Reinforcement-based outpatient treatment for opiate and cocaine abusers

A reinforcement-based intensive outpatient treatment was delivered to 37 recently detoxified, inner city, heroin and/or cocaine abusers who did not want methadone treatment. Attendance was scheduled and urine collected daily for the first 2 weeks, four times weekly for the next 2 weeks, and then thrice weekly for the final 8 weeks. As attendance incentives, patients received transportation assistance (bus tokens), and $28-$30 per week in vouchers to be spent on activities/items chosen and agreed upon with their counselor. As abstinence incentives, patients received weekend supported recreational activities, lunches, $42-$45 per week in vouchers, and rent or utilities payment ($150 over 4 weeks). Total potential earnings was $1,435 per patient; actual mean earnings was $583. Forty-three percent (n=16) completed 10 or more weeks of treatment. These 16 long-stay patients submitted 92% (SD=19) opiate- and cocaine-negative urines during their enrollment compared with 56% (SD=42) drug-negative urines submitted by 21 drop-outs, F(1,35)=9.99, p=0.003. Overall, 32% of clients became employed during their treatment episode; 94% of long-stay patients were employed at the end of their treatment episode. Patients who were drug-positive at intake were highly likely to drop out. Treatment outcomes compare favorably with those reported in the literature for outpatient nonmethadone treatment of opiate and cocaine abusers. Continued evaluation of this new treatment appears warranted.     

Reinforcement-based intensive outpatient treatment for inner city opiate abusers: a short-term evaluation

We evaluated 3-month outcomes for reinforcement-based intensive outpatient treatment (RBT), a new relapse prevention behavior therapy for inner city opiate abusers. The therapy provides abstinence-contingent partial support of housing, food and recreational activities, abstinence-contingent access to social skills and job finding group therapy and non-contingent individual counseling, all in the context of a day treatment program. Heroin abusers (n = 52), contacted at a 3-day detoxification unit, were randomly assigned to RBT (n = 28) or referred to community treatment resources (n = 24) after a staff escort from the detoxification unit. For RBT patients, treatment began on the day of discharge; 61% received partial rent support in a recovery house based on the need for drug-free housing; the remainder were eligible for partial support of utility payments where they lived. Abstinence-based contingencies were in effect for 1 month with three times per week counseling available for an additional 2 months. One month after detoxification, 61% of RBT versus 17% of referral patients were enrolled in outpatient treatment (P < 0.01); RBT patients were significantly less likely than controls to have returned to any drug use; and 50% of RBT versus 21% of controls reported 30 days of abstinence from heroin and cocaine with confirmatory negative urine (P < 0.05). RBT patients had significantly lower scores on the Beck Depression Inventory at 1 month (M = 9.0 versus 17.6 for controls; P < 0.05) and showed evidence of less alcohol use and higher rates of employment. These results establish the short-term efficacy for RBT and support continued development and evaluation of this new outpatient behavioral treatment.     

Voucher reinforcement for heroin and cocaine abstinence in an outpatient drug-free program

This study examined an abstinence-contingent voucher incentive program in opiate-dependent clients enrolled in outpatient drug-free (nonmethadone) treatment. Study participants were referred from local detoxification programs and randomly assigned to voucher (n = 29) or no-voucher (n = 23) conditions. Both groups received intensive cognitive-behavioral counseling; those in the voucher condition could earn up to $1,087.50 over 3 months for submitting urines negative for both opiates and cocaine. Voucher versus no-voucher groups did not differ significantly on mean days retained in treatment (35.9 vs. 39.3 days), mean number of opiate- and cocaine-negative urines submitted (8.3 vs. 6.2), longest duration of continuous abstinence (16.8 vs. 12.1 days), or percentage of participants abstinent for 4 weeks (20.7% voucher vs. 9% no voucher). Possible reasons for negative findings are discussed. Findings suggest that voucher programs must be better tailored to the clinical population and behavioral targets being addressed.     

