Characteristics of homeless HIV-positive outreach responders in urban US and their success in primary care treatment.

Homeless HIV+ persons with persistent mental illness and substance use disorders need services, but are hard to reach and enrol into treatment. Connecting them to services is a major challenge of the AIDS epidemic. This report describes characteristics of homeless HIV+ substance abusers who responded to outreach and enrolled in integrated treatment services. The target population was urban, homeless, HIV+ individuals with substance dependence and/or mental illness diagnoses. Health and physical functioning were measured using a refinement of the Medical Outcomes Study Health Survey. Questions based on the PRIME-MD measured subjects' mental health status. Outreach occurred at shelters, soup kitchens, and on the streets. The outreach team consisted of a nurse, substance abuse counsellor, and a formerly homeless person. Outreach contacted 3,059 individuals; 1,446 entered the clinic, 110 of 206 eligible candidates enrolled in the study, and 82.7% of study participants completed 12-month follow-up interviews. Enrollees exhibited 5th percentile composite health scores. They reported heavy street drug use and unmet service needs particularly for housing and financial assistance. Outreach successfully recruited targeted individuals into treatment. They stayed in treatment and demonstrated improvements on measures of physical and mental health 12-months later.

Effectiveness of outreach to homeless substance abusers.

Substance abuse is a frequent and complicating feature of homelessness. Barriers to service access have prevented homeless individuals from receiving substance abuse care. Outreach to homeless persons is a mechanism for identifying homeless substance abusers and engaging them in treatment. This study describes a program of substance abuse treatment conducted by a medical care provider for homeless persons in Baltimore, Maryland and compares characteristics of outreach recipients to those of walk-in clients. The study also examines the differences in drug abuse pathology and selected treatment outcomes among homeless and non-homeless clients and the extent to which homeless persons are unidentified in the drug abuse treatment reporting system of the state. Homelessness is about 5.5 times more prevalent in the clientele of drug abuse treatment programs than is reflected in the statewide substance abuse management information system of Maryland. Composite scores on the Addiction Severity Index for homeless individuals are significantly higher (reflecting more serious problems) on every measure in the interview, compared to non-homeless individuals. Except for residential treatment settings, homeless persons demonstrate a shorter length-of-stay in substance abuse treatment than housed clients. Our outreach effort successfully located its targets. Outreach clients reported significantly higher levels of substance abuse than walk-in clients. In addition 42.3% of outreach contacts became service recipients. These findings indicate that outreach can be a successful method of targeting and engaging a segment of homeless substance abusers who are otherwise difficult to engage in treatment.

Clonidine use and abuse among methadone program applicants and patients.

Forty-eight consecutive applicants and 30 known clonidine-abusing methadone patients at three methadone treatment programs were surveyed regarding their use of clonidine. Two distinct patterns of clonidine use emerged. Of 22 applicants who took clonidine illicitly, 15 used it primarily to decrease opioid withdrawal, as well as for its sedating effect. Applicants mostly obtained it from physicians, used an average dose of 0.37 mg at a time, and about one third believed clonidine to be addictive. In contrast, clonidine-using patients took clonidine primarily for its psychoactive effects, including the interaction with methadone, in addition to decreasing opioid withdrawal. Patients obtained clonidine frequently on the street and from family or friends, but less from physicians. The average reported dose for patients was 0.6 mg. The vast majority of these patients felt clonidine was addictive. Our findings, when coupled with the risk inherent in clonidine overdose, suggest that further research into the identification and treatment of clonidine abuse among methadone patients is warranted.

An evaluation of intravenous ethanol in hospitalized patients.

Alcohol withdrawal is a serious complication of heavy alcohol use and a condition requiring patient stabilization before initiating surgery or implementing lifesaving procedures for injury. Intravenous ethanol (IVE) is used to prevent withdrawal during these maneuvers. This report explores the use and potential problems of this practice in an academic urban medical center. This study was undertaken to improve the treatment of IVE recipients in an urban, academic health system providing trauma, surgery, and general inpatient services. All 68 patients, identified by a review of the pharmacy database for the period August 1993 through January 1994, received IVE during their stay. A priori outcome measures related to the course of therapy in the selected cases. Of all patients studied, 67.6% were admitted for alcohol-related trauma; 61.8% of IVE recipients had no documented risk factors for delirium tremens (59.5% of these were oriented); 17.6% were discharged on the same day the drip was discontinued; only 17.6% were referred to the alcohol consult team; and, throughout the course of therapy in all cases, no blood alcohol level (BAL) determinations were recorded in patients' records. The use of IVE is associated with potentially serious clinical concerns. We found a high prevalence of alcohol-related admissions, inconsistent IVE administration, and a low rate of alcohol consult requests. Guidelines to improve the selection, management, and disposition of IVE recipients are suggested.

Addictions training for physicians and other licensed health care professionals in Maryland.

