Treating cocaine-using methadone patients: predictors of outcomes in a psychosocial clinical trial

A randomized clinical trial of disulfiram at higher doses for the treatment of cocaine use disorder among methadone-stabilized patients

PURPOSE/BACKGROUND

Previously, disulfiram less than 250 mg/day increased cocaine use relative to placebo whereas disulfiram at 250 mg/day did not differ from placebo among methadone-stabilized individuals with dual cocaine and opioid dependence, suggesting disulfiram at higher doses needed to be tested. This study determined tolerability and efficacy of disulfiram at higher doses (250-500 mg/day).

METHODS/PROCEDURES

In a 14-wk, double blind, placebo-controlled clinical trial, 53 participants with cocaine and opioid dependence were enrolled, inducted onto methadone (weeks 1-2), randomized to receive placebo or disulfiram (250, 375 or 500 mg/day) during weeks 3-14, and provided weekly 1-h individual cognitive behavior therapy throughout. Thrice-weekly urine samples were tested for the presence of cocaine metabolite. Weekly vital signs and monthly mood assessments were obtained.

RESULTS/FINDINGS

Disulfiram groups generally did not differ on subject characteristics or retention. Cocaine-positive urine samples showed a significant increase over time in the placebo group (p = 0.04), with the placebo slope being significantly greater than horizontal. Cocaine-positive urine samples decreased over time in the disulfiram 250 mg (p = 0.014) and 375 mg (p = 0.015), but not 500 mg (p = 0.11), groups relative to placebo, although slopes of these medication groups did not differ significantly from horizontal (p > 0.15). No clinically significant differences across groups with respect to vital signs or mood ratings occurred.

IMPLICATIONS/CONCLUSIONS

Although preliminary due to the small sample size, disulfiram at 250-375 mg/day may be ineffective in reducing cocaine use and have limited efficacy to prevent increases in cocaine use among methadone-stabilized patients with dual cocaine and opioid dependence.

A review of research-supported group treatments for drug use disorders

This paper reviews methodologically rigorous studies examining group treatments for interview-diagnosed drug use disorders. A total of 50 studies reporting on the efficacy of group drug use disorder treatments for adults met inclusion criteria. Studies examining group treatment for cocaine, methamphetamine, marijuana, opioid, mixed substance, and substance use disorder with co-occurring psychiatric conditions are discussed. The current review showed that cognitive behavioral therapy (CBT) group therapy and contingency management (CM) groups appear to be more effective at reducing cocaine use than treatment as usual (TAU) groups. CM also appeared to be effective at reducing methamphetamine use relative to standard group treatment. Relapse prevention support groups, motivational interviewing, and social support groups were all effective at reducing marijuana use relative to a delayed treatment control. Group therapy or group CBT plus pharmacotherapy are more effective at decreasing opioid use than pharmacotherapy alone. An HIV harm reduction program has also been shown to be effective for reducing illicit opioid use. Effective treatments for mixed substance use disorder include group CBT, CM, and women's recovery group. Behavioral skills group, group behavioral therapy plus CM, Seeking Safety, Dialectical behavior therapy groups, and CM were more effective at decreasing substance use and psychiatric symptoms relative to TAU, but group psychoeducation and group CBT were not. Given how often group formats are utilized to treat drug use disorders, the present review underscores the need to understand the extent to which evidence-based group therapies for drug use disorders are applied in treatment settings.

Treatment for Individuals With Severe Mental Illness Who Use Illicit Drugs While Maintained on Methadone: Mindfulness and Modification Therapy

Substantial research has noted the serious consequences of 1) co-occurring severe mental illness (SMI) and substance use disorders, and 2) use of illicit drugs while maintained on methadone for opioid dependence. However, treatment needs of individuals who meet both of the above criteria remain largely unmet. This pilot study investigated the feasibility and acceptability of a 12-week, transdiagnostic group therapy (mindfulness and modification therapy [MMT]) tailored for opioid-dependent individuals (N = 6) with SMI and illicit drug use. Retention was 83%. At posttreatment and 2-month follow-up, participants rated the treatment as highly helpful (9 of 10; 8.67 of 10, respectively), reported routinely practicing the guided-mindfulness exercises, and reported high confidence that they would continue to practice. Assessments revealed clinically meaningful decreases in reported days of illicit drug use at posttreatment and follow-up, with large effect sizes. Preliminary evidence suggests that MMT may be a feasible and acceptable therapy that may improve treatment engagement in this underserved population.

