by Robert L. DuPont, David W. Griffin, Bernard R. Siskin, Sarah Shiraki and Edward Katze
page 1-17
Random drug testing in the workplace has become more common since federal guidelines were issued in 1988, despite the criticism that most positive tests are the result of occasional use of illicit drugs. In order to determine the relative probabilities of detecting frequent versus infrequent users of illicit drugs, a survey of 15 experts in the drug abuse field was conducted. Based on the responses, it was estimated that 55% of employed people who used any illicit drugs in the prior year were annual drug users, 37% were monthly users, and 8% were daily users. Analysis using probability theory indicated that among workplace drug users who test positive, 52% will be daily users, 41% will be monthly users , and only 7% will be annual users. At a 50% testing rate, random drug tests identify 40% of daily users, 8% of monthly users and only 1% of annual users during the course of a year. The estimated rate of illicit drug use among employees is approximately eight times the average random testing positive rate. Random drug tests in the workplace are effective in identifying near daily users of illicit drugs, but they are less effective at identifying infrequent drug users. Employers have found that random drug testing is a deterrent to both frequent and occasional use of illicit drugs.
by Michael Jon Kell
page 19-34
Objective: In contrast with the non-opiate dependent population, persons biologically-dependent upon opioids display an excess life-time prevalence of affective and anxiety disorders. Many of these addicts state that opiates, particularly methadone, relieve or diminish the severity of their dysphoria. The purpose of this study is to explore this phenomena by analyzing how a specific population of long-term addicts (mean years of addiction 16.9, SD 3.8) differs from a non-opiate dependent population regarding seasonality of birth.
Methods: Birth months were determined for 457 opiate dependent patients, placed onto methadone maintenance for intractable opiate dependence, born between 1930-1970 (sorted by sex, race, year and place of birth), and compared to normal US birth statistics. Affective and anxiety disorders were screened for using psychometric testing, verified by structured clinical interviews.
Results: A significant difference was noted when comparing monthly birth rates for patients and normals. Grouping the monthly data into birth trimesters (Oct-Jan; Feb-May; Jun-Sep) clearly shows this difference: opioid dependent persons - 38.5/29.8/31.8%; normals - 33.4/32.0/34.7%. As a group, intractable, opioid dependent patients demonstrate an increased life-time prevalence, relative to normals, of anxiety (27.8 vs. 13.9%), dysthymia (23.4 vs. 6.4%) and combined anxiety + dysthymia (17.9 vs. 1.5%); opioid dependent persons born between Oct-Jan demonstrated more anxiety (32.0 vs. 25.1%), dysthymia (29.3 vs, 19.5) and combined anx + dys (23.3 vs. 14.4) than those born in the other two trimesters.
Conclusion: Persons entering methadone maintenance for opiate dependence with comorbid anxiety, dysthymia or combined anxiety + dysthymia are more likely to have been born in the period of Oct-Jan. This may be due to a higher risk of developmental aberrations occurring in infants born during the light-limited portion of the year creating a later propensity for intractable, opiate dependence.
by Forest Tennant and David Moll
page 35-49
To determine the most prevalent forms of hepatitis in intravenous heroin addicts, 389 addicts consecutively admitted to outpatient treatment clinics throughout California were tested for antibodies to hepatitis A (anti-HAV), B core (anti-HBc), B surface (anti-HBs), C (anti-HCV), D (anti-HDV), and B surface antigen (HBsAg). The majority were also tested for serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase, lactic dehydrogenase, total bilirubin, globulins, albumin, and platelet count. The seroprevalence of each marker was: anti HAV (40.7%); anti-HBc (73.6%); anti HBs (46.7%); anti-HCV (93.6%); anti-HDV (9.6%), and HBsAg (3.5%). No single case was positive for IgM, anti-HAV, or for both HBsAg and anti-HDV, indicating the presence of recent hepatitis A or hepatitis D infection. Abnormal liver enzymes, serum proteins, total bilirubin, and platelet count were found to be abnormal in 5.3 to 44.8% of anti-HCV cases indicating persistent infection. Among anti-HCV cases, elevated total bilirubin or a low platelet count was invariably associated with one or more liver enzyme and protein abnormalities. We conclude that while acute hepatitis may be frequent and caused by various viral types, hepatitis C is the primary form of chronic hepatitis found in intravenous heroin addicts. Almost half of hepatitis C cases demonstrate liver function abnormalities indicating persistent infection that has the potential to be contagious and progress to cirrhosis, liver failure, and hepatocellular carcinoma.
