Betsy Bates

Less than 4% of high school seniors abused prescription opioids in the early 1990s. By 2002, between 8% and 10% of 12th graders were abusing prescription opioids.

The ominous numbers remain relentlessly high, translating into thousands of new users under the age of 18 each year.

To counter this alarming trend, officials at the National Institute of Drug Abuse are turning to child and adult psychiatrists, pediatricians, adolescent medicine specialists, family physicians, and internists to help them stem the tide of opioid abuse among adolescents and young adults.

A new initiative is underway to recruit office-based physicians to prescribe buprenorphine and coordinate counseling among vulnerable youth, according to Dr. Geetha Subramaniam, who unveiled the program at the NIDA's 8th annual “blending conference,” which is aimed at showcasing strategies for applying research findings to clinical practice.

The core message behind the initiative is that research now justifies use of buprenorphine in opioid-dependent adolescents, who historically fell through the cracks in programs designed to treat opioid addiction in adults.

Buprenorphine is a partial opioid agonist currently approved by the Food and Drug Administration for treating opioid dependence in patients as young as age 16 years. It is marketed as both Subutex, which is buprenorphine alone, and Suboxone, which is a combination of buprenorphine/naloxone. Both are available as sublingual tablets.

“We now have very robust evidence that this is a viable treatment option… in combination with psychological counseling,” Dr. Subramaniam said during an interview following the April meeting.

Early Intervention, Better Outcomes

Because extended treatment (up to 12 weeks) with buprenorphine keeps young patients in treatment longer, it has been shown to outperform short-term detoxification in terms of reducing positive urine screens for opioids as well as other drugs, including marijuana, cocaine, and intravenous drugs (including heroin), said Dr. Subramaniam, medical officer in NIDA's Bethesda, Md.–based Division of Clinical Neuroscience and Behavioral Research.

She and other experts expressed hope that by reaching young people with accessible, confidential, efficacious outpatient treatment, they can avert deeply entrenched drug abuse patterns with the potential of ruining lives.

“The idea is that medications can tremendously augment the effects of counseling and 12-Step involvement and treat these kids before they have accumulated the medical and psychosocial problems that are common complications of [years of] opioid use,” said Dr. George Woody, professor of psychiatry and director of the clinical trials unit at the University of Pennsylvania Center for Studies of Addictions in Philadelphia.

Existing research on treatments for opioid-dependent youth is outdated and limited to uncontrolled trials evaluating methadone. While methadone is a very effective treatment for opioid dependence, it is of limited application for young people because it is available only through specialized clinics. Patients aged 16–18 years are eligible for this treatment option only after they have failed two prior treatments and only if they have the consent of a legal guardian.

Standard detoxification/rehabilitation programs that typically work with adults may admit youth, but the young people feel stigmatized being there.

In a pivotal 12-week trial directed by Dr. Woody, treatment retention was strikingly improved among 13- to 17-year-olds randomly assigned to receive counseling and either buprenorphine therapy or traditional detoxification (JAMA 2008;300:2003–11).

At the 3-month mark, just 16 of 78 (21%) subjects who underwent detoxification and counseling remained in treatment, compared with 52 of 74 (70%) assigned to a protocol combining buprenorphine and counseling.

Buprenorphine appears to reduce cravings long enough for young people to take advantage of psychosocial interventions and to begin to make earnest lifestyle changes.

Significant differences exist between youth who use the different opioid drug classes, Dr. Subramaniam pointed out.

For one thing, teens dependent on heroin may ironically come to the attention of medical providers earlier in the course of their addiction for reasons both chemical and practical.

Prescription opioids are long-acting drugs most often obtained though an informal distribution system originating in the family medicine cabinet, at grandma's house, or in a teen's own supply of pain medications leftover from a sports injury or dental work.

Users, she said, “Can fly under the radar,” hiding their use and obtaining more drugs through friends, often for quite a period of time before their problem comes to light. Eventually, though, the drugs may become more difficult to obtain, and expensive to buy.

Users may eventually switch to heroin, a cheaper opioid, which may send them out onto the streets.

With heroin, “You have to keep feeding the addiction because it's very short-acting,” generally requiring multiple dosing throughout the day. It also requires IV administration, which puts users at high risk for hepatitis C and HIV infections.

Significant differences exist, too, between abusers of any opioid and those youth who use marijuana and/or alcohol. Opioid users were more likely to be white, non-urban school drop-outs and were more likely than problem users of marijuana and/or alcohol to also have cocaine and/or sedative use disorders, and 3 or more non-opioid substance use disorders (Drug and Alcohol Depend. 2009;99:141–9).

Opioids' Added Risks

Dr. Subramaniam's recent analysis of data from 88 studies showed that the added risks of opioid use among marijuana and alcohol users were substantial. The opioid users had significantly more major clinical problems than those using marijuana and alcohol (5.1 vs. 3.4), and also demonstrated greater psychiatric comorbidity, victimization, and treatment utilization (Addiction 2010;105:686–98).

Clearly, young opioid users are a population in need, Dr. Subramaniam said.

Medication/counseling programs may help to meet that need, if office-based physicians are willing to go through the government-sponsored training program that enables them to prescribe buprenorphine and ensure that appropriate counseling is available.

In some cases, office-based physicians provide counseling themselves, she said. Others establish close collaborative relationships with neighboring counseling programs.

In either case, patients require “very close monitoring in the early days of treatment as one aims to find the most optimal dose of buprenorphine during the induction phase.” Regular follow-up monitoring and counseling over the ensuing weeks and months is advised.

Family Support and Buy-In

As a child psychiatrist who specialized in addiction medicine before assuming her government post, Dr. Subramaniam has had years of hands-on clinical experience treating opioid-dependent youths with buprenorphine.“I always recommended that a supportive adult monitor compliance,” she said. “You need family support and buy-in.”

Office-based physicians who become qualified to prescribe buprenorphine through the waiver program can provide the agent to patients as young as age 16 years.

“What if the adolescent is younger?”

Dr. Subramaniam noted that research supports use of the drug in children as young as 15, since that was the youngest patient recruited for the NIDA sponsored clinical trial, she said.

Direction and guidance for thorny clinical issues are currently available through no-cost mentoring by senior physicians experienced in using buprenorphine through a Physician Clinical Support System sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA), noted Dr. Subramaniam. Information can be found at

www.pcssmentor.org

At NIDA, “We are trying to make a very concerted effort to provide training to clinicians and to educate them about why this is a good thing to do,” she said.

Office-based physicians “can have a tremendous impact,” echoed Dr. Woody.

“It's to everyone's advantage to become more familiar with this approach to addiction. The field is going in this direction.”

Dr. Subramaniam reported having no conflicts of interest. Dr. Woody disclosed that he has received a consulting fee from Alkermes Pharmaceuticals Inc., and serves on the RADARS system scientific advisory board.

For more information about receiving a waiver to practice opioid addiction therapy, go to

http://buprenorphine.samhsa.gov/waiver_qualifications

By Betsy Bates. Share your thoughts at

[email protected]

There is “robust evidence” that buprenorphine combined with counseling is a viable treatment option for opioid dependence, Dr. Geetha Subramaniam says.

Source Catherine Harrell/Elsevier Global Medical News

Less than 4% of high school seniors abused prescription opioids in the early 1990s. By 2002, between 8% and 10% of 12th graders were abusing prescription opioids.

The ominous numbers remain relentlessly high, translating into thousands of new users under the age of 18 each year.

To counter this alarming trend, officials at the National Institute of Drug Abuse are turning to child and adult psychiatrists, pediatricians, adolescent medicine specialists, family physicians, and internists to help them stem the tide of opioid abuse among adolescents and young adults.

A new initiative is underway to recruit office-based physicians to prescribe buprenorphine and coordinate counseling among vulnerable youth, according to Dr. Geetha Subramaniam, who unveiled the program at the NIDA's 8th annual “blending conference,” which is aimed at showcasing strategies for applying research findings to clinical practice.

The core message behind the initiative is that research now justifies use of buprenorphine in opioid-dependent adolescents, who historically fell through the cracks in programs designed to treat opioid addiction in adults.

Buprenorphine is a partial opioid agonist currently approved by the Food and Drug Administration for treating opioid dependence in patients as young as age 16 years. It is marketed as both Subutex, which is buprenorphine alone, and Suboxone, which is a combination of buprenorphine/naloxone. Both are available as sublingual tablets.

“We now have very robust evidence that this is a viable treatment option… in combination with psychological counseling,” Dr. Subramaniam said during an interview following the April meeting.

Early Intervention, Better Outcomes

Because extended treatment (up to 12 weeks) with buprenorphine keeps young patients in treatment longer, it has been shown to outperform short-term detoxification in terms of reducing positive urine screens for opioids as well as other drugs, including marijuana, cocaine, and intravenous drugs (including heroin), said Dr. Subramaniam, medical officer in NIDA's Bethesda, Md.–based Division of Clinical Neuroscience and Behavioral Research.

She and other experts expressed hope that by reaching young people with accessible, confidential, efficacious outpatient treatment, they can avert deeply entrenched drug abuse patterns with the potential of ruining lives.

“The idea is that medications can tremendously augment the effects of counseling and 12-Step involvement and treat these kids before they have accumulated the medical and psychosocial problems that are common complications of [years of] opioid use,” said Dr. George Woody, professor of psychiatry and director of the clinical trials unit at the University of Pennsylvania Center for Studies of Addictions in Philadelphia.

Existing research on treatments for opioid-dependent youth is outdated and limited to uncontrolled trials evaluating methadone. While methadone is a very effective treatment for opioid dependence, it is of limited application for young people because it is available only through specialized clinics. Patients aged 16–18 years are eligible for this treatment option only after they have failed two prior treatments and only if they have the consent of a legal guardian.

Standard detoxification/rehabilitation programs that typically work with adults may admit youth, but the young people feel stigmatized being there.

In a pivotal 12-week trial directed by Dr. Woody, treatment retention was strikingly improved among 13- to 17-year-olds randomly assigned to receive counseling and either buprenorphine therapy or traditional detoxification (JAMA 2008;300:2003–11).

At the 3-month mark, just 16 of 78 (21%) subjects who underwent detoxification and counseling remained in treatment, compared with 52 of 74 (70%) assigned to a protocol combining buprenorphine and counseling.

Buprenorphine appears to reduce cravings long enough for young people to take advantage of psychosocial interventions and to begin to make earnest lifestyle changes.

Significant differences exist between youth who use the different opioid drug classes, Dr. Subramaniam pointed out.

For one thing, teens dependent on heroin may ironically come to the attention of medical providers earlier in the course of their addiction for reasons both chemical and practical.

Prescription opioids are long-acting drugs most often obtained though an informal distribution system originating in the family medicine cabinet, at grandma's house, or in a teen's own supply of pain medications leftover from a sports injury or dental work.

Users, she said, “Can fly under the radar,” hiding their use and obtaining more drugs through friends, often for quite a period of time before their problem comes to light. Eventually, though, the drugs may become more difficult to obtain, and expensive to buy.

Users may eventually switch to heroin, a cheaper opioid, which may send them out onto the streets.

With heroin, “You have to keep feeding the addiction because it's very short-acting,” generally requiring multiple dosing throughout the day. It also requires IV administration, which puts users at high risk for hepatitis C and HIV infections.

Significant differences exist, too, between abusers of any opioid and those youth who use marijuana and/or alcohol. Opioid users were more likely to be white, non-urban school drop-outs and were more likely than problem users of marijuana and/or alcohol to also have cocaine and/or sedative use disorders, and 3 or more non-opioid substance use disorders (Drug and Alcohol Depend. 2009;99:141–9).

Opioids' Added Risks

Dr. Subramaniam's recent analysis of data from 88 studies showed that the added risks of opioid use among marijuana and alcohol users were substantial. The opioid users had significantly more major clinical problems than those using marijuana and alcohol (5.1 vs. 3.4), and also demonstrated greater psychiatric comorbidity, victimization, and treatment utilization (Addiction 2010;105:686–98).

Clearly, young opioid users are a population in need, Dr. Subramaniam said.

Medication/counseling programs may help to meet that need, if office-based physicians are willing to go through the government-sponsored training program that enables them to prescribe buprenorphine and ensure that appropriate counseling is available.

In some cases, office-based physicians provide counseling themselves, she said. Others establish close collaborative relationships with neighboring counseling programs.

In either case, patients require “very close monitoring in the early days of treatment as one aims to find the most optimal dose of buprenorphine during the induction phase.” Regular follow-up monitoring and counseling over the ensuing weeks and months is advised.

Family Support and Buy-In

As a child psychiatrist who specialized in addiction medicine before assuming her government post, Dr. Subramaniam has had years of hands-on clinical experience treating opioid-dependent youths with buprenorphine.“I always recommended that a supportive adult monitor compliance,” she said. “You need family support and buy-in.”

Office-based physicians who become qualified to prescribe buprenorphine through the waiver program can provide the agent to patients as young as age 16 years.

“What if the adolescent is younger?”

Dr. Subramaniam noted that research supports use of the drug in children as young as 15, since that was the youngest patient recruited for the NIDA sponsored clinical trial, she said.

Direction and guidance for thorny clinical issues are currently available through no-cost mentoring by senior physicians experienced in using buprenorphine through a Physician Clinical Support System sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA), noted Dr. Subramaniam. Information can be found at

www.pcssmentor.org

At NIDA, “We are trying to make a very concerted effort to provide training to clinicians and to educate them about why this is a good thing to do,” she said.

Office-based physicians “can have a tremendous impact,” echoed Dr. Woody.

“It's to everyone's advantage to become more familiar with this approach to addiction. The field is going in this direction.”

Dr. Subramaniam reported having no conflicts of interest. Dr. Woody disclosed that he has received a consulting fee from Alkermes Pharmaceuticals Inc., and serves on the RADARS system scientific advisory board.

For more information about receiving a waiver to practice opioid addiction therapy, go to

http://buprenorphine.samhsa.gov/waiver_qualifications

By Betsy Bates. Share your thoughts at

[email protected]

There is “robust evidence” that buprenorphine combined with counseling is a viable treatment option for opioid dependence, Dr. Geetha Subramaniam says.

Source Catherine Harrell/Elsevier Global Medical News

Less than 4% of high school seniors abused prescription opioids in the early 1990s. By 2002, between 8% and 10% of 12th graders were abusing prescription opioids.

The ominous numbers remain relentlessly high, translating into thousands of new users under the age of 18 each year.

To counter this alarming trend, officials at the National Institute of Drug Abuse are turning to child and adult psychiatrists, pediatricians, adolescent medicine specialists, family physicians, and internists to help them stem the tide of opioid abuse among adolescents and young adults.

A new initiative is underway to recruit office-based physicians to prescribe buprenorphine and coordinate counseling among vulnerable youth, according to Dr. Geetha Subramaniam, who unveiled the program at the NIDA's 8th annual “blending conference,” which is aimed at showcasing strategies for applying research findings to clinical practice.

The core message behind the initiative is that research now justifies use of buprenorphine in opioid-dependent adolescents, who historically fell through the cracks in programs designed to treat opioid addiction in adults.

Buprenorphine is a partial opioid agonist currently approved by the Food and Drug Administration for treating opioid dependence in patients as young as age 16 years. It is marketed as both Subutex, which is buprenorphine alone, and Suboxone, which is a combination of buprenorphine/naloxone. Both are available as sublingual tablets.

“We now have very robust evidence that this is a viable treatment option… in combination with psychological counseling,” Dr. Subramaniam said during an interview following the April meeting.

Early Intervention, Better Outcomes

Because extended treatment (up to 12 weeks) with buprenorphine keeps young patients in treatment longer, it has been shown to outperform short-term detoxification in terms of reducing positive urine screens for opioids as well as other drugs, including marijuana, cocaine, and intravenous drugs (including heroin), said Dr. Subramaniam, medical officer in NIDA's Bethesda, Md.–based Division of Clinical Neuroscience and Behavioral Research.

She and other experts expressed hope that by reaching young people with accessible, confidential, efficacious outpatient treatment, they can avert deeply entrenched drug abuse patterns with the potential of ruining lives.

“The idea is that medications can tremendously augment the effects of counseling and 12-Step involvement and treat these kids before they have accumulated the medical and psychosocial problems that are common complications of [years of] opioid use,” said Dr. George Woody, professor of psychiatry and director of the clinical trials unit at the University of Pennsylvania Center for Studies of Addictions in Philadelphia.

