Jonas Berge

Benzodiazepine, z-drug and pregabalin prescriptions and mortality among patients in opioid maintenance treatment—A nation-wide register-based open cohort study

BACKGROUND Use of sedatives may increase risk of death in opioid users. The aim of the study was to assess whether prescription of sedatives may be associated with mortality in patients in opioid maintenance treatment. METHODS This retrospective register-based open cohort study included nation-wide register data including all individuals who were dispensed methadone or buprenorphine as opioid maintenance treatment for opioid dependence between July, 2005 and December, 2012 (N=4501). Outcome variables were overdose mortality and non-overdose mortality, respectively. Extended Cox regression analyses examined associations between type of sedative prescriptions and death, controlling for sex, age, previous overdoses and suicide attempts, psychiatric in-patient treatment and opioid maintenance treatment status. Opioid maintenance was assumed to last for 90days (or 30days in a sensitivity analysis) after the last methadone or buprenorphine prescription. RESULTS Benzodiazepine prescriptions were associated with non-overdose death (HR: 2.02, 95% CI: 1.29-3.18) but not significantly associated with overdose death (1.49, 0.97-2.29). Z-drug (1.60, 1.07-2.39) and pregabalin prescriptions (2.82, 1.79-4.43) were associated with overdose death. In the sensitivity analysis, all categories of sedatives, including benzodiazepines, were significantly associated with overdose death. CONCLUSIONS Caution is advised when prescribing sedative drugs, including benzodiazepines, z-drugs and pregabalin, to patients in opioid maintenance treatment.

Role of parenting styles in adolescent substance use: results from a Swedish longitudinal cohort study

Objective Adolescent substance use is an area of concern because early substance use is associated with a higher risk of adverse outcomes. Parenting style, defined as the general style of parenting, as well as substance-specific parenting practices may influence childrens substance use behaviour. The present study aims to probe the impact of parenting style on adolescent substance use. Method A cohort of 1268 adolescents (48% girls), aged 12–13 years at baseline, from 21 junior high schools was assessed in the first semester of junior high school, and then again in the last semester of the 9th grade, 32 months later. Parenting style, operationalised as a fourfold classification of parenting styles, including established risk factors for adolescent substance use, were measured at baseline. Results Neglectful parenting style was associated with worse substance use outcomes across all substances. After adjusting for other proximal risk factors in multivariate analyses, parenting style was found to be unrelated to substance use outcomes with one exception: authoritative parenting style was associated with less frequent drinking. Association with deviant peers, delinquent behaviour, provision of alcohol by parents, and previous use of other substances were associated with substance use outcomes at follow-up. Conclusions The results of the present study indicate that parenting style may be less important for adolescent substance use outcomes than what has previously been assumed, and that association with deviant peers and delinquent behaviour may be more important for adolescent substance use outcomes than general parenting style.

Does the pattern of amphetamine use prior to incarceration predict later psychosis? A longitudinal study of amphetamine users in the Swedish criminal justice system

OBJECTIVES The aim of this longitudinal study was to investigate the relationship between self-reported amphetamine use prior to inclusion in the criminal justice system and hospitalization due to psychosis in the years following release. METHOD All the information was extracted from existing databases. Amphetamine-using clients in the criminal justice system in Sweden were identified using the European version of the addiction severity index (Europ-ASI) interview. Between 2001 and 2006, a total of 1709 individuals were identified. A follow-up of the subjects, using national registry data, was conducted in 2010. The outcome measure was hospitalization for primary or substance-induced psychotic episodes during the follow-up period. Data was analyzed in a multivariate logistic regression model. RESULTS Age of onset of amphetamine use, number of years used, and use in the month prior to baseline interview were all unrelated to risk of future hospitalization due to psychosis. Prior psychiatric hospitalization and experience of hallucinations not related to drug use, as well as being born outside of a Nordic country and being homeless, were all positively linked to hospitalization due to psychosis. CONCLUSIONS This study demonstrates that, in a cohort of amphetamine users within the criminal justice system, prior psychiatric morbidity and demographic risk factors are more important than baseline patterns of amphetamine use in predicting future risk of hospitalization due to psychosis.

