Self-Assessment of Addiction Medicine Core Competencies in Four Year Groups of Psychiatrists in Training: Efficacy of the Addiction Medicine Training Needs Assessment Scale in a Local Training Context.

BACKGROUND: In addiction medicine training, self-assessment is increasingly used to support self-regulation learning by identifying standards of excellence, competence gaps, and training needs. To ensure psychiatrists in Lithuania also develop specific addiction competencies, the Lithuanian Health Sciences University faculty in Kaunas developed an addiction psychiatry curriculum. OBJECTIVES: The aim of this research is to explore the efficacy of the AM-TNA scale to measure individual and group differences in proficiency in the core competencies of addiction medicine. A cross-sectional study and a convenience sample were used. METHOD: We studied the differences in performance in addiction medicine competencies between 4 successive year groups and analysed the variance to determine the statistical differences between the means of 4 year groups with biases, resulting from repeated measurement statistically corrected-for. RESULTS: Of the psychiatrists in training, 41% or 59% completed the scale. The assessment of competencies suggested that all but 2 competencies differ significantly (p < 0.05) between the 4 groups. The post hoc analyses indicated that mean scores for 24 of the 30 core competencies differed significantly between the year groups (p < 0.05) and showed a gradual increase in scores of self-assessed competencies over the 4 year groups. We found adequate scale variance and a gradual increase in self-assessed competencies between the 4 year groups, suggesting a positive association between the results of incremental professional training and improved self-assessed substance use disorders (SUD) competency scores. CONCLUSIONS: This study illustrates the efficacy of the AM-TNA scale as an assessment instrument in a local training context. Future research should aim to have larger sample sizes, be longitudinal in design, assess individual progress, and focus on comparing and combining self-reported competencies with validated objective external assessment and feedback.

Cognitive Impairments in Patients with GHB Use Disorder Predict Relapse in GHB Use.

BACKGROUND: The recreational use of gamma hydroxybutyrate (GHB) is associated with frequent overdoses, coma and the risk of developing GHB use disorder (GUD). Several studies suggest negative effects of GHB use or related comas on cognition. Since relapse rates are high in GUD and cognitive impairment has been associated with relapse in other substance use disorders, we aimed to (1) investigate the prevalence of cognitive impairment before and after detoxification, (2) analyse the relationship between GHB use, comas, and cognitive impairment, and (3) explore the association between cognitive impairment and relapse after detoxification in GUD patients. METHODS: In these secondary analyses of a prospective cohort study, a consecutive series of patients with GUD (n = 103) admitted for detoxification were recruited at six addiction care facilities in the Netherlands. The Montreal Cognitive Assessment (MoCA) was used to screen for cognitive impairments before and after detoxification. The follow-up duration for the assessment of relapse in GHB use was 3 months. RESULTS: A substantial number of patients with GUD screened positive for cognitive impairment before (56.3%) and after (30.6%) detoxification. Impairment on the MoCA memory domain was most frequent (58.8%). Cognitive impairment was not related to the severity of GUD or number of GHB-induced comas. Logistic regression analysis showed that only the memory score independently predicted relapse. DISCUSSION: Cognitive impairment seems highly prevalent among patients with GUD, possibly related to the risk of relapse. The absence of a relationship between the severity of GUD, level of GHB use, the number of GHB-induced comas, and cognitive impairment suggest that other factors may also contribute to the observed cognitive impairment.

Barriers and Facilitators to Seek Help for Substance Use Disorder among Dutch Physicians: A Qualitative Study.

