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Director's Report to the National Advisory Council on Drug Abuse - September, 2007

Research Findings - Services Research

Outpatient Treatment Engagement and Abstinence Rates Following Inpatient Opioid Detoxification

Many patients with chronic opioid dependence are referred to drug-free outpatient treatment following inpatient detoxification even though successful outpatient treatment engagement and abstinence from opioids occur only in a minority of cases. To determine if a setting that optimizes patient support can produce better outcomes, the authors performed a retrospective cohort analysis of medical records. These records document the post-discharge outcome in a treatment setting that maximizes the support during transition to abstinence-oriented outpatient care, with comprehensive social, medical and mental health services, including the availability of naltrexone. Participants were male veterans (N = 112) admitted at an urban VA medical center. Most patients (78%) successfully completed acute detoxification, 49% initiated naltrexone, and 76% accepted a VA aftercare plan. At 90-day follow-up, only 22% remained in aftercare, and < 3% had toxicology-verified abstinence from opioids. At one-year follow-up, 1 out of 5 had been readmitted for detoxification and 4.5% had died. This shows that most patients successfully detoxified from opioids, but even with intensive associated support services very few remained engaged and stabilized in abstinence-oriented outpatient treatment. Furthermore, this finding has broad and significant implications for post-detoxification referral practices in patients with opioid addiction throughout the addiction treatment field. Davison, J., Sweeney, M., Bush, K., Davis Correale, T., Calsyn, D., Reoux, J., Sloan, K., and Kivlahan, D. Outpatient Treatment Engagement and Abstinence Rates Following Inpatient Opioid Detoxification. J Addict Dis, 25(4), pp. 27-35, 2006.

Interim Methadone Maintenance Enhances Patient Engagement in Treatment

A total of 319 individuals meeting the criteria for current heroin dependence and methadone maintenance treatment, were randomly assigned to either interim methadone maintenance, consisting of an individually determined methadone dose and emergency counseling only for up to 120 days, or referral to community-based methadone treatment programs. Significantly more participants assigned to the interim methadone maintenance condition entered comprehensive methadone maintenance treatment by the 120th day from baseline (75.9%) than those assigned to the waiting list control condition (20.8%) (P<.001). Overall, in the past 30 days at follow-up, interim participants reported significantly fewer days of heroin use (P<.001), had a significant reduction in heroin-positive drug test results (P<.001), reported spending less money on drugs (P<.001), and received less illegal income (P<.02) than the waiting list participants. Thus interim methadone maintenance results in a substantial increase in the likelihood of entry into comprehensive treatment, and is an effective means of reducing heroin use and criminal behavior among opioid-dependent individuals awaiting entry into a comprehensive methadone treatment program. Schwatz, R.P., Brady, J.V., and Callaman, J.M. A Randomized Controlled Trial of Interim Methadone Maintenance. Arch Gen Psychiatry, 63 (Jan), pp. 102-109, 2006.

Requirements for Using Standard Screening Instruments Increased in Health Plans

Data from a nationally representative sample of health plans were used to detect trends in behavioral health care screening requirements for primary care providers between 1999 (N=424) and 2003 (N=368). The percentage of plans with any behavioral health screening requirement remained steady between 1999 and 2003 at 34%. However, among those that require screening, the percentage of plans that required primary care providers to use a standard screening questionnaire specifically designed to detect drug problems increased from 7.6% to 77.9% during that time. Plans most likely to require the use of a standard screening instrument include preferred provider organizations or point of service plans, for profit plans, those that do not contract out behavioral health services, those in the Western region of the country, and those in market areas of more than 4 million people. Horgan, C.M., Garnick, D.W., Merrick, E.L., and Hoyt, A. Health Plan Requirements for Mental Health and Substance Use in Primary Care. J Gen Intern Med, 22 pp. 930-936, 2007.

