Treatment For Substance Dependence Research Articles

Dissociative Disorders Among Inpatients With Drug or Alcohol Dependency

To determine the prevalence of dissociative disorders among inpatients with alcohol or drug dependency. The Dissociative Experiences Scale was used to screen 215 consecutive inpatients admitted to the dependency treatment center of a large mental hospital over a 1-year period (March 1, 2003, to March 31, 2004). Patients who had scores of 30.0 or above were compared with patients who scored below 10.0 on the scale. The patients in both groups were then evaluated using the Dissociative Disorders Interview Schedule and the Structured Clinical Interview for DSM-IV Dissociative Disorders. The interviewers were blind to the Dissociative Experiences Scale scores. Of the patients, 36.7% had a Dissociative Experiences Scale score of 30.0 or above. The prevalence of DSM-IV dissociative disorders was 17.2% (N = 37). On average, 64.9% of these patients' dissociative experiences had started 3.6 years (SD = 2.9; range, 1.0-11.0 years) before onset of the substance use. Patients with dissociative disorders were younger, and the mean duration of their remission periods was shorter. Dissociative disorder patients tended to use more than 1 substance, and drugs were used more frequently than alcohol in this group. The frequency of borderline personality disorder, somatization disorder, history of suicide attempt, and childhood abuse and neglect occurred more frequently in the dissociative disorder group than in the nondissociative disorder group. History of suicide attempt (p = .005), female sex (p = .050), and childhood emotional abuse (p = .010) were significant predictors of a dissociative disorder diagnosis. Significantly more patients with dissociative disorders stopped their treatment prematurely (p < .001). Impact of dissociative disorders on development and treatment of substance dependency requires further study.

Asians in the United States: substance dependence and use of substance-dependence treatment

Clinicians have often observed that Asians are unlikely to utilize substance-dependence treatment services but few have reported empirical data examining this phenomenon. This study used data from the National Household Survey on Drug Abuse, 2000–2002, and tested whether Asians in the United States have relatively low rates of drug and alcohol dependence and whether substance-dependent Asians use treatment services less than Caucasians. Subsequent analyses were undertaken to identify factors that explained these racial differences. Of the 5,118 Asians, 159 met criteria for past-year drug or alcohol dependence. Asians with past-year substance dependence were significantly less likely than substance-dependent Caucasians to report past-year treatment (odds ratio 0.42, 95% confidence interval 0.19–0.96). Differences in past-year substance-dependence prevalence appear to be partially explained by between-group differences in ever using substances; differences in past-year treatment use appear to be in part related to differences in levels of acculturation and education.

Adverse events among patients in a behavioral treatment trial for heroin and cocaine dependence: Effects of age, race, and gender

Safety monitoring is a critical element of clinical trials evaluating treatment for substance dependence, but is complicated by participants’ high levels of medical and psychiatric comorbidity. This paper describes AEs reported in a large ( N = 286), 29-week outpatient study of behavioral interventions for heroin and cocaine dependence in methadone-maintained outpatients. A total of 884 AEs were reported (3.1 per patient, 0.12 per patient-week), the most common being infections (26.8%), gastrointestinal (20.5%), musculoskeletal (12.3%), and general (10%) disorders. Serious AEs were uncommon (1.6% of total). Female participants reported significantly higher rates of AEs (incidence density ratio, IDR = 1.38, p < 0.0001); lower rates of AEs were reported by African Americans (IDR = 0.73, p < 0.0001) and participants over age 40 reported lower rates of AEs (IDR = 0.84, p = 0.0095). AE incidence was not associated with the study intervention or with psychiatric comorbidity. Further work is needed to adapt AE coding systems for behavioral trials for substance dependence; the standard Medical Dictionary for Regulatory Activities, International Federation of Pharmaceutical Manufacturers Associations (MedDRA) coding system used in this report did not contain a separate category for one of the most common types of AE, dental problems. Nonetheless, the data reported here should help provide a context in which investigators and IRBs can interpret the patterns of AEs they encounter.

New Directions for Families

SUMMARY In conjunction with the SAMHSA-funded Women with Co-Occurring Disorders and Violence Study, Arapahoe House refined and evaluated an intervention integrating treatment for substance dependence, mental illness, and trauma for women and their dependent children. The New Directions for Families program combines comprehensive residential and outpatient treatment with parenting and self-sufficiency skills development. The program provides gender-specific, culturally sensitive, and strengths-oriented services for families in a two-phase program over eight months. Services include treatment for individual recovery in each of the three problem areasmental health, alcohol and other drug abuse, trauma; basic needs of the family including employment; and social and family support systems. Consumers are involved in all aspects of the project-in designing and implementing the intervention and evaluation and in governing the project through participation on the project's local and national steering committees.

