Pay for Performance and Treatment Outcome in Agonist Treatment for Opioid Use Disorder.

BACKGROUND AND OBJECTIVES: Pay for performance (P4P) models have become more popular in reimbursement for medical services, including treatment for substance use disorders. However, studies have not examined whether P4P has an impact on treatment outcome in the individual in opioid agonist treatment (OAT). Thus, the present study was conducted at the individual level, rather than the programmatic level, to determine whether meeting the P4P early engagement criteria (four services in the initial 14 days of treatment and/or eight services within the initial 30 days of treatment) resulted in reduced opioid, benzodiazepine, and cocaine use. METHODS: We performed a retrospective study of 63 patients enrolled in OAT for opioid use disorder. χ2 analyses were conducted crossing P4P early engagement criteria status and urine drug screen (UDS) results for opioid, cocaine, and/or benzodiazepine use at 6 and 12 months postadmission. Methadone dosage and treatment retention were also considered. The odds ratio was used to determine the directionality of significant results. RESULTS: Significant relationships were revealed between patients meeting 30-day P4P early engagement criteria and opioid negative UDS, and with retention in treatment at 6 and 12 months. Methadone dosage was significant at a 6-month follow-up. DISCUSSION AND CONCLUSIONS: Since significant associations between opioid use and P4P as well as opioid use and methadone dose were revealed, findings partially supported hypothesis. SCIENTIFIC SIGNIFICANCE: P4P and methadone dosage may have some benefit to individuals in OAT in attaining short-term abstinence from opioids. P4P may be less useful in helping individuals achieve abstinence from other substances of abuse. (Am J Addict 2020;00:00-00).

Alcohol and other drug use in older adults: results from a community needs assessment.

BACKGROUND: With the "Baby Boomer" generation reaching older adulthood, substance abuse treatment providers find themselves needing to address the unique needs of this population. Heavy drinking in adults ages 65 and over is strongly correlated with depression, anxiety, decreased social support, and poor health. However, while alcohol misuse has been shown to be predictive of a lower quality of life in older adults, the generalizability of these findings to urban dwelling, lower socioeconomic status individuals remains unclear. AIMS: To identify potential treatment needs of this population, a city-funded needs assessment was conducted. METHODS: Subjects were 249 individuals (44% male) who voluntarily completed measures of quality of life (QOL), depression, and substance abuse. Measures used included the Psychological General Well-Being Schedule, the Geriatric Depression Scale-15, and the Alcohol Use Disorders Identification Test (AUDIT). RESULTS: Alcohol or substance abuse was reported by over 20% of respondents, with 3.4% of respondents engaged in maladaptive alcohol use. Scores on the AUDIT were predictive of increased depression (r = - .209, p = .01), anxiety (r = - .201, p = .002), lower general well-being (r = - .154, p = .019), and decreased self-control (r = - .157, p = .017). DISCUSSION: A substantial percentage of the sample reported alcohol and substance misuse. Alcohol use was predictive of depression, global psychological distress, and decreased quality of life. CONCLUSIONS: This needs assessment reinforces findings from previous studies and addresses the added dimension of examining this in an urban, lower socioeconomic population.

Impact of cannabis use during stabilization on methadone maintenance treatment.

BACKGROUND AND OBJECTIVES: Illicit drug use, particularly of cannabis, is common among opiate-dependent individuals and has the potential to impact treatment in a negative manner. METHODS: To examine this, patterns of cannabis use prior to and during methadone maintenance treatment (MMT) were examined to assess possible cannabis-related effects on MMT, particularly during methadone stabilization. Retrospective chart analysis was used to examine outpatient records of patients undergoing MMT (n = 91), focusing specifically on past and present cannabis use and its association with opiate abstinence, methadone dose stabilization, and treatment compliance. RESULTS: Objective rates of cannabis use were high during methadone induction, dropping significantly following dose stabilization. History of cannabis use correlated with cannabis use during MMT but did not negatively impact the methadone induction process. Pilot data also suggested that objective ratings of opiate withdrawal decrease in MMT patients using cannabis during stabilization. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: The present findings may point to novel interventions to be employed during treatment for opiate dependence that specifically target cannabinoid-opioid system interactions.

