Lateralization of a moving auditory image in patients with focal damage of the brain hemispheres.

Perception of the moving fused auditory image resulting from dichotic click-train stimulation was studied in 53 patients with focal damages of the temporal lobes. Patients with the right- and left-side damage differed in the click rate for perceived movement and in the movement trajectory length. The data are discussed in connection with right hemisphere specialization for directional hearing.

Enhanced treatment outcomes for cocaine-using methadone patients.

Cocaine dependent methadone patients were randomly assigned to 6 months of high intensity cognitive-behavioral therapy or low intensity therapy. A repeated measures ANOVA was conducted with patients stratified on severity of cocaine use at baseline. Both treatment groups showed significant and equivalent reductions in cocaine use during the post-treatment period. Completing either therapy and lower cocaine severity at baseline were associated with lower proportion of cocaine-positive urines across a 48-week post-treatment period. Examination of the treatment x cocaine severity interaction provided some evidence that high-severity patients improved more if exposed to high intensity treatment than to low intensity treatment. Positive outcomes for therapy completers relative to non-completers increased over time. The results are consistent with several clinical trials showing that: (1) participation in treatment is associated with reductions in cocaine use; and (2) the relationship between treatment intensity and outcome is not linear and may better be explained by an interaction between patient and treatment factors.

Leaving methadone treatment: lessons learned, lessons forgotten, lessons ignored.

Despite the demonstrated benefits of methadone maintenance, there have been concerns about the ethics, necessity and expense of maintaining addicts on methadone indefinitely. The inability of many patients to achieve normative levels of psychosocial functioning with methadone, combined with widely held attitudes favoring drug abstinence over replacement medication, has led to attempts to promote time-limited methadone treatment. This paper reviews the published research literature on post-discharge outcomes of patients exiting from extended methadone detoxification, "abstinence-oriented" methadone programs, and regular methadone maintenance programs. Virtually all of these studies document high rates of relapse to opioid use after methadone treatment is discontinued. Most of the patients studied left treatment without meeting clinical criteria for detoxification, although high relapse rates were also reported for patients who completed this program. The detrimental consequences of leaving methadone treatment are dramatically indicated by greatly increased death rates following discharge. Until more is learned about how to improve post-detoxification outcomes for methadone patients, treatment providers and regulatory/funding agencies should be very cautious about imposing disincentives and structural barriers that discourage or impede long-term opiate replacement therapy.

Patients' perspective on the process of change in substance abuse treatment.

Understanding how methadone patients view treatment for their cocaine dependence and the process of recovery from cocaine addiction, is important in helping to design treatment strategies that will effectively motivate and engage these patients. There has been little development or testing of treatment approaches for cocaine-dependent, methadone-maintained patients and research on the effectiveness of outpatient cocaine treatment has excluded the perspectives of patients. This article presents the patient's view, using ethnographic interviews with 17 patients enrolled in a relapse prevention treatment program for cocaine dependence, that was set up in an inner-city methadone maintenance clinic. Findings suggest that despite initial ambivalence or resistance, patients became highly engaged by the positively reinforcing treatment intervention. In addition, patients found the highly structured nature of the program and the cognitive behavioral techniques critical in reducing their cocaine use. Finally, patients responded positively to the psychodynamic issues addressed within a cognitive behavioral format, and reported improvements in certain areas of psychological functioning.

An enhanced positive reinforcement model for the severely impaired cocaine abuser.

This article describes a cognitive-behavioral treatment approach that has been extensively modified to work with inner-city methadone-maintained cocaine users. Modifications were deemed essential to address the problems of engagement and retention in treatment that are typically encountered with this population. While this approach relies on such basic tenets of treatment as relapse prevention, cognitive restructuring, and psychoeducation, an understanding of the particular psychological vulnerabilities of this population has been incorporated into the model. The modified approach utilizes positive reinforcement extensively. This includes use of concrete reinforcers to facilitate initial engagement, and use of interpersonal reinforcers (therapist positive regard, attention, and respect) to increase program retention and sustain posttreatment change. Preliminary results indicate that 63% of patients can complete this intensive 6-month program, with considerable reductions in cocaine use and significant change in drug injection behavior.

