The Brief Addiction Science Information Source (BASIS)

The WAGER Vol. 13(4) - Gambling Problems: All or Nothing?

The American Psychiatric Association diagnostic guidelines conceptualize pathological gambling (PG) as either present (five or more signs or symptoms) or absent (four or fewer signs or symptoms). This diagnostic scheme for PG weights all signs and symptoms equally. Many researchers and clinicians have suggested that a more continuous conceptualization, in which the diagnostic guidelines consider the severity of specific signs and symptoms, would be more appropriate for the disorder than this dichotomous unweighted approach.  In this edition of the WAGER, we review a study by Strong & Kahler (2007) which investigated the psychometric properties of the 10 DSM-IV criteria, and evaluated the gambling severity continuum.

Strong and Kahler analyzed data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a national general population survey of 43,093 adults that includes a DSM-IV-based measure of pathological gambling. The researchers applied a Rasch Model – an analysis that assesses the severity of symptoms and their probability of being endorsed by individuals at different places along a severity continuum of PG – to the 2,180 respondents who endorsed one or more lifetime PG criteria.

Figure 1. Probability of endorsing specific PG signs and symptoms at different levels of gambling problem severity (reproduced from Strong & Kahler, 2007).

Note. Level of Gambling Problem Severity is determined by the Rasch Model but corresponds roughly to number of symptoms endorsed. Each curve refers to a symptom: 1 = preoccupation w/ gambling; 2 = tolerance; 5 = escape; 6 = chasing; 7 = lying; 3 = loss of control; 10 = relying on others to cover debt; 4 = withdrawal; 9 = jeopardizing relationships; 8 = illegal acts.

Twelve percent of all gamblers endorsed being ‘preoccupied with gambling,’ and this problem fell in the mild range of the severity continuum; less than 0.1% of all gamblers endorsed committing “illegal acts to finance gambling,” and this problem fell at the most severe end of the continuum. Figure 1 shows the distribution of the 10 PG criteria along the dimension of gambling severity (i.e., # of symptoms endorsed). The symptoms are not equally distributed across the continuum; the figure also shows that, in some cases, a relatively larger increase in gambling severity is required before further gambling symptoms are observed. These gaps provide guidance about the relationship between specific symptoms and possible thresholds for different levels of gambling problem severity. Preoccupation (curve 1) appears to be a diagnostic gateway for other problems. Tolerance, escape, chasing, lying, and loss of control occur at similar severity levels, but a large increase in severity is required before reliance on others, withdrawal symptoms, jeopardizing relationships, or illegal acts occur.

This study’s main analyses utilized lifetime criteria for PG, which is a limitation. Lifetime measurements can be problematic because of memory recall problems and reinterpretation of past events, as well as other biases. An analysis of past year symptoms could possibly reveal a different structure to the data. Despite this limitation, this study suggests that, contrary the current unweighted dichotomous classification scheme for pathological gambling, gambling problems fall along a severity continuum and different signs and symptoms occur at different thresholds of severity.

What do you think? Comments should be addressed to Line Gebauer and Sarah Nelson.

References

Strong, D. R., & Kahler, C. W. (2007). Evaluating the continuum of gambling problems using the DSM-IV. Addiction, 102(713-721).

STASH Vol. 4(4) – You cannot always get what you need: Racial/Ethnic disparities of opioid analgesic prescribing in U.S. emergency departments

Pain lasting more than 24 hours affects over one quarter of Americans each year (National Center for Health Statistics, 2006) and costs approximately $100 billion in lost productivity, lost income, and health care costs (Stewart, Ricci, Chee, Morganstein, & Lipton, 2003).  Previous research examining U.S. emergency department visits from 1997 to 1999 found racial/ethnic disparities in the prescribing of opioid analgesics for back pain and migraines (Tamayo-Sarver, Hinze, Cydulka, & Baker, 2003).  During 2001, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) established standards of care for the management of pain (Chapman, 2000).  This week’s STASH examines the rates of opioid prescribing before and after the implementation of JCAHO standards of care among visits to the emergency room for the treatment of pain in the U.S. (Pletcher, Kertesz, Kohn, & Gonzales, 2008). 

Pletcher, Kertesz, Kohn, & Gonzales (2008) analyzed prescriptions related to approximately 375,000 emergency room visits over the course of 13 years (1993-2005). The authors utilized data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), a publicly available data set that uses a 4-stage probability sample design each year at randomly selected hospitals, excluding federal, military, and Veterans Administration hospitals, across the U.S.  NHAMCS data include patients’ demographics, reasons for visit, diagnoses, and treatment.  The authors analyzed NHAMCS data for patients with pain-related symptoms (e.g. pain, ache, soreness) and conducted logistic regression analyses to estimate the association between a doctor prescribing an opioid and race/ethnicity across time.

