Frances R. Levin

Rates of psychiatric comorbidity among U.S. residents with lifetime cannabis dependence

Cannabis is the most widely used illegal drug in the U.S. population. Surveys have estimated that the lifetime prevalence rate for cannabis dependence is approximately 4%. Though the presence of a psychiatric disorder increases the likelihood of developing substance dependence, the field lacks data regarding the association between mental disorders and cannabis dependence. The aim of this study is to describe the prevalence of psychiatric disorders among individuals with cannabis dependence. The National Comorbidity Survey was used to obtain these data. We found that 90% of respondents with cannabis dependence had a lifetime mental disorder, compared to 55% without cannabis dependence. Alcohol dependence, antisocial personality disorder, and conduct disorder had the strongest associations with cannabis dependence, followed by anxiety and mood disorders. A large proportion of respondents with internalizing disorders developed mood or anxiety disorders prior to onset of their first cannabis dependence symptom. Data regarding the prevalence of comorbid mental disorders underscore the importance of thorough and systematic evaluation of patients seeking treatment for cannabis dependence. The failure to identify comorbidity may lead to inadequate treatment, and a poorer prognosis.

Prevalence of adult attention-deficit hyperactivity disorder among cocaine abusers seeking treatment

In this study, 281 cocaine abusers seeking treatment were assessed for adult attention-deficit hyperactivity disorder (ADHD). Structured assessments included the SCID for DSM-IV, a SCID-like module for ADHD, and a pattern of drug use questionnaire. The sample consisted of 82% men, 67% African-Americans, 19% Hispanics, and 14% Caucasians identified at several treatment sites. Average age was 33.7 +/- .4 years. Twelve percent (n = 34) of the sample met DSM-IV criteria for childhood ADHD. Of the entire sample, 10% (n = 27), or 79% of the patients diagnosed with childhood ADHD, had adult ADHD. A history of conduct disorder and antisocial personality disorder were prevalent among those with adult ADHD (63% and 52%, respectively). This subpopulation of cocaine abusers may be one of the most difficult-to-treat cocaine-abusing groups, particularly if the ADHD remains undetected. To provide effective treatment for cocaine abusers, clinicians may need to identify subpopulations of patients, such as those with ADHD, and target both pharmacologic and nonpharmacologic interventions for these groups.

Posttraumatic stress disorder and short-term outcome in early methadone treatment

The aim of this study was to determine treatment adherence relative to frequency of violence and posttraumatic stress disorders (PTSD) among new methadone patients. Ninety-six opiate-abusing patients were evaluated for childhood physical and sexual abuse (CPSA), adulthood exposures to violence (ADVIOL), PTSD, and treatment adherence. Overall, 43% of the subjects dropped out of treatment within 3 months of intake. Occurrence of trauma or PTSD did not predict drop-out rates. A 2 (Gender) x 2 (PTSD) analysis of covariance (ANCOVA) with severity of other drug use on admission as a covariate, however, revealed a main effect for PTSD, F(4, 71) = 7. 69, p < or =.01, such that those patients with current PTSD revealed significantly more ongoing drug use at 3 months (M = 24.3, SD = 20. 9) than those without (M = 8.9, SD = 11.8). Examination of ongoing cocaine use using a 2 (Gender) x 2 (PTSD) ANCOVA also revealed a main effect for PTSD, F(4, 17) = 8.24, p < or = .005, such that those patients with current PTSD revealed significantly more ongoing cocaine use at 3 months postadmission (M = 51.6, SD = 37.6) than those without (M = 24.3, SD = 20.9). For both genders, CPSA and ADVIOL were associated with higher rates of PTSD, which in turn predicted poorer treatment adherence as measured by ongoing co-occurring drug abuse 3 months postadmission. Results underscore the need for routine assessment and targeted treatment of trauma in methadone patients.

Bipolar disorder and substance abuse

Substance use disorders are overrepresented in individuals with bipolar and bipolar spectrum disorders. Although awareness of this phenomenon has increased over the past 20 years, few empirically based treatment strategies have been developed for this challenging patient population. This review examines the relationship between bipolar and substance use disorders and treatment options that have been studied in this patient population. First, we examine the high prevalence rates of substance use disorders in individuals diagnosed with bipolar disorder, the common problems associated with establishing a bipolar disorder diagnosis in individuals who abuse substances, the possible explanations for the frequent coexistence of bipolar and substance use disorders, and the negative effect of substance abuse on the course of and treatment outcomes for bipolar disorder. The review then focuses on treatment approaches for this patient population, including integrated group therapy for co-occurring bipolar and substance use disorders and pharmacotherapies that target both disorders. Finally, we present suggestions for medications that might be tested for their efficacy in treating both disorders in specific subgroups of patients with bipolar and substance use disorders.

Treatment of depression in patients with opiate dependence

Depression is common among opiate-dependent patients and has been associated with worse prognosis. This article reviews the literature on treatment of depressive disorders and symptoms among patients with opiate dependence. Depression bears a complex relationship to opiate dependence and may represent an independent disorder or may be engendered by psychosocial stress or toxic and withdrawal effects of drugs. Primary treatments for opiate dependence (e.g., methadone or buprenorphine maintenance or residential treatment) are associated with substantial improvements in depression. Studies of antidepressant medications have produced mixed results, some positive but more negative. It is not clear what accounts for these differences, and more research is needed to determine how to select opiate-dependent patients most likely to benefit from antidepressants. Fewer studies have examined psychosocial or behavioral interventions, but some of these also show promise. The data suggest a stepped model of care in which depression is evaluated and observed during the outset of treatment for opiate dependence and if it does not improve, specific psychosocial interventions or antidepressant medications tried. Research is needed on such integrated models of care and treatment algorithms to determine their efficacy and cost effectiveness.

