Increasing program capability to provide treatment for co-occurring substance use and mental disorders: Organizational characteristics

The Dual Diagnosis Capability in Addiction Treatment and the Dual Diagnosis Capability in Mental Health Treatment indexes were used to document change in the capability of 14 substance abuse and mental health agencies to provide services to clients with co-occurring substance use and mental disorders (COD). COD capability significantly increased over 2 years, with the largest improvements seen in client assessment and staff training for COD. The role of agency structural characteristics and organizational readiness for change was also investigated. The study found modest evidence that some structural characteristics (e.g., agency size) and organizational readiness for change were related to increased COD capability. Further study is needed of how these factors affect implementation and fidelity to evidence-based practices, including how programs might compensate for or modify the effects of organizational factors to enhance implementation efforts.     

Levels of mint and wintergreen flavorants: Smokeless tobacco products vs. confectionery products

Nicotine and flavorant compound levels were measured in 10 “mint”-related sub-brands and 8 “wintergreen” sub-brands of smokeless tobacco (SLT). Also analyzed were “mint”-related and “wintergreen” confectionery products. Of the “mint” SLT, “Timberwolf Packs Mint Pouches” contained the highest menthol level (5.3 mg/g); the average for the five most-highly mentholated SLT products was 4.3 mg/g. The average for the most five most-highly mentholated confectionery products was 3.5 mg/g. For hard candy, a reported average of maximum use levels is 2.1 mg/g (Burdock, 2009). Of the “wintergreen” SLT, “Hawken Wintergreen” was found to contain the highest methyl salicylate (MS) level (29.7 mg/g). The average of the five highest SLT MS levels was 23.8 mg/g, i.e., 5× higher than the level found in the confectionery product with the highest MS level (LifeSavers Wint O Green Sugar Free, 4.6 mg/g). For hard candy, a reported average of maximum use levels is 2.0 mg/g (Burdock, 2009). Assuming 23.8 mg/g MS in SLT, SLT use at 15 g/day, 100% bodily absorption of the MS, and 60 kg body weight, the average daily intake would be 6.0 mg/kg-day, i.e., 12× the acceptable daily intake (ADI) of 0.5 mg/kg-day established for this compound by a joint FAO/WHO committee.     

Treatment of substance abusing patients with comorbid psychiatric disorders

Objective

To update clinicians on the latest in evidence-based treatments for substance use disorders (SUD) and non-substance use disorders among adults and suggest how these treatments can be combined into an evidence-based process that enhances treatment effectiveness in comorbid patients.

Method

Articles were extracted from Pubmed using the search terms “dual diagnosis,” “comorbidity” and “co-occurring” and were reviewed for evidence of effectiveness for pharmacologic and psychotherapeutic treatments of comorbidity.

Results

Twenty-four research reviews and 43 research trials were reviewed. The preponderance of the evidence suggests that antidepressants prescribed to improve substance-related symptoms among patients with mood and anxiety disorders are either not highly effective or involve risk due to high side-effect profiles or toxicity. Second generation antipsychotics are more effective for treatment of schizophrenia and comorbid substance abuse and current evidence suggests clozapine, olanzapine and risperidone are among the best. Clozapine appears to be the most effective of the antipsychotics for reducing alcohol, cocaine and cannabis abuse among patients with schizophrenia. Motivational interviewing has robust support as a highly effective psychotherapy for establishing a therapeutic alliance. This finding is critical since retention in treatment is essential for maintaining effectiveness. Highly structured therapy programs that integrate intensive outpatient treatments, case management services and behavioral therapies such as Contingency Management (CM) are most effective for treatment of severe comorbid conditions.

Conclusions

Creative combinations of psychotherapies, behavioral and pharmacological interventions offer the most effective treatment for comorbidity. Intensity of treatment must be increased for severe comorbid conditions such as the schizophrenia/cannabis dependence comorbidity due to the limitations of pharmacological treatments.     

Characteristics of online compulsive buying in Parisian students

Background

Online compulsive buying is a little-studied behavioral disorder.

Aims

To better understand its clinical aspects by focusing on (i) prevalence rate, (ii) correlation with other addictions, (iii) influence of means of access, (iv) motivations to shop to the internet and (v) financial and time-consuming consequences.

Design

Cross-sectional study.

Setting and participants

200 students in two different centers of Paris Diderot University — Paris VII.

Measurements

Brief self-questionnaires, to screen online compulsive buying, internet addiction, alcohol and tobacco use disorders, to rate frequency of online purchase by private-sale websites, by advertising banners, by mobile phone or to avoid stores, to rate motivations like “more discreet”, “lonelier”, “larger variety of products”, “more immediate positive feelings”, and “cheaper” and to assess the largest amount of online purchasing and the average proportion of monthly earnings, and time spent, both day and night.

