cardiovascular measures. The time course for the effects of cocaine was consistent with its pharmacokinetic profile following intranasal administration; increases in subject-rated and cardiovascular effects were observed almost immediately following administration and peaked at approximately 30 min. Pretreatment with baclofen had no significant effect alone, nor in combination with cocaine, on any outcome. CONCLUSIONS: These data demonstrated that acute administration of three clinically relevant baclofen doses did not influence the acute behavioral effects of intranasal cocaine in humans.

Administration, Intranasal↗

PubMed2001

Addiction as excessive appetite.

The excessive appetite model of addiction is summarized. The paper begins by considering the forms of excessive appetite which a comprehensive model should account for: principally, excessive drinking, smoking, gambling, eating, sex and a diverse range of drugs including at least heroin, cocaine and cannabis. The model rests, therefore, upon a broader concept of what constitutes addiction than the traditional, more restricted, and arguably misleading definition. The core elements of the model include: very skewed consumption distribution curves; restraint, control or deterrence; positive incentive learning mechanisms which highlight varied forms of rapid emotional change as rewards, and wide cue conditioning; complex memory schemata; secondary, acquired emotional regulation cycles, of which 'chasing', 'the abstinence violation effect' and neuroadaptation are examples; and the consequences of conflict. These primary and secondary processes, occurring within diverse sociocultural contexts, are sufficient to account for the development of a strong attachment to an appetitive activity, such that self-control is diminished, and behaviour may appear to be disease-like. Giving up excess is a natural consequence of conflict arising from strong and troublesome appetite. There is much supportive evidence that change occurs outside expert treatment, and that when it occurs within treatment the change processes are more basic and universal than those espoused by fashionable expert theories.

Behavior Therapy↗

PubMed2001

Effects of methadone on cognition, mood and craving in detoxifying opiate addicts: a dose-response study.

RATIONALE: Methadone is the most widespread pharmacological treatment for opiate dependency but relatively little is known of its effects on cognitive and psychomotor functioning, drug craving and mood. OBJECTIVE: The present study aimed to assess the acute effects of methadone in patients admitted to an opiate detoxification programme. METHODS: Patients were randomly allocated to one of two groups who received either 50% or 100% of their daily stabilisation dose, and a placebo, in a double-blind, cross-over design. Twenty patients completed the study, all were assessed pre- and post-drug on 2 separate testing days. RESULTS: Performance on a task tapping episodic memory (delayed recall of a prose passage) was significantly impaired following the 100% daily dose of methadone. Methadone treatment had no effect on craving or mood. Patients were unable to distinguish between methadone and placebo treatments. CONCLUSIONS: A single dose of methadone can induce episodic memory impairment in patients who have a history of heroin use averaging more than 10 years. Such impairment can be avoided by giving methadone in divided doses.

Adult↗

PubMed2005

Investigating the factor structure of the Questionnaire on Smoking Urges-Brief (QSU-Brief).

This study was designed to investigate the proposed two-factor structure of the 10-item Questionnaire on Smoking Urges-Brief (QSU-Brief) and to provide evidence for the psychometric properties of this questionnaire using the seven-point scoring set from the original QSU study [Tiffany, S.T., Drobes, D.J. (1991). The development and initial validation of a questionnaire on smoking urges. British Journal of Addiction, 86, 1467-1476.]. The study sample (N=576) was comprised of smokers presenting for treatment. Although an initial exploratory factor analysis appeared to replicate the original factor analytic findings of Cox et al. [Cox, L.S., Tiffany, S.T., Christen, A.G. (2001). Evaluation of the brief questionnaire of smoking urges (QSU-Brief) in laboratory and clinical settings. Nicotine and Tobacco Research, 3, 7-16.], when subjected to confirmatory factor analyses, a five-item, two-factor model using the most robust items from the original QSU-Brief factor analysis was the best explanation of the data in the present study. Good internal consistency reliability estimates were also obtained with this model. These results suggest that this shortened form of the QSU-Brief can be used with the original seven-point scoring set as a reliable assessment of the dual nature of smoking urges in a treatment-seeking population.

Adult↗

PubMed2004

Pharmacotherapy for pregnant women with addictions.

