Poster Abstracts from the AAAP 20th Annual Meeting and Symposium
Authors: McNicholas Laura F. 
Published: May 2010

We are very pleased that The American Journal on Addictions (AJA) has committed to continuing to publish all abstracts from poster presentations made at the 2009 annual meeting of the American Academy of Addiction Psychiatry (AAAP). Scientific presentations made at the meeting play a vital and important role in the content of the meeting, and AAAP has been committed to fostering this aspect of the program. Prior to the 2005 meeting, AJA published a small number of abstracts based upon ratings made by members of the Research Committee as a means for acknowledging the work presented. After discussion, the Board of Directors recommended publishing all abstracts from poster presentations, and recent changes in the Journal and consensus by the Board have resulted in this new initiative.

By publishing these abstracts, AAAP completes what may be viewed as a three‐step process. The first step is the submission of abstracts for a poster presentation at the meeting; these abstracts undergo peer review and critique by the Program Committee, and those that do not fulfill a minimal standard of quality are not accepted. The second step is then the actual presentation at the meeting. This new, final step is the publication of the abstract in a citable journal that is well established and respected in the field of addictions.

Our hope is that the opportunity to have an abstract published in the Journal will capture the attention of, and be attractive to, researchers in the field. The AAAP annual meeting provides a unique opportunity for researchers and clinicians to interact, and the AAAP and AJA are taking this step in an effort to reach out to members of the research community who may not traditionally attend and present at the meeting. Other steps taken by AAAP, such as major presentations at the meeting centered on NIDA's Clinical Trials Network (CTN), also seek to capitalize upon this unique opportunity for the research and treatment communities to interact and learn from each other.

It is the intent of AAAP and AJA that publication of all poster abstracts will occur following annual meetings into the future. We hope you will consider submitting a presentation for the 2010 annual meeting. The process is simple, the meeting is collegial and enjoyable, and there is now the additional bonus of a citable reference for your work.

Finally, congratulations to the authors of these abstracts.  

Poster 1: Buprenorphine‐Medication Assisted Treatment: A Retrospective Analysis of Health Plan Data

Charles Ruetsch, PhD, Health Analytics LLC, Columbia, Maryland; J Tkacz

Background/Objective: Buprenorphine‐medication assisted therapy (B‐MAT) is an effective treatment for opioid dependence (OD), but its cost benefit is unclear. This study estimated cost benefit of B‐MAT from the payor perspective.

Methods: A pre‐post case matched time series analysis of 2 groups (1. B‐MAT fill and, 2. no B‐MAT fills) were analyzed over time. Data were claims (Q4 2005 to Q3 2008) from a large MCO of members with a diagnosis of OD. A within subjects Poisson model was used to regress patient characteristics onto six service utilization count measures and a within subjects MANCOVA was used to analyze service cost measures.

Results: After controlling for demographics, Medicaid status, and health status, Group 1 had more Rx fills (5.21) and physician and outpatient visits (.88), but fewer hospital days (1.46) and ER visits (.22; p's < .05). Group 1 had higher Rx ($1,208) and physician and outpatient costs ($160), but lower inpatient hospital costs ($1,986; p's < .05). Overall, Group 1 had lower total healthcare costs ($11,200, p < .001). Utilization of costly services and costs decreased over time and the interaction terms indicate that B‐MAT patients drive most of the decreases.

Conclusions: Though B‐MAT patients incur higher pharmacy and office visit costs, they use fewer expensive health care services in other areas, resulting in an overall positive cost–benefit conclusion. Further, the longer that patients are on B‐MAT the lower their cost is overall compared to non‐B‐MAT patients.

Source of Funding: Reckitt Benckiser Pharmaceuticals.  

Poster 2: Compliance with Buprenorphine‐ Medication Assisted Treatment Decreases Drug Use among Opioid Addicts

Joseph Tkacz, MS, Health Analytics LLC, Columbia, Maryland; C Ruetsch

Background/Objective: Among those who are opioid dependent (OD), there is also a risk for poly‐substance abuse. Follow‐up substance abuse was examined on a national sample of OD patients during treatment with buprenorphine‐medication assisted therapy (B‐MAT).

Methods: Subjects (N = 1,426) were new B‐MAT patients who were randomly assigned to an intervention arm (B‐MAT + telephonic patient support medication compliance program) or control arm (B‐MAT alone) as part of a larger RCT. Measures included the Addiction Severity Index collected at baseline, 1, 2, 3, and 6 months. Difference in use of a variety of substances at 6 months was compared between subjects who were compliant (C) with B‐MAT and subjects who were noncompliant (NC). Compliance was defined as taking medication on at least 22 of the previous 28 days. Chi‐square tests of equality of proportions were used to compare groups.

Results: Compared to C subjects, NC subjects were significantly more likely to use: alcohol (44% vs. 33%), heroin (11% vs. 3%), methadone (5% vs. 1%), other opiates (22% vs. 7%), cocaine (6% vs. 2%), and cannabis (23% vs. 15%); p's < .05.

Conclusions: Results indicate that, in addition to less opioid use, C Ss used additional licit and illicit substances less often than did NC Ss. These results are particularly important given the number of OD patients who abuse multiple substances, and the high costs associated with drug dependence (eg, treatment, prison, crime, etc.). Future studies should compare the effectiveness of other treatment modalities on subsequent drug use patterns in opioid‐dependent patients.

Source of Funding: Reckitt Benckiser Pharmaceuticals.  

Poster 3: Predictors of Buprenorphine‐Medication Assisted Treatment Compliance among Opioid‐Dependent Patients: Results at Month Six

Charles Ruetsch, PhD, Health Analytics LLC, Columbia, Maryland; J Tkacz

Background/Objective: Compliance with buprenorphine medication assisted therapy (B‐MAT) drives early treatment outcomes among opioid‐dependent (OD) patients. This study examines the relationship between patient behavior, participation in a compliance program, and 3‐month treatment compliance.

Methods: Treatment (B‐MAT) seeking patients (N = 1,426), were randomly assigned to an intervention group (B‐MAT plus patient support program) or control group (B‐MAT as usual). Measures included the Addiction Severity Index and Treatment Services Review collected at baseline, 1, 2, 3, and 6 months. Chi‐square tests of equality of proportions were used to compare compliance between groups at each measurement period. Month six compliance was regressed onto group, demographic indicators, and baseline indicators. Subjects who were assigned to the intervention, but did not choose to participate, were excluded from analyses.

Results: Subjects assigned to the intervention were significantly more likely to be compliant with B‐MAT at all 4 follow‐up measurement periods (months 1, 2, 3, and 6; p's < .001). Baseline heroin and barbiturate use, the number of days receiving treatment for psychological problems, and the number of days experiencing medical problems were significant inverse predictors of B‐MAT compliance. Older subjects who were paid for more days of work were more likely to be compliant with B‐MAT.

Conclusions: Baseline drug use, medical and psychiatric issues, and a variety of demographic indicators were all predictive of B‐MAT compliance at month 6. Future research should focus on developing methods that allow or facilitate application of compliance programs, such as Here‐ToHelp™, among these more vulnerable populations.

Source of Funding: Reckitt Benckiser Pharmaceuticals.  

Poster 4: Differences in Opioid Dependence Severity by Health Insurance Ameliorated by Month Six of Buprenorphine Treatment

Charles Ruetsch, PhD, Health Analytics LLC, Columbia, Maryland; J Tkacz

Background/Objective: Few studies have examined the effect of patient insurance coverage on outcomes among opioid‐dependent (OD) patients in buprenorphine‐medication assisted therapy (B‐MAT). Vital to payors, both commercial and government, the purpose of this study was to understand differences in treatment outcomes between commercially insured B‐MAT patients and those with public sector coverage (ie, Medicare or Medicaid) or no insurance coverage.

Methods: Subjects (N = 1,426) were new B‐MAT patients who were randomly assigned to an intervention arm (B‐MAT + telephonic patient support medication compliance program) or control arm (B‐MAT alone) as part of a larger RCT. Measures included the Addiction Severity Index collected at baseline, 1, 2, 3, and 6 months.

