Library Watch - On Clinical Issues

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Last Update: 11.06.06

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...on Clinical Issues

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Summer 2006

A randomized controlled trial of interim methadone maintenance.

Schwartz RP; Highfield DA; Jaffe JH; Brady JV; Butler CB; Rouse CO et al. Archives of General Psychiatry 63(1): 102-109, 2006. (31 refs.)
Context: Effective alternatives to long waiting lists for entry into methadone hydrochloride maintenance treatment are needed to reduce the complications of continuing heroin dependence and to increase methadone treatment entry. Objective: To compare the effectiveness of interim methadone maintenance with that of the usual waiting list condition in facilitating methadone treatment entry and reducing heroin and cocaine use and criminal behavior. Design: Randomized, controlled, clinical trial using 2 conditions, with treatment assignment on a 3:2 basis to interim maintenance-waiting list control. Setting: A methadone treatment program in Baltimore. Participants: A total of 319 individuals meeting the criteria for current heroin dependence and methadone maintenance treatment. Interventions: Participants were randomly assigned to either interim methadone maintenance, consisting of an individually determined methadone dose and emergency counseling only for up to 120 days, or referral to community-based methadone treatment programs. Main Outcome Measures: Entry into comprehensive methadone maintenance therapy at 4 months from baseline; self-reported days of heroin use, cocaine use, and criminal behavior; and number of urine drug test results positive for heroin and cocaine at the follow-up interview conducted at time of entry into comprehensive methadone treatment (or at 4 months from baseline for participants who did not enter regular treatment). Results: Significantly more participants assigned to the interim methadone maintenance condition entered comprehensive methadone maintenance treatment by the 120th day from baseline (75.9%) than those assigned to the waiting list control condition (20.8%) (P <.001). Overall, in the past 30 days at follow-up, interim participants reported significantly fewer days of heroin use (P <.001), had a significant reduction in heroin-positive drug test results (P <.001), reported spending less money on drugs (P <.001), and received less illegal income (P <.02) than the waiting list participants. Conclusion: Interim methadone maintenance results in a substantial increase in the likelihood of entry into comprehensive treatment, and is an effective means of reducing heroin use and criminal behavior among opioid-dependent individuals awaiting entry into a comprehensive methadone treatment program.

Maturing out of alcohol dependence: The impact of transitional life events.

Dawson DA; Grant BF; Stinson FS; Chou PS. Journal of Studies on Alcohol 67(2): 195-203, 2006. (45 refs.)
Objective: The purpose of this study was to investigate the effects of transitional life events related to education, employment, and family formation on the likelihood of recovery from alcohol dependence as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), distinguishing the short- and long-term effects of these events and potential effect modification by treatment history, gender, and severity of dependence. Method: This analysis is based on data from the Wave 1 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a cross-sectional, retrospective survey of a nationally representative sample of U.S. adults 18 years of age and older. The analytic sample consisted of 4,422 individuals with prior-to-past-year (PPY) onset of DSM-IV alcohol dependence. Time-dependent proportional hazards models were used to estimate the effects of completing school, starting full-time work, getting married, becoming separated/divorced/widowed, and becoming a parent on the outcomes of nonabstinent recovery (NR; e.g., low-risk asymptomatic drinking) and abstinent recovery (AR). Results: Entry into and exit from a first marriage each increased the likelihood of NR during the first 3 years after those events occur-red (hazard rate ratio [HRR] = 1.37 and 1.76, respectively). However, individuals who were still dependent 3 or more years after those events occurred had a decreased likelihood of subsequent NR (HRR = 0.70 for both events), as did those who were still dependent 3 or more years after completing schooling (HRR = 0.54). The likelihood of AR was more than doubled in the 3 years after first becoming a parent (HRR = 2.22) but was decreased among individuals still dependent 3 or more years after starting full-time work. For the outcome of NR, all of the negative effects associated with still being dependent 3 or more years after the occurrence of key life events were more strongly negative among individuals with less severe cases of dependence. Conclusions: Transitional life events demonstrate many effects on recovery, including both direct effects consistent with role socialization and associations more reflective of selectivity than causation. Taken as a whole, these events appear to contribute to (but by no means fully explain) the high rates of recovery from alcohol dependence that have been observed even in the absence of treatment.

Association between non-medical and prescriptive usage of opioids.

