Knowledge about the issues surrounding drug consumption has increased considerably in recent years, undoubtedly because of the severity of addiction-related problems and the social concern about this subject. Clinically, this increased interest in addiction issues has led directly to more precise knowledge of the psychopathological aspects of addiction (e.g., comorbidities, dual pathologies, course and prognosis) (Fernández-Montalvo & López-Goñi, Reference Fernández-Montalvo and López-Goñi2010; Landa, Fernández-Montalvo, López-Goñi, & Lorea, Reference Landa, Fernández-Montalvo, López-Goñi and Lorea2006; Lorea, Fernández-Montalvo, López-Goñi, & Landa, Reference Lorea, Fernández-Montalvo, López-Goñi and Landa2009), the development of specific assessment tools (e.g., the European Addiction Severity Index [EuropASI] and ad hoc self-reports developed for specific substances) (López-Goñi, Fernández-Montalvo, & Arteaga, Reference López-Goñi, Fernández-Montalvo and Arteaga2012b) and the establishment of specific, empirically validated treatment programs (Fernández-Montalvo, López-Goñi, Illescas, Landa, & Lorea, Reference Fernández-Montalvo, López-Goñi, Illescas, Landa and Lorea2008; Secades & Fernández-Hermida, Reference Secades, Fernández-Hermida, Pérez, Fernández-Hermida, Fernández and Amigo2003). In the social and educational fields, which are closely related to the study of addictive behaviors, this change in addiction knowledge has also been important, as highlighted by prevention programs aimed at at-risk adolescents and the development of universal prevention programs in the educational field (National Institute on Drug Abuse, 2003).
To continue this progress, a major challenge for the coming years is to establish specific patient profiles corresponding to the drug of abuse. Beyond the characteristics common to all addicts, it is important to know the specific profiles of consumers of different substances. This knowledge will allow for the tailoring of currently available treatments to the specific problems presented by addicted patients when they come to a clinical centre.
In Spain, the main demand for treatment in addicted patients is related to alcohol and cocaine problems. According to the latest data from the Spanish Observatory on Drug-Addiction (Observatorio Español de la Droga y las Toxicomanías, 2011), alcohol is the most commonly used drug in the country, and abuse of cocaine creates the most demand for treatment. Consequently, alcoholics and cocaine addicts make up the majority of patients who demand therapeutic assistance in Spanish clinical settings. For example, in recent studies of addicted patients in clinical settings in Spain, between 35% and 45% of patients were alcoholics, and between 45% and 60% were cocaine addicts (Arias et al., Reference Arias, Szerman, Vega, Mesías, Basurte, Morant and Babín2013; Arteaga, Fernández-Montalvo, & López-Goñi, Reference Arteaga, Fernández-Montalvo and López-Goñi2012; Asociación Proyecto Hombre, 2013; Fernández-Montalvo, López-Goñi, & Arteaga, Reference Fernández-Montalvo, López-Goñi and Arteaga2012a, Reference Fernández-Montalvo, López-Goñi and Arteaga2012b; Fernández-Montalvo, López-Goñi, Arteaga, & Cacho, 2013; López-Goñi, Fernández-Montalvo, & Arteaga, Reference López-Goñi, Fernández-Montalvo and Arteaga2012a). In these same studies, only approximately 15% of treated patients abused other substances.
To address these addiction problems, Spanish addiction treatment centers tend to use standard treatment regimens. The treatment programs are empirically validated according to the criteria established by the scientific community (Secades & Fernández-Hermida, Reference Secades, Fernández-Hermida, Pérez, Fernández-Hermida, Fernández and Amigo2003). However, despite the essential need to adapt existing treatments to the specific characteristics of the patients, in Spain, few studies have specifically analyzed the clinical differences between patients seeking treatment for problems with alcohol or cocaine, the two most widely used substances (Araque, De los Riscos, De la Casa, & López-Torrecillas, 2004; Sánchez-Hervás, Tomás, & Morales, Reference Sánchez-Hervás, Tomás and Morales2001). Knowledge of the specific and differential characteristics of clinical patients with alcohol or cocaine dependence allows for treatments tailored to the patients’ specific needs.
