Treatment for illegal drug use disorders: the role of comorbid mood and anxiety disorders

Association of mental health related quality of life and other factors with treatment seeking for substance use disorders: A comparison of SUDs rooted in legal, partially legal, and illegal substances

The association of subjective mental health-related quality of life (MHRQOL) and treatment use among people experiencing common substance use disorders (SUDs) is not known. Furthermore, the association of a given substance's legal status with treatment use has not been studied. This work aims determine the association of MHRQOL with SUD treatment use, and how substance legal status modulates this relationship. Our analysis used nationally-representative data from the NESARC-III database of those experiencing past-year SUDs (n = 5,808) to compare rates of treatment use and its correlates among three groups: those with illicit substance use disorders (ISUDs); those with partially legal substance use disorders, i.e., cannabis use disorder (CUD); and those with fully legal substance use disorders, i.e., alcohol use disorder (AUD). Survey-weighted multiple regression analysis was used to assess the association of MHRQOL with likelihood of treatment use among these three groups, both unadjusted and adjusted for sociodemographic, behavioral, and diagnostic factors. Adults with past-year ISUDs were significantly more likely to use treatment than those with CUD and AUD. Among those with ISUDs, MHRQOL had no significant association with likelihood of treatment use. Those with past-year CUD saw significant negative association of MHRQOL with treatment use in unadjusted analysis, but not after controlling for diagnostic and other behavioral health factors. Those with past-year AUD had significant negative association of MHRQOL with treatment use in both unadjusted and adjusted analysis. If legalization and decriminalization continue, there may be a greater need for effective public education and harm reduction services to address this changing SUD landscape.

The BDNF Val68Met polymorphism causes a sex specific alcohol preference over social interaction and also acute tolerance to the anxiolytic effects of alcohol, a phenotype driven by malfunction of BDNF in the ventral hippocampus of male mice

BACKGROUND

The brain-derived neurotrophic factor (BDNF) Valine 66 to Methionine human polymorphism results in impaired activity-dependent BDNF release and has been linked to psychiatric disorders including depression and anxiety. We previously showed that male knock-in mice carrying the mouse Methionine homolog (Met68BDNF) exhibit excessive and compulsive alcohol drinking behaviors as compared to the wild-type Val68BDNF mice.

OBJECTIVE

Here, we set out to determine the potential mechanism for the heightened and compulsive alcohol drinking phenotypes detected in Met68BDNF mice.

RESULTS

We found that male, but not female Met68BDNF mice exhibit social anxiety-like behaviors. We further show that male Met68BDNF mice exhibit a preference for alcohol over social interaction. In contrast, alcohol place preference without an alternative social reward, is similar in male Met68BDNF and Val68BDNF mice. Since the Met68BDNF mice show social anxiety phenotypes, we tested whether alcohol reliefs anxiety similarly in Met68BDNF and Val68BDNF mice and found that male, but not female Met68BDNF mice are insensitive to the acute anxiolytic action of alcohol. Finally, we show that this acute tolerance to alcohol-dependent anxiolysis can be restored by overexpressing wild-type Val68BDNF in the ventral hippocampus (vHC) of Met68BDNF mice.

CONCLUSIONS

Together, our results suggest that excessive alcohol drinking in the Met68BDNF may be attributed, in part, to heighted social anxiety and a lack of alcohol-dependent anxiolysis, a phenotype that is associated with malfunction of BDNF signaling in the vHC of male Met68BDNF mice.

The role of mood disorders in the progression of and recovery from alcohol and drug use problems: A latent transition analysis

INTRODUCTION

Longitudinal research assessing whether mood disorders predict substance use behaviors is limited. We extend our prior work evaluating transition patterns with alcohol use to assess patterns with alcohol and drug use problems.

METHOD

Using National Epidemiologic Survey on Alcohol and Related Conditions prospective data, waves 1 and 2, we completed latent class analyses to empirically define classes of alcohol and drug problems from DSM disorder criteria. Latent transition analyses were used to assess associations of lifetime mood disorders at baseline with transitions across classes of alcohol and drug problems during follow-up.

