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Director's Report to the National Advisory Council on Drug Abuse - February, 2008

Research Findings - Services Research

Interim Methadone Maintenance Superior to Waitlisting in Enrollment, Retention, and Opaite Use

This study compares interim methadone maintenance (IM) to sample not offered methadone. Both groups were waitlisted for opiate treatment program (OTP) enrollment. As defined by US federal regulations, IM provides observed methadone dosing and emergency counseling only for a maximum of 120 days. Three hundred and nineteen individuals enrolled on an OTP waiting list were randomly assigned on a 3:2 basis to either IM or waiting list control. Outcomes were measured at OTP entry (or at 4 months from baseline for those who did not enter treatment), and 6 months thereafter. At the second follow-up, 129 (64.8%) of the IM participants reported being enrolled in an OTP, versus 33 (27.5%) of the controls, p < .001. Significant treatment condition_time interaction effects occurred for heroin and cocaine use (both p's < .001) and the ASI Legal composite score (p < .001). Moreover, a significant difference occurred between conditions at the second follow-up for heroin-positive drug tests (interim 48.1% versus control 72.3%, p = .001) but not for cocaine-positive drug tests. At 10 months after study enrollment, there are sustained benefits of IM as compared to waiting list in terms of increased treatment entry and reduced heroin use and criminal behavior. Schwartz, R.P., Jaffe, J.H., Highfield, D.A., Callaman, J.M., and O'Grady, K.E. A Randomized Controlled Trial of Interim Methadone Maintenance: 10-Month follow-up. Drug Alcohol Depend., 86 pp. 30-36, 2007.

Concurrent Drug and Alcohol Use in National Sample

This study estimates the prevalence, assesses predictors and evaluates factors associated with concurrent and simultaneous use of drugs and alcohol in the United States population. Using data from the 2000 National Alcohol Survey (n=7612), respondents were asked if they used specific drugs in the last 12 months. Current drinkers who reported using each type of drug were asked if they used alcohol and the drug at the same time. Approximately 10% reported using marijuana in the last 12 months (concurrent use); 7% reported drinking alcohol and using marijuana at the same time (simultaneous use). Approximately 5% of current drinkers reported using drugs other than marijuana in the last 12 months; 1.7% reported drinking alcohol and using drugs other than marijuana at the same time. Being younger, having less than a high school education, not having a regular partner and having heavier drinking patterns were associated with using alcohol and marijuana simultaneously. Simultaneous use of marijuana and alcohol as well as other drugs and alcohol were significantly related to social consequences, alcohol dependence, and depression. These results mirror clinical populations in which increasingly younger clients report use of alcohol and drugs and need treatment for both. Midanik, L., Tam, T., and Weisner, C. Concurrent and Simultaneous Drug and Alcohol Use: Results of the 2000 National Alcohol Survey. Drug Alcohol Depend., 90(1), pp. 72-80, 2007.

Prescription Opiate Misuse

Prescription opiate misuse is a major public health issue, especially in rural areas. The purpose of this analysis was to examine trends in prescription opiate misuse over time in a cohort of community-based rural probationers. Participants (N=800), recruited over a four-year period, were divided into cohorts according to the year in which they were interviewed. Prescription opiate misuse increased significantly between 2001 and 2004 (p<0.001). After adjustment for changes in demographic characteristics of the cohorts, misuse of prescription opiates was still significantly greater in 2004 compared with 2001. These data suggest changes in drug use patterns among community-based rural probationers from street to prescription drugs. Implications of the findings are discussed. Havens, J., Oser, C., and Leukefeld, C. Increasing Prevalence of Prescription Opiate Misuse Over Time Among Rural Probationers. J. Opioid Manag., 3, pp. 107-111, 2007.

Increase in the Prevalence of Prescription Drug Use Disorders in the United States

The purpose of this study was to examine changes in the prevalence of non-medical prescription drug use and DSM-IV non-medical prescription abuse and dependence in the United States between 1991-1992 and 2001-2002. The authors compared the prevalence of past-year non-medical prescription drug use and drug use disorders in the total sample and among lifetime non-medical users in two large national surveys conducted 10 years apart (NLAES and NESARC). From 1991-1992 to 2001-2002, the prevalence of DSM-IV non-medical prescription drug use increased by 53%, from 1.5% to 2.3% (p<0.001), and the prevalence of drug use disorders increased by 67% from 0.3% to 0.5% (p<0.001). The conditional prevalence of a disorder among users increased numerically from 19.9% to 23.6%, but this increase was not statistically significant (p=0.15). The authors concluded that there have been substantial increases in the prevalence of prescription drug non-medical use and prescription drug use disorders in the United States. Given the clinical utility of prescription drugs, they noted that urgent action is needed to find approaches that balance the need for access to these medications among those who need them, against their potential for abuse and dependence in subgroups of vulnerable individuals. Blanco, C., Alderson, D., Ogburn, E., Grant, B., Nunes, E., Hatzenbuehler, M., and Hasin, D. Changes In the Prevalence of Non-Medical Prescription Drug Use and Drug Use Disorders in the United States: 1991-1992 and 2001-2002. Drug Alcohol Depend., 90(2-3), pp. 252-260, 2007.

A Randomized Clinical Trial of Methadone Maintenance for Prisoners: Results at 1-Month Post-Release

Despite its effectiveness, methadone maintenance is rarely provided in American correctional facilities. This study is the first randomized clinical trial in the US to examine the effectiveness of methadone maintenance treatment provided to prisoners with pre-incarceration heroin addiction. A three-group randomized controlled trial was conducted between September 2003 and June 2005. Two hundred eleven Baltimore pre-release inmates who were heroin dependent during the year prior to incarceration were enrolled in this study. Participants were randomly assigned to the following: counseling only: counseling in prison, with passive referral to treatment upon release (n=70); counseling+transfer: counseling in prison with transfer to methadone maintenance treatment upon release (n=70); and counseling+methadone: methadone maintenance and counseling in prison, continued in a community-based methadone maintenance program upon release (n=71). Two hundred participants were located for follow-up interviews and included in the current analysis. The percentages of participants in each condition that entered community-based treatment were, respectively, counseling only 7.8%, counseling+transfer 50.0%, and counseling+methadone 68.6%, p<.05. All pairwise comparisons were statistically significant (all ps<.05). The percentage of participants in each condition that tested positive for opioids at 1-month post-release were, respectively, counseling only 62.9%, counseling+transfer 41.0%, and counseling+methadone 27.6%, p<.05, with the counseling only group significantly more likely to test positive than the counseling+methadone group. Methadone maintenance initiated prior to or immediately after release from prison appears to have beneficial short-term impact on community treatment entry and heroin use. This intervention may be able to fill an urgent treatment need for prisoners with heroin addiction histories. Kinlock, T., Gordon, M., Schwartz, R., O'Grady, K., Fitzgerald, T., and Wilson, M. A Randomized Clinical Trial of Methadone Maintenance for Prisoners: Results at 1-Month Post-Release. Drug Alcohol Depend., 91, pp. 220-227, 2007.

HIV Treatment: A Simulation Model

In recent studies, subjects who had achieved suppression of the human immunodeficiency virus (HIV) RNA level while receiving an initial 3-drug antiretroviral regimen successfully maintained suppression while receiving treatment with a "boosted" protease inhibitor (PI) alone. The long-term outcomes of this treatment simplification strategy were projected to inform the design of a proposed multi-center, randomized clinical trial. Published studies were used to estimate the efficacy, adverse effects, and cost of a sequence of HIV drug regimens for the simplification strategy, compared with those outcomes for the current standard-of-care (SOC) strategy. Using a published simulation model of HIV disease, researchers projected life expectancy, discounted quality-adjusted life expectancy (QALE), and discounted lifetime medical costs for each strategy. Results showed that subjects who have not developed PI-resistant HIV infection at the time of failure of the simplification regimen have a greater life expectancy (27.9 vs. 27.1 years) and QALE (14.9 vs. 14.7 years), compared with SOC subjects, because they receive an additional line of therapy without negative consequences for future treatment options. The QALE for the simplification strategy remains higher than that for the SOC, unless a large proportion of patients experiencing virologic failure while receiving the simplification regimen develop PI resistance. Depending on the probability of simplification regimen failure, the advantage is maintained even if HIV develops PI resistance in 42%-70% of subjects. Projected lifetime costs are $26,500-$72,400 per person lower for the simplification strategy than for the SOC strategy. An HIV treatment simplification strategy involving use of a boosted PI alone may lead to longer survival overall at lower cost, compared with the SOC combination therapy, because the simplification strategy potentially adds an additional line of therapy. The risk of emergence of PI resistance during treatment with a simplified regimen is a critical determinant of the viability of this strategy. Schackman, B., Scott, C., Sax, P., Losina, E., Wilkin, T., McKinnon, J., Swindells, S., Weinstein, M., and Freedberg, K. Potential Risks and Benefits of HIV Treatment Simplification: A Simulation Model of a Proposed Clinical Trial. Clin. Infect. Dis., 45(8), pp. 1062-1070, 2007.

