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Introduction and Aims Crystal methamphetamine (CM) is associated with a range of physical and mental health harms and may be of particular concern among young people at risk of early, problematic substance use, such as those in contact with the criminal justice system. This study aimed to investigate the prevalence and correlates of regular (i.e. at least weekly) CM use among young people preceding entry into custody. Design and Methods Data were collected from 207 participants aged 14–18 years as part of the 2015 Young People in Custody Health Survey, a cross-sectional survey of youth in custody in New South Wales, Australia. Participants were administered face-to-face structured interviews assessing sociodemographic, childhood and family characteristics, offending history, substance use and psychopathology. Multivariable logistic regression analyses were conducted to identify factors independently associated with regular CM use. Results Regular CM use was reported by 31% of participants and was independently associated with higher levels of antisocial traits/behaviour [adjusted odds ratio (AOR) 1.13, 95% confidence interval (CI) 1.02, 1.25], increased polydrug use (AOR 1.34, 95% CI 1.14, 1.58), injecting drug use (AOR 4.06, 95% CI 1.02, 16.16) and meeting symptom thresholds for two or more current psychological disorders (AOR 3.20, 95% CI 1.15, 8.94). Discussion and Conclusions Regular CM users present with more complex comorbidity than other young people in custody, increasing the health-care burden in custodial and community settings. Early identification and appropriate treatment of this comorbidity is crucial to improving the health, psychosocial and behavioural outcomes of this vulnerable group.

Background: Although substance use disorders (SUD) and attention-deficit/hyperactivity disorder (ADHD) show significant symptomatic overlap, ADHD is often overlooked in SUD patients. Objective: The aim of the present study was to characterize aspects of attention and inhibition (as assessed by a continuous performance test [CPT]) in SUD patients with and without a comorbid diagnosis of ADHD and in healthy controls, expecting the most severe deficits in patients with a combined diagnosis. Methods: The MOXO-CPT version, which incorporates visual and auditory environmental distractors, was administered to 486 adults, including healthy controls (n = 172), ADHD (n = 56), SUD (n = 150), and combined SUD and ADHD (n = 108). Results: CPT performance of healthy controls was better than that of individuals in each of the 3 clinical groups. The only exception was that the healthy control group did not differ from the ADHD group on the Timing index. The 3 clinical groups differed from each other in 2 indices: (a) patients with ADHD (with or without SUD) showed increased hyperactivity compared to patients with SUD only and (b) patients with ADHD showed more responses on correct timing as compared with the SUD groups (with or without ADHD). Conclusion: The CPT is sensitive to ADHD-related deficits, such as disinhibition, poor timing, and inattention, and is able to consistently differentiate healthy controls from patients with ADHD, SUD, or both. Our results are in line with previous research associating both ADHD and SUD with multiple disruptions across a broad set of cognitive domains such as planning, working memory, decision-making, inhibition control, and attention. The lack of consistent differences in cognitive performance between the 3 diagnostic groups might be attributed to various methodological aspects (e.g., heterogeneity in severity, type, and duration of substances use). Our results support the view that motor activity should be considered a significant marker of ADHD.

Psychostimulant use is associated with increased stroke risk. To determine the proportion of psychostimulant users among fatal strokes in young adults (15-44 years), all cases were retrieved from the National Coronial Information System (1/1/2009-31/12/2016). A total of 279 cases were identified: hemorrhagic (259), ischemic (8), thrombotic (8), and mycotic (4). Fifty (17.9%) were identified as psychostimulant users. Psychostimulants in blood were detected in 37/45 where toxicology was available, predominantly methamphetamine (32/45). Hemorrhagic strokes in the psychostimulant group were more likely to be intraparenchymal (OR 2.33). Psychostimulant users were less likely to be obese (OR 0.31), but more likely to have a history of tobacco use (OR 2.64). No psychostimulant user had a previous stroke history, was gravid/postpartum, or diagnosed with cerebral vasculitis or endocarditis. The work illustrates the substantial role of psychostimulant use in fatal strokes among young adults. In cases of hemorrhagic stroke among young adults, psychostimulant use should be considered.

Aims: This study addressed the age of onset of conduct disorder (CD) and oppositional defiant disorder (ODD) in treatment-seeking substance use disorder (SUD) patients with and without adult attention-deficit/hyperactivity disorder (ADHD) and its association with early onset of SUD. Methods: We examined data from the 2nd International ADHD in Substance Use Disorders Prevalence Study, including 400 adults in SUD treatment from Puerto Rico, Hungary, and Australia. ADHD, SUD, and CD/ODD were assessed with the Conners Adult ADHD Diagnostic Interview for DSM-IV, the MINI International Neuropsychiatric Interview, and the K-SADS, respectively. Cox regression analyses modeled time to emergence of CD/ODD separately for SUD patients with and without adult ADHD. Linear regression models examined associations between age of onset of SUD and presence of ADHD and adjusted for sex, age, and country. To assess the mediating role of CD/ODD on the association of ADHD with onset of SUD, adjusted regression models were estimated. Results: Treatment-seeking SUD patients with ADHD presented an earlier onset of CD/ODD compared with those without ADHD. CD/ODD symptom loads were higher among the SUD and ADHD group. Age of first substance use and SUD were significantly earlier in SUD patients with ADHD, and these findings remained significant after adjustment for demographics and coexisting CD/ODD. Conclusions: ADHD is associated with earlier onset of SUD as well as with an earlier onset of more frequent and more severe disruptive behavioral disorders. These findings may inform preventive interventions to mitigate adverse consequences of ADHD.

Globally, there are increasing concerns about the harms associated with methamphetamine use. This paper i) reports on the results of a cost-of-illness (CoI) study that quantified the social costs associated with methamphetamine use in Australia and, ii) drawing on examples from this study, critically examines the general applicability of CoI studies for the alcohol and other drug field. A prevalence approach was used to estimate costs in 2013/2014, the most recent year for which reasonably comprehensive data were available. The value selected for a statistical life-year in our central estimate was AUD 281,798. Other costs were estimated from diverse sources. Total cost was estimated at AUD 5023.8 million in 2013/14 (range, AUD 2502.3 to AUD 7016.8 million). The greatest cost areas were crime including costs related to policing, courts, corrections and victims of crime (AUD 3244.5 million); followed by premature death (AUD 781.8 million); and, workplace costs (AUD 289.4 million). The social costs of methamphetamine use in Australia in 2013/14 are high, and the identification of crime and premature mortality as the largest cost areas is similar to USA findings and represents important areas for prevention and cost remediation. However, caution is required in interpreting the findings of any CoI study, as there is uncertainty associated with estimates owing to data limitations. Moreover, CoI estimates on their own do not identify which, if any, of the costs are avoidable (with drug substitution being a particular problem) nor do they shed light on the effectiveness of any potential interventions. We also recognise that data limitations prevent some costs from being estimated at all.

