Itai Danovitch

State of the Art Treatments for Cannabis Dependence

The treatment of cannabis dependence can be viewed as a cup half empty or half full. On the one hand, few people who might benefit from treatment actually receive it. Among those who undergo treatment in randomized trials, long-term abstinence is achieved by fewer than 20%. Moderate use goals have been associated with decreases in consequences, but the differential impact of such goals on the long-term course of cannabis dependence is unknown. Optimal duration of treatment is unclear, and certain populations, particularly patients with co-occurring disorders, have not been studied adequately. Twelve-step programs are low cost, effective for other substance use disorders, and readily available in most regions of the world. However, their role and efficacy in cannabis dependence has not been examined. Finally, effective pharmacologic treatments are under development, but none have yet been firmly established. On the other hand, psychotherapeutic strategies used to treat other substance use disorders can be effective for cannabis dependence. A recent meta-analysis of psychosocial interventions for illicit substance use disorders found that treatments for cannabis dependence had comparatively larger effect sizes than treatments for other substance use disorders. Combination therapies have proven most effective, particularly those that begin with a motivational intervention, utilize incentives to enhance the commitment to change, and teach behavioral and cognitive copings skills to prevent relapse. Among adolescents, family engagement and collaboration with community stakeholders adds substantial value. Although only 9% of cannabis users develop cannabis dependence, the volume of people who smoke cannabis ensures that the total number of people in need of help is larger than the capacity of substance abuse specialty services. Thus, although efforts to refine and improve the efficacy of treatment interventions continue, innovations that increase the availability and accessibility of treatment are also needed. Computer- and phone-based interventions, social media, and brief interventions that can be implemented in primary care settings are areas that may hold promise for reaching at-risk populations. Adolescents and persons with co-occurring mental illness are at particularly high risk of cannabis dependence, and may suffer disproportionately from cannabis’s adverse effects. As in the treatment of other substance use disorders, there is a need for a continuing care model with long-term follow-up that extends past the periods typically evaluated in treatment studies. Additionally, there is a need for further investigation of genetic underpinnings and endophenotypes underlying cannabis dependence to identify neurobiological mechanisms for targeted intervention. One benefit of the societal focus on cannabis has been a prominent increase in research covering everything from the basic science to public health impact of cannabis. Over the next decade, physicians who provide treatment for individuals with cannabis dependence are likely to see their armamentarium of effective interventions expand, to the ultimate betterment of patients, their families, and society at large.

Quality of Life and Smoking

BACKGROUND AND OBJECTIVESnSmoking tobacco is the leading cause of preventable illness in the United States and around the world. However, much remains unknown about the factors that motivate individuals to smoke. Quality of life (QoL) has become an important measure of outcomes across all medical specialties, in both research and clinical settings. To date, there has not been a critical review of the research relevant to QoL in smokers. In this review, we describe which scales are used to quantify the QoL of smokers, the relationship between smoking and QoL and the positive impact of smoking cessation.nnnMETHODSnFifty-four relevant studies are included in our review.nnnRESULTSnLow QoL and depression are associated with higher odds of smoking initiation and lower odds of successful smoking cessation. There is a negative relationship between smoking and QoL and the magnitude of this association is related to the number of cigarettes smoked. Secondhand smoke also appears to be negatively associated with QoL. Smoking cessation significantly improves QoL. These findings have been replicated across populations with diverse socioeconomic and cultural groups around the world.nnnDISCUSSION AND CONCLUSIONSnQoL data promotes smokers and practitioners to become more sensitive to the sub-clinical adverse effects of cigarette smoking, thereby improving motivation to quit, cessation rates, and treatment outcomes.nnnSCIENTIFIC SIGNIFICANCEnUnderstanding the relationship between QoL and tobacco smoking is important for patients, clinicians, and researchers.

Hepatitis B and C Among Veterans on a Psychiatric Ward

Abstract Hepatitis B and C are public health problems. Psychiatric patients may be at risk of hepatitis B and C exposure due to lifestyle and inadequate health care. We aimed to determine prevalence of hepatitis B and C virus exposure and associated risk factors in acutely hospitalized psychiatric veterans. A total of 234 individuals consecutively admitted to the psychiatric wards at the West Los Angeles Veterans Affairs Hospital were asked to participate. A total of 129 patients consented and were screened for viral hepatitis risk factors, hepatitis B surface antigen, hepatitis B surface and core antibodies, and hepatitis C antibodies. About 31 and 38% of the patients had been exposed to hepatitis B and C viruses, respectively. Several risk factors were associated with exposure. Inpatient psychiatric veterans seem to have increased rates of hepatitis B and C exposure. This highlights the need for prevention of risk behavior in this vulnerable population.

