Substance Use Disorder Outcomes Research Articles

Childhood Neurobehavior Disinhibition Amplifies the Risk of Substance Use Disorder: Interaction of Parental History and Prenatal Alcohol Exposure

This investigation examined the influence of parental substance use disorder (SUD) and mother's alcohol consumption during pregnancy on neurobehavior disinhibition (ND) measured in 10- to 12-year-old children. The extent to which ND predicted SUD outcome 7 to 9 years later was also determined. SUD was documented in each parent and as the outcome variable in their 19-year-old sons. Average daily alcohol consumption during the mother's pregnancy was recorded using a structured interview. ND was assessed using indicators of behavior undercontrol, affect modulation and executive cognitive functions. Paternal SUD and the interaction between maternal SUD and alcohol consumption during pregnancy predicted child's ND score. ND at 10 to 12 years of age was a significant predictor of SUD at age 19. The disinhibitory disturbance associated with risk of SUD has both transmissible and teratogenic causes. The ramifications of this finding for pediatric practice are discussed.

Discrepancies in estimates of prevalence and correlates of substance use and disorders between two national surveys

To assess the degree to which methodological differences might influence estimates of prevalence and correlates of substance use and disorders by comparing results from two recent surveys administered to nationally representative US samples. Post-hoc comparison of data from the 2002 National Survey on Drug Use and Health (NSDUH) with data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) administered in 2001-02. Prevalence estimates for all substance use outcomes were higher in the NSDUH than in the NESARC; ratios of NSDUH to NESARC prevalences ranged from 2.1 to 5.7 for illegal drug use outcomes. In the NSDUH, past-year substance use disorder (SUD) prevalence estimates were higher for cocaine and heroin, but were similar to NESARC estimates for alcohol, marijuana and hallucinogens. However, prevalence estimates for past-year SUD conditional on past-year use were substantially lower in the NSDUH for marijuana, hallucinogens and cocaine. Associations among drug and SUD outcomes were substantially higher in the NESARC. Total SUD prevalence did not differ between surveys, but estimates for blacks and Hispanics were higher in the NSDUH. A number of methodological variables might have contributed to such discrepancies; among plausible candidates are factors related to privacy and anonymity, which may have resulted in higher use estimates in the NSDUH, and differences in SUD diagnostic instrumentation, which may have resulted in higher SUD prevalence among past-year substance users in the NESARC.

Impact of Helping Behaviors on the Course of Substance-Use Disorders in Individuals With Body Dysmorphic Disorder*

Alcoholics Anonymous and 12-step facilitated treatments for substance-use disorders (SUDs) encourage individuals with SUD to consider the needs of others and engage in helping behaviors as a method to become sober. SUDs are one of the most common comorbid disorders among individuals with body dysmorphic disorder (BDD). The purpose of this study is to examine prospectively the relationship between helping behaviors and the likelihood of SUD and BDD remission. Data on 163 individuals during the course of 3 years were derived from the Prospective Study of Body Dysmorphic Disorder, a longitudinal investigation of patterns and predictors of the course of BDD. Kaplan-Meier survival estimates were used to calculate probabilities of time to BDD and SUD remission. Cox regression analyses were conducted to calculate the relative likelihood of levels of helping behaviors as time-varying predictors of remission from both SUD and BDD. The course of SUD and BDD was chronic for most subjects; the estimated probability of remission from an SUD across 3 years was .29 and .17 for a full BDD remission. Results indicated that increases in helping behaviors were significantly predictive of SUD remission (hazard ratio [HR] = 2.59, p = .0134). Helping behaviors were also predictive of BDD remission among those with or without SUD but at a trend level of significance (HR = 1.51, p = .0676). These findings extend previous work reporting significant relationships between helping behaviors and positive long-term SUD outcomes. Implications of the mechanisms involved in the link between helping behaviors and remission from SUD and BDD are discussed.

