Joan Trujols

Cocaine Use Immediately Prior to Entry in an Inpatient Heroin Detoxification Unit as a Predictor of Discharges Against Medical Advice

Detection of benzyolecgonine, the major metabolite of cocaine, in the urinalysis conducted on the first day of an inpatient heroin detoxification treatment program was studied as a predictor of discharge against medical advice (AMA). With this aim, we conducted a chart-review procedure of 275 heroin dependents (DSM-III-R) who received methadone or dextropropoxyphene chlorhydrate to treat Opioid Withdrawal Syndrome. Data were analyzed following a case-control design. The 49 (17.8%) patients who did not complete the treatment due to discharged AMA were characterized by having achieved total heroin abstinence during fewer months from the time they began consumption of this substance to the time of hospitalization (p = .001). Moreover, those patients who requested discharge AMA were characterized by more frequent detection of benzoylecgonine in their urine on the day of admission (p = .004). The value of the odds ratio of this association was 3.81 (95% CI; 1.30 to 11.04). Lastly, noncompleters due to discharge AMA were more likely to be single than ever married (p = .037). The logistic regression model confirmed that there is a significant relationship between an AMA event and the presence of benzoylecgonine in urine upon beginning detoxification and to a shorter duration of the period of total heroin abstinence. In the discussion, the influence that recent interruption of cocaine consumption has on the decision to drop out of a detoxification program AMA is considered.

A controlled trial of daily versus thrice-weekly buprenorphine administration for the treatment of opioid dependence.

This study was aimed at determining whether thrice-weekly administration of buprenorphine is as effective as daily administration for treating opioid dependence. A total of 60 treatment-seeking opioid addicts were randomly assigned to take buprenorphine tablets sublingually either every day (8 mg) or thrice-weekly (16 mg on Mondays and Wednesdays and 24 mg on Fridays) over the course of a 12-week, double-blind, parallel trial. The buprenorphine dosing schedule had no significant effect on treatment retention. The rates of opioid-positive urine tests were significantly higher among those subjects who were given buprenorphine thrice weekly (58.5%) than among those who took it daily (46.6%). An analysis of the completers did not detect a significant effect of buprenorphine dosing schedule. The results obtained in our clinical trials indicate the advisability of daily doses of buprenorphine, at least at the beginning of a maintenance programme.

Patient-reported outcome measures: Are they patient-generated, patient-centred or patient-valued?

Background In the past two decades, there has been a growing interest in the development of a more patient-centred approach to assessing treatment outcomes. This interest has resulted in the increasing use of patient-reported outcome measures (PROMs) in both clinical trials and usual clinical practice. Aims To briefly discuss the paucity of efficacy and effectiveness studies in the field of mental health (exemplified by schizophrenia, depression and opioid dependence) that significantly incorporate the patients perspective. The limited concordance between the perspectives of patients and clinicians in outcome assessment is also addressed. Finally, we propose a new PROM classification system based on the degree to which these instruments incorporate the patients perspective. Conclusions PROMs may differ little from traditional instruments unless they truly incorporate the patients perspective and not just the perspectives of clinicians and researchers. Efforts to develop new PROMs that provide a more patient-centred outcome assessment should use qualitative and participatory methods to capture and incorporate patient perspectives and values.

Features and prevalence of patients with probable adult attention deficit hyperactivity disorder who request treatment for cocaine use disorders

To characterize those patients with probable adult attention deficit hyperactivity disorder (ADHD) who ask for treatment of cocaine use disorders; to estimate the prevalence of probable adult ADHD among these patients. This is a cross-sectional and multi-center study performed at outpatient resources of 12 addiction treatment centers in Spain. Participants were treatment-seeking primary cocaine abusers recruited consecutively at one center and through convenience sampling at the other centers. Assessments included semi-structured clinical interview focused on Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) ADHD criteria adapted to adulthood, and the Wender-Utah Rating Scale (WURS) for screening childhood history of ADHD according to patients. Probable adult ADHD was diagnosed when patients met DSM-IV criteria of ADHD in adulthood and scored WURS>32. All participants were diagnosed with current cocaine dependence (n=190) or abuse (n=15). Patients with probable adult ADHD, compared with patients having no lifetime ADHD, were more frequently male, reported higher impulsivity, and began to use nicotine, alcohol, cannabis, or cocaine earlier. Before starting the current treatment, patients with probable adult ADHD also showed higher cocaine craving for the previous day, less frequent cocaine abstinence throughout the previous week, and higher use of cocaine and tobacco during the previous month. Impulsivity and male gender were the only independent risk factors of probable adult ADHD in a logistic regression analysis. The prevalence of probable adult ADHD was 20.5% in the sub-sample of patients consecutively recruited (n=78). A diagnosis of probable adult ADHD strongly distinguishes among treatment-seeking cocaine primary abusers regarding past and current key aspects of their addictive disorder; one-fifth of these patients present with probable adult ADHD.

