Tõendusmaterjali kokkuvõte - EvSu Kliiniline küsimus nr 15 Kas kõiki alkoholitarvitamise häirega patsiente tuleb alkoholi ja bensodiasepiinide segakasutuse suhtes hinnata vs mitte hinnata? Kriitilised tulemusnäitajad: uuringumeetodi tundlikkus ja spetsiifilisus, positiivne ja negatiivne ennustatav väärtus Ravijuhendid Kokkuvõte tõendusmaterjali kvaliteedist Antud küsimusele vastamiseks vaadati läbi 1 alkoholi liigtarvitamise preventsiooni juhend ja 10 ravijuhendit. Ükski ravijuhend ei käsitlenud eraldi alkoholitarvitamise häiret ja bensodiasepiinide kasutamist, vaid tõdesid et tihtilugu on alkoholi tarvitamisega häirega koosesinev mitme aine kuritarvitamine (polysubstance abuse). Medinfokeskus teostas lisaotsingu ning teostati lisaotsing ka sekretariaadi liikme poolt. Vt. allpool. Ravijuhendid tuginesid oma soovitustes skriinida mitme aine kuritarvitamise suhtes peamiselt levimusuuringutele, mis näitasid, et paljudel juhtudel kaasneb alkoholi tarvitamisega ka mingi muu aine tarvitamine või esineb suurema tõenäosusega kaasuv psüühikahäire. NICE (2011) nentis, et suitsetamine, alkoholism ja uimastite tarvitamine esinevad tihtilugu koos viidates seminari materjalidele/raamatule (Farrell et al. 2011) ning 2000. aastal UK läbi viidud vaatlusuuringule (Coulthard 2002). Australia (2009) baseerus oma soovituse sõnastamiseks nõrga kvaliteediga tõendusmaterjalil tõendus: IV, mis on tõendus ekspertkomitee raportitest, arvamustest, kliinilisest kogemusest (Evidence from expert committee reports or opinions and/or clinical experience of respected authorities): Brecht et al. (2008) kombineerisid 5 longituuduuringu andmed, mis uurisid 10 aasta heroiini, kokaiini, metamfetamiini, marihuaana ja alkoholi kasutamise mustreid primaarselt heroiini (n=629), kokaiini (n=694) ja metamfetamiini (n=474) kasutajate seas. Tulemused näitasid, madalat heroiini, kokaiini ja metamfetamiini sekundaarset kasutamist kuid mõõdukat alkoholi ja marihuaana sekundaarset kasutamist. Degenhardt & Dunn (2008) analüüsisid andmeid 2004a. läbi viidud Austraalia leibkonna uimastite uuringust. Uuring näitas et enamtarvitatav aine oli alkohol, mida tarvitas 95% uuritavatest (n =11,595). Uuringu tulemused näitasid, et 49% GHB tarvitajatest ja 57% ketamiini kasutajatest tarvitasid ka alkoholi. Barett et al. (2006) uurisid 149 uimasteid kasutatavat üliõpilast. Uuringu tulemused näitasid, et alkoholi, tubakat ja kanepit tarvitati tihti üksteisega koos ning koos teiste ainetega. Hii ruut test näitas, et kui alkoholi tarvitati koos alljärgnevate ainetega: kanep, psilosübiin (magic mushrooms),, MDMA, kokaiin, amfetamiin, metüülfenidaat (ps < 0.01) või LSD (p < 0.05) siis alkoholi kasutamine eelnes teiste ainete kasutamisele. Paariviisiline t test näitas et kui alkoholi kombineeriti kokaiini (p < 0.01) või metüülfenidaadiga (p < 0.05), siis olid tarvitatavad alkoholi kogused oluliselt suuremad. McCabe et al. (2006) uurisid US ülikoolis õppivad bakalaureuseõppe üliõpilasi (n=4580). See vaatlusuuring hindas üheaegset mitme aine kuritarvitamist ja alkoholi tarvitamist koos retseptiravimite koostarvitamisega. Tulemused näitasid, et 12 kuu mitme aine kuritarvitamise levimus, mis sisaldas alkoholi tarvitamist ja kuritarvitatavate retseptiravimite tarvitamist oli 12.1% (sisaldades 6.9% mitme aine koos kuritarvitamist). Martin et al. (1996) hindasi samaaegset mitme aine kuritarvitamist (simultaneous polydrug use) 212 probleemse alkoholijooja (problem drinkers) seas. 61% uuritavatest raporteerisid mitme aine samaagset kuritarvitamist. Kõige tihemini esinevad alkoholi/uimasti kombinatsioonid olid alkohol ja kokaiin (60%), alkohol ja marihuaana (51%) ja alkohol ja rahustid (31%). Kõige levinum 3 aine kombinatsioon oli alkohol, kokaiin ja marihuaana (23%). 1
Medinfo ning sekretariaadi liikme poolt leitud tõendusmaterjal oli peamiselt ristläbilõikelised uuringud/vaatlusuuringud. Licht et al. (2012) viisid läbi läbilõikelise uuringu 98 Taani 3,4- methylenedioxymethamphetamine (MDMA) ("Ecstasy") ja hallutsinogeeni kasutaja seas. Tulemused näitasid et mitme aine kuritarvitamine oli sage eriti alkohol ja kanep. Alkoholi ja kanepit kasutati tavaliselt enne, samal ajal või pärast MDMA, LSD ja psilocybin kasutamist. Olthuis et al. (2013) poolt läbi viidud uuring näitas et 75% uuritavatest raporteeris mitme aine kuritarvitamist esmakordsel kokaiini amfetamiini, metamfetamiini, MDMA, heroiini, oopiumi, GHB, ketamiini, psilosübiin (magic mushrooms),meskaliini või PCP tarvitamisel. Mitme aine kuritarvitamine oli vähem levinud alkoholi, tubaka ja kanepi esmatarvitamisel, kuid rohkem levinud kui tarvitati ermakordselt "kangemaid" narkootilisi aineid, kui tarvitati samaaegselt alkoholi, tubakat ja/või kanepit. Austraalia (2009) tõi välja uuringu mis uuris remissiooni määra vastavalt häire tüübile (kuritarvitamis vs sõltuvus), aine tüübile (alkohol vs teised ained) ja mitme aine tarvitamise olemasolule (alkohol või uimasti vs alkohol+uimasti). valmis koosnes 12 297 uuritavast. Uuritavad kes olid kuritarvitajad jätsid suurema tõenäosusega tarvitamise võrreldes sõltuvuse diagnoosiga uuritavatega. Mitme aine koostarvitajad loobusid väiksema tõenäosusega tarvitamist võrreldes vaid ühe aine tarvitajatega (Karno et al. 2008). Nii Australia (2009) kui ka APA (2006) tõid välja uuringuid mis näitasid seosed mitme aine kuritarvitamise ning suurenenud psüühikahäirete esinemise vahel (Degenhardt & Hall 2003; Hien et al. 1997; Kessler et al 1996; McLellan & Druley 1977; Ross et al 1988; Tarter 1990; Webb et al. 1996). Kaks läbivaadatud ravijuhenditest soovitavad mitme aine kuritarvitamise kahtlusel kasutada struktureeritud hindamismeetodeid (Soome 2010; Austraalia 2009). NICE (2011) soovitab mitme aine kuritarvitamise kahtluse korral teostada sülje/uriini analüüs ning käsitleda tarvitatavate ainete tüüpi, sagedust ja manustamis viisi anamneesis. Soome (2010) soovitab oma juhendis kasutada Severity of Dependence Scale (SDS), toetudes ühele uuringule, mille tulemused näitavad et SDS on tundlikkus 97.9%, spetsiifilisus 94.2% ning AUC 0.991. Austraalia (2009) soovitab kasutada koguse-sageduse hinnanguid või struktuurset hindamisvahendit nagu ASSIST, kuid selle kohta viiteid ei esita. Sekretariaadi liikme poolt teostati lisaotsing, et leida uuringuid mis hindaksid Severity of Dependence Scale (SDS) ja ASSIST küsimustiku tundlikkust, spetsiifilisust, positiivset ja negatiivset ennustavat väärtust. Leitud uuringud näitavad, et ASSIST kui ka SDS on hea tundlikkuse ja spetsiifilisusega uuringumeetodid. (Bastiani et al. 2013, Grande et al. 2009; Hides et al. 2009a; Hides et al. 2009;Humeniuk et al. 