The Brief Addiction Science Information Source (BASIS)

STASH, Vol. 4(3) - OxyContin Use: Prescribed or Recreational?

OxyContin is an opioid agonist. Opioids are among the most potent analgesics; medical doctors prescribe analgesics to reduce or relieve pain (see STASH 1(2) for more information).  Like other opioids (both natural and synthetic), the Drug Enforcement Agency classifies OxyContin as a Schedule II substance (Drug Enforcement Agency, 2008).  Although doctors prescribe OxyContin, evidence suggests illicit use could be widespread among some populations (i.e., Davis and Johnson, 2008).  This week’s BASIS reviews a study by Carise, Leggett, Dugosh, et al. (2007), which explored rates of OxyContin use among a large sample of people seeking addiction treatment.  The data also provide information as to whether use was a regular function of prescribed use or, alternatively, illict and part of a pattern of persisting, multi-substance use problems.

As part of a large standardized intake interview, all admissions to 157 drug treatment programs self-reported information about their lifetime OxyContin use history (The Drug Evaluation Network System; Carise & Gruel, 2003).  The researchers also gathered information about other drug use patterns, past drug treatments, and whether participants took OxyContin for medical purposes or to experience its intoxicating effects recreationally.  The authors defined OxyContin abuse as having taken the drug to “get high or get a buzz,” and regular use as taking the drug more than 3 times per week for more than 1 year.  Three years of assessment interviews at treatment facilities in 22 states yielded 27,816 unique participants: 1,425 (5% of the total sample) used OxyContin, 1,243 (87% of users) regularly used OxyContin, 1,208 (97% of regular users) abused OxyContin, and 300 (24% of regular users) had a prescription.

Table 1.  Differences between treatment seekers who did and did not abuse OxyContin

Table 1 indicates that abusers of OxyContin were more likely than non abusers to be male, white, and to have used heroin, cocaine, and sedatives during their lifetimes.  Half of OxyContin abusers, but only 30% of non abusers, had received psychiatric medication during their lifetimes.  One third of the 300 people prescribed the drug sought additional medication through illicit means, and half (150 of 300) qualified for OxyContin abuse.

The authors might have identified a larger proportion of the sample as OxyContin abusers compared to other studies because their definition of abuse (i.e., use to get high) is less conservative than the more commonly used DSM-IV-TR definition (i.e., repeated impairment, failure to meet responsibilities, or negative consequences; American Psychiatric Association, 2000).   The admission interview did not ask participants which substances prompted their decision to seek treatment, so we do not know if OxyContin was the presenting problem or not.  The data is based on the self-report of participants, so they might have minimized or exaggerated their reports of abuse symptom severity depending upon the perceived value such reports during treatment intake.

Carise et al. offer findings that suggest only a small portion (5%) of substance treatment seekers use OxyContin.  Most patients obtained OxyContin illicitly (75%), and those with a prescription obtained additional medication illicitly (33%) or took the drug to feel intoxicated (56%). These findings suggest that with or without prescription, substance abuse treatment seekers include OxyContin as part of a larger pattern of substance abuse. To address this problem, improved systems for identification and treatment of people who abuse OxyContin is necessary to prevent illict use and unauthorized distribution. 

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

References
American Psychiatric Association. (2000). DSM IV-TR: Diagnostic and statistical manual of mental disorders--Text revision (Fourth ed.). Washington, D.C.: American Psychiatric Association.

Carise, D., & Gurel, O. (2003). Benefits of integrating assessment technology with treatment: The Drug Evaluation Network System project. In J. Sorenson, R. A. Rawson, J. Guydish & J. Zweben (Eds.), Drug abuse treatment through collaboration: Practice and research partnerships that work (pp. 181–195). Washington, DC: American Psychological Association.

Carise, D., Leggett Dugosh, K., McLellan, A. T., Camilleri, A., Woody, G. E., & Lynch, K. G. (2007). Prescription OxyContin abuse among patients entering addiction treatment. American Journal of Psychiatry, 164, 1750–1756.

Davis, W.R., Johnson, B.D. (2008). Prescription opoid use, misuse, and diversion among street drug users in New York City. Drug and Alcohol Dependence, 92(1-3), 267-276.

Addiction & the Humanities Vol.4 (3) –The Buzz: Taking a closer look at addiction in pop culture.

