Peter Banys

Cigarette Smoking Exacerbates Chronic Alcohol-Induced Brain Damage: A Preliminary Metabolite Imaging Study

BACKGROUND Cigarette smoking is common among alcohol-dependent individuals. Nevertheless, previous research has typically not accounted for the potential independent or compounding effects of cigarette smoking on alcohol-induced brain injury and neurocognition. METHODS Twenty-four 1-week-abstinent recovering alcoholics (RAs; 14 smokers and 10 nonsmokers) in treatment and 26 light-drinking controls (7 smokers and 19 nonsmokers) were compared on measures of common brain metabolites in gray matter and white matter of the major lobes, basal ganglia, midbrain, and cerebellar vermis, obtained via multislice short-echo time proton magnetic resonance spectroscopic imaging. Smoking and nonsmoking RAs were also contrasted on measures of neurocognitive functioning, as well as laboratory markers of drinking severity and nutritional status. RESULTS Chronic alcohol dependence, independent of smoking, was associated with lower concentrations of frontal N-acetylaspartate (NAA) and frontal choline-containing compounds, as well as lower parietal and thalamic choline. Smoking RAs had lower NAA concentrations in frontal white matter and midbrain and lower midbrain choline than nonsmoking RAs. A four-group analysis of covariance also demonstrated that chronic cigarette smoking was associated with lower midbrain NAA and choline and with lower vermian choline. In smoking RAs, heavier drinking was associated with heavier smoking, which correlated with numerous subcortical metabolite abnormalities. The 1-week-abstinent smoking and nonsmoking RAs did not differ significantly on a brief neurocognitive battery. In smoking RAs, lower cerebellar vermis NAA was associated with poorer visuomotor scanning speed and incidental learning, and in nonsmoking RAs lower vermis NAA was related to poorer visuospatial learning and memory. CONCLUSIONS These human in vivo proton magnetic resonance spectroscopic imaging findings indicate that chronic cigarette smoking exacerbates chronic alcohol-induced neuronal injury and cell membrane damage in the frontal lobes of RAs and has independent adverse effects on neuronal viability and cell membranes in the midbrain and on cell membranes of the cerebellar vermis. Higher smoking levels are associated with metabolite concentrations in select subcortical structures. Greater consideration of the potential effects of comorbid cigarette smoking on alcohol-induced brain damage and other diseases affecting the central nervous system is warranted.

Chronic cigarette smoking modulates injury and short-term recovery of the medial temporal lobe in alcoholics

Memory function is largely mediated by the medial temporal lobe (MTL), and its compromise has been observed in alcohol dependence and chronic cigarette smoking. The effects of heavy alcohol consumption and chronic smoking on hippocampal volumes and MTL metabolites and their recovery during abstinence from alcohol have not been assessed. Male alcoholics in treatment (ALC) [13 smokers (sALC) and 11 non-smokers (nsALC)] underwent quantitative magnetic resonance imaging and short-echo proton magnetic resonance spectroscopic imaging at 1 week and 1 month of sobriety. Outcome measures were compared with 14 age-matched, non-smoking light-drinkers and were related to visuospatial learning and memory. Over 1 month of abstinence, N-acetyl-aspartate, a neuronal marker, and membrane-associated choline-containing metabolites normalized in the MTL of nsALC subjects, but remained low in the MTL of sALC subjects. Metabolite concentration changes in both groups were associated with improvements in visuospatial memory. Hippocampal volumes increased in both groups during abstinence, but increasing volumes correlated with visuospatial memory improvements only in nsALC subjects. In summary, chronic cigarette smoking in alcohol-dependent men appears to have adverse effects on MTL metabolite recovery during short-term sobriety. These data may also have implications for other conditions with established MTL involvement and significant smoking co-morbidity, such as schizophrenia-spectrum and mood disorders.

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.

The clinical use of disulfiram (Antabuse): a review.

Disulfiram is a potent alcohol-sensitizing drug, the effectiveness of which remains unproven in the treatment of alcoholism after 40 years of use. Its clinical utility is more closely associated with nonspecific, nonpharmacological factors (such as social class, patient compliance, patient personality characteristics, and treatment structure) than with its aversive biochemistry. Disulfiram is not effective as a sole alternative to a structured treatment program. Disulfiram retains a place in standard alcoholism treatment programs because clinicians have found this agent useful for selected alcoholic patients. Clinical studies and clinical lore describe these patients as older, relapse-prone, socially stable, cognitively intact, not depressed, compulsive, capable of following rules, and tolerant of dependence. Another distinctly responsive (but evasive) group is court-probated patients. These characteristics also describe patients who are well-known to have good outcomes without disulfiram, thus they do not help clinicians to select suitable patients for this medication. Consequently, this article proposes the following selection criteria: (1) patients who can tolerate a treatment relationship; (2) patients who are relapse-prone (but in treatment); (3) patients who have failed with less structured approaches; (4) patients in early abstinence who are in crisis or under severe stress; (5) patients in established recovery for whom individual or group psychotherapy is a relapse risk; and (6) patients who specifically request it. With or without disulfiram, a treatment program needs to be highly structured and predictable in order to be useful to newly recovering patients. Recovery is a process with discernible phases of development, and the provision of structure is the core of early treatment, where behavior change is more important than insight. A well-structured program will have phases through which a patient may progress. Generally speaking, disulfiram is most useful early to establish sobriety and to allow time for other support structures, such as AA, therapist-patient relationships, and new personal relationships, to take hold. Disulfiram is best given to patients with prior treatment failures, early in treatment, briefly during crises in established sobriety, or to support unusual stresses, such as psychotherapy. Prescriptions should be short-term and not allow automatic refills. It should be necessary to attend a treatment program in order to obtain them. Supervision and monitoring dramatically increase compliance.(ABSTRACT TRUNCATED AT 400 WORDS)

Continuity of care and desipramine in primary cocaine abusers.

