Insight in substance use disorder: A systematic review of the literature

Affiliations.

  • 1 School of Psychology, University of Wollongong, Wollongong, Australia; Illawarra Health and Medical Research Institute, University of Wollongong, NSW, Australia. Electronic address: [email protected].
  • 2 School of Psychology, University of Wollongong, Wollongong, Australia; Illawarra Health and Medical Research Institute, University of Wollongong, NSW, Australia.
  • 3 School of Medicine and Public Health, University of Newcastle, Callaghan, Australia.
  • 4 Eastern Health Clinical School, Faculty of Medicine, Nursing & Health Sciences, Monash University, Melbourne, Australia; Turning Point, Eastern Health, Melbourne, Australia.
  • 5 School of Medicine and Public Health, University of Newcastle, Callaghan, Australia; Centre for Innovation in Mental and Physical Health and Clinical Treatment Strategic Research Centre, School of Medicine, Deakin University, Geelong, Australia.
  • 6 Centre for Innovation in Mental and Physical Health and Clinical Treatment Strategic Research Centre, School of Medicine, Deakin University, Geelong, Australia; Florey Institute for Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia.
  • 7 Illawarra Drug and Alcohol Service, Illawarra Shoalhaven Local Health District, Wollongong, Australia.
  • 8 National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia.
  • PMID: 32731008
  • DOI: 10.1016/j.addbeh.2020.106549

Insight refers to a person's understanding of themselves and the world around them. Recent literature has explored people's insight into their substance use disorder (SUD) and how this is linked to treatment adherence, abstinence rates, and comorbid mental health symptoms. The aim of this systematic review was to synthesise and critically examine the existing literature on insight in SUD. Five academic databases (Medline, PsychINFO, SCOPUS, CINAHL, Web of Science) were searched for key terms related to insight and substance use. Included studies were on humans aged 18 years or over with SUD that examined the relationship between substance use and insight using a quantifiable measure of insight. Of 10,067 identified papers, 20 met the inclusion criteria, employing 13 different measures of insight. The most commonly used measure was the Hanil Alcohol Insight Scale (HAIS) which was the only measure designed for a substance use population and was specific to alcohol use. Based on a pooled sample from five studies (n = 585), 57% of participants had poor insight, 36% had fair insight, and 7% had good insight on the HAIS. Better insight was generally related to negative consequences from substance use, better treatment adherence and maintaining abstinence. Insight appears to be an important factor to consider within SUD. Exploring the most appropriate way to measure insight and assess its role in SUD has implications for intervention design, and engaging and maintaining people with SUD in treatment.

Keywords: Addiction; Insight; Substance use disorder.

Copyright © 2020 Elsevier Ltd. All rights reserved.

Publication types

  • Research Support, Non-U.S. Gov't
  • Systematic Review
  • Mental Health
  • Substance-Related Disorders* / epidemiology
  • Open access
  • Published: 21 June 2021

A review of research-supported group treatments for drug use disorders

  • Gabriela López 1 ,
  • Lindsay M. Orchowski   ORCID: orcid.org/0000-0001-9048-3576 2 ,
  • Madhavi K. Reddy 3 ,
  • Jessica Nargiso 4 &
  • Jennifer E. Johnson 5  

Substance Abuse Treatment, Prevention, and Policy volume  16 , Article number:  51 ( 2021 ) Cite this article

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This paper reviews methodologically rigorous studies examining group treatments for interview-diagnosed drug use disorders. A total of 50 studies reporting on the efficacy of group drug use disorder treatments for adults met inclusion criteria. Studies examining group treatment for cocaine, methamphetamine, marijuana, opioid, mixed substance, and substance use disorder with co-occurring psychiatric conditions are discussed. The current review showed that cognitive behavioral therapy (CBT) group therapy and contingency management (CM) groups appear to be more effective at reducing cocaine use than treatment as usual (TAU) groups. CM also appeared to be effective at reducing methamphetamine use relative to standard group treatment. Relapse prevention support groups, motivational interviewing, and social support groups were all effective at reducing marijuana use relative to a delayed treatment control. Group therapy or group CBT plus pharmacotherapy are more effective at decreasing opioid use than pharmacotherapy alone. An HIV harm reduction program has also been shown to be effective for reducing illicit opioid use. Effective treatments for mixed substance use disorder include group CBT, CM, and women’s recovery group. Behavioral skills group, group behavioral therapy plus CM, Seeking Safety, Dialectical behavior therapy groups, and CM were more effective at decreasing substance use and psychiatric symptoms relative to TAU, but group psychoeducation and group CBT were not. Given how often group formats are utilized to treat drug use disorders, the present review underscores the need to understand the extent to which evidence-based group therapies for drug use disorders are applied in treatment settings.

Drug use disorders are a significant public health concern in the United States. According to the National Epidemiologic Survey of Alcohol and Related Conditions-III, the lifetime prevalence rate of DSM-5 drug use disorders is 9.9%, which includes amphetamine, cannabis, club drug, cocaine, hallucinogen, heroin, opioid, sedative/tranquilizer, and solvent/inhalant use disorders [ 1 ]. Drug use disorders are defined in terms of eleven criteria including physiological, behavioral and cognitive symptoms, as well as consequences of criteria, any two of which qualify for a diagnosis [ 2 , 3 ]. The individual and community costs of drug use are estimated at over $193 billion [ 4 , 5 ] and approximately $78.5 billion [ 6 ] for opioids alone. Consequences include overdose [ 7 ], mental health problems [ 8 ], and a range of medical consequences such as human immunodeficiency virus [ 9 , 10 ], hepatitis C virus [ 9 ], and other viral and bacterial infections [ 11 ].

Evidence-based practice was formally defined by Sackett et al. [ 12 ] in 1996 to refer to the “conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients” (p. 71). In 2006, the American Psychological Association [ 13 ] developed a policy on evidence-based practice (EBP) of psychotherapy, which emphasized the integration of best research evidence (i.e., data from meta-analyses, randomized controlled trials, effectiveness trials, and other forms of systematic case studies and reviews) with clinical expertise and judgment to deliver treatment in the context of a patient’s individual needs, preferences and culture. The shift towards EBP for substance use disorders has multiple benefits for practitioners and patients, including an increased focus on the implementation of treatments that are safe and cost-effective [ 14 ]. A recent survey of clinicians’ practices with substance use treatment found that clinicians often conducted therapy in groups [ 15 ]. While most clinicians who completed the survey reported use of evidence-based treatment practices (EBT) some also reported the use of non-EBT practices [ 15 ]. Ensuring that clinicians can readily access information regarding the current state of evidence regarding group-based therapies for substance use disorders is critical for fostering increased use of EBTs.

Although any effort to summarize a literature as large and complex as the psychological treatment literature is useful, there are several limitations. With few exceptions, research-supported treatment lists categorize treatments by formal change theory (e.g., cognitive-behavioral, interpersonal) and describe little about the context, format, or setting in which treatments were conducted and tested [ 16 ]. As a result, it is often difficult to ascertain from existing resources whether research supported treatments were conducted in group or individual format. A group format is often used in substance use treatment [ 17 ] and aftercare programs [ 18 , 19 , 20 , 21 , 22 ] . The discrepancy between the wide-spread use of group therapy in clinical practice and the relative paucity of research on the efficacy of group treatments has been noted by treatment researchers [ 23 ] and clinicians [ 24 ]. According to Lundahl’s [ 25 ] 2010 meta-analysis of studies evaluating the efficacy of motivational interviewing (MI), a commonly used treatment for substance use disorders, examination of the 119 studies concluded that studies of MI in a group format were too rare to draw solid conclusions about the efficacy of group MI. Also, it is possible that efficacy of treatments developed for individual delivery will be altered when delivered in a group format and vice versa. Given the limited empirical inquiry on group treatments for substance use, a framework organizing the literature on the efficacy of group therapy to treat substance use disorders would be useful. There is also a need for a more recent rigorous review of the empirical evidence to support group-based treatments for substance use disorders. Over 15 years ago, Weiss and colleagues conducted a review of 24 treatment outcome studies within the substance use disorder intervention literature comparing group therapy to other treatments conditions (i.e., no group therapy, individual therapy, group therapy plus individual therapy), and found no differences between group and individual therapy [ 26 ].

Given the importance of understanding the current evidence base for group-delivered treatments for substance use disorders, the present review sought to provide a summary of the literature on the benefits of group treatments for drug use disorders. Group treatments are potentially cost-effective, widely disseminable, and adaptable to a variety of populations but are lagging individual treatments in terms of research attention. Thus, highlighting characteristics of group treatments that are potentially efficacious is of import to stimulate further empirical inquiry. The review is organized by drug type (cocaine, methamphetamine, marijuana, opiate, mixed substance use disorders; SUD) and co-occurring SUD and psychiatric problems. We excluded studies focused on alcohol use disorder alone as this literature is summarized elsewhere (see Orchowski & Johnson, 2012). Given research suggesting that several factors impact outcomes of group treatments, including formal change theory driving the treatment approach (i.e., cognitive-behavioral, motivational interviewing), as well as patient factors [ 27 ], the review begins by first reviewing each theory of change (i.e., type of treatment), and then concludes by summarizing the research examining the extent to which patient factors influence the efficacy of group treatments for SUD.

To locate studies that evaluated a group treatment for SUD that met review inclusion criteria, the authors conducted a comprehensive literature search of PsycINFO and MedLine through 2020. Three individuals then examined abstracts of the articles for relevance. In addition, the authors utilized the reference lists of review studies and meta-analyses of SUD- treatments to locate additional studies that might meet the review inclusion criteria. The authors and a research assistant then reviewed full articles with relevance to the current study and excluded any studies that did not meet the review inclusion criteria (see Fig.  1 ).

figure 1

Electronic Search Strategy Flowchart

For inclusion in the review, studies needed to meet the following criteria: 1) report the findings of at least one group treatment; 2) provide at least one statistical comparison between the group treatment and a control condition; 3) randomize participants between the group treatment and control condition; 4) utilize a manualized treatment; 5) include patients with an interview-diagnosed SUD; and 6) provide information regarding the demographic characteristics of the participants in the study. Studies’ methods and results were used for data extraction. Studies which maintained a primary focus on the treatment of SUD, but also included treatment of a co-occurring psychiatric condition, were included in the review. Studies which included alcohol use as a comorbid diagnosis along another substance use were included. Studies examining the efficacy of group treatment for only alcohol use were excluded. The final set of articles included were 50 research studies that utilized a group treatment modality for the treatment of SUD, including separately examining cocaine, methamphetamine, marijuana, opioid, mixed substance, or SUD with comorbid psychiatric problems in adults.

It should be noted that several studies that met inclusion criteria were not reported in the present review because they did not report the use of a specific screening instrument for SUD as a part of the study inclusion/exclusion criteria. These studies are as follows and include these comparisons: group-based relational therapy [ 28 ] two studies by Guydish et al. [ 29 , 30 ] comparing a day treatment program to residential treatment (RT) program, a day treatment program to a coping skills group [ 31 ], standard care to a harm reduction group [ 32 ], 12 step group to a CBT group [ 33 ], medical management treatment (MMT) with CBT group to an MMT plus treatment reinforcement plan [ 34 ], treatment as usual to contingency management (CM) [ 35 ], professionally led recovery training group to treatment as usual (TAU) [ 36 ], two 4 month residential treatment programs [ 37 ], varying lengths of therapeutic community program (TPC) with and without relapse prevention [ 38 ], and Information and Referral plus peer advocacy to a Motivational group with CBT group [ 39 ].

Review of evidence-based theories of change

The 50 research studies meeting inclusion criteria tested the following group treatment modalities: contingency management (CM), motivational interviewing (MI), relapse prevention (RP), social support (SS), cognitive-behavioral (CBT), coping skills (CS), harm reduction (HR), cognitive therapy (CT), drug counseling (DC), recovery training (RT), standard group therapy (SGT), family therapy (FT), intensive group therapy (IGT), 12 step facilitation group therapy (12SG), relational psychotherapy mothers’ group (RPMG), psychoeducational therapy group (PET), behavioral skills (BS), and seeking safety (SS). Below, we briefly review the theory of change that drives each of these treatments.

Several treatment approaches are grounded in behavioral therapies and/or cognitive therapies. Broadly, cognitive therapy is an approach that focuses exclusively on targeting thoughts that are identified as part of a diagnosis or behavioral problem [ 28 ]. Cognitive-behavioral (CBT) therapy is an approach that targets specific symptoms, thoughts, and behaviors that are identified as part of a diagnosis or presenting problem [ 28 ]. Under the umbrella of CBT several other treatment modalities exist. For example, relapse prevention is a CBT treatment that hypothesizes that there are cognitive, behavioral, and affective mechanism that underlie the process of relapse [ 40 ]. Recovery training is a more specific form of relapse prevention, including education on addiction and recovery and reinforcing relapse prevention skills (e.g., understanding triggers, coping with cravings etc.) [ 41 , 42 ]. Other treatments focus on coping skills more broadly. For example, coping skills treatments include a focus on components of adaptability in interpersonal relationships, thinking and feeling, as well as approaches to self and life [ 28 ]. Some treatment approaches also recognize that individuals may not be ready to change their substance use. For example, motivational interviewing is often described as a therapy guiding technique in which the therapist is a helper in the behavior change process and expressed acceptance of the patient [ 43 ]. Standard group therapy includes 90 min sessions approximately twice a week in a group setting, [ 44 ] whereas intensive group therapy is a heavier dose of standard group therapy that includes 120-min sessions up to five times a week [ 44 ]. Psychoeducational therapy group focused on providing information on the immediate and delayed problems of substance use disorders to patients [ 45 ]. Lastly, dialectical behavior therapy (DBT) is a type of CBT therapy that focuses on helping regulate intense emotional states and provides skills to reduce arousal levels, and increase mindfulness, emotional regulation, and interpersonal skills [ 46 ].

Grounded within behavioral therapies, are behavioral skills training which focused on developing behaviors that are adaptive [ 28 ]. Contingency management is a type of behavioral therapy in which patients are reinforced or rewarded for positive behavioral change [ 47 ]. Harm reduction is a term for interventions aiming to reduce the problematic effects of behaviors [ 48 ]. Several treatment approaches also focus on interpersonal networks and building interpersonal skills. For example, social support is any psychological resources provided by a social network to help patients cope with stress [ 49 ]. Twelve-step facilitation group therapy is a more specific form of social support, which focuses on introducing patients to the 12 steps of alcoholics anonymous or related groups (i.e., cocaine or narcotics anonymous) to encourage 12-step meeting attendance in their community [ 33 , 50 ]. Seeking Safety is a present-focused and empowerment-based intervention focused on coping skills that emphasizes the importance of safety within interpersonal relationships [ 51 ]. Drug counseling describes treatment that aims to facilitate abstinence, encourage mutual support, and provide coping skills [ 52 ]. Finally, family therapy is a family-based intervention that aims to change, parenting behaviors and family interactions [ 53 ]. Overall, there are many overlapping components and skill sets in the models discussed above (See Table  1 ).

Group-based cocaine use treatments for adults

Nineteen studies were identified that targeted cocaine use and utilized some form of group therapy, the most of any drug in this review (see Table  2 ). Overall, the studies showed that all of the group therapy modalities included in this review generally reduced cocaine use when compared to treatment as usual (TAU), including day hospital groups [ 54 ]. Two studies, Magura et al. (1994) and Magura et al. (2002) did not find group differences between 8 months CBT and 8 months of TAU that consisted of methadone maintenance therapy among 141 patients with cocaine disorder [ 60 , 69 ]. When compared directly, individuals in CBT groups achieved longer abstinence than individuals in 12 step facilitation groups [ 33 ] or low intensity groups [ 64 , 65 ]. However, in another study, individuals with cocaine dependence receiving 12-step based Group Drug Counseling (GDC; similar to 12-step facilitation) had similar cocaine abstinence outcomes with or without additional individual CBT [ 41 ]. This may suggest that group 12-step facilitation is an effective intervention for cocaine dependence. Two studies demonstrated the superiority of CM groups for reducing cocaine use as compared to CBT [ 62 ] or TAU groups [ 61 , 62 ] at 12 weeks [ 54 ], 17 weeks [ 53 ], 26 weeks [ 53 ] and 52 weeks follow up [ 51 ]. Therefore, CBT group therapy and contingency management groups appear to be more effective at reducing cocaine use than TAU groups.

Group-based methamphetamine use treatments for adults

Only five treatment studies were identified that examined group treatments for methamphetamine use (see Table  3 ). Three studies found longer periods of abstinence for the group treatment (CM or drug+CM) than for TAU or non-CM conditions. The first study conducted by Rawson and colleagues compared matrix model (MM) with TAU in eight community outpatient settings [ 71 ]. The MM consisted of CBT groups, family education groups, social support groups, and individual counseling sessions along with weekly urine screens for 16 weeks. Participants in the MM condition attended more sessions, stayed in treatment longer, had more than twice as many contacts, evidence longer abstinence and greater self-reported psychosocial functioning relative to the TAU group. However, these significant differences did not persist 6 months later at follow-up.

Shoptaw et al. (2006) [ 73 ] compared four groups for treating methamphetamine dependence sertraline + CM, sertraline only, placebo + CM, and placebo [ 73 ]. Additionally, all participants attended a relapse prevention group conducted three times a week over a 14-week period. Findings provided support for the efficacy of CM for amphetamine use disorders. Group treatment (CM or drug + CM) was more effective for sustaining longer periods of abstinence relative to TAU or non-CM conditions. Roll et al. [ 72 ] found that effects of CM relative to TAU became larger as the duration of CM increased. Jaffe et al. [ 70 ] evaluated a culturally tailored intervention for 145 methamphetamine dependent gay and bisexual males. Participants in the Gay Specific CBT condition reported the most rapid decline in levels of methamphetamine use relative to standard CBT, CBT + CM, suggesting benefits for culturally appropriate group methamphetamine interventions.

Group-based marijuana use treatments for adults

Two studies examining group treatments for adults with marijuana use disorders were identified (see Table  4 ). Both studies were conducted by the same research group, utilizing the same inclusion criteria for marijuana use (50 times in 90 days). The studies examined group relapse prevention (RP) [ 76 ], specifically designed for adult marijuana users. The first trial [ 75 ] ( n  = 212) comparing relapse prevention to a social support group found participants in both group treatment conditions did well overall, with two-thirds (65%) reporting abstinence of marijuana use for 2 weeks after session 4 or the quit date and 63% reporting abstinence during the last 2 weeks of treatment. Gender differences emerged; no differences between group treatments were found for women, but men in the relapse prevention group reported reduced marijuana use at the 3-month follow-up compared to men in the social support group.

A second trial [ 74 ] randomized participants to 14 sessions of group RP enhanced with cognitive behavioral skills training, two sessions of motivational interviewing (MI) with feedback and advice on cognitive behavioral skills (modeled after the Drinkers Check-up) [ 77 ], or a 4-month delayed treatment control (DTC) group which consisted of the RP group or individual MI treatment of the participants choosing. Compared to individuals randomly assigned to the DTC condition, participants in the group RP and individual MI conditions evidenced a significantly greater reduction in marijuana use and related problems over 16-month follow-up. However, examination of participants’ reactions to DTC assignment indicated that participants who felt that changing their marijuana use was their own responsibility were more likely than those who did not to change their use patterns without treatment engagement.

Group-based opiate use treatments for adults

Five group treatment studies for opioid use were identified (see Table  5 ). Two studies compared the effectiveness of pharmacotherapy plus group therapies [ 79 , 80 , 81 ] to pharmacotherapy alone in samples of opioid dependent persons, and both found that adding group treatment improved outcomes. The first study compared Naltrexone with monthly medical monitoring visits to an enhanced group condition (EN) consisting of Naltrexone plus a Matrix Method (MM) [ 79 ]. MM consisted of hourly individual sessions, 90-min CBT group, and 60 min of cue-exposure weekly for weeks 1–12; hourly individual sessions and CBT group sessions for weeks 13–26; and 90-min social support group sessions for weeks 27–52. Results found that EN participants took more study medication, were retained in treatment longer, used less opioids while in treatment, and showed greater improvement on psychological and affective dimensions than Naltrexone only participants. No difference by treatment condition was found at 6- and 12-month follow-ups. Similarly, Scherbaum et al. [ 80 ] compared routine Methadone Maintenance Therapy (MMT) with routine MMT plus group CBT psychotherapy (20 90-min sessions for 20 weeks). MMT plus group CBT participants showed less drug use than participants in the MMT group (i.e., control group). In contrast, a higher dose of group therapy provided without methadone maintenance was less effective for heroin use than was a lower dose of group therapy with methadone maintenance (Sees et al. [ 81 ]. This suggests that the combination of pharmacotherapy and group therapy for opioid use is optimal.