The influence of intake urinalysis, psychopathology measures, and menstrual cycle phase on treatment compliance.

Drug abuse among women is a societal health problem which has received greater attention in recent years. Studies examining sex differences in drug abuse have shown consistent differences between males and females. In the current study, we retrospectively examined 75 treatment-seeking females to determine the relationships between intake measurements of psychopathology, intake urinalysis, menstrual cycle phase at admission, and treatment compliance. Our results support a relationship among these variables and a potential relationship between menstrual cycle phase and anxiety level is discussed. These results support the need for the development of individually tailored treatment programs.

Differences in peripheral noradrenergic function among actively drinking and abstinent alcohol-dependent individuals.

We examined whether excessive alcohol consumption was related to changes in plasma levels of noradrenaline (NA) and whether these changes recover following abstinence. We also explored whether there were differences in NA levels between Type I and Type II alcoholics and controls during active drinking and abstinence. Plasma concentrations of NA were determined in (1) 27 Caucasian men with alcohol dependence who were regularly drinking (active drinkers) within 24 hours of hospitalization, (2) 29 Caucasian alcohol-dependent men who were in remission (abstinent for a minimum of three months), and (3) 28 race- and gender-matched healthy controls. NA concentrations were significantly higher in actively drinking alcohol-dependent subjects compared to those in remission and controls. While Type I and Type II alcoholic individuals differed across clinical measures, NA levels were similar in the two subtypes. Both subtypes showed an elevation in NA levels during active drinking compared to controls, but NA levels did not differ between the two subtypes and controls during remission. The findings indicate that chronic exposure to alcohol may lead to disturbances in NA activity that may manifest in early abstinence. However, the changes in NA activity appears to normalize after a longer period of abstinence. Alterations in NA activity do not seem to be specific for Type I or Type II subtypes of alcoholism.

Gender differences in cue exposure reactivity and 9-month outcome.

Gender differences have been shown to be related to the course of cocaine dependence and treatment. While previous research has shown cue exposure procedures to be somewhat effective at reducing reactivity of substance dependent individuals to drug related stimuli, the few studies that have examined gender differences in craving and cue-reactivity have yielded equivocal results. We have recently demonstrated that an active cue-exposure procedure that featured cocaine-dependent individuals receiving immediate feedback about their level of physiological arousal following videotaped exposure to cocaine-related stimuli was capable of positively influencing in-treatment (helplessness, abstinence efficacy) as well as 9-month followup outcome (i.e., urinalysis) indices (Sterling, R., Gottheil, E., Murphy, J., & Weinstein, S. (2001). Cue exposure and abstinence efficacy. College on Problems of Drug Dependence, Phoenix, AZ, June 17, 2001). The purpose of the present study was to determine whether differential in-treatment or 9-month followup outcomes were obtained for male and female study participants. Subjects in this study were 81 individuals (47 male/34 female) who met DSM-IV criteria for cocaine dependence and who had consented to be randomly assigned to either the active cue-exposure or control conditions. Participants were compared along a myriad of pre-treatment, in-treatment, and 9-month followup measures. Other than males reporting more recent employment, there was no obvious systematic pattern of differences on pre-treatment indices. No gender differences in treatment retention were observed. With respect to 9-month followup, no gender differences on measures of addiction severity, psychological functioning, or urinalyses were noted. However males were more "cue-reactive" and more successful at establishing control over their reactivity to the cocaine stimuli. Additional research is needed to determine whether these differences in reactivity can be more clearly defined and utilized positively in a treatment setting.

Pre-treatment measures of impulsivity, aggression and sensation seeking are associated with treatment outcome for African-American cocaine-dependent patients.

