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Director's Report to the National Advisory Council on Drug Abuse - September, 2006

Research Findings - Services Research

Efficacious Treatment of Opioid Dependence in a Primary Care, Office-based Setting

The optimal level of counseling and frequency of attendance for medication distribution had not been established for the primary care, office-based buprenorphine-naloxone treatment of opioid dependence. This study from David A. Fiellin and colleagues from Yale University shows that once-weekly doses of buprenorphine and naloxone, combined with psychotherapy and delivered in a doctor's office, were just as effective in treating opiate addiction as thrice-weekly doses and extended weekly counseling. The authors conducted a 24-week randomized, controlled clinical trial with 166 patients assigned to one of three treatments: standard medical management and either once-weekly or thrice-weekly medication dispensing or enhanced medical management and thrice-weekly medication dispensing. Standard medical management was brief, manual-guided, medically focused counseling; enhanced management was similar, but each session was extended. The primary outcomes were the self-reported frequency of illicit opioid use, the percentage of opioid-negative urine specimens, and the maximum number of consecutive weeks of abstinence from illicit opioids. The three treatments had similar efficacies with respect to the mean percentage of opioid-negative urine specimens (standard medical management and once-weekly medication dispensing, 44 percent; standard medical management and thrice-weekly medication dispensing, 40 percent; and enhanced medical management and thrice-weekly medication dispensing, 40 percent; P=0.82) and the maximum number of consecutive weeks during which patients were abstinent from illicit opioids. All three treatments were associated with significant reductions from baseline in the frequency of illicit opioid use, but there were no significant differences among the treatments. The proportion of patients remaining in the study at 24 weeks did not differ significantly among the patients receiving standard medical management and once-weekly medication dispensing (48 percent) or thrice-weekly medication dispensing (43 percent) or enhanced medical management and thrice-weekly medication dispensing (39 percent) (P=0.64). Adherence to buprenorphine-naloxone treatment varied; increased adherence was associated with improved treatment outcomes. Patient satisfaction was significantly higher with once-weekly than with thrice-weekly medication dispensing, although this may represent a chance finding. This study further confirms that many patients can receive efficacious care for opioid dependence in a primary care, office-based setting. Furthermore, it establishes the level of care required to achieve optimal results and to most efficiently treat the increasing number of patients that have been attracted to this medical service. Fiellin, D.A., et al. Counseling Plus Buprenorphine-Naloxone Maintenance Therapy for Opioid Dependence. New England Journal of Medicine, 355(4), pp. 365-374, 2006.

Survival Benefits of AIDS Treatment

As widespread adoption of potent combination antiretroviral therapy (ART) reaches its tenth year, the objective of this study was to quantify the cumulative survival benefits of acquired immunodeficiency syndrome (AIDS) care in the United States. Eras were defined that corresponded to advances in standards of human immunodeficiency virus (HIV) disease care, including opportunistic infection prophylaxis, treatment with ART, and the prevention of mother-to-child transmission (pMTCT) of HIV. Per-person survival benefits for each era were determined using a mathematical simulation model. Published estimates provided the number of adult patients with new diagnoses of AIDS who were receiving care in the United States from 1989 to 2003. Compared with survival associated with untreated HIV disease, per-person survival increased 0.26 years with Pneumocystis jiroveci pneumonia prophylaxis alone. Four eras of increasingly effective ART in addition to prophylaxis resulted in per-person survival increases of 7.81, 11.05, 11.57, and 13.33 years, compared with the absence of treatment. Treatment for patients with AIDS in care in the United States since 1989 yielded a total survival benefit of 2.8 million years. pMTCT averted nearly 2900 infant infections, equivalent to 137,000 additional years of survival benefit. In conclusion, at least 3.0 million years of life have been saved in the United States as a direct result of care of patients with AIDS, highlighting the significant advances made in HIV disease treatment. Walensky, R., Paltiel, A., Losina, E., Mercincavage, L., Schackman, B., Sax, P., Weinstein, M., and Freedberg, K. The Survival Benefits of AIDS Treatment in the United States. J Infect Dis, 194(1), pp. 11-19, 2006.