Shaffer et al. [ 22 ] compared psychodynamic group therapy with a hatha yoga group. All participants received methadone maintenance and individual therapy. No differences between two treatment conditions were found. For all participants, longer participation in treatment was associated with reduction in drug use and criminal activity. Lastly, Des Jarlais et al. [ 78 ] compared a group social learning AIDS/drug injection treatment program (4 sessions, 60–90 min, over 2 weeks) to a control condition. All participants received information about AIDS and HIV antibody test counseling. Compared to control participants, intervention participants reported lower rates of drug injection over time.

Group treatments for mixed SUD for adults

Nine treatment studies were identified that targeted mixed substance use with group treatments (see Table  6 ). Three involved CBT. Downey et al. [ 82 ] compared group CBT plus individual CBT to group CBT plus vouchers in a sample of 14 polysubstance users (cocaine and heroin) maintained on buprenorphine. The study was significantly underpowered and they found no significant differences on treatment outcomes. Marques and Formiogioni [ 84 ] compared individual CBT to group CBT in a sample of 155 participants with alcohol and/or drug dependence. They found that both formats resulted in similar outcomes, with higher compliance in the group CBT participants (66.7% compliance with treatment). Rawson et al. [ 87 ] compared three 16-week treatments: CM, group CBT, and CM plus group CBT, among 171 participants with cocaine disorder or methamphetamine abuse. They found that CM produced better retention and lower rates of stimulant use than CBT during treatment, but CBT produced comparable longer-term outcomes.

Two studies involved Group Drug Counseling (GDC). Greenfield et al. [ 52 ] compared a group drug counseling (GDC) (mixed gender) to a women’s recovery group (WRG) that both met weekly, for 12 weeks, for 90-min sessions among 44 participants that had a substance use disorder other than nicotine. WRG evidenced significantly greater reductions in drug and alcohol use over the follow up compared with GDC. Schottenfeld et al. [ 88 ] compared GDC (weekly, 1-h group sessions) to a community reinforcement approach (CRA; twice weekly sessions for the first 12 weeks and then weekly the following 12 weeks) among 117 patients with an opioid and cocaine use disorder. There were no differences in retention or drug use.

Remaining studies examined other interventions. Margolin et al. [ 83 ] compared an HIV Harm reduction program (HHRP) that met twice weekly for 2 h to an active control group that met six times in a sample of 90 HIV-seropositive methadone-maintained injection drug users with opioid dependence, and abuse or dependence on cocaine. At follow up, they had lower addiction severity scores and were less likely to have engaged in high risk behaviors compared to control. McKay et al. [ 85 ] compared weekly phone monitoring and counseling plus a support group in the first 4 weeks (TEL), twice-weekly individualized relapse prevention, and twice-weekly standard group counseling (STND) among 259 referred participants with alcohol use disorder or cocaine disorder. STND resulted in more days abstinent than TEL. Nemes et al. [ 86 ] compared a 12-month group program (10 months inpatient and 2 months outpatient) to an abbreviated group program (6 months inpatient, 6 months outpatient) among 412 patients with multiple drug/alcohol use disorders. Results indicated that both groups had reduction in arrests and drug use. There were no significant difference between groups. Lastly, Smith et al. [ 89 ] compared a standard treatment program (STP, daily group counseling, family outreach, 12-step program introduction, four 2 h sessions for family) to an enhanced treatment program (ETP; twice weekly group on relapse prevention and interpersonal violence in additional to all STP components) among 383 inpatient veterans meeting for an alcohol, cocaine, or amphetamine use disorder. Results indicated that ETP had enhanced abstinence rates at 3-month and 12-month follow up compared to STP, regardless of type of drug use.

Group Treatments for SUD and Co-Occurring Psychiatric Problems

Individuals with psychiatric distress are at high risk for comorbid SUD [ 90 ]. Ten randomized controlled studies meeting our inclusion criteria examined the efficacy of group therapy for SUD and co-occurring psychiatric problems (see Table  7 ). Three studies described group treatment of SUD and co-occurring DSM-IV Axis II disorders [ 18 , 91 , 96 ], three studies examined group treatment of drug abuse and co-occurring DSM-IV classified Axis I disorders [ 92 , 93 , 99 ], one study explored group drug abuse treatment and co-occurring psychiatric problems among homeless individuals without limiting to DSM-IV Axis I or Axis II diagnoses [ 97 ], and one study focused on group drug treatment among individuals testing positive for HIV [ 98 ]. Within this diverse set of RCTs, participants generally included individuals diagnosed with any form of SUD; however, some studies focused specifically on individuals using cocaine [ 91 , 97 ] or cocaine/opioids [ 98 ].

A range of group treatment approaches are represented, including group psychoeducational therapy, group CBT approaches, group DBT, Seeking Safety and CM. DiNitto and colleagues [ 92 ] evaluated the efficacy of adding a group-based psychoeducational program entitled “Good Chemistry Groups” to standard inpatient SUD treatment services among 97 individuals with a dual diagnosis of SUD and a DSM-IV Axis I psychological disorder. The nine 60-min Good Chemistry Group sessions were offered 3 times per week for 3 weeks. When compared to standard inpatient treatment, the addition of the psychoeducational group was not associated with any changes in medical, legal, alcohol, drug, psychiatric or family/social problems among participants.

The efficacy of adding a psychoeducational group treatment to standard individual therapy to address HIV risk among cocaine users has also been examined [ 91 ]. Participants were randomly assigned to complete the following: 1) individually-administered Standard Intervention developed by the NIDA Cooperative Agreement Final Cohort sites [ 100 ] including HIV testing, and pre- and post-HIV testing counseling on risks relating to cocaine use, transmission of STDs/HIV, condom use, cleaning injection equipment, and the benefits of treatment; or) Standard Intervention plus four 2-h peer-delivered psychoeducational groups addressing stress management, drug awareness, risk reduction strategies, HIV education and AIDS. Among the sample of 966 individuals completing the 3-month follow-up, the group psychoeducational treatment was not differentially effective in reducing drug use and HIV risk behavior in comparison to standard treatment alone at 3-months post-baseline, regardless of treatment type, individuals with antisocial personality disorder (ASPD) demonstrated less improvement in crack cocaine use compared to individuals without ASPD or depression.

The following types of group CBT have sustained research evaluation meeting our inclusion criteria to address co-occurring SUD and Axis I or Axis II disorders: 1) group behavioral skills training; 2) group cognitive behavioral therapy; 3) group-based Seeking Safety [ 51 ], and 4) group dialectical behavioral therapy. Specifically, Jerrell and Ridgely [ 93 ] examined the efficacy of group behavioral skills (BS) training, group-based 12-step facilitation (TS) treatment, and intensive case management among 132 individuals with a dual diagnosis of SUD and another Axis I psychiatric problem over the course of 24-months. Based on the Social and Independent Living Skills program [ 101 ], the BS group included one group per week addressing self-management skills designed to enhance abstinence, including medication management, relapse prevention, social skills, leisure activities and symptom monitoring. Relative to participants in TS groups, participants in the BS groups evidenced increased psychosocial functioning and decreased psychiatric symptoms (i.e., schizophrenia, depressive symptoms, mania, drug use and alcohol use) across the 6-, 12- and 18-month follow-up assessments after treatment entry.

Lehman and colleagues’ [ 95 ] examination of the efficacy of group CBT for substance abuse compared to TAU among 54 individuals with SUD and either schizophrenia or a major affective disorder revealed no differences between treatment groups over the course of a 1-year follow-up period. More promising findings were reported in Fisher and Bentley’s [ 18 ] evaluation of a group CBT and group therapy based in the disease and recovery model (DRM) among 38 individuals with dual diagnosis of SUD and a personality disorder. Groups met three times per week for 12 weeks and were compared to TAU. Individuals in group CBT and group DRM indicated improved social and family functioning compared to TAU, and among those who completed the group in an outpatient setting, CBT was more effective in reducing alcohol use, enhancing psychological functioning and improving social and family functioning compared to DRM and TAU.

Group behavioral therapy plus abstinence contingent housing and work administered in the context of a day treatment program was compared to behavioral group treatment alone among individuals with cocaine abuse/dependence, non-psychotic psychiatric conditions, and homelessness [ 97 , 102 ]. The group behavioral therapy included 8 weeks of daily treatment (4 h and 50 min per day) of groups addressing relapse prevention training, assertiveness training, AIDS education, 12-step facilitation, relaxation, recreation development, goal setting, and goal planning. Participants also engaged in a process-oriented group as well as individual counseling and urine monitoring and engaged in a weekly 90 min psychoeducational group therapy during months 3–6 following treatment enrollment. Individuals who received contingency-based work and housing were provided with rent-free housing and employment in construction or food service industries after 2 consecutive weeks of abstinence [ 103 ]. Relative to BS groups alone, group behavioral day treatment plus contingency management was associated with greater abstinence at 2- and 6-month follow-ups [ 102 ] and were less likely to relapse [ 97 ], although gains were not maintained at 12-months [ 104 ]. Both groups evidenced positive changes in drug use overtime compared to baseline [ 104 ].

Zlotnick, Johnston and Najavits [ 99 ] evaluated the efficacy of Seeking Safety (SS), in comparison to treatment as usual (TAU) among 49 incarcerated women with substance use disorder (SUD) and full or subthreshold posttraumatic stress disorder (PTSD). SS aims to decrease PTSD and SUD through psychoeducational and present-focused and empowerment-based instruction on coping skills that emphasize abstinence and safety [ 51 ]. The SS group treatment included 90-min group sessions held three times per week, that were completed in addition to the 180 to 240 h of group and individual therapy provided in TAU. All participants showed similar improvement on assessments of PSTD, SUD, legal problems and other psychiatric concerns at 12-week, 3- and 6-month follow-ups following prison release. Nonetheless, there was a trend for improved PTSD and continued improvements in psychiatric symptoms at follow-up among participants completing SS compared to TAU. Greater completion of SS sessions was associated with increased improvement in PTSD as well as drug use among women [ 99 ].

Dialectical behavioral group therapy (DBT), a CBT-focused treatment for individuals with borderline personality disorder (BPD), has also been evaluated in comparison to TAU among individuals with BPD and co-occurring SUD [ 96 ]. Core elements of DBT are manualized [ 105 ], and have been evaluated in prior research [ 106 , 107 , 108 ]. Techniques center on providing the participant with acceptance and validation while maintaining a continual focus on behavior change, and include the following: mindfulness skills training, behavioral analysis of dysfunctional behavior, cognitive restructuring, coping skills training, exposure-based strategies addressing maladaptive emotions, and behavioral management skills training. DBT was administered through 2 ¼ hour weekly group sessions administered in combination with 60 min of weekly individual therapy and the opportunity for skills-coaching phone calls. Relative to TAU, participants randomly assigned to DBT demonstrated greater reductions in drug use during the 12-month treatment and at the 16-month follow-up assessment, as well as greater gains in adjustment at the 16-month follow-up assessment.

Although contingency management is commonly administered individually, Petry and colleagues [ 98 ] examined the efficacy of weekly 60-min group-based contingency management (CM) for reinforcing health behaviors and HIV-positive individuals with cocaine or opioid disorders ( N  = 170) in comparison to 12-step facilitation (TS) over the course of a 24-week period. Overall, participants in CM were more likely than those in TS to submit consecutive drug-free urine specimens, although the overall proportion of drug-free specimens did not vary between groups during treatment or over the follow-up period. Notably, during treatment, group CM was associated with greater reductions in HIV-risk behaviors as well as overall viral load compared to TS; although effects were not maintained over the follow-up period.

Across these studies, many trials showed positive gains for both group treatments examined [ 18 , 97 , 98 ], or no difference between groups when examining the benefit of adding group treatment to existing TAU [ 91 , 92 , 95 , 99 ]. However, one study demonstrated greater reductions in drug use among individuals with BPD and SUD who completed group DBT in comparison to TAU [ 96 ]. Further, BS groups were more effective than TS groups in improving psychosocial functioning and decreasing substance use [ 93 ]. Finally, CBT was more effective than DRM in reducing alcohol use, enhancing psychological functioning and improving social and family functioning compared to DRM and TAU among individuals dually diagnosed with SUD and a personality disorder [ 18 ].

Factors associated with treatment efficacy

Gender and treatment efficacy.

Five of the studies included in the present review examined whether treatment was differentially effective for men and women. Although Jarrell and Ridgely’s [ 93 ] evaluation of group BS, group TS and individual case management for individuals with SUD and co-occurring Axis I disorders did not examine whether group treatment types were differentially effective for men and women, data indicated that women—regardless of treatment group—reported higher role functioning (i.e.., independent living, work productivity, as well as immediate and extended social relationships), increased psychiatric symptomatology (depression, mania, drug use, alcohol use) across the follow-up periods compared to men.

Race and ethnicity and treatment efficacy

Among the studies included in the present review, only three examined whether treatment efficacy varied as a function of race and ethnicity. A secondary examination of the efficacy of group BS in comparison to group TS and individual case management [ 93 ] suggested that outcomes in each group treatment among ethnic and racial minority clients were equivalent to White participants during the 6-month follow [ 94 ]. The initial evaluation indicated that—regardless of group treatment type—racial/ethnic minority participants reported lower scores in personal well-being, lower life satisfaction (i.e., satisfaction with living), worse role functioning (i.e., independent living, work productivity, immediate and extended social relationships) over the follow-up periods compared to White participants [ 93 ].

Conclusions

In general, participants in group treatment for drug use disorders exhibit more improvement on typical measures of outcome (e.g., abstinence & use rates, objective measures, urinalysis) when compared to standard care without group [ 18 , 109 ] and those who refuse or drop out of treatment [ 110 ]. Specifically, CBT and CM appear to be more effective at reducing cocaine use than TAU groups. CM is effective in increasing periods of abstinence among users of methamphetamine. Both relapse prevention and social support group therapy were effective for marijuana use although relapse prevention was more helpful for men than for women. Brief MI and relapse prevention were both effective at reducing marijuana use. CBT and CBT-related treatments (including the matrix model) when added to pharmacotherapy were more effective for opioid use disorder than pharmacotherapy alone. Effective treatments for Mixed SUD include group CBT, CM, and women’s recovery group. Longer relapse prevention periods appear to be more helpful in reducing mixed SUD. Behavioral skills and behavioral skills plus contingency management helped decreased psychiatric symptoms and drug use behaviors. Psychoeducation groups alone, a commonly used intervention, were not effective at addressing SUD and co-occurring psychiatric problems. Additionally, it is important to note that there is potential for risk of bias in the studies included across four domains: participants, predictors, outcome, and analysis [ 111 ]. The current study did not comprehensively assess for risk of bias and this is a study limitation. Future research could assess for risk of bias by following the guidelines suggested by the Cochrane Handbook [ 112 ].

The current literature offers a wide variety of group treatments with varying goals and based on varying formal change theories. Overall, studies that reported between-group effect size ( n  = 7) reported small to medium effect sizes potentially suggesting differences were moderate but of potential theoretical interest. Of those seven studies, only two studies reported large effect sizes (both comparing an active treatment to a delayed treatment/untreated condition). In order to better characterize magnitude of intervention effects, future studies should report effect sizes and their confidence intervals [ 113 , 114 ]. Moreover, groups based on cognitive-behavioral theory [ 35 ], motivational enhancement theory [ 43 ], stages of change theory [ 115 ], 12-step theory [ 41 ] and psychoeducational group models [ 116 ] have all been the subject of recent studies. Steps of treatment have also been used to classify groups for acutely ill individuals with SUD versus middle stage (recovering) or after care groups, with the latter mainly focusing on relapse prevention. Group therapy is provided – at least as an augment to multimodal interventions – in most of the outpatient and inpatient programs in English speaking and European countries [ 17 , 117 ]. Therefore, continued efforts to implement and scale up group-based treatments for SUD known to be effective are needed. CM appears to be effective at addressing various drug use problems and further research should evaluate whether it would also be useful for marijuana use.

Future Research Questions

Studies of other group treatments for SUD that use rigorous, interview-based diagnosis, use control groups, randomly assign participants to condition, report the ethnic and racial composition of the sample, are adequately powered, implement a treatment manual, and compare outcomes to individual treatment as well are necessary.

Little is known regarding the possible mediators and moderators of treatment outcome in group interventions for SUD

Key Learning Objectives

Group treatment approaches are widely utilized and are often less costly to implement than individual treatments, currently we know very little whether one group approach is superior to another in the treatment of SUD.

Group treatment approaches seem to be more effective at improving positive outcomes (e.g., abstinence, use rates, objective measures, urinalysis) when compared to standard care without group [ 18 , 109 ], and those who refuse and drop out of treatment

More thorough randomized controlled trials of group SUD treatments are needed [ 110 ].

Availability of data and materials

Not applicable. The present study does not include original data. However, the authors of the study have listed all articles reviewed in this study in the reference section.

Abbreviations

Twelve Step Facilitation Group Therapy

Alcohol Dependence

Acquired Immunodeficiency Syndrome

Addiction Severity Index

Antisocial Personality Disorder

Abbreviated Program

Behavioral Skills

Borderline Personality Disorder

Cognitive Behavioral Therapy

Cocaine Dependence

Composite Diagnostic Interview Schedule

Contingency Management

Community Reinforcement Approach

Coping Skills

Cognitive Therapy

Dialectical Behavioral Therapy

Day Treatment

Drug Counseling

Diagnostic Interview Schedule

Diagnostic and Statistical Manual

Disease and Recovery Model

Delayed to Control

Evidence-Based Practice

Evidence-Based Treatment Practice

Enhanced Group Condition

Enhanced Treatment Program

Family Therapy

Group Drug Counseling

Human Immunodeficiency Virus

HIV Harm Reduction

Harm Reduction

Intensive Group Therapy

Individual Therapy

Motivational Interviewing

Matrix Model

Methadone Maintenance Therapy

National Institute of Drug Abuse

Psychoeducational Therapy Group

Pre-Post with Comparison Group (matched or otherwise)

Post Traumatic Stress Disorder

Random Assignment with Control

Relapse Prevention

Recovery Training

Random Assignment to Active Treatment

Relational Psychotherapy Mothers’ Group

Structured Clinical Interview for Diagnosis

Social Support

Standard Group Therapy

Substance Use Disorder

Seeking Safety

Standard Group Counseling

Standard Treatment Program

Treatment as Usual

Phone Monitoring and Counseling, with Support Group

Therapeutic Community Program

Twelve Step

Women’s Recovery Group

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López, G., Orchowski, L.M., Reddy, M.K. et al. A review of research-supported group treatments for drug use disorders. Subst Abuse Treat Prev Policy 16 , 51 (2021). https://doi.org/10.1186/s13011-021-00371-0

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Psychiatry Online

  • February 01, 2024 | VOL. 181, NO. 2 CURRENT ISSUE pp.83-170
  • January 01, 2024 | VOL. 181, NO. 1 pp.1-82

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Substance Use Disorders in Patients With Posttraumatic Stress Disorder: A Review of the Literature

  • Leslie K. Jacobsen , M.D. ,
  • Steven M. Southwick , M.D. , and
  • Thomas R. Kosten , M.D.

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OBJECTIVE: Alcohol use disorders and other substance use disorders are extremely common among patients with posttraumatic stress disorder (PTSD). This article reviews studies pertaining to the epidemiology, clinical phenomenology, and pathophysiology of comorbid PTSD and substance use disorders. METHOD: Studies were identified by means of computerized and manual searches. The review of research on the pathophysiology of PTSD and substance use disorders was focused on studies of the hypothalamic-pituitary-adrenal axis and the noradrenergic system. RESULTS: High rates of comorbidity suggest that PTSD and substance use disorders are functionally related to one another. Most published data support a pathway whereby PTSD precedes substance abuse or dependence. Substances are initially used to modify PTSD symptoms. With the development of dependence, physiologic arousal resulting from substance withdrawal may exacerbate PTSD symptoms, thereby contributing to a relapse of substance use. Preclinical work has led to the proposal that in PTSD, corticotropin-releasing hormone and noradrenergic systems may interact such that the stress response is progressively augmented. Patients may use sedatives, hypnotics, or alcohol in an effort to interrupt this progressive augmentation. CONCLUSIONS: Vigorous control of withdrawal and PTSD-related arousal symptoms should be sought during detoxification of patients with comorbid PTSD and substance use disorders. Inclusion of patients with comorbid PTSD and substance use disorders in neurobiologic research and in clinical trials will be critical for development of effective treatments for this severely symptomatic patient population.

Substance use disorders, particularly abuse of and dependence on central nervous system (CNS) depressants, are common in patients with posttraumatic stress disorder (PTSD). This article reviews clinical, epidemiologic, and neurobiologic studies relevant to the problem of comorbid PTSD and substance use disorders and discusses the clinical implications of these findings.