OBJECTIVE: Dependence on alcohol, nicotine, or illicit drugs during pregnancy continues to be a problem of major medical, social, and fetal consequences. The purpose of this systematic review was to summarize current experience that pertains to pharmacotherapy for pregnant women with specific chemical addictions. STUDY DESIGN: Studies were identified through Medline and HealthSTAR (1979-2003) that linked specific pharmacotherapy with pregnancy. This article reviews the English language literature for clinical studies that link the 2 conditions. In addition, reference lists of all articles that were obtained were evaluated for other potential citations. RESULTS: Pregnant women are excluded systematically from almost all drug trials. Most knowledge about the fetal effects from maternal substance and medication use comes from animal data and from case reports and small clinical series. With the exception of methadone and nicotine replacement, clinical experience with antiaddictive medications in pregnant women is either very limited (alcohol, stimulants) or nonexistent (cannabis, hallucinogens). CONCLUSION: Antiaddiction medications are important in the treatment of pregnant women with opioid and nicotine dependence and are of growing importance in the treatment of alcohol and stimulant dependence. Future directions will be toward increasing knowledge about current drug therapy and in developing new antiaddiction medications.

Adolescent↗

PubMed1999

Does clinical case management improve outpatient addiction treatment.

This project evaluated whether clinical case managers (CCMs) could increase access and utilization of social services in the community; and thereby improve outcomes of addiction treatment. No case management (NoCM)--patients received standard, group-based, abstinence-oriented, outpatient drug abuse counseling, approximately twice weekly. Clinical case management (CCM)--patients were treated in the same programs but also were assigned a CCM who provided access to pre-contracted, support services such as drug free housing, medical care, legal referral, and parenting classes from community agencies. CCM patients received more alcohol, medical, employment, and legal services than NoCM patients during treatment. At 6 month follow-up CCM patients showed significantly more improvement in alcohol use, medical status, employment, family relations, and legal status than NoCM patients. We conclude that CCM was an effective method of improving outcomes for substance abuse patients in community treatment programs. Essential elements for successful implementation included extensive training to foster collaboration; and pre-contracting of services to assure availability.

Adult↗

PubMed1998

Fluoxetine treatment of depressive disorders in methadone-maintained opioid addicts.

This study tested the effectiveness of fluoxetine as a treatment for depression in a population of methadone-maintained opioid addicts. Methadone-maintained opioid addicts (44) with depression received fluoxetine or placebo in addition to their methadone, in a double-blind randomized trial, for 12 weeks. Depressive symptoms decreased significantly overall with no significant differences between the groups treated with fluoxetine versus placebo. In addition, drug use outcomes, including cocaine and heroin self-reported use and urine toxicology were measured. There was a significant decrease in heroin use in treatment, but no medication effect. Cocaine use, was unchanged from pre-treatment to endpoint. In separately analyzing data for the subsample of subjects with the most severe depression, there was a significant decrease in depression during treatment and a significant decrease in self-reported cocaine use, but no medication effect on either depressive symptoms or on cocaine use. This study suggests that fluoxetine is not an effective agent in treating depression or cocaine use in this population.

Adult↗

PubMed2006

Toward an integrative model of the spectrum of mood, behavioral and personality disorders based on fear and anger traits: I. Clinical implications.

Current formal psychiatric approaches to nosology are plagued by an unwieldy degree of heterogeneity with insufficient appreciation of the commonalities of emotional, personality, behavioral, and addictive disorders. We address this challenge by building a spectrum model that integrates the advantages of Cloninger's and Akiskalian approaches to personality and temperament while avoiding some of their limitations. We specifically propose that "fear" and "anger" traits--used in a broader connotation than in the conventional literature--provide an optimum basis for understanding how the spectra of anxiety, depressive, bipolar, ADHD, alcohol, substance use and other impulse-control, as well as cluster B and C personality disorders arise and relate to one another. By erecting a bidimensional approach, we attempt to resolve the paradox that apparently polar conditions (e.g. depression and mania, compulsivity and impulsivity, internalizing and externalizing disorders) can coexist without cancelling one another. The combination of excessive or deficient fear and anger traits produces 4 main quadrants corresponding to the main temperament types of hyperthymic, depressive, cyclothymic and labile individuals, which roughly correspond to bipolar I, unipolar depression, bipolar II and ADHD, respectively. Other affective temperaments resulting from excess or deficiency of only fear or anger include irritable, anxious, apathetic and hyperactive. Our model does not consider schizophrenia. We propose that "healthy" or euthymic individuals would have average or moderate fear and anger traits. We further propose that family history, course and comorbidity patterns can also be understood based on fear and anger traits. We finally discuss the implications of the new derived model for clinical diagnosis of the common psychiatric disorders, and for subtyping depression and anxiety as well as cognitive and behavioral styles. We submit this proposed schema represented herein as a heuristic attempt to build bridges between basic and clinical science.

Alcoholism↗

PubMed2002

Measuring problem video game playing in adolescents.

