Antidepressant treatment does not improve buprenorphine retention among opioid-dependent persons.

Our goal was to determine whether treatment of depressive symptoms with escitalopram during buprenorphine treatment for opioid dependence would improve treatment retention compared to placebo in a 12-week, randomized, double-blind trial. Treatment dropout was defined as missing seven consecutive buprenorphine dosing days. Participants were 76% male, 80% non-Hispanic Caucasian, and 64% heroin users. At baseline, the mean Beck Depression Inventory II (BDI-II) score was 28.4 (+/-9.7). Sixty-one percent of participants completed the 12-week buprenorphine protocol. Dropout rates were 33.3% and 44.0% among those randomized to escitalopram or placebo, respectively (p = .19). Relative to baseline, mean BDI-II scores were significantly lower at all follow-up assessments, but the Treatment x Time interaction effect was not statistically significant (p = .18). Participants randomized to escitalopram also did not have a significantly lower likelihood of testing positive for either opiates or other drugs during follow-up. Depressive symptoms often resolved with buprenorphine treatment, and the immediate initiation of escitalopram does not improve treatment retention, depression outcomes, or illicit drug use. Clinicians should determine the need for antidepressant treatment later in buprenorphine care.

The use of urine drug testing to monitor patients receiving chronic opioid therapy for persistent pain conditions.

Urine testing is a practical, inexpensive, and valuable tool in general medical practice for patient guidance, treatment planning, and dosage determination in opioid-treated chronic pain patients. (Table 2) However, UDTs are under-utilized in clinical practice. In a recent survey among 248 primary care practitioners, only 6.9% reported obtaining this test before prescribing opioids and only 15% performed urine toxicology tests on patients already prescribed opioids. Since the UDT is mainly done for the benefit of the patient, the test results should not be the only means to detect substance abuse or monitor treatment compliance. Katz et al suggested that behavioral monitoring and UDTs for patients receiving chronic opioids creates a more comprehensive monitoring system than either alone. Inappropriate testing and overreliance on laboratory results would detract from the clinical management of and damage the clinical relationship with the patient. Therefore, training and education about the benefits and limitations of drug tests are essential to help staff members understand the importance of using test reports appropriately. This would also help the practitioners' concerns of iatrogenic addiction or relapse of previously addicted patients.

Enhanced sensitivity to the euphoric effects of alcohol in schizophrenia.

The purpose of this study was to determine whether schizophrenia was associated with alterations in alcohol response that might explain the elevated risk for AUDs in this population. In a randomized, double-blind, placebo-controlled, counter-balanced 3 test day laboratory study, the effects of alcohol were compared in 23 subjects with schizophrenia (without any previous alcohol use disorder (AUD) but with some alcohol exposure) and in 14 healthy subjects matched for age, gender, education, and lifetime exposure to alcohol. Standard alcohol drinks in a scheduled design were administered to produce blood alcohol levels of 0, 0.02-0.04 mg%, or 0.06-0.08 mg%. Schizophrenia symptoms, perceptual alterations, stimulant and depressant subjective effects of alcohol, and 'high' were measured before alcohol administration and at several post-drug time points. Verbal learning and recall, vigilance and distractibility, and motor function were assessed once per test day. Relative to healthy subjects, subjects with schizophrenia reported greater euphoria and stimulatory effects in response to alcohol. Alcohol produced small transient increases in positive psychotic symptoms and perceptual alterations without affecting negative symptoms. Alcohol also impaired several aspects of immediate and delayed recall, and vigilance, and distractibility. Schizophrenia patients showed increased euphoric and stimulatory responses to alcohol. These exaggerated positive responses to alcohol doses may contribute to the increased risk for AUDs associated with schizophrenia. The absence of 'beneficial' effects of alcohol does not support a self-medication hypothesis of alcohol use in schizophrenia.