A comparison of male and female cocaine abusers.

Little has been written about the differences between male and female cocaine abusers. We therefore compared sociodemographic characteristics, reasons for cocaine use, drug effects, depressive symptoms, and psychiatric diagnoses in 95 men and 34 women hospitalized for cocaine abuse. Men were more likely to be employed, to hold higher status jobs, and to be self-supporting. Women were more likely to cite specific reasons for drug use, while men tended to use cocaine as part of a larger pattern of antisocial behavior. Women were diagnosed more often as having major depression, and their depressive symptoms improved much more slowly than men's when drug free. These findings suggest that women cocaine abusers may initially experience more residual problems, eg, depression and job dissatisfaction, than men after becoming drug free. Drug treatment centers should be alert to possible differences based on gender.

The effect of depression on return to drinking: a prospective study.

BACKGROUND: The effect of depression on return to drinking among individuals with alcohol dependence is controversial. From February 1, 1993, to April 15, 1996, we consecutively recruited 40 women and 61 men hospitalized for alcohol dependence and followed them up monthly for 1 year to assess the effect of depression on drinking outcomes. METHODS: We conducted structured interviews during hospitalization and monthly following discharge for 1 year to determine whether depression at treatment entry affected the likelihood of return to drinking and whether this effect differed between sexes. Using survival analysis, we examined the effect of depressive symptoms and a diagnosis of current major depression at treatment entry on times to first drink and relapse during follow-up. RESULTS: A diagnosis of current major depression at the time of hospitalization was associated with shorter times to first drink (hazard ratio, 2.03; 95% confidence interval [CI], 1.28-3.21; P=.003) and relapse (hazard ratio, 2.12; 95% CI, 1.32-3.39; P=.002). There was no significant difference between women and men in this effect. Depressive symptoms as measured by the Beck Depression Inventory did not predict time to first drink or relapse in women or men. CONCLUSIONS: A diagnosis of current major depression at entry into inpatient treatment for alcohol dependence predicted shorter times to first drink and relapse in women and men. Our results differ from earlier reports that men and women differ in the effect of depression on return to drinking.

The National Institute on Drug Abuse Collaborative Cocaine Treatment Study. Rationale and methods.

The National Institute on Drug Abuse Collaborative Cocaine Treatment Study is a large, multisite psychotherapy clinical trial for outpatients who meet the DSM-IV criteria for cocaine dependence. For 480 randomized patients, the outcomes of 4 treatments are compared for an 18-month period. All treatments include group drug counseling. One treatment also adds cognitive therapy, one adds supportive-expressive psychodynamic therapy, and one adds individual drug counseling; one consists of group drug counseling alone. In addition, 2 specific interaction hypotheses, one involving psychiatric severity and the other involving degree of antisocial personality characteristics, are being tested. This article describes the main aims of the project, the background and rationale for the study design, the rationale for the choice of treatments and patient population, and a brief description of the research plan.

Psychosocial treatments for cocaine dependence: National Institute on Drug Abuse Collaborative Cocaine Treatment Study.

BACKGROUND: This was a multicenter investigation examining the efficacy of 4 psychosocial treatments for cocaine-dependent patients. METHODS: Four hundred eighty-seven patients were randomly assigned to 1 of 4 manual-guided treatments: individual drug counseling plus group drug counseling (GDC), cognitive therapy plus GDC, supportive-expressive therapy plus GDC, or GDC alone. Treatment was intensive, including 36 possible individual sessions and 24 group sessions for 6 months. Patients were assessed monthly during active treatment and at 9 and 12 months after baseline. Primary outcome measures were the Addiction Severity Index-Drug Use Composite score and the number of days of cocaine use in the past month. RESULTS: Compared with the 2 psychotherapies and with GDC alone, individual drug counseling plus GDC showed the greatest improvement on the Addiction Severity Index-Drug Use Composite score. Individual group counseling plus GDC was also superior to the 2 psychotherapies on the number of days of cocaine use in the past month. Hypotheses regarding the superiority of psychotherapy to GDC for patients with greater psychiatric severity and the superiority of cognitive therapy plus GDC compared with supportive-expressive therapy plus GDC for patients with antisocial personality traits or external coping style were not confirmed. CONCLUSION: Compared with professional psychotherapy, a manual-guided combination of intensive individual drug counseling and GDC has promise for the treatment of cocaine dependence.

Short term health-related quality of life improvement during opioid agonist treatment.

