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Int J Epidemiol 1999 Jun;28(3):514-20

The validity of drug users' self-reports in a non-treatment setting: prevalence and predictors of incorrect reporting methadone treatment modalities.

Langendam MW, van Haastrecht HJ, van Ameijden EJ

Municipal Health Service, Division of Public Health and Environment, Amsterdam, The Netherlands. mlangendam@gggd.amsterdam.nl

BACKGROUND: Epidemiological studies among drug users are often based on retrospective self-reports. However, among others, memory failure, being under the influence of drugs, psychopathology, misunderstanding of questions and socially desirable answering may generate inaccurate reporting. METHODS: This study validated self-reported current (methadone dosage) and medium-term (main location of methadone dispensing and frequency of methadone program attendance over the previous 4-6 months) aspects of methadone treatment in the Amsterdam AIDS cohort study among drug users, using data of the Central Methadone Register. In addition to descriptive measures, logistic regression analysis was used (adjusted for intra-individual correlation) to identify subgroups with incorrect reporting. Data collected at 4406 visits of 505 cohort participants were analyzed. RESULTS: Current methadone dosage was accurately reported (unweighted kappa [kappa]: 0.94, weighted kappa [kappa W]: 0.97). A low methadone dosage, short duration of school education and depressive or euphoric mood during the interview were significant and independent predictors of incorrect reporting of methadone dosage. For main location of dispensing kappa was 0.82, for frequency of program attendance kappa was 0.53 and kappa W 0.87. There was a tendency to reporting the extreme answering categories. Infrequent program attendance was the only significant predictor of incorrectly reporting frequency of program attendance. CONCLUSIONS: Drug users are able to give valid self-reports in a setting where social desirability does not play an important role. The main reasons of incorrect reporting were impaired cognitive functioning, memory failure and misunderstanding of questions.

PMID: 10405858, UI: 99334330

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Addiction 1999 Feb;94(2):241-54

An experimental intervention with families of substance abusers: one-year follow-up of the focus on families project.

Catalano RF, Gainey RR, Fleming CB, Haggerty KP, Johnson NO

University of Washington, Seattle, USA.

AIMS: Children whose parents abuse drugs are exposed to numerous factors that increase the likelihood of future drug abuse. Despite this heightened risk, few experimental tests of prevention programs with this population have been reported. This article examines whether intensive family-focused interventions with methadone treated parents can reduce parents' drug use and prevent children's initiation of drug use. DESIGN: Parents were assigned randomly into intervention and control conditions and assessed at baseline, post-test, and 6 and 12 months following the intervention. Children were assessed at baseline, and 6- and 12-month follow-up points. SETTING: Two methadone clinics in Seattle, Washington. PARTICIPANTS: One hundred and forty-four methadone-treated parents, and their children (n = 178) ranging in age from 3 to 14 years old. INTERVENTION: The experimental intervention supplemented methadone treatment with 33 sessions of family training combined with 9 months of home-based case management. Families in the control condition received no supplemental services. MEASUREMENT: Parent measures included: relapse and problem-solving skills, self-report measures of family management practices, deviant peer networks, domestic conflict and drug use. Child measures included self-report measures of rules, family attachment, parental involvement, school attachment and misbehavior, negative peers, substance use and delinquency. FINDINGS: One year after the family skills training, results indicate significant positive changes among parents, especially in the areas of parent skills, parent drug use, deviant peers and family management. Few changes were noted in children's behavior or attitudes. CONCLUSIONS: Programs such as this may be an important adjunct to treatment programs, helping to strengthen family bonding and to reduce parents' drug use.

Publication Types: Clinical trial Randomized controlled trial

PMID: 10396792, UI: 99325114

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Addiction 1999 Feb;94(2):231-9

Comparison of methadone and slow-release morphine maintenance in pregnant addicts.

Fischer G, Jagsch R, Eder H, Gombas W, Etzersdorfer P, Schmidl-Mohl K, Schatten C, Weninger M, Aschauer HN

Department of General Psychiatry, University Hospital of Vienna, Austria. gabriele.fischer@akh-wien.ac.at

AIMS: To investigate whether the neonatal abstinence syndrome (NAS) is different in children born to women maintained on slow-release morphine, compared with those maintained on methadone, and to compare additional drug consumption in these groups of women. DESIGN, SETTING AND PARTICIPANTS: An open, randomized trial was conducted in an established clinic. Forty-eight pregnant women who presented to the clinic as opiate or polysubstance abusers were enrolled and maintained on either methadone (24 women) or slow-release morphine (24 women) up to and following delivery. The program included psychosocial therapy and support for their opiate-addicted partners. MEASUREMENTS: Standard urinalysis methods were used to measure consumption of cocaine and benzodiazepines during pregnancy. Injection sites were monitored to indicate additional opiate use. NAS was measured according to Finnegan score and the amount of phenobarbiturates prescribed to alleviate the symptoms. FINDINGS: No difference was found in the number of days that NAS was experienced by neonates born to methadone or morphine maintained mothers (mean = 16 and 21 days, respectively). All children were born healthy and no serious complications arose. Fewer benzodiazepines (p < 0.05) and fewer additional opiates (p < 0.05) were consumed by the morphine-maintained women compared with those who took methadone, but no difference was seen in cocaine consumption. Nicotine consumption was reduced significantly in both groups during pregnancy (p < 0.02). CONCLUSIONS: Both methadone and morphine are suitable maintenance agents for pregnant opiate addicts. Maintenance agents that result in a less prolonged NAS should be studied in further trials.

Publication Types: Clinical trial Randomized controlled trial

PMID: 10396791, UI: 99325113

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Eur Addict Res 1999 Mar;5(1):50-1

NIH consensus panel recommends expanding access to and improving methadone treatment programs for heroin addiction.

Publication Types: Consensus development conference Review

PMID: 10383234, UI: 99308398

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Drug Alcohol Depend 1999 May 3;54(3):207-18

Enhanced treatment outcomes for cocaine-using methadone patients.

Rosenblum A, Magura S, Palij M, Foote J, Handelsman L, Stimmel B

Institute for Treatment and Services Research, National Development and Research Institutes, Inc., New York, NY 10048, USA.

Cocaine dependent methadone patients were randomly assigned to 6 months of high intensity cognitive-behavioral therapy or low intensity therapy. A repeated measures ANOVA was conducted with patients stratified on severity of cocaine use at baseline. Both treatment groups showed significant and equivalent reductions in cocaine use during the post-treatment period. Completing either therapy and lower cocaine severity at baseline were associated with lower proportion of cocaine-positive urines across a 48-week post-treatment period. Examination of the treatment x cocaine severity interaction provided some evidence that high-severity patients improved more if exposed to high intensity treatment than to low intensity treatment. Positive outcomes for therapy completers relative to non-completers increased over time. The results are consistent with several clinical trials showing that: (1) participation in treatment is associated with reductions in cocaine use; and (2) the relationship between treatment intensity and outcome is not linear and may better be explained by an interaction between patient and treatment factors.

Publication Types: Clinical trial Randomized controlled trial

PMID: 10372794, UI: 99300009

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Subst Use Misuse 1999 Jun;34(8):1137-65

Gender differences at admission and follow-up in a sample of methadone maintenance clients.

Chatham LR, Hiller ML, Rowan-Szal GA, Joe GW, Simpson DD

Institute of Behavioral Research, Texas Christian University, Fort Worth 76129, USA. ibr@tcu.edu

Although one-third of clients enrolled in methadone treatment in the United States are female, few studies have looked at gender differences at admission and follow-up. Using interview data from 435 clients (31% female) collected at admission and approximately 1 year after discharge, females were found to have more dysfunctional families of origin and greater prior and current psychological and medical problems. Both genders improved following treatment, as evidenced by reduced illicit drug, tobacco, and alcohol use, criminal involvement, and HIV/AIDS-risky behaviors. Females were more likely to seek further help for both drug misuse and psychological problems subsequent to discharge.

PMID: 10359226, UI: 99285721

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J Subst Abuse Treat 1999 Jun;16(4):329-35

Revisiting the effectiveness of methadone treatment on crime reductions in the 1990s.

Rothbard A, Alterman A, Rutherford M, Liu F, Zelinski S, McKay J

Department of Psychiatry, Medical Center, University of Pennsylvania, Philadelphia, USA. abr@cmhpsr.upenn.edu

This study examines the relationship between methadone treatment and the criminal activity of 126 individuals participating in treatment during the early 1990s. The primary question addressed is to what extent is methadone maintenance treatment associated with reductions in crime? Although prior studies in the 1970s and early 1980s showed significant decreases in crime for individuals in treatment programs, criteria for remaining in this treatment modality have changed in recent years, particularly with the advent of acquired immune deficiency syndrome and the need to reduce intravenous drug use. A pre-post study design is employed spanning a 6-year time period of subject recruitment and follow-up (1987-1993). Uniform administrative records on arrests are used for the analysis. A multiple regression model is employed to explain the variance in the number of arrests 2 years following program admission, with prior criminal history, prior and current drug treatment, and current cocaine use employed as explanatory variables. Results indicate that treatment retention has only a slight, though significant, effect on reducing criminal activity during treatment. Two other factors that appear to increase arrest activity are the use of cocaine and prior criminal history. The fact that arrests did not decrease during a treatment period of 18 months on average requires more investigation in light of the increase in cocaine use in this population.

Publication Types: Clinical trial

PMID: 10349606, UI: 99279223

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Alcohol Alcohol 1999 Mar-Apr;34(2):223-30

Craving for alcohol: findings from the clinic and the laboratory.

Sinha R, O'Malley SS

Department of Psychiatry, Yale University School of Medicine, New Haven, CT 06511, USA.

This paper presents a review of the current status of empirical research in the area of alcohol craving. After an introduction on the origins of the construct of craving, we first present clinical studies that have examined craving as a hallmark symptom of alcohol dependence and demonstrated its sensitivity as an outcome measure in assessing change in pharmacotherapy trials of alcohol dependence. There is also discussion regarding new multifactorial self-report instruments of alcohol craving with good reliability and predictive validity, that may be sensitive to detecting alcohol craving and assessing change in craving as it relates to relapse during treatment. Next, we examine the experimental paradigms that have been used to induce alcohol craving in the laboratory. Further, the methodological issues affecting laboratory-based paradigms are presented, while also elucidating the potential use of effective laboratory-based craving induction paradigms, both in clinical studies as well as in laboratory studies that examine the brain mechanisms associated with the concept of craving. Finally, directions for future research on craving in the laboratory and the clinic are presented in the context of developing more effective treatments for different phases of recovery from alcohol dependence.

Publication Types: Review Review literature

PMID: 10344782, UI: 99274579

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Br J Gen Pract 1999 Mar;49(440):236-7

Methadone treatment practices.

Morse GR

Publication Types: Letter

PMID: 10343434, UI: 99274902

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J Addict Dis 1999;18(2):5-21

Access to narcotic addiction treatment and medical care: prospects for the expansion of methadone maintenance treatment.

Lewis DC

Brown University Center for Alcohol and Addiction Studies, Providence, RI 02912, USA.

Methadone maintenance treatment (MMT) for opioid addiction is safe and effective but underutilized because of inaccessibility, under-financing and the stigma generally attached to maintenance therapies. In addition, cumbersome regulation of methadone prescription and treatment impedes the delivery of care and retards expansion of methadone maintenance into office practice settings. Exaggeration of the problem of methadone diversion further hinders development of MMT. Despite obstacles, methadone maintenance has been successfully expanded and extended into primary care settings abroad. Initial trials in the U.S. have shown that methadone maintenance in physician office-based settings yields positive results with some advantages over care in large methadone clinics. Alternatives to methadone, such as buprenorphine, are also being explored in primary care settings. With implementation of the NIH Consensus Statement on Effective Medical Treatment of Heroin Addiction, including training of primary care physicians, methadone maintenance treatment could reach many more patients, achieve higher success rates, and substantially reduce the deleterious effects of opioid addiction in the U.S.

