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Addiction to psychostimulant drugs, such as cocaine, D-amphetamine, and methamphetamine, is a public health issue that substantially contributes to the global burden of disease. Psychostimulant drugs promote an increase in dopamine levels within the mesocorticolimbic system, which is central to the rewarding properties of such drugs. Cannabinoid receptors (CB1R and CB2R) are expressed in the main areas of this system and implicated in the neuronal mechanisms underlying the rewarding effect of psychostimulant drugs. Here, we reviewed studies focusing on pharmacological intervention targeting cannabinoid CB1R and CB2R and their interaction in the modulation of psychostimulant responses. [ABSTRACT FROM AUTHOR]

In Hong Kong, the percentage of older drug users has increased over the last two decades. However, the motivations behind their drug-use behaviours have received little research attention. This study focuses on older drug users who are enrolled in methadone treatment programmes but still use illicit drugs (mixed use). Some studies in the criminological literature and government discourse consider drug users to be passive and lacking self-control. However, in-depth interviews in with 25 older mixed users (aged over 50 years) in Hong Kong revealed that mixed use is one of the various strategies they actively employ to improve their self-perceived quality of life. Using the framework of the selective optimization with compensation model, this study (1) describes the strategies older mixed users adopt as active agents to improve their self-perceived quality of life while coexisting with their addiction; and (2) explains how these strategies were affected and constrained by Hong Kong's prohibitionist drug policy. I infer that prohibitionist drug policies that emphasize on total drug abstinence may fail to cater to the needs of older drug users who have undergone several relapses and treatments in their lifetimes and do not think they can give up using drugs. This study also provides evidence to show how some drug users may act as active agents to manage and coexist with their addiction, and their agency seems to be constrained by the wider drug policy implemented in Hong Kong. [ABSTRACT FROM AUTHOR]

Abstract Background Violence occurs frequently in the life of forensic psychiatric patients, both as active aggression and in the form of victimization. Undoubtedly, these incidents shape personality, behavior, and affect the ability to interact adequately socially. Thus, such experiences may influence criminal recidivism and serve as forensic psychiatric/psychological predictors upon hospital discharge. Methods Hence, this study aimed at characterizing two distinct female forensic psychiatric patient populations (nonsubstance use mental disorders [n = 110] versus substance use disorder [n = 415]) regarding their active and passive violent experiences as well as contextualizing these with their individual crime recidivism rates. The analysis followed a record-based, retrospective approach. Results While both groups experienced aggression throughout childhood and youth equally often, substance use disorder patients were significantly more often exposed to violence during adulthood. On the other hand, severely mentally ill patients tended to react more often with violence during their hospital confinement. However, regarding their violent recidivism rate, no intergroup effects were observed. Finally, within the addicted group, a violent index crime as well as physical aggression during hospital confinement increased the odds for violent reoffending by approximately 2.4-fold (95% confidence interval 1.3–4.5) and 2.5-fold (95% confidence interval 1.1–5.9), respectively. Conclusion In summary, these findings underline the importance of active aggression rather than victimization as an influencing factor on resocialization especially in a substance use disorder patient population.

Background: People living in precarious housing or homelessness have higher than expected rates of psychotic disorders, persistent psychotic symptoms, and premature mortality. Psychotic symptoms can be modeled as a complex dynamic system, allowing assessment of roles for risk factors in symptom development, persistence, and contribution to premature mortality. Method: The severity of delusions, conceptual disorganization, hallucinations, suspiciousness, and unusual thought content was rated monthly over 5 years in a community sample of precariously housed/homeless adults (n = 375) in Vancouver, Canada. Multilevel vector auto-regression analysis was used to construct temporal, contemporaneous, and between-person symptom networks. Network measures were compared between participants with (n = 219) or without (n = 156) history of psychotic disorder using bootstrap and permutation analyses. Relationships between network connectivity and risk factors including homelessness, trauma, and substance dependence were estimated by multiple linear regression. The contribution of network measures to premature mortality was estimated by Cox proportional hazard models. Results: Delusions and unusual thought content were central symptoms in the multilevel network. Each psychotic symptom was positively reinforcing over time, an effect most pronounced in participants with a history of psychotic disorder. Global connectivity was similar between those with and without such a history. Greater connectivity between symptoms was associated with methamphetamine dependence and past trauma exposure. Auto-regressive connectivity was associated with premature mortality in participants under age 55. Conclusions: Past and current experiences contribute to the severity and dynamic relationships between psychotic symptoms. Interrupting the self-perpetuating severity of psychotic symptoms in a vulnerable group of people could contribute to reducing premature mortality. [ABSTRACT FROM AUTHOR]

Introduction: The abuse of prescription drugs (especially sedatives, hypnotics and opioid analgesics) is a serious and increasingly common phenomenon occurring across addiction clinics. Medications are prescribed for the treatment of chronic pain, sleep difficulties or as mood stabilisers in response to the rush of time and demands of performance. The onset of addiction is often protracted and subtle, but has a major impact on the quality of life and the health, economic or social status of the user. Patients may experience, among other things, cognitive impairment, fatigue, sleep disturbances, irritability, loss of motivation, headaches or impaired coordination of movements. This study is focused on cognitive impairment due to prescription drug dependence and how this impairment affects patients in everyday life. Objectives: This poster aims to introduce the audience to the possibilities of occupational therapy intervention in the context of addiction medicine. Methods: Data will be taken using standardized tests and questionnaires dealing with cognitive function. It will be conducted upon the patient's admission to addiction treatment and again after six months of cognitive rehabilitation following the initial survey. Data are collected at the General University Hospital in Prague, Department of Addictology, Prague, Czech Republic. Results: Data are being collected. Conclusions: The case study manifests multidisciplinary approach in care of patients addicted of prescription medicine. The aim is a comprehensive view of all aspects of the patient's life affected by prescription drug abuse with cognitive impairment. Grant affiliation: This paper was made possible by the institutional support programme Cooperatio, research area Health Sciences and Grant No. 260632 within the Specific Academic Research. Disclosure of Interest: None Declared [ABSTRACT FROM AUTHOR]

Introduction According to the World Health Organisation goals of treatment of drug addiction are: reducing of drug use and craving, improving of health, well-being and social functioning of the affected individual, prevention of future harms by decreasing the risk of complications and relapse. Wellness means a sense of overall well-being incorporating numerous aspects of an individual’s life. These include physical, mental, emotional, intellectual, occupational, and spiritual aspects. For those who suffer from mental and substance use disorders, wellness means feeling a sense of purpose in life, being actively involved in work or play that is satisfying, finding happiness, having joyful relationships, and having a healthy body and living environment. . Objectives We will present different dimensions of wellness and describe how to incorporate these dimensions into drug addiction treatment. Methods Presentation of theoretical frame and description of treatment programme at the Center for Treatment of Drug Addiction Ljubljana. Results When each of wellness dimensions is balanced, it is easier to maintain recovery process and avoid the triggers of relapse. Conclusions In the context of wellness, treatment goal is to maximize the capacity of person to feel, think and act in ways that enhance his/her ability to enjoy life and deal with the challenges he/she face. Wellness lifestyle includes a balance of health habits such as adequate sleep and rest, productivity, exercise, participation in meaningful activity, nutrition, productivity, social contact, and supportive relationships. Disclosure No significant relationships.

