2000 AAAP ANNUAL MEETING POSTERS
Poster 1: Alcohol and Substance Use as Risk Factors for Adolescent Incarceration
Westphal, James R, Louisiana State University Health Science Center, Shreveport, LA; Johnson, LJ
Objective: To determine substance-specific and severity of use risk factors for incarceration of juveniles in Louisiana. Methods: A substance use survey was administered to 343 jail and 1,293 prison offenders, ages 10-19, and compared to a stratified random sample of 11,736 students in public and private schools grades 6-12. Regression on incarceration status was per-formed with predictors suggested from previous studies reported in the literature. Results: Juveniles that were incarcerated used cocaine, inhalants, amphetamines, drank alcohol to intoxication and had a history of substance use disorder treatment at higher rates than did the school sample. However, the multi-variant analysis found that the use of cocaine, use of marijuana, smoking more than a pack per day, history of alcohol or drug treatment, and weekly or more frequent drinking of alcohol to intoxication, were the predictors of incarceration. The well-known risk factors of African-American ethnicity and male gender were also predictive. Conclusions: Indicators of substance dependence are predictive of juvenile justice involvement. Substance use disorder treatment should be considered as an integral component of the health care and rehabilitation of the juvenile offender.
Poster 2: Age of First Use of Substances as Predictor for Juvenile Incarceration
Johnson, Lera Joyce, Department of Psychology, Centenary College of Louisiana, Shreveport, LA; Westphal, JR
Objectives: To determine if age of first use of alcohol, tobacco and marijuana are predictive for juvenile incarceration in Louisiana. Methods: A substance use survey including questions about age of first use was administered to 343 jail and 1,293 prison offenders, ages 10-19, and compared to a random sample of 11,736 students in public and private schools grades 6-12. Results: Juveniles in the criminal justice sample showed significantly earlier ages of onset than did those in the community sample. Males in the community sample began to drink alcohol (10.9 vs 11.7 years), try tobacco products (11.2 vs 11.9 years) and smoke marijuana (12.8 vs 13.6 years) at significantly earlier ages than did females. Differences were not significant between males and females within the juvenile justice sample for ages when they began to drink (males 7.4, females 7.4 years), use tobacco products (males 7.7, females 7.5 years) or smoke marijuana (males 8.1, females 8.2 years). Conclusion: Early age of first substance use can be a robust predictor of juvenile justice involvement.
Poster 3: Abuse Potential of Modafinil (Provigil) when Compared with Oral Cocaine in a Sample of Stimulant Abusers
Wooten, Adam F, Department of Psychiatry, University of Kentucky, Lexington, KY; Hays, L; Rush,C
Objective: To study the abuse potential of modafinil by comparing the acute subject-rated effects of modafinil and oral cocaine in stimulant abusers. Methods: Nine human volunteers with recent histories of cocaine use received modafinil (200-600mg) and oral doses of cocaine (100-300mg). Drug effects were assessed before drug administration and periodically afterwards using a battery of subjective-effects questionnaires and performance measures. Results: Cocaine and modafinil dose-dependently increased blood pressure. Cocaine dose-dependently increased heart rate, though modafinil did not significantly. Subject ratings of "Willing to Take Again", "Feeling Stimulated" and "Liking the Drug" all increased with cocaine, though modafinil (even at doses of 600mg) showed little increase. Conclusion: Using oral cocaine as a reference, modafinil does not appear to have significant abuse potential, and may be indicated in other disorders currently treated with stimulants.
Poster 4: Risperidone in Substance Abusers with Bipolar Disorder
Albanese, Mark J, Tewksbury Hospital, Harvard Medical School, Tewksbury, MA; Khantzian, EJ; Clodfelter, R
Background: Reports have described the use of risperidone in patients with psychiatric disorders other than schizophrenia spectrum disorders. Little has been written about the use of risperidone in patients with comorbid substance use disorders. This report described a clinical experience using risperidone in substance-abusing patients with bipolar disorder. Methods: Twenty-four patients admitted to an intermediate-care inpatient substance abuse program and diagnosed with bipolar disorder were treated with risperidone in an open-label, nonblinded, naturalistic trial. All patients were followed clinically, assessed using the Clinical Global Impressions scale (CGI) and laboratory studies. Results: 1) Seventy-six percent of the patients showed improvement or much improvement. 2) In 18 cases, risperidone was combined safely with other psychiatric medications. 3) Six patients complained of mild side effects. 4) In eight patients, laboratory studies were completed, and were unremarkable. 5) Mean length of follow-up was 18 days. 6) Average period of abstinence prior to starting medication was 34 days. 7) By self-report, all patients remained abstinent, and some reported decreased craving. Conclusions: This report suggested that risperidone is efficacious and safe, both along and in combination with other psychiatric medications, in treating substance-abusing patients with bipolar disorder.
Poster 5: Valproic Acid for the Treatment of GHB Dependence
Allen, Timothy S, Department of Psychiatry, University of Kentucky, Lexington, KY; Hays, L
Gamma-Hydroxybutyrate (GHB) is a central nervous system depressant, which can lead to loss of consciousness and death; it has been associated with overdoses and date rape. Objective: To assess the possibility that valproic acid would be a suitable treatment for GHB dependence and withdrawal. Methods: This study reviews four cases of GHB dependence admitted to the University of Kentucky Medical Center, and reviews the literature on cases of GHB dependence. Results: The two patients who were treated with valproic acid experienced less psychosis, muscle cramps, insomnia and anxiety than had been shown by previously reported cases of GHB withdrawal. Conclusions: Although more cases using valproic acid would be necessary to make definitive conclusions, these cases suggest that it may be helpful in the treatment of GHB withdrawal. Since valproic acid is a GABA transaminase inhibitor, the breakdown of GABA is slowed by its administration. Exogenous GHB may shift the equilibrium between GABA and GHB therefore decreasing the amount of GABA produced by the body, resulting in a GABA deficiency when GHB is stopped. Valproic acid could therefore help preserve the small amount of endogenously produced GABA and prevent some of the more severe withdrawal signs.
