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Schwenker R, Dietrich CE, Hirpa S, Nothacker M, Smedslund G, Frese T, Unverzagt S. Motivational interviewing for substance use reduction. Cochrane Database Syst Rev 2023; 12:CD008063. [PMID: 38084817 PMCID: PMC10714668 DOI: 10.1002/14651858.cd008063.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
BACKGROUND Substance use is a global issue, with around 30 to 35 million individuals estimated to have a substance-use disorder. Motivational interviewing (MI) is a client-centred method that aims to strengthen a person's motivation and commitment to a specific goal by exploring their reasons for change and resolving ambivalence, in an atmosphere of acceptance and compassion. This review updates the 2011 version by Smedslund and colleagues. OBJECTIVES To assess the effectiveness of motivational interviewing for substance use on the extent of substance use, readiness to change, and retention in treatment. SEARCH METHODS We searched 18 electronic databases, six websites, four mailing lists, and the reference lists of included studies and reviews. The last search dates were in February 2021 and November 2022. SELECTION CRITERIA We included randomised controlled trials with individuals using drugs, alcohol, or both. Interventions were MI or motivational enhancement therapy (MET), delivered individually and face to face. Eligible control interventions were no intervention, treatment as usual, assessment and feedback, or other active intervention. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane, and assessed the certainty of evidence with GRADE. We conducted meta-analyses for the three outcomes (extent of substance use, readiness to change, retention in treatment) at four time points (post-intervention, short-, medium-, and long-term follow-up). MAIN RESULTS We included 93 studies with 22,776 participants. MI was delivered in one to nine sessions. Session durations varied, from as little as 10 minutes to as long as 148 minutes per session, across included studies. Study settings included inpatient and outpatient clinics, universities, army recruitment centres, veterans' health centres, and prisons. We judged 69 studies to be at high risk of bias in at least one domain and 24 studies to be at low or unclear risk. Comparing MI to no intervention revealed a small to moderate effect of MI in substance use post-intervention (standardised mean difference (SMD) 0.48, 95% confidence interval (CI) 0.07 to 0.89; I2 = 75%; 6 studies, 471 participants; low-certainty evidence). The effect was weaker at short-term follow-up (SMD 0.20, 95% CI 0.12 to 0.28; 19 studies, 3351 participants; very low-certainty evidence). This comparison revealed a difference in favour of MI at medium-term follow-up (SMD 0.12, 95% CI 0.05 to 0.20; 16 studies, 3137 participants; low-certainty evidence) and no difference at long-term follow-up (SMD 0.12, 95% CI -0.00 to 0.25; 9 studies, 1525 participants; very low-certainty evidence). There was no difference in readiness to change (SMD 0.05, 95% CI -0.11 to 0.22; 5 studies, 1495 participants; very low-certainty evidence). Retention in treatment was slightly higher with MI (SMD 0.26, 95% CI -0.00 to 0.52; 2 studies, 427 participants; very low-certainty evidence). Comparing MI to treatment as usual revealed a very small negative effect in substance use post-intervention (SMD -0.14, 95% CI -0.27 to -0.02; 5 studies, 976 participants; very low-certainty evidence). There was no difference at short-term follow-up (SMD 0.07, 95% CI -0.03 to 0.17; 14 studies, 3066 participants), a very small benefit of MI at medium-term follow-up (SMD 0.12, 95% CI 0.02 to 0.22; 9 studies, 1624 participants), and no difference at long-term follow-up (SMD 0.06, 95% CI -0.05 to 0.17; 8 studies, 1449 participants), all with low-certainty evidence. There was no difference in readiness to change (SMD 0.06, 95% CI -0.27 to 0.39; 2 studies, 150 participants) and retention in treatment (SMD -0.09, 95% CI -0.34 to 0.16; 5 studies, 1295 participants), both with very low-certainty evidence. Comparing MI to assessment and feedback revealed no difference in substance use at short-term follow-up (SMD 0.09, 95% CI -0.05 to 0.23; 7 studies, 854 participants; low-certainty evidence). A small benefit for MI was shown at medium-term (SMD 0.24, 95% CI 0.08 to 0.40; 6 studies, 688 participants) and long-term follow-up (SMD 0.24, 95% CI 0.07 to 0.41; 3 studies, 448 participants), both with moderate-certainty evidence. None of the studies in this comparison measured substance use at the post-intervention time point, readiness to change, and retention in treatment. Comparing MI to another active intervention revealed no difference in substance use at any follow-up time point, all with low-certainty evidence: post-intervention (SMD 0.07, 95% CI -0.15 to 0.29; 3 studies, 338 participants); short-term (SMD 0.05, 95% CI -0.03 to 0.13; 18 studies, 2795 participants); medium-term (SMD 0.08, 95% CI -0.01 to 0.17; 15 studies, 2352 participants); and long-term follow-up (SMD 0.03, 95% CI -0.07 to 0.13; 10 studies, 1908 participants). There was no difference in readiness to change (SMD 0.15, 95% CI -0.00 to 0.30; 5 studies, 988 participants; low-certainty evidence) and retention in treatment (SMD -0.04, 95% CI -0.23 to 0.14; 12 studies, 1945 participants; moderate-certainty evidence). We downgraded the certainty of evidence due to inconsistency, study limitations, publication bias, and imprecision. AUTHORS' CONCLUSIONS Motivational interviewing may reduce substance use compared with no intervention up to a short follow-up period. MI probably reduces substance use slightly compared with assessment and feedback over medium- and long-term periods. MI may make little to no difference to substance use compared to treatment as usual and another active intervention. It is unclear if MI has an effect on readiness to change and retention in treatment. The studies included in this review were heterogeneous in many respects, including the characteristics of participants, substance(s) used, and interventions. Given the widespread use of MI and the many studies examining MI, it is very important that counsellors adhere to and report quality conditions so that only studies in which the intervention implemented was actually MI are included in evidence syntheses and systematic reviews. Overall, we have moderate to no confidence in the evidence, which forces us to be careful about our conclusions. Consequently, future studies are likely to change the findings and conclusions of this review.
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Affiliation(s)
- Rosemarie Schwenker
- Institute of General Practice and Family Medicine, Center of Health Sciences, Martin Luther University Halle Wittenberg, Halle (Saale), Germany
| | - Carla Emilia Dietrich
- Institute of General Practice and Family Medicine, Center of Health Sciences, Martin Luther University Halle Wittenberg, Halle (Saale), Germany
| | - Selamawit Hirpa
- Institute of General Practice and Family Medicine, Center of Health Sciences, Martin Luther University Halle Wittenberg, Halle (Saale), Germany
- Department of Preventive Medicine, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Monika Nothacker
- Institute for Medical Knowledge Management, Association of the Scientific Medical Societies in Germany, Berlin, c/o Philipps University Marburg, Berlin & Marburg, Germany
| | | | - Thomas Frese
- Institute of General Practice and Family Medicine, Center of Health Sciences, Martin Luther University Halle Wittenberg, Halle (Saale), Germany
| | - Susanne Unverzagt
- Institute of General Practice and Family Medicine, Center of Health Sciences, Martin Luther University Halle Wittenberg, Halle (Saale), Germany
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Otome O, Wright A, Gunjaca V, Bowe S, Athan E. The Economic Burden of Infective Endocarditis due to Injection Drug Use in Australia: A Single Centre Study-University Hospital Geelong, Barwon Health, Victoria. Interdiscip Perspect Infect Dis 2022; 2022:6484960. [PMID: 36570593 PMCID: PMC9788891 DOI: 10.1155/2022/6484960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 11/13/2022] [Accepted: 11/25/2022] [Indexed: 12/23/2022] Open
Abstract
Background Injection drug use (IDU) is a well-recognized risk factor for infective endocarditis (IE). Associated complications from IDU result in significant morbidity and mortality with substantial cost implications. The aim of this study was to determine the cost burden associated with the management of IE due to IDU (IE-IDU). Methods We used data collected prospectively on patients with a diagnosis of IE-IDU as part of the international collaboration on endocarditis (ICE). The cost of medical treatment was estimated based on diagnosis-related groups (DRG) and weighted inlier equivalent separation (WIES). Results There were 23 episodes from 21 patients in 12 years (2002 to 2014). The costing was done for 22 episodes due to data missing on 1 patient. The median age was 39 years. The gender distribution was equal. Heroin (71%) and methamphetamine (33%) were the most frequently used. 74% (17/23) required intensive care unit (ICU) admission. The median ICU length of stay (LOS) was 4 days (IQR (Interquartile range); 2 to 40 days) whilst median total hospital LOS was 40 days (IQR; 1 to 119 days). Twelve patients (52%) underwent valve replacement surgery. Mortality was 13% (3/23). The total medical cost for the 22 episodes is estimated at $1,628,359 Australian dollars (AUD). The median cost per episode was a median cost of $ 61363 AUD (IQR: $2806 to $266,357 AUD). We did not account for lost productivity and collateral costs attributed to concurrent morbidity. Conclusion Within the limitations of this small retrospective study, we report that the management of infective endocarditis caused by injection drug use can be associated with significant financial cost.
