The Maudsley Addiction Profile (MAP): a brief instrument for assessing treatment outcome

Is it possible to evaluate addiction from clinical records? Testing a retrospective addiction severity evaluation measure

AIM

To compare an addiction severity score estimated from clinical records to addiction severity index (ASI) scores.

METHODS

During April-May 2004, 31 patients treated in a therapeutic community in the Piedmont region (Italy) were interviewed using the ASI questionnaire and their clinical records were used to obtain severity scores in seven areas: physical health, occupational functioning, alcohol use, drug use, legal problems, family/social relationships, psychological health. Correlation, agreement, and discriminatory capacity of the clinical records score in correctly classifying persons with low or high severity were investigated using Spearman, Kappa coefficient, and receiver operating characteristics curves.

CONCLUSIONS

Clinical records score showed good correlation, agreement, and discriminatory accuracy with respect to ASI scores, especially in the drug use and legal problems areas. Further research is suggested to study the use of the score in other settings.

Persistence of heroin use despite methadone treatment: poor coping self-efficacy predicts continued heroin use

AIM

To evaluate the association between coping self-efficacy and persistent use of heroin by patients enrolled in a methadone treatment program.

DESIGN AND METHODS

Cross-sectional survey. One hundred and ninety-one patients attending outpatient methadone clinics in South-East England, United Kingdom. Validated questionnaires were used to assess drug use (Maudsley Addiction Profile), alcohol use (Alcohol Use Disorders Identification Test), mental health (Hospital Anxiety and Depression Scale) and coping self-efficacy (brief 8-item Drug Taking Confidence Questionnaire).

RESULTS

Half of the participants (95/191) reported heroin use in the preceding 14-day period. Heroin use during methadone treatment was associated with financial problems (P = 0.008), spending time with other drug users (P < 0.001), cocaine use (P = 0.002), low mood (P = 0.002) and dissatisfaction with the daily methadone dose (P = 0.014). Compared with 'Heroin-abstinent' patients, the 'Heroin' group reported significantly lower mean coping self-efficacy scores (t = 9.8, d.f. = 182, P < 0.001, effect size 1.17). After correcting for the effects of co-variants in a logistic regression model, the main determinants of persistent heroin use were 'coping self-efficacy' [B -0.05; standard error (SE) 0.008; Wald 36.6; odds ratio (OR) 0.95, 95% confidence interval (CI) 0.94, 0.97; P < 0.001] and 'dissatisfaction with methadone dose' (B 0.93; SE 0.46; Wald 4.1; OR 2.5, 95% CI 1.03, 6.25; P = 0.042). Satisfaction with methadone dose showed no association with self-efficacy. DISCUSSION AND CONCLUSIONS; While heroin use during methadone treatment can partly be explained by inadequate dosing, our data suggest a more complex picture with significant contribution from poor coping self-efficacy. Efforts aimed at enhancing and maintaining the patients' self-efficacy and social skills are likely to improve heroin and other drug use outcomes with added benefits for treatment completion rates and the throughput of methadone programs.

Measurements in the Addictions for Triage and Evaluation (MATE): an instrument based on the World Health Organization family of international classifications

AIMS

To present and evaluate a measurement tool for assessing characteristics of people with drug and/or alcohol problems for triage and evaluation in treatment. Measurements in the Addictions for Triage and Evaluation (MATE) is composed of 10 modules, selected on the basis of a detailed set of specifications. Conceptually, the MATE was constructed according to the ICD and International Classification of Functioning (ICF) in the World Health Organization (WHO) classification system. Two of the ICF-related modules were newly designed.

DESIGN

Monitoring feasibility and field-testing in a treatment-seeking population with researcher and clinician-administered test-retest interviews, construct validation with related instruments and evaluation of the dimensional structure of the ICF-related modules.

SETTING

The research was conducted in a large, regional substance abuse treatment centre in the Netherlands and at the Municipal Health Service of Amsterdam. Participants A total of 945 treatment-seeking patients were recruited during routine intakes, 159 of whom were interviewed twice; 32 problem drug users were also recruited from the Amsterdam cohort studies among problem drug users. Findings Completion time was reasonably short, and there were relatively few missing data. The factor structure of the ICF-related modules revealed a three-factor model with an acceptable fit. Inter-rater reliability ranged between 0.75 and 0.92 and was satisfactory, but interviewer reliability ranged between 0.34 and 0.73, indicating that some of subscales need to be improved. Concurrent validity was indicated by significant correlations (>0.50) between the ICF-related modules and the WHO Disability Assessment Schedule II (WHODAS II) and WHO Quality of Life brief version (WHOQOL-BREF).

