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

Research Findings - Services Research

New Estimates of Crime Costs Available

Understanding the costs to society of criminal behavior is essential for economic evaluations of drug abuse services and policies because of the strong estimated association between drug use and crime. This paper combines cost-of-illness and jury compensation methods using the latest available data from a variety of sources, including National Criminal Victimization Survey, the FBI's Uniform Crime Reports and National Incident-Based Reporting System, the Current Population Survey, as well as other published data to update these estimates for 13 common offenses. Murder was the most costly crime on a per offense basis, with a cost of $8.9 million. It was followed by rape/sexual assault ($240,776), aggravated assault ($107,020), robbery ($42,310), arson ($21,103), motor vehicle theft ($10,772), stolen property ($7,974), household burglary ($6,462), embezzlement ($5,480), forgery and counterfeiting ($5,265), fraud ($5,032), vandalism ($4,860), and larceny/theft ($3,532). McCollister K, French M, Fang H. The Cost Of Crime To Society: New Crime-Specific Estimates For Policy And Program Evaluation. Drug Alcohol Depend. 2010; 108(1-2): 98-109.

Termination of Federal Disability Benefits Had Few Effects on National Survey Respondents with Likely Addictive Disorders

Data on 156,000 respondents to the 1994-2002 National Household Surveys on Drug Use/National Surveys on Drug Use and Health (NHSDA/NSDUH) were used to examine the effect of the 1997 termination of Supplemental Security Income for those with addictive disorders on public program (SSI and Welfare) participation, labor market participation, health insurance status, and health care utilization (emergency use, inpatient hospitalizations, psychiatric visits, psychiatric admissions). Subjects selected were those age 18-64 years with less than 16 years of education to reflect the population that is eligible for SSI and Welfare. About 20% reported substance use and associated symptoms consistent with an addictive disorder. Multivariate Log-linear and logistic regressions were estimated using a difference-in-difference-in-difference approach with propensity score adjustments to estimate the differences in the probability of these outcomes between those with likely addictions and non-substance abusers in the period before and after the termination policy went into effect. This method is an improvement on the extant literature because unlike simple pre/post- designs it can account for secular changes between the pre- and post- years that might affect the dependent variables (e.g. economic conditions and employment). Results reveal that there was an 81% (SE=.349) reduction in the use of SSI shortly after the termination. Welfare participation was not immediately affected but had dropped by 31% (SE=.115) by 1999. The probability of employment also increased significantly in the short run for individuals with addictive disorders, but the effect attenuated over time. There were no effects on health insurance status or healthcare utilization through 2002. Chatterji P, Meara E. Consequences Of Eliminating Federal Disability Benefits For Substance Abusers. J Health Econ. 2010; 29(2): 226-240.

Study Measures Costs of Gender-Specific, Peer-Delivered HIV-Prevention Interventions for Drug Abusing Women

Detailed information on the costs of providing one of three HIV-prevention interventions — the NIDA Cooperative Agreement Standard Intervention (SI), SI + a field-based well woman exam (WWE), and SI+WWE+ four education sessions (4ES) — for drug abusing women were measured along side a clinical trial comparing their effectiveness. Subjects were 501 women age 18 years and older who had reported sexual activity in the last four months, were using cocaine, heroin, amphetamines, or other injection drugs, and who had resided in the St. Louis metropolitan area during the study period (2000-2006). Societal and provider costs were measured using standard micro-costing techniques in which a comprehensive and detailed list of resources used to produce each intervention is identified, measured, and valued in dollar terms. Provider costs included variable cost items such as materials, tests, patient incentives, personnel costs, and fixed cost items such as building costs. Costs to society include those costs as well as patient travel and time costs. Average total costs per patient were $227.28 for the SI, 144.45 for the WWE, and $942.30 for the 4ES. Sensitivity analyses revealed that per patient costs varied according to the assumption used. For example, SI might cost as low as $98 per patient if rapid HIV tests were used instead of the enzyme immunoassay test, and 4ES costs could be as low as $549 if building rental and utility costs were half as much as those observed in the study. Ruger J, Ben Abdallah A, Cottler L. Costs Of HIV Prevention Among Out-Of-Treatment Drug-Using Women: Results Of A Randomized Controlled Trial. Public Health Rep. 2010; 125 (Suppl 1): 83-94.