Background: Childhood attention-deficit/hyperactivity disorder (ADHD) is a risk factor for substance misuse and substance use disorder (SUD) in adolescence and (early) adulthood. ADHD and SUD also frequently co-occur in treatment-seeking adolescents, which complicates diagnosis and treatment and is associated with poor treatment outcomes. Research on the effect of treatment of childhood ADHD on the prevention of adolescent SUD is inconclusive, and studies on the diagnosis and treatment of adolescents with ADHD and SUD are scarce. Thus, the available evidence is generally not sufficient to justify robust treatment recommendations. Objective: The aim of the study was to obtain a consensus statement based on a combination of scientific data and clinical experience. Method: A modified Delphi study to reach consensus based upon the combination of scientific data and clinical experience with a multidisciplinary group of 55 experts from 17 countries. The experts were asked to rate a set of statements on the effect of treatment of childhood ADHD on adolescent SUD and on the screening, diagnosis, and treatment of adolescents with comorbid ADHD and SUD. Results: After 3 iterative rounds of rating and adapting 37 statements, consensus was reached on 36 of these statements representing 6 domains: general (n = 4), risk of developing SUD (n = 3), screening and diagnosis (n = 7), psychosocial treatment (n = 5), pharmacological treatment (n = 11), and complementary treatments (n = 7). Routine screening is recommended for ADHD in adolescent patients in substance abuse treatment and for SUD in adolescent patients with ADHD in mental healthcare settings. Long-acting stimulants are recommended as the first-line treatment of ADHD in adolescents with concurrent ADHD and SUD, and pharmacotherapy should preferably be embedded in psychosocial treatment. The only remaining no-consensus statement concerned the requirement of abstinence before starting pharmacological treatment in adolescents with ADHD and concurrent SUD. In contrast to the majority, some experts required full abstinence before starting any pharmacological treatment, some were against the use of stimulants in the treatment of these patients (independent of abstinence), while some were against the alternative use of bupropion. Conclusion: This international consensus statement can be used by clinicians and patients together in a shared decision-making process to select the best interventions and to reach optimal outcomes in adolescent patients with concurrent ADHD and SUD.

Background: The International Collaboration on ADHD and Substance Abuse (ICASA) is a network of 28 centers from 16 countries initiated to investigate the link between attention deficit-hyperactivity disorder (ADHD) and substance use disorder (SUD). In this article, we present the mission, the results of finished studies, and the current and future research projects of ICASA. Methods: During the past 10 years, 3 cross-sectional studies were conducted: two International ADHD in Substance use disorders Prevalence (IASP-1 and IASP-2) studies, directed at the screening, diagnosis, and the prevalence of adult ADHD in treatment-seeking patients with SUD, and the Continuous performance test for ADHD in SUD Patients (CASP) study, testing a novel continuous performance test in SUD patients with and without adult ADHD. Recently, the prospective International Naturalistic Cohort Study of ADHD and Substance Use Disorders (INCAS) was initiated, directed at treatment provision and treatment outcome in SUD patients with adult ADHD. Results: The IASP studies have shown that approximately 1 in 6 adult treatment-seeking SUD patients also have ADHD. In addition, those SUD patients with adult ADHD compared to SUD patients without ADHD report more childhood trauma exposure, slower infant development, greater problems controlling their temperament, and lower educational attainment. Comorbid patients also reported more risk-taking behavior, and a higher rate of other psychiatric disorders compared to SUD patients without ADHD. Screening, diagnosis, and treatment of this patient group are possible even before abstinence has been achieved. The results of the CASP study are reported separately in this special issue. Conclusions: The ICASA research to date has demonstrated a high prevalence of comorbid ADHD and SUD, associated with elevated rates of additional comorbidities and risk factors for adverse outcomes. More research is needed to find the best way to treat these patients, which is the main topic of the ongoing INCAS study.

Introduction: Comorbid attention deficit/hyperactivity disorder (ADHD) is present in 15–25% of all patients seeking treatment for substance use disorders (SUDs). Some studies suggest that comorbid ADHD increases clinical severity related to SUDs, other psychiatric comorbidities, and social impairment, but could not disentangle their respective influences. Objectives: To investigate whether comorbid adult ADHD in treatment-seeking SUD patients is associated with more severe clinical profiles in these domains assessed altogether. Methods: Treatment-seeking SUD patients from 8 countries (N = 1,294: 26% females, mean age 40 years [SD = 11 years]) were assessed for their history of DSM-IV ADHD, SUDs, and other psychiatric conditions and sociodemographic data. SUD patients with and without comorbid ADHD were compared on indicators of severity across 3 domains: addiction (number of SUD criteria and diagnoses), psychopathological complexity (mood disorders, borderline personality disorder, lifetime suicidal thoughts, or behavior), and social status (education level, occupational and marital status, and living arrangements). Regression models were built to account for confounders for each severity indicator. Results: Adult ADHD was present in 19% of the SUD patients. It was significantly associated with higher SUD severity, more frequent comorbid mood or borderline personality disorder, and less frequent “married” or “divorced” status, as compared with the absence of comorbid ADHD. ADHD comorbidity was independently associated with a higher number of dependence diagnoses (OR = 1.97) and more psychopathology (OR = 1.5), but not marital status. Conclusions: In treatment-seeking SUD patients, comorbid ADHD is associated with polysubstance dependence, psychopathological complexity, and social risks, which substantiates the clinical relevance of screening, diagnosing, and treating ADHD in patients with SUDs.

Aims: To examine the role of attention deficit/hyperactivity disorder (ADHD) and impulsive personality disorders in nicotine addiction severity among treatment-seeking substance use disorder (SUD) patients. Methods: In a cross-sectional study, we examined data from the second International ADHD in Substance Use Disorders Prevalence Study (IASP-2) on 402 adults in SUD treatment from Puerto Rico, Hungary, and Australia using diagnostic interviews for ADHD, antisocial (ASP) and borderline (BPD) personality disorders, and the self-report Fagerström Test of Nicotine Dependence (FTND). We compared SUD patients with and without ADHD on nicotine addiction severity. We tested direct and indirect pathways from ADHD to nicotine addiction and mediation through ASP and BPD. Results: Overall, 81.4% of SUD patients reported current cigarette smoking. SUD patients with ADHD had higher FTND scores and smoked more cigarettes than those without ADHD, with an earlier onset and more years of smoking. ASP mediated the effect of ADHD on all aspects of nicotine addiction severity, whereas BPD did so only on some aspects of nicotine addiction severity. Conclusions: SUD patients with comorbid ADHD show more severe nicotine addiction than those without, which is largely explained by comorbid impulsive personality disorders. In SUD patients, it is important to screen for adult ADHD and other psychiatric disorders, especially those with impulse control deficits such as ASP and BPD.

Purpose The purpose of this paper is to examine the prevalence and predictors of low self-reported physical health status among NSW prison inmates. Design/methodology/approach Cross-sectional random sample of 1,098 adult male and female prisoners, interviewed as part of the 2015 Justice Health and Forensic Mental Health Network Patient Health Survey. Findings Almost a quarter of participants had “low self-reported physical health status”. Independent predictors of “low health status” were having been in out of home care before the age of 16 years, being illiterate, smoking 20 or more cigarettes a day, not eating more than one serve of fruit a day, not being physically active in the 12 months before incarceration, higher body mass index score and low self-reported mental health status. Many of these predictors are modifiable risk factors for chronic disease, which could be targeted during incarceration. Originality/value This paper demonstrates the utility of a using a single item measure of self-reported physical health status among Australian prisoners, and helps to characterise those prisoners in greatest need of intervention for issues relating to their health.

