Features of cocaine dependence with concurrent alcohol abuse

Polysubstance Use Patterns among Outpatients Undergoing Substance Use Disorder Treatment: A Latent Class Analysis

Substance Use Disorders (SUDs) pose significant challenges to both individuals and society at large. The primary focus of existing research with clinical SUD populations has been on individual substances, but research is required to better understand the profiles of individuals who use different substances simultaneously. The purpose of the current study was, therefore, to identify patterns of use among subjects (n = 1025) who reported using multiple substances by adopting a Latent Class Analysis (LCA) methodology. The Addiction Severity Index (ASI-lite) was included as a measure of substance misuse, we performed LCA to identify patterns of substance use through the administration of the ASI-Lite. Responses were collected from the following substances: alcohol, cannabis/cannabinoids, opioids and heroin, and cocaine. Results identified two latent classes: (1) alcohol use dominant, and (2) poly-abuser use dominants. Class 1 represented 60.0% of the sample and refers to individuals with the dominant use of alcohol, of those a higher proportion (47%) reported low-frequency use (1 to 7 days per month) and 26% reported a frequency of use of 24 to 30 days per month. Furthermore, 18% used alcohol in combination with cocaine. Class 2 represents 40.0% of the sample. This class is characterized by low-frequency and high-frequency users of several substances. The results obtained highlight the importance of deepening the study of the concomitant use of substances in individuals with SUDs to better understand the health risk of the combined use of two or more substances.

Occurrence and severity of cocaine-induced hallucinations: Two distinct phenotypes with shared clinical factors but specific genetic risk factors

Cocaine-induced transient hallucinations (CIH) are a frequent complication following cocaine intake that is associated with addiction severity.

METHODS

Two hundred and forty-two non-psychotic and Caucasian lifetime cocaine users were included in a French multicentric study. Clinical variables and dopamine pathway genotype data were extracted and tested with CIH scores using a zero-inflated binomial model, which allows for the exploration of factors associated with occurrence and severity separately.

RESULTS

Cocaine dependence (p_occurrence= 6.18 × 10^-5, p_severity= 9.25 × 10^-8), number of cocaine dependence DSM IV-Tr criteria (p_occurrence= 1.22 × 10^-7, p_severity= 5.09 × 10^-6), and frequency of intake during the worst period of misuse (p_occurrence= 8.51 × 10^-04, p_severity= 0.04) were associated with greater occurrence and higher severity of CIH. The genetic associations did not yield significant results after correction for multiple tests. However, some nominal associations of SNPs mapped to the VMAT2, DBH, DRD1, and DRD2 genes were significant. In the multivariate model, the significant variables were the number of cocaine dependence criteria, lifetime alcohol dependence, and the nominally associated SNPs.

CONCLUSION

Our study shows that CIH occurrence and severity are two distinct phenotypes, with shared clinical risk factors; however, they likely do not share the same genetic background.

The importance of considering polysubstance use: lessons from cocaine research

BACKGROUND

Polysubstance use (PSU) is prevalent among individuals with substance use disorders, but the vast majority of preclinical substance use research has focused on individual substances in isolation. Cocaine has been prevalent in the repertoire of persons who use more than one illicit substance.

METHODS

We conducted a meta-analysis combining results from literature searches and secondary data analyses to estimate the prevalence of simultaneous and concurrent cocaine + alcohol and cocaine + cannabis use among cocaine users. We next summarized the small body of literature on behavioral, cognitive and neurobiological consequences of cocaine PSU across species, with a focus on alcohol and cannabis. Finally, we used systematic literature searches to assess the extent to which human and animal studies on the neurobiological consequences of cocaine include PSU subjects.

RESULTS

The estimated prevalence of simultaneous and concurrent alcohol use among human cocaine users was 74% and 77%, respectively. The estimated prevalence of simultaneous and concurrent cannabis use among cocaine users was 38% and 64%, respectively. Consumption of alcohol or cannabis with cocaine enhances subjective responses to cocaine, concomitant with changes in cocaine metabolism that increase blood cocaine levels, and, in the case of alcohol, produce the psychoactive metabolite cocaethylene. There is also consistent evidence for neurobiological effects of cocaine + alcohol combinations. However, animal PSU research with cocaine lags behind human research.

CONCLUSION

Based on the prevalence and known consequences of PSU, consideration of PSU in both human and animal research is vital for understanding patterns of substance use.

Health profiles of clients in substance abuse treatment: a comparison of clients dependent on alcohol or cocaine with those concurrently dependent

The purpose of this study was to assess whether, among clients receiving substance abuse treatment (n = 616), those dependent on alcohol or cocaine differed significantly from those concurrently dependent on both drugs in terms of physical, mental, social, and economic harms as well as substance use behaviors.

METHODS

Clients from five substance abuse treatment agencies presenting with a primary problem of cocaine or alcohol were classified into three groups as dependent on: (1) alcohol alone, (2) cocaine alone, or (3) both cocaine and alcohol (i.e. concurrent dependence). Participants completed a self-administered questionnaire that included details of their drug and alcohol use, physical health, mental health, social health, economic health, and demographic characteristics.

