Faculty Bibliography

UNLABELLED:Opioid dependence is a growing public health problem. Maintenance on the antagonist naltrexone for clinic- or office-based treatment of opioid dependence is plagued by high rates of relapse. This paper identifies critical determinants of lapses to opioid use during naltrexone maintenance. Time retained in treatment was examined as a function of whether lapses to opioid use occurred while adherent to naltrexone (blocked use), or after having missed naltrexone doses (unblocked). METHOD/METHODS:Participants (N=83) met DSM-IV criteria for opioid dependence and identified a significant other willing to participate in their treatment. Following inpatient detoxification, participants were enrolled in a 26-week outpatient course of therapy and naltrexone maintenance. RESULTS:Patients with unblocked use had a very high rate of dropout (10% retained at 6 months), dropout usually occurring within 2 weeks after unblocked use. Patients with only blocked use had less dropout (33% retained at 6 months). However, episodes of blocked use were often followed by unblocked use and dropout. CONCLUSIONS:During naltrexone maintenance for opioid dependence unblocked opioid use calls for immediate intervention, such as detoxification or switching to the partial agonist buprenorphine. Episodes of blocked use warrant increased clinical attention, such as direct observation of naltrexone ingestion, increased dose, or increased intensity of treatment contact. Maintenance on oral naltrexone is a fragile treatment because it is so easily undermined by episodes of opioid use while non-compliant. New long-acting injectable or implantable formulations of naltrexone may address this limitation and should be investigated for treatment of opioid dependence.

During a randomized, double-blind, placebo controlled study of the effects of sertraline in depressed methadone-maintained patients, 82 completed the tridimensional personality questionnaire (TPQ) to assess whether temperament dimensions can affect treatment-related changes in mood and drug use. Mood outcome significantly differed according to scores on the reward dependence scale (RD). Low RD participants displayed a significantly better mood response to sertraline than high RD participants. Participants with high harm avoidance (HA) scores were more likely to be abstinent at the end of the 12 week trial of sertraline than low HA participants. High persistence (P) participants were less likely to be abstinent at the end of the 12-week trial. These results suggest that temperament dimensions may be important for identifying substance dependent patients more likely to benefit from pharmacological interventions for comorbid depressive disorders.

The purpose of this double-blind, three-arm, 12-week trial was to compare the efficacy of sustained-release methylphenidate or sustained-release bupropion to placebo in treating adult attention deficit hyperactivity disorder (ADHD) symptoms. The randomized sample consisted of 98 methadone-maintained patients who were pre-dominantly male (57%) and 40% Caucasian, 40% Hispanic and 20% African American. All participants met DSM-IV criteria for adult ADHD, with 53% meeting DSM-IV criteria for cocaine dependence/abuse. In addition to medication and treatment as usual at a methadone program, individuals received weekly individual cognitive behavioral treatment. Other than current employment status, there were no significant demographic differences across the three treatment groups. Seventy percent completed the 12-week trial. There were no differences in retention rate based on treatment group. A reduction in ADHD symptoms using the adult ADHD rating scale was observed in all three groups, but there were no significant differences in outcome between treatments. The placebo response rate was high, with 46% of the placebo group self-reporting substantial improvement in their ADHD symptoms (>30% reduction in adult ADHD rating scale). Using other ADHD outcome measures, the placebo response and medication response rates were substantially lower. There was no evidence of misuse of medication or worsening of cocaine use among those randomized to methylphenidate. Taken together, sustained-release methylphenidate or sustained-release bupropion did not provide a clear advantage over placebo in reducing ADHD symptoms or additional cocaine use in methadone-maintained patients.

Although marijuana dependence is prevalent, most individuals with marijuana dependence do not seek treatment. There are few data characterizing treatment seeking marijuana-dependent patients compared to patients presenting for treatment of other drugs regarding the severity of illness and motivation for treatment. Forty-two marijuana-dependent individuals were compared to 58 cocaine-dependent individuals seeking treatment. Compared to cocaine-dependent patients, those with marijuana dependence were younger and less likely to be dependent on alcohol or other drugs. Both groups had similar rates of comorbid anxiety and affective disorders. Marijuana-dependent individuals had lower total number of dependence symptoms but had a higher percentage of individuals endorsing withdrawal symptoms. Although marijuana-dependent individuals had less outpatient treatment exposure, the difference between the two groups was not significant and motivation for change, based on the University of Rhode Island Change Assessment, was similar for both groups of treatment seekers. However, the Circumstances, Motivation, Readiness for Treatment Scale suggested that cocaine-dependent individuals were more motivated for treatment. Taken together, these data suggest that treatment seeking marijuana-dependent individuals have substantial withdrawal dependence symptomatology although it is less clear if they are as motivated to seek out treatment as cocaine-dependent treatment seekers.

The literature on the diagnosis and treatment of depression is reviewed to arrive at recommendations for clinical practice, future research, and models of service delivery. The DSM-IV criteria are found to provide a sound basis for diagnosis, and a review of placebo-controlled trials of antidepressant medications among substance-dependent patients suggests medication is effective in the setting of careful diagnosis, preferably during a currently observed abstinent period. Clinical recommendations offered for the approach to patients with co-occurring depression and substance dependence include the following: 1) Initiate treatment for substance dependence and encourage abstinence; 2) Conduct a careful psychiatric history and apply DSM-IV criteria for primary or substance-induced depression; 3) If depression meets diagnostic criteria and persists despite treatment of substance use disorder, treat the depression. Future research should include trials of psychotherapeutic or behavioral treatments, studies of treatment algorithms and of integrated systems of care, and studies of methods for disseminating diagnostic and treatment methods in an effort to diminish traditional boundaries between the skill sets of mental health and substance abuse clinicians.

