Drug Addiction and Alcoholism

Introduction and Aims.Practice nurses (PN) are an alternative workforce for cessation support in primary care, but their role and effectiveness is underdeveloped and underresearched. This study evaluated a model of smoking cessation intervention in Australian general practice based on PNs. Smokers were identified by their general practitioner (GP) and referred to the PN for cessation support over four counselling visits and offered free nicotine patches.Design and Methods.Pre- and post-study using mixed quantitative and qualitative methods. Cessation outcomes were collected by patient self-report at 6 months. Semistructured interviews were conducted with PNs and GPs to provide qualitative data on the acceptability of the model.Results.The project involved 31 PNs, 35 GPs and 498 patients from 19 general practices in Sydney. Mean age of participating patients was 46 years and 61% were female. Mean number of PN counselling visits was 3.1. At 6 month follow up the point prevalence abstinence rate was 22% and continuous abstinence rate was 16%. Participants who had attended for four or more counselling visits with the PN were significantly more likely to quit. PNs and GPs expressed enthusiasm for the PN role in smoking cessation and belief in its value and feasibility.Discussion and Conclusions.Substantial rates of cessation were found in this uncontrolled study and the role was well accepted by PNs and GPs. The model shows promise as a means of providing cessation support in Australian primary care and further research in a randomised trial is warranted. [Zwar NA, Richmond RL, Forlonge G, Hasan I. Feasibility and effectiveness of nurse-delivered smoking cessation counselling combined with nicotine replacement in Australian general practice. Drug Alcohol Rev 2010]

Issues.Treatment seeking for methamphetamine withdrawal is low in Australia. Insufficient knowledge regarding the withdrawal syndrome of methamphetamine and the appropriate management of these symptoms may be a contributing factor to the low treatment attendance.Approach.A systematic review was performed using a range of electronic databases.Key Findings.Common methamphetamine withdrawal symptoms include symptoms relating to depression, agitation, cognitive impairment and fatigue. These symptoms may last anywhere from a few days to a few months. Methamphetamine withdrawal is most commonly undertaken in an outpatient setting, and psychosocial interventions remain the primary treatment approach in Australia. Two withdrawal scales (Amphetamine Withdrawal Questionnaire and Amphetamine Cessation Symptom Assessment) have been validated for the assessment of methamphetamine withdrawal. Only a small number of medications for methamphetamine withdrawal have been investigated, and to date no medications stand out over the others.Implications.Current recommendations for methamphetamine withdrawal tend to be based on clinical opinion and subsequently vary between settings. More research in the area is essential to ensure the development of more targeted, timely and effective withdrawal treatment interventions.Conclusion.The review exposed a lack of well-conducted research targeted towards the management of methamphetamine withdrawal. Further research is essential, and should focus on understanding the nature of methamphetamine withdrawal, its duration, course and effective treatment.[Pennay AE, Lee NK. Putting the call out for more research: The poor evidence base for treating methamphetamine withdrawal. Drug Alcohol Rev 2010]