RESULTS

The concurrent group drank similar amounts of alcohol as those in the alcohol group and used similar amounts of cocaine as the cocaine group. The alcohol group had significantly (p < .05) poorer health profiles than the concurrent group across most variables of the four health domains. An exception was significantly more accidental injuries (p < .05) in the alcohol group. In both bivariate and multivariate analyses, the concurrent group had significantly (p < .05) more accidental injuries, violence, and overdoses than the cocaine group. As well, the concurrent group had significantly (p < .05) higher scores on the anxiety and sexual compulsion scales than the cocaine group, controlling for demographic variables.

CONCLUSION

These findings can aid health care professionals to better respond to issues related to concurrent dependence of cocaine and alcohol.

A pilot trial of injectable, extended-release naltrexone for the treatment of co-occurring cocaine and alcohol dependence

BACKGROUND

There is a high co-occurrence of cocaine and alcohol use disorders, and patients with both of these problems are difficult to treat. There is a reasonable rationale and some empirical data to justify a pilot trial of an injectable, extended-release formulation of naltrexone for treating co-occurring cocaine and alcohol addiction.

METHODS

Eighty cocaine (n = 80) and alcohol dependent, treatment-seeking subjects were randomly assigned to receive either two monthly extended-release injections of naltrexone or two matching placebo injections in an 8-week clinical trial, with weekly medical management plus cognitive behavioral therapy visits.

RESULTS

No differences in reduction in cocaine or alcohol use were observed between the injectable naltrexone and placebo groups during the 8-week trial.

CONCLUSIONS

Injectable extended-release naltrexone, while an ideal method for ensuring medication adherence in these traditionally hard-to-treat patients, did not result in any measurable reduction in cocaine or alcohol use over the course of 8 weeks of treatment.

A double-blind, placebo-controlled trial of topiramate for the treatment of comorbid cocaine and alcohol dependence

BACKGROUND

Topiramate increases GABAergic activity and antagonizes the AMPA/kainate subtype of glutamate receptors. Through these mechanisms of action, topiramate may reduce alcohol and cocaine reward and may reduce alcohol and cocaine craving. Topiramate has been shown to reduce drinking in persons with alcohol dependence, and reduce relapse in stimulant-dependent patients. The current trial was intended to test the ability of topiramate to promote cocaine and alcohol abstinence among patients addicted to both drugs.

METHODS

The study was a double-blind, placebo-controlled, 13-week trial involving 170 cocaine and alcohol dependent subjects. After achieving a period of cocaine and alcohol abstinence, subjects were randomized to topiramate, 300 mg daily, or identical placebo capsules. In addition, subjects received weekly individual psychotherapy. Primary outcome measures included self-reported alcohol and cocaine use, and thrice weekly urine drug screens. Secondary outcome measures included cocaine and alcohol craving, Addiction Severity Index results, cocaine withdrawal symptoms, and clinical global improvement ratings.

RESULTS

Topiramate was not better than placebo in reducing cocaine use on the a priori primary outcome measure, or in reducing alcohol use. Topiramate was not better than placebo in reducing cocaine craving. Topiramate-treated subjects, compared to placebo-treated subjects, were more likely to be retained in treatment and more likely to be abstinent from cocaine during the last three weeks of the trial. Subjects who entered treatment with more severe cocaine withdrawal symptoms responded better to topiramate.

DISCUSSION

Topiramate plus cognitive behavioral therapy may reduce cocaine use for some patients with comorbid cocaine and alcohol dependence.

Efficacy of disulfiram and Twelve Step Facilitation in cocaine-dependent individuals maintained on methadone: a randomized placebo-controlled trial

BACKGROUND

Cocaine use remains a major problem within methadone maintenance programs. Disulfiram's efficacy in reducing cocaine use has been demonstrated in several trials, but its relative efficacy among individuals who use versus abstain from alcohol remains unclear. Treatment approaches which seek to enhance substance users' involvement in self-help activities (Twelve Step Facilitation, TSF) have been associated with better outcomes among alcohol and cocaine users, but have rarely been evaluated among methadone-maintained cocaine-opioid users.

METHODS

We conducted a randomized, placebo-controlled, double blind (for medication condition), factorial (2×2) trial with 4 treatment conditions: Disulfiram plus TSF, disulfiram plus standard counseling only, placebo plus TSF, and placebo plus standard counseling in the context of a community-based methadone maintenance program. Participants (N=112) received either disulfiram (250 mg/d) or placebo in conjunction with daily methadone maintenance.

RESULTS

Assignment to TSF was associated with less cocaine use throughout treatment and a higher number of cocaine-negative urines. While there were no significant main effects of disulfiram versus placebo, individuals without an alcohol use disorder demonstrated greater reductions in cocaine use over time when assigned to disulfiram.