Recent Advances in the Development of Treatments for Alcohol and Cocaine Dependence

Neuroscientific developments have promulgated interest in developing efficacious medications for the treatment of substance dependence. Previous pharmacological strategies that involve the use of relatively specific medications to alter corticomesolimbic dopaminergic neuronal activity--the critical pathway for expression of the reinforcing effects of abused drugs--have yielded modest efficacy in the treatment of alcohol dependence, and no medication has been established as a treatment for cocaine dependence. Since corticomesolimbic dopaminergic neurons interact with other neurotransmitters that modulate the effects of dopamine in the nucleus accumbens, would it not be possible to control these dopaminergic effects more reliably with a medication that acts contemporaneously on more than one neuromodulator of dopaminergic function? Further, since the long-term use of either alcohol or cocaine results in neuronal adaptations as a result of sensitisation, would the chances of effective therapy not be bolstered by administering a medication that was also able to mitigate these chronic effects? Thus, a new conceptual approach is needed. My proposal is that a medication--in this case topiramate--that principally potentiates inhibitory GABA(A) receptor-mediated input and antagonises excitatory glutamatergic afferents to the corticomesolimbic dopaminergic system should have therapeutic potential in treating either alcohol or cocaine dependence or perhaps both. This is because the principal neurochemical effects of topiramate would not only serve to decrease the acute reinforcing effects of alcohol or cocaine, but might also facilitate cessation of their use following a period of long-term use by decreasing neuronal sensitisation. This overview highlights the scientific concepts and clinical evidence for the development of topiramate in the treatment of alcohol dependence and introduces preliminary evidence to indicate that it might also have utility in treating cocaine dependence. Finally, to place the material on topiramate in context, information has been included on the utility and development of other medications that modulate GABA- or glutamate-mediated neuronal systems for the treatment of alcohol or cocaine dependence.

Profiles of Club Drug Users in Treatment

There is little in the literature about treatment of persons with problems with “club” or “party” drugs. This paper looks at the characteristics of individuals admitted to treatment for primary, secondary, or tertiary problems with club drugs such as ecstasy, gamma-hydroxybutyrate (GHB), ketamine, flunitrazepam (Rohypnol), methamphetamine, and hallucinogens (e.g., LSD) in programs funded by the Texas Commission on Alcohol and Drug Abuse. Some 38,350 unduplicated records from 1988 through 2003 of persons admitted with problems with club drugs were compared against users of alcohol or other drugs. Club drug users were more impaired on five of six Addiction Severity Index (ASI) indices at admission and they were more likely to use multiple substances more often. They were more likely than users of alcohol or other drugs to complete treatment, but this varied by drug. At follow-up 90 days after discharge, club drug users continued to report more ASI problems. Profiles of these clients show that ecstasy use has spread beyond the club culture, as indicated by the changes in client demographics over time. GHB clients presented a mixed picture of severe problems at admission and good response to treatment. Hallucinogen clients were young and less likely to complete treatment, while Rohypnol users were on the Texas-Mexico border. The methamphetamine epidemic has resulted in increased admissions, and the proportion of “Ice” smokers has increased. However, methamphetamine clients were less likely to complete treatment and their higher level of problems at admission and follow-up are of concern. Of special note are the indications of co-occurring problems and the need for both mental health and substance dependence treatment for some clients.

Evaluating vocational rehabilitation programs for substance users: issues in designing and implementing randomized studies

The last decade has witnessed a marked shift in the value placed on vocational services in substance dependency treatment. Because of the welfare-to-work reform movement, stricter work requirements for public assistance, and the elimination of federal disability benefits for addiction alone, patient employment is increasingly seen as an important treatment outcome. Indeed, vocational services for this population are becoming an essential component of the rehabilitation process. Since few evaluations have shown highly positive outcomes, these vocational programs lack an evidence base to guide the choice of service models and components. This paper addresses issues concerning research design and implementation that need to be examined if randomized clinical trials of vocational services for substance users are to yield better employment outcomes. It examines how these issues emanate from the way substance abuse treatment is organized and delivered. The design issues focus on characteristics of service programs that may limit effect sizes and statistical power in evaluation studies. Similarly, the implementation issues concern problems in clinical settings in which researchers may have different goals from clinicians, or may need to supervise certain clinicians in a research study. The paper suggests solutions to these design and implementation problems, including increased sample sizes, controlling interactions between counselor characteristics and counseling methods, developing innovative programs, and engaging service providers in the research process. Although the paper concentrates on vocational rehabilitation, the issues raised are pertinent to other human services as well.

