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Director's Report to the National Advisory Council on Drug Abuse - February, 2005

Research Findings - Services Research

Drug Abuse Treatment Is Cost-effective in Prison

This paper extends previous research that performed a cost-effectiveness analysis (CEA) of the Amity in-prison therapeutic community (TC) and Vista aftercare programs for criminal offenders in southern California. To assess the impact of treatment over time for this unique sample of criminal offenders (N=576), a 5-year follow-up CEA was performed to compare the cost of an offender's treatment-starting with the in-prison TC program and including any community-based treatment received post-parole-and the effectiveness of treatment in terms of days reincarcerated. The average cost of addiction treatment over the baseline and 5-year follow-up period was $7,041 for the Amity group and $1,731 for the control group. The additional investment of $5,311 in treatment yielded 81 fewer incarceration days (13%) among Amity participants relative to controls-a cost-effectiveness ratio of $65. When considering the average daily cost of incarceration in California ($72), these results suggest that offering treatment in prison and then directing offenders into community-based aftercare treatment is a cost-effective policy tool. McCollister, K.E., French, M.T., Prendergast, M.L., Hall, E. and Sacks, S. Long-term Cost Effectiveness of Addiction Treatment for Criminal Offenders. Justice Quarterly, 21(3), pp. 659-679, 2004.

Outcomes and Costs of Day Hospital Versus Community Day Treatment

The purpose of this study was to estimate the outcomes and costs of day hospital and nonmedical community-based day treatment for chemical dependency. A community sample of 271 adults (179 men) dependent on alcohol and/or drugs was recruited and randomized to either a hospital-based (medical) day treatment program or to a community-based (nonmedical) day treatment program. The day hospital (DH) program lasted for 3 weeks. One community-based program (CP2) lasted for 4 weeks, and the other (CP1) lasted for 6 weeks but with shorter treatment days and more criminal justice clients. Because of concerns regarding treatment fidelity, the CP1 was replaced with CP2 as the randomization site for the nonmedical, community-based arm of the trial halfway through the study. Abstinence rates were similar between DH and CP2 subjects, with 53% and 60% of each group, respectively, reporting no drinking for the 30 days preceding both follow-up interviews. DH subjects were less likely than those in either of the nonmedical programs to report medical problems at both follow-ups. Average episode costs per client were significantly (p < .01) lower at CP1 ($526) than at DH ($1,274) or CP2 ($1,163). A pattern of weaker effects was observed at the less costly problematic community program (CP1), including less abstinence than was reported at CP2 (only 40% of CP1 subjects were alcohol free at both follow-ups) and worse psychiatric, family/friend and employment outcomes than were reported at DH or CP2. Results demonstrate the clinical diversity that exists between nonmedical, community-based day treatment programs and show that nonmedical programs can compete with DH treatment in cost as well as in most outcomes. Kaskutas, L.A., Witbrodt, J. and French, M.T. Outcomes and Costs of Day Hospital Treatment and Nonmedical Day Treatment for Chemical Dependency. J. Stud. Alcohol, 65(3), pp. 371-82, 2004.

ADHD Status and Relapse In Adolescent Drug Abusers following Treatment

This study examined adolescent drug abusers in treatment (N = 220) to estimate the degree to which probable ADHD status increases the odds of post-treatment alcohol, marijuana, and other drug relapse during 6 months following discharge. Drug abusing youth with probable ADHD status exhibited 2.5 times the risk of post-treatment alcohol relapse when compared to youth without probable ADHD status while controlling for demographics, pretreatment conduct-disordered behavior, pretreatment alcohol use frequency, and treatment factors. A significant crude association between probable ADHD status and other drug relapse was not maintained when adjusted for pretreatment conduct-disordered behavior, pretreatment other drug use frequency, or treatment factors. The findings suggest that standard treatment approaches that do not directly address co-morbid disorders may result in elevated post-treatment relapse rates among recovering youth with ADHD. Latimer, W.W., Ernst, J., Hennessey, J., Stinchfield, R.D., and Winters, K.C. Relapse Among Adolescent Drug Abusers Following Treatment: The Role of Probable ADHD Status. Journal of Child and Adolescent Substance Abuse, 13(3), pp. 1-16, 2004.