Poster 6: Prevalence of Polysubstance Dependence
Jonnalagadda, MMR, Carolina Psychological Health Services, Jacksonville, NC; Kitchen, C; Bracey, D; Pinkney, L; Gyergyo, D
Objective: All textbooks of addiction psychiatry and psychiatry discuss different substance abuse disorders such as alcohol, cocaine, marijuana (THC). In the real world polysubstance dependence is more common. A retrospective review of 150 consecutive admissions showed that a very high percentage of people seeking help and/or who seem to get help are those with polysubstance dependence/abuse. Method: To illustrate this point, which has clinical/management implications, a total of 150 abusers admitted consecutively were analyzed. A graphological mode of representation was devised to depict this point. Results: The hypothesis that the number of multiple substance abusers (polysubstance dependence) is significantly higher was clearly demonstrated in this representation. The implications for treatment and management were outlined. Conclusions: The data supports that there should be agreed upon guidelines for professionals when dealing with polysubstance dependence, which is present in a significant number of people seen in treatment facilities.
Poster 7:Methamphetamine and Paranoia: The Methamphetamine Experience Questionnaire (MEQ)
Martin H. Leamon, MD, University of California, Davis; Henry R. Kranzler, MD, University of Connecticut, Farmington; David R. Gibson, PhD, University of California,, Davis; Gantt Galloway, PharmD, Haight-Ashbury Free Clinics
Background: Methamphetamine (METH) is a growing drug of abuse in the United States. Its effects and mechanisms of action are less well known than are those of cocaine. Both METH and cocaine can produce paranoia. Other studies have used the Cocaine Experience Questionnaire (CEQ) to examine cocaine-induced paranoia. Allelic association has been reported between cocaine-induced paranoia and genes encoding the neuronal dopamine transporter protein and the enzyme dopamine betahydroxylase. Objectives: To determine the prevalence and character of paranoid symptoms associated with METH use, and to determine potential phenotypic clusters of paranoid symptoms and substance use parameters. Methods: The Methamphetamine Experience Questionnaire (MEQ), adapted from the (CEQ), was administered to in- and out-of-treatment adult METH Dependent subjects who were enrolled in a large on-going study of METH use. The instrument was tested for reliability and analyzed for clustering of specific paranoia symptoms and substance use parameters. Blood samples were collected and stored for DNA extraction and genotyping. Preliminary Results: 53% of the sample to date (N=69) reported at least one paranoid experience with METH use. Most had multiple paranoid experiences, had concomitant hallucinations, and found the episodes more than moderately distressing. While most episodes were brief, they could last longer than 72 hrs. after intoxication. Over half of the subjects reported paranoid episodes during which they with acquired or used weapons. Paranoid episodes occurred with multiple use patterns and routes of administration, and equally with or without concomitant use of other substances. They were more likely to occur at higher doses and with routes of administration that produce more rapid changes in blood levels.
Poster 8: Disordered Gambling and Excessive Tobacco Use: Addiction Spectrum Behaviors?
Potenza, Marc N, Department of Psychiatry, Substance Abuse Center, Yale University School of Medicine, New Haven, CT; Steinberg MA; McLaughlin, SD; Wu, R; LaVelle, ET; Hemstock, DA; Rounsaville, BJ; O’Malley, SS
Pathological gambling (PG), classified as an impulse control disorder, has been postulated to lie along addictive or obsessive-compulsive spectrums. Nicotine dependence (ND) is commonly observed in individuals with PG, with comorbidity rates reported in the range of 65-85%. De-spite significant morbidity and mortality associated with PG and ND, the relationship between the disorders remains incompletely understood. The study hypothesized that individuals with disordered gambling reporting excessive tobacco use would represent a group with more severe gambling-related problems. To investigate, data from a gambling help line serving the Southern New England region of the United States were analyzed. Gambling-problem-related calls (n= 1,024) received from 2/98 to 2/99 were analyzed with regard to reports of excessive tobacco use. Gamblers with excessive tobacco use were more likely to report gambling-related financial problems, illegal behavior and arrest, depression and suicidality. Gamblers with excessive tobacco use were also more likely to report drug use problems and prior mental health treatment. These results have implications for not only provision of care to individuals with gambling disorders, but also the theoretical framework within which PG is conceptualized. Supported in part by P50 DA84733, NARSAD, the National Center for Responsible Gaming, a NIDA/APA Drug Abuse Re-search Scholar Program in Psychiatry (K12) Award, a US VA VISN 1 MIRECC, the CT DMHAS and the Mashantucket Pequot Tribal Nation.
Poster 9: Controversies about Addiction in Chronic Pain: Findings on the Internet
Streltzer, Jon, Department of Psychiatry, John A. Burns School of Medicine, University of Hawaii, Honolulu HI
Background: Two opposing schools of thought have emerged regarding the use of opioid analgesics to treat chronic pain; 1) Maintaining chronic pain patients on opioids does little to relieve pain, does not improve functioning, and subjects these patients to all the risks and complications of opioids, including addiction; and 2) Chronic pain patients do not generally abuse opioids which may often provide effective long-term relief. Methods: In order to understand attitudes and practices in the clinical community, Internet communications from a list serve created to discuss pain and addiction were monitored. Results: Personal experience in pain management was interpreted as finding addiction to be a problem ranging from frequently to never. Widely varying attitudes and clinical approaches were presented with regard to issues of need for assessment of addiction potential, "pseudoaddiction," diversion risk, megadosing, efficacy in relieving pain and the role of federal regulation. Scientific literature would be cited by some participants and critiqued and discounted by others without changing opinions. Conclusions: There appears to be little consensus among clinicians. Chronic pain patients are subject to widely varying practices that tend to be governed by individual philosophy.
