Simon J. Adamson

A prototype screening instrument for cannabis use disorder: the Cannabis Use Disorders Identification Test (CUDIT) in an alcohol-dependent clinical sample

The Cannabis Use Disorders Identification Test (CUDIT) was used for the first time as part of a randomized controlled trial for brief interventions in mild to moderate alcohol-dependent out-patients. This sample may be seen as a population at increased risk of cannabis use disorder. The CUDIT was developed by modifying the Alcohol Use Disorders Identification Test (AUDIT). The ability of the CUDIT to accurately screen for cannabis abuse or dependence was examined in the portion of the sample who reported some cannabis use over the preceding 6 months (n=53), as was self-reported frequency of cannabis use in the preceding 6 months. The CUDIT was superior to the frequency measure, achieving positive predictive power of 84.6% and sensitivity of 73.3% at a cut-off of 8, compared to positive predictive power of 81.8% and sensitivity of 60.0% for 80 or more cannabis use-days. These results indicate the viability of a screening measure for identifying cannabis use disorder in at risk populations.

An improved brief measure of cannabis misuse: the Cannabis Use Disorders Identification Test-Revised (CUDIT-R).

BACKGROUND Cannabis is widely used and significant problems are associated with heavier consumption. When a cannabis misuse screening tool, the CUDIT, was originally published it was noted that although it performed well there was concern about individual items. METHODS 144 patients enrolled in a clinical trial for concurrent depression and substance misuse were administered an expanded CUDIT, containing the original 10 items and 11 candidate replacement items. All patients were assessed for a current cannabis use disorder with the SCID. RESULTS A revised CUDIT-R was developed containing 8 items, two each from the domains of consumption, cannabis problems (abuse), dependence, and psychological features. Although the psychometric adequacy of the original CUDIT was confirmed, the CUDIT-R was shorter and had equivalent or superior psychometric properties. High sensitivity (91%) and specificity (90%) were achieved. CONCLUSIONS The 8-item CUDIT-R has improved performance over the original scale and appears well suited to the task of screening for problematic cannabis use. It may also have potential as a brief routine outcome measure.

Health status of clients receiving methadone maintenance treatment using the SF-36 health survey questionnaire

This study investigated the health status of a representative sample of clients (35 Maori, 72 non-Maori) receiving methadone maintenance treatment in New Zealand, using the SF-36 health survey. The publication of New Zealand norms in 1999 enabled comparisons of the health of the Methadone Treatment Programme study participants with that of the New Zealand population. Although over 50% of participants rated their health as good, very good or excellent, 44% rated their health as fair or poor and compared with population norms, the health of the study participants was significantly poorer on all eight SF-36 scales. Male and female participants rated their health similarly to male and female clients attending another New Zealand Methadone Treatment Programme. Results highlighted the impact of a chronic disorder and co-existing health-related problems on the health and well-being and day-to-day functioning of this client group. Higher frequency of benzodiazepine use was associated with poorer social functioning, mental health and role functioning and higher frequency of cannabis use was associated with poorer role functioning due to emotional problems. Findings support routine monitoring of health status with clients receiving methadone maintenance treatment as a guide to preventative and treatment interventions and health maintenance strategies.

Drinking goal selection and treatment outcome in out-patients with mild-moderate alcohol dependence

Selection of drinking goal is examined at baseline, post-treatment and at 6 months follow-up for a sample of mild-moderate alcohol-dependent out-patients. Drinking goal is identified as abstinent or controlled drinking, with the latter group being asked to further specify per session and per week drinking limits. Group comparisons for drinking goal post-treatment show those who were not assigned motivational enhancement therapy, had more drinking days and lower scores on the Alcohol Problems Questionnaire and Internal Motivation were more likely to choose controlled drinking. The only variable to predict independently whether or not the controlled drinking goal was within the promoted drinking guidelines was age, with younger participants more likely to choose a goal above this limit. Goal selection was significantly related to drinking outcome, with those aiming to drink within guidelines having better outcome than those aiming for higher limits. There was no significant difference in drinking outcome ca...

The pattern of intravenous drug use and associated criminal activity in patients on a methadone treatment waiting list.

Sixty-four patients on the Christchurch Methadone Treatment Programme waiting list were questioned on their drug-use behaviour, criminal activity and sources of income, both legal and illegal, for the preceding 7 days. Opioids used included morphine sulphate tablets, methadone and opium poppies, while other drugs used included tranquillizers, cannabis and alcohol. A significant minority were prescribed opioids. The mean cost of drugs used in 7 days across all subjects was 882 dollars. The mean financial gain from criminal sources for the same period was 1079 dollars and was derived from drug-related crime, property crime and prostitution. Few gender differences were found relating to criminal activity or drug use. The majority of the sample were on unemployment benefits of varying types while a minority were in paid employment. Those in paid employment did not earn significantly less from criminal activity, nor did they spend significantly less on drug use than did those not in paid employment. An important implication of these findings is that untreated opioid users are a substantial financial burden to the community, strongly supporting the argument for greater treatment provision.

Depression in patients with alcohol use disorders: Systematic review and meta-analysis of outcomes for independent and substance-induced disorders.