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Affiliation(s)
- Ohide Otome
- University of Western Australia, Perth, Australia
- SJOG Midland Public and Private Hospital, Midland, Australia
| | | | - Vanika Gunjaca
- University Hospital Geelong, Barwon Health, Geelong, Australia
| | - Steve Bowe
- Deakin Biostatistics Unit, Faculty of Health, School of Medicine, Deakin University, Geelong, Australia
| | - Eugene Athan
- University Hospital Geelong, Barwon Health, Geelong, Australia
- Deakin Biostatistics Unit, Faculty of Health, School of Medicine, Deakin University, Geelong, Australia
- Geelong Centre for Emerging Infectious Disease (GCEID), Geelong, Australia
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3
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Ponzoni L, Teh MT, Torres-Perez JV, Brennan CH, Braida D, Sala M. Increased Response to 3,4-Methylenedioxymethamphetamine (MDMA) Reward and Altered Gene Expression in Zebrafish During Short- and Long-Term Nicotine Withdrawal. Mol Neurobiol 2020; 58:1650-1663. [PMID: 33236326 DOI: 10.1007/s12035-020-02225-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 11/19/2020] [Indexed: 01/09/2023]
Abstract
An interactive effect between nicotine and 3,4-methylenedioxymethamphetamine (MDMA) has been reported but the mechanism underlying such interaction is not completely understood. This study used zebrafish to explore gene expression changes associated with altered sensitivity to the rewarding effects of MDMA following 2-week exposure to nicotine and 2-60 days of nicotine withdrawal. Reward responses to MDMA were assessed using a conditioned place preference (CPP) paradigm and gene expression was evaluated using quantitative real-time PCR of mRNA from whole brain samples from drug-treated and control adult zebrafish. Zebrafish pre-exposed for 2 weeks to nicotine showed increased conditioned place preference in response to low-dose, 0.1 mg/kg, MDMA compared to un-exposed fish at 2, 7, 30 and 60 days withdrawal. Pre-exposure to nicotine for 2 weeks induced a significant increase of c-Fos and vasopressin receptor expression but a decrease of D3 dopaminergic and oxytocin receptor expression at 2 days of withdrawal. C-Fos mRNA increased also at 7, 30, 60 days of withdrawal. Nicotine pre-exposed zebrafish submitted to MDMA-induced CPP showed an increase in expression of p35 at day 2, α4 at day 30, vasopressin at day 7 and D3 dopaminergic receptor at day 7, 30 and 60. These gene alterations could account for the altered sensitivity to the rewarding effects of MDMA in nicotine pre-exposed fish, suggesting that zebrafish have an altered ability to modulate behaviour as a function of reward during nicotine withdrawal.
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Affiliation(s)
- Luisa Ponzoni
- Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano, Milan, Italy
| | - Muy-Teck Teh
- Centre for Oral Immunobiology and Regenerative Medicine, Institute of Dentistry, Barts & The London School of Medicine and Dentistry, Queen Mary University of London, England, UK
| | - Jose V Torres-Perez
- School of Biological and Chemical Sciences, Queen Mary University of London, London, UK
| | - Caroline H Brennan
- School of Biological and Chemical Sciences, Queen Mary University of London, London, UK
| | - Daniela Braida
- Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano, Milan, Italy
| | - Mariaelvina Sala
- Neuroscience Institute, CNR, Via Vanvitelli 32, 20129, Milan, Italy.
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Noroozi M, Higgs P, Noroozi A, Armoon B, Mousavi B, Alikhani R, Bazrafshan MR, Astaneh AN, Bayani A, Moghaddam LF. Methamphetamine use and HIV risk behavior among men who inject drugs: causal inference using coarsened exact matching. Harm Reduct J 2020; 17:66. [PMID: 32957982 PMCID: PMC7507738 DOI: 10.1186/s12954-020-00411-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 09/09/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Understanding the association between methamphetamine (MA) use and HIV risk behavior among people who inject drugs (PWID) will assist policy-makers and program managers to sharpen the focus of HIV prevention interventions. This study examines the relationship between MA use and HIV risk behavior among men who inject drugs (MWID) in Tehran, Iran, using coarsened exact matching (CEM). METHODS Data for these analyses were derived from a cross-sectional study conducted between June and July 2016. We assessed three outcomes of interest-all treated as binary variables, including distributive and receptive needle and syringe (NS) sharing and condomless sex during the month before interview. Our primary exposure of interest was whether study participants reported any MA use in the month prior to the interview. Firstly, we report the descriptive statistics for the pooled samples and matched sub-samples using CEM. The pooled and matched estimates of the associations and their 95% CI were estimated using a logistic regression model. RESULTS Overall, 500 MWID aged between 18 and 63 years (mean = 28.44, SD = 7.22) were recruited. Imbalances in the measured demographic characteristics and risk behaviors between MA users and non-users were attenuated using matching. In the matched samples, the regression models showed participants who reported MA use were 1.82 times more likely to report condomless sex (OR = 1.82 95% CI 1.51, 4.10; P = 0.031), and 1.35 times more likely to report distributive NS sharing in the past 30 days, as compared to MA non-users (OR = 1.35 95% CI 1.15-1.81). Finally, there was a statistically significant relationship between MA use and receptive NS sharing in the past month. People who use MA in the last month had higher odds of receptive NS sharing when compared to MA non-users (OR = 4.2 95% CI 2.7, 7.5; P = 0.013). CONCLUSIONS Our results show a significant relationship between MA use and HIV risk behavior among MWID in Tehran, Iran. MA use was related with increased NS sharing, which is associated with higher risk for HIV exposure and transmission.
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Affiliation(s)
- Mehdi Noroozi
- Social Determinants of Health Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Peter Higgs
- Department of Public Health, School of Psychology & Public Health, La Trobe University, Bundoora, Victoria, Australia
| | - Alireza Noroozi
- Department of Neuroscience and Addiction, School of Advanced Technologies in Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Bahram Armoon
- Social Determinants of Health Research Center, Saveh University of Medical Sciences, Saveh, Iran.
| | - Bentolhoda Mousavi
- Psychosis Research Center, Department of Psychiatry, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Rosa Alikhani
- Psychosis Research Center, Department of Psychiatry, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Mohammad Rafi Bazrafshan
- Department of Nursing, School of Nursing, Larestan University of Medical Sciences, Larestan, Iran
| | - Ali Nazeri Astaneh
- Department of Psychiatry, University of Social Welfare and Rehabilitation Science, Tehran, Iran
| | - Azadeh Bayani
- Student Research Committee, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ladan Fattah Moghaddam
- Department of Nursing, Faculty of Nursing and Midwifery, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
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Prevalence and Predictors of Symptoms of Depression Among Individuals Seeking Treatment from Australian Drug and Alcohol Outpatient Clinics. Community Ment Health J 2020; 56:107-115. [PMID: 31515714 DOI: 10.1007/s10597-019-00451-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 09/07/2019] [Indexed: 12/13/2022]
Abstract
This study examined the prevalence of and sociodemographic characteristics associated with elevated symptoms of depression among clients seeking alcohol or other drug (AOD) treatment. Consenting clients attending two AOD outpatient clinics answered demographics, treatment questions and the Patient Health Questionnaire to assess depressive symptoms. Counts and percentages were calculated to determine the prevalence of elevated depressive symptoms. Logistic regression was used to model the odds of having elevated depressive symptoms for client demographics. Of the 203 clients who completed the survey (87% consent rate), 55% (n = 111) demonstrated elevated depressive symptoms. Females were twice as likely to experience elevated symptoms of depression compared to males (OR 2.07; 95% CI 1.05, 4.08; P = 0.037). The high rates of elevated depressive symptoms among individuals seeking AOD treatment highlight the importance of ongoing research to provide effective treatments for this comorbidity. Routine screening and clear treatment pathways may assist with providing high quality care.
