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Substance-Related Disorders and Associated Psychopathology:

Predicting Addictions Treatment Outcome

BY

Antonios Parahera kis

A thesis submitted to the Faculty of Graduate Studies and Research

in partial fulfilment of the iequirements for the degree of

Master of Science in Psychiatry

Department of Psychiatry

McGill University

Montréal, Québec, Canada

August 1997

@ Antonios Psraherakis, 1997

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ABSTRACT

Although there exists a plethora of studies in the field of addictions treatment

examining the factors that predict successful treatmect amorne, the profile of

persons who benefit the most from treatment has not yet emerged. The

present investigation was conducted to evaluate treatment outcornes of various

groups of individuals with different substance related disorders, to determine

the prevalence of psychiatric comorbidity arnong these groups and to examine

predictors of treatment outcome. Two hundred and thirty nine substance

abusing males and females were extensively assessed at admission with

regards to demographic characteristics, substance use variables, psychiatric

comorbidity and cognitive functioning. Six-month in-treatment performance

was evaluated by monitoring length of stay in treatment, rates of abstinence,

attendance in therapy sessions and completion status at discharge. Results

indicated that clients with opiate addiction had the worst prognosis and

outcome profiles. Elevated rates of psychiatric disorders and moderate to

severe psychological distress were observed among these individuals. High

levels of depression were found among fernales and persons abusing alcohol.

Outcome data showed that the primary drug of abuse, frequency of use and

reason for entering treatment were the most significant predictors of outcorne.

Even though these variables predicted treatment outcome, their predictive

validity was minimal thus limiting interpretability of findings and dictating a need

for more research.

iii

Malgre le grand nombre d'études qui ont et4 men& portant sur les facteurs qui

pourraient predire la reussite de la thérapie dans le domaine de la toxicomanie,

il n'existe toujours pas un profil fiable des personnes qui pourraient profiter le

plus de ce genre de traitement sp6cialisé. Le but de cette investigation fut

d'évaluer les résultats de la therapie chez divers groupes d'individus ayant

différents problèmes d'abus de substances afin de determiner la prévalence

d'une CO-rnorbidite psychiatrique parmi ces divers groupes ainsi que l'issue

probable de traitement. Deux cent trente-neuf hommes et femmes souffrant de

troubles réli6s a I'usage de substances ont et6 Bvalues lors de l'admission par

rapport aux caractéristiques démographiques, les variables dans I'usage de

substances, la CO-morbidité psychiatrique et le fontionnement cognitif. Leur

progrès, aprés six mois en thérapie, a bté évalué en tenant compte de la durée

de l'engagement en thérapie, taux d'abstinence, présence à quel nombre de

sessions de thérapie et état drach8vement à la fin du traitement. Les résultats

ont montre que les personnes dependantes aux opiacés avaient le profil du pire

pronostic et issue de traitement. Un taux élev6 de désordres psychiatriques

ainsi qu'un niveau de détresse allant de modér6 3 shvére ont 6t6 observes parmi

ces individus. Aussi, des taux de dépression Blevés ont Bté notes parmi les

femmes et ceux qui abusaient des boissons alcooliques. Les données ont

démontré que la drogue d'abus principale, la frequence d'utilisation et les

raisons de poursuivre un traitement pouvaient le mieux predire I'issue de

traitement. Même si ces variables ont pu prédire I'issue de traitement, leur

valeur pronostique fut minimale, donc limitant la possibilite d'interprétation des

résultats e t exigeant le besoin d'une recherche plus approfondie.

ACKNOWLEDGEMENTS

First and foremost, I would like to express my deepest gratitude and

appreciation to my supervisor Dr. Kathryn Giil for accepting me as a graduate

student, for agreeing to work with me in a field as perplexing as substance

abuse treatment, and for providing many helpful comments, unique insights,

constructive critique and tremendous support during the past two years.

Over these two years, many friends and acquaintmces have contributed

enormously in time and efforts, without whom this thesis would never have

reached this stage. I would Iike to mention Dr. Dara Charney for the valuable

time and energy she invested in this project and for her continuous support and

encouragement, Dr. Palacios-Boix for his support, Gail Gauthier, Erica

Robertson, Helen Pentney, Florence Dobson, Roberta Payette, Paula Randolph,

and Etel Radich for their support and for conducting many of the client

interviews, Mimi Rivard for al1 the data entry and for her technical and moral

support. Erica, I would also like to thank you for teaching me many clinical

skills and for supporting me enormously during the past two years.

Two people from the Addictions Unit who have contributed tremendously

in their own ways to the completion of this project were Carol McCullough and

Betty Stamatakos. Carol, I thank you wholeheartedly for the moral support and

guidance, and for tolerating my constant demands and variable moods. Betty,

despite searching long and hard for appropriate words, I am unable to corne up

with any that can do justice to acknowledge your extreme diligence and

v

valuable contribution. I really appreciated your unique abilities to alleviate my

stress and frustration, and I am so grateful for the hard work you put to

comfortably accommodate me at the Unit. Of course, I would never forget your

joyous humour and drollery when I needed a moment of laughter.

1 would also like to thank my friends Rajesh Malik for his support and

helpful editorial comrnents and Steven Gelber for his guidance and support

especially during the last months of the completion of this project.

My deepest gratitude and appreciation are expressed to al1 people who

participated voluntarily in this study.

From the large list of individuals mentioned above is missing the name of

Theresa-Lynne Neil. Despite the pain and anger that I caused her with my

studies, she never gave up on me and she never stopped contributing greatly

to this project. I would like to thank her once again for putting up with my

moods and frustration, for her availability for consultation and for her editorial

comrnents and recommendations on earlier versions of the manuscript.

Finally, I would like to express my appreciation and gratitude to my

family and especially Calvin for their support, encouraGement and comfort.

I would like to dedicate this thesis to my 8 e 0 Aeu~epq (uncle Lefteris) who has

supported me in many ways for the past several years.

TABLE OF CONTENTS

....................................................................................... ABSTRACT ii

... RÉSUMÉ ........................................................................................... III

...................................................................... ACKNO WLEDGEM ENTS iv

................................................................................. LIST OF TABLES viii

... .............................................................................. LISTOFFIGURES VIII

INTRODUCTION ................................................................................ 1

The Effectiveness of Specialized Substance Abuse Treatment .................. 3

Treatment Evaluation Studies .................................................... 4

Methodological Issues in Addiction Treatment

Evaluation Research .......................................................................... 12

Selection Bias .......................................................................... 12

............................. Random Assignrnent and Control Groups .... 1 3

Vaiidity of Self-Reports ............................................................. 14

................................ Timing of Assessment and Outcome Periods 14

Retention in Treatment ............................................................. 15

Client Characteristics and Their Role in

Treatment Outcorne .......................................................................... 16

Substance Use Variables ........................................................... 16

PsychiatricComorbidity ............................................................ 18

Cognitive Functioning ............................................................... 23

.............. ....................................... Objectives of the Present Study ... 25

vii

METHOD ......................................................................................... 27

Research Setting ............................................................................... 27

Participants ...................................................................................... 28

Procedure ........................................................................................ 28

Initial Assessrnent .................................................................... 28

Ps ychiatric Assessment ........................................................... 3 0

Cognitive Evaluation ................................................................. 3 0

Follow-up Period ................................................................. 32

DataAnalysis .......................................................................... 33

RESULTS ......................................................................................... 36

Description of the Sample .................................................................. 36

Demographic Cheracteristics ............................................ 36

Severity of Substance Use at lntake .......................................... 3 8

Psychiatrie Comorbidity and Psychological

Symptomatology at lnta ke ......................................................... 38

.............. ....................... Neurocognitive Functioning at lntake .... 43

Six-Month In-Treatment Performance ................................................... 43

Predictors of Length of Stay in Treatment ........................................... 45

..................................... ....................... Regression Analysis ... 45

Survival Analysis ..................................................................... 48

DISCUSSION .............................................................................*...... 53 REFERENCES ................................................................................... 65

APPENDIX A Discharge Sumrnary .................................................... 82

viii

LlST OF TABLES

Table 1 Demographic Characteristics Stratified by Gender .................... 37

Table 2 Substance Use History Stratified by Primary Drug of Abuse ....... 39

Table 3 Rates of Psychiatric Diagnoses by Primary Drug

........................................... of Abuse Measured by the DIS-SI 41

Table 4 Psychiatric Symptomatology a t lntake Measured

by the BDI and the SCL-90-R ................................................. 42

Table 5 Cognitive Functioning Scores by Primary Drug of Abuse ............ 44

Table 6 Six-Month Treatment Outcome by Primary Drug of Abuse .......... 46

Table 7 Multiple Regression Report for Client Variables

as Predictors of Length of Stay in Treatment ............................ 47

LlST OF FIGURES

Figure 1 The Effects of Primary Drug of Abuse on

.......................................... Six-Month Survivai in Treatment 49

Figure 2 The Effects of Depression on

............................................ Six-Month Survival in Treatment 5 1

Figure 3 The Effects of Depressive Symptomatology on

............................................ Six-Month Survival in Treatment 52

Psychoactive substance dependence', a chronic, relapsing psychiatric

disorder, is considered to be one of the major health and social problems

affecting society. lt occurs in al1 age groups and socio-economic strata.

Addiction is associated with severe physical, psychological, legal, economic,

social, and family complications affecting not only the individual sufferers but

also their families and the community at large. The costs of substance

dependence have been estimated at more than 18.45 billion dollars annually in

Canada (Single, Robson, Xie, Rehm, Moore, Choi et al., 1996). These

enormous economic costs are due t o medical and psychiatric illness, motor

vehicle accidents, violence and crime, suicide, homicide, and lost employment

and productivity (Eliany & Rush, 1 992; Frances & Miller, 1 991 ; Single et al.,

1 996). Recognizing these detrimental consequences, reduction of substance

use and its related complications has become a primary national health objective

(Institute of Medicine, 1 WOa).

Concurrent with the acknowledged need and demand for addiction

treatment are concerns about the costs associated with providing this service.

In a climate of escalating health care costs, increased health consequences,

reduced allocations and increased demand for services, the evaluation of health

1

Throughout this paper the term substance dependence refers to the misuse of alcohol andfor other psychoactive drugs such as cocaine, cannabis, heroin, tranquilizers, and narcotic analgesics. The terms substance abuse, dependence and addiction are used interchangeably.

intervention programs has become paramount. Programs must be carefully

evaluated to ensure that they are applied properly, achieve successful outcorne,

and are cost-effective. Evaluating addiction treatment prograrns is likely to

have an impact on reducing ineffective treatment strategies, while promoting

the adoption of more appropriate and efficient ones (Eliany & Rush, 1992).

