Urine Drug Test Results Among Adolescents and Young Adults in an Outpatient Office-Based Opioid Treatment Program.

PURPOSE: Urine drug testing (UDT) is an important feature of outpatient treatment for opioid use disorder, but associations with patient characteristics among adolescent and young adult patients are unknown. This study assessed UDT results in office-based opioid treatment and characteristics associated with treatment compliance. METHODS: This was a retrospective study of adolescent and young adult patients enrolled in office-based opioid treatment between January 1, 2009, and December 31, 2020. UDT results were described as positive results or expected and unexpected results. Expected results were negative UDTs for opioids, marijuana (THC [tetrahydrocannabinol]), or cocaine/methamphetamine, or a positive UDT for buprenorphine. Unexpected results were positive UDTs for opioids, THC, or cocaine/methamphetamine, or a negative UDT for buprenorphine. Treatment compliance was defined as ≥75% of UDTs provided being expected results. Counts and percentages described UDT results. Regressions evaluated associations between patient characteristics (retention time, age, sex, race/ethnicity, insurance, and comorbid mental health diagnoses) with treatment compliance, and assessed change of positivity rates for UDTs over time. RESULTS: A total of 407 patients were included. Overall, 305 patients (74.9%) demonstrated treatment compliance. Rates of expected UDT results increased with longer retention time (p <.001), except for methamphetamine. Buprenorphine expected results ranged from 77.0% to 96.5%. Diagnosis of stimulant use disorder was associated with decreased compliance (p = .04), while diagnoses of depression, anxiety, nicotine use disorder, and post-traumatic stress disorder were associated with increased compliance (p ≤.04). DISCUSSION: Proportion of expected UDT results increased with retention time. Diagnosis of specific mental health conditions affected treatment compliance. Further research regarding long-term health outcomes is needed.

Sleep time differs among people who co-use cocaine and cannabis compared to people who only use cocaine.

OBJECTIVE: People who use cocaine experience numerous sleep problems and often use cannabis to mitigate these problems. However, co-using cocaine and cannabis may result in worse sleep outcomes when compared to using cocaine only. The current study examined group differences in subjective sleep outcomes among people who use cocaine and people who co-use cocaine and cannabis. METHODS: Participants were 82 individuals with cocaine use disorder who were enrolled in a randomized clinical trial for cocaine treatment. Sleep outcomes, assessed at baseline prior to treatment, were measured with the Saint Mary's Hospital Sleep Questionnaire and included total sleep time, perceived sleep quality, difficulty falling asleep, and daytime alertness. Analysis of covariance and Kruskal-Wallis tests were used to compare sleep outcomes between participants with urine samples that tested positive for both cocaine and cannabis at baseline, those who tested positive for cocaine only, and those who tested negative for all drugs. RESULTS: Total reported sleep time was highest among those with a drug negative urine, followed by those with a cocaine positive urine and those who tested positive for cocaine and cannabis. There were no differences in perceived sleep quality, difficulty falling asleep, or daytime alertness between groups. CONCLUSIONS: People who co-use cocaine and cannabis may report reduced sleep time relative to those who only use cocaine. Co-use of cannabis may exacerbate sleep difficulties in people who use cocaine by decreasing total sleep time, although it is important to note that the groups each reported similar sleep quality. Implications for treatment and directions for future research are discussed.

Commercial herbal medicines used as African traditional medicines: Ngoma Herbal Tonic Immune Booster interferes with a rapid urine drug screening test.

