The effect of an abuse-deterrent opioid formulation (OxyContin) on opioid abuse-related outcomes in the postmarketing setting.

An extended-release opioid analgesic (OxyContin, OC) was reformulated with abuse-deterrent properties to deter abuse. This report examines changes in abuse through oral and nonoral routes, doctor-shopping, and fatalities in 10 studies 3.5 years after reformulation. Changes in OC abuse from 1 year before to 3 years after OC reformulation were calculated, adjusted for prescription changes. Abuse of OC decreased 48% in national poison center surveillance systems, decreased 32% in a national drug treatment system, and decreased 27% among individuals prescribed OC in claims databases. Doctor-shopping for OC decreased 50%. Overdose fatalities reported to the manufacturer decreased 65%. Abuse of other opioids without abuse-deterrent properties decreased 2 years later than OC and with less magnitude, suggesting OC decreases were not due to broader opioid interventions. Consistent with the formulation, decreases were larger for nonoral than oral abuse. Abuse-deterrent opioids may mitigate abuse and overdose risks among chronic pain patients.

Development and preliminary experience with an ease of extractability rating system for prescription opioids.

One important factor in the abuse potential of an opioid product is the ease with which active drug can be extracted. There are currently no standards for testing or reporting extractability. This article describes the development of an Extractability Rating System for use by the pharmaceutical industry and regulators. Despite several limitations, this effort serves as a call for standardized testing and reporting so that products can be accurately rated, and should help establish goals for drug developers who wish to develop "abuse-resistant" opioid products.

Initial validation of a computer-administered Addiction Severity Index: the ASI-MV.

The Addiction Severity Index--Multimedia Version (ASI-MV) is a CD-ROM-based simulation of the interviewer-administered Addiction Severity Index (ASI). Clients in treatment (N = 202) self-administered the ASI-MV to examine the test-retest reliability, criterion validity, and convergent-discriminant validity of the ASI-MV. Excellent test-retest reliability was observed for composite scores and severity ratings. Criterion validity, tested against the interviewer-administered ASI, was good for the composite scores. For severity ratings, variable agreement was observed between the ASI-MV and each interviewer, suggesting poor interrater reliability among interviewers. This conclusion was bolstered by a finding of superior convergent-discriminant validity for both composite scores and severity ratings compared to the standard ASI. The ASI-MV is a viable alternative to the expensive and potentially unreliable interviewer-administered version.

The role of therapist characteristics in training effects in cognitive, supportive-expressive, and drug counseling therapies for cocaine dependence.

The role of therapist characteristics in therapy training was examined for 62 therapists in a multisite psychotherapy outcome study that included cognitive therapy (CT), supportive-expressive (SE) psychodynamic therapy, and individual drug counseling (IDC) for cocaine-dependent patients. Demographic variables and experience and competence ratings prior to training were correlated with measures of change in competence during the training phase. Higher competence ratings before training were associated with greater change in competence for SE and higher average competence for IDC. More years of experience were associated with greater change in competence for CT therapists, but more hours of pre-training supervision in the CT treatment modality were associated with less change.

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.

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.

The National Institute on Drug Abuse Collaborative Cocaine Treatment Study. Rationale and methods.

The National Institute on Drug Abuse Collaborative Cocaine Treatment Study is a large, multisite psychotherapy clinical trial for outpatients who meet the DSM-IV criteria for cocaine dependence. For 480 randomized patients, the outcomes of 4 treatments are compared for an 18-month period. All treatments include group drug counseling. One treatment also adds cognitive therapy, one adds supportive-expressive psychodynamic therapy, and one adds individual drug counseling; one consists of group drug counseling alone. In addition, 2 specific interaction hypotheses, one involving psychiatric severity and the other involving degree of antisocial personality characteristics, are being tested. This article describes the main aims of the project, the background and rationale for the study design, the rationale for the choice of treatments and patient population, and a brief description of the research plan.

A comprehensive system for value accounting in psychiatry.

This article describes a clinical management tool, the Value Accounting System, developed for use by a national organization of psychiatric treatment facilities. The system integrates patient case-mix variables with data on services provided, key administrative and clinical processes, clinical effectiveness, and cost/price. A comprehensive database links critical quality information with fiscal information, yielding a management tool that is national in scope, standardized, and versatile enough (1) to address general questions of the effectiveness and value of psychiatric services and (2) to provide an empirical base for rational, clinical management decision making. Descriptive data are presented from an attempt to establish a database and implement the system. The management and scientific potential of the Value Accounting System to improve the quality and efficiency of mental health services are discussed.

Affective comorbidity in children and adolescents with attention deficit hyperactivity disorder.

