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Director's Report to the National Advisory Council on Drug Abuse - September, 2009

Research Findings - Services Research

Accessing Antiretroviral Therapy Following Release from Prison

Interruption of antiretroviral therapy (ART) during the first weeks after release from prison may increase risk for adverse clinical outcomes, transmission of human immunodeficiency virus (HIV), and drug-resistant HIV reservoirs in the community. The extent to which HIV-infected inmates experience ART interruption following release from prison is unknown. To determine the proportion of inmates who filled an ART prescription within 60 days after release from prison and to examine predictors of this outcome. This paper reports on a retrospective cohort study of all 2115 HIV-infected inmates released from the Texas Department of Criminal Justice prison system between January 2004 and December 2007 and who were receiving ART before release. Measured against the proportion of inmates who filled an ART prescription within 10, 30, and 60 days of release from prison. Among the entire study cohort (N = 2115), an initial prescription for ART was filled by 115 (5.4%) inmates within 10 days of release (95% confidence interval [CI], 4.5%-6.5%), by 375 (17.7%) within 30 days (95% CI, 16.2%-19.4%), and by 634 (30.0%) within 60 days (95% CI, 28.1%-32.0%). In a multivariate analysis of predictors (including sex, age, race/ethnicity, viral load, duration of ART, year of discharge, duration of incarceration, parole, and AIDS Drug Assistance Program application assistance), Hispanic and African American inmates were less likely to fill a prescription within 10 days (adjusted estimated risk ratio [RR], 0.4 [95% CI, 0.2-0.8] and 0.4 [95% CI, 0.3-0.7], respectively) and 30 days (adjusted estimated RR, 0.7 [95% CI, 0.5-0.9] and 0.7 [95% CI, 0.5-0.9]). Inmates with an undetectable viral load were more likely to fill a prescription within 10 days (adjusted estimated RR, 1.8 [95% CI, 1.2-2.7]), 30 days (1.5 [95% CI, 1.2-1.8]), and 60 days (1.3 [95% CI, 1.1-1.5]). Inmates released on parole were more likely to fill a prescription within 30 days (adjusted estimated RR, 1.3 [95% CI, 1.1-1.6]) and 60 days (1.5 [95% CI, 1.4-1.7]). Inmates who received assistance completing a Texas AIDS Drug Assistance Program application were more likely to fill a prescription within 10 days (adjusted estimated RR, 3.1 [95% CI, 2.0-4.9]), 30 days (1.8 [95% CI, 1.4-2.2]), and 60 days (1.3 [95% CI, 1.1-1.4]). This study shows that only a small percentage of Texas prison inmates receiving ART while incarcerated filled an initial ART prescription within 60 days of their release. Baillargeon J, Giordano T, Rich J, Wu Z, Wells K, Pollock B, Paar D. Accessing antiretroviral therapy following release from prison. JAMA. 2009;301(8):848-857.

Prevalence of Past Year Assault Among Inner-city Emergency Department Patients

This is one of the first studies to determine the rates of past year non-partner violent assault, both victimization and aggression, and assess variables associated with non-partner violent assault, particularly with regard to substance use. A cross-sectional computerized standardized survey study (n=10,744) was conducted to assess non-partner violent assault, physical and mental health, and substance use among patients presenting to an inner-city ED during 2 years. Patients (aged 19 to 60 years) with normal vital signs in an urban emergency department (ED) from 9 am to 11 pm were eligible; pregnant patients and those with a chief complaint of psychiatric evaluation were excluded. 10,744 patients were enrolled (80% response rate); 14% of the sample reported any past year non-partner violent assault (9% perpetration; 11% victimization). The authors conducted regression analyses, and found that participants with any past year non-partner violent assault (victimization or aggression) were more likely than their counterparts to be men (2.2), to be single (1.5), to be unemployed (1.1), to present to the ED for injury (1.9), and to report poor physical health (1.3) or poor mental health (1.9). They were less likely to be black (0.8), or older (0.95). Alcohol use (1.7), marijuana use (2.4), cocaine use (3.1), prescription drug use (1.4), and past treatment (1.7) were associated with experiencing past year non-partner violent assault. This study found a high percentage (14%) of patients seeking care in this inner-city ED experience violence with a non-partner. Substance use-specifically cocaine-was the strongest predictor of any non-partner violent assault. Cunningham R, Murray R, Walton M, Chermack S, Wojnar M, Wozniak P, Booth B, Blow F. Prevalence of past year assault among inner-city emergency department patients. Ann Emerg Med. 2009;53(6):814-823.e15.