Poster 10: Treatment of Comorbid Depression and Adolescent Substance Use Disorders Treatment Outcome
Subramaniam, Geetha, The Johns Hopkins University School of Medicine, Mountain Manor Treatment Center, Baltimore, MD; Lewis, L; Clemmey, P; Fishman, M
Objective: To assess the effectiveness of treatment of depressive disorders in dually diagnosed adolescents at an inpatient substance use disorders (SUD) treatment center, in improving post-discharge substance use outcomes. Methods: Adolescent patients admitted to an inpatient SUD treatment center who were diagnosed with major depression or had 4 symptoms of depressive disorder and received psychotropic medication treatment were enrolled in the study. Data was collected at intake and at 6-month follow-up using the Beck Depression Inventory (BDI), structured interviews using the Global Appraisal of Individual Needs (GAIN), and a chart review was performed for details of psychiatric treatment received during their inpatient SUD treatment. Post-discharge improvement at 6-mo follow-up was defined as 1) percent with < 15 days of substance use during the past 90 days, and 2) percent with BDI scores < 16. Results: Preliminary data analysis of 6-months follow-up of 40 subjects (with a rate of retention of > 90%), revealed that 56% had < 15 days of substance use, and 75% had BDI scores < 15. Conclusions: This study provides preliminary evidence to suggest that the concurrent treatment of depression during inpatient SUD treatment for adolescents with severe SUDs and comorbid depression leads to substantial improvement.
Poster 11: Changes in Ocular Adaptation with Cocaine Addiction
DeMet, Edward, VAMC Long Beach and University of California, Irvine, Long Beach, CA; Cho, A; Katz, M; DeMet, A
Objective: Cocaine is known to alter dopaminergic (DA) neurons although most measurements of such effects are relatively invasive and are unsuitable for routine screening. The retina of the eye is quite DA rich, and there have been several reports of altered ocular function in cocaine addicts. The present study compares light adaptive ocular potentials in recently detoxified cocaine users (N=12) with those of normal controls (N=10). Method: Light adaptive potentials are DA and cAMP dependent. They are measured as electrooculograms (EOG’s) in the dark and under bright light (1100 LUX). Movement components of the EOG’s are removed through the use of fixed targets. Results: Patients, on the average, had used cocaine within the previous two weeks. Ocular potentials in these subjects were 38% lower than controls. No decrease was evident in two other subjects who had recent but not chronic use. Depression ratings in the two groups differed although neither this, nor mania or anxiety levels reached clinical significance. Conclusion: The results support the hypothesis that light adaptive ocular potentials are attenuated in patients who are recently abstinent from cocaine use.
Poster 12: Disentangling the Risk for Substance Use Disorders from other Psychopathological States in Offspring: The High Risk Children of Opioid and Alcohol Dependent Parents
Wilens, Timothy E, Harvard Medical School, Massachusetts General Hospital, Boston, MA; Hahesy, AL; Biederman, J; Bredin, E; Abrantes, A; Brown, S; Monuteaux, M; Spencer, T
Objective: The literature suggests that the child and adolescent offspring of parents with a substance use disorder (SUD), including drug and alcohol abuse or dependence, are at increased risk for SUD and psychopathology. To disentangle the role of parental psychopathology and SUD on the risk for these disorders in their offspring, a high-risk design focused on the children of parents with and without SUD was used. Methods: Using structured psychiatric interviews, 96 families (187 parents and 183 children – mean age 11.6 years) were assessed with (N=30 families; 56 parents, 44 children) and without (N=66 families; 131 parents, 139 children) a SUD parent. Logistic regression was used to evaluate the risk of parental SUD and other psycho-pathological conditions on the risk for various psychiatric and SUD outcomes in their offspring. Results: Parental SUD was associated with increased risk for offspring SUD (OR n/a, p*0.05) and any psychopathology (OR=3.6, p*0.01) (including mood and anxiety disorders, with a trend for disruptive disorders) even when controlling for other psychopathology in the parents. In additional analyses, this finding was maintained after controlling for the corresponding parental diagnostic category. In contrast, parental psychopathology did not exhibit a significant association with child outcomes after adjustment for parental SUD. Conclusions: The results suggest that parental substance abuse confers a major risk for both SUD and psychopathology in the children.
Poster 13: Psychiatric Problems in Methamphetamine vs Cocaine Dependent Research Participants
Batki Steven L, Department of Psychiatry, SUNY Upstate Medical University, Syracuse, NY; Moon, JD; Hersh, D; Bradley, M; Aguillon, C; Smolar, S; Mengis, M; Delucchi, K; Morello, L; Pansarasa, C
Objective: To compare psychiatric problems in methamphetamine (MA) vs cocaine (COC) dependent research participants. Methods: Data were analyzed from 275 subjects (Ss) who were enrolled in three separate pharmacotherapy trials for the treatment of COC or MA dependence in San Francisco. 149 Ss were COC and 126 were MA dependent. Ss were assessed with the Addiction Severity Index (ASI), the Structured Clinical Interview for DSM-IV (SCID) and Beck Depression Inventory (BDI). Results: The MA and COC cohorts differed significantly in major demographic characteristics. MA subjects were younger (mean age 35.4 yrs. vs. 38.6, p=.0001); and were more likely to be white (MA 75% white vs. COC 70% African-American, p=<.0001); gay or bisexual (MA 51% vs. COC 22%, p=.004) and employed full time (MA 46% vs. COC 28%, p=.003). However, on most psychiatric variables, the cohorts did not significantly differ. Mean intake BDI scores were similar for both groups — 15.4 for the MA cohort and 14.5 for the COC group (p = NS). SCID diagnosis of current major depressive disorder was found in roughly the same proportion (12.1%) of COC Ss as in MA Ss (15.9%) (p= NS), al-though more MA Ss (27.8%) than cocaine Ss (12.8%) had past MDD. The ASI indicated that symptom prevalence was similar in both cohorts for depression, anxiety, hallucinations, cognitive problems and suicidality. 12% of COC Ss and 7% of MA Ss (p =.17) reported trouble con-trolling violent behavior. Conclusions: While MA and COC Ss differed in their stimulant drug of choice and differed markedly in their demographic characteristics, they appear to have similar levels of psychiatric severity. Supported by NIDA Grants P50 DA 09253 and R0 DA 11397.