2008; Iraurgi Castillo et al. 2010; Lundqvist et al. 2011; Martin et al 2006; van der Pol et al 2013). Kokkuvõtte uuringutest vaata Tabel 1. ASSIST (The Alcohol, Smoking and Substance Involvement Screening Test) arendati välja WHO tellimusel rahvusvahelise ainete kuritarvitamisega tegelevate teadlaste grupi poolt. ASSIST on mõeldud kasutamiseks esmatasandil ja üldmetidsiini tasandil (general medical care setting). ASSIST küsimustik on saadaval 11 keeles (inglise, araabia, hiina, pärsia, prantsuse, saksa, hindi, portugali, vene, hispaania ja ukraina). ASSIST küsimustik koosneb küsimustikust, mida viiakse läbi intervjuu vormis, patsiendi vastuste kaartidest (antakse kätte enne küsimuste küsimist), tagasisidelehest, informatsioonilehest. Vt. K15 Lisa 1 ASSIST küsimustik. Tervet ASSIST paketti leiab aadressilt: http://www.who.int/substance_abuse/activities/assist_test/en/ (WHO 2014). SDS (Severity of Dependence Scale) on 5-alapunktiline küsimustik. Kõiki viit alapunkti saab hinnata 4-pallilisel skaalal (0 3). Lõplik punktisumma arvutatakse liites kokku igas alapunktis saadud 2
tulemused. Mida kõrgem punktisumma seda tugevam sõltuvus. SDS võtab täitmiseks hinnanguliselt 1 minuti (WHO 2014). Vt. K15 Lisa 2 SDS küsimustik. Täisküsimustiku leiab siit: http://onlinelibrary.wiley.com/doi/10.1002/9780470693742.app5/pdf Kokkuvõte ravijuhendites leiduvatest soovitustest Antud küsimusele vastamiseks vaadati läbi 1 alkoholi liigtarvitamise preventsiooni juhend (USPSTF 2013) ja 10 ravijuhendit (BAP 2012, NICE 2011, SOOME 2010, NICE 2010a, AUSTRALIA 2009, SAMHSA 2009, WFSBP 2008, NSW 2008, APA 2006, SIGN 2003). Nendest 5 sisaldasid informatsiooni käesoleva küsimuse kohta (NICE 2011, Soome 2010, Australia 2009, SAMHSA 2009, APA 2006). 5 ravijuhendis (BAP 2012, NICE 2010a, WFSBP 2008, NSW 2008, SIGN 2003) ja alkoholi liigtarvitamise preventsiooni juhendis (USPSTF 2013) käesoleva küsimuse kohta informatsiooni ei sisaldunud. Eelpool mainitud ravijuhenditest vaadati läbi teemaga seotud tõenduspõhised uuringud, millest kokkuvõtted on esitatud viidetes tabeli vormis. NICE (2011) ütleb, et tõendusmaterjal näitab, et kliinilise hindamise käigus tuleks hinnata kaasuvat uimastite kuritarvitamist. Hinnata tuleks uimasti tüüpi, manustamise viisi ning kogust ja tarvitamise tihedust. Põhjalikku hindamist tuleks kaaluda täiskasvanutel, kelle AUDIT testi punktisumma on suurem kui 15. AUSTRALIA (2009) ütleb samuti, et patsiente kellel on alkoholi tarvitamise häire (alcohol-use disorder) tuleks skriinida teiste ainete kasutamise suhtes. Antud ravijuhend soovitab hindamiseks kasutada sageduse hinnanguid, või ASSIST küsimustikku. SOOME (2010) ütleb, et mitme aine kuritarvitamisttuleks kahtlustada kui alkoholi tugev tarvitaja või alkoholisõltuvusega inimene näitab üles uimasteid otsivat käitumist, on võõrutusravi käigus bensodiasepiinide tolerantne või kui ilmnevad võõrutuse sümptomid (withdrawal symptoms) kui ravimeid vähendatakse. SOOME (2010) ütleb, et mitme aine kuritarvitaja võõrutusravi peaks sisaldama kuritarvitatava aine kuritarvitamise ja sõltuvuse tasemete hindamist. Sõltuvuse raskust saab hinnata kasutades Sõltuvuse Raskuse Skaalat (Severity of Dependence Scale). APA (2006) soovitab teostada põhjalik kliiniline hinnanag ning integreerida teaduspõhised ravilähenemised (farmakoloogilised ja psühhosotsiaalsed) iga spetsiifilise aine kasutamise häire jaoks. SAMHSA (2009) ütleb, et anamnees peaks sisaldama teiste ainete peale alkoholi tarvitamist, eriti opioidide. Samuti tuleks patsiendil küsida retseptiravimite tarvitamise ja kuritarvitamise kohta. Ravijuhendite soovituste tekstid (inglise keeles): NICE 2011 It is recognised that smoking, drinking and drug taking behaviours cluster together (Farrell et al., 2001) and that excessive drinkers with high AUDIT scores are more likely to have used drugs in the past (Coulthard et al., 2002). Therefore, the evidence suggests that co-existing substance misuse should be assessed. Clinical assessment should include the type of drug and its route of administration, the quantity and the frequency with which it is used. The presence of comorbid substance misuse is associated with poorer outcomes for those with alcohol misuse and the GDG reviewed evidence on this along with the recommendation in the NICE (2007a) guideline on psychosocial management of substance misuse. It was agreed that assessment of comorbid drug misuse should therefore be a part of routine assessment of alcohol misuse. Consideration should begiven to the use of biological testing (for example, of urine or saliva samples) as part of a comprehensive assessment of drug misuse, but clinicians should not rely on it as the sole method of diagnosis and assessment. 3
Consider a comprehensive assessment for all adults referred to specialist alcohol services who score more than 15 on the AUDIT. A comprehensive assessment should assess multiple areas of need, be structured in a clinical interview, use relevant and validated clinical tools (see Section 5.16), and cover the following areas: alcohol use, including: consumption: historical and recent patterns of drinking (using, for example, a retrospective drinking diary), and if possible, additional information (for example, from a family member or carer) dependence (using, for example, SADQ or LDQ) alcohol-related problems (using, for example, APQ) other drug misuse, including over-the-counter medication physical health problems psychological and social problems cognitive function (using, for example, the Mini-Mental State Examination [MMSE]21) readiness and belief in ability to change. AUSTRALIA 2009 All patients with alcohol-use disorders should be screened for other substance use using quantity frequency estimates, or through structured screening instruments such as the ASSIST questionnaire. Strength: D, Evidence: IV SOOME 2010 The treatment of polysubstance abuse must be based on correct diagnosis and assessment of the severity of the state. Polysubstance use should be suspected if a heavy drinker or alcohol dependent person shows drug-seeking behaviour, if tolerance to benzodiazepines is observed during detoxification or if withdrawal symptoms appear when medication is reduced or withdrawn. An aggressive patient demanding a prescription, one obtaining prescriptions from various physicians or guilty of forging prescriptions may be a polysubstance user. At the clinic, a patient suspected of being a polysubstance user (intoxicated and lethargic, with incoordination or memory lapses, reduced inhibition, unpredictable or aggressive behaviour) should be given the required first aid. The patient should be assessed and referred to the emergency room, detoxification or sobering-up station. Further treatment should be ensured. Detoxification of a polysubstance user should include assessment of the stages of intoxicant abuse and dependence. The severity of dependence can be assessed using the Severity of Dependence Scale (SDS) comprising five questions and with drug screens [295, 296]. APA 2006 Many patients entering treatment for a specific substance use disorder abuse more than one substance, and co-occurring nicotine dependence is particularly common. Frequent drug combinations include 1) cocaine and alcohol; 2) cocaine and heroin; 3) heroin and benzodiazepines; 4) alcohol, cocaine, and benzodiazepines; 5) nicotine and any other drug; 6) multiple club drugs 4
