Drug addiction, dysregulation of reward, and allostasis.

INTRODUCTION The issue of social rehabilitation and reintegration (hereafter social reintegration2) is mentioned under the third strategy target of the EU Action Plan 2000–2004. The third EU strategy target is to 'substantially increase the number of successfully treated addicts', and point 3.1.3.4 instructs that 'Member States [are] to ensure that adequate attention is paid to social and professional rehabilitation and reintegration of former addicts'. However, social reintegration is also linked to social exclusion, which is mentioned in chapter 2 of the EU Action Plan, where it is stated that 'the EMCDDA [is] to develop indicators on drug-related crime, the availability of illicit drugs (including at street level) and drug-related social exclusion'. For the EMCDDA, social reintegration comes under strategy target four – that is, as a response to social exclusion – however, target two is clearly also relevant. Social exclusion is often perceived as a cause of problem drug use, although many see it as a consequence of problem drug use. We will not elaborate on this further here, except to note that social exclusion and problem drug use are two phenomena that are very closely interlinked and that social reintegration is a possible response to both. The EMCDDA Programme 2, 'Analysis of responses', set out to identify how social reintegration is understood in each Member State and to map the availability of social reintegration facilities in Member States according to these national perceptions. It became evident at an early stage that this would be a complex task, involving extensive data collection, as national reports generally provided insufficient data on this specific subject. eight countries turned out to be difficult to map and so, in February 2002, the EMCDDA launched a call for tender for a project, 'Mapping social reintegration services in EU countries'. 3 The aim of this project was to describe the state of the art of social reintegration in the following eight countries: The research specifications, to investigate 'the state of the art of social reintegration', suggested that the following should be identified for each of the eight countries: 1 Other contributors will be mentioned in the respective chapters. 2 Our country studies so far have shown that the term 'rehabilitation' is used ambiguously across Europe – from low-threshold refuges, to normal treatment, to actual reintegration into society. For this reason, we shall use the term 'social reintegration' in this report, as this is used much more …

European Monitoring Centre for Drugs and Drug Addiction

Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a comprehensive and integrated approach to the delivery of early intervention and treatment services through universal screening for persons with substance use disorders and those at risk. This paper describes research on the components of SBIRT conducted during the past 25 years, including the development of screening tests, clinical trials of brief interventions and implementation research. Beginning in the 1980s, concerted efforts were made in the US and at the World Health Organization to provide an evidence base for alcohol screening and brief intervention in primary health care settings. With the development of reliable and accurate screening tests for alcohol, more than a hundred clinical trials were conducted to evaluate the efficacy and cost effectiveness of alcohol screening and brief intervention in primary care, emergency departments and trauma centers. With the accumulation of positive evidence, implementation research on alcohol SBI was begun in the 1990s, followed by trials of similar methods for other substances (e.g., illicit drugs, tobacco, prescription drugs) and by national demonstration programs in the US and other countries. The results of these efforts demonstrate the cumulative benefit of translational research on health care delivery systems and substance abuse policy. That SBIRT yields short-term improvements in individuals' health is irrefutable; long-term effects on population health have not yet been demonstrated, but simulation models suggest that the benefits could be substantial.

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Screening, Brief Intervention, and Referral to Treatment (SBIRT): Toward a Public Health Approach to the Management of Substance Abuse.

Objective: To assess whether incentives improved treatment outcome in ambulatory cocaine-dependent patients. Method: Forty cocaine-dependent adults were randomly assigned to behavioral treatment with or without an added incentive program. The behavioral treatment was based on the Community Reinforcement Approach and was provided to both groups. Subjects in the group with incentives received vouchers exchangeable for retail items contingent on submitting cocaine-free urine specimens during weeks 1 through 12 of treatment, while the group without incentives received no vouchers during that period. The two groups were treated the same during weeks 13 through 24. Results: Seventy-five percent of patients in the group with vouchers completed 24 weeks of treatment vs 40% in the group without vouchers ( P =.03). Average durations of continuous cocaine abstinence documented via urinalysis during weeks 1 through 24 of treatment were 11.7±2.0 weeks in the group with vouchers vs 6.0±1.5 weeks in the group without vouchers ( P =.03). At 24 weeks after treatment entry, the voucher group evidenced significantly greater improvement than the no-voucher group on the Drug scale of the Addiction Severity Index (ASI). and only the voucher group showed significant improvement on the ASI Psychiatric scale. Conclusions: Incentives delivered contingent on submitting cocaine-free urine specimens significantly improve treatment outcome in ambulatory cocainedependent patients.

Incentives Improve Outcome in Outpatient Behavioral Treatment of Cocaine Dependence

Background: Major studies of psychiatric comorbidity in opioid abusers reported rates of comorbidity that far exceeded general population estimates. These studies were published more than a decade ago and reported on few women and few substance use diagnoses. Methods: Psychiatric and substance use comorbidity was assessed in 716 opioid abusers seeking methadone maintenance. Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition diagnostic assessment was conducted 1 month after admission. Rates of psychiatric and substance use disorder were compared by gender, and associations were assessed between psychiatric comorbidity and dimensional indexes of substance use severity, psychosocial impairment, and personality traits. Results: Psychiatric comorbidity was documented in 47% of the sample (47% women and 48% men). Antisocial personality disorder (25.1%) and major depression (15.8%) were the most common diagnoses. Patients had at least 2 substance use diagnoses, most often opioid and cocaine dependence. Demographics, substance use history, and personality variables discriminated between patients with vs without comorbidity. Psychiatric comorbidity also was associated with a more severe substance use disorder. Conclusions: Psychiatric comorbidity, especially personality and mood disorder, was common in men and women. The positive associations between psychiatric comorbidity and severity of substance use and other psychosocial problems were most consistent among those with antisocial personality.

Psychiatric and Substance Use Comorbidity Among Treatment-Seeking Opioid Abusers

Objective. To examine whether the addition of counseling, medical care, and psychosocial services improves the efficacy of methadone hydrochloride therapy in the rehabilitation of opiate-dependent ...

The Effects of Psychosocial Services in Substance Abuse Treatment

• We performed a double-blind, placebo-controlled, randomized 12-week trial of desipramine hydrochloride treatment of cocaine dependence among methadonemaintained patients. Fifty-nine patients completed the 12-week medication trial (36 received desipramine and 23 received placebo), and 94% were recontacted 1, 3, and 6 months after treatment. There were significantly more dropouts in the desipramine than in the placebo group. Baseline to 12-week comparisons of Addiction Severity Index interview data indicated that both groups showed improvements. At 12 weeks, the desipramine group showed significantly better psychiatric status than the placebo group but did not differ from the placebo group on any of 21 other outcome measures, including cocaine use. During the 12-week medication phase and at the 1-month follow-up evaluation, urine toxicology screenings showed no significant difference between groups, but the placebo group had significantly less cocaine use at both the 3- and 6-month follow-up points. We conclude that desipramine has few benefits with regard to control of cocaine use in this population.

https://jamanetwork.com/journals/psych/articlepdf/495946/archpsyc_49_11_008.pdf

Desipramine treatment of cocaine dependence in methadone-maintained patients.

Five men in a methadone treatment program who were also receiving desipramine had significantly higher desipramine serum levels when taking both drugs than when taking the antidepressant alone. Monitoring of desipramine serum levels may be useful with such patients.

I. O. Arndt

Papers

The Effects of Psychosocial Services in Substance Abuse Treatment

Desipramine treatment of cocaine dependence in methadone-maintained patients.

Increase in desipramine serum levels associated with methadone treatment.

Abstinence treatments for opiate addicts: Therapeutic community or naltrexone?: (471442004-001)