Short term health-related quality of life improvement during opioid agonist treatment.

BACKGROUND: Opioid dependence is associated with high levels of morbidity, yet sparse data exists regarding the health-related quality of life (HRQoL) of individuals with opioid dependence, particularly following treatment initiation. To inform cost-effectiveness analyses of treatment modalities, this study investigates short-term changes in HRQoL following enrollment into opioid agonist treatment (OAT), across treatment modalities and patient subgroups. METHODS: Data was analyzed from the Starting Treatment with Agonist Replacement Therapies (START) and Prescription Opioid Addiction Treatment Studies (POATS) randomized controlled trials. Participants included individuals dependent on prescription opioids (POs) or heroin, receiving limited-term or time-unlimited treatment. PO- or heroin-users in START received buprenorphine/naloxone (BUP/NX) or methadone (MET) over 24 weeks. PO-users in POATS received psychosocial care and short-term (4-week) taper with BUP/NX, with non-responders offered subsequent extended (12-week) stabilization and taper. HRQoL was assessed using the short-form SF-6D while in and out of OAT, with distinction between MMT and BUP/NX in START. Linear mixed effects regression models were fitted to determine the independent effects of OAT on HRQoL and characterize HRQoL trajectories. RESULTS: Treatment had a similar immediate and modest positive association with HRQoL in each patient subgroup. The association of OAT on HRQoL was statistically significant in each model, with effect sizes between 0.039 (heroin-users receiving BUP/NX) and 0.071 (PO-users receiving MET). After initial improvement, HRQoL decreased slightly, or increased at a diminished rate. CONCLUSIONS: OAT, whether delivered in time-limited or unlimited form, using BUP/NX or MET, is associated with modest immediate HRQoL improvements, with diminishing benefits thereafter.

Prospective 12-month course of bipolar disorder in out-patients with and without comorbid anxiety disorders.

BACKGROUND: The impact of anxiety disorders has not been well delineated in prospective studies of bipolar disorder. AIMS: To examine the association between anxiety and course of bipolar disorder, as defined by mood episodes, quality of life and role functioning. METHOD: A thousand thousand out-patients with bipolar disorder were followed prospectively for 1 year. RESULTS: A current comorbid anxiety disorder (present in 31.9% of participants) was associated with fewer days well, a lower likelihood of timely recovery from depression, risk of earlier relapse, lower quality of life and diminished role function over I year of prospective study. The negative impact was greater with multiple anxiety disorders. CONCLUSIONS: Anxiety disorders, including those present during relative euthymia, predicted a poorer bipolar course. The detrimental effects of anxiety were not simply a feature of mood state. Treatment studies targeting anxiety disorders will help to clarify the nature of the impact of anxiety on bipolar course.

3,4-methylenedioxymethamphetamine (MDMA): a review.

This article reviews the history, pharmacology, and adverse events associated with the use of 3,4-methylenendioxymethamphetamine (MDMA), commonly known as Ecstasy. Past research describing the neurotoxic effects of MDMA in animals, current research on the neurotoxic effects of MDMA in humans, and the attendant changes in psychologic functioning will be highlighted in this review. Finally, the limitations of human research on the effects of MDMA and suggestions for future MDMA research will be discussed.

Opioid antagonists in the treatment of alcohol dependence.

This article reviews the use of opioid antagonists in the pharmacologic treatment of alcohol dependence. The rationale for using the opioid antagonists naltrexone and nalmefene to prevent relapse in alcohol-dependent subjects is discussed by reviewing past and current clinical trials. The role of psychotherapies, particularly coping skills therapy, in combination with opioid antagonists is highlighted in the presentations of the clinical data. Finally, future research directions for opioid antagonists are discussed.

Impact of psychosocial treatments on associated problems of cocaine-dependent patients.

A previous report from the National Institute on Drug Abuse Collaborative Cocaine Treatment Study (P. Crits-Christoph et al., 1999) found relatively superior cocaine and drug use outcomes for individual drug counseling plus group drug counseling compared with other treatments. Using data from that study, the authors examined the relative efficacy of 4 treatments for cocaine dependence on psychosocial and other addiction-associated problems. The 487 patients were randomly assigned to 6 months of treatment with cognitive therapy, supportive-expressive therapy, or individual drug counseling (each with additional group drug counseling), or to group drug counseling alone. Assessments were made at baseline and monthly for 6 months during the acute treatment phase, with follow-up visits at 9 and 12 months. No significant differences between treatments were found on measures of psychiatric symptoms, employment, medical, legal, family-social, interpersonal, or alcohol use problems. The authors concluded that the superiority of individual drug counseling in modifying cocaine use does not extend broadly to other addiction-associated problems.

