Drug Interactions of Clinical Importance among the Opioids,Methadone and Buprenorphine,and Other Frequently Prescribed Medications: A Review

Drug interactions are a leading cause of morbidity and mortality. Methadone and buprenorphine are frequently prescribed for the treatment of opioid addiction. Patients needing treatment with these medications often have co‐occurring medical and mental illnesses that require medication treatment. The abuse of illicit substances is also common in opioid‐addicted individuals. These clinical realities place patients being treated with methadone and buprenorphine at risk for potentially toxic drug interactions. A substantial literature has accumulated on drug interactions between either methadone or buprenorphine with other medications when ingested concomitantly by humans. This review summarizes current literature in this area. (Am J Addict 2009;19:4–16)     

Substance Abuse Treatment Characteristics of Probation‐Referred Young Adults in a Community‐Based Outpatient Program

Although rates of substance abuse continue to rise among young adults ages 18–25, there is little information on the clinical characteristics of young adults referred to treatment, their readiness to change substance use behaviors, and treatment outcomes. These aspects were examined in young (18–25 years old) and older adult (26–45 years old) substance abusers entering treatment at a large, urban, outpatient substance abuse treatment facility. All clients were referred for outpatient treatment by the local Offices of Adult Probation during 1998–1999. The demographic and substance use characteristics, motivation level/readiness to change substance use behaviors, treatment attendance, completion, and “drug‐free” status based on patient self‐report and urine/breathalyzer data were assessed. Results. Substance‐abusing young adult probationers were more likely to be African‐American, with a significantly earlier age of onset of primary substance use. They were more likely to have a marijuana use disorder as compared with older adults, who in turn, were more likely to meet criteria for alcohol use disorders. Furthermore, as compared with older adults, young adults had significantly higher scores on precontemplation, and significantly lower scores on contemplation, determination, action, and maintenance subscales of motivation/change readiness. A significantly higher number of young adults did not complete outpatient treatment and were “drug‐positive” at discharge, as compared with older adults. Conclusions. Young adult probationers referred to substance abuse treatment show significantly different substance abuse and treatment characteristics as compared with their older adult counterparts. The findings suggest that specialized treatment approaches that focus on enhancing treatment readiness and motivation to change substance use behaviors may be of particular benefit to substance abusing young adults.     

Substance abuse treatment and pressures from the criminal justice system: data from a provincial client monitoring system

Aims Compulsory treatment is discussed increasingly as a way to reduce the population burden of addictive behaviours. This study explores the extent to which social control strategies exercised through the criminal justice system are used to bring people into substance abuse treatment at a system level. We also assessed whether particular subgroups may be more or less likely to be brought into treatment in this manner. Design We employed a secondary analysis of data from a client‐based information system which captured demographic, referral and substance use characteristics from people seeking treatment for substance abuse. Participants A census of clients (n = 45123) entering specialized Ontario addiction treatment programmes between 1 April 1999 and 31 March 2000. Findings Some 28.9% of clients reported legal problems at treatment intake, and 13.9% had an explicit corrections‐related condition of treatment contact. Logistic regression analyses indicated that legal problems and corrections‐related conditions of treatment were more prevalent among younger, unmarried and unemployed males, who had not completed high school. A number of important interactions were identified between these factors and substance of abuse. Conclusions Implications for equity, accessibility and effectiveness of substance abuse treatment are discussed in relation to the tendency of treatment mandates from criminal justice system to disproportionately affect the entry of this segment of substance‐abusing clients.     

Characteristics of Opinion Leaders in Substance Abuse Treatment Agencies

Objective. This study was part of a larger effort to test the effectiveness of technology transfer approaches related to evidence‐based treatment of co‐occurring substance abuse and mental health disorders. Specifically, this study examined characteristics of “opinion leaders” as technology transfer agents. Method. A network analysis was conducted within four large substance abuse treatment agencies to identify individuals that other counselors sought out for consultation on co‐occurring issues. The identified opinion leaders were then compared with other counselors on demographic variables, education and experience, and attitudes and knowledge about working with individuals with co‐occurring disorders. Results. The analyses demonstrate that opinion leaders differed from other counselors in competency‐related characteristics including more postgraduate education, relevant professional credentials, and years of experience in mental health treatment. They also had greater knowledge of the dynamics and treatment of co‐occurring disorders as well as a greater willingness and confidence in working with such clients. Conclusion. These results suggest that opinion leaders are used within agencies for information and consultation regarding treatment issues. Therefore, opinion leaders may provide an important vehicle for dissemination and adoption of evidence‐based treatment practices in community treatment settings.     

