Fetal exposure to alcohol is the leading cause of preventable mental retardation. The prevalence of fetal alcohol syndrome (FAS) and alcohol-related birth defects (ARBD) is estimated to be 1% of all births. Despite efforts to educate the public about FAS, prenatal alcohol exposure continues to pose a serious public health problem. Many of the women at highest risk for giving birth to affected infants fail to heed public service warnings about alcohol use during pregnancy. Although FAS and related conditions are not considered to be common, addiction specialists are among those most able to make a positive impact on this problem.

Identifying women who drink during pregnancy is a challenge, and recognizing their impaired children is difficult. However, prenatal effects of alcohol inflict a lifetime of suffering on patients and families who must deal with a myriad of emotional, behavioral, cognitive and social disabilities. Estimates of the economic cost of FAS have been as high as $2.8 billion for 1998, with more than 90% accounted for by the costs of providing home and residential care to affected adults with mental retardation and special education costs for affected children and adolescents.

Recommendations include prevention programs (education, birth control options, alcohol abuse treatment); developing statewide diagnostic clinics for early diagnosis; funding further research; funding and implementing long-term residential and job training for patients with FAS and FAE; increasing clinician awareness and education; and developing parent and citizen education centers.

Methods: Medical records were searched for Hmong patients in methadone treatment between January 1995 and September 1997. Diagnosis, history, urine drug screens and Addiction Severity Index (ASI) scores were extracted. Patients’ progress was assessed over 9 months.

Results: Forty-four Hmong patients were found. Data were available on 40 patients, mean age 47.7 years, 33 men/7 women, 93% married, 27% employed. Mean age of initial opium use was 22.3 years, mean years of opium use was 16, mean opium pipes smoked/day was 105. At admission, 100% met the DSM-IV criteria for opium dependence, 75% major depressive disorder, 68% PTSD. Average urine samples were 27/patient over 9 months with only four of 27 positive for opiates, mostly in the first 3 months. The ASI composite score improved from 3.9 at admission to 2.1 at 9 months (p<.01) with subscales of employment/support status changing from 4.4 to 1.5 (p<.01), drug use from 8.9 to 4.6 (p<.01), family/social relationships from 4.5 to 1.7 (p<.01) and psychiatric status from 6.2 to 4.5 (p<.01). Using outcome criteria modified from the Drug Abuse Research Project, 70% were highly successful, 15% moderately successful, 5% moderately unsuccessful and 10% highly unsuccessful.

Conclusions: These findings suggest that Hmong opium-dependent patients can show marked improvement while in methadone treatment. Limitations of this study include small sample size and lack of comparison group. Controlled studies are needed over longer periods of time.

Methods: Subjects consisted of 50 patients engaged in an outpatient dual diagnosis treatment program. The Twelve-Step Attitudes Questionnaire (TSAQ) was used to assess attitudes toward traditional 12-step meetings and DTR meetings for all patients who had attended at least one such meeting.

Results: Paired t tests showed that the TSAQ full-scale score was higher for DTR (t=2.43, df=26, p=.022), indicating more positive attitudes, while Factor 2 (difficulties specifically related to mental illness) was significantly lower for DTR (t=–2.95, df=26, p=.007). There was only a small, insignificant difference between scores for Factor 1 (general comfort with group participation and the 12-step model).

Conclusions: The results suggest that dual diagnosis patients who have attended both DTR and traditional 12-step programs find that mental illness causes fewer problems with their participation in DTR, thus validating the expectation that such specialized programs present fewer barriers to the dually diagnosed.

Methods: A retrospective chart review was performed at a private freestanding psychiatric facility that is strongly affiliated with the University of Kentucky Department of Psychiatry. This facility serves individuals in the central and eastern part of Kentucky. The reviewed charts included those with a discharge diagnosis of opioid dependence or polysubstance dependence during the period October 2000 through December 2001.

Results: One hundred sixty-two cases of OxyContin dependence were identified in 117 men and 45 women; 150 of these were from rural areas. In contrast, there were 96 cases of opioid dependence that did not include OxyContin with 52 men and 44 women being identified; 73 of these were from rural areas. The mean duration of use of OxyContin prior to admission to the hospital was 19.7 months. The mean age of OxyContin users was 30.9 with a mean of the other opioid users being 38.1. The mean dose of OxyContin used was 181 mg/day with the majority using intranasally. Although 48 of 162 were using by prescription, 160 (99%) were buying off the street. Fifty-six percent of the OxyContin-dependent individuals had a co-morbid chemical dependence diagnosis with the majority being sedative hypnotic users. In addition, 29.6% of the OxyContin users had a co-morbid psychiatric diagnosis with almost half of those having a depressive disorder.

Conclusions: Abuse of OxyContin has become an increasingly severe problem, particularly in rural Appalachian areas, resulting in numerous overdoses and deaths and an increase in hospitalization of opioid-dependent individuals.

Methods: Bivariate and multivariate analysis of mental health and substance abuse service use in the homeless was performed using data compiled by the U.S. Census Bureau.

Results: We found that African American and Latino homeless were less likely to use mental health and alcohol abuse services than Caucasian homeless. Clinical need (i.e., symptoms of mental illness and significant substance abuse history) and insurance predicted higher probability of service use. "Literal homelessness" predicted a lower probability of use.

Conclusions: Our findings suggest racial and ethnic disparities in the use of treatment services that may need to be addressed to improve mental health and substance abuse services for the homeless.

