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Background Offspring of parents with alcohol use disorder (AUD) have elevated risk of substance use. However, few studies have comprehensively assessed risks associated with different substances. This study investigated the risk of substance use disorders (SUDs) in adult children with severe parental AUD over four decades, contributing information on the risk of each disorder, the roles of important risk factors, and the general versus substance-specific nature of SUD risk. Methods Swedish national register data were used to follow children with and without ≥ 1 parent with an inpatient diagnosis of AUD from 1973 to 2018 to investigate risk of alcohol, opioid, cannabinoid, sedative/hypnotic, cocaine, other stimulant, hallucinogen, volatile solvent, and multiple drug use disorder. The composite outcomes any SUD, 1 SUD, and ≥ 2 SUDs including and excluding AUD were also investigated. Severe parental AUD and outcomes were defined with hospital inpatient diagnoses (ICD codes). Hazard ratios (HRs) were calculated with Cox regression. Model 1: unadjusted. Model 2: adjusted for child’s sex, parental education, and parental mortality. Model 3: Model 2 plus parental SUD. Model 4: Model 3 plus parental psychiatric disorder. Results Risks of all outcomes were higher in those with ( n  = 99,723) than without ( n  = 2,321,756) severe parental AUD. For SUD diagnoses, the highest unadjusted risks were for other stimulant (HR 5.33, 95% CI 5.03–5.64), volatile solvent (HR 4.95, 95% CI 3.98–6.15), and opioid (HR 4.62, 95% CI 4.37–4.87) use disorders. After full adjustment, risks declined, and HRs of the different diagnoses converged to approximately twice as high in the adult children of parents with AUD. Risks of any SUD and of ≥ 2 SUDs were more elevated (95% CIs did not overlap) when AUD was included than when AUD was excluded. Risk of ≥ 2 SUDs was higher than risk of 1 SUD, but only when AUD was included. Conclusions Severe parental AUD was associated with elevated risk for all SUDs. After full adjustment, SUD risks declined and converged but remained doubled. Sociodemographic factors, parental SUD, and parental psychiatric disorder explained much of the excess risk. Drug combinations that included alcohol elevated the risk of ≥ 2 SUDs and any SUD.

Background Addiction to sedative, hypnotic, and anxiolytic drugs (collectively referred to as benzodiazepines), medications commonly used to treat anxiety and sleeping problems, has been described as a hidden epidemic. Growing concerns about addiction and other negative outcomes associated with use of these narcotics have resulted in their regulation and recommendations for more restrictive prescription. However, there are few studies on experiences of long-term benzodiazepine use from the user perspective, and even fewer focusing on people with addiction, who may be the most affected by changing regulations. The aim of this study was to explore experiences of people with long-term use and addiction to benzodiazepines during a time of major changes in guidelines for the prescription of narcotic drugs. Methods This qualitative study included nineteen individual interviews with adults (> 18 years) diagnosed with addiction to benzodiazepines who were undergoing treatment at an urban outpatient clinic in Sweden. The in-depth interviews were pseudonymized, transcribed verbatim, and analyzed using reflexive thematic analysis. Results Two themes highlight the effect of changing prescription guidelines on long-term benzodiazepine users. The first theme, benzodiazepines were not always seen as problematic , but neither were the risks discussed , underscores the absence of psychiatric assessments and conversations about risks at the time of first prescription and highlights the need for clearer communication. The second theme, entangled in continued benzodiazepine use and increasing restrictions on prescribing , illustrates how addiction developed over time and describes how limited contact with prescribers facilitated long-term use, which often persisted until the participants were faced with deprescription. Conclusions This study describes the experiences of individuals with long-term use and addiction to benzodiazepines during a time of shifting attitudes towards prescribing. The results highlight areas for improvement in care for this vulnerable group of patients, including the need for proactive and regular communication about risks of addiction and additional support during deprescription.

Use of amphetamine and methamphetamine is widespread in the general population and common among patients with psychiatric disorders. Amphetamines may induce symptoms of psychosis very similar to those of acute schizophrenia spectrum psychosis. This has been an argument for using amphetamine-induced psychosis as a model for primary psychotic disorders. To distinguish the two types of psychosis on the basis of acute symptoms is difficult. However, acute psychosis induced by amphetamines seems to have a faster recovery and appears to resolve more completely compared to schizophrenic psychosis. The increased vulnerability for acute amphetamine induced psychosis seen among those with schizophrenia, schizotypal personality and, to a certain degree other psychiatric disorders, is also shared by non-psychiatric individuals who previously have experienced amphetamine-induced psychosis. Schizophrenia spectrum disorder and amphetamine-induced psychosis are further linked together by the finding of several susceptibility genes common to both conditions. These genes probably lower the threshold for becoming psychotic and increase the risk for a poorer clinical course of the disease. The complex relationship between amphetamine use and psychosis has received much attention but is still not adequately explored. Our paper reviews the literature in this field and proposes a stress-vulnerability model for understanding the relationship between amphetamine use and psychosis.

Pharmacoepidemiological studies have long raised concerns on widespread use of benzodiazepines and benzodiazepine-related drugs (BZDs), in particular long-term use, among adults and the elderly. In contrast, evidence pertaining to the rates of BZD use at younger ages is still scarce, and the factors that influence BZD utilisation and shape the different prescribing patterns in youths remain largely unexplored. We examined the prevalence rates, relative changes in rates over time, and prescribing patterns for BZD dispensation in young people aged 0-24 years in Sweden during the period January 1, 2006-December 31, 2013, and explored demographic, clinical, pharmacological, and prescriber-related attributes of BZD prescribing in this group. Through the linkage of 3 nationwide Swedish health and administrative registers, we collected data on 17,500 children (0-11 years), 15,039 adolescents (12-17 years), and 85,200 young adults (18-24 years) with at least 1 dispensed prescription for a BZD during 2006-2013, out of 3,726,818 Swedish inhabitants aged 0-24 years. Age-specific annual prevalence rates of BZD dispensations were adjusted for population growth, and relative changes in rates were calculated between 2006 and 2013. We analysed how BZD dispensation varied by sex, psychiatric morbidity and epilepsy, concurrent dispensation of psychotropic medication, type of dispensed BZD, and type of healthcare provider prescribing the BZD. Prescribing patterns were established in relation to duration (3 months, >3 to ≤6 months, or >6 months), dosage (<0.5 defined daily dosage [DDD]/day, ≥0.5 to <1.5 DDD/day, or ≥1.5 DDD/day), and \"user category\" (\"regular users\" [≥0.5 to <1.5 DDD/day for ≥1 year], \"heavy users\" [≥1.5 DDD/day for ≥1 year], or otherwise \"occasional users\"). Multinomial regression models were fitted to test associations between BZD prescribing patterns and individual characteristics of study participants. Between 2006 and 2013, the prevalence rate of BZD dispensation among individuals aged 0-24 years increased by 22% from 0.81 per 100 inhabitants to 0.99 per 100 inhabitants. This increase was mainly driven by a rise in the rate among young adults (+20%), with more modest increases in children (+3%) and adolescents (+7%). Within each age category, overall dispensation of BZD anxiolytics and clonazepam decreased over time, while dispensation of BZD hypnotics/sedatives, including Z-drugs, showed an increase between 2006 and 2013. Out of 117,739 study participants with dispensed BZD prescriptions, 65% initiated BZD prescriptions outside of psychiatric services (92% of children, 60% of adolescents, 60% of young adults), and 76% were dispensed other psychotropic drugs concurrently with a BZD (46% of children, 80% of adolescents, 81% of young adults). Nearly 30% of the participants were prescribed a BZD for longer than 6 months (18% of children, 31% of adolescents, 31% of young adults). A high dose prescription (≥1.5 DDD/day) and heavy use were detected in 2.6% and 1.7% of the participants, respectively. After controlling for potential confounding by demographic and clinical characteristics, the characteristics age above 11 years at the first BZD dispensation, lifetime psychiatric diagnosis or epilepsy, and concurrent dispensation of other psychotropic drugs were found to be associated with higher odds of being prescribed a BZD for longer than 6 months, high dose prescription, and heavy use. Male sex was associated with a higher likelihood of high dose prescription and heavy use, but not with being prescribed a BZD on a long-term basis (> 6 months). The study limitations included lack of information on actual consumption of the dispensed BZDs and unavailability of data on the indications for BZD prescriptions. The overall increase in prevalence rates of BZD dispensations during the study period and the unexpectedly high proportion of individuals who were prescribed a BZD on a long-term basis at a young age indicate a lack of congruence with international and national guidelines. These findings highlight the need for close monitoring of prescribing practices, particularly in non-psychiatric settings, in order to build an evidence base for safe and efficient BZD treatment in young persons.

Background There is limited knowledge on long-term outcomes of tapering treatment for individuals with problematic use of prescription narcotics, including opioids and benzodiazepines. The overall aim of the study is to investigate clinical trajectories and treatment outcomes of patients seeking treatment in addiction care. Methods This paper presents the study protocol and baseline characteristics of a cohort of patients seeking treatment for problematic use of prescription narcotic drugs at specialized outpatient addiction services. Treatment for addiction at the clinic includes drug tapering and treatment for underlying psychiatric disorders. Data in this prospective cohort study is collected from biomarkers, self-report questionnaires, patient medical records, and national registers at baseline and follow-up visits at 6, 12, and 24 months. Results A clinical cohort of 405 participants were enrolled in the study between 2018 and 2023. The study population (57.5% women; 42.5% men) at baseline had a mean age of 49.2 years (SD = 14.0). Participants in the cohort had used prescription narcotics for 11 years on average before seeking treatment, with opioid analgesics (66.2%) being the most common at baseline, followed by benzodiazepines (50.9%). Most participants (75.9%) had received prescription narcotics from their health care provider, although illegal sources were common. Besides substance use disorders, many also had anxiety disorders (46.3%) and depression (40.4%) at baseline. Previous treatment for problematic alcohol or drug use were reported by 14.0% and 21.6%, respectively. Discussion This prospective, naturalistic cohort will provide novel information on long-term outcomes of tapering treatment and identify prognostic factors for treatment success, including abstinence. Future papers will investigate individual and treatment-related characteristics of the patient population. Baseline data suggest that many patients with problematic use of prescription narcotics receive prescriptions over many years from their regular health care providers, which contradicts most clinical guidelines. Trial registration NCT03713983 22/10/2018.

Background Impulsivity is associated with several psychiatric disorders, including substance use disorders (SUD) and attention deficit hyperactivity disorder (ADHD). A widely used questionnaire to assess impulsivity is the Barratt Impulsiveness Scale (BIS), and the aim of the current study was to evaluate the psychometric properties of the Swedish version of the BIS (swe-BIS). Methods The original BIS was translated to Swedish and back-translated by an authorized translator. The swe-BIS was administered to healthy controls ( n  = 113), patients with alcohol use disorder ( n  = 97), amphetamine use disorder ( n  = 37) and attention deficit hyperactive disorder (ADHD; n  = 26). A subset of subjects ( n  = 62) completed the swe-BIS twice within 1 week. Psychometric evaluation of the swe-BIS included assessment of different indices of reliability (internal consistency, test-retest and agreement) and validity (response processess, divergent and convergent). Confirmatory factor analyses (CFA) were performed to assess several indices of model fit in five different models based on previously suggested subscales. Results Cronbach’s alpha for all swe-BIS items in the full sample was 0.89, ranging from 0.78–0.87 within the different subgroups. The Pearson test-retest correlation for total score was 0.78 ( p  < 0.001), with greater test-retest correlations within compared to across different subscales. The Bland-Altman plot indicated high level of agreement between test and retest. The healthy individuals had lower swe-BIS score compared to the patients (t(267.3) = − 8.6; p  < 0.001), and the swe-BIS total score was also significantly different between each of the four participant groups ( p  < 0.01 for all group comparisons). Furthermore, swe-BIS had greater correlations with impulsivity related scales compared to non-impulsivity related scales. The CFA analyses indicated that while no suggested model showed an optimal fit, the best model fit indices was found for the 3-factor model. Conclusions The swe-BIS was found to have good to excellent psychometric properties with respect to the assessed indices of reliability and validity, supporting use of the scale in clinical research in both healthy individuals and patients with SUD and ADHD.

IntroductionOpioid analgesic medications play a critical role in pain management but are associated with significant risks, including addiction. General practitioners in primary care account for a substantial proportion of opioid prescriptions, and prescribing practices may not always fully align with clinical guidelines. Given the limited evidence supporting long-term opioid use for chronic non-cancer pain, there is a pressing need for interventions that promote safer, guideline-concordant prescribing. The Smarta Val (Smart Choices) trial will evaluate whether a new multicomponent intervention, comprising an educational seminar, written materials and feedback on prescribing over 12 months, can improve opioid prescribing practices in primary care.Methods and analysisThis cluster randomised pragmatic trial will assess changes in opioid prescribing across primary healthcare centres (PHCCs) in Stockholm, Sweden. Consenting PHCCs will be randomised 1:1 to either the intervention group, receiving the multicomponent intervention, or the active control group, receiving a leaflet on prescribing recommendations. A sample size of 24 PHCCs per group is required to detect differences in opioid prescribing between groups. A third group of non-randomised observational reference PHCCs will be included to provide contextual information on prescribing practices during the study period. Data sources include regional healthcare databases, baseline and 12-month follow-up questionnaires, and an intervention delivery form. The primary outcome is the change in prescription of opioids at 12 months. Secondary outcomes are the change in prescription of opioids at 24 months and the change in the specific opioid substances prescribed at 12 months.Ethics and disseminationThe study has been approved by the Swedish Ethical Review Authority (Dnr 2021-06739-01). Participation in the study requires informed consent from PHCC managers in the intervention and active control groups. Results will be disseminated through international peer-reviewed journals and conference presentations.Trial registration numberNCT05577026.

ObjectivesFew studies have evaluated the prevalence of psychiatric disorders among treatment-seeking elite athletes (EA) or high-performance coaches (HPC) in psychiatric outpatient settings.MethodsDescriptive overview of EA and HPC with psychiatric disorders at two publicly funded psychiatric outpatient treatment clinics in Stockholm and Malmö, Sweden. Co-occurring psychiatric disorders were illustrated using Venn diagrams for EA and HPC, and male and female EA separately, among patients from the Stockholm clinic (SC) that used standardised diagnostic interviews.ResultsOverall, most patients were EA (n=221) compared with HPC (n=34). The mean age was 23.5 (±5.9) years for EA and 42.8 (±8.8) for HPC. Anxiety disorders were most common at the SC in EA and HPC (69% vs 91%, respectively). Stress-related disorders were found in 72% of HPC compared with 25% of EA. Affective disorders were found in 51% of EA and 52% of HPC. Eating disorders were common among EA (26%), especially females (37%). Substance use disorders were found in 17% of HPC. Comorbidity was generally common between affective and anxiety disorders.ConclusionStress and adjustment disorders were found in nearly three of the four HPC compared with one in four EA. Eating disorders were prevalent in around one in four athletes and about one in six HPC had a substance use disorder.

Amphetamine use disorder (AMPH) and attention deficit-hyperactivity disorder (ADHD) often co-occur and are associated with poor treatment outcomes. Elevated impulsivity is a core feature in both disorders. Little is known however about the specific neurocognitive profile regarding different facets of impulsivity, and specifically impulsive choice, in comorbid populations. Three groups (ADHD + AMPH, ADHD only and healthy controls (HC)) were assessed with self-reported impulsivity and cognitive tasks of impulsive choice, operationalized as delay aversion (DA) and reflection impulsivity. Twenty-nine participants with comorbid ADHD + AMPH, 25 participants with ADHD only and 116 HC completed screening, including self-rating scales, and cognitive testing. 20, 16 and 114 participants completed computerized cognitive tasks in the ADHD + AMPH group, ADHD group and HC group, respectively. The ADHD + AMPH group reported significantly higher motor, attentional and non-planning impulsiveness, and showed a significantly higher degree of impulsive choice, compared to both groups. There were no differences in task-related impulsiveness between ADHD only and HC. The current findings suggest that individuals with ADHD + AMPH have overall elevated levels of impulsivity compared to individuals with ADHD only. In addition, that ADHD + AMPH is specifically associated with impairments in task-related impulsive choice, which was not found in ADHD only compared to HC. The neurocognitive profile in this specific patient group may represent a need for more systematic screening within healthcare settings in order to develop effective and targeted treatment for comorbid patients. EudraCT, 2012-004298-20.

Improvement of arm-hand function and arm-hand skill performance in stroke patients is reported by many authors. However, therapy content often is poorly described, data on actual arm-hand use are scarce, and, as follow-up time often is very short, little information on patients' mid- and long-term progression is available. Also, outcome data mainly stem from either a general patient group, unstratified for the severity of arm-hand impairment, or a very specific patient group. To investigate to what extent the rate of improvement or deterioration of actual arm-hand use differs between stroke patients with either a severely, moderately or mildly affected arm-hand, during and after rehabilitation involving a well-defined rehabilitation program. Design: single-armed prospective cohort study. Outcome measure: affected arm-hand use during daily tasks (accelerometry), expressed as 'Intensity-of arm-hand-use' and 'Duration-of-arm-hand-use' during waking hours. Measurement dates: at admission, clinical discharge and 3, 6, 9, and 12 months post-discharge. Statistics: Two-way repeated measures ANOVAs. Seventy-six patients (63 males); mean age: 57.6 years (sd:10.6); post-stroke time: 29.8 days (sd:20.1) participated. Between baseline and 1-year follow-up, Intensity-of-arm-hand-use on the affected side increased by 51%, 114% and 14% (p < .000) in the mildly, moderately and severely affected patients, respectively. Similarly, Duration-of-arm-hand-use increased by 26%, 220% and 161% (p < .000). Regarding bimanual arm-hand use: Intensity-of-arm-hand-use increased by 44%, 74% and 30% (p < .000), whereas Duration-of-arm-hand-use increased by 10%, 22% and 16% (p < .000). Stroke survivors with a severely, moderately or mildly affected arm-hand showed different, though (clinically) important, improvements in actual arm-hand use during the rehabilitation phase. Intensity-of-arm-hand-use and Duration-of-arm-hand-use significantly improved in both unimanual and bimanual tasks/skills. These improvements were maintained until at least 1 year post-discharge.