A group motivational treatment for chemical dependency.

Patient "motivation" has been implicated as a critical component in addiction treatment outcomes. To date, treatments utilizing motivational elements have been conducted as individual interventions. We describe the development of a Group Motivational Intervention (GMI), a four-session, manual-driven group approach that employs key hypothesized motivational elements. These include the six motivational elements derived by Miller and Sanchez (1994) from successful alcoholism treatments, described with the acronym, FRAMES (feedback, responsibility, advice, menu of options, empathy, and self-efficacy). GMI is additionally informed by concepts derived from "self-determination theory" (Deci & Ryan, 1985), concerned with understanding motivation as either internal/autonomous or external/controlled. Evidence indicates that people will value and persist longer in behaviors that they perceive as autonomously motivated. GMI techniques utilize the interpersonal factors found to be autonomy-supportive in self-determination theory. Preliminary results from a randomized clinical trial suggest that key motivational processes are affected by GMI: patients perceive the GMI environment and group leader as significantly more "autonomy supportive" than treatment "as usual."

Follow-up of inpatient cocaine withdrawal for cocaine-using methadone patients.

Significant proportions of opiate-dependent persons entering methadone treatment are also addicted to cocaine and continue to use cocaine during treatment. One standard response to cocaine use has been inpatient detoxification. This study examined the effectiveness of this procedure by comparing pre- and posttreatment urine toxicologies for methadone patients who had been hospitalized for cocaine withdrawal. The results showed a negligible effect on cocaine abstinence (less than 1 out of 10 patients abstinent 12 weeks after detox) and a modest reduction in the frequency of cocaine use (one-quarter decline in urine tests positive after 12 weeks). These findings raise serious doubts about the cost-effectiveness of inpatient cocaine detoxification. Better strategies need to be implemented to enhance the chances of remaining abstinent once detoxified.

Modulating effect of alcohol use on cocaine use.

Clinical observations have indicated that alcohol may be employed by cocaine/crack users to attenuate negative effects of cocaine, especially when "coming down" from a cocaine binge. This issue was examined by interviewing 66 dual cocaine/alcohol users, with opiate dependence histories, enrolled in methadone treatment. A path analysis model was specified to test several hypotheses concerning the possible modulating effects of alcohol use on cocaine use. About 60% of the subjects reported often employing alcohol to ameliorate discomfort associated with tapering or ceasing cocaine/crack use. The main findings were: (a) more intense cocaine/crack craving and feeling that cocaine/crack use was out of control both led to increased use of alcohol to come down; (b) the more frequently alcohol was used to come down, the less use of cocaine/crack; and (c) more cocaine/crack use and more use of alcohol to come down both led to increased heavy alcohol use. Thus, treating alcohol abuse in this population must take into account the important function it serves in modulating cocaine/crack use.

A latent variable analysis of coexisting emotional deficits in substance abusers: alexithymia, hostility, and PTSD.

The emotional disturbance of substance abusers is often described as an inability to identify and express feelings coupled with an excess vulnerability to experience negative affect. However, there is only limited empirical support for this perspective. To validate this description, we first defined components of alexithymia, hostility, and posttraumatic stress disorder (PTSD) derived from established measures of each by conducting confirmatory factor analyses based on a self-report data set from a clinical sample of 253 alcoholics and drug addicts. We then fashioned and tested overarching latent variables representing the three aspects of emotional dysfunction (i.e., alexithymia, hostility, and PTSD) and finally tested the correlations among these overarching variables. We found a strong association between a factor labeled Bottled-Up Emotions and another labeled Neurotic Hostility (r = .62) as well as an association between PTSD and Bottled-Up Emotions (r = .66). The structure, magnitude, and intercorrelation of the latent variables did not depend on the type of psychoactive substance abused. These results support the view that features of alexithymia and hostility coexist in substance abusers and that this joint deficit is part of a broad disturbance across multiple psychological domains including pathological response to traumatic stress.

