John S. Cacciola

A new measure of substance abuse treatment: Initial studies of the Treatment Services Review.

This paper describes the development and initial testing of the Treatment Services Review (TSR). The TSR is a 5-minute, technician-administered interview that provides a quantitative profile of the number and types of treatment services received by patients during alcohol and drag abuse rehabilitation. Test-retest studies indicated satisfactory reliability administered either in person or over the phone. Tests of concurrent validity showed the ability to discriminate different levels of treatment services and good correspondence with independent measures of treatment provided. While additional studies are still needed with this instrument, the data collected thus far suggest that the TSR may serve two types of needs. First, at the programmatic level, the TSR may prove useful in describing and comparing programs in terms, of the nature and number of services actually delivered to patients. At the individual patient level, the TSR may offer a means of evaluating the “match” between a patients needs and the services actually provided.

Gender differences in the relapse experiences of cocaine patients

This study investigated potential gender differences in the onset, course, and termination of cocaine relapse episodes. The subjects were 98 cocaine dependent men and women who were participating in several treatment outcome studies. The Cocaine Relapse Interview was used to obtain data on specific relapse episodes that had occurred in a 6-month period before the interview. The analyses indicted that women reported more unpleasant affect and interpersonal problems and fewer positive experiences before relapse than men, and their relapses were more likely to have an impulsive quality. Women reported more help-seeking after initial use, whereas men reported stronger appetitive reactions and more self-justification. There were no gender differences in factors associated with terminating the relapse episodes. Clinical implications and limitations of the research are discussed.

The antisocial personality disorder diagnosis in substance abusers : problems and issues

This paper examines the question of whether antisocial personality disorder (APD) can be considered a viable substance abuse typology. The data for APD substance abusers are first reviewed with respect to six properties that apply to establishing the validity of a clinical typology. This is followed by a brief description of the historical context and development of current conceptualizations of antisocial personality. Some possible sources of diagnostic unreliability and instability that could serve to limit the validity of the APD diagnosis are then discussed. Finally, evidence indicating considerable psychiatric heterogeneity within APD substance abusers is described. The findings indicate that although APD substance abusers satisfy many of the criteria for a clinical subtype, the fit is sufficiently imprecise to suggest the need for further refinement. We attempt to point out some of the critical questions, issues, and lines of research that could help to guide future efforts to clarify, refine, and revise the APD formulation, particularly as it applies to substance abusers.

Reliability of the revised Psychopathy Checklist in substance abuse patients

The Psychopathy Checklist (PCL) and the slightly revised Psychopathy Checklist (PCL-R) represent an alternate conceptualization to the antisocial personality disorder formulation of antisociality. The PCL and PCL-R have been found to have high reliability and good predictive validity in prisoner populations. Thus far, almost all published work has been based on prisoners. This study examined the 1-month test-retest reliability of the PCL-R in 88 methadone-maintained male patients as well as the effects of increased information (interview, clinical chart review, partial and complete criminal records) on PCL-R scores and on two diagnostic derivations of the PCL-R. PCL-R scores and diagnostic proportions were not found to differ significantly between baseline and 1 month

Personality disorders and treatment outcome in methadone maintenance patients.

This study examined the relationship between personality disorders (PDs) and 7− month treatment outcome in 197 men admitted to methadone maintenance. Subjects reported pervasive improvement, and the amount of improvement did not significantly differ for those subjects with and without PDs. PD subjects entered treatment with more severe self-reported drug, alcohol, psychiatric, and legal problems, and despite progress, remained ntore problematic in those areas relative to subjects without PDs. Subjects with antisocial PD had admission and 7-month problem status similar to subjects with other PDs. The 7-month urinalysis results for opiates and cocaine showed no significant differences between subjects with and without PDs. Fewer PD subjects stayed in treatment continuously for the 7-month period. Several cluster B PDs—borderline, antisocial, and histrionic—predicted poorest overall outcomes. Methadone-maintained patients with PDs may warrant additional treatment services if they are to approach the functional level of patients without PDs.

