The objectives of this study were to determine the following: (a) the feasibility of expanding interim methadone treatment (IM), (b) the impact of IM on heroin and cocaine use, and (c) the effect of charging a modest fee for IM. Six clinics provided daily methadone plus emergency counseling only (IM) to heroin-addicted individuals on a waiting list for treatment. IM was provided for up to 120 days before transfer to regular methadone treatment. Drug testing was conducted at admission to IM and at transfer to methadone treatment program (MTP). Half the patients were charged $10/week for IM. Logistic regression analysis was used to determine the effect of fee status and other variables on transfer. Of 1,000 patients enrolled in IM, 762 patients (76.2%) were admitted to a regular MTP. For those who transferred (n = 762), opioid-positive tests decreased from 89.6% to 38.4%; cocaine, from 49.9% to 44.9% from admission to transfer. Logistic regression analysis indicated that fee status at baseline was not significantly associated with transfer. When limited public resources create waiting lists, IM can allow additional patients to sharply reduce heroin use while waiting for admission to MTP.
Opioid maintenance treatment (OMT) is the most widely used treatment for opioid dependence. Maintenance programmes differ in various aspects and may also change over time. This paper investigates the changes in treatment practices within a national OMT programme during a 10year period (2002-2011), especially with regard to the prescribing of methadone and buprenorphine. Data (n=34,001) were collected by annual assessments questionnaires. In 2002, only 16% of the OMT patients received buprenorphine as their maintenance medication. By 2011 this percentage had increased significantly (p<.001) to 50.3%. In the same period the number of patients more than tripled (from 1,984 to 6,640, p<.001), and programme attrition rates decreased (p=.020). This relatively rapid shift is a part of the increasing reliance of addiction medicine upon a range of medications administered by different routes which has not been previously charted within a national treatment programme.
This article presents a sociocultural alcohol/drug counseling model for counselors working with Latino users/abusers. Intended to supplement different treatment models, this model addresses pre-treatment issues of Latino users/abusers. A demographic overview of Latinos and a discussion of selected Latino cultural values and issues as they relate to substance use/abuse are included. These cultural values include Simpatía, Personalismo, Familismo, Gender Roles (Machismo and Hembrismo/Marianisimo), Vergüenza, and Espiritismo. Along with identifying misperceptions and issues that may occur within the counseling session, specific recommendations and interventions for counselors are provided.
This study examines gender similarities and differences in background characteristics, the effectiveness of treatment, and the predictors of post-release outcomes among incarcerated drug-using offenders. The sample of 1,842 male and 473 female treatment and comparison subjects came from a multi-site evaluation of prison-based substance abuse treatment programs. Three-year follow-up data for recidivism and post-release drug use were analyzed using survival analysis methods. Despite the greater number of life problems among women than men, women had lower three-year recidivism rates and rates of post-release drug use than did men. For both men and women, treated subjects had longer survival times than those who were not treated. There were both similarities and differences with respect to gender and the other predictors of the two post-release outcomes. Differences in background characteristics and in factors related to post-release outcomes for men and women suggest the plausibility of gender-specific paths in the recovery process.
Self-efficacy is a robust predictor of short- and long-term remission after treatment. This study examined the predictors of self-efficacy in the year after treatment and 15 years later. A sample of 420 individuals with alcohol use disorders was assessed five times over the course of 16 years. Predictors of self-efficacy at 1 year included improvement from baseline to 1 year in heavy drinking, alcohol-related problems, depression, impulsivity, avoidance coping, social support from friends, and longer duration of participation in Alcoholics Anonymous (AA). Female gender, more education, less change in substance use problems, and impulsivity during the first year predicted improvement in self-efficacy over 16 years. Clinicians should focus on keeping patients engaged in AA, addressing depressive symptoms, improving patient's coping, and enhancing social support during the first year and reduce the risk of relapse by monitoring individuals whose alcohol problems and impulsivity improve unusually quickly.
A major challenge facing many individuals attempting to abstain from substances is finding a stable living environment that supports sustained recovery. Sober living houses (SLHs) are alcohol- and drug-free living environments that support abstinence by emphasizing involvement in 12-step groups and social support for recovery. Among a number of advantages, they are financially self-sustaining and residents can stay as long as they wish. Although SLHs can be used as housing referrals after inpatient treatment, while clients attend outpatient treatment, after incarceration, or as an alternative to treatment, they have been understudied and underutilized.
To describe outcomes of SLH residents, we interviewed 245 individuals within 1week of entering SLHs and at 6-, 12-, and 18-month follow-up. Eighty-nine percent completed at least one follow-up interview. Outcomes included the Addiction Severity Index (ASI), Brief Symptom Inventory (BSI), and measures of alcohol and drug use. Covariates included demographic characteristics, 12-step involvement, and substance use in the social network.
