A randomized trial of intensive outpatient (IOP) vs. standard outpatient (OP) buprenorphine treatment for African Americans

Background

Buprenorphine is increasingly being used in community-based treatment programs, but little is known about the optimal level of psychosocial counseling in these settings. The aim of this study was to compare the effectiveness of OP and IOP level counseling when provided as part of buprenorphine treatment for opioid-dependent African Americans.

Methods

Participants were African American men and women starting buprenorphine treatment at one of two community-based clinics (N = 300). Participants were randomly assigned to OP or IOP. Measures at baseline, 3- and 6-month included the primary outcome of DSM-IV opioid and cocaine dependence criteria, as well as additional outcomes of illicit opioid and cocaine use (urine test and self-report), criminal activity, retention in treatment, Quality of Life, Addiction Severity Index composite scores, and HIV risk behaviors.

Results

Participants assigned to OP received, on average, 3.67 (SD = 1.30) h of counseling per active week in treatment. IOP participants received an average of 5.23 (SD = 1.68) h of counseling per active week (less than the anticipated 9 h per week of counseling). Both groups showed substantial improvement over a 6-month period on nearly all measures considered. There were no significant differences between groups in meeting diagnostic criteria for opioid (p = .67) or cocaine dependence (p = .63). There were no significant between group differences on any of the other outcomes. A secondary analysis restricting the sample to participants meeting DSM-IV criteria for baseline cocaine dependence also revealed no significant between-group differences (all ps > .05).

Conclusions

Buprenorphine patients receiving OP and IOP levels of care both show short-term improvements.     

Time to initiation of treatment for neonatal abstinence syndrome in neonates exposed in utero to buprenorphine or methadone

Background

The recommended standard of care calls for treating opioid-dependent pregnant women with methadone and observing neonates exposed in utero for five to seven postnatal days to see if treatment for neonatal abstinence syndrome (NAS) is needed. Data from a large multi-site randomized clinical trial comparing buprenorphine vs. methadone for the treatment of opioid dependence during pregnancy suggest buprenorphine-exposed neonates had less severe NAS, but may require pharmacologic treatment for NAS later than methadone-exposed neonates. The present study examined whether time to pharmacologic treatment initiation differed in a relatively large non-blinded clinical sample of buprenorphine- vs. methadone-exposed neonates treated for NAS.

Methods

Medical records for 75 neonates exposed to buprenorphine (n = 47) or methadone (n = 28) in utero who required treatment for NAS were examined. Time elapsed between birth and initiation of pharmacologic treatment was calculated for each neonate and time to treatment initiation compared between groups.

Results

Median time to treatment initiation (hours:minutes, IQR) was significantly later in buprenorphine- vs. methadone-exposed neonates (71:02, 44:21–96:27 vs. 34:12, 21:00–55:41, respectively, p < .001). Estimates of mean time to treatment initiation from parametric analyses that adjusted for maternal and neonatal characteristics were very similar (73:10 (95% CI: 61:00–87:18) vs. 42:36 (95% CI: 33:06–53:30), respectively, p = .0005). This difference was not dependent on maternal age or neonatal sex, gestational age, or birth weight.

Conclusions

These findings confirm results from randomized clinical trials, adding generality to the observation that buprenorphine-exposed neonates require treatment significantly later than methadone-exposed neonates.     

Methadone maintenance treatment may improve completion rates and delay opioid relapse for opioid dependent individuals under community corrections supervision

Aims

Several studies have demonstrated the importance of agonist therapies such as methadone and buprenorphine for preventing relapse for individuals being released from jail or prison to the community. No studies have examined the impact of methadone for increasing the completion of community supervision requirements and preventing opioid relapse for individuals under community corrections supervision. This observational study compared the community corrections completion rate and opioid relapse rate of individuals receiving methadone maintenance therapy (MMT) to individuals who did not.

Methods

Of the 2931 individuals enrolled under criminal justice supervision in the community, Treatment Accountability for Safer Communities (TASC), and who met criteria for opioid dependence, 329 (11%) individuals reported receiving MMT in the community.

Results

The majority of participants were White (79.8%) and male (63.5%), with a mean age of 31.33 years (SD = 9.18), and were under supervision for 10.4 months (SD = 9.1). MMT participants were less likely to fail out of supervision compared to individuals not in MMT (39.0% vs. 52.9%, p < 0.001), and had a lower rate of relapse (32.9%) and longer time to relapse (average days = 89.7, SD = 158.9) compared to the relapse rate (55.9%) and time to relapse (average days = 60.5, SD = 117.9) of those not on MMT.

