Predicting postdischarge opiate abstinence from admission measures of motivation and confidence.

Admission scores from a model comprising 3 motivation factors concerning the cessation of heroin use and a confidence scale concerning postdischarge abstinence were tested for their ability to predict postdischarge outcomes in patients beginning inpatient opiate detoxification. Statistically significant prediction of abstinence from heroin 30 days after discharge and the number of heroin-free days in the 3 months following admission was based on the confidence scale and a factor concerned with externally imposed constraints on continued heroin use. The single-scale confidence measure made the largest contribution to each prediction, indicating that such scales may be potentially useful outcome predictors for postdischarge abstinence. External constraints on heroin use may not provide a basis for success in this treatment modality. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Increased Vulnerability to Stress Following Opiate Exposures: Behavioral and Autonomic Correlates.

The authors used rats to study the impact of a history of opiate exposures on behavioral and autonomic responses to restraint stress. Brief restraint (30 min) provoked tachycardia and a pressor response, anxiety (as indexed by social interaction), grooming, and reduced exploration. The pressor response was reduced at 1 day, but not 7 days, after last opiate exposure; tachycardia was unaffected (Experiment 1). Stress-induced anxiety was potentiated 1 and 7 days after last opiate exposure (Experiment 2), and this potentiation was a function of dose (Experiment 3) and duration (Experiment 4) of opiate exposure. The results show that a history of opiate exposures alters vulnerability to stress and has implications for understanding coping, anxiety, and emotionality in former opiate users. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Betting on change: Modeling transitional probabilities to guide therapy development for opioid dependence.

This study investigated the process of change by modeling transitions among four clinical states encountered in 64 detoxified opiate-dependent individuals treated with daily oral naltrexone: no opiate use, blocked opiate use (i.e., opiate use while adhering to oral naltrexone), unblocked opiate use (i.e., opiate use after having discontinued oral naltrexone), and treatment dropout. The effects of baseline characteristics and two psychosocial interventions of differing intensity, behavioral naltrexone therapy (BNT) and compliance enhancement (CE), on these transitions were studied. Participants using greater quantities of opiates were more likely than other participants to be retained in BNT relative to CE. Markov modeling indicated a transition from abstinence to treatment dropout was approximately 3.56 times greater among participants in CE relative to participants in BNT, indicating the more comprehensive psychosocial intervention kept participants engaged in treatment longer. Transitions to stopping treatment were more likely to occur after unblocked opiate use in both treatments. Continued opiate use while being blocked accounted for a relatively low proportion of transitions to abstinence and may have more deleterious effects later in a treatment episode. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

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

This study examined an abstinence-contingent voucher incentive program in opiate-dependent clients enrolled in outpatient drug-free (nonmethadone) treatment. Study participants were referred from local detoxification programs and randomly assigned to voucher (n=29) or no-voucher (n=23) conditions. Both groups received intensive cognitive-behavioral counseling; those in the voucher condition could earn up to $1,087.50 over 3 months for submitting urines negative for both opiates and cocaine. Voucher versus no-voucher groups did not differ significantly on mean days retained in treatment (35.9 vs. 39.3 days), mean number of opiate- and cocaine-negative urines submitted (8.3 vs. 6.2), longest duration of continuous abstinence (16.8 vs. 12.1 days), or percentage of participants abstinent for 4 weeks (20.7% voucher vs. 9% no voucher). Possible reasons for negative findings are discussed. Findings suggest that voucher programs must be better tailored to the clinical population and behavioral targets being addressed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Monounsaturated oils do not all have the same effect on plasma cholesterol

The relationship between pupil size and subjective symptoms of opiate withdrawal during gradual opiate agonist detoxification has not yet been studied. In the current study, the authors sought to determine the relationship between pupil size and intensity of opiate withdrawal symptoms. To accomplish this, they examined 19 subjects meeting DSM-IV criteria for opiate dependence (304.00) on agonist therapy. All subjects were undergoing opiate detoxification with either methadone or the longer-acting 1-alpha acetylmethadol (LAMM). During two separate visits, subjects' pupil sizes were assessed in the dark using a pupillometer. At each visit, subjects completed two standardized assessment tools (the Subjective Opiate Withdrawal Scale [SOWS] and the Weak Opiate Withdrawal Scale [WOWS]) for measuring subjective symptoms of opiate withdrawal. It was found that changes in pupil size significantly correlated with WOWS, but not with SOWS, scores. Larger pupil sizes were associated with less withdrawal distress. The sensitivity of the pupillometric test to detect increases in opiate craving during opiate agonist medication reduction was 92%, with a specificity of 57%. The predictive value of a positive test was 79%, whereas the predictive value of a negative test was 80%. Pupillometry may provide an objective measure of the intensity of opiate withdrawal in subjects during gradual methadone detoxification.     

