Cocaine abuse among heroin addicts in Spain

Abuse of cocaine is becoming a major problem among heroin addicts in Spain. Between 1987 and 1988, 75% of patients admitted as inpatients for detoxification from opiate dependence had consumed cocaine during the 6 months prior to admission and 25% had abused cocaine daily or several times/week. These cocaine abusers showed more toxicologic and psychopathologic problems than opiate addicts who did not abuse cocaine. The opiate addicts who also abused cocaine had begun using illicit drugs earlier and showed a higher frequency of anti-HIV antibodies. They also had more antisocial personality disorders and persistence of depressive symptoms during opiate detoxification than heroin addicts who did not abuse cocaine. Based on these findings, we insist on the need to develop different treatments for detoxifying patients with this dual addiction.     

38例女性戒毒人员院内心理综合干预的半年操守情况分析

目的:探索较为有效的综合性的院内心理干预方法,以降低女性戒毒人员的复吸率和延长其操守时间。方法:采取授课、心理训练和疏导等方式,运用认知疗法、脱敏疗法、放松训练、心理疏导等方法进行心理干预。结果:干预出院后38例中13例半年内未复吸、12例已复吸、13例失访,半年复吸率在31 .6 % - 6 5 . 8%之间,且本次干预后的操守时间比干预前一次显著延长(P <0. 0 1)。结论:运用心理综合干预措施对院内女性戒毒者进行干预可降低其半年复吸率和延长操守时间。     

Opioid antagonist detoxification under anaesthesia versus traditional clonidine detoxification combined with an additional week of psychosocial support: a randomised clinical trial

BACKGROUND: While detoxification under anaesthesia accelerates the detoxification procedure, there is a lack of randomised clinical trials evaluating its effectiveness compared to traditional detoxification procedures, and a lack of data on long-term abstinence. METHODS: Prospective randomised clinical trial. Analysis by intention to treat and per protocol. Setting: Specialised substance abuse unit in a psychiatric teaching hospital and an intensive care unit of a general hospital. Participants: Seventy patients with opiate mono-dependence requesting detoxification: 36 randomised to RODA (treatment as allocated received by 26) and 34 randomised to classical clonidine detoxification (treatment as allocated received by 21). Main outcome measures: Successful detoxification, safety and self-reported abstinence at 3, 6 and 12 months after detoxification. RESULTS: Socio-demographics were similar in both groups at baseline. No complications were reported during or after anaesthesia. According to the intention to treat analysis, 28/36 (78%) RODA patients and 21/34 (62%) of the clonidine group successfully completed the detoxification process (p=0.14). In the intention to treat analysis, 30% of RODA patients were abstinent after 3 months compared to 14% in the clonidine group (p=0.11). No difference was found at 6 and 12 months (both groups showed less than 5% abstinence after 12 months). The per-protocol analysis showed similar results with no statistical differences either for ASI mean scores or for the SF36 questionnaire. CONCLUSION: Although the detoxification success rate and abstinence after 3 months were slightly better for the RODA procedure compared to clonidine treatment, these differences were not statistically significant and disappeared completely after 6 and 12 months.     

Intravenous and non-intravenous cocaine abusers admitted to inpatient detoxification treatment: a 3-year medical-chart review of patient characteristics and predictors of treatment re-admission

This naturalistic study examined the admissions and re-admissions of 341 intravenous (IV) and non-IV cocaine abusers over a 3-year period to an inpatient, hospital-based drug-and-alcohol detoxification treatment program. IV cocaine abusers reported higher rates of residential instability, unemployment, Hepatitis C, HIV and cirrhosis than non-IV cocaine abusers. In addition, IV cocaine abusers were administered more medical evaluative tests during treatment and accessed inpatient detoxification treatment more often during the 3-year study period. A Cox regression model demonstrated that residential instability and IV route of cocaine administration were significant predictors of inpatient detoxification re-admission. In light of the important differences between IV and non-IV cocaine-abusing groups, detoxification services should view route of cocaine administration as a key topic in treatment delivery and residential stability as an important topic in the discharge-and-referral process.     

