Gerhard Bühringer

What are the high risk periods for incident substance use and transitions to abuse and dependence? : implications for early intervention and prevention

Background: For a better understanding of the evolution of addictive disorders and the timely initiation of early intervention and prevention, we have to learn when and how quickly the critical transitions from first substance use (SU) to regular use and from first SU and regular SU to abuse and dependence occur. Little data are currently available on the transitions to substance use disorders (SUDs) across the spectrum of legal and illegal drugs taking into account gender differences. It is the aim of this paper to describe the high density incidence and transition periods of SU and SUD for alcohol, nicotine, cannabis and other illicit drugs for young males and females.

Pathologisches Glücksspiel in Deutschland: Spiel- und Bevölkerungsrisiken

Aims: To estimate (1) the »attractiveness« of different gambling options and (2) the prevalence of pathological gambling (PG) among actual gamblers and the entire population. Method: Representative sample of 7,817 respondents between 18 and 64 years old of the 2006 Epidemiological Survey of Substance Abuse (ESA). Lifetime and 12 month prevalence, preferred gambling options and diagnoses of PG (DSM-IV TR) were collected through self-administered questionnaires and telephone interviews. Results: Among the total population 71.5 % had gambled in their lifetime, 49.4 % in the prior 12 months. Lotto was preferred by 60.3 % of the sample, with lotteries, sports betting, casino gambling, gaming machines and illicit gambling trailing far behind. The types of gambling that were most commonly associated with a diagnosis of PG were internet gambling (7.0 %) and playing slot machines in casinos (6.7 %); different kinds of Lotto (0.1 %) were least likely to be associated. The total »population risk« for PG was 0.2 % (103,000 people) with nearly equal shares of sports betting, casino gambling and gaming machines (0.05‐0.06% or 24,000‐31,000) and far less frequently Lotto (0.02 % or 12,000). After differential diagnoses of »manic episodes« the total population risk was halved (to 0.09 % or 46,000). Conclusions: The prevalence rate of PG in the adult population is in the lower range of other European estimates. For preventive measures, large variations in the different types of gambling should be taken into account.

The Prospects and Limitations of Compulsory Treatment for Drug Addiction

During the 1980s, social scientists and policy makers have been examining the different kinds of pressures that affect the behavior of drug addicts, and have been discussing how these pressures may be better managed to get addicts into treatment, to change their drug-related behaviors during treatment, and to maintain these changes following treatment. This article reviews the pressures inherent in the legal, social, and treatment systems of the United States of America and the Federal Republic of Germany, and discusses the utility of combining elements of the legal and treatment systems. The article presents six propositions summarizing the conclusions reached at a conference regarding the assessment and use of pressures in addiction treatment. The article also presents the final recommendations that were made. It was concluded that the present lack of knowledge about the effectiveness of compulsory treatment raises ethical, as well as practical questions. Although compulsory treatment is a tempting solution to the drug addiction problem, a complete social policy analysis of the use of coercive pressure must be undertaken before acceptance would be appropriate. Compulsory treatment must be judged not in terms of moralistic ideas or political expediency, but in terms of the entire range of treatment policy options.

The role of mental disorders in the risk and speed of transition to alcohol use disorders among community youth

BACKGROUND Among adolescents and young adults with DSM-IV alcohol use disorders (AUDs), there are inter-individual differences in the speed of transition from initial alcohol use (AU) to AUD. AUDs are highly co-morbid with other mental disorders. The factors associated with rapid transition from first AU to AUD remain unknown and the role of mental disorders in rapid transitions is unclear. Given this background we examined (1) whether prior anxiety, mood, externalizing and non-alcohol substance use disorders are related to the risk and speed of transition from first AU to DSM-IV alcohol abuse (AA) and alcohol dependence (AD) and (2) whether early age of onset of prior mental disorders (PMDs) is a promoter of rapid transition. METHOD A total of 3021 community subjects (97.7% lifetime AU) aged 14-24 years at baseline were followed up prospectively for up to 10 years. AU and mental disorders were assessed with the DSM-IV/M-CIDI. RESULTS Among subjects with lifetime AU, several PMDs, such as specific phobia, bipolar disorder and nicotine dependence, were associated with an increased risk of AUD independent of externalizing disorders. Associations of PMDs with the speed of transition to AUDs were mostly weak and inconsistent. Only social phobia and externalizing disorders were associated with faster transitions to AD even after adjustment for other PMDs. Earlier age of onset of PMD was not associated with rapid transition. CONCLUSIONS Mental disorders are associated with the risk of AUD. With the possible exception of social phobia and externalizing disorders, they do not promote rapid transition, even if they occur particularly early. Future research needs to identify factors relevant to rapid transition to AUD.