Publication Types: Review Review, tutorial

Comments: Comment in: J Addict Dis 1999 ;18(2):1-4

PMID: 10334372, UI: 99265541

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J Addict Dis 1999;18(2):1-4

Heroin addiction and methadone maintenance: when will we ever learn.

Stimmel B

Publication Types: Comment Editorial

Comments: Comment on: J Addict Dis 1999 ;18(2):5-21

PMID: 10334371, UI: 99265540

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MCN Am J Matern Child Nurs 1999 May-Jun;24(3):138-44

Comparison of a rocking bed and standard bed for decreasing withdrawal symptoms in drug-exposed infants.

D'Apolito K

Vanderbilt University, School of Nursing, Nashville, Tennessee 37240-1104, USA. Karen.Dapolito@McMail.Vanderbilt.Edu

PURPOSE: To determine if the use of a mechanical rocking bed with maternal intrauterine sounds would decrease symptoms of withdrawal and promote neurobehavioral adaptation in drug-affected infants. METHODS: This was a repeated measures experimental design, with infants randomized to a standard bed or a rocking bed. The sample consisted of 14 full-term infants who were prenatally exposed to methadone plus other illicit drugs. RESULTS: Infants receiving the rocking bed therapy experienced a significant increase in withdrawal symptoms and sleep deprivation and displayed suboptimal neurobehavioral functioning on day 7 of life. IMPLICATIONS: The results suggest that the use of a mechanical rocking bed may be overstimulating for these fragile infants during the acute period of withdrawal.

Publication Types: Clinical trial Randomized controlled trial

PMID: 10326317, UI: 99258167

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Br J Gen Pract 1999 Feb;49(439):146

A decade of caring for drug users.

Byrne A

Publication Types: Letter

PMID: 10326275, UI: 99258125

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Br J Gen Pract 1999 Feb;49(439):145

Methadone prescribing in general practice.

Lindsay JI

Publication Types: Letter

PMID: 10326274, UI: 99258124

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Eur J Pharmacol 1999 Mar 26;369(3):357-64

Induction of antibodies to methadone during methadone maintenance treatment of heroin addicts and its possible clinical implications.

Gamaleya N, Dmitrieva I, Borg S, Ericcson N

Laboratory of Immunochemistry, Scientific Research Institute of Addiction, Moscow, GSP, Russian Federation.

By means of two different types of enzyme-linked immunosorbent assay (ELISA) techniques, antibodies to methadone were detected in blood plasma of heroin addicts on methadone maintenance treatment. In 11-15% of cases immunoglobulin (Ig) M antibodies were detected, while IgG antibodies were observed in 33-40%. At least two types of antibodies to methadone were induced-antibodies with high affinity to methadone and low-affinity antibodies more specific for morphine than for methadone. The methadone antibody-positive group of patients had a significantly higher plasma methadone concentration--440 ng/ml, than the antibody-negative group--250 ng/ml (P < 0.005) despite almost the same mean therapeutic doses of methadone. Of patients with all types of antibodies to methadone 52% were human immunodeficiency virus (HIV)-positive, whereas in the group without antibodies, HIV-positive reactions were observed in 10.5% only (P < 0.002). Alternatively, 87.5% of HIV-positive patients had antibodies to methadone, a fact which should be taken into consideration during methadone dose adjustment.

PMID: 10225375, UI: 99239881

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Am J Public Health 1999 May;89(5):662-5

Methadone dosing, heroin affordability, and the severity of addiction.

Bach PB, Lantos J

Robert Wood Johnson Clinical Scholars Program, Department of Medicine, University of Chicago, Ill., USA. bachp@biosta.mskcc.org

OBJECTIVES: This study sought to track changes in US heroin prices from 1988 to 1995 and to determine whether changes in the affordability of heroin were associated with changes in the use of heroin by users seeking methadone treatment, as indexed by methadone dose levels. METHODS: Data on the price of heroin were from the Drug Enforcement Administration; data on methadone doses were from surveys conducted in 1988, 1990, and 1995 of 100 methadone maintenance centers. Multivariable models that controlled for time and city effects were used to ascertain whether clinics in cities where heroin was less expensive had patients receiving higher doses of methadone, which would suggest that these patients had relatively higher physiological levels of opiate addiction owing to increased heroin use. RESULTS: The amount of pure heroin contained in a $100 (US) purchase has increased on average 3-fold between 1988 and 1995. The average dose of methadone in clinics was positively associated with the affordability of local heroin (P < .01). CONCLUSIONS: When heroin prices fall, heroin addicts require more methadone (a heroin substitute) to stabilize their addiction--evidence that they are consuming more heroin.

PMID: 10224975, UI: 99241486

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Drug Alcohol Depend 1999 Apr 1;54(2):127-35

Improvement in naltrexone treatment compliance with contingency management.

Preston KL, Silverman K, Umbricht A, DeJesus A, Montoya ID, Schuster CR

NIDA Intramural Research Program, NIH Addiction Research Centre, Baltimore, MD 21224, USA.

The efficacy of a voucher-based incentive program for improving adherence to outpatient, thrice weekly naltrexone maintenance was tested in a three group, randomized, 12-week clinical trial. Voucher incentives were given as follows: contingent group (n = 19) for each consecutive naltrexone dose ingested; non-contingent group (n = 19) on unpredictable schedule independently of taking naltrexone; no-voucher group (n = 20) none. Vouchers were exchangeable for goods and services. The contingent group had significantly longer treatment retention and ingested significantly more doses of naltrexone (consecutive and total) than either control group. Voucher incentives can significantly increase adherence to naltrexone maintenance in recently detoxified opioid dependent individuals.

Publication Types: Clinical trial Randomized controlled trial

PMID: 10217552, UI: 99231904

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Clin Perinatol 1999 Mar;26(1):173-83

The methadone-maintained pregnancy.

Kandall SR, Doberczak TM, Jantunen M, Stein J

Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York, USA.

Methadone treatment during pregnancy offers overwhelming advantages compared with the less acceptable option of medical detoxification or the unacceptably dangerous option of leaving heroin-addicted women dependent on street drugs. General agreement exists that pregnancy offers a unique opportunity to bring women into medical, obstetric, and drug treatment. Methadone maintenance in the setting of comprehensive service provision during pregnancy reduces maternal morbidity and mortality and promotes fetal stability and growth. With an accumulated experience of over 25 years, methadone maintenance has been shown to be an invaluable and often an essential ingredient in bettering the health of women during pregnancy, in improving the outcomes of those pregnancies, and in offering opiate-addicted women a chance to improve both their lives and the lives of their families.

Publication Types: Review Review, tutorial

PMID: 10214548, UI: 99231163

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Pharmacotherapy 1999 Apr;19(4):471-2

Methadone withdrawal when starting an antiretroviral regimen including nevirapine.

Heelon MW, Meade LB

Department of Pharmacy, Baystate Medical Center, Springfield, Massachusetts, USA.

Antiretrovirals from three drug classes, nucleoside analogs, nonnucleoside analogs, and protease inhibitors, can be combined to achieve viral suppression. The nonnucleoside analog nevirapine is an inducer of cytochrome P450 3A4 liver metabolism and has interactions with protease inhibitors and oral contraceptives. Methadone has two roles in human immunodeficiency viral infection: pain management and treatment of opioid abuse. A drug-drug interaction may result in decreased methadone blood levels when administered with nevirapine. A patient experienced methadone withdrawal symptoms when combining these agents.

PMID: 10212021, UI: 99227003

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Am Fam Physician 1999 Apr 1;59(7):1753-4

Prevention of relapse in alcohol dependence.

Malerich JA Jr

Publication Types: Comment Letter

Comments: Comment on: Am Fam Physician 1998 Jul;58(1):139-46

PMID: 10208698, UI: 99223397

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JAMA 1999 Apr 14;281(14):1318-25

Pharmacological treatment of alcohol dependence: a review of the evidence.

Garbutt JC, West SL, Carey TS, Lohr KN, Crews FT

Department of Psychiatry, Bowles Center for Alcohol Studies, School of Medicine, University of North Carolina at Chapel Hill, USA.

CONTEXT: Alcoholism affects approximately 10% of Americans at some time in their lives. Treatment consists of psychosocial interventions, pharmacological interventions, or both, but which drugs are most effective at enhancing abstinence and preventing relapse has not been systematically reviewed. OBJECTIVE: To evaluate the efficacy of 5 categories of drugs used to treat alcohol dependence--disulfiram, the opioid antagonists naltrexone and nalmefene, acamprosate, various serotonergic agents (including selective serotonergic reuptake inhibitors), and lithium. DATA SOURCES: Reports of randomized controlled trials, nonrandomized trials, and other study designs in English, French, and German identified from multiple searches of MEDLINE, EMBASE, and specialized databases; hand searching bibliographies of review articles; searches for unpublished literature; and discussions with investigators in the field. STUDY SELECTION: We included all studies on alcohol-dependent human subjects aged 18 years or older from all inpatient and outpatient settings between 1966 and December 1997 that met our inclusion criteria. DATA EXTRACTION: We abstracted the following information: study design and blinding, diagnostic instrument and severity assessment, drug interventions and cointerventions, demographic and comorbidity details about patients, compliance, and numerous outcome measures (eg, relapse, return to drinking, drinking or nondrinking days, time to first drink, alcohol consumed per unit of time, craving). We graded quality of the individual articles (scale, 0-100) independently from the strength of evidence for each drug class (A, strong and consistent evidence of efficacy in studies of large size and/or high quality; B, mixed evidence of efficacy; C, evidence of lack of efficacy; and I, insufficient evidence). DATA SYNTHESIS: Of 375 articles evaluated, we abstracted and analyzed data from 41 studies and 11 follow-up or subgroup studies. Naltrexone (grade A) reduces the risk of relapse to heavy drinking and the frequency of drinking compared with placebo but does not substantially enhance abstinence, ie, avoidance of any alcohol consumption. Acamprosate (grade A, from large-scale studies in Europe) reduces drinking frequency, although its effects on enhancing abstinence or reducing time to first drink are less clear. Controlled studies of disulfiram (grade B) reveal a mixed outcome pattern--some evidence that drinking frequency is reduced but minimal evidence to support improved continuous abstinence rates. The limited data on serotonergic agents were not very promising (grade I), although most studies were confounded by high rates of comorbid mood disorders. Lithium lacks efficacy (grade C) in the treatment of primary alcohol dependence. CONCLUSIONS: Recent reports documenting that naltrexone and acamprosate are more effective than placebo in the treatment of alcoholism justify clinical interest in use of these medications for alcohol-dependent patients. Use of disulfiram is widespread but less clearly supported by the clinical trial evidence; however, targeted studies on supervised administration of disulfiram may be warranted. Use of existing serotonergic agents or lithium for patients with primary alcohol dependence does not appear to be supported by the efficacy data available at this time; these medications may still have a positive effect in patients with coexisting psychiatric disorders.

Publication Types: Meta-analysis

PMID: 10208148, UI: 99222829

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Lancet 1999 Mar 27;353(9158):1101

Methadone and quality of life.

Torrens M, Domingo-Salvany A, Alonso J, Castillo C, San L

Publication Types: Comment Letter

Comments: Comment on: Lancet 1999 Jan 16;353(9148):221-6

PMID: 10199379, UI: 99213471

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J Am Acad Child Adolesc Psychiatry 1999 Apr;38(4):355-6

Methadone-induced hallucinations.