Results From Two Randomized Clinical Trials Evaluating the Impact of Quarterly Recovery Management Checkups With Adult Chronic Substance Users

Post-discharge monitoring and early reintervention have become standard practice when managing numerous chronic conditions. These two experiments tested the effectiveness of recovery management checkup (RMC) protocols for adult chronic substance users. RMC included quarterly monitoring; motivational interviewing to provide personalized feedback and to resolve ambivalence about substance use; treatment linkage, engagement and retention protocols to increase the amount of treatment received. Recruited from sequential addiction treatment admissions, participants in the two experiments were, on average, 36 versus 38 years of age, mainly female (59% versus 46%), African American (85% versus 80%) and met past-year criteria for dependence (87% versus 76%). Participants in both experiments were assigned randomly to the RMC or control condition and interviewed quarterly for 2 years. The Global Appraisal of Individual Needs (GAIN) was the main assessment instrument. RMC participant outcomes were better than control participants in both experiments. Effect sizes were larger in the second experiment in terms of reducing days to readmission (Cohen's d = 0.41 versus d = 0.22), successive quarters in the community using substances (d = -0.32 versus -0.19), past-month symptoms of abuse/dependence (d = -0.23 versus -0.02) and increasing the days of abstinence over 2 years (d = +0.29 versus 0.04). RMC, which provided ongoing monitoring and linkage, is feasible to conduct and is effective for adults with chronic substance dependence. Scott C, Dennis M. Results from two randomized clinical trials evaluating the impact of quarterly recovery management checkups with adult chronic substance users. Addiction. 2009;104(6):959-971.

Gender and Comorbidity Among Individuals With Opioid Use Disorders in the NESARC Study

This study examines gender differences in the association of lifetime mental and substance use disorders among individuals with opioid use disorders in the United States. The sample (N=578) is from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), which is a representative household survey. Bivariate analyses and logistic regression modeling were conducted. About 70% of the sample had a lifetime non-substance use Axis I disorder; women were about twice as likely as men to have either a mood or anxiety disorder. About half of the sample had a personality disorder, with women more likely to have paranoid disorder and men more likely to have antisocial personality disorder. Individuals with a lifetime mental disorder were about three times more likely than others to be dependent on other substances, independent of gender. The study demonstrated an inverse relationship between lifetime mental and other substance use disorders, with women having significantly higher odds for several of the mental disorders and men having greater odds of other substance use disorders. Grella C, Karno M, Warda U, Niv N, Moore A. Gender and comorbidity among individuals with opioid use disorders in the NESARC study. Addict Behav. 2009;34(6-7):498-504.

HAART Receipt and Viral Suppression Among HIV-Infected Patients With Co-Occurring Mental Illness and Illicit Drug Use

