Agreement between Youth Self-Report and Biospecimen-Confirmed Substance Use: A Systematic Review.

ContextBiospecimen analysis may enhance confidence in the accuracy of self-reported substance use among adolescents and transitional age youth (TAY). Associations between biospecimen types and self-reported use, however, are poorly characterized in the existing literature. Objective: We performed a systematic review of associations between biospecimen-confirmed and self-reported substance use. Data sources: PubMed, Embase, and Web of Science. Study selection: We included studies documenting associations between self-reported and biospecimen-confirmed substance use among adolescents (12-18 years) and TAY (19-26 years) published 1990-2020. Data extraction: Three authors extracted relevant data using a template and assessed bias risk using a modified JBI Critical Appraisal Tool. Results: We screened 1523 titles and abstracts, evaluated 73 full texts for eligibility, and included 28 studies. Most studies examined urine (71.4%) and hair (32.1%) samples. Self-report retrospective recall period varied from past 24 h to lifetime use. Agreement between self-report and biospecimen results were low to moderate and were higher with rapidly metabolized substances (e.g., amphetamines) and when shorter retrospective recall periods were applied. Frequently encountered sources of potential bias included use of non-validated self-report measures and failure to account for confounding factors in the association between self-reported and biospecimen-confirmed use. Limitations: Study heterogeneity prevented a quantitative meta-analysis. Studies varied in retrospective recall periods, biospecimen processing, and use of validated self-report measures. Conclusions: Associations between self-reported and biospecimen-confirmed substance use are low to moderate and are higher for shorter recall periods and for substances with rapid metabolism. Future studies should employ validated self-report measures and include demographically diverse samples.

Butyrylcholinesterase levels and subjective effects of smoked cocaine in healthy cocaine users.

BACKGROUND: Butyrylcholinesterase (BChE) is beginning to attract attention as a possible target for cocaine abuse treatment because of its role in metabolizing cocaine. OBJECTIVE: The purpose of this analysis was to assess whether endogenous BChE levels are associated with the subjective effects of cocaine. METHODS: Data from 28 participants in five inpatient cocaine self-administration studies were included in the present analysis. Four minutes after each smoked cocaine dose, participants rated their drug-related effects from 0-100 using a computerized self-report Visual Analogue Scale (VAS). The main outcome measures were nine change-in-VAS ratings between a baseline placebo dose and a 25-mg smoked cocaine dose. RESULTS: After controlling for age, sex, total years of cocaine use, total milligrams of cocaine administered before the 25-mg dose being analyzed, and baseline diastolic blood pressure, endogenous BChE was not significantly associated with any of the nine change-in-VAS ratings. CONCLUSION: Though BChE appears to be a possible target for cocaine abuse treatment, these data suggest that endogenous levels of BChE may not play a role in modifying the subjective effects of cocaine. Future larger studies of BChE in respect to the subjective effects produced by cocaine are needed to confirm or refute these findings.

Cognitive-behavioral therapy in depressed primary care patients with co-occurring problematic alcohol use: effect of telephone-administered vs. face-to-face treatment-a secondary analysis.

This secondary analysis of a larger study compared adherence to telephone-administered cognitive-behavioral therapy (T-CBT) vs. face-to-face CBT and depression outcomes in depressed primary care patients with co-occurring problematic alcohol use. To our knowledge, T-CBT has never been directly compared to face-to-face CBT in such a sample of primary care patients. Participants were randomized in a 1:1 ratio to face-to-face CBT or T-CBT for depression. Participants receiving T-CBT (n = 50) and face-to-face CBT (n = 53) were compared at baseline, end of treatment (week 18), and three-month and six-month follow-ups. Face-to-face CBT and T-CBT groups did not significantly differ in age, sex, ethnicity, marital status, educational level, severity of depression, antidepressant use, and total score on the Alcohol Use Disorders Identification Test. Face-to-face CBT and T-CBT groups were similar on all treatment adherence outcomes and depression outcomes at all time points. T-CBT and face-to-face CBT had similar treatment adherence and efficacy for the treatment of depression in depressed primary care patients with co-occurring problematic alcohol use. When targeting patients who might have difficulties in accessing care, primary care clinicians may consider both types of CBT delivery when treating depression in patients with co-occurring problematic alcohol use.

