Jason P. Connor

Polysubstance use: diagnostic challenges, patterns of use and health

Purpose of review Polysubstance use is common, particularly amongst some age groups and subcultures. It is also associated with elevated risk of psychiatric and physical health problems. We review the recent research findings, comment on changes to polysubstance diagnoses, report on contemporary clinical and epidemiological polysubstance trends, and examine the efficacy of preventive and treatment approaches. Recent findings Approaches to describing polysubstance use profiles are becoming more sophisticated. Models over the last 18 months that employ latent class analysis typically report a no use or limited-range cluster (alcohol, tobacco and marijuana), a moderate-range cluster (limited range and amphetamine derivatives), and an extended-range cluster (moderate range, and nonmedical use of prescription drugs and other illicit drugs). Prevalence rates vary as a function of the population surveyed. Wide-ranging polysubstance users carry higher risk of comorbid psychopathology, health problems, and deficits in cognitive functioning. Summary Wide-ranging polysubstance use is more prevalent in subcultures such as ‘ravers’ (dance club attendees) and those already dependent on substances. Health risks are elevated in these groups. Research into the prevention and treatment of polysubstance use is underdeveloped. There may be benefit in targeting specific polysubstance use and risk profiles in prevention and clinical research.

D2 dopamine receptor (DRD2) polymorphism is associated with severity of alcohol dependence

The A(1) allele of the D(2) dopamine receptor (DRD2) gene has been associated with alcohol dependence. However, the expression of this allele risk on the severity of drinking behavior in patients with alcohol dependence has not been systematically explored. The present study examines the association between DRD2 A(1)(+) (A(1)/A(1) and A(1)/A(2) genotypes) and A(1)- (A(2)/A(2) genotype) allele status and key drinking parameters in alcohol-dependent patients. A sample of Caucasian adults was recruited from an alcohol detoxification unit. A clinical interview and the Alcohol Dependence Scale (ADS) questionnaire provided data on consumption, dependence, chronology of drinking and prior detoxification. A(1)(+) allele compared to A(1)- allele patients consumed higher quantities of alcohol, commenced problem drinking at an earlier age, experienced a shorter latency between first introduction to alcohol to the onset of problem drinking and had higher ADS scores. Moreover, A(1)(+) allele patients had more detoxification attempts than their A(1)- allele counterparts. In sum, alcohol-dependent patients with the DRD2 A(1) allele compared to patients without this allele are characterized by greater severity of their disorder across a range of problem drinking indices. The implications of these findings are discussed.

Gender differences in the impact of families on alcohol use: a lagged longitudinal study of early adolescents.

AIMS From the pre-teen to the mid-teen years, rates of alcohol use and misuse increase rapidly. Cross-sectional research shows that positive family emotional climate (low conflict, high closeness) is protective, and there is emerging evidence that these protective mechanisms are different for girls versus boys. The aim of this study was to explore gender differences in the longitudinal impact of family emotional climate on adolescent alcohol use and exposure to peer drinking networks. DESIGN Three-wave two-level (individual, within-individual over time) ordinal logistic regression with alcohol use in the past year as the dependent measure and family variables lagged by 1 year. SETTING Adolescents completed surveys during school hours. PARTICIPANTS A total of 855 Australian students (modal age 10-11 years at baseline) participating in the International Youth Development Study (Victoria, Australia). MEASUREMENTS These included emotional closeness to mother/father, family conflict, parent disapproval of alcohol use and peer alcohol use. FINDINGS For girls, the effect of emotional closeness to mothers on alcohol use was mediated by exposure to high-risk peer networks. Parent disapproval of alcohol use was protective for both genders, but this effect was larger for boys versus girls, and there was no evidence that peer use mediated this effect. Peer drinking networks showed stronger direct risk effects than family variables. CONCLUSIONS Family factors unidirectionally impact on growth in adolescent alcohol use and effects vary with child gender.

The influence of parents, siblings and peers on pre- and early-teen smoking: A multilevel model