Poster 14: Cigarette Smoking and Low Birth Weight in an Urban Sample of Women at Risk of Drug Use During Pregnancy
Brady, Thomas M, Substance Abuse and Mental Health Services Administration, Rockville, MD
Objective: To investigate the role of drug use in the delivery of low birth weight infants. To advocate for smoking cessation programming in comprehensive maternal addiction programs. Methods: Self-reported data about illicit drug, alcohol and tobacco use were collected from women who had just given birth in eight participating hospitals in the Washington, DC area. Women with a history of recent drug use were over sampled to maximize the number of drug-using women included in the study. 709 women who completed the personal interview were asked to give their permission for research staff to access her medical record. The abstractors submitted the signed release form from a study respondent to the medical records department staff of the hospitals to obtain access to that woman’s chart. The analysis describes birth weight by demo-graphic characteristics, insurance coverage and drug use. Data are presented on other birth out-come measures such as head circumference and length at birth. This study employs a multivariate logistic regression model, controlling for age, race, income, education, multiparity, marital status, prenatal care and maternal weight gain. The logistic model also controls for crack, heroin, alcohol and marijuana use. Results: 25.5% of women self-reported cigarette smoking during their pregnancy. 12.7% of normal term women and 26.7% of all women had low birth weight infants. Of the 528 women who did not smoke cigarettes, the average birth weight of their infants was 3,000 grams. Of the 181 women who smoked cigarettes during their pregnancy, the average birth weight of their infants was 2,501 grams. Among smokers and non-smokers, there were also statistically significant differences in maternal weight gain, Apgar scores at five minutes, head circumference and infant length at birth. In a stratified analysis controlling for race, income and crack cocaine use, cigarette smokers were 2.1 times more likely to have low birth weight infants than women who did not smoke cigarettes (Chi Square 9.771, p <.01). Controlling for patient demographics, other drug use, maternal weight gain and prenatal care, the odds were that women who smoked cigarettes during their pregnancy were two and a half times as likely to have a low birth weight infant than women who did not smoke cigarettes [Wald Test 8.9815, Prevalence Odds Ratio 2.48, 95% confidence interval (1.4, 4.5)]. The magnitude of the association between cigarettes and low birth weight was more salient than other drugs, including crack cocaine. Conclusion: These data suggest that cigarette smoking is a major determinant of low birth weight infants among urban women, even among women at risk for other drug use during their pregnancy. Implications for Research and Practice: Prenatal care resources and outreach activities should continue to target pregnant women who use drugs. These findings illustrate similar re-sources should be expended for screening for tobacco use that are presently employed for screen-ing for other drugs. Smoking cessation activities need to be available for drug dependent women who present for substance abuse treatment. Funded by the National Institute on Drug Abuse.
Poster 15: Retention of Substance Abuse Outpatients: The Role of Psychiatric Comorbidity in the Era of Welfare Reform
Brady, Thomas M, Substance Abuse and Mental Health Services Administration, Rockville, MD; Baum, BH; Flaherty, JA
Objective: To determine if the presence of a dual diagnosis is a significant determinant of retention in treatment among Medicaid financed, adult substance abuse outpatients. Background: Dual diagnosis patients face a range of barriers to substance abuse treatment. In addition, the addiction treatment literature has illustrated that dual diagnosis patients have characteristics and traits that hinder their full participation in outpatient group therapy, limiting their ability to successfully engage and complete treatment. However, recent findings in retention studies suggest that dual diagnosis patients do not differ in their treatment experiences from sub-stance abuse outpatients. Methods: The setting of the study was a single addiction treatment program serving medically underserved communities in Chicago, Illinois. 82% of outpatients were of African descent and 54% were male. The utilization records of 437 outpatients were analyzed using an administrative data set, including 83 dual diagnosis patients and 354 substance use disorder patients. Evaluation endpoints included the utilization of group therapy visits and the completion of the primary phase of Intensive Outpatient Treatment (IOT). Analytic procedures included descriptive statistics, survival methods and regression analyses. Data were also analyzed using propensity score matching. Results: Dual diagnosis patients averaged 12.3 group therapy visits compared to 16.6 group therapy visits for substance use disorder patients. Without statistical adjustment, the odds were that dual diagnosis patients were 1.8 times more likely to not complete IOT primary care than patients with only diagnoses of substance use disorder (crude odds ratio of 1.82, Chi Squared 4.21, p = .04.). However, the effect of dual diagnosis was not significant when adjusting for age, race, sex and enrollment after welfare reform (January 1, 1997). There were significant interactions with the primary hypothesis and age, race and enrollment after welfare reform consistently altered the association between dual diagnosis and retention. Conclusion: A review of recent literature illustrates that the substance abuse treatment community has evolved in its ability to successfully engage addiction treatment clients who present with coexisting psychiatric disorders. The data of this study suggest that substance abuse clinicians and administrators should be optimistic about the prognosis of dual diagnosis patients in outpatient substance abuse treatment. Funded by NIMH. Submitted as partial fulfillment of the requirements for the PhD.
Poster 16: Serum Prolactin Levels and Response to Treatment Among Cocaine-Dependent Patients
Hill, Kevin P, Jefferson Medical College, Philadelphia PA; Patkar, AA; Sterling, RC; Gottheil, E; Weinstein, S
Objective: Considerable evidence indicates that dopaminergic (DA) mechanisms may modulate the central effects of cocaine. We investigated a) whether basal serum prolactin (PRL), an indirect measure of central DA activity, differed between cocaine-dependent (CD) subjects and controls and b) whether PRL levels among CD patients were related to their treatment. Method: 87 African-American (AA) CD (DSM-IV) subjects attending intensive outpatient treatment and 35 AA controls were studied. Blood samples were obtained after overnight fast. Sera were separated and PRL concentrations were measured by radioimmunoassay. The treatment outcome measures were number of negative urine drug screens, attendance, counselor ratings of improvement, and discharge status. T-tests and tests of correlation were used for data analyses. Results: The mean PRL levels among cocaine patients (9.08±4.10) were significantly higher compared to controls (7.14±3.36)(t=2.48, p<0.02). There was no correlation between PRL levels and age, sex, duration of use, ASI, BDI or SCL-90 scores. Furthermore, after dividing the cocaine patients into two groups (higher/lower PRL, median=7.78), patients in the lower PRL group were more likely to have negative urine drug screens (p=0.04), remain in treatment (p=0.17) and receive favorable ratings of improvement by counselors (p=0.01). Conclusion: The high PRL levels among CD patients compared to controls indicate that DA activity may be lower among CD patients com-pared to controls. More importantly, there seems to be a relationship between high PRL levels and various adverse measures of response to treatment. Studies on a larger subject group and neuroendocrine challenge tests are under way to confirm these findings.