BACKGROUND: Opioid dependence is associated with high levels of morbidity, yet sparse data exists regarding the health-related quality of life (HRQoL) of individuals with opioid dependence, particularly following treatment initiation. To inform cost-effectiveness analyses of treatment modalities, this study investigates short-term changes in HRQoL following enrollment into opioid agonist treatment (OAT), across treatment modalities and patient subgroups. METHODS: Data was analyzed from the Starting Treatment with Agonist Replacement Therapies (START) and Prescription Opioid Addiction Treatment Studies (POATS) randomized controlled trials. Participants included individuals dependent on prescription opioids (POs) or heroin, receiving limited-term or time-unlimited treatment. PO- or heroin-users in START received buprenorphine/naloxone (BUP/NX) or methadone (MET) over 24 weeks. PO-users in POATS received psychosocial care and short-term (4-week) taper with BUP/NX, with non-responders offered subsequent extended (12-week) stabilization and taper. HRQoL was assessed using the short-form SF-6D while in and out of OAT, with distinction between MMT and BUP/NX in START. Linear mixed effects regression models were fitted to determine the independent effects of OAT on HRQoL and characterize HRQoL trajectories. RESULTS: Treatment had a similar immediate and modest positive association with HRQoL in each patient subgroup. The association of OAT on HRQoL was statistically significant in each model, with effect sizes between 0.039 (heroin-users receiving BUP/NX) and 0.071 (PO-users receiving MET). After initial improvement, HRQoL decreased slightly, or increased at a diminished rate. CONCLUSIONS: OAT, whether delivered in time-limited or unlimited form, using BUP/NX or MET, is associated with modest immediate HRQoL improvements, with diminishing benefits thereafter.

Severity of cocaine dependence as a predictor of relapse to cocaine use.

The severity of cocaine dependence of 39 hospitalized patients was assessed by administering the Structured Clinical Interview for DSM-III-R. No significant relationship was found between severity of cocaine dependence and cocaine use at 3-month follow-up. These findings suggest that severity of cocaine dependence may be a poor predictor of relapse to cocaine use.

Patients who use drugs during inpatient substance abuse treatment.

OBJECTIVE: Drug use by patients during inpatient substance abuse treatment is frequently a cause of premature hospital discharge. The authors examined the histories of patients who used drugs while in inpatient substance abuse treatment, the methods used to detect drug use, and the temporal relationship of drug use episodes. METHOD: The authors reviewed the charts of patients admitted consecutively to an inpatient substance abuse treatment unit between 1981 and 1988. Of 729 patients, 42 were found to have used drugs while receiving inpatient treatment. The diagnoses and clinical histories of these 42 patients were compared with those of all other patients. Methods of detection and circumstances of drug use were recorded, and drug use episodes were plotted on a time line that was examined for temporal clustering. RESULTS: Significantly more of the patients who used drugs during inpatient substance abuse treatment had primarily used heroin or methadone before treatment. Random urine screens, self-report, and staff observation together detected approximately 85% of the patients who used drugs during treatment. Episodes of drug use did cluster in time, but within clusters the hospital stays of the patients who used drugs did not necessarily overlap. CONCLUSIONS: Temporal clustering of drug use episodes may occur because drug use by one patient heralds drug availability and stimulates craving in other inpatients. Clinicians should be aware that one episode of drug use may be followed by others. Multiple detection methods, including random comprehensive urine screens, should be used to test for drug use on inpatient units.

Pulmonary dysfunction in cocaine smokers.

The authors report another complication of freebase cocaine smoking. They found a significant reduction in the carbon monoxide diffusing capacity in the lungs of two patients. This suggests that inhalation of the freebase of cocaine may damage the pulmonary gas exchange surface.

Functional magnetic resonance imaging of human brain activation during cue-induced cocaine craving.

OBJECTIVE: Functional magnetic resonance imaging (MRI) was used to test whether brain activation was detectable in regions previously associated with cocaine cue-induced craving. METHOD: Blood oxygenation level dependent (BOLD) functional activation was measured during presentation of audiovisual stimuli containing alternating intervals of drug-related and neutral scenes to six male subjects with a history of crack cocaine use and six male comparison subjects. RESULTS: Significant activation was detected in the anterior cingulate and left dorsolateral prefrontal cortex in the cocaine-using group. In addition, a correlation between self-reported levels of craving and activation in these regions was found. CONCLUSIONS: These results suggest that functional MRI may be a useful tool to study the neurobiological basis of cue-induced craving.

Validity of substance use self-reports in dually diagnosed outpatients.

OBJECTIVE: The purpose of this study was to assess the validity of self-reports of substance use among outpatients dually diagnosed with substance use disorder and either bipolar disorder or posttraumatic stress disorder. METHOD: Self-reports of substance use were compared with supervised urine samples collected on the same day for 55 subjects. RESULTS: Self-reports were highly valid. Only 4.7% of cases involved subjects not reporting substance use detected by urine screens. CONCLUSIONS: Self-reports of substance use may be highly valid in nonpsychotic, dually diagnosed outpatients under certain conditions, i.e., when patients are in treatment, when urine samples are collected with patients' prior knowledge, when patients are well-known to staff, and when honest self-reporting is encouraged.