The current consensus agrees that gambling has a negative effect on health. This consensus was built on observations that gambling increases negative stress (distress). Because distress is a risk factor of health, gambling is bad for health. The phenomena of the positive stress feeling (eustress) that is created by electronic gambling for fun, e.g., not for money, led biofeedback experts to design new biofeedback casino games. The player can control these games by his eustress, e.g., he can collect virtual points only when he generates more eustress. But, the cost of the equipment and the therapist limits the power of the observations that can be collected on this phenomenon.

My assumption was that a simple apparatus of biofeedback gambling that can be used in the natural environment would help to collect new data about "eustress-dependent gambling." The purpose of this study was to define and to build such a new apparatus. We built the new apparatus under the concept of biofeedback on a cellular phone.

This new apparatus provides a new technical base allowing a new inductive definition of the influences of gambling on health, especially for investigating possible positive benefits of gambling on health. These findings could change the current consensus in the field.

Methods: A retrospective chart review was performed of 48 patients (mean age 71 years, range 64-83 years) referred to a psychiatrist due to an inability to stop smoking. All patients underwent a standard psychiatric evaluation and were offered therapy for smoking cessation. An individual treatment plan utilizing behavioral interventions, nicotine replacement and non-nicotine therapies was provided. Additional treatment was provided for those patients who met criteria for other psychiatric disorders.

Results: Of the 48 patients, 37 (77%) were no longer smoking 1 year after initial contact. Six (13%) did not return after initial evaluation. Characteristics associated with successful smoking cessation included male gender, marriage or relationship with a non-smoking partner, the presence of a social network and acceptance of treatment for co-morbid depression or anxiety disorders. The prevalence of a mood or anxiety disorder was high (45%) and appeared to be a significant factor in prior failed quit attempts. Treatment with antidepressants, and in some cases stimulants, proved to be quite successful.

Conclusions: Smoking cessation in the older adult is associated with multiple psychosocial, medical and psychiatric factors. Successful smoking cessation requires attention to the use of social supports and treatment of co-morbid psychiatric disorders.

About two thirds of patients in abstinence-oriented programs engage in some drinking during their first year of recovery. Recognizing relapse early may indicate need to redirect treatment efforts before further harm is done or the drinking pattern becomes less tractable. Biomarkers (especially carbohydrate-deficient transferrin [CDT]) often elevate well before self-acknowledgement of drinking. Use of biomarkers as a basis for patient feedback may also reinforce treatment progress.

Since 1996, 10 studies have been published on CDT as a marker of relapse. Several also considered GGT (gamma glutamyl transferase). All but one of the projects has yielded positive results. Using the tests in combination substantially raised sensitivity beyond that of either marker alone and had little adverse effect on specificity.

Future studies are needed on biomarker combinations. To date, studies have combined markers only according to the "simple binary inclusion rule" (i.e., results are labeled as positive if either marker is above cutoff). Other algorithms for combining results should also be evaluated. Combinations using newer markers (e.g., beta-hexosaminidase and acetaldehyde adducts) should also be researched. Use of covariates, especially gender, age, smoking status and BMI, should be considered to enhance validity of biomarker combinations. Investigations are needed to determine optimal ways of scoring biomarkers for identifying relapse (e.g., within-subject change vs. contrast with screening cutoff or some other value).

Methods: Participants were 10 alcohol-dependent young women ages 18-25 who were free from independent psychiatric disorders and 15 demographically-similar controls without substance use or psychiatric disorder. Participants were given the Beck Depression Inventory (BDI) and the Spielberger State Trait Anxiety Inventory (STAI). Subjects were administered a spatial working memory task while functional magnetic resonance imaging (fMRI) data were collected.

Results: There were no significant differences between groups on BDI or STAI scores. BDI scores were in the normal to mild depressed mood range, and all STAI scores were within the normal range. As reported previously, alcohol-dependent young women showed less BOLD response (p<.025) in bilateral frontal and right parietal regions. However, there was no relationship between BDI or STAI scores with BOLD response patterns in either group.

Conclusions: Alcohol use is associated with abnormal brain response to working memory tasks. However, among young alcohol-dependent women without an independent psychiatric disorder, variability in mood state does not appear to account for these brain abnormalities.

Methods: Research volunteers to a medication trial for pathological gambling were recruited through newspaper advertisements. Informed consent was given before any information was obtained. Demographic information, such as age, gender and the presence of psychiatric co-morbidity, was collected. In addition, the most preferred form of gambling, attendance rates to Gamblers Anonymous (GA) and acknowledgment of illness (insight) were recorded. Finally, research volunteers were asked to state the "most important reason they are interested in participating in research" and "what are your expectations of the research protocol?" Answers were recorded and categorized according to similar patterns of response.

Results: Forty consecutive research volunteers were assessed. The majority (35 of 40, or 88%) were men with an average age of 41.25 (SD ± 9.5). Almost 95% (38 of 40) of the volunteers admitted to having a problem with gambling. Despite this, nearly 90% (36 of 40) were not currently attending Gamblers Anonymous. Forms of preferred gambling included card games (13 of 46, or 28%), casino table games (10 of 46, or 22%), horse racing (8 of 46, or 17%), lottery (5 of 46, or 11%), sports betting (4 of 46, or 9%), bingo (3 of 46, or 7%) and slots (2 of 46, or 4%).