Results: At baseline, subjects with Medicaid/Medicare or no coverage (n = 606) had significantly higher legal, psychiatric, and employment composite scores, indicative of greater problem severity in these areas, compared to the commercially insured (p's < .05). The commercially insured group had a significantly higher alcohol composite score (p < .05). By month 6, there were no longer any differences between the two groups on the legal and psychiatric composite scores, yet the differences on employment and alcohol composites remained.

Conclusions: B‐MAT appears to have a positive impact on many areas of the OD patient's life. Future research is needed to elucidate why only certain differences between insurance groups disappeared after 6 months of treatment while others remained, and to investigate whether the sequela of other types of substance abuse (eg, alcohol) differ based on one's health insurance type.

Source of Funding: Reckitt Benckiser Pharmaceuticals.  

Poster 5: Cytochrome P450 Abnormalities in Patients Who Require High‐Dose Opioids

Forest Tennant, MD, Dr PH, Veract Intractable Pain Clinic, West Covina, California

Background: For unclear reasons, some chronic pain patients require very high‐dose opioid therapy to adequately control pain. Recently, it has become possible to test for some genetic cytochrome P450 enzyme abnormalities.

Methods: Fifteen (15) chronic pain patients who required 100 mg or more of morphine equivalence a day to control pain were tested for one or both the cytochrome P450, 2C9 or 2D6, genotypes. Their opioid serum concentrations were determined approximately 1 hour after their usual opioid dosage.

Results: One of 11 (9.0%) patients tested for genotype 2D6 was abnormal. This patient is of Asian extraction. Serum concentrations of oxycodone and its metabolite, oxymorphone, were undetectable 1 hour after dosing. Two (2) of 8 (25%) patients tested for 2C9 genotype were abnormal, and both had very high serum concentrations of fentanyl (8.1 and 16.4 mg/ml) 1 hour after dosing. All three patients with cytochrome P450 genotype abnormalities stated that opioids provided pain relief for a very short time, usually only 1 to 2 hours, after administration.

Conclusions: This preliminary investigation shows that genetic, cytochrome P450 abnormalities exist, in at least some high‐dose opioid patients, even though only two of many genotypes were tested here. Cytochrome P450 abnormalities may require high serum opioid concentrations to stimulate (“force”) enzyme activity and/or the abnormality may result in ultrafast metabolism. High‐dose opioid patients are often stigmatized as abusers or addicts, and this preliminary study compels further study and possibly a new clinical perception of these patients.

Source of Funding: None.  

Poster 6: Outcomes of Chronic Pain Patients Treated with Opioids for Over 10 Years

Forest Tennant, MD, Dr PH, Veract Intractable Pain Clinic, West Covina, California

Background: Recent epidemiologic studies indicate that about 10 million Americans now take opioid drugs for pain control. This relatively recent and dramatic occurrence has had little outcome study. The author recently reported 24 Southern California chronic pain patients who were treated with opioids over 10 years and who had positive social, physical, and functional results.

Methods: Physicians who have long‐term opioid‐treated pain patients were recruited by advertising in a trade journal for physicians. Once identified, physicians completed a questionnaire for each 10‐year patient. Information consisted of opioid use, dosage, underlying cause of pain, length of opioid therapy, stability of dosage, complications, and functional abilities.

Results: To date 50 total patients from six geographic sites have been identified. The majority of patients have remained on a stable opioid dosage for long periods and maintain good function in activities of daily living including dressing, reading, work, care for family, attendance at social functions, driving a car, and ambulation without assistance.

Conclusions: This survey study leaves out patients who may have experienced severe side effects or found opioids to be an impairment to normal activities of daily living and discontinued their use. Although the percentage of patients who fall in the “poor outcome” category is unknown, it is clear that long‐term opioid use is associated with a positive outcome in some chronic pain patients. Given the findings here, there is no obvious reason to discourage opioid use or encourage pain patients to cease opioids.

Source of Funding: None.  

Poster 7: Implementation of an Electronic Information System to Enhance Practice at an Opioid Treatment Program

Steven Kritz, MD, Addiction Research and Treatment Corporation, Brooklyn, New York; LS Brown, Jr, M Chu, R Zavala

Background: Adoption of electronic health systems (EHS) is commonly discussed in healthcare reform, especially in addiction treatment. We report the design and pre‐implementation quality and patient and staff satisfaction results of an integrated EHS in an outpatient opioid agonist treatment program, consisting of seven clinics and providing primary medical and HIV‐related care for approximately 3,000 predominantly minority adults in New York City.

Methods: Besides quality and satisfaction, three other aims (productivity, financial performance, and risk management) were in the parent study, using a pre‐post, prospective comparative design. Quality measures included: (1) viral load assessment in hepatitis C virus (HCV) infected patients, and (2) timely assessment of patients’ medical and addiction status at various intervals. Using an anonymous survey, patient and staff satisfaction were assessed. Associations were assessed with staff and patient variables.

Results: HCV viral load was appropriately performed in 92% of cases; annual medical assessments were timely for 83% of cases; annual addiction assessments were timely at 30 days, 90 days, and annually for 81%, 46%, and 70% of cases, respectively. Seventy‐four percent of patients were satisfied/very satisfied with their care, while 33% of clinicians and managers were satisfied/very satisfied with the pre‐EHS system for providing care.

Conclusions: These results provide insight into primary care and addiction treatment delivery in one large program and provide the basis of assessing the impact of an integrated EHS, further informing healthcare reform discussions.

Source of Funding: This R01 study is funded by the National Institute on Drug Abuse: DA022030.  

Poster 8: Design of a Novel Relapse Prevention Videogame as an Adjunct to Treatment for Alcoholic Patients

Marcia L Verduin, MD, University of Central Florida, Orlando, Florida and Orlando VA Medical Center, Orlando, Florida; S LaRowe, C Bowers, R Joyce, P Smith, H My‐ rick, J Salazar, B Stabile

Background: Relapse prevention (RP) therapy is well supported in the treatment of alcoholism. However, current delivery of RP therapy provides little opportunity to practice skills in a safe, realistic environment. Innovative approaches are needed to develop alternative settings for RP skill practice and maintenance.

Methods: Addiction specialists collaborating with serious games programmers developed an interactive videogame grounded in RP theory for alcoholics to play as an adjunct to standard treatment. The game is currently being evaluated in a randomized prospective clinical trial.

Results: The game concept for “Guardian Angel” is based on lifestyle management‐type games. The group developed four minigames housed within an overarching core game. In the core game, patients go about their daily lives while managing emotions, cravings, finances, and relationships. During each “day” of the game, patients must play one of the minigames—Route Planner (navigating home while avoiding potential triggers), Clean House (ridding their home of hidden alcohol and other triggers), Drink Refusal (practicing drink refusal skills), and Balance Out (“therapy” sessions to reinforce key RP skills). Feedback from focus groups has been uniformly positive. A laptop will be provided for attendees to play the game during the poster session.

Conclusions: An interactive videogame based on RP theory may provide a motivating, safe, realistic environment for alcoholics to practice their RP skills, in addition to standard treatment. Preliminary focus groups indicate that patients find the videogame acceptable and engaging. A clinical trial is underway to determine the efficacy of the game as an adjunct to treatment.

Source of Funding: Robert Wood Johnson Foundation.  

Poster 9: Cross‐Cultural Adaptations and Physician Training Integrating Alcohol Interventions into Routine Tuberculosis Care in Tomsk, Russia

Hilary Smith Connery, MD, PhD, McLean Hospital, Belmont, Massachusetts and Harvard Medical School, Boston, Massachusetts; V Livchits, A Shields, L McGrady, N Patrick, CS Lastimoso, A Grishkina, JE Hart, SS Shin, SF Greenfield

Background: IMPACT (Integrated Management of Physician‐delivered Alcohol Care for Tuberculosis patients) is a randomized controlled trial to assess the effectiveness of alcohol interventions as an integrated component of TB care provided to patients with co‐occurring TB and alcohol use disorders (AUD) in Tomsk, Russia. We discuss cross‐cultural adaptations and physician training to provide an alcohol brief counseling intervention (BCI) and medical management with naltrexone (NTX).

