Silke Behrendt

Transitions from first substance use to substance use disorders in adolescence: Is early onset associated with a rapid escalation?

BACKGROUND Early substance use (SU) in adolescence is known to be associated with an elevated risk of developing substance use disorders (SUD); it remains unclear though whether early SU is associated with more rapid transitions to SUD. OBJECTIVE To examine the risk and speed of transition from first SU (alcohol, nicotine, cannabis) to SUD as a function of age of first use. METHODS N=3021 community subjects aged 14-24 years at baseline were followed-up prospectively over 10-years. SU and SUD were assessed using the DSM-IV/M-CIDI. RESULTS (1) The conditional probability of substance-specific SU-SUD transition was the greatest for nicotine (36.0%) and the least for cannabis (18.3% for abuse, 6.2% for dependence) with alcohol in between (25.3% for abuse; 11.2% for dependence). (2) In addition to confirming early SU as a risk factor for SUD we find: (3) higher age of onset of any SU to be associated with faster transitions to SUD, except for cannabis dependence. (4) Transitions from first cannabis use (CU) to cannabis use disorders (CUD) occurred faster than for alcohol and nicotine. (5) Use of other substances co-occurred with risk and speed of transitions to specific SUDs. CONCLUSION Type of substance and concurrent use of other drugs are of importance for the association between age of first use and the speed of transitions to substance use disorders. Given that further research will identify moderators and mediators affecting these differential associations, these findings may have important implications for designing early and targeted interventions to prevent disorder progression.

The natural course of cannabis use, abuse and dependence during the first decades of life.

AIMS There has been little available information on the long-term natural course, persistence and remission of cannabis use, abuse and dependence. The current study estimated rates and risk factors associated with stability and variation in cannabis use patterns, cannabis abuse and cannabis dependence in a community sample over a 10-year period. DESIGN, SETTING AND PARTICIPANTS Prospective longitudinal, epidemiological study with a 4- and 10-year follow-up of a community sample (n = 3021) aged 14-24 years at baseline in Munich, Germany. MEASUREMENTS Cannabis use, abuse and dependence and associated risk factors were assessed by face-to-face interviews using the Munich Composite International Diagnostic Interview. Findings At baseline, one-third of the sample (34.2%) had used cannabis at least once. The cumulative incidence of cannabis use 10 years later was 50.7%. Fifty-six per cent of all repeated users (five times or more) at baseline reported cannabis use at 4-year follow-up. Ten years later, this proportion had decreased slightly to only 46.3%. Repeated (five times or more) users were almost three times more likely to report repeated use at 10-year follow up (OR = 2.8, 95% CI = 1.6-4.7), compared with those who had used cannabis fewer times. Peer use of cannabis, life-events and alcohol dependence also predicted use of cannabis at 10-year follow-up. CONCLUSIONS Among youth who have used cannabis repeatedly (five times or more) cannabis use is fairly stable and rates of remission relatively low until age 34 years. Patterns of progression suggest that early targeted preventive measures should delay first use and reduce the number of experiences using cannabis, as these factors appear critical in progression to persistent cannabis use and cannabis dependence.

What are the high risk periods for incident substance use and transitions to abuse and dependence? : implications for early intervention and prevention

Background: For a better understanding of the evolution of addictive disorders and the timely initiation of early intervention and prevention, we have to learn when and how quickly the critical transitions from first substance use (SU) to regular use and from first SU and regular SU to abuse and dependence occur. Little data are currently available on the transitions to substance use disorders (SUDs) across the spectrum of legal and illegal drugs taking into account gender differences. It is the aim of this paper to describe the high density incidence and transition periods of SU and SUD for alcohol, nicotine, cannabis and other illicit drugs for young males and females.

Socioeconomic differences in alcohol-attributable mortality compared with all-cause mortality: a systematic review and meta-analysis

BACKGROUND Factors underlying socioeconomic inequalities in mortality are not well understood. This study contributes to our understanding of potential pathways to result in socioeconomic inequalities, by examining alcohol consumption as one potential explanation via comparing socioeconomic inequalities in alcohol-attributable mortality and all-cause mortality. METHODS Web of Science, MEDLINE, PsycINFO and ETOH were searched systematically from their inception to second week of February 2013 for articles reporting alcohol-attributable mortality by socioeconomic status, operationalized by using information on education, occupation, employment status or income. The sex-specific ratios of relative risks (RRRs) of alcohol-attributable mortality to all-cause mortality were pooled for different operationalizations of socioeconomic status using inverse-variance weighted random effects models. These RRRs were then combined to a single estimate. RESULTS We identified 15 unique papers suitable for a meta-analysis; capturing about 133 million people, 3 741 334 deaths from all causes and 167 652 alcohol-attributable deaths. The overall RRRs amounted to RRR = 1.78 (95% confidence interval (CI) 1.43 to 2.22) and RRR = 1.66 (95% CI 1.20 to 2.31), for women and men, respectively. In other words: lower socioeconomic status leads to 1.5-2-fold higher mortality for alcohol-attributable causes compared with all causes. CONCLUSIONS Alcohol was identified as a factor underlying higher mortality risks in more disadvantaged populations. All alcohol-attributable mortality is in principle avoidable, and future alcohol policies must take into consideration any differential effect on socioeconomic groups.