CONCLUSIONS

The MATE can be used to allocate patients to substance abuse treatment. Because it is a comprehensive but flexible measurement tool that is also practical to use, the MATE is well suited for use in a heterogeneous population.

Heroin-assisted treatment in the Netherlands: History, findings, and international context

This monograph describes the history, findings and international context of heroin-assisted treatment (HAT) in the Netherlands. The monograph consists of (1) a short introduction and seven paragraphs describing the following aspects of HAT in the Netherlands: (2) history of HAT studies and implementation of routine HAT in the Netherlands; (3) main findings on efficacy, safety and cost-effectiveness from the two randomized controlled HAT trials in the Netherlands; (4) new findings from a large cohort study on the effectiveness of HAT in routine clinical practice in the Netherlands; (5) unique data on the patient's perspective of HAT; (6) data on the pharmacological and pharmaceutical basis for HAT in the Netherlands; (7) description of the registration process; and (8) account of the international context of HAT. Together, these data show that HAT can now be considered a safe and proven-effective intervention for the treatment of chronic, treatment-resistant heroin dependent patients.

The quality of eight health status measures were compared for chronic opioid dependence

OBJECTIVE

To provide a comparative analysis of the psychometric properties of eight measures of health status among chronic opioid-dependent patients.

STUDY DESIGN AND SETTING

Longitudinal data were analyzed for 251 patients enrolled in the North American Opiate Medication Initiative randomized controlled trial, conducted in Vancouver, British Columbia and Montreal, Quebec, Canada. Content validity, evidence of floor and ceiling effects, internal consistency, construct validity, and responsiveness were assessed for the Addiction Severity Index (ASI) medical and psychiatric (ASImed and ASIpsych) composite scores, the Maudesley Addiction Profile (MAP) physical and mental health scores (MAP-physical health score [MAP-PHS], MAP-mental health score [MAP-MHS]), the World Health Organization Disability Assessment Schedule-II, the EuroQol Group's EQ-5D index score and visual analog scale, EuroQol visual analog scale (EQ-VAS), and the Short Form SF-6D index score.

RESULTS

ASImed was best able to discriminate among patients with and without chronic conditions. The MAP-PHS and MAP-MHS were not unidimensional. ASImed and ASIpsych had prominent ceiling effects. ASImed, MAP-MHS, MAP-PHS, EQ-VAS, and EQ-5D were all responsive to decreases in illicit drug use.

CONCLUSION

None of the instruments performed uniformly as "best" or "worst." The EQ-5D appeared to be the preferable generic, indirect utility measure. Our results provide an evidence base to inform selection and further development of health status measures in opioid-dependent populations.

Alcohol usage and associated treatment outcomes for opiate users entering treatment in Ireland

Evidence has shown that frequency and quantity of drug usage are reduced after treatment but the effect of opioid addiction treatment on alcohol consumption remains unclear. As part of the national Research Outcome Study in Ireland Evaluating drug treatment effectiveness (ROSIE, see www.nuim.ie/rosie) comprehensive drug and alcohol data on 404 opiate users were collected. This study recruited and followed up at 1 and 3 years a prospective cohort of 404 users entering a new treatment episode. Descriptive and inferential statistics were computed and logistic modelling was used to identify key factors effecting outcomes. The cohort represented 8.2% of all new treatments. Follow-up interview rate at 3 years was 88%. Analysis revealed that those who abstained from alcohol use at 3 years were less likely to be using heroin at 3 years than non-abstainers. In addition, those who abstained from alcohol use at 3 years were also less likely to be using methadone, benzodiazepines and cocaine at 3 years than alcohol users. Outcomes for medium and heavy drinkers were found not to be as good as alcohol abstainers. Finally males tended to reduce the frequency and level of alcohol usage after entering treatment more than females. Results demonstrate to clinicians that an alcohol strategy is a key component of opiate treatment planning and a comprehensive and regular assessment of the client's alcohol and drug use profile is essential if treatment interventions are to have maximum impact on outcomes.