RESULTS

A three-class model of alcohol and drug problems was identified (No problems, Alcohol Problems Only, and Alcohol and Drug Problems) for males and females. Females with mood disorders were over two times more likely to transition from No Problems, and Alcohol Problems Only at baseline to having both Alcohol and Drug Problems at follow-up relative to those without mood disorders (aOR=2.30, 95 % CI=1.31-4.05, p = 0.004, and aOR=2.64, CI=1.24-5.62, p = 0.011, respectively). Furthermore, females with mood disorders were significantly less likely to recover from baseline Alcohol and Drug Problems to Alcohol Problems Only at follow-up (aOR=0.35, CI=0.12-0.98, p = 0.047) relative to those without mood disorders. There were no significant findings for males.

DISCUSSION

Our study provides evidence that mood disorders impact transitions through classes of alcohol and drug problems among females. The findings emphasize the need for ongoing evaluation of substance use among those with mood conditions, and recognition and treatment of mood disorders among those recovering from substance use problems.

A review of functional brain differences predicting relapse in substance use disorder: Actionable targets for new methods of noninvasive brain stimulation

Neuroimaging studies have identified a variety of brain regions whose activity predicts substance use (i.e., relapse) in patients with substance use disorder (SUD), suggesting that malfunctioning brain networks may exacerbate relapse. However, this knowledge has not yet led to a marked improvement in treatment outcomes. Noninvasive brain stimulation (NIBS) has shown some potential for treating SUDs, and a new generation of NIBS technologies offers the possibility of selectively altering activity in both superficial and deep brain structures implicated in SUDs. The goal of the current review was to identify deeper brain structures involved in relapse to SUD and give an account of innovative methods of NIBS that might be used to target them. Included studies measured fMRI in currently abstinent SUD patients and tracked treatment outcomes, and fMRI results were organized with the framework of the Addictions Neuroclinical Assessment (ANA). Four brain structures were consistently implicated: the anterior and posterior cingulate cortices, ventral striatum and insula. These four deeper brain structures may be appropriate future targets for the treatment of SUD using these innovative NIBS technologies.

Impulsive Personality Traits Mediate the Relationship Between Attention-Deficit/Hyperactivity Disorder Symptoms and Psychiatric Comorbidity among Patients with Severe Alcohol Use Disorder

Attention-deficit/hyperactivity disorder (ADHD) is an established risk factor for developing alcohol use disorder (AUD), and AUD-ADHD comorbidity is associated with additional psychiatric diagnoses. Several lines of evidence support the role of impulsivity as a pathway of these relationships; however, impulsivity is not a unitary construct. Thus, we sought to explore whether separate aspects of impulsivity may explain the relationship between ADHD symptoms and psychiatric comorbidity among inpatients (N = 136) with AUD. Methods: We assessed ADHD symptoms (childhood ADHD [Wender Utah Rating Scale], adult ADHD [Adult ADHD self-report scale]), health-related quality of life (HRQL; EQ-5D-5L), psychiatric comorbidity (Mini International Neuropsychiatric Interview), and impulsive personality traits (Urgency, Premeditation, Perseverance, Sensation seeking [UPPS] scale). Results: 19% of patients screened positive in the retrospective assessment of childhood ADHD, and 17% for adult ADHD. Participants reported moderate levels of problem severity in the HRQL dimensions, and 65% had ≥1 current psychiatric disorders other than AUD and ADHD. Multiple mediation indicated that there was a significant direct effect of childhood ADHD symptoms on psychiatric comorbidity (β = 0.224, 95% CI [0.080, 1.114]), and indirect effects of both reacting impetuously when experiencing negative emotions (negative urgency; β = 0.999, 95% CI [0.043, 0.461]) and the tendency to not finish tasks (lack of perseverance; β = 0.075, 95% CI [0.002, 0.297]). Conclusions: The subcomponents of impulsivity to react rashly when experiencing negative emotions and the tendency to not persist in activities seem to contribute to the relationship between ADHD symptoms (particularly those in childhood) and psychiatric comorbidity among patients with severe AUD.

