Use of naltrexone in the treatment of alcohol use disorders in patients with concomitant major mental illness.

We report the use of naltrexone for treatment of alcohol use disorder in patients with major psychiatric illness. We reviewed the records of 72 mentally ill outpatients treated with naltrexone for alcohol use disorders at a community mental health center. The psychiatric diagnoses included major depression (n = 37), schizophrenia (n = 17), bipolar illness (n = 11), schizoaffective disorder (n = 7), and gender identity disorder (n = 4). Sixty-one patients (85%) had histories of psychiatric hospitalization. Total retention in naltrexone treatment for at least eight weeks was 81.9%: 5 (6.9%) were lost to follow-up, and 8 (11.1%) discontinued the medication because of side effects, primarily nausea. Patients showed good clinical response to naltrexone, with 82% reducing their drinking by at least 75%, and only 17% relapsing at eight weeks. We conclude that naltrexone is useful in the treatment of dually-disordered patients. The hypothesis that clinical response to naltrexone is facilitated by active alcohol drinking during treatment is discussed.

When "enough" is not enough: new perspectives on optimal methadone maintenance dose.

Some methadone maintenance treatment (MMT) programs prescribe inadequate daily methadone doses. Patients complain of withdrawal symptoms and continue illicit opioid use, yet practitioners are reluctant to increase doses above certain arbitrary thresholds. Serum methadone levels (SMLs) may guide practitioners dosing decisions, especially for those patients who have low SMLs despite higher methadone doses. Such variation is due in part to the complexities of methadone metabolism. The medication itself is a racemic (50:50) mixture of 2 enantiomers: an active "R" form and an essentially inactive "S" form. Methadone is metabolized primarily in the liver, by up to five cytochrome P450 isoforms, and individual differences in enzyme activity help explain wide ranges of active R-enantiomer concentrations in patients given identical doses of racemic methadone. Most clinical research studies have used methadone doses of less than 100 mg/day [d] and have not reported corresponding SMLs. New research suggests that doses ranging from 120 mg/d to more than 700 mg/d, with correspondingly higher SMLs, may be optimal for many patients. Each patient presents a unique clinical challenge, and there is no way of prescribing a single best methadone dose to achieve a specific blood level as a "gold standard" for all patients. Clinical signs and patient-reported symptoms of abstinence syndrome, and continuing illicit opioid use, are effective indicators of dose inadequacy. There does not appear to be a maximum daily dose limit when determining what is adequately "enough" methadone in MMT.

Methadone dose and retention during treatment of heroin addicts with Axis I psychiatric comorbidity.

We studied 90 opioid-dependent subjects, 38 with one or more additional Axis I diagnosis and 52 with no psychiatric comorbidity. There were significant differences between these two groups regarding the methadone dose required for clinical stabilization, but not in the rate of retention in treatment. Dual Diagnosis patients, those with psychiatric comorbidity, required an average stabilization dose of 154 +/- 84 of methadone compared to 99 +/- 49 mg/day for patients whose only Axis I diagnosis was Opioid Dependence. In the 990-day period considered there were no differences between the two groups of patients in terms of retention in treatment.

Optimizing response to methadone maintenance treatment: use of higher-dose methadone.

Using signs, symptoms and serum methadone levels to guide evaluation, the authors treated 164 patients in a methadone maintenance program with doses of methadone exceeding 100 mg/d. The mean dose of these higher dose (HD) patients was 211 mg/d (range 110-780 mg/d). A comparison group (C) of 101 patients was randomly selected from the general clinic population (mean dose 65 mg/d). At intake the HD group reported $153/day of heroin use versus $87/day in the C group. The HD group had more patients whose opiate of choice was an oral pharmaceutical (30% versus 2% of the C group). Sixty-three percent of the HD group had comorbid Axis I psychiatric diagnoses compared to 32% of the C group. Response to psychopharmacologic treatment was enhanced by increased methadone dose in HD patients with "refractory" psychiatric disorders. Urine toxicologies described as "before" were collected prior to increase over 100 mg/d in the HD group or at the first routine urine toxicology collection of the calendar year for the C group. These results were compared to the most recent urine toxicologies for both groups ("after"). The percentage of toxicologies positive for illicit drugs in the HD group dropped from 87% "before" to 3% "after". The C group were 54% positive "before" and 37% positive "after". We conclude that doses of methadone in excess of 100 mg/d (range 110-780 mg/d in our sample of 164 patients) are not only safe but necessary to prevent illicit opiate use, stabilize psychiatric symptoms, and diminish abuse of alcohol and benzodiazepines in many patients.

An agency-based representative payee program and improved community tenure of persons with mental illness.

OBJECTIVE: Representative payee programs help severely mentally ill individuals manage money from their Social Security payments to cover expenses for necessities and to avoid homelessness and rehospitalization. This study examined a representative payee program operated by a community mental health center to determine the criteria used by clinicians and ease managers to refer clients to the program and to learn whether participation in the program was associated with reductions in hospitalization. METHODS: The retrospective study included 56 individuals with severe mental illness who were enrolled in the representative payee program at Community Counseling Centers of Chicago for one year and who also had received services from the agency for at least one year before enrollment. Criteria used to refer clients to the representative payee program were determined through chart reviews. Data on state hospitalizations before and after enrollment were available for the entire sample; additional data on Medicaid-funded private hospitalizations were available for a subset of 33 clients. RESULTS: The most common criteria for enrollment in the representative payee program were comorbid substance abuse or dependence (49 percent), a history of homelessness (33 percent), and frequent hospitalizations (32 percent). During the year of participation in the representative payee program, the mean number of days spent in state hospitals decreased markedly compared with the year before enrollment, from 68 days to seven days. A similar reduction was noted in the number of days spent in state and private hospitals, from 97 days to 15 days. CONCLUSIONS: Findings from this pre- and postintervention retrospective study are tentative in the absence of a more rigorous design. However, the results suggest that the representative payee program is quite effective in reducing hospital stays.

Initiating clozapine treatment in the outpatient clinic: service utilization and cost trends.

OBJECTIVE: Clozapine has been shown to be a cost-effective treatment for refractory psychosis among patients started on the medication in a hospital setting. The study examined service utilization and costs associated with clozapine treatment initiated in an outpatient clinic. METHODS: Subjects (N=28) included adult patients with a diagnosis of schizophrenia or schizoaffective disorder who began their clozapine treatment at an urban community mental health center. Subjects' charts were reviewed for information on service utilization in the year before and after starting clozapine, using an intent-to-treat approach. Hospitalization information was cross-checked against the Illinois Department of Human Services database. Costs were computed for hospitalization, medication, community outpatient services, and housing. RESULTS: Subjects' mean rate of hospitalization was reduced by more than half during the clozapine treatment year, and the mean number of days in the hospital decreased by more than two-thirds, from 23.5 days to 7.6 days. Mean hospitalization costs were reduced by more than half. Mean annual costs of medication rose from $648 in the year before clozapine treatment to $6,760 during the clozapine treatment year. Cost increases for medication, community services, and housing led to a marginal increase in the total cost of treatment. CONCLUSIONS: Patients initiating clozapine treatment on an outpatient basis showed a pattern of decreased hospitalization during the first year on clozapine. The cost savings associated with decreased hospitalization substantially, though not fully, offset the increased expense of clozapine during the first year of community-based treatment.