Katz LY

Publication Types: Letter

PMID: 10199103, UI: 99215316

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Nurs Times 1999 Mar 3-9;95(9):38-40

Dutch courage.

Sheldon T

PMID: 10196989, UI: 99212738

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Alcohol Clin Exp Res 1999 Mar;23(3):502-8

Variable dose naltrexone-induced hypothalamic-pituitary-adrenal stimulation in abstinent alcoholics: a preliminary study.

Farren CK, O'Malley S, Grebski G, Maniar S, Porter M, Kreek MJ

Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut 06511, USA. conor.farren@yale.edu

Opiate antagonists have been found to stimulate the hypothalamic-pituitary-adrenal axis. However, despite established usefulness in the management of alcoholism, systematic, oral dose-titrated natrexone-induced hypothalamic-pituitary-adrenal stimulation has never been studied in alcoholics. Six patients (5 males, 1 female) with DSM-IV alcohol dependence, who were at least 4 weeks abstinent from any alcohol [mean 55 days (+/-SE 7.5)], were given four challenges of oral naltrexone (0, 25, 50, and 100 mg) in a randomized order at least 3 days apart, after an overnight fast. Naltrexone was administered at 9 AM; serum ACTH, cortisol, and prolactin were measured at time 0 and at 9 time points over the next 4 hr. Subjects also filled out a side effect questionnaire and an alcohol urge questionnaire. Physiological measurements of blood pressure and pulse rate were taken at the same time points. Repeated-measures ANOVA of the changes in serum ACTHs over time revealed a significant effect of drug (placebo vs. any dose of naltrexone) (p < 0.05). Post-hoc analysis revealed a significant difference between placebo and the 25 mg dose (p < 0.01), the 50 mg dose (p < 0.01), but no significance between the placebo and the 100 mg dose (p = 0.1). A repeated-measures ANOVA of the changes in serum cortisols over time revealed a significant effect of drug (p < 0.01). Post-hoc analysis revealed a significant difference between placebo and the 25 mg dose (p < 0.01), between placebo and the 50 mg dose (p < 0.05), and placebo and the 100 mg dose (p < 0.01). There was a significant between dose difference in pulse rate changes over baseline (p < 0.01), and post-hoc analysis revealed a significant diminution in pulse rate at the 100 mg dose relative to placebo (p < 0.001), and to the other doses. There were no significant differences in reported side effects, alcohol urge questionnaire scores, or in other physiological measurements between doses. These data suggest a significant rise in ACTH and cortisol in response to naltrexone in alcoholics compared with placebo, with no differences between 25 mg, 50 mg, and 100 mg doses, and a significant diminution in pulse rate responses at the 100 mg dose.

Publication Types: Clinical trial

PMID: 10195825, UI: 99210200

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J Subst Abuse Treat 1999 Apr;16(3):221-8

Methadone maintenance. Does dose determine differences in outcome?

Blaney T, Craig RJ

Illinois School of Professional Psychology, Chicago, USA.

We conducted a naturalistic study to determine if higher methadone doses were more effective than lower doses in the outcome variables of illicit drug use, treatment retention, missed medication days, and ratings of patient progress by assigned counselor among 265 patients in a Department of Veterans Affairs Methadone Maintenance Treatment Program. Results indicated no significant differences on any outcome variable by methadone dose. However, we found a significant effect by assigned therapist. Some therapists achieved better outcome results on these same variables compared to other assigned therapists independent of dose level. We conclude that, while methadone maintenance dose is an important variable, researchers need to pay more attention to the interpersonal aspects of methadone maintenance treatment.

PMID: 10194739, UI: 99210643

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Med Health R I 1999 Mar;82(3):91-4

Treatment considerations in the opioid dependent patient.

Wartenberg AA

Faulkner Hospital, Boston, Massachusetts 02130, USA. AW447@aol.com

Publication Types: Review Review, tutorial

PMID: 10193138, UI: 99209218

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J Ment Health Adm 1995 Summer;22(3):214-25

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

Phillips CD, Hubbard RL, Dunteman G, Fountain DL, Czechowicz D, Cooper JR

Research Triangle Institute, Research Triangle Park, NC 27709, USA.

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

PMID: 10172390, UI: 95370723

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Drug Alcohol Depend 1999 Mar 1;54(1):69-81

Contingent reinforcement sustains post-detoxification abstinence from multiple drugs: a preliminary study with methadone patients.

Chutuape MA, Silverman K, Stitzer M

Behavioral Pharmacology Research Unit, Johns Hopkins University, School of Medicine, Baltimore, MD 21224, USA. chutuape@jhmi.edu

This study examined the efficacy of a urinalysis-based contingency management program for preventing relapse to abused drugs following a brief residential detoxification. Fourteen methadone maintenance patients who were chronic benzodiazepine users were enrolled in a 7-day inpatient benzodiazepine detoxification and randomly assigned to receive Contingency Management (N = 7) or Standard Care (N = 7) therapy upon return to outpatient methadone treatment. In the Contingency Management condition, a methadone take-home dose or a US $25 voucher (patient's choice) could be earned for each urine sample submitted on a Monday, Wednesday or Friday that was free of opiates, cocaine and benzodiazepines. Data analysis and interpretation focused on within-group post-hoc differences due to group differences on employment and legal status, potentially confounding baseline variables. Repeated measures analysis of variance showed that Contingency Management patients submitted significantly more drug-free urine samples during the intervention compared to pre-detoxification (p < 0.01), whereas no significance changes were observed from pre- to post-detoxification in the Standard Care patients. Employment and legal status of patients may have facilitated response to contingency management procedures, but did not prevent relapse when contingency management procedures were withdrawn. Overall, these preliminary results suggest that abstinence-based contingency management is a promising strategy for preventing relapse to multiple drugs of abuse in a subset of methadone maintenance patients when abstinence has been initiated through brief inpatient treatment.

Publication Types: Clinical trial Randomized controlled trial

PMID: 10101619, UI: 99201835

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Drug Alcohol Depend 1999 Mar 1;54(1):11-8

Methadone-maintenance outcomes for Hispanic and African-American men and women.

Mulvaney FD, Brown LS Jr, Alterman AI, Sage RE, Cnaan A, Cacciola J, Rutherford M

Center for Studies of Addiction, University of Pennsylvania School of Medicine, Philadelphia 19104, USA.

Six-month methadone-maintenance response and outcome were examined for African-American and Hispanic men and women in a large urban sample. A consistent pattern of improvement was indicated for both races and genders on the addiction severity index (ASI). There were virtually no statistically significant differences in ASI outcomes between Hispanics and African-Americans and men and women using conventional analysis of variance (ANOVA) procedures. Results from an additional equivalence analysis, however, indicated that baseline to 6-month changes for the different groups were generally not similar enough to consider them equivalent. Urine toxicologies obtained during the 6-month treatment period were also not statistically equivalent by race and gender. Evaluating outcomes by gender and race are discussed, as are the implications of using equivalence tests when examining group differences.

PMID: 10101613, UI: 99201829

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Bull N Y Acad Med 1995 Winter;72(2):359-70

Recent developments in maintenance prescribing and monitoring in the United Kingdom.

Brewer C

Stapleford Centre, Belgravia, London.

After a brief historical review of British drug legislation and public and governmental attitudes, this paper describes the wide range of policies and practices that have appeared since the explosion of illicit drug abuse in the 1960s. The spectrum goes from a reluctance to prescribe at all to maintenance on injectable opiates. Comparisons are made with differing attitudes to the availability of abortion in public health services. Compared with 5 years ago, about three times more methadone is being prescribed. There is a steady increase in prescriptions for injectable methadone but heroin maintenance is still rare. The "British System" permits great flexibility in the choice of opiates for maintenance. Some amphetamine-prescribing programs also exist. Hair analysis for drugs to monitor levels of both prescribed and unprescribed drugs is a welcome and promising alternative to undignified and often misleading urine tests.

PMID: 10101376, UI: 99201592

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Bull N Y Acad Med 1995 Winter;72(2):348-58

Methadone treatment by general practitioners in Amsterdam.

van Brussel G

Amsterdam City Health Department, The Netherlands.

In Amsterdam, a three-tiered program exists to deal with drug use and addiction. General practitioners form the backbone of the system, helping to deal with the majority of addicts, who are not criminals and many of whom desire to be free of addiction. Distinctions are made between drugs with "acceptable" and "unacceptable" risks, and between drug use and drug-related crime; patients who fall into the former categories are treated in a nonconfrontational, nonstigmatizing manner; such a system helps prevent the majority of patients from passing into unacceptable, criminalized categories. The overall program has demonstrated harm reduction both for patients and for the city of Amsterdam. PMID: 10101375, UI: 99201591

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Psychiatr Serv 1999 Mar;50(3):437

CSAT consensus panel supports expanded use of naltrexone for treatment of alcohol dependence. Center for Substance Abuse Treatment.

Publication Types: News

PMID: 10096661, UI: 99194325

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JAMA 1999 Mar 17;281(11):1000-5

Moderate- vs high-dose methadone in the treatment of opioid dependence: a randomized trial.

Strain EC, Bigelow GE, Liebson IA, Stitzer ML

Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA. ecsgss@aol.com

CONTEXT: Methadone hydrochloride treatment is the most common pharmacological intervention for opioid dependence, and recent interest has focused on expanding methadone treatment availability beyond traditional specially licensed clinics. However, despite recommendations regarding effective dosing of methadone, controlled clinical trials of higher-dose methadone have not been conducted. OBJECTIVE: To compare the relative clinical efficacy of moderate- vs high-dose methadone in the treatment of opioid dependence. DESIGN: A 40-week randomized, double-blind clinical trial starting in June 1992 and ending in October 1995. SETTING: Outpatient substance abuse treatment research clinic at the Johns Hopkins University Bayview Campus, Baltimore, Md. PARTICIPANTS: One hundred ninety-two eligible clinic patients. INTERVENTION: Daily oral methadone hydrochloride in the dose range of 40 to 50 mg (n = 97) or 80 to 100 mg (n = 95), with concurrent substance abuse counseling. MAIN OUTCOME MEASURES: Opioid-positive urinalysis results and retention in treatment. RESULTS: By intent-to-treat analysis through week 30 patients in the high-dose group had significantly lower rates of opioid-positive urine samples compared with patients in the moderate-dose group (53.0% [95% confidence interval [CI], 46.9%-59.2%] vs 61.9% [95% CI, 55.9%-68.0%]; P = .047. These differences persisted during withdrawal from methadone. Through day 210 no significant difference was evident between dose groups in treatment retention (high-dose group mean retention, 159 days; moderate-dose group mean retention, 157 days). Nineteen (33%) of 57 patients in the high-dose group and 11 (20%) of 54 patients in the moderate-dose group completed detoxification. CONCLUSIONS: Both moderate- and high-dose methadone treatment resulted in decreased illicit opioid use during methadone maintenance and detoxification. The high-dose group had significantly greater decreases in illicit opioid use.

Publication Types: Clinical trial Randomized controlled trial

PMID: 10086434, UI: 99184238

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Eur Addict Res 1999 Mar;5(1):36-42

Therapeutic drug monitoring for methadone: scanning the horizon.

Wolff K, Strang J

National Addiction Centre, Institute of Psychiatry, King's College, London, UK. k.wolff@iop.bpmf.ac.uk

The initial assessment and subsequent monitoring of compliance in methadone treatment programs are excessively reliant on the accuracy of self-report from opiate addicts themselves. Given the central position of methadone treatment in the therapeutic options currently available and with the increasing number of opiate addicts requiring treatment, improved methods of judging optimal methadone treatment are required. This paper explores the possible future options for assessing the adequacy of methadone prescribing from the analysis of methadone levels in urine, blood, hair and saliva. The particular promise of plasma therapeutic drug monitoring for methadone is explored, accompanied by an account of the state of the art at the time of writing.

