Prescription Drug Monitoring Program Use: National Dental PBRN Results.

INTRODUCTION: The American Dental Association recommends that dentists use a prescription drug monitoring program (PDMP) prior to prescribing an opioid for acute pain management. OBJECTIVE: The objective of this study was to examine dentists' experiences using their state PDMP, as well as the impact that state-mandated registration policies, mandated use policies, and practice characteristics had on the frequency with which dentists used their PDMP. METHODS: We conducted a web-based cross-sectional survey among practicing dentist members of the National Dental Practice-Based Research Network ( n = 805). The survey assessed prescribing practices for pain management and implementation of risk mitigation strategies, including PDMP use. Survey data were linked with network Enrollment Questionnaire data to include practitioner demographics and practice characteristics. RESULTS: Nearly half of respondents ( n = 375, 46.6%) reported having never accessed a PDMP, with the most common reasons for nonaccess being lack of awareness ( n = 214, 57.1%) and lack of knowledge regarding registration and use ( n = 94, 25.1%). The majority of PDMP users reported the program to be very helpful (58.1%) or somewhat helpful (31.6%). Dentists reported that PDMP use most often did not change their intended prescribing behavior (40.2%), led them not to prescribe an opioid (33.5%), or led them to prescribe fewer opioid doses (25.5%). Presence of a mandated use policy was significantly associated with increased frequency of PDMP use across a variety of situations, including prior to 1) prescribing any opioid for pain management, 2) issuing refills, 3) prescribing to new patients, and 4) prescribing to patients deemed high risk. CONCLUSION: Findings suggest that the majority of dentists find PDMPs helpful in informing their opioid-prescribing practices. Whereas the existence of a state-mandated use policy is a consistent predictor of dentists' PDMP use, outreach and education efforts may overcome key barriers to use identified in this study. KNOWLEDGE TRANSFER STATEMENT: Findings from this national survey suggest that the majority of practicing dentists find PDMPs helpful in informing their opioid-prescribing practices; however, consistent PDMP use was not common. Whereas the existence of a state-mandated use policy is a consistent predictor of dentists' PDMP use, outreach and education efforts may overcome key barriers to use identified in this study.

Effects of yohimbine and drug cues on impulsivity and attention in cocaine-dependent men and women and sex-matched controls.

BACKGROUND: Deficits in executive function have been associated with risk for relapse. Data from previous studies suggest that relapse may be triggered by stress and drug-paired cues and that there are significant sex differences in the magnitude of these responses. The aim of this study was to examine the impact of the pharmacological stressor and alpha-2 adrenergic receptor antagonist yohimbine and cocaine cues on executive function in cocaine-dependent men and women. METHODS: In a double-blind placebo controlled cross-over study, cocaine-dependent men (n=12), cocaine-dependent women (n=27), control men (n=31) and control women (n=25) received either yohimbine or placebo prior to two cocaine cue exposure sessions. Participants performed the Connors' Continuous Performance Test II prior to medication/placebo administration and immediately after each cue exposure session RESULTS: Healthy controls had a significant increase in commission errors under the yohimbine condition [RR (95% CI)=1.1 (1.0-1.3), χ(2)1=2.0, p=0.050]. Cocaine-dependent individuals exhibited a significant decrease in omission errors under the yohimbine condition [RR (95% CI)=0.6 (0.4-0.8), χ(2)1=8.6, p=0.003]. Cocaine-dependent women had more omission errors as compared to cocaine-dependent men regardless of treatment [RR (95% CI)=7.2 (3.6-14.7), χ(2)1=30.1, p<0.001]. Cocaine-dependent women exhibited a slower hit reaction time as compared to cocaine-dependent men [Female 354 ± 13 vs. Male 415 ± 14; t89=2.6, p=0.012]. CONCLUSIONS: These data add to a growing literature demonstrating significant sex differences in behaviors associated with relapse in cocaine-dependent individuals.

Efficacy of sertraline in preventing relapse of posttraumatic stress disorder: results of a 28-week double-blind, placebo-controlled study.