Introduction and Aims.High-dose methadone has been associated with rate-corrected QT (QTc) prolongation and ‘torsade de pointes’. The Medicines and Healthcare products Regulatory Agency (MHRA) advise electrocardiograms (ECGs) for patients on methadone with heart/liver disease, electrolyte abnormalities, concomitant QT prolonging medications/CYP3A4 inhibitors or prescribed methadone >100 mg daily. The percentage of patients fulfilling MHRA criteria for ECG monitoring and prevalence of QT prolongation in patients who had an ECG was assessed.Design and Methods.A cross-sectional study of opioid-dependent patients prescribed opioid maintenance that completed a screening questionnaire prior to referral for an ECG. MHRA criteria were assessed in the referred group. The automated QTc score was analysed with methadone dose, substance use and QT risk factors.Results.Of 155 patients screened; 57.4% (n = 89) fulfilled MHRA criteria for ECG monitoring (75.5% (n = 117) if cocaine included as QT prolonging drug). Eighty-three (53.5%) had ECGs; 19.3% (n = 16) prescribed QT prolonging medication, 22.9% (n = 19) prescribed >100 mg methadone and 47% (n = 39) used cocaine. Mean QTc interval was 429.0 ms (SD 26.4, 351–489). Eighteen per cent exceeded QTc gender-specific thresholds (?450 ms men and?470 ms women). Linear regression found total daily methadone dose (? = 0.318, P = 0.003) and stimulant use (? = ?0.213, P = 0.043) predictive of QTc length.Discussion.Over half to three-quarters of methadone maintenance patients fulfilled MHRA criteria for ECG monitoring, which has costly implications. QTc prolongation prevalence was 18.1% with no ‘clinically significant’ QTc prolongation >500 ms or torsade de pointes known to be present. Methadone dose and stimulant use were associated with longer QTc intervals. Further research on the clinical management of QTc prolongation with methadone is required.[Mayet S, Gossop M, Lintzeris N, Markides V, Strang J. Methadone maintenance, QTc and torsade de pointes: Who needs an electrocardiogram and what is the prevalence of QTc prolongation? Drug Alcohol Rev 2010]

Issues.Illicit drugs are never far from the media gaze and although identified almost a decade ago as ‘a new battleground’ for the alcohol and other drug (AOD) field there has been limited research examining the role of the news media and its effects on audiences and policy.Approach.This paper draws together media theories from communication literature to examine media functions. We illustrate how each function is relevant for media and drugs research by drawing upon the existing literature examining Australian media coverage during the late 1990s of escalating heroin-related problems and proposed solutions. Key Findings.Media can influence audiences in four key ways: by setting the agenda and defining public interest; framing issues through selection and salience; indirectly shaping individual and community attitudes towards risk; and feeding into political debate and decision making. Each has relevance for the AOD field. For example, media coverage of the escalating heroin-related problems in Australia played a strong role in generating interest in heroin overdoses, framing public discourse in terms of a health and/or criminal issue and affecting political decisions. Implications and Conclusion.Media coverage in relation to illicit drugs can have multifarious effects. Incorporating media communication theories into future research and actions is critical to facilitate understanding of the short- and long-term impacts of media coverage on illicit drugs and the avenues by which the AOD field can mitigate or inform future media debates on illicit drugs.[Lancaster K, Hughes CE, Spicer B, Matthew-Simmons F, Dillon P. Illicit drugs and the media: Models of media effects for use in drug policy research. Drug Alcohol Rev 2010]

Introduction and Aims.Despite considerable success in tobacco control, many teenagers in Australia and other industrialised countries still smoke tobacco. There is mixed evidence on the relative influence of proximal social networks (parents/siblings/peers) on pre- and early-teen smoking, and no research has examined how these influences compare after accounting for school- and community-level effects.The aim of this study was to compare the relative influences of parents, siblings and peers, after accounting for school- and community-level variation in smoking.Design and Methods.A cross-sectional fixed and random effects model of smoking prevalence was used, with individuals (n = 7314) nested within schools (n = 231) nested within communities (n = 30). Grade 6 and 8 students (modal ages 11 and 13 years) completed an on-line survey. Key variables included parent/sibling/peer use. Controls included alcohol involvement, sensation seeking, pro-social beliefs, laws/norms about substance use and school commitment.Results.There was significant variation in smoking at both the school and community levels, supporting the need for a multilevel model. Individual-level predictors accounted for much of the variance at higher levels. The strongest effects were for number of friends who smoke, sibling smoking and alcohol involvement. Smaller significant effects were found for parent smoking. At the community level, socioeconomic disadvantage was significant, but community-level variance in pro-social and drug-related laws/norms was not related to smoking.Discussion and Conclusions.Cross-level interactions were generally non-significant. Early teenage smoking was best explained by sibling and peer smoking, and individual risks largely accounted for the substantial variation observed across schools and communities. In terms of future tobacco control, findings point to the utility of targeting families in disadvantaged communities.[Kelly AB, O'Flaherty M, Connor JP, Homel R, Toumbourou JW, Patton GC, Williams J. The influence of parents, siblings and peers on pre- and early-teen smoking: A multilevel model. Drug Alcohol Rev 2010]

Patients with persistent nerve damage inhaled, and felt better, but did not get high, a Canadian study reports.