Regardless of referral source, improvements were noted on ASI scales (alcohol, drug, and employment), psychiatric severity on the BSI, arrests, and alcohol and drug use. Substance use in the social network predicted nearly all outcome measures. Involvement in 12-step groups predicted fewer arrests and lower alcohol and drug use.
Residents of SLHs made improvements in a variety of areas. Additional studies should use randomized designs to establish causal effects of SLHs. Results support the importance of key components of the recovery model used by SLHs: (a) involvement in 12-step groups and (b) developing social support systems with fewer alcohol and drug users.
Methadone Transition Treatment (MTT) is a treatment program for opioid-addicted individuals that takes advantage of a 1989 change in federal guidelines permitting the establishment of 180-day detoxification programs. Thirty-eight subjects were assigned to either high-dose (80 mg) or low-dose (40 mg) methadone in a double-blind design. Both conditions showed initial dramatic decreases in illicit drug use and distress symptoms (opioid craving, withdrawal symptoms, and dysphoria). The high-dose condition showed a nonsignificant trend toward less frequent illicit drug use during the period of stable methadone dosing. We speculate that intensive psychosocial treatment, including weekly individual counseling and three-times a week group therapy, may have dampened outcome differences between high- and low-dose methadone conditions. Treatment retention was high for both dosage conditions.
The Comprehensive Addiction Severity Index for Adolescents (CASI-A) is a 45 to 90-minute comprehensive, semi-structured clinical interview for evaluating adolescents who present for treatment at various provider agencies. CASI-A modules and their individual items were selected and revised based on theory, clinical wisdom, and adolescent experiences obtained during pilot interviews and focus groups. The CASI-A assesses known risk factors, concomitant symptomatology, and consequences of adolescent alcohol/drug use within seven primary areas of functioning: education status, alcohol/drug use, family relationships, peer relationships, legal status, psychiatric distress, and use of free time. The CASI-A is not a diagnostic or screening instrument, but rather a clinical assessment tool that obtains clinically pertinent information designed to guide treatment planning and to evaluate treatment outcome. The CASI-A's design makes it suitable for administration in a variety of settings, for repeat administration at posttreatment follow-up evaluations, and for assessment of virtually all adolescents in treatment regardless of their admission problem. Overall, the CASI-A has encouraging but preliminary evidence of validity and internal consistency. Information collected soon after admission during administration of the CASI-A by nonclinical interviewers corresponded quite well with that obtained over the course of the adolescent's treatment stay by the entire treatment team. Revisions to the instrument are being made in those areas where correspondence between information on the CASI-A and that extracted from clinical records dropped below 75%, or in those early subscales, where alpha coefficients dropped below .6. As a result of the encouraging results reported in this paper, we are beginning additional psychometric testing, refining the proposed scoring system, and developing a computerized data entry, scoring, and report system.
In his extraordinarily productive research career, G. Alan Marlatt contributed to and anticipated by decades a variety of major changes in the treatment of substance use disorders. This article briefly reviews and comments on his contributions to addiction psychology, cognitive-behavior therapy, alcohol expectancies, relapse prevention, moderation goals, harm reduction, and mindfulness meditation research. He departed suddenly and too soon, but left us with a rich heritage for more effective and humane treatment of those who suffer with addiction.
Using a complete birth cohort of all young men born in 1966 in Denmark (N = 43,403), the prevalence of a first-time drink-driving conviction among young men is estimated. More than 7% of the total male birth cohort was so convicted before the age of 27 years. In an examination of risk factors for a first-time drink-driving conviction, young adults coming from potentially vulnerable groups have an increased risk. Earlier criminal convictions of various types were also significant predictors of drink driving. Situational pressures also play a part and are controlled for, with the risk of a drink-driving conviction increased substantially in rural areas compared to metropolitan areas. The study concludes that disadvantages during adolescence, including parental substance abuse, having a teenage mother, and domestic violence, are associated with a first-time drink-driving conviction.
This paper touches upon three primary topics: description of the treatment methods and approaches that have proven to be most useful and successful in Israel's only residential center for alcoholics; summary of recent findings about the characteristics of alcoholics that have been treated at the residential center during the years 1982-1987 (the findings revealed a high percentage of married alcoholics and of unemployment) and some details about the follow-up investigation and the evaluation of the effectiveness of the center's treatment modality. The relatively high abstention rate - 40.9% of all patients (51.2% of those who completed treatment) - is the most important result of the study. Thus, this article integrates research data and relevant features of the Israeli residential treatment experience, in which the emphasis on involving the family is greater than elsewhere.
Cocaine abuse today is truly a national epidemic that encompasses all ages, economic and ethnic groups. This article focuses on the physiological effects of cocaine and the destructive nature of the drug in terms of the abuser's powerlessness over highly addictive qualities. Cocaine abuse in our nation will continue to increase unless the federal government develops more stringent policies to drastically decrease the amount of cocaine imported into the United States from source countries.
Since 1997, poisoning, particularly from heroin and other opioids, has been the leading cause of injury mortality in Massachusetts. Our aim was to describe recent trends in opioid-related poisoning deaths among Massachusetts residents.
