Comparison of opiate addicts' reports of psychiatric history with reports of significant-other informants

Adherence to pharmacotherapy in patients with alcohol and opioid dependence

AIMS

An important factor that has thus far limited the effectiveness of pharmacotherapies for patients with alcohol and opioid dependence is poor adherence to medication regimens. This paper presents a review of issues related to medication adherence in patients with these substance use disorders.

DESIGN AND METHODS

A literature review was conducted of English language publications relating to medication adherence among patients with alcohol or opioid dependence.

FINDINGS

The paper places the topic in the context of adherence difficulties among patients with a variety of chronic medical and psychiatric illnesses. Difficulties measuring adherence are discussed, and strategies to improve medication adherence are reviewed. These include specific interventions that prescribing clinicians can implement in their individual meetings with patients; the use of external reinforcers, such as positive and negative contingencies, and involvement of family members or significant others; and specific prescribing and dosing practices that may improve adherence.

CONCLUSIONS

As the use of pharmacotherapy for substance-dependent patients increases, rigorous and innovative approaches to encourage medication adherence should be sought.

Antisocial behavioral syndromes and return to drug use following residential relapse prevention/health education treatment

This study compared residential addiction treatment clients meeting full DSM-III-R criteria for antisocial personality disorder (ASPD) with those reporting syndromal levels of antisocial behavior only in adulthood (AABS) on time to and severity of first posttreatment drug use. Antisocial syndrome and selected other mental disorders were assessed using the Diagnostic Interview Schedule, Revised for DSM-III-R, and validity of self-reported posttreatment drug behavior was measured against results of hair analysis. Among subjects followed within 180 days after treatment exit, individuals with ASPD were at modestly increased risk of a first lapse episode compared to those with AABS. However, the two groups did not differ in severity of lapse. Participants with ASPD demonstrated poorer agreement between self-reported posttreatment drug behavior and hair data. These results add to the evidence suggesting that the DSM requirement for childhood onset in ASPD may be clinically important among substance abusers in identifying a severely antisocial and chronically addicted group at elevated risk for early posttreatment recidivism. Our findings support the importance of careful classification of antisocial syndromes among substance abusers and the identification of characteristics of these syndromes that underlie clients' risks for posttreatment return to drug use to provide optimally individualized treatment planning.

The use of collateral reports for patients with bipolar and substance use disorders

This study investigated the value of collateral informant reports of substance use for patients with current bipolar disorder and substance dependence. We collected collateral informant reports on 132 occasions for 32 patients and found a high level of agreement between collateral reports and self-report/urine screen data (75.0%). In only 3 instances did collateral informants report substance use for patients who denied use and had negative urine screens. Frequency of contact between informants and patients was associated significantly with the level of agreement. These findings suggest that obtaining collateral informant data when studying this population may be of limited value.

The test-retest reliability of the frequency of multiple drug use in young drug users entering treatment

Assessment of multiple drug use relies primarily on self-report. Several studies support the reliability of client self-reports of drug use but these studies have not involved assessment of the actual frequency of drug use. This test-retest reliability study assessed the frequency of drug use in a clinical sample of 103 multiple drug users, aged 16-25 years. At initial assessment, all participants completed the Drug Use History Form (DUHF) that inquired about the number of drug-using days and the daily frequency of use for 13 drug classes during four time intervals. The DUHF was readministered 2-4 weeks later. Reliability was assessed using Intra-class correlations (ICC's). The results indicated that clients do, in general, reliably report both the number of days of use and daily frequencies. The two frequency measures were not highly correlated. Reliability estimates declined over time but most markedly after 90 days, suggesting that assessments of drug use can be reliably extended beyond 30 days. Frequency estimates based solely on the number of days of use of a substance may be unreliable estimates of actual drug consumption, indicating limitations to this commonly used outcome measure.

Node-link mapping and psychological problems. Perceptions of a residential drug abuse treatment program for probationers

The current study examined program perceptions of 367 probationers admitted to a 4-month residential drug abuse treatment facility that focuses on group counseling. Prior research has shown that many individuals within the criminal justice system have both psychological and drug abuse problems, and that they often have limited success in drug abuse treatment programs. The current study examined whether the benefits of node-link mapping, a visual representation counseling technique that is especially beneficial in group counseling environments, would extend to individuals with psychological problems. Probationers were randomly assigned to mapping-enhanced or standard counseling. Those residents who had higher levels of psychological problems (based on a global indicator of psychological problems), and who received mapping-enhanced counseling, had more favorable perceptions of their counselors and fellow community members over time than their counterparts who received standard counseling.

Antisocial behavioral syndromes among residential drug abuse treatment clients

We compared residential addictions treatment clients meeting full criteria for antisocial personality disorder (ASPD+) with those reporting syndromal levels of antisocial behavior only in adulthood (AABS+) on demographics, antisocial symptomatology, drug history, axis I comorbidity and characteristics of index treatment episode. We examined these issues in the sample as a whole, as well as separately in male and female respondents. Among both men and women, ASPD+ initiated their antisocial behavior earlier, met more ASPD criteria and endorsed more violent symptoms, than AABS+. Male ASPD+ also met criteria for more lifetime axis I diagnoses and reported more years of drug involvement than male AABS+. Trends were observed toward poorer retention in treatment among ASPD+ than among AABS+ participants of both genders randomized to a planned duration of 180 days, but retention did not differ between ASPD+ and AABS+ randomized to a planned duration of 90 days. Our findings, which replicate and extend previously published results, carry potential implications for treatment programming and for the nosology of ASPD.

Drug Use during Pregnancy

Prevention and intervention services for pregnant, drug-using women have often developed prior to gaining empirical data on the antecedents of prenatal drug use. These data are important to address some of the underlying factors of drug use during pregnancy. A review of the literature indentified at least six categories of psychosocial risk factors that have been investigated as relevant to drug use among women, including pregnant women. These factors include: (1) history of childhood sexual abuse, (2) family history of alcohol or drug problems, (3) male partner's alcohol or drug use, (4) current depression, (5) social support, and (6) homelessness or transiency. An examination of these psychosocial risk factors indicates that the existing literature on these factors in drug use is limited by a lack of methodological rigor, resulting in large variations in prevalence rates due to factors such as definition. This paper summarizes the existing literature and methodological iussues regarding the relation between psychosocial risk factors and drug use among women, including pregnant women. It also discusses some of the limitations and issues in assessing prenatal drug use with a particular focus on self-report and urine toxicologies.

Familial factors in illicit drug abuse: an interdisciplinary perspective

Research on familial factors in illicit drug abuse has been approached from the perspectives of psychiatric epidemiology, which aims to assess familial clustering of disorders, and clinical psychiatry, which focuses on intrafamilial dynamics. To date, however, these two research traditions have existed in relative isolation from each other, and there has been little consideration given to enhancing the understanding of familial factors in drug abuse by combining these approaches. The intention of this article is to critically review the literature in these two areas and to offer suggestions as to how the strengths from each could be applied in a comprehensive research approach.

Reliability of a drug history questionnaire (DHQ)

Drug abusers' self-reports are vital to clinical and research endeavors, yet few studies have explicitly examined the test-retest reliability of drug abusers' reports of their pretreatment drug use. The present study evaluated the test-retest reliability of drug abusers' reports of (a) lifetime drug use using a drug history questionnaire (DHQ), and (b) demographic and drug-related events. Intraclass and Pearson correlation coefficients revealed reasonably good reliability for most reports of drug use and related events. Further research needs in this area are discussed.

History and significance of childhood attention deficit disorder in treatment-seeking cocaine abusers

Thirty-five percent of 298 treatment-seeking cocaine abusers met DSM-III-R criteria for childhood attention deficit hyperactivity disorder (ADHD). Subjects with childhood ADHD were likely to be male (78%), meet Research Diagnostic Criteria (RDC) for conduct disorder (93%) and antisocial personality disorder (47%), and report a history of conduct disorder in first-degree relatives. With respect to those without the disorder and regardless of co-occurrence with sociopathy, cocaine abusers with childhood ADHD were younger at presentation for treatment and reported more severe substance use, earlier onset of cocaine abuse, more frequent and intense cocaine use, intranasal rather than freebase or intravenous use of cocaine, higher rates of alcoholism, and more previous treatment. This pattern of cocaine use is consistent with clinical descriptions of self-medication of residual symptoms of ADHD in cocaine abusers. Data from this study suggest that there may be more cocaine abusers with a history of ADHD than previously recognized in clinical samples of cocaine users, and that these individuals may differ in clinically meaningful ways from those without childhood ADHD. Moreover, the poorer outcome of subjects with ADHD in this sample underlines the importance of identifying and treating residual symptoms of ADHD in cocaine abusers.

The role of significant life events in discriminating help-seeking among illicit drug users

This paper examines the role of significant life events in distinguishing two samples of illicit drug users: 120 help-seekers (the "agency group") and 120 not seeking help (the "non-agency group"). We examined 10 life areas clustered around the general categories of "substance use," "social functioning," and "emotional and interpersonal functioning." A range of objective and self-reported information was collected regarding each life area covering the 12 months prior to interview. Analysis revealed that the agency group experienced a greater number of negatively perceived drug-related life events than the non-agency group. These life events were also more likely to have occurred in recent months, prompting reported "concern" and "need for help" among the agency group. Additionally, length of use of current primary drug was seen to be a contributory variable in distinguishing between the groups.

Validity of patients' self-reported drug use as a function of treatment status

Recent reviews conclude that there is some evidence that drug abusers' self-reports are reliable and valid. However, there are wide variations among studies depending upon the samples and procedures used to obtain the data. The current study was conducted to extend the findings in this area. An examination of the intake interviews and same day urinalyses on 150 patients enrolling for outpatient opioid detoxification or maintenance revealed a fairly high agreement between drug use self-reports and urinalyses. A second study (N = 70) looking at the validity of self-reported drug use at intake and at 4 weeks follow-up revealed some noticeable changes in validity measures, suggesting that contingencies on positive urine results influence self reported drug use of addicts.

Measurement of HIV risk behaviors among intravenous drug users

This paper reviews issues related to the measurement of drug use and other behaviors in studies of human immunodeficiency virus (HIV) infection in intravenous drug users. These issues include: (1) choice of variables, (2) study design, (3) time frame of measurement, (4) categories of measurement, (5) interviewer effects, and (6) validity of measurement. Difficulties and approaches for measuring drug use and other intimate behaviors in intravenous drug users are discussed. Attempts to come to terms with these measurement issues in the context of HIV infection in intravenous drug users should lead to the further development of methods for use in the general context of drug abuse research.

Self-Report Interview Data for a Study of HIV-1 Infection among Intravenous Drug Users: Description of Methods and Preliminary Evidence on Validity

This article presents a description and preliminary evidence on validity of self-report interview methods being used in a study of HIV-1 infection and AIDS among intravenous drug users (IVDUs). The study population includes 2,616 currently active IVDUs living in or near Baltimore City, Maryland (USA), many of them reporting no prior treatment for drug dependence, and many with no history of criminal arrest or incarceration. These IVDUs were recruited in 1988–89 by extensive community outreach efforts; most learned of the study by word-of-mouth. To study IV drug use and HIV-1 infection in relation to onset of AIDS, the subjects are being interviewed, examined, and tested at baseline (recruitment), and periodically thereafter. This report compares information from the self-report baseline interview with independently collected data on physical stigmata of drug injection, T-lymphocyte cell subsets, and HIV-1 serostatus. The evidence generally supports the validity of these self-report data on IV drug use, including data from a year-by-year history of sharing injection equipment, obtained by retrospection at baseline.

A randomized controlled trial of recovery training and self-help for opioid addicts in New England and Hong Kong

The efficacy of a group relapse prevention program, Recovery Training and Self-help (RTSH), was investigated experimentally with opioid addicts in New England and Hong Kong. The experimental program featured weekly attendance at a professionally led recovery-training session, a peer-led self-help style meeting and a weekend recreational activity. Researchers randomly assigned newly recovering opioid addicts (N = 168) to experimental and control conditions, and followed them to assess their outcomes; 98% provided follow-up data. The intervention significantly reduced the probability and extent of relapse and helped unemployed subjects find work. RTSH also significantly reduced self-reported criminality. These findings suggest that relapse prevention programs can be effective in helping opioid addicts achieve long-term recovery.

Approval need in self-reports of addicts and family members

Ample evidence documents the tendency of research subjects to attribute to themselves socially desirable traits and to deny having socially undesirable qualities. This tendency is particularly marked among subjects who are defensive, lacking in self-esteem, or sensitive to status differences. Drug addicts often have all of these characteristics. This paper examines the extent to which need for social approval is reflected in methadone patients' and family members' self-reports of personal and family functioning. Results demonstrate the importance of taking the approval motive into account when conducting research with this population. Addicts tend to deny negative things about themselves and their families, while family members tend to exaggerate their own and their families' positive qualities. Implications for drug treatment programs and researchers are discussed.

Retrospective self-reports by clients differ from original reports: implications for the evaluation of drug treatment programs

In a longitudinal study, 344 drug addicts in treatment described their status at three points in time: at treatment intake, and at 2 months and 8 months after intake. At the final interview they retrospectively described their prior status at treatment entry and 2 months after treatment entry. The retrospective reports were systematically more negative than the original reports in such areas as illicit behavior, sources of income, and life satisfaction. The results were interpreted in terms of an impression management explanation which suggests that clients distort their early self-presentations to access desired treatment services. A consequence of having artificially elevated pretreatment measures is that even if treatment is beneficial, elevated pretreatment measures may obscure true gains during treatment.

Ex-addict versus nonaddict counselors' knowledge of clients' drug use

The accuracy of drug counselors' knowledge of their clients' drug use was assessed to determine whether counselor reports might constitute adequate research and evaluation data. Ex-addict paraprofessionals, non-ex-addict paraprofessionals, and degreed professional counselors (N = 82) reported on the drug use by 302 methadone maintenance and drug-free outpatient clients, as did the clients themselves. Counselor nonresponse rates to individual drug category items were acceptably low (less than or equal to 5%) for all but marijuana/hashish and over-the-counter drugs. Counselors' estimates of drug use rates at a group level were relatively accurate. However, reliability coefficients reflecting accuracy on a case-by-case basis were lower than desirable for use in prediction schemes for individual clients. Ex-addicts were overall somewhat more accurate than the other counselor groups.

Perceived marital and family environment of opiate addicts

Addicts have described their family environment as providing inadequate modeling of social and role skills, while having high expectations for achievement. These self-reports have not been compared to either the reports of other family members or observer ratings of addict families. Observer ratings are important because addicts have also described their families as having significantly less conflict than normative families. We administered the Moos Family Environment Scale (FES) to 73 addicts and found that our addicts' scores supported the previous descriptions of addicts' perceived family environment. Addicts' perceived family environment differed from normative samples. They perceived their family as providing little preparation for social roles, while expecting high achievement. When addicts' wives or mothers completed the FES (n = 27), they disagreed with the addicts' perceptions of having high expectations for achievement in the marriage or family. Relative to their mothers and wives, the addicts seemed to be insensitive to the lack of effective organization and limit setting in either their family of origin or marriage. However, the mothers and wives agreed with the addicts in reporting low levels of conflict, but behavioral ratings of the married addicts and their wives (n = 16) showed a poor correlation between the observed behavior and the couples' perceptions. Furthermore, the level of conflict appeared to be above rather than below normative samples. Thus, addicts' perceptions of their family environment demonstrated significant discrepancies from the perceptions of their wives and mothers and from ratings of their marital behavior.