INTRODUCTION AND AIMS Despite considerable success in tobacco control, many teenagers in Australia and other industrialised countries still smoke tobacco. There is mixed evidence on the relative influence of proximal social networks (parents/siblings/peers) on pre- and early-teen smoking, and no research has examined how these influences compare after accounting for school- and community-level effects.The aim of this study was to compare the relative influences of parents, siblings and peers, after accounting for school- and community-level variation in smoking. DESIGN AND METHODS A cross-sectional fixed and random effects model of smoking prevalence was used, with individuals (n = 7314) nested within schools (n = 231) nested within communities (n = 30). Grade 6 and 8 students (modal ages 11 and 13 years) completed an on-line survey. Key variables included parent/sibling/peer use. Controls included alcohol involvement, sensation seeking, pro-social beliefs, laws/norms about substance use and school commitment. RESULTS There was significant variation in smoking at both the school and community levels, supporting the need for a multilevel model. Individual-level predictors accounted for much of the variance at higher levels. The strongest effects were for number of friends who smoke, sibling smoking and alcohol involvement. Smaller significant effects were found for parent smoking. At the community level, socioeconomic disadvantage was significant, but community-level variance in pro-social and drug-related laws/norms was not related to smoking. DISCUSSION AND CONCLUSIONS Cross-level interactions were generally non-significant. Early teenage smoking was best explained by sibling and peer smoking, and individual risks largely accounted for the substantial variation observed across schools and communities. In terms of future tobacco control, findings point to the utility of targeting families in disadvantaged communities.

Concurrent and Simultaneous Polydrug Use: Latent Class Analysis of an Australian Nationally Representative Sample of Young Adults

Background: Alcohol use and illicit drug use peak during young adulthood (around 18–29 years of age), but comparatively little is known about polydrug use in nationally representative samples of young adults. Drawing on a nationally representative cross-sectional survey (Australian National Drug Strategy Household Survey), this study examines polydrug use patterns and associated psychosocial risk factors among young adults (n = 3,333; age 19–29). Method: The use of a broad range of licit and illicit drugs were examined, including alcohol, tobacco, cannabis, cocaine, hallucinogens, ecstasy, ketamine, GHB, inhalants, steroids, barbiturates, meth/amphetamines, heroin, methadone/buprenorphine, other opiates, painkillers, and tranquilizers/sleeping pills. Latent class analysis was employed to identify patterns of polydrug use. Results: Polydrug use in this sample was best described using a 5-class solution. The majority of young adults predominantly used alcohol only (52.3%), alcohol and tobacco (34.18%). The other classes were cannabis, ecstasy, and licit drug use (9.4%), cannabis, amphetamine derivative, and licit drug use (2.8%), and sedative and alcohol use (1.3%). Young adult males with low education and/or high income were most at risk of polydrug use. Conclusion: Almost half of young adults reported polydrug use, highlighting the importance of post-high school screening for key risk factors and polydrug use profiles, and the delivery of early intervention strategies targeting illicit drugs.

A prospective study of alcohol expectancies and self-efficacy as predictors of young adolescent alcohol misuse.

AIMS To test the relative contribution of two key Social Learning Theory constructs, alcohol expectancies (AEs) and drinking refusal self-efficacy (DRSE), in predicting early adolescent drinking behavior and examine the possible mediational role of DRSE over AE. METHODS High school students (N = 192, mean age 14) were administered measures assessing AE (Drinking Expectancy Questionnaire--Adolescent version; DEQ-A), DRSE (Drinking Refusal Self-Efficacy Questionnaire--Revised Adolescent version; DRSEQ-RA) and indices of alcohol consumption and problem drinking. Age, gender, peer drinking, tobacco use and positive and negative behavioral characteristics were included in the statistical models as known predictors of alcohol misuse. Subjects were followed up at 12 months, with 88.5% retention. RESULTS Initial confirmatory factor analyses verified factor structures of the DEQ-A and DRSEQ-RA. Prospective structural models controlling for Time 1 drinking behavior, age, gender, peer alcohol use, tobacco use and behavior problems identified that DRSE but not AE was associated with problem drinking 12-month post-initial assessment. DRSE mediated AE in predicting problem drinking. CONCLUSION Results suggest that DRSE is a more salient cognitive construct than AE in early adolescence alcohol use. In this age group, prevention and treatment strategies that build refusal self-efficacy may be more effective than strategies that challenge AEs.

Measurement of alcohol craving.

Despite considerable research activity and application in treatment, the construct of craving remains poorly understood. We propose that cravings and urges are cognitive-emotional events in time, characterised by frequency, duration, intensity and salience. Commonly used measures of alcohol craving are reviewed, and their strengths and weaknesses identified. Most measures confound craving with behaviours, or with separable cognitive phenomena such as expectancies, intentions, or perceived behavioural control. These confounds have limited our advances in understanding the determinants and consequences of craving. Based on the criteria applied in this review, among the better performing multi-item measures are the Penn Alcohol Craving Scale and Obsessive subscale of the Obsessive-Compulsive Drinking Scale. Optimal assessment strategies are likely to involve daily assessments of peak intensity of cravings, desires or urges and of the frequency and duration of craving episodes. Of particular interest are measures of intensity at times when individuals are at risk of drinking or of other functional impacts from craving.

