Predictive validity of cocaine, sedative, and alcohol dependence diagnoses.

This study examined the predictive validity of Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders-III-Revised (DSM-III-R) (R. L. Spitzer et al, 1990) based substance dependence diagnoses (i.e., cocaine, sedative, and alcohol) for 518 opioid-dependent outpatients entering methadone maintenance. Patients were followed over 1 year of treatment, which involved daily methadone substitution supplemented by individual and group counseling. Urine specimens were tested randomly 1–4 times per month. Patients diagnosed with current cocaine, sedative, or alcohol dependence were more likely to use these drugs than were patients with past only or no dependence syndrome. Current cocaine dependence predicted early treatment dropout. The results demonstrate the predictive and discriminant validity of several substance dependence diagnoses common among patients in substance abuse or other psychiatric treatment settings. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Pre- and postsynaptic neurotoxic effects of dopamine demonstrated by intrastriatal injection

The coexistence of psychiatric and substance abuse problems within the same patient occurs with significant frequency. These patients present serious challenges to a health care system which has traditionally treated mental health and substance abuse in separate venues, with differing and sometimes contradictory treatment modalities. Few studies exist on the treatment of the "dual diagnosis" patient utilizing an integrated approach, where both problems are addressed by the same staff on a single inpatient ward. We describe such a program in which dual diagnosis patients on one ward are separated into two different treatment tracks based upon the severity of their psychiatric illness. Follow-up measures at 3 months after discharge are compared for patients from each treatment track, with no significant difference found for the five outcome variables studied. This suggests that chronically mentally ill inpatients may benefit from integration of attention to their substance abuse problems with psychiatric treatment.     

Comparing Hatha yoga with dynamic group psychotherapy for enhancing methadone maintenance treatment: a randomized clinical trial

BACKGROUND: As more methadone treatment programs are funded in an attempt to curb substance abuse and HIV infection among i.v. drug users, more cost effective treatment approaches are being sought. OBJECTIVES: To investigate whether clients in outpatient methadone maintenance treatment who practice weekly Hatha yoga in a group setting experience more favorable treatment outcomes than those who receive conventional group psychodynamic therapy. METHODS: After a 5-day assessment period, 61 patients were randomly assigned to methadone maintenance enhanced by traditional group psychotherapy (ie, conventional methadone treatment) or an alternative Hatha yoga therapy (ie, alternative methadone treatment). Patients were followed for 6 months and evaluated on a variety of psychological, sociological, and biological measures. The revised Symptom Check List provided the primary psychological measures; the Addiction Severity Index provided various indices of addictive behaviors. RESULTS: The evidence revealed that there were no meaningful differences between traditional psychodynamic group therapy and Hatha yoga presented in a group setting. Both treatments contributed to a treatment regimen that significantly reduced drug use and criminal activities. Psychopathology at admission was significantly related to program participation regardless of treatment group. DISCUSSION: In addition to examining the characteristics of patients who present for treatment, this study identifies unexpected staff issues that complicate the integration of alternative and traditional treatment strategies. CONCLUSION: Alternative methadone treatment is not more effective than conventional methadone treatment, as originally hypothesized. However, some patients may benefit more from alternative methadone treatment than conventional methadone treatment. Additional research is necessary to determine characteristics that identify patients who might benefit from alternative methadone treatment.     

Construct refinement and confirmation for the Addiction Severity Index.

A series of analyses reconstruct and confirm the validity and reliability of hypothesized scales for the Addiction Severity Index. Using a diverse sample (n?=?990) of methadone maintenance substance abuse patients, a multistage scaling strategy was applied to identify 7 psychometrically integral addiction problem scales. Exploratory item analyses, confirmatory oblique item clustering, and 2nd order factor analysis verified that the scales comprised relatively little common variance and that each retained a substantial amount of unique and reliable variance. Concurrent and predictive validity were supported with a sample of 244 methadone patients assessed throughout treatment. The advantages of the new scales are discussed, including provision of computer code for calculating normalized standard scores for use in clinical practice and treatment outcome research. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Substance abuse issues in cancer patients. Part 1: Prevalence and diagnosis

Although rare, drug abuse problems present a complex set of physical and psychosocial issues that complicate cancer treatment and pain/ symptom management. Most oncologists are not be well versed in either the conceptual or practical issues related to addiction. As a result, they often struggle in their attempts to effectively treat patients who are or have been substance abusers, and they find it difficult to understand issues of addiction in patients with pain who have no history of substance abuse. In the first installment of a two-part series, the authors explore the epidemiology of substance abuse. An examination of the distinctions between abuse and dependence leads to definitions of these terms appropriate for the oncology setting. Guidelines for assessing aberrant drug-taking behavior are also offered. Part 2, which will appear in the next issue of ONCOLOGY, will discuss the clinical management of cancer patients with a history of substance abuse.     