The Addiction Severity Index medical and psychiatric composite scores measure similar domains as the SF-36 in substance-dependent veterans: concurrent and discriminant validity

Background: Recently attention has focused on the assessment of functional health status in substance-dependent individuals. The addiction severity index (ASI) is a widely used assessment instrument that includes scales to reflect current medical and psychiatric status. This study examines the concurrent validity of these ASI composite scores in relation to the short form 36-item health survey (SF-36), a well-established measure of health-related quality of life/functional health status. Methods: Veterans ( n = 674) were assessed at admission to substance dependence treatment. Correlations were performed between ASI composite scores and SF-36 scales and the physical and mental summary components (PSC and MSC, respectively). Areas under receiver operating characteristic (ROC) curves determined the descriminative ability of the ASI composites to ascertain impairment. Results: The ASI medical composite score demonstrated robust correlations with the four SF-36 scales that relate to physical health and with the PCS. The ASI psychiatric composite score had robust correlations with the four SF-36 scales related to mental health and with the mental component summary (MCS). ROC curves indicated that the ASI medical (AUC = 0.83) and psychiatric composites (AUC = 0.90) accurately detected subjects with impairment. Conclusions: ASI medical and psychiatric composite scores provide effective initial screening for patients with impaired functional status as measured by the corresponding SF-36 component summary scores.

Validity of Self-Reports and Drug Use Among Young People Seeking Treatment for Substance Abuse or Dependence

The present study assessed drug use and the validity of self-reports of drug use among young people seeking treatment. On admission the participants (n =316), 215 males and 101 females, were interviewed about their drug use. Urine samples were collected to screen for alcohol, amphetamine, benzodiazepines, cannabis, cocaine, methylenedioxymethamphetamine (MDMA) and opiate use. Self-reports of substance use were compared with urinalysis results. Seventy-three percent of the participants reported use of two or more substances. Single substance users were primarily alcohol users. Kappa agreement between self-report and urinalysis results was of acceptable concordance (≥ 0.65) except for alcohol (κ =0.19). Conditional kappa values were good (≥ 0.85) with exception of opiates (cond. κ =0.57). The self-reports were generally reliable among young people seeking treatment. No significant differences (p ≥ 0.54) were found in the validity of self-reports between the genders.

Employment Outcomes for Hard-to-Reach Persons with Chronic and Severe Substance Use Disorders Receiving Assertive Community Treatment

Many persons with chronic and severe substance use disorders (SUDs) enter and exit public substance dependence treatment systems with limited benefit, but continue overuse of high-cost health and human services. Less than a third holds jobs, earning income below U.S. federal poverty levels. Long-term integrated substance dependency treatment, rehabilitation, and support services will be essential to resolve substance dependence and employment problems. This single-group program evaluation reports adaptation of Assertive Community Treatment (ACT), a multi-component, team-based service model originally designed for persons with severe mental illnesses and multiple disabilities, for effectiveness with persons with severe SUDs. The ACT model delivers an integrated package of treatment, rehabilitation, and support to reduce substance misuse and increase employment. Of the 35 clients admitted 12 months prior to conclusion of this 2-year service demonstration, only one left treatment prematurely. Generally, clients modestly reduced substance misuse and increased employment. However, the evaluation design and small sample limit inferences of causation and generalizability of these promising outcomes. Persuading states to adopt expensive team-based approaches for this population will require firm evidence of favorable cost-benefit ratios.

Working It Out: Development and Testing of a Multimedia, Vocational Education Program

A self-administered, CD-ROM-based, interactive multimedia psychoeducational intervention, called Working It Out, was developed to improve employment functioning for clients in substance dependency treatment. The computer-based program's effectiveness was tested in comparison with printed material. During 2000–2001 194 clients with employment concerns in six treatment programs were randomly assigned to a CD-ROM or print material condition and evaluated at baseline and 6 months later. A main effect for improvement was observed on employment indices, but there was no condition-by-time interaction. Results suggest that clients are willing and able to use vocational rehabilitation information presented in any format, although the CD-ROM-based program received significantly better satisfaction ratings than did the print material.