The effect of persistence of cocaine use on 12-month outcomes for the treatment of heroin dependence

AIMS: To determine the effects of cocaine use across the study period on outcomes of treatment for heroin dependence 12 months post-treatment entry. DESIGN: Longitudinal cohort (12 months). Interviews were conducted at baseline, 3 and 12 months. SETTING: Sydney, Australia. PARTICIPANTS: Four hundred ninety-five heroin users recruited for the Australian Treatment Outcome Study and re-interviewed at 12-month follow-up. FINDINGS: Cocaine was widely used among treatment entrants in NSW, with almost all having a lifetime history of cocaine use and almost half having used in the month preceding baseline. While there was an overall decline in cocaine use across the study period, individual use patterns varied widely. Approximately half of the cohort did not report cocaine use at any data point, with the remainder reporting having used at one (29%), two (12%), or at all three (5%) points. Cocaine use across the study period was an independent predictor of most major treatment outcomes, with more cocaine use points predicting poorer outcome. Persistent cocaine use predicted a higher prevalence of homelessness, heroin use, daily injecting, needle sharing and injection-related health problems at 12 months as well as more extensive recent polydrug use. CONCLUSIONS: Cocaine use was common among individuals seeking treatment for primary heroin dependence in NSW. Any cocaine use over the study period was associated with poorer outcomes in virtually all areas. Persistent cocaine use over the study period, however, appeared particularly detrimental. Cocaine use among clients should evidently be a cause for concern amongst treatment providers and may warrant being specifically targeted during treatment.     

A 12-month prospective comparison of court-diverted with self-referred heroin users

Forty-seven heroin users referred by the Drug and Alcohol Court Assessment Programme (DACAP) were compared with 45 self-referred heroin users at 12 months post-presentation. Data at presentation indicated distinct subpopulations were generated by each referral source. Differences were recorded in age, heroin use, marital status, educational level, employment history and age of onset of anti-social behaviour. The DACAP scheme exerted an earlier health intervention effect in a sample experiencing dysfunction in other areas, principally legally and socially. Prospective data demonstrated that both samples reported significant reductions in the proportion using heroin. Differences between samples evident at presentation were expressed prospectively, in rates of employment, incarceration and involvement in methadone maintenance programmes. The limitations of diverting clientele from the legal system to the treatment system is discussed in light of these results.     

Leadership, burnout, and job satisfaction in outpatient drug-free treatment programs

Counselors are a critical component of substance abuse treatment programming, but their working experiences are not yet well understood. As treatment improvement efforts focus increasingly on these individuals, their perceptions of program leadership, emotional burnout, and job satisfaction and related attitudes take on greater significance. This study explores counselor views and the impact of organizational context using data from a nationwide set of 94 outpatient drug-free treatment programs in a hierarchical linear model analysis. Results show counselors hold generally positive opinions of program director leadership and job satisfaction and have low levels of burnout, but they also have important variations in their ratings. Higher counselor caseloads were related to poorer ratings, and leadership behaviors predicted both satisfaction and burnout. These findings add further evidence that treatment providers should also address the workplace environment for staff as part of quality improvement efforts.     

Psychosocial treatments for cocaine abuse 12-month treatment outcomes

The 12-month posttreatment outcome results for a randomized clinical trial that tested the effectiveness of various combinations of 4-month psychosocial treatment interventions are reported for 184 clients who used cocaine. Clients primarily used crack (93 %), and the majority were African American (95%). Overall, clients exhibited substantial pre-post treatment gains: reduced regular cocaine use, reduced other drug use, reduced regular alcohol use, and reduced involvement in illegal activities. Logistic regression models produced significant odds ratios showing that those who used cocaine regularly during the year after treatment were more likely to have attended fewer treatment sessions, to be female, to be less educated, to have been regular cocaine users prior to treatment, and to have spent fewer days incarcerated during the 12-months after treatment. It was concluded that treatment positively impacted posttreatment gains, and it was suggested that selective tailoring of additional treatment services may produce additional treatment gains.     

Family and client characteristics as predictors of outpatient treatment outcome for adolescent drug abusers

Adolescent drug abuse clients (N = 176) and their mothers, in six different outpatient drug-free programs, were assessed at admission and at follow-up, 15 months after initiation of treatment. Family therapy sessions were offered in all six programs in addition to individual and group counseling. The pretreatment assessment procedures, and thus also the variables analyzed for prediction of treatment outcome, emphasized family measures (including the Family Environment Scale, the Family Adaptability and Cohesion Scale, the Parent-Adolescent Communication Inventory, and other information about the family and the parents).Multiple regression analysis determined which of three demographic variables and 39 other independent pretreatment predictor variables had a significant relationship with each of the six outcome criteria (dependent variables). Four of these outcome criteria were based on client information, and two were based on information provided by the mother.The more positively the family's functioning and relationships were described by the client at pretreatment, the more client improvement was reported by either client or mother at follow-up. Eleven of the 12 predictor variables that were found to be significantly related to any of the treatment outcome criteria were measures, at pretreatment, either of the client's perceptions of family functioning, or of his or her relationship with parents, particularly with the mother. These findings show the power of the family factors as indicators of prognosis.The predictor variable that was found to have the largest number of significant relationships, predicting three of the six outcome criteria, was the “family independence” dimension of the FES (i.e., “The extent to which family members are encouraged to be assertive, self-sufficient”). It appears that the FES instrument may be quite effective for predicting improvement in the behavior of adolescent drug-abusing clients.     