BACKGROUND: The prevalent use of African traditional medicine by the general public has been reported. With commercialisation and marketing, some of the herbal medicines (HMs) used are readily available over the counter, most of them promoted as immune boosters. These commercial HMs have not been taken through clinical trials and other tests that would validate their composition and safety, and other properties such as their effect on laboratory diagnostic tests. OBJECTIVE: To investigate the cross-reactivity of selected HMs with commonly tested drugs of abuse (DoA) using a qualitative rapid urinalysis assay. METHODS: The six HMs selected were bought from local pharmacies. A rapid urinalysis screening test was performed with the Instant View Multi-Drug of Abuse Test kit from Labstix Diagnostics. Drug-free urine (DFU) was pooled from samples donated by healthy volunteers. Urine samples that had tested positive for DoA were obtained from a pharmacology laboratory. Aliquots of the urine samples were spiked with the HMs in neat and diluted form, and tested at various time intervals. RESULTS: The results for the DFU samples spiked with the HMs remained negative. There were no significant changes in pH or specific gravity of the samples. The results of samples that had tested positive for tetrahydrocannabinol (THC) were not altered by five of the HMs when spiked at 40% v/v. The HM Ngoma Herbal Tonic Immune Booster caused false-negative results for the THC test. CONCLUSION: An important finding is that the herbal mixture Ngoma Herbal Tonic Immune Booster caused false-negative results for the cannabinoid screening test. It adds to the list of substances that may be potential adulterants of urine for screening tests.

Predictive Value of Positive Drug Screening Results in an Urban Outpatient Population.

Urine drug testing (UDT) has become an essential component in the management of patients prescribed opioid analgesics for the treatment of chronic non-malignant pain. Several laboratory methods are available to monitor adherence with the pharmacological regimen and abstinence from illicit or unauthorized medications. Immunochemical screening methods are rapid and economical, but they have limitations, including lack of specificity, and confirmatory methods are often necessary to verify presumptive positive results. We analyzed the results of confirmatory assays in an outpatient setting to determine the predictive value of presumptive positive urine drug screen results using an automated immunoassay for eight common drugs or drug classes. Positive predictive values (PPVs), in descending order, were as follows: cannabinoids (100%), cocaine (100%), opiates (86.8%), benzodiazepines (74.6%), oxycodone (67.6%), methadone (44.1%) and amphetamines (9.3%). The number of positive barbiturate results was too small to be included in the statistical analysis.

Using Client's Routine Urinalysis Records From Multiple Treatment Systems to Model Five-Year Opioid Substitution Treatment Outcomes.

BACKGROUND: At global, national, and local level, the need for ongoing, timely and cost efficient, comprehensive drug treatment monitoring, and evaluation systems have clearly been well recognized. OBJECTIVES: To test the feasibility of linking laboratory data and client intake data and its usefulness for modeling retrospectively, for the first time, 5-year longitudinal drug treatment outcomes in an Irish opiate treatment setting. METHODS: A multisite, retrospective, longitudinal cohort study was implemented to evaluate outcomes for opiate users based on 1.7 million routine urinalysis results collected from 4,518 individuals presenting for opioid substitution treatment in Ireland from January 2006 to December 2010. RESULTS: Analysis of opiates, cocaine, benzodiazepine, and cannabis use at treatment intake, 6 months and at 1-5 year follow-ups revealed differences in urinalysis protocols; significant differences in age of first drug use between those using and not using opiates at 5 years; significant decreases in opiate use; increases in benzodiazepine use and significant increasing effects of concurrent cocaine and benzodiazepine use on the odds of using opiates. Time series analysis of weekly proportions opiate positive predicted 16% (95% confidence interval: 7%-25%) of clients would be opiate positive 5 years postinitial intake. CONCLUSIONS IMPORTANCE: Underutilized urinalysis data can be used to address the need for cost effective, efficient evidence of drug-treatment outcomes across time, place, and systems. Linking and matching the cross-sectional data across sites and times also revealed where improvements in electronic records could be made.

Continued Substance Use Among People Living With HIV-Hepatitis-C Co-Infection and Receiving Antiretroviral Therapy.

