Substance Abuse News

Although various kinds of substance use are associated with reduced educational attainment, these associations have been mixed and may also be partially due to risk factors such as socioeconomic disadvantages. A study of substance use and education among male twins from a veteran population has found a strong relationship among early alcohol use, alcohol dependence, daily nicotine use, and fewer years of educational attainment.

Results will be published in Alcoholism: Clinical & Experimental Research and are currently available at Early View.

Mixed Results

“Evidence for an association between substance use/abuse/dependence and reduced lifetime educational attainment is mixed,” said Julia D. Grant, research assistant professor of psychiatry at Washington University School of Medicine as well as corresponding author for the study.

“In addition,” said Matt McGue, a professor in the department of psychology at the University of Minnesota, “what is missing is an explanation for the basis of the association. We might consider two possibilities. One, adolescent substance use results in diminished educational achievement because substance use is neurotoxic to the developing adolescent brain, or because adolescents who use substances have experiences that reduce the likelihood they will pursue higher education.”

Another possibility, he added, is that “individuals who use substances in adolescence differ from those who do not on a range of risk factors prior to substance use exposure, which not only lead to their use of substances but also reduce the likelihood they achieve a college education. This possibility means that adolescent substance use is merely an indicator of the risk factors that diminish the likelihood of college attainment.”

Lifetime Educational Attainment

“Because our participants were in their late 30s when their educational attainment was assessed, we were better able to address lifetime educational attainment than most previous studies, which have focused on high school dropouts or educational attainment in 18-25 year-olds,” said Grant. “We also examined educational attainment in a veteran cohort that had access to education via benefits of the G.I. bill, thereby alleviating some of the economic barriers to higher education that might otherwise be confounded with alcohol and drug outcomes.”

Grant and her colleagues examined data collected from two points in time: a 1987 questionnaire, and a 1992 telephone diagnostic interview of 6,242 male twins (n=3,121 pairs with a mean age of 41.9 years in 1992) who had served in the U.S. military during the Vietnam-era and were therefore eligible for educational benefits after military service. Specific factors addressed were reduced educational attainment – defined as less than 16 years – as well as early alcohol and cannabis use, daily nicotine use, lifetime cannabis use, and alcohol, nicotine, cannabis, and any illicit drug dependence.

“Although all substance use measures were associated with lower educational attainment in preliminary analyses,” said Grant, “only early alcohol use, alcohol dependence, and daily nicotine use remained significantly associated with reduced educational attainment in twin pairs discordant for substance use. In contrast, the associations between cannabis/other illicit drugs and educational attainment were not significant, suggesting that this association may be attributable to familial influences shared by the two measures.”

Sober Twin More Likely to Finish College

“In this study, they conclude that within twin pairs discordant for adolescent substance use, the unexposed twin was more likely to complete college than his/her exposed cotwin,” said McGue. “This provides much stronger support for a causal influence than a standard epidemiological study because of the control afforded by comparing the discordant twins. However, it is important to recognize that it does not prove causality.”

“It is possible that early alcohol use and alcohol dependence impede later educational attainment,” noted Grant. “Possible mechanisms for this include cognitive and motivational changes stemming from early alcohol use/dependence that hinder academic success. Although daily nicotine use is not likely to impair cognitive functioning, it may lead to motivational changes that affect academic performance. It is also possible that the association between these substances and lower educational attainment remains because both are attributable to a factor that we did not control for in our present analyses, such as personality characteristics and cognitive ability prior to substance use.”

Complicated Relationship

Grant said these findings underscore the complicated relationship between substance use and educational attainment.

“By controlling for all familial influences that contribute to both substance use and educational attainment, through our discordant twin design, we have a much stronger indicator of the direct association between substance use and educational attainment,” she said. “However, because we were studying higher levels of education – 16+ years – in high school graduates, we may have understated the true effect of alcohol on education. It may be that these effects are more pronounced at even lower levels of education. Nonetheless, our findings lend credence to ongoing public health efforts to reduce adolescent smoking and drinking, which in turn may have beneficial effects on school dropout and lifelong educational attainment.”

