In young women, a link between childhood abuse and subliminal processing of aversive cues is moderated by impulsivity

BACKGROUND

Childhood maltreatment is a serious public health concern. The association between child maltreatment, adverse behaviors, mental health outcomes, and alterations to brain function and structure have begun to be characterized. Less is known about the specific associations of maltreatment subtypes with cue-response to evocative cues and the moderating effects of confounding mental health/behavioral variables.

METHODS

Fifty-four emerging adult women (aged 18-24) completed assessments for behaviors, mental health, and childhood maltreatment. They participated in a fMRI task featuring passive viewing of evocative (33 ms) cues presented by "backward masking" to prevent conscious processing. Correlations of abuse/neglect scores, behavioral/mental health factors, and brain function were assessed. Follow-up analyses investigated the moderating effects of behavioral/mental health factors on maltreatment and brain relationships.

RESULTS

Greater frequency of childhood abuse and neglect were correlated with higher scores of impulsivity, depressive symptoms, and anxious attachment. Childhood abuse was positively associated with increased medial orbitofrontal cortical (mOFC) response to aversive (vs. neutral) cues. Among the behavioral/mental health variables, only impulsivity appeared to have a moderating effect on the relationship between childhood abuse and brain response to aversive cues.

CONCLUSIONS

The link between childhood abuse and a heightened mOFC response to "unseen" aversive stimuli, moderated by impulsivity, adds to the growing literature on the impact of prior adversity on brain function. These findings offer further understanding for the way in which childhood maltreatment affects the brain processing of negative stimuli, helping to explain the well-documented link between childhood maltreatment and a variety of adverse outcomes in adulthood.

Psychotherapy for cocaine dependence

Dependence on cocaine is a new disorder for contemporary US clinicians. Until the 1980s sufficient quantities of the drug were not available to produce a true dependence. Thus far the only models for pharmacological intervention involve an interaction between medication and psychotherapy; that is, medication may be able to facilitate a drug-free interval during which time the patient can be engaged in psychotherapy. Psychotherapy programmes for cocaine dependence have generally been modelled on group-oriented treatments of the type used by Alcoholics Anonymous. Controlled studies of therapy programmes for cocaine dependence are currently being conducted and one prospective random-assignment study comparing day hospital and in-patient rehabilitation shows generally good results. Behavioural treatments aimed at reducing or extinguishing conditioned responses in cocaine addicts have also shown efficacy in a controlled study. More general relapse prevention procedures including rehearsal and role-playing are also used in the treatment of cocaine dependence. Combinations of psychotherapy and pharmacotherapy have so far shown the most promise in the treatment of this disorder.

Brain activity during simulated deception: an event-related functional magnetic resonance study

TheGuilty Knowledge Test (GKT) has been used extensively to model deception. An association between the brain evoked response potentials and lying on the GKT suggests that deception may be associated with changes in other measures of brain activity such as regional blood flow that could be anatomically localized with event-related functional magnetic resonance imaging (fMRI). Blood oxygenation level-dependent fMRI contrasts between deceptive and truthful responses were measured with a 4 Tesla scanner in 18 participants performing the GKT and analyzed using statistical parametric mapping. Increased activity in the anterior cingulate cortex (ACC), the superior frontal gyrus (SFG), and the left premotor, motor, and anterior parietal cortex was specifically associated with deceptive responses. The results indicate that: (a) cognitive differences between deception and truth have neural correlates detectable by fMRI, (b) inhibition of the truthful response may be a basic component of intentional deception, and (c) ACC and SFG are components of the basic neural circuitry for deception.

Three decision-making tasks in cocaine-dependent patients: do they measure the same construct?

AIMS

Substance-abusing populations perform poorly on decision-making tasks related to delay and risk. These tasks include: (1) the Delay Discounting Procedure (DDP), in which choices are made between smaller-sooner and later-larger rewards, (2) the Gambling Task (GT), in which choices are made between alternatives varying in pay-off and punishment, and (3) the Rogers Decision-Making Task (RDMT) in which subjects choose between higher or lower probability gambles. We examine the interrelationship among these tasks.

