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January 1997, Vol 54, No. 1 >
Article | January 1997

Psychiatric and Substance Use Comorbidity Among Treatment-Seeking Opioid Abusers

Robert K. Brooner, PhD; Van L. King, MD; Michael Kidorf, PhD; Chester W. Schmidt, Jr, MD; George E. Bigelow, PhD
Arch Gen Psychiatry. 1997;54(1):71-80. doi:10.1001/archpsyc.1997.01830130077015
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Background:  Major studies of psychiatric comorbidity in opioid abusers reported rates of comorbidity that far exceeded general population estimates. These studies were published more than a decade ago and reported on few women and few substance use diagnoses.

Methods:  Psychiatric and substance use comorbidity was assessed in 716 opioid abusers seeking methadone maintenance. Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition diagnostic assessment was conducted 1 month after admission. Rates of psychiatric and substance use disorder were compared by gender, and associations were assessed between psychiatric comorbidity and dimensional indexes of substance use severity, psychosocial impairment, and personality traits.

Results:  Psychiatric comorbidity was documented in 47% of the sample (47% women and 48% men). Antisocial personality disorder (25.1%) and major depression (15.8%) were the most common diagnoses. Patients had at least 2 substance use diagnoses, most often opioid and cocaine dependence. Demographics, substance use history, and personality variables discriminated between patients with vs without comorbidity. Psychiatric comorbidity also was associated with a more severe substance use disorder.

Conclusions:  Psychiatric comorbidity, especially personality and mood disorder, was common in men and women. The positive associations between psychiatric comorbidity and severity of substance use and other psychosocial problems were most consistent among those with antisocial personality.