INTRODUCTION: Substance use disorders (SUDs) among physicians affect their health, quality of life, but potentially also their quality of care. Despite the availability of effective specific Physician Health Programs (PHPs), physicians with SUD often experience barriers when seeking professional help. Therefore, we studied barriers and facilitators when seeking help for SUD among physicians from a multiple perspective approach. METHODS: A qualitative design was adopted for 2 sub-studies. First, answers of 2 open-ended questions (about anticipated barriers and facilitators) of an existing questionnaire were analyzed. This questionnaire was filled out by 1,685 general physicians (response rate = 47%). The answers of these open-ended questions were coded inductively. Second, 21 semi-structured interviews (about experienced barriers and facilitators) were performed with physician SUD-patients, significant others, and PHP employees. Themes identified in the first sub-study were used to deductively code the interview transcripts. Results were reported in accordance with the Consolidated Criteria for Reporting Qualitative Research guidelines. RESULTS: Barriers were found at the level of the individual physician (negative feelings and lack of disease awareness), whereas facilitators were found at the level of social relationships (confrontation with SUD and social support) and health services (supportive approach, good accessibility, and positive image of services). The interviews emphasized the importance of nonjudgmental confrontation by social relationships in the process of seeking help for SUD. CONCLUSION: Physicians with SUD face barriers when seeking help for SUD mostly at the level of the individual physician. Health services and people around physicians with SUD could facilitate the help-seeking process by offering confidential and nonpunitive support. Future studies should explore whether the barriers and facilitators identified in this study also hold for other mental health issues.

Premenstrual syndrome predicts alcohol craving in women with substance use disorders.

Premenstrual Syndrome (PMS) comprises psychological, somatic, and behavioral symptoms during the luteal phase of almost every menstrual cycle. PMS and premenstrual dysphoric disorder (PMDD) may be associated with substance use. Between 2018 and 2020 we studied the relationship between PMS and substance use within a prospective case-control design comparing a consecutive series of women having a substance use disorder and being treated in an addiction treatment center (ATC group, n = 151)) and one with community dwelling women attending their general practitioner (GP group, n = 101). The psychoactive substance use disorder women in the ATC were most frequently treated for was alcohol (39.7 percent), cannabis (20.5) and cocaine 7.9 percent) respectively. The relationship between PMS, problematic alcohol use, and craving for alcohol was explored with the Alcohol Use Disorders Identification Test (AUDIT), Premenstrual Screening Symptoms Tool (PSST), and Penn Alcohol Craving Scale (PACS). Descriptive analyses were used to report demographic variables, and the prevalence and nature of SUD according to DSM-5 and PMS in the two study populations and a two-step multiple hierarchical linear regression to assess the contribution of the variance of the AUDIT and PSST to craving, as measured with PACS. The frequency of PMS and PMDD is significantly higher in the ATC group than in the GP group (48.3 versus 26.7 percent and 16.6 versus 5.9 percent). Craving in the ATC group is better predicted (50 percent) by alcohol-related problems as measured by the AUDIT than in the GP group (25 percent). PMS complaints do contribute to craving in ATC group and not in GP group. There is a high prevalence of PMS/PMDD in the population with a substance use disorder. If these patients with PMS symptoms experience higher levels of craving, it may increase the risk of substance use relapse.

An international consultation on case reports in addiction medicine.

Background: A Case Report (CR) is a scientific documentation of a single clinical observation which serves to inform but also to educate the reader. Case reports help to compliment clinical critical thinking in Addiction Medicine (AM) when there is limited evidence base. Aim: This study aims to analyze how international clinical and research leaders in Addiction Medicine view Case Reports and their relevance to bridge the gap between evidence and practice. Methods: A semi-structured, audio-recorded interviews were conducted with 12 international Addiction Medicine scholars. Thematic content analysis was used to code the transcribed interview data. Results: Interviewees showed a positive view toward publishing Case Reports in Addiction Medicine. They found that medical students and clinicians working in the field of Addiction Medicine should be encouraged to share and record cases of clinical interaction. To aid this process (1) formal supervised training in case reporting within an academic environment must be facilitated. And (2) journals should also offer a place to publish Case Reports. Conclusion: The international scholars agree that Case Reports are important for the development of Addiction Medicine and that they can contribute to a better understanding of patients with substance use disorder.

Psychometric Properties of the Externalizing Spectrum Inventory: Replication and Extension across Clinical and Non-Clinical Samples.

