Sleep alterations in substance use disorders: a systematic review and meta-analysis

Practice Parameter for the Assessment and Treatment of Children and Adolescents With Substance Use Disorders

Substance use disorder (SUD) among women of reproductive age is a complex public health problem affecting a diverse spectrum of women and their families, with potential consequences across generations. The goals of this study were 1) to describe and compare the prevalence of patterns of injury requiring emergency department (ED) visits among SUD-positive and SUD-negative women and 2) among SUD-positive women, to investigate the association of specific categories of injury with type of substance used. This study was a secondary analysis of a large, multisource health care utilization data set developed to analyze SUD prevalence, and health and substance abuse treatment outcomes, for women of reproductive age in Massachusetts, 2002 through 2008. Sources for this linked data set included diagnostic codes for ED, inpatient, and outpatient stay discharges; SUD facility treatment records; and vital records for women and for their neonates. Injury data (ICD-9-CM E-codes) were available for 127,227 SUD-positive women. Almost two-thirds of SUD-positive women had any type of injury, compared to 44.8% of SUD-negative women. The mean (±SD) number of events also differed (2.27 ± 4.1 for SUD-positive women vs. 0.73 ± 1.3 for SUD-negative women, p < 0.0001). For four specific injury types, the proportion injured was almost double for SUD-positive women (49.3% vs 23.4%), and the mean (±SD) number of events was more than double (0.72 ± 0.9 vs. 0.26 ± 0.5, p < 0.0001). The numbers and proportions of motor vehicle incidents and falls were significantly higher in SUD-positive women (22.5% vs. 12.5% and 26.6% vs. 11.0%, respectively), but the greatest differences were in self-inflicted injury (11.5% vs. 0.8%; mean ± SD events = 0.19 ± 0.9 vs. 0.009 ± 0.2, p < 0.0001) and purposefully inflicted injury (11.5% vs 1.9%, mean ± SD events = 0.18 ± 0.1 vs. 0.02 ± 0.2, p < 0.0001). In each of the injury categories that we examined, injury rates among SUD-positive women were lowest for alcohol disorders only and highest for alcohol and drug disorders combined. Among 33,600 women identified as using opioids, 2,132 (6.3%) presented to the ED with overdose. Multiple overdose visits were common (mean ± SD = 3.67 ± 6.70 visits). After adjustment for sociodemographic characteristics, psychiatric history, and complex/chronic illness, SUD remained a significant risk factor for all types of injury, but for the suicide/self-inflicted injury category, psychiatric history was by far the stronger predictor. The presence of SUD increases the likelihood that women in the 15- to 49-year age group will present to the ED with injury. Conversely, women with injury may be more likely to be involved in alcohol abuse or other substance use. The high rates of injury that we identified among women with SUD suggest the utility of including a brief, validated screen for substance use as part of an ED injury treatment protocol and referring injured women for assessment and/or treatment when scores indicate the likelihood of SUD.

DSM-5 substance use disorder: how conceptual missteps weakened the foundations of the addictive disorders field.

Sleep quality in patients studied with laboratory-based polysomnography may differ from sleep quality in patients studied at home but remains clinically relevant and important to describe. We assessed objective sleep quality and explored factors associated with poor sleep in patients undergoing laboratory-based polysomnography. We reviewed diagnostic polysomnography studies from a 10-year period at a single sleep center. Total sleep time (TST) and sleep efficiency (SE) were assessed as markers of sleep quality. Poor sleep was defined as TST ≤ 4 hours or SE ≤ 50%. Multivariable analysis was performed to determine associations between objective sleep quality as an outcome and multiple candidate predictors including age, sex, race, body mass index, comorbidities, severity of obstructive sleep apnea, and central nervous system medications. Among 4957 patients (age 53 ± 15 years), average TST and median SE were 5.8 hours and 79%, respectively. There were 556 (11%) and 406 (8%) patients who had poor sleep based on TST and SE, respectively. In multivariable analysis, those who were older (per 10 years: 1.48 [1.34, 1.63]), male (1.38 [1.14,1.68]), and had severe obstructive sleep apnea (1.76 [1.28, 2.43]) were more likely to have short sleep. Antidepressant use was associated with lower odds of short sleep (0.77 [0.59,1.00]). Older age (per 10 years: 1.48 [1.34, 1.62]), male sex (1.34 [1.07,1.68]), and severe obstructive sleep apnea (2.16 [1.47, 3.21]) were associated with higher odds of poor SE. We describe TST and SE from a single sleep center cohort. Multiple demographic characteristics were associated with poor objective sleep in patients during laboratory-based polysomnography. Harrison EI, Roth RH, Lobo JM, et al. Sleep time and efficiency in patients undergoing laboratory-based polysomnography. J Clin Sleep Med. 2021;17(8):1591-1598.