The effect of treatment completion and length of stay on employment and crime in outpatient drug-free treatment

Length of stay in treatment has been found to be a significant predictor of positive post-treatment outcomes, such as decreases in unemployment and crime. However, length of stay may be an incomplete predictor of successful treatment. Surprisingly, few studies have examined whether completing treatment in addition to length of stay is an important factor in explaining positive treatment outcomes. The objective of our study is to examine the effect that treatment completion and length of stay have on post-treatment employment and crime for patients in outpatient drug-free treatment, the largest treatment modality in the United States. We use conditional logit and multiple regression models with program-level indicator variables (fixed effects) to estimate the effect of treatment completion and length of stay on employment and crime controlling for drug use severity, previous treatment history, and other patient demographics. Data are from the National Treatment Improvement Evaluation Study and include 986 adults enrolled in outpatient drug-free programs across the United States. We find that treatment completion and length of stay are significantly related to post-treatment employment. Holding length of stay constant, the occurrence of employment at follow-up among patients who complete their planned treatment is almost 2 times that of patients who do not complete treatment. However, treatment completion did not have a statistically significant effect on the probability of post-treatment crime. Although our results are mixed, these findings suggest that greater attention should be placed on evaluating the importance of both length of stay and treatment completion in treatment outcome studies.     

Manualized treatment for substance abusers with personality disorders: Dual focus schema therapy

The presence of an untreated personality disorder may be associated with worse compliance and outcome in substance abuse treatment. Therapeutic attention to the symptoms of personality disorder may reduce the severity of substance abuse and other Axis I symptoms which potentially contribute to relapse. A 24-week manual-guided individual cognitive-behavioral therapy approach has been developed that integrates relapse prevention with targeted intervention for early maladaptive schemas (enduring negative beliefs about oneself, others, and events) and coping styles. This Dual Focus Schema Therapy is being compared to 12-Step Drug Counseling for opioid-dependent individuals with personality disorders in an ongoing study funded by the National Institute on Drug Abuse. This article reviews Young’s (1994) schema-focused theory and approach and summarizes the treatment manual, which integrates relapse prevention for substance abuse.     

丁丙诺啡维持治疗海洛因依赖119例疗效观察

目的：观察丁丙诺啡维持治疗海洛因依赖的疗效,为进一步推广提供依据。方法：119例海洛因依赖者采用丁丙诺啡舌下片维持治疗（BMT）,维持治疗期间进行不良反应监测和生命质量量表评定。结果：119例海洛因依赖者1个月、6个月、12个月的维持率分别为42例（35．3%）、36例（30．2%）、34例（28．6%）。维持治疗期间不良反应轻,无肝肾功能损害。维持治疗前后,患者生命质量评分比较差异有统计学意义（P〈0．05）。结论：丁丙诺啡维持治疗能够显著改善海洛因依赖者的生命质量,不良反应轻,有助于提高脱毒后的操守率,值得推广应用。     

Improvement in psychological functioning among drug abusers: inpatient treatment compared to outpatient methadone maintenance

A total of 68 opiate and cocaine abusers, receiving hospital-based, multimodal treatment for drug abuse in a 14 to 21-day program, and 47 patients newly admitted to methadone maintenance were compared on changes in psychological functioning, using a pretreatment-posttreatment design. Psychological changes were assessed by the Adjective Checklist, measuring the construct of "need". Inpatient treatment resulting in abstinence was associated with positive, meaningful, and significant changes in need pattern that were internally consistent. An equivalent amount of time on methadone maintenance outpatient treatment produced no improvement in psychological functioning, except that these patients evidenced increased dependency needs. Implications are discussed.     