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Stuart AM, Baker AL, Denham AMJ, Lee NK, Hall A, Oldmeadow C, Dunlop A, Bowman J, McCarter K. Psychological treatment for methamphetamine use and associated psychiatric symptom outcomes: A systematic review. J Subst Abuse Treat 2019; 109:61-79. [PMID: 31856953 DOI: 10.1016/j.jsat.2019.09.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 08/02/2019] [Accepted: 09/09/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Regular methamphetamine use is associated with increased rates of psychiatric symptoms. Although there has been a substantial body of research reporting on the effectiveness of psychological treatments for reducing methamphetamine use, there is a paucity of research examining the effects of these treatments on co-occurring psychiatric symptoms. We addressed this gap by undertaking a systematic review of the evidence of the effectiveness of psychological treatments for methamphetamine use on psychiatric symptom outcomes in randomized controlled trials. METHODS A narrative synthesis of studies was conducted following the Cochrane Handbook for Systematic Reviews of Interventions and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement to inform methodology. Eight electronic peer-reviewed databases were searched. Ten eligible studies were assessed. RESULTS Most studies found an overall reduction in levels of methamphetamine use and psychiatric symptoms among samples as a whole. Although brief interventions were effective, there is evidence that more intensive interventions have greater impact on methamphetamine use and/or psychiatric symptomatology. Intervention attendance was variable. CONCLUSIONS The evidence suggests that a variety of psychological treatments are effective in reducing levels of methamphetamine use and improving psychiatric symptoms. Future research should consider how psychological treatments could maximize outcomes in the co-occurring domains of methamphetamine use and psychiatric symptoms, with increasing treatment attendance as a focus. PROSPERO registration number: CRD42016043657.
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Affiliation(s)
- Alexandra M Stuart
- School of Psychology, Faculty of Science, University of Newcastle, University Drive, Callaghan, NSW 2308, Australia
| | - Amanda L Baker
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, PO BOX 833, Newcastle, New South Wales 2300, Australia
| | - Alexandra M J Denham
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, PO BOX 833, Newcastle, New South Wales 2300, Australia
| | - Nicole K Lee
- Faculty of Health Sciences, Curtin University, Bentley, Western Australia 6102, Australia
| | - Alix Hall
- Hunter Medical Research Institute, LOT 1 Kookaburra Circuit, New Lambton Heights, New South Wales 2305, Australia
| | - Chris Oldmeadow
- Hunter Medical Research Institute, LOT 1 Kookaburra Circuit, New Lambton Heights, New South Wales 2305, Australia
| | - Adrian Dunlop
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, PO BOX 833, Newcastle, New South Wales 2300, Australia
| | - Jenny Bowman
- School of Psychology, Faculty of Science, University of Newcastle, University Drive, Callaghan, NSW 2308, Australia; Hunter Medical Research Institute, LOT 1 Kookaburra Circuit, New Lambton Heights, New South Wales 2305, Australia; Priority Research Centre for Health Behaviour, University of Newcastle, New South Wales 2308, Australia
| | - Kristen McCarter
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, PO BOX 833, Newcastle, New South Wales 2300, Australia.
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Independent associations and effect modification between lifetime substance use and recent mood disorder diagnosis with household food insecurity. PLoS One 2018; 13:e0191072. [PMID: 29360862 PMCID: PMC5779657 DOI: 10.1371/journal.pone.0191072] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 12/26/2017] [Indexed: 11/25/2022] Open
Abstract
Poor mental health and substance use are associated with food insecurity, however, their potential combined effects have not been studied. This study explored independent associations and effect modification between lifetime substance use and mood disorder in relation to food insecurity. Poisson regression analysis of data from British Columbia respondents (n = 13,450; 12 years+) in the 2007/08 Canadian Community Health Survey was conducted. Measures included The Household Food Security Survey Module (7.3% food insecure), recent diagnosis of a mood disorder (self-reported; 9.5%), lifetime use of cannabis, cocaine/crack, ecstasy, hallucinogens, and speed, any lifetime substance use, sociodemographic covariates, and the interaction terms of mood disorder by substance. For those with recent diagnosis of a mood disorder the prevalence of lifetime substance use ranged between 1.2 to 5.7% and were significantly higher than those without recent mood disorder diagnosis or lifetime use of substances (p’s < 0.05). For respondents with a recent mood disorder diagnosis or who used cannabis, food insecurity prevalence was higher compared to the general sample (p < 0.001); prevalence was lower for cocaine/crack use (p < 0.05). Significant effect modification was found between mood disorder with cannabis, ecstasy, hallucinogen and any substance use over the lifetime (PRs 0.51 to 0.64, p’s 0.022 to 0.001). Independent associations were found for cocaine/crack and speed use (PRs 1.68, p’s < 0.001) and mood disorder (PRs 2.02, p’s < 0.001). Based on these findings and the existing literature, future study about coping and resilience in the context of substance use, mental health, and food insecurity may lead to the development of relevant interventions aimed at mental well-being and food security.
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Kingston REF, Marel C, Mills KL. A systematic review of the prevalence of comorbid mental health disorders in people presenting for substance use treatment in Australia. Drug Alcohol Rev 2016; 36:527-539. [PMID: 27786426 DOI: 10.1111/dar.12448] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 04/25/2016] [Accepted: 05/24/2016] [Indexed: 11/29/2022]
Abstract
ISSUES The aim of this paper was to conduct a systematic review of the prevalence of comorbid mental health conditions in people accessing treatment for substance use in Australia. APPROACH A systematic review identified studies meeting the following eligibility criteria: reporting original data published in English; sample presenting for substance use treatment in Australia; assessing the prevalence of mental health and substance use conditions and reporting the percentage of participants with co-occurring mental health and substance use conditions. A narrative analysis was conducted because of the heterogeneity of methods used to assess key outcome variables and small number of studies assessing particular mental health outcomes. The abstracts of 1173 records were screened, and 59 full articles were assessed for eligibility. Eighteen studies were included in the review. KEY FINDINGS Prevalence estimates of current mental disorders in substance use treatment clients varied (47 to 100%). Mood and anxiety disorders were particularly prevalent, with the prevalence of current depression ranging from 27 to 85% and current generalised anxiety disorder ranging from 1 to 75%. IMPLICATIONS The high prevalence of mood and anxiety disorders in substance use treatment settings indicates a need for clinicians to screen and assess for these disorders as part of routine clinical care, and be familiar with evidence-based management and treatment strategies. CONCLUSION Although further studies are required to determine the prevalence of the full range of mental health disorders in this population, these findings emphasise the high prevalence of comorbid mental disorders are among individuals accessing substance use treatment in Australia. [Kingston REF, Marel C, Mills KL. A systematic review of the prevalence of comorbid mental health disorders in people presenting for substance use treatment in Australia. Drug Alcohol Rev 2017;36:527-539].
