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Director's Report to the National Advisory Council on Drug Abuse - February, 2010

Research Findings - Prevention Research

Preventive Intervention Ameliorates Genetic Risk for Problem Behavior

The present research addresses whether participation in an efficacious preventive intervention can ameliorate the risk that a genetic vulnerability factor is hypothesized to confer on increases in risk behaviors across preadolescence. As part of a preventive intervention study, 641 black families in rural Georgia were assigned randomly to a prevention or control condition. The prevention condition participated in the Strong African American Families preventive intervention, consisting of separate, concurrent sessions for parents and youths, followed by a joint parent-youth session in which families practiced skills they learned in the separate sessions. Involvement in risk behaviors was assessed when the youths were 11 (pretest), 12 (posttest), and 14 (long-term follow-up) years of age. A genetic vulnerability factor, that is, a variable-nucleotide repeat polymorphism in the promoter region of the SLC6A4 gene (5HTT), was assessed 2 years after the long-term follow-up assessment. Youths at genetic risk who were assigned to the control condition displayed greater increases in risk behaviors across the 29 months that separated the pretest and long-term follow-up assessments, compared with youths at genetic risk who were assigned to the Strong African American Families condition and youths without genetic risk who were assigned to either condition. This is the first study to demonstrate that participation in an efficacious preventive intervention can ameliorate a genetic risk for increasing involvement in health-compromising risk behaviors across preadolescence. Brody GH, Chen Y, Beach SR, Philibert RA, Kogan SM. Participation in a family-centered prevention program decreases genetic risk for adolescents ' Risky Behaviors. Pediatrics 2009;124(3):911-917.

Effects of the Linking the Interests of Families and Teachers (LIFT) Preventive Intervention

Substance use outcomes were examined for 351 fifth grade children (51% female) who participated in a randomized controlled trial designed to assess the efficacy of a school-based multimodal universal preventive intervention called Linking the Interests of Families and Teachers (LIFT). Twelve randomly chosen public elementary schools within a moderate-sized metropolitan area in the U.S. Pacific Northwest with higher than local median number of police contacts were invited to participate. Schools were randomly assigned to either a "services as usual" control condition or the LIFT intervention condition. Frequency of any use of tobacco, alcohol, and other drugs was assessed via self-report from grades 5 through 12. The LIFT universal preventive intervention is based in a developmental model centered on moment-to-moment social interaction processes thought to be important in initiating and continuing youth problem behaviors. The intervention included multiple components, including parent management training, child social and problem solving skills training, the recess Good Behavior Game, as well as parent-teacher communication aids such as a weekly newsletter for parents and the "LIFT Line," which was a dedicated phone line and answering machine within each intervention classroom. Latent variable growth models specified average level, linear growth and accelerated growth of tobacco, alcohol, and other drugs. The LIFT intervention had a significant effect on reducing the rate of growth in use of tobacco and illicit drugs, particularly for girls, and it had an overall impact on average levels of use of tobacco, alcohol, and illicit drugs. Average tobacco use reductions were mediated by increases in family problem solving. The intervention had significant indirect effects on growth in substance use through intervention effects on reduced playground aggression and increased family problem solving. The intervention was also associated with roughly a 10% reduced risk in initiating tobacco and alcohol use. DeGarmo DS, Eddy JM, Reid JB, Fetrow RA. Evaluating mediators of the impact of the Linking The Interests of Families and Teachers (LIFT) Multimodal Preventive Intervention on substance use initiation and growth across adolescence. Prev Sci. 2009;10(3):208-220.

Drug Prevention Intervention Effects Mediated by Delayed Drug Initiation

The authors examine whether delayed substance initiation during adolescence, achieved through universal family-focused interventions conducted in middle school, can reduce problematic substance use during young adulthood. Sixth-grade students enrolled in 33 rural mid-western schools and their families were randomly assigned to 3 experimental conditions. Self-report questionnaires provided data at 7 time points for the Iowa Strengthening Families Program (ISFP), Preparing for the Drug Free Years (PDFY), and control groups through young adulthood. Five young adult substance frequency measures, including drunkenness, alcohol-related problems, cigarettes, illicit drugs, and poly-substance use, were modeled as distal outcomes affected by the average level and rate of increase in substance initiation across the adolescent years in latent growth curve analyses. Results show that the models fit the data and that they were robust across outcomes and interventions, with more robust effects found for ISFP. The addition to the model of direct intervention effects on young adult outcomes was not supported, suggesting long-term effects were primarily indirect. Relative reduction rates calculated to quantify intervention-control differences in the estimated proportion of young adults indicating problematic substance use ranged from 19% to 31% for ISFP and from 9% to 16% for PDFY. Spoth R, Trudeau L, Guyll M, Shin C, Redmond C. Universal intervention effects on substance use among young adults mediated by delayed adolescent substance initiation. J Consult Clin Psychol. 2009;77(4):620-632.

Comprehensive School-Based Program Prevents Early Onset Substance Use, Violence and Sexual Risk Behavior

This research assessed the effectiveness of a 5-year trial of a comprehensive school-based program designed to prevent substance use, violent behaviors, and sexual activity among elementary-school students. The study involved a matched-pair, cluster-randomized, controlled design, with 10 intervention schools and 10 control schools. Fifth-graders (N = 1714) self-reported on lifetime substance use, violence, and voluntary sexual activity. Teachers of participant students reported on student (N = 1225) substance use and violence. Two-level random-effects count models (with students nested within schools) indicated that student-reported substance use (rate ratio [RR] = 0.41; 90% confidence interval [CI] = 0.25, 0.66) and violence (RR = 0.42; 90% CI = 0.24, 0.73) were significantly lower for students attending intervention schools. A 2-level random-effects binary model indicated that sexual activity was lower (odds ratio = 0.24; 90% CI = 0.08, 0.66) for intervention students. Teacher reports substantiated the effects seen for student-reported data. Dose-response analyses indicated that students exposed to the program for at least 3 years had significantly lower rates of all negative behaviors. Risk-related behaviors were substantially reduced for students who participated in the program, providing evidence that a comprehensive school-based program can have a strong beneficial effect on student behavior. Beets M, Flay B, Vuchinich S, et al. Use of a social and character development program to prevent substance use, violent behaviors, and sexual activity among elementary-school students in Hawaii. Am J Public Health 2009;99(8):1438-1445.

