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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 33  |  Issue : 4  |  Page : 211-218

No association between craving levels, personality traits, and treatment outcomes in patients with methamphetamine use disorder under deferred prosecution status


1 Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
2 Department of Psychiatry, National Cheng Kung University Hospital; Institute of Behavioral Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
3 Department of Psychiatry, National Cheng Kung University Hospital; Institute of Behavioral Medicine, College of Medicine, National Cheng Kung University, Tainan; Department of Psychiatry, National Cheng Kung University Hospital, Dou-Liou Branch, Yunlin, Taiwan
4 Department of Psychiatry, National Cheng Kung University Hospital; Institute of Behavioral Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Yanjiao Furen Hospital, Hebei, China

Date of Submission05-Sep-2019
Date of Decision11-Nov-2019
Date of Acceptance12-Nov-2019
Date of Web Publication23-Dec-2019

Correspondence Address:
Tzu-Yun Wang
No 138, Sheng Li Road, North District, Tainan 704
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TPSY.TPSY_45_19

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  Abstract 


Objective: Few studies have examined the outcome predictors in methamphetamine (MA) use disorder patients referred from the justice system. Craving and personality trait, such as novelty seeking (NS) and harm avoidance (HA), have important rôles in developing and sustaining addiction. Therefore, we investigated whether craving severity and personality traits are correlated with the MA use disorder treatment outcomes in those under the deferred prosecution status. Methods: We measured craving levels and personality traits of NS and HA at the beginning of a one-year treatment program for MA use disorder. We monitored urinary MA/amphetamine results during the one-year treatment program. Multiple linear regressions were used to examine the correlation between craving severity, personality traits, and MA use disorder treatment outcomes. Results: We first enrolled 98 patients, but only 56 patients completed the end-of-treatment assessments. We did not find any association between craving severity, personality traits, and MA treatment outcomes in those populations. But we found that age and percentage of positive urine MA/amphetamine results were significantly related to treatment completion (p < 0.05). Higher percentages of positive urine MA/amphetamine results were also significantly associated with shorter treatment duration (p = 0.01). In addition, positive urine results at baseline were significantly associated with higher percentages of positive urine tests in the following treatment course (p = 0.001). Conclusion: Our study data did not find that craving severity and personality traits were associated treatment outcomes in this special population. But urine MA/amphetamine results were more related with completion of programs. Further studies to evaluate the treatment outcomes and other potential outcome predictors in those were referred from the justice system are needed.

Keywords: amphetamine use disorder, completion of treatment, drug courts, substance use disorder


How to cite this article:
Tsai TY, Wang TY, Tseng HH, Chen KC, Lin SH, Chen PS, Lee I H, Yang YK, Lu RB. No association between craving levels, personality traits, and treatment outcomes in patients with methamphetamine use disorder under deferred prosecution status. Taiwan J Psychiatry 2019;33:211-8

How to cite this URL:
Tsai TY, Wang TY, Tseng HH, Chen KC, Lin SH, Chen PS, Lee I H, Yang YK, Lu RB. No association between craving levels, personality traits, and treatment outcomes in patients with methamphetamine use disorder under deferred prosecution status. Taiwan J Psychiatry [serial online] 2019 [cited 2020 Jan 27];33:211-8. Available from: http://www.e-tjp.org/text.asp?2019/33/4/211/273866




  Introduction Top


Methamphetamine (MA) is the second most used illicit drug worldwide and the primary illicit drug threat in Asia [1]. MA use disorder is associated with multiple morbidities, including HIV infection, hepatitis, cardiac effects, family disruptions, and prominent psychiatric consequences [2]. Although MA use continues to be a major problem in large parts of East and Southeast Asia, and accounts for a large share of people receiving treatment, the US Food and Drug Administration has not approved any medications for MA use disorder [3]. Psychosocial interventions remain the mainstay in the MA use disorder treatment programs, with various options for psychosocial treatment regimens [4]. The results of meta-analysis of the treatment effects from different psychosocial treatment models do not shown that any specific psychosocial treatment model is superior to the others [4]. But when compared to no intervention, any psychosocial treatment can reduce the dropout rate and increase continuous abstinence at the end of treatment and remarkably increase the longest period of abstinence [4]. In Taiwan, the most commonly used MA use disorder treatment model in many hospitals is the outpatient program, which combing outpatient follow-up, urine drug tests, group and individual psychotherapy, as well as case management [5].