CONCLUSIONS

TSF appears feasible in this methadone maintenance program and was associated with modest reductions in cocaine use, an often intractable problem in this setting. Support for the efficacy of disulfiram was weaker, as it appeared effective only for those without a current alcohol use disorder for this sample.

The impact of contingency management on quality of life among cocaine abusers with and without alcohol dependence

The use of quality of life (QOL) measures in substance abuse treatment research is important because it may lead to a broader understanding of patients' health status and effects of interventions. Despite the high rates of comorbid cocaine and alcohol use disorders, little is known about the QOL of this population, and even less about the impact of an efficacious behavioral treatment, contingency management (CM), on QOL. In this study, data from three clinical trials were retrospectively analyzed to examine QOL in outpatient cocaine abusers with and without alcohol dependence (AD) and the impact of CM on QOL over time as a function of AD status. Patients were randomized to standard care (n = 115) or standard care plus CM (n = 278) for 12 weeks. QOL was assessed at baseline and Months 1, 3, 6, and 9. At treatment initiation, AD patients had lower QOL total scores and they scored lower on several subscale scores than those without AD. CM treatment was associated with improvement in QOL regardless of AD status. These data suggest that CM produces benefits that go beyond substance abuse outcomes, and they support the use of QOL indexes to capture information related to treatment outcomes. 

A prospective 2-year study of emergency department patients with early-phase primary psychosis or substance-induced psychosis

OBJECTIVE

The authors examined treatment utilization and outcomes over 2 years among patients admitted to emergency departments with early-phase primary or substance-induced psychosis. The main hypothesis was that patients with substance-induced psychosis would have a more benign course of illness than those with primary psychosis

METHOD

Using a prospective naturalistic cohort study design, the authors compared 217 patients with early-phase primary psychosis plus substance use and 134 patients with early-phase substance-induced psychosis who presented to psychiatric emergency departments at hospitals in Upper Manhattan. Assessments at baseline and at 6, 12, 18, and 24 months included psychiatric diagnoses, service use, and institutional outcomes using the Psychiatric Research Interview for Substance and Mental Disorders; psychiatric symptoms using the Positive and Negative Syndrome Scale; social, vocational, and family functioning using the World Health Organization Psychiatric Disability Assessment Schedule; and life satisfaction using the Quality of Life Interview. Longitudinal analyses were conducted using generalized estimating equations.

RESULTS

Participants with primary psychosis were more likely to receive antipsychotic and mood-stabilizing medications, undergo hospitalizations, and have outpatient psychiatric visits; those with substance-induced psychosis were more likely to receive addiction treatments. Only a minority of each group received minimally adequate treatments. Both groups improved significantly over time on substance dependence, psychotic symptoms, homelessness, and psychosocial outcomes, and few group-by-time interactions emerged.

CONCLUSIONS

Patients presenting to Upper Manhattan emergency departments with either early-phase primary psychosis or substance-induced psychosis improved steadily over 2 years despite minimal use of mental health and substance abuse services.

Patterns of illegal drug use among an adult alcohol dependent population: results from the National Survey on Drug Use and Health

The use of illegal drugs is common in alcohol dependence and significant psychological and social consequences are associated with the concurrent use of alcohol and illegal drugs. However, little literature has examined the patterns of concurrent-drug use in alcohol dependent individuals. A latent class analysis (LCA) was used to determine whether patterns of past year illegal drug use existed in a national sample of 6059 alcohol dependent respondents of the combined 2005, 2006 and 2007 National Survey on Drug Use and Health. Multinomial logistic regression was then used to determine whether demographic variables, mental health disturbance and social consequences were predictive of drug use classes. Results of the LCA demonstrated a 5-class solution with optimal fit deduced by Bayesian Information Criterion minima. The five classes included: a close to zero probability of illegal drug use (class 1: 65%), medium marijuana, medium sedatives/tranquilizers and high analgesics (class 2: 7%), high marijuana, medium cocaine use (class 3: 21%), high probabilities of marijuana, cocaine, sedatives and analgesic use (class 4: 6%) and a high concurrent-drug use except other hallucinogens (class 5: 1%). Regression results suggest that younger age, comorbidity, engaging in deviant behaviors, sexually transmitted infection and incarceration are associated with concurrent illegal drug use in alcohol dependent individuals. Findings advocate that more intense psychiatric and drug dependence treatment resources may be needed for concurrent-drug using alcohol dependent populations and provide evidence for targeted prevention and treatment interventions.

High-dose naltrexone therapy for cocaine-alcohol dependence

This randomized, double-blind, placebo-controlled study compared the effects of high-dose (100 mg/d) naltrexone versus placebo in a sample of 87 randomized subjects with both cocaine and alcohol dependence. Medication conditions were crossed with two behavioral therapy platforms that examined whether adding contingency management (CM) that targeted cocaine abstinence would enhance naltrexone effects compared to cognitive behavioral therapy (CBT) without CM. Primary outcome measures for cocaine (urine screens) and alcohol use (timeline followback) were collected thrice-weekly during 12 weeks of treatment. Retention in treatment and medication compliance rates were low. Rates of cocaine use and drinks per day did not differ between treatment groups; however naltrexone did reduce frequency of heavy drinking days, as did CBT without CM. Notably, adding CM to CBT did not enhance treatment outcomes. These weak findings suggest that pharmacological and behavioral interventions that have shown efficacy in the treatment of a single drug dependence disorder may not provide the coverage needed when targeting dual drug dependence.