Currently, several major substance abuseldependence treatment

modalitiesZ exist. These include facilities for detoxification, methadone

maintenance, outpatient drug-free centres, therapeutic communities, and

inpatient programs (Anglin & Hser, 1992; Gerstein, 1994). Detoxification

focuses on providing the medical management of withdrawal symptorns in an

inpatient or outpatient setting. Methadone maintenance programs, also known

as narcotics substitution therapy, are outpatient proçrams where methadone is

administered orally in doses averaging between 20 to 100 milligrams. During

maintenance a variety of support services are offered to facilitate the patient's

rehabilitation. Outpatient drug-free programs usually last between 6 to 9

rnonths with the primary therapeutic interventions consisting of individual and

group counseling. Therapeutic communities are residential treatrnent programs

which are intended to change the behaviour and personality of addicts and to

improve their social functioning. Such treatment strategies are intensive and

In this paper, only a brief description of the existing addiction treatment modalities is given. ln addition, a discussion of a comparative evaluation of these treatment modalities is excluded since it is beyond the scope of the review undertaken here. The interested reader is referred to reports by Anglin and Hser (1 992), Gerstein (1 9941, and lnstitute of Medicine (1 990bI.

long-term and may

education classes,

3

include encounter-group therapy. tutorial learning sessions,

and residential job duties. Finally, inpatient programs are

typically hospital-based short-term (21 to 28 days) interventions that were

initially developed for alcohol-dependent clients. More recently, clients with

other drug dependencies have been treated in these facilities. While in

treatment patients attend educational groups on chernical dependency, self-help

group meetings. individual counseling sessions and participate in other topic-

focused groups. They also meet with health care professionals as needed.

The Effectiveness of S~ecialized Substance Abuse Tieatment

Evaluating the efficacy of drug abuse treatment interventions begins with

an understanding of what treatment is intended to accomplish. It is rare for

individuals who seek therapy for substance dependence to have only a single

addictive disorder. Usually, they suffer from severe medical, psychological,

social, and legal problems which complicate treatment plans and post-care

prognosis. These negative consequences are frequently the reasons leading to

treatment admission and are expected to resolve with successful treatment

(McLellan, Woody, Metzger, McKay, Durell. Alterman, & O'Brien, 1996).

It is widely accepted that the therapeutic goals of substance abuse

treatment differ according to the perspectives and interests of the people and

agencies involved in the management of addictive disorders. A t the same time,

however. there are some cornmonly agreed upon goals of what addictions

treatment should achieve. The foremost goal is to eliminate or reduce patient's

4

substance use. Secondary goals usually include improving physical and

psychological health, eliminating high risk behaviours, improving legal status,

reducing employment problems, increasing educational and vocational skills, as

well as improving family and social relationships (Office of National Drug

Control Policy [ONDCP], 1 994; 1 996).

Following agreement of reasonable expectations regarding the effects of

treatment, one can focus on the issue of whether clients in treatment

interventions show significant changes in substance related behaviours. To

address this matter treatment evaluators have employed simple "pre- to post-

treatment" designs comparing patient status on multiple dimensions a t fixed

intervals before, during, and after a treatment episode (McLellan et al., 1996).

The most extensive findings on the effectiveness of addiction treatment corne

from numerous medium-scale clinical trials and several major prospective

longitudinal studies involving thousands of patients and a variety of treatment

rnodalities and programs (Craddock, Rounds-Bryant, Flynn, & Hubbard, 1 997;

Eliany & Rush, 1992; Hoffmann & Miller. 1993; Hubbard, Marsden, Rachal.

Harwood, Cavanaugh, & Ginzburg, 1989; McLellan et al., 1994, 1996;

Simpson & Sells, 1 982; Tims, Fletcher, & Hubbard, 1 991 ).

f reatment evaluation studies. Traditional views of alcohol and drug

addiction have been pessimistic about treatment effectiveness, and some

commentators have argued that people who become dependent upon

substances seldom give them up and treatment has little effect on their

5

behaviour (Gossop. 1 992).

Early efforts to treat drug dependence were focused on the problem of

opiate addiction. Treatment was delivered entirely by private practitioners and

was concerned with the medical management of the opiate abstinence

syndrome. Later, as the number of individuals seeking treatment increased

steadily, the Public Health Service (PHs) hospitals were introduced to assist

patients with gradua1 withdrawal and to provide them with a drug-free

environment in which to recover (Maddux, 1988). Treatment in these facilities

was regarded as ineffective because the detoxification and unstructured

psychotherapy offered had limited, if any, success. Many clients failed to

complete treatment and those who did had very high relapse rates following

treatment. Approximately 70% of admitted clients left treatment prematurely,

and among those who completed treatrnent 87% to 90% relapsed 6 to 12

months following discharge (Maddux. 1988). Despite the negative trends,

these early treatment attempts are noteworthy simply because clinicians in

these hospitals provided the first systematic data on the impact of treatment on

drug abusing individuals.

Subsequent to these efforts several major clinicai trials were carried out

longitudinally to examine the effectiveness of specialized addictions treatment

programs. One of the most influential studies was the Drug Abuse Reponing

Program (DARP). This nationwide prospective investigation was conducted by

the National lnstitute of Mental HeaIth (NIMH) and the Institute for Behavioral

6

Research of Texas Christian University during the years 1969 to 1973. The

sample consisted of over 44.000 adult clients admitted to 52 treatment

programs in the United States and Puerto Rico. Subsarnples of these individuals

were interviewed a t intake, bi-rnonthly during treatment, and yearly after

treatment up to 12 years post-admission. A t the tirne of the interviews trained

evaluators gathered information on the patients' alcoholldrug consumption,

employrnent, criminality, and return to drug treatment. Overall results revealed

that al1 major treatment rnodalities examined (methadone maintenance,

residential drug-free. outpatient drug-free, and detoxification) were effective in

reducing clients' drug use both during and after treatment. Furthermore,

several subsamples of clients showed substantial reductions in criminal activity

during treatment which continued to decrease steadily throughout the follow-up

years (Simpson & Sells. 1982).

In general, the DARP project made several valuable contributions to the

knowledge in the field. First, a finding consistent across al1 treatment

modalities and client characteristics was that the most favourable outcomes,

defined as no drug use and no criminal activity, were related to the length of

time spent in treatment. Significantly poorer outcomes resulted from treatment

episodes shorter than 90 days, while more positive ones were associated with

increased time spent in treatment beyond 90 days. Second, clients with higher

social adjustment (Le. married, better educated and employed) had lower risk

of relapse to daily illicit drug use (Simpson, 1984).

7

The gradua1 evolution of the treatment system led to a second major

evaluation study. Building on the methodology and findings of DARP, the

Treatment Outcome Prospective Study (TOPS) carried out by the Research

Triangle Institute. attempted to capture the changes affecting the substance

abuse interventions and to evaluate their potential in treating addictive

disorders. The sample in this study included 11.750 clients admitted to 41

substance abuse treatment programs in 10 cities, between 1979 and 1981.

Assessrnent interviews were conducted at admission, one month following

initial intake, and every 3 months during treatment. Post-treatment follow-up

interviews were performed with subsamples of patients at three months, one

year, two years, and three to five years after discharge from therapy. Results

showed that one year after treatment discharge, 87% of cocaine users. 89%

of heroin users, and 55% of marijuana users had maintained abstinence from

their respective substances. Like the DARP project, the TOPS investigation

further supported the notion that treatment brings significant improvements in

terms of reducing substance use and illegal behaviour during and after a

treatment episode, and strengthened the importance of the amount of time

spent in treatment on outcome. However, TOPS data showed some important

differences on the characteristics and addictive behaviours of individuals

seeking treatment between 1969 and 1974, and those seeking treatment

between 1979 and 1981. During the DARP project, clients entered treatrnent

primarily for heroin and opiate addiction, whereas during the TOPS project,

8

many patients entering treatment presented patterns of multiple substance

abuse (Hubbard et al., 1989).

Another national longitudinal outcome evaluation study, known as the

Drug Abuse Treatment Outcome Study (DATOS), funded by the National

lnstitute on Drug Abuse (NIDA), was conducted with groups of clients admitted

to treatment centres between 1991 and 1993. Its objectives were to examine

the prevalence of major drugs of abuse, treatment processes and client-

treatment matching variables. Approximately 10,010 clients admitted to 96

treatment programs in 12 cities participated in this prospective study. The

major modalities studied included detoxification. methadone maintenance,

therapeutic community, drug-free outpatient, and chemical dependency units.

Preliminary results showed that substance abuse and illegal activity declined

considerably following initiation of treatment and continued to decline after

treatment (Craddock et al.. 19971. Furthermore, it appeared that clients

entering treatment programs in the 1990s were different from those who

received treatment services in the previous decades. In a recent report

Craddock et al. (1 997) compared client characteristics among treated patients

in the DARP, TOPS, and DATOS projects and found that clients in the DATOS

project were older, had a higher level of education, were less employed, relied

more on social assistance, were more often involved in illegal activities, and had

more comorbid problems (Le. poly-substance use, psychopathology, Acquired

lmrnunodeficiency Syndrome [AIDS], and Human lmmunodeficiency Virus [HIV]

9

complications). Based on these characteristics, it would appear that

populations have becorne progressively more troubled by substance abuse and

consequently more difficult to treat.

The studies discussed so far indicate that treatment for substance related

disorders c m help clients abstain frorn or significantly reduce drug and alcohol

consumption. In addition, considerable improvements in the areas of

employment. criminal activity, familylsocial relationships, as well as physical

and psychological health have been observed. However, the essential issue of

whether treated substance users fare better than addicts without any

specialized treatment has not been addressed. In order to deal with this

question, several studies were carried out where characteristics of substance-

abusing individuals out-of-treatment (Booth, Crowley, & Zhang, 1996; Carroll

& Rounsaville, 1992; Metzger. Woody. McLellan, O'Brien, Druley, Navaline, et

al.. 1993) or clients on waiting lists for treatment (Sisk, Hatziandreu. & Hughes

1990; Urschel, McLellan. Vandergift, & Incmikosk, 1991 ) were compared with

patients already in treatment programs.

Metzger and colleagues (1 993) examined and compared the substance

use patterns, needle sharing, and HIV infection rates o f two samples of patients

addicted to opiates. An "in-treatment" sample consisted of 152 patients

recruited from a methadone maintenance program, while another "out-of-

treatment" sample was comprised of 103 opiate patients who had not received

treatment for a t least one year, and were living in the same area as the "in-

10

treatment" individuals. lndependent interviewers assessed these participants

at admission and at six-month intervals for 3 years. Results indicated that rates

of substance use and needle sharing among the "in-treatment" sample were

significantly lower than the rates reported by the "out-of-treatment" sample.