As MA is a highly addictive drug, patients with MA use disorder attending treatment programs have high rates of relapse and dropout [6]. Medical treatment programs integrated with justice system, such as drug courts, have been found to be associated with better treatment outcomes with MA-dependent patients [7]. But currently in Taiwan, there are no drug courts. Instead of drug courts, there is a special condition called “the deferred prosecution with condition to complete the addition treatment,” which is designed to give drug users chances to receive addiction treatment before incarcerations. The rate of deferred prosecution has been gradually increased in recent years, especially in MA users. But no available data exist on the treatment response of MA use disorder individuals within a deferred prosecution with the stipulation to complete the addition treatment setting. Understanding the factors associated with these special population MA treatment outcomes is important, and clinicians can identify those with risk factors of poor treatment outcomes and offer personalized treatment programs to

enhance their treatment effects. Although previous studies tried to identify possible individual factors that profile MA users, and link these factors with treatment outcomes, the results are inconclusive [8]. Some studies suggested that demographic characteristics, MA use pattern, and severity are related with the treatment outcomes [8], but others are not [9]. Most importantly, those results may not be applied on those with deferred prosecution status. Therefore, studies in attempts to differentiate predictors of treatment outcomes in patients with MA use disorder in this population are still needed.

Craving reflects a strong desire to get drugs, to terminate withdrawal symptoms, or to improve unpleasant feelings immediately [10]. Both aversive internal and external stimuli can induce craving even after periods of sustained abstinence [11]. Craving has been hypothesized to play an important rôle in sustained drug use and relapse [11]. In previous studies, craving has been found to predict of addiction, in nicotine, heroin, and MA [11],[12],[13]. Thus, except for demographic factors, we hypothesize that craving could be a sensitive and easily used clinical outcome predictor for MA use disorder treatment, especially in those patients with deferred prosecution status.

Different personalities, such as novelty seeking (NS), harm avoidance (HA), and impulsiveness, are associated with the propensity of MA abuse [14]. In patients with MA use disorder, both HA and NS personality traits' scores are higher than normal controls [15]. In different types of substance abuse, high NS is related to increased risk of using addictive drugs [16], the higher amount of abused drugs [17], and increased relapse rates for several kinds of substance abuse [18],[19]. In particular, a study showed that higher level of NS is predictive to late dropout (one year) among patients receiving the methadone maintenance treatment for opioid dependence [20]. But previous studies had only followed up for a short period of time. The association between the long-term outcome in those were referred from justice system and personality traits and craving is still unknown.

In the current study, we intended to study the association between the craving severity and personality traits in patients with MA use disorder, and to follow the patients' outcome for one year. The patients were all referred from justice system with the deferred prosecution status.


  Methods Top


Study participants

The study protocol was approved by the institutional review board (protocol number = A-ER-106-197 and approval date = November 15, 2017) at National Cheng Kung University Hospital (NCKUH). The procedures were fully explained to each participant before they were asked to sign informed consent. Patients with MA use disorder were recruited from the NCKUH addiction clinics. They were all referred from justice system with the deferred prosecution status.

Each patient was initially interviewed and diagnosed by a board-certified psychiatrist and then were also screened by a study team member, who has been well-trained in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria and the Chinese version of the Mini International Neuropsychiatric Interview (MINI) [21]. The MINI was used because completing 4-6 hour-structured structured interviews, such as the Chinese version of the Modified Schedule of Affective Disorder and Schizophrenia-Lifetime [22], is difficult for MA use disorder patients. The MINI has good reliability and has been widely used in clinical trials and epidemiological studies [23]. The inter-rater reliability in Chinese version of the MINI is about 0.75 in previous studies [24],[25].

