Perspectives on overgrowth syndromes

Previous studies evaluated the prudent use and potential over use of drug screens in clinical decision making. However, the percentage of emergency physicians who can correctly identify which drugs are found on their hospital's basic drug screens has not been established. Results of physician closed-ended questionnaires were compared to the results of a telephone survey with each physician's individual hospital laboratory. Eighty-one (35.7%) of 227 emergency physicians responded. Four (4.9%) correctly identified what was on their individual institution's urine drug screens and 17 (21%) correctly identified what was on serum screens. In other results, 74.3% erroneously relayed that all benzodiazepines can be found on urine drug screens and 46.3% incorrectly answered that acetaminophen would be found on basic quantitative serum screens. Drug screen results can be misinterpreted if the drugs the physician expects to be screened for, and what is actually screened for, are not the same. Pharmacy and laboratory personnel have a responsibility to keep the physician informed of drug screen issues. They should be proactive in advising physicians of changes in drug testing and new drug screening methods or by providing reports on the occurrence of false positive results.     

Thoracolumbar burst fractures: correlation between post-traumatic spinal canal stenosis and initial neurological deficit

We sought to define the prevalence of positive drug screens in adolescent victims of major trauma. The records of 125 consecutive adolescent patients presenting with major trauma to an inner-city trauma center during the last nine months of 1990 were reviewed. Eighty-five (68%) received urine toxicology screens for alcohol and illicit drugs. Twenty-one (25%) of screened patients had a positive urine drug screen. The most commonly detected drugs were alcohol, cocaine, and opiates. Gender, race, mechanism of injury, mental status at presentation, injury severity score, and revised trauma score were not associated with a positive drug screen. We conclude that: 1) 25% of screened adolescent victims of major trauma seen at an inner-city trauma center had positive urine toxicology screens for alcohol or illicit drugs. 2) As none of the study variables was associated with a positive drug screen, selective drug screening cannot be supported.     

Patterns of current and lifetime substance use in schizophrenia

A structured interview and standardized rating scales were used to assess a sample of 194 outpatients with schizophrenia in a regional Australian mental health service for substance use, abuse, and dependence. Case manager assessments and urine drug screens were also used to determine substance use. Additional measurements included demographic information, history of criminal charges, symptom self-reports, personal hopefulness, and social support. The sample was predominantly male and showed relative instability in accommodations, and almost half had a history of criminal offenses, most frequently drug or alcohol related. The 6-month and lifetime prevalence of substance abuse or dependence was 26.8 and 59.8 percent, respectively, with alcohol, cannabis, and amphetamines being the most commonly abused substances. Current users of alcohol comprised 77.3 percent and current users of other nonprescribed substances (excluding tobacco and caffeine) comprised 29.9 percent of the sample. Rates of tobacco and caffeine consumption were high. There was a moderate degree of concordance between case manager determinations of a substance-use problem and research diagnoses. Subjects with current or lifetime diagnoses of substance abuse/dependence were predominantly young, single males with higher rates of criminal charges; however, there was no evidence of increased rates of suicide attempts, hospital admissions, or daily doses of antipsychotic drugs in these groups compared with subjects with no past or current diagnosis of substance abuse or dependence. Subjects with a current diagnosis of substance use were younger at first treatment and currently more symptomatic than those with no past or current substance use diagnosis. The picture emerging from this study replicates the high rate of substance abuse in persons with schizophrenia reported in North American studies but differs from the latter in finding a slightly different pattern of substances abused (i.e., absence of cocaine), reflecting relative differences in the availability of certain drugs.     

Factors affecting agreement between severely mentally ill alcohol abusers' and collaterals' reports of alcohol and other substance abuse.