APOE e4 genotype and cigarette smoking in adults with normal cognition and mild cognitive impairment: a retrospective baseline analysis of a national dataset.

BACKGROUND: APOE e4 genotype is known to be a risk factor for Alzheimer's disease and atherosclerosis. Recently, published evidence has shown that APOE e4 genotype may also be associated with the cessation of cigarette smoking. OBJECTIVES: The aim of this retrospective analysis was to explore whether any past smoking outcomes differed based on APOE e4 genotype in a large national dataset. METHODS: Data were extracted from the National Alzheimer's Coordinating Center's longitudinal Uniform Data Set study. We limited this retrospective baseline analysis to the normal cognition (n = 2995) and mild cognitive impairment (n = 1627) groups that had APOE genotype and smoking data. Because this was an exploratory retrospective analysis, we conducted descriptive analyses on all variables based on APOE e4 genotype. We controlled for demographic, clinical, medication and neurocognitive data in the analyses. RESULTS: In both the normal cognition group and the mild cognitive impairment group, e4 carriers and e4 non-carriers did not significantly differ on total years smoked, age when last smoked and the average # of packs/day smoked during the years they smoked. In both groups, e4 carriers and e4 non-carriers differed on various neurocognitive measures. CONCLUSION: These data do not support the recently published evidence of the association between APOE e4 genotype and smoking outcomes. SCIENTIFIC SIGNIFICANCE: Larger prospective clinical trials are needed to further explore the relationship between APOE genotype and smoking outcomes.

Experiences of transgender and gender diverse patients in emergency psychiatric settings: A scoping review.

Objective: This scoping review aims to characterize what is known about transgender and gender diverse (TGD) individuals in emergency psychiatric settings and identify what gaps persist in this literature. Methods: A search of 4 electronic databases (PubMed, Web of Science, GenderWatch, and PsycINFO) was used for data collection. Included were studies that looked at TGD individuals presenting to a psychiatric emergency department (ED) or ED with a primary mental health concern. Study screening progress was documented in a Preferred Reporting Items for Systematic reviews and Meta-Analyses flow chart. A total of 232 titles and abstracts were screened, 38 full texts were evaluated for eligibility, and 10 studies were included. Results: The studies reviewed identified mental health vulnerabilities unique to the TGD population, including service denial in health care settings, gender dysphoria, increased rates of non-suicidal self-injury, and in some studies an increase in suicidality. Societal inequities, including the risk of discrimination and residential instability, were also revealed. A subset of the studies identified best practices in caring for this population, including the use of non-judgmental, affirmative, and inclusive language, and on a structural level creating emergency environments that are confidential, inclusive, and therapeutic for these individuals. Conclusions: There is limited information on TGD individuals in emergency psychiatric settings, and thus it is difficult to form strong conclusions. However, the current evidence available suggests possible inequities in this population. Three major themes with regards to TGD individuals in emergency psychiatric settings were identified: mental health vulnerabilities, societal inequities, and best practices in caring for this population. Overall, there is a scarcity of literature in this field, and further research on the experiences of this population is needed to inform clinical practice.

The subjective effects of cocaine: relationship to years of cocaine use and current age.