Poster 17: Nevirapine Induced Opioid Withdrawal in Two Patients Previously Stable on Levoalpha-acetyl-methadol (LAAM)
Welsh, Christopher J, University of Maryland School of Medicine, Baltimore, MD; Carguilo, T
Objective: Nevirapine (viramune) is a non-nucleoside reverse transcriptase inhibitor that is an inducer of the cytochrome P-450 enzymes 2B6 and 3A4. There are several reports that it can increase the metabolism of methadone leading to decreased methadone levels and the precipitation of opioid withdrawal in patients previously maintained on a stable methadone dose. There are no reports of its effects on LAAM. Methods: Information was gathered through pharmacy records, patient interviews and chart notes from both the HIV clinic and the LAAM clinic. Case Reports: Two cases were presented in which patients previously on a stable dose of LAAM experienced opioid withdrawal shortly after beginning an anti-retroviral regimen that included nevirapine. Conclusions: Some potential differences in the time course and management of nevirapine-induced withdrawal from methadone, as compared to LAAM, were discussed. One of the patients reported symptoms of opioid intoxication for several days prior to reporting symptoms of opioid withdrawal. It is theoretically possible that early induction of the CYP 3A4 sys-tem resulted in an initial increase in metabolism of LAAM with a delay in metabolism of the more potent, longer acting metabolites. Both patients found that the increased 72-hour dose needed to cover them through the weekend was initially too sedating. The use of a 48-hour dose on Friday with a methadone "take-home" for Sunday helped alleviate this problem.
Poster 18: The Effects of a Dedicated Substance Abuse Elective on the Attitudes of Third Year Medical Students toward Addictions
Welsh, Christopher J, University of Maryland School of Medicine, Baltimore, MD; Bennet, M; Gandhi, D; Thompson, D; Weintraub, E
Objective: To assess attitudes related to substance abuse and dependence among third year medical students and to examine whether students who rotated on a Substance Abuse Con-sultation Service during their psychiatry clerkship demonstrate a greater change in attitudes toward addiction and substance-addicted patients than those medical students who did not rotate on the service. Methods: A battery of questionnaires was administered to the third year medical students (n=141) on the first day of their psychiatry clerkship and again on the last day. These included the Seaman-Mannello Scale, The Substance Abuse Attitudes Survey, and a general questionnaire assessing perceived knowledge about various topics in addictions. Thirty-five students (25%) were randomly assigned to do a two half-day selective on the Substance Abuse Consultation Service during their four week inpatient psychiatry rotation. The other 106 (75%) students did selectives in either an adult or child outpatient clinic, the general psychiatry consultation service, or the psychiatric emergency/urgent care service. Results: Changes in attitude scores between the pre-test and the post-test were compared between students who completed the substance abuse selective and those who completed another selective. Conclusions: Following the psychiatry clerkship, 3rd-year medical students: 1) demonstrated significant increases in self-perceptions of their knowledge & skills concerning SUDs, 2) viewed therapy/medical intervention (rather than punishment) as more warranted in the treatment of patients with SUDs, 3) viewed individuals with SUDs as having significantly more psycho-logical problems (rather than as people who are simply excessive drinkers), 4) viewed moderate drinking as significantly less harmful or morally wrong. No differences were found between students who rotated on the Substance Abuse Consultation Service and those who did not.
Poster 19: The Efficacy and Safety of Diazepam Day Detoxification (DDD) for Acute Alcohol Withdrawal in an Ambulatory Clinic
Selby, Peter, Centre for Addiction and Mental Health, University of Toronto, Toronto, Ontario, Canada; Chen, R; Wudom, K; Kahan, M; Marsh, D
Objective: To assess the efficacy and safety of oral diazepam symptom-triggered loading for the management of acute alcohol withdrawal in an outpatient setting. Methods: 37 consecutive charts of outpatients with alcohol dependence who underwent oral benzodiazepine detoxification were reviewed for a total of 56 unique procedures. The primary outcome was sustained reduction in withdrawal as measured using the CIWA-Ar scale. Secondary outcomes included the occurrence of seizures and hallucinations. Results: 76% of patients were male ranging from ages 20-70 years. 48% had a past history of withdrawal seizures, delirium tremens or alcohol liver disease. 50% had a concurrent psychiatric diagnosis, primarily depression, and 43% admitted to other substance use. In 50 cases, diazepam was administered. Four were too intoxicated and two had very minimal withdrawal to be medicated. There was a significant reduction in mean peak to discharge CIWA-Ar scores (11.05 vs 5.18, p<0.000001). Mean duration of follow-up was 30 days. Mean dose of diazepam required was 57 mg. 93% went home or to a non-medical detoxification center. Over 50% followed up for the intensive phase of therapy and 30% took naltrexone. Two patients receiving diazepam had an adverse outcome unrelated to acute withdrawal. In the unmedicated group, one had a seizure and the other had hallucinations. Only in eight procedures, patients were given take home doses of valium. Conclusions: DDD is a safe and effective meth-od of detoxification. A randomized controlled trial is warranted in ambulatory settings including emergency rooms.
