Stephen P. Weinstein

Gender differences and similarities in African-American crack cocaine abusers

Recent interest in womens health and patient-treatment matching has focused attention on gender differences among substance abusers. This article seeks to extend research in this area to African-American crack cocaine abusers. It describes gender differences and similarities in a large sample (652 males and 595 females) of this important group of patients at a publicly funded, inner-city intensive outpatient clinic. As in previous studies on white working-class inpatients, few significant gender differences were found on demographic characteristics or drug use or treatment histories. Moreover, there were few differences in psychiatric symptomatology, and none in treatment participation or retention. In contrast to some reports, we did not find that women entered treatment with higher levels of depression than men. Most statistically significant differences we found were either too small to be of practical importance, or reflected conventional gender differences ( e. g., women were more likely to care for dependents). —J Nerv Ment Dis 183:260-266, 1995

How Far Have We Come

Although the effects of domestic violence and partner abuse have been known throughout history, the topic has recently begun to receive attention in the research literature. Indeed, it was not until 1986 that two interdisciplinary journals were dedicated exclusively to the study of family violence. Popular lore has frequently cited a connection between substance use (particularly alcohol) and domestic violence; however, this interaction has now begun to be formally recognized and addressed in research and treatment paradigms. This chapter presents some of the research findings regarding the multidimensional relationship between family violence and alcohol and/or drug abuse. Theories and data about the causes of family violence and characteristics of the male batterer and of the substance-abusing men who batter are offered. The final section examines several current models of treatment and their outcome.

Inpatient Desire to Drink as a Predictor of Relapse to Alcohol Use Following Treatment

Cravings for alcohol are identified as a trigger for relapse, though laboratory studies of cravings produce mixed results in predicting relapse. The objective of this analysis is to assess the usefulness of craving as a predictor of relapse by assessing 218 adult, alcohol-dependent patients admitted to two separate residential addiction treatment programs. Days craving reported in the week prior to discharge predicted alcohol use at three-month follow-up. Admission spirituality, alcohol-refusal self-efficacy, and depression levels differentiated cravers from non-cravers. Patients who crave alcohol in residential treatment may be at higher relapse risk and identified by intake assessments of self-efficacy, depression, and spirituality.

Serotonin transporter (5-HTT) gene polymorphisms and susceptibility to cocaine dependence among African-American individuals

Studies indicate that the serotonin system, particularly the serotonin transporter (5‐HTT), may modulate the central effects of cocaine. We investigated whether a polymorphism in the 5′ promotor region (5‐HTTLPR) of the 5‐HTT gene confers susceptibility to cocaine dependence. One hundred and ninety‐seven cocaine‐dependent African‐American subjects and 101 controls were studied. Polymerase chain reaction based genotyping of a biallelic repeat polymorphism in the 5′ promotor region yielded 2 alleles containing 484 (S) and 528 bp (L) repeats, respectively. There were no significant differences between controls of European background (n = 40) and African‐American controls (n = 61) in distribution of genotypes (European: LL = 32.5%, LS = 40.0%, SS = 27.5%; African‐American: LL = 27.9%, LS = 57.4%, SS = 14.7%) (χ2= 3.60, df = 2, p = 0.16) or allele frequencies (European: L = 52.5%, S = 47.5%; African‐American: L = 56.6%, S = 43.4%) (χ2= 2.21, df = 1, p = 0.13). When cocaine patients were compared to an ethnically diverse control group (n = 101), frequencies of the L variant (65.0%) were significantly higher while the S variant (35.0%) was less frequent among cocaine patients compared to controls (L = 53.9%, S = 46.1%) (χ2= 6.83, df = 1, p < 0.01). Similarly, there were more cocaine patients with the LL genotype (41.1%) and less with the SS genotype (11.2%) compared to controls (LL = 29.7%, SS = 21.8%) (χ2= 7.43, df = 2, p < 0.05). However, after restricting controls to African‐American individuals only (n = 61), cocaine subjects and controls did not differ significantly with respect to genotype distribution (χ2= 4.24, df = 2, p = 0.12) or allele frequencies (χ2= 2.83, df = 1, p = 0.10). In conclusion, although comparisons with a heterogeneous control group indicated a possible association between allelic variants of 5‐HTTLPR and cocaine dependence among African‐American cocaine subjects, this relationship was not observed when the control group was limited to African‐American people only. Our findings need to be confirmed on larger samples of ethnically matched individuals.

Underreporting of Cocaine Use at Posttreatment Follow-up and the Measurement of Treatment Effectiveness

Substance abusers, especially cocaine abusers, may underreport their substance use in outcome interviews. Follow-up interviews were conducted and urine specimens were obtained on 633 persons 9 months after admission to a 3-month cocaine treatment program. Although 422 (67%) reported no use of cocaine in the past 30 days, 134 of these (32%) had cocaine-positive urines. This group did not differ on most characteristics at intake or follow-up from the 288 with cocaine-negative urines. The amount of treatment received did affect willingness to admit drug use. Of 132 treatment completers who reported no cocaine use at follow-up, 21 (16%) had positive urines. Of 91 early dropouts who also reported no cocaine use, 36 (40%) had positive urines. This differential rate of underreporting had the effect of seriously underrepresenting the effectiveness of treatment completion as compared with little or no treatment.

Impact of cannabis use during stabilization on methadone maintenance treatment.