Findings

Prevalence of online compulsive buying was 16.0%, while prevalence of internet addiction was 26.0%. We found no significant relationship with cyberdependence, alcohol or tobacco use disorders. Online compulsive buyers accessed more often shopping online by private-sale websites (56.2% vs 30.5%, p < 0.0001) or by mobile phone (22.5% vs 7.9%, p = 0.005) and preferred online shopping because of exhaustive offer (p < 0.0001) and immediate positive feelings (p < 0.0001). Online compulsive buyers spent significantly more money and more time in online shopping.

Conclusion

Online compulsive buying seems to be a distinctive behavioral disorder with specific factors of loss of control and motivations, and overall financial and time-consuming impacts. More research is needed to better characterize it.     

Criminal justice outcomes after engagement in outpatient substance abuse treatment

The relationship between engagement in outpatient treatment facilities in the public sector and subsequent arrest is examined for clients in Connecticut, New York, Oklahoma and Washington. Engagement is defined as receiving another treatment service within 14 days of beginning a new episode of specialty treatment and at least two additional services within the next 30 days. Data are from 2008 and survival analysis modeling is used. Survival analyses express the effects of model covariates in terms of “hazard ratios,” which reflect a change in the likelihood of outcome because of the covariate. Engaged clients had a significantly lower hazard of any arrest than non-engaged in all four states. In NY and OK, engaged clients also had a lower hazard of arrest for substance-related crimes. In CT, NY, and OK engaged clients had a lower hazard of arrest for violent crime. Clients in facilities with higher engagement rates had a lower hazard of any arrest in NY and OK. Engaging clients in outpatient treatment is a promising approach to decrease their subsequent criminal justice involvement.     

Drinking settings,alcohol consumption,and sexual risk behavior among gay men

We sought to 1) describe the settings or groups of settings where men who have sex with men (MSM) consume alcohol in 16 U.S. metropolitan statistical areas (MSA); and 2) investigate whether certain drinking settings or groups of settings are associated with higher levels of alcohol consumption, problem drinking, and sexual risk behavior. Latent class analysis was used to develop our measure of drinking settings. The final latent class model consisted of four distinct classes which captured the typical settings where MSM consumed alcohol: “home” “social,” “bar/social,” and “general” drinkers (i.e., drinks in all settings). Regression models showed that “general” drinkers were more likely than “social” drinkers to engage in frequent heavy drinking. Compared to ‘social’ drinkers, general drinkers were also more likely to engage in unprotected anal intercourse (UAIMP) and UAIMP with men met in bars and other venues (e.g., private parties, bath houses) while intoxicated. Assessment of drinking settings may be a means of identifying MSM who are at greater risk for frequent, heavy drinking and related sexual risk behavior.     

Diagnostic accuracy of brief PTSD screening instruments in military veterans

Post-traumatic stress disorder (PTSD) is prevalent but is under-detected and under-treated, despite available efficacious treatments. To improve detection rates, screening instruments such as the PTSD Checklist (PCL) and the Primary Care–PTSD (PC-PTSD) screen have been widely used. However, validation of these screening instruments among patients seeking treatment in substance use disorder (SUD) specialty treatment clinics and general mental health (MH) treatment clinics is limited. Therefore, this study assessed the area under the ROC curve (AUC), sensitivity, specificity, efficiency, and positive and negative predictive values of the PCL, PC-PTSD, and five abbreviated versions of the PCL in detecting PTSD among samples of patients seeking treatment in SUD specialty treatment (n = 158) and general MH treatment settings (n = 242). A computer-assisted structured diagnostic interview (C-DIS-IV) was used to ascertain patient DSM-IV PTSD diagnostic status. Based on the C-DIS-IV, prevalence of PTSD was found to be 36.7 and 52.9% in the SUD and MH samples, respectively. The PCL, PC-PTSD, and five abbreviated versions of the PCL were found to have adequate psychometric properties for screening patients in SUD (AUC ranged from 0.80 to 0.86) and MH (AUC ranged from 0.77 to 0.80) outpatient treatment settings.     