Marijuana Use Associated with School Dropout and Truancy

This paper explores the relationship between adolescent marijuana use and school attendance. Data were pooled from the 1997 and 1998 National Household Surveys on Drug Abuse to form a sample of 15,168 adolescents, aged 12-18 years, who had not yet completed high school. The analysis determined the role of marijuana use in adolescent school dropout and, conditional on being enrolled, estimated the number of days truant. The potential endogeneity of marijuana use was tested in all specifications. The results indicate that any marijuana use was positively associated with school dropout and truancy in all models. However, when chronic marijuana use (weekly or more frequent) was distinguished from non-chronic marijuana use (less frequent than weekly), chronic marijuana use was found to be the dominant factor in these relationships. The results have important implications for educators, substance abuse treatment providers, and policymakers. Roebuck, M.C., French, M.T., and Dennis, M.L. Adolescent Marijuana Use and School Attendance. Economics of Education Review, 23(2), pp. 133-141, 2004.

Implementation of Managed Care Did Not Affect Receipt of Mental Health Services for Clients in Substance Abuse Treatment

Mental health services affect treatment retention and outcomes for many clients in substance abuse treatment programs. This natural experiment assessed whether converting Medicaid from a fee-for-service program to a capitated, prepaid managed care program affected access to mental health services among clients treated for substance abuse. Medicaid enrollees who were being treated for substance abuse in Oregon were interviewed before treatment and after six months of service. One cohort (N=53) was interviewed one to six months before the implementation of managed care, a second (N=66) was interviewed two years after implementation, and a third (N=49) was interviewed three to four years after implementation. Logistic regression analyses were used to identify whether the implementation of managed care, the psychiatric need of the client, and other client characteristics affected the receipt of mental health services during the first six months of substance abuse treatment. Clients in all three cohorts had similar characteristics. The implementation of managed care did not affect whether clients received mental health services. Baseline psychiatric score derived from the Addiction Severity Index was the only client characteristic that predicted receipt of mental health services. Bigelow, D.A., McFarland, B.H., McCamant, L.E., Deck, D.D., and Gabriel, R.M. Effect of Managed Care on Access to Mental Health Services among Medicaid Enrollees Receiving Substance Treatment. Psychiatric Services, 55(7), pp. 775-779, 2004.

Substance Abuse Treatment Needs and Access in the USA: Interstate Variations

This study investigated interstate substance abuse treatment needs and access in the USA. After assessing the validity of recently developed survey and indicator measures, the study analyzed the geographic distribution and nature of state substance abuse treatment needs. Substance abuse treatment utilization index scores were regressed on the need measurements to identify differences among state populations in treatment access. Treatment needs clustered in stable, distinct geographic patterns. The most severe problems, primarily reflecting alcoholism, were in the West. Drug and alcohol substance use disorders and related problems were not significantly correlated at this level of aggregation. There was evidence of regionalization of the drug-of-choice mix in treatment admissions. Only 21% of the variations in state treatment utilization rates stemmed from the prevalence of substance use disorders and related problems. The biggest treatment gaps were in the South and South-West, regions with large minority populations. Development of interstate survey and indicator measures of treatment needs has created new opportunities to broaden our understanding of substance abuse epidemiology and treatment access in the USA. The nature and severity of drug and alcohol problems vary from state to state, but the interstate disparities in treatment services remain even after variations in treatment need have been discounted. Further research is needed to understand the causes of these differences in treatment access. McAuliffe, W.E., and Dunn, R. Substance Abuse Treatment Needs and Access in the USA: Interstate Variations. Addiction, 99(8), pp. 999-1014, 2004.