Mental illness (MI) and illicit drug use (DU) frequently co-occur. The study sought to determine the individual and combined effects of MI and DU on highly active antiretroviral therapy (HAART) receipt and HIV-RNA suppression among individuals engaged in HIV care. Using 2004 data from the HIV Research Network (HIVRN), researchers performed a cross-sectional study of HIV-infected patients followed at seven primary care sites. Outcomes of interest were HAART receipt and virological suppression, defined as an HIV-RNA <400 copies/ml. Independent variables of interest were: (1) MI/DU; (2) DU only; (3) MI only; and (4) Neither. Chi-square analysis was used for comparison of categorical variables, and logistic regression to adjust for age, race, sex frequency of outpatient visits, years in clinical care, CD4 nadir, and study site. During 2004, 10,284 individuals in the HIVRN were either on HAART or HAART eligible defined as a CD4 cell count < or =350. Nearly half had neither MI nor DU (41%), 22% MI only, 15% DU only, and 22% both MI and DU. In multivariate analysis, co-occurring MI/DU was associated with the lowest odds of HAART receipt (Adjusted Odds Ratio: 0.63 (95% CI: (0.55-0.72]), followed by those with DU only (0.75(0.63-0.87)), compared to those with neither. Among those on HAART, concurrent MI/DU (0.66 (0.58-0.75)), DU only (0.77 (0.67-0.88)), were also associated with a decreased odds of HIV-RNA suppression compared to those with neither. MI only was not associated with a statistically significant decrease in HAART receipt (0.93(0.81-1.07)) or viral suppression (0.93 (0.82-1.05)) compared to those with neither. Post-estimation testing revealed a significant difference between those with MI/DU and DU only, and MI/DU and MI only. Co-occurring MI and DU is associated with lower HAART receipt and viral suppression compared to individuals with either MI or DU or neither. Integrating HIV, substance abuse, and mental health care may improve outcomes in this population. Chander G, Himelhoch S, Fleishman J, Hellinger J, Gaist P, Moore R, Gebo K. HAART receipt and viral suppression among HIV-infected patients with co-occurring mental illness and illicit drug use. AIDS Care. 2009;21(5):655-663.

A Practical Clinical Trial of Coordinated Care Management to Treat Substance Use Disorders Among Public Assistance Beneficiaries

This study tested whether coordinated care management (CCM), a continuity of care intervention for substance use disorders (SUD), improved rates of abstinence when compared with usual welfare management for substance-using single adults and adults with dependent children applying for public assistance. The study was designed as a practical clinical trial and was implemented in partnership with a large city welfare agency. Participants were 421 welfare applicants identified via SUD screening and assigned via an unbiased computerized allocation program to a site that provided either CCM (n = 232) or usual care (UC; n = 189). Outcomes were assessed for 1 year post-baseline with self-reports and biological measures of substance use. As hypothesized, for participants not enrolled in methadone maintenance programs (n = 313), CCM clients received significantly more services than did UC clients. Nonmethadone CCM also showed significantly higher abstinence rates (odds ratio = 1.75; 95% confidence interval = 1.12, 2.76; d = 0.31) that emerged early in treatment and were sustained throughout follow-up. In contrast, no treatment services or outcome effects were found for methadone maintenance clients (n = 108). Findings suggest that CCM is promising as a wraparound to SUD treatment for welfare recipients. Morgenstern J, Hogue A, Dauber S, Dasaro C, McKay J. A practical clinical trial of coordinated care management to treat substance use disorders among public assistance beneficiaries. J Consult Clin Psychol. 2009;77 (2):257-269.

Race and Ethnic Differences in the Prevalence of Gambling Disorders: Results From a National Sample

Prior research suggests that racial minority groups in the United States are more vulnerable to develop a gambling disorder than whites. However, no national survey on gambling disorders exists that has focused on ethnic differences. Analyses of this study were based on the National Epidemiologic Survey on Alcohol and Related Conditions, a large (N=43,093) nationally representative survey of the adult (> or =18 years of age) population residing in households during 2001-2002 period. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Text Revision diagnoses of pathological gambling, mood, anxiety, drug use, and personality disorders were based on the Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV Version. The authors found that the prevalence rates of disordered gambling among blacks (2.2%) and Native/Asian Americans (2.3%) were higher than that of whites (1.2%). Demographic characteristics and psychiatric comorbidity differed among Hispanic, black, and white disordered gamblers. However, all racial and ethnic groups evidenced similarities with respect to symptom patterns, time course, and treatment seeking for pathological gambling. The prevalence of disordered gambling, but not its onset or course of symptoms, varies by racial and ethnic group. These varying prevalence rates may reflect, at least in part, cultural differences in gambling and its acceptability and accessibility. These data may inform the need for targeted prevention strategies for high-risk racial and ethnic groups. Alegria A, Petry N, Hasin D, Liu S, Grant B, Blanco C. Disordered gambling among racial and ethnic groups in the us: results from the National Epidemiologic Survey on Alcohol and Related Conditions. CNS Spectr. 2009;14(3):132-142.