Behavioral Health Care Carve-Outs Useful in Addressing Utilization, Access, and Cost

This review article assesses the evolution of behavioral health carve-outs, explains their underlying principles, and provides an overview of what is known about their performance in cost, access, and quality of care. As of 2003, some 170 million insured Americans receive their behavioral health care coverage through some type of carve-out arrangement. Research consistently finds that carve-outs reduce behavioral health care spending, on the order of 30%-40% when compared to fee-for-service or preferred provider arrangements, largely by reducing inpatient care and lowering payment rates for providers. Most studies find that carve-outs result in increased access by reducing out-of-pocket costs, although the quantity of services consumed by those who do consume services may have declined. The effects of carve-outs on quality of care is under researched, although there is some reason for concern that those with substance abuse disorders and very severe and complex mental disorders may be fairing worse under carve-outs. Managed behavioral health care organizations are experimenting with mechanisms to improve integration of medical and behavioral health care services, and include coverage of psychotropic medications in the plans, while public payers are attempting to establish purchasing cooperatives to decrease administrative costs and benefit from the resulting economies of scale. Frank, R.G., and Garfield, R.L. Managed Behavioral Health Care Carve-Outs: Past Performance and Future Prospects. Annu Rev Public Health, 28, pp. 303-320, 2007.

Availability of Drug Treatment Services for Adult Offenders

National Criminal Justice Treatment Practices, a nationally representative survey of prisons, jails, and community correctional agencies was conducted to estimate the prevalence of entry into and accessibility of correctional programs and drug treatment services for adult offenders. Substance abuse education and awareness is the most prevalent form of service provided, being offered in 74% of prisons, 61% of jails, and 53% of community correctional agencies; at the same time, remedial education is the most frequently available correctional program in prisons (89%) and jails (59.5%), whereas sex offender therapy (57.2%) and intensive supervision (41.9%) dominate in community correctional programs. Most substance abuse services provided to offenders are offered through correctional programs such as intensive supervision, day reporting, vocational education, and work release, among others. Although agencies report a high frequency of providing substance abuse services, the prevalence rates are misleading because less than a quarter of the offenders in prisons and jails and less than 10% of those in community correctional agencies have daily access to these services through correctional agencies; in addition, these are predominantly drug treatment services that offer few clinical services. Given that drug-involved offenders are likely to have dependence rates that are four times greater than those among the general public, the drug treatment services and correctional programs available to offenders do not appear to be appropriate for the needs of this population. The National Criminal Justice Treatment Practices survey provides a better understanding of the distribution of services and programs across prisons, jails, and community correctional agencies and allows researchers and policymakers to understand some of the gaps in services and programs that may negatively affect recidivism reduction efforts. Taxman, F., Perdoni, M., and Harrison, L. Drug Treatment Services for Adult Offenders: The State of the State. J Subst Abuse Treat, 32(3), pp. 239-254, 2007.

Availability of Drug Treatment Services for Juvenile Offenders

Despite consensus about the value of substance abuse treatment for delinquent youth, information about its prevalence and availability is inadequate and inconsistent. This article presents findings about treatment and other correctional service provision from a nationally representative survey of directors of 141 juvenile institutional and community corrections (CC) facilities, as part of the National Criminal Justice Treatment Practices Survey, conducted as part of the Criminal Justice Drug Abuse treatment Studies. Educational/General Educational Development programming and drug and alcohol education were the most prevalent types of correctional and substance abuse services. Other common services included physical health services and mental health assessment, provided to about 60% of youth across facilities, and mental health counseling, life and communication skills, and anger management, provided to about half of the youth. As with most other services, substance abuse treatment was more prevalent in large, state-funded residential facilities (where 66% provided treatment) than in local detention centers (20%) and CC facilities (56%). The number of youth attending substance abuse treatment in all types of facilities on any given day was very low. Young, D., Dembo, R., and Henderson, C. A National Survey of Substance Abuse Treatment for Juvenile Offenders. J Subst Abuse Treat, 32 (3), pp. 255-266, 2007.

DSM-III-R and DSM-V Diagnoses are Generally Concordant in Drug Users with Chronic and Severe Problems

This study determined the rates of concordance between the Diagnostic and Statistical Manual of Mental Disorders Version III-R (DSM-III-R) and the next version (DSM-IV) lifetime diagnoses for Substance Abuse and Dependence in a population (N=900) homogeneous for chronic and severe substance use disorder. The substance use disorder sections of the Structured Clinical Interview for DSM-III-R and DSM-IV were combined into a single interview and administered by trained clinical research interviewers. Analysis for each drug class was restricted to patients who reported prior use of the substance. Kappa values indicated excellent agreement between the 2 classification systems for Dependence diagnoses and fair to excellent concordance for Abuse diagnoses. However for cannabis the DSM-IV nosology resulted in lower rates of Dependence and higher rates of Abuse diagnoses. Stoller, K. B., King, V. L., Kidorf, M. S., Neufeld, K. S., and Brooner, R. K. DSM-III-R Versus DSM-IV Substance Use Disorders: Concordance in Drug Users Homogeneous for Chronic and Severe Problems. Addictive Disorders & Their Treatment, 5(4), pp. 165-171, 2006.

