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

Research Findings - Services Research

Cost-Effectiveness of Genetic Testing for Initial Anti-Retroviral Therapy

This study evaluated the clinical impact and cost-effectiveness of HLA-B*5701 testing to guide selection of first-line HIV regimens in the United States. Cost-effectiveness analysis was done using a simulation model of HIV disease. The prevalence of HLA-B*5701 and the probabilities of confirmed and unconfirmed severe systemic hypersensitivity reaction among patients taking abacavir testing HLA-B-5701 positive and negative were from the Prospective Randomized Evaluation of DNA Screening in a Clinical Trial study. The monthly costs of abacavir-based and tenofovir-based regimens were $1135 and $1139, respectively; similar virologic efficacy was assumed and this assumption was varied in sensitivity analysis. The patients represented a simulated cohort initiating HIV therapy. The interventions are first-line abacavir, lamivudine, and efavirenz without pretreatment HLA-B-5701 testing; the same regimen with HLA-B-5701 testing; and first-line tenofovir, emtricitabine, and efavirenz. The main outcome measures were: Quality-adjusted life years and lifetime medical costs discounted at 3% per annum, cost-effectiveness ratios ($/QALY). Abacavir-based treatment without HLA-B-5701 testing resulted in a projected 30.93 years life expectancy, 16.23 discounted quality-adjusted life years, and $472 200 discounted lifetime cost per person. HLA-B-5701 testing added 0.04 quality-adjusted months at an incremental cost of $110, resulting in a cost-effectiveness ratio of $36 700/QALY compared with no testing. Initiating treatment with a tenofovir-based regimen increased costs without improving quality-adjusted life expectancy. HLA-B-5701 testing remained the preferred strategy only if abacavir-based treatment had equal efficacy and cost less per month than tenofovir-based treatment. Results were also sensitive to the cost of HLA-B-5701 testing and the prevalence of HLA-B-5701. It is concluded that pharmacogenetic testing for HLA-B-5701 is cost-effective only if abacavir-based treatment is as effective and costs less than tenofovir-based treatment. Schackman, B.R., Scott, C.A., Walenskyding, R.P., Losinar, E., Freedbergding, K.A., and Sax, P.E. The Cost-Effectiveness of HLA-B-5701 Genetic Screening to Guide Initial Antiretroviral Therapy for HIV. AIDS, 22(15), pp. 2025-2033, 2008.

Methadone Maintenance for Prisoners: Findings at 6 mos Post-Release

This study examined the effectiveness of methadone maintenance initiated prior to or just after release from prison at 6 months post-release. A three-group randomized controlled trial was conducted between September 2003 and June 2005. Two hundred and eleven adult pre-release inmates, in a Baltimore pre-release prison, who were heroin-dependent during the year prior to incarceration, were assigned randomly to the following: counseling only: counseling in prison, with passive referral to treatment upon release (n = 70); counseling + transfer: counseling in prison with transfer to methadone maintenance treatment upon release (n = 70); and counseling + methadone: methadone maintenance and counseling in prison, continued in a community-based methadone maintenance program upon release (n = 71). Counseling + methadone participants were significantly more likely than both counseling only and counseling + transfer participants to be retained in drug abuse treatment (P = 0.0001) and significantly less likely to have an opioid-positive urine specimen compared to counseling only (P = 0.002). Furthermore, counseling + methadone participants reported significantly fewer days of involvement in self-reported heroin use and criminal activity than counseling only participants. Methadone maintenance, initiated prior to or immediately after release from prison, increases treatment entry and reduces heroin use at 6 months post-release compared to counseling only. This intervention may be able to fill an urgent treatment need for prisoners with heroin addiction histories. Gordon, M., Kinlock, T., Schwartz, R., and O 'Grady, K. A Randomized Clinical Trial of Methadone Maintenance for Prisoners: Findings at 6 months Post-Release. Addiction, 103(8), pp. 1333-1342, 2008.

Epidemiology of Chronic Prescription Opioid Use: Results From a Major National, Population-Based Survey

Chronic pain occurs commonly and accounts for significant suffering and costs. Although use of opioids for treatment of chronic pain is increasing, little is known about patients who use opioids regularly. The researchers report data from the second wave of the Healthcare for Communities survey (2000-2001), a large, nationally representative household survey. They compared regular users of prescription opioids to nonusers of opioids and calculated the percentage of individuals within a given demographic or disease state that reported chronic opioid use. Approximately 2% of the 7,909 survey respondents reported use of opioid medications for at least a month, which the Healthcare for Communities survey defined as "regular use." It was found that opioid users were more likely than nonusers to report high levels of pain interference with their daily lives and to rate their health as fair or poor. Arthritis and back pain were the most prevalent chronic, physical health conditions among users of opioids, with 63% of regular users of opioids reporting arthritis and 59% reporting back pain. The majority of regular users of opioids had multiple pain conditions (mean=1.9 pain conditions). This study indicates that regular opioid users appear to have an overall lower level of health status and to have multiple, chronic physical health disorders. Hudson, T., Edlund, M., Steffick, D., Tripathi, S., and Sullivan, M. Epidemiology of Regular Prescribed Opioid Use: Results From a National, Population-Based Survey. J. Pain Symptom Manage., 36(3), pp. 280-288, 2008.

Trends in Use of Prescription Opioid Medication by the Type of Noncancer Pain, From 2000-2005, Among Arkansas Medicaid and HealthCore Enrollees: Results From the TROUP Study

Use of prescription opioids for noncancer pain has increased significantly in recent years, but it is not known if trends differ among the most common noncancer pain conditions. The researchers examined trends in opioid prescribing for the years 2000 through 2005 for individuals with arthritis/joint pain, back pain, neck pain, and headaches by type and number of pain diagnoses, using data from claims records from 2 health insurers: HealthCore commercially insured members (N = 3,768,223) and Arkansas Medicaid (N = 127,866). Rates of headache, back pain, and neck pain diagnoses increased significantly in Arkansas Medicaid enrollees but more modestly among HealthCore enrollees. Rates of opioid use increased in both groups, with long-term use (>90 days '' supply per year) increasing at twice the rate of any use. It was found that rates of opioid use did not differ widely between noncancer pain conditions, but long-term opioid use rates doubled with each additional pain diagnosis. Mean days supply and cumulative yearly dose increased between 2000 and 2005 for all pain types and with increasing number of pain diagnoses, but dose per day supply remained relatively stable. The greatest increases in dose among all the pain conditions were seen in short-acting DEA Schedule II opioids. This study demonstrates increased use of opioids, particularly long-term use, in noncancer pain over a 6-year period among those with multiple pain types. These results appear to reflect a general increase in use of prescription opioids for noncancer pain rather than a condition-specific change in prescribing practices. Braden, J., Fan, M., Edlund, M., Martin, B., DeVries, A., and Sullivan, M. Trends in Use of Opioids by Noncancer Pain Type 2000-2005 Among Arkansas Medicaid and Health Core Enrollees: Results From the TROUP Study. J. Pain, 9(11), pp. 1026-1035, 2008.