Single- Versus Dual-Drug Target: Effects in a Brief Abstinence Incentive Procedure.

The number of drugs targeted may have an important influence on the ability of drug abusers to abstain during motivational incentive procedures. The authors investigated outcomes in methadone maintenance patients (n = 58), who had evidence of both opiate and cocaine use, when continuous abstinence from cocaine only (single target) or from both cocaine and heroin (dual target) was required to earn $200 in voucher incentives over a 4-day period. Study patients were equally likely to initiate and sustain abstinence from cocaine under the single- versus the dual-drug target. They were more likely to initiate opiate abstinence under the dual-target condition, demonstrating sensitivity to reinforcer effects. Results suggest that adding a second drug target does not impede short-term cocaine abstinence initiation. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Imaging of tuberculosis. II. Abdominal manifestations in 112 patients

We report on clinical and practical aspects of treatment of opiate addiction with a relatively new approach, rapid opiate detoxification (ROD). The goal is to induce rapid narcotic withdrawal in a controlled environment using narcotic antagonists while suppressing withdrawal symptoms with sedative drugs, thus effecting a dramatic abbreviation of the traditional withdrawal schedule. Twenty-five consecutive heroin-addicted patients presenting for detoxification were treated at a university hospital. There were 14 women and 11 men, with a mean age 32.6 years (range, 24-48). They underwent 29 separate detoxifications over a 4-month period. All but 3 of the detoxifications were effected with ROD. Several different techniques were used over the 4-month period, ranging from intramuscular and oral sedation to intravenous sedation, paralysis, and intubation. Efficacy of detoxification was demonstrated for all patients undergoing ROD; all were given 50 mg of naltrexone PO prior to discharge, and none had withdrawal symptoms. (The three patients treated with abstinence were not so tested.) We derive three conclusions from this early clinical experience: First, ROD appears to be a valuable tool in the treatment of heroin addiction. ROD is an efficient, effective technique that can play an important role in an integrated rehabilitation program. Second, the optimal method of ROD is yet to be determined; a continuum of approaches is available. Third, ROD is probably most suited to designated outpatient centers.     

Altered responsivity to central administrations of corticotropin-releasing factor in rats with a history of opiate exposures.

The authors studied the effects of a history of opiate exposures on behavioral responses to intracerebroventricular (ICV) microinjections of the stress-related peptide corticotropin-releasing factor (CRF). Rats were injected for 10 days with morphine (10 mg/kg) or saline, and 1 or 7 days later they received an ICV microinjection of CRF (0.5 μg or 2.5 μg) or artificial cerebrospinal fluid. Microinjections of CRF produced anxiety-like behavior, locomotor activity, and self-grooming. The anxiogenic response was altered so that morphine-treated rats showed reduced responses to 0.5-μg CRF but showed exaggerated responses to 2.5-μg CRF 1 or 7 days after last opiate exposure. These findings suggest that alterations in central CRF circuits may underpin the increased vulnerability to anxiety observed following opiate exposures. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

An Experimental Examination of the Initial Weeks of Abstinence in Cigarette Smokers.

Gaining experimental control over abstinence may help define processes that change during abstinence that may be related to the association between initial abstinence and relapse risk often noted in clinical trials. Adult smokers (n = 34) were randomly assigned to receive monetary incentives contingent on abstinence (CO ± 4 ppm) or noncontingent for 12 days. Carbon monoxide (CO) tests were conducted 3 times per day, saliva samples were collected on Days 5 and 12, and all other measures were collected 1 time per day. In the contingent group, 59% of participants abstained throughout the study versus 0% in the control condition. Abstinence was associated with increases in participant-rated ease of abstaining and confidence in abstinence; nicotine withdrawal severity and craving decreased over time. Results indicate that it is feasible to experimentally manipulate smoking abstinence and that doing so can enhance understanding of the relationship between early abstinence and relapse risk. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Potential benefits of estrogens and progestogens on breast cancer

Comparatively few studies have examined the effects of methadone given during a clinical detoxification programme. Furthermore, their results are different especially because of changing drop-out rates. This study was carried out on a drug-detoxification ward and investigated the effects of methadone given to alleviate withdrawal symptoms. Comparisons were undertaken with patients withdrawn during a one-year period before methadone was available. No significant difference was found between drop-out rates of patients with methadone-supported detoxification (n = 113, drop-out rate: 41.6%) and patients who did not receive methadone during detoxification (n = 108, drop-out rate: 37.0%). Nevertheless the drop-out rate in the first three days of withdrawal was reduced from 15.7% to 8.0%. On average the critical drop-out moment shifted from 5.3 days to 10.1 days. Interpretations of these findings should take into account, that the number of patients who underwent a voluntary detoxification programme for the first time was nearly doubled after methadone was offered on the ward and, additionally, many more patients tried to withdraw from methadone taken within an outpatient methadone-maintenance programme.     

