Changes in Millon Clinical Multiaxial Inventory scores among opiate addicts as a function of retention in methadone maintenance treatment and recent drug use.

The Millon Clinical Multiaxial Inventory (MCMI) was administered to 144 men and 86 women within 1 month of admission to methadone maintenance treatment and was readministered 18 months following admission. Based on prior research, we hypothesized there would be significant decreases on scales measuring affective disturbance, anxiety, and social isolation and little change in scales measuring antisocial and narcissistic traits. In addition, it was hypothesized that changes on the MCMI would be related to retention in treatment and illicit drug use during the interim between initial assessment and follow-up. Data were analyzed using a multivariate analysis of variance (MANOVA) for repeated measures. There was an overall decrease in MCMI scores, indicating less psychopathology between initial assessment and follow-up. MCMI scales did not change as a function of retention status, but decreases in MCMI scale scores were greater for subjects who were light drug users in the 6 months prior to the follow-up compared to heavy users. Inspection of individual MCMI scales supported our hypothesis; there were decreases on scales measuring affective disturbance, anxiety, and social isolation, but not on scales measuring antisocial and narcissistic traits.

An innovative approach to reducing cannabis use in a subset of methadone maintenance clients.

Cannabis use rates among methadone maintenance clients are high. We attempted to decrease cannabis use in our most stable clients by adding a requirement to the take home dose policy that clients provide cannabis free urines to achieve twice a week pick up status (2 x /week). The urine records and take home status of all clients were monitored for the 6 months prior to implementation of the policy change and 1 year following. A total of four of eight clients (50%) on 2 x /week status who were using cannabis discontinued their use in order to maintain 2 x /week status or to return to 2 x /week status if it had been lost.

A pilot study comparing severely and persistently mentally ill opiate-addicted patients in dual-diagnosis treatment with patients in methadone maintenance.

The authors describe a severely and persistently mentally ill (SPMI) opiate-addicted (OA) patient sample (n = 43) in a dual-diagnosis outpatient treatment program by demographic, clinical, and treatment characteristics and compare these with other dually diagnosed SPMI patients in the same treatment center (n = 297). Also, those SPMI/OA patients with physiological dependence (n = 20) were compared with a matched sample of OA patients in traditional methadone maintenance (n = 20). The authors then present a clinical evaluation of treatment course and outcome for the SPMI/OA patients (n = 43) and discuss implications from these pilot data.

Outcome of a second episode of methadone maintenance.

This paper reports the treatment progress of methadone maintenance clients who were discharged or withdrew from treatment and then were readmitted for a second episode of treatment. Thirty-nine clients in a contingency contract condition remained in treatment long enough (6 months) during both the initial and a second treatment episode, to be exposed to discharge sanctions that were part of the contingency contract. Of these clients 34 failed treatment during the initial treatment episode. Nine (26%) of these initial treatment failures improved their performance in the second episode compared to the first, and only one (20%) of five initial treatment successes who left treatment during their first treatment episode for non-contract reasons showed a poorer performance (failing the second after succeeding in the first episode). Of 17 clients in a condition that applied no contingencies for positive urines, three of 14 (21%) who failed during the initial treatment episode improved their performance, and two of three (67%) who succeeded during the initial treatment episode failed in the second episode. For a subset of clients the efficacy of contingency contracting may not be realized until it is reapplied during a subsequent admission.

Retention in methadone maintenance is associated with reductions in different HIV risk behaviors for women and men.

Using AIDS Initial Assessment questionnaire (AIA) data from 353 injection drug users (IDUs) newly admitted to methadone maintenance (MM), three dimensions of injection risk behavior ("sharing with sexual partner," "sharing with others," and "new needle use") were identified. Among IDUs who continued to inject drugs at 1 year, men retained in treatment obtained lower scores on the "sharing with others" scale than men not retained, even when controlling for initial scale scores and injection frequency. Associations between retention in MM and changes in sexual risk were examined using two AIA measures of sexual risk behavior ("number of IDU sexual partners" and "relative frequency of protected vaginal intercourse"). Controlling for injection frequency, prior sexual risk, and age, there was no difference in sexual risk for men retained in treatment versus those not retained. Among women, those who stayed in MM for 1 year reported significantly fewer IDU partners.

Pre-treatment characteristics, program philosophy and level of ancillary services as predictors of methadone maintenance treatment outcome.