The Adoption of Evidence-Based Practices in Public Sector Adolescent Addiction Treatment

This article examines the adoption and initial implementation phases of a statewide effort to narrow the gap between science and practice in the treatment of substance abuse disorders in adolescents. Although transporting evidence-based substance abuse services to community-based treatment settings has been described as a public health and federal research priority, the vast majority of substance abuse treatment services are not evidence-based, and relatively little research has examined the adoption and implementation of evidence-based practices. Four hundred thirty-two public sector therapists attended a workshop in contingency management (CM) and were interviewed monthly for the following 6 months to assess their adoption and initial implementation of CM to treat substance-abusing adolescent clients. Results showed that 58% (n = 131) of the practitioners with at least one substance-abusing adolescent client (n = 225) adopted CM. Rates of adoption varied with therapist service sector (mental health vs. substance abuse), educational background, professional experience, and attitudes toward treatment manuals and evidence-based practices. Competing clinical priorities and client resistance were most often reported as barriers to adopting CM, whereas unfavorable attitudes toward and difficulty in implementing CM were rarely cited as barriers. The fidelity of initial CM implementation among adopters was predicted by organizational characteristics as well as by several demographic, professional experience, attitudinal, and service sector characteristics. Fidelity, for example, was predicted by working in an organization with high motivational readiness for change, being certified in addiction counseling, having high caseloads and a high percentage of youth clients, being of younger age, and not holding negative attitudes toward treatment manuals. Overall, the findings support the amenability of public sector practitioners to adopt evidence-based practices and suggest that the predictors of adoption and initial implementation are complex and multifaceted. Future research may explore the conditions that support the fidelity of implementation of evidence-based practices or the sustainability of these innovations. Although research on these issues is costly and challenging to conduct, the authors argue that such work is critical for narrowing the gap between science and service. Henggeler, S., Chapman, J., Rowland, M., Halliday-Boykins, C., Randall, J., Shackelford, J., and Schoenwald, S. Statewide Adoption and Initial Implementation of Contingency Management for Substance-Abusing Adolescents. J. Consult. Clin. Psychol., 76(4), pp. 556-567, 2008.

Recovery Capital are Associated with Sustained Recovery, Higher Quality of Life, and Lower Stress

This study appears to be the first specifically designed to assess the differential role of psychosocial factors as prospective predictors of recovery outcome. The authors build on previous cross-sectional findings that recovery capital (social supports, spirituality, religiousness, life meaning, and 12-step affiliation) enhances the ability to cope with stress and enhances life satisfaction. The authors state that many recovering persons report quitting their drug use because they are "sick and tired" of the drug life. There has been little research on the millions of recovering persons in the United States, and most research has focused on substance use outcomes rather than on broader functioning domains. This study (a) tests the hypothesis that higher levels of recovery capital prospectively predict sustained recovery, higher quality of life, and lower stress one year later, and (b) examines the differential effects of recovery capital on outcomes across the stages of recovery. Recovering persons (N = 312), mostly inner-city ethnic minority members whose primary substance had been crack or heroin, were interviewed twice at a one-year interval in New York City between April 2003 and April 2005. The sample was 55% male; 63% African-American, 15% non-Hispanic white, and 22% of other or mixed ethnic/racial background; 18% were of Hispanic origin. Participants were classified into one of four baseline recovery stages: under 6 months, 6-18 months, 18-36 months, and over 3 years. Multiple regression findings generally supported the central hypothesis and suggested that different domains of recovery capital were salient at different recovery stages. For example, twelve-step involvement was the only significant predictor of sustained recovery among individuals with 6 to 18 months of recovery at baseline. The study's limitations are noted and implications of findings for clinical practice and for future research are discussed, including the need for a theoretical framework to elucidate the recovery process. Identifying recovery patterns over time, as well as the factors that promote and hinder positive outcomes over the course of this process may assist in realizing recovery potential and help to minimize the risk of return to active addiction by informing clinicians, the recovery community, and family. Laudet, A., and White, W. Recovery Capital as Prospective Predictor of Sustained Recovery, Life Satisfaction, and Stress Among Former Poly-Substance Users. Subst. Use Misuse, 43(1), pp. 27-54, 2008.

Medical Severity at Chemical Dependency Admission and Receiving Integrated Treatment Both Positively Associated with Remission from Substance Abuse at 5 Years

Five-year outcomes of 589 adult chemical dependency clients in a private health plan were examined to determine the statistical association between having a substance abuse-related medical condition (SAMC, e.g. injury and poisonings, anxiety and nervous disorders, hypertension), severity of medical condition as measured by the Addiction Severity Index, having been randomized to integrated substance abuse and medical treatment, or receiving continuing primary care services and being in remission from substance abuse. Logistic regression models informed by the stress and coping model revealed that while clients with SAMCs or who received more than one primary care visits had similar odds of remitting within 5 years as others, those with higher ASI medical severity scores had higher odds of remission (OR = 2.0, 95% CI 1.14-3.54), as did those who had been randomized into integrated care (OR = 1.48, 95% CI 1.04 - 2.13). Among those with SAMCs (n=458), severity of medical condition and randomization into integrated care were also positively associated with the odds of remission, but those with 2-10 primary care visits also had higher odds of remitting when compared with those with no visits (OR = 1.23, 95% CI = 1.23-7.27). Mertens, J., Flisher, A., Satre, D., and Weisner, C. The Role of Medical Conditions and Primary Care Services in 5-Year Substance use Outcomes among Chemical Dependency Treatment Patients. Drug Alcohol Depend., 98(1-2), pp. 45-53, 2008.