Effects of childhood abuse on relapse in a recently homeless substance-dependent veteran population.

The impact of childhood abuse, both childhood sexual abuse (CSA) and childhood physical abuse (CPA), is well documented. Both CSA and CPA have been associated with a number of mental health difficulties, including substance dependence. Though the association between abuse and mental health problems is well documented, what has received little attention is the impact that abuse histories may have on the ability to complete treatment for these problems. This study evaluates the association between abuse and failure to complete treatment due to substance relapse in 70 substance-dependent homeless men served by a Veterans Affairs Domiciliary Residential Rehabilitation and Treatment Program. Demographic and mental health variables were compared with incident rates of sexual and physical abuse as well as with rates of relapse prior to program completion. Contrary to predictions, results found that physical abuse, not sexual abuse, was associated with higher relapse rates. Limitations, implications, and future directions are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The dual diagnosis of attention-deficit/hyperactivity disorder and substance abuse: case reports and literature review

BACKGROUND: It is now recognized that attention-deficit/hyperactivity disorder (ADHD) may persist into adulthood. A number of studies have found an association between ADHD and substance abuse. This article describes three adult patients with both ADHD and substance abuse who were treated successfully with psychostimulants. A review of the relevant literature is included. METHOD: The patients were drawn from a university-based referral center for adults with ADHD. Evaluations for ADHD and substance abuse were completed. Medical therapy and follow-up were completed by the first author. RESULTS: All of the patients responded to psychostimulants and have remained abstinent from alcohol and other drugs for the past 2 to 3 years. CONCLUSION: This case series and review of the literature suggest that specific treatment for ADHD with psychostimulants is feasible in patients who also have substance abuse. Future studies should evaluate the prevalence of this "dual diagnosis" and the efficacy of differing management strategies.     

Computer model of a bovine type I collagen microfibril

It has been found that > 60% of bipolar I and almost 50% of bipolar II patients have a history of substance abuse (Regier et al., 1990). While previous studies have examined comorbidity of bipolar disorder and substance abuse, little has been done to examine the effect of substance abuse on the course of bipolar disorder. There has also been little distinction made between bipolar disorder occurring prior to substance abuse and that occurring after the onset of substance abuse. Given the high prevalence of substance abuse in bipolar patients, it would be useful to determine more about the effect of substance abuse on demographic and clinical features and on the course of illness. We attempted to do this with a retrospective chart review of 188 bipolar patients seen by D.L. Dunner between January 1992 and December 1993. Demographic and clinical information as well as information about course of illness were systematically extracted from the charts. We compared the means and percentages of these variables and analysed them for significance. Preliminary results show differences in demographics, clinical features and course of illness between patient groups. These differences may illustrate the clinical effects of substance abuse on the course of bipolar disorder. Our results also indicate that there are differences between patients whose bipolar disorder began prior to and those whose disorder began after the onset of substance abuse.     

Twelve-step and cognitive-behavioral treatment for substance abuse: A comparison of treatment effectiveness.

The comparative effectiveness of 12-step and cognitive-behavioral (C-B) models of substance abuse treatment was examined among 3,018 patients from 15 programs at the US Department of Veterans Affairs Medical Centers. Across program types, participants showed significant improvements in functioning from treatment admission to a 1-year follow-up. Although 12-step patients were somewhat more likely to be abstinent at the 1-year follow-up, 12-step, C-B, and combined 12-Step–C-B treatment programs were equally effective in reducing substance use and improving most other areas of functioning. The finding of equal effectiveness was consistency over several treatment subgroups: Patients attending the "purest" 12-step and C-B treatment programs, and patients who had received the "full dose" of treatment. Also, patients with only substance abuse diagnoses, those with concomitant psychiatric diagnoses, and patients who were mandated to treatment showed similar improvement at the 1-year follow-up, regardless of type of treatment received. These data provide important new evidence supporting the effectiveness of 12-step treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Randomized Trial of Drug Abuse Treatment-Linkage Strategies.

A clinical trial contrasted 2 interventions designed to link opioid-dependent hospital patients to drug abuse treatment. The 126 out-of-treatment participants were randomly assigned to (a) case management, (b) voucher for free methadone maintenance treatment (MMT), (c) case management plus voucher, or (d) usual care. Services were provided for 6 months. MMT enrollment at 3 months was 47% (case management), 89% (voucher), 93% (case management plus voucher), and 11% (usual care); at 6 months enrollment was 48%, 68%, 79%, and 21%, respectively. Case management and vouchers can be valuable in health settings to link substance abusers with medical problems to drug abuse treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Serotoninergic control of the activity and expression of glial GABA transporters in the rat cerebellum

OBJECTIVE: The purpose of the study was to compare staff versus patient perceptions of the causes and emotional impact of verbal and physical aggression on a psychiatric inpatient unit, and the corrective measures each group would endorse. METHODS: Fifty-four patients and 32 nursing staff members responded to similar questions about physical and verbal aggression. They also reported their emotional responses to aggression and steps they would endorse to reduce aggression at the medical center. Data was analyzed by chi-square tests for proportion comparisons between groups. RESULTS: "Verbal Abuse" was viewed an important contributor to physical aggression. Staff stressed patient substance abuse and violent lifestyles. Patients focused on the use of involuntary procedures and cultural differences between patients and staff. CONCLUSIONS: Patients endorsed more restrictive safety measures as long as the measures such as metal detectors and searches were applied to staff and visitors, as well as patients. Patients requested more input into decision-making processes through patient-staff workgroups.     