Conclusions

While the observational nature of this study prevents causal inferences, these results suggest that utilization of MMT in community corrections may increase the likelihood of completing supervision requirements and delay time to opioid relapse. Providing agonist therapies to opioid dependent individuals under supervision appears to be a critical strategy in this important population.     

Cigarette smoking in opioid-dependent pregnant women: Neonatal and maternal outcomes

Background

The relationship between cigarette smoking and neonatal and maternal clinical outcomes among opioid-agonist-treated pregnant patients is sparse.

Objectives

(1) Is smoking measured at study entry related to neonatal and maternal outcomes in pregnant women receiving opioid-agonist medication? (2) Is it more informative to use a multi-item measure of smoking dependence or a single-item measure of daily smoking? (3) Is the relationship between smoking at study entry and outcomes different between methadone and buprenorphine?

Methods

Secondary analyses examined the ability of the tobacco dependence screener (TDS) and self-reported past 30-day daily average number of cigarettes smoked, both measured at study entry, to predict 12 neonatal and 9 maternal outcomes in 131 opioid-agonist-maintained pregnant participants.

Results

Past 30-day daily average number of cigarettes smoked was significantly positively associated with total amount of morphine (mg) needed to treat neonatal abstinence syndrome (NAS), Adjusted Odds Ratio (AOR) = 1.06 (95% CI: 1.02, 1.09), number of days medicated for NAS, AOR = 1.04 (95% CI: 1.01, 1.06), neonatal length of hospital stay in days, AOR = 1.03 (95% CI: 1.01, 1.05), and negatively associated with 1-AOR = .995 (95% CI: .991,.999) and 5-min Apgar scores, AOR = .996 (95% CI: .994,.998). Simple effect tests of the two significant TDS × medication condition effects found TDS was unrelated to non-normal presentation and amount of voucher money earned in the methadone [AORs = .90 (95% CI: .74, 1.08, p > .24) and 1.0 (95% CI: .97, 1.03, p > .9)] but significant in the buprenorphine condition [AORs = 1.57 (95% CI: 1.01, 2.45, p < .05) and 1.08 (95% CI: 1.04, 1.12, p < .01)].

Conclusions

Regardless of prenatal methadone or buprenorphine exposure, heavier cigarette smoking was associated with more compromised birth outcomes.     

Initial insight into why physical activity may help prevent adolescent smoking uptake

Introduction

Whereas research supports the importance of regular physical activity to decrease the likelihood of smoking uptake, the mechanisms accounting for this relationship are poorly understood. We sought to determine whether the enjoyment or reward derived from physical activity is one mechanism underlying the relationship between smoking and physical activity.

Methods

The sample was composed of 1374 adolescents participating in a prospective longitudinal survey study of health behaviors. Variables were measured via self-report every six months for eight waves of data spanning four years.

Results

An associative processes latent growth curve model revealed a significant and negative indirect effect of baseline physical activity on baseline smoking through baseline physical activity reward (b_indirect = −.18, z = −3.11, p = .002; 95% CI = −.29, −.07). Similarly, there was a significant and negative indirect effect of physical activity trend on smoking trend through physical activity reward trend (b_indirect = −.16, z = −2.09, p = .04; 95% CI = −.30, −.01). The effect of physical activity on smoking at baseline and across time was completely mediated by physical activity reward. There was less support for the idea that smoking progression was associated with reduced physical activity reward and subsequent declines in physical activity.

Conclusions

This study provides the first evidence implicating physical activity reward as one mechanism by which physical activity reduces the likelihood of adolescent smoking uptake. Smoking prevention interventions that promote physical activity and target physical activity enjoyment may have an important impact on adolescent smoking initiation and progression.     

Results of a pilot randomized controlled trial of buprenorphine for opioid dependent women in the criminal justice system

Aims

Recent studies have demonstrated the efficacy of both methadone and buprenorphine when used with opioid dependent men transitioning from prison to the community, but no studies have been conducted with women in the criminal justice (CJ) system. The aim of this study was to determine the efficacy of buprenorphine for relapse prevention among opioid dependent women in the CJ system transitioning back to the community.

Methods

36 women under CJ supervision were recruited from an inpatient drug treatment facility that treats CJ individuals returning back to the community. Nine were enrolled in an open label buprenorphine arm then 27 were randomized to buprenorphine (n = 15) or placebo (n = 12; double-blind). All women completed baseline measures and started study medication prior to release. Participants were followed weekly, provided urine drug screens (UDS), received study medication for 12 weeks, and returned for a 3-month follow-up. Intent-to-treat analyses were performed for all time points through 3 month follow-up.

