The effectiveness of telephone-based continuing care in the clinical management of alcohol and cocaine use disorders: 12-month outcomes

This study of continuing care for substance dependent patients compared a telephone-based monitoring and brief counseling intervention (TEL) with 2 face-to-face interventions, relapse prevention (RP) and standard 12-step group counseling (STND). The participants were graduates of intensive outpatient programs who had current dependence on alcohol and/or cocaine. Self-report, collateral, and biological measures of alcohol and cocaine use were obtained over a 12-month follow-up. The treatment groups did not differ on abstinence-related outcomes in the complete sample (N = 359) or on cocaine use outcomes in participants with cocaine dependence (n = 268). However, in participants with alcohol dependence only (n = 91), TEL produced better alcohol use outcomes than STND on all measures examined and better outcomes than RP on some of the measures.     

Mediators of telephone-based continuing care for alcohol and cocaine dependence

A previous randomized trial with 224 alcohol and/or cocaine addicts who had completed an initial phase of treatment indicated that 12 weeks of telephone-based continuing care yielded higher abstinence rates over 24 months than did group counseling continuing care. The current study examined mediators of this treatment effect. Results suggested that self-help involvement during treatment and self-efficacy and commitment to abstinence 3 months after treatment mediated subsequent abstinence outcomes. These analyses controlled for substance use prior to the assessment of mediators. Conversely, there was no evidence that self-help beliefs or social support mediated the treatment effect. These results are consistent with a model in which treatment effects are first accounted for by changes in behavior, followed by changes in self-efficacy and in commitment to abstinence.     

Day treatment with contingency management for cocaine abuse in homeless persons: 12-month follow-up

Abstinence, employment, and homelessness treatment outcomes at 12-month follow-up are presented from a study comparing behavioral day treatment plus abstinence-contingent housing and work therapy with behavioral day treatment only among homeless persons who abuse crack cocaine. Within-group improvements were revealed, but group differences for drug abstinence found in J. B. Milby et al. (2000) failed to persist at 12 months. Drug use measurement and treatment termination explanations are discussed. Within- but not between-group differences were found for employment and homelessness outcomes at long-term follow-up. Research extending abstinence contingencies and continuous drug use monitoring is recommended. Questions about effectiveness of contingency management alone, role of coexisting psychiatric disorders on treatment outcome, and individualized treatment dosing are offered.     

Alcoholics anonymous and relapse prevention as maintenance strategies after conjoint behavioral alcohol treatment for men: 18-month outcomes

Ninety men with alcohol problems and their female partners were randomly assigned to 1 of 3 outpatient conjoint treatments: alcohol behavioral couples therapy (ABCT), ABCT with relapse prevention techniques (RP/ABCT), or ABCT with interventions encouraging Alcoholics Anonymous (AA) involvement (AA/ABCT). Couples were followed for 18 months after treatment. Across the 3 treatments, drinkers who provided follow-up data maintained abstinence on almost 80% of days during follow-up, with no differences in drinking or marital happiness outcomes between groups. AA/ABCT participants attended AA meetings more often than ABCT or RP/ABCT participants, and their drinking outcomes were more strongly related to concurrent AA attendance. For the entire sample, AA attendance was positively related to abstinence during follow-up in both concurrent and time-lagged analyses. In the RP/ABCT treatment, attendance at posttreatment booster sessions was related to posttreatment abstinence. Across treatment conditions, marital happiness was related positively to abstinence in concurrent but not time-lagged analyses.     

Long-term influence of duration and frequency of participation in alcoholics anonymous on individuals with alcohol use disorders

This study examined the influence of the duration and frequency of a baseline episode of participation in Alcoholics Anonymous (AA) among 473 individuals with alcohol use disorders on 1-year and 8-year outcomes and the effect of additional participation and delayed participation on outcomes. Compared with individuals who did not participate, individuals who affiliated with AA relatively quickly, and who participated longer, had better 1-year and 8-year alcohol-related outcomes. Individuals who continued to participate, and those who continued longer, had better alcohol-related outcomes than did individuals who discontinued participation, but individuals who delayed participation in AA had no better outcomes than those who never participated. In general, the frequency of participation was independently associated only with a higher likelihood of abstinence.     