DESIGN

A test battery was created which included the DDP, GT and RDMT, as well as measures of impulsivity, intellectual functioning and drug use.

SETTING

Subjects completed the test battery at an outpatient center, prior to beginning 12 weeks of treatment.

PARTICIPANTS

Thirty-two treatment-seeking cocaine dependent individuals (primarily African-American males) participated.

FINDINGS

Performance on the GT was significantly correlated with performance on the DDP (r = 0.37; p = 0.04). Reaction times on the RDMT correlated with performance on the GT (r = 0.36, p = 0.04) and DDP (r = 0.33, p = 0.07), but actual choices on the RDMT did not (p > 0.9 for both). While no significant relationships were observed between task performance and impulsivity, IQ estimate was positively correlated with both the GT (r = 0.44, p = 0.01) and RDMT (r = 0.41, p = 0.021). Split half reliability data indicated higher reliability when using only data from the latter half of the GT (r = 0.92 vs. r = 0.80).

CONCLUSIONS

These data offer preliminary evidence of overlap in the decision-making functioning tapped by these tasks. Possible implications for drug-taking behavior are discussed.

Mood state and recent cocaine use are not associated with levels of cocaine cue reactivity

Eighty-one cocaine-dependent outpatients were assessed for their reactions to cocaine-related cues in a laboratory setting. All subjects contributed a urine sample prior to the session. Compared with non-drug control cues, the cocaine stimuli produced increases in physiological arousal, self-reports of high, craving, and withdrawal, and self-reports of negative mood. Subjects who tested cocaine-positive on the day of testing differed only in skin resistance responding from those who tested cocaine-negative. Changes in cue-induced physiological and self-report measures were also not associated with between-subject variations in mood as measured by the Profile of Mood States (POMS) questionnaire administered prior to cue assessment. Thus, variations in baseline mood and recent cocaine use history do not introduce an additional source of variability in cue reactivity measurements. However, negative mood states at the start of a session were associated with higher levels of self-reported craving, high, and withdrawal both before and after cue exposure.

Comparing levels of cocaine cue reactivity in male and female outpatients

Thirty-eight female and 26 male cocaine-dependent outpatients were exposed to cocaine cues in a laboratory setting. Stimuli consisted of an audiotape of patients discussing cocaine use, a videotape of simulated cocaine preparation and use, and the handling of cocaine paraphernalia. Overall, the stimuli produced significant decreases in skin temperature and skin resistance, and significant increases in heart rate, self-reported drug states (high, craving, and withdrawal), and self-reported negative moods. Females were more likely to report increased craving in response to the cues than males, but there were no other gender differences in any of the responses. Levels of reactivity in females were comparable to the results of previous studies with all male samples. These results support the use of a constant set of cues in future treatment studies employing gender-balanced patient samples.

Limbic activation during cue-induced cocaine craving

OBJECTIVE

Since signals for cocaine induce limbic brain activation in animals and cocaine craving in humans, the objective of this study was to test whether limbic activation occurs during cue-induced craving in humans.

METHOD

Using positron emission tomography, the researchers measured relative regional cerebral blood flow (CBF) in limbic and comparison brain regions of 14 detoxified male cocaine users and six cocaine-naive comparison subjects during exposure to both non-drug-related and cocaine-related videos and during resting baseline conditions.

RESULTS

During the cocaine video, the cocaine users experienced craving and showed a pattern of increases in limbic (amygdala and anterior cingulate) CBF and decreases in basal ganglia CBF relative to their responses to the non-drug video. This pattern did not occur in the cocaine-naive comparison subjects, and the two groups did not differ in their responses in the comparison regions (i.e., the dorsolateral prefrontal cortex, cerebellum, thalamus, and visual cortex).