We investigated whether measures of impulsivity, aggression and sensation seeking differed between cocaine-dependent subjects and controls, and whether these measures were related to treatment-outcome for cocaine patients. Pre-treatment assessments of impulsivity (Barratt Impulsivity Scale [BIS]), aggression (Buss-Durkee Hostility Inventory [BDHI]) and sensation seeking (Zuckerman Sensation Seeking Scale [SSS]) were obtained for 141 African-American cocaine-dependent patients entering a 12-week, intensive outpatient treatment program and 60 controls. The outcome measures were number of negative urine drug screens, days in treatment, dropout rates and number of treatment sessions. Cocaine patients reported significantly higher scores on the SSS, the BIS and the BDHI than controls. Furthermore, the SSS scores showed a significantly negative correlation with days in treatment and negative urines, and a significant positive correlation with the dropout rate. The BIS and the BDHI scores were significantly associated with days in treatment and dropout rates respectively. A combination of the three variables contributed significantly toward predicting retention and abstinence. Higher levels of pretreatment impulsivity and aggression and sensation seeking seem to associated with poor treatment outcome for cocaine dependent patients receiving intensive outpatient treatment. Combining these behavioral measures with other clinical predictors may help in early identification of 'poor responders' who may benefit from additional or alternative treatment approaches.

Comparison of pretreatment characteristics and treatment outcomes for alcohol-, cocaine-, and multisubstance-dependent patients.

We investigated whether pretreatment characteristics and measures of outcome differed for alcohol-, cocaine-, and multisubstance-dependent patients receiving outpatient substance abuse treatment. One hundred and forty substance dependent individuals (32 alcohol, 76 cocaine, and 32 multisubstance) enrolled in a 12-week outpatient treatment program were compared across measures of addiction severity, personality, and treatment-readiness at admission. In-treatment, end-of-treatment and 9-month follow-up assessments of treatment outcome were then compared across the three groups. Outcome measures included reduction in problem severity, abstinence, retention, number of sessions attended, dropout, and counselor and patient ratings of treatment benefit. At admission, the multisubstance group had a higher proportion of positive urines, reported more severe drug, alcohol and psychiatric problems, and displayed higher impulsivity and anxiety scores than one or both of the other groups. However, multisubstance patients were more treatment ready in terms of adopting a total abstinence orientation than alcohol or cocaine patients. While a significant reduction in symptoms occurred for the total sample during treatment as well as at follow-up, comparisons of outcomes did not consistently favor any particular group. The three groups had equivalent improvements in eleven of fourteen during-treatment and five of seven follow-up measures. Despite pretreatment differences, in severity and treatment-readiness, outcomes were more similar than different for alcohol-, cocaine-, and multisubstance-dependent patients. Clinicians should be cautious about forecasting treatment-outcomes for addicted patients based on their primary substances of abuse.

Relationship between platelet serotonin uptake sites and measures of impulsivity, aggression, and craving among African-American cocaine abusers.

We investigated whether platelet-tritiated paroxetine binding, a measure of serotonin uptake sites, and behavioral measures of impulsivity, aggression, and craving differed between cocaine-dependent subjects and controls and whether paroxetine binding was related to these behavioral measures. One hundred and five African-American cocaine-dependent outpatients and 44 African-American controls were studied. Tritiated paroxetine binding sites on platelets were assayed, and standardized assessments of impulsivity, aggression, and craving were performed. The Bmax values of paroxetine binding were significantly reduced among cocaine patients compared to controls. Cocaine patients showed significantly higher scores on certain measures of sensation seeking, impulsivity, and aggression as compared to controls. Furthermore, paroxetine binding showed a significant negative correlation with most measures of sensation seeking, impulsivity, and aggression--though not craving--among cocaine patients. Our findings indicate that densities of serotonin uptake sites may be reduced among cocaine abusers and related to impulsive-aggressive behavioral dimensions.

Tobacco smoking: current concepts in etiology and treatment.

Tobacco smoking is the most important preventable cause of death and disease. Despite an increased awareness of the addictive nature of smoking and availability of effective treatments, smoking continues to be widespread among individuals with psychiatric disorders. Moreover, mental health professionals remain reluctant to address smoking among their patients for a variety of reasons. Recent research has provided a wealth of data that have shaped the concept of tobacco smoking as a chronic addictive disorder and also demonstrated the efficacy of smoking cessation interventions. This paper reviews the important factors that contribute to smoking and the various pharmacological and psychosocial interventions for smoking cessation from a biopsychosocial perspective. It also makes recommendations for the rational use of these interventions to treat nicotine dependence in individuals with psychiatric disorders.

High- and low-structure treatments for substance dependence: role of learned helplessness.