Results

The majority of participants were Caucasian (88.9%), young (M ± SD = 31.8 ± 8.4 years), divorced/separated (59.2%) women with at least a high school/GED education (M ± SD = 12 ± 1.7 years). GEE analyses showed that buprenorphine was efficacious in maintaining abstinence across time compared to placebo. At end of treatment, 92% of placebo and 33% of active medication participants were positive for opiates on urine drug screen (Chi-Square = 10.9, df = 1; p < 0.001). However, by the three month follow-up point, no differences were found between the two groups, with 83% of participants at follow-up positive for opiates.

Conclusions

Women in the CJ system who received buprenorphine prior to release from a treatment facility had fewer opiate positive UDS through the 12 weeks of treatment compared to women receiving placebo. Initiating buprenorphine in a controlled environment prior to release appears to be a viable strategy to reduce opiate use when transitioning back to the community.     

Intravenous buprenorphine and norbuprenorphine pharmacokinetics in humans

Background

Prescribed sublingual (SL) buprenorphine is sometimes diverted for intravenous (IV) abuse, but no human pharmacokinetic data are available following high-dose IV buprenorphine.

Methods

Plasma was collected for 72 h after administration of placebo or 2, 4, 8, 12, or 16 mg IV buprenorphine in escalating order (single-blind, double-dummy) in 5 healthy male non-dependent opioid users. Buprenorphine and its primary active metabolite, norbuprenorphine, were quantified by liquid chromatography–tandem mass spectrometry with limits of quantitation of 0.1 μg/L.

Results

Maximum buprenorphine concentrations (mean ± SE) were detected 10 min after 2, 4, 8, 12, 16 mg IV: 19.3 ± 1.0, 44.5 ± 4.8, 85.2 ± 7.7, 124.6 ± 16.6, and 137.7 ± 18.8 μg/L, respectively. Maximum norbuprenorphine concentrations occurred 10–15 min (3.7 ± 0.7 μg/L) after 16 mg IV administration.

Conclusions

Buprenorphine concentrations increased in a significantly linear dose-dependent manner up to 12 mg IV buprenorphine. Thus, previously demonstrated pharmacodynamic ceiling effects (over 2–16 mg) are not due to pharmacokinetic adaptations within this range, although they may play a role at doses higher than 12 mg.     

Family smoking history moderates the effect of expectancies on smoking initiation in college students

Aims

This report was designed to test the hypothesis that family history of smoking (FH) would moderate the effects of positive and negative smoking expectancies on initiation in a college sample.

Design

Secondary analysis of a study of college freshmen never-smokers (n = 196; 46% male) who completed a baseline interview and quarterly online follow-up assessments for 15 months.

Findings

Analyses indicated that FH moderated the effect of negative outcome expectancies (p = .003) but not the effects of expectancies for positive or negative reinforcement on the probability of smoking initiation. Stronger negative expectancies were associated with a decreased risk of initiation for family history positive but not family history negative participants.

Conclusions

Findings are consistent with previous tobacco research indicating that FH + adolescents have more negative expectancies about cigarette smoking. This suggests that adolescents observing negative consequences or receiving negative messages from their parents about cigarettes may be less likely to experiment with smoking.     

Effects of bupropion on cognitive performance during initial tobacco abstinence

Background

Bupropion may aid tobacco abstinence by quickly relieving symptoms of nicotine withdrawal, perhaps including impaired cognitive performance. We examined whether bupropion would attenuate abstinence-induced cognitive deficits on the first day of a brief quit attempt, when smokers are most likely to relapse.

Methods

Smokers (N = 24) with high quit interest were recruited for within-subjects cross-over test of bupropion vs placebo on ability to abstain during separate short-term practice quit smoking attempts. After introduction to working memory (N-back) and sustained attention (continuous performance task; CPT) tasks during the pre-quit smoking baseline, performance on these tasks was assessed after abstaining overnight (CO < 10 ppm) on the first day of each quit attempt, while on bupropion and on placebo.

Results

Compared to placebo, bupropion after abstinence improved correct response times for working memory (p = .01 for medication by memory load interaction) and for one measure of sustained attention (numbers, but not letters; p < .05).

Discussion

Bupropion may attenuate some features of impaired cognitive performance due to withdrawal on the first day of a quit attempt. Future studies could examine whether this effect of bupropion contributes to its efficacy for longer-term smoking cessation.     