In terms of why people chose to participate in research, 30 of 40 (75%) stated that the main reason for enrolling was to "reduce or stop gambling completely." Other reasons: 5 of 40 (13%) were "curious about gambling research," 4 of 40 (13%) were motivated by the financial incentives and 1 of 40 (3%) was motivated by altruism. In terms of expectations, 25 of 40 (63%) research volunteers expected the study medication to completely stop or reduce gambling behaviors, while 10 of 40 (25%) were skeptical that medications would work but were hopeful that it could, and 5 of 40 (13%) stated that they did think medications would work.

Conclusions: This descriptive study demonstrates that the therapeutic misconception is quite prevalent among these research volunteers. Possible reasons include being unaware of treatment options, desperately wanting treatment and psychological traits that predispose volunteers to being willing to try experimental medications. Further investigation is necessary to determine how large of an influence the therapeutic misconception may have on research outcome measures, such as medication response rates, protocol retention or placebo rates.

Methods: Six months of psychiatric emergency room records were reviewed, with demographic data being collected from all dually-diagnosed patients. Two weeks after discharge from the psychiatric emergency room, attempts were made to contact each dually-diagnosed patient and ascertain whether or not follow-up care was obtained.

Results: In this study, 1,276 dually-diagnosed patients were seen in the psychiatric emergency room, and 446 dually-diagnosed patients were contacted. Female patients were more likely to be contacted after discharge as compared to the entire dual diagnosis group. Sixty-nine percent of all discharged dual diagnosis patients did not attend any aftercare treatment. Patients who were referred to mental health services were more likely to attend than patients who were referred to substance abuse treatment (44% vs. 16%, respectively). Of the patients who did attend follow-up care (mental health services or substance abuse treatment), there were no significant differences in ethnicity or gender.

Conclusions: There is a high level of noncompliance to outpatient treatment among dual diagnosis patients, especially for substance abuse treatment. Gender appears to play a factor in locating discharged patients but not in terms of predicting who will follow-up. These results support the need for more innovative interventions to engage dual diagnosis patients into treatment.

Methods: Nineteen subjects with schizophrenia or schizoaffective disorder and alcohol dependence or abuse entered an 8-week open pilot trial of directly observed naltrexone treatment. Measures included Timeline Followback self-reports of alcohol use, the biomarkers GGT and CDT, and the PANSS. At baseline, the mean drinking days/week was 2.0 (±2.3) and mean number of drinks/week was 17.4 (±27.3). PANSS mean positive, negative and general psychopathology scores were 18.8 (±5.7), 14.5 (±3.2) and 37.2 (±6.8), respectively. Eight subjects were receiving atypical antipsychotics, and 11 were receiving typical antipsychotics (or a combination of typical and atypical).

Results: At baseline, there were no significant correlations between PANSS and level of alcohol use. Regarding the type of antipsychotic received, there was also no significant baseline correlation with alcohol use. However, a statistical trend emerged indicating a greater reduction in drinking associated with atypical antipsychotic medications. For subjects receiving atypicals, the median change in number of drinks per week was –3.5 versus only –0.3 in subjects receiving typicals or a combination (p=0.099).

Conclusions: The type of antipsychotic medication may influence the response to naltrexone treatment in individuals with schizophrenia in that atypical antipsychotics may be associated with greater reduction in drinking. The small sample size is a major limitation of this analysis. Further work with a larger number of subjects is required to better address this question.

Methods: By collecting the identification data from three hospitals and Tao-Yuan prison, we can get the size of help-seeking and arrested male addicts. After comparing the identification data from these two parts, we can get the conjunct size of these two. By the way of capture and recapture, the size of undetected addicts was estimated. To sum up the detected and undetected size, the estimated population and prevalence of male addicts was therefore made.

Results: The estimation of undetected size during 1999 in Tao-Yuan is about 15,000, and the prevalence rate is about 3.10% (95%CI=2.67–3.54%) for ages between 15 and 54 years old.

Conclusions: This research indicated that the prevalence rate of heroin or amphetamine abuse in Tao-Yuan County is not less than 3.10%. This rate is correspondent with active survey in Taiwan. The method of capture-recapture seems valuable on indirect estimation of sensitive illness.

Methods: We will eventually be interviewing 20 patients treated at the Inpatient Addictions Program at the Mayo Clinic. These patients will all have documented nicotine and alcohol dependence. All of these patients will have been treated with monitored disulfiram for their alcohol dependence to ensure compliance. We will then interview each patient and ascertain their pre-disulfiram tobacco use and their tobacco use while on disulfiram after 12 weeks. Inclusion criteria will be any patient over the age of 17 who has documented alcohol and nicotine dependence as noted by the staff physician on the Inpatient Addiction Program at the Mayo Clinic and meets the DSM-IV criteria for those diagnoses. Exclusion criteria include the presence of organic mental disorders, psychotic mental disorders, mental retardation or developmental disabilities. Exclusion criteria will also include any patient who is using another method to treat his or her nicotine dependence, including nicotine patches, nicotine gum, nicotine inhalers or buproprion.

Results: Results are not yet available as this study is still in the preliminary stages.

Conclusions: We hope to see if there is or is not a reason for employing disulfiram as a possible treatment for nicotine dependence. If there is an increase in nicotine use, then the theory of cross-addiction can be further studied. If there is a net decrease in the amount of nicotine used, then do psychological factors alone or in combination with disulfiram play a role? This could be the work of a further prospective study.

Methods: A Medline search for pertinent articles, reports from the Bureau of Justice Statistics, Department of Justice, etc., as well as reports from organizations such as GAINS were reviewed.