Publication Types: Review Review, tutorial

PMID: 10085499, UI: 99187426

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Drug Alcohol Depend 1999 Feb 1;53(3):191-5

Continued heroin use during methadone treatment: relationships between frequency of use and reasons reported for heroin use.

Best D, Gossop M, Stewart D, Marsden J, Lehmann P, Strang J

National Addiction Centre, Denmark Hill, London, UK.

Seventy-seven (77%) of a group of 109 attenders at an out-patient drug treatment service reported that they had used heroin in the 90 days before interview, of whom 24 (31%) had used every day. Daily users were more likely to explain their use in terms of needing to curb withdrawals than were occasional heroin users. The latter group were more likely to report availability as a reason for use. From a clinical perspective, it is likely that those who use opportunistically are less likely to change their use as a function of clinical responses (e.g. higher methadone dose) than are those whose use is motivated by the attempt to curb withdrawal symptoms.

PMID: 10080044, UI: 99179780

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Am J Drug Alcohol Abuse 1999 Feb;25(1):67-80

The autonomy of mood disorders among cocaine-using methadone patients.

Rosenblum A, Fallon B, Magura S, Handelsman L, Foote J, Bernstein D

Institute for Treatment and Services Research, National Development and Research Institutes, Inc., New York, New York 10048, USA. andrew.rosenblum@ndri.org

This study uses an algorithm to determine whether patients dually diagnosed with a mood disorder and cocaine dependence have either (a) an autonomous mood disorder (onset of mood disorder prior to substance use disorder (SUD) or mood disorder symptoms persist during periods of abstinence or (b) a nonautonomous mood disorder (onset of SUD preceded mood disorder and mood disorder symptoms remit during periods of abstinence). The relationship among autonomy, patient characteristics, and treatment completion is examined. The sample included 67 methadone patients with a mood disorder (87% major depression, 13% bipolar) who were enrolling in a 6-month psychosocial treatment for cocaine use. Of these subjects, 27% were rated as having an autonomous mood disorder and 73% a nonautonomous mood disorder. Mean age was 37 years; 55% were female and 82% were Hispanic or African-American. All subjects had been stabilized on methadone (mean = 70 mg). During the 30 days prior to study intake, subjects with an autonomous mood disorder, compared to subjects with a nonautonomous mood disorder, reported fewer days using cocaine (12.5 versus 21.1) and fewer days drinking four or more drinks of alcohol (1.1 versus 6. 1). Treatment completion was associated with less cocaine use, autonomy, and African-American ethnicity. However, when these variables were controlled using logistic regression, only autonomous mood disorder and ethnicity predicted treatment completion. These results suggest that autonomy may be a useful construct to measure, and that subjects with nonautonomous mood disorders may need special efforts to ensure treatment retention.

Publication Types: Clinical trial Randomized controlled trial

PMID: 10078978, UI: 99176864

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J Toxicol Clin Toxicol 1999;37(1):43-50

Opiate detoxification under anaesthesia: no apparent benefit but suppression of thyroid hormones and risk of pulmonary and renal failure.

Pfab R, Hirtl C, Zilker T

Toxikologische Abteilung, Medizinische Klinik, Munchen, West Germany. rudi.pfab@t-online.de

INTRODUCTION: The new technique for opiate detoxification using anaesthesia and high, repetitive doses of opiate-antagonists claims to detoxify addicts without withdrawal symptoms within 24-48 hours. We studied the method with 12 opiate addicts (5 L-polamidone, 4 dihydrocodeine, 3 heroin), using general anaesthesia and the antagonists naloxone 0.5 mg/kg and naltrexone > 150 mg. Objective and subjective withdrawal symptoms were measured until urine was free of drugs and patients had no withdrawal symptoms. Thyroid hormones were measured before, during, and after the anaesthesia period. RESULTS: All patients had moderate to severe opiate withdrawal symptoms. No detoxification was finished within 48 hours. The dihydrocodeine subjects were compared with conventionally detoxified controls; no difference was seen. The method suppressed thyroid hormones TT3, TT4, and TSH. The study was terminated because of side effects: 1 pulmonary failure and 2 renal failures. All patients survived without sequelae. CONCLUSION: There is no obvious benefit from this method, whereas the risks are high.

Publication Types: Clinical trial

PMID: 10078159, UI: 99177885

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N Z Med J 1999 Jan 22;112(1080):12-3

Neonatal abstinence syndrome following abrupt cessation of breastfeeding.

Malpas TJ, Darlow BA

Christchurch Women's Hospital, Christchurch.

Neonatal abstinence syndrome is seen commonly in infants born to women on methadone maintenance. Many of these infants are breast-fed but few data are available on the distribution of methadone in breast milk, particularly for women receiving doses greater than 60 mg daily. We report two infants who appeared to develop neonatal abstinence syndrome, after abrupt discontinuation of breast-feeding by women receiving 70 mg and 130 mg of methadone. Women on methadone maintenance on high doses should be counselled to wean breast-feeding gradually.

PMID: 10073159, UI: 99172814

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Med J Aust 1999 Feb 1;170(3):104-9

Mortality associated with New South Wales methadone programs in 1994: lives lost and saved.

Caplehorn JR, Drummer OH

Department of Public Health and Community Medicine, University of Sydney, NSW. johnc@dph1.health.usyd.edu.au

OBJECTIVES: To estimate the effects of methadone programs in New South Wales on mortality. DESIGN AND CASES: Retrospective, cross-sectional study of all 1994 New South Wales coronial cases in which methadone was detected in postmortem specimens taken from the deceased. Cases were people we identified as patients in NSW methadone maintenance programs or those whose deaths involved methadone syrup diverted from maintenance programs. OUTCOME MEASURES: Relative risks of fatal, accidental drug toxicity in the first two weeks of treatment and later; the number of lives lost as a result of maintenance treatment; preadmission risks and the number of lives saved by maintenance programs, calculated from data from a previous study. RESULTS: There was very close agreement between this study's classifications and official pathology reports of accidental drug toxicity. The relative risk (RR) of fatal accidental drug toxicity for patients in the first two weeks of methadone maintenance was 6.7 times that of heroin addicts not in treatment (95% CI RR, 3.3-13.9) and 97.8 times that of patients who had been in maintenance more than two weeks (95% CI RR, 36.7-260.5). Despite 10 people dying from iatrogenic methadone toxicity and diverted methadone syrup being involved in 26 fatalities. In 1994, NSW maintenance programs are estimated to have saved 68 lives (adjusted 95% CI, 29-128). CONCLUSIONS: In 1994, untoward events associated with NSW methadone programs cost 36 lives in NSW. To reduce this mortality, doctors should carefully assess and closely monitor patients being admitted to methadone maintenance and limit the use of takeaway doses of methadone.

Comments: Comment in: Med J Aust 1999 Feb 1;170(3):100-1

PMID: 10065120, UI: 99164514

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Med J Aust 1999 Feb 1;170(3):100-1

Accidental drug toxicity associated with methadone maintenance treatment.

Ali RL, Quigley AJ

Publication Types: Comment Editorial

Comments: Comment on: Med J Aust 1999 Feb 1;170(3):104-9

PMID: 10065117, UI: 99164511

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Subst Use Misuse 1999 Jan;34(1):103-18

Previous participation in outpatient methadone program and residential treatment outcome: a research note from Hong Kong.

Cheung YW, Ch'ien JM

Department of Sociology, The Chinese University of Hong Kong, People's Republic of China.

Methadone maintenance programs are good examples of harm-reduction efforts because heroin addicts stabilized on methadone have been found to be able to reduce illicit drug use and criminality and improve their life condition, even though they have not achieved abstinence. While excluding the criterion of abstinence allows the harm-reduction approach to distinguish itself from traditional treatment, little research attention has been paid to the relationship between methadone programs and abstinence-oriented treatment programs. This research note reports some of the findings of a study of 77 former male clients of SARDA, a voluntary residential treatment agency in Hong Kong, pertaining to such a relationship. Findings suggest that a client's previous participation in the Outpatient Methadone Program of the Department of Health could facilitate successful outcome in his subsequent participation in SARDA's treatment program and help him to continue his drug-free status in the post-SARDA treatment period. Conceptual and policy implications of the findings are discussed. [Translations are provided in the International Abstracts Section of this issue.]

PMID: 10052393, UI: 99159758

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Alcohol Alcohol Suppl 1996 Mar;1:1-87

Consensus Conference on the Neuropharmacology of Alcohol Dependence and the Role of Pharmacotherapy in its Treatment. Amsterdam, The Netherlands, September 16-17, 1994.

Publication Types: Consensus development conference Overall Review

PMID: 10048886, UI: 99156038

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Nurse Pract 1999 Feb;24(2):104

Drug reduces alcohol craving.

Publication Types: News

PMID: 10048082, UI: 99157642

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Alcohol Clin Exp Res 1999 Jan;23(1):115-20

Contribution of carbohydrate deficient transferrin to gamma glutamyl transpeptidase in evaluating progress of patients in treatment for alcoholism.

Allen JP, Sillamaukee P, Anton R

U. S. National Institute on Alcohol Abuse and Alcoholism, Rockville, Maryland 20892, USA.

Eight previous investigations have suggested that conjoint consideration of findings on tests for gamma glutamyl transpeptidase (GGT) and carbohydrate deficient transferrin (CDT) substantially enhances sensitivity of screening for alcohol problems while minimally diminishing specificity. Using results from a large clinical trial, the current study evaluated the two tests singly and in combination as measures of three clinically important treatment outcome criteria: any drinking, at least one day of heavy drinking, and at least three consecutive days of heavy drinking during the past month. When scored by quartile, CDT is slightly better at screening for alcohol problems in males than GGT. However, CDT seems less accurate in females than GGT. Use of the two tests in consort moderately improves the individual test accuracy in predicting drinking status for both genders.

Publication Types: Clinical trial Multicenter study

PMID: 10029211, UI: 99151669

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J Subst Abuse Treat 1999 Mar;16(2):163-7

The effects of naltrexone on alcohol and cocaine use in dually addicted patients.

Oslin DW, Pettinati HM, Volpicelli JR, Wolf AL, Kampman KM, O'Brien CP

Department of Psychiatry, University of Pennsylvania, Philadelphia, USA. oslin@mail.med.upenn.edu

Concurrent dependence on cocaine and alcohol is common among patients seeking addiction treatment. This study was undertaken to explore the effectiveness of naltrexone (150 mg) as a potential treatment for patients who are alcohol and cocaine dependent. Of 15 subjects enrolled in the 12-week, open medication trial, 7 subjects did not complete the study. Relapse to clinically significant drinking occurred in 7 subjects (47%). There was a reduction in the average daily amount of alcohol consumed from pretreatment to treatment (p < .001) and the percentage of days engaged in drinking behavior (p < .001). Similarly, there was a reduction in the average weekly amount spent on cocaine from pretreatment to treatment (p = .001) and the percentage of days using cocaine (p < .001). This preliminary study suggests that naltrexone (150 mg) may be tolerable in patients dependent upon alcohol and cocaine and may be effective in reducing both cocaine and alcohol use. The results of this study provide a rationale for a double-blind placebo-controlled study of the efficacy of naltrexone in this difficult to treat but prevalent population.

Publication Types: Clinical trial

PMID: 10023615, UI: 99147696----------

J Subst Abuse Treat 1999 Mar;16(2):113-21

Methadone patients and alcohol abuse.

