A survey of surgical patients' perspectives and preferences towards general anesthesia techniques and shared-decision making.

BACKGROUND: The decision about which type of general anesthetic to administer is typically made by the clinical team without patient engagement. This study examined patients' preferences, experiences, attitudes, beliefs, perceptions, and perceived social norms about anesthesia and about engaging in the decision regarding general anesthetic choice with their clinician. METHODS: We conducted a survey in the United States, sent to a panel of surgical patients through Qualtrics (Qualtrics, Provo, UT) from March 2022 through May 2022. Questions were developed based on the Theory of Planned Behavior and validated measures were used when available. A patient partner who had experienced both intravenous and inhaled anesthesia contributed to the development and refinement of the questions. RESULTS: A total of 806 patients who received general anesthesia for an elective procedure in the last five years completed the survey. 43% of respondents preferred a patient-led decision making role and 28% preferred to share decision making with their clinical team, yet only 7.8% reported being engaged in full shared decision making about the anesthesia they received. Intraoperative awareness, pain, nausea, vomiting and quickly returning to work and usual household activities were important to respondents. Waking up in the middle of surgery was the most commonly reported concern, despite this experience being reported only 8% of the time. Most patients (65%) who searched for information about general anesthesia noted that it took a lot of effort to find the information, and 53% agreed to feeling frustrated during the search. CONCLUSIONS: Most patients prefer a patient-led or shared decision making process when it comes to their anesthetic care and want to be engaged in the decision. However, only a small percentage of patients reported being fully engaged in the decision. Further studies should inform future shared decision-making tools, informed consent materials, educational materials and framing of anesthetic choices for patients so that they are able to make a choice regarding the anesthetic they receive.

The Current State of Combined Pediatric Anesthesiology-Critical Care Practice: A Survey of Dual-Trained Practitioners in the United States.

BACKGROUND: Combined practice in pediatric anesthesiology (PA) and pediatric critical care medicine (PCCM) was historically common but has declined markedly with time. The reasons for this temporal shift are unclear, but existing evidence suggests that length of training is a barrier to contemporary trainees. Among current practitioners, restriction in dual-specialty practice also occurs, for reasons that are unknown at present. We sought to describe the demographics of this population, investigate their perceptions about the field, and consider factors that lead to attrition. METHODS: We conducted a cross-sectional, observational study of physicians in the United States with a combined practice in PA and PCCM. The survey was distributed electronically and anonymously to the distribution list of the Pediatric Anesthesia Leadership Council (PALC) of the Society for Pediatric Anesthesia (SPA), directing the recipients to forward the link to their faculty meeting our inclusion criteria. Attending-level respondents (n = 62) completed an anonymous, 40-question multidomain survey. RESULTS: Forty-seven men and 15 women, with a median age of 51, completed the survey. Major leadership positions are held by 44%, and 55% are externally funded investigators. A minority (26%) have given up one or both specialties, citing time constraints and politics as the dominant reasons. Duration of training was cited as the major barrier to entry by 77%. Increasing age and faculty rank and lack of a comparably trained institutional colleague were associated with attrition from dual-specialty practice. The majority (88%) reported that they would do it all again. CONCLUSIONS: The current cohort of pediatric anesthesiologist-intensivists in the United States is a small but accomplished group of physicians. Efforts to train, recruit, and retain such providers must address systematic barriers to completion of the requisite training and continued practice.

Predicting Hospital Readmission via Cost-Sensitive Deep Learning.

With increased use of electronic medical records (EMRs), data mining on medical data has great potential to improve the quality of hospital treatment and increase the survival rate of patients. Early readmission prediction enables early intervention, which is essential to preventing serious or life-threatening events, and act as a substantial contributor to reduce healthcare costs. Existing works on predicting readmission often focus on certain vital signs and diseases by extracting statistical features. They also fail to consider skewness of class labels in medical data and different costs of misclassification errors. In this paper, we recur to the merits of convolutional neural networks (CNN) to automatically learn features from time series of vital sign, and categorical feature embedding to effectively encode feature vectors with heterogeneous clinical features, such as demographics, hospitalization history, vital signs, and laboratory tests. Then, both learnt features via CNN and statistical features via feature embedding are fed into a multilayer perceptron (MLP) for prediction. We use a cost-sensitive formulation to train MLP during prediction to tackle the imbalance and skewness challenge. We validate the proposed approach on two real medical datasets from Barnes-Jewish Hospital, and all data is taken from historical EMR databases and reflects the kinds of data that would realistically be available at the clinical prediction system in hospitals. We find that early prediction of readmission is possible and when compared with state-of-the-art existing methods used by hospitals, our methods perform significantly better. For example, using the general hospital wards data for 30-day readmission prediction, the area under the curve (AUC) for the proposed model was 0.70, significantly higher than all the baseline methods. Based on these results, a system is being deployed in hospital settings with the proposed forecasting algorithms to support treatment.

