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Whatever the substance, adolescents’ abuse shares common links
SAN DIEGO – Among adolescent daily cigarette smokers, the individual and concomitant use of alcohol, marijuana, and tobacco have unique and common associations with reinforcement sensitivity, with negative affect, and with electrophysiological signatures of reward function, results from a novel study demonstrated.
“The co-use of alcohol, marijuana, and tobacco in youth are associated bidirectionally with higher rates of substance use, higher levels of addiction severity, and with poorer treatment outcomes for youth who present for treatment,” lead study author Christopher J. Hammond, MD, said at the annual meeting and scientific symposium of the American Academy of Addiction Psychiatry.
Currently, the effects of combined alcohol, marijuana, and tobacco use on brain function are poorly understood, noted Dr. Hammond of the division of child and adolescent psychiatry at Johns Hopkins Bayview Medical Center, Baltimore.
Published studies to date suggest that alcohol, marijuana, and tobacco use disorders are linked separately to dysfunction in the neural substrates of reward and punishment processing, but none has examined co-use or comorbid disorders in adolescents.
In a cross-sectional, single-visit study, Dr. Hammond and his associates examined a population of 36 adolescent non-deprived daily cigarette smokers and 29 healthy controls from the greater New Haven, Conn., area, matched for age, gender, and grade level. The subjects ranged in age from 14 to 20 years and were administered self-report measures characterizing tobacco, marijuana, and alcohol use. The researchers also collected urine and breathalyzer measures to characterize tobacco and cannabis use.
All subjects completed a number of self-report questionnaires characterizing their substance use patterns, their addiction severity, impulsivity, sensitivity to reward and punishment, and depression. They also underwent a 45-minute EEG, during which they completed a resting EEG test and completed a reward task.
The adolescent daily cigarette smoker group had blunted or decreased sensitivity to punishment and increased impulsivity, compared with the healthy controls, Dr. Hammond reported.
Co-occurring drug use was high in the adolescent daily smoker group, with 80% reporting heavy marijuana use (defined as using it over 100 times during adolescence), and 67% reporting heavy episodic binge drinking (defined as consuming greater than four alcoholic beverages for females during one sitting and greater than five for males at least two or more times a month).
One out of two of the daily cigarette smokers were also daily marijuana smokers, and about 75% of the adolescent smokers had a positive urine drug screen for marijuana. They smoked an average of eight cigarettes per day, used cannabis about 17 days out of the month, and they had about 1.5 binge drinking episodes per month.
Next, the researchers used linear regression analyses to examine which of the psychological variables were associated with alcohol, marijuana, and tobacco use severity within the smoker group, after co-varying for age, gender, race/ethnicity, and full-scale IQ.
“For alcohol use, we found that depression, sensitivity to reward, and impulsivity were significantly associated with alcohol problem severity scores, even after controlling for sociodemographics and other drug use (P less than .05),” Dr. Hammond said.
“For marijuana use, we found that sensitivity to reward and impulsivity were significantly associated with cannabis problem severity, even after controlling for demographics and alcohol and other drug use (P less than .01),” he continued. “For tobacco use, we found that anxiety sensitivity was significantly associated with nicotine dependence scores, even after controlling for demographics and alcohol and marijuana use (P less than .001).”
On EEG analyses, the researchers found no main effects for group or group by condition for the feedback-related negativity (FRN) signal or for the event-related Theta oscillation between the adolescent non-deprived smokers and the healthy controls.
However, examination of the smoker subgroups revealed a unique and shared association between alcohol, marijuana, and tobacco and the EEG signals.
“With regard to substance use associations with the FRN smokers, regression analyses showed that cannabis use problem severity was associated with an increased FRN amplitude during the reward condition only,” Dr. Hammond said. “This finding remained significant after co-varying for demographics, for other drug use, for nicotine dependence and alcohol severity as well.
“We also found an association between alcohol problem severity and mean FRN amplitude, but with no differences across conditions,” he added. There was an association also “ between nicotine dependence and decreased FRN latency, but only during the reward and draw conditions, suggesting a nicotine severity association with speed of processing salient reward and stimuli.”
While the findings need to be better studied and replicated, “these associations may be leveraged to better personalize our interventions for these different substances of abuse,” Dr. Hammond observed. “The study also provides preliminary evidence for a dual-process model of substance use, specifically for cannabis. Cannabis severity in adolescent smokers is associated with increased bottom-up reward signaling and impaired top-down cognitive control over a salient or rewarding stimulus.”
The study was supported by the American Academy of Child and Adolescent Psychiatry and the National Institute on Drug Abuse. Dr. Hammond disclosed that he receives research funding from both organizations.
SOURCE: Hammond et al. AAAP 2017. Paper session A3.
SAN DIEGO – Among adolescent daily cigarette smokers, the individual and concomitant use of alcohol, marijuana, and tobacco have unique and common associations with reinforcement sensitivity, with negative affect, and with electrophysiological signatures of reward function, results from a novel study demonstrated.
“The co-use of alcohol, marijuana, and tobacco in youth are associated bidirectionally with higher rates of substance use, higher levels of addiction severity, and with poorer treatment outcomes for youth who present for treatment,” lead study author Christopher J. Hammond, MD, said at the annual meeting and scientific symposium of the American Academy of Addiction Psychiatry.
Currently, the effects of combined alcohol, marijuana, and tobacco use on brain function are poorly understood, noted Dr. Hammond of the division of child and adolescent psychiatry at Johns Hopkins Bayview Medical Center, Baltimore.
Published studies to date suggest that alcohol, marijuana, and tobacco use disorders are linked separately to dysfunction in the neural substrates of reward and punishment processing, but none has examined co-use or comorbid disorders in adolescents.
In a cross-sectional, single-visit study, Dr. Hammond and his associates examined a population of 36 adolescent non-deprived daily cigarette smokers and 29 healthy controls from the greater New Haven, Conn., area, matched for age, gender, and grade level. The subjects ranged in age from 14 to 20 years and were administered self-report measures characterizing tobacco, marijuana, and alcohol use. The researchers also collected urine and breathalyzer measures to characterize tobacco and cannabis use.
All subjects completed a number of self-report questionnaires characterizing their substance use patterns, their addiction severity, impulsivity, sensitivity to reward and punishment, and depression. They also underwent a 45-minute EEG, during which they completed a resting EEG test and completed a reward task.
The adolescent daily cigarette smoker group had blunted or decreased sensitivity to punishment and increased impulsivity, compared with the healthy controls, Dr. Hammond reported.
Co-occurring drug use was high in the adolescent daily smoker group, with 80% reporting heavy marijuana use (defined as using it over 100 times during adolescence), and 67% reporting heavy episodic binge drinking (defined as consuming greater than four alcoholic beverages for females during one sitting and greater than five for males at least two or more times a month).
One out of two of the daily cigarette smokers were also daily marijuana smokers, and about 75% of the adolescent smokers had a positive urine drug screen for marijuana. They smoked an average of eight cigarettes per day, used cannabis about 17 days out of the month, and they had about 1.5 binge drinking episodes per month.
Next, the researchers used linear regression analyses to examine which of the psychological variables were associated with alcohol, marijuana, and tobacco use severity within the smoker group, after co-varying for age, gender, race/ethnicity, and full-scale IQ.
“For alcohol use, we found that depression, sensitivity to reward, and impulsivity were significantly associated with alcohol problem severity scores, even after controlling for sociodemographics and other drug use (P less than .05),” Dr. Hammond said.
“For marijuana use, we found that sensitivity to reward and impulsivity were significantly associated with cannabis problem severity, even after controlling for demographics and alcohol and other drug use (P less than .01),” he continued. “For tobacco use, we found that anxiety sensitivity was significantly associated with nicotine dependence scores, even after controlling for demographics and alcohol and marijuana use (P less than .001).”
On EEG analyses, the researchers found no main effects for group or group by condition for the feedback-related negativity (FRN) signal or for the event-related Theta oscillation between the adolescent non-deprived smokers and the healthy controls.
However, examination of the smoker subgroups revealed a unique and shared association between alcohol, marijuana, and tobacco and the EEG signals.
“With regard to substance use associations with the FRN smokers, regression analyses showed that cannabis use problem severity was associated with an increased FRN amplitude during the reward condition only,” Dr. Hammond said. “This finding remained significant after co-varying for demographics, for other drug use, for nicotine dependence and alcohol severity as well.
“We also found an association between alcohol problem severity and mean FRN amplitude, but with no differences across conditions,” he added. There was an association also “ between nicotine dependence and decreased FRN latency, but only during the reward and draw conditions, suggesting a nicotine severity association with speed of processing salient reward and stimuli.”
While the findings need to be better studied and replicated, “these associations may be leveraged to better personalize our interventions for these different substances of abuse,” Dr. Hammond observed. “The study also provides preliminary evidence for a dual-process model of substance use, specifically for cannabis. Cannabis severity in adolescent smokers is associated with increased bottom-up reward signaling and impaired top-down cognitive control over a salient or rewarding stimulus.”
The study was supported by the American Academy of Child and Adolescent Psychiatry and the National Institute on Drug Abuse. Dr. Hammond disclosed that he receives research funding from both organizations.
SOURCE: Hammond et al. AAAP 2017. Paper session A3.
SAN DIEGO – Among adolescent daily cigarette smokers, the individual and concomitant use of alcohol, marijuana, and tobacco have unique and common associations with reinforcement sensitivity, with negative affect, and with electrophysiological signatures of reward function, results from a novel study demonstrated.
“The co-use of alcohol, marijuana, and tobacco in youth are associated bidirectionally with higher rates of substance use, higher levels of addiction severity, and with poorer treatment outcomes for youth who present for treatment,” lead study author Christopher J. Hammond, MD, said at the annual meeting and scientific symposium of the American Academy of Addiction Psychiatry.
Currently, the effects of combined alcohol, marijuana, and tobacco use on brain function are poorly understood, noted Dr. Hammond of the division of child and adolescent psychiatry at Johns Hopkins Bayview Medical Center, Baltimore.
Published studies to date suggest that alcohol, marijuana, and tobacco use disorders are linked separately to dysfunction in the neural substrates of reward and punishment processing, but none has examined co-use or comorbid disorders in adolescents.
In a cross-sectional, single-visit study, Dr. Hammond and his associates examined a population of 36 adolescent non-deprived daily cigarette smokers and 29 healthy controls from the greater New Haven, Conn., area, matched for age, gender, and grade level. The subjects ranged in age from 14 to 20 years and were administered self-report measures characterizing tobacco, marijuana, and alcohol use. The researchers also collected urine and breathalyzer measures to characterize tobacco and cannabis use.
All subjects completed a number of self-report questionnaires characterizing their substance use patterns, their addiction severity, impulsivity, sensitivity to reward and punishment, and depression. They also underwent a 45-minute EEG, during which they completed a resting EEG test and completed a reward task.
The adolescent daily cigarette smoker group had blunted or decreased sensitivity to punishment and increased impulsivity, compared with the healthy controls, Dr. Hammond reported.
Co-occurring drug use was high in the adolescent daily smoker group, with 80% reporting heavy marijuana use (defined as using it over 100 times during adolescence), and 67% reporting heavy episodic binge drinking (defined as consuming greater than four alcoholic beverages for females during one sitting and greater than five for males at least two or more times a month).
One out of two of the daily cigarette smokers were also daily marijuana smokers, and about 75% of the adolescent smokers had a positive urine drug screen for marijuana. They smoked an average of eight cigarettes per day, used cannabis about 17 days out of the month, and they had about 1.5 binge drinking episodes per month.
Next, the researchers used linear regression analyses to examine which of the psychological variables were associated with alcohol, marijuana, and tobacco use severity within the smoker group, after co-varying for age, gender, race/ethnicity, and full-scale IQ.
“For alcohol use, we found that depression, sensitivity to reward, and impulsivity were significantly associated with alcohol problem severity scores, even after controlling for sociodemographics and other drug use (P less than .05),” Dr. Hammond said.
“For marijuana use, we found that sensitivity to reward and impulsivity were significantly associated with cannabis problem severity, even after controlling for demographics and alcohol and other drug use (P less than .01),” he continued. “For tobacco use, we found that anxiety sensitivity was significantly associated with nicotine dependence scores, even after controlling for demographics and alcohol and marijuana use (P less than .001).”
On EEG analyses, the researchers found no main effects for group or group by condition for the feedback-related negativity (FRN) signal or for the event-related Theta oscillation between the adolescent non-deprived smokers and the healthy controls.
However, examination of the smoker subgroups revealed a unique and shared association between alcohol, marijuana, and tobacco and the EEG signals.
“With regard to substance use associations with the FRN smokers, regression analyses showed that cannabis use problem severity was associated with an increased FRN amplitude during the reward condition only,” Dr. Hammond said. “This finding remained significant after co-varying for demographics, for other drug use, for nicotine dependence and alcohol severity as well.
“We also found an association between alcohol problem severity and mean FRN amplitude, but with no differences across conditions,” he added. There was an association also “ between nicotine dependence and decreased FRN latency, but only during the reward and draw conditions, suggesting a nicotine severity association with speed of processing salient reward and stimuli.”
While the findings need to be better studied and replicated, “these associations may be leveraged to better personalize our interventions for these different substances of abuse,” Dr. Hammond observed. “The study also provides preliminary evidence for a dual-process model of substance use, specifically for cannabis. Cannabis severity in adolescent smokers is associated with increased bottom-up reward signaling and impaired top-down cognitive control over a salient or rewarding stimulus.”
The study was supported by the American Academy of Child and Adolescent Psychiatry and the National Institute on Drug Abuse. Dr. Hammond disclosed that he receives research funding from both organizations.
SOURCE: Hammond et al. AAAP 2017. Paper session A3.
REPORTING FROM AAAP
Key clinical point:
Major finding: Among adolescents who smoked cigarettes daily, 80% reported co-occurring heavy marijuana use, and 67% reported heavy episodic binge drinking.
Study details: A cross-sectional, single visit study of 36 adolescent nondeprived daily cigarette smokers and 29 healthy, age-matched controls.
Disclosures: The study was supported by the American Academy of Child and Adolescent Psychiatry and the National Institute on Drug Abuse. Dr. Hammond disclosed that he receives research funding from both organizations.
Source: Hammond et al. AAAP 2017. Paper session A3.
Pathological video game use can be ‘life-dominating’
SAN DIEGO – As a medical student, David L. Atkinson, MD, learned about a group of five adult men who played EverQuest, which bills itself as a 3D online world that “offers endless excitement, adventure, battle, and discovery.” They shared an apartment in Austin, Tex., and rotated which one would hold a full-time job while the other four spent their waking hours playing EverQuest.
“It was a little concerning,” recalled Dr. Atkinson, now a psychiatrist and the medical director of the teen recovery program at Children’s Health, Dallas. “EverQuest had a button in the game where you could order a pizza without interrupting your game play. Pathological video game use can be incredibly life-dominating.”
Many terms are used for pathological video game use, including problematic video game use, gaming disorder, and Internet gaming disorder, which is the term used in section III of DSM-5. Whether chronic video game use is a societal problem or an individual problem “is a very big question,” Dr. Atkinson said. “When we look at some of the prevalence data from Monitoring the Future, we have seen reductions in all kinds of substance use. We have seen reductions in teenage motor vehicle accidents and in teen pregnancy. If kids are playing video games and they’re all getting out of shape, that’s a cultural challenge. A clinician, though, may advocate against it as part of good health care.
