Alcohol and cocaine abusers 6 months after traditional treatment: do they fare as well as problem drinkers?

The role of affective temperament as a predictor of relapse in alcohol dependence

BACKGROUND

Personality traits have been proposed as relapse risk factors in alcohol use disorders. So far, no study has assessed the association between affective temperamental traits and the prospective relapse risk.

METHODS

This was a 3-month prospective naturalistic study, designed to assess the impact of affective temperaments in relapse. A sample of 61 alcohol-dependent patients was collected from an ambulatory clinical setting. Socio-demographic information, drinking and substance use habits, drinking status, craving and affective temperament traits were assessed.

RESULTS

Age, age of onset of alcohol abuse and dependence and drug consumption correlate with drinking status. Male alcohol-dependent patients who relapsed presented higher scores on cyclothymic temperament than patients with an alcohol dependence diagnosis who remain sober. Hierarchical logistic regression indicates that cyclothymic temperament predicted relapse in a 3-month follow-up. However, the coefficient was marginally significant after controlling for all potential confounding predictors.

CONCLUSIONS

Our results provide new insights about the role of affective temperaments in alcohol use disorders, specifically in predicting short-term relapse in detoxified male alcohol-dependent patients. Copyright © 2017 John Wiley & Sons, Ltd.

Differential Improvement of Executive Functions During Abstinence in Cocaine-Dependent Patients: A Longitudinal Study

BACKGROUND

In substance abusers, deficits in executive functioning (EF) are relevant to understanding the behavioral regulation of substance consumption and the failure to remain abstinent.

OBJECTIVE

To determine the course of EF impairment, measured with traditional and ecological instruments, after 1 and 3 months of abstinence in patients with cocaine dependence.

METHODS

26 cocaine-only-dependent in-patients (cocaine-dependent group, CDG) and 24 nondependent controls (control group, CG) recruited from a typical population were assessed using several EF tests and questionnaires [Stroop, verbal and graphic fluency, Wisconsin Card-Sorting Test (WCST), Tower of London (TOL), and Behavior Rating Inventory of Executive Function-Adult Version (BRIEF-A)] after three periods of abstinence: 1 week, 1 month, and 3 months.

RESULTS

At 1 week (baseline), CDG underperformed CG on most EF measures (WCST categories completed; TOL-total number of moves, execution time, and rule violations; and various BRIEF-A subscales). At 1 month, CDG moderately improved its performance on several measures, meanwhile the improvement in the 12 patients who would eventually complete the 3-month abstinence proved particularly significant when compared to their baseline values. In the a posteriori comparison of the baseline values of noncompleters versus completers, scores for the former were lower on the EF tasks, but higher on the BRIEF-A. Both groups, showed significantly worse scores than CG on both instruments.

CONCLUSIONS/IMPORTANCE

Cocaine-dependent patients showed marked difficulties in the EF associated mainly with adaptive behavior to their environment. Cocaine-dependent patients with better EF at baseline improved significantly during abstinence and had better treatment adherence. Results suggest that executive improvement and treatment adherence in cocaine abusers in abstinence is related to intrinsic cognitive characteristics of patients.

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.

The status of naltrexone in the treatment of alcohol dependence: specific effects on heavy drinking

BACKGROUND

In almost 2 decades of naltrexone research for treating alcoholism, there have been 29 published randomized placebo-controlled trials of opioid antagonists, primarily naltrexone, for the treatment of alcohol dependence. The present review builds on prior systematic reviews while maximizing the number of included studies to date, for the purpose of resolving inconsistencies in naltrexone's reported efficacy across trials. Clinical trial results in this article are evaluated by the type of outcome measure used to determine naltrexone's treatment advantage, that is, measures related to reducing heavy drinking versus those related to increasing abstinence.

METHODS

We conducted a Medline search to identify double-blind studies from 1990 to the present (2006) that evaluated the use of anopiate antagonist for the treatment of alcohol dependence. There were 29 studies identified, representing 5997 alcohol-dependent patients, which met our study inclusion criteria for this review. Studies were evaluated in this review on 4 prespecified drinking outcomes-2 related to "any drinking" and 2 related to "heavy or excessive drinking."