Outcome of long-term heroin-assisted treatment offered to chronic, treatment-resistant heroin addicts in the Netherlands

AIMS

To describe 4-year treatment retention and treatment response among chronic, treatment-resistant heroin-dependent patients offered long-term heroin-assisted treatment (HAT) in the Netherlands.

DESIGN

Observational cohort study.

SETTING AND INTERVENTION

Out-patient treatment in specialized heroin treatment centres in six cities in the Netherlands, with methadone plus injectable or inhalable heroin offered 7 days per week, three times per day. Prescription of methadone plus heroin was supplemented with individually tailored psychosocial and medical support.

PARTICIPANTS

Heroin-dependent patients who had responded positively to HAT in two randomized controlled trials and were eligible for long-term heroin-assisted treatment (n = 149).

MEASUREMENTS

Primary outcome measures were treatment retention after 4 years and treatment response on a dichotomous, multi-domain response index, comprising physical, mental and social health and illicit substance use.

FINDINGS

Four-year retention was 55.7% [95% confidence interval (CI): 47.6-63.8%].

TREATMENT

Response was significantly better for patients continuing 4 years of HAT compared to patients who discontinued treatment: 90.4% versus 21.2% [difference 69.2%; odds ratio (OR) = 48.4, 95% CI: 17.6-159.1]. Continued HAT treatment was also associated with an increasing proportion of patients without health problems and who had stopped illicit drug and excessive alcohol use: from 12% after the first year to 25% after 4 years of HAT.

CONCLUSIONS

Long-term HAT is an effective treatment for chronic heroin addicts who have failed to benefit from methadone maintenance treatment. Four years of HAT is associated with stable physical, mental and social health and with absence of illicit heroin use and substantial reductions in cocaine use. HAT should be continued as long as there is no compelling reason to stop treatment.

Cognitive impairment in dual diagnosis inpatients with schizophrenia and alcohol use disorder

Cognitive impairment has been found independently among individuals with schizophrenia and individuals with alcohol use disorders. Less is known about the nature and severity of cognitive impairment in patients with a dual diagnosis, though the co-occurrence of these disorders may further exacerbate cognitive impairment. The study investigates the possible additive effect of alcohol use disorder and schizophrenia on cognitive impairment among patients diagnosed with schizophrenia. Participants were inpatients with schizophrenia (n=30), inpatients with a dual diagnosis of schizophrenia and alcohol use disorder (n=30), and matched controls (n=30): all completed a comprehensive neuropsychological battery. Both patient groups were significantly impaired, relative to controls, across the battery. Dual diagnosis patients were significantly more impaired than schizophrenia patients on delayed verbal memory, and executive functioning, primarily set-shifting, working memory, and planning, and had higher psychiatric morbidity scores. The findings provide support for an additive effect of the two disorders on cognitive impairment. These cognitive deficits may affect capacity to engage in treatment, increase risk of relapse, and adversely affect treatment outcomes. An understanding of the cognitive profile of people with dual diagnosis may help to tailor treatment delivery to meet their specific needs, enhance cognitive strengths, accommodate deficits and improve treatment outcomes.

Routes to psychotic symptoms: trauma, anxiety and psychosis-like experiences

A social factor that has gained recent attention in understanding psychosis is trauma. In the current study the association of a history of trauma with persecutory ideation and verbal hallucinations was tested in the general public. Further, putative mediation variables including anxiety, depression and illicit drug use were examined. In a cross-sectional study, 200 members of the UK general public completed self-report questionnaires. A history of trauma was significantly associated with both persecutory ideation and hallucinations. Severe childhood sexual abuse and non-victimization events were particularly associated with psychotic-like experiences. The association of trauma and paranoia was explained by levels of anxiety. The association of trauma and hallucinations was not explained by the mediational variables. The study indicates that trauma may impact non-specifically on delusions via affect but that adverse events may work via a different route in the occurrence of hallucinatory experience. These ideas require tests in longitudinal designs.

Efficacy of prescribed injectable diacetylmorphine in the Andalusian trial: Bayesian analysis of responders and non-responders according to a multi domain outcome index

BACKGROUND

The objective of this research was to evaluate data from a randomized clinical trial that tested injectable diacetylmorphine (DAM) and oral methadone (MMT) for substitution treatment, using a multi-domain dichotomous index, with a Bayesian approach.