DAART in Methadone Clinics Associated with Improved HIV Treatment Outcomes

Directly administered antiretroviral therapy (DAART) in methadone clinics has the potential to improve treatment outcomes for human immunodeficiency virus (HIV)-infected injection drug users (IDUs). DAART was provided at 3 urban methadone clinics. Eighty-two participants who were initiating or reinitiating highly active antiretroviral therapy (HAART) received supervised doses of therapy at the clinic on the mornings on which they received methadone. Treatment outcomes in the DAART group were compared with outcomes in 3 groups of concurrent comparison patients, who were drawn from the Johns Hopkins HIV Cohort. The concurrent comparison patients were taking HAART on a self-administered basis. The 3 groups of concurrent comparison patients were as follows: patients with a history of IDU who were receiving methadone at the time HAART was used (the IDU-methadone group; 75 patients), patients with a history of IDU who were not receiving methadone at the time that HAART was used (the IDU-non-methadone group; 244 patients), and patients with no history of IDU (the non-IDU group; 490 patients). At 12 months, 56% of DAART participants achieved an HIV type 1 RNA level <400 copies/mL, compared with 32% of participants in the IDU-methadone group (P=.009), 33% of those in the IDU-non-methadone group (P=.001), and 44% of those in the non-IDU group (P=.077). The DAART group experienced a median increase in the CD4 cell count of 74 cells/mm3, compared with 21 cells/mm3 in the IDU-methadone group (P=.04), 33 cells/mm3 in the IDU-non-methadone group (P=.09), and 84 cells/mm3 in the non-IDU group (P=.98). After adjustment for other covariates in a logistic regression model, DAART participants were significantly more likely to achieve viral suppression than were patients in each of the 3 comparison groups. These results suggest that methadone clinic-based DAART has the potential to provide substantial clinical benefit for HIV-infected IDUs. Lucas, G., Mullen, B., Weidle, P., Hader, S., McCaul, M., and Moore, R. Directly Administered Antiretroviral Therapy in Methadone Clinics is Associated with Improved HIV Treatment Outcomes, Compared with Outcomes among Concurrent Comparison Groups. Clin Infect Dis, 42(11), pp. 1628-1635, 2006.

Medicaid Coverage and Access to Publicly Funded Opiate Treatment

Numerous studies have established the efficacy of methadone maintenance programs for treatment of opiate addiction. Participation in methadone treatment is associated with decreases in heroin use, criminal activity, and HIV risky behaviors. Moreover, methadone maintenance programs are considered to be a cost-effective form of treatment for opiate addiction costing approximately $13 per day. In this observational, longitudinally based study of 555 individuals, the changes in access to methadone maintenance treatment following Oregon's decision to remove substance abuse treatment from the Medicaid program was examined. Access was compared before and after the benefit change for two cohorts of adults addicted to opiates presenting for publicly funded treatment. Propensity score analysis was used to model some of the selective dis-enrollment from Medicaid that occurred after the benefit change. Logistic regression was used to compare access to methadone by cohort, controlling for client characteristics. Opiate users presenting for publicly funded treatment after the change were less than half as likely (OR = 0.40) to be placed in an opiate treatment program compared to the prior year. Further analysis revealed that those with no recent treatment history were less likely to present for treatment after the benefit change. These results have implications for states considering Medicaid cuts, especially if the anticipated increases in illegal activity, emergency room utilization, unemployment, and mortality can be demonstrated. Deck, D., Wiitala, W., and Laws, K. Medicaid Coverage and Access to Publicly Funded Opiate Treatment. J Behav Health Serv Res, 33(3), pp. 324-334, 2006.

Outreach Recovery Management Checkups Can Shorten the Cycle of Relapse, Treatment Reentry, and Recovery

A growing body of evidence suggests that a subset of drug-dependent substance users suffer from a severely chronic relapsing condition, whereby they may cycle repeatedly through periods of relapse, treatment reentry, incarceration, and recovery, over a course of many years. Eight quarterly interviews were conducted on 448 participants in both residential (60%) and outpatient (40%) drug abuse treatment programs randomly assigned to either an assessment-only condition or to a Recovery Management Checkup (RMC) condition in which outreach workers interviewed patients to assess their need for re-treatment. The sample was 85% African American, most (47%) were between 30 and 40 years of age, and about 60% were females. The intervention utilized motivational interviewing techniques to: (1) provide personalized feedback to participants about their substance use and related problems, (2) help the participant recognize their substance use problem and consider returning to treatment, (3) address existing barriers to treatment, and (4) schedule an assessment and facilitate reentry (reminder calls, transportation). The frequency, type, and predictors of transitions between points in the relapse, treatment reentry, and recovery cycle were measured. Results indicated that about one-third of the participants transitioned from one point in the cycle to another each quarter; 82% transitioned at least once, 62% multiple times. People assigned to RMC were significantly more likely to return to treatment sooner and receive more treatment. The probability of transitioning to recovery was related to the severity, problem orientation, desire for help, self-efficacy, self-help involvement, and recovery environment at the beginning of the quarter and the amount of treatment received during the quarter. These findings support the characterizations of addiction as a chronic condition, and demonstrate the need and effectiveness of post-discharge monitoring and checkups. The methods in this study also provide a simple but replicable method for learning more about the multiple pathways that individuals travel along before achieving a prolonged state of recovery. Scott, C.K., Dennis, K.L., and Foss, M.A. Utilizing Recovery Management Checkups to Shorten the Cycle of Relapse, Treatment Reentry, and Recovery. Drug Alcohol Depend. 78, pp. 325-338, 2005.