Methods: Alcohol interventions were delivered monthly by TB physicians as part of a 6‐month directly observed therapy, short‐course (“DOTS”) protocol for TB treatment. Patients with TB meeting CIDI‐SAM criteria for AUD provided informed consent for random assignment to receive BCI, NTX, BCI + NTX, or TAU (treatment as usual) adjunct to DOTS. Eighteen TB physicians were certified to perform all adjunct interventions through a series of trainings by a US‐Russian multidisciplinary team using in‐person and teleconferenced didactics, role‐plays, feedback, and mock interviews. AUD interventions were audiotaped, translated, and reviewed weekly by a bilingual United States–Russia fidelity team consisting of expert AUD supervisors and trained bilingual coders and Russian supervisors. TB physicians received ongoing corrective feedback and training for adherence to each intervention.

Results: Financial incentives and personalized training positively affected physician attitudes toward AUD intervention delivery and adherence to protocol. Cross‐cultural challenges include linguistic adaptations, altering cultural norms of physician–patient dialogue, and limited referral support services for AUDs.

Conclusions: Frequent dialogue and performance feedback with TB specialists by a multidisciplinary United States–Russian AUD training team resulted in cross‐culturally acceptable and feasible AUD interventions integrated into TB care.

Source of Funding: Supported in part by a grant from the National Institute on Alcohol Abuse and Alcoholism R01AA016318 (SS) and from the National Institute on Drug Abuse K24DA019855 (SFG).  

Poster 10: Ethics and Addiction: Moving Beyond Mistrust in Individual and Collective Care Relationship

Aymeric Reyre, MD, Avicenne Hospital, Paris, France and WHO Collaboratve Center for Ethics, Paris, France; O Taïeb, JF Rouchon, G Broder, E Hirsch, MR Moro, T Baubet

Background: Data from the literature as well as the daily care of addict patients stress the importance of pejorative representations they are carrying. These representations lead to a climate of mistrust responsible for major difficulties in establishing an authentic care relationship.

Methods: Our phenomenological analysis of mistrust is based on Georges Devereux's complementarist epistemology. It allows us to link anthropological, philosophical, and clinical viewpoints and opens tracks for the medical person's ethical positioning.

Results: The pragmatic approach based on the analysis of interactions in the economic field and on game theory, calls to bet on trust to maximize systemic efficiency. On the other hand, a philosophy of action lead to Michel Foucault's ethics of the “Care of the Self”: the medical staff, in an environment of mistrust, must develop a thinking and an aesthetic of its action. Finally, Paul Ricoeur and Hannah Arendt's moral philosophy calls for an ethics of mutual recognition and leads to rethinking the role of the promise in the care relationship.

Conclusions: It is possible to remove the care relationship from the stranglehold of mistrust: (1) by taking the risk of trust, (2) by reflecting on our action in the field of care and exposing this action to the opinions of the others, (3) by using promise wisely, without limitation or excess, (4) by forming “islets of trust” in our care institutions, spaces free from the need to promise, which could guarantee their democratic nature.

Source of Funding: None.  

Poster 12: Maternal Cigarette Smoking and Substance Use Disorders during Pregnancy and Offspring Bipolar Disorder

Timothy E Wilens, MD, Massachusetts General Hospital, Boston, Massachusetts; M Martelon, J Wozniak, M Monuteaux, M Evans, T Parcell, J Biederman

Objectives: Recent work has suggested a positive relationship between prenatal exposure to cigarettes and substances (alcohol or illicit drugs) and offspring psychiatric disorders. No study to date, however, has primarily examined these exposures with offspring bipolar disorder (BPD). We looked to replicate previous work from our group that reported a positive association between maternal use of cigarettes during pregnancy and offspring BPD using a separate sample.

Methods: As part of two family studies of BPD, 322 families, including 225 BPD subjects (mean age ± SD: 11.60 ± 3.50) and 97 controls (mean age ± SD: 13.70 ± 2.10), were comprehensively assessed with a structured psychiatric diagnostic interview for psychopathology and substance use. Maternal use of nicotine and substances during pregnancy were captured using two methods derived from structured psychiatric interviews.

Results: BPD offspring were more likely to be exposed to prenatal maternal smoking than control offspring (odds ratio (95% CI) = 2.48 (1.15, 5.32)). However, this association lost significance when adjusted for comorbidity with conduct and attention deficit hyperactivity disorders (odds ratio (95% CI) = 1.17 (.47, 2.94)). There was no association between substance use disorders (SUD; including drug or alcohol abuse or dependence) during pregnancy and offspring BPD. There were notable differences in the clinical characteristics of youth with BPD exposed to prenatal maternal smoking and alcohol use disorders.

Conclusions: We partially replicated previous findings showing that comorbid BPD is associated with maternal use of nicotine during pregnancy. Our results warrant further replication in larger, less comorbid, prospective samples.

Source of Funding: NIH R01 DA12945 (TW), K24 DA016264 (TW), and NIH R01 MH066237 (JW).  

Poster 13: Does Conduct Disorder Mediate the Development of Substance Use Disorders in Adolescents with Bipolar Disorder? A Case‐Control Family Study

Timothy E Wilens, MD, Massachusetts General Hospital, Boston, Massachusetts; MK Martelon, MJP Kruesi, T Parcell, D Westerberg, M Schillinger, M Gignac, J Biederman

Background: Recent work has highlighted important relationships among conduct disorder (CD), substance use disorders (SUD), and bipolar disorder (BPD) in youth. However because BPD and CD are frequently comorbid in the young, the impact of CD in mediating SUD in BPD youth remains unclear.

Methods: A total of 105 adolescents with DSM‐IV bipolar disorder (mean ± SD = 13.6 ± 2.50 years) and 98 controls (13.7 ± 2.10 years) were comprehensively assessed with a structured psychiatric diagnostic interview for psychopathology and SUD. The study was conducted from January 2000 through December 2004.

Results: Among bipolar disorder youth, those with CD were more likely to report cigarette smoking and/or SUD than youth without CD. However, CD preceding SUD or cigarette smoking did not significantly increase the subsequent risk of SUD or cigarette smoking. Adolescents with bipolar disorder and CD were significantly more likely to manifest a combined alcohol plus drug use disorder compared to subjects with bipolar disorder without CD (X2= 11.99, p < .001).

Conclusions: While bipolar disorder is a risk factor for SUD and cigarette smoking in a sample of adolescents with BPD, comorbidity with CD in adolescents, comorbidity with preexisting CD does not increase the risk for SUD. Further follow‐up of this sample through the full risk of SUD into adulthood is necessary to confirm these findings.

Source of Funding: National Institutes of Health grants RO1 DA12945 and K24 DA016264.  

Poster 14: Open Trial of Sustained Release Bupropion in Adults with ADHD plus Substance Use Disorders

Timothy E Wilens, MD, Massachusetts General Hospital, Boston, Massachusetts; JB Prince, J Waxmonsky, R Doyle, T Spencer, MK Martelon, M Evans

Objective: To evaluate the effectiveness and tolerability of bupropion in adults with Attention‐Deficit/ Hyperactivity Disorder (ADHD) and comorbid active Substance Use Disorders (SUD).

Methods: This was a 6‐week open trial of sustained‐release (SR) bupropion in adults aged 18 to 55 years diagnosed with both ADHD and SUD. Bupropion‐SR was initiated at 100 mg SR and increased weekly to a target dose of 200 mg SR twice daily. Subjects were assessed on multiple outcomes including ADHD, SUD, and adverse effects. All analyses were intent to treat, with last observation carried forward.

Results: Thirty‐two subjects were treated with bupropion, with 19 subjects completing the entire protocol (59%). At end point there were clinically significant reductions in the ADHD RS (34.1 ± 8.2 to 19.4 ± 11.4, −43%, t = 6.49, p < 0.0001) and the Clinical Global Impression (CGI) of ADHD severity (baseline = 5.0, endpoint = 3.8, −24%, t = 6.16, p < 0.0001). In contrast, there were clinically negligible effects on the self‐report of substance use (p's > 0.05) and on the overall CGI of SUD severity (−23%, t = 4.95, p < 0.0001).