Guidelines for allocating outpatient alcohol abusers to levels of care: Predictive validity

The purpose of this study was to assess the predictive validity of guidelines for allocating outpatients with an alcohol-use disorder to different levels of care in routine alcohol outpatient treatment facilities. It was hypothesized that patients matched to the recommended level of care would have (a) better outcomes than patients treated at a less intensive level of care, and (b) outcomes equivalent to patients treated at a more intensive level of care. Patients at two Dutch substance-abuse treatment centers who completed intake and were allocated at either a brief or standard outpatient treatment (n=471) were followed prospectively to determine differential outcomes for those who were and were not treated at the recommended level of car. The former patients were allocated according to an algorithm based on their treatment history, addiction severity, psychiatric impairment and social stability at baseline. 52.9% of the original sample was successfully contacted for follow-up 11 months after intake. Outcome was measured in terms of self-reported alcohol use 30 days prior to follow up and changes in number of excessive and nonexcessive drinking days between intake and follow up. Only 21% of the patients were matched to the level of care according to the guidelines. Patients allocated to the recommended level of care did not have better outcomes than those treated at a less intensive level of care, but they had outcomes comparable to patients treated at a more intensive level of care. The a priori allocation guidelines were followed for only a minority of the patients, and using them did not improve treatment outcome. Further work is needed to improve the content of the treatment allocation guidelines.     

Attempted suicide among heroin users: 12-month outcomes from the Australian Treatment Outcome Study (ATOS)

A cohort of 495 heroin users, recruited for the Australian Treatment Outcome Study (ATOS), were re-interviewed at 12 months regarding suicide attempts over the follow-up period. The proportion who had attempted suicide in the 12 months since baseline was not significantly different from that reported in the 12 months preceding ATOS enrolment (12.2% versus 9.1%), and attempted suicide did not decline significantly in any of the index treatment groups. Among males, there was no significant reduction in attempted suicide (8.7% versus 8.1%). Among females, however, the proportion reporting an attempt declined significantly from 19.7 to 9.8%. Of those who reported suicidal ideation at baseline, 22.8% made an attempt over the follow-up period, as did 19.0% of those who had major depression. Large, and significant, declines in suicidal ideation (23.1% versus 6.9%) and major depression (25.5% versus 10.9%) occurred over the study period. Independent predictors of a suicide attempt over the follow-up period were: social isolation, having made an attempt in the preceding 12 months, suicidal ideation at baseline, a greater number of treatment episodes and higher levels of baseline polydrug use.     

Buprenorphine: an alternative to methadone for heroin dependence treatment.

Eighty-five heroin addicts who were unwilling to receive methadone maintenance or enter therapeutic communities were assessed, single-blind, for the lowest sublingual dose of buprenorphine that blocked heroin craving (8.0 mg max). All doses were administered daily under observation. After maintenance for 4 to 12 weeks, abstinent subjects (confirmed by urine drug screens) entered a double-blind discontinuation trial and were randomly assigned to receive dose reductions (10% twice weekly for 5 weeks to zero dose, then placebo for 2 weeks) or a stable dose for 7 weeks. Subjects were terminated from discontinuation if heroin was used or they had increased craving/symptoms. Subjects completed the trial if they did not use heroin and had no increase in craving/symptoms. A wide dose range (1.5-8.0 mg/day) was effective in reducing heroin craving and use. Of 73 subjects who received buprenorphine for 4 to 52 weeks, 40 had no prior treatment, despite high levels (mean $/day heroin = 70.5 +/- 94.7) and many years (mean years = 10.7 +/- 8.6) of dependence. Subjects who received dose reductions developed abstinence symptoms, low energy most commonly, associated with drug-seeking behavior. Discontinuation trial outcome (n = 51) shows a highly significant difference between 29 subjects who received dose reductions (28 terminated, 1 completed) and 22 subjects who received no dose reductions (3 terminated; 19 completed) (chi-square = 36.08; p less than .00001). The findings suggest that buprenorphine could be an important medication for reducing demand for heroin by many heroin addicts who remain outside the present health-care system.(ABSTRACT TRUNCATED AT 250 WORDS)     

阳泉市3年海洛因非法使用情况研究

目的了解阳泉市海洛因滥用情况,并探讨了相应的措施。方法统计2003年1月-2005年12月期间由于海洛因的非法使用而被阳泉市公安局禁毒处拘留、并强制戒毒3个月~6个月的犯罪人员的案宗,内容包括海洛因非法使用者的年龄、性别、职业、文化程度。用EXCEL对数据进行统计分析并进行t检验。结果阳泉市海洛因非法使用以男性为主体,占83.3%。平均年龄(29±6)岁。20~29岁与30~39岁年龄段为其好发年龄。多为初中文化程度,达91.4%。多为无业人员,达到91.7%。复吸总人数占总样本人数的13.4%。女性复吸人员平均年龄小于总样本女性平均年龄。结论阳泉市海洛因非法使用以中青年男性、低学历、无业者为主。女性复吸低龄化。禁毒工作重在预防。     