Substance Abuse Treatment Outcomes

This longitudinal cohort study of 324 consecutive admissions to methadone maintenance treatment between August 1994 and September 1997 compared 1-year outcomes of opioid-dependent patients referred from a syringe exchange program (SEP; n = 81) versus other sources (n = 243). All participants received stepped-based counseling. The Addiction Severity Index was completed upon admission. Treatment outcomes were assessed using weekly urine testing and days in treatment. GEE regression models were used to evaluate the association between baseline variables and treatment outcomes. SEP referrals were older, included more males and African Americans, reported greater unemployment and heavier heroin, cocaine, and injection drug use at admission. During treatment, SEP referrals used more opioids (OR 2.57; 95% CI 1.86-3.56) and cocaine (OR 2.77; 95% CI 1.93-3.95), and were less likely to complete 1 year (35%) compared to other referrals (56%; hazard ratio 1.88; 95% CI 1.35-2.62). Nevertheless, referral source was not significantly associated with outcome when adjusted for baseline characteristics. Greater baseline frequency of substance and injection drug use, and younger age were positively associated with ongoing opioid and cocaine use. African American race and baseline unemployment were also associated with ongoing cocaine use. Younger age and greater baseline cocaine use were associated with poorer retention at 1 year. The poorer treatment response of SEP referrals is likely due to higher baseline problem severity. Specialized interventions may be required to reduce drug use and improve retention in this population. Neufeld, K., King, V., Peirce, J., Kolodner, K., Brooner, R., and Kidorf, M. A Comparison of 1-year Substance Abuse Treatment Outcomes in Community Syringe Exchange Participants Versus Other Referrals. Drug Alcohol Depend., 97, pp. 122-129, 2008.

An Examination of Attitudes Towards Opioid Substitution Therapies

Attitudes and beliefs about drug abuse treatment have long been known to shape response to that treatment. Two major pharmacological alternatives are available for opioid dependence: methadone, which has been available for the past 40 years, and buprenorphine, a recently introduced medication. This mixed-methods study examined the attitudes of opioid-dependent individuals toward methadone and buprenorphine. A total of 195 participants (n = 140 who were enrolling in one of six Baltimore area methadone programs and n = 55 who were out-of-treatment) were administered the Attitudes toward Methadone and toward Buprenorphine Scales, and a subset (n = 46) received an ethnographic interview. The majority of comments from out-of-treatment individuals regarding methadone were negative. Negative comments about methadone fell into four major categories: health effects, long-term nature of treatment with methadone, withdrawal symptoms upon discontinuation, and the impact of methadone on their peers who had entered treatment. The in-treatment group had significantly more positive attitudes toward methadone than did the out-of-treatment group (p < .001), while they did not differ in their attitudes toward buprenorphine. Participants believed that buprenorphine had fewer side effects than methadone. Both groups had significantly more positive attitudes toward buprenorphine than methadone. Addressing these attitudes may increase treatment entry and retention. Schwartz, R., Kelly, S., O 'Grady, K., Mitchell, S., Peterson, J., Reisinger, H., Agar, M., and Brown, B. Attitudes Toward Buprenorphine and Methadone Among Opioid-Dependent Individuals. Am. J. Addict., 17(5), pp. 396-401, 2008.

Expanding the Public Health Benefits of Syringe Exchange Programs

This study provides a brief history of community syringe exchange programs (SEPs), describes the clinical profile of those who attend them, identifies factors interfering with the transition of SEP participants to more comprehensive substance abuse treatment services, reviews studies designed to improve rates of treatment seeking, and offers practical suggestions to facilitate links between SEPs and substance abuse treatment. Relevant articles were identified using a PubMed literature search of English-language journals from 1997 to 2007. Studies were included that evaluated the effectiveness of SEPs or methods for increasing treatment enrolment in SEP participants or other out-of-treatment intravenous drug users. Relevant articles prior to 1997 were identified using reference lists of identified articles. SEPs were found to have little impact on rates of drug use or injections. Substance abuse treatment reduces human immunodeficiency virus transmission through drug use reduction and psychosocial functioning improvement, yet SEP participants only infrequently engage in treatment. Psychological and pharmacological interventions delivered at the SEP setting can improve treatment seeking in SEP participants. Use of SEPs by substance abuse treatment programs can improve harm-reduction efforts at these settings. Efforts to improve the link between SEPs and substance abuse treatment should include interventions to enhance cooperation across programs, motivate treatment enrollment and SEP use, and expand access to treatment. A more fluent and bidirectional continuum of services can enhance the public health benefits of both of these health care delivery settings. Kidorf, M., and King, V. Expanding the Public Health Benefits of Syringe Exchange Programs. Can. J. Psychiatry, 53(8), pp. 487-495, 2008.

Cigarettes and Waterpipe Smoking Among Medical Students in Syria

The authors studied the tobacco use, beliefs and attitudes among medical students in Syria. The research conducted was a cross-sectional study of a random sample of 570 medical students (first and fifth year) registered at the Damascus University Faculty of Medicine in 2006-2007. A self-administered questionnaire was used to determine demographic information, smoking behavior (cigarette, water-pipe), family and peer smoking, attitudes and beliefs about smoking and future role in advising patients to quit smoking. The overall prevalence of tobacco use was 10.9% for cigarettes (15.8% men, 3.3% women), 23.5% for water-pipe (30.3% men, 13.4% women) and 7.3% for both (10.1% men, 3.1% women). Both smoking methods were more popular among the fifth year students (15.4% and 27%) compared to their younger counterparts (6.6% and 19.7%). Regular smoking patterns predominated for cigarettes (62%), while occasional use patterns predominated for water-pipes (83%). More than two thirds of students (69%) thought they might not address or would have difficulty addressing smoking in their future patients. This study shows that the level of tobacco use among Syrian medical students is alarming and highlights the rapidly changing patterns of water-pipe use, especially among female students. The need for medical schools to address this important public health problem and address it more efficiently in their curricula was highlighted. Almerie, M. Q., Matar, H. E., Salam, M., Morad, A., Abdulaal, M., and Koudsi, A. Cigarettes and Waterpipe Smoking Among Medical Students. Int. J. Tuberc. Lung Dis., 12(9), pp. 1085-1091, 2008.

Reducing HIV and Partner Violence Risk Among Women with Criminal Justice System Involvement

Women with histories of incarceration show high levels of risk for HIV and intimate partner violence (IPV). This randomized controlled trial with women at risk for HIV who had recent criminal justice system involvement (n = 530) evaluated two interventions based on Motivational Interviewing to reduce either HIV risk or HIV and IPV risk. Baseline and 3, 6, and 9-month follow-up assessments measured unprotected intercourse, needle sharing, and IPV. Generalized estimating equations revealed that the intervention groups had significant decreases in unprotected intercourse and needle sharing, and significantly greater reductions in the odds and incidence rates of unprotected intercourse compared to the control group. No significant differences were found in changes in IPV over time between the HIV and IPV group and the control group. Motivational Interviewing-based HIV prevention interventions delivered by county health department staff appear helpful in reducing HIV risk behavior for this population. Weir, B.W., O'Brien, K., Bard, R.S., Casciato, C.J., Maher, J.E., Dent, C.W., Dougherty, J.A., and Stark, M.J. Reducing HIV and Partner Violence Risk Among Women with Criminal Justice System Involvement: A Randomized Controlled Trial of Two Motivational Interviewing-based Interventions. AIDS Behav., Online First 18 July 2008.