Optimal Performers in Drug Court have Consistently Negative Drug Screens

Graduation rates in drug courts average 50% to 70%, but it is unclear what proportion of graduates responded to the drug court services and what proportion might not have had serious drug problems on entry. This study cluster analyzes urine drug screen results during the first 14 weeks of treatment on 284 participants from three misdemeanor drug courts. A four-cluster solution (R 2 >.75) produced distinct subgroups characterized by (a) optimal performers with consistently drug-negative urine specimens (34% of the sample), (b) non-responders with consistently drug-positive specimens (21%), (c) non-complaints with consistently missed urine specimens (26%), and (d) responders with urine specimens that began as drug positive but became progressively drug negative over time (19%). With regard to longer-term outcomes, optimal performers were more likely to provide a drug-negative urine specimen at the 6-month follow-up. Authors propose adaptive approaches for drug courts. DeMatteo D, Marlowe DB, Festinger DS, Arabia PL. Outcome trajectories in drug court: Do all participants have serious drug problems? Criminal Justice and Behavior. 2009;36(4):354-368.

Community-Based Prevention System Reduces Substance Use and Delinquency in Grades 5 through 8

This study tested whether the Communities That Care (CTC) prevention system reduces adolescent alcohol, tobacco, and other drug use and delinquent behavior community wide. The Community Youth Development Study is the first randomized trial of the CTC prevention system. In 2003, 24 small towns in 7 states, matched within state, were randomly assigned to control or CTC conditions. A panel of 4407 fifth-grade students was surveyed annually through eighth grade. In the intervention condition, a coalition of community stakeholders received training and technical assistance to install the CTC prevention system. Coalitions used epidemiological data to identify elevated risk factors and depressed protective factors in the community, and chose and implemented tested programs to address their community's specific profile from a menu of effective programs for families, schools, and youths aged 10 to 14 years. Outcomes focused on incidence and prevalence of alcohol, tobacco, and other drug use and delinquent behavior by spring of grade 8. Results indicated that the incidences of alcohol, cigarette and smokeless tobacco initiation, and delinquent behavior were significantly lower in CTC than in control communities for students in grades 5 through 8. In grade 8, the prevalence of alcohol and smokeless tobacco use in the last 30 days, binge drinking in the last 2 weeks, and the number of different delinquent behaviors committed in the last year were significantly lower for students in CTC communities. Hawkins J, Oesterle S, Brown E, Arthur M, Abbott R, Fagan A, Catalano R. Results of a Type 2 Translational Research Trial to Prevent adolescent drug use and delinquency: A test of Communities That Care. Arch Pediatr Adolesc Med. 2009;163(9):789-798.

Long-term Effects of Project ALERT on Risky Sexual Behaviors

This study assesses the impact of a school-based drug prevention program, called Project ALERT, on risky sexual behavior among 1901 non-married, sexually active young adults who participated in one of two program variations as adolescents. It also tests for differences in program effect depending on program duration (middle school only vs. a combined middle school and high school program) and participants' gender. Using survey data from a randomized controlled experiment conducted in 45 Midwestern communities (55 schools), the authors assessed program effects on risky sexual behavior at age 21 with three measures: having unprotected sex because of drug use, engaging in inconsistent condom use, and having sex with multiple partners. Compared to control, Project ALERT reduced the likelihood of all risky sex outcomes except inconsistent condom use among these sexually active young adults. Program effects were found 5 and 7 years after program exposure and were partially mediated by reductions in alcohol and drug abuse. There were no significant differences in program effects by gender or by program duration compared to control. Ellickson P, McCaffrey D, Klein D. Long-term effects of drug prevention on risky sexual behavior among young adults. J Adolesc Health 2009;45(2):111-117.

Reduced Rates of Pregnancy Among Juvenile Justice Girls Exposed to Preventive Intervention

Preventing adolescent pregnancy is a national research priority that has had limited success. In the present study, the authors examined whether Multidimensional Treatment Foster Care (MTFC) relative to intervention services as usual (group care [GC]) decreased pregnancy rates among juvenile justice girls mandated to out-of-home care. Girls (13-17 years of age) with histories of criminal referrals (Mdn = 10) were randomly assigned to MTFC (n = 81) or GC (n = 85) as part of 2 randomized controlled trials. Pregnancy histories were assessed from baseline through 24 months. Fewer post baseline pregnancies were reported for MTFC girls (26.9%) than for GC girls (46.9%)--an effect that remained significant after controlling for baseline criminal referrals, pregnancy history, and sexual activity. MTFC has previously been shown to decrease arrest and lock-up rates. The present findings support the long-term preventive effects of MTFC on adolescent girls' pregnancy rates. Findings are consistent with the notion that programs that target delinquency by impacting general risk behavior pathways and contexts may more successfully prevent teen pregnancy than those that directly target sexual behaviors. Kerr D, Leve L, Chamberlain P. Pregnancy rates among juvenile justice girls in two randomized controlled trials of multidimensional treatment foster care. J Consult Clin Psychol. 2009;77(3):588-593.

Peer Health Advocates Function as Multi-Level Change Agents

The Risk Avoidance Partnership (RAP) Project conducted in Hartford, Connecticut, tests a program to train active drug injectors and crack cocaine users as "Peer Health Advocates" (PHAs) to deliver a modular HIV, hepatitis, and STI prevention intervention to hard-to-reach drug users in their networks and others in the city. The intervention was designed to diffuse health promotion and risk-reduction interventions by supporting PHAs to model prevention practices and deliver risk- and harm-reduction materials and information. The study compared change in behaviors and attitudes between baseline and 6-month follow-up of 112 primarily African-American and Latino PHAs, 223 of their drug-user network contact referrals, and 118 other study recruits (total n = 523). Results indicated significant HIV risk reduction among all study participants, associated with significant health advocacy action conducted by PHAs, and a relationship between exposure to the RAP peer-delivered intervention and risk reduction among all study groups. Findings suggest that active drug users' engagement in peer health advocacy can set in motion a feedback and diffusion process that supports both the continued work of the PHAs and the adoption of harm reduction and mimicking of health advocacy by their peers. Weeks M, Li J, Dickson-Gomez J, Convey M. Outcomes of a peer HIV prevention program with injection drug and crack users: The risk avoidance partnership. Subst Use Misuse 2009;44;251-279.

