Piloting the integration of SMART Recovery into outpatient alcohol and other drug treatment programs.

BACKGROUND: Research suggests peer support groups can amplify and extend treatment effects and enhance long-term recovery from Alcohol and Other Drug (AOD) problems. However, they are rarely integrated into outpatient treatment programs, resulting in a missed opportunity for peer-to-peer learning, and increased connection to others social networks where people want to reduce or cease substance use. METHOD: In this mixed-methods study, we examined the uptake, participant experiences and impacts of Self-Management and Recovery Training (SMART) when embedded in three public AOD treatment programs in a pilot program in Australia. Groups were delivered initially in-person but transitioned online during the COVID-19 pandemic. RESULTS: A total of 75 SMART Recovery groups were run by the pilot sites, with an average attendance of 6.5 people per meeting. Among Participants (N = 31) who completed the survey, 94% reported benefits relating to substance use (i.e., reduction/ successful maintenance of abstinence), 71% reported improvements in their mental health and wellbeing, 74% reported improvements in their physical health, and 81% reported feeling better connected with others. In-depth qualitative interviews were conducted with 10 participants to explore their experiences. Thematic analysis revealed four themes: motivation to attend, active ingredients, views on the integration of SMART into formal AOD, and the advantages and disadvantages of online groups. CONCLUSION: Taken together, these findings suggest embedding SMART Recovery in AOD treatment is a worthwhile endeavour. This was indicated by a good uptake and evidence of multiple and unique benefits to participants over and above their usual care, notably, better management of their AOD use, health, wellbeing, and sense of connection with others.

'A circuit breaker' - Interrupting the alcohol autopilot: A qualitative exploration of participants' experiences of a personalised mHealth approach bias modification intervention for alcohol use.

Objective: There is a need for low-cost, wide-reaching interventions to enhance accessibility of support for people with hazardous alcohol consumption. We assessed participant experiences of using a novel, personalised mHealth intervention offering approach bias modification (ApBM) for alcohol use in a community sample drinking at harmful levels to enable a deeper understanding of the end user and engagement. Methods: Eighteen semi-structured telephone interviews were conducted with adults in the community drinking at harmful/hazardous levels. A reflexive thematic analysis approach was used and data analysis followed iterative categorisation. Results: Engagement/Motivation and Clinical Value were overarching themes. The useable, accessible, customisable design described by participants enabled training to be readily integrated into routines, enhancing autonomy and self-efficacy beliefs, and facilitating engagement/motivation. Where autonomy or perceived self-efficacy were threatened by a rigid training schedule or lack of clarity/reminders, engagement was reduced. Training increased awareness of drinking behaviours, and encouraged participants to consider alternate goal-directed behaviours with feedback suggesting training may function as a 'circuit breaker', increasing time between alcohol craving and seeking, and enabling reflective processing, at least in the short term. Conclusions: This novel smartphone intervention for alcohol use may be a useful, accessible, 'just in time' adjunctive support tool for non-treatment seekers, meeting an important gap in the field. Findings have implications for the implementation of subsequent digital interventions, suggesting participants may stand to gain more from an intervention which enables autonomy and improves self-efficacy beliefs. Theoretically, findings speak to the role of inferential processing in behaviour change, but further research is needed to clearly elucidate ApBM training mechanisms. Practical recommendations for subsequent app iterations are suggested, along with additional opportunities worthy of consideration for future initiatives.

Does the effectiveness of mutual aid depend on compatibility with treatment philosophies offered at residential rehabilitation services?