Comorbidity of substance use disorders and other psychiatric disorders among adolescents: Evidence from an epidemiologic survey

This paper extends our knowledge of comorbidity of substance use disorders (SUDs) and other psychiatric disorders by examining comorbidity of specific types of SUDs and risk of comorbidity separately for abuse and dependence. The research question is whether there is specificity of risk for comorbidity for different SUDs and whether greater comorbidity is associated with dependence. Data are presented from a probability sample of 4175 youths aged 11–17 assessed with the NIMH DISC-IV and self-administered questionnaires. SUDs outcomes are alcohol, marijuana and other substances in past year. Mean number of other comorbid disorders ranged from 1.9 for marijuana abuse to 2.2 for other substance abuse and 1.9 for marijuana dependence to 2.8 for other substance dependence. None of the abuse SUDs does not increase risk of anxiety disorders, but dependence does. Both abuse and dependence increased risk of comorbid mood disorders. Similar results were observed for disruptive disorders. Patterns of comorbidity varied by substance, by abuse versus dependence, and by category of other psychiatric disorders. In general, there was greater association of comorbidity with other disorders for dependence versus abuse. Marijuana is somewhat less associated with other disorders than alcohol or other substances. The strongest association is for comorbid disruptive disorders, regardless of SUDs category. Having SUDs and comorbid other psychiatric disorders was associated with substantial functional impairment. Females with SUDs tended to have higher rates of comorbid disorders, as did older youths. There were no differences observed among ethnic groups. When comorbidity of SUDs with other disorders was examined, controlling for other non-SUDs disorders for each specific disorder examined, the greater odds for dependence versus abuse essentially disappeared for all disorders except disruptive disorders, suggesting larger number of comorbid non-SUDs in part account for the observed effects for dependence.

Modeling the complexity of post-treatment drinking: It's a rocky road to relapse

The most widely cited road block to successful treatment outcomes for psychological and substance use disorders has been described as the return to the previous behavior, or “relapse.” The operational definition of “relapse” varies from study to study and between clinicians, but in general the term is used to indicate the return to previous levels of symptomatic behavior. One explanation for the variation in the operationalization of relapse is the wide variety of behaviors for which the term is applied, including (but not limited to): depression, substance abuse, schizophrenia, mania, sexual offending, risky sexual behavior, dieting, and the anxiety disorders. A second explanation for the multitude of definitions for relapse is the inherent complexity in the process of behavior change. In this paper we present the most recent treatment outcome research evaluating relapse rates, with a special focus on the substance use disorders. Following this review of the literature we present an argument for the operationalization of relapse as a dynamic process, which can be empirically characterized using dynamical systems theory. We support this argument by presenting results from the analysis of alcohol treatment outcomes using catastrophe modeling techniques. These results demonstrate the utility of catastrophe theory in modeling the alcohol relapse process. The implications of these analyses for the treatment of alcohol use disorders, as well as a discussion of future research incorporating nonlinear dynamical systems theory is provided.

Assessment of risk for substance use disorder consequent to consumption of illegal drugs: Psychometric validation of the neurobehavior disinhibition trait.

Previous research has shown that the trait neurobehavior disinhibition (ND), which consists of affect, behavior, and cognitive indicators of self-regulation, is a significant predictor of substance use disorder (SUD) between childhood and young adulthood. The authors evaluated the psychometric properties of the ND trait in 278 boys evaluated at ages 10-12 and 16 years. ND score significantly predicted SUD and outcomes that commonly manifest in tandem with SUD by age 19, such as violence, arrests, committing crime while intoxicated, and concussion injury. In addition to predictive validity, the ND trait was found to have good construct, discriminative, and concurrent validity, as well as good test-retest and internal reliability. The ND trait may be useful for detecting youths at high risk for developing SUD and related outcomes.

