Memantine improves buprenorphine/naloxone treatment for opioid dependent young adults.

BACKGROUND: Opioid use disorders are considered a serious public health problem among young adults. Current treatment is limited to long-term opioid substitution therapy, with high relapse rates after discontinuation. This study evaluated the co-administration of memantine to brief buprenorphine pharmacotherapy as a treatment alternative. METHODS: 13-week double-blind placebo-controlled trial evaluating 80 young adult opioid dependent participants treated with buprenorphine/naloxone 16-4mg/day and randomized to memantine (15mg or 30mg) or placebo. Primary outcomes were a change in the weekly mean proportion of opioid use, and cumulative abstinence rates after rapid buprenorphine discontinuation on week 9. RESULTS: Treatment retention was not significantly different between groups. The memantine 30mg group was significantly less likely to relapse and to use opioids after buprenorphine discontinuation. Among participants abstinent on week 8, those in the memantine 30mg group (81.9%) were significantly less likely to relapse after buprenorphine was discontinued compared to the placebo group (30%) (p<0.025). Also, the memantine 30mg group had significantly reduced opioid use (mean=0, SEM±0.00) compared to the placebo group (mean=0.33, SEM±0.35; p<0.004) during the last 2 weeks of study participation. CONCLUSIONS: Memantine 30mg significantly improved short-term treatment with buprenorphine/naloxone for opioid dependent young adults by reducing relapse and opioid use after buprenorphine discontinuation. Combined short-term treatment with buprenorphine/naloxone may be an effective alternative treatment to long-term methadone or buprenorphine maintenance in young adults.

A systematic review of smoking cessation intervention studies in China.

INTRODUCTION: China has the highest number of tobacco smokers among the world's nations; however, no systematic review has been conducted of clinical trials on the efficacy of smoking cessation interventions in China. This paper summarizes findings of studies in order to compare the effect of pharmacotherapy, counseling, and Traditional Chinese Medicine (TCM) approaches on the abstinence rate. METHODS: Clinical trials of smoking cessation interventions published in English or Chinese were extracted from an electronic search of PubMed and WanFang databases. The search yielded 234 studies from the PubMed and 78 studies from the WanFang. RESULTS: Twenty-nine studies were included in this review. Of these, 11 (37.9%) were randomized controlled trials (RCTs) that assessed the following approaches: counseling (5 studies), TCM (3 studies), pharmacotherapy (1 study), a combination of pharmacotherapy and counseling (1 study), and physician advice (1 study). Pharmacotherapy alone or in combination with counseling generally resulted in a higher abstinence rate than counseling alone. TCM techniques such as acupuncture and ear point seed pressure yielded a much higher abstinence rate than pharmacotherapy and counseling. Findings are inconclusive, however, because most of the TCM studies were noncontrolled trials and did not provide a definition of "abstinence." Findings on the effectiveness of physician advice to quit smoking were also inconclusive. CONCLUSIONS: A review of smoking cessation studies revealed that pharmacotherapy was effective in China. More RCTs of TCM approaches and physician advice are needed with long-term follow-up assessments and biochemical verification of self-reported abstinence before these approaches are adopted as evidence-based smoking cessation interventions in China.

Adaptation of the patient feedback survey at a community treatment setting.

The Patient Feedback Survey is a performance improvement measure designed to assess the quality of outpatient substance abuse treatment. We modified and administered this measure to 500 individuals at a multisite treatment provider. Although the feedback scores were high in general, analyses of variance showed score variability in relation to type and length of treatment. Moreover, respondents who reported any use of marijuana, cravings for substances, or mutual-support group attendance (ie, Alcoholics Anonymous or Narcotics Anonymous) had lower feedback scores than respondents without these experiences. We highlight the importance of investigating treatment evaluations in the context of other recovery experiences.

Addressing Tobacco Through Organizational Change (ATTOC) in residential addiction treatment settings.

BACKGROUND: Smoking prevalence among persons in addiction treatment is 3-4 times higher than in the general population. However, treatment programs often report organizational barriers to providing tobacco-related services. This study assessed the effectiveness of a six month organizational change intervention, Addressing Tobacco Through Organizational Change (ATTOC), to improve how programs address tobacco dependence. METHODS: The ATTOC intervention, implemented in three residential treatment programs, included consultation, staff training, policy development, leadership support and access to nicotine replacement therapy (NRT) medication. Program staff and clients were surveyed at pre- and post-intervention, and at 6 month follow-up. The staff survey measured knowledge of the hazards of smoking, attitudes about and barriers to treating smoking, counselor self-efficacy in providing such services, and practices used to address tobacco. The client survey measured knowledge, attitudes, and tobacco-related services received. NRT use was tracked. RESULTS: From pre- to post-intervention, staff beliefs became more favorable toward treating tobacco dependence (F(1, 163)=7.15, p=0.008), NRT use increased, and tobacco-related practices increased in a non-significant trend (F(1, 123)=3.66, p=0.058). Client attitudes toward treating tobacco dependence became more favorable (F(1, 235)=10.58, p=0.0013) and clients received more tobacco-related services from their program (F(1, 235)=92.86, p<0.0001) and from their counselors (F(1, 235)=61.59, p<0.0001). Most changes remained at follow-up. CONCLUSIONS: The ATTOC intervention can help shift the treatment system culture and increase tobacco services in addiction treatment programs.