Clinical Phenomenology and Epidemiology

PTSD develops in some people after exposure to a severe traumatic event. The DSM-IV diagnosis of PTSD consists of symptoms in three clusters: 1) reexperiencing symptoms, including intrusive recollections of the trauma that are triggered by exposure to cues symbolizing the trauma; 2) avoidance symptoms, which involve diminished participation in activities and avoidance of thoughts, people, places, and memories associated with the trauma; and 3) arousal symptoms, which include difficulty sleeping, irritability, difficulty concentrating, hypervigilance, and exaggerated startle response.

Although intoxication and withdrawal symptoms vary across abused substances, all substance use disorders share key features. They include a maladaptive pattern of substance use leading to failure to fulfill work, school, or home obligations; legal problems; and substance-related interpersonal problems. Substance dependence further includes tolerance, withdrawal symptoms upon cessation of use, unsuccessful efforts to control use, and continued use despite persistent substance-related physical or psychological problems.

Persons with PTSD have elevated rates of comorbid psychiatric disorders. Studies of both combat veterans and civilians with PTSD have demonstrated that, among men with PTSD, alcohol abuse or dependence is the most common co-occurring disorder, followed by depression, other anxiety disorders, conduct disorder, and nonalcohol substance abuse or dependence (1 , 2) . Among women with PTSD, rates of comorbid depression and other anxiety disorders are highest, followed by alcohol abuse and dependence (1 , 2) . High rates of comorbidity of PTSD and substance use disorders were first reported in war-related studies, in which as many as 75% of combat veterans with lifetime PTSD also met criteria for alcohol abuse or dependence (2) . Among civilian populations, estimates of the prevalence of lifetime substance use disorders have ranged from 21.6% to 43.0% in persons with PTSD, compared with 8.1% to 24.7% in persons without PTSD (1 , 3 , 4) . Similarly, among substance abusers in the general population, the reported rate of PTSD is 8.3% (5) . Rates of PTSD appear to be higher among patients in inpatient substance abuse treatment (up to 42.5%) (6) and among pregnant women in residential treatment for substance abuse (62%) (7) . Surveys of substance-dependent adolescents have also found rates of PTSD ranging up to 19.2% (8) .

Patients with both PTSD and a substance use disorder have significantly higher rates of comorbid axis I and II disorders, psychosocial and medical problems, substance- or alcohol-related inpatient admissions, and relapse to substance use, compared with patients whose substance use is not complicated by PTSD (4 , 9) . Furthermore, patients with PTSD and substance use disorders tend to suffer from more severe PTSD symptoms, particularly those in the avoidance and arousal symptom clusters, than do patients with PTSD alone (10) . Conversely, one longitudinal study of patients with PTSD and a comorbid substance use disorder found at 6-month posttreatment follow-up that patients whose PTSD symptoms had remitted reported significantly less substance use than did patients with unremitted PTSD (11) .

Relationship of Substance Use to PTSD Symptoms

Elevated rates of comorbid depressive and anxiety disorders in patients with PTSD greatly complicate any effort to develop a model of the relationship between PTSD and substance use. High rates of comorbidity suggest that PTSD and substance use disorders are functionally related to one another. Two primary pathways have been described to explain these high rates of comorbidity. In the first, substance abuse precedes PTSD. To sustain their habit, some substance abusers repetitively place themselves in dangerous situations and, as a result, experience high levels of physical and psychological trauma (5) . For example, in a study of patients with PTSD and comorbid cocaine abuse, patients whose cocaine abuse developed first later developed PTSD as a result of trauma sustained in the context of procurement and use of cocaine (12) . Given that chronic substance use can lead to higher levels of arousal and anxiety as well as to sensitization of neurobiologic stress systems (13) , substance abuse may result in a higher level of vulnerability to development of PTSD after exposure to trauma.

In the second pathway, PTSD precedes development of substance use disorders. In this model, the use of substances is a form of self-medication. Patients report that CNS depressants, such as alcohol, cannabis, opioids, and benzodiazepines acutely improve PTSD symptoms (14) . Consistent with this, patients with PTSD report that onset and severity of substance abuse parallel the onset and escalation of PTSD symptoms (14) . In addition, clinical evidence suggests that the choice of substances of abuse (CNS depressants versus CNS stimulants) may stem from the particular constellation of PTSD symptoms that patients experience. For example, PTSD patients with alcohol dependence exhibit significantly more arousal symptoms that do PTSD patients with cocaine dependence (10) .

In the second model, withdrawal from substances, particularly CNS depressants, may initiate a cycle that perpetuates relapse and continued substance use. The withdrawal syndromes associated with many CNS depressants overlap extensively with the arousal symptoms of PTSD (15) ( Figure 1 ). Substances may be taken initially to ameliorate PTSD symptoms. As noted earlier, patients with PTSD have reported that CNS depressants acutely provide symptom relief (14) . Furthermore, objectively measured startle responses are reduced by alcohol (16) . However, the physiologic arousal resulting from substance withdrawal may have an additive effect with arousal symptoms stemming from PTSD. The resulting hyperaroused state may serve as a conditioned reminder of traumatic events and thus precipitate an increase in reexperiencing symptoms. Exacerbation of PTSD symptoms may then prompt relapse to substance use in an attempt to self-medicate. Thus, for the PTSD patient who already has symptoms of arousal, the additional arousal that accompanies withdrawal from substances may be intolerable. Alternatively, substances may be used to cope with the traumatic event itself (17) . This pattern may particularly apply when trauma that leads to PTSD occurs during adulthood. The initial calming effects from substance use may cue patients to resume substance use when PTSD symptoms reemerge.

Most published data support the second model, in which substance use follows or parallels traumatic exposure and the development of PTSD (18) . In a longitudinal study conducted by Chilcoat and Breslau (19) , 1,007 adults were reevaluated 3 and 5 years after an initial assessment. The researchers found that preexisting substance abuse did not increase subjects’ risk of subsequent exposure to trauma or their risk of developing PTSD after exposure to trauma. The relationship between exposure to trauma and increased risk for development of a substance use disorder was found to be specific to PTSD, as exposure to trauma without subsequent development of PTSD did not increase risk for development of a substance use disorder (19) . Of note, one study of patients with cocaine dependence and PTSD found that patients in whom PTSD preceded the onset of cocaine use were significantly more likely to suffer from comorbid major depression and to use benzodiazepines and opiates than were patients in whom PTSD developed after the onset of cocaine use (12) .

Pathophysiology

Our review of the literature on the pathophysiologic basis of comorbid PTSD and addiction selectively focuses on studies of the hypothalamic-pituitary-adrenal (HPA) axis and the noradrenergic system, as these have been most extensively studied in PTSD. It must be emphasized that many other neurobiological systems are involved in both the acute and chronic adaptation to stress and to substance use. These systems include the dopaminergic, γ-aminobutyric acid, benzodiazepine, and serotonergic systems, as well as the thyroid axis. Interactions among these systems in patients with comorbid PTSD and substance dependence are enormously complex. Thus, the potential relationships we discuss between the HPA axis, the noradrenergic system, and symptoms in patients with comorbid PTSD and substance use disorders should be viewed as one part of a far more complex whole.

HPA Axis in PTSD and Addiction

In humans and animals, acute stress elicits a cascade of neurohormonal events, including increased turnover of norepinephrine in terminal projection regions of the locus ceruleus and liberation of hypothalamic corticotropin-releasing hormone (CRH) into the pituitary portal system, which stimulates release of ACTH from the pituitary, which in turn triggers release of cortisol (human) or corticosterone (rat) from the adrenals (20) . Animal and human research has implicated this cascade in the pathophysiology of both substance use disorders and PTSD.

Humans with substance dependence most frequently identify stress and negative mood states as reasons for relapse and ongoing substance abuse (21) . Recently, a personalized stress imagery task was shown to reliably increase cocaine craving and salivary cortisol in cocaine-dependent patients (22) . Animal studies have shown that stress induces relapse to heroin and to cocaine self-administration in rats trained to self-administer these substances and then subjected to a prolonged drug-free period (23 , 24) . Similarly, in animals naive to illicit substances, a large range of stressors increases the proclivity toward drug self-administration (25) . Initial work on the pathophysiology of this phenomenon indicated that stress-induced or stress-enhanced drug self-administration is mediated by corticosterone (26) .

Evidence has accumulated to support a role for CRH in mediating the effects of stress on drug self-administration. Central, but not peripheral, administration of CRH has been shown to induce a long-lasting enhancement (sensitization) of the locomotor response to d-amphetamine (27) , and pretreatment with a CRH antagonist has been shown to block the development of stress-induced sensitization to d-amphetamine (28) . Indeed, central administration of anti-CRH antibody or the CRH receptor antagonist α-helical CRH has been found to block the locomotor hyperactivity induced by cocaine (29) .

Withdrawal from chronic cocaine or alcohol administration in rats produces anxiety-like behavior and decreased exploration that is associated with selective increases in CRH in the hypothalamus, amygdala, and basal forebrain (30 , 31) . Pretreatment with anti-CRH immunoserum or α-helical CRH, blocking the effects of CRH, completely prevents the development of these withdrawal-associated behaviors (30) . Consistent with these observations, CSF CRH is elevated in humans in acute alcohol withdrawal and then normalizes or decreases below normal levels with extended abstinence and resolution of withdrawal symptoms (32) . Shaham and colleagues (33) found that intracerebroventricular injection of CRH reinstated heroin seeking after extinction in rats trained to self-administer the drug. In addition, α-helical CRH attenuated the reinstatement effect of footshock stress (33) . Neither adrenalectomy nor chronic or acute exposure to the corticosterone synthesis inhibitor metyrapone interfered with the reinstatement effects of priming injections of heroin or of footshock stress. A potent, selective CRF1 receptor antagonist, CP-154,526, has been found to attenuate reinstatement of drug seeking induced by footshock stress after up to 14 days of extinction in rats trained to self-administer heroin or cocaine (34) .

Findings from both animal and human studies of the effects of chronic stress or of PTSD on HPA axis function vary depending on the experimental paradigm used or the population studied. In patients with PTSD, elevated (35) , reduced (36) , and normal (37) levels of cortisol secretion have been reported. A series of studies performed by Yehuda and colleagues demonstrated that patients with PTSD have an elevated number of lymphocyte glucocorticoid receptors (38) , enhanced suppression of cortisol after administration of dexamethasone (39) , a greater than normal decrease in the number of lymphocyte glucocorticoid receptors after administration of dexamethasone (39) , and higher than normal increases in ACTH after metyrapone blockade of cortisol synthesis (40) . All of these findings suggest that glucocorticoid negative feedback is enhanced in PTSD.

Animal studies examining the effects of uncontrollable stress on HPA axis function have reported initial increases of corticosterone secretion, followed by normalization of corticosterone secretion with ongoing chronic stress (41) . However, some investigators have failed to demonstrate normalization of corticosterone secretion with chronic uncontrollable stress (42) , particularly in animals that have been reared under stressful conditions (43) or when levels of chronic stress are high (44) . In a pattern similar to that found in humans with PTSD, animals subjected to a single episode of prolonged stress and then briefly restressed after a stress-free period showed enhancement of glucocorticoid negative feedback (45) .

Although both animal and human studies have suggested that glucocorticoid negative feedback may be enhanced in PTSD, the implications of these observations for CRH secretion in this disorder are unclear. As noted earlier, CRH-producing cells and CRH receptors exist both in the hypothalamus and in extrahypothalamic sites. Findings from some studies have suggested that hypothalamic and extrahypothalamic CRH-producing cells may respond differently to corticosterone. Specifically, corticosterone appears to restrain hypothalamic CRH-producing cells while stimulating extrahypothalamic CRH-producing cells, particularly those in the amygdala (46) . Replacement of corticosterone in adrenalectomized rats decreases CRH production in the parvocellular nucleus of the hypothalamus while increasing CRH production in the central nucleus of the amygdala (47) . This region-specific pattern of regulation is also seen in adrenally intact rats treated with high-stress levels of corticosterone for extended periods of time (48) . Thus, while glucocorticoid feedback may decrease CRH production and release in the hypothalamus, it may stimulate CRH production and release in other brain regions, including the amygdala. This possibility has been addressed in two studies of patients with PTSD, one that examined CSF concentrations of CRH at a single time point (49) and one that examined CSF concentrations of CRH at serial time points over a 6-hour period (37) . Both found significantly higher levels of CSF CRH in patients with PTSD than in normal comparison subjects. However, although elevated CSF CRH suggests that brain CRH may be elevated, the specific brain tissues producing CRH elevations cannot be determined from CSF data alone.

The possibility that brain CRH levels are elevated in PTSD is of great interest because of a rich preclinical literature indicating that elevated levels of CRH in the brain, particularly in the amygdala, potentiate fear-related behavioral responses, including the startle response (50) . These anxiogenic effects of CRH are reversed by administration of CRH antagonists (50) . As noted earlier, findings from animal and human studies have supported a role for CRH in mediating some effects of drugs of abuse, including stress- or priming-induced relapse to drug self-administration and symptoms of withdrawal (27 , 28 , 32 – 34) . Thus, elevated levels of CRH in the brain in PTSD may mediate both the symptoms of hyperarousal as well as the increased risk for substance abuse and dependence seen in this disorder. More specifically, elevated levels of CRH in the brain in PTSD may enhance the euphorigenic properties of certain drugs, such as stimulants, and may worsen the severity of withdrawal symptoms, thereby prompting patients to relapse to drug use. Conversely, brain CRH elevations induced by withdrawal from substance use may exacerbate symptoms of hyperarousal, which could trigger other symptoms of PTSD, prompting relapse to substance use.

Noradrenergic System in PTSD and Addiction

During chronic uncontrollable stress, norepinephrine turnover increases in specific brain regions, including the locus ceruleus, hypothalamus, hippocampus, amygdala, and cerebral cortex (51) . Evidence for noradrenergic dysregulation in patients with PTSD has included elevated 24-hour urinary epinephrine and norepinephrine excretion, a lower than normal number of platelet α 2 -adrenergic receptors, elevated 24-hour plasma norepinephrine, and exaggerated cardiovascular and 3-methoxy-4-hydroxyphenylglycol (MHPG) (a norepinephrine metabolite) responses to intravenous yohimbine (52) . Noradrenergic dysregulation has also been reported during states of withdrawal from chronic self-administration of alcohol and other abused substances. The levels of noradrenaline, norepinephrine, and MHPG in both plasma and CSF have been found to be increased and the number of platelet α 2 -adrenergic receptors decreased in alcoholics during acute withdrawal (53 , 54) . The severity of alcoholic withdrawal symptoms has been positively correlated with the concentration of MHPG in CSF (54) . Evidence for noradrenergic dysregulation in opiate withdrawal has included findings of elevated plasma MHPG in humans and elevated plasma and brain MHPG in animals (55 , 56) . In animals, the level of noradrenergic activity was significantly correlated with the severity of withdrawal symptoms (56) . These findings have prompted the use of the α 2 -adrenergic receptor agonist clonidine in the treatment of both opiate withdrawal symptoms and PTSD (57 , 58) .

Noradrenergic System/HPA Axis Interactions

Evidence that brain CRH and noradrenergic systems modulate each other has been reported. Stress has been shown to increase CRH levels in the locus ceruleus (59) , a primary source of noradrenergic projections to all cortices as well as to the thalamus and hypothalamus, while intraventricular administration of CRH has been found to increase the discharge rates of locus ceruleus neurons and to increase norepinephrine turnover in hippocampus, hypothalamus, and prefrontal cortex (60 – 62) . Conversely, stress-induced activation of the locus ceruleus has been blocked by administration of CRH antagonists (63) . Similar evidence exists for the interaction of the CRH and noradrenergic systems in the hypothalamus (64) and the amygdala, where stress induces increases in both CRH and norepinephrine (65) . Furthermore, norepinephrine in the amygdala appears to stimulate release of CRH (66) .

These observations have prompted the proposal by Koob (20) that interactions of the CRH and noradrenergic systems in the brain may, under some conditions, function as a feed-forward system, leading to the progressive augmentation of the stress response with repeated stress exposure that is characteristic of PTSD. This progressive augmentation of response with repeated stress has previously been conceptualized as kindling (67) . A feed-forward interaction between the CRH and noradrenergic systems may represent one neurobiologic underpinning of both PTSD and substance use disorders. More specifically, stress, including stress related to self-administration of or withdrawal from substances, may stimulate CRH release in the locus ceruleus, leading to activation of the locus ceruleus and release of norepinephrine in the cortex, which in turn may stimulate the release of CRH in the hypothalamus and amygdala (20) . Such an interaction between the brain noradrenergic and CRH systems may mediate the symptoms of hyperarousal seen in PTSD, including exaggerated startle response. The proclivity toward misuse of CNS depressants by patients with PTSD may reflect an attempt to interrupt this feed-forward interaction by suppressing activity of the locus ceruleus with these agents (68) .

Conclusions

Clinical and epidemiologic studies confirm that comorbidity of PTSD with substance use disorders is common and that the symptoms of patients with this comorbidity tend to be more severe and more refractory to treatment than those of patients suffering from either disorder alone. Despite the frequency with which patients with both diagnoses present for treatment, no systematic treatment approach of proven efficacy has been developed for this population. Furthermore, little is known about the impact on substance use disorder outcomes of the medications and psychosocial interventions commonly used to treat PTSD, or vice versa.

These limitations notwithstanding, the research conducted to date can inform both clinical practice and future clinical and preclinical research. For example, clinical research suggests that PTSD patients with substance dependence, particularly those who are addicted to CNS depressants, may find the physiologic arousal resulting from substance withdrawal intolerable due to additive effects with preexisting arousal symptoms related to PTSD. Successful detoxification of these patients may thus require inpatient admission to permit vigorous control of withdrawal and PTSD-related arousal symptoms.

Neurobiologic research indicates that high levels of CRH in the brain, particularly in the amygdala, may be common to both PTSD and to substance withdrawal states. Further, CRH antagonists reduce both the anxiety and the enhanced response to illicit substances (sensitization) that are induced by higher levels of brain CRH. These observations suggest that CRH antagonists could potentially have a role in the treatment of patients with PTSD and comorbid substance dependence. Although at present no CRH antagonist has been approved for human use, a series of CRH antagonists that can be administered peripherally have been developed and have been shown to cross the blood brain barrier (34 , 69) . These agents will be important tools for further defining the potential role of CRH antagonism in the treatment of patients with PTSD and substance dependence and will hopefully lead to development of orally active preparations.

Evidence of noradrenergic dysregulation in both PTSD and in withdrawal from CNS depressants has prompted the use of the α 2 -adrenoceptor agonist clonidine in both disorders (57 , 58) . Data from both preclinical and clinical research suggest that this agent, as well as the selective α 2 -adrenoceptor agonist guanfacine, would be effective in reducing noradrenergic hyperactivity in patients with PTSD and comorbid substance dependence. Guanfacine, given its greater selectivity, may offer a more favorable side effect profile. Given the dearth of established treatments for this patient population, controlled clinical trials to establish the efficacy of these agents are clearly indicated.

Finally, although preclinical work has resulted in considerable progress toward delineating the contributions of the HPA axis and noradrenergic systems to the pathophysiologic underpinnings of PTSD with comorbid substance dependence, few neurobiologic studies have been conducted in this patient population. The inclusion of subjects with this comorbidity may render such studies more complicated, but the data emerging from this work would better inform the clinical management of the difficult-to-treat symptoms of these frequently encountered patients. At the minimum, patients who participate in studies of PTSD or of substance dependence must be thoroughly evaluated for the presence of this comorbidity to permit adequate control of the effects of the comorbid condition on the neurobiologic processes under study.

Received May 11, 2000; revision received Aug. 22, 2000; accepted Nov. 17, 2000. From the Department of Psychiatry, Yale University School of Medicine, New Haven, Conn., and the VA Connecticut Healthcare System. Address correspondence to Dr. Jacobsen, Department of Psychiatry (116A), VA Connecticut Healthcare System, Yale University–West Haven Campus, 950 Campbell Ave., West Haven, CT 06516; [email protected] (e-mail). Supported in part by grants DA-00167, DA-04060, and DA-09250 from the National Institute on Drug Abuse.

Figure 1.

Figure 1. Symptoms of Increased Arousal in PTSD and Symptoms Associated With Withdrawal From CNS Depressants a

a From the DSM-IV criteria for PTSD, alcohol withdrawal, and sedative, hypnotic, or anxiolytic withdrawal.