Introduction Ayahuasca is an hallucinogenic tea prepared from the Amazonian vine Banisteriopsis caapi and the leaves of the plant Psychotria Viridis. Banisteriopsis caapi contains monoamine oxidase inhibitors (MAO) that render the N, N-dimethyltryptamine (DMT) of Psychotria Viridis active. This brew is being used as a sacrament in syncretic religions in urban areas of Brazil and worldwide with the purpose of enabling a spiritual experience as well as healing for a variety of conditions such as drug addiction, depression and anxiety disorders. Objectives This work aims to provide an understanding on the potential benefits of ayahuasca in psychiatric symptoms, as well as its neuropsychological functioning, neuroimaging and adverse events. Methods A non-systematic review was performed on PubMed database and Google Scholar, using the key words “Ayahuasca, Drug Addiction, Psychedelics, DMT, Neuroplasticity”. The review included experimental studies in humans, observational studies, systemic review articles and clinical trials. Results In a randomized placebo-controlled trial, ayahuasca had a significant antidepressant effect when compared to the placebo group. Long term ayahuasca usage was associated with structural alterations in the medial parts of the brain with no evidence of increased psychopathology or worse neuropsychological functioning. According to reviewed studies the incident of prolonged psychotic reaction among ayahuasca users is rare and the causal relation with ayahuasca is sometimes difficult to establish. Conclusions Despite the promising results, more controlled double-blinded studies with larger populations are necessary to better understand the therapeutic potentials and side effects of ayahuasca. Disclosure No significant relationships.

Background: The age-adjusted rate of suicide death in the USA has increased significantly since 2000 and little is known about national trends in non-fatal suicidal behaviors (ideation, plan, and attempt) among adults and their associated sociodemographic and clinical characteristics. This study examined trends in non-fatal suicidal behaviors among adults in the USA. Methods: Data were obtained from adults 18–65 years of age who participated in the National Survey on Drug Use and Health (NSDUH), including mental health assessment, from 2009 to 2017 (n = 335 359). Examinations of data involved trend analysis methods with the use of logistic regressions and interaction terms. Results: Suicidal ideation showed fluctuation from 2009 to 2017, whereas suicide plan and attempt showed significantly positive linear trends with the odds increasing by an average of 3% and 4%, respectively. Suicide plan increased the most for females and adults ages 18–34, and attempt increased the most for adults with drug dependence. Both plan and attempt increased the most among adults who either had mental illness but were not in treatment or had no mental illness. Conclusions: Given attempted suicide is the strongest known risk factor for suicide death, reducing non-fatal suicidal behaviors including attempt are important public health and clinical goals. The interactional findings of age, sex, mental health status, and drug dependence point toward the importance of tailoring prevention efforts to various sociodemographic and clinical factors. [ABSTRACT FROM AUTHOR]

Background: Substance use occurs at a high rate in persons with a psychiatric disorder. Genetically informative studies have the potential to elucidate the etiology of these phenomena. Recent developments in genome-wide association studies (GWAS) allow new avenues of investigation. Method: Using results of GWAS meta-analyses, we performed a factor analysis of the genetic correlation structure, a genome-wide search of shared loci, and causally informative tests for six substance use phenotypes (four smoking, one alcohol, and one cannabis use) and five psychiatric disorders (ADHD, anorexia, depression, bipolar disorder, and schizophrenia). Results: Two correlated externalizing and internalizing/psychosis factor were found, although model fit was beneath conventional standards. Of 458 loci reported in previous univariate GWAS of substance use and psychiatric disorders, about 50% (230 loci) were pleiotropic with additional 111 pleiotropic loci not reported from past GWAS. Of the 341 pleiotropic loci, 152 were associated with both substance use and psychiatric disorders, implicating neurodevelopment, cell morphogenesis, biological adhesion pathways, and enrichment in 13 different brain tissues. Seventy-five and 114 pleiotropic loci were specific to either psychiatric disorders or substance use phenotypes, implicating neuronal signaling pathway and clathrin-binding functions/structures, respectively. No consistent evidence for phenotypic causation was found across different Mendelian randomization methods. Conclusions: Genetic etiology of substance use and psychiatric disorders is highly pleiotropic and involves shared neurodevelopmental path, neurotransmission, and intracellular trafficking. In aggregate, the patterns are not consistent with vertical pleiotropy, more likely reflecting horizontal pleiotropy or more complex forms of phenotypic causation. [ABSTRACT FROM AUTHOR]

Explicit generalisations are statements that attribute a characteristic to all members of a social category (e.g. drug users). This article examines the tensions and negotiations that the use of generalisations prompts within support group interactions. Generalisations are practices for the cautious implementation of delicate actions. They can be used to convey perspectives on group members' experiences by implication (without commenting on them directly), by virtue of those members belonging to the category to which a generalisation applies. At the same time, generalisations can misrepresent some individual cases within that category. Using conversation analysis, the article investigates how generalisations are deployed, challenged, and then defended in support group interactions. These analyses identify a tension between utilising the sense-making resources that category memberships afford, and the protection of its members from unwelcome generalisations. Data consist of recorded support-group meetings for people recovering from drug addiction (in Italy) and for bereaved people (in the UK). (Bereavement, conversation analysis, delicacy, drug addiction, generalisation, individuality, membership categorisation, morality, support groups) [ABSTRACT FROM AUTHOR]

Naloxone, which reverses the effects of opioids, was synthesized in 1960, though the hunt for opioid antagonists began a half-century earlier. The history of this quest reveals how cultural and medical attitudes toward opioids have been marked by a polarization of discourse that belies a keen ambivalence. From 1915 to 1960, researchers were stymied in seeking a "pure" antidote to opioids, discovering instead numerous opioid molecules of mixed or paradoxical properties. At the same time, the quest for a dominant explanatory and therapeutic model for addiction was likewise unsettled. After naloxone's discovery, new dichotomizing language arose in the "War on Drugs," in increasingly divergent views between addiction medicine and palliative care, and in public debates about layperson naloxone access. Naloxone, one of the emblematic drugs of our time, highlights the ambivalence latent in public and biomedical discussions of opioids as agents of risk and relief. [ABSTRACT FROM AUTHOR]