Clinical Significance of Tobacco Withdrawal

Determination of the clinical significance of tobacco withdrawal is important for several reasons. First, the diagnosis of nicotine withdrawal and all disorders in the American Psychiatric Association's Diagnostic and Statistical Manual requires the syndrome causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Second, several countries have approved the use of nicotine replacement therapy solely for relief of withdrawal symptoms. This indication implies tobacco withdrawal produces clinically significant distress. Third, some have stated tobacco withdrawal is not clinically significant. To estimate the clinical significance of tobacco withdrawal, this review located six experimental studies that reported Profile of Mood States (POMS) scores after stopping smoking in untreated smokers and compared them with scores in psychiatric outpatients. The pre-cessation POMS Total Mood Disturbance scores (median = 13.6) were similar to adult norms (mean, M = 17.8) but during abstinence (M = 5 days), the scores had increased (M = 27.4) to be similar to that of psychiatric outpatient norms (M = 25.1). These results and others, suggest stopping smoking causes clinically significant distress. By demonstrating that tobacco withdrawal can produce clinically significant distress, this paper suggests tobacco withdrawal itself is a disorder worthy of intervention. In addition, it suggests that claims by the tobacco industry and others that tobacco withdrawal is insignificant are untrue. Hughes, J. Clinical Significance of Tobacco Withdrawal. Nicotine Tob Res, 8(2), pp. 153-156, 2006.

Juvenile Drug Court: Enhancing Outcomes by Integrating Evidence-Based Treatments

This study evaluated the effectiveness of juvenile drug court for 161 juvenile offenders meeting diagnostic criteria for substance abuse or dependence and determined whether the integration of evidence-based practices enhanced the outcomes of juvenile drug court. Over a 1-year period, a four-condition randomized design evaluated outcomes for family drug court with usual community services, juvenile drug court with usual community services, drug court with multi-systemic therapy, and drug court with multi-systemic therapy enhanced with contingency management for adolescent substance use, criminal behavior, symptomatology, and days in out-of-home placement. In general, findings supported the view that drug court was more effective than family court services in decreasing rates of adolescent substance use and criminal behavior. Possibly due to the greatly increased surveillance of youth in drug court, however, these relative reductions in antisocial behavior did not translate to corresponding decreases in re-arrest or incarceration. In addition, findings supported the view that the use of evidence-based treatments within the drug court context improved youth substance-related outcomes. Clinical and policy implications are discussed. Henggeler, S.W., Halliday-Boykins, C.A., Cunningham, P.B., Randall, J., Shapior, S.B., and Chapman, J.E. Juvenile Drug Court: Enhancing Outcomes by Integrating Evidence-Based Treatments. J Consult Clin Psychol, 74(1), pp. 42-54, 2006.

Prevalence of DSM/ICD-Defined Nicotine Dependence

In this study techniques of systematic review were used to estimate for adults (1) the lifetime and current prevalence of DSM/ICD-defined nicotine dependence and (2) the prevalence of individual DSM/ICD dependence criteria. Systematic computer searches and other methods located eleven population-based surveys of adults (>/=18 year olds) and two of young adults (18-30 year olds). In the USA and Germany, about 25% of adults had been dependent on nicotine in their lifetime, including 15% who were currently dependent. Similar or higher rates were seen in Asian men but <5% of Asian women had been dependent. About a third of ever-smokers and half of current smokers either had been or were currently dependent on nicotine and this did not consistently differ by age, country or sex. Impaired control over tobacco use was the most commonly endorsed criteria and giving up activities to use and spending lots of time with nicotine were the least commonly endorsed. This study is consistent with others that show that nicotine dependence is one of the most common mental disorders; however, about half of current smokers do not meet DSM/ICD dependence criterion, perhaps because they have not tried to stop, nicotine is more legal than other drugs of dependence, and nicotine causes fewer behavioral disturbances than other drugs of abuse. However none of these possible explanations have been empirically tested as yet. Hughes, Helzer, and Lindberg. Prevalence of DSM/ICD-defined Nicotine Dependence. Drug Alcohol Depend, available onlinw May 15, 2006.

Sanctions and Rewards in Drug Court Programs

This article documents the specific behaviors that are sanctioned and rewarded, and the sanctions and rewards used, perceptions of the efficacy of sanctions, level of standardization in the application of sanctions and rewards, participants' understanding of the sanctioning system, and the decision-making process regarding sanctioning in 5 judicial circuits in Florida. Using qualitative data gathered from interviews with 86 key stakeholders and analyzed using NUD*IST software, the authors compared responses between drug courts and traditional courts, as well as by respondent role (staff vs. offender). Main findings include: many more sanctions were used and more behaviors identified as being likely to result in a sanction in drug courts as compared to traditional courts, sanctions used in drug courts were more treatment oriented than in traditional courts, and drug courts appeared to emphasize tailoring sanctions to the individual participant rather than applying sanctions in a standardized manner. Applications to drug court practice and directions for future research are discussed. Lindquist, C.H., Krebes, C.P., and Lattimore, P.K. Sanctions and Rewards in Drug Court Programs. Implementation, Perceived Efficacy, and Decision Making. Journal of Drug Issues, 36(1), pp. 119-146, 2006.