Inclusion criterion was an adult male or female patient between 18 and 65 years old who met the DSM-IV criteria for the current MA dependence or abuse. Exclusion criteria were inability to sign informed consent and to complete copies of the questionnaire due to poor intellectual function. We also excluded those who had a serious medical or psychiatric health condition that requiring immediately hospitalizations because our treatment program is an outpatient-based program in the current study.

The three-stage treatment program

Our treatment program is based on the “Clinical Treatment Guideline for Schedule II Substance Users” (Taiwan Ministry of Health and Welfare, 2012; www.dep.mohw.gov.tw/DOMHAOH/cp-4097-43400-107.html). Our approach is a multicomponent treatment approach and has been organized into a standard treatment protocol that includes three stages of treatment:

  • The first treatment stage consists of weekly outpatient follow-up and urine amphetamine test. In the first stage, patients receive diagnostic interview to be evaluated for their substance use-related history and comorbid psychiatric condition. Examinations for comorbid physical condition are also done. Demographic data, social function and family support level, and psychological function will also be evaluated in this period. The treatment duration is four weeks in the first stage
  • The second stage of treatment program is provided if the patient has engaged well in the first stage of treatment. In the second treatment stage, the patient will be followed in outpatient clinic biweekly. Urine MA/amphetamine test, supportive psychotherapy, health education, and service linkages will be provided. Group psychotherapy will also be given in this stage, with totally 12 weekly sessions, using a cognitive behavioral therapeutic approach. The treatment duration is 8 weeks in the second stage
  • In the third treatment stage, the outpatient follow-up frequency will be monthly. Supportive psychotherapy and urine amphetamine screen will be given in every visit. Case managers integrate and monitor the treatment process in each patient during the whole treatment program. The treatment duration is 36 weeks in the third stage.


Measures

Visual analog scale, tridimensional personality questionnaire, and urine screening

Data used for analyses include those obtained at baseline and those after one-year treatment. All participants completed a standardized battery of psychosocial assessments at baseline. Measures used for this investigation include (a) visual analog scale (VAS) [26], (b) tridimensional personality questionnaire (TPQ) [27],[28], and (c) MA/amphetamine urinalysis results collected during each treatment visits.

The VAS was used to assess the level of craving for MA. We modified the VAS [26], with the following question: “How much did you crave/desire/want amphetamine in the preceding week?” The level of conscious craving was rated from 0 (none) to 100 (very much).

The TPQ was used to assess the personality traits. Because the reward dependence dimension is not reliable for Han Chinese in Taiwan (Cronbach's α = 0.54) [29], only the NS (32 items, Cronbach's α = 0.72) and HA (34 items, Cronbach's α = 0.89) dimensions were analyzed in our study. All participants were assessed at baseline to avoid confounding effects caused by psychotherapy.

Baseline demographic and clinical characteristics

We included patients' baseline demographic characteristics, including age, sex, educational attainment, marital and occupational status, as well as deferred prosecution status. Other variables include psychiatric comorbidities, physical comorbidities, and MA use onset age. We also measured the Severity of Dependence Scale (SDS) [30],[31] and family adaptation, partnership, growth, affection, and resolve (APGAR) (adaptation, partnership, growth, affection, and resolve) index [32] at baseline.

The SDS was a short and easily administrated scale which can be used to measure the degree of dependence in deferent types of substance users [30]. A score higher than four indicates problematic amphetamine use [31]. We used the SDS scores as a covariate to adjust the severity of substance dependence in analyzing the association between craving and personality traits and treatment outcome.

The family APGAR index was used to evaluate patients' family support. Chau et al. reported that the family APGAR index is a simple and useful instrument to screen out family dysfunctional patients in daily practice [32]. We also used the family APGAR index as a covariate to adjust the family support level in analyzing the association between craving and personality traits and treatment outcome.