CONCLUSIONS

These findings indicate that limbic activation is one component of cue-induced cocaine craving. Limbic activation may be similarly involved in appetitive craving for other drugs and for natural rewards.

Laboratory exposure to cocaine cues does not increase cocaine use by outpatient subjects

Sixty-nine cocaine-dependent outpatients were exposed to cocaine-related stimuli and to non-drug events on separate days. Cocaine cue sessions were always followed by a meeting with a trained clinician designed to eliminate any craving that remained following cue presentations. Urine samples were collected before each laboratory session and 1 to 3 days later. Neither rates of cocaine use nor average urine metabolite values differed following the two sessions. Nearly 90% of subjects had the same urine test result both before and after the cocaine cue session. Thus, laboratory presentation of cocaine cues to outpatient subjects did not increase their risk of subsequent drug-taking. These results suggest that with proper clinical protections, cue exposure can be used as a treatment outcome measure and a behavioral intervention in outpatient settings without increasing the risk of drug use.

Conditioning factors in drug abuse: can they explain compulsion?

There is a good deal of clinical evidence suggesting that compulsion to resume drug taking is an important part of the addiction syndrome. The symptoms comprising motivation to resume drug use, namely craving and compulsion, have been studied experimentally in human subjects. While much work remains to be done, there is evidence showing that these symptoms are influenced by learning. The research has been guided by animal studies demonstrating that drug effects can be conditioned. Much attention has been directed toward demonstrating the existence of drug conditioning in human addicts and exploring the neurological structures that may underlie such learned responses. We do not yet know the relative importance of learning in the overall phenomenon of relapse, and treatments based on conditioning principles are still under investigation.

Relationships among physiological and self-report responses produced by cocaine-related cues

In response to cocaine cues, 150 subjects with a history of cocaine abuse showed decreases in skin temperature and skin resistance and increases in heart rate and reported craving, high, and withdrawal responses. These responses were consistent across four years of data collection. Craving reports were not consistently associated with either high or withdrawal responses, and many subjects endorsed increases in both high and withdrawal states. Correlations revealed no pattern of association among physiological variables and responding did not differ between subjects who did and those who did not report increases in each of the drug states. Finally, physiological variables did not predict reported drug states in discriminant analyses. Cocaine cue reactivity cannot be easily related to a unitary state of high, withdrawal, or craving. It is suggested that future studies focus more on the prediction and measurement of treatment outcome than on the form of cue responses.

Failure of ritanserin to block cocaine cue reactivity in humans

As part of a double-blind placebo-controlled study of the effects of ritanserin on cocaine use and craving, reactivity to cocaine-related events was assessed both before and during medication. Twenty-two patients receiving ritanserin and 23 receiving placebo were exposed to cocaine cues while continuous measures of heart rate, skin temperature, and skin resistance were taken. Self-reports of high, withdrawal, and craving were also collected. The cues produced significant physiological responding as well as significant increases in high and craving during both sessions. Ritanserin reduced cue-elicited decreases in skin temperature, but had no effect on heart rate and skin resistance or on cue-induced high and craving. The results demonstrate that cue reactivity is a robust phenomenon across two assessment sessions but fail to support the use of ritanserin as a means of reducing cue-elicited drug states.

Effect of smoking cues and cigarette availability on craving and smoking behavior

This study examined whether smokers respond differently to smoking cues than to affectively neutral or unpleasant cues without smoking content, and whether reactivity is affected by expectations regarding the opportunity to smoke. Expectancy was manipulated by telling subjects in group SMOKE that they could smoke, and subjects in group NO SMOKE that they could not smoke following each cue-reactivity session. The dependent variables were subjective ratings of "desire to smoke", "high", "withdrawal", and mood, as well as latency to initiate smoking measured in group SMOKE. Statistical analyses demonstrated that only group SMOKE (a) reported greater "desire to smoke" and "withdrawal" to the smoking cues compared to the baseline, (b) reported greater "desire to smoke" to the smoking cues than to the unpleasant or to the neutral cues, and (c) smoked faster after the smoking cues than after the neutral cues. Both groups rated the unpleasant cues as affectively more negative than the neutral cues. The data suggest that the impact of drug-cues on craving and subsequent drug-use is due to their drug-related content, and not to negative affect. Furthermore, the impact of drug-related cues appears to be influenced by perceived drug-availability.