The objective of this research was to determine the efficacy of enhanced continuity of care and desipramine in increasing treatment attendance and abstinence from cocaine in primary cocaine abusers. Study design was a random assignment, placebo-controlled factorial with assessments at baseline and at 3 (first week of outpatient treatment), 8, and 12 weeks after start of study. Desipramine blood levels were taken at weeks 2 (inpatient), 3, and 8. Subjects (N = 94 men) were recruited on an inpatient ward and assigned to increased continuity of care or to standard treatment, and to active or placebo drug. Main outcome variables were toxicology-verified reports of cocaine use, and attendance at counseling sessions. Enhanced continuity of care increased abstinence from cocaine at week 3 and increased attendance at individual counseling sessions throughout the 12 weeks of the study. There were no main effects for desipramine. Blood levels above 123 ng/ml at week 2 predicted longer stays in outpatient. We conclude that enhanced continuity of care is a low cost intervention that improves early treatment outcome and attendance; desipramine effects do not warrant its therapeutic use.

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

Methadone Transition Treatment (MTT) is a treatment program for opioid-addicted individuals that takes advantage of a 1989 change in federal guidelines permitting the establishment of 180-day detoxification programs. Thirty-eight subjects were assigned to either high-dose (80 mg) or low-dose (40 mg) methadone in a double-blind design. Both conditions showed initial dramatic decreases in illicit drug use and distress symptoms (opioid craving, withdrawal symptoms, and dysphoria). The high-dose condition showed a nonsignificant trend toward less frequent illicit drug use during the period of stable methadone dosing. We speculate that intensive psychosocial treatment, including weekly individual counseling and three-times a week group therapy, may have dampened outcome differences between high- and low-dose methadone conditions. Treatment retention was high for both dosage conditions.

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

The purpose of this study was to examine the relationship of treatment outcomes in opioid detoxification to levels of counselor and peer alliance. Forty-one subjects were recruited from a larger, 180-day study of psychosocial treatment. Beginning at day 90, subjects completed monthly measures of alliance. Outcome measures included treatment retention, drug use and self-reported HIV risk. Measures of alliance were found to be internally consistent and moderately stable over time. During the final 30 days of the methadone taper, higher levels of both types of alliance were associated with less use of illicit opioids. Alliance with counselor was associated with less frequent needle sharing. For subjects who could be located for 30-day follow-up, greater alliance with peers was associated with more frequent HIV (sexual) risk behaviors. Results suggest that treatment outcome may be improved through approaches that address a patients alliance with both counselor and peers.

An open trial of low dose buprenorphine in treating methadone withdrawal

Buprenorphine (BPN) is a prescription analgesic with mixed opioid agonist and antagonist properties. This pilot study conducted detailed case studies with 15 methadone dependent patients. The study sought to determine whether repeated low doses (0.15 to 0.3 mg) of sublingual BPN would relieve opioid withdrawal symptoms. Subjects developed mild to moderate withdrawal symptoms within 26 to 31 hours of methadone discontinuation. Once in withdrawal, the subjects received 0.15 mg of BPN sublingually. A second dose of 0.15 mg was administered in an hour, and a 0.30 mg dose in 2 hours, if the subject obtained no relief of withdrawal symptoms. In 6 subjects a low dose of 0.15 to 0.30 mg sublingual BPN resulted in the disappearance of subjective and objective withdrawal symptoms within 10 minutes to 2.5 hours. Four others had brief, partial relief of symptoms. Five subjects failed to experience any relief of withdrawal symptoms after a total of 0.6 mg BPN administered over 3 hours. One nonresponder suffered what appeared to be a severe precipitated withdrawal reaction similar to that which can be produced in addicts by a naloxone challenge. The 4 Caucasian responders required 1 to 2 hours to respond to BPN, whereas the 2 African-American responders required only 10 to 20 minutes. Low (analgesic) doses of BPN were sufficient to treat all methadone withdrawal symptoms in 6 of 15 subjects. There may be ethnic differences in response to BPN. Low dose BPN may play a role in carefully monitored heroin detoxification treatment.

Methadone transition treatment: a treatment model for 180-day methadone detoxification.

For those drug addicts who do not meet the United States federal government regulations for methadone maintenance, methadone detoxification remains the primary option for treatment. Studies on the effectiveness of 21-day methadone detoxification, however, report low completion rates and high relapse. Revisions to the standard 21-day detoxification are needed. The research literature suggests that offering psychosocial services within an extended 180-day protocol may be an effective mode of treatment for those addicts who do not meet the requirements for entering methadone maintenance, or do not desire maintenance. Methadone Transition Treatment (MTT) is an innovative treatment organized around this strategy. MTT is transitional in that emphasis is place on working with patients to enter longer-term treatment. To aid the development of similar programs at other institutions, we describe the specific procedures of the MTT model and provide an evaluation of the model based on findings from an initial pilot study.