Conclusions: Several studies and reports conclude that there is an extremely high prevalence of substance abuse, mental illness and co-occurring disorders in the incarcerated population. The high number of incarcerated mentally ill and substance abusers is largely due to both intentional and unintentional criminalization of these populations. Inconsistent, and arguably inadequate, treatment opportunities currently exist for incarcerated individuals with co-occurring psychiatric and substance use disorders. There is a vast need for further research. Areas requiring further study include substance abuse/dependence and co-occurring disorders in "special" incarcerated populations, such as juveniles, women and minorities; more detailed epidemiology to better construct and evaluate treatment programs for incarcerated individuals with co-occurring psychiatric disorders; and empirical data to help evaluate the impact of jail diversion and drug courts on outcomes in offenders with psychiatric disorders.

Methods: Eight healthy, non-drug-abusing volunteers were trained to discriminate between d-amphetamine (15 mg) and placebo. After acquiring this discrimination, a range of doses of d-amphetamine (0, 2.5, 5, 10 and 15 mg) was tested alone and following pretreatment with risperidone (0 or 1 mg).

Results: d-Amphetamine functioned as a discriminative-stimulus and produced prototypical stimulant-like, subject-rated and physiological effects. Risperidone significantly attenuated the discriminative-stimulus effects of d-amphetamine and some, but not all, of the subject-rated effects.

Conclusions: Risperidone attenuates the discriminative-stimulus effects of d-amphetamine, which suggests that the drug-discrimination paradigm may be well suited for studies investigating the neuropharmacological effects of stimulants in humans. Further, risperidone may have some utility as a pharmacotherapy for amphetamine abuse.

Methods: A retrospective study of 11 treatment episodes for 10 patients treated in the addiction treatment inpatient unit at the Wade Park VAMC from November 2001 to August 2002 was done. Patients were given a 5-day tramadol taper with adjuvant doses of buprenorphine given if patients had a CINA >6. Pharmacological data were reviewed as well as withdrawal symptoms.

Results: The average length of stay was 4.9 days with four patients leaving against medical advice. Additionally, although all patients received some PRN medications for withdrawal symptoms, five patients had a CINA >6 requiring adjuvant treatment with buprenorphine.

Conclusions: Tramadol was used to manage withdrawal in veterans who had dependence to a variety of opioids as well as other substances. Tramadol was generally well tolerated by most veterans, with fewer than half of the veterans requiring adjuvant treatment with buprenorphine for severe withdrawal symptoms during any part of their treatment.

Methods: The program is a 170-bed voluntary post-detoxification residential facility for men. Two hundred ninety-five patients admitted to an inpatient substance abuse program over the past 4 years were referred to the authors for psychiatric evaluation and treatment. Of the 295 patients, 85 met DSM-IV criteria for bipolar disorder. Subjects of the present study are the 36 patients who were treated with risperidone in an open-label, nonblinded, naturalistic trial. At the time of diagnosis, patients had on average 51 days of abstinence (SD=45). Substance use and nonsubstance use diagnoses were made using criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4^th Edition. All patients were assessed weekly using the Clinical Global Impressions Scale (CGI). Side effects were recorded, and patients were asked about use of alcohol and drugs. Laboratory studies, usually complete blood count and liver function tests (LFT), were ordered if clinically indicated.

Results: Eighty-five percent of patients exhibited improvement or significant improvement. Substances of abuse were alcohol, cocaine and opioids. Co-morbid psychiatric diagnoses were PTSD, ADHD and panic disorder. Risperidone was safely combined with other psychiatric medications in 72% of cases. Six patients complained of mild side effects. Treatment did not have to be discontinued in any patient because of side effects or adverse effects. Improvement was associated with older age, higher risperidone dose and combining risperidone with other medications.

Conclusions: As we previously reported in a small study, this report suggests that risperidone is efficacious and safe, both alone and in combination with other psychiatric medications, in treating substance-abusing patients with bipolar disorder. Comparisons between patients with bipolar disorder only and bipolar disorder with a co-morbid Axis-I diagnosis revealed no differences in terms of dose of risperidone, outcome or length of follow-up. No differences based on the substance of choice were observed. The results suggest that the number of substances used did not influence outcome and length of follow-up. Patients who were treated more aggressively stayed in treatment longer. Patients on a medication combination and higher doses of risperidone were followed longer. Finally, significant correlations were observed between dose of risperidone and better outcome; although doses were in the small to moderate range, better outcomes were achieved with doses that were relatively higher within this range.

Methods: The division psychiatrist as part of quality assurance reviewed 839 charts. The division was located on the southern side of the demilitarized zone separating North Korea and South Korea. There were approximately 15,000 soldiers and civilians in the Second Infantry Division area of operation. The soldiers were mostly men because the division was heavy in combat arms.

Results: The more common diagnostic problems were dissatisfaction with military life as manifested by occupational problems (V62.2) and adjustment disorders, along with alcohol use disorders. Often, the alcohol problems started while in the military and often would start in Korea because the drinking age was only 19 years. In addition, alcohol was readily available and cheap on the Korean economy.

Methods: Demographic information, drug history and outcome measures were gathered by chart review and were evaluated for comparison.

Results: Forty-six physicians were evaluated, 35 (76.1%) of whom were monitored for a substance use disorder. Of those 35, 91.4% returned to work. The majority had alcohol (34.3%), opiates (34.3%) or both (17.1%) as their primary substance. Compared to those returning to work, those who did not return to work all used opiates, were represented by more anesthesiologists, used more by IV, had more significant medical problems related to using, had more psychiatric co-morbidity and had shorter length of addiction.