Substance Abuse Treatment Prevention, and Policy

It has been proposed that the substance abuse treatment delivery system cut across different components of the criminal justice continuum in order to reduce criminal recidivism and drug use. Arrest, at the front end of this continuum, may represent a critical moment to motivate people with substance use disorders (SUD) to seek treatment but is often over looked as an intervention point. Data from the 2002 National Survey on Drug Use and Health (NSDUH) were used to compare treatment need and recent treatment admission for participants with no criminal justice (CJ) involvement in the past year, past-year arrest, and CJ supervision (i.e., probation or parole status). Of those arrested, 44.8% met criteria for an SUD. However, only 14% of those arrested with an SUD received treatment in the year of their arrest. In multivariate modeling, arrest was an independent predictor of treatment admission (odds ratio (OR) = 8.74) similar in magnitude to meeting criteria for an SUD (OR = 8.22). Those further along the continuum - under supervision - were most likely to receive treatment (OR = 22.62). Arrest involves the largest number of individuals entering the criminal justice system. The NSDUH suggests that nearly 6 million individuals in the US experience an arrest annually and that nearly half meet criteria for an SUD. Although arrest involves the largest number of individuals entering the criminal justice system, it is also the most fleeting point as individuals can move in and out rather quickly. Minimally, arrest imposes contact between the individual and a law enforcement person and can be an opportunity for early intervention strategies such as pre-arraignment diversion into treatment or brief intervention strategies. Using brief intervention at this early point in the continuum may motivate a greater number of individuals to seek treatment or decrease drug and alcohol use. Pimlott Kubiak, S., Arfken, C.L., Swartz, J.A., and Koch, A.L. Substance Abuse Treatment Prevention, and Policy. BioMed Central, 1(20), pp. 1-10, 2006.

Screening for Serious Mental Illness in Populations with Co-occurring Substance Use Disorders: Performance of the K6 Scale

Serious mental illnesses (SMIs) such as schizophrenia, bipolar disorder, and major depression are prevalent among individuals with substance use disorders, particularly those in drug treatment programs. No screening tool has yet become the gold standard for identifying SMI among individuals with substance use disorders. One candidate instrument, the K6 screening scale, is brief, easy to administer and score, and has performed well, detecting SMI in studies using general population samples. The National Survey on Drug Use and Health data was used to examine the K6's psychometric properties in a sub sample of persons with substance use disorders and found that the K6 accurately screened for severe psychological distress associated with SMI among individuals with substance use disorders and across different psychiatric disorders. Swartz, J. A., and Lurigio, A.J. Screening for Serious Mental Illness in Populations with Co-occurring Substance Use Disorders: Performance of the K6 Scale. J Subst Abuse Treat, 31 pp. 287-296, 2006.

Prevalence of Drug Problems, Mental Health Problems, and Criminal Histories Among the Offending Sample of the CJDATS Studies

The national Criminal Justice Drug Abuse Treatment Studies (CJ-DATS) is a multisite research program to improve outcomes for offenders with drug problems who are reentering the community after incarceration. Baseline data from three ongoing CJ-DATS studies were pooled to examine the characteristics of study participants. These analyses suggest that CJ-DATS study participants have serious drug problems, criminal histories, and mental health problems that can decrease the likelihood of successful community reentry unless addressed. HIV-risk behavior was associated with several categories of criminal acts, suggesting that the relationship between sexual risk behaviors and crime may need further investigation. Fletcher, B.W., Lehman, W.E., Wexler, H.K., and Melnick, G. Who Participates in the Criminal Justice Drug Abuse Treatment Studies (CJ-DATS)? The Prison Journal, 87(1), pp. 1-33, 2007.

