Posttraumatic stress disorder, gender, and problem profiles in substance dependent patients

Patients with a chronic and severe substance-use disorder who also have a history of posttraumatic stress disorder (PTSD) are thought to have a unique set of problems. The present study assessed psychiatric disorders, psychosocial problems, and traumatic events with structured interviews in 747 men and 693 women enrolling in urban opioid substitution treatment programs from 1995 to 2001. Participants with versus without a history of PTSD were more likely to have a history of many other psychiatric disorders and demonstrated more current and historical medical, employment, family/social, and psychiatric problems. PTSD was generally unrelated to substance-use disorder severity or diagnoses, with the exception of an increased risk of alcohol dependence. Women were more likely than men to have experienced sexual assault, and less likely to have been physically assaulted, although these events precipitated PTSD at equivalent rates across gender. In contrast, witnessing or hearing about the death or injury of others was more likely to precipitate PTSD in women than men. Female gender, exposure to combat, sexual assault, or physical assault, and a history of major mood or anxiety disorder were the best predictors of PTSD in this group. Study limitations are noted.

A behavioral treatment for opioid-dependent patients with antisocial personality

Antisocial personality disorder (APD) is associated with increased problem severity in treatment-seeking opioid-dependent patients. Treatment studies have reported mixed results but generally show that patients with APD make progress that is often comparable to drug-dependent patients without the personality disorder. Much of this work is based on secondary analyses of studies evaluating responses to a variety of drug abuse treatment interventions. This study reports on a randomized prospective trial evaluating a behavioral approach for managing opioid-dependent patients with APD. Subjects (N = 100) met Diagnostic and Statistical Manual of Mental Disorders criteria for opioid dependence and APD using a structured clinical interview and were randomly assigned to either an experimental condition (n = 51), which used a highly structured contingency management intervention, or a control condition (n = 49), which reflected standard methadone treatment. Subjects in the experimental group had significantly better counseling attendance and some indication of lower psychosocial impairment compared to the control group. The experimental intervention increased attendance in subjects with low and high levels of psychopathy and with and without other psychiatric comorbidity. These findings support the development of interventions more tailored to drug-dependent patients with APD.

A stepped care approach for reducing cannabis use in opioid-dependent outpatients

This study evaluated rates of cannabis use and the effectiveness of an adaptive stepped care intervention for reducing cannabis use in methadone maintenance patients. Patients testing cannabis positive during a 6-month baseline were advanced to more weekly counseling (up to 9 hours per week) until producing four consecutive weeks of cannabis- and other drug-negative urine samples. Patients were followed up for 1 year. Continued access to uninterrupted methadone delivery was ultimately contingent upon attending scheduled counseling and achieving abstinence from all drug use. The results showed that 18% of the clinic census (n = 57) tested positive for cannabis. The effectiveness of the intervention was assessed for 15 patients testing positive for cannabis exclusively. Ten of these patients (67%) discontinued cannabis use prior to the intervention and remained at reduced care. Four of the five patients who were advanced to higher steps of care ultimately discontinued cannabis use; one left treatment against medical advice. The results suggest that motivated stepped care is an effective intervention for reducing cannabis use.

Comparing adaptive stepped care and monetary-based voucher interventions for opioid dependence

This 6-month randomized clinical trial (with 3-month follow-up) used a 2x2 design to compare the independent and combined effectiveness of two interventions designed to improve outcomes in treatment-seeking opioid dependent patients (n=236): motivated stepped care (MSC) and contingent voucher incentives (CVI). MSC is an adaptive treatment strategy that uses principles of negative reinforcement and avoidance to motivate both attendance to varying levels of counseling services and brief periods of abstinence [Brooner, R.K., Kidorf, M., 2002. Using behavioral reinforcement to improve methadone treatment participation. Sci. Pract. Perspect. 1, 38-46; Brooner, R.K., Kidorf, M.S., King, V.L., Peirce, J.M., Bigelow, G.E., Kolodner, K., 2004. A modified "stepped care" approach to improve attendance behavior in treatment seeking opioid abusers. J. Subst. Abuse Treat. 27, 223-232]. In contrast, CVI [Higgins, S., Delaney, D.D., Budney, A.J., Bickel, W.K., Hughes, J.R., Foerg, B.A., Fenwick, J.W., 1991. A behavioral approach to achieving initial cocaine abstinence. Am. Psychiatr. 148, 1218-1224] relies on positive reinforcement to motivate drug abstinence. The results showed that the combined approach (MSC+CVI) was associated with the highest proportion of drug-negative urine samples during both the randomized and 3-month follow-up arms of the evaluation. The CVI-only and the MSC-only conditions evidenced similar proportions of drug-negative urine samples that were both significantly greater than the standard care (SC) comparison group. Voucher-based reinforcement was associated with better retention, while adaptive stepped-based care was associated with better adherence to scheduled counseling sessions. These results suggest that both CVI and MSC are more effective than routine care for reducing drug use in opioid dependent outpatients, and that the overall benefits of MSC are enhanced further by adding positive reinforcement.

