History Of Substance Misuse Research Articles

P01-383 - Liaison psychiatry in a spinal cord injury unit: characteristics of patients with acute traumatic spinal cord injury (ATSCI)

IntroductionDespite of the evidence of high psychopathological disorders in patients with ATSCI, few data are available on their psychiatric morbidity prior to the injury.ObjectivesIdentify psychiatric morbidity pre-post ATSCI in a sample of patients admitted in the Spinal Injuries Unit of the Vall d’ Hebron University Hospital in Barcelona (Spain).Material and methods54 patients with ATSCI patients were admitted between 1st. October 2009 and 1st. October 2010. SPSS (version 16.1) was used to analyze the data.ResultsSeventy-six percent of the inpatients with ATSCI (41 cases) were evaluated by the psychiatrist and constitute the study sample. Twenty-seven (66%) were male and 14 (33%) female. The average age of the sample was 41 years with younger males (p < 0.05).Reasons for ATSCI in males were traffic accident (26%), accidental falls and sports accidents (both 18.5%). In women were suicidal attempt by precipitation, fall accident (28.6% both) and traffic accident (21.4%).41% of men versus 14% of women had a history of substance misuse (p < 0.01) while 64% of women versus the 14.8% of males had a prior psychiatric disorder (p < 0.01). 72.5% of men with ATSCI caused by traffic accident had used substances prior to the accident, those association was not found for women.91% of patients underwent psychopharmacological intervention.ConclusionsATSCI patients exhibit high psychiatric morbidity and require specialized assessment. The high incidence of substance use associated with road traffic injuries suggests the need to identify risk groups in order to establish effective preventive measures.

Predictors of institutional behavioural disturbance and offending in the community among young offenders

This study aimed to evaluate the contribution of conduct disorder (CD), substance misuse and attention deficit hyperactivity disorder (ADHD) symptoms to the history of delinquency, current institutional behavioural problems and critical incidents (CI). Fifty-four adolescents in a secure facility were screened for ADHD and CD and completed the Maudsley violence questionnaire, the disruptive behaviour and social problems scale and the self-report delinquency scale. Substance misuse history as well as CI over the previous 10 weeks were also recorded. Hierarchical multiple regressions showed that substance misuse and violent cognitions were the best predictors of self-reported delinquency. In contrast, ADHD predicted disruptive institutional behaviour above and beyond that of CD and substance misuse. The findings suggest that ADHD symptoms are important in predicting institutional behavioural disturbance, whereas substance misuse and violent cognitions are better predictors of delinquency in the community.

Long-term misuse of zopiclone in an alcohol dependent woman with a history of anorexia nervosa: a case report

IntroductionThe Z-drugs, zaleplon, zopiclone and zolpidem, are short-acting hypnotics which act at the same receptor as the benzodiazepines, but seemingly without the potential for misuse and the development of dependence of the older benzodiazepines. However, with increased prescribing of Z-drugs, reports of misuse and possible dependence began to appear in the literature, particularly in people with a history of substance misuse and comorbid psychiatric illness. Here we report the case of a woman with a history of chronic zopiclone use and anorexia nervosa, admitted for alcohol detoxification.Case presentationA 31-year old Caucasian British woman with a history of long-term zopiclone use and anorexia nervosa was admitted as an inpatient for a ten-day alcohol detoxification. Her weekly (four days out of seven) intake of alcohol was 180 units and her daily intake of zopiclone, 30 mg. Apart from a short period five years ago, she had been taking zopiclone for 13 years at daily doses of up to 90 mg. She admitted to using 'on top' of her prescribed medication, purchasing extra tablets from friends or receiving them gratis from her partner. After detoxification from alcohol and zopiclone, she was prescribed diazepam which she found ineffectual and voiced her intention of returning to zopiclone on leaving the hospital.ConclusionZopiclone is generally regarded as safer than benzodiazepines, however, this particular individual, who was using high doses of zopiclone over many years, may provide further evidence of a risk of dependency when this drug is prescribed for substance users with a comorbid psychiatric illness.