Craving Opioid Medication Predicts Aberrant Drug Behavior in Chronic Pain Patients

This study was performed to examine the relationship between the self-report of opioid medication craving and subsequent misuse of opioid medications among chronic pain patients. Six hundred thirteen adult patients from 5 regional pain treatment clinics, who were prescribed opioid medication for chronic noncancer pain were asked how often they have felt a craving for their medication on a scale from 0=never to 4=very often. All participants completed a series of baseline questionnaires. After 6 months the participants were administered a structured prescription drug use interview (Prescription Drug Use Questionnaire), and submitted a urine sample for toxicology assessment. Their treating physicians also completed a substance misuse behavior checklist (Prescription Opioid Therapy Questionnaire). It was found that 337 participants (55.0%) reported that they never felt a craving for their medication, whereas 276 (45.0%) reported some degree of craving their medication (seldom to very often). Those who reported craving their medication were significantly more often male (P<0.01), unmarried (P<0.05), had lower scores on social desirability (P<0.001), and had been prescribed opioids for a longer time (P<0.05) than those who did not report craving medication. At 6-month follow-up, those who reported craving their medication showed higher scores on the Prescription Drug Use Questionnaire (P<0.001), had a higher incidence of physician-rated aberrant drug behavior on the Prescription Opioid Therapy Questionnaire (P<0.05), showed a higher frequency of abnormal urine toxicology screens (P<0.001), and more often had a positive Aberrant Drug Behavior Index (P<0.001). These results suggest that self-reported craving is a potential marker for identification of those at risk for opioid medication misuse. Wasan A, Butler S, Budman S, Fernandez K, Weiss R, Greenfield S, Jamison R. Does Report Of Craving Opioid Medication Predict Aberrant Drug Behavior Among Chronic Pain Patients? Clin J Pain. 2009; 25(3): 193-198.

Screening for Atypical Suicide Risk Among People Presenting to Alcohol and Other Drug Treatment

Symptoms of internalizing disorders (depression, anxiety, somatic, trauma) are the major risk factors for suicide. Atypical suicide risk is characterized by people with few or no symptoms of internalizing disorders. In persons screened at intake to alcohol or other drug (AOD) treatment, this research examined whether person fit statistics would support an atypical subtype at high risk for suicide that did not present with typical depression and other internalizing disorders. Symptom profiles of the prototypical, typical, and atypical persons, as defined using fit statistics, were tested on 7408 persons entering AOD treatment using the Global Appraisal of Individual Needs (GAIN; Dennis et al., 2003a,b). Participants were 67% male, 45% white, and 73% under age 18 (mean = 19.9, SD = 8.9). In the past year, 86% had substance disorders, 51% had internalizing disorders (e.g., somatic, depression, anxiety, trauma, suicide), and 59% had externalizing disorders (ADHD, conduct disorders), Of those with suicide symptoms, the findings were as expected with the atypical group being higher on suicide and lower on symptoms of internalizing disorders. In addition, the atypical group was similar or lower on substance problems, symptoms of externalizing disorders, and crime and violence. The use of person fit statistics may be able to rapidly red-flag persons at high risk for suicide who are less likely to be identified using the usual screening methods alone. Person fit statistics were useful in identifying persons with atypical suicide profiles and in enlightening aspects of existing theory concerning atypical suicidal ideation. Conrad K, Bezruczko N, Chan Y, Riley B, Diamond G, Dennis M. Screening For Atypical Suicide Risk With Person Fit Statistics Among People Presenting To Alcohol And Other Drug Treatment. Drug Alcohol Depend. 2010; 106(2-3): 92-100.

