Drug and Alcohol Dependence, 27 (1991) 29-34 Elsevier Scientific Publishers Ireland Ltd.
29
Cocaine abuse among heroin addicts in Spain Marta Torrens, of Drug Addiction.
Section
Lluis San, Josh M. Peri and Jo& M. Olle
Hospital de1 Mar, Autonomous (Received
Abuse
of cocaine
is becoming
a major
problem
admitted as inpatients for detoxification from and 25% had abused cocaine daily or several gic problems than opiate addicts who did not drugs earlier and showed a higher frequency
among
June
heroin
cocaine;
depression;
Multiple data suggest that Spain is suffering a new era of epidemic dimensions with regard to the consumption of cocaine. Direct and indirect indicators, such as confiscations, health problems in emergency rooms and number of patients seeking treatment in drug addiction services, indicate the existence of an increasing population of cocaine consumers. Cocaine confiscations showed a 3-fold increase between 1985 and 1987. The amount of confiscated cocaine increased from 1134 kg in 1987 to 3471 kg in 1988 (Plan National sobre Drogas, 1989). Also cases of acute intoxication, adverse psychological reactions and withdrawal symptoms due to cocaine abuse have been detected in emergency rooms (Cami et al., 1987). Likewise the number of patients seeking treatment for cocaine dependence has increased from 188 in 1987 to 278 in 1988 (Sistema Estatal de Informacion sobre Toxicomanias, 1988; 1989). Correspondence to: Dr. Lluis San, Secci6n de Toxicomanias, Hospital de1 Mar, Passeig Maritim 25 - 29.08003 Barcelona, Spain.
0 1991 Elsevier in Ireland
ISpain)
15th. 1990)
addicts
in Spain.
Between
1987 and 1988, 75% of patients
than heroin addicts who did not abuse cocaine. for detoxifying patients with this dual addiction.
Based
on
HIV
Introduction
0376.8716/91/$03.50 Printed and Published
of Barcelona, Barcelona
opiate dependence had consumed cocaine during the 6 months prior to admission times/week. These cocaine abusers showed more toxicologic and psychopatholoabuse cocaine. The opiate addicts who also abused cocaine had begun using illicit of anti-HIV antibodies. They also had more antisocial personality disorders and
persistence of depressive symptoms during opiate detoxification these findings, we insist on the need to develop different treatments Key words: heroin;
University
Scientific
Publishers
Ireland
Heroin dependence, however, continues to be the main cause for seeking treatment for drug addiction in our country (97.1% of cases), while cocaine dependence represents only 1.7% (Sistema Estatal de Information sobre Toxicomanias, 1989). A similar trend to that observed in other countries shows that cocaine consumption is becoming a significant problem among heroin addicts (Kosten et al., 1986; 1987; 1988; Nurco et al., 1988). In 1988,44% of heroin addicts seeking treatment in Spain also used cocaine (Sistema Estatal de Information sobre Toxicomanias, 1989). However, studies about cocaine abuse on patients admitted to hospital units for detoxification of opiate dependence are not available. The present study concerns (a) the prevalence of cocaine use in heroin addicts admitted for opiate detoxification and the detection of cocaine abusers; and (b) the social and demographic characteristics, toxicologic history, presence of anti-HlV antibodies, current psychopathologic state, success and failure of inpatient opiate detoxification of heroin addicts abusing cocaine as opposed to those who did not, with a view to the repercussions that Ltd.
