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Substance Use Disorders - Science topic

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Resonance Breathing is a promising intervention for clients with substance use disorder (SUD). The intervention and technological advances (Apps) make it possible for people to train with the intervention by themselves and independent of location.
When planning a longer study for at-home use with an App over several weeks - what would you suggest would be the optimal length, frequency and duration of the overall training? That is, how many weeks, how often per week and how long per session (minutes)? Are there recommendations or best practice examples?
Our intended outcomes apart from HRV (pre/post) would include questionnaires about the SUD and fMRI. Specifically, executive functions, general well-being, substance use parameters.
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Hi Dominik,
The original protocol for HRV biofeedback training is 10 sessions, usually with 1 session per week (see Lehrer et al. attached), but we've also done studies with 8 sessions over 12 weeks and 3 sessions over 3 weeks, both of which produced good results for patients with SUD.
In both of these studies we modified the protocol to fit in the context the participants were in (i.e., university recovery housing and an inpatient SUD treatment facility). Sessions are usually 60min as it takes a while to get participants hooked up with equipment and to walk them through the day's training protocol.
In choosing your number of sessions consider what's most important in the study and who's in your sample. If this is a clinical trial of HRV biofeedback, I would do at least 5 sessions with participants and encourage daily practice between sessions to make sure folks get a sufficient dose.
Regarding practice time, we usually tell folks to do 20min/day, knowing they'll probably end up doing less. In a previous study we showed that 12 min of practice daily was sufficient to elicit significant reductions in negative affect and it didn't seem to matter if all the practice happened in one block each day, or was spread out throughout the day (Alayan et al.).
Also, a lot of people in our studies began using the breathing practice in the moment to manage acute stress and anxiety, even though we didn't instruct them to do so. Anecdotally people have reported this in-the-moment practice as being super helpful. Definitely something we plan on testing in future studies. If you can look at acute vs chronic practice effects in your study that would really help the field.
A couple of methodological suggestions: Be sure to track participants practice as you'll eventually want to check for practice effects in your analyses. Also, few studies to date have actually looked at substance use outcomes. Quite a few studies have shown HRV biofeedback reduces craving and other forms of negative affect in SUD patients, but whether this translates into actual reductions in substance use is an important open question.
David
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To evaluate participants with follow up interviews, who completed residential rehabilitation and now currently in the community. The objective is to assess why they relapsed if they did, and what helped them to be abstinent after engaging with a community.
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Norman G Hoffmann Thank you for adding more details, I certainly agree the choice of method collection will depend on the research problem/question. I hope our answers help Lahiru Channaka
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I am looking to assess patient satisfaction (specifically for a Cannabis Use Disorder Intervention) and also look at their potential barriers and facilitators to access this treatment intervention. I am doing a qualitative study surrounding this and struggling to find topic guides within this area. Any advice would be hugely appreciated.
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Fantastic - thank you Lafi
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Any examples of pharmacotherapy used currently? 
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In addiction is the mesolimbic pathway, also called reward pathway, as a dopaminergic pathway in the brain, involved
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I am concerned about differentiating first episodic psychotic break (in schizophrenia, schizoaffective d/o, or mania w/ psychosis) from substance-induced psychosis due to:
-energy drinks (poss. distinct in effects from caffeine due to other substances added such as taurine, ginseng, l-theanine, etc.)
-nutritional supplements, esp. androgenic substances and those used by bodybuilders
-any combination of these, or with other substances, esp. nicotine, alcohol, and stimulants.
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Thanks, Beatrice and Mary.  Mary, that's what I was thinking, even though I was hoping for a way to have a bit more diagnostic clarity, esp. to engage these FEP pts. who are often ambivalent they even need help.
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In the 4th edition of the “Diagnostic and statistical manual of mental disorders” (DSM-IV) of the American Psychiatric Association, “substance abuse” and “substance dependence” were regarded as separate diagnoses and hence have separately been subjects of research. However, in DSM-V (issued in 2013), “substance abuse” and “substance dependence” have been substituted by an overarching diagnosis “substance use disorders” in order to avoid ambiguities that existed when abuse and dependence were separate diagnoses.
 Therefore, in this era of DSM-V, would carrying out epidemiological studies on substance dependence (and for that matter on substance abuse) be of any practical relevance?
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The language has changed and I think you raise an interesting question. It might be helpful to view the current thinking around DSM V in terms of harm reduction. The harm reduction approach has been seen as dichotomous to abstinence but actually abstinence is part of the harm reduction continuum. The basic premise of harm reduction is that people are always going to use drugs, and if you look at the way DSM-5 is worded with mild moderate and severe it allows for the possibility of non problematic substance use. In the new language when we talk about dependence we're talking about the body's physical dependence for example if a patient taking pain medication as prescribed would develop a physical dependence. But this would not be considered a substance use disorder.