This study examined subject-collateral reports of alcohol use among a sample of 167 dually diagnosed individuals seeking outpatient treatment at a community mental health clinic. All subjects met Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) criteria for a schizophrenia-spectrum or bipolar disorder and for alcohol abuse or dependence. Subjects were recruited within 2 weeks of treatment entry and completed measures of cognitive functioning, alcohol dependence severity, psychiatric symptoms, and quantity and frequency of substance use over the previous 60 days using the Timeline Follow-Back interview (L. C. Sobell & M. B. Sobell, 1996). They also provided a urine sample, which was screened for recent drug use. Collateral interviews were conducted by phone and included an assessment of the subject's alcohol and drug use over the same 60-day period. Collaterals also reported their confidence in the accuracy of their reports. Overall, the results indicated generally poor subject-collateral agreement. However, subject-collateral agreement appeared better for those individuals (n = 97) with negative urine drug screens. The most consistent predictor of subject-collateral discrepancy scores was subjects' recent drug use. Recommendations for enhancing the validity of self-reports of substance use in a severely mentally ill population are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Polymedication and medication compliance in patients with chronic non-malignant pain

Most reports of polymedication among patients with chronic non-malignant pain have relied only on the patient's statements which have been proven to be unreliable regarding actual drug consumption. This study investigates the incidence of polymedication and medication compliance in these patients by applying objective methods. One-hundred-nine consecutive patients predominantly with facial, neuropathic or back pain were interviewed about present medication at first admission to the pain clinic. Reports were verified by toxicological urine screening, mainly with thin-layer chromatography (TLC) and gas chromatography-mass spectrometry (GC-MS) coupling. Follow-up investigations of 61 patients were conducted within 1 and 24 months after beginning therapy. Polymedication--here defined as daily intake of 3 or more preparations--was found in 41 patients (38%) in the initial investigation. In only 74 patients (68%) did the results of urine screening correspond with their reports: 23 patients (21%) concealed the consumption of drugs, and 2 patients (2%) did not take their medications. Ten cases were not interpretable. Fifty-four percent of the drugs concealed were psychotropic substances, mostly benzodiazepines, and 42% were analgesic combinations, partly with psychotropic additives. Drug intake was concealed significantly more often with polypharmacy which was occurring more frequently in patients with headache or facial pain, longer duration of pain, young age, psychiatric diagnosis and history of substance abuse. Patients with initial non-compliance were more likely to conceal drug consumption in follow-up investigations as well (P = 0.05). Therefore, screening for medication compliance in patients with chronic non-malignant pain is recommended, especially in those with the abovementioned risk factors.(ABSTRACT TRUNCATED AT 250 WORDS)     

Trajectories of PTSD and substance use disorders in a longitudinal study of personality disorders.

This study investigated the co-occurrence of posttraumatic stress disorder (PTSD) and substance use disorders (SUDs) in a sample (N = 668) recruited for personality disorders and followed longitudinally as part of the Collaborative Longitudinal Personality Disorders Study. The study both examined rates of co-occurring disorders at baseline and temporal relationships between PTSD and substance use disorders over 4 years. Subjects with a lifetime history of PTSD at baseline had significantly higher rates of SUDs (both alcohol and drug) than subjects without PTSD. Latent class growth analysis, a relatively novel approach used to analyze trajectories and identify homogeneous subgroups of participant on the basis of probabilities of PTSD and SUD over time, identified 6 classes, which were compared with respect to a set of functioning and personality variables. The most consistent differences were observed between the group that displayed low probabilities of both SUD and PTSD and the group that displayed high probabilities of both. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Contingency management for accurate predictions of urinalysis test results and lack of correspondence with self-reported drug use among polydrug abusers.