BACKGROUND: Residential rehabilitation treatment (including both Therapeutic Communities (TC) and non-TC rehabs) is a key component of service delivery for people seeking treatment for substance use disorders in Australia and globally. While mutual aid is often associated with better long-term outcomes, there is little evidence about whether inconsistencies between residential rehabilitation philosophies and particular types of mutual aid influence subsequent engagement and treatment outcomes. OBJECTIVE: To assess the uptake of mutual aid groups (12-step and other) on individuals leaving TC (n = 58) or non-TC (n = 78) residential treatment, and measure its impact on substance use outcomes. METHODS: Using secondary analysis of existing data, the current paper reports on 12-month outcomes from a prospective cohort study of 230 individuals entering specialist alcohol and other drug residential rehabilitation treatment in two Australian states. RESULTS: Participants who attended TC settings were more likely to attend non-spiritual mutual aid groups (i.e., SMART Recovery) than non-TC residents. Engaging in mutual aid groups was associated with significantly improved outcomes for the non-TC residents only, where it significantly predicted abstinence (OR = 5.8, CI = 1.5-18.46) and reduced frequency of use of participants' primary drug of concern (OR = 8.6, CI = 2.6-28.6). CONCLUSIONS/IMPORTANCE: Although 12-step is the most readily available and accessible form of mutual aid in Australia and benefited those attending non-TC residential rehabilitation, individuals exiting a TC program (whether they have completed treatment or not) may benefit from other forms of post-treatment recovery support, including alternative forms of peer-based support. The findings suggest treatment outcomes may be enhanced when the philosophies of residential treatment and post-discharge mutual aid are more compatible.

Enhancing the utility of the problem gambling severity index in clinical settings: Identifying refined categories within the problem gambling category.

BACKGROUND: The Problem Gambling Severity Index (PGSI) was intended for use in epidemiological research with gamblers across the continuum of risk. Its utility within clinical settings, where the majority of clients are problem gamblers, has been brought into question. AIMS: (1) Identify refined categories for the problem gambling category of the PGSI in help-seeking gamblers; (2) Validate these categories using the Gambling Symptom Assessment Scale (G-SAS); (3) Explore the relationship of these categories with indices of gambling and help-seeking behaviour. METHODS: Secondary data analysis of help-seeking problem gamblers from the Australian online gambling counselling/support service (Gambling Help Online [GHO]) from October 2012 to December 2015 (n = 5,881) and trial data evaluating an Australian online self-directed program for gambling (GamblingLess; n = 198). Both datasets included the PGSI, gambling frequency and expenditure. The GamblingLess dataset also included the G-SAS and help-seeking behaviour. RESULTS: A Latent Class Analysis, using GHO data, identified a 2-class solution. Multiple analytical methods identified a cut-off value of ≥ 19 distinguishing this 2-class solution (low problem severity: Median = 16; high problem severity: Median = 23). High problem severity gamblers had increased odds of being categorised in the higher GSAS category, greater gambling expenditure and having sought face-to-face support. The refined categories were not associated with gambling frequency, distance-based or self-directed help-seeking. CONCLUSION: These findings are consistent with a stepped-care approach, whereby individuals with higher severity may be better suited to more intensive interventions and individuals with lower severity could commence with less intensive interventions and step-up to intensive interventions.

The diagnostic accuracy of brief screening instruments for problem gambling: A systematic review and meta-analysis.

Non-gambling specialist services, such as primary care, alcohol and other drug use, and mental health services, are well placed to enhance the identification of people with gambling problems and offer appropriate generalist first level interventions or referral. Given time and resource demands, many of these clinical services may only have the capacity to administer very short screening instruments. This systematic review was conducted to provide a resource for health service providers and researchers in identifying the most accurate brief (1-5 item) screening instruments to identify problem and at-risk gambling for their specific purposes and populations. A systematic search of peer-reviewed and grey literature from 1990 to 2019 identified 25 articles for inclusion. Meta-analysis revealed five of the 20 available instruments met criteria for satisfactory diagnostic accuracy in detecting both problem and at-risk gambling: Brief Problem Gambling Screen (BPGS-2), NODS-CLiP, Problem Gambling Severity Index-Short Form (PGSI-SF), NODS-PERC, and NODS-CLiP2. Of these, the NODS-CLiP and NODS-PERC have the largest volume of diagnostic data. The Lie/Bet Questionnaire and One-Item Screen are also promising shorter options. Because these conclusions are drawn from a relatively limited evidence base, future studies evaluating the diagnostic accuracy of existing brief instruments across settings, age groups, and timeframes are needed.

Barriers and Facilitators of Responding to Problem Gambling: Perspectives from Australian Mental Health Services.