A Comparison of Voucher-Delivery Schedules for the Initiation of Cocaine Abstinence.

Studies on the use of shaping procedures to increase rates of cocaine abstinence have produced promising results. This study used a Brief Abstinence Test to examine the impact of reinforcement for initial reductions in cocaine use on a subsequent abstinence reinforcement test. Methadone maintenance patients showing evidence of cocaine use were exposed to two 1-week reinforcement conditions. During the shaping condition, participants could earn $50 vouchers on Wednesday and Friday for meeting quantitative urinalysis criteria and a $100 voucher on the following Monday for meeting the more stringent qualitative criteria. During the terminal condition, only the $100 earning opportunity for meeting the qualitative criteria was provided. Participants were more likely to meet the qualitative reinforcement criteria on Wednesday and Friday in the shaping condition than in the terminal condition. However, contrary to the initial hypothesis, the shaping reinforcement condition did not increase rates of abstinence on the final abstinence test. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

21-day outpatient methadone detoxification: an evaluation

A population consisting of all consecutive admissions between May 29, 1974 and July 30, 1974 was studied. Of the 169 applicants, 63 began the detoxification regimen. Persons participating in this program were in contact with the program only during their 21-day detoxification episode. The treatment setting was highly permissive. The primary objective was to help and assist individuals in their efforts to either reduce their use of opiates or attain a drug-free state. Thirty-one of the 63 individuals completed the program. Forty-five persons had lower opiate readings when their last three urine samples were analyzed. Interpretation of the data is guarded.     

Drug abuse treatment as HIV prevention: changes in social drug use patterns might also reduce risk

Fifty one individuals (37 male and 14 female) were asked to report on the social and behavioral circumstances related to their opiate drug use prior to and during a 90-day methadone detoxification treatment. Data were collected by means of a weekly structured interview. Questions were asked about each occasion of opiate use in the previous week with respect to time, source, cost, social circumstance, etc. Monitored urine samples were tested x 3/week to verify verbal reports. The study demonstrated beneficial effects of the detoxification treatment by showing dramatic decreases in rates and amounts of opiate drug use during treatment. Of perhaps greater significance, large scale changes were also noted in the frequency of use with others. This decline in use with others was most dramatic with respect to strangers and acquaintances. Implications of these observations for HIV transmission are discussed.     

A reinforcement-based Therapeutic Workplace for the treatment of drug abuse: Three-year abstinence outcomes.

Long-term Therapeutic Workplace effects were evaluated in heroin- and cocaine-dependent, unemployed, treatment-resistant young mothers. Participants were paid to work or to train in the Therapeutic Workplace but had to provide drug-free urine samples to gain daily access. Participants (N=40) were randomly assigned to a Therapeutic Workplace or usual care control group. Therapeutic Workplace participants could work for 3 years. Relative to controls, Therapeutic Workplace participants increased cocaine (28% vs. 54% negative; p=.04) and opiate (37% vs. 60% negative; p=.05) abstinence on the basis of monthly urine samples collected until 3 years after intake. The Therapeutic Workplace can be an effective long-term treatment of cocaine and heroin addiction in poor and chronically unemployed young mothers. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Detoxication in opiate addiction and prevention of recurrence: administration of naltrexone and cognitive behavior therapy

Rapid opiate withdrawal and relapse prevention in opiate addicts are made possible by naltrexone, clonidine and diazepam in combination with cognitive behavioural therapy according to the Community Reinforcement Approach. In an open pilot experiment 12 addicted patients achieved initial detoxification. At follow-up after a minimum of 6 months, 10 of these had not relapsed. Good results with this detoxification method could be booked by selecting highly motivated opiate addicts.     

A randomized controlled trial of the therapeutic workplace for community methadone patients: A partial failure to engage.

The Therapeutic Workplace is an employment-based treatment for drug addiction that uses wages for work to reinforce drug abstinence. The Therapeutic Workplace has promoted abstinence from heroin and cocaine in treatment-resistant mothers in methadone treatment. This study attempted to replicate that effect in crack cocaine users recruited from community-based methadone programs. Participants were randomly assigned to a Therapeutic Workplace (n=22) or usual care control (n=25) group. Therapeutic Workplace participants were invited to work in the workplace and earn vouchers every weekday for 9 months contingent on documented opiate and cocaine abstinence. The two groups did not differ significantly on measures of cocaine or opiate use collected during study participation. Daily attendance and urinalysis results of the Therapeutic Workplace group were analyzed, and only 7 of the 22 participants initiated consistent periods of abstinence and workplace attendance. Two individuals gained access to the workplace on a few days, and 9 participants attempted to gain access to the workplace but never provided a drug-negative urine sample. Possible reasons for differences between the current study and the previous Therapeutic Workplace study are considered. Procedures that increase participant contact with the Therapeutic Workplace and its reinforcement contingencies might increase the likelihood of these individuals being successful in the treatment program. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Facilitating outpatient treatment entry following detoxification for injection drug use: A multisite test of three interventions.

