Alcohol-related emergency department attendances after the introduction of the Sale and Supply of Alcohol Act 2012.

AIM: To measure changes in alcohol-related emergency department (ED) attendances after introduction of the Sale and Supply of Alcohol Act 2012. METHODS: Cross-sectional survey of Christchurch ED attendees in three-week sampling periods in 2013 and 2017. Participants had consumed alcohol within four hours, or their drinking had directly contributed to the attendance. The quantity of alcohol consumed and places of purchase and consumption for the index drinking episode were recorded. RESULTS: From 2013 to 2017 there was a non-significant (p=.41) reduction in the proportion of ED attendees eligible for the study, from 253/3400 (7.4%) to 258/3721 (6.9%). Among participants (n=169 in 2013, n=139 in 2017), liquor store purchasing increased from 41.7% in 2013 to 56.1% in 2017 (p<.01) but there was no significant change in quantity consumed in the index episode; last drink location; percentage of participants with an injury-related attendance; or pre-drinking. In both waves, most participants had purchased alcohol from off-licence venues and consumed their last drink at a private location. CONCLUSION: Alcohol-related ED attendances remained common after the Sale and Supply of Alcohol Act 2012 was introduced, and they mainly occurred in people who sourced alcohol from off-licence outlets and had their last drink at private locations.

Personality Predictors of Drinking Outcomes in Depressed Alcohol-Dependent Patients.

AIM: To evaluate the role of personality dimensions as predictors of drinking outcomes in depressed alcohol-dependent patients. METHODS: Temperament and character inventory (TCI) scores were obtained at baseline in a 24-week study of 127 depressed alcohol-dependent patients who received open-label naltrexone and were randomized to citalopram or placebo. The association between TCI personality dimensions and alcohol outcomes during follow-up was examined using general linear mixed models. RESULTS: Low novelty seeking, high self-directedness and high cooperativeness predicted less alcohol consumption on drinking days during follow-up. Temperament and character variables had no effect on the percentage of days abstinent from alcohol. Depression mediated the effects of self-directedness and cooperativeness on alcohol outcomes while the effect of novelty seeking remained after adjusting for depression scores in follow-up. CONCLUSION: Identifying personality characteristics at baseline predicts drinking outcomes in depressed, alcohol-dependent patients. In particular patients with high novelty seeking drank more heavily on drinking days and they may therefore need more intensive intervention to achieve good treatment outcomes.

A randomized trial of combined citalopram and naltrexone for nonabstinent outpatients with co-occurring alcohol dependence and major depression.

Despite the high rate of co-occurrence of major depression and alcohol dependence, the role of pharmacotherapy in their treatment remains unclear. In the new era of naltrexone for alcohol dependence, it is notable that only 1 study to date has examined the efficacy of antidepressant medication prescribed concurrently with naltrexone. We aimed to determine whether combining naltrexone with citalopram produced better treatment outcomes than naltrexone alone in patients with co-occurring alcohol dependence and depression, and to investigate whether either sex or depression type (independent or substance-induced depression) moderated treatment response. Participants were 138 depressed alcohol-dependent adults who were not required to be abstinent at the commencement of the trial. They were randomized to 12 weeks of citalopram or placebo, plus naltrexone and clinical case management. Treatment was well attended, and medications were reasonably well tolerated with high adherence rates. Substantial improvements in both mood and drinking occurred in both groups, with no significant differences between groups on any of the mood or drinking outcome measures, whether or not other variables were controlled for. No interaction effect was found for independent/substance-induced depression status, whereas there was a marginal effect found by sex, with greater improvement in 1 drinking outcome measure (percent days abstinent) in women taking citalopram. These findings suggest that citalopram is not a clinically useful addition to naltrexone and clinical case management in this treatment population. Independent/substance-induced depression status did not predict treatment response. Findings for sex were equivocal.

OPRM1 genotype and naltrexone response in depressed alcohol-dependent patients.

A functional polymorphism rs1799971 (A118G) in the µ-opioid receptor gene (OPRM1) produces an amino acid substitution Asn40Asp, which is believed to influence naltrexone response in nondepressed alcohol-dependent patients. In this study, patients with alcohol dependence and major depression (n=108) received open-label naltrexone and clinical case management for 12 weeks, and were randomized to citalopram or placebo. General linear mixed models examined the effect of the OPRM1 A118G genotype on alcohol outcomes during treatment. There was no evidence of any difference in the percentage of days abstinent, drinks per drinking day or percentage of heavy drinking days between Asp40 carriers and noncarriers during treatment. This study therefore failed to replicate the previous positive findings for this single nucleotide polymorphism in relation to naltrexone response, possibly indicating that the effect is not present in depressed patients.