Alexithymia, craving and attachment in a heavy drinking population

Up to fifty per cent of individuals with Alcohol use disorders (AUD) also have alexithymia a personality construct hypothesized to be related to attachment difficulties. The relationship between alexithymia, craving, anxious attachment and alcohol-dependence severity was examined in 254 patients participating in a Cognitive-Behavioral Therapy (CBT) program for alcohol-dependence. Participants completed the Toronto Alexithymia Scale (TAS-20), the Obsessive Compulsive Drinking Scale (OCDS), the Revised Adult Attachment Anxiety Subscale (RAAS-Anxiety) and the Alcohol Use Disorder Identification Test (AUDIT). MANOVA indicated that individuals with alexithymia reported significantly higher levels of total OCDS, obsessive thoughts about alcohol, and compulsive drinking urges and behavior, compared to the non-alexithymic group. Regression analyses found that anxious attachment partially mediated the relationship between alexithymia and craving. Anxious attachment may be a potential treatment target to reduce alcohol consumption in those with alcohol-dependence and alexithymia.

The Craving Experience Questionnaire: a brief, theory-based measure of consummatory desire and craving

BACKGROUND AND AIMS Research into craving is hampered by lack of theoretical specification and a plethora of substance-specific measures. This study aimed to develop a generic measure of craving based on elaborated intrusion (EI) theory. Confirmatory factor analysis (CFA) examined whether a generic measure replicated the three-factor structure of the Alcohol Craving Experience (ACE) scale over different consummatory targets and time-frames. DESIGN Twelve studies were pooled for CFA. Targets included alcohol, cigarettes, chocolate and food. Focal periods varied from the present moment to the previous week. Separate analyses were conducted for strength and frequency forms. SETTING Nine studies included university students, with single studies drawn from an internet survey, a community sample of smokers and alcohol-dependent out-patients. PARTICIPANTS A heterogeneous sample of 1230 participants. MEASUREMENTS Adaptations of the ACE questionnaire. FINDINGS Both craving strength [comparative fit indices (CFI = 0.974; root mean square error of approximation (RMSEA) = 0.039, 95% confidence interval (CI) = 0.035-0.044] and frequency (CFI = 0.971, RMSEA = 0.049, 95% CI = 0.044-0.055) gave an acceptable three-factor solution across desired targets that mapped onto the structure of the original ACE (intensity, imagery, intrusiveness), after removing an item, re-allocating another and taking intercorrelated error terms into account. Similar structures were obtained across time-frames and targets. Preliminary validity data on the resulting 10-item Craving Experience Questionnaire (CEQ) for cigarettes and alcohol were strong. CONCLUSIONS The Craving Experience Questionnaire (CEQ) is a brief, conceptually grounded and psychometrically sound measure of desires. It demonstrates a consistent factor structure across a range of consummatory targets in both laboratory and clinical contexts.

Measuring alcohol craving: development of the Alcohol Craving Experience questionnaire

AIMS To develop a measure of craving based on the Elaborated Intrusion (EI) theory of desire and to examine the construct, concurrent and discriminant validity of the instrument. DESIGN Cross-sectional. SETTING AND PARTICIPANTS Patients from a hospital alcohol and drug out-patient service (n = 230), participants in a randomized controlled trial (n = 219) and students in a university-based study of alcohol craving (n = 202) were recruited. MEASUREMENTS The Alcohol Craving Experience questionnaire (ACE) was developed to measure sensory aspects of craving (imagining taste, smell or sensations of drinking and intrusive cognitions associated with craving) when craving was maximal during the previous week (ACE-S: strength), and to assess frequency of desire-related thoughts in the past week (ACE-F: frequency). All participants completed the ACE and the Alcohol Use Disorders Identification Test (AUDIT). The Obsessive Compulsive Drinking Scale (OCDS) and the Depression Anxiety and Stress Scale (DASS) were completed by hospital patients and randomized control trial participants. FINDINGS Exploratory factor analysis on the ACE-S and ACE-F resulted in a three-factor structure representing imagery, intensity and intrusion. An attempt to confirm this factor structure required a reduction in items (two from ACE-S, five from ACE-F) before a good fit to the three-factor model was obtained. Concurrent validity with the OCDS, with severity of alcohol dependence and with depression, anxiety and stress, was demonstrated. The ACE discriminated between clinical and non-clinical populations and between those at higher risk of alcohol dependence and those at lower risk. CONCLUSIONS A new scale, the Alcohol Craving Experience questionnaire, based on the Elaborated Intrusion theory of desire appears to capture key constructs of the theory and correlate with indices of alcohol dependence.