“For instance, underage drinking in some American subcultures is normative. It doesn’t mean it’s a good idea.”
Most youth do not develop addictive behavior from playing games like EverQuest. “Substance use and gaming are different,” Dr. Atkinson said. “The amount of time spent at the expense of other things is one of the primary harms of video gaming, but financial concerns are not irrelevant. The new Star Wars Battlefront game would cost $2,100 if someone were to buy all of the available extras for the video game. Otherwise, it would take several hundred hours of game play to achieve all of these unlocked features.” While video games do not induce supraphysiologic dopamine release in the way drugs like cocaine do, the addictive potential is measured by an equation of reward versus effort. Obtaining a video game is not dependent upon social interactions, unlike drug use in states where the drug in question is illegal. In fact, the fewer social connections, the greater the risk of developing a video game use disorder.
“The perception of harm of video game addiction is very low, and parents do not consider the potential for developing an addiction before they buy a computer, handheld device, or video game console,” he said. “It is viewed as something that has to be limited ... not as something that is impossible to limit.” However, when parents begin to detect problems, they often find themselves unable to control their children’s or teens’ use of gaming, according to Dr. Atkinson.
In the DSM-5, Internet gaming disorder is defined as being preoccupied with games and withdrawn when not playing them, including irritability, anxiety, and sadness. Tolerance manifests as needing to spend more time playing the game. Typically, gamers cannot reduce their use despite effort, and there is a loss of interest in other activities and hobbies, Dr. Atkinson said. They may continue to engage in overuse of games despite knowing it’s a problem; they may lie about usage, may use games to escape anxiety or guilt, and may have lost or risked lose or risk relationships or career opportunities because of games.
“Not all gamers will do all of these things,” he emphasized. “For example, some gamers have disordered use and lose interest in other things, but don’t lie about it.” DSM-5 criteria also note that the video gaming itself must cause clinically significant impairment and must not be a manifestation of another disorder.
Tools aimed at helping in the diagnosis include the Problem Video Game Playing Questionnaire, the Internet Gaming Disorder Scale, the Internet Gaming Disorder Scale–Short-Form, the Problematic Online Gaming Questionnaire, the Game Addiction Scale, and the Electronic Gaming Motives Questionnaire, which measures enhancement, coping, social, and self-gratification motives.
According to Dr. Atkinson, 90% of children in Japan, Korea, North America, and Europe play video games. However, the prevalence of Internet gaming disorder is estimated to be 1% in the United States, 1.14% in Germany, and 5.9% in South Korea. Males have higher rates of pathological video game use, while afflicted females tend to have more problems. Pathological gaming use is associated with high levels of previous truancy and few leisure activities. It’s also associated with depression, poor impulse control, narcissistic traits, high anxiety, poor social competence, and less religiosity.
“The overlap with depression is very interesting,” Dr. Atkinson said. “ When they get rejected in a peer group or for a job, they tend to take it harder than people who don’t game. The gaming world is a place where you can be safe from rejection. If your credit card goes through, you’re allowed in.”
Anhedonia is another factor within the clinical syndrome of depression that is associated with video game use. A nationwide community sample of individuals in Korea showed that gaming and depression have their overlap most strongly with the “escape from negative emotions” model (J Nerv Ment Dis. 2017;205[7]:568-73). Other associated problems include greater obesity; metabolic indicators, such as high triglycerides and cholesterol; and sleep deprivation. Chronic gamers also tend to have less social support, less health promotion, and heightened social phobia. “When you’re gaming all the time, you’re going to have less opportunity to engage in an exposure paradigm to help you get over your social phobia,” Dr. Atkinson said. “Problem gamers are also more likely to have pathological use of pornography, poor impulse control, and ADHD symptoms.”
Studies of biobehavioral characteristics of those with pathological video game use suggest that there is a decreased dopamine striatal response (Neurosci Biobehav Rev. 2017 Apr;75:314-30). They also suggest decreased functional connectivity across areas of the brain, including decreased resting-state functional connectivity between ventral tegmental area and the nucleus accumbens, and lower tonic dopamine firing.
Parental management training can be successful at setting gaming limits in children under 12 years of age, he said. Pathological video game use is associated with physiologic stress in the family problem-solving task. One study of a brief 3-week family therapy intervention as measured by functional MRI showed that improvement in perceived family cohesion was associated with an increase in the activity of the caudate nucleus in response to the gamer’s viewing images of family cohesion and was inversely correlated with changes in online game playing time (Psychiatry Res. 2012 May 31;202[2]:126-31). “Bringing the family together may give them something to do besides gaming,” Dr. Atkinson said. “That can help them put games in a more balanced perspective.”
The largest evidence base supports cognitive-behavioral therapy for Internet gaming disorder, but there is insufficient evidence to make a clear statement of benefit (Clin Psychol Rev. 2017 Jun;54:123-33). Gaming-related cognitions accounted for a large portion of the variance in treatment response.
“Does the gaming cause the thoughts? Or do the thoughts cause the gaming?” Dr. Atkinson asked. “The cognitive model of CBT would tell you there’s a bidirectional relationship.”
As for medications, bupropion has been shown to reduce online gaming in depressed individuals, and escitalopram also may be efficacious. One comparative analysis showed that there were greater effects from using bupropion than for using escitalopram (Clin Psychopharmacol Neurosci. 2017 Nov 30;15[4]:361-8). Methylphenidate also has been shown to reduce online gaming (Compr Psychiatry. 2009 May-Jun;50[3]:251-6).
Parents who take video games away from their children often are met with a burst of aggression. “There’s an attempt to reestablish dominance in the situation, to obtain the old reinforcer or to reestablish control,” Dr. Atkinson said. “It’s different from tapering a drug; this is something that you have to plan for. Tapering video games is difficult to do. If the kid plays longer than they’re supposed to, what do you do then? You may have a fight to discontinue the video game. That’s one of the practical problems.”
Dr. Atkinson reported having no financial disclosures.
SOURCE: Atkinson DL. AAAP 2017.
SAN DIEGO – As a medical student, David L. Atkinson, MD, learned about a group of five adult men who played EverQuest, which bills itself as a 3D online world that “offers endless excitement, adventure, battle, and discovery.” They shared an apartment in Austin, Tex., and rotated which one would hold a full-time job while the other four spent their waking hours playing EverQuest.
“It was a little concerning,” recalled Dr. Atkinson, now a psychiatrist and the medical director of the teen recovery program at Children’s Health, Dallas. “EverQuest had a button in the game where you could order a pizza without interrupting your game play. Pathological video game use can be incredibly life-dominating.”
Many terms are used for pathological video game use, including problematic video game use, gaming disorder, and Internet gaming disorder, which is the term used in section III of DSM-5. Whether chronic video game use is a societal problem or an individual problem “is a very big question,” Dr. Atkinson said. “When we look at some of the prevalence data from Monitoring the Future, we have seen reductions in all kinds of substance use. We have seen reductions in teenage motor vehicle accidents and in teen pregnancy. If kids are playing video games and they’re all getting out of shape, that’s a cultural challenge. A clinician, though, may advocate against it as part of good health care.
“For instance, underage drinking in some American subcultures is normative. It doesn’t mean it’s a good idea.”
Most youth do not develop addictive behavior from playing games like EverQuest. “Substance use and gaming are different,” Dr. Atkinson said. “The amount of time spent at the expense of other things is one of the primary harms of video gaming, but financial concerns are not irrelevant. The new Star Wars Battlefront game would cost $2,100 if someone were to buy all of the available extras for the video game. Otherwise, it would take several hundred hours of game play to achieve all of these unlocked features.” While video games do not induce supraphysiologic dopamine release in the way drugs like cocaine do, the addictive potential is measured by an equation of reward versus effort. Obtaining a video game is not dependent upon social interactions, unlike drug use in states where the drug in question is illegal. In fact, the fewer social connections, the greater the risk of developing a video game use disorder.
“The perception of harm of video game addiction is very low, and parents do not consider the potential for developing an addiction before they buy a computer, handheld device, or video game console,” he said. “It is viewed as something that has to be limited ... not as something that is impossible to limit.” However, when parents begin to detect problems, they often find themselves unable to control their children’s or teens’ use of gaming, according to Dr. Atkinson.
In the DSM-5, Internet gaming disorder is defined as being preoccupied with games and withdrawn when not playing them, including irritability, anxiety, and sadness. Tolerance manifests as needing to spend more time playing the game. Typically, gamers cannot reduce their use despite effort, and there is a loss of interest in other activities and hobbies, Dr. Atkinson said. They may continue to engage in overuse of games despite knowing it’s a problem; they may lie about usage, may use games to escape anxiety or guilt, and may have lost or risked lose or risk relationships or career opportunities because of games.
“Not all gamers will do all of these things,” he emphasized. “For example, some gamers have disordered use and lose interest in other things, but don’t lie about it.” DSM-5 criteria also note that the video gaming itself must cause clinically significant impairment and must not be a manifestation of another disorder.
Tools aimed at helping in the diagnosis include the Problem Video Game Playing Questionnaire, the Internet Gaming Disorder Scale, the Internet Gaming Disorder Scale–Short-Form, the Problematic Online Gaming Questionnaire, the Game Addiction Scale, and the Electronic Gaming Motives Questionnaire, which measures enhancement, coping, social, and self-gratification motives.
According to Dr. Atkinson, 90% of children in Japan, Korea, North America, and Europe play video games. However, the prevalence of Internet gaming disorder is estimated to be 1% in the United States, 1.14% in Germany, and 5.9% in South Korea. Males have higher rates of pathological video game use, while afflicted females tend to have more problems. Pathological gaming use is associated with high levels of previous truancy and few leisure activities. It’s also associated with depression, poor impulse control, narcissistic traits, high anxiety, poor social competence, and less religiosity.
“The overlap with depression is very interesting,” Dr. Atkinson said. “ When they get rejected in a peer group or for a job, they tend to take it harder than people who don’t game. The gaming world is a place where you can be safe from rejection. If your credit card goes through, you’re allowed in.”
Anhedonia is another factor within the clinical syndrome of depression that is associated with video game use. A nationwide community sample of individuals in Korea showed that gaming and depression have their overlap most strongly with the “escape from negative emotions” model (J Nerv Ment Dis. 2017;205[7]:568-73). Other associated problems include greater obesity; metabolic indicators, such as high triglycerides and cholesterol; and sleep deprivation. Chronic gamers also tend to have less social support, less health promotion, and heightened social phobia. “When you’re gaming all the time, you’re going to have less opportunity to engage in an exposure paradigm to help you get over your social phobia,” Dr. Atkinson said. “Problem gamers are also more likely to have pathological use of pornography, poor impulse control, and ADHD symptoms.”
Studies of biobehavioral characteristics of those with pathological video game use suggest that there is a decreased dopamine striatal response (Neurosci Biobehav Rev. 2017 Apr;75:314-30). They also suggest decreased functional connectivity across areas of the brain, including decreased resting-state functional connectivity between ventral tegmental area and the nucleus accumbens, and lower tonic dopamine firing.
Parental management training can be successful at setting gaming limits in children under 12 years of age, he said. Pathological video game use is associated with physiologic stress in the family problem-solving task. One study of a brief 3-week family therapy intervention as measured by functional MRI showed that improvement in perceived family cohesion was associated with an increase in the activity of the caudate nucleus in response to the gamer’s viewing images of family cohesion and was inversely correlated with changes in online game playing time (Psychiatry Res. 2012 May 31;202[2]:126-31). “Bringing the family together may give them something to do besides gaming,” Dr. Atkinson said. “That can help them put games in a more balanced perspective.”
The largest evidence base supports cognitive-behavioral therapy for Internet gaming disorder, but there is insufficient evidence to make a clear statement of benefit (Clin Psychol Rev. 2017 Jun;54:123-33). Gaming-related cognitions accounted for a large portion of the variance in treatment response.
“Does the gaming cause the thoughts? Or do the thoughts cause the gaming?” Dr. Atkinson asked. “The cognitive model of CBT would tell you there’s a bidirectional relationship.”
As for medications, bupropion has been shown to reduce online gaming in depressed individuals, and escitalopram also may be efficacious. One comparative analysis showed that there were greater effects from using bupropion than for using escitalopram (Clin Psychopharmacol Neurosci. 2017 Nov 30;15[4]:361-8). Methylphenidate also has been shown to reduce online gaming (Compr Psychiatry. 2009 May-Jun;50[3]:251-6).
Parents who take video games away from their children often are met with a burst of aggression. “There’s an attempt to reestablish dominance in the situation, to obtain the old reinforcer or to reestablish control,” Dr. Atkinson said. “It’s different from tapering a drug; this is something that you have to plan for. Tapering video games is difficult to do. If the kid plays longer than they’re supposed to, what do you do then? You may have a fight to discontinue the video game. That’s one of the practical problems.”
Dr. Atkinson reported having no financial disclosures.
SOURCE: Atkinson DL. AAAP 2017.
SAN DIEGO – As a medical student, David L. Atkinson, MD, learned about a group of five adult men who played EverQuest, which bills itself as a 3D online world that “offers endless excitement, adventure, battle, and discovery.” They shared an apartment in Austin, Tex., and rotated which one would hold a full-time job while the other four spent their waking hours playing EverQuest.
“It was a little concerning,” recalled Dr. Atkinson, now a psychiatrist and the medical director of the teen recovery program at Children’s Health, Dallas. “EverQuest had a button in the game where you could order a pizza without interrupting your game play. Pathological video game use can be incredibly life-dominating.”
Many terms are used for pathological video game use, including problematic video game use, gaming disorder, and Internet gaming disorder, which is the term used in section III of DSM-5. Whether chronic video game use is a societal problem or an individual problem “is a very big question,” Dr. Atkinson said. “When we look at some of the prevalence data from Monitoring the Future, we have seen reductions in all kinds of substance use. We have seen reductions in teenage motor vehicle accidents and in teen pregnancy. If kids are playing video games and they’re all getting out of shape, that’s a cultural challenge. A clinician, though, may advocate against it as part of good health care.
“For instance, underage drinking in some American subcultures is normative. It doesn’t mean it’s a good idea.”
Most youth do not develop addictive behavior from playing games like EverQuest. “Substance use and gaming are different,” Dr. Atkinson said. “The amount of time spent at the expense of other things is one of the primary harms of video gaming, but financial concerns are not irrelevant. The new Star Wars Battlefront game would cost $2,100 if someone were to buy all of the available extras for the video game. Otherwise, it would take several hundred hours of game play to achieve all of these unlocked features.” While video games do not induce supraphysiologic dopamine release in the way drugs like cocaine do, the addictive potential is measured by an equation of reward versus effort. Obtaining a video game is not dependent upon social interactions, unlike drug use in states where the drug in question is illegal. In fact, the fewer social connections, the greater the risk of developing a video game use disorder.
“The perception of harm of video game addiction is very low, and parents do not consider the potential for developing an addiction before they buy a computer, handheld device, or video game console,” he said. “It is viewed as something that has to be limited ... not as something that is impossible to limit.” However, when parents begin to detect problems, they often find themselves unable to control their children’s or teens’ use of gaming, according to Dr. Atkinson.