Poster 20: The Effectiveness of a Residential Substance Abuse Treatment Program for Women and their Children
Worley, Linda LM, University of Arkansas for Medical Sciences, Little Rock, AR
Women with children represent a special population for substance abuse treatment programs. The unique needs of women and the requirements of child rearing often complicate the efforts of service providers to implement programs that have enduring effectiveness. Although there is a growing body of literature describing model substance abuse treatment programs for pregnant and parenting women, there is little research available about treatment outcomes for these women and their children. The purpose of this study was to examine the efficacy of a comprehensive, residential substance abuse treatment program for women and their children. A majority of the 72 participants were African-American, single mothers, for whom crack/cocaine was the drug of choice. The women and their children were assessed at intake, repeatedly during treatment and at 3, 6 and 12 months post-discharge. Significant improvements were seen in the areas of drug use and negative consequences of use, employment and self-sufficiency and family inter-action skills. Program completers showed more positive outcomes than non-completers. Young children enrolled in treatment with their mothers were assessed using a developmental screening test, and older children with a measure of drug refusal skills. Results from both child measures suggest a positive (though non-significant) trend toward improvement. Results suggest that the program was successful in treating families affected by addiction and offer evidence of continued program impact in the year after treatment.
Poster 21: A Safety Net of Prevention & Intervention: Managing the Substance Abusing Medical Student, University of Arkansas for Medical Sciences Student Mental Health Program
Worley, Linda LM, University of Arkansas for Medical Sciences, Little Rock, AR
Medical students are at significant risk to develop substance abuse problems as many self medicate with alcohol and other substances to escape stress. The University of Arkansas for Medical Sciences has developed a comprehensive Student Mental Health Service that integrates strong prevention programs with tiered treatment. The prevention component includes prematriculation presentations, freshman orientation presentations, lunch topics sponsored by the Student Advocacy Council (showing scenes from the Halloween episode of ER) and training for peer elected representatives of the Student Advocacy Council (SAC). These SAC leaders recognize and intervene with peers at risk, assisting them to seek confidential, accessible treatment. Students who are successful in discontinuing their drug and alcohol abuse undergo periodic drug screens to confirm their compliance. Drug screens within this tier of treatment are paid for by the Student Mental Health Service. Severe cases of substance use (student(s) demonstrating impairment, potentially placing others at risk) are treated within the mandated treatment portion of the program. This level of treatment is provided in an effort to salvage the student’s medical career while insuring the safety of patients. Mandated treatment begins with an evaluation of the student by a board certified addiction psychiatrist to develop an individualized treatment recommendation. This recommendation is shared with the student and their Dean and is formally agreed upon and placed in the student’s file. Consequences for non-compliance are determined by the Dean and by the student’s promotion’s committee. Periodic reports of treatment compliance are sent to the Dean and are placed in the student’s file.
Poster 22: Psychiatric Co-Morbidity in Addicted Lesbian and Gay Professionals Admitted to an Extended Chemical Dependency Treatment Program
Ziegler, Penelope P, The William J. Farley Center, Williamsburg, VA
Between May 1998 and May 2000, 22 persons identifying themselves as lesbian or gay were admitted to The William J. Farley Center extended treatment program for addicted professionals. A retrospective analysis of the medical records of these patients reveals several interesting pat-terns: 1) All (100%) of these patients revealed a history of sexual abuse and/or severe emotional abuse, compared to the overall rate of about 50%; 2) Lesbian patients generally used alcohol, sedatives (primarily benzodiazepines and/or butalbital) and/or opioid drugs; 3) Gay men had a broader range of drugs of choice and a high incidence of polysubstance dependence; 4) Younger gay men often included so-called "club drugs" in their chemical mix, especially Ecstasy, methamphetamine and inhalants such as amyl nitrate ("poppers"), whereas the rate of use of these drugs by heterosexual professional men was very low; 5) The most frequent psychiatric diagnoses in gay men were generalized anxiety disorder, dysthymic disorder and major depression, recurrent; the most frequent diagnoses in lesbians were post-traumatic stress disorder, panic disorder and generalized anxiety disorder; 6) Both men and women in this special population had high incidences of somatoform disorders and psychosomatic illness with chronic pain; 7) In those patients who had had prior treatment experiences, most reported that their psychiatric disorders and their unresolved internalized homophobia issues had either not been addressed at all or had been treated inappropriately.
Poster 23: The Prevalence of Prescribed Antidepressant Use Among Active Substance Users Entering Addiction Treatment
Soulounias, Bernadette L, Ashley Inc., Havre de Grace, MD
Objective: To describe the frequency and patterns of prescribed antidepressant use among active substance users, comparing relapse patients with primary patients and drugs used. Methods: Data was collected from 89 consecutive admissions to a residential addiction treatment program. Results: Thirty-eight percent of the persons admitted were taking prescribed antidepressants. Forty-four percent of these were females while only 31% of the admissions were females. The average age of the antidepressant group was the same as the group without antidepressants, 41.7 years. 36% of relapse patients were taking antidepressants while 41% of primary patients were. Antidepressants were started during period of active addiction in 76% of the patients and the doctor was aware of the addiction in 85% of the cases. The antidepressant was prescribed by the patient’s psychiatrist 47% of the time, by the primary care physician 23.5% of the time, and by a physician while in detoxification 23.5% of the time. 62% were taking one antidepressant, 26% were taking an antidepressant with a mood stabilizer and 38% were taking two or more psychiatric medications. There were many more sedative addicts among those taking antidepressants and many more marijuana and cocaine addicts among those not taking anti-depressants. The average number of drugs of dependence used was the same between those with medication and those without.
