Regular use of alcohol and tobacco in India and its association with age, gender, and poverty.

This study provides national estimates of regular tobacco and alcohol use in India and their associations with gender, age, and economic group obtained from a representative survey of 471,143 people over the age of 10 years in 1995-96, the National Sample Survey. The national prevalence of regular use of smoking tobacco is estimated to be 16.2%, chewing tobacco 14.0%, and alcohol 4.5%. Men were 25.5 times more likely than women to report regular smoking, 3.7 times more likely to regularly chew tobacco, and 9.7 times more likely to regularly use alcohol. Respondents belonging to scheduled castes and tribes (recognized disadvantaged groups) were significantly more likely to report regular use of alcohol as well as smoking and chewing tobacco. People from rural areas had higher rates compared to urban dwellers, as did those with no formal education. Individuals with incomes below the poverty line had higher relative odds of use of chewing tobacco and alcohol compared to those above the poverty line. The regular use of both tobacco and alcohol also increased significantly with each diminishing income quintile. Comparisons are made between these results and those found in the United States and elsewhere, highlighting the need to address control of these substances on the public health agenda.

Influence of antisocial personality subtypes on drug abuse treatment response.

This methodological study examined the impact of antisocial personality disorder (APD) and other psychiatric comorbidity on drug use and treatment retention in 513 new admissions to methadone maintenance treatment. Patients were classified into one of four groups: APD ONLY, APD plus other psychiatric disorder (APD MIXED), other psychiatric disorder, and no psychiatric disorder. Patients completed research assessments and were then followed for 1 year of treatment. Patients with APD had longer histories of heroin and cocaine use than non-APD patients and were more likely to meet criteria for cocaine dependence. Distinct clinical profiles emerged that differentiated APD ONLY from APD MIXED. APD ONLY patients exhibited higher rates of cocaine and heroin use, whereas those with APD MIXED exhibited higher rates of benzodiazepine use. Self-report measures supported urinalysis results, but group differences did not affect treatment retention. These differences in clinical profiles should be considered when evaluating treatment performance in substance abusers with APD.

Short-term stability of NEO-PI-R personality trait scores in opioid-dependent outpatients.

The present study examined the short-term stability of personality trait scores from the Revised NEO Personality Inventory (NEO-PI-R) among 230 opioid-dependent outpatients. The NEO-PI-R is a 240-item empirically developed measure of the five-factor model of personality (Neuroticism, Extraversion, Openness, Agreeableness, and Conscientiousness). Participants completed the NEO-PI-R at admission and again approximately 19 weeks later. Results indicated fair to good stability for all NEO-PI-R factor domain scores, with coefficients ranging from .68 to .74. Stability of NEO-PI-R scores was decreased among potentially invalid response patterns but was not significantly affected by drug-positive versus drug-negative status at follow-up.

Influence of psychiatric comorbidity on HIV risk behaviors: changes during drug abuse treatment.

This study evaluated whether psychiatric comorbidity is related to change in HIV high risk behaviors during outpatient drug abuse treatment. Participants were opioid abusers entering methadone treatment. Psychiatric and substance use diagnoses were determined at intake. Information on HIV high risk drug use and sexual behaviors, psychosocial functioning, and urine toxicology was assessed at intake and at month six. Subjects were divided into those with versus without a lifetime comorbid non-substance use psychiatric disorder. The comorbid group reported more injection equipment sharing, lower rates of condom use, and higher rates of alcohol use at intake and follow-up. Overall injection drug use behavior decreased over the follow-up period for both groups, however. Methadone treatment had a beneficial effect on HIV risk behaviors, and though some risk behaviors improved signiticantly for both groups, comorbid subjects continued to have higher rates of HIV risk factors than noncomorbid subjects.

A 12-year follow-up of a methadone medical maintenance program.

Methadone Medical Maintenance (MDM) is an alternative for treatment of stable methadone maintained individuals. It involves a monthly physician's visit, at which methadone take-home doses are dispensed to last until the next appointment. The safety and efficacy of this treatment modality is currently under investigation. The purpose of this study was to evaluate the long-term safety and efficacy of MDM in a methadone program in Baltimore. A sample of 21 patients was enrolled in the study and followed for 12 years. They were evaluated once a month by a primary care physician affiliated with a methadone clinic who collected urine toxicology samples and dispensed the monthly methadone dose. The results showed that only 6 (28.6%) patients dropped out during the 12 years of the study. Twelve (0.5%) of 2,290 urine samples collected were positive for drugs. No methadone overdose or diversion was observed. Participants reported significant improvement in their quality of life. The results of this study support the safety and efficacy of medical maintenance of stable methadone maintained individuals.