BACKGROUND: Co-infection with human immunodeficiency virus (HIV) and Hepatitis-C virus (HCV) poses a significant threat to personal and public health. Substance use among co-infected persons leads to increased morbidity and mortality. The purpose of this study is to examine the continued substance use of people living with HIV-HCV co-infection and receiving antiretroviral therapy (ART). METHODS: Individuals living with HIV infection in Atlanta, GA and currently receiving ART (N = 678) completed audio-computer-assisted self-interviews for demographic, health, and behavior characteristics; unannounced pill counts to assess ART adherence over one month; finger-stick blood specimens collected for HCV antibody testing and urine specimens for drug use screening; and obtained HIV viral load and CD4 cell counts from their medical provider. We performed cross-sectional analyses for behavioral and biological markers of health, health behaviors, and substance use. RESULTS: Among participants, 131 (19%) were HIV-HCV co-infected; 53% were HIV-mono-infected, and 60% of HIV-HCV co-infected participants tested positive for use of at least one non-alcohol drug: tetrahydrocannabinol (THC) and cocaine were most prevalent. HIV-HCV co-infected individuals were older, with no other significant differences. Within the HIV-HCV co-infected participants, drug users (N = 87) did not differ from non-drug users (N = 53) in terms of ART adherence. However, drug users were significantly more likely to have uncontrolled HIV (17%) compared with those who did not test drug positive (4%). CONCLUSIONS: Substance use is prevalent in persons with HIV-HCV co-infection and may interfere with ART. Research with a larger and more representative sample is needed to replicate and confirm these results.

Gender-specific predictors of retention and opioid abstinence during methadone maintenance treatment.

AIMS: Retention in methadone maintenance treatment (MMT) for 1 year is associated with positive outcomes including opioid abstinence, however, most studies have not investigated gender differences. We hypothesized that predictors of retention and opioid abstinence would differ between men and women, and aimed to determine which factors best predict retention and abstinence for each gender. METHODS: Data were available for 290 patients (173 M, 117 F) admitted to outpatient MMT. Regression analyses, stratified by gender, were conducted to identify unique predictors of MMT retention (<1 vs. >1 year) and opioid abstinence rate (proportion of opioid-free urine samples up to 1 year retention). RESULTS: Gender did not significantly predict treatment retention (mean = 231 days, 39% retained > 1 year) or opioid abstinence (49% overall). For males, significant predictors of > 1-year retention were urine samples negative for opioids (odds ratio [OR] = 6.67) and cannabinoids (OR = 5.00) during the first month, and not cocaine dependent (OR = 2.70). Significant predictors of higher long-term opioid abstinence were first-month urine samples negative for opioids and cocaine metabolites. For females, significant predictors of >1-year retention were first-month urine samples negative for cocaine metabolites (OR = 4.00) and cannabinoids (OR = 9.26), and no history of sexual victimization (OR = 3.03). The only significant predictor of higher opioid abstinence rate was first-month opioid-free urine samples. CONCLUSIONS: These findings indicate gender-specific predictors of MMT retention and opioid abstinence. Future studies on MMT outcomes should examine each gender separately, and consider unique pathways by which females and males adhere to, and benefit from MMT.

Application of drug testing using exhaled breath for compliance monitoring of drug addicts in treatment.

AIM: Exhaled breath has recently been identified as a possible matrix for drug testing. This study explored the potential of this new method for compliance monitoring of patients being treated for dependence disorders. METHODS: Outpatients in treatment programs were recruited for this study. Urine was collected as part of clinical routine and a breath sample was collected in parallel together with a questionnaire about their views of the testing procedure. Urine was analyzed for amphetamines, benzodiazepines, cannabis, cocaine, buprenorphine, methadone and opiates using CEDIA immunochemical screening and mass spectrometry confirmation. The exhaled breath was collected using the SensAbues device and analyzed by mass spectrometry for amphetamine, methamphetamine, diazepam, oxazepam, tetrahydrocannabinol, cocaine, benzoylecgonine, buprenorphine, methadone, morphine, codeine and 6-acetylmorphine. RESULTS: A total of 122 cases with parallel urine and breath samples were collected; 34 of these were negative both in urine and breath. Out of 88 cases with positive urine samples 51 (58%) were also positive in breath. Among the patients on methadone treatment, all were positive for methadone in urine and 83% were positive in breath. Among patients in treatment with buprenorphine, 92% were positive in urine and among those 80% were also positive in breath. The questionnaire response documented that in general, patients accepted drug testing well and that the breath sampling procedure was preferred. CONCLUSION: Compliance testing for the intake of prescribed and unprescribed drugs among patients in treatment for dependence disorders using the exhaled breath sampling technique is a viable method and deserves future attention.