30
cocaine abuse may have on the treatment inpatient opiate addicts. Materials
of
and method
We have studied retrospectively 120 heroin addicts of both sexes, who were referred to the detoxification unit of our hospital by the outpatients department of the same hospital. The criteria for admission were: opiate dependence according to DSM-III criteria, failure of outpatient detoxification treatment, poor physical condition and high heroin consumption by the intravenous route. Admission to the unit was voluntary and all subjects gave their written informed consent with the right to discontinue the programme and the freedom to leave the unit at any time. Those patients with concomitant illnesses or serious psychiatric disorders (schizophrenia, mania) were excluded. Patients were alloted to three groups according to cocaine use patterns during the previous 6 months: patients who had consumed cocaine daily or several times/week, patients who had consumed cocaine less than once/week and these who had not taken cocaine. The toxicologic history of each patient was evaluated by means of a structured interview, designed at our center, which was carried out during the first week of hospitalization. Psychopathologic evaluation included a clinical interview administration of and SCL-90/R (Derogatis, 19831 on day 4 and Beck’s Depression Inventory (BDIl (Burns and Beck, 19781 on days 2 and 11. Psychiatric diagnoses were established according to DSM-III criteria (American Psychiatric Association, 19801. The measurement of anti-HIV antibodies was carried out by ELISA and confirmed by Western blot. Patients were randomly treated with methadone or clonidine at scheduled doses according to their weight and the milligrams of heroin consumed daily (San et al., 1989al. No patient received specific treatment for cocaine abuse. The nurses, blind to the patient’s drug history, completed daily abstinence rating scales recording the presence or absence of 21 items
assessing the severity of opioid withdrawal symptoms. The overall score of the rating scale varied from 0 to 21 (San et al., 19901. The assessment of the success or failure of inpatient opioid detoxification took into consideration the characteristics and severity of withdrawal symptoms, the pharmacological treatment administered and the completion of detoxification. Results are expressed as mean f S.D. Statistical analysis was carried out using Student’s t-test for differences between means. For the comparison of proportions, x2-test with Yates correction and Fisher’s test were applied. A Pvalue of 0.05 was established as statistically significant. Results
Of the 120 heroin addicts admitted 91 were men and 29 women between 18 and 39 years of age (mean 25.5 f 4.4 years). Eighty-eight patients had used cocaine in the 6 months prior to admission and 32 had not (non-CA group). Of the 88 patients who used cocaine, there were 30 who consumed cocaine daily or several times per week and were considered to be cocaine abusers (CA group). The remaining 58 who had consumed cocaine less than once/week were excluded for the purposes of comparison between CA and non-CA groups. There were no statistically significant differences between CA and non-CA groups with respect to social and demographic characteristics, such as sex, age, legal status, employment and legal problems (Table Il. Patients in the CA group began taking cannabis, hallucinogens and opiates at significantly earlier ages than patients in the non-CA group; however, differences in the age at which they started taking alcohol, stimulants, benzodiazepines and cocaine were not statistically significant (Table 111. In the CA group, 46.7% of patients began consuming heroin immediately by the intravenous route, whereas 34.4% of non-CA patients used this route at the beginning of their addiction (x2 = 0.53; NSl. The mean dose of heroin consumed daily during the
31 Social and demographic characteristics Table I. heroin addicts undergoing inpatient detoxification.
of 62
CA (72 = 30)
NonCA (n = 32)
P
22 (73%)
25 (78%)
NS
7(22%)
NS
Sex
Male Female Age (years, mean f S.D.) Marital status
8 (27%) 25.1 f 3.6
26.7 f 4.4
NS
20 7 3
19 10 3
NS
5 8 17
1 12 19
NS
Employed Unemployed Unknown Arrest
7 17 6
7 20 5
NS
Yes No Imprisonment Yes
20 10
16 16
11 19
25
Single Cohabitation Divorced Social status Upper/middle Middle class Middle/Lower Employment
class class
No CA: cocaine abusers; significant.
NS
7
Non-CA: non cocaine abusers;
NS NS: not
week prior to admission was significantly higher in the CA group (766 f 724 vs. 435 & 310 mglday; P < 0.005). There was no significant difference in the current use pattern of other drugs, as shown in Table III. There was a greater prevalence of anti-HIV antibodies in CA patients than in non-CA patients (89% vs. 65%: x2 = 0.05; P = 0.02). In the CA group, 10 (33.30/b) patients were diagnosed as having antisocial personality disorders, whereas in the non-CA group only three patients (9.4%) were diagnosed as such (P < 0.005). Psychometric tests could not be performed on all patients, largely due to individual decisions to discontinue detoxification treatment. On BDI, patients of both groups showed moderate depression by the second day (CA group (n = 24) 18.58 + 6.37 vs. non-CA (n = 28)
Table II. undergoing
Age of onset of drug abuse in 62 heroin addicts inpatient detoxification. CA (n = 30
Non-CA (n = 32)
P
Cannabis Alcohol
13.9 * 2.81 14.2 -c 3.75
15.8 f 2.14 14.9 f 2.41
< 0.006 NS
Stimulants Hallucinogens Opiates Benzodiazepines Cocaine
15.8 16.4 17.7 18.5 18.6
17.3 18.4 20.2 21.2 20.0
NS < 0.01
29
Cocaine abuse among heroin addicts in Spain Marta Torrens, of Drug Addiction.
