Validity of the DSM-5 tobacco use disorder diagnostics in adults with problematic substance use.

BACKGROUND: DSM-5 tobacco use disorder (TUD) nosology differs from DSM-IV nicotine dependence (ND) by including craving and DSM-IV abuse criteria, a lower threshold (≥ 2 criteria), and severity levels (mild; moderate; severe). We assessed concurrent and prospective validity of the DSM-5 TUD diagnosis and severity and compared validity with DSM-IV ND diagnosis. METHODS: The sample included U.S. adults with current problematic substance use and past year cigarette smoking (N = 396). Baseline assessment collected information on DSM-IV ND and DSM-5 TUD criteria, smoking-related variables, and psychopathology. Over the following 90 days, electronic daily assessments queried smoking and cigarette craving. Variables expected to be related to TUD were validators: cigarette consumption, cigarette craving scale, Fagerström Test for Nicotine Dependence, and psychiatric disorders. Regression models estimated the association of each validator with DSM-5 TUD and severity levels, and differential association between DSM-5 TUD and DSM-IV ND diagnoses. RESULTS: DSM-5 TUD and DSM-IV ND were associated with most baseline validators (p-values < 0.05), with significantly stronger associations with DSM-5 TUD for number of days smoked (p = 0.023) and cigarette craving scale (p = 0.007). Baseline DSM-5 TUD and DSM-IV ND predicted smoking and craving on any given day during follow-up, with stronger associations for DSM-5 TUD (association difference [95% CI%]: any smoking, 0.53 [0.27, 0.77]; number of cigarettes smoked, 1.36 [0.89, 1.78]; craving scale, 0.19 [0.09, 0.28]). Validators were associated with TUD severity in a dose-dependent manner. CONCLUSION: DSM-5 TUD diagnostic measures as operationalized here demonstrated concurrent and prospective validity. Inclusion of new criteria, particularly craving, improved validity and clinical relevance.

Agreement between DSM-5 and DSM-IV measures of substance use disorders in a sample of adult substance users.

BACKGROUND: In DSM-5, definitions of substance use disorders (SUD) were changed considerably from DSM-IV, yet little is known about how well DSM-IV and DSM-5 SUD diagnoses agree among substance users. Because data from many studies are based on DSM-IV diagnostic criteria, understanding the agreement between DSM-5 and DSM-IV SUD diagnoses and reasons for discordance between these diagnoses is crucial for comparing results across studies. MEASUREMENTS: Prevalences and chance-corrected agreement of DSM-5 SUD and DSM-IV substance dependence were evaluated in 588 substance users in a suburban inpatient addiction program and an urban medical center, using a semi-structured interview (PRISM-5). Alcohol, tobacco, cannabis, cocaine, heroin, opioid, sedative, and stimulant use disorders were examined. Cohen's kappa was used to assess agreement between DSM-5 and DSM-IV SUD (abuse or dependence), DSM-5 SUD and DSM-IV dependence, and DSM-5 moderate/severe SUD and DSM-IV dependence. RESULTS: Agreement between DSM-5 and DSM-IV SUD was excellent for all substances (κ = 0.84-0.99), except for cannabis and tobacco (κ = 0.75; 0.80, respectively). The most common reason for diagnostic discrepancies was a positive DSM-5 SUD diagnosis but no DSM-IV diagnosis, due to the lowered DSM-5 SUD threshold. Agreement between DSM-5 SUD and DSM-IV dependence was excellent for all substances (κ = 0.88-0.94), except for alcohol, tobacco, and cannabis (κ = 0.63-0.75). Agreement between moderate/severe DSM-5 SUD and DSM-IV dependence was excellent across all substances. CONCLUSION: While care should be used in interpreting results of studies using different methods, studies relying on DSM-IV or DSM-5 SUD diagnostic criteria offer similar information and thus can be compared when accumulating a body of evidence.

Assessment of Didactic Transesophageal Echocardiography Education During Anesthesia Residency.

BACKGROUND: Transesophageal echocardiography can be a useful monitor during noncardiac surgery, in patients with comorbidities and/or undergoing procedures associated with substantial hemodynamic changes. The goal of this study was to investigate if transesophageal-echocardiography-related knowledge could be acquired during anesthesia residency. METHODS: After institutional review board approval, a prospective observational study was performed in two anesthesiology residency programs. After a 41-week didactic transesophageal-echocardiography-education curriculum residents' exam scores were compared to baseline. The educators' examination was validated against the National Board of Echocardiography's Examination of Special Competence in Advanced Perioperative Transesophageal Echocardiography. RESULTS: After the 41-week course, clinical anesthesia (CA)-3 exam scores increased 12% compared to baseline (P = .03), CA-2 scores increased 29% (P = .007), and CA-1 scores increased 25% (P = .002). Pearson correlation coefficient between the educators' exam score and the special competence exam percentile rank was 0.69 (P = .006). Pearson correlation coefficient between the educators' exam score and the special competence exam scaled score was 0.71 (P = .0045). CONCLUSIONS: The 41-week course resulted in significant increases in exam scores in all 3 CA-classes. While didactic knowledge can be learned by anesthesiology residents during training, it requires significant time and effort. It is important to educate residents in echocardiography, to prepare them for board examinations and to care for the increasingly older and sicker patient population. Further work needs to be done to determine optimal methods to provide such education.

