Parent Programs for Reducing Adolescent's Antisocial Behavior and Substance Use: A Randomized Controlled Trial.

Two theoretically based parent training programs, delivered in real-world settings by the social services, were examined in this randomized controlled trial for effectiveness in reducing adolescents' antisocial behavior and substance use. Two hundred and thirty-seven (237) adolescents in ages between 12 and 18 and their parents were assigned to one of two programs or to a wait-list control condition. The programs were the nine weekly group sessions program Comet 12-18 (Swedish Parent Management Training Program) and the six weekly ParentSteps (Swedish shortened version by Strengthening Families Program 10-14). Outcome measures were antisocial behavior, substance use, and delinquency, and psychosocial dysfunction. Data based on adolescents' and parents' ratings of the adolescents' problem behavior at baseline and 6 months later were analyzed with repeated measures ANVOA, Logistic regression, and Kruskal-Wallis H test. The results showed that parents' ratings of adolescents' antisocial behaviors decreased significantly over time, but no time by group effect emerged. No program effects were found in the adolescents' self-reported antisocial behavior, delinquency, or psychosocial functioning. A threefold risk of illicit drug use was found in both intervention groups. The results suggest that neither Comet nor ParentSteps had beneficial effects on adolescent's antisocial or delinquent behavior, or on alcohol use. The only significant group difference found was a threefold risk of drug use in the intervention adolescents at follow-up, but for several reasons this finding should be interpreted with caution. Trial registration number: ISRCTN76141538.

Stability and change in alcohol habits of different socio-demographic subgroups--a cohort study.

BACKGROUND: Stability in alcohol habits varies over time and in subgroups, but there are few longitudinal studies assessing stability in alcohol habits by socio-demographic subgroups and potential predictors of stability and change. The aim was to study stability and change in alcohol habits by sex, age, and socio-economic position (SEP). METHODS: Data derived from two longitudinal population based studies in Sweden; the PART study comprising 19 457 individuals aged 20-64 years in 1998-2000, and the Stockholm Public Health Cohort (SPHC) with 50 067 individuals aged 18-84 years in 2002. Both cohorts were followed-up twice; PART 2000-2003 and 2010, and SPHC 2007 and 2010. Alcohol habits were measured with the Alcohol Use Disorders Identification Test (AUDIT), and with normal weekly alcohol consumption (NWAC). Stability in alcohol habits was measured with intraclass correlation. Odds ratios were estimated in multinomial logistic regression analysis to predict stability in alcohol habits. RESULTS: For the two drinking measures there were no consistent patterns of stability in alcohol habits by sex or educational level. The stability was higher for older age groups and self-employed women. To be a man aged 30-39 at baseline predicted both increase and decrease in alcohol habits. CONCLUSIONS: The findings illustrate higher stability in alcohol habits with increasing age and among self-employed women with risky alcohol habits. To be a man and the age 30-39 predicted change in alcohol habits. No conclusive pattern of socio-economic position as predictor of change in alcohol habits was found and other studies of potential predictors seem warranted.

Gender differences in the prediction of parental servings of alcohol to adolescents and youth drunkenness.

This longitudinal study, funded by the Swedish National Institute of Public Health, explored gender differences in predictors of parental servings of alcohol to youth and youth drunkenness. Data were collected from 1,752 Swedish 7th-grade youth and their parents, at three occasions between 2007 and 2010. Measurements included youth alcohol use, parental warmth, and parental control. Two-level logistic regressions showed that 15-year-old girls are more likely to be served alcohol at home compared to boys, and that there are some gender differences in predictors of drunkenness. Limitations and implications of the findings are discussed and areas for future research identified.

Alcohol use in adolescence and risk of disability pension: a 39 year follow-up of a population-based conscription survey.