A judge in Florida has sharply rebuked P. David Soares over his handling of a case involving a pharmacy accused of being involved in a steroid ring.

Two groups of scientists have developed tests for gene doping in what the World Anti-Doping Agency hailed as a major breakthrough in fighting the next frontier in cheating in sports.

Floyd Landis, who was stripped of the 2006 Tour de France title for doping, is claiming that Lance Armstrong’s former team defrauded the government.

The decision was based on concerns that the country was not doing enough to protect its people from abuses by the police and the military.

Issues. There is a shortage of high-quality intervention-based evidence in the drug and alcohol misuse field. That is, evidence based on replicated effects using rigorous methodology, to establish a causal knowledge base around ethical, cost-effective methods relevant to clinical practice. The knowledge base in this field is limited participant recruitment challenges; difficulty generalising results from single-centre studies; lack of research culture; issues in managing research teams; incentives for descriptive research; and limited expertise in research design and working in multidisciplinary teams. Approach. An Australian national multicentre collaboration is proposed to overcome these barriers, and reduce the burden of drug and alcohol misuse by increasing the number of high-quality clinical trials in this field. It would involve: selecting a representative sample of centres nation-wide with expertise in specific drug and alcohol issues; creating an expert multidisciplinary team to facilitate clinical trials; simultaneous recruitment and implementation of clinical trials across centres; establishing a virtual infrastructure; forming an independent data-integrity and methodology review panel; and attracting and allocating funding for clinical trials. Implications. The ability to allocate funding, the involvement of multidisciplinary experts in drug and alcohol research, and the establishment of infrastructure and procedures are likely to result in the national multicentre group's capacity to prescribe the type of research conducted under its auspices. Conclusion. The proposed initiative is likely to increase the volume of high-quality clinical trials in the Australian drug and alcohol field, a key step towards reducing the burden of drug and alcohol misuse.[Sanson-Fisher R, Brand M, Shakeshaft A, Haber P, Day C, Conigrave K, Mattick R, Lintzeris N, Teesson M. Forming a national multicentre collaboration to conduct clinical trials: Increasing high-quality research in the drug and alcohol field. Drug Alcohol Rev 2010;29;469–474]

Introduction and Aims.Stepped-care has been recommended in the alcohol and other drug field and adopted in a number of service settings, but few research projects have examined this approach. This article aims to describe a pilot trial of stepped-care methods in the treatment of methamphetamine use and depression comorbidity.Design and Methods.An adaptive treatment strategy was developed based on recommendations for stepped-care among methamphetamine users, and incorporating cognitive behaviour therapy/motivational intervention for methamphetamine use and depression. The adaptive treatment strategy was compared with a fixed treatment, comprising an extended integrated cognitive behaviour therapy/motivational intervention treatment. Eighteen participants across two study sites were involved in the trial, and were current users of methamphetamines (at least once weekly) exhibiting at least moderate symptoms of depression (score of 17 or greater on the Beck Depression Inventory II).Results.Treatment delivered via the adaptive treatment (stepped-care) model was associated with improvement in depression and methamphetamine use, however, was not associated with more efficient delivery of psychological treatment to this population relative to the comparison treatment.Discussion and Conclusions.This pilot trial attests to the potential for adaptive treatment strategies to increase the evidence base for stepped-care approaches within the alcohol and other drug field. However, in order for stepped-care treatment in this trial to be delivered efficiently, specific training in the delivery and philosophy of the model is required.[Kay-Lambkin FJ, Baker AL, McKetin R, Lee N. Stepping through treatment: Reflections on an adaptive treatment strategy among methamphetamine users with depression. Drug Alcohol Rev 2010;29;475–482]

