Predicting Treatment Retention among Cocaine Users

Few studies have addressed treatment retention among cocaine-using samples. The current study develops and tests a model of treatment retention at the individual level, employing data from 110 cocaine users who initiated outpatient treatment. The model includes measures of extent of drug involvement, social isolation and support, motivation, and demographic characteristics. Logistic regression is used to fit a final model, which includes measures of the following: living alone, use of multiple substances prior to treatment, length of cocaine use, and external motivation. Treatment implications and directions for further research are discussed     

Client Demographics and Outcome in Outpatient Cocaine Treatment

A number of studies have begun to investigate the characteristics of cocaine abusers who are admitted to outpatient cocaine treatment programs. One study has published success rates for such treatment. A review of this literature indicates that much of what is known is based on clinical experience with what may be nonrepresentative samples of upper-middle socioeconomic status Caucasians. More systematic study and more representative samples are needed; the current study attempts to address these issues by sampling 81 clients admitted to a comprehensive outpatient cocaine program in a public agency, assessing demographics and treatment success. The results indicate that this sample is indeed different from those in most recent studies in race, marital status, income, employment, and other demographic variables. For example, the sample in this study included higher percentages of clients who were non-Caucasians, single, blue-collar or unemployed, and had relatively lower annual incomes. Fewer demographic variables than expected correlated with treatment success. Among factors that did correlate with such measures of treatment outcome as continuing in treatment (vs dropping out), percent of sessions attended, and alcohol- and drug-free were educational level, length of abstinence from cocaine prior to beginning treatment, number of previous treatments, secondary substance currently used, and quality of current living situation. Retention in treatment is similar to other published data but indicates that cocaine abusers are indeed difficult to engage and keep in treatment long enough to make a significant impact on their drug use.     

Use of Dopamine Agonist Pergolide in Outpatient Treatment of Cocaine Dependence

The dopamine agonist pergolide was evaluated in the treatment of 42 men who manifested cocaine dependence in a single-blind, 4-week-long placebo-controlled study, during 1998–1999 in São Paulo, Brazil. The patients were randomly assigned to two groups: the first group received pergolide (0.05–0.2 mg per day) and the second group received placebo (one to four tablets per day). Urine toxicology screens were obtained. The groups were compared in terms of depressive symptoms, “craving,” use of cocaine, side effects of medications, results of urine tests, and retention in treatment. At 3 months' follow-up, the participants were reassessed. No differences were found between the two groups.     

The Effect of an Orientation-to-Treatment Group on the Retention of Alcoholics in Outpatient Treatment

Seventy-five poor inner city alcoholics were exposed to a 1/2-hour videotape orienting them to treatment. When compared to a similar group that did not see the videotape, the orientation group attended more clinic sessions in the following month. A greater percentage of them made more than 10 visits, were still active after the month, and went on to inpatient rehabilitation. The orientation group is an effective, cost efficient way of increasing patient follow through with treatment.     

The Impact of an Outpatient Program for Women with Substance Use-Related Disorders on Retention

Meeting the needs of women manifesting substance-use disorders is a goal in developing treatment programs for this population. As retention in treatment is positively related to treatment outcome, the length of stay in outpatient treatment of alcohol- and other drug-dependent women in Brazil was compared between two programs. Data were analyzed from 181 women entering a Mixed-Gender Program from 1986 to 1996 and from 80 women entering a Women-Only Program from 1997 to 1998. A greater 3-month retention rate was observed in the Women-Only as opposed to the Mixed-Gender Program. Moreover, the impact was more significant among the alcohol-dependent women. This finding suggests that the heterogeneity of women with substance-use disorders has to be taken into account when developing appropriate treatment strategies.     

Increasing Retention of African-American Women on Welfare in Outpatient Substance User Treatment Using Low-Magnitude Incentives

Contingency management (CM) has been found to be effective in increasing treatment retention in various outpatient substance user treatment populations; however, the costs of established CM protocols often exceed the financial resources of community-based, nonprofit treatment programs. The results of the present study provide initial evidence that a low-magnitude contingency management protocol can be effective in increasing both treatment attendance and completion rates in a sample of 54 urban, African-American, substance-using women on welfare, without creating undue financial or logistical burden on the treatment agency. The study's limitations and future research are noted.     