(e.g., 3,4-methylenedioxymethamphetamine [MDMA], γ-hydroxybutyrate [GHB], ketamine); 7) club drugs with prescription medications (e.g., MDMA with sildenafil and/or fluoxetine); and 8) opioids, stimulants, sedatives, steroids, and other substances. The severity of abuse of each substance and the motivation to stop using each substance may vary widely in individuals who abuse multiple substances. The best recommendation is for the clinician to do a comprehensive assessment of the patient and integrate the evidence-based treatment approaches, including pharmacological and psychosocial treatments, for each specific substance use disorder. In community population samples studied in the National Comorbidity Survey, individuals with alcohol dependence had high rates of clinically significant depression during their lifetime (men: 24% depression and 11% dysthymia; women: 49% depression and 21% dysthymia). Individuals with bipolar disorder had high rates of alcohol (61%) and other substance (41%) dependence. Treatment-seeking individuals have even higher rates of co-occurring disorders. Use of multiple substances and co-occurring psychiatric and substance use disorders are now so common in treatment settings that these combinations should be expected. Thus, all patients with a substance use disorder should be carefully assessed for the presence of co-occurring psychiatric disorders, including additional substance use disorders. Conversely, patients with identified psychiatric disorders should be routinely assessed for the presence of a co-occurring substance use disorder. SAMHSA 2009 The history also should include use of substances other than alcohol, especially opioids, as well as the patient s history of use, misuse, or abuse of prescription medications. Misuse of opioid medications may complicate or contraindicate treatment with naltrexone. Abuse of sedatives and tranquilizers may complicate detoxification and treatment. More information on co-occurring psychiatric disorders can be found in TIP 42, Substance Abuse Treatment for Persons With Co-Occurring Disorders (CSAT,2005). 5
Tõendusmaterjali kokkuvõte - EvSu Tabel 1. Autor test Mida vaadati valim tundlikkus spetsiifilisus AUC Bastiani et al. 2013 Cross-sectional CAST ja SDS Kanepi sõltuvus 32,461 Italian adolescents (15 19 years) Cut off 3 3 CAST Overall 78.3 Jackknife 78.3 Cross validation 78.3 CAST Overall 82.3 Jackknife 82.3 Cross validation 82.9 CAST Overall 86.9 Jackknife 86.9 Cross validation 86.9 6 6 CAST full Overall 80.3 Jackknife 80.3 Cross validation 80.2 CAST full Overall 80.1 Jackknife 80.1 Cross validation 80.8 CAST full Overall 87.5 Jackknife 87.5 Cross validation 87.4 7 7 CAST MCA Overall 80.1 Jackknife 80.1 Cross validation 80.1 CAST MCA Overall 81.5 Jackknife 81.5 Cross validation 81.5 CAST MCA Overall 87.8 Jackknife 87.8 Cross validation 87.8 3 3 SDS Overall 74.7 Jackknife 74.7 Cross validation 74.7 SDS Overall 75.4 Jackknife 75.4 Cross validation 75.4 SDS Overall 82.8 Jackknife 82.8 Cross validation 82.8 4 4 SDS MCA Overall 72.3 Jackknife 72.3 Cross validation 72.3 SDS MCA Overall 81.5 Jackknife 81.5 Cross validation 81.5 SDS MCA Overall 84.2 Jackknife 84.2 Cross validation 84.2 Hides et al. 2009 Cross sectional study? ASSIST total substance involvement (TSI) score and specific substance involvement (SSI) scores for cannabis, alcohol and amphetamine Participants were 214 first-episode psychosis patients attending the Early Psychosis Prevention and Intervention Centre (EPPIC) in Melbourne, Australia. Score 16 2 4 1 TSI score 16 0.81 SSI Cannabis 0.79 Alcohol 0.73 Amphetamines 0.63 TSI 0.64 SSI Cannabis 0.64 Alcohol 0.62 Amphetamines 0.76 TSI 0.78 SSI Cannabis 0.76 Alcohol 0.71 Amphetamines 0.72 6
Humeniuk 2008 Cross sectional study? ASSIST Cocaine, ATS (amphetamine-type stimulants), benzodiazepines, Opioids 1047 participants, recruited from drug treatment (n=350) and primary health care (PHC) settings (n=697) Cocaine 82% ATS 66% Benzo 73% Opioids 91% Cocaine 91% ATS 73% Benzo 75% Opioids 80% Martin et al. 2006 Cross sectional study? Van der Pol et al. 2013 Cross sectional study? SDS cannabis a community sample of 14 18-year-old adolescent cannabis users (n =100) SDS Cannabis, in frequent users 577 Dutch frequent ( three days per week in the past 12 months) cannabis users between 18-30 years Score 1 2 3 4 5 6 7 8 9 10 Cut off 2 3 4 5 6 7 8 95.3 81.4 72.1 65.1 55.8 46.5 41.9 39.5 30.2 25.6 Cannabis dependance PPV 93.3 46.4 79.6 49.7 61.3 54.4 45.8 69.7 35.8 67.2 22.5 70.1 16.3 69.6 35.8 69.8 81.1 94.3 96.2 98.1 98.1 98.1 100.0 100.0 Cannabis dependance NPV 23.1 83.0 42.7 74.6 63.5 69.7 78.9 67.2 87.5 65.7 93.2 62.8 95.0 61.4 0.68 (0.64-0.73) Castillo et al. 2010 Cross sectional study? SDS Opiate dependance * SCAN (Schedules for Clinical Assessment in Neuropsychiatry) *AHU (active heroine 315 opiate-dependent patients in treatment. 2 3 4 5 6 7 8 Score 1 2 3 4 5 Cannabis abuse or dependance PPV 89.7 58.0 73.7 59.9 55.1 63.7 40.4 69.6 31.4 76.6 19.2 77.9 14.4 80.4 SCAN AHU 97.75 97.06 95.51 94.12 92.13 89.71 88.76 85.29 83.15 77.94 Cannabis abuse or dependance NPV 23.4 66.0 41.9 57.5 63.0 54.4 79.2 53.0 88.7 52.3 93.6 49.6 95.8 48.8 SCAN AHU 42.04 38.46 53.10 48.58 68.58 62.75 76.55 70.04 84.51 77.33 0.64 (0.60-0.69) 7
Lundqvist et al. 2011 Cross sectional epidemiological survey SDS use) 6 7 8 9 10 medication overuse amongst chronic headache patients 30 000 30 44 -year-old people Five hundred and eighteen subjects (113 men and 405 women) had chronic headache, Score 2 3 4 5 6 71.91 70.59 52.81 50.00 35.96 33.82 17.98 14.71 7.87 7.35 PPV 0.95 0.58 0.93 0.60 0.84 0.70 0.72 0.75 0.58 0.77 90.71 85.02 93.81 89.07 95.13 91.90 96.46 94.33 97.79 97.17 NPV 0.41 0.90 0.45 0.87 0.69 0.83 0.79 0.76 0.85 0.70 Grande et al. 2008 Cross sectional epidemiological survey SDS medication overuse amongst chronic headache patients A random sample of 30 000 people, aged 30 44 years, from the general population of Akershus County, Norway. 405 people had primary chronic headache. Score 2 3 4 5 6 0.94 0.92 0.84 0.72 0.59 0.41 0.45 0.67 0.79 0.85 Hides et al. 2007 Cross sectional study SDS cannabis 153 in-patients with a schizophrenia spectrum disorder in Brisbane, Australia Score 2 3 4 PPV 0.86 0.86 0.80 0.87 0.71 0.88 NPV 0.83 0.83 0.86 0.78 0.89 0.72 8