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  • Alcohol expectancies and distress tolerance: Potential mechanisms in the relationship between posttraumatic stress and alcohol use Personality and Individual Differences, Vol. 137
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  • Substance use disorder and posttraumatic stress disorder symptomology on behavioral outcomes among juvenile justice youth 21 December 2018 | The American Journal on Addictions, Vol. 28, No. 1
  • Is Integrated CBT Effective in Reducing PTSD Symptoms and Substance Use in Iraq and Afghanistan Veterans? Results from a Randomized Clinical Trial 23 June 2018 | Cognitive Therapy and Research, Vol. 42, No. 6
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  • Journal of Contemporary Psychotherapy, Vol. 48, No. 1
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  • Journal of Anxiety Disorders, Vol. 53
  • Journal of Substance Abuse Treatment, Vol. 85
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  • Psychological Medicine, Vol. 48, No. 16
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  • A Multisite Study of the Association Between Emotion Dysregulation and Deliberate Self-harm Among Substance Use Disorder Inpatients Addictive Disorders & Their Treatment, Vol. 10, No. 4
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  • Psychotherapie bei Abhängigkeits- erkrankungen und Posttraumatischer Belastungsstörung SUCHT, Vol. 57, No. 5
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review of literature on drug addiction

Characteristics of Alcohol, Marijuana, and Other Drug Use Among Persons Aged 13–18 Years Being Assessed for Substance Use Disorder Treatment — United States, 2014–2022

Weekly / February 8, 2024 / 73(5);93–98

Sarah Connolly, PhD 1 ,2 ; Taryn Dailey Govoni, MPH 3 ; Xinyi Jiang, PhD 2 ; Andrew Terranella, MD 2 ; Gery P. Guy Jr., PhD 2 ; Jody L. Green, PhD 3 ; Christina Mikosz, MD 2 ( View author affiliations )

What is already known about this topic?

Substance use, including drugs and alcohol, often begins during adolescence.

What is added by this report?

Among adolescents being assessed for substance use disorder treatment, the most commonly reported reasons for substance use included seeking to feel mellow or calm, experimentation, and other stress-related motivations. Most reported using substances with friends; however, approximately one half of respondents who reported past–30-day prescription drug misuse reported using alone.

What are the implications for public health practice?

Reducing stress and promoting mental health among adolescents might lessen motivations for substance use. Educating adolescents on harm reduction practices, including the risks of using drugs alone and ensuring they are able to recognize and respond to overdose (e.g., administering naloxone), could prevent fatal overdoses.

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The figure is a graphic with text about how clinicians can help address teen substance use with illustrations of teens doing healthy activities.

Substance use often begins during adolescence, placing youths at risk for fatal overdose and substance use disorders (SUD) in adulthood. Understanding the motivations reported by adolescents for using alcohol, marijuana, and other drugs and the persons with whom they use these substances could guide strategies to prevent or reduce substance use and its related consequences among adolescents. A cross-sectional study was conducted among adolescents being assessed for SUD treatment in the United States during 2014–2022, to examine self-reported motivations for using substances and the persons with whom substances were used. The most commonly reported motivation for substance use was “to feel mellow, calm, or relaxed” (73%), with other stress-related motivations among the top reasons, including “to stop worrying about a problem or to forget bad memories” (44%) and “to help with depression or anxiety” (40%); one half (50%) reported using substances “to have fun or experiment.” The majority of adolescents reported using substances with friends (81%) or using alone (50%). These findings suggest that interventions related to reducing stress and addressing mental health concerns might reduce these leading motivations for substance use among adolescents. Education for adolescents about harm reduction strategies, including the danger of using drugs while alone and how to recognize and respond to an overdose, can reduce the risk for fatal overdose.

Introduction

Initiation of substance use often occurs during adolescence ( 1 ), and adolescents commonly report using substances to feel good or get high and to relieve pain or aid with sleep problems ( 2 , 3 ). Adverse consequences of adolescent substance use include overdose, risk for development of substance use disorder (SUD), negative impact on brain development, and death. Prescription opioid misuse during adolescence is associated with SUD in adulthood ( 4 ). In the event of an overdose, immediate medical attention is necessary; bystanders can respond by calling emergency medical personnel and administering naloxone, which reverses overdoses caused by opioids. To guide the development and implementation of prevention strategies and help reduce substance use and fatal overdoses among youths, the motivations for substance use and the persons with whom adolescents report using substances were studied.

Data Source

Data were obtained from the National Addictions Vigilance Intervention and Prevention Program’s Comprehensive Health Assessment for Teens (CHAT) ( 5 ). CHAT is a self-reported, online assessment for persons aged 13–18 years who are being evaluated for SUD treatment. Assessments conducted during January 1, 2014–September 28, 2022, were analyzed. Because the assessment may be completed more than once, assessments completed by the same person within 60 days of a previous assessment were removed. The data set was restricted to assessments reporting past–30-day use of alcohol, marijuana, or other drugs* and with at least one option selected for motivation or persons with whom substances were used.

Respondents were asked to report specific substances used within six categories: 1) alcohol, 2) marijuana, hashish, or tetrahydrocannabinol (THC), 3) drugs other than alcohol or marijuana, † and misuse § of 4) prescription pain medications, ¶ 5) prescription stimulants,** or 6) prescription sedatives or tranquilizers. †† Motivation for use was asked for each of the six categories; each motivation question had 15 response options §§ and respondents were asked to select all options that applied. Respondents were also asked to select the persons with whom they used substances from four categories of substances: 1) alcohol, 2) marijuana, hashish, or THC, 3) drugs other than alcohol or marijuana, and 4) prescription drugs (which included prescription pain medications, prescription stimulants, and prescription sedatives or tranquilizers). Ten options describing the persons with whom substances were used were presented, ¶¶ and respondents were asked to select all that applied.

Data Analysis

The percentages of each motivation and the persons with whom substances were used were calculated.*** Responses were not mutually exclusive: a respondent could report more than one motivation or person with whom substances were used; therefore, the percentages sum to >100. R software (version 4.2.2; R Foundation) was used to conduct all analyses. This activity was reviewed by CDC, deemed not research, and was conducted consistent with applicable federal law and CDC policy. †††

Substance Use

Among 15,963 CHAT assessments conducted during the study period, 9,557 (60%) indicated past–30-day use of alcohol, marijuana, or other drugs. Of those, 9,543 reported at least one motivation or person with whom substances were used and were included in further analyses. Marijuana was most commonly reported (84% of assessments), followed by alcohol (49%) ( Figure ) ( Table ). Nonprescription drug use was indicated on 2,032 (21%) assessments; those most commonly reported were methamphetamine (8%), cough syrup (7%), and hallucinogens (6%). Prescription drug misuse was indicated on 1,812 (19%) assessments, with prescription pain medication reported most commonly (13%), followed by prescription sedatives or tranquilizers (11%), and prescription stimulants (9%).

Reasons Reported for Using Substances

Overall, the most common reasons adolescents reported for using substances were to feel mellow, calm, or relaxed (73%), to have fun or experiment (50%), to sleep better or to fall asleep (44%), to stop worrying about a problem or to forget bad memories (44%), to make something less boring (41%), and to help with depression or anxiety (40%). By category, the most frequently reported motivation for alcohol use and nonprescription drug misuse was to have fun or experiment (51% and 55%, respectively), whereas use to feel mellow, calm, or relaxed was the most reported motivation for use of marijuana (76%), and misuse of prescription pain medications (61%) and prescription sedatives or tranquilizers (55%). The most common motivation for prescription stimulant misuse was to stay awake (31%).

Persons with Whom Substances Were Used

Adolescents most commonly used substances with friends (81%), a boyfriend or girlfriend (24%), anyone who has drugs (23%), and someone else (17%); however, one half (50%) reported using alone. Although using with friends and using alone were reported most often for all substances, the prevalence varied by substance type. Approximately 80% of adolescents who reported using alcohol, marijuana, or nonprescription drugs reported using these substances with friends; however, 64% of those who reported misusing prescription drugs used them with friends. Among adolescents reporting prescription drug misuse, more than one half (51%) reported using these drugs alone, whereas using alone was reported by 44% of those who used marijuana, 39% of those who used nonprescription drugs, and 26% of those who used alcohol.

This analysis summarizing self-reported motivations for use of various substances among adolescents being assessed for SUD treatment who used alcohol, marijuana, or other drugs during the previous 30 days, and the persons with whom adolescents used these substances, found that many adolescents use substances to have fun or experiment or to seek relief mentally, emotionally, or physically. These findings are consistent with those reported in a 2020 study that examined motivations for the nonmedical use of prescription drugs in a sample of young adults, which identified recreational and self-treatment motivations among young adults over time and across drug classes ( 2 ). Anxiety and experiencing traumatic life events have been associated with substance use in adolescents ( 6 ). Specific reporting of motivations, including “to stop worrying about a problem or to forget bad memories” and “to help with depression or anxiety,” underscores the potential direct impact that improving mental health could have on substance use.

One half of adolescents reported using substances while alone. Of particular concern, more than one half of respondents who reported past–30-day prescription drug misuse reported using the drugs alone. Prescription drug misuse while alone presents a significant risk for fatal overdose, especially given the proliferation of counterfeit pills resembling prescription drugs and containing illegal drugs (e.g., illegally manufactured fentanyl) ( 7 ). Education about harm reduction behaviors, such as using in the presence of others and expanding access to naloxone to all persons who use drugs, could reduce this risk.

Adolescents most commonly reported using substances with friends, which presents the opportunity for bystander intervention in the event of an overdose. Nearly 70% of fatal adolescent overdoses occurred with a potential bystander present, yet in most cases no bystander response was documented ( 8 ). Overdose deaths can be prevented through education tailored to adolescents to improve recognition of signs of overdose and teach bystanders how to respond, including the administration of naloxone ( 9 ) and increasing awareness of local Good Samaritan laws, which protect persons against liability when they provide emergency care to others ( 10 ). In addition, ensuring access to effective, evidence-based treatment for SUD and mental health conditions might decrease overdose risk.

Limitations

The findings in this report are subject to at least three limitations. First, the population represents a convenience sample of adolescents being assessed for SUD treatment and is not generalizable to all adolescents in the United States. Second, the assessment is self-reported and subject to potential reporting and recall biases as well as social desirability bias. Finally, several questions on motivations and persons with whom respondents use substances refer to categories of substances; thus, it was not possible to ascertain to which specific drug a person might be referring in their response if use of more than one substance within a drug category was reported.

Implications for Public Health Practice

Harm reduction education specifically tailored to adolescents has the potential to discourage using substances while alone and teach how to recognize and respond to an overdose in others, which could thereby prevent overdoses that occur when adolescents use drugs with friends from becoming fatal. Public health action ensuring that youths have access to treatment and support for mental health concerns and stress could reduce some of the reported motivations for substance use. These interventions could be implemented on a broad or local scale to improve adolescent well-being and reduce harms related to substance use.

Acknowledgment

Akadia Kacha-Ochana, CDC.

Corresponding author: Sarah Connolly, [email protected] .

1 Epidemic Intelligence Service, CDC; 2 Division of Overdose Prevention, National Center for Injury Prevention and Control, CDC; 3 Inflexxion, Irvine, California.

All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

* Two assessments that reported using only methadone were excluded.

† The category “drugs, other than alcohol or marijuana” included the following nonprescription drugs: inhalants, cocaine, methamphetamines, hallucinogens, phenylcyclidine or ketamine, heroin, ecstasy or 3,4-methylenedioxy-methamphetamine, gamma hydroxybutyrate or rohypnol, cough syrup, illegally made fentanyl (added to assessment in 2017), and xylazine (added to assessment in 2022), methadone, “other drug,” and “any drug.”

§ Misuse is described as prescription medication use “not as prescribed,” “without a prescription from a doctor,” “to get high,” or “to change how you feel.”

¶ A description of prescription pain medications provided in the assessment states, “Examples of painkillers include Oxycontin, Vicodin, and Percocet. Pain medications help people feel less pain after surgery, and help manage intense chronic pain.”

** A description of prescription stimulants provided in the assessment states, “Examples of stimulants include Ritalin, Adderall, and Dexedrine. Stimulants help people concentrate or focus better.”

†† A description of prescription sedatives or tranquilizers provided in the assessment states, “Examples of sedatives include Valium, Xanax, and Klonopin. Sedatives or tranquilizers help people sleep or feel less anxious.”

§§ 1) To feel mellow, calm, or relaxed, 2) to sleep better or fall asleep, 3) to stay awake, 4) to feel less shy or more social, 5) to stop worrying about a problem or forget bad memories, 6) to have fun or experiment, 7) to be sexier or make sex more fun, 8) to lose weight, 9) to make something less boring, 10) to improve or get rid of the effects of other drugs, 11) to concentrate better, 12) to deal with chronic pain, 13) to help with depression or anxiety, 14) to fit in, or 15) other reasons.

¶¶ 1) Friend or friends, 2) brother or sister, 3) parent or parents, 4) adult relative or other adult, 5) relative near adolescent’s own age, 6) boyfriend or girlfriend, 7) coworker, 8) someone else, 9) anyone who has drugs, or 10) used alone.

*** The number of assessments for which an option was selected was divided by the total number of assessments in that substance type category.

††† 45 C.F.R. part 46.102(l)(2), 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C. Sect. 552a; 44 U.S.C. Sect. 3501 et seq.

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  • Richert T, Anderberg M, Dahlberg M. Mental health problems among young people in substance abuse treatment in Sweden. Subst Abuse Treat Prev Policy 2020;15:43. https://doi.org/10.1186/s13011-020-00282-6 PMID:32580732
  • O’Donnell J, Tanz LJ, Miller KD, et al. Drug overdose deaths with evidence of counterfeit pill use—United States, July 2019–December 2021. MMWR Morb Mortal Wkly Rep 2023;72:949–56. https://doi.org/10.15585/mmwr.mm7235a3 PMID:37651284
  • Tanz LJ, Dinwiddie AT, Mattson CL, O’Donnell J, Davis NL. Drug overdose deaths among persons aged 10–19 years—United States, July 2019–December 2021. MMWR Morb Mortal Wkly Rep 2022;71:1576–82. https://doi.org/10.15585/mmwr.mm7150a2 PMID:36520659
  • Walley AY, Xuan Z, Hackman HH, et al. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis. BMJ 2013;346:f174. https://doi.org/10.1136/bmj.f174 PMID:23372174
  • Hamilton L, Davis CS, Kravitz-Wirtz N, Ponicki W, Cerdá M. Good Samaritan laws and overdose mortality in the United States in the fentanyl era. Int J Drug Policy 2021;97:103294. https://doi.org/10.1016/j.drugpo.2021.103294 PMID:34091394

FIGURE . Percentage of persons aged 13–18 years being assessed for substance use disorder treatment reporting specific substances used during the previous 30 days* — National Addictions Vigilance Intervention and Prevention Program Comprehensive Health Assessment for Teens, United States, 2014–2022

Abbreviations: GHB = gamma hydroxybutyrate; MDMA = 3,4-methylenedioxy-methamphetamine; PCP = phenylcyclidine.

* Among those reporting previous 30-day use of any alcohol, marijuana, or other drugs, and at least one motivation or person with whom substances were used.

Abbreviation: THC = tetrahydrocannabinol. * Includes motivations or persons with whom adolescents used substances reported for any of the following: alcohol, marijuana, nonprescription drugs, prescription drug misuse, methadone, “other drug,” and “any drug.” † The alcohol motivation question is phrased, “People use alcohol for many reasons. Why have you used alcohol? Select all that apply.” The question asking with whom alcohol is used is phrased, “When you drink, who do you drink with? Select all that apply.” § The marijuana motivation question is phrased, “People use marijuana, hashish, or THC for many reasons. Why have you used marijuana, hashish, or THC? Select all that apply.” The question asking with whom marijuana is used is phrased, “When you use marijuana, hashish, or THC, who do you use it with? Select all that apply.” ¶ Inhalants, cocaine, methamphetamines, hallucinogens, phenylcyclidine or ketamine, heroin, ecstasy or 3,4-methylenedioxy-methamphetamine, gamma hydroxybutyrate or rohypnol, cough syrup, illegally made fentanyl (added to assessment in 2017), and xylazine (added to assessment in 2022). The motivation question is phrased, “People use drugs for many reasons. Why have you used drugs, other than alcohol or marijuana? Select all that apply.” The question asking with whom these substances are used is phrased, “When you use drugs, other than alcohol or marijuana, who do you use them with? Select all that apply.” This assessment section also included methadone, “other drug,” and “any drug,” which are captured by the same motivation question and the question asking with whom persons use. If a person reported methadone, “other drug,” or “any drug” in addition to one or more nonprescription drugs, the motivations and with whom they use (for methadone, “other drug,” or “any drug”) cannot be differentiated and are counted in this table. ** Includes persons who responded affirmatively to assessment questions asking about prescription pain medication use “not as prescribed,” “without a prescription from a doctor,” “to get high,” or “to change how you feel.” The motivation question is phrased, “People use drugs for many reasons. Why have you used prescription pain medications on your own? Select all that apply.” †† Includes persons who responded affirmatively to assessment questions asking about prescription stimulant use “not as prescribed,” “without a prescription from a doctor,” “to get high,” or “to change how you feel.” The motivation question is phrased, “People use drugs for many reasons. Why have you used prescription stimulants on your own? Select all that apply.” §§ Includes persons who responded affirmatively to assessment questions asking about prescription sedative and tranquilizer use “not as prescribed,” “without a prescription from a doctor,” “to get high,” or “to change how you feel.” The motivation question is phrased, “People use drugs for many reasons. Why have you used prescription sedatives or tranquilizers on your own? Select all that apply.” ¶¶ The question asking with whom substances are used is asked once for all prescription drugs and is phrased, “When you use prescription drugs, who do you use them with? Select all that apply.” The denominator for the number of assessments indicating past–30-day misuse of at least one prescription drug is 1,812. *** Motivation and persons with whom substances are used questions are in a “select all that apply” format; therefore, percentages sum to >100. Median and IQR summarize the number of motivations and the number of persons with whom they use substances that respondents selected for each question.

Suggested citation for this article: Connolly S, Govoni TD, Jiang X, et al. Characteristics of Alcohol, Marijuana, and Other Drug Use Among Persons Aged 13–18 Years Being Assessed for Substance Use Disorder Treatment — United States, 2014–2022. MMWR Morb Mortal Wkly Rep 2024;73:93–98. DOI: http://dx.doi.org/10.15585/mmwr.mm7305a1 .

MMWR and Morbidity and Mortality Weekly Report are service marks of the U.S. Department of Health and Human Services. Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services. References to non-CDC sites on the Internet are provided as a service to MMWR readers and do not constitute or imply endorsement of these organizations or their programs by CDC or the U.S. Department of Health and Human Services. CDC is not responsible for the content of pages found at these sites. URL addresses listed in MMWR were current as of the date of publication.

All HTML versions of MMWR articles are generated from final proofs through an automated process. This conversion might result in character translation or format errors in the HTML version. Users are referred to the electronic PDF version ( https://www.cdc.gov/mmwr ) and/or the original MMWR paper copy for printable versions of official text, figures, and tables.

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Literature review on the relation between drug use, impaired driving and traffic accidents

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The health consequences of drug use are a priority area for the EMCDDA and impaired driving and road traffic accidents linked to drugs constitute an important topic on which comprehensive information is lacking. The literature review addressed inter alia the relationship between different patterns of drug consumption, impaired driving and traffic accidents. In addition drug testing procedures and associated legislation regarding drug-impaired driving in the different EU Member States were described and the issues raised by such testing reviewed. The outcomes of the study included a scientific literature review and annotated bibliography on the relation between drug use, impaired driving and traffic accidents.

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review of literature on drug addiction

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A portrait of a woman wearing a black and tan dress, sitting on the edge of a stage.

Opinion Nicholas Kristof

The Addiction Recovery Story We Don’t Hear Enough

Katelyn Fullbright on the day she graduated from Women in Recovery. Credit... Barrett Emke for The New York Times

Supported by

By Nicholas Kristof

Photographs by Barrett Emke

Mr. Kristof is an Opinion columnist, reporting from Tulsa, Okla. Mr. Emke is a photographer based in Kansas City, Mo.

  • Feb. 14, 2024

Twenty women with felony records and a history of drug use are standing on the stage in a crowded auditorium in Tulsa, and the audience is rising in a standing ovation. The women are teary as they see the cops who arrested them, applauding wildly. It’s the happiest of graduations, and through the raucous cheering one glimpses a better way of dealing with drug and alcohol abuse.

You see, against all odds, this is an uplifting article about America’s curse of addiction.

The graduation was from the single best program I know of to fight substance use. It’s called Women in Recovery, and it’s a diversion program for women in the greater Tulsa area who otherwise face prison for drug-related offenses.

Women in Recovery says that 70 percent of women who start the program complete it, and of those who graduate, just 3.7 percent have returned to prison within three years of graduation. Roughly 130 women are in the program at any time.

As I watched the graduation, my imagination soared: What if everyone with a drug problem who was caught up in the criminal justice system had access to a comprehensive and long-term recovery program like this?

I dream a bit more: What if high-quality treatment programs were available free to all 48 million Americans over the age of 12 who, according to federal estimates, have a substance use disorder involving drugs, alcohol or both?

That could cost tens of billions of dollars. But anyone who thinks we can’t afford effective drug treatment doesn’t understand the costs of addiction.

A photo of a woman sitting and looking up at another woman who is tending to her face and hair.