We studied whether pretreatment levels of learned helplessness (LH) were related to outcomes for substance-dependent individuals receiving high-structure, behaviorally oriented (HSB) or low-structure, facilitative (LSF) treatment. The subjects were 120 substance-dependent patients randomly assigned to the HSB or the LSF treatment style for up to 12 weeks of weekly individual counseling. The two groups were compared across pretreatment characteristics as well as in-treatment, end-of- treatment, and 9-month postadmission follow-up outcome measures. Outcomes reflected reduction in problem severity, abstinence, retention, dropout rate, and ratings of treatment benefit. Significant and comparable reductions in symptoms occurred for the HSB and LSF patients both during treatment and at follow-up. Comparisons of other outcomes also did not consistently favor either treatment style. However, significant and consistent interactions were observed between LH and treatment styles with respect to several outcome measures, and these effects were independent of pretreatment levels of depression, addiction severity, and readiness for treatment. Specifically, the more "helpless" patients did significantly better in HSB treatment, whereas the less "helpless" patients had better outcomes in LSF treatment. A matching approach that assigns patients to high- and low-structure treatments based on pretreatment levels of LH might improve treatment outcomes for substance-dependent patients.

Nicotine dependence and treatment outcome among African American cocaine-dependent patients.

Despite a close association between tobacco and cocaine use, few studies have systematically examined whether smoking predicts an adverse outcome for cocaine-dependent patients. We investigated whether severity of nicotine dependence was related to treatment outcome for cocaine-dependent individuals. Standardized assessments of nicotine dependence (Fagerström Test for Nicotine Dependence; FTND), cocaine use, and personality were obtained for 105 African American cocaine-dependent outpatients. Outcome measures included negative urine drug screens, days in treatment, dropout, and number of treatment sessions attended. The sample was stratified into cocaine-positive and cocaine-negative groups based on admission urine drug screens, and relationships between nicotine dependence and outcome measures were examined in each group. In the cocaine-negative group, higher FTND scores were negatively correlated with number of negative urine drug screens during treatment even after controlling for other predictors, whereas FTND scores were not correlated to outcome in the cocaine-positive group. It seems that severity of tobacco use predicts poor outcome for cocaine-dependent patients who are cocaine free at the time of admission into outpatient treatment.

The genetic determinants of smoking.

Dependence on tobacco, like many other drug dependencies, is a complex behavior with both genetic and environmental factors contributing to the variance. The heritability estimates for smoking in twin studies have ranged from 46 to 84%, indicating a substantial genetic component to smoking. Candidate gene studies have detected functional polymorphisms in genes coding for the cytochrome P450 enzymes, and variations in these genes that lead to more rapid nicotine metabolism have been implicated in smoking. Similarly, smoking has been associated with polymorphisms in dopaminergic genes that may influence the dopamine receptor number and/or function. Animal experiments have localized specific subunits of the nicotinic receptors that may mediate the reinforcing properties of nicotine and have investigated their role in nicotine dependence. However, environmental factors have also been found to contribute to the risk of initiation and persistence of smoking. We review the scientific evidence that supports a role for genetic influences on smoking, discuss the specific genetic and neurobiological mechanisms that may mediate susceptibility to nicotine dependence, identify possible gene/environmental interactions that may be important in understanding smoking behavior, and suggest directions for future research. Insights into the genetic contributions to smoking can potentially lead to more effective strategies to reduce smoking.

Relationship between platelet serotonin uptake sites and treatment outcome among African-American cocaine dependent individuals.

We investigated whether platelet tritiated paroxetine binding, a measure of serotonin uptake sites differed between cocaine-dependent subjects and controls, and whether paroxetine binding was related to treatment-outcome for cocaine patients. One hundred twenty-five African-American cocaine-dependent individuals receiving outpatient treatment and 44 controls were studied. Tritiated paroxetine binding sites on platelets were assayed and standardized assessments of behavior were performed. The outcome measures were number of negative urine drug screens, days in treatment, dropout rates and number of treatment sessions attended. Cocaine patients had significantly lower Bmax values of paroxetine binding compared to controls. Furthermore, Bmax values showed a significant positive correlation with days in treatment and negative urines. A combination of Bmax and Addiction Severity Index (ASI) employment scores improved the prediction of days in treatment and a combination of Bmax and ASI drug scores enhanced the prediction of negative urines. The findings indicate that serotonergic mechanisms may be involved in cocaine dependence and may influence treatment-outcome among cocaine patients.

Differences in platelet serotonin transporter sites between African-American tobacco smokers and non-smokers.

RATIONALE: The serotonin transporter (5HTT) regulates the magnitude and duration of serotonergic neurotransmission. Although nicotine and other constituents of tobacco smoke may influence serotonin turnover among animals, few studies have examined whether smoking is associated with alteration in 5HTT in humans. OBJECTIVE: We investigated whether tobacco smokers and non-smokers differed in platelet tritiated paroxetine binding, a measure of 5HTT sites, and whether severity of nicotine dependence (ND) was related to 5HTT measures. METHODS: Tritiated paroxetine binding sites on platelets were assayed in 26 African-American smokers and 30 non-smokers. Severity of smoking was assessed using the Fagerstrom Test for Nicotine Dependence (FTND). Relationships between FTND scores and maximum number of transporter sites (B(max)) and affinity constant (K(d)) of paroxetine binding were determined. RESULTS: B(max) values showed a significant negative correlation with FTND scores (rho=-0.28, P<0.01). Notably, smokers with higher ND had significantly lower B(max) compared to those with lower ND and non-smokers; the latter two groups did not differ in B(max) ( F=3.92, P<0.05). Smokers scored higher on impulsivity than non-smokers, however, behavioral variables did not influence the relationship of smoking with B(max). Age, gender and K(d) values were not associated with smoking or B(max). CONCLUSIONS: Smoking, in particular higher nicotine dependence, appears to be correlated with decreased density of platelet 5HTT sites in African-Americans. The nature of the relationship and whether similar changes occur in the brain merit further investigation.

Seasonal variations in the binding of [3H]paroxetine to the platelet serotonin transporter sites in African-American cocaine-dependent patients and healthy volunteers.

Although seasonal fluctuations in several indices of serotonin function have been described, little is known about seasonality and serotonergic activity in substance abusers. We investigated whether there were seasonal differences in platelet serotonin transporter sites among cocaine dependent patients and controls. Platelet [(3)H]paroxetine binding, a measure of serotonin transporter sites, was assayed in 141 African-American cocaine-dependent subjects and in 60 race matched healthy volunteers who served as the control group. B(max) (density of serotonin transporter) and K(d) (affinity constant) values of [(3)H]paroxetine binding were compared during spring, summer, fall and winter. Consistent with our previous findings B(max) values were significantly lower in cocaine patients (639 +/- 234) than in controls (906 +/- 225) (t = 7.12, p < 0.001). Moreover, B(max) values showed a significant seasonal variation in controls with the highest values in summer and spring compared with fall and winter (F = 4.47, p < 0.01). However, there were no significant seasonal differences in B(max) values in cocaine patients. K(d) values did not show any seasonal changes in either group. There were no effects of age or gender on seasonal variations in B(max). The study demonstrates a seasonal effect on platelet serotonin uptake in healthy African-American volunteers. The lack of seasonal differences in transporter availability in cocaine patients indicates that the normal seasonal rhythm of serotonergic activity may be disturbed in cocaine abusers. Biological studies that employ platelet serotonin transporter sites as a marker of serotonin function should consider seasonal variations in these markers as a potential source of variance.

Tobacco and alcohol use and medical symptoms among cocaine dependent patients.

Despite the widespread use of tobacco and alcohol by illicit drug users, the medical effects of smoking and alcohol use remain understudied among such individuals. We investigated the relationship between smoking and alcohol use, and medical symptoms among 125 cocaine dependent patients. Subjects were assessed for smoking, alcohol use, and medical problems using a standardized self-report instrument (MILCOM). Medical symptoms were compared among nonsmokers, moderate smokers (less than 10 cigarettes per day), and heavy smokers (10 or more cigarettes per day) using partial chi-square statistics. Similar comparisons of medical symptoms were made between alcohol users (more than 2 drinks per day) and nonusers. Contrary to our expectations, there were no significant differences between nonsmokers, moderate smokers, and heavy smokers across most of the 14 major medical systems. However, regardless of the level of cocaine use, nonsmokers reported the fewest symptoms on the general subscale (p < 0.05) while moderate smokers reported the most nose/throat and respiratory symptoms (p < 0.01) among the three groups. As expected, significant relationships were observed between medical symptoms and alcohol use. Alcohol users reported more respiratory (p < 0.05), cardiovascular (p < 0.01), digestive (p < 0.05), head/neck (p < 0.001), eye (p < 0.01), and general (p < 0.05) symptoms than nonusers. While the findings generally support the link between alcohol and medical problems, it seems that the relationship between medical symptoms and smoking among cocaine patients may be more complex than that observed in the general population.

Relationship between tobacco smoking and positive and negative symptoms in schizophrenia.

In an attempt to understand the reasons behind the high prevalence of tobacco smoking in patients with schizophrenia, the study examined whether specific symptoms of schizophrenia were associated with smoking. Standardized assessments of nicotine dependence (Fagerstrom Test for Nicotine Dependence) and psychopathology (Positive and Negative Syndrome Scale) were performed on 87 inpatients with schizophrenia. Nearly 76% of patients were nicotine dependent. Significant positive correlations were found between Fagerstrom scores and the total negative symptom score and scores on the negative symptom subscales of blunted affect, social withdrawal, difficulty in abstract thinking, and stereotyped thinking. Fagerstrom scores were also significantly associated with impairment in attention, orientation, thinking, and impulse control. Positive symptoms were not significantly associated with smoking. A combination of negative symptoms, duration of illness, and alcohol use optimally predicted smoking in the sample. Neurobiological mechanisms could possibly underlie some of our findings and require further investigation.

No association between polymorphisms in the serotonin transporter gene and susceptibility to cocaine dependence among African-American individuals.

Genetic research of cocaine abuse has been relatively limited among the African-American population. Since the serotonin transporter (5HTT) may be involved in modulating effects of cocaine, we investigated whether allelic variants of the 5HTT gene may confer susceptibility to cocaine dependence among African-American individuals. One hundred and fifty-six cocaine-dependent subjects and 82 controls were studied. Polymerase chain reaction-based genotyping of a variable-number-tandem-repeat (VNTR) marker yielded three alleles designated 12, 10 and 9. Genotype and allele frequencies were compared using chi-square analyses. We found no differences between subjects and controls with respect to genotype distribution (cocaine: 12/12 = 50%, 10/12 = 35.3%, 10/10 = 13.5%, 9/12 = 1.3%; controls: 12/12 = 42.7%, 10/12 = 39.0%, 10/10 = 17.1%, 9/12 = 1.2%). Similarly, allele frequencies of the VNTR marker did not differ between the two groups (cocaine: 12 = 68.3%, 10 = 31.1%, 9 = 0.6%; controls: 12 = 62.8%, 10 = 36.6%, 9 = 0.6%). Our findings do not seem to support a relationship between VNTR polymorphisms and cocaine dependence among African-American patients. Further studies involving larger samples are required to confirm our results.

Relationship between tobacco smoking and medical symptoms among cocaine-, alcohol-, and opiate-dependent patients.

Despite widespread use of tobacco by alcohol and drug abusers, the medical effects of smoking remain understudied among such individuals. We investigated the relationship between tobacco smoking and medical symptoms among 87 cocaine-, 98 opiate- and 81 alcohol-dependent individuals receiving outpatient treatment. Smoking status was assessed and medical symptoms were recorded using a standardized 134-item self-report instrument (MILCOM). Almost 79% of patients were tobacco smokers. Analysis of variance revealed a main effect of tobacco smoking on medical symptoms. Smokers reported significantly more symptoms on the total scale as well as on the respiratory, cardiovascular, gastrointestinal, and nose/throat subscales compared to non-smokers. Furthermore, we found a significant interaction between tobacco smoking and substance abuse with respect to medical symptoms. While opiate and alcohol patients who smoked reported more symptoms than those who did not, unexpectedly, cocaine users who smoked reported fewer symptoms than those who did not smoke. While the findings support the link between smoking and medical problems among substance abusers, these effects do not seem to be uniform across various substances of abuse. In particular, cocaine patients seem to be affected differently than alcohol and opiate patients.