Attention deficit hyperactivity disorder and treatment outcome in opioid abusers entering treatment.

Symptoms of DSM-IV attention-deficit hyperactivity disorder (ADHD) were determined in patients entering methadone maintenance treatment. The relationship of ADHD to psychiatric and substance abuse comorbidity, attention testing, and treatment outcome was analyzed; 19% of patients had a history of ADHD, and 88% of these had current symptoms. Continuous Performance Testing indicated poorer attention in patients with ADHD. The only substance use disorder more common in the ADHD group was clonidine. There was significantly more current axis I, dysthymic disorder, anxiety disorder (including social phobia), and antisocial personality disorder in the ADHD patients. There was no difference between groups at the 1-year follow-up for illicit drug use, treatment retention, or treatment performance. The ADHD diagnosis did not convey significant prognostic implications for methadone maintenance treatment. A strong psychiatric assessment and treatment focus in the treatment program may help to explain the good treatment outcome.

Cocaine use early in treatment predicts outcome in a behavioral treatment program.

In this evaluation of baseline drug use as a predictor of treatment outcome, cocaine use during a 5-week baseline was compared in methadone maintenance patients who had < 5 (n = 10) versus > or = 5 (n = 9) weeks of abstinence during an experimental cocaine abstinence reinforcement treatment. Cocaine use was evaluated at the 1st and last visit and the 1st and last week of baseline and as a mean across the 5-week baseline treatment; response was calculated as a mean across 12 weeks of experimental treatment. Those who had successful outcomes (abstainers) used significantly less cocaine in the 5-week baseline than those with less successful outcomes (nonabstainers). Differences in cocaine use were not evident in the 1st baseline visit or week, but the abstainers used significantly less cocaine in the last visit and week of baseline compared with the nonabstainers. Cocaine use during baseline provided critical predictors of response to the experimental treatment.

Increasing employment of opioid dependent outpatients: an intensive behavioral intervention.

The impact of a new, mandatory employment requirement in a community-based methadone treatment program was evaluated. All patients who had been in the methadone substitution program for at least 1 year but who were not currently employed (n = 36) were required to enhance their treatment with 20 h of employment (paid or volunteer). Patients with significant psychiatric or medical disabilities were excluded from the routine treatment requirement. Patients were informed by counseling staff that they had 2 months to secure employment. Those who did not accomplish the goal within that time period were transferred to more intensive weekly counseling (i.e. up to 8 h/week) for 10 weeks, with the enhanced counseling focusing primarily on resistance to the employment goal. Patients who remained resistant to the treatment plan were eventually started on a 21 day methadone taper until employment was verified. Seventy-five percent of the patients secured employment and maintained the position for at least 1 month. Positions were found in an average of 60 days. Most patients (78%) continued working throughout the 6-month follow-up. Those who failed to find work or maintain employment engaged in more illicit drug use. These results demonstrate that behavioral contingencies can motivate many methadone maintenance patients to obtain verified employment in the community.

Preliminary evidence of good treatment response in antisocial drug abusers.

Antisocial personality disorder (APD) is a chronic debilitating condition strongly associated with the development and maintenance of severe drug and alcohol use disorder. The overlap of these problems is associated with high rates of personal and social suffering. Available literature consistently point to this as a population in need of effective clinical services. The present study reports preliminary data from a controlled clinical trial aimed at improving the treatment outcomes of antisocial drug abusers using an intensive behavioral approach relying upon a highly structured contingency management intervention. Drug abusers in methadone substitution therapy (n = 40) were assessed for APD and other psychiatric and substance use problems. Patients were randomly assigned to an experimental (n = 20) or control (n = 20) condition following stratification on demographic and selected clinical variables (baseline drug use, evidence of other non-substance use psychiatric diagnoses). Treatment outcome data are presented for the first 17 weeks of participation in the study (4 weeks baseline and 13 weeks randomized treatment), including results of weekly urine drug testing and monthly self-reports of drug use and other psychosocial problems. Patients in both study conditions attained generally good outcomes. These early results suggest that antisocial drug abusers can respond positively to drug abuse treatments with a behavioral focus, but fail to support superior effectiveness for the more intensive intervention used in the experimental condition.

Competing motivations: drug reinforcement vs non-drug reinforcement.