In the DSM-5, Internet gaming disorder is defined as being preoccupied with games and withdrawn when not playing them, including irritability, anxiety, and sadness. Tolerance manifests as needing to spend more time playing the game. Typically, gamers cannot reduce their use despite effort, and there is a loss of interest in other activities and hobbies, Dr. Atkinson said. They may continue to engage in overuse of games despite knowing it’s a problem; they may lie about usage, may use games to escape anxiety or guilt, and may have lost or risked lose or risk relationships or career opportunities because of games.
“Not all gamers will do all of these things,” he emphasized. “For example, some gamers have disordered use and lose interest in other things, but don’t lie about it.” DSM-5 criteria also note that the video gaming itself must cause clinically significant impairment and must not be a manifestation of another disorder.
Tools aimed at helping in the diagnosis include the Problem Video Game Playing Questionnaire, the Internet Gaming Disorder Scale, the Internet Gaming Disorder Scale–Short-Form, the Problematic Online Gaming Questionnaire, the Game Addiction Scale, and the Electronic Gaming Motives Questionnaire, which measures enhancement, coping, social, and self-gratification motives.
According to Dr. Atkinson, 90% of children in Japan, Korea, North America, and Europe play video games. However, the prevalence of Internet gaming disorder is estimated to be 1% in the United States, 1.14% in Germany, and 5.9% in South Korea. Males have higher rates of pathological video game use, while afflicted females tend to have more problems. Pathological gaming use is associated with high levels of previous truancy and few leisure activities. It’s also associated with depression, poor impulse control, narcissistic traits, high anxiety, poor social competence, and less religiosity.
“The overlap with depression is very interesting,” Dr. Atkinson said. “ When they get rejected in a peer group or for a job, they tend to take it harder than people who don’t game. The gaming world is a place where you can be safe from rejection. If your credit card goes through, you’re allowed in.”
Anhedonia is another factor within the clinical syndrome of depression that is associated with video game use. A nationwide community sample of individuals in Korea showed that gaming and depression have their overlap most strongly with the “escape from negative emotions” model (J Nerv Ment Dis. 2017;205[7]:568-73). Other associated problems include greater obesity; metabolic indicators, such as high triglycerides and cholesterol; and sleep deprivation. Chronic gamers also tend to have less social support, less health promotion, and heightened social phobia. “When you’re gaming all the time, you’re going to have less opportunity to engage in an exposure paradigm to help you get over your social phobia,” Dr. Atkinson said. “Problem gamers are also more likely to have pathological use of pornography, poor impulse control, and ADHD symptoms.”
Studies of biobehavioral characteristics of those with pathological video game use suggest that there is a decreased dopamine striatal response (Neurosci Biobehav Rev. 2017 Apr;75:314-30). They also suggest decreased functional connectivity across areas of the brain, including decreased resting-state functional connectivity between ventral tegmental area and the nucleus accumbens, and lower tonic dopamine firing.
Parental management training can be successful at setting gaming limits in children under 12 years of age, he said. Pathological video game use is associated with physiologic stress in the family problem-solving task. One study of a brief 3-week family therapy intervention as measured by functional MRI showed that improvement in perceived family cohesion was associated with an increase in the activity of the caudate nucleus in response to the gamer’s viewing images of family cohesion and was inversely correlated with changes in online game playing time (Psychiatry Res. 2012 May 31;202[2]:126-31). “Bringing the family together may give them something to do besides gaming,” Dr. Atkinson said. “That can help them put games in a more balanced perspective.”
The largest evidence base supports cognitive-behavioral therapy for Internet gaming disorder, but there is insufficient evidence to make a clear statement of benefit (Clin Psychol Rev. 2017 Jun;54:123-33). Gaming-related cognitions accounted for a large portion of the variance in treatment response.
“Does the gaming cause the thoughts? Or do the thoughts cause the gaming?” Dr. Atkinson asked. “The cognitive model of CBT would tell you there’s a bidirectional relationship.”
As for medications, bupropion has been shown to reduce online gaming in depressed individuals, and escitalopram also may be efficacious. One comparative analysis showed that there were greater effects from using bupropion than for using escitalopram (Clin Psychopharmacol Neurosci. 2017 Nov 30;15[4]:361-8). Methylphenidate also has been shown to reduce online gaming (Compr Psychiatry. 2009 May-Jun;50[3]:251-6).
Parents who take video games away from their children often are met with a burst of aggression. “There’s an attempt to reestablish dominance in the situation, to obtain the old reinforcer or to reestablish control,” Dr. Atkinson said. “It’s different from tapering a drug; this is something that you have to plan for. Tapering video games is difficult to do. If the kid plays longer than they’re supposed to, what do you do then? You may have a fight to discontinue the video game. That’s one of the practical problems.”
Dr. Atkinson reported having no financial disclosures.
SOURCE: Atkinson DL. AAAP 2017.
REPORTING FROM AAAP
Early psychotherapy may predict buprenorphine treatment retention
SAN DIEGO – an observational study found.
“Opioid use disorder and overdose deaths are devastating many communities across the country,” lead study author Ajay Manhapra, MD, said at the annual meeting and scientific symposium of the American Academy of Addiction Psychiatry. “We know that engagement in opioid agonist treatment with buprenorphine/methadone is associated with a two-thirds reduction in mortality and lower morbidity. However, 1-year retention rates are generally less than 50%.”
As part of a larger study on 3-year buprenorphine retention, Dr. Manhapra and his associates set out to investigate what factors predict long-term retention in buprenorphine treatment. From patients with an OUD diagnosis in the Marketscan database, they identified 16,190 individuals who filled their prescription of buprenorphine after the first 60 days of 2011 as new starts and calculated the treatment retention period as the time between the date of their first prescription to the last prescription until the end of 2014. The researchers used CPT codes to identify the receipt of any outpatient psychotherapy and multivariate Cox survival analysis to examine the effect of psychotherapy receipt on buprenorphine retention.
Dr. Manhapra reported that of the 16,190 patients, 15% were engaged in buprenorphine treatment for 30 days or fewer, 40% were engaged for 31 days to 1 year, 31% were engaged between 1 and 3 years, and 14% were engaged for more than 3 years. The mean duration of retention was 1.23 years. At the same time, the outpatient psychotherapy receipt rate in 2011 was 30.29% among those retained for 0-30 days, 35.30% among those retained for 31-364 days, 37.59% among those retained for 1-3 years, and 39.20% among those retained for more than 3 years.
Multivariate Cox survival analysis revealed that receipt of any psychotherapy in 2011 was associated with a lower risk of discontinuation of buprenorphine treatment (hazard ratio, 0.86; P less than .0001). “Is this a direct effect of psychotherapy? I don’t know,” said Dr. Manhapra, who also practices at the Hampton (Virginia) VA Medical Center. “Is this a selection bias not accounted for by the variables available? That is, those who have a better chance of sustained retention might have been selected for or chosen to receive psychotherapy. Those are possibilities. We need further observational and qualitative studies, and maybe more randomized trials.”
Dr. Manhapra disclosed that he has received support from the VA Interprofessional Fellowship in Addiction Treatment and from Research in Addiction Medicine Scholars.
SOURCE: Manhapra A et al. AAAP 2017. Paper session A5.
SAN DIEGO – an observational study found.
“Opioid use disorder and overdose deaths are devastating many communities across the country,” lead study author Ajay Manhapra, MD, said at the annual meeting and scientific symposium of the American Academy of Addiction Psychiatry. “We know that engagement in opioid agonist treatment with buprenorphine/methadone is associated with a two-thirds reduction in mortality and lower morbidity. However, 1-year retention rates are generally less than 50%.”
As part of a larger study on 3-year buprenorphine retention, Dr. Manhapra and his associates set out to investigate what factors predict long-term retention in buprenorphine treatment. From patients with an OUD diagnosis in the Marketscan database, they identified 16,190 individuals who filled their prescription of buprenorphine after the first 60 days of 2011 as new starts and calculated the treatment retention period as the time between the date of their first prescription to the last prescription until the end of 2014. The researchers used CPT codes to identify the receipt of any outpatient psychotherapy and multivariate Cox survival analysis to examine the effect of psychotherapy receipt on buprenorphine retention.
Dr. Manhapra reported that of the 16,190 patients, 15% were engaged in buprenorphine treatment for 30 days or fewer, 40% were engaged for 31 days to 1 year, 31% were engaged between 1 and 3 years, and 14% were engaged for more than 3 years. The mean duration of retention was 1.23 years. At the same time, the outpatient psychotherapy receipt rate in 2011 was 30.29% among those retained for 0-30 days, 35.30% among those retained for 31-364 days, 37.59% among those retained for 1-3 years, and 39.20% among those retained for more than 3 years.
Multivariate Cox survival analysis revealed that receipt of any psychotherapy in 2011 was associated with a lower risk of discontinuation of buprenorphine treatment (hazard ratio, 0.86; P less than .0001). “Is this a direct effect of psychotherapy? I don’t know,” said Dr. Manhapra, who also practices at the Hampton (Virginia) VA Medical Center. “Is this a selection bias not accounted for by the variables available? That is, those who have a better chance of sustained retention might have been selected for or chosen to receive psychotherapy. Those are possibilities. We need further observational and qualitative studies, and maybe more randomized trials.”
Dr. Manhapra disclosed that he has received support from the VA Interprofessional Fellowship in Addiction Treatment and from Research in Addiction Medicine Scholars.
SOURCE: Manhapra A et al. AAAP 2017. Paper session A5.
SAN DIEGO – an observational study found.
“Opioid use disorder and overdose deaths are devastating many communities across the country,” lead study author Ajay Manhapra, MD, said at the annual meeting and scientific symposium of the American Academy of Addiction Psychiatry. “We know that engagement in opioid agonist treatment with buprenorphine/methadone is associated with a two-thirds reduction in mortality and lower morbidity. However, 1-year retention rates are generally less than 50%.”
As part of a larger study on 3-year buprenorphine retention, Dr. Manhapra and his associates set out to investigate what factors predict long-term retention in buprenorphine treatment. From patients with an OUD diagnosis in the Marketscan database, they identified 16,190 individuals who filled their prescription of buprenorphine after the first 60 days of 2011 as new starts and calculated the treatment retention period as the time between the date of their first prescription to the last prescription until the end of 2014. The researchers used CPT codes to identify the receipt of any outpatient psychotherapy and multivariate Cox survival analysis to examine the effect of psychotherapy receipt on buprenorphine retention.
Dr. Manhapra reported that of the 16,190 patients, 15% were engaged in buprenorphine treatment for 30 days or fewer, 40% were engaged for 31 days to 1 year, 31% were engaged between 1 and 3 years, and 14% were engaged for more than 3 years. The mean duration of retention was 1.23 years. At the same time, the outpatient psychotherapy receipt rate in 2011 was 30.29% among those retained for 0-30 days, 35.30% among those retained for 31-364 days, 37.59% among those retained for 1-3 years, and 39.20% among those retained for more than 3 years.
Multivariate Cox survival analysis revealed that receipt of any psychotherapy in 2011 was associated with a lower risk of discontinuation of buprenorphine treatment (hazard ratio, 0.86; P less than .0001). “Is this a direct effect of psychotherapy? I don’t know,” said Dr. Manhapra, who also practices at the Hampton (Virginia) VA Medical Center. “Is this a selection bias not accounted for by the variables available? That is, those who have a better chance of sustained retention might have been selected for or chosen to receive psychotherapy. Those are possibilities. We need further observational and qualitative studies, and maybe more randomized trials.”
Dr. Manhapra disclosed that he has received support from the VA Interprofessional Fellowship in Addiction Treatment and from Research in Addiction Medicine Scholars.
SOURCE: Manhapra A et al. AAAP 2017. Paper session A5.
REPORTING FROM AAAP
Key clinical point: Psychotherapy at the beginning of buprenorphine treatment may affect retention in patients with opioid use disorder.
Major finding: Receipt of any psychotherapy in 2011 was associated with a lower risk of discontinuation of buprenorphine treatment by 2014 (hazard ratio, 0.86; P less than .0001).
Study details: An observational study of 16,190 individuals with OUD.
Disclosures: Dr. Manhapra disclosed that he has received support from the VA Interprofessional Fellowship in Addiction Treatment and from Research in Addiction Medicine Scholars.
Source: Manhapra A et al. AAAP 2017. Paper session A5.
Internet addiction ‘an impairing but treatable problem’
SAN DIEGO – The concept of Internet addiction is imperfect, but it has validity and describes an impairing but treatable problem, according to Diana D. Deister, MD.
“Timely diagnosis can lead to good treatment and symptom improvement,” she said at the annual meeting and scientific symposium of the American Academy of Addiction Psychiatry.
Frameworks for the diagnosis of Internet addiction (IA)/pathological Internet use (PIU) vary but are based mostly on DSM-IV substance abuse and dependency criteria, DSM-IV pathological gambling, or other models. “There are many different checklists and diagnostic instruments you can use, and common synonyms include pathological Internet use, problematic Internet use, and compulsive Internet use,” said Dr. Deister, a child and adolescent psychiatrist at Boston Children’s Hospital. “They may not all refer to the exact same problem you might encounter in clinical practice.”
The Internet Addiction Diagnostic Questionnaire, developed in 1998 by Kimberly S. Young, PsyD, is widely used in research and consists of eight yes or no questions (Cyberpsychol Behav. 1998;1[3]:237-44). Answering “yes” to five out of the eight questions gives you a diagnosis of IA. “There are no preferred symptoms that everybody has to have in order to make the diagnosis, so this is more like the current SUD diagnosis for DSM-5,” Dr. Deister explained. “And there’s no time criteria.”
Clinicians can secure a more detailed assessment of IA symptoms by using the Internet Addiction Test (IAT), which Dr. Young developed in 2013. This tool consists of 20 questions rated on a five-point Likert scale based on frequency, where 0 stands for “not applicable” and 5 stands for “always.” Questions include “How often do you find that you stay online longer than you intended?” “How often do you block out disturbing thoughts about your life with soothing thoughts of the Internet?” And “How often do you feel depressed, moody, or nervous when you are offline, which goes away once you are back online?” A score of 80-100 is considered to meet criteria for IA, a score of 50-79 is considered borderline IA, while a score of below 50 is considered not pathological. Variations of this test can be found in the medical literature, including the Internet Process Addiction Test (Behav Sci. 2015;5:341-52), which contains subscales of Internet use: surfing, online gaming, social networking, and sex.
Dr. Deister noted that imaging studies of brain pathways in IA have demonstrated that mesolimbic dopaminergic projections to the nucleus accumbens from the ventral tegmental area are involved, as well as diminished activity of the ventral medial prefrontal cortex. In a tract-based spatial statistics study, researchers used diffusor tensor imaging (DTI) to study the white matter integrity in 18 adolescents with IA, and 18 age- and gender-matched controls (PLoS ONE. 7[1]:e30253. doi:10.1371/journal.pone.0030253). Compared with controls, the IA group scored higher in the IAT, the Strengths and Difficulties Questionnaire, the Screen for Child Anxiety Related Emotional Disorders scale, and Family Assessment Device measure. DTI scans demonstrated widespread reductions of fractional anisotropy (FA; a measure of white matter health) in major white matter pathways. In addition, significantly negative correlations were found between FA values in the left genu of the corpus callosum and the Screen for Child Anxiety Related Emotional Disorders, and between FA values in the left external capsule and in the IAT.