"It Ruined My Life": The effects of the War on Drugs on people who inject drugs (PWID) in rural Puerto Rico

BACKGROUND

The War on Drugs has raised the incarceration rates of racial minorities for non-violent drug-related crimes, profoundly stigmatized drug users, and redirected resources from drug prevention and treatment to militarizing federal and local law enforcement. Yet, while some states consider shifting their punitive approach to drug use, to one based on drug treatment and rehabilitation, nothing suggests that these policy shifts are being replicated in Puerto Rico.

METHODS

This paper utilizes data from 360 PWID residing in four rural towns in the mountainous area of central Puerto Rico. We initially recruited 315 PWID using respondent-driven sampling (RDS) and collected data about risk practices and conducted HIV and HCV testing. During a second phase, we conducted 34 micro-ethnographic assays, in which we randomly recruited 34 participants from the first phase and included their ego networks in this phase. Our ethnographic inquiry produced significant data regarding the effects of the war on drugs on the local drug trade, drug availability, and injectors' social networks.

RESULTS

Findings suggest that repressive policing has been ineffective in preventing drug distribution and use among those in our study. This type of law enforcement approach has resulted in the disproportionate incarceration of poor drug users in rural Puerto Rico, and mainly for nonviolent drug-related crimes. In addition, incarceration exposes PWID to a form of a cruel and unusual punishment: having to quit heroin "cold turkey" while the prison environment also represents a HIV/HCV risk. In turn, the war on drugs not only diverts resources from treatment but also shapes treatment ideologies, punishing non-compliant patients.

CONCLUSION

Shifting the emphasis from repression to treatment and rehabilitation is likely to have a positive impact on the health and overall quality of life of PWID and their communities.

Efficacy of Cognitive Behavioral Therapy on Opiate Use and Retention in Methadone Maintenance Treatment in China: A Randomised Trial

Aims

Methadone maintenance treatment (MMT) is widely available in China; but, high rates of illicit opiate use and dropout are problematic. The aim of this study was to test whether cognitive behavioral therapy (CBT) in conjunction with MMT can improve treatment retention and reduce opiate use.

Method

A total of 240 opiate-dependent patients in community-based MMT clinics were randomly assigned to either weekly CBT plus standard MMT (CBT group, n=120) or standard MMT (control group, n=120) for 26 weeks. The primary outcomes were treatment retention and opiate-negative urine test results at 12 weeks and 26 weeks. The secondary outcomes were composite scores on the Addiction Severity Index (ASI) and total scores on the Perceived Stress Scale (PSS) at 12 weeks and 26 weeks.

Results

Compared to the control group in standard MMT, the CBT group had higher proportion of opiate-negative urine tests at both 12 weeks (59% vs. 69%, p<0.05) and 26 weeks (63% vs. 73%, p<0.05); however, the retention rates at 12 weeks (73.3% vs. 74.2%, p=0.88) and 26 weeks were not different (55.8% vs. 64.2%, p=0.19) between the two groups. At both 12 and 26 weeks, all of the ASI component scores and PSS total scores in the CBT group and control group decreased from baseline; but the CBT group exhibited more decreases in ASI employment scores at week 26 and more decrease in the PSS total score at week 12 and week 26.

Conclusions

CBT counselling is effective in reducing opiate use and improving employment function and in decreasing stress level for opiate-dependent patients in MMT in China.

Trial Registration

ClinicalTrials.gov NCT01144390

Patterns of abstinence or continued drug use among methadone maintenance patients and their relation to treatment retention

The efficacy and effectiveness of methadone maintenance treatment (MMT) in the medical management of opioid addiction has been well-established, but treatment outcomes are compromised by the continued use of licit and illicit drugs during MMT. The present study examined the relationship between in-treatment illicit drug use and retention and dropout of 604 MMT patients in Washington, D.C. Sixty-eight percent of patients did not test positive for an unprescribed drug during the study period. Of patients who tested positive for an illicit drug during the baseline period, 55% tested positive for cocaine, 44% for opiates, 23% for THC, 20% for benzodiazepines, 7% for PCP, and 4% for amphetamines. Those testing positive were three times more likely to leave treatment than those who did not test positive. Testing positive for one drug doubled the rate of attrition; testing positive for multiple drugs quadrupled the risk of attrition. Non-prescribed opioid or benzodiazepine use was a predictor of MMT dropout, but prescribed opioid or benzodiazepine use was not. Continued illicit drug use poses significant risk for subsequent premature termination of MMT. Assertive clinical management of continued illicit drug use could provide mechanisms to enhance MMT retention and long-term recovery outcomes.