Therapeutic alliance as a predictor of outcome and retention in the National Institute on Drug Abuse Collaborative Cocaine Treatment Study.

The authors examined the relation between therapeutic alliance, retention, and outcome for 308 cocaine-dependent outpatients participating in the National Institute on Drug Abuse Collaborative Cocaine Treatment Study. High levels of alliance were observed in supportive-expressive therapy (SE), cognitive therapy (CT), and individual drug counseling (IDC), and alliance levels increased slightly but significantly from Session 2 to Session 5 in all groups. In contrast to other studies, alliance was not a significant predictor of drug outcome. However, alliance did predict patient retention differentially across the 3 treatments. In SE and IDC, either higher levels of alliance were associated with increased retention or no relationship between alliance and retention was found, depending on the time alliance was measured. In CT, higher levels of alliance were associated with decreased retention.

Pharmacotherapies for cocaine dependence.

This article reviews the history of pharmacologic trials for the treatment of cocaine dependence as well as current treatments under investigation. The rationale for use of agents such as dopaminergic agents, antidepressants, and anticonvulsants is discussed. Early clinical trials with pharmacologic agents have demonstrated both positive and negative results; the possible reasons for these mixed outcomes is also discussed. Recent studies focusing on disulfiram, dopamine-selective antagonists, citicoline, aspirin, and a cocaine-specific vaccine are presented to highlight innovative and potentially effective treatments for individuals with cocaine dependence.

Predictors of self-help group attendance in cocaine dependent patients.

OBJECTIVE: While referral to self-help groups for patients dependent on drugs other than alcohol has become widespread in the substance abuse treatment field, little is known about the characteristics of people who attend these groups. This study examines particular sociodemographic and clinical characteristics as possible predictors of attendance at self-help groups in the National Institute on Drug Abuse Collaborative Cocaine Treatment Study. METHOD: A multicenter study randomly assigned 487 patients (76.8% men) to one of four psychosocial treatments for cocaine dependence. Patients were treated for 24 weeks. Among other measures, the Weekly Self-Help Questionnaire was administered each week and completed, at least once, by 411 subjects. RESULTS: Approximately two thirds of the patients attended one or more self-help meetings during the 24-week period. Patients initially more likely to attend self-help groups frequently were those who were unemployed, had no religious preference, had more severe baseline drug use and reported treatment for prior substance-related problems. Patients with more severe baseline drug use and those who previously received treatment for substance-related problems were more likely to maintain frequent attendance throughout the study period. Only severity of baseline drug use predicted more frequent attendance during Month 6, although there was a trend in Month 6 favoring more frequent attendance by women. These findings remained significant when treatment condition was added to the models. CONCLUSIONS: Although these findings are consistent with past research on alcohol dependent individuals, they challenge popular clinical notions about the types of people who attend self-help groups. These findings demonstrate that self-help groups can appeal to a wide variety of cocaine dependent patients.

The use of collateral reports for patients with bipolar and substance use disorders.

This study investigated the value of collateral informant reports of substance use for patients with current bipolar disorder and substance dependence. We collected collateral informant reports on 132 occasions for 32 patients and found a high level of agreement between collateral reports and self-report/urine screen data (75.0%). In only 3 instances did collateral informants report substance use for patients who denied use and had negative urine screens. Frequency of contact between informants and patients was associated significantly with the level of agreement. These findings suggest that obtaining collateral informant data when studying this population may be of limited value.

Self-help group attendance and participation among cocaine dependent patients.

The authors examined frequency and patterns of self-help group attendance and active participation over a 6-month period among 411 patients receiving treatment in the NIDA Collaborative Cocaine Treatment Study. Nearly two-thirds of patients attended at least one self-help group, and nearly all of these actively participated. Alcoholics Anonymous and Narcotics Anonymous meetings were attended most frequently. Statistical analyses included chi square, one-way analyses of variance, and cluster techniques. While patterns of attendance were relatively consistent over time, findings suggest that a treatment emphasizing the importance of self-help groups is likely to encourage more self-help group attendance and participation over time.

Group therapy for patients with bipolar disorder and substance dependence: results of a pilot study.