γ-Amino butyric acid and glutamate abnormalities in adolescent chronic marijuana smokers

Background

An increasing body of evidence from neuropsychological and neuroimaging studies suggests that exposure to marijuana throughout adolescence disrupts key cortical maturation processes occurring during this developmental phase. GABA-modulating pharmacologic treatments that elevate brain GABA concentration recently have been shown to decrease withdrawal symptoms and improve executive functioning in marijuana-dependent adult subjects. The goal of this study was to investigate whether the lower ACC glutamate previously reported in adolescent chronic marijuana smokers is associated with lower ACC GABA levels.

Methods

Standard and metabolite-edited proton MRS data were acquired from adolescent marijuana users (N = 13) and similarly aged non-using controls (N = 16) using a clinical 3T MRI system.

Results

The adolescent marijuana-using cohort showed significantly lower ACC GABA levels (−22%, p = 0.03), which paralleled significantly lower ACC glutamate levels (−14%, p = 0.01). Importantly, the lower ACC GABA and glutamate levels detected in the adolescent cohort remained significant after controlling for age and sex.

Conclusions

The present spectroscopic findings support functional neuroimaging data documenting cingulate dysfunction in marijuana-dependent adolescents. Glutamatergic and GABAergic abnormalities potentially underlie cingulate dysfunction in adolescent chronic marijuana users, and the opportunity for testing suitable pharmacologic treatments with a non-invasive pharmacodynamic evaluation exists.     

Illicit use of buprenorphine in a community sample of young adult non-medical users of pharmaceutical opioids

Background

There is growing evidence about illicit use of buprenorphine in the U.S. The study aims to: (1) identify prevalence and predictors of illicit buprenorphine use in a community sample of 396 young adult (18–23 years old) non-medical users of pharmaceutical opioids and (2) describe knowledge, attitudes and behaviors linked to illicit buprenorphine use as reported by a qualitative sub-sample (n = 51).

Methods

Participants were recruited using respondent-driven sampling. Qualitative interview participants were selected from the larger sample. The sample (n = 396) was 54% male and 50% white; 7.8% reported lifetime illicit use of buprenorphine.

Results

Logistic regression analysis results indicate that white ethnicity, intranasal inhalation of pharmaceutical opioids, symptoms of opioid dependence, and a greater number of pharmaceutical opioids used in lifetime were statistically significant predictors of illicit buprenorphine use. Qualitative interviews revealed that buprenorphine was more commonly used by more experienced users who were introduced to it by their “junkie friends.” Those who used buprenorphine to self-medicate withdrawal referred to it as a “miracle pill.” When used to get high, reported experiences ranged from “the best high ever” to “puking for days.” Participants reported using buprenorphine/naloxone orally or by intranasal inhalation. Injection of buprenorphine without naloxone was also reported.

Conclusion

Our findings suggest that illicit buprenorphine use is gaining ground primarily among whites and those who are more advanced in their drug use careers. Continued monitoring is needed to better understand evolving patterns and trends of illicit buprenorphine use.     

Evidence for greater cue reactivity among low-dependent vs. high-dependent smokers

Introduction

Cue reactivity paradigms are well-established laboratory procedures used to examine subjective craving in response to substance-related cues. For smokers, the relationship between nicotine dependence and cue reactivity has not been clearly established. The main aim of the present study was to further examine this relationship.

Methods

Participants (N = 90) were between the ages 18–40 and smoked ≥10 cigarettes per day. Average nicotine dependence (Fagerström Test for Nicotine Dependence; FTND) at baseline was 4.9 (SD = 2.1). Participants completed four cue reactivity sessions consisting of two in vivo cues (smoking and neutral) and two affective imagery cues (stressful and relaxed), all counterbalanced. Craving in response to cues was assessed following each cue exposure using the Questionnaire of Smoking Urges-Brief (QSU-B). Differential cue reactivity was operationally defined as the difference in QSU scores between the smoking and neutral cues, and between the stressful and relaxed cues.

Results

Nicotine dependence was significantly and negatively associated with differential cue reactivity scores in regard to hedonic craving (QSU factor 1) for both in vivo and imagery cues, such that those who had low FTND scores demonstrated greater differential cue reactivity than those with higher FTND scores (β = −.082; p = .037; β = −.101; p = .023, respectively). Similar trends were found for the Total QSU and for negative reinforcement craving (QSU factor 2), but did not reach statistical significance.

Discussion

Under partially sated conditions, less dependent smokers may be more differentially cue reactive to smoking cues as compared to heavily dependent smokers. These findings offer methodological and interpretative implications for cue reactivity studies.     