Two Interventions Reduce Sexual Risks among IDU in Ukraine

A brief human immune-deficiency virus (HIV) testing and counseling intervention was compared to a more time-consuming and expensive street-based intervention with injection drug users (IDUs). A cross-over experimental design was used in which 900 IDUs were recruited, followed by a ''wash-out '' period with no recruitment, a reversal of intervention assignment areas and an additional recruitment of 900 IDUs with baseline and 6-month follow-up assessments. The project was conducted in Kiev, Odessa and Makeevka/Donesk Ukraine with a total of 798 IDUs. HIV testing and ACASI data were collected from all. Participants in both conditions reduced their injection and sex risks significantly; however, there was little difference in outcomes between conditions. IDUs who knew they were HIV-infected at baseline were significantly more likely to practice safe sex than those unaware or HIV-negative; those who first learned that they were infected at baseline changed their safe sex practices significantly more than those who already knew that they were infected at baseline and those who were HIV-negative. Booth R, Lehman W, Dvoryak S, Brewster J, Sinitsyna L. Interventions with injection drug users in Ukraine. Addiction. 2009;104(11):1864-1873.

Variations in Risk Reduction with a Peer Intervention in Thailand & the US

This study assessed the efficacy of a network-oriented peer education intervention promoting HIV risk reduction among injection drug users and their drug and sexual network members in Chiang Mai, Thailand and Philadelphia, USA. A total of 414 networks with 1123 participants were enrolled. The experimental intervention consisted of 6 small group peer educator training sessions and 2 booster sessions delivered to the network index only. All participants in both arms received individual HIV counseling and testing. Follow-up visits occurred every six months for up to 30 months. There were 10 HIV seroconversions, 5 in each arm. The number of participants reporting injection risk behaviors dropped dramatically between baseline and follow-up in both arms at both sites. Index members in the intervention arm engaged in more conversations about HIV risk following the intervention compared to control indexes. There was no evidence of change in sexual risk as a result of the intervention. Reductions in injection risk behaviors were observed: 37%, 20%, and 26% reduction in odds of sharing cottons, rinse water and cookers, respectively, and 24% reduction in using a syringe after someone else. Analysis of the individual sites suggested a pattern of reductions in injection risk behaviors in the Philadelphia site. In both sites, the intervention resulted in index injection drug users engaging in the community role of discussing reduction in HIV injection risk behaviors. Latkin CA, Donnell D, Metzger D, et al. The efficacy of a network intervention to reduce HIV risk behaviors among drug users and risk partners in Chiang Mai, Thailand and Philadelphia, USA. Soc Sci Med. 2009;68(4):740-748.

Brief Motivational Intervention Reduces HIV Risk and Increases HIV Testing among Offenders Under Community Supervision

Risky drug- and sex-related behaviors put criminal offenders at high risk for HIV. Intervening with this population under supervision can potentially reduce risk. This study reports a randomized trial that examines the efficacy of brief negotiation interviewing (BNI) compared to usual education activities. BNI is a computerized, self-directed intervention that combines a short structured interview with a brief counseling session. The study examined whether BNI could decrease HIV risks and increase testing for HIV in a cohort of criminal-justice-involved clients. The trial randomly assigned 212 participants to experimental (108) and control (104) conditions. Interview data were collected at baseline and at 2-month follow-up. Results indicate that the BNI intervention group had a significantly higher rate of HIV testing and was more likely to consider behavioral changes. Alemagno S, Stephens R, Stephens P, Shaffer-King P, White P. Brief motivational intervention to reduce HIV risk and to increase HIV testing among offenders under community supervision. J Correct Health Care. 2009; 15(3):210-221.

Parenting Interventions for American Indian Communities: A Cultural Approach to Implementation

The current investigation puts forth the authors' conceptualization of a cultural approach to implementing evidence-based practices with American Indian (AI) families. Their approach involves two phases, the motivational phase, which sets an historical context for current difficulties; and the intervention phase, which links evidence-based skills with cultural traditions, beliefs, and values. This report presents preliminary evidence for the efficacy of the intervention phase, overlaid onto the Incredible Years parenting program (Webster-Stratton, 1992). Forty-nine families with American Indian children, ages 3-11 (26 boys), participated in the study; all families participated in the motivational phase and were subsequently randomized to the culturally linked intervention or to a control condition (delayed intervention condition). Significant pre- and post improvements in parenting and child behavior were observed in the intervention group as compared to those in the control group. Moreover, a majority of participants reported high levels of satisfaction with the intervention. Dionne R, Davis B. Initial evaluation of a cultural approach to implementation of evidence-based parenting interventions in American Indian communities. J Community Psychol. 2009;37(7):911-921.

Implementation of Evidence-Based Prevention under Real World Conditions Can Positively Impact Youth, Parent and Family Outcomes

It is becoming increasingly common for community teams or coalitions to implement programming for children and families designed to promote positive youth development and prevent adolescent problem behaviors. However, there has been only limited rigorous study of the effectiveness of community teams' programming efforts to produce positive outcomes. This study employed a community-level randomized control design to examine protective parent and youth skills outcomes of evidence-based preventive interventions selected from a menu and delivered by community teams supported by a community-university partnership model called PROSPER. Twenty-eight rural communities in two states were randomized across intervention and control conditions. Data were collected through written questionnaires that were completed by approximately 12,000 middle school students in the fall of the 6th grade, prior to intervention delivery, and again in the spring of the 7th, 8th, and 9th grades. Positive intervention effects were found for youth, parent, and family outcomes (e.g., association with antisocial peers, child management, parent-child affective quality) at each post-intervention assessment point. Improvements in these family and youth skill outcomes are expected to support long-term reductions of adolescent problem behaviors, such as substance abuse. This study supports the use of research-based models for diffusion of evidence-based prevention interventions, in this case a model for delivery via community teams. Redmond C, Spoth R, Shin C, Schainker L, Greenberg M, Feinberg M. Long-term protective factor outcomes of evidence-based interventions implemented by community teams through a community-university partnership. J Prim Prev. 2009;30(5):513-530.