Despite high rates of comorbidity between problem gambling and mental health disorders, few studies have examined barriers or facilitators to the implementation of screening for problem gambling in mental health services. This exploratory qualitative study identified key themes associated with screening in mental health services. Semi-structured interviews were undertaken with 30 clinicians and managers from 11 mental health services in Victoria, Australia. Major themes and subthemes were identified using qualitative content analysis. Six themes emerged including competing priorities, importance of routine screening, access to appropriate screening tools, resources, patient responsiveness and workforce development. Barriers to screening included a focus on immediate risk as well as gambling being often considered as a longer-term concern. Clinicians perceived problem gambling as a relatively rare condition, but did acknowledge the need for brief screening. Facilitators to screening were changes to system processes, such as identification of an appropriate brief screening instrument, mandating its use as part of routine screening, as well as funded workforce development activities in the identification and management of problem gambling.

Validity and sensitivity of the longitudinal asymmetry index to detect gait asymmetry using Microsoft Kinect data.

Gait asymmetry information is a key point in disease screening and follow-up. Constant Relative Phase (CRP) has been used to quantify within-stride asymmetry index, which requires noise-free and accurate motion capture, which is difficult to obtain in clinical settings. This study explores a new index, the Longitudinal Asymmetry Index (ILong) which is derived using data from a low-cost depth camera (Kinect). ILong is based on depth images averaged over several gait cycles, rather than derived joint positions or angles. This study aims to evaluate (1) the validity of CRP computed with Kinect, (2) the validity and sensitivity of ILong for measuring gait asymmetry based solely on data provided by a depth camera, (3) the clinical applicability of a posteriorly mounted camera system to avoid occlusion caused by the standard front-fitted treadmill consoles and (4) the number of strides needed to reliably calculate ILong. The gait of 15 subjects was recorded concurrently with a marker-based system (MBS) and Kinect, and asymmetry was artificially reproduced by introducing a 5cm sole attached to one foot. CRP computed with Kinect was not reliable. ILong detected this disturbed gait reliably and could be computed from a posteriorly placed Kinect without loss of validity. A minimum of five strides was needed to achieve a correlation coefficient of 0.9 between standard MBS and low-cost depth camera based ILong. ILong provides a clinically pragmatic method for measuring gait asymmetry, with application for improved patient care through enhanced disease, screening, diagnosis and monitoring.

Are the demographic and clinical features of pathological gamblers seeking treatment in Singapore changing?

INTRODUCTION: The expansion in gambling activities over the past decade has made gambling more accessible than ever. This could bring changes in the sociodemographic and clinical profiles of those seeking treatment for pathological gambling. METHODS: This study examined the differences between two cohorts of 150 patients each, treated at the National Addictions Management Service between 2001 and 2006 (cohort-1) and between 2006 and 2008 (cohort-2), respectively. RESULTS: Compared to cohort-1, cohort-2 was significantly younger (p-value less than 0.01), comprised fewer Chinese and were more highly educated (p-value less than 0.05), with no significant difference in gender or marital status. Regarding the type of gambling activities, cohort-2 was more likely to engage in soccer betting (p-value less than 0.01). Although the proportion presenting with any comorbidity remained unchanged, alcohol use disorders had increased more than three-fold and suicide risk was slightly elevated, although not significantly. DISCUSSION: Clinicians should undertake routine screening and assessment of alcohol misuse and suicide risk, offering brief interventions, where necessary, for this vulnerable population.

Changes in neuropsychological functioning during alcohol detoxification.

This study investigates changes in neuropsychological functioning during early abstinence from alcohol. 30 alcohol-dependent inpatients were tested at intake (day 4 of admission) and post detoxification (day 26), using a test-retest design. The neuropsychological battery included measures of pre-morbid IQ, full-scale IQ, verbal and non-verbal measures of memory and executive function. IQ was within the normal range at intake and comparable with age-adjusted normative values and there were some impairments in memory and executive function. There were significant increases in performance scores post detoxification in working memory, verbal fluency and verbal inhibition but not in non-verbal executive function tasks (mental flexibility and planning ability). Despite increased scores on tests of verbal and memory skills after 3 weeks of abstinence, complex executive abilities showed little change. These may have a negative impact on engagement and response to treatment and compromise clinical outcomes, heightening the risk of relapse.