Conclusions: Results from this open trial suggest that in adults with ADHD and SUD, treatment with bupropion‐SR is associated with clinically significant reductions in ADHD, but not SUD.

Source of Funding: NIH K24DA016264, Departmental funds for clinical trial.  

Poster 15: Addiction Psychiatry Service: A Specialty Addiction Consultation‐Liaison Service in an Academic Medical Center

Joji Suzuki, MD, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts; J Kauffman, M Renaud, S Brenner, E Margetson, J Peteet, D Curtiss, A Fife

Background: Substance use disorders contribute significantly to the morbidity and mortality of hospitalized medical patients. To better manage medical/surgical patients with substance use disorders in the general hospital setting, a specialized multidisciplinary addiction consultation‐liaison team (Addiction Psychiatry Service) has been providing expert diagnostic, management, interventional, and referral services.

Methods: Consultations received by the Addiction Psychiatry Service during the period of January 2008 through December 2008 were reviewed for demographic and clinical characteristics. The history, development, composition of the service, as well as the integration with the existing psychiatric consultation‐liaison service were also examined.

Results: A total of 996 patients were referred to Addiction Psychiatry Service in the year 2008, with the following demographic and clinical characteristics: mean age 51.6 (range 17–87), male 63.9%, ethnicity (White 47.7%, African‐American 31.8%, Latino 20.5%), consulting service (medicine 56.8%, surgery 17.8%, ICU 15.1%, OB/GYN 6.2%, ED 2.1%, neurology 2.1%), reason for consultation (withdrawal management 61.3%, counseling/referral to treatment 44.9%, delirium 11.4%, pain vs. addiction 10.2%, transfer to detoxification treatment 5.1%), substances used (alcohol 59.1%, opioids 26.1%, cocaine 22.1%, cannabis 7.6%, benzodiazepines 3.6%, amphetamines .4%, barbiturates .4%), and referrals accepted by patient (outpatient individual 37.1%, intensive outpatient 23.6%, methadone maintenance 11.2%, outpatient dual diagnosis 7.9%, inpatient detoxification 5.6%, residential and partial hospital 3.4%).

Conclusions: Hospitalized patients in an academic medical setting have high rates of substance use disorders. A multidisciplinary addiction consultation‐liaison service may be a useful model for supporting the medical/surgical staff to better care for patients with substance use disorders.

Source of Funding: None.  

Poster 16: Ethnographic Survey of Hispanic Adolescent Heroin Users in Dallas County

Carlos F Tirado, MD, MPH, University of Texas Southwestern Medical Center, Dallas, Texas; C Coton, KR Williams, JC Maxwell, B Adinoff

Background: Since 2005, Dallas County has seen an unprecedented rise in the rate of intranasal and intravenous heroin use among Hispanic children and adolescents. There are documented cases of children as young as nine seeking opioid detoxification and there have been at least 26 heroin‐related deaths in children under age 18 since 2005. Statewide, Hispanics represent the largest proportion of heroin users entering treatment under age 25.

Methods: Seventy‐two (N = 72) consecutive English speaking/reading respondents of Mexican and Mexican‐American origin between age 13 and 18 with a primary diagnosis of heroin dependence were recruited from three participating drug rehab programs over a 7‐month period. Subjects participated in a 90‐minute self‐report and structured interview session to obtain data on intranasal heroin use patterns, psychiatric comorbidity, high‐risk sexual behaviors, and cultural and familial factors related to level of acculturation and intergenerational drug and alcohol use.

Results: Sixty percent of respondents were female. Roughly one‐third of respondents were born in Mexico versus 85% of parents reported as Mexican born. Average age at interview was 15.7 years with average age of first use of heroin 13.5 years and age of initiation of daily use 14.1 years. One in six respondents had used heroin IV and one in four reported at least one certain heroin‐related overdose. Nearly half (46%) of respondents reported they first tried heroin on school grounds. A third of respondents reported greater than four lifetime sexual partners. Fifty‐one percent reported sometimes or rarely/never using a condom. Seventy‐four percent of respondents reported at least one prior 30+ day residential treatment episode. One in five reported prior psychiatric treatment for depression. The most common secondary drugs of abuse were marijuana (46%), cocaine (22%), and alcohol (21%). One in six reported some form of physical, sexual, or psychological trauma. Forty‐percent reported having used alcohol to the point of intoxication with a first or second degree relative and 46% reported using drugs to get high with a first‐ or second‐degree relative. Preliminary hypothesis testing revealed no statistically significant relationship between level of acculturation and IV drug use or frequency of treatment entry.

Conclusions: There are clear and concerning trends signaling the disproportionate and increasing use of intranasal heroin among young Hispanics in North Texas. Adolescent Hispanics who are in treatment centers have well‐established heroin dependence and problem use of several other drugs. The use of heroin in area schools is troubling, but provides opportunity for assertive preventive measures. The presence of a psychiatric disorder and history of trauma is present in nearly one in five respondents. Drug and alcohol use and legal problems among first‐ and second‐degree male relatives and use of drugs and alcohol with family members is highly prevalent. As a group, survey respondents trended toward a mostly integrated‐assimilated acculturative experience vis‐à‐vis language and behavior, but trended toward a Hispanic/Mexican personal identity/ethos.

Source of Funding: U10DA020024, Clinical Trials Network (CTN)—National Institutes of Drug Abuse, NIH Office of Health Disparities Research.  

Poster 19: On‐Site Basic Health Screening and Brief Health Counseling of Chronic Medical Conditions for Veterans in Methadone Maintenance Treatment

Ayman Fareed, MD, Atlanta Veterans Administration Medical Center, Decatur, Georgia and Emory University School of Medicine, Atlanta, Georgia; D Musselman, J Byrd‐Sellers, G Barnet III, S Vayalapalli, J Casarella, K Drexler, L Phillips

Background: In order to improve the delivery of health services for chronic medical conditions in our methadone clinic, we added an on‐site health screening and brief health counseling to the treatment plans for patients receiving methadone maintenance treatment at the Atlanta Veterans Affairs Medical Center (VAMC). We then conducted a follow‐up retrospective chart review to assess whether this intervention improved health outcome for those patients.

Methods: We reviewed the charts of 102 patients who received treatment at Atlanta VAMC methadone clinic between 2002 and 2008. We sought to determine whether our increased health education and screening intervention was associated with improved: (1) Drug addiction outcome (as measured by comparing percentage of opiate and cocaine positive drug screens from admission to most recent). (2) Basic health screening (as measured by the patient's compliance with primary care physicians (PCP) appointments and current smoking status). (3) Management of co‐occurring medical conditions (as measured by levels of LDL cholesterol, hemoglobin A1c, and systolic blood pressure (SBP)). (4) Presence of QTc prolongation (difference in QTc between baseline and most recent EKG).

Results: Illicit drug use (opiate and cocaine) markedly decreased in patients overall. The effect was more robust for those successfully “retained” (n = 55, p < .0001) in treatment, compared to those who “dropped out” (n = 40, p = .05) of treatment. Compliance with PCP appointments was high (82% and 88% before and after the on‐site intervention, respectively) for “retained” patients. LDL cholesterol level was within normal range for all patients. A1c improved by 40% after the on‐site intervention as reflected by the decreased percentage of patients with A1c > 7% from before to after the intervention (90% vs. 50%, p = .05). However, the prevalence of uncontrolled hypertension did not significantly improve after the on‐site intervention (38% vs. 28%, p = .34). As might be expected with MMT, the prevalence of QTc prolongation actually increased from 399 msec (±92) to 439 msec (±22) after the on‐site intervention (p = .003).