Cocaine dependence with and without PTSD among subjects in the National Institute on Drug Abuse Collaborative Cocaine Treatment Study.

OBJECTIVE: This study examined the prevalence of lifetime traumatic events and current symptoms of posttraumatic stress disorder (PTSD) among treatment-seeking cocaine-dependent outpatients and compared patients with and without PTSD on current substance use, psychopathology, and sociodemographic characteristics. METHOD: The subjects were 122 adult cocaine-dependent outpatients participating in a treatment outcome study of psychosocial therapy. In addition to standard self-report and interview measures of psychopathology and substance use, the subjects completed the Trauma History Questionnaire and the PTSD Checklist before entering treatment. RESULTS: These patients experienced a large number of lifetime traumatic events (mean = 5.7); men experienced more general disasters and crime-related traumas than women, and women experienced more physical and sexual abuse than men. According to self-report measures, 20.5% of the subjects currently met the DSM-III-R criteria for PTSD; the rate of PTSD was 30.2% among women and 15.2% among men. Patients with PTSD had significantly higher rates of co-occurring axis I and axis II disorders, interpersonal problems, medical problems, resistance to treatment, and psychopathology symptoms than patients without PTSD. Psychopathology symptoms represented the most consistent difference between the two groups and provided the best prediction of PTSD status in a logistic regression. However, the groups did not differ significantly in current substance use or sociodemographic characteristics. CONCLUSIONS: These findings underscore the value of screening substance abusers for PTSD, because it can identify a small but substantial number who might require additional treatment. Further studies of the relationship between PTSD and substance abuse appear warranted.

Tricyclic antidepressants in the treatment of alcoholism and drug abuse.

Although the frequent coexistence of substance abuse and depression is widely recognized, studies assessing the efficacy of tricyclic antidepressants in patients who abuse alcohol and/or drugs have been problematic because of controversies about how to diagnose depression in this population, failure to measure plasma antidepressant levels, and inconsistent treatment outcome measures. Some studies have, however, demonstrated the effective use of specific tricyclic antidepressants in selected subgroups of substance abusers; for example, desipramine may facilitate initiation of cocaine abstinence, and doxepin may benefit certain opioid addicts. Although imipramine has shown only equivocal success in the treatment of alcoholics, preliminary studies of serotonin uptake inhibitors show some promise in this population. As research design in this field becomes more consistent, future studies may more clearly identify subgroups of chemically dependent patients who respond to specific antidepressant drugs.

Group therapy for patients with bipolar disorder and substance dependence: results of a pilot study.

BACKGROUND: The authors' goal was to pilot test a newly developed manual-based group psychotherapy, called Integrated Group Therapy (IGT), for patients with bipolar disorder and substance dependence. METHOD: In this open trial, patients with DSM-IV bipolar disorder and substance dependence (N = 45) were recruited in sequential blocks to receive either group therapy (N = 21) or 6 monthly assessments, but no experimental treatment (N = 24). RESULTS: When compared with patients who did not receive group therapy, patients who received IGT had significantly better outcomes on the Addiction Severity Index drug composite score (p < .03), percentage of months abstinent (p < .01), and likelihood of achieving 2 (p < .002) or 3 (p < .004) consecutive abstinent months. CONCLUSION: IGT is a promising treatment for patients with bipolar disorder and substance dependence, who have traditionally had poor outcomes. It is unclear, however, how much of the improvement among the group therapy patients is attributable to the specific content of the treatment. A study comparing this treatment with another active psychotherapy treatment is warranted.

Medication compliance among patients with bipolar disorder and substance use disorder.

BACKGROUND: This study examined patterns of medication compliance and reasons for noncompliance among patients with bipolar disorder and substance use disorder. METHOD: Forty-four patients with current bipolar disorder and substance use disorder were administered a structured interview regarding lifetime compliance with prescribed psychotropic medications. RESULTS: Patients who were prescribed both lithium and valproate were significantly (p = .03) more likely to report full compliance with valproate than with lithium. Side effects were the most common reason for lithium noncompliance, but were not cited as a reason for valproate noncompliance. Also, a common pattern of noncompliance among patients prescribed benzodiazepines, neuroleptics, and tricyclic antidepressants was the use of more medication than prescribed. CONCLUSION: Valproate may have greater acceptability than lithium among patients with bipolar disorder and substance use disorder. Clinicians should also be aware that these patients may take higher doses of medication than prescribed.

Variations in therapist effectiveness in the treatment of patients with substance use disorders: an empirical review.