Gender: Post Traumatic Stress Syndrome

Patients with a chronic and severe substance use disorder who also have a history of post-traumatic stress disorder (PTSD) are thought to have a unique set of problems. The present study assessed psychiatric disorders, psychosocial problems, and traumatic events with structured interviews in 747 men and 693 women enrolling in urban opioid substitution treatment programs from 1995 to 2001. Participants with versus without a history of PTSD were more likely to have a history of many other psychiatric disorders and demonstrated more current and historical medical, employment, family/social, and psychiatric problems. PTSD was generally unrelated to substance use disorder severity or diagnoses, with the exception of an increased risk of alcohol dependence. Women were more likely than men to have experienced sexual assault, and less likely to have been physically assaulted, although these events precipitated PTSD at equivalent rates across gender. In contrast, witnessing or hearing about the death or injury of others was more likely to precipitate PTSD in women than men. Female gender, exposure to combat, sexual assault, or physical assault, and a history of major mood or anxiety disorder were the best predictors of PTSD in this group. Peirce, J.M., Kindbom, K.A., Waesche, M.C., Yuscavage, A.S., and Brooner, R.K. Posttraumatic Stress Disorder, Gender, and Problem Profiles in Substance Dependent Patients. Subst. Use Misuse, 43, pp. 596-611, 2008.

Clients May Be Willing to Pay for Methadone Maintenance, But Not Enough to Cover the Costs

This study examines how much clients would be willing to pay for methadone maintenance treatment and how the amount varies with the hypothetical effectiveness of treatment and availability of case management. It also estimates clients' likely responsiveness to price changes (elasticity of demand). 241 heroin users who had been referred to, but had not yet entered, methadone maintenance treatment in Baltimore, MD were asked to state a preference among three hypothetical treatment programs that varied across three domains: weekly fee paid by the client out-of-pocket ($5-$100), presence/absence of case management, and time spent heroin-free (3-24 months). Each subject was asked to complete 18 orthogonal comparisons. Subsequently each subject was asked if they likely would enroll in their preferred choice among the three hypothetical programs. Expected willingness to pay (WTP) was computed as the probability of enrollment times the fee considered in each choice from a multivariate logistic model that controlled for program attributes. The median fee subjects were willing to pay for a program offering 3 months heroin-free was $7.30, which rose to $17.11 per week for programs that offered 24 months heroin-free. The availability of case management increased the median amount clients would pay by $5.64 per week. The price elasticity was 0.39 (S.E. 0.042) meaning that the subjects were relatively unresponsive to price changes. These results suggest that clients are willing to pay for treatment but the median amount they likely will pay is far less than the average cost of $82 per week of treatment. Although they will pay more for programs with higher rates of treatment success and for the presence of case management, it is still not enough to offset the costs. Bishai, D., Sindelar, J., Ricketts, E., Huettner, S., Cornelius, L., Lloyd, J., Havens, J., Latkin, C., and Strathdee, S. Willingness to Pay for Drug Rehabilitation: Implications for Cost Recovery. J. Health Econ., 27(4), pp. 959-972, 2008.

The Heterogeneity of Cannabis Use Disorders

DSM-IV criteria were examined to identify theoretically possible subtypes of cannabis dependence based on various combinations of the criteria. Prior research documented high homogeneity of alcohol use disorders (AUDs) as clinical entities. However, it is unknown whether this finding extends to other substance use disorders. The authors investigated this by examining the prevalence of all possible DSM-IV criteria-based clinical subtypes of current and lifetime cannabis use disorders in the general population. The number of possible (i.e., theoretical) clinical subtypes of cannabis abuse and dependence based on different combinations of the DSM-IV criteria was calculated using the combinatorial function. This number was compared with the subtypes actually observed in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a large U.S. national sample (N=43,093). Clinical and demographic correlates of the subtypes were examined with 2 tests whose target population was the United States civilian non-institutionalized population. All DSM-IV cannabis abuse and dependence criteria were assessed with the Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV Version (AUDADIS-IV). Of all possible cannabis dependence subtypes, 29 (69%) were observed in the 12-month timeframe, and 41 (98%) in the lifetime timeframe. The corresponding numbers of subtypes for cannabis abuse were 12 (75%), current and 15 (100%), lifetime. These findings suggest that, in contrast to alcohol disorders, cannabis use disorders were highly heterogeneous. Diagnostically, these results underscore the need for clinicians to recognize the diverse symptom presentations of cannabis dependence. Future research should investigate whether there are differences in the course and treatment response of these clinical subtypes of cannabis use disorders, and the heterogeneity of other substance use disorders. Blanco, C., Ogburn, E., Perez de Los Cobos, J., Lujan, J., Nunes, E., Grant, B., Liu, S., and Hasin, D. DSM-IV Criteria-based Clinical Subtypes of Cannabis use Disorders: Results from the National Epidemiological Survey on Alcohol and Related Conditions (NESARC). Drug Alcohol Depend., 96(1-2), pp. 136-144, 2008.

HIV Sexual Risk Behaviors Among Ketamine and Non-Ketamine Using Criminal Offenders Prior to Prison Entry

This study is the first to examine ketamine use and its association with HIV sexual risk behaviors among a criminal offending population in the United States. Data were collected from 716 inmates as part of the Transitional Case Management (TCM) protocol within the Criminal Justice Drug Abuse Treatment Studies (CJ-DATS) cooperative agreement. Bivariate analyses were used to identify differences between ketamine users (n=44) and nonketamine users (n=672). Three Poisson regression models were used to identify the significant correlates of high risk sexual behaviors in the 30 days prior to incarceration - (1) number of times had unprotected sex while high, (2) number of times had unprotected vaginal sex, and (3) number of times had unprotected anal sex. Results indicate that ketamine was a significant correlate in all of the Poisson regression models. Findings indicate that ketamine use may be a marker for engaging in HIV risk behaviors among criminal offenders. Oser, C., Havens, J., Staton-Tindal, M., Wong, C., Leukefeld, C., and Prendergast, M. HIV Sexual Risk Behaviors Among Ketamine and Non-Ketamine Using Criminal Offenders Prior to Prison Entry. Addiction Research and Theory, 16(3), pp. 289-302, 2008.