An examination of the cocaine relapse process

Although empirical studies of the relapse process have been done with alcoholics, smokers, and opiate addicts, comparatively little information is available on the relapse process in cocaine abusers. This paper presents data from the Cocaine Relapse Interview (CRI), a structured interview that assesses factors associated with the onset, course, and termination of cocaine relapse episodes. In a sample of 95 cocaine dependent patients, the experiences that occurred with the greatest frequency immediately prior to relapse were wanting drugs, being alone, having money, and feeling extremely bored and lonely. Following the onset of the relapse, the most frequent experience was unpleasant affect, although positive reactions were also relatively common. The factors perceived as most important in terminating relapse were painful internal states, help-seeking behaviors, and other coping responses. Three types of relapse experiences, or pathways, were identified: (a) unpleasant affect--painful internal states prior to and throughout the relapse; (b) positive affect--positive affect and pleasant social experiences prior to relapse coupled with a relatively unproblematic course; and (c) sensation seeking--sensation seeking and interpersonal problems prior to relapse coupled with mixed emotional reactions and antisocial behavior during the relapse, and interpersonal problems at relapse termination.

Reliability and Validity of the Revised Psychopathy Checklist in Women Methadone Patients

The Revised Psychopathy Checklist (PCL-R) has been found to be a reliable and valid measure of psychopathy in men prisoners. More recently the PCL-R has been shown to be a reliable instrument in assessing psychopathy in men methadone patients. To date, only two studies have reported on the reliability of the PCL-R with women prisoners and no published studies address the question of the reliability and validity of the PCL-R with women substance abusers. This investigation examines the homogeneity and internal consistency of the PCL-R in a sample of 58 women methadone patients. Additionally, the 1-month test-retest reliability was examined along with the relationship of the PCL-R to other diagnostic and self-report measures. Results show that the PCL-R appears to be a reliable and valid measure of psychopathy in women methadone patients.

Treatment response of antisocial substance abusers

We evaluated the relationship of antisociality to 7-month treatment response in 224 alcohol-and/or cocaine-dependent men. Subjects with and without a DSM-III antisocial personality disorder (ASPD) responded similarly and positively to treatment in a number of functional domains, including substance use. A more detailed analysis comparing subjects with ASPD, subjects meeting adult but not childhood ASPD criteria (A-ASPD), and subjects meeting neither adult nor childhood ASPD criteria (pure non-ASPD) revealed similar and positive responses to treatment among the three groups. The antisocial groups had more cocaine and alcohol use at the baseline evaluation, but at 7-month follow-up, they had levels of use not significantly different than the pure non-ASPD group. The findings suggest that an ASPD diagnosis or an adult antisocial lifestyle, at least as measured by DSM-III criteria, does not predict short-term treatment response.

Comparability of Telephone and In-Person Structured Clinical Interview for DSM-III-R (SCID) Diagnoses

The SCID was administered twice, once by telephone and once in person (1 week later) to 41 college age men. For major depression (lifetime K = .64, current K = .66), results indicated good agreement. The lifetime occurrence estimate based on the telephone SCID diagnosis was lower than the in-person SCID estimate. Kappas for specific diagnoses were calculable for simple phobia (lifetime K = .47, current K = -.03) and social phobia (lifetime K = .29). Base rates were less than 10% for all individual diagnoses except lifetime major depression; therefore, the kappas may be unstable. For all diagnoses where there were any positive cases, percentages of negative agreement and specificity were high, whereas percentages of positive agreement and sensitivity were lower. Overall agreement was fair for specific lifetime diagnoses but poor for current diagnoses. These results suggest caution in assuming comparability of in-person and telephone SCID diagnoses. Circumstances under which a telephone SCID may be useful and ways to improve reliability are discussed.

A cocaine-positive baseline urine predicts outpatient treatment attrition and failure to attain initial abstinence

The primary study objective was to ascertain whether a prior finding that the baseline cocaine urine toxicology predicted treatment dropout for cocaine dependent outpatients could be extended to three additional cocaine dependent outpatient treatment samples and whether the urine toxicology also predicted attainment of initial abstinence for the four samples. A secondary objective was to ascertain the extent to which other baseline variables accounted for additional outcome variance over and above that afforded by urine toxicology. To evaluate the first objective, the relationships between the baseline cocaine urine and each of two measures of within treatment response--the completion of treatment or the attainment of initial abstinence--were determined for each of the treatment samples. The second objective was evaluated by a stepwise, hierarchical logistic regression analysis, with the urine toxicology entered in the first step, baseline Addiction Severity Index (ASI) variables in the second step, and achievement of initial abstinence as the outcome. In all four samples, patients with a urine indicative of recent cocaine use were less than half as likely to complete treatment or achieve initial abstinence. Individual ASI baseline variables did not contribute statistically significant variance over and above that predicted by the cocaine urine toxicology. The findings confirm the utility of the initial cocaine urine as a predictor of unfavorable outpatient treatment response.