The Externalizing Spectrum Inventory aims at assessing personality features that underlie externalizing disorders such as substance abuse and antisocial behaviors. The objective was to replicate the psychometric properties of the 160-item Externalizing Spectrum Inventory in Dutch clinical and non-clinical samples. First, Cronbach's alpha, test-retest reliability and the factor structure were analyzed on a mixed sample of inpatients (n = 149), undergraduates (n = 227), and community participants (n = 178). The factor structure was evaluated through confirmatory and exploratory factor analyses; for the latter Parallel Analysis was used, based on Minimum Rank Factor Analysis. Next, the criterion validity was analyzed using the Aggression Questionnaire and the NEO-Five Factor Inventory as external measures. The Dutch Externalizing Spectrum Inventory subscales showed sufficient reliability (α=.68-.94; ICC=.68-.91), except in the undergraduate sample (α=.49-.96; ICC=.43-.97). The factor structure of the Externalizing Spectrum Inventory was not confirmed and the exploratory analysis yielded different factor solutions across samples. The criterion validity was supported with regard to trait aggression and partly supported with regard to the Five Factor Model. The results suggest that the ESI-160 and its original factor model can be used for prediction purposes. However, further research of the factor structure is strongly recommended.

Prolonged Ketamine and Norketamine Excretion Profiles in Urine After Chronic Use: A Case Series.

PURPOSE/BACKGROUND: Ketamine (K) is used as a party drug with hallucinogenic properties with a half-life of about 2.5 hours. Data are available with respect to the detection window (ie, when a person is still tested positive for the drug and/or metabolite after use) of K after single use. Nevertheless, no data are available with respect to the detection window of K in urine after chronic use. METHODS/PROCEDURES: This retrospective case series describes 7 patients with K dependency as their main addiction who have been admitted to an addiction center for K detoxification. Their abstinence-oriented care involved routine urinary screening of K and its metabolites, as well as traditional drugs of abuse, such as cocaine and cannabinoids. FINDINGS/RESULTS: Urine samples remained positive for all the cases identified after 22 to 96 days. A peak detection period of 61, 40, and 96 days for K, norketamine, and dehydronorketamine, respectively, measured using liquid chromatography-tandem mass spectrometry at a cutoff concentration of 1.0 ng/mL, is defined. The K/norketamine and K/dehydronorketamine ratios varied over time between 0.33 and 3.06, and 0.01 and 0.36 for all patients, respectively, implying a large interindividual variation in K metabolism. IMPLICATIONS/CONCLUSIONS: Ketamine and its metabolites have a prolonged excretion profile in urine, which requires frequent measurements (at least weekly) to guide abstinence treatment. Further research is needed to develop an algorithm that can differentiate new K use from residual urinary K excretion in urine of chronic daily users.

Demoralization in Patients With Substance Use and Co-Occurring Psychiatric Disorders.

OBJECTIVE: In recent years, treatment of substance use disorder has rekindled emphasis on recovery which, being a gradual process, starts with remoralization. In this study, we examine the level of demoralization throughout the treatment process for patients with comorbid substance dependence and psychiatric disorders. METHODS: 217 patients with co-occurring disorders and 179 community-based individuals participated in this study. Demoralization was measured twice over one month as inpatient treatment happened. RESULTS: In contrast with the community sample, we found high levels of demoralization in the clinical cohort, with 86% of patients having demoralization scores above threshold. During the first month there was a statistically significant reduction in demoralization scores. However, clinically relevant change appeared limited, with only 3% of patients moving from dysfunctional to functional status in this naturalistic setting without targeted intervention aimed at remoralization. CONCLUSIONS: Although the level of demoralization is significantly improved during the first month of treatment, patients still remain strongly demoralized. Clinically relevant improvement is limited. It could be worthwhile to set up targeted interventions aimed at remoralization. Furthermore, we advocate for the assessment of demoralization in the clinical setting to monitor patients' treatment outcomes.

Using the Pictorial Representation of Illness and Self Measure (PRISM) to Quantify and Compare Suffering From Trauma and Addiction.

OBJECTIVE: In a sample of people with substance use disorder who had experienced psychological trauma, this study aimed to quantify differences in perceived suffering due to addiction-related problems and to trauma-related problems. METHODS: The sample comprised 146 inpatients with substance use disorder: 25% had posttraumatic stress disorder (PTSD), 21% had subthreshold PTSD; and the remainder constituted the trauma-only group. PTSD, substance use disorder, and suffering were assessed using validated instruments. Suffering was measured using the Pictorial Representation of Illness and Self Measure (PRISM). RESULTS: No differences were found among the PTSD, subthreshold PTSD, and trauma-only group in the suffering attributed to addiction-related problems. Those in the PTSD group appraised their suffering due to trauma-related problems as greater than the other groups. In the PTSD group, but not the subthreshold PTSD group, suffering due to trauma-related problems was appraised as greater than that due to addiction-related problems. CONCLUSIONS: This is the first study to demonstrate quantitative comparisons between different health problems using the "common currency" of suffering. Our results indicate that even among those in an inpatient substance use disorder treatment program, comorbid PTSD may be more personally salient and cause greater suffering, with implications for therapeutic interventions available on substance use disorder treatment programs.