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Hello all,
I am writing my first research paper on web-based for substance use disorder, specifically alcohol abuse. Does anyone know of any research published or unpublished that I may look at?
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If you are looking for something specific to Alcohol Use Disorders, Moderate Drinking (MD) has strong research support and is recognized by APA Division 12 as an empirically supported treatment for Alcohol Use Disorders.
MD is an online module program based on behavioral self-control training. The program is structured, interactive, and individualized to each user, which allows for goal setting, self-monitoring of behavior, and providing feedback on progress. MD incorporates a number of modules based on different skills, including: motivation, identifying/managing triggers, and problem solving. In addition, MD treatment recommends choosing a goal, building motivation for change, trying short-term abstinence, setting drinking goals/limits, and self-monitoring drinking.
Here are some key references and additional information can also be found on APA Division 12's website (where you can also request clinical resources):
Hester, R. K., Delaney, H. D., Campbell, W., & Handmaker, N. (2009). A web application for moderation training: Initial results of a randomized clinical trial. Journal of Substance Abuse Treatment, 37, 266-276. doi:10.1016/j.jsat.2009.03.001.
Rotgers, F., Kern, M., & Hoeltzel, R. (2002). Responsible drinking: The path to moderation. Berkeley, CA: New Harbinger.
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Opioids include the illicit drug heroin, as well as the medically prescribed pain relievers oxycodone, hydrocodone, codeine, morphine, fentanyl and others. These drugs can lead to addictive behavior, increased emergency visits, hospitalizations, switching to heroin, and overdose. Opioid abuse has increased dramatically since 1999. However, there is limited literature that argues that pain is under-treated, and people may seek other sources to address their pain, such as illegal buying of drugs from friends, and families, and shopping for doctors. The value of analyzing the limited research will focus on how under-treated pain is associated with drug abuse and heroin use. 
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The most extensive study on the effects of immigration and diversity on social capital is that by Robert Putnam, and his conclusion was that diversity decreases social capital: http://www.boston.com/news/globe/ideas/articles/2007/08/05/the_downside_of_diversity/?page=full
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I am searching for research supporting AA 12-step meetings during college years for those diagnosed with substance use disorders.
Thanks.
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Thank you Margaret.
The students I am referring are in a safe collegiate recovery program that includes a residence hall that is substance free. They are all in recovery and are required to attend meetings and have a sponsor. I am searching for evidence-based research that supports the requirements or presents alternative evidence.
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I have thought of 8 session Relapse Prevention module and Motivational Interviewing module already.
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You might want to check out this book:  Cognitive-Behavioural Integrated Treatment (C-BIT): A Treatment Manual for Substance Misuse in People with Severe Mental Health Problems
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We have been tracking street prices of opioids in the United States, with the hope that they may be useful to both clinicians and researchers in determining optimal Dx, Tx and Rx strategies for SUBSTANCE USE DISORDERS (e.g. some clinicians are reluctant to prescribe buprenorphine because they know that patients can sell it at substantial value, etc) 
We have found, for example, that oxycodone in almost any formulation (e.g. mixed with acetaminophen as brand name Percocet) costs about $1/mg almost everywhere in the US; in pure form (instant release) it can cost more in low doses (e.g. a 30mg pill of oxycodone can cost as much as $50 but usually costs $30) and in high doses (e.g. an 80mg pill of oxycodone sold as Oxycontin with OROS REMS "abuse" prevention costs only $50 as it is not easily converted into an IV formulation).  By contrast, the street price of tramadol is low, but so is its relative psychoactive effect on a per-milligram basis (orally).  
The dataset is small now, but our hypothesis is that (at least with opioids) STREET PRICES reflect the IV-morphine-equivalence of a dose of an opioid, and thereby its "desirability" for misuse by an individual with opioid use disorder (DSM Dx 304.xx, ICD-10 F-11.20).
Does anyone have anecdotal or statistical data they could (or would) contribute to this dataset?  Likewise, we are interested in the addiction medicine community's opinion of the value of tracking street prices as a predictor of misuse potential.
This data will also be used to study the prevailing view (in the popular press and some academic articles) that pharmaceutical opioid users switch to "illegal" (Schedule I in the US) opioids (primarily diacetylmorphine) because they are cheaper for the same morphine-equivalent dosage.