Noisy neighbors and broken-down elevators are common downsides of apartment living. You also can add unwanted tobacco smoke to the list of hazards, according to research to be presented Sunday, April 29, at the Pediatric Academic Societies (PAS) annual meeting in Boston.

Studies have shown that tobacco smoke can seep from one apartment into another. The extent to which this happens, however, is unclear.

Unwanted Tobacco Smoke

Researchers from the American Academy of Pediatrics Julius B. Richmond Center of Excellence surveyed a nationally representative sample of adults living in apartments to examine factors associated with unwanted tobacco smoke. The center, named for a former U.S. surgeon general, is committed to protecting children from tobacco and secondhand smoke.

Apartment dwellers were asked whether they experienced smoke incursion, which was defined as smelling tobacco smoke in their building and/or unit. They also were asked if they had children and if their apartment building had any smoking restrictions. Only respondents who reported that no one had smoked in their home for the previous three months were included in the study.

Results showed that nearly one-third of the 323 eligible respondents reported smelling tobacco smoke in their buildings, and half of these residents reported smelling smoke in their own units. In particular, residents with children were more likely to smell smoke in their building than those with no children (41 percent vs. 26 percent).

Daily Exposure to Smoke

Survey results also showed that 38 percent of those who reported smelling smoke said they did so weekly, while 12 percent smelled smoke daily.

“A significant number of residents of multi-unit housing are being unwillingly exposed to tobacco smoke, in some cases on a daily basis, and children seem to be especially vulnerable,” said lead author Karen M. Wilson, MD, MPH, FAAP, section head, pediatric hospital medicine at Children’s Hospital Colorado and assistant professor of pediatrics, University of Colorado School of Medicine. “This exposure could put children at risk for respiratory diseases and illness if it is persistent or if the child has a significant respiratory illness such as asthma or cystic fibrosis.”

“A smoke-free building protects the shared indoor air that all residents, including infants and children, are forced to breathe. Every parent needs to hear about this research because it could be their infant or child who is exposed next,” said Jonathan P. Winickoff, MD, MPH, FAAP, associate professor in pediatrics, MassGeneral Hospital for Children, Boston.

Residents receiving government housing subsidies also were more likely to smell smoke.

Options Are Limited

“Options for such housing are limited, and residents forced to experience smoke exposure in their buildings may not have the option to move to a smoke-free complex,” Dr. Wilson added.

Partial measures, such as limiting common area smoking, appeared to be ineffective at protecting nonsmokers from exposure in their own units. As long as smoking was allowed in the individual units of a building, higher rates of exposure were reported. Only completely smoke-free buildings were associated with lower incursion rates.

“This finding supports grassroots efforts by multi-unit housing resident groups, apartment managers and owners to make buildings smoke-free for the comfort, health and safety of their residents, and because of the far lower costs associated with managing nonsmoking apartments,” Dr. Wilson concluded.

During high school the parents of teenagers’ friends can have as much effect on the teens’ substance use as their own parents, according to prevention researchers.

“Among friendship groups with ‘good parents’ there’s a synergistic effect — if your parents are consistent and aware of your whereabouts, and your friends’ parents are also consistent and aware of their (children’s) whereabouts, then you are less likely to use substances,” said Michael J. Cleveland, research assistant professor at the Prevention Research Center and the Methodology Center, Penn State. “But if you belong to a friendship group whose parents are inconsistent, and your parents are consistent, you’re still more likely to use alcohol. The differences here are due to your friends’ parents, not yours.”

Parents Can Play a Key Role

Cleveland and his colleagues report parenting behaviors and adolescents’ substance-use behaviors to be significantly correlated in the “expected directions” in this month’s issue of the Journal of Studies on Alcohol and Drugs. Results show higher levels of parental knowledge and disciplinary consistency leading to a lower likelihood of substance use, whereas lower levels lead to a higher likelihood of substance use.

However if adolescents’ parents are consistent and generally aware of their children’s activities, but the parents of the children’s friends are inconsistent and generally unaware of their own children’s activities, the adolescents are more likely to use substances than if their friends’ parents were more similar to their own parents.

