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We examined the occurrence of violent traumatic events, DSM-III-R diagnosis of posttraumatic stress disorder (PTSD), and PTSD symptoms, and the relationship of these variables to drug abuse severity. One-hundred fifty opioid-dependent drug abusers who were participants in a randomized trial of two methadone treatment interventions were interviewed using the Diagnostic Interview Schedule, the Addiction Severity Index, and the Beck Depression Inventory. Twenty-nine percent met diagnostic criteria for PTSD. With the exception of rape, no gender differences in the prevalence of violent traumatic events were observed. The occurrence of PTSD-related symptoms was associated with greater drug abuse severity after controlling for gender, depression, and lifetime diagnosis of PTSD. The high rate of PTSD among these methadone patients, the nature of the traumatic events to which they are exposed, and subsequent violence-related psychiatric sequelae have important implications for identification and treatment of PTSD among those seeking drug abuse treatment.

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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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BACKGROUND: A history of major depressive disorder (MDD) predicts failure to quit smoking. We determined the effect of nortriptyline hydrochloride and cognitive-behavioral therapy on smoking treatment outcome in smokers with a history of MDD. The study also addressed the effects of diagnosis and treatment condition on dysphoria after quitting smoking and the effects of dysphoria on abstinence. METHODS: This was a 2 (nortriptyline vs placebo) x 2 (cognitive-behavioral therapy vs control) x 2 (history of MDD vs no history) randomized trial. The participants were 199 cigarette smokers. The outcome measures were biologically verified abstinence from cigarettes at weeks 12, 24, 38, and 64. Mood, withdrawal, and depression were measured at 3, 5, and 8 days after the smoking quit date. RESULTS: Nortriptyline produced higher abstinence rates than placebo, independent of depression history. Cognitive-behavioral therapy was more effective for participants with a history of depression. Nortriptyline alleviated a negative affect occurring after smoking cessation. Increases in the level of negative affect from baseline to 3 days after the smoking quit date predicted abstinence at later assessments for MDD history-negative smokers. There was also a sex-by-depression history interaction; MDD history-positive women were less likely to be abstinent than MDD history-negative women, but depression history did not predict abstinence for men. CONCLUSIONS: Nortriptyline is a promising adjunct for smoking cessation. Smokers with a history of depression are aided by more intensive psychosocial treatments. Mood and diagnosis interact to predict relapse. Increases in negative affect after quitting smoking are attenuated by nortriptyline.

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Earlier research indicated that a 10-session mood management (MM) intervention was more effective than a 5-session standard intervention for smokers with a history of major depressive disorder (MDD). In a 2 x 2 factorial design, the present study compared MM intervention to a contact-equivalent health education intervention (HE) and 2 mg to 0 mg of nicotine gum for smokers with a history of MDD. Participants were 201 smokers, 22% with a history of MDD. Contrary to the earlier findings, the MM and HE interventions produced similar abstinence rates: 2 mg gum was no more effective than placebo. History-positive participants had a greater increase in mood disturbance after the quit attempt. Independent of depression diagnosis, increases in negative mood immediately after quitting predicted smoking. No treatment differences were found in trends over time for measures of mood, withdrawal symptoms, pleasant activities and events, self-efficacy, and optimism and pessimism. History-positive smokers may be best treated by interventions providing additional support and contact, independent of therapeutic content.

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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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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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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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Depression, whether conceptualized as a trait, symptom, or as a diagnosable disorder, is overrepresented among smokers. Depressed smokers appear to experience more withdrawal symptoms on quitting, are less likely to be successful at quitting, and are more likely to relapse. This article documents these relationships and explores several potential links between smoking and depression. The potential efficacy of antidepressant therapy, cognitive-behavioral therapy, and nicotine replacement therapy for smokers with depressive disorders or traits is discussed. Clinical implications and the role of patient treatment matching are also discussed.

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As the United States continues its "War on Drugs," physicians who prescribe opioids for the purpose of pain control must recognize that legal issues are an important part of the prescription process. Physicians who do not correctly prescribe opioids may mark their patients as drug abusers and themselves as misprescribers. Efforts are under way to characterize appropriately the conditions under which opioids should be prescribed for the management of pain. California and Texas have passed intractable pain laws, which permit the prescribing of opioid medication for chronic pain patients. These laws were necessary because claims were made against prescribers who legitimately administered opioids to chronic pain patients. Physicians must be aware that once a patient has been diagnosed an addict, it is not legal to prescribe opioids for the purpose of maintaining or detoxifying that patient; treatment of pain is still permissible, however. It is clear that new standards of care must be developed to reduce the liability of legitimate prescribers from sanctions in either criminal or civil settings. With new standards of care, prescriptions for opioids written in good faith for the treatment of pain should survive legal scrutiny.