DAART Superior to Self-Administered Therapy for HIV+ Drug Users

Directly administered antiretroviral therapy (DAART) is one approach to improve treatment adherence among human immunodeficiency virus (HIV)-infected drug users. In this randomized, controlled trial ( identifier, NCT00367172), the biological outcomes of a 6-month community intervention of DAART were compared with those of self-administered therapy among HIV-infected drug users. Patients randomized to receive DAART received supervised therapy 5 days per week from workers in a mobile health care van. The primary outcome, using an intention-to-treat approach, was the proportion of patients achieving either a reduction in HIV-1 RNA level of > or = 1.0 log10 copies/mL or an HIV-1 RNA level < or = 400 copies/mL at 6 months. Secondary outcomes included the mean change from baseline in HIV-1 RNA level and CD4+ T lymphocyte count. Of the 141 patients who met the entry criteria, 88 were randomized to receive DAART, and 53 were randomized to receive self-administered therapy; 74 (84%) of 88 of the patients randomized to receive DAART accepted the intervention. Of the 74 patients who initiated DAART, 51 (69%) completed the full 6-month intervention. At the end of 6 months, a significantly greater proportion of the DAART group achieved the primary outcome (70.5% vs. 54.7; P=.02). Additionally, compared with patients receiving self-administered therapy, patients receiving DAART demonstrated a significantly greater mean reduction in HIV-1 RNA level (-1.16 log10 copies/mL vs. -0.29 log10 copies/mL; P=.03) and mean increase in CD4+ T lymphocyte count (+58.8 cells/microL vs. -24.0 cells/microL; P=.002). This randomized, controlled trial was, to the authors' knowledge, the first to demonstrate the effectiveness of DAART at improving 6-month virologic outcomes among drug users. These results suggest that DAART should be more widely available in HIV treatment programs that target drug users who have poor adherence to treatment. Altice, F., Maru, D., Bruce, R., Springer, S., and Friedland, G. Superiority of Directly Administered Antiretroviral Therapy Over Self-Administered Therapy Among HIV-infected Drug Users: A Prospective, Randomized, Controlled Trial. Clin. Infect. Dis., 45(6), pp. 770-778, 2007.

HIV Treatment Access for IDUs in Ukraine

Injection drug use (IDU) accounts for 70 percent of HIV cases in Ukraine. Until buprenorphine maintenance therapy (BMT) was introduced, few effective strategies aimed at achieving reduction in illicit drug use were available as a conduit to anti-retroviral therapy (ARV) among IDUs. In October 2005, BMT was scaled-up using Global Fund resources in six regions within Ukraine. Entry criteria included opioid dependence, HIV-1 seropositivity, age >or=18 years and reported interest in BMT. All sites included a multidisciplinary team. To date, 207 patients have been initiated on BMT. The existing infrastructure allows for further scale-up of and administration of BMT and the possibility of co-administration with ARV. The process for prescription and administration of buprenorphine and ARV is at times cumbersome and constrained by current regulations. More IDU need BMT to improve overall health outcomes. Central to expanding access will be legislative changes to existing drug policy. Moreover, the cost of buprenorphine is prohibitively expensive. Sustainable substitution therapy in Ukraine requires lower negotiated prices for buprenorphine, the addition of methadone, or both to the existing formulary for HIV+ drug users. Bruce, R., Dvoryak, S., Sylla, L., Altice, F. HIV Treatment Access and Scale-Up for Delivery of Opiate Substitution Therapy with Buprenorphine for IDUs in Ukraine: Programme Description and Policy Implications. Int. J. Drug Policy,18, pp. 326-328, 2007.

HIV/AIDS, TB and Drug Treatment Services

Injection drug use (IDU) plays a critical role in the HIV epidemic in several countries throughout the world. In these countries, injection drug users are at significant risk for both HIV and tuberculosis, and active IDU negatively impacts treatment access, adherence and retention. Comprehensive strategies are therefore needed to effectively deliver preventive, diagnostic and curative services to these complex patient populations. The researchers propose that developing co-located integrated care delivery systems should become the focus of national programmes as they continue to scale-up access to antiretroviral medications for drug users. Existing data suggest that such a programme will expand services for each of these diseases; increase detection of tuberculosis (TB) and HIV; improve medication adherence; increase entry into substance use treatment; decrease the likelihood of adverse drug events; and improve the effectiveness of prevention interventions. Key aspects of integration programmes include: co-location of services convenient to the patient; provision of effective substance use treatment, including pharmacotherapies; cross-training of generalist and specialist care providers; and provision of enhanced monitoring of drug-drug interactions and adverse side effects. Central to implementing this agenda will be fostering the political will to fund infrastructure and service delivery, expanding street-level outreach to IDUs, and training community health workers capable of cost effectively delivering these services. Sylla, L., Bruce, R., Kamarulzaman, A., and Altice, F. Integration and Co-Location of HIV/AIDS, Tuberculosis and Drug Treatment Services. Int. J. Drug Policy, 18(4), pp. 306-312, 2007.

Specialized Prisons and Services Results From a National Survey

The National Criminal Justice Treatment Practices Survey conducted a national survey of correctional and community-corrections institutions, to describe the types of services provided, as part of the National Criminal Justice Drug Abuse Treatment Studies (CJDATS). Responses from wardens or administrators of adult correctional institutions were examined to describe services provided by three types of prisons: those that serve a cross-section of offenders, those that specialize in serving offenders with special psychosocial and medical needs, and those that specialize in serving legal status or gender specific populations. These data present a current snapshot of the types of specialized prisons, services available, and the proportions of offenders who access these services. Nationally about 12% of prisons are considered specialized, and these institutions were over-sampled. About half of the surveyed prisons were considered specialized and this group was divided into service-oriented (psychosocial: substance abuse, mental health and medical) and more functional population specialization (other) related to structural and process aspects of incarceration (e.g., reception, parole violators, youth, females, and work release). Most prisons report a surprising overall number and types of services (including assessment and treatment services) offered, ranging from requisite medical to faith-based or spiritual services. But, many of the services available are inadequate (e.g, most prisons report conducting mental health assessments and COD assessments, but about 40% do not use a standardized tool). Prisons report offering assessments (TB and mental health) and physical health services to the majority of inmates. Yet, fewer than half of offenders received counseling (mental health, COD, family, and domestic violence) and job placement, services that are considered critical to reentering offenders. Specialized facilities tend to offer more services than generic prisons. Prisons that specialize in psychosocial needs tend to offer more HIV counseling, HCV screening, social skills training, anger management, and cognitive skills development than other prisons. The survey addressed networking and integration of services using an integration scale examining different operational practices to collaborate services with other organizations or with community correctional partners (e.g., parole, probation, etc.). Specialized facilities focused on psychosocial need showed most integration (M=4.94) (out of 11), compared to other prisons (M=1.18), or generic facilities (3.84), suggesting that psychosocial facilities make greater efforts to coordinate services between prison and community treatment services. Cropsey, K.L., Wexler, H.K., Taxman, F.S., Melnick, G., and Young, D.W. Specialized Prisons and Services Results from a National Survey. The Prison Journal, 87(1), pp. 1-28, 2007.