Our goal is to create a "live" street price dataset that will be freely available to researchers and clinicians.  The difference between the retail price of pharmaceutical opioids and their street prices is substantial - often by an order of magnitude.  Again, the hypothesis is that street prices reflect "demand" which reflects the misuse potential.  We also think this could be useful clinically, for both addiction medicine and pain management - clinicians should be aware when, for example, they prescribe a bottle Percocet 10/325 TID #90, which has a street value of $900, but costs a Medicare (part D) patient only $10 at the pharmacy.
[NB1 Buprenorphine defies this rule - it's morphine-equivalency is low as it is an agonist/antagonist etc, but it still costs $8 on the street for an 8mg pill.  Any theories here?  NB2 We define "street" as anything other than legal pharmacy purchases; obviously, this data is reported by SUD patients/ISDs but we see such little variation that we believe it is accurate.  We also don't see why a patient would exaggerate or minimize this cost when speaking with their caregiver/clinician.  ALL FEEDBACK WELCOME.]
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When saying therapeutic I mean either to detox themselves or to use as a maintenance medication. Some are surely only using it as a bridge between doses of their preferred opiate but as it's shown in the Appalachian study this is a smaller percentage. Also the high affinity of Buprenorphine for the mu receptor discourages users from bridging because once they take their preferred opiate if there is still much Buprenorphine attached to the receptors it'll block the other opiate. The Naloxone has no therapeutic purpose in the Suboxone formulation. It's included entirely to discourage misuse. Due to it's poor sublingual bioavailability practically none of the Naloxone makes it into a persons blood when Suboxone is taken as prescribed.  
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I am a candidate masters in advanced psychiatric nursing at the university of the Western Cape, South Africa. My area of interest is substance use disorders as well as psychiatric disorders. My research topic is Psychiatric comorbidity with substance use disorders in adult inpatient treatment centers. I experience difficulty in searching for an appropriate tool to measure this phenomena, especially with the DSM 5 criteria.
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Hi Helen,
I am an addiction psychiatrist and researcher, and find that the PRISM is particularly good for this purpose. Most of the tools or diagnostic instruments have been based on the DSM IV however, and haven't been updated for DSM5 yet. This is, by and large, not a major problem.
This article is somewhat dated but summarizes the range of tools pretty well.
Kind regards,
Shalini
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See this article in JAMA Psych - http://app.jamanetwork.com/?doi=10.1001/jamapsychiatry.2015.0546&utm_source=email&utm_medium=app&utm_campaign=share  -- raises the obvious question of whether cycloserine can be a useful medication, with or without CBT.  I am wondering if any addiction docs have Rx-ed cycloserine as part of psychopharmacology for SUD pts.  Thank you.
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I am looking for a treatment strategy to work with clients with co-occurring mental illness diagnoses.
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Thank you for clarification re: NICE recommendation
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Research for a paper and material on this specific combination of subjects is proving illusive?
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Interesting that you refer to it as an addiction.  I like your descriptive form.  I've known some who suffer this addiction.  Hard to watch and hard to be around accept for short intervals.  They suck all the air out of a room.  If someone else were to have a thought, it might be hard to find a moment to exercise it.  You've given me some food for a short paper I have to write for a class.  Thank You again!!!
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The DSM-5, published in May 2013, finally included a section on Addictive Disorders, however the general concept of "addiction" is not to be found in the current DSM.  It's admittedly hard to define.  Note that there is also no "Substance Use Disorder - Generalized", rather the substances are enumerated, e.g. Dx 304.xx Opioid Use Disorder, etc.  I know the APA can get political as it has real impact in terms of reimbursement, disability, and CMS coverage, especially with the Mental Health Parity and Addiction Equity Act kicking in this year.  I'm wondering if any international bodies (WHO, etc) have published a DEFINITION of addiction or even of "substance use disorder", or if anyone has tried to define the condition with specificity in the academic literature.  I find it interesting that we, in the US, now have a law forcing payors to treat "addiction" as any other disease, yet we have no consensus medical definition of "addiction", or at least one that I can find.  Are addictive disorders a type of addiction? (I'm not joking, but asking for accurate Dx purposes -- I'm wondering if someone has really thought this through or published on the subject.)
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Here is the short definition from American Society of Addiction Medicine (highly credible), rewriten in 2011 and considering addiction as a brain chronic illness.
"Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.
Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death."
If you are interested, I suggest you look at the long definition. Many interesting points of view from neurobiology and genetic. Here's the link.
