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

Research Findings - Services Research

Randomized Placebo-Controlled Clinical Trial of 5 Smoking Cessation Pharmacotherapies

Little direct evidence exists on the relative efficacies of different smoking cessation pharmacotherapies, yet such evidence is needed to make informed decisions about their clinical use. The purpose of this study is to assess the relative efficacies of 5 smoking cessation pharmacotherapy interventions using placebo-controlled, head-to-head comparisons. 1504 adults from 2 urban research sites who smoked at least 10 cigarettes per day during the last 6 months were studied. Participants were excluded if they reported using any form of tobacco other than cigarettes; current use of bupropion; having a current psychosis or schizophrenia diagnosis; or having medical contraindications for any of the study medications. Participants were randomized to 1 of 6 treatment conditions: nicotine lozenge, nicotine patch, sustained-release bupropion, nicotine patch plus nicotine lozenge, bupropion plus nicotine lozenge, or placebo. In addition, all participants received 6 individual counseling sessions. The main outcome measures were biochemically confirmed 7-day point-prevalence abstinence assessed at 1 week after the quit date (post-quit), end of treatment (8 weeks post-quit), and 6 months post-quit. Other outcomes were initial cessation, number of days to lapse, number of days to relapse, and latency to relapse after the first lapse. All pharmacotherapies differed from placebo when examined without protection for multiple comparisons (odds ratios, 1.63-2.34). With such protection, only the nicotine patch plus nicotine lozenge (odds ratio, 2.34, P < .001) produced significantly higher abstinence rates at 6-month post-quit than did placebo. While the nicotine lozenge, bupropion, and bupropion plus lozenge produced effects that were comparable with those reported in previous research, the nicotine patch plus lozenge produced the greatest benefit relative to placebo for smoking cessation. Piper ME, Smith SS, Schlam TR, Fiore MC, Fraser D, Baker TB. A randomized placebo-controlled clinical trial of 5 smoking cessation pharmacotherapies. Arch Gen Psychiatry 2009; 66(11):1253-1262.

A Randomized Clinical Trial of Methadone Maintenance for Prisoners: Results at 12 months Post-release

This study examined the impact of prison-initiated methadone maintenance at 12 months post-release. Males with pre-incarceration heroin dependence (N = 204) were randomly assigned to (a) Counseling Only: counseling in prison, with passive referral to treatment upon release; (b) Counseling + Transfer: counseling in prison with transfer to methadone maintenance treatment upon release; and (c) Counseling + Methadone: counseling and methadone maintenance in prison, continued in the community upon release. The mean number of days in community-based drug abuse treatment were, respectively, Counseling Only, 23.1; Counseling + Transfer, 91.3; and Counseling + Methadone, 166.0 (p < .01); all pairwise comparisons were statistically significant (all ps < .01). Counseling + Methadone participants were also significantly less likely than participants in each of the other two groups to be opioid-positive or cocaine-positive according to urine drug testing. These results support the effectiveness of prison-initiated methadone for males in the United States. Kinlock TW, Gordon MS, Schwartz RP, Fitzgerald TT, O'Grady KE. A randomized clinical trial of methadone maintenance for prisoners: Results at 12 months post-release. J Subst Abuse Treat. 2009;37(3):277-285.

Addiction Treatment is Costly to Patients Even if They Receive Free Care

A study of 302 individuals in treatment in Dayton, Ohio assessed the cost to the patient of attending addiction treatment. It found that patients in outpatient treatment paid approximately $28.50 for each visit including $23.50 in time costs, $3.69 in transportation costs, $0.45 in cash or in-kind payments, and $0.84 in miscellaneous costs. For an average treatment episode this amounts to $571. Episode costs for patients receiving methadone were approximately $1,853 per episode and those for patients in inpatient treatment were $10,749. Although patients with other health conditions pay time, transportation and other costs as well, the nature of treatments for addiction, which can require multiple visits over several weeks, months, or years, makes these costs potentially more burdensome than those for many other diseases. McCollister K, French M, Pyne J, Booth B, Rapp R, Carr C. The cost of treating addiction from the client's perspective: Results from a multi-modality application of the client DATCAP. Drug Alcohol Depend. 2009;104(3):241-248.