Implementing Evidence-Based Prevention in the US and Netherlands

This paper describes the degree to which implementation of the Communities That Care (CTC) prevention operating system, a theoretically based community-based strategic approach to reducing youth involvement in problem behaviors, was reached in 22 communities in 2 countries: the US (12 communities) and the Netherlands (10 communities). Core elements of CTC and results from two implementation measures conducted in both countries are reported here. The implementation process of CTC in the US and the Netherlands was compared. The US data came from a group-randomized trial of CTC, conducted in 24 small to medium communities in seven states, which began implementation in 2002. The Netherlands data came from 10 Dutch cities that implemented CTC between 2000 and 2006. Similarities and differences of the implementation process are discussed. Milestones (goals met by the communities) and benchmarks (actions by community members or conditions put in place to achieve the targeted goals) of the CTC implementation process were assessed along with interviews of coalition board members. Assessment of milestones and benchmarks suggested that the US achieved high implementation of CTC in the 24 communities. Implementation in the Netherlands was similar, but somewhat lower. Both countries were successful at recruiting and engaging key stakeholders and establishing community planning boards. Common challenges to implementation in both countries included the adoption and implementation of tested, effective programs--largely due to concern about uptake of new programs over familiar programs without evidence of effectiveness. Also, while both countries identified key stakeholders and board members, challenges were noted in both countries around these efforts and around specific roles and coordination of CTC planning with other community efforts, with lack of technology for facilitating this identified as a specific issue. Overall, both countries were successful in mobilizing stakeholders and using data to guide the selection and adoption of evidence-based prevention interventions. This cross-national comparison demonstrates potential for a system of implementation for science-based prevention programs. Jonkman HB, Haggerty KP, Steketee M, Fagan A, Hanson K, Hawkins JD. Communities That Care, core elements and context: Research of implementation in two countries. Soc. Dev. Issues. 2009;30(3):42-57.

The Role of Actor and Message Characteristics in Antismoking Public Service Announcements

This study examined whether the appeal of actors (i.e., their likeability and attractiveness) used in antismoking public service announcements (PSAs) interacts with adolescents' risk of future smoking to predict adolescents' smoking resistance self-efficacy and whether the antismoking messages in the PSAs further moderates this relationship. The study design involved a 2 (future smoking risk: low, high) x 2 (actor appeal: low, high) x 3 (PSA antismoking message: tobacco industry manipulation, short-term smoking effects, long-term smoking effects) analysis. A diverse sample of 110 adolescents (55% female, aged 11-17 years), with varying levels of experience with smoking, rated their smoking resistance self-efficacy after viewing each of the PSAs. A total of 22 (18%) of the sample reported smoking at least a puff of a cigarette in the past, but none of the participants were current smokers. Overall, PSAs that used long-term smoking effects messages were associated with the strongest smoking resistance self-efficacy, followed in turn by PSAs that used short-term smoking effects messages and by tobacco industry manipulation messages. There was a significant interaction between actor appeal and PSA antismoking message. The use of more appealing actors was associated with stronger smoking resistance self-efficacy only in long-term smoking effects PSAs. The use of less appealing actors was associated with stronger smoking resistance self-efficacy for tobacco industry manipulation PSAs and short-term smoking affects PSAs. Future smoking risk did not moderate any of these findings. Antismoking PSAs that emphasize long-term smoking effects are most strongly associated with increased smoking resistance self-efficacy. The effect of these PSAs can be strengthened by using actors whom adolescents perceive to be appealing. Shadel W, Fryer C, Tharp-Taylor S. Uncovering the most effective active ingredients of antismoking public service announcements: The role of actor and message characteristics. Nicotine Tob Res. 2009;11(5):547-552.

International Spanish/English Smoking Cessation Trial Yields 20% Abstinence Rates at One Year

Traditional smoking cessation methods, such as nicotine replacement therapy and smoking cessation groups, yield between 14% and 27% abstinence rates at 6 months. Evidence-based Internet interventions with comparable abstinence rates could be a powerful global tool to reduce tobacco-related morbidity and mortality. This study reports on a randomized control trial in which 500 Spanish-speaking and 500 English-speaking adult Internet users, smoking at least 5 cigarettes a day and intending to quit in the next month, were recruited online from 68 countries. Consenting participants who completed baseline measures, logged cigarettes smoked on 3 days within a week, and set a quit date were randomized to four intervention conditions. Each condition added new elements: Condition 1 was the "Gua Para Dejar de Fumar," a static National Cancer Institute evidence-based stop smoking guide; Condition 2 consisted of Condition 1 plus E-mail reminders to return to the site; Condition 3 consisted of Condition 2 plus mood management lessons; and Condition 4 consisted of Condition 3 plus a "virtual group" (an asynchronous bulletin board). Main outcome measures were 7-day point prevalence abstinence at 1, 3, 6, and 12 months after initial quit date. There were no significant differences among the four conditions. The overall 12-month 7-day abstinence rates were 20.2% for Spanish speakers and 21.0% for English speakers when those with missing data were assumed to be smoking. Internet smoking cessation interventions with such abstinence rates that are provided globally could contribute substantially to tobacco control efforts. Muoz R, Barrera A, Delucchi K, Penilla C, Torres L, Pérez-Stable E. International Spanish/English internet smoking cessation trial yields 20% abstinence rates at 1 year. Nicotine Tob Res. 2009;11(9):1025-1034.