BACKGROUND: The role of alcohol consumption for disability pension (DP) is controversial and systematic reviews have not established causality. We aimed to assess the role of adolescent alcohol use for future DP. We wanted to find out whether an increased risk mainly would affect DP occurring early or late in life as well as whether the level of alcohol consumption and patterns of drinking contribute differently in DP receiving. METHODOLOGY/PRINCIPAL FINDINGS: The study is a 39-year follow-up of 49 321 Swedish men born in 1949-1951 and conscripted for compulsory military service in 1969-1970. As study exposures (i) "risk use" of alcohol composed of measures related to pattern of drinking, and (ii) the level of consumption based on self-reported volume and frequency of drinking had been used. Information on DP was obtained from social insurance databases through 2008. "Risk use" of alcohol was associated with both "early DP" and "late DP", i.e. granted below and above the approximate age of 40 years, with crude hazard ratio (HR) of 2.89 (95% confidence intervals (CI) 2.47-3.38) and HR of 1.87 (95%CI: 1.74-2.02), respectively. After adjustment for covariates, HR was reduced to 1.32 (95%CI: 1.09-1.59) and 1.14 (95%CI: 1.05-1.25), respectively. Similar patterns were seen for moderate (101-250 g 100% alcohol/week) and high (>250 g) consumption, though the risk disappeared when fully adjusted. CONCLUSIONS/SIGNIFICANCE: Alcohol use in adolescence, particularly measured as "risk use", is associated with increased risk of future DP. The association is stronger for "early DP", but remains significant even for DP granted in older ages. Therefore, pattern of drinking in adolescent should be considered an important marker for future reduced work capacity.

Treatment seeking and subsequent 1-year drinking outcomes among treatment clients in Sweden and the U.S.A.: a cross-cultural comparison.

Cross-cultural comparisons provide a method for distinguishing unique aspects as well as shared aspects of different cultures. Theoretically framed by a health-services conceptual model, we examine the extent that culture-specific versus common characteristics are associated with treatment seeking and drinking outcome. Swedish (n=997) and U.S. (n=501) alcohol-dependent individuals were interviewed at baseline and 1-year (n=635 and n=384 respectively). Both studies gathered comparable background, help-seeking, and drinking data. Regression models tested predictors of 1-year follow-up drinking defined as abstinence or moderate drinking versus heavy drinking. Swedish individuals were older and had social networks comprised mostly of substance abusers compared to U.S. individuals who reported higher problem severity and greater drug involvement. Whereas U.S. individuals reported greater prior mutual-help attendance, Swedish individuals reported greater prior treatment involvement. Better 1-year drinking outcomes were reported by women, younger age groups and those with an abstinence goal in both samples. Cultural and institutional differences were apparent. For example, with Swedish individuals having a mostly non-using network predicted better outcomes, whereas lower problem severity was a predictor for U.S. individuals.

Does the prevention paradox apply to various alcohol habits and problems among Swedish adolescents?

BACKGROUND: The prevention paradox states that a majority of alcohol-related problems in a population come from moderate drinkers because they are more numerous than heavy drinkers, although the latter have a higher individual risk of adverse outcomes. We examined the extent to which the prevention paradox applies to the relationship between alcohol consumption, heavy episodic drinking (HED) and alcohol-related problems in adolescents; an area in which studies are lacking. METHODS: A total of 7288 alcohol-consuming adolescents aged 13-17 years were examined. The proportions (%) of problems related to drinking measures [the upper 10% and bottom 90% of drinkers by annual alcohol intake, and those with frequent (monthly), less frequent, and no heavy drinking episodes] were calculated. RESULTS: The bottom 90% of consumers by annual intake accounted for a large majority of the alcohol-related problems among boys and girls at all ages. The share of problems accounted for by monthly HEDs increased with age, from ∼10% among those aged 13 years to >50% among those aged 17 years. Attributable proportions for the top 10% alcohol consumers ranged between 22% and 37%. CONCLUSIONS: Our analyses suggest that the prevention paradox is valid for adolescent boys and girls aged ≥15 years and applies to a large range of alcohol-related problems of varying severity. Our results imply that not only that prevention directed at all adolescents is essential, but also that HED should be particularly noticed.

Mortality and causes of death among violent offenders and victims--a Swedish population based longitudinal study.

BACKGROUND: Most previous studies on mortality in violent offenders or victims are based on prison or hospital samples, while this study analyzed overall and cause specific mortality among violent offenders, victims, and individuals who were both offenders and victims in a general sample of 48,834 18-20 year-old men conscripted for military service in 1969/70 in Sweden. METHODS: Each person completed two non-anonymous questionnaires concerning family, psychological, and behavioral factors. The cohort was followed for 35 years through official registers regarding violent offenses, victimization, and mortality. The impact of violence, victimization, early risk factors and hospitalization for psychiatric diagnosis or alcohol and drug misuse during follow up on mortality was investigated using Cox proportional hazard regression analyses. RESULTS: Repeat violent offenses were associated with an eleven fold higher hazard of dying from a substance-related cause and nearly fourfold higher hazard of dying from suicide. These figures remained significantly elevated also in multivariate analyses, with a 3.03 and 2.39 hazard ratio (HR), respectively. Participants with experience of violence and inpatient care for substance abuse or psychiatric disorder had about a two to threefold higher risk of dying compared to participants with no substance use or psychiatric disorder. CONCLUSIONS: Violent offending and being victimized are associated with excess mortality and a risk of dying from an alcohol or drug-related cause or suicide. Consequently, prevention of violent behavior might have an effect on overall mortality and suicide rates. Prevention of alcohol and drug use is also warranted.