RESULTS

In the treatment of alcohol dependence, we found that 19 (70%) of 27 clinical trials that measured reductions in "heavy or excessive drinking" demonstrated an advantage for prescribing naltrexone over placebo, whereas only 9 (36%) of 25 clinical trials that measured abstinence or "any drinking" found an advantage for medication over placebo.

CONCLUSION

The majority of double-blind clinical trials in the literature favored prescribing naltrexone for alcohol dependence to reduce heavy drinking. This finding is consistent with our understanding of naltrexone's mechanism of action of decreasing excessive drinking by reducing the reward associated with drinking alcohol. Thus, we conclude that outcome measures related to heavy or excessive drinking are most relevant to defining naltrexone's therapeutic effects. Factors influencing naltrexone response (treatment adherence and distinct patient subgroups) are also discussed.

Neurocognitive deficits in cocaine users: a quantitative review of the evidence

Studies on the neurocognitive effects of cocaine abuse are equivocal with respect to the specific types of deficits observed, although the vast majority of studies indicate that at least some deficits in certain broad functions such as attention, learning and memory, executive functions, and response speed exist. All of these studies based their results on null hypothesis statistical significance testing (NHSST). It is argued that effect size analysis, which provides information about the magnitude of difference, offers a more valid index of cognitive impairments in a population when compared to NHSST. Accordingly, the objective of the current study was to conduct an effect size analysis (or a meta-analysis in cases where the same test measure was utilized in more than one study) to determine the type and the magnitude of the specific cognitive deficits found as a result of cocaine use. Effect sizes were calculated for each test variable across 15 empirical studies that met inclusion criteria. The results from 481 cocaine users and 586 healthy normal controls revealed that cocaine use had the largest effect on several measures of attention (0.40 < d < 1.10). Moderate to large effect sizes (d > 0.50) were also obtained on tests of visual memory and working memory. Minimal effect sizes (d < 0.30) were obtained on tests of verbal fluency and other language functions and sensory-perceptual functions. Tests of executive functioning produced mixed findings and were interpreted in terms of degree rather than nature of impairment. The results are consistent with findings from neuroimaging and neurochemical studies that have found cocaine use to be associated with dysfunctions in the anterior cingulate gyrus and orbitofrontal cortex; these regions are highly implicated in the mediation of attentional and executive functions, respectively. Methodological limitations of the empirical studies included in the analysis are discussed.

Drug-use patterns among men who have sex with men presenting for alcohol treatment: differences in ethnic and sexual identity

Two important gaps in our current understanding of drug and alcohol use among men who have sex with men (MSM) are that, first, little is known about the extent of drug- and alcohol-use disorders among MSM and, second, how these may vary among MSM who differ by ethnic/racial or sexual identity. This article is a descriptive study of the alcohol- and drug-use patterns and alcohol and drug diagnoses in an ethnically and sexually diverse sample of treatment-seeking MSM whose primary diagnosis is either alcohol abuse or alcohol dependence. The severity of alcohol problems did not vary by either ethnic or sexual identity, although the types of drugs that were used by participants did. African Americans reported a significantly higher number of drinks per drinking day compared with those in the other ethnic categories.Gay-identified men and those identified as either non-Hispanic Whites or Hispanic/Latino were significantly more likely to have used stimulant drugs (amphetamine or methamphetamine) in the past 6 months, and non-Hispanic Whites were less likely to have used marijuana compared with the other ethnic groups. A very high rate of comorbidity of drug- and alcohol-use disorders was found in this sample of ethnically diverse MSM. These results have important implications for the design of effective treatment interventions.

Matching substance abuse aftercare treatments to client characteristics

This study investigated matching client attributes to different aftercare treatments. A naturalistic sample of adults entering substance abuse treatment was randomized into either Structured Relapse Prevention (RP, n=61) or a 12-Step Facilitation (TSF, n=72) aftercare program. Four patient attributes were matched to treatment: age, gender, substance abuse profile, and psychological status. Substance use outcomes were assessed 3 and 6 months posttreatment. At 6 months, four significant matches were uncovered. Females and individuals with a multiple substance abuse profile reported better alcohol outcomes with TSF aftercare than their cohorts exposed to RP aftercare. Individuals with high psychological distress at treatment entry were able to maintain longer periods of posttreatment abstinence with TSF aftercare compared to their cohorts exposed to RP. Inversely, RP was found to maintain abstinence significantly longer for individuals reporting low distress compared to those with high distress. Finally, better outcomes were achieved when random assignment to aftercare was consistent with participant preference. Overall, an Alcoholics Anonymous approach to aftercare appears to provide the most favorable substance use outcomes for most groups of substance abusers. RP may be most suitable for clients whose psychological distress is low, especially where maintenance of abstinence is targeted. Where choice in aftercare program is possible, matching client preference with type of aftercare program can improve outcome.