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Darke S, Hall W, Ross M, Wodak A.  Benzodiazepine use and HIV risk-taking behavior among injecting drug users . Drug Alcohol Depend . 1992;;31:31-36.
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Iguchi MY, Handelsman L, Bickel WK, Griffiths RR.  Benzodiazepine and sedative use/abuse by methadone maintenance clients . Drug Alcohol Depend . 1993;;32:257-266.
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Holland BS, Copenhaver MD.  Improved Bonferroni-type multiple testing procedures . Psychol Bull . 1988;;104:145-149.
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1 +
Group for the Advancement of Psychiatry.  Substance abuse disorders: a psychiatric riority . Am J Psychiatry . 1991;;148:1291-1300.
2 +
Rounsaville BJ, Weissman MM, Crits-Christoph K, Wilber C, Kleber H.  Diagnosis and symptoms of depression in opiate addicts: course and relationship to treatment outcome . Arch Gen Psychiatry . 1982;;39:151-156.
3 +
Woody GE, Luborsky L, McLellan AT, O'Brien CP, Beck AT, Blaine J, Herman I, Hole A.  Psychotherapy for opiate addicts . Arch Gen Psychiatry . 1983;;40:636-645.
4 +
Woody GE, McLellan AT, Luborsky L, O'Brien CP.  Sociopathy and psychotherapy outcome . Arch Gen Psychiatry . 1985;;42:1081-1086.
5 +
Schuckit MA.  The clinical implications of primary diagnostic groups among alcoholics . Arch Gen Psychiatry . 1985;;42:1043-1049.
6 +
Rounsaville BJ, Kosten TR, Weissman MM, Kleber HD.  Prognostic significance of psychopathology in treated opiate addicts . Arch Gen Psychiatry . 1986;;43:739-745.
7 +
Rounsaville BJ, Dolinsky ZS, Babor TF, Meyer RE.  Psychopathology as a predictor of treatment outcome in alcoholics . Arch Gen Psychiatry . 1987;;44:505-513.
8 +
Nace EP, Davis CW, Gaspari JP.  Axis II comorbidity in substance abusers . Am J Psychiatry . 1991;;148:118-120.
9 +
Rounsaville BJ, Anton SF, Carroll K, Budde D, Brigitte AP, Gawin F.  Psychiatric diagnoses of treatment-seeking cocaine abusers . Arch Gen Psychiatry . 1991;;48:43-51.
10 +
Rutherford MJ, Cacciola JS, Alterman Al.  Relationships of personality disorders with problem severity in methadone patients . Drug Alcohol Depend . 1994;;35:69-76.
11 +
Schoenbaum EE, Hartel D, Selwyn PA, Klein RS, Davenny K, Rogers M, Feiner C, Friedland G.  Risk factors for human immunodeficiency virus infection in intravenous drug users . N Engl J Med . 1989;;321:874-979.
12 +
Des Jarlais DC, Friedman SR, Novick DM, Sotheran JL, Thomas P, Yancovitz SR, Mildvan D, Weber J, Kreek MJ, Maslansky R, Bartime S, Spira T, Marmor M.  HIV-1 infection among intravenous drug users in Manhattan, New York City, from 1977 through 1987 . JAMA . 1989;;261:1008-1012.
13 +
Nemoto T, Brown LS, Foster K, Chu A.  Behavioral risk factors of human immunodeficiency virus infection among intravenous drug users and implications for preventive intervention . AIDS Educ Prev . 1990;;2:116-126.
14 +
Haverkos HW, Lange WR.  Serious infections other than human immunodeficiency virus among intravenous drug abusers . J Infect Dis . 1990;;161:894-902.
15 +
Vlahov D, Anthony JC, Munoz A, Margolick J, Nelson KE, Celentano DD, Solomon L, Polk BF.  The Alive Study: A longitudinal study of HIV-1 infection in intravenous drug users: description of methods . Drug Issues . 1991;;21:759-776.
16 +
Metzger D, Woody GE, DePhilippis D, McLellan AT, O'Brien CP, Platt J.  Risk factors for needle sharing among methadone-treated patients . Am J Psychiatry . 1991;;148:641-643.
17 +
Bass JB.  Tuberculosis in the 1990s . Alcohol Clin Exp Res . 1995;;19:3-5.
18 +
Nelson KE, Vlahov D, Solomon L, Cohn S, Munoz A.  Temporal trends of incident human immunodeficiency virus infection in a cohort of injecting drug users in Baltimore, Md . Arch Intern Med . 1995;;155:1305-1311.
19 +
Rounsaville BJ, Weissman MM, Kleber, H, Wilber, C.  Heterogeneity of psychiatric diagnosis in treated opiate addicts . Arch Gen Psychiatry . 1982;;39:161-166.
20 +
Khantzian EJ, Treece C.  DSM-III psychiatric diagnosis of narcotic addicts . Arch Gen Psychiatry . 1985;;42:1067-1071.
21 +
Robins LN, Helzer JE, Weissman MM, Orvaschel H, Gruenbert E, Burke JD Jr, Regier DA.  Lifetime prevalence of specific psychiatric disorders in three sites . Arch Gen Psychiatry . 1985;;41:949-958.
22 +
Strain EC, Stitzer ML, Bigelow GE.  Early treatment time course of depressive symptoms in opiate addicts . J Nerv Ment Dis . 1991;;179:215-221.
23 +