CO Exposure and Subjective Nicotine/Tobacco Effects in Waterpipe Tobacco Smokers

Waterpipe tobacco smoking is increasing in popularity though the toxicant exposure and effects associated with this tobacco use method are not well understood. In this study, 61 waterpipe tobacco smokers (56 males; mean age ± SD , 30.9 ± 9.5 years; mean number of weekly waterpipe smoking episodes, 7.8 ± 5.7; mean duration of waterpipe smoking 8.5 ± 6.1 years) abstained from smoking for at least 24 hr and then smoked tobacco from a waterpipe ad libitum in a laboratory. Before and after smoking, expired-air carbon monoxide (CO) and subjective effects were assessed; puff topography was measured during smoking. It was found that each mean waterpipe use episode duration was 33.1 ± 13.1 min. Expired-air CO increased significantly from a mean of 4.0 ± 1.7 before to 35.5 ± 32.7 after smoking. On average, participants took 169 ± 100 puffs, with a mean puff volume of 511 ± 333 ml. Urge to smoke, restlessness, craving, and other tobacco abstinence symptoms were reduced significantly after smoking, while ratings of dizzy, lightheaded, and other direct effects of nicotine increased. In this study expired-air CO and puff topography data indicate that, relative to a single cigarette, a single waterpipe tobacco smoking episode is associated with greater smoke exposure. Abstinent waterpipe tobacco smokers report symptoms similar to those reported by abstinent cigarette smokers, and these symptoms are reduced by subsequent waterpipe tobacco smoking. Taken together, these data are consistent with the hypothesis that waterpipe tobacco smoking is likely associated with the risk of tobacco/nicotine dependence. Maziak W, Rastam S, Ibrahim I, Ward, KD, Shihadeh A, Eissenberg T. CO exposure, puff topography, and subjective effects in waterpipe tobacco smokers. Nicotine Tob Res. 2009;1:1-6.

Are Differences in Guidelines for the Treatment of Nicotine Dependence and Dependence on Other Drugs Justified?

Despite the many similarities between nicotine dependence and other drug dependences, national guidelines for their treatment differ in several respects. The recent national guideline for the treatment of nicotine dependence has (i) less emphasis on detailed assessment; (ii) less emphasis on treatment of psychiatric comorbidity; (iii) less acceptance of reduction of use as an initial treatment goal; (iv) greater emphasis on pharmacological interventions; and (v) less emphasis on psychosocial treatment than national guidelines for non-nicotine dependences. These treatment differences may occur because (i) nicotine does not cause behavioral intoxication; (ii) psychiatric comorbidity is less problematic with nicotine dependence; (iii) psychosocial problems are less severe with nicotine dependence; and (iv) available pharmacotherapies for nicotine dependence are safer, more numerous and more easily available. However, it is unclear to the authors whether these treatment differences are, in fact, justifiable because of the scarcity of empirical tests. Several possible empirical tests are suggested to answer this question. Hughes JR, Weiss RD. Are differences in guidelines for the treatment of nicotine dependence and non-nicotine dependence justified? Addiction. 2009;1-7 [E-pub ahead of print].