BACKGROUND: Little is known about whether the duration of cocaine use or an individual's age may influence the acute effects of cocaine, patterns of use, and specific treatment needs. OBJECTIVES: This post hoc analysis determined whether the duration of cocaine use or current age influenced the acute subjective response to cocaine. Data from four smoked cocaine self-administration laboratory studies were combined and analyzed to determine whether the subjective effects of a 25-mg smoked cocaine dose varied as a function of years of cocaine use or current age. METHODS: Thirty-six nontreatment-seeking healthy cocaine users (ages 32-49) were admitted to studies lasting from 12 to 105 days. Participants rated the subjective effects of each cocaine dose from 0 to 100 by completing a computerized self-report visual analogue scale (VAS). The main outcome measures were the change in VAS ratings between a baseline placebo dose and the first 25-mg dose of smoked cocaine. RESULTS: No significant relationship was found between the subjective effects of cocaine and years of cocaine use (mean 20.9, range 5-30) or current age (mean 41.1, range 32-49). CONCLUSION: Among long-term cocaine users between the ages of 32 and 49, the acute subjective effects of cocaine did not vary as a function of years of cocaine use or current age. SCIENTIFIC SIGNIFICANCE: These data fail to support the incentive sensitization theory for addiction by Robinson and Berridge, as cocaine "liking" and "wanting" remained the same regardless of age or years of cocaine use.

A pilot study of neurocognitive function in older and younger cocaine abusers and controls.

This pilot study compared basic neurocognitive functioning among older and younger cocaine abusers and control participants, as a preliminary assessment of whether specific cognitive deficits exist in an aged cocaine-abusing population. We hypothesized an interaction between aging and cocaine abuse, such that older cocaine abusers would exhibit decreased neuropsychological test performance relative to both younger cocaine abusers and older control participants. Four groups (n = 20 each) were examined: older cocaine abusers (ages 51-70), younger cocaine abusers (ages 21-39), and two non-illicit substance-using control groups. Basic neuropsychological and psychiatric measures were administered to all participants. Older participants performed more poorly than younger participants on the Mini-Mental State Examination (MMSE, p < .01), Digit Span Backward (p < .01), and Trail Making Test (TMT) Parts A and B (p < .01). Cocaine abusers performed more poorly than controls on TMT A (p < .01). Older and younger cocaine abusers used similar amounts of cocaine (p > .05). Older cocaine abusers performed more poorly than older control participants and younger cocaine abusers on the Digit Span Forward (p < .0125). Older cocaine abusers also performed more poorly than younger cocaine abusers on TMT A (p < .0125). This study provides preliminary evidence that older cocaine abusers use a significant amount of cocaine and that there is an interaction between aging and cocaine abuse on psychomotor speed, attention, and short-term memory. Future examination of neurocognitive function in older cocaine abusers is clearly warranted.

Which Emergent Medication Should I Give Next? Repeated Use of Emergent Medications to Treat Acute Agitation.

Agitation is a common symptom encountered among patients treated in psychiatric emergency settings. While there are many guidelines available for initial management of the acutely agitated patient, there is a notable dearth of guidelines that delineate recommended approaches to the acutely agitated patient in whom an initial medication intervention has failed. This manuscript aims to fill this gap by examining evidence available in the literature and providing clinical algorithms suggested by the authors for sequential medication administration in patients with persistent acute agitation in psychiatric emergency settings. We discuss risk factors for medication-related adverse events and provide options for patients who are able to take oral medications and for patients who require parenteral intervention. We conclude with a discussion of the current need for well-designed studies that examine sequential medication options in patients with persistent acute agitation.

Prescription use disorders in older adults.

The number of older adults needing substance abuse treatment is projected to rise significantly in the next few decades. This paper will focus on the epidemic of prescription use disorders in older adults. Particular vulnerabilities of older adults to addiction will be considered. Specifically, the prevalence and patterns of use of opioids, stimulants, and benzodiazepines will be explored, including the effects of these substances on morbidity and mortality. Treatment intervention strategies will be briefly discussed, and areas for future research are suggested.

Case Report: Buprenorphine Induction Using Transdermal Buprenorphine in a Veteran With Opioid Use Disorder and Psychosis, Managing Precipitated Withdrawal.