Conclusions: Factors such as type of substance, route of administration, problems associated with use, co-morbid conditions and length of addiction may be prognostic of return to work.

Methods: All 31 files of dual male patients who fulfilled the DSM-IV diagnostic criteria of dependency to cocaine were analyzed from February 2001 to January 2002. The study design was retrospective and observational of patients with addictive disorder. Medical records of patients with addictive disorder to cocaine were retrospectively reviewed, to verify the usefulness of mirtazapine in diminishing the desire for cocaine in the acute (first 6 weeks) phase of treatment (abstinence). Patients were treated with mirtazapine for 6 weeks, while interned voluntarily in a therapeutic community, CRETA, in Mexico City. One patient was admitted to the study without craving symptoms and remained free of craving during the whole study period. The consumption desire was evaluated with an analog visual scale (AVS) of desire (not validated) used in this therapeutic community at the beginning and every week (during 6 weeks) of treatment. The result was measured on the basis of the desire scale (1-10). Responders were defined as improvement of at least 50% on the consumption desire scale, compared to baseline. The tolerability was measured by documentation of adverse events and dropout rate. The student t test was applied to analyze the results from the AVS of desire.

Results: Ninety-three percent of the patients can be classified as responders (50% or more improvement on AVS of desire) at week 4, and by week 6, 100% of patients are responders. Twenty-three percent of patients showed full response to treatment, meaning that these patients had at week 6 no desire to consume cocaine at all. The initial score on the AVS of desire decreased from 7.4 at baseline to only 1.3 after 6 weeks of treatment with mirtazapine. The reduction on the desire scale starts at week 2 and persists up to week 6. The average dose of mirtazapine was in the course of 6 weeks of treatment 18.3 mg/day: 15 mg was the minimum dose and 30 mg was the maximum. Fifty-one percent of the patients received carbamazepine at the beginning of the study and from the second week on, only 16% of the patients continued until the end of the study. The only adverse event found was sedation in 67% of the patients and persisted until the end of the study in 54% of the patients. No patients were withdrawn from the study due to side effects.

Conclusions: Mirtazapine seems to be a good therapeutic resource to help in the treatment of cocaine-addicted patients. This study has shown that mirtazapine can be effective in reducing craving in this type of patient.

Methods: In this double-blind, placebo-controlled study, 52 patients with DSM-IV/SCID co-morbid diagnoses of bipolar I disorder and alcohol dependence were randomized to two treatment groups: valproate plus treatment as usual (TAU) (TAU included lithium carbonate and psychosocial treatment) versus placebo plus TAU. Subjects were examined every 2 weeks for a 24-week period using the Timeline Followback for Recent Drinking, the Hamilton Rating Scale for Depression-17, the Beck-Rafaelson Mania Scale and a four-item self-report craving scale for alcohol. The Mixed Model with restricted maximum likelihood procedure and unrestricted covariance matrix was used to analyze longitudinal data.

Results: The results revealed that the valproate group had a lower proportion of heavy drinking days than the placebo group. Although the valproate group also had a lower proportion of any drinking days, this did not reach statistical significance. Also, manic and depressive symptoms improved in both groups. No statistical difference was found between the two groups on either manic or depressive symptoms.

Conclusion: Valproate appears to be effective in decreasing heavy alcohol use among bipolar alcoholics. The effects of valproate on heavy alcohol use are not clearly linked to its effects on mood symptoms. To our knowledge, this is the first clinical trial ever completed in this population.

Methods: Early treatment response (90 days) is compared across two studies: one using methadone (N=127) and one using LAAM (N=158). In both studies, new admissions were randomized to one of two conditions. In the Motivated Stepped Care conditions (Methadone MSC n=65, LAAM MSC n=80), uninterrupted treatment was ultimately contingent upon counseling attendance and producing brief periods of abstinence. In Standard Stepped Care conditions (Methadone SSC n=62, LAAM SSC n=78), treatment was not contingent on attendance or drug use. All participants were advanced to more intensive weekly counseling schedules in response to missed sessions or continuing drug use (stepped care approach).

Results: Independent of the study condition, methadone was associated with better early retention than LAAM (95% vs. 68% at 90 days). The MSC intervention had a negative effect on retention with LAAM; no effects were observed for methadone. Methadone was also associated with better counseling attendance and showed a condition effect in the expected direction (Methadone: MSC 83% vs. SSC 44%). MSC plus LAAM had no effect on counseling (LAAM: MSC 48% vs. SSC 44%). Rates of drug use were low across conditions and medications, but within subject comparisons in the study with methadone showed large reductions in drug use pre-post exposure to the MSC condition.

Conclusions: The MSC approach was associated with better rates of early treatment participation and response in participants receiving methadone but not LAAM, and independent of counseling condition (MSC vs. SSC), early treatment response was better in new admissions receiving methadone than LAAM.

Methods: This pilot project examines five consecutive cases of dextromethorphan use and abuse at the Mayo Clinic Child and Adolescent Psychiatry inpatient unit over a 1½-year period. As such, it represents a more severely ill population of adolescents. During inpatient hospitalization, all patients received laboratory evaluation, psychological testing, MRI and psychopharmacological treatment. A literature review indicates that dextromethorphan metabolites may mimic the action of PCP at the glutamatergic NMDA receptor. Further, cytochrome CYP2D6.1 and CYP3A polymorphisms may influence the rate of drug metabolism. The authors offer potential relationships between these factors and the emergence of protracted psychotic illness with co-morbidity.