CRACK COCAINE, ALCOHOL, AND OTHER DRUG USE PATTERNS AMONG HOMELESS PERSONS WITH OTHER MENTAL DISORDERS

This study examined the co-occurrence of cocaine, alcohol, marijuana, and other drug use among treatment seeking homeless persons to determine whether alcohol use predicted cocaine use differently than marijuana and other drugs predicted cocaine use. Participants were 141 homeless persons with substance use and other nonpsychotic mental disorders seeking drug treatment at a metropolitan health care agency for homeless persons. They were 72.3% male, 27.7% female, 82.7% African American, 17.3% Caucasian, with an average age of 37.7 (SD 7.1) years and had 13.1 (SD 2.4) average years of education. Results supported the assertion that cocaine use was strongly associated with extent of alcohol use and that the association between cocaine and alcohol was stronger than the association between cocaine and other drug use, including marijuana. Participants with cocaine plus alcohol disorders were retained longer in treatment than disorders of cocaine only with no differences in abstinence outcome. The findings should drive further research into the use of alcohol as a trigger or predictor of cocaine use, the deleterious effects of the combined use of cocaine and alcohol, and specialized treatments for polysubstance users.

Predictors of treatment outcome in outpatient cocaine and alcohol dependence treatment

We examined the ability of several baseline variables to predict treatment outcome in a pharmacotherapy trial that included 164 participants who were both cocaine- and alcohol-dependent and were selected for a randomized, double-blind, placebo-controlled study. Predictor variables included results from the baseline Addiction Severity Index (ASI), initial Urine Drug Screen results, cocaine and alcohol craving and cocaine and alcohol withdrawal symptoms at the start of treatment. Successful treatment was defined as four continuous weeks of self-reported cocaine abstinence verified by urine drug screens. In respect to demographic characteristics, there were no significant differences between patients who achieved four weeks of abstinence from cocaine and those who did not. Baseline variables that most consistently predicted cocaine abstinence included initial urine drug screen (UDS) results, the initial Cocaine Selective Severity Assessment (CSSA) scores, and initial self-reported cocaine use in past 30 days, whereas cocaine craving, cocaine composite scores, alcohol craving, alcohol withdrawal symptoms, and alcohol composite scores did not. The results of this study suggest that cocaine dependence severity in general, and initial UDS results, the CSSA scores and frequency of recent cocaine use in particular, have a significant impact on treatment outcome in the treatment of cocaine-dependent patients with comorbid alcoholism. Initial UDS results and CSSA scores are very useful predictors of treatment outcome and could be used as stratifying variables in outpatient cocaine and alcohol medication trials.

Differences between adult non-drug users versus alcohol, cocaine and concurrent alcohol and cocaine problem users

Concurrent drug use is a serious public health concern with significant morbidity and mortality associated with the combined use of alcohol and cocaine. Multinomial logistic regression was used to assess differences between non-drug users and alcohol, cocaine and concurrent problem users incorporating data from the 2005 National Survey on Drug Use and Health. Results demonstrated that alcohol and cocaine use is associated with mental health disturbance, other drug use and adverse social consequences. Furthermore, concurrent users were more likely to report cigarette and marijuana use as well as lifetime STDs and arrest for breaking the law. Study results have implications for planning prevention and treatment services differentially for alcohol, cocaine and concurrent users and support the need for more intense resources allocated to the prevention and treatment of the concurrent use of alcohol and cocaine.

Meta-analysis of depression and substance use and impairment among cocaine users

BACKGROUND

The study evaluated, among cocaine users, the hypothesized positive association of depression and concurrent cocaine use and impairment, alcohol use and impairment, and general drug use and impairment. The hypothesis that gender would moderate these associations, with women showing a stronger correlation between depression and measures of substance use and impairment, was also tested. Also examined was the association of depression with future cocaine use and impairment and substance use treatment participation.

METHODS

Empirical reports on adult cocaine users published in English in peer-reviewed journals since 1986 that contained data on depression and substance use outcome(s) were obtained using a systematic search. Studies that placed restrictions on range of depression scores to select the sample, experiments that administered cocaine to subjects, and trials of antidepressant medications were excluded. The search yielded 60 studies for the analysis including 53 reports that collected data from clinical venues and seven that were community-based.

RESULTS

As hypothesized, the analyses showed that depression is associated with concurrent cocaine-, alcohol-, and general drug use and impairment. Effect sizes were small. Hypothesized moderating effects of gender were not supported. Depression was not associated, at a statistically significant level, with treatment participation or future cocaine use and impairment.

