Faculty Bibliography

The purpose of this study was to implement an empirical assessment of the clinical response to standard alcohol detoxification during withdrawal from both alcohol and cocaine. One hundred forty-nine males consecutively admitted in acute alcohol withdrawal to a hospital-based detoxification unit were studied. All subjects completed a 4-day chlordiazepoxide detoxification. Patients who used drugs other than cocaine were excluded. Fifty-five subjects withdrawing only from alcohol and 94 subjects withdrawing from both alcohol and cocaine, as evidenced by positive urinalysis and history, were studied. Both groups reported similar amounts of daily alcohol intake and had a similar age of onset of alcohol dependence. Parental alcoholism was equally frequent in both groups. Statistically, several variables were directly related to severity of alcohol withdrawal, including associated cocaine abuse, age, abnormal laboratory values, and duration of homelessness. As measured by the Alcohol Withdrawal Scale (AWS), alcohol withdrawal was less severe among cocaine users, not only at intake but throughout the 4-day detoxification. Singly addicted alcoholics were older and had longer drinking histories, more prior detoxifications, and more abnormal laboratory values than cocaine users. A multiple regression analysis demonstrated a significant relationship between cocaine and severity of alcohol withdrawal. Cocaine users more frequently requested reductions in chlordiazepoxide dosages than singly addicted alcoholics, complaining of dysphoria, sedation, and weakness. The severity of alcohol withdrawal was associated with recent cocaine use, age, laboratory abnormalities, and duration of homelessness. Concurrent cocaine withdrawal in the sample was associated with reduced severity of alcohol withdrawal. Possible neurobiological mechanisms, as well as study limitations affecting interpretation of the findings, are discussed. Tailored detoxification as opposed to standard detoxification regimens may be more appropriate for the clinical management of combined alcohol-cocaine withdrawal

Compared 101 patients with a substance abuse diagnosis admitted in 1994 with 100 patients admitted in 1988 to examine changes in comorbidity of substance abuse and mental disorders at a teaching hospital. The 1994 group was older. The proportion of Ss abusing marijuana, opiates and cocaine during the 24 hrs before admission had increased. There was a decrease in the number of Ss who identified their most serious substance abuse problem to be with cocaine, alcohol, crack cocaine and opiates. An increasing number of Ss had used self-help groups, outpatient clinics for drug treatment and private therapists for substance abuse treatment. Relatively little change in clinical and demographic parameters was found.

Methadone programs today are faced with high rates of illicit drug use and patient attrition. Attempts to reduce illicit drug use and improve compliance have included the use of contingency contracting systems. Contingency contracting relies on the use of rewarding or aversive incentives to alter noncompliant behaviors. Their use has led to improvements in retention and compliance for a subgroup of otherwise noncompliant methadone maintenance program patients. Practical considerations in the implementation of contingency contracts, observations of their time-limited effects, and the need for more potent and efficacious incentives have become issues needing further research. (journal abstract)

The combination of a token economy and a self-help model made it feasible to organize and maintain an intensive dual-diagnosis treatment program in a public municipal hospital acute psychiatric ward. The program described here, which integrates the token economy and 12-step approaches, fosters voluntary and active patient participation in the process of simultaneous recovery from mental illness and addiction; it also networks the patient with community resources. Implementation of the clinical program involved addressing multiple clinical and organizational obstacles, including a multihandicapped and often nonmotivated patient population, a lack of psychiatric staff trained in managing substance abuse, and the need to integrate mental health with substance abuse clinical interventions. The program has been operating more than 5 years and has treated more than 1,000 patients. As the token economy became an integral part of the ward routine, violence on the ward declined substantially, and patient participation in group activities increased significantly

Questions have arisen about the implications of notifying drug abusers of their HIV serostatus. One major concern is that awareness of HIV infection would have a negative impact on abstinence from drug abuse. In order to ascertain the effects of serostatus notification, the authors reviewed the clinical records of 73 methadone patients who learned of their serostatus within 20 weeks after enrolling in the clinic and thereafter remained in treatment for at least 1 year. They found that, at serostatus notification, seropositive patients were more likely to be socially disadvantaged and were younger than the seronegatives at first opiate use. After serostatus notification, seropositives had more 'fair hearings' for noncompliance with program norms and used more cocaine. Although the patients notified of HIV infection may have more behavioral problems, further research is needed to determine whether or not this reflects antecedent behavior patterns and drug use

In this paper we report on a community based sample of heroin addicts not in addiction treatment who responded to the offer of experimental treatment (buprenorphine) for heroin addition. Comparison to a sample of methadone maintenance clients from the same geographic area reveals that on average the community sample began heroin use later, attained a higher level of education, and were most likely to have had a significant cohabitation relationship. The methadone maintenance sample, on the other hand, reported significantly greater regular use of drugs of abuse other than heroin. Each group may represent a different subgroup drawn from the heterogeneous heroin-addicted population. Implications for improved recruitment into treatment and enhanced treatment design are drawn from these findings