Substance Abuse Treatment in Human Immunodeficiency Virus: The Role of Patient Provider Discussions

Substance abuse treatment is associated with decreases in human immunodeficiency virus (HIV) risk behavior and can improve HIV outcomes. The purpose of this study was to examine factors associated with substance abuse treatment utilization, including patient-provider discussions of substance use issues. 951 HIV-infected adults receiving care at 14 HIV Research Network primary care sites were surveyed regarding drug and alcohol use, substance abuse treatment, and provider discussions of substance use issues. Although 71% reported substance use, only 24% reported receiving substance abuse treatment and less than half reported discussing substance use issues with their HIV providers. In adjusted logistic regression models, receipt of substance abuse treatment was associated with patient-provider discussions. Patient-provider discussions of substance use issues were associated with current drug use, hazardous or binge drinking, and Black race or ethnicity, though substance use was comparable between Blacks and Whites. These data suggest potential opportunities for improving engagement in substance abuse treatment services. Korthuis, P.T., Josephs, J.S., Fleishman, J.A., Hellinger, J., Himelhoch, S., Chander, G., Morse, E., and Gebo, K.A. Substance Abuse Treatment in Human Immunodeficiency Virus: The Role of Patient/Provider Discussions. J. Subst. Abuse Treat., 35 pp. 294-303, 2008.

Factors Associated with Early Therapeutic Alliance Among Adolescents in Substance Abuse Treatment

Given the importance of the therapeutic alliance in achieving positive treatment outcomes, research is needed to illuminate the factors that contribute to the development of this important relationship. The aim of this study was to expand upon the existing literature by examining predictors of the early therapeutic alliance among adolescents treated in two outpatient programs. Use of multilevel modeling techniques revealed that the majority of the variance in adolescents' ratings of the therapeutic alliance was due to adolescent factors (91%), while the variance in therapist ratings of alliance were nearly equally divided between adolescent and therapist factors (52% vs. 48%). Participant age was found to be the only significant predictor of therapist-rated alliance, with therapists reporting higher alliances with older adolescents. Adolescents reporting higher levels of social support, greater problem recognition, and more reasons for quitting also reported higher therapeutic alliance ratings. Future research is needed to examine if early identification of adolescents with low social support and problem recognition combined with brief treatment readiness interventions can be a promising approach to help improve therapeutic engagement and post-treatment substance use outcomes. Garner, B., Godley, S., and Funk, R. Predictors of Early Therapeutic Alliance Among Adolescents in Substance Abuse Treatment. J. Psychoactive Drugs, 40(1), pp. 55-65, 2008.

Violence Against Women

This research note examines the prevalence and correlates of intimate partner violence (IPV) and other violence (OV) among women (N = 529) at risk for HIV and with histories of criminal justice system involvement. The 3-month prevalences of IPV and OV were 31.2% and 18.7%, respectively. IPV was associated with having a current main partner, substance use, sexual risk behavior, trading sex, anxiety, depression, and lower self-esteem. OV was associated with no current employment or schooling, unstable housing, drug use, trading sex, anxiety, depression, and lower self-esteem. The high prevalence of violence demonstrates the need for intervention in this population; the correlates show that effective interventions must address the complex issues in these women's lives. Weir, B., Bard, R., O'Brien, K., Casciato, C., and Stark, M. Violence Against Women with HIV Risk and Recent Criminal Justice System Involvement: Prevalence, Correlates, and Recommendations for Intervention. Violence Against Women, 14(8), pp. 944-960, 2008.

A National Survey of Psychiatric Disorders in Pregnant and Postpartum Women

Psychiatric disorders and substance use during pregnancy are associated with adverse outcomes for mothers and their offspring, and information about the epidemiology of these conditions in this population is lacking. The objective of this study is to examine sociodemographic correlates, rates of DSM-IV Axis I psychiatric disorders, substance use, and treatment seeking among past-year pregnant and postpartum women in the United States. The study's main outcome measures include the prevalence of 12-month DSM-IV Axis I psychiatric disorders, substance use, and treatment seeking. The study relied on face-to-face interviews conducted in the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), one of the largest nationally representative surveys to date to include information on psychiatric disorders in pregnant women. A total of 43,093 respondents were interviewed, of whom 14,549 were women 18 to 50 years old with known past-year pregnancy status. The analysis found that pregnant and postpartum women had significantly lower rates of alcohol use disorders and any substance use, except illicit drug use, than non-pregnant women. In addition, currently pregnant women had a lower risk of having any mood disorder than non-pregnant women. The only exception was the significantly higher prevalence of major depressive disorder in postpartum than in non-pregnant women. Age, marital status, health status, stressful life events, and history of traumatic experiences were all significantly associated with higher risk of psychiatric disorders in pregnant and postpartum women. Lifetime and past-year treatment-seeking rates for any psychiatric disorder were significantly lower among past-year pregnant than non-pregnant women with psychiatric disorders. It was interesting to note that most women with a current psychiatric disorder did not receive any mental health care in the 12 months prior to the survey regardless of pregnancy status. The authors' concluded that pregnancy per se is not associated with increased risk of the most prevalent mental disorders, although the risk of major depressive disorder may be increased during the postpartum period. In addition, groups of pregnant women with particularly high prevalence of psychiatric disorders were identified. Low rates of maternal mental health care underscore the need to improve recognition and delivery of treatment for mental disorders occurring during pregnancy and the postpartum period. Vesga-Lopez, O., Blanco, C., Keyes, K., Olfson, M., Grant, B., and Hasin, D. Psychiatric Disorders in Pregnant and Postpartum Women in the United States. Arch. Gen. Psychiatry, 65(7), pp. 805-815, 2008.

Organizational Structure and Therapist Adherence on Longer-Term Reduction of Behavior Problems of Youth

The current study investigated the relations among therapist adherence to an evidence-based treatment for youth with serious antisocial behavior (i.e., Multisystemic Therapy), organizational climate and structure, and improvement in youth behavior problems one-year post treatment. Participants were 1,979 youth and families treated by 429 therapists across 45 provider organizations in North America. Hierarchical Linear Modeling (HLM) results showed therapist adherence predicted improvement in youth behavior. Two structure variables and one climate variable predicted changes in youth behavior, and the climate variable also predicted therapist adherence. No statistical support for formal mediation of organizational effects through adherence was found, though examination of changes in parameter estimates suggest a possible interplay of organizational climate with adherence and youth behavior change. The data suggest that adherence to an evidence-based treatment can be maintained largely irrespective of organizational structure. Additional research is needed to illuminate which aspects of the mental health service provider organizations in general, and of organizations implementing evidence-based treatments specifically, have the potential to affect the implementation and outcomes of evidence-based treatments. Schoenwald, S., Carter, R., Chapman, J., and Sheidow, A. Therapist Adherence and Organizational Effects on Change in Youth Behavior Problems One Year after Multisystemic Therapy. Adm. Policy Ment. Health, 35(5), pp. 379-394, 2008.