Endovascular treatment of acute ischaemic stroke under conscious sedation: Predictors of poor outcomes.

BACKGROUND AND AIMS: Though, many practitioners prefer conscious sedation (CS), it is unclear which factors most influence neurological outcome following mechanical thrombectomy under CS. The aim of this retrospective study is to identify these factors. METHODS: After institutional review board approval, data were collected for the patients >18 years of age who underwent endovascular treatment of AIS under CS at our comprehensive stroke centre between January 2009 and June 2015. The primary outcome measure was the modified Rankin Scale (mRS) at discharge. A good outcome was defined as mRS 0-3 and poor outcome as mRS 4-6. Univariate and logistic regression analysis were performed to identify the independent predictors of poor outcomes at discharge. A P < 0.05 was considered statistically significant. RESULTS: One hundred two patients, aged 67 ± 16 years were included. The anterior cerebral circulation was affected in 88 patients (86%), and the median National Institute of Health Stroke Scale (NIHSS) score at presentation was 17.5 (range: 1-36). Overall, 21 (21%) patients had good outcome and 81 (79%) had poor outcome. Logistic regression identified the modified treatment in cerebral ischaemia (mTICI) score [odds ratio (OR): 0.443, confidence interval (CI): 0.244-0.805], NIHSS score (OR: 1.290, CI: 1.125-1.481) and previous transient ischaemic attack (TIA) (OR: 6.988, CI: 1.342-36.380) as significant independent predictors of poor outcome at discharge. CONCLUSION: The outcome of patients who underwent endovascular treatment of AIS under CS depends on the mTICI score, NIHSS score and history of previous TIA.

Intraoperative ketamine for prevention of postoperative delirium or pain after major surgery in older adults: an international, multicentre, double-blind, randomised clinical trial.

BACKGROUND: Delirium is a common and serious postoperative complication. Subanaesthetic ketamine is often administered intraoperatively for postoperative analgesia, and some evidence suggests that ketamine prevents delirium. The primary purpose of this trial was to assess the effectiveness of ketamine for prevention of postoperative delirium in older adults. METHODS: The Prevention of Delirium and Complications Associated with Surgical Treatments [PODCAST] study is a multicentre, international randomised trial that enrolled adults older than 60 years undergoing major cardiac and non-cardiac surgery under general anaesthesia. Using a computer-generated randomisation sequence we randomly assigned patients to one of three groups in blocks of 15 to receive placebo (normal saline), low-dose ketamine (0·5 mg/kg), or high dose ketamine (1·0 mg/kg) after induction of anaesthesia, before surgical incision. Participants, clinicians, and investigators were blinded to group assignment. Delirium was assessed twice daily in the first 3 postoperative days using the Confusion Assessment Method. We did analyses by intention-to-treat and assessed adverse events. This trial is registered with clinicaltrials.gov, number NCT01690988. FINDINGS: Between Feb 6, 2014, and June 26, 2016, 1360 patients were assessed, and 672 were randomly assigned, with 222 in the placebo group, 227 in the 0·5 mg/kg ketamine group, and 223 in the 1·0 mg/kg ketamine group. There was no difference in delirium incidence between patients in the combined ketamine groups and the placebo group (19·45% vs 19·82%, respectively; absolute difference 0·36%, 95% CI -6·07 to 7·38, p=0·92). There were more postoperative hallucinations (p=0·01) and nightmares (p=0·03) with increasing ketamine doses compared with placebo. Adverse events (cardiovascular, renal, infectious, gastrointestinal, and bleeding), whether viewed individually (p value for each >0·40) or collectively (36·9% in placebo, 39·6% in 0·5 mg/kg ketamine, and 40·8% in 1·0 mg/kg ketamine groups, p=0·69), did not differ significantly across groups. INTERPRETATION: A single subanaesthetic dose of ketamine did not decrease delirium in older adults after major surgery, and might cause harm by inducing negative experiences. FUNDING: National Institutes of Health and Cancer Center Support.