Concurrent Drug and Alcohol Use in National Sample

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

Organizational Characteristics Associated with Treatment Orientation in Services for Offenders

This article examines the association between the organizational characteristics of drug abuse treatment programs for offenders and the provision of wraparound services and three types of treatment orientations. Data are from the National Criminal Justice Treatment Practices Survey, which was conducted with program directors (N = 217). More wraparound services were provided in inpatient treatment, specialized treatment facilities, community setting (vs. correctional), when services were provided for more types of client populations, when staff were college-educated, and when treatment was planned for over 180 days. Therapeutic community orientation provided more often in prison-based treatment and specialized treatment facilities. Services with a cognitive-behavioral therapy orientation were provided more often when community treatment was perceived as more important, when staff had more influence on treatment, and when treatment was for 91-180 days. Services with a 12-step orientation were provided more often by staff specialized in substance abuse. Study findings have implications for developing effective reentry programs for offenders that bridge correctional and community treatment. Grella, C., Greenwell, L., Prendergast, M., Farabee, D., Hall, E., Cartier, J., and Burdon, W. Organizational Characteristics of Drug Abuse Treatment Programs for Offenders. J Subst Abuse Treat, 32(3), pp. 291-300, 2007.

Organization, Financing, Promotion, and Cost of U.S. Quitlines

Quitlines have been established as an effective, evidence-based, population-wide strategy to deliver smoking-cessation treatment, and are now available in most states across America. However, little is known about the organization, financing, promotion, and cost of state quitlines. To determine this, in 2004, the North American Quitline Consortium surveyed the 50 states and Washington DC to obtain information about state quitlines. Data were analyzed in fall 2005 through spring 2006. Analyses of these data are reported in this paper. It was found that 38 states reported having a quitline in 2004. State governments funded most (89.5%) quitlines. Median state quitline operating budgets in 2004 were 500,000 dollars; this translates into a modest annual median operating cost of 0.14 dollar per capita or 0.85 dollar per adult smoker. A lesser amount was spent for quitline promotion. Quitline services varied, with 97.4% of respondents providing mailed self-help resources, 89.5% providing proactive telephone counseling, and 89.2% providing referrals to other services. Many quitlines provide services in languages other than English. Only 21.1% of quitlines reported providing cessation medication at no cost. Promotional strategies varied widely. From this study it was found that a large majority of U.S. smokers live in states with tobacco quitlines, which provide cessation treatment at a remarkably modest per capita cost. There is a great deal of congruence in services and promotional strategies among states. Further research is required to determine how external factors such as the federal National Network of Tobacco Cessation Quitlines funding for state quitlines and the availability of a national portal number (1-800-QUITNOW), both implemented in 2004, affect state quitlines. Keller, P., Bailey, L., Koss, K., Baker, T., and Fiore, M. Organization, Financing, Promotion, and Cost of U.S. Quitlines, 2004. Am J Prev Med, 32(1), pp. 32-37, 2007.

Evaluation of a Combined Online and In Person Training in the Use of Buprenorphine

A specific physician training course is required to prescribe buprenorphine to patients. To evaluate this buprenorphine training methodology, the authors surveyed physicians who had completed a combined online and in person buprenorphine curriculum. Of 53/70 (76%) survey respondents, 57% were psychiatrists and 40% generalists. On a scale of 1 (very poor) to 7 (superlative), the overall training rated a mean of 5.8. The online course (5.0) rated lower than in person training components (p < .001) except for material that addressed the logistics of office practice. The in person patient interview received the highest rating (mean 6.3, p < .001). The 67% of physicians who intended to prescribe buprenorphine after the training were more likely than hesitant physicians to agree that the course provided enough information (p < .05) and that telephone access to experienced providers would improve their confidence (p < .05). Among physicians hesitant to prescribe, 41% cited lack of experience as the main barrier, with 24% concerned about induction difficulty and reimbursement. Overall, physicians preferred in person instruction and may benefit from additional experiential training and support after curriculum participation. These findings suggest important ways to overcome barriers to physicians prescribing of buprenorphine. Gunderson, E., Fiellin, D., Levin, F., Sullivan, L., and Kleber, H. Evaluation of a Combined Online and In Person Training in the Use of Buprenorphine. Subst Abuse, 27(3), pp. 39-45, 2006.