Peer Influence Very Powerful

“The peer context is a very powerful influence,” said Cleveland. “We’ve found in other studies that the peer aspect can overwhelm your upbringing.”

While long suspected to be the case, the researchers believe this to be the first study where parenting at the peer level proved to have a concrete and statistically significant impact on child outcomes.

Friendship Groups Studied

The researchers surveyed 9,417 ninth-grade students during the spring semester, and then again the following spring semester. The students came from 27 different rural school districts in Pennsylvania and Iowa, all participating in the Promoting School-university-community Partnerships to Enhance Resilience (PROSPER) study. In ninth grade, the researchers asked the students to name five of their closest friends. The researchers identified social networks within the schools by matching up the mutually exclusive friendships. Overall, the researchers identified 897 different friendship groups, with an average of 10 to 11 students in each group.

At that time students also answered questions about their perceptions of how much their parents knew about where they were and who they were with. They were also asked about the consistency of their parents’ discipline. In the tenth-grade follow-up, students responded to questions about their substance use habits, specifically their use of alcohol, cigarettes and marijuana.

Parents Can Influence Friends, Too

Behaviors of friends’ parents influenced substance use even when taking into account the effects of the teens’ own parents’ behaviors and their friends’ substance use, demonstrating the powerful effect of peers on adolescent behavior.

“I think that it empowers parents to know that not only can they have an influence on their own children, but they can also have a positive influence on their children’s friends as well,” said Cleveland. “And that by acting together — the notion of ‘it takes a village’ — can actually result in better outcomes for adolescents.”

Minors who were familiar with television alcohol advertisements were more likely to have tried alcoholic beverages and binge drink than those who could not recall seeing such ads, according to a study to be presented Sunday, April 29, at the Pediatric Academic Societies (PAS) annual meeting in Boston.

“Underage drinking remains an important health risk in the U.S.,” said lead author Susanne E. Tanski, MD, MPH, FAAP, assistant professor in the Department of Pediatrics at Children’s Hospital at Dartmouth, Dartmouth-Hitchcock Medical Center. “In this study, we have shown a link between recognition of nationally televised alcohol advertisements and underage drinking initiation and heavier use patterns.”

Promoting Risky Behaviors

Previous research by Dr. Tanski and her colleagues showed an association between seeing smoking and drinking in movies and adolescents engaging in these risky behaviors. This study expanded on that research by exploring whether there is an association between young people’s exposure to television alcohol advertising and substance use.

The researchers surveyed a national sample of 2,541 youths ages 15 to 20 years. Participants were asked about their age, gender, race, if their friends drank, if their parents drank, whether they had a favorite alcohol ad and whether they owned alcohol-branded merchandise. They also were asked questions to assess whether they engaged in “sensation-seeking” behavior.

Participants then were shown 20 still images selected from television ads for the top beer and spirit alcohol brands that aired on national television in the year before the survey as well as 20 ads for fast-food restaurants. The images were digitally edited to remove the brands and logos. Individuals were asked if they remembered seeing the ad, if they liked the ad and if they knew the product or restaurant being advertised.

TV Ads and Teens

Results showed that 59 percent of underage youths previously drank alcohol. Of those who drank, 49 percent binge drank (had more than six drinks in a row) at least once in the past year.

Familiarity with TV alcohol advertising was significantly higher for drinkers than for non-drinkers. Other factors linked with drinking alcohol included older age, seeing alcohol in movies, having a favorite alcohol ad, having greater propensity for sensation seeking, having friends who drink alcohol, and having parents who drink alcohol at least weekly.

Among those who drank alcohol, familiarity with TV alcohol advertising was linked with greater alcohol use and binge drinking. Other factors linked with more hazardous drinking included owning alcohol-branded merchandise, having a favorite alcohol ad, older age, male gender, sensation seeking and friend drinking.

More Strict Standards Needed?

Familiarity with fast-food TV advertising was not linked to drinking behavior, suggesting that the relationship between alcohol ad familiarity and drinking is specific and not due to overall familiarity with advertising, Dr. Tanski said.