A randomized trial of long-term reinforcement of cocaine abstinence in methadone-maintained patients who inject drugs

This study determined whether long-term abstinence reinforcement could maintain cocaine abstinence throughout a year long period. Patients who injected drugs and used cocaine during methadone treatment (n = 78) were randomly assigned to 1 of 2 abstinence-reinforcement groups or to a usual care control group. Participants in the 2 abstinence-reinforcement groups could earn take-home methadone doses for providing opiate- and cocaine-free urine samples; participants in 1 of those groups also could earn 5,800 US dollars in vouchers for providing cocaine-free urine samples over 52 weeks. Both abstinence-reinforcement interventions increased cocaine abstinence, but the addition of the voucher intervention resulted in the largest and most sustained abstinence. Therefore, voucher-based reinforcement of cocaine abstinence in methadone patients can be a highly effective maintenance intervention.     

Correlation between self-reported cocaine use and urine toxicology in an inner-city prenatal population.

To determine the prevalence of recent cocaine use and the accuracy of self-reported use, the results of a urine assay for the major cocaine metabolite benzoylecgonine were compared with self-reported cocaine use in an inner-city prenatal population offered routine voluntary urine toxicology screening at the time of registration for prenatal care. During a 1-year period, 6866 women registered for prenatal care and 5200 (76%) consented to urine assays for cocaine metabolites. Of the women consenting to urine assays, 253 (5%) had positive assays for benzoylecgonine. Women with positive assays were significantly more likely than those with negative assays to be older (mean [SD] 27 [5] versus 23 [6] years), black, single, and unemployed. In addition, women with positive assays were significantly more likely to be multiparous, report > two sexual partners in the previous year, and acknowledge a history of a sexually transmitted disease (STD). Forty-seven percent of women with positive assays acknowledged cocaine use in the 6 months prior to sampling. Women with positive assays who denied cocaine use were significantly more likely than those who admitted use to be younger (mean [SD] 26 [5] versus 28 [4] years), to report > or = two sexual partners in the past year, and acknowledge a history of an STD. This analysis revealed a poor correlation between self-reported cocaine use and the results of urine assays for cocaine metabolites among women seeking prenatal care in an inner-city institution.     

Contingent take-home incentive: effects on drug use of methadone maintenance patients.

This study examined contingent methadone take-home privileges for effectiveness in reducing on-going supplemental drug use of methadone maintenance patients. Fifty-three new intakes were randomly assigned to begin receiving take-home privileges after 2 consecutive weeks of drug-free urines or to a noncontingent procedure in which take-homes were delivered independently of urine test results. The contingent procedure produced more individuals with at least 4 consecutive weeks of abstinence (32% vs. 8%); 28% of noncontingent subjects also achieved abstinence after shifting to the contingent procedure. Lower baseline rate of drug-free urines was strongly associated with successful outcome, whereas the type of drug abused (cocaine vs. benzodiazepines) did not influence outcomes. Findings support a recommendation for using contingent take-home incentives to motivate abstinence during methadone maintenance treatment.     