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Addiction medicine specialists, besieged with the adverse consequences of opioids, not unreasonably develop reservations about their use. Opioid prohibition may be appropriate when working with addicts, but drug abstinence is not always the most appropriate nor optimal treatment of pain patients. Consultation concerning the management of chronic pain patients may require an attitude adjustment of challenging proportions for the addiction medicine specialist; it is a role substantially different from that usually assumed in treating alcohol- and drug-dependent patients. Rather than relentlessly pursuing psychotropic drug abstinence as the treatment goal, restoration of function should be the primary treatment goal for the chronic pain patient. Unlike the chemically dependent patient whose level of function is impaired by substance use, the chronic pain patient's level of function may improve with adequate, judicious use of medications, which may include opioids. Evaluating for addiction in a patient who is prescribed long-term opioids for pain control is often problematic. While the concept of addiction may include the symptoms of physical dependence and tolerance, physical dependence and/or tolerance alone does not equate with addiction. In the chronic pain patient taking long-term opioids, physical dependence and tolerance should be expected, but the maladaptive behavior changes associated with addiction are not expected. Thus, it is the presence of these behaviors in the chronic pain patient that is far more important in diagnosing addiction.

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During the past several years, there has been an increasing recognition and acceptance that the use of tobacco products often produces nicotine dependence and nicotine addiction. Despite this, the substance abuse treatment community has been slow to promote smoking cessation for patients who are in substance abuse treatment for another addiction. Dogma, although starting to change, persists that cigarette smoking pales in comparison to other addictions and should not be addressed at the time of initial treatment for another addiction. The limited research to date, which will be reviewed in this article, does not support this dogma. In addition, patients presenting for substance abuse treatment report high interest in stopping smoking, including interest in stopping when they initially present for substance abuse treatment.

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Alternative explanations for symptoms that occur during the period of drug (medical or nonmedical) withdrawal are examined. These symptoms are not necessarily due to the discontinuation of the drug and should be considered when treating a patient for a withdrawal syndrome. The rationale behind treating withdrawal syndromes and criteria to consider for hospitalizing a patient during the withdrawal period are discussed. The main focus of this article is the appropriate use of prescription drugs for treating withdrawal syndromes. In addition, protocols of the Drug Detoxification, Rehabilitation, and Aftercare Project of the Haight Ashbury Free Clinics are reviewed in detail. Finally, information is provided on some potentially promising medications that are currently being investigated for the treatment of withdrawal.

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As the significance of drug use and/or abuse in the workplace is explored, and the public is encouraged to embrace the War on Drugs, policymakers and treatment personnel must not concentrate only on illicit drugs but on licit drugs as well. This article explores the impact of cigarette smoking in the workplace and reviews alternatives for decreasing or eliminating exposure to involuntary smoke in the workplace.

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Since the 1988 Surgeon General's report on nicotine addiction, more attention is being given to nicotine dependence as a substantial contributing factor in cigarette smokers' inability to quit. Many new medications are being investigated for treating nicotine withdrawal and for assisting in long-term smoking abstinence. Medications alone probably will not be helpful; they should be used as adjuncts in comprehensive smoking abstinence programs that address not only the physical dependence on nicotine but also the psychological dependence on cigarette smoking.

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The U.S. Surgeon General's 1988 report on nicotine addiction has increased the need for the substance abuse treatment community to become more involved in smoking cessation programs. A unique approach to nicotine detoxification has been developed at the Haight Ashbury Free Clinics' Drug Detoxification, Rehabilitation and Aftercare Project. After an evaluation by a physician, a thorough explanation of the treatment plan, and if the patient is interested, a combination of clonidine via the transdermal patch (Catapres-TTS) and of nicotine replacement via nicotine polacrilex (Nicorette) is used. By combining a Nicorette taper with clonidine, the physician can control the rate of nicotine withdrawal (Nicorette) and the extent to which withdrawal symptoms are treated (clonidine). This appears to be an effective, comfortable method for detoxification from cigarettes and nicotine. Its use should prove helpful as an adjunct to a comprehensive smoking cessation program.

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