Conclusions: Our retrospective study supports the previous literature that methadone maintenance therapy is effective in reducing illicit drug use. Although patients with history of heroin dependence and in methadone maintenance treatment are at increased risk for chronic medical conditions like hepatitis C and diabetes, there are minimal federal guidelines for medical care, other than a physical exam upon admission, and basic screening for some infectious diseases, eg, HIV and Hepatitis C for those patients. Our study demonstrated the need for, and potential benefit of, enhancing the delivery of health promotion services for chronic medical conditions in methadone‐maintained patients. Improving management of hepatitis C, diabetes, hypertension, and other related conditions, in this high risk, difficult‐to‐treat, and underserved population may reduce their morbidity and premature mortality.

Source of Funding: Supported in part by VA HSR&D awards SHP 08‐144, IIR 07‐138, and NIH R18 DK066204‐04 (LSP).  

Poster 20: Benzodiazepine Prescribing and Adherence to Safe Prescribing Standards by Providers

Cletus Carvalho, MD, University of Kentucky, Lexington, Kentucky

Background: Benzodiazepines are a broad group of medications frequently used for anxiety, alcohol detoxification, agitation, and epilepsy among other indications. Some patients have a history of drug use or become dependent on prescribed benzodiazepines. Licensing and expert groups recommend prescribing them carefully after excluding drug use, making proper diagnoses, getting a family history of drug use, frequent urine drug screens, and using treatment contracts. It is unclear how often prescribers practice safe prescribing.

Objectives: How frequently did providers adhere to prescribing standards and miss comorbid substance use.

Methods: A total of 100 patients admitted to an inpatient psychiatric unit with substance use disorders, except nicotine dependence, were studied. Data were collected from two sources: (1) participant interview, (2) review of participant's outpatient medical record. Provider demographics were obtained from a database of the Kentucky Licensure Board.

Results: Sixty‐four percent were male and 36% female. Fifty‐four percent were on benzodiazepines for > 2 years. One hundred percent had benzodiazepine, 44% alcohol, and 56% opioid dependence. Sixty‐seven percent used more benzodiazepines than prescribed and 37% diverted them. Sixty‐nine percent of providers were PCPs and 11% psychiatrists. Forty‐three percent had a documented diagnosis for benzodiazepine use. None documented knowledge of substance use, treatment contracts, Kentucky All‐Schedule Prescription Electronic Reports (KASPERs) or patient's substance use history from supports. Only 34% of providers documented a history of substance use at the start of treatment and 3% performed a urine drug screen. None of the nonmental health providers documented referrals for psychotherapy.

Conclusions: Outpatient practitioners in central Kentucky are minimally adherent to safe benzodiazepine prescribing standards. All patients were substance users and had benzodiazepine dependence. None reported this to providers and many over used prescribed benzodiazepines. Medication diversion was common. Clear prescribing standards for benzodiazepines and education need to be established for providers.

Source of Funding: None.  

Poster 21: Amygdala Reactivity Is Inversely Related to Level of Cannabis Use

Jack R Cornelius, MD, MPH, University of Pittsburgh, Pittsburgh, Pennsylvania; H Aizenstein, J Hayes, AR Hariri

Background/Objective: The amygdala plays a central role in the shaping of emotional reactions, especially to threat. Recent evidence suggests that amygdala function is regulated by both exogenous and endogenous cannabinoid signaling. Phan et al. (2008) reported that an acute dose of oral THC is associated with a decrease in threat‐related amygdala reactivity during a social threat stimulus task. In addition, Hariri et al. (2009) have reported that genetic variation associated with relatively increased endocannabinoid signaling is also associated with decreased threat‐related amygdala reactivity. In the current study, we examined the effect of reduced cannabis use on threat‐related amygdala reactivity.

Methods: Subjects for this fMRI study were recruited from among participants in our double‐blind, placebo‐controlled trial of fluoxetine in comorbid youth with cannabis dependence/major depression. A threat‐related amygdala reactivity task was completed during BOLD fMRI scans at study baseline and then again 12 weeks later at the end of the trial.

Results: Data are currently available from the first six subjects with pre‐ and post‐treatment fMRI data. Amygdala reactivity showed a significant increase during the treatment study as the level of cannabis use decreased (t = 2.70, df = 5, p < .02). One subject who showed an increase rather than a decrease in cannabis use during the treatment study showed a decrease in amygdala reactivity, unlike the pattern noted in the other participants.

Conclusions: These findings are consistent with the reports of Phan et al. and Hariri et al. suggesting that cannabinoids have an inhibitory effect on amygdala function. Such inhibitory effects may contribute to the anxiolytic effects of cannabinoids.

Sources of Funding: Supported by R01 DA019142, 3R01 DA019142‐04S1, P50 DA05605R01 AA13370, R01AA15173, and K24AA015320.  

Poster 22: Adapting and Implementing Evidence‐Based Practices in Young Adults with Substance Use Disorder: A Pilot Study

John F Kelly, PhD, Massachusetts General Hospital, Boston, Massachusetts and Harvard Medical School, Boston, Massachusetts; MT Kane, L Mograss

Background: Epidemiological research indicates that rates of substance use disorder (SUD) are 2–3 times higher among young adults (18–25 years) than either adolescents or older adults. This group has been shown also to possess the highest density of substance and psychiatric problems. Evidence suggests the earlier that treatment is initiated, the shorter the duration of SUD, yet, these youth have low intrinsic motivation to enter treatment and often do not complete it. New evidence‐based protocols intended to engage unmotivated adolescents and older adults are promising, but have not been tested with young adults. This study reports preliminary findings from the adaptation and implementation of Community Reinforcement Approaches (CRA and CRAFT) in combination with proactive (“assertive”) outreach intended to engage families and youth in an outpatient addiction treatment setting within a general hospital.

Methods: Prospective follow‐up was conducted with consecutive clinic admissions assessed at intake and 3‐months using the Global Appraisal of Individual Needs (GAIN), BDI‐II, STAI, STAXI. The nature and amount of health service utilization was also measured.

Results: Young adults enrolled in the program (N = 16; 93% White, M age 21; 65% female) showed increased engagement in treatment during the 3‐month follow‐up period along with significant and substantial improvements in multiple measures of substance use, mental health, HIV risk behaviors, employment, and illegal activity (p's < .01).

Conclusions: These preliminary results suggest these evidence‐based practices can be successfully adapted and implemented to effect treatment engagement and substantial short‐term changes among this high risk and typically unmotivated population of young adults.

Source of Funding: MGH Department of Psychiatry.  

Poster 23: “Whippets” The Clinical Manifestations of Nitrous Oxide Induced Subacute Combined Degeneration

Payam M Sadr, MD, Institute Maricopa Integrated Health Services—Desert Vista Behavioral, Mesa, Arizona

Background: Nitrous oxide (N2O) is routinely used in medical or dental settings as an anesthetic, but can also be inhaled illicitly for its euphoria creating properties. Wide commercial use of N2O in mini canisters as a propellant for the dispensing of whipped cream has made these “whippet” canisters easily accessible for recreational drug use. Excessive use and misuse of N2O can induce a central nervous system (CNS) condition known as subacute combined degeneration of the spinal cord. The condition is characterized, like vitamin B12 deficiency, by a gliosis with spongiform degeneration of the posterior and lateral columns in the CNS.

Methods: Case Report: A 25‐year‐old Middle Eastern male presented with ataxia, complaining of numbness of the lower extremities, and deficit in positional and vibratory sense at the knees and ankles bilaterally. Patient's gait was abnormal and not meeting any particular diagnostic criteria of neurological pathology. A provisional diagnosis of Mood Disorder/R/O malingering was made on the initial evaluation based on patient's history of polysubstance dependence and certain social factors. Furthermore a differential diagnosis of vitamin B12 deficiency was entertained. However, with his normal serum Vitamin B12 levels, normochromic RBC's on peripheral smear, a negative Schillings test and without knowledge of the patient's habit of abusing nitrous oxide, a provisional diagnosis of malingering was made. He was subsequently admitted to the psychiatry ward. After a few days of questioning, the patient admitted that he had been abusing nitrous oxide via “whippets” canisters. His history of nitrous oxide abuse consisted of 25–30 “whippets” a day over a 2‐ to 3‐month period. An MRI of spine T‐2 weighed image showed diffuse hyper intensities in the posterior aspect of cervical and upper thoracic spine. Ultimately, a diagnosis of cervical myeloneuropathy secondary to nitrous oxide induced subacute combined degeneration was made. Treatment was started with cobalamine IM injections 500 meg/day for 1 week coupled with 3 g of methionine, which was subsequently changed to SAM 800 mg BID for 2 weeks. The patient's ataxic gate improved significantly within 2 weeks; however, the vibratory sense deficits persisted with slower improvement over the following 3 weeks.