CONCLUSIONS

Depression is consistently but modestly associated with measures of cocaine-, alcohol-, and general drug use and impairment among cocaine users. Associations of depression with treatment participation and with future cocaine use and impairment are not immediately evident, although limitations of data warrant cautious interpretation.

Gender differences with high-dose naltrexone in patients with co-occurring cocaine and alcohol dependence

This is a randomized, double-blind, placebo-controlled clinical trial that evaluated the efficacy of a higher-than-typical daily dose of naltrexone (150 mg/day), taken for 12 weeks, in 164 patients (n = 116 men and n = 48 women) with co-occurring cocaine and alcohol dependence. Patients were stratified by gender and then randomly assigned to either naltrexone or placebo, and to either cognitive-behavioral therapy or a type of medical management. The two primary outcomes were cocaine use and alcohol use. Significant Gender x Medication interactions were found for cocaine use via urine drug screens (three way, with time) and self-reports (two way) for drug severity (two way) and alcohol use (two way). The type of psychosocial treatment did not affect outcomes. Thus, 150 mg/day naltrexone added to a psychosocial treatment resulted in reductions in cocaine and alcohol use and drug severity in men, compared to higher rates of cocaine and alcohol use and drug severity in women.

A double blind, placebo-controlled trial that combines disulfiram and naltrexone for treating co-occurring cocaine and alcohol dependence

BACKGROUND

This is a double blind, placebo-controlled trial that evaluated the efficacy of disulfiram, naltrexone and their combination in patients with co-occurring cocaine and alcohol dependence.

METHODS

208 patients were randomized to disulfiram (250 mg/day), naltrexone (100 mg/day), the combination, or placebo for 11 weeks. Outcomes were in-trial abstinence from cocaine and/or alcohol.

RESULTS

Few safety concerns were reported, although medication adherence was low in a number of patients for both medications, alone or in combination. In the primary analyses (GEE modeling), abstinence from cocaine as measured by cocaine-negative urines and days of self-reported abstinence from cocaine or alcohol did not differ between placebo and any of the medication groups. However, patients taking disulfiram (alone or in combination) were most likely to achieve combined abstinence from cocaine and alcohol. Secondary analyses revealed that patients taking the disulfiram-naltrexone combination were most likely to achieve 3 consecutive weeks of abstinence from cocaine and alcohol.

CONCLUSION

There was an association between disulfiram treatment and abstinence from cocaine and alcohol. More patients taking the disulfiram-naltrexone combination achieved 3 consecutive weeks of abstinence in treatment than placebo-treated patients.

Psychiatric Distress in Incarcerated Women With Recent Cocaine and Alcohol Abuse

PURPOSE

Women frequently abuse cocaine and alcohol before incarceration. Research indicates that women in criminal justice settings also suffer high rates of psychiatric distress. This study aimed to determine how preincarceration abuse of alcohol and cocaine affected current psychiatric distress among female jail detainees held for 10-14 days.

METHODS

A probability sample of women in a large urban jail (n = 469) were assessed for use of alcohol and cocaine during the 6 months before incarceration and for their current psychiatric distress. They were grouped based on their level of alcohol consumption and cocaine use: high cocaine/high alcohol; high cocaine/low alcohol; low cocaine/high alcohol; and low cocaine/low alcohol. Profile analysis was used to examine the relation of psychiatric distress, as measured by the Brief Symptom Inventory, to levels of recent alcohol and cocaine use.

RESULTS

Psychiatric distress is highest (and similar) among women in the high cocaine groups, regardless of alcohol use, and psychiatric distress is lowest among those who used both substances infrequently. Characteristics of psychiatric distress differed based on level of alcohol use, but only when cocaine use was low. High alcohol and cocaine use alone and together also predict the likelihood of psychiatric distress reaching a diagnosable level of severity.

CONCLUSIONS

High cocaine, alcohol, or combined use is related to higher levels of psychiatric distress among incarcerated women in this jail. Women should be screened at the time of incarceration, and women who have alcohol and other drug problems should receive treatment that includes mental health services.

Ethanol consumption reduces the adverse consequences of self-administered intravenous cocaine in rats

RATIONALE

Human drug users report that the initial positive effects of cocaine are followed by a dysphoric state characterized by anxiety and drug-craving. As a means of presumably attenuating these negative aftereffects, 50-90% of cocaine users choose to co-administer ethanol during cocaine binges. This co-administration reportedly prolongs the "high" and diminishes the "low" associated with cocaine use.

OBJECTIVE

The current study was intended to assess whether this phenomenon could be modeled in the animal laboratory. We have previously shown that animals running a straight alley for an intravenous cocaine reward develop a unique approach-avoidance "conflict" behavior that is characterized by stop and retreat behaviors as the subjects approach the goal box. The retreats are thought to reflect the concurrent positive (reward) and negative (anxiety) associations with the goal box and can be dose-dependently reduced by pretreatment with diazepam, which presumably attenuates the anxiety stemming from the conflict.

METHODS

To test the role of ethanol in reducing cocaine-induced anxiety, rats were trained to run a straight-arm alley for a single daily injection of cocaine (1.0 mg/kg IV).

