Substitute addiction: a concern for researchers and practitioners

Commentary: Similarities and Differences Between Harm-Reduction and Substitute Addiction-- Implications for the Health Professions

"Substitute addiction" refers to the process of achieving abstinence or resolution of one addictive behavior and subsequently engaging in one or more additional addictive behaviors in its place. Substitute addiction, a concept in the abstinence-based recovery field for decades, is viewed as a cause for concern because resolving one addictive behavior might not fully remove harm or ensure recovery. Conversely, "harm-reduction treatment" refers to a counseling orientation that focuses on helping service users reduce substance-related harm and improve their quality of life without necessarily requiring abstinence or use reduction. Harm-reduction treatment assesses a constellation of addictive behaviors in the larger context of a person's life to holistically reduce harm in that constellation. In this commentary, we define and compare both constructs and point out their implications for addictions treatment.

A 5-year longitudinal examination of the co-occurring patterns of gambling and other addictive behaviors

OBJECTIVE

We examined the co-occurring patterns of problem gambling and substance/behavioral addiction severity over a five-year period and the predictors of the different co-occurring patterns of problem gambling and addiction severity.

METHODS

We conducted a secondary analysis of the Quinte Longitudinal Study (QLS) data. The QLS is a 5-year prospective longitudinal study of gambling and problem gambling in the Quinte Region in Southern Ontario. The QLS consists of a total of 4,121 participants, including a sample of participants at risk of developing problem gambling. Severity of problem gambling, substance use, and behavioral addictions were used to examine their co-occurring patterns over time. Predictors of the co-occurring patterns included the presence of mental health disorders, personality, stress, happiness, lifesatisfaction, social support, family history, and demographics.

RESULTS

Six co-occurring patterns of problem gambling and addiction severity were identified. The largest co-occurring pattern was characterized by concurrent decrease in gambling and other addictive behaviors. Several co-occurring patterns were characterized by moderate-to-severe problem gambling and other addiction severity that remained stable over time. No co-occurring pattern represented a decrease in gambling followed by increase in other addictive behaviors (e.g., addiction substitution). The presence of mental health disorders, stress, and lifesatisfaction significantly predicted the different co-occurring patterns.

CONCLUSIONS

Taken together, the results suggest that in a non-clinical sample, gambling and other co-occurring addictive behaviors are likely to simultaneously decrease over time. Comorbidity of mental health disorders significantly influences co-occurring patterns of gambling and other addictive behaviors.

New-onset addictions in patients with alcohol dependence: A cross-sectional study

BACKGROUND

Individuals who are addicted to one addiction are at an increased risk for developing another new addiction. New-onset addictions among patients with alcohol dependence needs to be considered for more effective treatment of alcohol dependence.

METHODS

In this cross-sectional study, Japanese outpatients with alcohol dependence were assessed using a comprehensive, originally designed questionnaire to determine whether they were addicted to substances or behaviors other than alcohol. The prevalence rates of new-onset addictions were compared between alcohol-dependent patients who had abstained from alcohol for a year or more and those who had not. Multiple regression analysis was performed to examine the association between the number of new-onset addictions and the demographic and clinical characteristics.

RESULTS

One hundred and nine outpatients with alcohol dependence (54.6±11.0 years; 97 men) participated in the study. The prevalence of new-onset addictions was 41.3%. No significant differences were found in the prevalence of new-onset addictions between the patients who had abstained for a year or more and those who had not. Multiple regression analysis revealed that the number of new-onset addictions was positively associated with the presence of psychiatric comorbidity (β = 0.24; p = 0.02) and use of benzodiazepines (β = 0.20; p = 0.04) with a R2 of 0.153.

CONCLUSION

Alcohol dependent patients with characteristics such as psychiatric comorbidity and use of benzodiazepines should be given more attention to the development of new-onset addictive behaviors. On the other hand, those behaviors could be acceptable for harm-reduction unless excessive and loss of control.

Narcotics Anonymous attendees' perceptions and experiences of substitute behaviors in the Western Cape, South Africa

BACKGROUND

Much remains unknown about the dynamics of substitute behaviors during addiction recovery among persons attending recovery support groups. Insight into the nature, motives for, and course of substitute behaviors could help to shape recovery support and harm reduction services.

METHODS

Twenty-three semi-structured in-depth interviews (n = 14 males and n = 9 females) were conducted with a convenience sample of Narcotics Anonymous attendees from a number of groups in the Western Cape, South Africa. Participants ranged in age from 22-55 years (M = 39.3, SD = 9.35).

RESULTS

Thematic analysis yielded four themes: (i) substance-to-substance substitution; (ii) substance-to-behavior substitution; (iii) substitute behaviors and harm (reduction) and (iv) support needs to manage and resolve substitute behaviors. According to the study, participants' substitute behaviors developed across recovery stages; were temporary or long-term replacements for substance use disorders and were engaged for distraction, isolation from others, calming, assuaging boredom, keeping occupied, filling a perceived experiential void, modifying mood and to self-medicate. While substitutes were utilized for harm reduction or relapse prevention, the potential for ostensibly healthy behaviors to threaten recovery and lead to relapse was also recognized.

CONCLUSIONS

Self-monitoring, ongoing vigilance, and awareness of when substitutes become genuine addictions are critical for timely, suitable interventions.