Predictors of methadone maintenance treatment outcome have not been extensively studied as they relate to variations in program philosophy, nor have such predictors received much examination among recently treated, older cohorts of opioid addicts for whom drug use patterns have changed. Predictors of outcome were examined at 18 months post-treatment entry for 353 admissions to methadone maintenance who received random assignment to one of three counseling conditions: (1) medication only, (2) standard counseling and (3) enhanced services; and one of two contingency conditions: (1) no contingencies, and (2) contingency contracting in a six-cell 3 x 2 design. Subjects in contingency contracting conditions were placed on contingency contracts for positive urine toxicology results and ultimately discharged for unremitting drug use. All subjects completed the Addiction Severity Index (ASI) and provided weekly urine specimens. Predictors of urinalysis results and treatment retention were determined using bivariate and multivariate techniques. Interactions between subject characteristics by experimental condition assignment were also examined as predictors. Higher rates of total positive urine specimens were predicted by younger age, greater pre-treatment frequency of smoking cocaine, lower ASI psychiatric composite scores, and higher ASI legal composite scores. Higher rates of opiate positive specimens were predicted by younger age, lower pre-treatment frequency of alcohol intoxication, higher ASI legal and lower ASI employment and psychiatric composite scores, and assignment to medication only/no contingencies condition. Higher rates of cocaine positives were predicted by younger age, black race, lower ASI psychiatric composite score, greater pre-treatment frequency of intravenous and smoked cocaine use, less pre-treatment frequency of marijuana use, and lower methadone dose level. Assignment to enhanced/contingency contracting predicted lower rates of cocaine positives. Treatment retention was predicted by older age, non-black race, lower ASI legal composite score, higher methadone dose level and assignment to non-contingent conditions. While subject variables over which treatment providers have little control were, thus, related to outcome, type of treatment provided and methadone dose also influenced outcome.

Effects of psychiatric care for dual diagnosis patients treated in a drug dependence clinic.

This study examines outcome of treatment for psychoactive substance dependence in a clinic which made psychiatric care readily available. Veterans entering outpatient treatment for substance dependence (n = 222) received psychiatric evaluation for additional Axis I disorders using DSM-III-R criteria. Patients provided urine toxicology specimens at least weekly. Outcome (urinalysis results and treatment retention) was compared for patients with dual diagnosis (n = 103, 46.4%) and with substance only diagnosis (n = 119, 53.6%). Psychotropic medications were prescribed for 80.4% of the dual diagnosis subjects. In the first 6 months of treatment, dual diagnosis subjects compared to substance only diagnosis subjects gave a significantly greater percentage of urines positive for cocaine and opioids. In the second 6 months, dual diagnosis subjects who remained (n = 72, 70.0%) significantly reduced from the first 6 months their percentage of cocaine and opioid positives and did not differ in percent positives from substance only diagnosis subjects who continued past 6 months (n = 70, 58.8%). Treatment retention of dual diagnosis subjects (median months = 14.3) exceeded that of substance only diagnosis subjects (8.9; Lee-Desu Statistic = 9.02, p < .003). Dual diagnosis patients may initially perform more poorly than substance only diagnosis patients in substance dependence treatment. However, in the presence of psychiatric care, they eventually exhibit comparable success.

Users of free treatment slots at a community-based methadone maintenance clinic.

At a community-based methadone clinic in Seattle, WA, 360 opiate-addicted individuals were enrolled in a treatment demonstration project. The treatment slots were free to clients and, unlike other funded treatment slots, did not require proof of eligibility based on documentation of indigence. The clients were compared with 70 clients enrolled in a research project begun 2 years earlier in which the sample was drawn from a population using normal funding sources at the same program. Subjects in the later demonstration project were older and had fewer years of education. A higher percentage of the demonstration project subjects were African American. These differences indicate that introduction of free treatment opened opportunities to individuals who have difficulty accessing treatment under normal circumstances. Subjects in the treatment demonstration project were more likely to have obtained needles from legal sources and used bleach to clean needles. These findings probably reflect the impact of needle exchange and outreach programs, established in the year prior to the demonstration project.

Reporting of HIV risk behaviors by injection drug using heterosexual couples in methadone maintenance.

This study sought to identify differences within injection drug using (IDU) couples in reporting of sexual and needle risk behavior. Subjects were thirty-nine heterosexual couples entering methadone maintenance. In 33.3% of couples, one member reported sharing needles while the other member reported no sharing. In 12.9% of couples, one member reported sharing injection equipment, while the other member reported no sharing. Agreement was 77.4% between members of monogamous couples regarding frequency of condom use, 80.7% regarding vaginal intercourse with condoms, and 25.8% regarding vaginal intercourse without condoms. Within couples, a number of differences between members of the couple in injection equipment sharing were noted, suggesting that individuals who attempt to protect themselves by not sharing injection equipment may be placed at risk by their sexual partners. Further clinical and research efforts should be directed toward reducing barriers to behavior that would protect both partners. Implications for self-report measurement of HIV risk behavior and for preventive interventions are discussed.

Longitudinal changes in injection behaviors in a cohort of injection drug users.

