واکنش پذیری نشانه و اثرات مواجهه نشانه در مبارزه با مواد مخدر پس از درمان کاربران ترک کرده

Abstract After 12 months of inpatient treatment, 16 opiate-addicted patients were exposed to drug-related stimuli. The results of this study indicate that cue reactivity in opiate-addicted subjects is still present after 12 months of intensive inpatient treatment. After exposing subjects to drug-related stimuli, there is an increase in craving, feelings of depression, and anger. Because posttreatment subjects are likely to be confronted with these stimuli following discharge, a reduction of this reactivity is desirable. In the present study, cue reactivity (feelings of depression, anger, tension, craving, and physical symptoms) reduced after protocolized cue exposure treatment. This effect maintained for at least 6 weeks after the last cue exposure session.

Introduction Cue reactivity to drug related stimuli is a frequently observed phenomenon in drug-dependent subjects Childress et al. 1993 and Powell et al. 1993. Cue reactivity refers to a classical conditioned response (CR) that occurs when a (post)addicted subject is exposed to drug-related stimuli (CS). This response is presumed to consist of physiological and/or subjective reactions (Siegel, 1983). Craving, a subjective desire to use the drug of choice, is believed to play an important role in the occurrence of relapse in abstinent drug-addicted persons in their natural setting (Childress, McLellan, & O’Brien, 1986). Besides craving, other subjective cue-elicited reactions have been reported, including subjective withdrawal symptoms, subjective drug-agonistic effects, mood swings, and anxiety Glautier & Tiffany 1995 and Powell et al. 1993. Physiological reactions that have been investigated include skin conductance, heart rate, salivation, and body temperature (Glautier, Drummond, & Remington, 1992). The exact nature of the relation between subjective and physiological signs of reactivity is still subject to debate (Tiffany, 1990). Furthermore, whether the direction of the conditioned response is drug antagonistic (withdrawal) or drug agonistic (drug-like), is still unclear (Stewart, de Wit, & Eikelboom, 1984). Conditioned reactivity to substance-related cues is believed to be an important factor within addictive use of alcohol Glautier & Drummond 1994 and Staiger & White 1991, opiates (Powell et al., 1990), nicotine (Niaura et al., 1988), and cocaine (Robbins, Ehrman, Childress, & O’Brien, 1992). These studies have shown an increase in reactivity when addicted subjects are exposed to drug-related cues, as compared with exposure to neutral cues. Albeit, individual differences in nature and extent of the cue-elicited response cannot be ignored (Rees & Heather, 1995). Human experimental studies reveal that cue reactivity may still be present after detoxification (Powell et al., 1990). In addition, subjects who have repeatedly been exposed to drug-related cues during their treatment, showed a reduction in cue reactivity. Cue Exposure Treatment (CET) refers to a protocolized, repeated, exposure to drug-related cues, aimed at the reduction of cue reactivity by extinction, a behavior therapy technique. The present study is designed to examine the occurrence and nature of cue reactivity in subjects who have been treated for drug dependence in an intensive, drug-free inpatient treatment program for a minimal period of 12 months. At time of the study, the subjects participated in an outpatient resocialization program. It was hypothesized that cue reactivity, if present, would decrease in this population after a protocolized nine-session CET. Enduring effects of CET were studied by evaluating cue reactivity of the study subjects 6 weeks after the last exposure session. Subjects The study group consisted of 16 patients who, after clinical detoxification and intensive inpatient treatment for at least 12 months in the drug-free therapeutic community “Emiliehoeve,” participated in the outpatient resocialization phase of the program. All subjects participated voluntarily and signed an informed consent. The inclusion criteria were: age 18–60, opiate dependency according DSM-IV criteria, inhalation (“chasing the dragon”) as primary mode of heroin administration, successful completion of the clinical treatment program, abstinence from any drugs for at least 6 months preceding the