Factors affecting the outcome of methadone maintenance treatment in opiate dependence

This study aimed to measure the rates of ongoing heroin abuse among patients on methadone maintenance treatment (MMT) and sought to identify patient and treatment characteristics associated with poorer outcome. The study was carried out at an outpatient drug treatment clinic and included all patients who were on the MMT during a three month period in 2004. Treatment response was measured from analysis of opiate positive urine samples. Of the 440 patients, 63% were male and their mean age was 32 years (range 17 to 52 years). 163 patients (37%) had a comorbid psychiatric illness. The average methadone dose was 74 mg. On average, 71% of urine samples were opiate negative. Shorter time in treatment (less than 24 months), lower dose of methadone, cocaine abuse and intermittent benzodiazepine abuse were each found to be significantly associated with lower rates of opiate abstinence. Outcomes were not associated with gender, age and accessing counselling. Dual diagnosed patients tended to have higher rates of abstinence (p = 0.08). MMT clients who abuse cocaine and benzodiazepines are at increased risk of continuing opiate abuse. Higher doses of methadone might be necessary to prevent illicit opiate abuse.     

Brief coping skills treatment for cocaine abuse: 12-month substance use outcomes

Patients (N = 108) in a study of cocaine-specific coping skills training (CST), which was found to reduce cocaine use during a 3-month follow-up, were followed for an additional 9 months. CST involved coping skills training in the context of high-risk situations. Control treatment used meditation-relaxation. Both were added to comprehensive private substance abuse treatment. Patients in CST who relapsed had significantly fewer cocaine use days than did the control group during the first 6 months, then both conditions did equally well. Patients in CST also drank alcohol more frequently in the last 6 months than did contrast patients but did not differ in heavy drinking days. For cocaine use outcomes, no interaction of treatment was found with gender, education, route of administration, drug use severity, sociopathy, or depression. Implications include the need to investigate different lengths and combinations of treatment.     

Problem-based learning outcomes: the glass half-full.

PURPOSE: To compare the characteristics and outcome data of students from a single institution with a two-track, problem based learning (PBL) and standard (STND) curriculum. METHOD: PBL and STND students from nine graduating classes at Southern Illinois University School of Medicine were compared using common medical school performance outcomes (USMLE Step 1, USMLE Step 2, clerkship mean ratings, number of clerkship honors and remediation designations, and the senior clinical competency exam), as well as common admission and demographic variables. RESULTS: PBL students were older, and the cohort had a higher proportion of women. The two tracks had similar USMLE Step 1 and 2 mean scores and pass rates. Performance differences were significant for PBL students in two clerkships as well as in the clerkship subcategories of clinical performance, knowledge and clinical reasoning, and noncognitive behaviors. In addition, the proportion of PBL students earning honors was greater. CONCLUSIONS: The traditional undergraduate educational outcomes for the PBL and STND students are very positive. In several of the clerkship performance measures, the PBL students performed significantly better, and in no circumstance did they perform worse than the STND students.     

Impact of psychosocial treatments on associated problems of cocaine-dependent patients.

A previous report from the National Institute on Drug Abuse Collaborative Cocaine Treatment Study (P. Crits-Christoph et al., 1999) found relatively superior cocaine and drug use outcomes for individual drug counseling plus group drug counseling compared with other treatments. Using data from that study, the authors examined the relative efficacy of 4 treatments for cocaine dependence on psychosocial and other addiction-associated problems. The 487 patients were randomly assigned to 6 months of treatment with cognitive therapy, supportive-expressive therapy, or individual drug counseling (each with additional group drug counseling), or to group drug counseling alone. Assessments were made at baseline and monthly for 6 months during the acute treatment phase, with follow-up visits at 9 and 12 months. No significant differences between treatments were found on measures of psychiatric symptoms, employment, medical, legal, family-social, interpersonal, or alcohol use problems. The authors concluded that the superiority of individual drug counseling in modifying cocaine use does not extend broadly to other addiction-associated problems.     

Motivational interviewing in drug abuse services: a randomized trial

Motivational interviewing (MI) is a directive, client-centered brief intervention to elicit behavior change by helping clients explore and resolve ambivalence. In this clinical trial, 152 outpatients and 56 inpatients entering public agencies for treatment of drug problems were randomly assigned to receive or not receive a single session of manual-guided MI. Drug use was assessed by self-report, urine toxicology, and collateral reports from significant others at baseline, 3, 6, 9, and 12 months. Contrary to prior reports, MI showed no effect on drug use outcomes when added to inpatient or outpatient treatment, although both groups showed substantial increases in abstinence from illicit drugs and alcohol.     