Mixed Results for Step Down Continuing Care in the Treatment of Substance Abuse

This study examined the predictors of participation in step down continuing care (i.e., contiguous episode of care at a lower level of intensity) in publicly funded substance abuse treatment programs, and the relation between participation in step down care and alcohol and crack cocaine use outcomes over a 36-month follow-up. The sample included patients in residential/inpatient programs (IP; N = 134) and intensive outpatient programs (IOP; AT = 370). About one-third of IP patients received step down continuing care; fewer than 25% of IOP patients received step down continuing care. Patients who received step down continuing care following IP had greater social support at intake and were more likely to be female and White than those who did not receive continuing care. Patients who received continuing care following IOP were more likely than those who did not to be female and employed, and were older, had higher self-efficacy, and shorter lengths of stay in IOP. Participation in step down care was not associated with other factors assessed at intake. In the IP sample, receiving step down continuing care was not associated with better alcohol or crack cocaine use outcomes over the 36-month follow-up. In the IOP sample, there were no main effects favoring continuing care for either alcohol or crack cocaine use outcomes. However, patients who received continuing care had less crack cocaine use in the first six months of the follow-up. These findings suggest that new models of continuing care are needed that are more acceptable to patients, produce better outcomes, and are cost-effective. McKay, J.R., Foltz, C., Leahy, P., Stephens, R., Orwin, R.G., and Crowley, E.M. Step Down Continuing Care in the Treatment of Substance Abuse: Correlates of Participation and Outcome Effects. Evaluation and Program Planning, 27(3), pp. 321-331, 2004.

Alcohol and Marijuana Use Among College Students

Previous research has shown that the recent tightening of college alcohol policies has reduced college students' drinking. Over the period in which these stricter alcohol policies have been put in place, marijuana use among college students has increased. This raises the question of whether current policies aimed at reducing alcohol consumption are inadvertently encouraging marijuana use. This paper addressed this question by investigating the relationship between the demands for alcohol and marijuana for college students using data from the 1993, 1997, and 1999 waves of the Harvard School of Public Health's College Alcohol Study (CAS). Researchers found that alcohol and marijuana are economic complements and that policies that increase the full price of alcohol are associated with decreased participation in marijuana use. Williams, J., Pacula, R.L., Chaloupka, F.J., and Wechsler, H. Alcohol and Marijuana Use Among College Students: Economic Complements or Substitutes? Health Economics, 13(9), pp. 825-843, 2004.

To What Extent Are Key Services Offered in Treatment Programs for Special Populations?

Many substance abuse treatment (SAT) facilities offer programs tailored for special populations such as women, adolescents, gays/lesbians and others. Previous research shows that there are specific services that are integral to the successful treatment of these populations (e.g., family therapy for adolescents, childcare and transportation assistance for women, and HIV testing and counseling for gays/lesbians). This study examines whether facilities that report having programs for special populations actually offer the recommended services. The data come from the 2000 National Survey of Substance Abuse Treatment Services, which contains information on service offerings, special programs and other characteristics for all SAT facilities in the USA. The results indicate that facilities with special programs are more likely to offer the recommended key services. However, often less than half of these facilities provide the key services. There are consistent differences by ownership status, with for-profit facilities less likely to offer many of the key services. To What Extent are Key Services Offered in Treatment Programs for Special Populations? Olmstead, T. and Sindelar, J.L. Journal of Substance Abuse Treatment, 27(1), pp. 9-15, 2004.