Approximately one year ago, HBO launched The Addiction Project  in partnership with the Robert Wood Johnson Foundation, the National Institute of Drug Abuse, and the National Institute of Alcohol Abuse and Alcoholism (Leis, 2007). Mental health advocates lauded the film and education project as “groundbreaking” and hoped it would educate the public about addiction (Leis, 2007) and create a new dialogue about addiction. Fast forward one year and addiction is still in the headlines. Now, the very same organizations that praised The Addiction Project for its honest portrayal of addiction are upset by “Celebrity Rehab with Dr. Drew” on VH1 (Jesella, 2008). This week’s Humanities inquires whether presentations of addiction in the popular culture are potentially harmful.

HBO’s Addiction Project featured a documentary, a book, four independent addiction-themed movies, a website, and a national community grassroots campaign coordinated by Faces and Voices of Recovery, Join Together, and Community Anti-Drug Coalitions of America (CADCA). These three groups brought together elected officials, people in recovery, and community-based organizations to promote awareness and discuss new policies for addiction treatment. Many reviewers praised the series, which was honored by the Academy of Television Arts and Sciences Governors Award in 2007.

Two recent changes in the media have influenced the depiction of addiction: the public’s desire for celebrity gossip and the explosion of reality television shows.  Celebrity gossip has become so popular that following Brittney Spears, who has been to rehabilitation three times in the past year, has become an industry in and of itself. During the past year, millions of Americans have viewed her every move. You can see the importance of celebrity gossip in our daily lives by measuring the rapid growth of the celebrity gossip website TMZ.com. According to Alexa.com, a company that analyses web traffic, TMZ.com is one of the top 200 websites for Internet traffic in the U.S. and one of the top 1,000 websites worldwide. It has become so popular that photographs and footage shot by TMZ staff have found their way into national news broadcasts. 

The other vehicle driving this voyeuristic behavior is reality television. The popularity of reality television began with MTV’s “Real World” series in 1992. The show placed seven strangers together in an apartment for several months and followed their every move (MTV, 2008). Between 1992 and 2008 there has been a multitude of reality TV shows many of which aired on MTV and VH1. A spin-off of the “Real World” on MTV was “The Surreal Life” on VH1 that used celebrity participants. Reality television was recently bolstered by the 14-week writers’ strike (Mitchell & Goldmann, 2008) that left television executives without scripts. To fill open time slots, TV executives opted for a variety of new reality television shows.

Recent media depictions of substance use and unsuccessful attempts at rehabilitation have some addiction experts worried that celebrities (e.g. Lindsay Lohan and Britney Spears) are making a mockery of the rehabilitation experience and the seriousness of addiction (Reuters, 2007). The exposure of rehabilitation by Dr. Drew Pinsky, a practicing physician board-certified in addiction medicine, in the VH1 reality show “Celebrity Rehab with Dr. Drew” (Kotlyar, 2008) has fueled heated discussion. Groups  such as Faces and Voices of Recovery are mobilizing against “Celebrity Rehab,” arguing that the drama that plays out on the show sensationalizes addiction (Faces and Voices of Recovery, 2008) and takes advantage of vulnerable people. Can people suffering from mental disorder give truly informed consent to have their story televised? Concerned groups argue the show’s depiction does not match reality. For example, most people who seek treatment do not have access to the quality of the facilities shown on “Celebrity Rehab” (Faces and Voices of Recovery, 2008). Opponents of the show “believe that when people see this show, they’ll wonder why they should help people with addiction and why people should get insurance coverage for their care” (Calderone, 2008). This might make it difficult to fix inequalities in the reimbursement for addiction treatment compared with other chronic diseases.

“Celebrity Rehab” seems to be the logical marriage of the public’s incessant need for up-to-the-minute gossip on celebrities (e.g. TMZ.com), the popularity of reality television, and celebrity voyeurism. Dr. Pinsky defends his show arguing that the public’s focus is already on celebrities and their battles with addiction.  What he is attempting to do is harness that focus and help the public understand that rehabilitation is not easy and that it takes a lot of hard work (Celizic, 2008). VH1 executives defend the show stating “Celebrity Rehab is as real as it gets… this is about as scared straight as you’re going to get” (Miller, 2008). The show spans the entire 21 days inpatient rehabilitation process. However, the time restrictions of television allow VH1 to show only approximately one percent of everything that occurred during the 21 days filmed (Kotlyar, 2008). Despite the criticism, the show has opened to favorable reviews (Maynard, 2008; Rhodes, 2008).   