Substance Abuse Treatment Duration for Medicaid versus HMO's

As Medicaid clients have come to be enrolled in managed care, concerns have arisen about the ability of private sector systems to meet the needs of enrollees with substance abuse problems. This paper describes treatment initiation and duration for Medicaid and commercial substance abuse treatment clients in a large HMO. This study was a prospective secondary analysis of information from HMO databases. Subjects included 641 adult Medicaid clients who contacted the HMO's addiction medicine department in 1996-1997 and 447 commercial HMO addiction medicine patients during that same time. Chief dependent variables were initiation and duration of substance abuse treatment after the index event. Logistic regression showed that longer HMO enrollment predicted treatment initiation after substance abuse assessment, but Medicaid status was not a significant predictor. A competing risks analysis using Cox proportional hazards models indicated that once subjects had initiated, Medicaid was not significantly related to exit from substance abuse treatment. Analysis of health plan dis-enrollment by Medicaid clients indicated that the most common reason was loss of Medicaid eligibility. The investigators conclude that these results raise the possibility that state Medicaid policies may make it difficult for clients to obtain suitable chemical dependency treatment services. McFarland, B.H., Lynch, F.L., Freeborn, D.K., Green, C.A., Polen, M.R., Deck, D.D., and Dickinson, D.M. Substance Abuse Treatment Duration for Medicaid Versus Commercial Clients in a Health Maintenance Organization. Med Care, 44(6), pp. 601-606, 2006.

Adoption of Buprenorphine is Contingent Upon Profit Status As Well As Client and Staff Characteristics

The recent approval of buprenorphine for the treatment of opiate dependence offers an opportunity to analyze innovation adoption in community-based treatment. Using data collected from national samples of 299 privately funded and 277 publicly funded treatment centers, this research examined buprenorphine adoption using baseline data collected between 2002 and 2004 as well as follow-up data collected 12 months later. Private centers were significantly more likely than public centers to report current use of buprenorphine. The baseline data indicated that early adoption was positively associated with center accreditation, physician services, availability of detoxification services, current use of naltrexone, and the percentage of opiate-dependent clients. Multivariate analyses of follow-up data suggest that adoption was greater in accredited centers, for-profit facilities, organizations offering detoxification services, and naltrexone-using centers. Future research should continue to monitor the extent to which buprenorphine is adopted in these settings. Knudsen, H., Ducharme, L., and Roman, P. Early Adoption of Buprenorphine in Substance Abuse Treatment Centers: Data from the Private and Public Sectors. J Subst Abuse Treat, 30(4), pp. 363-373, 2006.

Treatment Barriers at Centralized Intake

The 59-item Barriers to Treatment Inventory (BTI) was administered to 312 substance abusers at a centralized intake unit following assessment but before treatment entry to assess their views on barriers to treatment. Factor analysis identified 25 items in 7 well-defined latent constructs: Absence of Problem, Negative Social Support, Fear of Treatment, Privacy Concerns, Time Conflict, Poor Treatment Availability, and Admission Difficulty. The factorial structure of the barriers is consistent with the findings of other studies that asked substance abusers about barriers to treatment and is conceptually compatible with Andersen's model of health care utilization. Factors were moderately to highly correlated, suggesting that they interact with one another. Selected characteristics were generally not predictive of barrier factors. Overall, results indicate that the BTI has good content validity and is a reliable instrument for assessing barriers to drug treatment. Rapp, R., Xu, J., Carr, C., Lane, D., Wang, J., and Carlson, R. Treatment Barriers Identified by Substance Abusers Assessed at a Centralized Intake Unit. J Subst Abuse Treat, 30(3), pp. 227-235, 2006.

Over Half of Male Cocaine Addicts Were Able to Sustain Abstinence Exceeding Five Years

The study examined long-term outcomes (mortality, substance use, mental health, employment, criminal involvement) among a cocaine dependent sample. This 12-year follow-up study, conducted in 2002-2003, updates information obtained at intake and two face-to-face interviews conducted in 1990-1991 and 1991-1992 among 321 male cocaine-dependent veterans admitted to drug treatment in 1988-1989. At the 2002-2003 follow-up, 28 had died (consistent with death rates for non drug abusing males) and 266 were interviewed. A mixed model examining the longitudinal relationships demonstrated that treatment was associated with lower levels of cocaine use over the 12-year follow-up period after entry into the index treatment and more stable recovery (i.e., 52% continuously abstinent from cocaine for at least 5 years). Only two measures at intake predicted stable recovery at follow-up: only ethnicity (being White) and having greater confidence in one's ability to avoid cocaine use in high-risk situations. Individuals achieving stable recovery reported less psychiatric symptoms, criminal involvement, and unemployment during the year prior to the interview. Hser, Y., Stark, M.E., Paredes, A., Huang, D., Anglin, M.D., and Rawson, R. A 12-year Follow-up of a Treated Cocaine-dependent Sample. J Subst Abuse Treat, 30 pp. 219-226, 2006.

