Predictors of outcome in treatment of opiate addicts: evidence for the multidimensional nature of addicts' problems

Pursuing the epidemiology and familial risks of depression and developing an evidence based psychotherapy

This commentary, as requested, presents the highlights of my research career. The epidemiology of psychiatric disorders study, challenged in a small study, the notion that diagnosis for psychiatric disorders could be made in a community survey. This pilot study was the basis for the Epidemiology Catchment Area Study (ECA) with 18,000 participants and the many more updated surveys, which followed. The families at High and Low Risk for Depression study in its 40th year challenged the notion that children didn't get depressed and showed that parental depression was the major risk for depression, which began in youth and reoccurred over the lifespan. Interpersonal psychotherapy (IPT), now has been tested in over 150 clinical trials, recommended by the World Health Organization (WHO), globally in China, Germany, Ukraine, and many more countries.

Improved Quality of Life Following Addiction Treatment Is Associated with Reductions in Substance Use

People seeking treatment for substance use disorders (SUD) ultimately aspire to improve their quality of life (QOL) through reducing or ceasing their substance use, however the association between these treatment outcomes has received scant research attention. In a prospective, multi-site treatment outcome study (‘Patient Pathways’), we recruited 796 clients within one month of intake from 21 publicly funded addiction treatment services in two Australian states, 555 (70%) of whom were followed-up 12 months later. We measured QOL at baseline and follow-up using the WHOQOL-BREF (physical, psychological, social and environmental domains) and determined rates of “SUD treatment success” (past-month abstinence or a statistically reliable reduction in substance use) at follow-up. Mixed effects linear regression analyses indicated that people who achieved SUD treatment success also achieved significantly greater improvements in QOL, relative to treatment non-responders (all four domains p < 0.001). Paired t-tests indicated that non-responders significantly improved their social (p = 0.007) and environmental (p = 0.033) QOL; however, their psychological (p = 0.088) and physical (p = 0.841) QOL did not significantly improve. The findings indicate that following treatment, QOL improved in at least some domains, but that reduced substance use was associated with both stronger and broader improvements in QOL. Addressing physical and psychological co-morbidities during treatment may facilitate reductions in substance use.

What we have learned from the Methadone Maintenance Treatment of Dual Disorder Heroin Use Disorder patients

Mental Disorders and Heroin Use Disorder (HUD) often co-occur and constitute correlated risk factors that the authors believe are best considered from a unitary perspective. In this article we review and discuss data collected by the V.P. Dole Research Group in Dual Disorder (V.P. Dole DD-RG) patients according to the following six discussion points: (1) Treatment of personality disorders during Methadone Maintenance Treatment (MMT); (2) Treatment of Mood Disorders during MMT; (3) Treatment of Anxiety Disorders during MMT; (4) Treatment of Psychotic Disorders during MMT; (5) Treatment of violence during MMT; (6) Treatment of Alcohol Use Disorder (AUD) during MMT. In treating Mood Disorder in HUD patients, we must bear in mind the interactions (potentiation and side effects) between psychopharmacology, used substances and agonist opioid medications; the use of psychiatric medications as an anti-craving drug, and the possible use of agonist and antagonist opioid medications in treating the other mental disorders. In treating chronic psychosis in HUD patients, we must consider the potentiation and side effects of antipsychotic drugs consequent on HUD treatment, worsening addiction hypophoria and inducing a more severe reward deficiency syndrome (RDS) in hypophoric patients. Violence and AUD during MMT can benefit from adequate dosages of methadone and co-medication with Sodium gamma-hydroxybutyrate (GHB). The experience of our V.P. Dole DD-RG suggests the following: (a) DD is the new paradigm in neuroscience in deepening our understanding of mental health; (b) To successfully treat DD patients a double competence is needed; (c) In managing DD patients priority must be given to Substance Use Disorder (SUD) treatment (stabilizing patients); (d) Antidepressant use is ancillary to SUD treatment; antipsychotic use must be restricted to acute phases; mood stabilizers must be preferred; any use of Benzodiazepines (BDZs) must be avoided.

Psychiatric symptoms, quality of life, and HIV status among people using opioids in Saint Petersburg, Russia

BACKGROUND

The Russian Federation is experiencing a very high rate of HIV infection among people who inject drugs (PWID). However, few studies have explored characteristics of people with co-occurring opioid use disorders and HIV, including psychiatric symptom presentations and how these symptoms might relate to quality of life. The current study therefore explored a.) differences in baseline psychiatric symptoms among HIV+ and HIV- individuals with opioid use disorder seeking naltrexone treatment at two treatment centers in Saint Petersburg, Russia and b.) associations between psychiatric symptom constellations and quality of life.

METHODS

Participants were 328 adults enrolling in a randomized clinical trial evaluating outpatient treatments combining naltrexone with different drug counseling models. Psychiatric symptoms and quality of life were assessed using the Brief Symptom Inventory and The World Health Organization Quality of Life-BREF, respectively.

RESULTS

Approximately 60% of participants were HIV+. Those who were HIV+ scored significantly higher on BSI anxiety, depression, psychoticism, somatization, paranoid ideation, phobic anxiety, obsessive-compulsive, and GSI indexes (all p<0.05) than those HIV-. A K-means cluster analysis identified three distinct psychiatric symptom profiles; the proportion of HIV+ was significantly greater and quality of life indicators were significantly lower in the cluster with the highest psychiatric symptom levels.

