Long-Term Trajectory of Substance Abuse and Psychiatric Comorbidity Rumi Kato Price, PhD, mpe



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Long-Term Trajectory of Substance Abuse and Psychiatric Comorbidity*

  • Rumi Kato Price, PhD, MPE

  • Washington University School of Medicine

  • St. Louis MO, USA

  • E-mail price@rkp.wustl.edu


Acknowledgments*

  • National Institute on Drug Abuse (K02DA00221, R01DA09281).

  • Longer Life Foundations, Washington University School of Medicine and the Reinsurance Group of America.

  • National Institute of Mental Health (R01MH60691).





VES Long-Term Followups. Questions to Address:

  • In what ways is long-term drug use harmful?

  • Why do some drug users continue to abuse drugs so long?

  • What areas do we expect problems will get worse?



VES Long-Term Followups Mortality and Morbidity over 30 Years

  • Mortality.

  • Drug use transition patterns.

  • Social and physical functioning.

  • Psychiatric profiles over time.

  • Drug abuse, PTSD and suicidality.

  • Predictors of remission from drug abuse over time.

  • Emerging drug use trends in middle age.



VES Long-Term Followups











VES Samples (N=1,227): Demographic Characteristics





Opiate Use After Vietnam by Men First Addicted in Vietnam, Compared to NARA Patients



Substance Use and Psychiatric Problems (%)



Why A 95% Remission Rate?

  • Military personnel are different from civilian addicts - less psychopathology.

  • Later age of onset.

  • “Setting” - extinguishing conditional response was easy after coming back to U.S. (Zinberg, Archive 1972).

  • Lack of availability of drugs after return to U.S.



VES Long-Term Followups: Mortality and Morbidity over 25 Years







Drugs kill.

  • Drugs kill.

  • A more malignant picture of the long-term impact of heroin use starting in Vietnam.

  • Alcoholism and depression additional significant risk factors for premature death up to mid-40’s.

  • Even a short-term intensive drug use appears to signal premature death.



VES-III. 25-Year Followup

  • Drug use transition patterns.

  • Social and physical functioning.

  • Psychiatric profiles over time.

  • Drug abuse, PTSD and suicidality.

  • Patterns of remission from drug abuse over time.



Alcohol Heavy alcohol use1 Dependence2

  • Alcohol Heavy alcohol use1 Dependence2

  • Any illicit drug Heavy use Dependence/abuse2

  • Marijuana Heavy use Dependence/abuse2

  • Cocaine Heavy use

  • Opiates Heavy use

  • Illicit drugs other Heavy use

  • than marijuana Dependence/abuse2



Landmark events (negative or positive).

  • Landmark events (negative or positive).

  • Employment.

  • Employment.

  • Married or cohabitating.

  • Number of children.1

  • Number of important people (max = 4).1

  • Number of important people who are regular alcohol/drug users (max = 4).1



Posttraumatic stress disorder (PTSD) (based on traumatic event before or 1972 or after).1,2

  • Posttraumatic stress disorder (PTSD) (based on traumatic event before or 1972 or after).1,2

  • Major depression.1,2

  • Adult antisocial personality (ASP).1,2

  • Suicidal ideation.1



Sampling status (D+, D-, nonveteran).

  • Sampling status (D+, D-, nonveteran).

  • Enlistment status.

  • Aptitude (military IQ test).

  • Race.

  • High school education.

  • Age.

  • Family psychopathology (depression, ASP symptoms, drinking problems, drug problems, hospitalization, life interference, suicide attempts).







Annual Prevalence Rates of Psychopathology:1972-1996





Yearly Size Social Circles: 1972-19961



VES Long-Term Followups: Mortality and Morbidity over 30 Years



Dynamics of Polydrug Abuse Over Time

  • What’s the relationship between use of one drug and use of another drug over time?

  • Is there evidence for switching from “harder” drug to a “softer” drug (“substitution” hypothesis)?

  • Is there evidence for reducing the number of drugs abused (“unpiling” hypothesis)?

  • Is there evidence for quitting all together at once (“rock-bottom” hypothesis)?



Basics of Latent Transition Analysis



Latent Transition Analysis Estimation

  • For 2 classes, 2 times, 3 endorsement items to endorse:

  • P(Y) = n Ln (1111211311T11112 212312

  • +1111211311T12 122 222322

  • +2121221321T21112 212312

  • +2121221321T22 122 222322).

  • P(Y) - Total log likelihood.

  • i - Probability of starting in class i.