Moreover, HIV seropositivity among the "out-of-treatment" group increased

significantly compared to the treated patients. These authors concluded that

although findings were supportive of treatment effectiveness, they were not

indicative of whether treatment per se was responsible for the positive changes.

They further speculated that "out-of-treatment" individuals might have lacked

the motivation for treatment that could be found among the "in-treatment"

patients, and that motivation rather than the effects of treatment might explain

the differences observed among the two groups.

Clarification of this issue comes from a study carried out by Urschel et

al. (1 991) with male veterans requesting treatment for cocaine abuse. Forty-

two patients who applied for treatment were put on a waiting list for four

weeks and were followed weekly by independent evaluators who gathered

information on clients' substance use, psychiatric and medical status, as well

as social and family relationships. Of these individuals 84% did not receive any

treatment during the waiting period, while 16% received some type of

treatment services. Results showed that among the prooortion of addicts who

waited the four week period, 53% showed no change or slight increases in the

severity o f their drug, medical, psychiatric, and legal complications, while 57%

11

reported increased employment and social problems. Urschel and colleagues

(1 991) concluded that these data suggest that motivation by itself does not

lead ro improved status observed in substance-abusing persons who receive

formal addiction treatment,

Despite favourable outcomes from these and other large-scale studies the

utility of addiction treatment is frequently debated. The chronic nature of this

disease and the ability of some individuals to abstain for periods of time with

lirnited or no intervention at al1 has lead critics to question the effectiveness of

treatment interventions which yield one-year abstinence rates of only 25%

(Miller, 1992). It also appears that the effects of treatment are not consistent

across individuals and that there is substantial variability in post-treatment

outcomes (McLellan et al., 1994). For example, in a subsample of TOPS

patients, Hubbard and Marsden (1 986) reported that at one-year follow-up,

12% of clients were totally abstinent from their primary substances, had not

been engaged in any criminal activity, and showed improvements in

employment, family, and psychological problems. Unlike these clients, 18% of

the same sample were incarcerated, 29% reçumed substance use, and 13%

had received sdditional services in other facilities. Sirnilar unfavourable findings

have been reponed in other studies (Chaprnan-Walsh, Hingson, & Merrigan,

1991 ; Woody, McLellan, & Luborsky, 1984). In an attempt to address outcome

variability, researchers have suggested that it may be due to the numerous

methodological shortcomings in this area of research.

12

Methodoloaical Issues in Addiction Treatment Evaluation Research

Several critical reviewers have pointed out the lack of methodological

rigor that has plagued evaluation research (Crawford & Chalupsky, 1977; Hill

& Blane, 1967) suggesting that most studies did not meet either scientific or

practical criteria for replication. Unlike these earlier reviews, more recent

reports have noted significant improvements in the quality and characteristics

of methodology used in substance treatment evaluation studies (Miller, Brown,

Simpson, Handmaker, Bien, Luckie et a1.J 995; Morley, Finney, Monahan, &

Floyd, 1996; Sobell, Brochu, Sobell, Roy, & Stevens, 1987). These

ameliorations included the use of more sophisticated research designs, more

reliable and valid client assessrnent and outcome measures, and multiple

sources of outcome data such as biochemical tests and collateral reports. Even

in the light of more favourable reports, various critics still continue to emphasize

the existence of serious methodological shortcomings which make current

findings defective and do not allow one to make any firm conclusions about

treatment efficacy. Some of the most important and relevant issues are

discussed below:

Seiection bias. in their report on the effectiveness of alcohol and drug

prevention and treatment programs, Eliany and Rush (1 992) noted that in order

to choose participants suitable for their studies, evaluators frequently employed

specific selection criteria. lndividuals who might not conform to the study in

some way, for example, patients in a certain age or gender group, or with

13

certain types of psychopathology, or who disagree with treatment objectives

have often been excluded from evaluation research. The consequences of this

practice are that the sample is not representative of the general population. and

the treatment outcome may be biased favouring one type of treatment over

another. In addition, researchers do not report on what basis they selected

their sample. making it difficult, if not impossible, to judge the value of their

results (Eliany & Rush, 1 992).

Random assiunment and control aiouDs. When assessing the

efficacy of any treatrnent. two necessary components for adequate evaluation

must be met: random assignment of subjects and control groups. Without

these conditions one cannot clearly demonstrate that the changes observed

during treatment are the outcome of the therapy per se (Holder, Longabaugh,

Miller. & Rubonis, 1991). In addition. there is a common belief that some

individuals may improve without any treatment (Eliany & Rush, 1992). Based

on these considerations it would be advisable for investigators to randornly

assign their subjects into different treatment modalities and to include a no-

treatment cornparison group in order to determine the effectiveness of any

treatment program. While this may be highly desirable it is a difficult condition

to meet in clinical practice where patients require and demand immediate

attention. and where ethical concerns and practical limitations must be taken

into consideration. Because of such difficulties, these rnethodological

cornponents should not be regarded as fundamental to treatment evaluation

1 4

studies (Eliany & Rush, 1992).

Validitv of self-re~orts. Verbal reports of substance abusing

individuals have been considered as unreliable and inaccurate (Sobell & Sobell,

1989). Self-reports have been regarded as an inappropriate measure due to the

patient's fallible memory, denial or under-reporting of substance consumption,

and desire to give socially acceptable responses. Similarly, poorly designed

questions complicate the client's a bility to give accurate answers (Babor.

Brown, & Del Boca, 1990; Carroll, 1995; Fuller, 1988). A t the same time,

however, a number of authors daim that self-reports are an inexpensive.

noninvasive, and reasonable source of information and c m be accurate and

valid under appropriate assessment conditions (Carroll, 1 995; Sobell & Sobell,

1989). These conditions require that the patient be drug-free at the time of the

interview, questions asked should be properly designed and worded, recall and

mernory should be facilitated, confidentiality should be assured, good rapport

between patient and interviewer should be established, and collateral reports

as well as biochemical tests such as urine screening and breathalyser tests

should be collected (Babor & Del Boca, 1992; McLellan et al., 1996; Sobell &

Sobell, 1 989; Zanis, McLellan, & Randall, 1 994).

Timing of assessment and outcome periods. Widely debated in

the literature is the issue of when, and for how long, patients should be

evaluated following treatrnent. Factors that influence individual alcohol and

drug consumption must be taken inta consideration. For example, constraints

1 5

that limit substance availability (e.g. hospitalization, incarceration) preclude

accurate estimation of substance consumption. The period of substance abuse

to be monitored should only represent the treatment episode under investigation

in order to avoid the effects produced by previous treatments or other

controlled environments. This period should not be either too short or too long

so that one can measure the full intensity and complexity of the behaviour

being evaluated (Babor, Longabaugh, Zweben, Fuller, Stout, Anton, & Randall,

1994).

Related to this issue, is the distinction made between short- and long-

term treatment outcome time periods. Short-term outcome objectives include

reduction of drug use and amelioration of medical, psychological, and social

status. Long-term goals consist of maintenance of therapeutic attainments

beyond the time of the treatment episode. 00th should be evaluated since they

are thought to be equally essential aspects of treatment evaluation. Because

outcome results tend to be unstable, and different outcomes Vary over time, it

is unlikely that a single follow-up assessrnent will be optimal for al1 research

questions. For these reasons, researchers often schedule reassessments at

regular intervals, for example every 3 or 6 months with the 1-year end point

being the most common (Babor et al., 1994; McLellan et al., 1996).

Retention in treatment. Although little evidence exists showing why

substance abuse patients drop out of treatment, high rates of attrition are well

documented. The majority of studies on treatment retention have reponed that

16

more than 50% of clients drop out within the first month of treatment (Stark,

1992). On the other hand, length of stay in treatment has been linked to

successful outcornes in terms of reduced drug use, decreased criminal activity,

and improved psychological, medical and social functioning (Gottheil, McLellan,

& Druley, 1992; Hoffmann & Miller, 1993; Hubbard et al., 1989; McLellan et

al., 1996; Simpson & Sells, 1982; Tims et al.. 1991). In order to predict

retention in treatment, investigators have focused on numerous client

characteristics at the initiation of treatment. Such factors include

sociodernographic and substance use variables, presence of comorbid

psychiatry disorders, and severity of psychological and social functioning.

However, it has been difficult to evaluate the strength of these indicators of

outcome across studies because methodological issues have impeded research

from being more useful for understanding client attrition from treatment

programs. These issues include the use of different patient and treatment

measures during assessments, different follow-up intervals, and failure to report

the magnitude of the contribution of these various factors to alcohol and drug

use (McLellan et al., 1 994).

Client Characteristics and their Role in Tieatment Outcome

Substance use variables. Unlike sociodemographic factors which

have met with very limited success as indicators of treatment outcome (Agosti.

Nunes, Stewart, & Quitkin, 1991 ; Gainey, Wells, Hawkins, & Catalano, 1993;

McLellan e t al., 1994) several substance use variables such as primary drug of

17

abuse, severity of dependence, polydrug use and history of prior treatment have

been found to be associated with treatment outcome (Gainey et al., 1993;

Hoffmann & Miller, 1 993; McLellan et al., 1994; Stark, 1 992).

Some evidence indicateç that an individual's primary drug of abuse can

predict treatment retention and success. In their study of abstinent-oriented

programs, Hoffmann and Miller (1 993) found that 63% of alcohoiics were able

to abstain from alcohol for up ta one year following treatment discharge,

whereas individuals wno abused substances other than alcohol were found to

have significantly poorer outcomes. Similarly, elevated treatment attrition rates

(more than 55%) have been noted among cocaine abusers, especially during the

first weeks of treatment (Agosti et al., 1991 ; Gainey et a!., 1993). The severity

of current drug use has also been related to retention in treatment and post-

treatment outcomes. For instance, McLellan and colleagues (1 994) discovered

that the severity of patients' drug and alcohol use and the severity of substance

problems at intake as measured by the Addictions Severity Index (ASI) were

significant predictors of post-treatment substance use.