Allelic and genotypic associations of DRD2 TaqI A polymorphism with heroin dependence in Spanish subjects: a case control study

BackgroundConflicting associations with heroin dependence have been found involving the A1 allele of dopamine D2 receptor gene (DRD2) Taq I A polymorphism.MethodsWe compared two samples of unrelated Spanish individuals, all of European origin: 281 methadone-maintained heroin-dependent patients (207 males and 74 females) who frequently used non-opioid substances, and 145 control subjects (98 males and 47 females).ResultsThe A1-A1 genotype was detected in 7.1% of patients and 1.4% of controls (P = 0.011, odds ratio = 5.48, 95% CI 1.26–23.78). Although the A1 allele was not associated with heroin dependence in the entire sample, the frequency of A1 allele was higher in male patients than in male controls (24.4% vs. 16.3%, P = 0.024, odds ratio = 1.65, 95% CI 1.07–2.57). A logistic regression analysis showed an interaction between DRD2 alleles and gender (odds ratio = 1.77, 95% CI 1.15–2.70).ConclusionOur results indicate that, in Spanish individuals, genotypes of the DRD2 Taq I A polymorphism contribute to variations in the risk of heroin dependence, while single alleles contribute only in males.

Development and psychometric properties of the Verona Service Satisfaction Scale for methadone-treated opioid-dependent patients (VSSS-MT).

We adapted the 32-item Verona Service Satisfaction Scale (VSSS-32) to assess opioid-dependent patient satisfaction with services received from methadone treatment centres. The preliminary version of the VSSS for methadone treatment (VSSS-MT) was filled out anonymously and completed by 516 randomly recruited patients. After exploratory factor analysis and item refinement, the definitive 27-item VSSS-MT accounted for 58.8% of the total variance, comprising four factors: Basic Interventions, Specific Interventions, Social Worker Skills, and Psychologist Skills. These factors showed good to excellent internal reliabilities (Chronbachs alpha: 0.91, 0.85, 0.87, and 0.92, respectively). At test-retest, intraclass correlation coefficients of VSSS-MT overall and factor scores were fair to good. The results of this study suggest that the VSSS-MT measures, briefly but also multidimensionally, opioid-dependent patient satisfaction with methadone treatment centres.

Stages of change in dialectical behaviour therapy for borderline personality disorder.

OBJECTIVESnThe study aims at evaluating the suitability of applying the transtheoretical model (TTM) stage-of-change construct to the treatment with dialectical behaviour therapy (DBT) of borderline personality disorder (BPD).nnnDESIGNnStages of change were assessed by means of the University of Rhode Island Change Assessment (URICA) scale prior to and after 3 months DBT skills group psychotherapy.nnnMETHODnThe sample was comprised of 79 people with BPD (86% of females) at pre-treatment, and 42 patients (80% of females) at post-treatment. All patients were referred from clinical services and diagnosed by means of two semi-structured interviews.nnnRESULTSnIn pre-treatment assessment, precontemplation scores correlated significantly and negatively with the other subscales (contemplation, action, and maintenance) and these three subscales also correlated significantly and positively with each other. The precontemplation stage was directly related to drop-out from the DBT group. The action subscale and the committed action (CA) composite score were significantly higher by the end of the DBT group treatment. However, with the absence of a control group it cannot be assured that these increases were directly related to DBT intervention.nnnCONCLUSIONSnIn this observational design the stages of change of TTM seemed applicable to the DBT conceptualization of BPD and could further our understanding of the process of change in people with BPD treated with DBT.