Can induced moods trigger drug-related responses in opiate abuse patients?

This study investigated the ability of four hypnotically induced mood states (euphoria, depression, anxiety, and anger) to trigger craving and other drug-related conditioned responses in detoxified opiate abuse patients. Hypnotically induced depression produced significant increases in drug craving for opiates. Depression also tended to increase global self-ratings of opiate withdrawal. Other trends included increases in self-rated craving by induced anxiety and increases in withdrawal symptoms by induced anger. These results suggest that negative mood states, perhaps in the context of repeated attempts at self-medication, may become conditioned stimuli capable of triggering craving and other drug-related conditioned responses. The ability of depression to produce reliable effects in this particular patient group may reflect the high lifetime prevalence of depression diagnoses for this sample. The implications of these findings for therapeutic strategies are discussed.

Role reversals in families of substance misusers: a transgenerational phenomenon

Fifty adult methadone maintained opiate misusers were seen with their spouse and/or family of origin in outpatient therapy as part of a Veterans Administration Research project supported by NIDA. Family treatment was offered in an attempt to improve and enhance family relationships/social supports and to aid in the decrease or cessation of drug use. In this study, 42 of the 50 patients had parents who were substance misusers. The subjects were evaluated by constructing a Three-Generational Family Tree to define and clarify the nature of problems across the generations. Success or failure was measured by the Addiction Severity Index (ASI) which assessed drug use, problems with family, health, social relationships, legal difficulties, and employment as well as psychiatric symptoms. A recurrent problem of the "absent father" was identified across both generations studied. Thirty of the 50 opiate misusing men had absent fathers (usually due to alcohol or other drug misuse) and 27 of these 30 became absent fathers (also usually due to substance misuse) when they had children of their own. The absence of a father produced major developmental problems seen in these families. Particularly important was the "Parentified Child," forced to prematurely assume adult responsibilities. This age inappropriate role assumption was common in both the patients and their children, and was seen as a contributor to the initiation of drug misuse. A structured clinical intervention is described using the three-generational family tree to bring out these relationship issues, followed by supportive family therapy to restructure wounded family relationships from the family of origin and to bring about appropriate role expectations in the marital families. The findings suggest an improvement in legal difficulties, drug use, and psychiatric symptoms.

Using cue reactivity to screen medications for cocaine abuse: a test of amantadine hydrochloride

The use of responding to drug-related stimuli as a dependent measure for studies of anticraving medications was assessed. Cocaine-dependent subjects receiving either amantadine hydrochloride, a putative anticraving agent, or placebo were exposed to drug-related cues prior to and 7 days after the initiation of the medication. Measurements of heart rate, skin resistance, skin temperature, and self-reported craving were taken during each stimulus session. Amantadine increased physiological reactivity to the drug-related cues compared to the placebo while having no effect on craving. Although the results discourage the use of amantadine as an anticraving medication, they do suggest that responses elicited by drug-related stimuli provide a valuable set of dependent measures for use in future medication trials of anticraving agents.