CONCLUSION

Higher levels of psychiatric symptoms and lower quality of life indicators among HIV+ (compared to HIV-) individuals injecting drugs support the potential importance of combining interventions that target improving psychiatric symptoms with drug treatment, particularly for HIV+ patients.

Associations among depression, suicidal behavior, and quality of life in patients with human immunodeficiency virus

AIM: To investigate the potential associations among major depression, quality of life, and suicidal behavior in human immunodeficiency virus (HIV) patients.

METHODS: A detailed MEDLINE search was carried out to identify all articles and book chapters in English published from January 1995 to January 2015.

RESULTS: Based on the main findings, the prevalence of major depressive disorder (MDD) ranged from 14.0% to 27.2%. Furthermore, the prevalence of suicidal ideation varied from 13.6% to 31.0% whereas, attempted suicides were reported to range from 3.9% to 32.7%. Interestingly, various associated risk factors for both depression and suicide were identified in HIV patients. Finally, consistent associations were reported among MDD, suicidal ideation, and poor quality of life in individuals living with HIV.

CONCLUSION: Although additional studies are needed to elucidate this complex association, our results suggest the importance of early detection of both MDD and suicidality in patients living with HIV.

What happens in treatment doesn't stay in treatment: cocaine abstinence during treatment is associated with fewer problems at follow-up

OBJECTIVE

Cocaine users often present to treatment with a multitude of problems typically considered addiction related; however, there is little evidence that reductions in cocaine use are followed by reductions in these problems. This study evaluated the relationship between rates of cocaine use during treatment and the level of non-cocaine life problems experienced during a 12-month period following treatment in a pooled sample of 434 cocaine-dependent individuals participating in 1 of 5 randomized controlled trials.

METHOD

Structural equation modeling and latent growth curve modeling were used to evaluate the relationship between frequency of cocaine use within treatment (8 or 12 weeks) and a latent construct of global problems indicated by the days of problems reported on the Addiction Severity Index across follow-up time points (1, 3, 6, and 12 months after treatment).

RESULTS

Both a continuous latent cocaine use outcome measure (percent days abstinent, percent positive urines, and maximum days of consecutive abstinence) and a dichotomous measure of cocaine use (≥21 consecutive days of abstinence) during the treatment period were associated with frequency of cocaine use and global problems during follow-up. Overall, results indicated that greater cocaine abstinence during the treatment period was associated with higher rates of abstinence and fewer global problems experienced following treatment.

CONCLUSION

This is one of the first studies to support a model that suggests addiction-related problems decrease in accordance with achieving abstinence from cocaine, thereby providing evidence that within-treatment cocaine abstinence has benefits that extend beyond the frequency of drug use.

Baseline characteristics and treatment outcomes in prescription opioid dependent patients with and without co-occurring psychiatric disorder

BACKGROUND

Given the growing prevalence of prescription opioid dependence and the considerable rates of additional psychopathology in drug dependence, we examined the association between the presence of a co-occurring Axis I psychiatric disorder and sociodemographic and clinical characteristics in this secondary analysis of patients entering a treatment study for dependence on prescription opioids. Treatment outcomes were also compared.

METHODS

Patients dependent on prescription opioids participated in a multi-site, two-phase, randomized, controlled trial to assess different lengths of buprenorphine-naloxone pharmacotherapy and different intensities of counseling (Clinicaltrials.gov identifier: NCT00316277). Among the 653 participants entering the first phase of the trial, 360 entered the second phase, receiving 12 weeks of buprenorphine-naloxone treatment; they are reported here. Half of those participants (180/360) had a current co-occurring psychiatric disorder in addition to substance dependence.

RESULTS

Sociodemographic characteristics were similar overall between those with and without a co-occurring psychiatric disorder, but women were 1.6 times more likely than men to have a co-occurring disorder. On several clinical indicators at baseline, participants with a co-occurring disorder had greater impairment. However, they had better opioid use outcomes at the conclusion of 12 weeks of buprenorphine-naloxone stabilization than did participants without a co-occurring disorder.

CONCLUSIONS

Prescription opioid-dependent patients with a co-occurring psychiatric disorder had a better response to buprenorphine-naloxone treatment despite demonstrating greater impairment at baseline. Additional research is needed to determine the mechanism of this finding and to adapt treatments to address this population.

Baseline predictors of treatment outcome in Internet-based alcohol interventions: a recursive partitioning analysis alongside a randomized trial

Background

Internet-based interventions are seen as attractive for harmful users of alcohol and lead to desirable clinical outcomes. Some participants will however not achieve the desired results. In this study, harmful users of alcohol have been partitioned in subgroups with low, intermediate or high probability of positive treatment outcome, using recursive partitioning classification tree analysis.

Methods

Data were obtained from a randomized controlled trial assessing the effectiveness of two Internet-based alcohol interventions. The main outcome variable was treatment response, a dichotomous outcome measure for treatment success. Candidate predictors for the classification analysis were first selected using univariate regression. Next, a tree decision model to classify participants in categories with a low, medium and high probability of treatment response was constructed using recursive partitioning software.