Massachusetts death files for the years 1990-2003, as coded by International Classification of Disease, Ninth Revision and International Classification of Disease, Tenth Revision, were used to identify all poisoning deaths and opioid-related poisoning deaths; rates were age-adjusted and grouped by year, sex, and race/ethnicity.
From 1990 to 2003, opioid-related fatal poisoning rates increased by 529% from 1.4 per 100,000 in 1990 to 8.8 per 100,000 in 2003. The proportion of total poisoning deaths associated with opioids rose from 28% in 1990 to 69% in 2003.
Massachusetts experienced a significant increase in opioid-related poisoning death rates. To guide future public health interventions, further investigation is necessary to better delineate the specific opioids involved, the circumstances surrounding these deaths, and the medical and behavioral health care options available.
This study examines the relationship between methadone treatment and the criminal activity of 126 individuals participating in treatment during the early 1990s. The primary question addressed is to what extent is methadone maintenance treatment associated with reductions in crime? Although prior studies in the 1970s and early 1980s showed significant decreases in crime for individuals in treatment programs, criteria for remaining in this treatment modality have changed in recent years, particularly with the advent of acquired immune deficiency syndrome and the need to reduce intravenous drug use. A pre-post study design is employed spanning a 6-year time period of subject recruitment and follow-up (1987-1993). Uniform administrative records on arrests are used for the analyses. A multiple regression model is employed to explain the variance in the number of arrests 2 years following program admission, with prior criminal history, prior and current drug treatment, and current cocaine use employed as explanatory variables. Results indicate that treatment retention has only a slight, though significant, effect on reducing criminal activity during treatment. Two other factors that appear to increase arrest activity are the use of cocaine and prior criminal history. The fact that arrests did not decrease during a treatment period of 18 months on average requires more investigation in light of the increase in cocaine use in this population.
This report describes trends in treatment admissions for methamphetamine/amphetamine (MA) abuse from 1992 to 2002 in California and assesses predictors of treatment retention and completion. Results show such admissions increasing fivefold and representing a growing proportion of overall treatment admissions. Patients admitted for MA abuse were increasingly diverse in race/ethnicity, older in age, and more frequently under legal supervision status over time. There was a decrease in injection drug use. Several user characteristics played consistent roles as risk factors for noncompletion and shorter treatment retention for both residential and outpatient admissions: having lower than a high school education, being younger at treatment admission, having a disability, having greater severity of MA use, and using injection drugs. Consistently, those with legal supervision status at admission had higher completion rates and longer retention than those reporting no legal status. Overall, findings suggested that clients with greater socioeconomic disadvantage and more severe problems may require greater efforts (e.g., services) to be retained in treatment.
The paper examines trends in the use of inpatient substance abuse detoxification provided at general hospitals using data from the Healthcare Utilization and Cost Project - National Inpatient Survey. Most persons who received inpatient detoxification did not also receive rehabilitation while an inpatient. The percentage receiving rehabilitation declined between 1992 and 1997 from 38.9% to 21.1%. The decrease in the probability of receiving rehabilitation occurred across gender, age, region, insurance status, income levels, diagnoses, admission source, and discharge destination. Two other notable trends are that average length of stay for detoxification dropped by one third over the six-year period, from 7.7 days to 5.2 days and the percentage of admissions through the emergency room increased from 35.6% to 40.1%. Detoxification offers an opportunity to link patients with rehabilitation. This analysis indicates that those opportunities may be missed.
In this observational study, longitudinal trends (1994-2002) in hospital admissions with co-occurring alcohol/drug abuse and addiction (ADAA; N=43,073) were examined to determine prevalence and hospital costs by payer group and type of drug used. Four primary drug types were reported: 49% used a combination of two or more drugs, 25% used alcohol only, 11.8% used opioids only, and 6.5% used cocaine only. Costs of admissions increased significantly for those using two or more drugs (119%, from US$12.7 to US$27.8 million), alcohol (120%, from US$9 to US$19.8 million), and opioids (482%, from US$1.7 to US$9.9 million). Medicaid/Medicare represented 70% of the overall number of admissions and also paid 70% of hospital costs. Among Medicaid/Medicare and uninsured admissions, illicit drug use was more common, whereas among private payer admissions, alcohol abuse was more common. Hospital admissions with co-occurring ADAA must be considered when estimating the scope of ADAA and its financial burden.
This article examines the extent to which U.S. outpatient substance abuse treatment (OSAT) facilities provide HIV counseling and testing (C&T) to clients between 1995 and 2005. We also examine organizational and client characteristics associated with OSAT facilities' provision of HIV C&T. Data were collected from a nationally representative sample of outpatient treatment facilities in 1995 (n = 618), 2000 (n = 571), and 2005 (n = 566). Results show that in 1995, 26.8% of OSAT clients received HIV C & T; by 2005, this proportion had increased, but only to 28.8%. Further, results from random-effects interval regression analysis show that C&T is especially widespread in public and nonprofit facilities, in methadone facilities, and in units that serve injection drug users and commercial sex workers. HIV C&T was also more widespread in units that employed formal intake protocols. Despite widespread efforts to increase HIV C&T services in OSAT care, only a small and stable minority of clients receive these services. Adoption of formal intake procedures may provide one vehicle to increase provision of C&T services.
