David McDowell

Circuit parties and patterns of drug use in a subset of gay men.

Abstract This study examined the characteristics of gay men attending circuit parties and their drug use. In particular, the role of methylenediomethamphetamine (MDMA, “ecstasy”) was considered in relation to other drug use and sexual behavior. A one page survey was distributed to 173 men attending a circuit party. Respondents were generally gay men, Caucasian, employed, and well—educated. Twenty—five percent self—identified as HIV—positive. Eighty—six percent reported using at least one substance on the day of the party; polydrug use was frequent. The most common substances were MDMA, ketamine, and metham—phetamine. MDMA use was highly associated with ketamine, metham—phetamine, and cocaine use. MDMA use was also associated with significantly more receptive anal intercourse. Circuit parties are settings of increased drug use and associated high—risk sexual behavior. A better understanding of these issues is needed to develop interventions aimed at reducing drug use and sexual risk taking among gay men who attend circuit parties.

Bupropion Treatment for Cocaine Abuse and Adult Attention-Deficit/Hyperactivity Disorder

Abstract There are few published studies assessing the efficacy of pharmacologic treatments for attention-deficit hyperactivity disorder (ADHD) among substance abusers seeking treatment. Eleven patients who met DSM-IV diagnostic criteria for cocaine dependence and adult ADHD were entered into a 12-week single-blind trial of divided daily doses of bupropion (BPR). All patients received weekly individual standardized relapse prevention therapy. Treatment compliance and retention were good. Patients reported significant reductions in attention difficulties, hyperactivity and impulsivity. Self-reported cocaine use, cocaine craving, and cocaine positive toxicologies, also decreased significantly. In a previously published trial, 12 patients who met similar diagnostic criteria for adult ADHD and cocaine dependence were entered into a 12-week trial of divided daily doses of sustained-release methylphenidate (MPH). Improvements observed on BPR were similar to, and did not differ from those previously observed with MPH. These preliminary data suggest that BPR may be as effective as sustained-release MPH, when combined with relapse prevention therapy, for cocaine abusers with adult ADHD. However, a future study directly comparing BPR to MPH in a double-blind placebo-controlled trial is needed.

A preliminary trial: double-blind comparison of nefazodone, bupropion-SR, and placebo in the treatment of cannabis dependence.

The present study investigated the efficacy of nefazodone and bupropion-sustained release for treating cannabis dependence. A double-blind, placebo-controlled, piggy back design was employed to assess if nefazodone and bupropion-sustained release increased the probability of abstinence from cannabis and reduced the severity of cannabis dependence and cannabis withdrawal symptoms during a 13-week outpatient treatment program. One-hundred and six participants (Mean = 32 years; females n = 25) were randomized to one of three medication conditions (nefazodone, bupropion-sustained release, or placebo) and participated in a weekly, individually based coping skills therapy program. Results indicated an increased probability of achieving abstinence over the course of treatment and a decrease in the severity of cannabis dependence and the withdrawal symptom of irritability. There were no significant effects demonstrated for nefazodone and bupropion-sustained release on cannabis use or cannabis withdrawal symptoms. The results indicate nefazodone and bupropion-sustained release may have limited efficacy in treating cannabis dependence.

Venlafaxine Treatment of Cocaine Abusers with Depressive Disorders

Objective: There appears to be a link between depression and cocaine that is both complex and elusive. The purpose of this study was to examine the effect of venlafaxine, a broad spectrum antidepressant, in the treatment of 13 patients who were diagnosed with cocaine dependence and comorbid major depressive disorder (MDD). Method: The majority of the patients in the study were part of a larger double-blind trial using desipramine. This subgroup consisted of people who had failed to respond to desipramine or could not tolerate its side effects. Thirteen patients were enrolled, 10 men and 3 women. Of the patients, 11 completed the 12-week study. All of the patients had a Hamilton Depression (HAM-D) score greater than 14 at baseline, and each had used at least

Pergolide mesylate for cocaine abuse: a controlled preliminary trial.

20 worth of cocaine per week in the 4 weeks prior to entering the study. In addition, all of the patients received weekly relapse prevention therapy throughout the study. The median dose of venlafaxine was 150 mg/day. Results: The 11 patients who completed the study had significant reductions in mood symptoms by the end of the study. The average total HAM-D score at baseline was 18.0 ± 3.2; at Week 2, it was 1.9 ± 0.94; and at the end of the study, it was 1.4 ± 1.8. The majority of patients reported reductions of cocaine use short of abstinence. All subjects reported a greater than 75% reduction in cocaine use compared to baseline. There were no serious side effects. Conclusions: The results of this small study indicate that venlafaxine may be a safe, well-tolerated, rapidly acting, and effective treatment for patients with a dual diagnosis of depression and cocaine dependence.