Background The potential of methamphetamine, and high-potency crystal methamphetamine in particular, to precipitate psychotic symptoms and psychotic illness is the subject of much speculation internationally. Established psychotic illness is disabling for individuals and costly to society. The aim of this study was to investigate whether use of crystal methamphetamine was associated with greater prevalence of self-reported psychotic illness, compared to use of other forms of methamphetamine. Methods The sample comprised participants interviewed as part of an annual cross-sectional survey of Australian people who inject drugs. Comparisons were made between groups according to the nature of their methamphetamine use: crystal methamphetamine or other forms of methamphetamine. Self-reported diagnoses of psychotic illness and other mental health problems were compared between groups. Predictors of self-reported psychotic illness were examined using multivariable logistic regression analyses. Results Self-reported psychotic illness was highly prevalent among users of crystal methamphetamine (12.0%), and significantly more so than among users of other forms of methamphetamine (3.9%) (OR=3.36; CI: 1.03–10.97). Significant predictors of self-reported psychosis in the cohort were: use of crystal methamphetamine; dependent use; lack of education beyond high school; and younger age. Conclusion Highly increased prevalence of self-reported psychotic illness is associated with use of high-potency crystal methamphetamine in people who inject drugs, particularly where there is dependent use. There is an urgent need to develop effective interventions for dependent crystal methamphetamine use; and a need to monitor for symptoms of psychotic illness in drug-using populations.

Introduction Violence is a major burden of harm among injecting drug users (IDU), however, the liability to violent offending is not well understood. The current study aimed to better understand differences in the liability to violence by determining whether IDU could be disaggregated into distinct violent offending classes, and determining the correlates of class membership. Methods A total of 300 IDU from Sydney, Australia were administered a structured interview examining the prevalence and severity of drug use and violent offending histories, as well as early life risk factors (maltreatment, childhood mental disorder, trait personality). Results IDU were disaggregated into four distinct latent classes, comprising a non-violent class (24%), an adolescent-onset persistent class (33%), an adult-onset transient class (24%) and an early-onset, chronic class (19%). Pairwise and group comparisons of classes on predispositional and substance use risks showed that the EARLY class had the poorest psychosocial risk profile, while the NON class had the most favourable. Multinomial logistic regression revealed that higher trait impulsivity and aggression scores, having a history of conduct disorder, frequent childhood abuse, and more problematic alcohol use, were independently associated with more temporally stable and severe violent offending. The model explained 67% of variance in class membership (χ 2 = 207.7, df = 51, p Conclusions IDU can be meaningfully disaggregated into distinct violent offending classes using developmental criteria. The age of onset of violence was indicative of class membership insomuch as that the extent of early life risk exposure was differentially associated with greater long-term liability to violence and drug use.

Objective: Given the paucity of research among prisoners, this study aimed to examine the prevalence and psychiatric comorbidity associated with adult ADHD. Method: The study was conducted at four NSW correctional facilities (2 male; 2 female). Results: Thirty-five percent of the sample screened positive for adult ADHD, and 17% of the sample met criteria for a full diagnosis. After adjustment, benzodiazepine dependence, borderline personality disorder, social phobia, antisocial personality disorder, and a number of lifetime psychological disorders remained significantly and independently associated with the diagnosis of adult ADHD. Lowering the threshold on the ADHD Self-Rating Scale to ≥3 (vs. ≥4) increased the sensitivity (80%-93%), but lowered the specificity (55%-47%). Conclusion: Adult ADHD among NSW prisoners is elevated, with substance use disorders and psychiatric comorbidity common. A greater acceptance of this disorder among prisoners, and appropriate treatment, is warranted.

Background Some university students consume pharmaceutical stimulants without a medical prescription with the goal of improving their academic performance. The prevalence of this practice has been well documented in the US, but less so in other countries. The potential harms of using prescription stimulants require a better understanding of the prevalence of this practice within Australian universities. Methods An internet survey of 1136 Australian students was conducted in 2015 in three large Australian universities. Students were asked about their personal use of prescription stimulants, attitudes and experiences with prescription stimulants. They were also asked about their use of caffeine, energy drinks and illicit drugs to enhance their academic performance. Results Lifetime self-reported use of stimulant medication to improve academic performance was 6.5, and 4.4% in the past year. Students were far more likely to report using coffee and energy drinks (41.4 and 23.6% respectively, lifetime use) than prescription stimulants to help them study and complete university assessments. Non-medical use of prescription stimulants was strongly associated with a history of illicit drug use. Conclusion The prevalence of nonmedical prescription stimulant use to improve academic performance is low among university students in Australia, especially when compared with their use of coffee and energy drinks.

Characteristics of death attributed solely to methamphetamine toxicity (MT, n = 93) by forensic pathologists were examined and compared to cases of multiple drug toxicity (MDT, n = 634). The mean age of MT cases was 36.7 years, and 86.0% were male. Strenuous activity was reported in 12.9%. The most common witness observations were: collapse (60.3%), difficulty in breathing (36.2%), and hyperthermia (27.6%). MT cases had higher blood methamphetamine (0.54 vs. 0.11 mg/L) and amphetamine (0.04 vs. 0.02 mg/L) concentrations and lower likelihoods for opioids (12.5% vs. 80.9%), hypnosedatives (27.3 vs. 60.7%), antidepressants (14.8 vs. 29.8%), and antipsychotics (9.1 vs. 19.7%). MT cases had significantly heavier hearts than MDT cases (423.4 vs. 385.8 g) and were more likely to have cardiomegaly (37.1 vs. 20.4%) and replacement fibrosis (25.7 vs. 14.5%). The clinical picture was of a sudden cardiac event in a middle-aged man with a high methamphetamine concentration. Cardiovascular signs of heavy methamphetamine use are frequently seen.

All Australian cases of methamphetamine-related suicide (2009-2015) retrieved from the National Coronial Information System were examined to determine crude mortality rates, characteristics and circumstances of death, and blood toxicology. There were 300 cases, 18.2% of all methamphetamine-related deaths, and 1.6% of all completed suicides. The mean age was 33.1 years, and 77.0% were male. The crude mortality rate was 1.9 per 106 , with males having a significantly higher rate than females (2.9 vs. 0.9 per 106 ). A quarter were known to have previous suicide attempts, and a history of psychosis was noted in 12.3%. In 40.7% of cases, witnesses described the decedent as having been agitated and/or aggressive immediately prior to the incident. The vast majority (85.3%), and of both sexes (males 87.0%, females 79.7%), used violent methods. Hanging (70.3%) was overwhelmingly the most frequent method among both males (70.1%) and females (71.0%). Prescription medications were frequently present: hypnosedatives (23.6%), antidepressants (19.5%), and antipsychotics (8.4%). Self-poisoning cases were significantly more likely to have antidepressants (odds ratio: 4.2) and opioids (4.9) present, but less likely to have cannabis (0.3). Methamphetamine-related suicide makes a large contribution to methamphetamine-related death and represents a substantial clinical and public health problem.

The study aimed to determine the clinical characteristics of fatal methamphetamine-related stroke in Australia, 2009-2015. There were 38 cases, 60.5% male, with a mean age of 40.3 years. In no case was there evidence that this was the first time methamphetamine had been used by the decedent, and 52.6% had known histories of injecting drug use. The stroke was hemorrhagic in 37 of 38 cases. In 21.1% of cases, the stroke was purely parenchymal and, in 18.4%, involved purely the subarachnoid space. A ruptured berry aneurysm was present in 31.6% and in 68.8% of initial subarachnoid hemorrhages. There was evidence of systemic hypertension in 8 of 25 cases in which full autopsy findings were available. With increased use of methamphetamine, there is a high probability of increased hemorrhagic stroke incidence among young people. In cases of fatal hemorrhagic stroke among young cases presenting to autopsy, the possibility of methamphetamine use should be borne in mind.