Buprenorphine induction can lead to precipitated opioid withdrawal, even when using novel techniques such as transdermal buprenorphine. Involuntary limb movements are a distressing symptom of precipitated withdrawal that can be difficult to treat. We report a case of a military veteran transitioning from methadone to buprenorphine for the treatment of opioid use disorder (OUD) using small doses of transdermal buprenorphine. Herein, we review the literature associated with opioid withdrawal-related restlessness. Despite the known risk of concurrent benzodiazepine and buprenorphine administration, including decreased respiratory rate and death, we present a clinical presentation in which this medication combination may be necessary while under medical supervision. We suggest a stepwise algorithm for pharmacotherapy in patients experiencing involuntary limb movements associated with precipitated withdrawal. To safeguard the success of medication-assisted treatment (MAT) for opioid addiction, clinicians should be aware of potential clinical challenges when managing precipitated opioid withdrawal in patients with complex psychiatric comorbidities.

Novel Objective Biomarkers of Alcohol Use: Potential Diagnostic and Treatment Management Tools in Dual Diagnosis Care.

Alcohol use disorders are highly prevalent conditions that generate a large fraction of the total public health burden. These disorders are concentrated in mentally ill populations, in which reliability of self-reporting of alcohol consumption may be especially compromised. The application of objective biomarkers for alcohol use may therefore play an important role in these patients. This article provides a description and comparative overview of traditional versus novel biomarkers of alcohol consumption. Greater professional familiarity with and use of novel biomarkers as diagnostic and treatment management tools may enhance clinical standards and research on alcohol use in patients with a dual diagnosis.

The relational neurobehavioral approach: can a non-aversive program manage adults with brain injury-related aggression without seclusion/restraint?

PURPOSE: The Relational Neurobehavioral Approach (RNA) is a set of non-aversive intervention methods to manage individuals with brain injury-related aggression. New data on interventions used in the RNA and on how the RNA interventions can be used with patients with acquired brain injury (ABI) who have differing levels of functional impairment are provided in this paper. METHOD: The study was conducted over a 6-week period in a secure 65-bed program for individuals with ABI that is housed in two units of a skilled nursing facility (SNF). Implementation of the RNA was compared between two units that housed patients with differing levels of functional impairment (n = 65 adults). Since this was a hierarchical clustered dataset, Generalized Estimating Equations regression was used in the analyses. RESULTS: RNA interventions used to manage the 495 aggressive incidents included the following: Aggression ignored, Closer observation, Talking to patient, Reassurance, Physical distraction, Isolation without seclusion, Immediate medication by mouth, Holding patient. Different interventions were implemented differentially by staff based on level of functional impairment and without use of seclusion or mechanical restraint. CONCLUSIONS: The RNA can be used to non-aversively manage aggression in patients with brain injury and with differing levels of functional impairment. Programs adopting the RNA can potentially manage brain injury-related aggression without seclusion or mechanical restraint. Implications for Rehabilitation The Relational Neurobehavioral Approach (RNA) is a set of non-aversive intervention methods to manage individuals with brain injury-related aggression. RNA methods can be used to manage aggression in patients with brain injury who have differing levels of functional impairment. Successful implementation of the RNA may allow for the management of brain injury-related aggression without seclusion or mechanical restraint.

"Being with a Buddha": A Case Report of Methoxetamine Use in a United States Veteran with PTSD.

Methoxetamine (MXE) is a ketamine analogue with a high affinity for the N-methyl-D-aspartate (NMDA) receptor. MXE is a newly emerging designer drug of abuse and is widely available through on-line sources and is not detected by routine urine drug screens. In this report, we describe a United States (US) veteran with posttraumatic stress disorder (PTSD) and heavy polysubstance use, who injected high dose MXE for its calming effect. Given MXE's structural similarities to ketamine and recent work showing that ketamine reduces PTSD symptoms, we hypothesize that MXE alleviated this veteran's PTSD symptoms through action at the NMDA receptor and via influences on brain-derived neurotrophic factor (BDNF). To our knowledge, this is the first case report of self-reported use of MXE in the US veteran population. More awareness of designer drugs, such as MXE, is an important first step in engaging patients in the treatment of designer drug addiction in both military/veteran settings and civilian settings.