Smoking Cessation via the Internet: a Randomized Clinical Trial of an Internet Intervention as Adjuvant Treatment in a Smoking Cessation Intervention

Internet interventions for smoking cessation are ubiquitous. Yet, to date, there are few randomized clinical trials that gauge their efficacy. To address this question, the authors performed a randomized clinical trial (N= 284, n= 140 in the treatment group, n= 144 in the control group) of an Internet smoking cessation intervention. Smokers were randomly assigned to receive either bupropion plus counseling alone, or bupropion and counseling in addition to 12 weeks of access to the Comprehensive Health Enhancement Support System for Smoking Cessation and Relapse Prevention (CHESS SCRP; a Web site which provided information on smoking cessation as well as support). It was found that access to CHESS SCRP was not significantly related to abstinence at the end of the treatment period (OR= 1.13, 95% CI 0.66-2.62) or at 6 months post quit (OR= 1.48, 95% CI 0.66-2.62). However, the number of times participants used CHESS SCRP per week was related to abstinence at both ends of treatment (OR= 1.79, 95% CI 1.25-2.56) and at the 6-month follow-up (OR= 1.59, 95% CI 1.06-2.38). Participants with access to CHESS SCRP logged in an average of 33.64 times (SD=30.76) over the 90-day period of access. Rates of CHESS SCRP use did not differ by ethnicity, level of education or gender (all p>.05). In sum, results suggest that participants used CHESS SCRP frequently and that CHESS SCRP use was related to success in smoking cessation. Japuntich, S., Zehner, M., Smith, S., Jorenby, D., Valdez, J., Fiore, M., Baker, T., and Gustafson, D. Smoking Cessation via the Internet: a Randomized Clinical Trial of an Internet Intervention as Adjuvant Treatment in a Smoking Cessation Intervention. Nicotine Tob Res, 8 Suppl 1, pp. S59-S67, 2006.

Mechanisms of Prescription Drug Diversion Among Drug-Involved

Prescription drug diversion involves the unlawful channeling of regulated pharmaceuticals from legal sources to the illicit marketplace, and can occur along all points in the drug delivery process, from the original manufacturing site to the wholesale distributor, the physician's office, the retail pharmacy, or the patient. However, empirical data on diversion are limited. In an attempt to develop a better understanding of how specific drug-using populations are diverting prescription opioids and other medications, or obtaining controlled drugs that have already been diverted, qualitative interviews and focus group data were collected on four separate populations of prescription drug abusers in Miami, Florida--club drug users, street-based illicit drug users, methadone maintenance patients, and HIV positive individuals who abuse and/or divert drugs. Sources of abused prescription drugs cited by focus group participants were extremely diverse, including their physicians and pharmacists; parents and relatives; "doctor shopping"; leftover supplies following an illness or injury; personal visits to Mexico, South America and the Caribbean; prescriptions intended for the treatment of mental illness; direct sales on the street and in nightclubs; pharmacy and hospital theft; through friends or acquaintances; under-the-door apartment flyers advertising telephone numbers to call; and "stealing from grandma's medicine cabinet." While doctor shoppers, physicians and the Internet receive much of the attention regarding diversion, the data reported in this paper suggest that there are numerous active street markets involving patients, Medicaid recipients and pharmacies as well. In addition, there are other data which suggest that the contributions of residential burglaries, pharmacy robberies and thefts, and "sneak thefts" to the diversion problem may be understated. Inciardi, J.A., Surratt, H.L., Kurtz, S.P., and Cicero, T.J. Mechanism of Prescription Drug Diversion Among Drug-Involved Club-and Street Based Populations. Pain Med, 8(2), pp. 171-183, 2007.

Depression Predicts Smoking Early but Not Late in a Quit Attempt

This study examined the relationship between a history of depression, and smoking after a quit attempt. A total of 677 smokers participating in a randomized smoking cessation trial (Smith et al., 2001), for this study they provided recent data on current depression, depression history, and depression-related measures and smoking at 1 week and 6 months after a quit date. Depression history predicted smoking at 1 week postquit but not at 6 months postquit. Smoking during the first week was not predictive of smoking at 6 months in those with a history of depression but was predictive among those with no history of depression. Prediction models including depression history and depression-related measures (e.g., negative affect, negative cognitive style) showed that depression history was a powerful predictor of smoking early in the quit attempt. Japuntich, S., Smith, S., Jorenby, D., Piper, M., Fiore, M., and Baker, T. Depression Predicts Smoking Early but Not Late in a Quit Attempt. Nicotine Tob Res, 9(6), pp. 677-686, 2007.