Web-based Evidence on the Treatment of Behavioral Addictions in United States Model Treatment Centers

Behavioral addictions are highly comorbid with substance use disorders, presenting in as many as 54% of service users receiving substance use treatment. Few studies have examined whether treatment centers are attentive to such other addictions, which may undermine treatment. This study examined the mention and treatment of behavioral addictions on United States treatment center websites. The 2021 Newsweek America's Best Addiction Treatment Centers website was utilized to examine the mention and treatment of behavioral addictions in 300 leading treatment centers across 25 states in the United States. Of 289 active websites, only 61 (21.1%) treatment centers mentioned anything about behavioral addictions. The highest prevalence was for gambling (n = 38), sex (n = 22), food/eating (n = 21), and internet gaming (n = 12). A total of 49 treatment centers reported treating those addictions. The most prevalent treatments involved 12-step programming (n = 18), cognitive behavioral therapy (CBT; n = 16), individual counseling (n = 16), and group therapy (n = 15). Little formalized importance via websites was provided regarding the mention or treatment of behavioral addictions at treatment centers. A greater emphasis on concurrent and substitute behavioral addictions is needed to improve the quality of life and lower the possibility of relapse among those persons in addictions treatment.

Service Providers’ Perceptions of Substitute Addictions in the Western Cape, South Africa

Globally little is known regarding substance use service providers’ perceptions of substitute behaviours and this significant gap could hinder service provision and recovery outcomes. Semi-structured focus group discussions (including 22 service providers across five sites) were conducted in residential treatment facilities in the Western Cape, South Africa. Service providers recognised substances (e.g. cigarettes and caffeine) and behaviours (e.g. gambling, eating, love, sex, shopping, exercise, and gaming) as potential substitutes. Identified substitute motives included managing cravings; self-medication; filling the experiential void of the primary substance, and time-spending. Concurrent behaviours and addictions were believed to be a key mechanism underlying substitution however, service providers did not uniformly screen for co-occurring behavioural addictions. Substitute behaviours were primarily considered a pathway to relapse and service providers emphasised prevention, detection and family education. To suitably intervene, screening for co-occurring behaviours should be an integral part of the assessment of those presenting for substance use treatment.

Coping and Co-Occurrence of Gaming Disorder and Substance Use in Recovering Substance Users

BACKGROUND

There are a wide range of negative effects associated with both substance use disorders and behavioural disorders and their co-occurrence. Understanding the way in which at-risk populations (e.g., substance-abstinent users) interact with potentially addictive behaviours (e.g., gaming) and substance use-while navigating life stressors through differing coping styles-can inform preventative strategies.

METHODS

Therefore, the present study investigated 64 clinical participants and 138 general population participants. Each cohort was required to complete a battery of psychometric scales exploring problematic behaviours, problematic substance use, co-occurrence, and coping styles. Additional exploratory direct comparisons of gamers in the clinical cohort and gamers in the general cohort were carried out.

RESULTS

The study's findings suggest that gamers from different populations (i.e., general and clinical) share similar at-risk behaviours. These problematic behaviours were more pronounced among abstinent substance use gamers, and more specifically among poly-substance use gamers.

CONCLUSIONS

The findings of the present study add to the literature and suggest that dysfunctional coping style and the co-occurrence of problematic behaviours may have an impact on the assessment and potential treatment of substance abstinent gamers. The findings offer support for an integrated treatment approach, wherein both substance use and the other problematic behaviours (e.g., gaming) are considered in tandem.

Changes in sports gambling behavior during the COVID-19 pandemic in Canada

Sports betting is one of the most popular forms of gambling in Canada; recent prevalence estimates indicate that 7.9% of Canadian adults endorsed gambling on sports in the past year. The ongoing COVID-19 pandemic led to the temporary closure of most major sports leagues worldwide beginning in March of 2020. These sudden closures created a dramatic decrease in the availability of sports betting opportunities in the early stages of the pandemic, followed by a subsequent increase in availability as most sport leagues returned during the summer of 2020. Using a retrospective self-report measure of gambling participation, the present study investigated how the gambling behaviors of N = 85 past-year sports gamblers changed over the course of the pandemic. It was hypothesized that sports gamblers would report an initial decrease in gambling behaviors from pre-pandemic baseline levels to the early stages of the pandemic in May of 2020 when the availability of sports gambling was heavily restricted, followed by an increase in gambling behaviors from May to August, in accordance with the re-emergence of live sporting events. The general pattern of results supported the hypotheses, though gambling behaviors did not completely return to baseline levels. Beyond quantifying the changes in gambling behaviors over the early stages of the pandemic in Canada, results may have implications regarding the utility of voluntary gambling exclusion programs as well as legislation concerning gambling access.

Cross-Addiction Risk Profile Associations with COVID-19 Anxiety: a Preliminary Exploratory Study

"Cross-addiction" involves a person substituting one form of addictive behaviour for another. Indeed, cross-additive presentations have been frequently described (e.g. from drugs to alcohol, gambling to sex), and risk profiles have been assumed. Nevertheless, there has been a dearth of evidence considering the occurrence of cross-addiction risk profiles in the community. This research is imperative for informing effective prevention/intervention policies, especially under anxiety-provoking conditions, such as the current coronavirus pandemic. To address this need, a cross-sectional exploratory research design was utilized, with quantitative survey data obtained from 968 respondents (18-64; M age  = 29.5 years, SD = 9.36), who completed an online survey regarding a range of addictive behaviours (i.e. abuse of alcohol, drug, smoking, online gaming, shopping, internet, exercise, online gambling, sex, and social media) and their anxiety about the coronavirus. Latent class/profiling analyses were implemented to (a) explore profiles of cross-addiction risk, (b) describe the characteristics and the proportions of these profiles, and (c) identify their differential associations with the pandemic precipitated anxiety. Findings revealed two distinct profiles/types, the "cross-addiction low risk" (57.4%) and the "cross-addiction high risk" (42.6%). Those in the latter scored consistently higher across all behaviours assessed, were more likely to suffer from concurrent addictive problems, and reported significantly higher levels of pandemic-related anxiety. Implications for prevention, assessment, and treatment and future research are discussed.