Measuring Patient Satisfaction During Treatment May Improve Retention

Patient satisfaction surveys, widely used in health care delivery systems, may provide useful data for improving patient retention and outcomes. This study examined the relationship between methadone patients' treatment satisfaction at three months post-admission and their 3-month treatment outcomes and 12-month treatment retention. The study sample consisted of 283 opioid-addicted individuals newly enrolling in one of six Baltimore area methadone maintenance treatment programs: 48% were female, 77% were categorized as African American and the mean age was 42 years. All of the participants had reported using opiates, 70% reported using cocaine, and 24% reported using marijuana in the 30 days prior to treatment entry. New methadone treatment admissions were assessed at 3 months post-admission for satisfaction with their counselors and programs. Correlations examined the relationship between 3-month satisfaction and Addiction Severity Index (ASI) scores. Regression analysis assessed the relationship between satisfaction and drug testing at 3 months and was used to predict whether participants were retained in treatment at 12 months. Findings from this study suggest a positive association between patient satisfaction and measures of treatment outcome and retention. Participants who were more satisfied with their counselors and programs had lower Drug and Legal ASI composite scores at 3 months. Participants who were more satisfied with their programs remained in treatment for at least 12 months. The authors suggest that methadone treatment programs should consider administering measures of treatment satisfaction to their patients at 3 months post-admission to identify patients with low satisfaction scores who may be at risk for prematurely leaving treatment. Measuring patient satisfaction during treatment may help programs meet patients' needs and improve retention. More research is needed to examine how patient satisfaction can be integrated into drug treatment program practice. Kelly S, O 'Grady K, Brown B, Mitchell S, Schwartz R. The Role of Patient Satisfaction in Methadone Treatment. Am J Drug Alcohol Abuse. 2010; 36(3): 150-154.

Social Support May Be An Important Factor in Treatment Entry

Social support has been found to be important in influencing entry into drug-addiction treatment, as well as for retention in treatment and ultimate recovery. This study was conducted to determine the psychometric properties of a measure of social support, the Community Assessment Inventory (CAI), and to examine the role of social support in recovery. The CAI and the Addiction Severity Index (ASI) were administered to 196 opioid-dependent adults in (n = 135) or out of (n = 61) methadone treatment in Baltimore, Maryland, between 2004 and 2006. Sixty percent of the total sample was male, 74% was African American, and the mean age was 41 years old. Just over half the total sample had been employed at least part-time during most of the three years prior to the baseline interview. Analyses focused on six research questions: 1) What are the relationships among the CAI scales at baseline in the total sample?; 2) What are the relationships between CAI scales at baseline and CAI scales at the 3-month assessment for the in-treatment group?; 3) What are the relationships between baseline CAI scales and baseline Addiction Severity Index (ASI) (26) composite scores in the total sample?; 4) Are there significant differences in levels of support at baseline between in- and out-of-treatment opioid-addicted individuals?; 5) What are the relationships between CAI scales at baseline and drug use and illegal activity at the 3-month follow-up for the in-treatment group?; and 6) Are there significant changes over time in perceived levels of support by individuals in treatment? Baseline CAI scale scores indicated a generally high level of internal consistency (alpha scores). Pearson correlations showed that the scales were stable and had good discriminate validity with the ASI composite scores. One-way analysis of variance indicated that in-treatment participants reported significantly more support at baseline than out-of-treatment participants. An important finding in this study was that individuals who were in treatment, as compared with those who were out of treatment, perceived significantly greater support from their partners or family with whom they lived, family members outside the home, friends, and their communities at treatment entry. This study's findings indicate the CAI may be a useful measure of social support and that such support is an important factor in treatment entry. Kelly S, O 'Grady K, Schwartz R, Peterson J, Wilson M, Brown B. The Relationship of Social Support To Treatment Entry And Engagement: The Community Assessment Inventory. Subst Abus. 2010; 31(1): 43-52.