Screening Behavioral Risks in Populations

The concept of behavioral risk refers to health behaviors that increase the likelihood of a variety of illness conditions. With increased scientific research, it has become clear that this concept is useful in understanding the linkage between behavior and health. This paper reviews scientific, conceptual, and practical issues related to the identification of health risk behaviors in primary care. It includes both a literature review and an analysis of the feasibility of screening and health risk appraisal from a public health perspective, giving special attention to four behavioral risk factors: cigarette smoking, alcohol misuse, physical inactivity, and unhealthy diet. The review indicates that there are a wide variety of acceptable screening tests that can be used for population screening programs, and a large number of health risk appraisal instruments to employ in medical and work settings where preventive health services are available. Given the variety of available assessment procedures, the choice of a given instrument will depend on the target population, the purpose of the program, the time available for assessment, and a number of other practical considerations, such as cost. Multiple risk factor screening is feasible, but there is no single instrument or procedure that is optimal for all risk factors or populations. Based on the results of this review, the specific test or combination of tests is less important than the use of screening to make both patients and healthcare providers more aware of the critical importance of monitoring behavioral risk factors on a routine basis. We conclude that while further research and development work needs to be done, sufficient progress has been made to warrant a more ambitious effort that would bring behavioral risk factor screening into the mainstream of preventive medicine and public health. (with Robert Wood Johnson) Babor, T.F., Sciamanna, C.N., Pronk, N.P. Assessing Multiple Risk Behaviors in Primary Care: Screening Issues and Related Concepts. American Journal Preventive Medicine. 27(2 Suppl.), pp. 42-53, 2004.

Effectiveness of Commonly Available Substance Abuse Treatment

Strong efficacy research has been conducted on novel treatment approaches for adolescent substance abusers, yet, little is known about the effectiveness of the substance abuse treatment approaches most commonly available to youths, their families, and referring agencies. This report compares the 12-month outcomes of adolescent probationers (N = 449) who received either Phoenix Academy, a therapeutic community for adolescents that uses a treatment model that is widely implemented across the U.S., or an alternative probation disposition. Across many pretreatment risk factors for relapse and recidivism, groups were well matched after case-mix adjustment. Repeated measures analyses of substance use, psychological functioning, and crime outcomes collected 3, 6, and 12 months after the baseline interview demonstrated that Phoenix Academy treatment is associated with superior substance use and psychological functioning outcomes over the period of observation. As one of the most rigorous evaluations of the effectiveness of a traditional community-based adolescent drug treatment program, this study provides evidence that one such program is effective. Implications of this finding for the dissemination of efficacious novel treatment approaches are discussed. Morral, A.R., McCaffrey, D.F. and Ridgeway, G. Effectiveness of Community-Based Treatment for Substance-Abusing Adolescents: 12-Month Outcomes of Youths Entering Phoenix Academy or Alternative Probation Dispositions. Psychology of Addictive Behaviors. 18(3), pp. 257-268, 2004.

Out of Touch or on The Money: Do the Clinical Objectives of Addiction Treatment Coincide with Economic Evaluation Results?

Previous economic studies have examined the association between substance abuse treatment and reduced costs to society, but it remains uncertain whether the economic measures used in cost and benefit-cost analyses of treatment programs correspond in direction and magnitude with clinical outcomes. In response to this uncertainty, the present study analyzed a longitudinal data set of addiction treatment clients to determine the statistical agreement between clinical and economic outcomes over time. Data were collected from 1,326 clients in the Chicago cohort of the Persistent Effects of Treatment Study. These individuals were interviewed at baseline and at 6-, 24-, 36-, and 48-month follow-up periods (92% follow-up). Correlations between clinical and economic measures were generally small (rho = 0.1 to 0.3) and often became non-significant when controlling for baseline severity. The results demonstrate that although some associations exist, outcomes should be evaluated along both clinical and economic dimensions. Dismuke C.E., French M.T., Salome H.J., Foss, M.A., Scott, C.K., and Dennis, M.L. Out of Touch or on the Money: Do the Clinical Objectives of Addiction Treatment Coincide with Economic Evaluation Results? Journal of Substance Abuse Treat, 27(3), pp. 253-263, 2004.