Alcohol and Drug Abuse in Treated Alcoholics: A Comparison of Men and Women

A survey of 229 male patients and 198 female patients who met lifetime DSM-III criteria for alcohol abuse or dependence was carried out in Toronto, Canada. The patients were evaluated with the National Institute of Mental Health Diagnostic Interview Schedule and other substance abuse rating scales. The prevalence of individual alcohol and drug symptoms, the patterns of abuse, and the prevalence of drug disorders were compared in the two sexes. The study patients were younger than previous treatment samples and were more likely to have other drug disorders. While the overall prevalence of drug disorders was similar in male and female alcoholics, women were more likely to abuse sedatives and minor tranquilizers while men were more prone to the abuse of cannabis and tobacco. Men continue to be more likely to have social and occupational problems resulting from alcohol abuse, to start abusing alcohol earlier in their lives, to have been abusing for longer, and to report higher quantity and frequency of alcohol consumption. With one or two exceptions, the sexes do not differ on other indicators of pathologic use, withdrawal or tolerance, medical sequelae or treatment history. While men have significantly more alcohol problems than women, as measured by the DIS and the MAST, these differences disappear when length of alcohol abuse history, antisocial personality disorder and employment status are controlled for. Similarly, when these variables are controlled for, women exhibit more symptoms of alcohol dependence as measured by the ADS. Women alcoholics come into treatment earlier in their alcoholic careers.     

Validation of a Short Version of the Revised Drug Use Screening Inventory in a Brazilian Sample of Adolescents

The revised Drug Use Screening Inventory (DUSI‐R) is a self‐report questionnaire designed to quantify the severity of problems that are commonly associated with consumption of alcohol and other drugs. This study extends research conducted on the US population to determine whether the DUSI‐R's substance abuse scale discriminates Brazilian youths in treatment (n = 41) from a general population sample (n = 43). A Portuguese translation of the substance abuse scale was administered in paper and pencil format at the time of intake into treatment and to randomly selected youths in school. The mean score on the 15‐item substance abuse scale in the treatment group was 6.7 compared to 1.9 in the comparison group (t = 6.78; p < .001). The optimal cut‐off score of two positive endorsements has 85% sensitivity and 70% specificity. This study demonstrates that the DUSI‐R's substance abuse scale is valid for screening Brazilian youths who require treatment. (Am J Addict 2010;00:1–4)     

Drug Abuse Treatment Outcome Study of Adolescents: A Comparison of Client Characteristics and Pretreatment Behaviors in Three Treatment Modalities

Objectives: The present study presents background and pretreatment characteristics of adolescent substance abuse treatment clients, and it provides a mechanism for describing perhaps the largest research sample of adolescents who were in drug treatment in this decade. Methods: The sample was 3382 subjects who presented for treatment from 1993 to 1995 in 37 programs in Pittsburgh, Pennsylvania; Miami, Florida; Minneapolis, Minnesota; Chicago, Illinois; Portland, Maine; and New York City, New York. Informed permission for the youth to participate was obtained from the subject's custodial parent/guardian, and both the youth and the youth's parents or guardians provided informed assent if they agreed to participate as subjects. Adolescents then were interviewed privately and confidentially by a trained professional interviewer who was independent of the treatment programs. The interviews queried subjects about their background, including education and employment; physical and mental health; use of tobacco, alcohol, and other drugs; sexual experiences; legal problems; religious beliefs; and treatment experience. Results: The long-term residential treatment modality was the least gender balanced of the modalities and had the most African-American and Hispanic clients. This modality was distinguished by the proportion of clients who were referred to treatment by the juvenile or criminal justice system. Compared with other clients in other modalities, short-term inpatient clients were more likely to be female and white. Inpatient clients also reported more indicators of psychiatric impairment. Outpatient clients were slightly younger than clients in the other modalities, and more of them were attending school at the time of admission to treatment. Outpatient clients had the least criminally involved lifestyles, their rates of (regular daily or weekly) drug use were also the lowest of the three modalities for all drugs assessed, and they had the least drug treatment experience. Conclusions: These results merit several recommendations. One is the need for more community-based adolescent substance abuse treatment programs. An additional recommendation is for more substance abuse treatment programs in facilities that serve incarcerated youth. Finally, and perhaps most critically, it is recommended that programs be designed to address such specialized issues as comorbid substance abuse and psychiatric problems, family dysfunction, physical and sexual abuse, gender and ethnic differences, and academic performance.     