Substance Misuse Education for Physicians: Why Older People are Important.

This perspective article focuses on the need for training and education for undergraduate medical students on substance-related disorders, and describes initiatives undertaken in the United Kingdom (UK), Netherlands, United States (US), and Norway to develop the skills, knowledge, and attitudes needed by future doctors to treat patients adequately. In addition, we stress that in postgraduate training, further steps should be taken to develop Addiction Medicine as a specialized and transverse medical domain. Alcohol use disorder is a growing public health problem in the geriatric population, and one that is likely to continue to increase as the baby boomer generation ages. Prescription drug misuse is a major concern, and nicotine misuse remains problematic in a substantial minority. Thus, Addiction Medicine training should address the problems for this specific population. In recent years, several countries have started an Addiction Medicine specialty. Although addiction psychiatry has been a subspecialty in the UK and US for more than 20 years, in most countries it has been a more recent development. Additional courses on addiction should be integrated into the curriculum at both undergraduate and postgraduate levels, as well as form part of the continuous training of other medical specialists. It is recommended that further research and mapping of what is currently taught in medical programs be undertaken, so as to enhance medical education in addiction and improve treatment services.

Baclofen as relapse prevention in the treatment of gamma-hydroxybutyrate dependence: a case series.

In the last decade, gamma-hydroxybutyrate (GHB) abuse and dependence have increased. It has been reported that GHB dependence has a high rate of relapse, serious complications of intoxication, and a potentially life-threatening withdrawal syndrome. Nevertheless, in clinical practice, there is no known medical treatment to support GHB relapse prevention. We describe a case series of patients who were supported through an off-label treatment with baclofen to avoid a relapse into GHB abuse, for a period of 12 weeks. Nine of 11 patients did not relapse while taking a dose ranging from 30 to 60 mg per day, one patient relapsed after 5 weeks, and one stopped after 7 weeks. Baclofen was well tolerated; patients reported mild side effects such as fatigue, nausea, dry mouth, excessive sweating, and depressive feelings. Although systematic evidence is still lacking, our practice-based experience suggests that treatment with baclofen to assist abstinence might be effective in patients with GHB dependence. Further systematic controlled studies are necessary to establish the exact efficacy and safety of baclofen as relapse prevention for GHB-dependent patients.

Baclofen as relapse prevention in the treatment of Gamma- Hydroxybutyrate (GHB) dependence: an open label study.

BACKGROUND: GHB dependence is a growing health problem in several western countries, especially the Netherlands. Attempts to stop using GHB are often followed by relapse shortly after successful detoxification. Craving for GHB use and co-morbid psychiatric symptom levels are thought to be the major factors contributing to the high relapse rates. Given its pharmacological profile, baclofen might prove an effective anti-craving agent for patients with GHB dependence. The aim of the current study is to assess the potential of baclofen as an anti-craving agent relapse prevention intervention in GHB dependent patients. METHODS/DESIGN: In an open label non-randomized trial treatment with baclofen to a maximum of 60 mg/day will be compared with treatment as usual (TAU) in recently detoxified GHB dependent patients (n = 80). The primary outcome measure will be the level of GHB use. Secondary outcome measures are craving levels, psychiatric symptom levels and quality of life. Questionnaires will be administered during 12 weeks of baclofen treatment and at follow-up (six months after the start of treatment). DISCUSSION: It is hypothesized that baclofen treatment compared to TAU will be associated with significantly reduced GHB use. In addition, we hypothesize that baclofen treatment will be associated with decreased craving and anxiety levels, and higher quality of life. If results are in line with our hypotheses, further studies on the efficacy of baclofen using placebo controlled designs and long term follow-up are warranted. TRIAL REGISTRATION: The Netherlands Trial Register with number NTR4528 . Registered 19 April 2014.