Substitute Behaviors following Residential Substance Use Treatment in the Western Cape, South Africa

The dynamics of substitute behaviors and associated factors remain poorly understood globally, and particularly in low- and middle-income contexts. This prospective study describes the prevalence and types of substitute behaviors as well as predictors, correlates, and motivations associated with substitution in persons (n = 137) admitted to residential substance use treatment in the Western Cape province of South Africa. The brief assessment of recovery capital, overall life satisfaction scale, and an adapted version of the addiction matrix self-report measure were completed during and post-treatment. Results indicate that substitutes were employed consciously for anticipated appetitive effects, for time-spending, (re)connecting with others, and enjoyment. At follow-up, 36% of service users had substituted their primary substance(s) with another substance or behavior; 23% had relapsed and 40% had maintained abstinence. While some service users may be especially vulnerable to developing substitute behaviors, targeted prevention and intervention efforts can reduce this risk.

Anhedonia in tobacco withdrawal among African-American smokers

Anhedonia-diminished interest and pleasure in response to rewards-may be a symptom of tobacco withdrawal that is understudied in priority populations. This experiment investigated the magnitude and correlates of various dimensions of anhedonia during tobacco withdrawal among African-American (AA) smokers-a population subject to health disparities. AA smokers (N = 607; ≥ 10 cigarettes/day, 37.8% female, M[SD] age = 50.0[10.6] years) completed self-report measures assessing expected pleasure from (i.e., consummatory anhedonia) and desire to engage in (i.e., anticipatory anhedonia) various types of hypothetically experienced rewards at counterbalanced 16-hr tobacco deprived and nondeprived lab visits. Other tobacco withdrawal symptom measures (e.g., craving, negative affect, hunger) were also assessed. Tobacco deprivation most robustly increased scores on a composite measure of consummatory anhedonia directed toward various reward domains (i.e., hobbies, sensory experiences, social activities; d = .32, p < .001). Deprivation modestly increased consummatory and anticipatory anhedonia directed toward sexual rewards (ds = .09-.12, ps < .02), did not significantly change anhedonia toward food rewards, and decreased anhedonia directed toward psychoactive drug rewards (i.e., increased desire for and pleasure from drugs; ds = -.21 to -.19, ps < .001). Deprivation-induced changes in anhedonia were modestly correlated with other withdrawal symptoms (average |r|s = .04-.23) and were amplified among participants with higher nicotine dependence and lower positive affect-related traits (|β|s = .10-.12, ps < .01). Some dimensions of anhedonia may be genuine expressions of acute tobacco withdrawal in AA smokers. Applying multi-dimensional anhedonia conceptualizations might advance basic knowledge and treatment of tobacco use disorder, improve smoking cessation outcomes, and address tobacco-related health disparities facing AA smokers. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

A systematic review of addiction substitution in recovery: Clinical lore or empirically-based?

This systematic review synthesized the literature examining addiction substitution during recovery from substance use or behavioral addictions. A total of 96 studies were included with sample sizes ranging from 6 to 14,885. The most common recovery addictions were opioids (30.21%), followed by cannabis (20.83%), unspecified use (17.71%), nicotine (12.50%), alcohol (12.50%), cocaine (4.17%), and gambling (2.08%). Statistical results were provided by 70.83% of the studies. Of these, 17.65% found support for addiction substitution, whereas 52.94% found support for concurrent recovery. A total of 19.12% found no statistical changes and 10.29% found both significant increases and decreases. The remaining 29.17% of studies provided descriptive data, without statistical tests. Predictors of addiction substitution were provided by 22.92% of the studies and 11.46% included information on impact of addiction substitution on treatment outcomes. Overall, male gender, younger age, greater substance use severity, and presence of mental health disorders were associated with addiction substitution. Addiction substitution was associated with poorer treatment outcomes. A limitation of the present systematic review is the use of significance counting for the quantitative synthesis. More research examining changes in addiction during recovery would aid in the development of more effective treatments for addictive disorders and prevent addiction substitution.

Effects of a cannabis use disorder text message-delivered treatment on young adult alcohol misuse: Differential effects by gender

Alcohol misuse is more prevalent, frequent, and severe among young adults who use cannabis. Treatment of dual alcohol and cannabis users may have mixed results, with some studies reporting that alcohol misuse increases when cannabis use decreases (substance substitution), while others report that alcohol misuse decreases along with decreasing cannabis use (treatment spillover), and others report no association. Additionally, little research tests whether gender differences are found in treatment of dual alcohol and cannabis users, which may be expected given previous alcohol-focused treatments showing larger effects for females. In the current study, we present a secondary analysis of a randomized clinical trial testing a text message-delivered cannabis use disorder (CUD) treatment (peer network counseling text or "PNC-txt"). The trial included 101 young adults ages 18-25 who met criteria for CUD. We tested whether alcohol use and binge drinking frequency (4+/5+ drinks for women/men) decreased in response to the PNC-txt treatment, which has previously shown effectiveness in reducing cannabis use days. Latent growth models tested PNC-txt effects on the monthly rate of change in alcohol use and binge drinking across three months. In the full sample, we found no evidence of significant treatment effects on alcohol use (d = -0.07) or binge drinking (d = -0.10). Moderation analyses, however, indicated the PNC-txt effect on both alcohol use and binge drinking differed significantly by gender. PNC-txt led to significantly larger decreases in alcohol use (d = -0.53) and binge drinking days (d = -0.43) across the three months for females, whereas the study saw opposite (but nonsignificant) effects for males (d = 0.30 and 0.16 for alcohol use and binge drinking, respectively). We found no evidence that reductions in alcohol use and binge drinking were associated with cannabis use decreases, arguing against direct substitution or spillover effects. These results provide evidence that treatments focused on cannabis use may have secondary beneficial effects for young-adult alcohol misuse, although such effects may be limited to women.

