Kathleen M. Grant

Methamphetamine-Associated Psychosis

Methamphetamine (METH) is a frequent drug of abuse in U.S. populations and commonly associated with psychosis. This may be a factor in frequent criminal justice referrals and lengthy treatment required by METH users. Persecutory delusions and auditory hallucinations are the most consistent symptoms of METH-associated psychosis (MAP). MAP has largely been studied in Asian populations and risk factors have varied across studies. Duration, frequency and amount of use as well as sexual abuse, family history, other substance use, and co-occurring personality and mood disorders are risk factors for MAP. MAP may be unique with its long duration of psychosis and recurrence without relapse to METH. Seven candidate genes have been identified that may be associated with MAP. Six of these genes are also associated with susceptibility, symptoms, or treatment of schizophrenia and most are linked to glutamatergic neurotransmission. Animal studies of pre-pulse inhibition, attenuation of social interaction, and stereotypy and alterations in locomotion are used to study MAP in rodents. Employing various models, rodent studies have identified neuroanatomical and neurochemical changes associated with METH use. Throughout this review, we identify key gaps in our understanding of MAP and suggest potential directions for future research.

Bupropion Attenuates Methamphetamine Self-Administration in Adult Male Rats

Bupropion is a promising candidate medication for methamphetamine use disorder. As such, we used a preclinical model of drug-taking to determine the effects of bupropion on the reinforcing effects of methamphetamine (0.025, 0.05 or 0.1 mg/kg/infusion). Specificity was determined by investigating the effects of bupropion on responding maintained by sucrose. In the self-administration study, rats were surgically prepared with indwelling jugular catheters and trained to self-administer methamphetamine under an FR5 schedule. A separate group of rats was trained to press a lever for sucrose. Once responding stabilized, rats were pretreated with bupropion (0, 10, 30 and 60 mg/kg i.p.) 5 min before chamber placement in a unique testing order. Following acute testing, rats were then repeatedly pretreated with 30 and 60 mg/kg bupropion. Acute treatments of bupropion dose dependently reduced drug intake for 0.025-0.1 mg/kg methamphetamine; sucrose deliveries were only reduced with the high bupropion dose. Repeated exposure to 60 mg/kg bupropion before the session resulted in a consistent decrease in methamphetamine intake (0.05 and 0.1 mg/kg) and sucrose deliveries. Considered together, this pattern of findings demonstrates that bupropion decreases responding for methamphetamine, but the effects are only somewhat specific.

Psychological Burden and Gender Differences in Methamphetamine-Dependent Individuals in Treatment.

ABSTRACT Background and Objectives: Little is known about gender differences in methamphetamine (METH)-dependent users. The objective of this study was to examine potential gender differences in four domains: drug use history, psychological burden, current symptomology, and coping strategy. Methods: One hundred twenty four METH-dependent individuals (men; n = 75) were enrolled from substance use treatment programs. Participants filled out detailed questionnaires in the four domains. Results: Men reported earlier first alcohol and drug use than women, but there was no difference in the age of first METH use or frequency of METH use. Women reported experiencing problems because of METH use at a younger age. Women were also more likely to have injected METH in the past year and they reported greater severity of drug problems compared to men. METH-dependent women had greater psychological burden, reported more use of an emotional-coping strategy, and had greater childhood emotional and sexual trauma. Conclusions: Overall, this study suggests that, unlike many other illicit drugs, severity of use and problems associated with use were not elevated in METH-dependent men compared to women. In fact, several factors indicated more severe patterns of use or risk factors in women.