Despite the widespread use of psychotherapy for patients with substance use disorders, the effectiveness of psychotherapists conducting such treatment has received little research attention. In this paper, empirical studies of therapists' differences in patient outcome and dropout rates are comprehensively reviewed. The main conclusions are that therapists show diverse rates of effectiveness, and that such differences appear independent of both therapists' professional background and of patient factors at the start of therapy. The primary therapist characteristic thus far associated with higher effectiveness is the possession of strong interpersonal skills. Guidelines for research on therapist effectiveness are presented.

Impact of psychosocial treatments on associated problems of cocaine-dependent patients.

A previous report from the National Institute on Drug Abuse Collaborative Cocaine Treatment Study (P. Crits-Christoph et al., 1999) found relatively superior cocaine and drug use outcomes for individual drug counseling plus group drug counseling compared with other treatments. Using data from that study, the authors examined the relative efficacy of 4 treatments for cocaine dependence on psychosocial and other addiction-associated problems. The 487 patients were randomly assigned to 6 months of treatment with cognitive therapy, supportive-expressive therapy, or individual drug counseling (each with additional group drug counseling), or to group drug counseling alone. Assessments were made at baseline and monthly for 6 months during the acute treatment phase, with follow-up visits at 9 and 12 months. No significant differences between treatments were found on measures of psychiatric symptoms, employment, medical, legal, family-social, interpersonal, or alcohol use problems. The authors concluded that the superiority of individual drug counseling in modifying cocaine use does not extend broadly to other addiction-associated problems.

Therapeutic alliance as a predictor of outcome and retention in the National Institute on Drug Abuse Collaborative Cocaine Treatment Study.

The authors examined the relation between therapeutic alliance, retention, and outcome for 308 cocaine-dependent outpatients participating in the National Institute on Drug Abuse Collaborative Cocaine Treatment Study. High levels of alliance were observed in supportive-expressive therapy (SE), cognitive therapy (CT), and individual drug counseling (IDC), and alliance levels increased slightly but significantly from Session 2 to Session 5 in all groups. In contrast to other studies, alliance was not a significant predictor of drug outcome. However, alliance did predict patient retention differentially across the 3 treatments. In SE and IDC, either higher levels of alliance were associated with increased retention or no relationship between alliance and retention was found, depending on the time alliance was measured. In CT, higher levels of alliance were associated with decreased retention.

Affective illness in substance abusers.

The evaluation and treatment of substance abusers are complicated tasks, requiring a multifaceted approach. In addition to the patient's substance abuse problems, a substantial minority appear to be suffering from concurrent, nondrug-related psychiatric disorders. The early identification of such individuals allows for the development of specific treatment strategies that address both the substance abuse and the associated nondrug psychopathology. On the other hand, attention to nondrug psychopathology should not preclude our simultaneously addressing the patient's substance abuse problem. Thus, manic depressive patients who are also alcoholic may need a treatment program that includes alcoholism counseling. Alcoholics Anonymous, and chronic administration of disulfiram in addition to lithium carbonate and a supportive psychotherapeutic relationship. As in other areas of medicine, attention to the "whole patient" is the sine qua non of good treatment.

Subtypes of cocaine abusers.

We have characterized five subtypes of cocaine abusers on the basis of clinical presentation, family history data, and response to specific treatment interventions. These include depressed patients who value the euphorigenic effects of the drug, patients with bipolar or cyclothymic disorder who use cocaine to augment manic or hypomanic symptoms or to alleviate depression, adults with ADD, residual type, who find that cocaine has a paradoxical effect of increasing attention span and decreasing motor restlessness, patients with narcissistic and borderline personality disorders who use cocaine for its social prestige and because it bolsters self-esteem, and patients with antisocial personality disorder who use cocaine as part of an overall pattern of antisocial behavior. Although not all cocaine abusers fit neatly into these categories, careful psychiatric evaluation and subtyping is essential in designing a specific treatment program for these patients. As the prevalence rate of cocaine abuse increases, studies that examine the efficacy of various treatment approaches for specific subtypes of cocaine abusers will be essential. It is hoped that our work will be a step in that direction.

Treatment of chronic cocaine abuse and attention deficit disorder, residual type, with magnesium pemoline.

Research suggests that attention deficit disorder (ADD) may persist into adulthood, perhaps predisposing certain individuals to stimulant abuse. The authors describe two adults with chronic cocaine abuse and apparent residual ADD. After failing to respond to conventional treatment modalities, these patients were administered magnesium pemoline. Both displayed a sustained reduction in their cocaine use, without abusing pemoline. This finding suggests that the diagnostic assessment of cocaine abusers should include a search for a history of ADD. A carefully selected subgroup of this population may benefit from treatment with other stimulant medications.