“At present, the alcohol industry employs voluntary standards to direct their advertising to audiences comprised of adults of legal drinking age,” Dr. Tanski said. “Our findings of high levels of familiarity with alcohol ads demonstrate that underage youth still frequently see these ads. While this study cannot determine which came first — the exposure to advertising or the drinking behavior — it does suggest that alcohol advertising may play a role in underage drinking, and the standards for alcohol ad placement perhaps should be more strict.”

People with an opioid addiction had the highest risk of death when compared with rates for alcohol and other drugs, according to a new study by the Centre for Addiction and Mental Health (CAMH).

For those dependent on opioids, the risk of death was 5.71 times higher than healthy individuals in the population of the same age, gender and race. Those with methamphetamine use disorders were next highest with a 4.67-fold risk, followed by those with addictions to cannabis (3.85), alcohol (3.83) and cocaine (2.96). Alcohol dependence was related to the highest number of deaths overall.

Mortality Rates Among Drug Users

The study, available online in the journal Drug and Alcohol Dependence, is the largest North American study to compare mortality rates among different drug users with the longest follow-up. It tracked records of more than 800,000 individuals hospitalized with drug dependence between 1990 and 2005. Of this group, more than 188,000 died during this period.

The findings mean that if 10 individuals in the general population died, then over the same period there would be 57 deaths among people dependent on opioids, which includes prescription opioids as well as heroin.

“One reason for undertaking this study was to examine whether methamphetamine posed a particular threat to drug users, as it has been called ‘America’s most dangerous drug,’” says CAMH Scientist Dr. Russell Callaghan, who led the study. Globally, methamphetamine and similar stimulants are the second most commonly used class of illicit drugs.

High Risk of Death

“The risk is high, but opioids are associated with a higher risk. We also wanted to compare mortality risks among several major drugs of abuse, as this comparison hasn’t been done on this scale before.”

Alcohol dependence affected the highest number of individuals, with 166,482 deaths and 582,771 hospitalizations over the study period. In the methamphetamine group, there were 4,122 deaths out of 74,139 hospitalizations, and for opioids, 12,196 deaths out of 67,104 hospitalizations.

Specific causes of mortality were not examined in this study, so the deaths may not be directly caused by drugs but due to related injuries, infectious disease or unrelated reasons. The researchers are now exploring mortality causes for each drug group, which may also point to reasons why women had a higher risk of death for alcohol, cocaine and opioids than males.

“These are not occasional, recreational drug users, but people who have been hospitalized for drug dependence,” notes co-author Dr. Stephen Kish, Senior Scientist at CAMH.

To calculate mortality rates, Dr. Callaghan and colleagues examined hospital records of all California inpatients with a diagnosis of methamphetamine, alcohol, opioid, cannabis or cocaine-related disorders from 1990-2005. They excluded records with evidence of multiple drug use disorders. The inpatient records were then matched to death records from the California Vital Statistics Database. Rates were adjusted by age, sex and race to the California population in 2000.

Risk Greater for Marijuana Users

“One surprising finding was the high rate of death among cannabis users,” says Dr. Callaghan. “There could be many potential reasons, including the fact that they may have other chronic illnesses such as psychiatric illnesses or AIDS, which can also increase the risk of death.”

The findings point to the importance of brief interventions for people receiving medical care for drug dependence on other related risks such as infectious diseases or injuries, says Dr. Callaghan.

New research by scientists at the University of Cambridge suggests that chronic cocaine abuse accelerates the process of brain ageing. The study, published today 25 April in Molecular Psychiatry, found that age-related loss of grey matter in the brain is greater in people who are dependent on cocaine than in the healthy population.

For the study, the researchers scanned the brains of 120 people with similar age, gender and verbal IQ. Half of the individuals had a dependence on cocaine while the other 60 had no history of substance abuse disorders.