Characterizing psychosis risk traits in Africa: A longitudinal study of Kenyan adolescents.

The schizophrenia prodrome has not been extensively studied in Africa. Identification of prodromal behavioral symptoms holds promise for early intervention and prevention of disorder onset. Our goal was to investigate schizophrenia risk traits in Kenyan adolescents and identify predictors of psychosis progression. 135 high-risk (HR) and 142 low-risk (LR) adolescents were identified from among secondary school students in Machakos, Kenya, using the structured interview of psychosis-risk syndromes (SIPS) and the Washington early recognition center affectivity and psychosis (WERCAP) screen. Clinical characteristics were compared across groups, and participants followed longitudinally over 0-, 4-, 7-, 14- and 20-months. Potential predictors of psychosis conversion and severity change were studied using multiple regression analyses. More psychiatric comorbidities and increased psychosocial stress were observed in HR compared to LR participants. HR participants also had worse attention and better abstraction. The psychosis conversion rate was 3.8%, with only disorganized communication severity at baseline predicting conversion (p=0.007). Decreasing psychotic symptom severity over the study period was observed in both HR and LR participants. ADHD, bipolar disorder, and major depression diagnoses, as well as poor occupational functioning and avolition were factors relating to lesser improvement in psychosis severity. Our results indicate that psychopathology and disability occur at relatively high rates in Kenyan HR adolescents. Few psychosis conversions may reflect an inadequate time to conversion, warranting longer follow-up studies to clarify risk predictors. Identifying disorganized communication and other risk factors could be useful for developing preventive strategies for HR youth in Kenya.

Intraoperative awareness risk, anesthetic sensitivity, and anesthetic management for patients with natural red hair: a matched cohort study.

PURPOSE: The red-hair phenotype, which is often produced by mutations in the melanocortin-1 receptor gene, has been associated with an increase in sedative, anesthetic, and analgesic requirements in both animal and human studies. Nevertheless, the clinical implications of this phenomenon in red-haired patients undergoing surgery are currently unknown. METHODS: In a secondary analysis of a prospective trial of intraoperative awareness, red-haired patients were identified and matched with five control patients, and the relative risk for intraoperative awareness was determined. Overall anesthetic management between groups was compared using Hotelling's T(2) statistic. Inhaled anesthetic requirements were compared between cohorts by evaluating the relationship between end-tidal anesthetic concentration and the bispectral index with a linear mixed-effects model. Time to recovery was compared using Kaplan-Meier analysis, and differences in postoperative pain and nausea/vomiting were evaluated with Chi square tests. RESULTS: A cohort of 319 red-haired patients was matched with 1,595 control patients for a sample size of 1,914. There were no significant differences in the relative risk of intraoperative awareness (relative risk = 1.67; 95% confidence interval 0.34 to 8.22), anesthetic management, recovery times, or postoperative pain between red-haired patients and control patients. The relationship between pharmacokinetically stable volatile anesthetic concentrations and bispectral index values differed significantly between red-haired patients and controls (P < 0.001), but without clinical implications. CONCLUSION: There were no demonstrable differences between red-haired patients and controls in response to anesthetic and analgesic agents or in recovery parameters. These findings suggest that perioperative anesthetic and analgesic management should not be altered based on self-reported red-hair phenotype.

Cost-effectiveness of interventions to prevent HIV and STDs among women: a randomized controlled trial.

Injection drug use is a leading transmission route of HIV and STDs, and disease prevention among drug users is an important public health concern. This study assesses cost-effectiveness of behavioral interventions for reducing HIV and STDs infections among injection drug-using women. Cost-effectiveness analysis was conducted from societal and provider perspectives for randomized trial data and Bernoullian model estimates of infections averted for three increasingly intensive interventions: (1) NIDA's standard intervention (SI); (2) SI plus a well woman exam (WWE); and (3) SI, WWE, plus four educational sessions (4ES). Trial results indicate that 4ES was cost-effective relative to WWE, which was dominated by SI, for most diseases. Model estimates, however, suggest that WWE was cost-effective relative to SI and dominated 4ES for all diseases. Trial and model results agree that WWE is cost-effective relative to SI per hepatitis C infection averted ($109 308 for in trial, $6 016 in model) and per gonorrhea infection averted ($9 461 in trial, $14 044 in model). In sensitivity analysis, trial results are sensitive to 5 % change in WWE effectiveness relative to SI for hepatitis C and HIV. In the model, WWE remained cost-effective or cost-saving relative to SI for HIV prevention across a range of assumptions. WWE is cost-effective relative to SI for preventing hepatitis C and gonorrhea. WWE may have similar effects as the costlier 4ES.