In addition, other investigators have noted that a history of a secondary

drug of abuse and polysubstance use to be associated with poor outcornes in

terms of early drop-out and post-treatment drug use (Booth et al., 1996;

Brower, Blow, Hill & Mudd, 1994; Brown, Seraganian, & Tremblay, 1994;

Gainey et al. 19931. For example, Booth and colleagues (1 996) found that

opiate addicted individuals who also injected cocaine were less likely to have

18

entered and stayed in treatment compared to those who only used opiates. In

another outcome study of "pure" alcoholics, "pure" cocaine addicts and dual

(alcohol + cocaine) substance addicts, outcomes measured by multiple indices

of functioning and quality of life were found to be similar for the three groups.

but the dual addiction group had a poorer prognosis when abstinence was the

only measure of outcome (Brower et al., 1994). Furthermore, drug category

emerged as a significant predictor of abstinence in the 30 days prior t o

follow-up contact. Still another study, conducted on a Montreal population,

found that cocaine-dependent alcoholics had a greater tendency to relapse

during treatment than "pure" alcoholics. However, the patients in the former

group were younger. more likely to be unmarried, and had more extensive

substance use histories and more prior treatment than the "pure" alcoholic

group (Brown et al., 1994).

Finally, other studies have shown that individuals who had a greater

nurnber of previous treatments for substance abuse were more likely to have

poorer treatment outcomes in terms of post-treatment drug use (McLellan et al..

1994) and higher subsequent readmission rates ranging from 34% to 45% in

individuals with only addictive disorders and more than 70% in addicts with

psychiatric disorders (Moos, Mertens, & Brennan, 1 994; Woogh, 1990).

Psvchiatric comorbiditv. There is a substantial body of evidence

indicating a frequent occurrence of psychiatric disorders among individuals with

substance-related problems. The Epiderniologic Catchment Area study (ECA,

19

[Regier, Farmer, Rae, Locke, Keith, Judd, & Goodwin, 19901) and the National

Comorbidity Survey (NCS, [Kessler, McGonagle, Zhao, Nelson, Hughes,

Eshlemen et al., 19941) revealed that there was a high prevalence for lifetime

comorbidity of substance abuse and other psychiatric disorders. Using the

Diagnostic Interview Schedule (DIS), a structured diagnostic instrument based

on criteria derived from the American Psychiatric Association's Diagnostic and

Statistical Manual-Third Edition (DSM-III), investigators in the ECA survey,

found that 37% of people with an alcohol use disorder and 53% of those with

a drug-related disorder had additional psychiatric diagnoses (Regier, et al.,

1990). The NCS survey employed the Composite lnternational Diagnostic

Interview, a highly standardized diagnostic instrument based on definitions and

criteria derived from the World Health Organization's lnternational Classification

of Diseases (ICD-1 O), and reported that 48% of the respondents with an alcohol

related disorder and more than 56% of those with a drug disorder met criteria

for additional mental disorders (Kessler e t al., 1994, 1996). The rates of

coexisting disorder appeared to be significantly higher among samples of

substance abusers in treatment facilities as compared to those individuals with

untreated substance disorders. Alcoholics were 3.8 times and other drug

addicts were 4.2 times higher than the genaral population to be diagnosed with

an additional mental disorder. In many cases, the most common diagnoses

were made for affective, anxiety and personality disorders (Alterman &

Cacciola, 1991 ; Brown and Schuckit, 1988; Kessler et al., 1996; Regier et al.,

20

1990; Rounsaville, Anton, Carroll, Budde, Prusoff, & Gawin. 1991; Weiss.

Mirin, & Griffin, 1 992).

The relationship between addictive disorders and other forms of

psychopathology has long been debated. Many different types of causal

relationships have been identified and several hypotheses have been introduced,

to explain the development and progression of comorbidity between substance

abuse and psychiatric disorders. One such hypothesis proposes that the

primary psychiatric illness precedes the development of the addictive disorder

(Khatzian, 1985). In other words, substance abuse and addictive behaviour are

the consequences of certain psychiatric disorders. Furtherrnore, proponents of

this hypothesis contend that certain individuals "self-rnedicate" with alcohol or

other psychoactive drugs in an attempt to alleviate intolerable States of specific

psychiatric symptornatology. The individual's primary drug of abuse is not

accidental, but is chosen for its pharrnacological ability to relieve specific

distressing symptoms or feelings (Khatzian, 1985; Weiss, Griffin, & Mirin,

1992). Another hypothesis suggests that the substance abuse itself produces

or exacerbates underlying psychiatricdisorders (Lehman. Myers, & Corty, 1989;

Meyer, 1986; Negrete, 1993). In this scheme, the use or abuse of

psychoactive substances may produce alterations in mental function, subjective

feelings, and overt behaviour resembling the symptoms of a major psychiatric

syndrome. In addition, substance abuse c m also intensify the severity of

symptoms of a coexisting psychiatric disorders (Negrete, 1993).

21

Several studies addressing the impact of psychiatric comorbidity on

treatment outcorne have demonstrated that addicted patients with coexistent

psychiatric disorders have significantly worse prognoses than those with no

psychiatric diagnoses, including a decreased rate of remission, an increased

vulnerability for relapse. higher readmission rates, and a need for more inpatient

and outpatient treatment services (Alterman, McLellan, & Shifman, 1993;

Miller. 1991 ; Moos et al., 1994; Rounçaville. Kosten, Weissman. & Kleber,

1986). However, these findings are not consistent across studies, and the

prognostic ability of psychiatric variables to predict treatment outcome has been

minimal. Findings from some studies suggest that presence of psychiatric

comorbidity accounts for small proportions of treatment outcome variability and

that these proportions are not clinically significant (Alterman et al., 1993).

Furthermore, Alterman and colleagues (1 993) reported that only 10% to 15%

of the variance in treatment outcome was predicted by the severity of

psychiatric illness. Others have reported percentages ranging from 5%

(McLellan et al., 1994) to 20% (Charney. Paraherakis, Negrete, & Gill, 1997).

Thus, one should be cautious when interpreting the results from these studies,

since the reported predictive validity of psychiatric variables may have lirnited

clinical significance.

While elevated rates of depression have been found among individuals

with addictive disorders (Grant & Harford, 1995; Kessler et al.. 1994; Regier

et al., 1 990), the impact of depression on addictions outcome has y ielded

22

conflicting results. Some outcome studies generally indicate worse prognoses

in patients with comorbid depression (Alterman et al., 1993; Miller, 1991 ;

Moos, et al.. 1994; Rounsaville et ai., 19861, while some others find no relation

between depression and treatment outcome (Araujo, Goldberg, Eyma,

Madhusoodanan, Buff, Shamim et al., 1996). Still others show that

concomitant depression may predict better outcomes among alcoholic women

(Rounsaville, Dolinsky, Babor & Meyer, 19871, longer treatment retention

among cocaine addicted men (Agosti et al., 19911, and greater attendance to

therapy sessions in methadone patients (Joe, Brown, & Simpson, 1995). Frorn

the findings discussed so far, it is evident that further research is required to

clarify the impact of depression on treatment outcome of addicted individuals.

Similar variability has been indicated with respect to the prognostic

significance of antisocial personality disorder (ASPD) among drug and alcohol

abusers. Individuals with concomitant addictive and ASPD have been found to

show less improvement than non-ASPD patients on many variables associated

with treatment outcome such as alcohol and stimulant use, criminal activity,

and psychiatrie status (Gill, Nominal, & Crowley, 1992; Hasin, Endicott &

Keller, 1 991 ; Hesselbrock, 1 991 ; Liskow, Powell, Nickel, & Penick, 1 990;

Woody, McLellan, & O'Brien, 1990; Woody, McLellan, Luborsky, & O'Brien,

1985). Hesselbrock (1 991) found that alcoholics with ASPD had poorer one-

year drinking outcomes than did alcoholics without an ASPD diagnosis.

Notewonhy are studies demonstrating that substance abusers with ASPD

engage in more HIV risk behaviours

needle sharing, and thus are at higher

23

such as promiscuity, prostitution, and

risk for contracting and spreading AlDS

(Gill, et al., 1992). Contrary to this, Schuckit (1985) found that although

alcoholics with primary ASPD reported more illicit drug use and had poorer

social functioning than primary alcoholics, the two groups did not differ with

respect to alcohol related outcomes at one-year follow-up.

In summary, the existence of psychiatric comorbidity in substance

abusers is of considerable interest in terrns of the etiology of the dual disorders,

effects on treatment retention and outcorne, and overall service utilization and

costs. Additional investigations are needed to explain some of the conflicting

findings involving psychiatric illness in substance abusers and to examine the

role of psychiatric factors in predicting treatment failure in these individuals.

Counitive functionina. The neuropsychological profile associated with

chronic alcohol or drug abuse has been well documented (Fals-Stewart &

Lucente, 1 994; Fals-Stewart & Schafer. 1 992; Grant, 1987; Miller, 1 985;

Parsons & Farr, 1 981 ; Reed & Grant, 1990). The cognitive abnorrnalities noted

in patients wi th psychoactive substance use disorders typically include impaired

visuospatial abilities, short-term memory deficits especially for non-verbal

patterned materials, problem solving and abstract reasoning deficits, as well as

reduced psychomotor speed. Many experts daim that these deficits are not

permanent, as there appears to be considerable recovery of function with

prolonged abstinence (Drake, Butters, Shear, Smith, Irwin, & Schuckit, 1994;

24

Goldrnan, 1986; Grant, 1987). In order to benefit from the treatment process,

a patient must be capable of receiving and integrating new information and

translating this input into more concrete behavioral change. Understanding the

pattern of cognitive impairments seen in individuals with substance abuse

disorders may be useful in contributing to their therapeutic management and

predicting outcorne (Parsons & Farr, 1981 ).

Investigations on the prognostic utility of cognitive status for treatment

outcorne have yielded mixed results. Crawford (1 980) found that alcoholics

with cognitive deficits had lower rates of success than alcoholics without such

deficits (30% versus 70% success rates). Walker, Donovan, Kinlahan, and

O'Leary (1 983) reported that alcoholic patients who had the highest level of

functioning at intake were significantly more likely to have a full-tirne job at

nine-month follow-up. Abbott and Gregson (1 981) showed that performance

on various neurocognitive indices significantly predicted the number of weeks

to first drink after treatment.

Other studies have examined the association between cognitive

impairment and participation in treatment interventions (Fals-Stewart & Lucente,

1994; Fals-Stewart & Schafer, 1992; Fais-Stewart, Shanahan, & Brown, 1 995).

Fals-Stewart and Lucente (1 994) reported that patients with higher levels of

impairment on cognitive functioning as measured by the Wechsler Adult

Intelligence Scale (WAISI stayed in treatment for shoner periods of time, were

rated as less participatory by clinical staff, and were discharged from treatrnent

25

more frequently due to less compliance with program rules. While these studies

would indicate that a relationship of some sort exists between neurocognitive

dysfunction and treatment outcorne, the nature of the relationship requires

further clarification.