Background Methamphetamine dependence is a major public health problem. This study examined the nature, and extent, of cardiovascular disease amongst cases of methamphetamine-related death in Australia, 2009–2015. Methods Analysis of 894 cases of methamphetamine-related death with full autopsy reports retrieved from the National Coronial Information System. Results The mean age was 37.9 yrs (range 15–69 yrs) and 78.5% were male. A quarter (26.3%) of cases had enlarged hearts and left ventricular hypertrophy was diagnosed in 18.9%. Severe coronary artery disease was present in 19.0%, the left coronary artery being the vessel most frequently stenosed (16.6%). Replacement fibrosis (evidence of earlier ischaemic events) in the heart muscle was observed in 19.8% of cases, and cardiomyopathy was diagnosed in 5.5%. Histological evidence of hypertension was observed in 32.7% of cases. With the exception of cardiomyopathy, equally common amongst both sexes, cardiovascular disease was more common amongst males, and those aged >35yrs. Clinically significant levels of cardiovascular disease were also observed amongst cases where the cause of death was not attributed to cardiovascular disease: cardiomegaly (19.3%), left ventricular hypertrophy (14.6%), severe coronary artery disease (9.4%), replacement fibrosis (14.4%), cardiomyopathy (3.3%). Conclusions Cardiovascular disease was highly prevalent, despite the relatively young age of cases. With methamphetamine use increasing rapidly in major regions, cardiovascular disease and cardiovascular-related death will likely increase amongst methamphetamine users.

Background: To detect attention deficit hyperactivity disorder (ADHD) in treatment seeking substance use disorders (SUD) patients, a valid screening instrument is needed.Objectives: To test the performance of the Adult ADHD Self-Report Scale V 1.1(ASRS) for adult ADHD in an international sample of treatment seeking SUD patients for DSM-IV-TR; for the proposed DSM-5 criteria; in different subpopulations, at intake and 1-2 weeks after intake; using different scoring algorithms; and different externalizing disorders as external criterion (including adult ADHD, bipolar disorder, antisocial and borderline personality disorder).Methods: In 1138 treatment seeking SUD subjects, ASRS performance was determined using diagnoses based on Conner's Adult ADHD Diagnostic Interview for DSM-IV (CAADID) as gold standard.Results: The prevalence of adult ADHD was 13.0% (95% CI: 11.0-15.0%). The overall positive predictive value (PPV) of the ASRS was 0.26 (95% CI: 0.22-0.30), the negative predictive value (NPV) was 0.97 (95% CI: 0.96-0.98). The sensitivity (0.84, 95% CI: 0.76-0.88) and specificity (0.66, 95% CI: 0.63-0.69) measured at admission were similar to the sensitivity (0.88,95% CI: 0.83-0.93) and specificity (0.67,95% CI: 0.64-0.70) measured 2 weeks after admission. Sensitivity was similar, but specificity was significantly better in patients with alcohol compared to (illicit) drugs as the primary substance of abuse (0.76 vs. 0.56). ASRS was not a good screener for externalizing disorders other than ADHD.Conclusions: The ASRS is a sensitive screener for identifying possible ADHD cases with very few missed cases among those screening negative in this population. (C) 2013 Elsevier Ireland Ltd. All rights reserved.

Relationships among attempted suicide, nonsuicidal self-harm, and physical assault were examined in 400 regular users of heroin and/or psychostimulants. Twenty-eight percent had episodes of nonsuicidal self-harm, 32% had attempted suicide, and 95% had been violently assaulted. The number of suicide attempts and nonsuicidal self-harm incidents were correlated (ρ = 0.44). There were also significant correlations between the number of assaults and nonsuicidal self-harm incidents (ρ = 0.17), and suicide attempts (ρ = 0.27). The mean age onset for non-suicidal self-harm (18.9 yrs) was significantly younger than that of initial suicide (22.3 yrs). The age at initial physical assault (16.0yrs) was significantly younger than that of nonsuicidal self-harm and initial suicide attempt. Screening for all forms of violence appears warranted when determining suicide risk for this population.

The major physical and psychological health effects of methamphetamine use, and the factors associated with such harms.Comprehensive review.Physical harms reviewed included toxicity and mortality, cardiovascular/cerebrovascular pathology, dependence and blood-borne virus transmission. Psychological harms include methamphetamine psychosis, depression, suicide, anxiety and violent behaviours.While high-profile health consequences, such as psychosis, are given prominence in the public debate, the negative sequelae extend far beyond this. This is a drug class that causes serious heart disease, has serious dependence liability and high rates of suicidal behaviours.The current public image of methamphetamine does not portray adequately the extensive, and in many cases insidious, harms caused.

Aim : To ascertain the demographic characteristics, circumstances of death, toxicological results, and major autopsy findings of cocaine-related fatalities. Design : Inspection of the coronial records of all cocaine-related deaths that occurred in New South Wales, Australia between 1 January 1993 and 31 December 2002. Setting : New South Wales, Australia. Findings : 146 cases were identified. Cocaine was implicated in the direct cause of death in 86% of cases, an antecedent cause in 8% and a significant condition contributing to death in 7%. The mean age of decedents was 34.1years, and 84% were male. Half were employed, and 26% were in professional employment. The predominant route of administration was injection (86%), however nasal (8%), oral (3%), smoking (1%), and anal (1%) administration were all recorded. The most common location of death was a private home (53%). No intervention occurred prior to death in 82% of cases. The median blood benzoylecgonine concentration was 0.40 mg/L (range 0.00–20.00 mg/L). Cases had a mean of 3.5 drugs, with morphine (79%) the most common co-occurring drug. In 5% of cases cocaine was the sole drug detected. Cardiac pathology was noted in 57% of cases, most commonly coronary artery atherosclerosis (39%) and cardiac hypertrophy (14%). In 15% of cases moderate to severe arterial occlusion was noted. Cerebrovascular pathology was noted in 22% of cases, most commonly cerebrovascular atherosclerosis (10%). Conclusions : Cocaine-related deaths are a significant clinical problem in New South Wales.

This study aimed to examine the physical and psychological harms of cocaine use and investigate the role of injecting versus non-injecting routes of administration in the severity of such harms. Two hundred and twelve cocaine users from inner-city and south-western Sydney were administered a structured interview containing sections on demographics, drug treatment history, drug use history, cocaine use patterns, cocaine dependence and physical and psychological problems associated with cocaine use. Serious physical and psychological symptoms were prevalent among both injecting and non-injecting cocaine users. The prevalence and extent of symptoms was greater among injecting cocaine users, however route of administration did not prove to be a significant independent predictor of harm when other factors, such as frequency of use and level of dependence, were taken into account. While the level of physical and psychological harm was greater among cocaine injectors, it would appear that factors engendered by injecting, such as more frequent use and higher levels of dependence, result in higher levels of harm, rather than the route of administration per se. Physical and psychological problems were also reported among infrequent users, suggesting that cocaine can cause harm irrespective of frequency or method of use. Harm reduction initiatives should be targeted towards all cocaine users, not just those who seek treatment for dependence or present with acute medical complications.

