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...on Clinical Issues
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www.ProjectCork.org
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Summer 2009
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Assessing the effectiveness of an Internet-based videoconferencing platform for delivering intensified substance abuse counseling.
King VL; Stoller KB; Kidorf M; Kindbom K; Hursh S; Brady T et al. Journal of Substance Abuse Treatment 36(3): 331-338, 2009. (33 refs.)
Enhanced schedules of counseling can improve response to routine opioid-agonist treatment, although it is associated with increased time demands that enhance patient resistance and non-adherence. Internet-based counseling can reduce these concerns by allowing patients to participate from home. This study assesses treatment satisfaction and response to Internet-based (CRC Health Group's e-Getgoing) group counseling for partial responders to methadone maintenance treatment. Patients testing positive for an illicit substance (n = 37) were randomly assigned to e-Getgoing or onsite group counseling and followed for 6 weeks. Patients in both conditions responded favorably to intensified treatment by achieving at least 2 consecutive weeks of abstinence and 100% attendance to return to less-intensive care (e-Getgoing: 70% vs. routine: 71%, ns). Treatment satisfaction was good and comparable across conditions. E-Getgoing patients expressed a preference for the Internet-based service, reporting convenience and increased confidentiality as major reasons. Integrating Internet-based group counseling with on-site treatment services could help expand the continuum of care in methadone maintenance clinics. Copyright 2009, Elsevier Science.
Cannabis use disorder: Epidemiology and management.
Copeland J; Swift W. International Review of Psychiatry 21(2): 96-103, 2009. (71 refs.)
This paper provides an overview of the epidemiology of cannabis use, cannabis use disorders and its treatment. Cannabis is the most commonly used illicit drug internationally. While use is decreasing in the developed world, it appears to be stable or increasing in developing countries and some indigenous communities. Early initiation and regular adolescent use have been identified as particular risk factors for later problematic cannabis (and other drug) use, impaired mental health, delinquency, lower educational achievement, risky sexual behaviour and criminal offending in a range of studies. It is estimated that approximately one in ten people who had ever used cannabis will become dependent with risk increasing markedly with frequency of use. There has been an increase in the proportion of treatment provided for cannabis use. There are as yet no evidence-based pharmacotherapies available for the management of cannabis withdrawal and craving. Relatively brief cognitive behavioural therapy and contingency management have the strongest evidence of success, and structured, family-based interventions, provide potent treatment options for adolescents. With criminally involved young people and those with severe, persistent mental illness, longer and more intensive therapies provided by interdisciplinary teams may be required. Copyright 2009, Taylor & Francis.
Drugs, detention, and death: A study of the mortality of recently released prisoners.
Krinsky CS; Lathrop SL; Brown P; Nolte KB. American Journal of Forensic Medicine and Pathology 30(1): 6-9, 2009. (21 refs.)
It has been theorized that drug abusers recently released from prison have an increased risk of fatal drug overdose. The objective of this study was to determine whether persons released from prison in the state of New Mexico have an increased risk of death due to unintentional drug overdose in the time immediately after release from prison. A total of 96 people were identified who had been released from prison and subsequently suffered an unnatural death in 2001 through 2003. Among those who had drug-caused deaths, there was a significantly increased risk of dying in the first 2 weeks after release versus the subsequent 10 weeks RR = 3.08 (P < 0.001, 95% CI: 1.83-5.16). For those who died in the first 2 months after release, there was an increased risk of fatal drug overdose compared with dying of other unnatural causes (P = 0.025). Of those who died of fatal drug overdoses within the first 2 months, the average incarceration time was significantly longer than those who lived longer than 2 months after release (P = 0.021) and they were more likely to have used opiates (P < 0.0001) and sedatives (P = 0.01). Prisoners are at an increased risk of a fatal unintentional drug overdose immediately after release. The time surrounding release provides an opportunity for education on the risks of accidental overdose and the development of interventions to mitigate these risks. Copyright 2009, Lippincott, Williams & Wilkins.
Effect of religiosity and spirituality on drug treatment outcomes.
Conner BT; Anglin MD; Annon J; Longshore D. Journal of Behavioral Health Services & Research 36(2): 189-198, 2009. (12 refs.)