Results

Based on literature review, 46 potentially relevant baseline predictors were identified. Five variables were selected using univariate regression as candidate predictors for the classification analysis. Two variables were found most relevant for classification and selected for the decision tree model: ‘living alone’, and ‘interpersonal sensitivity’. Using sensitivity analysis, the robustness of the decision tree model was supported.

Conclusions

Harmful alcohol users in a shared living situation, with high interpersonal sensitivity, have a significantly higher probability of positive treatment outcome. The resulting decision tree model may be used as part of a decision support system but is on its own insufficient as a screening algorithm with satisfactory clinical utility.

Trial registration

Netherlands Trial Register (Cochrane Collaboration): NTR-TC1155.

Suicidal ideation and HIV risk behaviors among a cohort of injecting drug users in New Delhi, India

Background

Data on mental health among injecting drug users in South Asia is scarce yet poor mental health among users has significant implications for the success of HIV prevention and treatment programmes. A cohort of 449 injecting drug users in Delhi was examined on the following issues (1) examine trends in suicidal ideation, suicide plan and suicidal attempts over a 12-month period, (2) examine association between injecting practices (receive and give used syringes) and suicidal ideation over a 12 month study period.

Methods

An observational study was conducted providing phased interventions with follow up interviews every 3 months to 449 injecting drug users (IDUs), from August 2004 to November 2005. The study was conducted in Yamuna Bazaar, a known hub of drug peddling in Delhi. Interventions included nutrition, basic medical services, needle exchange, health education, HIV voluntary counseling and testing, STI diagnosis and treatment, oral buprenorphine substitution, and detoxification, each introduced sequentially.

Results

Suicidal ideation and suicide attempts, did not significantly change over 12 months of observation, while suicide plans actually increased over the time period. Keeping other factors constant, IDUs with suicidal ideation reported more giving and receiving of used syringes in the recent past. Conclusions: Mental health services are warranted within harm reduction programmes. Special attention must be paid to suicidal IDUs given their higher risk behaviours for acquiring HIV and other blood borne infections. IDU intervention programmes should assess and address suicide risk through brief screening and enhanced counseling.

Psychiatric co-morbidity and substance use disorders: treatment in parallel systems or in one integrated system?

Psychiatric co-morbidity among substance users refers to the simultaneous presence of at least another psychiatric disorder in a person diagnosed with a substance use disorder. Co-morbid patients represent a substantial number of people in treatment and present greater disorder severity from both the clinical and social perspectives than those people diagnosed with only one type of disorder. We present an overview of the current state of the art concerning the choice of site of treatment, the kind of intervention, the length of such treatment, and future goals, aiming to establish a more effective intervention, and finally so as to further improve clinical outcomes.

Modified therapeutic community aftercare for clients triply diagnosed with HIV/AIDS and co-occurring mental and substance use disorders

This clinical trial evaluated a modified therapeutic community aftercare (MTC-A) program for a population triply diagnosed with HIV/AIDS, a substance use disorder, and a mental disorder. After six months of MTC residential treatment (MTC-R), subjects were randomly assigned to MTC-A (n=42) or to standard aftercare (C; n=34). Follow-up interviews at six and 12 months assessed eight outcome domains and adherence to prescribed HIV medication. A propensity model was used to re-balance the retrieved sample. At the six-month follow-up, High stratum MTC-A clients (those with greater psychological functioning and stable physical health at baseline) had greater improvement overall and for substance use and mental health than C clients in the same stratum. In contrast, C clients in the Low/Medium stratum (those with poorer psychological functioning and improved physical health) had more favorable outcomes overall and for substance use than their MTC-A counterparts; however, this stratum was not re-balanced effectively. Differences in HIV medication adherence were not detected. Clients with greater psychological functioning and stable health at treatment entry benefit more from the MTC-A program. In view of the potentially progressive nature of HIV, measuring physical and mental health during treatment and controlling for changes could be important in future research.

Do methadone and buprenorphine have the same impact on psychopathological symptoms of heroin addicts?

BACKGROUND

The idea that the impact of opioid agonist treatment is influenced by the psychopathological profile of heroin addicts has not yet been investigated, and is based on the concept of a specific therapeutic action displayed by opioid agents on psychopathological symptoms. In the present report we compared the effects of buprenorphine and methadone on the psychopathological symptoms of 213 patients (106 on buprenorphine and 107 on methadone) in a follow-up study lasting 12 months.

METHODS

Drug addiction history was collected by means of the Drug Addiction History Rating Scale (DAH-RS) and psychopathological features were collected by means of the Symptom Checklist-90 (SCL-90), using a special five-factor solution. Toxicological urinalyses were carried out for each patient during the treatment period.

RESULTS

No statistically significant differences were detected in psychopathological symptoms, including 'worthlessness-being trapped', 'somatization', and 'panic-anxiety'. Methadone proved to be more effective on patients characterized by 'sensitivity-psychoticism', whereas buprenorphine was more effective on patients displaying a 'violence-suicide' symptomatology.

CONCLUSIONS

Heroin-dependent patients with psychiatric comorbidities may benefit from opioid agonist treatment not only because it targets their addictive problem, but also, precisely due to this, because it is effective against their mental disorder too.