Tõendusmaterjali kokkuvõte - EvSu Viited Ravijuhendid The management of harmful drinking and alcohol dependence in primary care, a national clinical guideline, Scottish Intercollegiate Guidelines Network, 2003 Treatment of Alcohol Abuse, Current Care Guideline, The Finnish Medical Society Duodecim and the Finnish Society of Addiction Medicine,2010 NSW Health Drug and Alcohol Psychosocial Interventions Professional Practice Guidelines, 2008 Guidelines for the Treatment of Alcohol Problems, Australian Government Department of Health and Ageing, 2009 Incorporating Alcohol Pharmacotherapies Into Medical Practice. Treatment Improvement Protocol (TIP) Series, Substance Abuse and Mental Health Services Administration, 2009. Practice Guideline For The Treatment of Patients With Substance Use Disorders, 2nd Edition, American Psychiatric Association, 2006 Alcohol-use disorders: Diagnosis and clinical management of alcohol-related physical complications, National Institute for Health & Clinical Excellence, 2010 Alcohol-use disorders: preventing harmful drinking, NICE public health guidance 24, 2010 Alcohol-Use Disorders: Diagnosis, Assessment and Management of Harmful Drinking and Alcohol Dependence, National Institute for Health & Clinical Excellence, 2011 World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Substance Use and Related Disorders, Part 1: Alcoholism, 2008 Evidence-based guidelines for the pharmacological management of substance abuse, harmful use, addiction and comorbidity: recommendations from The British Association for Psychopharmacology,2012 Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse: U.S. Preventive Services Task Force Recommendation Statement, U.S. Preventive Services Task Force, 2013 SIGN 2003 Soome 2010 NSW 2008 Austraalia 2009 SAMHSA 2009 APA 2006 NICE 2010a NICE 2010b NICE 2011 WFSBP 2008 BAP 2012 USPSTF 2013 Viited Kokkuvõtte (abstract või kokkuvõtlikum info) SOOME Aims: To assess the validity of the Severity of Dependence Scale Viide kirjandusallikale de las Cuevas c, Sanz EJ, de la 9
(SDS) as a screening test to detect benzodiazepine dependence in regular benzodiazepine users. Method: One hundred regular benzodiazepine users, recruited from neurotic benzodiazepine users attending the Mental Health Outpatient Services of the Canary Islands Health Service, were administered the SDS and responses were compared with the Composite International Diagnostic Interview (CIDI) diagnosis of benzodiazepine dependence. Receiver Operating Characteristic (ROC) analysis was used to determine which cut-off score on SDS allowed the best trade-off between sensitivity and specificity. Results: SDS was shown to have high diagnostic utility, and a score higher than six on the scale appears to be an appropriate threshold for problematic benzodiazepine use. The SDS had a specificity of 94.2% and a sensitivity of 97.9%, and the area under the curve was of 0.991. AUSTRALIA 2009 This analysis combined data from five longitudinal studies conducted in California and examined 10-year patterns of heroin, cocaine, methamphetamine (meth), marijuana, and alcohol use for primary users of heroin (n=629), cocaine (n=694), and meth (n=474). Results suggest relatively low levels of use of non-primary heroin, cocaine, and meth, but moderate levels of alcohol and marijuana use. Growth models showed declining primary drug levels for heroin and meth users and relatively consistent levels over 10 years for cocaine users, while levels of non-primary drugs remained at consistently low levels or declined in tandem with the primary drug. Results indicate that group descriptions of primary heroin, cocaine, or meth use trajectories over time may present valid information about drug use patterns in general. This study examined rates of remission from substance-use disorders based on type of disorder (abuse vs dependence), type of substance (alcohol vs other drug), and polysubstance involvement (alcohol or drug vs alcohol and drug). Method: Participants in the National Epidemiologic Survey on Alcohol and Related Conditions were included if they met criteria for a prior-to-past-year alcohol- and/ or drug-use disorder (N = 12,297). Odds ratios were computed to examine differences in the rate of remission as of the past year. Results: Individuals with a prior-to-past-year diagnosis of abuse were more likely to be remitted, compared with those with a diagnosis of dependence. Individuals with both prior-to-past-year alcohol- and drug-use disorders were less likely to be remitted, compared with those with only an alcohol- or drug-use disorder. No differences were observed in remission rates comparing individuals with a prior-to-past-year alcohol-use disorder with those with a drug-use disorder. Degenhardt and Dunn 2008 paper about GHB and ketamine use, was derived from a subsection of respondents (aged 14-39 years only) from the 2004 Australian Household Drug Survey. The most commonly used drug was alcohol, used by 95% of the total surveyed population (n =11,595), with 28% of the total consuming more than 11 drinks in one day in the previous year, and 49% of Fuente JA et al. The Severity of Dependence Scale (SDS) as screening test for benzodiazepine dependence: SDS validation study. Addiction 2000;95:245 50. Brecht M-L, Huang D, Evans E, et al. Polydrug use and implications for longitudinal research: ten-year trajectories for heroin, cocaine, and methamphetamine users. Drug Alcohol Depend 2008;96:193 201. Karno MP, Grella CE, Niv N, et al. Do substance type and diagnosis make a difference? A study of remission from alcohol- versus drug-use disorders using the National Epidemiologic Survey on Alcohol and Related Conditions. J Stud Alcohol Drugs 2008;69:491 495. Degenhardt L, Dunn M. The epidemiology of GHB and ketamine use in an Australian household survey. Int J Drug Policy 2008;19:311 316. 10