by Robert C. Freeman, Gloria M. Rodriguez and John F. French
page 51-66
Data from an AIDS Demonstration Research project in Paterson, NJ, that enrolled out-of-treatment injection drug users (IDUs) were analyzed to detect demographic patterns and risk factors associated with infection with human immunodeficiency virus (HIV) and human T-lymphotropic virus types I or II (HTLV-I/II). Of 410 IDUs screened, 44.2% were HIV-positive and 19.3% were HTLV-I/II positive. African-Americans were significantly more likely than other racial groups to be HTLV-I/II-seropositive and to be HIV-seropositive. Over one-fifth of African-Americans - but no Latinos or whites - were doubly infected with HIV and HTLV-I/II. In logistic regression analysis, African-American race, long-term injection drug use, and age were significant predictors of HTLV-I/II-seropositivity. While the associations between recent needle practices and HTLV-I/II-seropositivity fell short of significance, the trends in the data were consistent with a hypothesis that HTLV-I/II is transmitted through the sharing of injection equipment. Public health implications of the data are discussed.
by Dominique L. Musselman and Michael Jon Kell
page 67-82
Questions continue in the literature concerning potential cause and effect relationships between opiate dependency and several organically-based psychiatric disorders. For example, does opiate dependency produce secondary anxiety and dysthymic syndromes in otherwise healthy persons? or is narcotics misuse by a patient an attempt to self-medicate pre-existing psychopathology? Does the severity of psychopathologic symptoms decrease with time in treatment? To resolve such questions, we routinely conduct psychiatric evaluations on all opioid dependent patients enrolled into methadone maintenance. In this study, we report upon treatment outcomes for a cohort of 71 patients evaluated for psychopathology upon intake and followed up after being in treatment for a mean time of 24.5 (SD 8.0) months. Based upon objective psychometric testing with confirmatory clinical interview, significant, longitudinal improvements were seen in the symptom severity of anxiety and dysthymia present upon intake evaluation. Personality profiles also improved with treatment. In general, patients presenting with more severe psychopathology required more visits with professional staff in order to stabilize their life situations and personal relationships. No correlation was noted between drug use and severity of psychopathology. Data support the thesis that many opioid dependent patients are self-medicating themselves for preexisting organic psychopathology, most commonly, a combined anxiety-dysthymia syndrome. Improvement seems to occur secondary to the mood stabilizing properties of methadone in disorders thought to be mediated or moderated by endogenous endorphins rather than because of psychotherpeutic interventions.
by Lisa Borg, Ann Ho, Julie E. Peters and Mary Jeanne Kreek
page 83-96
Methadone, when used in the appropriate dose, prevents opioid withdrawal during the 24-hour period following medication. However, the appropriate dose for a given patient may be difficult to determine due to variations in methadone metabolism which is affected by many factors. Early opioid withdrawal, requiring a higher dose of methadone, is often difficult to diagnose because many of the symptoms are also symptoms of other syndromes common in the methadone maintenance population. In this study, ten patients in stable methadone maintenance treatment reporting >/= 4 Himmelsbach signs of abstinence were compared with 10 patients reporting fewer symptoms. Until recently, accurate, precise, and affordable determination of serum methadone level has not been readily available from commercial laboratories. This study has found that such measures are now available. Serum specimens from each subject were sent to three commercial laboratories for determination of serum methadone level. Results from the three laboratories were highly correlated. No statistical correlation was found between serum methadone level and number of Himmelsbach signs. Of the subjects reporting four or more symptoms, 40% had low serum methadone levels (<150 ng/ml); 60% did not. Of the subjects reporting fewer than four symptoms, 90% had serum methadone levels >/= 150 ng/ml. Subjects with >/= 4 Himmelsbach signs had lower dose adjusted serum methadone levels, the amount of methadone circulating per mg dose, (t = 1.54, p < .0702). Thus for patients who report symptoms which could be attributable to opioid withdrawal, measurement of serum methadone level may help to differentiate complaints due to early abstinence from those due to other medical conditions.
by Peggy A. Compton, Walter Ling, V. Charles Charuvastra and Donald R. Wesson
page 97-114
The partial m-opiate agonist, buprenorphine, is the subject of recent evaluation as a potential pharmacotherapy for cocaine dependence. This paper reviews the extant preclinical and clinical evidence of buprenorphine effectiveness in treating cocaine abuse, including data from our large methadone comparison trial and a smaller buprenorphine dose ranging study. Although buprenorphine appears to reduce the cocaine self-administration in studies of non-opiate dependent animals, clinical evidence for the same response in opiate addicts abusing cocaine has not been demonstrated. Further efficacy trials should await preclinical demonstrations of effectiveness in samples with opiate and cocaine exposure.
Issues in Illicit Drug Use: Diagnosis, Management, and Treatment
by Lynn Kasner Morgan
page 115-127
Public Policy Statement on Primary Medical Care for HIV Infected Patients in Addiction Treatment
page 129-130
Public Policy Statement on HIV Testing of Patients in Addiction Treatment Facilities
page 131-133
8th National Conference on Nicotine Dependence October 12-15, 1995 Toronto, Ontario, Canada
Transcribed by Emma McCulloch
20 October 1998