AIMS: Some researchers suggest that for some people, video game playing is an addictive behaviour similar to substance dependence. Our aim was to design and validate a scale to measure the problems associated with the apparently addictive use of all types of video games and video game systems, because there is no instrument at the present time that can be used for this purpose. DESIGN: We reviewed the DSM-IV criteria for substance dependence and for pathological gambling, as well as the literature on the addictions in order to design a short scale (PVP; problem video game playing) that is quick and easy to apply. PARTICIPANTS: The scale was administered to 223 Spanish adolescents aged between 13 and 18 years. The study was carried out in Granada and Algeciras, Spain. FINDINGS: Psychometric analyses show that the PVP seems to be unidimensional and has acceptable internal consistency (Cronbach's alpha) at 0.69. The pattern of associations between the scale scores and alternative measures of problem play supports its construct validity (higher total scores in the scale were associated with higher frequency of play, mean and longest times per session, self and parents' perception of playing to excess, and scores in the Severity of Dependence Scale). CONCLUSIONS: Our results confirm that the excessive use of video games is associated with a number of problems which resemble a dependence syndrome, and the PVP appears as a useful instrument for the measurement of such problems.

Adolescent↗

PubMed2022

Cross-ancestry meta-analysis of opioid use disorder uncovers novel loci with predominant effects in brain regions associated with addiction.

Despite an estimated heritability of ~50%, genome-wide association studies of opioid use disorder (OUD) have revealed few genome-wide significant loci. We conducted a cross-ancestry meta-analysis of OUD in the Million Veteran Program (N = 425,944). In addition to known exonic variants in OPRM1 and FURIN, we identified intronic variants in RABEPK, FBXW4, NCAM1 and KCNN1. A meta-analysis including other datasets identified a locus in TSNARE1. In total, we identified 14 loci for OUD, 12 of which are novel. Significant genetic correlations were identified for 127 traits, including psychiatric disorders and other substance use-related traits. The only significantly enriched cell-type group was CNS, with gene expression enrichment in brain regions previously associated with substance use disorders. These findings increase our understanding of the biological basis of OUD and provide further evidence that it is a brain disease, which may help to reduce stigma and inform efforts to address the opioid epidemic.

Behavior, Addictive↗

PubMed2005

Nucleus accumbens long-term depression and the expression of behavioral sensitization.

Drug-dependent neural plasticity related to drug addiction and schizophrenia can be modeled in animals as behavioral sensitization, which is induced by repeated noncontingent or self-administration of many drugs of abuse. Molecular mechanisms that are critical for behavioral sensitization have yet to be specified. Long-term depression (LTD) of alpha-amino-3-hydroxy-5-methyl-isoxazole-4-propionic acid receptor (AMPAR)-mediated synaptic transmission in the brain has been proposed as a cellular substrate for learning and memory. The expression of LTD in the nucleus accumbens (NAc) required clathrin-dependent endocytosis of postsynaptic AMPARs. NAc LTD was blocked by a dynamin-derived peptide that inhibited clathrin-mediated endocytosis or by a GluR2-derived peptide that blocked regulated AMPAR endocytosis. Systemic or intra-NAc infusion of the membrane-permeable GluR2 peptide prevented the expression of amphetamine-induced behavioral sensitization in the rat.

Animals↗

PubMed2006

Dopaminergic responses to self-administered cocaine in Rhesus monkeys do not sensitize following high cumulative intake.

Sensitization of mesolimbic dopamine (DA) systems by administration of psychostimulants has been observed repeatedly in rodents. This phenomenon has been incorporated into theories of neurobiological adaptation underlying addiction, and is believed to be a mechanism whereby drug-associated cues acquire the ability to control behaviour via a conditioned release of DA. However, we have previously demonstrated in nonhuman primates that drug cues that cause cocaine seeking do not promote a conditioned increase in DA release of sufficient endurance to be measured in 2-min samples. In addition, imaging studies in humans and nonhuman primates that have been chronically exposed to psychostimulants have not demonstrated an increase in DA release upon psychostimulant challenge. Here we report that following 32 weeks of self-administration by rhesus monkeys, no increase over time in the DA response to self-administered cocaine was observed in any striatal subregion or individual animal. These results are consistent with clinical imaging studies showing a lack of DA sensitization, and might provide a mechanism to explain our previous observation that the rodent and primate differ in neurochemical response to drug-associated cues.

Adaptation, Physiological↗

PubMed2003

Eye movements to smoking-related cues: effects of nicotine deprivation.