Validating of the Organizational Readiness for Change Scale

This study examined the convergent validity and concurrent validity of the Organizational Readiness for Change (ORC; Lehman, W.E.K., Greener, J.M., and Simpson, D.D. Assessing Organizational Readiness for Change. Journal of Substance Abuse Treatment 22, pp. 197-210, 2002) scale among practitioners who treat adolescents. Within the context of a larger study, the authors administered the ORC scale and measures of practitioner attitudes toward evidence-based practices as well as treatment manuals to a heterogeneous sample of 543 community-based therapists in the state mental health and substance abuse treatment sectors. Using a contextual random-effects regression model, the association between ORC scale domains and measures of practitioner characteristics and attitudes were examined at both therapist and agency levels. The results support the convergent validity and concurrent validity of several domains. Namely, the domains focusing on motivational readiness and training needs were associated with higher appeal and openness to innovations. Those on program resources and climate were less related, however. Discussion focuses on the utility of the ORC scale in helping evaluate the needs of programs considering the adoption of evidence-based practices. Henggeler, S.W., Saldana, L., Chapman, J.E., and Rowland, M.D. The Organizational Readiness for Change Scale in Adolescent Programs: Criterion Validity. J. Subst. Abuse Treat., 32(2), pp. 121-131, 2007.

Institutionalization Confounds Results Unless the Correct Model for Correction is Applied

Drug treatment clients are at high risk for institutionalization, i.e., spending a day or more in a controlled environment where their freedom to use drugs, commit crimes, or engage in risky behavior may be circumscribed. Some longitudinal studies ignore institutionalization at follow-up, thus outcome measures and treatment effect estimates conflate treatment effects on institutionalization with effects on many of the outcomes of interest. Causal modeling is used as a framework for evaluating the four standard approaches for addressing the institutionalization confound to illustrate the effects of each approach using a case study comparing drug use outcomes of 1,256 youths who enter either residential or outpatient treatment modalities. Common methods provide biased estimates of the treatment effect except under improbable assumptions. Common methods for estimating treatment effects in the presence of institutionalization during the evaluation were not found to be robust to violations of the assumptions. Depending on which model is used, the same data show significant positive or negative results. Thus, institutionalization is likely to confound treatment effect estimates in studies on populations like those in ATM. McCaffrey, D.F., Morral, A.R., Ridgeway, G., and Griffin, B. Interpreting Treatment Effects When Cases Are Institutionalized. Drug Alcohol Depend., 89(2-3), pp. 126-138, 2007.

Licensing/Accreditation Improve Quality of Substance Abuse Treatment

Licensing and accreditation are widely used to improve and convey organizational quality. The objective of this study was to provide substance abuse treatment stakeholders with better evidence about how well licensing and accreditation actually correlate with staffing and treatment practices. Regressions using data from national surveys of outpatient substance abuse treatment facilities indicated that no form of licensing or accreditation was associated with better staff-to-client ratios or with one important aspect of comprehensive treatment-the percentage of clients receiving routine medical care. There were several positive associations between licensing/accreditation and other aspects of treatment comprehensiveness. Three categories of licensure/accreditation were also positively associated with use of after-treatment plans. Post hoc analyses revealed that accreditation was associated with units' organizational contexts and referral sources as well as the nature of the competitive environment. Licensing/accreditation may reveal as much about units' institutional environments as about the quality of treatment provided. Wells, R., Lemak, C., Alexander, J., Nahra, T., Ye, Y., and Campbell, C. Do Licensing and Accreditation Matter in Outpatient Substance Abuse Treatment Programs? J. Subst. Abuse Treat., 33(1), pp. 43-50, 2007.

Hepatitis C Care

Since 2002, clinicians have been encouraged to offer chronic hepatitis C virus (HCV) treatment to patients with injection drug use histories. Researchers conducted 69 baseline and 35 follow-up interviews between September 2002 and November 2004 with HCV patients who were treatment-naive and receiving regular medical care at an HIV or methadone clinic in New York City at baseline. Of the 31 patients reinterviewed, 20 (65%) were offered treatment but only 2 (7%) were treated. Reasons for failure to be reinterviewed were loss to follow-up at the original site of care (30), death (6), and refusal to be reinterviewed (2). Whereas offers of HCV treatment may be increasing, there is a need to improve continuity of care, patient-provider communication, and patient education regarding HCV treatment options for treatment rates to improve. Schackman, B., Teixeira, P., and Beeder, A. Offers of Hepatitis C Care Do Not Lead to Treatment. J. Urban Health, 84(3), pp. 455-458, 2007.

Violence and HIV Risk Among Incarcerated Women

The association between history of violence and risk for HIV infection among incarcerated women was examined. Specifically, physical violence and rape were considered as they relate to unprotected sex with male primary and non primary (male or female) sexual partners among a sample of HIV negative female inmates (n = 1,588) housed in Connecticut's sole correctional facility for women between November 1994 and October 1996. A supplement to the mandatory Connecticut Department of Correction Inmate Medical Screening/Health History was used to collect information on each woman's background, history of violence, and unprotected sex practices. Multivariate logistic regression was used to determine the associations between violence and unprotected sex by partner type. Experiencing any violence was found to be significantly associated with increased odds of unprotected sex with one's primary partner, even after controlling for race, history of sex work, drug use, employment status, and having other non primary partners. Of particular importance was having a history of physical violence. History of violence was not significantly associated with unprotected sex with non primary partners. These findings demonstrate the considerable vulnerability of incarcerated women to violence and suggest that this history is associated with increased unprotected sex practices, especially with male primary partners. HIV prevention interventions among women should take experiences of violence into account. Conversely, violence prevention and interventions aimed at coping with violence can be a part of the HIV prevention agenda for incarcerated women. Future longitudinal research can confirm the relationships of violence to HIV risk in women. Ravi, A., Blankenship, K., and Altice, F. The Association Between History of Violence and HIV Risk: A Cross-Sectional Study of HIV-Negative Incarcerated Women in Connecticut. Womens Health Issues, 17(4), pp. 210-216, 2007.

Persistent Pain is Associated with Substance Use After Detoxification: a Prospective Cohort Analysis

This study investigated whether persistent pain is associated with increased odds of substance use after detoxification. The data analyzed was from a prospective cohort of individuals enrolled in a randomized controlled trial (RCT) to improve linkage with primary medical care. The study occurred in an urban residential detoxification program; where adults (n = 397) enrolled in the RCT with heroin, alcohol or cocaine as a substance of choice and at least one follow-up interview. The key independent variable was pain status: persistent pain (moderate to very severe pain at all available interviews), no pain (mild pain or less at all available interviews) and intermittent pain (all others). There were four outcomes of interest: self-reported use of any substance; heroin/opioid use; heavy alcohol use; and cocaine use 24 months after detoxification. Multivariable logistic regression controlled for several covariates including demographics, physical/sexual abuse, depressive symptoms, and duration of follow-up and addiction severity at study entry. The authors found that pain in detoxification patients was common; 16% had persistent pain and 54% had intermittent pain. Persistent pain was associated with an increased odds for use of any substance [adjusted odds ratio (AOR) 4.2, 95% confidence interval (CI) 1.9-9.3], heroin/opioid use (AOR 5.4, 95% CI 2.1-13.8) and heavy alcohol use (AOR 2.2, 95% CI 1.0-4.5) at the 24-month follow-up. A statistically non-significant increase in the odds of cocaine use (AOR 2.0, 95% CI 0.9-4.6) was also observed. From this study, it is shown that among individuals leaving residential detoxification, chronic pain is a common problem and is associated independently with long-term substance use after detoxification. Addressing pain as a treatable chronic condition among adults receiving detoxification presents a potential opportunity to improve long-term clinical outcomes and warrants further intervention research. Larson, M., Paasche-Orlow, M., Cheng, D., Lloyd-Travaglini, C., Saitz, R., and Samet, J. Persistent Pain is Associated with Substance Use After Detoxification: A Prospective Cohort Analysis. Addiction, 102(5), pp. 752-760, 2007.

Strategies for Identifying Drug Use in Private Health Plan Populations Not Widely Disseminated

This study, based on a nationally-representative survey of 368 private health plans representing 767 insurance products conducted in 2003, analyzed screening practices specific to mental health, alcohol abuse, and drug abuse. Just over 8% of products verify specific primary care practitioner screening for alcohol (8.2%) and drug (8.3%) compared with 34.4% that verify mental health screening. In addition, 33.% of products distributed guidelines for treating for alcohol or drug abuse problems, compared with 78.0% that do so for depression. These differences may reflect assumptions about prevalence in this population and/or employers concerns about costs associated with each disorder. Garnick, D.W., Horgan, C.M., Merrick, E.L., and Merrick, A.H. Identification and Treatment of Mental and Substance Use Conditions: Health Plan Strategies. Med. Care, 45 pp. 1060-1067, 2007.