Loss of Brain Volume

The researchers found that the rate of age-related grey matter volume loss in cocaine-dependent individuals was significantly greater than in healthy volunteers. The cocaine users lost about 3.08 ml brain volume per year, which is almost twice the rate of healthy volunteers (who only lost about 1.69 ml per year). The accelerated age-related decline in brain volume was most prominent in the prefrontal and temporal cortex, important regions of the brain which are associated with attention, decision-making, and self-regulation as well as memory.

Previous studies have shown that psychological and physiological changes typically associated with old age such as cognitive decline, brain atrophy and immunodeficiency are also seen in middle-aged cocaine-dependent individuals. However, this is the first time that premature ageing of the brain has been associated with chronic cocaine abuse.

Premature Aging

Dr Karen Ersche, of the Behavioural and Clinical Neuroscience Institute (BCNI) at the University of Cambridge, said: “As we age, we all lose grey matter. However, what we have seen is that chronic cocaine users lose grey matter at a significantly faster rate, which could be a sign of premature ageing. Our findings therefore provide new insight into why the cognitive deficits typically seen in old age have frequently been observed in middle aged chronic users of cocaine.”

The scientists also highlight concerns that premature ageing in chronic cocaine users is an emerging public health concern. The United Nations Office on Drugs and Crime estimates that cocaine is used by up to 21 million individuals worldwide, with approximately 1 per cent of these individuals becoming dependent.

Dr Ersche said: “Our findings clearly highlight the need for preventative strategies to address the risk of premature ageing associated with cocaine abuse. Young people taking cocaine today need to be educated about the long-term risk of ageing prematurely.”

An Issue for Older Adults Too

The concern of accelerated ageing is not limited to young people but also affects older adults who have been abusing drugs such as cocaine since early adulthood.

Dr Ersche added: “Our findings shed light on the largely neglected problem of the growing number of older drug users, whose needs are not so well catered for in drug treatment services. It is timely for heath care providers to understand and recognise the needs of older drug users in order to design and administer age-appropriate treatments.”

Adolescents who misuse alcohol and other drugs to the point where they need treatment must contend with costly and limited options for youth-specific care, as well as high relapse rates following treatment. Mutual-help groups such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) are widely available but little research has addressed their benefits for adolescents. An assessment of 12-step meetings and recommended activities has found that attendance, participation, and finding a sponsor promote greater abstinence among adolescents.

Results will be published in the July 2012 issue of Alcoholism: Clinical & Experimental Research and are currently available at Early View.

Long-Term Recovery Support

“Most substance use disorder (SUD) treatment is short-term and relapse rates post-discharge are typically high without continued support,” explained John F. Kelly, associate director of the Center for Addiction Medicine at Massachusetts General Hospital, and associate professor in psychiatry at Harvard Medical School. “Mutual-help organizations such as AA and NA can help fill this gap, providing free and flexible long-term recovery support in the communities in which people live.”

Kelly and his co-author assessed 127 adolescent outpatients (95 males, 32 females) aged 14-19 years old – who were enrolled in a naturalistic study of treatment effectiveness – at intake as well as at three, six, and 12 months later. Effects of the youths’ attendance and active involvement in activities, such as contact with their sponsor, on their subsequent abstinence were tracked over time.

“We found that about one quarter to one third of the youth attended AA/NA throughout the year-long study period following treatment, and that more meeting attendance was associated with significantly better substance use outcomes – particularly attending meetings at least once per week or more,” said Kelly. “Importantly, youth who also were in contact with an AA or NA sponsor or who participated verbally during AA/NA meetings had an even better outcome over and above the positive effects from merely attending. These findings support the common clinical recommendation that individuals should ‘go to meetings, get a sponsor, and get active.’ This is the first evidence to support this common clinical recommendation among young people.”

Encouraging A.A. Attendance

Kelly suggested that medical practitioners, counselors, and other clinicians can enhance the likelihood that youth will attend and participate in AA/NA by encouraging or facilitating their attendance early in treatment.