Treatment Fidelity and Retention are Associated with Adolescent Addiction Treatment Outcomes

The purpose of this study was to examine the extent to which exposure to Adolescent Community Reinforcement Approach (A-CRA) intervention procedures mediated the relationship between treatment retention and outcomes. The underlying theory of A-CRA is that rearranging environmental contingencies so that non-using behavior is more rewarding than drug using behavior will prevent or reduce alcohol and other drug (AOD) use. Data from 399 adolescents, who participated in one of four randomly controlled trials of the Adolescent Community Reinforcement Approach (A-CRA) intervention, were used. Exposure to A-CRA was a key measure of treatment fidelity, a count of the 15 procedures and case-management activities which are outlined in the A-CRA and case-management manuals and are scored dichotomously as either completed or not completed. As anticipated, zero-order correlations indicated that retention in treatment was a significant predictor of AOD use (r = -0.18, p < .001). However, the association between retention and AOD use was reduced to non-significance (p = .39) when exposure to A-CRA procedures was included in the structural equation model. The results of this study suggest that exposure to treatment procedures may be a mediator in the treatment process, providing support for "specific ingredients" of treatment impacting treatment outcome. The current findings are useful, as little research to date has identified significant mediators of the relationship between retention and treatment outcomes or identified target thresholds of treatment exposure. Garner B, Godley S, Funk R, Dennis M, Smith J, Godley M. Exposure to adolescent community reinforcement approach treatment procedures as a mediator of the relationship between adolescent substance abuse treatment retention and outcome. J Subst Abuse Treat. 2009;36(3):252-264.

Drug Use and Sexually Transmitted Diseases Among Female and Male Arrested Youths

Knowledge of the rates and correlates of sexually transmitted diseases (STD) among incarcerated juvenile offenders has been limited to mostly male samples. Data were collected on 442 female and 506 male youths processed at a centralized juvenile justice intake facility. FemaleĞmale, multi-group latent class analyses identified two subgroups, of youths, High Risk and Lower Risk, described by a latent construct of risk based on drug test results, STD test results, and a classifica-tion for the seriousness of arrest charge. The results found a similar classification distinguished High Risk and Lower Risk male and female youths. High Risk youth had higher rates of positive STD results, of positive urinalysis for marijuana and cocaine, and of being charged with a serious offense. In addition, 66% of the girls and 57% of the boys in this sample who tested positive for an STD were released back into the community after arrest. Overall, the findings raise serious public health and social welfare concerns, for both the youths and the community. Dembo R, Belenko S, Childs K, Wareham J. Drug use and sexually transmitted diseases among female and male arrested youths. J Behav Med. 2009;32:129-141.

Violent Offenses Associated with Co-Occurring Substance Use and Mental Health Problems: Evidence from CJ-DATS

The present study examines the relationship between substance use, mental health problems, and violence in a sample of offenders released from prison and referred to substance abuse treatment programs. Data from 34 sites (n = 1,349) in a federally funded coopera-tive, the Criminal Justice Drug Abuse Treatment Studies (CJ-DATS), were analyzed. Among parolees referred to substance abuse treatment, self-reports for the six-month period before the arrest resulting in their incarceration revealed frequent problems with both substance use and mental health. For most offenders with substance use problems, the quantity of alcohol consumed and the frequency of drug use were associated with a greater probability of self-reported violence. Mental health problems were not indicative of increases in violent behavior, with the exception of antisocial personality problems, which were associated with violence. The paper emphasizes the importance of providing substance abuse treatment in relation to violent behavior among offenders with mental health problems being discharged to the community. Sacks S, Cleland C, Melnick G, Flynn P, Knight K, Friedmann P, Prendergast M, Coen C. Violent offenses associated with co-occurring substance use and mental health problems: Evidence from CJ-DATS. Behav Sci Law. 2009;27(1):51-69.