Drinking Goals and Their Association With Treatment Retention and Treatment Outcomes Among Clients in Outpatient Alcohol Treatment

Background: Few studies have compared characteristics of clients entering alcohol treatment who differ in their drinking goal preferences or have investigated the relevance of drinking goals as a predictor of treatment outcomes. Objectives: To investigate associations between baseline drinking goal preferences and client characteristics as well as treatment retention and outcomes among clients in outpatient alcohol treatment. Methods: Secondary data analyses on a longitudinal multicenter study investigating the effectiveness of outpatient alcohol treatment in Switzerland among 805 clients. Assessments were conducted at treatment admission, discharge, and at 6- and 12-month follow ups. At-risk drinking was assessed through the alcohol use disorders identification test. Treatment retention was defined as regular discharge with or without transition into another institution. Results: Clients aiming to abstain from drinking were more likely to be in retreatment, to be assigned to treatment by a health institution, to have no at-risk alcohol use, and to be already alcohol abstinent at the time of admission relative to clients who aimed to control their drinking. Clients without at-risk alcohol use at admission showed higher treatment retention when aiming for controlled drinking than for abstinence, while there was no difference in treatment retention among clients with at-risk use. Clients with at-risk use at admission were more likely to reach not-at-risk alcohol use status when aiming for alcohol abstinence than for controlled drinking. Conclusions: Drinking goals are associated with variables of alcohol use and treatment assignment. They have different effects on treatment retention and treatment outcomes according to alcohol use at the time of admission.     

Comparative Cocaine Abuse Treatment Strategies:

The current investigation explores the clinical utility in providing a series of enhanced clinical services to a sample of 303 cocaine-abusing clients (primarily crack smokers) relative to a standard group therapy treatment program. In addition to examining the comparative impact of six varying psychosocial treatment approaches for cocaine abuse on client retention and treatment exposure rates, an additional emphasis has been to examine the ability of fixed and dynamic client variables in predicting client outcome in this regard. No fixed (e.g., sex, income, marital status, income level, or employment status) or dynamic (e.g., recent alcohol use, antisocial personality disorder diagnoses, or motivational variables) client characteristics were useful in predicting client client retention or treatment exposure rates. Program characteristics, however, or the frequency, intensity, and/or type of treatment services offered, were related to client retention and treatment exposure. Treatment exposure and retention were significantly enhanced by providing clients with more frequent and intensive group therapy, or by adding individual treatment services to a standard group therapy treatment regimen. With a population such as cocaine abusers, who typically have an extremely high treatment dropout rate, an obvious strategy is to focus efforts on engaging and retaining clients in treatment, and maximizing levels of treatment exposure. The current findings suffest that one successful approach towards enhancing psychosocial treatments for cocaine abuse is to increase the frequency, intensity, and/or types of treatment services offered.     

Measuring Outcome in the Treatment of Cocaine Abuse:

THe Halikas-Crosby Drug Impairment Rating Scale for Cocaine (HAL DIRS-C) is designed to measure the advers impact of cocaine use upon life functioning over the previous week. The HAL DIRS-C demonstrated excellent split-half and interrater reliability. Internal consistency of the HAL DIRS-C was shown to be high. All items correlated significantly with total score and loaded on a single factor. The HAL DIRS-C correlated significantly with self-reported cocaine use, craving for cocaine, and independent ratings of the severity of addiction. The HAL DIRS-C was found to be sensitive to clinical change across weekly administrations. The scale is brief, east to administer, and both interviewer and client-friendly. our results suggest that the HAL DIRS-C may be useful as a standardized measure of improvement or outcome in clinical research involving the treatment of cocaine abuse.     

Desipramine, amantadine, or fluoxetine in buprenorphine-maintained cocaine users

The clinical efficacy of promising cocaine anti-craving medications was examined in combination with buprenorphine. Twenty-one opioid-dependent cocaine abusers were enrolled in a double-blind, 12-week trial in which they received on a daily basis buprenorphine (8 mg, s.l.) plus either desipramine (150 mg, p.o.), amantadine (300 mg, p.o.), or fluoxetine (60 mg, p.o.). Urine samples and self-reported drug use were obtained 1–3 times/week. The order of greatest patient retention across the 12 weeks was desipramine (83.3%) > amantadine (66.7%) > fluoxetine (20.0%). The desipramine and amantadine groups appeared to have greater increases in opioid- and cocaine-free urines than the fluoxetine group. These results suggest that desipramine and amantadine may facilitate greater opioid and cocaine abstinence than fluoxetine.     

Development of Fc-Fused Cocaine Hydrolase for Cocaine Addiction Treatment: Catalytic and Pharmacokinetic Properties

Cocaine abuse is a worldwide public health and social problem without a US Food and Drug Administration (FDA)-approved medication. Accelerating cocaine metabolism that produces biologically inactive metabolites by administration of an efficient cocaine hydrolase (CocH) has been recognized as a promising strategy for cocaine abuse treatment. However, the therapeutic effects of CocH are limited by its short biological half-life (e.g., 8 h or shorter in rats). In this study, we designed and prepared a set of Fc-fusion proteins constructed by fusing Fc(M3) with CocH3 at the N-terminus of CocH3. A linker between the two protein domains was optimized to improve both the biological half-life and catalytic activity against cocaine. It has been concluded that Fc(M3)-G₆S-CocH3 not only has fully retained the catalytic efficiency of CocH3 against cocaine but also has the longest biological half-life (e.g., ～?136 h in rats) among all of the long-acting CocHs identified so far. A single dose (0.2 mg/kg, IV) of Fc(M3)-G₆S-CocH3 was able to significantly attenuate 15 mg/kg cocaine-induced hyperactivity for at least 11 days (268 h) after the Fc(M3)-G₆S-CocH3 administration.     