Classical conditioning in drug-dependent humans

Repetitive use of psychoactive drugs produces a variety of learned behaviors. These can be classified in the laboratory according to an operant/classical paradigm, but in vivo the two types of learning overlap. The classically conditioned responses produced by drugs are complex and bi-directional. There has been progress in classifying and predicting the types of conditioned responses, but little is known of mechanisms. New techniques for understanding brain function such as micro-dialysis probes in animals and advanced imaging techniques (PET and SPECT) in human subjects may be utilized in conditioning paradigms to "open the black box." Because the existence of conditioned responses in drug users is now well established, clinical studies have been instituted to determine whether modification of conditioned responses can influence clinical outcome. A recently completed study in cocaine addicts has produced evidence that outcome can be improved by a passive extinction technique over an 8-week outpatient treatment program.

Conditioned responses to cocaine-related stimuli in cocaine abuse patients

Subjects with a history of free-basing and smoking cocaine but no history of opiate injections were exposed to three sets of stimuli. They received cocaine-related stimuli in one session, opiate-related stimuli in a second session, and non-drug stimuli on a third occasion. Compared to the opiate and non-drug cues, the cocaine-related events caused reliable decreases in skin temperature and skin resistance, and reliable increases in heart rate, self-reported cocaine craving, and self-reported cocaine withdrawal. Furthermore, control subjects lacking a history of cocaine or opiate use failed to show such differential responding. These results suggest that cocaine-related stimuli evoke Pavlovian conditioned responses in cocaine abuse patients. Such findings encourage continuing efforts to develop drug treatment strategies based on conditioning principles.

Developing and evaluating new treatments for alcoholism and cocaine dependence

Progress in the treatment of any disorder requires the development of methods for evaluation as well as the development of potentially effective new treatments. In this chapter we briefly describe a new instrument to be used in the measurement of substance abuse treatment, the Treatment Services Review. Some of the potential problems in evaluation research are discussed, such as the tendency for more severely ill patients to be more willing to give up their right to choose treatment and agree to randomization. These unexpected tendencies in study volunteers limit the generalizability of treatment research. Evaluation techniques are illustrated by two studies comparing inpatient and outpatient rehabilitation. The results for both alcohol dependence and cocaine dependence were positive, but there was no evidence of a significant advantage for one treatment environment over the other. This has important implications for program funding. We also describe our search for a new treatment technique based on a conditioning model for cocaine dependence. Pilot studies suggested an improvement in treatment outcome for the patients receiving the experimental treatment, and therefore, a prospective study with random assignment was conducted.

Cue reactivity in addictive behaviors: theoretical and treatment implications

Several learning theory based models propose that substance users may have conditioned reactions to stimuli (cues) associated with substance use and that these reactions may increase the probability of relapse. The conditioned withdrawal, conditioned compensatory response, and appetitive motivational models were evaluated in light of empirical evidence from cue reactivity studies with alcoholics, smokers, opiate users, and cocaine users. The nature of the stimuli that elicit reactivity and the nature of the responses elicited are most consistent with an appetitive motivational model and do not appear to support the other two models. A few studies have been conducted or are underway that investigate the use of cue exposure with response prevention as a treatment to decrease cue reactivity. Preliminary work with alcoholics, opiate users and cocaine users is promising but insufficient evidence exists to evaluate this approach. The implications for theory and treatment are discussed.

Integrating systemic cue exposure with standard treatment in recovering drug dependent patients

Repeated drug administration readily produces classically conditioned responses in animal and human experimental studies. The majority of patients applying for treatment of drug dependence show both autonomic and subjective responses when exposed to drug-related stimuli. These responses are presumed to have been conditioned during a period of active drug use, persist after traditional treatment for drug dependence, and may constitute one of several factors which predispose to relapse. Preliminary data are presented from a novel treatment approach which is designed to test whether drug-conditioned responses can be reduced or extinguished by systematic exposure to drug-related cues and whether such extinction improves the overall results of treatment.