Interest in improving the quality of addiction treatment has led to the development of clinical paradigms that emphasize the principle of tailored care-matching treatments to the specific needs of each client or client subgroup. This work analyzes how trends in the provision of tailored treatment practices (TTPs) have changed between 1995 and 2005 across outpatient substance abuse treatment (OSAT) programs in the United States. Categories of interest include measures to capture needs assessment and treatment planning activities, treatment offerings for special populations, and case management activities. Results show that TTPs have diffused in an uneven fashion in the population of OSAT programs between 1995 and 2005. Specifically, needs assessment/treatment planning and case management remain a relatively common practice among OSAT programs, while treatment for special populations (especially same-race therapy) is less widely practiced and, indeed, experienced some decline over the study period. This trend is troublesome given that minority clients constitute a large proportion of those utilizing OSAT programs.
Drug abuse is the primary reason women enter prison and is the primary health problem of women in prison. There has been little research conducted specifically with this population; information must be drawn from studies with nonincarcerated addicted women and incarcerated addicted men. The purpose of this paper is to review what is known about the treatment and aftercare needs of this group (including relapse and recidivism prevention) and to propose an agenda for future research. (C) 1998 Elsevier Science Inc.
The type and amount of medical services provided to 2,394 patients in methadone maintenance programs in three states was studied. Data were obtained from on-site confidential interviews with the entire treatment staff at seven programs. It was found that there were marked differences in the number and type of medical staff. Thus, there was ten times more coverage by physicians at some programs than others. In general, there were notable differences in the treatment staff available. Comparable variations among the programs were found with respect to the actual provision of medical services. Thus, the number of patients seen by the medical staff on a weekly basis varied from a high of 185 patients to a low of 36 patients. Similarly, the proportion of each program's patients receiving medical treatment per week varied from 53 to 14 percent. Reasons for those variations in medical services are considered.
Two-hundred and sixty eight opioid addicts completed a 2.5 year follow-up during which we examined the psychosocial antecedents and consequences of leaving, reentering and remaining in treatment. Compared to those addicts who obtained more sustained treatment, the addicts who were only detoxified had fewer psychological problems and were more often male, black and younger. These baseline differences complicated comparisons between these minimally treated addicts and the rest, but among those who had more than minimal treatment, continuous treatment was better than intermittent treatment in controlling substance abuse and legal problems. Further analyses involved dividing the 30 months of follow-up into 6 month blocks and comparing the 6 months before, during and after leaving or reentering treatment. We found that addicts left treatment at periods of relative abstinence and good psychosocial adjustment, although they increased their alcohol abuse during the period of leaving treatment. During the 6 months after leaving, patients often returned to drug abuse and then rapidly deteriorated in social adjustment. When reentering treatment, the majority (75%) stayed for over 6 months and improved steadily in most areas. At reentry patients also had less criminal activity, less physical disability, and less opiate use suggesting a carry-over of treatment benefits, but they had more problems with their spouse and more alcohol and cocaine use than they had when first entering treatment suggesting new precipitants for reentry into treatment.
In 2006, the Medicare program covered 37 million elderly persons and 7 million persons younger than 65 years, but little is known about substance abuse (SA) service utilization. Using the 5% Sample of Medicare claims data, the study examines individuals who used SA detoxification ("detox") and/or rehabilitation ("rehab") services under Medicare in 2001 and 2002. SA claimants less than 65 years of age (disabled) were compared to claimants more than 65 years of age (elderly). The disabled were more likely to have a co-occurring mental disorder than elderly claimants (50% vs. 14%) and more likely to have serious mental illness (21% vs. 2.3%). Disabled claimants were more than three times as likely to receive any detox service as elderly claimants (17% vs. 6%). The rate of claimants receiving rehab services within 30 days of detox is about one third for disabled claimants and one quarter for elderly claimants.
Adolescents engaged in substance abuse treatment manifest a rate of cigarette smoking approximately four times higher than that of youth in the general population ( approximately 80% vs. 20%) and a high rate of smoking persistence into adulthood. Although there has been a shift toward the implementation of no-smoking policies in substance abuse treatment programs, few studies have examined the relation between cigarette-smoking bans and key clinical outcomes. The current study examined the medical charts of all adolescents (N = 520) admitted to the only adolescent hospital-based substance abuse treatment program in the northern two thirds of the province of British Columbia, Canada. During the span of the study period (March 2001-December 2005), the treatment site moved from a partial smoking ban to a total smoking ban, and then retreated to partial smoking ban. The total smoking ban was not associated with a lower proportion of adolescent smokers seeking treatment at the facility or a lower treatment completion rate among smokers. Total smoking bans do not appear to be an obstacle for adolescent smokers seeking residential substance abuse treatment, nor do total smoking bans appear to compromise the treatment completion rates of smokers in comparison to nonsmokers. Despite these null findings, the effective implementation of smoke-free policies in adolescent substance abuse treatment programs requires not only large-scale organizational change but also the transformation of current commonly held beliefs about tobacco dependence in addictions treatment and recovery communities.