Celebrities and their public fight against addiction will continue to be the buzz in pop culture. Society’s desire for contact with celebrities does not seem to be waning.  Reality television shows offer television audiences an opportunity for guilt-free voyeurism.  Are people watching shows like “Celebrity Rehab” to understand the struggles of addiction?  Maybe, but just as many are probably watching because they enjoy seeing other people, especially the rich and famous, suffer. It gives them an opportunity to compare their lives to those they see on television. Their struggle with addiction in the public eye is an opportunity to educate the public at large.  Addiction advocates and treatment specialists need to constructively shape the discussion and ensure that the public is not misled, all the while making sure that those seeking treatment get the care they deserve. 

What do you think?  Does “Celebrity Rehab with Dr. Drew” glamorize substance use and take advantage of the mentally ill or is it a continuation of the dialogue started by the HBO’s Addiction Project, focused on a younger audience?

Comments can be addressed to John H Kleschinsky.

References
Calderone, T. (2008). Letter to President of VH1.   Retrieved March 09, 2008, from http://www.facesandvoicesofrecovery.org/pdf/01.25.2008_NAATP_celeb_rehab.pdf

Celizic, M. (2008, Jan 08, 2008). Dr. Drew treats celebrities' demons on new show: TODAY contributor helps the famous, and no-as-famous, with addictions.   Retrieved March 09, 2008, from http://www.msnbc.msn.com/id/22555361/

Faces and Voices of Recovery. (2008). Speak out about VH1's "Celebrity Rehab with Dr. Drew". Campaigns: Retrieved March 09, 2008, from http://www.facesandvoicesofrecovery.org/about/campaigns/celebrity_rehab.php

Jesella, K. (2008). Does 'Rehab' host go too far? [Electronic Version]. Chicago Tribune. Retrieved March 09, 2008 from http://www.chicagotribune.com/features/lifestyle/health/chi-0212_health_rehab_rfeb12,1,7277025.story.

Kotlyar, A. (2008). Celebrity Rehab with Dr. Drew. VH1.com   Retrieved March 09, 2008, from http://www.vh1.com/shows/dyn/celebrity_rehab_with_dr_drew/series.jhtml

Leis, R. (2007). HBO's Groundbreaking 14-Part Series, The ADDICTION Project, Kicks Off March 15. Announcement   Retrieved March, 09, 2007, from http://www.jointogether.org/news/yourturn/announcements/2007/hbo-the-addiction-project.html

Maynard, J. (2008, January 10, 2008). VH1's 'Celebrity Rehab' Could Become a Habit.   Retrieved March 09, 2008, from http://www.washingtonpost.com/wp-dyn/content/article/2008/01/09/AR2008010903434.html

Miller, M. (2008). VH1 puts reality into rehab. Los Angeles Times   Retrieved March 09, 2008, from http://www.latimes.com/entertainment/la-et-rehab9jan09,1,6990632.story

Mitchell, G., & Goldmann, S. (2008). Writers Guild Members Overwhelmingly Ratify New Contract. News Release   Retrieved March 14, 2008, from http://www.wga.org/subpage_newsevents.aspx?id=2780

MTV. (2008). The Real World New York. Real World   Retrieved March 14, 2008, from http://www.mtv.com/ontv/dyn/realworld-season1/series.jhtml

Reuters. (2007, July 26, 2007). Experts: Lohan, Spears making mockery of rehab. Health   Retrieved March 09, 2008, from http://www.cnn.com/2007/HEALTH/07/25/celebrities.rehab.reut/index.html

Rhodes, J. (2008). Shocking Celebrity Rehab Moments Revealed. TV Guide   Retrieved March 09, 2008, from http://seattlepi.nwsource.com/tvguide/349330_tvgif30.html

ASHES Vol.4(3) - Bet You Can't Have Just One

During the 1970s, Russell (1971) made the claim that smoking more than 20 cigarettes a day would result in a nicotine addiction and associated withdrawal symptoms. In 2000, the Dependence and Assessment of Nicotine Dependence in Youth (DANDY) study challenged Russell’s claim and reported that withdrawal symptoms could appear from smoking as few as 5 cigarettes a day (J. DiFranza, Savageau, & Fletcher, 2002). In this week’s ASHES, we review DiFranza et al’s 2007 article examining how quickly nicotine dependence symptoms appeared among an adolescent population.