Results: Cessation of N2O use and treatment with cobalamine injections resulted in patient's physiologic and psychiatric improvement. This approach confirmed the case to be one of subacute combined degeneration, caused by excessive N2O use.

Conclusions: The increasing tendency of individuals to try alternative ways of “getting high” can have dire consequences as exemplified by this patient's use of the nitrous oxide contained in “whippets.” Obtaining a more detailed social history can enable physicians to more quickly identify the treatable deteriorating effect of nitrous oxide on the nervous system. Awareness of such cases can better educate treating personnel in the etiology and treatment of the neurological sequelae of substance abuse.

Source of Funding: Case study within residency program.  

Poster 24: Psychometric Evaluation of the Gambling Motives Questionnaire in an Indian Tribe in Rural Southern California

Alvaro Camacho, MD, University of California, San Diego, California and Sun Valley Research Center, Imperial, California; P Collins, T Fong, B Ng, SH Stewart

Background: Problem gambling has been reported to have a higher prevalence than bipolar disorder or schizophrenia. People gamble for a variety of reasons and understanding them may be helpful in clinical practice.

Methods: We surveyed 54 Natives receiving psychiatric treatment about their gambling problems and motives using the NODS and Gambling Motives Questionnaire. A principal component analysis was used to examine the structure of the GMQ in this cultural group and GMQ factor scores were correlated with specific gambling problem items on the NODS.

Results: A principal component analysis revealed a three‐factor structure with factors clearly reflecting enhancement, coping, and social gambling motives. Coping motives were significantly associated with gambling to escape from problems (r = .488, p < .005), and chasing losses (r = .619, p < .001). Enhancement motives were significantly associated with tolerance (r = .388, p < .05), withdrawal (r = .735, p < .001), loss of control (r = .565, p < .001), chasing losses (r = .619, p < .001), lying (r = .347, p < .05), risking significant relationships (r = .614, p < .001), and financial bailout (r = .521, p < .005). Social motives were associated with tolerance (r = .526, p < .005) and gambling to escape from problems (r = .400, p < .05).

Conclusion: Positive enhancement gambling motives are separable from positive reinforcement social gambling motives in terms of both factor structure and relations with gambling problems. The GMQ thus appears a promising instrument for examining gambling motives in our clinical setting.

Source of Funding: None.  

Poster 26: Mislabeled, Misdosed, and Contaminated: A Meta‐Analysis of Black Market Anabolic Steroids

D Zach Smith, MD, Boston Medical Center and Boston VA Healthcare System, Boston, Massachusetts; T Pulas, JA Renner, Jr

Background: Current estimates place the number of anabolic steroid users in the United States at over 1 million. Demand for anabolic steroids to improve appearance and enhance athletic abilities continues despite strong efforts to restrict use. Because steroid manufacture is controlled in nearly all countries, the majority of users obtain anabolic steroids illicitly, through so‐called “underground labs.” These labs are unregulated and not subject to any established form of pharmaceutical quality control or testing. High profits have also spurred on an increasing amount of anabolic steroid counterfeiting.

Methods: A literature search was conducted using PubMed for studies involving the chemical analysis of illegally obtained anabolic steroids. In addition, further internet searches for independent, verifiable assays of black market anabolic steroids were conducted. For inclusion, laboratory methods had to be clearly identified and in accord with accepted standards.

Results: There were 217 lab tests that were eligible for inclusion in this analysis. Assays revealed that 29.6% of black market anabolic steroids did not contain any of their purported drug, and there were frequent substitutions of other steroids. Of the steroids that were correctly labeled, nearly half (44.4%) contained dosages that were at least 20% in error, with a range of .75% to 460% of labeled content. Heavy metal contaminants (tin, lead, arsenic) were found in 20% of samples tested.

Conclusions: Misrepresentation of anabolic steroid content is widespread in the black market. Potential health risks of use of incorrectly labeled and contaminated steroids merit further recognition and investigation.

Source of Funding: Self‐financed; no outside sources of funding.  

Poster 27: Suboxone in Patients with and without Psychiatric Comorbidity

Aronica Cotton, BS, Howard University College of Medicine and Hospital, Washington, DC; A Thomas, WB Lawson

Background: Buprenorphine has been called the greatest advance in opioid treatment in 25 years. It is a partial agonist and is usually made available as suboxone when combined with naloxone. It has produced results comparable to methadone in reducing morbidity in opioid dependent individuals but is safer and more easily accessible. There has been limited research in those with psychiatric comorbidity.

Methods: Opioid abusers referred to an outpatient practice had their charts reviewed. Most were assessed with standardized instruments including the PHQ‐9 and the Mood Disorders Questionnaire. They were all diagnosed by a SCID and DIGS trained psychiatrist.

Results: The charts of 50 patients were studied, half of which had Axis 1 comorbid disorders including PTSD, major depression, bipolar affective disorder, and schizoaffective disorder. No relationship was found between the presence and absence of a comorbid diagnosis, symptom severity, or demographics and suboxone dose, retention in the program or lost to follow‐up. Six patients with severe mental illness and multiple hospitalizations the 2 years before suboxone showed no admissions for 2 years after starting treatment.

Conclusions: Suboxone seems as effective in addicts with and without psychiatric comorbidity. Suboxone seems to prevent hospitalization in patients frequently admitted. The presence of a comorbid psychiatric diagnosis should not restrict the use of suboxone.

Source of Funding: None.  

Poster 28: Effectiveness of Motivational Incentives Programs with Dual Disordered Patients

Thomas M Kelly, PhD, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; A Douaihy, DC Daley

Background/Objective: Motivational incentives programs (MIPs) have been shown to be valuable adjuncts to addiction treatment. Yet, MIPs are relatively new treatments and research has not determined the limitations of their effectiveness. One empirical question is whether MIPs are effective among severely disordered patients, such as patients with both substance and nonsubstance‐related disorders, or dual disordered patients.

Methods: The effectiveness of an MIP implemented in a Partial Hospitalization group program for dual disordered patients was measured by testing for differences between patients exposed to the MIP and patients not exposed to the MIP. Time spent in treatment was the main outcome variable. Patients were awarded up to 15 chances a week to draw for prizes from a fishbowl and chances were awarded based on consistency of attendance. Eighty‐six (51.5%) patients were exposed to the MIP and 81 (48.5%) were not (N = 167). Patients exposed to the MIP remained in the Partial Hospitalization program longer compared to patients not exposed to the MIP (MIP patient mean (SD) days = 12.7 (8.1) vs. Non‐MIP patient mean (SD) days = 7.4 (6.3), df = 165, p < .0001). Survival analyses confirmed that patients who were exposed to the MIP remained in the Partial Hospitalization program longer than patients not exposed to the MIP (OR = 2.0, df = 1 p < .0001, 95% CI = 1.5, 2.8) while controlling for gender as a covariate (OR = .8, df = 1, p = .18, 95% CI = .6,1.1).

Conclusions: Dual disordered patients remain in partial hospitalization treatment for addiction longer when they participate in a MIP that is conducted as an adjunct to group therapy.

Source of Funding: NIDA CTN UDA20036A.  

Poster 29: Prevalence and Correlates of Withdrawal‐Related Insomnia among Adults with Alcohol Dependence: Results from a National Survey

Kirk J Brower, MD, University of Michigan, Ann Arbor, Michigan; BE Perron

Background: Insomnia during acute alcohol withdrawal as well as persisting insomnia during post‐acute withdrawal is associated with relapse. Rates of insomnia in clinical samples of alcohol‐dependent patients range from 36% to 91%, but the prevalence of withdrawal‐related insomnia in the general population is unknown. The purpose of this study was to describe the prevalence of insomnia as a symptom of acute alcohol withdrawal and its correlates in a general population of alcohol‐dependent individuals.