Comparison of demographic and clinical characteristics between opioid-dependent individuals admitted to a community-based treatment setting and those enrolled in a research-based treatment setting

Despite the significant developments in pharmacotherapy and behavioral treatments for addiction, the dissemination of new treatment methods into the community has been slow. It has been pointed out that treatments developed in research settings may be impractical in community treatment settings, which might help explain the transition lag. Screening and recruitment of participants for research studies might partially explain this, as there is evidence that substance-abusing individuals who participate in clinical research are different on a number of measures from treatment seekers. However, no study has directly compared treatment seekers with research participants drawn from similar populations using prospective methods. This study compared the demographic characteristics, drug use and psychosocial problem severity levels, and personality traits of opioid-dependent individuals seeking help in a community setting (n = 502) with those of opioid-dependent individuals in a primarily research-based drug abuse treatment setting (n = 459); both settings offered a similar set of treatment services (opioid agonist medication and counseling). Although the overall findings revealed numerous similarities between the groups, differences were also observed. Most notably, there were significantly fewer women in the research sample than in the community-based treatment sample. Other differences included a modest but statistically significant increase in psychosocial problem severity levels in the community-based treatment sample and higher drug use problem severity levels in the research sample. Interestingly, many of these differences were strongest in women as compared with men.

A 12-month controlled trial of methadone medical maintenance integrated into an adaptive treatment model

Methadone medical maintenance (MMM) reduces the reporting schedule for stable and well-functioning methadone maintenance patients to once a month, with counseling provided by medical staff. We report on the 12-month outcomes of 92 highly stable methadone maintenance patients randomly assigned to one of three study conditions: routine care, MMM at the methadone maintenance program, and MMM at a physician's office. Methadone medical maintenance patients received a 28-day supply of methadone, whereas routine care patients received five or six take-home methadone doses each week. All patients performed a medication recall once a month and submitted two urine samples each month. An adaptive stepped-care system of treatment intensification was used for patients who failed recall or who had drug-positive urine specimens. Seventy-seven patients completed the 12-month study period. Dropout was caused primarily by problems with handling methadone and disliking the recall frequency. There were low rates of drug use or failed medication recall. Treatment satisfaction was high in all groups, but the MMM patients initiated more new employment or family/social activities than did routine care patients over the study period. The stepped-care approach was well tolerated and matched patients to an appropriate step of service within a continuum of treatment intensity.

HIV risk behaviors during pharmacologic treatment for opioid dependence: A comparison of levomethadyl acetate hydrochloride, buprenorphine, and methadone

The efficacies of three opioid substitution medications for reducing HIV risk behaviors in opioid-dependent patients were assessed in a randomized double-blind clinical trial comparing levomethadyl acetate [corrected] (LAAM), buprenorphine (BUP), and methadone (METH). Individually optimized flexible dosing was used for each group, with weekly possible doses of 255-391 mg of LAAM, 56-112 mg of BUP, and 420-700 mg of METH. An interview regarding specific HIV risk behaviors, including injecting, equipment sharing, and sexual activity, yielded data for pretreatment and four in-study time points for 137 subjects. Declines in risk behaviors during treatment were evident in all groups for most measures of injecting and equipment sharing. Only the METH group showed consistent declines in measures of sexual behaviors. These results demonstrate that all three medications can be highly effective in decreasing HIV risk behaviors when the dose is optimized. Reductions in sexual behaviors for the METH group are consistent with known METH side effects.