A community engagement orientation among people with a history of substance misuse and incarceration

• Summary: Community engagement, or acting on behalf of the collective, can provide a variety of rewards. Nonetheless, people who misuse substances are less likely to endorse such goals as making a contribution to society or correcting systemic inequities. As people modify their use of drugs or alcohol, they have been shown to draw purpose from community engagement. This mixed methods study examined contributors to a community engagement orientation among 68 respondents with a history of substance misuse and incarceration.• Findings: In the initial qualitative analysis, four themes emerged related to the respondents’ sense of purpose in life. The theme most frequently mentioned, community engagement, is the focus of this study. Discriminant analyses revealed that those endorsing community engagement goals were older at the onset of heavy drinking, more likely to have received public assistance, more highly educated, as were their mothers, manifested greater self-esteem, and had previously been involved in an organization addressing community concerns.• Applications: Social workers might assist clients in identifying and manifesting what they believe to be their purpose in life, with particular attention to community engagement. In this way, they may utilize the wisdom gained from challenging experiences to benefit others and bring about social change.

Economic Grand Rounds: The Cost of Collaboration: Predictors of Hours Spent in Collateral Contacts

Collateral contacts, while at the heart of wraparound care, are time consuming and often nonreimbursable. This column presents data from a study of 1,639 child patients. It examined whether the amount of time that clinicians spent in collateral activities could be predicted by demographic variables, child diagnosis, parental psychopathology or family history of mental disorders, or staff variables. For every 60 minutes of direct patient contact, approximately 20 minutes of collateral activities were performed by the clinician. The best predictors of spending time in collateral activities were having parents who were not married, a mother with depression or anxiety, a child patient with a history of substance misuse or abuse, and a child patient with a history of maltreatment.

Economic Grand Rounds: The Cost of Collaboration: Predictors of Hours Spent in Collateral Contacts

Collateral contacts, while at the heart of wraparound care, are time consuming and often nonreimbursable. This column presents data from a study of 1,639 child patients. It examined whether the amount of time that clinicians spent in collateral activities could be predicted by demographic variables, child diagnosis, parental psychopathology or family history of mental disorders, or staff variables. For every 60 minutes of direct patient contact, approximately 20 minutes of collateral activities were performed by the clinician. The best predictors of spending time in collateral activities were having parents who were not married, a mother with depression or anxiety, a child patient with a history of substance misuse or abuse, and a child patient with a history of maltreatment. (Psychiatric Services 61:440–442, 2010)

An exploratory study of the relationship between parental attitudes and behaviour and young people's consumption of alcohol

BackgroundConcern is growing regarding frequent and excessive misuse of alcohol by young people. The average age at which young people in Europe start to drink is twelve and a half, and during the last decade, the quantity of alcohol consumed by younger adolescents in the UK has increased. Families are known to play an important role in shaping young people's alcohol misuse, although family risk and protective factors associated with misuse in a UK context are in need of further investigation.MethodsThe study used a cross-sectional design, involving secondary analyses of self-completion questionnaire responses from 6,628 secondary school children (i.e. aged 11-16 years), from 12 schools within an urban location in Wales. Items relating to family functioning and perceived parental attitudes were first subjected to factor analysis. Associations of family closeness and conflict, parental monitoring and attitudes and family history of substance misuse with children's self reported alcohol consumption were examined using logistic regression analyses.ResultsApproximately three quarters of respondents reported having tried alcohol, most of whom had first tried alcohol aged 12 or under. Parental monitoring and family closeness were positively correlated with one another and were both associated with significantly lower levels of drinking behaviours. Family violence and conflict, more liberal parental attitudes towards substance use and towards alcohol and petty crime, and family history of substance misuse were positively correlated with one another and with higher levels of drinking behaviours. Parental monitoring was identified as the family functioning factor most consistently associated with drinking behaviour in multivariate analyses.ConclusionsSignificant relationships were found between young people's drinking behaviours and perceptions of risk and protective factors in the family environment. Parental monitoring was strongly associated with family closeness and appeared to form one part of a parenting style of more general communication and regulation of children's behaviour. Findings support the need for alcohol misuse prevention interventions which address risk and protective factors within the family setting. Timing of such prevention work should be related both to the development of family relationships and the age at which young people begin drinking alcohol.