OBJECTIVE: The study examined the efficacy of sertraline, compared with placebo, in sustaining improvement and preventing relapse over 28 weeks in patients with posttraumatic stress disorder (PTSD) who had completed a 12-week double-blind, placebo-controlled acute treatment study and a subsequent 24-week open-label study of continuation treatment with sertraline. METHOD: Ninety-six patients were randomly assigned, in a double-blind design, to 28 weeks of maintenance treatment with sertraline (50-200 mg, N=46; 78% were women) or placebo (N=50; 62% were women). Measures used in biweekly assessments included the Clinician-Administered PTSD Scale, the Impact of Event Scale, and the Clinical Global Impression severity and improvement ratings. Kaplan-Meier analyses were used to estimate time to discontinuation from the study due to relapse, relapse or study discontinuation due to clinical deterioration, and acute exacerbation. RESULTS: Continued treatment with sertraline yielded lower PTSD relapse rates than placebo (5% versus 26%). Patients who received placebo were 6.4 times as likely to experience relapse as were patients who received sertraline. Kaplan-Meier analyses confirmed the protective effect of sertraline in significantly extending time in remission. The ability of sertraline to sustain improvement was comparable across the three core PTSD symptom clusters (reexperiencing/intrusion, avoidance/numbing, and hyperarousal). A regression analysis found early response during acute treatment to be associated with a more than 16-fold reduced risk of relapse after placebo substitution. Sertraline, at a mean endpoint dose of 137 mg, was well tolerated, with no sertraline-related adverse events observed at a rate of 10% or higher. CONCLUSIONS: The results provide evidence for the ability of sertraline both to sustain improvement in PTSD symptoms and to provide prophylactic protection against relapse.

Paroxetine for social anxiety and alcohol use in dual-diagnosed patients.

The objective of this study was to compare the efficacy and tolerability of paroxetine to matched placebo in adults with co-occurring social anxiety disorder and alcohol use disorder. Outcome measures included standardized indices of social anxiety and alcohol use. Fifteen individuals meeting DSM-IV criteria for both social anxiety disorder and alcohol use disorder were randomized to treatment. Paroxetine (n = 6) or placebo (n = 9) was given in a double-blind format for 8 weeks using a flexible dosing schedule. Dosing began at 20 mg/d and increased to a target dose of 60 mg/d. There was a significant effect of treatment group on social anxiety symptoms, where patients treated with paroxetine improved more than those treated with placebo on both the Clinical Global Index (CGI) and the Liebowitz Social Anxiety Scale (Ps < or = 0.05). On alcohol use, there was not a significant effect of treatment on quantity/frequency measures of drinking, but there was for the CGI ratings (50% paroxetine patients versus 11% placebo patients were improvers on drinking, P < or = 0.05). This pilot study suggests that paroxetine is an effective treatment for social anxiety disorder in individuals with comorbid alcohol problems, and positive treatment effects can be seen in as little as 8 weeks. Further study is warranted to investigate its utility in helping affected individuals reduce alcohol use.

Divalproex loading in the treatment of cocaine dependence.

The current pilot project was designed to evaluate the safety and tolerability of a loading dose of divalproex (DVPX) in subjects with cocaine dependence. Seventeen cocaine-dependent subjects were enrolled in an eight-week, open-label trial of 20 mg/kg/day DVPX. Subjects were seen weekly and urine drug screens were obtained at each visit. Over the eight-week trial, craving intensity and frequency as well as reported time using cocaine decreased significantly. Retention in the current study was 79% at week four and 50% at week eight. The medication and dosing strategy was well tolerated. This pilot study indicates that DVPX loading is well tolerated and may be efficacious in the treatment of cocaine dependence. A placebo-controlled trial would be of interest.

Exposure therapy in the treatment of PTSD among cocaine-dependent individuals: description of procedures.

An estimated 30% to 50% of cocaine-dependent individuals meet criteria for lifetime PTSD. This comorbidity has detrimental effects on clinical presentation, and treatment course and outcome. Cocaine dependence is associated with increased rates of exposure to trauma, more severe symptoms, higher rates of treatment attrition and retraumatization, and greater vulnerability to PTSD when compared to other substance use disorders. These associations underscore the need for effective treatments that address issues particular to PTSD in a manner tolerable to cocaine-dependent individuals. This article describes a manualized psychotherapy developed specifically for individuals with PTSD and cocaine dependence. Concurrent Treatment of PTSD and Cocaine Dependence (CTPCD) provides coping skills training, cognitive restructuring techniques, and relapse prevention strategies to reduce cocaine use. In-vivo and imaginal exposure therapy techniques are incorporated to reduce PTSD symptom severity. Primary treatment goals include psychoeducation specific to the interrelationship between PTSD and cocaine dependence, and clinically meaningful reductions in cocaine use and PTSD symptomatology. Secondary goals include a reduction in HIV high-risk behaviors and improved functioning in associated areas, such as anger and negative affect management.

