National Institute on Drug Abuse
Director's Report to the National Advisory Council on Drug Abuse
Clinical and Services Research
Mortality Following Inpatient Addictions Treatment: Role of Tobacco Use in Community-Based Cohort
In a population-based retrospective cohort study, Hurt et al. examined the medical records of 845 residents (mean age of 41.4 years, 35% women) of Olmstead County (Rochester, Minnesota) from the time they were admitted to Mayo's inpatient alcoholism treatment unit (between 1972 and 1983) through 1994. The underlying cause of death was classified as alcohol, tobacco related, both, or neither based on the classification from the CDC. About 75% of those admitted for alcoholism treatment were long-term heavy smokers. The investigators found that 222 patients died (death certificates were available for 214) at a death rate 2.5 times greater than what would be expected in a group of people at this age and sex. Of the deaths, 51% were due to tobacco-related causes, most notably heart disease, emphysema and lung cancer; and 34% (73) deaths were due to alcohol-related causes, including accidents, liver disease and suicide. The authors conclude that patients previously treated for alcoholism and/or other non-nicotine drug dependence had an increased cumulative mortality that was due more to tobaccorelated than to alcohol-related causes and that nicotine dependence treatment is imperative in such high-risk patients. Richard D. Hurt, Kenneth P. Offord, Ivana T. Croogan, Leigh Gomez-Dahl, Thomas E. Kottke, Tobert M. Morse, and L. Joseph Melton, JAMA, 275(14): pp. 1097-1108, April 10, 1996.
Diagnosis and Clinical Assessment
Drs. Chung, Langenbucher, Labouvie, and Morgenstern have reported on the results of their large scale diagnostic project at the Rutgers University Center of Alcohol Studies. In a sample of 295 substance users seeking treatment, data on symptomatology associated with DSM-IV substance use disorders were collected by administering the Comprehensive International Diagnostic Instrument-Expanded Substance Abuse Module (CIDI-SAM) and used to determine, by gender, the developmental sequence of symptoms for cannabis, cocaine, and alcohol. Results indicated important differences in the sequential development of dependence symptoms as they related to drug-of-choice and gender. Males acquired fewer symptoms of dependence than did women during an equal period of time. Results also suggested that a distinct sequence of symptoms of cocaine dependence emerges for men and for women, unlike the moderately correlated order in which symptoms appear in men and women for cannabis and alcohol dependence. In summary, cocaine dependence may present a unique problem, emerging with more malignancy than marijuana and alcohol and following a different developmental pattern for males and females.
Smoking Cessation and Heart Disease
Dr. Joy Schmitz from the University of Texas Health Science Center at Houston is studying two treatments for tobacco dependence in women with heart disease: 1) a coping-skills relapse prevention (RP) intervention; or 2) an educational intervention based on the health belief model (HBM). Pretreatment measures are also being examined to determine whether they predict differential response to the two interventions. Results to date show a significant reduction in mean smoking rate and CO level in both treatment conditions across sessions, with a non-significant trend favoring RP treatment over HBM. There is early evidence of important differential treatment effects as a function of patient characteristics, such as age and baseline level of self-esteem. For older subjects, the probability of quitting smoking is higher when receiving RP rather than HBM. For younger subjects, the probability of quitting smoking is relatively equal for the two treatments. Subjects with high self esteem respond better with RP, and those with low self-esteem respond relatively equally to the two treatments. Schmitz, J.M., Bordnick, P.S., & Le, T. Smoking Cessation in Women with Heart Disease Risk: A Preliminary Comparison of Two Treatment Models. Presented at the Society for Research on Nicotine and Tobacco Annual Meeting, Washington, D.C., March, 1996.
Treatment of Smokeless Tobacco Users
Dr. Dorothy Hatsukami from the University of Minnesota examined the effects of group behavioral treatment versus minimal contact and of nicotine versus placebo gum on cessation of smokeless tobacco use in a 2x2 study. Participants were randomly assigned to one of the four treatments. Dr. Hatsukami concludes that 2 mg nicotine gum is not more successful than placebo gum with either minimal intervention or as an adjunct to behavioral treatment. However, withdrawal symptoms were significantly reduced by nicotine gum, compared with placebo during the initial phases of cessation. The ineffectiveness of nicotine gum on treatment outcome may be attributed to the relatively low level of nicotine gum or its similarity with smokeless tobacco. Secondly, behavioral treatment with and without the use of 2 mg nicotine gum produced continuous abstinence rates comparable to minimal contact without active nicotine gum. However, when point-prevalence data were analyzed, behavioral treatment demonstrated greater treatment success than minimal contact, both during and shortly after treatment. Thus it may be that smokeless tobacco users are more likely to be able to return to abstinence after a lapse if they are involved with a more intensive treatment approach. Hatsukami, D., Jensen, J., Allen, S., Grillo, M., & Bliss, R. Effects of Behavioral and Pharmacological Treatment on Smokeless Tobacco Users. Journal of Consulting and Clinical Psychology, 64, pp. 153-161, 1996.