Obstructive sleep apnea screening and postoperative mortality in a large surgical cohort.

OBJECTIVE: A recent investigation at Barnes-Jewish Hospital located in St. Louis, Missouri, found that an estimated 22% of adults presenting for inpatient surgery screened as high risk for obstructive sleep apnea (OSA). Surgical patients with OSA have multiple comorbidities and are at increased risk for perioperative complications. Our objective was to determine if a prior diagnosis of OSA or a positive screen for OSA was associated with increased risk for 30-day and one-year mortality. METHODS: B-J APNEAS (Barnes-Jewish Apnea Prevalence in Every Admission Study) was a prospective cohort study. Unselected adult surgical patients at Barnes Jewish Hospital were prospectively enrolled between February 2006 and April 2010. All patients completed preoperative OSA screening and those who were at risk for OSA according to a combination of the Berlin and Flemons screening tools received targeted postoperative interventions. STOP (loud Snoring, daytime Tiredness, Observed apneas, and high blood Pressure) and STOP-BANG (STOP, plus body mass index [BMI], age, neck circumference, and gender) scores also were obtained. RESULTS: Overall, the sample included 14,962 patients, of whom 1939 (12.9%) reported a history of OSA. All four screening tools identified a high prevalence of undiagnosed patients at risk for OSA (9.5%-41.6%), but agreement among screens was not strong with κ statistic ranging from 0.225 to 0.611. There was no significant difference in 30-day postoperative mortality between patients with possible OSA (based on their history or on a positive OSA screen with any of the four instruments) and the rest of the surgical population. Significant differences in one-year mortality were noted between the low-risk and high-risk groups as identified by the Flemons' (4.96% vs 6.91%; p<0.0001), STOP (5.28% vs 7.57%; p<0.0001) and STOP-BANG (4.13% vs 7.45%; p<0.0001) screens. After adjusting for risk factors, none of the OSA screening tools independently predicted mortality rate up to one year postoperatively. CONCLUSION: Neither a prior diagnosis of OSA nor a positive screen for OSA risk was associated with increased 30-day or one-year postoperative mortality. Differences in 1 year postoperative mortality were noted with three of the screening tools. The results of our study highlight uncertainties and research priorities for the medical community.

Postoperative recovery with bispectral index versus anesthetic concentration-guided protocols.

BACKGROUND: Use of the bispectral index (BIS) monitor has been suggested to decrease excessive anesthetic drug administration, leading to improved recovery from general anesthesia. The purpose of this substudy of the B-Unaware and BAG-RECALL trials was to assess whether a BIS-based anesthetic protocol was superior to an end-tidal anesthetic concentration-based protocol in decreasing recovery time and postoperative complications. METHODS: Patients at high risk for awareness were randomized to either BIS-guided or end-tidal anesthetic concentration-guided general anesthesia in the original trials. Outcomes included time to postanesthesia care unit discharge readiness, time to achieve a postoperative Aldrete score of 9-10, intensive care unit length of stay, postoperative nausea and vomiting, and severe postoperative pain. Univariate Cox regression and chi-square tests were used for statistical analyses. RESULTS: The BIS cohort was not superior in time to postanesthesia care unit discharge readiness (hazard ratio, 1.0; 95% CI, 1.0-1.1; n = 2,949), time to achieve an Aldrete score of 9-10 (hazard ratio, 1.2; 95% CI, 1.0-1.4; n = 706), intensive care unit length of stay (hazard ratio, 1.0; 95% CI, 0.9-1.1; n = 2,074), incidence of postoperative nausea and vomiting (absolute risk reduction, -0.5%; 95% CI, -5.8 to 4.8%; n = 789), or incidence of severe postoperative pain (absolute risk reduction, 4.4%; 95% CI, -2.3 to 11.1%; n = 759). CONCLUSIONS: In patients at high risk for awareness, the BIS-guided protocol is not superior to an anesthetic concentration-guided protocol in time needed for postoperative recovery or in the incidences of common postoperative complications.