Client incentives versus contracting and staff incentives: How care continuity interventions in substance abuse treatment can improve residential to outpatient transition

Interventions for improving transition from short-term residential to outpatient treatment were examined. Usual care (UC; n = 114) was referral to a preferred outpatient program with advance appointment optional. Client incentive (CI; n = 97) offered up to $100 in gift cards for intake and attendance during the first 30 days of treatment. Contracting with staff incentives (CSI; n = 49) consisted of meeting with an outpatient counselor prior to residential discharge, signing an attendance contract, receiving an appointment and payment to staff if clients attended. CSI significantly improved rates of successful transition (84%) and admission (74%) compared to UC (64% contact; 49% admitted). CI did not result in significantly improved outcomes (74%; 60%). CSI was likely mediated by the reliability (92 versus 52% in UC) and immediacy (1.0 versus 3.9 days) of appointment scheduling. This study supports use of CSI for improving rates of transition between residential and outpatient continuing care treatment.     

Randomized trial of a reentry modified therapeutic community for offenders with co-occurring disorders: crime outcomes

This article describes a randomized study to determine the effectiveness of a reentry modified therapeutic community (RMTC) for offenders with co-occurring substance use and mental disorders (co-occurring disorders or COD). Men with COD, approved for community corrections placement postrelease, were recruited from nine Colorado prisons and stratified according to the type of treatment received while incarcerated (i.e., a prison modified therapeutic community [MTC] program or standard care). When released, each offender was randomly assigned either to the experimental RMTC (E-RMTC) condition (n = 71) or to the control parole supervision and case management (PSCM) condition (n = 56). An intent-to-treat analysis 12 months postprison release showed that the E-RMTC participants were significantly less likely to be reincarcerated (19% vs. 38%), with the greatest reduction in recidivism found for participants who received MTC treatment in both settings. These findings support the RMTC as a stand-alone intervention and provide initial evidence for integrated MTC programs in prison and in aftercare for offenders with COD.     

A survey of PTSD screening and referral practices in VA addiction treatment programs

Veterans with posttraumatic stress disorder (PTSD) and substance use disorders (SUDs) demonstrate worse outcomes following treatment for SUDs than do veterans with SUDs only, and so PTSD treatment may enhance SUD outcomes for patients. A survey of current practice patterns in VA SUD treatment programs was undertaken to determine their concurrence with emerging practice guidelines for the assessment and treatment of SUD–PTSD comorbidity. Clinicians in outpatient SUD clinics and/or inpatient SUD programs were surveyed in six VA medical centers in 1999 and 2001 (respondents n = 57 and n = 39, respectively). Although one half to two thirds of clinicians working with SUD patients routinely screen for trauma exposure and PTSD, few assessments are systematically conducted using validated measures. Routine referrals to PTSD specialty and dual-diagnosis programs and to veterans' centers are made by between 35% and 60% of providers across inpatient and outpatient settings. Implications for improvement of clinical outcomes are discussed.     

Two Models of Integrating Buprenorphine Treatment and Medical Staff within Formerly “Drug-Free” Outpatient Programs

“Drug-free” outpatient programs deliver treatment to the largest number of patients of all treatment modalities in the U.S., providing a significant opportunity to expand access to medication treatments for substance use disorders. This analysis examined staff perceptions of organizational dynamics associated with the delivery of buprenorphine maintenance within three formerly “drug-free” outpatient treatment programs. Semi-structured interviews (N = 15) were conducted with counseling and medical staff, and respondents were predominantly African American (n = 11) and female (n = 12). Themes and concepts related to medical staff integration emerged through an inductive and iterative coding process using Atlas.ti qualitative analysis software. Two treatment clinics incorporated buprenorphine maintenance into their programs using a co-located model of care. Their staff generally reported greater intra-organizational discord regarding the best ways to combine medication and counseling compared to the clinic using an integrated model of care. Co-located program staff reported less communication between medical and clinical staff, which contributed to some uncertainty about proper dosing and concerns about the potential for medication diversion. Clinics that shift from “drug-free” to incorporating buprenorphine maintenance should consider which model of care they wish to adapt and how to train staff and structure staff communication.     

Antisocial personality disorder predicts methamphetamine treatment outcomes in homeless,substance-dependent men who have sex with men

One-hundred-thirty-one homeless, substance-dependent MSM were enrolled in a randomized controlled trial to assess the efficacy of a contingency management (CM) intervention for reducing substance use and increasing healthy behavior. Participants were randomized into conditions that either provided additional rewards for substance abstinence and/or health-promoting/prosocial behaviors (“CM-full”; n = 64) or for study compliance and attendance only (“CM-lite”; n = 67). The purpose of this secondary analysis was to determine the affect of ASPD status on two primary study outcomes: methamphetamine abstinence, and engagement in prosocial/health-promoting behavior. Analyses revealed that individuals with ASPD provided more methamphetamine-negative urine samples (37.5%) than participants without ASPD (30.6%). When controlling for participant sociodemographics and condition assignment, the magnitude of this predicted difference increases to 10% and reached statistical significance (p < .05). On average, participants with ASPD earned fewer vouchers for health-promoting/prosocial behaviors than participants without ASPD ($10.21 [SD = $7.02] versus $18.38 [SD = $13.60]; p < .01). Participants with ASPD displayed superior methamphetamine abstinence outcomes regardless of CM schedule; even with potentially unlimited positive reinforcement, individuals with ASPD displayed suboptimal outcomes in achieving health-promoting/prosocial behaviors.     