Opioid substitution treatment in New Zealand: a 40 year perspective.

We provide an overview of the history and philosophy of the treatment for opioid dependence, which has been dominated by methadone substitution treatment for the past 40 years in New Zealand. Although changes in approach have occurred over this time, influenced by various sociopolitical events and changing ideologies, opioid substitution treatment has still "not come of age". It remains undermined by stigma and risk concerns associated with methadone and has struggled to be accessible and attractive to illicit opioid drug users, comprehensive and integrated into mainstream health care. However, the introduction in 2012 of Pharmac-subsidised buprenorphine combined with naloxone (Suboxone) in the context of an emerging trend towards a broader recovery and well-being orientation could signal a new era in treatment. The availability of buprenorphine-naloxone may also facilitate a further shift in treatment from primarily siloed specialist addiction services to integrated primary care services. This shift will help reduce stigma, promote patient self-management and community integration and align opioid substitution treatment with treatment for other chronic health conditions such as diabetes and asthma.

The NEEDNT Food List: non-essential, energy-dense, nutritionally-deficient foods.

AIM: To provide a list of non-essential, energy-dense, nutritionally-deficient foods in New Zealand (NEEDNT foods) which are usually high in calories and either bereft of nutritional benefits or easily replaced with lower calorie, more nutritious alternatives. METHODS: The List was compiled using the National Heart Foundation and Diabetes New Zealand "Foods to Avoid", "Stop Eating" and "Optional Foods" lists and the Canterbury District Health Board "Supermarket Shopping Guide". Foods and beverages were included if they contained alcohol, saturated fat, added sugar, were prepared using a high fat cooking method or contained a large amount of energy relative to their essential nutrient value. As it has no energy value, salt was not a criterion for inclusion on the List. RESULTS: Over 50 potential foods or groups of foods were identified that contained alcohol, saturated fat, added sugar, were prepared using a high fat cooking method or contained a large amount of energy relative to their essential nutrient value. Fifty foods/groups of foods were included on the final list (Table 1). CONCLUSIONS: The NEEDNT Food List will be a useful tool for medical practitioners and other health professionals working with people wanting to lose weight [corrected].

Consumer and treatment provider perspectives on reducing barriers to opioid substitution treatment and improving treatment attractiveness.

In New Zealand approximately 4600 people receive opioid substitution treatment (OST) for opioid dependence, primarily methadone maintenance treatment. This study explored ways in which OST could be improved, given the significant waiting times for treatment. Two parallel surveys were conducted: 1) peer interviews with 85 regular daily or almost daily opioid drug users (51.8% receiving OST, 18.8% not currently receiving OST, and 29.4% never received OST) and; 2) a census of all 18 specialist OST service providers. When asked how OST might be improved, the four categories most commonly cited by the opioid users were 'better treatment by staff', 'more flexibility', 'better takeaway arrangements', and 'decreased waiting time'. Both opioid users and specialist services rated 'restricted takeaways' and 'having to go on a waiting list' in the top three perceived barriers to OST. Almost all services reported significant resource issues and barriers to the transfer of stable clients from specialist services to continuing treatment in primary care. The findings from this study indicate how OST can be made more accessible and attractive and thus achieve better uptake and retention.

An improved brief measure of cannabis misuse: the Cannabis Use Disorders Identification Test-Revised (CUDIT-R).

BACKGROUND: Cannabis is widely used and significant problems are associated with heavier consumption. When a cannabis misuse screening tool, the CUDIT, was originally published it was noted that although it performed well there was concern about individual items. METHODS: 144 patients enrolled in a clinical trial for concurrent depression and substance misuse were administered an expanded CUDIT, containing the original 10 items and 11 candidate replacement items. All patients were assessed for a current cannabis use disorder with the SCID. RESULTS: A revised CUDIT-R was developed containing 8 items, two each from the domains of consumption, cannabis problems (abuse), dependence, and psychological features. Although the psychometric adequacy of the original CUDIT was confirmed, the CUDIT-R was shorter and had equivalent or superior psychometric properties. High sensitivity (91%) and specificity (90%) were achieved. CONCLUSIONS: The 8-item CUDIT-R has improved performance over the original scale and appears well suited to the task of screening for problematic cannabis use. It may also have potential as a brief routine outcome measure.