Existing research on treatments for opioid-dependent youth is outdated and limited to uncontrolled trials evaluating methadone. While methadone is a very effective treatment for opioid dependence, it is of limited application for young people because it is available only through specialized clinics. Patients aged 16–18 years are eligible for this treatment option only after they have failed two prior treatments and only if they have the consent of a legal guardian.

Standard detoxification/rehabilitation programs that typically work with adults may admit youth, but the young people feel stigmatized being there.

In a pivotal 12-week trial directed by Dr. Woody, treatment retention was strikingly improved among 13- to 17-year-olds randomly assigned to receive counseling and either buprenorphine therapy or traditional detoxification (JAMA 2008;300:2003–11).

At the 3-month mark, just 16 of 78 (21%) subjects who underwent detoxification and counseling remained in treatment, compared with 52 of 74 (70%) assigned to a protocol combining buprenorphine and counseling.

Buprenorphine appears to reduce cravings long enough for young people to take advantage of psychosocial interventions and to begin to make earnest lifestyle changes.

Significant differences exist between youth who use the different opioid drug classes, Dr. Subramaniam pointed out.

For one thing, teens dependent on heroin may ironically come to the attention of medical providers earlier in the course of their addiction for reasons both chemical and practical.

Prescription opioids are long-acting drugs most often obtained though an informal distribution system originating in the family medicine cabinet, at grandma's house, or in a teen's own supply of pain medications leftover from a sports injury or dental work.

Users, she said, “Can fly under the radar,” hiding their use and obtaining more drugs through friends, often for quite a period of time before their problem comes to light. Eventually, though, the drugs may become more difficult to obtain, and expensive to buy.

Users may eventually switch to heroin, a cheaper opioid, which may send them out onto the streets.

With heroin, “You have to keep feeding the addiction because it's very short-acting,” generally requiring multiple dosing throughout the day. It also requires IV administration, which puts users at high risk for hepatitis C and HIV infections.

Significant differences exist, too, between abusers of any opioid and those youth who use marijuana and/or alcohol. Opioid users were more likely to be white, non-urban school drop-outs and were more likely than problem users of marijuana and/or alcohol to also have cocaine and/or sedative use disorders, and 3 or more non-opioid substance use disorders (Drug and Alcohol Depend. 2009;99:141–9).

Opioids' Added Risks

Dr. Subramaniam's recent analysis of data from 88 studies showed that the added risks of opioid use among marijuana and alcohol users were substantial. The opioid users had significantly more major clinical problems than those using marijuana and alcohol (5.1 vs. 3.4), and also demonstrated greater psychiatric comorbidity, victimization, and treatment utilization (Addiction 2010;105:686–98).

Clearly, young opioid users are a population in need, Dr. Subramaniam said.

Medication/counseling programs may help to meet that need, if office-based physicians are willing to go through the government-sponsored training program that enables them to prescribe buprenorphine and ensure that appropriate counseling is available.

In some cases, office-based physicians provide counseling themselves, she said. Others establish close collaborative relationships with neighboring counseling programs.

In either case, patients require “very close monitoring in the early days of treatment as one aims to find the most optimal dose of buprenorphine during the induction phase.” Regular follow-up monitoring and counseling over the ensuing weeks and months is advised.

Family Support and Buy-In

As a child psychiatrist who specialized in addiction medicine before assuming her government post, Dr. Subramaniam has had years of hands-on clinical experience treating opioid-dependent youths with buprenorphine.“I always recommended that a supportive adult monitor compliance,” she said. “You need family support and buy-in.”

Office-based physicians who become qualified to prescribe buprenorphine through the waiver program can provide the agent to patients as young as age 16 years.

“What if the adolescent is younger?”

Dr. Subramaniam noted that research supports use of the drug in children as young as 15, since that was the youngest patient recruited for the NIDA sponsored clinical trial, she said.

Direction and guidance for thorny clinical issues are currently available through no-cost mentoring by senior physicians experienced in using buprenorphine through a Physician Clinical Support System sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA), noted Dr. Subramaniam. Information can be found at

www.pcssmentor.org

At NIDA, “We are trying to make a very concerted effort to provide training to clinicians and to educate them about why this is a good thing to do,” she said.

Office-based physicians “can have a tremendous impact,” echoed Dr. Woody.

“It's to everyone's advantage to become more familiar with this approach to addiction. The field is going in this direction.”

Dr. Subramaniam reported having no conflicts of interest. Dr. Woody disclosed that he has received a consulting fee from Alkermes Pharmaceuticals Inc., and serves on the RADARS system scientific advisory board.

For more information about receiving a waiver to practice opioid addiction therapy, go to

http://buprenorphine.samhsa.gov/waiver_qualifications

By Betsy Bates. Share your thoughts at

[email protected]

There is “robust evidence” that buprenorphine combined with counseling is a viable treatment option for opioid dependence, Dr. Geetha Subramaniam says.

Source Catherine Harrell/Elsevier Global Medical News

Major Finding: Of 284 children aged 3-5 years who had been exposed to a traumatic event, 44% met full revised criteria for PTSD with discernable impairing symptoms.

Data Source: Results on the Preschool Age Psychiatric Assessment (PAPA), a validated instrument administered to caregivers, and the Preschool PTSD Criteria administered in studies at Tulane University in New Orleans.

Disclosures: Dr. Drury reported no relevant financial disclosures.

LOS ANGELES — Nearly half of preschool children meet age-adjusted criteria for posttraumatic stress disorder after experiencing a significant traumatic event, and some children are symptomatic even after relatively minor medical procedures, according to a researcher from Tulane University in New Orleans.

“Children under 6 years of age are particularly vulnerable to stressful experiences because of the rapid neural development they are undergoing,” Dr. Stacy S. Drury said at the International Conference on Pediatric Psychological Trauma.

In a study of 284 children aged 3-5 years who had been exposed to a traumatic event, 44% met full revised criteria for PTSD with discernable impairing symptoms, Dr. Drury, said at the meeting, which was sponsored by the University of Southern California, Los Angeles, and the University of California, Irvine.

No statistically significant differences were seen in rates of PTSD based on the type of trauma children experienced: a single-incident trauma (a motor vehicle accident, burn, or fall) (38%), observed domestic violence (42%), or Hurricane Katrina (48%).

Children were diagnosed using the structured Preschool Age Psychiatric Assessment (PAPA), a validated instrument administered to caregivers.

The study utilized the Preschool PTSD Criteria, which is less reliant on verbalization and abstract thought than DSM-IV PTSD criteria for adults (J. Am. Acad. Child Adolesc. Psychiatry 2003;42:561-70).

A second study assessed PTSD in 69 preschool children seen at a hospital-based primary care clinic more than 12 months after events that ranged from medical encounters that involved no procedures, procedures such as receiving stitches or getting a shot, nonmedical traumas such as motor vehicle accidents, and high-risk events such as abuse or neglect.

Dr. Drury showed that even “small things,” like stitches, had a lasting effect on some children. “Fifteen months after the event, these symptoms were recognizable to parents … and persistent,” she said.

Dr. Drury reviewed burgeoning neurobiological literature demonstrating that early stress results in changes within biocircuitry of the developing brain, altering the central nervous system, cortisol levels, and neurotransmitters.

“Altered neural circuits lead to lasting vulnerability,” she emphasized, adding that much more research needs to be done to pinpoint the timing of trauma and its ramifications on early brain development and behavior.

“Trauma at 1 year is very different than trauma at 3 or at 6 years old, in part because of what areas of the brain are developing most rapidly,” she said.

She and colleagues are developing cognitive behavioral therapies that can be delivered early to parents and children following symptoms of PTSD.

Dr. Drury reported no relevant financial disclosures.

Major Finding: Of 284 children aged 3-5 years who had been exposed to a traumatic event, 44% met full revised criteria for PTSD with discernable impairing symptoms.

Data Source: Results on the Preschool Age Psychiatric Assessment (PAPA), a validated instrument administered to caregivers, and the Preschool PTSD Criteria administered in studies at Tulane University in New Orleans.

Disclosures: Dr. Drury reported no relevant financial disclosures.

LOS ANGELES — Nearly half of preschool children meet age-adjusted criteria for posttraumatic stress disorder after experiencing a significant traumatic event, and some children are symptomatic even after relatively minor medical procedures, according to a researcher from Tulane University in New Orleans.

“Children under 6 years of age are particularly vulnerable to stressful experiences because of the rapid neural development they are undergoing,” Dr. Stacy S. Drury said at the International Conference on Pediatric Psychological Trauma.

In a study of 284 children aged 3-5 years who had been exposed to a traumatic event, 44% met full revised criteria for PTSD with discernable impairing symptoms, Dr. Drury, said at the meeting, which was sponsored by the University of Southern California, Los Angeles, and the University of California, Irvine.

No statistically significant differences were seen in rates of PTSD based on the type of trauma children experienced: a single-incident trauma (a motor vehicle accident, burn, or fall) (38%), observed domestic violence (42%), or Hurricane Katrina (48%).

Children were diagnosed using the structured Preschool Age Psychiatric Assessment (PAPA), a validated instrument administered to caregivers.

The study utilized the Preschool PTSD Criteria, which is less reliant on verbalization and abstract thought than DSM-IV PTSD criteria for adults (J. Am. Acad. Child Adolesc. Psychiatry 2003;42:561-70).

A second study assessed PTSD in 69 preschool children seen at a hospital-based primary care clinic more than 12 months after events that ranged from medical encounters that involved no procedures, procedures such as receiving stitches or getting a shot, nonmedical traumas such as motor vehicle accidents, and high-risk events such as abuse or neglect.

Dr. Drury showed that even “small things,” like stitches, had a lasting effect on some children. “Fifteen months after the event, these symptoms were recognizable to parents … and persistent,” she said.

Dr. Drury reviewed burgeoning neurobiological literature demonstrating that early stress results in changes within biocircuitry of the developing brain, altering the central nervous system, cortisol levels, and neurotransmitters.

“Altered neural circuits lead to lasting vulnerability,” she emphasized, adding that much more research needs to be done to pinpoint the timing of trauma and its ramifications on early brain development and behavior.

“Trauma at 1 year is very different than trauma at 3 or at 6 years old, in part because of what areas of the brain are developing most rapidly,” she said.

She and colleagues are developing cognitive behavioral therapies that can be delivered early to parents and children following symptoms of PTSD.

Dr. Drury reported no relevant financial disclosures.

Major Finding: Of 284 children aged 3-5 years who had been exposed to a traumatic event, 44% met full revised criteria for PTSD with discernable impairing symptoms.

Data Source: Results on the Preschool Age Psychiatric Assessment (PAPA), a validated instrument administered to caregivers, and the Preschool PTSD Criteria administered in studies at Tulane University in New Orleans.

Disclosures: Dr. Drury reported no relevant financial disclosures.

LOS ANGELES — Nearly half of preschool children meet age-adjusted criteria for posttraumatic stress disorder after experiencing a significant traumatic event, and some children are symptomatic even after relatively minor medical procedures, according to a researcher from Tulane University in New Orleans.

“Children under 6 years of age are particularly vulnerable to stressful experiences because of the rapid neural development they are undergoing,” Dr. Stacy S. Drury said at the International Conference on Pediatric Psychological Trauma.

In a study of 284 children aged 3-5 years who had been exposed to a traumatic event, 44% met full revised criteria for PTSD with discernable impairing symptoms, Dr. Drury, said at the meeting, which was sponsored by the University of Southern California, Los Angeles, and the University of California, Irvine.

No statistically significant differences were seen in rates of PTSD based on the type of trauma children experienced: a single-incident trauma (a motor vehicle accident, burn, or fall) (38%), observed domestic violence (42%), or Hurricane Katrina (48%).

Children were diagnosed using the structured Preschool Age Psychiatric Assessment (PAPA), a validated instrument administered to caregivers.

The study utilized the Preschool PTSD Criteria, which is less reliant on verbalization and abstract thought than DSM-IV PTSD criteria for adults (J. Am. Acad. Child Adolesc. Psychiatry 2003;42:561-70).

A second study assessed PTSD in 69 preschool children seen at a hospital-based primary care clinic more than 12 months after events that ranged from medical encounters that involved no procedures, procedures such as receiving stitches or getting a shot, nonmedical traumas such as motor vehicle accidents, and high-risk events such as abuse or neglect.

Dr. Drury showed that even “small things,” like stitches, had a lasting effect on some children. “Fifteen months after the event, these symptoms were recognizable to parents … and persistent,” she said.

Dr. Drury reviewed burgeoning neurobiological literature demonstrating that early stress results in changes within biocircuitry of the developing brain, altering the central nervous system, cortisol levels, and neurotransmitters.

“Altered neural circuits lead to lasting vulnerability,” she emphasized, adding that much more research needs to be done to pinpoint the timing of trauma and its ramifications on early brain development and behavior.

“Trauma at 1 year is very different than trauma at 3 or at 6 years old, in part because of what areas of the brain are developing most rapidly,” she said.

She and colleagues are developing cognitive behavioral therapies that can be delivered early to parents and children following symptoms of PTSD.

Dr. Drury reported no relevant financial disclosures.

LOS ANGELES – Nearly half of preschool children meet age-adjusted criteria for posttraumatic stress disorder after experiencing a significant traumatic event, and some children are symptomatic even after relatively minor medical procedures, according to a researcher from Tulane University in New Orleans.

“Children under 6 years of age are particularly vulnerable to stressful experiences because of the rapid neural development they are undergoing,” said Dr. Stacy S. Drury at the International Conference on Pediatric Psychological Trauma sponsored by the University of Southern California, Los Angeles, and the University of California, Irvine.

In a study of 284 children aged 3-5 years who had been exposed to a traumatic event, 44% met full revised criteria for PTSD with discernable impairing symptoms, said Dr. Drury, who holds faculty positions in the departments of psychiatry, pediatrics, and neurology.

No statistically significant differences were seen in rates of PTSD based on the type of trauma children experienced: a single-incident trauma (a motor vehicle accident, burn, or fall) (38%), observed domestic violence (42%), or Hurricane Katrina (48%).

Children were diagnosed using the structured Preschool Age Psychiatric Assessment (PAPA), a validated instrument administered to caregivers.

The study used the Preschool PTSD Criteria, which is less reliant on verbalization and abstract thought than DSM-IV PTSD criteria for adults (J. Am. Acad. Child Adolesc. Psychiatry 2003;42:561–70). Specifically, the criteria developed at Tulane by Dr. Michael S. Scheeringa and associates eliminate developmentally inappropriate items (such as an individual's sense of a foreshortened future) and instead include such relevant indicators as the loss of previously acquired developmental skills such as language or toilet training.

A new diagnostic cluster appears in preschool criteria for PTSD, requiring at least one of the following behaviors frequently reported in traumatized children: new separation anxiety, new onset of aggression, or new fears without obvious links to the trauma, such as fear of the dark.

A second study assessed PTSD in 69 preschool children seen at a hospital-based primary care clinic more than 12 months after events that ranged from medical encounters that involved no procedures, procedures such as receiving stitches or getting a shot, nonmedical traumas such as motor vehicle accidents, and high-risk events such as abuse or neglect.

Although specific statistics were not released, Dr. Drury showed that even “small things,” like stitches, had a lasting effect on some children. “Fifteen months after the event, these symptoms were recognizable to parents–and persistent,” she said.

Dr. Drury reviewed burgeoning neurobiological literature demonstrating that early stress results in changes within biocircuitry of the developing brain, altering the central nervous system, cortisol levels, and neurotransmitters.

“Altered neural circuits lead to lasting vulnerability,” she emphasized, adding that much more research needs to be done to pinpoint the timing of trauma and its ramifications on early brain development and behavior.

“Trauma at 1 year is very different than trauma at 3 or at 6 years old, in part because of what areas of the brain are developing most rapidly,” she said.

She and her colleagues are developing cognitive behavioral therapies that can be delivered early to parents and children following symptoms of PTSD, or even as a preventive measure for children newly diagnosed with cancer or another serious illness.

Working to reduce “learned helplessness” on the part of the child begins by teaching parents how to reduce overcontrol in the parent-child relationship, leading children to a new sense of efficacy and mastery.

Meanwhile, children learn relaxation techniques, including controlled breathing and muscle contraction and release, an exercise one child enthusiastically dubbed, “old man wiggles.”

Traditional cognitive-behavioral therapy components such as systematic densensitization are adapted for preschoolers, and have been shown to be highly effective in reducing symptoms during 6-12 brief, manualized sessions, she said.

Dr. Drury reported no relevant financial disclosures.