Pharmacological and behavioral treatments of cocaine dependence: controlled studies

The cocaine epidemic has stimulated novel treatments aimed at reducing relapse to this extremely addicting drug. After detoxification and standard treatment, former cocaine users continue to exhibit strong cocaine craving and physiological changes when presented with cocaine-related stimuli. Because these conditioned responses may increase the risk of relapse, a new treatment has been developed to extinguish such responses. The extinction process, consisting of repeated presentations of cocaine-related stimuli until the stimuli gradually lose their ability to evoke conditioned responses, is integrated into a comprehensive rehabilitation program. Cocaine dependence is often combined with opiate dependence. Desipramine has been added to methadone maintenance in an attempt to reduce dependence on both substances. Methadone impedes catabolism of desipramine so that relatively low doses of desipramine may produce antidepressant effects and possibly reduce the desire to use cocaine. Preliminary evidence from a placebo-controlled study of desipramine in combination with methadone suggests that desipramine produces significant improvements in psychological functioning, but its effects on reduction of cocaine use are less dramatic.

The value of DSM-III for psychotherapy. A feasibility study

Establishing the usefulness of DSM-III for psychotherapy will probably require numerous studies. This paper reports a feasibility study for one kind of investigation: the use of clinical records to survey the DSM-III diagnoses and therapy outcome of 30 patients who had outpatient psychotherapy. We were interested in what range of DSM-III diagnoses was represented by patients in outpatient therapy; whether judgments of diagnosis and outcome could be made reliably from clinical records; how well patients in the therapy fit DSM-III diagnoses; if patients did not fit well, why not? We found that an exploration of the relationship between DSM-III diagnosis and outcome from clinical records is feasible; a relatively wide range (13) of DSM-III diagnoses was represented by the 30 patients; 80% of the patients fit well or moderately well into a DSM-III diagnosis; most of the 20% who did not fit well represent the class of problems of living, which does not mean, however, that their problems were minor or unimportant; in some cases the diagnosis--even when it fit the patient well--did not express the essence of the problem for which he or she was to be treated; there was a small correlation (.19) between the patient's rating on axis V and therapy outcome. The findings are discussed in terms of the pro and con arguments that have been made about DSM-III.

Role of conditioning factors in the development of drug dependence

Conditioned opioid phenomena have now been documented in both opiate-dependent and abstinent patients. Although the existence of these phenomena is generally accepted, their potential role in drug use and relapse is still under study. Our own research indicates that both physiologic and subjective responses may be conditioned, and that these responses are present in a significant proportion of patients who abuse opiates. Patients' responsivity (for example, craving or a reduction in skin temperature) may vary depending upon mood, cognitive set, and the individual relevance of the drug-related stimuli. Extinction procedures have been developed that are effective in reducing both subjective and physiologic conditioned responses. The clinical impact of these extinction procedures is now being assessed in a large-scale treatment-outcome study with abstinent patients. The results of this project will help determine the actual clinical significance of these complex but potentially important phenomena.

Conditioned responses in a methadone population. A comparison of laboratory, clinic, and natural settings

The incidence of conditioned high, craving, and withdrawal in methadone-maintained patients was compared across three settings: an artificial laboratory setting, clinic extinction sessions, and in self-reports from the natural home environment. A significant proportion of methadone patients showed increased craving and withdrawal in response to drug-related stimuli, even in the artificial laboratory setting. As stimulus opportunities became more varied (clinic extinction sessions) and closer to those in the patient's own home environment, the proportion of patients experiencing subjective craving and withdrawal increased. These results are discussed in terms of the nature of, and inter-relationships among, the conditioned responses found in opiate abusers and the potential role of these responses in relapse to drug use in the abstinent patient.