Psychiatric comorbidity is associated with drug use and HIV risk in syringe exchange participants

The present study evaluated the effects of psychiatric comorbidity on substance use disorder prevalence, HIV risk behavior, and other problem severity in male and female out-of-treatment injection drug users newly registered at a syringe exchange program. Participants (N = 338) were administered the Structured Clinical Interview for the DSM-IV, the Addiction Severity Index, and the Risk Assessment Battery, and classified into one of four diagnostic groups: (1) no antisocial personality disorder (APD) or Axis I psychiatric disorder (N = 162), (2) APD only (N = 74), (3) Axis I psychiatric disorder only (N = 55), or (4) APD plus Axis I psychiatric disorder (N = 47). Psychiatric comorbidity was associated with higher rates of substance use disorder and more HIV risk and other problem severity. In general, participants with both APD and an Axis I disorder exhibited the most problem severity. APD was uniquely associated with higher prevalence for each substance use disorder assessed in this study and with elevated HIV risk. These results support and extend studies conducted with opioid-dependent individuals recruited from treatment and community settings, and reinforce the need to develop interventions to encourage syringe exchange program participants to enroll in treatment.

Involving significant others in the care of opioid-dependent patients receiving methadone

Positive, abstinence-oriented, social support is associated with good substance abuse treatment outcome but few interventions are designed to help patients improve their social supports. This article reports on a behavioral intervention designed to encourage opioid-dependent patients receiving methadone to include drug-free family members or friends in treatment and to use these individuals to facilitate development of a supportive, non-drug-using social network. This report uses data from a quality assurance program review of the treatment response of 59 opioid-dependent outpatients who identified a drug-free significant other to participate in their treatment. Fifty-five (93.2%) brought a significant other (most often the patient's mother, 29%) to both the initial evaluation session and at least one joint session. Social support activities were family- (33%), church- (28%), and self-help group-related (30%). Approximately 78% of patients who participated in the social support intervention achieved at least four consecutive weeks of abstinence. Women responded better than men. We conclude that methadone-maintained patients can and will include non-drug-using family members and friends in treatment, and these individuals can be mobilized to help patients improve their recovery.

Challenges in motivating treatment enrollment in community syringe exchange participants

Participants of syringe exchange programs (SEPs) exhibit high rates of substance use disorder but remain extremely ambivalent about seeking treatment. This study evaluated the effectiveness of motivational interviewing (MI) for encouraging SEP participants to enroll in substance abuse treatment. New opioid-dependent registrants to the Baltimore Needle Exchange Program (BNEP) (n =302) completed the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), and the Addiction Severity Index (ASI) and were randomly assigned to one of three treatment referral conditions: (1) MI, (2) job readiness (JR) (attention control), or (3) standard referral. Participants in each condition who expressed interest in treatment were referred to a treatment readiness group that provided further encouragement and referral to programs that were accepting new admissions. Participants were observed for 1 year following the intervention. The results showed that 10.9% of study participants enrolled in substance abuse treatment, although no condition effects were observed. White participants and those diagnosed with major depression were most likely to enter treatment. The results suggest that a single motivational interview is insufficient to motivate changes in treatment seeking in this population, whereas the identification of predictors of treatment enrollment is worthy of further investigation.

Prevalence and correlates of cocaine physical dependence subtypes using the DSM-IV in outpatients receiving opioid agonist medication

The present study used a cross-sectional design to examine the relationship between endorsement of physiological dependence to cocaine (i.e., tolerance and/or withdrawal) and lifetime, and current problem severity (i.e., psychiatric and substance use disorders, medical and psychosocial problems) for opioid and cocaine dependent individuals (n=719) newly admitted to a treatment program using opioid-agonist medication. All participants completed the structured clinical interview for the Diagnostic and Statistical Manual (DSM-IV) (SCID-IV) and the Addiction Severity Index (ASI). Participants were first classified into physiological (n=549) versus non-physiological (n=170) cocaine dependence groups for one set of analyses and then categorized into one of four groups for further analyses: (1) tolerance only (n=215), (2) tolerance plus withdrawal (n=279), (3) withdrawal only (n=55) or (4) no physiological dependence (n=170). Those participants who endorsed physiological dependence reported higher rates of lifetime psychiatric and substance use disorders, higher rates of current drug use and more current problems. The four-group analyses showed that endorsement of withdrawal, with or without tolerance, was associated with the most severe problems. These findings suggest that physiological dependence to cocaine (particularly the presence of withdrawal) is a marker for a more severe substance use disorder and higher rates of comorbid psychopathology and other problems.