Associations between family history of substance use, childhood trauma, and age of first drug use in persons with methamphetamine dependence

Objectives:The current study examined the association among family history of substance use problems, childhood maltreatment, and age of first drug use in a sample of men and women seeking treatment for methamphetamine dependence. Various forms of childhood maltreatment were considered as mediators of the association between family history of substance use problems and age of first drug use. Methods:Participants (N = 99, 40% women, mean age 33) who were under treatment for methamphetamine dependence completed a baseline interview that obtained demographic information, past substance use by participants, history of drug/alcohol problems in their family of origin, and age at first use of any drug (excluding alcohol and tobacco). The Early Trauma Inventory Self-Report-Short Form was used to assess child maltreatment experiences before the age of 18. Results:Family history of substance use problems and childhood physical (but not emotional or sexual) trauma significantly predicted age of first drug use. Further, childhood physical trauma mediated the association between family history of substance use problems and age of first drug use. Conclusions:These findings suggest that the experience of childhood physical abuse may be an important mechanism through which family history of substance use is associated with an earlier age of first drug use.

Trauma and Substance Use Disorders in Rural and Urban Veterans.

CONTEXT Disparities in the prevalence, morbidity, and mortality of multiple mental health conditions have been described between rural and urban populations. However, there is limited information regarding differences in exposure to trauma and trauma-related mental health conditions in these populations. Given the number of veterans who are returning to rural communities after serving in Operation Enduring Freedom and Operation Iraqi Freedom, differences in trauma exposure are of particular relevance. Trauma exposure is related to a variety of mental health disorders including substance use disorders (SUD). PURPOSE The objectives of this preliminary study were to describe lifetime military and nonmilitary trauma and to compare trauma history between rural and urban veterans in SUD treatment. METHODS Sixty adults in SUD treatment were enrolled at 3 Veterans Health Administration sites in Nebraska over a 3-month period in 2008. Subjects completed an interview with study staff, which assessed SUD diagnoses and childhood, lifetime, and military trauma. Rural or urban status was determined by self-report of childhood residence. Childhood trauma, lifetime trauma, and response to military trauma were compared between rural and urban veterans. FINDINGS Although there were no significant differences in trauma exposure between rural and urban groups, there was an association between specific types of trauma and measures typically associated with increased substance abuse severity and poorer SUD treatment outcome. CONCLUSION This is the first study, to our knowledge, which compared trauma exposure between rural and urban veterans and identified an association between childhood trauma exposure and multiple SUD treatment attempts.

Community-Level Barriers to Recovery for Substance-Dependent Rural Residents

This article identifies potential barriers to substance use recovery associated with rural residence. The evidence is discussed and illustrated with examples. Fourteen specific barriers to substance abuse recovery are identified within 4 broad categories: access to treatment services, access to other professionals, access to peer support groups, and barriers to confidentiality. Although telehealth, expansion of mental health care, intensive referral, and other efforts might enhance access to care, the evidence suggests practitioners and researchers should remain aware of community-level barriers to recovery from substance use disorder and work with clients to overcome them.

The Veteran-Initiated Electronic Care Coordination: A Multisite Initiative to Promote and Evaluate Consumer-Mediated Health Information Exchange

INTRODUCTION Information continuity is critical to person-centered care when patients receive care from multiple healthcare systems. Patients can access their electronic health record data through patient portals to facilitate information exchange. This pilot was developed to improve care continuity for rural Veterans by (1) promoting the use of the Department of Veterans Affairs (VA) patient portal to share health information with non-VA providers, and (2) evaluating the impact of health information sharing at a community appointment. MATERIALS AND METHODS Veterans from nine VA healthcare systems were trained to access and share their VA Continuity of Care Document (CCD) with their non-VA providers. Patients and non-VA providers completed surveys on their experiences. RESULTS Participants (n = 620) were primarily older, white, and Vietnam era Veterans. After training, 78% reported the CCD would help them be more involved in their healthcare and 86% planned to share it regularly with non-VA providers. Veterans (n = 256) then attended 277 community appointments. Provider responses from these appointments (n = 133) indicated they were confident in the accuracy of the information (97%) and wanted to continue to receive the CCD (96%). Ninety percent of providers reported the CCD improved their ability to have an accurate medication list and helped them make medication treatment decisions. Fifty percent reported they did not order a laboratory test or another procedure because of information available in the CCD. CONCLUSIONS This pilot demonstrates feasibility and value of patient access to a CCD to facilitate information sharing between VA and non-VA providers. Outreach and targeted education are needed to promote consumer-mediated health information exchange.

