[Pharmacological Treatment in Alcohol-, Drug- and Benzodiazepine-Dependent Patients – the Significance of Trazodone.]

[Pharmacological treatment in alcohol-, drug- and benzodiazepine-dependent patients – the significance of trazodone.]

Neuropsychopharmacol Hung. 2013 Jun; 15(2): 85-93
Funk S

Currently detoxification of drug and alcohol dependent patients is pharmacologically unresolved, and long-term treatment following the acute phase is also not very successful including a high number of relapses. We would need medications that on the short term cease: the severe vegetative symptoms, the pain, the extremely distressing psychosyndrome characterised by restlessness, anxiety or acute depressive symptoms, and the craving. The optimal would be if there was one medication capable of simultaneously alleviating or diminishing all the above symptoms without causing dependency and preventing relapse in the long-term. Dependency is almost all cases accompanied by primary and/or secondary mood disorder or sleep disorder which should also be treated. It should be considered, however, that following withdrawal of the agent benzodiazepine dependency often develops. The serotonin antagonist and reuptake inhibitor (SARI) trazodone is effective in the treatment of depression accompanied by sleeping disorder and it has also shown efficacy in alcohol and benzodiazepine-dependency. Its administration may improve the efficacy of detoxification and treatment of following conditions, may decrease medication load and the risk of the development of benzodiazepine dependency. In our clinical practice we frequently use this agent to treat our patients simultaneously suffering from depression and addiction problems, gaining experience comparing it to other pharmacotherapies (benzodiazepines or other antidepressants). The medication is not approved for alcohol and drug dependence, however, treatment t of comorbid conditions is not against to the official recommendations. Our aim was, in addition to reviewing the literature, to share our experience which, although cannot be considered an evidence based study, we deemed worthy of publishing. We cannot, at this point, put forward a protocol addressing all related scientific problems and problems of off-label treatment, and we could not so far treat enough patients with trazodone so that our results would be statistically proven. “Acute” and long term treatment of dependency is not sufficiently effective with a substantial relapse rate, which is in part related to the lack of specific medication also for long term treatment. Among the available psychopharmacons, trazodone is a possible choice, since, as based on patients’ reports and clinical observations, improvement of their depressive conditions and sleep problems potentially decreases the risk of relapse of drug and alcohol dependence. HubMed – addiction

Residential Placement for Veterans With Addiction: American Society of Addiction Medicine Criteria vs. a Veterans Homeless Program.

J Nerv Ment Dis. 2013 Jul; 201(7): 567-71
Westermeyer J, Lee K

The goal of this study was to compare placements of patients with addiction undertaken by a) a unidimensional, protocol-driven, independent “permanent” housing “wet” program versus b) a multidimensional, patient-individualized, contingency-based housing approach. The sample consisted of eight veterans in a single team’s panel admitted to a housing program and eight matched veterans on the verge of homelessness placed by the team according to the American Society of Addiction Medicine (ASAM) criteria. The two groups (matched for sex, race-ethnicity, and age [SD, 5 years]) were similar on demography, substance disorder, and psychiatric comorbidity. Measures consisted of a) description of the placements, b) 12-month postplacement outcomes using a 12-item scale, and c) a Drug Abuse Research Project-based 10-item scale to assess recovery processes at two 6-month preplacement and two 6-month postplacement intervals. The veterans in the housing program escalated drinking and/or drug use; all were readdicted by the end of 12 months after placement. In the ASAM-criteria group, five of the eight patients had brief slips lasting 2 days or less, but none were readdicted at 12 months. The housing program group experienced five nontrivial outcomes: three imprisonments for felonies, one life-threatening medical complication, and one death. In conclusion, the findings support close monitoring and relevant contingencies using the ASAM criteria in the treatment of substance use disorder. HubMed – addiction

Reduced Abuse, Therapeutic Errors, and Diversion Following Reformulation of Extended-Release Oxycodone in 2010.