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Affiliation(s)
- Rosemary E F Kingston
- Centre of Research Excellence in Mental Health and Substance Use, University of New South Wales, Sydney, Australia.,National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Christina Marel
- Centre of Research Excellence in Mental Health and Substance Use, University of New South Wales, Sydney, Australia.,National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Katherine L Mills
- Centre of Research Excellence in Mental Health and Substance Use, University of New South Wales, Sydney, Australia.,National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
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Johnson H. Concurrent Drug and Alcohol Dependency and Mental Health Problems Among Incarcerated Women. ACTA ACUST UNITED AC 2016. [DOI: 10.1375/acri.39.2.190] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Holly Johnson
- Australian Institute of Criminology, Canberra, Australia
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10
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McCarter KL, Halpin SA, Baker AL, Kay-Lambkin FJ, Lewin TJ, Thornton LK, Kavanagh DJ, Kelly BJ. Associations between personality disorder characteristics and treatment outcomes in people with co-occurring alcohol misuse and depression. BMC Psychiatry 2016; 16:210. [PMID: 27389521 PMCID: PMC4936287 DOI: 10.1186/s12888-016-0937-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 06/15/2016] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Personality disorders are highly comorbid with alcohol misuse and depressive symptomatology; however, few studies have investigated treatment outcomes in this population. The aim of this study was to examine relationships between baseline personality disorder cluster profiles and overall and treatment-related changes for those with co-occurring alcohol misuse and depression. METHODS Secondary analysis was conducted using a subset of data (N = 290) from two randomised controlled trials of psychological interventions for co-occurring alcohol misuse and depression, which did not specifically target personality disorders. Baseline dimensional personality disorder cluster scores were derived from the International Personality Disorder Examination Questionnaire (IPDEQ). Four treatment conditions were compared: a brief integrated intervention, followed by no further treatment, or nine further sessions of integrated-, alcohol-, or depression-focused treatment. Associations between IPDEQ scores and changes in alcohol use, depressive symptoms and functioning from baseline to the 6- and the 12-month follow-ups were of primary interest. RESULTS Personality disorder cluster scores moderately negatively impacted on overall change (primarily Cluster C), as well as treatment-related outcomes (primarily Cluster A), particularly changes in depressive symptoms and psychosocial functioning. Longer interventions appeared to be more effective in the longer-term (e.g., at 12-month follow-up), with integrated interventions relatively more effective than single-focused ones for individuals with higher personality disorder cluster scores. CONCLUSIONS Greater attention needs to be paid to particular personality disorder clusters during the assessment and treatment of individuals with co-occurring alcohol misuse and depression. Integrated interventions, incorporating motivational interviewing and cognitive behaviour therapy, may provide a useful therapeutic framework. Integrated interventions also provide opportunities for adjunctive components focussing on other issues and coping strategies (e.g., to offset negative affective states), potentially tailored to the characteristics and needs of individual participants.
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Affiliation(s)
- Kristen L. McCarter
- School of Psychology, University of Newcastle, Callaghan, NSW 2308 Australia
| | - Sean A. Halpin
- School of Psychology, University of Newcastle, Callaghan, NSW 2308 Australia
| | - Amanda L. Baker
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW 2308 Australia
| | - Frances J. Kay-Lambkin
- NHMRC Centre for Research Excellence in Mental Health and Substance Use, National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW 2052 Australia ,Centre for Brain and Mental Health Research, University of Newcastle, Callaghan, NSW 2308 Australia
| | - Terry J. Lewin
- Centre for Brain and Mental Health Research, University of Newcastle, Callaghan, NSW 2308 Australia ,Hunter New England Mental Health, PO Box 833, Newcastle, NSW 2300 Australia
| | - Louise K. Thornton
- NHMRC Centre for Research Excellence in Mental Health and Substance Use, National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW 2052 Australia ,Centre for Brain and Mental Health Research, University of Newcastle, Callaghan, NSW 2308 Australia
| | - David J. Kavanagh
- Centre for Children’s Health Research, Institute of Health & Biomedical Innovation and School of Psychology & Counselling, Queensland University of Technology, Brisbane City, QLD 4000 Australia
| | - Brian J. Kelly
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW 2308 Australia ,Centre for Brain and Mental Health Research, University of Newcastle, Callaghan, NSW 2308 Australia
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Uebel H, Wright IM, Burns L, Hilder L, Bajuk B, Breen C, Abdel-Latif ME, Ward M, Eastwood J, Feller JM, Falconer J, Clews S, Oei JL. Epidemiological Evidence for a Decreasing Incidence of Neonatal Abstinence Syndrome, 2000-11. Paediatr Perinat Epidemiol 2016; 30:267-73. [PMID: 26849178 DOI: 10.1111/ppe.12282] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND This study analyses the incidence of Neonatal Abstinence Syndrome (NAS) in a large geographically defined population in Australia. METHOD Database linkage analysis of all births between 2000 and 2011 in New South Wales (NSW), Australia. The diagnosis of NAS was derived from hospital coding P96.1, 'Neonatal withdrawal symptoms from maternal use of drugs of addiction'. Temporal trends were studied by comparing epoch 1 (2000-05) with epoch 2 (2006-11). The relationship with changes in maternal factors was further analysed. RESULTS The NAS was coded in 3842 of 1 022 263 live born infants (0.38%). NAS incidence peaked at 5.07 per 1000 live births in 2002, decreasing to 3.18 in 2011 and was negatively correlated with maternal age (r = -0.7). The rate of NAS in epoch 2 (3.4 per 1000 births, 95% CI 3.28, 3.58) was significantly lower than in epoch 1 (4.1 per 1000 births, 95% CI 3.96, 4.33). Epoch 2 mothers were significantly older (mean 29.8 years vs. 28.3 years), less likely to be multiparous (OR 0.7, 95% CI 0.6, 0.9) or smoke (OR 0.4, 95% CI 0.4, 0.5). They were more likely to engage in antenatal care earlier (mean first visit: 14.1 vs. 18.9 weeks). Most infants (~80%) were born at term (>37 weeks gestation). CONCLUSION The incidence of NAS as a discharge diagnosis has decreased in our population since 2002. Mothers are also older and engaging earlier in prenatal care. Whether these changes alter NAS presentation and diagnosis or whether pregnant women are using drugs that do not cause typical NAS (e.g. amphetamines) is uncertain and requires further study.
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Affiliation(s)
- Hannah Uebel
- School of Women's and Children's Heath, University of New South Wales, Kensington, NSW, Australia
| | - Ian M Wright
- Illawarra Health and Medical Research Institute and Graduate School of Medicine, The University of Wollongong, Wollongong, NSW, Australia.,Department of Paediatrics, The Wollongong Hospital, Wollongong, NSW, Australia
| | - Lucy Burns
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
| | - Lisa Hilder
- School of Women's and Children's Heath, University of New South Wales, Kensington, NSW, Australia.,Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia
| | - Barbara Bajuk
- Perinatal Services Network, Westmead, NSW, Australia
| | - Courtney Breen
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
| | - Mohamed E Abdel-Latif
- Department of Neonatology, The Canberra Hospital, Garran, ACT, Australia.,Faculty of Medicine, the Australian National University, Deakin, ACT, Australia
| | - Meredith Ward
- School of Women's and Children's Heath, University of New South Wales, Kensington, NSW, Australia.,Department of Newborn Care, Royal Hospital for Women, Randwick, NSW, Australia
| | - John Eastwood
- School of Women's and Children's Heath, University of New South Wales, Kensington, NSW, Australia.,Sydney Local Health District, Sydney, NSW, Australia.,Ingham Institute of Applied Medicine, University of New South Wales, Liverpool, NSW, Australia
| | - John M Feller
- School of Women's and Children's Heath, University of New South Wales, Kensington, NSW, Australia.,Sydney Children's Hospital, Randwick, NSW, Australia
| | | | - Sara Clews
- The Langton Centre, Surry Hills, NSW, Australia
| | - Ju Lee Oei
- School of Women's and Children's Heath, University of New South Wales, Kensington, NSW, Australia.,Department of Newborn Care, Royal Hospital for Women, Randwick, NSW, Australia.,Ingham Institute of Applied Medicine, University of New South Wales, Liverpool, NSW, Australia
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Herbeck DM, Brecht ML, Lovinger K, Raihan A, Christou D, Sheaff P. Poly-Drug and Marijuana Use Among Adults Who Primarily Used Methamphetamine. J Psychoactive Drugs 2013; 45:132-40. [DOI: 10.1080/02791072.2013.785824] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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13
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Couture MC, Evans JL, Sothy NS, Stein ES, Sichan K, Maher L, Page K. Correlates of amphetamine-type stimulant use and associations with HIV-related risks among young women engaged in sex work in Phnom Penh, Cambodia. Drug Alcohol Depend 2012; 120:119-26. [PMID: 21820251 PMCID: PMC3226861 DOI: 10.1016/j.drugalcdep.2011.07.005] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2011] [Revised: 06/25/2011] [Accepted: 07/09/2011] [Indexed: 10/14/2022]
Abstract
BACKGROUND Amphetamine-type stimulant (ATS) use has increased in Cambodia and emerged as a significant problem among female sex workers (FSWs), potentially contributing to increased risk of HIV. We examined the prevalence of ATS use and its effect on sexual risk behaviors, and sexually transmitted infections (STI) among FSWs in Phnom Penh, Cambodia. METHODS A one-year prospective study among young women engaged in sex work in brothels, entertainment establishments and on a freelance basis. Socio-demographics, sexual risks, and recent ATS use were assessed by self-report. Blood and urine samples were collected to detect HIV, Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC). Bivariate and multivariate longitudinal analyses were conducted to assess the effects of ATS use on number of sex partners, inconsistent condom use with paying partners and incident STI. RESULTS ATS use was higher among women working freelance (35.6%) and in brothels (34.8%) compared to women working in entertainment establishments (17.7%) or in multiple venues (14.8%). ATS users reported more sex partners and days drunk in the previous month. In multivariate longitudinal analysis, ATS use was associated with having a higher number of sex partners (adjusted relative ratio 1.49; 95% CI: 1.00-2.21) and incident STI (adjusted odds ratio 5.41; 95% CI: 1.15-25.48), but not inconsistent condom use with paying partner. CONCLUSION ATS users had more sex partners, high level of alcohol use, and were at increased risk of STI. Our findings underscore ATS use as an important emerging risk exposure that should be integrated into HIV prevention interventions targeting this population.
