Propoxyphene form maintenance treatment of narcotic addiction.

Two studies compared propoxyphene napsylate (Darvon-N) with methadone hydrochloride as maintenance treatment for narcotic addicts. Most measures indicated that methadone was more effective than propoxyphene as a maintenance drug. Patients receiving propoxyphene reported more withdrawal-related symptoms early in treatment, tended to drop out sooner than patients receiving methadone, and were more likely to abuse heroin. Nevertheless, follow-up interviews at one and six months after treatment indicated no between-group differences in adjustment.

Problem-service 'matching' in addiction treatment. A prospective study in 4 programs.

BACKGROUND: Our initial attempts to "match" substance-abuse patients from an employee assistance program to an optimal setting or program failed. Scientifically, we found no differential predictors of better outcomes by setting or program. From a practical perspective, it was impossible to place patients in the intended programs. This led to a second study, designed to identify specific patient problems and match professional services to those problems within each of the 4 programs. METHODS: Ninety-four new patients admitted to 4 substance-abuse treatment programs were randomly assigned to standard treatment and treated in the usual manner or were assigned to "matched" services, in which patients received at least 3 professional sessions directed at their important employment, family, or psychiatric problems. RESULTS: Matched patients stayed in treatment longer, were more likely to complete treatment, and had better posttreatment outcomes than did the standard patients treated in the same programs. CONCLUSIONS: For logistical, financial, and clinical reasons, it is improbable that patients will be matched to specific types of programs. However, within any program, it is possible and practical to match appropriate services to patients' specific treatment problems. This strategy was clinically and administratively practical, attractive to patients, and responsible for a 20% to 30% increase in the effectiveness of this substance-abuse treatment system.

Therapist success and its determinants.

This study examined the relatively unexplored contribution of the therapist's performance in determining outcomes of treatment. Nine therapists were studied: three performed supportive-expressive psychotherapy; three, cognitive-behavioral psychotherapy; and three, drug counseling. Profound differences were discovered in the therapists' success with the patients in their case loads. Four potential determinants of these differences were explored: patient factors; therapist factors; patient-therapist relationship factors; and therapy factors. Results showed that patient characteristics within each case load (after random assignments) were similar and disclosed no differences that would have explained the differences in success; therapist's personal qualities were correlated with outcomes but not significantly (mean r = .32); an early-in-treatment measure of the patient-therapist relationship, the Helping Alliance Questionnaire, yielded significant correlations with outcomes (mean r = .65); among the therapy techniques, "purity" provided significant correlations with outcomes (mean r = .44), both across therapists and within each therapist's case load. The three therapist-related factors were moderately associated with each other.

Desipramine treatment of cocaine dependence in methadone-maintained patients.

We performed a double-blind, placebo-controlled, randomized 12-week trial of desipramine hydrochloride treatment of cocaine dependence among methadone-maintained patients. Fifty-nine patients completed the 12-week medication trial (36 received desipramine and 23 received placebo), and 94% were recontacted 1, 3, and 6 months after treatment. There were significantly more dropouts in the desipramine than in the placebo group. Baseline to 12-week comparisons of Addiction Severity Index interview data indicated that both groups showed improvements. At 12 weeks, the desipramine group showed significantly better psychiatric status than the placebo group but did not differ from the placebo group on any of 21 other outcome measures, including cocaine use. During the 12-week medication phase and at the 1-month follow-up evaluation, urine toxicology screenings showed no significant difference between groups, but the placebo group had significantly less cocaine use at both the 3- and 6-month follow-up points. We conclude that desipramine has few benefits with regard to control of cocaine use in this population.

Predicting response to alcohol and drug abuse treatments. Role of psychiatric severity.

Male alcoholics (n = 460) and drug addicts (n = 282) were evaluated at six-month follow-up after treatment in six rehabilitation programs. Initial analyses of the unstratified samples showed significant patient improvement, but no evidence of differential effectiveness from different treatments or from "matching" patients to treatments. The two samples were then divided into groups based on the number, duration, and intensity of their psychiatric symptoms at admission, ie, their overall "psychiatric severity." Patients with low psychiatric severity improved in every treatment program. Patients with high psychiatric severity showed virtually no improvement in any treatment. Patients with midrange psychiatric severity (60% of the samples) showed outcome differences from different treatments and especially from specific patient-program matches. These findings support the effectiveness and specificity of different substance abuse treatments, suggest methodologic reasons for the lack of similar findings in previous studies, and demonstrate the importance of psychiatric factors in substance abuse treatment.