LOS ANGELES – Nearly half of preschool children meet age-adjusted criteria for posttraumatic stress disorder after experiencing a significant traumatic event, and some children are symptomatic even after relatively minor medical procedures, according to a researcher from Tulane University in New Orleans.

“Children under 6 years of age are particularly vulnerable to stressful experiences because of the rapid neural development they are undergoing,” said Dr. Stacy S. Drury at the International Conference on Pediatric Psychological Trauma sponsored by the University of Southern California, Los Angeles, and the University of California, Irvine.

In a study of 284 children aged 3-5 years who had been exposed to a traumatic event, 44% met full revised criteria for PTSD with discernable impairing symptoms, said Dr. Drury, who holds faculty positions in the departments of psychiatry, pediatrics, and neurology.

No statistically significant differences were seen in rates of PTSD based on the type of trauma children experienced: a single-incident trauma (a motor vehicle accident, burn, or fall) (38%), observed domestic violence (42%), or Hurricane Katrina (48%).

Children were diagnosed using the structured Preschool Age Psychiatric Assessment (PAPA), a validated instrument administered to caregivers.

The study used the Preschool PTSD Criteria, which is less reliant on verbalization and abstract thought than DSM-IV PTSD criteria for adults (J. Am. Acad. Child Adolesc. Psychiatry 2003;42:561–70). Specifically, the criteria developed at Tulane by Dr. Michael S. Scheeringa and associates eliminate developmentally inappropriate items (such as an individual's sense of a foreshortened future) and instead include such relevant indicators as the loss of previously acquired developmental skills such as language or toilet training.

A new diagnostic cluster appears in preschool criteria for PTSD, requiring at least one of the following behaviors frequently reported in traumatized children: new separation anxiety, new onset of aggression, or new fears without obvious links to the trauma, such as fear of the dark.

A second study assessed PTSD in 69 preschool children seen at a hospital-based primary care clinic more than 12 months after events that ranged from medical encounters that involved no procedures, procedures such as receiving stitches or getting a shot, nonmedical traumas such as motor vehicle accidents, and high-risk events such as abuse or neglect.

Although specific statistics were not released, Dr. Drury showed that even “small things,” like stitches, had a lasting effect on some children. “Fifteen months after the event, these symptoms were recognizable to parents–and persistent,” she said.

Dr. Drury reviewed burgeoning neurobiological literature demonstrating that early stress results in changes within biocircuitry of the developing brain, altering the central nervous system, cortisol levels, and neurotransmitters.

“Altered neural circuits lead to lasting vulnerability,” she emphasized, adding that much more research needs to be done to pinpoint the timing of trauma and its ramifications on early brain development and behavior.

“Trauma at 1 year is very different than trauma at 3 or at 6 years old, in part because of what areas of the brain are developing most rapidly,” she said.

She and her colleagues are developing cognitive behavioral therapies that can be delivered early to parents and children following symptoms of PTSD, or even as a preventive measure for children newly diagnosed with cancer or another serious illness.

Working to reduce “learned helplessness” on the part of the child begins by teaching parents how to reduce overcontrol in the parent-child relationship, leading children to a new sense of efficacy and mastery.

Meanwhile, children learn relaxation techniques, including controlled breathing and muscle contraction and release, an exercise one child enthusiastically dubbed, “old man wiggles.”

Traditional cognitive-behavioral therapy components such as systematic densensitization are adapted for preschoolers, and have been shown to be highly effective in reducing symptoms during 6-12 brief, manualized sessions, she said.

Dr. Drury reported no relevant financial disclosures.

LOS ANGELES – Nearly half of preschool children meet age-adjusted criteria for posttraumatic stress disorder after experiencing a significant traumatic event, and some children are symptomatic even after relatively minor medical procedures, according to a researcher from Tulane University in New Orleans.

“Children under 6 years of age are particularly vulnerable to stressful experiences because of the rapid neural development they are undergoing,” said Dr. Stacy S. Drury at the International Conference on Pediatric Psychological Trauma sponsored by the University of Southern California, Los Angeles, and the University of California, Irvine.

In a study of 284 children aged 3-5 years who had been exposed to a traumatic event, 44% met full revised criteria for PTSD with discernable impairing symptoms, said Dr. Drury, who holds faculty positions in the departments of psychiatry, pediatrics, and neurology.

No statistically significant differences were seen in rates of PTSD based on the type of trauma children experienced: a single-incident trauma (a motor vehicle accident, burn, or fall) (38%), observed domestic violence (42%), or Hurricane Katrina (48%).

Children were diagnosed using the structured Preschool Age Psychiatric Assessment (PAPA), a validated instrument administered to caregivers.

The study used the Preschool PTSD Criteria, which is less reliant on verbalization and abstract thought than DSM-IV PTSD criteria for adults (J. Am. Acad. Child Adolesc. Psychiatry 2003;42:561–70). Specifically, the criteria developed at Tulane by Dr. Michael S. Scheeringa and associates eliminate developmentally inappropriate items (such as an individual's sense of a foreshortened future) and instead include such relevant indicators as the loss of previously acquired developmental skills such as language or toilet training.

A new diagnostic cluster appears in preschool criteria for PTSD, requiring at least one of the following behaviors frequently reported in traumatized children: new separation anxiety, new onset of aggression, or new fears without obvious links to the trauma, such as fear of the dark.

A second study assessed PTSD in 69 preschool children seen at a hospital-based primary care clinic more than 12 months after events that ranged from medical encounters that involved no procedures, procedures such as receiving stitches or getting a shot, nonmedical traumas such as motor vehicle accidents, and high-risk events such as abuse or neglect.

Although specific statistics were not released, Dr. Drury showed that even “small things,” like stitches, had a lasting effect on some children. “Fifteen months after the event, these symptoms were recognizable to parents–and persistent,” she said.

Dr. Drury reviewed burgeoning neurobiological literature demonstrating that early stress results in changes within biocircuitry of the developing brain, altering the central nervous system, cortisol levels, and neurotransmitters.

“Altered neural circuits lead to lasting vulnerability,” she emphasized, adding that much more research needs to be done to pinpoint the timing of trauma and its ramifications on early brain development and behavior.

“Trauma at 1 year is very different than trauma at 3 or at 6 years old, in part because of what areas of the brain are developing most rapidly,” she said.

She and her colleagues are developing cognitive behavioral therapies that can be delivered early to parents and children following symptoms of PTSD, or even as a preventive measure for children newly diagnosed with cancer or another serious illness.

Working to reduce “learned helplessness” on the part of the child begins by teaching parents how to reduce overcontrol in the parent-child relationship, leading children to a new sense of efficacy and mastery.

Meanwhile, children learn relaxation techniques, including controlled breathing and muscle contraction and release, an exercise one child enthusiastically dubbed, “old man wiggles.”

Traditional cognitive-behavioral therapy components such as systematic densensitization are adapted for preschoolers, and have been shown to be highly effective in reducing symptoms during 6-12 brief, manualized sessions, she said.

Dr. Drury reported no relevant financial disclosures.

Major Finding: Many women who opt for contralateral prophylactic mastectomy are at low risk of recurrence based on family history and absence of aggressive mutations.

Data Source: Study of 2,965 women who underwent mastectomy for stage 0-III unilateral breast cancer from January 2007 to December 2005.

Disclosures: Neither Dr. King nor any of her coauthors reported any relevant financial disclosures.

SAN ANTONIO — Breast cancer patients undergoing prophylactic contralateral mastectomy are generally not at high risk for contralateral breast cancer, and may be influenced by anxiety or imaging studies that may not have clinical relevance, based on a study presented at the San Antonio Breast Cancer Symposium.

Rates of prophylactic contralateral mastectomy have increased “dramatically” among women with all stages of breast cancer in the United States in recent years, said Dr. Tari A. King, a breast cancer surgeon at Memorial Sloan-Kettering Cancer Center in New York.

From January 1997 to December 2005, for example, rates of the procedure increased from 7% to 24% of women who underwent mastectomy at her institution, she said in an interview following her presentation.

Dr. King and her associates sought to learn whether the increase in prophylactic mastectomy could be attributed to better awareness of risk factors for contralateral recurrence or treatment factors related to the index lesion.

A total of 2,965 women underwent mastectomy for stage 0-III unilateral breast cancer during the study period, 407 of whom (13.7%) opted to have a prophylactic mastectomy of the contralateral breast within 12 months.

The vast majority, 367, had the contralateral procedure immediately following breast cancer surgery, the investigators reported.

Women who opted for prophylactic contralateral mastectomy were younger than those who did not undergo the added surgery (mean age, 45 vs. 54 years) and more likely to be white (93% vs. 7%).

The P values for both characteristics were highly significant at less than .0001.

Equally significant was that women choosing contralateral prophylactic mastectomy were more likely to have a family history of breast cancer (68% vs. 32%).

Dr. King noted, however, that 43% of patients opting for additional surgery had no first-degree relatives with breast cancer. Almost half (49%) had two first-degree relatives with breast cancer, and just 8% had two or more first-degree relatives with the disease.

Just 13% of those who underwent prophylactic surgery were considered “high risk” because they were BRCA gene carriers (n = 37) or had undergone prior mantle radiation for Hodgkin's disease (n = 15).

Index cancer pathology revealed only ductal carcinoma in situ in 22% of patients who opted to have their contralateral breasts removed, suggesting that they were at exceedingly low risk of a contralateral recurrence, they reported.

The mean tumor size was larger among women who failed to have prophylactic surgery (2.16 cm vs. 1.53 cm), as was positive node status (57% vs. 47%); both differences were statistically significant at respective P values of less than .0001 and .001.

Clinical management factors strongly associated with prophylactic surgery included MRI at diagnosis and an additional biopsy in the contralateral breast because of MRI results.

Nearly half of women who decided on additional surgery (43%) had undergone an MRI, compared with just 16% of those who did not opt to have a prophylactic mastectomy.

The MRIs led to an additional contralateral or bilateral biopsy in 29% of women who chose added surgery, compared with just 4% in the group who did not (P less than .0001).

However, many of the women with MRI findings never had a biopsy to confirm whether a malignancy was present in the contralateral breast, instead deciding preemptively on a contralateral prophylactic mastectomy.

“There's no going back” if a patient decides on a prophylactic mastectomy before a biopsy can determine whether a lesion seen on MRI is benign, Dr. King stressed in her interview.

Breast conservation surgery was attempted in more women in the prophylactic mastectomy group (28%, compared with 16%; P less than .0001), the investigators reported.

The same women were more likely to undergo breast reconstruction, 87% vs. 51% (P less than .0001), suggesting that some women may have chosen the added surgery in order to achieve cosmetic symmetry.

All prophylactic contralateral mastectomies were performed by surgeons whose practice was limited to breast cancer surgery.

Within that group of 13, the rate of contralateral prophylactic mastectomy ranged from 3% of patients to 26%. A multivariate analysis found no independent association between choice of surgeon and prophylactic contralateral mastectomy, however.

Rates of distant metastasis were statistically similar (4% and 7%) in women who did and did not undergo contralateral prophylactic mastectomies, they reported.

After a median follow-up of 6 years, contralateral breast cancer developed in 12 (0.4%) women who did not undergo contralateral prophylactic mastectomies, Dr. King and her associates reported.

Just 13% of those who had prophylactic contralateral mastectomy were considered 'high risk.'

Source DR. KING

Major Finding: Many women who opt for contralateral prophylactic mastectomy are at low risk of recurrence based on family history and absence of aggressive mutations.

Data Source: Study of 2,965 women who underwent mastectomy for stage 0-III unilateral breast cancer from January 2007 to December 2005.

Disclosures: Neither Dr. King nor any of her coauthors reported any relevant financial disclosures.

SAN ANTONIO — Breast cancer patients undergoing prophylactic contralateral mastectomy are generally not at high risk for contralateral breast cancer, and may be influenced by anxiety or imaging studies that may not have clinical relevance, based on a study presented at the San Antonio Breast Cancer Symposium.

Rates of prophylactic contralateral mastectomy have increased “dramatically” among women with all stages of breast cancer in the United States in recent years, said Dr. Tari A. King, a breast cancer surgeon at Memorial Sloan-Kettering Cancer Center in New York.

From January 1997 to December 2005, for example, rates of the procedure increased from 7% to 24% of women who underwent mastectomy at her institution, she said in an interview following her presentation.

Dr. King and her associates sought to learn whether the increase in prophylactic mastectomy could be attributed to better awareness of risk factors for contralateral recurrence or treatment factors related to the index lesion.

A total of 2,965 women underwent mastectomy for stage 0-III unilateral breast cancer during the study period, 407 of whom (13.7%) opted to have a prophylactic mastectomy of the contralateral breast within 12 months.

The vast majority, 367, had the contralateral procedure immediately following breast cancer surgery, the investigators reported.

Women who opted for prophylactic contralateral mastectomy were younger than those who did not undergo the added surgery (mean age, 45 vs. 54 years) and more likely to be white (93% vs. 7%).

The P values for both characteristics were highly significant at less than .0001.

Equally significant was that women choosing contralateral prophylactic mastectomy were more likely to have a family history of breast cancer (68% vs. 32%).

Dr. King noted, however, that 43% of patients opting for additional surgery had no first-degree relatives with breast cancer. Almost half (49%) had two first-degree relatives with breast cancer, and just 8% had two or more first-degree relatives with the disease.

Just 13% of those who underwent prophylactic surgery were considered “high risk” because they were BRCA gene carriers (n = 37) or had undergone prior mantle radiation for Hodgkin's disease (n = 15).

Index cancer pathology revealed only ductal carcinoma in situ in 22% of patients who opted to have their contralateral breasts removed, suggesting that they were at exceedingly low risk of a contralateral recurrence, they reported.

The mean tumor size was larger among women who failed to have prophylactic surgery (2.16 cm vs. 1.53 cm), as was positive node status (57% vs. 47%); both differences were statistically significant at respective P values of less than .0001 and .001.

Clinical management factors strongly associated with prophylactic surgery included MRI at diagnosis and an additional biopsy in the contralateral breast because of MRI results.

Nearly half of women who decided on additional surgery (43%) had undergone an MRI, compared with just 16% of those who did not opt to have a prophylactic mastectomy.

The MRIs led to an additional contralateral or bilateral biopsy in 29% of women who chose added surgery, compared with just 4% in the group who did not (P less than .0001).

However, many of the women with MRI findings never had a biopsy to confirm whether a malignancy was present in the contralateral breast, instead deciding preemptively on a contralateral prophylactic mastectomy.

“There's no going back” if a patient decides on a prophylactic mastectomy before a biopsy can determine whether a lesion seen on MRI is benign, Dr. King stressed in her interview.

Breast conservation surgery was attempted in more women in the prophylactic mastectomy group (28%, compared with 16%; P less than .0001), the investigators reported.

The same women were more likely to undergo breast reconstruction, 87% vs. 51% (P less than .0001), suggesting that some women may have chosen the added surgery in order to achieve cosmetic symmetry.

All prophylactic contralateral mastectomies were performed by surgeons whose practice was limited to breast cancer surgery.

Within that group of 13, the rate of contralateral prophylactic mastectomy ranged from 3% of patients to 26%. A multivariate analysis found no independent association between choice of surgeon and prophylactic contralateral mastectomy, however.

Rates of distant metastasis were statistically similar (4% and 7%) in women who did and did not undergo contralateral prophylactic mastectomies, they reported.

After a median follow-up of 6 years, contralateral breast cancer developed in 12 (0.4%) women who did not undergo contralateral prophylactic mastectomies, Dr. King and her associates reported.

Just 13% of those who had prophylactic contralateral mastectomy were considered 'high risk.'

Source DR. KING

Major Finding: Many women who opt for contralateral prophylactic mastectomy are at low risk of recurrence based on family history and absence of aggressive mutations.

Data Source: Study of 2,965 women who underwent mastectomy for stage 0-III unilateral breast cancer from January 2007 to December 2005.

Disclosures: Neither Dr. King nor any of her coauthors reported any relevant financial disclosures.

SAN ANTONIO — Breast cancer patients undergoing prophylactic contralateral mastectomy are generally not at high risk for contralateral breast cancer, and may be influenced by anxiety or imaging studies that may not have clinical relevance, based on a study presented at the San Antonio Breast Cancer Symposium.

Rates of prophylactic contralateral mastectomy have increased “dramatically” among women with all stages of breast cancer in the United States in recent years, said Dr. Tari A. King, a breast cancer surgeon at Memorial Sloan-Kettering Cancer Center in New York.