Cinciripini et al. have recently published results showing the effects of smoking schedules on cessation outcome. Several procedures for smoking prior to quitting were compared to determine which would produce the highest abstinence rates one year later.
All procedures had a preestablished quit date and a standard behavioral intervention, including the contingent return of a $110 deposit depending on attendance, compliance with instructions, and abstinence. However, the procedures differed in having a particular schedule of smoking for the five weeks prior to the quit date. Four groups were set up to compare 1) gradual reduction by smoking at prescheduled times, 2) smoking usual amount at prescheduled times, 3) gradual reduction by smoking at self-selected times, and 4) smoking usual amount at self-selected times. Abstinence at one year was 44%, 32%, 18%, and 22% for the four groups, respectively. The highest abstinence rates were found in the two groups that were allowed to smoke at prescheduled times only. For example, in the group that had gradually reduced smoking at prescheduled times, abstinence was 44%--a remarkably high rate, considering that the nicotine patch was not used. In contrast, the worst results were found with the group which reduced smoking by lighting up at self-selected times. The abstinence in this group was only 18%. Apparently, these smokers were choosing optimal times and situations for enjoyment--and subsequently had a very high relapse rate. In comparison, the prescheduling of cigarettes meant that smoking occurred at times unrelated to critical events, such as a cup of coffee, a meal, or a period of boredom. As a result, much of the enjoyment was taken out of smoking, the stimulus control ("triggering") by critical events was disrupted, and the opportunity to learn how to cope with smoking urges was increased. The results of this research are particularly important since many smokers who try to quit choose the "common sense" procedure of cutting down at self-selected times-one of the worst procedures they could devise. Cinciripini, P. M., Lapitsky, L., Seay, S., Wallfisch, A., Kitchens, K., and Vunakis, H. V. The Effects of Smoking Schedules on Cessation Outcome: Can We Improve on Common Methods of Gradual and Abrupt Nicotine Withdrawal? Journal of Consulting and Clinical Psychology, 63, pp. 388-399, 1995.
Multisystemic Therapy for Delinquents
Dr. Scott Henggeler of the Medical University of South Carolina has recently reported that with home-based multisystemic therapy it is possible to virtually eliminate treatment dropout in delinquents. He reports that of 118 delinquents randomly assigned to either home-based multisystemic therapy or usual community services, 98% in the multisystemic therapy completed the full 5-month treatment. However, 78% of those assigned to usual community services received no substance abuse or mental health treatment in the 5 months after referral. Multisystemic therapy is a comprehensive therapy approach offering individualized treatment, the use of multiple strategies, unlimited availability of therapists, and increased accessibility of services. Henggeler, S. W., Pickrel, M. P., Brondino, M. J., Crouch, J. L. Eliminating (Almost) Treatment Dropout of Substance Abusing or Dependent Delinquents Through Home-Based Multisystemic Therapy. Am J Psychiatry 153:3, March 1996.
Retaining Cocaine-Abusing Women in a Therapeutic Community
Researchers found that cocaine abusing women whose children were living with them during residential treatment remained in the programs significantly longer than women whose children were not living with them at the facility. Some 77% of women in the Demonstration Group (with their children living in the facility) were still in the program at 3 months, compared to 45% of the Standard Group (i.e., without their children); at 6 months, the corresponding figures were 65% vs. 18%, and at 12 months 29% vs. 5% (p<.05). The average length of stay for women in the demonstration group was 300.4 days, compared to 101.9 days for women in the standard group (t=2.83, p<.05). The clear implication is that providing facilities to accommodate children is a major factor in improving retention and outcome for drug abusing mothers in treatment. In addition, having the children in the facility provides opportunities to assess and meet their needs which may, in turn, affect the mother's prognosis. Hughes, P.H., Coletti, S.D., Neri, R.L., Urmann, C.F., Stahl, S., Sicilian, D.M., Anthony, J.C. Retaining Cocaine-Abusing Women in a Therapeutic Community: The Effect of a Child Live-In Program, American Journal of Public Health, 85(8), pp. 1149-1152, 1995.
Postpartum Women in Outpatient Drug Abuse Treatment
This study compared a sample of post-partum crack-abusing women randomly assigned to an intensive day treatment program (DT) and a traditional outpatient program (OP). DT subjects were significantly more likely to remain in treatment beyond 4 months than women in the OP group (60.2% versus 46.1%; z=2.17, p=.02). The completion rate was significantly higher for DT (45%) as compared to the OP (21%) (z=3.4, p=.000). Barriers to treatment that correlated most significantly (p<.01) with retention focus on what the authors identify as personal feelings or conditions and problem denial. These include: a desire to be in another program correlated significantly (-.33); having a relapse (-.25); believing they could manage recovery on their own (-19); child's medical problems (.19); and attitudes of program staff (-.18). Strantz, I.H. and Welch, S.P. Postpartum Women In Outpatient Drug Abuse Treatment: Correlates of Retention/Completion, Journal of Psychoactive Drugs, 27(4), pp. 357-73, 1995.
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