Stress, Depression, and Occupational Injury among Migrant Farmworkers in Nebraska

Agriculture is one of the most dangerous industries in the United States. Farmworkers, including migrant farmworkers, are at risk for work-related injuries. This study explores the association between stress, depression, and occupational injury among migrant farmworkers in Nebraska. Occupational injury was hypothesized to significantly increase the odds of farmworkers being stressed and depressed. Two hundred migrant farmworkers (mean age = 33.5 years, standard deviation (SD) = 12.53; 93.0% men, 92.9% of Mexican descent) were interviewed. In bivariate analyses, results indicated that stress and depression were positively associated with occupational injury. Two logistic regression models were developed. Occupational injury was a significant factor for depression, but not for stress. Participants who had been injured on the job were over seven times more likely to be depressed. These results highlight the interconnection between the work environment and mental health. More must be done to foster well-being in rural, agricultural communities. Improving occupational health and safety information and training, integrating behavioral health services into primary care settings, and strengthening the protections of the Migrant and Seasonal Agricultural Worker Protection Act may improve conditions for migrant farmworkers in the rural Midwest.

Intensive referral to mutual-help groups: A field trial of adaptations for rural veterans

OBJECTIVE A multisite field trial testing whether improved outcomes associated with intensive referral to mutual help groups (MHGs) could be maintained after the intervention was adapted for the circumstances and needs of rural veterans in treatment for substance use disorder (SUD). METHODS In three Veterans Affairs treatment programs in the Midwest, patients (N=195) received standard referral (SR) or rural-adapted intensive referral (RAIR) and were measured at baseline and 6-month follow-up. RESULTS Both groups reported significant improvement at 6-months, but no significant differences between SR and RAIR groups in MHG participation, substance use, addiction severity, and posttraumatic stress symptoms. Inconsistent delivery of the intervention resulted in only one-third of the RAIR group receiving the full three sessions, but this group reported significantly greater 6-month abstinence from alcohol than those receiving no sessions. CONCLUSION Further research should explore implementation problems and determine whether consistent delivery of the intervention enhances 12-step facilitation. PRACTICE IMPLICATIONS The addition of rural-specific elements to the original intensive referral intervention has not been shown to increase its effectiveness among rural veterans.

Development of a Discrete Choice Experiment (DCE) Questionnaire to Understand Veterans’ Preferences for Tobacco Treatment in Primary Care

BackgroundProviders often prescribe counseling and/or medications for tobacco cessation without considering patients’ treatment preferences.ObjectiveThe primary aims of this study are to describe (1) the development of a discrete choice experiment (DCE) questionnaire designed to identify the attributes and levels of tobacco treatment that are most important to veterans; and (2) the decision-making process in choosing between hypothetical tobacco treatments.MethodsWe recruited current smokers who were already scheduled for a primary care appointment within a single Veterans Affairs (VA) healthcare system. Subjects were asked to rate the importance of selected treatment attributes and were interviewed during two rounds of pilot testing of initial DCE instruments. Key attributes and levels of the initial instruments were identified by targeted literature review; the instruments were iteratively revised after each round of pilot testing. Using a ‘think aloud’ approach, subjects were interviewed while completing DCE choice tasks. Constant comparison techniques were used to characterize the issues raised by subjects. Findings from the cognitive interviews were used to revise the initial DCE instruments.ResultsMost subjects completed the DCE questionnaire without difficulty and considered two or more attributes in choosing between treatments. Two common patterns of decision-making emerged during the cognitive interviews: (1) counting ‘pros’ and ‘cons’ of each treatment alternative; and (2) using a ‘rule-out’ strategy to eliminate a given treatment choice if it included an undesirable attribute. Subjects routinely discounted the importance of certain attributes and, in a few cases, focused primarily on a single ‘must-have’ attribute.ConclusionCognitive interviews provide valuable insights into the comprehension and interpretation of DCE attributes, the decision processes used by veterans during completion of choice tasks, and underlying reasons for non’-compensatory decision-making.