The relationship between substance use and posttraumatic stress disorder in a methadone maintenance treatment program

Introduction and Aims

Posttraumatic stress disorder (PTSD) is frequently linked with substance abuse. The self-medication hypothesis suggests that some people may use illicit substances in an attempt to self-treat psychiatric symptoms. This study explores the relationship between substance abuse and PTSD symptom clusters in a methadone maintenance population.

Design and Methods

Clients of a methadone maintenance program at a public Drug and Alcohol Service were invited to complete the PTSD Checklist–Civilian Version, a screening tool for PTSD. Information about their history of substance use was also collected.

Results

Eighty clients (43 female, 37 male), aged 35 ± 8.0 years (mean ± SD), participated in the study, of which 52.7% screened positive for PTSD. Severity of marijuana use was significantly associated with a number of reexperiencing and hyperarousal symptoms and with overall severity of PTSD symptoms. Opiate, amphetamine, and benzodiazepine use did not appear to be related to PTSD symptoms.

Discussion and Conclusions

In this sample, marijuana may be used to self-treat certain PTSD symptoms, supporting the self-medication hypothesis. Further research is required to confirm the association between a diagnosis of PTSD and substance use. Given the high prevalence of PTSD in the substance-using population, routine PTSD screening in the substance abuse treatment setting may be justified.     

Detoxification of opiate addicts with multiple drug abuse: a comparison of buprenorphine vs. methadone

Over the last few years, there has been a growing tendency for opioid addicts to abuse multiple drugs, although many patients are in substitution therapy with methadone. Abuse of multiple drugs leads to a more complicated withdrawal syndrome; it is therefore necessary to investigate new drug strategies as a treatment for detoxification. Buprenorphine appears to be an effective and safe drug in opioid-addicted patient detoxification. In this study, we have compared the short-term efficacy of an 11-day low-dose buprenorphine/14-day carbamazepine regime [BPN/CBZ] (n = 14) to an 11-day methadone/14-day carbamazepine regime [MET/CBZ] (n = 12) in a double-dummy, randomized 14-day inpatient detoxification treatment study. Twenty-six inpatients met the DSM-IV criteria for opioid dependence and were included in this study. All patients abused various additional drugs. Fourteen of 26 patients (53.8 %) completed the study. Seven non-completers (seven of 12 = 58.3 %) were treated with methadone/carbamazepine and five non-completers (five of 14 = 35.7 %) received buprenorphine/carbamazepine, but the difference in the dropout rate was not significant. However, patients with buprenorphine/carbamazepine showed significantly fewer withdrawal symptoms after the first two weeks of treatment. The present study supports the hypothesis that buprenorphine/carbamazepine is more effective than methadone/carbamazepine in detoxification strategies for opioid addict with additional multiple drug abuse. No severe side effects occurred during treatment in either group.     

Acute effects of drug abuse in schizophrenic patients: clinical observations and patients' self-reports

Substance abuse among schizophrenic patients is an increasingly recognized clinical phenomenon. The authors review experimental and observed clinical effects of drug abuse and patients' subjective experiences of acute intoxication. Though drug abuse may exacerbate psychotic symptoms, abused drugs may also lead to transient symptom reduction in subgroups of schizophrenic patients. Some patients report feeling less dysphoric, less anxious, and more energetic while intoxicated. Models of the relationship of drug abuse and schizophrenia, particularly the self-medication hypothesis, are discussed in reference to these data.     

Comparisons of patients with comorbid psychiatric and substance use disorders: implications for treatment and service delivery