This study empirically tested one component of a comprehensive model of the role of religiosity and spirituality (R/S) in drug treatment that is presented as a companion article in this special issue. Data collected from individuals dependent on heroin receiving narcotic replacement therapy were used to assess the effects of R/S on drug treatment outcomes. Based on their R and S scores, participants were assigned to one of four groups: those whose scores remained consistently high across the 12-month study period were compared to those whose scores were consistently low, increased, or decreased across the same period. Results indicated that at both study completion (12 months after admission) and 6 months after that participants in the consistently high and increasing spirituality groups self-reported significantly fewer days of heroin and cocaine/crack use than those in the consistently low group (p < 0.05). There were no significant differences among the religiosity groups on heroin or cocaine/crack use. Analysis indicated that at 12 months the results of urinalysis for the presence of opiates, but not cocaine/crack, were dependent on spirituality group membership (p < 0.01) but not religiosity. Results also indicated that at the 6-month follow-up, there were significantly more participants in the decreasing group who were not in maintenance treatment who had a positive urinalysis and fewer in the increasing group than would be expected if the two variables were independent (p < 0.05). Implications for addictions health services are discussed. Copyright 2009, Springer.
Learning sobriety together: Behavioural couples therapy for alcoholism and drug abuse.
Fals-Stewart W; Lam WKK; Kelley ML. Journal of Family Therapy 31(2): 115-125, 2009. (27 refs.)
Among the various types of partner- and family-involved interventions used to treat adults with substance use disorders, Behavioural Couples Therapy (BCT) has garnered the strongest empirical support for its efficacy. During the past thirty years, multiple studies have consistently found married or cohabiting substance-abusing patients who engage in BCT, compared to traditional individual-based counselling or partner-involved attention control treatments, report significantly greater (1) reductions in substance use, (2) levels of relationship satisfaction, and (3) greater improvements in other areas of relationship and family adjustment (e.g. reductions in partner violence, improvements in custodial children's adjustment). In addition to discussing the theoretical rationale for BCT as a treatment of substance abuse, this article describes specific therapeutic techniques used as part of this intervention and summarizes the relevant evaluative empirical literature. Copyright 2009, Wiley-Blackwell.
Mindfulness-based stress reduction in therapeutic community treatment: A stage 1 trial.
Marcus MT; Schmitz J; Moeller G; Liehr P; Cron SG; Swank P et al. American Journal of Drug and Alcohol Abuse 35(2): 103-108, 2009. (23 refs.)
Objective: This trial compared Mindfulness-Based Stress Reduction, adapted for therapeutic community treatment (MBTC), with treatment as usual (TAU) for reducing stress and increasing retention in a residential facility for substance use disorders. Method: Four-hundred and fifty-nine participants, who met DSM-IV criteria for substance dependence were recruited (TAU = 164, MBTC = 295). Results: A survival analysis of time to dropout did not show a significant difference between groups, however level of participation in MBTC was associated with decreased likelihood of dropout (p = .01), and higher Symptoms of Stress Inventory (SOSI) scores at baseline were associated with increased likelihood of dropout (p = .03). Conclusion: The association between retention and level of stress on intake as well as level of participation in MBTC provides support for further research on integrating MBTC into therapeutic community treatment. Copyright 2009, Taylor & Francis.
Multiple drug ingestion by ecstasy abusers in the United States.
Black DL; Cawthon B; Robert T; Moser F; Caplan YH; Cone EJ. Journal of Analytical Toxicology 33(3): 143-147, 2009. (14 refs.)