Clinical judgement versus self-rating of demoralization in outpatients with a substance-use disorder: A cross-sectional study.

PURPOSE: To investigate the ability of case managers, working in ambulatory treatment settings specialized in addiction care, to clinically judge demoralization in substance-dependent patients. DESIGN AND METHODS: In a cross-sectional study, clinical judgments of case managers were compared with the patients' scores on the Demoralization Scale, by calculating the sensitivity and specificity scores. FINDINGS: Case managers identified demoralization in 85% of the cases (sensitivity), the specificity of 62% suggests that demoralization was overestimated by case managers. PRACTICE IMPLICATIONS: Demoralization is a frequently occurring phenomenon in patients. Methods should be developed that allow professionals and patients to identify demoralization collaboratively, and to develop tailored interventions to prevent demoralization and its negative consequences.

Success Rates of Monitoring for Healthcare Professionals with a Substance Use Disorder: A Meta-Analysis.

In the past decades, monitoring programs have been developed for healthcare professionals with substance use disorders. We aimed to explore estimates of abstinence and work retention rates after participation in such monitoring programs. A literature search was performed using PubMed, Embase, PsycINFO, and CINAHL. Twenty-nine observational studies reporting on success rates (abstinence and work retention) of monitoring for healthcare professionals with a substance use disorder were included in the meta-analysis. Quality-effects models calculated pooled success rates and corresponding 95%-Confidence Intervals (CI), with subgroup analyses on monitoring elements and patient characteristics. Pooled success rates were 72% for abstinence (95%-CI = 63-80%) and 77% for work retention (95%-CI = 61-90%). Heterogeneity across studies was partly explained by the starting moment of monitoring, showing higher abstinence rates for studies that started monitoring after treatment completion (79%; 95%-CI = 72-85%) compared to studies that started monitoring with treatment initiation (61%; 95%-CI = 50-72%). About three-quarters of healthcare professionals with substance use disorders participating in monitoring programs are abstinent during follow-up and working at the end of the follow-up period. Due to selection and publication bias, no firm conclusions can be drawn about the effectiveness of monitoring for healthcare professionals with SUD.

Reorganization of Substance Use Treatment and Harm Reduction Services During the COVID-19 Pandemic: A Global Survey.

Background: The coronavirus disease 2019 (COVID-19) pandemic has impacted people with substance use disorders (SUDs) worldwide, and healthcare systems have reorganized their services in response to the pandemic. Methods: One week after the announcement of the COVID-19 as a pandemic, in a global survey, 177 addiction medicine professionals described COVID-19-related health responses in their own 77 countries in terms of SUD treatment and harm reduction services. The health responses were categorized around (1) managerial measures and systems, (2) logistics, (3) service providers, and (4) vulnerable groups. Results: Respondents from over 88% of countries reported that core medical and psychiatric care for SUDs had continued; however, only 56% of countries reported having had any business continuity plan, and 37.5% of countries reported shortages of methadone or buprenorphine supplies. Participants of 41% of countries reported partial discontinuation of harm-reduction services such as needle and syringe programs and condom distribution. Fifty-seven percent of overdose prevention interventions and 81% of outreach services were also negatively impacted. Conclusions: Participants reported that SUD treatment and harm-reduction services had been significantly impacted globally early during the COVID-19 pandemic. Based on our findings, we highlight several issues and complications resulting from the pandemic concerning people with SUDs that should be tackled more efficiently during the future waves or similar pandemics. The issues and potential strategies comprise the following: (1) helping policymakers to generate business continuity plans, (2) maintaining the use of evidence-based interventions for people with SUDs, (3) being prepared for adequate medication supplies, (4) integrating harm reduction programs with other treatment modalities, and (5) having specific considerations for vulnerable groups such as immigrants and refugees.

A Global Survey on Changes in the Supply, Price, and Use of Illicit Drugs and Alcohol, and Related Complications During the 2020 COVID-19 Pandemic.