Factors Associated with Drug Dealing Differ between White and Black Youths

Data on 13,706 Black and White youths 12-17 years of age who responded to the 2006 National Survey on Drug Use and Health were used to examine the associations between drug dealing and the use of drugs, drug availability, and the family's receipt of public assistance, all measured in the past 12 months. Separate backward stepwise logistic regressions were estimated by race to assess the factors that had the strongest associated with drug dealing. Among White youths, males were more likely to report drug dealing (AOR = 3.3; 95% CI=2.30, 4.75), as were those who used marijuana (13.9; 8.32-23.19), cocaine (1.8; 1.06-2.97), and hallucinogens (1.9; 1.26-2.86); who misused prescription drugs (2.6; 1.78-3.79), perceived easy availability of cocaine (1.5; 1.06-2.27), and had been approached by someone selling drugs (3.4; 2.39-4.81); and whose families were not on public assistance (0.3, 0.12-0.67). Among Blacks, males (3.7; 1.66—8.13), those using marijuana (12.6; 6.85-23.27), and those who perceived easy availability of crack (1.9; 1.02-3.41) and marijuana (5.0; 1.70-14.62), were more likely to sell drugs. Floyd L, Alexandre P, Hedden S, Lawson A, Latimer W, Giles N. Adolescent Drug Dealing And Race/Ethnicity: A Population-Based Study Of The Differential Impact Of Substance Use On Involvement In Drug Trade. Am J Drug Alcohol Abuse. 2010; 36(2): 87-91.

Identifying Service Needs Across Recovery Stages to Inform Service Development

Substance use disorders (SUD) are, for many, chronic conditions that are typically associated with severe impairments in multiple areas of functioning. "Recovery" from SUD is, for most, a lengthy process; improvements in other areas of functioning do not necessarily follow the attainment of abstinence. The current SUD service model providing intense, short-term, symptom-focused services is ill-suited to address these issues. A recovery-oriented model of care is emerging, which provides coordinated recovery-support services using a chronic-care model of sustained recovery management. Information is needed about substance users' priorities, particularly persons in recovery who are not currently enrolled in treatment, to guide the development of recovery-oriented systems. As a first step in filling this gap, the authors present qualitative data on current life priorities among a sample of individuals that collectively represent successive recovery stages (N = 356). The sample consisted of 56% men, 62% African American, and 19% were of Hispanic origin. The average age was 43: Participants ranged in age from 19 to 65 years. Educational attainment averaged 12 years: Nineteen percent were employed part-time, 21% fulltime; 60% cited government or other benefits (e.g., veteran's pension) as their primary source of income. Nearly one quarter (22%) reported being seropositive for HIV antibodies and 30% for hepatitis C. Findings suggest that many areas of functioning remain challenging long after abstinence is attained, most notably employment and education, family/social relations, and housing. Although the ranking of priorities changes somewhat across recovery stages, employment is consistently the second most important priority, behind working on one's recovery. Findings suggest that individuals in recovery continue to experience many difficulties and to need support in many areas of functioning long after abstinence has been reached. Laudet A, White W. What Are Your Priorities Right Now? Identifying Service Needs Across Recovery Stages To Inform Service Development. J Subst Abuse Treat. 2010; 38(1): 51-59.

Psychiatric Disorders in Smokers Seeking Treatment for Tobacco Dependence and Relationship to Cessation

