John Marsden

Validation of the alcohol, smoking and substance involvement screening test (ASSIST)

AIM The concurrent, construct and discriminative validity of the World Health Organizations Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) were examined in a multi-site international study. PARTICIPANTS One thousand and 47 participants, recruited from drug treatment (n = 350) and primary health care (PHC) settings (n = 697), were administered a battery of instruments. MEASUREMENTS Measures included the ASSIST; the Addiction Severity Index-Lite (ASI-Lite); the Severity of Dependence Scale (SDS); the MINI International Neuropsychiatric Interview (MINI-Plus); the Rating of Injection Site Condition (RISC); the Drug Abuse Screening Test (DAST); the Alcohol Use Disorders Identification Test (AUDIT); the Revised Fagerstrom Tolerance Questionnaire (RTQ); and the Maudsley Addiction Profile (MAP). FINDINGS Concurrent validity was demonstrated by significant correlations between ASSIST scores and scores from the ASI-Lite (r = 0.76-0.88), SDS (r = 0.59), AUDIT (r = 0.82) and RTQ (r = 0.78); and significantly greater ASSIST scores for those with MINI-Plus diagnoses of abuse or dependence (P < 0.001). Construct validity was established by significant correlations between ASSIST scores and measures of risk factors for the development of drug and alcohol problems (r = 0.48-0.76). Discriminative validity was established by the capacity of the ASSIST to discriminate between substance use, abuse and dependence. Receiver operating characteristic (ROC) analysis was used to establish cut-off scores with suitable specificities (50-96%) and sensitivities (54-97%) for most substances. CONCLUSIONS The findings demonstrated that the ASSIST is a valid screening test for identifying psychoactive substance use in individuals who use a number of substances and have varying degrees of substance use.

Meta-analysis of drug-related deaths soon after release from prison

Aims The transition from prison back into the community is particularly hazardous for drug-using offenders whose tolerance for heroin has been reduced by imprisonment. Studies have indicated an increased risk of drug-related death soon after release from prison, particularly in the first 2 weeks. For precise, up-to-date understanding of these risks, a meta-analysis was conducted on the risk of drug-related death in weeks 1 + 2 and 3 + 4 compared with later 2-week periods in the first 12 weeks after release from prison. Methods English-language studies were identified that followed up adult prisoners for mortality from time of index release for at least 12 weeks. Six studies from six prison systems met the inclusion criteria and relevant data were extracted independently. Results These studies contributed a total of 69 093 person-years and 1033 deaths in the first 12 weeks after release, of which 612 were drug-related. A three- to eightfold increased risk of drug-related death was found when comparing weeks 1 + 2 with weeks 3–12, with notable heterogeneity between countries: United Kingdom, 7.5 (95% CI: 5.7–9.9); Australia, 4.0 (95% CI: 3.4–4.8); Washington State, USA, 8.4 (95% CI: 5.0–14.2) and New Mexico State, USA, 3.1 (95% CI: 1.3–7.1). Comparing weeks 3 + 4 with weeks 5–12, the pooled relative risk was: 1.7 (95% CI: 1.3–2.2). Conclusions These findings confirm that there is an increased risk of drug-related death during the first 2 weeks after release from prison and that the risk remains elevated up to at least the fourth week.

Acute risk of drug‐related death among newly released prisoners in England and Wales

AIMS To investigate drug-related deaths among newly released prisoners in England and Wales. DESIGN Database linkage study. PARTICIPANTS National sample of 48,771 male and female sentenced prisoners released during 1998-2000 with all recorded deaths included to November 2003. FINDINGS There were 442 recorded deaths, of which 261 (59%) were drug-related. In the year following index release, the drug-related mortality rate was 5.2 per 1000 among men and 5.9 per 1000 among women. All-cause mortality in the first and second weeks following release for men was 37 and 26 deaths per 1000 per annum, respectively (95% of which were drug-related). There were 47 and 38 deaths per 1000 per annum, respectively, among women, all of which were drug-related. In the first year after prison release, there were 342 male deaths (45.8 were expected in the general population) and there were 100 female deaths (8.3 expected in the general population). Drug-related deaths were attributed mainly to substance use disorders and drug overdose. Coronial records cited the involvement of opioids in 95% of deaths, benzodiazepines in 20%, cocaine in 14% and tricyclic antidepressants in 10%. Drug-related deaths among men were more likely to involve heroin and deaths among women were more likely to involve benzodiazepines, cocaine and tricyclic antidepressants. CONCLUSIONS Newly released male and female prisoners are at acute risk of drug-related death. Appropriate prevention measures include overdose awareness education, opioid maintenance pharmacotherapy, planned referral to community-based treatment services and a community overdose-response using opioid antagonists.