Substance Use Disorder Status Moderates the Association between Personality Traits and Problematic Mobile Phone/Internet Use

BACKGROUND

Associations between personality traits and problematic smartphone use (PSU) among individuals with substance use disorder (SUD) have not been widely investigated. The current study aims to assess whether SUD status moderates the association between personality traits and PSU.

METHODS

The study group included 151 individuals with SUD and a normative sample (NS) comprised of 554 non-SUD students. The following self-report questionnaires were used: the Mobile Phone Problem Use Scale (MPPUS-10) to assess problematic smartphone use (PSU), the Internet Addiction Test (IAT) to assess intensity of internet use, and the NEO Five-Factor Inventory (NEO-FFI) to assess Personality traits.

RESULTS

SUD status moderated the association between neuroticism and openness to new experiences on PSU. That is, greater neuroticism and openness were significantly associated with more excessive PSU among the NS. In the SUD group, greater openness was a significant protective factor against PSU. Moderation results were similar when using the IAT (which was significantly correlated with MPPUS) as an outcome.

CONCLUSIONS

The presence of SUD may influence how personality traits are associated with problematic mobile phone/internet use. Given that this is among one of the first studies examining this topic, findings should be replicated with additional studies.

Exploring life-course patterns of substance abuse: a qualitative study

OBJECTIVES

This research sought to examine how older adults with substance abuse issues understand the pattern of their use. Qualitative interviews explored: (1) Whether self-reported age of onset of substance abuse in fact aligned with the age when use became problematic; (2) Patterns of substance use over the life-course; (3) Precipitants of substance use throughout the lifespan; (4) Factors that prevented identification of problem use; (5) How participants came to recognize that their substance use was problematic.

METHOD

Participants were 11 men and 9 women aged 62-78 years (M = 69.80, SD = 3.86) who were clients of an older adult substance abuse treatment program. Semi-structured interviews were conducted and transcribed for thematic analysis.

RESULTS

Interview data revealed discrepancies between self-identified age of substance abuse onset and reported problematic use throughout the lifetime. Thematic analysis revealed factors that contributed to participants not recognizing problem use earlier in life, such as normalizing and minimizing the impact of use and lack of severe consequences earlier in life. Additionally, factors that led to increased use (i.e. retirement, grief), and to recognition of problem use and treatment-seeking were identified (i.e. social, financial, legal, and health problems).

CONCLUSION

In general, self-reported age of substance abuse onset and patterns of substance abuse were highly variable across participants. These results have implications for assessment of substance use among older adults, as well as preventative efforts to decrease risk of substance abuse.

Are Comorbid Disorders Associated with Changes in Gambling Activity? A Longitudinal Study of Younger and Older Subjects with DSM-IV Pathological Gambling

This study investigates the association of comorbid disorders with gambling activity in a longitudinal follow-up study of younger and older adult subjects with DSM-IV pathological gambling (PG). The subjects included 57 younger adults with PG (≥ 18/ < 40 years) and 48 older adults with PG (≥ 60 years). Subjects were assessed at baseline and every 6 months for a mean (SD) of 31.4 (13.1) months. Comorbidity was assessed using a modification of the Longitudinal Interval Follow-up Evaluation (LIFE). During follow-up, rates of problem severity were highest for anxiety disorders, mood disorders, and impulse control disorders. Among all subjects with PG, greater severity of depression or posttraumatic stress disorder was associated with increased gambling activity. In older subjects, greater severity of agoraphobia and social phobia were associated with lowered gambling activity. In younger subjects, greater severity of any substance use disorder, an alcohol use disorder, or compulsive computer use were associated with lowered gambling activity. The latter findings provide presumptive evidence for the substitute addiction hypothesis. We conclude that increased severity of several comorbid disorders could serve as triggers for increased gambling or predict lowered gambling activity. On the other hand, certain comorbid disorders could be triggered by increased gambling activity. Knowing these interrelationships is important to gaining a better understanding of PG and its clinical management.

Substitute Addictions in Persons with Substance Use Disorders: A Scoping Review

Substitute addictions, addictive behaviors that sequentially replace each other's functions, have implications for recovery trajectories but remain poorly understood. We sought to scope the extent, range, and characteristics of research on substitute addictions in persons with substance use disorders. Method: Using Arksey and O'Malley's framework for scoping reviews, a systematic search was conducted to identify publications that referenced substitute addictions up to April 2018. Study characteristics were extracted and summarized to provide an overview of the extant literature. Results: The 63 included studies show that substitute addictions are terminologically and conceptually ambiguous. Much of the available literature is concentrated in developed contexts - and in particular the United States of America. While presentations varied, at least two sub-types of substitute addictions appeared: long-term replacement and temporary replacement. Existing theories suggest a multifactorial etiology. Conclusions: The findings suggest a strong need for: increased awareness of substitute addictions and its potential consequences for recovery; interventions that structure prevention and pre-, during-, and post-treatment interactions as well as future research to explore its nature and dynamics drawing on multiple methods.

