Influence of antisocial personality subtypes on drug abuse treatment response.

This methodological study examined the impact of antisocial personality disorder (APD) and other psychiatric comorbidity on drug use and treatment retention in 513 new admissions to methadone maintenance treatment. Patients were classified into one of four groups: APD ONLY, APD plus other psychiatric disorder (APD MIXED), other psychiatric disorder, and no psychiatric disorder. Patients completed research assessments and were then followed for 1 year of treatment. Patients with APD had longer histories of heroin and cocaine use than non-APD patients and were more likely to meet criteria for cocaine dependence. Distinct clinical profiles emerged that differentiated APD ONLY from APD MIXED. APD ONLY patients exhibited higher rates of cocaine and heroin use, whereas those with APD MIXED exhibited higher rates of benzodiazepine use. Self-report measures supported urinalysis results, but group differences did not affect treatment retention. These differences in clinical profiles should be considered when evaluating treatment performance in substance abusers with APD.

Short-term stability of NEO-PI-R personality trait scores in opioid-dependent outpatients.

The present study examined the short-term stability of personality trait scores from the Revised NEO Personality Inventory (NEO-PI-R) among 230 opioid-dependent outpatients. The NEO-PI-R is a 240-item empirically developed measure of the five-factor model of personality (Neuroticism, Extraversion, Openness, Agreeableness, and Conscientiousness). Participants completed the NEO-PI-R at admission and again approximately 19 weeks later. Results indicated fair to good stability for all NEO-PI-R factor domain scores, with coefficients ranging from .68 to .74. Stability of NEO-PI-R scores was decreased among potentially invalid response patterns but was not significantly affected by drug-positive versus drug-negative status at follow-up.

Influence of psychiatric comorbidity on HIV risk behaviors: changes during drug abuse treatment.

This study evaluated whether psychiatric comorbidity is related to change in HIV high risk behaviors during outpatient drug abuse treatment. Participants were opioid abusers entering methadone treatment. Psychiatric and substance use diagnoses were determined at intake. Information on HIV high risk drug use and sexual behaviors, psychosocial functioning, and urine toxicology was assessed at intake and at month six. Subjects were divided into those with versus without a lifetime comorbid non-substance use psychiatric disorder. The comorbid group reported more injection equipment sharing, lower rates of condom use, and higher rates of alcohol use at intake and follow-up. Overall injection drug use behavior decreased over the follow-up period for both groups, however. Methadone treatment had a beneficial effect on HIV risk behaviors, and though some risk behaviors improved signiticantly for both groups, comorbid subjects continued to have higher rates of HIV risk factors than noncomorbid subjects.

Attention deficit hyperactivity disorder and treatment outcome in opioid abusers entering treatment.

Symptoms of DSM-IV attention-deficit hyperactivity disorder (ADHD) were determined in patients entering methadone maintenance treatment. The relationship of ADHD to psychiatric and substance abuse comorbidity, attention testing, and treatment outcome was analyzed; 19% of patients had a history of ADHD, and 88% of these had current symptoms. Continuous Performance Testing indicated poorer attention in patients with ADHD. The only substance use disorder more common in the ADHD group was clonidine. There was significantly more current axis I, dysthymic disorder, anxiety disorder (including social phobia), and antisocial personality disorder in the ADHD patients. There was no difference between groups at the 1-year follow-up for illicit drug use, treatment retention, or treatment performance. The ADHD diagnosis did not convey significant prognostic implications for methadone maintenance treatment. A strong psychiatric assessment and treatment focus in the treatment program may help to explain the good treatment outcome.

Drug abuse treatment success among needle exchange participants.

OBJECTIVE: Although lowering incidence rates of human immunodeficiency virus (HIV) transmission is the primary goal of needle exchange programs (NEPs), other desirable outcomes are possible. Referring exchange participants to more comprehensive drug abuse treatment programs has the potential to reduce or eliminate the use of drugs. This possibility was evaluated by comparing the treatment responses of new admissions with an outpatient opioid agonist treatment program in Baltimore, Maryland. METHODS: New admissions (1994 - 1997) to an opioid agonist treatment program were first grouped by referral source (needle exchange, n = 82 vs. standard referrals, n = 243) and then compared on admission demographic and clinical variables and response to treatment during the first three months. Outcome measures included retention rates, self-reported drug use and injecting frequencies, self-reported illegal activities for profit, and results from weekly urinalysis testing for opioids and cocaine. RESULTS: Patients from the NEP were significantly older and more likely to be male, African American, and unemployed than standard referral patients. Needle exchange patients also had a greater baseline severity of drug use than patients in the standard referral group. Despite these baseline differences, both groups achieved comparably good short-term treatment outcomes (including reduced drug use and criminal activity for profit); treatment retention was also good, although slightly better in the standard referral group (88% vs. 76%). CONCLUSION: These data demonstrate the feasibility and merits of creating strong linkages between NEPs and more comprehensive drug abuse treatment clinics.

