José Pérez de los Cobos

Probability and predictors of transition from first use to dependence on nicotine, alcohol, cannabis, and cocaine: Results of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC)

BACKGROUND This study aims to estimate general and racial-ethnic specific cumulative probability of developing dependence among nicotine, alcohol, cannabis or cocaine users, and to identify predictors of transition to substance dependence. METHODS Analyses were done for the subsample of lifetime nicotine (n=15,918), alcohol (n=28,907), cannabis (n=7389) or cocaine (n=2259) users who participated in the first and second wave of the National Epidemiological Survey on Alcohol and Related Conditions (NESARC). Discrete-time survival analyses were implemented to estimate the cumulative probability of transitioning from use to dependence and to identify predictors of transition to dependence. RESULTS The cumulative probability estimate of transition to dependence was 67.5% for nicotine users, 22.7% for alcohol users, 20.9% for cocaine users, and 8.9% for cannabis users. Half of the cases of dependence on nicotine, alcohol, cannabis and cocaine were observed approximately 27, 13, 5 and 4 years after use onset, respectively. Significant racial-ethnic differences were observed in the probability of transition to dependence across the four substances. Several predictors of dependence were common across the four substances assessed. CONCLUSIONS Transition from use to dependence was highest for nicotine users, followed by cocaine, alcohol and cannabis users. Transition to cannabis or cocaine dependence occurred faster than transition to nicotine or alcohol dependence. The existence of common predictors of transition dependence across substances suggests that shared mechanisms are involved. The increased risk of transition to dependence among individuals from minorities or those with psychiatric or dependence comorbidity highlights the importance of promoting outreach and treatment of these populations.

Probability and predictors of remission from life-time nicotine, alcohol, cannabis or cocaine dependence: results from the National Epidemiologic Survey on Alcohol and Related Conditions

AIM To estimate the general and racial/ethnic specific cumulative probability of remission from nicotine alcohol cannabis or cocaine dependence, and to identify predictors of remission across substances. DESIGN Data were collected from structured diagnostic interviews using the Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV version. SETTING The 2001-2002 National Epidemiological Survey of Alcohol and Related Conditions (NESARC) surveyed a nationally representative sample from US adults (n = 43,093) selected in a three-stage sampling design. PARTICIPANTS The subsamples of individuals with life-time DSM-IV diagnosis of dependence on nicotine (n = 6937), alcohol (n = 4781), cannabis (n = 530) and cocaine (n = 408). MEASUREMENTS Cumulative probability estimates of dependence remission for the general population and across racial/ethnic groups. Hazard ratios for remission from dependence. FINDINGS Life-time cumulative probability estimates of dependence remission were 83.7% for nicotine, 90.6% for alcohol, 97.2% for cannabis and 99.2% for cocaine. Half of the cases of nicotine, alcohol, cannabis and cocaine dependence remitted approximately 26, 14, 6 and 5 years after dependence onset, respectively. Males, Blacks and individuals with diagnosis of personality disorders and history of substance use comorbidity exhibited lower hazards of remission for at least two substances. CONCLUSIONS A significant proportion of individuals with dependence on nicotine, alcohol, cannabis or cocaine achieve remission at some point in their life-time, although the probability and time to remission varies by substance and racial/ethnic group. Several predictors of remission are shared by at least two substances, suggesting that the processes of remission overlap. The lower rates of remission of individuals with comorbid personality or substance use disorders highlight the need for providing coordinated psychiatric and substance abuse interventions.

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.

Methadone tapering plus amantadine to detoxify heroin-dependent inpatients with or without an active cocaine use disorder: two randomised controlled trials

The efficacy of methadone tapering plus amantadine to detoxify heroin-dependent patients with or without an active cocaine use disorder was studied in a closed unit with two successive double-blind, placebo-controlled, 14-day trials. In the first trial, 40 heroin-dependent inpatients with an active cocaine use disorder were treated using methadone tapering, as well as amantadine (200-300 mg per day) or placebo. In the second trial, 40 heroin-dependent inpatients without an active cocaine use disorder received the same treatment. In both the trials, amantadine did not have a statistically significant effect on treatment completion, nor did it contribute, in completers, to a more rapid reduction in craving and opiate withdrawal. In the first trial, women were six times more likely than men to be non-completers, and on the last day of treatment, the first trials completers and non-completers presented a comparable clinical state.

Pharmacological and clinical dilemmas of prescribing in co-morbid adult attention-deficit/hyperactivity disorder and addiction

The present article reviews whether available efficacy and safety data support the pharmacological treatment of adult attention‐deficit/hyperactivity disorder (ADHD) in patients with concurrent substance use disorders (SUD). Arguments for and against treating adult ADHD with active SUD are discussed. Findings from 19 large open studies and controlled clinical trials show that the use of atomoxetine or extended‐release methylphenidate formulations, together with psychological therapy, yield promising though inconclusive results about short term efficacy of these drugs in the treatment of adult ADHD in patients with SUD and no other severe mental disorders. However, the efficacy of these drugs is scant or lacking for treating concurrent SUD. No serious safety issues have been associated with these drugs in patients with co‐morbid SUD‐ADHD, given their low risk of abuse and favourable side effect and drug–drug interaction profile. The decision to treat adult ADHD in the context of active SUD depends on various factors, some directly related to SUD‐ADHD co‐morbidity (e.g. degree of diagnostic uncertainty for ADHD) and other factors related to the clinical expertise of the medical staff and availability of adequate resources (e.g. the means to monitor compliance with pharmacological treatment). Our recommendation is that clinical decisions be individualized and based on a careful analysis of the advantages and disadvantages of pharmacological treatment for ADHD on a case‐by‐case basis in the context of active SUD.