Mephedrone: use, subjective effects and health risks.

AIMS To assess the patterns of use, subjective effect profile and dependence liability of mephedrone, supported by corroborative urine toxicology. DESIGN Cross-sectional structured telephone interview. SETTING UK-based drug users associated with the dance music scene. PARTICIPANTS A total of 100 mephedrone users, recruited through their involvement with the dance music scene. MEASUREMENTS Assessment of pattern of use, acute and after effects, DSM dependence criteria and gas chromatography-mass spectrometry urinalysis. FINDINGS Mephedrone consumption results in typical stimulant-related subjective effects: euphoria, increased concentration, talkativeness, urge to move, empathy, jaw clenching, reduced appetite and insomnia. Thirty per cent of the sample potentially met criteria for DSM-IV dependence and there was evidence of a strong compulsion to use the drug (47% had used the drug for 2 or more consecutive days). Self-reported recent consumption of mephedrone was confirmed by toxicological analysis in all of the 14 participants who submitted a urine sample. CONCLUSION Mephedrone has a high abuse and health risk liability, with increased tolerance, impaired control and a compulsion to use, the predominant reported dependence symptoms.

Treatment retention and 1 year outcomes for residential programmes in England.

This paper reports changes in substance use behaviours at 1-year follow-up, and investigates the relationship between time in treatment and observed outcomes. A total of 408 clients were interviewed at intake to 23 residential treatment programmes, and 286 (70%) of these were interviewed at 1 year. Substantial improvements were found in terms of abstinence from opiates, psychostimulants and benzodiazepines. At 1 year, half of the clients were abstinent from heroin. Reductions in injecting, sharing injecting equipment, heavy drinking and criminal behaviour were found. Critical treatment thresholds were identified using multiple logistic regression analyses. Longer stays in treatment were predictive of better 1 year outcomes.

Outcomes after methadone maintenance and methadone reduction treatments: two-year follow-up results from the National Treatment Outcome Research Study

This paper provides a detailed analysis of the 2-year outcomes for 351 drug misusers allocated on an intention-to-treat basis to methadone maintenance or methadone reduction treatments. Both groups showed substantial reductions in their use of illicit drugs and in other outcome areas. However, whereas most methadone maintenance patients received maintenance, only about one third of those allocated to methadone reduction received methadone reduction, and many actually received a form of methadone maintenance. Reduction patients were more likely to receive low doses of methadone, and were less likely to remain in treatment. For maintenance patients, higher doses and retention in treatment were both associated with improvements in illicit heroin use at 2 years. For the reduction patients, the more rapidly the methadone was reduced, the worse the heroin use outcomes. For patients in both treatment conditions, reductions in heroin use were associated with improvements in other outcome areas. The more severely dependent patients showed better outcomes in methadone maintenance. Methadone reduction treatment processes were associated with poor outcomes, and many patients who were allocated to methadone reduction treatment did not receive reduction treatment as intended. This calls into question the appropriateness of either the initial treatment planning process or the treatment delivery process, or both. A clearer distinction should be made between methadone maintenance and methadone reduction. Treatment goals should be made explicit both to the patient and to the clinical staff at the start of treatment. We suggest the need for a reappraisal of the goals and procedures of methadone reduction treatment.

Psychotic symptoms in methamphetamine psychotic in-patients

The present study was aimed at exploring the prevalence and factor structure of methamphetamine (MA) psychotic symptoms. The data were obtained from a cross-country evaluation of substance use, health, and treatment in MA psychotic in-patients. The prevalence rates of lifetime and current psychotic symptoms were determined by using Mini-International Neurospychiatric Interview-Plus, Module M. The Manchester scale was used to assess the severity of psychotic symptoms during the week prior to assessment. All eight items of the Manchester scale were subjected to principal-component analysis, eigenvalue one test, and varimax rotation. The data of 168 patients (127 male and 41 female) included in the analyses were obtained from Australia, Japan, the Philippines and Thailand. Persecutory delusion was the most common lifetime psychotic symptom found in 130 participants (77.4%), followed by auditory hallucinations, strange or unusual beliefs, and thought reading. Auditory hallucinations were the most common current symptom found in 75 participants (44.6%), followed by strange or unusual beliefs and visual hallucinations. Current negative symptoms were also found in 36 patients (21.4%). Apart from a factor of anxiety and depression, the results yielded a two-factor model of MA psychotic symptoms, which were negative and positive/disorganized syndromes. The negative syndrome comprised poverty of speech, psychomotor retardation, and flattened/incongruous affects. The positive syndrome consisted of delusions, hallucinations, and incoherent speech. Both positive/disorganized and negative syndromes should be taken into account in assessing MA psychotic symptoms. The clinical findings do not support the shortcomings of amphetamine-induced psychosis in modelling the negative symptoms of schizophrenia.