The impact of substance use on brain structure in people at high risk of developing schizophrenia.

Ventricular enlargement and reduced prefrontal volume are consistent findings in schizophrenia. Both are present in first episode subjects and may be detectable before the onset of clinical disorder. Substance misuse is more common in people with schizophrenia and is associated with similar brain abnormalities. We employ a prospective cohort study with nested case control comparison design to investigate the association between substance misuse, brain abnormality, and subsequent schizophrenia. Substance misuse history, imaging data, and clinical information were collected on 147 subjects at high risk of schizophrenia and 36 controls. Regions exhibiting a significant relationship between level of use of alcohol, cannabis or tobacco, and structure volume were identified. Multivariate regression then elucidated the relationship between level of substance use and structure volumes while accounting for correlations between these variables and correcting for potential confounders. Finally, we established whether substance misuse was associated with later risk of schizophrenia. Increased ventricular volume was associated with alcohol and cannabis use in a dose-dependent manner. Alcohol consumption was associated with reduced frontal lobe volume. Multiple regression analyses found both alcohol and cannabis were significant predictors of these abnormalities when simultaneously entered into the statistical model. Alcohol and cannabis misuse were associated with an increased subsequent risk of schizophrenia. We provide prospective evidence that use of cannabis or alcohol by people at high genetic risk of schizophrenia is associated with brain abnormalities and later risk of psychosis. A family history of schizophrenia may render the brain particularly sensitive to the risk-modifying effects of these substances.

Clinical predictors and patterns of absconding in a low secure challenging behaviour mental health unit

Aims : To compare the clinical characteristics of patients who absconded and those who did not abscond; and to show the types of absconding behaviour in a low secure challenging behaviour mental health unit. Method : A retrospective case control study was conducted. Details of the absconding incidents were collected from an electronic incident database. Clinical predictors of patients who absconded (cases) and those who did not (controls) were compared. Statistical analysis was performed to determine statistical significance of the observed differences. Results : 80 admissions resulted from 78 patients during a period of 6½ years. 22% of the inpatients absconded from the unit. 84% of the incidents occurred while patients were utilising their unescorted leave. Only one patient escaped from the building. No serious incidents resulted from any of the abscondings. On univariate analysis, the following predictors were more likely to be statistically associated with patients who absconded from the unit: a history of absconding behaviour and a history of substance misuse or dependence. A history of non-compliance with treatment, a history of sexually inappropriate behaviour and a history of childhood conduct problems showed a trend towards statistical significance. Conclusion : The clinical characteristics of patients who abscond from low secure units show similarities with those who abscond from other psychiatric inpatient settings. Declaration of interests : None.

Lifetime history of substance misuse in first‐episode psychosis: prevalence and its influence on psychopathology and onset of psychotic symptoms

Substance misuse (SM) (drug/alcohol dependence or abuse) in psychotic illness is an increasingly recognized problem. We aimed to estimate the prevalence and examine the influence of SM on age at onset of psychosis and psychopathology among patients with first-episode psychosis. One hundred seventy-one consecutive patients with first-episode psychosis were assessed. SM, age of onset of psychosis and psychopathology were determined using valid instruments. Seventy-seven (46%) patients had a lifetime history of SM and were predominately males, had more positive symptoms, and in the majority of cases (84%), started misusing substances before the onset of psychosis (SM-BP). There was no difference in age of onset between patients with SM-BP and the rest of the sample. Lifetime history of SM is common and may influence psychopathology, but does not appear to influence or bring forward the age at onset of psychotic symptoms.