Mediation Effects for the Aban Aya Drug Abuse Prevention Program

This study illustrates a method to evaluate mediational mechanisms in a longitudinal prevention trial, the Aban Aya Youth Project (AAYP). In previous studies, interventions of AAYP were found to be effective in reducing the growth of violence, substance use and unsafe sex among African American adolescents. In this article, the authors hypothesize that the effects of the intervention in reducing the growth of substance use behavior were achieved through effects in changing intermediate processes such as behavioral intentions, attitudes toward the behavior, estimates of peers' behaviors, best friends' behaviors, and peer group pressure. In evaluating these mediational mechanisms, difficulties arose because the growth trajectories of the substance use outcome variable and some of the mediating variables were curvilinear. In addition, all of the multivariate mediational measures had planned missing data so that a score from the multiple items for a mediator could not be formed easily. A latent growth modeling (LGM) approach was introduced to address these issues; namely, a two-domain LGM mediation model, in which the growth curves of the outcome and the mediator are simultaneously modeled and the mediation effects are evaluated. Results showed that the AAYP intervention effects on adolescent drug use were mediated by normative beliefs of prevalence estimates, friends' drug use behavior, perceived friends' encouragement to use, and attitudes toward the behavior. Liu L, Flay B. Evaluating mediation in longitudinal multivariate data: Mediation effects for the Aban Aya youth project drug prevention program. Prev Sci. 2009;10(3):197-207.

Drug Use Among Patrons of Electronic Music Dance Events

The prevalence of drug and alcohol use among patrons of clubs featuring electronic music dance events was determined by using biological assays at entrance and exit. Using a portal methodology that randomly selects groups of patrons on arrival at clubs, oral assays for determining level and type of drug use and level of alcohol use were obtained anonymously. Patrons provided self-reported data on their personal characteristics. A total of 362 patrons were interviewed at entrance and provided oral assay data, and 277 provided data at both entrance and exit. Overall, one quarter of all patrons surveyed at entrance were positive for some type of drug use. Based on the authors' exit sample, one quarter of the sample were positive at exit. Individual drugs most prevalent at entrance or exit included cocaine, marijuana, and amphetamines/stimulants. Only the amphetamine/stimulant category increased significantly from entrance to exit. Drug-using patrons arrive at the club already using drugs; few patrons arrive with no drug use and leave with detectable levels of drug use. Clubs vary widely in drug-user prevalence at entrance and exit, suggesting that both events and club policies and practices may attract different types of patrons. Approximately one half of the total entrance sample arrived with detectable alcohol use, and nearly one fifth arrived with an estimated blood alcohol concentration of .08 or greater. Based on our exit sample data, one third of patrons were intoxicated, and slightly less than one fifth were using both drugs and alcohol at exit. Clubs attract a wide array of emerging adults, with both genders and all ethnicities well represented. Clubs also attract emerging adults who are not in college and who are working full time. Thus, these clubs present a potentially important location for prevention strategies designed to reduce the risks associated with drug and alcohol use for young people. Miller B, Furr-Holden D, Johnson M, Holder H, Voas R, Keagy C. Biological markers of drug use in the club setting. J Stud Alcohol Drugs 2009;70(2):261-268.

Racial/Ethnic Differences in Parental Concern about Their Child's Drug Use in a Nationally Representative Sample in the United States

Parental concern and negative attitudes toward drug use may prevent youth from being involved in drug use. However, few studies have addressed parental concern about children's drug use and its possible variation by race/ethnicity. This study examined the potential racial/ethnic differences in parental concern about their children's drug use with a nationally representative sample. The data were from the 2003 National Survey of Children's Health, a random household telephone survey of parents of children up to age 17 (n = 102,353). The sample for this study was restricted to parents of children aged 6 to 17 years (n = 61,046). Multivariate logistic regression models were performed while controlling for children's age, gender, family structure, and family poverty level, and simultaneously accommodating the complex survey design. Parents of African American and Hispanic children expressed more concern about drug use than parents of white children, even after controlling for potential confounders (adjusted odds ratio (AOR), 1.9; 95% CI, 1.8-2.1 and AOR, 1.9; 95% CI, 1.7-2.1, respectively). The finding that level of parental concern about adolescent drug use was different across race/ethnicity groups may have implications for parental participation in school-based adolescent prevention programs. Zhu S, Wang Y, Browne DC, Wagner FA. Racial/ethnic differences in parental concern about their child's drug use in a nationally representative sample in the United States. J Natl Med Assoc. 2009;101(9):915-919.

Executive Functions in Children: Associations with Aggressive Behavior and Appraisal Processing

This study investigated whether and how deficits in executive functioning and distortions in appraisal processing are related to subtypes of aggressive behavior. The sample included 83 boys assessed using multi-informant reports and performance measures. Deficits in two executive functions, response inhibition and planning ability were related primarily to reactive aggression. Hostile attributional biases moderated relations between planning ability and proactive and reactive aggression subtypes, with minimal relations between planning deficits and aggression at low levels of hostile attributional bias. As the level of hostile attributional bias increased, the relation between planning deficits and reactive aggression became increasingly large in a positive direction whereas the relation between planning deficits and proactive aggression became increasingly negative. Additionally, hostile encoding moderated the relation between behavioral inhibition and reactive aggressive behavior. Results also suggested a mediational role for response inhibition in the relation between planning ability and reactive aggression. Ellis M, Weiss B, Lochman J. Executive functions in children: Associations with aggressive behavior and appraisal processing. J Abnorm Child Psychol. 2009;37(7):945-956.

Abuse and Distress among Sex Workers on the US-Mexico Border

This study examined histories of past emotional, physical, and sexual abuse as correlates of current psychological distress using data from 916 female sex workers (FSWs) who were enrolled in a safer-sex behavioral intervention in Tijuana and Ciudad (Cd.) Juarez, Mexico. It was hypothesized that histories of abuse would be associated with higher symptom levels of depression and somatization and that social support would moderate the relationship. Nonparametric correlations and a series of hierarchical regression analyses revealed that all forms of past abuse predicted higher levels of depressive symptoms, and physical and sexual abuse were significantly associated with higher levels of somatic symptoms. Social support was also significantly associated with fewer symptoms of distress; however, it was not shown to moderate the relationship between abuse history and distress. Ulibarri M, Semple S, Rao S, et al. History of abuse and psychological distress symptoms among female sex workers in two Mexico-U.S. border cities. Violence Vict. 2009; 24(3):399-413.