The interaction of co-occurring mental disorders and recovery management checkups on substance abuse treatment participation and recovery

This article examines the effectiveness of quarterly Recovery Management Checkups (RMCs) for people with substance disorders by level of co-occurring mental disorders (34% none, 27% internalizing disorders, and 39% internalizing and externalizing) across two randomized experiments with 92% to 97% follow-up. The 865 participants are 82% African American, 53% female, and age 37 on average. RMC involves identification of those in need of treatment, motivational interviews, and treatment linkage assistance. It is effective in linking participants in need to treatment, with equal or better outcomes among those with more mental disorders. The data support the utility of monitoring and re-intervention for clients with co-occurring disorders.

Co-occurring disorders in substance abuse treatment: issues and prospects

This article explores the epidemiology of co-occurring disorders (CODs) with an emphasis on the implications of study findings for the functioning and potential of substance abuse treatment. Severity of disorder is discussed as an issue that may have particular significance for the selection of specialized as opposed to traditional substance abuse treatment forms. Exploration is made, as well, of the resources currently available to substance abuse treatment, especially the human resources available, and the implications of resource availability for undertaking initiatives specific to COD. Findings from standard and enhanced treatment for comorbid individuals are examined in an effort to clarify areas of need for specialized and typical treatment personnel. Issues are raised for consideration by the clinical research and treatment provider communities in terms of assessment and diagnosis, manpower and training, and response to the challenge of relapse in this population.

Substance abuse treatment entry, retention, and outcome in women: a review of the literature

This paper reviews the literature examining characteristics associated with treatment outcome in women with substance use disorders. A search of the English language literature from 1975 to 2005 using Medline and PsycInfo databases found 280 relevant articles. Ninety percent of the studies investigating gender differences in substance abuse treatment outcomes were published since 1990, and of those, over 40% were published since the year 2000. Only 11.8% of these studies were randomized clinical trials. A convergence of evidence suggests that women with substance use disorders are less likely, over the lifetime, to enter treatment compared to their male counterparts. Once in treatment, however, gender is not a significant predictor of treatment retention, completion, or outcome. Gender-specific predictors of outcome do exist, however, and individual characteristics and treatment approaches can differentially affect outcomes by gender. While women-only treatment is not necessarily more effective than mixed-gender treatment, some greater effectiveness has been demonstrated by treatments that address problems more common to substance-abusing women or that are designed for specific subgroups of this population. There is a need to develop and test effective treatments for specific subgroups such as older women with substance use disorders, as well as those with co-occurring substance use and psychiatric disorders such as eating disorders. Future research on effectiveness and cost-effectiveness of gender-specific versus standard treatments, as well as identification of the characteristics of women and men who can benefit from mixed-gender versus single-gender treatments, would advance the field.

Mental disorders and drug abuse in persons living with HIV/AIDS

This article reviews the literature on the prevalence of mental and substance use disorders among persons living with HIV/AIDS. Drug use, both injection and non-injection, substantially increases the risk for HIV infection. While injection drug users have the highest prevalence rates for HIV, substantially elevated rates of HIV infection are also present among crack cocaine users and individuals with substance use disorders generally. Persons with HIV/AIDS and a mental and/or substance use disorder have highly variable patterns of accessing services. Persons with HIV/AIDS who have a serious mental illness are more highly involved with services than other groups. Most individuals with co-occurring disorders report some involvement with outpatient primary medical care, although ancillary services such as mental health and substance abuse treatment, transportation assistance, and case management improve involvement in medical care. Women with HIV/AIDS and co-occurring mental and substance use disorders experience unique vulnerabilities, particularly those related to exposure to traumatic events. Given the complexity of needs with which triply or multiply diagnosed individuals present, effective treatment programmes are likely to be those that provide some degree of integrated care.

Significance of comorbidity for the long-term course of opiate dependence

OBJECTIVE

Studies on drug dependence show a high prevalence of comorbidity with additional mental disorders. Comorbidity patients also show more poly-substance use and other psychosocial problems. This study analyzed the importance of comorbidity for the long-term course of opiate dependence.

METHOD

350 opiate-dependent patients were examined at yearly follow-ups over 4 years using the EuropASI for the assessment of drug-related problems and the CIDI for diagnostic of psychiatric disorders. 196 patients were reached at final follow up (56%).

RESULTS

Of the patients reached at final follow-up, 30% had severe, 29% mild and 41% no clinically relevant disorders at baseline. However, the linear relationship at baseline--the more severe the disorder, the greater the impairment through drug-related problems--was not present at final follow-up. The results show that lifetime diagnosis of mental disorder had no prognostic relevance for the long-term course of drug dependency.

CONCLUSION

The assumption that opiate users with an additional mental disorder are more vulnerable in their course of addiction could not be confirmed.

Patterns of substance abuse among treatment-seeking pathological gamblers

Substance abuse patterns were reviewed for a group of patients admitted to the Gambling Treatment Program at the Brecksville Veterans Administration Medical Center. A retrospective chart review of 113 consecutively admitted patients between September 2000 and September 2001 found that 66.4% of pathological gamblers had a lifetime history of substance abuse or dependence at some point in their lives. A history of substance abuse or dependence was less common among gamblers aged 60 and above. In the year prior to admission, 58.1% of those with a history of substance abuse or dependence were actively using substances. Alcohol was the most commonly used substance, followed by marijuana and cocaine. In most gamblers with comorbid disorders, the onset of substance dependence preceded the onset of problem gambling. Pathological gamblers engaged in multiple impulsive and dysfunctional behaviors including suicide attempts, compulsive shopping and spending, and compulsive sexual behavior, and the presence of comorbid substance abuse disorders may influence the degree to which pathological gamblers engage in these additional problematic behaviors. These factors have important implications for treatment and prevention of relapse, as well as for theories of addictions.

