Emerging adult age status predicts poor buprenorphine treatment retention.

Emerging adults (18-25 years old) are often poorly retained in substance use disorder treatment. Office-based buprenorphine often enhances treatment retention among people with opioid dependence. In this study, we examined the records of a collaborative care buprenorphine treatment program to compare the treatment retention rates of emerging adults versus older adults. Subjects were 294 adults, 71 (24%) aged 18-25, followed in treatment with buprenorphine, nurse care management, and an intensive outpatient program followed by weekly psychosocial treatment. Compared to older adults, emerging adults remained in treatment at a significantly lower rate at 3 months (56% versus 78%) and 12 months (17% versus 45%), and were significantly more likely to test positive for illicit opioids, relapse, or drop out of treatment. Further research into factors associated with buprenorphine treatment retention among emerging adults is needed to improve treatment and long-term outcomes in this group.

Benzodiazepine use during buprenorphine treatment for opioid dependence: clinical and safety outcomes.

BACKGROUND: Prescribing benzodiazepines during buprenorphine treatment is a topic of active discussion. Clinical benefit is unclear. Overdose, accidental injury, and benzodiazepine misuse remain concerns. We examine the relationship between benzodiazepine misuse history, benzodiazepine prescription, and both clinical and safety outcomes during buprenorphine treatment. METHODS: We retrospectively examined outpatient buprenorphine treatment records, classifying patients by past-year benzodiazepine misuse history and approved benzodiazepine prescription at intake. Primary clinical outcomes included 12-month treatment retention and urine toxicology for illicit opioids. Primary safety outcomes included total emergency department (ED) visits and odds of an ED visit related to overdose or accidental injury during treatment. RESULTS: The 12-month treatment retention rate for the sample (N=328) was 40%. Neither benzodiazepine misuse history nor benzodiazepine prescription was associated with treatment retention or illicit opioid use. Poisson regressions of ED visits during buprenorphine treatment revealed more ED visits among those with a benzodiazepine prescription versus those without (p<0.001); benzodiazepine misuse history had no effect. The odds of an accidental injury-related ED visit during treatment were greater among those with a benzodiazepine prescription (OR: 3.7, p<0.01), with an enhanced effect among females (OR: 4.7, p<0.01). Overdose was not associated with benzodiazepine misuse history or prescription. CONCLUSIONS: We found no effect of benzodiazepine prescriptions on opioid treatment outcomes; however, benzodiazepine prescription was associated with more frequent ED visits and accidental injuries, especially among females. When prescribing benzodiazepines during buprenorphine treatment, patients need more education about accidental injury risk. Alternative treatments for anxiety should be considered when possible, especially among females.

Bipolar disorder as a risk factor for repeat DUI behavior.

BACKGROUND: Bipolar disorder (BD) is more prevalent among people with substance use disorders (SUD) than the general population. SUD among recidivist driving under the influence (DUI) populations are extremely prevalent; not surprisingly, recent evidence suggests that rates of BD also are elevated among DUI offenders. Studies of BD patients with SUD have found high prevalence of other psychiatric disorders and relatively low rate of treatment engagement. This study examines both the prevalence of other mental disorders and treatment status among a cohort of DUI offenders with BD and SUD. METHODS: A consecutively selected cohort (N=729) of repeat DUI offenders attending a two-week inpatient treatment program completed a standardized diagnostic interview (the Composite International Diagnostic Interview: CIDI). The CIDI generated DSM-IV diagnoses. RESULTS: This study yielded three main results for this repeat DUI offender sample: (1) BD is associated with significantly higher lifetime prevalence of alcohol, drug, and non-substance psychiatric disorders (e.g., PTSD); (2) approximately one quarter of BD participants have not discussed their mania with a professional; and (3) only half of the BD participants in this cohort have had mania treatment they consider effective and even fewer have had any treatment during the past twelve months. LIMITATIONS: Participants were predominantly Caucasian males attending treatment as a sentencing option in a single Massachusetts DUI program. CONCLUSION: These findings suggest that clinicians in DUI treatment settings should consider both evaluating for BD and initiating therapy.

Substance use disorder and other predictors of antidepressant-induced mania: a retrospective chart review.

OBJECTIVE: To determine if substance use disorder (SUD) is a predictor of antidepressant-induced mania (ADM) in bipolar disorder, correcting for confounding factors in a regression model. METHOD: 335 antidepressant trials were identified in 98 patients treated in an academic bipolar specialty clinic from 2000 to 2004. Patient charts were reviewed, and histories of SUD and ADM (primary outcome; defined as a hypomanic or manic episode within 12 weeks of beginning an antidepressant trial) were identified. Mood disorder diagnoses were made using the Structured Clinical Interview for DSM-IV mood module, and SUD diagnoses were defined using DSM-IV criteria. Potential confounding variables were also examined and included in a multivariable regression model. Concomitant mood stabilizer, antimanic, and antidepressant use was adjusted for in the regression model. RESULTS: In univariate analyses, there was no evidence of an association between ADM and past SUD. However, after adjustment for confounding variables in a multivariable regression model, there was a strong relationship (OR = 5.06, 95% CI = 1.31 to 19.64, p < .05). Other statistically significant predictors of ADM in the regression model were type II subtype of bipolar illness, female gender, and tricyclic antidepressant (TCA) use (vs. bupropion). CONCLUSIONS: Along with other factors, a history of SUD was a strong predictor of ADM. Possible underestimation of ADM in randomized clinical trials may occur due to the exclusion of subjects with SUD. Type II illness, female gender, and TCA use also appeared to be predictors of ADM, while bupropion use appeared to predict lower likelihood of ADM.