Patient-reported Outcomes of Quality of Life, Functioning, and Gi/psychiatric Symptom Severity in Patients with Inflammatory Bowel Disease (ibd)

Background: Patients with inflammatory bowel disease (IBD) are at risk for psychiatric disorders that impact symptom experience and health-related quality of life (HRQOL). Therefore, comprehensive biopsychosocial assessments should be considered in ambulatory care settings. Patient-Reported Outcomes Measurement Information System (PROMIS) measures created by the National Institutes of Health have shown construct validity in a large IBD internet-based cohort, but their validity in ambulatory settings has not been examined. We sought to validate PROMIS patient-reported measures of HRQOL, functioning, and psychiatric symptom severity at a tertiary IBD clinic. Methods: Adult patients (n = 110) completed the PROMIS Global Health scale, PROMIS-29, SF-12, and WHODAS 2.0. Pearsons correlation coefficients (r) determined the relationships between scores to validate the PROMIS Global Health Physical and Mental metrics, compared with the SF-12 and WHODAS 2.0. We compared these measures by disease subtype of Crohns disease or ulcerative colitis. Results: PROMIS measures were highly correlated (r range = 0.64–0.82) with standard measures of HRQOL and functioning. On the PROMIS Global Health measures, 20.9% had impaired physical health, and 13.7% had impaired mental health. Impairments were reported in pain interference (20% of patients), anxiety (18.2%), satisfaction with social role (15.5%), physical functioning (10.9%), fatigue (10%), depression (7.3%), and sleep disturbance (5.5%). Patients with Crohns disease had worse scores than those with ulcerative colitis on measures of the global physical health (P = 0.027), physical functioning (P = 0.047), and pain interference (P = 0.0009). Conclusions: PROMIS instruments provide valid assessment of HRQOL and functioning in ambulatory adults with IBD. Of note, patients with Crohns disease demonstrated significantly worse impairments than those with ulcerative colitis.

Screening for depression in hospitalized medical patients

&NA; Depression among hospitalized patients is often unrecognized, undiagnosed, and therefore untreated. Little is known about the feasibility of screening for depression during hospitalization, or whether depression is associated with poorer outcomes, longer hospital stays, and higher readmission rates. We searched PubMed and PsycINFO for published, peer‐reviewed articles in English (1990‐2016) using search terms designed to capture studies that tested the performance of depression screening tools in inpatient settings and studies that examined associations between depression detected during hospitalization and clinical or utilization outcomes. Two investigators reviewed each full‐text article and extracted data. The prevalence of depression ranged from 5% to 60%, with a median of 33%, among hospitalized patients. Several screening tools identified showed high sensitivity and specificity, even when self‐administered by patients or when abbreviated versions were administered by individuals without formal training. With regard to outcomes, studies from several individual hospitals found depression to be associated with poorer functional outcomes, worse physical health, and returns to the hospital after discharge. These findings suggest that depression screening may be feasible in the inpatient setting, and that more research is warranted to determine whether screening for and treating depression during hospitalization can improve patient outcomes.

Quality of life and recreational cannabis use

INTRODUCTIONnCannabis is now the most commonly used illicit drug in the United States and use is increasing. Frequent cannabis use has been associated with adverse social and health effects. We sought to evaluate the relationship between recreational cannabis use and Quality of Life (QoL), a person-centered measure that characterizes the overall sense of health and wellbeing. We hypothesized that QoL would be unchanged or increased among recreational cannabis users, who did not meet criteria for a Cannabis Use Disorder (CUD) and that QoL would be lower among those who met criteria for a CUD.nnnMETHODSnWe conducted a systematic review, employing guidelines from Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The results were categorized into tables and identified trends.nnnRESULTSnFourteen studies met our pre-defined selection criteria. The studies were heterogeneous and their quality was low. With one exception, we did not identify any population for whom cannabis use was associated with improved QoL. QoL was lower in persons who used cannabis heavily, or who met criteria for CUD. However, this association was inconsistent and the magnitude was weaker than the relationship between QoL and use of other addictive substances (including tobacco and illicit drugs).nnnCONCLUSIONnIn this systematic review, heavy cannabis use or CUD was associated with reduced QoL. It is unknown whether reduced QoL drives cannabis use, or whether cannabis use can lead to reduced QoL. Prospective studies are needed to evaluate the causal relationship between cannabis and QoL.nnnSCIENTIFIC SIGNIFICANCEnFurthering the understanding of the relationship between cannabis and QoL can inform public policy, prevention efforts, outcomes, and an objective understanding of the effects of cannabis users. (Am J Addict 2017;26:8-25).

Expanding Treatment Potential for Substance Use Disorders

The treatment of substance use disorders is rapidly changing and the potential to identify and treat individuals suffering from addiction continues to increase. Advances in brain imaging technology and genetics have expanded our understanding of the neurobiology of addiction. New behavioral psychotherapies, as well as novel delivery mechanisms, are changing the nature of standard treatment approaches. Pharmacotherapy options continue to expand in terms of number of effective medications identified as well as treatment delivery models. Treatment methods for certain subpopulations of individuals with substance use disorders have been advanced greatly. This issue of the Psychiatric Clinics of North America provides an overview of cutting-edge developments in addiction science and treatment. While the treatment expertise for managing patients with substance use disorders frequently is concentrated in subspecialists, it is of great importance for general psychiatry practitioners to be familiar with the developments in addiction science and treatment. Substance use disorders occupy a unique place in our system of care. Historically, much of the treatment of individuals with substance use disorders evolved outside of traditional medical and psychiatric care, with mutual assistance groups and other nonprofessionals playing a primary role. This model has changed in recent decades, with dramatic developments in the understanding of the neurobiological mechanisms underpinning the behavioral patterns of addiction. The treatment of substance use disorders has evolved into a scientifically based clinical model, with strong correlations between basic science knowledge and available effective treatments. General psychiatry practitioners in practically all treatment settings will inevitably encounter individuals with substance use disorders. Awareness of the state