Faith-based alcohol treatment in England and Wales: New evidence for policy and practice

While the historical importance of religion in alcohol treatment is well known, the size, scope and significance of contemporary activities remain unclear. Here we begin to address this gap in knowledge by presenting results from a mixed methods study of faith-based alcohol treatment in England and Wales. The paper begins by mapping location, religious affiliation, organisational structure and service provision. We then discuss evidence regarding challenges, opportunities and tensions bound up with faith-based organisations 'filling gaps' left by long term restructuring of alcohol service provision, recent 'austerity' funding cuts and relationships between secular and faith-based organisations. In the final substantive section, we engage with questions of ethics and care by focusing on the internal workings of a subset of faith-based programs that make requirements for religious participation. Drawing on the variegated experiences of service-users, we reflect on the ethics of religious conversion in faith-based alcohol treatment. The conclusion offers policy and practice relevant insights and outlines areas for future research on religion, austerity, and alcohol treatment.

Potential for cannabis adaptation among participants in a drunk driving intervention

Background

Some alcohol interventions have been found to have the adverse outcome of increasing non-alcohol-related substance use. It is unknown, however, how changes in alcohol use over the course of alcohol ignition interlocks - a common DUI intervention - may impact other substance use.

Methods

Alcohol and cannabis use were measured using hair ethylglucuronide and Delta-9-Tetrahydrocannabinol concentrations in blood, respectively. Participants (N = 69) were measured at the interlock installation period and again 6-months later while the interlock was installed. A mixed ANOVA was conducted to examine changes in levels of ethanol and THC over time.

Results

On measures of marijuana use, there was a significant interaction effect between the group that increased alcohol use and time F(2, 66) = 7.863, p =.001; partial η ² =.192; as well as a main effect for time F(2, 66) = 21.106, p <.001; partial η ² =.242.

Conclusions

Installing interlocks may inadvertently increase cannabis use among those who decrease alcohol use. Crash risk associated with cannabis use is notably less than that of alcohol use, however, continued cannabis use may be problematic when the device is removed and alcohol use is expected to return to the higher pre-interlock levels.

Decreased drinking in adults with co-occurring cannabis and alcohol use disorders in a treatment trial for marijuana dependence: Evidence of a secondary benefit?

The purpose of the present study was to investigate whether cannabis dependent users who met criteria for a secondary diagnosis of alcohol use disorder (AUD) would increase their use of alcohol in response to decreasing their use of marijuana in a behavioral treatment trial for cannabis use disorder (CUD). This phenomenon is commonly known as "substance substitution." Participants were randomly assigned to one of four 9-session treatment conditions with cannabis and alcohol use measured at baseline, posttreatment, and at 4 follow-ups through 14 months. Of those enrolled (n = 198), 27 (13.6%) also met criteria for AUD. Linear mixed models were used to analyze alcohol use over time with cannabis use and time as predictors. Findings demonstrated that there were no associations between declines in cannabis use and changes in alcohol consumption in the full sample. However, among those with CUD who also had AUD, declines in cannabis use significantly predicted concurrent declines in alcohol use (p < .05). This study did not find evidence of substance substitution among individuals receiving treatment for CUD. Contrary to expectations, the results indicated that individuals with AUD were more likely to decrease, rather than increase, their alcohol use when they reduced their marijuana use. Treatment for CUD in this study appeared to result in improvements in substance use generally, at least for those with comorbid AUD.

The associations between low-level gaming, high-level gaming and problematic alcohol use

The current study aimed to investigate associations between gaming and different patterns of problematic alcohol use, controlling for important demographics, personality and mental health covariates. Data was collected by an online survey during fall 2016 (N = 5217). Students who had participated in a survey among students in Bergen, Norway, one year earlier were invited to participate. Crude and adjusted binary logistic regression analyses were conducted in order to assess the relationship between different patterns of problematic alcohol use and gaming (i.e. low-level gaming and high-level gaming vs. no gaming) while controlling for important covariates. The different gaming groups were categorised based on the number of symptoms of "gaming addiction" (in total seven) that they endorsed: 4 > symptoms = low-level gaming, 4 ≤ symptoms = high-level gaming. Only 0.2% (n = 11) endorsed all seven symptoms. Low-level gaming was positively associated with patterns of problematic alcohol use in the crude analyses; these associations became non-significant when controlling for demographic variables. High-level gaming was inversely associated with patterns of problematic alcohol use when controlling for demographics, personality, and mental health covariates. The inverse relationship between high-level gaming and problematic alcohol use (when controlling for covariates) suggest that heavy investment in gaming may protect against excessive alcohol use and alcohol-related harm. Possible explanations discussed for the inverse associations include high-level gamers having less available time to drink, intoxication being incompatible with gaming, and/or high-level gamers experiencing sufficient satisfaction/escape and social bonding by gaming, hence having less need for alcohol.

Current Smoking: An Independent Predictor of Elevated A1C in Persons With Type 2 Diabetes

Purpose

The purpose of this study is to examine the association of current smoking as one of several potential predictors of elevated A1C in adults with type 2 diabetes (T2D).