Evidence-Based Treatment for Drug-Involved Adult Offenders

This study was designed to estimate the extent and organizational correlates of evidence-based practices (EBPs) in correctional facilities and community-based substance abuse treatment programs that manage drug-involved adult offenders. The authors' surveyed correctional administrators and treatment program directors affiliated with a national sample of 384 criminal justice and community-based programs providing substance abuse treatment to adult offenders in the United States in 2004. Correctional administrators reported the availability of up to 13 specified EBPs, and treatment directors up to 15. The sum total of EBPs indicates their extent. Linear models were used to estimate the extent of EBPs on variables measuring structure and leadership, culture and climate, administrator attitudes, and network connectedness of the organization. The authors found that most programs offer fewer than 60% of the specified EBPs to drug-involved offenders. In multiple regression models, offender treatment programs that provided more EBPs were community based, accredited, and network connected, with a performance-oriented, nonpunitive culture, more training resources, and leadership with a background in human services, a high regard for the value of substance abuse treatment, and an understanding of EBPs. The authors felt that this study supports the contention that the use of EBPs among facility- and community-based programs that serve drug-involved adult offenders has room for improvement. Initiatives to disseminate EBPs might target these institutional and environmental domains, but further research is needed to determine whether such organization interventions can promote the uptake of EBPs. Friedmann, P., Taxman, F., and Henderson, C. Evidence-Based Treatment Practices for Drug-Involved Adults in the Criminal Justice System. J Subst Abuse Treat, 32(3), pp. 267-277, 2007.

National Criminal Justice Treatment Practices Survey: Methods and Procedures

The National Criminal Justice Treatment Practices (NCJTP) survey provides a comprehensive inquiry into the nature of programs and services provided to adult and juvenile offenders involved in the justice system in the United States. The multilevel survey design covers topics such as the mission and goals of correctional and treatment programs; organizational climate and culture for providing services; organizational capacity and needs; opinions of administrators and staff regarding rehabilitation, punishment, and services provided to offenders; treatment policies and procedures; and working relationships between correctional and other agencies. The methodology generates national estimates of the availability of programs and services for offenders. This article details the methodology and sampling frame for the NCJTP survey, response rates, and survey procedures. Limitations of the survey methods are also discussed. Taxman, F., Young, D., Wiersema, B., Rhodes, A., and Mitchell, S. The National Criminal Justice Treatment Practices Survey: Multilevel Survey Methods and Procedures. J Subst Abuse Treat, 32(3), pp. 225-238, 2007.

Organizational Context of Effective Drug Treatment Practices for Juvenile Offenders

This study examined the extent to which organizational context predicted use of consensus-based elements of effective substance abuse treatment practices with juvenile offenders. Data was obtained as part of the National Criminal Justice Treatment Practices Survey, conducted as part of the Criminal Justice Drug Abuse Treatment Studies. Surveys were conducted with directors of substance abuse treatment programs located in residential facilities (institutional sample) or directors of community-based treatment agencies providing services to adolescents in their home communities (community sample). The two settings differed significantly in the number and types of effective practices they were using. Community programs were more likely to have staff qualified to deliver substance abuse treatment, involve families in treatment, and assess their treatment outcomes. In contrast, institutional programs were more likely to provide comprehensive services. Resources dedicated to training, internal support for new programming, and network connectedness with non-criminal-justice facilities were associated with greater use of effective practices. These findings highlight the importance of establishing corrections-community partnerships designed to promote continuity of care for juvenile offenders. Henderson, C., Young, D., Jainchill, N., Hawke, J., Farkas, S., and Davis, R. Program Use of Effective Drug Abuse Treatment Practices for Juvenile Offenders. J Subst Abuse Treat, 32(3), pp. 279-290, 2007.