Exposure therapy in the treatment of PTSD among cocaine-dependent individuals: preliminary findings.

Individuals (n = 39) participated in an outpatient, 16-session individual, manual-guided psychotherapy designed to treat concurrent PTSD and cocaine dependence. Therapy consisted of a combination of imaginal and in-vivo exposure therapy techniques to treat PTSD symptoms and cognitive-behavioral techniques to treat cocaine dependence. Although the dropout rate was high, treatment completers (i.e., patients who attended at least 10 sessions; n = 15) demonstrated significant reductions in all PTSD symptom clusters and cocaine use from baseline to end of treatment. Significant reductions in depressive symptomatology, as measured by the Beck Depression Inventory, and psychiatric and cocaine use severity, as measured by the Addiction Severity Index, were also observed. These improvements in PTSD symptoms and cocaine use were maintained over a 6-month follow-up period among completers. The average pre- to posttreatment effect size was 1.80 for PTSD symptoms and 1.26 for drug and alcohol use severity. Baseline comparisons between treatment completers and noncompleters revealed significantly higher avoidance symptoms, as measured by the Impact of Events Scale, and fewer years of education among treatment noncompleters as compared to completers. This study provides preliminary evidence to suggest that exposure therapy can be used safely and may be effective in the treatment of PTSD in some individuals with cocaine dependence. However, the study is limited by the uncontrolled nature of the study design, small number of subjects, and high dropout rate.

Review of sertraline and its clinical applications in psychiatric disorders.

Sertraline (Zoloft, Pfizer) has been shown in numerous controlled studies to have similar efficacy to other selective serotonin (5-HT) re-uptake inhibitors (SSRIs) in the treatment of depression and anxiety disorders. Further research is indicating that the efficacy of sertraline extends even beyond the treatment of depression and anxiety to include utility in eating disorders, premenstrual dysphoric disorder (PMDD) and possibly substance abuse treatment. Along with other SSRIs, sertraline offers several advantages over older antidepressants, including improved patient tolerability, low risk of lethality in overdose and no dependence potential. In head-to-head comparisons, sertraline appears to be at least as well-tolerated as other SSRIs and may even have a more favourable side effect profile. Low potential for pharmacokinetic drug interactions is another advantage of sertraline. Unlike fluoxetine, fluvoxamine and paroxetine, sertraline is not a potent inhibitor of any of the cytochrome P450 isoenzyme systems. As a result of its proven efficacy, good tolerability and lack of pharmacokinetic interactions, sertraline should be considered first-line in the treatment of anxiety and depressive disorders.

Alcohol and substance abuse.

Substance abuse and dependence is a public health problem with far-reaching societal implications. The acute toxicity of substances of abuse and medical consequences of chronic use are substantial. On a more optimistic note, a great deal of progress has been made in understanding and treating substance use disorders. Expanding knowledge concerning the neurobiology of substances of abuse and substance use disorders has led to a growth in pharmacotherapeutic treatment options. A growth in understanding of behavioral processes, motivational issues, and processes of behavioral change has been important in designing new and increasingly more effective psychosocial treatments. A growing body of evidence indicates that the treatment of substance use disorders can be effective, making early diagnosis and treatment or referral increasingly important.

Adverse outcomes in a controlled trial of pergolide for cocaine dependence.

We conducted a double-blind, multiple dose comparison study of pergolide versus placebo for the treatment of cocaine dependence. In the present study, we examined patients who met criteria for cocaine dependence without comorbid alcohol dependence (N = 255). Study completion rates favored placebo (48.9%) over the low dose (33.3%) and high dose (21.5%) pergolide subjects (chi2(2) = 14.17, p < or = 0.001). Treatment effectiveness scores (TES) were significantly higher for the placebo group (31.7) than the low dose (25.2) and high dose (14.2) pergolide groups (F2,252 = 6.21, p = 0.002). There were no significant differences in side effect profiles after first dose of pergolide or placebo, or at study termination. Results of this study suggest that pergolide was not efficacious in the treatment of cocaine dependence due to reduced study participation. Caution regarding the outpatient use of pergolide in similar populations is warranted.

