Substance use disorders

Basic competencies in assessing and treating substance use disorders should be core to the training of any clinical psychologist, because of the high frequency of risky or problematic substance use in the community, and its high co-occurrence with other problems. Skills in establishing trust and a therapeutic alliance are particularly important in addiction, given the stigma and potential for legal sanctions that surround it. The knowledge and skills of all clinical practitioners should be sufficient to allow valid screening and diagnosis of substance use disorders, accurate estimation of consumption and a basic functional analysis. Practitioners should also be able to undertake brief interventions including motivational interviews, and appropriately apply generic interventions such as problem solving or goal setting to addiction. Furthermore, clinical psychologists should have an understanding of the nature, evidence base and indications for biochemical assays, pharmacotherapies and other medical treatments, and ways these can be integrated with psychological practice. Specialists in addiction should have more sophisticated competencies in each of these areas. They need to have a detailed understating of current addiction theories and basic and applied research, be able to undertake and report on a detailed psychological assessment, and display expert competence in addiction treatment. These skills should include an ability to assess and manage complex or co-occurring problems, to adapt interventions to the needs of different groups, and to assist people who have not responded to basic treatments. They should also be able to provide consultation to others, undertake evaluations of their practice, and monitor and evaluate emerging research data in the field.

Cognitive behaviour therapy (CBT) for the treatment of co-occurring depression and substance use : current evidence and directions for future research

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.

Adolescent peer aggression and its association with mental health and substance use in an Australian cohort

Prospective longitudinal birth cohort data was used to examine the association between peer aggression at 14 years and mental health and substance use at 17 years. A sample of 1590 participants from the Western Australian Pregnancy Cohort (Raine) study were divided into mutually exclusive categories (victims, perpetrators, victim-perpetrators and uninvolved). Involvement in any type of peer aggression as a victim (10.1%), perpetrator (21.4%), or a victim-perpetrator (8.7%) was reported by 40.2% of participants. After adjusting for confounding factors, those who were a victim of peer aggression had increased odds of later depression and internalising symptoms whilst perpetrators of peer aggression were found to be at increased risk of depression and harmful alcohol use. Victim-perpetrators of peer aggression were more likely to have externalising behaviours at 17 years. These results show an independent temporal relationship between peer aggression and later mental health and substance use problems in adolescence.

Music in the prevention and treatment of substance misuse

Issues Research shows that young people at risk of developing a substance use disorder often use substances to deal with problems, particularly relationship problems and emotional problems. Music listening is a widely available and engaging activity that may help young people address these problem areas. This study was part of a larger project to develop a phone app for young people in which they use music for emotional wellbeing. Approach Three focus groups with young people aged 15–25 years were conducted and the transcripts were analysed by three of the authors using a thematic analysis procedure (Braun & Clarke, 2006). Key Findings: Young people used music in four main ways to achieve wellbeing: relationship building through sharing music; cre- ating an ambience using music; using music to experience an emotion more fully; and using music to modify an emotion. Several mecha- nisms by which music achieved these functions were identified. Par- ticipants also articulated specific times when they would not use music and why. Discussion and Conclusions The information from these focus groups provides many avenues for the development of the app and for understanding how music listening helps young people to achieve wellbeing. These ideas can readily be used with young people at risk of developing substance use problems as it gives them an engaging and low cost alternative for managing their emotions and building relationships.

Does adolescent's exposure to parental intimate partner conflict and violence predict psychological distress and substance use in young adulthood? A longitudinal study

Little is known about the extent to which parental conflict and violence differentially impact on offspring mental health and substance use. Using data from a longitudinal birth cohort study this paper examines: whether offspring exposure to parental intimate partner violence (involving physical violence which may include conflicts and/or disagreements) or parental intimate partner conflict (conflicting interactions and disagreements only) are associated with offspring depression, anxiety and substance use in early adulthood (at age 21); and whether these associations are independent of maternal background, depression and anxiety and substance use. Data (n = 2,126 women and children) were taken from a large-scale Australian birth-cohort study, the Mater University of Queensland Study of Pregnancy (MUSP). IPC and IPV were measured at the 14-year follow-up. Offspring mental health outcomes – depression, anxiety and substance use were assessed at the 21-year follow-up using the Composite International Diagnostic Interview (CIDI). Offspring of women experiencing IPV at the 14-year follow-up were more likely to manifest anxiety, nicotine, alcohol and cannabis disorders by the 21-year follow-up. These associations remained after adjustment for maternal anxiety, depression, and other potential confounders. Unlike males who experience anxiety disorders after exposure to IPV, females experience depressive and alcohol use disorders. IPV predicts offspring increased levels of substance abuse and dependence in young adulthood. Gender differences suggest differential impact.

Monitoring substance use in prisons: Assessing the potential value of wastewater analysis

Prison substance use is a major concern for prison authorities and the wider community. Australia has responded to this problem by implementing the National Corrections Drug Strategy. Across Australia, the true extent of prison substance use cannot be determined. As a result, the effectiveness of the interventions employed as part of this strategy cannot be properly assessed. This has important implications for the allocation of corrective services resources and future policy development. This article explores the benefits and limitations, as well as the ethical and practical issues in using wastewater analysis (WWA) to measure levels of substance use in prisons. It reports results from the first application of WWA to an Australian prison, which supports the use of WWA in this context. Given the increasing concern for prescription misuse in prisons, we also highlight the novel use of WWA to measure the extent of prescription misuse by prisoners. The article concludes that as a result of its objectivity, sensitivity and cost-effectiveness, the use of WWA in prisons warrants further consideration in Australia.