Poster 24: Comparison of Patients with Opioid, Cocaine and Opioid Plus Cocaine Dependence
Strain, Eric C, The Johns Hopkins University School of Medicine, Baltimore, MD; Jones, H; Johnson, RE; Brooner, RK; Bigelow, GE
Objective: To compare pretreatment characteristics of opioid dependent (n=124), cocaine dependent (n=149) and opioid+cocaine dependent (n=96) patients enrolling in an outpatient treatment/research clinic. Methods: Participants were evaluated at onset of treatment using the Addiction Severity Index (ASI) and Structured Clinical Interview for DSM-IV (SCID), and demographic information was collected using a standard form. Data were analyzed using logistic regression and analysis of variance. Sex differences were examined since rates of psychiatric disorders can vary by sex. Results: Groups did not differ significantly for age, race or years of education, but did differ for marital and employment status and number of previous treatments. Men were more likely to be married and employed. Opioid+cocaine dependent patients were less likely to be married than opioid dependent patients. There was a higher rate of previous treatment episodes in opioid and opioid+cocaine dependent versus cocaine dependent only patients. ASI composite scores did not differ between sexes and showed a variable pattern across groups. Lifetime diagnosis of major depression was more likely in females and among patients with cocaine only versus opioid only dependence. Antisocial personality disorder was more common among patients with opioid+cocaine versus opioid only dependence and in men. Con-clusions: These results suggest opioid, cocaine and opioid+cocaine dependent individuals entering a treatment/research clinic differ demographically on measures of psychiatric severity and as a function of sex. No single group is clearly more severe than others. Rather, each group appears to have a unique profile that suggests different treatment needs. Supported by NIH K01 DA00332 and R01 DA10754.
Poster 25: MDMA-Related Neurotoxicity and Malignant Hyperthermia: New Syndrome or a New Variant of the Serotonin Syndrome and/or the Neuroleptic Malignant Syndromes
Nodal, Raul F, James A. Haley VAH University of South Florida Medical School, Tampa, FL; Brown, M; Ordorica, P
Objective: To establish the differences and similarities between these three syndromes in an attempt to develop effective therapeutic approaches based on their pathophysiological mechanism. Methods: A review of the English-language international scientific literature published from 1978 to 2000 was conducted. Conclusions: Although far from definitive at this time, there seems to exist a significant overlap in the pathophysiology of these three syndromes. Serotonin dysfunction appears to have a predominant role as the "final common pathway" involved in the dysregulation of the anterior hypothalamus, which leads to the severe hyperthermia that is central to these syndromes and is responsible for the secondary manifestations in other systems: musculoskeletal (rhabdomyolysis), hepatic (cell necrosis), renal (acute failure secondary to myoglobinuria) and hematological (coagulopathy). The interrelationships between exogenous and endogenous opiates, monoamines, glutaminerigic, gabaergic and neurohormonal systems in the etiology of these syndromes is discussed and, in part, explains how similar syndromes can be caused by different drugs (MDMA, neuroleptics, L-tryptophan, etc.) by ultimately depleting or interfering with serotonin at the hypothalamic level. The literature suggests that the therapeutic interventions for these syndromes will need to address the serotonergic dysfunction in the early stages of the syndromes in order to reverse the anterior hypothalamic dysfunction responsible for the core symptom of hyperthermia in these patients.
Poster 26:Smoking Cessation During Early Recovery in Alcohol Dependent Individuals: Epidemiology, Treatment Options, Clinical and Economic Implication
Karam-Hage, Maher A, University of Michigan Department of Psychiatry and Alcohol Research, Ann Arbor, MI; Thompson, K; Brower, K
It is estimated that 70-80% of alcoholics are smokers. Unfortunately, alcoholics are not likely to attempt abstinence from nicotine or succeed at smoking cessation. The traditional belief that quitting smoking while in early recovery could cause relapse to alcohol or other substances has limited the effort patients and therapists may make to eliminate nicotine dependence. Further-more, nicotine dependence is usually seen as a secondary or irrelevant problem in most treatment and rehabilitation centers. This is due, in part, to little research on smoking cessation tailored for alcoholics and substance abusers. Very few randomized and controlled studies have been completed in this particular population. In fact, only in the past 10 to 15 years researchers have started to examine the feasibility and efficacy of such interventions. On the other hand, the majority of research has examined the effectiveness of behavioral therapy, nicotine replacement therapy or a combination. Another important tool, the antidepressant bupropion or Wellbutrin (recently marketed for smoking cessation as Zyban), has not been tried among alcoholics or substance abusers during early recovery. This medication could help patients who desire to quit smoking, which might decrease the risk of relapse to alcohol and other substances. Bupropion has been proven safe and remarkably effective as an adjunct to smoking cessation therapy in the general population. This review focused on smoking cessation strategies among alcoholics and substance abusers during early recovery with a particular emphasis on bupropion. The possible link between nicotine addiction and rehabilitation from alcohol dependence when it is incorporated with smoking cessation therapy was explored. The rationale and feasibility of using bupropion in smoking cessation therapy for individuals in early recovery from alcoholism was presented.
Poster 27: Characteristics of Drug-Related Violence in Psychiatric Inpatients
Wines, James D Jr, Alcohol and Drug Abuse Research Center and Department of Mental Health Services Research, McLean Hospital-Harvard Medical School, Belmont, MA; Kon, P; Makar, R; Robinson, T; Armbrust, M; Eisen, SV; Mendelson, JH.
Objective: Preventing violence is a national priority. Substance abuse is an important risk factor for violent behavior. Over half of all homicides or serious assaults may involve alcohol or other drugs. Despite extensive scientific literature documenting the strong statistical association between drug use and homicidal behavior, information regarding the clinical phenomenology is scarce. Methods: Patients (n=226) admitted to a locked, dual-diagnosis unit completed The Behavior and Symptom Identification Scale (Basis-32) on admission (Adm) and discharge (D/c). The Basis-32 is a 32-item, self-report instrument used to assess patient functioning and psychiatric symptoms, including problems related to "controlling temper, outbursts of anger, violence." All questions are scored on a 5-point scale: 0-(No difficulty), 1-(A little difficulty), 2-(Moderate difficulty), 3-(Quite a bit of difficulty) and 4-(Extreme difficulty). Results: a) Demo-graphics: Male 70%, Female 30%; Mean age: 40; Not Married 43%; Unemployed 64%; Medicare: 52%; Mean LOS: 11days; Primary diagnosis: Alcohol 47%, Illicit Drugs 34%, Mood Disorder 11%; b) Mean Basis-32 Score Adm 2.1 vs D/c 1.3, p<.001; c) Mean Violence Score Adm 1.15 vs D/c 0.71, p<.001; and d) Violent Behavior rated "Quite a bit" or "Extreme:" Adm 17% vs D/c 6%. Conclusions: Further research, including prospective studies, is needed to more fully characterize the natural history of drug-related violence.
