Several self-report instruments were used to compare the efficacy of the treatment programs. The investigators found a modest advantage to the MTC approach, with significant differential of treatment effect on only 3 of 34 measures. Patients in the MTC appeared to do better on measures of psychiatric severity and housing stability. There was no difference between groups, however, on measures of substance use, crime, or employment. Nevertheless, the investigators said, the findings suggest that "adding a restricted array of targeted and time-limited interventions can improve outpatient substance abuse treatment."
In a separate review of 4 other studies, Sacks and colleagues found that there was support for MTCs when the MTC model is "reshaped to accommodate the individual needs, impairments, and deficits of clients with co-occurring disorders."5Behavioral approach
A randomized prospective trial of a behavioral approach for treating opioid-dependent patients who also had antisocial personality disorder (APD) was reported by Karin Neufeld, MD, and colleagues6 from Johns Hopkins University. The investigators compared an experimental condition involving a structured contingency management intervention with a control that used standard methadone(Drug information on methadone) maintenance.
Most earlier studies of the treatment response of this population, the authors pointed out, have been retrospective or post hoc evaluations of response to standard treatment programs for drug abuse. "Less is known about the response of these patients to interventions that target both unique and shared symptoms of both disorders," they said.
In this study, 100 patients in a methadone maintenance program for opioid dependence who also met di-agnostic criteria for APD were randomized to either continue in the unchanged methadone maintenance program or receive additional behavioral intervention. The experimental condition protocol consisted of 9 steps of care with rapid delivery of predictable and increasingly positive consequences for attendance at scheduled counseling sessions and abstinence from drug use.
The control group was also offered counseling sessions and was exposed to some positive and negative incentives such as the privilege of a take-home methadone dose or the imposition of a less convenient clinic dose time. The investigators noted that the positive and negative incentives in the control were presented separately and were determined for the individual solely by the clinical staff, rather than being consistently available in conjunction with behavioral targets, and that they were only available after relatively extended periods of treatment.
Attendance at counseling sessions was recorded, as were results of weekly urine tests for presence of opiates, cocaine, sedatives, and alcohol(Drug information on alcohol). Clinical assessments were accomplished with the Structured Clinical Interview for DSM-III-R, Psychopathy Checklist-Revised, and the Addiction Severity Index.
The investigators found a significantly higher (4-fold) rate of attendance (80%) at scheduled counseling in the experimental group. They note this rate is also considerably higher than the average of approximately 50% reported in other studies of opioid-dependent patients receiving methadone. There was also a higher incidence of drug-negative urine specimens in the experimental group, although the difference was not statistically significant.
High psychopathy was associated with drug use in both groups, although the association was weakened when treatment condition, number of APD symptoms, and other psychiatric comorbidity were controlled for. The investigators indicate that this suggests that the negative influence of high psychopathy on drug use can be modified by at least some types of treatment.
"While notable clinical improvement may not render this an 'easy to manage' group of patients because of ongoing symptoms of antisocial personality," Neufeld and colleagues commented, "the clinical gains they can achieve provide a strong basis for therapeutic optimism."6
In a "Perspective" article, Sacks and colleagues7 suggested areas for future research, including those that will inform allocation of treatment resources and those that will promote the conceptualization of addiction as a chronic, rather than an acute condition. They note that most studies of patients with co-occurring disorders have been conducted in mental health settings rather than in substance abuse treatment sites, and so have disproportionately sampled a subgroup with more severe and persistent mental disorders.
Treatment outcomes for this population should be assessed for both mental health and substance use disorders, Sacks and colleagues believe, and ideally comprise a broad array of domains that mark treatment progress and stabilization. For substance abuse, these could include criminal activity, HIV risk behavior, employment, stable housing, and participation in parenting and family activities. Appropriate mental health outcomes include symptom change, medication compliance, and improved psychological well-being.
Applying the results of research and effectively integrating care within the substance abuse and mental health treatment systems, Sacks and colleagues said, "will require each system to augment the treatment it currently provides to meet the full range of its clients' differential needs."7