Alcohol use, heavy episodic drinking and subsequent problems among adolescents in 23 European countries: does the prevention paradox apply?

AIMS: According to the prevention paradox, a majority of alcohol-related problems in a population can be attributed to low to moderate drinkers simply because they are more numerous than heavy drinkers, who have a higher individual risk of adverse outcomes. We examined the prevention paradox in annual alcohol consumption, heavy episodic drinking (HED) and alcohol-related problems among adolescents in 23 European countries. DESIGN AND SETTING: Survey data from the 2007 European School Survey Project on Alcohol and Drugs (ESPAD) among 16-year-old students were analysed. PARTICIPANTS: A total of 38,370 alcohol-consuming adolescents (19,936 boys and 18,434 girls) from 23 European countries were included. MEASUREMENTS: The upper 10% and the bottom 90% of drinkers by annual alcohol intake, with or without HED, and frequency of HED, were compared for the distribution of 10 different alcohol-related problems. FINDINGS: Although the mean levels of consumption and alcohol-related problems varied largely between genders and countries, in almost all countries the heavy episodic drinkers in the bottom 90% of consumers by volume accounted for most alcohol-related problems, irrespective of severity of problem. However, adolescents with three or more occasions of HED a month accounted for a majority of problems. CONCLUSIONS: The prevention paradox, based on measures of annual consumption and heavy episodic drinking, seems valid for adolescent European boys and girls. However, a minority with frequent heavy episodic drinking accounted for a large proportion of all problems, illustrating limitations of the concept. As heavy episodic drinking is common among adolescents, our results support general prevention initiatives combined with targeted interventions.

Predictors of repeated emergency department visits among persons treated for addiction.

BACKGROUND/AIMS: To determine whether frequent emergency department (ED) users who enter specialized treatment programs for alcohol and/or drug problems have any characteristics that predict their future ED use. METHODS: Adult patients (783 alcohol users, 405 illicit drug users) were interviewed. Data from the medical database on utilization of ED and the emergency departments' specific units for addictive diseases (EDAD) 12 months before and 12 months after the interview were linked with patient characteristics in logistic regression models. RESULTS: Among alcohol users, prior ED/EDAD visits predicted repeat future visits to these sites (OR 11.6; 95% CI 6.5-20.5). Prior inpatient hospital care with addiction diagnosis was a predictor of future multiple visits to the EDAD only (OR 3.1; 95% CI 1.5-6.5). Among drug users, predictors of future ED/EDAD visits were use of heroin (OR 2.7; 95% CI 1.4-5.4) and prior ED/EDAD visits (OR 27.3; 95% CI 12.7-58.4). Drug users' EDAD utilization was also predicted by inpatient hospital care with addiction diagnosis. CONCLUSION: The strongest predictive factors of visiting ED repeatedly were previous repeat emergency care use and hospitalization with addiction diagnosis. Entering regular addiction treatment does not appear to alter the pattern of ED utilization.

Self-reported drug use and mortality among a nationwide sample of Swedish conscripts - a 35-year follow-up.

BACKGROUND: Drug users in clinical samples have elevated mortality compared with the general population, but little is known about mortality among users of drugs within the general population. AIM: To determine whether self-reported use of illicit drugs and non-prescribed sedatives/hypnotics among young men in the general population is related to mortality. METHODS: A 35-year follow-up of 48024 Swedish men, born 1949-1951 and conscripted in 1969/1970, among whom drug use was reported by 8767 subjects. Cross-record linkage was effected between individual data from the Swedish conscription and other national registers. Deaths and causes of death/1000 person-years were calculated. Cox PH regression was used to estimate hazard ratios (HRs) for death with 95% confidence intervals (95% CIs). An HR was calculated for users of different dominant drugs at conscription compared with non-users by age interval, after adjusting for confounders and hospitalisation with a drug-related diagnosis. RESULTS: Drug users showed elevated mortality (HR 1.61, p<0.05) compared with non-users. After adjusting for risk factors, users of stimulants (HR 4.41, p<0.05), cannabis (HR 4.27, p<0.05), opioids (HR 2.83, p>0.05), hallucinogens (HR 3.88, p<0.05) and unspecified drugs (HR 4.62, p<0.05) at conscription with a drug-related diagnosis during follow-up showed an HR approaching the standard mortality ratios in clinical samples. Among other drug users (95.5%), only stimulant users showed statistically significantly increased mortality (HR 1.96, p<0.05). CONCLUSIONS: In a life-time perspective, drug use among young men in the general population was a marker of premature death, even a long time after exposure.