Introduction: Drug addiction, also called substance use disorder, is a disease that affects a person's brain and behavior and leads to an inability to control the use of a legal or illegal drug or medicine. there is a complex interplay of neurobiology, genetics, and the environment --nature and nurture-- that play into the development of addiction, alcohol, and other drug use disorder.Substances such as alcohol, marijuana and nicotine also are considered drugs. Research has shown that women often use drugs differently, respond to drugs differently, andcan have unique obstacles to effective treatment as simple as not being able to find child care orbeing prescribed treatment that has not been adequately tested on women. Objectives: describe the socio-demographic and clinical characteristics of female patients admitted to the addictology department of Arrazi Hospital in Salé Methods: Retrospective study with descriptive and analytical aims on the files of women who were admitted to the addictology service since its opening in 2000, with the aim of specifying the prevalence and the characteristics of addictive behaviors in the female population. Results: in progress Conclusions: in progress Disclosure of Interest: None Declared [ABSTRACT FROM AUTHOR]

Legal frameworks and the challenges for treatment and rehabilitation of offenders with intellectual disabilities Speaker: Farzaneh Saeedzadeh Sardahaee, MD, PhD, Consultant psychiatrist St. Olav University Hospital, Trondheim, Norway Lack of timely diagnostic and treatment for mild intellectual disability amongst offenders presents special challenges to clinicians and prison system alike. On the one hand, appropriate treatment for their psychiatric symptoms may not be implemented as they can be mislabeled primarily as behavioral issues. Different approaches to such perceived behavioral issues within judiciary (or prison) system and health care system is a potential conflict area. On the other hand, treatment and rehabilitation of offenders with intellectual disability require both resources and expertise that may not be readily available in prison systems, pre- or past sentencing. Furthermore, the scope of such challenges varies greatly based on different legal frameworks for sentencing offenders with intellectual disability within Europe. In the first section an overview of Norwegian legal framework for offenders with intellectual disability is briefly presented. Then using the example of a young female offender with mild intellectual disability, drug dependence and multiple psychiatric morbidities, the speaker examines complexities of dual diagnoses, inter-disciplinary and multiagency cooperation follow-up and challenges faced in the recovery process. A brief introduction to the current Norwegian follow-up system for offenders with intellectual disability is discussed before examining recent changes in legal framework for sentencing offenders with intellectual disability in Norway, and its ramifications, as well as potential benefits for treatment and future rehabilitation of offenders. Finally, the speaker reflects on points for further improvement, especially considering the multi-agency nature of treatment and rehabilitation of offenders with intellectual disability. Disclosure of Interest: None Declared [ABSTRACT FROM AUTHOR]

Background: Previous literature has extensively investigated the brain activity during response inhibition in adults with addiction. Inconsistent results including both hyper- and hypo-activities in the fronto-parietal network (FPN) and the ventral attention network (VAN) have been found in adults with addictions, compared with healthy controls (HCs). Methods: Voxel-wise meta-analyses of abnormal task-evoked regional activity were conducted for adults with substance dependence (SD) and behavioral addiction during response inhibition tasks to solve previous inconsistencies. Twenty-three functional magnetic resonance imaging studies including 479 substance users, 38 individuals with behavioral addiction and 494 HCs were identified. Results: Compared with HCs, all addictions showed hypo-activities in regions within FPN (inferior frontal gyrus and supramarginal gyrus) and VAN (inferior frontal gyrus, middle temporal gyrus, temporal pole and insula), and hyper-activities in the cerebellum during response inhibition. SD subgroup showed almost the same activity patterns, with an additional hypoactivation of the precentral gyrus, compared with HCs. Stronger activation of the cerebellum was associated with longer addiction duration for adults with SD. We could not conduct meta-analytic investigations into the behavioral addiction subgroup due to the small number of datasets. Conclusion: This meta-analysis revealed altered activation of FPN, VAN and the cerebellum in adults with addiction during response inhibition tasks using non-addiction-related stimuli. Although FPN and VAN showed lower activity, the cerebellum exhibited stronger activity. These results may help to understand the neural pathology of response inhibition in addiction. [ABSTRACT FROM AUTHOR]

Background: The present paper provides an updated review of both the large number of new/novel/emerging psychoactive substances (NPS) and their associated psychopathological consequences. Focus was here given on identification of those NPS being commented in specialised online sources and the related short-/long-term psychopathological and medical ill-health effects. Methods: NPS have been identified through an innovative crawling/navigating software, called the 'NPS.Finder®', created in order to facilitate the process of early recognition of NPS online. A range of information regarding NPS, including chemical and street names; chemical formula; three-dimensional image and anecdotally reported clinical/psychoactive effects, were here made available. Results: Using the 'NPS.Finder®' approach, a few thousand NPS were here preliminarily identified, a number which is about 4-fold higher than those figures suggested by European and international drug agencies. NPS most commonly associated with the onset of psychopathological consequences included here synthetic cannabinoids/cannabimimetics; new synthetic opioids; ketamine-like dissociatives; novel stimulants; novel psychedelics and several prescription and over-the-counter medicines. Conclusions: The ever-increasing changes in terms of recreational psychotropics' availability represent a relatively new challenge for psychiatry, as the pharmacodynamics and pharmacokinetics of many NPS have not been thoroughly understood. Health/mental health professionals should be informed about the range of NPS; their intake modalities; their psychoactive sought-after effects; the idiosyncratic psychotropics' combinations and finally, their medical and psychopathological risks. [ABSTRACT FROM AUTHOR]

Supply-side interventions such as prescription drug monitoring programs, "pill mill" laws, and dispensing limits have done little to quell the burgeoning opioid crisis. An increasingly popular demand-side alternative to these measures – now adopted by 38 jurisdictions in the USA and 7 provinces in Canada — is court-mandated involuntary commitment and treatment. In Massachusetts, for example, Part I, Chapter 123, Section 35 of the state's General Laws allows physicians, spouses, relatives, and police officers to petition a court to involuntarily commit and treat a person whose alcohol or drug abuse poses a likelihood of serious harm. This paper explores the ethical underpinnings of this law as a case study for others. First, we highlight the procedural and substantive standards of Section 35 and evaluate the application of the law in practice, including the frequency with which it has been invoked and outcomes. We then use this background to inform an ethical critique of the law. Specifically, we argue that the infringement of autonomy and privacy associated with involuntary intervention under Section 35 is not currently justified on the grounds of a lack of evidenced benefits and a risk of significant of harm. Further ethical concerns also arise from a lack of standard of care provided under the Section 35 pathway. Based on this analysis, we advance four recommendations for change to mitigate these ethical shortcomings. [ABSTRACT FROM AUTHOR]