115 GHB-users and 57% of ketamine-users consuming 11 drinks or more in one day in the previous year.this may suggest either that use of GHB or ketamine lowers personal resistance to drinking alcohol, or conversely it opposes its effects (thereby reducing intoxication, as do amphetamines, for example). However, no evidence is available on this aspect. Simultaneous polysubstance use (SPU) is a common phenomenon, yet little is known about how various substances are used with one another. In the present study 149 drug-using university students completed structured interviews about their use of various substances. For each substance ever used, participants provided details about the type, order and amount of all substances co-administered during its most recent administration. Alcohol, tobacco and cannabis were frequently co-administered with each other and with all other substances. Chi-squared tests revealed that when alcohol was used in combination with any of cannabis, psilocybin, MDMA, cocaine, amphetamine, methylphenidate (ps < 0.01) or LSD (p < 0.05) its initial use preceded the administration of the other substance. Paired samples t-tests revealed that when alcohol was used with cocaine (p < 0.01) or methylphenidate (p < 0.05) it was ingested in greater quantities than when used in their absence. Patterns of cannabis use were not systematically related to other substances administered. Finally, using one-sample t-tests, tobacco use was demonstrated to be increased relative to 'sober' smoking rates when used with alcohol, cannabis, psilocybin, MDMA, cocaine, amphetamine (ps < 0.001), LSD (p < 0.01) or methylphenidate (p < 0.05). Results suggest that many substances are routinely used in a SPU context and that the pattern in which a substance is used may be related to other substances co-administered. Objective: In this study, we sought to examine the prevalence, correlates, and consequences associated with simultaneous polydrug use and concurrent polydrug use of alcohol and prescription drugs. For purposes of this investigation, simultaneous polydrug use referred to the co-ingestion of different drugs at the same time, and concurrent polydrug use referred to the use of different drugs on separate occasions within the past 12 months. Method: Undergraduate students attending a large public midwestern university in the United Sates were randomly selected to self-administer a Web survey. The sample consisted of 4,580 undergraduate students, with a mean (SD) age of 19.9 (2.0) years; the sample consisted of 50% women, and the racial breakdown was 65% while, 13% Asian, 7% black, 5% Hispanic, and 10% other race/ethnicity. The survey assessed simultaneous polydrug use and concurrent polydrug use of alcohol and four classes of prescription drugs: (1) pain medication, (2) stimulant medication, (3) sedative medication, and (4) sleeping medication. Results: The 12 month prevalence for polydrug use involving alcohol and abusable prescription drugs was 12.1% (including 6.9% simultaneous polydrug use). The majority of polydrug use Barrett SP, Darredeau C, Pihl RO. Patterns of simultaneous polysubstance use in drug using university students. Hum Psychopharmacol 2006; 21: 255 263. McCabe SE, Cranford JA, Morales M, et al. Simultaneous and concurrent polydrug use of alcohol and prescription drugs: prevalence, correlates, and consequences. J Stud Alcohol 2006;67:529 537. 11
involving alcohol and each class of prescription drugs was simultaneous polydrug use, with the exception of sleeping medication. Simultaneous polydrug was associated with more alcohol-related and other drug use-related problems than concurrent polydrug use. Over the past 30 years in the United States, there have been marked secular increases in polydrug use. Alcohol and other substance use disorders are highly comorbid. Yet, little research has characterized patterns of polydrug use in persons with alcohol dependence. In particular, little is known about this population's use of alcohol and other drugs in combination or on the same day, which is termed simultaneous polydrug use (SPU). This research assessed patterns of SPU in 212 problem drinkers who participated in an alcohol treatment outcome study. Subjects were given a Time-Line Follow-Back interview that assessed the use of alcohol and nine other drug classes for each day of the 120 days before treatment entry. A majority of subjects (61%) reported SPU during this assessment interval. Subjects who reported SPU were disproportionately younger, male, and unmarried, compared with those who did not report SPU. The most common alcohol/drug combinations were alcohol with cocaine (60% of subjects who reported SPU), alcohol with marijuana (51% of SPU subjects), and alcohol with sedatives (31% of SPU subjects). The most common three-drug combination was alcohol, cocaine, and marijuana (23% of SPU subjects). Alcohol use and drug use were associated at the event level, significantly more than association predicted by the base rates of the individual behaviors. Time-Line Follow-Back data correlated highly with a questionnaire measure of SPU. Results indicate that polydrug use is an important focus for assessment and intervention in alcohol treatment programs. 12 Martin CS, Clifford PR, Maisto SA, et al. Polydrug use in an inpatient treatment sample of problem drinkers. Alcohol Clin Exp Res 1996;20:413 417. Degenhardt L, Hall W. Patterns of co-morbidity between alcohol use and other substance use in the Australian population. Drug Alcohol Rev 2003;22:7 13. Webb E, Ashton CH, Kelly P, et al. Alcohol and drug use in UK university students. Lancet 1996; 348:922 925. APA 2006 Kessler RC, Nelson CB, McGonagle KA, Edlund MJ, Frank RG, Leaf PJ: The epidemiology of co-occurring addictive and mental disorders: implications for prevention and service utilization. Am J Orthopsychiatry 1996; 66:17 31 [G] McLellan AT, Druley KA: Non-random relation between drugs of abuse and psychiatric diagnosis. J Psychiatr Res 1977; 13:179 184 [G] Ross HE, Glaser FB, Germanson T: The prevalence of psychiatric disorders in patients with alcohol and other drug problems. Arch Gen Psychiatry 1988; 45:1023 1031 [G] Hien D, Zimberg S, Weisman S, First M, Ackerman S: Dual diagnosis subtypes in urban substance abuse and mental health clinics. Psychiatr Serv 1997; 48:1058 1063 [G] RachBeisel J, Scott J, Dixon L: Co-occurring severe mental illness and substance use disorders: a review of recent research. Psychiatr Serv 1999; 50:1427 1434 [F] Tarter RE: Evaluation and treatment of adolescent substance abuse: a decision tree method. Am J Drug Alcohol Abuse 1990; 16:1 46 [G] NICE 2011
