Diagnostic sequence of cocaine use disorder in relation to other mental health conditions among college students

Abstract

Objective: Cocaine use is increasing. Comorbidities and diagnostic sequencing are needed among college students to inform treatment of cocaine use disorder (CUD). Method: Using electronic medical records from the psychiatric clinic at the student health care center of a large, public university from 2005 to 2015, patients diagnosed with CUD were identified. Their top mental health conditions were identified and assessed to see whether the first diagnosis of these conditions was made (1) before, (2) at the same time as, or (3) after the first diagnosis of CUD. Results: Among the 50 CUD patients, their most common mental health comorbidities were alcohol use disorder, anxiety, depression, and cannabis use disorder. Anxiety and depression were likely to be diagnosed before CUD; alcohol and cannabis use disorders were likely to be diagnosed concurrently with CUD. Conclusion: Diagnostic sequencing can be used to inform screening, workup, and treatment for patients with CUD.     

Making It Happen: The Case for Compromise in the Federal Cocaine Law Debate

The US has taken an active role in formulating drugs policy for over a century, and thus much debate on how best to control drug use occurs in that country. Though most Americans support keeping drugs illegal, voices for changing the specifics of how prohibition is administered have grown louder and more effective in the past ten years—witness the recent success on the state and local level for rolling back restrictions on medical cannabis or punitive state mandatory minimum penalties (i.e. Rockefeller drug laws). Expectedly, these successful reforms have happened with the support of voters in those particular states and localities where reforms have been introduced. On the federal level, the accusation of racism has become a familiar cry among anti‐prohibitionists, who argue that cocaine laws, in particular, disproportionately affect African‐Americans and contribute to racial division. The federal government makes a great distinction in sentencing between powder cocaine, usually snorted, and crack cocaine, which is smoked. A person caught in possession of five grams of crack gets an automatic mandatory minimum sentence of five years in prison. Possessing cocaine in its powder form does not carry a mandatory minimum. Additionally, these laws are the target of much debate because, for trafficking in the drug, it takes 100 times more powder cocaine than crack to trigger the same mandatory minimum penalty (the so‐called “100 to 1 quantity ratio”). I will argue that repealing the mandatory minimum sentence for crack is both justified based on the evidence and politically viable. Although the number of people affected by this law every year is minuscule, African‐Americans are undoubtedly disproportionately affected by the penalty. Eliminating the provision should not be expected to have a deleterious effect on crime or drug control efforts, and would instead have a positive effect in reinvigorating faith in the criminal justice system and in promoting positive race relations. Very importantly, it is a politically realistic reform for making prohibition work better. Erasing or dramatically changing the more controversial 100 to 1 quantity ratio—though affecting far more people than the mandatory minimum for crack possession—may or may not justify itself based on the evidence. Nonetheless, it is certainly not a politically realistic option for lawmakers.     

Longitudinal cost of services in a homeless sample with cocaine use disorder

ABSTRACT

Homeless people with cocaine use disorder have multiple comorbidities and costly service needs. This study examined service costs associated with cocaine use and substance service use in substance, psychiatric, and medical service sectors. 127 homeless participants with cocaine use disorder were interviewed annually. Self-report and agency-report service use and cost data were combined. Pairwise comparisons were made with cocaine abstinence and substance service use in relation to mean and yearly proportional service costs in 3 service sectors. Among substance service users, the achievement of abstinence was not associated with decreased substance service costs. Cocaine abstinence was associated with proportional reduction of substance service costs over time. Substance service use was associated with proportional reduction of psychiatric service costs over time among the abstinent subgroup. Conversely, substance service use was associated with continuing higher medical service expenditures in the abstinent subgroup and higher psychiatric service expenditures in those not abstinent. Homeless individuals who achieved cocaine abstinence after using substance services had decreased substance service expenditures. Individuals with continued substance service use had greater medical and psychiatric service costs. Policy-based on maximizing benefits while minimizing costs appears insufficiently complex to incorporate the multiple needs and associated with the costs of treating homeless populations.     

Introducing the female condom to drug users in Brazil

Brazil is currently the number two country in the world for reported cases of AIDS, and the rate of heterosexually acquired cases is on the rise. Moreover, because of the changing focus of the epidemic, the ratio of male to female cases dropped from 28 : 1 in 1984 to 2.7 : 1 in 1997. While women's risk of infection continues to grow, there is evidence to suggest that traditional approaches to HIV risk reduction have not effectively addressed women's special needs. Within such a setting this study sought to introduce drug-involved women to the female condom – a female-controlled method of protection from HIV. As part of a larger HIV/AIDS intervention study targeting low-income, cocaine users, the primary aim of this initiative was to assess the level of acceptability of this new device among women at high-risk for HIV infection in Rio de Janeiro, Brazil. In conjunction with individual pre-test HIV prevention counseling, clients participated in a detailed education/demonstration session with the female condom. Women were asked to try the female condom with their partners and to report their experiences at two points of contact. Outcome data indicate that a sizable proportion (71.1%) of the sexually active women used the female condom during vaginal sex on one or more occasions. In addition, many women continued to use the female condom as a method of risk reduction over the three-month follow-up period. These data suggest that the female condom can have an important role in HIV prevention efforts in Brazil.     

Cocaine-Exposed Toddler-Caregiver Dyads During Free Play at 24 Months

Some women continue to use cocaine during pregnancy, placing their fetus at risk for developmental problems. While gross problems are not evident after controlling for experimental flaws, subtle effects continue to be found. Social interactions of cocaine-exposed and nonexposed toddlers and their caregivers were assessed during a Free Play test to determine if psychobehavioral deficits were clinically observable. Risk factors were evaluated to assess whether the child’s socioemotional-behavioral behaviors were related to exposure and/or interactions with caregivers or the environment. Twenty-four-month-old cocaine-exposed and nonexposed toddlers were evaluated with the Child Behavior Check List while they played with their caregivers. Caregivers’ vocalizations were scored as contingent pairs if they occurred within 3 seconds of the child’s. The proportion of pairs was compared by group. Quality of caregivers’ vocalizations was rated as positive or negative based on approval, encouragement, and criticism. General linear model analyses indicate that cocaine-exposed children showed more dysfunctional behaviors than noncocaine-exposed children. Deficits increased when income and number of dependents were included. Caregivers in the drug group emitted fewer vocalizations during play before receiving a toy, indicating fewer opportunities for learning. No effect of quality of caregiver communication or gender by cocaine exposure interaction emerged. Cocaine exposure predicts poor developmental outcomes, but the toddler-caregiver relationship and reduced access to resources are additional risks that had previously been attributed to cocaine exposure. Early intervention services are needed to reduce the impact of low income, increase preschool readiness, and optimize functioning of these fragile families.