Targeting Nicotine Addiction in a Substance Abuse Program

The potential benefits of addressing nicotine addiction as part of substance dependency treatment may include improved response to interventions for other addictions and, over the long term, reduced tobacco-related morbidity and mortality. The authors recount the experiences of three inpatient programs that instituted nicotine addiction interventions and a tobacco-free policy for both facilities and patients. After making adjustments to counter temporary adverse effects of the policy, two of the programs are achieving higher overall treatment completion rates than prior to implementation. Outstanding research issues include quantifying the costs and benefits of the antinicotine interventions, determining the long-term impact of tobacco-free treatment, and tailoring treatment to various patient groups.

Personality, substance of choice, and polysubstance involvement among substance dependent patients

The authors compared the association of several personality traits, drug of choice, and polysubstance involvement in 325 individuals (44% male) receiving treatment for substance dependence on heroin, cocaine, and/or alcohol. Measures included the Structured Clinical Interview for DSM-III-R, the MacAndrew Alcoholism Scale (MAC), the socialization scale of the California Psychological Inventory (CPI-Soc), the novelty seeking dimension of the Temperament and Character Inventory (TCI-NS), and the conscientiousness domain of the NEO Five-Factor Inventory (NEO-C). Analyses adjusted for demographic covariates, affective and antisocial personality disorder, and substance dependence severity. Although scant evidence supported the hypothesis that these personality traits were associated with substance choice, CPI-Soc and MAC were associated linearly with the extent of polysubstance involvement. Also, patients who were dependent on two or more substances displayed higher levels of TCI-NS, CPI-Soc, and MAC. Findings implicate an association between behavioral disinhibition and a continuum of addiction defined primarily in terms of polysubstance involvement.

Bridging the gap: a hybrid model to link efficacy and effectiveness research in substance abuse treatment.

Many behavioral and pharmacologic treatments for which there is strong empirical support are rarely used in clinical practice in the treatment of substance dependence. In an effort to facilitate greater emphasis on issues such as utility, practicality, and cost earlier in the evaluation of promising therapies, the authors propose a hybrid model to link efficacy and effectiveness research. A hybrid model may foster broader use of empirically validated treatments in substance abuse treatment programs and enhance the scientific yield of effectiveness research. The hybrid model retains essential features of efficacy research (randomization, use of control conditions, independent assessment of outcome, and monitoring of treatment delivery) while expanding the research questions to also address issues of importance in effectiveness studies. Such issues include diversity in settings, clinicians, and patients; cost-effectiveness of treatment; training issues; and patient and clinician satisfaction.

The Role of Work in Substance Dependency Treatment: A Preliminary Overview

This article describes four alternative models for the role of client work in substance dependency treatment. The most common model is Work as a Positive Outcome, which conceptualizes work (employment) as a desirable outcome of treatment. The Work Infusion Model conceptualizes work as a therapeutic factor in treatment. The Contingent Sanctions Model requires clients to work to avoid undesirable consequences, such as losing treatment. The Work as Reinforcement Model offers paid work as a reward for treatment adherence. This article discusses whether either standard substance dependency treatment or vocational services within treatment programs increase client employment, whether clients want to work, and whether sufficient services are available. The empirical support for each model of client work is summarized. Critical issues that must be addressed in this area are outlined.“Work spares us from three great evils: boredom, vice and need.” Voltaire (1759)

High‐ and Low‐Structure Treatments for Substance Dependence: Role of Learned Helplessness

We studied whether pretreatment levels of learned helplessness (LH) were related to outcomes for substance‐dependent individuals receiving high‐structure, behaviorally oriented (HSB) or low‐structure, facilitative (LSF) treatment. The subjects were 120 substance‐dependent patients randomly assigned to the HSB or the LSF treatment style for up to 12 weeks of weekly individual counseling. The two groups were compared across pretreatment characteristics as well as in‐treatment, end‐of‐treatment, and 9‐month postadmission follow‐up outcome measures. Outcomes reflected reduction in problem severity, abstinence, retention, dropout rate, and ratings of treatment benefit. Significant and comparable reductions in symptoms occurred for the HSB and LSF patients both during treatment and at follow‐up. Comparisons of other outcomes also did not consistently favor either treatment style. However, significant and consistent interactions were observed between LH and treatment styles with respect to several outcome measures, and these effects were independent of pretreatment levels of depression, addiction severity, and readiness for treatment. Specifically, the more “helpless” patients did significantly better in HSB treatment, whereas the less “helpless” patients had better outcomes in LSF treatment. A matching approach that assigns patients to high‐ and low‐structure treatments based on pretreatment levels of LH might improve treatment outcomes for substance‐dependent patients.