Test-retest reliability of DSM-5 substance disorder measures as assessed with the PRISM-5, a clinician-administered diagnostic interview.

AIM: In DSM-5, the definitions of substance use disorders (SUD) were changed considerably, yet little is known about the reliability of DSM-5 SUD and its new features. METHODS: The test-retest reliability of DSM-5 SUD and DSM-IV substance dependence (SD) was evaluated in 565 adult substance users, each interviewed twice by different clinician interviewers using the semi-structured Psychiatric Research Interview for Substance and Mental Disorders, DSM-5 version (PRISM-5). DSM-5 SUD and DSM-IV SD criteria were assessed for past year and lifetime, yielding diagnoses and severity levels for alcohol, tobacco, cannabis, cocaine, heroin, opioids, sedatives, hallucinogen, and stimulant use disorders. Cohen's and intraclass correlation coefficients (ICC) assessed reliability for categorical and graded outcomes, respectively. Factors potentially influencing reliability were explored, including inpatient vs. community participant, days between interviews gender, age, race/ethnicity, and SUD severity. RESULTS: DSM-5 SUD diagnoses had substantial to excellent reliability for most substances (κ = 0.63-0.94), and moderate for others (hallucinogens, stimulants, sedatives; κ = 0.50-0.59). For graded outcomes (DSM-5 SUD mild, moderate, severe; criteria count 0-11), reliability was substantial to excellent (ICC = 0.74-0.99). Comparisons of DSM-5 SUD and DSM-IV SD reliability showed few significant differences. Reliability of the DSM-5 craving criterion was excellent for heroin (κ = 0.84-0.95) and moderate to substantial for other substances (κ = 0.49-0.76). The only factor influencing reliability of SUD was severity, with milder disorders significantly more likely to be discordant between the interviews. CONCLUSION: Reproducibility is crucial to good measurement. In a large sample using rigorous methodology, diagnoses and dimensional measures from clinician-administered interviews for DSM-5 SUD were generally highly reliable.

HealthCall delivered via smartphone to reduce co-occurring drug and alcohol use in HIV-infected adults: A randomized pilot trial.

AIMS: Co-occurrence of drug and alcohol use among people living with HIV is linked to poor medication adherence and lack of viral suppression. HealthCall, a technological enhancement of brief Motivational Interviewing (MI), involves brief daily self-monitoring, positive reinforcement, and personalized feedback. This randomized pilot study among people living with HIV investigated the feasibility and efficacy of reducing non-injection drug and alcohol use with MI+HealthCall as adapted for smartphone technology. DESIGN: An urban, largely-minority community sample of adults living with HIV were screened for eligibility: last 30 day use of non-injection drugs (≥4days of crack/cocaine, methamphetamine, or heroin use) and binge drinking (≥1day of 4+ standard drinks). Those eligible were randomized to one of two groups: MI-only (n=21) and MI+HealthCall-S (n=21). Trained counselors delivered the brief MI at baseline. Drug and alcohol use assessments were completed at baseline, 30 and 60days (end of treatment). Primary outcomes derived from a Timeline Follow Back (TLFB) of the past 30 days included (1) total number of days used primary drug (NumDU) (2) total quantity of primary drug used (dollar amount spent per day; QuantU), (3) total number of drinking days (NumDD) and (4) mean number of drinks per day (QuantDD). Feasibility was determined by HealthCall use rates, patient satisfaction questionnaire (1-5 scale, 5 being best), and retention. FINDINGS: The median daily use rate for HealthCall was 95%, patient satisfaction was excellent (4.5) and retention was high (93%). Both treatment groups reduced drug and alcohol use by end of treatment, with MI+Healthcall-S showing significantly greater reductions than MI-only in QuantU (p=0.01) and NumDU (p=0.046). P-values for reductions in alcohol quantity and frequency in the MI+Healthcall group were 0.09-0.11. CONCLUSIONS: This proof-of-concept randomized trial indicates that HealthCall on the smartphone is a highly feasible intervention in urban, minority individuals with HIV, and suggests efficacy in reducing co-occurring drug and alcohol use. Results suggest opportunities for brief behavioral intervention that may be enhanced through interactive mobile technology to address complex alcohol and drug use patterns that interfere with HIV care, medication adherence and ultimately, viral suppression. A larger randomized trial is warranted to replicate and extend present results.

Effects of State-Level Tobacco Environment on Cigarette Smoking are Stronger Among Those With Individual-Level Risk Factors.

