Organic mood syndrome associated with detoxification from methadone maintenance

OBJECTIVE: The authors delineate the clinical characteristics of mood state changes that occur in stable opioid-dependent patients undergoing therapeutic detoxification from methadone maintenance treatment. METHOD: Twenty-four patients participated in a blinded protocol for gradual methadone dose reduction that included weekly assessments of affective state using the Profile of Mood States (POMS) as well as weekly assessments of signs and symptoms of opioid withdrawal. Data obtained before methadone dose reduction and during the 2-week period of maximal dysphoric symptoms were compared. Changes in affective and opioid withdrawal measures were compared in patients who differed in their success in completing the detoxification regimen. RESULTS: Sustained increases in POMS scores of greater than 20 points were observed in 12 of the 24 patients during the course of detoxification. The emergence of symptoms of dysphoria was accompanied by insomnia, loss of appetite, and somatic complaints consistent with symptoms of opioid withdrawal but only minimal levels of objective signs of withdrawal. Greater changes from baseline in mood state and opioid withdrawal measures occurred in patients who were unable to complete the detoxification regimen. CONCLUSIONS: The development of an organic mood syndrome is a common occurrence in patients undergoing slow detoxification from methadone maintenance treatment and is associated with a poor outcome.     

Children with asthma have improved pulmonary functions after massage therapy

OBJECTIVE: Opioid withdrawal has been associated with poor fetal growth, preterm delivery, and fetal death. We sought to evaluate the safety of antepartum opioid detoxification in selected gravidas. METHODS: Between 1990 and 1996, women with singleton gestations who reported opioid use were offered inpatient detoxification. Predetoxification sonography was performed to confirm gestational age and to exclude fetuses with growth restriction and oligohydramnios. Women with mild withdrawal symptoms were given clonidine initially, and methadone was substituted if symptoms persisted. Objective signs of withdrawal were treated with methadone from the outset. Antenatal testing was performed once gestations reached 24 weeks. Newborns were observed for signs of neonatal abstinence syndrome and were treated as necessary. Obstetric and neonatal outcome data were collected. RESULTS: Thirty-four gravidas elected to undergo opioid detoxification at a mean gestational age of 24 weeks. The median maximum dose of methadone was 20 mg per day (range 10-85 mg), and the median time to detoxification was 12 days (range 3-39 days). Overall, 20 women (59%) successfully underwent detoxification and did not relapse, ten (29%) resumed antenatal opioid use, and four (12%) did not complete detoxification and opted for methadone maintenance. There was no evidence of fetal distress during detoxification, no fetal death, and no delivery before 36 weeks. Fifteen percent of neonates were treated for narcotic withdrawal. CONCLUSION: In selected patients, opioid detoxification can be accomplished safely during pregnancy.     

Comparable efficacy of contingency management for cocaine dependence among African American, Hispanic, and White methadone maintenance clients.

Cocaine use is a significant problem among methadone maintenance clients. Contingency management (CM) is a reinforcement-based approach with demonstrated efficacy for reducing cocaine use. This study examines whether the efficacy of CM treatment for cocaine-dependent individuals receiving methadone maintenance for opioid dependence differs by ethnicity. Participants were 191 African American, Hispanic, and White cocaine-dependent methadone maintenance clients, randomly assigned to standard methadone treatment or standard methadone treatment plus CM for 12 weeks. Hispanic participants were younger, less educated, and reported fewer years of cocaine use than did African American and White participants and reported fewer years of heroin use than did African American participants. African American participants were less likely to report a history of psychiatric symptoms or treatment in comparison with Hispanic and White participants. While CM was associated with longer duration of continuous cocaine abstinence and a greater proportion of submitted urine samples negative for cocaine, ethnicity was not related to treatment outcomes, and there was no significant interaction between treatment and ethnicity. CM appears to be an efficacious treatment for cocaine dependence among methadone maintenance clients, regardless of ethnicity. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Predicting cocaine group treatment outcome in cocaine-abusing methadone patients.