Utilization of Medicaid Substance Abuse Services Among Adolescents

This study examined race and gender disparities in utilization of substance abuse treatment among adolescents enrolled in Medicaid in Tennessee. By using Medicaid enrollment, encounter, and claims data, utilization of substance abuse services for the population of adolescents enrolled in TennCare was examined in two ways. The first utilization measure considered annual utilization rates and probability of use of substance abuse services for the statewide population of enrolled adolescents (approximately 170,000 per year). The second examined the age at which the first substance abuse service was received for the 8,473 youths who had that service paid for by TennCare during state fiscal years 1997 to 2001. Proportionally, among adolescents, more whites than blacks and more males than females used substance abuse services. The disparities were greater than differences in prevalence rates explain. Black females had the greatest disparity in service utilization. Whites and females received their first substance abuse service at a younger age than blacks or males in this Medicaid population. However, the age difference may not be clinically significant. The low utilization rates, in general, and the disparities in service use by race and gender raise questions about the identification of substance use problems at both provider and system levels. Heflinger, C., Chatman, J., and Saunders, R. Racial and Gender Differences in Utilization of Medicaid Substance Abuse Services among Adolescents. Psychiatr Serv, 57(4), pp. 504-511, 2006.

Episodic Homelessness and Health Care Utilization

The authors examined whether episodes of homelessness are associated with sub optimal medical utilization even when accounting for concurrent addiction severity and depression. They used data from a 30-month cohort of patients with HIV/AIDS and alcohol problems. Housing status, medical service utilization, addiction severity, and depressive symptoms were assessed at biannual standardized research interviews. Utilization outcomes included ambulatory visits, emergency department (ED) visits, and hospitalizations. The main independent variable, homelessness, was defined as spending >1 night in a shelter or on the street in the past 6 months. Separate multivariable longitudinal regression models for each outcome calculated incidence rate ratios (IRR) comparing utilization rates during 6-month intervals, homeless versus housed. Additional models assessed whether addiction severity and depressive symptoms accounted for utilization differences. Of the 349 subjects, 139 (39%) reported homelessness at least once during the study period. Among those reporting homelessness, the median number of nights homeless was 30 per 6-month observation period. Homelessness was associated with higher ED utilization (IRR=2.17; 95% CI=1.72-2.74) and hospitalizations (IRR=2.30; 1.70-3.12), despite no difference in ambulatory care utilization (IRR=1.09; 0.89-1.33). These utilization findings attenuated but remained significant when adjusting for addiction severity and depressive symptoms. The authors conclude that expanded access to addiction, psychiatric and ambulatory medical care alone without consideration of housing stability may not be sufficient to mitigate intensive medical utilization patterns among HIV-infected patients with alcohol problems. Kim, Kertesz, Horton, Tibbetts, and Samet. Episodic Homelessness and Health Care Utilization in a Prospective cohort of HIV-infected Persons with Alcohol Problems. BMC Health Serv Res, 6(1), pp. 19-19, 2006.

Using Cell Phones with Cocaine-Addicted Homeless Patients in Treatment

This is the first study to examine whether cell phones could be used to collect ecological momentary assessment (EMA) data with homeless crack cocaine-addicted adults in treatment. The study adapted an EMA method to examine behavior in real time using cell phones and computer-automated telephone interviewing. Participants treated in an intensive outpatient treatment program were given cell phones for a 2-week period to record current states of cocaine craving and using episodes. Results showed cell phone technology could reliably deliver a computerized survey. This homeless population used a cell phone to report craving and using episodes. Drug use reported via EMA was in agreement with urine toxicology results for 73% of participants. Of 30 participants, 24 (80%) completed the full 2-week protocol. Participants indicated the survey made them more aware of phenomena leading to cravings and use, suggesting the usefulness of EMA as a potential intervention. Freedman, M.J., Lester, K.M., McNamara, C., Milby, J.B., and Schumacher, J.E. Cell Phones for Ecological Momentary Assessment With Cocaine-addicted Homeless Patients in Treatment. J Subst Abuse Treat, 30(2), pp. 105-111, 2006.

Self-report Measures are Superior to Biological Measures of Use for Quantifying Problem Severity

Structural equation modeling was used to demonstrate that multiple self-report and biological measures are influenced by the same underlying factor (substance use) and that no single measure is without error. The archival sample used included data from 337 adults (59% female; 85% African American; age normally distributed) with substance dependence. Individual measures and several possible combinations of them (including one based on the latent factors and another based on the Global Appraisal of Individual Needs (GAIN) Substance Frequency Scale was used to examine how well each measure predicted a wide range of substance-related problems. The measure with the highest construct validity in these analyses varied by drug and problem. Despite their advantages for detection, biometric measures were frequently less sensitive to the severity of other problems. Composite measures based on the substance-specific latent factors performed better than simple combinations of the biometric and psychometric measures. The Substance Frequency Scale from the GAIN performed as well as or better than all measures across problem areas, including the latent factor for any use. While the research was limited in some ways, it has important implications for the ongoing debate about the proper way to combine biometric and psychometric data. Lennox, R., Dennis, M.L., Scott, C.K., and Funk, R. Combining Psychometric and Biometric Measures of Substance Use. Drug Alcohol Depend, 83 pp. 95-103, 2006.