Ottomanelli G

A literature review was conducted on the excess use of alcohol by methadone patients. Although the rate of alcohol abuse among methadone patients was found to be high (compared to general population estimates), the rate was comparable to individuals who engaged in risk-taking behaviors and individuals under stress, such as college students and emergency room patients. Comparisons of rates for different samples was difficult because of the varying criteria used to define alcohol abuse and the absence of operational criteria applicable across different populations. Another source of difficulty was that some studies evaluated motivational variables (why the person drank) and found them to be more important predictors than sociodemographic variables (for example, history of drinking and social class). Contrary to the expectation that methadone patients who consumed excessive amounts of alcohol would require higher dosages of methadone, it was found that nonalcohol-abusing methadone patients requested the higher dosage levels. This finding, however, was subject to methodological confounds. The issue of whether the methadone patient who abused alcohol has a negative treatment outcome was a multifaceted question. The definition of treatment outcome for alcohol-abusing methadone patients determined whether the investigator concluded that there was a negative impact versus minimal impact.

Publication Types: Review Review, tutorial

PMID: 10023608, UI: 99147689

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J Subst Abuse Treat 1999 Mar;16(2):105-12

Medications for alcohol, illicit drug, and tobacco dependence. An update of research findings.

Litten RZ, Allen JP

National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD 20892-7003, USA.

Physiologic, behavioral, and social factors contribute to dependence on alcohol, nicotine, and other drugs. During the past decade substantial research has focused on identification/development of medications to assist in reducing urge to use these substances. This article describes these agents and reviews recent research findings on them.

Publication Types: Review Review, tutorial

PMID: 10023607, UI: 99147688

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Ann Oncol 1998 Dec;9(12):1257

Divergent illicit drug policies in Europe.

Publication Types: News

PMID: 10232889, UI: 99241732

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Addiction 1998 Sep;93(9):1433-4

Maternal use of heroin and methadone and infant birth weight.

MacQueen AR

Publication Types: Letter

PMID: 9926549, UI: 99125465

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AIDS Care 1998 Dec;10(6):735-49

Personal social networks and HIV status among women on methadone.

el-Bassel N, Cooper DK, Chen DR, Schilling RF

School of Social Work, Columbia University, New York, NY 10025, USA. NE5@columbia.edu

This objective of this study was to examine the association between a women's HIV status and specific (IDUs) characteristics of her social networks with respect to (1) number of injection drug users (2) number of drug partners and (3) number of HIV-positive contacts in her personal networks, after controlling for the respondent's demographic characteristics and drug use. Participants were recruited through posted announcements in three methadone clinics in Harlem, New York City. Individuals were considered eligible if they were enrolled as patients in one of the clinics for at least three months. A social network questionnaire modeled after the General Social Survey network section was developed by the investigators. Face-to-face interviews were conducted by trained interviewers and included demographics, drug use, self-reported HIV status of the woman and her network members, and the social network structures. Univariate analysis found that HIV-positive and HIV-negative women had different network profiles. HIV-positive women were more likely to associate with a higher number of current drug users, injection drug users, injection drug users who were HIV-positive, drug partners, drug partners who used injection drugs, and drug partners who were HIV-positive. Multivariate analysis indicated that HIV-positive respondents were more likely to associate with HIV-positive network members than their HIV-negative counterparts. The findings suggest that to better understand the spread of HIV among female drug users and to design more effective HIV/AIDS prevention programs, efforts should move beyond focusing on individual attributes to address the contextual dynamics of social networks.

PMID: 9924528, UI: 99123603

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Lancet 1999 Jan 16;353(9148):221-6

Role of maintenance treatment in opioid dependence.

Ward J, Hall W, Mattick RP

Division of Psychology, Australian National University, Canberra.

Methadone maintenance treatment (MMT) involves the daily administration of the oral opioid agonist methadone as a treatment for opioid dependence-a persistent disorder with a substantial risk of premature death. MMT improves health and reduces illicit heroin use, infectious-disease transmission, and overdose death. However, its effectiveness is compromised if low maintenance doses of methadone (<60 mg) are used and patients are pressured to become prematurely abstinent from methadone. Pregnancy and psychiatric comorbidity are not contraindications for MMT. As an alternative to MMT, other oral opioid agents (eg, naltrexone, buprenorphine) may increase patient choice and avoid some of the more unpleasant aspects of MMT. The public-health challenge for the future is to develop and continue to deliver safe and effective forms of opioid maintenance treatment to as many opioid-dependent individuals as can benefit from them.

Publication Types: Review Review, tutorial

Comments: Comment in: Lancet 1999 Mar 27;353(9158):1101

PMID: 9923893, UI: 99120768

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Lancet 1999 Jan 16;353(9148):213

New treatments for alcohol dependency better than old.

Bonn D

Publication Types: News

PMID: 9923889, UI: 99120764

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J Med Assoc Thai 1998 Dec;81(12):947-52

Methadone maintenance: results of treatment in heroin addict at Thanyarak Hospital (1990-1996).

Verachai V, Dechongkit S, Patarakorn A, Lukanapichonchut L

Thanyarak Hospital, Pathumthani, Thailand.

Methadone maintenance is a treatment program designed for chronic heroin addicted patients. The purpose is to make them maintain their productive function and adaptive social behavior. The retrospective descriptive study was done from 1990 to 1996. 195 cases joined the Methadone Maintenance Program (MMP) during this period. 188 cases were men and 7 cases were women. The average age was 31.9 +/- 7.2 yr. (19-49 yr. old). 105 cases were single and 90 cases were married. 155 cases were labourers (79.2%). 159 cases (81.5%) used more than 500 mg of heroin a day, it may be assumed that they spent 327 +/- 159 baht a day ($13 +/- 5). The duration of heroin usage before MMP was 8.7 +/- 5.4 yr. (4-25 yr.) In and out of the detoxification treatment program was 12.7 +/- 10.1 times (4-44 times). We found that 11 cases successfully decreased and then stopped the methadone. 32 cases were in the program for more than 1 year and also joined the program until the end of this study. This meant that 43 cases (22%) were successful in stopping their heroin addicted behavior. The average dose of methadone administration was 61.5 mg (40-80 mg mostly). The average time for the patients attending the program was 8.2 months (2-80 months). 38 cases who attended the program for more than 1 1/2 years were in the older-aged and married group. We found no difference in the previous heroin usage or methadone dose in these patients before they attended the MMP. The 32 cases which remained on MMP used mostly less than 40 mg of methadone a day. Two-thirds of the cases discontinued the program due to their positive urine test findings for heroin up to 8 times. Although the MMP was a good way to decrease the heroin addicted behavior, it's not a promising way to stop this problem.

PMID: 9916382, UI: 99114413

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Am J Psychiatry 1999 Jan;156(1):27-33

Day treatment versus enhanced standard methadone services for opioid-dependent patients: a comparison of clinical efficacy and cost.

Avants SK, Margolin A, Sindelar JL, Rounsaville BJ, Schottenfeld R, Stine S, Cooney NL, Rosenheck RA, Li SH, Kosten TR

Yale University School of Medicine, Conn, USA. kelly.avants@yale.edu

OBJECTIVE: This study examined the differential efficacy and relative costs of two intensities of adjunctive psychosocial services--a day treatment program and enhanced standard care--for the treatment of opioid-dependent patients maintained on methadone hydrochloride. METHOD: A 12-week randomized clinical trial with 6-month follow-up was conducted in a community-based methadone maintenance program. Of the 308 patients who met inclusion criteria, 291 began treatment (day treatment program: N=145; enhanced standard care: N=146), and 237 completed treatment (82% of those assigned to the day treatment program and 81% of those receiving enhanced standard care). Two hundred twenty of the patients participated in the 6-month follow-up (75% of those in the day treatment program and 73% of those in enhanced standard care provided a follow-up urine sample for screening). Both interventions were 12 weeks in duration, manual-guided, and provided by master's-level clinicians. The day treatment was an intensive, 25-hour-per-week program. The enhanced standard care was standard methadone maintenance plus a weekly skills training group and referral to on- and off-site services. Outcome measures included twice weekly urine toxicology screens, severity of addiction-related problems, prevalence of HIV risk behaviors, and program costs. RESULTS: Although the cost of the day treatment program was significantly higher, there was no significant difference in the two groups' use of either opiates or cocaine. Over the course of treatment, drug use, drug-related problems, and HIV risk behaviors decreased significantly for patients assigned to both treatment intensities. Improvements were maintained at follow-up. CONCLUSIONS: Providing an intensive day treatment program to unemployed, inner-city methadone patients was not cost-effective relative to a program of enhanced methadone maintenance services, which produced comparable outcomes at less than half the cost.

Publication Types: Clinical trial Randomized controlled trial

PMID: 9892294, UI: 99107312

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Aust N Z J Public Health 1998 Dec;22(7):771-6

Correlates of retention on the South Australian Methadone Program 1981-91.

Gaughwin M, Solomon P, Ali R

Drug and Alcohol Resource Unit, Royal Adelaide Hospital, South Australia.

OBJECTIVES: To investigate correlates of retention on the South Australian Methadone Program during 1981-91. DESIGN: Retrospective study of a nonstratified random sample of 229 HIV-negative clients who received methadone between January 1981 and June 1991. Data were collected from clinical records of the 229 HIV-negative clients and also from the 40 clients known to be infected with HIV during the decade. RESULTS: Being HIV positive, receiving larger maximum doses of methadone, receiving methadone from a private pharmacy and enrolling later in the decade were all associated with longer retention times on the program. CONCLUSIONS: This study supports the findings of previous studies, that maximum dose of methadone is crucial to retention in methadone programs, But even allowing for maximum dose, obtaining methadone from a private pharmacy was also strongly associated with retention on the program. The more 'humane' clinic policy later in the decade is likely to have increased retention and reduced illicit drug use also. PMID: 9889441, UI: 99106115

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Psychopharmacology (Berl) 1998 Dec;140(4):486-95

Abuse liability of flunitrazepam among methadone-maintained patients.

Farre M, Teran MT, Roset PN, Mas M, Torrens M, Cami J

Pharmacology Research Unit, Institut Municipal d'Investigacio Medica, and Universitat Autonoma de Barcelona, Spain.

Abuse liability and acute subjective and psychomotor effects of flunitrazepam were assessed in ten methadone-maintained males with history of benzodiazepine and alcohol use, who voluntarily participated in a double-blind, controlled, cross-over, randomized clinical trial. There were six experimental sessions in which a single oral dose of flunitrazepam 1, 2, and 4 mg; triazolam 0.5 and 0.75 mg; and placebo was given. Evaluations included physiological measures; psychomotor performance tasks (simple reaction time, Digit Symbol Substitution Test, balance task, Maddox-wing device); and self-administered subjective effects questionnaires [Addiction Research Center Inventory (ARCI), Profile of Mood States (POMS), a series of visual analog scales (VAS)]. All drugs but flunitrazepam 1 mg caused an impairment of psychomotor tasks. Effects were more evident with the highest doses of both drugs. Only flunitrazepam 4 mg produced a significant decrease in balance time. Triazolam 0.75 mg induced increases in sedation measured by ARCI-PCAG, depression in POMS, and VAS-drowsiness scores. Flunitrazepam 4mg caused euphoria-related effects as measured by increases in ARCI-MBG and "high" scores in the VAS. Our findings of flunitrazepam-induced euphoria in methadone-maintained subjects together with epidemiological evidence of flunitrazepam abuse by opioid dependents, suggest that it may be included in the group of benzodiazepines with a relatively high abuse potential.

Publication Types: Clinical trial Randomized controlled trial

PMID: 9888625, UI: 99103700

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J Subst Abuse Treat 1999 Jan;16(1):23-30

Use of methadone take-home contingencies with persistent opiate and cocaine abusers.