Gay Men, Lesbians and Substances of Abuse and the “Club and Circuit Party Scene”

A small, controlled study was conducted to assess whether pergolide mesylate has clinical promise as a treatment for cocaine abuse prior to embarking on a larger, randomized, double-blind, controlled trial. Fourteen individuals were placed on placebo for 2 weeks, followed by a 24-week single-blind study in which they were placed on pergolide for 12 weeks, followed by placebo for 12 weeks. Another 14 patients received single-blind placebo for two weeks and then were randomized into a 24-week double-blind, placebo-controlled, multiple baseline design. Initially, patients enrolled in the study were placed on risperidone (n = 9) or placebo (n = 5). During the first 12 weeks, retention was worse for those receiving pergolide compared to risperidone or placebo. Neither risperidone nor pergolide were more efficacious in reducing cocaine use than placebo. Although earlier open studies found pergolide to show promise as a treatment for cocaine abuse, this study did not support these earlier findings. Comparing an agent to both an active control and placebo group may better predict whether a promising new agent will have clinical utility compared to the standard open trial.

Dissociative Identity Disorder and Substance Abuse: The Forgotten Relationship

Abstract Many researchers believe that substance use rates are higher among gay men and lesbians than in the general population. In particular, recreational drugs, used as part of weekend and night “life” are particularly popular. In recent years these so called “club drugs” have become a regular part of many gay men and womens social life. MDMA, better known as “Ecstasy,” is a synthetic amphetamine derivative, with some unique physiological properties. MDMA can induce depression and panic attacks in those who use it. A serious concern is the potential that MDMA may cause long lasting, even permanent neuropsychiatric damage, in particular to serotonin neurons. Ketamine, “Special K,” is a dissasociative anesthetic which induces feelings of unreality, and may even cause catato-nia (a “K hole”). GHB is a naturally occurring biological substance which has effects similar to alcohol. Modest doses can cause sleep, and coma. There have been a growing number of reports of fatal overdoses associated with GHB. The clinician working with gay and lesbian people is urged to become aware of these particular substances, as well as other recreational drugs, as well as their dangers, in order to more effectively work with his or her clients.

A Randomized, Double-Blind, Placebo-Controlled Trial of Venlafaxine for the Treatment of Depressed Cocaine-Dependent Patients

The treatment and research of dissociative disorders, particularly dissociative identity disorder (DID), are hampered by professional skepticism and diagnostic uncertainties. Almost always associated with severe and sustained childhood trauma, its chief manifestations are at least two distinct and separate identities which have an independent manner of existing in the world. It is also associated with a high degree of psychiatric comorbidity. Among the most frequent diagnoses found in patients with DID are substance use and dependence. For a variety of reasons there has been little dialogue among the disciplines that study patients with trauma and those that study and treat substance abuse. Clinicians dealing with a primarily substance-abusing population are likely to encounter but not recognize these patients. The authors present several representative cases illustrative of features of patients with DID. The epidemiology, phenomenology and presentation of DID, as well as its relation to posttraumatic stress disorder are discussed. Little systematic investigation exists on the treatment of DID in general, and substance abuse in DID in particular. The authors draw upon the existing literature, and their experience to discuss treatment strategies aimed at treating patients with both diagnoses. Ignoring either diagnosis is likely to be detrimental to patients; both disorders and their coexistence need to be addressed.

Methylphenidate treatment for cocaine abusers with adult attention-deficit/hyperactivity disorder: a pilot study.

OBJECTIVE This study tested the hypothesis that the antidepressant venlafaxine would be an effective treatment for cocaine abusers with concurrent depressive disorders. METHODS This was a randomized, 12-week, double-blind, placebo-controlled trial of outpatients (N = 130) meeting DSM-IIIR criteria for cocaine dependence and major depression or dysthymia (by SCID interview). Participants were treated with venlafaxine, up to 300 mg/day versus placebo. All patients received weekly individual manual-guided relapse prevention therapy. Weekly outcome measures included Clinical Global Impression Scale (CGI), self-reported cocaine use, urine toxicology and the Hamilton Depression Scale (Ham-D). RESULTS Mood response, defined as a 50% reduction in the Ham-D between randomization and end of study, was 41% (26/64) on venlafaxine, and 33% (22/66) on placebo (p = .39). Measures of depression (Ham-D and CGI) improved more rapidly on venlafaxine than placebo, but these differences disappeared by weeks 6-8. Cocaine outcomes did not differ between treatment groups, and the proportion of patients achieving three or more consecutive weeks of urine-confirmed abstinence was low (venlafaxine: 16%; placebo: 15%). Reduction in cocaine use was associated with mood response. CONCLUSIONS Overall, venlafaxine was not superior to placebo on either mood or cocaine use outcomes. Mood improvement was associated with improvement in cocaine use. However, placebo mood response was only moderate, and the proportion of patients achieving sustained abstinence was low. This suggests that the subgroup of cocaine-dependent patients with depressive disorders is relatively treatment resistant, and that further research is needed to improve outcomes for these patients.