Background and Aims: COVID-19 has infected more than 77 million people worldwide and impacted the lives of many more, with a particularly devastating impact on vulnerable populations, including people with substance use disorders (SUDs). Quarantines, travel bans, regulatory changes, social distancing, and "lockdown" measures have affected drug and alcohol supply chains and subsequently their availability, price, and use patterns, with possible downstream effects on presentations of SUDs and demand for treatment. Given the lack of multicentric epidemiologic studies, we conducted a rapid global survey within the International Society of Addiction Medicine (ISAM) network in order to understand the status of substance-use patterns during the current pandemic. Design: Cross-sectional survey. Setting: Worldwide. Participants: Starting on April 4, 2020 during a 5-week period, the survey received 185 responses from 77 countries. Measurements: To assess addiction medicine professionals' perceived changes in drug and alcohol supply, price, use pattern, and related complications during the COVID-19 pandemic. Findings: Participants reported (among who answered "decreased" or "increased") a decrease in drug supply (69.0%) and at the same time an increase in price (95.3%) globally. With respect to changes in use patterns, an increase in alcohol (71.7%), cannabis (63.0%), prescription opioids (70.9%), and sedative/hypnotics (84.6%) use was reported, while the use of amphetamines (59.7%), cocaine (67.5%), and opiates (58.2%) was reported to decrease overall. Conclusions: The global report on changes in the availability, use patterns, and complications of alcohol and drugs during the COVID-19 pandemic should be considered in making new policies and in developing mitigating measures and guidelines during the current pandemic (and probable future ones) in order to minimize risks to people with SUD.

Prevalence of cognitive impairment in patients with substance use disorder.

INTRODUCTION AND AIMS: Cognitive impairments in substance use disorder predict treatment outcome and are assumed to differ between substances. They often go undetected, thus the current study focuses on the prevalence of and differences in cognitive functioning across substances by means of a cognitive screen at the early stage of addiction treatment. DESIGN AND METHODS: The Montreal Cognitive Assessment was administered to outpatients seeking treatment for substance use disorder. Patient characteristics (age, years of regular use, polysubstance use, severity of dependence/abuse, depression, anxiety and stress) were also taken into account. RESULTS: A total of 656 patients were included (n = 391 used alcohol, n = 123 used cannabis, n = 100 used stimulants and n = 26 used opioids). The prevalence of cognitive impairments was 31%. Patients using alcohol had a lower total- and memory domain score than those using cannabis. Patients using opioids scored lower on visuospatial abilities than those using cannabis or stimulants. Younger patients scored higher than older patients. No effect was found for the other investigated characteristics. DISCUSSION AND CONCLUSIONS: Given the high prevalence of cognitive impairments, standard screening at an early stage of treatment is important to determine the course of treatment and maximise treatment outcome. Caution is needed in interpreting results about opioids due to an underrepresentation of this patient group, and more research is needed on the effect of age on Montreal Cognitive Assessment performance.

Changes over time in Lithuanian schoolchildren's attitudes toward addictive behaviors: Promoting and preventing factors.

BACKGROUND: Concern is growing about the high prevalence of traditional and new forms of addictive behaviors among young people due to the health risks and a better understanding of the factors causing these behaviors is needed. AIM: To evaluate tendencies in the attitudes of Lithuanian schoolchildren toward addictive behaviors over a three year period and to ascertain the promoting and preventing factors of such behaviors. METHODS: The researchers developed a survey which was conducted twice over a three year period. The sample consisted of pupils in the 5th, 9th and 12th grades (N = 1590, age range 11-19 years) from both urban and rural areas. RESULTS: Both the recognition of and involvement in addictive behaviors significantly increased with age. Motivation to abstain due to internal factors decreased with age and increased among pupils already involved in addictive behaviors. Time- and age-related differences were found regarding substance abuse and behavioral addictions. Whilst betting adverts were increasingly noticed over time, smoking adverts were decreasingly noticed over the three year period and it was concomitant with inconsistent changes in self-reported involvement in these behaviors. CONCLUSIONS: Most significant changes in the attitudes of Lithuanian pupils toward addictive behaviors occur between the ages of 11 and 15 years. However, age-related changes differ for the pupils' attitudes toward substance abuse and behavioral addictions. Increasing awareness of the potential risk of addictive behaviors does not prevent their increasing prevalence with age. Increased risk of involvement in addictive behavior correlates with decreased internal motivation to abstain from addictive behavior and decreased recognition of its potential risks. No clear correlation was found between significant changes in noticing adverts and involvement in addictive behaviors.