From January 1997 to December 2005, for example, rates of the procedure increased from 7% to 24% of women who underwent mastectomy at her institution, she said in an interview following her presentation.

Dr. King and her associates sought to learn whether the increase in prophylactic mastectomy could be attributed to better awareness of risk factors for contralateral recurrence or treatment factors related to the index lesion.

A total of 2,965 women underwent mastectomy for stage 0-III unilateral breast cancer during the study period, 407 of whom (13.7%) opted to have a prophylactic mastectomy of the contralateral breast within 12 months.

The vast majority, 367, had the contralateral procedure immediately following breast cancer surgery, the investigators reported.

Women who opted for prophylactic contralateral mastectomy were younger than those who did not undergo the added surgery (mean age, 45 vs. 54 years) and more likely to be white (93% vs. 7%).

The P values for both characteristics were highly significant at less than .0001.

Equally significant was that women choosing contralateral prophylactic mastectomy were more likely to have a family history of breast cancer (68% vs. 32%).

Dr. King noted, however, that 43% of patients opting for additional surgery had no first-degree relatives with breast cancer. Almost half (49%) had two first-degree relatives with breast cancer, and just 8% had two or more first-degree relatives with the disease.

Just 13% of those who underwent prophylactic surgery were considered “high risk” because they were BRCA gene carriers (n = 37) or had undergone prior mantle radiation for Hodgkin's disease (n = 15).

Index cancer pathology revealed only ductal carcinoma in situ in 22% of patients who opted to have their contralateral breasts removed, suggesting that they were at exceedingly low risk of a contralateral recurrence, they reported.

The mean tumor size was larger among women who failed to have prophylactic surgery (2.16 cm vs. 1.53 cm), as was positive node status (57% vs. 47%); both differences were statistically significant at respective P values of less than .0001 and .001.

Clinical management factors strongly associated with prophylactic surgery included MRI at diagnosis and an additional biopsy in the contralateral breast because of MRI results.

Nearly half of women who decided on additional surgery (43%) had undergone an MRI, compared with just 16% of those who did not opt to have a prophylactic mastectomy.

The MRIs led to an additional contralateral or bilateral biopsy in 29% of women who chose added surgery, compared with just 4% in the group who did not (P less than .0001).

However, many of the women with MRI findings never had a biopsy to confirm whether a malignancy was present in the contralateral breast, instead deciding preemptively on a contralateral prophylactic mastectomy.

“There's no going back” if a patient decides on a prophylactic mastectomy before a biopsy can determine whether a lesion seen on MRI is benign, Dr. King stressed in her interview.

Breast conservation surgery was attempted in more women in the prophylactic mastectomy group (28%, compared with 16%; P less than .0001), the investigators reported.

The same women were more likely to undergo breast reconstruction, 87% vs. 51% (P less than .0001), suggesting that some women may have chosen the added surgery in order to achieve cosmetic symmetry.

All prophylactic contralateral mastectomies were performed by surgeons whose practice was limited to breast cancer surgery.

Within that group of 13, the rate of contralateral prophylactic mastectomy ranged from 3% of patients to 26%. A multivariate analysis found no independent association between choice of surgeon and prophylactic contralateral mastectomy, however.

Rates of distant metastasis were statistically similar (4% and 7%) in women who did and did not undergo contralateral prophylactic mastectomies, they reported.

After a median follow-up of 6 years, contralateral breast cancer developed in 12 (0.4%) women who did not undergo contralateral prophylactic mastectomies, Dr. King and her associates reported.

Just 13% of those who had prophylactic contralateral mastectomy were considered 'high risk.'

Source DR. KING

LOS ANGELES — Lesbian, gay, and bisexual adults have a higher risk of substance use disorders than do heterosexuals, but this risk is not uniform among sexual minority groups, according to data from the population-based National Epidemiologic Survey on Alcohol and Related Conditions.

The data also pointed to profound differences in substance abuse rates within commonly grouped sexual orientation categories when participants were categorized not just by the way in which they described their sexual identity (lesbian, gay, bisexual, or heterosexual), but also by the way they described their sexual behavior and attraction.

Two-thirds of 577 lesbian, bisexual, and gay adults reported being discriminated against on the basis of their sexual orientation, gender, race, or a combination of these.

About half of individuals who had experienced all three kinds of discrimination met criteria for a substance use disorder, and among those exposed to “very high levels of discrimination” (above 70 on a 0-72 discrimination scale for overall discrimination in the past year), the probability of a substance use disorder was almost 100%, Dr. Sean Esteban McCabe said at the annual meeting of the American Academy of Addiction Psychiatry. Discrimination was measured by using questions derived from the Experiences of Discrimination scales.

A clear dose-response relationship was seen between scores on the discrimination Sscale and substance use disorders, both for lifetime discrimination and for past-year discrimination, with a sharp increase seen in such disorders beginning at low to moderate discrimination scale scores among people who had recently experienced discrimination.

Conversely, members of a sexual minority group who had not experienced discrimination had rates of substance use disorders “comparable to heterosexuals,” said Dr. McCabe, a psychologist at the Substance Abuse Research Center and Institute for Research on Women and Gender at the University of Michigan in Ann Arbor.

The finding confirmed Dr. McCabe's hypothesis that cultural and environmental factors are the most likely explanation for elevated substance use disorders among sexual minorities—“not… sexual orientation itself.”

Overall, substance abuse disorders were substantially higher among lesbian, bisexual, and gay respondents than among heterosexuals in Wave 2 data from NESARC, a representative survey of nearly 35,000 adults—including the largest national sample of minority sexual groups ever enrolled in study on alcohol and drug use.

Past-year prevalence for any substance disorder was 25.8%, 24.3%, and 5.8%, respectively, among lesbian, bisexual, and heterosexual women, and 31.4%, 27.6%, and 15.6%, respectively, among gay, bisexual, and heterosexual men.

However, “risk was not uniform across dimensions of sexual minority women and men,” emphasized Dr. McCabe. For example, women who reported exclusive same-sex sexual behavior had a past-year prevalence of substance use disorder of 9.1%, statistically similar to the 5.8% rate among heterosexual women.

In contrast, women who reported sexual behavior with both sexes had a past-year prevalence rate of substance abuse of 26.8%, a highly significant elevation over rates in other women.

Women who reported attraction only to the same sex had a past year prevalence rate of substance use disorders of 11.4%, not dissimilar to rate seen in women who said they were attracted equally to both sexes (9.6%), those who said they were mostly attracted to the other sex (13.2%), and those who said they were only attracted to the other sex (5.6%). Among women, the highest past-year prevalence rate of substance abuse disorders was highest, by far, among those who said they were mostly attracted to the same sex, at 24.2%.

Among men, differences were seen among past-year substance use disorder prevalence rates depending on how they described their sexual behavior, but those differences were not as striking as those seen among women.

For example, men who reported only same sex sexual behavior had a rate of 17.9%, compared to a 15.7% rate among men who reported only having sex with women. Men who reported sex with both sexes had a significantly higher rate of substance use disorders—26.3%.

Dr. McCabe reported no disclosures.

My take

Heightened Awareness Is Crucial

Dr. Sean Esteban McCabe's presentation underscores the importance for health care providers to consider lifestyle differences in identifying individuals at greater risk for substance use disorders. Initial screenings should include questions regarding issues of sexual orientation, sexual behavior, and attraction. Further, providers need to develop a heightened awareness for substance use disorders in individuals identified to be in sexual minorities. Brief screening tools, such as the CAGE, should be employed to identify individuals in this population at risk of substance abuse. It is imperative the clinician identify patients in a sexual minority and develop a further understanding of the prevalence of substance use disorders, treatment needs, and appropriate interventions for this population.

TONIA WERNER, M.D., is assistant professor and chief of forensic psychiatry in the department of psychiatry at the University of Florida, Gainesville. She reports no conflicts relevant to this study.

LOS ANGELES — Lesbian, gay, and bisexual adults have a higher risk of substance use disorders than do heterosexuals, but this risk is not uniform among sexual minority groups, according to data from the population-based National Epidemiologic Survey on Alcohol and Related Conditions.

The data also pointed to profound differences in substance abuse rates within commonly grouped sexual orientation categories when participants were categorized not just by the way in which they described their sexual identity (lesbian, gay, bisexual, or heterosexual), but also by the way they described their sexual behavior and attraction.

Two-thirds of 577 lesbian, bisexual, and gay adults reported being discriminated against on the basis of their sexual orientation, gender, race, or a combination of these.

About half of individuals who had experienced all three kinds of discrimination met criteria for a substance use disorder, and among those exposed to “very high levels of discrimination” (above 70 on a 0-72 discrimination scale for overall discrimination in the past year), the probability of a substance use disorder was almost 100%, Dr. Sean Esteban McCabe said at the annual meeting of the American Academy of Addiction Psychiatry. Discrimination was measured by using questions derived from the Experiences of Discrimination scales.

A clear dose-response relationship was seen between scores on the discrimination Sscale and substance use disorders, both for lifetime discrimination and for past-year discrimination, with a sharp increase seen in such disorders beginning at low to moderate discrimination scale scores among people who had recently experienced discrimination.

Conversely, members of a sexual minority group who had not experienced discrimination had rates of substance use disorders “comparable to heterosexuals,” said Dr. McCabe, a psychologist at the Substance Abuse Research Center and Institute for Research on Women and Gender at the University of Michigan in Ann Arbor.

The finding confirmed Dr. McCabe's hypothesis that cultural and environmental factors are the most likely explanation for elevated substance use disorders among sexual minorities—“not… sexual orientation itself.”

Overall, substance abuse disorders were substantially higher among lesbian, bisexual, and gay respondents than among heterosexuals in Wave 2 data from NESARC, a representative survey of nearly 35,000 adults—including the largest national sample of minority sexual groups ever enrolled in study on alcohol and drug use.

Past-year prevalence for any substance disorder was 25.8%, 24.3%, and 5.8%, respectively, among lesbian, bisexual, and heterosexual women, and 31.4%, 27.6%, and 15.6%, respectively, among gay, bisexual, and heterosexual men.

However, “risk was not uniform across dimensions of sexual minority women and men,” emphasized Dr. McCabe. For example, women who reported exclusive same-sex sexual behavior had a past-year prevalence of substance use disorder of 9.1%, statistically similar to the 5.8% rate among heterosexual women.

In contrast, women who reported sexual behavior with both sexes had a past-year prevalence rate of substance abuse of 26.8%, a highly significant elevation over rates in other women.

Women who reported attraction only to the same sex had a past year prevalence rate of substance use disorders of 11.4%, not dissimilar to rate seen in women who said they were attracted equally to both sexes (9.6%), those who said they were mostly attracted to the other sex (13.2%), and those who said they were only attracted to the other sex (5.6%). Among women, the highest past-year prevalence rate of substance abuse disorders was highest, by far, among those who said they were mostly attracted to the same sex, at 24.2%.

Among men, differences were seen among past-year substance use disorder prevalence rates depending on how they described their sexual behavior, but those differences were not as striking as those seen among women.

For example, men who reported only same sex sexual behavior had a rate of 17.9%, compared to a 15.7% rate among men who reported only having sex with women. Men who reported sex with both sexes had a significantly higher rate of substance use disorders—26.3%.

Dr. McCabe reported no disclosures.

My take

Heightened Awareness Is Crucial

Dr. Sean Esteban McCabe's presentation underscores the importance for health care providers to consider lifestyle differences in identifying individuals at greater risk for substance use disorders. Initial screenings should include questions regarding issues of sexual orientation, sexual behavior, and attraction. Further, providers need to develop a heightened awareness for substance use disorders in individuals identified to be in sexual minorities. Brief screening tools, such as the CAGE, should be employed to identify individuals in this population at risk of substance abuse. It is imperative the clinician identify patients in a sexual minority and develop a further understanding of the prevalence of substance use disorders, treatment needs, and appropriate interventions for this population.

TONIA WERNER, M.D., is assistant professor and chief of forensic psychiatry in the department of psychiatry at the University of Florida, Gainesville. She reports no conflicts relevant to this study.

LOS ANGELES — Lesbian, gay, and bisexual adults have a higher risk of substance use disorders than do heterosexuals, but this risk is not uniform among sexual minority groups, according to data from the population-based National Epidemiologic Survey on Alcohol and Related Conditions.

The data also pointed to profound differences in substance abuse rates within commonly grouped sexual orientation categories when participants were categorized not just by the way in which they described their sexual identity (lesbian, gay, bisexual, or heterosexual), but also by the way they described their sexual behavior and attraction.

Two-thirds of 577 lesbian, bisexual, and gay adults reported being discriminated against on the basis of their sexual orientation, gender, race, or a combination of these.

About half of individuals who had experienced all three kinds of discrimination met criteria for a substance use disorder, and among those exposed to “very high levels of discrimination” (above 70 on a 0-72 discrimination scale for overall discrimination in the past year), the probability of a substance use disorder was almost 100%, Dr. Sean Esteban McCabe said at the annual meeting of the American Academy of Addiction Psychiatry. Discrimination was measured by using questions derived from the Experiences of Discrimination scales.

A clear dose-response relationship was seen between scores on the discrimination Sscale and substance use disorders, both for lifetime discrimination and for past-year discrimination, with a sharp increase seen in such disorders beginning at low to moderate discrimination scale scores among people who had recently experienced discrimination.

Conversely, members of a sexual minority group who had not experienced discrimination had rates of substance use disorders “comparable to heterosexuals,” said Dr. McCabe, a psychologist at the Substance Abuse Research Center and Institute for Research on Women and Gender at the University of Michigan in Ann Arbor.

The finding confirmed Dr. McCabe's hypothesis that cultural and environmental factors are the most likely explanation for elevated substance use disorders among sexual minorities—“not… sexual orientation itself.”

Overall, substance abuse disorders were substantially higher among lesbian, bisexual, and gay respondents than among heterosexuals in Wave 2 data from NESARC, a representative survey of nearly 35,000 adults—including the largest national sample of minority sexual groups ever enrolled in study on alcohol and drug use.

Past-year prevalence for any substance disorder was 25.8%, 24.3%, and 5.8%, respectively, among lesbian, bisexual, and heterosexual women, and 31.4%, 27.6%, and 15.6%, respectively, among gay, bisexual, and heterosexual men.

However, “risk was not uniform across dimensions of sexual minority women and men,” emphasized Dr. McCabe. For example, women who reported exclusive same-sex sexual behavior had a past-year prevalence of substance use disorder of 9.1%, statistically similar to the 5.8% rate among heterosexual women.

In contrast, women who reported sexual behavior with both sexes had a past-year prevalence rate of substance abuse of 26.8%, a highly significant elevation over rates in other women.

Women who reported attraction only to the same sex had a past year prevalence rate of substance use disorders of 11.4%, not dissimilar to rate seen in women who said they were attracted equally to both sexes (9.6%), those who said they were mostly attracted to the other sex (13.2%), and those who said they were only attracted to the other sex (5.6%). Among women, the highest past-year prevalence rate of substance abuse disorders was highest, by far, among those who said they were mostly attracted to the same sex, at 24.2%.

Among men, differences were seen among past-year substance use disorder prevalence rates depending on how they described their sexual behavior, but those differences were not as striking as those seen among women.

For example, men who reported only same sex sexual behavior had a rate of 17.9%, compared to a 15.7% rate among men who reported only having sex with women. Men who reported sex with both sexes had a significantly higher rate of substance use disorders—26.3%.

Dr. McCabe reported no disclosures.

My take

Heightened Awareness Is Crucial

Dr. Sean Esteban McCabe's presentation underscores the importance for health care providers to consider lifestyle differences in identifying individuals at greater risk for substance use disorders. Initial screenings should include questions regarding issues of sexual orientation, sexual behavior, and attraction. Further, providers need to develop a heightened awareness for substance use disorders in individuals identified to be in sexual minorities. Brief screening tools, such as the CAGE, should be employed to identify individuals in this population at risk of substance abuse. It is imperative the clinician identify patients in a sexual minority and develop a further understanding of the prevalence of substance use disorders, treatment needs, and appropriate interventions for this population.

TONIA WERNER, M.D., is assistant professor and chief of forensic psychiatry in the department of psychiatry at the University of Florida, Gainesville. She reports no conflicts relevant to this study.

Major Findings: Children aged 2–5 who had a fall serious enough to require medical attention were 5.8 times more likely than other preschoolers to meet diagnostic criteria for depression. In more than half of these children, the first depression symptom occurred only after a major fall.