Cannabis use in some individuals can meaningfully introduce de novo risk for the initiation of opioid use and development of opioid use disorder. These risks may be particularly high during adolescence when cannabis use may disrupt critical periods of neurodevelopment. Current research studying the combination of genetic and environmental factors involved in substance use disorders is poorly understood. More research is needed, particularly to identify which adolescents are most at risk and to develop effective interventions addressing contributing factors such as trauma and psychiatric comorbidity. [ABSTRACT FROM AUTHOR]

Children tend to be represented as the quintessential victims of the 'drug problem', with drug-using parents, particularly mothers, characterised as vectors of the risks posed. Although evidence of drug use is not per se an impediment to retaining care of, or contact with, children (per Lady Hale in Re B [2013] UKSC 33, at para. 143), it does pose one of the greatest challenges to social and political norms about 'good parenting', and often has a powerful impact on decisions about care within UK family courts. While there is a considerable body of scholarship assessing criminal justice responses to drug use, there has been little research into how the family serves as an important site for the constitution of drug harms and the making of 'drugs' and 'addiction'. This paper is informed by qualitative analysis of approximately 150 case reports in which drug use has been cited as relevant in the determination of guardianship/parenting. The purpose will not be to contest the difficult decisions that judges had to make in these cases but, using perspectives rooted in Science and Technology Studies and feminist drug scholarship, to remain attendant to the ontological multiplicity of objects that emerge from attempts to stabilise drug harms in legal narratives. [ABSTRACT FROM AUTHOR]

The question as to whether people with an addiction have control (and to what extent) over their addiction, and voluntarily decide to use substances is an ongoing source of controversy in the context of research on addiction, health policy and clinical practice. We describe and discuss a set of five challenges for further research into voluntariness (definition[s], measurement and study tools, first person perspectives, contextual understandings, and connections to broader frameworks) based on our own research experiences and those of others. [ABSTRACT FROM AUTHOR]

The available treatments for disorders affecting large segments of the population are often costly, complex, and only marginally effective, and many have numerous side effects. These disorders include dementias, debilitating neurological disorders, the multiple types of drug addiction, and the spectrum of mental health disorders. Preliminary studies have shown that a variety of psychedelic and similar U.S. Drug Enforcement Administration Schedule I drugs may offer better treatment options than those that currently exist and pose potentially the same or even less risk than do legal psychoactive (alcohol, caffeine, nicotine) and nonpsychoactive (aspirin, acetaminophen, ibuprofen) substances. The pharmaceutical industry and academia, however, have largely avoided this avenue of research. Fairness to the affected populations demands that these drugs be adequately studied and, if they or their congeners are shown to be effective, made available with the proper caveats, instructions, and protections that other potentially abused medications (e.g., narcotics) receive. These substances may prove to relieve patients' struggles with less effective treatments and decrease mortality from nontreatment of some conditions. [ABSTRACT FROM AUTHOR]

Background: Exposure to traumatic events is surprisingly common, yet little is known about its effect on decision making beyond the fact that those with post-traumatic stress disorder are more likely to have substance-abuse problems. We examined the effects of exposure to severe trauma on decision making in low-income, urban African Americans, a group especially likely to have had such traumatic experiences. Method: Participants completed three decision-making tasks that assessed the subjective value of delayed monetary rewards and payments and of probabilistic rewards. Trauma-exposed cases and controls were propensity-matched on demographic measures, treatment for psychological problems, and substance dependence. Results: Trauma-exposed cases discounted the value of delayed rewards and delayed payments, but not probabilistic rewards, more steeply than controls. Surprisingly, given previous findings that suggested women are more affected by trauma when female and male participants' data were analyzed separately, only the male cases showed steeper delay discounting. Compared with nonalcoholic males who were not exposed to trauma, both severe trauma and alcohol-dependence produced significantly steeper discounting of delayed rewards. Conclusions: The current study shows that exposure to severe trauma selectively affects fundamental decision-making processes. Only males were affected, and effects were observed only on discounting delayed outcomes (i.e. intertemporal choice) and not on discounting probabilistic outcomes (i.e. risky choice). These findings are the first to show significant differences in the effects of trauma on men's and women's decision making, and the selectivity of these effects has potentially important implications for treatment and also provides clues as to underlying mechanisms. [ABSTRACT FROM AUTHOR]

Summary: We propose that discussions of benzodiazepines in the current psychiatric literature have become negatively biased and have strayed from the scientific evidence base. We advocate returning to the evidence in discussing benzodiazepines and adhering to clear definitions and conceptual rigour in commentary about them. [ABSTRACT FROM AUTHOR]

Background: Violence occurs frequently in the life of forensic psychiatric patients, both as active aggression and in the form of victimization. Undoubtedly, these incidents shape personality, behavior, and affect the ability to interact adequately socially. Thus, such experiences may influence criminal recidivism and serve as forensic psychiatric/psychological predictors upon hospital discharge., Methods: Hence, this study aimed at characterizing two distinct female forensic psychiatric patient populations (nonsubstance use mental disorders [ n  = 110] versus substance use disorder [ n  = 415]) regarding their active and passive violent experiences as well as contextualizing these with their individual crime recidivism rates. The analysis followed a record-based, retrospective approach., Results: While both groups experienced aggression throughout childhood and youth equally often, substance use disorder patients were significantly more often exposed to violence during adulthood. On the other hand, severely mentally ill patients tended to react more often with violence during their hospital confinement. However, regarding their violent recidivism rate, no intergroup effects were observed. Finally, within the addicted group, a violent index crime as well as physical aggression during hospital confinement increased the odds for violent reoffending by approximately 2.4-fold (95% confidence interval 1.3-4.5) and 2.5-fold (95% confidence interval 1.1-5.9), respectively., Conclusion: In summary, these findings underline the importance of active aggression rather than victimization as an influencing factor on resocialization especially in a substance use disorder patient population.