Initial Strategies for Integrating Buprenorphine into HIV Care Settings in the United States

The Centers for Disease Control and Prevention's HIV Prevention Strategic Plan through 2005 advocated for increasing the proportion of persons with human immunodeficiency virus (HIV) infection and in need of substance abuse treatment who are successfully linked to services for these 2 conditions. There is evidence that integrating care for HIV infection and substance abuse optimizes outcomes for patients with both disorders. Buprenorphine, a recently approved medication for the treatment of opioid dependence in physicians' offices, provides the opportunity to integrate the treatment of HIV infection and substance abuse in one clinical setting, yet little information exists on the models of care that will most successfully facilitate this integration. To promote the uptake of this type of integrated care, the current review provides a description of 4 recently implemented models for combining buprenorphine treatment with HIV primary care: (1) an on-site addiction/HIV specialist treatment model; (2) a HIV primary care physician model; (3) a nonphysician health professional model; and (4) a community outreach model. Sullivan, L.E., Bruce, R.D., Haltiwanger, D., Lucas, G.M, Eldred, L., Finkelstein, R., and Fiellin, D.A. Initial Strategies for Integrating Buprenorphine into HIV Care Settings in the United States. Clin Infect Dis, 43 pp. S191-S196, 2006.

Lack of HIV Seropositivity Among a Group of Rural Probationers: Explanatory Factors

Human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) in rural America has been described as an epidemic, and the HIV prevalence rate among criminal justice populations is higher than the general population. Thus, criminally involved populations in Southern rural areas are at elevated risk for contracting HIV because of drug and sexual practices; however, little is known about HIV/AIDS in the fastest growing criminal justice population - probationers. This study examined possible explanations for the lack of HIV seropositivity found in a purposive sample of rural probationers. Data were examined from 800 felony probationers from 30 counties in Kentucky's Appalachian region. Measures included HIV prevalence within the 30 counties, migration patterns, HIV knowledge, substance use, and sexual risk behaviors. These probationers had a high level of HIV knowledge, reported minimal injection drug use, practiced serial monogamy, and reported minimal engagement in transactional sex. However, these probationers also reported negligible condom use, and injection drug users shared needles and works. Findings suggest the importance of developing programs targeting safe sex practices in rural areas. Oser, C.B., Smiley McDonald, H.M., Havens, J.R., Leukefeld, C.G., Webster, J.M., and Cosentino-Boehm, A.L. Lack of HIV Seropositivity Among a Group of Rural Probationers: Explanatory Factors. J Rural Health, 22(3), pp. 273-275, 2006.

Validating of the Organizational Readiness for Change Scale

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

Licensing/Accreditation Improve Quality of Substance Abuse Treatment

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

The Role of African-American Clergy in Providing Informal Services to Drug Users in the Rural South: Preliminary Ethnographic Findings

To date, no ethnographic studies of the role of African-American clergy in providing informal services to drug users in the rural South have been reported. The researchers conducted qualitative interviews with 15 African-American ministers and 26 African-American drug users in Arkansas' Mississippi River Delta region to explore this issue. All drug users reported significant religiosity, and 9 had discussed drug problems with clergy. Every minister had provided assistance to at least one drug user or his/her family during the previous year, including direct counseling, referrals to treatment programs, aiding negotiations with formal institutions, and providing for basic needs. Ministers stated that clergy are not well-prepared to address drug problems, and most acknowledged a need for professional training. They also discussed barriers to education. The findings contribute to understanding rural informal drug treatment resources. It is suggested that professional treatment providers should investigate the potential benefits of improving outreach efforts to assist African-American ministers who are engaged in drug abuse issues. Sexton, R.L., Carlson, R.G., Siegal, H.A., and Leukefeld, C.G. The Role of African-American Clergy in Providing Informal Services to Drug Users in the Rural South: Preliminary Ethnographic Findings. J Ethn Subst Abuse, 5(1), pp. 1-21, 2006.