Cost-effectiveness of peer-delivered interventions for cocaine and alcohol abuse among women: a randomized controlled trial.

AIMS: To determine whether the additional interventions to standard care are cost-effective in addressing cocaine and alcohol abuse at 4 months (4 M) and 12 months (12 M) from baseline. METHOD: We conducted a cost-effectiveness analysis of a randomized controlled trial with three arms: (1) NIDA's Standard intervention (SI); (2) SI plus a Well Woman Exam (WWE); and, (3) SI, WWE, plus four Educational Sessions (4ES). RESULTS: To obtain an additional cocaine abstainer, WWE compared to SI cost $7,223 at 4 M and $3,611 at 12 M. Per additional alcohol abstainer, WWE compared to SI cost $3,611 and $7,223 at 4 M and 12 M, respectively. At 12 M, 4ES was dominated (more costly and less effective) by WWE for abstinence outcomes. CONCLUSIONS: To our knowledge, this is the first cost-effectiveness analysis simultaneously examining cocaine and alcohol abuse in women. Depending on primary outcomes sought and priorities of policy makers, peer-delivered interventions can be a cost-effective way to address the needs of this growing, underserved population. TRIAL REGISTRATION: ClinicalTrials.gov NCT01235091.

Motives and simultaneous sedative-alcohol use among past 12-month alcohol and nonmedical sedative users.

BACKGROUND: Simultaneous sedative-alcohol use (SSAU) is a matter of public health concern. It is important to address the various motives individuals may have for involvement in SSAU. OBJECTIVE: To explore the motives associated with SSAU. METHODS: Data were collected as part of the ongoing Prescription Drug Misuse, Abuse, and Dependence study in St. Louis. For this analysis, the sample included 173 participants who reported nonmedical sedative use for more than 5 days, and use of alcohol, in the past 12 months. SSAU was defined as past 12-month use of sedatives and alcohol together/at the same time. RESULTS: Past 12-month SSAU was reported by 61% of the sample. Multivariate logistic regression indicated that for every increment of one motive, participants were significantly more likely to report SSAU (adjusted odds ratio (aOR): 1.30; 95% confidence interval (CI): 1.12-1.52). Furthermore, reporting sedative use "to get high, to change mood, to relieve stress, to party, and 'just because' " was independently associated with the past 12-month SSAU. Past 12-month SSAU was also found to be significantly associated with simultaneous use of sedatives and cannabis in the past 12 months. CONCLUSION: A higher number of motives, as well as specific motives reported for sedative use, were found to be significantly associated with past 12-month SSAU. SCIENTIFIC SIGNIFICANCE: Findings underscore the need for considering motives in tailoring preventive interventions for reducing SSAU. It may be equally important to direct efforts toward decreasing the number of motives, as well as addressing the specific motives reported for sedative use.

Effects of major depression on crack use and arrests among women in drug court.

AIMS: We examined whether a current major depressive episode (MDE) at baseline predicted crack use and arrests at follow-up among women enrolled in drug court. DESIGN: Primary analyses used zero-inflated Poisson (ZIP) and zero-inflated negative binomial (ZINB) regression analyses to predict both yes/no and number of (i) days of crack use and (ii) arrests at 4-month follow-up from current (30-day) MDE at baseline. Secondary analyses addressed risk conferred by current versus past MDE at baseline. SETTING/PARTICIPANTS: Participants were 261 women in drug court. MEASUREMENTS: MDE was assessed using the Diagnostic Interview Schedule. Days using crack and number of arrests were assessed using the Washington University Risk Behavior Assessment for Women. FINDINGS: Having a current MDE at baseline predicted likelihood of crack use at follow-up, but not days of crack use among those who used. Current MDE at baseline did not predict presence or number of arrests at the 4-month follow-up. Women with current MDE at baseline were more likely to be using crack at follow-up than were those with recent (31+ days to 12 months) but not current MDE (odds ratio = 5.71); past MDE at baseline did not increase risk of crack use. CONCLUSIONS: Predictors of any versus no crack use or arrests appear to differ from predictors of frequency of these behaviors. Current major depression, but not past major depression, appears to be associated with increased risk of crack use among women attending drug court.

The three latent classes of adolescent delinquency and the risk factors for membership in each class.