Illicit drug use among pregnant women enrolled in treatment for cigarette smoking cessation.

INTRODUCTION: Smoking during pregnancy is the leading preventable cause of poor pregnancy outcomes in the United States. In population studies and nationwide surveys, pregnant smokers report more illicit drug use than pregnant nonsmokers. The purpose of this study was to examine the prevalence of illicit drug use among pregnant women enrolled in clinical trials for smoking cessation. METHODS: Urine specimens from 115 pregnant women were tested for illicit drug use during a study intake visit (~10th week of pregnancy) and during the final antepartum (FAP) smoking-status assessment (~28th week of pregnancy). Participants smoked about 18 cigarettes/day prepregnancy, were generally young (<25 years), Caucasian, with a high school education and without private insurance. RESULTS: About 34% of specimens from the intake visit and 25% of those from the FAP assessment tested positive for an illicit drug. The most common drug detected was marijuana (90% of positive specimens), followed by opioids (18%), cocaine (5%), benzodiazepines (3%), and methadone (3%). None tested positive for amphetamines. The majority of women (53%) who tested positive for an illicit substance at intake also tested positive at the FAP assessment. CONCLUSIONS: Approximately a quarter to a third of pregnant women enrolled in these smoking-cessation trials were determined to be using illicit drugs, with marijuana use being the most prevalent. Those providing smoking-cessation services to pregnant women may want to be prepared to assist with obtaining services for other drug use as well.

Utility of cocaine drug screens to predict safe delivery of general anesthesia for elective surgical patients.

Cocaine has been associated with acute hemodynamic changes, causing anesthesia providers to be concerned about adverse hemodynamic events during general anesthesia. We sought to determine if there were differences in the prevalence of adverse hemodynamic events, and if hemodynamic instability could be predicted in cocaine-positive patients undergoing general anesthesia for elective surgery. A retrospective cohort study was conducted in 300 (150 cocaine-positive, 150 cocaine-negative) consecutive adults with similar general anesthesia plans who were hemodynamically normal at baseline. Subjects were excluded if they were not alert at baseline, or if they required more than 1 surgical procedure. Slightly more than 50% of subjects were female, but cocaine-positive subjects were significantly more likely to be male (chi2 = 5.9; P = .02). Baseline systolic pressure (P = .001; mean difference, 6.5 mm Hg; 95% confidence interval [CI], 2.7-70.2), mean arterial pressure (P = .04; mean difference, 2.9 mm Hg; 95% CI, 1.0-5.7), and heart rate (P = .02; mean difference, 3.3/min; 95% CI, 0.46-6.2) were significantly higher, but not clinically important in the cocaine-positive cohort. Our study demonstrates that use of drug screen results alone is insufficient to predict the safe administration of general anesthesia in patients undergoing elective surgeries.

Zinc reduces the detection of cocaine, methamphetamine, and THC by ELISA urine testing.