Comorbid Major Depressive Disorder as a Prognostic Factor in Cocaine‐Abusing Buprenorphine‐Maintained Patients Treated with Desipramine and Contingency Management

Depression is common among patients who abuse both opiates and cocaine, and its treatment has had mixed success. This study compares buprenorphine-maintained patients with lifetime major depressive disorder (MDD, N = 53) with those never depressed (ND, N = 96) on cocaine and opiate-free urines during a 12-week outpatient double-blind, placebo-controlled, randomized clinical trial. The 149 subjects were assigned to four groups: 1) desipramine (DMI) + contingency management (CM); 2) DMI + noncontingency management (NCM); 3) placebo + CM; and 4) placebo + NCM. Depression assessments included Hamilton Depression Rating Scale, Center for Epidemiological Studies Depression Inventory, and Structured Clinical Interview for DSM-IV interview for diagnosis of lifetime MDD. Urine toxicologies were performed thrice weekly and the CES-D was performed monthly. The MDD group had a larger proportion of females (45% vs 21%, P = 0.02) and were more likely to be married (13.2% vs 7.3%, P = 0.02) than the ND group. Treatment retention did not vary by depression status. Hierarchical Linear Modeling found that depressive symptoms decreased comparably across the four treatment groups. Although participation in CM improved drug-free urines more for patients with MDD than for the ND group (Z = 2.44, P = 0.01), treatment with DMI was significantly more efficacious for the ND group than for the MDD group (Z = -2.89, P = 0.003). These results suggest that patients with MDD may respond better to behavioral treatments such as CM than to desipramine plus buprenorphine. The ND cocaine-abusing, opiate-dependent patients may be more responsive to the anticraving effects of DMI.

On beyond urine: clinically useful assessment instruments in the treatment of drug dependence

Although there are a wealth of clinically useful, brief, and low-cost assessment instruments available for use with drug-dependent populations, relatively few are broadly used in clinical practice. With an emphasis on: (1). the multidimensional nature of drug users' problems; and (2). assessments that can be integrated into empirically validated treatments, clinically useful assessments in four general categories (evaluation and diagnosis of drug dependence, identifying concurrent disorders and problems, treatment planning, and evaluation of treatment outcome) are briefly summarized. Progress in the field of drug abuse treatment has been significantly hampered by the failure to adopt, across research and clinical settings, a common set of assessments.

Social adjustment of family members and significant others (FSOs) of drug users

This study investigated the social adjustment of female family members and significant others (FSOs) of illicit drug users in order to gain insight into the impact of drug use upon those close to the user. Using the Social Adjustment Scale-Self Report (SAS-SR), we examined the social adjustment self-ratings (overall and in seven specific role areas) of 41 female partners and 24 mothers of drug users. We compared these ratings to the ratings they reported for their drug-using partners or children, to each other, and to self-ratings drawn from community comparison samples. As expected, results showed that the female FSOs reported significantly better social adjustment than the drug users in most role areas. However, their social adjustment was compromised relative to the community samples. Partners of drug users reported poorer adjustment than parents of drug users overall and in the specific areas of marital and economic functioning. Further inquiry is needed to improve our understanding of the impact of drug use on the users' family members.

The relationship of psychiatric comorbidity to treatment outcomes in methadone maintained patients

The authors examined the relationship of comorbid non-substance use psychiatric disorders to preadmission problem status and treatment outcomes in 278 methadone maintenance patients. Recent admissions were assigned DSM-III-R Axis I and II diagnoses according to structured diagnostic interviews. The Addiction Severity Index was administered at admission to assess past and current substance use and psychosocial problems and again 7 months later. Treatment retention and month 7 drug urinalysis results were also obtained. Across substance use and psychosocial domains, participants showed significant and comparable levels of improvement regardless of comorbidity. Comorbid participants received more concurrent psychiatric treatment which may have accounted for the lack of differential improvement among groups. Nevertheless, psychiatric comorbidity was associated with poorer psychosocial and medical status at admission and follow-up and participants with the combination of Axis I and II comorbidity had the most severe problems. Admission and month 7 substance use were, for the most part, not related to psychiatric comorbidity, although there was a trend indicating more treatment attrition for participants with personality disorders.

Novelty seeking as a predictor of treatment retention for heroin dependent cocaine users

This study examined the relationship between novelty seeking between treatment retention and among heroin dependent cocaine users. Participants were treated with buprenorphine maintenance and contingency management. The Tridimensional Personality Questionnaire's (TPQ) Novelty Seeking scale was administered to 68 participants prior to buprenorphine induction. Demographics, mood and anxiety disorders, antisocial personality disorder, and substance use were also assessed. Variables with significant relationships with overall retention were entered into a logistic regression analysis. In addition, using a survival analysis, all variables with significant relationships with time to drop-out were entered into a multivariate proportional hazards regression with time dependent covariates. Results demonstrated that although high novelty seekers, in comparison to low novelty seekers, were more likely to drop-out by the end of treatment, they had higher retention rates during the early phases of treatment. It is suggested that buprenorphine and contingency management were viewed by participants as novel treatment components and thus facilitated high novelty seekers' success early in treatment. If replicated, results suggest that inclusion of novel treatment components might facilitate retention among this at-risk group.