The increasing demand for treatment for cannabis dependence in Australia and internationally has led to the identification of significant gaps in knowledge of effective interventions. A randomized controlled trial of brief cognitive-behavioral interventions (CBT) for cannabis dependence was undertaken to address this issue. A total of 229 participants were assessed and randomly assigned to either a six-session CBT program (6CBT), a single-session CBT intervention (1CBT), or a delayed-treatment control (DTC) group. Participants were assisted in acquiring skills to promote cannabis cessation and maintenance of abstinence. Participants were followed-up a median of 237 days after last attendance. Participants in the treatment groups reported better treatment outcomes than the DTC group. They were more likely to report abstinence, were significantly less concerned about their control over cannabis use, and reported significantly fewer cannabis-related problems than those in the DTC group. Those in the 6CBT group also reported more significantly reduced levels of cannabis consumption than the DTC group. While the therapist variable had no effect on any outcome, a secondary analysis of the 6CBT and 1CBT groups showed that treatment compliance was significantly associated with decreased dependence and cannabis-related problems. This study supports the attractiveness and effectiveness of individual CBT interventions for cannabis use disorders and the need for multisite replication trials.
Alcohol use patterns among Vietnam combat veterans is an area with little research. This study evaluated three groups of Vietnam subjects on a chemical dependency unit who had a current Axis I diagnosis of alcohol abuse. No subject possessed a PTSD diagnosis. Two groups involved in-country veterans divided by presence or absence of PTSD based on the MMPI-PTSD scale (In-country and PTSD). The third group did not experience combat and was below the mean on the MMPI-PTSD scale (Noncombat). These groups were compared on the MMPI and the Alcohol Use Inventory (AUI), a measure of alcohol use patterns. Results showed that the PTSD Group had significantly higher scores on the MMPI and AUI reflective of deteriorated and binge drinking patterns. Discussion focused on the "hidden" dimension of PTSD among chemically dependent Vietnam veteran inpatients. The Relapse Prevention model was endorsed.
To provide information that will reduce the gap between research and practice, the transfer of a complex drug abuse counseling technology is examined. This technology, cognitive mapping, is a graphic tool shown to effectively facilitate communication and problem solving in group and individual counseling sessions. Unlike some techniques, mapping requires substantial counselor time, effort, and expertise to learn and to use. This article briefly describes the development and evolution of mapping and supporting research. It then focuses on our efforts to develop mapping training that will facilitate use of this evidence-based technique in drug abuse treatment. Major training and transfer pitfalls are noted, and strategies for successful training are recommended.
Craving to smoke is often conceptualized and measured as a tonic, slowly changing state induced by abstinence. In this article, we review the literature on the existence, causes, and treatment of cue-induced cravings: intense, episodic cravings typically provoked by situational cues associated with drug use. In laboratory research, smokers exposed to smoking-related cues demonstrate increased craving as well as distinct patterns of brain activation. Observational field studies indicate that such cue-induced cravings are substantially responsible for relapse to smoking but that smoking can often be averted by coping responses. The effects of pharmacological interventions are mixed. Steady-state medications (bupropion, varenicline, nicotine patch) do not appear to protect smokers from cue-induced cravings. However, acutely administered nicotine medications (such as nicotine gum and lozenge), used after cue exposure as "rescue medications," can help a smoker's recovery from cue-induced cravings. Cue-induced craving plays an important role in smoking and relapse and likely in other addictions as well. Treatments to mitigate the effect of cue-induced craving are both important and needed.
In recent years, interest in shortening of opioid detoxification has increased with the rising demands to find more cost-effective approaches for treatment of opioid dependence. This study was designed to evaluate the efficacy of administration of high doses of buprenorphine during 24 h in the management of acute opioid withdrawal. A total of 40 treatment-seeking opioid dependents were admitted and randomly assigned to two groups in a double blind, parallel trial. Buprenorphine was administered intramuscularly. Twenty patients received 12 mg buprenorphine in 24 h and the remaining 20 patients treated with conventional doses of buprenorphine tapered down over 5 days. Variables that were assessed included retention in treatment, rates of successful detoxification, the Subjective Opiate Withdrawal Scale (OOWS) scores, the Objective Opiate Withdrawal Scale (SOWS) scores, intensity of craving, drug side effects, and levels of hepatic enzymes (ALT and AST). There was no significant difference between the two groups on most variables. The main difference was in the time that maximal withdrawal symptoms occurred, which in the experimental protocol group appeared early while in the conventional protocol group appeared later during the detoxification period. Moreover, the experimental protocol was not only tolerated well but also accompanied with significantly less elevation in the ALT levels compared to the conventional treatment. However, patients in this group used more indomethacin and trazodone for symptom palliation. This study suggests that administration of high doses of buprenorphine in 24 h may be a reasonable approach for shortening of opioid detoxification. However, a larger study to confirm our results is warranted.