The goal of the present research is to examine the relationship of psychiatric disorders to tobacco dependence and cessation outcomes. Data were collected from 1,504 smokers (58.2% women; 83.9% White; mean age = 44.67 years, SD = 11.08) making an aided smoking cessation attempt as part of a clinical trial in the mid-west. Psychiatric diagnoses were determined with the Composite International Diagnostic Interview structured clinical interview. Tobacco dependence was assessed with the Fagerstršm Test of Nicotine Dependence (FTND) and the Wisconsin Inventory of Smoking Dependence Motives (WISDM). Psychiatric diagnostic groups included those who were never diagnosed, those who had ever been diagnosed (at any time, including in the past year), and those with past-year diagnoses (with or without prior diagnosis). Some diagnostic groups had lower follow-up abstinence rates than did the never diagnosed group (p < .05). At 8 weeks after quitting, strong associations were found between cessation outcome and both past-year mood disorder and ever diagnosed anxiety disorder. At 6 months after quitting, those ever diagnosed with an anxiety disorder (OR = .72, p = .02) and those ever diagnosed with more than one psychiatric diagnosis (OR = .74, p = .03) had lower abstinence rates. The diagnostic categories did not differ in smoking heaviness or the FTND, but they did differ in dependence motives assessed with the WISDM. This study indicates that information on recent or lifetime psychiatric disorders may help clinicians gauge relapse risk and may suggest dependence motives that are particularly relevant to affected patients. These findings also illustrate the importance of using multidimensional tobacco dependence assessments. Piper M, Smith S, Schlam T, Fleming M, Bittrich A, Brown J, Leitzke C, Zehner M, Fiore M, Baker T. Psychiatric Disorders In Smokers Seeking Treatment For Tobacco Dependence and Relationship To Cessation. J Consult Clin Psychol. 2010; 78(1): 13-23.

Persistent Gaps in Provision of HIV Counseling and Testing in Substance Abuse Treatment

This article examines the extent to which U.S. outpatient substance abuse treatment (OSAT) facilities provided HIV counseling and testing (C&T) to clients between 1995 and 2005, and the organizational and client characteristics associated with OSAT facilities' provision of HIV C&T. Data were collected from a nationally representative sample of outpatient treatment facilities in 1995 (n = 618), 2000 (n = 571), and 2005 (n = 566). Results show that in 1995, 74% of programs provided any HIV testing, but only an average of 26.8% of clients in these programs received HIV C&T. By 2005, services were offered in 82% of programs, but only 28.8% of clients, on average, received C&T. Further, results from random-effects interval regression analysis show that C&T is especially widespread in public and nonprofit facilities, in methadone facilities, and in units that serve injection drug users. HIV C&T was also more widespread in units that employed formal intake protocols. Despite widespread efforts to increase HIV C&T services in OSAT care, only a small and stable minority of clients received these services over the decade studied. The authors suggest that program adoption of formal intake procedures may provide one vehicle to increase provision of C&T services. Pollack HA, D'Aunno T. HIV Testing And Counseling In The Nation's Outpatient Substance Abuse Treatment System, 1995-2005. J Subst Abuse Treat. 2010; 38: 307-316.

Effect of Incarceration History on Outcomes of Primary Care Office-Based Buprenorphine/ Naloxone

Behaviors associated with opioid dependence often involve criminal activity, which can lead to incarceration. The impact of a history of incarceration on outcomes in primary care office-based buprenorphine/naloxone is not known. The purpose of this study is to determine whether having a history of incarceration affects response to primary care office-based buprenorphine/ naloxone treatment. In this post hoc secondary analysis of a randomized clinical trial, investigators compared demographic, clinical characteristics, and treatment outcomes among 166 participants receiving primary care office-based buprenorphine/naloxone treatment stratifying on history of incarceration. This study shows that participants with a history of incarceration have similar treatment outcomes with primary care office-based buprenorphine/naloxone than those without a history of incarceration (consecutive weeks of opioid-negative urine samples, 6.2 vs. 5.9, p = 0.43; treatment retention, 38% vs. 46%, p = 0.28). This study shows that a prior history of incarceration does not appear to impact primary care office-based treatment of opioid dependence with buprenorphine/naloxone. Wang EA, Moore BA, Sullivan LE, Fiellin DA. Effect Of Incarceration History On Outcomes Of Primary Care Office-Based Buprenorphine/Naloxone. J Gen Intern Med. 2010; 1-5.