The abuse of ecstasy-type drugs such as 3,4-methylenedioxymethamphetamine (MDMA) and 3,4-methylenedioxyamphetamine (MDA) is generally associated with young adults attending "Rave" parties. Little toxicological information has been reported regarding ecstasy usage by individuals undergoing monitoring in other settings in the United States. The goal of this study was to determine the prevalence and patterns of licit and illicit drugs in urine specimens of ecstasy users. A survey of laboratory data over the years 2005-2007 revealed that 198 urine specimens were confirmed positive (cutoff concentration 100 ng/mL) for MDMA and/or MDA from the following types of donors (# positive specimens): Correctional (159); Sports (19); Workplace (9); Pain Patients (8); and Special Test Requests (3). Of these, 122 (61.6%) were positive for MDMA and MDA, 70 (35.4%) were positive for MDMA, and 6 (3.0%) were positive for MDA. A majority (84.3%) of the specimens contained multiple drugs and/or metabolites in addition to MDMA and MDA. The median number of drugs/metabolites reported for these ecstasy users was 5 (range, 1-9). In addition to MDMA/MDA, the most commonly identified drug groups (%) were cannabis (THCCOOH) (61.6%); amphetamine/ metham-phetamine (38.4%); benzoylecgonine (30.8%); diazepam-related (9.6%); opiates (7.1%); alprazolam (5.6%); and others (5.6%). Although multidrug ingestion appears to be common amongst ecstasy users, caution is recommended in interpretation. Illicit ecstasy in the United States and Canada frequently contains methamphetamine and other active substances, and multidrug use may not have been intentional. Copyright 2009, Preston Publications.
OxyContin (R) abuse and overdose.
Aquina CT; Marques-Baptista A; Bridgeman P; Merlin MA. Postgraduate Medicine 121(2): 163-167, 2009. (31 refs.)
Background: OxyContin (R) (controlled-release oxycodone hydrochloride) (Purdue Pharma, Stamford, CT) was approved in 1995 by the US Food and Drug Administration (FDA) for moderate-to-severe chronic pain. Crushing and snorting the delayed-release tablets results in a rapid release of the drug, increased absorption, and high peak serum concentrations. The propensity for addiction to OxyContin (R) and the trend of increased prescription drug abuse have made it imperative for physicians and health care providers to recognize the clinical presentation of overdose and know how to manage associated complications. Objectives: In this review of OxyContin (R), we discuss current trends in its abuse and the clinical presentation of overdose. We review the specific effects of the drug on body systems and the recognition of symptomatology, differential diagnosis, and management. Discussion: Many of the clinical findings in acute opioid overdoses are nonspecific, making diagnosis difficult. OxyContin (R) overdose presents with a typical opiate toxidrome, including decreased respirations, miosis, hypothermia, bradycardia, hypotension, and altered mental status. The presence of coingestants can cloud the clinical picture. If OxyContin (R) overdose is suspected, early ventilation and oxygenation should be administered, which is generally sufficient to prevent death. Even in the absence of a confirmation, cautious administration of naloxone-the opiate receptor antagonist and antidote for opioid overdoses-may have both diagnostic and therapeutic effects. Summary: With increasing rates of prescription drug abuse, OxyContin (R) will continue to present challenges to physicians and health care providers. Physicians should be aware of potential patients who are seeking OxyContin (R) for recreational use. Copyright 2009, JTE Multimedia.
Television-supported self-help for problem drinkers: A randomized pragmatic trial.
Kramer J; Riper H; Lemmers L; Conijn B; van Straten A; Smit F. Addictive Behaviors 34(5): 451-457, 2009. (51 refs.)
Objectives: To test the effectiveness of a television-supported self-help intervention for problem drinking. Methods: Dutch television viewers (N = 181) drinking in excess of the guidelines for low-risk alcohol use were randomly assigned either to the Drinking Less TV self-help course (consisting of five televised sessions supplemented by a self-help manual and a self-help website) or to a waitlisted control group. To ensure trial integrity, intervention delivery was mimicked beforehand by sending intervention participants weekly DVDs in advance of the actual telecasts in 2006. Pre-post assessments were carried out on both groups, as well as a 3-month follow-up assessment on the intervention group to study effect maintenance. The primary outcome measure was low-risk drinking. Results: The intervention group was more successful than the waitlist group in achieving low-risk drinking at post-intervention (OR = 9.4): the effects were maintained in the intervention group at 3-month follow-up. Conclusions: The low-threshold television-based course Drinking Less appears effective in reducing problem drinking. Copyright 2009, Elsevier Science.
Ten things that motivational interviewing is not.
Miller WR; Rollnick S. Behavioural and Cognitive Psychotherapy 37(2): 129-140, 2009. (42 refs.)