Poster 32: Impact of an Addiction Psychiatry Fellowship on General Psychiatry Residents
Berman, Jeffrey A, UMDNJ, Division of Addiction Psychiatry, Robert Wood Johnson Medical School, New Brunswick NJ; Marcus, AA; Delaney, BR; Simring, S; Ziedonis, D
Introduction: Substance use presents as primary, substance induced psychiatric or co-occurring psychiatric disorders. General Psychiatry (GP) residencies should provide comprehensive addictions training. Addiction Psychiatry fellowships (APFs) exist in association with 33 GP programs. Goals: Do affiliated APFs impact on GP residents’ 1) scope of addictions training; 2) perceptions about preparation and comfort levels in treating addictive disorders and 3) interests in more addictions training? Methods: A 21-item survey was developed and IRB approved. Surveys were distributed to residents (PGY I-IV) in seven BG programs with approved APFs and in seven GP programs without APFs. The Statistical Package for Social Sciences (SPSS) was used. Results: 194 (51%) surveys were returned (96 from APF affiliated programs and 98 from non-APF affiliated programs). 1) Residents from APF affiliated programs report more formal training in: medical complications of substance use (p<.01), detox procedures (p<.01), diagnosis of substance induced mood, anxiety and psychotic disorders (p<.01), Twelve Step Recovery Groups (p<.01), ASAM Levels of Care (p<.01) and psychosocial issues (p<.05)). 2) GP residents from APF affiliated programs felt "more comfortable" treating primary, substance induced and co-occurring addictive disorders (p<.01). 3) GP residents from non-APFs affiliated programs had greater interest in obtaining more addictions training during their GP residencies (p<.01). Conclusion: APFs appear to impact positively on GP residents. They receive more addictions-related training and perceive themselves more prepared and comfortable treating addictive disorders. APF programs appear to offer more addictions training.
Poster 33: Childhood Trauma and Suicidal Behavior in Cocaine Dependent Patients
Marcus, Abir A, UMDNJ, Robert Wood Johnson Medical School, New Brunswick, NJ; Berman, JA; Roy, A
Objective: To determine the association of childhood trauma with suicidal behavior in cocaine dependent men. The hypothesis was that male cocaine dependent patients who attempted suicide would report significantly more childhood trauma than male cocaine dependent patients who had never attempted suicide. Method: A consecutive series of one hundred male cocaine dependent patients were interviewed about suicidal behavior using a semi-structured interview. A suicide attempt was defined as a self-destructive act with some intent to end one’s life. All patients completed the 34-items Childhood Trauma Questionnaire (CTQ). In the statistical analysis, the t test and the chi-square test were used. Results: Patients who attempted suicide (N=34) reported significantly higher CTQ scores for childhood emotional abuse, sexual abuse, physical abuse, emotional neglect and physical neglect, than patients who had never attempted suicide (N=66). ). They also had significantly higher weighted total CTQ score. A strength of this report was that it concerned males only and a specific aspect of suicidality (an attempt) among patients all of whom have the same primary psychiatric diagnoses (cocaine dependence). Another aspect of the report was that suicidal behavior was associated with childhood trauma involving neglect. These childhood neglect data suggest that future studies of childhood traumas and suicidal behavior might consider aspects of both childhood abuse and childhood neglect.
Poster 39: A New Method to Detect Carbohydrate-Deficient Transferrin and Its Clinical Utility as a Marker for Alcohol Relapse
Melin, Gabrielle J, Mayo Clinic, Rochester, MN; Tinsley, J; Hall-Flavin, D; O’Brien, J; Bergen, B; Lacey, J
Carbohydrate-Deficient Transferrin (CDT) was discovered over twenty years ago and serves as a marker for excessive alcohol consumption. CDT is present in the serum of all humans in low levels. Production increases when alcohol is consumed excessively. CDT is an altered form of Transferrin, which is made primarily by the liver and is present in human serum. A detectable increase in CDT will occur in subjects when 50-80 g alcohol/day is consumed for seven to ten days. The half-life of CDT is approximately 15 days. It is not completely understood how exposure to alcohol results in the increased production of CDT.
Many methods currently exist for measuring CDT. The Gold Standard, Isoelectric Focusing (IEF), involves separation of CDT based on charge and staining with use of anti-human anti-bodies. A recent discovery changes how the results utilizing older methods are interpreted. The original nomenclature was based on the number of sialic acid residues absent from the Transferrin molecule. It is now known that the Transferrin molecule is deficient in entire oligosaccharide (otherwise know as N-Glycan chains) side chains. The mass of one of these side chains is significantly more than a single sialic acid residue. This can be detected accurately by the use of mass spectrometry, which we propose to be a superior method. The basic idea behind mass spec is Mass/Charge. Proteins have large masses; transferrin has a mass of 79,560 Daltons. One N-Glycan chain is 2205 Daltons. In order to reduce the ratio, the charge is increased by vaporizing the protein. The protein is surrounded with water, which has charges. The compound is then injected into the Mass Spectrometer. A computer program extrapolates down to the parent protein. In essence, a fingerprint of the molecule is obtained.Serum samples from 20 patients admitted to an inpatient Addictions Treatment program were analyzed. The sample was comprised of men and women ranging from age 27 to 70. The subjects last drink of alcohol was required to be within 72 hours of admission and their first blood draw. Two more samples were obtained, one at one week and one at three weeks. This allowed sufficient time for the production of CDT to decrease with abstinence and therefore, return CDT levels to each subject’s baseline. Knowing a patient’s baseline CDT level is the key to detecting relapse. This study is being continued to verify the results and show the superiority of this method to other methods currently available.
2000 AAAP Annual Meeting Proceedings Copyright 2001 AAAP