“The reason these white matter tracts could be important is that there have been previous studies showing that you can improve the health of your white matter tracks through exercise and physical therapy,” Dr. Deister said. “So it may be that this knowledge could lead to new treatments for some of these patients.”
One study of the dose dependence of IA symptoms found that adolescents who met criteria for addictive Internet use, compared with those who met criteria for borderline-addictive Internet use, had higher rates of peer problems (adjusted odds ratio, 7.14 vs. AOR, 5.28); conduct problems (AOR, 22.31 vs. AOR, 4.77); hyperactivity (AOR, 9.49 vs. AOR, 5.58); and emotional symptoms (AOR, 19.06 vs. AOR, 2.85; Int J Adolesc Med. 2014;26[3]:369-75). Multivariate regression analysis revealed that Internet addictive behavior was independently associated with using the Internet for retrieving sexual information (AOR, 1.17) and for participating in games with monetary rewards (AOR, 1.90).
Dr. Deister said IA and aggression go hand in hand. A study of 714 middle school students in Seoul, South Korea, showed a linear association between aggression and IA (Cyberpsychol Behav Soc Netw. 2015;18[5]:260-7). A separate qualitative study of 27 university students in the United States found that the consequences of Internet use led to decreased physical activity, decreased sleep, decreased face-to-face time with other people, and poorer academic performance and concentration (PLoS ONE. 2015;10[2]:e0117372). Another study found that trait anhedonia at baseline predicted greater levels of compulsive Internet use, addiction to online activities, and greater likelihood of addiction to online/offline games (Comput Human Behav. 2016;62:475-9).
Treatment for IA takes all the usual forms, but outcome studies are limited. Cognitive-behavioral therapy for IA was first developed as a 12-week model with a familiar design of behavior modification, cognitive restructuring, harm reduction, and relapse prevention, Dr. Deister said. One study of treatment outcomes that used CBT in 128 IA patients found that 95% of patients were able to manage symptoms at the end of 12 weeks of treatment, while 78% sustained recovery 6 months after treatment (J Behav Addict. 2013;2[4]:209-15). Meanwhile, a meta-analysis of 12 studies related to IA found that medications and psychotherapy were found to be effective for improving IA status, time spent online, and depression and anxiety symptoms (Clin Psychol Rev. 2013;33:317-29). A more recent intention-to-treat analysis of IA disorders in adolescents and adults found that patients referred to treatment showed significant improvements in compulsive Internet use over time (J Behav Addict. 2017;6[4]:579-92). Differential effects were found depending on patients’ compliance, with high compliance generally resulting in significantly higher rates of change.
Dr. Deister reported having no financial disclosures.
SAN DIEGO – The concept of Internet addiction is imperfect, but it has validity and describes an impairing but treatable problem, according to Diana D. Deister, MD.
“Timely diagnosis can lead to good treatment and symptom improvement,” she said at the annual meeting and scientific symposium of the American Academy of Addiction Psychiatry.
Frameworks for the diagnosis of Internet addiction (IA)/pathological Internet use (PIU) vary but are based mostly on DSM-IV substance abuse and dependency criteria, DSM-IV pathological gambling, or other models. “There are many different checklists and diagnostic instruments you can use, and common synonyms include pathological Internet use, problematic Internet use, and compulsive Internet use,” said Dr. Deister, a child and adolescent psychiatrist at Boston Children’s Hospital. “They may not all refer to the exact same problem you might encounter in clinical practice.”
The Internet Addiction Diagnostic Questionnaire, developed in 1998 by Kimberly S. Young, PsyD, is widely used in research and consists of eight yes or no questions (Cyberpsychol Behav. 1998;1[3]:237-44). Answering “yes” to five out of the eight questions gives you a diagnosis of IA. “There are no preferred symptoms that everybody has to have in order to make the diagnosis, so this is more like the current SUD diagnosis for DSM-5,” Dr. Deister explained. “And there’s no time criteria.”
Clinicians can secure a more detailed assessment of IA symptoms by using the Internet Addiction Test (IAT), which Dr. Young developed in 2013. This tool consists of 20 questions rated on a five-point Likert scale based on frequency, where 0 stands for “not applicable” and 5 stands for “always.” Questions include “How often do you find that you stay online longer than you intended?” “How often do you block out disturbing thoughts about your life with soothing thoughts of the Internet?” And “How often do you feel depressed, moody, or nervous when you are offline, which goes away once you are back online?” A score of 80-100 is considered to meet criteria for IA, a score of 50-79 is considered borderline IA, while a score of below 50 is considered not pathological. Variations of this test can be found in the medical literature, including the Internet Process Addiction Test (Behav Sci. 2015;5:341-52), which contains subscales of Internet use: surfing, online gaming, social networking, and sex.
Dr. Deister noted that imaging studies of brain pathways in IA have demonstrated that mesolimbic dopaminergic projections to the nucleus accumbens from the ventral tegmental area are involved, as well as diminished activity of the ventral medial prefrontal cortex. In a tract-based spatial statistics study, researchers used diffusor tensor imaging (DTI) to study the white matter integrity in 18 adolescents with IA, and 18 age- and gender-matched controls (PLoS ONE. 7[1]:e30253. doi:10.1371/journal.pone.0030253). Compared with controls, the IA group scored higher in the IAT, the Strengths and Difficulties Questionnaire, the Screen for Child Anxiety Related Emotional Disorders scale, and Family Assessment Device measure. DTI scans demonstrated widespread reductions of fractional anisotropy (FA; a measure of white matter health) in major white matter pathways. In addition, significantly negative correlations were found between FA values in the left genu of the corpus callosum and the Screen for Child Anxiety Related Emotional Disorders, and between FA values in the left external capsule and in the IAT.
“The reason these white matter tracts could be important is that there have been previous studies showing that you can improve the health of your white matter tracks through exercise and physical therapy,” Dr. Deister said. “So it may be that this knowledge could lead to new treatments for some of these patients.”
One study of the dose dependence of IA symptoms found that adolescents who met criteria for addictive Internet use, compared with those who met criteria for borderline-addictive Internet use, had higher rates of peer problems (adjusted odds ratio, 7.14 vs. AOR, 5.28); conduct problems (AOR, 22.31 vs. AOR, 4.77); hyperactivity (AOR, 9.49 vs. AOR, 5.58); and emotional symptoms (AOR, 19.06 vs. AOR, 2.85; Int J Adolesc Med. 2014;26[3]:369-75). Multivariate regression analysis revealed that Internet addictive behavior was independently associated with using the Internet for retrieving sexual information (AOR, 1.17) and for participating in games with monetary rewards (AOR, 1.90).
Dr. Deister said IA and aggression go hand in hand. A study of 714 middle school students in Seoul, South Korea, showed a linear association between aggression and IA (Cyberpsychol Behav Soc Netw. 2015;18[5]:260-7). A separate qualitative study of 27 university students in the United States found that the consequences of Internet use led to decreased physical activity, decreased sleep, decreased face-to-face time with other people, and poorer academic performance and concentration (PLoS ONE. 2015;10[2]:e0117372). Another study found that trait anhedonia at baseline predicted greater levels of compulsive Internet use, addiction to online activities, and greater likelihood of addiction to online/offline games (Comput Human Behav. 2016;62:475-9).
Treatment for IA takes all the usual forms, but outcome studies are limited. Cognitive-behavioral therapy for IA was first developed as a 12-week model with a familiar design of behavior modification, cognitive restructuring, harm reduction, and relapse prevention, Dr. Deister said. One study of treatment outcomes that used CBT in 128 IA patients found that 95% of patients were able to manage symptoms at the end of 12 weeks of treatment, while 78% sustained recovery 6 months after treatment (J Behav Addict. 2013;2[4]:209-15). Meanwhile, a meta-analysis of 12 studies related to IA found that medications and psychotherapy were found to be effective for improving IA status, time spent online, and depression and anxiety symptoms (Clin Psychol Rev. 2013;33:317-29). A more recent intention-to-treat analysis of IA disorders in adolescents and adults found that patients referred to treatment showed significant improvements in compulsive Internet use over time (J Behav Addict. 2017;6[4]:579-92). Differential effects were found depending on patients’ compliance, with high compliance generally resulting in significantly higher rates of change.
Dr. Deister reported having no financial disclosures.
SAN DIEGO – The concept of Internet addiction is imperfect, but it has validity and describes an impairing but treatable problem, according to Diana D. Deister, MD.
“Timely diagnosis can lead to good treatment and symptom improvement,” she said at the annual meeting and scientific symposium of the American Academy of Addiction Psychiatry.
Frameworks for the diagnosis of Internet addiction (IA)/pathological Internet use (PIU) vary but are based mostly on DSM-IV substance abuse and dependency criteria, DSM-IV pathological gambling, or other models. “There are many different checklists and diagnostic instruments you can use, and common synonyms include pathological Internet use, problematic Internet use, and compulsive Internet use,” said Dr. Deister, a child and adolescent psychiatrist at Boston Children’s Hospital. “They may not all refer to the exact same problem you might encounter in clinical practice.”
The Internet Addiction Diagnostic Questionnaire, developed in 1998 by Kimberly S. Young, PsyD, is widely used in research and consists of eight yes or no questions (Cyberpsychol Behav. 1998;1[3]:237-44). Answering “yes” to five out of the eight questions gives you a diagnosis of IA. “There are no preferred symptoms that everybody has to have in order to make the diagnosis, so this is more like the current SUD diagnosis for DSM-5,” Dr. Deister explained. “And there’s no time criteria.”
Clinicians can secure a more detailed assessment of IA symptoms by using the Internet Addiction Test (IAT), which Dr. Young developed in 2013. This tool consists of 20 questions rated on a five-point Likert scale based on frequency, where 0 stands for “not applicable” and 5 stands for “always.” Questions include “How often do you find that you stay online longer than you intended?” “How often do you block out disturbing thoughts about your life with soothing thoughts of the Internet?” And “How often do you feel depressed, moody, or nervous when you are offline, which goes away once you are back online?” A score of 80-100 is considered to meet criteria for IA, a score of 50-79 is considered borderline IA, while a score of below 50 is considered not pathological. Variations of this test can be found in the medical literature, including the Internet Process Addiction Test (Behav Sci. 2015;5:341-52), which contains subscales of Internet use: surfing, online gaming, social networking, and sex.
Dr. Deister noted that imaging studies of brain pathways in IA have demonstrated that mesolimbic dopaminergic projections to the nucleus accumbens from the ventral tegmental area are involved, as well as diminished activity of the ventral medial prefrontal cortex. In a tract-based spatial statistics study, researchers used diffusor tensor imaging (DTI) to study the white matter integrity in 18 adolescents with IA, and 18 age- and gender-matched controls (PLoS ONE. 7[1]:e30253. doi:10.1371/journal.pone.0030253). Compared with controls, the IA group scored higher in the IAT, the Strengths and Difficulties Questionnaire, the Screen for Child Anxiety Related Emotional Disorders scale, and Family Assessment Device measure. DTI scans demonstrated widespread reductions of fractional anisotropy (FA; a measure of white matter health) in major white matter pathways. In addition, significantly negative correlations were found between FA values in the left genu of the corpus callosum and the Screen for Child Anxiety Related Emotional Disorders, and between FA values in the left external capsule and in the IAT.
“The reason these white matter tracts could be important is that there have been previous studies showing that you can improve the health of your white matter tracks through exercise and physical therapy,” Dr. Deister said. “So it may be that this knowledge could lead to new treatments for some of these patients.”
One study of the dose dependence of IA symptoms found that adolescents who met criteria for addictive Internet use, compared with those who met criteria for borderline-addictive Internet use, had higher rates of peer problems (adjusted odds ratio, 7.14 vs. AOR, 5.28); conduct problems (AOR, 22.31 vs. AOR, 4.77); hyperactivity (AOR, 9.49 vs. AOR, 5.58); and emotional symptoms (AOR, 19.06 vs. AOR, 2.85; Int J Adolesc Med. 2014;26[3]:369-75). Multivariate regression analysis revealed that Internet addictive behavior was independently associated with using the Internet for retrieving sexual information (AOR, 1.17) and for participating in games with monetary rewards (AOR, 1.90).
Dr. Deister said IA and aggression go hand in hand. A study of 714 middle school students in Seoul, South Korea, showed a linear association between aggression and IA (Cyberpsychol Behav Soc Netw. 2015;18[5]:260-7). A separate qualitative study of 27 university students in the United States found that the consequences of Internet use led to decreased physical activity, decreased sleep, decreased face-to-face time with other people, and poorer academic performance and concentration (PLoS ONE. 2015;10[2]:e0117372). Another study found that trait anhedonia at baseline predicted greater levels of compulsive Internet use, addiction to online activities, and greater likelihood of addiction to online/offline games (Comput Human Behav. 2016;62:475-9).
Treatment for IA takes all the usual forms, but outcome studies are limited. Cognitive-behavioral therapy for IA was first developed as a 12-week model with a familiar design of behavior modification, cognitive restructuring, harm reduction, and relapse prevention, Dr. Deister said. One study of treatment outcomes that used CBT in 128 IA patients found that 95% of patients were able to manage symptoms at the end of 12 weeks of treatment, while 78% sustained recovery 6 months after treatment (J Behav Addict. 2013;2[4]:209-15). Meanwhile, a meta-analysis of 12 studies related to IA found that medications and psychotherapy were found to be effective for improving IA status, time spent online, and depression and anxiety symptoms (Clin Psychol Rev. 2013;33:317-29). A more recent intention-to-treat analysis of IA disorders in adolescents and adults found that patients referred to treatment showed significant improvements in compulsive Internet use over time (J Behav Addict. 2017;6[4]:579-92). Differential effects were found depending on patients’ compliance, with high compliance generally resulting in significantly higher rates of change.
Dr. Deister reported having no financial disclosures.
REPORTING FROM AAAP
Hospitalization risk twice as likely for veterans with mental illness
SAN DIEGO – compared with their peers who had no psychiatric or addiction diagnosis, according to results of a large VA database study.
“Our patients sit at the center of two public health crises,” David T. Moore, MD, PhD, said at the annual meeting and scientific symposium of the American Academy of Addiction Psychiatry. “One is the incredibly reduced life expectancy for adults with mental illnesses. There may be a 20-year reduced life expectancy. Their mortality rate for chronic medical conditions such as heart disease and COPD is increased by two- to fourfold, and is associated with greater hospitalization rates, longer lengths of stay, and increased readmission rates. The second part of this crisis is the incredible cost associated with medical hospitalizations. About 1 in every $20 in the entire U.S. economy goes toward inpatient medical hospitalization.”
The final analysis included 952,252 veterans with a mental illness and 1,064,140 without a psychiatric or addiction diagnosis. Dr. Moore reported that among veterans with mental illness, 100,191 (7.1%) were hospitalized on a medical unit at some point during the study period, compared with only 31,759 (2.9%) of veterans with no psychiatric or addiction diagnosis. The Charlson Comorbidity Index was significantly increased in veterans with mental health diagnoses, compared with those who did not have mental health diagnoses.
“There was more tobacco use; they were much more likely to receive an opioid prescription; [and] they used more outpatient medical services, whether it be primary care visits or specialty care visits,” Dr. Moore said of the hospitalized veterans. “They are sicker, but they also use more outpatient medical services, suggesting that they do not lack access to adequate outpatient medical care.”