METHODS

Sixty two long-term, socially-excluded heroin injectors, not benefiting from available treatments were randomized to receive either DAM or MMT for 9 months in Granada, Spain. Completers were 44 and data at the end of the study period was obtained for 50. Participants were determined to be responders or non responders using a multi-domain outcome index accounting for their physical and mental health and psychosocial integration, used in a previous trial. Data was analyzed with Bayesian methods, using information from a similar study conducted in The Netherlands to select a priori distributions. On adding the data from the present study to update the a priori information, the distribution of the difference in response rates were obtained and used to build credibility intervals and relevant probability computations.

RESULTS

In the experimental group (n = 27), the rate of responders to treatment was 70.4% (95% CI 53.287.6), and in the control group (n = 23), it was 34.8% (95% CI 15.354.3). The probability of success in the experimental group using the a posteriori distributions was higher after a proper sensitivity analysis. Almost the whole distribution of the rates difference (the one for diacetylmorphine minus methadone) was located to the right of the zero, indicating the superiority of the experimental treatment.

CONCLUSION

The present analysis suggests a clinical superiority of injectable diacetylmorphine compared to oral methadone in the treatment of severely affected heroin injectors not benefiting sufficiently from the available treatments.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN52023186.

Assessing Non-Injecting Heroin Use in Birmingham, UK: A Comparison of Characteristics and Reasons for Non-Injecting in Samples of Never-Injected and Formerly-Injecting Heroin Users in Contact with Adult Drug Treatment

Aims: To explore reasons why individuals who prefer to use heroin by routes other than injection have abstained from injecting despite entrenched heroin use. Methods: A cross-sectional interview using structured and semi-structured questions was carried out with 40 non-injecting heroin users (20 former injectors and 20 who had never injected) recruited at two Community Drug Team sites in Birmingham, UK. Results: The most endorsed reason for non-injection was worry about appearance. Additional reasons included identity issues and stigmatized status of injecting. ‘Never injectors’ were younger (p<0.05), more likely to have an educational qualification (OR: 4.89; 95% CI: 1.20, 19.94), had higher measured heroin dependence (p=0.05) and lower prior exposure to injecting (p<0.001) than former injectors. There was no difference between the groups in estimated prevalence of injection among peers. Conclusions: This study points to continuity between injecting and non-injecting cultures, challenges the concept of injection as a natural progression from non-injecting heroin use, and highlights personal addiction career factors in injection transitions.

Validity and reliability of the Severity of Dependence Scale (SDS) in a Brazilian sample of drug users

The Severity of Dependence Scale (SDS) is a short, five-item scale which provides a measure of degree of dependence upon different drugs. The present study explores the validity and reliability of a Portuguese version of the instrument with a sample of 374 Brazilian drug users. Concurrent validity of the SDS was assessed in relation to reported quantity of drugs used and to DSM-IV dependence items, and test-retest reliability was assessed with a subsample of 42 subjects. The SDS total scores for powder cocaine, crack cocaine, cannabis and alcohol were significantly and highly positively correlated with severity of dependence as measured by DSM-IV, and with the estimated quantity of drugs used in the last month. Test-retest coefficients were high for all drugs studied. Principal components analysis showed that the SDS scores lie on a single dimension with the exception of crack cocaine where scores lie on a single dimension for treatment attenders and on two dimensions for community samples. The results indicate that the Portuguese version of the SDS is a valid research tool for measuring severity of dependence upon powder cocaine (snorted), crack cocaine (smoked), cannabis and alcohol.

Validation of the World Health Organization Alcohol, Smoking and Substance Involvement Screening Test (ASSIST): report of results from the Australian site