Self-rated Health Status Among HIV+ Patients

The purpose of the study was to assess how patients with HIV who are enrolled in a clinical trials cohort rate their health and to compare their ratings with those of patients with HIV from 2 other cohorts: the HIV Cost and Services Utilization Study (HCSUS), and Adult AIDS Clinical Trials Group protocol 320 (ACTG 320). Baseline information was analyzed for the 1649 subjects enrolled in the Adult AIDS Clinical Trials Group Longitudinal Linked Randomized Trials (ALLRT) study prior to March 2002 who had self-rated health data available. Those results were compared with results from 2 other groups: 1) HCSUS, the only nationally representative sample of people in care for HIV in the U.S., which conducted baseline interviews in 1996 and 1997, and 2) ACTG 320, a randomized, double-blinded, placebo-controlled trial comparing a 3-drug antiretroviral regimen with a 2-drug combination, which enrolled subjects in the same general time frame as HCSUS. T tests, Pearson correlations, and linear regression were used to determine factors associated with self-rated health and z scores were used to compare results between cohorts. The mean (SD) rating scale value on a 0-100 scale for ALLRT participants was 79.8 (16.8). Values were significantly lower for subjects who were older, had a history of injection drug use, had lower CD4 cell counts, or were beginning salvage antiretroviral therapy. Subjects in ALLRT reported significantly better self-rated health at baseline than those in HCSUS or ACTG 320 (11-12% higher rating scale values in ALLRT; p<0.05). When cohort differences were accounted for through regression and stratification, the differences in scores between subjects in ALLRT and HCSUS increased and the differences in scores between subjects in ALLRT and ACTG 320 diminished. Self-rated health varied significantly by age, CD4 count, injection drug use history, and salvage therapy status. Differences in self-rated health for clinical trials and non-clinical trials samples appear to be substantial and should be considered when applying trial results to clinical populations. Mrus, J., Schackman, B., Wu, A., Freedberg, K., Tsevat, J., Yi, M., and Zackin, R. Variations in Self-rated Health among Patients with HIV Infection. Qual Life Res, 15(3), pp. 503-514, 2006.

An Employment Framework for Justifying Increase Substance Abuse Spending

A large number of studies examining the cost of substance abuse often ignore indirect costs. This article argues that lost productivity (un/under-employment) is a substantial and restorable cost of substance abuse. The authors offer a framework for estimating the cost of substance abuse in terms of lost productivity, arguing that it makes sense to argue in favor or appropriate levels of spending by the states to restore substance abusers to full productivity in society. The authors acknowledge that criminal justice costs are another important social cost, however, a major advantage of employment is that full recovery makes a positive contribution to society, whereas not committing a crime does not. In addition, employment reduces the likelihood of relapse. Authors conclude by indicating the importance of including the relative effectiveness of treatments in the framework, as treatments vary widely in efficacy and the fidelity with which they are delivered. Meara, E., and Frank, R.G. Spending on Substance Abuse Treatment: How Much is Enough? Addiction, 100 pp. 1240-1248, 2005.

Reducing Shame May Reduce Substance Abuse

The current analyses sought to clarify the relations of shame-proneness and guilt-proneness to addictive behaviors in three studies drawing from two very different populations—college students and incarcerated jail inmates. Previous research has demonstrated that shame-proneness (the tendency to feel bad about the self) relates to a variety of life problems, whereas guilt-proneness (the tendency to feel bad about a specific behavior) is more likely to be adaptive. Thus the authors hypothesized that across all three samples, shame-proneness would be positively correlated with alcohol and drug problems and guilt-proneness would be inversely or unrelated to alcohol and drug problems. First, responses to the drug and alcohol scales of the Millon Clinical Multiaxial Inventory-II were compared to results of Tangney's 15-item, scenario-based Test of Self-Conscious Affect (TOSCA) using semi-partial correlations that eliminate shared variance between guilt and shame scores in two separate studies involving college undergraduates (Study 1 N =235, Study 2 N =249). Consistent with hypotheses, shame scores were positively correlated with both alcohol and drug abuse scores, whereas guilt scores were negatively related to alcohol and drug abuse scores. Focusing in on a population in which substance abuse has been shown to be above average, a third study focused on jail inmates (Study 3 N =332). The Texas Christian University Correctional: Residential Treatment Form, Initial Assessment (TCU-CRTF) in addition to the Alcohol Problems (12 items) and Drug Problems (12 items) scales from Morey's Personality Assessment Inventory (PAI) were used to measure alcohol and drug abuse. Tangney's 19-item TOSCA for Socially Deviant Populations was used to measure shame and guilt. Results for the CRTF and PAI scores reflected the same pattern of results as for college students. However, though consistent with hypotheses, some guilt semi-partial correlations were non-significant. Though results were not causal in nature, they support the use of shame-reduction interventions for problem substance abuse populations. Dearing, R.L., Stuewig, J., and Tangney, J.P. On the Importance of Distinguishing Shame from Guilt: Relations to Problematic Alcohol and Drug Use. Addict Behav. 30, pp. 1392-1404, 2006.