Methods

Using a cross-sectional design, baseline data (N = 282) were analyzed from a randomized clinical trial examining treatment of obstructive sleep apnea in persons with T2D. Sociodemographic, clinical, and behavioral data were collected using questionnaires and physical examinations. Physical activity (mean daily steps walked) was measured with the BodyMedia Armband. Participants were asked if they never smoked, had previously smoked, or currently smoke. The sample distributions of demographic and clinical characteristics were examined using descriptive statistics. Continuous variables were described using means and standard deviations; categorical variables were described as numbers and percentages. Multiple linear regression analysis with backward selection was conducted to develop a parsimonious predictive model for the dependent variable A1C.

Results

Participants were generally middle-aged and, on average, obese with suboptimal blood glucose control; almost 1 of every 5 participants currently smoked. After controlling for age, race, education, financial difficulty, diabetes education, physical activity, and diabetes knowledge, 4 variables were found in the final model to be independently associated with higher A1C: (1) current smoking status, (2) younger age, (3) longer diabetes duration, and (4) higher diabetes-related distress.

Conclusions

The study found that not only is smoking prevalent among persons with T2D with self-reported sleep problems but smoking is also an independent predictor of elevated A1C. The results highlight the vital role diabetes educators have in promoting risk reduction through education and support for smoking cessation.

Examining heterotypic continuity of psychopathology: a prospective national study

BACKGROUND

Individuals with one psychiatric disorder are at increased risk for incidence and recurrence of other disorders. We characterize whether the magnitude of such heterotypic continuity varies based on whether the first disorder remits or persists over time.

METHOD

Cohorts were selected from participants in the National Epidemiologic Survey on Alcohol and Related Conditions wave 1 (2001-2002) and wave 2 (2004-2005) surveys with ⩾1 mood, anxiety, or substance use disorder at wave 1. Among respondents remitting (n = 6719) or not remitting (n = 3435) from ⩾1 of disorder at wave 2, the analyses compared the odds of developing new disorders.

RESULTS

As compared with adults whose disorders persisted from wave 1 to wave 2, those with ⩾1 remission had lower odds of incidence or recurrence of another disorder. Remission from alcohol dependence [odds ratio (OR) 0.4, 95% confidence interval (CI) 0.3-0.5] and drug dependence (OR 0.4, 95% CI 0.3-0.6) were associated with the lowest odds of incidence of another disorder. Social anxiety disorder was associated with the lowest adjusted odds of recurrence (adjusted OR = 0.2, 95% CI 0.1-0.6). Remission of disorders within one class (mood, anxiety, substance use) was consistently associated with lower odds of incidence or recurrence of disorders from the same class than with developing disorders from the other classes.

CONCLUSIONS

Remission from common psychiatric disorders tends to decrease the risk for incidence or recurrence of disorders and this effect is stronger within than across disorder classes. These results do not support the concept of heterotypic continuity as a substitution of one disorder for another.

Five-year follow-up of people diagnosed with compulsive shopping disorder

BACKGROUND

The authors assessed clinical symptoms and self-reported shopping and spending behavior in people diagnosed with compulsive shopping (CS) at a 5-year follow-up interview.

METHODS

All met the criteria of McElroy et al. for lifetime CS and had the disorder for >1year. Structured and semistructured instruments and self-report questionnaires were used to collect data.

RESULTS

Of the original 26 subjects, 17 (65%) were interviewed and are the focus of this report. At follow-up, their ages ranged from 23 to 67years (mean=44years). Lifetime psychiatric comorbidity was common, but few had current psychiatric disorders at follow-up. Interest in shopping and spending decreased for eight (47%), stayed the same for five (29%), and increased for four (24%) subjects. Eleven subjects (65%) reported having attempted to quit their CS and three (18%) reported successfully doing so. Triggers for returning to CS included feelings of pressure/excitement/tension to shop; boredom; negative feelings such as sadness, depression, frustration, or anger; and the desire for positive feelings like happiness, power, or elation. Mean scores on the Compulsive Buying Scale (CBS) and the shopping version of the Yale-Brown Obsessive-Compulsive Scale showed overall improvement in CS symptoms (d=1.16 and d=-1.19, respectively); subjects were also less impulsive (d=-0.48). At baseline and follow-up, those with a lifetime mood disorder tended to have greater CS severity.

CONCLUSIONS

While the subjects showed overall improvement, most had ongoing symptoms of CS. The implications of the findings are discussed.

Examining the association between substance use disorder treatment and smoking cessation

AIMS

To examine rates of smoking cessation among people with last year substance use disorder (SUD) and how these rates differ among those that have ever received SUD treatment, those who have never received treatment and those who received last year out-patient and/or in-patient treatment.

DESIGN

Cross-sectional study based on 2009-12 National Survey on Drug Use and Health (NSDUH).

SETTING AND PARTICIPANTS

A total of 12 796 adult life-time smokers with any last year SUD. The sample is representative of the non-institutionalized US adult population.

MEASUREMENTS

We described smoking cessation rates by type of SUD and SUD treatment. We used a logistic regression model identifying the association between smoking cessation and life-time SUD treatment, adjusting for confounders. We also estimated models identifying the association between smoking cessation and last year out-patient and in-patient SUD treatment.

FINDINGS

Multivariate models identified significantly lower odds of quitting among those with life-time SUD treatment [odds ratio (OR)=0.561, P-value<0.001] compared with those without SUD treatment. Past year in-patient and out-patient SUD treatment was associated with lower odds of quitting in an unadjusted comparison (OR=0.559, P-value=0.043). In multivariate models, associations were suggestive of lower odds of quitting among those in treatment but there were no significant associations between smoking cessation and receiving in-patient and out-patient services (OR=0.753, P-value=0.312), in-patient services only (OR=0.397, P-value=0.192) or out-patient services only (OR=0.689, P-value=0.214).