The concurrent, construct, discriminative and predictive validity of the World Health Organization's Alcohol Substance Involvement Screening Test (ASSIST) were examined in an Australian sample. One hundred and fifty participants, recruited from drug treatment (n = 50) and primary health care (PHC) settings (n = 100), were administered a battery of instruments at baseline and a modified battery at 3 months. Measures included the ASSIST; the Addiction Severity Index-Lite (ASI-Lite); the Severity of Dependence Scale (SDS); the MINI International Neuropsychiatric Interview (MINI-Plus); the Rating of Injection Site Condition (RISC); the Drug Abuse Screening Test (DAST); the Alcohol Use Disorders Identification Test (AUDIT); the Revised Fagerstrom Tolerance Questionnaire (RTQ); and the Maudsely Addiction Profile (MAP). Concurrent validity was demonstrated by significant correlations between ASSIST scores and scores from the ASI-lite, SDS, AUDIT and DAST; and significantly greater ASSIST scores for those with diagnoses of abuse or dependence. Construct validity was established by significant correlations between ASSIST scores and measures of risk factors for the development of drug and alcohol problems. Participants diagnosed with attention deficit/hyperactivity disorder or antisocial personality disorder had significantly higher ASSIST scores than those not diagnosed as such. Discriminative validity was established by the capacity of the ASSIST to discriminate between substance use, abuse and dependence. ROC analysis was able to establish cut-off scores for an Australian sample, with suitable specificities and sensitivities for most substances. Predictive validity was demonstrated by similarity in ASSIST scores obtained at baseline and at follow-up. The findings demonstrated that the ASSIST is a valid screening test for psychoactive substance use in individuals who use a number of substances and have varying degrees of substance use.

Cannabis use in adolescents: the impact of risk and protective factors and social functioning

The study uses a school-based sample to test the social and familial risk and protective factors relating to cannabis use. Based on a self-completion survey of 2078 14-16-year-olds (mean age of 15 years) attending seven standard state-run secondary schools in south London, an assessment was made of rates and risk factors for cannabis use. Twenty-four per cent of the total sample had ever used cannabis, with 15% having done so in the month prior to assessment. In addition to greater likelihood of illicit drug use, lifetime cannabis users were less likely to spend time regularly with both their mothers and fathers, but more likely to spend free time with friends who smoked, drank alcohol and used illicit drugs, and with friends involved in criminal activities. Among those who had ever used cannabis, frequency of cannabis use was predicted (using linear regression) by two onset factors (earlier initiation of drinking and cannabis use were both linked to more frequent use) and two social factors (more time spent with drug-using friends and less time spent with the mother). Overall, the study showed that early onset, itself predicted by social networks, is linked to more frequent use of cannabis and that this appears to be sustained by less time spent with parents and more with drug-using peers.

Drug use and perceived treatment need among newly sentenced prisoners in England and Wales

AIMS

To investigate pre-custody levels of drug use among newly sentenced prisoners and factors associated with perceived drug treatment need.

DESIGN, SETTING AND PARTICIPANTS

A sample of 1457 prisoners was recruited to a general purpose longitudinal survey of convicted prisoners starting a new sentence.

MEASUREMENTS

Data were collected by structured interviews on reception to prison. Measures were taken of illicit drug use, drug treatment history, current treatment needs, psychological health and a range of social problems.

FINDINGS

Life-time use of heroin, crack cocaine, cocaine powder, amphetamines or cannabis was reported by 79% of prisoners. Cannabis was the drug reported most commonly, but approximately a third had used heroin or crack cocaine during the year before custody. Nearly half of recent drug users reported wanting help or support with a drug problem during their sentence. Dependence on heroin and cocaine, previous drug treatment, employment, accommodation and psychological health problems were all associated positively with perceived treatment need.

CONCLUSIONS

The prevalence of pre-custody drug use among this sample of newly sentenced prisoners was high. Because treatment need was associated with a range of drug, health and social factors, assessment and referral to appropriate interventions should occur as soon as possible on reception. Treatment should be coordinated with other services and support.

Assessing comorbid substance use in detained psychiatric patients: issues and instruments for evaluating treatment outcome

This review assesses the issues involved in the selection and treatment of patients comorbid for mental illness and substance misuse being treated in secure psychiatric facilities. It includes those individuals who have a history of offending and whose placement is the result of severe behavioral disturbance. The relevant issues in the assessment and treatment of these patients are reviewed and a battery of tests is suggested on the basis of their usefulness with this population in terms of their brevity, ease of administration, and for their value in planning treatment, providing motivational feedback, and monitoring change. The paucity of assessment tools developed specifically for this patient population is highlighted.