This study used latent class analysis to examine subpopulation membership based on self-reports of delinquent behaviors obtained from Australian youth. Three discrete identifiable classes were derived based on 51 indicators of physical violence, property damage, minor infractions, drug use, and social delinquency. One class of youth engaged in primarily rule breaking and norm violations including underage alcohol use, typical of this age period. A second class was more actively delinquent emphasizing drug use, trespassing, and various forms of disobedience. A third class of highly delinquent youth differed from their counterparts by endorsing drug use, thievery that involved stealing money, goods, and cars, property damage, gambling, precocious sexual experiences, involvement with pornographic materials, and fighting. Multinomial logistic regression predicting class membership indicated highly delinquent youth were more likely to be older males, use venting coping strategies, and be fun or novelty seeking compared with rule breakers. Findings are discussed in terms of refining current taxonomic arguments regarding the structure of delinquency and implications for prevention of early-stage antisocial behavior.

Heavy use versus less heavy use of sedatives among non-medical sedative users: Characteristics and correlates.

Non-medical use of sedatives is an ongoing problem. However, very little is known about the characteristics of individuals who use sedatives non-medically, or the motives behind such use. The present analysis, involving a sample of individuals reporting non-medical use of sedatives in the past 12 months (N=188), examined the relationship between socio-demographic variables, past-year use of other licit and illicit drugs, type of non-medical use (use in ways other than as prescribed, use when not prescribed, or both), motives, and past 12-month sedative use. Past 12-month sedative use was dichotomized as Heavy Use (>90 pills in past 12 months) and Less Heavy Use (≤90 pills), using a median split. Multivariate logistic regression analyses indicated that Heavy Use of sedatives was significantly associated with positive diagnoses for sedative use disorder and prescription opioid use disorder, a higher number of motives for sedative use, and reporting 'sedative use in ways other than as prescribed' and 'both forms of non-medical use, namely, other than as prescribed, and when not prescribed,' compared to non-prescribed use. Although in univariate analyses a positive diagnosis for past 12-month cocaine use disorder, and individual motives for sedative use such as 'to get high' and 'for pain relief', significantly predicted past 12-month Heavy Use, their effects diminished and became non-significant after adjusting for other covariates. Findings underscore the need for considering differential risk factors in tailoring preventive interventions for reducing non-medical sedative use.

Costs of HIV prevention among out-of-treatment drug-using women: results of a randomized controlled trial

We developed a micro-costing methodology to estimate the realresource costs consumed by delivery of the National Institute on Drug Abuse (NIDA) Cooperative Agreement Standard Intervention (SI) for human immunodeficiencyvirus (HIV) prevention, plus two enhanced modules, in a three-arm randomized controlled trial (RCT) among drug-using women. To our knowledge, this is the first micro-costing study of the SI and enhanced modules andthe first of its kind targeting drug-using women

Test-re-test reliability of DSM-IV adopted criteria for 3,4-methylenedioxymethamphetamine (MDMA) abuse and dependence: a cross-national study.

AIMS: This study evaluated the prevalence and reliability of DSM-IV adopted criteria for 3,4-methylenedioxymethamphetamine (MDMA) abuse and dependence with a purpose to determine whether it is best conceptualized within the category of hallucinogens, amphetamines or its own category. DESIGN: Test-re-test study. PARTICIPANTS: MDMA users (life-time use >5 times) were recruited in St Louis, Miami and Sydney (n=593). The median life-time MDMA consumption was 50 pills at the baseline. MEASUREMENTS: The computerized Substance Abuse Module for Club Drug (CD-SAM) was used to assess MDMA abuse and dependence. The Discrepancy Interview Protocol (DIP) was used to determine the reasons for the discrepant responses between the two interviews. Reliability of diagnoses, individual diagnostic criteria and withdrawal symptoms was examined using the kappa coefficient (κ). findings for baseline data, 15% and 59% met MDMA abuse and dependence, respectively. Substantial test-re-test reliability of the diagnoses was observed consistently across cities (κ=0.69). 'Continued use despite knowledge of physical/psychological problems' (87%) and 'withdrawal' (68%) were the two most prevalent dependence criteria. 'Physically hazardous use' was the most prevalent abuse criterion. Six dependence criteria and all abuse criteria were reported reliably across cities (κ: 0.53-0.77). Seventeen of 19 withdrawal symptoms showed consistency in the reliability across cities. The most commonly reported reason for discrepant responses was 'interpretation of question changed'. Only a small proportion of the total discrepancies were attributed to lying or social desirability. CONCLUSION: The adopted DSM-IV diagnostic classification for MDMA abuse and dependence was moderately reliable across cities. findings on MDMA withdrawal support the argument that MDMA should be separated from other hallucinogens in DSM.