Contingent reinforcement sustains post-detoxification abstinence from multiple drugs: a preliminary study with methadone patients

This study examined the efficacy of a urinalysis-based contingency management program for preventing relapse to abused drugs following a brief residential detoxification. Fourteen methadone maintenance patients who were chronic benzodiazepine users were enrolled in a 7-day inpatient benzodiazepine detoxification and randomly assigned to receive Contingency Management (N = 7) or Standard Care (N = 7) therapy upon return to outpatient methadone treatment. In the Contingency Management condition, a methadone take-home dose or a US $25 voucher (patient's choice) could be earned for each urine sample submitted on a Monday, Wednesday or Friday that was free of opiates, cocaine and benzodiazepines. Data analysis and interpretation focused on within-group post-hoc differences due to group differences on employment and legal status, potentially confounding baseline variables. Repeated measures analysis of variance showed that Contingency Management patients submitted significantly more drug-free urine samples during the intervention compared to pre-detoxification (p < 0.01), whereas no significance changes were observed from pre- to post-detoxification in the Standard Care patients. Employment and legal status of patients may have facilitated response to contingency management procedures, but did not prevent relapse when contingency management procedures were withdrawn. Overall, these preliminary results suggest that abstinence-based contingency management is a promising strategy for preventing relapse to multiple drugs of abuse in a subset of methadone maintenance patients when abstinence has been initiated through brief inpatient treatment.     

The value of acupuncture detoxification programs in a substance abuse treatment system

Our purpose is to compare baseline characteristics and detoxification readmission rates of clients treated at outpatient acupuncture programs and at short-term residential programs, two options available to persons seeking substance abuse detoxification. This was a retrospective cohort study using data on clients discharged from publicly funded detoxification programs in Boston between January 1993 and September 1994. Multivariate models were used to examine the effect on 6-month detoxification readmission rates of treatment at residential detoxification programs (used by 6,907 clients) versus at outpatient acupuncture programs (used by 1,104 clients) after adjusting for baseline differences. Acupuncture clients were less likely to be readmitted for detoxification within 6 months (odds ratio [OR] 0.71, 95% confidence interval [CI] 0.53–0.95). Similar results were found when the analysis was performed on a subsample of clients that were relatively similar in terms of baseline characteristics (OR 0.61, 95% CI 0.39–0.94). We determined that acupuncture detoxification programs are a useful component of a substance abuse treatment system.     

Acute and protracted cocaine abstinence in an outpatient population: a prospective study of mood, sleep and withdrawal symptoms

This study addresses unresolved questions about cocaine withdrawal by prospectively assessing monitored cocaine abstinence over 28 days in a sample of 24 male and female cocaine-dependent outpatients. Based on results from urine drug screens and self-reported substance use, it is likely that these patients were abstinent from cocaine during the assessment period. Abstinence-related symptoms were monitored at 2, 5, 10, 14, 21, and 28 days following last cocaine use. For patients who were known to relapse, assessments began again after the last day of cocaine use. Consistent with findings from inpatient studies of cocaine abstinence, linear improvements in negative affect, low cocaine craving, and increases in cognitive skills were reported over the 28 days. Also consistent with inpatient studies of cocaine withdrawal, a phasic withdrawal syndrome was not observed in this outpatient sample. Unlike inpatient studies, no disturbances in sleep were reported.     

Follow-up of inpatient cocaine withdrawal for cocaine-using methadone patients

Significant proportions of opiate-dependent persons entering methadone treatment are also addicted to cocaine and continue to use cocaine during treatment. One standard response to cocaine use has been inpatient detoxification. This study examined the effectiveness of this procedure by comparing pre- and posttreatment urine toxicologies for methadone patients who had been hospitalized for cocaine withdrawal. The results showed a negligible effect on cocaine abstinence (less than 1 out of 10 patients abstinent 12 weeks after detox) and a modest reduction in the frequency of cocaine use (one-quarter decline in urine tests positive after 12 weeks). These findings raise serious doubts about the cost-effectiveness of inpatient cocaine detoxification. Better strategies need to be implemented to enhance the chances of remaining abstinent once detoxified.     