Characteristics of older opioid maintenance patients

The aging "baby boomer" population has higher rates of substance use than previous cohorts and is predicted to put increased demands on substance abuse treatment services; however, little is known about older illicit drug abusers. This study compared 41 older (age 50-66 years) and 26 younger (age 25-34 years) opioid maintenance patients on psychiatric, substance use, medical, general health, demographic, and psychosocial characteristics using standardized instruments. The health of both groups was compared to age and sex-matched U.S. population norms. Both groups had high rates of lifetime psychiatric and substance abuse/dependence diagnoses, and poor general health compared to population norms. The older group began using illicit substances significantly later in life, and had significantly more medical problems and worse general health than the younger group. The inevitable increasing medical morbidity and physical limitations of an increasingly large older population with substance use problems will challenge treatment providers and planners. Low rates of positive urine opioid tests occurred for both older and younger patients without age-specific services.

Regular use of alcohol and tobacco in India and its association with age, gender, and poverty

This study provides national estimates of regular tobacco and alcohol use in India and their associations with gender, age, and economic group obtained from a representative survey of 471,143 people over the age of 10 years in 1995-96, the National Sample Survey. The national prevalence of regular use of smoking tobacco is estimated to be 16.2%, chewing tobacco 14.0%, and alcohol 4.5%. Men were 25.5 times more likely than women to report regular smoking, 3.7 times more likely to regularly chew tobacco, and 9.7 times more likely to regularly use alcohol. Respondents belonging to scheduled castes and tribes (recognized disadvantaged groups) were significantly more likely to report regular use of alcohol as well as smoking and chewing tobacco. People from rural areas had higher rates compared to urban dwellers, as did those with no formal education. Individuals with incomes below the poverty line had higher relative odds of use of chewing tobacco and alcohol compared to those above the poverty line. The regular use of both tobacco and alcohol also increased significantly with each diminishing income quintile. Comparisons are made between these results and those found in the United States and elsewhere, highlighting the need to address control of these substances on the public health agenda.

Behavioral contingencies improve counseling attendance in an adaptive treatment model

Poor patient adherence remains a serious obstacle to improving the effectiveness of many drug abuse therapies and the overall quality of care delivered in programs. The present study evaluated the utility and efficacy of incorporating behavioral contingencies in a stepped care treatment approach to motivate patient attendance to the varying amounts of prescribed weekly counseling. Study participants were opioid-dependent patients (n = 127) newly admitted to an ambulatory treatment program that provides methadone. Participants were randomly assigned to a Motivated Stepped Care condition (MSC; n = 65) with behavioral contingencies to specifically motivate counseling attendance vs. a Standard Stepped Care condition (SSC; n = 62) without these contingencies. The MSC vs. SSC condition was associated with a higher rate of counseling attendance (83% vs. 44%, p < .001) and a lower rate of poor treatment response (46% vs. 79%, p < .001). The behavioral contingencies were well tolerated and strongly associated with excellent attendance across both lower and higher doses of weekly counseling.

Prevalence of psychiatric and substance use disorders in opioid abusers in a community syringe exchange program

The present study evaluates the prevalence of psychiatric and substance use disorders in male and female intravenous opioid abusers participating at a community needle exchange program (NEP). All participants (n = 422) were administered the Structured Clinical Interview for the DSM-IV (SCID) for Axis I disorders and antisocial personality disorder (APD). Psychiatric and substance abuse comorbidity were highly prevalent. Major depression was the most common current and lifetime Axis I non-substance use disorder (6 and 21% of the sample, respectively); 37% were diagnosed with APD. Over 50% of the sample was diagnosed with at least one non-substance use Axis I disorder or APD. In addition to opioid dependence, cocaine dependence was the most prevalent current and lifetime substance use disorder (68 and 78% of the sample, respectively), followed by alcohol and cannabis dependence. Overall, participants reported a mean of over one current and over three lifetime substance use disorders in addition to opioid dependence. Women reported higher rates of post-traumatic stress disorder (PTSD), while men were more likely diagnosed with APD. Presence of a psychiatric disorder was associated with increased prevalence of substance use disorder for all drug classes. The high rates of comorbidity observed in this sample suggest that the harm reduction efforts of NEPs can be significantly enhanced through referral of participants to programs that treat substance use and/or other psychiatric disorders.