Central stimulants in adults with AD/HD. Can they be abused?]

As early as in 1979, abuse was observed when adults with MBD were treated with psychostimulants. In a study from 1981, five patients (19%) had been stimulated or excited. It was concluded that there was no reason to believe that adults with MBD were immune from stimulant abuse problems. In subsequent studies, it has been the rule to exclude patients who abuse alcohol or drugs. Obviously, there has been agreement that treatment implies a considerable risk of abuse of stimulants. However, nobody has systematically studied the frequency of psychostimulant abuse in subjects with AD/HD with and without abuse of alcohol and drugs, neither during the study nor at follow-up. There has been some attempts at using pemoline, a stimulant which cannot be abused. However, the mental and physical complications have been severe. Some preliminary studies indicate that stimulants can be used to treat alcoholics and substance abusers with concurrent AD/HD. Before such treatment can be recommended, the observations should be confirmed in controlled studies with representative materials, and the patients should be followed over a long period of time. It seems that stimulants are not an appropriate treatment for subjects with psychopathic personality and antisocial behaviour.     

Psychology of comorbid posttraumatic stress disorder and substance abuse: lessons from combat veterans

This article provides important phenomenological observations, conceptual models, research findings, theoretical ideas, and psychotherapeutic techniques that are proving useful in working with combat veterans who display both PTSD and substance abuse disorders. Some of the clinical challenges of treating patients displaying a complicated trauma response are explored, such as the phenomena of patient and therapist dichotomous thinking, a "tuned-out" patient style, and difficulty establishing or maintaining therapeutic alliance. A clinically useful model (cocomplication model) is presented that views PTSD and substance abuse as tending mutually to impede resolution of one another, so that over time the patient may never achieve significant resolution of either problem. An overview of historical and current models of PTSD is then presented in order to provide a context for understanding ways that pretrauma variables might help determine the nature, persistence, and severity of adverse psychological reactions to overwhelming stress. Pathogenic beliefs developed in response to childhood mistreatment, abuse, or neglect are capable of mediating responses to later trauma. Once reinforced in combat or by other trauma, such beliefs may become particularly tenacious and compelling. Pathogenic beliefs incompatible with recovery from the trauma response and from addiction are reviewed. Testing for safety among traumatized populations is discussed and treatment suggestions are provided to avoid confirmation of pathogenic beliefs. A clinical case is provided that illustrates the application of these concepts to formulation and treatment.     

Effects of reinforcer magnitude on data-entry productivity in chronically unemployed drug abusers participating in a therapeutic workplace.

The Therapeutic Workplace is a substance abuse treatment wherein patients are hired and paid to work in a job contingent on daily drug-free urine samples. The present study examined data-entry productivity of 6 unemployed methadone patients who demonstrated relatively variable and low data-entry response rates. A within-subject reversal design was used to determine whether increasing reinforcement magnitude tenfold could increase response rates. Four of the 6 participants showed the highest rates of responding in the high magnitude reinforcement condition. Two participants, who had the lowest overall response rates, showed less robust changes to the magnitude manipulation. The results suggest that reinforcement magnitude can be used to improve productivity in Therapeutic Workplace participants. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Review of Clinical management of substance abuse programs.

Reviews the book, Clinical management of substance abuse programs by Robert J. Craig (see record 1987-97819-000). Clinical management of substance abuse programs is a significant contribution to substance abuse program management. The author provides the program director with specific information about increasing program effectiveness. His thesis is that broad program activities have greater impact on total patient care than does any individual activity with a particular patient. The book is divided into three parts. Part I is devoted to the following sections: (a) an introduction and review of the book's contents, (b) diagnostic interviewing, and (c) psychological testing. The three chapters in Part II review general models of treatment, including multimodal, combined alcohol and drug, and treatment matching. Part III, which contains four chapters, details clinical program management activities. In this section the author offers the nuts and bolts for designing a substance abuse program based on effective evaluation and quality control. The author is successful in providing a basic text to assist clinician/managers in designing more effective treatment programs for substance abusers. I recommend this book to any professional responsible for program development in substance abuse treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Radioimmunuassay compared to thin-layer and gas--liquid chromatography for detecting methadone in human urine