Risk and speed of transitions to first alcohol dependence symptoms in adolescents : a 10-year longitudinal community study in Germany

BACKGROUND Although in many western countries alcohol use (AU) and symptoms of alcohol dependence (AD) are frequent in adolescence, temporal patterns and trajectories remain understudied. It is unclear whether early onset of AU is associated with the speed of transition to first AD symptoms and whether specific first AD symptoms and their timing are associated with AD. AIMS To examine (i) the incidence patterns of self-reported first AD symptoms; (ii) whether early AU is associated with the risk and speed of transition to first AD symptoms; and (iii) whether first AD symptoms and their timing are associated with AD. DESIGN A total of 3021 community subjects from Germany aged 14-24 years at baseline followed prospectively over 10 years. AU, AD symptoms and AD were assessed using the Munich-Composite International Diagnostic Interview (DIA-X/M-CIDI). FINDINGS Among first AD symptoms, tolerance (13.1%) and much time spent (5.0%) were most prevalent. Five to 30% of all first AD symptoms occurred during the first year after first AU. Early AU was not related to the risk of first AD symptoms. The speed of transition to first AD symptoms was greater among those with AU onset in later adolescence. Tolerance and loss of control were associated with AD development (risk difference 3.9% and 15.4%), as was early onset of tolerance, much time spent and loss of control. CONCLUSION Early AU and early AD symptoms are frequent among adolescents. Early self-reported tolerance, much time spent and loss of control are particularly predictive for AD and important targets for early preventive interventions.

Dysfunctional decision-making in pathological gambling: Pattern specificity and the role of impulsivity

Dysfunctional decision-making in individuals with pathological gambling (PGs) may result from dominating reward-driven processes, indicated by higher impulsivity. In the current study we examined (1) if PGs show specific decision-making impairments related to dominating reward-driven processes rather than to strategic planning deficits and (2) whether these impairments are related to impulsivity. Nineteen PGs according to DSM-IV and 19 matched control subjects undertook the Cambridge Gambling Task (CGT) to assess decision-making. The delay discounting paradigm (DDP) as well as the UPPS Impulsive Behavior Scale (measuring urgency, premeditation, perseverance and sensation seeking) were administered as multidimensional measures of impulsivity. Results revealed that (1) PGs exhibited higher risk seeking and an immediate reward focus in the CGT and, in contrast, comparable strategic planning to the control group. (2) Decision-making impairments were related to more severe delay discounting and, specifically, to increased urgency and less premeditation. Our findings suggest (1) the necessity to disentangle decision-making components in order to improve etiological models of PGs, and (2) that urgency and premeditation are specifically related to disadvantageous decision-making and should be tackled in intervention strategies focusing on emotion tolerance and control strategies.

The role of mental disorders in the risk and speed of transition to alcohol use disorders among community youth

BACKGROUND Among adolescents and young adults with DSM-IV alcohol use disorders (AUDs), there are inter-individual differences in the speed of transition from initial alcohol use (AU) to AUD. AUDs are highly co-morbid with other mental disorders. The factors associated with rapid transition from first AU to AUD remain unknown and the role of mental disorders in rapid transitions is unclear. Given this background we examined (1) whether prior anxiety, mood, externalizing and non-alcohol substance use disorders are related to the risk and speed of transition from first AU to DSM-IV alcohol abuse (AA) and alcohol dependence (AD) and (2) whether early age of onset of prior mental disorders (PMDs) is a promoter of rapid transition. METHOD A total of 3021 community subjects (97.7% lifetime AU) aged 14-24 years at baseline were followed up prospectively for up to 10 years. AU and mental disorders were assessed with the DSM-IV/M-CIDI. RESULTS Among subjects with lifetime AU, several PMDs, such as specific phobia, bipolar disorder and nicotine dependence, were associated with an increased risk of AUD independent of externalizing disorders. Associations of PMDs with the speed of transition to AUDs were mostly weak and inconsistent. Only social phobia and externalizing disorders were associated with faster transitions to AD even after adjustment for other PMDs. Earlier age of onset of PMD was not associated with rapid transition. CONCLUSIONS Mental disorders are associated with the risk of AUD. With the possible exception of social phobia and externalizing disorders, they do not promote rapid transition, even if they occur particularly early. Future research needs to identify factors relevant to rapid transition to AUD.