Suicide Ideation, Attempts, Prevalent Among Adolescents in Substance Abuse Treatment

Data from CSAT/SAMHSA's Adolescent Treatment Models program were analyzed to determine the rates of suicide ideation and attempts among adolescents entering 11 treatment programs across the country. 948 clients, including 110 in long-term residential, 468 in short-term residential, and 370 in outpatient treatment, were followed for one year post-intake with interim assessments and were assessed with the Global Appraisal of Individual Needs (GAIN). Results indicate that 30% of the youth reported ideating in at least one interview, and 12% reported a suicide attempt. Multivariate regression results reveal that those with a conduct disorder (OR=1.09, CI 1.03-1.15), depression (OR=1.22, CI 1.10-1.36) had higher odds of ideating, while Black adolescents had lower odds (OR=0.24, CI 0.08-0.73). Attempts were more likely among those who had ideated (OR=8.55, CI 3.62-20.17) or who had a conduct disorder (OR=1.23 CI 1.10-1.38). The results suggest that efforts to prevent suicide among adolescents in substance abuse treatment, particularly those with conduct disorders, may be appropriate. Ramchand R, Griffin B, Harris K, McCaffrey D, Morral A. A prospective investigation of suicide ideation, attempts, and use of mental health service among adolescents in substance abuse treatment. Psychol Addict Behav. 2008;22(4):524-532.

Young Adults Seek Treatment for Smoking Cessation Less Often Than Older Adults

Young adult smokers (18-24 year olds) do not seek treatment for smoking cessation as often as older smokers. Two commonly hypothesized reasons for this are that younger smokers are not aware of treatments or cannot afford them. The State of Vermont provides free smoking cessation treatment, and most young smokers are aware of this; thus, the PI and study team tested whether young adult smokers from Vermont would still underutilize treatment via a secondary analysis of the popula-tion-based 2005 VT Adult Tobacco Survey. (n=2000). It was found in this study with small sample size and limited racial variability, that young adult smokers from Vermont were less likely to have used medication (24% vs. 58%; relative risk=0.42) or psychosocial (28% vs. 53%; relative risk =0.54) treatment than middle-aged smokers (25-44 year olds). This study indicates that reasons other than awareness and cost cause young adult smokers to not seek treatment. Hughes JR, Cohen B, Callas PW. Treatment seeking for smoking cessation among young adults. J Subst Abuse Treat. 2009:1-3.

Non-structured Treatment Interruptions Among Injection Drug Users in Baltimore, MD

This study characterized patterns of highly active antiretroviral therapy (HAART) use and predictors of non-structured treatment interruptions (NTIs) among injection drug users (IDUs) in Baltimore, MD. Three hundred thirty-five IDUs who initiated HAART from 1996 to 2006 were studied. NTIs were defined as any subsequent 6-month interval where HAART was not reported. Predictors of the first NTI and subsequent restart of HAART were examined using Cox regression. Two hundred sixty (78%) reported > or =1 NTI. Of 215 with > or =1 follow-up visit after the NTI, 44 (20%) never restarted HAART, 62 (29%) restarted and remained on HAART, and 109 (51%) reported multiple NTIs. NTIs were less likely among those who initiated HAART in later calendar years and had a recent outpatient visit and more likely among women, persons with detectable HIV RNA at the prior visit, and those who reported injecting daily. Among those with NTIs, interruptions occurred earlier in persons who were younger, who did not have a prior AIDS diagnosis, and who were actively injecting; NTIs lasted longer in persons who had higher HIV RNA levels, in persons who were incarcerated, and in persons drinking alcohol. A recent outpatient visit and not actively injecting were associated with restarting HAART. NTIs were common in this population and occurred most frequently in the setting of active drug use and disruption of health care. Effective linkages between primary care for HIV and substance abuse treatment may improve HAART outcomes in this population. Kavasery R, Galai N, Astemborski J, Lucas G, Celentano D, Kirk G, Mehta S. Nonstructured treatment interruptions among injection drug users in Baltimore, MD. J Acquir Immune Defic Syndr. 2009;50(4):360-366.