Chutuape MA, Silverman K, Stitzer ML

Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA. chutuape@welchlink.welch.jhu.edu

This study investigated conditions under which methadone patients with urinalysis evidence of persistent multiple drug abuse would respond to take-home incentive procedures. Study subjects submitted > or = 80% opiate and/or cocaine positive urines during a 5-week baseline period (M, W, F urine testing) while maintained on 60 mg methadone. Doses were raised to 80-100 mg methadone under blind conditions and subjects were randomly assigned to receive methadone take-home doses under one of three conditions: (a) earn a 1-day take-home privilege for each opiate and cocaine-free test delivered (daily contingent condition), (b) three negative test results required for the first take-home privilege, with each subsequent negative test earning one take-home dose; a positive test reset the contingency back to three again (weekly contingent condition), or (c) a control group that did not receive take-home privileges (no take-home control). Five of 21 subjects (24%) assigned to a contingent take-home intervention (2 from condition a, 3 from condition b) showed marked reductions in drug use and delivered 4 or more consecutive weeks of drug-free urines during a 16-week intervention. No subject in the control group met these criteria. Percent positive urines decreased by 14% and 18% from baseline in daily and weekly contingency groups, respectively, compared to a decline of 2% in the no take-home control group (planned contrast of means p < .07 and .05, respectively). Thus, the study demonstrated that take-home incentives can be effective for reducing during-treatment use of opiates and cocaine in methadone patients with a poor prognosis related to their persistent multiple drug use.

Publication Types: Clinical trial Randomized controlled trial

PMID: 9888118, UI: 99105065

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Eur J Anaesthesiol 1998 Nov;15(6):806-7

Thoracotomy without opioids in a heroin addict maintained with oral methadone.

Voyagis GS, Dimitriou V, Semeophoridou M, Tragou A

Publication Types: Letter

PMID: 9884877, UI: 99100615

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J Consult Clin Psychol 1998 Dec;66(6):924-31

When is less treatment better? The role of social anxiety in matching methadone patients to psychosocial treatments.

Avants SK, Margolin A, Kosten TR, Rounsaville BJ, Schottenfeld RS

Substance Abuse Center, Yale University School of Medicine, New Haven, Connecticut 06529, USA. kelly.avants@yale.edu

In response to a need to match drug users to the most appropriate and cost-effective level of care, it was hypothesized the socially anxious methadone-maintained patients would attain greater benefit from coping skills training provided in the context of a low-intensity enhanced standard methadone maintenance intervention (E-STD) than in the context of a high-intensity, socially demanding day treatment program (DTP). Social anxiety was assessed in 307 methadone-maintained patients using the Social Anxiety and Distress Scale prior to randomization to either E-STD or DTP. The hypothesis was supported: Socially anxious patients were drug free longer during treatment, were more likely to be abstinent at treatment completion, and had greater reductions in HIV risk behaviors if assigned to the lower intensity intervention, which was provided at 1/3 the cost of the DTP.

Publication Types: Clinical trial Randomized controlled trial

PMID: 9874905, UI: 99092064

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Subst Use Misuse 1998 Dec;33(14):2819-34

The impact of methadone on consumption of inpatient care and mortality, with special reference to HIV status.

Stenbacka M, Leifman A, Romelsjo A

Department of Clinical Neuroscience, Center for Clinic of Dependence Disorders, Karolinska Institute, Stockholm, Sweden.

This study investigates the impact of methadone treatment on inpatient care admissions and mortality among 331 methadone-maintained patients compared with 1,483 similar untreated opiate misusers. The methadone patients manifested a lower mortality during treatment than the comparison group and those patients who had left their treatment. The annual incidence rate decreased from 1.4 inpatient care admissions per year for those who had stayed 0-1 year, less than 1 for those who stayed more than 2 years, and 0.3 for those who had stayed longer (>4 years) in methadone treatment. A similar decrease occurred in both sexes. The incidence rate decreased more among the HIV-negative than the HIV-positive patients. The low incidence of inpatient care during treatment may be due to treatment but may also be partly due to selection factors.

PMID: 9869446, UI: 99084791

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Subst Use Misuse 1998 Dec;33(14):2803-17

Changes in mortality, arrests, and hospitalizations in nonvoluntarily treated heroin addicts in relation to methadone treatment.

Fugelstad A, Agren G, Romelsjo A

Center for Dependency Disorders of St. Goran's Hospital, Stockholm, Sweden.

This study analyzes the mortality, hospitalizations, and arrests in a cohort of severe intravenous heroin users divided into three groups: those in methadone treatment, those discharged from treatment, and those who never received treatment. The study population consists of 101 heroin users, of whom 56 were HIV-seropositive. Because of intensive drug misuse, they underwent coercive residential treatment in Stockholm during the 3-year period 1986-1988. The mortality was lower in the methadone group, and all seven deaths were related to HIV-infection. Outside the program, 24 of 29 persons died from external violence and poisoning.

PMID: 9869445, UI: 99084790

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Curr Opin Obstet Gynecol 1998 Dec;10(6):435-40

Methadone in the management of narcotic addiction in pregnancy.

Archie C

Publication Types: Editorial Review Review, tutorial

PMID: 9866009, UI: 99083241

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J Addict Dis 1998;17(4):71-90

Changes in HIV risk behaviors among cocaine-using methadone patients.

Magura S, Rosenblum A, Rodriguez EM

National Development Institute, 2 World Trade Center, New York, NY 10048, USA.

Cocaine use among methadone patients has been related to higher prevalence of HIV risk behaviors. HIV risk behaviors for cocaine-using patients in methadone treatment (N = 207) were examined for two time periods, the current month in-treatment and the month previous to treatment admission. All needle-related and sexually-related risk behaviors (except for needle hygiene) significantly and substantially declined over the average two year time interval. Several variables were associated with needle and sexual risks in multivariate regression analysis. Dropping apparent opiate use underreporters from the analysis did not alter the results. From a harm reduction perspective, high priority should be given to retaining cocaine-using patients in methadone maintenance, intensifying in-program services for those with anti-social personality, bipolar disorder or alcoholism, as well as increasing access to needle exchanges and free condoms.

PMID: 9848033, UI: 99064499

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Public Health Rep 1998 Jun;113 Suppl 1:107-15

Methadone treatment protects against HIV infection: two decades of experience in the Bronx, New York City.

Hartel DM, Schoenbaum EE

Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY 10467, USA. works@mhv.net

OBJECTIVE: We undertook a study of the role of methadone maintenance in protecting injecting drug users (IDUs) from human immunodeficiency virus (HIV) infection from the earliest days of the HIV epidemic in New York City to the present. The historical context of the epidemic in the Bronx is discussed. METHODS: For close to two decades, we have been tracking changes in injecting drug use and HIV infection levels in a Bronx cohort study of IDUs. An initial sample of 622 IDUs was recruited from a methadone treatment program in 1985, with historical data going back to 1978. Behavioral interviews and HIV testing were performed and methadone treatment program records (urine toxicology and methadone dose history) were reviewed. We examined both prevalent and incident HIV infections. The sample included African Americans (24.3%), Latinos (50.3%), and white non-Latinos (24.4%). The average methadone dose was 64 milligrams (mg) per day with an average time in treatment of five and a half years. RESULTS: We found a very low rate of incident infection of 1.7 per 100 person-years observation since 1986. Because of this low rate of infection, we were unable to determine the association between methadone treatment factors and HIV seroincidence. We found that our prevalence data on the 622 IDUs enrolled from 1985 to 1988 yielded strong findings on the role of methadone maintenance in a period when most infections occurred in this population. HIV seroprevalence was 42.9%. Logistic regression analysis revealed associations of methadone dose > or = 80 mg (adjusted odds ratio = 3.07/yr, 95% confidence interval (CI): 1.23-7.68) and last year entered methadone treatment (adjusted odds ratio = 1.22/yr, 95% CI: 1.06-1.41) to HIV infection, independent of year of last cocaine injection, needle sharing in shooting galleries, number of IDU sex partners, low income, and African American of Latino ethnicity. CONCLUSIONS: Properly dosed, long-term methadone treatment was found to be a central protective factor in preventing HIV infection from the earliest days of the epidemic in New York City. It is crucial to have high quality drug treatment programs in place before an epidemic draws our attention to the inadequacies through excess and unnecessary morbidity and mortality.

PMID: 9722816, UI: 98390040

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Alcohol Alcohol Suppl 1996 Mar;1:77-81

Opioid antagonists in the treatment of alcohol dependence: clinical efficacy and prevention of relapse.

O'Malley SS

Department of Psychiatry, School of Medicine, Yale University, New Haven, CT 06511, USA.

Placebo-controlled studies have demonstrated that patients treated with opioid antagonists had fewer drinking days, lower rates of resumed heavy drinking, and reduced alcohol craving, when compared with placebo-treated patients. Patients who received an opioid antagonist were also less likely to drink heavily if they sampled alcohol during treatment. One study also demonstrated that patients who were treated with the opioid antagonist naltrexone had lower serum aspartate aminotransferase and alanine aminotransferase levels than placebo-treated patients. This is consistent with self-reported decreases in alcohol consumption. These patients also had less severe alcohol-related problems than placebo-treated patients, as indicated by the Addiction Severity Index. Opioid antagonists might act by reducing the reinforcing effects of alcohol and the incentive to drink. These agents, when combined with comprehensive treatment programs, are an effective adjunctive treatment for alcohol-dependent patients.

Publication Types: Review Review, tutorial

PMID: 9845042, UI: 99059175

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Alcohol Alcohol Suppl 1996 Mar;1:43-53

Neurobehavioral basis for the pharmacotherapy of alcoholism: current and future directions.

Anton RF

Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, USA.

Results from studies of pharmacotherapies for primary alcoholism are reviewed, including selective serotonin (5-hydroxytryptamine, 5-HT) reuptake inhibitors (e.g. fluoxetine), opiate antagonists (e.g. naltrexone) and dopamine agonists (e.g. bromocriptine). Because there is considerable co-morbidity between alcohol dependence, anxiety, and affective disorders, results from studies of medications used to treat these psychiatric disorders are also reviewed, including the 5-HT agonist buspirone and the noradrenergic agent desipramine. The neurobehavioral model of alcohol dependence implies that combinations of medications may lead to more effective treatment; thus, identifying subtypes of alcoholic patients will be important in determining which therapies or combinations of therapy will be most effective in treating alcohol dependence. For example, in an ongoing study, we are attempting to subtype an alcoholic population for treatment selection by measuring endogenous opioid activity. Because endogenous opioids are involved in analgesia, we exposed male and female subjects with alcoholism [some of whom had post-traumatic stress disorder (PTSD)] to cold-induced pain and measured their response before and after administration of naloxone or placebo. The naloxone injection reduced pain response. In addition, women who have PTSD are much more sensitive to stress, which may be related to levels of brain opioid activity.

Publication Types: Review Review, tutorial

PMID: 9845037, UI: 99059170

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Drug Alcohol Depend 1998 Nov 1;52(3):257-60

One-year mortality rates following methadone treatment discharge.

Zanis DA, Woody GE

Department of Psychiatry, University of Pennsylvania, Philadelphia, USA. Zanis@research.TRC.upenn.edu

OBJECTIVES: Mortality among 507 patients in a methadone program over a 1-year period was assessed. METHODS: Mortality was determined for patients in treatment (n = 397), and 12 months later for those discharged (n = 110). RESULTS: Of discharged patients, 8.2% (9/110) had died, of which six were caused by heroin overdose. None of the discharged clients were in treatment at the time of death. All deaths were among clients who either dropped out of treatment or were discharged unfavorably from the program. Comparatively, only 1% (4/397) of patients died while enrolled in treatment. CONCLUSION: Death rates, especially overdose, are high among patients who are unfavorably discharged or drop out of methadone treatment. Efforts should be made to retain these at-risk patients in methadone treatment even though treatment response may be suboptimal.