To determine how the injecting behaviors of injection drug users (IDUs) change over time in the context of the epidemic of acquired immunodeficiency syndrome (AIDS) and what factors may be associated with such changes, a cohort of IDUs (n = 313) initially in treatment provided structured interviews regarding drug injecting behaviors. Repeat interviews in 18 months assessed behavior change in subjects who could be contacted for follow-up (n = 220, 70.3%). The study occurred in a state where sterile syringes can be purchased without prescription in drug stores. Injection drug use occurred for 180 (81.8%) of the 220 subjects in the 12 months prior to the initial interview but in only 121 (55.0%) in the 10 months prior to the follow-up interview (p < 0.0001). Similarly, sharing of equipment decreased from 63.1% to 31.8% (p < 0.0001). Sharing with multiple partners declined from 41.9% to 10.6% (p < 0.0001). Factors associated with ongoing risk included use of injected and non-injected psychoactive substances, less time in drug dependence treatment during follow-up interval, having a sexual partner who was an IDU and not using a drug store as the primary source of syringes. Factors associated with multiple-partner sharing included use of psychoactive substances, younger age and nonwhite race.

Contingency management of urinalysis results and intensity of counseling services have an interactive impact on methadone maintenance treatment outcome.

In a 3 x 2 factorial design, 360 new admissions to methadone maintenance were randomly assigned to one of three levels of counseling: (1) "medication only," (2) "standard" counseling, and (3) "enhanced" services; and one of two contingency contracting conditions: (1) no contingencies (NC), and (2) contingency contracting (CC). Contingency contracting included discharge for continuous positive urines; subsequently CC subjects were discharged at a greater rate than the NC group. However, CC subjects were more likely to be readmitted. NC subjects provided more urines positive for any illicit drug use than did CC subjects. For opiate positives a significant level of counseling by contingency contracting interaction was found with medication only/CC subjects obtaining fewer opiate positives than medication only/NC subjects. The impact of reduced or enhanced services and of contingency contracting will not be fully understood until longer term follow-up (18 and 24 month) is completed. Results suggest that contingency management procedures could be utilized in settings offering minimum services (e.g., "interim methadone") to achieve treatment outcomes similar to programs offering standard counseling services.

Using drugs to facilitate sexual behavior is associated with sexual variety among injection drug users.

Little normative data exist about the frequency and variety of sexual behavior of injection drug users. Sexual behaviors of a group of 313 injection drug users (225 men and 88 women) were assessed by a structured interview at the start of an acquired immune deficiency syndrome prevention project. Celibacy was reported by 12.3% of men and 26.9% of women in the year before the initial interview. Male injection drug users who had been sexually active reported a mean number of 4.61 (median, 2.0) female sexual partners in the previous year; sexually active women reported a mean number of 5.28 (median, 1.0) male sexual partners. Sexually active men and women reported median condom use frequency at 0% of vaginal intercourse events (mean for men, 10.31%; mean for women, 14.48%). Male injection drug users who reported using drugs to help them relax for sex, to enhance sexual performance, or to meet sexual partners reported greater frequency of anal intercourse, fellatio, and cunnilingus, less relative frequency of vaginal intercourse, more sexual partners, and greater involvement in being paid for sex and paying for sex than did men who did not report using drugs to enhance sex. Men who used drugs to enhance sex also reported higher frequency of use of a number of different drug classes than men who did not use drugs to enhance sex. For women, using drugs to enhance sex was related to greater frequency of anal intercourse and having more sexual partners. Implications for treatment of drug abusers and future research are discussed.

Outcome of contingency contracting for illicit drug use in a methadone maintenance program.

This study evaluates the outcome of a mandatory, clinic wide, structured contingency contracting system in a methadone maintenance program. The system involved weekly urine screening and placement on written individualized contracts for any of 106 male patients who displayed illicit drug use. Methadone dose decreases were the penultimate and detoxification and discharge the ultimate contingencies for unremitting drug use. Sixty subjects (56.6%) received contracts and 36 (35%) eventually left treatment. The contracts did not decrease the overall number of positive urines for the contract subjects, but opiate use did decrease significantly for subjects on more stringent contracts.

Risk reduction in sexual behavior: a condom giveaway program in a drug abuse treatment clinic.

Just before and 4 months after initiation of a condom giveaway program, a questionnaire regarding sexual behavior and condom acquisition was administered to 103 men attending an outpatient drug abuse treatment clinic. Jars filled with a variety of condoms were placed in every clinic room. Condom taking varied as a function of room. Sixty percent of the subjects reported taking condoms. At follow-up, clients reported increases in condom possession and in use of condoms for vaginal intercourse.

Alcohol use and high-risk behavior by intravenous drug users in an AIDS education paradigm.