Aim To investigate the frequency of non-fatal cocaine overdose, and responses to overdoses, among injecting and non-injecting cocaine users. Design Cross-sectional study. Setting Sydney, Australia. Participants Two hundred current cocaine users. Measurements Structured interview. Findings Thirteen per cent of the sample had overdosed on cocaine, 7% in the preceding 12 months. Cocaine injectors were more likely to have overdosed, both ever (17 ∨ 6%) and in the preceding 12 months (9 ∨ 3%). The most common symptoms of overdose were palpitations (68%), intense sweating (44%) and seizures (40%). The use of other drugs in combination with cocaine prior to the most recent overdose was prevalent (64%), most commonly opioids (40%), alcohol (24%) and cannabis (24%). Those who had overdosed were more likely to be female, had longer cocaine use careers, had used more cocaine in the preceding month and preceding 6 months, had higher levels of cocaine dependence and more extensive polydrug use. Twenty-four per cent had witnessed a cocaine overdose, 13% in the preceding 12 months. Injectors were more likely to have witnessed overdoses, both ever (35% ∨ 8%) and in the preceding 12 months (20% ∨ 3%). Conclusions Experience of, and exposure to, overdose were not rare events. Cocaine users need to be aware of the possibility and nature of overdose, and that cocaine overdose can occur irrespective of method of use. There is a need to emphasise the potential danger of combining cocaine with other drugs.

A striking finding of the Illicit Drug Reporting System (IDRS) in recent years has concerned the emergence in Sydney of a number of different forms of potent methamphetamine. This paper demonstrates the operation of the IDRS in detecting and documenting an increase in both the availability and use of these forms of methamphetamine in Sydney, and Australia more widely, since 1998. Data from different components of the IDRS are utilized to propose that there are currently at least three forms of methamphetamine available in Sydney that are considered by the market to be distinct commodities: methamphetamine powder ('speed'), base methamphetamine ('base') and crystalline methamphetamine ('ice'/'shabu'/'crystal meth'). Base and ice are more potent forms of methamphetamine than speed, and international experience, along with preliminary data obtained from the IDRS, suggest that their use is associated with harms in a number of domains.

This paper describes trends in the price, purity, availability and use of cocaine in Sydney, Australia monitored by the Illicit Drug Reporting System (IDRS) between 1996 and 2000. The IDRS monitors illicit drug trends by means of triangulation of data from interviews with injecting drug users (IDU), reports of key informants, and analysis of indicator data. The price of a 'cap' of cocaine fell from 80 Australian dollars in 1997 to 50 Australian dollars in 1998, and remained at the lower price in subsequent years. Cocaine purity was high in all years (range 50-64%), and was highest in the 1997-1998 period. The availability of cocaine and its use by IDU increased substantially, 1997 and 1998, and remained high in subsequent years. The median number of cocaine use days also increased substantially between 1997 (4 days) and 1998 (25 days), and remained at higher levels than prior to 1998 in subsequent years. Cocaine use was primarily of powder, by injection, and strongly associated with existing heroin injectors. The availability and use of crack remained rare in Sydney. Use of cocaine among IDU was associated with more frequent injections, more injection-related health problems, higher levels of needle sharing, and higher levels of criminality. It is concluded that the use and availability of cocaine in Sydney increased substantially between 1997 and 1998, and has remained entrenched in the Sydney illicit drug market. The regular and formal monitoring of illicit drug trends enabled substantial changes in the cocaine market in Sydney to be detected, and the information to be fed back to the health and law enforcement sectors.

Background In response to concern about whether mixing caffeinated energy drinks with alcohol (AED) increases alcohol consumption and related harm, and the role of industry in this debate, we conducted a comprehensive review of the research evidence on the effects of AED and documented industry involvement in this research. Method A systematic review of 6 databases. Studies must have examined the effect of consuming alcohol with energy drinks (ED) or caffeine on alcohol-related outcomes. Results 62 studies were identified; 29 were experiments, 9 had industry ties (8 with Red Bull GmbH). Young adults who consumed AED drank more alcohol and experienced more alcohol-related harm than other drinkers. There was insufficient evidence to conclude that AED led to increased alcohol consumption or altered the nature of alcohol-related harm. However, AED consumers reported that AED increased stimulation and alertness, offset fatigue from drinking, and facilitated drinking. Experimental research also found that combining ED or caffeine with alcohol increased stimulation and alertness, offset alcohol-related fatigue and increased the desire to keep drinking. It did not change BAC, perceived intoxication, perceived impairment and it did not reverse alcohol-induced impairment on simple psychomotor tasks. Combining ED/caffeine with alcohol reduced alcohol-induced impairment on some but not all aspects of complex tasks. Although few in number, studies with industry ties presented contrary evidence. Conclusion A growing body of evidence suggests that AED may facilitate drinking and related harms via its effects on intoxication but a causal link needs to be confirmed. The influence of industry involvement in this area of research needs to be monitored.

Borderline personality disorder (BPD) and substance use disorders (SUDs) often co-occur, partly because they share risk factors. In this international multicenter study, risk factors for BPD were examined for SUD patients. In total, 1,205 patients were comprehensively examined by standardized interviews and questionnaires on psychiatric diagnosis and risk factors, and it was found that 1,033 (85.7%) had SUDs without BPD (SUD) and 172 (14.3%) had SUD with BPD (SUD + BPD). SUD + BPD patients were significantly younger, more often females and more often diagnosed with comorbid adult attention deficit/hyperactivity disorder. SUD + BPD patients did not differ from SUD patients on most risk factors typical for SUD such as maternal use of drugs during pregnancy or parents having any SUD. However, SUD + BPD patients did have a higher risk of having experienced emotional and physical abuse, neglect, or family violence in childhood compared to SUD patients, suggesting that child abuse and family violence are BPD-specific risk factors in patients with SUDs. (C) 2015 S. Karger AG, Basel

Attention deficit hyperactivity disorder (ADHD) is a known risk factor for substance use disorder (SUD); however, the potential additive contribution of comorbid ADHD to drug-specific dependence in SUD populations is largely unknown. The current study aimed to assess this association between ADHD symptoms and drug-specific SUD complexity and chronicity.A cross-sectional survey was administered to a convenience sample of 489 adults receiving SUD treatment at 16 Australian drug and alcohol treatment centres between September 2010 and August 2011. Participants were screened for adult ADHD symptoms using the Adult ADHD Self-Report Scale. Associations between ADHD screening status and drug-specific SUD complexity and chronicity were assessed using multivariate logistic and modified Poisson regression analysis, controlling for a range of potential confounders.Overall, 215 (44%) patients screened positive for concurrent adult ADHD and SUD. After Simes' correction, a significant positive association was observed between ADHD screening status and current amphetamine SUD (odds ratio (OR) = 1.85; 95% confidence interval (CI): 1.19-2.36). Patients who screened positive for ADHD were significantly more likely to report SUD history for heavy alcohol use (OR = 2.05; 95% CI: 1.21-3.45) and amphetamine (OR = 1.96; 95% CI: 1.26-3.06) as well as significantly increased risk of moderate (3-4 years) duration for benzodiazepine and amphetamine SUDs and long (≥5 years) duration for alcohol, opiates other than heroin or methadone, and amphetamine SUDs.The findings provide evidence that there is increased drug dependence complexity and chronicity in treatment-seeking SUD patients who screen positively for ADHD, specifically for amphetamine, alcohol, opiates other than heroin or methadone, and benzodiazepines.

An investigation into whether or not the level of harm associated with injecting drug use varies depending on the drug that is injected was conducted among 151 primary heroin injectors and 145 primary amphetamine injectors. Compared to primary amphetamine injectors, primary heroin injectors were more dependent on their primary drug, had poorer social functioning, and had recently exhibited a higher degree of criminal behaviour. There were no differences between the two groups in terms of the prevalence of needle sharing, their health, or their psychological functioning, despite the amphetamine users being significantly younger and having used less frequently. It is concluded that while there are some harms that are attributable to injecting per se, the type of drug that is injected does play a mediating role in the relationship between injecting drug use and its associated harm.

