Charles C. Thornton

Comparison of Pretreatment Characteristics and Treatment Outcomes for Alcohol-, Cocaine-, and Multisubstance-Dependent Patients

Abstract 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 pre-treatment 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.

Nicotine dependence and treatment outcome among African American cocaine-dependent patients

Despite a close association between tobacco and cocaine use, few studies have systematically examined whether smoking predicts an adverse outcome for cocaine-dependent patients. We investigated whether severity of nicotine dependence was related to treatment outcome for cocaine-dependent individuals. Standardized assessments of nicotine dependence (Fagerström Test for Nicotine Dependence; FTND), cocaine use, and personality were obtained for 105 African American cocaine-dependent outpatients. Outcome measures included negative urine drug screens, days in treatment, dropout, and number of treatment sessions attended. The sample was stratified into cocaine-positive and cocaine-negative groups based on admission urine drug screens, and relationships between nicotine dependence and outcome measures were examined in each group. In the cocaine-negative group, higher FTND scores were negatively correlated with number of negative urine drug screens during treatment even after controlling for other predictors, whereas FTND scores were not correlated to outcome in the cocaine-positive group. It seems that severity of tobacco use predicts poor outcome for cocaine-dependent patients who are cocaine free at the time of admission into outpatient treatment.

No association between polymorphisms in the serotonin transporter gene and susceptibility to cocaine dependence among African-American individuals.

Genetic research of cocaine abuse has been relatively limited among the African-American population. Since the serotonin transporter (5HTT) may be involved in modulating effects of cocaine, we investigated whether allelic variants of the 5HTT gene may confer susceptibility to cocaine dependence among African-American individuals. One hundred and fifty-six cocaine-dependent subjects and 82 controls were studied. Polymerase chain reaction-based genotyping of a variable-number-tandem-repeat (VNTR) marker yielded three alleles designated 12, 10 and 9. Genotype and allele frequencies were compared using chi-square analyses. We found no differences between subjects and controls with respect to genotype distribution (cocaine: 12/12 = 50%, 10/12 = 35.3%, 10/10 = 13.5%, 9/12 = 1.3%; controls: 12/12 = 42.7%, 10/12 = 39.0%, 10/10 = 17.1%, 9/12 = 1.2%). Similarly, allele frequencies of the VNTR marker did not differ between the two groups (cocaine: 12 = 68.3%, 10 = 31.1%, 9 = 0.6%; controls: 12 = 62.8%, 10 = 36.6%, 9 = 0.6%). Our findings do not seem to support a relationship between VNTR polymorphisms and cocaine dependence among African-American patients. Further studies involving larger samples are required to confirm our results.

Relationship Between Platelet Serotonin Uptake Sites and Treatment Outcome Among African-American Cocaine Dependent Individuals

Abstract We investigated whether platelet tritiated paroxetine binding, a measure of serotonin uptake sites differed between cocaine-dependent subjects and controls, and whether paroxetine binding was related to treatment-outcome for cocaine patients. One hundred twenty-five African-American cocaine-dependent individuals receiving outpatient treatment and 44 controls were studied. Tritiated paroxetine binding sites on platelets were assayed and standardized assessments of behavior were performed. The outcome measures were number of negative urine drug screens, days in treatment, dropout rates and number of treatment sessions attended. Cocaine patients had significantly lower Bmax values of paroxetine binding compared to controls. Furthermore, Bmax values showed a significant positive correlation with days in treatment and negative urines. A combination of Bmax and Addiction Severity Index (ASI) employment scores improved the prediction of days in treatment and a combination of Bmax and ASI drug scores enhanced the prediction of negative urines. The findings indicate that serotonergic mechanisms may be involved in cocaine dependence and may influence treatment-outcome among cocaine patients.

Predicting treatment-outcome in cocaine dependence from admission urine drug screen and peripheral serotonergic measures.

We investigated whether urine drug screens (UDS) at admission and platelet paroxetine binding, a measure of serotonin transporter sites, were related to outcome measures for cocaine patients in treatment. Tritiated paroxetine binding sites on platelets were assayed and UDS were obtained for 105 African American cocaine-dependent outpatients. Outcome measures included number of negative urines, days in treatment, dropouts, and number of treatment sessions attended. A significant association was found between cocaine-positive UDS at admission and negative urines, treatment retention, dropouts, and treatment sessions; while Bmax values of paroxetine binding (density of serotonin transporter sites) were significantly associated with treatment retention and negative urines. Moreover, UDS and paroxetine binding combined to enhance prediction of retention and abstinence. Although both admission UDS and paroxetine binding seem to contribute individually in predicting outcome of cocaine patients, a combination of the two variables seems to have a stronger effect in terms of predicting treatment-outcome.

Drinking and socializing in "introverted" and "extraverted" alcoholics.