Mapping the Clinical Complexities of Adolescents with Substance Use Disorders: A Typological Study

SUMMARY Because of the vast improvements in adolescent substance use assessment, it is widely recognized that adolescent substance use disorders (SUD) encompasses diverse drugs, patterns and etiologies and are characterized by extensive heterogeneity in other life domains. The next step in advancing adolescent SUD assessment is to classify adolescents with SUD into treatment-oriented typologies so that the question “What works with whom under what conditions?” can be empirically investigated. This paper: (1) identifies and describes seven subtypes of 205 adolescents with SUD in alcohol and other drug (AOD) treatment aged 12–18 years (via dimensions of delinquency, psychosocial problems, chemical dependency, and sexual risk behavior); and (2) examines whether certain patterns are distinctive among youth court-mandated to AOD treatment. Each profile type is described in terms of relative problem severity, prevalence for youth mandated to treatment through the courts, demographics, and performance on external measures of mental health and substance use disorders. Multiple logistic regression demonstrated that three profile types yielded 75.6% accuracy (sensitivity = 75.8%, specificity = 75.5%) for discrimination between court-mandated and non-court-mandated to treatment youth, even when controlled for the contributions of youth age, sex, and ethnicity. This paper discusses the need for triage to multiple treatments with varying levels of intensity for different subgroups of adolescents. If cost-effective services by setting by youth typology could be empirically identified and replicated, perhaps an empirically-guided cost-containment strategy would be developed and implemented by managed care and state government. In this way, the trend for a decline in the number and types of on-site services provided by AOD treatment programs might reverse, improving adolescent SUD outcomes.

Cannabis and neurodevelopment: implications for psychiatric disorders

The developing brain is susceptible to the effects of exogenous cannabinoids both during the perinatal period through maternal cannabis use and in young adolescent users. Emerging data from human and animal perinatal exposure studies demonstrate a subtle rather than gross effect of cannabis upon later functioning including; specific cognitive deficits especially in visuospatial function; impulsivity, inattention and hyperactivity; depressive symptoms; and substance use disorders. From animal studies motor control systems, neuroendocrine function and nociception may additionally be affected. Fetal studies indicate that these outcomes may be through cannabinoid mediated influences on the ontogeny of, especially dopamine and opioid, neurotransmitter systems. The effect of cannabinoids in the adolescent suggest long-term deleterious outcomes in cognition, depressive symptoms, schizophrenia and substance use disorders. Much of these data support a neurodevelopmental effect, however, predisposing genetic and/or environmental factors cannot be excluded from human studies. Gender specific differences have been observed in both human and animal studies implying sex hormone and related factors may interact with cannabinoids in neurodevelopment. Further understanding how cannabinoids influence neurodevelopment will inform public debate about the health effects of cannabis but also open avenues in discerning how modulation of the endocannabinoid system may assist in the development of therapeutic tools for a variety of neuropsychiatric disorders.

The Clinical Dilemma of Using Medications in Substance-Abusing Adolescents and Adults with Attention-Deficit/Hyperactivity Disorder: What Does the Literature Tell Us?

Adolescents and adults with attention-deficit/hyperactivity disorder (ADHD) and substance use disorders (SUD) are increasingly recognized in clinical practice. The role of pharmacological treatment for ADHD in these comorbid individuals remains unclear. A systematic review of the medical literature was conducted through PubMed, supplemented with data from scientific presentations, to evaluate the role of medication treatment of ADHD in substance abusing individuals with ADHD. Meta-analysis was used to evaluate the effects of medication therapy on ADHD and SUD outcomes in general, while specifically addressing trial design, trial duration, retention, class of medication, age group, concurrent psychotherapy, and outcome in both SUD and ADHD domains. Four studies in adolescents and five studies in adults with ADHD plus SUD were identified (two controlled and seven open studies; n = 222 subjects). The standard mean difference (SMD) indicated statistically significant improvements in ADHD and SUD that were not maintained when evaluating controlled studies only. Albeit limited by power, trial duration, retention rate, and age group did not influence outcome. No worsening of SUD or drug-drug interactions were observed in any of the studies. The results could not be accounted for by any single study or by publication bias. Treating ADHD pharmacologically in individuals with ADHD plus SUD has a moderate impact on ADHD and SUD that is not observed in controlled trials and does not result in worsening of SUD or adverse interactions specific to SUD. Further controlled trials evaluating the effect of novel combinations of psychotherapy and ADHD pharmacotherapy on SUD relapse in these groups are warranted.