Section
Lluis San, Josh M. Peri and Jo& M. Olle
Hospital de1 Mar, Autonomous (Received
Abuse
of cocaine
is becoming
a major
problem
admitted as inpatients for detoxification from and 25% had abused cocaine daily or several gic problems than opiate addicts who did not drugs earlier and showed a higher frequency
among
June
heroin
cocaine;
depression;
Multiple data suggest that Spain is suffering a new era of epidemic dimensions with regard to the consumption of cocaine. Direct and indirect indicators, such as confiscations, health problems in emergency rooms and number of patients seeking treatment in drug addiction services, indicate the existence of an increasing population of cocaine consumers. Cocaine confiscations showed a 3-fold increase between 1985 and 1987. The amount of confiscated cocaine increased from 1134 kg in 1987 to 3471 kg in 1988 (Plan National sobre Drogas, 1989). Also cases of acute intoxication, adverse psychological reactions and withdrawal symptoms due to cocaine abuse have been detected in emergency rooms (Cami et al., 1987). Likewise the number of patients seeking treatment for cocaine dependence has increased from 188 in 1987 to 278 in 1988 (Sistema Estatal de Informacion sobre Toxicomanias, 1988; 1989). Correspondence to: Dr. Lluis San, Secci6n de Toxicomanias, Hospital de1 Mar, Passeig Maritim 25 - 29.08003 Barcelona, Spain.
0 1991 Elsevier in Ireland
ISpain)
15th. 1990)
addicts
in Spain.
Between
1987 and 1988, 75% of patients
than heroin addicts who did not abuse cocaine. for detoxifying patients with this dual addiction.
Based
on
HIV
Introduction
0376.8716/91/$03.50 Printed and Published
of Barcelona, Barcelona
opiate dependence had consumed cocaine during the 6 months prior to admission times/week. These cocaine abusers showed more toxicologic and psychopatholoabuse cocaine. The opiate addicts who also abused cocaine had begun using illicit of anti-HIV antibodies. They also had more antisocial personality disorders and
persistence of depressive symptoms during opiate detoxification these findings, we insist on the need to develop different treatments Key words: heroin;
University
Scientific
Publishers
Ireland
Heroin dependence, however, continues to be the main cause for seeking treatment for drug addiction in our country (97.1% of cases), while cocaine dependence represents only 1.7% (Sistema Estatal de Information sobre Toxicomanias, 1989). A similar trend to that observed in other countries shows that cocaine consumption is becoming a significant problem among heroin addicts (Kosten et al., 1986; 1987; 1988; Nurco et al., 1988). In 1988,44% of heroin addicts seeking treatment in Spain also used cocaine (Sistema Estatal de Information sobre Toxicomanias, 1989). However, studies about cocaine abuse on patients admitted to hospital units for detoxification of opiate dependence are not available. The present study concerns (a) the prevalence of cocaine use in heroin addicts admitted for opiate detoxification and the detection of cocaine abusers; and (b) the social and demographic characteristics, toxicologic history, presence of anti-HlV antibodies, current psychopathologic state, success and failure of inpatient opiate detoxification of heroin addicts abusing cocaine as opposed to those who did not, with a view to the repercussions that Ltd.