Effects of Phendimetrazine Treatment on Cocaine vs Food Choice and Extended-Access Cocaine Consumption in Rhesus Monkeys

There is currently no Food and Drug Administration-approved pharmacotherapy for cocaine addiction. Monoamine releasers such as d-amphetamine constitute one class of candidate medications, but clinical use and acceptance are hindered by their own high-abuse liability. Phendimetrazine (PDM) is a schedule III anorectic agent that functions as both a low-potency monoamine-uptake inhibitor and as a prodrug for the monoamine-releaser phenmetrazine (PM), and it may serve as a clinically available, effective, and safer alternative to d-amphetamine. This study determined efficacy of chronic PDM to reduce cocaine self-administration by rhesus monkeys (N=4) using a novel procedure that featured both daily assessments of cocaine vs food choice (to assess medication efficacy to reallocate behavior away from cocaine choice and toward choice of an alternative reinforcer) and 20 h/day cocaine access (to allow high-cocaine intake). Continuous 21-day treatment with ramping PDM doses (days 1–7: 0.32 mg/kg/h; days 8–21: 1.0 mg/kg/h) reduced cocaine choices, increased food choices, and nearly eliminated extended-access cocaine self-administration without affecting body weight. There was a trend for plasma PDM and PM levels to correlate with efficacy to decrease cocaine choice such that the monkey with the highest plasma PDM and PM levels also demonstrated the greatest reductions in cocaine choice. These results support further consideration of PDM as a candidate anti-cocaine addiction pharmacotherapy. Moreover, PDM may represent a novel pharmacotherapeutic approach for cocaine addiction because it may simultaneously function as both a monoamine-uptake inhibitor (via the parent drug PDM) and as a monoamine releaser (via the active metabolite PM).     

Randomized Comparison of Intensive Outpatient vs. Individual Therapy for Cocaine Abusers

Abstract

One of the fastest growing approaches to treating cocaine addiction is intensive outpatient treatment (INT). Nevertheless, there have been no previously reported controlled clinical trials comparing this approach to the more traditional (IND) or individual plus group (IND-GRP). This early report of the results of a clinical trial comparing these three approaches indicated that patients who remained in treatment and completed a twelve-week course of care demonstrated significant improvements in drug use and psychological functioning. However, INT, IND, and IND-GRP did not differ on any of the assessments made during treatment or at treatment completion. The results underscored the importance of remaining in a course of care in order to effect behavioral change. A next step would involve a systematic comparison of those persons who do best in each modality in an effort to define the variables which could help match a patient to a treatment in which he/she is most likely to remain.     

Health Profiles of Clients in Substance Abuse Treatment: A Comparison of Clients Dependent on Alcohol or Cocaine With Those Concurrently Dependent

The purpose of this study was to assess whether, among clients receiving substance abuse treatment (n = 616), those dependent on alcohol or cocaine differed significantly from those concurrently dependent on both drugs in terms of physical, mental, social, and economic harms as well as substance use behaviors. Methods: Clients from five substance abuse treatment agencies presenting with a primary problem of cocaine or alcohol were classified into three groups as dependent on: (1) alcohol alone, (2) cocaine alone, or (3) both cocaine and alcohol (i.e. concurrent dependence). Participants completed a self-administered questionnaire that included details of their drug and alcohol use, physical health, mental health, social health, economic health, and demographic characteristics. Results: The concurrent group drank similar amounts of alcohol as those in the alcohol group and used similar amounts of cocaine as the cocaine group. The alcohol group had significantly (p < .05) poorer health profiles than the concurrent group across most variables of the four health domains. An exception was significantly more accidental injuries (p < .05) in the alcohol group. In both bivariate and multivariate analyses, the concurrent group had significantly (p < .05) more accidental injuries, violence, and overdoses than the cocaine group. As well, the concurrent group had significantly (p < .05) higher scores on the anxiety and sexual compulsion scales than the cocaine group, controlling for demographic variables. Conclusion: These findings can aid health care professionals to better respond to issues related to concurrent dependence of cocaine and alcohol.     