Substance use and substance use disorders in recently deployed and never deployed soldiers

Sleep quality and duration – Potentially modifiable risk factors for Coronary Artery Disease?

Several large-scale studies examining outcome predictors across various substance use treatments indicate a need to focus on psychiatric comorbidity as a very important predictor of poorer SUD treatment involvement and outcome. We have previously argued that current cognitive-behavioral treatments (CBT) approaches to SUD treatment do not focus on the necessary content in treatment in order to effectively address specific forms of psychiatric comorbidity, and thus only provide clients with generic coping strategies for managing psychiatric illness (as would be achieved in other SUD treatment approaches; Conrod et al., 2000). Furthermore, following our review of the literature on dual-focused CBT treatment programs for concurrent disorders in this article, we argue that combining CBT-oriented SUD treatments with specific CBT treatments for psychiatric disorders is not as straightforward as one would think. Rather, it requires very careful consideration of the functional relationship between specific disorders, patient reactions to specific treatment components, and certain barriers to treatment in order to achieve an integrated dual-diagnosis focus in treatment that is meaningful and to which clients can adhere. Keywords: substance abuse; cognitive-behavioral; diagnosis; psychiatric disorders; comorbidity The efficacy of cognitive-behavioral treatments (CBT) for substance use disorders (SUDs) is now indisputable. The articles presented in the current special issue on CBT approaches such as relapse prevention, guided self-change, behavioral couples therapy, and the community reinforcement approach, review evidence that clearly establishes that each produces significant improvements in SUD symptoms. The benefits of these various CBT approaches to SUD treatment are now also revealing themselves in other domains, such as in improving employment (Meyers, Villanueva, & Smith, this issue), family discord and partner aggression (Fals-Stewart et al., this issue), optimism and thought suppression (Witkiewitz, Mariait, & Walker, this issue), substance abuse in special populations (Sobell & Sobell, this issue), adaptive coping (Ouimette, Finney, & Moos, 1999), psychosocial functioning (Ouimette et al, 1999), criminal activity and use of health care services (Sacks & DeLeon, 1997), and comorbid psychiatric symptoms (Brown & Schuckit, 1988). Several large-scale studies examining outcome predictors across various substance use treatments (MacLellan et al., 1994; Ouimette, Gima, Moos, & Finney, 1999; Project MATCH, 1997) are now indicating that theoretical orientation of the treatment is not a strong determinant of SUD treatment outcome. Nonetheless, such studies have also identified a need to focus on psychiatric coniorbidity as a very important predictor of poorer SUD treatment involvement and outcome. Several reports indicate that individuals with SUDs who demonstrate psychiatric comorbidity are less likely to access addiction treatment services (Wu, Kouzis, & Leaf, 1999), demonstrate poor compliance with traditional substance use treatments (Drake, Mueser, Clark, & Wallach, 1996), and generally show a lesser response to such treatments with respect to rates of relapse to substance abuse, employment status, and psychosocial functioning (McLellan et al., 1994; Ouimette, Gima, Moos, & Finney, 1999; Project MATCH, 1997). The current article will examine the literature on the outcome of CBT approaches for the SUD client who suffers from a concurrent mental disorder. MODELS OF COMORBIDITY: How ARE SUD AND MENTAL DISORDERS RELATED? Before we examine different CBT approaches to treatment of concurrent SUD and mental disorders, it is worthwhile to consider various theoretical models of the relationship between SUDs and mental disorders. These models can inform ways of conceptualizing primary targets of therapy for dually diagnosed patients. The first model suggests that chronic and severe substance abuse is a strong contributor to the development of psychopathology and accounts for much of the co-occurrence between SUDs and other mental disorders. …