Next, the researchers performed a subset analysis of all veterans with any mental health diagnosis. Compared with those who were not hospitalized during the study period, those hospitalized were older (a mean age of 52 vs. 45 years, respectively), more likely to be homeless (21% vs. 12%; relative risk, 1.8), and receive a VA pension, which is correlated with poor functioning and disability (7.1% vs. 2.9%; RR, 2.4). The only psychiatric disorder correlated with correlated with medical hospitalization was personality disorder (6.3% vs. 3.7%; RR, 1.7). The researchers also observed that a higher proportion of hospitalized patients had an alcohol use disorder (34% vs. 23%; RR, 1.7) and drug use (31% vs. 17%; RR, 1.8). “The use of benzodiazepines had the greatest relative risk for medical hospitalizations,” Dr. Moore said.
In unadjusted analyses, veterans with the following diagnoses were at increased risk for hospitalization: drug use disorder (odds ratio, 4.58), alcohol use disorder (OR, 3.84), bipolar disorder (OR, 3.29), major depressive disorder (OR, 3.04), schizophrenia (OR, 2.98), and posttraumatic stress disorder (OR, 1.91).
After adjusting for other health factors in multiple regression, alcohol use disorder was the only psychiatric or addiction disorder strongly associated with medical hospitalizations (OR, 1.95). After accounting for sociodemographic characteristics, medical comorbidities, use of outpatient medical services, and alcohol use, the OR for medical hospitalizations among veterans with mental illness decreased from 2.52 to 1.24.
“It looks like a lot of the folks with drug use disorders who are being hospitalized may also have co-occurring alcohol use disorders,” Dr. Moore said. “That may partly account for their hospitalization risk.”
He concluded that the study’s overall findings “leave us with a lot of questions about what to do. The majority of patients who are hospitalized have a mental illness. Is this a setting where we should be engaging them and trying to connect them with outpatient services?”
Dr. Moore reported having no financial disclosures.
SOURCE: Moore et al. AAAP 2017. Paper session A1.
SAN DIEGO – compared with their peers who had no psychiatric or addiction diagnosis, according to results of a large VA database study.
“Our patients sit at the center of two public health crises,” David T. Moore, MD, PhD, said at the annual meeting and scientific symposium of the American Academy of Addiction Psychiatry. “One is the incredibly reduced life expectancy for adults with mental illnesses. There may be a 20-year reduced life expectancy. Their mortality rate for chronic medical conditions such as heart disease and COPD is increased by two- to fourfold, and is associated with greater hospitalization rates, longer lengths of stay, and increased readmission rates. The second part of this crisis is the incredible cost associated with medical hospitalizations. About 1 in every $20 in the entire U.S. economy goes toward inpatient medical hospitalization.”
The final analysis included 952,252 veterans with a mental illness and 1,064,140 without a psychiatric or addiction diagnosis. Dr. Moore reported that among veterans with mental illness, 100,191 (7.1%) were hospitalized on a medical unit at some point during the study period, compared with only 31,759 (2.9%) of veterans with no psychiatric or addiction diagnosis. The Charlson Comorbidity Index was significantly increased in veterans with mental health diagnoses, compared with those who did not have mental health diagnoses.
“There was more tobacco use; they were much more likely to receive an opioid prescription; [and] they used more outpatient medical services, whether it be primary care visits or specialty care visits,” Dr. Moore said of the hospitalized veterans. “They are sicker, but they also use more outpatient medical services, suggesting that they do not lack access to adequate outpatient medical care.”
Next, the researchers performed a subset analysis of all veterans with any mental health diagnosis. Compared with those who were not hospitalized during the study period, those hospitalized were older (a mean age of 52 vs. 45 years, respectively), more likely to be homeless (21% vs. 12%; relative risk, 1.8), and receive a VA pension, which is correlated with poor functioning and disability (7.1% vs. 2.9%; RR, 2.4). The only psychiatric disorder correlated with correlated with medical hospitalization was personality disorder (6.3% vs. 3.7%; RR, 1.7). The researchers also observed that a higher proportion of hospitalized patients had an alcohol use disorder (34% vs. 23%; RR, 1.7) and drug use (31% vs. 17%; RR, 1.8). “The use of benzodiazepines had the greatest relative risk for medical hospitalizations,” Dr. Moore said.
In unadjusted analyses, veterans with the following diagnoses were at increased risk for hospitalization: drug use disorder (odds ratio, 4.58), alcohol use disorder (OR, 3.84), bipolar disorder (OR, 3.29), major depressive disorder (OR, 3.04), schizophrenia (OR, 2.98), and posttraumatic stress disorder (OR, 1.91).
After adjusting for other health factors in multiple regression, alcohol use disorder was the only psychiatric or addiction disorder strongly associated with medical hospitalizations (OR, 1.95). After accounting for sociodemographic characteristics, medical comorbidities, use of outpatient medical services, and alcohol use, the OR for medical hospitalizations among veterans with mental illness decreased from 2.52 to 1.24.
“It looks like a lot of the folks with drug use disorders who are being hospitalized may also have co-occurring alcohol use disorders,” Dr. Moore said. “That may partly account for their hospitalization risk.”
He concluded that the study’s overall findings “leave us with a lot of questions about what to do. The majority of patients who are hospitalized have a mental illness. Is this a setting where we should be engaging them and trying to connect them with outpatient services?”
Dr. Moore reported having no financial disclosures.
SOURCE: Moore et al. AAAP 2017. Paper session A1.
SAN DIEGO – compared with their peers who had no psychiatric or addiction diagnosis, according to results of a large VA database study.
“Our patients sit at the center of two public health crises,” David T. Moore, MD, PhD, said at the annual meeting and scientific symposium of the American Academy of Addiction Psychiatry. “One is the incredibly reduced life expectancy for adults with mental illnesses. There may be a 20-year reduced life expectancy. Their mortality rate for chronic medical conditions such as heart disease and COPD is increased by two- to fourfold, and is associated with greater hospitalization rates, longer lengths of stay, and increased readmission rates. The second part of this crisis is the incredible cost associated with medical hospitalizations. About 1 in every $20 in the entire U.S. economy goes toward inpatient medical hospitalization.”
The final analysis included 952,252 veterans with a mental illness and 1,064,140 without a psychiatric or addiction diagnosis. Dr. Moore reported that among veterans with mental illness, 100,191 (7.1%) were hospitalized on a medical unit at some point during the study period, compared with only 31,759 (2.9%) of veterans with no psychiatric or addiction diagnosis. The Charlson Comorbidity Index was significantly increased in veterans with mental health diagnoses, compared with those who did not have mental health diagnoses.
“There was more tobacco use; they were much more likely to receive an opioid prescription; [and] they used more outpatient medical services, whether it be primary care visits or specialty care visits,” Dr. Moore said of the hospitalized veterans. “They are sicker, but they also use more outpatient medical services, suggesting that they do not lack access to adequate outpatient medical care.”
Next, the researchers performed a subset analysis of all veterans with any mental health diagnosis. Compared with those who were not hospitalized during the study period, those hospitalized were older (a mean age of 52 vs. 45 years, respectively), more likely to be homeless (21% vs. 12%; relative risk, 1.8), and receive a VA pension, which is correlated with poor functioning and disability (7.1% vs. 2.9%; RR, 2.4). The only psychiatric disorder correlated with correlated with medical hospitalization was personality disorder (6.3% vs. 3.7%; RR, 1.7). The researchers also observed that a higher proportion of hospitalized patients had an alcohol use disorder (34% vs. 23%; RR, 1.7) and drug use (31% vs. 17%; RR, 1.8). “The use of benzodiazepines had the greatest relative risk for medical hospitalizations,” Dr. Moore said.
In unadjusted analyses, veterans with the following diagnoses were at increased risk for hospitalization: drug use disorder (odds ratio, 4.58), alcohol use disorder (OR, 3.84), bipolar disorder (OR, 3.29), major depressive disorder (OR, 3.04), schizophrenia (OR, 2.98), and posttraumatic stress disorder (OR, 1.91).
After adjusting for other health factors in multiple regression, alcohol use disorder was the only psychiatric or addiction disorder strongly associated with medical hospitalizations (OR, 1.95). After accounting for sociodemographic characteristics, medical comorbidities, use of outpatient medical services, and alcohol use, the OR for medical hospitalizations among veterans with mental illness decreased from 2.52 to 1.24.
“It looks like a lot of the folks with drug use disorders who are being hospitalized may also have co-occurring alcohol use disorders,” Dr. Moore said. “That may partly account for their hospitalization risk.”
He concluded that the study’s overall findings “leave us with a lot of questions about what to do. The majority of patients who are hospitalized have a mental illness. Is this a setting where we should be engaging them and trying to connect them with outpatient services?”
Dr. Moore reported having no financial disclosures.
SOURCE: Moore et al. AAAP 2017. Paper session A1.
REPORTING FROM AAAP
Key clinical point: In order to improve the health of veterans with mental illness, more efforts are needed to target alcohol use.
Major finding: Among veterans with mental illnesses, 7.1% were hospitalized, compared with 2.9% of their peers with no psychiatric or addiction diagnosis.
Study details: A database analysis of 952,252 veterans with a mental illness and 1,064,140 without a psychiatric or addiction diagnosis.
Disclosures: Dr. Moore reported having no financial disclosures.
Source: Moore et al. AAAP 2017. Paper session A1.
Long-acting naltrexone tied to fewer detox admissions, more treatment engagement
SAN DIEGO – Persistence with long-acting naltrexone treatment was associated with significantly reduced detoxification admissions and concurrent engagement in treatment, a retrospective study of veterans found.
The Food and Drug Administration has approved long-acting naltrexone hydrochloride for the treatment of alcohol use disorder (AUD) and opioid use disorder (OUD), but little is known about the patients who initiate and continue this therapy, Grace Chang, MD, MPH, said at the annual meeting and scientific symposium of the American Academy of Addiction Psychiatry. In an effort to evaluate the characteristics associated with long-term naltrexone treatment persistence, Dr. Chang, chief of consultation-liaison psychiatry at the VA Boston Healthcare System, and her associates studied 154 veterans who initiated long-acting naltrexone therapy for AUD or OUD between 2014 and 2015.
Among those who died in the study year after the index shot, no difference in the average number of long-acting naltrexone injections was observed (5.3 in the OUD group vs. 6.8 in the AUD group, P = .62). There was a long interval between the last known injection of long-acting naltrexone and the date of death (381 days in the OUD group vs. 326 days in the AUD group, P = .67). The cause of death was unknown in 57% of cases, while 21% were from natural causes, and 21% were tied to overdose or self-inflicted injury.
The rates of posttraumatic stress disorder in the OUD and AUD groups were about the same, but the AUD patients had higher rates of mood disorder and anxiety disorder. The AUD patients had higher rates of cardiac disease and pulmonary disease, while the OUD patients had higher rates of musculoskeletal problems. Renal disease was relatively rare in both groups. “The AUD patients started using their drug of choice earlier, but the groups were comparable in being able to attain over 2 years of abstinence at some point,” said Dr. Chang, who is also professor of psychiatry at Harvard Medical School, Boston. “Both groups had about two detoxes in the year prior to the index shot.
“ We were also curious about what other drugs they were using prior to starting naltrexone. The OUD patients used more stimulants, more cocaine, and more sedative hypnotics. Smoking was endemic in both of these groups, as was marijuana use.”
The average interval from the time patients in both groups made the decision to start long-acting naltrexone to the time they received their first shot was about 2 months. “It’s safe to say that no one rushed into this,” Dr. Chang said. “The mean number of injections for the study year was about 5, which was very high, and the range was from 1 to 13, which suggests that some people got a shot every single month. Both of the groups had similar numbers of individual treatment sessions, which was about one. They had almost two residential admissions after the index shot and at least one other appointment with a prescribing psychiatrist.”
On Poisson regression analysis, factors associated with increased medication persistence included percent service connection and number of individual, group, residential, and other treatment modalities attended (P less than .05 for all associations). For each unit increase in the number of individual sessions, the number of long-acting naltrexone shots would go up by 7%, Dr. Chang said. For each unit increase in the number of group sessions, the number of long-acting naltrexone therapy shots would go up by 5%, while for each residential admission session, the number of long-acting naltrexone shots would go up by 14%.
“Keep in mind that our patients had an average of two residential admissions, so the number of shots went up by 28%,” she said. “For the number of other appointments with the addiction psychiatrist, the number of shots went up by 6%.”
Dr. Chang acknowledged certain limitations of the study, including its retrospective design and the relatively small sample size. “What was good to see is that the number of inpatient detox admissions was halved, when comparing the year before and the year after the shot,” she said. “This was highly statistically significant. Concurrent psychosocial treatment is highly important in the treatment persistence with this modality.”
Dr. Chang reported having no relevant financial disclosures.
SAN DIEGO – Persistence with long-acting naltrexone treatment was associated with significantly reduced detoxification admissions and concurrent engagement in treatment, a retrospective study of veterans found.
The Food and Drug Administration has approved long-acting naltrexone hydrochloride for the treatment of alcohol use disorder (AUD) and opioid use disorder (OUD), but little is known about the patients who initiate and continue this therapy, Grace Chang, MD, MPH, said at the annual meeting and scientific symposium of the American Academy of Addiction Psychiatry. In an effort to evaluate the characteristics associated with long-term naltrexone treatment persistence, Dr. Chang, chief of consultation-liaison psychiatry at the VA Boston Healthcare System, and her associates studied 154 veterans who initiated long-acting naltrexone therapy for AUD or OUD between 2014 and 2015.
Among those who died in the study year after the index shot, no difference in the average number of long-acting naltrexone injections was observed (5.3 in the OUD group vs. 6.8 in the AUD group, P = .62). There was a long interval between the last known injection of long-acting naltrexone and the date of death (381 days in the OUD group vs. 326 days in the AUD group, P = .67). The cause of death was unknown in 57% of cases, while 21% were from natural causes, and 21% were tied to overdose or self-inflicted injury.
The rates of posttraumatic stress disorder in the OUD and AUD groups were about the same, but the AUD patients had higher rates of mood disorder and anxiety disorder. The AUD patients had higher rates of cardiac disease and pulmonary disease, while the OUD patients had higher rates of musculoskeletal problems. Renal disease was relatively rare in both groups. “The AUD patients started using their drug of choice earlier, but the groups were comparable in being able to attain over 2 years of abstinence at some point,” said Dr. Chang, who is also professor of psychiatry at Harvard Medical School, Boston. “Both groups had about two detoxes in the year prior to the index shot.
“ We were also curious about what other drugs they were using prior to starting naltrexone. The OUD patients used more stimulants, more cocaine, and more sedative hypnotics. Smoking was endemic in both of these groups, as was marijuana use.”
The average interval from the time patients in both groups made the decision to start long-acting naltrexone to the time they received their first shot was about 2 months. “It’s safe to say that no one rushed into this,” Dr. Chang said. “The mean number of injections for the study year was about 5, which was very high, and the range was from 1 to 13, which suggests that some people got a shot every single month. Both of the groups had similar numbers of individual treatment sessions, which was about one. They had almost two residential admissions after the index shot and at least one other appointment with a prescribing psychiatrist.”