Why people change? The role of cognitive-control processes in the onset and cessation of substance abuse disorders

Background: The current effectiveness of preventative and therapeutic interventions for substance use disorders (SUDs) is less than satisfying. Progress in understanding the processes related to the onset, course, and cessation of SUDs merits top priority, given the high prevalence and the severe negative consequences. Aims: This position paper, after summarizing major factors related to onset and cessation processes, discusses the possible role of cognitive‐control dysfunctions in the complex interaction between mechanisms of change (mediators) and risk factors (moderators). Findings: In past decades, research has expanded our knowledge about the impact of SUDs on human behaviour. Formal interventions are effective, but there is limited information about the mechanisms responsible for change during the onset and cessation of SUDs and for individual differences related to them. Preliminary results suggest that impairments in higher order control functions play a role in SUDs. Conclusions: Deficiencies in our understanding of behaviour‐change processes during the onset and cessation of SUDs require that research have a different focus. A better understanding of the relevance of impairments in executive‐control functions might help to improve formal preventative and therapeutic interventions and social conditions. Such interventions might reduce the chances that a SUD will develop or increase the likelihood of recovery from it. Copyright

Differences in pathological gambling prevalence estimates: facts or artefacts?

The paper aims at investigating whether survey methodology has recently converged to justify the common practice of comparing prevalence estimates and interpreting differences within and between countries. To this end, prevalence studies of problem (PrG) and pathological gambling (PG) published in peer‐reviewed journals between 2000 and 2010 were critically reviewed. A systematic computer‐based literature search was conducted within various databases and major gambling journals. In a two‐step search process, a total of 39 studies reporting current prevalence data of non‐clinical national samples from different countries were identified. Analyses revealed wide ranges in estimated PrG/PG rates for adults, adolescents, and college students, whereas similar estimates were reported in two studies on PrG/PG in seniors. Despite the discussion on methodological consistency in the field of gambling research, comparability of the reported estimates was found to be still highly limited by major variation between studies with regard to survey description, administration format, exclusion criteria, assessment instrument, cut‐off scores, sample frame, and reference period. The interpretation of differences in PrG and PG prevalence estimates within and between countries may be improved by using valid and reliable instruments and by applying comparable survey methodology in well‐defined populations. Copyright

CANDIS treatment program for cannabis use disorders: Findings from a randomized multi-site translational trial

BACKGROUND In a recent paper, we reported the efficacy of a modular cognitive-behavioral intervention for treating adolescents and adults with cannabis use disorders (CUD). In this study, we examine the outcome of this intervention after translating it into clinical practice. METHODS A multi-site, randomized controlled trial of 279 treatment seekers with ICD-10 cannabis use disorders aged 16- 63 years was conducted in 11 outpatient addiction treatment centers in Germany. Patients were randomly assigned to an Active Treatment (AT, n=149) or Delayed Treatment Control (DTC, n=130). Treatment consisted of 10 sessions of fully manualized individual psychotherapy that combined Cognitive-Behavioral Therapy, Motivational EnhancementTherapy and problem-solving training. Assessments were conducted at baseline, during each therapy session, at post-treatment and at three and six month follow-ups. RESULTS At post assessment 53.3% of AT patients reported abstinence (46.3% negative urine screenings) compared to 22% of DTC patients (17.7% negative drug screenings) (p<0.001, Intention-to-treat analysis). AT patients improved in the frequency of cannabis use, number of cannabis dependence criteria, severity of dependence, as well as number and severity of cannabis-related problems. Effect sizes were moderate to high. While abstinence rates in the AT group decreased over the 3-month (negative urine screenings: 32.4%) and 6-month (negative urine screenings: 35.7%) follow-up periods, the effects in secondary outcomes were maintained. CONCLUSIONS The intervention can successfully be translated to and applied in clinical practice. It has the potential to improve access to evidence-based care for chronic CUD patients.