Future generations won’t understand how America could tolerate more than 100,000 overdose deaths a year and shattered families across the country, plus the crime and homelessness that flow from addiction. It should be a national scandal that fewer than one-quarter of Americans with substance use disorder get treatment. That’s partly because some people resist help, but perhaps one factor behind our pathetic national response is hopelessness, a misperception that nothing works.

The lesson of Women in Recovery is simple: Addiction is not hopeless. I’ve been visiting and following Women in Recovery for a decade now (and spoken at two of its graduations), and it’s not a panacea: Some graduates struggle and relapse. But it’s one of several highly effective initiatives that — often but not always — turn around the lives of participants and shore up communities. I’ve written about two programs that I’ve seen in my home state, Oregon — Blanchet Farm and Provoking Hope — that likewise have a strong record of helping people get back on their feet.

This is Part 7 of the series “How America Heals,” in which I explore the ways millions of Americans have been left behind: educational failure, homelessness, chronic pain, loneliness and woeful health. But it’s also an attempt to underscore that while we have problems, we also have solutions — imperfect ones and sometimes expensive ones, but paths nonetheless to take us to a much better place. We can do better.

How America Heals

A series in which Nicholas Kristof examines the interwoven crises devastating parts of America and explores paths to recovery.

review of literature on drug addiction

Treatment for addiction is a prime example. The United States has some 17,000 substance use clinics, but frankly, many of them don’t seem particularly effective. When someone has wrestled with addiction for many years, a brief period of detox and counseling may be helpful but is often a thin and fleeting intervention. In addition, these programs are frequently expensive and thus inaccessible. Medicaid provides some coverage, but it’s inadequate and depends on the state the patient lives in. Women in Recovery would be unaffordable for most participants if they had to pay for it themselves; people in the program joke that they were lucky to be arrested and thus get access to it.

What sets Women in Recovery apart and helps it succeed, I think, is that it lasts 18 months for a typical woman — much longer than most recovery programs — and is comprehensive, aiming to restore her mental health, reunite her with her children, teach her a skill, get her a job, coach her on financial literacy and knit her back into a community.

The participants have an average history of 15 years of addiction, and it takes time to rewire their brains. But, imperfectly, it works.

“Every single judge in the courthouse is so proud of you,” Judge Michelle Keely told the women from a podium before handing out their graduation certificates. Women in Recovery “is the best program we have in Oklahoma,” she told me in a separate interview, adding that she believes it’s “incredibly replicable” in other jurisdictions.

Among those standing on the stage before the raucous crowd was Katelyn Fullbright, 27, who had been a star athlete and an A student early in high school. Then she veered into trouble, and at 16 a boyfriend introduced her to cocaine and meth.

“It started off with small amounts,” she told me. “And just dating bad boys. That’s definitely a fault of mine.”

To finance her habit, Fullbright began selling drugs. She married a man who was also in the drug world, and soon enough she was arrested with a large quantity of drugs and faced a 10-year prison sentence.

@nytopinion “I thought that drugs and money were going to solve all my problems,” says Katelyn Fullbright, who struggled with addiction for years before being charged with drug trafficking at the age of 22. “It’s a survival instinct, I think, whenever you’re living in active addiction, to think a certain way. You get so caught up in that type of lifestyle that you don’t know any different.” Katelyn found help in Women in Recovery, an addiction treatment program based in Tulsa, Okla. The comprehensive addiction treatment program typically lasts 18 months and aims at restoring women’s mental health and preparing them to enter the workforce. “The thing about Women in Recovery is that not only do they focus on the addiction, like rehabs and other facilities, they focus on the trauma, the ‘Why do you use?’” says Katelyn. “That’s a game changer right there.” #addictionrecovery #nytopinion ♬ original sound - New York Times Opinion

She was able to get into Women in Recovery but didn’t like it. For the first few months, participants are virtually under house arrest. They wear ankle monitors, share apartments with other participants and mostly move between their homes and the Women in Recovery office, where they get intensive therapy and group classes. Contact with old friends is tightly limited.

“I was super resentful toward the program,” Fullbright recalled. “They wouldn’t let me talk to my husband because he’s a felon, been to prison four times.”

So after three months, Fullbright ran off with her husband to Washington State and plunged back into the haze of drugs. But a bit more than a year later, in April 2021, she was caught, shipped back to Tulsa in handcuffs and sent to prison.

“I got high all the time” in prison, she recalled, describing it as “inmate-run,” with drugs widely available. But she was getting tired of addiction and crime. Her mother encouraged her to apply from prison to re-enter Women in Recovery, and Fullbright agreed. “I was just tired of breaking her heart,” she said. So in August 2022, after more than a year in prison, Fullbright returned to Women in Recovery.

With help from the program, she divorced her husband and joined Narcotics Anonymous, which she found very helpful. As Fullbright and other participants advanced through Women in Recovery, they earned more freedom. After some months she won the right to live on her own and hold a job.

Jobs are crucial, but it’s often difficult for people with felony convictions to find employment and housing. It helps that Women in Recovery has built a record of success and won the trust of businesses. Many Tulsa companies offer apprenticeships to graduates of the program.

An oil company took a chance on hiring Fullbright as an administrative assistant, and she is enjoying her work there so much that she is now thinking of going to a university to become a petroleum geologist. When she was looking for her own apartment, she feared that her criminal record might make it impossible to rent, but she told her story — and the woman in the rental office said she loved Women in Recovery and offered her an apartment.

Now Fullbright is feeling confident about the future. “I don’t ever have to put drugs back in my body again to make me feel better, and I’m now attracted to men who have it together, who work jobs,” she told me.

Her mom, Karol Turner, was in the audience as Fullbright graduated and couldn’t stop beaming. “There were some pretty dark days,” she said. “She made a lot of poor decisions, but she’s come full circle.”

Fullbright’s cousin, Gena Smithee, who was in the hospital room when Fullbright was born and has been close to her ever since, put it more concisely: “She’s back!”

Just think how many lives could be saved, how much heartbreak averted, if more people could get this kind of help — regardless of whether they had committed crimes.

Roughly half of inmates in state prisons have substance use disorders, yet only 10 percent get some kind of professional treatment for them. No wonder recidivism rates are so high.

When proponents proposed a diversion program for women facing prison for drug offenses, prosecutors and judges in Tulsa rolled their eyes. They had seen other drug recovery programs that had disappointing records, and officials were wary of a bleeding heart initiative — “hugs and then drugs,” as Judge Keely put it to me — that might jeopardize public security.

But the program’s success changed minds. Oklahoma conservatives from the governor down now praise Women in Recovery and are seeking to expand it. “I’m a Republican, right-wing conservative prosecutor,” said Steve Kunzweiler, the Tulsa district attorney, and he raves about the program as a way to turn criminals into taxpaying citizens.

Drugs affect not only the people who use them, of course, but also their children. So Women in Recovery has pursued a two-generation model, working with participants’ children and helping moms earn back custody of their children. That means parenting classes, counseling for mothers and children alike, supervised meetings at first and gradually more responsibility.

As I see it, Women in Recovery’s greatest achievement may be breaking the cycle that too often transmits addiction from one generation to the next.

Karigan Schumacher, 17, told me she grew up in chaos, with both parents addicted, along with previous generations in her family. Her mom, Aja Richburg, had been addicted to meth since the age of 15 and went through program after program, so Karigan had little hope when Richburg entered Women in Recovery.

“It had never worked before,” Karigan told me. “So at this point, I didn’t really think that this was going to work, either.” But after a few months, things seemed to brighten.

“I started to feel something was different,” Karigan said. “I realized that she’s getting better.”

Richburg was able to regain custody of Karigan and her other two children, and she says they are now a family again. “I have bought a house all on my own,” she said. “I take my kids on vacations. We do all the things that normal families do.”

One of those things normal moms do is watch over their teenage children and disapprove of problem boyfriends. So when Karigan had a crush on a boy whom Richburg regarded as a bad influence, tensions rose.

“I was mad about it because I really liked this guy,” Karigan told me. “But at the same time, I understand why she’s so adamant about the people I hang out with.” That boy is now history.

Is Women in Recovery replicable? Could there be a Men in Recovery program? Could similar initiatives for men and women alike be introduced in other parts of the country or abroad, including for people not arrested for crimes?

Estimates of the total economic cost of addiction in the United States vary considerably, but some of these figures exceed $1 trillion per year — a staggering sum. When treatment is unavailable, people still get medical care: Every 13 seconds , someone arrives at an emergency department somewhere in America after misusing drugs, requiring enormously expensive interventions. Researchers find that some treatment programs pay for themselves many times over, but there is great variation in the effectiveness of programs.

Mimi Tarrasch, who founded Women in Recovery in 2009 and still runs the program, says it costs $30,000 per woman per year, or about $45,000 per participant over a typical 18-month cycle. That’s less than the cost of a long period of incarceration, which is the alternative for many participants, so Oklahoma officials see Women in Recovery as a way to save millions of dollars. Just over half of the organization’s funding now comes from the government, with the remainder from private donations, particularly from the George Kaiser Family Foundation .

Women in Recovery is cheaper than many programs for addiction treatment in part because it is not technically a residential program and does not need medical staff or security guards at the ready. It is more like an intensive outpatient program that also provides housing in inexpensive shared apartments.

Because Women in Recovery has tracked outcomes such as completion, job placement and recidivism more than most treatment programs, it has been able to expand in part with public money , part of a “pay for results” model that is based on the savings it brings to taxpayers.

Yet let’s be honest. Women adhere to the tough regimen and stay sober in part because they know that if they fail they will be sent to prison. So liberals like me who oppose the war on drugs must face an awkward question: Would this program be cost-effective and succeed if the alternative weren’t prison?

Many participants in Women in Recovery told me that they worked so hard to enter the program — and then to stay in and succeed — in part because otherwise they would be incarcerated. That said, they added that there were other important reasons they wanted to enter the program and overcome addiction. They were afraid of overdoses. They yearned for normal lives. Perhaps more than anything, they wanted to be reunited with their children and be good moms. So on balance, they believed that the program would still work without the threat of incarceration.

That proposition was tested when Oklahoma drastically eased its drug laws in 2016. Women in Recovery has still hummed along. I suspect that it may be a bit more difficult to replicate the success of Women in Recovery in states with lenient drug laws, but that this would not be a major obstacle.

Demi Harris’s story is a reminder of how difficult addiction is to overcome. For generations, her family members had abused alcohol or drugs, and she herself began to smoke cigarettes and marijuana at the age of 5. That’s also when she learned to steal food and diapers to provide for her younger siblings, when her mother was in a stupor from drug use.

Subjected to severe physical and sexual abuse, Harris began to use meth at 14. Her sister was murdered, and Harris accumulated a long criminal record and finally was admitted to Women in Recovery when she was 34, in 2021.

“It was the last hope I had,” she told me. “I was going to end up back in prison for life or I was going to end up dead.”

Harris thrived in the program from the start. Women in Recovery sent her to welding school and then found her a job as a welder. She loves welding and also volunteers in her free time, visiting prison to encourage inmates to try to overcome addiction and re-enter society.

“I honestly, I love this program,” Harris said of Women in Recovery. “It literally changed my whole entire life.”

I’m sitting with Harris in her company’s offices, where she’s taking a break from welding. The receptionist is casting admiring glances at Harris.

When I write about addiction, it’s normally about the overdoses, the heartache, the burden on families. So it’s exhilarating to write about a program associated with pride, joy and success. It’s a reminder that we have solutions, however imperfect, and we as a nation have resources to scale them up. I dream of a time when there are rigorous, evidence-based programs such as this all across America, for men as well as women, sprinkling hope for millions of families desperate for answers.

The Times is committed to publishing a diversity of letters to the editor. We’d like to hear what you think about this or any of our articles. Here are some tips . And here’s our email: [email protected] .

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Nicholas Kristof became a columnist for The Times Opinion desk in 2001. He has won two Pulitzer Prizes, for his coverage of China and of the genocide in Darfur. @ NickKristof

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Examining the short and long-term impacts of child sexual abuse: a review study

  • Review Paper
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  • Published: 15 February 2024
  • Volume 4 , article number  56 , ( 2024 )

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  • Sana Ali   ORCID: orcid.org/0000-0003-3474-000X 1 , 2 ,
  • Saadia Anwar Pasha   ORCID: orcid.org/0000-0002-6416-7358 3 ,
  • Ann Cox   ORCID: orcid.org/0000-0002-8399-8050 4 &
  • Enaam Youssef 5  

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Child sexual abuse is a growing problem, representing an egregious abuse of power, trust, and authority with far-reaching implications for the victims. This review study highlights the intricate psychological impacts of child sexual abuse, addressing both short and long-term consequences. Existing literature highlights the deep impacts on the victims’ psychological health and well-being, necessitating an in-depth examination of the subject. Drawing from a sample of n = 19 research articles selected through stringent inclusion and exclusion criteria and the PRISMA approach, this study synthesizes results from publications spanning 2010 to 2022. The review reveals various detrimental impacts on the victims’ psychological well-being, including short-term consequences, i.e., isolation, bullying, stress, anxiety, and post-traumatic stress disorder (PTSD). Long-term effects encompass PTSD in later life, disrupted intimate relationships, social and emotional health concerns, revictimization, and more. In conclusion, the study emphasizes the lack of a definitive number of impacts, highlighting the need to discuss and raise awareness about child sexual abuse. This increased awareness is important for parents, guardians, and responsible authorities to effectively counteract these crimes against children. Also, providing emotional support to victims is important to mitigate the long-term impacts. The researchers offer implications and discuss limitations, providing an extensive overview and foundation for future research and interventions.

Avoid common mistakes on your manuscript.

Introduction

Child sexual abuse is prevalent across class, race, and ethnicity, with both short-term and long-term impacts. It mainly involves an interaction between the abuser and the child, in which the child is the focus of the sexual stimulation of an observer or the offender (Wagenmans et al. 2018 ). Child sexual abuse is anticipated as silencing the minor, and consequently, reporting such incidents is much less. Even without knowing the full ratio of the relevant incidents, experts agree that 500,000 children face sexual abuse yearly (YWCA.org 2017 ). This sexual offence against children has always been an existing phenomenon in all societies and historical eras. For instance, ancient civilizations openly adopted child sexual abuse as a normal, cultural, and social practice aimed at the learning and development of children (Ali 2019 ). Despite the perceptions about child sexual abuse historically varied, we found varying perceptions ranging from acceptance (justifiable) to rejection (children’s rights violation) (DiLillo et al. 2014 ). Child sexual abuse is not limited only to penetration; instead, showing a child pornographic photos, voyeurism, touching a child’s genitals, and even making the child touch or see the perpetrator’s private body parts is also considered sexual abuse (National Sexual Violence Resource Center 2011 ). It is also notable that both boys and girls are strongly susceptible to sexual abuse. However, girls are more vulnerable as they confront sexual abuse three times more than boys, while boys are more likely to be severely injured or die after sexual molestation (National Sexual Violence Resource Center 2011 ). A report by the World Health Organization in 2006 revealed that more than 20% of women and 8% of men in 39 countries reported that they had faced sexual abuse during childhood.

Similarly, data from 2012 to 2013 shows that 2% of boys and 4% of girls experience some sexual abuse every year (Chan et al. 2013 ). Another report (UNICEF 2020a ) revealed that more than 120 million individuals worldwide face forced sexual acts during their childhood. Most are females (89%), and 11% are males. Globally, this statistic is much higher as every one out of four girls and one in every six boys during the early years of their lives (YWCA.org 2017 ).

Similarly, sexual abuse of children is possible in almost every social setting and location, i.e., schools, roads, justice institutions, and homes. Also, it is prevalent equally among all socio-economic classes and age groups; children facing sexual abuse sometimes cannot realize their molestation (Selengia et al. 2020 ). Around 92.0 of the reported incidents were linked by acquittances (closed relatives), indicating the prevalence of incestuous abuse (Ali et al. 2021 ). Notably, there are three dynamic factors behind child sexual abuse, i.e., psychological, economic, and social. For instance, social factors involve one’s personal experience of sexual exploitation during childhood (Middleton et al. 2017 ). Economic factors involve poverty. For example, parents may ask their girl child to look for a capable man to take care of her primary needs, which may further lead to engaging in sexual activities in return for monetary support (Simuforosa 2015 , p. 1792).

On the other hand, psychological factors are mainly defined as sexual interest in children due to a mental disorder (Tenbergen et al. 2015 ). However, the economic factors responsible for perpetuating child sexual abuse mainly involve forcibly engaging children in sexual acts, selling or buying children pornography, and all the other relevant factors that lead to the economic benefits for the perpetrators (Ali 2019 ). Notably, the impacts of child sexual use are detrimental from different aspects. For instance, these impacts are immediate yet prolonged, indicating their severity during adulthood. According to (Downing et al. 2021 ), stress-induced variations in the pro-inflammatory substances, i.e., alterations in gene expression and cortisol, mediate these detrimental impacts.

Additionally, risky sexual behaviours against children and the opposite gender are further attributed to the impacts of child sexual abuse (Fisher et al. 2017 , p. 11). Child sexual abuse poses an influential societal challenge, demanding careful examination to understand its complexities fully.

Aim and purpose

This research aims to scrutinize the role of Child Sexual Abuse as a risk factor for causing several psychological concerns among the victims. The researcher has reviewed some studies on Child Sexual Abuse and its impacts. Drawing on the aims of this article, the study aims to examine (1) the short-term psychological impacts of Child Sexual Abuse and (2) the long-term psychological impacts of Child Sexual Abuse according to studies conducted during the past twelve years (2010–2022). The overarching goal is to provide a comprehensive synthesis of existing literature, shedding light on the multifaceted consequences of child sexual abuse over both short and long-term durations. By systematically analyzing and assessing a selected set of articles, this study seeks to contribute to the understanding of prevalent themes, methodologies, and gaps in the existing literature surrounding the psychological impacts of child sexual abuse. The significance of this work extends to informing future research, interventions, and policymaking related to child protection and well-being. Finally, the aim is to facilitate the development of targeted and effective strategies for preventing, intervening, and supporting individuals affected by children.

In response to the urgent need for a comprehensive understanding, this review study uses the PRISMA approach to navigate existing literature. Addressing the CSA in current knowledge, we highlight the major difficulties associated with unravelling the complexities of child sexual abuse. This review not only synthesizes an extensive body of research but also discusses their findings and insights to overcome the inherent challenges in comprehending the short and long-term impacts of child sexual abuse. Our study seeks to make a distinctive contribution by explaining the intercity of this fragile subject matter, thus laying the groundwork for more effective interventions and support systems. It addresses the following research questions based on the aims and purposes of current research.

RQ1. What constitutes Child Sexual Abuse, and how can it be accurately defined within the current literature?

RQ2. How does Child Sexual Abuse affect the mental health and overall well-being of individuals, considering both short-term and long-term impacts?

This study is based on the systematic literature review approach. The review-based studies are a significant part of the existing literature as they closely witness the ongoing trends and complexities in the field under study (Ali and Pasha 2022 ). Besides, the relevant studies also highlight the major findings to further the gap and conduct an in-depth analysis of the other aspects of the same concern.

Assumptions and justifications

In the context of this systematic literature review, certain assumptions were made to facilitate the synthesis and analysis of the selected studies. These assumptions are integral to the nature of the review process. First, it was deemed that the definitions of key terms, i.e., “child sexual abuse” and “psychological impacts,” were relatively consistent across the selected studies. This assumption is grounded in the anticipation that researchers within the field comply with widely accepted definitions and classifications. While variations in terminologies exist, a comprehensive screening process and compliance with inclusion criteria mitigated possible discrepancies. The study focused on articles with clear and relevant definitions, assuring homogeneity in the selected literature.

Further, the decision to include articles published from 2010 onwards was based on the assumption that recent research mirrors current trends and developments in comprehending the psychological impacts of child sexual abuse. The rationale is rooted in the dynamic nature of research, focusing on current perspectives. This assumption allows for analyzing the most recent insights into the subject matter and recognizing the evolving nature of societal attitudes and academic discourse.

Evaluation of assumptions

While these assumptions were important for the systematic review process, it is important to acknowledge their probable impact on the results. A few considerations emphasize how these assumptions may affect the outcomes. For example, despite efforts to ensure consistency, variations in definitions across studies may introduce complexities in interpreting psychological impacts. This could influence the synthesis of results, and readers should be aware of the potential heterogeneity in conceptualizing key terms. Besides, the focus on recent publications assumes that newer research accurately represents the current landscape. However, this may bias contemporary perspectives, potentially bypassing practical insights from earlier studies.