Changes in cannabis use among psychotic clients without specialised substance use treatment

The need to address substance use among people with psychosis has been well established. However, treatment studies targeting substance use in this population have reported mixed results. Substance users with psychosis in no or minimal treatment control groups achieve similar reductions in substance use compared to those in more active substance use treatment, suggesting a role for natural recovery from substance use. This meta-analysis aims to quantify the amount of natural recovery from substance use within control groups of treatment studies containing samples of psychotic substance users, with a particular focus on changes in cannabis use. A systematic search was conducted to identify substance use treatment studies. Meta-analyses were performed to quantify reductions in the frequency of substance use in the past 30 days. Significant but modest reductions (mean reduction of 0.3–0.4 SD across the time points) in the frequency of substance use were found at 6 to 24 months follow up. The current study is the first to quantify changes in substance use in samples enrolled in no treatment or minimal treatment control conditions. These findings highlight the potential role of natural recovery from substance use among individuals with psychosis, although they do not rule out effects of regression to the mean. Additionally, the results provide a baseline from which to estimate likely changes or needed effects sizes in intervention studies. Future research is required to identify the processes underpinning these changes, in order to identify strategies that may better support self-management of substance use in people with psychosis.

Cognitive Functioning in Alcohol and Other Substance Use Disorders in Young Adulthood : A Genetic Epidemiological Study

Alcohol and other substance use disorders (SUDs) result in great costs and suffering for individuals and families and constitute a notable public health burden. A multitude of factors, ranging from biological to societal, are associated with elevated risk of SUDs, but at the level of individuals, one of the best predictors is a family history of SUDs. Genetically informative twin and family studies have consistently indicated this familial risk to be mainly genetic. In addition, behavioral and temperamental factors such as early initiation of substance use and aggressiveness are associated with the development of SUDs. These familial, behavioral and temperamental risk factors often co-occur, but their relative importance is not well known. People with SUDs have also been found to differ from healthy controls in various domains of cognitive functioning, with poorer verbal ability being among the most consistent findings. However, representative population-based samples have rarely been used in neuropsychological studies of SUDs. In addition, both SUDs and cognitive abilities are influenced by genetic factors, but whether the co-variation of these traits might be partly explained by overlapping genetic influences has not been studied. Problematic substance use also often co-occurs with low educational level, but it is not known whether these outcomes share part of their underlying genetic influences. In addition, educational level may moderate the genetic etiology of alcohol problems, but gene-environment interactions between these phenomena have also not been widely studied. The incidence of SUDs peaks in young adulthood rendering epidemiological studies in this age group informative. This thesis investigated cognitive functioning and other correlates of SUDs in young adulthood in two representative population-based samples of young Finnish adults, one of which consisted of monozygotic and dizygotic twin pairs enabling genetically informative analyses. Using data from the population-based Mental Health in Early Adulthood in Finland (MEAF) study (n=605), the lifetime prevalence of DSM-IV any substance dependence or abuse among persons aged 21—35 years was found to be approximately 14%, with a majority of the diagnoses being alcohol use disorders. Several correlates representing the domains of behavioral and affective factors, parental factors, early initiation of substance use, and educational factors were individually associated with SUDs. The associations between behavioral and affective factors (attention or behavior problems at school, aggression, anxiousness) and SUDs were found to be largely independent of factors from other domains, whereas daily smoking and low education were still associated with SUDs after adjustment for behavioral and affective factors. Using a wide array of neuropsychological tests in the MEAF sample and in a subsample (n=602) of the population-based FinnTwin16 (FT16) study, consistent evidence of poorer verbal cognitive ability related to SUDs was found. In addition, participants with SUDs performed worse than those without disorders in a task assessing psychomotor processing speed in the MEAF sample, whereas no evidence of more specific cognitive deficits was found in either sample. Biometrical structural equation models of the twin data suggested that both alcohol problems and verbal ability had moderate heritabilities (0.54—0.72), and that their covariation could be explained by correlated genetic influences (genetic correlations -0.20 to -0.31). The relationship between educational level and alcohol problems, studied in the full epidemiological FT16 sample (n=4,858), was found to reflect both genetic correlation and gene-environment interaction. The co-occurrence of low education and alcohol problems was influenced by overlapping genetic factors. In addition, higher educational level was associated with increased relative importance of genetic influences on alcohol problems, whereas environmental influences played a more important role in young adults with lower education. In conclusion, SUDs, especially alcohol abuse and dependence, are common among young Finnish adults. Behavioral and affective factors are robustly related to SUDs independently of many other factors, and compared to healthy peers, young adults who have had SUDs during their life exhibit significantly poorer verbal cognitive ability, and possibly less efficient psychomotor processing. Genetic differences between individuals explain a notable proportion of individual differences in risk of alcohol dependence, verbal ability, and educational level, and the co-occurrence of alcohol problems with poorer verbal cognition and low education is influenced by shared genetic backgrounds. Finally, various environmental factors related to educational level in young adulthood moderate the relative importance of genetic factors influencing the risk of alcohol problems, possibly reflecting differences in social control mechanisms related to educational level.