study, and adequate understanding of the Dutch language. The 16 persons in the study consisted of 7 female and 9 male subjects. The average number of clinical admissions for the treatment of drug-dependence was two (range 1–8). The mean age of these subjects was 29.5 years (range 20–42). The mean Addiction Severity Index (ASI; McLellan, Luborski, Woody, & O’Brien, 1980) score at intake was 3.3 (SD = 1.3). The mean severity scores, ranging from no problems (0) to extreme problems (9), on the separate ASI areas were: medical problems 1.6 (SD = 2.2), employment problems 2.9 (SD = 2.1), alcohol problems 1.4 (SD = 2.3), drug problems 5.5 (SD = 1.0), legal problems 3.9 (SD = 2.3), social problems 3.3 (SD = 2.3), and psychiatric problems 4.3 (SD = 1.7). Procedure and Assessments At intake, before detoxification, the ASI (McLellan et al., 1980) was administered to asses the severity of drug-related problems. After detoxification, all subjects received intensive inpatient treatment for at least 12 months. In the subsequent outpatient resocialization phase of the treatment program, subjects were asked to participate in the CET program. CET consisted of a nine-session, protocolized exposure to drug-related cues. Twelve different stimuli (slides, video, drug-use material, simulation of drug-use ritual) were presented to the subjects during the study. The assessment sessions consisted of the presentation of four different cues (two slides and two videos). Every cue was presented for 5 minutes. The neutral cues consisted of a slide of a landscape and a film of natural scenery (video). The drug cues consisted of a slide of drug users who prepared smokeable heroin and inhaled heroin (“chasing the dragon”) and a film of this ritual (video). The slide and video stimuli were presented to the subjects within the same session. Assessments of reactivity to drug-related and neutral cues were conducted prior to the CET after nine CET sessions (posttreatment), and after 6 weeks following the last CET session (follow-up). These assessments consisted of a (single-item) craving scale, the Profile of Mood States (POMS) and the Physical Symptom Checklist (PSC). The CET and assessment procedure have been described by Powell, Gray, and Bradley (1993). Craving Scale A single-item self-rating scale was used to assess the intensity of craving each minute during the presentation of the stimuli. The scale ranged from 0 (no craving) to 10 (excessive craving). For each stimulus a mean craving score of the subject was calculated. For purposes of the study, craving was defined as the strength of the attraction to use drugs (Powell,1995). It was explicitly communicated with the subjects that craving could also occur when they felt they were able to resist drug use. Profile of Mood States The abridged Dutch version of the POMS (McNair, Lorr, & Droppelman, 1971) has acceptable psychometric properties. Five subscales were used in this study (Depression, Anger, Fatigue, Vigor, and Tension). Furthermore, a total score is calculated by adding the scores of the subscales used (the subscale Vigor is recoded). The POMS consisted of 32 items that can be scored on a 5-point scale, from 0 (none) to 5 (extremely intense). Physical Symptoms Checklist This checklist was adopted from Powell, Bradley, and Gray (1992). The PSC measures physical symptoms that reflect characteristics of opiate withdrawal and drug-agonistic states. Furthermore, a residual category was used to report ambiguous physical signs. The subject could complete the PSC on a 4-point scale, ranging from 0 (symptom not present) to 3 (symptom strongly present). The craving scale was completed by the subject every minute during presentation of the stimulus. Administration of the POMS and PSC questionnaires took place after each presentation of a neutral or drug-related cue. The same sequence of stimulus presentation was used in each measurement-session (neutral slide, drug slide, neutral video, drug video). Analysis Because of the small sample size and the non-normal distribution of some variables, nonparametric Wilcoxon Matched-Pairs Test was used for analyzing differences on reactivity between neutral and drug cues on baseline measurement. This same statistical test was used to analyze changes between baseline drug reactivity, posttreatment drug reactivity and 6-week follow-up drug reactivity.

