Dynamic effects among patients' treatment needs, beliefs, and utilization: a prospective study of adolescents in drug treatment

Risk for inhalant initiation among middle school students: understanding individual, family, and peer risk and protective factors

OBJECTIVE

Because initiation of inhalants at an early age is associated with a range of health and behavioral problems, including an increased likelihood of inhalant dependence (based on criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition), we conducted discrete time survival analyses to determine the role of time-invariant and time-variant (over five waves) risk and protective factors as well as grade in inhalant initiation among middle school students.

METHOD

The current study uses data from 3,215 students who were initially surveyed as sixth graders in 2008-2009 and were resurveyed in seventh and eighth grades. Students were part of a larger substance use prevention trial conducted in greater Los Angeles. The sample is racially/ethnically diverse (54% Hispanic/Latino, 16% Asian, 14% White, 3% African American) and 51% male.

RESULTS

Seventeen percent of youths initiated inhalants during middle school. Higher drug refusal self-efficacy, familism (i.e., values related to family), and parental respect were associated with decreased odds of inhalant initiation. Having a significant adult or older sibling who used substances was associated with increased risk of initiation, but adult influence declined linearly and by the end of seventh grade was no longer a risk factor. Self-rated popularity was associated with inhalant initiation in seventh grade only, and perceived substance use by peers was associated with inhalant initiation in sixth grade only.

CONCLUSIONS

The influence of adults, siblings, and peers on inhalant use may be strongest in sixth and seventh grade. Interventions to prevent inhalant initiation should target sixth and seventh graders, address influence by family and peers, and provide skills training to improve drug refusal self-efficacy.

Estimating the causal effects of cumulative treatment episodes for adolescents using marginal structural models and inverse probability of treatment weighting

BACKGROUND

Substance use treatment is rarely a one-time event for individuals with substance use disorders. Sustained reductions in substance use and its related symptoms may result from multiple treatment episodes.

METHODS

We use a marginal structural model with inverse-probability-of-treatment weighting to estimate the causal effects of cumulative treatment experiences over a period of 9 months on drug use at the end of 1-year among 2870 adolescents receiving care in community-based treatment settings. During the 9 months, adolescents move in and out of outpatient and residential treatment with periods where they only receive biological drug screening (BDS) or no treatment at all. The use of inverse-probability-of-treatment weighting reduces confounding bias due to observed baseline and time-varying measures over the course of follow-up; weights were estimated using generalized boosted models.

RESULTS

Each additional period of treatment (representing at least one day, 1 session, or 1 BDS during the 90 day period between follow-up visits) yielded reductions in average substance use frequency at 1-year relative to no treatment during the 90-day period. For residential treatment it was a 16% decrease (95% CI=-27%, -7%), for outpatient treatment it was a 9% decrease (95% CI=-18%, -0%), and for BDS (with no additional outpatient or residential treatment) it was an 11% decrease (95% CI=-20%, -3%).

CONCLUSIONS

Using robust statistical methods, we find promising (albeit preliminary) evidence that additional periods of outpatient and residential treatment, as well as biological drug screening, lead to reductions in substance use outcomes at one year.

Development and validation of the cannabis refusal self-efficacy questionnaire (CRSEQ) in adult cannabis users in treatment

BACKGROUND

There are few valid clinical assessment instruments for cannabis. Self-efficacy, or the ability of users to resist temptation, is a central feature of social cognitive theory. This study outlines the development and validation of the cannabis refusal self-efficacy questionnaire (CRSEQ), which measures the situational confidence to refuse cannabis.

METHOD

One thousand two hundred and forty-six patients referred for cannabis assessment completed the CRSEQ including measures of cannabis consumption and dependence severity (severity of dependence scale-cannabis, SDS-C). The CRSEQ was subject to independent exploratory (n=621, mean age 26.88, 78.6% male) and confirmatory (n=625, mean age 27.51, 76.8% male) factor analysis.

RESULTS

Three factors: Emotional Relief, Opportunistic and Social Facilitation were identified. They provided a good statistical and conceptual fit for the data. Emotional relief cannabis refusal self-efficacy was identified as most predictive of cannabis dependence, after controlling for cannabis consumption.