The impact of drug use in social networks of patients with substance use and bipolar disorders.

In this exploratory analysis, we assessed the effect of drug use among social-network members on recovery from drug dependence in patients with co-occurring bipolar disorder. Patients (n = 57) enrolled in a group therapy study completed assessments over 15 months. Patients with zero to one drug users in their social networks at intake had few days of drug use during treatment and follow-up, whereas those with ≥ 2 drug users had significantly more days of drug use. Multivariate analysis showed that patients who consistently named multiple drug users in their social networks had a marked increase in drug use over 15 months, while those who never or occasionally named multiple drug users had a small decline in drug use over time. Multiple drug users in social networks of treatment-seeking drug-dependent patients with co-occurring bipolar disorder may indicate poor drug use outcomes; efforts to reduce the association with drug users may be useful. This clinical trial has been registered in a public trials registry at clinicaltrials.gov (identifier is NCT00227838).

Measuring principal substance of abuse in comorbid patients for clinical research.

Few individuals with substance use disorders limit their intake to one substance of abuse; however, many studies focus on a single substance. Unfortunately, the optimal method to determine the principal substance is unclear. In particular, this issue is problematic in patients with co-occurring psychiatric illness, who commonly use multiple substances. Hence we compared three methods for assessing the principal substance of abuse in 150 subjects with bipolar disorder and substance dependence: 1) the Addiction Severity Index interview, 2) a self-administered questionnaire, and 3) the most frequently used substance. While most subjects were concordant on the interview and the other two methods, we found substantial disagreement (9.3% between the interview and the questionnaire, and 12.7% between the interview and the most frequently used substance) and partial agreement (14.0%). These findings from a comorbid population demonstrate that different methods to assess principal substance of abuse could lead to different conclusions about treatment outcomes. Hence studies of comorbid patients may benefit from 1) using more than one method to assess principal substance and 2) reporting use of all substances as well as a targeted substance.

Assessment of depressive symptom severity among patients with co-occurring bipolar disorder and substance dependence.

BACKGROUND: We examined a modified version of the Hamilton Depression Rating Scale (HDRS) among treatment-seeking patients with co-occurring bipolar disorder and substance dependence in order to elucidate key features of depression in this specific population of patients. METHODS: Patients with current bipolar disorder and substance dependence who were prescribed mood stabilizers (n=105) completed a 27-item version of the HDRS that was subjected to item and principal components analyses. Preliminary validity analysis consisted of comparing the derived total and component scores to the depressed mood indicators from the Addiction Severity Index (ASI). RESULTS: Eleven items representing two related components labeled "melancholia" and "anxiety" were retained. The 11-item HDRS total and component scores were higher for those who reported serious depression, serious anxiety, cognitive problems, and suicidal ideation on the ASI than for those who did not report these problems. LIMITATIONS: We conducted the analyses with a relatively small sample of patients who were primarily white and were diagnosed with bipolar I disorder, thus limiting the generalizability of findings. Moreover, we obtained limited data regarding construct validity of the 11-item scale. CONCLUSIONS: Our psychometric evaluation of the HDRS led us to retain 11 items representing primarily melancholic and neurovegetative symptoms of depression. These findings suggest that sample-specific item characteristics of the HDRS need to be evaluated prior to using this scale to assess depressive symptom severity among patients with complex diagnostic and treatment characteristics.

Suppressed anger, evaluative threat, and cardiovascular reactivity: a tripartite profile approach.

Despite decades of theory and research implicating suppressed anger in the development of cardiovascular disorders involving cardiovascular reactivity (CVR), to date the theoretical components of low anger expression, guilt feelings over agonistic reactions, and defensive strivings to avoid social disapproval have not been used conjointly to profile suppressed anger for the prediction of CVR. The purpose of this study, then, was to cluster analyze measures of anger expression, hostility guilt, and social defensiveness to create a suppressed anger profile (low anger expression, high hostility guilt, high social defensiveness) and a non-suppressed profile from a sample of college males. Social evaluative threat may be a potent stressor for people who defensively suppress anger expression. Thus, to examine the combined effects of suppressed anger and social evaluative threat, participants, prior to telling a story to a Thematic Apperception Card (TAT), were randomly assigned to either a high-threat (story will be compared to stories created by the mentally ill) or a low-threat condition (story used to study effects of talking on cardiovascular responses). Blood pressure (BP) and heart rate (HR) were monitored during a rest period and the subsequent TAT card period. As predicted, suppressed anger males in the high-threat condition showed the highest levels of diastolic BP and HR change from the rest period. The suppressed anger group's systolic BP reactivity was independent of threat manipulation. Research implications are discussed.