Treatment retention

Treatment retention was measured by two different variables: (a) total number of days in treatment and (b) a dichotomous classification of completing the one-year treatment or not. To assess treatment retention is important using these two different measures because longer duration of treatment is one of the important predictors of favorable treatment outcomes [33].

Statistical analysis

Multiple linear regression model was used to determine the correlation between severity of craving, and personality trait with the outcome of urine MA/amphetamine positive percentage, or treatment retention. We used two indices for treatment retention, including total number of days in treatment and whether one-year treatment was completed. When we examined the correlation between treatment retention, we controlled for age, sex, education, marriage, occupation, onset age, SDS, family support condition, urine MA/amphetamine results, as well as physical and psychiatric comorbidities. When we examined the correlation between craving, personality traits, and urinary amphetamine results, we controlled for age, sex, education, marriage, occupation, onset age, SDS, family support condition, visits, urine MA/amphetamine results at baseline, as well as physical and psychiatric comorbidities.

All study data were computed using Statistical Package for the Social Science software version 18.0 for Windows (SPSS, Inc., Chicago, Illinois, USA). The differences between groups were considered significant if p-values were smaller than 0.05.


  Results Top


At baseline, there were 98 patients with MA use disorder (mean age = 39.2 ± 9.2 years old, male = 86.7%, and mean MA use onset age = 29.5 ± 10.3 years) [Table 1]. Most of them were single or divorced/separated (82.7%), with education years less than 12 years (81%), and 78.6% had regular job [Table 1]. About 39.8% of the participants had amphetamine-positive urine tests, and 39.8% of the patients had psychiatric comorbidities other than MA use disorder [Table 1]. The mean scores of craving and personality traits were listed as following: VAS = 8.86 ± 14.02; TPQ-NS = 14.63 ± 4.59; and HA = 14.07 ± 5.11 [Table 1].
Table 1. Clinical characteristics, craving levels, and personality traits in patients with methamphetamine use disorder at baseline and after one-year treatment

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There were 56 patients (mean age = 37.8 ± 9.2 years old, male = 83.9%, and mean MA use onset age = 31.1 ± 10.2 years) completed the one-year program. The rate of having completed one-year treatment for MA use disorder in this population was 57.1%. The rate of urine MA/amphetamine-positive results was 1.8% after 1-year treatment in those completed treatment [Table 1]. The mean scores of craving and personality traits after 1-year treatment in these patients are also listed in [Table 1]. In those who drop out from treatment (noncompleter group), there was a significantly higher rate of positive urine MA/amphetamine test in the baseline assessment [Table 1] and in the whole course [Table 1].{Figure 1}

The associations between craving, personality traits, and retention outcome are shown in [Table 2] and [Table 3]. After covarying for age, sex, education, marriage, occupation, onset age, SDS, family support condition, urine MA/amphetamine-positive results, and physical and psychiatric comorbidities, neither the VAS nor the personality traits were associated with the duration of retention in treatment [Table 2]. Only the percentages of urine MA/amphetamine-positive results were negatively associated with the duration of treatment retention (β = −280.94, t = −3.64, p = 0.001). Craving severity and personality traits were not associated with the completion of the 1-year treatment program, either [Table 3]. But age (β = −0.17, Wald = 4.43, p < 0.05) and the percentage of urine MA/amphetamine-positive results (β = −10.61, Wald = 6.06, p = 0.01) were negatively associated with the completion of treatment. Positive urine MA/amphetamine test in the baseline assessment were also negatively associated with the completion of treatment (β = −0.93, Wald = 4.76, p < 0.05), but the effects were not significant after adjusting for other possible confounding factors (β = −1.45, Wald = 2.77, nonsignificance).
Table 2. Association between craving levels, personality traits, and duration of retention in treatment

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Table 3. Association between craving levels, personality traits and completion of the 1 year treatment program