Alcohol and drug use in groups of cannabis users: Results from a survey on drug use in the Swedish general population

BACKGROUND AND OBJECTIVES Although cannabis is well studied in the scientific literature, relatively little is known about the relationship between the frequency of cannabis use and the use of alcohol and other drugs. The aim of this study was to identify differences between frequent and occasional cannabis users with respect to the use of other illicit drugs, hazardous alcohol use, and unauthorized use of prescription drugs. METHODS Results from a questionnaire on drug use taken by 22,095 individuals in the Swedish general population were analyzed with a logistic regression model. Active cannabis use was defined as having used cannabis in the past 12 months. Use of cannabis two-to-three times per week or more was classified as frequent use. RESULTS Cannabis users were more likely to report hazardous alcohol use, use of other illicit drugs, and unauthorized use of prescription drugs than were non-users. Within the group of active cannabis users, frequent cannabis use, compared to occasional use, was associated with the use of other illicit drugs and negatively associated with hazardous alcohol use. DISCUSSION AND CONCLUSIONS The association between cannabis use and hazardous alcohol use, use of other illicit drugs, and unauthorized use of prescription drugs was expected. However, the negative association between frequent cannabis use and hazardous alcohol use among active cannabis users was surprising. This indicates that frequent cannabis users may differ from more occasional users in clinical needs. SCIENTIFIC SIGNIFICANCE These results show a previously unknown characteristic of the association between frequency of cannabis use and hazardous alcohol use in the general population.

Long-term risk factors for substance-induced and primary psychosis after release from prison. A longitudinal study of substance users

PURPOSE The purpose of this study was to determine long-term risk factors for substance-induced and primary psychosis after release from prison. MATERIAL We used a longitudinal register-based cohort study combining European version of Addiction Severity Index (Europ-ASI) interviews and the Swedish inpatient register. The study included 6217 individuals who were in the Swedish criminal justice system from 2001 to 2006. MEASUREMENTS The outcomes were substance-induced and primary psychosis as defined by the International Classification of Disease - 10th version. All variables for estimating baseline risk were drawn from the Europ-ASI interview, and included information on substance use, demographics and health. The interview database and the inpatient register were coupled, and groups were compared by using tests of significance and logistic regression. RESULTS Polydrug use was the strongest predictor for substance induced psychosis (OR=9.55, 95% CI 3.42-26.67), but all substances imposed an increased risk. Previous psychiatric hospitalization and non-drug related hallucinations were significant, but weaker, risk factors. The only substance variable that predicted primary psychosis was cannabis (OR=2.62, 95% CI 1.39-4.96), but previous psychiatric hospitalization (OR=3.22, 95% CI 2.27-4.54) and non-drug related hallucinations (OR=4.00, 95% CI 2.82-5.67) were even stronger predictors. CONCLUSIONS Cannabis use was a risk factor for primary psychosis, but other health related individual risk factors were even more important. Polydrug use was the strongest risk factor for substance-induced psychosis.

Parental Awareness of Substance Use Among Adolescents in a Junior High School Sample

There is a lack of studies assessing parental awareness of adolescent alcohol, cigarette, and drug use in the general adolescent population. A total of 1,426 adolescents aged 14 to 16, and their parents, answered questions about adolescent substance use annually during junior high school. Sensitivity for parental report of adolescent substance use was low: 5.6% to 26% for drunkenness, 14.3% to 20.6% for cigarettes, and 4.9% to 12% for illicit drugs. Higher age and higher frequency of use were positively associated with parental awareness of drunkenness and cigarette use. Female sex was associated with higher parental awareness of drunkenness. Higher school performance was negatively associated with parental awareness of drunkenness in Grade 9 and with cigarette use in Grades 8 to 9. Parental awareness of adolescent drunkenness, and cigarette and illicit drug use in the general population is low. Factors of importance for parental awareness are identified.

Opioid and amphetamine dependence is associated with methicillin-resistant Staphylococcus aureus (MRSA): An epidemiological register study with 73,201 Swedish in- and outpatients 1997-2013.