ANKK1 and DRD2 pharmacogenetics of disulfiram treatment for cocaine abuse

OBJECTIVE

Disulfiram is a potential cocaine addiction pharmacotherapy. Since dopamine deficiency has been found with cocaine addiction, our objective was to examine whether functional variants in the ankyrin repeat and kinase domain-containing 1 (ANKK1) and/or the dopamine receptor D2 (DRD2) genes interact with response to treatment with disulfiram.

MATERIALS AND METHODS

Cocaine and opioid codependent (DSM-IV) patients were stabilized on methadone and subsequently randomized into treatment groups - disulfiram (250 mg/day, N=31) or placebo (N=37). They were genotyped for ANKK1 (rs1800497) and DRD2 (rs2283265) polymorphisms, and the data were evaluated for an association between a cocaine-free state, as assessed by cocaine-free urine samples, and disulfiram treatment. Data were analyzed using repeated measures analysis of variance corrected for population structure.

RESULTS

Patients with CT or TT ANKK1 genotypes dropped from 80 to 52% cocaine-positive urines on disulfiram (N=13; P≤0.0001), whereas those on placebo (N=20) showed no treatment effect. Patients carrying the CC ANKK1 genotype showed no effect on treatment with disulfiram (N=18) or placebo (N=17). The GT/TT DRD2 genotype group showed a significant decrease in the number of cocaine-positive urine samples on disulfiram (N=9; 67-48%; P ≤ 0.0001), whereas the GG DRD2 genotype group showed only a marginal decrease (N=23; 84-63%; P=0.04). Genotype pattern analysis revealed that individuals carrying at least one minor allele in either gene responded better to disulfiram treatment (N=13; P ≤ 0.0001) compared with individuals carrying only the major alleles (N=17).

CONCLUSION

A patient's genotype for ANKK1, DRD2, or both, may be used to identify individuals for whom disulfiram may be an effective pharmacotherapy for cocaine dependence.

Pharmacogenetic randomized trial for cocaine abuse: disulfiram and dopamine β-hydroxylase

BACKGROUND

Disulfiram has been an effective cocaine addiction pharmacotherapy, and one of its possible mechanisms of efficacy is through copper chelation and inhibition of an enzyme involved in catecholamine metabolism, dopamine β-hydroxylase (DβH), which converts dopamine to norepinephrine. A variant in the gene encoding DβH leads to reduced DβH activity, and as such, disulfiram might not be an effective treatment of cocaine dependence for individuals with this variant. This study explored that potential matching.

METHODS

Seventy-four cocaine- and opioid-codependent (DSM-V) subjects were stabilized on methadone for 2 weeks and subsequently randomized into disulfiram (250 mg/day, n = 34) and placebo groups (n = 40) for 10 weeks. We genotyped the DBH gene polymorphism, -1021C/T (rs1611115), that reduces DβH enzyme levels and evaluated its role for increasing cocaine free urines with disulfiram.

RESULTS

With repeated measures analysis of variance, corrected for population structure, disulfiram pharmacotherapy reduced cocaine-positive urines from 80% to 62% (p = .0001), and this disulfiram efficacy differed by DBH genotype group. Patients with the normal DβH level genotype dropped from 84% to 56% on disulfiram (p = .0001), whereas those with the low DBH level genotype showed no disulfiram effect.

CONCLUSIONS

This study indicates that the DBH genotype of a patient could be used to identify a subset of individuals for which disulfiram treatment might be an effective pharmacotherapy for cocaine dependence.

Randomized, double blind, placebo-controlled trial of disulfiram for the treatment of cocaine dependence in methadone-stabilized patients

This study examined the dose-related efficacy of disulfiram for treating cocaine dependence in methadone-stabilized cocaine dependent participants.