BACKGROUND: The authors' goal was to pilot test a newly developed manual-based group psychotherapy, called Integrated Group Therapy (IGT), for patients with bipolar disorder and substance dependence. METHOD: In this open trial, patients with DSM-IV bipolar disorder and substance dependence (N = 45) were recruited in sequential blocks to receive either group therapy (N = 21) or 6 monthly assessments, but no experimental treatment (N = 24). RESULTS: When compared with patients who did not receive group therapy, patients who received IGT had significantly better outcomes on the Addiction Severity Index drug composite score (p < .03), percentage of months abstinent (p < .01), and likelihood of achieving 2 (p < .002) or 3 (p < .004) consecutive abstinent months. CONCLUSION: IGT is a promising treatment for patients with bipolar disorder and substance dependence, who have traditionally had poor outcomes. It is unclear, however, how much of the improvement among the group therapy patients is attributable to the specific content of the treatment. A study comparing this treatment with another active psychotherapy treatment is warranted.

The relationship of self-efficacy expectancies to relapse among alcohol dependent men and women: a prospective study.

OBJECTIVE: We studied the relationship of self-efficacy expectancies measured during inpatient alcohol treatment and time to first drink and time to relapse following hospitalization. We also examined whether the relationship of in-hospital self-efficacy and posttreatment drinking outcome differed by gender. METHOD: We measured self-efficacy expectancies using the Situational Confidence Questionnaire (SCQ) in 100 subjects (59 men) during inpatient treatment for alcohol dependence. We followed subjects monthly for 1 year and examined the relationship of their in-hospital SCQ scores to posttreatment drinking behavior, as measured by time to first drink, time to relapse and percent abstinent days. RESULTS: Self-efficacy during hospitalization was related to relapse during the 12 months following hospitalization. Survival analysis demonstrated that in-hospital SCQ scores greater than 45 were predictive of better drinking outcomes. The median number of days to relapse after treatment were 30 and 135, respectively, in those with in-hospital SCQ scores less than or equal to 45 compared with those with SCQ scores greater than 45. There were no gender differences in self-efficacy measured during hospitalization, nor were there gender differences in the relationship of self-efficacy to time to relapse. However, men with SCQ scores less than or equal to 45 had fewer abstinent days during follow-up. CONCLUSIONS: Among both men and women being treated for alcohol dependence, a cut-off score of 45 on the SCQ may be especially important in helping clinicians assess patients who are at high risk for more rapid return to drinking after hospitalization.

Utilization of psychosocial treatments by patients diagnosed with bipolar disorder and substance dependence.

We investigated psychosocial treatment interventions, mood symptoms, and substance use among 24 patients with bipolar disorder and substance dependence. Patients were assessed for 6 months following hospital discharge. Psychotherapy and Alcoholics Anonymous (AA) attendance decreased over time. Moreover, the focus of patients' psychotherapy changed over time, with decreasing emphasis on the patients' specific disorders. Mood symptoms and substance use did not change significantly over time, although there was a trend toward more frequent drug use over time. These findings point to infrequent utilization over time of psychosocial treatments focusing specifically on bipolar and substance use disorder.

Psychosocial treatments for cocaine dependence: National Institute on Drug Abuse Collaborative Cocaine Treatment Study.

BACKGROUND: This was a multicenter investigation examining the efficacy of 4 psychosocial treatments for cocaine-dependent patients. METHODS: Four hundred eighty-seven patients were randomly assigned to 1 of 4 manual-guided treatments: individual drug counseling plus group drug counseling (GDC), cognitive therapy plus GDC, supportive-expressive therapy plus GDC, or GDC alone. Treatment was intensive, including 36 possible individual sessions and 24 group sessions for 6 months. Patients were assessed monthly during active treatment and at 9 and 12 months after baseline. Primary outcome measures were the Addiction Severity Index-Drug Use Composite score and the number of days of cocaine use in the past month. RESULTS: Compared with the 2 psychotherapies and with GDC alone, individual drug counseling plus GDC showed the greatest improvement on the Addiction Severity Index-Drug Use Composite score. Individual group counseling plus GDC was also superior to the 2 psychotherapies on the number of days of cocaine use in the past month. Hypotheses regarding the superiority of psychotherapy to GDC for patients with greater psychiatric severity and the superiority of cognitive therapy plus GDC compared with supportive-expressive therapy plus GDC for patients with antisocial personality traits or external coping style were not confirmed. CONCLUSION: Compared with professional psychotherapy, a manual-guided combination of intensive individual drug counseling and GDC has promise for the treatment of cocaine dependence.

Opioid withdrawal during risperidone treatment.