Sociopathy and psychotherapy outcome.

One hundred ten nonpsychotic opiate addicts were randomly assigned to receive paraprofessional drug counseling alone or counseling plus professional psychotherapy. The outcomes of patients who received psychotherapy were examined in terms of their DSM-III diagnoses. Four groups were compared: those with opiate dependence alone (N = 16); opiate dependence plus depression (N = 16); opiate dependence plus depression plus antisocial personality disorder (N = 17); and opiate dependence plus antisocial personality disorder (N = 13). Those with opiate dependence plus antisocial personality disorder alone improved only on ratings of drug use. Patients with opiate dependence alone or with opiate dependence plus depression improved significantly and in many areas. Opiate-dependent patients with antisocial personality plus depression responded almost as well as those with only depression. Antisocial personality disorder alone is a negative predictor of psychotherapy outcome, but the presence of depression appears to be a condition that allows the patient to be amenable to psychotherapy, even though the behavioral manifestations of sociopathy are present.

Psychotherapy for opiate addicts. Does it help?

Opiate addicts beginning a new treatment episode on a methadone maintenance program were offered random assignment to drug counseling alone or to counseling plus six months of either supportive-expressive psychotherapy or cognitive-behavioral psychotherapy. Sixty percent of patients meeting the study criteria expressed an interest and 60% of these actually became engaged. One hundred ten subjects completed the study intake procedure and kept three or more appointments within the first six weeks of the project. Measures including standardized psychological tests, independent observer ratings, and continuous records of licit and illicit drug use were done at baseline and seven-month follow-up. All three treatment groups showed significant improvement, but patients receiving the additional psychotherapies showed improvement in more areas and to a greater degree than those who received counseling alone, and with less use of medication. More than a third of opiate addicts in our treatment program thus both were interested in professional psychotherapy and apparently benefitted from it. Certain administrative procedures appear necessary to maximize the chances that psychotherapy can be used effectively with drug-addicted patients.

Alcohol abuse in patients with dilated cardiomyopathy. Laboratory vs clinical detection.

Detection of alcohol abuse is of utmost importance in the diagnosis and management of alcoholic cardiomyopathy. The ability of laboratory tests and clinical signs to detect alcohol abuse was compared in 31 patients with severe heart failure due to underlying dilated cardiomyopathy. Alcoholic cardiomyopathy was diagnosed in 13 patients and a variety of nonalcoholic cardiomyopathies were diagnosed in the remaining 18 patients. At the time of hospital admission, all patients received a complete cardiovascular examination as well as routine hematologic and biochemical tests. Details concerning past and recent alcohol intake were obtained by an individual who was unaware of the diagnostic status of the patients. The two groups of patients did not differ with respect to clinical presentation, self-report of recent drinking patterns, or clinical signs and medical history items that have been found to be associated with chronic alcohol abuse. However, the group with alcoholic cardiomyopathy had significantly higher values for mean corpuscular volume and gamma-glutamyltranspeptidase. Our results suggest that a combination of routine laboratory tests may be effective in the detection of alcohol abuse in patients with dilated cardiomyopathy.

Determinants of condom use among intravenous drug users.

OBJECTIVE: To examine the factors associated with condom use among a cohort of sexually active intravenous drug users (IVDU). DESIGN: Data were collected via personal interview at the fourth-month assessment point of a longitudinal study monitoring HIV infection and risk behaviors among IVDU. SETTING: A community-based methadone clinic. PARTICIPANTS: A total of 158 sexually active heterosexual male and female IVDU, including both methadone patients and out-of-treatment individuals with a history of opiate abuse. MAIN OUTCOME MEASURES: We describe a new approach to identify the determinants of condom use. Previous studies have described subjects as either 'condom users' or 'condom non-users', using an individual's overall behavior as the unit of analysis. By analyzing condom use during the most recent sexual encounter, we avoided the problem of interpreting inconsistent condom use. Data were analyzed using forward stepwise logistic regression. RESULTS: Thirty-four per cent of the heterosexual subjects (n = 160) reported using a condom during their last sexual encounter. Being HIV-positive and having either a causal or commercial partner were each associated with increased probability of using a condom (odds ratio, 10.6, 4.4 and 12.1, respectively). No interactions with sex were found. CONCLUSIONS: Our results suggest that knowing that one is HIV-positive is an important determinant of condom use; HIV testing may therefore increase the use of condoms. In addition, interventions to change sexual behaviors may need to focus on the type of sexual partner.