Figure 1: Percentage of emergency department pain-related visits for which a doctor prescribed an opioid analgesic by race/ethnicity and survey year (adapted from Pletcher, Kertesz, Kohn, & Gonzales, 2008)

During the study period, the percentage of pain related visits that resulted in an opioid prescription increased from 23% (95% CI, 21%-24%) during 1993 to 37% (95% CI, 34%-39%) during 2005 (significant linear trend, p<.001).  As figure 1 shows, doctors prescribed opioid analgesics to a higher percentage of white patients than non-white patients at all time points.  Compared to white patients, black patients were 36% less likely to receive an opioid analgesic for pain than white patients, Hispanics were 31% less likely and Asians were 27% less likely1.  To offset the differences in the prescribing of opioid analgesics doctors prescribed non-opioid analgesics at a higher rate for non-white (32%) than white (26%) patients.

There are several limitations to this study worth discussing.  First, the NHAMCS does not include substantial clinical information.  Specifically, the survey does not ask if the patient requested an opioid, the ability of patients to pay for a prescription, or in what quantity the doctor prescribed the opioid.  Second, the survey instrument does not record information about drug and alcohol abuse or dependency.  Lastly, hospital staff might have misclassified participant’s race/ethnicity because survey data is based on recording of staff perception of participant’s race/ethnicity rather than the participant’s self-report of race/ethnicity.

Although overall rates of opioid prescribing for pain have increased since hospitals implemented the JCAHO standards of care in 2001, a discrepancy in the rates of opioid prescribing between whites and other races and ethnicities remained constant throughout the study period.  Although it is possible that the discrepancy highlighted in this study is due to an over-prescribing among white-patients who abuse opioids, this does not appear to be the case because researchers found the same discrepancy in children, who are unlikely to be abusing opioids. These results suggest a true racial/ethnic bias among healthcare providers is involved and indicate that JCAHO and other health advocates will need to do more to decrease disparities in health care.  To attempt to explain discrepancies in doctors’ prescribing for pain relief, future versions of the NHAMCS could include information about patients’ alcohol and drug history, opioid prescribing history, and awareness of medical options to treat pain. 

What do you think? Comments can be addressed to John H Kleschinsky.

Notes

1. Adjusted for age, sex, insurance, type of pain, cancer diagnosis, alcohol intoxication/withdrawal/abuse, alcohol dependence, drug intoxication/withdrawal/abuse, drug dependence, hospital location, owner and setting, and survey year.

References

Chapman, C. R. (2000). New JCAHO Standards for Pain Management: Carpe Diem! APS Bulletin   Retrieved January 24, 2008, from http://www.ampainsoc.org/pub/bulletin/jul00/pres1.htm

National Center for Health Statistics. (2006). Health. Hyattsville, MD: CDC.

Pletcher, M. J., Kertesz, S. G., Kohn, M. A., & Gonzales, R. (2008). Trends in opioid prescribing by race/ethnicity for patients seeking care in US emergency departments. Journal of the American Medical Association, 299(1), 70-78.

Stewart, W. F., Ricci, J. A., Chee, E., Morganstein, D., & Lipton, R. (2003). Lost productive time and cost due to common pain conditions in the US workforce. Journal of the American Medical Association, 290(18), 2443-2454.

Tamayo-Sarver, J. H., Hinze, S. W., Cydulka, R. K., & Baker, D. W. (2003). Racial and ethnic disparities in emergency department analgesic prescription. American Journal of Public Health, 93(12), 2067-2073.

Addiction & the Humanities Vol 4. (4) - "When I was a kid, I inhaled. That was the point."

Part of what affects politicians’ ability to lead is their use of personal biases and experiences to enrich leadership style and effectiveness, and create a positive public image. The current debate about the legalization of marijuana relates directly to politicians’ personal experiences with substance use. These personal experiences affect the public’s perception of the politician’s image and potentially influence the public’s perceptions of drug use. This week’s HUMANITIES uses Barack Obama’s honesty about drug use to consider the effect that politicians’ personal experiences might have on politics and the public.