An Examination of Substance Use Disorder Type, Legal Status of Drug, and Treatment Outcomes

From the anti-tobacco and anti-marijuana campaigns of the twentieth century to the current controversies surrounding vaporizer use and the opioid epidemic, substances and substance use have been at the forefront of cultural, public health, and legal debates for decades. This work explores treatment outcomes among those with substance use disorders (SUD) by 1) comparing legal, semi-legal, and illegal drug types and their impact on treatment outcomes and 2) evaluating the extent that there exist discrepancies between those who need and those who receive treatment. Methods: Binary logistic regression models were employed with data from the 2018 National Survey on Drug Use and Health (NSDUH) to examine the relationship between type of SUD and treatment outcomes. Results: Results indicate that those with SUD to illegal drugs were generally more likely to report a need and receive treatment than those with SUD to a legal drug (alcohol use disorder). Those with SUD to some types of illegal drugs did not report more need, but in some cases reported more treatment. Additionally, analyses indicated that across treatment outcomes, those with marijuana use disorder (semi-legal drug) were less likely to report needing or receiving treatment than those with alcohol use disorder. Conclusions: This research examined the role of drugs' legal status and type of SUD in need for treatment and treatment received. The discrepancy between needing and receiving treatment suggests those with some types of SUDs may be pushed into treatment at higher rates based on the stigma surrounding the substance they use.

Depression and substance use disorders: Clinical comorbidity and shared neurobiology

Mood disorders, including major depressive disorder (MDD), are the most prevalent psychiatric illnesses, and pose an incredible burden to society, both in terms of disability and in terms of costs associated with medical care and lost work time. MDD has extremely high rates of comorbidity with substance use disorders (SUD) as many of the same neurobiological circuits and molecular mechanisms regulate the reward pathways disrupted in both conditions. MDD may induce SUDs, SUD may contribute to MDD development, or underlying vulnerabilities and common life experience may confer risk to developing both conditions. In this chapter we explore theories of MDD and SUD comorbidity, the neurobiological underpinnings of depression, overlapping cellular and molecular pathways for both conditions, and current treatment approaches for these comorbid conditions.

Psychiatric comorbidities in alcohol use disorder

Alcohol use disorder is a major contributor to the morbidity and mortality burden worldwide. It often coexists with other psychiatric disorders; however, the nature of this comorbidity is still a matter of debate. In this Series paper, we examine the main psychiatric disorders associated with alcohol use disorder, including the prevalence of co-occurring disorders, the temporal nature of the relationship, and mechanisms that might explain comorbidity across the lifespan. Overall, this disorder co-occurs with a wide range of other psychiatric disorders, especially those disorders involving substance use and violent or aggressive behaviour. The causal pathways between alcohol use disorder and other psychiatric disorders are heterogeneous. Hypotheses explaining these relationships include reciprocal direct causal associations, shared genetic and environmental causes, and shared psychopathological characteristics of broader diagnostic entities (eg, externalising disorders). Efforts to untangle the associations between alcohol use disorder and other disorders across the lifespan remain a crucial avenue of research.

Lifetime and 12-month treatment for mental disorders and suicidal thoughts and behaviors among first year college students

OBJECTIVES

Mental disorders and suicidal thoughts and behaviors (STB) are common and burdensome among college students. Although available evidence suggests that only a small proportion of the students with these conditions receive treatment, broad-based data on patterns of treatment are lacking. The aim of this study is to examine the receipt of mental health treatment among college students cross-nationally.

METHODS

Web-based self-report surveys were obtained from 13,984 first year students from 19 colleges in eight countries across the world as part of the World Health Organization's World Mental Health-International College Student Initiative. The survey assessed lifetime and 12-month common mental disorders/STB and treatment of these conditions.

RESULTS

Lifetime and 12-month treatment rates were very low, with estimates of 25.3-36.3% for mental disorders and 29.5-36.1% for STB. Treatment was positively associated with STB severity. However, even among severe cases, lifetime and 12-month treatment rates were never higher than 60.0% and 45.1%, respectively.

CONCLUSIONS

High unmet need for treatment of mental disorders and STB exists among college students. In order to resolve the problem of high unmet need, a reallocation of resources may focus on innovative, low-threshold, inexpensive, and scalable interventions.

Correlates of Illicit Drug Use Among Indigenous Peoples in Canada: A Test of Social Support Theory

Relying on a national stratified random sample of Indigenous peoples aged 19 years old and above in Canada, this study investigates the correlates of illicit drug use among Indigenous peoples, paying special attention to the association between social support measures and illegal drug use. Results from multivariate logistical regression show that measures of social support, such as residential mobility, strength of ties within communities, and lack of timely counseling, are statistically significant correlates of illicit drug use. Those identifying as Christian are significantly less likely to use illegal drugs. This is the first nationwide analysis of the illicit drug usage of Indigenous peoples in Canada. The results are robust because we have controlled for a range of comorbidity variables as well as a series of sociodemographic variables. Policy implications from these findings are discussed.

