Best Treatment for Violence With Pcp Intoxication?

Outpatient Treatment of PCP Abusers

Phencyclidine (PCP) abuse is a persistent public health problem in many urban areas of the United States, with recent trends suggesting an increase of abuse after a period of decline[1]. Despite this increase, most clinical and research attention centers on acute or subacute PCP intoxication, especially the organic mental disorders (toxic delirium, psychosis, or depression) that PCP can induce[2, 3]. Discussion of chronic PCP use and the clinical characterization and treatment of chronic PCP abusers are rare, even in detailed review articles[4, 5].

We are aware of only one published study of outpatient treatment for PCP abusers. That study reviewed clinical experience with 158 patients (73% male) seeking treatment from a private clinic[6]. No data on treatment outcome are given. However, it was noted that the patients’ strong psychological dependence on PCP made treatment difficult.

This study reports our experience with an outpatient treatment program for PCP abusers, including data on the characteristics of patients and their treatment outcome.

METHODS

Subjects. Subjects were 37 unselected male patients who sought outpatient treatment for PCP abuse at the Brentwood Division, West Los Angeles VA Medical Center over a 38-month period and then attended at least one treatment session. All subjects were PCP abusers, defined by DSM-III criteria[7] applied to the clinical history obtained from the admission interviews, plus review of past medical records (if any). Referral sources included self-referral (54.0%), another hospital program (8.1%), family or friend (5.4%), employer (5.4%), and the criminal justice system (probation, parole, or court) (27.0%).

Treatment program. The treatment approach was supportive, behavioral, and educational, with primary goals of eliminating drug-seeking and drug-taking behavior, and increasing problem-solving skills. All patients attended a weekly therapy group for PCP abusers, and were also encouraged to attend community 12-step meetings. Individual supportive counseling was available on request; formal long-term psychotherapy was not offered. Vocational and nutritional counseling and recreational and occupational therapy activities were available upon physician referral.

The only requirement for remaining in treatment was active participation, operationally defined as no more than two unexcused absences in a row. Attending a session behaviorally intoxicated was considered an absence. Patients were encouraged to be honest about their drug use, and were not discharged for drug use per se. A weekly urine sample for PCP assay and drug screen was collected under direct observation at each weekly group therapy session in order to monitor subjects’ drug use. However, patients were not automatically discharged from the group because of a positive urine test.

Urine assays. Urine samples were refrigerated within 4 hours of collection and assayed within 4 days. PCP assays were performed in the hospital’s Clinical Psychopharmacology Unit, using gas chromatography with nitrogen/phosphorus detection after PCP was extracted from the raw samples by octodeoxylsulfate column extraction and liquid/liquid back-extraction[8]. False positive results due to common known interfering substances such as diphenhydramine were avoided by adjusting assay parameters. Periodic checks were conducted to test authenticity of PCP samples by gas chromatography/mass spectrography. Assay sensitivity was 0.1 ng/mL, intraassay variability was 3%, and interassay variability was 5%.

Statistical analysis. Comparisons between subject groups were done by t-test for continuous variables and chi-square test for categorical variables. All tests were 2-tailed, with significance level set at .05. Multivariate analyses to predict treatment outcome variables from subject characteristics were done by step-wise multiple linear regression using the BMDP computer program package[9], with F-to-enter set at 4.0 and F-to-remove at 3.9. In order to have a ratio of at least 5 subjects per independent variable, only 7 subject characteristics were used in the analyses: age, education level, number of arrests, number of prior drug abuse treatments, frequency of PCP use (in ordinal numerical code), duration of PCP use, and number of group meetings attended.

RESULTS

Subject Characteristics

The mean age of subjects was 32.4 years (range 22-62); 27 (73.0%) were Black, 7 (18.9%) Hispanic, and 3 (8.1%) White. Twelve subjects (32.4%) were never married, 7 (18.9%) were currently married, 9 (24.3%) divorced, 8 (21.6%) separated, and 1 (2.7%) widowed. A majority of patients (67.6%) were unemployed at the time of admission. The educational level averaged 12.4 years (range 4-16) of schooling, with 31 (84%) patients being high school graduates, and only one a college graduate. In the 24 months prior to admission, two-thirds (25) of the patients had been arrested at least once, with 35% (13) being arrested 2 to 5 times.

This was the first drug treatment program for about two-thirds (25) of the patients. Eight (21.6%) had one prior treatment admission (21.6%), 3 (8.1%) had two prior admissions, and 1 (2.7%) had three prior drug treatment admissions. Of those patients previously admitted to a drug treatment program, 9 had been in treatment within the past year.

PCP was the only drug abused for 24% of the patients. The remainder also abused other drugs, chiefly alcohol, marijuana, and (free-base) cocaine. At the time of admission, 14 (38%) patients were using PCP at least daily, another 17 (46%) at least weekly, and 3 (8%) less than once a week. Three (8%) patients denied using any PCP in the month prior to admission. Duration of PCP use averaged 7.2 years (range 3-15). All subjects’ route of administration of PCP was smoking.

PCP Effects

There was frequent group consensus on the psychological effects of PCP and motivations for its use. The two main psychological effects often cited as maintaining PCP use were the feelings of strength, power, and invulnerability it engendered; and a psychic numbing that was used to self-medicate dysphoric affects, especially anger and rage (“I use PCP because I want to forget”). Some subjects were attracted by the challenge of the risk in using PCP, i.e., not knowing what would happen. Three types of acute intoxication responses were described: stimulation, depression, and hallucinogenic. Many subjects reported being able to predict which response they would have by the concentration of the PCP that they used. Almost all subjects had had religious experiences while intoxicated: feelings of meeting God, impending death, etc.

Treatment Outcome

Subjects were in the therapy program for an average of 21 weeks (range 1-155). They attended an average of 68.4% of the group meetings (range 25-100%), with 9 subjects (24%) attending all scheduled meetings during their time in the program. Four subjects (11%) attended only one group meeting; another 17 subjects (46%) attended only 2-4 meetings. Subjects gave urine samples showing presence of PCP an average of 78% of the time (range 0-100%). According to verbal self-report, PCP use occurred before only 28.6% of the group meetings.