Experimenting with drugs as a youth is an experience that most public figures try to keep quiet. Barack Obama is one of the few politicians who have been honest and forthcoming with information regarding his substance-related ‘skeletons in the closet’: marijuana and cocaine use. In interviews, debates, and a 1995 memoir, Dreams from my Father, Obama is candid about the personal internal struggles that he faced during his youth that led him to drug use. In Dreams from my Father, he says “I blew a few smoke rings, remembering those years. Pot had helped, and booze; maybe a little blow [cocaine] when you could afford it. Not smack [heroin], though - Mickey, my potential initiator, had been just a little too eager for me to go through with that. Said he could do it blindfolded, but he was shaking like a faulty engine when he said it…(Obama, 1995, p. 85)”

Obama’s reasoning for his honesty regarding past drug use is that he feels he owes it to younger voters to be frank about the situation. When questioned about this in the past, he responded “young people who are already in circumstances that are far more difficult than mine need to know that you can make mistakes and still recover”("Obama Admissions on Drug Use Could Signal New Era in Politics," 2007; Romano, 2007, p. A01). Obama maintains this view and told some students at a high school “You know, I made some bad decisions that I've actually written about. You know, got into drinking. I experimented with drugs,” he says. “There was a whole stretch of time that I didn't really apply myself a lot. It wasn't until I got out of high school and went to college that I started realizing, ‘Man, I wasted a lot of time’” (Saul, 2007, p. 1).

Many major news outlets (e.g., Fox, The Washington Post, The Daily News) have described Obama’s honesty as marking a new era in politics. Previously, admissions of substance-use might have been taboo for the public; the new era involves the acceptance of candidates whose life experiences might differ from the majority of voters. Further, according to Romano (2007) and articles on the Fox news website ("Obama Admissions on Drug Use Could Signal New Era in Politics," 2007), middle-aged voters who support Obama may continue to do so because, as baby boomers, they are part of a generation that spent a decade experimenting with drugs. For them, Obama’s current success proves that early substance abuse does not guarantee lifelong failure.

Despite his success, it is important to ask whether Obama’s honesty about his drug use marks a shift in public opinion about political leaders and their personal conduct. If so, the public should give potential adverse implications equal consideration. A shift towards accepting drug use and experimentation in adolescents could persuade observers to reason that addiction and substance use prevention for youth is unnecessary. However, a favorable shift in public opinion towards substance use is not reason to accept all substance use experimentation. Obama is not suggesting that adolescents can experiment with substances without worrying about short term negative consequences. Rather, he describes the circumstances surrounding his personal experimentation, while still admitting his error – turning to substance use as a solution. Far from implying leniency, this shift suggests that prevention programs and treatment for substance use and addiction are still a necessary part of youth education. Some adolescent experiments with substance use will have tragic consequences. It is for those unlucky individuals that prevention programs are continually further developed and improved.

What do you think? Comments can be addressed to Ingrid R. Maurice

References

Obama Admissions on Drug Use Could Signal New Era in Politics [Electronic (2007). Version]. FoxNews.com. Retrieved December 11, 2007.

Obama, B. (1995). Dreams From my Father: A Story of Race and Inheritance: Times Books, a division of Random House.

Romano, L. (2007). Effect of Obama's Candor Remains to Be Seen [Electronic Version]. The Washington Post. Retrieved January 3, 2007 from http://www.washingtonpost.com/wp-dyn/content/article/2007/01/02/AR2007010201359.html.

Saul, M. (2007). Barack Obama tells N.H. kids of his alcohol, drug use during teen years [Electronic Version]. The Daily News. Retrieved November 21, 2007 from http://www.nydailynews.com/news/politics/2007/11/21/2007-11-21_barack_obama_tells_nh_kids_of_his_alcoho.html.

ASHES Vol. 4(4): Nicotine without All the Smoke: Smokers’ Preferences for Medicinal Nicotine or Smokeless Tobacco

As a result of the many difficulties associated with quitting smoking (e.g., psychological and physiological withdrawal) and even the challenges to reducing smoking (e.g., unintended increase in smoking intensity via deeper puffs), tobacco control experts have recommended the use of pure nicotine products as a “harm-reduction strategy”.  Studies show that the use of medicinal nicotine (MN; e.g., nicotine gum, an inhaler) significantly reduces smoking (Bolliger et al., 2000; Wennike, Danielsson, Landfelt, Westin, & Tonnesen, 2003).  Alternatively, people occasionally advocate smokeless tobacco (SLT) as another potential aid in smoking reduction; SLT products contain chemical toxins but are arguably less harmful than smoking (Royal College of Physicians of London, 2000).  This week’s ASHES reviews an investigation of the comparative appeal of MN and SLT to current smokers.

