Patrick J. Abbott

Extended vs short-term buprenorphine-naloxone for treatment of opioid-addicted youth: a randomized trial.

CONTEXT The usual treatment for opioid-addicted youth is detoxification and counseling. Extended medication-assisted therapy may be more helpful. OBJECTIVE To evaluate the efficacy of continuing buprenorphine-naloxone for 12 weeks vs detoxification for opioid-addicted youth. DESIGN, SETTING, AND PATIENTS Clinical trial at 6 community programs from July 2003 to December 2006 including 152 patients aged 15 to 21 years who were randomized to 12 weeks of buprenorphine-naloxone or a 14-day taper (detox). INTERVENTIONS Patients in the 12-week buprenorphine-naloxone group were prescribed up to 24 mg per day for 9 weeks and then tapered to week 12; patients in the detox group were prescribed up to 14 mg per day and then tapered to day 14. All were offered weekly individual and group counseling. MAIN OUTCOME MEASURE Opioid-positive urine test result at weeks 4, 8, and 12. RESULTS The number of patients younger than 18 years was too small to analyze separately, but overall, patients in the detox group had higher proportions of opioid-positive urine test results at weeks 4 and 8 but not at week 12 (chi(2)(2) = 4.93, P = .09). At week 4, 59 detox patients had positive results (61%; 95% confidence interval [CI] = 47%-75%) vs 58 12-week buprenorphine-naloxone patients (26%; 95% CI = 14%-38%). At week 8, 53 detox patients had positive results (54%; 95% CI = 38%-70%) vs 52 12-week buprenorphine-naloxone patients (23%; 95% CI = 11%-35%). At week 12, 53 detox patients had positive results (51%; 95% CI = 35%-67%) vs 49 12-week buprenorphine-naloxone patients (43%; 95% CI = 29%-57%). By week 12, 16 of 78 detox patients (20.5%) remained in treatment vs 52 of 74 12-week buprenorphine-naloxone patients (70%; chi(2)(1) = 32.90, P < .001). During weeks 1 through 12, patients in the 12-week buprenorphine-naloxone group reported less opioid use (chi(2)(1) = 18.45, P < .001), less injecting (chi(2)(1) = 6.00, P = .01), and less nonstudy addiction treatment (chi(2)(1) = 25.82, P < .001). High levels of opioid use occurred in both groups at follow-up. Four of 83 patients who tested negative for hepatitis C at baseline were positive for hepatitis C at week 12. CONCLUSIONS Continuing treatment with buprenorphine-naloxone improved outcome compared with short-term detoxification. Further research is necessary to assess the efficacy and safety of longer-term treatment with buprenorphine for young individuals with opioid dependence. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00078130.

Community Reinforcement Approach in the Treatment of Opiate Addicts

The authors studied the efficacy of the community reinforcement approach (CRA) as compared to standard counseling in opiate-dependent patients on methadone maintenance. One hundred eighty subjects were randomized to three treatment conditions: standard, CRA, and CRA with relapse prevention (CRA/RP). Of these, 151 subjects were followed up 6 months after intake. Since few of the RP sessions had been concluded at the 6-month follow-up, the two CRA groups were combined for analyses. Weekly urinalysis drug screens and Addiction Severity Index (ASI) scores at intake and 6 months were compared. The combined CRA groups did significantly better than the standard group in the following areas: consecutive opiate-negative urinalysis (3 weeks), and the 6-month ASI drug composite score. These results support the benefit of adding CRA strategies to the treatment of patients who are opiate dependent and on methadone maintenance. Because of insufficient treatment exposure to RP at the 6-month follow-up, the additive effect of RP could not be adequately evaluated; further follow-up will be required.

Hypochondriacal Beliefs and Attitudes in Family Practice and Psychiatric Patients

Beliefs and attitudes which can be responsible for hypochondriacal behavior were explored by administering the Illness Attitude Scales and two distress scales to patients attending a family practice clinic, nonpsychotic psychiatric outpatients and a random group of employees. Family practice patients were more distressed, had more hypochondriacal concerns and had more bodily preoccupations than employees and took more precautions about their health. Psychiatric patients were more distressed and had more fears about illness and death than family practice patients, yet took fewer precautions about their health. The findings appear to have implications for treatment.

Traditional and Western Healing Practices for Alcoholism in American Indians and Alaska Natives

The American Indian and Alaska Native population is a culturally diverse population with a current census of 1,959,000. Prior to White contact, there was historically little use of alcoholic beverages except for American Indians in the Southwest. After White contact, use and misuse of alcohol escalated rapidly; however, the prevalence, patterns, and problems of drinking alcoholic beverages vary enormously even in tribes closely linked geographically. American Indians and Alaska Natives have preserved and revitalized a number of traditional healing practices and applied these to the treatment of alcohol-related problems. These healing practices include the following: nativistic movements, sacred dances, sweat lodges, talking circle, four circles, and cultural enhancement programs. Additionally, Western treatment approaches have been applied in the treatment of problems related to alcohol, such as medication for detoxification, disulfiram (Antabuse), Alcoholics Anonymous, and behavioral interventions. Several investigators have completed a small number of naturalistic follow-up studies, but no one has undertaken a randomized controlled trial looking at specific methods of alcohol treatment in American Indians or Alaska Natives. American Indian and Alaska Native communities have adapted and integrated both Traditional and Western approaches to fit their own unique sociocultural needs.