CONCLUSIONS

Life-time smokers with past year substance use disorder who had ever received substance use disorder treatment appear to be less likely to quit smoking than those who have never received treatment. This pattern persists across type of substance use disorder.

"First Things First": What is the First Thing?

This op-ed piece comments on the down-side of an otherwise useful 12-step slogan, "First Things First," which generally refers to staying sober (not drinking or using no matter what). While important, there are environmental, microsocial, psychiatric, and neurobiological considerations that may place other needs at an equal or higher priority than sobriety per se. That is, other changes may be needed to set the stage for, or enhance efforts at sobriety, prior to or concurrent with attempting to quit one's drug of choice. Perhaps slogans should be considered in a broader context and not be taken too literally.

Testing the drug substitution switching-addictions hypothesis. A prospective study in a nationally representative sample

IMPORTANCE

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

OBJECTIVE

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

DESIGN, SETTING, AND PARTICIPANTS

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

MAIN OUTCOMES AND MEASURES

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

RESULTS

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

CONCLUSIONS AND RELEVANCE

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

Food-addiction scale measurement in 2 cohorts of middle-aged and older women

BACKGROUND

Excess weight is a major threat to public health. An addiction-like tendency toward certain foods may contribute to overeating.

OBJECTIVE

We aimed to describe the prevalence and associated characteristics in relation to a food-addiction scale in middle-aged and older women.

DESIGN

We examined the prevalence and associated characteristics of a food-addiction scale measure in a cross-sectional analysis of 134,175 women participating in 2 ongoing prospective cohort studies of US nurses.

RESULTS

Overall, 7839 (5.8%) of the women surveyed met the criteria for food addiction measured by using the modified Yale Food Addiction Scale. The prevalence of food addiction was 8.4% in the younger cohort of women aged 45-64 y and 2.7% in the older cohort of women aged 62-88 y. In the multivariate model, body mass index (BMI; in kg/m²) ≥ 35.0 (compared with 18.5-22.9) was associated with food addiction, a prevalence ratio (PR) of 15.83 (95% CI: 12.58, 19.91) in the younger cohort of women, and a PR of 18.41 (95% CI: 11.63, 29.14) in the older cohort of women. Several other demographic characteristics and other factors were associated with the food-addiction measure in both cohorts of women.

CONCLUSIONS

To our knowledge, for the first time in a large, US-based population of women, we documented the prevalence of food addiction by using a novel measurement scale in middle-aged and older women. The results may provide insight into the strong association between behavioral attributes of food consumption and the development of obesity.

Spirituality in addictions treatment: wisdom to know…what it is

Spirituality has long been integrated into treatments for addiction. However, how spirituality differs from other related constructs and implications for recovery among nonspiritual persons remains a source of discussion. This article examines ways in which spirituality is delineated, identifies variables that might mediate the relations between spirituality and recovery from substance abuse disorders, describes distinctions between spiritual and nonspiritual facets of addictions treatment, and suggests means to assist in further clarification of this construct.

Hidden addiction: Television

BACKGROUND AND AIMS

The most popular recreational pastime in the U.S. is television viewing. Some researchers have claimed that television may be addictive. We provide a review of the definition, etiology, prevention and treatment of the apparent phenomenon of television addiction.

METHODS

Selective review.

RESULTS

We provide a description of television (TV) addiction, including its negative consequences, assessment and potential etiology, considering neurobiological, cognitive and social/cultural factors. Next, we provide information on its prevention and treatment.

DISCUSSION AND CONCLUSIONS

We suggest that television addiction may function similarly to substance abuse disorders but a great deal more research is needed.

Perspectives of "functional failure"

The present dialogue piece briefly examines six perspectives of functional failure (individual-level, societal-level, life spheres impacted, number of severe consequences, attribution of consequences to drug misuse, and socio-environmental generalizability) as they might apply to seven degrees of drug misuse (constant, dependence, heavy, binging, controlled use, "dry," sober). Variation in judgments of failure is posited across the perspectives and across degrees of drug misuse.

Substance use after participation in laboratory studies involving smoked cocaine self-administration

OBJECTIVE

Laboratory studies in which drugs of abuse are self- or experimenter-administered to non-treatment-seeking research volunteers provide valuable data about new pharmacotherapies for substance use disorders, as well as behavioral and performance data for understanding the neurobiology of drug abuse. This paper analyzed follow-up data from six smoked cocaine self-administration laboratory studies, in order to determine whether changes in substance use occurred 1 and 3 months after study participation compared to pre-study baseline.

METHODS

Ninety-eight healthy, non-treatment-seeking cocaine users were admitted to inpatient and combined inpatient/outpatient studies lasting from 12 to 105 days. The studies allowed participants to self-administer repeated doses of smoked cocaine (0, 6, 12, 25, and/or 50mg per dose) on multiple occasions. Participants returned for follow-up at 1 and 3 months, at which time self-reported consumption of cocaine, alcohol, marijuana, and nicotine was assessed.

RESULTS

Compared to baseline ($374.04/week, S.D. $350.09), cocaine use significantly decreased at 1 month ($165.13/week, S.D. $165.56) and 3 months ($118.59/week, S.D. $110.48) after study participation (p<0.001; results based on the 39 participants who completed all 3 time points). This decrease was not accompanied by a change in other drug use, e.g., a compensatory increase in alcohol, marijuana or nicotine use.