PIP: This study was conducted to assess the factors associated with condom use among a cohort of sexually active intravenous drug users (IVDU) sampled from a community-based methadone clinic in Philadelphia, Pennsylvania. Personal interview data were taken from 158 sexually active heterosexual male and female IVDUs at the 4-month assessment point of a longitudinal study monitoring HIV infection and risk behaviors among them. The patient sample included methadone patients and out-of-treatment individuals with a history of opiate abuse. to avoid the problem of interpreting inconsistent condom use, investigators queried condom use among participants only at their most recent sexual encounter. 34% reported using a condom at last sexual encounter. Being HIV-seropositive and having either a casual or commercial partner were each associated with increased probability of using a condom. Knowing that one is HIV-seropositive is therefore an important determinant of condom use which suggests that HIV testing may increase condom use. Interventions to change sexual behavior may also need to focus upon the type of sexual partner.

Long-term changes in psychological symptomatology associated with HIV serostatus among male injecting drug users.

OBJECTIVE: To examine long-term changes in psychological symptomatology from 6 to 24 months after notification of HIV serostatus among male injecting drug users (IDU). DESIGN: Self-report and interview data were collected at 6-month intervals as part of a longitudinal study monitoring HIV infection and risk-associated behaviors among IDU. SETTING: A community-based methadone-maintenance clinic. PARTICIPANTS: Ninety-seven male IDU (81 HIV-seronegative, 16 HIV-seropositive), including both methadone-maintained and out-of-treatment IDU. MAIN OUTCOME MEASURES: Analyses of long-term changes in psychological symptomatology associated with HIV serostatus among male IDU. RESULTS: Analyses of long-term changes in psychological symptomatology between groups revealed no significantly greater levels of overall psychological distress or significant elevations on subscales of the Symptom Checklist-90 for HIV-seropositive compared with HIV-seronegative male IDU. Also, no significantly higher scores on the Beck Depression Inventory or the psychiatric composite score of the Addiction Severity Index were observed between groups. CONCLUSIONS: Our results suggest that HIV-seropositive male IDU do not express greater levels of psychological symptomatology from 6 to 24 months following notification of seropositivity compared with HIV-seronegative male IDU. Several explanations for these findings are considered. Future work should examine why male IDU do not report significant and long-term elevations in symptoms post-notification of HIV seropositivity. Also, studies of changes in psychological symptomatology as a function of HIV serostatus among female IDU need to be conducted to assess implications for treatment interventions among this underserved population.

Endogenous opioids in cerebrospinal fluid of opioid-dependent humans.

Endogenous opioid systems may be altered as a consequence of addiction, but evidence to support this idea is meager so far. We obtained 136 cerebrospinal fluid (CSF) samples from 72 opioid addicts during four distinct states: methadone maintenance, detoxification from methadone, opioid antagonist treatment, and drug-free status. CSF endorphins were measured in 86 patients samples using a radioreceptor assay (RRA), and beta-endorphin levels were measured in 85 patient samples using a radioimmuno assay (RIA). During detoxification, both RRA fraction I and beta-endorphin showed a generally similar pattern of changes. Both were lowest when measured 40-50 hr after the last opioid dose, and both showed an apparent rebound to higher than methadone maintenance values at 60-70 hr following the last dose. During methadone maintenance and drug-free states, the addicts' levels of fraction I RRA endorphins in the CSF were higher than levels found in a normal control group. Fraction II endorphins were also elevated in the addicts who were drug free. In contrast, CSF beta-endorphin during both methadone maintenance and drug-free states was lower in the addicts as compared to the normal, drug-naive group. Except for the pattern found during detoxification, there were no consistent changes in endorphin levels across different states of addiction.