Dasgupta N; Kramer ED; Zalman MA; Carino S; Smith MY; Haddox JD et al. Drug and Alcohol Dependence 82(2): 135-142, 2006. (19 refs.)
Understanding and managing prescription opioid abuse is one of the major challenges in pain management worldwide. The relationships between prescriptive usage of opioids and reported morbidity at the national level, using data front the Drug Abuse Warning Network (DAWN), were examined. When the major prescription opioids were evaluated, the association between prescriptive medical use in kilograms and reported morbidity, as measured by a ratio between the two, was similar for the intermediate-potency opioids (hydrocodone, methadone, oxycodone, and morphine). This rate was much lower for low-potency opioids (codeine, meperidine, pentazocine, and propoxyphene) and much greater for high-potency opioids (hydromorphone and fentanyl). When the drugs were adjusted by potency (relative to morphine), the rates of reported morbidity per kilogram of morphine equivalent opioid in prescriptive usage were similar among the opioids. Using the potency-adjusted total kilograms of opioid in prescriptive use for all the opioids evaluated, there was a statistically significant association (r(2) = 0.9791) with the reported morbidity for prescription analgesics as a class, as measured in the DAWN system. These data suggest that non-medical use of opioids is predictable based on potency and extent of prescriptive use.

Cannabis-induced koro-like syndrome: A case report and mini review.

Kalaitzi CK; Kalantzis A. Urologia Internationalis 76(3): 278-280, 2006. (27 refs.)
The genital-shrinking syndrome is a transient state of acute anxiety characterized by the triad of a deep-seated fear of penile shrinkage, its disappearance into the abdomen, and apprehension regarding inevitable impotence or even death. It is also known by the Malayo-Indonesian term 'koro'. In the West, koro syndrome has been reported only in relation with various somatic, psychiatric and drug-induced disorders. The vast majority of nonpsychiatric cases was related to neurological disorders or intoxication with cannabis or amphetamine. This is the first case of cannabis-induced koro-like syndrome ever reported in Greece.

Differences among those who complete and fail to complete inpatient detoxification.

Blondell RD; Amadasu A; Servoss TJ; Smith SJ. Journal of Addictive Diseases 25(1): 95-104, 2006. (29 refs.)
Some individuals hospitalized for alcohol or drug detoxification leave against medical advice (AMA). We hypothesized that certain characteristics would be associated with AMA discharges. A case-control study of 1,426 hospital admissions for detoxification (representing 1,080 individuals) was conducted to compare patients leaving the hospital AMA (n = 231) with a random sample of those completing detoxification (n = 286). Latino ethnicity, detoxification from drugs, Friday or Saturday discharge, Medicaid or no health insurance, and not being treated by one specific attending physician were characteristics associated with an AMA discharge in a backward logistic regression model. Although 85% of the patients with all these characteristics left AMA, only one patient, without any of these five characteristics, did so. We conclude that clinicians can use certain clinical features to predict AMA discharge. Additional research could evaluate if treatment strategies that consider these ethnic and socioeconomic disparities may reduce rates of AMA discharge.

Early therapeutic alliance and treatment outcome in individual and family therapy for adolescent behavior problems.

Hogue A; Dauber S; Stambaugh LF; Cecero JJ; Liddle HA. Journal of Consulting and Clinical Psychology 74(1): 121-129, 2006. (50 refs.)
The impact of early therapeutic alliance was examined in 100 clients receiving either individual cognitive-behavioral therapy (CBT) or family therapy for adolescent substance abuse. Observational ratings of adolescent alliance in CBT and adolescent and parent alliance in family therapy were used to predict treatment retention (in CBT only) and outcome (drug use, externalizing, and internalizing symptoms in both conditions) at post and 6-month follow-up. There were no alliance effects in CBT. In family therapy, stronger parent alliance predicted declines in drug use and externalizing. Adolescents with weak early alliances that subsequently improved by midtreatment showed significantly greater reductions in externalizing than adolescents whose alliances declined. Results underscore the need for ongoing developmental calibration of intervention theory and practice for adolescent clinical populations.

Efficacy of acupuncture for treating cocaine addiction: A review paper. (review).