DESIGN

One hundred and sixty-one cocaine- and opioid-dependent volunteers were entered into a 14-week, double blind, randomized, placebo-controlled clinical trial at two sites.

METHODS

Participants were stabilized on methadone during weeks 1-2 and received disulfiram at 0, 62.5, 125 or 250 mg/day during weeks 3-14. All participants also received weekly cognitive behavioral therapy. Thrice-weekly urine samples and weekly self-reported drug use assessments were obtained.

RESULTS

Baseline subject characteristics, retention and drug use did not differ across groups. Outcome analyses were performed on those who participated beyond week 2. Opioid-positive urine samples and self-reported opioid use did not differ by treatment group. The prevalence of alcohol use was low prior to and during the trial and did not differ by treatment group. Cocaine-positive urines increased over time in the 62.5 and 125 mg disulfiram groups and decreased over time in the 250 mg disulfiram and placebo groups (p < 0.0001). Self-reported cocaine use increased in the 125 mg disulfiram group relative to the other three treatment groups (p = 0.04).

CONCLUSIONS

Disulfiram may be contraindicated for cocaine dependence at doses <250 mg/day. Whether disulfiram at higher doses is efficacious in reducing cocaine use in dually cocaine and opioid dependent individuals needs to be determined.

Correlates of stimulant treatment outcome across treatment modalities

OBJECTIVE

This study evaluated variables associated with stimulant use outcomes in stimulant users (N = 800) receiving care in community outpatient psychosocial or methadone maintenance treatment clinics as part of a national multi-site clinical trial.

METHODS

Results from the full sample were examined first, and then predictors were examined separately in the two treatment modalities.

RESULTS

A cocaine-positive urine sample at study intake was the most robust and consistent correlate of stimulant use outcome in all analyses. Psychiatric distress, social environment and employment had differential effects on outcome across modalities.

CONCLUSIONS/SIGNIFICANCE

This study confirms that intake assessments have considerable value in identifying problems to be addressed in treatment.

The impact of benzodiazepine use on methadone maintenance treatment outcomes

The purposes of this study were to examine predictors of benzodiazepine use among methadone maintenance treatment patients, to determine whether baseline benzodiazepine use influenced ongoing use during methadone maintenance treatment, and to assess the effect of ongoing benzodiazepine use on treatment outcomes (i.e., opioid and cocaine use and treatment retention). A retrospective chart review of 172 methadone maintenance treatment patients (mean age = 34.6 years; standard deviation = 8.5 years; 64% male) from January 1997 to December 1999 was conducted. At baseline, 29% were "non-users" (past year) of benzodiazepine, 36% were "occasional users," and 35% were "regular/problem users." Regular/problem users were more likely to have started opioid use with prescription opioids, experienced more overdoses, and reported psychiatric comorbidity. Being female, more years of opioid use, and a history of psychiatric treatment were significant predictors of baseline benzodiazepine use. Ongoing benzodiazepine users were more likely to have opioid-positive and cocaine-positive urine screens during methadone maintenance treatment. Only ongoing cocaine use was negatively related to retention. Benzodiazepine use by methadone maintenance treatment patients is associated with a more complex clinical picture and may negatively influence treatment outcomes.

The North American Opiate Medication Initiative (NAOMI): profile of participants in North America's first trial of heroin-assisted treatment

The North American Opiate Medication Initiative (NAOMI) is a randomized controlled trial evaluating the feasibility and effectiveness of heroin-assisted treatment (HAT) in the Canadian context. Our objective is to analyze the profile of the NAOMI participant cohort in the context of illicit opioid use in Canada and to evaluate its comparability with patient profiles of European HAT studies. Recruitment began in February 2005 and ended in March 2007. Inclusion criteria included opioid dependence, 5 or more years of opioid use, regular opioid injection, and at least two previous opiate addiction treatment attempts. Standardized assessment instruments such as the European Addiction Severity Index and the Maudsley Addiction Profile were employed. A total of 251 individuals were randomized from Vancouver, BC (192, 76.5%), and Montreal, Quebec (59, 23.5%); 38.5% were female, the mean age was 39.7 years (SD:8.6), and participants had injected drugs for 16.5 years (SD:9.9), on average. In the prior month, heroin was used a mean of 26.5 days (SD:7.4) and cocaine 16 days (SD;12.6). Vancouver had significantly more patients residing in unstable housing (88.5 vs. 22%; p < 0.001) and higher use of smoked crack cocaine (16.9 days vs. 2.3 days in the prior month; p < 0.001), while a significantly higher proportion of Montreal participants reported needle sharing in the prior 6 months (25% vs. 3.7%; p < 0.001). In many respects, the patient cohort was similar to the European trials; however, NAOMI had a higher proportion of female participants and participants residing in unstable housing. This study suggests that the NAOMI study successfully recruited participants with a profile indicated for HAT. It also raises concern about the high levels of crack cocaine use and social marginalization.