Data Source: Longitudinal study of 666 children representing a larger community sample of more than 3,000 children of the same age.

Disclosures: Dr. Egger reported no relevant financial conflicts of interest.

LOS ANGELES – Serious falls were strongly associated with childhood depression in a study of preschoolers aged 2–5 years.

A series of longitudinal studies conducted at Duke University has found associations between high-stress events and cumulative stressors in the lives of young children and DSM-IV diagnoses, with serious falls emerging as a uniquely important contributor, Dr. Helen Link Egger said at an international conference on pediatric psychological trauma.

In the current study, a weighted representative sample of 666 preschoolers was statistically reflective of a larger community sample of more than 3,000 children of the same age. The children who suffered a serious fall were 5.8 times more likely than others to meet criteria for childhood depression, Dr. Egger said.

The rate of depression in children who fell was 18%, compared with 3.6% in the other children enrolled in the study.

No association was detected between depression and the age at which children fell.

Because the study captured baseline data, the researchers were able to show that 58% of children who fell during the time period of the study developed their first depressive symptom only after the injury.

The findings do not prove causality, but they do raise numerous questions, said Dr. Egger of the center for developmental epidemiology, department of psychiatry and behavioral sciences, Duke University, Durham, N.C.

Of particular interest is whether maternal depression or household environmental factors may set the stage for some childhood falls, as well as for the depression that some of the same children develop, she said.

Beyond physical safety hazards, children who fall may be “living in a household where nobody is watching out for them,” she suggested. If so, the trauma associated with the fall itself and the resulting trip to the emergency room may not be a causal factor in depression, but rather a reflection of caregiving that is not attentive or deeply attached. Factors significantly more common in children who fell included a recent change in day care (41.2% of children who fell, compared with 13.5% of those who did not); death of a loved one (30.4% of children who fell, 13.7% of those who did not); death of a sibling or peer (4.4% of children who fell, 0.5% of those who did not); and removal from the home because of physical abuse (1.7% of children who fell, 0.1% of those who did not).

Children with any injury requiring medical attention, including falls, were 2.7 times more likely than other preschoolers to meet criteria for separation anxiety disorder, with a quarter of the injured children meeting criteria for that DSM-IV diagnosis. Serious injuries occurred in more than 12% of children studied, with serious falls accounting for almost half.

Falls are a major cause of early childhood injury nationally as well, according to the Centers for Disease Control and Prevention. Between the years 2000 and 2006, more than half of all injuries to infants were falls, and falls accounted for 43% of injuries to children aged 1–4 years.

Dr. Egger noted that links between traumatic events in early childhood and psychological sequelae are likely very complex and might depend on the child's pre-existing emotional, developmental, and behavioral characteristics; parental and socioeconomic risk factors; and the event's direct impact on neurocognition.

Major Findings: Children aged 2–5 who had a fall serious enough to require medical attention were 5.8 times more likely than other preschoolers to meet diagnostic criteria for depression. In more than half of these children, the first depression symptom occurred only after a major fall.

Data Source: Longitudinal study of 666 children representing a larger community sample of more than 3,000 children of the same age.

Disclosures: Dr. Egger reported no relevant financial conflicts of interest.

LOS ANGELES – Serious falls were strongly associated with childhood depression in a study of preschoolers aged 2–5 years.

A series of longitudinal studies conducted at Duke University has found associations between high-stress events and cumulative stressors in the lives of young children and DSM-IV diagnoses, with serious falls emerging as a uniquely important contributor, Dr. Helen Link Egger said at an international conference on pediatric psychological trauma.

In the current study, a weighted representative sample of 666 preschoolers was statistically reflective of a larger community sample of more than 3,000 children of the same age. The children who suffered a serious fall were 5.8 times more likely than others to meet criteria for childhood depression, Dr. Egger said.

The rate of depression in children who fell was 18%, compared with 3.6% in the other children enrolled in the study.

No association was detected between depression and the age at which children fell.

Because the study captured baseline data, the researchers were able to show that 58% of children who fell during the time period of the study developed their first depressive symptom only after the injury.

The findings do not prove causality, but they do raise numerous questions, said Dr. Egger of the center for developmental epidemiology, department of psychiatry and behavioral sciences, Duke University, Durham, N.C.

Of particular interest is whether maternal depression or household environmental factors may set the stage for some childhood falls, as well as for the depression that some of the same children develop, she said.

Beyond physical safety hazards, children who fall may be “living in a household where nobody is watching out for them,” she suggested. If so, the trauma associated with the fall itself and the resulting trip to the emergency room may not be a causal factor in depression, but rather a reflection of caregiving that is not attentive or deeply attached. Factors significantly more common in children who fell included a recent change in day care (41.2% of children who fell, compared with 13.5% of those who did not); death of a loved one (30.4% of children who fell, 13.7% of those who did not); death of a sibling or peer (4.4% of children who fell, 0.5% of those who did not); and removal from the home because of physical abuse (1.7% of children who fell, 0.1% of those who did not).

Children with any injury requiring medical attention, including falls, were 2.7 times more likely than other preschoolers to meet criteria for separation anxiety disorder, with a quarter of the injured children meeting criteria for that DSM-IV diagnosis. Serious injuries occurred in more than 12% of children studied, with serious falls accounting for almost half.

Falls are a major cause of early childhood injury nationally as well, according to the Centers for Disease Control and Prevention. Between the years 2000 and 2006, more than half of all injuries to infants were falls, and falls accounted for 43% of injuries to children aged 1–4 years.

Dr. Egger noted that links between traumatic events in early childhood and psychological sequelae are likely very complex and might depend on the child's pre-existing emotional, developmental, and behavioral characteristics; parental and socioeconomic risk factors; and the event's direct impact on neurocognition.

Major Findings: Children aged 2–5 who had a fall serious enough to require medical attention were 5.8 times more likely than other preschoolers to meet diagnostic criteria for depression. In more than half of these children, the first depression symptom occurred only after a major fall.

Data Source: Longitudinal study of 666 children representing a larger community sample of more than 3,000 children of the same age.

Disclosures: Dr. Egger reported no relevant financial conflicts of interest.

LOS ANGELES – Serious falls were strongly associated with childhood depression in a study of preschoolers aged 2–5 years.

A series of longitudinal studies conducted at Duke University has found associations between high-stress events and cumulative stressors in the lives of young children and DSM-IV diagnoses, with serious falls emerging as a uniquely important contributor, Dr. Helen Link Egger said at an international conference on pediatric psychological trauma.

In the current study, a weighted representative sample of 666 preschoolers was statistically reflective of a larger community sample of more than 3,000 children of the same age. The children who suffered a serious fall were 5.8 times more likely than others to meet criteria for childhood depression, Dr. Egger said.

The rate of depression in children who fell was 18%, compared with 3.6% in the other children enrolled in the study.

No association was detected between depression and the age at which children fell.

Because the study captured baseline data, the researchers were able to show that 58% of children who fell during the time period of the study developed their first depressive symptom only after the injury.

The findings do not prove causality, but they do raise numerous questions, said Dr. Egger of the center for developmental epidemiology, department of psychiatry and behavioral sciences, Duke University, Durham, N.C.

Of particular interest is whether maternal depression or household environmental factors may set the stage for some childhood falls, as well as for the depression that some of the same children develop, she said.

Beyond physical safety hazards, children who fall may be “living in a household where nobody is watching out for them,” she suggested. If so, the trauma associated with the fall itself and the resulting trip to the emergency room may not be a causal factor in depression, but rather a reflection of caregiving that is not attentive or deeply attached. Factors significantly more common in children who fell included a recent change in day care (41.2% of children who fell, compared with 13.5% of those who did not); death of a loved one (30.4% of children who fell, 13.7% of those who did not); death of a sibling or peer (4.4% of children who fell, 0.5% of those who did not); and removal from the home because of physical abuse (1.7% of children who fell, 0.1% of those who did not).

Children with any injury requiring medical attention, including falls, were 2.7 times more likely than other preschoolers to meet criteria for separation anxiety disorder, with a quarter of the injured children meeting criteria for that DSM-IV diagnosis. Serious injuries occurred in more than 12% of children studied, with serious falls accounting for almost half.

Falls are a major cause of early childhood injury nationally as well, according to the Centers for Disease Control and Prevention. Between the years 2000 and 2006, more than half of all injuries to infants were falls, and falls accounted for 43% of injuries to children aged 1–4 years.

Dr. Egger noted that links between traumatic events in early childhood and psychological sequelae are likely very complex and might depend on the child's pre-existing emotional, developmental, and behavioral characteristics; parental and socioeconomic risk factors; and the event's direct impact on neurocognition.

Major Finding: Conduct disorder in a child with ADHD “solidly” and “independently” predicted substance use (hazard ratio, 5.26), including alcohol use or dependence (2.85), drug use or dependence (2.36), and cigarette smoking (2.74).

Data Source: Ten-year prospective, longitudinal case-control family study of ADHD youth (n = 361) and controls (n = 417) first assessed by comprehensive interview at about age 11 and, for most recent findings, at about age 20.

Disclosures: The presenter receives research support from numerous pharmaceutical companies that make medications used to treat ADHD. This study was funded exclusively by government grants, including from the National Institute of Mental Health.

LOS ANGELES – Early conduct disorder in children with ADHD predicts substance use disorders in adolescence and early adulthood, according to researchers who conducted a long-term prospective study on 778 children.

“I'm a child psychiatrist. I treat kids and work with families. I'd like to know in 10-year-olds, whom do I worry about?” said Dr. Timothy E. Wilens, who is a a pediatric psychopharmacologist at Massachusetts General Hospital in Boston and lead investigator of a 10-year, prospective study of 361 children with ADHD and 417 matched controls.

Children aged 10–11 years and their families underwent extensive interviews, and at periodic intervals over the subsequent decade, culminating in a follow-up evaluation when subjects were in their early 20s.

His overall hypothesis–that attention-deficit/hyperactivity disorder (ADHD) in school-age children would confer an elevated risk of later substance use–was supported, with significant hazard ratios for any substance use of 2.15; alcohol use or dependence, 2.19; drug use or drug dependence, 4.12; and cigarette smoking, 3.21.

As expected, conduct disorder in a child with ADHD “solidly” and independently predicted substance use (hazard ratio, 5.26), including alcohol use or dependence (2.85), drug use or dependence (2.36), and cigarette smoking (2.74).

“We know conduct disorder is big,” he said at the annual meeting of the American Academy of Addiction Psychiatry.

“What you may not know is that you can identify it in a 10-year-old pretty clearly, and if you see it in a 10-year-old, you know you're going to have a problem in adolescence.”

What failed to materialize in the study was a hypothesized link to other independent risk factors for eventual substance use in children with ADHD.

Early difficulties with socialization, family environment, school performance, full-scale IQ or the digit span subtest, arithmetic skills, and a family history of ADHD or substance use all failed to significantly increase the risk of substance use over and above the baseline risk faced by children with ADHD.

Similarly, neither depression nor anxiety independently increased risk for substance use.

“Remember, we have a bit of a ceiling effect here,” cautioned Dr. Wilens, who nonetheless expressed surprise at the results.

One strong trend that failed to reach significance because of a small sample size was a possible link between bipolar disorder and later substance use in children with ADHD.

Previous studies conducted by Dr. Wilens and his group also have drawn associations between substance use among older children with ADHD when they have experienced parental substance use during certain vulnerable developmental stages, he said.

Overall, however, Dr. Wilens said the study suggests that children with ADHD who do not have conduct disorder or severe mood dysregulation face a baseline elevated risk of substance abuse that is not exacerbated by other comorbidities.

He drew attention to a large body of research showing that substance use initiation is delayed if children with ADHD are well managed with medication, although the protective effects of medication are lost in adulthood.

“Aggressively treating the ADHD is really critical,” he said.

He also advised careful assessment of potential conduct disorder in young children, which might present as a history of aggressiveness, bullying, a dearth of positive interactions with other children, harm to animals or younger children, a problematic response to parental discipline, and a lack of empathy.

Minor property damage such as breaking windows might be part of the picture in a 10-year-old, but conduct disorder is likely to look different in younger children, Dr. Wilens said.

“You're not going to see them stealing a car.”

Major Finding: Conduct disorder in a child with ADHD “solidly” and “independently” predicted substance use (hazard ratio, 5.26), including alcohol use or dependence (2.85), drug use or dependence (2.36), and cigarette smoking (2.74).

Data Source: Ten-year prospective, longitudinal case-control family study of ADHD youth (n = 361) and controls (n = 417) first assessed by comprehensive interview at about age 11 and, for most recent findings, at about age 20.

Disclosures: The presenter receives research support from numerous pharmaceutical companies that make medications used to treat ADHD. This study was funded exclusively by government grants, including from the National Institute of Mental Health.

LOS ANGELES – Early conduct disorder in children with ADHD predicts substance use disorders in adolescence and early adulthood, according to researchers who conducted a long-term prospective study on 778 children.

“I'm a child psychiatrist. I treat kids and work with families. I'd like to know in 10-year-olds, whom do I worry about?” said Dr. Timothy E. Wilens, who is a a pediatric psychopharmacologist at Massachusetts General Hospital in Boston and lead investigator of a 10-year, prospective study of 361 children with ADHD and 417 matched controls.

Children aged 10–11 years and their families underwent extensive interviews, and at periodic intervals over the subsequent decade, culminating in a follow-up evaluation when subjects were in their early 20s.

His overall hypothesis–that attention-deficit/hyperactivity disorder (ADHD) in school-age children would confer an elevated risk of later substance use–was supported, with significant hazard ratios for any substance use of 2.15; alcohol use or dependence, 2.19; drug use or drug dependence, 4.12; and cigarette smoking, 3.21.

As expected, conduct disorder in a child with ADHD “solidly” and independently predicted substance use (hazard ratio, 5.26), including alcohol use or dependence (2.85), drug use or dependence (2.36), and cigarette smoking (2.74).

“We know conduct disorder is big,” he said at the annual meeting of the American Academy of Addiction Psychiatry.

“What you may not know is that you can identify it in a 10-year-old pretty clearly, and if you see it in a 10-year-old, you know you're going to have a problem in adolescence.”

What failed to materialize in the study was a hypothesized link to other independent risk factors for eventual substance use in children with ADHD.

Early difficulties with socialization, family environment, school performance, full-scale IQ or the digit span subtest, arithmetic skills, and a family history of ADHD or substance use all failed to significantly increase the risk of substance use over and above the baseline risk faced by children with ADHD.

Similarly, neither depression nor anxiety independently increased risk for substance use.

“Remember, we have a bit of a ceiling effect here,” cautioned Dr. Wilens, who nonetheless expressed surprise at the results.

One strong trend that failed to reach significance because of a small sample size was a possible link between bipolar disorder and later substance use in children with ADHD.

Previous studies conducted by Dr. Wilens and his group also have drawn associations between substance use among older children with ADHD when they have experienced parental substance use during certain vulnerable developmental stages, he said.

Overall, however, Dr. Wilens said the study suggests that children with ADHD who do not have conduct disorder or severe mood dysregulation face a baseline elevated risk of substance abuse that is not exacerbated by other comorbidities.

He drew attention to a large body of research showing that substance use initiation is delayed if children with ADHD are well managed with medication, although the protective effects of medication are lost in adulthood.

“Aggressively treating the ADHD is really critical,” he said.

He also advised careful assessment of potential conduct disorder in young children, which might present as a history of aggressiveness, bullying, a dearth of positive interactions with other children, harm to animals or younger children, a problematic response to parental discipline, and a lack of empathy.

Minor property damage such as breaking windows might be part of the picture in a 10-year-old, but conduct disorder is likely to look different in younger children, Dr. Wilens said.

“You're not going to see them stealing a car.”

Major Finding: Conduct disorder in a child with ADHD “solidly” and “independently” predicted substance use (hazard ratio, 5.26), including alcohol use or dependence (2.85), drug use or dependence (2.36), and cigarette smoking (2.74).

Data Source: Ten-year prospective, longitudinal case-control family study of ADHD youth (n = 361) and controls (n = 417) first assessed by comprehensive interview at about age 11 and, for most recent findings, at about age 20.

Disclosures: The presenter receives research support from numerous pharmaceutical companies that make medications used to treat ADHD. This study was funded exclusively by government grants, including from the National Institute of Mental Health.

LOS ANGELES – Early conduct disorder in children with ADHD predicts substance use disorders in adolescence and early adulthood, according to researchers who conducted a long-term prospective study on 778 children.