A Critical Look at Dual-Focused Cognitive-Behavioral Treatments for Comorbid Substance Use and Psychiatric Disorders: Strengths, Limitations, and Future Directions

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. …

A survey of PTSD screening and referral practices in VA addiction treatment programs

Veterans with posttraumatic stress disorder (PTSD) and substance use disorders (SUDs) demonstrate worse outcomes following treatment for SUDs than do veterans with SUDs only, and so PTSD treatment may enhance SUD outcomes for patients. A survey of current practice patterns in VA SUD treatment programs was undertaken to determine their concurrence with emerging practice guidelines for the assessment and treatment of SUD–PTSD comorbidity. Clinicians in outpatient SUD clinics and/or inpatient SUD programs were surveyed in six VA medical centers in 1999 and 2001 (respondents n = 57 and n = 39, respectively). Although one half to two thirds of clinicians working with SUD patients routinely screen for trauma exposure and PTSD, few assessments are systematically conducted using validated measures. Routine referrals to PTSD specialty and dual-diagnosis programs and to veterans' centers are made by between 35% and 60% of providers across inpatient and outpatient settings. Implications for improvement of clinical outcomes are discussed.

The impact of substance use disorders on clinical outcome in 643 patients with first‐episode psychosis

Studies investigating the impact of comorbid substance use disorders (SUD) in psychosis have tended to focus on cross-sectional data, with few studies examining the effects of substance use course on clinical outcome. The main aim of the present study was to assess the impact of baseline SUD and course of SUD on remission of positive symptoms. The Early Psychosis Prevention and Intervention Centre admitted 786 first-episode psychosis (FEP) patients between 1998 and 2000. Data on SUD and clinical outcome were collected from patients' medical records (MR) of 643 patients who met inclusion criteria. Lifetime prevalence of SUD was 74%, with 62% having a SUD at baseline. This reduced to 36% in those patients who completed 18 months of treatment at the EPPIC program. A Cox regression analysis indicated that a decrease or cessation of substance use significantly increased the probability of remission, whilst persistent SUD substantially reduced the likelihood. In addition, patients who reduced use appeared to have better outcomes at 18 months than those patients who had never used substances. Baseline SUD was not found to have any significant influence on symptom remission. Patients presenting with FEP have high rates of SUD. Effective management of psychosis within a specialized service is associated with reductions in SUD over the course of treatment, although persistent substance use is associated with non-compliance, treatment drop-out and poor remission rates. As such, young people with FEP and comorbid substance use should be offered integrated treatment that addresses both disorders.

Direct and mediated associations between P300 amplitude in childhood and substance use disorders outcome in young adulthood

Attenuated amplitude of the P300 wave has been frequently documented in youths at high risk for substance use disorders (SUDs). This investigation had two aims: 1) determine whether P300 amplitude in late childhood is a predictor of SUD outcome by age 19; and 2) evaluate whether neurobehavior disinhibition (ND) mediates this association. Boys (aged 10-12) were recruited through proband biological fathers with either a lifetime DSM-III-R diagnosis of SUD (N = 67) or no adult psychiatric disorder (N = 94). P300 amplitude was recorded during an auditory oddball task. Neurobehavior disinhibition was evaluated using tests of executive cognitive function, behavior under control, and emotion dysregulation. The relationship is assessed using multiple and logistic regressions. Substance use disorder by age 19 was significantly predicted by P300 amplitude (odds ratio [OR] = .958; 95% confidence interval [CI] = .918-.999; Wald chi (2) = 3.992; df = 1; p = .045) and ND score (OR = 1.060; 95% CI = 1.023-1.098; Wald chi (2) = 10.267; df = 1; p = .0014) measured at age 10 to 12. P300 amplitude also significantly correlated with ND severity (beta = -.217; t = -2.412; df = 6,160; p = .017). Low P300 amplitudes were observed in children who succumbed to SUD by age 19. These results indicate that ND mediates the association between attenuated P300 amplitude in childhood and SUD at age 19; however, P300 amplitude is not a specific childhood marker of SUD.