Hostility, somatic symptoms, and hypochondriacal fears and beliefs

The authors administered self-rating scales of anger-hostility, somatic symptoms, and hypochondriacal fears and beliefs to seven groups of patients and nonpatients. Somatic symptoms were positively correlated with anger-hostility and were negatively correlated with feelings of friendliness; the correlation coefficients ranged from low to moderately high and were significant in most groups. Somatic symptoms tended to be associated more strongly with symptoms of anxiety and depression than with those of hostility. The associations of hypochondriacal fears and beliefs with hostility were inconsistent, varied between groups and with the concern measured. The findings do not support the view that anger or hostility are main or specific etiological factors either in somatization or in hypochondriacal fears or beliefs.

Ambulatory Medical Detoxification for Alcohol

In the past decade, ambulatory medical detoxification for alcohol withdrawal has become increasingly utilized due to pressures to contain cost of treatment and research demonstrating its effectiveness. The research that describes this area spans the last 15 years. This article reviews the available literature on ambulatory detoxification and attempts to summarize and synthesize what is known about this area in order to make ambulatory medical detoxification readily reproducible in clinical practice. Finally, this article concludes with an analysis of the advantages and disadvantages of outpatient alcohol detoxification as compared to inpatient treatment.

Effects of buprenorphine and hepatitis C on liver enzymes in adolescents and young adults.

Objective:The purpose of this study was to explore changes in transaminase values associated with buprenorphine treatment and hepatitis C status among opioid-dependent subjects aged 15 to 21 years. Methods:One hundred fifty-two subjects seeking treatment for opioid dependence were randomized to 2-week detoxification with buprenorphine/naloxone (DETOX) or 12 weeks with buprenorphine/naloxone (BUP). Liver chemistries including transaminases were obtained baseline and at 4, 8, and 12 weeks. One hundred eleven patients had at least one set of transaminases during treatment and were included in analyses of treatment effects. Results:Overall, 8 of the 60 BUP participants versus 12 of the 51 DETOX participants had at least one elevated alanine aminotransferase value during follow-up (&khgr;2 = ns). Five of the 60 BUP participants versus 11 of the 51 DETOX participants had at least one elevated aspartate aminotransferase value (&khgr;2 = 3.194, P = 0.048). Twenty eight of the 152 participants were hepatitis C (HCV) positive at baseline and 4 seroconverted within 12 weeks, 2 in each group. HCV status was significantly associated with transaminase abnormalities (P = 0.009 and 0.006 for alanine aminotransferase and aspartate aminotransferase, respectively). HCV status had a strong effect on transaminase abnormalities among participants assigned to DETOX, but not among those assigned to BUP. Conclusions:No evidence was found for hepatotoxicity of buprenorphine in this exploratory analysis. HCV was present in a significant minority of participants and was a significant predictor of transaminase elevation. Results suggest that stabilization on buprenorphine may decrease the frequency of transaminase abnormalities associated with HCV in opioid-dependent young people. The high rate of seroconversion underscores the importance of effective treatment and prevention.

A Review of the Community Reinforcement Approach in the Treatment of Opioid Dependence

Abstract This article reviews the Community Reinforcement Approach (CRA) in the treatment of opioid dependence. It covers the use of CRA with both methadone maintenance patients and patients withdrawing from opioids. The data reviewed in the use of CRA in combination with methadone maintenance shows improvement in a number of areas. These include the reduction of opioid use, as well as other drugs of abuse, improved legal status, less psychiatric symptoms, and improved vocational and social functioning. CRA coupled with vouchers can assist in retaining patients in treatment long enough to improve opioid detoxification rates from buprenorphine and coupled with naltrexone may sustain abstinence. Further, the use of a standardized computerized format may extend the utility of CRA.

Retrospective Analyses of Additional Services for Methadone Maintenance Patients

We report on the 6-month outcome of a retrospective analysis of additional treatment services for patients entering a methadone maintenance program who transferred from community methadone treatment programs (n = 83) or entered off the street (n = 83) not currently on methadone. Patients were participating in a clinical treatment trial examining the effectiveness of Community Reinforcement Approach and Relapse Prevention. Patients in the methadone transfer group were using less heroin at intake than patients newly initiated onto methadone and both groups improved from additional treatment services in the following problem areas specifically: drug, alcohol, legal, employment, social, and in some measures of psychiatric distress. Therefore, both groups of patients in this study benefited from additional treatment services.

Co-Morbid Alcohol/Other Drug Abuse/Dependence and Psychiatric Disorders in Adolescent American Indian and Alaska Natives

Abstract Adolescent American Indians and Alaska Natives are a diverse and heterogeneous population with significant social, psychological, and substance use risk factors. This paper reviews the adolescent research to date that has examined the overlap between alcohol/other drug abuse/dependence, mental disorders, and psychiatric symptoms. In the few studies that have been completed there has been significant overlap. No national studies have been done, but there are scattered local and tribal reports. Of the studies that were surveyed, many of them report a significant co-morbidity of alcohol/other drug abuse/dependence with affective and disruptive disorders (ADHD, conduct, oppositional defiant).