Methods: Data were analyzed from the 2001‐2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), which surveyed a total of 43,093 adult respondents.

Results: The prevalence of withdrawal‐related insomnia was 31.7%, which ranked fourth among the eight listed DSM‐IV withdrawal symptoms, behind nausea, restlessness, and autonomic symptoms (sweating/heart beating fast). A family history of alcohol use disorders, female gender, middle age (35–54 years), lifetime drug use disorders except nicotine dependence, lifetime major depression, later age of onset for alcohol dependence (after 27 years old), and 7 or more years of heavy drinking were associated with insomnia in bivariate analyses.

Conclusions: Withdrawal‐related insomnia is a common symptom among physiologically alcohol‐dependent adults in the general population, related to gender, middle age, family history, comorbid diagnoses, and drinking severity. Its prevalence in the general population provides a representative base rate against which to compare the widely varying rates in clinical populations. Because of its relatively frequent prevalence and association with relapse, assessment of insomnia with rating scales and targeted treatment is recommended as a guideline.

Source of Funding: NIH Grant K24 AA00304.  

Poster 31: Reliability of Self‐Reported Medical Problems in Patients with Schizophrenia and Alcohol Use Disorders

Zsuzsa Szombathyne Meszaros, MD, PhD, SUNY Upstate Medical University, Syracuse, New York; JA Dimmock, R Ploutz‐Snyder, SL Batki

Background/Objective: Schizophrenia and alcohol use disorders (AUDs) are major risk factors for a variety of medical problems, yet there has been little research on the medical status of patients in whom both conditions coexist. Mortality and morbidity of these patients is high compared to the general population due to the “dual neglect” of medical problems by the patients and their health care providers. The objective of the present study was to assess reliability of self‐reported medical problems in a research setting.

Methods: Self‐reported medical diagnoses were recorded and compared to medical records in 90 patients with schizophrenia or schizoaffective disorder and co‐occurring alcohol use disorders who participated in a 12‐week controlled outpatient trial of directly monitored oral naltrexone treatment. All patients underwent a medical history, physical examination, and review of medical records in the screening phase.

Results: On average, participants spontaneously reported 76.6% of their medical problems. The most commonly “forgotten” diagnoses were the following: low back pain (6 of 12 reported), GERD (15 of 21 reported), coronary artery disease (0 of 5 reported), hypertension (26 of 31 reported), hyperlipidemia (14 of 18 reported), asthma (17 of 19 reported), seizure disorder (4 of 6 reported) and chronic renal failure (0 of 2 reported). Reliability of self report was independent of socioeconomic status, education, drug use, or psychosis severity.

Conclusions: Thorough review of medical records is necessary in patients with co‐occurring AUD and schizophrenia to avoid neglecting important medical conditions.

Source of Funding: NIAAA R01 AA013655.  

Poster 32: Nonalcohol Substance Use in Alcohol‐Dependent Patients with Schizophrenia or Schizoaffective Disorder

Steven L Batki, MD, University of California San Francisco and San Francisco VA Medical Center, San Francisco, California and SUNY Upstate Medical University, Syracuse, New York; JA Dimmock, R Ploutz‐Snyder, KB Carey, SA Maisto, ZS Meszaros, MB Cavallerano, K Canfield, L Leontieva

Background/Objective: Alcohol use disorders are highly prevalent in patients with serious mental illness. We describe co‐occurring nonalcohol substance use among patients with schizophrenia or schizoaffective disorder and co‐occurring alcohol use disorder entering a trial of directly observed naltrexone treatment. We also examine the relationships between nonalcohol substance use and alcohol use severity as well as schizophrenia versus schizoaffective disorder diagnosis.

Method: Rates of nonalcohol substance use disorders (SUDs) were compared for schizophrenia and schizoaffective disorder and correlational analyses were conducted between alcohol and other substance use.

Results: Of the 90 participants, 45 (50%) had schizophrenia and 45 (50%) had schizoaffective disorder. Eighty‐six (95.6%) had alcohol dependence, and 4 (4.4%) had alcohol abuse. The mean ASI alcohol composite score was 0.53 (± .2). The mean number of drinking days in the past 30 was 14.8 (± 8.6) days. The mean and median number of standard drinks/week were 35.1 (± 45.5) and 17.9, respectively. Twenty‐eight (31.1%) subjects had co‐occurring cannabis abuse or dependence and 30 (33.3%) had cocaine abuse or dependence. Forty‐four subjects (48.9%) reported using cannabis and 29 (32.2%) reported using cocaine in the baseline month. Urine drug screens were positive for cannabis in 29 subjects (32.2%) and were positive for cocaine in 24 subjects (26.7%). Significantly more participants with schizoaffective disorder, rather than schizophrenia, had co‐occurring cocaine abuse or dependence. The frequency of cannabis and cocaine use correlated significantly with heavy alcohol use frequency.

Conclusions: Prevalence of nonalcohol SUDs was substantially higher in this sample than in the general population. Schizoaffective disorder, compared to Schizophrenia, was associated with even higher rates of co‐occurring cocaine abuse or dependence. The frequency of cannabis and cocaine use was significantly related to the amount of alcohol use.

Source of Funding: NIAAA R01 AA 016355‐04 (PI: Batki).  

Poster 33: COMT Inhibition May Offer a New Hope in Treatment of Cocaine Craving (Pilot)

Rahim Shafa, MD, Metrowest CNS Research Center, Natick, Massachusetts; HM Abdolmaleky, S Yaqubi, SN Ghaemi

Background: Cocaine is known to be strongly involved with the dopamine (DA) signaling pathway. Like most drugs of abuse cocaine causes a dramatic surge of DA in the Nucleus Accumbens (NAc). It is demonstrated that acute cocaine use enhances DA transmission but its chronic use depletes DA brain concentration. Repeated Imaging studies demonstrated destructive outcome of cocaine on the basal ganglia and chronic cocaine abusers are more prone to develop Parkinson's disease than the general population. Based on the DA depletion theory, a number of dopaminergics (bromocriptine, amantadine, pergolide) have been tried in treatment of cocaine addiction with mixed results, including abuse potential of bromocriptine. A metanalysis of DA‐agonists trials (17 studies) did not support their use in the treatment of cocaine addiction. DA deficiency syndrome is one of the major players in substance dependency and/or craving. Catechol‐O‐methyl transferase (COMT) is the rate limiting enzyme which maintains the balance of the DA level in the synaptic cleft through DA degradation. COMT overactivity is a significant player in the pathogenesis of major psychiatric disorders and their comorbid substance abuse, because of an increase in DA‐degradation leading to hypodopaminergic state, inducing drug seeking traits in individuals with the reward deficiency syndrome. Based on our studies on COMT genes (located on chromosome 22q11.21), hyper‐expression of Membrane Bound COMT (MB‐COMT) isoform, resulted from its promoter DNA hypomethylation could decrease the DRD1 and DRD2 gene expression level (the DA receptor subtypes believed to be involved in hedonic activities) in the frontal lobe, leading to a further deficiency in DA signaling. Recently, we reported a robust clinical response in the treatment of polysubstance dependence using entacapone (a COMT‐Inhibitor); concluding that COMT‐inhibitors should be considered as new therapeutics for the treatment of psychopathologies related to dopamine deficiency, such as drug dependence. Here we examined the anticraving effects of entacapone in cocaine dependence (DSM‐IV‐TR).

Methods: In an open clinical trial, entacapone was administered to 36 patients with cocaine dependence, who had exhausted the standard care. Entacapone was given as a single or combination drug therapy. The average dose was 1,200 mg/day, (additional PRN was allowed up to 3,000 mg/day). Patients’ improvement was evaluated based on clinical global index (CGI), in a 12‐weeks abstinence follow‐up model. Patients’ abstinence was evaluated by clinical interview and bimonthly 12 Panel Urine Toxic Screen.

