Predictors of abstinence maintenance after cocaine inpatient detoxification: A prospective study.

BACKGROUND AND OBJECTIVES: Cocaine is a highly addictive substance, and with no approved medication for cocaine use disorder (CUD), leading to a heavy burden. Despite validated psychosocial treatments, relapse rates after detoxification are very high in CUD. Few consistent factors can predict abstinence after detoxification. Our study, therefore, aimed at identifying factors predicting abstinence among CUD patients after inpatient detoxification. METHODS: Eighty-one CUD inpatients were included during detoxification and characterized for clinical and sociodemographic data at baseline and at a follow-up of 3 months after discharge, including a standard measure of their abstinence duration from cocaine. We performed Cox univariate analyzes to determine the factors associated with abstinence maintenance, followed by a multivariate Cox regression to identify independent predictors. RESULTS: Abstinence maintenance was shorter in patients injecting cocaine (hazard ratio [HR] = 5.16, 95% confidence interval [CI]: 2.01-13.27, p < .001) and using cocaine heavily in the month before inclusion (HR = 1.03, 95% CI: 1.00-1.06, p = .046). Conversely, abstinence maintenance was longer in patients with longer inpatient detoxification stays (HR = 0.96, 95% CI: 0.94-0.99, p = .015) and prescribed with selective serotonin reuptake inhibitors (SSRIs) (HR = 0.30, 95% CI: 0.16-0.56, p < .001). DISCUSSION AND CONCLUSIONS: Patients with severe CUD may require longer inpatient stays to achieve abstinence. Regarding SSRI prescription, more specific studies are needed to provide stronger recommendations about their use in clinical practice. SCIENTIFIC SIGNIFICANCE: Our findings suggest several modifiable factors to improve inpatient treatment response in CUD. As there are no specific recommendations about the optimal duration of inpatient stay, our results could pave the way for evidence-based guidelines.

[Women's vulnerability to alcohol and its impact on health]. / Vulnérabilité des femmes face à l'alcool et impacts sur la santé.

At the same level of consumption as men, specific vulnerabilities often expose women to the more rapid onset of more serious illnesses (cardiovascular and liver diseases, cancers, brain and cognitive damage, sleep disorders, risk of accidents, etc.). This worrying fact is still little known by the general population. Special prevention measures are needed, such as dedicated campaigns for women, specific guidelines for lower-risk drinking, systematic early detection of risky drinking among women, and brief intervention in the event of problem drinking.

Could reasons for admission help to screen unhealthy alcohol use in emergency departments? A multicenter French study.

Background: Many patients admitted to general emergency departments (EDs) have a pattern of drinking that could lead to future alcohol-related complications. However, it is often difficult to screen these patients in the context of emergency. The aim of this study is to analyze whether reasons for admission could help to screen patients who have an unhealthy alcohol use. Method: Patients were recruited among six public hospital ED in France, between 2012 and 2014. During a one-month period in each hospital, anonymous questionnaires including sociodemographic questions, AUDIT-C and RAPS4-QF were administered to each patients visiting the ED. The reason for admission of each patient was noted at the end of their questionnaire by the ED practitioner. Results: Ten thousand Four hundred twenty-one patients were included in the analysis. Patients who came to the ED for injuries and mental disorders were more likely to report unhealthy alcohol use than non-harmful use or no use. Among male patients under 65 years old admitted to the ED for a mental disorder, 24.2% drank more than four drinks (40 g ethanol) in typical day at least four time a week in the last 12 months. Among these patients, 79.7% reported daily or almost daily heavy episodic drinking (HED, 60 g ethanol), and all were positive on the RAPS4-QF. Conclusion: This study highlights that unhealthy alcohol use is frequent among ED patients and particularly among those who come for injuries or mental disorders. Men under 65 years old with a mental disorder require special attention because of their increased prevalence of daily or almost daily HED.

Measuring craving: A systematic review and mapping of assessment instruments. What about sexual craving?

BACKGROUND AND AIMS: Craving is central in the definition of addictive disorders because of its diagnostic and prognostic value. Its measurement is essential in clinical practice. Previous reviews provided a better overview of existing instruments; however, they do not consider emerging substances and behaviors such as sexual addictions. Our objectives were threefold: (1) to provide a systematic review of craving assessment instruments and their psychometric characteristics within a transdiagnostic approach, (2) to highlight and map their conceptual relationships and (3) to identify potential sexual craving assessment instruments. METHODS: The review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. The PubMed, Embase, PsychInfo and Cochrane/Central databases were searched for publications that met the following inclusion criterion: validation studies of craving assessment instruments, regardless of target substance or behavior. The original search identified 4561 references and included 147 articles. Each selected study was a peer-reviewed publication. RESULTS: This review provides a synthesis of the psychometric properties of 36 original instruments and identified 93 variations of these instruments (e.g. translations). We were able to highlight five transdiagnostic families of instruments, each corresponding to a conceptual model. Only one instrument for assessing craving in the domain of compulsive sexual behavior, focused on pornography use, has been identified: the Pornography Craving Questionnaire. CONCLUSION: This review mapped all craving assessment instruments from a transdiagnostic perspective, finding 36 original instruments and 93 variations. The evolution of instruments to measure craving mirrors the evolution of the concept of craving which has progressively integrated cognitive, conditioning and sensory dimensions, and attests to the importance of the context of assessment. Development of an instrument to measure 'sexual craving' is needed and could be based on the data from our review.

Repetitive Transcranial Magnetic Stimulation (rTMS) as a Promising Treatment for Craving in Stimulant Drugs and Behavioral Addiction: A Meta-Analysis.