MI Cost-Effective for Relapse Prevention, But Not Smoking Cessation, Among Low-Income Pregnant Women

Study assesses the cost-effectiveness of a motivational intervention (MI) for smoking cessation and relapse prevention. Subjects were 302 low-income pregnant women recruited from multiple obstetrical sites in the Boston metropolitan area and randomized into the treatment versus control (UC - usual care) conditions. Outcomes included smoking cessation and relapse, maternal and infant outcomes, economic costs, life-years (LYs) and quality-adjusted life-years (QALYs) saved, and incremental cost-effectiveness ratios. The cost-effectiveness of MI for relapse prevention compared to UC was estimated to be $851/LY saved and $628/QALY saved. Including savings in maternal medical costs in sensitivity analyses resulted in cost savings for MI for relapse prevention compared to UC. For smoking cessation, MI cost more but did not provide additional benefit compared to UC, although a sensitivity analysis suggested that it may be cost-effective at conventional levels if it could induce 8-10% of smokers to quit. Ruger, J., Weinstein, M., Hammond, S., Kearney, M., and Emmons, K. Cost-Effectiveness of Motivational Interviewing for Smoking Cessation and Relapse Prevention among low-Income Pregnant Women: A Randomized Controlled Trial. Value Health, 11(2), pp. 191-198, 2008.

Quality-of-Life Tradeoffs for Hepatitis C Treatment

The authors investigated differences between how patients and providers evaluate the quality-of-life tradeoffs associated with HCV treatment in computer-assisted interviews. They interviewed 92 treatment-naive HCV patients at gastroenterology, methadone maintenance, and HIV clinics at 3 hospitals in New York City, and 23 physicians or nurses experienced in treating HCV at other hospitals in New York City. Subjects completed rating scale and standard gamble evaluations of current health and hypothetical descriptions of HCV symptoms and treatment side effects on a scale from 0 (death or worse than death) to 1 (best possible health). Treatment side effects were rated worse by patients than providers using the rating scale (moderate side effects 0.42 v. 0.62; severe side effects 0.24 v. 0.40) and standard gamble (moderate side effects 0.61 v. 0.91; severe side effects 0.52 v. 0.75) (all P < or = 0.01). A year of severe side effects was equivalent to 4.1 years of mild HCV symptoms avoided for patients if they returned to their current health after treatment compared with 2.0 years avoided if they achieved average population health. For patients with depression symptoms, HCV treatment with severe side effects had lower value unless it would also improve their current health. Patients have more concerns about treatment side effects than providers. Further research is warranted to develop HCV decision aids that elicit patient preferences and to evaluate how improved communication of the risks and benefits of HCV treatment and more effective treatment of depression may alter these preferences. Schackman, B., Teixeira, P., Weitzman, G., Mushlin, A., and Jacobson, I. Quality-of-life Tradeoffs for Hepatitis C Treatment: Do Patients and Providers Agree? Med. Decis. Making, 28(2), pp. 233-242, 2008.

Ten-Year Trend in Addiction Treatment Shows a Decline in Special Population (Same-Race) Therapy

This work analyzes how trends in the provision of tailored treatment practices (TTPs) have changed between 1995 and 2005 across outpatient substance abuse treatment (OSAT) programs in the United States. Categories of interest include measures to capture needs assessment and treatment planning activities, treatment offerings for special populations, and case management activities. Results of national surveys conducted in 1995, 2000, and 2005 show that TTPs have diffused in an uneven fashion in the population of OSAT programs between 1995 and 2005. Specifically, needs assessment/treatment planning and case management remain a relatively common practice among OSAT programs, while treatment for special populations (especially same-race therapy) is less widely practiced and, indeed, experienced some decline over the study period. This trend is troublesome given that minority clients constitute a large proportion of those utilizing OSAT programs. Alexander, J.A., Nahra, T.A., Lemak, C.H., Pollack, H., and Campbell, C.I. Tailored Treatment in the Outpatient Substance Abuse Treatment Sector: 1995-2005. J. Subst. Abuse Treat., 34(3), pp. 282-292, 2008.

Generic Preference-Weighted Quality of Life Measures Correlated with Some, But Not All, ASI Subscales

Data collected from 574 subjects seeking substance abuse treatment as part of a clinical trial at one of seven centers in a medium-sized Midwestern City were used to assess the correlation between two generic preference-weighted quality of life scales, the Quality of Life Well-Being Scale - QWB-SA; and the Medical Outcomes Study SF-12 - SF-12SG - with Addiction Severity Index subscales. In unadjusted analyses, the QWB-SA measure was correlated significantly with six of seven ASI subscales and the SF-12 SG was correlated with four of seven. In adjusted analyses, both preference-weighted measures were correlated significantly with diagnostic, physical health, mental health and drug use measures, but not with legal or alcohol use measures. The QWB-SA was also correlated with employment problems and the SF-12 SG was correlated with family/social problems. This suggests that cost utility analyses (CUA) based on generic quality of life scores may reasonably capture the physical and mental health, and substance abuse improvements due to substance abuse interventions but not their full effect on the individual, family, or society, potentially leading to an underinvestment in substance abuse treatment. Pyne, J. M., McCollister, K., French, M., Tripathi, S., Rapp, R., and Booth, B. Preference-weighted Health-Related Quality of Life Measures and Substance Use Disorder Severity. Addiction, 103(8), pp. 1320-1329, 2008.

Substance Use and Delinquency in Criminal Justice Involved Youth Appear Temporally Interdependent in Models Accounting for Time in Controlled Environments

To assess the nature of the temporal association between substance use and delinquency in a sample of 449 ethnically-diverse youth recruited from the Los Angeles juvenile probation system, cross-lagged path models were estimated using full information maximum likelihood-robust estimation in MPlus 4.2. Participants were assessed using the Global Appraisal of Individual Needs (GAIN) at baseline (n=499), and at 3 month (n=406), 6 month (n=410) and 1 year (n=408) follow-ups. Substance use was measured using a continuous composite score equal to the sum of the standardized scores on the Substance Use Frequency Scale (SFS) and Substance Problem Scale (SPS). Delinquency was assessed using results from the Drug Crime Scale (DCS), Interpersonal Crime Scale (ICS) and Property Crime Scale (PCS). The preferred model treated each of these crime scales as indicators of a latent delinquency variable and controlled for gender, age, ethnicity and crime spent in a controlled environment, the latter of which had not been controlled for in previous studies. Estimates of the standardized paths from substance use to criminal behavior ranged from 0.074 to 0.082 and from criminal behavior to substance use ranged from 0.075 to 0.124 across time lags, all of which were significantly different from zero. These results provide support for the hypothesis that the observed temporal relationship between substance use and delinquency is the result of a third causal factor such as a propensity for general deviance, suggesting that interventions could target either behavior and influence both. D 'Amico, E., Edelen, M., Miles, J., and Morral, A. The Longitudinal Association Between Substance Use and Delinquency Among High-Risk Youth. Drug Alcohol Depend., 93(1-2), pp. 85-92, 2008.