Predicting Unmet Health Services Needs among Incarcerated Substance Users

Negative health consequences of illicit drug use, such as cardiovascular complications and infectious diseases, increase the likelihood of the need for health care. Evidence suggests, with the exception of emergency services, drug users generally are medically underserved. In addition, the effect of illicit drug use on health care utilization is becoming important for the criminal justice system. This study examined data for 661 incarcerated men in the Kentucky prison system focused on predictors of unmet physical, behavioral, and overall health care needs among chronic substance users. Analyses revealed that White incarcerated drug users were more likely to report unmet physical and overall health care needs than non-Whites and those with high school education or above were more likely to report unmet physical, behavioral, and overall health care needs. In addition, more episodes of serious illness, more mental health problems, and poorer self-rated health were predictive of all three types of unmet health care needs. A longer career of drug use emerged as a significant predictor of unmet behavioral health care needs, whereas more frequent drug use in the year before incarceration predicted unmet physical health care needs. Further research directions and implications for in-prison health care planning are discussed. Narevic, E., Garrity, T.F., Schoenberg, N.E., Hiller, M.L., Webster, J.M., Leukefeld, C.G., and Tindall, M.S. Factors Predicting Unmet Health Services Needs among Incarcerated Substance Users. Subst Use Misuse, 41, pp. 1077-1094, 2006.

Heroin Dependence and HIV Infection In Malaysia

Malaysia is experiencing severe problems with heroin dependence and HIV infection. This study of one hundred seventy seven (n=177) heroin-dependent subjects enrolled in a heroin-treatment program in Muar, Malaysia explored the association of heroin dependence and other HIV risk behaviors, to the prevalence of HIV and other infectious diseases. Subjects were evaluated with the AIDS Risk Inventory; serological tests for HIV, hepatitis B, and hepatitis C; and chest X-ray. It was found that all of the subjects were male; 67.8% were Malays, 28.8% Chinese, and 2.3%. Indian. Subjects had a mean (SD) age of 37.2 (9.1) years and 14.4 (8.5) years of using heroin; 76.3% reported lifetime injection drug use (IDU), and 41.5% reported current IDU. Test results showed 30 of 156 (19.2%) tested HIV positive, 143 of 159 (89.9%) tested hepatitis C positive, and 25 of 159 (15.7%) had radiological evidence of pulmonary tuberculosis. Malay subjects had a significantly higher prevalence of current IDU, needle sharing (p<0.01), and HIV infection (p<0.05) compared with Chinese subjects. Lifetime IDU, needle sharing, lack of consistent condom use, and Malay ethnicity were significantly associated with HIV infection. This study demonstrates the high prevalence of HIV infection among heroin-dependent individuals in Malaysia, and supports the importance of interventions to reduce the major risk factors for HIV, including IDU, needle sharing, and unprotected sex. Chawarski, M., Mazlan, M., and Schottenfeld, R. Heroin Dependence And HIV Infection In Malaysia. Drug Alcohol Depend, 82(1), pp. S39-S42, 2006.

Gender Differences in the Prediction of Condom Use Among Incarcerated Juvenile Offenders

This study seeks to predict condom-protected vaginal intercourse among incarcerated youth using the Information-Motivation-Behavioral skills (IMB) model as the theoretical framework. The IMB model is a three-factor conceptualization of HIV preventive behavior including information on HIV/AIDS transmission and prevention methods, motivation to act on the knowledge and change risky behavior, and behavioral skills in performing the specific prevention act. Data was collected from youth held in a detention center located in a Southern city. Adolescents 13 years of age or older and recently incarcerated (within 3 days of booking) were eligible for the study. The study sample included 523 adolescents (328 male and 195 female. Participants were predominately African-American (90%), with an average age of 15, and average level of highest education was 9th grade. Survey data was collected for a self-report measure of AIDS knowledge, pre-condom peer influence, risk perception, condom attitudes, condom use self-efficacy, frequency of vaginal intercourse, and frequency of condom-protected vaginal intercourse. Results revealed that being male, peer influence, positive condom attitudes, and condom self-efficacy significantly predicted condom use. Separate gender analyses revealed that condom use among males was predicted by peer influence and positive condom attitudes, whereas condom use among females was predicted by peer influence, self-efficacy, and condom attitudes. Compared with males, females reported significantly greater knowledge, less peer influence, higher perceived risk for infection, more positive condom attitudes, and more self-efficacy. Despite these findings, females reported less condom use than males. The authors conclude that females find it difficult to use condoms consistently despite their awareness. They suggest that power imbalances and other dynamics operating within relationships between boys and girls need to be explored further in developing effective HIV prevention interventions. Robertson, A.A., Stein, J.A., and Baird-Thomas, C. Gender Differences in the Reduction of Condom Use among Incarcerated Juvenile Offenders: Testing the Information-motivation-behavior Skills (IMB) Model. J Adolesc Health, 38(2006), pp. 18-25, 2006.