Training workshops positively impact beliefs about contingency management in a nationwide dissemination effort

In 2011, the Veterans Administration called for nationwide implementation of contingency management (CM) in its intensive outpatient substance use disorders treatment programs, and this study evaluated the impact of the initial 1 and ½ day training workshops on knowledge and perceptions about CM among 159 clinical leaders from 113 clinics. Workshop attendance significantly increased CM-related knowledge (d = 1.88) and changed attendees' perceptions of CM (ds = 0.26–0.74). Endorsement of barriers to CM adoption decreased and positive impressions of CM increased. These perceptions about CM emerged as key correlates of post-training preparedness to implement CM. Results suggest that training workshops can be an effective avenue for increasing CM-related knowledge, as well as addressing persistent misperceptions about CM that may impede adoption efforts. Continued efforts to introduce educational materials and offer training and consultation opportunities may increase understanding about this evidence-based intervention among clinicians, thereby leading to improved patient outcomes.     

A possible link between sensation-seeking status and positive subjective effects of oxycodone in healthy volunteers

Sensation-seeking is a personality trait that is linked to use and abuse of drugs. Laboratory studies have established that high sensation seekers, as measured by different instruments, are more likely to report abuse liability-related subjective effects from drugs such as nicotine, alcohol, and d-amphetamine than low sensation seekers. One class of drugs that has not been studied to date in this fashion is opioids. Accordingly, a retrospective analysis encompassing five studies that examined oxycodone effects, including its abuse liability-related effects, was conducted in subjects categorized as high or low sensation seekers. In addition, because there appear to be sex differences in how males and females respond to opioids, this factor was taken into account in the analysis. Seventy one subjects who scored on the lower end (15 and 19 low sensation-seeking males and females, respectively) or the higher end (23 and 14 high sensation-seeking males and females) of the Disinhibition subscale of the Sensation-Seeking Scale-Form V were studied for their responses to 0, 10, and 20 mg of oral oxycodone. Ratings of “pleasant bodily sensations” were significantly higher after oxycodone administration than placebo only in male and female high sensation seekers. Ratings of “take again,” “drug liking,” “carefree,” and “elated (very happy)” also tended to differentiate high from low sensation seekers although Group × Dose interactions were only marginally significant with the latter three ratings. Male and female low sensation seekers and female high sensation seekers reported dysphoric effects (e.g., ratings of nauseated) particularly after administration of the 20 mg oxycodone dose. The results of this analysis provide suggestive evidence that high sensation seekers are more likely to experience greater positive subjective effects from oxycodone than low sensation seekers, but likelihood of experiencing negative effects is more complex (involving both sensation-seeking status and sex).     

Characterizing the subjective and psychomotor effects of carisoprodol in healthy volunteers

Carisoprodol is a centrally acting drug used to relieve skeletal muscle spasms and associated pain in acute musculoskeletal conditions. There is evidence from different sources that this oral muscle relaxant is abused and that it is associated with impairment leading to arrests for “driving under the influence” as well as increased risk of automobile accidents. Its subjective and psychomotor effects in healthy volunteers at therapeutic and supratherapeutic doses have not been well-characterized, and form the basis of this report. Fifteen healthy volunteers (8 males, 7 females) were administered 0, 350, and 700 mg of carisoprodol in separate sessions and for 6 h afterwards they completed a battery of tests at fixed time intervals so as to assess the subjective and psychomotor effects of the drug. The supratherapeutic dose, 700 mg, increased visual analog scale ratings of terms that were more reflective of sedation (e.g., “sleepy,” “heavy, sluggish feeling”) than those of abuse liability, and produced impaired performance on several psychomotor tests. The therapeutic dose, 350 mg, while producing few and mild subjective effects, still produced psychomotor impairment. The fact that the therapeutic dose of carisoprodol produced minimal subjective effects while adversely affecting performance is of concern in that patients prescribed this drug may feel relatively normal and engage in tasks (driving) that could put themselves and others at risk.     

