Patient-reported outcome measures: are they patient-generated, patient-centred or patient-valued?

BACKGROUND: In the past two decades, there has been a growing interest in the development of a more patient-centred approach to assessing treatment outcomes. This interest has resulted in the increasing use of patient-reported outcome measures (PROMs) in both clinical trials and usual clinical practice. AIMS: To briefly discuss the paucity of efficacy and effectiveness studies in the field of mental health (exemplified by schizophrenia, depression and opioid dependence) that significantly incorporate the patient's perspective. The limited concordance between the perspectives of patients and clinicians in outcome assessment is also addressed. Finally, we propose a new PROM classification system based on the degree to which these instruments incorporate the patient's perspective. CONCLUSIONS: PROMs may differ little from traditional instruments unless they truly incorporate the patient's perspective and not just the perspectives of clinicians and researchers. Efforts to develop new PROMs that provide a more patient-centred outcome assessment should use qualitative and participatory methods to capture and incorporate patient perspectives and values.

Personality traits of cocaine-dependent patients associated with cocaine-positive baseline urine at hospitalization.

BACKGROUND: Cocaine abstinence at treatment entry is considered a predictor of good response in cocaine dependence treatment. Therefore, identification of factors facilitating pretreatment cocaine abstinence could be useful for developing new therapeutic strategies. OBJECTIVE: This retrospective chart review study examines the association between personality traits and cocaine-positive baseline urinalysis (CPB) in cocaine-dependent inpatients. METHODS: All 107 participants met DSM-IV criteria for cocaine dependence, and were admitted consecutively to a closed addiction unit for detoxification treatment. Personality was assessed with the Temperament and Character Inventory and the Millon Clinical Multiaxial Inventory (MCMI-II). RESULTS: CPB was detected in 80 patients (74.8%). The logistic regression model solely based on personality dimensions showed that only the MCMI-II avoidant traits were significantly associated with a decreased probability of cocaine-dependent patients presenting CPB. The logistic regression model based on both personality dimensions and substance use-related variables alike retained the number of days of cocaine use during the last 30 days as a risk factor, and alcohol dependence and the MCMI-II schizoid dimension as protective factors in predicting CPB results. CONCLUSION AND SCIENTIFIC SIGNIFICANCE: Avoidant and schizoid traits are personality dimensions of cocaine-dependent patients that are associated with cocaine abstinence prior to inpatient admission. These findings suggest an inverse relationship between social isolation and CPB. Notwithstanding, more research is needed, not only to assess the generalizability of these findings, but also to enrich the personality and substance use model with variables related to readiness to change.

Development and validation of the scale to assess satisfaction with medications for addiction treatment-methadone for heroin addiction (SASMAT-METHER).

OBJECTIVE: To develop and examine the psychometric properties of a scale to specifically assess satisfaction with methadone in heroin-dependent patients. METHODS: The 44-item preliminary version of the scale to assess satisfaction with medications for addiction treatment-methadone for heroin addiction (SASMAT-METHER) was obtained from a pool of items designed to assess satisfaction with any medication-addiction combination. Theoretical domains of the initial SASMAT-METHER were overall satisfaction, pharmacotherapy, initiation, anti-addictive effect on heroin, mental state, physical state, personal functioning, acceptability, and anti-addictive effect on secondary substances. The Treatment Satisfaction Questionnaire for Medication 1.4 version (TSQM 1.4) and the Verona Service Satisfaction Scale for Methadone Treatment (VSSS-MT) were used for concurrent validation. Participants included heroin-dependent patients receiving methadone treatment for at least the last 3 months. RESULTS: The preliminary version of the SASMAT-METHER scale was completed by 241 patients, with 180 surveys considered suitable for factor analysis. Principal component analysis of these SASMAT-METHER surveys revealed a 3-factor structure that accounted for 40.4% of total variance. Based on similarities between empirically-obtained factors and theoretical domains, factors 1 through 3 were named 'Personal Functioning and Well-Being' (7 items), 'Anti-Addictive Effect on Heroin' (5 items), and 'Anti-Addictive Effect on Other Substances' (5 items). All factors showed good to excellent internal consistency (Cronbach's α: 0.83-0.92) and test-retest reliability (intraclass correlation coefficients: 0.66-0.89). Correlations between overall SASMAT-METHER and TSQM 1.4 scores were stronger (Pearson r=0.69) than correlations between overall SASMAT-METHER and VSSS-MT scores (Pearson r=0.26). CONCLUSION: These results present evidence for the validity and reliability of SASMAT-METHER.