Risperidone in cocaine-dependent patients with comorbid psychiatric disorders.

BACKGROUND: : A high percentage of individuals with cocaine dependence have a comorbid psychiatric illness, which complicates treatment of the substance abuse. This report will describe clinical experience using risperidone in cocaine-dependent patients with psychiatric disorders. METHOD: : Sixteen male patients with cocaine dependence and comorbid psychiatric disorder (DSM-III-R) diagnoses, who were admitted to a voluntary, post-detoxification, intermediate-care inpatient substance abuse program, were started on risperidone (mean starting dose 2.3 mg/day) in an open-label, naturalistic trial. Patients were assessed weekly using the Clinical Global Impressions scale to assess overall functioning, a Likert scale for craving, the Abnormal Involuntary Movement Scale, interviews with substance abuse counselors and patients, and laboratory tests. All patients had at least one other substance use diagnosis besides cocaine dependence, and 13 patients were taking another psychiatric medication. RESULTS: : Of the 16 patients, 13 (81%) were rated improved or much improved on the CGI scale, and all patients reported mild or no craving at the last assessment (after a mean of 32.6 days of risperidone treatment). No patient developed extrapyramidal symptoms or hypomania. Compared to a 32% historical completion rate for patients receiving treatment as usual, fourteen (88%) of these patients completed the program, and 9 moved on to the next level of care. CONCLUSION: : The results of this naturalistic trial suggest that risperidone is safe and well tolerated in patients with cocaine dependence and comorbid psychiatric illness. In the short term, risperidone may also be effective in reducing cocaine craving and use and may increase the likelihood of completing substance abuse treatment.

Underdiagnosis of bipolar disorder in men with substance use disorder.

OBJECTIVE: Recent reports indicate that bipolar disorder is frequently underdiagnosed in the clinical population, leading to overuse of antidepressants and underuse of mood stabilizers. This study assessed rates of diagnosis of bipolar disorder in a substance abuse population. METHOD: The study involved a retrospective chart review of data from 295 patients admitted to an inpatient substance abuse program for men. Data were then analyzed from the 85 patients in the sample who were diagnosed as meeting DSM-IV criteria for bipolar disorder on intake into the program. Charts were reviewed for relevant clinical and demographic data. The primary outcome measure was the rate of previous misdiagnosis. RESULTS: Of the 85 patients diagnosed with bipolar disorder upon intake, 42 (49%) had not been previously diagnosed with bipolar disorder; of these 42, 6 (14%) patients had not been assessed previously, while 36 (86%) had been assessed previously and had received many other psychiatric diagnoses, including major depression (77%), attention-deficit/hyperactivity disorder (20%), and panic disorder (3%). Among the comorbid substance use disorders in these patients, alcohol dependence was the most common (62%), followed by cocaine (38%), opioid (26%), polysubstance (12%), and sedative-hypnotic (2%) dependence. Other comorbid Axis I disorders included posttraumatic stress disorder (14%), attention-deficit/hyperactivity disorder (10%), panic disorder (2%), and generalized anxiety disorder (2%). CONCLUSION: This study found that bipolar disorder had not been previously diagnosed in approximately 50% of a sample of Caucasian males in a substance abuse population who were diagnosed with bipolar disorder upon admission to an inpatient substance abuse program.

The bipolar patient with comorbid substance use disorder: recognition and management.

Bipolar patients with comorbid substance abuse or dependence ("dual diagnosis" patients) represent a major public health problem. Substance abuse generally predicts poor outcome and higher morbidity/mortality in bipolar disorder. For the purposes of this review, open and controlled studies of dual diagnosis assessment and treatment were located through electronic searches of several databases. Pertinent case reports were also evaluated. The results of the search were evaluated in light of the authors' own research on dual diagnosis patients. Literature searching revealed few controlled studies to guide pharmacotherapy of bipolar patients with comorbid substance abuse or dependence. However, preliminary evidence suggests that the best outcomes are usually achieved with antiepileptic mood stabilisers and/or atypical antipsychotics, combined with appropriate psychosocial interventions. The latter may include classical 12-step groups, integrated group therapy or individual psychotherapy. While it is often difficult to determine the precise pathway to comorbid bipolar disorder/substance abuse, it is clear that both disorders must be vigorously treated. This requires a carefully integrated biopsychosocial approach, involving appropriate mood stabilisers and psychosocial interventions. Many more controlled studies of these combined treatment approaches are needed.

The MICA Case Conference Program at Tewksbury Hospital, Mass.: an integrated treatment model.

This report describes the MICA (Mentally Ill Chemically Abusing) Program at the Tewksbury Hospital campus in Tewksbury, Massachusetts. Several campus facilities collaborate in the MICA Program. Through Expert Case Conferences, principles of integrated psychosocial treatment with dual diagnosis patients are demonstrated. An expert clinician focuses on the interplay between psychological pain, characterological traits, defenses, and the patient's drug of choice. Patients who have participated in the program have reported positive experiences. The staff reported that the program has resulted in facility improvement in assessment and treatment of complex dual diagnosis patients.