RESULTS

Rats that had the opportunity to then drink either an 8% or a 4% sucrose-ethanol solution immediately following their daily runway trial came to exhibit fewer retreats than rats that did not drink ethanol following their cocaine injection.

CONCLUSIONS

These results suggest that ethanol effectively reduces the development of approach-avoidance conflict in animals running an alley for IV cocaine, a result that may account for the prevalence of cocaine-ethanol co-administration in humans.

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.

Opponent process properties of self-administered cocaine

Over the past decade, data collected in our laboratory have demonstrated that self-administered cocaine produces Opponent-Process-like behavioral effects. Animals running a straight alley once each day for IV cocaine develop over trials an approach-avoidance conflict about re-entering the goal box. This conflict behavior is characterized by a stop in forward locomotion (usually at the very mouth of the goal box) followed by a turn and 'retreat' back toward the goal box. The results of a series of studies conducted over the past decade collectively suggest that the behavioral ambivalence exemplified by rats running the alley for IV cocaine stems from concurrent and opponent positive (rewarding) and negative (anxiogenic) properties of the drug--both of which are associated with the goal box. These opponent properties of cocaine have been shown to result from temporally distinct affective states. Using a conditioned place preference test, we have been able to demonstrate that while the initial immediate effects of IV cocaine are reinforcing, the state present 15 min post-injection is aversive. In our most recent work, the co-administration of IV cocaine with either oral ethanol or IV heroin was found to greatly diminish the development and occurrence of retreat behaviors in the runway. It may therefore be that the high incidence of co-abuse of cocaine with either ethanol or heroin, stems from the users' motivation to alleviate some of the negative side effects of cocaine. It would seem then that the Opponent Process Theory has provided a useful conceptual framework for the study of the behavioral consequences of self-administered cocaine including the notion that both positive and negative reinforcement mechanisms are involved in the development and maintenance of cocaine abuse.

Efficacy of disulfiram and cognitive behavior therapy in cocaine-dependent outpatients: a randomized placebo-controlled trial

CONTEXT

Disulfiram has emerged as a promising treatment for cocaine dependence, but it has not yet been evaluated in general populations of cocaine users.

OBJECTIVES

To compare the effectiveness of disulfiram therapy with that of a placebo condition in reducing cocaine use and to compare the effectiveness of 2 active behavioral therapies-cognitive behavior therapy (CBT) and interpersonal psychotherapy (IPT)-in reducing cocaine use.

DESIGN

Randomized, placebo-controlled, double-masked (for medication condition), factorial (2 x 2) trial with 4 treatment conditions: disulfiram plus CBT, disulfiram plus IPT, placebo plus CBT, and placebo plus IPT.

SETTING

A community-based outpatient substance abuse treatment program.

PATIENTS

A total of 121 individuals meeting the criteria for current cocaine dependence.

INTERVENTIONS

Patients received either disulfiram (250 mg/d) or placebo in identical capsules. Medication compliance was monitored using a riboflavin marker procedure. Both behavioral therapies (CBT and IPT) were manual guided and were delivered in individual sessions for 12 weeks.

MAIN OUTCOME MEASURES

Random regression analyses of self-reported frequency of cocaine use and results of urine toxicology screens.

RESULTS

Participants assigned to disulfiram reduced their cocaine use significantly more than those assigned to placebo, and those assigned to CBT reduced their cocaine use significantly more than those assigned to IPT (P<.01 for both). Findings were consistent across all study samples (eg, intention to treat, treatment initiators, and treatment completers). Benefits of disulfiram use and CBT were most pronounced for participants who were not alcohol dependent at baseline or who fully abstained from drinking alcohol during treatment. Adverse effects experienced by participants who received disulfiram were mild and were not considerably different from those experienced by participants who received placebo.

CONCLUSIONS

Disulfiram and CBT are effective therapies for general populations of cocaine-dependent individuals. Disulfiram seems to exert a direct effect on cocaine use rather than through reducing concurrent alcohol use.