宜昌市阿片类物质依赖者复发情况调查

目的:了解宜昌市阿片类物质依赖人群中戒毒治疗后复发的一般情况和复发影响因素,为复发的预防干预提供依据。方法:应用《阿片类物质依赖复发情况问卷》,在调查人员指导下,对宜昌市220名阿片类物质依赖者进行调查。问卷由被调查对象集体自行匿名填写完成,由调查员检查验收。结果:本次调查目标人群220例,回收问卷220份,可进行统计分析的有效问卷217份(98.6%)。217例调查对象的年龄33.3a±s6.0a,既往滥用药物时间8.8a±s3.7a;曾经戒毒的总次数范围2-108次;出戒毒所后最易复发的时间段为"戒毒后的d1-5"(43.4%);调查问卷将复发影响因素设计为"躯体生理因素、心理因素、药物成瘾性因素和社会环境因素"4个因子,因子分分别为185.3、219.0、234.8和242.7;对4个因子的差异进行秩和检验,结果显示差异具有统计学显著性(χ2=154.249,P<0.001);4个因子按照因子分排序为"社会环境因素"、"药物成瘾性因素"、"心理因素"和"躯体生理因素";保持操守不复发的前3位因素均为"社会环境因素"。结论:宜昌市阿片类物质依赖者在戒毒后复发的主要影响因素是社会环境因素,进行预防复发干预的关键时间段是"戒毒(出戒毒所)后的前5d",提示预防复发的重要措施是针对不同个体的具体情况,提供社会支持和心理干预。     

Severity of childhood trauma is predictive of cocaine relapse outcomes in women but not men

We prospectively examined the gender-specific effects of childhood trauma on cocaine relapse outcomes in an inpatient sample of treatment engaged cocaine dependent adults. Cocaine dependent men (n=70) and women (n=54) participating in inpatient treatment for cocaine dependence were assessed on severity of childhood trauma and followed for 90 days after discharge from treatment. Greater severity of childhood emotional abuse was associated with an increased risk of relapse in women. Severity of emotional abuse, sexual abuse, and overall childhood trauma was associated with the number of days cocaine was used during follow-up in women, as was the association of severity of physical abuse and overall childhood trauma with the average amount of cocaine used per occasion. No associations between childhood trauma and cocaine relapse outcomes were found in men. These findings demonstrate that childhood trauma increases the likelihood of cocaine relapse and drug use escalation after initial relapse in women but not in men. Comprehensive assessments of childhood trauma and specialized treatments that address trauma-related pathophysiology could be of benefit in improving cocaine treatment outcomes in women.     

Outcomes after detoxification for heroin dependence: findings from the Australian Treatment Outcome Study (ATOS)

As part of the Australian Treatment Outcome Study (ATOS), 177 (88%) heroin users entering detoxification (DTX) and 66 (83%) heroin users not in treatment (NT) were interviewed at baseline and 3 months to examine drug use, risk-taking, overdose, crime and psychopathology outcomes. The majority (76%) of the DTX group had entered additional treatment at 3 months, mainly further detoxification, and 54% were currently in treatment, mainly maintenance and residential rehabilitation. There were reductions in heroin use and other drug use in those entering detoxification. Forty-two per cent were abstinent at 3 months compared to 20% in the NT group. There were also reductions in crime among those entering DTX, and less marked reductions in the NT group. Psychopathology showed less change. Detoxification may, in some part, function as a gateway to further treatment and those entering DTX showed modest but significant improvements across drug use and crime at 3 months. [Teesson M, Havard A, Ross J, Darke S. Outcomes after detoxification for heroin dependence: findings from the Australian Treatment Outcome Study (ATOS). Drug Alcohol Rev 2006;25:241 - 247]     

Bulimia in opiate-addicted women: developmental cousin and relapse factor

There has been a growing awareness that eating disorders and substance abuse may coexist in the same individual. While several studies have documented the prevalence of these problems, few have addressed their relationship in the recovering patient. In the present study, the charts and hospital course of all female patients admitted to an inpatient treatment program for opiate dependency were reviewed. Approximately 20% of the patients had bulimic pathology that predated the drug abuse and re-emerged during detoxification. A theoretical model is presented which examines the possible developmental interplay between the two disorders and the role that renewed food problems may serve as a prodrome for relapse. The difficulty in addressing these issues during both the assessment and treatment phases of recovery is also discussed.     

