Posttraumatic Stress Disorder in Older Alcoholic Combat Veterans

SATU at the Veterans Administration Medical Center comprises 102 beds across five inpatient programs and is a part of a large, 1300-bed psychiatric hospital. SATU programs include medical detoxification, 45-day alcohol and 45-day drug therapeutic communities, a 45-day therapeutic community for older veterans or veterans with serious psychiatric disorders, and one 14-day skills-training, relapse prevention program. SATU has been in existence since 1975. Our patients’ average age is 40 years, with a range of 19-69 years. The racial mix of admitted patients is approximately 65% white, 32% black, and 3% Hispanic. Over a given year, SATU discharges approximately 1200 patients. These patients seek services for alcohol and other substance abuse/ dependence disorders. Patients with a primary diagnosis of alcohol dependence, with other drug use, account for approximately 40% of our case mix. Patients who are principally drug dependent, with or without other alcohol/ drug use, account for approximately 60% of our case mix. Of our admissions, just less than 50% undergo formal detoxification using therapeutic medications (e.g., Librium, methadone). Typically, when a veteran comes in for substance abuse treatment, he enters Read more […]

A Point of View Concerning Treatment Approaches with Narcotic Antagonists

When narcotic antagonists were first introduced into the treatment of drug addiction, patients were placed on the medication without regard to selection criteria and assessments of “successes” or “failures” were made only on the basis of their retention in the program. Since that time, however, our evaluation criteria have become more refined and we have begun to look at more complex questions such as: Are these compounds “helpful” and if so, “for whom” and by what treatment techniques can we augment their usefulness? A salient aspect of our naltrexone studies, for example, is addressed to the question of “for whom?” Hopefully when our data analysis is completed, it will contribute to either affirming or negating the conceptual model that we have formulated to aid us in the differential diagnosis and treatment of opiate dependent individuals. For my presentation today I have chosen to share with you some aspects of our point of view concerning treatment approaches based on our clinical experience. As investigators, we are all committed to the rigors of science with its demand for carefully controlled data. However, I am not addressing myself to specific research data, but rather to some issues concerning the application Read more […]

Human Dependence on Tobacco and Opioids: Common Factors

Recent years have seen increasing acceptance of the notion that tobacco is an addictive or dependence-producing substance, particularly as it is used in cigarette smoking. This idea is supported by the observations that tobacco serves as a reinforcer (i.e., it maintains behavior leading to its use) and that most people who smoke cigarettes would like to quit but cannot, even in the face of well documented health risks and economic sacrifices (Surgeon General’s Report 1979). The term “drug dependence” suggests that (1) the drug serves as a reinforcer, (2) behavior occurs which is maintained by the opportunity to take the drug, and/or (3) other reinforcers are sacrificed as a consequence of taking the drug (). Many cigarette smokers in some degree satisfy these criteria for drug dependence (). Since cigarette smoking has only recently been conceptualized as an instance of drug dependence, it should be useful to systematically compare cigarette smoking with another more thoroughly studied dependence process such as opioid dependence or narcotic addiction. At first blush, cigarette smoke and opioid drugs appear to produce vastly differing pharmacological and behavioral effects: large doses of opioids can produce Read more […]

Drug effects on behavior maintained by food, electric-shock presentation and stimulus-shock termination

Although early experiments did not find differences in drug effects depending on the type of event, more recent studies have reported several instances in which the maintaining event appeared to influence the effects of several drugs on behavior. For example, morphine, methadone, and the narcotic antagonists naloxone and nalorphine decreased responding maintained under 5-minute fixed-interval food-presentation schedules at doses that increased responding comparably maintained by the presentation of an electric shock (). Under similar schedule conditions, both amphetamine () and cocaine () increased responding maintained by these two events. However, appropriate doses of pentobarbital, ethanol, and chlordiazepoxide increased responding maintained by food, while only decreasing responding under shock-presentation schedules (). These findings suggested that there were several conditions under which certain drugs appeared to affect similar performances maintained under comparable schedules in an event-dependent manner. Further, as shown in Figure Effects of chlordiazepoxide on different control rates of responding under S-minute fixed-interval schedules of food or shock presentation. The event pen was defected downward Read more […]

Psychotherapy and Naltrexone in Opioid Dependence

An issue of current importance to psychiatry is the efficacy of psychotherapy and phamacotherapy in comparison to one another and in combination. In addiction treatment, the importance of individual counseling for the successful use of opioid antagonists such as naltrexone has often been suggested but as yet there is insufficient data to support this contention. Furthermore, naltrexone efficacy studies have not controlled for the type or degree of patients’ involvement in interpersonal aspects of treatment. The present pilot study evaluated the effectiveness of naltrexone in conjunction with a high intervention treatment that included individual counseling as compared with a low intervention treatment that excluded such counseling. Method Sixty-six opioid-dependent volunteers were randomly assigned at intake to either a low intervention (N=31) or high intervention (N=35) treatment group. All subjects were over 18 years of age, had been addicted to opiates for at least one year, were free of serious medical and psychiatric illness and signed an informed consent. An attempt was made to match the two groups for level of opioid dependence immediately prior to entering the study and number of subjects who entered the study Read more […]