Aims. To assess in current injecting heroin and amphetamine users to what extent their history of injecting represents a transition from amphetamine to heroin. Design. Cross-sectional survey. Setting. Sydney, Australia. Participants. One hundred and fifty-one primary heroin injectors and 145 primary amphetamine injectors recruited through advertisements, needle exchanges, methadone maintenance clinics and by word of mouth. Findings. Six major transition patterns were detected: heroin-heroin (n = 61), amphetamines-heroin (n = 60), heroin-amphetamines-heroin (n = 30), amphetamines-amphetamines (n = 80), amphetamines-heroin-amphetamines (n = 41) and heroin-amphetamines (n = 24). A logistic regression analysis predicting presence or absence of a transition from the original primary drug indicated that length of injecting career, years of education and original drug injected were independent predictors. Thus, the longer the injecting career, the greater the likelihood of a transition. If the original drug injected was amphetamine, the greater the likelihood of transition; and the more prior years of education, the lower the chances of a transition. Conclusions. While there was a small preponderance of movement from primary amphetamine injecting to primary heroin injecting, there was also movement in the other direction. Heroin use is not necessarily a stable endpoint for injecting careers.

The extent to which the onset of criminality with respect to heroin use accounts for heterogeneity within a heroin-using population was investigated among 400 community and incarcerated methadone maintenance patients. Those for whom crime preceded heroin use (primary antisocials) were younger and more likely to be male than those for whom heroin use preceded crime (secondary antisocials). Primary antisocials were also more likely to have committed violent crime and to qualify for a diagnosis of antisocial personality disorder (ASPD). It is concluded that taking the order of onset of heroin use and criminality into account may reduce the risk of overdiagnosing ASPD among this population and help clarify the relationship between drug use and crime.

Aims. To examine the drug use and injection risk-taking among incarcerated methadone maintenance (MM) patients; to determine the impact of a diagnosis of antisocial personality disorder (ASPD) on prison-based MM treatment; to compare incarcerated patients with community patients. Design. Structured interview. Settings. New South Wales (NSW) prisons and community methadone maintenance (MM) units. Participants. One hundred incarcerated MM patients and 183 community MM patients. Measurements. Subjects were interviewed about drug use and needle risk-taking in the previous 6 months, and assessed for a diagnosis of ASPD. Findings. Heroin had been used by 38% of prison MM patients in the 6 months prior to interview, on a median of 4.5 days. Forty-four per cent of prison patients had injected a drug in the preceding 6 months. A third (32%) of prison subjects had borrowed used injecting equipment within the preceding 6 months, and 35% had lent used injecting equipment to others. Community patients were more likely to have injected a drug in the preceding 6 months (84% vs. 44%), to have used heroin (72% vs. 38%) and to have done so more frequently (20 vs. 4.5 days). Prisoners, however, were more likely to have borrowed (32% vs. 15%) and lent (35% vs. 21%) injecting equipment in that time. While injecting at lower rates than their community counterparts, the injecting occasions of prisoners were of much higher levels of risk. A diagnosis of ASPD was unrelated to both drug use and needle risk-taking. Conclusions. Incarcerated patients injected less frequently than community patients, but had higher levels of needle risk-taking.

The proposed two-factor structure of the Psychopathy Checklist (Revised) was assessed by confirmatory factor analyses on a sample of 376 community and prison based methadones maintenance patients. Confirmatory factor analyses indicated that the two-factor model proposed by previous researchers did not fit well with the data from this population. Exploratory analyses extracted five interpretable factors, three psychological factors (glibness/manipulative, callousness, irresponsibility), and two behavioral factors (criminal behaviors, promiscuity), which accounted for 61% of the variance. The data provided support for the psychometric reliability of the PCL-R, as indicated by a Chronbach's alpha of 0.83, weighted kappas for concordance between raters ranging from 0.51 to 1.00, and 100% agreement on diagnoses of psychopathy between raters. The data indicate that a two-factor structure does not adequately capture the dimensions of psychopathy in this population. While the factors do fall into distinct psychological and behavioral dimensions, more than two general factors are required to describe the dimensions of psychopathy.

Impulsivity and consequent risk-taking are features of both Attention Deficit Hyperactivity Disorder (ADHD) and substance use disorder (SUD). To date there are no data on the impact of comorbid ADHD on the likelihood and frequency of risk-taking behaviour among individuals with SUD. The current study aimed to examine drug-related, sexual and driving-related risk behaviours in people seeking treatment for SUD with co-occurring symptoms of Attention Deficit Hyperactivity Disorder (ADHD), taking into account potential confounders. 489 Australian adult SUD treatment seekers were administered a structured interview assessing demographics, drug use and SUD treatment history, psychiatric history, self-reported adult ADHD symptoms and self-reported drug-related, sexual and driving-related risk behaviours. Almost a third (32%) screened positive for adult ADHD symptoms with onset prior to age 12. Those screening positive were more likely to report early onset (

Objective There is a paucity of research as to how injecting drug users (IDU) might be differentiated in the severity of their violent offending. This paper reported on the risks associated with severity, as well as issues around severity classification and the impact on observed relationships with known major risk factors. Method A cross-sectional survey administered to 300 IDU, who had injected drugs weekly or more in the past 12 months. A structured questionnaire addresses potential substance use and early-life risk factors for violent offending. Results Four severity groups were identified: non-violent (24%), low (34%), moderate (22%) and high (20%) level offenders. Higher severity groups had more prevalent and more severe histories of childhood maltreatment, child psychopathology and dysfunctional trait personalities, as well as more severe substance use problems than low-level and non-violent IDU. Regression analyses found that only two of 15 risk factors remained uniformly associated with violent offending across the four classification schemes tested: (1) having committed violence under the influence and (2) having more impulsive trait personalities. Conclusions Disaggregating IDU into distinct subgroups showed that the extent and severity of predispositional and substance use risk exposure corresponded to the severity of violent offending. There is a need to establish a systematic method for classifying severity given that there were clinically meaningful differences between groups which require further exploration and replication, and because there was extensive variation in the risks associated with severity across schemes.

It remains unclear whether violent offending among injecting drug users (IDU) is the direct result of drug use factors or whether they are predisposed to violent behaviour from childhood. The current study sought to identify substance use and early-life correlates of lifetime violent offending among IDUs and to determine what risks contributed to recent violent offending.Three hundred community-based regular IDUs were administered a face-to-face cross-sectional structured interview examining correlates of violent offending.One-third (34%) of IDUs had committed violence in the past 12 months, 42% more than 12 months ago and 24% had never been violent. Predispositional and substance use risk profiles were poorer among IDUs who had been violent, but many of these risks were even more prevalent and severe among those who had been violent in the past 12 months. Multinomial logistic regression found that IDUs who had been violent in the past 12 months had greater polysubstance and higher trait aggressive personalities than the other IDUs, whereas they were further differentiated from non-recent violent IDUs in having more involvement in drug dealing and more likely to screen positive for conduct disorder.Drug use factors alone did not adequately explain the likelihood of violent offending among IDUs. Instead, there appeared to be complex interactions between early-life risks and substance use which created a liability to violent offending, and the level of exposure to these risks appeared to explain differences in violent offending patterns.