Federal workplace drug testing was initiated during the late 1980s. Since then, numerous methods have been employed to subvert these drug tests, adulteration of urine samples being the most common. A wide variety of adulterants has been reported to date along with suitable methods of their detection. Recently, websites have claimed that zinc sulfate can be an effective adulterant to bypass drug testing. Herein, these claims are investigated using standard drug detection kits and urine samples adulterated with zinc. Drug-free urine samples were fortified with different amounts methamphetamines and benzoylecgonine, to which zinc sulfate was added to study its effect. Urine samples from acute marijuana smokers were also obtained in order to study the effects of zinc supplements on THC drug testing. All urine drug testing was performed using ELISA detection kits manufactured by Immunalysis. Both zinc sulfate and zinc supplements are effective in interfering with the detection of all three drugs by Immunalysis drug detection kits. Also, no suitable method could be established to detect zinc in urine samples. Zinc can be an effective adulterant in urine for some illicit drugs that are commonly screened under routine drug testing.

Prevalence of illicit drug use among the Italian athlete population with special attention on drugs of abuse: a 10-year review.

The objective of this study was to assess the prevalence of illicit drugs use among young adults, in particular elite athletes. This study considers the data obtained from anti-doping analyses performed on nearly 100,000 urine samples from 2000 to 2009 by the World Anti-Doping Agency accredited Italian Anti-Doping Laboratory. The percentage of adverse analytical findings varies on a yearly basis, but it is in the range 1.0-1.8% (not considering atypical findings, such as an altered endogenous steroid profile). Among positive results, there is a high prevalence of stimulants and drugs of abuse. The drug of abuse found most frequently is the tetrahydrocannabinol (cannabis) metabolite, accounting for 0.2-0.4% of the total samples analysed (18% of the positive results). The second most frequently encountered drug is cocaine, as detected from cocaine metabolites, accounting for 0.1% of the total samples analysed (7% of positive results). Other stimulants found included amphetamines, ephedrines, carphedon, modafinil, and anorexic compounds. No amphetamine-like designer drugs were detected. These data are indicative of the widespread prevalence of cocaine and cannabis use among the young adult population. However, due to the particular population studied, it must be considered an underestimation of the phenomenon among elite athletes with respect to the general population.

Effect of acute cocaine use on vasospasm and outcome in aneurysmal subarachnoid hemorrhage.

BACKGROUND: Although acute cocaine use has been correlated with aneurysmal subarachnoid hemorrhage, its effect on vasospasm and outcome is controversial. We investigated the effect of acute cocaine use on response to vasospasm treatment and neurologic outcome in patients with aneurysmal subarachnoid hemorrhage. METHODS: Data from 600 patients with aneurysmal subarachnoid hemorrhage admitted to the University of Illinois Medical Center in Chicago between June 2002 and July 2007 were retrospectively analyzed. Patients who were positive for cocaine on urine toxicology or admitted to cocaine use within 72 hours of admission were compared with control patients with no history of cocaine use. Patients with unknown or remote history were excluded. RESULTS: Of the 600 patients with aneurysmal subarachnoid hemorrhage, 27 (5%) were excluded. Thirty-one patients (5%) acutely used cocaine before admission. Cocaine users were younger than control (45.1 vs 54.1; P ≤ .0003), and were more likely to smoke tobacco, drink alcohol, and have renal dysfunction. There was no significant difference in Hunt-Hess or Fisher grade. In univariate and multivariate analyses, there was no difference in unfavorable short-term outcome (modified Rankin scale > 3), incidence of symptomatic or radiologic vasospasm, stroke, or death. The number of interventional procedures for the treatment of vasospasm did not differ between the two groups. CONCLUSIONS: There is no significant difference in incidence of symptomatic vasospasm or neurologic outcome between cocaine users and nonusers. The severity of the vasospasm and the response to treatment, as indicated by the number of vasospasm interventions, did not differ between the two groups.

Nonreporting of cannabis use: Predictors and relationship to treatment outcome in methadone maintained patients.