Comparison of demographic and clinical characteristics between opioid-dependent individuals admitted to a community-based treatment setting and those enrolled in a research-based treatment setting

Despite the significant developments in pharmacotherapy and behavioral treatments for addiction, the dissemination of new treatment methods into the community has been slow. It has been pointed out that treatments developed in research settings may be impractical in community treatment settings, which might help explain the transition lag. Screening and recruitment of participants for research studies might partially explain this, as there is evidence that substance-abusing individuals who participate in clinical research are different on a number of measures from treatment seekers. However, no study has directly compared treatment seekers with research participants drawn from similar populations using prospective methods. This study compared the demographic characteristics, drug use and psychosocial problem severity levels, and personality traits of opioid-dependent individuals seeking help in a community setting (n = 502) with those of opioid-dependent individuals in a primarily research-based drug abuse treatment setting (n = 459); both settings offered a similar set of treatment services (opioid agonist medication and counseling). Although the overall findings revealed numerous similarities between the groups, differences were also observed. Most notably, there were significantly fewer women in the research sample than in the community-based treatment sample. Other differences included a modest but statistically significant increase in psychosocial problem severity levels in the community-based treatment sample and higher drug use problem severity levels in the research sample. Interestingly, many of these differences were strongest in women as compared with men.

Clinical efficacy of gabapentin versus tiagabine for reducing cocaine use among cocaine dependent methadone-treated patients

BACKGROUND

GABAergic medications appear to reduce the reinforcing effects of cocaine by attenuating cocaine-induced dopamine release. This study evaluated gabapentin and tiagabine compared to placebo in reducing cocaine taking behavior.

METHODS

A total of 76 treatment seeking, cocaine dependent, methadone-treated, predominately Caucasian male subjects were randomly assigned to tiagabine 24 mg/day (N=25), gabapentin 2400 mg/day (N=26) or placebo (N=25) in a 10-week double-blind placebo-controlled trial. Study medications were slowly increased to their full dosages by the end of week 5 and maintained through week 10. The primary outcome measure was thrice-weekly drug free urine samples.

RESULTS

Treatment retention was significantly less for the gabapentin group relative to the other groups (log rank=5.29, d.f.=1, p=0.02). The proportion of cocaine-free urine samples during weeks 6-10 was significantly larger in the tiagabine treated group (p<0.05). The longitudinal data showed significant change in thrice-weekly cocaine free urines that reached a greater abstinent rate for the tiagabine treated group (22%) compared to gabapentin (5%) or placebo (13%) treated groups. Mixed-effects ordinal regression models showed a significant tiagabine by time interaction compared to gabapentin (Z=2.48, d.f.=1, p=0.01) and placebo (Z=3.90, d.f.=1, p=0.0001). The gabapentin group did not differ from placebo.

CONCLUSION

Gabapentin showed poor treatment retention and ineffectiveness in reducing cocaine use. Tiagabine significantly reduced cocaine taking behavior compared to placebo or gabapentin among methadone-stabilized cocaine abusers.

High methadone dose significantly reduces cocaine use in methadone maintenance treatment (MMT) patients

AIM

To evaluate whether effective methadone treatment affects cocaine use.

METHODS

421 consecutive patients admitted to a methadone maintenance clinic in Israel (1993-2002) were prospectively studied. Patients' urine samples were analyzed for cocaine during months 1 and 13.