The article discusses the ethical responsibilities of the physicians in America who are dealing with an opioid abuse crisis as of 2017, and it mentions physician-patient relations, as well as pain management and treatment of opioid use disorder (OUD). Prescriptions for opioids are addressed, along with prescription drug monitoring programs (PDMPs) and the U.S. Controlled Substances Act of 1970. America's National All Schedules Prescription Electronic Reporting Act of 2005 is assessed.

In this paper, we claim that we can only seek to eradicate the stigma associated with the contemporary opioid overdose epidemic when we understand how opioid stigma and the epidemic have co-evolved. Rather than conceptualizing stigma as a parallel social process alongside the epidemiologically and physiologically defined harms of the epidemic, we argue that the stigmatized history of opioids and their use defines the epidemic. We conclude by offering recommendations for disrupting the burden of opioid stigma. [ABSTRACT FROM AUTHOR]

BackgroundIndividuals with one psychiatric disorder are at increased risk for incidence and recurrence of other disorders. We characterize whether the magnitude of such heterotypic continuity varies based on whether the first disorder remits or persists over time.MethodCohorts were selected from participants in the National Epidemiologic Survey on Alcohol and Related Conditions wave 1 (2001–2002) and wave 2 (2004–2005) surveys with ⩾1 mood, anxiety, or substance use disorder at wave 1. Among respondents remitting (n = 6719) or not remitting (n = 3435) from ⩾1 of disorder at wave 2, the analyses compared the odds of developing new disorders.ResultsAs compared with adults whose disorders persisted from wave 1 to wave 2, those with ⩾1 remission had lower odds of incidence or recurrence of another disorder. Remission from alcohol dependence [odds ratio (OR) 0.4, 95% confidence interval (CI) 0.3–0.5] and drug dependence (OR 0.4, 95% CI 0.3–0.6) were associated with the lowest odds of incidence of another disorder. Social anxiety disorder was associated with the lowest adjusted odds of recurrence (adjusted OR = 0.2, 95% CI 0.1–0.6). Remission of disorders within one class (mood, anxiety, substance use) was consistently associated with lower odds of incidence or recurrence of disorders from the same class than with developing disorders from the other classes.ConclusionsRemission from common psychiatric disorders tends to decrease the risk for incidence or recurrence of disorders and this effect is stronger within than across disorder classes. These results do not support the concept of heterotypic continuity as a substitution of one disorder for another. [ABSTRACT FROM PUBLISHER]

This article compares Buddhist and Christian approaches to the drug problem among ethnic minorities in northern Thailand. Government programmes implemented through Buddhist monasteries aim to construct Buddhist subjects and realise agendas of national security in border areas. Yet, they also offer development support and access to resources. Meanwhile, gospel rehabilitation centres provide much-needed drug treatment services while drawing highlanders into transnational spheres of Christian fellowship. Consequently, I argue that the relationship between ethnic minorities and the state can be defined in terms of aspiration and negotiation, as well as resistance and evasion, as has been previously argued in the literature. [ABSTRACT FROM AUTHOR]

Introduction: This research aims to review the impact of drug addiction, domestic violence and suicide in Australia through the lens of disaster risk reduction. This study explores whether drug addiction, domestic violence and suicide can be considered as disasters according to established thresholds and definitions; and whether contemporary health emergency and disaster risk management (HEDRM) practice can be adapted to support action to reduce the impact of these events and inform disaster risk reduction. Method: A literature review was conducted to explore drug addiction, domestic violence and suicide as societal disruptions causing disasters. Key Australian government reports describing deaths associated with suicide, domestic violence and drug addiction were identified, following which a constrained snowball sampling was applied to the bibliography of each document to gather further key articles and inform the evolution of the impact of these themes in Australia over the period 2000-2018. The search strategy included both peer reviewed and grey literature. We used the search terms 'social disruption', 'non-traditional', 'drug addiction', 'domestic violence, 'suicide' and 'societal disruption' as key words and included articles if they demonstrated an analysis of the theme related to health impact related to disaster settings. Results: Utilizing the Australian Disaster Resilience Knowledge Hub and the international CRED criteria for a disaster, the impact on human health of drug addiction, domestic violence, and suicide upon the Australian population each meet the criteria of a disaster. Conclusion: Public health practice through the lens of the determinants of social disruption combined with activities that consider hazards, vulnerability, and exposure, can institute prevention, preparedness, response, and recovery programs to reduce the impact of drug addiction, domestic violence, and suicide. [ABSTRACT FROM AUTHOR]

BackgroundCannabis is a widely used drug associated with increased risk for psychosis. The dopamine hypothesis of psychosis postulates that altered salience processing leads to psychosis. We therefore tested the hypothesis that cannabis users exhibit aberrant salience and explored the relationship between aberrant salience and dopamine synthesis capacity.MethodWe tested 17 cannabis users and 17 age- and sex-matched non-user controls using the Salience Attribution Test, a probabilistic reward-learning task. Within users, cannabis-induced psychotic symptoms were measured with the Psychotomimetic States Inventory. Dopamine synthesis capacity, indexed as the influx rate constant Kicer, was measured in 10 users and six controls with 3,4-dihydroxy-6-[18F]fluoro-l-phenylalanine positron emission tomography.ResultsThere was no significant difference in aberrant salience between the groups [F1,32 = 1.12, p = 0.30 (implicit); F1,32 = 1.09, p = 0.30 (explicit)]. Within users there was a significant positive relationship between cannabis-induced psychotic symptom severity and explicit aberrant salience scores (r = 0.61, p = 0.04) and there was a significant association between cannabis dependency/abuse status and high implicit aberrant salience scores (F1,15 = 5.8, p = 0.03). Within controls, implicit aberrant salience was inversely correlated with whole striatal dopamine synthesis capacity (r = −0.91, p = 0.01), whereas this relationship was non-significant within users (difference between correlations: Z = −2.05, p = 0.04).ConclusionsAberrant salience is positively associated with cannabis-induced psychotic symptom severity, but is not seen in cannabis users overall. This is consistent with the hypothesis that the link between cannabis use and psychosis involves alterations in salience processing. Longitudinal studies are needed to determine whether these cognitive abnormalities are pre-existing or caused by long-term cannabis use. [ABSTRACT FROM PUBLISHER]