Differences in behavioral health disorders and unmet treatment needs between medical marijuana users and recreational marijuana users: Results from a national adult sample

BACKGROUND

Available data suggest that medical marijuana users may have more mental health problems than recreational marijuana users. There is limited information about differences in behavioral health disorders and unmet treatment needs between medical and recreational marijuana users.

METHODS

We compared past-year prevalence of behavioral health disorders and unmet treatment needs across three marijuana subgroups (recreational use only, medical use only, and both). Sex-stratified logistic regression was performed to determine their associations with marijuana use status. We analyzed data from adults (≥18 years) who used marijuana in the past year (N=15,440) from 2013 to 2014 National Surveys on Drug Use and Health.

RESULTS

Among 15,440 past-year marijuana users, 90.2% used recreational marijuana only, 6.2% used medical marijuana only, and 3.6% used both. Both users had the highest prevalence of behavioral health disorders and unmet treatment needs overall, with no significant sex differences. In the sex-specific logistic regression analysis, medical only users and both users showed somewhat different patterns of associations (reference group=recreational only users). Medical only users had decreased odds of alcohol or drug use disorders, and unmet need for alcohol or drug treatment among males and females. Additionally, female medical only users had decreased odds of opioid use disorder. Both users had increased odds of major depressive episode, hallucinogen use disorder, and unmet need for mental health services among males, and cocaine use disorder among females.

CONCLUSIONS

Different approaches tailored to individuals' sex and motives for marijuana use is needed for the prevention and treatment of behavioral health problems.

The role of consumer perspectives in estimating population need for substance use services: a scoping review

Background

A growing body of research assesses population need for substance use services. However, the extent to which survey research incorporates expert versus consumer perspectives on service need is unknown. We conducted a large, international review to (1) describe extant research on population need for substance use services, and the extent to which it incorporates expert and consumer perspectives on service need, (2) critically assess methodological and measurement approaches used to study consumer-defined need, and (3) examine the potential for existing research that prioritizes consumer perspectives to inform substance use service system planning.

Methods

Systematic searches of seven databases identified 1930 peer-reviewed articles addressing population need for substance use services between January 1980 and May 2015. Empirical studies (n = 1887) were categorized according to source(s) of data used to derive population estimates of service need (administrative records, biological samples, qualitative data, and/or quantitative surveys). Quantitative survey studies (n = 1594) were categorized as to whether service need was assessed from an expert and/or consumer perspective; studies employing consumer-defined need measures (n = 217) received further in-depth quantitative coding to describe study designs and measurement strategies.

Results

Almost all survey studies (96%; n = 1534) used diagnostically-oriented measures derived from an expert perspective to assess service need. Of the small number (14%, n = 217) of survey studies that assessed consumer’s perspectives, most (77%) measured perceived need for generic services (i.e. ‘treatment’), with fewer (42%) examining self-assessed barriers to service use, or informal help-seeking from family and friends (10%). Unstandardized measures were commonly used, and very little research was longitudinal or tested hypotheses. Only one study used a consumer-defined need measure to estimate required service system capacity.

Conclusions

Rhetorical calls for including consumer perspectives in substance use service system planning are belied by the empirical literature, which is dominated by expert-driven approaches to measuring population need. Studies addressing consumer-defined need for substance use services are conceptually underdeveloped, and exhibit methodological and measurement weaknesses. Further scholarship is needed to integrate multidisciplinary perspectives in this literature, and fully realize the promise of incorporating consumer perspectives into substance use service system planning.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2153-z) contains supplementary material, which is available to authorized users.

Perceived unmet need and barriers to care amongst street-involved people who use illicit drugs

INTRODUCTION AND AIMS

Research on perceived unmet need for care for mental health and substance use problems focuses on general populations to the detriment of hidden populations. This study describes prevalence and correlates of perceived unmet need for care in a community-based sample of street-involved people who use illicit drugs and identifies barriers to care.