Abstract Background: While methicillin-resistant Staphylococcus aureus (MRSA) is increasing in prevalence globally, Sweden is still a low-prevalence country enabling studies on the natural MRSA spread in subpopulations unaffected by a surrounding highly infected population. Substance dependence and injection drug use have been risk factors for MRSA carriage and infection in other countries. In this retrospective, longitudinal register study, we investigated MRSA epidemiology 1997–2013 in opioid and amphetamine-dependent individuals, in comparison with alcohol-dependent subjects. Methods: Data from the national Swedish in- and outpatients registers included 73,201 individuals from 1997, 1999, 2004, 2009 and 2013. We analyzed substance use disorder and demographic predictors for MRSA using generalized estimating equations. Results: The main finding was that both opioid (adjusted odds ratio [AOR] = 2.82; 95% confidence interval [CI] = 2.16, 3.67) and amphetamine dependence (AOR = 2.71; 95% CI = 1.70, 4.16) were significantly associated with MRSA diagnosis compared with alcohol dependence, when adjusting for age, sex and year. Conclusions: These findings are of value to understand the dynamics of MRSA epidemiology among substance dependent persons with presumably low socioeconomic status and potential injection drug use, and implicate repeated surveillance of MRSA among these patients.

Both localized and systemic bacterial infections are predicted by injection drug use: A prospective follow-up study in Swedish criminal justice clients

Background Both skin and soft tissue infections (SSTI) and systemic bacterial infections are common in people who inject drugs (PWID), but data on incidence and risk factors are lacking. We compared registered diagnoses for such infections in Swedish criminal justice clients with regard to injecting drug use. Methods Baseline interview data from the Swedish Prison and Probation Service on drug use in PWID and non-PWID with problematic alcohol use were linked to follow-up data from national Swedish registers on hospital diagnoses and/or death. Associations between drug use and later diagnosis of SSTI and systemic bacterial infection (septicemia or bacterial infection of the heart, bone/joints or central nervous system) were analyzed by Cox regression. Results Incidence rates of SSTI was 28.3 per 1,000 person-years for PWID (n = 2,444) and 10.0 for non-PWID with problematic alcohol use (n = 735). Incidence rates of systemic bacterial infection was 9.1 per 1,000 person-years for PWID and 2.7 per 1,000 person-years for non-PWID. Injection drug use was associated with a significantly increased risk of bacterial infections, for main drugs heroin (SSTI: Hazard ratio [HR] 2.45; systemic infection: HR 2.75), amphetamine (SSTI: HR 1.60; systemic infection: HR 2.19), and polysubstance use (SSTI: HR 1.92; systemic infection: HR 2.01). In relation to injection use of amphetamine and polysubstance use, PWID mainly using heroin had higher risk of SSTI. Conclusions Injection drug use predicted both SSTI and systemic bacterial infection, with a particularly high risk of SSTI in PWID mainly using heroin. The results imply the need for increased attention to bacterial infections among PWID, in terms of clinical management, prevention and research.

Gambling Disorder in Male Violent Offenders in the Prison System: Psychiatric and Substance-Related Comorbidity

Gambling disorder is an addiction that can cause major suffering, and some populations seem to be more vulnerable than others. Offender populations have a remarkably high prevalence of gambling problems and they are also over-represented in a number of diagnoses related to gambling disorder, like substance use disorders and antisocial personality disorder. Yet, there are few studies investigating gambling disorder prevalence and related psychiatric comorbidity in this group. This study aims to investigate the prevalence of, and association between, gambling disorder and other psychiatric diagnoses in a sample of young, male violent offenders. Two hundred and sixty-four male offenders, all serving sentences for violent crimes (recruited between 2010 and 2012) participated in this study and went through comprehensive psychiatric evaluation, including assessment for Diagnostic and Statistical Manual of Mental Disorders 4th Edition criteria. Sixteen percent of the participants met criteria for gambling disorder. Antisocial personality disorder, cannabis, cocaine and anabolic steroids abuse were significantly more common among participants with gambling disorder. The gambling disorder group also showed significantly lower educational attainment. Cocaine abuse and failure to graduate elementary and middle school in expected time were independently associated with gambling disorder in a regression analysis. This study confirms the previously described high prevalence of gambling disorder in offenders. The psychiatric comorbidity was high and the problems had started early, with lower educational attainment in the gambling disorder group. The findings stress the importance of increased awareness of gambling problems among convicted offenders and of gambling research on young people with delinquent behavior. There is a need of more research to investigate this further, in order to develop preventive strategies and treatment.