Cost Estimation of Drug Abuse Treatment

The Drug Abuse Treatment Cost Analysis Program (DATCAP) was designed in the early 1990s as a research guide to collect and analyze financial data from addiction treatment programs. This paper introduces the Brief DATCAP and presents some preliminary findings. Initial feedback from respondents in four adult and one adolescent treatment programs suggests that the Brief DATCAP is understandable, and easier and quicker to complete than the DATCAP. More importantly, preliminary results indicate that cost estimates from the Brief DATCAP differ from those of the longer DATCAP by less than 2%. These results have important research and policy implications because a shorter yet reasonably accurate cost instrument will enhance the feasibility and precision of future economic evaluations of addiction interventions. French, M.T., Roebuck, M.C., and McLellan, A.T. Cost Estimation When Time and Resources are Limited: The Brief DATCAP. Journal of Substance Abuse Treat, 27(3), pp. 187-193, 2004.

Gender Differences in Older Adult Treatment Outcomes For Alcohol Dependence

This study examined clinical characteristics and treatment outcomes of older alcohol-dependent men and women in a mixed-age private outpatient chemical dependency program. The sample comprised 92 patients aged 55 to 77 (63 men and 29 women). The measures consisted of demographic characteristics, alcohol and drug use and dependence, drinking history, health status, psychiatric symptoms, length of stay in treatment, use of Alcoholics Anonymous and 6-month treatment outcomes. Results showed that women reported later initiation of heavy drinking (5+ drinks per occasion) than the men, but had similar drinking levels at the treatment intake interview. At the 6-month follow-up, 79.3% of women reported abstinence from alcohol and drugs in the prior 30 days versus 54.0% of men (p = .02). Greater length of stay in treatment predicted abstinence at 6 months. Among those who were not abstinent, none of the women reported heavy drinking in the 30 days prior to follow-up, whereas non-abstinent men reported a mean (SD) of 4.0 (9.2) heavy drinking days (p = .025). The results suggest that older women may have better drinking outcomes compared with older men, following treatment for alcohol dependence. Satre, D.D., Mertens, J.R., and Weisner, C. Gender Differences in Older Adult Treatment Outcomes for Alcohol Dependence. Journal of Studies on Alcohol, 65(5), pp. 638-642, 2004.

Five-Year Treatment Outcomes Favorable to Older Adults

This study compared 5-year treatment outcomes of older adults to those of middle-aged and younger adults in a large managed care chemical dependency program. Investigators examined age group differences in individual, treatment and extra-treatment factors, which may influence long-term outcome. Seventy-seven per cent of original study participants completed a telephone interview 5 years after outpatient chemical dependency treatment at Kaiser Permanente. This sample (N = 925) included 65 patients aged 55-77, 296 patients aged 40-54 and 564 patients aged 18-39 (age at baseline). Measures at follow-up included alcohol and drug use, Addiction Severity Index (ASI), Alcoholics Anonymous Affiliation Scale, social resource and self-reported health questions. Mortality data were obtained from contact with family members of patients as well as automated health plan records. Older adults were less likely to be drug-dependent at baseline than younger and middle-aged adults, and had longer retention in treatment than younger adults. At 5 years, older adults were less likely than younger adults to have close family or friends who encouraged alcohol or drug use. Fifty-two per cent of older adults reported total abstinence from alcohol and drugs in the previous 30 days versus 40% of younger adults. Older women had higher 30-day abstinence than older men or younger women. Among participants dependent only on alcohol, there were no significant age differences in 30-day abstinence. In logistic regression analysis, age group was not significant. Variables associated with greater age that independently predicted 30-day abstinence in the logistic regression model included longer retention in treatment and having no close family or friends who encouraged alcohol or drug use at 5 years; female gender was also significant. Results indicate that older adults have favorable long-term outcome following treatment relative to younger adults, but these differences may be accounted for by variables associated with age such as type of substance dependence, treatment retention, social networks and gender. Age differences in these characteristics inform intervention strategies to support long-term recovery of older adults and provide direction for investigation of how age affects outcome. Satre, D.D., Mertens, J.R., Arean, P.A and Weisner, C. Five-year Alcohol and Drug Treatment Outcomes of Older Adults Versus Middle-aged and Younger Adults in a Managed Care Program. Addiction, 99(10), pp. 1286-1297, 2004.