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After we had corrected for multiple possible confounding factors (age, sex, education, marriage, occupation, onset age, SDS, family support condition, visits, urine MA/amphetamine results at baseline, as well as physical and psychiatric comorbidities), a regression analysis did not show the association between urinary amphetamine test results and craving scales and personality traits in patients with MA use disorder [Table 4]. But positive urine MA/amphetamine test in the baseline assessment was associated with the percentage of urine MA/amphetamine-positive results in the following treatment course (β = 0.14, t = 3.65, p = 0.001).
Table 4. Association between craving levels, personality traits, and the percentage of positive urine methamphetamine/amphetamine tests

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  Discussion Top


Contrary to our hypothesis, we did not find any significant correlations between craving personality traits and MA use disorder treatment outcomes in the current study [Table 1]. Neither craving nor personality trait was associated with the completion of treatment [Table 3], treatment retention [Table 2], or urine MA/amphetamine-positive results [Table 4] in those with deferred prosecution status. But older age (p< 0.05), positive urine MA/amphetamine results in the beginning of treatment (p< 0.001), and higher percentage of urine-positive results during the whole treatment (p< 0.001) were all significantly associated with dropout from treatment [Table 1].

Contrary to previous studies [11],[18],[34],[35],[36] our data [Table 3] did not support that craving level and personality trait were important indicators for treatment outcomes in patients who were referred from the justice system. Active criminal justice involvement including referred to treatment by the court, probation, or parole officers, or currently on probation or parole, can overcome some baseline poor treatment outcome indicators and have similar treatment outcomes as those presenting to treatment voluntarily [37]. Drug courts, the most frequently mentioned tool for promoting to treatment by the justice system, have been found to be associated with better rates of engagement, retention, completion, and abstinence, compared to outpatient treatment without drug court in MA-dependent adults [7]. We suggest that cooperating with justice system may contribute to improving treatment adherence in those populations. Craving and personality traits, therefore, may not significantly affect their treatment outcomes. Instead, other demographic factors or factors related to substance use severity may have more significant effects. Some demographic variables have been suggested to be related with program completion, such as age, marital status, and employment [38],[39]. In our sample, we found that age [Table 1] was significantly negatively correlated with treatment completion (p< 0.05). Based on this result, we suggest that to predict MA users for completing a long-term treatment is difficult, and that many demographic data and socioeconomic background should be considered first, not only their personality trait and craving status.

We found that the higher percentages of positive MA/amphetamine urine tests were significantly associated with shorter retention in treatment program, and those who had positive urine MA/amphetamine test in the beginning of treatment secession were more likely to continuously have positive urine screens results and drop out from treatment. Many large clinical studies on MA treatment also showed the same finding. More specifically, data collected from 420 adults who participated in the Methamphetamine Treatment Project (MTP) showed that pretreatment MA use predicts in-treatment performance and posttreatment outcomes [8]. Several factors, such as greater frequency of baseline MA use, having MA positive testing for three consecutive time points, are associated with poor treatment outcomes [8]. Another study that used data from four randomized controlled trials of pharmacological treatments for MA use disorder also showed that participants' ability to achieve a brief period of initial abstinence, measured as the number of MA-negative urine screens, is important and correlated with treatment retention [40]. They found that each additional negative urine screen achieved during the first 2 weeks of the study reduced multiplicatively the odds of dropout by 41%, and each additional negative screen during the first two weeks of treatment is associated with a relative decrease in the likelihood of noncompletion of approximately 25% [40]. There are some explanations both for our observations and results from these studies [8],[40]. First, addicted patients often have difficulties in delaying gratification [40]. Those who are able to achieve a brief period of initial abstinence may believe that they are receiving an effective treatment and be more likely to continue participation in treatment programs. In those who are not able to achieve initial abstinence, they may lose faith and drop out without waiting longer for the treatment effects. Second, those who have more negative urine results initially or during the treatment may have less severe MA use problems. They can maintain in our outpatient programs, which treatment intensity was less intensive than other treatment models, and fulfilled the requirements from the justice systems. Third, the observed association may be the result of a shared common cause, such as readiness to quit MA. From these points, there may be some ways to improve MA use disorder treatment outcomes. Clinicians may focus intensively on relapse prevention during the initial treatment period or apply an adaptive design that initiates additional retention strategies for individuals who fail to achieve early abstinence in the initial phase of treatment. In those with severe MA use disorder, higher intensive treatment models or a form of compulsory abstinence during the early treatment period, such as an inpatient detoxification phase, may be required. Patients that were referred from the justice system may not be treatment-seeking, with low levels of readiness or motivation to quit using MA. Early interventions to increase readiness and motivation may be required to increase retention.