A randomized trial of integrated group therapy versus group drug counseling for patients with bipolar disorder and substance dependence.

OBJECTIVE: Although bipolar disorder and substance use disorder frequently co-occur, there is little information on the effectiveness of behavioral treatment for this population. Integrated group therapy, which addresses the two disorders simultaneously, was compared with group drug counseling, which focuses on substance use. The authors hypothesized that patients receiving integrated group therapy would have fewer days of substance use and fewer weeks ill with bipolar disorder. METHOD: A randomized controlled trial compared 20 weeks of integrated group therapy or group drug counseling with 3 months of posttreatment follow-up. Sixty-two patients with bipolar disorder and current substance dependence, treated with mood stabilizers for >or=2 weeks, were randomly assigned to integrated group therapy (N=31) or group drug counseling (N=31). The primary outcome measure was the number of days of substance use. The primary mood outcome was the number of weeks ill with a mood episode. RESULTS: Intention-to-treat analysis revealed significantly fewer days of substance use for integrated group therapy patients during treatment and follow-up. Groups were similar in the number of weeks ill with bipolar disorder during treatment and follow-up, although integrated group therapy patients had more depressive and manic symptoms. CONCLUSIONS: Integrated group therapy, a new treatment developed specifically for patients with bipolar disorder and substance dependence, appears to be a promising approach to reduce substance use in this population.

Anxiety disorders among patients with co-occurring bipolar and substance use disorders.

Bipolar and substance use disorders are known to co-occur frequently, but limited attention has been paid to anxiety disorders that may accompany this dual diagnosis. Therefore, we examined the prevalence and nature of anxiety disorders among treatment-seeking patients diagnosed with current bipolar and substance use disorders, and investigated the association between anxiety disorders and substance use. Among 90 participants diagnosed with bipolar disorder I (n = 75, 78%) or II (n = 15, 22%), 43 (48%) had a lifetime anxiety disorder, with post-traumatic stress disorder (PTSD) occurring most frequently (n = 21, 23%). We found that those with PTSD, but not with the other anxiety disorders assessed, began using drugs at an earlier age and had more lifetime substance use disorders, particularly cocaine and amphetamine use disorders, than those without PTSD. Further examination revealed that (1) most participants with PTSD were women, (2) sexual abuse was the most frequently reported index trauma, and (3) the mean age of the earliest index trauma occurred before the mean age of initiation of drug use. Our findings point to the importance of further investigating the ramifications of a trauma history among those who are dually diagnosed with bipolar and substance use disorders.

Substance use and perceived symptom improvement among patients with bipolar disorder and substance dependence.

BACKGROUND: Bipolar disorder (BPD) is the Axis I disorder with the highest risk for coexisting substance use disorder. One explanation for this phenomenon is the 'self-medication hypothesis', which states that some patients experience improvement in psychiatric symptoms as a result of substance use. We thus investigated reasons for substance use and perceived substance-induced improvement in BPD symptoms among patients with current BPD and substance dependence. METHODS: A total of 45 patients received six monthly assessments; 21 also received integrated group therapy (IGT), focusing simultaneously on BPD and substance dependence, while 24 did not receive IGT. Patients reported at intake their current reasons for initiating substance use (including BPD symptoms) and the effects of substance use on those symptoms. RESULTS: Nearly all patients initiated substance use because of at least one BPD symptom, especially depression (77.8%) and racing thoughts (57.8%); most (66.7%) reported improvement in at least one BPD symptom as a result of substance use. Among patients reporting substance-induced improvement in BPD symptoms, those receiving IGT reported fewer days of drug use over the 6-month study period than those not receiving IGT; this difference was not significant among patients without substance-induced improvement in BPD symptoms. LIMITATIONS: The study is limited by its small sample size and by the potential inaccuracy of self-reports regarding the effects of substance use on mood. CONCLUSIONS: Substance dependent patients who report that substance use improves their BPD symptoms may benefit from treatment that focuses simultaneously on both disorders.

History of abuse and drinking outcomes following inpatient alcohol treatment: a prospective study.

Little is known about the impact of sexual or physical abuse history on response to alcohol treatment. This prospective study investigated the relationships between sexual and physical abuse histories, participants' characteristics, and response to inpatient alcohol treatment. Forty-one women and 59 men were assessed monthly for 1 year following hospitalization for alcohol dependence. Survival analyses showed that sexual abuse history was associated with shorter times to first drink and relapse. Physical abuse history was not associated with poorer drinking outcomes. Although women were more likely than men to have a history of sexual abuse, no gender differences were found in drinking outcomes. Poorer drinking outcomes were found among participants who at baseline were not married, had less than a college education, were not employed full time, or carried a diagnosis of depression or other psychiatric disorder. When adjusted for these characteristics, the associations between sexual abuse history and times to first drink and relapse were no longer statistically significant. While sexual abuse history is a clinically meaningful predictor of return to drinking we note the importance of considering patients' background and clinical characteristics in examining the impact of sexual abuse history on drinking outcomes following treatment.