Limitation in DSM-IV Cannabis Tolerance as Indicator of Dependence in Adolescents

The usefulness of the Diagnostic and Statistical Manual's (4th ed.; DSM-IV; American Psychiatric Association, 1994) tolerance criterion as an indicator of dependence has been debated. The authors of this study evaluated the performance of the DSM's cannabis tolerance criterion, operationally defined as a percentage increase in quantity needed to get high, in distinguishing adolescents with and without cannabis dependence. Two samples of adolescent cannabis users (ages 12-19) provided data (ns = 417 and 380). Tolerance, defined as a percentage increase (median increase = 300% and 175%, respectively, in the samples), had only moderate overall sensitivity and specificity in distinguishing those with and without cannabis dependence. Results suggest limitations of the DSM-IV's change-based operational definition of tolerance in adolescents. Chung, T., Martin, C.S., Winters, K.C., Cornelius, J.R., and Langenbucher, J.W. Limitations in the Assessment of DSM-IV Cannabis Tolerance as an Indicator of Dependence in Adolescents. Experimental and Clinical Psychopharmacology, 12(2), pp. 136-146, 2004.

Predicting Incentives to Change among Adolescents with Substance Abuse Disorder

This study assessed the degree and nature of motivation and treatment readiness among adolescents admitted to substance abuse services, and whether such factors vary across subgroups of youth based on their social, legal, or clinical profiles. Data come from interviews with 249 youth, 12-18 years of age, who have been admitted to inpatient, residential, or outpatient substance abuse treatment. Measures are adapted from an instrument developed to assess multiple domains of motivation to change (e.g., intrinsic and extrinsic motivation, treatment readiness). Results suggest that the incentive to change among adolescents with substance-abusing behavior is modest at best, regardless of dimension. Nonetheless, ethnicity, type of substance use, and psychopathology significantly predict incentives to change, though the predictors depend on which dimension is considered. The most robust predictor of incentives is the severity of negative consequences associated with youth's substance use-the greater the severity, the greater the incentives. Breda, C., and Heflinger, C.A. Predicting Incentives to Change Among Adolescents with Substance Abuse Disorder. American Journal of Drug and Alcohol Abuse, 30(2), pp. 251-267, 2004.

Effects of Family Background and Pre-incarceration Socio-environmental Factors on Post-release Drug Use for Prisoners

This study compared the effects of family background and pre-incarceration socio-environmental variables on post-release drug use for prison-based drug treatment participants in order to explain observed disparities in rates of 3-year post-release drug use between African Americans and whites. The sample (279 African Americans, 512 whites) comprised male treatment participants who were supervised by a U.S. probation officer following incarceration. Researchers used event history analysis to model time to first drug use during post-release supervision. Results indicated that none of the family background or socio-environmental factors predicted post-release drug use. Variables predictive of drug use for one or both racial groups were socio-demographic characteristics and pre-incarceration behaviors such as age at release, prior incarcerations, and pre-incarceration employment. There were no significant between-group differences for these predictors. Researchers conclude that future study of the effects of socio-environmental variables on post-release drug use will require evaluation of post-release social environment at time of release. Rounds-Bryant, J., Motivans, M.A., and Pelissier, B.M.M. Correlates of Drug Treatment Outcomes for African American and White Male Federal Prisoners: Results from the TRIAD Study, 30(3), pp. 495-514, 2004.

