Interventions/Wilmer: a continuum of care for substance abusers in the criminal justice system.

This article describes a 300-bed substance abuse treatment program that is part of a continuum of care focused on preventing drug and criminal recidivism in substance abusing criminals incarcerated in Dallas County, Texas. It is the product of a joint effort of the judiciary, the Dallas County Supervision and Corrections Department, the State of Texas Criminal Justice Division, and Interventions Co., a not-for-profit treatment provider. The program is rooted in over 25 years of treatment experience and incorporates therapeutic community (TC) technology combined with 12-Step programming, behavior modification, job training (having a job is required for graduation), educational, and medical/psychiatric elements. Treatment is conceived as part of a continuum of care to provide substantial and sustained support for the inmate in the difficult process of adapting to the community post incarceration. Treatment plans are individualized and are based on an extended workup in which the individual's status in a number of domains is assessed. Specialized services, such as transportation and childcare, facilitate recovery. Once in the community, urine monitoring, groups, and counseling continue. The program is beginning its fourth year of operation and approximately 600 inmates have started the program. A formal evaluation is in process.

Medical maintenance: an interim report.

In a pilot study, 130 methadone maintained subjects with a six-month history of good treatment performance were assigned randomly, for a one-year study period, to an experimental condition (once per month non-random urine screen, counseling session and doctor visit, two times per month methadone pick up, a quarterly true random urine screen, and participation in a diversion control program), or they were assigned to a control condition of staying under standard conditions for six months and then being transferred to the experimental condition for six months. Three out of four subjects (73%) completed the year in good standing with no differences between control and experimental conditions. Subject satisfaction was such that the Institutional Review Board judged that return to standard conditions would be a hardship. A Study of Medical Maintenance (SMM) continues and extends the pilot study with two protocols: (1) for new subjects and (2) for subjects entered from the pilot study. SMM requires a once per month random urine screen and extends the experimental condition to two years but is otherwise identical to the pilot study; 71 of 107 S's (66%) entered protocol 1 and are in good standing. Pilot subjects (N = 75) are holding their good performance, some for over four years. The reduced levels of services in these studies free up resources which can be applied to entering IDU's into treatment thereby contributing to a slowing of the HIV epidemic.

Medical maintenance: a pilot study.

In a one year study, 130 methadone maintained subjects with a six month history of good treatment performance were assigned randomly to an experimental condition of one monthly non-random urine screen, one monthly counseling session, one monthly doctor visit, two times per month methadone pick up, a quarterly true random urine screen and participation in a diversion control program or to a control condition of staying under standard conditions for six months and then being transferred to the experimental condition for six months. Results of urine screens and scores on the Addiction Severity Index (ASI) at entrance and six month intervals showed no differences between groups. Three out of four subjects completed the year in good standing. Subject satisfaction was such that the IRB judged that return to standard conditions would be a hardship. Experimental conditions were cheaper such that resources freed up could be applied to the HIV epidemic.

Enhanced assays detect increased chromosome damage and sister-chromatid exchanges in heroin addicts.

To refine previous studies of chromosome damage (CD) and sister-chromatid exchanges (SCE) in heroin addicts, we applied new methods developed in our laboratory to enhance detection of the cytogenetic effects of low-level radiation exposure in hospital workers. For CD analysis, we applied our thymidine-fluorodeoxyuridine-caffeine (TFC) enhancement procedure in which cells at setup receive 1 x 10(-7) M fluorodeoxyuridine to inhibit thymidylate synthetase and 4 X 10(-5) M thymidine to satisfy the induced requirement, and then in G2 receive 2.2 mM caffeine to modulate DNA repair. For SCE enhancement, caffeine treatment was initiated in G1 at 19 h before harvest. Using both standard and enhanced procedures for CD and SCE analysis, blood samples were evaluated from 20 street heroin addicts and 22 controls. Standard 2-day CD and 3-day SCE assays showed small, insignificant genotoxic increases in addicts while the enhanced CD and SCE assays showed highly significant increases. Most CD events were in the form of chromatid and chromosome breaks. There were no rings and only a few dicentrics were observed in the TFC-enhanced cultures. Although quadriradials are rare, 10 were found in addict TFC-cultures and 3 in control TFC-cultures. With the standard CD assay, the mean number of chromosome breaks per 100 cells was 0.727 for controls and 1.056 for addicts (not significant). With the TFC-enhanced assay, the same measure showed 1.483 chromosome breaks for controls and 5.143 for addicts (highly significant, ANOVA: p less than 0.0001). A highly significant difference was also observed for chromatid-type damage with the TFC-enhanced assay (chromatid breaks per 100 cells: 16.793 for controls; 48.191 for addicts). The SCE data also showed significant differences with the enhanced assay. Scoring 25 cells/condition, standard SCE cultures showed 10.892 SCE/cell for controls and 11.732 SCE/cell for addicts (not significant). With CAF enhancement there were 13.08 SCE/cell for controls and 17.05 SCE/cell for addicts (ANOVA: p less than 0.008). These findings indicate that detection of CD and SCE effects can be significantly enhanced by the use of these new procedures. The finding of greatly increased chromatid damage in the addicts with the TFC procedure suggests that at least part of the CD detected occurred in vitro and is not a product of prior in vivo damage. Therefore exposure to this drug and perhaps other environmental agents may not only leave a residue of DNA or chromosome damage but may also induce a sensitivity to further genotoxic damage that is revealed by using the enhanced procedures.