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Affiliation(s)
- Marie-Claude Couture
- University of California San Francisco, Global Health Sciences, 50 Beale street, Suite 1200, San Francisco CA 94105, USA
| | | | - Neth San Sothy
- National Center for HIV/AIDS, Dermatology and STD. #245H, Sreet 6A, Phum Kean Khlang, Sangkat Prekleap Russey Keo, Phnom Penh, Cambodia
| | - Ellen S. Stein
- University of California San Francisco, Global Health Sciences, 50 Beale street, Suite 1200, San Francisco CA 94105, USA
| | - Keo Sichan
- Cambodian Women’s development Agengy, #19, Street 242, Sangkat Boeng Prolit, Khan 7 Makara, Phnom Penh, Cambodia
| | - Lisa Maher
- University of New South Wales, National Centre in HIV Epidemiology and Clinical Research, CFI Building, Corner Boundary and West Streets, Darlinghurst NSW 2010, Australia
| | - Kimberly Page
- University of California San Francisco, Global Health Sciences, 50 Beale street, Suite 1200, San Francisco CA 94105, USA,Corresponding author: K. Page, University of California San Francisco, Global Health Sciences, 50 Beale street, Suite 1200, San Francisco CA 94105, USA., , Phone: 415-597-4954., Fax: 415-597-8299
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Kay-Lambkin FJ, Baker AL, Lee NM, Jenner L, Lewin TJ. The influence of depression on treatment for methamphetamine use. Med J Aust 2011; 195:S38-43. [PMID: 21806517 DOI: 10.5694/j.1326-5377.2011.tb03264.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2010] [Accepted: 04/18/2011] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To determine whether the presence of comorbid depression influences response to psychological treatment for methamphetamine use. DESIGN Randomised controlled clinical trial. SETTING AND PARTICIPANTS Our study was conducted between 2001 and 2005 at two sites in Australia: the Hunter Region of New South Wales and the city of Brisbane, Queensland. The 214 participants, who were all using methamphetamine at least once a week in the month prior to the study, were self-referred or referred from health services or drug and alcohol clinical services. Participants were divided into two groups based on whether or not they had depressive symptoms at baseline. INTERVENTIONS The control group received only a self-help booklet; the two treatment groups received either two or four counselling sessions involving cognitive behaviour therapy and motivational interviewing techniques to manage methamphetamine use. MAIN OUTCOME MEASURES Changes in methamphetamine use and depression at 5 weeks and 6 months after baseline. RESULTS Over 70% of participants met criteria for depression at baseline, and depression was associated with significantly greater severity of methamphetamine use and related issues. Benzodiazepine use was significantly higher among depressed than non-depressed participants. Reductions in methamphetamine use between baseline and 5 weeks were independently predicted by comorbid depression, in favour of increased change among those with baseline depression. Depressed participants who received three or four counselling sessions showed a significant reduction in depression at 5 weeks. However, reductions in methamphetamine use and depression compared with baseline were no longer evident at 6 months. CONCLUSIONS Over the short term, comorbid depression did not negatively affect response to treatment, with some evidence of a dose-response treatment effect for reduction in depression. This was not maintained at 6 months, indicating that methamphetamine-focused treatment may not enable people with comorbid depression to make sustained improvement at the level of their counterparts without depression. TRIAL REGISTRATION NUMBER ACTRN12611000355976.
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Affiliation(s)
- Frances J Kay-Lambkin
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia.
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Hayatbakhsh MR, Najman JM, Bor W, Williams GM. Predictors of young adults' amphetamine use and disorders: a prospective study. Drug Alcohol Rev 2011; 28:275-83. [PMID: 21462412 DOI: 10.1111/j.1465-3362.2009.00032.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION AND AIMS Understanding the risk factors that predict amphetamine use and development of amphetamine abuse or dependence (disorder) may help guide preventive interventions. This study aimed to investigate the correlates and predictors of young adults' amphetamine use and use disorders. DESIGN AND METHODS Prospective cohort, population-based study which started in Brisbane, South East Queensland (Australia) in 1981. The study participants were a cohort of 2042 young adults, followed up from birth to young adulthood. At the 21-year follow-up, amphetamine use was assessed via a self-report questionnaire, and amphetamine use disorder (AUD) was assessed using the Composite International Diagnostic Interview (CIDI-Auto). Potential predictors (15 risk factors) were assessed between baseline (antenatal visit) and the 21-year follow-up. These included participant's gender, mother's age and education, maternal marital status and quality of marital relationship, maternal tobacco and alcohol consumption, mother-child communication, child mental health and problem behaviours, child smoking and alcohol consumption and child school performance. RESULTS Young adult amphetamine users were more likely to have concurrent symptoms of mental illness and problem behaviours and to use or abuse cigarettes, cannabis, or other illicit drugs. In multivariate analyses, young adults' amphetamine use and disorder were disproportionately more common among males and those who have prospectively reported aggression/delinquency or smoking at 14 years, or who have experienced childhood sexual abuse. CONCLUSIONS Our findings suggest that problem behaviours, smoking and childhood sexual abuse are predictors of initiation to use of amphetamines and development of amphetamine abuse and dependence.