Relation between cognitive distortions and neurobehavior disinhibition on the development of substance use during adolescence and substance use disorder by young adulthood: a prospective study

Objective: Previous research has demonstrated that neurobehavior disinhibition increases the risk for a diagnosis of substance use disorder (SUD). This investigation tested the hypothesis that a deficiency in the capacity to appraise the effects of alcohol and drugs and interpret social interactions mediates the relation between neurobehavior disinhibition in childhood and SUD by early adulthood. Methods: Boys with fathers having lifetime SUD ( N = 88) and no SUD or other psychiatric disorder ( N = 127) were prospectively tracked from ages 10–12 to 19 years. Neurobehavior disinhibition was evaluated at baseline followed by assessments of cognitive distortions and substance use involvement in early and mid-adolescence. SUD outcome was evaluated up to age 19 years. Results: Cognitive distortions (age 12–14 years) mediated the association between neurobehavior disinhibition (age 10–12 years) and marijuana use (age 16 years) which, in turn, predicted SUD by age 19 years. Cognitive distortions in early adolescence did not directly predict SUD by young adulthood. Conclusions: Inaccurate social cognition, significantly predicted by childhood neurobehavior disinhibition, biases development toward marijuana use prodromal to SUD. These results indicate that cognitive processes, in conjunction with psychological self-regulation, comprise important components of the individual liability to SUD.

Substance use and posttraumatic stress disorders: Symptom interplay and effects on outcome

This study examined concurrent and prospective associations between substance use disorder (SUD) and posttraumatic stress disorder (PTSD) diagnosis and symptoms and mechanisms underlying these associations. Participants ( n=133) were assessed at intake and 6 months following inpatient SUD treatment. Patients differed by baseline PTSD status on psychiatric comorbidity and substance use history but not on current substance use symptoms. Participants with alcohol use disorders reported a greater number of reexperiencing symptoms. Baseline PTSD status did not predict substance use outcome. However, change in PTSD status over follow-up predicted substance use outcomes; those with unremitted PTSD demonstrated poorer SUD outcome than those with remitted PTSD. General psychiatric distress at follow-up was associated with poorer outcomes, and such distress mediated the association between PTSD change status and substance use outcome. Findings suggest that clinicians should assess for PTSD among those with SUD and, during treatment, should monitor PTSD and other psychological symptoms, which may be risk factors for relapse to substance abuse.

Validity of the Drug Use Screening Inventory for Predicting DSM-III-R Substance Use Disorder

SUMMARY The Drug Use Screening Inventory (DUSI) has been shown to have sound psychometric properties for quantifying the severity of health, behavior and psychosocial problems concomitant to substance use in adolescents. Its utility for identifying youth who will develop a disorder of abuse/dependence has, however, not been investigated. In this longitudinal study, the DUSI was administered to a sample of boys at ages 12–14, 16 and 19 in a repeated measures design. An overall problems severity score of 24% at ages 12–14 and 16 predicted a DSM-III-R substance use disorder (SUD) outcome at age 19 with 73% and 84% accuracy respectively. Parental history of SUD did not increase prediction of SUD outcome in the youth. These findings indicate that the DUSI, taking only 15–20 minutes to complete, is a useful practical instrument to identify youth who could benefit most from prevention interventions.

Individual traits and family contexts predict sons’ externalizing behavior and preliminary relative risk ratios for conduct disorder and substance use disorder outcomes

An ontogenetic framework for elucidating the etiology of substance use disorders (SUD) requires identifying how individual traits and family contexts combine to increase risk for SUD outcomes. In this study, we examine individual traits in family context to identify processes that account for the relationship between fathers’ SUD+ status and sons’ externalizing behaviors. Results obtained from SUD+ ( n=89) and SUD− ( n=139) families show that fathers’ abusive propensities toward their sons mediated the relationship between fathers’ SUD+ status and sons’ externalizing behavior scale (EBS) scores 2 years later. Moreover, individual traits, family contextual variables and deviant peer affiliations accounted for 58% of the variance on sons’ EBS scores. Also, high risk cluster (HRC) and low risk cluster (LRC) memberships were derived from cluster analyses of the continuous risk factor scores that predicted sons’ EBS scores. Preliminary relative risk ratios show that sons classified into the HRC at age 10–12 were at greater risk for DSM-III-R conduct disorder and SUD outcomes at age 16 than sons assigned to the LRC, SUD+ or SUD− groups. Implications for selected family-based prevention initiatives are presented.