The Deleterious Effects of Changing Treatment Providers for In-Prison Therapeutic Communities

Corrections officials frequently use private contractors to operate in-prison, therapeutic community (TC) treatment programs. However, the recurrent competitive bidding process inherent in state agencies contracting for services sometimes results in a treatment-provider change. Few studies have focused on whether this change leads to better or worse treatment motivation and engagement for clients and how it might be evaluated. Using data collected during the larger Criminal Justice Drug Abuse Treatment Studies Performance Indicators for Corrections study, quantitative assessments of client functioning were made at two points in time. Changing to new treatment providers in three in-prison TC treatment facilities caused significant disruptions, leading to decreased client-counselor rapport and peer support as well as lower levels of treatment readiness, participation, and satisfaction of clients. Qualitative client and staff interviews provided further insight relevant for correctional administrators and treatment providers who may be considering similar changes. General recommendations for provider transition planning are offered. Saum, C.A., O'Connell, D.J., Martin, S.S., Hiller, M.H., Bacon, G.A., and Simpson, D.D. Tempest in a TC: Changing Treatment Providers for In-Prison Therapeutic Communities. Criminal Justice and Behavior, 34(9), pp. 1168-1178, 2007.

Organizations With the Most Need for Improvement are Most Likely to Engage in Change Activities

This study examined the characteristics of 42 community-based treatment units in a single state in the Southwest. Data were obtained from 284 counselors. Findings showed that treatment programs with expressed higher needs for improvement were 1.3 times more likely to engage in change activities. Treatment programs in which staff perceived pressures for change were 57% more likely to engage in change activities, and those perceiving staffing shortages were 86% more likely to engage in change. Organizational climate also played a role in change, raising the likelihood of engaging in change activities 93% for lower staff cohesion, 83% for lower communication, 143% for higher job stress, and 80% for limited openness to change. Furthermore, organizations with greater staff consensus (i.e., smaller standard deviations) on ratings of organizational climate were also more an average of 85% more likely to engage in change. Courtney, K.O., Joe, G.W., Rowan-Szal, G.A., and Simpson, D.D. Using Organizational Assessment as a Tool for Program Change. J. Subst. Abuse Treat., 33(2), pp. 131-137, 2007.

Training to Adopt Evidence Based Practices Changes Therapeutic Behaviors

Training assessment data collected at two time points from substance abuse treatment counselors who participated in training on dual diagnosis and another on therapeutic alliance (N=253 ) were examined to determine the impact of training to adopt new evidence-based practices. Customized evaluations were collected to assess counselor perceptions of training quality, relevance, and resources in relation to its use during the 6 months after the conference. Higher ratings for relevance of training concepts and materials to service the needs of clients, desire to have additional training, and level of program support were related to greater trial use during the follow-up period (R=.55 and .42; p<.001). Primary resource-related and procedural barriers cited by the counselors included lack of time and redundancy with existing practices. Bartholomew, N.G., Joe, G.W., Rowan-Szal, G.A., and Simpson, D.D. Counselor Assessments of Training and Adoption Barriers. J. Subst. Abuse Treat., 33(2), pp. 193-199, 2007.

Providers with Positive Organizational Climates are Most Likely to Adopt Innovations that Improve Patient Care

The process of innovation adoption was investigated using longitudinal records collected from a statewide network of almost 59 treatment programs over a 2-year period. Program-level measures of innovation adoption were defined by averaged counselor ratings of program training needs and readiness, organizational functioning, quality of a workshop training conference, and adoption indicators at follow-up. Findings showed that staff attitudes about training needs and past experience with training (job relevant/not relevant) are predictive of their subsequent ratings of training quality and progress in adopting innovations a year later. Organizational climate (clarity of mission, cohesion, openness to change) is also positively related to innovation adoption (p<.05). In programs that lack an open atmosphere for adopting new ideas, it was found that counselor trial usage is likely to be attenuated (r=-.33; p<.05). Most important was evidence that innovation adoption based on training for improving treatment engagement was significantly related to client self-reports of improved treatment participation (r=.50; p<.01) and rapport (r=.35; p<.35) recorded several months later. Simpson, D.D., Joe, G.W., and Rowan-Szal, G.A. Linking The Elements of Change: Program and Client Responses To Innovation. J. Subst. Abuse Treat., 33(2), pp. 201-209, 2007.

Efficacy of Bupropion Alone and in Combination with Nicotine Gum

In this double-blind, placebo-controlled smoking cessation treatment study, 608 participants were randomly assigned to receive active bupropion and active 4-mg gum (AA, n = 228), active bupropion and placebo gum (AP, n = 224), or placebo bupropion and placebo gum (PP, n = 156). Relative to the PP group, the AA and AP groups were each significantly more likely to be abstinent at 1 week, end of treatment, and 6 months but not at 12 months post quit. After the first week post quit there were no differences in abstinence rates between the AA and AP groups. The authors found no significant individual difference variables that moderated outcome beyond 1 week post quit. Piper, M., Federman, E., McCarthy, D., Bolt, D., Smith, S., Fiore, M., and Baker, T. Efficacy of Bupropion Alone and in Combination With Nicotine Gum. Nicotine Tob. Res., 9(9), pp. 947-954, 2007.

Rural-Urban Differences in Prescription Opiate Misuse

The prevalence of prescription opiate misuse among 2 cohorts of felony probationers (N = 1525) were compared. Multiple logistic regression was utilized to determine the independent correlates of prescription opiate misuse among rural (n = 782) and urban (n = 743) probationers participating in an HIV-intervention study. After adjustment for differences in demographic and drug use characteristics, rural participants were almost five times more likely than their urban counterparts to have misused prescription opiates. The prevalence of prescription opiate misuse was significantly higher among the rural probationers; however, given the paucity of illicit opiates and relatively recent emergence of prescription opiates in rural areas, rural substance abuse treatment may be ill-prepared to treat prescription opiate misuse. Havens, J., Oser, C., Leukefeld, C., Webster, J., Martin, S., O 'Connell, D., Surratt, H., and Inciardi, J. Differences in Prevalence of Prescription Opiate Misuse Among Rural and Urban Probationers. Am. J. Drug Alcohol Abuse, 33(2), pp. 309-317, 2007.

Gender Differences in Housing Patterns and Homelessness

Homeless individuals experience high rates of morbidity and mortality, yet many homeless studies include small percentages of female participants. The authors therefore sought to determine correlates of homelessness separately for men and women in a sample of individuals visiting free food programs. Between August 2003 and April 2004, 324 individuals were recruited from San Francisco free food programs and interviewed regarding housing, sociodemographics, health, drug use, sex trade, and incarceration. Over one-half of women and almost three-fourths of men reported homelessness in the prior year. Among women, white race, younger age, not living with minor children, engaging in sex trade and recent incarceration were strongly associated with homelessness; however, only incarceration maintained the strong association in adjusted analysis (OR = 7.16, CI = 3.83-13.4). Among men, heavy alcohol use, drug use, years spent living in San Francisco and monthly income were strongly associated with homelessness; however, only years living in San Francisco (OR = 0.28, CI = 0.19-0.42) and monthly income maintained strong association in adjusted analysis (OR = 0.27, CI = 0.13-0.57). Housing patterns and the strongest correlates of homelessness among individuals visiting free food programs differ by sex. These results suggest the need to characterize homelessness and develop effective homeless interventions separately for men and women. Riley, E., Weiser, S., Sorensen, J., Dilworth, S., Cohen, J., and Neilands, T. Housing Patterns and Correlates of Homelessness Differ by Gender Among Individuals Using San Francisco Free Food Programs. J. Urban Health, 84(3), pp. 415-422, 2007.