Predictors of early relapse among adolescent crack users

Relapse is associated with a poor prognosis among drug users. Crack cocaine users are more prone to severe dependence because of the intensity of use. Additionally, initiating drug use during adolescence worsens users' prognosis due to the increased rates of impulsivity and other risk behaviors. This study aimed to identify the predictors of early relapse among adolescent crack users discharged from inpatient treatment. A cohort study was conducted with 89 psychiatric inpatients aged 12–17 years from two different hospitals in southern Brazil who met the criteria for crack abuse or dependence. Demographic data, substance use disorders, psychiatric comorbidities, and crack consumption profile were assessed during hospitalization using the Teen Addiction Severity Index, Schedule for Affective Disorders and Schizophrenia for School Age Children—Present and Lifetime, and Crack Consumption Profile. Participants were re-assessed at 1 and 3 months after hospital discharge to determine their crack cocaine use based on self-report, family/caregiver information, and urine tests, whenever possible. There were extremely high rates of relapse (valid percent) in the first and third months, 65.9 and 86.4%, respectively. Statistically significant associations were observed between relapse in the first month and length of cocaine/crack cocaine use, and length of hospital stay. Data at 3 months were not analyzed because of the small number of patients who did not relapse. The high rates and significant associations found in this study suggest that intensive outpatient treatment strategies targeting this population should be developed and implemented to prevent early relapse after detoxification. One of the possible approaches, based on recent studies, might explore motivation as a strategy to reduce the rate of early relapse.     

An open-label study of a functional opioid kappa antagonist in the treatment of opioid dependence

Several lines of evidence, including the well-established observation that kappa opiate agonists produce dysphoria and psychotomimetic effects in humans, suggest that dysfunction of the endogenous kappa opioid system may contribute to opioid and cocaine addiction. The objective of this open-label study was to determine the effectiveness of a functional kappa antagonist as a treatment for opioid dependence. This was accomplished by combining a partial mu agonist/kappa antagonist (buprenorphine, 4 mg, sublingual) with a mu antagonist (naltrexone, 50 mg by mouth), theoretically leaving kappa antagonism as the major medication effect. Subjects were treatment-seeking heroin-dependent (as per Diagnostic and Statistical Manual of Mental Disorders, 4th ed.) men (41 +/- 7 years old; 19 +/- 8 years heroin use) eligible for methadone maintenance. After inpatient detoxification and a naloxone-challenge test to verify that they were not physically dependent on opioids, subjects received naltrexone. Starting on the fourth day, patients also received liquid buprenorphine. All patients received medication at the clinic 6 days per week and a full program of psychosocial treatment. The major endpoints of the study were: pupil diameter to determine if the mu agonist effects of buprenorphine were blocked by naltrexone, urine toxicology, and retention in treatment. Five patients (33%) completed the 3-month study. Four were abstinent from opioids and cocaine for the entire study, and one was abstinent from opioids and cocaine for the last 9 weeks. Six subjects dropped out due to either minor side effects or disliking the sensation of sublingual buprenorphine. There were no significant changes in pupillary diameter. The positive response to treatment exceeds that expected from naltrexone alone (90% dropout). These promising results suggest that controlled studies of this medication combination should be conducted.     