OBJECTIVE: Individuals with co-occurring psychiatric and substance use disorders are treated in mental health and substance abuse treatment systems, yet research on comorbid disorders rarely includes comparisons across systems. Knowledge about patients who share the label "comorbid" but are found in different treatment sectors should illuminate service issues and inform policy development. Differences across systems should provide support for separate treatments; similarities should indicate the value of the integration of services. The hypothesis that there are meaningful clinical differences between patients with comorbid mental health disorders and patients in drug treatment was tested. METHOD: As part of a larger longitudinal study, 106 patients with comorbid illness from mental health (N=106) and drug treatment (N=120) settings were compared regarding diagnosis, drug use, and problem severity. Data were obtained by using the Diagnostic Interview Schedule for DSM-IV and the Addiction Severity Index. RESULTS: Few differences between groups emerged. There were no diagnostic differences except that schizophrenia spectrum disorders were more common among mental health (43%) than drug treatment (31%) patients. Although more drug abuse than mental health subjects reported drug use in the 30 days before treatment entry, the average number of days of drug use in this period was not different. CONCLUSIONS: These findings document the high prevalence of severe mental illness in drug treatment clients and of serious drug problems in mental health patients. Only minimal differences emerged between the groups and none that indicated need for specialized treatments in separate systems of care.     

Elimination of methadone benefits in the Oregon Health Plan and its effects on patients

OBJECTIVES: This prospective study assessed the impacts of a policy change to Oregon's Medicaid program (Oregon Health Plan; OHP) that eliminated methadone benefits for 60 percent of active methadone patients. Recipients of OHP Standard (expanded Medicaid benefits, which were discontinued after the policy change) self-selected into two groups: those who paid for methadone after the policy change and those who terminated treatment. OHP Plus beneficiaries (traditional Medicaid) did not lose benefits. METHODS: A total of 149 patients participated in the study, and interviews were conducted at baseline (time of policy change) and one, three, and 12 months after the policy change. Patients were assessed with the Addiction Severity Index (ASI), Timeline Follow Back assessment, and chart review. RESULTS: Patients who left treatment because they were unable to pay for methadone services showed significant elevations in ASI composite scores for drug and legal problems at baseline and at two and three months after the policy change. The patients who attempted to self-pay experienced significantly more employment problems than the other two groups. The OHP Standard recipients who paid for their methadone treatment over the year were more likely to have additional resources to pay for methadone, be employed, and have stable housing. CONCLUSIONS: The elimination of methadone treatment benefits in the OHP had substantial negative impacts for patients with the greatest indicators of need.     

Buprenorphine and methadone in the treatment of opioid dependence: methods and design of the COBRA study

Buprenorphine and methadone are the two established substitution drugs licensed in many countries for the treatment of opioid dependence. Little is known, however, about how these two drugs are applied and how they work in clinical practice. In this paper we present the aims, methods, design and sampling issues of a collaborative multi-stage epidemiological study (COBRA) to address these issues. Based on a nationally representative sample of substitution physicians, the study is designed as an observational, naturalistic study, consisting of three major parts. The first part was a national survey of substitution doctors (prestudy, n = 379 doctors). The second part was a cross-sectional study (n = 223 doctors), which consisted of a target-week assessment of 2,694 consecutive patients to determine (a) the severity and problem profiles and treatment targets; (b) the choice and dosage scheme of the substitution drug; (c) past and current interventions, including treatment of comorbid hepatitis C; and (d) cross-sectional differences between the two drugs with regard to comorbidity, clinical course, acceptance/compliance and social integration. The third part consists of a prospective-longitudinal cohort study of 48 methadone-treated and 48 buprenorphine-treated patients. The cohort is followed up over a period of 12 months to investigate whether course and outcome of the patients differ by type or treatment received in terms of clinical, psychosocial, pharmaco-economic and other related measures. The response rate among substitution doctors was 57.1%; that among eligible patients was 71.7%. Comparisons with the federal registers reveal that the final samples of doctors and patients may be considered nationally representative with regard to regional distribution, training, type of setting as well as the frequency of patients treated with buprenorphine or methadone. The COBRA study provides a unique comprehensive database, informing about the natural allocation and intervention processes in routine care and about the course and outcome of patients treated with buprenorphine or methadone.     