Individual differences in latent neuropsychological abilities at addictions treatment entry

The latent structure of neuropsychological abilities and risk factors for impairment were examined in 197 persons entering addictions treatment. Confirmatory factor analysis yielded 4 factors: Executive, Memory, Verbal, and Processing Speed. The measurement model was consistent with evidence that neuropsychological test performance is factorially complex and supported by multiple brain regions. Path analyses showed that risk factors explained 34%-57% of the true variance in abilities. Age, education, and medical status had the most generalized and robust associations with abilities. Drug use disorder diagnoses, childhood behavior problems, familial alcoholism, and psychopathology were also significantly related to specific latent abilities. Knowledge of neuropsychological impairment may be clinically useful, and selected risk factors may help treatment providers decide which clients should receive formal neuropsychological assessment.

Predictors of outpatient treatment retention: patient versus substance use characteristics

The present study examined predictors of participation and retention for patients treated at an urban, hospital-based outpatient substance abuse treatment clinic. All patients were interviewed using the Addiction Severity Index (ASI) at the time of admission. Based on lifetime diagnostic history of psychoactive substance abuse/dependence, patients (N=268) were classified as: alcohol-only, drug(s)-only, and alcohol+drug(s). Alcohol-only patients were significantly older, more likely to be Caucasian, married, have less than a high school education, and be employed than drug-only or alcohol/drug patients. Using multiple regression analysis, substance use status did not predict treatment participation and retention, whereas race, gender and employment composite score were significant predictors. Specifically, patients attended more sessions and remained in treatment longer if they were Caucasian, male and had a high employment composite score. These findings suggest that type of substance abuse may be overemphasized as a predictor of outpatient drug-free treatment retention, and that greater emphasis should be placed on tailoring treatment to patients' cultural, gender and vocational needs.

The relationship between psychosocial well-being and alcohol and drug use following substance misuse treatment

The relationship between psychosocial status and alcohol and drug use at 12-month follow-up was evaluated for clients of two addictions treatment programs (90 treated for alcohol; 51 for drugs or drugs and alcohol). Psychosocial status at follow-up was mostly unrelated to alcohol use among clients who were not using drugs prior to treatment. Among drug users, returning to both alcohol and drug use was strongly associated with poorer psychosocial status, with partial correlational analyses indicating that (a) drug use was the main factor associated with poorer status and (b) poorer status was likely a consequence rather than a precursor of drug use. The implications of these findings are discussed.

Open trials as a method of prioritizing medications for inclusion in controlled trials for cocaine dependence

This paper describes a rapid and systematic method of using open trials to identify medications that may be useful for the treatment of cocaine dependence. Results of these open trials can be used to prioritize medications for inclusion in subsequent double-blind, placebo-controlled trials. Preliminary results are presented from the evaluation of propranolol, nefazodone, and the combination of phentermine and fenfluramine (phen/fen). Each medication was evaluated in an open trial, and results were compared to results obtained from a group that received a multivitamin. Outcome measures included treatment retention, urine toxicology screens, self-reported cocaine use, and changes on the Addiction Severity Index (ASI). Treatment retention was significantly better in the propranolol group than in the multivitamin group. Concurrent alcohol abuse was associated with increased rates of attrition in the multivitamin group, and the phen/fen group, but not in the propranolol group. Neither the nefazodone nor the phen/fen groups showed any outcome advantages over the multivitamin group. We conclude that propranolol may enhance retention among cocaine-dependent patients, especially among those who also abuse alcohol. These results encourage a double-blind, placebo-controlled trial of propranolol.