Update on anticonvulsants for the treatment of alcohol withdrawal.

Some anticonvulsants have been shown to be as effective as some benzodiazepines for the treatment of alcohol withdrawal. Anticonvulsants may offer advantages over benzodiazepines in the outpatient treatment of alcohol withdrawal: they lack abuse potential, have minimal interactions with alcohol, and may be more effective in ameliorating psychiatric symptoms of alcohol withdrawal. Carbamazepine appears to be as effective as lorazepam and oxazepam in ameliorating the symptoms of alcohol withdrawal. In addition, a recent study indicates that carbamazepine may suppress post-withdrawal alcohol use. Divalproex may also reduce symptoms of alcohol withdrawal, based on several open-label studies. However, both carbamazepine and divalproex have limited usefulness in alcoholics with severe hepatic or hematologic complications. Newer anticonvulsants, such as gabapentin and vigabatrin, also appear to reduce alcohol withdrawal symptoms in preclinical and open-label clinical trials while lacking the toxicities of carbamazepine and divalproex. Controlled trials are underway exploring the efficacy and safety of newer anticonvulsants for the treatment of alcohol withdrawal.

New developments in the pharmacotherapy of alcohol dependence.

Neuroscientific underpinnings and pharmacotherapeutic treatments of substance use disorders are rapidly developing areas of study. In particular, there have been exciting new developments in our understanding of the involvement of excitatory amino acid neurotransmitter systems and the opiate and serotonin systems in the pathophysiology of alcohol withdrawal, alcohol dependence, and in subtypes of individuals with alcoholism. In this article, new developments in the pharmacotherapy of alcohol dependence will be reviewed. In particular, the use of anticonvulsants in alcohol withdrawal and protracted abstinence syndromes will be discussed. New data on opiate antagonists and acamprosate, an agent that exerts actions through excitatory amino acid systems in relapse prevention, will be reviewed. Finally, there will be a review of new data concerning the use of serotonin reuptake inhibitors in subtypes of alcoholism and the use of combination pharmacotherapy.

Gabapentin in the treatment of cocaine dependence: a case series.

BACKGROUND: Although multiple medications have been studied for the treatment of cocaine dependence, no medication has been shown to have a robust effect on craving and use. This pilot project was designed to evaluate the safety and tolerability of gabapentin in subjects with cocaine dependence. METHOD: Thirty cocaine-dependent subjects (DSM-IV criteria) were enrolled in an 8-week, open-label trial of 1,200 mg/day of gabapentin in divided doses. Urine drug screens, subjective measures of craving, and cocaine use interviews were conducted at each weekly visit. RESULTS: Baseline rating of amount and frequency of craving decreased significantly by week 8 (78% vs. 25% for amount, p = .000; 74% vs. 23% for frequency, p = .004). Positive urine drug screens for cocaine decreased from 86% at baseline to 29% at weeks 4 and 8. There were no reports of significant side effects or adverse events. CONCLUSION: This pilot study indicates that gabapentin is safe and well tolerated and may be beneficial in the treatment of cocaine dependence. A placebo-controlled trial would be of interest.

Skin conductance hypo-responding in recently abstinent cocaine dependent inpatients.

Skin conductance has been used as a measure of physiological arousal in cocaine cue reactivity studies. In this study, skin conductance responses in recently abstinent (average 3.1 +/- 1.7 days) cocaine dependent inpatients (N = 30) were assessed. A video depicting individuals preparing and using cocaine was the cue stimulus. Skin conductance responses were not increased by the stimulus cue. Several explanations are explored that may support not using skin conductance as an outcome measure in recently abstinent cocaine dependent patients.

A double-blind, placebo-controlled outpatient trial of pergolide for cocaine dependence.