Radioimmunoassay was compared to thin-layer and gas--liquid chromatographic methods for detection of methadone in the urine of patients undergoing methadone maintenance therapy as treatment of heroin abuse. With urine samples known to contain methadone, 84% were positive by thin-layer chromatography as compared to 99% positives by the other two methods. This difference is attributed to the difference in sensitivity of the three methods. All three methods gave consistently positive results with urine samples from patients receiving 25 mg of methadone per day or more. With smaller daily doses the percentage of positive results obtained with thin-layer chromatography decreased. Analysis of urine samples not containing methadone showed no incidence of cross reaction of other drugs with the methadone radioimmunoassay. The methadone radioimmunoassay appears to be both sensitive and reliable; however, certain other factors limit its use as a primary screening method.     

Distress Tolerance as a Predictor of Early Treatment Dropout in a Residential Substance Abuse Treatment Facility.

A large percentage of individuals who enter residential substance abuse treatment drop out before completing treatment. Given that early treatment dropout places individuals at an increased risk for relapse, identifying the mechanisms underlying treatment dropout would have several important theoretical and clinical implications. In the current study, the authors examined levels of psychological and physical distress tolerance as a predictor of early treatment dropout in a residential substance abuse treatment facility. In a sample of 122 individuals entering a residential substance abuse treatment facility, level of psychological distress tolerance was predictive of early treatment dropout above and beyond relevant self-report variables. There was no relationship between physical distress tolerance and early treatment dropout. Implications for future studies and treatment development or modification are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Relation of low-severity violence to women's health

OBJECTIVE: To determine if women who experience low-severity violence differ in numbers of physical symptoms, psychological distress, or substance abuse from women who have never been abused and from women who experience high-severity violence. DESIGN: Cross-sectional, self-administered, anonymous survey. SETTING: Four community-based, primary care, internal medicine practices. PATIENTS: Survey respondents were 1,931 women aged 18 years or older. SURVEY DESIGN: Survey included questions on violence; a checklist of 22 physical symptoms; the Symptom Checklist-22 (SCL-22) to measure depression, anxiety, somatization, and self-esteem; CAGE questions for alcohol use; and questions about past medical history. Low-severity violence patients had been "pushed or grabbed" or had someone "threaten to hurt them or someone they love" in the year prior to presentation. High-severity violence patients had been hit, slapped, kicked, burned, choked, or threatened or hurt with a weapon. MAIN RESULTS: Of the 1,931 women, 47 met criteria for current low-severity violence without prior abuse, and 79 met criteria for current high-severity violence without prior abuse, and 1,257 had never experienced violence. The remaining patients reported either childhood violence or past adult abuse. When adjusted for socioeconomic characteristics, the number of physical symptoms increased with increasing severity of violence (4.3 for no violence, 5.3 for low-severity violence, 6.4 for high-severity violence, p < .0001). Psychological distress also increased with increasing severity of violence (mean total SCL22 scores 32.6 for no violence, 35.7 for low-severity violence, 39.5 for high-severity violence, p < .0001). Women with any current violence were more likely to have a history of substance abuse (prevalence ratio [PR] 1.8 for low-severity, 1.9 for high-severity violence) and to have a substance-abusing partner (PR 2.4 for both violence groups). CONCLUSIONS: In this study, even low-severity violence was associated with physical and psychological health problems in women. The data suggest a dose-response relation between the severity of violence and the degree of physical and psychological distress.     

Physical and mental comorbidity of substance use disorders in psychiatric consultations. European Consultation-Liaison Workgroup

Comorbidity of substance use disorders with physical and mental disorders was investigated among 1249 consecutive psychiatric consultation patients admitted to six general hospitals in Finland. Of the patients 354 (28%) were diagnosed with substance use disorders (ICD-10), of which 22% were due to use of at least two different types of psychoactive substances. Alcohol dependence (117/226) in male patients and acute drug intoxication (49/128) at a similar rate as alcohol dependence (44/128) in female patients were the most common clinical conditions. With few exceptions, all substance use disorders were comorbid and in 63% of affected patients comprised a "triple diagnosis" (i.e., physical, mental, and substance use diagnoses concurrently). Poisonings and personality disorders in both sexes, digestive system diseases in men, and injuries in women were related to substance use disorders. Conclusions for service provision were: (1) the high level of co-occurrence of physical and mental disorders with substance use disorders calls for comprehensive, multi-disciplinary assessment of any substance use problems ascertained in psychiatric consultations; (2) poisoning with substance use involvement and mental comorbidity was the most common combined clinical condition justifying provision of addiction psychiatric emergency consultations in general hospitals; (3) polydrug use indicating severe problems and complex treatment needs should be identified; and (4) psychiatric referrals of patients with physical alcohol-related disorders should be ensured in general hospitals.