“Starting an on-site NA or AA young person’s meeting is another good idea,” he added. “Not all youth will be motivated to attend, but the more severely substance-involved ones will be more likely to give meetings a try and these are the ones most likely to benefit. It is also a good idea to facilitate a good match between the patient’s primary substance, cannabis/other drugs or alcohol, and the mutual-help organization to which they are being referred, Marijuana Anonymous, NA, or AA. Not doing this can lead to a poor initial match, which can be difficult to overcome.”

Kelly said that one of the key elements to success in 12-step involvement is the creation of a personal connection between the patient and an existing community AA or NA member.

A.A. for Young People

“This community member can then make introductions, answer questions, and generally act as an initial guide and onsite facilitator,” he said. “This is probably the most significant part of ensuring that young people get to their first meeting and have a positive experience – it’s hard for anyone to walk in ‘cold’ to a large AA or NA meeting. Another possibility is for parents or counselors to take adolescents to meetings or to arrange to meet them at meetings to help facilitate attendance and engagement. Once there, young people report that they like the camaraderie and social affiliation offered at meetings; they appreciate knowing that they are not the only ones suffering from addiction problems, and they report liking the attention, care, and support they get at meetings.”

The U.S. Joint Commission recently approved new hospital accreditation measures related to alcohol screening, brief intervention, and referral to treatment (SBIRT) for all hospitalized patients. Yet little is known about the effectiveness of brief interventions (BIs) or inpatient acceptability of SBIRT when performed by healthcare professionals other than physicians. A new study has found high hospital-patient acceptability of and comfort with nurse-delivered SBIRT.

Results will be published in the April 2012 issue of Alcoholism: Clinical & Experimental Research.

Identifying Unhealthy Alcohol Use

“SBIRT is widely endorsed for identifying and managing unhealthy alcohol use that ranges from hazardous or ‘risky’ drinking to the more serious alcohol abuse and dependence,” explained Lauren M. Broyles, a research health scientist at the VA Pittsburgh Healthcare System, assistant professor of medicine at the University of Pittsburgh, and corresponding author for the study.

“A more recent focus has extended to identification of hazardous drinking – consumption that exceeds guidelines established by the National Institute on Alcohol Abuse and Alcoholism – as more than 14 standard drinks/week or more than four/occasion for men, and more than seven standard drinks/week or more than three/occasion for women and healthy individuals age 65 or older,” she said. “Despite [supporting] evidence, recommendations and mandates concerning SBIRT implementation, uptake by healthcare providers in real-world clinical settings is still relatively limited.”

“SBIRT is a brief conversation, about 10 to 15 minutes, about hazardous alcohol consumption,” added Deborah S. Finnell, a research nurse scientist at the VA Western New York Healthcare System and associate professor of nursing at the University at Buffalo. “Healthcare team members could easily deliver SBIRT, assuming they are qualified. Since nurses provide 24-hour care in hospitals, nurses are most likely to have contact with patients compared with other healthcare team members, such as physicians and social workers.”

High Rate of Acceptability

Broyles and her colleagues conducted a cross-sectional survey of 355 (342 males, 13 females) hospitalized medical-surgical patients at a large university-affiliated medical center that is part of the U.S. Department of Veterans Affairs.

Results indicated acceptability for nurse-delivered SBIRT was high. Patient acceptability for eight out of 10 individual nurse-delivered SBIRT tasks was greater than 84 percent. Roughly 20 percent of the patients reported some degree of personal discomfort with the discussions; in general these individuals had a lower belief in their ability to reduce their drinking risk, were older than 60 years of age, had a positive alcohol screening, and were of non-black race.

“We found, in general, that acceptability for nurse-delivered SBIRT tasks was associated with how people perceived their own alcohol-related risks,” explained Broyles. “Patients had higher acceptability if they felt that they were able to determine and reduce their own alcohol-related health risks, and if they had expressed concern about their own alcohol use. Conversely, roughly 20 percent of the patients expressed annoyance or embarrassment with the questions while also showing high levels of acceptability. While this might seem contradictory, patients might feel embarrassed or uncomfortable with the topic or discussion even though they see the discussions as a legitimate, necessary, and acceptable part of the nurse’s role.”