CONCLUSIONS

The CRSEQ is recommended as a psychometrically sound and clinically useful measure for cannabis misuse treatment planning and assessment.

Enhancing the salience of dullness: behavioral and pharmacological strategies to facilitate extinction of drug-cue associations in adolescent rats

Extinction of drug-seeking is an integral part of addiction treatment, and can profoundly reverse or ameliorate the harmful consequences of drug use. These consequences may be the most deleterious during adolescence. The studies presented here build from recent evidence that adolescent rats are more resistant to extinction training than adults, and therefore may require unique treatment strategies. We used unbiased place-conditioning in male rats to show that passive, un-explicit extinction pairings resulted in delayed extinction in 40-day-old adolescents relative to 80-day-old adults. However, explicit-pairing of a previously cocaine-associated context with the absence of drug produces extinction in adolescents as rapidly as in adults. These data suggest that successful extinction of drug-paired associations in adolescents may be facilitated by stronger acquisition of a new (extinction) memory. Drug-paired associations are largely controlled by the prelimbic prefrontal cortex (plPFC) and its influence on the nucleus accumbens (NAc). This pathway mediates the motivational salience attributed to incoming stimuli through the D1 dopamine receptor. D1 receptors on plPFC outputs to the accumbens are transiently overproduced during adolescence. Since D1 receptors are selectively responsive to potent stimuli, we hypothesized that the adolescent plPFC hinders competition between potent drug-paired associations and the subtler, drug-free information necessary for extinction. To harness this unique profile of the adolescent plPFC, we aimed to increase the salience of unrewarded extinction memories by activating plPFC D1 receptors during extinction training. In a second study, extinction of drug-cue associations was facilitated in adolescents by elevating dopamine and norepinephrine in the PFC during extinction training with atomoxetine. In a third study, direct microinjection of the D1 receptor agonist SKF38393 mimicked this effect, also facilitating extinction in adolescent subjects. Furthermore, pharmacological intervention attenuated subsequent drug-primed reinstatement of cocaine-conditioned preferences. We establish a potential direction for distinct strategies to treat this vulnerable population.

Theory-based processes that promote the remission of substance use disorders

Four related theories about the personal and social resources that shield individuals from developing substance use disorders and foster the process of remission from these disorders are described. These theories are social control theory, behavioral economics and behavioral choice theory, social learning theory, and stress and coping theory. Next, the social processes specified by these theories are highlighted, including the provision of support, goal direction, and monitoring; engagement in rewarding activities other than substance use, exposure to abstinence-oriented norms and models, and attempts to build self-efficacy and coping skills. Then, a review of the literature considers evidence about the association between the personal and social resources specified by the four theories and remission from substance use disorders. The discussion highlights several issues that need to be addressed to enhance our understanding of the protective resources involved in stable remission, such as how to develop integrated measures of the key resources and specify their associations with substance use outcomes, the extent to which the resources amplify or compensate for the influence of treatment, and how treatment and continuing care can be tailored to strengthen the protective resources that promote remission.

Equity of access to treatment, and barriers to treatment for illicit drug use in Australia

AIMS AND DESIGN

This study investigated equity of access to treatment and barriers to treatment for illicit drug use, using Andersen's behavioural model of health service utilization.

SETTING AND PARTICIPANTS

The study involved 492 drug users who had received treatment and 193 who had not.

MEASUREMENTS

Participants were interviewed to gather data relating to 19 predisposing, need and enabling variables.

FINDINGS

Never-treated participants exhibited less need for treatment than those who had received treatment. They experienced less negative emotion, used their main drug less often, had fewer drug-related health problems and fewer drug-using friends, were less likely to have blood-borne virus infections and were more likely to be using drugs for 'fun'. They also had more negative attitudes towards drug treatment staff, were less likely to believe that appropriate treatment was available and less likely to believe that professional help was necessary to get off drugs. Prevalence of physical and mental health problems was high in both groups.

CONCLUSIONS

The study documented significant unmet treatment need and identified several sources of inequity and barriers to treatment that would be amenable to policy and service development. Drug user organizations and peer educators and motivational interventions in primary care settings should be utilized to market the nature and benefits of treatment effectively, and to address the causes of drug users' negative attitudes towards treatment.