Sibling Outcomes from a Randomized Trial of Evidence-Based Treatments with Substance Abusing Juvenile Offenders

This study examined the substance use and delinquency outcomes for the nearest age siblings of substance abusing and delinquent adolescents that participated in a randomized clinical trial evaluating the effectiveness of integrating evidence-based practices into juvenile drug court. The sample of 70 siblings averaged 14.4 years of age, 50% were male, 71% were African-American, and 27% were white. Measures of sibling substance use and delinquency were collected at four points in time (i.e., pretreatment, 4, 12 and 18 months). Multilevel longitudinal models were used to evaluate whether changes in sibling substance use and delinquency paralleled the treatment effects observed for their substance abusing delinquent brothers and sisters in the juvenile drug court study. Parallel sibling outcomes were obtained for substance use but not for criminal behavior, and possible reasons for the divergence in these results were discussed. Rowland, M.D., Chapman, J. E., and Henggeler, S. W. Sibling Outcomes from a Randomized Trial of Evidence-Based Treatments with Substance Abusing Juvenile Offenders. J. Child and Adolescent Substance Use, 17(3), pp. 11-26, 2008.

Health Plans Use Multiple Methods to Maintain Provider Networks

Executives from a nationally-representative sample of 363 health plans with 812 insurance products were surveyed in 2003 on the methods they used to retain behavioral health care providers. These included methods applied to all providers and targeted methods applied to high-quality providers. Common methods applied to all providers included formal procedures for dealing with provider grievances (99.0% of products) and conducting provider satisfaction surveys (79.9% of plans). Among products with provider surveys topics commonly included were accuracy of claims payments (98.4%), satisfaction with utilization review and authorization decisions (95.9%), speed of response to treatment authorization requests (94.9%), and provider administrative burden (91.0%). Less common topics were the overall satisfaction with the fee schedule (59.0%), volume and type of referrals (44.0%), and collaboration and communication with primary care physicians (47.9%). Methods targeted at high-quality providers included reducing their administrative burden (53.8%), paying them higher fees (43.7%), and steering clients to their practices (16.5%). Annual bonuses and guaranteed volume were seldom used as methods to retain high-quality providers. Analysis by provider type revealed that compared with Health Maintenance Organizations (HMOs), Point of Service (POS) products were less likely to use any of the techniques while Preferred Provider Organizations (PPO) products were more likely to use higher fees or reduced administrative burden but less likely to steer referrals. Compared with products with specialty contracts with Managed Behavioral Health Care Organizations (MBHOs), those with internal management were considerably less likely to use higher fees while those with comprehensive contracts with MBHOs were more likely to steer referrals. For-profit products were less likely to steer referrals but more likely to use decreased administrative burdens or higher fees than were not-for-profit products. Garnick, D., Horgan, C., Reif, S., Merrick, E., and Hodgkin, D. Management of Behavioral Health Provider Networks in Private Health Plans. J. Ambul. Care Manage., 31(4), pp. 330-341, 2008.

Problematic Use of Tobacco and Other Drugs High among Public Primary Care Patients in South Africa

Prevalence and risk and protective factors for the problematic use of tobacco, alcohol, and other drugs were assessed in a sample of 2,618 Black and mixed-race patients who received care at one of 14 public primary care clinics in Cape Town, South Africa. These 14 clinics comprised a stratified, random sample of the 49 such clinics in Cape Town. Subjects were interviewed in person in private rooms by trained research assistants matched for gender and language. Substance use was assessed using the WHO ASSIST instrument and those with a score indicating medium or high risk were coded as having problematic use. Risk and protective factor and other information were obtained by an instrument developed for the study. Included in that instrument was an assessment of stress from the International Classification of Primary Care, Second Edition which lists 23 stressors that may be reasons for encounters, as well as one additional question on unplanned pregnancy. As in other countries, prevalence rates for problematic substance use were higher for men than for women. For example, 43.1% of men in the sample reported using tobacco compared with only 19.5% of women. And while 7.4% of men reported using drugs other than tobacco and alcohol, only 1.1% of women did. Multivariate logistic analysis revealed those who were younger and those who had more stressors had higher odds of using tobacco, while those who were more highly educated and participated in religious activities had lower odds of using tobacco. In addition, black women reported extremely low rates of tobacco use (odds = 0.04 95% CI = 0.01-0.22) compared to other groups. Risk factors for problematic use of other drugs included being colored, being employed, and having more stressors, while protective factors again included religious involvement. Again, Black women had very low prevalence rates with only 3 respondents reporting other drug use. Ward, C., Mertens, J., Flisher, A., Bresick, G., Sterling, S., Little, F., and Weisner, C. Prevalence and Correlates of Substance Use Among South African Primary Care Clinic Patients. Subst. Use Misuse, 43(10), pp. 1395-1410, 2008.

Reactivity to Psychological and Pharmacological Stress Provocation: Gender Differences

The purpose of this study is to examine the influence of gender and smoking status on reactivity in two human laboratory stress paradigms. Participants were 46 (21 men, 25 women) healthy individuals who completed the Trier Social Stress Task (i.e., performed speech and math calculations in front of an audience) and a pharmacological stress provocation (i.e., administration of corticotrophin releasing hormone (CRH)) after an overnight hospital stay. Approximately half (53%) of the participants were smokers. Cortisol, adrenocorticotrophin hormone (ACTH), physiologic measures (heart rate, blood pressure), and subjective stress were assessed at baseline and at several time points post-task. Men demonstrated higher baseline ACTH and blood pressure as compared to women; however, ACTH and blood pressure responses were more pronounced in women. Women smokers evidenced a more blunted cortisol response as compared to non-smoking women, whereas smoking status did not affect the cortisol response in men. Finally, there was a more robust cardiovascular and subjective response to the Trier as compared to the CRH. Although preliminary, the findings suggest that women may be more sensitive than men to the impact of cigarette smoking on cortisol response. In addition, there is some evidence for a more robust neuroendocrine and physiologic response to acute laboratory stress in women as compared to men. Investigation of relationships between stress response and mood/anxiety disorders in individuals with substance use disorders may provide important insights into mechanisms underlying gender differences in addiction. Back, S., Waldrop, A., Saladin, M., Yeatts, S., Simpson, A., McRae, A., Upadhyaya, H., Contini Sisson, R., Spratt, E., Allen, J., Kreek, M., and Brady, K. Effects of Gender and Cigarette Smoking on Reactivity to Psychological and Pharmacological Stress Provocation. Psychoneuroendocrino-logy, 33(5), pp. 560-568, 2008.