Schizophrenia and substance abuse comorbidity: nicotine addiction and the neonatal quinpirole model

This review focuses on nicotine comorbidity in schizophrenia, and the insight into this problem provided by rodent models of schizophrenia. A particular focus is on age differences in the response to nicotine, and how this relates to the development of the disease and difficulties in treatment. Schizophrenia is a particularly difficult disease to model in rodents due to the fact that it has a plethora of symptoms ranging from paranoia and delusions of grandeur to anhedonia and negative affect. The basis of these symptoms is believed to be due to neurochemical abnormalities and neuropathology in the brain, which most models have attempted to emulate. A brief review of findings regarding nicotine use and abuse in schizophrenics is presented, with findings using rodent models that have been able to provide insight into the mechanisms of addiction. A common clinical approach to the treatment of nicotine addiction in the schizophrenic population has been that these drugs are used for self-medication purposes, and it is clear that self-medication may actually be directed at several symptoms, including cognitive impairment and anhedonia. Finally, our laboratory has reported across a series of studies that neonatal treatment with the dopamine D(2)/D(3) receptor agonist quinpirole results in long-term increases in dopamine-like receptor sensitivity, consistent with data reporting increases in dopamine D(2) receptor function in schizophrenia. Across these studies, we have reported several behavioral, neurochemical, and genetic consistencies with the disease, and present a hypothesis for what we believe to be the basis of psychostimulant addiction in schizophrenia.     

Measuring program performance in methadone treatment using in-treatment outcomes: an illustration

Quality measurement and quality assurance in substance abuse treatment have, over the past few years, become a major policy issue. In addition, there is interest in the degree to which client outcomes can play a role in measuring treatment program performance. This article discusses the movement toward outcome-based performance measurement in substance abuse treatment. Examples of the products that such a performance measurement system might produce are provided. Why outcomes must be case-mix adjusted is discussed. In addition, using data from 18 methadone programs and more than 2,000 methadone clients from the Treatment Outcome Prospective Study, an illustration of case-mix-adjusted performance measurement is provided.     

Self-reported drug abuse in male adolescents with behavioral disturbances, and follow-up for future schizophrenia.

BACKGROUND:The prevalence of illicit drug abuse in persons with schizophrenia is greater then in the general population and has been attributed to self-medication of the symptoms of the illness; however, limited data indicate that drug abuse is already prevalent before the manifestation of psychosis, consistent with the possibility that drug abuse might be associated with increased risk for schizophrenia. METHODS: The Israeli Draft Board screens the entire, unselected population of 16- to 17-year-old male adolescents for behavioral or personality disturbances. In a cohort of 270,000 male adolescents screened, 50,413 adolescents were suspected of having behavioral or personality disturbances and were questioned about drug use and abuse. These adolescents were followed for hospitalization for schizophrenia using a national, population-based psychiatric hospitalization registry; 268 of 50,413 (.5%) were hospitalized for schizophrenia over the following 5-11 years. RESULTS: The prevalence of self-reported drug abuse in adolescents later hospitalized for schizophrenia was 12.4%, compared with 5.9% prevalence of drug abuse in adolescents not later hospitalized; adjusted RR = 2.016, 95% confidence interval: 1.309-3.104. CONCLUSIONS: In this cohort of male adolescents with behavior disturbances, these results further support the hypothesis that drug abuse may be associated with increased risk for future schizophrenia.     

Symptoms and lifetime treatment experiences in psychotic patients with and without substance abuse

The main objective of this study was to compare symptom load and lifetime treatment experiences between psychotic patients with substance abuse problems and psychotic patients without substance abuse problems. This is a cross-sectional study of 48 patients (26 inpatients and 22 outpatients) in a clinic for early intervention in psychosis. Patients' were grouped into two categories based on whether they had a substance abuse problem or not. Twenty-one (43.8%) had a substance abuse problem and 27 (56.2%) had not. We used the Positive and Negative Symptom Scale (PANSS) scale to measure symptoms and several scales to measure substance abuse. Parametric tests (independent t-tests) were used to compare continuous variables, and chi-square tests were used to compare frequencies. Positive symptoms, negative symptoms, general psychopathology symptoms and the total score of psychotic symptoms did not differ significantly between the groups with psychosis alone and psychosis with substance abuse. The delusion subscore was significantly higher in the group with psychosis alone (t = -2.3, df = 41, P < 0.05), and the anxiety subscore was significantly higher in the group with psychosis with substance abuse (t = -2.3, df = 41, P < 0.05). There were no significant differences in the subscores for negative symptoms. The absence of differences in psychotic symptoms between the two groups with psychosis does not imply a strong relationship between psychotic symptoms and substance abuse. These results do not support the self-medication hypothesis. The higher rates of institutionalization among substance abusers may be explained by mechanisms other than exacerbations of psychotic symptoms, as there are few differences in symptoms among abusers and non-abusers.     