Background Institutional monographs/medical textbooks mention seizures as a neurological complication of cocaine, but no systematic reviews (SRs) have been published on this issue. We aimed to conduct a SR of the literature on the relationship between cocaine use and seizures and to summarize the biological plausibility of that relationship. Methods The pathophysiological mechanisms that may underlie an association between cocaine and seizures were summarized; a SR was then performed using three databases (EMBASE, Medline, PsycINFO) and the Cochrane-library to search for published papers (1980–2012) aimed at quantifying the associations between cocaine use and seizures. The inclusion criteria for selection were: articles based on clinical trials, cohort, case-control (CC) or cross-sectional (CS) studies, participants ≥14 years old and not pregnant, and use of cocaine in the last 72 h. Information was extracted, evaluated and cross-checked independently by two researchers. Results Of the 1243 potentially relevant articles initially identified; one CC and 22 CS studies were finally selected. The CC study did not find cocaine use to be a risk-factor for seizures. In addition to the limitations of the CS design, these studies had important methodological weaknesses and biases. Conclusions Despite its biological plausibility, no rigorous scientific evidence supports a causal relationship between cocaine use and seizures. The misinterpretation of the role of cocaine may have important implications in medical services. Well-conducted studies are urgently needed.

Altres ajuts: The ICASA Foundation (www.adhdandsubstanceabuse.org) developed the IASP study, and arranged with its participating institutes that each of these institutes would seek funding for their regional process and data sampling efforts. The ICASA Network sought funding for the central organization costs. Altres ajuts: MISSSI/PND0080-2011 Available studies vary in their estimated prevalence of attention deficit/hyperactivity disorder (ADHD) in substance use disorder (SUD) patients, ranging from 2 to 83%. A better understanding of the possible reasons for this variability and the effect of the change from DSM-IV to DSM-5 is needed. A two stage international multi-center, cross-sectional study in 10 countries, among patients form inpatient and outpatient addiction treatment centers for alcohol and/or drug use disorder patients. A total of 3558 treatment seeking SUD patients were screened for adult ADHD. A subsample of 1276 subjects, both screen positive and screen negative patients, participated in a structured diagnostic interview. Prevalence of DSM-IV and DSM-5 adult ADHD varied for DSM-IV from 5.4% (CI 95%: 2.4-8.3) for Hungary to 31.3% (CI 95%:25.2-37.5) for Norway and for DSM-5 from 7.6% (CI 95%: 4.1-11.1) for Hungary to 32.6% (CI 95%: 26.4-38.8) for Norway. Using the same assessment procedures in all countries and centers resulted in substantial reduction of the variability in the prevalence of adult ADHD reported in previous studies among SUD patients (2-83%→ 5.4-31.3%). The remaining variability was partly explained by primary substance of abuse and by country (Nordic versus non-Nordic countries). Prevalence estimates for DSM-5 were slightly higher than for DSM-IV. Given the generally high prevalence of adult ADHD, all treatment seeking SUD patients should be screened and, after a confirmed diagnosis, treated for ADHD since the literature indicates poor prognoses of SUD in treatment seeking SUD patients with ADHD.

This study aimed to compare emotion perception and social inference in opioid maintenance patients with abstinent ex-users and non-heroin-using controls, and determine whether any deficits in could be accounted for by cognitive deficits and/or risk factors for brain damage.Case-control.Sydney, Australia.A total of 125 maintenance patients (MAIN), 50 abstinent opiate users (ABST) and 50 matched controls (CON).The Awareness of Social Inference Test (TASIT) was used to measure emotion perception and social inference. Measures were also taken of executive function, working memory, information processing speed, verbal/non-verbal learning and psychological distress.After adjusting for age, sex, pre-morbid IQ and psychological distress, the MAIN group was impaired relative to CON (β = -0.19, P 0.05) and ABST (β = -0.19, P 0.05) on emotion perception and relative to CON (β = -0.25, P 0.001) and ABST (β = -0.24, P 0.01) on social inference. In neither case did the CON and ABST groups differ. For both emotion perception (P 0.001) and social inference (P 0.001), pre-morbid IQ was a significant independent predictor. Cognitive function was a major predictor of poor emotion perception (β = -0.44, P 0.001) and social inference (β = -0.48, P 0.001). Poor emotion recognition was also predicted by number of heroin overdoses (β = -0.14, P 0.05). Neither time in treatment or type of maintenance medication (methadone or buprenorphine) were related to performance.People in opioid maintenance treatment may have an impaired capacity for emotion perception and ability to make inferences about social situations.

Attention deficit hyperactivity disorder (ADHD) is a highly comorbid disorder, and, as such, there is much confusion surrounding the exact role it plays in increasing susceptibility to harmful behaviors. To date, no studies have examined the impact of adult ADHD on severity of substance use, while controlling for comorbid psychiatric disorders. Using a structured cross-sectional survey of 269 regular polysubstance users in Sydney, Australia, this study aimed to determine whether ADHD was a risk factor for more severity of substance use, and whether this effect remained when Borderline Personality Disorder (BPD) and Conduct Disorder (CD) diagnoses were controlled for. Rates of psychiatric disorders were high, with 45% meeting criteria for ADHD, 47% for BPD, and 64% for CD. While bivariate analyses showed that adult ADHD was significantly associated with all indicators of drug use severity, this effect did not remain once confounding factors were controlled. While ADHD accounted for very few differences in drug use severity, CD was found to independently predict all drug use severity indicators, including earlier onset, greater polydrug use, more frequent stimulant use, and greater risk for stimulant dependence. These results suggest that CD, rather than ADHD, is the strongest predictor of differences in patterns of drug use severity. The extensive comorbidity among this sample highlights the great potential for misattributing drug use risks to ADHD, and that it is important to account for psychiatric comorbidity to properly discern what underlying variables account for differences in harmful drug use behaviors.

To determine age-related patterns of drug use initiation, drug sequencing and treatment entry among regular psychostimulant users.Cross-sectional study of 269 regular psychostimulant users, administered a structured interview examining onset of use for major licit and illicit drugs.The mean age at first intoxication was not associated with age or gender. In contrast, younger age was associated with earlier ages of onset for all of the illicit drug classes. Each additional year of age was associated with a 4 month increase in onset age for methamphetamine, and 3 months for heroin. By the age of 17, those born prior to 1961 had, on average, used only tobacco and alcohol, whereas those born between 1986 and 1990 had used nine different drug classes. The period between initial use and the transition to regular use, however, was stable. Age was also negatively correlated with both age at initial injection and regular injecting. Onset sequences, however, remained stable. Consistent with the age-related patterns of drug use, each additional year of age associated with a 0.47 year increase in the age at first treatment.While the age at first intoxication appeared stable, the trajectory through illicit drug use was substantially truncated. The data indicate that, at least among those who progress to regular illicit drug use, younger users are likely to be exposed to far broader polydrug use in their teens than has previously been the case.

To examine the literature pertaining to the diversion and misuse of pharmaceutical stimulants.Relevant literature was identified through comprehensive MEDLINE, EMBASE and PubMed searches.The evidence to date suggests that the prevalence of diversion and misuse of pharmaceutical stimulants varies across adolescent and young adult student populations, but is higher than that among the general population, with the highest prevalence found among adults with attention deficit-hyperactive disorder (ADHD) and users of other illicit drugs. Concerns that these practices have become more prevalent as a result of increased prescribing are not supported by large-scale population surveys. Information on trends in misuse in countries where there have been recent increases in prescription and consumption rates, however, is limited. Little is known about the frequency and chronicity of misuse, or the extent of associated harms, particularly among those populations, i.e. adolescents, young adult student populations, those with ADHD and illicit drug users, where abuse may be more likely to occur.Continued monitoring of the diversion and misuse of pharmaceutical stimulants is of major clinical importance. Despite recognition of the abuse liability of these medications, there is a paucity of data on the prevalence, patterns and harms of diversion and misuse among populations where problematic use and abuse may be most likely to occur (e.g. adolescents, young adults, illicit drug users). Comprehensive investigations of diversion and misuse among these populations should be a major research priority, as should the assessment of abuse and dependence criteria among those identified as regular users.