Kim YHJ; Schiff E; Hovell M. Journal of Addictive Diseases 24(4): 115-132, 2005. (42 refs.)
Acupuncture is being used in more than three hundred treatment facilities for treating substance abuse including cocaine addiction. Previous review papers could not evaluate the role of acupuncture for treating cocaine addiction because of lack of clinical trials at the time. Since then, several important Studies were conducted in the field. This paper reviews existing clinical trials using acupuncture to treat cocaine addiction. The existing evidence fails to document the benefit of acupuncture in treating cocaine addiction as the sole treatment. Further efforts to document the efficacy of the NADA protocol to treat cocaine addiction as the sole treatment should be re-evaluated. There is a limited amount of evidence showing possible benefits of acupuncture when used as an adjunctive therapy to complement existing substance abuse treatment program. Future efforts should concentrate on systematic studies investigating the role of acupuncture as an adjunctive treatment for cocaine addiction. In addition, more formative research exploring the efficacy of different types and protocols of acupuncture treatments for cocaine addiction should be thoroughly investigated.

Efficacy of maintenance treatment with naltrexone for opioid dependence: A meta-analytical review. (review).

Johansson BA; Berglund M; Lindgren A. Addiction 101(4): 491-503, 2006. (42 refs.)
Aims: To determine the efficacy of naltrexone in reducing illicit opioid use and the potential moderating role of treatment retention. Design: First, randomized controlled trials (RCTs) comparing the regimens of treatment using the opioid antagonist, naltrexone, with controls were analysed by meta-analysis for treatment effect with regard to a range of outcome criteria. The degree of heterogeneity was also determined. The moderating effect of other interventions during naltrexone maintenance was then estimated, particularly with regard to their effect on treatment retention. Participants: Fifteen studies involving 1071 patients were found. Measurements: All available outcomes were analysed in 10 studies of naltrexone versus control (seven placebo) and six studies of randomized psychosocial/psychopharmacological interventions. Findings: Significant heterogeneity was found in the efficacy of naltrexone. Level of retention in treatment was found to be a moderator, explaining most of the heterogeneity found. Overall, naltrexone was significantly better than control conditions in reducing the number of opioid-positive urines. This effect was only present in the high retention subgroup for differences in retention. Contingency management (CM) increased retention and naltrexone use, resulting in a reduced number of opioid-positive urines. Conclusion: Retention is important to the effect of naltrexone in treating opioid dependence. Contingency management is a promising method of increasing retention.

Effectiveness of drug and alcohol counselling during methadone treatment: Content, frequency, and duration of counselling and association with substance use outcomes.

Gossop M; Stewart D; Marsden J. Addiction 101(3): 404-412, 2006. (51 refs.)
The study investigates the relationship between the type and severity of drug and alcohol use problems, and the provision of drug- and alcohol-counselling in methadone programmes. The study also specifically investigates the relationship between content, frequency and duration of counselling provided during the first month of treatment, and heroin, cocaine, and alcohol use outcomes at 6 months. The sample comprised 276 patients receiving outpatient methadone treatment who were followed-up 6 months after treatment entry. Data on client characteristics, drug and alcohol problems and on counselling received were collected by structured face-to-face interviews. Drug-focused counselling was associated with less frequent heroin and cocaine use at follow-up, but was not related to pre-treatment drug use. Alcohol-focused counselling was provided for those with higher levels of drinking at admission but was not significantly associated with drinking outcome at 6 months. Results indicate that there are complex interactions between presenting substance use problems, provision of counselling and treatment outcomes. These interactions differ by substance type.

Risk profile of individuals who provide assistance with illicit drug injections.

Fairbairn N; Wood E; Small W; Stoltz JA; Li K; Kerr T. Drug and Alcohol Dependence 82(1): 41-46, 2006. (22 refs.)
Background: Assisted injection is a common practice among injection drug users (IDU) that carries significant risk for health-related harm. However, little is known about the individuals who provide assistance with injections. Methods: We evaluated factors associated with providing help injecting among participants enrolled in the Vancouver Injection Drug User Study (VIDUS) using univariate and logistic regression analyses. We also examined self-reported relationships between the provider and the receiver of assisted injection, if compensation was provided for assistance, and what type of compensation was given. Results: Of the 704 IDU eligible for this analysis, 193 (27.4%) had provided help injecting during the last 6 months. Variables independently associated with providing help injecting included: lending one's own syringe (adjusted odds ratio [AOR] = 3.99, p = 0.004); frequent heroin injection (AOR = 3.75, p < 0.001); unstable housing (AOR = 2.15, p < 0.001); binge drug use (AOR = 2.01, p = 0.012); frequent cocaine injection (AOR = 1.95, p = 0.002); and frequent use of crack cocaine (AOR = 1.85, p = 0.002). Help was most often provided to a casual (47.2%) or a close friend (41.5%). Of the 96 (49.7%) individuals who received compensation for providing help, the most common forms of compensation were drugs (89.6%) and money (45.8%). Conclusion: Providing help injecting was common among IDU in this cohort and was associated with various high-risk behaviours, including elevated levels of syringe lending. These findings indicate the need for interventions that offset the risks associated with this dangerous practice.