The authors examined predictors of cocaine group treatment outcome in methadone maintenance treatment (MMT) patients, including cocaine urinalysis at intake and demographic variables. Clinic policy is that patients identified as using cocaine must attend a weekly cocaine-focused, cognitive–behavioral therapy (CBT) group. Cocaine treatment is based on a behavioral (escape) contingency model whereby completers must attend group-counseling sessions and produce cocaine-negative urinalysis results. Among the 113 patients enrolled in the cocaine group, 43 (38%) were treatment completers (who attended 6 consecutive weeks of group and produced 6 consecutive weeks of cocaine-free urine tests) and 70 (62%) were treatment noncompleters. Treatment completion (i.e., cocaine abstinence) was significantly associated with baseline cocaine-free urinalysis and higher methadone dose. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Implosive therapy treatment of heroin addicts during methadone detoxification.

Examined the effectiveness of implosive therapy with heroin addicts during detoxification from methadone. 24 Ss with comparable histories of heroin addicition and similar maintenance levels of methadone were assigned to an implosive therapy, eclectic counseling, or control group. The 2 treatment groups received 12 sessions of implosive therapy or eclectic counseling and were followed for a subsequent 6-wk period. The implosive therapy Ss were the only ones to reduce significantly their methadone level during treatment and the follow-up period. (1 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Drug abuse treatment readmissions and outcomes. Three-year follow-up of DARP patients

Temporal patterns of drug abuse treatment reentry and other outcome measures were examined over a three-year period based on a national follow-up sample of persons admitted to treatment in the Drug Abuse Reporting Program (DARP) during 1969 to 1972. Follow-up treatment modes included methadone maintenance, residence in a therapeutic community, outpatient drug-free treatment, outpatient detoxification treatment, and a comparison group whose members completed intake only and did not return for treatment in the DARP. Treatment readmission patterns were examined in relation to outcome measures for illicit drug use, alcohol use, employment, and criminality over time. The findings showed there were reliable associations between readmission patterns and posttreatment outcomes, which suggested there were beneficial effects of drug abuse treatment.     

Contingent take-home incentive: Effects on drug use of methadone maintenance patients.

Examined contingent methadone take-home privileges for effectiveness in reducing on-going supplemental drug use of methadone maintenance patients. 53 new intakes were randomly assigned to begin receiving take-home privileges after 2 consecutive weeks of drug-free urines or to a noncontingent procedure in which take-homes were delivered independently of urine test results. The contingent procedure produced more individuals with at least 4 consecutive weeks of abstinence (32 vs 8%); 28% of noncontingent Ss also achieved abstinence after shifting to the contingent procedure. Lower baseline rate of drug-free urines was strongly associated with successful outcome, whereas the type of drug abused (cocaine vs benzodiazepines) did not influence outcomes. Findings support a recommendation for using contingent take-home incentives to motivate abstinence during methadone maintenance treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Motivation as a predictor of early dropout from drug abuse treatment.

Examined measures of motivation for drug use change and treatment with respect to psychometric properties and prediction of early dropouts from methadone maintenance. Three scales developed by D. D. Simpson (1992) were used to obtain personal assessments: Drug Use Problems, Desire for Help, and Treatment Readiness. Data were collected at intake from 311 methadone maintenance clients admitted to 3 outpatient treatment agencies, of which 24% dropped out of treatment within 60 days. The scales were found to be reliable. Social stability (marital status, employment, and fewer prior arrests), previous treatment experience, expectations for reducing future drug use, higher methadone dose level, and higher motivation were identified as significant predictors of treatment retention beyond 60 days. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

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.     

Nursing care in ambulatory methadone programs. A comparative literature study between The Netherlands and The United States

In this article, the results are discussed of a literature study on nursing care for heroin addicts in out-patient methadone maintenance clinics in the Netherlands and the United States. In the Netherlands, the most important aim of methadone maintenance is to limit the harm caused by heroin use. Community based methadone maintenance is the subject in several Dutch evaluation studies. Care is described in these studies, however the medical role is not distinguished from the nursing role and functions. Research variables are basic care assumptions and client satisfaction. In the USA, heroin misuse is considered a disease more than in the Netherlands. Nurses in the American methadone maintenance clinics have a more independent function compared with the nurses in the Netherlands. The main variables in the American studies on nursing care in the out-patient methadone maintenance clinics are the nursing process as well as the development and testing of nursing interventions. Further nursing research concerning the methadone maintenance clinics in the Netherlands is needed because the nursing contribution in maintaining and improving the basic health status of the heroin misuser is of vital importance. The American nursing research and the associated outcomes could be used as a guideline.     

Validation of a contemplation ladder in an adult substance use disorder sample.