Objectives: The occurrence of a relapse during abstinence is an important issue that must be addressed during treatment for drug addiction. We investigated the influence of drug exposure pattern on morphine-seeking behaviour following withdrawal. We also studied the role of the hippocampus in this process to confirm its involvement in drug relapse. Methods: Male Sprague-Dawley rats that were trained to self-administer morphine (1.0 mg/kg) using 2, 4, 6, 8, or 10 h daily sessions underwent withdrawal in their home cages and were re-exposed to the operant chamber to evaluate morphine-seeking behaviour. During the relapse session, rats were intravenously injected with morphine (0.25 mg/kg) or saline before re-exposure to the chamber. In the second experiment, rats were administered a microinjection of saline or cobalt chloride (CoCl2, 1 mM), a synaptic blocker, into the CA1 of the hippocampus prior to the relapse test. Results: In the first experiment, more morphine-seeking behaviour was observed in the 2 h group (animals trained to self-administer morphine during a 2 h daily session spread over 21 days) during the relapse session, despite all groups being exposed to similar amounts of morphine during the training period before withdrawal. In the second experiment, pretreatment with CoCl2 markedly reduced morphine-seeking behaviour in the 2 h group. Conclusions: The present findings suggest that the exposure pattern influences the degree of relapse and that control of memorisation is important for prevention of relapse. [ABSTRACT FROM AUTHOR]

Background Psychiatric comorbidity is common among individuals with addictive disorders, with patients frequently suffering from anxiety disorders. While the genetic architecture of comorbid addictive and anxiety disorders remains unclear, elucidating the genes involved could provide important insights into the underlying etiology. Methods Here we examine a sample of 1284 Mexican-Americans from randomly selected extended pedigrees. Variance decomposition methods were used to examine the role of genetics in addiction phenotypes (lifetime history of alcohol dependence, drug dependence or chronic smoking) and various forms of clinically relevant anxiety. Genome-wide univariate and bivariate linkage scans were conducted to localize the chromosomal regions influencing these traits. Results Addiction phenotypes and anxiety were shown to be heritable and univariate genome-wide linkage scans revealed significant quantitative trait loci for drug dependence (14q13.2-q21.2, LOD = 3.322) and a broad anxiety phenotype (12q24.32-q24.33, LOD = 2.918). Significant positive genetic correlations were observed between anxiety and each of the addiction subtypes (ρ g = 0.550–0.655) and further investigation with bivariate linkage analyses identified significant pleiotropic signals for alcohol dependence-anxiety (9q33.1-q33.2, LOD = 3.054) and drug dependence-anxiety (18p11.23-p11.22, LOD = 3.425). Conclusions This study confirms the shared genetic underpinnings of addiction and anxiety and identifies genomic loci involved in the etiology of these comorbid disorders. The linkage signal for anxiety on 12q24 spans the location of TMEM132D , an emerging gene of interest from previous GWAS of anxiety traits, whilst the bivariate linkage signal identified for anxiety-alcohol on 9q33 peak coincides with a region where rare CNVs have been associated with psychiatric disorders. Other signals identified implicate novel regions of the genome in addiction genetics. [ABSTRACT FROM AUTHOR]

BackgroundHeritability estimates from twin studies of the multi-faceted phenotype of nicotine dependence (ND) range from moderate to high (31–60%), but vary substantially based on the specific ND-related construct examined. The current study estimated the aggregate role of common genetic variants on key ND constructs.MethodGenomic-relationship-matrix restricted maximum likelihood (GREML) was used to decompose phenotypic variance across multiple ND indices using 796 125 polymorphisms from 2346 unrelated ‘lifetime ever smokers’ of European ancestry. Measures included DSM-IV ND and Fagerström Test for Nicotine Dependence (FTND) summary measures and constituent constructs (e.g. withdrawal severity, tolerance, heaviness of smoking and time spent smoking). Exploratory and confirmatory factor models were used to describe the covariance structure across ND measures; resulting factor(s) were the subject(s) of GREML analyses.ResultsFactor models indicated highly correlated DSM-IV and FTND factors for ND (0.545, 95% confidence interval 0.50–0.60) that could be represented as a higher-order factor (NIC DEP). Additive genetic influence on NIC DEP was 33% (s.e. = 0.14, p = 0.009). Post-hoc analyses indicated moderate genetic effects on the DSM-IV (34%, s.e. = 0.14, p = 0.008) and FTND (26%, s.e. = 0.14, p = 0.032) factors, both of which were influenced by the same genetic effects (rG-SNP = 1.00, s.e. = 0.09, p < 0.00001).ConclusionsOverall, common single nucleotide polymorphisms accounted for a large proportion of the genetic influences on ND-related phenotypes that have been observed in twin studies. Genetic contributions across distinct ND scales were largely influenced by shared genetic factors. [ABSTRACT FROM PUBLISHER]

This article explores whether the British decision-makers and public were conscious of the habit-forming nature of opium at the time of the Chinese war of 1839–42, the First Opium War. While most political historians have assumed that the British authorities understood the nature of the drug, social historians argue that notions of addiction only arose, in Britain, at the end of the nineteenth century. Examining the abundant press, pamphlet, and parliamentary literature generated by the war debate, this article examines in what terms opium use was characterized. It considers the groups that intervened on both sides of the debate and draws lessons from the arguments they deployed for and against the war. Situating the source literature within the context of early Victorian values and mores, finally, it argues that the British leaders and political nation were aware of the drug's habit-forming properties. Not only was it widely recognized that it was something dangerous that was being introduced, at the point of a gun, into China, but there can be said to have existed, in Britain, a layman's notion of drug addiction. [ABSTRACT FROM PUBLISHER]

BackgroundCannabis use is decreasing in England and Wales, while demand for cannabis treatment in addiction services continues to rise. This could be partly due to an increased availability of high-potency cannabis.MethodAdults residing in the UK were questioned about their drug use, including three types of cannabis (high potency: skunk; low potency: other grass, resin). Cannabis types were profiled and examined for possible associations between frequency of use and (i) cannabis dependence, (ii) cannabis-related concerns.ResultsFrequent use of high-potency cannabis predicted a greater severity of dependence [days of skunk use per month: b = 0.254, 95% confidence interval (CI) 0.161–0.357, p < 0.001] and this effect became stronger as age decreased (b = −0.006, 95% CI −0.010 to −0.002, p = 0.004). By contrast, use of low-potency cannabis was not associated with dependence (days of other grass use per month: b = 0.020, 95% CI −0.029 to 0.070, p = 0.436; days of resin use per month: b = 0.025, 95% CI −0.019 to 0.067, p = 0.245). Frequency of cannabis use (all types) did not predict severity of cannabis-related concerns. High-potency cannabis was clearly distinct from low-potency varieties by its marked effects on memory and paranoia. It also produced the best high, was preferred, and most available.ConclusionsHigh-potency cannabis use is associated with an increased severity of dependence, especially in young people. Its profile is strongly defined by negative effects (memory, paranoia), but also positive characteristics (best high, preferred type), which may be important when considering clinical or public health interventions focusing on cannabis potency. [ABSTRACT FROM PUBLISHER]