Intentions to quit smoking among youth in substance abuse treatment

Introduction

Smoking cessation interventions for adolescents in substance abuse treatment have shown promise. However, a better understanding of the correlates of substance use disordered (SUD) youths’ intentions toward smoking cessation will help tailor cessation interventions to this population. The current study examined tobacco use, smoking-related self-efficacy, substance use and intentions to quit using alcohol and illicit drugs as correlates of intentions to quit smoking among youth in SUD treatment.

Methods

Participants were 178 adolescents who were in inpatient (n = 90) or outpatient (n = 88) SUD treatment and had smoked at least once in the past 30 days. The sample was 44% female, 72% non-Hispanic Caucasian, with a mean age of 16.2 years (SD = 1.2). Participants rated the likelihood that they would be nonsmokers in the next year (9-point scale).

Results

SUD youth intention to quit smoking averaged 4.9 out of 10 (SD = 3.2), comparable to intention to quit drinking (M = 5.3, SD = 3.6), but lower than their intention to quit using drugs (M = 6.0, SD = 3.4). Teens’ intentions to quit smoking were associated with nicotine dependence (r = −.30, p < .01) and smoking cessation related self-efficacy (r = .36, p < .01), but not with pretreatment substance use severity (r = −.15). Controlling for nicotine dependence, teens’ intentions to quit smoking were positively related to smoking cessation self-efficacy (pr = .26, p < .01) and intention to quit using illicit drugs (pr = .15, p < .05), but unrelated to intention to quit drinking.

Discussion

Findings highlight the appropriateness of addressing adolescent tobacco use during SUD treatment, but emphasize the importance of assessing intention and other cognitions for each substance, as they may differ markedly.     

Binge drinking trajectory and neuropsychological functioning among university students: A longitudinal study

Background

Adolescence is a time of considerable neurodevelopment. Binge drinking (BD) during this period increases the vulnerability to its neurotoxic effects. This longitudinal study aimed to investigate the relationship between BD trajectory over university years and neuropsychological functioning.

Methods

Cohort-study. Two-year follow-up. A total of 89 university students were assessed: 40 Non-BD (at Initial and Follow-up), 16 Ex-BD (BD at Initial but not at Follow-up) and 33 BD (at both times). Neuropsychological assessment of working memory, episodic memory and executive abilities was carried out during their first (Initial) and third (Follow-up) academic year at the University of Santiago de Compostela.

Results

BD subjects performed less well on the Wechsler Memory Scale-III (WMS-III) Logical Memory Subtest (immediate theme recall, P = .034; delayed theme recall, P = .037; and percent retention, P = .035) and committed more perseverative errors on the Self-Ordered Pointing Task (SOPT) (P = .021) than Non-BD. There were no differences between Ex-BD and Non-BD.

Conclusions

Binge drinking trajectory during adolescence is associated with neuropsychological performance. Persistent BD, but not Ex-BD, is associated with verbal memory and monitoring difficulties. This is compatible with the hypothesis that heavy alcohol use during adolescence may affect cognitive functions that rely on the temporomesial and dorsolateral prefrontal cortex.     

Reinforcing integrated psychiatric service attendance in an opioid-agonist program: A randomized and controlled trial

Background

The benefits of integrating substance abuse and psychiatric care may be limited by poor service utilization. This randomized clinical trial evaluated the efficacy of using contingency management to improve utilization of psychiatric services co-located and integrated within a community-based methadone maintenance treatment program.

Methods

Opioid-dependent outpatients (n = 125) with any current psychiatric disorder were randomly assigned to: (1) reinforced on-site integrated care (ROIC), with vouchers (worth $25.00) contingent on full adherence to each week of scheduled psychiatric services; or (2) standard on-site integrated care (SOIC). All participants received access to the same schedule of psychiatrist and mental health counseling sessions for 12-weeks.

Results

ROIC participants attended more overall psychiatric sessions at month 1 (M = 7.53 vs. 3.97, p < .001), month 2 (M = 6.31 vs. 2.81, p < .001), and month 3 (M = 5.71 vs. 2.44, p < .001). Both conditions evidenced reductions in psychiatric distress (p < .001) and similar rates of drug-positive urine samples. No differences in study retention were observed.

Conclusions

These findings suggest that contingency management can improve utilization of psychiatric services scheduled within an on-site and integrated treatment model. Delivering evidenced-based mental health counseling, or modifying the contingency plan to include illicit drug use, may be required to facilitate greater changes in psychiatric and substance abuse outcomes.