Obiectives of the Piesent Studv

The first objective of this investigation was to determine the current and

lifetime prevalence of psychiatric comorbidity among individuals with various

psychoactive substance related disorders and to examine the relationship

between severity of psychiatric disorder and early indicators of treatment

outcome. Treatment outcome was primariiy defined as length of stay in

treatment. Secondary indices of treatment outcome included rates of

abstinence as measured by mandatory urine screening tests, attendance in

individual and group psychotherapy sessions and completion status (defined as

completing recornrnended treatment or dropout). Although findings in the

literature require funher elucidation, they suggest that psychiatric comorbidity

in substance abusers, especially depression, leads to significantly shorter

periods of survival in treatment, poorer attendance in therapy and lower rates

of abstinence. The hypothesis tested here was that individuals with coexistent

depressive disorder or severe depressive symptomatology would have

significant poorer outcomes compared to individuals without mood disorders.

The second objective was to compare outcomes of patients with different

primary drugs of abuse and to examine the factors which predict successful

26

treatment outcome among these various groups. Again, the primary outcome

measure was length of stay in treatrnent while attendance in therapy,

abstinence rates and completion status were considered as secondary

measures. Client characteristics were divided into five categories: demographic

factors (age. sex, race, education, employment status. living arrangements),

substance use variables (primary drug of abuse, frequency of use. secondary

drug of abuse. number of years problem use, severity of substance related

complications). psychiatric comorbidity (presence of psychiatric disorders),

psychological symptomatology (levels of psychological distress) and

neurocognitive functioning. All these categories of variables were carefully

examined in order to measure the ability of each factor to predict treatment

outcome. Factors related to substance use, psychiatric illness and cognitive

functioning were expected to be significant indicators of treatment outcome,

especially of length of stay in treatment.

METHOD

Research Setting

This study was carried out at the Addictions Unit of the Montreal General

Hospital (MGH). The Unit offers outpatient treatment and inpatient

detoxification to English speaking patients of the Montreal region and

surrounding metropolitan areas. These services are delivered by an

interdisciplinary team of psychiatrists, physicians, psychologists, social

workers, psychiatric nurses, and occupational therapistç. The Addictions Unit

treatment program is abstinence-oriented and includes group and individual

therapy, medical and psychiatric care, outpatient and inpatient detoxification,

psycho-educational and prevocational counselling, as well as couple and family

therapy. For the first six weeks of treatment, al1 patients receive one 45-minute

individual therapy session, one to two 90-minute group therapy sessions per

week, and psychiatric monitoring as required. Following this period, treatment

continues for a maximum period of one year during which patients receive

group therapy and psychiatric monitoring for those who still need psychiatric

care. During the individual and group sessions clients deal with issues related

to abstinence, substance use, as well as other drug related problems. Therapy

sessions rely on a supportive, psycho-educational approach and do not differ

in any aspect depending on the drug of choice, gender, or any other factor.

Psychiatric monitoring consisted of the assessrnent and treatment of cornorbid

psychiatric disorders.

Particinants

The sarnple consisted of adult substance abusing males and females who

sought treatment at the Addictions Unit during the period of November 1994

to August 1996. Following placement of their names on the Unit's waiting list,

al1 clients received information about the program and were invited to take part

in a treatment evaluation study. All clients were eligible for the study since

there were no exclusion criteria.

Procedure

Client assessments were conducted by the investigator as well as

Addictions Unit therapists during the first three weeks of treatment. During this

period, al1 clients were required to give urine specimens for screening of alcohol

and drug consumption each time they visited the clinic.

initiai assessment. On the first week, detailed information on

demographics, current and lifetime drug and alcohol use, addiction treatment

history, psychiatrie status, educational background, employment and legal

status. as well as family history was obtained using a semi-structured interview

schedule. This interview lasted approximately one hour and thirty minutes.

Following the interview. patients were asked to complete the Beck Depression

lnventory (BDI. [Beck & Steer, 19871), and the Symptorn Check List-90-Revised

(SCL-90-R, [Derogatis, 19831). The BDI is one of the most widely used

instruments for the assessment and detection of depression. It is a 21-item

self-report instrument which assesses affective, cognitive, behavioral, somatic,

29

and interpersonal aspects of depression and requires five to ten minutes to

complete. Each item consists of a series of four statements scaled to indicate

increasing depressive symptomatology. Respondents indicate which statement

best describes how they have been feeling over the past seven days. The BDI

is scored by summing the ratings of the 21 items, with total scores ranging

from O to 63. A score of 20 or higher has been used to define moderate to

çevere depression (see Kendall, Hollon, Beck, Hammen & Ingram, 1987). The

BDI has been shown to have very good reliability and validity, and high

correlations between BDI and other scales (e. g. SCL-90) have been reported

(see Beck & Steer. 1987; and Beck, Steer, & Garbin, 1988). The SCL-90-R is

a multidimensional standardized self-report inventory designed to measure

psychological distress during the past week. Subscales of the questionnaire

include interpersonal sensitivity. somatization, obsessive-compulsiveness,

depression. anxiety, phobic anxiety. hostility, paranoid ideation, and

psychotism. Each item is rated on a five-point scale from O (not at all) to 4

(extremely) and the entire inventory requires ten to twenty minutes to complete.

Three global indices provide an assessrnent of the intensity of perceived

distress (Global Severity lndex [GSI]), the number of symptoms experienced

(Positive Symptom Total [PST]), and a summary measure combining intensity

and number of symptoms (Positive Symptom Distress lndex [PSDI]). Similarly

to the BDI. the SCL-90-R has been shown to be both a reliable and valid

instrument (see Derogatis, 1983).

Psvchiatric assessment. Approximately one week after the initial

assessment, a psychiatric evaluation3 was conducted on a randorn sample of

the patient population using the computerized version of the Diagnostic

Interview Schedule-Screening Interviews (DIS-SI, [Robins & Marcus, 19881).

The DIS-SI is a computer-based instrument which screens for DSM-III-R

(American Psychiatrie Association, 1 987) current and lifetime psychiatric

disorders including drug and alcohol abuse and dependence. The DIS-Sl elicited

information about the lifetime history of psychiatric disturbance, the age of

onset of each positive diagnosis, the age of the most recent difficulty, and for

episodic syndromes, the duration of the longest episode (Helzer, 1 993). This

instrument has been shown to be a relatively reliable and valid research

instrument and is brief to administer (Robins & Marcus, 1988).

Co~nitive evaluati~n. On the third week, cognitive functioning was

evaluated in a randomly selected sample of patients using a brief

neuropsychological test battery which included the Trail Making A and 6

(Reitan, 1958), and the Shipley Inçtitute of Living Scale (SILS) (Zachary, 1992).

The Trail Making is a brief problem-solving test that is a sensitive indicator of

neuropsychological dysfunction, especially in terms of visuospatial abilities. It

consisted of two parts: Part A required the subject to draw a line connecting

25 circles numbered 1 to 25 as quickly as possible in ascending order. In Part

Due to the length of the psychiatric and cognitive evaluations, it was not possible to test the entire patient sample for psychiatric diagnoses and cognitive dysfunction. Therefore, a random subsample of patients was evafuated during the second and third week following admission.

31

8, the respondent had to rapidly connect 25 circles numbered 1 to 13 and

lettered A to L, alternating between numbers and letters. The scores for the

Trail Making A and B consisted of the number of seconds required for

completion. Scores falling below the 25th percentile indicated neurocognitive

impairment (Reitan, 1958). The SlLS was designed to assess general

intellectual functioning and to aid in detecting cognitive impairment.

Specifically, it measures the discrepancy between vocabulary and abstract

concept formation. The scale consisted of two subtests: a 40-item vocabulary

test and a 20-item test of abstract thinking. On the Vocabulary subtest

individuals were asked ta choose which word (of four possible choices) had the

sarne or nearly the same meaning as a specified target word. The Abstraction

subtest used a completion format. The individual was presented with logical

sequence and then was asked to fil1 in the numbers or letters that best

completed the sequence. The responses were then scored to yield six summary -

scores: a Vocabulary Score, an Abstraction Score, a Total Score, a Conceptual

Quotient (CQ) as impairment index, an Abstraction Quotient (AQ) which is the

CQ adjusted for age and educational level, and an estimated Full Scale

Intelligence Quotient (10) score based on either the Wechsler Adult Intelligence

Scale (WAIS, [Wechsler, 19551) or the Wechsler Adult lntelligence Scale-

Revised (WAIS-R, [Wechsler, 1981 1). The most commonly used derived score,

the CQ, was designed as an objective measure of intellectual impairment. The

assumption underlying the development of the CQ was that persons with intact

32

intellectual functioning should have equal abilities in the areas of vocabulary

skills and abstract thinking. lndividuals with significant intellectual impairment

show a discrepancy between vocabulary skills and abstract thinking (Zachary,

1992). These neuropsychological tests were chosen because of their brevity

to administer and their relative sensitivity to cognitive impairment in chronic

alcoholics and drug users (Parsons & Farr. 1 981 ).

FONOW-up ~eriod. After the three-week assessrnent period, each

patient followed the standard Addictions Unit treatment program consisting of

weekly group psychotherapy, medical and psychiatrie monitoring as well as

random urine screening. All clients were assigned one of three colours (red,

blue or yellow) which were posted daily in the clinic. These colours appeared

randomly. with a variable frequency, and were unpredictable. Patients were

required to give a urine specimen each time they visited the Unit if their

assigned colour was posted on that day. A primary care therapist who wrote

monthly reports on treatment progress (attendance, relapses, etc.) was also

assigned for each patient. Clinic charts were examined for urine analysis

results and discharge summaries.

During the follow-up period, several outcome measures were examined

in order to evaluate in-treatment performance. These measures included length

of stay in treatment, attendance at therapy sessions, self-reponed relapses, and

random urine screening analyses.

Survival in treatrnent was determined from the discharge summary

33

(Appendix A). It was calculated as the number of days from initial assessment

to the date of last contact with the Unit. Other measures of outcome taken

from the discharge surnmary were the reason for discharge, and the amount of

drug use at discharge. Outcome variables collected from the clinic chart

included attendance at treatment sessions, self-reported relapses, and rneasures

of abstinence provided by the mandatory random urine screening program at

the Unit. Three indices were constructed from the urine screen records: 1) the

rate of urine testing; 2) the rata of positive drug tests for each patient over the

course of treatment; and 3) the rate of positive drug tests for the primary drug

of use.

Data analvsis. All information collected during the initial assessment

and follow-up periods. was coded and entered into a database using the

scientific software program RSI1 (RS/1, 1991 ). All subsequent statistical

analyses were conducted using the microcornputer version 7.0 of the Statistical

Package for the Social Sciences (SPSS, [SPSS, 1 9951).