Links between Perceived Racism, Low Academic Control, and Depression among African American Youth

Experiences with racism are a common occurrence for African American youth and may result in negative self perceptions relevant for the experience of depressive symptoms. This study examined the longitudinal association between perceptions of racism and depressive symptoms, and whether perceived academic or social control mediated this association, in a community epidemiologically-defined sample of urban African American adolescents. Participants were 500 African American middle school students (46.4% female) who were initially assessed in the fall of first grade as part of an evaluation of two school-based preventive interventions whose immediate targets were early learning and aggressive behavior in first grade. The original sample consisted of 678 children and families, representative of students entering first grade in nine Baltimore City public elementary schools, who were recruited for participation in the intervention trials. Structural equation modeling revealed that experiences with racism were associated with low perceived academic control, which in turn was associated with increased depressive symptoms. Findings suggest that experiences with racism can have long lasting effects for African American youth's depressive symptoms, and highlight the detrimental effects of experiences with racism for perceptions of control in the academic domain. Lambert S, Herman K, Bynum M, Ialongo N. Perceptions of racism and depressive symptoms in African American adolescents: The role of perceived academic and social control. J Youth Adolesc. 2009;38(4):519-531.

Adolescent Substance Use May Increase in Reaction to Exposure to Natural Disasters

Little systematic research attention has been devoted to the impact of natural disasters on adolescent substance use. The present study examined relationships among exposure to Hurricane Rita, post-traumatic stress (PTS) symptoms, and changes in adolescent substance use from 13 months pre-disaster to seven and 19 months post-disaster. Subjects were 280 high school students in southwestern Louisiana who participated in a drug abuse prevention intervention trial prior to the hurricane. Two-thirds of participants were female and 68% were white. Students completed surveys at baseline (13 months pre-hurricane) and two follow-ups (seven and 19 months post-hurricane). Results indicated objective exposure to the hurricane predicted increases in marijuana use, and post-hurricane negative life events predicted increases in alcohol, marijuana, and cigarette use (ps < .10). These findings suggest that increased substance use may be one of the behaviors that adolescents exhibit in reaction to exposure to hurricanes. Rohrbach L, Grana R, Vernberg E, Sussman S, Sun P. Impact of Hurricane Rita on adolescent substance use. Psychiatry. 2009;72(3):222-237.

Assessment of HIV Risks among Male Clients of Female Sex Workers on the US-Mexico Border

Research rarely has directly assessed male clients of female sex workers (FSW). A total of 400 men aged 18 years or older who had paid or traded for sex with a FSW in Tijuana during the past 4 months were recruited in Tijuana's "zone of tolerance," where prostitution is practiced openly under a municipal permit system. Efforts were made to balance the sample between residents of the United States (San Diego County) and of Mexico (Tijuana). Participants underwent interviews and testing for HIV, syphilis, gonorrhea, and Chlamydia. Logistic regression identified correlates of HIV infection. Mean age was 36.6 years. One-quarter had injected drugs within the previous 4 months. Lifetime use of heroin, cocaine, and methamphetamine was 36%, 50%, and 64%, respectively. Men had frequented FSWs for an average of 11 years, visiting FSWs an average of 26 times last year. In the past 4 months, one-half reported having unprotected sex with a FSW; 46% reported being high fairly or very often when having sex with a FSW. Prevalence of HIV, syphilis, gonorrhea, and Chlamydia was 4%, 2%, 2.5%, and 7.5%; 14.2% were positive for at least one infection. Factors independently associated with HIV infection were living in Mexico, ever using methamphetamine, living alone, and testing positive for syphilis. Male clients of FSWs in Tijuana had a high sex and drug risk profile. Although sexually transmitted infection prevalence was lower than among FSWs, HIV prevalence was comparable suggesting the need for interventions among clients to prevent spread of HIV and sexually transmitted infections. Patterson T, Goldenberg S, Gallardo M, et al. Correlates of HIV, sexually transmitted infections, and associated high-risk behaviors among male clients of female sex workers In Tijuana, Mexico. AIDS 2009;23(13):1765-1771.

HIV Risk among IDU on the US-Mexico Border

Tijuana is situated on the Mexico-USA border adjacent to San Diego, CA, on a major drug trafficking route. Increased methamphetamine trafficking in recent years has created a local consumption market. Factors associated with methamphetamine use and routes of administration by gender among injection drug users (IDUs) were examined. From 2006-2007, IDUs > or =18 years old in Tijuana were recruited using respondent-driven sampling, interviewed, and tested for HIV, syphilis, and TB. Logistic regression was used to assess associations with methamphetamine use (past 6 months), stratified by gender. Among 1,056 participants, methamphetamine use was more commonly reported among females compared to males (80% vs. 68%, p < 0.01), particularly, methamphetamine smoking (57% vs. 34%; p < 0.01). Among females (N = 158), being aged >35 years (AOR, 0.2; 95% CI, 0.1-0.6) was associated with methamphetamine use. Among males (N = 898), being aged >35 years (AOR, 0.5; 95% CI, 0.3-0.6), homeless (AOR, 1.4 (0.9-2.2)), and ever reporting sex with another male (MSM; AOR, 1.9; 95% CI, 1.4-2.7) were associated with methamphetamine use. Among males, a history of MSM was associated with injection, while sex trade and >2 casual sex partners were associated with multiple routes of administration. HIV was higher among both males and females reporting injection as the only route of methamphetamine administration. Methamphetamine use is highly prevalent among IDUs in Tijuana, especially among females. Routes of administration differed by gender and subgroup which has important implications for tailoring harm reduction interventions and drug abuse treatment. Rusch M, Lozada R, Pollini R, Vera A, Patterson T, Case P, Strathdee S. Polydrug use among IDUs in Tijuana, Mexico: Correlates of methamphetamine use and route of administration by gender. J Urban Health 2009;86(5):760-775.