Probability and predictors of remission from life-time nicotine, alcohol, cannabis or cocaine dependence: results from the National Epidemiologic Survey on Alcohol and Related Conditions.

AIM: To estimate the general and racial/ethnic specific cumulative probability of remission from nicotine alcohol cannabis or cocaine dependence, and to identify predictors of remission across substances. DESIGN: Data were collected from structured diagnostic interviews using the Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV version. SETTING: The 2001-2002 National Epidemiological Survey of Alcohol and Related Conditions (NESARC) surveyed a nationally representative sample from US adults (n = 43,093) selected in a three-stage sampling design. PARTICIPANTS: The subsamples of individuals with life-time DSM-IV diagnosis of dependence on nicotine (n = 6937), alcohol (n = 4781), cannabis (n = 530) and cocaine (n = 408). MEASUREMENTS: Cumulative probability estimates of dependence remission for the general population and across racial/ethnic groups. Hazard ratios for remission from dependence. FINDINGS: Life-time cumulative probability estimates of dependence remission were 83.7% for nicotine, 90.6% for alcohol, 97.2% for cannabis and 99.2% for cocaine. Half of the cases of nicotine, alcohol, cannabis and cocaine dependence remitted approximately 26, 14, 6 and 5 years after dependence onset, respectively. Males, Blacks and individuals with diagnosis of personality disorders and history of substance use comorbidity exhibited lower hazards of remission for at least two substances. CONCLUSIONS: A significant proportion of individuals with dependence on nicotine, alcohol, cannabis or cocaine achieve remission at some point in their life-time, although the probability and time to remission varies by substance and racial/ethnic group. Several predictors of remission are shared by at least two substances, suggesting that the processes of remission overlap. The lower rates of remission of individuals with comorbid personality or substance use disorders highlight the need for providing coordinated psychiatric and substance abuse interventions.

Drug-dependent inpatients reporting continuous absence of spontaneous drug craving for the main substance throughout detoxification treatment.

INTRODUCTION AND AIMS: Drug craving is considered to be an essential component of substance dependence. We aimed to characterise drug-dependent inpatients reporting continuous absence of subjective spontaneous drug craving. DESIGN AND METHODS: This is a 3 year chart-review study designed to compare drug-dependent inpatients who did not report craving everyday (non-cravers) and their counterparts who did (cravers). All participants were recruited consecutively and completed a 14 day detoxification treatment. Craving was defined as a desire to use the main detoxification substance. This substance was chosen by patients, who completed a craving visual analogue scale, the Beck Depression Inventory and the State-Trait Anxiety Inventory daily. The Temperament and Character Inventory and the Addiction Severity Index were also used. RESULTS: Of the 195 patients who completed the detoxification treatment, 45 (23.1%) were non-cravers and 32 (16.4%) were cravers. The main detoxification substances were alcohol, benzodiazepines, cannabis, cocaine, heroin and methadone. Non-cravers named methadone as the main detoxification substance more frequently than cravers, and benzoylecgonine was less frequently present in their urine at treatment entry. A decreased score on the Temperament and Character Inventory dimension of harm avoidance (i.e. trait anxiety) was the only independent predictor of absence of craving (odds ratio = 1.16, 95% confidence interval = 1.03-1.31). During admission, non-cravers had lower Beck Depression Inventory and State-Trait Anxiety Inventory scores than cravers. These differences were not accounted for by pharmacological treatment. DISCUSSION AND CONCLUSIONS: Drug -dependent inpatients who report absence of craving are characterised by relatively low levels of depression and anxiety throughout detoxification treatment, and relatively low levels of trait anxiety.