Individuals who have MA use disorders often deny having a problem with drugs and fail to seek treatment, despite the negative consequence impacts on their life. It has been suggested that denial may reflect a deficit in self-awareness and/or monitoring [41], with the underlying mechanism of poor overall cognitive functions and weakened connectivity between the rostral anterior cingulate and regions of the frontal lobe, limbic system, occipital lobes, and cerebellum in MA users [42]. Therefore, to cooperate with the justice system to initiate treatment in patients with MA use disorder may be needed. Emerging data also showed that forced treatment treatment by the criminal justice system may improve their outcomes [37]. In Taiwan, the recidivism among male subjects being incarcerated for illicit drug use in Taiwan is high, with 67.9% of them having repeated offends during the following five years after detoxification [43]. Although MA users had lower recidivism rate than heroin users, a substantial percentage (64.7%) of subjects still reoffends and has a median survival time of 16.0 months [43]. Hence, we suggest that more efforts to develop MA treatment models in community, especially cooperating with the justice system, are needed. Our study provided initial data on those with MA use disorder under deferred prosecution status; however, further enlargement of study sample size and collecting more data on potential outcome predictors is still required.

Study limitations

  • The psychosocial intervention is not as intense as manual guide treatment programs in previous study, such as matrix model [6]. But our treatment program was as long as one year. Under the concept that suggests drug addiction is a chronic disease, we suppose that a longer psychosocial treatment program may be more suitable for MA use disorder patients. In addition, our program is based on Clinical Treatment Guideline for Schedule II Substance Users (Taiwan Ministry of Health and Welfare, 2012 at www.dep.mohw.gov.tw/DOMHAOH/cp-4097-43400-107.html), which is the main treatment model used in hospitals in treating patients with MA use disorder in Taiwan. Nevertheless, further development for more sophisticated treatment models for MA use disorder patients is still needed in Taiwan. We suggest that our initial finding in the current study may offer directions in modification of MA use disorder treatment models in the future
  • Our patients were in deferred prosecution status, which means that they joined our treatment programs because of the requests of prosecutors. The main purpose for the request is like drug courts, using justice system to ask patients with drug use problems to receive treatment, instead of being in prison. Therefore, to apply our results on patients who voluntary join treatment programs may need more studies to confirm. Because of these limitations, our study findings should be interpreted with caution to avoid overinterpreting the study data.


Summary

  • There was no significant association between craving severity, personality traits, and treatment outcomes in patients with MA use disorder under deferred prosecutor status.
  • Positive urine MA/amphetamine results at baseline assessment were associated with subsequently higher percentages of positive urine MA/amphetamine results during the whole treatment course.
  • Older age and higher percentages of positive urine MA/amphetamine results were related to dropout from MA treatment.
  • More studies on those were prompted to treatment by the criminal justice system in Taiwan are needed to determine the treatments effects and potential outcome predictors.



  Acknowledgment Top


The authors thank Shish-Shuan Peng, Chien-Yu Tseng, Hung-Yi Chan, Yu Ting Hung, and Hsin-Han Wu for their assistance in preparation of the manuscript.


  Financial Support and Sponsorship Top


The study was supported by research grants from the Ministry of Science and Technology (MOST 106-2314-B-006-037, MOST-107-2314-B-006-067 to TYW), from the Ministry of Health and Welfare (MOHW107-TDU-B-211-123003, MOHW108-TDU-B-211-133003 to TYW), and from the project of Integrated Drug Addiction Treatment Center, Ministry of Health and Welfare, Taiwan.


  Conflicts of Interest Top


All authors declare that they have no conflicts of interest.



 
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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