Background To compare the cognitive performances of maintenance patients (MAIN), abstinent ex-users (ABST) and healthy non-heroin using controls (CON). Methods Case control study of 125 MAIN (94 subjects maintained on methadone, 31 on buprenorphine), 50 ABST and 50 CON. Neuropsychological tests measuring executive function, working memory, information processing speed, verbal learning and non-verbal learning were administered. Results There were no differences between the cognitive profiles of those maintained on methadone or buprenorphine on any administered test. After controlling for confounders, the MAIN group had poorer performance than controls in six of the 13 administered tests, and were poorer than the ABST group in five. The MAIN group exhibited poorer performance in the Haylings Sentence Completion, Matrix Reasoning, Digit Symbol, Logical Memory (immediate and delayed recall), and the Complex Figure Test (immediate recall). There were no differences between the ABST and CON groups on any of the administered tests. Conclusions Poorer cognitive performance, across a range of test and domains, was seen amongst maintenance patients, regardless of their maintenance drug. This is a group that is likely might benefit from approaches for managing individuals with cognitive and behavioural difficulties arising from brain dysfunction.

To estimate the prevalence, nature and correlates of symptomatology consistent with adult attention deficit hyperactivity disorder (ADHD) among illicit psychostimulant users.Cross-section survey.Sydney, Australia.269 regular illicit psychostimulant users.Structured interview assessing demographics, drug use and treatment history, psychostimulant dependence and self-reported symptoms consistent with adult ADHD.Almost half (45%) screened positive for adult ADHD (ADHD+). Symptoms of inattention (90%) were more prevalent than symptoms of hyperactivity/impulsivity (57%). Of those who screened positive for adult ADHD, only 17% had received a prior diagnosis of ADHD. The ADHD+ group differed from other participants in several respects: an earlier initiation of substance use and injecting drug use; more extensive polydrug use; a higher frequency of recent stimulant use and injecting drug use; a greater likelihood of stimulant dependence; and a greater likelihood of having received treatment for drug dependence. After controlling for other factors, screening positive for ADHD was associated independently with fewer years of education, earlier initiation of regular tobacco use and more extensive life-time polydrug use.Clinicians should be aware of the potential for patients of drug and alcohol treatment services to have undiagnosed and/or untreated ADHD that may impact on their compliance with, and retention in, treatment.

To determine whether there were differences in drug use profiles, psychopathology, and severity of violence among regular illicit drug users in respect to the order of onset of drug use and violence.A cross-sectional survey utilising self-report data was administered to 327 regular illicit drug users in Sydney, Australia.Those who first committed violent crime prior to illicit drug use were found to have more serious offending patterns (greater frequency, arrest for more serious violence, earlier age of onset, and more weapon use). Being male, having a history of child abuse and greater severity of conduct disorder were independent predictors of committing violence before drug use.Whilst the nature of the data does not permit causative conclusions, it appears that the order of onset of illicit drug use and violent crime is associated with heterogeneous offending patterns. Early onset violence was associated with more severe violent crimes in later adulthood, whereas violence which proceeded drug use was more strongly linked to systemic risks. The findings have implications for early intervention among children with conduct disorder and also for using drug and alcohol treatment services to reduce specific risks associated with violence.

The aim of this study is to determine the prevalence of risk factors and possible symptoms of cardiovascular disease among regular psychostimulant users.A total of 239 regular psychostimulant users were administered a structured interview on health and cardiovascular disease symptoms.Thirty per cent had a family history of cardiovascular disease, 37% had sought treatment for possible symptoms of cardiovascular disease and 14% had been prescribed medications for symptoms of possible cardiovascular problems. The most commonly reported severe symptoms were: chronic shortness of breath (17%), chest pains (15%), palpitations (14%), chronic fatigue (13%) and dizziness/loss of consciousness (11%). Chest pains had been experienced on at least a weekly basis in the past 12 months by 13%. All symptoms occurred at significantly higher levels after the initiation of psychostimulant use. Higher levels of psychostimulant dependence were positively correlated with the number of frequently occurring symptoms (r = 0.23). Independent correlates of higher levels of frequently occurring symptoms were higher level of psychostimulant dependence, higher levels of alcohol dependence, a family history of cardiovascular disease and a diagnosis of cardiovascular disease.While a great deal of clinical attention has been given to the sequelae of psychostimulant use, such as psychosis, the potential effects upon the cardiovascular systems of users are worthy of specific public health attention.

Aims To determine the comparative levels of violent offending and victimization among regular methamphetamine and heroin users. Design Cross-sectional Setting Sydney, Australia. Participants A total of 400 regular methamphetamine (METH) and heroin (HER) users (118 methamphetamine users: METH; 161 regular heroin users: HER; 121 regular users of both: BOTH). Findings Eighty-two per cent reported a life-time history of committing violent crime, 41% in the past 12 months. There were no group differences in life-time violence, but the METH group were significantly more likely than the HER group to have committed violence in the past 12 months (odds ratio 1.94). Nearly all (95%) reported that they had been a victim of violent crime, 46% in the preceding 12 months, with no group differences. Those who had committed a violent crime in the past 12 months were 13.23 times more likely to have been a victim in that period. The majority believed it unlikely that they would be a victim of (78%), or commit (87%), a violent crime in the next 12 months. Conclusions Regular methamphetamine use appears to be associated with an increased risk of violent offending, but not victimization, compared with heroin use. Language: en

AIM: To examine the demographic characteristics, circumstances, toxicology and major organ pathology of MDMA-related deaths in Australia. METHODS: Retrospective review of cases in which MDMA was a cause of death, as identified from the National Coronial Information System. RESULTS: 82 cases over a 5-year period were identified. The majority of decedents were male (83%), with a median age of 26 years. Deaths were predominantly due to drug toxicity (82%), with MDMA the sole drug causing death in 23% of cases, and combined drug toxicity in 59% of cases. The remaining deaths (18%) were primarily due to pathological events/disease or injury, with MDMA a significant contributing condition. Cardiovascular pathology, typically atherosclerosis, was detected in 58% of decedents, with moderate-severe atherosclerosis in 23% of cases. The prevalence of such pathology is higher than that expected among similarly aged members of the general population. Cerebrovascular pathology, primarily cerebral haemorrhage and hypoxic damage, was present in 12% of cases. CONCLUSIONS: MDMA has contributed to a clinically significant number of deaths in Australia. The prevalence of cardiovascular pathology was similar to that among methamphetamine and cocaine fatalities. Whilst cardiovascular pathology may reflect the use of other stimulants, the cardiotoxic properties of MDMA have been well-documented. Future studies examining MDMA-related morbidity and mortality in the context of other risk factors are recommended. Overall, the current study highlights the need to educate users about the potential harms of MDMA use, particularly that in conjunction with other stimulants, opioids and alcohol, which are known to increase overall toxicity. Language: en