Prescription drug abuse among ecstasy users in Miami.

Kurtz SP; Inciardi JA; Surratt HL; Cottler L. Journal of Addictive Diseases 24(4): 1-16, 2005. (57 refs.)
This Study examines the nature, extent and consequences of prescription drug abuse among 143 ecstasy users in Miami. Participants were recruited through nightclub and college campus outreach, and through respondent referrals. Instrumentation included the Risk Behavior Assessment, Substance Abuse Module and Center for Epidemiological Studies Depression Scale. Median age was 23, 42% were female and 50% Hispanic. An arrest history was reported by 44%, and 33% reported prior drug/alcohol treatment. Prescription drug abuse was reported by 87%; alprazolam (57%), oxycodone (36%), hydrocodone (32%) and diazepam (30%) were cited most often. Prescription drug abusers were more likely to report polydrug use, drug treatment histories, risky drug use behaviors, and symptoms of depression. They also reported numerous physical, psychological and social consequences of prescription drug abuse. Additional studies among larger samples are needed to understand the processes of prescription drug access and the extent of integration in club drug using cultures.

Privilege and confidentiality in 12-step self-help programs: Believing the promises could be hazardous to an addict's freedom. (review).

Coleman P. Journal of Legal Medicine 26(4): 435-474, 2005. (199 refs.)
A wide gap exists between perception and reality on the question of whether an individual can prevent others from revealing statements he or she made while dealing with addiction in a 12-step self-help group. The simple but troubling explanation for this disparity is that, although people are routinely assured whatever they say during meetings will not be repeated, neither state nor federal laws support these promises. As a variety of studies demonstrate the advantages associated with participating in peer-run programs, especially when attendance is combined with conventional treatment, researchers encourage physicians to persuade their patients to participate. These recommendations are appropriate as most people in recovery benefit from the support of others who also are struggling with sobriety and from the continual monitoring organizations like Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) provide. Traditional lengthy therapy, even if it were as effective, is not a good alternative because it has become too expensive. Thus, physicians should refer their patients to established self-help groups, but only after fully explaining the limitations on confidentiality and privilege. Failure to do so could subject physicians to both disciplinary action and civil liability. This article provides information important for people in these programs as well as their attorneys and therapists. Part I defines addiction and discusses the human and financial costs attributed to this compulsive disorder. Part II explains the law surrounding confidentiality, privilege, and the duty to report certain information. Part III briefly describes the history and evolution of self-help groups in treating people with drug and alcohol problems. It also compares and contrasts such programs to group therapy and substance abuse counseling with an eye toward determining whether the differences justify disparate protections. Part IV analyzes relevant court decisions. Part V canvasses state statutes on group therapy and points out that they do not encompass associations lacking a professional therapist or clergyman to whom confidentiality and privilege might apply. This section also reviews federal and state legislative treatment of substance abuse counselors and suggests these laws could be expanded to include self-help members. Part VI cautions physicians who refer patients to these groups that, to avoid both civil liability and licensure problems, they should alert their patients that, under exceptional circumstances, their statements made in working through the 12 steps might be disclosed. This warning will satisfy the duty to alert patients to potential risks and protect physicians from claims that they failed to obtain informed consent for the recommended treatment--namely, joining a self-help group. Finally, Part VII proposes a uniform statute that grants confidentiality and a qualified privilege to communications between and among self-help participants. The article concludes that the only way to eliminate the problem is to pass legislation that shields these conversations absent either consent to release or clear and convincing evidence of a compelling need for the information.

Confronting the obstacles to screening and interventions for alcohol problems in trauma centers.

Gentilello LM Journal of Trauma 59(3 Supplement): s137-s143, 2005. (32 refs.)
Despite the demonstrated clinical benefits and decreased risks of injury recurrence, brief alcohol interventions are still not routine practice in trauma centers. Although alcohol and drugs play a significant role in trauma, few trauma specialists are aware of the potential benefits of interventions because alcohol treatment specialists have not widely disseminated their findings to other specialties. This article addresses some key obstacles that must be overcome to facilitate brief interventions as routine trauma practice. Included are discussions on training, cost and reimbursement factors, responsibility of the trauma surgeon, patient privacy and confidentiality issues, insurance laws and regulations, needed collaboration with partners, and research priorities and funding.