Alcohol and Health Risks

“This study also highlights the importance of being patient-centered,” said Finnell. “Patients are accepting of receiving information from nurses about changing their alcohol use and about self-help groups. Specifically, when patients can make the connection between their alcohol use and health risks, they may be more accepting of having the conversation with the nurse and continuing that conversation about decreasing the amount of alcohol they consume. Additionally, nurses providing patient-centered care will be sensitive to signs that the patient is uncomfortable during the conversation.”

Broyles agreed. “For hazardous drinkers, nurses and other healthcare providers can normalize alcohol screening and BI by drawing analogies, for themselves and their patients, to screening and structured health behavior advice for other health conditions,” she said. “Normalizing talk about unhealthy alcohol use and alcohol use disorders in general medical settings, by general medical providers, in general medical encounters in this way may help both providers and patients feel more comfortable.”

Finnell said she was not surprised that patients were comfortable with nurse-delivered SBIRT. “I have been amazed at what patients share with me during my interactions with them,” she said. “Americans consistently rank nurses ‘very high’ or ‘high’ on honesty and ethical standards. The concept of trust is an important element in the nurse-patient relationship.”

Appropriate Training Needed

Both Broyles and Finnell emphasized the need for appropriate training, practice, support, and pragmatic strategies for incorporating alcohol SBIRT into existing clinical practices and routines. “Our findings suggest that once trained in SBIRT and motivational interviewing techniques, providers can proceed with greater confidence in alcohol-related risk assessment and risk-reduction conversations with patients,” said Broyles.

“While this study focused on nurse-delivered SBIRT, the take-home points are highly relevant to other clinicians,” added Finnell. “Clinicians who have been asked about barriers to delivering SBIRT report concern about jeopardizing their relationship with the patient. This study shows that patients are accepting of alcohol-related discussions, particularly brief counseling about alcohol, educational materials about changing alcohol use, and information about alcohol self-help groups. The findings from this study should alert nurses, physicians, and other health care providers to be prepared to meet the needs of these patients.”

Quitting smoking is never easy. However, when you’re poor and uneducated, kicking the habit for good is doubly hard, according to a new study by a tobacco dependence researcher at The City College of New York (CCNY).

Christine Sheffer, associate medical professor at CCNY’s Sophie Davis School of Biomedical Education, tracked smokers from different socioeconomic backgrounds after they had completed a statewide smoking cessation program in Arkansas.

Whether rich or poor, participants managed to quit at about the same rate upon completing a program of cognitive behavioral therapy, either with or without nicotine patches. But as time went on, a disparity between the groups appeared and widened.

Hardest Time With Cravings

Those with the fewest social and financial resources had the hardest time staving off cravings over the long run. “The poorer they are, the worse it gets,” said Professor Sheffer, who directed the program and was an assistant professor with the University of Arkansas for Medical Sciences at the time.

She found that smokers on the lowest rungs of the socioeconomic ladder were 55 percent more likely than those at the upper end to start smoking again three months after treatment. By six months post-quitting, the probability of their going back to cigarettes jumped to two-and-a-half times that of the more affluent smokers. The research will be published in the March 2012 issue of the “American Journal of Public Health” and will appear ahead-of-print online under the journal’s “First Look” section.

More Poor People Smoke

In their study, Professor Sheffer and her colleagues noted that overall, Americans with household incomes of $15,000 or less smoke at nearly three times the rate of those with incomes of $50,000 or greater. The consequences are bleak. “Smoking is still the greatest cause of preventable death and disease in the United States today,” noted Professor Sheffer. “And it’s a growing problem in developing countries.”

Professor Sheffer suggested reasons it may be harder for some to give up tobacco forever.

Smoking relieves stress for those fighting nicotine addiction, so it is life’s difficulties that often make them reach for the cigarette pack again. Unfortunately, those on the lower end of the socioeconomic scale suffer more hardships than those at the top – in the form of financial difficulties, discrimination, and job insecurity, to name a few. And for those smokers who started as teenagers, they may have never learned other ways to manage stress, said Professor Sheffer.