Results: Four of the five cases demonstrate protracted symptoms of psychosis requiring ongoing antipsychotic medication treatment. Psychological testing supported diagnostic conclusion of paranoid psychosis with disordered thinking.

Conclusions: We present a case series of patients with psychotic illness, the onset of which is chronologically associated with the inappropriate use of dextromethorphan. We speculate that the use of high-dose dextromethorphan plays a critical function in the development of protracted psychosis in the subset of patients who have abused this drug.

Methods: We present three cases where an anticonvulsant agent was added to a standard therapy for severe alcohol or sedative-hypnotic withdrawal. In each of these three cases, extremely high doses of benzodiazepines (>100 mg of lorazepam or its equivalent/24 hrs) were required and either valproic acid or gabapentin was used adjunctively. In one of three cases, pre-existing therapeutic levels of valproic acid (for co-morbid bipolar disorder) had no observable attenuating effect on the severity of the withdrawal.

Results: The adjunctive use of anticonvulsant agents in the treatment of severe alcohol or sedative-hypnotic withdrawal states can help rapidly stabilize a patient’s clinical status and can reduce the time required to taper the primary agent being used to treat the withdrawal state. An important clinical observation is that patients who are maintained on anticonvulsant agents may develop a tolerance to their ability to treat withdrawal states.

Conclusions: Clinicians treating patients with anticonvulsants for other purposes must be aware that these agents do not seem to impart any protective effect from the alcohol/sedative-hypnotic withdrawal syndrome.

Methods: A retrospective study of 786 patients enrolled in the program in 1996 and 1997. Patients filled out a questionnaire at the time of registration. Data included drug use history (age at first use), behavior (frequency, type) and drug treatment history. The dependent variable, attendance, was assigned two values, high or low, based on whether or not the patient made on average a minimum of one visit to the program site every 2 weeks over the course of enrollment. Statistical analysis of Tracking Point, the DCNEP database, was performed using SAS program. Logistic regression was used to examine the effect of the multiple variables mentioned above on DCNEP attendance while adjusting for potential confounders (demographic variables).

Results: Individuals who reported a history of attending a drug treatment program prior to enrolling in the DCNEP showed a higher probability to be regular attendees to the program site than their counterparts who did not (CI: 1.082-1.928, p=0.012). Male members were more likely to attend than female members even after adjusting for prior drug treatment history (CI: 1.141-2.364, p=0.007).

Conclusions: Male gender and a history of enrollment in a drug treatment program may be associated with needle exchange program attendance. Further research is needed to better delineate the relationship between these two programs and to explore the reasons behind gender participation differences.

Methods: Baseline characteristics of 499 subjects enrolled in the TASC trial were analyzed to identify characteristics associated with readiness to stop smoking. Readiness to quit was assessed to two self-rated measures: being in the preparation/action stages of change and scoring at least 8 on the contemplation ladder. The analysis examined predictions of patients’ intention to quit smoking in the next month and contemplation ladder ratings by demographic characteristics, cigarette smoking behavior, history of substance use disorders and depression.

Results: Participants in the preparation/action stages of change experienced significantly lower rates of current (p=0.011) and past (p=0.014) major depressive disorder and displayed significantly less current depressive symptoms (p=0.008). Patients with contemplation ladder ratings between 8 and 10 also displayed significantly less current depressive symptoms on the BDI (p=0.022). Logistic regression models confirmed that depression was negatively associated with intention to quit, but different models suggested that increasing age, shorter duration of smoking history, race other than white and a greater number of past quit attempts were positively associated with readiness to quit.

Conclusions: Among smokers in intensive treatment for alcohol use disorders, a history of depressive disorder and depressive symptoms predict less interest in quitting smoking.

In recent years, the importance of understanding the variability of how drugs are metabolized has become widely recognized. Some polymorphisms associated with increased or decreased metabolic activity of the P450 hepatic enzyme system have been identified. With the development of microarray technology, it is now possible to screen patients for many of these polymorphisms.

Clinicians who use the Aldehyde Dehydrogenase (ALDH) inhibitor disulfiram as a deterrent to alcohol consumption have long noted that a subset of disulfiram-compliant alcoholics are able to consume alcohol without experiencing evident symptoms or acetaldehyde toxicity. These individuals may represent a population of alcoholics at particularly high risk for relapse and/or morbidity associated with alcohol use. Understanding the etiology of this phenomenon may provide the basis for prospective identification of these individuals and allow for more timely, effective treatment interventions.

Active metabolites of disulfiram include diethylthiomethylcarbamate (ME-DTC) and its sulfoxide and sulfone metabolites formed through oxidative biotransformation from phase II intermediates. ME-DTC may act preferentially for ALDH-1; the latter two metabolites exert inhibitory effects on both ALDH-1 and ALDH-2. A close relationship has been reported between increased oxidative formation of ME-DTC, acetaldehyde levels and the level of expression of the alcohol-disulfiram reaction. While severe alcohol-related hepatocellular damage has been associated with decreased inactivation of ALDH due to a decrease in the oxidative P450 catalyzed formation of ME-DTC and its metabolites, other potential causes have not been explored, including differences in functional expression of enzymes responsible for the oxidative formation of ME-DTC and its metabolites.