Development of the treatment outcomes profile

AIM To develop the Treatment Outcomes Profile (TOP), a new instrument for monitoring substance misuse treatment. DESIGN Prospective cohort, psychometric evaluation with 7-day retest and 1-month follow-up to assess inter-rater reliability, concurrent, discriminant and construct validity, and change sensitivity. PARTICIPANTS A sample of 1021 service users, aged 16-62 years. Recruitment from 63 treatment agencies in England, collectively providing opioid substitution treatment, psychosocial interventions, in-patient detoxification and residential rehabilitation. MEASUREMENTS Thirty-eight frequency, rating scale and period prevalence measures, with 28-day recall, across substance use, health, crime and social functioning domains, administered as personal interview by 163 treatment keyworkers. FINDINGS Twenty outcome measures met inter-rater reliability criteria: days used alcohol, opioids, crack cocaine, cocaine powder, amphetamines, cannabis and one other named substance; days injected and period prevalence of direct or indirect needle/syringe sharing; subjective rating of physical and psychological health; days committed shop theft and drug selling, period prevalence of vehicle, property, fraud/forgery and assault/violence offences; rating of quality of life; days worked and attended for education/training; and period prevalence of acute housing problems and risk of eviction. Intraclass correlation coefficients for scale measures and Cohens kappa for dichotomous measures reached or exceeded 0.75 and 0.61, respectively. There were satisfactory validity assessments and change sensitivity of scale items judged by effect size and smallest detectable difference. The TOP clinical tool contains an additional 10 items for individual treatment planning and review. CONCLUSIONS The TOP is a reliable and valid 20-item instrument for treatment outcomes monitoring.

Mephedrone: still available and twice the price

In April, 2010, the β ketoamfetamine stimulant mephedrone (4-methylmethcathinone) and several similar compounds were classified as Class B substances in the UK under the Misuse of Drugs Act. Legislation was prom pted by public health concerns, with the expectation that these controls would limit availability and use. As part of our group’s ongoing research into new synthetic drugs, we did an online survey of 150 mephedrone users (average age 24 years) in June, 2010. We have compared our fi ndings with those from a previous online survey we did in November, 2009, and a telephone interview of users in 2010 before the legislation. Our key objective in this comparison was to assess whether the new legislative control of mephedrone had aff ected its availability and use. Of the 150 respondents to the 2010 survey, 95 (63%) reported that they had continued to use mephedrone since the law had changed. 52 of these respondents (55%) said that they intended to continue using the same amount of mephedrone, and 38 (40%) reported that they would now use less. 85 respondents (57%) had bought mephedrone from a dealer, an increase of almost 40% from the 41% who had reported purchasing from a dealer in the telephone study of users done before legislation. In the current 2010 survey, the mean price per gram paid for mephedrone was £16 (mode, £20), compared with a mean price of £10 when the drug was obtainable online before legislation. These fi ndings suggest that classifi cation of mephedrone has had a limited eff ect on controlling its availability and use. Before the introduction of the legislation, users generally obtained mephedrone via the internet. Now they buy it from street dealers, on average at double the price. We suspect that, in time, there are likely to be reductions in purity, and increases in health harms.

Change and stability of change after treatment of drug misuse: 2-year outcomes from the National Treatment Outcome Research Study (UK)

The National Treatment Outcome Research Study (NTORS) is a longitudinal, multisite, prospective cohort study that assesses changes in illicit drug use and other problems after treatment in national (UK) drug misuse treatment programmes. Clients were recruited from 54 residential and community-based drug treatment programmes throughout England. Four modalities were studied: inpatient drug dependence units, residential/rehabilitation programmes, methadone maintenance, and methadone reduction programmes. Data on substance use behaviours and physical and psychological health were collected by structured face-to-face interviews at intake, 1- and 2-year follow-up. Data are presented for 549 clients. A majority of clients achieved widespread improvements across a range of outcome measures after treatment in existing treatment services. For most outcomes, reductions in problem behaviours at the group level occurred within the first year and were maintained at 2 years. Considerable stability of outcomes at the individual level was also found. Abstinence from illicit drugs was substantially increased among clients from both residential and community programmes, and there were also substantial reductions in frequency of use of heroin, nonprescribed methadone, benzodiazepines, and crack cocaine. Injecting and shared use of injecting equipment was also reduced. Heavy drinking was common at intake and was not reduced at follow-up. Psychological and physical health problems were reduced on both groups at follow-up. These changes represent important clinical benefits to the individual clients, to their families, and to society.