30
cocaine abuse may have on the treatment inpatient opiate addicts. Materials
of
and method
We have studied retrospectively 120 heroin addicts of both sexes, who were referred to the detoxification unit of our hospital by the outpatients department of the same hospital. The criteria for admission were: opiate dependence according to DSM-III criteria, failure of outpatient detoxification treatment, poor physical condition and high heroin consumption by the intravenous route. Admission to the unit was voluntary and all subjects gave their written informed consent with the right to discontinue the programme and the freedom to leave the unit at any time. Those patients with concomitant illnesses or serious psychiatric disorders (schizophrenia, mania) were excluded. Patients were alloted to three groups according to cocaine use patterns during the previous 6 months: patients who had consumed cocaine daily or several times/week, patients who had consumed cocaine less than once/week and these who had not taken cocaine. The toxicologic history of each patient was evaluated by means of a structured interview, designed at our center, which was carried out during the first week of hospitalization. Psychopathologic evaluation included a clinical interview administration of and SCL-90/R (Derogatis, 19831 on day 4 and Beck’s Depression Inventory (BDIl (Burns and Beck, 19781 on days 2 and 11. Psychiatric diagnoses were established according to DSM-III criteria (American Psychiatric Association, 19801. The measurement of anti-HIV antibodies was carried out by ELISA and confirmed by Western blot. Patients were randomly treated with methadone or clonidine at scheduled doses according to their weight and the milligrams of heroin consumed daily (San et al., 1989al. No patient received specific treatment for cocaine abuse. The nurses, blind to the patient’s drug history, completed daily abstinence rating scales recording the presence or absence of 21 items
assessing the severity of opioid withdrawal symptoms. The overall score of the rating scale varied from 0 to 21 (San et al., 19901. The assessment of the success or failure of inpatient opioid detoxification took into consideration the characteristics and severity of withdrawal symptoms, the pharmacological treatment administered and the completion of detoxification. Results are expressed as mean f S.D. Statistical analysis was carried out using Student’s t-test for differences between means. For the comparison of proportions, x2-test with Yates correction and Fisher’s test were applied. A Pvalue of 0.05 was established as statistically significant. Results
Of the 120 heroin addicts admitted 91 were men and 29 women between 18 and 39 years of age (mean 25.5 f 4.4 years). Eighty-eight patients had used cocaine in the 6 months prior to admission and 32 had not (non-CA group). Of the 88 patients who used cocaine, there were 30 who consumed cocaine daily or several times per week and were considered to be cocaine abusers (CA group). The remaining 58 who had consumed cocaine less than once/week were excluded for the purposes of comparison between CA and non-CA groups. There were no statistically significant differences between CA and non-CA groups with respect to social and demographic characteristics, such as sex, age, legal status, employment and legal problems (Table Il. Patients in the CA group began taking cannabis, hallucinogens and opiates at significantly earlier ages than patients in the non-CA group; however, differences in the age at which they started taking alcohol, stimulants, benzodiazepines and cocaine were not statistically significant (Table 111. In the CA group, 46.7% of patients began consuming heroin immediately by the intravenous route, whereas 34.4% of non-CA patients used this route at the beginning of their addiction (x2 = 0.53; NSl. The mean dose of heroin consumed daily during the
31 Social and demographic characteristics Table I. heroin addicts undergoing inpatient detoxification.
of 62
CA (72 = 30)
NonCA (n = 32)
P
22 (73%)
25 (78%)
NS
7(22%)
NS
Sex
Male Female Age (years, mean f S.D.) Marital status
8 (27%) 25.1 f 3.6
26.7 f 4.4
NS
20 7 3
19 10 3
NS
5 8 17
1 12 19
NS
Employed Unemployed Unknown Arrest
7 17 6
7 20 5
NS
Yes No Imprisonment Yes
20 10
16 16
11 19
25
Single Cohabitation Divorced Social status Upper/middle Middle class Middle/Lower Employment
class class
No CA: cocaine abusers; significant.
NS
7
Non-CA: non cocaine abusers;
NS NS: not
week prior to admission was significantly higher in the CA group (766 f 724 vs. 435 & 310 mglday; P < 0.005). There was no significant difference in the current use pattern of other drugs, as shown in Table III. There was a greater prevalence of anti-HIV antibodies in CA patients than in non-CA patients (89% vs. 65%: x2 = 0.05; P = 0.02). In the CA group, 10 (33.30/b) patients were diagnosed as having antisocial personality disorders, whereas in the non-CA group only three patients (9.4%) were diagnosed as such (P < 0.005). Psychometric tests could not be performed on all patients, largely due to individual decisions to discontinue detoxification treatment. On BDI, patients of both groups showed moderate depression by the second day (CA group (n = 24) 18.58 + 6.37 vs. non-CA (n = 28)
Table II. undergoing
Age of onset of drug abuse in 62 heroin addicts inpatient detoxification. CA (n = 30
Non-CA (n = 32)
P
Cannabis Alcohol
13.9 * 2.81 14.2 -c 3.75
15.8 f 2.14 14.9 f 2.41
< 0.006 NS
Stimulants Hallucinogens Opiates Benzodiazepines Cocaine
15.8 16.4 17.7 18.5 18.6
17.3 18.4 20.2 21.2 20.0
NS < 0.01