INTRODUCTION: To better understand the impact of the state-level tobacco environment (eg, tobacco control policies, attitudes towards smoking) on cigarette smoking, we examined whether the relationship of state tobacco environments to smoking is modified by individual-level vulnerability factors. METHODS: In a nationally representative sample of US adults (N = 34 638), past-year smoking and heavy smoking were examined. State-level tobacco environment was defined by tobacco-related control policies and attitudes, ranging from permissive to restrictive; individual vulnerability was defined by childhood maltreatment and/or parental substance problems. Additive interaction tested differences in state-level tobacco environment effects on smoking and heavy smoking by individual-level vulnerability. RESULTS: Significant interactions (P values < .01) indicated that the state tobacco environment had the strongest relationship to smoking outcomes among individuals with greatest individual vulnerability. For example, among respondents with childhood maltreatment and parental substance problems, those in states with permissive tobacco environments had 13.3% greater prevalence of smoking than those in restrictive states. Among respondents with neither individual-level risk factor, those in permissive states had 2.8% greater prevalence than those in restrictive states (interaction P value = .0002). CONCLUSIONS: Further restricting states' smoking environments could help reduce the prevalence of smoking and heavy smoking, particularly among those at increased individual risk in the general population. IMPLICATIONS: This study shows that the protective effect of restrictive state-level tobacco environments on smoking or heavy smoking was stronger among those especially vulnerable due to individual-level risk factors (parental substance problems, childhood maltreatment). Thus, public health campaigns to influence attitudes towards smoking or legislation to strengthen tobacco control could have a broad effect, particularly impacting those with vulnerability to smoking, which may help decrease smoking prevalence and reduce the massive public health burden of tobacco-related morbidity and mortality.

Childhood maltreatment, personality disorders and 3-year persistence of adult alcohol and nicotine dependence in a national sample.

BACKGROUND AND AIMS: Persistent cases of alcohol and nicotine dependence are associated with considerable morbidity and mortality, and are predicted by childhood maltreatment and personality disorders. Our aim was to test whether personality disorders (individually or conjointly) mediate the relationship between childhood maltreatment and the persistence of dependence. DESIGN: Personality disorders, modeled dimensionally, were tested as mediators of the relationship between childhood maltreatment and the 3-year persistence of alcohol and nicotine dependence in participants in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) who had current alcohol and nicotine dependence in their baseline interview. Individual personality disorders were assessed in separate models. Then, those that were significant were examined jointly in multiple mediator models to determine their total and unique effects. SETTING: A large, nationally representative US survey. PARTICIPANTS: Participants ≥ 18 years who completed baseline and 3-year follow-up NESARC interviews who had baseline alcohol dependence (n = 1172; 68% male) or nicotine dependence (n = 4017; 52.9% male). MEASUREMENTS: Alcohol Use Disorder and Associated Disabilities Interview Schedule (AUDADIS-IV) measures of childhood maltreatment, personality disorders and alcohol/nicotine dependence. FINDINGS: Individual models indicated that many personality disorders mediated the relationship between childhood maltreatment and the 3-year persistence of alcohol and nicotine dependence (each explaining 6-46% of the total effect, Ps < 0.05). In multiple mediator models, borderline and antisocial symptoms remained significant mediators, each explaining 20-37% of the total effect (Ps < 0.01). CONCLUSIONS: Personality disorder symptoms (especially borderline and antisocial) help explain the association between childhood maltreatment and persistent alcohol and nicotine dependence.

The risk for persistent adult alcohol and nicotine dependence: the role of childhood maltreatment.

BACKGROUND AND AIMS: Alcohol and nicotine dependence are associated with considerable morbidity and mortality, especially when cases are persistent. The risk for alcohol and nicotine dependence is increased by childhood maltreatment. However, the influence of childhood maltreatment on dependence course is unknown, and is evaluated in the current study. DESIGN: Physical, sexual and emotional abuse, and physical and emotional neglect, were evaluated as predictors of persistent alcohol and nicotine dependence over 3 years of follow-up, with and without control for other childhood adversities. SETTING: National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). PARTICIPANTS: NESARC participants completing baseline and follow-up who met criteria at baseline for past-year alcohol dependence (n = 1172) and nicotine dependence (n = 4017). MEASUREMENTS: Alcohol Use Disorder and Associated Disabilities Interview Schedule (AUDADIS) measures of alcohol/nicotine dependence, childhood maltreatment and other adverse childhood experiences (e.g. parental divorce). FINDINGS: Controlling for demographics only, physical, sexual and emotional abuse and physical neglect predicted 3-year persistence of alcohol dependence [adjusted odds ratio (AOR) = 1.50-2.99; 95% CI = 1.04-4.68] and nicotine dependence (AOR = 1.37-1.74; 95% CI = 1.13-2.11). With other childhood adversities also controlled, maltreatment types remained predictive for alcohol persistence (AOR = 1.53-3.02; 95% CI = 1.07-4.71) and nicotine persistence (AOR = 1.35-1.72; 95% CI = 1.11-2.09). Further, a greater number of maltreatment types incrementally influenced persistence risk (AOR = 1.19-1.36; 95% CI = 1.11-1.56). CONCLUSIONS: A history of childhood maltreatment predicts persistent adult alcohol and nicotine dependence. This association, robust to control for other childhood adversities, suggests that maltreatment (rather than a generally difficult childhood) affects the course of dependence.