Outcome Trajectories in Drug Court Do All Participants Have Serious Drug Problems?

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 squared > .75) produced distinct subgroups characterized by (a) consistently drug-negative urine specimens (34% of the sample), (b) consistently drug-positive specimens (21%), (c) consistently missed urine specimens (26%), and (d) urine specimens that began as drug positive but became progressively drug negative over time (19%). These data suggest that approximately one third of the participants might not have had serious drug problems on entry. Approximately one fifth appeared to respond to drug court services, and nearly one half continued to exhibit problems after 14 weeks. Implications for adaptive programming in drug courts are discussed. 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;36:354-368.

Factors Influencing Consent to HIV Testing Among Wives of Heavy Drinkers in India

This study examined the influence of socio cultural factors, perception of risk and exposure to violence on consent to HIV testing among at risk women in an urban slum in India. Married women (n=100) chosen via a multistage probability sampling in a section of Bangalore, India, between 18 and 44 years, sexually active and considered to be at risk because of their husband's hazardous drinking were recruited for the study. Factors influencing refusal of and consent to HIV testing were documented. Data collected on 100 participants indicated that over half the sample (58%) refused consent for HIV testing. There were no significant differences between the groups who consented and those who refused on perception of risk and exposure to violence. Reasons women refused testing include the following: spouse/family would not allow it (40%), believed that they were not at risk or would test negative (29%) and underwent HIV testing during an earlier pregnancy (21%). Among those who consented for HIV testing, 79% did so because the testing site was easily accessible, 67% consented because testing was free and because the importance of HIV testing was understood. The findings highlight the role of social, logistic and awareness related factors in utilizing voluntary counseling and testing services by women in this slum community. Generaliza-tion of the findings is a limitation, however few studies documents factors important to promote HIV testing in, particularly among at risk monogamous women. Furthermore, this study indicates better consent rates among women in developing countries are ultimately achievable by improving logistics, increasing awareness and involving significant others. Satyanarayana V, Chandra P, Vaddiparti K, Benegal V, Cottler L. Factors influencing consent to HIV testing among wives of heavy drinkers in an urban slum in India. AIDS Care. 2009;21(5):615-621.

Factors Mediating and Moderating the Relationship Between Gender and Utilization of Health Care Among Puerto Rican Drug Users in New York

This study examined factors that mediate and moderate the relationship between gender and utilization of mental health and medical services in the past year among Puerto Rican drug users (308 females; 892 males) recruited in New York City. Experience of sexual or physical abuse, injection drug use, relationship variables (e.g., having a sexual partner who is an injection drug user), and serious or chronic mental/medical conditions were used as potential mediators and moderators. Both sexual and physical abuse mediated gender effects on use of mental health services. Having chronic medical problems mediated the relationship between gender and utilization of medical and mental health services. Significant interaction effects of gender by depression, physical abuse, and HIV sero-status on utilization of medical services were found. Health (particularly mental health) care was under-utilized by both women and men, despite high rates of depression and chronic medical conditions. The finding of under-use of medical services by HIV-positive drug users (particularly by HIV-positive women) indicates a need for further efforts to engage all HIV-positive persons in care. The findings also indicate an on-going need for mental and other health services for drug users who have been victims of abuse. Kang S, Deren S. Factors mediating and moderating the relationship between gender and utilization of health care among Puerto Rican drug users in New York. Drug Alcohol Depend. 2009;102(1-3):138-143.

