Short- and long-term smoking cessation for three levels of intensity of behavioral treatment.

Efficacy and costs of 3 levels of medical-behavioral treatment intensity in conjunction with nicotine replacement therapy (NRT) were compared in 240 one-pack-a-day smokers: (a) a low-intensity (LI) group that received 8 weeks of NRT (n = 80) and 1 advice and education (A&E) session with a nurse practitioner (NP); (b) a moderate-intensity (MI) group that was provided NRT and 4 A&E sessions with an NP (n = 80); and (c) a high-intensity (HI) group that received treatment combining NRT, 4 A&E sessions, and 12 weeks of individualized cognitive-behavioral therapy (n = 80). Biochemically confirmed abstinence rates at 9, 26, and 52 weeks posttreatment initiation were highest for the HI (45%, 37%, 35%) group, followed by the LI (35%, 30%, and 27%) and MI (27%, 12%, 12%) groups. Group differences approached statistical significance at 9 weeks and were statistically significant at both 26 and 52 weeks. The cost of LI treatment was $308, that of MI was $338, and the HI treatment cost was $582.

Detection and diagnosis of psychiatric disorders in primary medical care settings.

Research efforts accelerated in the 1990s to define the presentation of common psychiatric disorders in primary care settings. Two diagnostic instruments, the DSM-IV-PC and the PRIME-MD, were introduced in 1994, and a self-report form of the PRIME-MD, the PHQ, was published in 1999. These tools have streamlined the larger, often cumbersome psychiatric nomenclature of the DSM-III and DSM-IV and appear to be more useful in general medical settings. It still is not practical to use either instrument in its entirety for all patients in a busy primary care practice. Studies have suggested an efficient and effective, two-step method of screening primary care patients for psychiatric disorders, however. In this approach, a limited number of probing questions extracted from the PRIME-MD or PHQ (or DSM-IV-PC) are posed to patients, either in person or by a written self-report (i.e., a general health update or review of systems). Then a follow-up evaluation is done to confirm or refute positive screening results. Short, simple questionnaires that address specific topics (e.g., CAGE for alcohol screening or the GDS for mood disorders in older adults) complete and complement this approach. This method has the advantage of being easy to incorporate into routine office practice using minimal physician or office staff time, while showing acceptable sensitivity and specificity in studies to date. More research, particularly prospective studies, is needed to confirm the effectiveness of this approach and expand it beyond the few available studies that have focused mostly on depressive disorders.

Effectiveness of propranolol for cocaine dependence treatment may depend on cocaine withdrawal symptom severity.

Propranolol may reduce symptoms of autonomic arousal associated with early cocaine abstinence and improve treatment outcome. This trial was an 8-week, double-blind, placebo-controlled trial of propranolol in 108 cocaine dependent subjects. The primary outcome measure was quantitative urinary benzoylecgonine levels. Secondary outcome measures included treatment retention, addiction severity index results, cocaine craving, mood and anxiety symptoms, cocaine withdrawal symptoms, and adverse events. Propranolol treated subjects had lower cocaine withdrawal symptom severity but otherwise did not differ from placebo treated subjects in any outcome measure. However, in a secondary, exploratory analysis, subjects with more severe cocaine withdrawal symptoms responded better to propranolol in comparison to placebo. In these subjects, propranolol treatment was associated with better treatment retention and lower urinary benzoylecgonine levels as compared with the placebo treatment. Propranolol may be useful only for the treatment of cocaine dependent patients with severe cocaine withdrawal symptoms.

The relationship between psychopathology and smoking cessation treatment response.

The study evaluated the relationship of psychopathology to treatment response of 208 smokers prescribed transdermal nicotine (8 weeks). Participants were relatively high functioning (DSM-IV axis V score) outpatients in a university-based clinic. The primary study objective was to determine whether patients with a history of either a DSM-IV axis I or II diagnosis would have poorer during treatment response (patch adherence, smoking) and lower rates of smoking cessation at post-patch follow-up (study weeks 9, 26, 52) than those without a diagnosis. While there was some indication that patients with a history of psychopathology wore the patch less frequently, psychopathology was not associated with during- and post-treatment smoking.

Open trials as a method of prioritizing medications for inclusion in controlled trials for cocaine dependence.

This paper describes a rapid and systematic method of using open trials to identify medications that may be useful for the treatment of cocaine dependence. Results of these open trials can be used to prioritize medications for inclusion in subsequent double-blind, placebo-controlled trials. Preliminary results are presented from the evaluation of propranolol, nefazodone, and the combination of phentermine and fenfluramine (phen/fen). Each medication was evaluated in an open trial, and results were compared to results obtained from a group that received a multivitamin. Outcome measures included treatment retention, urine toxicology screens, self-reported cocaine use, and changes on the Addiction Severity Index (ASI). Treatment retention was significantly better in the propranolol group than in the multivitamin group. Concurrent alcohol abuse was associated with increased rates of attrition in the multivitamin group, and the phen/fen group, but not in the propranolol group. Neither the nefazodone nor the phen/fen groups showed any outcome advantages over the multivitamin group. We conclude that propranolol may enhance retention among cocaine-dependent patients, especially among those who also abuse alcohol. These results encourage a double-blind, placebo-controlled trial of propranolol.

Cotinine replacement levels for a 21 mg/day transdermal nicotine patch in an outpatient treatment setting.