A 2.5 year follow-up of treatment retention and reentry among opioid addicts

Two-hundred and sixty eight opioid addicts completed a 2.5 year follow-up during which we examined the psychosocial antecedents and consequences of leaving, reentering and remaining in treatment. Compared to those addicts who obtained more sustained treatment, the addicts who were only detoxified had fewer psychological problems and were more often male, black and younger. These baseline differences complicated comparisons between these minimally treated addicts and the rest, but among those who had more than minimal treatment, continuous treatment was better than intermittent treatment in controlling substance abuse and legal problems. Further analyses involved dividing the 30 months of follow-up into 6 month blocks and comparing the 6 months before, during and after leaving or reentering treatment. We found that addicts left treatment at periods of relative abstinence and good psychosocial adjustment, although they increased their alcohol abuse during the period of leaving treatment. During the 6 months after leaving, patients often returned to drug abuse and then rapidly deteriorated in social adjustment. When reentering treatment, the majority (75%) stayed for over 6 months and improved steadily in most areas. At reentry patients also had less criminal activity, less physical disability, and less opiate use suggesting a carry-over of treatment benefits, but they had more problems with their spouse and more alcohol and cocaine use than they had when first entering treatment suggesting new precipitants for reentry into treatment.     

The effect of anxiety and depression on completion/withdrawal status in patients admitted to substance abuse detoxification program

A large proportion of patients entering substance abuse treatment carry psychiatric diagnoses, and some studies have found that those with psychopathology are more likely to withdraw before treatment is completed. We performed a prospective study of patients entering an inpatient substance abuse detoxification program to determine if the degree of anxiety and/or depression correlated with higher dropout rates. On entry to the unit, all patients were administered the Hamilton Rating Scales for Depression and Anxiety. Of the 148 patients studied, 97 (65.5%) completed treatment and 51 (34.5%) withdrew prematurely. There were no significant differences in Hamilton Depression and Anxiety Rating Scale scores between completers and withdrawers. This was true for the total study population, as well as for subgroups of patients based on primary drug abused (heroin or cocaine). Although anxiety and depression are common in substance abusers, we were unable to detect differences on validated anxiety and depression rating scales between those completing and those withdrawing from substance abuse detoxification.     

Heroin snorters versus injectors: comparison on drug use and treatment outcome in age-matched samples

Drug use histories and treatment outcomes were compared for age, race and gender-matched samples of intravenous (IV; n = 28) versus intranasal (IN; n = 28) opiate abusers entering a 3-day inpatient detoxification unit. Data were derived from the Addiction Severity Index (ASI) interview. Both groups reported daily heroin use prior to detoxification, but IV users reported more days of alcohol and multiple drug use during the past 30 days. Despite age matching, IV users also started using alcohol at an earlier age and accumulated more lifetime months of regular alcohol, cocaine and multidrug use. IV users were more likely to enter treatment following the detox, but no significant outcome differences were noted at 1 and 3 months post-detoxification. The results show that intravenous, as compared to intranasal, opiate users have both a more severe pattern and a more extensive history of the use of non-opiate drugs.     

Personality, stress, and social support in cocaine relapse prediction

This study identified prospective psychosocial predictors of relapse status and drug abuse severity in male subjects in the first year after residential treatment for cocaine dependence. Personality, stress, and social support measures from an intake assessment, and stress and support measures reflecting status during the three-month period prior to the one in which relapse was identified were used as predictors. A number of hypotheses were confirmed. Detached personality and stress predicted both cocaine relapse and outcome drug abuse severity. Perceived social support quality and social network size predicted cocaine relapse. Implications for relapse prevention are presented.     

Relapse outcomes in a randomized trial of residential and day drug abuse treatment

Relapse outcomes at 6-, 12-, and 18-month intervals were compared between clients randomly assigned to day (n=114) versus residential (n=147) drug abuse treatment. Day clients were more likely than residential clients to relapse 6 months post-admission (OR=3.06, p<0.001); however, no setting differences at 12 or 18 months were found. Few baseline predictors were prospectively related to relapse at 12 and 18 months. These predictors were usual employment status (part-time OR=17.47, p<0.001; full-time OR=2.54, p<0.001), history of drug injecting (OR=5.39, p<0.01), multiple sex partners (OR=1.16, p<0.01), and not having a gay sexual partner (OR=0.05, p<0.03) during 6 months prior to admission. Still, these baseline predictors, together with the existing literature, could be used by drug treatment professionals to identify individuals who may be at high risk for relapse over time, and to offer specialized treatment and aftercare resources as intervention and prevention measures.