Heavy episodic drinking in early adolescence: gender-specific risk and protective factors.

This longitudinal study examined possible gender differences regarding risk and protective factors for heavy episodic drinking among 1,222 seventh-grade students (aged 13) in the City of Stockholm, Sweden, with follow-up 2 years later. Logistic regression analyses showed that several factors predicted heavy episodic drinking. The strongest predictors for boys' heavy episodic drinking in the ninth grade were heavy episodic drinking (odds ratio [OR] = 5.30) and smoking in the seventh grade (OR = 5.80). Drinking peers (OR = 2.47) and smoking (OR = 2.44) in the seventh grade showed the strongest association for girls. Furthermore, high parental monitoring and having a secure attachment to parents may have a protective effect when risk factors are present. Our results lend support to prevention initiatives to strengthen the parent-child relation and focus on adolescents' ability to resist peer pressure and of limiting parental provision of alcohol. The study's limitations are noted.

Early risk factors for criminal offending in schizophrenia: a 35-year longitudinal cohort study.

BACKGROUND: Recent evidence suggests that factors predicting offending among individuals with no mental disorder may also predict offending among individuals with schizophrenia. AIMS: The aims of the study were (1) to explore the prevalence of risk factors for criminal offending reported at age 18 among males later diagnosed with schizophrenia, (2) to explore the associations between risk factors reported at age 18 and lifetime criminal offending, (3) to predict lifetime serious violent offending based on risk factors reported at age 18, and (4) to compare the findings with those in males with no later diagnosis of schizophrenia. METHODS: The study was a prospective, longitudinal study of a birth cohort followed up through registers after 35 years. The cohort consisted of 49,398 males conscripted into the Swedish Army in 1969-1970, of whom 377 were later diagnosed with schizophrenia. RESULTS: Among the subjects later diagnosed with schizophrenia, strong associations were found between four of the items reported at age 18 and lifetime criminal offending: (1) low marks for conduct in school, (2) contact with the police or child care authorities, (3) crowded living conditions, and (4) arrest for public drinking. Three of these four risk factors were found to double the risk of offending among males with no later diagnosis of schizophrenia. CONCLUSIONS: Criminality in individuals with schizophrenia may at least partly be understood as a phenomenon similar to criminality in individuals in the general population.

Adolescent alcohol use trajectories: Predictors and subsequent problems.

This study aimed at identifying different alcohol drinking trajectories in early to late adolescence. We also examined whether certain factors predicted membership of a specific trajectory and to what extent trajectory membership was linked to later negative consequences. Data were drawn from a longitudinal cohort study starting with 1923 adolescents including all seventh grade students in six school districts in Stockholm, Sweden 2001 (age 14), with follow-up in 2002, 2003, and 2006 (age 19). Cluster- and multinomial logistic regression analyses revealed four developmental pathways: low, gradually increasing, high, and suddenly increasing consumption. "High consumers" and "sudden increasers" reported higher levels of alcohol consumption, heavy episodic drinking, and alcohol-related problems both at age 14-16 and at age 19. The "gradual increasers" were more likely to smoke cigarettes, have easy access to alcohol, visit youth recreation centres, have friends who drink, and report a poorer health, compared to the "low consumer/abstainer group". "High consumers" were more likely to have drinking peers than both "low consumers/abstainers" and "gradual increasers".

Were the changes to Sweden's maintenance treatment policy 2000-06 related to changes in opiate-related mortality and morbidity?

AIMS: To analyse whether changes in maintenance treatment of opiate-dependent subjects in Sweden were related to changes in opiate-related mortality and inpatient care from 1998 to 2006. DESIGN: We collected data from surveys of methadone maintenance treatment units, of buprenorphine and methadone sales, and of mortality and inpatient care in Sweden. SETTING: Sweden. PARTICIPANTS: Patients in maintenance treatment. MEASUREMENTS: Survey data of treatment policy to all units in 2003 and 2005. Trend tests and correlation analyses of data on sales, mortality, inpatient care and forensic investigations. FINDINGS: The surveys showed a marked change to a less restrictive policy, with increased use of 'take-away doses' and a reduction of discharges due to side misuse. The one-year retention rate stayed high. Sales of buprenorphine and methadone and the number of patients in treatment increased more than threefold from 2000 to 2006, with the greatest increase for buprenoprphine, introduced in year 2000. There was a significant 20-30% reduction in opiate-related mortality and inpatient care between 2000-2002 and 2004-2006 but not of other drug-related mortality and inpatient care. This decline was larger in Stockholm County, which had a less restricted treatment policy. However, a significant increase in buprenorphine- and methadone-related mortality occurred. For the study period 1998-2006, statistically significant declines occurred only in Stockholm County. CONCLUSIONS: The liberalization of Sweden's drug policy correlated with an increase in maintenance treatment, a decrease in opiate-related mortality and inpatient care and an increase in deaths with methadone and buprenorphine in the tissues.