Shiffman, Gitchell, Rohay, Hellebusch, and Kemper (2007) conducted two studies comparing smokers’ self-reported preference for MN or SLT.  In Study 1, the researchers contacted participants via a random-digit-dial telephone interviewing system using numbers from the United States Scientific Telephone Sample; 66% of those contacted completed the survey. The interviewer played current smokers (n=283) a recording of a 1-minute advertisement describing each product (as seen in Table 1), and asked them standard market research questions about which one they preferred. Study 2 followed the same procedure.  However, in Study 1, the advertisements introduced prototypical forms of both MN and SLT (e.g., nicotine gum, chewing tobacco, respectively) whereas in Study 2, both products were introduced in a novel manner, as lozenges.  Here we only report the findings of Study 1 because the results refer to the more widely known forms of MN and SLT.

Table 1. MN and SLT Readings (adapted from Shiffman et al., 2007)

Analyses indicated participants reported a significant preference for MN:  59% of participants preferred MN whereas only 22% of participants reported preferring SLT (p<0.0001).  Previous SLT users (n=69) expressed a greater preference for MN than SLT (44% vs. 39%), as did nonusers (n=214; 64% vs. 17%).  However, a chi-square analysis indicated independence between the groups; nonusers’ preference was significantly greater than that of previous SLT users (p=.0003).  Both previous MN users (n=37) and nonusers (n=246) preferred MN to SLT (67% vs. 19%, 58% vs. 23%, respectively), but there was no interaction between the groups’ preferences (p=ns).   

There are two intertwined limitations of this study.  First, participants assessed their preference for a product based only on a 1-minute description; without a more detailed explanation of the product or the opportunity to experiment with it, it is unlikely that participants could form a valid opinion.  Second, people’s intended or expected actions often differ from their actual behaviors (Baumeister, Vohs, & Funder, 2007).  Therefore, although participants expressed an increased likelihood of using MN, it is possible that given the opportunity, participants would choose SLT or an entirely different option. 

The results of this study serve as an initial aid in creating both safe and appealing ways for smokers to obtain nicotine without smoking.  Although public health strategies previously encouraged people to quit nicotine consumption altogether, the use of replacement nicotine has been shown to reduce smoking, which reduces the amount of toxins ingested into the body.  Further investigations are needed to determine the least harmful and most attractive forms of pure nicotine products before this concept of replacement nicotine can be seriously utilized as a public health strategy.

What do you think?  Comments can be addressed to Sara Kaplan.

References

Bates, C., Fagerstrom, K., Jarvis, M. J., Kunze, M., McNeill, A., & Ramstrom, L. (2003). European Union policy on smokeless tobacco:  A statement in favour of evidence based regulation for public health. Tobacco Control, 12(4), 360-367.

Baumeister, R. F., Vohs, K. D., & Funder, D. C. (2007). Psychology as the science of self-reports and finger movements:  Whatever happened to actual behavior? Perspectives on Psychological Science 2(4), 396-403.

Bolliger, C. T., Zellweger, J. P., Danielsson, T., van Biljon, X., Robidou, A., Westin, A., et al. (2000). Smoking reduction with oral nicotine inhalers:  Double blind, radnomized clinical trial of efficacy and safety. British Medical Journal, 321, 329-333.

Royal College of Physicians of London. (2000). Nicotine addiction in Britain:  A report of the Tobacco Advisory Group of The Royal College of Physicians. London: Royan College of Physicians.

Shiffman, S., Gitchell, J., Rohay, J. M., Hellebusch, S. J., & Kemper, K. E. (2007). Smokers' preferences for medicinal nicotine vs. smokeless tobacco. American Journal of Health Behavior 31(5), 462-472.

Wennike, P., Danielsson, T., Landfelt, B., Westin, A., & Tonnesen, P. (2003). Smoking reduction promotes smoking cessation: Results from a double blind randomized, placebo-controlled trial of nicotine gum with 2-year follow-up. Addiction, 98(10), 1395-1402.

The DRAM, Vol 4(3) - Famous Last Words: It’s Only a Few Miles

One drinking myth is that people who drink more can handle their alcohol better than those who drink less. This fallacy might provide heavier drinkers with the opportunity to rationalize driving while under the influence of intoxicants.  This week’s DRAM reviews a study assessing actual and perceived impairments in psycho-motor functioning among a group of heavy and light drinkers.