The relationship between alcohol consumption and high-risk behavior for HIV infection was examined among 313 in-treatment intravenous drug users (IVDUs) by random assignment of these subjects to one of three interventions: (1) structured interview regarding risk behavior; (2) interview plus one group AIDS education session; (3) interview, AIDS education plus optional HIV testing. Alcohol users (n = 148) had more needle sharing and sexual partners than did nondrinkers. Follow-up interviews revealed no significant behavioral changes as a function of intervention condition or alcohol use. Better interventions, including more vigorous treatment of alcohol use, are needed to reduce risk behaviors among IVDUs.

Longitudinal sexual behavior changes in injecting drug users.

OBJECTIVE: To determine whether injection drug users (IDU) maintained sexual behavior risk reduction over an 18-month period that had been noted previously over a 4-month period. DESIGN: A repeated measures design was utilized with IDU assessed initially at study enrollment and again 18 months later. METHODS: Sexual behaviors of a group of 220 IDU (148 men and 72 women) were assessed by a structured interview at the start of an AIDS prevention project and again 18 months later. RESULTS: Having multiple sex partners during the 12 months before initial assessment was reported by 42.6% of the men and 35.7% of the women. Significantly fewer had multiple sex partners during the 10 months before follow-up assessment (men, 20.9%; women, 14.3%). Condom use for vaginal intercourse increased from a mean of 11.9% initially to 27.8% at follow-up for men. The increase in condom use was greater for those with multiple sex partners. Women did not report significant increases in condom use. Continued involvement in unsafe sexual behaviors was associated with exchanging sex for money or drugs, using drugs to help meet sexual needs, alcohol use and drug use. CONCLUSIONS: Risk reductions noted previously were maintained over 18 months for the majority of the sample. Drug-use treatment and interventions that closely examine the interplay between drug use and sexuality for individual IDU are recommended as strategies to further reduce the sexual risk of HIV transmission among IDU.

Ineffectiveness of AIDS education and HIV antibody testing in reducing high-risk behaviors among injection drug users.

The effectiveness of education in reducing high-risk human immunodeficiency virus (HIV) transmission behaviors was examined in 313 injection drug users. Involvement in high-risk behaviors was assessed via structured interview at study entry and 4 months following the intervention. Subjects were randomly assigned to (1) AIDS education, (2) AIDS education with optional HIV antibody testing, or (3) a wait list. The sample as a whole decreased its involvement in high-risk behaviors, but there were no significant differences as a function of experimental group assignment.

Validity of the MCMI Drug Abuse Scale varies as a function of drug choice, race, and axis II subtypes.

The validity of the Drug Abuse Scale (T) from the Million Clinical Multiaxial Inventory (MCMI) was studied by administering the MCMI to 110 male veterans seeking treatment for opioid or cocaine dependence. Only 26 and 23% of the sample obtained base rate (BR) scores above the clinical relevant cutoffs of 84 and 74, respectively. Covariables associated with elevated scores on the T Scale were Black race, presence of narcissistic/antisocial personality features, and more severe psychopathology in general. The authors urge caution in using the Drug Abuse Scale for the purpose of identifying drug abusers.

Urine screening practices in methadone maintenance clinics. A survey of how the results are used.

The urinalysis practices of 324 methadone maintenance clinics were surveyed using a brief self-report questionnaire. Results indicate that there is wide variability in collection practices and clinic responses to positive findings. Virtually all clinics provide counseling and revocation of take-home methadone doses as a response to positive urinalysis results. However, increase in urine screening frequency, methadone dose adjustments, contingency contracting, group therapy, and eventual discharge are interventions also used. The implementation of different interventions varied as a function of clinic size, city size, region of the country, and program funding source.

Needle-use practices among intravenous drug users in an area where needle purchase is legal.

Needle-use practices of intravenous drug users (IVDUs) were examined in a region (Seattle, King Country, Washington State, USA) where needle purchase is legal. IVDUs in treatment (n = 313) were administered extensive structured interviews concerning drug and injection equipment-use practices. Of the 80.2% reporting intravenous drug use in the previous year, 78.3% reported sharing needles. Of the 47.7% reporting intravenous use in the previous 30 days, only 40.5% shared needles, with 59.3% sharing with only one other person. Most needle-sharing partners were very well known (63%) or well known (17%) to the subjects. The most frequent method for obtaining needles was 'buying in a drug store', ranked first by 65% of the sample. Subjects whose primary source was 'buying in a drug store' shared equipment less frequently during drug-use events in the previous year (mean: 16.2%) than those with other primary sources (mean: 28.5%). Compared with findings from other regions where needle purchase and possession are illegal without a prescription, fewer subjects in the current investigation shared needles, and those who did shared with a smaller number of people. The apparent association between legalized injection equipment and reduced sharing of equipment among IVDUs should be further examined in longitudinal studies of needle-sharing before and after legalization is instituted.