On Poisson regression analysis, factors associated with increased medication persistence included percent service connection and number of individual, group, residential, and other treatment modalities attended (P less than .05 for all associations). For each unit increase in the number of individual sessions, the number of long-acting naltrexone shots would go up by 7%, Dr. Chang said. For each unit increase in the number of group sessions, the number of long-acting naltrexone therapy shots would go up by 5%, while for each residential admission session, the number of long-acting naltrexone shots would go up by 14%.
“Keep in mind that our patients had an average of two residential admissions, so the number of shots went up by 28%,” she said. “For the number of other appointments with the addiction psychiatrist, the number of shots went up by 6%.”
Dr. Chang acknowledged certain limitations of the study, including its retrospective design and the relatively small sample size. “What was good to see is that the number of inpatient detox admissions was halved, when comparing the year before and the year after the shot,” she said. “This was highly statistically significant. Concurrent psychosocial treatment is highly important in the treatment persistence with this modality.”
Dr. Chang reported having no relevant financial disclosures.
SAN DIEGO – Persistence with long-acting naltrexone treatment was associated with significantly reduced detoxification admissions and concurrent engagement in treatment, a retrospective study of veterans found.
The Food and Drug Administration has approved long-acting naltrexone hydrochloride for the treatment of alcohol use disorder (AUD) and opioid use disorder (OUD), but little is known about the patients who initiate and continue this therapy, Grace Chang, MD, MPH, said at the annual meeting and scientific symposium of the American Academy of Addiction Psychiatry. In an effort to evaluate the characteristics associated with long-term naltrexone treatment persistence, Dr. Chang, chief of consultation-liaison psychiatry at the VA Boston Healthcare System, and her associates studied 154 veterans who initiated long-acting naltrexone therapy for AUD or OUD between 2014 and 2015.
Among those who died in the study year after the index shot, no difference in the average number of long-acting naltrexone injections was observed (5.3 in the OUD group vs. 6.8 in the AUD group, P = .62). There was a long interval between the last known injection of long-acting naltrexone and the date of death (381 days in the OUD group vs. 326 days in the AUD group, P = .67). The cause of death was unknown in 57% of cases, while 21% were from natural causes, and 21% were tied to overdose or self-inflicted injury.
The rates of posttraumatic stress disorder in the OUD and AUD groups were about the same, but the AUD patients had higher rates of mood disorder and anxiety disorder. The AUD patients had higher rates of cardiac disease and pulmonary disease, while the OUD patients had higher rates of musculoskeletal problems. Renal disease was relatively rare in both groups. “The AUD patients started using their drug of choice earlier, but the groups were comparable in being able to attain over 2 years of abstinence at some point,” said Dr. Chang, who is also professor of psychiatry at Harvard Medical School, Boston. “Both groups had about two detoxes in the year prior to the index shot.
“ We were also curious about what other drugs they were using prior to starting naltrexone. The OUD patients used more stimulants, more cocaine, and more sedative hypnotics. Smoking was endemic in both of these groups, as was marijuana use.”
The average interval from the time patients in both groups made the decision to start long-acting naltrexone to the time they received their first shot was about 2 months. “It’s safe to say that no one rushed into this,” Dr. Chang said. “The mean number of injections for the study year was about 5, which was very high, and the range was from 1 to 13, which suggests that some people got a shot every single month. Both of the groups had similar numbers of individual treatment sessions, which was about one. They had almost two residential admissions after the index shot and at least one other appointment with a prescribing psychiatrist.”
On Poisson regression analysis, factors associated with increased medication persistence included percent service connection and number of individual, group, residential, and other treatment modalities attended (P less than .05 for all associations). For each unit increase in the number of individual sessions, the number of long-acting naltrexone shots would go up by 7%, Dr. Chang said. For each unit increase in the number of group sessions, the number of long-acting naltrexone therapy shots would go up by 5%, while for each residential admission session, the number of long-acting naltrexone shots would go up by 14%.
“Keep in mind that our patients had an average of two residential admissions, so the number of shots went up by 28%,” she said. “For the number of other appointments with the addiction psychiatrist, the number of shots went up by 6%.”
Dr. Chang acknowledged certain limitations of the study, including its retrospective design and the relatively small sample size. “What was good to see is that the number of inpatient detox admissions was halved, when comparing the year before and the year after the shot,” she said. “This was highly statistically significant. Concurrent psychosocial treatment is highly important in the treatment persistence with this modality.”
Dr. Chang reported having no relevant financial disclosures.
REPORTING FROM AAAP
Key clinical point: The number of inpatient detoxification admissions was halved when the year before and the year after the start of long-term naltrexone were compared.
Major finding: Factors associated with increased medication persistence included percent service connection and the number of individual, group, residential, and other treatment modalities attended (P less than .05 for all associations).
Study details: A retrospective analysis of 154 veterans who initiated long-acting naltrexone therapy between 2014 and 2015.
Disclosures: Dr. Chang reported having no relevant financial disclosures.
Early intervention key to treating substance use disorders
SAN DIEGO – Intervening early can positively affect outcomes for patients struggling with substance use disorders, regardless of their current stage of development and place in the life cycle, speaker after speaker said at the annual meeting and scientific symposium of the American Academy of Addiction Psychiatry.
The prenatal/perinatal period represents a high-risk window for the kindling and precipitation of substance use disorders (SUDs), because of the stress of pregnancy, delivery, recovery, and the newly assumed parenting role. “Offspring who are exposed in utero have an earlier age of initiation of substance use, as well as a greater risk of substance use disorders later on in life,” said Justine Wittenaur Welsh, MD, director of the Emory Adolescent Substance Use Treatment Services, Atlanta. “We as treatment providers need to start to think about how to screen for these individuals. What types of early intervention can we provide, and how do we integrate this into our treatment planning?”
According to data on current illicit drug use among pregnant women from the Substance Abuse and Mental Health Services Administration, the risk is highest among those aged 15-17 years (14.6%), followed by those aged 18-25 years (8.6%), and 26-44 years (3.2%). “We also know that rates of substance use are higher in the first trimester, compared with the second and the third,” said Dr. Welsh, who holds a faculty position in the department of psychiatry and behavioral sciences at Emory University. “But unfortunately, a significant number of pregnant women return to substance use after they deliver. This is really important for treatment providers, to intervene early before a return to substance use. We know that improving the postnatal environment does reduce the risk of substance use, even in individuals who have in utero exposures.”
SUDs confer a host of adverse effects to both the baby and the mother. “With tobacco, although there are a significant number of poisonous chemicals in cigarettes that the baby would be exposed to, we believe it’s the carbon monoxide and the nicotine exposure that confers the most known damage,” Dr. Welsh said. In utero exposure to cigarettes increases the likelihood to initiate smoking during adolescence by twofold (Neurotoxicol Teratol. 2005;27[2]:267-77), and a dose-response relationship has been observed between prenatal smoking and psychiatric hospitalization for substance abuse in offspring (Am J Psychiatry. 2002;159[1]:48-54). In utero exposure to cigarettes also increases the risk for offspring cigarette use. “The exposure to greater than a half-pack of cigarettes per day has a 5.5-fold increased risk for early cigarette experimentation, while exposure to one pack per day or more is associated with twice the risk of developing nicotine dependence,” she said.
As for in utero alcohol exposure, consuming greater than or equal to three drinks is associated with an alcohol disorder at age 21 (odds ratio, 2.95) if the exposure occurred in early pregnancy; Arch Gen Psychiatry. 2006;63[9]:1009-16). In utero alcohol exposure also has been more predictive of adolescent alcohol use than family history. “It’s also been associated with an increased number of abuse/dependency symptoms in offspring, for nicotine, alcohol, and illicit drugs,” Dr. Welsh said. “It has also been associated with an increased risk of cigarette use and substance use disorders in offspring.”
In utero cannabis exposure has been associated with a twofold increased risk of tobacco and marijuana use later in life (Addiction 2006;101[9]:1313-22), as well as with a twofold increased risk of smoking cigarettes daily and of using marijuana during adolescence. In utero cocaine exposure has been associated with a twofold increased risk of using tobacco, a 2.2-fold increased risk of using alcohol, and a 1.8-fold risk of using marijuana, as well as a 2.1-fold increased risk of having an SUD by age 17. “Prenatal exposure and postnatal parent/caregiver cocaine use is uniquely related to teen use of cocaine at age 14,” Dr. Welsh said. “In addition, exposure in the first trimester is associated with earlier marijuana and alcohol initiation.”
Real-world barriers to SUD treatment in adolescents include a lack of coordination between treatment resources, fear of losing custody of children, shame and stigma, concerns about criminal prosecution, domestic violence, and other obstacles such as transportation, finances, and child care. Dr. Welsh pointed out that pregnant women with SUDs usually receive prenatal care and addiction treatment from different providers. “We should be thinking about an integrated treatment model to improve maternal and prenatal care for patients using substances prior to or during pregnancy,” she said. “Some sites have developed combined maternity care units as a way to reduce some of these barriers to treatment. We also need to be thinking about the infants themselves. In order to counter the drug-exposed child’s early disadvantages, service providers must be prepared to intervene early, focusing on things like nutrition, psychomotor assessments, early educational needs assessments, as well as modification of existing treatment services for people with in utero exposures. This can be a difficult population to treat.”
One resource for addressing fetal alcohol spectrum disorders that she recommended is Treatment Improvement Protocol 58, published by Substance Abuse and Mental Health Services Administration. She described one young adult with significant substance use issues who was diagnosed with fetal alcohol syndrome as a child. “This young adult didn’t know about the FAS diagnosis,” Dr. Welsh said. “I expressed to the mother that, ‘this is an ethical dilemma. I’m treating someone and I know this directly impacts my treatment planning. They have a real-world diagnosis that I feel they have a right to know about.’ It made me think: If I think it’s so important that this young adult knows the diagnosis, why are we not screening for it in our general patient populations more often?
“As child psychiatrists we often ask, ‘Were there any in utero exposures?’ When treating adults, I’m asking about family history, but I’m not asking about in utero exposures. This may not be information that they’re privy to, but it’s worth starting a conversation about.”
, a 14-session, evidence-based curriculum that addresses parenting skills, children’s social skills, and family life skills training, are among the treatment options aimed at decreasing the risk of substance use progression in offspring.
‘Adolescents indeed care about their health’
During a separate presentation, Peter Jackson, MD, a psychiatrist at the University of Vermont Medical Center, Burlington, noted that an estimated 3.4 million adolescents in the United States meet criteria for an SUD, but fewer than 10% enter treatment each year. Of those who do enter treatment, 50% relapse within 6 months.
“It’s not the same story for illicit drugs, unfortunately, and that’s largely due to marijuana,” Dr. Jackson said. He noted that adolescent cannabis use is inversely proportional to how dangerous they perceive it to be. “This is evidence that adolescents indeed care about their health,” he said. “They use when they think it’s safe, and they use less when they think it’s unsafe.” Recent Monitoring the Future data also demonstrate that e-cigarette use is outpacing cigarette use among 8th, 10th, and 12th graders, while the past-year misuse of acetaminophen/hydrocodone (Vicodin) among 12th graders has dropped dramatically in the past 5 years. So has misuse of all prescription opioids among 12th graders despite high opioid overdose rates among adults.
Adolescents are more likely to be secretive about their substance use, compared with older adults. “Also, with many substances, especially alcohol, they are more likely to use in a binge pattern,” Dr. Jackson said. “They haven’t accumulated as many negative consequences from their use, so voluntarily seeking treatment is less common than in adults. They’re most often referred through the justice department or legal channels.”
Screening instruments to consider using include the CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble), which has been validated as an adolescent-specific screening instrument. A score of two or more has a strong correlation with meeting criteria for an SUD. The American Academy of Pediatrics recommends the Screening, Brief Intervention, and Referral to Treatment (SBIRT), though this intervention has not been as rigorously evaluated in adolescents, compared with adults.
Dr. Jackson frowned on the notion perpetuated by some parents and caregivers that novelty seeking behavior involving alcohol and other substances is okay if it’s controlled somehow, with statements such as, “I just make sure they’ve given up their car keys and make sure it stays in my own basement. That way nobody leaves here drunk.”
“I think we can do better than that,” Dr. Jackson said.
Well-validated behavioral treatment approaches for adolescent patients include the adolescent community reinforcement approach (A-CRA); cognitive-behavioral therapy (particularly in groups); motivational enhancement therapy (MET); contingency management, and 12-step facilitation.
“Colloquially, in pop culture, we’ve been pressed on this message at times that adolescents don’t care what their parents think; they only care what their peers think,” Dr. Jackson said. “That’s not true from literature we’ve seen, so we need to put the family back in its important place.”
In a meta-analysis of promising behavioral approaches for adolescent SUD, five out of six found to have promising to excellent empirical support were family-based therapies: multidimensional family therapy, functional family therapy, multisystemic family therapy, behavioral strategic family therapy, and family behavior therapy (J Child and Adolesc Psychology. 2008;37[1]:236-59). “That’s a huge take-home point when working with adolescents: Involve the family,” Dr. Jackson said. “As providers, do we have a tendency to side only with the parent or side only with the adolescent? If we do, we should be cautious and thoughtful, because we can very effectively work with both parties. If you have an adolescent who shows up [for counseling] but then walks right out the door, you still have a parent, maybe two parents or other concerned loved ones sitting there. You still have a target for intervention.”
Even if the adolescent never returns to your office, he continued, clinicians can do an intervention with the family to statistically decrease the SUD for the adolescent. “That’s really promising,” he said. In adults, the best evidence for treatment engagement of a loved one following these family-specific interventions is for the Community Reinforcement and Family Training (CRAFT) method (64%-74%), followed by the Johnson Intervention (23%-30%) and Al-Anon/Nar-Anon facilitation (13%-29%). These interventions are being studied more specifically in adolescents and young adults.
A key tip for parents of teens coping with substance abuse is the old adage actions speak louder than words. “You can tell your child not to smoke marijuana until you’re blue in the face, but then if you go out on the back porch and smoke marijuana, that’s a really bad message for behavior change,” Dr. Jackson said. “Words also speak louder than no words. Some parents have never told their adolescent children what their opinion is, and that they’re concerned. Maybe those parents have been convinced that adolescents don’t care what they think. In fact, they do care what they think.”
Once engaged, older adults do well
Among older adults, triggers for SUDs vary considerably from that of their younger counterparts. “We tend to think of this as a population that carries a lot of wisdom and has the coping skills to deal with life,” Olivera J. Bogunovic, MD, a psychiatrist who is medical director of ambulatory services in the division of alcohol and drug abuse at McClean Hospital, Belmont, Mass., said during a separate presentation. “In fact, this is a very vulnerable population at increased risk of mood disorders. For example, many men spend their careers working 60 or 80 hours a week, then they stop working. What is there for them? They sometimes turn to substance abuse. Similarly, older women who lose a loved one may turn to drinking. There’s a lot of room for prevention. The good news is that this group of patients is very responsive to treatment. Once engaged, they do very well.”
Nicotine is the chief addictive substance affecting older adults (17%), followed by alcohol (12% in a binge capacity, dependence 1%), illicit drugs (1.8%), and medications (1.6% for pain medications and 12% on benzodiazepines). Alcohol use disorders encompass a spectrum of problems for this patient population, including at-risk drinking, problem drinking, and dependence. Presentations, complications, and consequences are wide-ranging. “We sometimes miss the symptoms of alcohol use disorders when patients present in emergency rooms,” Dr. Bogunovic said. “Unfortunately, if it’s not treated initially it results in serious medical comorbidities and complications.”
