The role of social cohesion among residents in a therapeutic community.

According to the Therapeutic Community (TC) treatment approach, social affiliation with the drug-free peer community is the basis for patients initiating therapeutic change. A total of 322 TC residents were assessed with regard to social affiliation, acceptance of TC philosophy, perceived benefit of program components, level of depression, and length of time in treatment. Residents exhibited a higher level of affiliation with TC members than with untreated substance abusers they knew outside the program. Being female, and separated from a spouse, were each associated with a higher level of TC member affiliation. After controlling for sociodemographic characteristics, two variables emerged as unique significant correlates of affiliation: perceived benefit for recovery of TC treatment was associated with greater TC member affiliation, whereas level of depression was inversely correlated. These findings are interpreted in relation to the goals of the TC process and to implications for treatment.

A bacterial method for the nitrogen isotopic analysis of nitrate in seawater and freshwater.

We report a new method for measurement of the isotopic composition of nitrate (NO3-) at the natural-abundance level in both seawater and freshwater. The method is based on the isotopic analysis of nitrous oxide (N20) generated from nitrate by denitrifying bacteria that lack N2O-reductase activity. The isotopic composition of both nitrogen and oxygen from nitrate are accessible in this way. In this first of two companion manuscripts, we describe the basic protocol and results for the nitrogen isotopes. The precision of the method is better than 0.2/1000 (1 SD) at concentrations of nitrate down to 1 microM, and the nitrogen isotopic differences among various standards and samples are accurately reproduced. For samples with 1 microM nitrate or more, the blank of the method is less than 10% of the signal size, and various approaches may reduce it further.

Buprenorphine treatment of heroin dependence (detoxification and maintenance) in a private practice setting.

At the conclusion of a 3-year demonstration project in a medical setting in which refusal to accept methadone was an inclusion criterion, 12 subjects were unable to detoxify from buprenorphine and remained adamant in their refusal to enroll in a MMTP. In order to study the feasibility of expanding opportunities for treatment previously unavailable to this under-served population of heroin addicts, these 12 subjects plus an additional 11 subjects (N = 23) were recruited for a 12 months trial of buprenorphine treatment conducted in an office-based setting on a fee-for-service basis. An additional cohort of 40 heroin dependent subjects were entered in a protocol for detoxification only. The findings demonstrate both feasibility and patient acceptance of office based fee-for-service buprenorphine treatment, supporting the need for (1) additional studies of this population and (2) changes in government regulations to reintroduce addiction treatment under physician auspices in private practice settings.

Network therapy for addiction: bringing family and peer support into office practice.

Network therapy was developed as a specialized type of combined individual and group therapy to ensure greater success in the office-based treatment of addicted patients by using both psychodynamic and cognitive-behavioral approaches to individual therapy while engaging the patient in a group support network composed of family members and peers. This article outlines the role of group cohesiveness as a vehicle for engaging patients in this treatment; the patient's family and peers are used as a therapeutic network, joining the patient and therapist at intervals in therapy sessions. This network is managed by the therapist to provide cohesiveness and support, to undermine denial, and to promote compliance with treatment. The author presents applications of the network technique designed to sustain abstinence and describes means of stabilizing the patient's involvement. Some specific techniques discussed include ambulatory detoxification, disulfiram and naltrexone administration, relapse prevention, and contingency contracting. Also discussed are recent research on the use of psychiatric residents and counselors for treatment, and use of the Internet in dissemination.

The impact of managed care on substance abuse treatment: a report of the American Society of Addiction Medicine.

This report examines the impact of managed care (MC) and related developments on substance abuse treatment, and evaluates how it has been associated with a decline in the availability of proper treatment for many addicted patients. A trend toward carve-out and for-profit MC organizations is associated with lower financial incentives for intensive treatment than in earlier staff-model and not-for-profit MC organizations. The value of substance abuse insurance coverage has declined by 75% between 1988 and 1998 for employees of mid-to large-size companies, compared with only an 11.5% decline for general health insurance. The shift towards MC has also been associated with a drastic reduction in frequency and duration of inpatient hospitalization, and there is no clear evidence that this reduction has been offset by a corresponding increase in outpatient support. In a survey of physicians treating addiction, the majority felt that MC had a negative impact on detoxification and rehabilitation, and on their ethical practice of addiction medicine.

Correlates of protracted homelessness in a sample of dually diagnosed psychiatric inpatients.

The authors assessed sociodemographic, drug use, and diagnostic correlates of protracted homelessness in a sample of 147 dually diagnosed patients who required admission to the hospital. When 58 patients with protracted homelessness, defined as continuous undomiciled status for over a year, were compared with 74 patients without protracted homelessness, significant differences were found with regard to diagnosis, employment status, criminality, Brief Psychiatric Rating Scale score on admission, and history of injection drug use. The results of a multiple logistic regression analysis confirmed that a history of injection drug use, current unemployment, and a diagnosis of schizophrenia were positively associated with a history of protracted homelessness. No significant relationships were obtained between protracted homelessness and demographics or chronicity of mental illness.

Technology transfer of Network Therapy to community-based addictions counselors.

This paper describes a technology transfer initiative in which Network Therapy (NT), a substance abuse treatment that utilizes peer and family support, was disseminated to a cohort of addictions counselors located in an outpatient community-based addictions treatment center. Training methods included a didactic seminar, role-playing, use of videotaped illustrations, and clinical supervision, and are described in detail. Counselors then implemented the NT approach with a sample of cocaine-abusing patients (N = 10) who were being treated concurrently with the standard program provided by the treatment setting. NT patients were compared by chart review with a cohort of cocaine abusers who received community treatment--as-usual (TAU) (N = 20). The groups did not differ on demographic variables or the amount of TAU received at the community program. However, NT patients had significantly less positive urinalyses than TAU patients, though they were not significantly different in terms of treatment retention. Implications for technology transfer are discussed.

