Randy S. Burke

Psychometric Evaluation of the National Opinion Research Center DSM-IV Screen for Gambling Problems (NODS)

The present study examined the reliability, validity, and clinical utility of a brief self-report measure of gambling behavior, the National Opinion Research Center DSM-IV Screen for Gambling Problems (NODS). Participants were 157 consecutively enrolled male military veterans taking part in substance use disorder treatment. The NODS displayed good internal consistency. Concurrent and discriminant validity were demonstrated by comparing scores on the NODS to scores on the South Oaks Gambling Screen and to a measure of medical problems, respectively. Overall, the NODS appears to be a reliable, valid, and clinically useful measure of gambling problems among patients in substance use disorder treatment programs.

Carisoprodol: Abuse Potential and Withdrawal Syndrome

Carisoprodol (N-isopropyl-2 methyl-2-propyl-1,3-propanediol dicarbamate; N-isopropylmeprobamate) is a centrally acting skeletal muscle relaxant whose primary active metabolite is meprobamate, a substance with well established abuse potential similar to that of benzodiazepines. A number of reports show that carisoprodol has been abused for its sedative and relaxant effects, to augment or alter the effects of other drugs, and by the intentional combination of carisoprodol and other noncontrolled medications because of the relative ease (as compared to controlled substances) of obtaining prescriptions. The diversion and abuse of carisoprodol and its adverse health effects appear to have dramatically increased over the last several years. Clinicians have begun to see a withdrawal syndrome consisting of insomnia, vomiting, tremors, muscle twitching, anxiety, and ataxia in patients who abruptly cease intake of large doses of carisoprodol. Hallucinations and delusions may also occur. The withdrawal symptoms are very similar to those previously described for meprobamate withdrawal, suggesting that what may actually be occurring is withdrawal from meprobamate accumulated as a result of intake of excessive amounts of carisoprodol. However carisoprodol itself is capable of modulating GABA(A) function, and this may contribute both to the drugs abuse potential and to the occurrence of a withdrawal syndrome with abrupt cessation of intake. Carisoprodol has been classified as a controlled substance in several states in the US and restrictions on the use of the drug have been imposed in some European countries. Carisoprodol is metabolized to a controlled substance, has clear evidence of abuse potential and increasing incidence of abuse, and has shown evidence of a withdrawal syndrome with abrupt cessation from intake. This article will discuss the abuse potential of carisoprodol and the associated withdrawal syndrome, and consider implications for future use of the drug.

Relation Between Cognitive Testing Performance and Pattern of Substance Use in Males at Treatment Entry

This study examined the frequency and pattern of cognitive impairment in individuals entering substance use disorder treatment and additionally examined the relation between pattern of cognitive impairment and type of substance(s) used: alcohol (n = 116), cocaine (n = 49), alcohol/cocaine (n = 76), and alcohol/multiple substance (n = 54). The Cognistat, a screening measure of cognitive functioning, and the Addiction Severity Index were given to male veterans at the time of entering 3- to 4-week residential/day drug treatment. The most prominent areas of impairment were memory (37% of the total sample) and similarities or abstract concept formation (21% of the total sample). Moderate or greater severity of impairment was noted on at least one Cognistat scale in 35% of the participants. Results indicated no significant differences in the patterns of cognitive domain impairment between groups based on type(s) of substances used at the time of entering treatment. Multiple substance use was significantly related to greater levels of psychiatric problems as identified by the Alcohol Severity Index. Given the rate of impairment in memory and verbal abstract reasoning noted, it is suggested that cognitive screening be a standard consideration in residential substance use disorder treatment to assist in treatment selection and delivery that is optimized to provide maximal benefit to patients.

Using vouchers to increase continuing care participation in veterans: does magnitude matter?

The present study examined the comparative effects of adding contingency management (CM) schedules to an existing substance abuse continuing care program, with the goal of increasing attendance. We retrospectively examined the attendance of 135 veterans enrolled in one of three CM programs and a quasi-control condition of 55 veterans. Results indicated that participants enrolled in the two higher magnitude CM voucher programs increased both continuing care attendance and length of participation. Findings support the use of CM to increase continuing care attendance among veterans with substance use disorders, and suggest that voucher magnitude and bonuses both had a positive impact.

Inappropriate psychiatric admission of elderly patients with unrecognized delirium.