In this way, the main objectives of the current study were to determine the characteristics of a sample of addicted patients undergoing treatment and determine whether their profiles differed depending on the drug of consumption: alcohol or cocaine. To achieve these objectives, a group of alcoholics entering outpatient treatment was compared with a group of cocaine addicts in terms of various socio-demographic, consumption, psychopathological and adjustment variables. Based on the literature, the main hypothesis of this study was that alcoholics would be older and would present a more severe substance abuse profile, with more psychological and maladjustment consequences of their addictive behavior. In contrast, cocaine addicts would be younger and would be better adjusted to daily life.
Method
The protocol for this study was approved by the ethics committees of the Public University of Navarra and of the Fundación Proyecto Hombre de Navarra.
Participants
The initial sample consisted of 285 consecutive addicted patients who sought outpatient treatment at the Proyecto Hombre Addiction Treatment Program in Pamplona, Spain, from October 2010 to July 2012. This was a cognitive-behavioral intervention on an individual outpatient basis, aimed at abstinence, and it is not required to pay for treatment. The main therapeutic techniques were related to stimulus control and in vivo exposure, as well as relapse prevention. During the first 6 months the treatment included weekly sessions (45–60 minutes); during the last 6 months sessions were biweekly. Successful program completion typically requires approximately 12 months and is achieved when a patient completes all therapeutic sessions.
The patients had to meet the following admission criteria: (a) meet the diagnostic criteria of alcohol or cocaine dependence according to the DSM-IV-TR (American Psychiatric Association, 2000); (b) be between 18 and 65 years old; (c) give their informed consent to participate in the study; and (d) complete the three assessment sessions.
Fifty-one (17.9%) of the 285 initial subjects did not meet the criteria mentioned above. Therefore, the final sample was composed by 234 subjects (109 alcoholics and 125 cocaine addicts). This is a convenience sample, but representative of Spanish substance abusers in outpatient treatment (Observatorio Español de la Droga y las Toxicomanías, 2011). The mean age of the individuals included in the study was 37.8 years (SD = 9.4); the sample included 189 (80.8%) men and 45 (19.2%) women. The socioeconomic level was middle to lower-middle class.
Assessment
The EuropAsi (Kokkevi & Hartgers, Reference Kokkevi and Hartgers1995) is the European version of the Addiction Severity Index (McLellan, Luborsky, Woody, & O´Brien, Reference McLellan, Luborsky, Woody and O´Brien1980). This measure, which has an interview format, yields two types of scores: the Interviewer Severity Ratings (ISR) and the Composite Scores (CS). The ISR assess the need for treatment in the following seven areas: (a) general medical state; (b) labor and economic situation; (c) drug consumption; (d) alcohol consumption; (e) legal problems; (f) family and social relationships; and (g) psychiatric state. Severity scores range from 0 (no problem) to 9 (extreme problem) in each area, and the cut-off score for each area is 4. These areas are directly related to the severity of consumption (López-Goñi et al., Reference López-Goñi, Fernández-Montalvo, Menéndez, Yudego, García and Esarte2010). In this study, we also used the Composite Scores (CS) of the EuropASI. The CS were developed for research purposes; they are arithmetically based indicators of current (last 30 days) problem severity that range between 0.00–1.00, with higher values denoting higher degrees of severity. They assess the following nine areas: (a) general medical state; (b) economic situation; (c) labor satisfaction; (d) alcohol consumption; (e) drug consumption; (f) legal problems; (g) family relationships; (h) social relationships; and (i) psychiatric state. For the current study, the CS were calculated according to the method proposed by Koeter and Hartgers (Koeter & Hartgers, Reference Koeter and Hartgers1997). The Spanish version of the EuropAsi was developed by Bobes, González, Sáiz, and Bousoño (Reference Bobes, González, Saiz and Bousoño1996). In this study, both the ISR and CS were used because they offer complementary information (López-Goñi et al., Reference López-Goñi, Fernández-Montalvo and Arteaga2012b).
