Psychometric evaluation of the Dutch version of the Subjective Opiate Withdrawal Scale (SOWS)

AIM: To evaluate the psychometric properties of the Dutch version of the 16-item Subjective Opiate Withdrawal Scale (SOWS). The SOWS measures withdrawal symptoms at the time of assessment. METHODS: The Dutch SOWS was repeatedly administered to a sample of 272 opioid-dependent inpatients of four addiction treatment centers during rapid detoxification with or without general anesthesia. Examination of the psychometric properties of the SOWS included exploratory factor analysis, internal consistency, test-retest reliability, and criterion validity. RESULTS: Exploratory factor analysis of the SOWS revealed a general pattern of four factors with three items not always clustered in the same factors at different points of measurement. After excluding these items from factor analysis four factors were identified during detoxification (temperature dysregulation, tractus locomotorius, tractus gastro-intestinalis and facial disinhibition). The 13-item SOWS shows high internal consistency and test-retest reliability and good validity at different stages of withdrawal. CONCLUSION: The 13-item SOWS is a reliable and valid instrument to assess opioid withdrawal during rapid detoxification. Three items were deleted because their content does not correspond directly with opioid withdrawal symptoms.     

Cocaine Precipitation of Patient-Identified Opiate Withdrawal

Self-reported opiate withdrawal symptoms were precipitated by cocaine use in 27 of 35 opiate-dependent men. While 13 had used cocaine to relieve withdrawal symptoms, relief occurred only while they were high from cocaine, followed by more severe withdrawal than usual. Similar symptoms were also reported by 24 of 31 non-opiate-dependent cocaine abusers. Severity of symptoms was greater for the opiate-dependent subjects. These results are consistent with noradrenergic sensitivity in opiate-dependent subjects.     

Effects of Information on the Opiate Withdrawal Syndrome

This study investigates the effect of information about withdrawal upon the subsequent withdrawal syndrome experienced by opiate addicts. Thirty addicts admitted to an inpatient treatment programme were randomly assigned to two groups. The ‘informed’ group was given full information about the withdrawal programme and the type and intensity of symptoms they might expect. The other, ‘uninformed’ groups received a general interview dealing with routine ward issues. All subjects were asked to complete the Opiate Withdrawal Scale during and subsequent to the detoxification procedure for a period up to 50 days. The informed group reported a significantly lower peak withdrawal score and lower levels of withdrawal symptomatology during the post-methadone phase of treatment. In addition, the informed group were more likely to complete the methadone withdrawal programme. The implications of these results are discussed. In particular it is pointed out that this comparatively straightforward and low-cost procedure can have considerable clinical benefits.     

A Rating Scale for Assessment of Alcohol Withdrawal Psychopathology (AWIP)

For patients in alcohol withdrawal, there are several scales designed to assess physiological disturbances, but there seems to be a lack of scales for assessment of psychopathology. To develop and evaluate a rating scale for psychopathology, items from the Comprehensive Psychopathological Rating Scale (CPRS) were selected, and patients meeting the DSMR-III-R criteria for alcohol dependence (303.90) were rated on these items. The patients were divided into two groups according to the length of time passed since their last period of alcohol consumption. The groups are referred to as the group (n = 53) in early withdrawal, rated daily during 1 week and the group (n = 13) in late withdrawal, rated once a week for 7 weeks. To justify inclusion in the new scale, items had to either indicate psychopathology in at least half of the patients in one of the groups in withdrawal, or be sensitive to changes over time at a 0.1% level of significance. Seventeen items fulfilled one of these criteria. The scale was tested for inter-rater reliability in a new sample of patients (n = 30) in early withdrawal. Inter-rater reliability, as well as internal consistency, was found satisfactory. This new scale, capable of identifying psychopathology and changes over time, may be used alone or together with physiological scales to identify subgroups of patients undergoing withdrawal.     

Routine hospital alcohol detoxification practice compared to symptom triggered management with an Objective Withdrawal Scale (CIWA-Ar)

Charts of patients hospitalized for uncomplicated alcohol withdrawal were examined and detoxification practices compared. Patients detoxified using a Clinical Institute Withdrawal Assessment for Alcohol-revised (CIWA-Ar) based PRN protocol on the addiction unit received significantly fewer chlordiazepoxide milligram equivalents over shorter duration than patients managed by other detoxification methods on other hospital units. Significantly fewer patients received benzodiazepines in the CIWA-Ar protocol managed group, but inter-group differences (p < 0.01) remained when only medicated patients were compared. Differences between the protocol and non-protocol groups did not reach statistical significance when PRN only strategies were examined, suggesting that the use of a symptom-triggered strategy may account for the noted effects.     