  • Tij - Transition probability.

  • kit - Endorsement probability for item k if the observation is in class i at time t.

  • n - Number of observations with the given pattern of endorsement.

  • The EM algorithm to select parameters that maximize P(Y).



Latent Transition Model of Polydrug Abuse*





LTA Endorsement Patterns: Alcohol + Nicotine - 4 classes, Unconstrained





Polydrug use is certainly common; however, substance abusers appear to have their “choice” of substance.

  • Polydrug use is certainly common; however, substance abusers appear to have their “choice” of substance.

  • Gradually increasing abstinence applies to most substances, except for cocaine.

  • Switching of the main substance use is asymmetrical (MJ to ALC, OP to COC).

  • “Narrowing of repertoire” occurs gradually over time.



VES Long-Term Followups Consequences of Drug Abuse over 30 Years







VES Long-Term Followups Consequences of Drug Abuse over 30 Years















PTSD most stable over time; drug dependence declines, but suicidal behavior increases over time to midlife.

  • PTSD most stable over time; drug dependence declines, but suicidal behavior increases over time to midlife.

  • Associations become stronger over time.

  • Alcohol dependence and antisocial personality not as strong as predictors of suicidal ideation over time.

  • Drug dependence exacerbates PTSD and suicidal ideation; once the course is set, self-medication kicks in.



VES Long-Term Followups: Mortality and Morbidity over 30 years



Patterns and Predictors of Remission

  • Are the remission patterns stable over time?

  • Are the remission patterns different across classes of substances?

  • How common is spontaneous remission?

  • Are the predictors of remission the same as covariates of long-term abuse?



A reasonable range of inclusion criteria beyond any use.

  • A reasonable range of inclusion criteria beyond any use.

    • Alcohol - 7+ drinks/day, daily drinking 2+ weeks, 6+ drinks/day/per week for several weeks.
    • Nicotine - 20 cigarettes/day at least year.
    • Marijuana and other illicit drugs - 5+ times use.
  • Abuse to remission threshold higher than occasional use, but lower than DSM level.

    • Alcohol: on - 7+ drinks/day when drinking most; off - quit attempt 3+ months.
    • Nicotine: on - 20 cigarettes/day usually; off - quit attempt 3+ months.
    • Marijuana other illicit drugs - “Most frequent” use;
    • off - not “most frequent use.”




“Spontaneous” Remission from Licit and Illicit Substance Abuse



VES Long-Term Followups: Mortality and Morbidity over 30 years

  • Predictors of remission - Can we detect a symptom pattern that is likely to lead to remission?



Flow of the ANN: A Multilayer Perceptron (MLP) Model



VES Long-Term Followups Symptom Patterns Predicting Remission

  • Predictive power was in a good range when socio-environmental measures were included; better than DSM symptoms alone.

  • Unique ANN weights capturing subtle changes? e.g., Hazardous use accompanied remission from cocaine heavy use and operated differently from severity symptoms (potentially a “make or break”role).

  • Time-dependent logistic regression and on ANN weight structure analyses were inconsistent.



VES-IV: “Suicide” Study

  • Quasi case-control design to take advantage of the existence of a large number of suicidals.

  • Episode-based interview to capture protective factors mitigating suicide risk.

  • Quantitative-qualitative integration to examine the patterns of interactions between risk and protective factors.





VES Long-Term Followups: Mortality and Morbidity over 30 years









VES Limitations

  • Special population: disadvantaged Vietnam veterans with high levels of trauma and opiate exposure.

  • Cohort and gender specific population.

  • Impact of censoring by death unknown.

  • Yearly-assessed measures not available for some behaviors.

  • Most yearly measured retrospective self-report since 1972.

  • Measures since 1996 still tentative.



VES Followups Over 30 Years Summary (1)



VES Followups Over 30 Years Summary (2)



VES Followups over 30 Years Summary (3)



VES-III & IV Collaborators

  • WU Medicine Rumi Kato Price, Lee Robins,

  • Edward Spitznagel, George Murphy,

  • Collins Lewis

  • WU Social Work Enola Proctor, Sally Haywood

  • St. Louis VA Katherine Virgo, Seth Eisen

  • Readjustment Counseling Services (Vet Center)

  • Gary Collins, Rodney Haug, Robert

  • Mathes

  • St. Louis Crisis Services Center

  • G. Lee Judy

  • Consultants Bruce Goldberger, Gery Ryan

  • Contract Work Research Triangle Institute,

  • Psychemedics




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