Background: In the 26 years since it was first introduced in this journal, motivational interviewing (MI) has become confused with various other ideas and approaches, owing in part to its rapid international diffusion. Methods: Based on confusions that have arisen in publications and presentations regarding MI, the authors compiled a list of 10 concepts and procedures with which MI should not be addled. Results: This article discusses 10 things that MI is not: (1) the transtheoretical model of change; (2) a way of tricking people into doing what you want them to do; (3) a technique; (4) decisional balance; (5) assessment feedback; (6) cognitive-behavior therapy; (7) client-centered therapy; (8) easy to learn; (9) practice as usual; and (10) a panacea. Conclusion: Clarity about what does (and does not) constitute MI promotes quality assurance in scientific research, clinical practice, and training. Copyright 2009, Cambridge University Press.
Trends in volatile substance abuse.
Spiller H; Lorenz DJ. Journal of Addictive Diseases 28(2): 164-170, 2009. (13 refs.)
This article evaluates whether social, geographic, and demographic factors are related to trends in volatile substance abuse. Two datasets were obtained. Dataset 1 was all patients reported to U.S. poison centers with inhalation abuse of a non-pharmaceutical substance between 2000 and 2005. Dataset 2 was annual data from the U.S. Department of Labor and U.S. Census Bureau for the 50 states for the years 2000 -2005 for unemployment rate, population density, poverty rate, high school graduation rate and percentage of population with bachelor degree. The two datasets were compared for geographic (by state) and temporal (by year) relationships using U.S. government demographic categories. The U.S. poison centers state that 12,428 patients with volatile substance abuse have been reported over the 6 year period of 2000-2005, with a mean of 2,071 patients annually. A strong negative trend was found between volatile substance abuse and population density, with volatile substance abuse increasing as population density decreased. This trend remained consistent over the 6 years of evaluation. No trend was found when comparing volatile substance abuse and poverty rate, unemployment rate, or high school graduation rate. Volatile substance abuse appears to increase as population density decreases, following a previously suggested relationship with a rural setting. Volatile substance abuse to increases as percentage of population with a bachelor's degree decreases. Copyright 2009, Haworth Press.
What's in a label? Ecstasy sellers' perceptions of pill brands.
Duterte M; Jacinto C; Sales P; Murphy S. Journal of Psychoactive Drugs 41(1): 27-37, 2009. (45 refs.)
This article presents selected findings from a qualitative study of Ecstasy sellers and their sales practices, knowledge of distribution networks, buyer-seller relationships, and self-reported drug use. In-depth interviews were conducted with 80 men and women who had sold five or more hits of Ecstasy five or more times in the six months prior to the interview. Study participants described their perceptions of the various types of Ecstasy they had distributed or used themselves. The participants had experience with a variety of Ecstasy labels, from the popular "Blue Dolphin" tablets to the powdered form called "Molly." Pill brand mentions on Ecstasy-related websites to compare were compared to interviewees' descriptions of Ecstasy brands. We demonstrate that considering Ecstasy branding increases our understanding of buyer and seller relationships. Copyright 2009, Haight-Ashbury Publishing.
Evaluation of the Staying Alive programme: Training injection drug users to properly administer naloxone and save lives.
Tobin KE; Sherman SG; Beilenson P; Welsh C; Latkin CA. International Journal of Drug Policy 20(2): 131-136, 2009. (14 refs.)
Background: In response to the high rates of opiate-related overdoses and deaths in the United States, a number of overdose prevention programmes have been implemented that include training drug users to administer naloxone, an opiate antagonist. The purpose of this study was to evaluate the Staying Alive (SA) programme in Baltimore, Maryland, which trained drug users to prevent and respond to opiate overdose using techniques including mouth-to-mouth resuscitation and administration of naloxone. Methods: Participants for the SA programme were recruited from multiple locations by Baltimore City Health Department Needle Exchange programme staff. A 1-h training was conducted by two facilitators. Participants who successfully completed the programme were provided with a kit that contained naloxone. Participants in the evaluation study were enrolled prior to the training session. The present analysis includes 85 participants who completed a pre- and post-test evaluation survey. Results: At both time points, 43 participants reported having witnessed an overdose. Post-training, naloxone was administered by 19 with no reported adverse effects. Post-training, a greater proportion of participants reported using resuscitation skills taught in the SA programme along with increased knowledge specifically about naloxone. Conclusions: Results from this study provide additional evidence to support the effectiveness of overdose prevention training programmes that include skills building for drug users to administer naloxone. Copyright 2009, Elsevier Science.
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