PMID: 9839152, UI: 99056531

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Drug Alcohol Depend 1998 Nov 1;52(3):243-50

Ultra-rapid opiate detoxification using deep sedation with oral midazolam: short and long-term results.

Cucchia AT, Monnat M, Spagnoli J, Ferrero F, Bertschy G

Departement Universitaire de Psychiatrie Adulte, Site de Cery, Prilly-Lausanne, Switzerland.

The present study describes an ultra-rapid opiate detoxification method using direct transition from heroin or methadone to oral naltrexone after deep sedation with oral midazolam in conjunction with ondansetron and clonidine treatment. Twenty patients were detoxified with the method. No serious events occurred, but two out of three patients vomited during the acute phase of deep sedation, which involves some risks. Withdrawal symptoms were still present 24 Hrs after detoxification and 80% of the patients relapsed during a 6-month follow-up.

PMID: 9839150, UI: 99056529

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Drug Alcohol Depend 1998 Nov 1;52(3):211-20

Serum time course of naltrexone and 6 beta-naltrexol levels during long-term treatment in drug addicts.

Ferrari A, Bertolotti M, Dell'Utri A, Avico U, Sternieri E

Dipartimento di Medicina Interna, Universita di Modena, Italy.

The pharmacokinetics of naltrexone have been scarcely explored in patients during chronic treatment despite the observation that the pharmacological effect of the drug is related to its plasma concentrations. In this study we investigated the time course of serum levels of naltrexone and its active metabolite, 6 beta-naltrexol, in 13 heroin addicts (3 F, 10 M; age 22-32 years) in the 24 h after 100 mg of naltrexone orally. Six patients were studied once, at different times during chronic treatment, whereas in seven patients the study was done at the beginning and after 1 month of naltrexone treatment. Four of these patients also repeated the study after 3 months of naltrexone treatment. Serum naltrexone and 6 beta-naltrexol were assayed by GLC with a nitrogen-phosphorus detector. Our results showed large differences among patients in serum naltrexone and 6 beta-naltrexol levels. On the other hand, there were no differences in serum time course of both substances in the same patient over 3 months. Peak levels and AUCs of naltrexone were lower than those of 6 beta-naltrexol in ten addicts and higher than those of the metabolite in three patients. No significant differences in the apparent half-lives of the two drugs were detected among groups. These data are consistent with the occurrence of a decreased first-pass metabolism of naltrexone in three patients leading to a larger availability of an oral dose. The increased bioavailability of the drug is not very important for opioid receptor antagonist activity but may play a role in naltrexone treatment safety.

PMID: 9839147, UI: 99056526

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Drug Alcohol Depend 1998 Nov 1;52(3):183-92

Factors associated with lapses to heroin use during methadone maintenance.

Wasserman DA, Weinstein MG, Havassy BE, Hall SM

Department of Psychiatry, University of California, San Francisco 94143, USA. WASSERMAN.DAVID_A@SANFRANCISCO.VA.GOV

This prospective, observational study investigated factors predicting a lapse to heroin use in 74 heroin-abstinent methadone maintenance patients. After baseline data collection, participants were assessed twice per week for 7 weeks and again at 6 months after baseline. Proportional hazards regression and logistic regression were used to investigate the effects of study predictors on heroin use. A goal of absolute heroin abstinence consistently predicted a lower risk of a lapse, whereas marijuana use was associated with a greater risk. Stress variables were not predictive. The abstinence goal and stress results were consistent with the authors' previous studies of other drug treatment samples. This line of research suggests that factors influencing lapses are similar across drug treatment populations and the role of stress in precipitating relapse remains unresolved.

PMID: 9839144, UI: 99056523

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Harv Ment Health Lett 1998 Dec;15(6):8

How is naltrexone used in the treatment of alcoholism?

Osser DN

Harvard Medical School, USA.

PMID: 9833574, UI: 99050768

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AANA J 1998 Aug;66(4):360-4

Reentry using naltrexone: one anaesthesia department's experience.

Hudson S

Kentucky Association of Nurse Anesthetists, USA.

The responsibilities of administrative managers may include dealing with the practitioner who is seeking to reenter the workplace while recovering from drug or alcohol addiction. The following article offers assistance when considering the development of a policy for reintroducing and monitoring these individuals in an anaesthesia department. In this instance, naltrexone was found useful in facilitating reentry into anaesthesia practice after inpatient treatment and while following a comprehensive aftercare program. The AANA Peer Assistance Advisors have compiled a model policy and reentry contract. For copies of policies, video resources, or other additional information, contact AANA staff member Susan Burger at (847) 692-7050, extension 3011.

PMID: 9830862, UI: 99048554

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Psychiatr Serv 1998 Nov;49(11):1483-5

Patient outcomes after initiation of Sabbath closure of a methadone maintenance clinic in Israel.

Gelkopf M, Bleich A, Hayward R, Adelson M

Dr. Miriam and Sheldon G. Adelson Clinic for Drug Abuse Treatment and Research, Tel-Aviv Sourasky Medical Center, Israel. bleich@post.tau.ac.il

The study examined whether closing of a methadone maintenance clinic in Israel on the Sabbath was associated with adverse patient outcomes. One take-home dose of methadone was given to all patients for that day regardless of whether they had earned take-home privileges. No difference was found in dropout rates for the six-month periods before and after Saturday closure was initiated. Results of random, twice-weekly urinalyses for all patients did not indicate increased use of heroin. The findings suggest that closure of a methadone clinic at least one day a week does not jeopardize patient outcome. Cutting hours of operation would reduce workload and enable clinics to function more economically.

PMID: 9826253, UI: 99041626

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AIDS 1998 Oct 22;12(15):2059-66

Prevalence and incidence rate of HIV, hepatitis B and C among drug users on methadone maintenance treatment in Geneva between 1988 and 1995.

Broers B, Junet C, Bourquin M, Deglon JJ, Perrin L, Hirschel B

Division of Infectious Diseases, University Hospital, Geneva, Switzerland.

OBJECTIVES: To evaluate the prevalence and incidence rates of infection with HIV, hepatitis B (HBV) and hepatitis C (HCV), in a cohort of drug users (DU) in Geneva, Switzerland. DESIGN: Prospective open cohort study. SETTING: Private methadone maintenance treatment (MMT) program. PATIENTS, PARTICIPANTS: Over 700 DU in treatment between 1988 and 1995 were tested biannually for HIV, HBV and HCV infection. INTERVENTION: None. MAIN OUTCOME MEASURE: Prevalence for HIV, HBV and HCV at study entry, determined by gender, by injection behaviour, by year of start of MMT and incidence rates for HIV, HBV and HCV, assuming equal risk of seroconversion on each day of the interval between last negative and first positive test. RESULTS: The prevalence at entry into treatment declined dramatically over time for all three viruses. Comparing DU entering treatment before 1988 to those entering treatment after 1993, the prevalence of HIV was 38.2% versus 4.5%, of HBV 80.5% versus 20.1%, and of HCV 91.6% versus 29.8%, respectively. Follow-up rate was 80%. The incidence rates for HIV and HBV were 0.6% and 2.1% per person-year of follow-up, respectively. For HCV the rate was higher (4.2%) especially among women (9.6%). CONCLUSION: These data suggest that DU have changed HIV risk-taking behaviour in response to HIV prevention campaigns. Current prevention efforts should focus on improvement of HCV prevention, identification of high-risk individuals and maintaining safe behaviour.

PMID: 9814875, UI: 99030040

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Addiction 1998 Aug;93(8):1169-75

Drug use and injection risk-taking among prison methadone maintenance patients.

Darke S, Kaye S, Finlay-Jones R

National Drug and Alcohol Research Centre, University of New South Wales, Australia.

AIMS: To examine the drug use and injection risk-taking among incarcerated methadone maintenance (MM) patients; to determine the impact of a diagnosis of antisocial personality disorder (ASPD) on prison-based MM treatment; to compare incarcerated patients with community patients. DESIGN: Structured interview. SETTINGS: New South Wales (NSW) prisons and community methadone maintenance (MM) units. PARTICIPANTS: One hundred incarcerated MM patients and 183 community MM patients. MEASUREMENTS: Subjects were interviewed about drug use and needle risk-taking in the previous 6 months, and assessed for a diagnosis of ASPD. FINDINGS: Heroin had been used by 38% of prison MM patients in the 6 months prior to interview, on a median of 4.5 days. Forty-four per cent of prison patients had injected a drug in the preceding 6 months. A third (32%) of prison subjects had borrowed used injecting equipment within the preceding 6 months, and 35% had lent used injecting equipment to others. Community patients were more likely to have injected a drug in the preceding 6 months (84% vs. 44%), to have used heroin (72% vs. 38%) and to have done so more frequently (20 vs. 4.5 days). Prisoners, however, were more likely to have borrowed (32% vs. 15%) and lent (35% vs. 21%) injecting equipment in that time. While injecting at lower rates than their community counterparts, the injecting occasions of prisoners were of much higher levels of risk. A diagnosis of ASPD was unrelated to both drug use and needle risk-taking. CONCLUSIONS: Incarcerated patients injected less frequently than community patients, but had higher levels of needle risk-taking.

PMID: 9813898, UI: 99031441

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Am J Addict 1998 Fall;7(4):288-98

A pilot study comparing severely and persistently mentally ill opiate-addicted patients in dual-diagnosis treatment with patients in methadone maintenance.

Jaffe C, Comtois KA, Calsyn DA, Saxon AJ

Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, USA.

The authors describe a severely and persistently mentally ill (SPMI) opiate-addicted (OA) patient sample (n = 43) in a dual-diagnosis outpatient treatment program by demographic, clinical, and treatment characteristics and compare these with other dually diagnosed SPMI patients in the same treatment center (n = 297). Also, those SPMI/OA patients with physiological dependence (n = 20) were compared with a matched sample of OA patients in traditional methadone maintenance (n = 20). The authors then present a clinical evaluation of treatment course and outcome for the SPMI/OA patients (n = 43) and discuss implications from these pilot data.

PMID: 9809133, UI: 99026661

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Am J Addict 1998 Fall;7(4):272-82

Effect of LAAM dose on opiate use in opioid-dependent patients. A pilot study.

Oliveto AH, Farren C, Kosten TR

Department of Psychiatry, Yale University School of Medicine, West Haven, CT, USA. oliveto.alison_h@west-haven.va.gov

The authors conducted a 16-week study with nine opioid-dependent individuals (six male; four white/two African American/three Hispanic; age 36.8 +/- 2.2 years). Participants were assigned to either a low-dose (165 mg/week; n = 5) or high-dose (330 mg/week; n = 4) Levo-alpha-acetylmethadol (LAAM) condition according to a randomized, double-blind, within-subjects crossover design, such that they were inducted onto one maintenance dose for 4 weeks and then were crossed over to receive the converse for 4 weeks. Subsequently, individuals underwent detoxification from LAAM. Eight of nine participants completed the study protocol. The proportion of urine samples positive for opiates was 0.22 +/- 0.08 and 0.53 +/- 0.12, under the high- and low-dose conditions, respectively (F = 11.8; P = 0.01). These results show that LAAM dose regimen affects the degree of abstinence from opioids.

Publication Types: Clinical trial Randomized controlled trial

PMID: 9809131, UI: 99026659

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Alcohol Clin Exp Res 1998 Oct;22(7):1430-6

Nalmefene causes greater hypothalamic-pituitary-adrenal axis activation than naloxone in normal volunteers: implications for the treatment of alcoholism.