Relationship of Clinical Symptoms and Substance Use in Schizophrenia Patients on Conventional Versus Atypical Antipsychotics

A large body of research documents the high prevalence and devastating consequences of substance abuse among individuals diagnosed with schizophrenia. One prominent theory of the high rate of comorbidity between these disorders is that substance abuse in schizophrenia is an attempt to self‐medicate psychiatric symptoms including negative symptoms and depression as well as side effects including extrapyramidal reactions (EPR). Consistent with this notion, novel antipsychotic medications, which have been shown to reduce negative and depressive symptoms while exhibiting a lower propensity to cause EPR, have been associated with reduced substance abuse in patients with schizophrenia. To further explore the self‐medication hypothesis as it relates to the mechanism by which atypical antipsychotics reduce substance abuse, we compared schizophrenia patients with a history of substance abuse medicated with either conventional (n = 35) or atypical (n = 35) antipsychotics. Patients with schizophrenia who did not have a history of substance abuse who were on conventional (n = 23) vs. atypical antipsychotics (n = 29) were also examined. Assessments included the Positive and Negative Symptom Scale, Hamilton Rating Scale for Depression, Simpson–Angus, and Abnormal Involuntary Movement Scale. Compared with conventional medications, atypical antipsychotic drugs were associated with reduced levels of substance use (primarily alcohol). Interestingly, however, in substance‐abusing patients there were no significant differences between patients on conventional vs. atypical agents with respect to positive or negative symptoms, depression, or EPR. These data suggest that theories related to self‐medication of symptoms and side effects do not appear to account for the difference in rates of substance use found in schizophrenia patients on atypical vs. conventional antipsychotic medications.     

Outpatient treatment entry and health care utilization after a combined medical/substance abuse intervention for hospitalized medical patients

CONTEXT: Drug-abusing patients utilize extensive amounts of health services resources, yet the acute medical hospitalization has typically not been used effectively to engage patients in substance abuse treatment. OBJECTIVES: To assess the effect of an integrated substance abuse/acute medical care day hospital (DH) intervention. DESIGN AND SETTING: Prospective, consecutive chart review of patients referred to a day hospital program from the medicine service at an urban tertiary care teaching hospital. From the referral cohort, a comparison group receiving usual care was identified. PARTICIPANTS: One hundred twenty adult medicine inpatients with active substance abuse and self-identified motivation to enter treatment. MAIN OUTCOME MEASURES: Outpatient substance abuse treatment entry and post-intervention health services utilization. RESULTS: Following DH treatment, 50.6% entered further outpatient substance abuse treatment (vs 2.4% comparison patients; P<.001). There was a significant increase in ambulatory medical visits for DH patients (pre-6 month 0.49 vs post-6 month 3.46; P<.001), greater than the change noted for comparison patients. However, there was no difference noted in pre-post hospitalization or emergency department utilization following the DH intervention. CONCLUSIONS: A DH program for substance abusing hospitalized medicine patients that introduces substance abuse treatment during treatment for an acute medical illness does appear to improve outpatient substance abuse treatment entry and ambulatory care utilization after hospital discharge. This project was supported in part by the Lattman Family Foundation and by Public Health Service Grant NIDA K23 DA 13988-01.     

Dimensions of Multiple Drug Use and a Typology of Drug Users

An accurate evaluation of the effectiveness of substance abuse treatment depends largely upon the construction of measures which will capture the complexity of multiple substance use patterns. Of 256 subjects assessed for a drug abuse treatment programme, 90% had used drugs from four or more of eight classes (Alcohol, Cannabis, Hallucinogens, Narcotics, Sedative Hypnotics, Solvents, Stimulants, Tranquillizers) during the past year. A principal components analysis of frequency data from the drug classes indicated four orthogonal factors, explaining 72% of the variance. Cluster analysis (Ward's method) grouped subjects into five clusters, provisionally labelled A (predominantly alcohol), ADR (combining high use of alcohol,‘depressant’ and ‘recreational'drugs), D (predominantly ‘depressant’ drugs), R (mainly ‘recreational’ drugs) and S (very high use of solvents). Four of the clusters (A, D. R. S) combined drugs similar to the principal component factors, with a fifth cluster (ADR) indicating high use of all drug classes except solvents. The clusters also differed in several important ways, including age, social class, social stability, age at onset of drug problem, number of drug classes used, and present severity of drug and alcohol problems.     