J Pain. 2013 Jun 28;
Severtson SG, Bartelson BB, Davis JM, Muñoz A, Schneider MF, Chilcoat H, Coplan PM, Surratt H, Dart RC

This study evaluated changes in abuse exposures, therapeutic error exposures, and diversion into illegal markets associated with brand extended-release oxycodone (ERO) following introduction of reformulated ERO. Original ERO and reformulated ERO street prices also were compared. Data from the Poison Center and Drug Diversion programs of the Researched Abuse, Diversion and Addiction-Related Surveillance (RADARS) System were used. Quarterly rates 2 years prior to introduction of reformulated ERO (October 2008 through September 2010) were compared to quarterly rates after introduction (October 2010 through March 2012) using negative binomial regression. Street prices were compared using a mixed effects linear regression model. Following reformulated ERO introduction, poison center ERO abuse exposures declined 38% (95% confidence interval [CI]: 31-45) per population and 32% (95% CI: 24-39) per unique recipients of dispensed drug. Therapeutic error exposures declined 24% (95% CI: 15-31) per population and 15% (95% CI: 6-24) per unique recipients of dispensed drug. Diversion reports declined 53% (95% CI: 41-63) per population and 50% (95% CI: 39-59) per unique recipients of dispensed drug. Declines exceeded those observed for other prescription opioids in aggregate. After its introduction, the street price of reformulated ERO was significantly lower than original ERO.This article indicates that the abuse, therapeutic errors, and diversion of ERO declined following the introduction of a tamper-resistant reformulation of the product. Reformulating abused prescription opioids to include tamper-resistant properties may be an effective approach to reduce abuse of such products. HubMed – addiction

Organizational structure, leadership and readiness for change and the implementation of organizational cultural competence in addiction health services.

Eval Program Plann. 2013 Jun 6; 40C: 74-81
Guerrero EG, Kim A

Increasing representation of racial and ethnic minorities in the health care system and on-going concerns about existing health disparities have pressured addiction health services programs to enhance their cultural competence. This study examines the extent to which organizational factors, such as structure, leadership and readiness for change contribute to the implementation of community, policy and staffing domains representing organizational cultural competence. Analysis of a randomly selected sample of 122 organizations located in primarily Latino and African American communities showed that programs with public funding and Medicaid reimbursement were positively associated with implementing policies and procedures, while leadership was associated with staff having greater knowledge of minority communities and developing a diverse workforce. Moreover, program climate was positively associated with staff knowledge of communities and having supportive policies and procedures, while programs with graduate staff and parent organizations were negatively associated with knowledge of and involvement in these communities. By investing in funding, leadership skills and a strategic climate, addiction health services programs may develop greater understanding and responsiveness of the service needs of minority communities. Implications for future research and program planning in an era of health care reform in the United States are discussed. HubMed – addiction

Redevelopment of tertiary psychiatric services in British Columbia: A prospective study of clinical, social, and residential outcomes of former long-stay inpatients.

Schizophr Res. 2013 Jun 28;
Petersen KL, Nicholls TL, Groden D, Schmitz N, Stip E, Goldner EM, Arnold LM, Lesage A

The objective of this study is to assess the clinical and social outcomes for a cohort of patients who were part of the redevelopment of psychiatric services in British Columbia.This study used a naturalistic, quasi-experimental design, to examine the outcomes of a cohort of 189 long-stay patients at Riverview Hospital (RVH), some of whom moved into Tertiary Psychiatric Residential Facilities (TPRFs), some into the community in less structured facilities, and some remained at RVH. Data was collected from clinical files at RVH and at each participating site, semi-structured interviews and self-report measures were completed with patients. In addition, semi-structured interviews were also conducted with staff members.There was very minimal evidence of transinstitutionalization to prisons or homelessness; one participant resided in a correctional facility, one resided in a forensic facility, and one participant spent some time homeless. In addition, the majority of participants remained in residences that provided 24h care. Eighty percent of our population was diagnosed with a schizophrenia spectrum disorder. Psychiatric symptoms remained fairly stable; some embarrassing social behaviors increased; however, aggressive behaviors showed no increase; neuropsychological deficits did not deteriorate, there were even some improvements. Participants demonstrated increases in several independent living skills including: money management, food preparation and storage, job skills, and transportation skills. In addition, participants experienced a significant increase in their perceived quality of life.This study builds on existing research demonstrating that well-planned and appropriately resourced hospital closures can lead to positive psycho-social outcomes for participants and can successfully avoid negative outcomes such as transinstitutionalization to the judiciary system and homelessness. HubMed – addiction