Researchers recruited 1,246 sixth graders from Massachusetts public schools and used a trained interviewer to administer three surveys per year from January 2002 to January 2006. Nearly 1000 (i.e., 970) participants completed all the surveys. Each subject used a calendar to record the following personal smoking milestones at each assessment: first puff, inhalation, start of monthly, weekly, and daily smoking, and changes in type, duration, frequency (including periods of abstinence) of smoking. Researchers also collected responses to the Hooked on Nicotine Checklist (HONC; J. R. Difranza & Wellman, 2006), and the International Statistical Classification of Diseases, 10th Revision (ICD-10; World Health Organization, 1992) criteria for tobacco dependence. Endorsement of one or more of the 10 HONC scale items indicated a loss of autonomy (1). Researchers classified participants as tobacco dependent if they experienced three or more of the 22 ICD-10 items.

The study found that both loss of autonomy and development of tobacco dependence occurred soon after first tobacco use. Focusing on the 217 participants who inhaled, researchers found that 127 had indeed lost autonomy over tobacco use and that 10% did so within two days of their first cigarette inhalation experience. Smoking an estimated minimum of seven cigarettes per month resulted in a loss of autonomy. Researchers also found that 83 participants, all of whom inhaled, developed ICD-10 defined dependence as soon as 13 days after their first inhalation, and that approximately 50% of them did so upon reaching a 46-cigerette per month smoking frequency (~1-2 cigarettes a day; J. R. DiFranza et al., 2007). Table 1 presents the percentage of participants (n=217) who endorsed HONC Scale items and how frequently these symptoms occurred before and after the onset of daily smoking.

Table 1: Smoking Milestones & Their Association with Daily Smoking*

*adapted from Table 3, Incidence of Milestones and Their Association With Daily Smoking in DiFranza, J. R., Savageau, J. A., Fletcher, K., O'Loughlin, J., Pbert, L., Ockene, J. K., et al. (2007). Symptoms of Tobacco Dependence After Brief Intermittent Use. Archives of Pediatric & Adolescent Medicine, 7(161), 704-710.
*The milestones are listed sequentially as they occur before and after the onset of daily (e.g, loss of autonomy occurred before smoking everyday and failed quit attempts occurred after.

The study was limited by its use of interviews as its main data collection source. This methodology risks recall errors due to length of time between subsequent interviews. Furthermore, there are also personal biases that arise from and skew self-reported data. Lastly, researchers included biological tests of tobacco dependence through the collection of saliva samples (to test cotinine levels), for some but not all participants.

DiFranza et al.’s research suggests that a relatively brief time lag exists between the first tobacco use experience and the appearance of physiological dependence to tobacco and the withdrawal symptoms that emerge upon cessation. The study’s findings serve to remind adolescents that first time experimentation with various dependence producing substances is not innocuous. The days following first tobacco experience are crucial in determining whether an adolescent will experience dependence-related symptoms. The implication for substance abuse prevention programs and health administrators is that this brief time lag necessitates readily available and rapid responses to experimenting adolescents in order to interrupt the onset of withdrawal symptoms and the development of addiction.

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

Note: 1 Full autonomy is lost when the sequelae of tobacco use, either physical or psychological, present a barrier to quitting.(J. DiFranza et al., 2002)

References

DiFranza, J., Savageau, J., & Fletcher, K., et al. (2002). Development of symptoms of tobacco dependence in youths: 30 month follow up data from the DANDY study. Tobacco Control, 11(3), 228-235.

DiFranza, J. R., Savageau, J. A., Fletcher, K., O'Loughlin, J., Pbert, L., Ockene, J. K., et al. (2007). Symptoms of Tobacco Dependence After Brief Intermittent Use. Archives of Pediatric & Adolescent Medicine, 7(161), 704-710.

Difranza, J. R., & Wellman, R. J. (2006). Hooked on Nicotine Checklist (HONC).   Retrieved March 11, 2008, 2008, from http://fmchapps.umassmed.edu/honc/TOC.htm

Russell, M. (1971). Cigarette smoking: natural history of a dependence disorder. British Journal of Medical Psychology, 44(1), 1-16.

World Health Organization. (1992). International Classification of Diseases, 10th Revision (ICD-10). Geneva, Switzerland.

The DRAM Vol. 4(2) - Gender and Drinking – Maybe We Aren’t so Different After All

Researchers have found men to be at greater risk for developing alcohol use disorders than women (Grant, 1997; Warner, Kessler, Hughes, Anthony, & Nelson, 1995); however, with the shift away from traditional gender roles in the United States (e.g., an increased proportion of women working outside the home, a decreased proportion of women bearing children; Thronton & Freedman, 1983), some have observed a trend toward convergence of male and female drinking patterns (Greenfield & Room, 1997). This week’s DRAM reviews a national study about the changes in drinking customs and the prevalence of alcohol disorders among men and women in the United States.