Data from the entire sample of patients were analyzed together and then

stratified by gender, and primary drug of abuse, in order to describe the

characteristics of the population. Variables included demographic information,

employment status, marital status. drug type, age of onset and duration of

substance abuse problems, past history of substance abuse treatment,

psychiatric diagnoses and cognitive functioning. Analysis of the substance

abuse profiles of different groups formed on the basis of gender or

34

primarylsecondary drugs of abuse (ALCOHOL only, ALCOHOL + [alcohol with

a secondary drug of abuse], COCAINE+ [cocaine with or without a secondary

drug of abuse], OPIATES+ [opiates with or without a secondary drug of

abuse], and SEDATIVES+ (sedative-hypnotics with or without a secondary

drug of abuse]) were conducted using Analysis of Variance (ANOVA) as well

as Multiple Analysis of Variance (MANOVA) techniques for continuous variables

and Chi-square tests for dichotomous variables.

In order to examine the current and lifetirne prevalence of psychiatric

disorders in the entire study population (stratified by primary substance of

abuse) Chi-square and ANOVA tests were conducted. The impact of

comorbidity on treatment outcome was examined by comparing groups of

individuals with no comorbid diagnoses to those diagnosed with depression,

anxiety disorders, or ASPD across al1 outcorne measures (length of stay in

treatment, relapse rates, amount of therapy received, and completion status).

Post-hoc tests were performed using t-tests with a Bonferroni correction or

Scheffé.

Analysis of outcome for the different primarylsecondary drug categories

was carried out using multiple indices such as length of stay in treatment, rates

of relapse, attendance in group and individual therapy, and completion status

a t discharge. Multiple stepwise regression analysis techniques were used to

determine the variables that were most predictive of treatment outcome.

lndicators of outcome in the various groups described above were analyzed

35

using multiple client factors (demographics, drug use variables, psychiatric

diagnoses, psychological distress, and cognitive impairment).

Survival analysis were also conducted to examine the time dependent

aspects of treatment outcome. The survival functions for length of stay in

treatment were calculated using the SPSS survival program. Groups for this

analyçis were formed on the basis of gender, primary drug of abuse and

psychiatric comorbidity. Statistical cornparisons of the survival functions were

performed using the Wilcoxon (Gehan) statistic in SPSS (SPSS, 1995).

RESULTS

Descii~tion of the Sample

Demoaranhic characteristics. The final sample for the analyses

consisted of 159 male and 80 female substance abusing adults. The mean age

was 39.45 (t 0.7) years. As presented in Table 1, 33.5% of the sample were

females while ethnic minority groups comprised 7.1 % of the sample. Results

indicated that participants entered treatment at the Addictions Unit primarily for

health (38.4%) and family (26.7%) complications. The majority of the sample

(61 .O%) had completed secondary school and more than one third of them

(36.0%) had completed higher education. At admission. nearly half (41.2%)

were holding a job with males having significantly higher rates of employment

than females (x2,, 238 = 16.51, p = 0.001 ). Employment (34.7%) and social

assistance (39.0%) were the two major sources of financial support, with males

relying more on employment fhan females (X2z ,,, = 17.08. p =0.003). A large

proportion of men reported being single compared to women (X2,, ,,, =7.99, p=0.019) and one third (32.8%) of the sample reported living alone. Both

males and females were compared on al1 outcorne variables using t-tests and

Chi-square analysis. There were no significant differences between them on

any important demographic. substance abuse, psychiatric and cognitive factors.

Therefore. both males and females were cornbined for al1 subsequent analyses

and gender was not considered further.

Following comparisons between the two genders, the entire sample was

Table 1. Demographic Characteristics Stratified by Gender

Gender - --

Variable Males (n = 1 59) Females (n = 80)

AGE (Mean t SE) 38.4 (1.8) 41 .5 (1.4)

SEX (%) 66.5 33.5

RACE ( % l

Caucasian

Other

REASON FOR TREATMENT (%)

Health

Family

EOUCATION (%)

Secondary

Collegel University

EMPLOYMENT (%)

Unemployed

Emplo y ed

FINANCIAL SUPPORT (%)

Employment

Social Assistance

MARITAL STATUS (%)

Single

Married

Divorced

LIVING ARRANGEMENTS (%)

Farnily or Friands 61.7 67.5

Alone 35.7 30.0

* Significant differences between groups (p < 0.05).

38

stratified into five groups on the basis of primary drug of abuse. As mentioned

above, the drug groups were: 1) ALCOHOL, 2) ALCOHOL +, 3) COCAINE +, 41

OPIATES + , 5) SEDATIVES + (see Data Analysis section). Five participants

were lost from further analyses because they did not fit into any of the larger

drug categories.

Seveiitv of substance use at intake. Chi-square and ANOVA

analyses of information on substance abuse obtained a t admission revealed

significant differences on several drug use variables between the five primary

drug groups (see Table 2). There was a significant effect of age (F,

233 = 16.1 5, p = O .O01 ) and post-hoc analysis çhowed that the ALCOHOL and

SEDATIVES + groups were significantly older compared to the COCAlNE + and

OPIATES + groups (p c 0.05). Similarly, age of first drug use was significantly

different between groups (F, 228 = 42.93, p = 0.001 ), with the ALCOHOL and

ALCOHOL + groups starting a t a younger age (p ~0.05). There was also a

significant gender difference with females comprising the majority (77.3%) of

the SEDATIVES + group (X2,, 234=21 .50. p = 0.001 ). Furthermore, there was

a significant difference in the number of years of problem use (F,, ,,, =8.30, p =0.001), with the ALCOHOL and ALCOHOL + groups having significantly

more years of problem use (p ~0.05). The OPIATES+ and SEDATIVES+

groups were found to be more frequent daily users (xZ4, 227 = 75.04. p = 0.001 ).

Psvchiatric comorbiditv and psvchological svm~tomatoloav at

intake. in order to determine the prevalence of psychiatric comorbidity,

40

psychiatric evaluations were administered to a subsample of randomly selected

patients (n=85, [see Psychiatric Assessrnent section above]). Due to

stratification by primary drug of abuse, two individuals were lost from further

analyses. To examine for differences between drug groups, al! information

obtained during the psychiatric açsessment was analyzed using ANOVA and

Chi-square tests. As shown in Table 3, there were significant differences

between drug groups on Antisocial Personality Disorder (ASPD) (XZ,, gg = 14.63,

p =0.006), Childhood Conduct disorder X2,, ,, = 1 1.70, p = 0.02) with the

COCAINE + group exhibiting higher rates of these disorders (p < O.Os), and

phobia X2, ,, =9.84, p =0.04) with the SEDATIVE+ group showing higher

rates (p < 0.05)-

Upon admission to the Addictions Unit, participants reported moderate

levels of depression as indicated by the mean BDI score (M = 19.58 1.0.73).

Although a one-way ANOVA failed to reveal significant differences between the

five drug groups( F,, ,, , = 2.21 9, p = O.O68), there was a significant difference

on BDI scores between genders with females scoring higher (M =22.97 f

1.42) than males (M = 18.06 t 0.80, (FI* ,,, = 10.43, p =0.001). Further chi-

square analysis were conducted after dichotomizing BDI scores as above or

below 20 (a score 2 20 suggests the presence of rnoderate to severe

depression) revealing several significant differences between groups. As

indicated in Table 4, individuals who belonged to the ALCOHOL and

ALCOHOL+ groups had significantly higher percentage of BDI scores 2 20

Table 3. Rates of Psychiatric Diagnoses by Primary Drug of Abuse Measured by the DIS-SI

Drug Group

Psychiatric Disorder Alcohol Alcohol+ Cocaine + Opiates + Sedatives + (n=29) (n=21) (n = 18) (n = 8) (n = 71

Depression (90)

Anxiety (%)

Panic (%)

Phobia (%)

ASPD (%)

Conduct Disorder (96)

Mean Number of Diagnoses

( A l SE)

% Using Psychiatric Medication

* Significant differences between groups (p < 0.05).

43

compared to the three rernaining drug groups (x ' , ,,,=9.36, p =0.05).

Psychological symptomatology measured by the SCL-90-R indicated that

patients had experienced rnoderate levels of psychological distress during the

week prior to entering treatment (mean SCL-90-R total score = 1 09.1 4 + 4.20).

All SCL-90-R subscales and global indices were significantly different between

groups. ANOVAs revealed that scores on GSI (F,, 208 = 7.38, p = 0.001 ), PST

(F,, ,,, = 5.82, p =0.001), PSDl (F,, ,,, = 8.36, p = 0.001 ) and Total Symptorn

Score (F,, ,,, = 7.37, p = 0.001) were significantly different between drug

groups. Post-hoc analysis showed that the ALCOHOL+ and SEDATIVES +

groups obtained significantly higher scores (p < 0.05, [see Table 41).

Neurocoanitive functioninu at intake. The neurocognitive battery

was administered to a subsample of 11 0 individuals. From these patients, four

were lost from the analysis due to stratification by drug category. Comparisons

of cognitive functioning among the five drug groups indicated that there was

a significant difference between groups on the Trail Making A ( F,, ,, = 3.66,

p =0.008), with the SEDATIVES+ group spending significantly more time

completing the task than the other drug groups (p<0.05). As presented in

Table 5, there were no other significant differences between groups on any

other index of cognitive functioning.

In order to compare outcornes between the different primary drug groups,

in-treatment performance was determined using several indices. As presented

Table 5. Cognitive Functioning Scores by Primary Drug of Abuse

Cognitive Measure Alcohol Alcohol + Cocaine + Opiates + Sedatives + (n = 37) (n = 27) (n = 25) (n =8) (n =9)

TRAIL MAKING

Part A Scorea

Part B Score

% with Cognitive Impairment'

SlLS

Vocabulary Total

Abstraction Total

cab AOC

WAlS-R I Q

% with Cognitive lmpairment2

* Significant differences between groups (p < 0.05). a Trail Making scores are presented in seconds. I % based on Trail Making B scores. b CQ = Conceptuai Quotient. 2 % based on CQ scores. c A Q = Abstraction Quotient,

in Table 6, significant differences between groups were observed on various

outcome measures including length of stay in treatment (F,, ,,,=3.51,

p =O.OO8), the number of positive urine screens (F,, ,,, = 1 1.88, p = 0.001 ), the

number of positive urine screens for primary drug of abuse (F, ,,, =29.55, p=0.001), and the number of individual therapy sessions attended (F, ,

,,, =4.98, p = 0.001 . Post-hoc tests indicated that the OPIATE + group stayed

in treatment for significantly shorter periods of tirne (M = 62.48 t 1 1.891, had

significantly higher rates of positive urine screens (M =69.94 + 7.0), and

tested significantly higher on positive urine screens for primary drug of abuse

(M = 67.35 & 7.4, [p < 0.05 1). Sirnilarly, the SEDATIVES + and ALCOHOL +

groups received significantly higher amounts of individual therapy (p < 0.05)

compared to the three other groups.