While there is broad recognition of the high societal costs of substance use disorders (SUD), treatment rates are low. We examined whether, in the United States, participants with substance or alcohol use disorder would report a greater willingness to enter SUD treatment located in a primary care setting (primary care) or more commonly found specialty care setting in the United States (usual care). Randomized survey-embedded experiment. US web-based research panel in which participants were randomized to read one-paragraph vignettes describing treatment in usual care (specialty drug or alcohol treatment center), primary care or collaborative care within a primary care setting. A total of 42451 panelists aged 18+ were screened for substance or alcohol use disorder using validated diagnostic criteria. Participants included 344 with a substance use disorder and 634 with an alcohol use disorder not in treatment with no prior treatment history. Willingness to enter treatment across vignettes by condition. Among participants with a substance use disorder, 24.6% of those randomized to usual care reported being willing to enter drug treatment compared with 37.2% for primary care [12.6 percentage point difference; 95% confidence interval (CI)=0.8, 24.4) and 34.0% for collaborative care (9.4 percentage point difference; 95% CI=-2.0, 20.8). Among participants with an alcohol use disorder, 17.6% of those randomized to usual care reported being willing to enter alcohol treatment compared with 20.3% for primary care (2.6 percentage point difference; 95% CI=-4.9, 10.1) and 20.8% for collaborative care (3.1 percentage point difference; 95% CI=-4.3, 10.6). The most common reason for not being willing to enter drug (63%) and alcohol (78%) treatment was the belief that treatment was not needed. In the United States, people diagnosed with substance or alcohol use disorders appear to be more willing to enter treatment in a primary care setting than in a specialty drug treatment center. Expanding availability of primary care-based substance use disorder treatment could increase treatment rates in the United States.

This study investigated the role of personality and stress in the development of substance use disorder among substance use disorder patients in Kaduna State. A cross sectional design was adopted in the study and participants were 47 substance use disorder (SUD) patients (42 males and 5 females) between the ages of 18 – 40 years. They were drawn from the substance use disorder patients of Federal Neuropsychiatric Hospitals Kaduna using purposive sampling method in Kaduna. The questionnaire measures; Social and Psychological Determinants of Drug Abuse Questionnaire [1]. ‘The Big Five Inventory’ (BFI) as developed by John and Srivastava [2], Drug Abuse Screening Test (DAST-28) developed by Skinner [3] and The Life Events Inventory’ [4] were completed by the participants. Prediction for the development of drugs use was considered using neuroticism, extraversion, and openness to experience, agreeability, conscientiousness and stress. While cross-sectional design was adopted for the study. Linear Regression Analysis and Hierarchical multiple regression analysis was applied to analyze the data. Results showed that neuroticism did not significantly predict substance use disorder (R= .040; F= .072, P &gt; .05) thus, accounted for about 0.2% variance for the substance use disorder among clients. While extraversion significantly predict substance use disorder (R= .303; F= 4.557, P &lt; .05) thus, accounted for about 9.2% variance for the substance use disorder among clients. Openness to experience did not significantly predict substance use disorder (R= .235; F= 2.625, P &gt; .05) thus, accounted for about 5.5% variance for the substance use disorder among clients. Agreeableness did not significantly predict substance use disorder (R= .241; F= 2.772, P &gt; .05) thus, accounted for about 5.8% variance for the substance use disorder among clients. Also, the results indicates a no statistically significantly positive impact of agreeableness (β= .345 t= 1.665, p &gt; .05) on substance use disorder. Conscientiousness did not significantly predict substance use disorder (R= .257; F= 3.024, P &gt; .05) thus, accounted for about 6.3% variance for the substance use disorder among clients. Stress did not significantly predict substance use disorder (R= .020; F= .018, P &gt; .05) thus, accounted for no variance for substance use disorder among clients. In hypothesis seven, it was shown that the first model was jointly significant F (5, 41) = 3.159, P&lt; 0.05, R2 = 0.280. Both conscientiousness and extraversion were the significant predictors of substance use disorder. It is suggested that, clinicians treating the patients at the hospital should endeavor to assess personality factors and substance abuse disorders to ascertain their co-morbidity status and if found, should be treated for both at the same time to enhance better quality of life and reduce susceptibility to substance use disorder.

Utilizing SBIRT as a Framework for Transforming How We Think About Prevention and Early Intervention for Youth and Young Adults

This is the second of two Special Issues of Substance Abuse devoted to mindfulness meditation based interventions for substance use disorders (SUDs) and their spectrum. first part was published as the December 2009 issue of Substance Abuse (1). It featured five articles describing results of studies evaluating mindfulness based interventions: a systematic review of literature on this topic, by Zgierska et al. (2), and four original research papers by Bowen et al. (3), Brewer et al. (4), Vidrine et al. (5) and Waters et al. (6). Combined, findings from these pilot-level studies suggest that mindfulness meditation based interventions may be efficacious for SUDs. This second Special Issue further adds to the mindfulness literature by presenting results of five additional studies that evaluated effects of mindfulness-based interventions in a range of substance-abusing client populations. Papers in this issue illustrate the ways in which mindfulness practice has been combined with other behavioral treatments and/or adapted to meet the needs of specific client populations. In their study: Linguistic analysis to assess the effect of a mindfulness intervention on self-change for adults in substance use recovery, Liehr and colleagues used an innovative method to measure self-change in participants in a therapeutic community who received Mindfulness Based Therapeutic Community (MBTC) versus treatment as usual. They used a linguistic analysis method applied to participant-written stories of stress and found that the MBTC group used fewer negative words than the control group over all time points. Britton and colleagues, in the study: The Contribution of Mindfulness Practice to a Multicomponent Behavioral Sleep Intervention Following Substance Abuse Treatment in Adolescents, found that mindfulness practice was associated with improved sleep, psychological health and reduced substance use. In Psychosocial Treatment for Methamphetamine Use Disorders: a preliminary randomized controlled trial of cognitive behavior therapy (CBT) and acceptance and commitment therapy (ACT), Smout and colleagues found that, although ACT did not improve treatment outcomes or attendance compared to CBT, it may be a viable therapeutic alternative for methamphetamine use disorders. In their article, Development of an Acceptance-based Coping Intervention for Alcohol Dependence Relapse Prevention, Vieten and colleagues describe the development and pilot-testing of a mindfulness-based relapse prevention intervention for alcohol dependent individuals who stopped drinking within the past 6 months. Amaro and colleagues, in their study: Addiction Treatment Intervention: An Uncontrolled Prospective Pilot Study of Spiritual Self-Schema Therapy with Latina Women, noted high rates of intervention acceptability, and positive changes in outcomes relevant to HIV prevention and recovery from addiction. Although conclusive data for mindfulness meditation based interventions as therapies for SUDs are lacking, the preliminary evidence reported in these and prior studies suggests their efficacy. promise of mindfulness based therapies is supported by the consistency of positive results demonstrated across different study designs, intervention modalities, subject populations and addictive disorders treated (2). Additional support for the potential efficacy of these interventions in SUDs can be drawn from the results of studies of other clinical conditions; mindfulness based therapies have been shown effective or potentially effective for a variety of medical and mental health disorders, including stress, anxiety, depression, emotion dysregulation, avoidance coping,(7–12) all known risk factors for relapse in SUDs (13,14). In this context, mindfulness meditation based interventions may be particularly helpful for patients with co-occurring substance use and mental health disorders (dual diagnosis). In addition, mindfulness based interventions appear safe, satisfying to clients and may have long-lasting effects in the context of continued meditation practice (2,7) – all vital qualities of an ideal treatment. success of mindfulness based interventions and the unsatisfactory outcomes of many existing therapeutic modalities indicate that the time is right for, rigorous assessment of mindfulness based therapies for addictive disorders.