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.

Preliminary evidence of good treatment response in antisocial drug abusers.

Antisocial personality disorder (APD) is a chronic debilitating condition strongly associated with the development and maintenance of severe drug and alcohol use disorder. The overlap of these problems is associated with high rates of personal and social suffering. Available literature consistently point to this as a population in need of effective clinical services. The present study reports preliminary data from a controlled clinical trial aimed at improving the treatment outcomes of antisocial drug abusers using an intensive behavioral approach relying upon a highly structured contingency management intervention. Drug abusers in methadone substitution therapy (n = 40) were assessed for APD and other psychiatric and substance use problems. Patients were randomly assigned to an experimental (n = 20) or control (n = 20) condition following stratification on demographic and selected clinical variables (baseline drug use, evidence of other non-substance use psychiatric diagnoses). Treatment outcome data are presented for the first 17 weeks of participation in the study (4 weeks baseline and 13 weeks randomized treatment), including results of weekly urine drug testing and monthly self-reports of drug use and other psychosocial problems. Patients in both study conditions attained generally good outcomes. These early results suggest that antisocial drug abusers can respond positively to drug abuse treatments with a behavioral focus, but fail to support superior effectiveness for the more intensive intervention used in the experimental condition.

Predictive validity of cocaine, sedative, and alcohol dependence diagnoses.

This study examined the predictive validity of Structured Clinical Interview for DSM-III-R (Spitzer, Williams, Gibbon, & First, 1990) based substance dependence diagnoses (i.e., cocaine, sedative, and alcohol) for 518 opioid-dependent outpatients entering methadone maintenance. Patients were followed over 1 year of treatment, which involved daily methadone substitution supplemented by individual and group counseling. Urine specimens were tested randomly 1-4 times per month. Patients diagnosed with current cocaine, sedative, or alcohol dependence were more likely to use these drugs than were patients with past only or no dependence syndrome. Current cocaine dependence predicted early treatment dropout. The results demonstrate the predictive and discriminant validity of several substance dependence diagnoses common among patients in substance abuse or other psychiatric treatment settings.

Smoking habits and attitudes in a methadone maintenance treatment population.

This study characterized smoking habits and attitudes about quitting in methadone maintenance treatment (MMT) patients, with attention to race and gender differences. Of 179 patients surveyed, 92% (n = 165) were current smokers. These patients reported smoking a mean of 24.8 cigarettes per day. Mean age at smoking initiation was 13.6 years with 53% starting at age 13 or younger. The mean Fagerstrom tolerance questionnaire (FTQ) score was 7.5. Blacks as compared to Whites smoked fewer cigarettes per day (21.6 versus 27.5), had lower expired CO levels (18.8 versus 21.6 ppm), but higher urinary cotinine levels (1812 versus 1419 ng/ml) and were more likely to smoke menthol cigarettes (95 versus 46%). Females scored higher than males on the FTQ measures of nicotine dependence (8.0 versus 7.2), and lower than males on a measure of quit smoking self-efficacy. Subjects in the sample as a whole were well aware of health risks of smoking, as indicated by high scores on health risk perception questions. Sixty-one percent (n = 110) of subjects planned to quit within the next 6 months, 57% were 'very interested' in an on-site quit smoking program and 80% expressed interest in using nicotine replacement products. Overall, these results indicate high rates of smoking in MMT patients, confirm within a drug abusing population prior findings of racial differences in smoking habits, and suggest that MMT patients are interested in quitting and in using nicotine replacement products. The data support feasibility of implementing smoking cessation treatments with this population in a setting that allows for convenient access to patients and close monitoring of progress.

Motivating methadone patients to include drug-free significant others in treatment: a behavioral intervention.