Changes in smoking status among substance abusers: baseline characteristics and abstinence from alcohol and drugs at 12-month follow-up

The impact of change in smoking status on 12-month substance abuse (SA) treatment outcomes was examined among an HMO population seeking SA treatment. Of the 749 participants who entered the study at baseline, 649 (86.9%) were retained at the 12-month follow-up. At treatment entry, 395 participants were smokers and 254 were nonsmokers. At 12-month follow-up, 13% of the 395 baseline smokers reported quitting smoking and 12% of the 254 baseline nonsmokers reported starting/relapsing to smoking. Those who quit smoking were less likely to be diagnosed as alcohol dependent compared to those that remained smokers. Those who started/resumed smoking were more likely to be diagnosed as both alcohol and drug dependent at treatment entry compared to all other groups. Total days abstinent from alcohol and illicit drugs was greatest for individuals who quit smoking (adjusted M=310.6) or who were nonsmokers (adjusted M=294.7) and lowest for those who started/resumed smoking (adjusted M=246.6) or remained smokers (adjusted M=258.2), even after controlling for demographic (i.e. age, income), psychosocial (ASI psychiatric severity), and other treatment characteristics (length of treatment stay, prescribed bupropion) that were associated with days abstinent at 12 months. Self-initiated smoking cessation does not appear to be detrimental to SA treatment outcomes, and may be beneficial. Starting/resuming smoking after entering SA treatment may be a clinical marker for individuals at greater risk of relapse. Future studies may want to measure the smoking status of all participants at all time points in order to include this higher-risk group of substance using smokers.     

A 12-month controlled trial of methadone medical maintenance integrated into an adaptive treatment model

Methadone medical maintenance (MMM) reduces the reporting schedule for stable and well-functioning methadone maintenance patients to once a month, with counseling provided by medical staff. We report on the 12-month outcomes of 92 highly stable methadone maintenance patients randomly assigned to one of three study conditions: routine care, MMM at the methadone maintenance program, and MMM at a physician's office. Methadone medical maintenance patients received a 28-day supply of methadone, whereas routine care patients received five or six take-home methadone doses each week. All patients performed a medication recall once a month and submitted two urine samples each month. An adaptive stepped-care system of treatment intensification was used for patients who failed recall or who had drug-positive urine specimens. Seventy-seven patients completed the 12-month study period. Dropout was caused primarily by problems with handling methadone and disliking the recall frequency. There were low rates of drug use or failed medication recall. Treatment satisfaction was high in all groups, but the MMM patients initiated more new employment or family/social activities than did routine care patients over the study period. The stepped-care approach was well tolerated and matched patients to an appropriate step of service within a continuum of treatment intensity.     

233例静脉注射海洛因滥用者HIV感染情况分析

目的：了解静脉注射海洛因滥用者HIV感染情况及高危行为与HIV感染率的关系。方法：对北京市公安局强制隔离戒毒所2006年10月-2007年10月收治的233例静脉注射海洛因滥用者进行HIV血清抗体检测,采用自行设计的“药物滥用情况调查问卷”和“高危性行为调查问卷”进行问卷调查。结果：被调查对象男性居多（124例占61．7％）,平均年龄32．9a±s8．7a（最小年龄19a,最大年龄51a）,以无业者（占50．8％）和私营／个体劳动者（占15．6％）为主,有13例（占5．6%）抗-HIV阳性。该人群平均吸毒时间5．0a±s3．4a,平均吸食剂量0．37g±s0．49g,滥用场所主要集中在自己家中（87．6％）。使用的注射器主要来自药店／百货店（占79．4％）,37．9％共用过注射器。有8-3％除配偶以外有4个以上性伴,有8．6％患有各种性病。结论：静脉注射海洛因滥用者是HIV感染的高危人群,静脉注射毒品、共用注射器、不安全性行为是感染HIV的主要途径,应对该人群实施有效的干预措施,增强自觉规避HIV感染高危行为的意识,从而有利于遏制HIV／AIDS在该群体中的蔓延。