Retention and patient engagement models for different treatment modalities in DATOS

A model to explain treatment retention in terms of process components--therapeutic involvement and session attributes for the 1st month--and patient background factors were tested in long-term residential (LTR), outpatient drug free (ODF), and outpatient methadone (OMT) treatments. The data was collected in the national Drug Abuse Treatment Outcome Studies (DATOS), and included 1362 patients in LTR, 866 in ODF, and 981 in OMT programs. Structural equation models showed there were positive reciprocal effects between therapeutic involvement and session attributes in all three modalities, and these variables had direct positive effects on treatment retention. Motivation at intake was a strong determinant of therapeutic involvement. Other patient background factors were significantly related to retention, including pretreatment depression, alcohol dependence, legal pressure, and frequency of cocaine use.

Referral and screening for substance abuse treatment in jails

As jails and prisons have become filled to capacity with inmates arrested and convicted for drug-related offenses, efforts have intensified to reduce subsequent drug use, drug-related crime, and recidivism among this population. Faced with the drug abuse epidemic; treatment resources in the community have expanded more quickly than in detention and corrections facilities. Many large jails and prisons do not presently have a substance abuse treatment program despite clear evidence of widespread drug and alcohol dependence problems among inmate populations. Where substance abuse treatment resources are available, administrators face difficult choices in determining which inmates will receive services. This paper provides a discussion of issues related to referral and screening procedures for in-jail substance abuse treatment programs. Referral and screening systems implemented in several jails across the country are reviewed.

Psychiatric severity and treatment response in a comprehensive methadone maintenance treatment program

The purpose of this study was to investigate the influence of the severity of concomitant psychiatric symptomatology on some selected measures of methadone maintenance treatment efficacy in a comprehensive methadone maintenance treatment program (MMTP). The cohort studied included 267 patients who entered a maintenance program in the years 1991-92. Two groups of patients differing in the severity of psychiatric symptomatology were obtained on the bases of the referral to the psychiatrist and the ascertainment of a current disorder. These two groups were compared for retention in treatment, urine tests positive for morphine while in treatment and methadone dose during an observation period of 2 years. The outcome of the study suggests that on these outcome parameters, patients on MMTP who are more psychiatrically ill can perform as well as the other patients.

Nonpharmacologic approaches to substance abuse treatment

Familiarity with nonpharmacologic approaches to substance abuse treatment is critical for medical practitioners to act effectively to prevent the progression of substance use to medically harmful use, abuse, or dependence; to identify patients with substance use disorders and motivation behavioral changes; and to maximize the likelihood of successful treatment. At their most basic level, these nonpharmacologic approaches involve components of practice that are requisite to the successful management of any medical disorder: fostering an empathic, supportive relationship; routinely evaluating the system or problem area; providing accurate medical information about diagnosis, natural history, and treatment; and following up on identified problems to improve compliance, evaluate the impact of treatment, and modify treatment as indicated. Because of the nature of substance use disorders, their impact on multiple areas of functioning, and the conditioned craving that occurs following repeated substance use, nonpharmacologic treatments can improve outcome, even when effective pharmacologic treatments are also employed. Treatment of nicotine dependence provides a useful example. Physician advice to stop smoking substantially increases the likelihood of smoking cessation and long-term abstinence. Combined with physician advice, nicotine replacement therapies, using nicotine gum or transdermal preparations, approximately double the rate of long-term abstinence, compared with physician advice alone. Providing behavioral treatment in addition to physician advice and nicotine replacement treatment leads to the highest rates of sustained abstinence, significantly higher than advice alone or rates associated with nicotine replacement alone. Nonpharmacologic treatments complement pharmacologic approaches often by addressing different target symptom and problem areas. In the case of nicotine dependence, nicotine replacement ameliorates withdrawal symptoms and craving associated with withdrawal. Behavioral treatment improves outcome by focusing on cue-evoked craving and developing effective long-term strategies to avoid or cope with craving and other cues. As discussed in this article, brief motivation approaches are particularly well suited for general medical practice settings. These approaches have been evaluated most extensively and shown to be most effective in preventing the progression of heavy drinking to problem drinking and alcohol dependence. Following a thorough evaluation of a patient's drinking habits, providing advice about sensible and safe drinking to patients identified as heavy drinkers leads to meaningful reductions in drinking. For patients who have developed problems of abuse or dependence, motivation approaches can be used to foster an interest and commitment to stop use and accept a referral to treatment. This article also provides an overview of the major psychosocial approaches used in more intensive specialty treatment of patients with substance use disorders. Familiarity with these approaches is essential for clinicians in general medical settings to facilitate referral of patients and monitor and improve the efficacy of treatments provided to patients. Medical practitioners must be able to educate patients about the need for more intensive specialty treatment and about what treatment entails. Medical practitioners must also be able to engage in informed discussions with substance abuse treatment specialists about the specific treatment recommendations made for a patient and the rationale for them. Medical practitioners who are informed about the treatment plans, rationale for treatment, and patient progress can play critical roles in encouraging patients to persist with the often difficult process of treatment.