An evaluation of group work as an intervention to reduce the impact of substance misuse for offender patients in a high security hospital

Despite established epidemiological links between substance misuse, mental illness, and violent behaviour, the impact of interventions for offender patients is not well understood. The high security hospital is a unique environment which restricts access to substances while attempting to address substance misuse behaviours. In this study, 22 high secure patients with a history of substance misuse participated in a CBT group-work programme. They were assessed pre and post with the Stages of Change Readiness and Treatment Eagerness Scale, and the Psychological Inventory of Drug-Based Thinking Styles. A small number also engaged in a qualitative review of the impact of participation. Treatment had a positive significant effect on patients' perceptions and awareness of substance misuse behaviours and associated problems. Some patients reported particular benefits from engaging in psycho-drama relapse prevention skills training. One of the patients who refused the group subsequently tested positive for a urine drug screen test. Overall, results indicate some positive aspects of a substance misuse intervention with male high secure patients. However, acknowledged limitations highlight the need for further research to support these findings, to monitor the behaviours in high security of former substance misusers, and for maintenance/ongoing work for those transferred to conditions of lower security.

S65-01 Chronic non cancer pain and misuse and dependence of analgesic drugs

As the chronic disease model is now accepted as the model to treat individuals in the community in the UK, it has become important to recognise that individuals tend to present with more than one concomittant problem (comorbidity). A increasing patient centred approach to treatment and recovery has helped to recognise the dual concept of pain and dependence within the clinical environment. There is an ever increasing prevalence of this dual presentation and this has helped to effectively manage individuals with a substance misuse history and associated chronic pain and others treated for their chronic pain with strong analgesic and subsequently experiencing substance misuse and dependence problems.This presenation aims to provide the literature overview of these populations, clinical characteristics and problems presenting in a pain and dependence clinic in Scotland. Several models of practice will also be presented.

Getting out and staying out: does substance use treatment have an effect on outcome of mentally disordered offenders after discharge from medium secure service?

Although a majority of mentally disordered offenders have substance use problems (Wright et al, 2002), as yet there have been few attempts to understand the human and financial cost of this problem in forensic mental health services. The current study examined the effect of a drugs and alcohol programme (Derry, 2005) on re‐admission rates. As would be expected, patients with a history of substance misuse were found to be more likely to use drugs and alcohol on discharge. This group of patients were found to be at increased risk of re‐admission to forensic mental health services. Patients who participated in a 24‐session cognitive behavioural substance use programme were found to spend significantly more time in the community (89%) than those who did not (77%). These initial findings suggest that treatment for drug and alcohol problems can be effective in reducing re‐admission rates, and warrants further investigation.

Socio-demographic and clinical characteristics of re-presentation to an Australian inner-city emergency department: implications for service delivery

BackgroundPeople who have complex health care needs frequently access emergency departments for treatment of acute illness and injury. In particular, evidence suggests that those who are homeless, or suffer mental illness, or have a history of substance misuse, are often repeat users of emergency departments. The aim of this study was to describe the socio-demographic and clinical characteristics of emergency department re-presentations. Re-presentation was defined as a return visit to the same emergency department within 28 days of discharge from hospital.MethodsA retrospective cohort study was conducted of emergency department presentations occurring over a 24-month period to an Australian inner-city hospital. Characteristics were examined for their influence on the binary outcome of re-presentation within 28 days of discharge using logistic regression with the variable patient fitted as a random effect.ResultsFrom 64,147 presentations to the emergency department the re-presentation rate was 18.0% (n = 11,559) of visits and 14.4% (5,894/40,942) of all patients. Median time to re-presentation was 6 days, with more than half occurring within one week of discharge (60.8%; n = 6,873), and more than three-quarters within two weeks (80.9%; n = 9,151). The odds of re-presentation increased three-fold for people who were homeless compared to those living in stable accommodation (adjusted OR 3.09; 95% CI, 2.83 to 3.36). Similarly, the odds of re-presentation were significantly higher for patients receiving a government pension compared to those who did not (adjusted OR 1.73; 95% CI, 1.63 to 1.84), patients who left part-way through treatment compared to those who completed treatment and were discharged home (adjusted OR 1.64; 95% CI, 1.36 to 1.99), and those discharged to a residential-care facility compared to those who were discharged home (adjusted OR 1.46: 95% CI, 1.03 to 2.06).ConclusionEmergency department re-presentation rates cluster around one week after discharge and rapidly decrease thereafter. Housing status and being a recipient of a government pension are the most significant risk factors. Early identification and appropriate referrals for those patients who are at risk of emergency department re-presentation will assist in the development of targeted strategies to improve health service delivery to this vulnerable group.