Special section: the most critical unresolved issues associated with contemporary vocational rehabilitation for substance users. The critical relationship between employment services and patient motivation

Several interventions and service delivery models now exist to help unemployed people in treatment for substance use disorder seek gainful employment (Platt, 1995). Some of these interventions can be conveniently offered within substance user treatment settings. One of the best known examples of these interventions is job seeking skills training and support services that help patients develop resumes, complete employment applications, learn effective networking strategies, and develop and practice effective responses to common issues and questions raised during employment interviews. A wide range of more comprehensive off-site employment programs that provide intensive vocational training and rehabilitation also exist in many communities. The growing availability of on-site services in substance user treatment programs also creates the

Combining stepped-care approaches with behavioral reinforcement to motivate employment in opioid-dependent outpatients

Employment is associated with improved treatment outcome for opioid-dependent outpatients receiving methadone (e.g., Platt, 1995). Opioid-dependent individuals typically enter treatment unemployed and many remain unemployed despite reductions in heroin use. Additional interventions are needed to motivate employment seeking behaviors and outcome. This article reports on a promising approach to reduce the chronic unemployment commonplace in treatment-seeking, opioid-dependent patients--a "stepped care" service delivery intervention that incorporates multiple behavioral reinforcements to motivate patient participation in and adherence to the treatment plan. This therapeutic approach (Motivated Stepped Care--MSC; Brooner and Kidorf (2002) was refined and modified to motivate and support a range of positive treatment behaviors and outcomes in patients with opioid-dependence (Kidorf et al. 1999), including job-seeking and acquisition. Patients who are unemployed after one year of treatment are systematically advanced to more intensive steps of weekly counseling and remain there until employment is attained. Those who remain unemployed despite exposure to at least 4 weeks of counseling at the highest step of care (Step 3, which is 9 h weekly of counseling) are started on a methadone taper in preparation for discharge, which is reversible upon attaining a job. This article describes the MSC approach and presents rates of employment for patients who were judged capable of working (n = 228). A review of medical and billing records during August--September 2002 revealed that the great majority of these patients were employed (93%), usually in full-time positions. Employment was associated with less frequent advancement to higher intensities of weekly counseling because of drug use. Further, multiple indices of improved employment stability and functioning, including months of work, hours of work, and annualized salary, were associated with better drug use outcomes. These data suggest that the MSC intervention is an effective platform for motivating and supporting both job seeking and employment in patients with chronic and severe substance use disorder.

A multicenter randomized evaluation of methadone medical maintenance

Methadone medical maintenance (MMM) is a rational, cost-effective method to match treatment intensity to level of needed services. In the present study, 73 highly stable methadone maintenance patients were randomly assigned to either a routine methadone treatment, MMM--a once monthly reporting schedule--at the methadone maintenance program or MMM at a physician office. A 'stepped care' intensified treatment approach was used for patients who had drug-positive urine specimens or failed the medication recall procedure. Patients left two urine specimens for analysis each month (at least one on a random basis) and responded to one medication recall each month. Results are presented for the first 6 months of the 1-year trial. Only 1% of urine specimens were positive for illicit drugs, there was no evidence of methadone diversion and there were very low rates of medication misuse, with no between group differences. MMM patients initiated more new employment or family/social activities than the routine care patients. MMM patients were more satisfied with their treatment than the routine treatment patients, but all patients rated themselves satisfied or very satisfied with their treatment. Stepped care was well-tolerated and helped match patients to an appropriate intensity of service. The good outcomes observed with the present sample suggest that MMM can be implemented effectively as part of a continuum of care in clinic and office-based sites.

Drug user treatment referrals and entry among participants of a needle exchange program

OBJECTIVE

To compare characteristics of needle exchange program (NEP) participants who requested methadone treatment to those who did not, compare participants who subsequently enrolled into treatment to those who did not enroll, and suggest possible barriers to treatment among NEP participants.

METHODS AND MATERIALS

Between 8/94 and 2/97, data pertaining to demographics and drug use were collected from Baltimore NEP participants upon registration. Participants were made aware that referrals to off-site methadone maintenance were available upon request. Odds ratios and multiple logistic regression models were used to compare those who requested treatment to those who did not and those who entered treatment to those who did not enter.

RESULTS

Among 2659 NEP participants, 86% were African-American, 28% were female, 9% were employed, and the median age was 38 years. Requesting a drug user treatment referral was associated with female gender [Adjusted Odds Ratio (AOR) = 2.02], age > 38 years (AOR = 1.96), use of speedballs during the past 6 months (AOR = 3.38), and age > 20 years at time of first injection (AOR = 1.59). Among 139 individuals who requested treatment, males were twice as likely as females to enter treatment (OR = 2.45). In an open-ended survey, health insurance (p = .02) and not living with children (p = .01) were associated with drug user treatment entry.

CONCLUSIONS

Even though female NEP participants were more likely to request methadone treatment, they were less likely than males to enter treatment. Although NEPs can be a bridge to drug user treatment, these data suggest that barriers to utilizing treatment referrals are important issues to resolve, especially for women who use community needle exchange programs.