Thus, considering the problem’s complexity and continuous research, the researcher selected three specialized platforms: PubMed, Science Direct, and APA PsycNet. However, the selection criteria were not restricted to any age, gender, race, ethnicity, nationality, and language. The keywords for the search were “impacts of child sexual abuse, child sexual abuse, psychological effects of child sexual abuse, short-term effects of child sexual abuse, and long-term effects of child sexual abuse. Later the researcher tabulated the data using Microsoft Excel, which further helped calculate the included articles’ percentages and frequencies. The researcher used the PRISMA method for systematic review, as suggested by (Page and McKenzie 2021 ). Table  1 summarizes the inclusion and exclusion criteria used in the current study:

Based on the PRISMA method of screening, evaluation and Selection, the researchers gathered a total of 113 records from the selected database. After removing the duplicates, 106 total articles were further screened for full-text availability (93). Finally, the researchers selected n  = 19 articles adhering to the selection criteria (See Fig.  1 ).

figure 1

PRISMA flow chart for the articles selection process

Table  2 summarizes the frequencies and percentages of the literature according to their database. It is observable that most of the articles were from PubMed (n = 11 or 57.8). APA PsyNet provided n = 7 or 36.8% articles, while n  = 1 (5.2%) article was obtained from Science Direct.

Table  3 summarizes the frequencies and percentages of the selected literature according to their publication years. As visible, most of the studies ( n  = 12, 63.1%) were published from 2015 to 2020, indicating that these years focused mainly on research scholars in psychology, communication, sociology, criminology, and other fields. These results also reflect the prevalence of the relevant concern demanding a strong consideration towards children’s rights and health protection (Ali and Pasha 2022 ). Followed by 04 or 21.0% of studies published between 2010–2015, n  = 03 or 1.7% of studies published until the end of November 2022.

Concerning the frequencies and percentages of the cited literature according to their designs, most studies (09 or 47.3%) were based on a review approach. Followed by experimental design ( n  = 06 or 31.5%), 03 or 15.7% of studies were based on the perspective method. Finally, online n  = 1 (5.2%) of the study was based on the case study method, and the same number of studies ( n  = 1, 5.2%) was categorized as “other” (See Table  4 ). Additionally, n  = 11 or 7.8% of studies were based on a qualitative approach, n = 11 or 57.8% were based on the quantitative approach, and only one study was based on the mixed method approach (See Table  5 ).

The researchers calculated the frequencies and percentages of the cited literature according to the data-gathering approaches used by the relevant researchers (See Table  3 ). Most studies ( n  = 13, 68.4%) were based on the survey method. Besides, the interview approach was preferred in 04% of studies. While n  = 1 (5.2%) study was based on the literature review approach, and the same number of literature ( n  = 1, 5.2%) was categorized as “other”.

Validation of selected methodology

The methodology used in this systematic literature review underwent a thorough validation process to ensure its reliability and comprehensiveness. Key elements of the validation process are.

Adherence to PRISMA Guidelines: The systematic review methodology rigorously adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, as Page and McKenzie ( 2021 ) recommended. PRISMA guidelines are widely recognized and accepted standards for conducting systematic reviews, assuring a systematic and transparent approach to literature synthesis.

Inclusion and Exclusion Criteria: Establishing clear and strict inclusion and exclusion criteria contributed to the robustness of the methodology. These criteria were designed to select studies that specifically addressed the psychological impacts of child sexual abuse, enhancing the relevance and reliability of the synthesized literature.

Search Strategy: The search strategy employed in selecting articles was exhaustive, using three specialized platforms—PubMed, Science Direct, and APA PsycNet. The chosen keywords were carefully selected to encompass diverse dimensions of child sexual abuse and its psychological impacts, minimizing the risk of overlooking pertinent studies.

Data Tabulation and Analysis: Using Microsoft Excel for data tabulation provided a structured and organized approach to handling the extensive information extracted from the selected articles. This facilitated a systematic calculation of frequencies and percentages, assuring accuracy and consistency in reporting.

PRISMA Flow Chart: A PRISMA flow chart (Fig.  1 ) visually represents the systematic article selection, screening, and inclusion process. This chart improves transparency and serves as a visual validation of the methodological stringency applied in the study.

While this systematic review does not involve the same type of validation as experimental or modelling studies, the validation lies in compliance with established guidelines, rigorous criteria for article selection, and transparent reporting of the review process. These elements collectively contribute to the robustness and credibility of the methodology used in this study.

Review of literature

Defining child sexual abuse.

According to (Pulverman et al. 2018 ), the definition of child sexual abuse has been a major concern for many researchers since the 1970s. The prevalent cases and recent concerns indicate that providing and establishing the definition of child sexual abuse is urgent and needs strong consideration. Notably, it is important to keep the complexity and sensitivity of the relevant issue under consideration when providing a potential definition of child sexual abuse (Pulverman et al. 2018 ) theoretically defined child sexual abuse as the unconscionability of the acts, which further indicates four types of activities such as the relationship of power between an adult and child, the child in the lower position facing inequality, the child’s susceptibility is exploited based on their detriment, and truancy of true consent (Table 6 ).

Defining sexual abuse can vary on a different basis. For instance, (Vaillancourt-Morel et al. 2016 ) argue that child sexual abuse mainly relies on the legal definition. Several self-reported cases of child sexual abuse remained affirmed, leading to further legal actions, yet some cases indicate doubtful accusations. As in the empirical study (Vaillancourt-Morel et al. 2016 ), results indicated 21.3% sexual abuse among females and 19.6% among males. At the same time, 7.1% of females and 3.8% remained consistent with self-defined child sexual abuse. However, (Ma 2018 ) stated that the relevant definition could vary according to the prevalence estimation. Besides, this definition is based on five criteria, including the age of the childhood, the age of the perpetrator or the age difference between the victim and the perpetrator, the relationship between the victim and the perpetrator, the type of sexual acts performed by the perpetrator, and the extension of the coercion. According to (Pulverman et al. 2018 ), child sexual abuse can be defined as unwanted sexual activities between an adult and a child, including vaginal, oral, and anal penetration. Besides, online child sexual abuse, including online sex, child pornography, and others, is also considered a vital type of child sexual abuse.

Impacts of child sexual abuse

Child sexual abuse is strongly detrimental to children’s physical and psychological health. In this regard, researchers and medical experts claim physical consequences as serious as brain damage and immediate death. Minor injuries are also found in some cases. However, death is the most common physical outcome of child sexual abuse (Habes et al. 2022 ). As noted by (Beltran 2010 ), no single impact patterns exist. Sometimes, a victim does not show any prominent impacts that may impede the development of a psychological syndrome that adversely affects a child’s social, emotional and cognitive abilities. Some researchers claim that only 20–30% of children remain emotionally and physically stable after sexual molestation. However, although they remain normal, internally, they develop latent effects of sexual abuse. The short-term and immediate psychological impacts of sexual abuse may involve painful emotions, Post-traumatic stress disorder, cognitive distortions, and disturbed mood. These victims respond to sexual abuse in diverse ways that can be changed over time. However, the psychological harm is still severe and can result in even adverse consequences. During sexual abuse, victims can feel fear, anxiety, self-blame, guilt, confusion, and anger. They feel self-conscious and humiliated, unable to talk about what happened, which can result in stress and frustration (Pulverman et al. 2018 ). Table  1 below provides a summary of studies witnessing the physical and psychological consequences of child sexual abuse (Table 7 ).

(Batool and Abtahi 2017 ) named short-term effects “initial effects”, as these reactions mainly occur during the first two years of abuse. Previous studies revealed that 66.0% of children were emotionally disturbed due to sexual abuse, 5.2% were mild to moderately disturbed, and 24.0% remained stable after the sexual abuse. Similarly, a study conducted by (Fontes et al. 2017 ) also witnessed the short-term impacts of sexual abuse on the mental health of the victims. Results gathered by using the Propensity Score Matching technique revealed that 13.3% of sexually abused children reported a greater feeling of loneliness, 7.5% were having difficulty in making friends, and 9.5% reported insomnia. Despite these effects differing among male and female children, both were equally confronting to the relevant mental disturbances.

Further, regarding the long-term effects of child sexual abuse, (Petersen et al. 2014 ) stated that it results in both short and long-term effects. A survivor may feel peer rejection, confusion, lack of self-confidence, conduct disorder, oppositional defiant disorder, and aggression. Similarly, in the later years, the survivor may also develop other extreme psychiatric disorders such as depression, low economic productivity, drug addiction and even severe medical illness. According to (Hodder and Gow 2012 ), long-term child sexual abuse can also result in substance abuse, long-term depression, negative attributions, and even eating disorders. Most recently, practitioners also found even more chronic mental disorders such as delusions, schizophrenia, and personality disorders. However, children who have experienced abuse involving penetration are more likely to develop these chronic psychotic and schizophrenic disorders. Likewise, sexually abused children also have low self-esteem and overly sexualized behaviour, which, in many cases, results in teen pregnancy and motherhood and even an increased vulnerability to another victimization (Townsend 2013 ). Besides, socially isolated children with a disability or emotional disorder are comparatively more vulnerable to victimization. Once the abuse has happened, they also face threats to end the relationship if they refuse to perform sex or threats to publicly share their sexual images (UNICEF 2020b ) (Table 8 ).

Wagenmans et al. ( 2018 ) highlighted the occurrence of prolonged and severe psychological disorders among individuals who previously experienced child sexual abuse. As noted, the prolonged effects are more common when there is a repetitive and interpersonal nature of abuse, mostly leading to develop Post-Traumatic Stress Disorder (PTSD) in later years. Those with a history of Child Sexual Abuse risk developing issues in interpersonal relationships, emotional regulation, and self-concept that result in “Complex PTSD” (p. 2). As (Gupta and Garg 2020 ) noted, child sexual abuse indicates an increased self-harming behaviour, fear, depression, impaired brain development, and others that are criteria for developing Post-Traumatic Stress Disorder (PTSD). Notably, this sexual abuse is not limited to physical and sexual harm; it also involves emotional abuse that further indicates the severity of the relevant issue today. It is also worth mentioning that most victims report sexual abuse in their later life. These victims also indicate their revictimization as one of the most consistent outcomes of child sexual abuse (Papalia et al. 2021 ). The term revictimization is also defined as any further victimization even during childhood, adolescence, or adulthood after the first incident of sexual abuse during childhood (P.1). However, there can be different factors, including sex, mental health issues, age at initial abuse, and others as different determinants of revictimization (Papalia et al. 2021 ). (MacIntosh and Ménard 2021 ) synthesized the status of research witnessing the long-term impacts of child sexual abuse over the past thirty years. As noted, different researchers have witnessed different impacts. Disturbed academic functioning, substance abuse and alcoholism in later years, revictimization and developing Post-Traumatic Stress Disorder (PTSD). Besides, sexual disorders, sex-related cognitions, disturbed intimate relationships, and emotional aspects of sexuality remain highlighted, witnessed, and still need much more consideration. Finally, the study by (Schreier et al. 2017 ) highlighted another important dimension regarding the impacts of child sexual abuse, as their focus was on the victims’ siblings as an important factor to determine in post-abuse scenarios. As noted, siblings can confront several emotional responses after disclosing the child’s sexual abuse. Siblings’ reactions are important as negative behaviour can increase the post-abuse stress among the victim and the family. Thus, it is concluded that the siblings should also be provided clinical services to reduce the negative impacts of child sexual abuse. Siblings also indicate symptoms of distress on an average level that needs strong consideration.

The gathered evidence unequivocally highlights the pervasive and profound negative impacts of child sexual abuse on the psychological health, cognitive development, and overall well-being of victims. The complex dynamics of the relationship between the abuser and the child, initially built on trust and affection, morph into a distressing paradigm of power, domination, victimization, and, in some examples, revictimization. The susceptibility of children in such situations places their psychological health at considerable risk, necessitating urgent and effective preventive measures to protect their well-being. This study serves to highlight the enduring and detrimental repercussions of child sexual abuse that can persist throughout a child’s life. The complexities of the psychological toll highlight the need for targeted interventions and support mechanisms. Our findings indicate that discussions and heightened awareness surrounding child sexual abuse are imperative. It is not merely a matter of quantifying impacts but a call to action to proactively empower parents, guardians, and responsible authorities to counteract these blatant crimes against children. Thus, our study affirms the critical importance of providing emotional support to victims, recognizing it as an integral component in mitigating the long-term impacts of child sexual abuse. By shedding light on the deep consequences and supporting awareness, we aim to contribute to the collective efforts toward a safer environment for children, free from the effects of sexual abuse.

Implications

Incidents of child sexual abuse are prevalent, especially since access to vulnerable children is even more feasible due to social media and other digital platforms (Ali et al. 2021 ). Consequently, children are at increased risk of maltreatment, particularly sexual abuse. Consequently, this research has some implications for the service and police departments, parents, and mental healthcare practitioners across the globe.

Families should receive prevention support and guidance through proper risk assessment and multi-level parent education (Tener et al. 2020 ). Parents informing the children about the protection measures can also help them prevent any detrimental incident that may further nullify the impacts of sexual abuse.

Providing mental healthcare services to the victims, their families, and their siblings, as also emphasized by (Schreier et al. 2017 ), also ensures the children’s mental well-being and development, especially among those who have been through any abusive exposure.

Besides psychological impacts, there are other detrimental impacts that child faces after sexual abuse that necessitate the provision of adequate healthcare services. These healthcare services aim to ensure the different consequences of abuse and that the victim may overcome the incident (Rahnavardi et al. 2022 ).

Medical healthcare providers, including staff, should also support and guide the victim and their families. Although exposure to a CSA victim can be traumatizing for healthcare practitioners, their behaviour and support patterns can help the victims cope with the challenges, especially with the psychological impacts (Pérez-Fuentes et al. 2013 ).

A victim can also face other consequences that may further worsen the impact of sexual abuse, including bullying. Schools and teachers can also effectively nullify these impacts by supporting and scrutinizing the victims. The focus should be on avoiding any further outcomes on their mental health (Sawyerr and Bagley 2017 ).

Implementing laws and active consideration towards welfare programs and training sessions for children, parents, and teachers as caregivers can also mitigate the impacts of child sexual abuse (Batool and Abtahi 2017 ).

Limitations and recommendations

Although this study synthesized the findings of recent literature witnessing both short-term and long-term impacts of child sexual abuse, it also contains some primary limitations. First, this study does not involve human subjects or clinical trials that may witness the impacts under study in a particular setting. Second, the Selection of the cited articles was strict and based on only three databases, limiting its scope. Third, the research does not provide any country-specific evidence. Instead, the cited literature is scattered and based on studies from around the world. Finally, although the study empirically witnesses the impacts of child sexual abuse, there are many regions where empirical research on child sexual abuse, its impacts, and causes are understudied. Consequently, this study emphasizes conducting more research on the impacts of child sexual abuse, its prevalence, and causal factors that may further provide strong insights regarding the relevant issue and help propose implications and nullify its impacts.

Data availability

No data is associated with this research project.

Code availability

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S.A. conceived the first draft of the manuscript. Dr. S.A.P. gathered data and conducted the analysis. Dr. A.C. revised the manuscript and formatted the language and references. Dr. E.Y. contributed in the final revisions and also contributed to restructuring the questions and validation of selected methodology.

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Ali, S., Pasha, S., Cox, A. et al. Examining the short and long-term impacts of child sexual abuse: a review study. SN Soc Sci 4 , 56 (2024). https://doi.org/10.1007/s43545-024-00852-6

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Idaho DHW reviews contracts with the state's syringe exchanges after police search

by CBS2 News Staff

FILE - In this photo illustration, a package of NARCAN (Naloxone) nasal spray sits on the counter at a Walgreens pharmacy.{ }The Washington State Department of Health is offering public high schools across the state naloxone, also known by the brand name Narcan, to help combat the rise in opioid-related overdose deaths. (Photo Illustration by Drew Angerer/Getty Images)

BOISE, Idaho (CBS2) — According to a recent news release, the Department of Health and Welfare (DHW) launched an internal review of its contracts for services with Idaho's syringe exchange programs after police executed a search warrant on Wednesday at Idaho Harm Reduction Project's (IHRP) Boise and Caldwell offices.

Idaho law requires the DHW Division of Public Health to implement provisions of the Syringe and Needle Exchange Act passed in 2019, where nine organizations operate a safer syringe program, five of which receive supplies and resources from DHW.

DHW has maintained a contract with IHRP since March 2020.

"The department does not condone or support the use of illegal drugs or those who profit from it," DHW Interim Director Dean Cameron said. "Substance use has a pervasive and devastating impact on Idaho families and children. The department supports all efforts to protect Idahoans from the impacts of illicit drug use."

Cameron submitted a letter to Governor Little on Friday with details about actions part of the internal review. The letter can be read below:

review of literature on drug addiction

Belleville declares addiction emergency after latest overdose surge

Eastern ontario city says 23 people overdosed since tuesday afternoon.

review of literature on drug addiction

Overdoses are rising — but resources to help are scarce, Belleville, Ont., mayor says

Social sharing.

Mike Juby was outside Bridge Street United Church in Belleville, Ont., on Tuesday afternoon when people suddenly started dropping to the sidewalk all around him.

There were "ambulances left, right and centre" as paramedics loaded people onto stretchers and rushed them to hospital, he recalled.

"It was ugly," Juby said. "They're all my friends. I know every one of them. It's a tough, tough go."

Emergency officials in Belleville say 14 people overdosed in the eastern Ontario city's core between 2 and 4 p.m. Tuesday.

At one point police shut down a section of road and asked residents to avoid going downtown, describing the situation as an "overdose emergency." None of the overdoses proved fatal.

The city said Thursday morning it's had 23 overdoses since 2 p.m. Tuesday and it is declaring a state of emergency over the situation.

  • 'Overdose emergency' prompts warning to avoid downtown Belleville

Tuesday's cluster of overdoses happened along Bridge Street E., surrounding the church where a drop-in centre run by the John Howard Society of Belleville offers food, showers and laundry service for homeless and other vulnerable residents.

The past 24 hours have had a "huge impact" on those why rely on and work at the site, according to J.J. Cormier, the organization's executive director.

A woman with red hair in a tight ponytail stares. Behind her is a police SUV and a large, stone church buidling.

"There were five individuals who were outside, walking on the sidewalk, and all five of them collapsed at the exact same time," Cormier said.

"These people are … our family, and we're their family."

Juby said watching so many people he knows overdose at the same time was frustrating and scary.

"It's disappointing. It hurts," he said.

"I don't know where it's coming from, but I hope it stops."

A man wearing a black hooded jacket and cap stares standing in front of a large, stone church building.

'Laced drug' to blame, says minister

A spokesperson for Ontario Minister of Health Sylvia Jones said in an emailed statement Thursday afternoon "the overdoses [were] caused by a laced drug in the region" and officials were working to limit its spread.

While harm reduction workers in Ottawa and Toronto have discovered animal tranquillizers  in local drugs, Medical Officer of Health for Hastings Prince Edward Public Health (HPEPH) Dr. Ethan Toumishey had said Wednesday it was too soon to determine exactly what caused Belleville's surge in overdoses.

Toumishey added that while the spike in cases was "particularly high" this week, the problem isn't new.

"It continues to raise the alarm, but … the alarm has been ringing for a while now," Toumishey said.

review of literature on drug addiction

Leaders in Belleville sounded that alarm in November during an earlier news conference amid another spate of overdose calls.

  • Belleville, Ont., sees 'astronomical' spike in overdose calls

On Tuesday, Mayor Neil Ellis said the city faces a "very serious drug problem, addictions and mental health crisis."

He and police Chief Mike Callaghan said the problem is too big for Belleville to tackle on its own and called on the provincial government for a plan to help.

"We need funds … human resources, capital resources to get in front of this," Ellis said. "I don't see anything on the horizon."

State of emergency

On Thursday morning, the mayor declared an addiction, mental health and homelessness emergency under provincial law , and extended the call for help to the federal government.

In an interview with CBC News, Ellis said emergency services and hospitals in the city are currently "at capacity."  

"When you have as many [overdoses] as we did in the last 24 hours, there doesn't seem to be an end to it," he said.

The city needs more mental health counselling, doctors, nurse practitioners and detox centres, but "we don't have any capital or any facilities that that we can turn to," said Ellis, a Liberal MP from 2015 to 2021.

"It's time for us to take action or come up with a plan, but it's all three levels of government that are going to have to do this."

review of literature on drug addiction

At least 23 people overdosed in Belleville, Ont., since Tuesday

Less than an hour before this declaration, a spokesperson for Ontario's health minister sent CBC a statement that pointed to the province's $3.8-billion  Roadmap to Wellness mental health and addictions plan .

The spokesperson said Belleville-specific investments include nearly $35 million for mental health and addiction organizations and nearly $2 million to pair health-care workers with police on distress calls.

In a follow-up statement, they said the province's chief medical officer of health and other provincial resources are working with Belleville's health unit and checking with nearby units.

ABOUT THE AUTHOR

review of literature on drug addiction

Dan Taekema is CBC’s reporter covering Kingston, Ont. and the surrounding area. He’s worked in newsrooms in Chatham, Windsor, Hamilton, Toronto and Ottawa. You can reach him by emailing [email protected].