A behavioral pharmacological conceptualization of drug abuse is summarized, which views drug abuse as learned operant behavior that is reinforced by positive effects produced by drugs of abuse. In this view drug abuse may be better characterized as involving attraction rather than compulsion. Incentive-based treatments may be useful for overcoming and competing with the reinforcing effects of drugs of abuse. Illustrative examples of incentive-based treatments for drug abuse, and their results, are described. The efficacy of incentive-based treatments indicates that many substance abusers possess the necessary skills to achieve abstinence and suggests that motivational interventions alone may be sufficient in many cases. Areas for further research are discussed that relate to refining and developing incentive-based therapies and to improving their practical utility and public acceptability.

Predictive validity of cocaine, sedative, and alcohol dependence diagnoses.

This study examined the predictive validity of Structured Clinical Interview for DSM-III-R (Spitzer, Williams, Gibbon, & First, 1990) based substance dependence diagnoses (i.e., cocaine, sedative, and alcohol) for 518 opioid-dependent outpatients entering methadone maintenance. Patients were followed over 1 year of treatment, which involved daily methadone substitution supplemented by individual and group counseling. Urine specimens were tested randomly 1-4 times per month. Patients diagnosed with current cocaine, sedative, or alcohol dependence were more likely to use these drugs than were patients with past only or no dependence syndrome. Current cocaine dependence predicted early treatment dropout. The results demonstrate the predictive and discriminant validity of several substance dependence diagnoses common among patients in substance abuse or other psychiatric treatment settings.

Dose-related efficacy of levomethadyl acetate for treatment of opioid dependence. A randomized clinical trial.

OBJECTIVE: To compare the clinical efficacy of different doses of levomethadyl acetate hydrochloride (known as LAAM) in the treatment of opioid dependence. DESIGN: A randomized controlled, double-blind, parallel group, 17-week study. SETTING: Outpatient facilities at Johns Hopkins University Bayview Medical Center, Baltimore, Md. PATIENTS: Opioid-dependent volunteers (N=180) applying to a treatment-research clinic. INTERVENTION: Thrice-weekly (Monday/Wednesday/Friday) oral LAAM dose conditions of 25/25/35 mg, 50/50/70 mg, and 100/100/140 mg and nonmandatory counseling. MAIN OUTCOME MEASURES: Retention in treatment, self-reported heroin use, and opioid-positive urine specimens. RESULTS: Retention was independent of subjects' sex and dose. Self-reported heroin use decreased in a dose-related manner. At final assessment, patients in the high-dose condition reported using heroin 2.5 of 30 days as compared with 4.1 or 6.3 days for patients in the medium-dose and low-dose conditions, respectively (high dose vs low dose, P<.05); urinalysis results were similarly dose related. Overall, 20 (34%) of 59 patients in the high-dose condition remained opioid-abstinent for 4 consecutive weeks, as compared with 8 (14%) of 59 in the medium-dose and 7 (11%) of 62 in the low-dose conditions (P<.01). Self-report and urinalysis data are consistent with a greater than 90% reduction in illicit opioid use by the high-dose group relative to pretreatment levels. CONCLUSION: Opioid substitution treatment with LAAM substantially reduces illicit opioid use. The clinical efficacy of LAAM is positively related to dose.

Sedative use disorders in opiate-dependent patients: association with psychiatric and other substance use disorders.

Opiate-dependent patients (N = 231), classified by sedative disorder status, were characterized according to DSM-IIIR on substance use and psychiatric disorders. Twenty-one percent currently (CUR+) had sedative use disorder, 39% had a history (HX+) of sedative use disorder, and 40% had no history (HX-) of this disorder. Several group differences were found. The HX+ and CUR+ groups had more lifetime drug use disorders (means = 4.5 and 4.3 vs. 3.2 in the HX- group), including alcohol, cannabis, stimulants, cocaine, and hallucinogens. In contrast, other psychiatric disorders (e.g., anxiety and depression) were low in prevalence and did not differ across groups, with the exception of a higher prevalence of antisocial personality disorder in the HX+ and CUR+ groups (39.6% and 38.5% vs. 17.9% in HX- group). The results suggest that sedative use disorder is related more to a severe spectrum of multiple substance abuse than it is to self-medication of underlying mood or anxiety disorders.

Cost-effectiveness of treatment for drug-abusing pregnant women.