“I'm a child psychiatrist. I treat kids and work with families. I'd like to know in 10-year-olds, whom do I worry about?” said Dr. Timothy E. Wilens, who is a a pediatric psychopharmacologist at Massachusetts General Hospital in Boston and lead investigator of a 10-year, prospective study of 361 children with ADHD and 417 matched controls.

Children aged 10–11 years and their families underwent extensive interviews, and at periodic intervals over the subsequent decade, culminating in a follow-up evaluation when subjects were in their early 20s.

His overall hypothesis–that attention-deficit/hyperactivity disorder (ADHD) in school-age children would confer an elevated risk of later substance use–was supported, with significant hazard ratios for any substance use of 2.15; alcohol use or dependence, 2.19; drug use or drug dependence, 4.12; and cigarette smoking, 3.21.

As expected, conduct disorder in a child with ADHD “solidly” and independently predicted substance use (hazard ratio, 5.26), including alcohol use or dependence (2.85), drug use or dependence (2.36), and cigarette smoking (2.74).

“We know conduct disorder is big,” he said at the annual meeting of the American Academy of Addiction Psychiatry.

“What you may not know is that you can identify it in a 10-year-old pretty clearly, and if you see it in a 10-year-old, you know you're going to have a problem in adolescence.”

What failed to materialize in the study was a hypothesized link to other independent risk factors for eventual substance use in children with ADHD.

Early difficulties with socialization, family environment, school performance, full-scale IQ or the digit span subtest, arithmetic skills, and a family history of ADHD or substance use all failed to significantly increase the risk of substance use over and above the baseline risk faced by children with ADHD.

Similarly, neither depression nor anxiety independently increased risk for substance use.

“Remember, we have a bit of a ceiling effect here,” cautioned Dr. Wilens, who nonetheless expressed surprise at the results.

One strong trend that failed to reach significance because of a small sample size was a possible link between bipolar disorder and later substance use in children with ADHD.

Previous studies conducted by Dr. Wilens and his group also have drawn associations between substance use among older children with ADHD when they have experienced parental substance use during certain vulnerable developmental stages, he said.

Overall, however, Dr. Wilens said the study suggests that children with ADHD who do not have conduct disorder or severe mood dysregulation face a baseline elevated risk of substance abuse that is not exacerbated by other comorbidities.

He drew attention to a large body of research showing that substance use initiation is delayed if children with ADHD are well managed with medication, although the protective effects of medication are lost in adulthood.

“Aggressively treating the ADHD is really critical,” he said.

He also advised careful assessment of potential conduct disorder in young children, which might present as a history of aggressiveness, bullying, a dearth of positive interactions with other children, harm to animals or younger children, a problematic response to parental discipline, and a lack of empathy.

Minor property damage such as breaking windows might be part of the picture in a 10-year-old, but conduct disorder is likely to look different in younger children, Dr. Wilens said.

“You're not going to see them stealing a car.”

Major Findings: Children aged 2–5 who had a fall serious enough to require medical attention were 5.8 times more likely than other preschoolers to meet diagnostic criteria for depression. In more than half of these children, the first depression symptom occurred only after a major fall.

Data Source: Longitudinal study of 666 children representing a larger community sample of more than 3,000 children of the same age.

Disclosures: Dr. Egger reported no relevant financial conflicts of interest.

LOS ANGELES — Serious falls were strongly associated with childhood depression in a study of preschoolers aged 2–5 years.

A series of longitudinal studies conducted at Duke University has found associations between high-stress events and cumulative stressors in the lives of young children and DSM-IV diagnoses, with serious falls emerging as a uniquely important contributor, Dr. Helen Link Egger said at an international conference on pediatric psychological trauma.

In the current study, a weighted representative sample of 666 preschoolers was statistically reflective of a larger community sample of more than 3,000 children of the same age. The children who suffered a serious fall were 5.8 times more likely than others to meet criteria for childhood depression, Dr. Egger said.

The rate of depression in children who fell was 18%, compared with 3.6% in the other children enrolled in the study. No association was detected between depression and the age at which children fell.

Since the study captured baseline data, the researchers were able to show that 58% of children who fell during the time period of the study developed their first depressive symptom only after the injury.

The findings do not prove causality, but they do raise numerous questions, said Dr. Egger of the center for developmental epidemiology, department of psychiatry and behavioral sciences, Duke University, Durham, N.C.

Of particular interest is whether maternal depression or household environmental factors may set the stage for some childhood falls, she said.

Beyond physical safety hazards, children who fall may be “living in a household where nobody is watching out for them,” she suggested. If so, the trauma associated with the fall itself and the resulting trip to the emergency room may not be a causal factor in depression, but rather a reflection of caregiving that is not attentive or deeply attached.

Factors significantly more common in children who fell included a recent change in day care (41.2% of children who fell, compared with 13.5% of those who did not); death of a loved one (30.4% of children who fell, 13.7% of those who did not); death of a sibling or peer (4.4% of children who fell, 0.5% of those who did not); and removal from the home due to physical abuse (1.7% of children who fell, 0.1% of those who did not).

Children with any injury requiring medical attention, including falls, were 2.7 times more likely than other preschoolers to meet criteria for separation anxiety disorder, with a quarter of the injured children meeting criteria for that DSM-IV diagnosis. Serious injuries occurred in more than 12% of children studied, with serious falls accounting for almost half.

Links between traumatic events in early childhood and psychological sequelaearey depend on the child's pre-existing emotional, developmental, and behavioral characteristics; parental and socioeconomic risk factors; and the event's impact on neurocognition, Dr. Egger noted.

Children who fall may be 'living in a household where nobody is watching out for them.'

Source DR. EGGER

Major Findings: Children aged 2–5 who had a fall serious enough to require medical attention were 5.8 times more likely than other preschoolers to meet diagnostic criteria for depression. In more than half of these children, the first depression symptom occurred only after a major fall.

Data Source: Longitudinal study of 666 children representing a larger community sample of more than 3,000 children of the same age.

Disclosures: Dr. Egger reported no relevant financial conflicts of interest.

LOS ANGELES — Serious falls were strongly associated with childhood depression in a study of preschoolers aged 2–5 years.

A series of longitudinal studies conducted at Duke University has found associations between high-stress events and cumulative stressors in the lives of young children and DSM-IV diagnoses, with serious falls emerging as a uniquely important contributor, Dr. Helen Link Egger said at an international conference on pediatric psychological trauma.

In the current study, a weighted representative sample of 666 preschoolers was statistically reflective of a larger community sample of more than 3,000 children of the same age. The children who suffered a serious fall were 5.8 times more likely than others to meet criteria for childhood depression, Dr. Egger said.

The rate of depression in children who fell was 18%, compared with 3.6% in the other children enrolled in the study. No association was detected between depression and the age at which children fell.

Since the study captured baseline data, the researchers were able to show that 58% of children who fell during the time period of the study developed their first depressive symptom only after the injury.

The findings do not prove causality, but they do raise numerous questions, said Dr. Egger of the center for developmental epidemiology, department of psychiatry and behavioral sciences, Duke University, Durham, N.C.

Of particular interest is whether maternal depression or household environmental factors may set the stage for some childhood falls, she said.

Beyond physical safety hazards, children who fall may be “living in a household where nobody is watching out for them,” she suggested. If so, the trauma associated with the fall itself and the resulting trip to the emergency room may not be a causal factor in depression, but rather a reflection of caregiving that is not attentive or deeply attached.

Factors significantly more common in children who fell included a recent change in day care (41.2% of children who fell, compared with 13.5% of those who did not); death of a loved one (30.4% of children who fell, 13.7% of those who did not); death of a sibling or peer (4.4% of children who fell, 0.5% of those who did not); and removal from the home due to physical abuse (1.7% of children who fell, 0.1% of those who did not).

Children with any injury requiring medical attention, including falls, were 2.7 times more likely than other preschoolers to meet criteria for separation anxiety disorder, with a quarter of the injured children meeting criteria for that DSM-IV diagnosis. Serious injuries occurred in more than 12% of children studied, with serious falls accounting for almost half.

Links between traumatic events in early childhood and psychological sequelaearey depend on the child's pre-existing emotional, developmental, and behavioral characteristics; parental and socioeconomic risk factors; and the event's impact on neurocognition, Dr. Egger noted.

Children who fall may be 'living in a household where nobody is watching out for them.'

Source DR. EGGER

Major Findings: Children aged 2–5 who had a fall serious enough to require medical attention were 5.8 times more likely than other preschoolers to meet diagnostic criteria for depression. In more than half of these children, the first depression symptom occurred only after a major fall.

Data Source: Longitudinal study of 666 children representing a larger community sample of more than 3,000 children of the same age.

Disclosures: Dr. Egger reported no relevant financial conflicts of interest.

LOS ANGELES — Serious falls were strongly associated with childhood depression in a study of preschoolers aged 2–5 years.

A series of longitudinal studies conducted at Duke University has found associations between high-stress events and cumulative stressors in the lives of young children and DSM-IV diagnoses, with serious falls emerging as a uniquely important contributor, Dr. Helen Link Egger said at an international conference on pediatric psychological trauma.

In the current study, a weighted representative sample of 666 preschoolers was statistically reflective of a larger community sample of more than 3,000 children of the same age. The children who suffered a serious fall were 5.8 times more likely than others to meet criteria for childhood depression, Dr. Egger said.

The rate of depression in children who fell was 18%, compared with 3.6% in the other children enrolled in the study. No association was detected between depression and the age at which children fell.

Since the study captured baseline data, the researchers were able to show that 58% of children who fell during the time period of the study developed their first depressive symptom only after the injury.

The findings do not prove causality, but they do raise numerous questions, said Dr. Egger of the center for developmental epidemiology, department of psychiatry and behavioral sciences, Duke University, Durham, N.C.

Of particular interest is whether maternal depression or household environmental factors may set the stage for some childhood falls, she said.

Beyond physical safety hazards, children who fall may be “living in a household where nobody is watching out for them,” she suggested. If so, the trauma associated with the fall itself and the resulting trip to the emergency room may not be a causal factor in depression, but rather a reflection of caregiving that is not attentive or deeply attached.

Factors significantly more common in children who fell included a recent change in day care (41.2% of children who fell, compared with 13.5% of those who did not); death of a loved one (30.4% of children who fell, 13.7% of those who did not); death of a sibling or peer (4.4% of children who fell, 0.5% of those who did not); and removal from the home due to physical abuse (1.7% of children who fell, 0.1% of those who did not).

Children with any injury requiring medical attention, including falls, were 2.7 times more likely than other preschoolers to meet criteria for separation anxiety disorder, with a quarter of the injured children meeting criteria for that DSM-IV diagnosis. Serious injuries occurred in more than 12% of children studied, with serious falls accounting for almost half.

Links between traumatic events in early childhood and psychological sequelaearey depend on the child's pre-existing emotional, developmental, and behavioral characteristics; parental and socioeconomic risk factors; and the event's impact on neurocognition, Dr. Egger noted.

Children who fall may be 'living in a household where nobody is watching out for them.'

Source DR. EGGER

A revolution is brewing in the treatment of patients with co-occurring posttraumatic stress disorder and substance use, inspired by a growing body of evidence that the disorders can be successfully addressed simultaneously.

An estimated half of returning veterans and a third of civilians with PTSD have co-occurring substance abuse, and up to 42% of people in treatment for addictions have a current diagnosis of PTSD. Yet few programs traditionally addressed both issues simultaneously. Patients presenting with PTSD were excluded from research studies and many treatment programs if they had an ongoing substance use problem.

Barriers blocked the route to dual treatment at substance abuse clinics as well, where clinicians were reticent to address, much less treat, PTSD.

“There's been a kind of historical trepidation to deal with PTSD when people are trying to get stabilized in a substance abuse program,” said Mark P. McGovern, Ph.D., a psychologist at Dartmouth Medical School, Hanover, N.H.

“The thought has been, you don't want to open Pandora's box and undermine the original goal of substance use stabilization,” Dr. McGovern explained in a telephone interview. “But for many patients, Pandora's box was already open and the demons were out. They were suffering nightmares, flashbacks, [and] extreme anxiety, and until you dealt with those symptoms they were never going to stop using substances.”

Impact of Binge Drinking

Dr. Thomas Kosten, professor of psychiatry at Baylor University, Houston, and research director of the VA Substance Use Disorders Quality Enhancement Research Initiative, described a similar epiphany that occurred in the PTSD treatment community, which traditionally had insisted that patients be sober before beginning therapy.

“The new veterans with PTSD cannot be effectively treated with behavioral therapies like prolonged exposure unless their binge alcohol abuse is controlled,” he said. “Otherwise, any gains in therapy during the week will be lost in a weekend of binge drinking, and binge drinking occurs in half of these vets. This problem is too common to ignore.”

Lisa Najavits, Ph.D., a psychologist and professor of psychiatry at Harvard Medical School, Boston, said the “big myth” that substance abuse and PTSD must be treated sequentially persisted during much of the 20th century, even as a preponderance of evidence showed that severity of symptoms was higher and PTSD and addiction treatment outcomes were poorer in dually diagnosed patients than in those with just one diagnosis.

“It has really been a mini-revolution to turn that around,” said Dr. Najavits, who developed an internationally adopted dual treatment module, Seeking Safety (

www.seekingsafety.org

The payoff of integrated treatment, experts agree, has offered tantalizing suggestions and some solid evidence of enhanced outcomes for symptoms of both PTSD and substance use disorders.

Once the concept was put to the test, “we realized that a great deal of 'treatment resistance' was because individuals had two, three, or four disorders, yet we were only treating one disorder,” said Dr. Kathleen T. Brady, professor of psychiatry and director of the clinical neuroscience division at the Medical University of South Carolina, Charleston.

Dr. Najavits' 25-stage integrative model, which draws on four content areas—cognitive, behavioral, and interpersonal therapy and case management—focuses on the here and now, using practical strategies for reducing anxiety, managing relationships, and incorporating “recovery thinking.”

Seven empirical studies of Seeking Safety found improvements in substance use, social adjustment, general psychiatric symptoms, suicidal thoughts and planning, depression, problem solving skills, and quality of life.

In another twist on treatment delivery possibilities, Dr. McGovern recently published preliminary results of a randomized study exploring PTSD within the context of an existing addiction treatment model in 53 patients, comparing the addition of cognitive-behavioral therapy (CBT) to individual addiction counseling (Addict. Behav. 2009;34:892-7).

The now-completed study found that while both approaches led to an improvement in substance abuse disorders, the CBT component was significantly more efficacious in reducing PTSD symptoms. Furthermore, patients randomized to receive CBT “stayed in treatment at much greater rates,” he said.

New Medication Options

One development that has made dual treatment a reality has been the availability of “excellent medications” for addiction that can allow patients to focus on PTSD treatment, Dr. Kosten said.

Depot naltrexone, which persists for a month after injection, can assist in alcohol abstention, while buprenorphine reduces the need for opiates, covering two of the substances most abused by patients with co-occurring PTSD, he said.

At times, other medications directed at PTSD symptoms, such as the alpha adrenergic blockers prazosin or doxazosin, might be useful as well.

A randomized, controlled study by researchers at Yale University, New Haven, Conn., directly compared medications (disulfiram or naltrexone) to placebo in 254 patients being treated for alcohol dependence in a 12-week study conducted at three VA outpatient clinics.

Compared with study subjects without PTSD, those with the added disorder had better alcohol use outcomes and improvement of psychiatric symptoms when they received one or other of the active medications, reported Dr. Ismene Petrakis and associates (Biol. Psychiatry 2006;60:777-83).

Another study offers insight into integrated treatment for patients with opiate addictions. The prospective observational study found comparable reductions in drug use by patients with or without PTSD when opioid substitution was employed, even though the PTSD group had a lengthier mean history of addiction (J. Stud. Alcohol 2006;67:228-35). The PTSD subgroup used higher doses of opiate medications, but actually attended more psychosocial treatment sessions and had better treatment retention.

Motivation to Get Treatment

“I can only speculate about the difference between outcomes … but my guess is that the patients with PTSD were more sensitive to the discomfort associated with missing a dose of methadone and thus were more motivated to get to the clinic for treatment each day,” said the lead author of the study, Jodie A. Trafton, Ph.D., in an interview.

If true, the increased-distress hypothesis, also postulated by other researchers, “might suggest that maintenance therapies or very slow tapers during detoxification might be particularly helpful for patients with these comorbidities,” said Dr. Trafton, who directs the VA Program Evaluation and Resource Center, Menlo Park, Calif.