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Smedslund G, Berg RC, Hammerstrøm KT, Steiro A, Leiknes KA, Dahl HM, Karlsen K. Motivational interviewing for substance abuse. Cochrane Database Syst Rev 2011; 2011:CD008063. [PMID: 21563163 PMCID: PMC8939890 DOI: 10.1002/14651858.cd008063.pub2] [Citation(s) in RCA: 158] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND There are 76.3 million people with alcohol use disorders worldwide and 15.3 million with drug use disorders. Motivational interviewing (MI) is a client-centred, semi-directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence. The intervention is used widely, and therefore it is important to find out whether it helps, harms or is ineffective. OBJECTIVES To assess the effectiveness of motivational interviewing for substance abuse on drug use, retention in treatment, readiness to change, and number of repeat convictions. SEARCH STRATEGY We searched 18 electronic databases, 5 web sites, 4 mailing lists, and reference lists from included studies and reviews. Search dates were November 30, 2010 for Cochrane Library, Medline, Embase and PsychINFO. SELECTION CRITERIA Randomized controlled trials with persons dependent or abusing substance. Interventions were MI or motivational enhancement therapy. The outcomes were extent of substance abuse, retention in treatment, motivation for change, repeat conviction. DATA COLLECTION AND ANALYSIS Three authors independently assessed studies for inclusion, and two authors extracted data. Results were categorized into (1) MI versus no-treatment control, (2) MI versus treatment as usual, (3) MI versus assessment and feedback, and (4) MI versus other active treatment. Within each category, we computed meta-analyses separately for post-intervention, short, medium and long follow-ups. MAIN RESULTS We included 59 studies with a total of 13,342 participants. Compared to no treatment control MI showed a significant effect on substance use which was strongest at post-intervention SMD 0.79, (95% CI 0.48 to 1.09) and weaker at short SMD 0.17 (95% CI 0.09 to 0.26], and medium follow-up SMD 0.15 (95% CI 0.04 to 0.25]). For long follow-up, the effect was not significant SMD 0.06 (95% CI-0.16 to 0.28). There were no significant differences between MI and treatment as usual for either follow-up post-intervention, short and medium follow up. MI did better than assessment and feedback for medium follow-up SMD 0.38 (95% CI 0.10 to 0.66). For short follow-up, there was no significant effect . For other active intervention there were no significant effects for either follow-up.There was not enough data to conclude about effects of MI on the secondary outcomes. AUTHORS' CONCLUSIONS MI can reduce the extent of substance abuse compared to no intervention. The evidence is mostly of low quality, so further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
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Affiliation(s)
- Geir Smedslund
- Norwegian Knowledge Centre for the Health ServicesPostboks 7004St. Olavs plassOsloN‐0130Norway
| | - Rigmor C Berg
- Norwegian Knowledge Centre for the Health ServicesPostboks 7004St. Olavs plassOsloN‐0130Norway
| | - Karianne T Hammerstrøm
- Norwegian Knowledge Centre for the Health ServicesPostboks 7004St. Olavs plassOsloN‐0130Norway
| | - Asbjørn Steiro
- Norwegian Knowledge Centre for the Health ServicesPostboks 7004St. Olavs plassOsloN‐0130Norway
| | - Kari A Leiknes
- Norwegian Knowledge Centre for the Health ServicesPostboks 7004St. Olavs plassOsloN‐0130Norway
| | - Helene M Dahl
- Institute of Clinical MedicineDepartment of Clinical PsychiatryUniversity of Tromsø, Asgard,TromsøNorway9291
| | - Kjetil Karlsen
- Institute of Clinical MedicineDepartment of Clinical PsychiatryUniversity of Tromsø, Asgard,TromsøNorway9291
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Maher L, Phlong P, Mooney-Somers J, Keo S, Stein E, Couture MC, Page K. Amphetamine-type stimulant use and HIV/STI risk behaviour among young female sex workers in Phnom Penh, Cambodia. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2011; 22:203-9. [PMID: 21316935 DOI: 10.1016/j.drugpo.2011.01.003] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2010] [Revised: 12/17/2010] [Accepted: 01/14/2011] [Indexed: 11/16/2022]
Abstract
BACKGROUND Use of amphetamine-type substances (ATS) has been linked to increased risk of HIV and other sexually transmitted infections (STI) worldwide. In Cambodia, recent ATS use is independently associated with incident STI infection among young female sex workers (FSWs). METHODS We conducted 33 in-depth interviews with women (15-29 years old) engaged in sex work to explore ATS use and vulnerability to HIV/STI. RESULTS Participants reported that ATS, primarily methamphetamine in pill and crystalline forms (yama), were cheap, widely available and commonly used. Yama was described as a "power drug" (thnam kamlang) which enabled women to work long hours and serve more customers. Use of ATS by clients was also common, with some providing drugs for women and/or encouraging their use, often resulting in prolonged sexual activity. Requests for unprotected sex were also more common among alternatives intoxicated clients and strategies typically employed to negotiate condom use were less effective. CONCLUSION ATS use was highly functional for young women engaged in sex work, facilitating a sense of power and agency and highlighting the occupational significance and normalization of ATS in this setting. This highly gendered dynamic supports the limited but emerging literature on women's use of ATS, which to date has been heavily focused on men. Results indicate an urgent need to increase awareness of the risks associated with ATS use, to provide women with sustainable alternatives for income generation, to better regulate the conditions of sex work, and to work with FSWs and their clients to develop and promote culturally appropriate harm reduction interventions.
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Affiliation(s)
- L Maher
- National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Sydney, Australia.
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KAY-LAMBKIN FRANCESJ, BAKER AMANDAL, MCKETIN REBECCA, LEE NICOLE. Stepping through treatment: Reflections on an adaptive treatment strategy among methamphetamine users with depression. Drug Alcohol Rev 2010; 29:475-82. [DOI: 10.1111/j.1465-3362.2010.00203.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Wallace C, Galloway T, McKetin R, Kelly E, Leary J. Methamphetamine use, dependence and treatment access in rural and regional North Coast of New South Wales, Australia. Drug Alcohol Rev 2010; 28:592-9. [PMID: 19930011 DOI: 10.1111/j.1465-3362.2008.00016.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION AND AIMS To identify the sociodemographic, health, drug use patterns, treatment coverage and barriers to treatment among regular methamphetamine users in rural and regional North Coast of New South Wales. DESIGN AND METHODS A structured questionnaire was used to measure sociodemographic factors, health and well-being, drug use patterns, methamphetamine dependence, engagement in methamphetamine treatment and barriers to treatment. Participants were 140 regular methamphetamine users. Dependent and non-dependent participants were compared to identify factors associated with dependence. RESULTS Participants were predominantly in their thirties, male and had low levels of education, high levels of unemployment and polydrug use. Participants who were dependent on methamphetamine (59%) were more likely to report impaired mental health and to have been diagnosed with depression, anxiety and drug-induced psychosis. One quarter of dependent methamphetamine users had received treatment in the last year and half had ever received treatment. The main barriers to receiving treatment were a lack of perceived need or motivation to seek treatment and concerns about confidentiality. DISCUSSION AND CONCLUSIONS Methamphetamine users living on the North Coast of New South Wales require treatment options tailored to address a complex array of physical and psychological problems. The findings highlight the need for psychiatric support and improved coordination between mental health and drug and alcohol services in rural and regional areas.
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Affiliation(s)
- Cate Wallace
- Public Health Training and Development Branch, New South Wales Department of Health, North Sydney, Australia.
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20
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Plüddemann A, Flisher AJ, McKetin R, Parry C, Lombard C. Methamphetamine use, aggressive behavior and other mental health issues among high-school students in Cape Town, South Africa. Drug Alcohol Depend 2010; 109:14-9. [PMID: 20064699 PMCID: PMC3784347 DOI: 10.1016/j.drugalcdep.2009.11.021] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2009] [Revised: 11/16/2009] [Accepted: 11/17/2009] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Methamphetamine use has become a growing problem in a number of countries over the past two decades, but has only recently emerged in South Africa. This study investigated the prevalence of methamphetamine use among high-school students in Cape Town and whether students reporting methamphetamine use were more likely to be at risk for mental health and aggressive behavior problems. METHODS A cross-sectional survey of 15 randomly selected high schools in Cape Town, of 1561 males and females grade 8-10 students (mean age 14.9), was conducted using the Problem Oriented Screening Instrument for Teenagers (POSIT) and the Beck Depression Inventory (BDI). RESULTS Findings indicated that 9% of the students had tried methamphetamine at least once. Ordinal logistic regression analyses showed that methamphetamine use in the past year was significantly associated with higher aggressive behavior scores (OR=1.81, 95% CI: 1.04-3.15, p<0.05), mental health risk scores (OR=2.04, 95% CI: 1.26-3.31, p<0.01) and depression scores (OR=2.65, 95% CI: 1.64-4.28, p<0.001). CONCLUSIONS Methamphetamine use has become a serious problem in Cape Town, particularly among adolescents. Screening adolescents in school settings for methamphetamine use and behavior problems may be useful in identifying youth at risk for substance misuse, providing an opportunity for early intervention. These findings have implications for other parts of the world where methamphetamine use may be occurring at younger ages and highlight the importance of looking at co-morbid issues related to methamphetamine use.