Farrell, M., Cowing, L. R., Marsden, J., et al. (2001) Substitution treatment for opioid dependence: a review of the evidence and the impact. In: Development and Improvement of Substitution Programmes: Proceedings. Seminar Organized by the Co-operation Group to Combat Drug Abuse and Illicit Trafficking in Drugs (Pompidou Group), Strasbourg, France, 8 9 October 2001. Strasbourg: Council of Europe. Coulthard, M., Farrell, M., Singleton, N. & Meltzer, H. (2002) Tobacco, Alcohol and Drug Use and Mental Health. The Office for National Statistics, London: The Stationary Office. Süstemaatilised ülevaated Kokkuvõte süstemaatilistest ülevaadetest Medinfo lisaotsing 16.11.2014 Otsistrateegia: (((((((alcohol) AND polysubstance use)) OR (co-occurring alcohol and benzodiazepines use))) AND (assessment OR detection OR screening OR diagnosis))) AND (systematic reviews OR meta-analysis OR cohort studies OR clinical guidelines OR RCT) Piirangud: Publication date from 2008/01/01; English; Estonian Kokku kirjeid: 21 Sekretariaadi liikme poolt teostatud lisaotsingud 1. ((("alcohol drinking"[mesh Terms] OR ("alcohol"[all Fields] AND "drinking"[all Fields]) OR "alcohol drinking"[all Fields] OR "alcohol"[all Fields] OR "alcohol use"[all Fields]) AND ("disease"[mesh Terms] OR "disease"[all Fields] OR "disorders"[all Fields])) AND ("benzodiazepines"[mesh Terms] OR "benzodiazepines"[all Fields])) AND ("diagnosis"[subheading] OR "diagnosis"[all Fields] OR "screening"[all Fields] OR "mass screening"[mesh Terms] OR ("mass"[all Fields] AND "screening"[all Fields]) OR "mass screening"[all Fields] OR "screening"[all Fields] OR "early detection of cancer"[mesh Terms] OR ("early"[all Fields] AND "detection"[all Fields] AND "cancer"[all Fields]) OR "early detection of cancer"[all Fields]) AND ("loattrfull text"[sb] AND ("2000/01/01"[PDAT] : "2014/12/31"[PDAT]) AND "humans"[mesh Terms]) 2. (polysubstance[all Fields] AND ("substance-related disorders"[mesh Terms] OR ("substancerelated"[all Fields] AND "disorders"[all Fields]) OR "substance-related disorders"[all Fields] OR "abuse"[all Fields])) OR (polysubstance[all Fields] AND dependance[all Fields])) AND ("diagnosis"[subheading] OR "diagnosis"[all Fields] OR "screening"[all Fields] OR "mass screening"[mesh Terms] OR ("mass"[all Fields] AND "screening"[all Fields]) OR "mass screening"[all Fields] OR "screening"[all Fields] OR "early detection of cancer"[mesh Terms] OR ("early"[all Fields] AND "detection"[all Fields] AND "cancer"[all Fields]) OR "early detection of cancer"[all Fields]) 3. ((((("alcoholism"[mesh Terms] OR "alcoholism"[all Fields] OR ("alcohol"[all Fields] AND "dependence"[all Fields]) OR "alcohol dependence"[all Fields]) OR ("alcoholism"[mesh Terms] OR "alcoholism"[all Fields] OR ("alcohol"[all Fields] AND "abuse"[all Fields]) OR "alcohol abuse"[all Fields])) OR (polysubstance[all Fields] AND ("dependency (psychology)"[mesh Terms] OR ("dependency"[all Fields] AND "(psychology)"[all Fields]) OR "dependency (psychology)"[all Fields] OR "dependence"[all Fields]))) OR polysubstance[all Fields]) OR (polysubstance[all Fields] AND ("substance-related disorders"[mesh Terms] OR ("substance-related"[all Fields] AND "disorders"[all Fields]) OR "substance-related disorders"[all Fields] OR "abuse"[all Fields]))) AND (((Bendep-SRQ[All Fields] OR (Benzodiaepine[All Fields] AND ("dependency (psychology)"[mesh Terms] OR ("dependency"[all Fields] AND "(psychology)"[all Fields]) OR "dependency (psychology)"[all Fields] 13
OR "dependence"[all Fields]) AND ("self report"[mesh Terms] OR ("self"[all Fields] AND "report"[all Fields]) OR "self report"[all Fields]) AND ("questionnaires"[mesh Terms] OR "questionnaires"[all Fields] OR "questionnaire"[all Fields]))) OR (("helping behavior"[mesh Terms] OR ("helping"[all Fields] AND "behavior"[all Fields]) OR "helping behavior"[all Fields] OR "assist"[all Fields]) AND ("questionnaires"[mesh Terms] OR "questionnaires"[all Fields] OR "questionnaire"[all Fields]))) OR (Severity[All Fields] AND ("dependency (psychology)"[mesh Terms] OR ("dependency"[all Fields] AND "(psychology)"[all Fields]) OR "dependency (psychology)"[all Fields] OR "dependence"[all Fields]) AND ("weights and measures"[mesh Terms] OR ("weights"[all Fields] AND "measures"[all Fields]) OR "weights and measures"[all Fields] OR "scale"[all Fields]))) AND ("loattrfull text"[sb] AND "2004/09/29"[PDat] : "2014/09/26"[PDat] AND "humans"[mesh Terms] AND English[lang]) Kokkuvõtte (abstract või kokkuvõtlikum info) Objective: To describe patterns of simultaneous polysubstance use (SPU) among Danish 3,4-methylenedioxymethamphetamine (MDMA) ("Ecstasy") and hallucinogen users. Methods: A cross-sectional survey of 98 active MDMA and/or hallucinogen users recruited through homepage advertisements, flyers, and word of mouth in Denmark. Lifetime and recent substance use and SPU at last recalled use was described by structured interviews. Hair samples from a subset of participants were analyzed for MDMA. Results: The participants had used an average of 12.6 (95% confidence interval: 11.7-13.4) psychoactive substances during their lifetime. SPU was prevalent among MDMA, d-lysergic acid diethylamide (LSD), and psilocybin users, in particular with alcohol and cannabis. Among MDMA users, 69% had combined MDMA with amphetamines, 56% with hallucinogens, and 47% with cocaine. At last recalled use, MDMA was taken with 2.1 ± 1.2 substances in 32 different combinations. The participants preferred specific drug combinations and named several, which in their experience enhanced or counteracted each other. Alcohol and cannabis were typically used before, during, and after MDMA, LSD, and psilocybin, whereas amphetamines were predominantly taken before these substances. When LSD was combined with MDMA, the majority took MDMA after LSD. Simultaneous polysubstance use (SPU) is a common phenomenon, yet little is known about its role in substance use initiation. Methods: In the present study, 226 cannabis users completed structured interviews about their substance use history. For each substance ever used, participants provided details of their age of first use, their use in the preceding 30 days and whether they co-administered any other licit or illicit substances the first time they used the substance. Viide kirjandusallikale Licht CL, Christoffersen M, Okholm M, et al. Simultaneous polysubstance use among Danish 3,4- methylenedioxymethamphetamine and hallucinogen users: combination patterns and proposed biological bases. Hum Psychopharmacol. 2012;27:352-63. Olthuis JV, Darredeau C, Barrett SP. Substance use initiation: the role of simultaneous polysubstance use. Drug Alcohol Rev. 2013 Jan;32(1):67-71. Results: For most illicit substances [powder cocaine, crack, amphetamine, methamphetamine, 3,4-methylenedioxymethamphetamine (MDMA; ecstasy), heroin, opium, gamma-hydroxybutyric acid (GHB), ketamine, psilocybin (magic mushrooms), mescaline, phencyclidine (PCP), peyote and inhalants], results showed that a clear majority of participants ( 75%) reported SPU during their first-ever use of the substance. While SPU was less common on occasions of first use of alcohol, tobacco and cannabis, a high proportion of SPU on occasions of first use of 'harder' drugs could be accounted for by the co-use of alcohol, tobacco and/or cannabis. Purpose: Psychometric and screening properties of the Cannabis Abuse Screening Test (CAST) and of the Severity Dependence Scale (SDS) were investigated using DSM-IV diagnoses of cannabis dependence (CD) as external criteria. Performance Bastiani L, Siciliano V, Cruzio O, et al. Optimal scaling of the CAST and of SDS 14