This study examined plasma cotinine replacement levels of 56 outpatient smokers administered a 21 mg/day transdermal nicotine patch (Nicoderm CQ ). The percentage of cotinine replacement ranged from 35 to 232% (mean 107%; median 90.5%). Four subject variables were found to be significantly correlated with percentage of cotinine replacement-baseline cotinine level, prior quit attempts, gender, and the Fagerström Tolerance Questionnaire score. A two-variable model consisting of baseline cotinine level and gender provided the most powerful predictor combination. The percentage of cotinine replacement was not predictive of post-treatment smoking. The relatively high levels of cotinine replacement obtained using the Nicoderm CQ 21 mg/day patch suggest cautious use of higher dose treatment with this particular patch.

Nicodermal patch adherence and its correlates.

The patch adherence behavior of 101 smokers receiving 8 weeks of the nicodermal patch was examined while undergoing one of three levels of adjunctive psychosocial treatment. Additionally, regression analyses were undertaken to: (1) identify subject variables predictive of patch adherence and (2) to determine the predictive validity of patch treatment dropout, smoking and patch adherence during patch treatment to smoking 9 and 26 weeks post-treatment entry. Fifty-five percent of the patients wore the patch as prescribed for at least 50 of 56 treatment days. A multiple regression model including the Fagerström severity of dependence score, psychosocial treatment group, and the URICA commitment score predicted 18% of the variance in days of patch use. All treatment dropouts were found to be smoking at followup. Although both smoking and low patch compliance during treatment were significant predictors subjects of week 9 and 26 smoking for the remaining subjects, at the individual variable level of analysis, only smoking during treatment predicted week 9 and 26 outcomes in a two-variable predictor model.

Reliability and validity of the aggregate method of determining number of cigarettes smoked per day.

The authors evaluated the reliability of two pretreatment assessments (screening and intake) of cigarettes smoked per day (CPD) by the commonly used aggregate method. The validity of the aggregate method was also determined by comparison with results of the timeline followback (TLFB) method for the identical periods. The study participants were 49 outpatients undergoing nicotine patch treatment. The reliability of the two aggregate method evaluations of CPD was quite high by Pearson product-moment correlation (r) and good when based on the intraclass correlation. Correspondence between the CPD assessments based on the aggregate and TLFB methods for the two time-points ranged from fair (screening) to good (intake). Overall, the study findings indicate that the aggregate method provides reasonably consistent data.

Results of two levels of adjunctive treatment used with the nicotine patch.

The authors compared 9-, 16-, 26-, and 52-week outcomes for two randomly assigned groups of nicotine-dependent subjects: 1) nicotine patch plus four smoking cessation sessions with a nurse-practitioner giving advice and instruction (n = 36; moderate-intensity condition, MI); or 2) the foregoing treatments plus 16 weekly individual cognitive/ behavioral relapse-prevention therapy sessions (n = 33; high-intensity condition, HI). Patch completion rates were 69.7% in the HI group and 55.6% in the MI group (NS). Self-reported abstinence rates at the four follow-up points were comparable for the two treatment groups; HI: 39%, 36%, 36%, and 36%; MI: 44%, 28%, 25%, and 28%, respectively. There was some indication that MI patients with high nicotine dependence had lower abstinence rates than highly dependent HI patients.

Effects of an appointment reminder call on patient show rates.

A pilot study (N = 80) was conducted to determine if (1) prospective substance-dependent patients randomly selected to be reminded (TC) of their scheduled intake evaluation the day before their first appointment would have a higher show rate than those not contacted (NC); and (2) if TC subjects administered a satisfaction questionnaire 1-3 days after intake would exhibit higher treatment retention rates at one week and one month posttreatment entry than NC subjects not exposed to the questionnaire. The findings suggest that reminding prospective patients of their initial scheduled appointments and following up with phone calls to those who fail to show can improve the rate at which patients will initiate treatment, provided initial appointments are scheduled in a timely manner (7 days or less). Similarly, the combination of the reminder call and the satisfaction questionnaire were associated with higher treatment retention rates for those whose initial appointments were scheduled in a timely manner.

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.

A randomized double-blind study of neuroelectric therapy in opiate and cocaine detoxification.

Prior research on the use of transcranial neuroelectric stimulation suggested that the application of low-amperage, low-frequency alternating current via surface electrodes placed in the mastoid region could relieve the physiological signs and subjective symptoms of withdrawal and craving during opiate detoxification. These effects were reported without gradual tapering of the opiate or the addition of other medications. To test the efficacy of one particular form of neuroelectric therapy (NET), a double-blind, randomized, placebo-controlled study was conducted comparing active NET and placebo NET in the treatment of withdrawal and stabilization of 18 opiate-dependent and 25 cocaine-dependent subjects. Scores on scales for measuring substance withdrawal and craving for each abused substance, as well as the multiple dimensions of mood, were compared for degree of difference across the 10 days of treatment. There was an overall completion rate of 88%, with both cocaine and opiate groups reporting a comfortable detoxification and substantial improvement over the course of a 12-day hospitalization. There was no significant difference between the active or placebo groups, suggesting that placebo was as effective as active NET in reducing drug withdrawal or craving during cocaine and opiate detoxification. However, all placebo patients received 0.2 mA of current, which may have provided a degree of active current. Suggestions are offered for future research.