Attention-deficit hyperactivity disorder and substance abuse: relationships and implications for treatment.

&NA; Attention‐deficit hyperactivity disorder (ADHD) and substance‐use disorders are related to each other in a variety of ways. Although within the child‐psychiatry literature earlier investigations were inconsistent regarding such a link, recent prospective studies that followed hyperactive children and normal controls into adulthood have found that hyperactive adults with a history of ADHD are more likely than controls to have substance‐use disorders. The substance‐abuse literature is less consistent regarding the potential association between ADHD and substance abuse. However, recent studies suggest that persons with a substance‐use disorder, and particularly those with a cocaine‐use disorder, may be more likely than the general population to have a childhood history of ADHD. Some of the inconsistency regarding this association Is due to differences in diagnostic criteria, type of assessments used, and reliability of information obtained. Each of the potential relationships that may exist between ADHD and substance abuse has treatment implications for the clinician. Pharmacological as well as nonpharmacological approaches deserve further investigation. Because pharmacotherapy is a central component in the treatment of childhood ADHD, clinicians designing a strategy to treat both a substance‐use disorder and ADHD need to consider pharmacological interventions. At present, the literature on pharmacological treatment for childhood ADHD is extensive and that for adult ADHD is growing; information regarding the treatment of cocaine abuse and concomitant ADHD symptoms remains limited.

Dronabinol for the treatment of cannabis dependence: A randomized, double-blind, placebo-controlled trial

Cannabis dependence is a substantial public health problem. Behavioral treatments have shown promise, but there are no effective medications for cannabis dependence. The purpose of this study was to evaluate the safety and efficacy of dronabinol, a synthetic form of delta-9-tetrahydrocannabinol, a naturally occurring pharmacologically active component of marijuana, in treating cannabis dependence. 156 cannabis-dependent adults were enrolled in a randomized, double-blind, placebo-controlled, 12-week trial. After a 1-week placebo lead-in phase, participants were randomized to receive dronabinol 20mg twice a day or placebo. Doses were maintained until the end of week 8 and then tapered off over 2 weeks. All participants received weekly motivational enhancement and relapse prevention therapy. Marijuana use was assessed using the timeline follow back method. There was no significant difference between treatment groups in the proportion of participants who achieved 2 weeks of abstinence at the end of the maintenance phase (dronabinol: 17.7%; placebo: 15.6%). Although both groups showed a reduction in marijuana use over time, there were no differences between the groups. Treatment retention was significantly higher at the end of the maintenance phase on dronabinol (77%), compared to placebo (61%) (P=.02), and withdrawal symptoms were significantly lower on dronabinol than placebo (P=.02). This is the first trial using an agonist substitution strategy for treatment of cannabis dependence. Dronabinol showed promise, it was well-tolerated, and improved treatment retention and withdrawal symptoms. Future trials might test higher doses, combinations of dronabinol with other medications with complementary mechanisms, or with more potent behavioral interventions.

Changes in mood, cognitive performance and appetite in the late luteal and follicular phases of the menstrual cycle in women with and without PMDD (premenstrual dysphoric disorder)

Although its been reported that women with premenstrual dysphoric disorder (PMDD) have increased negative mood, appetite (food cravings and food intake), alcohol intake and cognitive deficits premenstrually, few studies have examined these changes concurrently within the same group of women or compared to women without PMDD. Thus, to date, there is not a clear understanding of the full range of PMDD symptoms. The present study concurrently assessed mood and performance tasks in 29 normally cycling women (14 women who met DSM-IV criteria for PMDD and 15 women without PMDD). Women had a total of ten sessions: two practice sessions, 4 sessions during the follicular phase and 4 sessions during the late luteal phase of the menstrual cycle. Each session, participants completed mood and food-related questionnaires, a motor coordination task, performed various cognitive tasks and ate lunch. There was a significant increase in dysphoric mood during the luteal phase in women with PMDD compared to their follicular phase and compared to Control women. Further, during the luteal phase, women with PMDD showed impaired performance on the Immediate and Delayed Word Recall Task, the Immediate and Delayed Digit Recall Task and the Digit Symbol Substitution Test compared to Control women. Women with PMDD, but not Control women, also showed increased desire for food items high in fat during the luteal phase compared to the follicular phase and correspondingly, women with PMDD consumed more calories during the luteal phase (mostly derived from fat) compared to the follicular phase. In summary, women with PMDD experience dysphoric mood, a greater desire and actual intake of certain foods and show impaired cognitive performance during the luteal phase. An altered serotonergic system in women with PMDD may be the underlying mechanism for the observed symptoms; correspondingly, treatment with specific serotonin reuptake inhibitors (SSRIs) remains the preferred treatment at this time.

Treatment of Cannabis Use Disorders: A Review of the Literature

Cannabis is the most widely used illicit drug in the United States. Despite the fact that there are large numbers of people with cannabis dependence, relatively little attention has been paid to the treatment of this condition. This article seeks to critically review the existing literature about the various psychosocial and pharmacologic treatments of cannabis dependence. We begin with a discussion of the early treatment literature which draws primarily from anecdotal experience and open, uncontrolled trials and proceed through two recent, large, randomized controlled trials of psychotherapies for the treatment of cannabis dependence. We conclude that while a number of psychotherapies have been found to be effective in treating this disorder, with the exception of adding vouchers to reinforce negative urine toxicology screens, no form of psychotherapy has been found to be more effective than any other. In addition, we review the only two clinical pharmacotherapy trials for cannabis dependence as well as the pre-clinical laboratory pharmacotherapy trials in cannabis dependent individuals. We also review pertinent dual-diagnosis pharmacotherapy trials and discuss potential future directions in treatment research for the pharmacotherapy of cannabis dependence.

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.