Drug Use and Associated Factors in the Mortality of HIV+ Women

Deaths were studied over a 10-year period among participants in the Women's Interagency HIV Study. Deaths were ascertained by National Death Index Plus match, and causes of death determined by death certificate. From 1995 through 2004, 710 of 2,792 HIV-infected participants died. During this interval, the standardized mortality ratio fell from a high of 24.7 in 1996 to a plateau with a mean of 10.3 from 2001 to 2004. Over the decade, deaths from non-AIDS causes increased and accounted for the majority of deaths by 2001-2004. The most common non-AIDS causes of death were trauma or overdose, liver disease, cardiovascular disease, and malignancy. Independent predictors of mortality besides HIV-associated variables were depressive symptoms and active Hepatitis B or C. Women who were overweight or obese were significantly less likely to die of AIDS than women of normal weight. French A, Gawel S, Hershow R, et al. Trends in mortality and causes of death among women with HIV in the United States: A 10-year study. J Acquir Immune Defic Syndr. 2009;51(4):399-406.

Isolated Antibody to Hepatitis B Core Antigen (Anti-HBc) among HIV+ and HIV- Women

Isolated antibody to hepatitis B core antigen (anti-HBc) is a common serologic finding in persons infected with human immunodeficiency virus (HIV), but the outcome and clinical significance are uncertain. Repeated hepatitis B virus (HBV) serologic tests were performed on women who participated in the Women's Interagency HIV Study and who had isolated anti-HBc at study entry. Tests were performed for 322 women (282 HIV-infected and 40 HIV-uninfected) at a median of 7.5 years after study entry, of whom 71% women retained isolated anti-HBc serologic status, 20% acquired antibody to hepatitis B surface antigen (anti-HBs), and 2% acquired hepatitis B surface antigen (HBsAg). In unadjusted analysis, increasing age, injection drug use, and hepatitis C viremia were negatively associated with acquisition of anti-HBs. Among HIV-infected women, predictors of acquisition of anti-HBs were an increase in CD4 cell count and the use of highly active antiretroviral therapy (HAART). Receipt of drugs with activity against HBV and self-reported HBV vaccination did not predict anti-HBs acquisition. In the multivariable regression model, HAART use remained a significant predictor of anti-HBs acquisition, whereas women with hepatitis C viremia were more likely to retain isolated anti-HBc serologic status. Isolated anti-HBc status remained stable over time for the majority of women, especially women with chronic hepatitis C virus infection. Development of anti-HBs was predicted by HAART use and an increase in CD4 cell count. The authors conclude that a proportion of HIV-infected women with isolated anti-HBc have prior natural HBV infection with anti-HBs that is at an undetectable level because of immune dysfunction. Isolated anti-HBc in the presence of chronic hepatitis C virus infection may be attributable to a different phenomenon, such as dysfunctional antibody production. French A, Lin M, Evans C, et al. Long-term serologic follow-up of isolated Hepatitis B core antibody in HIV-infected and HIV-uninfected women. Clin Infect Dis. 2009;49(1):48-154.

Factors Associated with STI Incidence among Thai Methamphetamine Users

Methamphetamine users aged 18 to 25 years were enrolled in a 12-month randomized behavioral intervention trial in Chiang Mai, Thailand in 2005. Behavioral questionnaires were administered at visits every 3 months, and biologic specimens were collected at baseline and 12 months to test for common STIs (chlamydia, gonorrhea, HSV-2, and HIV). Poisson regression with robust variance was used to determine risk factors for incident STIs. Overall, 12.7% of 519 participants acquired at least 1 STI. Chlamydia was the most common (10.6%), followed by HSV-2 (4.0%), gonorrhea (2.9%), and HIV (0.6%). Risk factors for both men and women included self-reported incarceration, having a casual sex partner during follow-up, and having a prevalent STI at baseline. Additionally, among women, having 2 or more heterosexual partners, and among men, having a greater frequency of drunkenness were risk factors for STI acquisition. Although HIV incidence was low in this population, incidence of other STIs is high compared with previous studies of young Thai adults. Sutcliffe C, Aramrattana A, Sherman S, Sirirojn B, German D, Wongworapat K, Quan V, Keawvichit R, Celentano D. Incidence of HIV and sexually transmitted infections and risk factors for acquisition among young methamphetamine users in northern Thailand. Sex Transm Dis. 2009;36(5):284-289.

Correlates of Incarceration among Thai Methamphetamine Users

Correlates of incarceration among young methamphetamine users in Chiang Mai, Thailand were observed in cross-sectional data collected from 2005 to 2006 among 1189 young methamphetamine users, of whom 22% reported ever having been incarcerated. Participants were surveyed about their recent drug use, sexual behaviors, and incarceration. Biological samples were obtained to test for sexually transmitted and viral infections. In multivariate analysis, incarceration history was associated with frequent public drunkenness, starting to use illicit drugs at an early age, involvement in the drug economy, tattooing, injecting drugs, and unprotected sex. HIV, HCV, and herpes simplex virus type 2 (HSV-2) infections also were correlated with incarceration. Thomson N, Sutcliffe CG, Sirirojn B, Kaewvichit R, Wongworapat K, Sintupat K, Aramrattana A, Celentano DD. Correlates of incarceration among methamphetamine users in Chiang Mai, Thailand. Am J Public Health 2009;99(7);1232-1238.