Mazindol Augmentation of Antipsychotic Treatment for Schizophrenic Patients with Comorbid Cocaine Abuse or Dependence

Abstract

Objectives: Cocaine abuse has a negative impact on the natural history of schizophrenia. There are no proven treatments for cocaine abuse in schizophrenia patients. The catecholamine reuptake inhibitor, mazindol, has been reported to reduce cocaine abuse in some studies. Here we report the results of a double-blind, randomized, placebo-controlled 6-week pilot study of mazindol augmentation of antipsychotic pharmacotherapy in patients diagnosed with comorbid schizophrenia and cocaine abuse or dependence.

Methods: Patients diagnosed with schizophrenia or schizoaffective disorder and cocaine abuse or dependence participated in group therapy focused on substance abuse issues and were randomly assigned to mazindol (1 mg tid, increased to 2 mg tid after 1 week) or matched placebo in addition to their current antipsychotic medication for 6 weeks.

Results: Twenty-four patients were included in the analysis, with 11 and 13 randomized to the mazindol and placebo groups, respectively. While safe and well-tolerated, mazindol was ineffective in reducing cocaine consumption, cocaine craving, and psychiatric symptoms.

Conclusions: These results do not support the efficacy of mazindol in decreasing cocaine craving, cocaine consumption, and psychiatric symptoms in schizophrenic and schizoaffective patients.     

Urine Toxicology Samples in Cocaine Treatment Trials

Abstract

Studies show that symptom-triggered dosing is best for treatment of alcohol withdrawal in patients on chemical dependence wards without other illness. On general medical hospital wards, withdrawal may be affected by comorbid medical illness. A clinical trial was undertaken to determine whether there is a difference between symptom-triggered (ST) and fixed-schedule (FS) dosing of lorazepam in patients hospitalized on general medical wards at a university medical center. One hundred eighty-three subjects were assessed by their nurses with the Revised Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale. Subjects in the ST arm received lorazepam doses based on CIWA-Ar score. Subjects in the FS arm received scheduled lorazepam with tapering over 4 days. Symptom-triggered dosing for alcohol withdrawal for general medicine inpatients results in less lorazepam given with similar reduction in CIWA-Ar scores for the first 2 days, but a higher proportion of protocol errors.     

Preclinical Assessment of Lisdexamfetamine as an Agonist Medication Candidate for Cocaine Addiction: Effects in Rhesus Monkeys Trained to Discriminate Cocaine or to Self-Administer Cocaine in a Cocaine Versus Food Choice Procedure

Background:

Chronic amphetamine treatment decreases cocaine consumption in preclinical and human laboratory studies and in clinical trials. Lisdexamfetamine is an amphetamine prodrug in which L-lysine is conjugated to the terminal nitrogen of d-amphetamine. Prodrugs may be advantageous relative to their active metabolites due to slower onsets and longer durations of action; however, lisdexamfetamine treatment’s efficacy in decreasing cocaine consumption is unknown.

Methods:

This study compared lisdexamfetamine and d-amphetamine effects in rhesus monkeys using two behavioral procedures: (1) a cocaine discrimination procedure (training dose = 0.32mg/kg cocaine, i.m.); and (2) a cocaine-versus-food choice self-administration procedure.

Results:

In the cocaine-discrimination procedure, lisdexamfetamine (0.32–3.2mg/kg, i.m.) substituted for cocaine with lower potency, slower onset, and longer duration of action than d-amphetamine (0.032–0.32mg/kg, i.m.). Consistent with the function of lisdexamfetamine as an inactive prodrug for amphetamine, the time course of lisdexamfetamine effects was related to d-amphetamine plasma levels by a counter-clockwise hysteresis loop. In the choice procedure, cocaine (0–0.1mg/kg/injection, i.v.) and food (1g banana-flavored pellets) were concurrently available, and cocaine maintained a dose-dependent increase in cocaine choice under baseline conditions. Treatment for 7 consecutive days with lisdexamfetamine (0.32–3.2mg/kg/day, i.m.) or d-amphetamine (0.032–0.1mg/kg/h, i.v.) produced similar dose-dependent rightward shifts in cocaine dose-effect curves and decreases in preference for 0.032mg/kg/injection cocaine.

Conclusions:

Lisdexamfetamine has a slower onset and longer duration of action than amphetamine but retains amphetamine’s efficacy to reduce the choice of cocaine in rhesus monkeys. These results support further consideration of lisdexamfetamine as an agonist-based medication candidate for cocaine addiction.     

对儿科门诊治疗呼吸道疾病方案的研究

目的分析秋季儿科门诊治疗呼吸道疾病的治疗方案是否具合理性。方法抽取连续12 d的门诊儿科处方进行所用药物的统计学处理,以判断所选药间的相关性。结果治疗上感组与治疗支气管炎组所选药物间无显著性差异(P>0.05);抗菌治疗的同时也抗病毒治疗。结论二者的治疗方案相同,但不具合理性。