Karen L. Sees

Mood management and nicotine gum in smoking treatment : A therapeutic contact and placebo-controlled study

Earlier research indicated that a 10-session mood management (MM) intervention was more effective than a 5-session standard intervention for smokers with a history of major depressive disorder (MDD). In a 2 x 2 factorial design, the present study compared MM intervention to a contact-equivalent health education intervention (HE) and 2 mg to 0 mg of nicotine gum for smokers with a history of MDD. Participants were 201 smokers, 22% with a history of MDD. Contrary to the earlier findings, the MM and HE interventions produced similar abstinence rates: 2 mg gum was no more effective than placebo. History-positive participants had a greater increase in mood disturbance after the quit attempt. Independent of depression diagnosis, increases in negative mood immediately after quitting predicted smoking. No treatment differences were found in trends over time for measures of mood, withdrawal symptoms, pleasant activities and events, self-efficacy, and optimism and pessimism. History-positive smokers may be best treated by interventions providing additional support and contact, independent of therapeutic content.

When to begin smoking cessation in substance abusers

During the past several years, there has been an increasing recognition and acceptance that the use of tobacco products often produces nicotine dependence and nicotine addiction. Despite this, the substance abuse treatment community has been slow to promote smoking cessation for patients who are in substance abuse treatment for another addiction. Dogma, although starting to change, persists that cigarette smoking pales in comparison to other addictions and should not be addressed at the time of initial treatment for another addiction. The limited research to date, which will be reviewed in this article, does not support this dogma. In addition, patients presenting for substance abuse treatment report high interest in stopping smoking, including interest in stopping when they initially present for substance abuse treatment.

Opioid use in the treatment of chronic pain: Assessment of addiction

Addiction medicine specialists, besieged with the adverse consequences of opioids, not unreasonably develop reservations about their use. Opioid prohibition may be appropriate when working with addicts, but drug abstinence is not always the most appropriate nor optimal treatment of pain patients. Consultation concerning the management of chronic pain patients may require an attitude adjustment of challenging proportions for the addiction medicine specialist; it is a role substantially different from that usually assumed in treating alcohol- and drug-dependent patients. Rather than relentlessly pursuing psychotropic drug abstinence as the treatment goal, restoration of function should be the primary treatment goal for the chronic pain patient. Unlike the chemically dependent patient whose level of function is impaired by substance use, the chronic pain patients level of function may improve with adequate, judicious use of medications, which may include opioids. Evaluating for addiction in a patient who is prescribed long-term opioids for pain control is often problematic. While the concept of addiction may include the symptoms of physical dependence and tolerance, physical dependence and/or tolerance alone does not equate with addiction. In the chronic pain patient taking long-term opioids, physical dependence and tolerance should be expected, but the maladaptive behavior changes associated with addiction are not expected. Thus, it is the presence of these behaviors in the chronic pain patient that is far more important in diagnosing addiction.

Violent traumatic events and drug abuse severity

We examined the occurrence of violent traumatic events, DSM-III-R diagnosis of posttraumatic stress disorder (PTSD), and PTSD symptoms, and the relationship of these variables to drug abuse severity. One-hundred fifty opioid-dependent drug abusers who were participants in a randomized trial of two methadone treatment interventions were interviewed using the Diagnostic Interview Schedule, the Addiction Severity Index, and the Beck Depression Inventory. Twenty-nine percent met diagnostic criteria for PTSD. With the exception of rape, no gender differences in the prevalence of violent traumatic events were observed. The occurrence of PTSD-related symptoms was associated with greater drug abuse severity after controlling for gender, depression, and lifetime diagnosis of PTSD. The high rate of PTSD among these methadone patients, the nature of the traumatic events to which they are exposed, and subsequent violence-related psychiatric sequelae have important implications for identification and treatment of PTSD among those seeking drug abuse treatment.

History of alcohol or drug problems, current use of alcohol or marijuana, and success in quitting smoking.