Methodological issues such as social desirability bias, subjective outcome measures, therapist enthusiasm and fidelity to the intervention remain a major problem in assessing the effectiveness of psychosocial treatments for substance misuse. Alcoholics Anonymous and other 12-step programmes are still widely used, although it is difficult to formally assess their ef fectiveness. Motivational interviewing is perhaps the most commonly used professional psychosocial treatment for substance misuse, but brief interventions based on this technique report a disappointing effect size (~0.2). Contingency management is perhaps the most effective reported modality, although it remains politically controversial. Cognitive–behavioural therapy and community reinforcement have been widely studied, but the results are often disappointing (effect sizes seldom exceed 0.5, despite very large trials). Residential rehabilitation remains an established treatment, but patient selection prevents formal cost-effectiveness studies. [ABSTRACT FROM AUTHOR]

This study explored the characteristics of a representative sample of patients who were addicted to either alcohol or cocaine, comparing the profiles of both types of drug users. A sample of 234 addicted patients (109 alcoholics and 125 cocaine addicts) who sought outpatient treatment in a Spanish clinical centre was assessed. Data on sociodemographic, consumption, psychopathological and maladjustment characteristics were collected using the European Addiction Severity Index (EuropASI), the Symptom Checklist-90-Revised (SCL-90-R) and the Millon Clinical Multiaxial Inventory (MCMI-II). Demographically, differences were observed with regard to age (alcoholics were older than cocaine addicts; t = 12.2, p = .001), employment (the alcoholic group had more labor problems; χ2 = 6.2, p = .045) and family consequences (worse in alcoholics; t = 2.3, p = .025). The EuropASI results showed statistically significant differences in addiction severity, with alcoholics showing a greater severity than cocaine addicts. In terms of psychopathology, alcoholics presented more associated symptomatology than cocaine addicts. According to these results, patients with alcohol dependence have a different profile from patients with cocaine dependence, resulting in different repercussions for important areas of their lives. These differences should be taken into account when standard treatments for addiction are implemented. [ABSTRACT FROM AUTHOR]

Distance to the object is a new approach that highlights the complex nature of the link between groups and social representations. It is composed of three elements: knowledge, involvement, and level of practices associated with the social object. This study aims to replicate a previous study that has demonstrated the validity of distance to the object in order to explore social representations of cannabis. We carried out a research on the social representations of cocaine. Respondents (n = 200) completed a questionnaire including opinions related to cocaine and constitutive elements of the distance to cocaine. The regression analysis on the representational dimensions revealed a significant effect of the distance variable on two dimensions (social facilitator, addiction and social dangerousness). The groups that were "distant" from the object showed stronger adherence to the normative component than to the functional component of SR, in opposition to those who were "close" to the object. The concept of distance to the object is thus heuristic as it offers an integrative grid of reading that permits to understand and highlight the link individuals maintain with a social representation. [ABSTRACT FROM AUTHOR]

BackgroundChildhood psychotic symptoms have been used as a subclinical phenotype of schizophrenia in etiological research and as a target for preventative interventions. However, recent studies have cast doubt on the specificity of these symptoms for schizophrenia, suggesting alternative outcomes such as anxiety and depression. Using a prospective longitudinal birth cohort we investigated whether childhood psychotic symptoms predicted a diagnosis of schizophrenia or other psychiatric disorders by 38 years of age.MethodParticipants were drawn from a birth cohort of 1037 children from Dunedin, New Zealand, who were followed prospectively to 38 years of age (96% retention rate). Structured clinical interviews were administered at age 11 to assess psychotic symptoms and study members underwent psychiatric assessments at ages 18, 21, 26, 32 and 38 to obtain past-year DSM-III-R/IV diagnoses and self-reports of attempted suicides since adolescence.ResultsPsychotic symptoms at age 11 predicted elevated rates of research diagnoses of schizophrenia and post-traumatic stress disorder (PTSD) and also suicide attempts by age 38, even when controlling for gender, social class and childhood psychopathology. No significant associations were found for persistent anxiety, persistent depression, mania or persistent substance dependence. Very few of the children presenting with age-11 psychotic symptoms were free from disorder by age 38.ConclusionsChildhood psychotic symptoms were not specific to a diagnosis of schizophrenia in adulthood and thus future studies of early symptoms should be cautious in extrapolating findings only to this clinical disorder. However, these symptoms may be useful as a marker of adult mental health problems more broadly. [ABSTRACT FROM PUBLISHER]

Context: The detection and replication of genes involved in psychiatric outcome has been notoriously difficult. Phenotypic measurement has been offered as one explanation, although most of this discussion has focused on problems with binary diagnoses. Objective: This article focuses on two additional components of phenotypic measurement that deserve further consideration in evaluating genetic associations: (1) the measure used to reflect the outcome of interest, and (2) the developmental stage of the study population. We focus our discussion of these issues around the construct of impulsivity and externalizing disorders, and the association of these measures with a specific gene, GABRA2. Design, Setting, and Participants: Data were analyzed from the Collaborative Study on the Genetics of Alcoholism Phase IV assessment of adolescents and young adults (ages 12–26; N = 2,128). Main Outcome Measures: Alcohol dependence, illicit drug dependence, childhood conduct disorder, and adult antisocial personality disorder symptoms were measured by psychiatric interview; Achenbach youth/adult self-report externalizing scale; Zuckerman Sensation-Seeking scale; Barratt Impulsivity scale; NEO extraversion and consciousness. Results: GABRA2 was associated with subclinical levels of externalizing behavior as measured by the Achenbach in both the adolescent and young adult samples. Contrary to previous associations in adult samples, it was not associated with clinical-level DSM symptom counts of any externalizing disorders in these younger samples. There was also association with sensation-seeking and extraversion, but only in the adolescent sample. There was no association with the Barratt impulsivity scale or conscientiousness. Conclusions: Our results suggest that the pathway by which GABRA2 initially confers risk for eventual alcohol problems begins with a predisposition to sensation-seeking early in adolescence. The findings support the heterogeneous nature of impulsivity and demonstrate that both the measure used to assess a construct of interest and the age of the participants can have profound implications for the detection of genetic associations. [ABSTRACT FROM PUBLISHER]