Alcohol-abusing teenage boys. Testing a hypothesis on alcohol abuse and personality factors, using a personality inventory

This is the second part of an investigation of alcohol-abusing teenage boys, focusing on personality. One group of 50 High-consumers and one group of 50 0-consumers were selected from 862 18-year-old boys in the general population summoned to the Regional Recruiting and Replacement Office in Solna. These boys answered a personality inventory (KSP) to test a hypothesis on alcohol abuse and personality factors which might indicate psychopathy. The results support the hypothesis that alcohol-abusing teenage boys have psychopathic personality traits while the non-consuming boys have normal personalities. The study cannot reveal whether the differences in personality were the result of the high alcohol consumption or if the psychopathic personality traits preceded the high consumption. A reasonable hypothesis for further research is that vulnerable boys living under poor social conditions react to their situation with motoric restlessness, impulsiveness and aggressive acting-out behaviour. Due to this their social adjustment as grown ups is poor with consequent alcohol and drug abuse and criminality.     

Symptoms and lifetime treatment experiences in psychotic patients with and without substance abuse

The main objective of this study was to compare symptom load and lifetime treatment experiences between psychotic patients with substance abuse problems and psychotic patients without substance abuse problems. This is a cross-sectional study of 48 patients (26 inpatients and 22 outpatients) in a clinic for early intervention in psychosis. Patients’ were grouped into two categories based on whether they had a substance abuse problem or not. Twenty-one (43.8%) had a substance abuse problem and 27 (56.2%) had not. We used the Positive and Negative Symptom Scale (PANSS) scale to measure symptoms and several scales to measure substance abuse. Parametric tests (independent t-tests) were used to compare continuous variables, and chi-square tests were used to compare frequencies. Positive symptoms, negative symptoms, general psychopathology symptoms and the total score of psychotic symptoms did not differ significantly between the groups with psychosis alone and psychosis with substance abuse. The delusion subscore was significantly higher in the group with psychosis alone (t=?2.3, df=41, P<0.05), and the anxiety subscore was significantly higher in the group with psychosis with substance abuse (t=?2.3, df=41, P<0.05). There were no significant differences in the subscores for negative symptoms. The absence of differences in psychotic symptoms between the two groups with psychosis does not imply a strong relationship between psychotic symptoms and substance abuse. These results do not support the self-medication hypothesis. The higher rates of institutionalization among substance abusers may be explained by mechanisms other than exacerbations of psychotic symptoms, as there are few differences in symptoms among abusers and non-abusers.     

Methadone maintenance as a therapeutic approach in the treatment of opiate dependent patients

Treatment of opiate addicts is still difficult, and often has only limited success. Methadone therapy offers an alternative, in particular for patients who have repeatedly attempted conventional treatment without success. According to experience in Switzerland, about two-thirds of these patients become medically stable and socially rehabilitated during methadone therapy, or even drug-free in the long term following therapy. The therapy does not consist solely in a daily dose of methadone, but also involves intensive psychosocial care. In Germany, methadone therapy has been under discussion for more than 20 years. In this discussion doubts have been expressed about the criteria used to assess the indications for and the degree of success attained with methadone therapy. In addition, ethical arguments question whether social rehabilitation should be a primary goal of therapy. In order to objectify the discussion, methadone therapy is now being tested in Germany. A social consensus must be sought on goals and strategies in the treatment of opiate addicts.     

Clinicians' and clients' perspectives on the impact of assertive community treatment.