Previous research suggests higher rates of smoking, and smoking cessation failure, in alcohol- and drug-abusing populations. The present study examined the relationship of alcohol/drug treatment history and current alcohol and marijuana consumption with success in smoking cessation treatment in a smoking clinic population. Participants were 199 smokers; 23% reported a history of alcohol/drug problems, 12.6% reported a history of drug treatment, 78.7% reported alcohol use, and 21.3% reported marijuana use during treatment. Results indicate no significant differences in abstinence rates based on history of alcohol/drug problem or treatment. Differences were found for any current alcohol use but not for marijuana use. Both alcohol use at baseline and any alcohol use during treatment predicted smoking at all follow-up points. Alcohol users had significantly lower quit rates than did participants reporting no use. Neither use of marijuana at baseline nor during treatment predicted outcome. These findings suggest that even low to moderate levels of alcohol consumption during smoking cessation may decrease treatment success.

Self-Efficacy and Illicit Opioid Use in a 180-Day Methadone Detoxification Treatment.

Self-efficacy ratings coincided with illicit opioid use across the 3 phases of a 180-day methadone detoxification treatment. Efficacy ratings increased after patients received their first dose of methadone, did not change while they were maintained on a stable dose of methadone, and declined during the taper as they attempted to face high-risk situations without the full benefit of methadone. Efficacy ratings measured at a point before a phase of treatment predicted illicit opioid use across that phase. For clarification of the relation between self-efficacy and illicit opioid use, 3 conceptual models proposed by J.S. Baer, C.S. Holt, and E. Lichtenstein (1986) were tested. Self-efficacy influenced subsequent drug use in parallel with previous behavior, but this influence was found only at the start of the stabilization phase and immediately before the start of the taper phase. These findings highlight the usefulness of the self-efficacy concept for the treatment of opioid addiction.

Contingency contracting with monetary reinforcers for abstinence from multiple drugs in a methadone program.

Positive monetary contingencies for treating opioid dependence complicated by other drug use were examined. Participants (N = 102) entered 6-month methadone transition treatment (MTT) and were randomized into experimental conditions: 51 entered MTT with contingency contracts using monetary reinforcers and targeting abstinence from illicit drug and alcohol use, and 51 entered MTT without contingency contracts targeting abstinence. Outcomes were evaluated by random urinalysis and breath analysis. After 4 months of treatment, individuals in the contingency condition had longer periods of continuous abstinence (p<.005) and more drug-free tests overall (p<.04). Effects were limited, however, to the contracting period. The authors conclude that contingency contracting using monetary reinforcers may be a useful adjunct for achieving abstinence from multiple drugs of abuse during MTT.

A Cost-Effectiveness and Cost-Benefit Analysis of Contingency Contracting–Enhanced Methadone Detoxification Treatment

We examined treatment costs in an ongoing study in which 102 opioid-addicted patients had been randomly assigned to either 180-day methadone detoxification or the same treatment enhanced with contingency contracting. In the latter condition, study participants received regular reinforcers contingent on negative urine toxicology screens and breath analyses for a range of drugs and alcohol. Both conditions involved psychosocial treatment, and all participants were stabilized to a daily methadone dose of approximately 80 mg during the first 4 months, followed by a 2-month taper. Individuals participating in the enhanced condition were more likely to provide continuously drug-free urine samples and alcohol-free breath samples during the final month of treatment than were participants in the control condition. Cost of treatment was calculated individually for each participant based on actual services received. First, unit cost for each service was determined, including adjusted staff salaries for direct treatment and opportunity cost of facilities utilized during service delivery. Next, we valued each patients use of services during the first 120 days of the study and then added the cost of methadone, laboratory work, and contingent reinforcers. A subsample (n = 45) also provided data on health care utilization during treatment, which we valued using standard Medicare unit costs. The marginal cost of enhancing the standard treatment with contingency contracting was approximately 8%. An incremental cost of

Low (40 mg) versus high (80 mg) dose methadone in a 180-day heroin detoxification program

17.27 produced an additional 1% increase in the number of participants providing continuously substance-free urine and breath samples during month 4 of the study. For every additional dollar spent on treatment, a

The relationship of counselor and peer alliance to drug use and HIV risk behaviors in a six-month methadone detoxification program☆☆☆

4.87 health care cost offset was realized; however, this difference was statistically insignificant due to extreme variances and small subsample size.