The present study introduced a novel behavioral approach for encouraging methadone-treated patients to bring drug-free significant other support into treatment. Seventy-five patients referred to high-intensity psychosocial treatment due to chronic drug use were given 3 weeks to identify a drug-free significant other. Patients noncompliant with this intervention were started on a methadone dose taper that was stopped when significant other support was identified. Patients and their significant others were required to attend a significant other group one time per week for a minimum of 6 weeks. Eighty-five percent of the patients brought a drug-free significant other into treatment. Significant others included family members, partners, and friends. Patients who identified significant other support complied with 77% of their scheduled sessions. The results demonstrated that most methadone patients have drug-free support people who are willing to participate in their treatment. These individuals can be utilized to help patients initiate the process of building new drug-free social support networks.

Psychiatric and substance use comorbidity among treatment-seeking opioid abusers.

BACKGROUND: Major studies of psychiatric comorbidity in opioid abusers reported rates of comorbidity that far exceeded general population estimates. These studies were published more than a decade ago and reported on few women and few substance use diagnoses. METHODS: Psychiatric and substance use comorbidity was assessed in 716 opioid abusers seeking methadone maintenance. Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition diagnostic assessment was conducted 1 month after admission. Rates of psychiatric and substance use disorder were compared by gender, and associations were assessed between psychiatric comorbidity and dimensional indexes of substance use severity, psychosocial impairment, and personality traits. RESULTS: Psychiatric comorbidity was documented in 47% of the sample (47% women and 48% men). Antisocial personality disorder (25.1%) and major depression (15.8%) were the most common diagnoses. Patients had at least 2 substance use diagnoses, most often opioid and cocaine dependence. Demographics, substance use history, and personality variables discriminated between patients with vs without comorbidity. Psychiatric comorbidity also was associated with a more severe substance use disorder. CONCLUSIONS: Psychiatric comorbidity, especially personality and mood disorder, was common in men and women. The positive associations between psychiatric comorbidity and severity of substance use and other psychosocial problems were most consistent among those with antisocial personality.

Concurrent validity of cocaine and sedative dependence diagnoses in opioid-dependent outpatients.

The present study evaluated the relationship between diagnoses of cocaine and sedative dependence and drug use early in treatment among opioid-dependent patients in methadone substitution therapy. New admissions (n = 138) were assessed via the Structured Clinical Interview for the DSM III-R (SCID) for presence of Axis I and Axis II disorders and followed for five weeks on standard methadone maintenance. Patients submitted urines three times per week tested for opioids, cocaine, and benzodiazepines. Patients diagnosed with current cocaine dependence (n = 90) submitted a higher proportion of cocaine-positive urines (M = 0.84) than patients diagnosed with past cocaine dependence (n = 32; M = 0.28) and those diagnosed with no cocaine use disorder (n = 14; M = 0.12), P < 0.001. Current cocaine dependence diagnosis accounted for 52% of the cocaine use variance. Patients exhibiting current sedative dependence (n = 25) submitted a higher proportion of benzodiazepine-positive urines (M = 0.60) than patients with past sedative dependence (n = 44; M = 0.20) and those with no sedative use disorder (n = 60; M = 0.05), P < 0.001. Current sedative dependence diagnosis accounted for 37% of the benzodiazepine use variance. Lifetime major depression (12%) and antisocial personality disorder (39%) were the most common nonsubstance use comorbid diagnoses. Axis I nonsubstance use disorder was associated with benzodiazepine use, while Axis II disorder was associated with both benzodiazepine and cocaine use early in treatment (P < 0.05). These data demonstrate the concurrent validity of DSM-III-R cocaine and benzodiazepine use diagnoses, and support the potentially important relationship between drug use and other psychiatric disorders.

Evaluating the reinforcement value of clinic-based privileges through a multiple choice procedure.

A novel multiple choice procedure was utilized to evaluate the potential reinforcement value of three clinic-based incentives available during routine methadone treatment: methadone take-homes, methadone dose increases, and extra counseling. Fourteen methadone maintenance patients who were not earning any of these incentives completed a multiple choice form in which they made choices between pairs of incentives and subsequently between each incentive and a series of monetary values. Choice behavior was intermittently reinforced by randomly awarding to patients one of their chosen preferences. Results demonstrated that take-homes were worth US$20.24 and were rated as more desirable than dose increases (US$13.89) and extra counseling (US$7.47). The study updates and extends past research in this area and provides a methodology for establishing both a monetary value for clinic-based incentives and an absolute magnitude between preferences. The procedure could be used to examine a larger number of potential reinforcers and to understand individual differences in responding to incentive-based treatment programs.