Lifetime alcohol use and cognitive performance in older adults.

Substance use is an important clinical issue in the older adult population. As older adults are susceptible to cognitive disorders, the intersection of the fields of substance use and cognitive neuroscience is an active area of research. Prior studies of alcohol use and cognitive performance are mixed, and inconsistencies may be due to under- or over-adjustment for confounders. This article adds to this literature by conducting a secondary analysis of self-reported lifetime history of alcohol use and cognitive performance in older adults (n = 133). It was hypothesized that current alcohol users would have poorer cognitive performance compared to never/minimal and former alcohol users. Older adult participants were classified into never/minimal alcohol users, former alcohol users, and current alcohol users. A neurocognitive battery included a global cognitive measure and individual measures of attention, memory, fluency, and executive function. A directed acyclic graph-based approach was used to select variables to be included in the multiple linear regression models. Though unadjusted analyses showed some significant associations between alcohol use and cognitive performance, all associations between alcohol use and cognitive performance were eliminated after adjusting for age, education, sex, race, and smoking pack years. Alcohol drink years were not significantly associated with cognitive performance among current and former alcohol users. These results suggest that lifetime alcohol use is not significantly associated with cognitive performance in older adults after adjustment for key confounders. Inconsistencies in prior studies may be due to uncontrolled confounding and/or unnecessary adjustment of mediators and/or colliders.

Does trauma exposure predict prescription drug problems beyond the contribution of post-traumatic stress disorder and depression? An analysis of the Mind Your Heart cohort study.

It is not clear from prior studies whether trauma exposure predicts substance use problems independent of psychiatric comorbidities. Most prior studies were cross-sectional in nature, and none focused on prescription drug problems. To address this gap in the literature, the current article is a secondary analysis of veterans from the Mind Your Heart prospective cohort study. The primary research question is whether trauma exposure predicts prescription drug problems even after controlling for major psychiatric symptoms, such as post-traumatic stress disorder and depression. Multinomial logistic regression was used to assess whether the 10-item lifetime Brief Trauma Questionnaire (e.g., serious car accidents, war traumas, life-threatening illness, natural disasters, physical, or sexual abuse) predicts prescription drug problems as determined by a self-report categorical question (three answer choices) over a 4-year follow-up time period (n = 661 [100%] at year 1; 83.4% at year 2; 85.9% at year 3; and 78.2% at year 4). Trauma exposure was positively associated with prescription drug problems in unadjusted and age-, sex-, and race-adjusted analyses at follow-up. After accounting for post-traumatic stress disorder (PTSD Checklist-17 Civilian Version) and depression (Patient Health Questionnaire-9) symptoms, trauma exposure was no longer associated with prescription drug problems at all time points (relative risk ratios range 0.91-1.47). These results were robust to different missing data strategies. Trauma exposure was not associated with prescription drug problems over a 4-year follow-up in a prospective cohort study of veterans. Future directions include detailed measures of prescription drug problems and recruitment from community sites.

Substance use history in behavioral-variant frontotemporal dementia versus primary progressive aphasia.

As older adults are prone to cognitive disorders, the interaction of the fields of substance use and misuse and cognitive neuroscience is an emerging area of research. Substance use has been reported in some subtypes of frontotemporal dementia, such as behavioral variant frontotemporal dementia. However, characterization of substance use in other subtypes of frontotemporal dementia, such as primary progressive aphasia, is unknown. The objective of this baseline analysis was to explore whether any measures of substance use history differed significantly among behavioral variant frontotemporal dementia (n = 842) and primary progressive aphasia (n = 526) in a large national dataset. The National Alzheimer's Coordinating Center's Uniform Data Set study is a national dataset that collects data on patients with various cognitive disorders and includes some questions on substance use. Each substance use variable was used as the outcome and the frontotemporal dementia subtype as the predictor. Total years smoked cigarettes, age when last smoked cigarettes, average number of packs/day smoked when participants smoked, and any recent, remote, or combined recent/remote history of alcohol abuse or drug abuse did not significantly differ between the behavioral variant frontotemporal dementia and primary progressive aphasia subtypes (all p-values > .001). A significantly greater percentage of participants smoked in the last 30 days in the behavioral variant frontotemporal dementia subtype (10.4%, n = 834) compared to the primary progressive aphasia subtype (3.3%, n = 517; p < .001). Clinical providers in both the dementia and substance use fields are encouraged to screen for and monitor substance use in all frontotemporal dementia subtypes.