Development of a brief treatment instrument for routine clinical use with methadone maintenance treatment clients: the methadone treatment index.

Routine measurement of treatment outcome between clinician and client in alcohol and drug user treatment services is an important quality improvement initiative. It is particularly important for clients receiving long-term treatment such as methadone maintenance treatment, as fluctuations in substance use, functioning, and health are to be expected. Although there are a number of standardized alcohol and drug user treatment outcome instruments available for research and clinical use, a key challenge is to develop clinical instruments that will actually be used routinely in busy practice settings by a range of staff. Such instruments need to be brief, acceptable to staff and clients, easy to use, provide immediate feedback, and meet adequate psychometric requirements. This report describes development work undertaken in three studies of the Methadone Treatment Index (MTI). The MTI is a brief instrument comprising measures of recent substance use, aspects of social and behavioral functioning, and physical and psychological health. The MTI was designed in consultation with clinicians and clients for use in monitoring treatment progress with clients receiving methadone maintenance treatment. Key findings were that the MTI was acceptable to clients, produced clinically relevant information, and has satisfactory psychometric properties, although it was not used to measure change in this study. Further evaluation of the MTI on a longitudinal basis is supported.

Five-year outcomes of alcohol-dependent persons treated with motivational enhancement.

OBJECTIVE: The purpose of this study was to determine whether the superior treatment effect of motivational enhancement therapy (MET) previously demonstrated at 6 months was sustained at a 5-year posttreatment follow-up. METHOD: Patients with mild to moderate alcohol dependence had completed a trial in which all patients were assessed, attended a brief feedback session, and were randomized to four sessions of MET, nondirective reflective listening, or no further counseling. The primary drinking outcome was unequivocal heavy drinking (UHD), defined as drinking 10 or more standard drinks on six or more occasions over a 6-month period. At the 6-month follow-up, 108 of 122 patients agreed to a further follow-up interview. RESULTS: Seventy-seven patients were successfully followed for a mean (SD) of 58 (14) months after the completion of treatment. Although the group as a whole had continued to improve, with rates of UHD reduced from 51 % at 6 months to 25% at 5 years, there was no difference by treatment group in drinking for UHD or a range of lower drinking thresholds. CONCLUSIONS: Although 5-year outcomes were indistinguishable among the three treatment groups, this was the result of patients in the comparison conditions catching up to the drinking gains of MET patients rather than a deterioration in drinking for MET patients. Individuals allocated to receive MET achieved a greater reduction sooner than either of the comparison treatment conditions.

Social phobia in an outpatient alcohol and drug treatment sample.

OBJECTIVE: To examine characteristics of patients with social phobia (SP) in alcohol and drug treatment settings and to identify features distinguishing this group from patients with and without other psychiatric conditions. METHOD: A random sample of 105 patients completing an initial assessment at two outpatient alcohol and drug treatment services were assessed and agreed to a 9 month follow-up interview, completed by n=102 (97%). At baseline the Composite International Diagnostic Interview (CIDI) was administered. Current diagnoses at baseline were used to separate the sample into those with SP (n=33), other current psychiatric disorders (OPD, n=40), and those with no current psychiatric diagnosis other than a substance use disorder (NPD, n=29). The novel methodology used in this study compared the SP group first to the NPD group to see if SP was associated with a different presentation, and then compared the SP group to the OPD group to see if any identified differences were associated with SP per se or psychopathology generally. The three groups were compared on demographic, current clinical, and past treatment utilization variables at baseline, while follow-up data were used to compare the groups on treatment outcome and treatment utilization. RESULTS: The SP group did not differ from either group in a systematic way. What differences did emerge tended to show a difference between OPD and NPD, with SP intermediate between the two, or that SP and OPD together were different from NPD. CONCLUSIONS: Despite the relatively small sample size, these findings suggest that in substance use disorder treatment settings, patients with coexisting SP do not represent a distinctly high-needs or at-risk group in the broader context of patient populations, for which coexisting psychiatric diagnoses are the norm rather than the exception.

Coexisting psychiatric disorders in a New Zealand outpatient alcohol and other drug clinical population.