Moreover, in this study, certain items of the EuropASI were used to obtain specific information about the presence of psychopathological problems in the sample (Psychiatric scale items 3, 4, 6, 7, 9, 10). Other items indicated the patients’ level of adjustment in different areas: family and social relationships (Family and social scale items 10b-18b), labor situation (Employment and support scale item 8, 19, 20) and history of abuse (Family and social scale items 18A-18C).
The Symptom Checklist-90-Revised (SCL-90-R, Derogatis, Reference Derogatis1992; Spanish version by González de Rivera, Reference González de Rivera2002) is a self-administered general psychopathological assessment questionnaire. It consists of 90 questions that are answered on a 5-point Likert-type scale, ranging from 0 (none) to 4 (very much). The questionnaire aims to assess the respondent’s psychiatric symptoms. The SCL-90-R has been shown to be sensitive to therapeutic change and thus may be used for either single or repeated assessments. The SCL-90-R measures nine areas of primary symptoms: somatisation, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation and psychoticism. It also provides three indices that reflect the subject’s overall level of symptom severity. The internal consistency of the measure ranges from .70 to .90.
The Millon Clinical Multiaxial Inventory (MCMI-II; Millon, Reference Millon1997; Spanish version of Millon & Avila, Reference Millon and Ávila1998) is a self-report questionnaire with 175 true/false items. It was designed to identify clinical states and personality disorders that are similar to those referenced in the DSM-IV-TR. The MCMI-II contains ten basic personality scales: (1) Schizoid; (2) Phobic; (3) Dependent; (4) Histrionic; (5) Narcissistic; (6) Antisocial; (7) Aggressive/sadistic; (8) Compulsive; (9) Passive-aggressive; and (10) Self-destructive. In addition to the basic personality scales, there are three pathological personality scales: Schizotypal (S), Borderline (B) and Paranoid (P). The nine symptom scales of the MCMI-II were not taken into account in this study as they are not relevant to the purposes of our research. The internal consistency of the measure ranges from .66 to .89.
Procedure
Once the clinical sample was selected using the previously described criteria, the assessment of the sample was carried out in three sessions before beginning the treatment. Each session took place once a week for three weeks; the time interval between sessions was the same for each participant. The subjects were interviewed by clinical psychologists who had eight or more years of experience in treating addictions and in applying the assessment tools used in this study. In the first session, data related to socio-demographic characteristics and drug consumption were collected using the EuropASI. The ISRs were calculated according to the 2-step methodology suggested by Bobes et al. (Reference Bobes, Bascarán, Bobes-Bascarán, Carballo, Díaz, Flórez and Sáiz2008). In the second session, the presence of psychopathological symptoms was assessed using the SCL-90-R. Finally, in the third session, the personality characteristics were assessed using the MCMI-II. Because the combination of different substances is common in addicted patients, the group membership of each patient was determined according to the main substance that motivated the search for treatment (assessed by the EuropASI), together with the therapist opinion. After the assessment sessions, patients began the standard treatment provided by Proyecto Hombre for addiction.
Data analysis
Descriptive analyses were conducted for all variables. Bivariate analyses were employed using χ2 or t-test statistics, depending on the nature of the variables studied. Regarding multivariate analysis, a logistic regression analysis (forward method) was conducted to determine which specific factors were more relevant in differentiating between the groups studied. This analysis used the following models: (1) socio-demographic and consumption; (2) severity of addiction; and (3) clinical variables. A difference of p ≤ .05 was considered significant. Statistical analyses were conducted using SPSS (version 15.0 for Windows).
Results
Comparison of socio-demographic and consumption variables
The comparison between alcoholics and cocaine addicts on socio-demographic characteristics showed statistically significant differences for all variables studied (Table 1). Cocaine addicts were younger than alcoholics and were more likely to be male. Regarding marital status, cocaine abuse patients were more likely to be single, and with regard to employment, they were more likely to be occupationally active compared to alcoholics.
Comparisons of socio-demographic and drug abuse characteristics
Note: *p ≤ .05; **p ≤ .01; ***p ≤ .001.
Regarding drug abuse characteristics, cocaine addicts were more likely to show poly-dependence than alcoholics, whereas alcoholics presented a higher frequency of daily consumption.