Drug deaths in police custody: is dual diagnosis a significant factor?

This study examined cases for possible mental health issues based on a study of 43 deaths in custody that had been supervised by the PCA between 1998 and 2002 involving the use of drugs. In 18 of the 43 cases, there was evidence of one of three groups of mental health symptoms--in five cases, there was evidence of psychosis, in five of previous self-harm or suicidal attempts, and in a further eight, there were indications of anxiety or depression. This constitutes a total of 42% of the cases studied. Those with mental health factors were more likely to have swallowed the drugs used, were more likely to have used prescription drugs and were more likely to have been believed to be faking their symptoms by the officers involved in these cases. While it is recognised that mental health problems are widespread in the criminal justice system, the diversity of conditions and the marked overlap with the use of alcohol and illicit drugs has not been sufficiently recognised, either in the training of officers or in the procedures for intervention in the custody suite.

Are the Twelve Steps more acceptable to drug users than to drinkers? A comparison of experiences of and attitudes to Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) among 200 substance misusers attending inpatient detoxification.

The present study is a cross-sectional interview-based investigation comparing experiences of and attitudes towards Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) in a sample of 200 patients attending inpatient substance misuse detoxification services. Two hundred consecutive admissions were recruited; 100 each from one drug and one alcohol in-patient treatment service in which attendance at AA/NA was a voluntary adjunct to a generic treatment programme. Although there were no differences in the history of AA/NA attendance, the drug users (who were on average younger) reported significantly more positive attitudes towards AA/NA, more willingness to attend during their in-patient treatment and greater intention to attend following completion of their detoxification. In particular, despite no differences in spiritual/religious orientation, the drug users reported more positive views of the Twelve Steps. As AA/NA remain popular and accessible forms of substance misuse support, it is critical that we develop a clearer understanding of their impact and of the scope for their integration with generic forms of substance misuse treatment.

Ethnic and gender differences in drinking and smoking among London adolescents.

OBJECTIVES: The study examines stages of drinking and smoking careers and transitions from initiation to regular use among adolescents, as a function of ethnic status and gender. DESIGN: The data were collected using a confidential, self-completion questionnaire assessing onset and frequency of drinking and smoking. The sample consisted of 1777 adolescents, between the ages of 11 and 14, drawn from eight secondary schools in south-west London. RESULTS: For both smoking and drinking, white children were more likely to have ever smoked tobacco and drunk alcohol, and were also more likely to progress from initiation to regular use than were either black or Asian children. Asian children reported the latest onset and the lowest prevalence rates for both drinking and smoking. Males reported experimenting with both cigarettes and alcohol at an earlier age than females, although a lower proportion of males report regular and lifetime involvement with both alcohol and tobacco. Furthermore, a significantly higher proportion of females who try smoking go on to do so regularly. DISCUSSION: The importance of sociocultural factors in relation to race and gender in predicting onset and escalation of substance use is discussed. The fact that age of onset does not appear to be a significant determinant of transition rate from initiation to regular use is also explored.

Drinking and smoking as concurrent predictors of illicit drug use and positive drug attitudes in adolescents.

The study investigates the relationship between smoking and drinking, and the use of illicit drugs in a cohort of London adolescents. A high prevalence of drug experimentation and positive attitudes to illicit drug use were characteristic of those who both drank alcohol and smoked cigarettes on a regular basis. There was then a clear hierarchy in which lower prevalence of use and more negative attitudes marked those who only smoked, then those who only drank, while non-smokers and non-drinkers (the largest group) had lowest lifetime and recent drug use prevalence and the most negative attitudes about drug use.

Conjugated linoleic acid inhibits differentiation of pre- and post- confluent 3T3-L1 preadipocytes but inhibits cell proliferation only in preconfluent cells.