A multisite, randomized trial within the National Drug Abuse Treatment Clinical Trials Network (CTN) was conducted to test 3 interventions to enhance treatment initiation following detoxification: (a) a single session, therapeutic alliance intervention (TA) added to usual treatment; (b) a 2-session, counseling and education, HIV/HCV risk reduction intervention (C&E), added to usual treatment; and (c) treatment as usual (TAU) only. Injection drug users (n = 632) enrolled in residential detoxification at 8 community treatment programs were randomized to 1 of the 3 study conditions. TA participants reported entering outpatient treatment sooner and in greater numbers than TAU participants. Reported treatment entry for C&E fell between TA and TAU with no significant differences between C&E and the other conditions. There were no differences among the interventions in retention, as measured by weeks of outpatient treatment for all participants who reported treatment entry. Alliance building interventions appear to be effective in facilitating transfer from detoxification to outpatient treatment, but additional treatment engagement interventions may be necessary to improve retention. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Motivational interviewing with cocaine-dependent patients: A pilot study.

A brief motivational interviewing (MI) intervention was evaluated within the context of an outpatient, cocaine-detoxification program. MI was hypothesized to assist patients in completing the detoxification program and to improve outcomes during subsequent treatment. Participants (N = 105) were randomly assigned to MI or to detox-only conditions. Results indicated that although participants completed the detoxification program at equal rates, completers who received MI increased use of behavioral coping strategies and had fewer cocaine-positive urine samples on beginning the primary treatment. MI patients with lower initial motivation were more likely to complete detoxification. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effects of acute and prolonged opiate abstinence on extinction behaviour in rats.

We examined the role of withdrawal in relapse to drug-seeking and drug-taking by testing the effects of opiate abstinence on extinction behaviour in rats trained to self-administer heroin. Male Long-Evans rats responded for IV heroin under a heterogeneous chain (VI 120 s; FR 1) schedule in which "seeking" responses preceded a "taking" response which produced a drug infusion. Responding was then measured in extinction during acute (6, 12, and 24 hr) and prolonged (3, 6, 12, and 25 day) abstinence. Sucrose consumption and somatic withdrawal were assessed at each testing period. During acute abstinence, responses on the "drug-seeking" manipulandum increased at 24 hr, whereas responses on the "drug-taking" manipulandum increased at 6 hr. Both responses were elevated during the 12-day abstinence test. Sucrose consumption was reduced and somatic withdrawal scores were increased in opiate-experienced rats at each test period. Results suggest that heroin abstinence has different effects on drug-seeking and drug-taking and that these effects do not temporally coincide with somatic measures of opioid withdrawal. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A randomized trial of contingency management delivered in the context of group counseling.

Objective: Contingency management (CM) is efficacious in reducing drug use. Typically, reinforcers are provided on an individual basis to patients for submitting drug-negative samples. However, most treatment is provided in a group context, and poor attendance is a substantial concern. This study evaluated whether adding CM to group-based outpatient treatment would increase attendance and drug abstinence relative to standard care. Method: Substance abusing patients (N = 239) initiating outpatient treatment at 2 community-based clinics were randomized to standard care with frequent urine sample monitoring for 12 weeks (SC) or that same treatment with CM delivered in the context of group counseling sessions. In the CM condition, patients earned opportunities to put their names in a hat based on attendance and submission of drug-negative samples. At group counseling sessions, therapists selected names randomly from the hat, and individuals whose names were drawn won prizes ranging from $1 to $100. Results: Patients assigned to CM earned a median of $160 in prizes, and they attended significantly more days of treatment (d = 0.25), remained in treatment for more continuous weeks (d = 0.40), and achieved longer durations of drug abstinence (d = 0.26) than patients randomized to SC. Group adherence and therapeutic alliance also improved with CM. In addition, HIV risk behaviors were significantly lower in CM relative to SC patients during early phases of treatment and at the 12-month follow-up. Conclusions: These data demonstrate that CM delivered in the context of outpatient group counseling can increase attendance and improve drug abstinence. (PsycINFO Database Record (c) 2011 APA, all rights reserved)