Contingency management procedures have proven effective in the treatment of drug-dependent patients. These procedures, however, often require frequent urine testing, which is too costly for community treatment programs. To make urine testing procedures more cost effective, the feasibility of reinforcing accurate predictions of urine drug screen (UDS) results was evaluated. Participants made extremely accurate UDS predictions, particularly when they made drug-positive predictions, regardless of whether predictions were reinforced. However, self reports of recent drug use had poor correspondence with predictions of UDS results. Results suggested that if programs only tested samples predicted to be drug free, considerable cost savings could be incurred. Further research is needed to determine if validity would be enhanced by using a proportion of costs saved to provide nominal reinforcement when samples were verified to be drug free. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Non-prescribed drug use during methadone treatment by clinic- and community-based patients

We investigated the efficacy of methadone maintenance treatment in clinic-based (n = 10) and community-based (n = 10) patients by studying the relationships between dose, plasma concentrations of methadone and non-prescribed drug-use using logistic regression. We found that clinic-based patients had significantly reduced odds of having a urine sample test positive for illicit drugs when compared to community-based patients (OR = 0.20; 95% confidence interval 0.10-0.38: p < 0.001). There was no relationship between either methadone dose or plasma methadone concentration and testing positive for non-prescribed drugs (including cocaine, cannabis, amphetamine, ecstasy, benzodiazepines). We looked specifically at the misuse of opiate drugs. Location was again important and clinic-based patients had significantly reduced odds of having a urine sample test positive for opiate drugs (OR = 0.36, 95% confidence interval 0.18-0.71: p approximately 0.004). Opiate drug use in our patients was also significantly related to plasma methadone concentration, increasing noticeably when the drug concentration < 0.48 nmol/L (p approximately 0.04). We found no relationship between methadone dose and odds of having a positive urine drug test in either clinic- or community-based patients.     

Multisite randomized trial of behavioral interventions for women with co-occurring PTSD and substance use disorders.

The authors compared the effectiveness of the Seeking Safety group, cognitive–behavioral treatment for substance use disorder and posttraumatic stress disorder (PTSD), to an active comparison health education group (Women’s Health Education [WHE]) within the National Institute on Drug Abuse’s Clinical Trials Network. The authors randomized 353 women to receive 12 sessions of Seeking Safety (M = 6.2 sessions) or WHE (M = 6.0 sessions) with follow-up assessment 1 week and 3, 6, and 12 months posttreatment. Primary outcomes were the Clinician Administered PTSD Scale (CAPS), the PTSD Symptom Scale–Self Report (PSS-SR), and a substance use inventory (self-reported abstinence and percentage of days of use over 7 days). Intention-to-treat analysis showed large, clinically significant reductions in CAPS and PSS-SR symptoms (d = 1.94 and 1.12, respectively) but no reliable difference between conditions. Substance use outcomes were not significantly different over time between the two treatments and at follow-up showed no significant change from baseline. Study results do not favor Seeking Safety over WHE as an adjunct to substance use disorder treatment for women with PTSD and reflect considerable opportunity to improve clinical outcomes in community-based treatments for these co-occurring conditions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Reliability and validity of 6-month timeline reports of cocaine and heroin use in a methadone population.

59 persons addicted to heroin and maintained by methadone reported on daily heroin and cocaine use during 2 timeline calendar interviews administered 6 wks apart. Retrospective reports covering 6 mo were compared with urine samples taken weekly during the interval. Test–retest correlations were high and timeline estimates of drug use frequency were significantly correlated with the frequency of drug-positive urine results. Thus, timeline reports of drug-use frequency appeared both reliable and valid. Ss either over- or under-reported by an average of about 15%, and they did not identify instances of drug use with greater than chance accuracy when particular episodes of drug use occurred. These results support the use of timeline reports to make group comparisons of long-term drug use, but suggest that timeline data should not be used to identify specific drug-use episodes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Substance use disorder and posttraumatic stress disorder comorbidity: Addiction and psychiatric treatment rates.