Alcohol expectancies and changes in beer consumption of first-year college students.

The present study used a prospective design to evaluate the relationship between alcohol expectancies and the progression of beer consumption of first-year college students over a 2-month period. One hundred and fifty-four first-year undergraduate students completed the Alcohol Expectancy Questionnaire (AEQ; Brown, Goldman, Inn, & Anderson, 1980) and a measure of precollege drinking during their first week of college, and completed a retrospective diary account of alcohol consumption also during the first week and at 1-month and 2-month follow-up. Beer was consumed considerably more frequently than other alcoholic beverages and was used as the dependent measure. The results showed that each AEQ subscale was positively correlated with beer consumption at almost all time points, and the magnitude of these correlations was generally higher for male subjects. Furthermore, the expectancies that alcohol increases social assertiveness and that alcohol is associated with global, positive changes were positively correlated with increases in beer consumption from Session 1 to Session 2 and from Session 1 to Session 3 for male, but not female, subjects. The findings extend previous research by demonstrating that certain alcohol expectancies are related to progressive increases over time in the amount of beer consumed.

Contingent methadone take-home doses reinforce adjunct therapy attendance of methadone maintenance patients.

Two studies utilized within-subjects designs to determine whether take-home methadone doses can reinforce adjunct therapy attendance of drug abuse patients. These studies varied the reinforcement density and the schedule of methadone take-home doses. In Study 1, patients (n = 10) either could or could not receive a take-home following each therapy session. Study 2 patients (n = 15) could either earn take-homes following each therapy session attended (i.e., 2 take-homes per week) or could earn one take-home dose following each attendance to two consecutive sessions attended. In both studies experimental conditions alternated during three-week blocks of time. Across studies, any reinforcement by take-home doses produced more attendance at therapy sessions than that observed in the no reinforcement condition. Take-home incentive effects were strongest when each of the two weekly therapy sessions was reinforced by a methadone take-home dose. Increased attendance was not associated with reduced drug use, due perhaps to high rates of pre-study drug use and limited therapy duration. Contemporary opioid abusers present with multiple problems that methadone was never intended to treat. The present studies illustrate a method by which methadone treatment can improve the likelihood of delivering other services that may prove effective in treating some of these problems.

Descriptive analysis of cocaine use of methadone patients.

The increasing prevalence of cocaine use among opioid-dependent participants in methadone treatment has been documented, but there is little information about the quantity-frequency aspects of use. This study examined the cocaine use of methadone maintenance patients to determine amounts and patterns of use as well as use in combination with other drugs. Forty-five cocaine using methadone maintenance patients (78% used i.v.) reported their drug use for each day over the past 7 days after receiving information about their most recent urinalysis test results. Average reported use was 0.23 g cocaine/day on 3.4 days/week. Heroin and cocaine were typically used simultaneously, while only a subset of patients (47%) who used alcohol drank within close proximity to cocaine. Patients who used cocaine with alcohol and/or heroin on the same day (N = 28) reported more cocaine use (M = 1.0 g/week) than patients who used cocaine alone (N = 17; M = 0.49 g/week). The results suggest that methadone maintenance patients generally engage in relatively low dose cocaine use, especially when compared to non opioid dependent patients applying to cocaine treatment programs. The study further shows that patients had clear preferences for drug use combinations, which suggests that interventions for cocaine use might focus on modifying drugs used in combination with cocaine.

Beverage preference, beverage type and subject gender as determinants of alcohol consumption in the laboratory.

Effects of beverage preference, beverage type and subject gender on ad libitum consumption of alcoholic beverages in the laboratory were evaluated. Undergraduate social drinkers (18 male, 18 female), with equal numbers of each gender stating a preference for beer, wine or mixed drinks, were selected. Subjects participated in three separate 30-minute ad lib drinking sessions and were presented with one of the three types of alcoholic beverage at each session. Data on total volume of beverage and of absolute ethanol consumed as well as blood alcohol concentration (BAC) attained were collected in each session. Subjects preferring wine or mixed drinks drank more alcohol and reached higher BACs when imbibing their beverage of choice than when drinking non-preferred beverages. Subjects preferring beer, however, showed no differences on these drinking measures as a function of beverage type. Men's reports of routine alcohol use had a high positive correlation with actual alcohol consumption observed in the laboratory, whereas for female subjects the correlation was near zero. Implications for interpretation of past ad lib drinking studies and the planning of future ones are discussed.