Objectives: To explore factors that might contribute to misattribution of mental status changes to psychiatric illness when an elderly patient actually has a delirium (mental status changes due to a medical condition). Methods: Records of 900 elderly patients referred to a Veterans Affairs psychiatric inpatient unit and 413 to an inpatient psychiatric team at a public hospital from 2001 to 2007 were reviewed. Cases referred because of symptoms secondary to an unrecognized delirium underwent further analysis of preadmission assessments. Comparisons were made to elderly patients with delirium appropriately admitted to medical units. Results: Thirty (2.3%) of the patients referred to psychiatric units were found to have a physical disorder requiring medical intervention within twelve hours. Compared to 30 delirious patients admitted to medical units, those inappropriately referred to psychiatric units had significantly lower rates of adequate medical histories, physical examinations, cognitive assessments, and laboratory/radiological studies. Among patients with delirium referred to psychiatric units, 66.7% had a history of mental illness, versus 26.7% of comparable admissions to medical units (&khgr;2 (7) = 60.00, P < 0.001). Conclusions: Our findings suggest that elderly patients with delirium admitted to psychiatric units are less likely to undergo complete diagnostic assessments than delirious elderly patients admitted to medical units. Symptoms of delirium appear more likely to be incorrectly attributed to psychiatric illness in patients with a history of mental illness than in patients without such a history. Possible explanations for these findings and suggestions for addressing these issues are offered.

Smoking Cessation in Recovery: Comparing 2 Different Cognitive Behavioral Treatments

ObjectivesThe purpose of this pilot demonstration study was to evaluate the feasibility and effectiveness of adding a contingency management (CM) component to the standard cognitive-behavioral smoking cessation treatment offered to veterans in a residential substance-abuse treatment program. Specifically, we assessed the impact of CM on (1) engagement in smoking cessation treatment, (2) retention in smoking cessation treatment, and (3) abstinence from smoking. MethodsParticipants were 65 male veterans in inpatient treatment for a primary substance use disorder who expressed interest in quitting smoking. Participants were enrolled in either the standard or CM smoking cessation treatment program. All participants were offered 4 sessions of cognitive-behavioral group counseling; participants in the CM program also had the opportunity to earn cash vouchers for session attendance and abstinence from smoking. ResultsThe CM treatment program showed superior treatment engagement and retention rates. Survival analysis showed that 58% of participants receiving the CM treatment were smoke-free on quit day, versus only 17% of participants in standard care. In addition, the end of treatment continuous abstinence rate was significantly higher in the CM condition compared with standard care (21% vs. 0%). ConclusionsThese preliminary results suggest that contingency management approaches may be useful for maximizing participation in smoking cessation treatment and improving treatment outcomes among recovering substance users.

Carisoprodol: update on abuse potential and legal status.

Carisoprodol is a centrally acting skeletal muscle relaxant of which meprobamate, a controlled substance, is the primary active metabolite. The abuse of carisoprodol has increased dramatically in the last several years. A withdrawal syndrome occurs in some patients who abruptly cease carisoprodol intake. The symptoms of this syndrome are similar to those seen with meprobamate withdrawal, suggesting that they may result from withdrawal from meprobamate accumulated with intake of excessive carisoprodol; however, carisoprodol is capable of modulating GABAA function, which may contribute to its abuse potential.There has been considerable debate about whether carisoprodol should be considered a controlled substance. Carisoprodol was removed from the market in Norway on May 1, 2008, but may still be used by specially approved patients. Carisoprodol was classified as a controlled substance in several US states, and effective January 11, 2012, became a schedule IV controlled substance at the US federal level. This article updates the literature on abuse potential and examines recent developments regarding the legal status of carisoprodol.

Abuse of combinations of gabapentin and quetiapine.