The safety of modafinil in combination with oral ∆9-tetrahydrocannabinol in humans

Marijuana (cannabis) is the most widely used illicit substance globally, and cannabis use is associated with a range of adverse consequences. Currently, no medications have been proven to be effective for the treatment of cannabis addiction. The goals of this study were to examine the safety and efficacy of a potential treatment medication, modafinil, in combination with oral ?9-tetrahydrocannabinol (THC). Twelve male and female occasional cannabis users participated in an outpatient double-blind, placebo-controlled, crossover study. Across four sessions, participants were randomly assigned to a sequence of four oral treatments: (1) 400 mg modafinil + placebo, (2) 15 mg THC + placebo, (3) 400 mg modafinil + 15 mg THC, or (4) placebo + placebo. Outcome measures included heart rate, blood pressure, performance on the Rapid Visual Information Processing (RVIP), and the Hopkins Verbal Learning Test (HVLT), and subjective measures. Oral THC increased heart rate, and produced increased subjective ratings of feeling “high” and “sedated,” as well as increased ratings of euphoria. Modafinil alone increased the Profiles of Mood States (POMS) subscales of vigor and tension. These findings support the safety of modafinil in combination with THC. The effects of modafinil in combination with a range of doses of THC need to be determined in future studies.     

Alcohol and drug treatment involvement, 12-step attendance and abstinence: 9-year cross-lagged analysis of adults in an integrated health plan

This study explored causal relationships between post-treatment 12-step attendance and abstinence at multiple data waves and examined indirect paths leading from treatment initiation to abstinence 9-years later. Adults (N = 1945) seeking help for alcohol or drug use disorders from integrated healthcare organization outpatient treatment programs were followed at 1-, 5-, 7- and 9-years. Path modeling with cross-lagged partial regression coefficients was used to test causal relationships. Cross-lagged paths indicated greater 12-step attendance during years 1 and 5 and were casually related to past-30-day abstinence at years 5 and 7 respectfully, suggesting 12-step attendance leads to abstinence (but not vice versa) well into the post-treatment period. Some gender differences were found in these relationships. Three significant time-lagged, indirect paths emerged linking treatment duration to year-9 abstinence. Conclusions are discussed in the context of other studies using longitudinal designs. For outpatient clients, results reinforce the value of lengthier treatment duration and 12-step attendance in year 1.     

The feasibility and acceptability of a brief intervention for clients of substance use services experiencing symptoms of post traumatic stress disorder

Background

Trauma exposure and post traumatic stress disorder (PTSD) are common among clients of substance use services. Existing treatments for these co-occurring conditions tend to be lengthy, treatment retention is relatively poor, and they require extensive training and clinical supervision. The aim of the present study was to conduct a preliminary examination of the feasibility and acceptability of a brief intervention for PTSD symptoms among individuals seeking substance use treatment.

Methods

An uncontrolled open-label pilot study was conducted among 29 inpatients of a medicated detoxification unit in Sydney, Australia. All participants completed a baseline interview followed by the brief intervention. The intervention consists of a single, one-hour manualised session providing psychoeducation pertaining to common trauma reactions and symptom management. PTSD and substance use outcomes were assessed at 1-week, 1-month and 3-month post-intervention.

Results

PTSD symptom severity (assessed using the Clinicians Administered PTSD Scale) decreased significantly from baseline to 1-week follow up (β − 10.87, 95%CI: − 19.75 to − 1.99) and again between the 1-week and 3-month follow-ups (β − 15.38, 95%CI: − 23.20 to − 7.57). Despite these reductions, the majority of participants continued to meet criteria for a diagnosis of PTSD and there was no change in participants' negative post-traumatic cognitions. Participants expressed high levels of satisfaction with the intervention.

Conclusions

Brief psychoeducation for traumatised clients attending substance use services appears to be feasible, acceptable, and may be of some benefit in reducing PTSD symptoms. However, participants continued to experience symptoms at severe levels; thus, brief intervention may best be conceptualised as a “stepping stone” to further trauma treatment.     

Treating depression and substance use: a randomized controlled trial

Few integrated substance use and depression treatments have been developed for delivery in outpatient substance abuse treatment settings. To meet the call for more "transportable" interventions, we conducted a pilot study to test a group cognitive-behavioral therapy (CBT) for depression and substance use that was designed for delivery by outpatient substance abuse treatment counselors. Seventy-three outpatient clients were randomized to usual care enhanced with group CBT or usual care alone and assessed at three time points (baseline and 3 and 6 months postbaseline). Our results demonstrated that the treatment was acceptable and feasible for delivery by substance abuse treatment staff despite challenges with recruiting clients. Both depressive symptoms and substance use were reduced by the intervention but were not significantly different from the control group. These results suggest that further research is warranted to enhance the effectiveness of treatment for co-occurring disorders in these settings.