Pregnant Women Treated in Women-only Versus Mixed-gender Programs Receive More Services

This study-compared characteristics of pregnant women treated in women-only (WO) and mixed-gender (MG) substance abuse treatment programs and compared services provided by these two types of programs. Participants were 407 pregnant women who were admitted to 7 WO programs and 29 MG programs in 13 counties across California during 2000-2002. Pregnant women treated in WO programs demonstrated greater severity in drug use, legal problems, and psychiatric problems than those treated in the MG programs. They were also less likely to be employed and more likely to be homeless. Women-only programs were more likely to offer childcare, children's psychological services, and HIV testing. The greater problem severity of pregnant women treated in WO programs suggests that these specialized services are filling an important gap in addiction services, although further expansion is warranted in psychiatric, legal, and employment services. Hser, Y., and Niv, N. Pregnant Women in Women-Only and Mixed-Gender Substance Abuse Treatment Programs: A Comparison of Client Characteristics and Program Services. J Behav Health Serv Res, 4(On-Line), pp. 1-12, 2006.

Participation by TC Staff Members in Methadone Sensitivity Training was Associated with a Lower Abstinence Orientation and Higher Knowledge of Methadone Treatment

This study examined a residential therapeutic community (TC) treatment program that began allowing clients to enroll in methadone maintenance. 104 staff members with patient contact in four TC facilities were invited to participate on a voluntary basis, and 46 women and 41 men (84%) agreed. Staff self-report measures included the 14-item Abstinence Orientation Scale (AOS), the 12-item Methadone Knowledge Scale (MKS), and the 6-item Disapproval of Drug Use Scale (DDU). Staff members who affirmed participation in addiction treatment themselves had greater methadone knowledge than those who had not. Staff members (N=40) who participated in a 2-hour methadone sensitivity training course had significantly greater methadone knowledge and lower abstinence orientation than those (N=45) who did not attend the training (p<.001). The TC staff in this study had stronger abstinence orientation (M=3.22) than found in prior studies of methadone clinic staff in New York (M=2.67) and Australia (2.95), which may represent a barrier to methadone in residential settings. Nevertheless, the TC sample did not differ on MHS scores from prior studies of methadone clinic staff. Results suggest that staff experience is correlated with attitudes and knowledge about methadone and that staff training is associated with changing attitudes and knowledge about methadone. Andrews, S., Sorensen, J. L., Guydish, J., Delucchi, K., and Greenberg, B. Knowledge and Attitudes About Methadone Maintenance Among Staff Working in a Therapeutic Community. Journal of Maintenance in the Addictions, 3(1), pp. 47-59, 2005.

Exposure to Transphobia and HIV Risk Behavior Among Transgendered Women

This study examined the relationship between exposure to transphobia -- societal discrimination and stigma of individuals who do not conform to traditional notions of gender -- and risk for engaging in unprotected receptive anal intercourse (URAI) among 327 transgendered women of color. Overall, 24% of participants had engaged in URAI at least once in the past 30 days. Individuals who self-identified as pre-operative transsexual/transgendered women were significantly more likely than self-identified females to have engaged in URAI. Although exposure to transphobia was not independently related to URAI, an interaction between age and experiencing discrimination was observed. Among transgendered women 18-25 years old, those reporting higher levels of exposure to transphobia had a 3.2 times higher risk for engaging in URAI compared to those reporting lower levels. Findings from this study corroborate the importance of exposure to transphobia on HIV risk, particularly among transgendered young adults. Sugano, E., Nemoto, T., and Operario, D. The Impact of Exposure to Transphobia on HIV Risk Behavior in a Sample of Transgendered Women of Color in San Francisco. AIDS Behav, 10(2), pp. 217-225, 2006.

Performance Measures for Alcohol and Other Drug Services

Performance measures, which evaluate how well health care practitioners' actions conform to practice guidelines, medical review criteria, or standards of quality, can be used to improve access to treatment and the quality of treatment for people with alcohol and other drug problems. This article examines different types of quality measures, how they fit within the continuum of care, and the types of data that can be used to arrive at these measures. The Washington Circle measures--identification, initiation of treatment, and treatment engagement--are a widely used set of performance measures. Garnick, D., Horgan, C., and Chalk, M. Performance Measures for Alcohol and other Drug Services. Alcohol Res Health, 29(1), pp. 19-26, 2006.


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