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Affiliation(s)
- Andreas Plüddemann
- Alcohol & Drug Abuse Research Unit, Medical Research Council, PO Box 19070, Tygerberg 7505, South Africa.
| | - Alan J. Flisher
- Division of Child and Adolescent Psychiatry, Adolescent Health Research Unit, University of Cape Town, South Africa and Research Centre for Health Promotion, University of Bergen, Norway
| | - Rebecca McKetin
- National Drug and Alcohol Research Centre, University of New South Wales, Australia
| | - Charles Parry
- Alcohol & Drug Abuse Research Unit, Medical Research Council, South Africa and Department of Psychiatry, University of Stellenbosch, South Africa
| | - Carl Lombard
- Biostatistics Unit, Medical Research Council, South Africa
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Topp L, Hudson SL, Maher L. Mental health symptoms among street-based psychostimulant injectors in Sydney's Kings Cross. Subst Use Misuse 2010; 45:1180-200. [PMID: 20441457 DOI: 10.3109/10826080903443586] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Urban frontline services have recorded increases in psychostimulant-related presentations. A convenience sample of 183 street-based psychostimulant injectors recruited in April 2006 was administered the Kessler Psychological Distress Scale (K10) to assess psychological distress. Homelessness, unemployment, and recent public injection, along with gender (female) and financial and relationship problems, best predicted clinically significant K10 scores. Drug use measures were not significantly associated with distress once indicators of social marginalization were included. The risk environment of the street-based drug market accounts for much of the distress experienced in this milieu, highlighting the need for broad structural interventions, together with drug-specific responses.
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Affiliation(s)
- Libby Topp
- Centre for Health Research in Criminal Justice, Justice Health, Pagewood, Australia
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22
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Lee NK, Pohlman S, Baker A, Ferris J, Kay-Lambkin F. It's the thought that counts: Craving metacognitions and their role in abstinence from methamphetamine use. J Subst Abuse Treat 2010; 38:245-50. [DOI: 10.1016/j.jsat.2009.12.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2009] [Revised: 11/27/2009] [Accepted: 12/31/2009] [Indexed: 10/19/2022]
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Weinberger AH, Sofuoglu M. The impact of cigarette smoking on stimulant addiction. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2009; 35:12-7. [PMID: 19152200 DOI: 10.1080/00952990802326280] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Stimulant users smoke cigarettes at high rates; however, little is known about the relationship between tobacco and stimulants. METHODS Our goal in this article is to synthesize a growing literature on the role of cigarette smoking in stimulant addiction. RESULTS Early nicotine exposure may influence the development of stimulant addiction. Preclinical and clinical studies suggest a facilitatory role of nicotinic agonists for stimulant addiction. Smoking appears to be associated with more severe stimulant use and poorer treatment outcomes. CONCLUSIONS It is important to assess smoking and smoking-related variables within stimulant research studies to more fully understand the comorbidity. Integrating smoking cessation into stimulant treatment may improve nicotine and stimulant treatment outcomes.
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Affiliation(s)
- Andrea H Weinberger
- Program for Research on Smokers with Mental Illness (PRISM), Substance Abuse Center, Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA.
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Roxburgh A, Degenhardt L. Characteristics of drug-related hospital separations in Australia. Drug Alcohol Depend 2008; 92:149-55. [PMID: 17884302 DOI: 10.1016/j.drugalcdep.2007.07.020] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2007] [Revised: 07/13/2007] [Accepted: 07/14/2007] [Indexed: 11/26/2022]
Abstract
BACKGROUND To examine (a) numbers of alcohol and drug-related hospital separations, 1999-2005; (b) demographics of these separations; (c) principal diagnoses co-occurring with drug-related problems; (d) length of hospital stay. METHODS Data from the National Hospital Morbidity Database (NHMD) were analysed. Hospital separations where alcohol, opioids, amphetamine, cannabis, cocaine, other drugs (such as sedatives and hypnotics) and pharmaceutical poisoning were mentioned were examined. RESULTS Numbers per million persons were highest for alcohol, followed by other drugs, particularly sedatives and hypnotics. Alcohol and opioid-related problems were prominent among older age groups, whereas cannabis and pharmaceutical poisoning problems had greater proportions among 15-24 year olds. Opioid-related separations were relatively high in number within the context of prevalence of use, and often accompanied by principal diagnoses of physical or general health problems. Almost half of amphetamine and cannabis-related separations were accompanied by principal diagnoses of mental health problems. CONCLUSIONS This research highlights the complexities of drug-related hospital presentations, indicating the need for thorough assessment of physical and mental problems, as well as a drug use history at the time of admission. Continued development of integrated models of care, targeting both mental health and drug use are essential. Consistent with the international literature, many of these separations are preventable, particularly those for pharmaceutical poisoning. Finally, ongoing efforts to reduce the significantly greater harms related to opioid use, as well as increasing treatment opportunities for opioid-dependent people in Australia is an important public health priority.
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Affiliation(s)
- Amanda Roxburgh
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW 2052, Australia.
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Phillips PA. Dual diagnosis: an exploratory qualitative study of staff perceptions of substance misuse among the mentally ill in Northern India. Issues Ment Health Nurs 2007; 28:1309-22. [PMID: 18058336 DOI: 10.1080/01612840701686468] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Dual diagnosis is well recognized as a significant clinical problem. It is associated with poor outcomes, staff difficulties, and management problems. This exploratory study investigated the extent and clinical correlates of dual diagnosis and traditional substance use among the mentally ill by interviewing staff from several substance misuse and mental health services in Northern India, using a semi-structured interview schedule and focus groups. Dual diagnosis was seen as a common problem according to staff interviewed from substance misuse and mental health services, although types of substance use reported were different than in western studies. Traditional substance use (the use of substances in distinct cultural, religious, and social settings that is not prohibited, such as khat or betel nut) also was reported as common among those with dual diagnosis. Substance misuse among the mentally ill is common in Northern India. Opportunities exist for informing mental health nursing practice about "traditional" substance use.
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Affiliation(s)
- Peter A Phillips
- City University London, Department of Mental Health And Learning Disability, Philpot Street, London E1 2EA, England.
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Tait RJ, Ngo HTT, Hulse GK. Mortality in heroin users 3 years after naltrexone implant or methadone maintenance treatment. J Subst Abuse Treat 2007; 35:116-24. [PMID: 17931824 DOI: 10.1016/j.jsat.2007.08.014] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2007] [Accepted: 08/08/2007] [Indexed: 11/30/2022]
Abstract
Concerns that treatment for heroin dependence using naltrexone may increase suicide rates during treatment and fatal overdoses posttreatment have been expressed. There is also disquiet about mortality during induction onto methadone. We assessed mortality during specific periods following treatment with naltrexone implants or methadone. Data were assembled using the Western Australian Data Linkage System. The methadone cohort comprised all those who started methadone in Western Australia during 2001-2002: The naltrexone cohort comprised all Western Australian heroin-dependent persons who received their first implant in 2001-2002. There were 15 (2.7%) deaths in the methadone cohort (n = 553) and 6 (1.8%) deaths in the naltrexone cohort (n = 341). Mortality rates for the "initial 14-day period," "stable treatment," and "overall" were 94.47, 0.0, and 5.83 deaths/1,000 person-years for the methadone group. In the naltrexone group, the rates "during first treatment (0-6 months)," "post first treatment," and overall were 0.0, 4.21, and 3.76 deaths/1,000 person-years. The age-standardized mortality rate ratio for naltrexone compared to methadone was 0.645 (95% confidence interval = 0.123-1.17). Increased mortality during induction onto methadone was confirmed. Evidence relating naltrexone to either increased suicide or overdose was not found. Overall mortality rates for naltrexone implant were similar to those for methadone, but increased mortality during methadone induction was avoided.
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Affiliation(s)
- Robert James Tait
- School of Psychiatry and Clinical Neurosciences, University of Western Australia, QE II Medical Center, Nedlands, WA 6009, Australia.