OBJECTIVE: Clients in an assertive community treatment program and their clinicians were asked to rate clients' current difficulties in 13 quality-of-life areas to determine whether improvement in any area predicted reductions in hospitalization and incarceration. METHODS: A peer counselor interviewed 45 clients about psychiatric symptoms, substance use and abuse, medical issues, medication compliance, primary supports, social supports, vocational and occupational issues, housing, daily living skills, economic issues and entitlements, legal involvement, behavioral issues, and treatment involvement. The clients' clinicians rated the clients in these same areas. Ratings of clients' difficulties in these areas at program entry were based on combined ratings made at intake and after a review of clients' charts. Data on hospitalization and incarceration were obtained from medical and police records. Logistic regression analyses were used to seek predictors of declines in admissions to hospitals and jails (referred to as institutional admissions). RESULTS: Institutional admissions decreased after program entry; decreases were larger among clients admitted in recent years. Clients improved significantly in all 13 quality-of-life areas based on comparisons of both clinicians' and clients' ratings and baseline ratings; however, clients rated themselves as having less difficulty than their clinicians thought they had in the areas of substance abuse, medication compliance, primary supports, social supports, daily living skills, and treatment involvement. Based on clinicians' ratings, improvement in substance abuse issues predicted declines in institutionalized admissions. Based on clients' ratings, improvement in social support and economic issues predicted declines. CONCLUSIONS: These findings emphasize the importance of clients' perspectives in treatment planning and suggest that clinicians may overlook the smaller incremental steps toward improvement that are valued by clients.     

Easy-access Services in Low-threshold Opiate Agonist Maintenance

Background  There is currently evidence that methadone and buprenorphine maintenance is effective in reducing substance abuse. However, it is not known whether psychosocial support improves the outcome of methadone maintenance in the absence of control measures, such as regular urine testing. Materials and Methods  In a prospective observational study, the effectiveness of standard psychosocial support [SPS] was compared with enhanced psychosocial support [EPS]. EPS included intensive case management and drop-in centres. Subjects were administered the Addiction Severity Index before and after treatment and were followed up at 18 months post-treatment, and case files were reviewed. No subjects in either SPS or EPS condition were subjected to a substantial amount of control measures such as urine testing. Results  Clients in EPS support received more treatment according to case-files, and showed a lower proportion of no-shows compared with those receiving SPS. Subjects in both SPS and EPS reduced drug use and legal problems, but enhanced care was more effective at reducing social problems, family problems and psychiatric severity. Mortality was slightly, although non-significantly higher in the control group. Change in psychiatric and social problems were associated with the absence of no-shows. Discussion  Enhanced psychosocial support appeared to be effective at reducing problems associated with drug use in a low-threshold buprenorphine or methadone maintenance setting without substantial measures of control.     

Forms of knowledge, cognitive impairment and drug abuse: a demonstration

Chronic abusers of alcohol and other drugs often exhibit persistent deficits on neuropsychological tests. These deficits are usually attributed to drug-induced brain dysfunction or to familial factors that depress performance independent of drug abuse. The aim of this study was to determine the plausibility of a third explanation: namely that some neuropsychological deficits of drug abusers arise because they acquire different forms of knowledge from non-drug abusers. This hypothesis predicts that drug abusers should excel on tests of knowledge that is related to their lifestyle. Sixty-three clients from a local methadone clinic and a comparison group of 24 non-abusing subjects who were knowledgeable about drugs listened to a song about cocaine addiction. They were asked to identify the title, artist, year the song was first popular and the meaning of the song. There were no significant differences between the groups in identifying the song title, artist or year, but the drug-abusers were significantly more likely to state that the song was about cocaine or drug addiction. In interpreting deficits by drug abusers on neuropsychological tests, differences in knowledge acquired should be considered.     

Patients who use drugs during inpatient substance abuse treatment.