Outcome predictors in substance use disorders

Given the heterogeneous nature of substance abuse, it is notable that several predictors of response are independent of the primary drug of abuse or the treatment setting [208]. Although the strength of the relationship of predictor to outcome varies, the following factors have been identified consistently: severity of dependence or withdrawal; psychiatric comorbidity; substance-related problems; motivation (abstinence commitment); length of treatment; negative affective states; cognitive factors; personality traits and disorders; coping skills; multiple substance abuse; contingency contracting or coercion; genetic factors; sleep architecture; urges and craving; self-efficacy; and economic and social factors. Although it is well known that severity of dependence (including polysubstance abuse), serious psychiatric comorbidity, and social problems are associated with poor treatment response, only recently has research examined the efficacy of intervention strategies that specifically address these problems. Adequate treatment of psychiatric comorbidity and improvement in social, economic, and family functioning lead to better treatment outcomes. The development of specific techniques to enhance self-efficacy, motivation, coping skills, and functioning in the community are concrete examples of how the identification of factors associated with positive outcomes has led to the development of new treatments. Despite significant accomplishments, the field is left with many unanswered questions. Although several biologic markers, such as neuroendocrine response and sleep architecture, show promise as outcome predictors, it is not known whether these are critical factors in the initiation of substance use or its progression to dependence. Determining whether biologic markers are epiphenomena reflecting the amount and duration of substance abuse or are fundamental to the pathophysiology of dependence is a matter of urgent concern. With some exceptions, identification of biologic predictors has not led to innovative therapies. One of these exceptions is the development of naltrexone for the treatment of alcoholism, which was based in a solid theoretical rationale and followed by hypothesis-driven experiments. Similar opportunities should emerge from current basic science and clinical research. The application of pharmacogenetic techniques to the field of addiction also holds great promise. As future studies are undertaken, researchers and clinicians must be mindful that differences in outcome predictors across drugs of abuse and treatments may emerge as subgroups of individuals with addictive disorders and new therapies are identified. There is already evidence that early onset alcoholism is associated with poor response under some circumstances, yet may be a predictor of response to targeted pharmacotherapy with ondansetron [64, 112]. As the ability to subtype disorders based on meaningful biologic differences grows, it is anticipated that several relevant outcome predictors that are specific for pharmacotherapy will emerge.

Alcohol use among out-of-treatment crack using African-American women

OBJECTIVE

The purpose of this study was to categorize the quantity and frequency of alcohol use among African-American women who were abusing crack cocaine and to explore relationships between categories of alcohol use and demographic variables, cocaine use, comorbidity, and risky sexual behaviors.

METHOD

Data were collected from 635 out-of-treatment crack cocaine-abusing African-American women in the Raleigh/Durham area of North Carolina. The women were categorized as light (n = 272), moderate (n = 216), or heavy drinkers (n = 147).

RESULTS

Women classified as heavy drinkers were demographically similar to light and moderate drinkers. Heavy drinkers used more crack cocaine and were more likely to engage in sexual risk behaviors than were the other two drinking groups. The heavy drinkers also reported greater psychological distress, and they were more likely to report histories of physical, sexual, and emotional abuse.

CONCLUSIONS

Heavy alcohol use among crack-abusing African-American women may be a marker for a host of underlying problems that require special attention. The HIV prevention programs and substance abuse treatment programs that provide services to crack-abusing women should screen for heavy drinking. Women identified as heavy drinkers should undergo more in-depth assessments and receive additional referrals as appropriate.

Concurrent cocaine withdrawal alters alcohol withdrawal symptoms

This study compares alcohol withdrawal severity during outpatient detoxification in alcohol dependent subjects (ALC) and in subjects dependent on both alcohol and cocaine (ALC/COC). Subjects included 123 ALC and 66 ALC/COC subjects. Baseline demographic and drug use variables, alcohol withdrawal symptoms, and the total amount of oxazepam taken during alcohol detoxification were compared between the two groups. Compared to ALC subjects, ALC/COC subjects were younger, more likely to be African-American, and had less severe histories of alcohol dependence. However, alcohol withdrawal symptom severity did not differ significantly between the two groups. Nevertheless, controlling for differences in alcohol use history, ALC/COC subjects still received less oxazepam than did ALC subjects to treat alcohol withdrawal symptoms. Despite similar intensity of alcohol withdrawal symptoms, ALC/COC subjects received less oxazepam to treat alcohol withdrawal symptoms compared to ALC subjects. Both subject and clinician factors may explain the difference in oxazepam use.

Evidence for opponent-process actions of intravenous cocaine and cocaethylene

The affective response to cocaine (COC) has been suggested to follow a time-course and pattern that adheres to the prediction of opponent-process models of drug actions. While the initial impact of the drug is positive, within a few minutes that effect wanes and is replaced by an aversive state characterized by anxiety and drug craving. We have demonstrated this phenomenon in animals by showing that rats prefer distinctive environments associated with the immediate effects of intravenous COC (1.0 mg/kg) but avoid environments associated with the state present 15-min postinjection. Human addicts have reported taking ethanol with their COC as a means of attenuating the negative aftereffects of COC administration. The combination of ethanol and COC results in the production of cocaethylene (CE), a metabolite of COC having psychostimulant properties. The current study was devised to assess whether the immediate and delayed affective responses to CE might account for the self-medication strategy of COC addicts pretreating themselves with ethanol. Rats developed conditioned place preferences for environments paired with the immediate effects of a 1.44-mg/kg intravenous dose of CE (equimolar to a 1.0-mg/kg dose of COC). While no aversive effects were observed at 0, 5, or 15 min postinjection, reliable place avoidance was detected for an environment paired with the internal state present 30-min post-CE. These data are consistent with the view that the development of CE may account for efficacy of ethanol to delay and weaken the aversive aftereffects of COC.