This study compares substance use disorder (SUD) patients with and without a comorbid diagnosis of posttraumatic stress disorder (PTSD) on their use of addiction and psychiatric services over the 6-month period before an inpatient substance abuse admission. Compared with non-PTSD patients, PTSD patients had a greater number of hospital overnights for addiction treatment. Given no significant between-groups differences on any substance use indexes, PTSD patients apparently overuse costly inpatient addiction services. Despite their greater rates of psychiatric comorbidity, PTSD patients did not receive treatment for psychiatric problems at greater rates than did non-PTSD patients. Among PTSD patients, use of PTSD treatment was low. Assessment of psychiatric comorbidity and referral to treatment targeting co-occurring PTSD and other disorders are suggested as possible ways to reduce the high treatment costs associated with SUD-PTSD comorbidity. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Bladder tumours detected on screening: results at 7 years

Current illicit drug and alcohol users were identified by laboratory evaluation of urine samples from nonpsychotic patients without a primary clinical diagnosis of a substance use disorder seen in a psychiatric emergency room. Urine screens revealed that 32 of 93 nonpsychotic patients (34 percent) had used a substance just before visiting the emergency room. Compared with nonusers, users were more often Caucasian females with adjustment disorders who admitted their previous substance use. The prevalence of concurrent use among nonpsychotic patients was higher than among psychotic patients. Nonpsychotic and psychotic users differed in gender, marital status, level of suicidality, self-report of use, the clinician's suspicion of use, use of seclusion during the visit, admitting status, level of care, and disposition.     

Coping strategy use following computerized cognitive-behavioral therapy for substance use disorders.

Coping strategies are emerging as a predictor of treatment outcome for substance users and may be particularly important among computerized and self-change approaches. We used data from a randomized clinical trial of a computer-based version of cognitive–behavioral therapy (CBT4CBT) to: (1) examine the association between observer ratings of coping skills and self-reported coping strategies; (2) evaluate whether participants assigned to the CBT4CBT program reported greater use of coping strategies compared with those not exposed to the program; and (3) examine the differential effect of coping strategies by treatment group on drug-related outcomes. Individuals (N = 77) seeking treatment for substance dependence at a community-based outpatient substance abuse treatment facility were recruited and randomized to receive treatment-as-usual (TAU), or TAU plus CBT4CBT, with the Coping Strategies Scale administered at baseline and posttreatment. Self-reported coping strategy use was strongly correlated with observer ratings on a role-play assessment of coping skills. Although no significant group differences were found across time for coping strategy use, results suggested that as coping strategy use increased, drug use decreased, and this relationship was stronger for participants who received CBT4CBT. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Functional associations among trauma, PTSD, and substance-related disorders

This review article presents several potential functional pathways which may explain the frequent co-occurrence of PTSD and substance abuse disorders in traumatized individuals. Emerging empirical studies which have examined these potential pathways are reviewed, including studies on relative order of onset, PTSD patients' perceptions of various drug effects, comparisons of PTSD patients with and without comorbid substance use disorders, and correlational studies examining the relations between severity of specific PTSD symptom clusters and substance disorder symptoms. Research on the acute and chronic effects of alcohol and other drugs on cognitive and physiological variables relevant to PTSD intrusion and arousal symptoms is reviewed to highlight ways in which these two sets of PTSD symptoms might be functionally interrelated with substance abuse. Finally, based on these findings, recommendations are made for the treatment of individuals with comorbid PTSD-substance use disorders.     

Posttraumatic stress disorder and substance abuse relapse among women: A pilot study.

The authors compared substance-dependent women with and without a comorbid diagnosis of posttraumatic stress disorder (PTSD) on their alcohol and drug use after inpatient substance abuse treatment. Participants were 31 women with a diagnosed substance dependence disorder. Forty-two percent of the entire sample (n?=?13) met DSM-III—R criteria for current PTSD. Follow-up interviews revealed that approximately 70% of the women relapsed during the 3 months posttreatment. Although rates of relapse did not significantly differ by PTSD status, PTSD women were found to relapse more quickly than non-PTSD women. Although preliminary, study findings suggest that the presence of PTSD among substance-dependent women may have prognostic significance as well as important treatment implications. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Two-year posttreatment functioning and coping of substance abuse patients with posttraumatic stress disorder.