Developing brief measures of motivation to abstain from substance use that reliably predict treatment retention and outcome is a high priority in the addiction field. This study examined the psychometric properties of a contemplation ladder designed to assess readiness to abstain from alcohol and drug use respectively, on the basis of the contemplation ladder for smoking cessation developed by Biener and Abrams (1991). Participants were 394 substance-using male and female welfare recipients referred for treatment. The combined alcohol and other drug (AOD) ladder showed discriminant validity with demographic and health characteristics, convergent validity with conceptually related treatment motivation variables, concurrent validity with baseline AOD treatment and substance use variables, and predictive validity for participation in treatment services up to 1 month later and abstinence outcomes up to 1 year later. The AOD ladder showed predictive validity for those in drug-free treatment and no treatment at baseline but not for those in methadone maintenance. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Heroin craving and drug use in opioid-maintained volunteers: Effects of methadone dose variations.

Recent data indicate that opioid agonist and antagonist challenges decrease and increase (respectively) heroin craving in physically dependent individuals. This study investigated effects of methadone dose variations on craving and new drug use in 18 outpatients who were given money contingencies. In Phase 1, volunteers were told in different test sessions that methadone dose would increase, decrease, or stay the same; drug-abstinence contingencies were suspended for 24 hr. Craving significantly increased and new heroin use marginally increased (relative to maintenance dose) only when a dose reduction was paired with a dose decrease instruction. In Phase 2 (detoxification), craving and heroin use significantly increased as methadone dose decreased. Thus, loss of μ-receptor agonist effect increased craving and risk of relapse. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Natural classes of treatment response.

This study examines an approach to identifying patterns of treatment response over time. Treatment response profiles are identified by cluster analyzing a repeated measure of patient performance collected at intervals during treatment. The procedure is demonstrated in Study 1 using monthly urinalysis results of 103 patients entering methadone maintenance treatment. The internal, external, and face validities of derived treatment response profiles are evaluated. A logistic regression model predicting treatment response is then constructed from intake variables found to correspond with the treatment response profiles. Study 2 replicates the procedures on an independent sample. Treatment response profiles facilitate the analysis of treatment response offering advantages over common measures of treatment outcome, such as performance at follow-up, change in performance from treatment entry to follow-up, or performance summed across treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Randomised trial of heroin maintenance programme for addicts who fail in conventional drug treatments

OBJECTIVE: To evaluate an experimental heroin maintenance programme. Design: Randomised trial. SETTING: Outpatient clinic in Geneva, Switzerland. SUBJECTS: Heroin addicts recruited from the community who were socially marginalised and in poor health and had failed in at least two previous drug treatments. INTERVENTION: Patients in the experimental programme (n=27) received intravenous heroin and other health and psychosocial services. Control patients (n=24) received any other conventional drug treatment (usually methadone maintenance). Main outcome measures: Self reported drug use, health status (SF-36), and social functioning. RESULTS: 25 experimental patients completed 6 months in the programme, receiving a median of 480 mg of heroin daily. One experimental subject and 10 control subjects still used street heroin daily at follow up (difference 44%; 95% confidence interval 16% to 71%). Health status scores that improved significantly more in experimental subjects were mental health (0.58 SD; 0.07 to 1.10), role limitations due to emotional problems (0.95 SD; 0.11 to 1.79), and social functioning (0.65 SD; 0.03 to 1.26). Experimental subjects also significantly reduced their illegal income and drug expenses and committed fewer drug and property related offences. There were no benefits in terms of work, housing situation, somatic health status, and use of other drugs. Unexpectedly, only nine (38%) control subjects entered the heroin maintenance programme at follow up. CONCLUSIONS: A heroin maintenance programme is a feasible and clinically effective treatment for heroin users who fail in conventional drug treatment programmes. Even in this population, however, another attempt at methadone maintenance may be successful and help the patient to stop using injectable opioids.     

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Comparatively few studies have examined the effects of methadone given during a clinical detoxification programme. Furthermore, their results are different especially because of changing drop-out rates. This study was carried out on a drug-detoxification ward and investigated the effects of methadone given to alleviate withdrawal symptoms. Comparisons were undertaken with patients withdrawn during a one-year period before methadone was available. No significant difference was found between drop-out rates of patients with methadone-supported detoxification (n = 113, drop-out rate: 41.6%) and patients who did not receive methadone during detoxification (n = 108, drop-out rate: 37.0%). Nevertheless the drop-out rate in the first three days of withdrawal was reduced from 15.7% to 8.0%. On average the critical drop-out moment shifted from 5.3 days to 10.1 days. Interpretations of these findings should take into account, that the number of patients who underwent a voluntary detoxification programme for the first time was nearly doubled after methadone was offered on the ward and, additionally, many more patients tried to withdraw from methadone taken within an outpatient methadone-maintenance programme.     