This study is concerned with possible relationships of alcohol consumption and of the introversion-extraversion dimension of personality to observed socializing behavior of male alcoholics. Considering the effects of alcohol consumption alone, most of us would agree that inhibitions in social situations are lessened with a few drinks. Alcoholics themselves, moreover. often state that they drink to become more sociable,’ and sober alcoholics have been found to describe themselves, on an objective personality test, as more extraverted when drinking than when sober..‘ Experimental studies of the effects of alcohol on the alcoholic, which began about a decade ago and pioneered a new era in alcoholism research, have provided more direct evidence in this regard. Docter and Bernal,’ for example, found that their two alcoholic patients were silent and uncommunicative without alcohol but became talkative. demanding, and assertive in their relationships with each other and with the experimenters after drinking vodka. Mendelson er a1.,4 similarly, observed that their alcoholic subjects increased their socializing and maintained it for a period of 19 days while drinking up to 30 ounces of alcohol daily; the level of social interaction declined markedly, however. when the dose was increased to 40 ounces per day. Though several more recent studies of actual drinking behavior appear to support two major conclusions, namely. that alcoholics’ socializing behavior increases with drinking initially’-5-9 but that it declines with prolonged drinking,5-8 the evidence is based largely on unquantified observations of very small samples of patients. Further, control groups of nondrinking alcoholics have typically been lacking. The first purpose of the current study, then, is to provide objective quantified data on the socializing behavior of larger samples of drinking and nondrinking alcoholics over the course of a 6-week treatment-research program in order to test two hypotheses: alcoholics’ socializing behavior will increase with the onset of drinking, and it will decrease as drinking continues. The second purpose of this study was to explore the role played by a relevant personality factor, that of the introversion-extraversion dimension, in affecting the drinking and socializ.ing behavior of alcoholics. Some writers have argued that alcoholics are primarily introverts who drink to achieve a more extraverted psychologic state;“J.Il other investigators have reported a higher percentage of extraverts than introverts among their alcoholic patients.l?-14 whereas still others have found an even balance of introverts and extraverts.15,10 Normative data published by Eysenck and Eysenck” support the latter observations, namely, that alcoholics d o not differ from the general population on the introversion-extraversion dimension. It may be true. however, that introverted alcoholics may drink, in part, to achieve a more

High- and low-structure treatments for substance dependence: role of learned helplessness.

We studied whether pretreatment levels of learned helplessness (LH) were related to outcomes for substance‐dependent individuals receiving high‐structure, behaviorally oriented (HSB) or low‐structure, facilitative (LSF) treatment. The subjects were 120 substance‐dependent patients randomly assigned to the HSB or the LSF treatment style for up to 12 weeks of weekly individual counseling. The two groups were compared across pretreatment characteristics as well as in‐treatment, end‐of‐treatment, and 9‐month postadmission follow‐up outcome measures. Outcomes reflected reduction in problem severity, abstinence, retention, dropout rate, and ratings of treatment benefit. Significant and comparable reductions in symptoms occurred for the HSB and LSF patients both during treatment and at follow‐up. Comparisons of other outcomes also did not consistently favor either treatment style. However, significant and consistent interactions were observed between LH and treatment styles with respect to several outcome measures, and these effects were independent of pretreatment levels of depression, addiction severity, and readiness for treatment. Specifically, the more “helpless” patients did significantly better in HSB treatment, whereas the less “helpless” patients had better outcomes in LSF treatment. A matching approach that assigns patients to high‐ and low‐structure treatments based on pretreatment levels of LH might improve treatment outcomes for substance‐dependent patients.

Coping Styles and Response to High versus Low‐Structure Individual Counseling for Substance Abuse

We compared outcomes during and after treatment for mixed substance dependent patients (N=143) randomly assigned to a high-structure, behaviorally-oriented (HSB) or a low-structure, facilitative (LSF) individual counseling style. We hypothesized that patients with different coping characteristics would respond differently to the two styles of counseling. Patients were treated in once-weekly individual HSB or LSF counseling for up to 12 weeks. Outcome measures included patient and counselor ratings of benefit, retention, symptom reduction, and negative urines; follow-up assessments included control of substance use and psychosocial adjustment. While no differences in outcomes during or after treatment were found for the HSB and LSF patients, both groups did improve equally. Contrary to our hypothesis, our coping measures did not predict different outcomes for patients treated in the LSF and HSB styles. Post-hoc analyses, however, revealed that outcomes could be predicted in each style from patterns of pretreatment characteristics, which included measures of coping strategies, psychological characteristics, and treatment readiness. Moreover, the patterns associated with positive outcomes were different for the HSB and LSF patients: high treatment readiness was most important for success in HSB counseling, while low psychiatric severity and positive coping styles were important for the LSF clients. The finding of no HSB-LSF outcome differences calls into question the exclusive emphasis on behavioral treatment approaches by the present-day managed care industry. Also, the traditional approach to matching studies, ie, employing one patient characteristic at a time to predict differential outcomes for particular treatments, may be simplistic. An alternative approach employing multivariate statistical procedures to predict outcomes from several patient characteristics may hold more promise.