The North American Opiate Medication Initiative (NAOMI): profile of participants in North America's first trial of heroin-assisted treatment

The North American Opiate Medication Initiative (NAOMI) is a randomized controlled trial evaluating the feasibility and effectiveness of heroin-assisted treatment (HAT) in the Canadian context. Our objective is to analyze the profile of the NAOMI participant cohort in the context of illicit opioid use in Canada and to evaluate its comparability with patient profiles of European HAT studies. Recruitment began in February 2005 and ended in March 2007. Inclusion criteria included opioid dependence, 5 or more years of opioid use, regular opioid injection, and at least two previous opiate addiction treatment attempts. Standardized assessment instruments such as the European Addiction Severity Index and the Maudsley Addiction Profile were employed. A total of 251 individuals were randomized from Vancouver, BC (192, 76.5%), and Montreal, Quebec (59, 23.5%); 38.5% were female, the mean age was 39.7 years (SD:8.6), and participants had injected drugs for 16.5 years (SD:9.9), on average. In the prior month, heroin was used a mean of 26.5 days (SD:7.4) and cocaine 16 days (SD;12.6). Vancouver had significantly more patients residing in unstable housing (88.5 vs. 22%; p < 0.001) and higher use of smoked crack cocaine (16.9 days vs. 2.3 days in the prior month; p < 0.001), while a significantly higher proportion of Montreal participants reported needle sharing in the prior 6 months (25% vs. 3.7%; p < 0.001). In many respects, the patient cohort was similar to the European trials; however, NAOMI had a higher proportion of female participants and participants residing in unstable housing. This study suggests that the NAOMI study successfully recruited participants with a profile indicated for HAT. It also raises concern about the high levels of crack cocaine use and social marginalization.

Development of the Treatment Outcomes Profile

AIM

To develop the Treatment Outcomes Profile (TOP), a new instrument for monitoring substance misuse treatment.

DESIGN

Prospective cohort, psychometric evaluation with 7-day retest and 1-month follow-up to assess inter-rater reliability, concurrent, discriminant and construct validity, and change sensitivity.

PARTICIPANTS

A sample of 1021 service users, aged 16-62 years. Recruitment from 63 treatment agencies in England, collectively providing opioid substitution treatment, psychosocial interventions, in-patient detoxification and residential rehabilitation.

MEASUREMENTS

Thirty-eight frequency, rating scale and period prevalence measures, with 28-day recall, across substance use, health, crime and social functioning domains, administered as personal interview by 163 treatment keyworkers.

FINDINGS

Twenty outcome measures met inter-rater reliability criteria: days used alcohol, opioids, crack cocaine, cocaine powder, amphetamines, cannabis and one other named substance; days injected and period prevalence of direct or indirect needle/syringe sharing; subjective rating of physical and psychological health; days committed shop theft and drug selling, period prevalence of vehicle, property, fraud/forgery and assault/violence offences; rating of quality of life; days worked and attended for education/training; and period prevalence of acute housing problems and risk of eviction. Intraclass correlation coefficients for scale measures and Cohen's kappa for dichotomous measures reached or exceeded 0.75 and 0.61, respectively. There were satisfactory validity assessments and change sensitivity of scale items judged by effect size and smallest detectable difference. The TOP clinical tool contains an additional 10 items for individual treatment planning and review.

CONCLUSIONS

The TOP is a reliable and valid 20-item instrument for treatment outcomes monitoring.

What makes one person paranoid and another person anxious? The differential prediction of social anxiety and persecutory ideation in an experimental situation

BACKGROUND

In recent years a close association between anxiety and persecutory ideation has been established, contrary to the traditional division of neurosis and psychosis. Nonetheless, the two experiences are distinct. The aim of this study was to identify factors that distinguish the occurrence of social anxiety and paranoid thoughts in an experimental situation.

METHOD

Two hundred non-clinical individuals broadly representative of the UK general population were assessed on a range of psychological factors, experienced a neutral virtual reality social environment, and then completed state measures of paranoia and social anxiety. Clustered bivariate logistic regressions were carried out, testing interactions between potential predictors and the type of reaction in virtual reality.

RESULTS

The strongest finding was that the presence of perceptual anomalies increased the risk of paranoid reactions but decreased the risk of social anxiety. Anxiety, depression, worry and interpersonal sensitivity all had similar associations with paranoia and social anxiety.