Changes in HIV risk behaviors among cocaine-using methadone patients.

Cocaine use among methadone patients has been related to higher prevalence of HIV risk behaviors. HIV risk behaviors for cocaine-using patients in methadone treatment (N = 207) were examined for two time periods, the current month in-treatment and the month previous to treatment admission. All needle-related and sexually-related risk behaviors (except for needle hygiene) significantly and substantially declined over the average two year time interval. Several variables were associated with needle and sexual risks in multivariate regression analyses. Dropping apparent opiate use underreporters from the analyses did not alter the results. From a harm reduction perspective, high priority should be given to retaining cocaine-using patients in methadone maintenance, intensifying in-program services for those with anti-social personality, bipolar disorder or alcoholism, as well as increasing access to needle exchanges and free condoms.

Gender differences in psychiatric comorbidity among cocaine-using opiate addicts.

Psychiatric comorbidity was examined for a sample of 212 methadone patients dually addicted to opiates and cocaine, focusing on gender differences. Diagnoses were determined by the SCID for DSM-III-R. Men displayed more lifetime (but not current) substance use disorders, while women displayed more lifetime and current non-substance use disorders. There were several significant interactions among psychiatric disorders and gender. Women were more likely than men to present with concurrent mood and anxiety disorders. Women with ASPD were unlikely to have alcohol use disorder, but likely to have opioid use disorder. Men with anxiety were likely to be diagnosed with ASPD. Treatment implications of the findings are discussed.

Hepatitis C and substance use in a sample of homeless people in New York City.

This study examined the prevalence of hepatitis C virus (HCV) antibodies and its association with substance use and sexual behavior among a sample of 139 persons visiting a mobile medical clinic in Manhattan. Ninety percent were unstably housed or were living on the street. The prevalence of HCV antibodies was 32%. Prevalence was also high for hepatitis B core antibodies (47%), HIV antibodies (15%), and syphilis exposure (14%); 76% tested positive for cocaine. Among subjects who reported ever injecting (20%), 86% were HCV positive; 19% of non-injectors were HCV positive. In separate multivariate logistic regression models (with injection controlled), HCV was predicted by quantitative hair assays for cocaine and self-reported duration of crack-cocaine use. Alcohol dependence and sexual behavior did not predict HCV. Hepatitis C is a significant public health problem among the urban homeless population, with injection drug use and, to a lesser extent, cocaine use implicated as risk factors.

Daily cocaine use patterns: effects of contextual and psychological variables.

This study identifies factors that predict daily cocaine use among clients in a methadone maintenance program who participated in a cocaine treatment trial. Cocaine use decreased the longer clients remained in treatment, and the amount of cocaine used depended upon the day of the week, with Saturday typically having the greatest use and Sunday having the least. Logistic regression analyses showed that several other factors were related to daily cocaine use: peak cocaine craving, resistance to use cocaine, and several triggers or stimuli to use cocaine. These stimuli included receiving money, being offered cocaine, and seeing cocaine and/or related paraphernalia. However, even with these variables controlled, day of the week and time in treatment continued to be significant predictors. This suggests that (a) other time-varying variables need to be included in order to fully account for cocaine use variation from day to day and (b) time in treatment is a robust predictor of reduced cocaine use despite the strong influences of craving, external stimuli, and day of the week.

Neurobehavioral treatment for cocaine-using methadone patients: a preliminary report.

Preliminary outcome evaluation results are reported for an innovative cocaine abuse treatment model adapted for cocaine-using methadone patients. Sixty-two patients were randomly assigned to six months of high intensity ("neurobehavioral") or lower intensity ("control") therapy for cocaine dependence. Therapy was completed by 49% of neurobehavioral and 53% of control patients. In paired comparisons between intake and six-month follow-up, neurobehavioral patients but not controls showed significant declines in cocaine and other drug use (measured by urinalysis and self-reports), as well as significant improvement in psychological status. The findings suggest that specialized cocaine abuse treatment can benefit methadone patients; intake to the study is continuing.