The overall aim of this small pilot study is to use microarray analysis to determine potential variations in P450 polymorphisms associated with the variable response to disulfiram presumably based on differences in metabolic rate. A review of the pharmacokinetics and pharmacodynamics of disulfiram and its metabolites as well as preliminary data from this study will be presented.

It is estimated that 15 patients will be in the study group and 15 patients in the control group.

Methods: Substance-abusing adolescents entering residential treatment (n=153) were recruited for this study. All subjects were administered the GAIN and the BDI at intake. The mental health indices in the GAIN include the general mental health distress index (GMDI) and the depression symptom index (DSI). BDI scores of 16 or more and GMDI sores of 7 or more were used as cutoffs for clinically-significant depression/distress. A proportion of this sample (68%) was evaluated and diagnosed by psychiatrists. Correlation and chi-square analyses were performed to analyze the data.

Results: BDI scores and GMDI scores correlated significantly (r=0.482, p=0.00). Similarly, BDI scores and DSI scores correlated significantly (r=0.445, p=0.00). Using GMDI and BDI cutoffs, 86% of those who scored 7 or more on the GMDI and 91% of those who scored 16 or more on the BDI were given a major psychiatric diagnosis by psychiatrists.

Conclusions: These data suggest that the GMDI and DSI are valid measures of depression given their significant correlations with the BDI. The mental health indices in the GAIN may also serve as effective screening tools in detecting major psychiatric disorders such as depression among substance abusing adolescents, particularly those who score 7 or more on the GMDI.

Methods: A total of 13 normal adult males participated in this study. They did not have any previous histories of psychiatric and medical disorders. We defined the experimentally induced hangover state at 13 hours after drinking a high dose of alcohol (1.5 g/kg of body weight). Venous blood samples were taken before alcohol drinking and during the experimentally induced hangover state. Monocytes were separated and stimulated with phytohemagglutinin; ELISA was used to measure the production of the cytokines IL-1b , IL-2, IL-4, IL-6, IL-10, IL-12, INF-gamma and TNF-alpha.

Results: The production of the cytokines IL-10, IL-12 and INF-gamma were increased during the hangover state.

Conclusions: There were changes in the production of the cytokines IL-10, IL-12 and INF-gamma during the hangover state. Thus, our results support the hypothesis that acute alcohol treatment might affect the Th1/Th2 immune balance by altering the production of IL-12 and IL-10 by monocytes. They suggest that the elevated level of monocyte-derived IL-10 contributes to cellular immune abnormalities during hangover state.

Methods: Subjects (N=14) participated in a 6-week double-blind, randomized clinical trial of gabapentin vs. placebo for treating alcohol-associated insomnia. All subjects met SCID-determined DSM-IV criteria for alcohol dependence and had insomnia not due to other sleep disorders, medical/psychiatric problems or medication. Insomnia persisted despite at least 1 week of abstinence in the absence of acute withdrawal (CIWA < 8). We had not broken the study blind as of August 2002, but the course of insomnia and drinking for the entire group was examined.

Results: Subjects were seven men and seven women with a mean (SD) age of 41.7 (12.9) years, including 11 whites, two blacks and one Hispanic. At baseline, subjects had a mean Sleep Problems Score of 13.1 (5.5) and drank a mean of 5.4 (3.6) drinks/day on 70% of days during a 6-week pretrial period. Nine (64.3%) of 14 patients completed the 6-week trial. For completers, the Sleep Problems Score improved significantly (p=0.048) over the 6 weeks, as did the percentage of drinking days (p=0.001). However, 89% had at least one drink, and 56% had at least one heavy drinking day. Change scores for sleep did not correlate with change scores for percentage of drinking days (p=0.23) or drinks/day (p=0.21).

Conclusions: The study confirms high relapse rates in outpatient alcoholics selected for insomnia, but failed to find that improved sleep correlated with reduced drinking.

Methods: A chart review of 30 patients from a residential program who were admitted during the first 3 months of 2002 was conducted. Nine patients were identified who did not have psychotic or bipolar symptoms and were treated with quetiapine for severe anxiety. Patients were evaluated during the 28-day residential program and for 3 months post-discharge. On admission, patients were evaluated with the Hamilton Depression (HAM-D) Rating Scale and a 10-point Likert scale (an attitudinal assessment scale) to assess cravings for the drug of choice. Both evaluations were repeated during follow-up sessions and at discharge. All nine patients had high HAM-D and Likert scale scores on admission that remained high after treatment with the above-mentioned medications. During treatment, all nine patients desired to leave treatment prematurely because of their incapacitating anxiety, which prevented them from tolerating individual, group or family therapy. Quetiapine was considered for adjunctive therapy after patients expressed a desire to leave treatment.

Results: Change in HAM-D scores at 2-week follow-up and discharge varied, from a decrease of 29 points to an increase of two points for one nonresponder. Mean decrease in HAM-D for the responders was 17.6 (p<0.05). The Likert 10-point craving scale score decreased by as much as eight points, with one nonresponder reporting an increase of one point (p<0.05). The mean decrease in Likert score was 5.8 for the responders. All eight responders completed the 28-day residential program and were discharged to structured living or outpatient programs. They continued to take quetiapine and achieved sobriety for more than 3 months.

Conclusions: Results of this report suggest that treatment with quetiapine may be beneficial in the treatment of substance dependence disorders. It is not known if these benefits are due to improvement of anxiety or a decrease in craving that is independent of the anxiety. It is not known if quetiapine has similar benefits in substance abusers in the absence of anxiety disorders. Further investigation is needed before quetiapine becomes an established treatment for substance dependence disorders. For a select group of patients, however, quetiapine may offer some advantages in preventing relapse of substance dependence disorders.