Adaptive Interventions in Drug Court: A Pilot Study

This pilot study (N 30) experimentally examines the accesptability and feasibility of using an adaptive intervention in a misdemeanor drug court. The adaptive algorithm adjusted the frequency of court hearings and case management sessions according to pre-specified criteria in response to participants' performance. Results reveal that the adaptive algorithm was acceptable to clients and staff, was feasible to implement with greater than 85% fidelity, and showed promise for eliciting substantial improvements in drug abstinence and graduation rates. Compared to drug court as usual, participants in the adaptive condition were more likely to receive responses from the drug court team for inadequate performance and received those responses after a shorter period. This suggests the adaptive algorithm more readily focused the team's attention on poorly performing individuals, allowing them to address problems before they developed too fully. This demonstration of acceptability and feasibility of implementing an adaptive intervention in drug court suggests that further research is warranted to test the efficacy of the adaptive intervention. Marlowe, D.B., Arabia, P.L., Dugosh, K.L., Benasutti, K.L., Croft, J.R., and McKay, J.R. Adaptive Interventions in Drug Court: A Pilot Experiment. Criminal Justice Review, 33(3), pp. 343-360, 2008.

Voluntary Screening of Recently Arrested Adolescents for Sexually Transmitted Diseases

Adolescent offenders may be at high risk for sexually transmitted diseases (STDs). With previous research and interventions focused on incarcerated adolescents, data are needed on STD prevalence and risk factors among newly arrested youth released to the community, a far larger subgroup. Participants were recruited from all arrested youth processed at the Hillsborough County, Florida Juvenile Assessment Center during the last half of 2006 (506 males, 442 females). Participants voluntarily providing urine samples for drug testing as part of standard protocol also consented to having their specimens split and tested for chlamydia and gonorrhea, using an FDA-approved nucleic acid amplification test. STD prevalence was found similar to those previously reported among incarcerated adolescents: 11.5% tested positive for chlamydia, 4.2% for gonorrhea, and 13.2% for either or both infections. Prevalence was significantly higher among females: 19.2% of females had either or both infections compared with 10.5% of males. Prevalence was higher for 17 to 18 year olds (15.2% of males, 25.5% of females), blacks, detained youths, drug users, and those engaged in sexual risk behaviors. Previous STD testing experience was limited. The study indicated that a voluntary STD screening protocol is feasible for arrested youth entering the juvenile justice system, and these offenders are at high risk for STDs. Because most arrested youths are released back to the community, routine testing and treatment of recently arrested youths, and expanded access to risk reduction and prevention programs, can yield substantial public health benefits. Belenko, S., Dembo, R., Weiland, D., Rollie, M., Salvatore, C., Hanlon, A., and Childs, K. Recently Arrested Adolescents are at High Risk for Sexually Transmitted Diseases. Sex. Transm. Dis., 35(8), pp. 758-763, 2008.

Initial Subjective Effects of Opioids in Patients Treated for Pain as a Predector of Opioid Addiction

This pilot case-control study (n=40) retrospectively assessed between-groups differences in subjective opioid effects in patients treated for the first time with opioids for chronic pain. Cases were individuals in an inpatient substance abuse treatment center for primary prescription opioid addiction whose initial exposure to prescription opioids was reported for chronic pain. Controls had not developed prescription opioid addiction as measured in part by close monitoring on long-term opioid therapy at a pain management center. Twenty subjects in each group completed a battery of measures to capture data related to the individual's first exposure to prescription opioids. The Morphine Benzedrine Group subscale of an adapted 49-item Addiction Center Research Inventory (ARCI), designed to measure euphoria and other drug effects, showed an average score of 8.70 (+/- 4.18) in cases versus 2.55 (+/- 3.36) in controls (p < 0.001), indicating a significantly greater "euphoric" effect of opioids in the cases compared to the controls. Differences in the subjective response to opioids suggest that: (1) a subgroup of patients does develop euphoria when taking opioids for pain, which may be a risk factor for eventual development of prescription opioid addiction; and (2) subjective effects predictive of eventual addiction may include stimulation vs. sedation, and other experiences not typically associated with opioids. (PsycINFO Database Record (c) 2008 APA, all rights reserved). Bieber, C., Fernandez, K., Borsook, D., Brennan, M., Butler, S., Jamison, R., Osgood, E., Sharpe-Potter, J., Thomson, H., Weiss, R., and Katz, N. Retrospective Accounts of Initial Subjective Effects of Opioids in Patients Treated for Pain Who Do or Do Not Develop Opioid Addiction: A Pilot Case-Control Study. Exp. Clin. Psychopharmacol., 16(5), pp. 429-434, 2008.

Psychological Mediators of Buproprion Sustained-Release Treatment for Smoking Cessation

This study aimed to test simultaneously our understanding of the effects of bupropion sustained-release (SR) treatment on putative mediators and our understanding of determinants of post-quit abstinence, including withdrawal distress, cigarette craving, positive affect and subjective reactions to cigarettes smoked during a lapse. The specificity of bupropion SR effects was also tested in exploratory analyses. The study was performed using data from a randomized, placebo-controlled clinical trial of bupropion SR. Results were submitted to mediation analyses at the Center for Tobacco Research and Intervention, Madison, WI. A total of 403 adult, daily smokers without contraindications to bupropion SR use were studied. Participants were assigned randomly to receive a 9-week course of bupropion SR or placebo pill and to receive eight brief individual counseling sessions or no counseling. Ecological momentary assessment ratings of smoking behavior and putative mediators were collected pre- and post-quit. Results of structural equation and hierarchical linear models did not support the hypothesis that bupropion SR treatment improves short-term abstinence by reducing withdrawal distress or affecting the subjective effects of a lapse cigarette, but provided partial support for mediation by cigarette craving reduction and enhanced positive affect. Bupropion SR effects on point-prevalence abstinence at 1 month post-quit were also mediated partially by enhanced motivation to quit and self-efficacy. Results of this study provide some support for models of bupropion SR treatment and relapse and suggested that motivational processes may partially account for bupropion SR efficacy. McCarthy, D., Piasecki, T., Lawrence, D., Jorenby, D., Shiffman, S., and Baker, T. Psychological Mediators of Bupropion Sustained-Release Treatment for Smoking Cessation. Addiction, 103(9), pp. 1521-1533, 2008.


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