Probability of Cost-effectiveness Depends on the Value Attached to the Outcome

Cost-effectiveness analysis compares the incremental costs of interventions to achieve an incremental improvement in a given outcome. As such, unless the outcome has an inherent value, or has been assigned one by society, cost-effectiveness ratios in and of themselves may not provide adequate guidance for allocation decisions. In addition, given that incremental cost-effectiveness ratios are computed from sample data, there is an inherent variability in the estimates. The authors calculated the incremental cost-effectiveness ratios of four treatments drug abuse counseling (TAU), motivational enhancement therapy plus cognitive behavioral training (MET/CBT), TAU + Contingency Management (CM) and MET/CBT + CM on the Longest Duration Abstinent (LDA) during treatment, the relative effectiveness of which were studied under a NIDA grant analyzing 136 marijuana-dependent young adults. They then conducted a bootstrap analysis and constructed an acceptability curve to arrive at the probability that each intervention would be deemed most cost-effective at different dollar values of an extra week of LDA. The findings show that the optimal intervention depends on how much society values an extra week of LDA. For example, if society valued (or were willing to pay) $250 for an extra week LDA then MET/CBT would have the highest probability of being the optimal choice. If society were willing to pay $1,000, MET/CBT would still be the optimal choice, but at $3,000 MET/CBT + CM, the most expensive intervention, would be optimal. Research is needed to determine society's value of standard drug abuse outcomes. Olmstead, T., Sindelar, J., Easton, C., and Carroll, K. The Cost-Effectiveness of Four Treatments for Marijuana Dependence. Addiction, 102(9), pp. 1443-1453, 2007.

Communication, Staff Cohesiveness, Clarity of Mission, and Work Stress are Key Components in the Organizational Dynamics of Counselors in Their Workplace

This study examined drug counselor perceptions of their programs and their skills in relation to their attitudes about innovations training and its utilization. Latent profile analysis of measures on organizational climate and staff attributes for 1047 counselors from 345 programs defined three categories of counselors: isolated, integrated, and exceptional. All had generally positive views of their professional skills, although the isolated group scored lower on scales representing professional growth and influence on peers. They were less positive about the "climate" of programs in which they worked and were higher on stress. Program resources predicted the counselor groups with the isolated having more limited resources. Counselor categorizations also differed in terms of workshop training experiences, with the isolated group of counselors reporting significantly less exposure, satisfaction, and program-wide use of workshop training. The results emphasize the importance of considering communication, staff cohesiveness, clarity of mission, and work stress as key components in the organizational dynamics of counselors in their workplace. Joe, G., Broome, K., Simpson, D., and Rowan-Szal, G. Counselor Perceptions of Organizational Factors and Innovations Training Experiences. J. Subst. Abuse Treat., 33(2), pp. 171-182, 2007.

Interim Methadone Maintenance was Equally Effective for Both Intravenous and Intranasal Heroin Addicts

This study compared the characteristics of intravenous (i.v.) and intranasal (i.n.) heroin users seeking methadone treatment, and examined their response to treatment. Participants consisted of 319 heroin-dependent adults assigned randomly to receive interim methadone treatment or to a waiting list control on a 3:2 basis. Interim methadone treatment consisted of providing an adequate and stable dose of methadone, but no psychosocial services, to heroin-dependent adults for up to 120 days while they awaited an opening for comprehensive methadone treatment. At baseline, over 60% of participants were i.n. users and had been for an average of over 12 years; i.v. users, compared to i.n. users, were more likely to have ever used cocaine, to have used cocaine in the past 30 days, to have more medical complications and to report more income generated from criminal behavior. Both i.v. and i.n. users reduced their self-reported days of heroin use, cocaine use and days of criminal activity in response to interim methadone treatment. Thus interim treatment is effective for both groups. Highfield, D., Schwartz, R., Jaffe, J., and O 'Grady, K. Intravenous and Intranasal Heroin-Dependent Treatment-Seekers: Characteristics and Treatment Outcome. Addiction, 102(11), pp. 1816-1823, 2007.

Pilot Study Shows that a Brief, Didactic and Experiential Course can Improve Physician Knowledge and Attitudes about AA

Implementation of a brief, didactic and experiential educational intervention about AA was evaluated for its impact on physician knowledge and attitudes, using a before-after repeated measures study design. Thirty-six first-year internal medicine resident physicians received an educational intervention, which consisted of a 45-minute lecture about AA, a visit to an AA meeting, and a 30-minute debriefing session the next day. Residents' knowledge and attitudes were assessed by a brief written anonymous survey before and after the educational intervention. Residents reported increases in self-perceived knowledge about AA and had more favorable attitudes towards AA after the intervention (average p<.001). Pilot study shows that a brief, didactic and experiential course can improve physician knowledge and attitudes about AA, and holds promise for improving physician interface with this commonly used intervention. Rose, A.J., Stein, M.R., Arnsten, J.H., and Saitz, R. Teaching Internal Medicine Resident Physicaians About Alcoholics Anonymous: A Pilot Study of an Educational Intervention. Subst. Abuse, 27(3), pp. 5-11, 2006.

Cultural Competence among Healthcare Providers

Mandates for culturally competent substance abuse and mental health services call for behavioral health providers to recognize and engage cultural issues. These efforts to incorporate culture typically focus on client culture, but provider views of culture can also influence the provision of services. Analysis of 42 semi-structured interviews with behavioral health providers suggests that culture is considered by many to be an obstacle to help seeking and treatment of substance-abusing youth. Although some providers do not highlight cultural issues, others conceptualize culture in terms of (a) generalized Hispanic cultural attributes, (b) male-dominant gender roles, and (c) the culture of poverty. Recommendations for provider training on cultural issues focus on ways they might critically consider their ideas about culture. Quintero, G., Lilliott, E., and Willging, C. Substance Abuse Treatment Provider Views of "Culture": Implications for Behavioral Health Care in Rural Settings. Qual. Health Res., 17(9), pp. 1256-1267, 2007.

Violence Against Homeless Women

Research on violence against homeless women has focused mainly on individual rather than community-level risk factors. Using an ecological conceptual framework, the researchers estimated the independent association of community characteristics with sexual and physical assault in a probability sample of 974 homeless women. Participants were interviewed at 66 assistance programs in Los Angeles County, California in 1997. Individual responses were linked to community-level data from land use files and the U.S. Census by the facility ZIP codes. Multivariate logistic regression analysis showed that women using service providers in closer proximity to Skid Row had higher odds of physical assault (OR=1.48; 95% CI=1.03, 2.14). A number of individual characteristics were also associated with violent victimization. To reduce violence against homeless women, ensuring the safety of locations for shelters and other assistance programs should be a planning priority for local housing authorities. Heslin, K., Robinson, P., Baker, R., and Gelberg, L. Community Characteristics and Violence Against Homeless Women in Los Angeles County. J. Health Care Poor Underserved, 18(1), pp. 203-218, 2007.

Recovery More Than Total Abstinence: An Ongoing Process of Growth, Self-Change, and Reclaiming the Self

Combining quantitative and qualitative analyses, this study examines recovery definitions and experiences among persons who self-identify as "in recovery." The author addresses two questions: (a) Does recovery require total abstinence from all drugs and alcohol?, and (b) Is recovery defined solely in terms of substance use or does it extend to other areas of functioning as well? Inner-city residents with resolved dependence to crack or heroin were interviewed yearly three times (N = 289) in the study. Most individuals defined recovery as total abstinence. However, the authors commented that recovery goes well beyond abstinence; it is experienced as an ongoing process of growth, self-change, and reclaiming the self. Implications for clinical and assessment practice are discussed, including the need to effect paradigmatic shifts from pathology to wellness and from acute to continuing models. Laudet, A. What Does Recovery Mean To You? Lessons from the Recovery Experience for Research & Practice. J.Subst.Abuse Treat. 33, pp. 243-256, 2007.

Gender-specific Substance Abuse Treatment for Women Promotes Continuity of Care

Research has stressed the value of providing specialized services to women and suggests the importance of treatment duration. This quasiexperimental retrospective study reports on the continuity of care for women with children who were admitted to long-term residential substance abuse treatment. Women were admitted to 7 agencies offering specialized, women's only treatment (SP, n = 747) or to 9 agencies that provided standard mixed-gender treatment (ST, n = 823). Client and treatment data were gathered from administrative sources. Women in SP programs (37%) were more likely than those in ST programs (14%) to continue care. Multivariate analyses revealed that SP clients who completed treatment with longer stays were most likely to continue care. The findings show that specialized treatment for women promotes continuing care and demonstrate the importance of treatment completion. Claus, R.E., Kissin, W., Krupski, A., Campbell, K., and Stark, K. Does Gender-Specific Substance Abuse Treatment for Woman Promote Continuity of Care. J. Subst. Abuse Treat., 32, pp. 29-39, 2007.