In vitro attachment of Pneumocystis carinii from mouse and rat origin

Cigarette smoking has been shown to increase consequent to the acute administration of methadone. This suggests the possibility that differences in maintenance dose levels might be associated with differential smoking rates. It is of special concern that higher maintenance levels of methadone may lead to more cigarette smoking because of the putative beneficial effects of higher doses on illicit drug use, treatment retention, and the like. Two experiments were conducted to test the hypothesis that higher maintenance doses of methadone are related to more cigarette smoking. Smoking was measured by self-report and expired carbon monoxide, and the amounts were correlated with subjects' methadone dose levels. The results showed smoking rates of 85% and that self-reported smoking significantly correlated (r = -.52) with CO. Maintenance doses, however, were not correlated with smoking levels. This suggests that the acute effects of methadone on smoking are nullified as clients habituate to dose level, and that decisions regarding appropriate methadone dosage can be made on other grounds.     

Patient outcomes after initiation of Sabbath closure of a methadone maintenance clinic in Israel

The study examined whether closing of a methadone maintenance clinic in Israel on the Sabbath was associated with adverse patient outcomes. One take-home dose of methadone was given to all patients for that day regardless of whether they had earned take-home privileges. No difference was found in dropout rates for the six-month periods before and after Saturday closure was initiated. Results of random, twice-weekly urinalyses for all patients did not indicate increased use of heroin. The findings suggest that closure of a methadone clinic at least one day a week does not jeopardize patient outcome. Cutting hours of operation would reduce workload and enable clinics to function more economically.     

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)     

A controlled trial comparing buprenorphine and methadone maintenance in opioid dependence

BACKGROUND: Buprenorphine is a partial agonist at the mu-opioid receptor that has been proposed as an alternative to traditional full agonist maintenance therapy for the treatment of opioid addiction. We report on a clinical trial in which the relative safety and efficacy of long-term fixed-dose buprenorphine maintenance was examined in comparison to low- and high-dose methadone maintenance. METHODS: Two hundred twenty-five treatment-seeking opioid addicts (46 women, 179 men) were randomly assigned to receive, in a double-blind manner, either 8 mg/d of buprenorphine, 30 mg/d of methadone, or 80 mg/d of methadone maintenance over a 1-year period. Objective and subjective measures of efficacy (urine toxicology, retention, craving, and withdrawal symptoms) were examined at the study midpoint and at termination, and safety data were tabulated over the entire 52-week study period. RESULTS: Patients assigned to high-dose methadone maintenance performed significantly better on measures of retention, opioid use, and opioid craving than either the low-dose methadone or the buprenorphine group at both 26-week and 52-week time points. Performance on these measures was virtually identical between the latter two groups. No serious adverse health effects attributable to buprenorphine were noted. CONCLUSIONS: Buprenorphine maintenance at 8 mg/d appears to be less than optimally efficacious under the conditions of the present study. Continued research is needed to reconcile these findings with the more positive results reported by other investigative groups. There are no apparent health risks associated with long-term buprenorphine maintenance at this dosage.     

Hemodynamic performance of four mechanical bileaflet prosthetic valves in the mitral position: an echocardiographic study

Plasma methadone concentrations and its main metabolite D,L-2-ethylidiene-1,5-dimethyl-3,5-diphenylpyrrolidine (EDDP) were determined in 93 patients under methadone maintenance treatment to assess their relationship with heroin use and opioid withdrawal symptoms. Neither plasma concentrations of methadone nor EDDP were significantly different when patients that used heroin in last 3 months were compared with those testing negative for this drug (methadone, 355 +/- 217 versus 369 +/- 216 ng/ml, t = 0.29, P = NS; EDDP, 49 +/- 28 versus 54 +/- 40 ng/ml, t = 0.51, P = NS). No correlation between opioid withdrawal scale scores and plasma concentrations of methadone (r = 0.02, P = NS) and EDDP (r = -0.14, P = NS) was found. Therapeutic drug monitoring during methadone maintenance seems to be useful for assessing compliance with treatment but not for predicting heroin use and subjective withdrawal symptoms.