Consequences of Multiple Drug Use: Specifying the Causes

In order to illustrate these points, three specific consequences of drug use will be discussed in some detail below. These three consequences are traffic accidents, involvement in delinquent/criminal acts by youth and young adults, and emergency room visits related to drug abuse. Traffic Accidents The Monitoring-the-Future surveys contain several questions concerning traffic accidents. The seniors are first asked how many accidents (i.e., a collision involving property damage or personal injury — not bumps or scratches in parking lots) they had while they were driving in the past 12 months. If the answer is one or more, the senior is asked how many occurred after he/she was drinking alcoholic beverages and then how many occurred after he/she was smoking marijuana or hashish. By piecing together the information from these separate questions, it is possible to estimate the proportion that would be due to alcohol, to marijuana, and to alcohol and marijuana. The data in Table “Motor Vehicle Accidents and Their Connection to Use of Alcohol, Use of Marijuana, and Use of Both Alcohol and Marijuana” are for seniors in the class of 1980 classified according to the extent of alcohol and marijuana use reported during the Read more […]

The Epidemiology of Multiple Drug Use

How much multiple drug use is there? What proportion of the population at any one point in time is using/abusing multiple substances? Has use of multiple substances become more normative in the recent past as opposed to exclusive use of a favorite drug? What are the principal consequences of multiple drug use? Do these consequences differ according to pharmacological parameters for interactive potential or are there other parameters of almost equal predictive value? To what extent are the consequences attributed to single drugs (traffic accidents labeled as alcohol related) really the result of impaired judgment and performance from ingestion of multiple substances? These are just a few of the questions that need to be addressed within the scientific and public policy communities. In the following section some epidemiological data pertinent to understanding the “extent” of multiple drug use are presented. Monitoring-the-Future Studies Each year since 1975, researchers at the Institute for Social Research at the University of Michigan have administered questionnaires to about 17,000 high school seniors attending schools randomly chosen to be representative of all high schools in the continental United States. These Read more […]

Drug Impairment Reviews: Opiates and Minor Tranquilizers

STUDY: Gordon, N.B. Reaction Times of Methadone-Treated Heroin Addicts. Psychopharmacologia, 16:337-344. 1970. Site: Rockefeller University and Yeshiva University, New York City, New York. Subjects: The subjects were divided into six groups. Groups 1 and 3 both had been maintained for at least 1 year on methadone for the treatment of heroin addiction. Group 1 had 18 males whose average age was 32.5 years; group 3 had 9 females whose average age was 33.5 years. Group 2 consisted of 20 unpaid male volunteers who did not use drugs; they averaged 32.5 years. The participants in groups 4 and 5 had recently withdrawn from narcotic drugs. The 20 males in group 4 averaged 31.5 years and had withdrawn 14 days earlier. The 19 males in group 5 averaged 30 years and had withdrawn 4 days earlier. Group 6 consisted of 9 females whose average age was 23 years. They were paid volunteers from the nonprofessional hospital staff, and did not use drugs. Method: Measurements were taken under controlled laboratory conditions; urines were tested (details were not given) for drugs to assure conformity to group. Variations of reaction time were tested in a button-pressing situation: (a) simple reaction time (one of six stimuli); (b) Read more […]

Measurement and Extinction of Conditioned Withdrawal-Like Responses in Opiate-Dependent Patients

As O’Brien has reviewed elsewhere in this volume (), there has been much experimental work on opiates and Pavlovian conditioning processes since Wikler’s original observations of withdrawal-like responses in drug-free patients (). Several studies have found evidence of conditioned withdrawal-like and opiate-like responses in rats, monkeys, and humans (). Addict patients viewing slides or videotapes of drug-related stimuli () or handling drug objects in a preparation ritual () experience subjective craving and withdrawal-like changes in physiological measures of skin temperature, heart rate, pupillary dilation, etc. Research from our own laboratory has demonstrated that opiate withdrawallike responses in humans can be conditioned to an arbitrary conditioned stimulus (). These studies leave little doubt that conditioned withdrawal-like phenomena exist and can be both reliably elicited and measured. They do not, however, address the clinical significance of these responses. Though Wikler (1948) proposed conditioned withdrawal as the primary cause of relapse in drug-free patients, this link has not been clinically tested and is still controversial. Based on interviews with Baltimore street addicts, McAuliffe () had recently Read more […]

Buprenorphine, Heroin, and Methadone: Comparison of Relative’ Reinforcing Properties

Buprenorphine is a partial agonist of the morphine type. It is both a long-acting opiate antagonist, like naltrexone, and a potent opiate agonist with respect to analgesia, physiological and subjective reactions in man (). However, buprenorphine does not induce physical dependence in several species and appears to produce only minimal physical dependence in man (). Buprenorphine’s positive morphine-like agonist effects combined with its antagonist potency, low toxicity, and minimal capacity for producing physical dependence, suggested that it should be valuable for the treatment of opiate addiction (). Clinical studies have shown that buprenorphine maintenance (8 mg/ day s.c.) significantly suppressed self-administration of heroin (21 to 40.5 mg/day) by male heroin addicts over 10 days of heroin availability in comparison to buprenorphine placebo (). Buprenorphine (0.282 to 0.789 mg/kg/day i.v.) also significantly suppressed opiate self-administration in the rhesus monkey drug self-administration model (). Recent clinical studies have shown that sublingual administration of buprenorphine (1-2 mg) should be suitable for daily maintenance for the treatment of narcotic addiction (). The opiate agonist effects of Read more […]