Individual and System Factors Influence Waiting Time for Addiction Treatment

The authors of this study assessed waiting time preceding clinical assessment at a centralized intake unit and during the period after the assessment but before treatment entry. The analysis included 577 substance abusers who were enrolled in a large clinical trial of two brief treatment interventions in a midsize metropolitan area in Ohio. Bivariate analyses identified individual and system factors that influenced pre-assessment and post-assessment waiting time, as well as total wait to treatment services. Multivariate analyses demonstrated that longer wait time for an assessment is influenced by being court referred, less belief in having a substance abuse problem, and less desire for change. A shorter wait to actually enter treatment is predicted by having a case manager, being more ready for treatment, and having less severe employment and alcohol problems. The different influences present during the two waiting periods suggest that assessment and treatment programs need to implement system changes and entry enhancement interventions that are specific to the needs of substance abusers at each waiting period. Carr, C.J., Jiangmin, X.U., Redko, C., Lane, T., and Rapp, R. Individual and System Influences on Waiting Time for Substance Abuse Treatment. J. Subst. Abuse Treat., May 16, 2007 (e-pub ahead of print).

Children Are Important Sources of Social Support for Women in Addiction Treatment

The authors examined the status of children and the types of support available from children as reported by women in substance abuse treatment. Their findings indicate that children are viewed as sources of social support to women in addiction treatment. Children were viewed as providing as much sobriety support to respondents as that provided by adult network members. In addition, both children living with the respondent and children in the care of others were viewed as providers of specific types of social support. These study findings indicate that treatment providers need to be aware of the extent to which women clients may rely on support from children. Focusing only on adult relationships misses the fact that children may be a strong source of support for women in treatment, particularly for women in residential treatment, where the need for support may be greater. Tracy, E., and Martin, T. Children's Roles in The Social Networks of Women in Substance Abuse Treatment. J. Subst. Abuse Treat., 32(1), pp. 81-88, 2007.

Older Women Have Better Long-Term Addiction Treatment Outcomes Than Older Men

This study examined participants at seven-year follow-up to assess long-term outcomes of older women (n = 25) and men (n = 59) ages 55 and over in an outpatient addiction program. It measured demographic characteristics, alcohol and drug use, psychiatric symptoms, Addiction Severity Index, treatment length, and outcomes. At seven years, 76.0% of women reported abstinence in the prior 30 days versus 54.2% of men (p = 0.05). Logistic regression analysis revealed that longer treatment stay predicted abstinence. Findings indicate that older women have better long-term addiction outcome than older men, but treatment length is more significant than gender in predicting outcome. Satre, D., Blow, F., Chi, F., and Weisner, C. Gender Differences in Seven-year Alcohol and Drug Treatment Outcomes Among Older Adults. Am. J. Addict., 16(3), pp. 216-221, 2007.

Measuring Offender Attributes and Engagement in Treatment Using the Client Evaluation of Self and Treatment

Monitoring drug abuse treatment delivery and progress requires the use of reliable and valid instruments to measure client motivation, psychosocial and cognitive functioning, and other treatment process dynamics. As part of the Criminal Justice Drug Abuse Treatment Studies (CJDATS) protocol to examine client performance indicators for corrections-based treatment populations, this study examined psychometric properties of the 108-item TCU Criminal Justice Client Evaluation of Self and Treatment (CJ CEST), which is composed of 15 scales across 3 major domains. Treatment Motivation includes scales on desire for help; treatment readiness; treatment needs; and pressures for treatment. Psychosocial Functioning includes scales on depression; anxiety; self-esteem; decision-making; hostility; and risk-taking. Treatment Engagement includes scales on treatment participation; treatment satisfaction; counseling rapport; peer support; and social support. The sample included 3,266 offenders from 26 corrections-based treatment programs located in 6 states. Overall, the client assessment demonstrated good reliabilities at individual and program levels, and in test-retest administrations. Additionally, evidence for construct validity was favorable, based on confirmatory factor analyses. All but 4 scales had conventionally acceptable fit indices; the remaining 4 scales (desire for help; treatment readiness; decision making; risk taking) had acceptable GFIs, but other indices indicated possible multidimensionality. Multilevel analyses were used to examine program level variation, after controlling for client-level attributes (e.g., age, race, time in treatment). Over 20% of treatment readiness and counseling rapport was at the program level, but only 5-7% of offender anxiety and hostility. Differences were also found between male-only and female-only programs (all but 3 programs). Women were more motivated and involved in their treatment, and had stronger social support systems. Finally, bivariate correlations were examined between CJ CEST scales and criminal thinking scales (using the CTU Criminal Thinking Scales), after removing program differences. Less criminal thinking was found with higher overall motivation, psycosocial functioning, and engagement. In conclusion, the CJ CEST is a brief yet comprehensive instrument that effectively and efficiently measures client needs and functioning at intake. It also is appropriate for use during treatment to monitor client progress over time. Garner, B.R., Garner, K.K., Flynn, M.P., Morey, J.T., and Simpson, D.D. Measuring Offender Attributes and Engagement in Treatment Using the Client Evaluation of Self and Treatment. Criminal Justice & Behavior, 34(9), pp. 1113-1130, 2007.

Several Treatment Components Not Associated with Crime and Employment Outcomes of Substance Abuse Treatment

This study examines the associations between various components of treatment services and post-treatment employment and crime using data from 960 adults in outpatient non-methadone clinics from the 1992-1995 National Treatment Improvement Evaluation Study. Using principal components analysis to create treatment service factors based on both patient self-reports and treatment record extracts to minimize the effects of measurement error, the authors include measures of five treatment components - logistical services (including job training and employment counseling), medical services, parent training and counseling, and two life skills training factors - in addition to variables such as the number of individual and group counseling sessions and pre-treatment employment and criminal involvement, in multivariate models to estimate the relationship between services and post-treatment employment and crime. The overall effects of services measured in this way were generally insignificant. The authors conclude that either service is unrelated to these outcomes or that they are not measuring the key aspects of service provision that may be important. Dunlap, L., Zarkin, G., Lennox, R., and Bray, J. Do Treatment Services for Drug Users in Outpatient Drug-free Treatment Programs Affect Employment and Crime? Subst. Use Misuse, 42(7), pp. 1161-1185, 2007.

Research Agenda for Employee Assistance Programs

Research suggests that employee assistance programs (EAPs) yield improved clinical and work outcomes and are cost-effective. However, much of that literature is old and of poor scientific quality, and it pre-dates the move to provision of these services by managed behavioral healthcare organizations. It also covers EAP models that are very different from the broad-based provision of services common today. This comment summarizes the salient issues and sets an agenda for further research on EAPs. Levy Merrick, E., Volpe-Vartanian, J., Horgan, C., and McCann, B. Alcohol & Drug Abuse: Revisiting Employee Assistance Programs and Substance Use Problems in the Workplace: Key Issues and a Research Agenda. Psychiatr. Serv., 58(10), pp. 1262-1264, 2007.

Self-rated Health and its Determinants Among Adults in Syria: a Model From the Middle East

Self-rated health (SRH) has been widely used to research health inequalities in developed western societies, but few such studies are available in developing countries. Similar to many Arab societies, little research has been conducted in Syria on the health status of its citizens, particularly in regards to SRH. This Study aims to investigate and compare determinants of SRH in adult men and women in Aleppo, Syria. The authors performed a cross-sectional survey of adults 18 to 65 years old residing in Aleppo, Syria (2,500,000 inhabitants) in 2004. The study involved 2038 household representatives (45.2% men, age range 18-65 years, response rate 86%). SRH was categorized as excellent, normal, and poor. Odds ratios for poor and normal SRH, compared to excellent, were calculated separately for men and women using logistic regression. It was found that women were more likely than men to describe their health as poor. Men and women were more likely to report poor SRH if they were older, reported two or more chronic health problems, or had high self perceived functional disability. Important gender-specific determinants of poor SRH included being married, low socioeconomic status, and not having social support for women, and smoking with low physical activity for men. The authors conclude that women were more likely than men to describe their health as poor. The link with age and pre-existing chronic conditions seems universal and likely reflects natural aging process. Determinants of SRH differed between men and women, possibly highlighting underlying cultural norms and gender roles in the society. Understanding the local context of SRH and its determinants within the prevailing culture will be important to tailor intervention programs aimed at improving health of the Syrian and similar Arab societies. Asfar, T., Ahmad, B., Rastam, S., Mulloli, T., Ward, K., and Maziak, W. Self-Rated Health and its Determinants Among Adults in Syria: A Model From the Middle East. BMC Public Health, 7, pp. 177-186, 2007.