Comparison of severity of addiction
The severity of each patient’s addiction was evaluated using the EuropAsi (Table 2). The patients who were receiving treatment for alcoholism presented with greater addiction severity than cocaine addicts in five of the seven areas scored by an interviewer: medical, employment/support, alcohol use, family/social and psychiatric. In contrast, cocaine patients presented with greater severity in terms of drug use and legal status. When composite scores were taken into account, alcoholics showed a more severe economic situation. Moreover, as expected, alcoholics showed a higher severity in the alcohol area and cocaine addicts in the drug use area.
Comparisons of drug addiction severity variables
Note: CS = Composite Scores. ISR = Interviewer Severity Ratings.
* p ≤ .05; **p ≤ .01; ***p < .001.
Comparison of clinical variables
The entire sample showed moderately high scores on the SCL-90-R (approximately 60th percentile) used to assess psychopathological symptoms (Table 3). There were significant differences between the two patient groups on two general scales (GSI and PSDI) and in two specific dimensions (depression and psychoticism). In all cases, alcoholics had higher scores than cocaine patients.
Comparisons of clinical variables
Note: *p ≤ .05; **p ≤ .01; ***p ≤ .001.
In comparison with cocaine abuse patients, alcoholics also had significantly higher Millon Clinical Multiaxial Inventory II (MCM-II) scores on six scales: Schizoid, Phobic, Compulsive, Self-destructive, Schizotypal and Paranoid.
Comparison of maladjustment variables
Regarding maladjustment variables, the whole sample presented with important repercussions in the areas studied. Comparison between groups showed several differences regarding various adaptation variables (Table 4): problems with siblings (more frequent in alcoholics), problems with intimate friends (more frequent in cocaine addicts), labor problems (mainly in alcoholics), debts due to consumption (more frequent in cocaine addicts), and severity of psychological symptoms (more depressive and anxiety problems in alcoholics; more hallucinations in cocaine addicts).
Comparisons of maladjustment variables
Note: *p ≤ .05; **p ≤ .01; ***p ≤ .001.
Multivariate analysis
The results from logistic regression analysis showed that model 2 (related to severity of addiction) was the model that explained a higher percentage of the variance (adjusted R 2 = .837). Specifically, the variables introduced by the model were ISR alcohol, ISR drugs and CS economic. These three variables correctly classified 90.1% of cases.
Multivariate analysis (final models)
Note: Substance is the dependent variable (0 = Alcohol; 1 = Cocaine).
Adj. = Adjusted; Ed. = Education; C. classified = Correctly classified; PSDI = Positive Symptom Distress Index.
* p ≤ .05; **p ≤ .01; ***p < .001.
In contrast, model 1 (related to socio-demographic and consumption variables) correctly classified 84.1% of the cases, and model 3 (related to clinical variables) correctly classified 64.5% of the cases.
When logistic regression analyses were carried out separately with men and women, model 2 was the model that correctly classified the higher rate of cases.
Discussion
In this study, the profiles of patients addicted to alcohol and cocaine who seek treatment were analyzed and compared. Abuses of these two substances are the two main drug problems in Spain (Observatorio Español de la Droga y las Toxicomanías, 2011). The goal of this study was to identify the different characteristics of both types of patients so that the existing treatment programs may be adapted to the specific problems presented by the patients. The results obtained revealed the existence of significant differences between the two groups of addicted patients. These differences were observed in terms of socio-demographic, psychopathological and adjustment variables.
From a socio-demographic perspective, there were clear differences between the two groups of patients. Alcoholics were older (by more than 10 years), with more family impact (higher divorce rate) and labor impact (lower percentage of employment), and with more continuous consumption (daily, in most cases). For cocaine addicts, patients were younger, more likely to be single, employed with a paid job that allowed them to afford cocaine consumption, and showed less frequent consumption that was more focused on the weekends, most likely associated with leisure situations. An important finding to note is that poly-dependence was significantly higher in cocaine addicts. These data are consistent with the profiles found in other studies conducted in recent years (Asociación Proyecto Hombre, 2013; Observatorio Español de la Droga y las Toxicomanías, 2011).