Issues. A strong body of evidence guides clinical responses to alcohol and tobacco dependence and there is an emerging evidence base informing responses to cannabis dependence. Nevertheless, there are still important gaps in the evidence base. Approach. Three researchers, with backgrounds in alcohol, tobacco and cannabis research examine current clinical research and practice to identify potential future priorities for clinical research. Key Findings. Clinical outcomes will be improved by research that enhances engagement and retention of a broader range of consumers, especially underrepresented and disadvantaged populations who may not respond as well to mainstream interventions. Research might focus on innovative client recruitment approaches, varying treatment intensity, use of new technology and assertive outreach. Assessment of treatment outcome will be enhanced by strategies that facilitate longer-term follow up of participants, adoption of shared measures of non-abstinent outcomes and extending the focus and outcome measures beyond drug use. Translation of research into clinical strategies will be enhanced by improving links between theory and interventions, increased attention on factors that influence treatment fidelity, designing treatment studies that are relevant to a variety of clinical settings, focussing on clinician characteristics as treatment variables and developing methodologies that address the capacity of participants to discriminate between placebo and pharmacotherapy. Implications. A range of future research priorities have been identified that have the potential to better engage and retain clients in a range of treatment settings and enhance translation of research findings into improved treatment outcomes.[Allsop S, Carter O, Lenton S. Enhancing clinical research with alcohol, tobacco and cannabis problems and dependence. Drug Alcohol Rev 2010;29;483–490]

Introduction and Aims. Staff interactions with their clients are an important factor in the quality of care that is provided to people in drug treatment. Yet there is very little research that addresses staff attitudes or clients' perceptions of discrimination and prejudice by staff with regard to treatment outcomes. This research aimed to assess whether perceptions of discrimination by staff predict drug treatment completion. Design and Methods. The study used a mixed methods approach. Ninety-two clients in residential rehabilitation facilities in Sydney were administered a series of quantitative measures assessing drug history, severity of drug use, treatment history, perceptions of staff discrimination and treatment motivation. Clients were followed up regularly until an outcome (dropout or completion) was obtained for the full sample. Results. Perceptions of discrimination were a significant predictor of treatment completion, with greater perceived discrimination associated with increased dropout. Qualitative interviews with 13 clients and eight health-care workers from these treatment services were then conducted to gain insight into how perceived discrimination may impact on treatment experiences. Clients and staff discussed how they would address the issue of perceived discrimination during the current treatment experience. Discussion and Conclusions. Adopting a mixed methods approach facilitated exploration of the impact of perceived discrimination on treatment from both clients' and health-care workers' perspectives. This methodology may also enhance interpretation and utilisation of these findings in drug treatment.[Brener L, von Hippel W, von Hippel C, Resnick I, Treloar C. Perceptions of discriminatory treatment by staff as predictors of drug treatment completion: Utility of a mixed methods approach. Drug Alcohol Rev 2010;29;491–497]

Issues. Reductions in control group consumption over time that are possibly related to research design affect the impact of brief alcohol interventions (BAI) in clinical settings. Approach. We conducted a systematic review to identify research design factors that may contribute to control group change, strategies to limit these effects and implications for researchers. Studies with control group n > 30 were selected if they published baseline and outcome consumption data, conducted trials in clinical settings in Anglophone countries and did not censor gender or age. Key Findings. Among 38 studies cited in 20 reviews through October 2009, 16 met criteria (n = 31–370). In 54%, controls received alcohol specific handouts, advice and/or referral. Both the number and depth of assessments were highly variable. The percentage change in consumption ranged from?0.10 to?0.84 (mean?0.32), and effect size from 0.04 to 0.70 (mean 0.37). Published data were insufficient for meta-analysis. Implications. Researchers should consider strategies to reduce the impact of research design factors, such as procedures to enhance sample diversity, blind subjects to study purpose to limit social desirability bias, reduce the number and depth of instruments (assessment reactivity), and finally, analytic techniques to decrease the impact of outliers and regression to the mean. Conclusions. This review identifies problems with retrospective analysis of predictors of control group change, and underscores the need to design prospective studies to permit identification, quantification and adjustment for potential sources of bias in BAI trials.[Bernstein JA, Bernstein E, Heeren TC. Mechanisms of change in control group drinking in clinical trials of brief alcohol intervention: Implications for bias toward the null. Drug Alcohol Rev 2010;29;498–507]