To the Editor: Medications may be misused, particularly if they produce sedative or anxiolytic effects. We describe misuse of combinations of gabapentin and quetiapine. Case report. A 42-year-old man was admitted to a treatment program after his second arrest for driving under the influence of an unknown substance. He had used marijuana and cocaine but stopped after obtaining employment requiring drug testing. Afterward, he had negative drug screens but sometimes appeared “stoned.” He had prescriptions for quetiapine and gabapentin and misused these 2 medications together to replace the drugs he had taken. Taking up to 5 tablets of gabapentin 300 mg with 3 to 4 tablets of quetiapine 200 mg simultaneously produced a sensation of sedation and euphoria. His girlfriend was prescribed and also misused gabapentin with quetiapine when she could not afford cocaine, taking 3 to 4 tablets of gabapentin 300 mg with 2 to 3 tablets of quetiapine 200 mg, sometimes with beer. She described similar, although weaker, effects. The couple was acquainted with 3 others who misused the same combination by taking 400–800 mg of quetiapine with 900–1,800 mg of gabapentin. Prescriptions were reportedly obtained by fabrication or exaggeration of symptoms. Tablets were sometimes sold or traded for illicit drugs. Evidence exists for abuse of both gabapentin and quetiapine. Both have been removed from several prison formularies because of abuse by inmates. A woman substituted gabapentin 600–1,500 mg daily for cocaine.1 Florida inmates admitted snorting gabapentin powder for effects reminiscent of cocaine.2 Benzodiazepine-like withdrawal and dependence have been described.3,4 Gabapentin has been misused to potentiate the effect of methadone.5 About 20 cases of gabapentin addiction have been described in Europe.6 There are several reports of oral quetiapine abuse (800–1,200 mg at a time) for sedating and anxiolytic effects.7 Quetiapine powder is sometimes snorted intranasally8; intravenous abuse has also occurred.9 Drug-seeking behavior, compulsive use, diversion, dependence, and withdrawal have been described.10,11 Quetiapine is sometimes called “quell” or “baby heroin” by inmates. Gabapentin inhibits voltage-gated calcium channels and entails an increase in γ-aminobutyric acid neurotransmission, as well as modulation of excitatory amino acids at N-methyl-d-aspartate receptor sites.4 Quetiapine acts as an antagonist at serotonin 5-HT1A and 5-HT2A, dopamine D1 and D2, histamine H1, and adrenergic α1 and α2 receptors.7 With the 2 drugs combined, many neuroreceptors are affected, and effects at high doses could be significant. Toxicity may exist for patients taking large amounts of gabapentin and/or quetiapine. Clinicians should exercise vigilance when using either to treat patients who use alcohol or illicit drugs, particularly if gabapentin and quetiapine are prescribed concomitantly.

Anxiety Sensitivity as a Moderator of the Association between Smoking Rate and Panic-Relevant Symptoms among a Community Sample of Middle-aged Adult Daily Smokers

The aim of the present investigation was to evaluate the moderating role of anxiety sensitivity (AS) in the relation between smoking rate and panic vulnerability variables among a community-based sample of adults. Results indicated that the interaction between AS and smoking rate significantly predicted anxious arousal, agoraphobic avoidance, and anticipatory anxiety. Specifically, participants who reported higher levels of AS and heavier smoking rates reported the highest levels of panic vulnerability. These data suggest that this combination of high AS and heavier smoking is particularly problematic in regard to panic symptoms.

Is it time for carisoprodol to become a controlled substance at the federal level

Carisoprodol (N-isopropyl-2 methyl-2-propyl-1,3-propanediol dicarbamate; N-isopropylmeprobamate; Soma) is a commonly prescribed, centrally acting skeletal muscle relaxant. As the chemical nomenclature suggests, carisoprodol is structurally related to meprobamate. In fact, the primary active metabolite of carisoprodol is meprobamate. Meprobamate is a schedule IV controlled substance at the federal level with a known risk for causing addiction. Research has shown the abuse potential of meprobamate to be equal to, if not greater than, that of benzodiazepines. With meprobamate having this degree of abuse potential, one might expect a risk of misuse of carisoprodol. Indeed, a number of reports suggest this to be a valid concern. Carisoprodol has been abused (usually in amounts much larger than the recommended daily dose of 350 mg three or four times daily) for its sedative and relaxant effects. Carisoprodol has also been used to augment or alter the effects of other drugs (eg, to increase the sedating effects of benzodiazepines or alcohol, or to prevent jitteriness during cocaine use and help calm persons after its intake). Abuse has also occurred by the intentional combination of carisoprodol and other noncontrolled medications because of the relative ease (as compared with controlled substances) of obtaining prescriptions. The combination of carisoprodol and tramadol has been reported by individuals misusing the two medications together to result in significant relaxation and euphoria. The diversion and abuse of carisoprodol and its adverse health effects appear to have dramatically increased over the last several years. According to the Drug Abuse Warning Network (DAWN), numbers of emergency department episodes involving carisoprodol were 6,569 in 1994, 7,771 in 1995, 11,239 in 2001, 10,094 in 2002, 17,366 in 2004, and 19,513 in 2005, representing an almost 300% increase from 1994 to 2005. According to the National Survey on Drug Use and Health (NSDUH) data from 2002 to 2005, the occurrence of misuse of carisoprodol was approximately equal to that of clonazepam. Carisoprodol manufactured in Guadalajara and sold under the name Somacid is reported to be easily obtained in Mexico with the purchase of several thousand pills at a time possible. Workers in Mexican pharmacies near the US border have said they fill carisprodol orders several times per week for American teenagers, a trend they say has been going on for years. According to the Los Angeles Police Department, carisoprodol is being diverted, trafficked, and abused nationwide, and is the pharmaceutical drug most frequently encountered at the US-Mexico border crossing. In the US, the street value of Soma is