Personal Adjustment and Substance Abuse Problems in a Longitudinal Study of TANF Recipients and the Potential Need for Treatment

Objective: This study assessed the need over time for treatment of personal adjustment and substance abuse problems among chronic drug using and other recipients of Temporary Assistance for Needy Families (TANF). Methods: Participants were administered the personal adjustment problems and substance abuse problems scales contained in the Multidimensional Addictions and Personality Profile (MAPP) at intake, one‐year, and two‐year interviews. Results: Most participants who were not chronic users had total scale scores that would indicate no recommended referral or a referral to outpatient treatment. Approximately one‐third of chronic users had scores that would indicate referral to inpatient treatment. Many chronic users had comorbid conditions but reported receiving no psychological or substance abuse treatment. Conclusions: Many TANF recipients may be experiencing coexisting personal and substance abuse related problems that are going untreated.     

The Community Reinforcement Approach to the Treatment of Substance Use Disorders

Empirical support is presented for the Community Reinforcement Approach (CRA), a broad‐spectrum cognitive‐behavioral treatment for substance use disorders. At the core of CRA is the belief that an individual's environment can play a powerful role in encouraging or discouraging drinking and drug use. Consequently, it attempts to rearrange contingencies so that sober behavior is more rewarding than substance‐abusing behavior. Originally tested in the early 1970s with a small sample of alcohol‐dependent inpatients, it has repeatedly proven to be successful over the years with larger, diverse populations. Empirical backing is also presented for a new variant of CRA that works through family members to engage treatment‐resistant individuals into substance abuse treatment.     

Risk factors for symptom exacerbation among treated patients with substance use disorders

Aims The purpose of this study was to develop an index of risk factors to identify patients prospectively with substance use disorders whose substance use symptoms exacerbate during or shortly after treatment, and to identify characteristics of care that may reduce the likelihood of exacerbation. Design, setting, participants On the basis of data obtained from a nation‐wide outcomes monitoring system, a group of 2809 treated patients experienced an exacerbation of their substance use symptoms. These patients were matched on baseline substance abuse problems with 5618 patients who remained stable or improved. Measurements and findings Risk factors for substance use symptom exacerbation included younger age, non‐married status and residential instability; long‐term use of drugs, prior arrests, prior alcohol treatment, alcohol and drug abuse or dependence diagnoses, cocaine abuse or dependence and more severe self‐rated drug problems; and psychiatric problems. High‐risk patients who obtained a longer episode of mental health care were less likely to experience an exacerbation of symptoms. Conclusions Clinicians can identify at treatment entry patients whose substance use symptoms are likely to exacerbate and, by providing these patients a longer duration of care, may reduce the likelihood of symptom exacerbation.     

Substance Use Before and During Pregnancy: Links to Intimate Partner Violence

Although some research has found links between women's experiences of intimate partner violence and their use of substances, little research has examined how this potential relationship changes when women become pregnant. Furthermore, most of the past research examining women's experiences of intimate partner violence and their use of substances has focused on only one type of violence, typically, physical assault. Thus less is known concerning how other important forms of violence, such as psychological aggression and sexual coercion, may be related to women's substance use and substance abuse disorders. This research studies 85 prenatal care patients to describe the women's use of alcohol and illicit drugs, both before and during pregnancy, in relation to their experiences of various types of intimate partner violence before and during pregnancy (including psychological aggression, physical abuse, and sexual coercion). The Conflict Tactics Scales 2 was used to assess the women's experiences of intimate partner violence. The women were asked about their frequency of alcohol use, and alcohol using women were administered a short version of the Michigan Alcohol Screening Test to assess the women for symptoms of alcohol disorder. The women's use of illicit drugs was assessed by asking the women about their frequencies of various types of drug use and drug using women were administered the Drug Abuse Screening Test to assess the women for symptoms of drug disorder. The results showed that before pregnancy, women who were physically assaulted by their partners were somewhat more likely to drink alcohol and use illicit drugs compared with women who did not experience such violence, even though these differences did not reach the traditional level of statistical significance; however, among the substance‐using women, those who experienced each type of violence were more likely to be frequent users of substances compared with the non‐victims, and they evidenced a greater number of substance disorder symptoms compared with the non‐victims. After the women became pregnant, the links between women's experiences of intimate partner violence and their use of substances became stronger, with the women who experienced each type of partner violence being more likely to use both alcohol and illicit drugs. Furthermore, among the substance using women, those who were psychologically and physically abused had somewhat elevated levels of substance disorder symptoms during pregnancy compared with women who did not suffer such victimization. These findings underscore the importance of providing routine screening for various types of violent victimization and substance use within the context of many types of women's health care settings, including substance abuse treatment programs, domestic violence programs, and prenatal care services.     