Involuntary Substance-Abuse Treatment Has Higher Compliance Rates

A common problem in the treatment of substance dependence is the high number of dropouts (see Journal Watch Psychiatry Jul 9 2003). To investigate whether legal mandates increase compliance with alcohol-abuse treatment, researchers conducted a prospective, 12-week, follow-up study of 19 Veterans Affairs patients who were mandated by courts to undergo …

Shared Care: lessons from one model of shared care nursing in primary care

This paper is an exploration of the issues which arise when developing a model of shared care for substance misusers in primary care. A rural primary care group (PCG) developed a shared care nurse (SCN) role to provide improved care for substance misusing clients, and to support professionals in both primary and specialist care. The SCN was employed by the specialist drug service (SDS) and, for the purposes of the pilot project, the SCN held clinics at three general practitioner (GP) practices. An evaluation of this pilot project forms the basis of this paper. Semi-structured interviews were undertaken with clients of the shared care service and with professionals involved in the treatment of substance misusing clients. These interviews were recorded, transcribed and then analysed for salient themes. Questionnaires were distributed to members of the primary health care teams who had not been interviewed, and responses were also thematically analysed. This paper highlights the benefits and barriers encountered in developing a new model of care for substance misusing clients. It clearly illustrates improved satisfaction with service provision, both for service providers and clients. There continued to be difficulties, however, with waiting lists and clear referral pathways for the treatment of substance dependency.

Metaanalyser som grundlag for evidensbaseret misbrugsbehandling: En diskussion af fem metaanalyser af behandlingseffekter

Evidence-based medicine rests on the assumption of a hierarchy of evidence. The highest level of evidence is assumed to come from meta-analyses of randomised clinical trials. Five illustrative recent meta-analyses of psycho-social treatment for substance dependence are discussed (Prendergast et al. 2002; Irvin et al. 1999; SBU 2001; Griffith et al. 2000; Pearson &amp; Lipton 1999). In all cases the methodological strengths and weaknesses of the study are discussed, as well as the clinical and theoretical implications of the analysis. Studies that attempt to address very broad questions such as “does treatment work” produce conclusions that appear inconsistent and may be flawed, and the clinical and theoretical implications of the findings of such meta-analyses are unclear. In contrast, analyses of specific treatments produce findings that are clinically and theoretically meaningful. In cases where the populations or settings studied are diverse, but the type of treatment is similar, well-conducted meta-analyses may produce significant data on the degree to which the apparent effectiveness of a specific treatment can be generalised to new populations or settings. It is concluded that the efficacy of specific classes of interventions for drug or alcohol use disorders may be a relevant target for meta-analyses, whereas meta-analyses that attempt to do too much by asking very global questions are unproductive, and that although meta-analyses are generally effective at addressing the question of whether a given treatment has support in the existing research, they are not able to answer questions about what should be the means and ends of drug policy and drug treatment at a more general level.

DRUG PROBLEM RECOGNITION, DESIRE FOR HELP, AND TREATMENT READINESS IN A SOUP KITCHEN POPULATION

This study determined hypothesized predictors of three components of motivation for change—drug problem recognition, desire for help, and treatment readiness—in a high-risk, drug-using population. The sample consisted of 190 guests at two inner-city soup kitchens in Brooklyn, NY who reported drug/alcohol use and were not participating in substance dependency treatment. Ever receiving addiction treatment, having no trade/job skills, and more severe symptoms of depression were associated with greater drug problem recognition. More recent days of drug/alcohol use, intensive pattern of drug use, and greater problem recognition were associated with greater desire for help. Caring for children, more recent days of drug/alcohol use, physical health problems, and desire for help were the direct predictors of treatment readiness. Problem recognition had a strong indirect effect on readiness mediated through desire for help. Knowledge of a drug user's motivational state and the factors leading to it can help guide the development of more effective interventions.