Results: Entacapone was significantly effective (average CGI improvement of 51.8%) in 77.8% of the treatment population when used either as acute or maintenance treatment. Of those who responded initially, 50% maintained abstinence for the 12‐week follow‐up. These patients did not demonstrate drug preference for entacapone and there was no serious adverse event.

Conclusions: Unlike dopaminergics, entacapone did not show abuse potential, perhaps because entacapone inhibits COMT; the enzyme which degrades intrinsic DA, and therefore, there would be a natural act of balance imposed on how much increase of DA might be achieved in the intersynaptic milieu as a result of enzyme inhibition versus dopaminergics which directly stimulate DA receptors and therefore causing the gene downregulation or an acute DA surge. Based on this pilot study, the use of COMT‐inhibitors (ie, entacapone) may offer a novel way of addressing DA hypothesis in the treatment of cocaine addiction. Pursuit of controlled clinical trials are recommended.

Source of Funding: None.  

Poster 34: Anxiolytic‐Like Effects of Chamaemelum Nobile 1. Ethanolic Extract in Male Wistar Rats

Mojdeh Dooraghi, BD, Islamic Azad University‐Karaj Branch, Tehran, Iran; J Solati, B Shahsavari

Background: Anxiety disorders are among the most common psychiatric disorders that affect all age groups of the general population. Currently, the preferred treatment is with pharmacological drugs that have anti‐anxiety properties. However, these agents have numerous and often serious adverse effects. Herbal remedies have been shown to be effective as alternative treatments, at least in mild to moderate cases of anxiety.

Methods: The purpose of this study is to characterize the putative anxiolytic‐like effects of Chamaemelum Nobile (Roman chamomile) using the elevated plus maze (EPM) in rats. Supplementation of alcoholic extract (provided by ethanol 70% using Soxhlet apparatus) was dissolved in water and orally administered at different doses to adult male wistar rats, before behavioral evaluation in an EPM.

Results: Continuous supplementation of this extract for 14 days (at .2 and .5 g/kg) significantly increased time‐spent and arm entries into open arms of EPM versus control groups (p < .05). However, no changes in the locomotor activity occurred.

Conclusions: This result suggests that ethanolic extract of Chamaemelum Nobile might prove to be an effective anxiolytic agent.

Source of Funding: Islamic Azad University‐Karaj Branch.  

Poster 35: Anxiety and Depressive Symptoms in Alcoholics: Correlation with Urge to Drink during Early Abstinence

Terry Schneekloth, MD, Mayo Clinic, Rochester, Minnesota; M Willenbring, L Gupta, VS Pankratz

Background: Anxiety and depressive symptoms and disorders have been commonly observed in actively drinking and treatment‐seeking alcoholics. The relationship between anxiety and depression and alcohol use disorders has been extensively explored in multiple studies. Prior studies have focused on the relationship between persistent anxiety and mood symptoms or disorders and relapse. No study to date has incorporated a measure of urge to drink and examined for associations between anxiety and depressive symptoms and urge to drink alcohol. The primary purpose of this study was to assess for associations between anxiety and depressive symptoms and urge to drink alcohol in a clinical population. This study also assessed these symptoms as potential clinical correlates of relapse in alcoholics during primary addiction treatment and the first 3 months posttreatment.

Methods: A total of 43 male veterans with alcohol dependence receiving residential treatment were followed on a weekly basis for 4 weeks and a monthly basis for the subsequent 3 months. Study subjects completed several symptom screening instruments at each time point. Symptom screening measures included Spielberger State‐trait anxiety inventory (STAI), Hamilton anxiety rating scale (HAM‐A), Hamilton depression rating scale (HAM‐D), and the alcohol urge questionnaire (AUQ). Statistical analysis included descriptive statistics of categorical and numerical variables. Group differences in variables were compared at each time point with the rank sum test, and variables were examined for correlation utilizing the Pearson correlation coefficient.

Results: The 37 subjects who completed the study without relapse had significantly lower AUQ scores at baseline than the six subjects who did not complete the study. Noncompleters reported significantly greater urges to drink during weeks 1–3 and depressive symptoms at weeks 1–2. Anxiety and depressive symptoms, as measured by the HAM‐A, HAM‐D, and State and Trait Anxiety Inventory, were positively correlated with AUQ scores at a significant level at week 1 and multiple other time points.

Conclusions: These findings reveal association of fewer depressive symptoms and lower urges to drink with study completion and remaining abstinent. Moreover, they demonstrate a significant correlation between anxiety and depressive symptoms and urge to drink. The results suggest the potentially negative impact of persistent depressive and anxiety symptoms on urge to drink and sobriety in alcoholics as they complete treatment and begin their early abstinence.

Source of Funding: Minnesota Medical Foundation and Mayo Clinic Department of Psychiatry and Psychology.  

Poster 36: Integrating Alcoholics Anonymous Teaching within Psychiatry Training Programs

Sherry Nykiel, MD, Partners Healthcare Addiction Psychiatry Fellowship, Boston, Massachusetts; HS Connery

Background: Trainees in psychiatry programs frequently treat patients with co‐occurring substance use disorders, yet rarely is a full didactic seminar dedicated to teaching them about the history and use of Alcoholics Anonymous (AA) and other 12‐step programs.

Methods: A literature and internet search was performed to review the history and development of AA in the context of significant figures in medicine (William Silkworth), psychiatry/psychology (Carl Jung, Williams James), and society (John D. Rockefeller). This information was integrated into the introductory half of a didactic teaching seminar for psychiatry trainees; the second half reviews programmatic aspects of AA and how to effectively engage patients in using AA. AA resources and literature are paired with the didactic to provide tools for clinicians referring patients.

Results: The didactic was presented to first‐ through fourth‐year psychiatry residents in training, as well as teaching faculty. Audience feedback was overwhelmingly positive and trainees reported greater confidence in making referrals to AA as well as appreciating the evolution of AA within a broader context of the history of psychiatry.

Conclusions: Teaching residents, fellows, and mental health staff about the historical evolution of AA within the context of the history of psychiatry provides a novel approach to engaging clinician interest in 12‐step programs. This is effectively followed with training on 12‐step program use and referral resources. This pilot seminar is now being refined by presentations to trainees and staff in multiple clinical contexts with brief pre‐ and postseminar feedback surveys. The final seminar will be made available for public use.

Source of Funding: None.  

Poster 38: Explanatory Models of Illness and Addiction Severity in Patients with Drug Dependence in a Paris Suburb: Role of Migration

Olivier Taïeb, MD, PhD, Avicenne Hospital, Paris, France; S Chevret, MR Moro, MG Weiss, T Ferradji, A Reyre, G Broder, T Baubet

Background: With its substantial health burden and social impact, understanding of drug addiction is especially likely to benefit from study of the interrelationship of culture, mental health, and illness experience. Objectives of this study were to assess illness explanatory models (considering illness experience, meaning and help seeking); addiction severity among patients with drug dependence (opiates, cocaine, cannabis, amphetamines, and/or hallucinogens); and the role of migration.

Methods: Adapted EMIC (explanatory model interview catalogue) interviews and the addiction severity index (ASI) were conducted with 70 outpatients (mean age 36.0 years ± SD 6.1) at Avicenne Hospital, in Bobigny, a Paris suburb. Among them, 42 were either first‐ or second‐generation immigrants to France, most from North Africa. Explanatory models were analyzed according to migration status, assessing potential confounders with multivariate linear models.

Results: Explanatory models were heterogeneous. Migration modified illness experience and its meaning. Compared to nonmigrants, migrants reported fewer somatic (p = .03) and violence‐related symptoms (p = .03). They attributed the causes of their addiction more frequently to social (p = .02) and magico‐religious factors (p = .04) and less to psychological factors (p = .04). Conversely, no difference in ASI composite scores was found between migrants and nonmigrants.

Conclusions: Distinctive patterns of illness explanatory models are reported by drug‐dependent patients. The impact of migration should be considered in clinical practice.

Source of Funding: Programme Hospitalier de Recherche Clinique National AOM98‐163, French Ministry of Health, Paris, France.