Physicians and other health care providers have multiple opportunities in the course of a typical practice year to identify and treat individuals who abuse alcohol and other drugs. Although substance abuse is very common in clinical practice, providers routinely fail to intervene in a timely fashion due to negative attitudes, incomplete knowledge, and poorly developed practice skills. Over the past ten years, addictions training of licensed health care providers nationally and in Maryland has improved significantly. This article describes recent national training trends and current educational programs statewide for medical students, physicians in residency and fellowship programs, and licensed providers in dentistry, nursing, pharmacy, psychology, and social work. Several strategies for improving professional training in addictions in the future are discussed and the importance of shifting to an interprofessional training model is emphasized.

Outpatient benzodiazepine detoxification procedure for methadone patients.

Benzodiazepines are used by a substantial minority of opioid addicts on methadone maintenance. Alprazolam, now the most widely prescribed benzodiazepine in the United States, appears to have supplanted diazepam as the benzodiazepine drug of choice in this population. Its greater addiction liability, shorter half-life, and more intense withdrawal symptoms make addiction to alprazolam more likely and its management in methadone patients more complicated. This article describes a slow outpatient tapered reduction procedure that was utilized to detoxify benzodiazepine dependent methadone patients seen over a two-year period. The reduction procedure was offered to 22 opioid addicts on methadone maintenance who were regularly ingesting low to moderate amounts of benzodiazepines, primarily alprazolam. Of the 22 patients, 4 patients refused outpatient detoxification, and 18 were started on a reduction procedure. Twelve patients completed the detoxification procedure which averaged 7.8 weeks. Comparisons are made between completers and non-completers and essential design features of the procedure are discussed.

Psychosocial correlates of drug use among Latino youth leading autonomous lives.

Drug use and psychosocial profile of young Central American immigrants in Washington, D.C., were compared to the National Household Survey of Latinos. The immigrants showed: (1) more exposure to alcohol and illicit drugs; (2) interrelated marijuana, cocaine, PCP, and hallucinogenic drug use; and (3) a positive association between psychosocial competency and ratio of perceived supports/threats. Drug involvement intensity was negatively associated with psychosocial competence and positively with instrumental drug use, CAGE scores, and problems. Crisis scores and drug involvement were related only in the high support/threat group. Supportive environments may be more effective than threats in preventing drug use.

Medical services provided to 2,394 patients at methadone programs in three states.

The type and amount of medical services provided to 2,394 patients in methadone maintenance programs in three states was studied. Data were obtained from on-site confidential interviews with the entire treatment staff at seven programs. It was found that there were marked differences in the number and type of medical staff. Thus, there was ten times more coverage by physicians at some programs than others. In general, there were notable differences in the treatment staff available. Comparable variations among the programs were found with respect to the actual provision of medical services. Thus, the number of patients seen by the medical staff on a weekly basis varied from a high of 185 patients to a low of 36 patients. Similarly, the proportion of each program's patients receiving medical treatment per week varied from 53 to 14 percent. Reasons for those variations in medical services are considered.

Alcohol and the steady-state disposition kinetics of methadone in rats.

In order to examine whether alcohol alters the steady-state disposition of chronic or acute doses of methadone, three groups (N = 5 each) of male Sprague-Dawley rats were administered oral doses of methadone daily for 14 days. Group 1 received oral doses of alcohol twice daily whereas groups 2 and 3 were given isocaloric sucrose. Water was provided ad libitum and food consumption was controlled by paired feeding. On day 15, all of the animals were given the last dose as C14 methadone. Group 2 received a concurrent dose of alcohol but groups 1 and 3 received isocaloric sucrose. Blood was drawn at timed intervals for 48 hr. Methadone and its major metabolite (M1) in plasma were separated by thin-layer chromatography and underwent liquid scintillation counting. The elimination half-life (t1/2, beta) and the area under the plasma concentration-time curve (AUC) of methadone and M1 were determined in all of the three groups. Group 1 demonstrated the smallest AUC and the shortest t1/2 for methadone and M1 (p less than .05). Group 2 displayed the highest amount of unchanged methadone (p less than .05) in the first 2 hr after administration, but its t1/2 and AUC of methadone and M1 were not significantly different from those of group 3. These data may help explain why there is a high incidence of heavy drinking among methadone-maintained patients.

A behavioral treatment of alcoholic methadone patients.

Alcoholism is a frequent complication of methadone treatment and is one of the few behaviors found to correlate with methadone treatment failure. To eliminate drinking among severely alcoholic patients, we tested the efficacy of incorporating methadone into a behavioral contingency to reinforce disulfiram ingestion. Methadone was dispensed to alcoholic narcotic addicts contingent upon their ingesting disulfiram, and as a control patients were urged to take disulfiram but received methadone regardless of whether they took disulfiram. The results indicated that the reinforced disulfiram treatment was highly successful in controlling alcoholism. In addition, nonstatistically significant trends suggested that the reinforced disulfiram treatment resulted in a superior adjustment, as reflected in arrest rate, unemployment, and illicit drug use. There appeared to be no significant physiologic or behavioral adverse effects.