Background: Reasons for the increased prevalence of cigarette smoking in schizophrenia are unclear. Studies assessing clinical symptoms have sampled heterogeneous populations, with discrepant findings.Aims: To examine the relationship between clinical features, social adjustment and nicotine dependence in a geographically defined population of people with schizophrenia.Method: Cross-sectional clinical study of 131 people with schizophrenia in Nithsdale, Scotland.Results: Smokers were younger, mostly males and three times more likely to be unemployed. Those with severe nicotine dependence had greater scores on the positive subscale of the Positive and Negative Syndrome Scale (PANSS), and were prescribed higher doses of antipsychotic. Those with mild-moderate dependence had greater scores on the PANSS negative subscale. Greater symptom severity was associated with poorer social adjustment. Psychopathology and social adjustment were similar in quitters and never-smokers.Conclusions: Our findings indicate an association between nicotine dependence, clinical symptoms and social adjustment in schizophrenia. Although causal links cannot be inferred, identifying the relationship between nicotine dependence and psychopathology may have some value in the management of smoking in schizophrenia. Further longitudinal studies are required to explore this relationship. [ABSTRACT FROM AUTHOR]

BackgroundThe suicide rate is higher in prisoners compared with the general population. The aim was to describe the characteristics of and longitudinal trends in prisoner suicides in England and Wales.MethodA case series was ascertained from the Safer Custody and Offender Policy Group at the Ministry of Justice and included a 9-year (1999–2007) national census of prisoner suicides. Questionnaires were completed by prison staff on sociodemographic, custodial, clinical and service-level characteristics of the suicides.ResultsThere was a fall in the number of prison suicides and a decline in the proportion of young prisoner (18–20 years) suicides over time. Females were over-represented. Upward trends were found in prisoners with a history of violence and with previous mental health service contact. A downward trend was found in those with a primary psychiatric diagnosis of drug dependence. Drug dependence was found to be significant in explaining suicides within the first week of custody.ConclusionsThe findings provide an important insight to aid a target set in the National Suicide Prevention Strategy in England to reduce suicides in the prisoner population by 20% and highlight an important area for policy development in mental health services. Examining trends identified subgroups that may require improved mental healthcare and recognized those that appeared to be having their treatment needs more adequately met. Evidence suggests that targeted suicide prevention strategies for subgroups of prisoners are required. [ABSTRACT FROM PUBLISHER]

BackgroundNicotine dependence has been shown to represent a heritable condition, and several research groups have performed linkage analysis to identify genomic regions influencing this disorder though only a limited number of the findings have been replicated.MethodIn the present study, a genome-wide linkage scan for nicotine dependence was conducted in a community sample of 950 probands and 1204 relatives recruited through the University of California, San Francisco (UCSF) Family Alcoholism Study. A modified version of the Semi-Structured Assessment for the Genetics of Alcoholism (SSAGA) with additional questions that probe nicotine use was used to derive DSM-IV nicotine dependence diagnoses.ResultsA locus on chromosome 2q31.1 at 184 centiMorgans nearest to marker D2S2188 yielded a logarithm (base 10) of odds (LOD) score of 3.54 (point-wise empirical p=0.000012). Additional peaks of interest were identified on chromosomes 2q13, 4p15.33-31, 11q25 and 12p11.23-21. Follow-up analyses were conducted examining the contributions of individual nicotine dependence symptoms to the chromosome 2q31.1 linkage peak as well as examining the relationship of this chromosomal region to alcohol dependence.ConclusionsThe present report suggests that chromosome 2q31.1 confers risk to the development of nicotine dependence and that this region influences a broad range of nicotine dependence symptoms rather than a specific facet of the disorder. Further, the results show that this region is not linked to alcohol dependence in this population, and thus may influence nicotine dependence specifically. [ABSTRACT FROM PUBLISHER]

The use of opioid contracts, which often require patients to submit to random drug screens, have become widespread amongst physicians using opioids to treat chronic pain. The main purpose of the contract is to improve care through better adherence to opioid therapy but there is little evidence as to its efficacy. The author suggests the use of opioid contracts and random drug testing destroys patients' trust which impacts health outcomes, and that physicians' motivation for their use are concerns about prosecution, medication abuse and misuse, and addiction. Statistics are provided to counter fears, and evidence is offered suggesting opioid contracts are unenforceable and lack efficacy; random drug testing is often inconclusive, and a patient's trust improves adherence to treatment. [ABSTRACT FROM AUTHOR]

Background: Naltrexone has considerable potential in helping to prevent relapse in heroin dependency. A longer-lasting formulation for naltrexone treatment is desirable to further reduce non-adherence and relapse during treatment of opiate dependence.Aims: To evaluate the safety and effectiveness of a 6-month naltrexone implant in reducing opioid use after in-patient treatment.Method: A group of 56 abstinence-oriented patients who completed in-patient treatment for opioid dependence were randomly and openly assigned to receive either a 6-month naltrexone implant or their usual aftercare. Drug use and other outcomes were assessed at 6-month follow-up.Results: Patients receiving naltrexone had on average 45 days less heroin use and 60 days less opioid use than controls in the 180-day period (both P<0.05). Blood tests showed naltrexone levels above 1 ng/ml for the duration of 6 months. Two patients died, neither of whom had received an implant.Conclusions: Naltrexone implant treatment safely and significantly reduces opioid use in a motivated population of patients. [ABSTRACT FROM AUTHOR]

BackgroundThe ?gateway? pattern of drug initiation describes a normative sequence, beginning with alcohol and tobacco use, followed by cannabis, then other illicit drugs. Previous work has suggested that ?violations? of this sequence may be predictors of later problems but other determinants were not considered. We have examined the role of pre-existing mental disorders and sociodemographics in explaining the predictive effects of violations using data from the US National Comorbidity Survey Replication (NCS-R).MethodThe NCS-R is a nationally representative face-to-face household survey of 9282 English-speaking respondents aged 18 years and older that used the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI) to assess DSM-IV mental and substance disorders. Drug initiation was estimated using retrospective age-of-onset reports and ?violations? defined as inconsistent with the normative initiation order. Predictors of violations were examined using multivariable logistic regressions. Discrete-time survival analysis was used to see whether violations predicted progression to dependence.ResultsGateway violations were largely unrelated to later dependence risk, with the exception of small increases in risk of alcohol and other illicit drug dependence for those who initiated use of other illicit drugs before cannabis. Early-onset internalizing disorders were predictors of gateway violations, and both internalizing and externalizing disorders increased the risks of dependence among users of all drugs.ConclusionsDrug use initiation follows a strong normative pattern, deviations from which are not strongly predictive of later problems. By contrast, adolescents who have already developed mental health problems are at risk for deviations from the normative sequence of drug initiation and for the development of dependence. [ABSTRACT FROM AUTHOR]