Keyes, Grant, and Hasin (2008) analyzed data from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), in which professional interviewers conducted face-to-face interviews with 42,693 civilian non-institutionalized participants aged 18 years and older. Participants responded to the Alcohol Use Disorder and Associated Disabilities Interview Schedule (AUDAIS-IV; a survey that contains over 40 questions used to evaluate alcohol use disorders). The participants reported the largest number of drinks they consumed during their period of heaviest drinking, and reported their frequency of binge drinking (i.e., 5+ drinks once per week or more often during period of heaviest drinking).  To study gender differences in drinking behavior over time, the researchers divided participants into four birth cohorts: People in Cohort 1 were born in the years from 1913 through 1932; Cohort 2 from 1933 -1949; Cohort 3 from 1950-1967; and Cohort 4 from 1968-1984.  The researchers divided Cohorts 2 and 3 at 1950 because previous findings indicated a greater risk of developing alcohol disorders among those born after 1950 (Johnson & Gerstein, 1998).  They then divided Cohorts 3 and 4 at 1968 to specifically examine those who entered the period of risk for alcohol disorders after the 1980s (i.e., the peak of per capita alcohol consumption in the United States; Lakins, Williams, Hsiao-Ye, & Hilton, 2005).

Overall, men consumed a larger average number of drinks in one sitting (6.94) than women (2.98) during their period of heaviest drinking (a male-to-female ratio of 2.3:1).  Cohort analyses suggest that consumption differences between men and women narrowed over time: from Cohort 1 to Cohort 4 the male-to-female ratio dropped from 2.9:1 to 2.1:1.  Following the peak in per capita alcohol consumption in the United States, the prevalence of alcohol dependence increased from 14.4% to 17.2%, while the prevalence of alcohol abuse decreased from 22.1% to 14.3%.  However, Figure 1 shows that the decline in alcohol abuse among females was significantly smaller than that among males (differences of 5.3% and 10.4%, respectively). This trend narrowed the difference in prevalence of alcohol disorders between genders. 

Figure 1 Prevalence of lifetime DSM-IV alcohol abuse and dependence by gender and birth Cohorts 3 and 4

The study is subject to the typical limitations of a cross-sectional design, such as recall bias.  Further, cross-section designs are not ideal for interpreting trends. To illustrate, participants in the older cohorts might have had difficulty remembering their drinking behaviors, resulting in an underestimation of the prevalence of alcohol dependence among the older cohorts.  Although these discrepancies make it difficult to compare drinking behavior by cohort, they should not confound the comparisons of interest between the genders.   

Keyes, Grant and Hasin’s findings, that the differences in male and female drinking patterns are diminishing, provide support for the findings of earlier researchers (e.g., Johnson & Gerstein, 1998).  The significantly smaller decrease in alcohol abuse among women in Cohorts 3 and 4 suggests that public health workers place increased emphasis on prevention efforts that target women.  It is important that we continue to study these trends to gain an improved understanding about why the gender gap in alcohol disorders is narrowing, and to assure appropriate treatment for the individuals in need of treatment.

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

References

Grant, B. F. (1997). Prevalence and correlates of drug use and DSM-IV alcohol dependence in the United States:  Results of the National Longitudinal Alcohol Epidemiologic Survey. Journal of Studies on Alcohol 58, 464-473.

Greenfield, T. K., & Room, R. (1997). Situational norms for drinking and drunkenness:  Trends in the US adult population, 1979-1990. Addiction, 92, 33-47.

Johnson, R. A., & Gerstein, D. R. (1998). Initiation of use of alcohol, cigarettes, marijuana, cocaine, and other substances in US birth cohorts since 1919. American Journal of Public Health, 88(1), 27-33.

Keyes, K. M., Grant, B. F., & Hasin, D. S. (2008). Evidence for a closing gender gap in alcohol use, abuse and dependence in the United States population. Drug and Alcohol Dependence, 93, 21-29.

Lakins, N., Williams, G. D., Hsiao-Ye, Y., & Hilton, M. E. (2005). Apparent per capita alcohol consumption:  National, state, and regional trends, 1977-2003. Rockville, Maryland NIAAA, Division of Biometry and Epidemiology, Alcohol Epidemiologic Data System.

Thronton, A., & Freedman, D. (1983). The changing American family. Population Bulletin, 39, 1-44.

Warner, L. A., Kessler, R. C., Hughes, M., Anthony, J. C., & Nelson, C. B. (1995). Prevalence and correlates of drug use and dependence in the United States: results from the National Comorbidity Survey. Archives of General Psychiatry, 52(3), 219-229.