Underreporting of drug use is common and influenced by multiple factors. Cannabis (THC) use nonreporting and its relationship to heroin and cocaine use were investigated in 690 patients enrolled in 25- to 29-week clinical trials of contingency management plus methadone maintenance. Urine specimens and self-reports of drug use were collected 3 times/week. Potential predictors of THC use nonreporting were analyzed by multiple logistic regression; relationships between THC use nonreporting and % cocaine- and opiate-positive urines were analyzed by multiple regression. Compared to non-THC users (n=317), patients with THC-positive urines (n=373) were more likely to be male and have more years of THC use, but were not different on other characteristics. Nonreporting to user ratios were: THC 191/373 (51.2%); opiates 17/686 (2.5%); cocaine 21/681 (3.1%). Predictors of THC use nonreporting were low rate of THC-positive urines during treatment, fewer days of THC use in the last 30 before treatment, African-American race, and absence of antisocial personality disorder. Nonreporting of THC use was associated with significantly greater opiate and cocaine use. Contingency management decreased cocaine use in THC nonreporters to the level of reporters. Nonreporting of THC use is a significant predictor of greater cocaine and heroin use. This association can be eliminated with contingency management therapy.

Time for tea, anyone?

There have been suggestions that urine samples positive for benzoylecognine, the diagnostic metabolite of cocaine, may be the result of consumption Mate de Coca, a commercially available tea made from coca (Erythroxylon coca) leaves. The Jockey Club in Great Britain commissioned research into this subject as several jockeys have tested positive for benzoylecognine over the past few years. Urine samples collected at various time points within 24 h after ingestion of a 250 ml infusion of Mate de Coca tea were analysed using three different methods. All samples tested positive for benzoylecognine.

A placebo controlled, double-blind study of mecamylamine treatment for cocaine dependence in patients enrolled in an opiate replacement program.

A placebo controlled, double-blind trial of mecamylamine treatment of cocaine dependence was performed in methadone or LAAM maintained subjects who met DSM-IV criteria for cocaine dependence. After an eight-week placebo run-in screening period, 35 subjects were randomly assigned to receive either mecamylamine (6 mg/day) or placebo transdermal patches for a 16-week treatment period. Outcome measures included quantitative urine benzoylecognine (BE) levels, self-report of cocaine use, cocaine craving, global impression scores, mood, retention, and safety. Mecamylamine was well tolerated, and study retention did not differ by treatment group. Evidence for cocaine use, based on urine BE levels and cocaine abstinence rates, did not differ by treatment group. Self reported cocaine use, cocaine craving, and global impression scores showed moderate improvement in both groups, with a significantly greater reduction in cocaine craving (p < 0.05) and self-rated severity of cocaine dependence (p < 0.05) in the placebo group. This pilot study does not support the effectiveness of mecamylamine for the treatment of cocaine dependence in methadone or LAAM maintained patients.

Disability payments, drug use and representative payees: an analysis of the relationships.

AIMS: This study attempted to determine: if US federal cash disability payments increase the use of cocaine or opiates among those requalifying for supplemental security income (SSI) disability benefits compared with those who lost benefits; if drug use peaks at the beginning of the month after the receipt of the disability cash disbursement; and if money management by representative payees of requalifying SSI recipients suppresses drug use. DESIGN: A multi-site, prospective, 2 year longitudinal design was used with follow-up interviews conducted every 6 months. Urine samples were collected at the final three follow-up interviews. SETTING: Data were collected in Chicago, IL, Los Angeles, CA, and Seattle, WA, USA. PARTICIPANTS: This study used a randomly selected sample of 740 former recipients of SSI who had received disability benefits for drug addiction and alcoholism (DA&A) in 1996, were between the ages of 21 and 59 years, had not received concurrent social security disability insurance and provided testable urine samples and complete self-report data for at least one follow-up interview. MEASUREMENTS: Independent variables included demographics, SSI status at follow-up, representative payee status, drug treatment participation and income. Time of drug testing was operationalized as the first 10 days of the month versus the last 20-21 days based on when the urine sample was collected. The dependent variables were cocaine and opiate use, determined by urinalysis results. FINDINGS: Participants were 28% more likely to test positive for cocaine use in the first 10 days of the month than later in the month. This effect was general across all subjects and was not restricted to those receiving SSI benefits. No such effect was found for opiate use. Receiving SSI benefits did not increase cocaine or opiate use generally, nor did having a representative payee suppress use. CONCLUSIONS: The findings do not support the contentions that federal cash benefits appreciably increase drug use or that representative payees discourage use, at least when use is defined dichotomously. The 'check effect' for cocaine use appears to be general and not confined to those receiving federal cash benefits. The lack of a 'check effect' for opiate use is probably the result of the difference between a relatively steady state of opiate use associated with addiction and a binge pattern of cocaine use triggered by suddenly flush resources.