Unobserved Versus Observed Office Buprenorphine/Naloxone Induction: A Pilot Randomized Clinical Trial

Physician adoption of buprenorphine treatment of opioid dependence may be limited in part by concerns regarding the induction process. Although national guidelines recommend observed induction, some physicians utilize unobserved induction outside the office. The aim of this pilot randomized clinical trial was to assess preliminary safety and effectiveness of unobserved versus observed office buprenorphine/naloxone induction among patients entering a 12-week primary care maintenance study. Participants (N=20) with DSM-IV opioid dependence were randomly assigned to unobserved or office induction, stratifying by past buprenorphine use. All patients received verbal and written instructions. A withdrawal scale was used during initiation and to monitor treatment response. Clinic visits occurred weekly for 4 weeks then decreased to monthly. The primary outcome, successful induction one week after the initial clinic visit, was defined as retention in buprenorphine/naloxone treatment and being withdrawal free. Secondary outcomes included prolonged withdrawal beyond 2 days after medication initiation and stabilization at week 4, defined as being in treatment without illicit opioid use for the preceding 2 weeks. Outcome results were similar in the two groups: 6/10 (60%) successfully inducted in each group, 3/10 (30%) experienced prolonged withdrawal and 4/10 (40%) stabilized by week 4. These pilot study results suggest comparable safety and effectiveness of unobserved and office induction and point toward utilization of non-inferiority design during future definitive protocol development. By addressing an important barrier for physician adoption, further validation of the unobserved buprenorphine induction method will hopefully lead to increased availability of effective opioid dependence treatment. Gunderson E, Wang X, Fiellin D, Bryan B, Levin F. Unobserved Versus Observed Office Buprenorphine/Naloxone Induction: A Pilot Randomized Clinical Trial. Addict Behav. 2010; 35(5): 537-540.

A Brief Alcohol Intervention for Hazardously Drinking Incarcerated Women

The purpose of this study is to test the hypothesis that among hazardously drinking incarcerated women who are returning to the community, a brief alcohol intervention will result in less alcohol use at follow-up relative to standard of care. Eligible participants endorsed hazardous alcohol consumption-four or more drinks at a time on at least 3 separate days in the previous 3 months or a score of 8 or above on the Alcohol Use Disorders Identification Test. Participants were randomized to either an assessment-only condition or to two brief motivationally focused sessions, the first delivered during incarceration, the second 1 month later after community re-entry. Participants recalled drinking behaviors at 3 and 6 months after the baseline interview using a 90-day time-line follow-back method. The 245 female participants averaged 34 years of age, and were 71% Caucasian. The mean percentage of alcohol use days in the 3 months prior to incarceration was 51.7% and heavy alcohol use days were 43.9%. Intervention effects on abstinent days were statistically significant at 3 months (odds ratio = 1.96, 95% confidence interval 1.17, 3.30); the percentage of days abstinent was 68% for those randomized to intervention and 57% for controls. At 6 months the effect of the intervention was attenuated and no longer statistically significant. This paper shows that among incarcerated women who reported hazardous drinking, a two-session brief alcohol intervention increased abstinent days at 3 months, but this effect decayed by 6 months. Study participants continued to drink heavily after return to the community. More intensive intervention pre-release, and after re-entry may benefit hazardously drinking incarcerated women. Stein M, Caviness C, Anderson B, Hebert M, Clarke J. A Brief Alcohol Intervention For Hazardously Drinking Incarcerated Women. Addiction. 2010; 105(3): 466-475.

A Behavioral Decision Model Testing the Association of Marijuana Use and Sexual Risk Behavior in Young Adult Women

The authors created a model conceptualizing sexual risk as a series of discrete event-specific behavioral decisions and tested the hypothesis that marijuana use was associated with increased sexual risk-taking. Three hundred eight marijuana-using women aged 18-24 completed a 90-day time-line-follow-back to assess sexual behaviors and marijuana use. A sequential logit model estimated the effect of marijuana use on the likelihood of being sexually active, partner type when sexually active, and condom nonuse conditional on partner type. Participants had a mean age of 20.4 years, with 67% Caucasian. Marijuana use was associated with an increased likelihood of being sexually active (OR 1.6; 95% CI 1.33, 1.93) and with condom nonuse when sexually active with casual partners (OR 2.58; 95% CI 1.1, 6.09). This behavioral decision model identified where marijuana use was associated with sexual risk, and suggests where interventions designed to reduce risk may have an impact. Stein MD, Anderson BJ. A Behavioral Decision Model Testing the Association of Marijuana Use and Sexual Risk in Young Adult Women. AIDS Behav. 2010: 1-10.