BACKGROUND AND OBJECTIVES Illicit drug use, particularly of cannabis, is common among opiate-dependent individuals and has the potential to impact treatment in a negative manner. METHODS To examine this, patterns of cannabis use prior to and during methadone maintenance treatment (MMT) were examined to assess possible cannabis-related effects on MMT, particularly during methadone stabilization. Retrospective chart analysis was used to examine outpatient records of patients undergoing MMT (n = 91), focusing specifically on past and present cannabis use and its association with opiate abstinence, methadone dose stabilization, and treatment compliance. RESULTS Objective rates of cannabis use were high during methadone induction, dropping significantly following dose stabilization. History of cannabis use correlated with cannabis use during MMT but did not negatively impact the methadone induction process. Pilot data also suggested that objective ratings of opiate withdrawal decrease in MMT patients using cannabis during stabilization. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE The present findings may point to novel interventions to be employed during treatment for opiate dependence that specifically target cannabinoid-opioid system interactions.

A retrospective case control study of alcohol relapse and spiritual growth.

In the context of an NIAAA/Fetzer Institute-funded study designed to look at the impact of spirituality in an inpatient alcohol treatment, this retrospective case control study investigated whether spiritual growth occurred during an inpatient phase of treatment for alcohol dependence, the degree to which spiritual gains (if noted) would be maintained at follow-up, and whether spiritual growth would be associated with follow-up sobriety. To accomplish this goal, thirty-six individuals who reported relapsing to alcohol at three-month follow-up were compared with thirty-six matched controls who reported abstinence at follow-up. Spiritual development and change was assessed via a set of six measures. Paired t-tests revealed that spiritual growth occurred across all measures during the treatment phase. Repeated measures analysis of variance (ANOVA) indicated that this growth was maintained at three-month follow-up. Two-way repeated measures ANOVA revealed that while non-relapsers maintained spiritual growth over the course of four weeks of treatment and in the three-month period following treatment, renewed alcohol use was associated with decreased spirituality.

Comparison of Pretreatment Characteristics and Treatment Outcomes for Alcohol-, Cocaine-, and Multisubstance-Dependent Patients

Abstract We investigated whether pretreatment characteristics and measures of outcome differed for alcohol-, cocaine-, and multisubstance-dependent patients receiving outpatient substance abuse treatment. One hundred and forty substance dependent individuals (32 alcohol, 76 cocaine, and 32 multisubstance) enrolled in a 12-week outpatient treatment program were compared across measures of addiction severity, personality, and treatment-readiness at admission. In-treatment, end-of-treatment and 9-month follow-up assessments of treatment outcome were then compared across the three groups. Outcome measures included reduction in problem severity, abstinence, retention, number of sessions attended, dropout, and counselor and patient ratings of treatment benefit. At admission, the multisubstance group had a higher proportion of positive urines, reported more severe drug, alcohol and psychiatric problems, and displayed higher impulsivity and anxiety scores than one or both of the other groups. However, multisubstance patients were more treatment ready in terms of adopting a total abstinence orientation than alcohol or cocaine patients. While a significant reduction in symptoms occurred for the total sample during treatment as well as at follow-up, comparisons of outcomes did not consistently favor any particular group. The three groups had equivalent improvements in eleven of fourteen during-treatment and five of seven follow-up measures. Despite pre-treatment differences, in severity and treatment-readiness, outcomes were more similar than different for alcohol-, cocaine-, and multisubstance-dependent patients. Clinicians should be cautious about forecasting treatment-outcomes for addicted patients based on their primary substances of abuse.

Relationship between serotonin transporter gene polymorphisms and platelet serotonin transporter sites among African-American cocaine-dependent individuals and healthy volunteers

Alterations in the serotonin transporter (5-HTT) have been implicated in a variety of psychiatric disorders including cocaine dependence. A polymorphism in the promoter region of the serotonin transporter gene (5-HTTLPR) appears to influence the expression of 5-HTT in human cell lines. We investigated whether 5-HTTLPR variants were related to differences in measures of platelet 5-HTT sites in cocaine-dependent patients and healthy volunteers (controls). Polymerase chain reaction-based genotyping of a 44 base pair insertion/deletion polymorphism in 5-HTTLPR was performed in 138 cocaine-dependent African-American subjects and 60 African-American controls. This yielded a short (S) and a long (L) allele. Platelet 5-HTT sites were measured using the tritiated paroxetine binding assay. Relationships of 5-HTTLPR genotypes with Bmax (density of serotonin transporter) and Kd (affinity constant) were examined. Bmax values were significantly lower in cocaine-dependent patients (640±233) than controls (906±225) (P<0.001); however, 5-HTTLPR genotype distributions or allele frequencies did not differ between the two groups. There were no significant differences in Bmax between the three genotypes among cocaine-dependent patients (LL=690±246, LS=620±235, SS=587±183; P=0.14) or controls (LL=909±233, LS=938±279, SS=866±143; P=0.65). All three genotypes in cocaine-dependent patients showed comparable reductions in Bmax from the corresponding genotypes in controls. Demographic variables, severity of substance use or depression were unrelated to Bmax or 5-HTTLPR genotypes. Although platelet 5-HTT densities are reduced in patients with cocaine dependence compared with healthy volunteers, these genotypic variations in the serotonin transporter do not seem to influence levels of platelet 5-HTT in cocaine-dependent patients or healthy volunteers.

Patient Treatment Choice and Compliance: Data from a Substance Abuse Treatment Program

The authors tested the hypothesis that patients (treatment-seeking cocaine-dependent persons) given the opportunity to choose between treatment approaches would do better than patients randomly assigned to the same approaches in treatment retention and 9-month outcome. Subjects were 34 patients who voluntarily chose to enter individual therapy 1 hour per week (IND) and 33 who chose intensive group therapy for 3 hours, 3 times weekly (INT). There were no significant differences between these two groups on demographic, personality, or addiction severity variables or in treatment retention or 9-month outcome. Comparison with samples of 30 patients who had been randomly assigned to IND and 30 to INT did not confirm the hypothesis that patients who chose their treatment would either remain in treatment for longer periods of time or manifest improved 9-month outcomes. The authors raise several motivational issues.