Treatment utilization and personality organization among drug abusers in Sweden

Treatment utilization and personality organization in a case-finding sample of 1824 drug abusers in the greater Stockholm area were assessed by using a standardized questionnaire, with the client's contact persons as informants. Level of personality organization was strongly associated, negatively with the number of concurrent treatment contacts, problems of coordination between concurrent treatment agents, and was positively correlated with agreement between treatment agents in the assignment of principal treatment responsibility and their opinions about the appropriateness of this assignment. Psychiatric ICD-9 diagnosis was not associated with any of these variables.

Psychological dysfunction and HIV/AIDS risk behavior

The relationship between psychological problems and human immunodeficiency virus HIV/AIDS risk-taking behaviors was examined among 834 daily opioid users entering methadone treatment programs. A composite measure of psychological dysfunction was created using depression, anxiety, and hostility scales. This measure was found to be significantly related to needle risk in terms of injecting with used equipment, sharing of drug paraphernalia, and sharing with strangers. Psychological dysfunction was also related to sexual risk taking in terms of number of partners, unprotected sex with other injection drug users, and trading sex. Use of cocaine was significantly related to all measures of injection and sex-related risk taking; use of speedball (heroin and cocaine) was significantly related to use of dirty equipment and sharing of paraphernalia. The implications of study findings for AIDS prevention programming are discussed.

Does HIV test result influence methadone maintenance treatment retention?

We compared groups of opioid users new to methadone maintenance to determine if persons who first learn that they are HIV-seropositive in a drug treatment program are more likely to drop out of treatment than persons who learn they are seronegative. We found no difference in patients' continuation in methadone treatment at either 6 or 12 weeks associated with HIV serostatus. Our findings suggest that voluntary HIV testing can be implemented as part of AIDS prevention programs with little fear of adversely affecting treatment outcomes.

Inpatient and day hospital treatment services for cocaine and alcohol dependence

We compared the treatment services provided male cocaine and alcohol dependent patients in a one month day hospital and a one month inpatient rehabilitation program. The quantity of medical, employment, alcohol, drug, legal, family/social, and psychiatric treatments were ascertained using the recently developed Treatment Services Review instrument. The day hospital program provided more drug and alcohol treatments to alcoholic patients than the inpatient program, but the inpatient program provided more employment services. By contrast, the inpatient program provided more alcohol, medical, employment, and psychiatric services to cocaine dependent patients, although more drug treatments were provided by the day hospital. The day hospital also appeared to provide a greater differentiation of services for the two patient groups than the inpatient program. The evidence provides interesting information concerning the nature of treatments provided by different programs and also supports the validity and utility of the TSR as a measure of treatment provided.

Substance misuse and comorbid psychopathology in a high-risk group: a study of siblings of cocaine misusers

Vulnerability to drug misuse and psychopathology was explored among 673 siblings of 298 opioid-addicted probands. Disorders were evaluated based on family history information obtained from the proband. Results indicated that (1) siblings of cocaine misusers showed high vulnerability to developing drug misuse, alcoholism, and antisocial personality disorder; (2) siblings of probands with specific comorbid diagnoses were vulnerable to developing a range of disorders (no specificity of aggregation was found); (3) proband major depression was related to a broad spectrum of sibling disorders; (4) the presence of a major psychiatric disorder was strongly associated with substance misuse among siblings; (5) psychopathology appeared to precede drug misuse in terms of age of onset. These findings corroborate those previously obtained with siblings of opioid addicts, and they are discussed in terms of implications for the classification and treatment of substance misuse.

Family functioning as a predictor of progress in substance abuse treatment

This study tested the hypothesis that the level of family functioning is related to changes in the patient's progress while in treatment. We studied the relation of family functioning, as measured by the Family Adaptability and Cohesion Scales' (FACES II) dimensions of cohesion and adaptability, to 7 dimensions of the severity of patient drug use, as measured by the Addiction Severity index (ASI). The results indicated that family functioning, the cohesion dimension in particular, predicts severity of patient's dysfunction resulting from drug use and family and psychological problems. In particular, 28% of the variability in the ASI Drug Problems, 52% of the variability in the ASI Family Problems, and 29% of the variability in the ASI Psychological Problems were accounted for by the FACES II cohesion score. Although the study has several limitations, it supports the relevance of family factors in the treatment of drug-addicted patients.

Families are helped by drug treatment

Twenty-six pairs of heroin addicts applying for methadone maintenance treatment and their family members were interviewed before being admitted to a drug treatment program and 3 months after entry into treatment to determine whether treatment resulted in changes in family or individual functioning. Results revealed a considerable lessening of family and patient problems in the first months of drug treatment. Family members and patients reported significantly fewer family crises and family difficulties with the patient. Both family members and patients reported improvement on several mood indicators and significant lessening of the patient's family/social problems and drug problems.