Organizational Climates Affect Patient Outcomes

Counselor ratings of the organizational climates (N=531) of 163 clinics taken during training sessions at three regional Addiction Technology Transfer Centers across the country showed positive relationships with patient ratings (N=3,475) of counselor rapport (R2=.19;p<.05) and treatment satisfaction (R2=.27; p<.001). Most measures of client engagement in treatment (rapport, satisfaction, and participation) were shown to be significantly correlated with staff member perceptions of organizational functioning (17 of 23; p<.05). In particular, these programs had fewer agency needs and more favorable ratings for their resources, staff attributes, and climate. These findings help establish a link between clinic organizational climate and patient engagement in treatment. Greener, J.M., Joe, G.W., Simpson, D.D., Rowan-Szal, G.A., and Lehman, W.E. Influence of Organizational Functioning On Client Engagement in Treatment. J. Subst. Abuse Treat., 33(2), pp. 139-147, 2007.

Organizational Characteristics (Accreditaiton, Size, Treatment Approach) Significantly Predict Patient Engagement in Treatment

This study explored client and program differences in engagement in treatment using data from a nationwide set of 94 outpatient drug-free treatment programs in a hierarchical linear model analysis. The results show that elements of program context, including structural features (e.g., smaller size and Joint Commission on the Accreditation of Healthcare Organizations/Commission on Accreditation of Rehabilitation Facilities accreditation; R=.40 to.65; p<.01)) and staff's perceptions of personal efficacy, organizational climate (R=.40; p<.01), and communal workplace practices (R=.40; p<.01), relate to better overall client engagement (R=.40; p<.01). These findings add further evidence that treatment providers should also address the workplace environment for staff as part of quality improvement efforts. Broome, K.M., Flynn, P.M., Knight, D.K., and Simpson, D.D. Program Structure, Staff Perceptions, and Client Engagement in Treatment. J. Subst. Abuse Treat., 33(2), pp. 149-158, 2007.

Measuring Offender Progress in Treatment Using The Client Assessment Inventory

The accurate and reliable assessment of client psychological and cognitive change during correctional substance abuse treatment has gained increasing importance during the past decade as criminal justice systems seek to evaluate and understand those treatment elements associated with long-term change. The 103-item Client Assessment Inventory (CAI) is a self-report instrument for measuring client change during treatment, using 14 subscales across four cognitive and behavioral domains. The Developmental dimension includes subscales on maturity; responsibility; and values. The Socialization dimension includes subscales on drug/criminal lifestyle; maintaining images; work attitude; and social skills. The Psychological dimension includes subscales on cognitive skills; emotional skills; and self-esteem/self-efficacy. The program participation dimension includes subscales on philosophy/understands program rules; engagement; attachment/investment; and role model. The reliability and internal consistency of the CAI, as adapted for use in criminal justice settings, were examined with data gathered from 1,170 offenders. The research addressed the utility of the CAI for different subpopulations of offenders (e.g., race/ethnicity, gender) across a variety of correctional treatment settings. Total CIA demonstrated high reliability (alpha = .96). Subscale alphas ranged from .42 to .90; with work attitudes and maintaining image demonstrating low unidimensionality (alphas = .42 and .53). Female clients were significantly higher on 9 of 14 subscales, after controlling for ethnicity, treatment program, and treatment retention. A sub-sample (n=165) were retested after 1 week. Total CAI test-retest reliability was Kappa = .68; subscale Kappa's ranged from .31 to .54.Validity of the instrument was evaluated using time in treatment at CAI administration, which ranged from 2 weeks to 15 mos. Longer time in treatment was associated with significantly higher scores on 13 of 14 scales. Overall, the data support the use of the CAI as a consistent, reliable, and easily administered instrument for measuring client performance and progress in treatment in both therapeutic community (TC) and non-TC correctional treatment settings. Sacks, J.Y., McKendrick, K., and Kressel, D. Measuring Offender Progress in Treatment Using The Client Assessment Inventory. Criminal Justice and Behavior, 64(9), pp. 1131-1142, 2007.

A Model for Implementing Evidence-based Practices

A model for the study of implementing evidence-based practices in addiction treatment clinics is presented. Data from over 800 treatment programs nationwide served as the basis for an implementation model based on the TCU organizational readiness for change (ORC) survey. The ORC represents a standardized assessment of organizational functioning that describes environments, settings, and staffing, and the findings from incumbent perspectives are interpreted in the context of a stage-based approach to program changes. Basically the model moves from planning and preparation, to training, adoption activities by leaders to overcome resistance to change, followed by implementation activities, culminating in evaluation of practice improvement. Simpson, D.D., and Flynn, P.M. Moving Innovation into Treatment: A Stage-Based Approach to Program Change. J. Subst. Abuse Treat., 33(2), pp. 111-120, 2007.

Gender Differences in Treatment Engagement Among a Sample Of Incarcerated Substance Abusers

This article examines gender differences in treatment engagement, psychosocial variables, and criminal thinking among a sample of male and female substance abusers (N = 2,774) enrolled in 20 prison-based treatment programs in five different states as part of the National Institute on Drug Abuse-funded Criminal Justice Drug Abuse Treatment Studies cooperative agreement. Results indicate that inmates in female treatment programs report more psychosocial dysfunction, less criminal thinking, and higher engagement than in male facilities, and there is a more negative relationship between psychosocial variables and treatment engagement (compared to male programs). Only one subscale of criminal thinking had a significant gender interaction, with males having a significantly stronger relationship between cold-heartedness and low treatment engagement. Implications for treatment interventions with a gender-specific focus are discussed. Staton-Tindall, M., Garner, B.R., Morey, J.S., Leukefeld, C., Krietemeyer, J., Saum, C.A., and Oser, C.B. Gender Differences in Treatment Engagement Among a Sample Of Incarcerated Substance Abusers. Criminal Justice and Behavior, 34(9), pp. 1143-1156, 2007.

An Assessment of Criminal Thinking Among Incarcerated Youths in Three States

The Texas Christian University Criminal Thinking Scales (CTS) instrument has been shown to predict outcomes for institutionalized adult offenders. This article examines responses among male (n = 151) and female (n = 52) incarcerated adolescents, and they were compared to norms for incarcerated adult offenders. The results indicated that the adolescent sample had higher scores on four scales (Entitlement, Justification, Personal Irresponsibility, and Power of Orientation) but not on Criminal Rationalization. Scores did not differ by gender or ethnicity of respondents. The results provide convergent validity indicating that the scores for adolescents were correlated with prior history of criminal behavior, substance use, family dysfunction, and Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition diagnoses of conduct disorder and oppositional defiant disorder. Thus, the CTS may provide useful diagnostic information to help identify youth with a constellation of problem behaviors that predict poor outcomes following incarceration. It also may prove helpful in accounting for individual variations in response to treatment for incarcerated adolescents who receive treatment during reentry back into the community. Dembo, R., Turner, C. W., and Jainchill, N. An Assessment of Criminal Thinking Among Incarcerated Youths in Three States. Criminal Justice and Behavior, 34(9), pp. 1157-1167, 2007.