Best regards
(sorry for any syntaxic error, english isn't my first language :))
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Michael:
Evidence-Based SmartPhone Apps for Smoking Cessation
There are hundreds of smoking cessation smartphone apps (iTunes App Store and Google Play store) or Facebook apps, but a recent study [1] of 47 iOS apps and 51 Android apps has found that these still do not include many of the guidelines of the US Public Health Service’s Clinical Practice Guidelines for Treating Tobacco Use and Dependence: none of the reviewed apps included an option or suggestion to call a quit-line (which according to the guidelines can more than double a smoker’s chance of successfully ending their habit), nor was medication to resist cravings discussed in most (3 apps recommended it), and many apps also lacked even basic advice on how to work towards smoking cessation effectively. Conclusions: very few apps adhere to key evidence-based practices shown to help smokers quit.
However, my own review of the recent literature to date finds some commendable exceptions in five apps:
NCI QuitPal
Developed by the National Cancer Institute using both the latest evidence-based smoking cessation methods as well as behavior change theory [2]. Available at: http://smokefree.gov/apps-quitpal
QuickStart App
Created by the Tobacco Control Research Branch at the National Cancer Institute in collaboration with tobacco control professionals and smoking cessation experts and with input from ex-smokers [3]. At: http://smokefree.gov/apps-quitstart.
SmartQuit
From 2Morrow Inc, SmartQuit app has demonstrated efficacy in a pilot RCT clinical trial [4]conducted at the Fred Hutchinson Cancer Research Center. It uses “acceptance and commitment therapy” (ACT), which helps people to accept their urges and let them pass [5].
It is to be brought to market by the end of the year. It shall be targeted at companies, health plans and states. Now in preview on iTunes [6].
QuitGuide
Developed by MMG, Inc., for the Tobacco Control Research Branch of the National Cancer Institute (NCI). Written by tobacco control professionals and cessation counselors, with the help of ex-smokers and experts [7].
UbiQUITous
UbiQUITous is an evidence-based app on Facebook dedicated to helping users quit smoking, leveraging the power of a smoker's social network to help them quit smoking by posting their daily quit progress to their Facebook timeline, and directly notifying supporters on important "quit milestones" , and providing tailored information on quitting, integrated social support, and proactive contact to users. The protocol design of the RCT [NCT01746472: http://www.clinicaltrials.gov/ct2/show/NCT01746472] studying its efficacy has been detailed [8].
NHS Stop Smoking iPhone App
The NHS in the UK has developed this app in conformance with evidence-based guidelines on smoking cessation [9].
REFERENCES
1. Abroms LC, Lee Westmaas J, Bontemps-Jones J, Ramani R, Mellerson J. A content analysis of popular smartphone apps for smoking cessation. Am J Prev Med 2013; 45(6):732-6. http://www.ajpmonline.org/article/S0749-3797(13)00479-0/abstract.
2. Massett H, Atkinson NL, Kraiger A, Grady M, Killam B, Barry B. APHA Presentation: NCI Quitpal: An evidence-based app to help people quit smoking. American Public Health Association (APHA) 141st Annual Meeting. Boston MA 6 Nov 2013. At: https://apha.confex.com/apha/141am/webprogramadapt/Paper284220.html.
3. Sadasivam RS, Delaughter K, Crenshaw K, et al. Development of an interactive, Web-delivered system to increase provider-patient engagement in smoking cessation. J Med Internet Res 2011; 13(4):e87. At: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3222193/.
4. Innovative Smartphone Application of a New Behavioral Method to Quit Smoking. Clinical Trials: http://clinicaltrials.gov/show/NCT01812070.
5. Schimmel-Bristow A1, Bricker JB, Comstock B. Can Acceptance & Commitment Therapy be delivered with fidelity as a brief telephone-intervention? Epub 2011 Nov 17. Addict Behav. 2012 Apr;37(4):517-20. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3718556/.
8. Cobb NK, Jacobs MA, Saul J, Wileyto EP, Graham AL. Diffusion of an evidence-based smoking cessation intervention through Facebook: a randomised controlled trial study protocol. BMJ Open 2014; 4(1):e004089. http://bmjopen.bmj.com/content/4/1/e004089.full.
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Looking for information regarding the Substance Abuse Subtle Screening Inventory - 3
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I researched/used the "Randomized response technique" to measure drug use 40 years ago. I'd be interested in other people trying it. See:
Goodstadt, M. S., & Gruson, V. (1975). The Randomized Response Technique: A Test on Drug Use. . Journal of the American Statistical Association, 70(352), 814-818.
Goodstadt, M. S., & Cook, G. (1978). The validity of reported drug use: the randomized response technique. Int J Addict, 13(3), 359-367.