The Chicago Social Drinking project, a longitudinal study, recruited participants through newspaper advertisements, fliers, and word of mouth.  Brumback, Cao, and King (2007) derived their sample of 21-35 year olds from the Chicago project sample. The sample of 132 (77 HD and 55 LD) research participants was 66% white and 53% female. Investigators identified participants as either light or heavy drinkers using two measures (The Quantity-Frequency Index; Callhalan, Cisin, & Crossley, 1969; Timeline Follow-Back Interview; Sobell & Sobell, 1995). The authors used previous studies (King & Byars, 2004; King & Epstein, 2005) to operationally define heavy social drinkers (HD) as those, who for at least the last two years before the study, consumed >10 alcoholic drinks weekly and had occurrences of binge drinking 1-5 times per week .  They defined light social drinkers (LD) as those, who for the last two years before the study, consumed <6 drinks per week with rare or no binge drinking.  The authors defined binge drinking as >5 drinks in a single occasion for males, and >4 for females.

To assess alcohol-related impairment, the authors first measured perceptual motor speed with the Digit Symbol Substitution Test (DSST, from WAIS-R; Wechsler, 1981), and motor speed and coordination with the Grooved Pegboard (Lafayette Instruments, Lafayette, IN).  Next, the participants consumed one 08g/kg, 190 proof ethanol beverage. After 15 minutes, the researchers re-administered the same two impairment measures, tested participants for blood alcohol concentration (BAC), and asked participants to report subjective measures of impairment: the degree of their overall impairment, how unsafe it would be to drive at the present, and whether others could detect impairment.

Figure 1. Mean scores of self rated impairment items 15 minutes after drinking alcoholic beverage.

Items rated on a 10 point scale: 0=not at all; 10=extremely.
Note: **p<0.001; *p<0.01. Adapted from Brumback et al. (2007)

BAC levels 15 minutes after drinking were 0.074g/dl for LD and 0.084g/dl for HD, a statistically but not clinically significant difference (0.08 is the legal limit in the US; Highway Loss Data Institute, 2008). After drinking, both HD and LD performed significantly worse on impairment measures, and both HD and LD were impaired equally (i.e., main effect and interaction terms were not significantly different for either Pegboard or DSST tasks). Figure 1 shows that HD were more likely than LD to self-report less subjective impairment, feeling safer driving, and that others would be less likely to detect their impairment.

The social implications of the data are limited because scores on neither the objective nor subjective tests measure actual functional impairment (i.e., driving) or the decision to drive. However, these findings suggest that after having adapted to the subjective effects of alcohol, heavy drinkers might require higher levels of consumption to achieve the same subjective effect once achieved at a lower dose. In this study both LD and HD had equal doses, but, according to a neuroadaptation model, the HD would report less impairment; the findings did support this notion. HD group members perceived themselves to be less intoxicated than the LD group. Because psychomotor impairments were similar between the two groups, the belief that those who drink more can handle their alcohol better than lighter drinkers is indeed a myth: risks for driving drunk are the same for all types of drinkers. What seems to be different is the ability of heavy drinkers to recognize their level of intoxication. This means that those who are at greater risk for deciding to drive while intoxicated are also those who tend to drink more heavily.

What do you think?  Comments can be addressed to Leslie Bosworth.

References

Brumback, T., Cao, D., & King, A. (2007). Effects of alcohol on psychomotor performance and perceived impairment in heavy binge social drinkers. Drug and Alcohol Dependence, 91, 10-17.

Callhalan, V., Cisin, I., & Crossley, H. M. (1969). American drinking practices: A national study of drinking behavior and attitudes. New Brunswick, NJ: Rutgers Center for Alcohol Studies.

Highway Loss Data Institute. (2008). DUI/DWI laws.   Retrieved January 15, 2008, from http://www.iihs.org/laws/dui.aspx

King, A. C., & Byars, J. (2004). Alcohol induced performance impairment in heavy episodic and light social drinkers. Journal of Studies of Alcohol, 65, 27-36.

King, A. C., & Epstein, A. M. (2005). Alcohol dose-dependent increase in smoking urge in light smokers. Alcoholism: Clinical and Experimental Research, 29, 547-552.

Sobell, L. C., & Sobell, M. B. (1995). Alcohol timeline follow-back users' manual. Toronto, Canada: Addiction Research Foundation.

Wechsler, D. (1981). WAIS-R Manual: Wechsler Adult Intelligence Scale-Revised. New York: Harcourt, Brace, & Jovanovich.