Organizational Effects on HIV Testing in Corrections

This study compares the provision of HIV testing in a nationally representative sample of correctional agencies and community-based substance abuse treatment programs and identifies the internal organizational-level correlates of HIV testing in both organizations. Data are derived from the administrator/director survey included in the Criminal Justice Drug Abuse Treatment Study's' National Criminal Justice Treatment Practices Survey. Using an organizational diffusion theoretical framework, organizational characteristics were examined for their relationship to HIV testing in correctional agencies and treatment programs. Administrators/directors were asked: "Is HIV/AIDS testing offered to clients at your facility/location?" 49%-50% of both correctional and treatment programs conducted HIV testing. Organizational correlates were more predictive of HIV testing in correctional agencies, in multivariate logistic regression analyses. Specifically, larger correctional agencies, those with more financial resources, and those with more training and development were more likely to test. At the same time, correctional agencies with administrators with more education, and with greater systems integration with the judiciary, were less likely to test. In community treatment programs for offenders, only program size was related to testing, with larger programs more likely to test. One implication is that staff training is likely to be effective in increasing HIV testing in corrections. Oser, C., Tindall, M., and Leukefeld, C. HIV Testing in Correctional Agencies and Community Treatment Programs: The Impact of Internal Organizational Structure. J Subst Abuse Treat, 32(3), pp. 301-310, 2007.

Organizational, but Not Client, Factors Associated with Substance Abuse Treatment Cost

This study uses data from the Alcohol and Drug Services Survey (ADSS) to estimate the statistical associations between organizational and client characteristics on per client and per day costs of outpatient substance abuse treatment. Variables examined include facility ownership, average length of stay, and visits per enrollment day, and client characteristics such as gender, age, and primary drug of abuse. The authors found several organizational characteristics were statistically significant in the model estimating cost per episode, including log of point prevalence client count (-0.53, p<.01), log of average length of stay (0.73, p<.01), log of visits per enrollment day (0.45, p<.01), log of labor cost index (0.50, p<.01), proportion of counselor time spent in direct counseling (-0.52, p<.01), and location outside a metropolitan area (-0.19. p<.05). None of the client variables are statistically significant in this model. These findings suggest there exists increasing returns to scale in outpatient substance abuse treatment indicating that mergers of substance abuse treatment programs may be economically beneficial. Beaston-Blaakman, A., Shepard, D., Horgan, C., and Ritter, G. Organizational and Client Determinants of Cost in Outpatient Substance Abuse Treatment. J Ment Health Policy Econ, 10(1), pp. 3-13, 2007.

Deaf Recovering Addicts Residing in Oxford Houses Have Similar Aftercare Outcomes to Hearing Residents

Deaf individuals seeking substance abuse recovery are less likely to have access to treatment and aftercare services because of a lack of culturally and linguistically specific programs and insufficient information about existing services. This study found no significant differences between 10 randomly selected Deaf and 10 hearing men, matched for age, ethnicity, and time spent living in Oxford Houses (OH) in terms of sense of community and abstinence self-efficacy. This led to the conclusion that integrating deaf recovering addicts into OH aftercare is not problematic. However, consistent with previous studies, there was a significant difference between the two groups in levels of employment, with all deaf residents being under employed whereas all hearing residents were fully employed. Results suggest that special employment help may be needed to sustain recovery and a return to independent living. Alvarez, J., Adebanjo, A.M., Davidson, M.K., Davis, M.I., and Jason, L.A. Oxford House: Deaf-Affirmative Support. Project Muse Scholarly Journal Online, 151(4), pp. 418-422, 2006.

When Interaction Terms are Correlated, the Power Needed to Detect Mediated Moderation can be Problematic

Mediated moderation occurs when the interaction between two variables affects a mediator, which then affects a dependent variable. In this article, the researchers describe the mediated moderation model and evaluate it with a statistical simulation using an adaptation of product-of-coefficients methods to assess mediation. The researchers also demonstrate the use of this method with a substantive example from the adolescent tobacco literature. In the simulation, relative bias (RB) in point estimates and standard errors did not exceed problematic levels of +/- 10% although systematic variability in RB was accounted for by parameter size, sample size, and nonzero direct effects. Power to detect mediated moderation effects appears to be severely compromised under one particular combination of conditions: when the component variables that make up the interaction terms are correlated and partial mediated moderation exists. Implications for the estimation of mediated moderation effects in experimental and nonexperimental research are discussed. Morgan-Lopez, A., and MacKinnon, D. Demonstration and Evaluation of a Method for Assessing Mediated Moderation. Behav Res Methods, 38(1), pp. 77-87, 2006.


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