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BACKGROUND: Recent in vivo research using magnetic resonance spectroscopy demonstrated that chronic cigarette smoking exacerbates regional chronic alcohol-induced brain injury. Other studies associated cigarette smoking with gray matter volume reductions in healthy adults, with greater brain atrophy in aging, and with poorer neurocognition. Although cigarette smoking is common among alcohol-dependent individuals, previous research did not account for the potential effects of chronic smoking on regional brain volumes in alcoholism. METHODS: High-resolution T1-weighted magnetic resonance images from one-week-abstinent, alcohol-dependent individuals and light drinkers were automatically segmented into gray matter, white matter, and cerebral spinal fluid of lobes and subcortical structures. A brief neuropsychological test battery was used to assess cognition in alcohol-dependent individuals. The alcoholic and nondrinking groups were retrospectively divided into chronic smokers and nonsmokers, and the volumetric data were analyzed as a function of alcohol and smoking status. RESULTS: Chronic alcohol dependence was associated with smaller volumes of frontal and parietal white matter, parietal and temporal gray matter, and thalami, accompanied by widespread sulcal but not ventricular enlargements. Chronic cigarette smoking was associated with less parietal and temporal gray matter and with more temporal white matter. Among alcoholics, better visuospatial learning and memory and greater visuomotor scanning speed were correlated with larger lobar white matter volumes in the nonsmoking alcohol-dependent group only. CONCLUSIONS: These data provide preliminary evidence that comorbid chronic cigarette smoking accounts for some of the variance associated with cortical gray matter loss and appears to alter relationships between brain structure and cognitive functions in alcohol-dependent individuals.

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This article must be considered a work-in-progress. The California Society of Addiction Medicine seeks to briefly enumerate some guiding principles for initial consideration. It is the Society's hope that the issues presented here can promote further discussion and planning in collaboration with our colleagues in the criminal justice system, the community of California treatment providers, and other social service agencies, and in future consultations with experts at the National Institutes of Health and other relevant research and treatment agencies in California, Washington, and elsewhere.

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CONTEXT: Despite evidence that methadone maintenance treatment (MMT) is effective for opioid dependence, it remains a controversial therapy because of its indefinite provision of a dependence-producing medication. OBJECTIVE: To compare outcomes of patients with opioid dependence treated with MMT vs an alternative treatment, psychosocially enriched 180-day methadone-assisted detoxification. DESIGN: Randomized controlled trial conducted from May 1995 to April 1999. SETTING: Research clinic in an established drug treatment service. PATIENTS: Of 858 volunteers screened, 179 adults with diagnosed opioid dependence were randomized into the study; 154 completed 12 weeks of follow-up. INTERVENTIONS: Patients were randomized to MMT (n = 91), which required 2 hours of psychosocial therapy per week during the first 6 months; or detoxification (n = 88), which required 3 hours of psychosocial therapy per week, 14 education sessions, and 1 hour of cocaine group therapy, if appropriate, for 6 months, and 6 months of (nonmethadone) aftercare services. MAIN OUTCOME MEASURES: Treatment retention, heroin and cocaine abstinence (by self-report and monthly urinalysis), human immunodeficiency virus (HIV) risk behaviors (Risk of AIDS Behavior scale score), and function in 5 problem areas: employment, family, psychiatric, legal, and alcohol use (Addiction Severity Index), compared by intervention group. RESULTS: Methadone maintenance therapy resulted in greater treatment retention (median, 438.5 vs 174.0 days) and lower heroin use rates than did detoxification. Cocaine use was more closely related to study dropout in detoxification than in MMT. Methadone maintenance therapy resulted in a lower rate of drug-related (mean [SD] at 12 months, 2.17 [3.88] vs 3.73 [6.86]) but not sex-related HIV risk behaviors and in a lower severity score for legal status (mean [SD] at 12 months, 0.05 [0.13] vs 0.13 [0.19]). There were no differences between groups in employment or family functioning or alcohol use. In both groups, monthly heroin use rates were 50% or greater, but days of use per month dropped markedly from baseline. CONCLUSIONS: Our results confirm the usefulness of MMT in reducing heroin use and HIV risk behaviors. Illicit opioid use continued in both groups, but frequency was reduced. Results do not provide support for diverting resources from MMT into long-term detoxification.

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Positive monetary contingencies for treating opioid dependence complicated by other drug use were examined. Participants (N = 102) entered 6-month methadone transition treatment (MTT) and were randomized into experimental conditions: 51 entered MTT with contingency contracts using monetary reinforcers and targeting abstinence from illicit drug and alcohol use, and 51 entered MTT without contingency contracts targeting abstinence. Outcomes were evaluated by random urinalysis and breath analysis. After 4 months of treatment, individuals in the contingency condition had longer periods of continuous abstinence (p<.005) and more drug-free tests overall (p<.04). Effects were limited, however, to the contracting period. The authors conclude that contingency contracting using monetary reinforcers may be a useful adjunct for achieving abstinence from multiple drugs of abuse during MTT.

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

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

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To examine patterns of use of acute walk-in services by substance abusers, the authors studied demographic characteristics and type of substance abuse among 1,838 patients treated at a Veterans Affairs substance abuse triage unit. They found that African-American and male substance abusers appeared most likely to return for triage services. Among heroin users, the strongest predictor of return was gender. Among alcoholics, homelessness was the sole predictor of return. No predictors were found for cocaine users. The authors conclude that the relationship between return rates and type of substance abuse needs further study.

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Self-efficacy ratings coincided with illicit opioid use across the 3 phases of a 180-day methadone detoxification treatment. Efficacy ratings increased after patients received their first dose of methadone, did not change while they were maintained on a stable dose of methadone, and declined during the taper as they attempted to face high-risk situations without the full benefit of methadone. Efficacy ratings measured at a point before a phase of treatment predicted illicit opioid use across that phase. For clarification of the relation between self-efficacy and illicit opioid use, 3 conceptual models proposed by J.S. Baer, C.S. Holt, and E. Lichtenstein (1986) were tested. Self-efficacy influenced subsequent drug use in parallel with previous behavior, but this influence was found only at the start of the stabilization phase and immediately before the start of the taper phase. These findings highlight the usefulness of the self-efficacy concept for the treatment of opioid addiction.

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

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The clinical research information system (CRIS) at the San Francisco VA Medical Center was designed to provide information on use of services and treatment outcomes and to support the clinics for treatment of substance abuse. This system fills a niche often neglected by centralized hospital systems, which are usually designed to satisfy administrative demands for automated fiscal functions, but not designed to support patient care. Full integration with our central computing system remains a goal; for now, CRIS operates as a self-contained clinical system with several workstations linked by a telephone network.

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

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

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

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