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Baker A, Dawe S. Amphetamine use and co-occurring psychological problems: Review of the literature and implications for treatment. AUSTRALIAN PSYCHOLOGIST 2007. [DOI: 10.1080/00050060500094654] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- A Baker
- Centre for Mental Health Studies, University of Newcastle , Newcastle, New South Wales
| | - S Dawe
- School of Applied Psychology, Griffith University , Brisbane, Queensland, Australia
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Gregg L, Barrowclough C, Haddock G. Reasons for increased substance use in psychosis. Clin Psychol Rev 2007; 27:494-510. [PMID: 17240501 DOI: 10.1016/j.cpr.2006.09.004] [Citation(s) in RCA: 138] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2006] [Accepted: 09/29/2006] [Indexed: 11/25/2022]
Abstract
Around half of all patients with schizophrenia are thought to abuse drugs or alcohol and there is good evidence to suggest that they have poorer outcomes than their non substance using counterparts. However, despite more than twenty years of research there is still no consensus on the aetiology of increased rates of substance use in people with psychosis. There is a clear need to understand the reasons for such high rates of substance use if treatments designed to help patients abstain from substance use are to be successful. This paper provides an update of the literature examining the reasons for substance use by people with psychosis, and includes a comprehensive review of the self report literature. The main theories as to why people with psychosis use substances are presented. There is evidence to suggest that cannabis may have a causal role in the development of psychopathology but not for other substances. The self report literature provides support for an 'alleviation of dysphoria' model of substance use but there is little empirical support for the self medication hypothesis, or for common factor models and bidirectional models of comorbidity. It is likely that there are multiple risk factors involved in substance use in psychosis and more work to develop and test multiple risk factor models is required.
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Affiliation(s)
- Lynsey Gregg
- Division of Clinical Psychology, School of Psychological Sciences, University of Manchester, Rutherford House, Manchester Science Park, Manchester, United Kingdom.
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Wood E, Stoltz JA, Li K, Montaner JSG, Kerr T. Changes in Canadian heroin supply coinciding with the Australian heroin shortage. Addiction 2006; 101:689-95. [PMID: 16669902 DOI: 10.1111/j.1360-0443.2006.01385.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIMS Previous studies have largely attributed the Australian heroin shortage to increases in local law enforcement efforts. Because western Canada receives heroin from similar source nations, but has not measurably increased enforcement practices or funding levels, we sought to examine trends in Canadian heroin-related indices before and after the Australian heroin shortage, which began in approximately January 2001. METHODS During periods before and after January 2001, we examined the number of fatal overdoses and ambulance responses to heroin-related overdoses that required the use of naloxone in British Columbia, Canada. As an overall marker of Canadian supply reduction, we also examined the quantity of heroin seized during this period. Lastly, we examined trends in daily heroin use among injection drug users enrolled in the Vancouver Injection Drug Users Study (VIDUS). RESULTS There was a 35% reduction in overdose deaths, from an annual average of 297 deaths during the years 1998-2000 in comparison to an average of 192 deaths during 2001-03. Similarly, use of naloxone declined 45% in the period coinciding with the Australian heroin shortage. Interestingly, the weight of Canadian heroin seized declined 64% coinciding with the Australian heroin shortage, from an average of 184 kg during 1998-2000 to 67 kg on average during 2001-03. Among 1587 VIDUS participants, the period coinciding with the Australian heroin shortage was associated independently with reduced daily injection of heroin [adjusted odds ratio: 0.55 (95% CI: 0.50-0.61); P < 0.001]. CONCLUSIONS Massive decreases in three independent markers of heroin use have been observed in western Canada coinciding with the Australian heroin shortage, despite no increases in funding to Canadian enforcement efforts. Markedly reduced Canadian seizure activity also coincided with the Australian heroin shortage. These findings suggest that external global heroin supply forces deserve greater investigation and credence as a potential explanation for the Australian heroin shortage.
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Affiliation(s)
- Evan Wood
- British Columbia Centre for Excellence in HIV/AIDS, St Paul's Hospital, Canada.
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Abstract
This paper is the 27th consecutive installment of the annual review of research concerning the endogenous opioid system, now spanning over 30 years of research. It summarizes papers published during 2004 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia; stress and social status; tolerance and dependence; learning and memory; eating and drinking; alcohol and drugs of abuse; sexual activity and hormones, pregnancy, development and endocrinology; mental illness and mood; seizures and neurologic disorders; electrical-related activity and neurophysiology; general activity and locomotion; gastrointestinal, renal and hepatic functions; cardiovascular responses; respiration and thermoregulation; and immunological responses.
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, Flushing, NY 11367, USA.
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Kay-Lambkin FJ, Baker AL, Lewin TJ. The 'co-morbidity roundabout': a framework to guide assessment and intervention strategies and engineer change among people with co-morbid problems. Drug Alcohol Rev 2005; 23:407-23. [PMID: 15763746 DOI: 10.1080/09595230412331324536] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
This paper describes the nature and consequences of co-morbidity, as applied to co-occurring mental health and alcohol/other drug (AOD) use problems. The 'co-morbidity roundabout' is introduced as a useful metaphor for conceptualizing the current experiences of people with co-occurring mental health and AOD use problems. In order to successfully negotiate the 'roundabout', the 'drivers' (people with co-morbid mental health and AOD use problems) must consider a range of internal and external conditions (knowledge about services, support from family, friends, health providers, motivation to change, etc.), account for their vehicle's characteristics (other conditions and demands, including social/legal/financial issues), keep their travel itinerary in mind (plans for change including treatment) and navigate through the many detours and dead-ends that they may confront (eligibility for services, accessibility of treatments, etc.). Co-morbidity is a major contributing factor in 'drivers' failing to successfully negotiate, or even becoming 'stuck' on, the 'roundabout'. A summary of relevant treatment research is also presented, including descriptions of brief interventions and more intensive treatment approaches. Finally, the 'co-morbidity roundabout' metaphor is expanded to assist clinicians to translate the findings from this treatment research into clinical practice. Further suggestions are made for improved navigation through and exit from the 'roundabout', including recommendations for the use of a stepped-care approach to the assessment and treatment of clients with co-morbid mental health and AOD use problems.
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Baker A, Lee NK, Claire M, Lewin TJ, Grant T, Pohlman S, Saunders JB, Kay-Lambkin F, Constable P, Jenner L, Carr VJ. Brief cognitive behavioural interventions for regular amphetamine users: a step in the right direction. Addiction 2005; 100:367-78. [PMID: 15733250 DOI: 10.1111/j.1360-0443.2005.01002.x] [Citation(s) in RCA: 118] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIMS The present study sought to replicate and extend a small pilot study conducted by Baker, Boggs & Lewin (2001) which demonstrated that brief interventions consisting of motivational interviewing and cognitive-behaviour therapy (CBT) were feasible and associated with better outcomes compared with a control condition. DESIGN Randomized controlled trial (RCT). SETTING Greater Brisbane Region of Queensland and Newcastle, NSW, Australia. PARTICIPANTS The study was conducted among 214 regular amphetamine users. MEASUREMENTS Demographic characteristics, past and present alcohol and other drug use and mental health, treatment, amphetamine-related harms and severity of dependence. FINDINGS The main finding of this study was that there was a significant increase in the likelihood of abstinence from amphetamines among those receiving two or more treatment sessions. In addition, the number of treatment sessions attended had a significant short-term beneficial effect on level of depression. There were no intervention effects on any other variables (HIV risk-taking, crime, social functioning and health). Overall, there was a marked reduction in amphetamine use among this sample over time and, apart from abstinence rates and short-term effects on depression level, this was not differential by treatment group. Reduction in amphetamine use was accompanied by significant improvements in stage of change, benzodiazepine use, tobacco smoking, polydrug use, injecting risk-taking behaviour, criminal activity level, and psychiatric distress and depression level. CONCLUSIONS A stepped-care approach is recommended. The first step in providing an effective intervention among many regular amphetamine users, particularly those attending non-treatment settings, may include provision of: a structured assessment of amphetamine use and related problems; self-help material; and regular monitoring of amphetamine use and related harms. Regular amphetamine users who present to treatment settings could be offered two sessions of CBT, while people with moderate to severe levels of depression may best be offered four sessions of CBT for amphetamine use from the outset, with further treatment for amphetamine use and/or depression depending on response. Pharmacotherapy and/or longer-term psychotherapy may be suitable for non-responders. An RCT of a stepped-care approach among regular amphetamine users is suggested.
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Affiliation(s)
- Amanda Baker
- Centre for Mental Health Studies, University of Newcastle, University Drive, Callaghan, New South Wales, Australia
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