Psychiatric comorbidity, psychological distress, and quality of life in gamma-hydroxybutyrate-dependent patients.

Understanding the psychiatric state and psychological distress level of patients with gamma-hydroxybutyrate dependence is important to develop effective detoxification and relapse management methods. The aim of the current study was to assess the prevalence among gamma-hydroxybutyrate-dependent individuals of psychiatric comorbidity and psychological distress levels and their association with the individuals' pattern of misuse and quality of life. There were 98 patients tested with the Mini International Neuropsychiatric Interview-plus, the Brief Symptom Inventory, the Depression Anxiety Stress scale, and the EuroQoL-5D as a part of the Dutch gamma-hydroxybutyrate detoxification monitor in 7 addiction treatment centers. Participants were selected from those undergoing inpatient gamma-hydroxybutyrate detoxification treatment between March 2011 and September 2012. Males accounted for 68% of the participants and the average age was 28-years-old. A high rate of psychiatric comorbidity (79%) was detected, including anxiety (current 38%, lifetime 40%), mood (13%, 31%), and psychotic disorders (13%, 21%). The level of psychological distress was significantly higher than the standard outpatient reference group, especially in patients with current psychiatric comorbidity (Brief Symptom Inventory Global Severity Index mean 1.61 versus 1.09, p ≤ 0.01). Increased gamma-hydroxybutyrate misuse (higher dose and shorter interval between doses) was associated with the presence of lifetime psychosis, current mood disorders (rpb = 0.23, p = 0.025), and psychoticism as a symptom of psychological distress. Current anxiety, mood disorders and high psychological stress had a negative effect on participants' quality of life. Gamma-hydroxybutyrate dependence is characterized by serious psychiatric comorbidity and psychological distress, both of which are, in turn, associated with increased gamma-hydroxybutyrate use and a lower quality of life. This needs to be considered during detoxification to avoid complicated withdrawal. Providing treatment for patients' mental health issues is vital for ensuring treatment compliance, avoiding relapse and improving the patients' quality of life.

The Effect of Co-occurring Substance Use on Gamma-hydroxybutyric Acid Withdrawal Syndrome.

OBJECTIVES: Gamma-hydroxybutyric acid (GHB) withdrawal is a complex syndrome which can be potentially life-threatening. Additionally, GHB-dependent patients frequently report co-occurring substance use of other psychoactive drugs. We assessed the add-on effect of co-use on GHB withdrawal symptoms. METHODS: We conducted an open-label, pretest-posttest design study with 95 patients selected from 229 inpatients admitted for detoxification, who were divided into GHB only (GO, n = 40), GHB plus sedatives (GSE, n = 38), and GHB plus stimulants (GST, n = 17) groups. GHB withdrawal was evaluated by means of the Subjective Withdrawal Scale. Co-use add-on effects on the severity of withdrawal symptoms were evaluated 2.5 hours after the last illicit GHB self-administration (T1) when withdrawal was expected and 2.5 hours later, after administration of a very low dose of pharmaceutical GHB (T2). RESULTS: The GO group reported high scores of psychomotor retardation symptoms at both T1 and T2, and also high cravings, agitation, and restlessness at T1, and anxiety at T2. The GSE group reported the highest score in psycho-autonomic distress symptoms at both T1 and T2, whereas the GST group reported the highest score in psycho-motor stress factor at T2. There was no significant difference in withdrawal intensity in all symptom clusters between T1 and T2 for both GSE and GO groups. However, after 5 hours, the GST group reported significant decreases in intensity for all symptoms except for psycho-motor stress. At T1, GST and GSE groups reported more muscle twitches than the GO group as a significant add-on effect to the GHB withdrawal. At T2, the GST group experienced more agitation (P = 0.009), restlessness (P = 0.001), and rapid pulse (P = 0.034) than the GO group. CONCLUSIONS: Co-use, especially of stimulants, caused an add-on effect on the GHB withdrawal symptoms within the first 5 hours.