The aim of this study was to determine the effects of baseline cocaine use on treatment outcomes for heroin dependence over a 24-month period.
A longitudinal cohort (24 months) study was carried out. Interviews were conducted at baseline, 3, 12, and 24 months.
The study setting was Sydney, Australia.
Six hundred fifteen heroin users were recruited for the Australian Treatment Outcome Study.
Cocaine use was common at baseline (40%) but decreased significantly over the study period. Even after taking into account age, sex, treatment variables, current heroin use, and baseline polydrug use, baseline cocaine use remained a significant predictor of poorer outcomes across a range of areas. Baseline cocaine users were more likely to report heroin use, unemployment, needle sharing, criminal activity, and incarceration over the 24-month study period.
Cocaine consumption among heroin users has repercussions across a range of areas that persist far beyond the actual period of use. Consequently, treatment providers should regard cocaine use among clients as an important marker for individuals who are at risk of poorer treatment outcome.
Cocaine abuse and dependence continue to be widespread. Currently, there are no pharmacotherapies shown to be effective in the treatment of cocaine dependence.
A 33-week outpatient clinical trial of fluoxetine (60 mg/day, po) for cocaine dependence that incorporated abstinence-contingent voucher incentives was conducted. Participants (N = 145) were both cocaine and opioid dependent and treated with methadone. A stratified randomization procedure assigned subjects to one of four conditions: fluoxetine plus voucher incentives (FV), placebo plus voucher incentives (PV), fluoxetine without vouchers (F), and placebo without vouchers (P). Dosing of fluoxetine/placebo was double blind. Primary outcomes were treatment retention and cocaine use based on thrice-weekly urine testing.
The PV group had the longest treatment retention (M = 165 days) and lowest probability of cocaine use. The adjusted predicted probabilities of cocaine use were 65% in the P group, 60% in the F group, 56% in the FV group, and 31% in the PV group.
Fluoxetine was not efficacious in reducing cocaine use in patients dually dependent on cocaine and opioids.
Of a randomly selected sample of 214 patients treated with aversion therapy for cocaine dependence in four chemical dependency units operated by Schick Shadel Hospitals, 156 were followed up 12 to 20 months posttreatment (average 15.2 months). Significant other validation was obtained in 33%. Total abstinence from cocaine for the group overall was 53% at one year post treatment, and current abstinence of at least 6 months at follow-up was 68.6%. Those treating with aversion for cocaine alone had a one-year abstinence of 39% and a current abstinence of 62.4%. Those treating with aversion for alcohol and cocaine had a one-year total abstinence from cocaine of 69% and a current abstinence of 76%. Those treating with aversion for cocaine and marijuana had a one-year total abstinence from cocaine of 50% and a current abstinence of 65%. Those treating with aversion for alcohol, cocaine, and marijuana had a one-year total abstinence from cocaine of 73% and a current abstinence of 73%. One-year total abstinence from alcohol was 54% for those receiving aversion for both alcohol and cocaine and 77% for those receiving aversion for alcohol, cocaine, and marijuana. Current abstinence from alcohol at follow-up was 68% and 81%, respectively. One-year total abstinence from marijuana was 42% for those treating with aversion for cocaine and marijuana and 64% for those treating with aversion for alcohol, cocaine, and marijuana. Current abstinence at follow-up from marijuana was 61% and 81%, respectively. The use of aversion therapy for both alcohol and cocaine in alcoholics who were also using cocaine was associated with higher total abstinence rates (88% vs. 55%) from cocaine when compared with alcoholics who used cocaine but received no aversion as part of their program. The conclusion is tentative since the follow-up rate in this study was lower than that of the previous study (64% vs. 84%). Being around other users accounted for 49% of relapse situations. Family/Work stress was associated with relapse in 33% of cases and unpleasant feelings in 24% of cases. The use of both reinforcement treatments and the use of support following treatment were associated with improved abstinence rates from cocaine. Those patients who reported losing all urges for cocaine after treatment had a total abstinence from cocaine of 90%, those who reported losing all the uncontrollable urges had a total abstinence of 64%, and those who reported still having the urge reported only 33% total abstinence from cocaine.