Health-care service utilization in substance abusers receiving contingency management and standard care treatments

Aim To determine the impact of standard care and contingency management treatments on the utilization of general health‐care services by substance abusers. Participants, design and measurements This secondary analysis pooled 1028 treatment‐seeking substance abusers from five randomized clinical trials that compared the effects of standard care (SC, n = 362) to standard care plus contingency management (CM, n = 666). In each trial, subjects in the CM condition showed significantly greater reductions in substance use than their SC counterparts. For each subject, utilization of 15 general health‐care services was measured 1 year prior to treatment intake and up to 9 months following treatment intake. Post‐intake utilization data were prorated to be comparable to the 1‐year pre‐intake data. Paired t‐tests evaluated changes in service utilization pre‐ and post‐intake, and difference‐in‐differences regression models were used to estimate the impact of CM, compared to SC, on changes in the utilization of each of the 15 health services. Setting Out‐patient community substance abuse clinics in Connecticut and Massachusetts, USA. Findings Utilization of several types of out‐patient services increased significantly between the pre‐ and post‐intake periods [e.g. dental visits (0.47, P < 0.001), community health center visits (0.50, P < 0.001), visits to a mental health professional office (1.03, P = 0.001)], while in‐patient hospital care for mental health problems decreased significantly (?3.50 nights, P < 0.001). A substantial portion of these changes occurred during the treatment period. No significant differences were found between the two treatment conditions. Conclusions Initiating out‐patient substance abuse treatment is associated with changes in general health‐care service utilization, independent of the type of treatment offered.     

Prevalence and Characteristics of Clients with Co‐Occurring Disorders in Outpatient Substance Abuse Treatment

This article reports on the prevalence of probable mental health disorders among clients entering outpatient substance abuse treatment, their clinical characteristics, and past access to substance abuse and mental health care. Four hundred fifteen individuals (74% of those eligible) entering three publicly funded outpatient substance abuse treatment facilities in Los Angeles County were screened for a probable mental health disorder. Of the 210 with a positive screener (just over 50% of those screened), 195 (93%) were interviewed. Depression and anxiety were the most common disorders, and more than a third had two or more probable disorders. Close to 70% reported using alcohol, and almost half reported using crack or cocaine. Half had never received any mental health treatment, and for a third this was their first episode of addiction treatment; 22% were on psychotropic medications. Levels of physical and mental health functioning were lower than the 25th percentile of the U.S. population norms. Our results indicate high rates of co‐occurring mental health disorders among individuals entering these outpatient substance abuse treatment clinics in Los Angeles. Identifying people with probable mental health disorders as they enter treatment has the potential to increase access to care among those with limited prior access.     

Cost and Usage Impacts of Treatment Initiation: A Comparison of Alcoholism and Drug Abuse Treatments

An extensive literature on substance abuse and mental health treatments suggests that they often lead to decreased usage and/or spending on other medical treatments. We compare alcohol and drug abuse treatment costs with a model that decomposes total treatment costs into amount of treatment (outpatient visits or inpatient days) and costs per treatment. The analysis compares alcohol and drug abuse treatment costs regarding: (1) the incremental costs attributable to changed short-term substance abuse and nonsubstance abuse treatments; (2) the impacts of current substance abuse treatments on short-term nonsubstance abuse, long-term substance abuse, and long-term nonsubstance abuse treatments; and (3) the difference in inpatient and outpatient impacts. Our findings indicate that alcoholism and drug abuse treatment initiation have similar impacts on coincident and subsequent utilization and costs. For both treatments, the largest portions of the cost impacts occur for inpatient treatments, and for treatments that occur within 6 months of the initiation. The similarity of results suggests that it may often be reasonable to infer utilization and cost impacts for one type of care from studies that examine the other.