Psychometrics of the Inmate Prerelease Assessment for Reentry Planning

The Inmate Prerelease Assessment (IPASS) was developed specifically as a measure of post release risk for prison-based treatment graduates. By taking into account historical drug use and criminal activity of inmates as well as their performance during prison-based treatment, the IPASS provides a "priority" score indicating the relative need for more (versus less) intensive treatment services on release. The present study used data from offenders paroling from prisons in a southwest (N = 127) and Midwest (N = 75) state to examine the psychometric properties of the IPASS subscales. With regard to construct validity, psychometric properties ranged from good to excellent. The IPASS scales also showed strong internal consistency, with coefficient alphas greater than .80 for the Texas Christian University Drug Screen, Client Evaluation of Treatment, and Counselor Evaluation of Client scales. Further research will explore alternatives on how the Client and Counselor scales are optimally incorporated into the IPASS priority score and will examine the score in relation to aftercare participation and post release outcomes. Farabee, D., Knight, K., Garner, B.R., and Calhoun, S. The Inmate Prerelease Assessment for Reentry Planning. Criminal Justice and Behavior, 34(9), pp. 1188-1197, 2007.

A Validation Study of the Co-Occurring Disorders Screening Instrument For Mental Disorders Developed Under the Criminal Justice Drug Abues Treatment Studies

Three standardized screening instruments--the Global Appraisal of Individual Needs Short Screener, the Mini-International Neuropsychiatric Interview-Modified, and the Mental Health Screening Form (MHSF)--were compared to two shorter instruments, the 6-item Co-Occurring Disorders Screening Instrument for Mental Disorders (CODSI-MD) and the 3-item CODSI for Severe Mental Disorders (CODSI-SMD) for use with offenders in prison substance abuse treatment programs, which was developed as part of the Criminal Justice Drug Abuse Treatment Studies (CJDATS). Results showed that the CODSI screening instruments were comparable to the longer instruments in overall accuracy and that all of the instruments performed reasonably well. The CODSI instruments showed sufficient value to justify their use in prison substance abuse treatment programs and to warrant validation testing in other criminal justice populations and settings. Sacks, S., Melnick, G., Coen, C., Banks, S., Friedmann, P.D., Grella, C., Knight, K., and Zlotnick, C. CJDATS Co-Occurring Disorders Screening Instrument For Mental Disorders: A Validation Study. Criminal Justice and Behavior, 34(9), pp. 1198-1215, 2007.

Screening, Assessment, and Referral Practices in Adult Correctional Settings: A National Perspective

The use of screening and assessment tools to gauge substance abuse disorders and the risk for recidivism are two widely recommended practices. A national survey of adult prisons, jails, and community correctional agencies was conducted to examine the practices used to place offenders in appropriate treatment services. Study findings indicate that 58.2% of the surveyed respondents report the use of a standardized substance abuse-screening tool, and that 34.2% use an actuarial risk tool. The provision of higher intensity treatment programs, the use of standardized risk tools, and the provision of more community referral services were all independently associated with the use of a standardized substance abuse-screening tool. Because practices vary considerably, agencies desiring to improve correctional programming should consider different dissemination, implementation, and technology transfer strategies. Taxman, F. S., Cropsey, K.L., Young, D.W., and Wexler, H. Screening, Assessment, and Referral Practices in Adult Correctional Settings: A National Perspective. Criminal Justice and Behavior, 34(9), pp. 1216-1234, 2007.

Case Managment of Substance Abuse Patients Can Lower Costs of Mental and Physical Healthcare

This study examines the relationship between specific dimensions of case management and the utilization of health and ancillary social services in outpatient substance abuse treatment. Results were from the 2005 National Drug Abuse Treatment System Survey, a random national telephone survey of 552 addiction treatment provider organizations conducted by the Universities of Michigan and Chicago. In general, results suggest that more active case management during the referral process and providing case management both on-site and off-site are most consistent with predictions of greater use of health (p<.05) and ancillary social services (p<.05) by substance abuse clients. However, these effects are specific to general health care and mental health services. Case management had no significant effect on use of social services or aftercare plans. Alexander, J., Pollack, H., Nahra, T., Wells, R., and Lemak, C. Case Management and Client Access to Health and Social Services in Outpatient Substance Abuse Treatment. J. Behav. Health Serv. Res., 34(3), pp. 221-236, 2007.

Oxford House: Deaf-Affirmative Support For Substance Abuse Recovery

Previous research indicates that Oxford House, a network of resident-run recovery homes, serves a diverse group of individuals in recovery. The present study found no significant differences between deaf and hearing men living in Oxford House in terms of sense of community and abstinence self-efficacy. However, unlike most of the hearing participants, none of the Deaf Oxford House members were able to achieve full employment. The study's findings indicate that Oxford House may be a promising option for individuals seeking recovery from substance abuse. However, as Oxford House members must be self-supporting, Oxford Houses designed for the Deaf community will need to accommodate to employment problems facing recovery deaf addicts. Leonard, J.A., Alvarez, J., Adebanjo, A.M., Davidson, M.K., and Davis, M.I. Oxford House: Deaf-Affirmative Support for Substance Abuse Recovery. Project Muse Scholarly Journals Online, 151(4), pp. 418-422, 2006.

Application of Gelberg-Andersen Behavioral Model

The Gelberg-Andersen Behavioral Model for Vulnerable Populations was applied to predict health services utilization (HSU) in 875 homeless US women. Structural models assessed the impact of predisposing (demographics, psychological distress, alcohol/drug problems, and homelessness severity), enabling (health insurance, source of care, barriers) and need (illness) variables on HSU (preventive care, outpatient visits, and hospitalizations). Homelessness severity predicted illness, barriers and less insurance. Distress predicted more barriers, illness and less outpatient HSU. Drug problems predicted hospitalizations. Barriers predicted more illness and less outpatient HSU. Health and homelessness indicators were worse for White women. Better housing, access to care and insurance would encourage appropriate HSU. Stein, J., Andersen, R., and Gelberg, L. Applying the Gelberg-Andersen Behavioral Model for Vulnerable Populations to Health Services Utilization in Homeless Women. J. Health Psychol., 12(5), pp. 791-804, 2007.

It is More Than the Money: Adolescents with Substance Use Problems Have Many Reasons for Participating in Research

The authors of this paper examined reasons why adolescents with substance use problems continued to participate in follow-up interviews. The sample consisted of 145 adolescents between the ages of 12 and 18, who completed an outcome study following outpatient treatment for substance use. Participants were asked to report on 18 possible reasons for continued participation. Adolescents' top reason for continued participation was financial compensation; however, a high percentage of adolescents responded favorably to several other attitudinal questions concerning their follow-up participation, suggesting that the adolescents had a primarily positive view of their research experience and that reasons for research participation are multidimensional. Reasons other than financial compensation that were reported include fulfillment of a commitment, wanting to help others, and the perception that the research was important and credible. Garner, B.R., Passetti, L.L., Orndorff, M.G., and Godley, S.H. Reasons for and Attitudes Toward Follow-Up Research Participation Among Adolescents Enrolled in an Outpatient Substance Abuse Treatment Program. J. of Child and Adol. Subst. Abuse, 164, pp. 45-58, 2007.

Crack Cocaine Trajectories Among Users In a Midwestern American City

Although crack cocaine first appeared in cities in the United States in the mid-1980s, little is known about its use over long periods of time. This study identified crack cocaine user groups on the basis of long-term trajectories. Following a natural history approach, data were collected periodically from 1996 to 2005. Group-based modeling assessed the probability of a crack smoker becoming abstinent during the observation period. A targeted sampling plan guided the recruitment of a community sample of crack cocaine users in Dayton, Ohio. Crack smokers (n = 430) 18 years or older whose urine tested positive for cocaine metabolites at the baseline interview. Interviewer-administered and audio computer self-administered, structured questionnaires were used to collect data on a range of variables, including frequency of crack use. Abstinence was defined as not having used crack for at least 6 consecutive months during the study. Three trajectory-based groups were identified: (1) No Change, characterized by a very low probability of abstinence; (2) Some Change, characterized by a low to moderate probability of abstinence; and (3) Dramatic Change, characterized by a high probability of abstinence. African Americans and men were significantly less likely to become abstinent. For the majority of the people (63.6%), crack use was uninterrupted by extended periods of abstinence during the study. Crack cocaine use that persists for a decade or longer may well be the norm for a large proportion of people who have experience with the drug. Falck, R., Wang, J., and Carlson, R. Crack Cocaine Trajectories Among Users In a Midwestern American City. Addiction, 102(9), pp. 1421-1431, 2007.


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