Prevalence of psychotic symptoms in substance users: a comparison across substances.

BACKGROUND: Psychotic symptoms (delusions and hallucinations) are reported to be increased among persons using illicit substances, but little is known about the comparative frequency with which the symptoms occur with abuse of different substances. To establish this, we interviewed individuals who had wide experience of commonly used drugs. METHODS: Four hundred seventy-six intravenous drug users, crack-cocaine users, and heroin snorters recruited via street outreach were interviewed using the Composite International Diagnostic Interview-Substance Abuse Model to assess dependence on a number of substances including amphetamines, cannabis, cocaine, and opioids. As a part of this assessment, we assessed a history of delusions and hallucinations in the context of use of, or withdrawal from, these specific substances. RESULTS: From 27.8% to 79.6% users of amphetamine, cannabis, cocaine, and opiates met Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised, dependence for that specific substance. The prevalence of psychotic symptoms associated with each specific substance ranged from users with no diagnosis to users with severe dependence as follows: amphetamines (5.2%-100%), cannabis (12.4%-80.0%), cocaine (6.7%-80.7%), and opiates (6.7%-58.2%). The risk of psychotic symptoms increased for respondents who abused (odds ratio [OR], 12.2) or had mild (OR, 17.1), moderate (OR, 47.0), or severe dependence (OR, 114.0) on cocaine when compared to those who were users with no diagnosis. A similar pattern was evident in cannabis, opiate, and amphetamine users. CONCLUSIONS: Most users dependent on illicit substances experience psychotic symptoms in the context of use of, or withdrawal from, these substances. Psychotic symptoms increased with the severity of the substance use disorders for all 4 substances. These findings emphasize the importance of developing services to target this population as they are at a heightened risk for developing psychotic symptoms.

Does readiness to change predict reduced crack use in human immunodeficiency virus prevention?

This study examines crack cocaine (crack) use, readiness to change, and gender in a sample of 923 men and women randomized to standard human immunodeficiency virus (HIV) education (standard intervention [SI]) or peer-delivered intervention (enhanced intervention [EI]). Four levels of crack use characterized frequency of use in the past 30 days; readiness was assessed on three levels (precontemplation, contemplation, and preparation/action). Differences between intervention groups on crack use and readiness by gender were examined from baseline to 3-month follow-up. Overall, participants reduced their crack use from baseline, with those in the EI showing greater improvement than those in the SI. A small proportion of participants improved readiness; those who improved were more likely to improve their crack use. No significant gender differences were found. These findings suggest that the readiness construct does not fully capture the dynamics of change among out-of-treatment crack users. Further research is needed to fully comprehend the dynamics of change among this group.

A psycho-economic model of ecstasy consumption and related consequences: a multi-site study with community samples.

Becker and Murphy's (1988) theory of rational behavior suggests that economic factors play an influential role in the decision leading to drug consumption and possibly dependence. Psychological models, on the other hand, emphasize internal regulatory cues that motivate drug use and play a contributory role in dependence. Until now, the confluence of both economic and psychological models has not been tested empirically. The present study used latent-variable structural equation modeling (SEM) to examine the influence of both economic (social anomie, unit price, and time spent acquiring drugs) and psychological risk factors (motivation, depression, and sexual risk behaviors) on self-reported ecstasy use. Data were obtained from 612 recreational ecstasy users in the United States and Australia participating in a NIDA-funded epidemiological study examining trends in ecstasy use. The sample was mainly white (61%), male (58%), and young (mean age = 23 yrs [5.25]). All of the hypothesized latent constructs were statistically reliable and correlated in the expected direction. A saturated SEM indicated that monetary and opportunity cost, but not income, significantly predicted ecstasy use. Among the psychological measures, motivational cues were the strongest predictor of both use and dependence. Inclusion of gender, age, race, education, and site variables did not appreciably alter the final model parameters. The implications of incorporating the role of economic factors in shaping a more refined understanding of addiction are discussed. Suggestions for future research and study limitations are also noted.