Severity of Precipitated Opiate Withdrawal Predicts Drug Dependence by DSM-III-R Criteria

Drug diagnoses in DSM-III-R are based on the dependence syndrome concept which hypothesizes that dependence on drugs is defined by behavioral and physiological changes but is separate from the social problems related to drug use. Previous studies provide support for the dependence syndrome in drug use; however, no study has examined whether biological indications of addiction are related to the dependence syndrome. The present study tests this relationship in 52 opiate addicts who were administered the Naloxone Challenge Test. The severity of withdrawal was correlated positively with the opiate dependence score, derived from the number of DSM-III-R criteria met. We also found that opiate withdrawal was inversely related to cocaine dependence and unrelated to any other drug use. Opiate withdrawal was not correlated with a global measure of social problems or to frequency or length of drug use. Our results support the validity of the dependence syndrome in opiate addiction because dependence is correlated with severity of withdrawal, is fairly specific to the drug, and is not related to social problems.     

The Severity of Ethanol Withdrawal Scale in Scale-Driven Alcohol Withdrawal Treatment: A Quality Assurance Study

This quality assurance study compared two scales that drive the medicinal treatment of alcohol withdrawal syndrome (AWS): the new Severity of Ethanol Withdrawal Scale (SEWS) and the default Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar). Prospectively entered outcome data from medical intensive care (SEWS) and acute psychiatric inpatient (CIWA-Ar) units were collected and analyzed. Measures included scale administration patterns, mean lengths of time on treatment medication, and mean medication doses for the first 24 hours and for the total AWS episode. The administration patterns of the two scales were highly associated despite separate ward locations and personnel. Time-on-medication for SEWS patients shortened on average by one hospital day over the CIWA-Ar group. At the same time, however, total chlordiazepoxide doses, or the first 24 hours and over the total AWS episode, averaged twice the magnitude in the SEWS group over the CIWA-Ar. The data suggest that the SEWS shortens AWS course of treatment significantly, likely due to better assessment leading to improved medication treatment early in the course. Contributing SEWS scale factors may include item weighting, dichotomous item scoring, and ease of scale use by the nursing staff. New prospective studies should focus on these clinical metrics along with reference to biological mechanisms of an apparent improved treatment effect using the SEWS.     

Comparison of Clinician Ratings to Self Reports of Withdrawal during Clonidine Detoxification of Opiate Addicts

Opiate withdrawal symptom ratings by trained clinicians were compared to self-reports of withdrawal discomfort during an outpatient, blinded, randomized clinical trial of clonidine detoxification for methadone maintained subjects. The randomized comparison group of subjects were detoxified using a slow tapering of methadone over 1 month. For all 39 subjects in this study the observer and self-ratings were substantially correlated (γ =. 75), but moderate levels of disagreement also occurred and the observer ratings were often lower. The difference in actual withdrawal scores and amount of shared variance between the observer and self-ratings were used as indices of disagreement for each individual subject. We found that detoxification failures had significantly less interrater agreement than the successes and that subjects who reported more distress than the observers noted were more likely to fail at detoxification. Subjects being detoxified using clonidine were more likely to fail at detoxification. Subjects being detoxified using clonidine were more likely to demonstrate this association between failure and disagreement on self versus observed withdrawal than were the methadone group. We concluded     

Elevation of Central Arterial Stiffness and Vascular Ageing in Opiate Withdrawal: Cross-sectional and Longitudinal Studies