Neonatal intensive care unit (NICU) and drug treatment costs were compared in two groups of pregnant drug abusing women: 100 admissions to a multidisciplinary treatment program and active in care at the time of delivery and 46 controls not entering drug treatment. Clinical measures included urine toxicology at delivery, infant birthweight. Apgar scores and need for and duration of NICU services. Cost measures included drug treatment and NICU costs. Treatment patients showed better clinical outcome at delivery, with less drug use and higher infant estimated gestational age, birthweight and Apgar scores. Infants of treatment patients were also less likely to require NICU services and, for those that did, had a shorter stay. When total cost was examined (including drug treatment), mean net savings for treatment subjects was $4644 per mother/infant pair. The study demonstrates the cost-effectiveness of treatment for pregnant drug abusing women, with savings in NICU costs exceeding costs of drug treatment.

Motivating methadone patients to include drug-free significant others in treatment: a behavioral intervention.

The present study introduced a novel behavioral approach for encouraging methadone-treated patients to bring drug-free significant other support into treatment. Seventy-five patients referred to high-intensity psychosocial treatment due to chronic drug use were given 3 weeks to identify a drug-free significant other. Patients noncompliant with this intervention were started on a methadone dose taper that was stopped when significant other support was identified. Patients and their significant others were required to attend a significant other group one time per week for a minimum of 6 weeks. Eighty-five percent of the patients brought a drug-free significant other into treatment. Significant others included family members, partners, and friends. Patients who identified significant other support complied with 77% of their scheduled sessions. The results demonstrated that most methadone patients have drug-free support people who are willing to participate in their treatment. These individuals can be utilized to help patients initiate the process of building new drug-free social support networks.

Psychiatric and substance use comorbidity among treatment-seeking opioid abusers.

BACKGROUND: Major studies of psychiatric comorbidity in opioid abusers reported rates of comorbidity that far exceeded general population estimates. These studies were published more than a decade ago and reported on few women and few substance use diagnoses. METHODS: Psychiatric and substance use comorbidity was assessed in 716 opioid abusers seeking methadone maintenance. Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition diagnostic assessment was conducted 1 month after admission. Rates of psychiatric and substance use disorder were compared by gender, and associations were assessed between psychiatric comorbidity and dimensional indexes of substance use severity, psychosocial impairment, and personality traits. RESULTS: Psychiatric comorbidity was documented in 47% of the sample (47% women and 48% men). Antisocial personality disorder (25.1%) and major depression (15.8%) were the most common diagnoses. Patients had at least 2 substance use diagnoses, most often opioid and cocaine dependence. Demographics, substance use history, and personality variables discriminated between patients with vs without comorbidity. Psychiatric comorbidity also was associated with a more severe substance use disorder. CONCLUSIONS: Psychiatric comorbidity, especially personality and mood disorder, was common in men and women. The positive associations between psychiatric comorbidity and severity of substance use and other psychosocial problems were most consistent among those with antisocial personality.

Concurrent validity of cocaine and sedative dependence diagnoses in opioid-dependent outpatients.

The present study evaluated the relationship between diagnoses of cocaine and sedative dependence and drug use early in treatment among opioid-dependent patients in methadone substitution therapy. New admissions (n = 138) were assessed via the Structured Clinical Interview for the DSM III-R (SCID) for presence of Axis I and Axis II disorders and followed for five weeks on standard methadone maintenance. Patients submitted urines three times per week tested for opioids, cocaine, and benzodiazepines. Patients diagnosed with current cocaine dependence (n = 90) submitted a higher proportion of cocaine-positive urines (M = 0.84) than patients diagnosed with past cocaine dependence (n = 32; M = 0.28) and those diagnosed with no cocaine use disorder (n = 14; M = 0.12), P < 0.001. Current cocaine dependence diagnosis accounted for 52% of the cocaine use variance. Patients exhibiting current sedative dependence (n = 25) submitted a higher proportion of benzodiazepine-positive urines (M = 0.60) than patients with past sedative dependence (n = 44; M = 0.20) and those with no sedative use disorder (n = 60; M = 0.05), P < 0.001. Current sedative dependence diagnosis accounted for 37% of the benzodiazepine use variance. Lifetime major depression (12%) and antisocial personality disorder (39%) were the most common nonsubstance use comorbid diagnoses. Axis I nonsubstance use disorder was associated with benzodiazepine use, while Axis II disorder was associated with both benzodiazepine and cocaine use early in treatment (P < 0.05). These data demonstrate the concurrent validity of DSM-III-R cocaine and benzodiazepine use diagnoses, and support the potentially important relationship between drug use and other psychiatric disorders.

Increasing opiate abstinence through voucher-based reinforcement therapy.