BACKGROUND In patients with an alcohol use disorder, depression is commonly categorised as independent (ID) or substance-induced (SID). It is not established whether these conditions respond differently to treatment. METHODS MEDLINE, Embase and Cochrane databases from 1980 to 2014 were searched for studies on alcohol use disorders with coexisting depressive symptoms. Meta-analyses were conducted using random effects models, to derive pooled effect estimates of the change in depression during treatment and the effect of antidepressant therapy. RESULTS Twenty-two studies met inclusion criteria for the review, of which 11/22 were included in the meta-analysis. All studies reported a large improvement in depression symptom score, most of which occurred within the first 3-6 weeks of treatment. The amount of improvement during follow up was similar in studies on ID in comparison to those in undifferentiated depression. Evidence on the outcome for SID was limited. The effect size of antidepressant therapy compared to placebo was 0.25 (0.06, 0.44) for ID and 0.08 (-0.31, 0.47) for SID or undifferentiated depression. LIMITATIONS Few studies examined the natural history and treatment response of SID. There was heterogeneity between studies, which was partly explained by baseline depression severity. CONCLUSIONS Treatment for depression co-occurring with an alcohol use disorder is associated with a large early improvement in depression, even if depression is believed to be independent of drinking. The effect of antidepressant therapy on depression in patients with alcohol use disorders is modest, with stronger evidence in ID.

Client language during motivational enhancement therapy and alcohol use outcome.

BACKGROUND The exact link between the process engaged in during Motivational Interviewing based interventions, such as Motivational Enhancement Therapy (MET), and outcome is yet to be fully understood. AIMS This preliminary study examined Client Language during MET and outcome. METHOD A modified Motivational Interviewing Skills Code Version 2.0 was used to code 106 audiotaped MET sessions from 28 participants who received 3-4 sessions of MET within the context of a randomized controlled trial for mild-moderate alcohol dependence. Client Language was analyzed within sessions (categorized into Early, Mid, or End Intervals) and across sessions, and in relation to six month drinking outcome (drinking within/over national drinking guidelines, i.e. Remitted/Unremitted Drinkers). RESULTS Unremitted Drinkers uttered a significantly higher frequency of Sustain Talk, lower Ability Language strength (over all MET and during End Intervals), and lower Commitment Language strength (during Session 2 and 4, and change over MET). CONCLUSIONS Notwithstanding limitations, this exploratory study was unique in examining the strength of Client Language within and across sessions. It produced potentially valuable findings that warrant further investigation including supporting the clinical benefit of monitoring Client Language to predict outcome.

GAMBLING IN MILD–MODERATE ALCOHOL-DEPENDENT OUTPATIENTS

There is a growing interest in the comorbidity of “substance use disorder” and “problem gambling,” although there has been little study specifically on people with “alcohol dependence” who are being treated in general alcohol- and drug-user outpatient settings. This study aimed to determine the nature and extent of gambling in a sample of 124 mild–moderate alcohol-dependent outpatients. Of these, 79.8% had gambled in the previous 6 months and 29.8% on at least a weekly basis. Although a wide range of gambling modes was used, by far the commonest was Lotto, a national weekly lottery, at 60.5%. Some 19.4% were found to manifest current “problem gambling” [i.e., scored at least 1 on the South Oaks Gambling Screen (SOGS) instrument], and a further 4.0% were found to manifest pathological gambling confirmed by Diagnostic and Statistical Manual of Mental Disorders–-Version IV (DSMIV) diagnosis. “Problem gamblers” were significantly more likely to be involved in all modes of gambling compared with non problem gamblers. However, the most differentiating modes, in order, were gambling machines, dogs, casino, and horses. Treatment implications of these findings are discussed. A two-arm model of intervention for problem gambling within the alcohol- and drug-user treatment setting is proposed.

A randomized trial of combined citalopram and naltrexone for nonabstinent outpatients with co-occurring alcohol dependence and major depression.

Abstract Despite the high rate of co-occurrence of major depression and alcohol dependence, the role of pharmacotherapy in their treatment remains unclear. In the new era of naltrexone for alcohol dependence, it is notable that only 1 study to date has examined the efficacy of antidepressant medication prescribed concurrently with naltrexone. We aimed to determine whether combining naltrexone with citalopram produced better treatment outcomes than naltrexone alone in patients with co-occurring alcohol dependence and depression, and to investigate whether either sex or depression type (independent or substance-induced depression) moderated treatment response. Participants were 138 depressed alcohol-dependent adults who were not required to be abstinent at the commencement of the trial. They were randomized to 12 weeks of citalopram or placebo, plus naltrexone and clinical case management. Treatment was well attended, and medications were reasonably well tolerated with high adherence rates. Substantial improvements in both mood and drinking occurred in both groups, with no significant differences between groups on any of the mood or drinking outcome measures, whether or not other variables were controlled for. No interaction effect was found for independent/substance-induced depression status, whereas there was a marginal effect found by sex, with greater improvement in 1 drinking outcome measure (percent days abstinent) in women taking citalopram. These findings suggest that citalopram is not a clinically useful addition to naltrexone and clinical case management in this treatment population. Independent/substance-induced depression status did not predict treatment response. Findings for sex were equivocal.

Drug use and Addiction: Evolutionary Perspective

Drug use creates a significant amount of harm in modern societies. From an evolutionary perspective, the pervasive use of drugs and the ongoing risk of drug addiction can be explained in terms of the action of drugs on evolved motivational–emotional systems. Addiction arises through interaction of these evolutionarily ancient systems, designed to promote the pursuit of natural rewards, and contemporary environments where purified and potent forms of drugs are readily available. This evolutionary analysis is extended to account for developmental patterns in problem drug use, and to explain the existence of behavioural addictions, such as problem gambling. The paper concludes by considering some of the clinical and public policy implications of the evolutionary perspective presented.