DESIGN AND METHODS

A sample of 320 street-involved people who use drugs participated in a structured, interviewer-assisted survey in Edmonton, Canada. The survey included the Perceived Need for Care Questionnaire, which assessed unmet need for care for mental health and substance use problems across seven service types. Logistic regression examined the associations between perceived unmet need, extent of socioeconomic marginalisation and problem severity. Barriers underlying unmet service needs were also examined.

RESULTS

Most (82%) participants reported unmet need for one or more services during the past year. Odds of reporting one or more unmet needs were elevated amongst participants reporting substantial housing instability (adjusted odds ratio = 2.37; 95% confidence interval 1.19-4.28) and amongst participants meeting criteria for drug dependence (adjusted odds ratio = 1.22; 95% confidence interval 1.03-1.50), even after adjustment for sociodemographic covariates. Structural, rather than motivational barriers were the most commonly reported reasons underlying unmet service needs.

DISCUSSION AND CONCLUSION

Street-involved people who use drugs experience very high rates of perceived unmet need for care for mental health and substance use problems. General population studies on perceived unmet need are insufficient for understanding needs and barriers to care in hidden populations.[Hyshka E, Anderson JT, Wild TC. Perceived unmet need and barriers to care amongst street-involved people who use illicit drugs. Drug Alcohol Rev 2017;36:295-304].

Neuroscience of inhibition for addiction medicine: from prediction of initiation to prediction of relapse

A core deficit in drug addiction is the inability to inhibit maladaptive drug-seeking behavior. Consistent with this deficit, drug-addicted individuals show reliable cross-sectional differences from healthy nonaddicted controls during tasks of response inhibition accompanied by brain activation abnormalities as revealed by functional neuroimaging. However, it is less clear whether inhibition-related deficits predate the transition to problematic use, and, in turn, whether these deficits predict the transition out of problematic substance use. Here, we review longitudinal studies of response inhibition in children/adolescents with little substance experience and longitudinal studies of already addicted individuals attempting to sustain abstinence. Results show that response inhibition and its underlying neural correlates predict both substance use outcomes (onset and abstinence). Neurally, key roles were observed for multiple regions of the frontal cortex (e.g., inferior frontal gyrus, dorsal anterior cingulate cortex, and dorsolateral prefrontal cortex). In general, less activation of these regions during response inhibition predicted not only the onset of substance use, but interestingly also better abstinence-related outcomes among individuals already addicted. The role of subcortical areas, although potentially important, is less clear because of inconsistent results and because these regions are less classically reported in studies of healthy response inhibition. Overall, this review indicates that response inhibition is not simply a manifestation of current drug addiction, but rather a core neurocognitive dimension that predicts key substance use outcomes. Early intervention in inhibitory deficits could have high clinical and public health relevance.

Chronic postnatal stress induces voluntary alcohol intake and modifies glutamate transporters in adolescent rats

Postnatal stress alters stress responses for life, with serious consequences on the central nervous system (CNS), involving glutamatergic neurotransmission and development of voluntary alcohol intake. Several drugs of abuse, including alcohol and cocaine, alter glutamate transport (GluT). Here, we evaluated effects of chronic postnatal stress (CPS) on alcohol intake and brain glutamate uptake and transporters in male adolescent Wistar rats. For CPS from postnatal day (PD) 7, pups were separated from their mothers and exposed to cold stress (4 °C) for 1 h daily for 20 days; controls remained with their mothers. Then they were exposed to either voluntary ethanol (6%) or dextrose (1%) intake for 7 days (5-7 rats per group), then killed. CPS: (1) increased voluntary ethanol intake, (2) did not affect body weight gain or produce signs of toxicity with alcohol exposure, (3) increased glutamate uptake by hippocampal synaptosomes in vitro and (4) reduced protein levels (Western measurements) in hippocampus and frontal cortex of glial glutamate transporter-1 (GLT-1) and excitatory amino-acid transporter-3 (EAAT-3) but increased glutamate aspartate transporter (GLAST) levels. We propose that CPS-induced decrements in GLT-1 and EAAT-3 expression levels are opposed by activation of a compensatory mechanism to prevent excitotoxicity. A greater role for GLAST in total glutamate uptake to prevent enlarged extracellular glutamate levels is inferred. Although CPS strongly increased intake of ethanol, this had little impact on effects of CPS on brain glutamate uptake or transporters. However, the impact of early life adverse events on glutamatergic neurotransmission may underlie increased alcohol consumption in adulthood.