Predictois of Lenqth of Stay in Tieatment

To examine the factors that predicted treatment outcome, al1 variables

derived from client characteristics (demographics, substance use, psychiatric

illness, psychological distress and cognitive functioning) were tested against al1

indices of outcome (length of stay in treatment, rates of abstinence, attendance

in therapy, completion status). With the exception of the primary measure of

outcome (survival in treatment), al1 secondary measures were not predicted by

any client factors.

Rearession analvsis. Multiple stepwise regression analyses were

47

performed to determine predictors of treatment outcorne and to examine their

contribution to the variation (expressed as R2) in the dependent variable. First,

regression analyses were conducted using predictor variables that were

available on the entire starting sample of 239 individuals. Such variables

included demographic characteristics (age, sex, race, education, etc.),

substance use variables (primary drug of abuse, frequency and number of years

of use), and measures of psychological distress (BDI total score, SCL-90-R total

score and SCL-90-R su bscales).

Results showed that from al1 variables entered into the equation, the

reason for entering treatment and the frequency of the primary drug of abuse

were significant predictors of length of stay in treatment (F,, ,,,=9.24,

p =0.001) out to six months of follow-up. As indicated in Table 7, the reason

for entering treatment was negatively correlated with survival in treatrnent

(r =-O. 1 60) and it accounted for 7.7% of the variance. The frequency of the

primary drug of abuse was also negatively correlated with the stay in treatment

(r =-0.205) and accounted for 4.2% of the variance.

Table 7 Multble Regession Report for Client Variables as Predictors

of Lenoth of Stav in Treatment

Predictor r R R2 f l t P = - - -

Reason For Treatment -0.160 0.277 0.077 -0.1 87 -2.88 0.004

Frequency of Use

of Primary Drug -0.205 0.205 0.042 -0.227 -3.50 0.001

Further multiple regression analysis was performed with the random

subsamples of patients who were administered the DIS-SI and the cognitive

battery. Variables entered into the regression analysis included psychiatric

diagnoses of depression, anxiety, ASPD as well as the Trail Making A, 6 and

SiLS scores. Results revealed that the SlLS vocabulary raw score was related

to length of stay in treatment (F,, ,, =4.51, p = 0.036). It was positively

correlated with the dependent variable( r = 0.21 8) and it accounted for 4.8% of

the variance.

Suivival anal~sis. Survivai functions4 for length of stay in treatment

stratified by the primary drug of abuse were examined using the SPSS survival

program and the Wilcoxon (Gehan) statistic. Survival analysis is potentially a

powerful analytic technique for examining the time dependent aspects of

outcome of treatment. As shown in Figure 1, the prirnary drug of abuse was

a significant indicator of survival in treatment, with the OPIATE + group staying

in treatment for significantly shorter period of time (p = 0.009). Other client

variables failed to predict survival in treatment including gender and the

presence or absence of a psychiatric diagnosis.

In order to examine treatment outcome between individuals with or

without mood disorders survival analyses were conducted using the diagnoses

Cox proportional hazard regression analysis was conducted using factors such as demographics, drug use variables as well as psychiatric and cognitive measures ta estimate length of stay in treatrnent. Results from this analysis failed to reveal any significant predictots of survival Iikely due to missing data on many predictor variables 1i.e- DIS-SI, Trail Making, S I E ) and subsequent loss of power.

50

for depression obtained from the DIS-SI. As presented in Figure 2, results failed

to reveal any significant differences between clients who were diagnosed with

a mood disorder and those without such diagnosis. Finally, further analysis

comparing groups formed on the basis of BDI cut-off scores of less than or

greater than 20 did not indicate any significant differences between the two

groups of patients (see Figure 3).

* No Depression + Depression

Length of Stay in Treatment (# of Days)

Figure 2. The Effects of Depression on Six-month Survival in Treatment. Results indicated that clients

with a diagnosis of depression (based on DIS-SI criteria) did not differ in terms of survival in treatment from clients

who were not diagnosed wit h depression, (W ilcoxon [Gehan] statist ic=O. 2 1, p=0 64 ) .

The present study attempted to determine the prevalence of psychiatric

comorbidity among individuals with various substance abuse disorders, examine

the relationship between psychiatric comorbidity and treatment outcome, and

explore client characteristics as potential early indicators of treatment success

or failure. Using a variety of assessment rneasures at intake, participants

admitted to an addictions treatment clinic, were extensively evaluated in terms

of dernographic characteristics, severity of alcohol and drug use, educational

and employment status, legal complications, marital and family relations,

psychiatric comorbidity, and cognitive functioning. These persons were

monitored for six months and differences in their performance in terms of

survival in treatment, abstinence rates, attendance in therapy and completion

status were examined.

Results indicated that this group of individuals had a broad spectrum of

demographic characteristics. All socio-economic strata were represented,

including a range of occupational domains and educational levels. The majority

of the sample were Caucasians, and females comprised more than one third of

the sample. The main reasons that led these people to seek help for their

psychoactive substance abuse problems were health and family complications.

Close to half of the sample were unemployed and over a third were relying on

social assistance. Analyses based on gender yielded mostly non-significant

results, especially for variables relating to drug abuse history and treatment

54

outcorne. Significant differences on variables related to employment, source

of support, and marital status were observed but these differences are not

necessarily related to drug use. Wornen were found to be married, unemployed

and relying on social assistance more frequently than men. Given the literature

on women's physiological vulnerability to the effects of alcohol (Anglin, Hser,

& Booth, 1987), it is particularly surprising that there were no significant

differences on years of problem use. In addition, it haç been observed that

women tend to leave treatment prernaturely regardless of age, race, or type of

treatment setting (Anglin et al., 1987). This finding of early dropout among

females in previous studies could be attributed to an inability of treatment

programs to meet the medical, emotional, and social needs of women. In the

current investigation, no such tendency of premature withdrawal was observed

suggesting that the Addictions Unit treatment program was able to address

several of the demands related to female gender. However, further clarification

of the impact of gender on treatment outcome is necessary, particularly since

female substance abusers have not been as extensively studied as males.

Analyses cornparing drug categories revealed rather interesting results.

It was found that cocaine addicted patients enter treatment at a significantly

younger age compared to individuals who abuse other drugs. Perhaps, this was

a consequence of the more severe negative family and employment

consequences reponed by the cocaine dependent group. Similarly, individuals

abusing alcohol appear to stan their use a t a younger age and they were

55

generally inclined to seek treatment for their substance related problems after

a decade or more of problematic use. The majority of opiate addicts were using

daily, while the majority of the sedative group were older and females. Findings

on six-month outcornes indicated that compared to other substance abusers,

opiate addicted persons stayed in treatment for very brief durations, completed

recommended therapy less frequently and had lower rates of abstinence as

indicated by the urine toxicology screening. I t should also be mentioned that

52% of this group of clients had dropped out of the program within the first

month. These results clearly demonstrate the difficulties of this group of

addicts to engage and remain in treatment.

ln addition to the low rates of retention in treatment, one should take into

serious consideration the detrimental effects of opiates on the lives of individual

addicts. Opiate dependence has wider public health implications, particularly

in terms of the AlDS epidemic. Many opiate-dependent persons, especially

heroin users who make up a majority of opiate dependence cases, administer

drugs intravenously. Needle-sharing and high-risk sexual practices make

intravenouç drug-users a very high-risk group for the transmission of HIV

(Canadian Centre on Substance Abuse [CCSA], 1997; Gill, Nolimal & Crowley,

1992; Des Jarlais, Friedman & Stoneburner, 1988). Researchers have found

that by controlling drug use, long-term retention in treatment for drug

dependence can play an important rote in limiting the spread of AlDS (CCSA,

1997; Hubbard, Marsden, Cavanaugh, Rachal, & Ginzburg, 1989). Therefore,

56

the effectiveness of treatments for opiate dependence and their ability to retain

patients in treatment represent critical research issues.

Other findings of the current study indicated that although there were no

significant differences between groups on the total therapy sessions received,

the ALCOHOL+ and SEDATIVES + groups attended significantly more

individual therapy sessions than any other group. Attendance in individual

therapy correlated with higher rates of psychiatric comorbidity (depression,

anxiety and phobia), more frequent usage of psychiatric medication, and higher

levels of psychological distress found among these two groups of addicts.

Nevertheless, the nurnber of treatment sessions received by these patients is

likely to be confounded by the length of çtay in treatment since these two

groups along with the ALCOHOL only group stayed in treatment longer.

Evaluation of psychological functioning using neurocognitive tests

revealed that individuals with sedative-hypnotic dependence required significant

longer periods of time to complete the Trail Making A test. It is possible that

some dysfunction exists in regards to the visuospatial abilities of these

individuals but the severity of this impairment and its relation to treatment

outcome remains to be determined. Analyses of other indices of cognitive

functioning, especially the Trail Making 6 and the SILS Conceptual Quotient,

failed to indicate significant differences between drug categories and predict

treatment outcome. Compared to the findings of other studies using similar

standardized instruments to assess cognitive deficits (Fals-Stewart & Schafer,

57

1 992; Hoff, Riordan, Morris, Cestaro, Wieneke, Alpert et al., 1 996; OtLeary,

Radford, Chaney, & Schau, 1979; Rosselli & Ardila, 19961, the current findings

showed that the present sample suffered fairly mild levels of cognitive

dysfunction. Despite the fact that assessrnent of cognitive abilities in

substance abusers is recommended after three weeks of abstinence (Parsons

& Farr, 1981 1, this waiting period is primarily based on studies conducted with

alcoholics and it does not necessarily apply to the evaluation of clients who

abuse other substances. Clarification of this issue necessitates careful

neurocognitive evaluation in drug abusers other than alcoholics.

With regards to the prevalence of psychiatric comorbidity among the

various groups of individuals entering treatment at the Addictions Unit elevated

levels of mood, anxiety and ASPD disorders, ranging from over 37% (anxietyl

to 56% (depression) were observed. Similar high prevalence rates of

psychopathology among substance abusers have been documented in the past

(Alterman & Cacciola, 1991; Kessler et a1.,1994; Regier et al., 1990;

Rounsaville et al., 1991). Analyses of data on psychiatric disorders by drug

group showed that cocaine addicred individuals reported the highest levels of

ASPD disorder and the SEDATIVES + individuals report higher rates of phobia.