Kosten TR, Gawin FH, Rounsaville BJ, Kleber HD.  Cocaine abuse among opioid addicts: demographic and diagnostic factors in treatment . Am J Drug Alcohol Abuse . 1986;;12:1-16.
24 +
Kolar AF, Brown BS, Weddington WW, Ball JC.  A treatment crisis: cocaine use by clients in methadone maintenance programs . J Subst Abuse Treat . 1990;;7:101-107.
25 +
Strain EC, Brooner RK, Bigelow GE.  Clustering of multiple substance use and psychiatric diagnoses in opiate addicts . Drug Alcohol Depend . 1991;;27:127-134.
26 +
Kosten TR, Morgan C, Falcione J, Schottenfeld R.  Pharmacotherapy for cocaineabusing methadone-maintained patients using amantadine or desipramine . Arch Gen Psychiatry . 1992;;49:894-898.
27 +
Kidorf M, Stitzer ML.  Descriptive analysis of cocaine use in methadone patients . Drug Alcohol Depend . 1993;;32:267-275.
28 +
Darke S, Hall W, Ross M, Wodak A.  Benzodiazepine use and HIV risk-taking behavior among injecting drug users . Drug Alcohol Depend . 1992;;31:31-36.
29 +
Iguchi MY, Handelsman L, Bickel WK, Griffiths RR.  Benzodiazepine and sedative use/abuse by methadone maintenance clients . Drug Alcohol Depend . 1993;;32:257-266.
30 +
Folstein MF, Folstein SE, McHugh PR.  Mini-Mental State: a practical method for grading the cognitive state of patients for the clinician . J Psychiatr Res . 1975;;12:189-198.
31 +
Spitzer SL, Williams JBW, Gibbon M, First MB.  The Structured Clinical Interview for DSM-III-R (SCID) . Arch Gen Psychiatry . 1992;;49:624-629.
32 +
Williams JBW, Gibbon M, First MB, Spitzer RL, Davies M, Borus J, Jowes MJ, Kane J, Pope HG Jr, Rounsaville BJ, Wittchen HU.  The Structured Clinical Interview for DSM-III-R (SCID), II: multisite test-retest reliability . Arch Gen Psychiatry . 1992;;49:630-636.
33 +
Perry JC.  Problems and considerations in the valid assessment of personality disorders . Am J Psychiatry . 1992;;149:1645-1653.
34 +
Costa PT. McCrae RR. The NEO Personality Inventory Manual . Odessa, Fla: Psychological Assessment Resources; 1985;.
35 +
Costa PT, McCrae RR. The NEO-PI/NEO-FFI Manual Supplement . Odessa, Fla: Psychological Assessment Resources; 1989;.
36 +
McLellan AT, Luborsky L, Woody GE, O'Brien CP.  An improved diagnostic evaluation instrument for substance abuse patients: the Addiction Severity Index . J Nerv Ment Dis . 1980;;168:26-33.
37 +
McCrae RR, Costa PT.  Validation of the five-factor model of personality across instruments and observers . J Pers Soc Psychol . 1987;;52:81-90.
38 +
Leong FTL, Dollinger SJ.  NEO Personality Inventory . In: Keyser DJ, Sweetland RC, eds. Test Critiques . Austin, Tex: PRO-ED; 1990;:527-539.
39 +
Kosten TR, Rounsaville BJ, Kleber HD.  Concurrent validity of the Addiction Severity Index . J Nerv Ment Dis . 1983;;171:606-610.
40 +
McLellan AT, Luborsky LK, Woody GE, O'Brien CP, Druley KA.  Predicting response to alcohol and drug abuse treatments . Arch Gen Psychiatry . 1983;;40:620-625.
41 +
Holland BS, Copenhaver MD.  Improved Bonferroni-type multiple testing procedures . Psychol Bull . 1988;;104:145-149.
42 +
Holm S.  A simple sequentially rejective multiple test procedure . Scand J Stat . 1979;;6:65-70.
43 +
Kosten TR, Rounsaville BJ, Kleber HD.  DSM-III personality disorders in opiate addicts . Compr Psychiatry . 1982;;23:572-581.
44 +
Bryant KJ, Rounsaville BJ, Spitzer RL, Williams JB.  Reliability of dual diagnosis . J Nerv Ment Dis . 1992;;180:251-257.
45 +
Kadden RM, Kranzler HR, Rounsaville BJ.  Validity of the distinction between 'substance-induced' and 'independent' depression and anxiety disorder . Am J Addict . 1995;;4:107-117.
46 +
Rounsaville BJ, Kleber HD.  Untreated opiate addicts: how do they differ from those seeking treatment? Arch Gen Psychiatry . 1985;;42:1072-1077.
47 +
Robins E, Guze SB.  Classification of affective disorders: the primary-secondary, the endogenous-reactive, and the neurotic-psychotic concepts . In: Williams TA, Katz MM, Shields JA, eds. Recent Advances in Psychobiology of the Depressive Illnesses: Proceedings of a Workshop Sponsored by the National Institute of Mental Health . Washington, DC: Dept of Health, Education, and Welfare; 1972;;283-293.
48 +
Kessler RC, McGonagle KA, Zhao S, Nelson CB, Hughes M, Eshleman S, Wittchen H-U, Kendler KS.  Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: results from the National Comorbidity Survey . Arch Gen Psychiatry . 1994;;51:8-19.
49 +
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50 +
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