of the SDS and of the CAST were compared. Methods: Cross-sectional European School Survey Project on Alcohol and Other Drugs (ESPAD) was carried out in Italy in 2009. The sample consisted of 5787 Italian adolescents aged 15-19 who reported cannabis last year use. Unidimensionality, internal reliability, external validity, and optimal scaling of the 6 items for CAST and 5 items for SDS were performed. The Munich Composite International Diagnostic Interview (M-CIDI) was used as a gold standard for DSM- IV diagnoses, and all outputs were assessed by 10-fold cross validation procedure. Results: Both scales were uni-dimensional and Cronbach's α was 0.74 for SDS and 0.78 for CAST. High and comparable area under curve (AUC) values indicate a good ability of both scales to discriminate between individuals with and without dependence diagnosis. Based on balanced sensitivity and specificity, the optimal cut-off scores for problematic use disorders were 7 for CAST MCA and 4 for SDS MCA. Both CAST and SDS overestimated CD prevalence Aims: This study aims to determine the reliability and validity of the ASSIST for detecting substance use disorders in first-episode psychosis. Methods:Participants were 214 first-episode psychosis patients attending the Early Psychosis Prevention and Intervention Centre (EPPIC) in Melbourne, Australia. Participants were administered the ASSIST, Alcohol Use Disorders Identification Test (AUDIT), the Severity of Dependence Scale (SDS) and the Brief Psychiatric Rating Scale (BPRS). Presence of DSM-IV substance abuse and dependence disorders in the previous 12 months was assessed using the Structured Clinical Interview for DSM-IV (SCID-IV). Scale in a national sample of adolescents. Addict Behav. 2013;38:2060-7 Hides L, Cotton SM, Berger G, et al. The reliability and validity of the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) in first-episode psychosis. Addict Behav. 2009;34:821-5. Results: The ASSIST total substance involvement (TSI) score and specific substance involvement (SSI) scores for cannabis, alcohol and amphetamine use demonstrated high levels of internal consistency and acceptable levels of concurrent and discriminative validity. Individuals with cutoff scores of >/=2, 4 and 1 on the ASSIST cannabis, alcohol and amphetamine SSI scores were 5 to 6 times more likely to meet the diagnostic criteria for these substance use disorders. Aim: The concurrent, construct and discriminative validity of the World Health Organization's Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) were examined in a multi-site international study. Methods:1047 participants, recruited from drug treatment (n = 350) and primary health care (PHC) settings (n = 697), were administered a battery of instruments. Measures included the ASSIST; the Addiction Severity Index-Lite (ASI-Lite); the Severity of Dependence Scale (SDS); the MINI International Neuropsychiatric Interview (MINI-Plus); the Rating of Injection Site Condition (RISC); the Drug Abuse Screening Test (DAST); the Alcohol Use Disorders Identification Test (AUDIT); the Revised Fagerstrom Tolerance Questionnaire (RTQ); and the Maudsley Addiction Profile (MAP). Humeniuk R, Ali R, Babor T.F, et al. Validation of the Alcohol, Smoking And Substance Involvement Screening Test (ASSIST). Addiction. 2008;103:1039-47 Results: Concurrent validity was demonstrated by significant correlations between ASSIST scores and scores from the ASI-Lite (r = 0.76-0.88), SDS (r = 0.59), AUDIT (r = 0.82) and RTQ (r = 0.78); and significantly greater ASSIST scores for those with MINI-Plus diagnoses of abuse or dependence (P < 0.001). Construct validity was established by significant correlations between ASSIST scores and measures of risk factors for the development of drug and alcohol problems (r = 0.48-0.76). Discriminative validity was established by the capacity of the ASSIST to discriminate between substance use, abuse and dependence. Receiver operating characteristic (ROC) analysis was used to establish cut-off scores with suitable specificities (50-96%) and sensitivities (54-97%) for most substances. 15
The Severity of Dependence Scale (SDS) is a five-item scale that has been reported to be a reliable and valid screening instrument for dependence and a measure of dependence severity in adults across several substance classes. To date no data have been reported on its performance in a population of adolescent cannabis users. The current study assessed the psychometric properties of the SDS in a community sample of 14-18-year-old adolescent cannabis users (n=100). Internal consistency (alpha=0.83) and test-retest coefficients (ICC=0.88) were high and a principal components analysis of the scale found all items to load on a single factor. Total SDS score correlated significantly with frequency of cannabis use and number of DSM-IV dependence criteria met, indicating good concurrent validity. Receiver Operating Characteristic curve analysis was used to determine the most appropriate SDS cut-off score for use as an indicator of cannabis dependence, with optimal discrimination at an SDS score of 4. These findings indicate that the SDS is a reliable and valid measure of severity of cannabis dependence among adolescents, has high diagnostic utility, and that an SDS score of 4 may be indicative of cannabis dependence. The Severity of Dependence Scale (SDS) measures with five items the degree of psychological dependence on several illicit drugs, including cannabis. Its psychometric properties have not yet been examined in young adult frequent cannabis users, an eminently high-risk group for cannabis dependence. Internal consistency and criterion validity of the SDS were investigated within an enriched community based sample of 577 Dutch frequent ( three days per week in the past 12 months) cannabis users between 18-30 years. Criterion validity was tested against the Composite International Diagnostic Interview (CIDI) 3.0 DSM-IV diagnosis cannabis dependence, and psychometric properties were assessed separately for males and females and for ethnic subgroups. Principal component analysis showed that all items of the scale loaded on a single factor and reliability of the SDS total score was good (Cronbach's α = 0.70). However, criterion validity against the CIDI diagnosis cannabis dependence was low: area under curve (AUC) was 0.68 (95% confidence interval: 0.64-0.73) and at the optimal differentiating cut-off (SDS 4), sensitivity was 61.3% and specificity 63.5%. Results were similar for subgroups on gender and ethnicity. While internal consistency of the SDS is good, its use as a screener to differentiate between dependence and nondependence within populations of young adult frequent cannabis users is not recommended. Method: A structured interview was administered to 315 opiate-dependent patients in treatment.the diagnostic performance of the SDS was measured via Receiver Operating Characteristic (ROC) analysis according to the DSM-IV diagnosis of heroin dependence, as measured by section 12 of the Schedule for Clinical Assessment in Neuropsychiatry (SCAN). Results: ROC analysis revealed the SDS to be a test of high diagnostic utility for the measurement of opiate dependence (Area Under Curve =0.8875). The cut-off point on the SDS at which there is optimal discrimination between the presence and absence of a diagnosis of heroin dependence was found to be 5 (i.e. a score of 5 or more). This score provides the best trade-off between sensitivity (83.15%) and specificity (84.51%). Similar results were found for heroin current consumption (AUC = 0.8325; cut-off = 5; sensitivity = 77.94 and specificity = 77.33). Methods: In a cross-sectional epidemiological survey, an age- and genderstratified sample of 30,00030- to 44-year-old people were recruited via a posted questionnaire. Those with self-reported chronic headache were interviewed by neurological residents at Akershus University Hospital, Oslo. Headache was classified according to the International Classification of Headache Disorders. Split file methodology was employed for data analysis. Results: Severity of Dependence Scale score was a significant predictor of medication overuse amongst chronic headache patients. Medication overuse could be predicted with sensitivity, specificity, positive and negative predictive values of 0.79, 0.84, 0.84 and 0.79, respectively, in men and 0.76, 0.77, 0.73 and 0.79 in women. Linear regression and factor analysis suggested a redundancy for Martin G, Copeland J, Gates P, et al. The Severity of Dependence Scale (SDS) in an adolescent population of cannabis users: reliability, validity and diagnostic cut-off. Drug Alcohol Depend. 2006;83:90-3 van der Pol P, Liebregts N, de Graaf R, et al. Reliability and validity of the Severity of Dependence Scale for detecting cannabis dependence in frequent cannabis users. Int J Methods Psychiatr Res. 2013;22:138-43 Iraurgi Castillo I, González Saiz F, Lozano Rojas O, et al. Estimation of cutoff for the Severity of Dependence Scale (SDS) for opiate dependence by ROC analysis. Actas Esp Psiquiatr. 2010;38:270-7. Lundqvist C, Benth JŠ, Grande RB, et al. An adapted Severity of Dependence Scale is valid for the detection of medication overuse: the Akershus study of chronic headache. Eur J Neurol. 2011;18:512-8. 16
the SDS question 'Do you think your use of your headache medication was out of control?' Removal of this question improved Chronbach's alpha=0.76. Objective: To evaluate the Severity of Dependence Scale (SDS) in people with primary chronic headache and analyse the pattern of medication overuse. Design: Cross sectional epidemiological survey. A posted questionnaire screened for chronic headache. Neurological residents interviewed those with selfreported chronic headache. The International Classification of Headache Disorders was used. Split file methodology was employed for data analysis. Grande RB, Aaseth K, Saltyte Benth J, et al. The Severity of Dependence Scale detects people with medication overuse: the Akershus study of chronic headache. J Neurol Neurosurg Psychiatry. 2009 Jul;80(7):784-9. Setting: Akershus University Hospital, Oslo, Norway. Participants: A random sample of 30,000 people, aged 30-44 years, from the general population of Akershus County, Norway. 405 people had primary chronic headache. Results: The screening questionnaire response rate was 71% and the participation rate of the interview 74%. Among 405 people with primary chronic headache, 95% had chronic tension-type headache, 4% had chronic migraine and <1% had other primary chronic headaches. Of 386 persons with chronic tension-type headache, 44% had medication overuse and 47% had co-occurrence of migraine. Simple analgesics, combination analgesics, triptans, ergotamine, opioids and a combination of acute medications were overused by 65%, 27%, 4%, <1%, 1% and 2% of people, respectively. The mean SDS score was significantly higher in those with than in those without medication overuse (5.6 vs 2.7; p<0.001). Aims: To determine the reliability and validity of the Severity of Dependence Scale (SDS) for detecting cannabis dependence in a large sample of in-patients with a schizophrenia spectrum disorder. Methods: Cross-sectional study.participants were 153 in-patients with a schizophrenia spectrum disorder in Brisbane, Australia. Participants were administered the SDS for cannabis dependence in the past 12 months. The presence of Diagnostic and Statistical Manual Version-IV (DSM-IV) cannabis dependence in the previous 12 months was assessed using the Comprehensive International Diagnostic Interview (CIDI). Hides L, Dawe S, Young RM, et al. he reliability and validity of the Severity of Dependence Scale for detecting cannabis dependence in psychosis. J Neurol Neurosurg Psychiatry. 2009 Jul;80(7):784-9. Results: The SDS had high levels of internal consistency and strong construct and concurrent validity. Individuals with a score of >or = 2 on the SDS were nearly 30 times more likely to have DSM-IV cannabis dependence. The SDS was the strongest predictor of DSM-IV cannabis dependence after controlling for other predictor variables. World Health Organization. The ASSIST screening test and feedback card. Geneva: World Health Organization, 2014. World Health Organization. Severity of Dependence Scale (SDS). Geneva: World Health Organization, 2014. 17