Heroin dependence remains a serious and costly public health problem, even in patients receiving methadone maintenance treatment. This study used a within-subject reversal design to assess the effectiveness of voucher-based abstinence reinforcement in reducing opiate use in patients receiving methadone maintenance treatment in an inner-city program. Throughout the study subjects received standard methadone maintenance treatment involving methadone, counseling, and urine monitoring (three times per week). Thirteen patients who continued to use opiates regularly during a 5-week baseline period were exposed to a 12-week program in which they received a voucher for each opiate-free urine sample provided: the vouchers had monetary values that increased as the number of consecutive opiate-free urines increased. Subjects continued receiving standard methadone maintenance for 8 weeks after discontinuation of the voucher program (return-to-baseline). Tukey's posthoc contrasts showed that the percentage of urine specimens that were positive for opiates decreased significantly when the voucher program was instituted. (P < or = 0.01) and then increased significantly when the voucher program was discontinued during the return-to-baseline condition (P < or = 0.01). Rates of opiate positive urines in the return-to-baseline condition remained significantly below the rates observed in the initial baseline period (P < or = 0.01). Overall, the study shows that voucher-based reinforcement contingencies can decrease opiate use in heroin dependent patients receiving methadone maintenance treatment.

Sustained cocaine abstinence in methadone maintenance patients through voucher-based reinforcement therapy.

BACKGROUND: Chronic cocaine abuse remains a serious and costly public health problem. This study assessed the effectiveness of a voucher-based reinforcement contingency in producing sustained cocaine abstinence. METHODS: A randomized controlled trial compared voucher-based reinforcement of cocaine abstinence to noncontingent voucher presentation. Patients were selected from 52 consecutively admitted injecting heroin abusers in a methadone maintenance treatment program. Patients with heavy cocaine use during baseline period (N = 37) participated. Except where otherwise indicated, the term cocaine abuse is used in this article in a generic sense and not according to the DSM-III-R definition. Patients exposed to abstinence reinforcement received a voucher for each cocaine-free urine sample (ie, negative for benzoylecgonine) provided three times per week throughout a 12-week period; the vouchers had monetary values that increased as the number of consecutive cocaine-free urine samples increased. Control patients received noncontingent vouchers that were matched in pattern and amount to the vouchers received by patients in the abstinence reinforcement group. RESULTS: Patients receiving vouchers for cocaine-free urine samples achieved significantly more weeks of cocaine abstinence (P = .007) and significantly longer durations of sustained cocaine abstinence (P = .001) than controls. Nine patients (47%) receiving vouchers for cocaine-free urine samples achieved between 7 and 12 weeks of sustained cocaine abstinence; only one control patient (6%) achieved more than 2 weeks of sustained abstinence. Among patients receiving vouchers for cocaine-free urine samples, those who achieved sustained abstinence ( > or = 5 weeks) had significantly lower concentrations of benzoylecgonine in baseline urine samples than those who did not achieve sustained abstinence (P < or = .01). Patients receiving voucher reinforcement rated the overall treatment quality significantly higher than controls (P = .002). CONCLUSION: Voucher-based reinforcement contingencies can produce sustained cocaine abstinence in injecting polydrug abusers.

Validity of intravenous drug abusers' self-reported changes in HIV high-risk drug use behaviors.

The HIV-1 high-risk drug use behavior of intravenous drug abusers was assessed both retrospectively (for 6 months) and prospectively (for 6 months) via structured interview and urinalysis testing. Subjects were 281 intravenous drug abusers, 146 enrolled in outpatient methadone treatment (Treatment group) and 135 not in treatment (Community group). The Treatment group reported fewer drug injections and less needle sharing and had fewer positive urinalyses for opiates and cocaine than did the Community group. Reported drug injection and needle sharing declined over time, and an increasing proportion of subjects reported abstinence from these behaviors. In contrast to the behavioral reports of subjects, positive urinalyses indicating opiate and/or cocaine use did not decline over time. Almost half (45.8%) of the reported increase in injection abstinence from intake to month six was disconfirmed by urinalysis. In contrast to this large discrepancy regarding reported behavior change, there was good agreement between reported injection abstinence and urinalysis results at single points in time. These data indicate that the validity of the reported HIV-1 risk behavior change of drug abusers may be less than that of reported risk behavior occurrence. The data raise important questions about the validity of reported reductions in high-risk drug use behaviors, and indicate the importance of using biological indicators of HIV-1 risk behavior (such as urinalysis) whenever possible.