Extinguishing conditioned responses during opiate dependence treatment turning laboratory findings into clinical procedures

Former opiate addicts (even those who have remained drug-free for several months) often report symptoms of opiate withdrawal (eg. nausea, gooseflesh, etc.) and/or intense drug craving when exposed to stimuli previously associated with the act of drug injection. This phenomenon of learned or "conditioned" withdrawal/craving is widely reported and is potentially important in explaining relapse to drug use. However, no effective, clinically applicable intervention had been available to "extinguish" these conditioned phenomena. An ongoing project to develop such an intervention has revealed: Conditioned withdrawal and craving are pervasive among both methadone maintained patients (even though actual physical withdrawal is blocked) and drug-free patients even after 30 days of inpatient Therapeutic Community rehabilitation. Conditioned withdrawal and craving can be effectively extinguished in an intensive, three-week, inpatient procedure. Emotional states such as anger, depression and anxiety can elicit and exacerbate conditioned withdrawal and craving. They may also act as an integral part of a conditioned stimulus complex. The authors discuss the problems associated with turning a laboratory-based procedure into a clinical intervention. Encouraging preliminary results from an integrated treatment "package" are presented.

Behavioral therapies for substance abuse

The authors review more than two decades of research in the use of behavioral interventions for the treatment of drug and alcohol abuse. This survey covers major areas of research activity, including the use of aversive stimuli (chemical, electrical, and covert), skills training, contingency management, extinction/desensitization, and combined behavioral treatments. The reviewers conclude that while many of these treatment interventions hold promise, few have been fully explored with the use of properly controlled group studies. Suggestions are offered which may facilitate research and aid in the evaluation of behavioral interventions for substance abuse.

Aversive therapies for substance abuse: do they work?

More than two decades of research in the use of aversive behavioral interventions for the treatment of drug and alcohol abuse is reviewed. This survey covers only the areas of conditioned aversive states (using chemical or electrical stimuli) and extinction/desensitization. While many of these treatment interventions hold promise, none has been fully explored with properly controlled group studies. Suggestions are offered which may aid in the evaluation of behavioral interventions for substance abuse and increase the clinical impact of this work.

Use of naltrexone to extinguish opioid-conditioned responses

Opioid use generates many conditioned responses associated with the sights, sounds, smells, and rituals experienced during addiction. Environmental stimuli alone can provoke withdrawal symptoms and contribute to relapses in treated patients. The use of naltrexone in a program designed to progressively extinguish conditioned drug responses is described. Since naltrexone effectively blocks opiate effects at the receptor level, heroin injections produce no euphoria. Unreinforced self-injections diminish the responses learned during the period of drug abuse and protect the patient from rapid readdiction. Patients are confronted with a hierarchical set of drug-related stimuli and taught a muscular relaxation procedure to relieve arousal and discomfort. The continued administration of naltrexone, the self-induced relaxation response, and the repeated presentation of drug-related stimuli result in the eventual diminution or extinction of the arousal properties of the imagery and environmental stimuli associated with addiction.

The psychiatrically severe drug abuse patient: methadone maintenance or therapeutic community?

The present research was conducted to examine the effects of pretreatment psychiatric status and treatment duration on improvement following drug abuse rehabilitation. Percent improvement from admission to 6-month follow-up was measured on three criteria: drug use, employment, and criminality. Analyses of the total samples in both the Therapeutic Community (TC) and Methadone Maintenance (MM) programs indicated some quantitative differences between the two modalities but all measures showed a strong and positive relation between treatment duration and percent improvement. When patients in the two program samples were divided, on the basis of admission psychiatric status, into LOW, MID, and HIGH severity groups, different findings emerged. LOW severity patients in both programs showed the greatest absolute levels of improvement in most measures, more improvement at shorter treatment durations, and less additional improvement at longer treatment durations. MID severity patients in both programs showed the most dramatic effects of treatment duration, with generally large improvements in all criteria at greater treatment lengths. Qualitatively different results were seen between the treatment programs for the HIGH severity patients. HIGH severity MM patients showed low absolute levels of improvement but longer treatment durations were associated with modest improvements. HIGH severity TC patients also showed low absolute levels of improvement but unlike any other group, greater lengths of treatment were associated with negative change (worsened status) across all measures. The authors discuss these results with regard to the general efficacy of drug-dependence treatment and the specific issue of the psychiatrically impaired drug abusers.