Crack cocaine and schizophrenia as risk factors for PPD reactivity in the dually diagnosed.

We studied factors contributing to an increased risk of PPD positive status among 147 inpatients dually diagnosed for mental illness and substance abuse in a large urban hospital. Ninety-three percent (N = 137) were tested for PPD on admission. The rate of positive PPDs was 30.7%. Significant correlates of PPD positive status were the diagnosis of schizophrenia/psychosis NOS (p < .05), and crack cocaine use in the 30 days prior to admission (p < .01). A multiple logistic regression revealed a relative risk of 3.53 (p < .005) for PPD positive status for the crack using group and a relative risk of 2.16 (p < .06) for PPD positive status for the schizophrenic group. Reasons for why patients whose primary drug of abuse is crack cocaine and those whose diagnosis is schizophrenia/psychosis NOS may be at an increased risk for exposure to tuberculosis are discussed as are the implications for public health.

Evaluation of a multisystems model for treating perinatal cocaine addiction.

Two stages of a gender-specific treatment program for perinatal cocaine-addicted women were introduced into a coed peer-led day treatment program and evaluated for outcomes. Stage I (N = 21) targeted gender-specific needs, but did not expressly promote family reintegration. Stage II (N = 27) augmented the gender-specific program with a multisystems model for family reintegration. As a control for historical effects, nonperinatal clients whose treatment remained the same during the periods corresponding to the two stages, were evaluated for outcomes (N = 66 for Stage I, N = 75 for Stage II). As hypothesized, urine toxicology and retention data were significantly improved for perinatal clients treated in Stage II, as compared with those treated in Stage I; no such improvements were noted for non-perinatal clients. The data support a conclusion that introducing a multisystems framework into a gender-specific program selectively improves clinical outcomes for inner-city perinatal cocaine-addicted women.

Impact of social anxiety in a "therapeutic community"--oriented cocaine treatment clinic.

The authors assessed social-evaluative anxiety in 50 cocaine abusers attending an outpatient therapeutic-community (TC)-oriented clinic. This group-based modality presumes that the ability of clients to self-disclose is key to recovery. Fully half of the clients tested, some of whom had been attending treatment for a number of months, showed an elevation of social withdrawal and distress. Newcomers with higher social anxiety scores were less likely to drop out of treatment over the first 3 months, and self-reported level of social anxiety decreased over this time interval. These findings suggest that social anxiety may be an important consideration in treatment for cocaine abuse and that the rigors of a modified TC with intense focus on group involvement may reduce social anxiety.

Modified therapeutic community treatment for homeless dually diagnosed men. Who completes treatment?

We studied a modified therapeutic community designed for the treatment of patients with combined substance abuse and psychiatric disorders. This model has been ap117117plied on a limited basis in clinical practice, and little is known about the characteristics of patients who are likely to complete the prescribed stay in such a program. In this report, we present characteristics of 189 homeless dually diagnosed men who entered a shelter-based, modified therapeutic community with a prescribed 6-month stay. Thirty-four percent of admissions completed the prescribed stay. These patients were more likely to have fewer inpatient psychiatric admissions and more job experience than those who did not complete their stay. Findings are discussed in terms of their similarities and differences to findings from traditional therapeutic communities for the singly diagnosed.

Homelessness and mental illness in a professional- and peer-led cocaine treatment clinic.

The combined problems of substance abuse, mental illness, and homelessness among the urban poor represent a major public health issue. The study evaluated 340 patients attending a cocaine day treatment program that integrates peer leadership and professional supervision. Thirty-six percent of the sample had a major mental illness, and 39 percent were homeless. Sixty-nine percent achieved an acceptable final urine toxicology status, and the median number of program visits was 46. Homelessness, a longer history of cocaine use, and a diagnosis of schizophrenia were associated with positive treatment outcomes. The results support the feasibility of a cocaine abuse treatment model combining professional and peer leadership.

Use of the Internet for addiction education. Combining network therapy with pharmacotherapy.

The authors prepared a course in addiction psychiatry for the Internet that combines a psychosocial and a medication modality for alcoholism; namely, network therapy and naltrexone. Responses of those who accessed the course revealed 679 counts (visits) at the Web Site. A group of 210 unique respondents, of whom 154 were psychiatrists, answered a demographic question set. Over half of these psychiatrists completed the course and evaluated it. The majority indicated that it helped them understand "a good deal" about the management of alcoholism and the use of network therapy and naltrexone. This result suggests the feasibility of using the Internet as a vehicle for teaching in addiction psychiatry, an area where needs for training are often unmet.

HIV risk factors in dually diagnosed patients.

The authors examined correlates of HIV seropositivity in a sample of dually diagnosed inpatients. The subjects were 147 consecutively admitted patients to a specialized dual-diagnosis unit in a municipal hospital who were given a structured interview and HIV testing. The HIV seroprevalence was 19%, with women having a nearly fourfold increased risk of being HIV seropositive, as compared with men. Cocaine as drug of choice was also highly significant as a risk factor for HIV infection, independent of gender. This finding suggests that targeted prevention and education programs need to be developed for the dually diagnosed patient.

Differences between men and women in dual-diagnosis treatment.

The authors reviewed the charts of all women and a randomly selected sample of men over a 6-month period on two addiction treatment units at Bellevue Hospital Center in New York. The men were more likely to be admitted with schizophrenia and to have used substances of abuse other than alcohol, and the women were more likely to be admitted with affective disorders. Also, the women on the dual-diagnosis ward were more likely to be domiciled (i.e., not homeless), and the women on both units were significantly more likely to report having been crime victims. These findings suggest that dually diagnosed women need a substantially different treatment paradigm from men.