Transactional Sex among Street Children in Pakistan

The study examined HIV risk behaviors and factors associated with exchanging sex among male street children in Lahore, Pakistan with a survey that was conducted from August 2003 to March 2004 among 565 registrants, ages 5-19, of Project Smile, a program that aimed to enhance the lives of street children in Lahore. Multivariate log-binomial regression was used to evaluate the independent effect of covariates on exchange of sex for money, goods, or drugs. Approximately 40% of participants reported having exchanged sex during the past 3 months. In multivariate analysis, the factors associated with exchanging sex were living on the street for longer than 48 months (Prevalence Ratio [PR]=1.36, 95% Confidence Interval [CI]: 0.99-1.85), reporting ever having used drugs (PR=1.87, 1.10-3.16), cutting ones self (PR=1.66, 95% CI: 1.26-2.19), and having heard of HIV/AIDS (PR=1.36, 95% CI: 1.03-1.80) after adjusting for demographic and street life variables. The finding that children who have heard about HIV/AIDS are more likely to exchange sex suggests that children at HIV risk talk about HIV, but accuracy of their conversations is unclear. Street children in Pakistan are in great need of HIV education and safe alternatives for generating income. Towe V, ul Hasan S, Zafar S, Sherman S. Street life and drug risk behaviors associated with exchanging sex among male street children in Lahore, Pakistan. J Adolesc Health 2009;44(3):222-228.

Risk Behavior in Sociocentric Network of Eastern European MSM

This study recruited four sociocentric networks (n = 156) of men who have sex with men in Budapest, Hungary, and St. Petersburg, Russia. The sampling approach was based on identifying an initial "seed" in the community for each network, and then recruiting three successive friendship group waves out from the seed. HIV prevalence in the networks was 9%, and the composite rate of other sexually transmitted diseases was 6%. Fifty-seven percent of participants reported both main and casual male partners, and 2/3 reported unprotected anal intercourse in the past 3 months. Fifty-five percent of men's most recent anal intercourse acts were with nonexclusive partners, and 56% of most recent anal intercourse acts were unprotected. Sexual risk was associated with more often talking with friends about AIDS, higher ecstasy use, and less often drinking. Amirkhanian Y, Kelly J, Takacs J, Kuznetsova A, DiFranceisco W, Mocsonaki L, McAuliffe T, Khoursine R, Toth T. HIV/STD prevalence, risk behavior, and substance use patterns and predictors in Russian and Hungarian sociocentric social networks of Men Who Have Sex With Men. AIDS Educ. Prev. 2009;21(3):266-279.

Sexual HIV Risk Behavior among IDU in Baltimore

This study compared male and female injection drug users (IDUs) on perceived risk of contracting HIV and examined the associations between risk perceptions and sharing injection drugs or equipment, engaging in casual sex, and engaging in commercial sex. Baseline data from 271 IDUs recruited between 2000 and 2005 from the Baltimore, Maryland site of the International Neurobehavioral HIV Study was analyzed. Although there was no significant difference in levels of perceived risk between males and females, males reported significantly more casual sex, whereas females reported more commercial sex. Logistic regression analyses with the entire sample indicated that sharing of injection drugs or equipment was consistently associated with greater perceived risk. There was also a significant interaction between gender and having had casual sex, such that females who had engaged in casual sex were significantly more likely to perceive that they were at greater risk for contracting HIV. Results suggest that male IDUs should be targeted for HIV risk-reduction programs focusing on casual and commercial sex. Mitchell M, Latimer W. Gender differences in high risk sexual behaviors and injection practices associated with perceived HIV risk among injection drug users. AIDS Educ. Prev. 2009;21(4):384-394.

Characteristics of Hospitalized HIV+ Crack Users

A total of 1038 HIV+ inpatients were interviewed in public hospitals in Miami, Florida, and Atlanta, Georgia, to examine patient factors associated with use of HIV care, use of antiretroviral therapy, and unprotected sexual intercourse. Multivariate analyses and multiple logistic regression models showed that use of crack cocaine and heavy drinking were associated with never having had an HIV-care provider, high-risk sexual behavior, and not receiving antiretroviral therapy. Inpatient interventions that link and retain HIV-positive persons in primary care services could prevent HIV transmission and unnecessary hospitalizations. Metsch LR, Bell C, Cardenas G, et al. Hospitalized HIV-infected patients in the era of highly active antiretroviral therapy. Am J Public Health 2009;99(6):1045-1049.

Global Reach of an Internet Smoking Cessation Intervention among Spanish- and English-Speaking Smokers

This investigation is a secondary analysis of demographic, smoking, and depression information in a global sample of Spanish- and English-speaking smokers who participated in a series of randomized controlled smoking cessation trials conducted via the Internet. The final sample consisted of 17,579 smokers from 157 countries. Smoking profiles were similar across languages and world regions and consistent with characteristics of participants in traditional smoking cessation studies. Participants were predominantly Spanish-speakers, evenly divided between men and women and relatively few indicated using traditional smoking cessation methods (e.g., groups or medication). This study demonstrates that substantial numbers of smokers from numerous countries seek Web-based smoking cessation resources, and adds to the growing support for Web-assisted tobacco interventions as an additional tool to address the need for global smoking cessation efforts. Barrera A, Pérez-Stable E, Delucchi K, Muoz R. Global reach of an internet smoking cessation intervention among Spanish- and English-speaking smokers from 157 countries. Int J Environ Res Public Health 2009;6(3):927-940.

Higher Rates of Current Smoking in Indigenous and Mixed Ethnicity Youth in Jujuy, Argentina

Latin America is the world region with the highest rates of youth tobacco use and widest socioeconomic gaps, yet no data are available on smoking among Indigenous people, the largest disadvantaged group in the region. A self-administered survey of 3,131 8th grade youth enrolled in a random sample of 27 urban and rural schools was administered in 2004 in Jujuy, Argentina. Standard questions adapted from global surveys were used. Compared with youth of European background, Indigenous and Mixed ethnicity youth had higher prevalence of current smoking. The odds of current smoking remained significantly elevated for Indigenous (OR 1.9; 95% CI = 1.1 - 3.3) and Mixed youth (OR 2.0; 95% CI = 1.2 - 3.4) after controlling for confounders. Other risk factors that were associated with current smoking included: having any friends who smoke, repeating a grade in school, depressive symptoms in previous year, drinking any alcohol in the previous week and thrill seeking orientation. These results underscore the importance of social and cultural diversity aspects of the global tobacco epidemic. Alderete E, Kaplan C, Gregorich S, Meja R, Pérez-Stable E. Smoking behavior and ethnicity in Jujuy, Argentina: Evidence from a low-income youth sample. Subst Use Misuse 2009;44(5):632-646.


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