The relevance of age at first alcohol and nicotine use for initiation of cannabis use and progression to cannabis use disorders

BACKGROUND A younger age at onset of use of a specific substance is a well-documented risk-factor for a substance use disorder (SUD) related to that specific substance. However, the cross-substance relationship between a younger age at onset of alcohol use (AU) and nicotine use (NU) and the risk of cannabis use disorders (CUD) in adolescence and early adulthood remains unclear. AIMS To identify the sequence of and latency between initial AU/NU and initial cannabis use (CU). To investigate whether younger age at AU- and NU-onset is associated with any and earlier CU-onset and a higher risk of transition from first CU to CUD, taking into account externalizing disorders (ED) and parental substance use disorders as putative influential factors. METHODS Prospective-longitudinal community study with N=3021 subjects (baseline age 14-24) and up to four assessment waves over up to ten years with additional direct parental and family history information. Substance use and CUD were assessed with the DSM-IV/M-CIDI. RESULTS Most subjects with CU reported AU (99%) and NU (94%). Among users of both substances, 93% reported AU prior to CU (87% for NU). After adjustment for ED and parental substance use disorders younger age at AU-onset was associated with any CU. Younger age at NU-onset was associated with earlier CU initiation. Younger age at AU- and NU-onset was not associated with a higher risk of CUD. CONCLUSIONS The cross-substance relevance of younger age at first AU and NU for the risk of CUD is limited to early CU involvement.

Review on psychotherapeutic interventions for cannabis disorders

Ubersicht uber psychotherapeutische Interventionen bei cannabisbezogenen Storungen Ziel: Ubersicht uber die Literatur zur psychotherapeutischen Behandlung von Cannabismissbrauch und Abhangigkeit. Ergebnisse: Beschrankungen von acht identifizierten Studien werden beschrieben. Als wirksame Therapiekomponenten stellten sich die Motivationssteigerungs-Therapie, die kognitive Verhaltenstherapie, das Notfallmanagement und verschiedene Arten der Familientherapie fur jungere gefahrdete Cannabiskonsumenten heraus. Schlussfolgerungen: Insgesamt belegen die Studien, dass es sowohl einen steigenden Bedarf als auch eine potenzielle Wirksamkeit von Behandlungen gibt, die speziell auf cannabisabhangige und gefahrdete Konsumenten zugeschnitten sind. Trotzdem besteht immer noch ein erheblicher Forschungsbedarf zu spezifischen psychologischen Interventionen auf diesem Gebiet. Insbesondere in Europa herrscht ein eklatanter Mangel an Interventionsstudien und der Entwicklung von Behandlung...

Gamblers seeking treatment: Who does and who doesn’t?

Abstract Background and aims: As only a minority of pathological gamblers (PGr) presents for treatment, further knowledge about help-seeking behavior is required in order to enhance treatment utilization. The present study investigated factors associated with treatment participation in gamblers in Germany. As subclinical pathological gamblers (SPGr, fulfilling one to four DSM-IV-criteria) are target of early intervention due to high risk of transition to pathological gambling, they were subject of special interest. Methods: The study analyzed data from a general population survey (n = 234, SPGr: n = 198, PGr: n = 36) and a treatment study (n = 329, SPGr: n = 22, PGr: n = 307). A two-step weighting procedure was applied to ensure comparability of samples. Investigated factors included socio-demographic variables, gambling behavior, symptoms of pathological gambling and substance use. Results: In PGr, regular employment and non-German nationality were positively associated with being in treatment while gambling on the Internet and gaming machines and fulfilling more DSM-IV-criteria lowered the odds. In SPGr, treatment attendance was negatively associated with married status and alcohol consumption and positively associated with older age, higher stakes, more fulfilled DSM-IV criteria and regular smoking. Conclusions: In accordance to expectations more severe gambling problems and higher problem awareness and/or external pressure might facilitate treatment entry. There are groups with lower chances of being in treatment: women, ethnic minorities, and SPGr. We propose target group specific offers, use of Internet-based methods as possible adaptions and/or extensions of treatment offers that could enhance treatment attendance.