Differences among out-of-treatment drug injectors who use stimulants only, opiates only or both: implications for treatment entry

The goal of this study was to compare drug and alcohol use, psychological symptoms and substance abuse treatment entry among 583 street-recruited, out-of-treatment injection drug users (IDUs) who used stimulants only, opiates only or both stimulant and opiate. Data analyzed from structured interviews indicated that stimulant-only users had the most severe alcohol problems and the highest psychological symptom scores for hostility, paranoia and psychoticism. In the 2 months following their interview only 3% of the stimulant-only users entered substance abuse treatment, as compared to nearly half of the participants in the other two groups. Even after controlling for variables that differed among the groups by logistic regression analysis, stimulant only users were still 24-25 times less likely than opiate only or both stimulant and opiate users to enter treatment. Researchers and clinicians are challenged to better understand and address the unique needs of stimulant users, including potential psychological problems and alcohol abuse, in order to attract them to treatment and serve them through a comprehensive treatment approach.

Implications of recent research for program quality in cocaine dependence treatment

Great strides have been made in recent years regarding the development and evaluation of treatments for cocaine dependence. In particular, several behavioral strategies have been developed with demonstrated effectiveness for diverse populations of cocaine-dependent individuals. These include contingency management, cognitive behavioral treatments, and manualized individual disease model approaches. In addition, large-scale client surveys have identified several correlates of good outcome in the treatment of cocaine dependence, including retention in treatment, increasing compliance, providing services and treatments that address the patient's comorbid psychosocial problems, and encouraging involvement in self-help groups. Finally, greater adoption by treatment providers of strategies commonly used in treatment efficacy research might also contribute to improved treatment quality.

The effects of naltrexone on alcohol and cocaine use in dually addicted patients

Concurrent dependence on cocaine and alcohol is common among patients seeking addiction treatment. This study was undertaken to explore the effectiveness of naltrexone (150 mg) as a potential treatment for patients who are alcohol and cocaine dependent. Of 15 subjects enrolled in the 12-week, open medication trial, 7 subjects did not complete the study. Relapse to clinically significant drinking occurred in 7 subjects (47%). There was a reduction in the average daily amount of alcohol consumed from pretreatment to treatment (p < .001) and the percentage of days engaged in drinking behavior (p < .001). Similarly, there was a reduction in the average weekly amount spent on cocaine from pretreatment to treatment (p = .001) and the percentage of days using cocaine (p < .001). This preliminary study suggests that naltrexone (150 mg) may be tolerable in patients dependent upon alcohol and cocaine and may be effective in reducing both cocaine and alcohol use. The results of this study provide a rationale for a double-blind placebo-controlled study of the efficacy of naltrexone in this difficult to treat but prevalent population.

Cocaine metabolism in humans after use of alcohol. Clinical and research implications

The simultaneous administration of cocaine and alcohol implies a pharmacological interaction at pharmacodynamic and pharmacokinetic levels. The latter involves an alteration of cocaine kinetics and metabolism, as well as the biosynthesis of newly active metabolites, such as cocaethylene. Cocaethylene is metabolized along the same pathways as cocaine. Its detection in biological samples indicates the combined consumption of cocaine and alcohol. From epidemiological and toxicological data, it has been suggested that the combination of alcohol and cocaine produces an increased toxicity in addition to behavioral changes. There has been some debate regarding the contribution of cocaethylene to this rise of toxicity. Its pharmacological and toxicological profile is very similar to cocaine. During the interaction of both substances, the rise in cocaine plasma concentrations can explain many of cardiovascular and behavioral effects observed. The contribution of cocaethylene to the interaction is probably minor; its effects are likely additive to those of cocaine. Perhaps its longer elimination half-life can help in understanding long-lasting effects of the alcohol-cocaine combination.

Concurrent use of cocaine and alcohol is more potent and potentially more toxic than use of either alone--a multiple-dose study

BACKGROUND

Simultaneous abuse of cocaine and alcohol is widespread and increasingly detected in patients seeking emergent care. This double-blind, randomized, within-subjects study used a paradigm more closely approximating practices of drug abusers to better understand the pathogenesis of cocaine-alcohol abuse.

METHODS

Subjects meeting DSM-IV criteria for cocaine dependence and alcohol abuse participated in three drug administration sessions: four doses of intranasal cocaine (1 mg/kg every 30 min) with oral alcohol (1 g/kg) administered following the initial cocaine dose and a second dose (120 mg/kg) at 60 min calculated to maintain plasma alcohol concentration at approximately 100 mg/dL during cocaine administration; four doses of cocaine/placebo alcohol; four doses of cocaine placebo/alcohol. Pharmacokinetic, physiological, and behavioral effects were followed over 8 hours.

RESULTS

Cocaine-alcohol produced greater euphoria and increased perception of well-being relative to cocaine. Heart rate significantly increased following cocaine-alcohol administration relative to either drug alone. Cocaine concentrations were greater following cocaine-alcohol administration. Cocaethylene had a longer halflife with increasing concentrations relative to cocaine at later time points.

CONCLUSIONS

Enhanced psychological effects during cocaine-alcohol abuse may encourage ingestion of larger amounts of these substances over time placing users at heightened risk for greater toxicity than with either drug alone.