The anti-suicidal potential of buprenorphine: a case report.

The very strong relationship between suicide, depressive disorders, and substance use disorders is well recognized. Certain pain syndromes are significantly associated with suicide, irrespective of co-occurring medical or psychiatric diagnosis. Chronic pain, depression, substance use disorders, and suicide appear to involve overlapping neural pathways and brain regions that function in the processing of emotional and physical pain, as well as maintaining reward and anti-reward circuitry. In this article, we employ a clinical case to illustrate how various stressors disrupted the balance between pain and opioid-facilitated analgesia. This disruption resulted in excessive use of short-acting opioids to treat pain with ensuing allostatic overload and culmination in chronic suicidal ideation with a suicide attempt. Sublingual buprenorphine was selected to treat the opioid use disorder. We propose that the unique pharmacodynamics of this drug served to stabilize dysregulated neural circuits, neurotransmitters, and neuropeptides, allowing the mitigation of pain, assuaging opioid cravings, easing depression, and resolving suicidal ideation. To our knowledge, this is the first case report to describe the possible anti-suicidal effect of sublingual buprenorphine.

Association of alcohol use biomarkers and cognitive performance in veterans with problematic alcohol use and posttraumatic stress disorder: data from the mind your heart study.

The authors conducted a study of alcohol use biomarkers and cognitive performance among 85 veterans with problematic alcohol use and posttraumatic stress disorder (PTSD). All analyses were adjusted for demographics, depression, anxiety, and PTSD symptoms. Elevated levels of aspartate aminotransferase were associated with worse performance on the Trail Making Test Part A and Hopkins Verbal Learning Test. Two other biomarkers were not associated with any neurocognitive measures. Indirect alcohol use biomarkers (e.g., aspartate aminotransferase) may have a specific role in identifying veterans with problematic alcohol use and PTSD who show a change in psychomotor speed and immediate verbal memory performance.

Alcohol use biomarkers predicting cognitive performance: a secondary analysis in veterans with alcohol dependence and posttraumatic stress disorder.

OBJECTIVE: We conducted a secondary analysis of baseline data from a recently completed pharmacological pilot clinical trial among 30 veterans with alcohol dependence and posttraumatic stress disorder (PTSD). This trial included baseline measures of alcohol use biomarkers, both indirect (carbohydrate-deficient transferrin, GGT [γ-glutamyltransferase], mean corpuscular volume, AST [aspartate aminotransferase], alanine aminotransferase) and direct (ethyl glucuronide, ethyl sulfate), as well as neurocognitive measures (Trail Making Test parts A and B, Hopkins Verbal Learning Test-Revised, Balloon Analogue Risk Task, Delay Discounting Task). METHODS: Two regression models were estimated and tested for each neurocognitive measure (dependent measure). The first model included the alcohol use biomarker alone as the predictor. The second model included the alcohol use biomarker along with the following 3 additional predictors: Beck Depression Inventory, Clinician-Administered PTSD Scale, and receiving medications. RESULTS: In both models, the indirect biomarkers, such as GGT and AST, significantly predicted performance on the Hopkins Verbal Learning Test-Revised %Retention. GGT alone significantly predicted performance on the Trail Making Test part A. CONCLUSIONS: Indirect alcohol use biomarkers may have a specific role in identifying those veterans with alcohol dependence and PTSD who have impaired cognitive performance. However, direct alcohol use biomarkers may not share such a role.