Auricular acupuncture in the treatment of cocaine abuse. A study of efficacy and dosing.

A single-blind, randomized, placebo-controlled study was performed to evaluate auricular acupuncture (AAc) in the treatment of cocaine addiction. Two linked but concurrent studies were done. In Study 1, residential clients (N = 236) were randomized to true acupuncture (Ac), sham Ac, and conventional treatment without Ac. Treatment group subjects received Ac at three ear points considered to be specific for the treatment of substance abuse (SA). Control subjects received three nonspecific (sham) points. In Study 2, day treatment clients (N = 202) were randomized to one of three dose levels of true Ac (28, 16, or 8 treatments). Subjects received Ac at five, rather than three, specific ear points. Nonspecific (sham) points were not used in Study 2. With rare exception, the data failed to identify significant treatment differences among the true and sham Ac, and psychosocial groups. Furthermore, no differences were observed among the three dose levels of true Ac.

Increasing employment of opioid dependent outpatients: an intensive behavioral intervention.

The impact of a new, mandatory employment requirement in a community-based methadone treatment program was evaluated. All patients who had been in the methadone substitution program for at least 1 year but who were not currently employed (n = 36) were required to enhance their treatment with 20 h of employment (paid or volunteer). Patients with significant psychiatric or medical disabilities were excluded from the routine treatment requirement. Patients were informed by counseling staff that they had 2 months to secure employment. Those who did not accomplish the goal within that time period were transferred to more intensive weekly counseling (i.e. up to 8 h/week) for 10 weeks, with the enhanced counseling focusing primarily on resistance to the employment goal. Patients who remained resistant to the treatment plan were eventually started on a 21 day methadone taper until employment was verified. Seventy-five percent of the patients secured employment and maintained the position for at least 1 month. Positions were found in an average of 60 days. Most patients (78%) continued working throughout the 6-month follow-up. Those who failed to find work or maintain employment engaged in more illicit drug use. These results demonstrate that behavioral contingencies can motivate many methadone maintenance patients to obtain verified employment in the community.

Pharmacotherapy of schizophrenia patients with comorbid substance abuse.

Substance abuse worsens the course of schizophrenia and significantly impairs the relationship between the patient and the health care team. Recent advances in laboratory studies of substance abuse and the pharmacology of schizophrenia open up new possibilities for pharmacotherapy of substance abuse in schizophrenia patients. D1 dopaminergic receptor agonists may directly block the drive for stimulant use. D2 dopaminergic receptor antagonists may indirectly block the drive for stimulant and nicotine use, while opioid antagonists appear to reduce the drive to use alcohol. New generations of neuroleptics with serotonin (5-HT2) receptor antagonism and/or 5-HT1A agonist activity may reduce substance abuse in schizophrenia patients who self-medicate negative symptoms or neuroleptic side effects. Pharmacotherapy efficacy may be enhanced by adding contingency management, social skills training, and other manualized programs. Tables are provided of potentially useful medications. Preliminary results are presented of cocaine-abusing schizophrenia patient treated with desipramine and traditional neuroleptics.