Schluger JH, Ho A, Borg L, Porter M, Maniar S, Gunduz M, Perret G, King A, Kreek MJ

The Laboratory of the Biology of the Addictive Diseases, The Rockefeller University, New York, New York 10021-6399, USA.

Among other actions, opioid antagonists modulate the control endogenous opioids exert on the hypothalamic-pituitary-adrenal (HPA) axis. Naloxone, nalmefene, and naltrexone are the opioid antagonists approved for use in man and are primarily mu-opioid selective. Naltrexone and nalmefene have been demonstrated to be useful in the treatment of alcoholism. Compared with naloxone, nalmefene has a longer half-life, is more potent at the mu-receptor, and has a higher affinity for kappa- and delta-opioid receptors. We conducted an inpatient study comparing the effects of 10 and 30 mg doses of intravenous naloxone and nalmefene in normal, nonsubstance nor alcohol-abusing, volunteers. Significant increases in ACTH and cortisol were observed after both antagonists, without an apparent dose-response relationship; however, both doses of nalmefene resulted in greater HPA axis activation than either dose of naloxone (ACTH: p <0.005). These results indicate that kappa- and delta-opioids may play important roles in the regulation of the HPA axis; nalmefene may be useful as both a probe to explore the HPA axis physiology and as a pharmacotherapeutic agent.

PMID: 9802524, UI: 99017510

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Br J Gen Pract 1998 Jul;48(432):1435-6

Drug misuse.

Ashworth AJ, Kidd BA

Publication Types: Letter

PMID: 9800413, UI: 99016795

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Drug Alcohol Depend 1998 Oct 1;52(2):167-71

Retention in treatment of heroin users in Italy: the role of treatment type and of methadone maintenance dosage.

D'Ippoliti D, Davoli M, Perucci CA, Pasqualini F, Bargagli AM

Department of Epidemiology, Lazio Regional Health Authority, Rome, Italy.

Retention in treatment among 1503 heroin users attending public treatment centres in 1995 was studied. Three different treatments were considered: methadone maintenance, drug-free program and naltrexone. The retention rate after 1 year was 40% for patients in methadone maintenance, 18% in naltrexone and 15% in drug-free program. For patients in maintenance, methadone dosage and clinic policy were the most important factors for retention. Patients taking > or = 60 mg/day and 30-59 mg/day were respectively 70 and 50% more likely to remain in treatment than those receiving a < 30 mg daily dose. Patients in maintenance-oriented clinics were 30% more likely to remain in treatment than those in abstinence-oriented centres.

PMID: 9800146, UI: 99016528

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AIDS Educ Prev 1998 Oct;10(5):403-16

Relationship of HIV testing and high-risk behaviors among clients in methadone maintenance treatment.

Grella CE, Campos M, Anglin MD

UCLA Drug Abuse Research Center 90024, USA.

This article reports on the association between frequency of HIV testing and high-risk behaviors among 339 individuals in the Los Angeles Enhanced Methadone Maintenance Project. Individuals who reported taking three or more HIV tests prior to entering treatment (45% of the sample) were more likely to know someone who was HIV positive, to engage in illegal activity, to perceive their risk for HIV as high, and to use condoms; they were less likely to disinfect injection equipment; and they scored higher on measures of HIV knowledge and depression as compared with less frequent testers. The strongest predictor of frequent HIV testing (three or more tests) after treatment entry, reported by 43% of the sample, was having a high number of injection-sharing partners. Although a substantial number of individuals in methadone maintenance treatment continued to take HIV tests, test taking was more strongly related to high-risk injection behavior than to sexual behavior.

PMID: 9799937, UI: 99016319

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J Neurosurg Anesthesiol 1998 Oct;10(4):205-10

Simultaneous increases in respiration and sympathetic function during opiate detoxification.

Hoffman WE, McDonald T, Berkowitz R

Department of Anesthesiology, University of Illinois at Chicago, 60612, USA.

This study evaluated the relationship between the sympathetic withdrawal response and increases in spontaneous ventilation during naltrexone treatment in opioid-dependent patients. Naltrexone was given in repeated increasing doses by orogastric tube to 16 opioid-dependent patients during propofol anaesthesia. Sympathetic activity was evaluated in 64-second segments by low frequency heart rate variability (0.02-0.10 Hz) and minute ventilation was measured every 15 minutes. During naltrexone treatment, heart rate and blood pressure increased with no change in the electroencephalogram as measured by the bispectral index. Sympathetic activity increased five-fold and minute ventilation increased by 50% during naltrexone administration. There was a significant correlation between the time of the peak sympathetic response and peak ventilation (r = 0.83, p < 0.001). In three control patients, who received anaesthesia for surgery without naltrexone treatment, no increases in sympathetic or respiratory parameters were seen. These results indicate that peak sympathetic and respiratory stimulation occur together during opiate receptor antagonism in opioid addicts.

Publication Types: Clinical trial

PMID: 9796603, UI: 99010627

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Obstet Gynecol 1998 Nov;92(5):854-8

Opioid detoxification in pregnancy.

Dashe JS, Jackson GL, Olscher DA, Zane EH, Wendel GD Jr

Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas 75235-9032, USA.

OBJECTIVE: Opioid withdrawal has been associated with poor fetal growth, preterm delivery, and fetal death. We sought to evaluate the safety of antepartum opioid detoxification in selected gravidas. METHODS: Between 1990 and 1996, women with singleton gestations who reported opioid use were offered inpatient detoxification. Predetoxification sonography was performed to confirm gestational age and to exclude fetuses with growth restriction and oligohydramnios. Women with mild withdrawal symptoms were given clonidine initially, and methadone was substituted if symptoms persisted. Objective signs of withdrawal were treated with methadone from the outset. Antenatal testing was performed once gestations reached 24 weeks. Newborns were observed for signs of neonatal abstinence syndrome and were treated as necessary. Obstetric and neonatal outcome data were collected. RESULTS: Thirty-four gravidas elected to undergo opioid detoxification at a mean gestational age of 24 weeks. The median maximum dose of methadone was 20 mg per day (range 10-85 mg), and the median time to detoxification was 12 days (range 3-39 days). Overall, 20 women (59%) successfully underwent detoxification and did not relapse, ten (29%) resumed antenatal opioid use, and four (12%) did not complete detoxification and opted for methadone maintenance. There was no evidence of fetal distress during detoxification, no fetal death, and no delivery before 36 weeks. Fifteen percent of neonates were treated for narcotic withdrawal. CONCLUSION: In selected patients, opioid detoxification can be accomplished safely during pregnancy.

PMID: 9794682, UI: 99008813

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J Addict Dis 1998;17(3):75-89

Psychiatric comorbidity in methadone maintained patients.

Mason BJ, Kocsis JH, Melia D, Khuri ET, Sweeney J, Wells A, Borg L, Millman RB, Kreek MJ

Laboratory of the Biology of Addictive Diseases, Rockefeller University, New York, NY, USA.

Diagnosing comorbid psychiatric disorders in methadone maintained patients may help to identify subgroups with different outcomes and needs for treatment. In this study, 75 methadone maintenance clinic patients in treatment longer than 30 days were assessed with the Addiction Severity Index, Global Assessment Scale and Mini-Mental Status Exam, and were interviewed for DSM-III-R psychiatric diagnosis using the computerized Diagnostic Interview Schedule. Psychiatric diagnoses were prevalent in the sample with depression, phobic disorders, antisocial personality and generalized anxiety the most common. Both number of DSM-III-R diagnoses and severity of psychopathology were correlated with outcome measures such as concurrent drug abuse, family-social problems and employment status.

PMID: 9789161, UI: 99005590

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J Addict Dis 1998;17(3):35-47

Alcoholic patients' experience and attitudes on pharmacotherapy for alcoholism.

Swift RM, Duncan D, Nirenberg T, Femino J

Center for Alcohol and Addiction Studies, Brown University, Providence, RI, USA. Robert_Swift@brown.edu

Clinical studies have demonstrated that pharmacotherapies may improve alcoholism treatment, when combined with traditional psychosocial therapies. Recently, the opioid antagonist, naltrexone, has been approved as an adjunct in alcoholism treatment, and several other pharmacotherapies for alcoholism are under development. Because of the abstinence orientation of many patients, we assessed attitudes regarding medications, and explored whether alcoholic patients would consider taking medication as part of their alcoholism treatment. Active patients (n = 127) in three alcohol treatment settings were surveyed with an anonymous questionnaire which asked demographics, personal alcoholism history and questions about medication use. They were asked whether they felt disulfiram and naltrexone were helpful for alcoholics and whether they would take the medications. The findings indicate that the patients were divided about the use of pharmacotherapy for the treatment of alcoholism. The strongest predictor of willingness to take medication was a belief that the medication would be helpful.

PMID: 9789158, UI: 99005587

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Drug Alcohol Depend 1998 Sep 1;52(1):79-84

Published erratum appears in Drug Alcohol Depend 1999 Apr 1;54(2):179

Levels of intravenous drug misuse among clients prescribed oral dexamphetamine or oral methadone: a comparison.

Charnaud B, Griffiths V

Cornwall Community Drugs Team, Trengweath, Redruth, UK.

There has been a considerable increase in the number of intravenous amphetamine misusers during the last decade, and the development of effective treatment strategies for this high-risk group has become critical. The use of substitute prescribing is one option, but reservations have been expressed as to its demonstrated effectiveness in reducing injecting practice and associated risks. This study compares the effect of substitute prescribing on the injecting practices of two groups of intravenous drug misusers: 120 primary opiate misusers, prescribed oral methadone; and 60 primary amphetamine misusers, prescribed dexamphetamine elixir. The levels of intravenous drug misuse at time of discharge for the two groups was similar, with 67% of the opiate misusers and 70% of the amphetamine misusers having stopped injecting.

PMID: 9788010, UI: 99004278

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Drug Alcohol Depend 1998 Sep 1;52(1):57-61

Staff attitudes and retention of patients in methadone maintenance programs.

Caplehorn JR, Lumley TS, Irwig L

Department of Public Health, University of Sydney, N.S.W., Australia.

A study was made of the effect of staff commitment to abstinence-oriented policies on retention of patients in methadone maintenance. Staff working in six public methadone programs in Sydney, Australia, were surveyed in 1989 and 1992 using the Abstinence Orientation Scale. The association of the clinics' median Abstinence Orientation scores with the time in treatment of a random sample of their 1988-1989 admissions was summarized using Cox regression. Patients' risk of discharge increased by a factor of three with every one unit increase in the clinics' median Abstinence Orientation scores, (RR 3.4, 95% CI 2.3-5.0). Abstinence-oriented policies were shown to disadvantage ex-prisoners.

Publication Types: Clinical trial

PMID: 9788007, UI: 99004275

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Ann Med 1998 Aug;30(4):406-11

New treatment options for substance abuse from a public health viewpoint.

Sinclair JD

Department of Mental Health and Alcohol Research, National Public Health Institute, Helsinki, Finland. david.sinclair@ktl.fi

Naltrexone is the first safe and effective pharmaceutical adjunct for use in the treatment of alcohol abuse. Theoretically it could be effective also as a means for terminating methadone maintenance and in the treatment of other forms of substance abuse. Two general types of protocols have been used with naltrexone. One protocol is similar to the protocol appropriate for use with disulfiram; it is designed to preclude use of the substance while on naltrexone. The other protocol is based on preclinical research showing that opioid antagonists can cause extinction of alcohol drinking; it is designed to maximize the effects from extinction. The results from the clinical trials are consistent with the conclusion that the major benefits from naltrexone treatment, regardless of protocol, are being caused by extinction. The extinction protocol is better from the position of public health, increasing the range of patients who can be treated, reducing the total cost and allowing patients to be treated with d