Effectiveness and medical costs of divalproex versus lithium in the treatment of bipolar disorder: results of a naturalistic clinical trial

OBJECTIVE: The clinical, quality of life (QOL), and medical cost outcomes of treatment with divalproex were compared with lithium in patients with bipolar I disorder over 1 year. METHODS: In a pragmatic, randomized clinical trial, 201 adults hospitalized with bipolar I manic or mixed episodes were randomized to divalproex or lithium, in addition to usual psychiatric care, and followed for 1 year. All subsequent treatment of bipolar disorder was managed by the patient's psychiatrist. Symptoms of mania and depression were evaluated at baseline and at hospital discharge. Assessments at the start of maintenance therapy and after 1, 3, 6, 9 and 12 months included manic and depressive symptoms, disability days and QOL. Medical resource use data were also collected monthly and costs were estimated using national sources. RESULTS: Divalproex-treated patients (12%) were less likely to discontinue study medications for lack of efficacy or adverse effects than lithium-treated patients (23%). No statistically significant differences between the treatment groups were observed over the 1-year maintenance phase for clinical symptoms, QOL outcomes, or disability days. Mean estimated total medical costs were USD 28,911 for the divalproex group compared with USD 30,666 for the lithium treatment group. Patients continuing mood stabilizer therapy at 3 months had slightly better health outcomes and substantially lower total medical costs than those who discontinued therapy ( USD 10,091 versus USD 34,432, respectively). CONCLUSIONS: Divalproex maintenance treatment for bipolar disorder resulted in comparable medical costs, clinical and QOL outcomes compared with lithium. Patients remaining on mood stabilizer therapy had substantially lower total medical costs and better health outcomes compared with those who discontinued therapy.     

Clusters of alcohol use disorders diagnostic criteria and predictors of alcohol use after liver transplantation for alcoholic liver disease

BACKGROUND: Establishing the correct alcohol use disorder diagnosis is clinically relevant because several reports of post-transplant alcohol use suggest that a pre-transplant diagnosis of alcohol dependence (rather than abuse) predicts relapse to alcohol use. Numerous combinations of specific symptoms are possible to achieve diagnostic significance. OBJECTIVE: The authors hypothesized that there would be distinct clusters of liver transplant recipients who showed specific combinations of alcohol-related symptoms and that these clusters would be predictive of alcohol-abuse outcome after transplant. METHOD: A group of 120 ALD liver transplant recipients received the Structured Clinical Interview for DSM-IV (SCID) module for alcohol abuse/dependence, and a cluster analysis was performed. RESULTS: Within the clusters of those with alcohol dependence, cluster assignment did not predict those more likely to drink. However, those assigned to the alcohol abuse cluster were significantly less likely to drink than those with alcohol dependence. CONCLUSION: Results therefore suggest that the prognosis regarding continued abstinence posttransplant is much more positive for individuals with a diagnosis of abuse than for those who meet criteria for alcohol dependence.     

Differential transitions between cocaine use and abstinence for men and women

The longitudinal course of cocaine dependence is characterized by alternating periods of abstinence and relapse. Although gender has emerged as an important predictor of relapse, previous studies have examined mean differences in use by gender. Focusing strictly on differences in averages between men and women does not address potential gender differences in transitions between use and abstinence. Transition rates for men and women were compared using data from the National Institute on Drug Abuse Collaborative Cocaine Treatment Study. Abstinence and nonabstinence for each of the 6 months of active treatment was determined by using a composite measure of use that incorporated information from weekly and monthly self-reports and urine toxicology screenings. Random effects were introduced to describe intersubject heterogeneity in transition rates. In this sample of 454 patients, rates of transition between abstinence and use were significantly different between men and women, with men showing twice the rate of transition between states despite similar average levels of use. These data may have important implications for both treatment planning and the types of outcomes considered in clinical practice and research.     