A critical analysis of user satisfaction surveys in addiction services: opioid maintenance treatment as a representative case study.

Background Satisfaction with services represents a key component of the user’s perspective, and user satisfaction surveys are the most commonly used approach to evaluate the aforementioned perspective. The aim of this discursive paper is to provide a critical overview of user satisfaction surveys in addiction treatment and harm reduction services, with a particular focus on opioid maintenance treatment as a representative case. Methods We carried out a selective critical review and analysis of the literature on user satisfaction surveys in addiction treatment and harm reduction services. Results Most studies that have reported results of satisfaction surveys have found that the great majority of users (virtually all, in many cases) are highly satisfied with the services received. However, when these results are compared to the findings of studies that use different methodologies to explore the patient’s perspective, the results are not as consistent as might be expected. It is not uncommon to find that “highly satisfied” patients report significant problems when mixed-methods studies are conducted. To understand this apparent contradiction, we explored two distinct (though not mutually exclusive) lines of reasoning, one of which concerns conceptual aspects and the other, methodological questions. Conclusion User satisfaction surveys, as currently designed and carried out in addiction treatment and harm reduction services, do not significantly help to improve service quality. Therefore, most of the enthusiasm and naiveté with which satisfaction surveys are currently performed and interpreted – and rarely acted on in the case of nonoptimal results – should be avoided. A truly participatory approach to program evaluation is urgently needed to reshape and transform patient satisfaction surveys.

Validation of the Spanish version of the borderline symptom list, short form (BSL-23)

BackgroundThe Borderline Symptom List-23 (BSL-23) is a reliable and valid self-report instrument for assessing Borderline Personality Disorder (BPD) severity. The psychometric properties of the original version have proven to be adequate. The aim of the present study was to validate the Spanish language version of the BSL-23.MethodsThe BSL-23 was administered to 240 subjects with BPD diagnosis. Factor structure, reliability, test-retest stability, convergent validity, and sensitivity to change were analyzed.ResultsThe Spanish version of the BSL-23 replicates the one-factor structure of the original version. The scale has high reliability (Cronbach’s alpha=.949), as well as good test-retest stability, which was checked in a subsample (n=74; r=.734; p<.01). The Spanish BSL-23 shows moderate to high correlations with depressive symptomatology, state and trait anxiety, hostility and impulsivity scores and BPD measures. The Spanish BSL-23 is able to discriminate among different levels of BPD severity and shows satisfactory sensitivity to change after treatment, which was verified by assessing change before and after 12 group sessions of Dialectical Behavioral Therapy in a subgroup of 31 subjects.ConclusionsSimilar to the original BSL-23, the Spanish BSL-23 is a reliable and valid instrument for assessing BPD severity and sensitivity to change.

Patient satisfaction with methadone maintenance treatment: the relevance of participation in treatment and social functioning.

BACKGROUNDnPatients satisfaction with methadone maintenance treatment (MMT) is a key measure of treatment quality. The main objective of the present study is to identify independent factors that contribute significantly to satisfaction with MMT.nnnMETHODnParticipants were a representative sample of methadone-maintained patients (n=123) from the region of La Rioja. Satisfaction with MMT was assessed with the Verona Service Satisfaction Scale for Methadone Treatment (VSSS-MT), and mental health status with the General Health Questionnaire-28 (GHQ-28). Multivariate linear- and logistic-regression analyses were performed to identify variables independently associated with satisfaction with MMT.nnnRESULTSnMultiple linear regression analysis revealed that the variables independently associated with VSSS-MT total score were number of hours per week that the centre dispensed methadone (β=0.193), number of patients per centre (β=0.233), perceived frequency of receiving information about methadone dose changes (β=0.246), perceived influence on these changes (β=0.194), and Social Dysfunction subscale of GHQ-28 (β=-0.179). Multivariate binary logistic regression showed that the variables independently associated with the likelihood of being satisfied with MMT were number of years of education completed (OR=0.835), number of patients per centre (OR=1.009), perceived frequency of receiving information about methadone dose changes (OR=1.571), and Social Dysfunction subscale of GHQ-28 (OR=0.748).nnnCONCLUSIONSnPatients from larger centres, who perceive themselves as participating to some extent in treatment decisions, and showing lower deterioration in social functioning are more likely to be satisfied with MMT.