A clinical, controlled study of l-alpha-acetylmethadol in the treatment of narcotic addiction.

The authors compared l-alpha-acetylmethadol (LAAM) with methadone for clinical effectiveness in the treatment of narcotic addiction. LAAM was as effective as methadone on all outcome measures, including length of stay in treatment. Two clinicopharmacologic properties of LAAM caused some patients to ask for a switch to methadone. The authors describe these phenomena and discuss their impact on the clinical effectiveness of LAAM.

An evaluation of the Cleveland criteria for inpatient treatment of substance abuse.

OBJECTIVE: This study examined the validity of the Cleveland Admission, Discharge, and Transfer Criteria, a comprehensive system for assigning alcohol- and drug-abusing patients to appropriate levels of care. METHOD: The subjects were 143 alcoholic and cocaine-dependent male patients in an intensive Veterans Administration day treatment program for substance abusers. Patients who should have received inpatient treatment according to the Cleveland criteria were compared with those who were properly "matched" to day treatment according to the criteria. The outcome measures were treatment completion, results of urine toxicology screens, and self-reports of substance use and psychosocial functioning. RESULTS: Patients who met the criteria for inpatient care were not more likely to drop out of day hospital treatment, and there was no evidence that they were drinking or using cocaine more frequently during follow-up. Furthermore, they did not appear to be doing worse on any of the other outcome measures, with the exception of psychological status. CONCLUSIONS: The results suggest that for male substance abusers in the lower socioeconomic levels, the Cleveland criteria may not be effective in differentiating patients who can manage well with day hospital treatment and those who require inpatient treatment.

Psychotherapy in community methadone programs: a validation study.

OBJECTIVE: The authors tested the efficacy of individual psychotherapy in the rehabilitation counseling of psychiatrically symptomatic opiate-dependent patients during methadone maintenance treatment in community programs. METHOD: Volunteers in three community programs were randomly assigned to 24 weeks of counseling plus supplemental drug counseling or to counseling plus supportive-expressive psychotherapy. Follow-ups were done 1 and 6 months after treatment ended. A total of 84 subjects were evaluated at both follow-up points. RESULTS: During the study the patients receiving supportive-expressive psychotherapy and those receiving drug counseling had similar proportions of opiate-positive urine samples, but the patients receiving supportive-expressive psychotherapy had fewer cocaine-positive urine samples and required lower doses of methadone. One month after the extra therapy ended both groups had made significant gains, but there were no significant differences between groups. By 6-month follow-up many of the gains made by the drug counseling patients had diminished, whereas most of the gains made by the patients who received supportive-expressive psychotherapy remained or were still evident; many significant differences emerged, all favoring supportive-expressive psychotherapy. CONCLUSIONS: Psychotherapy can be delivered to psychiatrically impaired patients in community methadone programs. Additional counseling is associated with early benefits comparable to those from psychotherapy, but these gains are not sustained. The gains associated with psychotherapy persist and in some cases strengthen for at least 6 months after the end of therapy.

Are supplementary services provided during methadone maintenance really cost-effective?

OBJECTIVE: Previous research has suggested that support services supplementing methadone maintenance programs vary in their cost-effectiveness. This study examined the cost-effectiveness of varying levels of supplementary support services to determine whether the relative cost-effectiveness of alternative levels of support is sustained over time. METHOD: A group of 100 methadone-maintained opiate users were randomly assigned to three treatment groups receiving different levels of support services during a 24-week clinical trial. One group received methadone treatment with a minimum of counseling, the second received methadone plus more intensive counseling, and the third received methadone plus enhanced counseling, medical, and psychosocial services. The results at the end of the trial period have been published elsewhere. This article reports the results of an analysis at a 6-month follow-up. RESULTS: The follow-up analysis reaffirmed the preliminary findings that the methadone plus counseling level provided the most cost-effective implementation of the treatment program. At 12 months, the annual cost per abstinent client was $16,485, $9,804, and $11,818 for the low, intermediate, and high levels of support, respectively. Abstinence rates were highest, but modestly so, for the group receiving the high-intensity, high-cost methadone with enhanced services intervention. CONCLUSIONS: This study suggests that large amounts of support to methadone-maintained clients are not cost-effective, but it also demonstrates that moderate amounts of support are better than minimal amounts. As funding for these programs is reduced, these findings suggest a floor below which supplementary support should not fall.