  • Follow @DanTaekema on Twitter

With files from Avanthika Anand and Andrew Foote

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Over-the-counter medicine abuse – a review of the literature

Background:.

The sale of over-the-counter (OTC) medicines from pharmacies can help individuals self-manage symptoms. However, some OTC medicines may be abused, with addiction and harms being increasingly recognised. This review describes the current knowledge and understanding of OTC medicine abuse.

Comprehensive search of international empirical and review literature between 1990 and 2011.

OTC medicine abuse was identified in many countries and although implicated products varied, five key groups emerged: codeine-based (especially compound analgesic) medicines, cough products (particularly dextromethorphan), sedative antihistamines, decongestants and laxatives. No clear patterns relating to those affected or their experiences were identified and they may represent a hard-to-reach group, which coupled with heterogeneous data, makes estimating the scale of abuse problematic. Associated harms included direct physiological or psychological harm (e.g. opiate addiction), harm from another ingredient (e.g. ibuprofen-related gastric bleeding) and associated social and economic problems. Strategies and interventions included limiting supplies, raising public and professional awareness and using existing services and Internet support groups, although associated evaluations were lacking. Terminological variations were identified.

Conclusions:

OTC medicine abuse is a recognised problem internationally but is currently incompletely understood. Research is needed to quantify scale of abuse, evaluate interventions and capture individual experiences, to inform policy, regulation and interventions.

The mechanisms by which individuals can obtain medicines include not only their traditional prescribing by doctors, but also the ability to purchase medicines directly. The most obvious example of this is the community or retail pharmacy, where the metonymic term over-the-counter (OTC) originates and is used to describe such medicines. Such availability has been argued to offer benefits in terms of convenient access to, and choice of, medicines as well as involving individuals as active participants in their own health and the treatment of illness ( Bond & Bradley, 1996 ; Nettleton, 2006 ). The range of medicines available is often more restrictive compared to prescribed medicines, and there are often limitations to indications and doses, although there has been a trend towards increasing deregulation of medicines from prescription to OTC supply and most recently availability from Internet pharmacies ( Bessell et al., 2003 ). There has been a tendency for the public to perceive OTC medicines to be safer than prescription medicines ( Bissell et al., 2001 ; Hughes et al., 2002 ; Raynor et al., 2007 ), but it has been recognised that OTC medicines have the potential for harm as well as benefit ( Lessenger & Feinberg, 2008 ). This may result in what has been variously referred to as the misuse or abuse of OTC medicines and their potential to cause addiction and dependency. A number of specific OTC medicines and therapeutic groups have been implicated and in a recent review for doctors, for example, Lessenger and Feinberg (2008 ) suggested medicines such as stimulants, laxatives, sedatives and dissociative substances such as dextromethorphan as being liable to abuse. They noted that in relation to abused drugs, “the literature is sparse about OTC medicines” and their review tellingly omits opiate-based OTC analgesics. The latter are available for purchase in many countries and combine codeine or dihydrocodeine with either ibuprofen or paracetamol and have led to particular concerns about addiction and also gastric or hepatic damage, respectively ( Reay, 2009 ; Frei et al., 2010).

As Lessenger and Feinberg (2008 ) noted, there is a relative lack of literature relating to OTC medicines that may be abused, and only one previous review has been undertaken (Reed et al., 2011); this was limited only to codeine-based OTC medicines and certain prescribed medicines and focused mainly on the context for England but similarly concluded that there was little current OTC evidence relating to the prevalence of misuse and dependence and treatment. The aim of this article, therefore, is to undertake a comprehensive review of the international empirical and other relevant literatures, to describe current knowledge and understanding about the range of OTC abuse. Specific objectives were to identify the different types of OTC medicines implicated, the scale of OTC abuse, the characteristics of those affected, harms associated with OTC medicine abuse and also approaches to dealing with it in terms of policy and interventions.

Review strategy

A thematic literature review approach was adopted, since there were a range of questions identified which a systematic review would have been inappropriate for, and also because including both review and empirical literature was considered advantageous in mapping out the breadth of understanding in this area.

Initial searches were conducted using ISI Web of Science, CINAHL, EMBASE and Medline together with specific searches of journals such as the Pharmaceutical Journal using combinations of the following terms: “over the counter”, “OTC”, “medicine”, “drug”, “misuse”, “abuse”, “addiction”, “dependency” and “non-prescription”. Additional searches were then undertaken based on identified medicines, and these included “codeine”, “pseudoephedrine”, “dextromethorphan”, “antihistamine”, “laxative” and also specific products, such as “Nurofen Plus” or “Coricidin”, for example, as they were identified in the literature. Reference lists of included publications were also checked and further searching was undertaken as a result. Additional grey literature was explored by strategies such as extensively contacting researchers in the field, to identify current research and non-peer-reviewed research publications. Additional non-peer-reviewed journal literature such as official organisation documents were also identified by searching OpenSIGLE, key organisations such as the Royal Pharmaceutical Society of Great Britain, the Medicines and Health Care products Regulatory Authority and the Proprietary Association of Great Britain together with more general searches of common search engines such as Google. Searches were undertaken for publications from 1990 to 2011 and inclusion criteria included publications published in English, empirical, review or opinion pieces. Exclusion criteria included non-English language publications and reference exclusively to prescribed or illicitly obtained medicines. Prescribed medicines were specifically excluded since, whilst this represents an important category, it covers very different mechanisms of governance.

Literature review findings

A total of 53 publications were identified, including 25 empirical studies, 11 case reports, 11 reviews articles, 1 book chapter, 1 doctoral thesis, 1 parliamentary enquiry and 3 key publications from organisations. The empirical studies represented 10 countries, with the United Kingdom (England, Wales, Scotland and Northern Ireland) being the most studied, followed by the United States ( Table I ). The earliest identified study was conducted in 1996. A range of methods had been used in empirical studies, with various scales of surveys being most commonly used, as well as primary data collection of treatment centres and secondary data collection of emergency department presentations. Qualitative methods were identified in only two empirical studies and several studies reported on findings from pilot stages only ( Fleming et al., 2004 ; Sweileh et al., 2004 ; Orriols et al., 2009 ). The findings are now described in more detail, organised in relation to the objectives described earlier – types of medicine implicated, scale of OTC abuse, associated harms, characteristics of those affected and approaches to dealing with OTC abuse – with an additional theme relating to terminology also being included.

Summary of empirical studies

Note: OTC, over-the-counter; GP, general practitioner.

Medicines implicated in OTC abuse

OTC medicine abuse was identified in many countries and although implicated products varied, five key groups emerged: codeine-based (especially compound analgesic) medicines, cough products (particularly dextromethorphan), sedative antihistamines, decongestants and laxatives. This variation may be related to both geographical variation and methodological and study design factors.

Geographical variation was evident and different products were subject to abuse in different countries. This appeared to be associated with variation in the availability of products, such as codeine-based analgesic or cough medicines in several countries but not in the United States, for example; specific trends, such as adolescent dextromethorphan abuse in the United States; and variation in regulation, such as availability of prescription medicines for purchase in some countries. In Jordan, for example, antibiotics and benzodiazepines were commonly cited by pharmacists as being abused, as regulations restricting their supply were not always enforced ( Albsoul-Younes et al., 2010 ). Despite such international variation, common themes emerged and this Jordanian study typified several others in identifying five key groups of non-prescription medicines that were implicated in OTC abuse namely: sympathomimetic decongestants, cough products, analgesics, antihistamines and laxatives (see Table II ). These reflected a similar categorisation made by Matheson et al. (2002 ) and MacFadyen et al. (2001 ), who identified Nytol (a brand of diphenhydramine, an antihistamine) as the product of misuse most suspected by pharmacists in Scotland, and, like Hughes et al. (1999b), these were broadly similar to the methodological design of studies such as Orriols et al. (2009 ), who grouped their survey of pharmacy customers into whether they purchased codeine (an analgesic), dextromethorphan (a cough suppressant), pseudoephedrine (a decongestant) or an antihistamine. Cough products (and especially dextromethorphan) appeared to be the focus of several studies and data from the United States ( Steinman, 2006 ; Levine, 2007 ; Peters et al., 2007 ; Substance Abuse and Mental Health Services Administration, 2008 ; Ford, 2009 ).

Examples of medicines/therapeutic groups implicated in OTC abuse

Note: OTC, over-the-counter; NRT, nicotine replacement therapy; GP, general practitioner.

Methodologically, studies varied as to whether they focused on a particular product or sought to capture the range of products involved. It was also apparent that sampling influenced the emergent data, and, for example, studies that used pharmacists appeared to generate more detailed and varied descriptions of medicines that may be abused or misused (Hughes et al., 1999b; Matheson et al., 2002 ) compared to patient/customer/public accounts ( Wazaify et al., 2005 ; Ajuoga et al., 2008 ; Major & Vincze, 2010 ), reflecting pharmacists’ knowledge of products and brands.

Scale of OTC medicine abuse

Attempts to describe the extent of OTC medicine abuse have been made using a variety of methods and data sources, which were often geographically related, but reflected heterogeneous participant groups and data. These included pharmacists’ perceptions of abuse (often in UK studies), data from drug treatment centres and poisons centres (e.g. in the United States), sales of codeine-containing medicines, perceptions of members of the public and self-reported abuse from specific groups such as US adolescents and gym users. The heterogeneous nature of these data sources makes assessing the international scale of OTC medicine abuse difficult to determine and making comparisons between countries difficult.

Data relating to the United Kingdom have been obtained from various sources. One of the most frequently referred to in the literature ( Phelan & Akram, 2002 ; Ford & Good, 2007 ; Reay, 2009 ) involved the data reported from the UK-based on-line support group, Overcount , indicating the number of individuals who have registered with the site. This figure had been quoted as ranging from “more than 4000” ( Ford & Good, 2007 ) to 16,000 ( Reay, 2009 ), but specific details of the data were not provided in either source and no further information about it were identified in this review. Several UK studies have explored the experiences and perceptions of pharmacists in relation to OTC medicine misuse and abuse and estimates of the extent of the problem were presented as a result. The earliest identified study involved a postal survey of pharmacists in a county in England ( Paxton & Chapple, 1996 ), which reported that 69% of pharmacists considered there to be some form of OTC medicine misuse in their pharmacies. Matheson et al. (2002 ) reported on two postal surveys of pharmacists in Scotland undertaken in 1995 and 2000, which reported pharmacists’ belief that OTC product misuse was occurring in their area as 67.8% and 68.5%, respectively. Also involving Scottish pharmacists and a postal survey, MacFadyen et al. (2001 ) reported that 31% of pharmacists perceived there to be frequent misuse and 58% perceived occasional misuse. This study also estimated that a mean of 5.6 patients were suspected of misusing medicines for each pharmacy in an “average week”, with the maximum being 40 in one pharmacy. In Wales, Pates et al. (2002 ) also used a postal survey design and reported that 66% of respondents believed the presence of a problem in their area. In Northern Ireland, Hughes et al. (1999b) reported that pharmacist estimates of abuse in the previous 3 months ranged from 0 to 700, with a median of 10 and a mode of 6. Wazaify et al. (2006 ) reported that six pharmacists identified 196 clients suspected of OTC abuse/misuse over 6 months. Geographically, urban pharmacies were associated with more suspected abuse than rural ones in two Scottish studies ( MacFadyen et al., 2001 ; Matheson et al., 2002 ) and Mattoo et al. (1997 ) reported that of those attending a clinic in India for addiction to codeine cough syrups, 80% were urban residents. Others studies identified no difference (Hughes et al., 1999b).

Data relating to the United States have been reported from a range of sources, ranging from specifically collected national level data, to surveys of specific groups, such as gym users, nicotine gum users and high school students. The Annual National Survey on Drug Use and Health (NSDUH) has provided data relating to specific issues such as, for example, abuse of OTC cough medicines amongst adolescents ( Substance Abuse and Mental Health Services Administration, 2008 ), which revealed that in 2006 around 3.1 million people aged 12–25 stated that they had used an OTC cough and cold medicine to “get high” for a non-medical reason. This appeared to involve dextromethorphan, a cough suppressant, in 140 different products. Emergency department admissions were used by the Drug Abuse Warning Network (DAWN) to provide national-level data relating to the involvement of dextromethorphan in admissions ( Substance Abuse and Mental Health Services Administration, 2010 ). This revealed that for 2004 0.7% ( n = 12,584) of all emergency department admissions involved dextromethorphan and that the rate of visits was significantly higher amongst adolescents (aged 12–20) than other age groups. The third national-level data collected in the United States involved that collected in the treatment episode data set (TEDS) for treatment admissions by the Drug and Alcohol Services Information System (DASIS) ( Substance Abuse and Mental Health Services Administration, 2004 ). Data from 2002 revealed that, as primary sources of abuse, only 4% of the 1.9 million admissions related to prescription or OTC medicines, which were described as including cough products, aspirin, sleep aids, diphenhydramine and other antihistamines. Of these, OTC medicines accounted for only 1% ( n = 600) of admissions, and the authors noted that:

OTC medications are relatively rare as primary substances of abuse. They are more commonly noted as secondary or tertiary substances of abuse upon admission. ( Substance Abuse and Mental Health Services Administration, 2004 )

A more recent study from the United States also used drug treatment admissions ( Gonzales et al., 2010 ), but reported on the state of California only. Prescription and OTC medicines in this study accounted for 6841 (3.2%) of admissions, with adolescents (12–18-year-olds) accounting for 1.5% of overall admissions. As in the above national-level study, the Californian study found OTC medicines to be relatively low, representing only 1.9% ( n = 139) of the total prescribed and OTC medicine admissions. These were found to be statistically more likely to be reported by adolescents, who were more likely to cite “self” for referral to treatment than older clients, who cited “others” more often. The authors identified methodological concerns about the recording of such data, noting that OTC and prescription medicine recording by treatment staff was inconsistent, and may be due to not only the relatively recent inclusion of such data but also two further factors:

First, new prescription and OTC medications come on the market frequently. Second, there is wide variability in prescription and OTC drugs in relation to brand names, generic names, chemical names, and street names, which can change over time. ( Gonzales et al., 2010 )

Steinman (2006 ) focused on the adolescent US population and surveyed 39,345 high school students in one county and reported 4.7% as having occasionally misused OTC medicines, with 2.1% reporting use in the past month; the study did not explore the types of product involved. Hughes et al. (2004 ) identified 20% of those using nicotine replacement therapy (NRT) gum for more than 90 days as being addicted, and Ajuoga et al. (2008 ) identified 37.2% of HIV positive patients as misusing OTC products. Kanayama et al. (2001 ) used data from a survey of gym users and national data on fitness club membership to estimate a national incidence of 1.5 million individuals using adrenal hormones and 2.8 million using ephedrine.

The situation in Jordan was studied by Albsoul-Younes et al. (2010 ), who adopted similar methods to UK studies, and found that 94.1% of pharmacists suspected some abuse or misuse of OTC products, and a mean estimate of “abusers” in the last 3 months per pharmacy to be 18.6 for regular, and 15.4 for new customers. From a total of 710 patients attending treatment clinics in Cape Town, South Africa in a 6-month period, Myers, Siegfried and Parry (2003 ) identified 17 cases involving OTC codeine abuse.

Wazaify et al. (2005 ) surveyed members of the public in Northern Ireland and described almost one-third of participants as having personally encountered OTC abuse (based on either personal experience, knowledge or observation). The most recent study identified ( Nielsen et al., 2010 ) involved an on-line survey of 909 Australian individuals who used codeine and identified 138 (17.3%) as being “likely to be codeine dependent” using a severity of dependence scale. Two studies sampled pharmacy customers: in France, Orriols et al. (2009 ) questioned 53 pharmacy customers using surveys about their codeine use in the previous month and identified 15% as misusing, 7.5% as abusing and 7.5% as being dependent. Major and Vincze (2010 ) randomly surveyed pharmacy customers in Hungary and reported that almost one-third had personally experienced OTC abuse. With a specific focus on analgesic use, Agaba et al. (2004 ) randomly sampled an area in Nigeria and reported analgesic abuse in 22.6% of respondents. They collected data on patients’ self-reported weekly use and overall duration and defined abuse as being a cumulative lifetime use exceeding 5000 “pills”.

OTC medicine sales data were identified in two reviews. Almarsdóttir and Grimsson (2000 ) used secondary data and reported on a significant rise in codeine sales between 1993 and 1998 in Iceland and attributed this not to the hypothesised influence of legislative changes but to an increased Western consumption of medicines generally or more specifically OTC codeine abuse reporting by treatment centres. Reed et al. (2011) reported on national UK sales data relating to codeine-containing OTC medicines from a trade association. Data indicated that 21.4 million packs of codeine-containing OTC medicines were sold during 2008. This represented an increase from 19.5 million packets in 2006 but trends were not identifiable due to the limited data available.

Who is addicted to OTC medicines? Data relating to those who may be addicted to OTC medicines were obtained from several different sources. Several studies relied on the perceptions of pharmacists, whilst others relied on sampling the public, pharmacy customers or those suspected of actual abuse. Several studies analysed the case reports obtained from addiction centres. Overall, there was no consensus as to who may be affected by OTC medicine abuse. Amongst the first type, Akram (2000 ) summarised several early UK studies as involving “middle-aged females”, whereas Albsoul-Younes et al. (2010 ) reported that Jordanian pharmacists perceived the majority of abusers to be 26–50-year-old males. Similarly, Sweileh et al. (2004 ) reported pharmacists as perceiving males to be more likely products than females in all categories except laxatives, in the 20–40-year-old age range. Other studies provided more equivocal pharmacist perceptions, and Pates et al. (2002 ) noted that 54% of pharmacists considered all types of people to be suspected of OTC misuse, although female customers were more likely to be suspected of abusing or misusing laxatives. Of the remainder, there was variation in the ages suspected and Ajuoga et al. (2008 ) found no association between OTC product misuse amongst HIV positive US patients and age, gender, ethnicity or education status.

Some studies, however, did include designs that permitted the collection of demographic data. Myers et al. (2003 ), for example, examined details of patients attending a drug treatment centre in Cape Town, South Africa. It should be noted that in this study, although some data pertained to an OTC-specific medicine (codeine), the main findings did not present OTC medicines and those on prescription separately. This was also the case for data collected in the United States by the DAWN ( Substance Abuse and Mental Health Services Administration, 2010 ). Steinman (2006 ) reported that female students misused OTC medicines more than males, and misuse was also higher amongst older white students and Native American youths. Agaba et al. (2004 ) reported those abusing analgesics to be slightly older than those who did not abuse. Nielsen et al. (2010 ) compared codeine-dependent users and codeine users and, although not reporting any statistical data, found the former to be younger, with lower educational level, less likely to be in full-time employment but more likely to have used illicit substances and had family history of alcohol or drug problems.

Harms related to OTC medicine abuse

A range of problems and harms associated with OTC medicine abuse were identified and these comprised three broad categories ( Fig. 1 ). First, there were direct harms related to the pharmacological or psychological effects of the drug of abuse or misuse. Second, there were physiological harms related to the adverse effects of another active ingredient in a compound formulation. Both these types of harm led to concerns about overdoses and presentation at emergency services. Third, there were those harms related to other consequences, such as progression to abuse of other substances, economic costs and effects on personal and social life. Direct harms included addiction and dependence to an opiate such as codeine ( Mattoo et al., 1997 ; Orriols et al., 2009 ; Nielsen et al., 2010 ). Other direct problems included convulsions and acidosis due to a codeine and antihistamine (diphenhydramine) containing antitussive medicine ( Murao et al., 2008 ) and tachycardia, hypertension and lethargy due to abuse of Coricidin cough and cold tablets (dextromethorphan and chlorphenamine) ( Banerji & Anderson, 2001 ). Lessenger and Feinberg (2008 ) produced a comprehensive list of physical findings of nonmedical use of abused OTC products, noting agitation with nicotine gum, caffeine and ephedra, priapism with ephedrine and pseudoephedrine, psychiatric effects with dextromethorphan, euphoric psychosis with Coricidin and chlorphenamine and gastrointestinal disturbances with laxatives. Also within this category of direct harms were concerns raised about chronic rebound headache associated with repeated use of analgesics.

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Examples of types of harm associated with OTC medicine abuse.