CONCLUSION

Study participation was not associated with increased post-study cocaine, alcohol, marijuana, or nicotine use. Thus, human laboratory models of cocaine self-administration, conducted in non-treatment-seeking research volunteers, are relatively safe, and study participation does not exacerbate ongoing drug use.

Marijuana use and tobacco smoking cessation among heavy alcohol drinkers

BACKGROUND

Whereas problem drinking impedes smoking cessation, less is known whether marijuana use affects smoking cessation outcomes and whether smoking cessation treatment leads to changes in marijuana smoking.

METHODS

In a randomized clinical trial that recruited 236 heavy drinkers seeking smoking cessation treatment, we examined whether current marijuana smokers (n=57) differed from the rest of the sample in tobacco smoking and alcohol use outcomes and whether the patterns of marijuana use changed during treatment.

RESULTS

Half of the marijuana users reported smoking marijuana at least weekly (an average of 42% of possible smoking days), the other half used infrequently, an average of 5% of possible days. There were no significant differences between the marijuana use groups and non-users on smoking outcomes and marijuana use did not predict smoking lapses. All participants made large reductions in weekly alcohol consumption during the trial, with weekly marijuana users reducing their drinking by 47% and at a faster rate than non-marijuana users after the 8-week follow-up. Weekly marijuana smokers also steadily decreased their marijuana use over the course of the study (at 8-, 16-, and 26-week follow-ups) by more than 24%.

CONCLUSIONS

These data suggest that frequent marijuana smokers may benefit from smoking cessation interventions, even when marijuana use is not explicitly discussed. These individuals do not show any more difficulty than other cigarette smokers in making efforts to reduce tobacco smoking and in fact, make meaningful changes in marijuana use and heavy drinking. Future clinical trials should examine whether smoking cessation treatment that addresses both marijuana and tobacco smoking leads to substantial reductions in marijuana use.

A framework for the specificity of addictions

Research over the last two decades suggests that a wide range of substance and behavioral addictions may serve similar functions. Yet, co-occurrence of addictions has only been reported among a minority of addicts. "Addiction specificity" pertains to a phenomenon in which one pattern of addictive behaviors may be acquired whereas another is not. This paper presents the PACE model as a framework which might help explain addiction specificity. Pragmatics, attraction, communication, and expectation (PACE) variables are described, which may help give some direction to future research needs in this arena.

Drug addiction, love, and the higher power

This discussion piece suggests that reliance on a Higher Power in drug abuse recovery programs is entertained among some addicts for its psychobiological effects. Prayer, meditation, early romantic love, and drug abuse may have in common activation of mesolimbic dopaminergic pathways of the brain and the generation of intense emotional states. In this sense, reliance on a Higher Power may operate as a substitute addiction, which replaces the psychobiological functions formerly served by drug use. Implications of this perspective are discussed.

Tobacco use moderates the association between major depression and obesity

OBJECTIVE

Based on a maladaptive coping explanation, the relationship between major depression (MD) and obesity could be strong among nonsmokers, who may engage in unhealthy eating and sedentary behavior to cope with depression. By contrast, the MD-obesity association could be weak among smokers, who can use tobacco (instead of food or sedentary behavior) to cope with mood symptoms. This study examined smoking status and tobacco dependence as moderators of the MD-obesity link.

DESIGN

Correlational, cross-sectional population-based survey of 41,654 U.S. adults.

MAIN OUTCOME MEASURES

Obesity (body mass index [BMI] ≥30 kg/m2) and quantitative BMI value.

RESULTS

Current smoking status moderated the association between past-year MD and current obesity, as well as the link between MD and BMI value (ps ≤ .0001). MD predicted obesity and BMI among nonsmokers (ps < .0001) but did not do so in smokers (ps ≥ .10). Similar findings emerged with tobacco dependence as the moderator. Each finding persisted after accounting for demographics, psychiatric variables, and potential confounds.

CONCLUSION

Tobacco use characteristics appear to moderate the MD-obesity association in the U.S. population. These findings may shed light on the mechanisms linking MD and obesity and have implications for identifying which individuals may benefit most from obesity interventions that target depressive symptoms. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

Prevalence of the addictions: a problem of the majority or the minority?

An increasing number of research studies over the last three decades suggest that a wide range of substance and process addictions may serve similar functions. The current article considers 11 such potential addictions (tobacco, alcohol, illicit drugs, eating, gambling, Internet, love, sex, exercise, work, and shopping), their prevalence, and co-occurrence, based on a systematic review of the literature. Data from 83 studies (each study n = at least 500 subjects) were presented and supplemented with small-scale data. Depending on which assumptions are made, overall 12-month prevalence of an addiction among U.S. adults varies from 15% to 61%. The authors assert that it is most plausible that 47% of the U.S. adult population suffers from maladaptive signs of an addictive disorder over a 12-month period and that it may be useful to think of addictions as due to problems of lifestyle as well as to person-level factors.

Relationship of high school and college sports participation with alcohol, tobacco, and illicit drug use: a review

This study provides an exhaustive review of 34 peer-reviewed quantitative data-based studies completed on high school and college sports involvement and drug use. The studies reviewed suggest that participation in sport is related to higher levels of alcohol consumption, but lower levels of both cigarette smoking and illegal drug use. Additional research is needed in this domain to further elucidate the relationship between these variables.