Methods: A descriptive study of 107 IV drug users who were recruited from a total of 391 inpatient drug addicts was done at Balikli Greek Foundation Hospital Psychiatry Clinics in Istanbul in 2000. All patients were diagnosed with heroin dependence according to DSM-IV criteria by two psychiatrists. Sociodemographic and clinical features were determined by a questionnaire. Serologic tests were assessed by microparticle enzyme immunoassay technique (Abbott). Frequency, chi-square and t test statistics were done on data.

Results: The study group contained eight women and 99 men. The mean age of the group was 28.9 years (SD=6.9); the mean length of time of IV heroin use was 1.9 years (SD=1.8). The rate of injector sharing was 48.6% (N=53). The distribution of serologic test results was as follows: HbsAg 2.8% (N=3), Anti-HBs 29.9% (N=32), Anti-HCV 44.9% (N=48), Anti-HIV I-II 4.7 (N=5).

Conclusions: The rate of seropositivity with HBV, HCV and HIV is found higher than the general population. Because viral hepatitis and HIV infections are growing health problems in Turkey, educational and preventive interventions should be planned especially for high-risk groups throughout the country.

Methods: A cross-sectional assessment of 100 inpatient substance users without co-morbid psychiatric disorders and 100 age-, gender- and education-matched healthy controls was done at Balikli Greek Foundation Hospital Psychiatry Clinics in Istanbul in 2000. Sociodemographic information, clinical features related to substance use, suicidal thoughts, intention and attempts were collected by an informative questionnaire formed by the investigators. Two psychiatrists conducted diagnostic interviews according to DSM-IV criteria, and a psychologist applied the Beck Depression Inventory and the Beck Hopelessness Scale to all participants.

Results: The patient group has significantly higher rates of suicidal ideation (x²=43.78, df=1, p<0.001), intention (x²=76.4, df=1, p<0.001) and higher frequency of suicide attempts (x²=22.58, df=1, p<0.001) than controls. Beck Depression Inventory and Beck Hopelessness Scale mean scores of the patient group are significantly higher than controls’ means.

Conclusions: As the participants have no co-morbid Axis I disorder, the presence of substance use disorder is accepted to be the main reason for suicidal features of the study group. These results indicate the necessity of a careful assessment of suicidal signs of substance users without Axis I co-morbidity.

Dialectic Behavioral Psychotherapy (Marsha M. Linehan, 1990) is a multimodal therapy concept of treating patients with a borderline personality disorder. In follow-up studies in the Archives of General Psychiatry, Marsha M. Linehan showed that using this model of group therapy leads to a reduction of self-injuring (parasuicidal gestures, drug and substance abuse, eating disorders) and internal stress as well as to an improvement in the quality of life.

At the Department of Psychiatry of the University Hospital in Graz, we developed a modified form of the DBT concept for the treatment of bulimic patients as bulimic women show feelings of inner tension, very similar to the feelings of tension arising in borderline patients, and a feeling of release as soon as they make the decision to vomit.

Eight female bulimic women (diagnosed according to DSM-IV criteria) attended a weekly skills training group for 1 year while they were also in individual therapy. Patients were assessed weekly using the Beck Depression Inventory (BDI), the State-Trait-Anxiety Inventory (STAI) and a specifically-developed daily protocol concerning binging/purging frequency, hunger attacks and used skills. Every 3 months, they were also examined using the "Fragebogen zum Essverhalten" (FEV), "Fragebogen zur Messung der Psychotherapiemotivation" (FMP) and the "Fragebogen zur Beurteilung des eigenen Körpers" (FbeK).

After 1 year of regular attendance of the skills training group, binging/purging behavior could be reduced by almost one-half through improved cognitive control. Depressive feelings decreased vastly (18 points in BDI to 6 points after 1 year), and therefore, all women gained quality of life.

Methods: The present pilot study represents a review of cognitive function data in a group of licensed professionals with substance use disorders. Patients were administered the MicroCog as part of a chemical dependency screening protocol. The sample included 56 physicians, 14 doctoral-level health care professionals and 26 attorneys. Standard scores for each of the seven MicroCog subtests and general cognitive proficiency and functioning scores were analyzed and compared with MicroCog norms for physicians.

Results: Z-test comparisons of professional groups with the normative sample did not reveal significant differences, although the information processing speed and reasoning/calculation subtests approached significance. In 47 of 56 (84%) MD profiles, two or more subtest scores fell one standard deviation or more below the mean (below the 16^th percentile) compared with normal MDs. This was true for 11 of 12 of the other health professionals and 17 of 26 (73%) attorneys. In 35 of 56 (61%) MD cases, 10 of 12 other health professionals and 13 of 26 (50%) attorneys, either general cognitive functioning or proficiency scores fell one or more standard deviations below the normal MD means.

Conclusions: These findings, while preliminary, raise important issues for physician, health professional and attorney health, substance use treatment in these populations and return to practice issues. Specific issues raised include effects of substance use on professional functioning prior to treatment; consideration of cognition in selection of treatment strategy; use of feedback on cognition to enhance treatment motivation and retention in treatment; use of repeat testing to monitor changes; explain slow progress and modify intervention strategies; and use of repeat testing to assist with readiness to return to practice.