The finding of most elevated ASPD rates in cocaine addicts is unusual since

some evidence in the literature suggests that opiate dependent persons report

the highest rates of ASPD disorder (Schuckit, 1985). Consistent with the

elevated rates of psychiatric illness was the finding that almost half of the

58

sample (48.8%) reported using psychiatric medication at admission. In addition

to the substance related disorder, there was an average of 3.5 coexistent

psychiatric diagnoses per individual. Finally, psychiatric symptomatology

measured by the BDI and the SCL-90-R showed that this group of patients

experienced moderate to severe levels of psychological distress the week prior

to entering treatment.

As discussed earlier, one of the goals of this study was to examine the

relationship between depression and outcome of treatment. The specific

hypothesis that patients with a diagnosis of depression or severe depressive

symptomatology would have poorer treatment outcornes was not supported.

This is consistent with some research findings which have failed to show any

significant relationship between depression and outcome of treatment (Araujo

et al., 1996; Roberts, & Nishimoto, 1996; Hoffman, Caudill, Koman, Luckey,

& Flynn, 1993; Sterling, Gottheil, Weinstein, & Shannon, 1994). Contrary to

rhese and the current investigation, others have reported that addicted patients

with high levels of depression remain in treatment longer (Agosti et al. 1991 ),

attend more therapy sessions (Joe e t al., 1995). or have worse prognoses in

general (Alterman et al., 1993; Miller. 1991 ; Moos, et al., 1994; Rounsaville et

al., 1986). Based on al1 these inconclusive and conflicting results, it is apparent

that funher research is required to clarify the impact of depression among

addicted individuals on treatment outcome.

Further exploration of treatment outcome predictors using regression

59

analysis techniques showed that the reason for seeking help for their substance

related problems predicted length of stay in treatment. In other words, clients

who entered treatment primarily for family, health and employment reasons

remained in the program for significantly longer durations than clients who

entered treatment for other reasons such as legal or financial problems. The

predictive value of this indicator was small, explaining only 7.7% of the

variance. Factors such as age, race, gender and other demographic variables

were found not to be related to treatment outcome. Some investigators have

suggested in fact that interactions between demographic characteristics such

as gender and treatment outcome are trivial, and have contended that other

variables such as psychosocial factors and treatment modalities may play a

more important role in outcome (Stark, 1992).

Subsequent regression analysis on substance use variables indicated that

the frequency of use of the primary drug of abuse was a significant indicator

of six-month survival in treatment. That is, the more frequently the individual

used substances before the initiation of treatment the less helshe remained in

the program. Again, the variance accounted for by this variable was srnall,

explaining 4.2% of the variation. Although regression analyses did not yield a

significant relationship between primary drug of abuse and retention in

treatment, survival analysis demonstrated that the primary drug of abuse was

a significant indicator of the rate of dropping out and length of stay in

treatment. It was shown that individuals who abused opiates had a tendency

60

to withdraw from treatment at a faster rate especially during the first month of

therapy. I t is possible that this premature dropout may be the result of the

more severe withdrawal effects experienced by opiate addicted persons.

Moreover, one must keep in mind that the opiate group had the highest rates

of daily use and the lowest rates of abstinence, suggesting a more severe

dependence. It is possible that intervention for opiate addicts vvithin

mainstream addiction treatment clinics needs to be more specialized to meet the

specific physiological and psychological demands associated with opiate

dependence.

Several experts have asserted that opiate abusers who are stabilized on

methadone, a synthetic opioid. may respond to subsequent treatment in a

similar rnanner to those addicted to other drugs (Laqueille. Bayle, Spadone.

Jalfre. & Loo, 1996). Methadone is a long-acting opiate that produces a milder

withdrawal of longer duration than morphine or heroin. It is important to note

that methadone can be used to treat opiate dependence in two distinct ways;

as a substitution agent (methadone maintenance) or detoxification agent.

Methadone maintenance typically involves long-term, continued use of

methadone in conjunction with psychosocial rehabilitation. In the case of

detoxification, the goal of treatment is to stabilize patients with a dose of

methadone and then decrease the doses in order to eliminate physical

dependence.

In many treatment centres, detoxification from opiates is normally

61

considered the first step in a long-term treatment program aimed ultimately at

abstinence from illicit opiate use (Kleber, 1994). Patients may be detoxified in

either an inpatient or an outpatient setting. The former provides a controlled

environment and constant care in a hospital, while the latter involves the

patient being given prescriptions for the detoxification agent to use while living

at home.

A variety of studies published in the United States have reported

pessimistic findings about the effectiveness of detoxification when compared

to other treatment rnodalities such as methadone maintenance or therapeutic

communities (Nurco, Kinlock, & Hanlon, 1994; Simpson, Joe & Bracy, 1982).

Simpson et al.3 (1 982) analysis of data from the DARP project demonstrated

that detoxification is not associated with positive outcomes in the long-term.

Specifically, only 1 5 % of detoxified patients had highly favourable outcomes

at one year post-treatment (i.e. no illicit drug use, and no arrests or

incarcerations), as opposed to approximately 25% highly favourable outcomes

with the other treatment modalities. Simpson attributed this ineffectiveness to

the shon length of detoxification treatment, stating that al1 treatments of less

than 90 days are of limited utility. Based on the present results and a large

body of literature showing very poor outcomes for opiate dependent patients,

the utility of detoxification and outpatient drug-free abstinence programs must

be seriously challenged. Methadone maintenance has become the therapy of

choice for opiate addiction in the United States, a treatment modality that is

62

seriously under-utilized in Canada. The present findings should reinforce the

need for centres such as the Addictions Unit to consider methadone

maintenance as a treatment option.

In spite of the contributions of the work undertaken here, several

methodological considerations must be acknowledged. First, information on

drug intake was collected by self-report. Questions have been raised

concerning the reliability and validity of self-reported drug and alcohol intake

(Babor et al., 1990; Carroll, 1995; Fuller, 1988; Sobell & Sobell, 1989).

However, the data collected in this study closely followed suggestions put

forward by several experts in this area of research (see Carroll, 1995; Sobell &

Sobell, 1989). The information gathered was based on confidential interviews,

using a variety of instruments and procedures that have been validated in many

similar studies (Babor et al., 1994; Kranzler, Del Boca, & Rounsaville, 1996;

McLellan, et al., 1996) and drug consumption was confirmed by random urine

screening . Second, the current investigation did not evaluate long-term goals of

treatrnent such as maintenance of therapeutic attainments beyond the time of

the treatment episode. It has been recommended that both short- as well as

long-term outcornes be evaluated since they are thought to be equally essential

aspects of treatment effectiveness (Babor et al, 1 994; McLellan et al., 1 996).

However, outcome results tend to be unstable over time and later follow-up

evaluations of a specific treatment episode could becorne contaminated by the

63

effects of subsequent treatments (McLellan et al., 1994). For these reasons,

the present investigation focused only on short-term (six-month) outcornes as

suggested by some investigators (see McLellan et al., 1994). Furthermore, it

is unlikely that a single follow-up evaluation could be optimal for al1 research

questions, and thus future investigations should focus on evaluating the long-

term treatrnent success by scheduling reassessments at regular intervals, for

exampie every 3 or 6 months.

In conclusion, it should be noted that this study was one of the first to

compare treatment outcornes among a large variety of substance abusing

groups. The results demonstrate some of the cornplexities involved in treating

substance abuse disorders and in predicting treatment outcorne. As expected,

elevated rates of psychiatric dysfunction were observed among individuals with

alcohol and drug problems. However, the presence of psychiatric comorbidity,

especially mood disorder, was not predictive of length of stay in treatment,

rates of abstinence, attendance in therapy and completion status. Future

studies should attempt to examine the impact of depression on the course and

outcome of addictions treatment by exploring the distribution of primary versus

substance-induced depression as well as the severity and presentation of

specific features of depression. The fact that substance use variables emerged

as meaningful predictors of outcome further validates and expands existing

literature in the area of treatment outcome. The finding that opiate addicted

individuals were found to be less successful than other substance abusers,

64

especially the first month of therapy, is of great importance not only to

treatment programs but aiso to the public at large. It is significant that

retention of these addicts in treatment could help lirnit the spread of HIV by

reducing drug use, needle sharing and high-risk sexual practices. Therefore,

increasing the effectiveness of opiate addiction treatment will contribute not

only to successful comprehensive treatment of opiate dependence but also to

a crucial public health response to the AlDS epidemic.

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Discharge Sumrnary Forrn

MONTREAL GENERAL HOSPITAL

ADDlCTlONS UNIT, GRIFFITH EDWARDS HOUSE

1604 Pine Avenue West, Montreal H3G 184

TEL# (5 14) 934-831 1 FAX# (51 4) 934-8262

DISCHARGE SUMMARY

Unit#: PATIENT NAME:

Prirnary Care Therapist:

DATEOF ADMISSION: OISCHARGE DATE: (day, month, year) (day, month, year)

REASON FOR DISCHARGE FROM ADDICTIONS UNIT:

1) Patient completed al1 recommended treatment, 2) Referred to another Tx facility, 3) Referral to another MGH Unit, 4) Patient failed to attend group Tx following initial assessment, 5) Patient stopped attending (Le. drop-out), 6) Discharged due to non cornpliance with program rules, 7) Patient Incarcerated, 8) Patient Died, 9) Other(list details1

DATE OF LASTCONTACT WITH UNIT BEFORE DISCHARGE: (date last attended group or individual therapy session) (day, month, year)

STATUS AT OISCHARGE

DRUG USE AT DISCHARGE: 1) no drug use, 2) some drug use (occasional slips), 3) full relapse, 4) patient never ceased drug use, 99) unknown

MARITAL STATUS AT DISCHARGE: 1) never married, 2) marriedlcommonlaw, 3) separated, 4) divorced. 5)

widowed, 99) unknown

LIVING ARRANGEMENTS AT DISCHARGE: 1) with spouselpartner, 2) children only, 3) parentslsiblings, 4) friends, 5) alone, 6) prison/jail, 7) other, 99) unknown

EMPLOYMENT STATUS AT DISCHARGE: 1 ) unemployed, 2) employed full-tirne, 3) employed part-tirne, 4) self-employed, 5) retired, 6) housewife, 7) student, 8) disabled, 9) other, 99) unknown

MAJORSOURCEOFSUPPORTATDISCHARGE: 1) employrnent, 2) UIC, 3) welfare, 4) family, 5) pension, 6) prostitution, 7) drug dealing, 8) other crime (breaking and entering, shoplifting) ,99) unknown

EDUCATION/SKILL DEVELOPMENT STATUS: O) no change compared to admission, 1) currently enrolled in an educational program, 2) was enrolled in an educational program-dropped out while in Tx, 31 was enrolled-completed program while in Tx, 99) unknown or not applicable

NOTES: