Alcohol use and psychopathology in opioid addicts on methadone maintenance

Monitoring people at risk of drinking by a rapid urinary ethyl glucuronide test

Alcohol and illicit drug abuse are major public health problems worldwide. Since alcohol is the predominant substance of choice in polydrug abusers, monitoring its use, along with urinary drug screening in patients in rehabilitation programs, appeared to be crucial in identifying patients at risk of alcohol disorders leading to impaired quality of life. Ethyl β-D-6-glucuronide, a non-oxidative, non-volatile, stable and minor direct ethanol metabolite, has a 6h to 4 day window of detection in urine after the last alcohol intake. Each of the 119 subjects (85 males, 34 females) registered with the Public Health Service for Drug Dependence Treatment provided a urine sample for ethylglucoronide (EtG) determination in an immunochemical test with a 500 ng/ml cutoff. All results were evaluated with confirmation criteria of a fully validated gas chromatography/mass spectrometry assay. The diagnostic performance of the EtG immunochemical test was assessed using Receiver Operating Characteristic Curve analysis. The immunochemical test specificity was 100% for EtG urinary values above 500 ng/ml. No false positive results were found. With levels below 500 ng/ml, 12% of the samples were classified as negative. The average consumption of the incorrectly classified subjects was 171 ng/ml, with a misclassification error of 6.5% to 18.5%. High agreement between EtG as determined in an immunochemical test and gas chromatography/mass spectrometry, suggests that the rapid EtG test is a reliable, cost-effective alcohol monitoring assay for patient management in many non-forensic settings, such as drug rehabilitation programs.

Comorbid Psychopathology and Alcohol Use Patterns among Methadone Maintenance Treatment Patients

130 patients from a methadone maintenance treatment program agreed to complete Symptoms Checklist 90-Revised (SCL-90R) and Alcohol Use Disorders Identification Test (AUDIT) self-report scales. Scores higher than the proposed cut-score on SCL-90R scale were observed on depression, obsessions-compulsions, paranoid ideation, anxiety, anger-hostility, somatization, interpersonal sensitivity, and psychoticism subscales. In sum, 42.9% of our sample exhibited depressive symptomatology, 34.9% obsessive-compulsive symptoms, 29.1% somatization, 27.2% anxiety symptoms, 22.2% paranoid ideation, 19% phobic anxiety, 15.1% psychoticism, and 15.1% hostility and 11.9% presented with symptoms of interpersonal sensitivity. Mean score on AUDIT scale was 6.9 ± 7.9. 63.0% of our participants scored below cut-off and were classified as having a low level of alcohol-related problems; 24.4% scored in the range of 8–15 which is an indication of alcohol abuse whereas 12.6% scored 16 and above indicative of serious abuse/addiction. Scores on AUDIT scale were positively correlated with length of time on methadone treatment, but not with length of time on drug use or age of our participants. Positive correlations were observed among AUDIT and SCL-90R scores, namely, with global severity index score, positive symptom distress index, positive symptom total, and all primary symptom dimensions subscales except phobic anxiety.

The Cedar Project: methadone maintenance treatment among young Aboriginal people who use opioids in two Canadian cities

INTRODUCTION AND AIMS

The Cedar Project is a community-based study aiming to identify variables associated with ever being on methadone maintenance treatment (MMT) among young Aboriginal people using drugs and to discuss possible barriers to MMT in this population.

DESIGN AND METHODS

This is a prospective cohort study with recruitment by health-care providers, outreach, and word of mouth in Vancouver and Prince George. Participants included 605 Aboriginal participants who were age 14-30 years, reported illicit drug use in the month prior to enrolment, and provided written informed consent. Variables associated with ever being on MMT were analysed through χ(2) -testing and multivariate logistic regression, limited to people reporting opioid use (n = 397).

RESULTS

Less than half of participants reporting daily injection of opioids had ever been on MMT. In adjusted multivariate logistic regression analyses, older age [odds ratio (OR) 1.17; 95% confidence interval (CI) 1.08-1.28)]; female gender (OR 3.76; 95% CI 2.00-7.07); hepatitis C antibody positivity (OR 2.76; 95% CI 1.53-4.95); and daily opioid injection (OR 2.59; 95% CI 1.46-4.61) were positively associated with ever being on MMT. Weekly or more alcohol use (OR 0.43; 95% CI 0.21-0.87) was negatively associated with ever being on MMT.

DISCUSSION AND CONCLUSION

MMT access by young Aboriginal people is low. The associations between MMT use and other variables need further study to steer efforts directed at recruitment into MMT. The removal of barriers to MMT and inclusion of young Aboriginal people in the development of treatment programs based on Indigenous values are urgently required to help Aboriginal people who use drugs.

[Multiple psychoactive substance use (alcohol, tobacco and cannabis) in the French general population in 2005]

OBJECTIVE

To quantify the different forms of polydrug use in the French population and the principal factors associated with it.

METHODS

Data came from the Baromètre Santé 2005, a general population study. Polydrug use was approached by 2 indicators: regular use of at least 2 products among alcohol, tobacco and cannabis, and the use during the year of at least 2 illegal drugs besides cannabis (not necessarily concomitantly).

RESULTS

Regular use of some combination of alcohol, tobacco and cannabis was reported by 8.3% of the population. Those aged 20-24 years combined tobacco and cannabis most frequently, with 11.6% reporting this joint use. Regular consumption of all 3 products was rare, reported by less than 1% of those aged 15-64 years. It was highest among those aged 20-29 years, but still less than 2% of the age group. The principal combination for those aged 35 years or older was alcohol and tobacco, and those in this group rarely combined cannabis with another substance. There was a strong association between cannabis use and use of other illicit psychoactive substances. Lifetime use of illicit psychoactive substances except for cannabis was reported by 10.0% of the 15-34 year-olds; for use during the previous year, it was 2.3%. The factors associated with these practices were unemployment, male gender, and youth. Postsecondary education appeared to distance young adults from the different forms of polydrug use.

DISCUSSION

Because use of multiple psychoactive substances is often associated with risk-taking or vulnerability, particular attention to these practices is justified. Surveys in the general population do not cover the most vulnerable or most "desocialized" populations and do not allow the most dangerous forms of polydrug use to be described. They supply useful information for assessing the extent of the most common combined uses in the population and their probable health and social repercussions.

Alcohol and cocaine use and abuse among opioid addicts engaged in a methadone maintenance treatment program

Alcohol and cocaine abuse result in unsatisfactory treatment outcomes for heroin and illicit opioid addicts engaged in Methadone Maintenance Treatment Programs (MMTPs). This study aims to clarify the impact of MMT, which focuses on cessation of opioid abuse and diminishing psychopathology to acceptable levels (stabilization) on alcohol and cocaine abuse. Of specific interest was whether reduction of polysubstance abuse and associated psychopathological complications diminished illicit opioid abuse and/or increased retention in treatment. Changes in cocaine and alcohol use that occurred in 53 heroin addicts who had been stabilized were monitored. A control group was composed of patients terminated from treatment due to noncompliance with treatment recommendations, poor attendance, or failure to have opioid abuse stabilized, within a year. The association of psychiatric severity with alcohol and cocaine abuse in these methadone maintained patients was assessed. Cessation of illicit opioid abuse and retention in treatment are positively correlated with decrease in alcohol and cocaine abuse and the absence of the psychosocial complications associated with such abuse.

Alcohol use outcomes and heavy drinking at 4-5 years among a treatment sample of drug misusers

This paper investigates alcohol outcomes and heavy drinking among 418 drug misusers from the National Treatment Outcome Research Study who completed followup interviews at 1, 2, and 4-5 years. About a quarter of the sample were drinking heavily at intake. Alcohol consumption at followup was predicted by drinking prior to intake, and about a quarter of those who were classified as alcohol abstainers, medium-level drinkers, or heavy drinkers at intake, remained in the same drinking category at all assessment points. Drinking outcomes were not related to opioid use. Heavy drinkers at followup were more likely to be using non-opioid drugs. The poor drinking outcomes are a matter for concern. Drug misusers with concurrent alcohol problems may require special treatment provision. The extent of heavy drinking among drug misusers both before and after treatment indicates a need to develop and strengthen programs and interventions to tackle alcohol-related problems in this patient group.

The National Treatment Outcome Research Study (NTORS): 4-5 year follow-up results

AIMS

The National Treatment Outcome Research Study (NTORS) is the first prospective national study of treatment outcome among drug misusers in the United Kingdom. NTORS investigates outcomes for drug misusers treated in existing services in residential and community settings.

DESIGN, SETTING AND PARTICIPANTS

The study used a longitudinal, prospective cohort design. Data were collected by structured interviews at intake to treatment, 1 year, 2 years and at 4-5 years. The sample comprised 418 patients from 54 agencies and four treatment modalities.

MEASUREMENTS

Measures were taken of illicit drug use, injecting and sharing injecting equipment, alcohol use, psychological health and crime.

FINDINGS

Rates of abstinence from illicit drugs increased after treatment among patients from both residential and community (methadone) programmes. Reductions were found for frequency of use of heroin, non-prescribed methadone, benzodiazepines, injecting and sharing of injecting equipment. For most variables, reductions were evident at 1 year with outcomes remaining at about the 1 year level or with further reductions. Crack cocaine and alcohol outcomes at 4-5 years were not significantly different from intake.

CONCLUSIONS

Substantial reductions across a range of problem behaviours were found 4-5 years after patients were admitted to national treatment programmes delivered under day-to-day conditions. The less satisfactory outcomes for heavy drinking and use of crack cocaine suggest the need for services to be modified to tackle these problems more effectively. Despite differences between the United Kingdom and the United States in patient populations and in treatment programmes, there are many similarities between the two countries in outcomes from large-scale, multi-site studies.

Schizoid phenomena in substance abusers

It is hypothesized that the spectrum of schizoid disorders, schizoid phenomena, and the underlying psychodynamics can often be found in the gamut of addictions and stand in the way of recovery. Features of schizoidness, the varieties of schizoid presentations, the etiology and pathogenesis of drug/alcohol abuse in the schizoid, and readily clinically apparent psychodynamic features are discussed. Schizoid phenomena can be dealt with effectively with an informed psychotherapy.

Dual dependence: assessment of dependence upon alcohol and illicit drugs, and the relationship of alcohol dependence among drug misusers to patterns of drinking, illicit drug use and health problems

AIMS

The study investigates severity of alcohol dependence among drug misusers. Specifically, it investigates the inter-relationship of alcohol and drug dependence and associations with alcohol consumption, drug consumption and substance-related problems.

DESIGN, SETTING, PARTICIPANTS

The sample comprised 735 people seeking treatment for drug misuse problems, who were current (last 90 days) drinkers.

MEASUREMENTS

Data were collected by structured face-to-face interviews. Dependence upon illicit drugs and upon alcohol was measured by the Severity of Dependence Scale (SDS).

FINDINGS

Three groups of drinkers were identified: non-alcohol-dependent drug misusers (63%); low-dependence (19%); and high-dependence (18%). Many drug misusers were drinking excessively and alcohol dependence was related to patterns of alcohol and drug consumption. High-dependence drinkers were more likely to drink extra-strength beer; they were less frequent users of heroin and crack cocaine but more frequent users of benzodiazepines, amphetamines and cocaine powder; they reported more psychological and physical health problems. The SDS was found to have good reliability and validity as a measure of alcohol dependence. SDS scores for alcohol and drug dependence were unrelated.

CONCLUSIONS

Alcohol use is an important and under-rated problem in the treatment of drug misusers. A comprehensive assessment of alcohol use among drug misusers should include separate assessments of alcohol consumption, alcohol-related problems and severity of alcohol dependence.

Excessive alcohol consumption and drinking expectations among clients in methadone maintenance

Excessive alcohol consumption and related problems are common among clients in methadone maintenance treatment (MMT), yet relatively little is known about the psychological and social determinants of alcohol-related attitudes and behaviors during treatment. This study reports on the prevalence of alcohol dependence, patterns of alcohol consumption and preliminary findings about clients' beliefs that they will change their drinking behavior in the future. Data were gathered from personal interviews with 66 clients attending a MMT program in South London (some 80.5% of the eligible caseload). Forty-one percent of the overall sample met DSM-IV criteria for alcohol dependence in the past 12 months. Among clients who reported drinking in the past month (n = 50), 54% were classified as dependent, and these clients reported consuming an average of 23.5 UK standard units of absolute alcohol (188g/6.58 ounces) on a typical drinking day in the past month. Exploratory analyses suggested that expectations to change drinking behavior were predicted by subjective norms (social pressures), perceived functions of alcohol use, past drinking levels and current dose of methadone. Clinicians engaged in alcohol problems assessment and counseling during MMT could usefully examine these influences to strengthen treatment provision.

MMPI-2 typology of pregnant drug-dependent women in treatment

The present study examined the validity of Minnesota Multiphasic Personality Inventory-2 (MMPI-2) typology for pregnant drug-dependent women. A 3-cluster solution based on 7 MMPI-2 clinical scales emerged as the best model and was replicated across split-half samples and different primary substance-use diagnoses and treatment modalities. The 3 subtypes identified included Type I (n = 40, 24%) with no clinical elevation, Type II (n = 72, 42%) with elevated psychopathic deviate scale, and Type III (n = 58, 34%) with elevations on all 7 scales. Analyses with interview and self-report measures showed good concurrent validity. Type II had higher retention than Type I and Type III across methadone and medication-free treatments, showing some predictive validity. An a priori method for classifying new cases on the basis of the proposed typology was developed and validated. Study findings support MMPI-2's use with pregnant drug-dependent women for assessment and possibly treatment planning.

Patterns of drinking and drinking outcomes among drug misusers. 1-year follow-up results

This article investigates patterns of drinking and drinking outcomes among 753 drug-misusing clients recruited to the National Treatment Outcome Research Study (NTORS). More than one third of those who were drinking at intake reported problematic or highly problematic patterns of alcohol consumption. About one third of the sample were abstinent from alcohol at intake and at follow-up. Some improvements in drinking behavior were found at 1-year follow-up, especially among the heaviest and most problematic drinkers. Improvements were specifically related to patterns of preintake drinking behavior. The majority of clients made little change to their pattern of pretreatment drinking behavior and the continued heavy drinking of many drinkers at follow-up is a disappointing finding. Drinking problems have been given insufficient attention in the treatment of illicit substance misuse problems, and efforts should be made to develop and strengthen the assessment and treatment of drinking problems among drug misusers.

Personality and psychopathology of drug addicts in Puerto Rico

Drug abuse is one of the most pressing sociomedical problems of society. The purpose of this study was to examine the personality and psychopathology of addicts. 229 addicts in treatment programs scored high on Neuroticism and on the Lie Scale and low on Psychoticism and Extraversion on the Eysenck Personality Questionnaire for Puerto Rico. An Addiction Scale, based on a factor analysis, showed a high component of Neuroticism items.

Heavy drinking, alcohol-dependent vs. nondependent methadone-maintenance clients: a follow-up study

This study of methadone-maintenance clients interviewed approximately 1 year after discharge from treatment revealed that outcomes differed between heavy-drinking clients who are alcohol dependent and those who are not. Alcohol-dependent clients seem to benefit more from treatment but continue to have severe cocaine-use problems, suggesting they also may be cocaine dependent. The results emphasized the value in differentiating between these types of drinking clients, and they suggest that failure to do so may account for earlier contradictory results about the role alcohol consumption has in treatment outcomes for methadone-maintenance clients.

Correlates of alcohol use among methadone patients

This study examines the predictors of alcoholism among 201 patients from three methadone maintenance treatment programs (MMTPs) in New York City. Using the Michigan Alcohol Screening Test, one-fifth of the sample met criteria for alcohol dependence. Few subjects were currently enrolled in any form of chemical dependency treatment other than MMTP. Alcoholics started to use alcohol at an early age, and almost every alcoholic subject admitted to alcohol abuse before entering MMTPs. More alcoholics than nonalcoholics reported symptoms of somatization, obsessive-compulsive behavior, depression, phobic anxiety, and psychosis. Logistic regression indicated that alcoholism among MMTP patients was associated with years drinking, years of sharing needles, utilization of drug abuse detoxification but not alcohol detoxification, smaller increases in methadone dosage over time, and psychiatric symptomatology. Findings are discussed in terms of their implications for designing more efficacious treatment approaches for dually addicted patients in MMTPs.

Correlates of heavy drinking and alcohol related problems among men and women in drug treatment programs

A series of analyses were conducted to explore if there were significant differences in heavy drinking and alcohol-related problems in clients admitted to different types of drug treatment programs and whether such differences, if found, could be attributed to variation in social characteristics, drug use behavior, drinking norms, drinking contexts, or in reasons for combining alcohol and drug use. Men and women (N = 246) in four types of publicly funded treatment programs were interviewed at intake regarding drinking and drug use patterns and related problems. The results of the study showed significant differences in drinking behavior and alcohol-related problems of clients in different treatment modalities. Men in a county jail substance abuse program exhibited the highest frequency of heavy drinking and highest rates of alcohol problems; clients of methadone programs reported the lowest rates and those in therapeutic communities described intermediate rates. A series of regression analyses showed that the only significant predictors of the frequency of heavier drinking and drunkenness were drinking context and reasons for combining alcohol and drug use. In addition, age (youthfulness) was associated with the frequency of getting drunk. The most powerful predictors of alcohol-related problems were the frequency of getting drunk and drinking to enhance the effects of other drugs. Heavy drinking and drinking to prevent getting sick from drugs were also significantly associated with drinking problems. The frequency of drug use (by specific type) and most social characteristics showed no direct association with drinking patterns or problems.