OBJECTIVE: Drug use by patients during inpatient substance abuse treatment is frequently a cause of premature hospital discharge. The authors examined the histories of patients who used drugs while in inpatient substance abuse treatment, the methods used to detect drug use, and the temporal relationship of drug use episodes. METHOD: The authors reviewed the charts of patients admitted consecutively to an inpatient substance abuse treatment unit between 1981 and 1988. Of 729 patients, 42 were found to have used drugs while receiving inpatient treatment. The diagnoses and clinical histories of these 42 patients were compared with those of all other patients. Methods of detection and circumstances of drug use were recorded, and drug use episodes were plotted on a time line that was examined for temporal clustering. RESULTS: Significantly more of the patients who used drugs during inpatient substance abuse treatment had primarily used heroin or methadone before treatment. Random urine screens, self-report, and staff observation together detected approximately 85% of the patients who used drugs during treatment. Episodes of drug use did cluster in time, but within clusters the hospital stays of the patients who used drugs did not necessarily overlap. CONCLUSIONS: Temporal clustering of drug use episodes may occur because drug use by one patient heralds drug availability and stimulates craving in other inpatients. Clinicians should be aware that one episode of drug use may be followed by others. Multiple detection methods, including random comprehensive urine screens, should be used to test for drug use on inpatient units.     

Imipramine treatment of methadone maintenance patients with affective disorder and illicit drug use

Of 17 consecutive patients receiving methadone maintenance treatment who had primary or chronic depression, nine (53%) improved in both mood and drug abuse after imipramine treatment. This finding suggests a potential for helping such dual-diagnosis patients reduce drug abuse and associated risk for HIV. Further controlled trials are warranted.     

Reward related neurotransmitter changes in a model of depression: An in vivo microdialysis study

Objectives: The self-medication hypothesis assumes that symptoms related to potential monoaminergic deficits in depression may be relieved by drug abuse. The aim of this study was to elucidate the neurotransmitter changes in a rat model of depression by measuring their levels in the nucleus accumbens shell, which is typically involved in the drug of abuse acquisition mechanism. Methods: Depression was modelled by the olfactory bulbectomy (OBX) in Wistar male rats. In vivo microdialysis was performed, starting from the baseline and following after a single methamphetamine injection and behaviour was monitored. The determination of neurotransmitters and their metabolites was performed by high-performance liquid chromatography combined with mass spectrometry. Results: OBX animals had lower basal levels of dopamine and serotonin and their metabolites. However, γ-aminobutyric acid (GABA) and glutamate levels were increased. The methamphetamine injection induced stronger dopamine and serotonin release in the OBX rats and lower release of glutamate in comparison with sham-operated rats; GABA levels did not differ significantly. Conclusions: This study provides an evidence of mesolimbic neurotransmitter changes in the rat model of depression which may elucidate mechanisms underlying intravenous self-administration studies in which OBX rats were demonstrated to have higher drug intake in comparison to intact controls.     

Alcoholism: beliefs and attitudes among Canadian alcoholism treatment practitioners.

OBJECTIVES: To explore differences in views concerning adjunctive medications and theoretical orientation among Canadian practitioners from different professional backgrounds who treat alcoholism. METHODS: A survey of clinicians from different disciplines was conducted by mail. The response rate was 56%: 95 drug and alcohol counsellors, 46 social workers, 81 nonpsychiatrist addiction physicians, and 74 addiction psychiatrists. The number of items in the questionnaire was reduced using principal component analysis. Group differences were explored using analysis of variance with Bonferroni correction and Scheffé's posthoc comparisons. RESULTS: Physicians and nonphysicians differed in their views on the utility of medications in treating alcohol problems, the disease concept of alcohol problems, and the classification of alcohol abuse or dependence as psychiatric conditions. No group differences emerged on views regarding cognitive-behavioural treatment, pharmacological-only interventions, combined treatment, and recovery without treatment. Psychopathology in the alcoholic was significantly more likely to be considered as secondary to the use of alcohol by nonpsychiatrist physicians. Nonphysician practitioners viewed alcoholic behaviour as self-medication. CONCLUSIONS: Groups differed on questionnaire items concerning medication use and the disease concept of alcoholism. Agreement on several areas may facilitate bridging the gap across disciplines. The implications of these results are discussed.