For people with lower socioeconomic status (SES), it can be tougher to avoid temptation as well. “Lower SES groups, with lower paying jobs, aren’t as protected by smoke-free laws,” said Sheffer, so individuals who have quit can find themselves back at work and surrounded by smokers. Also fewer of them have no-smoking policies in their homes.

Not Addressed in Treatment

These factors are rarely addressed in standard treatment programs. “The evidence-based treatments that are around have been developed for middle-class patients,” Professor Sheffer pointed out. “So (in therapy) we talk about middle-class problems.”

Further research would help determine how the standard six sessions of therapy might be altered or augmented to help. “Our next plan is to take the results of this and other studies and apply what we learned to revise the approach, in order to better meet the needs of poor folks,” she said. “Maybe there is a better arrangement, like giving ‘booster sessions’. Not everybody can predict in six weeks all the stresses they will have later on down the road.”

“Some people say [quitting] is the most difficult thing in their life to do,” said Sheffer. “If we better prepare people with more limited resources to manage the types of stress they have in their lives, we’d get better results. “

The research was funded by National Institutes of Health National Cancer Institute (R03 CA141995–01A1) and the National Center for Research Resources (RR 020146). The treatment program was funded by the Arkansas Department of Health.

Individuals addicted to prescription painkillers are more likely to succeed in treatment with the aid of the medication buprenorphine-naloxone (Suboxone), report McLean Hospital and Harvard Medical School researchers in today’s online edition of the Archives of General Psychiatry.

“Adjunctive Counseling During Brief and Extended Buprenorphine-Naloxone Treatment for Prescription Opioid Dependence,” is the first large-scale study to address treatment of prescription opioid addiction.

Addicted to Painkillers

According to lead author Roger Weiss, MD, Chief of the Division of Alcohol and Drug Abuse at McLean Hospital, most studies examining treatments for opioid dependence have been done with heroin-dependent patients at methadone clinics, resulting in the lack of data on treatment for patients addicted to prescription painkillers, especially in the offices of primary care doctors.

“Despite the tremendous increase in the prevalence of addiction to prescription painkillers, little research has focused on this patient population,” said Weiss, a professor of Psychiatry at Harvard Medical School. “This is notable because recent data tell us that the use of prescription painkillers for non-medical reasons is 20 times more common than heroin and 50 percent more people seek treatment for prescription drug abuse than for heroin.”

600 Patients Studied

Part of the National Institute on Drug Abuse (NIDA) Clinical Trials Network, this is the first randomized large scale clinical trial for the treatment of prescription opioid abuse, involving 10 sites nationwide and more than 600 treatment-seeking outpatients dependent on prescription opioids and either taking more than prescribed or using them illicitly. Each participant received Suboxone—a combination of buprenorphine, which alleviates opioid withdrawal and craving, and naloxone, which prevents abuse if the drug is not taken orally as prescribed—in conjunction with Standard Medical Management, in which physicians evaluated treatment effectiveness and recommended abstinence and self-help participation. Fifty percent of study participants also received additional more intensive individual addiction counseling.

According to Weiss, 49 percent of patients benefitted from Suboxone during a 12-week course of the medication. However, once the medication was discontinued, patients had a high rate of relapse. Monitored in four week increments, individuals showed an increasing rate of relapse the longer they remained off Suboxone. Another interesting finding, noted Weiss was that neither having chronic pain, nor participation in intensive addiction counseling affected the participant’s success rate.

Suboxone and Recovery

“We were surprised by some of these findings because there was an overall assumption that this population—those who have had little to no exposure to heroin—would do better in terms of not needing long-term medication intervention,” said Weiss. “It is clear that given the prescription drug abuse epidemic, we need to continue to look at the viability of longer-term use of Suboxone and whether it can continue to provide sustained recovery from addiction to pain medications.”

According to the National Survey on Drug Use and Health, an estimated 1.9 million people in the United States meet abuse or dependence criteria for prescription pain relievers. In addition, the Centers for Disease Control and Prevention report that annually, more people die from prescription painkiller overdoses than from heroin and cocaine combined.