To assess the sleep detection and staging validity of a non-contact, commercially available bedside bio-motion sensing device (S+, ResMed) and evaluate the impact of algorithm updates. Polysomnography data from 27 healthy adult participants was compared epoch-by-epoch to synchronized data that were recorded and staged by actigraphy and S+. An update to the S+ algorithm (common in the rapidly evolving commercial sleep tracker industry) permitted comparison of the original (S+V1) and updated (S+V2) versions. Sleep detection accuracy by S+V1 (93.3%), S+V2 (93.8%), and actigraphy (96.0%) was high; wake detection accuracy by each (69.6%, 73.1%, and 47.9%, respectively) was low. Higher overall S+ specificity, compared to actigraphy, was driven by higher accuracy in detecting wake before sleep onset (WBSO), which differed between S+V2 (90.4%) and actigraphy (46.5%). Stage detection accuracy by the S+ did not exceed 67.6% (for stage N2 sleep, by S+V2) for any stage. Performance is compared to previously established variance in polysomnography scored by humans: a performance standard which commercial devices should ideally strive to reach. Similar limitations in detecting wake after sleep onset (WASO) were found for the S+ as have been previously reported for actigraphy and other commercial sleep tracking devices. S+ WBSO detection was higher than actigraphy, and S+V2 algorithm further improved WASO accuracy. Researchers and clinicians should remain aware of the potential for algorithm updates to impact validity. A commentary on this article appears in this issue on page 935.

Medicolegal Issues with Reference to NDPS and MHCA in Management and Rehabilitation of Persons with Substance Use Disorders.

Poster Abstracts from the AAAP 20th Annual Meeting and Symposium

IntroductionChronic obstructive pulmonary disease (COPD) patients have poor sleep quality, longer time to sleep onset and frequent nocturnal awakenings. Poor sleep quality in COPD is associated with poor quality of life (QoL), increased exacerbations and increased mortality. Pulmonary rehabilitation (PR) improves functional status and QoL in COPD but effects on sleep are unclear. PR improves subjective sleep quality but there is paucity of objective actigraphy data. We hypothesized that actigraphy would demonstrate subjective and objective improvement in sleep following PR. Paired comparisons (t-test or Wilcoxon-signed-rank test) were performed before and after PR data on all variables.MethodsThis retrospective study of COPD patients undergoing PR utilized actigraphy watch recordings before and after 8-weeks of PR to assess changes in sleep variables including total time in bed (TBT), total sleep time (TST), sleep onset latency (SOL), sleep efficiency (SE), wakefulness after sleep onset (WASO) and total nocturnal awakenings. A change in Pittsburg Sleep Quality Index (PSQI) was a secondary outcome. PSQI was performed before and after PR.ResultsSixty-nine patients were included in the final analysis. Most participants were male (97%), non-obese (median BMI 27.5, IQR 24.3 to 32.4 kg/m2) with an average age of 69 ± 8 years and 71% had severe COPD (GOLD stage 3 or 4). Prevalence of poor sleep quality (PSQI ≥5) was 86%. Paired comparisons did not show improvement in actigraphic sleep parameters following 8-weeks PR despite improvements in 6-min-walk distance (6MWD, mean improvement 54 m, 95% CI 34 m to 74 m, p<0.0001) and St. George’s Respiratory Questionnaire scores (SGRQ, mean improvement 7.7 points, 95% CI 5.2 to 10.2, p<0.0001). Stratified analysis of all sleep variables by severity of COPD, BMI, mood, mental status, 6-MWD and SGRQ did not show significant improvement after PR. In Veterans with poor sleep quality (PSQI ≥ 5), PR improved subjective sleep quality (PSQI, mean difference 0.79, 95% CI 0.07 to 1.40, p = 0.03).ConclusionsPulmonary rehabilitation improved subjective sleep quality in Veterans who had poor sleep quality at the beginning of the PR but did not improve objective sleep parameters by actigraphy. Our findings highlight the complex interactions among COPD, sleep and exercise.