The incidence and characteristics of violent men in substance abuse treatment

Linkage between marital violence and substance abuse has been noted in men seeking treatment for substance-use disorders. The present study examined (1) the incidence of family violence in men admitted into substance abuse treatment; (2) the psychosocial characteristics associated with marital violence; and (3) the comparability of violent substance abusers to their treatment cohorts. Fifty-nine men in substance abuse treatment involved in a significant relationship in the past year were assessed for substance abuse, family violence, psychosocial functioning, and personality attributes. Fifty-eight percent of men reported at least one incident of physical familial violence in the past year, while 100% of the men reported having engaged in psychological abuse in the past year. Additionally, greater violence was associated with interpersonal insensitivity, hostile outbursts, and poorer overall functioning independent of substance abuse. Finally, violent male substance abusers reported significantly more hostility, suspiciousness, projection of blame, and interpersonal inadequacy than did the less violent substance abusers. These findings suggest that, in drug-treatment settings, systematic objective screening for family violence is routinely called for.

Treatment outcome of cocaine-alcohol dependent patients

Cocaine dependent patients (n = 27) with and without concurrent alcohol dependence disorder were compared on measures of substance use, addiction severity (ASI), coping, and psychopathology taken before, during, and after outpatient relapse prevention treatment for cocaine dependence. At pre-treatment, the cocaine-alcohol (CA) group reported more frequent alcohol use, and more severe alcohol and family/social problems compared to the cocaine-only (CO) group. By the end of treatment, both groups reported significantly fewer days of alcohol and cocaine use, with sustained reductions observed at 24 weeks following treatment. On most of the addiction severity and psychiatric symptomatology scales, results indicated overall improvement as a function of time, however scores remained relatively 'worse' in the CA group. Implication of these findings and the need for specific programming in the treatment of dual drug use are explored.

The role of spouses of substance abusers in treatment: gender differences

Studies exploring gender differences among substance abusers in treatment have been fairly consistent in finding that females who enter treatment express more severe psychological and psychosocial disturbances than males, despite presenting with shorter and less intense substance abuse histories. However, strands of evidence suggest that the presence of a spouse, generally perceived as an asset in the treatment of the substance abuser, may have different implications for females than for males. In order to clarify this issue, 67 male and 18 female married substance abusers in treatment and their spouses were questioned on their substance use and psychological and social functioning. Similar to other studies, the female substance abusers reported greater disturbance on dimensions of employment and psychological functioning, but less severity of alcohol abuse. Comparison of male and female spouses, however, revealed that male spouses were likely to present with the following characteristics: (1) more symptoms of substance abuse and depression, (2) less overall physical well-being, and (3) to be less inclined to help others or be involved with their children than the female spouses. These findings are consistent with the view that the process of substance abuse is telescoped in females and is associated with more disturbed functioning in women on admission to treatment than in men. However, contextual differences--specifically in terms of availability of spousal support--may contribute significantly both to the understanding of differences in female versus male substance abusers in treatment as well as to the development of guidelines for adapting treatment based on gender.

Cocaine babies: a result of multiple teratogenic influences

The history of cocaine use is reviewed. Cocaine teratogenesis has only recently been studied, and initial human studies had serious methodological flaws. These flaws included ascertainment bias, publication bias (studies finding cocaine effects have been more likely to be presented or published), and overemphasis on the perinatal period. Comparison with alcohol teratogenesis shows that alcohol is a more potent teratogen, which, however, produces major and specific effects (fetal alcohol syndrome) in less than 10% of offspring with heavy alcohol exposure during pregnancy. Nonspecific minor congenital anomalies or fetal alcohol effects are seen in a larger number. Personal experience with two groups of children exposed to cocaine in utero is reviewed. Insurance patients gained weight, took vitamins, and generally, their children did well in spite of cocaine use. Indigent patients were usually unmarried and often "street people," probably used more cocaine, generally used other drugs as well, often did not gain weight during pregnancy, and were much more likely to have children with problems. Surveys show that most cocaine users also use alcohol, often simultaneously. Those who use both agents are more likely to have troubled backgrounds and antisocial behavior and to drop out of treatment programs than those who use only alcohol. Cocaethylene or ethylbenzoylecgonine is formed in the liver when cocaine and alcohol are simultaneously ingested. It is a potent stimulant and dopamine uptake blocker that is more toxic to myocardial cells than is cocaine. Good nutrition is now known to be very important in preventing congenital anomalies and fetal death. A multihit model of neurologic handicap, which stresses the importance of a good postnatal environment, is briefly outlined.(ABSTRACT TRUNCATED AT 250 WORDS)