The National Institute on Drug Abuse recommends that adults consume no more than two drinks per day, but the quantity is even lower for elderly. “For men it is no more than one drink per day, while for women it’s questionable if that one drink per day is even recommended,” Dr. Bogunovic said. The prevalence of at-risk drinking among older adults ranges from 3% to 25% and the rates for problem drinking range from 2.2% to 9.6%. Alcohol dependence rates, meanwhile, range from 2% to 3% among men and less than 1% among women.
Cross-sectional data indicate a low prevalence of illicit drug use in older adults, but longitudinal data from the National Survey on Drug Abuse and others suggest an increased use of cannabis and prescription opioids. “A lot of people do not think about opioid use disorders in the elderly,” she said. “The prevalence rate in methadone clinics is less than 2%. However, with the epidemic crisis we’re seeing opioid use disorders in the elderly. What’s important to know is that they also respond to medications for treatment, more so with suboxone than with naltrexone, as we know those patients sometimes have complications that need to be treated with pain medication.”
Elderly patients constitute 13% of the population yet they account for 30% of prescriptions, mainly benzodiazepines and prescription opioids. “Two-thirds of patients who are struggling with SUDs struggled with an SUD at some point in their youth,” said Dr. Bogunovic, who holds a faculty position in the department of psychiatry at Harvard Medical School, Boston. “They continue to use for longer periods of time, with some intermittent periods of sobriety. Of those 15% who do have an alcohol use problem, they are prescribed benzodiazepines. That can be a lethal combination, because there is a combined effect of both alcohol and benzodiazepines that can result in hip fractures, subdural hematomas, and other medical comorbidity.”
Risk factors for development of alcohol use disorder in elderly include physiologic changes in the way alcohol is metabolized; gender, family history, or prior personal history of alcohol use disorder; having a concomitant psychiatric disorder; and having a chronic medical illness, such as severe arthritis. Compared with their male peers, older women generally drink less often and less heavily, but they are more likely to start drinking heavily later in life. Older men face an increased risk of alcohol-related problems tied to cumulative use over the years.
“Social factors also play a role, so it’s important to perform a skilled diagnostic interview and a psychiatric evaluation but also to evaluate the motivational stage of change, because that’s the right moment to do the intervention, knowing what the patient’s values are,” she said. Recommended screenings include the Short Michigan Alcoholism Screening Instrument–Geriatric Version (SMAST-G), the SBIRT, the CAGE-AID, and the Opioid Risk Tool. Compliance with treatment tends to be greater in older adults, compared with their younger counterparts. “They don’t like a confrontational approach, so it’s important to communicate with empathy in a straightforward manner and pay attention to what is important to patients and motivate them,” she noted. “Involve family members or other social support whenever possible.”
Relapses are common, but clinicians should encourage patients to continue treatment, “because they can do very well,” Dr. Bogunovic emphasized. “And we can offer them a good life after that.”
Dr. Welsh disclosed that she has consulted for GW Pharmaceuticals and that she has received training fees from Chestnut Health Systems. Dr. Jackson and Dr. Bogunovic reported having no financial disclosures.
SAN DIEGO – Intervening early can positively affect outcomes for patients struggling with substance use disorders, regardless of their current stage of development and place in the life cycle, speaker after speaker said at the annual meeting and scientific symposium of the American Academy of Addiction Psychiatry.
The prenatal/perinatal period represents a high-risk window for the kindling and precipitation of substance use disorders (SUDs), because of the stress of pregnancy, delivery, recovery, and the newly assumed parenting role. “Offspring who are exposed in utero have an earlier age of initiation of substance use, as well as a greater risk of substance use disorders later on in life,” said Justine Wittenaur Welsh, MD, director of the Emory Adolescent Substance Use Treatment Services, Atlanta. “We as treatment providers need to start to think about how to screen for these individuals. What types of early intervention can we provide, and how do we integrate this into our treatment planning?”
According to data on current illicit drug use among pregnant women from the Substance Abuse and Mental Health Services Administration, the risk is highest among those aged 15-17 years (14.6%), followed by those aged 18-25 years (8.6%), and 26-44 years (3.2%). “We also know that rates of substance use are higher in the first trimester, compared with the second and the third,” said Dr. Welsh, who holds a faculty position in the department of psychiatry and behavioral sciences at Emory University. “But unfortunately, a significant number of pregnant women return to substance use after they deliver. This is really important for treatment providers, to intervene early before a return to substance use. We know that improving the postnatal environment does reduce the risk of substance use, even in individuals who have in utero exposures.”
SUDs confer a host of adverse effects to both the baby and the mother. “With tobacco, although there are a significant number of poisonous chemicals in cigarettes that the baby would be exposed to, we believe it’s the carbon monoxide and the nicotine exposure that confers the most known damage,” Dr. Welsh said. In utero exposure to cigarettes increases the likelihood to initiate smoking during adolescence by twofold (Neurotoxicol Teratol. 2005;27[2]:267-77), and a dose-response relationship has been observed between prenatal smoking and psychiatric hospitalization for substance abuse in offspring (Am J Psychiatry. 2002;159[1]:48-54). In utero exposure to cigarettes also increases the risk for offspring cigarette use. “The exposure to greater than a half-pack of cigarettes per day has a 5.5-fold increased risk for early cigarette experimentation, while exposure to one pack per day or more is associated with twice the risk of developing nicotine dependence,” she said.
As for in utero alcohol exposure, consuming greater than or equal to three drinks is associated with an alcohol disorder at age 21 (odds ratio, 2.95) if the exposure occurred in early pregnancy; Arch Gen Psychiatry. 2006;63[9]:1009-16). In utero alcohol exposure also has been more predictive of adolescent alcohol use than family history. “It’s also been associated with an increased number of abuse/dependency symptoms in offspring, for nicotine, alcohol, and illicit drugs,” Dr. Welsh said. “It has also been associated with an increased risk of cigarette use and substance use disorders in offspring.”
In utero cannabis exposure has been associated with a twofold increased risk of tobacco and marijuana use later in life (Addiction 2006;101[9]:1313-22), as well as with a twofold increased risk of smoking cigarettes daily and of using marijuana during adolescence. In utero cocaine exposure has been associated with a twofold increased risk of using tobacco, a 2.2-fold increased risk of using alcohol, and a 1.8-fold risk of using marijuana, as well as a 2.1-fold increased risk of having an SUD by age 17. “Prenatal exposure and postnatal parent/caregiver cocaine use is uniquely related to teen use of cocaine at age 14,” Dr. Welsh said. “In addition, exposure in the first trimester is associated with earlier marijuana and alcohol initiation.”
Real-world barriers to SUD treatment in adolescents include a lack of coordination between treatment resources, fear of losing custody of children, shame and stigma, concerns about criminal prosecution, domestic violence, and other obstacles such as transportation, finances, and child care. Dr. Welsh pointed out that pregnant women with SUDs usually receive prenatal care and addiction treatment from different providers. “We should be thinking about an integrated treatment model to improve maternal and prenatal care for patients using substances prior to or during pregnancy,” she said. “Some sites have developed combined maternity care units as a way to reduce some of these barriers to treatment. We also need to be thinking about the infants themselves. In order to counter the drug-exposed child’s early disadvantages, service providers must be prepared to intervene early, focusing on things like nutrition, psychomotor assessments, early educational needs assessments, as well as modification of existing treatment services for people with in utero exposures. This can be a difficult population to treat.”
One resource for addressing fetal alcohol spectrum disorders that she recommended is Treatment Improvement Protocol 58, published by Substance Abuse and Mental Health Services Administration. She described one young adult with significant substance use issues who was diagnosed with fetal alcohol syndrome as a child. “This young adult didn’t know about the FAS diagnosis,” Dr. Welsh said. “I expressed to the mother that, ‘this is an ethical dilemma. I’m treating someone and I know this directly impacts my treatment planning. They have a real-world diagnosis that I feel they have a right to know about.’ It made me think: If I think it’s so important that this young adult knows the diagnosis, why are we not screening for it in our general patient populations more often?
“As child psychiatrists we often ask, ‘Were there any in utero exposures?’ When treating adults, I’m asking about family history, but I’m not asking about in utero exposures. This may not be information that they’re privy to, but it’s worth starting a conversation about.”
, a 14-session, evidence-based curriculum that addresses parenting skills, children’s social skills, and family life skills training, are among the treatment options aimed at decreasing the risk of substance use progression in offspring.
‘Adolescents indeed care about their health’
During a separate presentation, Peter Jackson, MD, a psychiatrist at the University of Vermont Medical Center, Burlington, noted that an estimated 3.4 million adolescents in the United States meet criteria for an SUD, but fewer than 10% enter treatment each year. Of those who do enter treatment, 50% relapse within 6 months.
“It’s not the same story for illicit drugs, unfortunately, and that’s largely due to marijuana,” Dr. Jackson said. He noted that adolescent cannabis use is inversely proportional to how dangerous they perceive it to be. “This is evidence that adolescents indeed care about their health,” he said. “They use when they think it’s safe, and they use less when they think it’s unsafe.” Recent Monitoring the Future data also demonstrate that e-cigarette use is outpacing cigarette use among 8th, 10th, and 12th graders, while the past-year misuse of acetaminophen/hydrocodone (Vicodin) among 12th graders has dropped dramatically in the past 5 years. So has misuse of all prescription opioids among 12th graders despite high opioid overdose rates among adults.
Adolescents are more likely to be secretive about their substance use, compared with older adults. “Also, with many substances, especially alcohol, they are more likely to use in a binge pattern,” Dr. Jackson said. “They haven’t accumulated as many negative consequences from their use, so voluntarily seeking treatment is less common than in adults. They’re most often referred through the justice department or legal channels.”
Screening instruments to consider using include the CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble), which has been validated as an adolescent-specific screening instrument. A score of two or more has a strong correlation with meeting criteria for an SUD. The American Academy of Pediatrics recommends the Screening, Brief Intervention, and Referral to Treatment (SBIRT), though this intervention has not been as rigorously evaluated in adolescents, compared with adults.
Dr. Jackson frowned on the notion perpetuated by some parents and caregivers that novelty seeking behavior involving alcohol and other substances is okay if it’s controlled somehow, with statements such as, “I just make sure they’ve given up their car keys and make sure it stays in my own basement. That way nobody leaves here drunk.”
“I think we can do better than that,” Dr. Jackson said.
Well-validated behavioral treatment approaches for adolescent patients include the adolescent community reinforcement approach (A-CRA); cognitive-behavioral therapy (particularly in groups); motivational enhancement therapy (MET); contingency management, and 12-step facilitation.
“Colloquially, in pop culture, we’ve been pressed on this message at times that adolescents don’t care what their parents think; they only care what their peers think,” Dr. Jackson said. “That’s not true from literature we’ve seen, so we need to put the family back in its important place.”
In a meta-analysis of promising behavioral approaches for adolescent SUD, five out of six found to have promising to excellent empirical support were family-based therapies: multidimensional family therapy, functional family therapy, multisystemic family therapy, behavioral strategic family therapy, and family behavior therapy (J Child and Adolesc Psychology. 2008;37[1]:236-59). “That’s a huge take-home point when working with adolescents: Involve the family,” Dr. Jackson said. “As providers, do we have a tendency to side only with the parent or side only with the adolescent? If we do, we should be cautious and thoughtful, because we can very effectively work with both parties. If you have an adolescent who shows up [for counseling] but then walks right out the door, you still have a parent, maybe two parents or other concerned loved ones sitting there. You still have a target for intervention.”
Even if the adolescent never returns to your office, he continued, clinicians can do an intervention with the family to statistically decrease the SUD for the adolescent. “That’s really promising,” he said. In adults, the best evidence for treatment engagement of a loved one following these family-specific interventions is for the Community Reinforcement and Family Training (CRAFT) method (64%-74%), followed by the Johnson Intervention (23%-30%) and Al-Anon/Nar-Anon facilitation (13%-29%). These interventions are being studied more specifically in adolescents and young adults.
A key tip for parents of teens coping with substance abuse is the old adage actions speak louder than words. “You can tell your child not to smoke marijuana until you’re blue in the face, but then if you go out on the back porch and smoke marijuana, that’s a really bad message for behavior change,” Dr. Jackson said. “Words also speak louder than no words. Some parents have never told their adolescent children what their opinion is, and that they’re concerned. Maybe those parents have been convinced that adolescents don’t care what they think. In fact, they do care what they think.”
Once engaged, older adults do well
Among older adults, triggers for SUDs vary considerably from that of their younger counterparts. “We tend to think of this as a population that carries a lot of wisdom and has the coping skills to deal with life,” Olivera J. Bogunovic, MD, a psychiatrist who is medical director of ambulatory services in the division of alcohol and drug abuse at McClean Hospital, Belmont, Mass., said during a separate presentation. “In fact, this is a very vulnerable population at increased risk of mood disorders. For example, many men spend their careers working 60 or 80 hours a week, then they stop working. What is there for them? They sometimes turn to substance abuse. Similarly, older women who lose a loved one may turn to drinking. There’s a lot of room for prevention. The good news is that this group of patients is very responsive to treatment. Once engaged, they do very well.”
Nicotine is the chief addictive substance affecting older adults (17%), followed by alcohol (12% in a binge capacity, dependence 1%), illicit drugs (1.8%), and medications (1.6% for pain medications and 12% on benzodiazepines). Alcohol use disorders encompass a spectrum of problems for this patient population, including at-risk drinking, problem drinking, and dependence. Presentations, complications, and consequences are wide-ranging. “We sometimes miss the symptoms of alcohol use disorders when patients present in emergency rooms,” Dr. Bogunovic said. “Unfortunately, if it’s not treated initially it results in serious medical comorbidities and complications.”
The National Institute on Drug Abuse recommends that adults consume no more than two drinks per day, but the quantity is even lower for elderly. “For men it is no more than one drink per day, while for women it’s questionable if that one drink per day is even recommended,” Dr. Bogunovic said. The prevalence of at-risk drinking among older adults ranges from 3% to 25% and the rates for problem drinking range from 2.2% to 9.6%. Alcohol dependence rates, meanwhile, range from 2% to 3% among men and less than 1% among women.
Cross-sectional data indicate a low prevalence of illicit drug use in older adults, but longitudinal data from the National Survey on Drug Abuse and others suggest an increased use of cannabis and prescription opioids. “A lot of people do not think about opioid use disorders in the elderly,” she said. “The prevalence rate in methadone clinics is less than 2%. However, with the epidemic crisis we’re seeing opioid use disorders in the elderly. What’s important to know is that they also respond to medications for treatment, more so with suboxone than with naltrexone, as we know those patients sometimes have complications that need to be treated with pain medication.”
Elderly patients constitute 13% of the population yet they account for 30% of prescriptions, mainly benzodiazepines and prescription opioids. “Two-thirds of patients who are struggling with SUDs struggled with an SUD at some point in their youth,” said Dr. Bogunovic, who holds a faculty position in the department of psychiatry at Harvard Medical School, Boston. “They continue to use for longer periods of time, with some intermittent periods of sobriety. Of those 15% who do have an alcohol use problem, they are prescribed benzodiazepines. That can be a lethal combination, because there is a combined effect of both alcohol and benzodiazepines that can result in hip fractures, subdural hematomas, and other medical comorbidity.”