Educational Outreach to Improve Emergency Medical Services Systems of Care for Stroke in Montana

The goal of this study was to improve stroke knowledge, identification, and acute care among first responders (FRs) and emergency medical technicians (EMTs) through educational outreach and support. Beginning in 2006, the Montana Stroke Initiative implemented outreach to FRs and EMTs and emergency medical services (EMS) statewide. Cross-sectional telephone surveys of FRs and EMTs were used to evaluate changes in stroke knowledge and practice in 2006 (n = 988) and 2009 (n = 944), overall and in rural and urban counties. The respondents to the 2009 survey were more likely to report the availability of a stroke protocol in their service (69% vs. 61%, p = 0.001), training in the use of a stroke screening tool (62% vs. 42%, p < 0.001), use of a stroke screening tool (62% vs. 40%, p < 0.001), and an adequate level of knowledge about stroke (81% vs. 66%, p < 0.001) compared with the respondents to the 2006 survey. Significant improvements in each of these areas were achieved for both rural and urban FRs and EMTs. Educational outreach to FRs and EMTs was associated with marked improvement in selected components of the EMS system of stroke care. Oser C, McNamara M, Fogle C, Gohdes D, Helgerson S, Harwell T. Educational Outreach To Improve Emergency Medical Services: Systems Of Care For Stroke In Montana. Prehosp Emerg Care. 2010; 14(2): 259-264.

Risk Practices Associated with Bacterial Infections Among Injection Drug Users in Denver, Colorado

There has been limited research on bacterial infections (e.g., skin and soft tissue abscesses, endocarditis) among injection drug users (IDUs), despite these infections often resulting in serious morbidity and costly medical care. Although high-risk practices that contribute to bacterial infections are not entirely clear, certain injection practices have been found to increase risk in past studies. The objectives of this study are to examine rates of bacterial infections among IDUs in Denver, Colorado, and high-risk practices that predict skin infections. Structured interviews were conducted with 51 active heroin, cocaine, and methamphetamine IDUs (over 18 years). Among all participants, 55% reported a lifetime history of at least one skin infection, and 29% reported having an infection in the last year. Those with a skin infection in the last year were significantly more likely to inject intramuscularly (OR = 1.57) and to report greater heroin injection frequency (OR = 1.08) compared to IDUs with no history of skin infections. Heroin and speedball injectors reported a higher number of past abscesses compared to methamphetamine and cocaine injectors. Intervention strategies to reduce bacterial infections should focus on high-risk injection practices. Learning about rates of bacterial infections and high-risk practices associated with these infections can benefit researchers developing risk reduction interventions for IDUs. Phillips K, Stein M. Risk Practices Associated With Bacterial Infections Among Injection Drug Users In Denver, Colorado. Am J Drug Alcohol Abuse. 2010; 36(2): 92-97.

The Need for Culturally Appropriate, Gender-Specific Global HIV Prevention Efforts with Vulnerable Women

More than 25 years into the HIV/AIDS epidemic, women are rapidly becoming the face of the pandemic. An estimated 15.4 million women aged 15 or older are living with HIV—approximately 46% of the global total of people infected with HIV (UNAIDS, 2007). Women in Sub-Saharan Africa are among the most affected by HIV/AIDS, representing 61% of infections among adults in this region (UNAIDS, 2007). Furthermore, it is estimated that 75% of all women living with HIV are in Sub-Saharan Africa (UNAIDS, 2006). With approximately one in three people infected with HIV, Southern Africa continues to be the global epicenter of the epidemic (UNAIDS, 2006) and accounts for more than one third of HIV infections worldwide (UNAIDS, 2008). It is estimated that 52% of all women aged 15 or older living with HIV are in this region (UNAIDS, 2006). Throughout Sub-Saharan Africa, adolescent women, particularly orphans, are at increased risk for HIV. Wechsberg W, Luseno W. The Need For Culturally Appropriate, Gender-Specific Global HIV Prevention Efforts With Vulnerable Women. J Prev Interv Community. 2010; 38 (2): 85-88.