Northern Ireland Tier 4 Child and Adolescent Mental Health Services: A Survey of Admissions to the Child and Family Centre, January 2001–April 2004

In-patient care, provided at Tier 4 level, is a specialised field aimed at provision of high-quality care for young people with serious mental health problems. This survey investigates how the regional in-patient unit for children in Northern Ireland functioned. A retrospective investigation was performed of cases admitted under the care of the lead clinician in the unit during the three-year period from January 2001 until April 2004. There were 115 admissions to in-patient care during the period investigated, 14 of these being re-admissions. Sixty-one young people were from within the Eastern Health and Social Services Board area, 16 were from the Northern Health and Social Services Board area, another 16 were from the Western Health and Social Services Board area and the remaining eight were from the Southern Health and Social Services Board area. The mean length of stay was 10.5 weeks. Nineteen young people admitted were emergency referrals. Forty-five young people fulfilled diagnostic criteria for more than one ICD-10 diagnosis. Thirty-seven young people had experienced permanent parental separation. Ten young people were exposed to violence within the parental relationship. Five young people were on the Child Protection Register and 13 were looked-after children. Eighteen mothers had a history of depression. Eight fathers were noted to have a history of substance misuse and four received other psychiatric diagnoses. In 11 cases there was documented evidence of trauma other than abuse. In conclusion, the Child and Family Centre aims to provide a comprehensive and equitable Tier 4 service for young people and their families. Issues such as distance from the unit affect equity. Future service planning should bear this in mind. Tier 4 adolescent services should be developed to meet the needs of the older adolescent population. Family therapists, child psychotherapists, occupational therapists and dieticians should be recruited as a matter of urgency. There is a need for better liaison with adult mental health services. Northern Ireland requires appropriate therapeutic residential and or community service provision for severely disturbed children.

Job Searching with A History of Drugs and Crime

Abstract: This article explores the experiences and aspirations of offenders with histories of substance misuse in job searching. The analysis is based upon qualitative data from a localised study of 27 men and two women who were undertaking community‐based court orders in Scotland. Their perspectives on job searching, job‐readiness and aspirations for sustained employment including the role of self‐employment are presented. The article concludes that with adequate support, greater tolerance and flexibility by employers and job searchers could contribute to reducing the vicious cycle of suspicion and dishonesty. Policy action needs to be sustained and possibly augmented to include enterprise training.

Aggressive behaviour in an acute general adult psychiatric unit

Aims and MethodThe study aimed to identify the correlates of aggressive behaviour in an adult acute psychiatric ward. Over a period of 9 months, all incidents of verbal and physical aggressive behaviour exhibited by in-patients were routinely assessed using the Overt Aggression Scale.ResultsOf the 535 patients admitted during the study period, 80 (15%) were involved in a total of 124 aggressive incidents. Of these 80, 44 (55%) had a history of previous violence and 54 (68%) had a history of substance misuse. The majority of events occurred early in the hospital stay and in most cases aggression was against staff. There were significant differences between aggressive and non-aggressive patients in terms of gender and ethnicity, with the lowest rate occurring in European females.Clinical ImplicationsThese results reinforce clinical impressions, and empirical evidence, and allow risk assessment to be performed with greater confidence. The relevance of ethnicity (or more likely culture) highlights the difficulties of a ‘one size fits all’ approach to risk assessment.