Boosting, a Modern Statistical Technique, Can Overcome Many Obstacles in Causal Effect Modeling

Causal effect modeling with naturalistic rather than experimental data is challenging. In observational studies participants in different treatment conditions may also differ on pretreatment characteristics that influence outcomes. Propensity score methods can theoretically eliminate these confounds for all observed covariates, but accurate estimation of propensity scores is impeded by large numbers of covariates, uncertain functional forms for their associations with treatment selection, and other problems. This paper demonstrates that boosting, a modern statistical technique, can overcome many of these obstacles. Authors illustrate this approach with a study of adolescent probationers in substance abuse treatment programs. Propensity score weights estimated using boosting eliminate most pretreatment group differences, and substantially alter the apparent relative effects of adolescent substance abuse treatment. McCaffrey, D.F., Ridgeway,G,. and Morral, A.R. Propensity Score Estimation with Boosted Regression for Evaluating Causal Effects in Observational Studies. Psychological Methods, 9, 2004.

Social Context of HIV Risk Behaviours Among Male-to-Female Transgenders of Colour

To explore the social context of drug use and sexual behaviours that put male-to-female (MTF) transgenders at risk for HIV, focus groups were conducted consisting of African American, Latina and Asian and Pacific Islander MTF transgenders (N=48) who reside or work in San Francisco, California. Participants were likely to report having unprotected sex with primary partners to signify love and emotional connection, as well as to receive gender validation from their partners. In contrast, viewing sex work with customers as a business encouraged intentions to use condoms. Safer sex intentions with customers were frequently undermined by urgent financial needs, which stemmed from transphobia, employment discrimination and costly procedures associated with gender transition. Participants reported using drugs as a way to cope with or escape life stresses associated with relationships, sex work, transphobia and financial hardship. Interventions with at-risk MTF transgenders should address the interpersonal and social context of unsafe sex and drug use, particularly the unique roles of relationship issues with male partners, stigma, discrimination and community norms regarding sex work and drug use. Nemoto, T., Operario, D., Keatley, J. and Villegas, D. Social Context of HIV Risk Behaviours among Male-to-Female Transgenders of Colour. AIDS Care, 16(6), pp. 724-735, 2004.

HIV Risk Behaviors Among Male-to-Female Transgender Persons of Color in San Francisco

The authors examined HIV risk behaviors among African American, Asian/Pacific Islander (API), and Latina male-to-female (MTF) transgender persons in order to improve HIV prevention programs. Individual survey interviews with MTF transgender persons of color (n = 332; 112 African Americans, 110 Latinas, and 110 APIs) were conducted. Prevalence and correlates of receptive anal sex and unprotected receptive anal sex (URAS) varied by type of partner (primary, casual, or commercial sex partners). URAS with primary partners was associated with drug use before sex; URAS with casual partners was associated with HIV-positive status and drug use before sex; and URAS with commercial sex partners was associated with African American ethnicity and low income. Findings on current risk behaviors among MTF transgender persons provided meaningful implications for HIV prevention interventions. Nemoto, T., Operario, D., Keatley, J., Han, L., and Soma, T. HIV Risk Behaviors Among Male-to-Female Transgender Persons of Color in San Francisco. American Journal of Public Health, 94(7), pp. 1193-1999, 2004.

An HIV Prevalence-based Model for Estimating Urban Risk Populations of Injection Drug Users and Men Who Have Sex with Men