Short-term stability of NEO-PI-R personality trait scores in opioid-dependent outpatients

The present study examined the short-term stability of personality trait scores from the Revised NEO Personality Inventory (NEO-PI-R) among 230 opioid-dependent outpatients. The NEO-PI-R is a 240-item empirically developed measure of the five-factor model of personality (Neuroticism, Extraversion, Openness, Agreeableness, and Conscientiousness). Participants completed the NEO-PI-R at admission and again approximately 19 weeks later. Results indicated fair to good stability for all NEO-PI-R factor domain scores, with coefficients ranging from .68 to .74. Stability of NEO-PI-R scores was decreased among potentially invalid response patterns but was not significantly affected by drug-positive versus drug-negative status at follow-up.

Influence of antisocial personality subtypes on drug abuse treatment response

This methodological study examined the impact of antisocial personality disorder (APD) and other psychiatric comorbidity on drug use and treatment retention in 513 new admissions to methadone maintenance treatment. Patients were classified into one of four groups: APD ONLY, APD plus other psychiatric disorder (APD MIXED), other psychiatric disorder, and no psychiatric disorder. Patients completed research assessments and were then followed for 1 year of treatment. Patients with APD had longer histories of heroin and cocaine use than non-APD patients and were more likely to meet criteria for cocaine dependence. Distinct clinical profiles emerged that differentiated APD ONLY from APD MIXED. APD ONLY patients exhibited higher rates of cocaine and heroin use, whereas those with APD MIXED exhibited higher rates of benzodiazepine use. Self-report measures supported urinalysis results, but group differences did not affect treatment retention. These differences in clinical profiles should be considered when evaluating treatment performance in substance abusers with APD.

Influence of psychiatric comorbidity on HIV risk behaviors: changes during drug abuse treatment

This study evaluated whether psychiatric comorbidity is related to change in HIV high risk behaviors during outpatient drug abuse treatment. Participants were opioid abusers entering methadone treatment. Psychiatric and substance use diagnoses were determined at intake. Information on HIV high risk drug use and sexual behaviors, psychosocial functioning, and urine toxicology was assessed at intake and at month six. Subjects were divided into those with versus without a lifetime comorbid non-substance use psychiatric disorder. The comorbid group reported more injection equipment sharing, lower rates of condom use, and higher rates of alcohol use at intake and follow-up. Overall injection drug use behavior decreased over the follow-up period for both groups, however. Methadone treatment had a beneficial effect on HIV risk behaviors, and though some risk behaviors improved signiticantly for both groups, comorbid subjects continued to have higher rates of HIV risk factors than noncomorbid subjects.

A 12-year follow-up of a methadone medical maintenance program

Methadone Medical Maintenance (MDM) is an alternative for treatment of stable methadone maintained individuals. It involves a monthly physician's visit, at which methadone take-home doses are dispensed to last until the next appointment. The safety and efficacy of this treatment modality is currently under investigation. The purpose of this study was to evaluate the long-term safety and efficacy of MDM in a methadone program in Baltimore. A sample of 21 patients was enrolled in the study and followed for 12 years. They were evaluated once a month by a primary care physician affiliated with a methadone clinic who collected urine toxicology samples and dispensed the monthly methadone dose. The results showed that only 6 (28.6%) patients dropped out during the 12 years of the study. Twelve (0.5%) of 2,290 urine samples collected were positive for drugs. No methadone overdose or diversion was observed. Participants reported significant improvement in their quality of life. The results of this study support the safety and efficacy of medical maintenance of stable methadone maintained individuals.

Attention deficit hyperactivity disorder and treatment outcome in opioid abusers entering treatment

Symptoms of DSM-IV attention-deficit hyperactivity disorder (ADHD) were determined in patients entering methadone maintenance treatment. The relationship of ADHD to psychiatric and substance abuse comorbidity, attention testing, and treatment outcome was analyzed; 19% of patients had a history of ADHD, and 88% of these had current symptoms. Continuous Performance Testing indicated poorer attention in patients with ADHD. The only substance use disorder more common in the ADHD group was clonidine. There was significantly more current axis I, dysthymic disorder, anxiety disorder (including social phobia), and antisocial personality disorder in the ADHD patients. There was no difference between groups at the 1-year follow-up for illicit drug use, treatment retention, or treatment performance. The ADHD diagnosis did not convey significant prognostic implications for methadone maintenance treatment. A strong psychiatric assessment and treatment focus in the treatment program may help to explain the good treatment outcome.