Mortality and cause of death among 1705 illicit drug users: a 37 year follow up.

INTRODUCTION AND AIMS: To examine the overall mortality and causes of deaths of a large cohort of users of illicit drugs in Stockholm over 37 years. DESIGN AND METHODS: People with substance abuse were identified through records collected by different institutions in Stockholm in 1967. Subjects were followed in registers recording mortality and cause of death and in-patient care stays until 2003. RESULTS: More than half (n = 860) of the 1705 identified substance abusers died at an average age of 47 years, 25-30 years younger than the general population. The standardised rate ratio (SRR) for mortality was 3.3 among men and 3.5 among women. Incidence of mortality per 1000 person-years was also increased, but somewhat lower for women. The difference between these two measures is mainly explained by a lower mortality among women in general. In-patient care stays with both alcohol and drug-related diagnoses were associated with higher risk of dying among women than men: SRR = 14.5 and SRR = 4.0, respectively. Accidents and suicide were the most common cause of death among the youngest subjects (15-24 years) and cardiovascular diseases and tumours among the oldest (> or =55 years). DISCUSSION AND CONCLUSIONS: Accidents and suicide, especially at a young age, are two common causes of death that might be prevented by increased awareness in medical personnel, along with better treatment and supportive measures.

Gender differences in mutual-help attendance one year after treatment: Swedish and U.S. samples.

OBJECTIVE: In the United States, many people turn to Alcoholics Anonymous (AA) and other mutual-help groups as a first source of help for an alcohol or drug problem, whereas others are introduced to AA while in treatment. Because AA and similar groups in the United States add to the treatment system and function without governmental funds, they represent an important element in ongoing care for individuals with substance-use disorders in the health care system. In countries with free (or more affordable) and more comprehensive systems of care, their role is less clearly defined. METHOD: In this study, we compared men and women from representative treatment samples from studies with parallel designs, one Swedish (n = 1,525) and the other American (n = 926), to explore whether rates and correlates of attendance at 1-year follow- up (63% and 78% followed) differ by gender. We explore individual characteristics (demographic, severity, motivational) and formal and informal influences (treatment, mutual help, coercive, social) as possible help-seeking correlates of attendance. RESULTS: In both countries, similar proportions of men and women attended mutual-help groups. However, twice as many U.S. clients reported attendance. Moreover, twice as many U.S. clients set abstinence as a treatment goal. In multivariate models, having an abstinence goal, a perceived need for treatment, suggestions from one's employment environment, and prior mutual-help attendance predicted posttreatment attendance for men and women in both countries. Gender differences were also found. CONCLUSIONS: Given the stages in which individuals seek care and the cyclical nature of relapse and recovery, mutual-help groups are an efficient resource in the continuum of services.

An 18-year follow-up of patients admitted to methadone treatment for the first time.

An 18-year addiction career, 1985-2003, for 157 heroin dependent subjects (73% men; 49% human immunodeficiency virus seropositive) admitted for the first time to Stockholm's Methadone Maintenance Treatment program during 1989 to 1991 was analyzed with data from seven official registers and patient records. Regression analyses and incidence rates for various outcomes were calculated for subjects in first methadone maintenance treatment at the end of the observation period, discharged from first methadone maintenance treatment, in second methadone maintenance treatment, and discharged from second methadone maintenance treatment. Being human immunodeficiency virus positive (HR = 3.8), lodging (HR = 1.9) and prison sentence (HR = 1.7) predicted mortality for the 45% deceased. Approximately 70% of living subjects participated in methadone maintenance treatment at some period each year. Subjects in first or second methadone maintenance treatment had less criminality and had spent more time in methadone maintenance treatment (70% to 100%) than those discharged from first or from second methadone maintenance treatment (50%). Efforts and interventions should be intensified to increase time in treatment also for those with high problem severity.