Treatment goals, continuity of care, and outcome in a day hospital substance abuse rehabilitation program.

OBJECTIVE: Relationships between day hospital treatment goals, self-help group participation, and substance use outcome were examined for 180 alcohol- or cocaine-dependent male patients in a day hospital Veterans Administration substance abuse program. METHOD: The primary goals assessed were completion of the day hospital program and participation in posttreatment self-help groups. For subjects who completed the day hospital program, progress toward three other goals was also assessed: decreased denial, endorsement of 12-Step beliefs, and participation in self-help groups during the day hospital program. The outcome measures were urine toxicology and self-reports of alcohol or cocaine use at 4- and 7-month post-intake follow-up interviews. RESULTS: Day hospital completion and participation in posttreatment self-help groups predicted better outcome. Self-help participation also predicted outcome after day hospital completion was controlled. Among subjects who completed the day hospital program, the other three goals did not predict substance use outcome. However, involvement with self-help groups during the day hospital program and decreases in denial predicted continued involvement with self-help groups. CONCLUSIONS: Patients who complete day hospital substance abuse rehabilitation and then continue to participate in self-help groups are likely to have lower rates of alcohol and cocaine use during follow-up. Furthermore, the beneficial effect of self-help group participation does not appear to be strictly the result of motivation or some other patient characteristic.

Efficacy of enhanced outreach counseling to reenroll high-risk drug users 1 year after discharge from treatment.

OBJECTIVE: Because discharged methadone maintenance patients represent a population at particularly high public health risk, the authors studied such patients 1 year after their discharge from a methadone program. METHOD: The locations of 94 of 110 discharged patients were successfully determined 1 year after discharge. Nine (10%) of these patients had died, 37 (39%) were already reenrolled in treatment, and 7 (7%) did not require treatment. The 41 remaining subjects were randomly assigned to either the enhanced outreach counseling condition (N = 27) or a standard referral condition (N = 14). RESULTS: Within 2 weeks following this intervention, 17 (63%) of the 27 patients in the enhanced outreach counseling program and one (7%) of the 14 patients not in the program had reenrolled in treatment. CONCLUSIONS: These data suggest that enhanced outreach counseling may be an effective outreach strategy as well as a risk-reduction for discharged methadone maintenance patients.

Pretreatment source of income and response to methadone maintenance: a follow-up study.

The authors assessed the relationship between source of pretreatment income and response to treatment at 6-month follow-up in 165 male veterans admitted to a methadone maintenance treatment program. Subjects were grouped according to whether the majority of their pretreatment income was based on job earnings, public assistance, or criminal activity. Significant improvements in drug use, legal status, and psychological functioning were found in the employed group. The group supported by criminal activity showed the most significant and pervasive improvements, especially in the areas of drug use and family, legal, and employment problems. The group receiving public assistance showed no significant improvements on any of the 16 criterion measures, including drug use.

Twelve-month follow-up of psychotherapy for opiate dependence.

To provide information on the long-debated issue of the value of psychotherapy as an addition to paraprofessional counseling services for opiate addicts receiving methadone maintenance, the authors obtained 12-month follow-up data on 93 such patients randomly assigned to a 6-month course of either paraprofessional drug counseling or counseling plus professional psychotherapy. The psychotherapy patients had a significantly better overall status at 7-month follow-up and also at 12-month follow-up, 6 months after the psychotherapy ended. The authors conclude that psychotherapy can be evaluated by using scientific methods and that it can have measurable and sustained benefits in the treatment of opiate addiction.

Antisocial personality disorder in patients with substance abuse disorders: a problematic diagnosis?

The authors' literature review suggests that the relationship between antisocial personality disorder and substance abuse is complex and not yet fully understood. The confusion regarding the relationship between the disorders may be magnified by the emphasis in DSM-III and DSM-III-R on behavioral criteria and their failure to require that antisocial behaviors exist independently of substance abuse. The DSM-III and DSM-III-R formulations of antisocial personality disorder may encompass two subgroups of substance abusers--"true" psychopathic individuals and symptomatic psychopaths with little psychopathy. Psychoneurotic symptoms and favorable treatment responses might be found more often in the latter group.