The Physician Clinical Support System-Buprenorphine (PCSS-B): A Novel Project to Expand/Improve Buprenorphine Treatment

Opioid dependence is largely an undertreated medical condition in the United States. The introduction of buprenorphine has created the potential to expand access to and use of opioid agonist treatment in generalist settings. Physicians, however, often have limited training and experience providing this type of care. Some physicians believe having a mentoring relationship with an experienced provider during their initial introduction to the use of buprenorphine would ease implementation. The authors' goal was to describe the development, implementation, resources, and evaluation of the Physician Clinical Support System-Buprenorphine (PCSS-B), a federally funded program to improve access to and quality of treatment with buprenorphine. The authors provide a description of the PCSS-B, a national network of 88 trained physician mentors with expertise in buprenorphine treatment and skills in clinical education. They provide information regarding the use the PCSS-B core services including telephone, email and in-person support, a website, clinical guidance, a warm-line and outreach to primary care and specialty organizations. Between July 2005 and July 2009, 67 mentors and 4 clinical experts reported providing mentoring services to 632 participants in 48 states, Washington DC and Puerto Rico. A total of 1,455 contacts were provided through email (45%), telephone (34%) and in-person visits (20%). Seventy-six percent of contacts addressed a clinical issue. Eighteen percent of contacts addressed a logistical issue. The number of contacts per participant ranged from 1-125. Between August 2005 and April 2009 there were 72,822 visits to the PCSS-B website with 179,678 pages viewed. Seven guidance were downloaded more than 1000 times. The warm-line averaged more than 100 calls per month. The PCSS-B model provides support for a mentorship program to assist non-specialty physicians in the provision of buprenorphine and may serve as a model for dissemination of other types of care. Egan JE, Casadonte P, Gartenmann T, Martin J, McCance-Katz EF, Netherland J, Renner JA, Weiss L, Saxon AJ, Fiellin DA. The Physician Clinical Support System-Buprenorphine (PCSS-B): A Novel Project to Expand/Improve Buprenorphine Treatment. J Gen Intern Med. 2010: 1-6.

Methamphetamine ("tik") Use and Its Association with Condom Use among Out-of-school South African Females

Little is known about the association between methamphetamine use and sexual risk behaviors among young South African women between 13 and 20 years of age. This study examined the association between methamphetamine use and condom use among out-of-school South African female adolescents. Black and Colored female adolescents were interviewed and categorized into methamphetamine user (n = 261) or non-user (n = 188) groups. Methamphetamine use was reported by 58% of the total sample. Higher methamphetamine rates were found among young Colored females (87%) than among young Black females (11%). In a multiple logistic regression analysis that adjusted for relevant confounders and included an interaction term for race and methamphetamine use, Colored female methamphetamine users were over six times more likely than other participants to report not using a condom the last time they had sex (OR = 6.21; 95% CI = 1.21, 31.94). The conclusions and scientific significance of this study are that efforts are needed to reduce methamphetamine use and related sexual risk among adolescent females in Colored communities and to prevent the spread of methamphetamine use in Black African communities. Wechsberg W, Jones H, Zule W, Myers B, Browne F, Kaufman M, Luseno W, Flisher A, Parry C. Methamphetamine ("tik") Use And Its Association With Condom Use Among Out-Of-School Females In Cape Town, South Africa. Am J Drug Alcohol Abuse. 2010; 36(4): 208-213.


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