The relevance of age at first alcohol and nicotine use for initiation of cannabis use and progression to cannabis use disorders

BACKGROUND A younger age at onset of use of a specific substance is a well-documented risk-factor for a substance use disorder (SUD) related to that specific substance. However, the cross-substance relationship between a younger age at onset of alcohol use (AU) and nicotine use (NU) and the risk of cannabis use disorders (CUD) in adolescence and early adulthood remains unclear. AIMS To identify the sequence of and latency between initial AU/NU and initial cannabis use (CU). To investigate whether younger age at AU- and NU-onset is associated with any and earlier CU-onset and a higher risk of transition from first CU to CUD, taking into account externalizing disorders (ED) and parental substance use disorders as putative influential factors. METHODS Prospective-longitudinal community study with N=3021 subjects (baseline age 14-24) and up to four assessment waves over up to ten years with additional direct parental and family history information. Substance use and CUD were assessed with the DSM-IV/M-CIDI. RESULTS Most subjects with CU reported AU (99%) and NU (94%). Among users of both substances, 93% reported AU prior to CU (87% for NU). After adjustment for ED and parental substance use disorders younger age at AU-onset was associated with any CU. Younger age at NU-onset was associated with earlier CU initiation. Younger age at AU- and NU-onset was not associated with a higher risk of CUD. CONCLUSIONS The cross-substance relevance of younger age at first AU and NU for the risk of CUD is limited to early CU involvement.

Efficacy of a targeted cognitive-behavioral treatment program for cannabis use disorders (CANDIS*)

AIMS To examine the efficacy, 3- and 6-month follow-up effects of a psychological treatment for older adolescents and adults with DSM-IV cannabis use disorders. The program was tailored to the needs of this patient population. EXPERIMENTAL PROCEDURES A randomized controlled clinical trial of 122 patients aged 16 to 44 years with DSM-IV cannabis dependence as the main substance use diagnosis was conducted. Patients were randomly assigned to either Active Treatment (AT, n = 90) or a Delayed Treatment Control group (DTC, n = 32). Treatment consisted of 10 sessions of therapy, detailed in a strictly enforced manual. Assessments were conducted at baseline, during each therapy session, at post treatment and at follow-up assessments at 3 and 6 months. RESULTS The treatment retention rate was 88%. Abstinence was achieved in 49% of AT patients and in 13% of those in DTC (p < 0.001; intend-to-treat (ITT) analysis). Further, AT patients improved significantly (p < = 0.001) in the frequency of cannabis use per week, addiction severity, number of disability days, and overall level of psychopathology. Program effects were maintained over a 3-month- (abstinence rate: 51%) and 6-month follow-up (45%) period. CONCLUSION The treatment program is effective in obtaining abstinence as well as reducing cannabis use and improves the associated social and mental health burden.

Gender differences in socioeconomic inequality of alcohol‐attributable mortality: A systematic review and meta‐analysis

INTRODUCTION AND AIMS The present analysis contributes to understanding the societal distribution of alcohol-attributable harm by investigating socioeconomic inequality and related gender differences in alcohol-attributable mortality. DESIGN AND METHODS A systematic literature search was performed on Web of Science, MEDLINE, PsycINFO and ETOH from their inception until February 2013. Articles were included when they reported data on alcohol-attributable mortality by socioeconomic status (SES), operationalised as education, occupation, employment status or income. Gender-specific relative risks (RR) comparing low with high SES were pooled using random effects meta-analyses. Gender differences were additionally investigated in random effects meta-regressions. RESULTS Nineteen articles from 14 countries were included. For women, significant RRs across all measures of SES, except employment status, were found, ranging between 1.75 [95% confidence interval (CI) 1.21-2.54; occupation] and 4.78 (95% CI 2.57-8.87; income). For men, all measures of SES showed significant RRs ranging between 2.88 (95% CI 2.45-3.40; income) and 12.25 (95% CI 11.45-13.10; employment status). While RRs for men were in general slightly higher, only for occupation this gender difference was above chance (P = 0.01). Results refer to deaths 100% attributable to alcohol. DISCUSSION AND CONCLUSIONS The results are predominantly based on data from high-income countries, limiting generalisability. Alcohol-attributable mortality is strongly distributed to the disadvantage of persons with a low SES. Marked gender differences in this inequality were found for occupation. Possibly male-dominated occupations of low SES were more strongly related to risky drinking cultures compared with female-dominated occupations of the same SES.