CONCLUSIONS

The study shows that social anxiety and persecutory ideation share many of the same predictive factors. Non-clinical paranoia may be a type of anxious fear. However, perceptual anomalies are a distinct predictor of paranoia. In the context of an individual feeling anxious, the occurrence of odd internal feelings in social situations may lead to delusional ideas through a sense of 'things not seeming right'. The study illustrates the approach of focusing on experiences such as paranoid thinking rather than diagnoses such as schizophrenia.

Family functioning of out-of-treatment cocaine base paste and cocaine hydrochloride users

Knowledge of family structure and behavioral dynamics of out-of-treatment drug users under poverty becomes relevant, because of the role that the family plays in drug use and rehabilitation.

HYPOTHESES

1. The perception of drug users about their family functioning reveals a dysfunctional organization and communication-connection problems with their families; and 2. the family system of cocaine base paste (CBP) users presents greater dysfunctionality than cocaine hydrochloride (CH) users.

METHOD

Cross-sectional descriptive design of primary users of CH (n=236) and primary users of CBP (n=231) during the last month, out-of-substance abuse treatment during the last 6 months.

INSTRUMENTS

Risk Behavior Questionnaire and How-Is-Your-Family Questionnaire.

RESULTS

The total sample presented 72.9% of families with risk functioning; CBP users registered a more deteriorated family structure and communication-connection than CH users.

CONCLUSIONS

CBP and CH users, who are hidden from health treatment services, do indeed present a high degree of family dysfunction; and the CBP group, compared to the CH group, presented various indicators of greater risk in their family dysfunction.

Validation of the Alcohol, Smoking And Substance Involvement Screening Test (ASSIST)

AIM

The concurrent, construct and discriminative validity of the World Health Organization's Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) were examined in a multi-site international study.

PARTICIPANTS

One thousand and 47 participants, recruited from drug treatment (n = 350) and primary health care (PHC) settings (n = 697), were administered a battery of instruments.

MEASUREMENTS

Measures included the ASSIST; the Addiction Severity Index-Lite (ASI-Lite); the Severity of Dependence Scale (SDS); the MINI International Neuropsychiatric Interview (MINI-Plus); the Rating of Injection Site Condition (RISC); the Drug Abuse Screening Test (DAST); the Alcohol Use Disorders Identification Test (AUDIT); the Revised Fagerstrom Tolerance Questionnaire (RTQ); and the Maudsley Addiction Profile (MAP).

FINDINGS

Concurrent validity was demonstrated by significant correlations between ASSIST scores and scores from the ASI-Lite (r = 0.76-0.88), SDS (r = 0.59), AUDIT (r = 0.82) and RTQ (r = 0.78); and significantly greater ASSIST scores for those with MINI-Plus diagnoses of abuse or dependence (P < 0.001). Construct validity was established by significant correlations between ASSIST scores and measures of risk factors for the development of drug and alcohol problems (r = 0.48-0.76). Discriminative validity was established by the capacity of the ASSIST to discriminate between substance use, abuse and dependence. Receiver operating characteristic (ROC) analysis was used to establish cut-off scores with suitable specificities (50-96%) and sensitivities (54-97%) for most substances.

CONCLUSIONS

The findings demonstrated that the ASSIST is a valid screening test for identifying psychoactive substance use in individuals who use a number of substances and have varying degrees of substance use.

Neuropsychological predictors of clinical outcome in opiate addiction

A growing literature supports a role for neurocognitive deficits such as impaired decision-making in the development and maintenance of addictive behaviour. On the basis of these findings, it has been suggested that measures of neurocognitive functioning may be applied to the task of predicting clinical outcome in drug addiction. This in turn may have relevance for differentiating treatment based on individual patient needs. To explore this hypothesis we obtained neurocognitive measures of planning, impulsivity and decision-making from 37 opiate dependent individuals within 6 weeks of starting a community drug treatment programme and we followed them up 3 months into the programme. Performance on two tests of decision-making, but not on tests of planning, motor inhibition, reflection impulsivity or delay discounting, was found to predict abstinence from illicit drugs at 3 months with high specificity and moderate sensitivity. In particular, two thirds of the participants performing normally on the Cambridge Gamble Task and the Iowa Gambling Task, but none of those impaired on both, were abstinent from illicit drugs at follow up. Other neuropsychological, psychiatric or psychosocial factors measured in this sample did not explain this finding. The results are discussed in terms of the brain circuitry involved and the potential implications for the planning of treatment services for opiate dependence.