Relationship Between Stress, Substance Use and Sexual Risk Behaviors Among Primary Care Patients in Cape Town, South Africa

Authors assessed the relationship between stress, substance use and sexual risk behaviors in a primary care population in Cape Town, South Africa. A random sample of participants (and over-sampled 18-24-year-olds) from 14 of the 49 clinics in Cape Town's public health sector using stratified random sampling (n = 2,618), was selected. PI and study team evaluated current hazardous drug and alcohol use and three domains of stressors (Personal Threats, Lacking Basic Needs, and Interpersonal Problems). It was found that several personal threat stressors and an interpersonal problem stressor were related to sexual risk behaviors. With stressors included in the model, hazardous alcohol use, but not hazardous drug use, was related to higher rates of sexual risk behaviors. These findings suggest a positive screening for hazardous alcohol use should alert providers about possible sexual risk behaviors and vice versa. Additionally, it can be seen from this study that it is important to address a broad scope of social problems and incorporate stress and substance use in HIV prevention campaigns. Avalos LA, Mertens JR, Ward CL, Flisher AJ, Bresick GF, Weisner CM. Stress, substance use and sexual risk behaviors among primary care patients in Cape Town, South Africa. AIDS Behav. 2009:0-1.

Management Practices in Substance Abuse Treatment Programs

Efforts to understand how to improve the delivery of substance abuse treatment have led to a recent call for studies on the "business of addiction treatment." This study adapts an innovative survey tool to collect baseline management practice data from 147 addiction treatment programs enrolled in the Network for the Improvement of Addiction Treatment 200 project (NIATx). Measures of "good" management practice were strongly associated with days to treatment admission. Management practice scores were weakly associated with revenues per employee but were not correlated with operating margins. Better management practices were more prevalent among programs with a higher number of competitors in their catchment area. McConnell KJ, Hoffman KA, Quanbeck A, McCarty D. Management practices in substance abuse treatment programs. J Subst Abuse Treat. 2009:79-89.

Psychotic Symptoms, Disorders and Outcomes Among US Latinos

In US regional studies, Latinos frequently endorse psychotic symptoms associated with impairment and mental health service use, yet do not meet criteria for psychotic disorder. Using a nationally representative Latino sample (N = 2554), the authors examined the prevalence of psychotic symptoms, their relationship to psychotic disorder, their correlates, and their relationship to mental health outcomes. In this sample, 9.5% (SE = 0.7) endorsed 1 or more lifetime psychotic symptoms, yet 93% of endorsers did not meet Structured Clinical Interview for DSM-IV criteria for psychotic disorders. Endorsement was associated with physical and emotional distress, particularly lifetime anxiety and current substance use disorder. Acculturation to US society and reliance on spiritual/religious help were also associated with psychotic symptom endorsement. These symptoms have substantial clinical significance, being independently associated with suicidal ideation, mental health-related disability, and outpatient mental health service utilization. Endorsed psychotic symptoms in Latinos may constitute a clinically significant marker of general psychiatric vulnerability rather than a sign of psychotic disorder. Lewis-Fern‡ndez R, Horvitz-Lennon M, Blanco C, Guarnaccia P, Cao Z, Alegr’a M. Significance of endorsement of psychotic symptoms by US Latinos. J Nerv Ment Dis. 2009;197(5):337-347.

The Attitudes of Females in Drug Court Toward Additional Safeguards in Research Studies

This article examines the attitudes of 97 women from the St. Louis City Drug Court who previously participated in an HIV prevention study. Data from the previous study indicated that the women met multiple criteria for vulnerability in research. Federal regulations require that such participants be provided with "additional safeguards." The survey explored the following questions: (1) What are participants' attitudes toward commonly proposed additional safeguards for vulnerable participants in research, and (2) Are attitudes toward safeguards related to participants' previous compliance with an HIV prevention protocol? The researchers found preferences regarding safeguards in research were not significantly related to participants' compliance in the previous study. However, most participants wanted researchers to take extra measures not only to provide consent information, but to ensure that they are not high on drugs, that they understand relevant information, and that they retain consent information at each visit. Most participants wanted researchers themselves, and not a third party, to assume this responsibility. DuBois JM, O'Leary CC, Cottler LB. The attitudes of females in drug court toward additional. Prev Sci. 2009;10:0-1.


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