Ambivalence toward methadone treatment among intravenous drug users.

Interviews were conducted with a sample of jailed intravenous opioid users who were not in treatment at the time of their arrest and who were admitted to an in-jail methadone maintenance program. At release, subjects were to be referred to dedicated slots in participating community methadone programs. Virtually all subjects were daily injectors of heroin and cocaine. Although the majority of subjects had previous episodes of methadone maintenance, most reported anxieties about methadone, such as bone decalcification and possible overdosing. Women and subjects who shared needles were more likely to report fears about methadone. Only 52% of the subjects stated that they intended to report to a methadone program after their release and 45% did not expect to remain in treatment for more than one year. Subjects who stated that they were not afraid of methadone, frequently injected drugs, and rarely used crack were more likely to express intentions to enroll and remain in community methadone treatment. Ambivalence toward methadone treatment may be a result of unrealistic concerns about the side effects of methadone and personal heuristics regarding the nature of addiction and the efficacy of treatment.

Treatment intensity and reduction in drug use for cocaine-dependent methadone patients: a dose-response relationship.

This study examined the impact of treatment intensity on cocaine use. Seventy-seven cocaine-using methadone patients were enrolled in a six-month, structured, manual-driven, cognitive-behavioral treatment program. Sessions consisted of five individual and/or group sessions per week. At intake subjects showed extensive polydrug abuse, psychiatric comorbidity, criminal histories, and HIV risk behaviors. Treatment intensity was measured by dividing number of sessions attended into quartiles. Paired comparisons, within treatment quartiles, were made between subjects' intake and six-month self-reports of cocaine use. Subjects in quartiles two through four showed significant reductions in frequency of cocaine use at follow-up, with subjects who received the most treatment showing the greatest reductions in cocaine use. Bivariate and multivariate analyses showed that treatment sessions attended remained a strong predictor of reduction in cocaine use at follow-up, even after controlling for drug use at intake and background variables. The results indicate that there is a substantial treatment dose-response relationship.

Problem-based learning at the University of Southern California School of Dentistry.

Responding to the recent Institute of Medicine report on dental education, the Center for Craniofacial Molecular Biology (CCMB) of the University of Southern California School of Dentistry has developed a parallel track program in dental education leading to the D.D.S. degree. This program was proposed in May of 1995, and the first class of twelve students was admitted in September of that year. Currently two classes are enrolled and plans to admit a further twelve students (Class of 2001) are in place. The educational strategy for this program is totally problem-based. Students work in groups of six with a faculty facilitator, not necessarily a content expert. Facilitators are largely drawn from the multidisciplinary pool of research faculty at the center. All learning is mediated through biomedical and biodental problem cases. No formal lectures or classes are scheduled. The learning of clinical dental skills is promoted through focussed dental patient simulations in which students review clinical charts, radiographs, medical reports and then explore identified, hands-on learning needs using patient simulators in a clinical context. Early patient exposure is obtained through dental office visits and other special patient clinics. Initial experience with this program suggests that the problem-based learning (PBL) students learn as well (if not better) than their traditional program peers and develop excellent group and cognitive analytical skills. The absence of a pool of dentally related biomedical cases suitable for a PBL program has necessitated the use of innovative approaches to their development and presentation. It is believed that this educational approach will produce dental clinicians equipped with the self-motivated, life-long learning skills required in the ever-changing world of bio-dental sciences in the twenty-first century.

Ethics competencies in the business of dentistry.

Ethics is the systematic study of human conduct examined in the light of moral values and principles. It is the most important competency in dentistry, in business, and in life. Competency in ethics requires an understanding of its accepted principles, and such competency is the obligation of every dental professional.