Results of preclinical studies suggest that pergolide, a mixed D(1)/D(2) dopamine receptor agonist, may be useful in treating cocaine dependence. To empirically investigate this possibility, we conducted a 5-year, double-blind, placebo-controlled clinical trial of two doses of pergolide (0.05 and 0.25 mg bid) in subjects with cocaine dependence and combined cocaine/alcohol dependence. Data analysis was performed on an intent to treat population (N=358) and a per protocol population (N=108) with urine drug screens (UDS) used as the main outcome measure. There were no significant effects on UDS at either pergolide dose. Pergolide had no significant effect on alcohol use in the comorbid alcohol/cocaine dependence group. Pergolide does not appear to have clinical value in the treatment of cocaine dependence or in decreasing alcohol use in cocaine-dependent individuals at the presently studied doses.

Cocaine dependence with and without post-traumatic stress disorder: a comparison of substance use, trauma history and psychiatric comorbidity.

This study examined the relationship between substance use, trauma history, post-traumatic stress disorder (PTSD), and psychiatric comorbidity in a treatment seeking sample of cocaine dependent individuals (N = 91). Structured clinical interviews revealed that 42.9% of the sample met DSM-III-R criteria for lifetime PTSD. Comparisons between individuals with and without lifetime PTSD revealed that individuals with PTSD had significantly higher rates of exposure to traumatic events, earlier age of first assault, more severe symptomatology, and higher rates of Axis I and Axis II diagnoses. The results illustrate a high incidence of PTSD among cocaine dependent individuals. Routine assessment of trauma history and PTSD may assist in the identification of a subgroup of cocaine users in need of special prevention and treatment efforts.

Parental stress and child behavioral outcomes following substance abuse residential treatment. Follow-up at 6 and 12 months.

Residential treatment programs specifically designed for alcohol/drug-addicted women and their children have become a popular treatment modality across the United States. Outcome evaluation of these programs are beginning to show promising results. In this article, outcome data from a study of a residential substance abuse treatment program for women and young children in rural South Carolina will be presented. Data from 35 women and 23 children in the area of addiction severity, parenting and child emotional and behavioral development at 6 and 12 months following discharge from a substance abuse residential treatment program is examined. Results showed that women who completed treatment had better scores on addiction severity and parental stress, and their children had improved behavioral and emotional functioning at 6 and 12 months after discharge from the program. These results suggest that residential treatment has benefits for mothers and their children. This data adds to the growing body of evidence supporting intensive and inclusive care for certain groups of individuals with substance use disorders during critical periods.

Comorbidity of psychiatric disorders and posttraumatic stress disorder.

Posttraumatic stress disorder (PTSD) commonly co-occurs with other psychiatric disorders. Data from epidemiologic surveys indicate that the vast majority of individuals with PTSD meet criteria for at least one other psychiatric disorder, and a substantial percentage have 3 or more other psychiatric diagnoses. A number of different hypothetical constructs have been posited to explain this high comorbidity; for example, the self-medication hypothesis has often been applied to understand the relationship between PTSD and substance use disorders. There is a substantial amount of symptom overlap between PTSD and a number of other psychiatric diagnoses, particularly major depressive disorder. It has been suggested that high rates of comorbidity may be simply an epiphenomenon of the diagnostic criteria used. In any case, this high degree of symptom overlap can contribute to diagnostic confusion and, in particular, to the underdiagnosis of PTSD when trauma histories are not specifically obtained. The most common comorbid diagnoses are depressive disorders, substance use disorders, and other anxiety disorders. The comorbidity of PTSD and depressive disorders is of particular interest. Across a number of studies, these are the disorders most likely to co-occur with PTSD. It is also clear that depressive disorder can be a common and independent sequela of exposure to trauma and having a previous depressive disorder is a risk factor for the development of PTSD once exposure to a trauma occurs. The comorbidity of PTSD with substance use disorders is complex because while a substance use disorder may often develop as an attempt to self-medicate the painful symptoms of PTSD, withdrawal states exaggerate these symptoms. Appropriate treatment of PTSD in substance abusers is a controversial issue because of the belief that addressing issues related to the trauma in early recovery can precipitate relapse. In conclusion, comorbidity in PTSD is the rule rather than the exception. This area warrants much further study since comorbid conditions may provide a rationale for the subtyping of individuals with PTSD to optimize treatment outcomes.