Regarding addiction severity, the results for the EuropAsi variables were in the same direction. Alcoholics showed more severity in terms of medical status, employment situation, family and social relationships, and psychiatric state. Alternatively, cocaine addicts obtained higher scores in terms of general drug use and legal situation. These results are most likely related to socio-demographic differences. The profile of an alcoholic is that of an older person with more years of consumption and, consequently, with greater repercussions for daily life (Hatton et al., Reference Hatton, Burton, Nash, Munn, Burgoyne and Sheron2009). The results on the SCL-90-R and MCMI-II supported this same idea, with significantly more psychopathological problems in alcoholics. These results are similar to those obtained in other studies (Bravo de Medina, Echeburúa, & Aizpiri, 2007).
The data related to maladjustment variables also showed significant differences when comparing alcoholics to cocaine addicts, with the profile generally worse in alcoholics except for a few variables directly related to cocaine consumption. Specifically, debts due to consumption and the presence of hallucinations were variables more frequently observed in cocaine addicts.
On the other hand, results of the multivariate analysis carried out showed that variables related to severity of the addiction were the main predictors of belonging to alcoholics group or cocaine addicts group. Similar results were found when men and women were analyzed separately. According to these results, the specific dependence of a substance seems to be the most relevant variable to predict the belonging group, in both men and women. Anyway, gender differences in addiction have recently shown to be an important variable to take into account when studying and treating substance dependent patients (Fernández-Montalvo, López-Goñi, Azanza, & Cacho, Reference Fernández-Montalvo, López-Goñi, Azanza and Cacho2014).
Therefore, according to these results, treatment programs for alcoholism should consider, beyond the drinking itself, the problems observed in other areas of daily life for these patients. Inattention to these aspects of life (family, social, occupational, medical, etc.) could decisively influence the recovery of these patients and increase their relapse rates (Bodin & Romelsjo, Reference Bodin and Romelsjo2007; Echeburúa, Bravo de Medina, & Aizpiri, 2008 ). In addition to immediate alcohol consumption, factors that maintain long-term consumption must be addressed. Appropriate social, familiar, labor and medical support during the treatment process may help the recovery of these patients. In contrast, patients addicted to cocaine show better adjustment to everyday life (McKay et al., Reference McKay, Van Horn, Rennert, Drapkin, Ivey and Koppenhaver2013), and their problems seem to be more focused on the immediate impact directly related to consumption. Consequently, intervention should focus on the factors that encourage short-term consumption, mainly during the leisure period on the weekend. In both cases, situational elements appear more important than personality dimensions or psychopathological characteristics in establishing the type of treatment that could be more adequate for drug-addicted patients. This generates a therapeutic optimism and encouragement to carefully design individually-tailored strategies to improve treatment results. For example, as it has been highlighted by Tryon and Winograd (Reference Tryon and Winograd2011), better outcomes can be expected when patients and therapist agree on therapeutic goals and the processes to achieve these goals, according to real needs of patients.
Several limitations of the present study must be taken into consideration. The first is related to the sample that was evaluated. Although our study included a relatively large sample of patients who were being treated for drug abuse, only 19.2% of the sample were women. There are reasons to believe that women who suffer from drug addictions have different problems from those of addicted men. Moreover, the present study only included patients who completed the assessment; patients who did not complete the three assessment sessions were not considered. We assume that patients who withdraw from a treatment program at an early stage have different profiles from those of the patients who were analyzed in this study. For all of these reasons, we must be cautious when attempting to generalize our results. Moreover, in this study psychopathological symptoms have been evaluated with a self-report (the SCL-90-R). Due to the importance of these types of symptoms, it would be interesting to assess them with a structured interview in future studies.
In conclusion, the results of this study show that patients with alcohol dependence and cocaine dependence have different profiles, with different repercussions for important areas of life. Consequently, these differences should be taken into account when standard treatments for addiction are implemented. Addressing these factors is likely to be the best way to improve the effectiveness of the interventions and to decrease the rate of dropouts and relapses.
This study was supported by a grant (Res. 359/2012) from Departamento de Salud del Gobierno de Navarra (Spain). The authors thank the “Proyecto Hombre de Navarra” programme staff for their help in assessing the clinical sample.