Results Pretreatment Differences on Drug Versus Neutral Cues The mean score of the subjects’ reactivity after presenting the slide stimuli is summarized in Table 1. As indicated, Craving (Z = 1.4; p = .018), Depression (Z = 2.41; p = .016), Anger (Z = 2.94; p = .003), and Total score of the POMS (Z = 2.31; p = .021) elicited an increased reaction to the drug-related slides, compared to neutral slides in the pre-CET phase. Table 1. Mean and Standard Deviation of Reaction of Subjects on Slide Cues Before and After Cue Exposure Treatment (CET), Including 6-Week Follow-Up (n = 16) legend Pre-CET Post-CET 6-Week Follow-Up NeutralM (SD) DrugM (SD) NeutralM (SD) DrugM (SD) NeutralM (SD) DrugM (SD) Craving 0.0 (0.1) 1.0 (1.5)* 0.0 (0.0) 0.1 (0.2) 0.0 (0.0) 0.1 (0.1) Depression 2.1 (3.7) 3.1 (4.0)* 0.4 (1.0) 0.3 (0.8) 0.7 (2.0) 0.7 (2.3) Anger 2.4 (3.7) 5.4 (5.0)** 0.6 (1.8) 1.3 (3.0) 1.3 (2.6) 2.1 (3.2) Fatigue 2.6 (2.9) 2.4 (3.0) 1.6 (1.9) 2.1 (2.5) 2.3 (3.4) 2.0 (3.8) Vigor 7.9 (3.9) 7.4 (4.2) 8.2 (3.7) 8.0 (4.5) 8.0 (3.3) 7.4 (4.0) Tension 5.3 (4.5) 3.6 (2.3) 0.8 (1.5) 0.8 (1.3) 1.6 (2.2) 1.1 (1.6) POMS—total 15.8 (6.8) 18.9 (9.9)* 11.1 (4.9) 12.4 (5.9) 12.6 (8.2) 13.3 (6.6) Withdrawal-like symptoms 1.7 (1.6) 2.3 (1.7) 0.9 (1.1) 0.9 (1.4) 1.1 (1.5) 1.0 (1.3) Drug-agonistic symptoms 0.4 (0.6) 0.6 (0.9) 0.3 (0.6) 0.3 (0.6) 0.1 (0.3) 0.1 (0.3) Ambiguous symptoms 2.9 (2.7) 2.9 (2.8) 0.6 (0.9) 0.5 (0.9) 0.5 (1.1) 0.4 (0.8) legend Note. Wilcoxon Matched-Paired Signed-Ranks test (differences on neutral vs. drug cues). * p < .01; ** p < .001. Table options The mean score of the subjects’ reactivity after presenting the video stimuli is summarized in Table 2. Increased reactivity to the drug-related video was observed, compared to the neutral video in Depression (Z = 1.93; p = .053), Anger (Z = 2.91; p = .004) and Craving (Z = 3.06; p = .002). An increase in withdrawal symptoms after exposure to drug-related video cues was also observed, but this difference was not statistically significant (Z = 1.79; p = .072) at the .05 level. Table 2. Mean and Standard Deviation of Reaction of Subjects on Video Cues Before and After Cue Exposure Treatment (CET), Including 6-Week Follow-Up (n = 16) legend Pre-CET Post-CET 6-Week Follow-Up NeutralM (SD) DrugM (SD) NeutralM (SD) DrugM (SD) NeutralM (SD) DrugM (SD) Craving 0.0 (0.0) 1.9 (1.5)** 0.0 (0.0) 0.1 (0.3) 0.0 (0.0) 0.2 (0.8) Depression 1.6 (2.9) 2.8 (4.2)* 0.3 (0.9) 0.3 (0.9) 0.7 (2.0) 0.6 (1.8) Anger 2.3 (3.6) 6.8 (7.3)** 1.2 (2.4) 2.3 (5.0) 1.3 (2.7) 2.4 (3.1) Fatigue 3.3 (4.6) 2.8 (3.3) 2.4 (2.3) 2.2 (2.3) 2.4 (4.4) 2.3 (3.7) Vigor 7.6 (4.4) 7.0 (4.3) 7.6 (4.4) 8.0 (4.4) 7.4 (4.0) 8.4 (3.8) Tension 3.6 (2.3) 4.4 (4.1) 0.9 (1.5) 1.3 (2.0) 0.9 (1.6) 1.2 (1.4) POMS—total 15.2 (7.1) 19.2 (11.8) 12.5 (5.3) 13.1 (6.7) 13.5 (7.7) 12.9 (6.3) Withdrawal-like symptoms 1.9 (1.6) 3.0 (2.4) 0.9 (1.4) 1.7 (2.2) 0.8 (1.2) 1.3 (1.1) Drug-agonistic symptoms 0.5 (0.8) 0.6 (0.8) 0.3 (0.6) 0.3 (0.6) 0.3 (0.6) 0.3 (0.6) Ambiguous symptoms 2.4 (2.6) 2.9 (2.6) 0.7 (1.1) 0.9 (1.4) 0.3 (0.6) 0.5 (1.0) legend Note. Wilcoxon Matched-Pairs Signed-Ranks test (differences on neutral vs. drug cues). * p < .01; ** p < .001. Table options Change of Reactivity After Cue Exposure Treatment The reactivity to the presentation of the drug-related slides, as measured by pre-post CET comparison, decreased for Withdrawal symptoms (Z = 2.19; p = .029), Ambiguous symptoms (Z = 2.8; p = .006), Depression scale (Z = 2.34; p = .02), Tension (Z = 3.30; p = .001), Anger (Z = 2.66; p = .008), POMS-total score (Z = 2.45; p = .014), and Craving (Z = 2.37; p = .018). Cue reactivity on the drug-related slides did not increase after the nine-session CET on any of the measures. Reactivity on the drug-related video stimuli decreased for Withdrawal symptoms (Z = 2.01; p = .045), Ambiguous symptoms (Z = 2.67; p = .008), Depression (Z = 2.49; p = .013), Anger (Z = 2.06; p = .039), Tension (Z = 2.39; p = .017), and Craving (Z = 3.06; p = .002). Like the slide cues, reactivity did not increase on any of the measures following the nine-session CET. Stability of Cue Reactivity After 6-Week Follow-Up To observe the stability of the effects of CET, posttreatment reactivity was compared to 6-week follow-up reactivity. Results indicated that the 6-week follow-up reactivity did not differ (p < .05) from the post-CET reactivity on any of the measures.