Inattention and hyperactive-impulsive symptoms have been associated with nicotine dependence. In an open-label randomized trial (N = 454) of transdermal nicotine versus nicotine nasal spray, we examined whether increases in inattention and hyperactive-impulsive symptoms measured by self-report in the first quit week predicted relapse at the end of 8 weeks of treatment (EOT). During the first quit week, 166 (37%) participants reported an increase whereas 288 (63%) reported no change/decrease in total symptoms; changes were not influenced by treatment type. In a logistic regression model of abstinence, an increase in total symptoms in the first quit week significantly reduced odds of abstinence at EOT (continuous change score: OR = 0.94, 95% CI = 0.91-0.98, p = .002; dichotomized change score: OR = 0.57, 95% CI = 0.37-0.87, p = .009). Early increases in inattention and hyperactive-impulsive symptoms following quit date during nicotine replacement therapy predicted relapse to smoking, suggesting that treatments targeting these symptoms in the first quit week may facilitate abstinence.
To summarize the major findings of the five Cochrane reviews on substitution maintenance treatments for opioid dependence.
We conducted a narrative and quantitative summary of systematic review findings. There were 52 studies included in the original reviews (12,075 participants, range 577-5894): methadone maintenance treatment (MMT) was compared with methadone detoxification treatment (MDT), no treatment, different dosages of MMT, buprenorphine maintenance treatment (BMT), heroin maintenance treatment (HMT), and l-alpha-acetylmethadol (LAAM) maintenance treatment (LMT).
Outcomes considered were retention in treatment, use of heroin and other drugs during treatment, mortality, criminal activity, and quality of life.
Retention in treatment: MMT is more effective than MDT, no treatment, BMT, LMT, and heroin plus methadone. MMT proved to be less effective than injected heroin alone. High doses of methadone are more effective than medium and low doses. Use of heroin: MMT is more effective than waiting list, less effective than LAAM, and not different from injected heroin. No significant results were available for mortality and criminal activity.
These findings confirm that MMT at appropriate doses is the most effective in retaining patients in treatment and suppressing heroin use but show weak evidence of effectiveness toward other relevant outcomes. Future clinical trials should collect data on a broad range of health outcomes and recruit participants from heterogeneous practice settings and social contexts to increase generalizability of results.
Alcohol dependence (AD) and posttraumatic stress disorder (PTSD) frequently co-occur. However, little systematic study has examined the importance of their temporal order of onset. In this study, differences in clinical presentation and response to cognitive-behavioral substance-use therapy by order of onset were examined among 94 (51 men and 43 women) individuals with AD and PTSD. The findings revealed that women with primary AD and men with primary PTSD presented as more distressed and/or depressed than their counterparts at treatment entry. A relationship between increased alcohol intake and higher PTSD symptom levels was observed during treatment. In general, the primary PTSD group derived greater overall benefit (e.g., in physical health, alcohol use, social functioning) as compared with the primary AD group. Finally, women with primary AD appeared particularly vulnerable to continued psychiatric distress and depression at the end of treatment. These findings increase awareness of the importance of considering the order of onset and may ultimately lead to treatment improvements for this population.
The present study assesses the prevalence of items from a modified version of the Drug Abuse Screening Test, Short Form (DAST-10) for substances other than alcohol among undergraduate students. More than 4,500 undergraduate students at a large Midwestern research university completed a web-based survey in 2005. Nearly 1 every 10 undergraduate students experienced three or more DAST-10 items in the past 12 months. Although the prevalence of illicit drug use did not differ by gender, undergraduate men were significantly more likely than women to report DAST-10 items. Less than 6% of individuals who reported three or more drug DAST-10 items had ever used treatment services for substance use. As a brief screening instrument, the DAST-10 offers promise for detecting possible drug abuse among college students. Based on the prevalence of drug use, colleges and universities are encouraged to provide screening opportunities to identify and to provide services for students at high risk for drug abuse.
This retrospective study evaluated the efficacy and tolerability of directly observed therapy with peginterferon alfa-2a and once-daily ribavirin (RBV) for chronic hepatitis C in 49 opioid-addicted injection drug users (IDUs) participating in a drug treatment program at a specialized outpatient center. Patients also received prophylactic citalopram to minimize the risk of interferon-induced depression. Patients had daily access to and support from specialist physicians, nurses and counseling services at the center, and a 24-hour helpline. Sustained virological response was achieved by 48 of 49 patients (98%) overall, including 20 of 21 (95%) hepatitis C virus (HCV) Genotype 1/4-infected patients and 28 of 28 (100%) Genotype 2/3-infected patients. Treatment was well tolerated, and no unexpected side effects of peginterferon treatment were seen. The safety profile of once-daily RBV was not different from twice-daily dosing. Decline in hemoglobin levels was similar to those reported in clinical trials including once-daily RBV and did not lead to dose reduction or treatment withdrawal. Our data demonstrate that HCV-infected IDUs on stable L-polamidone (methadone) or buprenorphine maintenance can be successfully and safely treated with peginterferon alfa-2a and RBV in an optimal substitution setting.
Few studies have investigated whether dually diagnosed patients with co-occurring substance use and psychiatric disorders (DD) respond as well to substance use disorder (SUD) treatments as patients with SUD do. Here we assessed whether male veteran DD and SUD patients with alcohol dependence diagnoses differed in the process and outcomes of residential SUD treatment. The main findings showed that (a) DD patients did not perceive SUD programs as positively as patients with SUD did and had worse proximal outcomes at discharge from treatment; (b) DD patients did as well as SUD patients on 1- and 5-year substance use outcomes but had worse psychiatric outcomes; and (c) patients who perceived treatment more positively and had better outcomes at discharge had better longer term outcomes. Thus, residential SUD programs are relatively effective in reducing DD patients' substance use problems; however, they are less successful in engaging DD patients in treatment and addressing their psychiatric problems.
This article investigates whether California's Proposition 36 has promoted the workforce professionalism of drug treatment services during its first 5 years of implementation. Program surveys inquiring about organizational information, Proposition 36 implementation, and staffing were conducted in 2003 and 2005 among all treatment providers serving Proposition 36 clients in five selected California counties (San Diego, Riverside, Kern, Sacramento, and San Francisco). A 1-hour self-administered questionnaire was completed by 118 treatment providers representing 102 programs. This article examines five topics that are relevant to drug treatment workforce professionalism: resources and capability, standardized intake assessment and outcome evaluation, staff qualification, program accreditation, and information technology. Results suggest that Proposition 36 had a positive influence on the drug treatment workforce's professionalism. Improvements have been observed in program resources, client intake assessment and outcome evaluation databases, staff professionalization, program accreditation, and information technology system. However, some areas remain problematic, including, for example, the consistent lack of adequate resources serving women with children.
This study reports findings from an investigation of the efficacy of high-dose nicotine patch (NP) therapy for heavy smokers with a history of alcohol dependence. One hundred thirty participants were randomly assigned to 42 or 21 mg of transdermal nicotine. Follow-up assessments were conducted at 4, 12, 24, and 36 weeks. Differences between dose conditions were nonsignificant, although, unexpectedly, outcomes favored participants in the 21-mg NP condition. Nicotine abstinence rates in the 21- and 42-mg NP conditions on Week 36 follow-up were 16.9% and 9.2%, respectively. Patch condition did not interact with severity of nicotine dependence. However, nicotine abstinence at follow-up was related to a longer length of alcohol abstinence. No evidence was found for better outcomes as a function of the percentage of baseline cotinine replaced by NPs. Future research should focus primarily on investigating ways to improve smoking quit rates for smokers in early alcohol recovery.
This study examined whether ethnic differences exist in access to care, receipt of services, and associated outcomes of 1,057 offenders participating in California's Proposition 36. Data are based on intake and 3-month follow-up interviews conducted as part of a multisite prospective treatment outcome study. Logistic regressions were conducted to examine ethnicity and other predictors of treatment placement and services intensity. Across ethnic groups, services intensity in several domains was inadequately matched to need, and few services besides substance abuse treatment were provided. Blacks and Hispanics received alcohol and employment services that were not commensurate with their greater need. Although Blacks were more likely to be placed in residential programs, their employment status worsened from intake to follow-up. There were few other ethnic differences in outcomes. Assessing and eliminating ethnic-associated differences in health service delivery, even as moderate as our findings revealed, may improve program processes and outcomes.
This review summarizes recent findings from human research regarding genetic influences in alcohol abuse and dependence. Genes explain about 50% of the vulnerabilities leading to heavy drinking and associated problems. Most genetic influences appear to impact at least four prominent intermediate characteristics (phenotypes) that interact with environmental events to produce the alcoholism risk: a flushing response to alcohol; a low level of response to alcohol; personality characteristics that include impulsivity, sensation seeking, and neuronal and behavioral disinhibition; and through psychiatric symptoms. Polymorphisms potentially related to each phenotype have been identified, and studies were conducted to evaluate their characteristics in the context of environmental and psychosocial forces. A search is underway to identify genes that contribute to these phenotypes; the ultimate goals of which are better prediction of how to best prevent heavy drinking and problems, identifying individuals who may respond best to existing treatments, and development of new therapeutic approaches based on the biological underpinnings of alcoholism.
To explore why some Proposition 36 offenders do not enter drug treatment, we analyzed self-reported and administrative data to compare the characteristics, perceptions, and rearrest rates of 124 untreated and 1,335 treated offenders assessed by 30 sites in five California counties. Offenders were comparable in many domains at assessment; however, untreated offenders were younger, not employed, more criminally severe, and less motivated for treatment. To avoid incarceration was the primary reason for choosing Proposition 36, but there were fewer untreated offenders who felt ready for treatment (12.9% vs. 35.7%) and there were more who accepted the Proposition 36 program only upon recommendation by others (37.9% vs. 11.7%). Reasons for not entering treatment included rearrest (31.6%), no desire for treatment (23.9%), and assignment to a program that was too far away (11.1%). Both groups had fewer total arrests after assessment, but recidivism was higher among untreated offenders. Understanding untreated Proposition 36 offenders can aid efforts to improve treatment entry rates and related outcomes.