The central cardiovascular impacts of clinical opiate withdrawal have not been explored in detail. Pulse Wave Analysis (SphygmoCor) was conducted in healthy controls and opiate-dependent populations. A total of 1,294 patients (69.2 % male) were studied in quintuplicate on 2,089 occasions. Four groups were studied: control (N = 576), buprenorphine stabilized (N = 592), withdrawal (N = 112) and severe withdrawal (N = 14). Control patients were younger than the other groups (29.96 ± 0.45 years v. 32.53 ± 0.74–39.28 ± 3.86) but had similar sex ratios. Multiple regression was used to correct for the effects of age, and significant exacerbations were found in withdrawal in the vascular age (RA), augmentation index, subendocardial perfusion ratio (SEVR <100; R.R. 2.07 95 % C.I. 1.17–3.68, P = 0.02) and central systolic pressure both as factors themselves and in interactions with age (all P < 0.01). The elevation of modelled RA at 60 years was from 69.66 in controls to 97.54 in withdrawal (40.02 %). The effects on RA were found in both sexes and confirmed on longitudinal analysis. The elevation of RA in withdrawal was most marked after 40 years of age (P = 0.027). These results show increased vascular stiffness and cardiovascular age but reduced subendocardial perfusion in opiate withdrawal. Given the daily recurrent nature of withdrawal, these effects are likely cumulative.     

Development of an instrument to measure pain in rheumatoid arthritis: Rheumatoid Arthritis Pain Scale (RAPS)

OBJECTIVE: To develop a valid and reliable clinical instrument for measuring pain in adult patients with rheumatoid arthritis. The resulting Rheumatoid Arthritis Pain Scale (RAPS) is a quantitative, single-score, self-report 24-item instrument. METHODS: Psychometric evaluation of RAPS was conducted following estimation of content validity and a pilot study. The actual study used a convenience sample of 120 adults, 18 years of age or older, with pain of at least 3 months duration. The setting was a large rheumatology private practice in a metropolitan southwestern city. The gate control and affective motivational theories of pain served as a framework guiding the development of RAPS, which includes items suggestive of the multidimensional pain experience in rheumatoid arthritis. Four subscales, physiological, affective, sensory-discriminative, and cognitive, evaluated numerous pain factors. RESULTS: Findings indicate a high estimate for internal consistency for the total scale and a moderate to high estimate of internal consistency for projected subscales. Data were analyzed using Cronbach's coefficient alpha, Pearson product-moment correlation coefficients, and exploratory factor analysis. Using Cronbach's coefficient alpha, RAPS showed an internal consistency reliability coefficient of 0.92, a strong indicator of reliability. Reliability assessments for the 4 subscales also indicate reliability, with Cronbach's coefficients ranging from 0.65 to 0.86. Exploratory factor analysis yielded 3 factors with criteria for factor loadings > or = 0.4. CONCLUSION: The study's findings provided support for RAPS as a reliable and valid measurement of rheumatoid arthritis pain. Assessment of rheumatoid arthritis pain and its relationship to treatment outcomes could significantly impact the treatment interventions.     

The Measurement of Opiate Dependence

The application of a dimensional concept of dependence which has received much attention over recent years in relation to alcohol, is explored here in relation to opiate dependence. A Severity of Opiate Dependence Questionnaire (SODQ) was completed by 98 subjects attending a New York drug treatment clinic. The factor structure of this questionnaire was explored and a strong first factor (39% of variance) identified which loaded on items conceptually related to a dimensional opiate dependence syndrome. Some preliminary investigation was made of issues relating to validity: SODQ correlated significantly with ‘number affixes a day’ and with a subjective measure of dependence (OSDQ), but not with quantity of heroin used or milestones in drug career. Research leads are discussed.     

The Discriminative Stimulus Properties of Acute Ethanol Withdrawal (Hangover) in Rats

Twenty male Sprague-Dawley rats were trained to discriminate pentylenetetrazole (PTZ, 15 mg/kg, intraperitoneally) from saline (SAL) under a drug discrimination procedure. Test sessions were conducted with 10 randomly selected subjects. Tests with various doses of PTZ resulted in a dose-dependent increase in the percentage of total session responses emitted on the PTZ-appropriate lever without a significant change in response rates across a wide range of test PTZ doses. Rats did not generalize the PTZ stimulus to ethanol (ETOH) up to ETOH test doses that completely suppressed responding. High acute ETOH doses (2, 3, and 4 g/kg) administered at various time points prior to discrimination test sessions engendered responding on the PTZ-appropriate level in a quantitative fashion, that was dose- and time-dependent. This acute ETOH delayed effect from these high doses replicates our previously published study using a Drug 1-Drug 2 discrimination task with Chlordiazepoxide and PTZ. More importantly, we suggest that the present behavioral assay may be a sensitive animal analogue of human "hangover" phenomena.     