OBJECTIVE: To describe the extent of psychiatric disorder and mental health service utilization in a representative outpatient alcohol and other drug (AOD) treatment sample in New Zealand. METHOD: A total of 105 patients were randomly recruited from two outpatient AOD treatment services in New Zealand and completed a diagnostic interview within the first 2 months of treatment. Axis I psychiatric diagnoses were made using the computerized Composite International Diagnostic Interview (CIDI-Auto), and were supplemented by the South Oaks Gambling Scale (SOGS) and the conduct disorder and antisocial personality disorder section of the Diagnostic Interview for Genetic Studies (DIGS). RESULTS: Seventy-four per cent of the sample had a current non-substance or gambling axis I disorder, with a lifetime rate of 90%. The most commonly diagnosed of these coexisting psychiatric disorders were major depressive episode (34%), social phobia (31%) and posttraumatic stress disorder (31%). Past contact with mental health services was common, while contact at the time of baseline assessment was uncommon. CONCLUSIONS: Coexisting psychiatric disorder was the rule and not the exception in this sample. AOD patients are clearly part of the larger population of mental health patients. AOD services need to be capable of comprehensive assessment and treatment planning, which includes coexisting psychiatric disorders, and should work toward better integration with other mental health services.

The costs of not treating hepatitis C virus infection in injecting drug users in New Zealand.

This paper estimates future health service costs of the current practice in New Zealand of not funding treatment of hepatitis C virus (HCV) infections. Costs are estimated separately for Maori and non-Maori, male and female IDUs. Markov modelling is used to track the infection and progression of HCV to severe liver disease and death, and accumulated costs are estimated for the life of the cohort. Upper and lower estimates of costs are calculated based on different assumptions of the rate of progression of HCV to more severe liver disease. Costs are estimated at dollars 24.6 million per 1000 non-Maori men IDUs (discounted at 3%), under progression assumptions based on liver clinic studies, compared with dollars 10.3 million per 1000 using lower rates of progression based on community studies. Similarly, corresponding costs for non-Maori women are estimated at dollars 27.6 million and $11.2 million per 1000 IDUs. Costs for women are higher because their greater life expectancy is associated with more cases of liver cirrhosis (LC) at older ages. Future costs for Maori are lower than non-Maori, because Maori are more likely to die at younger ages and hence fewer progress to more advanced liver disease. The current situation in New Zealand of not treating HCV infections will result in considerable future costs as some people with HCV progress to more severe liver disease. Provisional estimates are that the accumulated costs of HCV-related liver disease for all IDUs currently infected will be between dollars 166 million at lower rates of disease progression (discounted at 3%) to dollars 400 million at upper rates. Some of the associated morbidity and mortality could have been avoided if the HCV infections had been treated.

A prototype screening instrument for cannabis use disorder: the Cannabis Use Disorders Identification Test (CUDIT) in an alcohol-dependent clinical sample.

The Cannabis Use Disorders Identification Test (CUDIT) was used for the first time as part of a randomized controlled trial for brief interventions in mild to moderate alcohol-dependent out-patients. This sample may be seen as a population at increased risk of cannabis use disorder. The CUDIT was developed by modifying the Alcohol Use Disorders Identification Test (AUDIT). The ability of the CUDIT to accurately screen for cannabis abuse or dependence was examined in the portion of the sample who reported some cannabis use over the preceding 6 months (n=53), as was self-reported frequency of cannabis use in the preceding 6 months. The CUDIT was superior to the frequency measure, achieving positive predictive power of 84.6% and sensitivity of 73.3% at a cut-off of 8, compared to positive predictive power of 81.8% and sensitivity of 60.0% for 80 or more cannabis use-days. These results indicate the viability of a screening measure for identifying cannabis use disorder in at risk populations.

Barriers to optimal care for patients with coexisting substance use and mental health disorders.

OBJECTIVE: This paper describes qualitative research that was carried out as part of a project aimed at drawing up a series of guidelines for the assessment and management for people with coexisting substance use and mental health disorders, or dual diagnosis. METHOD: A core consultation team of 14 experts with experience in the areas of both substance use and mental health in New Zealand was established to advise on the development of eight clinical scenarios. The clinical scenarios were selected to highlight a range of real life issues in the treatment of people with coexisting substance use and mental health disorders and were presented at 12 focus groups around New Zealand. The 261 participants of the focus groups were asked to comment on what was optimal management for each of the scenarios and to identify barriers to optimal care in their region. Written notes were analysed for recurring and strongly stated themes and these comprise the results of the study. RESULTS: While there was marked regional variation in treatment approaches and service structures, many of the barriers to optimal care that were identified were common to all regions. The results are considered under the headings of systems issues, clinical issues and attitudes. CONCLUSIONS: A wide variety of barriers that impede the delivery of optimal care have been identified. These range from the attitudes of individual clinicians to the structure of the systems within which they work. A system of key principles and processes for organizing treatment in a way which helps overcome these barriers is proposed.