Conjugated linoleic acid (CLA; 18:2) is a group of isomers (mainly 9-cis, 11-trans and 10-trans, 12-cis) of linoleic acid. CLA is the product of rumen fermentation and can be found in the milk and muscle of ruminants. Animals fed CLA have a lower body fat content. The objective of this study was to establish the possible mechanisms by which CLA affects adipogenesis. 3T3-L1 is a well-established cell line that is used extensively in studying adipocyte biology. These cells typically grow in a culture medium until they reach confluence, at which time they are induced to differentiate by hormonal treatment (d 0). Treatment of 3T3-L1 cells with 25 to 100 micromol/L CLA inhibited differentiation in a dose-dependent manner, while linoleic acid treatment did not differ from DMSO-treated controls. Continuous treatment from d -2, -1, 0 or 2 to d 8 and treatment from d -2 to d 0 and from d 0 to d 2 inhibited differentiation. Differentiation was monitored morphologically (oil Red-O staining), enzymatically (reduction of activity of glycerol-3-phosphate dehydrogenase), and by northern analysis of peroxisome proliferator-activated receptor gamma2, CCAAT/enhancer binding protein alpha and adipocyte specific protein 2 mRNA. CLA inhibited cell proliferation of nonconfluent cells but did not affect cell division of confluent cells, as indicated by 5-bromo-2'-deoxyuridine incorporation and mitochondria metabolism. Therefore, CLA inhibited differentiation before confluence and during induction. However, cellular proliferation was only inhibited prior to induction. These results imply that fat reduction caused by CLA treatment may be attributed to its inhibition of both proliferation and differentiation of preadipocytes in animals.

Inhibitors of preadipocyte differentiation induce COUP-TF binding to a PPAR/RXR binding sequence.

Inhibition of preadipocyte differentiation by 2,3,7,8 tetrachlorodibenzo-p-dioxin (TCDD) or retinoic acid (RA) identified another transcription factor which appears to be important for preadipocyte differentiation. Within 15 min of treating 3T3-L1 cells with TCDD, the aryl hydrocarbon receptor (AhR) is present within the cell nucleus, and increased binding of COUP-TF to an oligomer of the PPAR gamma 2/RXR binding sequence (ARE7) occurs. Following 2 days of RA treatment, increased binding of COUP-TF to the ARE7 oligomer also occurs. In untreated preadipocytes, COUP-TF mRNA increased at confluence and then decreased after induction. TCDD treatment did not alter COUP-TF mRNA changes. Dephosphorylating the nuclear extracts from TCDD and RA-treated cells eliminated binding of COUP-TF to ARE7. This is the first indication that COUP-TF may play a role in preadipocyte differentiation and that COUP-TF binding to DNA is correlated with TCDD and RA-induced phosphorylation.

Neuroendocrine differentiation in cervical carcinoma.

AIMS: To examine neuroendocrine differentiation, as shown by chromogranin A (CGA) expression, in cervical carcinomas. METHODS: Sixty seven cervical carcinomas were studied and were classified as adenocarcinomas, adenosquamous carcinomas or squamous cell carcinomas based on the assessment of haematoxylin and eosin staining and stains for mucin. Where features of glandular differentiation were identified, sections were also stained for evidence of intestinal type mucin. CGA immunostaining was done and the results were graded on a three point scale: 0, + (1-5% of cells positive) and ++ (> 5% of cells positive). These findings were then analysed with respect to lymph node status, tumour differentiation and clinical outcome. RESULTS: There were 32 adenocarcinomas, 18 adenosquamous carcinomas and 17 squamous cell carcinomas. Positive staining was seen in 14 (20.9%) cases, of which four were strongly positive. All but one case were either adenocarcinomas or adenosquamous carcinomas. There was a trend for CGA positivity to be related to intestinal differentiation but this failed to reach statistical significance. No correlation could be demonstrated between CGA staining and lymph node status, tumour differentiation and clinical outcome. CONCLUSIONS: Neuroendocrine differentiation is common in cervical carcinomas where there is evidence of glandular differentiation. Whilst the numbers in this study are relatively small, the presence of neuroendocrine cells in otherwise typical carcinomas does not seem to have any association with clinical behaviour.