Psychopathology, parent relations, and careers in vocational training: a prospective study

Twenty substance-abusing male clients, representative of the clients participating in a vocational training program in Oslo, were followed prospectively during 2-3 years. Forty-two percent of the nonpsychotic clients completed the training program as opposed to 25% in the psychotic/near psychotic group. All dropouts reported a feeling of being rejected by their fathers as opposed to 28% of the clients who completed the program (p less than .001). The study indicates the need for an evaluation of psychopathology and parent relationships before entering a vocational training program and development of a more differentiated training model.

Relationship of marital structure and interactions to opiate abuse relapse

Several aspects of marital functioning were associated with subsequent relapse to opiate abuse in 17 married addicts. The addicts and spouses were evaluated in a task-oriented interview and rated using the Beavers Timberlawn Family Assessment instrument. The global health-pathology ratings on this instrument indicated that most couples had rigid patterns of interacting, rather than a chaotic lack of structure or a flexible, negotiated partnership. Within this range of rigid functioning, higher ratings were associated with longer times drug-free (up to 18 months with a mean of 7 months). On the seven subscales of the Beavers', five were significantly correlated with the time drug-free: effective and clear leadership, closeness between the spouses, a nonhostile mood, empathy, and efficient negotiation and problem solving. The subscales associated with drug abstinence were quite different for a group of seven single ex-addicts participating in the same outpatient program, but living with their parents. For these single ex-addicts three subscales were correlated with the time drug-free: parental reaction to separation strivings, the open expression of thoughts and feelings, and empathy. This difference in the subscales associated with abstinence for married versus single addicts suggested some specificity in the characteristics of family structure and interaction that may be related to drug abstinence.

The use of the Diagnostic Interview Schedule in drug-dependent patients

In an attempt to diagnose other psychiatric disorders in substance abusers, some clinicians and investigators have utilized the NIMH Diagnostic Interview Schedule (DIS). This study assessed the validity of the DIS in a drug-dependent population by comparing DIS diagnoses with clinical diagnoses in 124 hospitalized drug abusers. Every attempt was made to establish the validity of the clinical diagnoses; these represented a consensus of two independent psychiatrists, based on repeated clinical interviews, observation of ward behavior, and information obtained from relatives regarding patient and family history. Concordance between clinical and DIS diagnoses (represented by the kappa statistic and percent agreement) was only moderate for DSM-III Axis I disorders other than substance abuse. In addition, the DIS diagnosed alcoholism less often and antisocial personality disorder more often than the clinicians. Factors contributing to the discrepancy between clinical and DIS diagnoses in this specific population include (a) drug abuse effects, whereby distinguishing between drug effects and primary psychiatric symptoms may be difficult; and (b) the effect of the treatment process itself, whereby patients are encouraged to rethink the role drugs have played in causing some of their difficulties. Patients' reports of the chronology of their symptoms may thus change according to what they have learned in treatment. The authors conclude that the DIS, like any single diagnostic interview, may have limited utility early in the treatment of drug-dependent patients, since their recollection of their previous symptoms may change dramatically as a result of treatment efforts.

The antecedents and benefits of achieving abstinence in opioid addicts: a 2.5-year follow-up study

This report examines long-term and short-term benefits of achieving abstinence from opioids in a sample of opioid addicts who were reevaluated 2.5 years following seeking treatment. Extensive assessment of drug use history and drug-associated problems had been obtained when the subjects applied for treatment. At follow-up evaluations, detailed information was obtained on intervening course of drug use, treatment, legal problems, psychological problems, social functioning, occupational functioning, and medical status. The results were as follows: (1) Achieving abstinence from illicit opioids was associated with concurrent improvement in other aspects of functioning including reduction of criminal activity, improved medical status, improved social functioning, and reduced abuse of other psychoactive substances. However, many of these improvements were reversed immediately if relapse to opioid use occurred. (2) Achieving abstinence was associated with being in drug treatment, especially treatment in a methadone maintenance program. (3) Achievement of abstinence was not successfully predicted by client characteristics measured at entrance into treatment. (4) Long-range benefits of abstinence were detectable in social functioning even for those who had relapsed at the time of follow-up reevaluation.

Psychotherapy/counseling for opiate addicts: strategies for use in different treatment settings

The authors review evidence from outcome studies of psychotherapy for opiate addicts and make recommendations regarding the use of psychotherapy on the basis of the findings. The place of psychotherapy is evaluated for three types of treatment settings: outpatient drug-free treatment, narcotic antagonist treatment, and methadone maintenance. The heterogeneity of opiate addicts is emphasized, as is the need for multidimensional assessment of clients in order to maximize the effectiveness of psychotherapies offered. In each of the treatment settings evaluated, psychotherapy appears to be most promising for a subgroup of those seen. For outpatient drug-free treatment, psychotherapy appears to be most useful for the new client with no treatment history, the successful client graduating from a more intensive program, the client who has temporarily relapsed, and the client leaving jail or a hospital. In a narcotic antagonist program, psychotherapy appears to be most useful for clients entering the program from illicit heroin use and not for those switching from methadone maintenance to a narcotic antagonist program. Moreover, in the maintenance phase of the program, preliminary evidence suggests the value of family therapy for aiding treatment retention. Regarding psychotherapy in the context of a methadone maintenance program, it appears to be best reserved for those addicts who present to treatment with relatively severe levels of psychiatric symptoms.