A small but significant percentage of opioid-dependent patients will require neuroleptic treatment. Several classes of drugs have been shown to affect opioid metabolism. Two patients who were hospitalized with a diagnosis of opioid dependence received concomitant treatment with opioids and risperidone. After receiving risperidone for several days, both patients exhibited symptoms of opioid withdrawal despite having no change in their opioid doses. These withdrawal symptoms resolved soon after risperidone was discontinued. This finding suggests the possibility that risperidone may precipitate opioid withdrawal in opioid-dependent patients.

A relapse prevention group for patients with bipolar and substance use disorders.

Although bipolar disorder is the Axis I disorder associated with the highest risk of having a coexisting substance use disorder, no specific treatment approaches for this dually diagnosed patient population have thus far been developed. This paper describes a 20-session relapse prevention group therapy that the authors have developed for the treatment of patients with coexisting bipolar disorder and substance use disorder. The treatment uses an integrated approach by discussing topics that are relevant to both disorders and by highlighting common aspects of recovery from and relapse to each disorder.

"Seeking safety": outcome of a new cognitive-behavioral psychotherapy for women with posttraumatic stress disorder and substance dependence.

Women with current posttraumatic stress disorder (PTSD) comprise 30-59% of substance abuse treatment samples and experience a more severe course than women with either disorder alone. As yet, no effective treatment for this population has been identified. This paper reports outcome results on 17 women who completed a new manual-based 24-session cognitive behavioral group therapy protocol treatment, based on assessments at pretreatment, during treatment, posttreatment, and at 3-month follow-up. Results showed significant improvements in substance use, trauma-related symptoms, suicide risk, suicidal thoughts, social adjustment, family functioning, problem solving, depression, cognitions about substance use, and didactic knowledge related to the treatment. Patients' treatment attendance, alliance, and satisfaction were also very strong. Treatment completers were more impaired than dropouts, yet more engaged in the treatment. Overall, our data suggest that women with PTSD and substance abuse can be helped when provided with a treatment designed for them. All results are clearly tentative, however, due to the lack of a control group, multiple comparisons, and absence of assessment of dropouts.

Medication compliance among patients with bipolar disorder and substance use disorder.

BACKGROUND: This study examined patterns of medication compliance and reasons for noncompliance among patients with bipolar disorder and substance use disorder. METHOD: Forty-four patients with current bipolar disorder and substance use disorder were administered a structured interview regarding lifetime compliance with prescribed psychotropic medications. RESULTS: Patients who were prescribed both lithium and valproate were significantly (p = .03) more likely to report full compliance with valproate than with lithium. Side effects were the most common reason for lithium noncompliance, but were not cited as a reason for valproate noncompliance. Also, a common pattern of noncompliance among patients prescribed benzodiazepines, neuroleptics, and tricyclic antidepressants was the use of more medication than prescribed. CONCLUSION: Valproate may have greater acceptability than lithium among patients with bipolar disorder and substance use disorder. Clinicians should also be aware that these patients may take higher doses of medication than prescribed.

The Addiction Severity Index as a screen for trauma and posttraumatic stress disorder.

OBJECTIVE: The Addiction Severity Index (ASI) includes items to assess patients' history of trauma (physical or sexual). The goal of this study was to assess the sensitivity and specificity of those questions in relation to the Trauma History Questionnaire (THQ), a more thorough measure of lifetime trauma and, in addition, to an actual posttraumatic stress disorder (PTSD) diagnosis. METHOD: At the start of treatment cocaine dependent outpatients (N = 110, 65.5% male) were assessed on the ASI, the THQ and a PTSD symptom checklist as part of a multisite clinical trial. RESULTS: Specificity of the ASI questions was higher than sensitivity for both sexual trauma (specificity = .96, sensitivity = .46) and physical trauma (specificity = .71, sensitivity = .50), while for PTSD the sensitivity of the ASI (.91) was higher than its specificity (.43). Other findings indicated that patients were more likely to report trauma on the THQ than on the ASI (which may be due to the self-report format of the THQ); that the ASI was better at assessing sexual than assessing physical trauma; and that the higher the number of ASI trauma items endorsed, the more likely was the PTSD diagnosis. Finally, PTSD patients had greater severity than non-PTSD patients on other ASI items (e.g., psychological severity, need for treatment). CONCLUSIONS: The ASI trauma questions show stronger utility as a screen for PTSD than for trauma. Results of the study are discussed in light of ways to modify the ASI to screen more accurately for trauma, clinical implications, and limitations of the study method.