AIMS/OBJECTIVE:To arrive at recommendations for addressing co-occurring psychiatric and substance use disorders in the development of the Diagnostic and Statistical Manual of Mental Disorders fifth edition (DSM-V) criteria. METHODS:Synthesis of findings of other papers from a consensus conference and from the literature on diagnosis and treatment of co-occurring psychiatric and substance use disorders. Most of the relevant studies examine co-occurring depression. RESULTS:The diagnosis and treatment of psychiatric syndromes that co-occur with substance use disorders has been a source of controversy, fueled in part by limitations of pre-DSM-IV nosologies. The DSM-IV scheme of classifying co-occurring disorders as primary (also referred to as independent) or substance-induced has promise in terms of good predictive validity, although pertinent longitudinal and treatment studies are limited. The substance-induced category answers the need of clinicians for a way to categorize patients with clinically significant psychiatric symptoms that occur in the setting of ongoing substance use. CONCLUSIONS:DSM-V should retain the primary (independent) and substance-induced categories. In DSM-IV these categories are broadly defined and leave much to clinical judgement. Existing data sets should be brought to bear to refine the criteria, making them more detailed with clearer anchor points and more specificity around particular substances and psychiatric syndromes. More longitudinal studies and clinical trials are also needed. Looking beyond DSM-V, co-occurring psychiatric syndromes are likely to be important in the quest for a nosology founded on pathophysiology.

The relationship between verbal skills and retention among adolescents in substance abuse treatment is understudied. In order to assess verbal predictors of retention, twenty-eight 16-19 year old adolescents in a therapeutic community for substance abuse were evaluated between 30 and 90 days after admission. These adolescents were then followed prospectively for 1 year. Verbal and non-verbal cognitive screens, audio taped narrative responses, and self-reports of socio-emotional function and psychiatric symptoms were completed. Verbal scores were associated with self-restraint and counselor reports of therapeutic engagement and comprehension. General verbal scores predicted attrition, while therapeutic expressiveness (verbal expressiveness in a therapeutic context) predicted retention. Remediation of verbal communication skills may be an overlooked aspect of the therapeutic process in treating adolescent substance abusers.

Behavioral naltrexone therapy (BNT) was developed to address the shortcomings of naltrexone maintenance for opiate dependence and improve compliance by integrating several empirically validated methods, including the use of a significant other to monitor compliance, voucher incentives, and motivational techniques. An uncontrolled Stage I pilot trial (N = 47) of BNT was conducted. Baseline demographic and clinical variables were evaluated as predictors of retention with univariate tests. Significant predictors were entered together into a multiple regression model. Poorer (shorter) retention in treatment was associated with methadone use and higher average bags per day of heroin. Other variables that became non-significant in multiple regression analysis included older age and depressive symptoms. Individuals with greater physiologic dependence and/or dependence on longer-acting opiates are at higher risk to drop out from naltrexone maintenance and may require a more gradual detoxification and more intensive behavioral therapy aimed at enhancing initial compliance.

OBJECTIVE:The authors used the Psychiatric Research Interview for Substance and Mental Disorders for DSM-IV (PRISM-IV) to test the reliability of DSM-IV-defined disorders, including primary and substance-induced disorders, in substance-abusing subjects. METHOD/METHODS:Substance-abusing patients (N=285) from substance abuse/dual-diagnosis treatment settings and mental health treatment settings participated in test and blind retest interviews with the PRISM-IV, which includes specific guidelines for assessment of substance abusers. RESULTS:Kappas for primary and substance-induced major depressive disorder ranged from 0.66 to 0.75. Reliability for psychotic disorders, eating disorders, antisocial personality disorder, and borderline personality disorder was in the same range. Reliability for most anxiety disorders was lower. Reliability was good to excellent (kappas >/=0.65) for most substance dependence disorders. Continuous measures (severity, age at onset) had intraclass correlation coefficients >0.70 with few exceptions. Reliability was better for primary than for substance-induced disorders, although not greatly so. CONCLUSION/CONCLUSIONS:Most DSM-IV psychiatric disorders can be assessed in substance-abusing subjects with acceptable to excellent reliability by using specifically designed procedures. Good reliability improves the likelihood of significant study results.

OBJECTIVE:Clinicians frequently encounter patients presenting with both depression and substance abuse, and their diagnosis has been a source of controversy. The authors examined whether baseline and past diagnoses of DSM-IV primary (independent) or substance-induced depression or other psychiatric syndromes predict 1-year course of depression in substance-dependent patients. METHOD/METHODS:Inpatients with current DSM-IV major depressive disorder (MDD) and DSM-IV alcohol, cocaine, or opiate dependence (N = 110) were evaluated with the Psychiatric Research Interview for Substance and Mental Disorders (PRISM) and followed for 12 months after discharge. Logistic regression for repeated measures modeled the odds of MDD and depressed mood over time as a function of baseline diagnoses and past independent depression, controlling for demographics, substance use, and antidepressant treatment during the follow-up. Subject recruitment was conducted from July 25, 1995 to May 14, 1997. RESULTS:Over the 12 months, 88% of the patients experienced depressed mood for at least 1 week, and 57% experienced MDD. Depression during follow-up was equally likely among patients with current (baseline) DSM-IV independent or substance-induced MDD; in the latter group, past independent MDD increased the likelihood of MDD during the follow-up. Panic attacks, posttraumatic stress disorder (trend), borderline personality, and antisocial personality also significantly predicted depression during the follow-up. CONCLUSIONS:In substance-dependent patients, both DSM-IV primary and substance-induced MDD predict future depression, warranting consideration for specific treatment. The data suggest the importance of a careful psychiatric history that includes attention to past episodes of independent depression as well as anxiety and cluster B personality syndromes.