RATIONALE: According to recent theories of addiction, nicotine deprivation may influence biases in the orienting and maintenance of attention on smoking-related cues. OBJECTIVES: We examined the effect of nicotine deprivation on different aspects of attentional biases for smoking-related cues. METHODS: Smokers' eye movements to smoking-related and control pictures were assessed during a visual probe task under deprived and non-deprived conditions. RESULTS: When deprived, smokers maintained their gaze for longer on smoking-related than control cues, relative to when non-deprived. Deprivation also increased craving and pleasantness ratings of smoking cues. Across both deprived and non-deprived conditions, smokers were more likely to shift their gaze towards smoking cues and were faster to respond to probes replacing smoking cues, relative to non-smoking cues, but these attentional bias measures were not significantly affected by the deprivation manipulation. CONCLUSIONS: Results suggest a selective effect of deprivation on the maintenance of attention on smoking-related cues.

Adult↗

PubMed2006

Effects of self reflection on engagement in a 12-step addiction treatment programme: a linguistic analysis of diary entries.

Thirty clients receiving Twelve-Step Facilitation Therapy in a rehabilitation setting formed the intervention group. They were asked to complete in third person a weekly evaluation of progress based on reading personal "Feelings" diaries they had written on a daily basis over a period of one week, starting 3weeks previously. The diaries of the clients and of a further 60 clients in two matched control groups were compared. One control group consisted of clients receiving treatment before the intervention was introduced, and clients in the second control group received treatment after the intervention was terminated. Clients in the control groups were matched to the intervention group according to presenting disorder (alcohol, drugs or food), gender and age. Analysis of the number of words written and diaries produced suggested that the experimental group's productivity was enhanced. Linguistic and cluster analyses indicated that the clients in the Intervention group referred more frequently to key elements of the programme (steps and spirituality) and responded in a more integrated way to the major aspects of their treatment regime. The study supported the expectation that by promoting self-reflection on progress in therapeutic settings, an increase in programme engagement can be expected.

Adult↗

PubMed2005

Medical illness and comorbidities in drug users: implications for addiction pharmacotherapy treatment.

Providing effective medical care to those with substance use disorders can be a challenge to clinicians. In this article, we briefly summarize issues that occur frequently in the medical treatment of substance users. The focus of this article is twofold. The first is to briefly summarize common co-occurring medical illnesses in those manifesting substance use disorders with an emphasis on issues related to providing effective treatment for these diseases in this population. Using specific examples of frequently occurring comorbid medical illness in substance users, including infectious diseases (hepatitis C and HIV disease), sexually transmitted diseases, and pregnancy as examples, the complexities of medical care for this population is demonstrated. Second, this article addresses some of the difficulties encountered in pharmacotherapy aimed specifically at treatment of substance use disorders. For example, difficulties in managing concomitant opiate therapy in those requiring medications for medical illness that may have strong and adverse interactions with opiates are addressed. Adverse events reported for some substance use disorder pharmacotherapies are also highlighted. We conclude with a brief review of models of care that have been effective in addressing the needs of this challenging population that can provide additional means for enhancing the clinical care of substance users.

Antiviral Agents↗

PubMed1998

A comparison of subjective, psychomotor and physiological effects of a novel muscarinic analgesic, LY297802 tartrate, and oral morphine in occasional drug users.

This study compared the subjective, physiological and psychomotor effects of a novel muscarinic analgesic (LY297802) and oral morphine in healthy volunteers. Nine, non-dependent, occasional drug users participated in nine experimental sessions in which they received the following conditions: placebo, 0.1, 0.3, 0.56 and 1 mg of oral LY297802 and 10, 30, 56 and 100 mg of oral morphine. Subjective drug effects were assessed using the Visual Analog Scale (VAS), the Addiction Research Center Inventory (ARCI) and subjective and objective agonist and antagonist scales of the Adjective Rating Scale (ARS). These measures were collected 30 min before and every 30 min post drug administration for a 4-h period. Psychomotor performance was evaluated using the Digit Symbol Substitution Test (DSST) at these same time intervals. Physiological measures were collected continuously throughout the sessions. Oral morphine produced significant increases in some subjective effects scales, including elevations on the VAS, ARCI and ARS. In contrast, LY297802 did not engender changes different from placebo on any of these indices. Morphine produced significant dose-dependent effects in DSST performance, heart rate, blood oxygen saturation and pupil diameter. LY297802 significantly and dose dependently increased heart rate, mean arterial pressure and diastolic blood pressure. These results suggest that LY297802 does not induce subjective effects similar to morphine, but that it has some significant physiological effects.

Adult↗