Issues and Approach. The high rates of co-occurring depression and substance use, and the negative impact of this on illness course and outcomes have been well established. Despite this, few clinical trials have examined the efficacy of cognitive behaviour therapy (CBT). This paper systematically reviews these clinical trials, with an aim of providing recommendations for how future research can develop a more robust evidence base for the treatment of these common comorbidities. Leading electronic databases, including PubMed (ISI) and PsychINFO (CSA), were searched for peer-reviewed journal articles using CBT for the treatment of co-occurring depression and substance use. Of the 55 articles identified, 12 met inclusion criteria and were included in the review. Key Findings. There is only a limited evidence for the effectiveness of CBT either alone or in combination with antidepressant medication for the treatment of co-occurring depression and substance use. While there is support for the efficacy of CBT over no treatment control conditions, there is little evidence that CBT is more efficacious than other psychotherapies. There is, however, consistent evidence of improvements in both depression and substance use outcomes, regardless of the type of treatment provided and there is growing evidence that that the effects of CBT are durable and increase over time during follow up. Conclusions. Rather than declaring the ‘dodo bird verdict’ that CBT and all other psychotherapies are equally efficacious, it would be more beneficial to develop more potent forms of CBT by identifying variables that mediate treatment outcomes.[Hides L, Samet S, Lubman DI. Cognitive behaviour therapy (CBT) for the treatment of co-occurring depression and substance use: Current evidence and directions for future research. Drug Alcohol Rev 2010;29;508–517]

Issues. Comorbidity between anxiety and substance use disorders is common, yet it is poorly understood and poorly treated. Approach. Narrative literature review. PsycINFO and Medline databases were searched for clinical trials of anxiety and substance use disorders using clinical queries for 2005–2009. Key Findings. There are few well-conducted treatment outcome trials for comorbid anxiety and substance use disorders. Some recent (2005–2009) outcome literature has focused on specific mechanisms (anxiety sensitivity and tension reduction alcohol expectancies) that may underlie comorbidity between anxiety and substance use disorders and may lead to more targeted intervention. Implications and Conclusion: The research base for understanding and treating comorbid anxiety and substance use disorders needs to be broadened. In particular research is needed with a focus on: (i) specifying particular comorbid relationships between anxiety and substance use disorders; (ii) the mechanisms that may underlie and maintain those relationships; and (iii) well-conducted evaluations of treatments that target those mechanisms.[Baillie AJ, Stapinski L, Crome E, Morley K, Sannibale C, Haber P, Teesson M. Some new directions for research on psychological interventions for comorbid anxiety and substance use disorders. Drug Alcohol Rev 2010;29;518–524]

Introduction and Aims. To examine how young people in New Zealand engage with alcohol and reproduce alcohol marketing messages and alcohol-related branding in ‘Bebo’, a popular social networking site (SNS) on the Internet. Design and Methods. Data are drawn from information posted on approximately 150 Bebo Web pages and analysed by way of textual analysis and cyberspace ethnography. Results. Social networking sites, such as Bebo, provide young people with a digital space in which to share a range of alcohol marketing messages via peer-to-peer transmission. Bebo also enables youth to communicate to one another how they consume alcohol and their views of alcohol marketing messages. The information being shared by young people who use Bebo is openly provided in the form of personal information, forum comments, digital photographs and answering quizzes about their engagement with alcohol. Discussion and Conclusions. Through this sharing of information in the digital Internet environment, young people are creating ‘intoxigenic social identities’ as well as ‘intoxigenic digital spaces’ that further contribute towards the normalisation of youth consumption of alcohol. A better understanding of how youth are using the Internet to share their experiences with alcohol and engagement with alcohol-related messages is crucial to public health research as alcohol marketing practices rapidly evolve.[Griffiths R, Casswell S. Intoxigenic digital spaces? Youth, social networking sites and alcohol marketing. Drug Alcohol Rev 2010]