Coordinate and independent effects of heroin, cocaine, and alcohol abuse on T-cell E-rosette formation and antigenic marker expression.

Simultaneous and independent use of cocaine and alcohol by heroin addicts was shown to variably modulate the ability of their T cells to form E-rosettes with sheep erythrocytes (E). As reported previously, the percentages of E-rosette-forming T cells of both active and total types were depressed in association with heroin addiction. We show here that the kinetic curve of the rate of E-rosette formation is also depressed by heroin use and that the use of cocaine but not alcohol by heroin addicts reverses depression of E-rosette formation by heroin. The percentages of E-rosette-forming T cells from the bloods of heroin addicts who used both alcohol and cocaine, as well as the kinetic rate curves of E-rosette formation, were intermediate between the essentially normal levels found for heroin addicts who used cocaine and the severely depressed levels evident for users of heroin alone or heroin plus alcohol. Modulation of the levels of E-rosette formation by alcohol used in conjunction with cocaine and/or heroin was variably dose dependent. Polydrug effects evident by analyses of E-rosette formation were not seen when the percentages of lymphocytes reactive with LYT-3 (anti-E-receptor, 9.6 epitope) and OKT-3 (anti-total T cell) monoclonal antibodies were assessed cytofluorometrically, although the data suggested that subnormal percentages of LYT-3+ T cells were present when heroin addicts also used cocaine. These findings are relevant to basic understanding of T-cell physiology from a neuroimmunological perspective and also suggest ways that addictive drugs may modulate the immunocompetence of drug addicts.

Parallel increases in sister-chromatid exchanges at base level and with UV treatment in human opiate users.

The SCE base level frequency and SCE levels induced by far-UV (254 nm) treatment of cells in early G1 and early S phases of the cell cycle were significantly higher in leukocytes from heroin addicts as compared to controls. The increased SCE levels in addicts was greatest at base level and smallest after UV irradiation of cells in S phase. These results corroborate and extend our previous findings of increased chromosome damage and reduced DNA-repair synthesis in heroin users. Since opiates do not directly damage DNA, the elevated cytogenetic effects associated with opiate use probably arise from secondary promotional effects related to opiate-mediated alterations in leukocyte metabolism.

Westend, a methadone clinic: structural aspects of addiction.

A case of a 1970s methadone clinic is presented within the context of a theory of family dynamics which includes a "perverse triangle." The study of the clinic, its clients, and their families reveals a number of pervasive conflicts and covert coalitions. In the clinic, clients and paraprofessionals combine to undercut professionals and limit the effects of any meaningful treatment. Nontherapeutic alliances, first experienced in the family of the addict, are replicated not only in the clinic but in the treatment system as a whole. The effects of these pathogenic relationships, at any organizational level, are to inhibit the maturation of the addict.

Alteration of T and null lymphocyte frequencies in the peripheral blood of human opiate addicts: in vivo evidence for opiate receptor sites on T lymphocytes.

Street opiate addiction produces a significant depression in the absolute number of total T lymphocytes in peripheral blood as measured by the ability of the lymphocytes to rosette sheep red blood cells (SRBC). Associated with the decrease in T cells, there is an increase in the absolute number of null lymphocytes but no significant changes in B lymphocytes or total white blood cell count. The T cell values for 2 different populations of addicts (n = 12 and 32) are 31.8% and 23.1%, whereas the null cell values are 51.1% and 57.6%, respectively. The values for comparable control populations (n = 18 and 10) are: T% = 70.7% and 67.4%, and null % = 9.2% and 14.5%. Self-reported use of marihuana does not significantly alter the distribution of cell populations. A 1- to 3-hr incubation of addicted-derived lymphocytes with 10(-6) to 10(-7) M Naloxone reverses both T cell depression and null cell increase by allowing the null cells to express SRBC receptors. Cyclic AMP and dibutyryl cyclic AMP can also convert the null cells to T cells. The conversion of null to T lymphocytes has additionally been measured by monitoring the increase in PHA-stimulated growth in 72-hr cultures as determined by tritiated thymidine incorporation into DNA. These results support the hypothesis that opiates can alter T lymphocyte number and function in vivo, and that this alteration may produce a significant degeneration in the immune competence of street opiate addicts.