Issues of cost and complexity have limited the study of the population sizes of men who have sex with men (MSM) and injection drug users (IDUs), two groups at clearly increased risk for human immunodeficiency virus (HIV) and other acute and chronic diseases. Authors developed a prototypical, easily applied estimation model for these populations and applied it to Miami, Florida. This model combined HIV prevalence estimates, HIV seroprevalence rates, and census data to make plausible estimates of the number and proportion of MSM and IDUs under a number of assumptions. Sensitivity analyses were conducted to test the robustness of the model. The model suggests that approximately 9.5% (plausible range 7.7%-11.3%) of Miami males aged 18 years or older are MSM (point estimate, N =_76,500), and 1.4% (plausible range 0.9%-1.9%) of the total population aged 18 years or older are IDUs (point estimate, N=_23,700). Males may be about 2.5 times more likely than females to be IDUs. The estimates were reasonably robust to biases. The model was used to develop MSM and IDU population estimates in selected urban areas across Florida and should be replicable in other medium-to-large urban areas. Such estimates could be useful for behavioral surveillance and resource allocation, including enhanced targeting of community-based interventions for primary and secondary HIV prevention. Lieb, S., Friedman, S.R., Zeni, M.B., Chitwood, D.D., Liberti, T.M., Gates, G.J., Metsch, L.R., Maddox, L.M., and Kuper, T. Comprehensive Model of Substance Abuse Treatment Processes Introduced. Journal of Urban Health: Bulletin of the New York Academy of Medicine, 81(3), pp. 401-415, 2004.

Case Management Does Not Appear to Improve Outcomes for HIV/AIDS Substance Abuse Patients

A recent clinical trial at San Francisco General Hospital examined the effects of extended-contact case management (52 weekly contacts extending beyond hospital discharge) compared to typical brief-contact (one or two contacts prior to hospital discharge) sessions prior to hospital discharge) for general-medical (44%), outpatient detoxification (25%), and emergency department patients (22%). Case management emphasized education about unsafe drug use and sexual practices related to HIV transmission. Results after 18 months showed no between-condition differences for substance abuse, HIV transmission risk, physical or mental health, service use, nor perceived quality of life. Death from AIDS-related causes (16% of the sample) were the same for both groups. Results demonstrate the importance of using control groups to assess intervention effect levels. Findings call into question claims by several demonstration projects lacking control conditions that case management can improve patient outcomes for substance abuse and HIV risk. Sorensen, J.L., and Masson, C.L. Case Management for Substance Abusers with HIV/AIDS: Lessons from a Clinical Trial. Directions in Rehabilitation Counseling, 15, pp. 193-201, 2004.

Use of a SAMHSA Standard to Guide Change Efforts Can Increase General Medical Use of Buprenorphine among Rural Physicians

The Opiate Medication Initiative for Rural Oregon Residents trained physicians and counselors in Central and Southwestern Oregon to use buprenorphine and develop service models that supported patient participation in drug abuse counseling. The Change Book from Addiction Technology Transfer Centers was used to structure the change process. Fifty-one individuals (17 physicians, 4 pharmacists, 2 nurse practitioners, and 28 drug abuse counselors and administrators) from seven counties completed the training and contributed to the development of community treatment protocols. A pre-post measure of attitudes and beliefs toward the use of buprenorphine suggested significant improvements in attitude after training, especially among counselors. Eight months after training, 10 of 17 physicians trained had received waivers to use buprenorphine and 29 patients were in treatment with six of the physicians. The Change Book facilitated development of county change teams and structured the planning efforts. The initiative also demonstrated the potential to concurrently train physicians, pharmacists, and counselors on the use of buprenorphine. McCarty, D., Rieckmann, T., Green, C. Gallon, G. and Knudsen, J. Training Rural Pactitioners to Use Buprenorphine: Using the Change Book to Facilitate Technology Transfer. Journal of Substance Abuse Treatment, 26, pp. 203-208, 2004.

Addiction Severity Associated with Increased Inpatient & Ambulatory Care Treatment

Research examining managed care in a large urban hospital found that addiction severity was associated with both inpatient and ambulatory care treatment. The study also found that homelessness and substance abuse exacerbate the health care needs of HIV-infected patients, increasing their use of emergency department and inpatient services. The study indicates that substance abuse treatment is likely to reduce the utilization of general medical public health services, especially among addicts with HIV-infections. Masson, C.L, Sorensen, J.L., Phibbs, C.S., and Okin, R.L. Predictors of Medical Service Utilization Among Individuals with Co-occurring HIV Infection and Substance Abuse Disorders. AIDS Care, 16, pp. 744-755, 2004.


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