Addiction is a mental disorder with limited available treatment options. The therapeutic potential of repetitive transcranial magnetic stimulation (rTMS) on it, by targeting craving in particular, has been explored with heterogenous results. This meta-analysis uses updated evidence to assess overall rTMS efficacy on craving, differential effects between addiction types clustered into three groups (depressant (alcohol, cannabis, opiate), stimulant (nicotine, cocaine, methamphetamine), and behavioral addiction (gambling, eating disorder)), and stimulation settings. Studies on substance use, gambling, and eating disorders are included, with unrestricted stimulation settings, by searching the PubMed, Embase, PsycINFO, and Cochrane databases up to 30 April 2020. A total of 34 eligible studies (42 units of analysis) were identified. Because of highly significant heterogeneity in primary results, a sensitivity analysis was performed on a remaining sample of 26 studies (30 units of analysis). Analyses performed using random effects model revealed a small effect size favoring active rTMS over shamTMS stimulation in the reduction in craving. We found a significant difference between addiction types, with a persistent small effect only for stimulant and behavioral groups. In these groups we found no difference between the different combinations of target and frequency of stimulation, but a significant correlation between number of sessions and craving reduction. In conclusion, efficacy of rTMS on craving in stimulant and behavioral addiction was highlighted, but recommendations on optimal stimulation settings and its clinical application await further research.

Influence of Clinical Markers of Dopaminergic Behaviors on Depressive Symptoms During Withdrawal in Cocaine Users.

Background: During cocaine withdrawal, transient depressive symptoms that do not meet the criteria for depression, but promote relapse, are frequently observed. Their temporality could evoke a role of dopamine, especially since the underlying mechanism of these depressive symptoms is not well understood. We hypothesized that variation in the dopaminergic activity profile, modeled from clinical markers, could be implicated in the development of depressive symptoms during cocaine withdrawal. Methods: We compared patients reporting depressive symptoms (RDS+) or not (RDS-) during cocaine withdrawal. We evaluated dopaminergic activity through indirect clinical markers based on the known dopaminergic behaviors. A combined criterion was constructed for hyper and hypo dopaminergic models according to the O'Brien method and illustrated by the Hedges' effect-size and forest-plot graph. A multidimensional factorial analysis was carried out to determine which parameters discriminate RDS+/RDS- patients. Results: 313 patients were included, and 77% reported depressive symptoms during cocaine withdrawal. Hyperdopaminergic variables used to discriminate the two groups had a large overall effect size (-0.669) and included psychotic symptoms (-0.524), hallucinations (-0.548), and delusions (-0.528). The overall effect of the hypodopaminergic component was considerable (-0.604) with a large effect size for the severity of dependence (-0.616), withdrawal symptoms (-0.578), and anhedonia (-0.528). The combined model including hyperdopaminergic and hypodopaminergic components had the largest effect size (-0.785). Conclusion: The dopaminergic activities profile, assessed by indirect clinical markers, seems to characterize patients with depressive symptoms very well during cocaine withdrawal. RDS+ patients reported moreover higher levels of psychotic symptoms and more severe cocaine use disorder than RDS-.

The Early Impact of the COVID-19 Lockdown on Stress and Addictive Behaviors in an Alcohol-Consuming Student Population in France.

Background: This study evaluated factors linked with perceived stress related to the COVID-19 pandemic and lockdown and addictive behaviors prior to and during lockdown in a sample of students who indicated engaging in alcohol consumption behaviors before lockdown. Methods: Cross-sectional study. French students from four universities participated in this study, and 2,760 students reported alcohol use. During the first week of lockdown, students reported their perceived levels of stress regarding COVID-19. Substance use and addictive behaviors were reported before and during lockdown, and media exposure, demographical, living conditions, and environmental stressors were reported during lockdown. Results: Women reported greater levels of stress (95% CI: 1.18 to 1.93, p < 0.001). Highly-stressed students also report less social support (95% CI: -1.04 to -0.39, p < 0.001) and were more likely to worry about the lockdown (95% CI: 0.27 to -0.65, p < 0.001). Alcohol-related problemswere more prevalent among the most stressed students (95% CI: 0.02 to 0.09, p = 0.004) as well as eating problems (95% CI: 0.04 to 0.36, p = 0.016) and problematic internet use (95% CI, 0.06 to 0.14, p < 0.001). Students reporting the highest levels of stress also indicated more compulsive eating during the previous seven days (95% CI, 0.21 to 1.19, p = 0.005). Conclusions: The level of stress was strongly related to four categories of variables: (i) intrinsic characteristics, (ii) addictive behaviors before lockdown, (iii) lockdown-specific conditions, and (iv) addictive behaviors during the lockdown. Several variables linked to COVID-19 were not directly linked with perceived stress, while perceived stress was found to correlate with daily life organization-related uncertainty and anticipated consequences of lockdown. Importantly, social support seems to be a protective factor on high level of stress.

[Alcohol and emergencies]. / Alcool et urgences.

Thirty percent of emergency department admissions are related to an alcohol misuse. Eighty percent of acute intoxications admitted in emergency departments concern patients with alcohol addiction. Care protocols validated in all of emergency departments are necessary for prevention of alcohol withdrawal syndrome. Risky uses require ultra-brief interventions, situations of abuse (light use disorders) require brief interventions and situations of dependence (moderate to severe use disorders) require motivational interviews to promote the emergence of a process of change. The key word for alcohol intervention in emergencies is: empathy. Search addictive comorbidities (tobacco and cannabis) and psychiatric comorbidities (depression and suicidal risk) must be systematic. The coordination between emergency departments and addictology departments is essential. In the emergency department, the goal is to optimise patient care path for all addictive behaviors.