Continuity of health impairment and substance misuse among adult prisoners in Queensland, Australia

Prisoners experience high rates of chronic physical health problems, poor mental health and high rates of substance misuse. However, little is known about what happens to prisoners after release from custody, except that many re‐offend and a disproportionate number die from drug overdose, suicide, accidents and other causes. Using a prospective design, 160 prisoners in Queensland, Australia were interviewed prior to release then 1 and 4 months post‐release. Most prisoners had a history of substance misuse and many reported poor mental health pre‐release. The prevalence of these problems was also high post‐release and there was a high degree of continuity of impairment. These findings add support to calls for (a) population‐level pre‐release planning and post‐release support for prisoners returning to the community, and (b) screening and targeted intervention for those most at risk of poor post‐release outcomes.

Down‐regulation of amygdala preprotachykinin A mRNA but not 3H‐SP receptor binding sites in subjects affected by mood disorders and schizophrenia

Increasing evidence suggests that substance P (SP) neurokinin-1 (NK1) receptors are involved in stress and emotional responses, representing a potential target for the treatment of anxiety and depression in humans. Given the important role of the amygdaloid complex in the regulation of emotional behavior, we examined the mRNA levels of preprotachykinin A [PPT-A, a precursor of both SP and neurokinin A (NKA)] and 3H-SP binding sites in the amygdala of patients affected by bipolar disorder, major depression or schizophrenia as compared with matched control individuals. By means of in situ hybridization, a significant reduction of PPT-A mRNA expression levels was detected in the three diagnostic groups, mainly in the basal, lateral and accessory basal amygdaloid nuclei, but not in the temporal cortical area proximal to the amygdala. Receptor autoradiography performed on adjacent sections showed no change in 3H-SP binding sites as compared with controls. No significant correlation was found between levels of PPT-A mRNA expression or binding sites and subject age, gender, hemisphere side, cause of death or history of substance misuse (marijuana, alcohol, cocaine/amphetamine). An inverse relationship between PPT-A mRNA expression levels and lifetime antipsychotic treatment (Fluphenazine) in the schizophrenic and bipolar disorder groups was found. Post-mortem delay was also negatively correlated with NK1 binding sites. The results confirm an involvement of the tachykinins in psychiatric disorders, suggesting there is a generalized impairment of the SP system in the amygdala in mood disorders and schizophrenia rather than this being a disease-related phenomenon.

Self-Reported Substance Misuse in Greek Male Prisoners

The aim of this survey was to determine levels and severity of self-reported alcohol and drug misuse and associated physical and mental health problems in Greek male prisoners. The sample consisted of 80 randomly selected convicted and remanded male prisoners in a prison in northern Greece. The Mini International Neuropsychiatric Interview (MINI) was used to assess psychiatric disorders including substance abuse and dependence. All prisoners who participated completed the Alcohol Use Disorders Identification Test (AUDIT). Those who reported daily use of opiates and stimulants completed the Severity of Dependence Scale (SDS). Information was obtained from medical notes about the prisoners’ hepatitis B and HIV status. The MINI identified 27.5% of the prisoners as dependent on opiates, 26.3% on alcohol and 73.8% as cannabis users, while 13.8% were misusing both alcohol and illicit drugs. Severity of dependence was rated, using SDS, as serious for all opiate and stimulant users. In terms of physical health examination of medical records indicated that no prisoner was HIV-positive but 26.5% were hepatitis-B-positive. Of those who had a previous history of substance misuse, 31.2% fulfilled the criteria for depression and 37.5% for antisocial personality disorder. Similarly, 15% of those misusing substances had a previous history of deliberate self-harm and 16% were assessed to have moderate to high suicide risk.