Risk factors for development of alcohol use disorder in elderly include physiologic changes in the way alcohol is metabolized; gender, family history, or prior personal history of alcohol use disorder; having a concomitant psychiatric disorder; and having a chronic medical illness, such as severe arthritis. Compared with their male peers, older women generally drink less often and less heavily, but they are more likely to start drinking heavily later in life. Older men face an increased risk of alcohol-related problems tied to cumulative use over the years.
“Social factors also play a role, so it’s important to perform a skilled diagnostic interview and a psychiatric evaluation but also to evaluate the motivational stage of change, because that’s the right moment to do the intervention, knowing what the patient’s values are,” she said. Recommended screenings include the Short Michigan Alcoholism Screening Instrument–Geriatric Version (SMAST-G), the SBIRT, the CAGE-AID, and the Opioid Risk Tool. Compliance with treatment tends to be greater in older adults, compared with their younger counterparts. “They don’t like a confrontational approach, so it’s important to communicate with empathy in a straightforward manner and pay attention to what is important to patients and motivate them,” she noted. “Involve family members or other social support whenever possible.”
Relapses are common, but clinicians should encourage patients to continue treatment, “because they can do very well,” Dr. Bogunovic emphasized. “And we can offer them a good life after that.”
Dr. Welsh disclosed that she has consulted for GW Pharmaceuticals and that she has received training fees from Chestnut Health Systems. Dr. Jackson and Dr. Bogunovic reported having no financial disclosures.
SAN DIEGO – Intervening early can positively affect outcomes for patients struggling with substance use disorders, regardless of their current stage of development and place in the life cycle, speaker after speaker said at the annual meeting and scientific symposium of the American Academy of Addiction Psychiatry.
The prenatal/perinatal period represents a high-risk window for the kindling and precipitation of substance use disorders (SUDs), because of the stress of pregnancy, delivery, recovery, and the newly assumed parenting role. “Offspring who are exposed in utero have an earlier age of initiation of substance use, as well as a greater risk of substance use disorders later on in life,” said Justine Wittenaur Welsh, MD, director of the Emory Adolescent Substance Use Treatment Services, Atlanta. “We as treatment providers need to start to think about how to screen for these individuals. What types of early intervention can we provide, and how do we integrate this into our treatment planning?”
According to data on current illicit drug use among pregnant women from the Substance Abuse and Mental Health Services Administration, the risk is highest among those aged 15-17 years (14.6%), followed by those aged 18-25 years (8.6%), and 26-44 years (3.2%). “We also know that rates of substance use are higher in the first trimester, compared with the second and the third,” said Dr. Welsh, who holds a faculty position in the department of psychiatry and behavioral sciences at Emory University. “But unfortunately, a significant number of pregnant women return to substance use after they deliver. This is really important for treatment providers, to intervene early before a return to substance use. We know that improving the postnatal environment does reduce the risk of substance use, even in individuals who have in utero exposures.”
SUDs confer a host of adverse effects to both the baby and the mother. “With tobacco, although there are a significant number of poisonous chemicals in cigarettes that the baby would be exposed to, we believe it’s the carbon monoxide and the nicotine exposure that confers the most known damage,” Dr. Welsh said. In utero exposure to cigarettes increases the likelihood to initiate smoking during adolescence by twofold (Neurotoxicol Teratol. 2005;27[2]:267-77), and a dose-response relationship has been observed between prenatal smoking and psychiatric hospitalization for substance abuse in offspring (Am J Psychiatry. 2002;159[1]:48-54). In utero exposure to cigarettes also increases the risk for offspring cigarette use. “The exposure to greater than a half-pack of cigarettes per day has a 5.5-fold increased risk for early cigarette experimentation, while exposure to one pack per day or more is associated with twice the risk of developing nicotine dependence,” she said.
As for in utero alcohol exposure, consuming greater than or equal to three drinks is associated with an alcohol disorder at age 21 (odds ratio, 2.95) if the exposure occurred in early pregnancy; Arch Gen Psychiatry. 2006;63[9]:1009-16). In utero alcohol exposure also has been more predictive of adolescent alcohol use than family history. “It’s also been associated with an increased number of abuse/dependency symptoms in offspring, for nicotine, alcohol, and illicit drugs,” Dr. Welsh said. “It has also been associated with an increased risk of cigarette use and substance use disorders in offspring.”
In utero cannabis exposure has been associated with a twofold increased risk of tobacco and marijuana use later in life (Addiction 2006;101[9]:1313-22), as well as with a twofold increased risk of smoking cigarettes daily and of using marijuana during adolescence. In utero cocaine exposure has been associated with a twofold increased risk of using tobacco, a 2.2-fold increased risk of using alcohol, and a 1.8-fold risk of using marijuana, as well as a 2.1-fold increased risk of having an SUD by age 17. “Prenatal exposure and postnatal parent/caregiver cocaine use is uniquely related to teen use of cocaine at age 14,” Dr. Welsh said. “In addition, exposure in the first trimester is associated with earlier marijuana and alcohol initiation.”
Real-world barriers to SUD treatment in adolescents include a lack of coordination between treatment resources, fear of losing custody of children, shame and stigma, concerns about criminal prosecution, domestic violence, and other obstacles such as transportation, finances, and child care. Dr. Welsh pointed out that pregnant women with SUDs usually receive prenatal care and addiction treatment from different providers. “We should be thinking about an integrated treatment model to improve maternal and prenatal care for patients using substances prior to or during pregnancy,” she said. “Some sites have developed combined maternity care units as a way to reduce some of these barriers to treatment. We also need to be thinking about the infants themselves. In order to counter the drug-exposed child’s early disadvantages, service providers must be prepared to intervene early, focusing on things like nutrition, psychomotor assessments, early educational needs assessments, as well as modification of existing treatment services for people with in utero exposures. This can be a difficult population to treat.”
One resource for addressing fetal alcohol spectrum disorders that she recommended is Treatment Improvement Protocol 58, published by Substance Abuse and Mental Health Services Administration. She described one young adult with significant substance use issues who was diagnosed with fetal alcohol syndrome as a child. “This young adult didn’t know about the FAS diagnosis,” Dr. Welsh said. “I expressed to the mother that, ‘this is an ethical dilemma. I’m treating someone and I know this directly impacts my treatment planning. They have a real-world diagnosis that I feel they have a right to know about.’ It made me think: If I think it’s so important that this young adult knows the diagnosis, why are we not screening for it in our general patient populations more often?
“As child psychiatrists we often ask, ‘Were there any in utero exposures?’ When treating adults, I’m asking about family history, but I’m not asking about in utero exposures. This may not be information that they’re privy to, but it’s worth starting a conversation about.”
, a 14-session, evidence-based curriculum that addresses parenting skills, children’s social skills, and family life skills training, are among the treatment options aimed at decreasing the risk of substance use progression in offspring.
‘Adolescents indeed care about their health’
During a separate presentation, Peter Jackson, MD, a psychiatrist at the University of Vermont Medical Center, Burlington, noted that an estimated 3.4 million adolescents in the United States meet criteria for an SUD, but fewer than 10% enter treatment each year. Of those who do enter treatment, 50% relapse within 6 months.
“It’s not the same story for illicit drugs, unfortunately, and that’s largely due to marijuana,” Dr. Jackson said. He noted that adolescent cannabis use is inversely proportional to how dangerous they perceive it to be. “This is evidence that adolescents indeed care about their health,” he said. “They use when they think it’s safe, and they use less when they think it’s unsafe.” Recent Monitoring the Future data also demonstrate that e-cigarette use is outpacing cigarette use among 8th, 10th, and 12th graders, while the past-year misuse of acetaminophen/hydrocodone (Vicodin) among 12th graders has dropped dramatically in the past 5 years. So has misuse of all prescription opioids among 12th graders despite high opioid overdose rates among adults.
Adolescents are more likely to be secretive about their substance use, compared with older adults. “Also, with many substances, especially alcohol, they are more likely to use in a binge pattern,” Dr. Jackson said. “They haven’t accumulated as many negative consequences from their use, so voluntarily seeking treatment is less common than in adults. They’re most often referred through the justice department or legal channels.”
Screening instruments to consider using include the CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble), which has been validated as an adolescent-specific screening instrument. A score of two or more has a strong correlation with meeting criteria for an SUD. The American Academy of Pediatrics recommends the Screening, Brief Intervention, and Referral to Treatment (SBIRT), though this intervention has not been as rigorously evaluated in adolescents, compared with adults.
Dr. Jackson frowned on the notion perpetuated by some parents and caregivers that novelty seeking behavior involving alcohol and other substances is okay if it’s controlled somehow, with statements such as, “I just make sure they’ve given up their car keys and make sure it stays in my own basement. That way nobody leaves here drunk.”
“I think we can do better than that,” Dr. Jackson said.
Well-validated behavioral treatment approaches for adolescent patients include the adolescent community reinforcement approach (A-CRA); cognitive-behavioral therapy (particularly in groups); motivational enhancement therapy (MET); contingency management, and 12-step facilitation.
“Colloquially, in pop culture, we’ve been pressed on this message at times that adolescents don’t care what their parents think; they only care what their peers think,” Dr. Jackson said. “That’s not true from literature we’ve seen, so we need to put the family back in its important place.”
In a meta-analysis of promising behavioral approaches for adolescent SUD, five out of six found to have promising to excellent empirical support were family-based therapies: multidimensional family therapy, functional family therapy, multisystemic family therapy, behavioral strategic family therapy, and family behavior therapy (J Child and Adolesc Psychology. 2008;37[1]:236-59). “That’s a huge take-home point when working with adolescents: Involve the family,” Dr. Jackson said. “As providers, do we have a tendency to side only with the parent or side only with the adolescent? If we do, we should be cautious and thoughtful, because we can very effectively work with both parties. If you have an adolescent who shows up [for counseling] but then walks right out the door, you still have a parent, maybe two parents or other concerned loved ones sitting there. You still have a target for intervention.”
Even if the adolescent never returns to your office, he continued, clinicians can do an intervention with the family to statistically decrease the SUD for the adolescent. “That’s really promising,” he said. In adults, the best evidence for treatment engagement of a loved one following these family-specific interventions is for the Community Reinforcement and Family Training (CRAFT) method (64%-74%), followed by the Johnson Intervention (23%-30%) and Al-Anon/Nar-Anon facilitation (13%-29%). These interventions are being studied more specifically in adolescents and young adults.
A key tip for parents of teens coping with substance abuse is the old adage actions speak louder than words. “You can tell your child not to smoke marijuana until you’re blue in the face, but then if you go out on the back porch and smoke marijuana, that’s a really bad message for behavior change,” Dr. Jackson said. “Words also speak louder than no words. Some parents have never told their adolescent children what their opinion is, and that they’re concerned. Maybe those parents have been convinced that adolescents don’t care what they think. In fact, they do care what they think.”
Once engaged, older adults do well
Among older adults, triggers for SUDs vary considerably from that of their younger counterparts. “We tend to think of this as a population that carries a lot of wisdom and has the coping skills to deal with life,” Olivera J. Bogunovic, MD, a psychiatrist who is medical director of ambulatory services in the division of alcohol and drug abuse at McClean Hospital, Belmont, Mass., said during a separate presentation. “In fact, this is a very vulnerable population at increased risk of mood disorders. For example, many men spend their careers working 60 or 80 hours a week, then they stop working. What is there for them? They sometimes turn to substance abuse. Similarly, older women who lose a loved one may turn to drinking. There’s a lot of room for prevention. The good news is that this group of patients is very responsive to treatment. Once engaged, they do very well.”
Nicotine is the chief addictive substance affecting older adults (17%), followed by alcohol (12% in a binge capacity, dependence 1%), illicit drugs (1.8%), and medications (1.6% for pain medications and 12% on benzodiazepines). Alcohol use disorders encompass a spectrum of problems for this patient population, including at-risk drinking, problem drinking, and dependence. Presentations, complications, and consequences are wide-ranging. “We sometimes miss the symptoms of alcohol use disorders when patients present in emergency rooms,” Dr. Bogunovic said. “Unfortunately, if it’s not treated initially it results in serious medical comorbidities and complications.”
The National Institute on Drug Abuse recommends that adults consume no more than two drinks per day, but the quantity is even lower for elderly. “For men it is no more than one drink per day, while for women it’s questionable if that one drink per day is even recommended,” Dr. Bogunovic said. The prevalence of at-risk drinking among older adults ranges from 3% to 25% and the rates for problem drinking range from 2.2% to 9.6%. Alcohol dependence rates, meanwhile, range from 2% to 3% among men and less than 1% among women.
Cross-sectional data indicate a low prevalence of illicit drug use in older adults, but longitudinal data from the National Survey on Drug Abuse and others suggest an increased use of cannabis and prescription opioids. “A lot of people do not think about opioid use disorders in the elderly,” she said. “The prevalence rate in methadone clinics is less than 2%. However, with the epidemic crisis we’re seeing opioid use disorders in the elderly. What’s important to know is that they also respond to medications for treatment, more so with suboxone than with naltrexone, as we know those patients sometimes have complications that need to be treated with pain medication.”
Elderly patients constitute 13% of the population yet they account for 30% of prescriptions, mainly benzodiazepines and prescription opioids. “Two-thirds of patients who are struggling with SUDs struggled with an SUD at some point in their youth,” said Dr. Bogunovic, who holds a faculty position in the department of psychiatry at Harvard Medical School, Boston. “They continue to use for longer periods of time, with some intermittent periods of sobriety. Of those 15% who do have an alcohol use problem, they are prescribed benzodiazepines. That can be a lethal combination, because there is a combined effect of both alcohol and benzodiazepines that can result in hip fractures, subdural hematomas, and other medical comorbidity.”
Risk factors for development of alcohol use disorder in elderly include physiologic changes in the way alcohol is metabolized; gender, family history, or prior personal history of alcohol use disorder; having a concomitant psychiatric disorder; and having a chronic medical illness, such as severe arthritis. Compared with their male peers, older women generally drink less often and less heavily, but they are more likely to start drinking heavily later in life. Older men face an increased risk of alcohol-related problems tied to cumulative use over the years.
“Social factors also play a role, so it’s important to perform a skilled diagnostic interview and a psychiatric evaluation but also to evaluate the motivational stage of change, because that’s the right moment to do the intervention, knowing what the patient’s values are,” she said. Recommended screenings include the Short Michigan Alcoholism Screening Instrument–Geriatric Version (SMAST-G), the SBIRT, the CAGE-AID, and the Opioid Risk Tool. Compliance with treatment tends to be greater in older adults, compared with their younger counterparts. “They don’t like a confrontational approach, so it’s important to communicate with empathy in a straightforward manner and pay attention to what is important to patients and motivate them,” she noted. “Involve family members or other social support whenever possible.”
Relapses are common, but clinicians should encourage patients to continue treatment, “because they can do very well,” Dr. Bogunovic emphasized. “And we can offer them a good life after that.”
Dr. Welsh disclosed that she has consulted for GW Pharmaceuticals and that she has received training fees from Chestnut Health Systems. Dr. Jackson and Dr. Bogunovic reported having no financial disclosures.
EXPERT ANALYSIS FROM AAAP