In relation to harms from other ingredients, two analgesic combination products – paracetamol and codeine (co-codamol) and ibuprofen and codeine – were considered problematic, with ibuprofen-containing medicine being particularly highlighted ( Chetty et al., 2003 ; Dyer et al., 2004 ; Lambert & Close, 2005 ; Ford & Good, 2007 ; Dobbin & Tobin, 2008 ; Dutch, 2008 ; Ernest et al., 2010 ; Frei et al., 2010 ; Robinson et al., 2010 ). Dutch (2008 ) and Ford and Good (2007 ) reported on two hospital and three primary care presentations, respectively, of patients who had used a combination analgesic containing ibuprofen and codeine. Ford and Good (2007 ) noted the side effects relating to ibuprofen and Dutch (2008 ) reported both patients having perforated gastric ulcers. Hypokalaemia secondary to renal acidosis was identified as a result of abuse of this combination product ( Chetty et al., 2003 ; Dyer et al., 2004 ; Lambert & Close, 2005 ; Ernest et al., 2010 ). Dobbin and Tobin (2008) reported on 77 cases reported through personal networks of one of the authors where harm and dependence to ibuprofen and codeine OTC products had occurred. They identified similar clinical presentations as noted above and one death.

In relation to other consequences, several studies have referred to the association of OTC medicine abuse and the use of illicit substances ( Levine, 2007 ; Reay, 2009 ) or obtaining codeine supplies from “street” supplies ( Sproule et al., 1999 ). Tinsley and Watkins (1998 ) reported on seven patients with dependence (according to DSM-IV criteria for amphetamine-like abuse) to ephedrine or pseudoephedrine and reported adverse social consequences in relation to losing jobs, family-marital stresses, relapse into alcohol misuse, motor vehicle violations and accidents.

Interventions and support

A range of strategies were identified that were aimed at minimising the harm associated with OTC medicine abuse, and supporting and treating affected individuals, although there was no evidence of any associated evaluation of these. Strategies ranged from pharmacy-based approaches reported by pharmacists in their actual work, to suggested interventions such as increasing awareness of the problem, providing additional training, to allowing pharmacists to provide treatment withdrawal programmes.

Many empirical studies that surveyed pharmacists sought their practical strategies and a number of common approaches emerged ( Matheson et al., 2002 ; Pates et al., 2002 ; Albsoul-Younes et al., 2010 ). These included removing products from sight, claiming products were not in stock or not stocked anymore, alerting or counselling customers to the abuse potential of products, refusing sales, suggesting customers contact their doctor and supplying only limited amounts. A Delphi survey of experts in the field of addiction and OTC medicines also identified similar strategies ( McBride et al., 2003 ), as well as broader strategies based on raising public awareness, establishing an official body to monitor Internet sales, limiting advertising and making warnings on packets more visible. Fleming et al. (2004 ) developed a harm reduction model that comprised a manual and treatment algorithms for involving a customer’s doctor, the appropriate signposting for opioid, laxative and antihistamine abuse. Lack of pharmacist confidence and general practitioner (GP) engagement and competing work demands were identified as barriers. Wazaify et al. (2006 ) reported that the same model led to some clients agreeing to stop using a medicine, using an alternative and being referred to their doctor for prescribing. No clients were recruited to enable collection of quality of life data. Raising awareness was recognised as being necessary amongst both the public ( McBride et al., 2003 ; Reay, 2009 ) and health care professionals such as doctors ( Williams & Kokotailo, 2006 ; Lessenger & Feinberg, 2008 ; Reay, 2009 ). A harm reduction strategy was proposed by Temple (1996 ) whereby pharmacists would set a contract with individuals experiencing OTC medicine abuse to have regular supplies of medicines, reducing over time and involving detailed record keeping and adequate communication between pharmacies and involving drug team coordinators.

The All Party Parliamentary Drug Misuse Group (APPDMG) in the United Kingdom ( Reay, 2009 ) concluded that increased recognition and support were needed for the voluntary groups that provided support for those with an OTC problem. Two specific websites – Overcount and CodeineFree – were identified and considered to provide a valuable service that was not formally recognised ( Reay, 2009 ).

Definitions and terminology

Considerable terminological variation was apparent in the identified literature. Some literature referred only to the term “misuse” and appeared to use this generically, to describe all forms of problematic OTC medicine use in pharmacies ( MacFadyen et al., 2001 ; Matheson et al., 2002 ; Pates et al., 2002 ; Myers et al., 2003 ; Ajuoga et al., 2008 ). As Akram (2000 ) noted, however, this is unfortunate because it does not distinguish between misuse and abuse as separate problems, although some attempts to do this were identified in the literature:

Misuse is defined as using an OTC product for a legitimate medical reason but in higher doses or for a longer period than recommended, e.g. taking more of a painkiller than recommended to treat headache. Abuse is the non-medical use of OTC drugs, e.g. to experience a ‘high’ or lose weight. ( Wazaify et al., 2005 , p. 170)

According to Fleming et al. (2004 ), misuse applied to potentially all medicines, whereas abuse related to specific medicines, such as laxatives, antihistamines and codeine-based products. There was no mention in the literature of the transition between misuse and abuse, as has been recognised in the medical prescribing situation of involuntary addiction ( Reay, 2009 ). Further distinctions were identified within these broad categories and, for example, with misuse, it was argued to be possible to view this as resulting from using a medicine at a higher than recommended dose, or using it to treat symptoms for which the medicine is not indicated ( Abbott & Fraser, 1998 ); with OTC medicine abuse, a distinction has also been made between sole OTC medicine abuse and substitution, where an individual is dependent on another medicine, often an illicit drug, and uses an OTC product when the other is unavailable ( Abbott & Fraser, 1998 ; Temple, 2003 ).

Several studies did draw upon the wider literature relating to clinical classification such as DSM-IV ( American Psychiatric Association, 2000 ) or ICD - 10 ( World Health Organisation, 1992 ) in specifically contrasting the terms abuse and dependence or “pharmacodependence” ( Orriols et al., 2009 ) and misuse and dependence ( Hughes et al., 2004 ). Several studies used the word “dependant” in relation to some use of the word codeine ( Tinsley & Watkins, 1998 ; Orriols et al., 2009 ). The term “addiction” was identified in some literature ( Hughes et al., 2004 ; Reay, 2009 ), but was infrequently used overall and, as Reay (2009 ) noted, this may have occurred due to the perceived stigmatising effect that the term and that of “addict” might have on those affected. One mixed methods study ( Nielsen et al., 2010 ) used the DSM-IV definition of dependence (but not abuse) as inclusion criteria for their qualitative interviews with codeine-dependent individuals and described some users having “therapeutic dependence” to doses at or less than the maximum, often over a prolonged period.

An additional and significant definitional point concerned the terms used to describe not only the condition but the actual individual themselves, who were affected by OTC medicine problems. Within the empirical literature, this related partly to the study design and sample and included the use of the word “patient” in studies where the participants were those attending hospitals to seek treatment ( Mattoo et al., 1997 ; Myers et al., 2003 ) and the term “client” in a study which studied a pharmacy-based intervention ( Fleming et al., 2004 ). Two studies referred to those affected by OTC medicine abuse and/or misuse as “customers” ( McBride et al., 2003 ; Albsoul-Younes et al., 2010 ) reflecting the commercial nature of OTC medicine sales, although Albsoul-Younes et al. (2010 ) also used the term “abusers” uniquely. One further definition offered was that relating to individuals who “manage their drug use as part of their normal daily routine” and were termed “recreational users”, to describe a heterogeneous group of individuals who may be abusing anabolic steroids, and “soft drugs” such as cannabis or LSD, or OTC medicines ( Scottish Specialist in Pharmaceutical Public Health, 2004 ).

This review of the literature has revealed a number of themes and data to inform understanding of OTC medicine abuse, However, what is perhaps most apparent is the extent of the omissions in the extant literature, particularly as they relate to the lack of:

  • qualitative methods that may be appropriate for exploring individual perspectives;
  • reliable quantitative data in some countries;
  • fully evaluated or implemented interventions;
  • data relating to Internet supplies; and
  • consensus over definitional terms.

These concerns are now considered in turn, before a number of specific suggestions for further research and policy involvement are proposed.

The various definitions described previously have a number of implications for research and understanding in this area. First, whilst they can positively reflect a range of different types of societal medicine use, they may also lead to confusion, particularly if, like some studies did, there are not accurate and consistent attempts to distinguish between them. This may be further complicated by the origins of these terms, with some such as “dependency” and “abuse” being associated with a clinical or diagnostic perspective ( American Psychiatric Association, 2000 ), “addiction” carrying a societal broader interpretation and “misuse” being associated with pharmacy studies particularly. This reflects enduring debates about and changes to terminology in the wider addiction literature, including the WHO’s adoption of “dependence” over “addiction” ( World Health Organisation, 1964 ) nearly half a century ago, to recent debates about these terms in the DSM-IV and proposed DSM-V ( Dean & Rud, 1984 ; O’Brien et al., 2006 ). Underscoring this definitional variation are also fundamental issues about stigma, identify and also agency. The use of the term “dependency” and not “addiction” has been argued to have occurred due to issues of stigma of the latter ( Dean & Rud, 1984 ; Erickson & Wilcox, 2006 ; Reay, 2009 ) as well as the issue of an “addict” or “spoilt” identity ( Goffman, 1990 ; McIntosh & Mckeganey, 2000 ). In terms of agency, it is interesting to reflect on the distinction between misuse and abuse in some of the extant literature, since this appears to recognise a difference between intentionally experimenting with a medicine (to elicit a different effect) and abusing it, and unintentionally deviating from standard use (taking at different dose or indication) and therefore misusing it. Whether these can be adequately mapped onto additional concerns about the loss of control in addiction, as argued by Reith (2004 ), for example, are additional issues. One further omission is the absence of any reference to pseudo-addiction in the OTC literature identified in this review. Pseudo-addiction has been defined as the under-treatment of pain ( Bell & Salmon, 2009 ), which may lead to symptoms that are similar to dependency and which reveal a potentially even more complex area.

Methodologically, quantitative approaches have dominated, illustrated by the use of cross-sectional descriptive survey designs, often using self-completion postal surveys of pharmacist participants in UK studies. Response rates appear to have varied significantly using this approach, and whilst Matheson et al. (2002 ) reported very good response rates across two surveys using a prepaid envelope and two reminder letters, and Hughes et al. (1999b) received responses from just under half of pharmacists sampled using two mailings. These studies reflect a trend to using pharmacists proxies and hence obtaining data that reported on pharmacists’ perceptions of the problem and the profile of those they considered to be affected, which as Orriols et al. (2009 ) noted is “much too subjective to obtain reliable qualitative and quantitative data”. Although not explicitly noted by the researchers, this may reflect a belief that those who are abusing or misusing OTC medicines may be a hard-to-reach or covert ( Reay, 2009 ) group and hence using pharmacist proxies is perhaps perceived as being more appropriate. However, several study designs have involved sampling those suspected of abusing/misusing OTC medicines, either via pharmacies ( Phelan & Akram, 2002 ; Orriols et al., 2009 ), at targeted venues such as gyms ( Kanayama, et al., 2001 ) or by post ( Sproule et al., 1999 ). Although these represent less subjective accounts of the problem, they have resulted in poor response rates except in the study by Orriols et al. (2009 ), who argued that allowing purchasers to complete a questionnaire away from the pharmacy and return it via post, as compared to completing it in the pharmacy, meant those who were abusing or misusing could complete the forms anonymously. However, Orriols et al. (2009 ) were disappointed by the poor level of pharmacy participation, which may be related to the need for the pharmacies involved to undertake the administration of the questionnaires, as was identified in other studies ( Wazaify et al., 2006 ).

Of particular note is that qualitative methods have been neglected and only one identified study used focus groups ( Björnsdóttir et al., 2009 ) and one which reported the use of semi-structured interviews ( Mattoo et al., 1997 ) presented detailed statistical data and the absence of qualitative data suggested this was a structured survey design. Nielsen et al. (2010 ) used qualitative interviews and reported a range of different types of abuse of codeine, as well as barriers to treatment, illustrating the unique data that this method can generate. Adopting such methods may reveal further insights that could help understanding of the contested definitional issues raised above, as well as providing more than the proxy summaries of those perceived to be affected, as offered by some pharmacist-participant studies.

The use of secondary data sources, such as those in various US reports ( Substance Abuse and Mental Health Services Administration, 2004 , 2008 , 2010 ) and using details of patients attending drug treatment centres in South Africa ( Myers et al., 2003 ), for example, offers potentially more robust statistical information on the extent of the problem. However, such data are not unproblematic and in the case of some US data, for example, prescription and OTC medicines were often reported together.

Linked to the source of this last type of secondary data is any evaluation or indeed thorough detail of treatment options for those affected by OTC medicine abuse. Empirical studies have identified a range of often pragmatic solutions, but evidence-based interventions and attendant evaluations are a clear omission in this field.

Finally, the emergence of new forms of medicine supply, such as via the Internet, in what Fox et al. (2005 ) termed the “second moment” of “e-pharmacy” has not been studied, despite being recognised as a potential threat ( McBride et al., 2003 ). Such developments may not only stretch the metonymic accuracy of the term OTC, but also require a redefinition of what such supplies involve, as such supplies transcend national boundaries and attendant regulation in many cases ( Bessell et al., 2003 ) and may challenge the international patterns identified.

In relation to policy, this review confirms that there is a problem in a number of countries but concerns about what is being investigated – whether this is misuse, abuse, dependency, addiction or pseudo-addiction – coupled with a lack of systematic data on the scale of the problem make appropriate and proportionate policy-based interventions difficult to consider. There exists a tension between making OTC medicines available to individuals to increase their access to medicines and enabling them to self-manage conditions and accepting that there is some degree of risk of such products being misused or abused, with potentially serious consequences for some. Raising awareness of potential problems of OTC medicines, as the recent response in the United Kingdom has illustrated in terms of making purchasers aware of the possibility of addiction, would appear a prudent response. But whilst this may arguably warn those using products for the first time, for those with an existing problem, more support may be needed in the clinical pathway.

This review of the literature relating to OTC medicine abuse has revealed that there is a recognised problem internationally involving a range of medicine and potential harms. Methodological concerns have emerged in relation to the use of proxy, self-report and non-OTC specific data and the relative lack of qualitative research involving individual experiences of OTC medicine abuse. These represent urgent areas where research is needed; to explore the extent of the problem and to provide insights into those affected, coupled wih providing clarification of the type of problem being investigated. Such research is needed to inform policy, regulation and the preparedness of a range of health care professionals to avoid harm to those who purchase OTC medicines that may be liable to abuse.

Declaration of interest

This review was part of a larger study that was funded by the Pharmacy Practice Research Trust. The author reports no conflict of interest. The author alone is responsible for the content and writing of this paper.

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    PMID: 32731008 DOI: 10.1016/j.addbeh.2020.106549 Abstract Insight refers to a person's understanding of themselves and the world around them. Recent literature has explored people's insight into their substance use disorder (SUD) and how this is linked to treatment adherence, abstinence rates, and comorbid mental health symptoms.

  7. Addiction Recovery: A Systematized Review

    Results: From a total of 9520 articles, 39 were reviewed and analyzed. Five attributes were selected, including the process of change, being holistic, being client-centric, learning healthy coping, and being multistage. Antecedents are organized into 2 interacting categories: personal and social resources.

  8. A systematic review on Substance Addiction: medical diagnosis or

    Systematic review of scientific literature (search of scientific articles in PubMed/MEDLINE database and use of a psychiatry textbook) related with SA and its relationship to free will. ... Although several will-independent risk factors for drug addiction have been identified (e.g. genetic vulnerabilities), as well as significant drug-induced ...

  9. Insight in substance use disorder: A systematic review of the literature

    The concept of insight was initially identified as being important within psychosis ( Beck et al., 2004, Cuesta and Peralta, 1994, Ekinci and Ekinci, 2013, Martin et al., 2010 ), as people with a diagnosis of schizophrenia often did not acknowledge or recognise their illness.

  10. A review of research-supported group treatments for drug use disorders

    This paper reviews methodologically rigorous studies examining group treatments for interview-diagnosed drug use disorders. A total of 50 studies reporting on the efficacy of group drug use disorder treatments for adults met inclusion criteria. Studies examining group treatment for cocaine, methamphetamine, marijuana, opioid, mixed substance, and substance use disorder with co-occurring ...

  11. PDF Literature Review: A Review of the Research on the Treatment of

    Introduction Drug abuse is a serious public health problem that affects almost every community and family in some way. Each year drug abuse causes millions of serious illnesses or injuries among Americans. Drug abuse also plays a role in many major social problems, such as drugged driving, violence, stress, and child abuse.

  12. Literature Review: Substance Use Treatment Programs

    The review describes the scope of substance use among youth, the theoretical base of substance-use treatment programs, risk factors that can lead to substance use disorders, protective factors that can buffer against substance use disorders, various types of treatment programs and outcome evidence, limitations to treatment programs, and the rese...

  13. Adolescents and substance abuse: the effects of substance abuse on

    Substance abuse during adolescence. The use of substances by youth is described primarily as intermittent or intensive (binge) drinking and characterized by experimentation and expediency (Degenhardt et al., Citation 2016; Morojele & Ramsoomar, Citation 2016; Romo-Avilés et al., Citation 2016).Intermittent or intensive substance use is linked to the adolescent's need for activities that ...

  14. Substance Use Disorders in Patients With Posttraumatic Stress Disorder

    Our review of the literature on the pathophysiologic basis of comorbid PTSD and addiction selectively focuses on studies of the hypothalamic-pituitary-adrenal (HPA) axis and the noradrenergic system, as these have been most extensively studied in PTSD. ... in Proceedings of the College on Problems of Drug Dependence Annual Meeting. Bethesda, Md ...

  15. Risk and protective factors of drug abuse among adolescents: a

    This study aims to fill this gap in the literature and inform programs aimed at reducing substance use among LGB youth: Cross-sectional: Marijuana, inhalants, prescription pain medication, and other illegal drugs ... this review focused on worldwide drug abuse studies, rather than the broader context of substance abuse including alcohol and ...

  16. Substance abuse and violence : A review of the literature

    Volume 8, Issue 2 March-April 2003, Pages 155-174 Substance abuse and violence: A review of the literature Sharon M. Show more Add to Mendeley https://doi.org/10.1016/S1359-1789 (01)00057-XGet rights and content Most alcohol and drug use occurs among persons who are not violent.

  17. Drugs and Crime

    Abstract. Drug law violations and other crimes related to substance abuse incur dire costs in terms of both financial outlay and human suffering. This review of the current professional literature addresses the identification of risk factors and the longitudinal course of addiction and criminal behavior. Results indicate that neither criminally ...

  18. Characteristics of Alcohol, Marijuana, and Other Drug Use Among Persons

    Motivations for drug use among persons aged 13-18 years being assessed for substance use disorder treatment who reported use of alcohol, marijuana, or other drugs during the previous 30 days and persons with whom they used substances — National Addictions Vigilance Intervention and Prevention Program Comprehensive Health Assessment for ...

  19. Literature review on the relation between drug use, impaired driving

    The outcomes of the study included a scientific literature review and annotated bibliography on the relation between drug use, impaired driving and traffic accidents. Download as PDF. English (en) ... The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) is the reference point on drugs and drug addiction information in Europe ...

  20. Opinion

    It's the happiest of graduations, and through the raucous cheering one glimpses a better way of dealing with drug and alcohol abuse. You see, against all odds, this is an uplifting article about ...

  21. Examining the short and long-term impacts of child sexual abuse: a

    Child sexual abuse is a growing problem, representing an egregious abuse of power, trust, and authority with far-reaching implications for the victims. This review study highlights the intricate psychological impacts of child sexual abuse, addressing both short and long-term consequences. Existing literature highlights the deep impacts on the victims' psychological health and well-being ...

  22. A Review of the Literature

    1 A Review of the Literature Go to: Overview This literature review is part of the Substance Abuse and Mental Health Services Administration's (SAMHSA's) Treatment Improvement Protocol (TIP) 49, Incorporating Alcohol Pharmacotherapies Into Medical Practice.

  23. Department of Health reviews contracts with Idaho's syringe ...

    BOISE, Idaho (CBS2) — According to a recent news release, the Department of Health and Welfare (DHW) launched an internal review of its contracts for services with Idaho's syringe exchange programs after police executed a search warrant on Wednesday at Idaho Harm Reduction Project's (IHRP) Boise and Caldwell offices. Idaho law requires the DHW Division of Public Health to implement ...

  24. Belleville declares addiction emergency after latest overdose surge

    A spokesperson for Ontario Minister of Health Sylvia Jones said in an emailed statement Thursday afternoon "the overdoses [were] caused by a laced drug in the region" and officials were working to ...

  25. Over-the-counter medicine abuse

    This review of the literature relating to OTC medicine abuse has revealed that there is a recognised problem internationally involving a range of medicine and potential harms. Methodological concerns have emerged in relation to the use of proxy, self-report and non-OTC specific data and the relative lack of qualitative research involving ...

  26. christine on Instagram: " book review: If an Egyptian Cannot Speak

    83 likes, 14 comments - cella_reading on April 1, 2023: "懶 book review: If an Egyptian Cannot Speak English • 2022 Wow — this book. It was so fant..." christine on Instagram: "🤍 book review: If an Egyptian Cannot Speak English • 2022 Wow — this book.