RESULTS

On admission 55(13.1%) of 421 patients had urine positive for cocaine and 366 had negative. Of the 55 cocaine-positive patients, 45(81.8%) stayed in treatment at least one year, as did 267(73%) of cocaine-negative. After one year (n=312) 31 of 45 cocaine users stopped and 25 of 267 started. Methadone dose was highest in 31 patients who stopped cocaine (176.1+/-42.1 mg/ day), followed by 14 who did not stop (161.4+/-37.5 mg/day), and 25 who started during treatment (122.9+/-48.7 mg/day), or 242 who never used cocaine (119.5+/-48.4 mg/day) (ANOVA, F=15.6, p<0.0005).

CONCLUSIONS

High methadone dose may reduce cocaine use in patients addicted to both heroin and cocaine.

Motivationally enhanced group counseling for substance users in a soup kitchen: a randomized clinical trial

Soup kitchens tend to serve residentially unstable adults characterized by a high prevalence of substance abuse. In this study, 289 soup kitchen guests who reported drug or alcohol problems were randomly assigned to information and referral (I&R) plus peer advocacy (peers encouraging subjects to participate in other services) (N = 139) or to an experimental 12-session motivational group (three sessions per week for 4 weeks) followed by a 36-session cognitive-behavioral group (three sessions per week for 12 weeks), plus I&R and peer advocacy. Mean age was 42; 82% male; 68% African-American; 81% unstable residence; 14% HIV+. Experimentals were significantly more likely than the controls to have increased their participation in some type of substance abuse intervention during the follow-up period. In addition, experimentals were significantly more likely than controls to have reduced both drinking and heavy drinking at follow-up (there was no difference between groups in reduction of cocaine use). Interaction analysis indicated that the experimental intervention was more effective for participants with higher rather than lower substance abuse severity at baseline. These results support the concept that motivationally enhanced group counseling, provided as a low-threshold outreach intervention, can help to increase participation in formal treatment and 12-step groups and to reduce substance abuse, particularly for those starting with high severity of use.

A conceptual framework for drug treatment process and outcomes

Evidence from specialized treatment evaluations and large-scale natural studies of treatment effectiveness is organized conceptually into a "treatment model" for summarizing how drug treatment works. Sequential relationships between patient and treatment program attributes, early patient engagement, recovery stages, retention, and favorable outcomes are discussed--along with behavioral, cognitive, and skills training interventions that have been shown to be effective for enhancing specific stages of the patient recovery process. Applications of the treatment model for incorporating science-based innovations into clinical practice for improving early engagement and retention, performance measurements of patient progress, program monitoring and management using aggregated patient records, and organizational functioning and systems change also are addressed.

Aktuelle Konsumformen bei Drogenabhängigkeit — Implikationen für Substitutionsprogramme in ambulanten Einrichtungen und bei behandelnden Ärzten

BACKGROUND

Anonymous evaluation of the current conditions of drug scene and drug consumption, entrance age, personal motives for drug consumption and satisfaction among opioid-dependent clients with treatments available within an ambulant maintenance treatment setting.

METHODS

The questionnaire for the study was based on representative studies and covered 112 questions regarding drug consumption. In addition, an instrument of the "Hessische Landesstelle gegen die Suchtgefahren", which measures satisfaction of opioid clients regarding public drug-treatment centers, was used.

RESULTS

A total of 158 opioid clients within an ambulant maintenance treatment setting were enrolled in the study. The mean age at first drug consumption was 15.1 (2.4) years for men and 15.2 (3.5) years for women. The Spearman correlation showed a significant positive correlation (r=0.284) between age and time of first drug consumption (p=0.019). Cannabis was the most frequent entrance drug (55.8%), followed by alcohol (33.8%), opioids (17.6%) and nicotine (11.8%). Additional consumption of benzodiazepines was observed in 44.7% of men and 39.7% of women, of cannabis in 74.5% of men and 52.4% of women, and of sustained-release morphine in 41.4% of men and 33.3% of women. Within the previous 6-12 months cocaine was consumed significantly less (p=0.024) by men (63.8%) than by women (90.5%). 93.3% of the drug users rated a follow-up assistance programme after withdrawal and 71.9% special care programmes for designer drugs very important.

IMPLICATIONS

The present study supports the assumption of an earlier age of first drug consumption. In view of our findings on entrance age, and on polytoxicomanic consumption patterns and gender-specific differences, we believe that the objectives of substitution programmes can only be reached if programmes are adequately adapted to the actual conditions of the drug scene and are able to cooperate with other public drug-treatment systems.