The relationship between neuropsychological impairment in alcoholics and treatment outcome at one year.

One hundred and thirty-two (132) patients with a diagnosis of alcohol dependence who participated in an inpatient treatment program were assessed on select neuropsychological measures and followed for a one year period. Neuropsychological, personality, and demographic variables did not predict outcome defined as abstinence at one year follow-up. Relapsed patients displayed slightly better initial neuropsychological functioning compared to abstainers, although this effect was not significant when these measures were controlled for age and education. These findings and the clinical implications of neuropsychological assessment in alcoholic populations is discussed.     

Addressing heavy drinking in smoking cessation treatment: a randomized clinical trial

Heavy alcohol use frequently co-occurs with cigarette smoking and may impede smoking cessation. This clinical trial examined whether smoking cessation treatment that incorporates brief alcohol intervention can improve smoking cessation outcomes (7-day verified point prevalence abstinence) and reduce drinks consumed per week. Heavy drinkers seeking smoking cessation treatment were assigned by urn randomization to receive, along with 8 weeks of nicotine replacement therapy, either a 4-session standard smoking cessation treatment (ST, n = 119) or standard treatment of equal intensity that incorporated brief alcohol intervention (ST-BI, n = 117). Across follow-ups over 26 weeks, participants in ST-BI reported approximately 20% fewer drinks per week (p < .027) and greater smoking abstinence (adjusted odds ratio = 1.56; 95% confidence interval = 1.01, 2.43) than did those in ST; however, effects on smoking were primarily evident at 2 weeks after quit date and were essentially absent by 16 weeks. The effect of ST-BI on smoking outcome was most robust among moderately heavy drinkers compared with that on very heavy drinkers. Integrating brief alcohol intervention into smoking cessation treatment appears feasible, but further development is needed to yield lasting effects on smoking.     

Motivational enhancement for 12-step involvement among patients undergoing alcohol detoxification

Forty-eight patients undergoing inpatient detoxification for alcohol dependence were assigned to either brief advice (BA) to attend Alcoholics Anonymous or a motivational enhancement for 12-step involvement (ME-12) intervention that focused on increasing involvement in 12-step self-help groups. Attendance at 12-step groups did not differ significantly by treatment condition over 6 months of follow-up, nor did drinking outcomes. There was a significant interaction between 12-step experience and treatment condition, indicating that ME-12 was associated with relatively better alcohol outcomes at the low ends of 12-step experience, whereas BA was associated with relatively better outcomes at the high ends of 12-step experience. Results indicate that among patients undergoing alcohol detoxification, ME-12 may be beneficial only for those who have little experience with 12-step groups.     

Neuropsychiatric effects of cocaine use disorders

Individuals who use cocaine report a variety of neuropsychiatric symptoms that are yet to be adequately targeted with treatment modalities. To address this problem requires an understanding of these symptoms and their neurobiological origins. Our paper reviewed the existing data on the neuropsychiatic implications of cocaine. We conducted a Medline search from 1984-2004 using terms, such as "cocaine", "cocaine addiction", "cocaine abuse", "cocaine neuropsychiatry" and "dual diagnosis". The search produced additional reference materials that were used in this review, although we focused on data that have likely clinical implications. The literature evidence suggested that, whereas acute cocaine overdose is potentially fatal, the ingestion of mild-to-moderate doses could result in fatal or nonfatal neuropsychiatric events. Also, chronic cocaine use may be associated with deficits in neurocognition, brain perfusion and brain activation patterns. Some of these deficits were unresolved with periods of abstinence ranging from 3-200 days. Taken together, these studies suggest the need for further investigations to fully characterize the neurobiological substrates of cocaine use disorders (CUDs) with the future possibility of more efficient treatment modalities.