Recent research examining comorbidity associated with attention deficit hyperactivity disorder (ADHD) has raised the possibility of the existence of subtypes of the disorder. If this is the case, delineating subgroups is clinically imperative. Two hundred seventy nonrepetitive, consecutively admitted children and adolescent inpatients received structured diagnostic interviews (Schedule for Affective Disorders and Schizophrenia in School Aged Children). Twenty-eight percent of these children met the criteria for ADHD. Of those children with an ADHD diagnosis, 68% also met the criteria for an affective disorder. Thirty-six percent met the full criteria for major depression disorder. Eight percent met the criteria for an affective psychosis and 22% were diagnosed with bipolar disorder. There was a significant overlap between ADHD and bipolar disorder, suggesting the possibility of a lack of specificity in the diagnostic instruments used in this population. The results support the clinical necessity of carefully assessing for occult affective illness in all children and adolescents with attention deficit disorder.

Effects of training in time-limited dynamic psychotherapy: changes in therapist behavior.

Sixteen therapists participated in a year-long manualized training program as part of the Vanderbilt II study of time-limited dynamic psychotherapy. Changes in therapist behavior were measured with the Vanderbilt Therapeutic Strategies Scale (an adherence measure), the Vanderbilt Psychotherapy Process Scale (VPPS), and interpersonal process codings using the Structural Analysis of Social Behavior (SASB). The training program successfully changed therapists' technical interventions in line with the manualized protocol. After training, there was increased emphasis on the expression of in-session affect, exploration of the therapeutic relationship, an improved participant-observer stance, and greater use of open-ended questions. There was also an indication of unexpected deterioration in certain interpersonal and interactional aspects of therapy as measured by the VPPS and SASB ratings. These results question the assumption that greater control of the therapy variable is straightforwardly achieved with manuals and adherence scales. Changing or dictating specific therapist behaviors to achieve technical adherence may alter other therapeutic variables in unexpected and even counterproductive ways.

Effects of training in time-limited dynamic psychotherapy: mediators of therapists' responses to training.

Sixteen therapists were enrolled in a year-long manualized training program as part of the Vanderbilt II study of time-limited dynamic psychotherapy (TLDP). The training program successfully changed therapists' interventions in line with prescriptions of the TLDP manual, but some unanticipated changes ran counter to the intent of the training, including increased negative interpersonal transactions as indicated by process measures such as the Structural Analysis of Social Behavior (SASB). We examined therapist variables, patient variables, and training variables that appeared to mediate therapist responses to the training program. Results indicate that patient difficulty may mediate certain aspects of therapists' responses to training. Therapists with self-reported hostile and controlling introjects showed the greatest technical adherence, which was intriguing because prior research has linked hostile therapist introject to greater frequency of counter-therapeutic interpersonal process. Of special interest were differences in effects of training associated with individual training faculty. This finding, if generalizable, has important implications for manualized therapy research, especially multisite trials.

Assessment of Axis II personality disorders among female substance abusers.

16 female substance abusers were assessed for the presence of personality disorders using two structured interviews and two self-report questionnaires. Although high prevalence of personality disorders was detected by each instrument, there was little agreement among the four methods for assessing these disorders.

Cyclical psychodynamics and the triangle of insight: an integration.

This paper attempts to integrate a recent dynamic conceptualization of patients' problems known as "cyclical maladaptive pattern" (Strupp and Binder 1984) with a more traditional model, the "triangle of insight" (Menninger 1958). The integration is offered as an effort to illustrate the theoretical continuity of the two models. The integrated model also serves as a useful step toward improved specification of the principles and procedures implicit in the creation of a comprehensive psychodynamic formulation, potentially enhancing research, training, and the clinical practice of psychodynamic psychotherapy. An illustrative case is presented.

The effects of thematic context and presentation mode on memory for sentence voice.

A sentence in discourse may appear in the passive voice to emphasize the logical object rather than the logical subject when it is thematically more important. Two experiments are reported that explore the impact of this textual function of voice on sentence memory. The first experiment required subjects to listen to prose passages and then recall them. Sentences were recalled predominantly in the active voice regardless of voice or thematic focus in the prose passage, showing that the English-language bias for the active voice was a more important determinant of sentence reconstruction than was the experiment manipulation of thematic context. The second experiment required subjects to listen to or read either prose passages or lists of unrelated sentences and then to try to recognize "key" sentences that were either unchanged or changed lexically, semantically, or in voice. Recognition, both overall and specifically for voice, was better for sentences that were read than for those that were heard, and recognition for semantic change was consistently higher than for any other. Only when passages were read was there evidence in support of a thematic textual influence on memory for sentence voice.