The Development and Psychometric Evaluation of the HIV Stigmatizing Attitudes Scale (HSAS) in Tanzania

AIDS and Behavior - HIV stigmatizing attitudes are embedded in social context, making it important to develop culturally specific tools for accurate measurement. The goal of this study was to...     

Use of an Objective Clinical Scale in the Assessment and Management of Alcohol Withdrawal in a Large General Hospital

A modified version of the Clinical Institute Withdrawal Assessment Scale (CIWA) was used in the management of alcohol withdrawal in a general hospital. Patients who developed seizures or confusion were noted to score higher on the scale, even before these complications, than patients who remained uncomplicated (21.7 ± 1.2 compared to 15.6 ± 0.55).
When the score was used as a guide for treatment, it was found that patients scoring >15 were at significantly increased risk of severe alcohol withdrawal if they remained untreated (RR, 3.72; 95% confidence interval, 2.85-4.85). The higher the score the greater this relative risk. Some patients however, still suffered complicated withdrawals although their scores were low or they were apparently adequately treated.
It is concluded that the use of an objective clinical scale of alcohol withdrawal is valuable in a general hospital to identify those patients in early withdrawal who need sedation to avoid complication. There will however, be a small group of patients whose clinical course will be difficult to predict and further work is needed to determine the reasons for this.     

Development and validation of the Attitudes Towards Smoking Scale (ATS-18)

Aim. To develop and test the validity of a scale measuring attitudes towards smoking in current and former cigarette smokers. Design and participants. In a first mail survey, we collected qualitative data from 616 smokers. In a second mail survey, we collected quantitative data from 529 smokers and ex-smokers. We conducted a 16-month follow-up survey among 93 participants in the second survey. Setting. Geneva, Switzerland, 1995–98. Findings. The study resulted in a three-dimensional, 18-item scale: the "Attitudes Towards Smoking Scale" (ATS-18). The scale was validated with reference to criteria of content-, construct and predictive validity. The three subscales measure perceptions of adverse effects of smoking (10 items), psychoactive benefits (four items) and pleasure of smoking (four items). Internal consistency coefficients (0.85, 0.88 and 0.81) and test–retest correlations were high (0.90, 0.75, 0.89, respectively). Differences in attitude scores between smokers in the pre-contemplation and preparation stages of change were - 0.83, 0.71 and 1.23 standard deviation units, respectively. A differential score (advantages minus disadvantages of smoking) predicted smoking cessation in baseline smokers and relapse in baseline ex-smokers. Conclusion. ATS-18 is a valid and reliable instrument which can be used in both research and clinical settings.     

Opiate antagonistic properties of an octapeptide somatostatin analog.

The somatostatin analog D-Phe-Cys-Phe-D-Trp-Lys-Thr-Cys-NH-CH(CH2OH)CHOHCH3 (SMS 201-995) displaces [3h[naloxone from its binding sites (IC50, 38 +/- 60 nM), being more than 200 times more potent than somatostatin. As measured by the difference between [3H]dihydromorphine, [3H][D-Ala2,D-Leu5]enkephalin, and (-)-[3H]bremazocine binding, SMS 201-995 appears to be highly specific for the opiate mu binding site. Electrophysiological data from hippocampal cultures and results from animal studies (tail flick, mydriasis) demonstrate the opiate antagonistic properties of SMS 201-995. SMS 201-995 is an opiate mu antagonist with a peptide structure. That this property is displayed by a somatostatin analog is somewhat unexpected.     

Methadone vs. L-alpha-acetylmethadol (LAAM) in the Treatment of Opiate Addiction

The authors conducted a meta-analysis of the reported randomized, controlled trials comparing methadone to L-alphaacetylmethadol (LAAM) to assess the efficacy of LAAM relative to methadone in the treatment of opiate addiction. All studies were conducted in standard outpatient opiate addiction treatment clinics. Most patients were men from lower socioeconomic strata. A statistically significant risk difference favoring methadone was detected for retention-in-treatment and discontinuation of treatment because of side effects. The risk difference for illicit drug use favored LAAM, but was not significant. A small treatment difference in favor of methadone was noted. LAAM does appear to be a relatively effective alternative in the treatment of opiate addiction, more so in certain select situations.