Although she is not a prescriber, Dr. Najavits advocates a medical consultation for patients with co-occurring PTSD and substance abuse, to determine whether these or other medications might be helpful during the intensive Seeking Safety program.

Because it is a difficult group to treat, strategies should aim at “giving the client as much care and support as possible,” including medication, 12-step group meetings, domestic violence counseling, parenting skills training, and HIV testing and counseling—essentially any adjunctive intervention that is relevant and scientifically sound.

“The more the better,” she said.

One challenge shared by many of the integrated therapy models is reaching potential patients who could benefit, Dr. McGovern said.

Denial is a common component of both diagnoses, and even patients who are ready to tackle one issue might be reluctant to acknowledge or address the other. PTSD, for example, might present as a sleep problem or chronic pain, either of which could prompt the writing of prescriptions with the potential of exacerbating co-occurring substance abuse.

When Dr. McGovern and associates offered free evaluations and treatments for dual diagnosis patients, they were stunned at the lack of response from the community. “We thought if we built it they would come,” he said. “We had clear recruitment challenges.”

Reaching dually diagnosed patients early, when intervention is most likely to succeed, would be aided if primary care physicians as well as psychiatrists were better trained to recognize these hidden disorders, experts agreed.

A heightened awareness and specialized training also would increase the number of providers able to treat PTSD and substance abuse.

“The hardest thing for non–substance abuse providers to do is ask and monitor for substance abuse, including urine toxicology for illicit drugs and breath alcohol [tests] as needed,” Dr. Kosten said.

His advice? “Do not avoid discussing the use of abused drugs at the first meeting with the patient. They are more than happy to discuss it, although the younger patients do not view binge alcohol as a problem and need to be convinced.”

If patients say they can quit any time, Dr. Kosten challenges them, asking whether they will stop for a week and monitoring their adherence with a breath alcohol test during a Monday morning appointment. He also asks permission to talk to a significant other about the patient's drinking.

“It is easy when you do it right from the start and do not wait to address the 'delicate issue' of substance abuse in a patient with PTSD,” he said. “They already know that it is a problem. Lots of friends and relatives have usually told them.”

Asked to offer advice to clinicians treating patients with co-occurring PTSD and substance abuse, Dr. Brady emphasized the heterogeneity of the disorders.

“No two patients look alike,” she said. “Every patient needs a careful evaluation and individualized treatment plan. The treatment provider must be flexible—ready to change treatment strategies if what they initially try doesn't work, because we [still] have a lot of uncertainties in treatment.”

Disclosures: Dr. Kosten has served on the speakers bureau for Reckitt Benkizer, maker of buprenorphine, and as a consultant to Alkermes Pharmaceuticals, maker of Vivitrol (naltrexone). Dr. Brady has received research support from GlaxoSmithKline and served as a consultant for Ovation Pharmaceuticals, now Lundbeck Inc. The other experts interviewed reported no relevant conflicts.

'Individuals had two, three, or four disorders, yet we were only treating one disorder.'

Source DR. BRADY

'Do not wait to address the “delicate issue” of substance abuse in a patient with PTSD.'

Source DR. KOSTEN

A revolution is brewing in the treatment of patients with co-occurring posttraumatic stress disorder and substance use, inspired by a growing body of evidence that the disorders can be successfully addressed simultaneously.

An estimated half of returning veterans and a third of civilians with PTSD have co-occurring substance abuse, and up to 42% of people in treatment for addictions have a current diagnosis of PTSD. Yet few programs traditionally addressed both issues simultaneously. Patients presenting with PTSD were excluded from research studies and many treatment programs if they had an ongoing substance use problem.

Barriers blocked the route to dual treatment at substance abuse clinics as well, where clinicians were reticent to address, much less treat, PTSD.

“There's been a kind of historical trepidation to deal with PTSD when people are trying to get stabilized in a substance abuse program,” said Mark P. McGovern, Ph.D., a psychologist at Dartmouth Medical School, Hanover, N.H.

“The thought has been, you don't want to open Pandora's box and undermine the original goal of substance use stabilization,” Dr. McGovern explained in a telephone interview. “But for many patients, Pandora's box was already open and the demons were out. They were suffering nightmares, flashbacks, [and] extreme anxiety, and until you dealt with those symptoms they were never going to stop using substances.”

Impact of Binge Drinking

Dr. Thomas Kosten, professor of psychiatry at Baylor University, Houston, and research director of the VA Substance Use Disorders Quality Enhancement Research Initiative, described a similar epiphany that occurred in the PTSD treatment community, which traditionally had insisted that patients be sober before beginning therapy.

“The new veterans with PTSD cannot be effectively treated with behavioral therapies like prolonged exposure unless their binge alcohol abuse is controlled,” he said. “Otherwise, any gains in therapy during the week will be lost in a weekend of binge drinking, and binge drinking occurs in half of these vets. This problem is too common to ignore.”

Lisa Najavits, Ph.D., a psychologist and professor of psychiatry at Harvard Medical School, Boston, said the “big myth” that substance abuse and PTSD must be treated sequentially persisted during much of the 20th century, even as a preponderance of evidence showed that severity of symptoms was higher and PTSD and addiction treatment outcomes were poorer in dually diagnosed patients than in those with just one diagnosis.

“It has really been a mini-revolution to turn that around,” said Dr. Najavits, who developed an internationally adopted dual treatment module, Seeking Safety (

www.seekingsafety.org

The payoff of integrated treatment, experts agree, has offered tantalizing suggestions and some solid evidence of enhanced outcomes for symptoms of both PTSD and substance use disorders.

Once the concept was put to the test, “we realized that a great deal of 'treatment resistance' was because individuals had two, three, or four disorders, yet we were only treating one disorder,” said Dr. Kathleen T. Brady, professor of psychiatry and director of the clinical neuroscience division at the Medical University of South Carolina, Charleston.

Dr. Najavits' 25-stage integrative model, which draws on four content areas—cognitive, behavioral, and interpersonal therapy and case management—focuses on the here and now, using practical strategies for reducing anxiety, managing relationships, and incorporating “recovery thinking.”

Seven empirical studies of Seeking Safety found improvements in substance use, social adjustment, general psychiatric symptoms, suicidal thoughts and planning, depression, problem solving skills, and quality of life.

In another twist on treatment delivery possibilities, Dr. McGovern recently published preliminary results of a randomized study exploring PTSD within the context of an existing addiction treatment model in 53 patients, comparing the addition of cognitive-behavioral therapy (CBT) to individual addiction counseling (Addict. Behav. 2009;34:892-7).

The now-completed study found that while both approaches led to an improvement in substance abuse disorders, the CBT component was significantly more efficacious in reducing PTSD symptoms. Furthermore, patients randomized to receive CBT “stayed in treatment at much greater rates,” he said.

New Medication Options

One development that has made dual treatment a reality has been the availability of “excellent medications” for addiction that can allow patients to focus on PTSD treatment, Dr. Kosten said.

Depot naltrexone, which persists for a month after injection, can assist in alcohol abstention, while buprenorphine reduces the need for opiates, covering two of the substances most abused by patients with co-occurring PTSD, he said.

At times, other medications directed at PTSD symptoms, such as the alpha adrenergic blockers prazosin or doxazosin, might be useful as well.

A randomized, controlled study by researchers at Yale University, New Haven, Conn., directly compared medications (disulfiram or naltrexone) to placebo in 254 patients being treated for alcohol dependence in a 12-week study conducted at three VA outpatient clinics.

Compared with study subjects without PTSD, those with the added disorder had better alcohol use outcomes and improvement of psychiatric symptoms when they received one or other of the active medications, reported Dr. Ismene Petrakis and associates (Biol. Psychiatry 2006;60:777-83).

Another study offers insight into integrated treatment for patients with opiate addictions. The prospective observational study found comparable reductions in drug use by patients with or without PTSD when opioid substitution was employed, even though the PTSD group had a lengthier mean history of addiction (J. Stud. Alcohol 2006;67:228-35). The PTSD subgroup used higher doses of opiate medications, but actually attended more psychosocial treatment sessions and had better treatment retention.

Motivation to Get Treatment

“I can only speculate about the difference between outcomes … but my guess is that the patients with PTSD were more sensitive to the discomfort associated with missing a dose of methadone and thus were more motivated to get to the clinic for treatment each day,” said the lead author of the study, Jodie A. Trafton, Ph.D., in an interview.

If true, the increased-distress hypothesis, also postulated by other researchers, “might suggest that maintenance therapies or very slow tapers during detoxification might be particularly helpful for patients with these comorbidities,” said Dr. Trafton, who directs the VA Program Evaluation and Resource Center, Menlo Park, Calif.

Although she is not a prescriber, Dr. Najavits advocates a medical consultation for patients with co-occurring PTSD and substance abuse, to determine whether these or other medications might be helpful during the intensive Seeking Safety program.

Because it is a difficult group to treat, strategies should aim at “giving the client as much care and support as possible,” including medication, 12-step group meetings, domestic violence counseling, parenting skills training, and HIV testing and counseling—essentially any adjunctive intervention that is relevant and scientifically sound.

“The more the better,” she said.

One challenge shared by many of the integrated therapy models is reaching potential patients who could benefit, Dr. McGovern said.

Denial is a common component of both diagnoses, and even patients who are ready to tackle one issue might be reluctant to acknowledge or address the other. PTSD, for example, might present as a sleep problem or chronic pain, either of which could prompt the writing of prescriptions with the potential of exacerbating co-occurring substance abuse.

When Dr. McGovern and associates offered free evaluations and treatments for dual diagnosis patients, they were stunned at the lack of response from the community. “We thought if we built it they would come,” he said. “We had clear recruitment challenges.”

Reaching dually diagnosed patients early, when intervention is most likely to succeed, would be aided if primary care physicians as well as psychiatrists were better trained to recognize these hidden disorders, experts agreed.

A heightened awareness and specialized training also would increase the number of providers able to treat PTSD and substance abuse.

“The hardest thing for non–substance abuse providers to do is ask and monitor for substance abuse, including urine toxicology for illicit drugs and breath alcohol [tests] as needed,” Dr. Kosten said.

His advice? “Do not avoid discussing the use of abused drugs at the first meeting with the patient. They are more than happy to discuss it, although the younger patients do not view binge alcohol as a problem and need to be convinced.”

If patients say they can quit any time, Dr. Kosten challenges them, asking whether they will stop for a week and monitoring their adherence with a breath alcohol test during a Monday morning appointment. He also asks permission to talk to a significant other about the patient's drinking.

“It is easy when you do it right from the start and do not wait to address the 'delicate issue' of substance abuse in a patient with PTSD,” he said. “They already know that it is a problem. Lots of friends and relatives have usually told them.”

Asked to offer advice to clinicians treating patients with co-occurring PTSD and substance abuse, Dr. Brady emphasized the heterogeneity of the disorders.

“No two patients look alike,” she said. “Every patient needs a careful evaluation and individualized treatment plan. The treatment provider must be flexible—ready to change treatment strategies if what they initially try doesn't work, because we [still] have a lot of uncertainties in treatment.”

Disclosures: Dr. Kosten has served on the speakers bureau for Reckitt Benkizer, maker of buprenorphine, and as a consultant to Alkermes Pharmaceuticals, maker of Vivitrol (naltrexone). Dr. Brady has received research support from GlaxoSmithKline and served as a consultant for Ovation Pharmaceuticals, now Lundbeck Inc. The other experts interviewed reported no relevant conflicts.

'Individuals had two, three, or four disorders, yet we were only treating one disorder.'

Source DR. BRADY

'Do not wait to address the “delicate issue” of substance abuse in a patient with PTSD.'

Source DR. KOSTEN

A revolution is brewing in the treatment of patients with co-occurring posttraumatic stress disorder and substance use, inspired by a growing body of evidence that the disorders can be successfully addressed simultaneously.

An estimated half of returning veterans and a third of civilians with PTSD have co-occurring substance abuse, and up to 42% of people in treatment for addictions have a current diagnosis of PTSD. Yet few programs traditionally addressed both issues simultaneously. Patients presenting with PTSD were excluded from research studies and many treatment programs if they had an ongoing substance use problem.

Barriers blocked the route to dual treatment at substance abuse clinics as well, where clinicians were reticent to address, much less treat, PTSD.

“There's been a kind of historical trepidation to deal with PTSD when people are trying to get stabilized in a substance abuse program,” said Mark P. McGovern, Ph.D., a psychologist at Dartmouth Medical School, Hanover, N.H.

“The thought has been, you don't want to open Pandora's box and undermine the original goal of substance use stabilization,” Dr. McGovern explained in a telephone interview. “But for many patients, Pandora's box was already open and the demons were out. They were suffering nightmares, flashbacks, [and] extreme anxiety, and until you dealt with those symptoms they were never going to stop using substances.”

Impact of Binge Drinking

Dr. Thomas Kosten, professor of psychiatry at Baylor University, Houston, and research director of the VA Substance Use Disorders Quality Enhancement Research Initiative, described a similar epiphany that occurred in the PTSD treatment community, which traditionally had insisted that patients be sober before beginning therapy.

“The new veterans with PTSD cannot be effectively treated with behavioral therapies like prolonged exposure unless their binge alcohol abuse is controlled,” he said. “Otherwise, any gains in therapy during the week will be lost in a weekend of binge drinking, and binge drinking occurs in half of these vets. This problem is too common to ignore.”

Lisa Najavits, Ph.D., a psychologist and professor of psychiatry at Harvard Medical School, Boston, said the “big myth” that substance abuse and PTSD must be treated sequentially persisted during much of the 20th century, even as a preponderance of evidence showed that severity of symptoms was higher and PTSD and addiction treatment outcomes were poorer in dually diagnosed patients than in those with just one diagnosis.

“It has really been a mini-revolution to turn that around,” said Dr. Najavits, who developed an internationally adopted dual treatment module, Seeking Safety (

www.seekingsafety.org

The payoff of integrated treatment, experts agree, has offered tantalizing suggestions and some solid evidence of enhanced outcomes for symptoms of both PTSD and substance use disorders.

Once the concept was put to the test, “we realized that a great deal of 'treatment resistance' was because individuals had two, three, or four disorders, yet we were only treating one disorder,” said Dr. Kathleen T. Brady, professor of psychiatry and director of the clinical neuroscience division at the Medical University of South Carolina, Charleston.

Dr. Najavits' 25-stage integrative model, which draws on four content areas—cognitive, behavioral, and interpersonal therapy and case management—focuses on the here and now, using practical strategies for reducing anxiety, managing relationships, and incorporating “recovery thinking.”

Seven empirical studies of Seeking Safety found improvements in substance use, social adjustment, general psychiatric symptoms, suicidal thoughts and planning, depression, problem solving skills, and quality of life.

In another twist on treatment delivery possibilities, Dr. McGovern recently published preliminary results of a randomized study exploring PTSD within the context of an existing addiction treatment model in 53 patients, comparing the addition of cognitive-behavioral therapy (CBT) to individual addiction counseling (Addict. Behav. 2009;34:892-7).

The now-completed study found that while both approaches led to an improvement in substance abuse disorders, the CBT component was significantly more efficacious in reducing PTSD symptoms. Furthermore, patients randomized to receive CBT “stayed in treatment at much greater rates,” he said.

New Medication Options

One development that has made dual treatment a reality has been the availability of “excellent medications” for addiction that can allow patients to focus on PTSD treatment, Dr. Kosten said.

Depot naltrexone, which persists for a month after injection, can assist in alcohol abstention, while buprenorphine reduces the need for opiates, covering two of the substances most abused by patients with co-occurring PTSD, he said.

At times, other medications directed at PTSD symptoms, such as the alpha adrenergic blockers prazosin or doxazosin, might be useful as well.

A randomized, controlled study by researchers at Yale University, New Haven, Conn., directly compared medications (disulfiram or naltrexone) to placebo in 254 patients being treated for alcohol dependence in a 12-week study conducted at three VA outpatient clinics.

Compared with study subjects without PTSD, those with the added disorder had better alcohol use outcomes and improvement of psychiatric symptoms when they received one or other of the active medications, reported Dr. Ismene Petrakis and associates (Biol. Psychiatry 2006;60:777-83).

Another study offers insight into integrated treatment for patients with opiate addictions. The prospective observational study found comparable reductions in drug use by patients with or without PTSD when opioid substitution was employed, even though the PTSD group had a lengthier mean history of addiction (J. Stud. Alcohol 2006;67:228-35). The PTSD subgroup used higher doses of opiate medications, but actually attended more psychosocial treatment sessions and had better treatment retention.