The 2-year posttreatment course of substance abuse patients with posttraumatic stress disorder (PTSD) was examined in a multisite evaluation of Veterans Affairs substance abuse treatment. Substance abuse patients with PTSD (SUD-PTSD) were compared with patients with only substance use disorder (SUD only) and patients with other comorbid psychiatric diagnoses (SUD-PSY) on outcomes during the 2 years after treatment. SUD-PTSD patients had a poorer long-term course on substance use, psychological symptom, and psychosocial outcomes than SUD-only and SUD-PSY patients. Coping methods were examined as mediators of the effect of PTSD on substance use outcomes. Greater use of avoidance coping styles and less use of approach coping at 1 year partially accounted for the association of PTSD with 2-year substance use. Treatments that address multiple domains of functioning and focus on alternative coping strategies are recommended for this population. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Comparing self-reported cocaine use with repeated urine tests in outpatient cocaine abusers.

Sixty-one participants in outpatient therapy for cocaine dependence provided urine samples and self-reports of cocaine use 3 times a week for 4 weeks. Participants later gave a retrospective self-report of cocaine use for the month on the Addiction Severity Index (ASI). Comparisons with urine test values revealed substantial underreporting of cocaine use on both measures, and results from the 2 forms of self-report were only imperfectly correlated. More participants admitted to at least 1 cocaine use episode on the ASI than on the repeated self-reports, but the repeated reports provided a more accurate index of the relative frequency of cocaine use during the month. Self-reports can enhance cocaine use detection when urines are infrequently collected and can help determine whether consecutive positive urine samples represent elevated metabolite levels from a single drug use episode. However, self-reports cannot substitute for regular urine sampling. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Family risk factors and adolescent substance use: Moderation effects for temperament dimensions.

This research tested for moderation in the relation of family risk factors (parent–child conflict, family life events, and parental substance use) to adolescent substance use (tobacco, alcohol, and marijuana). A sample of 1,810 participants was surveyed at the mean age of 11.5 years and followed with 2 yearly assessments. Temperament dimensions were assessed with the Revised Dimensions of Temperament Survey and the Emotionality, Activity, and Sociability Inventory. Multiple-group latent growth analyses indicated moderation occurred through (a) alteration of effects of parental variables on the adolescent substance use intercept and on the peer substance use intercept and slope and (b) alteration of the effect of the peer substance use intercept on the adolescent substance use slope. The impact of parental risk factors was decreased among participants with higher task attentional orientation and positive emotionality (resilience effect) and was increased among participants with higher activity level and negative emotionality (vulnerability effect). Results from self-report data were corroborated by independent teacher reports. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The validity of self-reported cocaine use in two groups of cocaine abusers.

To evaluate the validity of 2 self-report methods for estimating cocaine use, Timeline Follow-Back (TLFB) and weekly calendar reports from 65 patients with a cocaine use disorder were compared with urine drug test results. The TLFB showed fair to moderate validity, and the weekly calendar showed moderate to high validity in measuring the frequency of cocaine use. Similar results were obtained when the self-report measures were used to time specific cocaine use episodes. In addition to evidence for superiority of the weekly calendar, the validity of self-reports was inversely related to the percentage of positive urine test results. Furthermore, there was some evidence that validity increased as the time window over which the comparisons were drawn increased. Given the central role of self-reports in the clinical and research evaluation of drug use, factors affecting their validity warrant further investigation. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Urine drug testing for social service agencies. A Canadian experience

The introduction of urine drug testing for this program has been considered a success by the social services agencies in Nova Scotia for the following reasons: 1. The results of urine drug testing have been accepted by the Family Courts of Nova Scotia because the urine collection and testing are performed with chain of custody procedures from collection to reporting and the analysis includes confirmation of all positive immunoassay screening tests. 2. Urine drug testing (with established screening and confirmation cut-offs) provides an objective indication of recent drug use compared with relying on self-reporting of drug use. 3. Urine drug testing is believed to be a deterrent to drug use because several individuals with a history of drug use have consistently tested negative for 6 to 12 months (30% of the clients). 4. Some clients with a history of substance abuse are successful in becoming drug free with the support of the social workers and the deterrent effect of random drug testing.