Motivation to Get Treatment

“I can only speculate about the difference between outcomes … but my guess is that the patients with PTSD were more sensitive to the discomfort associated with missing a dose of methadone and thus were more motivated to get to the clinic for treatment each day,” said the lead author of the study, Jodie A. Trafton, Ph.D., in an interview.

If true, the increased-distress hypothesis, also postulated by other researchers, “might suggest that maintenance therapies or very slow tapers during detoxification might be particularly helpful for patients with these comorbidities,” said Dr. Trafton, who directs the VA Program Evaluation and Resource Center, Menlo Park, Calif.

Although she is not a prescriber, Dr. Najavits advocates a medical consultation for patients with co-occurring PTSD and substance abuse, to determine whether these or other medications might be helpful during the intensive Seeking Safety program.

Because it is a difficult group to treat, strategies should aim at “giving the client as much care and support as possible,” including medication, 12-step group meetings, domestic violence counseling, parenting skills training, and HIV testing and counseling—essentially any adjunctive intervention that is relevant and scientifically sound.

“The more the better,” she said.

One challenge shared by many of the integrated therapy models is reaching potential patients who could benefit, Dr. McGovern said.

Denial is a common component of both diagnoses, and even patients who are ready to tackle one issue might be reluctant to acknowledge or address the other. PTSD, for example, might present as a sleep problem or chronic pain, either of which could prompt the writing of prescriptions with the potential of exacerbating co-occurring substance abuse.

When Dr. McGovern and associates offered free evaluations and treatments for dual diagnosis patients, they were stunned at the lack of response from the community. “We thought if we built it they would come,” he said. “We had clear recruitment challenges.”

Reaching dually diagnosed patients early, when intervention is most likely to succeed, would be aided if primary care physicians as well as psychiatrists were better trained to recognize these hidden disorders, experts agreed.

A heightened awareness and specialized training also would increase the number of providers able to treat PTSD and substance abuse.

“The hardest thing for non–substance abuse providers to do is ask and monitor for substance abuse, including urine toxicology for illicit drugs and breath alcohol [tests] as needed,” Dr. Kosten said.

His advice? “Do not avoid discussing the use of abused drugs at the first meeting with the patient. They are more than happy to discuss it, although the younger patients do not view binge alcohol as a problem and need to be convinced.”

If patients say they can quit any time, Dr. Kosten challenges them, asking whether they will stop for a week and monitoring their adherence with a breath alcohol test during a Monday morning appointment. He also asks permission to talk to a significant other about the patient's drinking.

“It is easy when you do it right from the start and do not wait to address the 'delicate issue' of substance abuse in a patient with PTSD,” he said. “They already know that it is a problem. Lots of friends and relatives have usually told them.”

Asked to offer advice to clinicians treating patients with co-occurring PTSD and substance abuse, Dr. Brady emphasized the heterogeneity of the disorders.

“No two patients look alike,” she said. “Every patient needs a careful evaluation and individualized treatment plan. The treatment provider must be flexible—ready to change treatment strategies if what they initially try doesn't work, because we [still] have a lot of uncertainties in treatment.”

Disclosures: Dr. Kosten has served on the speakers bureau for Reckitt Benkizer, maker of buprenorphine, and as a consultant to Alkermes Pharmaceuticals, maker of Vivitrol (naltrexone). Dr. Brady has received research support from GlaxoSmithKline and served as a consultant for Ovation Pharmaceuticals, now Lundbeck Inc. The other experts interviewed reported no relevant conflicts.

'Individuals had two, three, or four disorders, yet we were only treating one disorder.'

Source DR. BRADY

'Do not wait to address the “delicate issue” of substance abuse in a patient with PTSD.'

Source DR. KOSTEN

Major Finding: Significant improvement in ADHD symptoms and a sharp reduction in substance use were observed in both the OROS methylphenidate and placebo groups.

Data Source: A randomized, controlled trial of 303 adolescents with ADHD and a substance use problem.

Disclosures: The trial was sponsored by the National Institute of Drug Abuse. The lead investigator reported no conflicts of interest.

LOS ANGELES — Psychostimulant treatment failed to outperform placebo in treating adolescents with comorbid attention-deficit/hyperactivity disorder and substance use disorders when structured cognitive-behavioral therapy was integrated into a randomized, placebo-controlled trial.

However, highly significant improvement in ADHD symptoms and a sharp reduction in substance use were observed regardless of whether adolescents received OROS methylphenidate or placebo in the 16-week trial, reported Dr. Paula Riggs at the annual meeting of the American Academy of Addiction Psychiatry.

Rather than being seen as a negative trial, the study appears to speak to the usefulness of structured, individualized weekly CBT, said Dr. Riggs, primary investigator of the 11-center trial and professor of psychiatry at the University of Colorado, Denver.

The trial enrolled 303 adolescents aged 13-18 years who met DSM-IV criteria for ADHD and for a substance use problem (other than nicotine dependence, and excluding current opiate dependence or methamphetamine abuse or dependence).

The average age of participants was 16.5 years. About 80% were male and 20% female. Whites constituted 64% of the medication arm and 55% of the placebo arm. Roughly a fourth of the subjects in each group were African American; 15% were Hispanic. About one-third of subjects had ADHD-inattentive type, 67% had ADHD-combined type, and less than 2% had ADHD-hyperactive type.

Cannabis and alcohol use/dependence were the most commonly represented substance use disorders, although use and/or abuse of hallucinogens, opioids, cocaine, and amphetamines also were reported.

Adolescents with major depression, anxiety disorders, and/or conduct disorder were included in the trial, resulting in a high baseline level of psychopathology among participants.

“We wanted to keep this real and generalizable,” Dr. Riggs said.

Despite this severity, almost 75% of adolescents completed the trial.

In the medication arm, 80% of 151 patients were compliant with doses, which were successfully titrated to 72 mg/day in 96% and sustained at that dose in 86%.

Participants received either the active (titrated) drug or placebo along with weekly, individual CBT using a standardized manual targeting drug abuse. An intent-to-treat analysis was used to calculate results.

“This was the shocker,” Dr. Riggs said. “We saw a clinically and statistically significant reduction in ADHD symptoms in both groups.”

Symptoms declined 46% in the medication group and 45% in the placebo group.

Parents reported symptom reductions of 26% and 30% in adolescents receiving active medication or placebo on a DSM-IV symptom checklist at 8 weeks, and 24% and 30.9% reductions at 16 weeks.

Past 28-day substance use reports declined by 6.1 days (43%) in the medication arm and 4.9 days (33%) in the placebo arm—a statistically insignificant between-group difference.

Slightly more negative drug screens—3.8 compared with 2.8—were found in adolescents assigned to receive active medication, and this group also showed greater improvements in problem-solving skills and focused-coping skills that had been addressed in CBT, Dr. Riggs reported.

Subjects deemed by investigators to be “medication responders” had twice as many negative drug screens as nonresponders or those receiving placebo.

Titrated OROS methylphenidate was “stunningly safe and well-tolerated” in the trial, with 11 serious adverse events, 7 of which occurred in the placebo group. The only event seen more frequently in the medication arm was limb injury, an event not considered to be related to the medication.

The trial results were inconsistent with trials pitting psychostimulants against placebo in non–substance-abusing youth.

However, they were consistent with three previous controlled psychostimulant trials in the non–substance-abusing adolescents when concurrent CBT was included for subjects in both the medication and placebo arms.

As in this trial, significant reductions were seen in ADHD in both groups, but with no significant advantage to medication over placebo.

Trials of psychostimulants show that 20%–50% of adolescents continue to have functionally impairing symptoms despite medication, and there is no long-term benefit of psychostimulant treatment for ADHD “on a broad range of psychosocial outcomes,” including school failure, drop-out rates, and substance use, Dr. Riggs said.

Standardized CBT might enhance self-efficacy and self-esteem, and there might be benefit as well of having a “therapist empathetic and in your corner once a week,” she said.

Disclosures: Dr. Riggs reported no relevant financial conflicts of interest.

Major Finding: Significant improvement in ADHD symptoms and a sharp reduction in substance use were observed in both the OROS methylphenidate and placebo groups.

Data Source: A randomized, controlled trial of 303 adolescents with ADHD and a substance use problem.

Disclosures: The trial was sponsored by the National Institute of Drug Abuse. The lead investigator reported no conflicts of interest.

LOS ANGELES — Psychostimulant treatment failed to outperform placebo in treating adolescents with comorbid attention-deficit/hyperactivity disorder and substance use disorders when structured cognitive-behavioral therapy was integrated into a randomized, placebo-controlled trial.

However, highly significant improvement in ADHD symptoms and a sharp reduction in substance use were observed regardless of whether adolescents received OROS methylphenidate or placebo in the 16-week trial, reported Dr. Paula Riggs at the annual meeting of the American Academy of Addiction Psychiatry.

Rather than being seen as a negative trial, the study appears to speak to the usefulness of structured, individualized weekly CBT, said Dr. Riggs, primary investigator of the 11-center trial and professor of psychiatry at the University of Colorado, Denver.

The trial enrolled 303 adolescents aged 13-18 years who met DSM-IV criteria for ADHD and for a substance use problem (other than nicotine dependence, and excluding current opiate dependence or methamphetamine abuse or dependence).

The average age of participants was 16.5 years. About 80% were male and 20% female. Whites constituted 64% of the medication arm and 55% of the placebo arm. Roughly a fourth of the subjects in each group were African American; 15% were Hispanic. About one-third of subjects had ADHD-inattentive type, 67% had ADHD-combined type, and less than 2% had ADHD-hyperactive type.

Cannabis and alcohol use/dependence were the most commonly represented substance use disorders, although use and/or abuse of hallucinogens, opioids, cocaine, and amphetamines also were reported.

Adolescents with major depression, anxiety disorders, and/or conduct disorder were included in the trial, resulting in a high baseline level of psychopathology among participants.

“We wanted to keep this real and generalizable,” Dr. Riggs said.

Despite this severity, almost 75% of adolescents completed the trial.

In the medication arm, 80% of 151 patients were compliant with doses, which were successfully titrated to 72 mg/day in 96% and sustained at that dose in 86%.

Participants received either the active (titrated) drug or placebo along with weekly, individual CBT using a standardized manual targeting drug abuse. An intent-to-treat analysis was used to calculate results.

“This was the shocker,” Dr. Riggs said. “We saw a clinically and statistically significant reduction in ADHD symptoms in both groups.”

Symptoms declined 46% in the medication group and 45% in the placebo group.

Parents reported symptom reductions of 26% and 30% in adolescents receiving active medication or placebo on a DSM-IV symptom checklist at 8 weeks, and 24% and 30.9% reductions at 16 weeks.

Past 28-day substance use reports declined by 6.1 days (43%) in the medication arm and 4.9 days (33%) in the placebo arm—a statistically insignificant between-group difference.

Slightly more negative drug screens—3.8 compared with 2.8—were found in adolescents assigned to receive active medication, and this group also showed greater improvements in problem-solving skills and focused-coping skills that had been addressed in CBT, Dr. Riggs reported.

Subjects deemed by investigators to be “medication responders” had twice as many negative drug screens as nonresponders or those receiving placebo.

Titrated OROS methylphenidate was “stunningly safe and well-tolerated” in the trial, with 11 serious adverse events, 7 of which occurred in the placebo group. The only event seen more frequently in the medication arm was limb injury, an event not considered to be related to the medication.

The trial results were inconsistent with trials pitting psychostimulants against placebo in non–substance-abusing youth.

However, they were consistent with three previous controlled psychostimulant trials in the non–substance-abusing adolescents when concurrent CBT was included for subjects in both the medication and placebo arms.

As in this trial, significant reductions were seen in ADHD in both groups, but with no significant advantage to medication over placebo.

Trials of psychostimulants show that 20%–50% of adolescents continue to have functionally impairing symptoms despite medication, and there is no long-term benefit of psychostimulant treatment for ADHD “on a broad range of psychosocial outcomes,” including school failure, drop-out rates, and substance use, Dr. Riggs said.

Standardized CBT might enhance self-efficacy and self-esteem, and there might be benefit as well of having a “therapist empathetic and in your corner once a week,” she said.

Disclosures: Dr. Riggs reported no relevant financial conflicts of interest.

Major Finding: Significant improvement in ADHD symptoms and a sharp reduction in substance use were observed in both the OROS methylphenidate and placebo groups.

Data Source: A randomized, controlled trial of 303 adolescents with ADHD and a substance use problem.

Disclosures: The trial was sponsored by the National Institute of Drug Abuse. The lead investigator reported no conflicts of interest.

LOS ANGELES — Psychostimulant treatment failed to outperform placebo in treating adolescents with comorbid attention-deficit/hyperactivity disorder and substance use disorders when structured cognitive-behavioral therapy was integrated into a randomized, placebo-controlled trial.

However, highly significant improvement in ADHD symptoms and a sharp reduction in substance use were observed regardless of whether adolescents received OROS methylphenidate or placebo in the 16-week trial, reported Dr. Paula Riggs at the annual meeting of the American Academy of Addiction Psychiatry.

Rather than being seen as a negative trial, the study appears to speak to the usefulness of structured, individualized weekly CBT, said Dr. Riggs, primary investigator of the 11-center trial and professor of psychiatry at the University of Colorado, Denver.

The trial enrolled 303 adolescents aged 13-18 years who met DSM-IV criteria for ADHD and for a substance use problem (other than nicotine dependence, and excluding current opiate dependence or methamphetamine abuse or dependence).

The average age of participants was 16.5 years. About 80% were male and 20% female. Whites constituted 64% of the medication arm and 55% of the placebo arm. Roughly a fourth of the subjects in each group were African American; 15% were Hispanic. About one-third of subjects had ADHD-inattentive type, 67% had ADHD-combined type, and less than 2% had ADHD-hyperactive type.

Cannabis and alcohol use/dependence were the most commonly represented substance use disorders, although use and/or abuse of hallucinogens, opioids, cocaine, and amphetamines also were reported.

Adolescents with major depression, anxiety disorders, and/or conduct disorder were included in the trial, resulting in a high baseline level of psychopathology among participants.

“We wanted to keep this real and generalizable,” Dr. Riggs said.

Despite this severity, almost 75% of adolescents completed the trial.

In the medication arm, 80% of 151 patients were compliant with doses, which were successfully titrated to 72 mg/day in 96% and sustained at that dose in 86%.

Participants received either the active (titrated) drug or placebo along with weekly, individual CBT using a standardized manual targeting drug abuse. An intent-to-treat analysis was used to calculate results.

“This was the shocker,” Dr. Riggs said. “We saw a clinically and statistically significant reduction in ADHD symptoms in both groups.”

Symptoms declined 46% in the medication group and 45% in the placebo group.

Parents reported symptom reductions of 26% and 30% in adolescents receiving active medication or placebo on a DSM-IV symptom checklist at 8 weeks, and 24% and 30.9% reductions at 16 weeks.

Past 28-day substance use reports declined by 6.1 days (43%) in the medication arm and 4.9 days (33%) in the placebo arm—a statistically insignificant between-group difference.

Slightly more negative drug screens—3.8 compared with 2.8—were found in adolescents assigned to receive active medication, and this group also showed greater improvements in problem-solving skills and focused-coping skills that had been addressed in CBT, Dr. Riggs reported.

Subjects deemed by investigators to be “medication responders” had twice as many negative drug screens as nonresponders or those receiving placebo.

Titrated OROS methylphenidate was “stunningly safe and well-tolerated” in the trial, with 11 serious adverse events, 7 of which occurred in the placebo group. The only event seen more frequently in the medication arm was limb injury, an event not considered to be related to the medication.

The trial results were inconsistent with trials pitting psychostimulants against placebo in non–substance-abusing youth.

However, they were consistent with three previous controlled psychostimulant trials in the non–substance-abusing adolescents when concurrent CBT was included for subjects in both the medication and placebo arms.

As in this trial, significant reductions were seen in ADHD in both groups, but with no significant advantage to medication over placebo.

Trials of psychostimulants show that 20%–50% of adolescents continue to have functionally impairing symptoms despite medication, and there is no long-term benefit of psychostimulant treatment for ADHD “on a broad range of psychosocial outcomes,” including school failure, drop-out rates, and substance use, Dr. Riggs said.

Standardized CBT might enhance self-efficacy and self-esteem, and there might be benefit as well of having a “therapist empathetic and in your corner once a week,” she said.

Disclosures: Dr. Riggs reported no relevant financial conflicts of interest.