Pharmacokinetic Interactions Between Buprenorphine/Naloxone and Tipranavir/Ritonavir in HIV-negative Subjects

HIV-infected patients with opioid dependence often require opioid replacement therapy. Pharmacokinetic interactions between HIV therapy and opioid dependence treatment medications can occur. HIV-seronegative subjects stabilized on at least 3 weeks of buprenorphine/naloxone (BUP/NLX) therapy sequentially underwent baseline and steady-state pharmacokinetic evaluation of open-label, twice daily tipranavir 500 mg co-administered with ritonavir 200 mg (TPV/r). Twelve subjects were enrolled and 10 completed the study. Prior to starting TPV/r, the geometric mean BUP AUC(0-24h) and C(max) were 43.9 ng h/mL and 5.61 ng/mL, respectively. After achieving steady-state with TPV/r (> or = 7 days), these values were similar at 43.7 ng h/mL and 4.84 ng/mL, respectively. Similar analyses for norBUP, the primary metabolite of BUP, demonstrated a reduction in geometric mean for AUC(0-24h) [68.7-14.7 ng h/mL; ratio=0.21 (90% CI 0.19-0.25)] and C(max) [4.75-0.94 ng/mL; ratio=0.20 (90% CI 0.17-0.23)]. The last measurable NLX concentration (C(last)) in the concentration-time profile, never measured in previous BUP/NLX interaction studies with antiretroviral medications, was decreased by 20%. Despite these pharmacokinetic effects on BUP metabolites and NLX, no clinical opioid withdrawal symptoms were noted. TPV steady-state AUC(0-12h) and C(max) decreased 19% and 25%, respectively, and C(min) was relatively unchanged when compared to historical control subjects receiving TPV/r alone. No dosage modification of BUP/NLX is required when co-administered with TPV/r. Though mechanistically unclear, it is likely that decreased plasma Ritonavir levels while on BUP/NLX contributed substantially to the decrease in TPV levels. BUP/NLX and TPV/r should therefore be used cautiously to avoid decreased efficacy of TPV in patients taking these agents concomitantly. Bruce R, Altice F, Moody D, et al. Pharmacokinetic interactions between buprenorphine/naloxone and tipranavir/ritonavir in HIV-negative subjects chronically receiving buprenorphine/naloxone. Drug Alcohol Depend. 2009;105(3):234-239.

Trends in Prescribed Opioid Therapy for Non-Cancer Pain for Individuals with Prior Substance Use Disorders

Long-term opioid therapy for non-cancer pain has increased. Caution is advised in prescribing for persons with substance use disorders, but little is known about actual health plan practices. This paper reports trends and characteristics of long-term opioid use in persons with non-cancer pain and a substance abuse history. Using health plan data (1997-2005), the study compared age-sex-standardized rates of incident, incident long-term and prevalent long-term prescription opioid use, and medication use profiles in those with and without substance use disorder histories. The CONsortium to Study Opioid Risks and Trends study included over one million adult enrollees of two health plans, Kaiser Permanente of Northern California (KPNC) and Group Health Cooperative (GH) of Seattle, Washington. At KPNC (1999-2005), prevalence of long-term use increased from 11.6% to 17.0% for those with substance use disorder histories and from 2.6% to 3.9% for those without substance use disorder histories. Respective GH rates (1997-2005), increased from 7.6% to 18.6% and from 2.7% to 4.2%. Among persons with an opioid disorder, KPNC rates increased from 44.1% to 51.1%, and GH rates increased from 15.7% to 52.4%. Long-term opioid users with a prior substance abuse diagnosis received higher dosage levels, were more likely to use Schedule II and long-acting opioids, and were more often frequent users of sedative-hypnotic medications in addition to their opioid use. Since these patients are viewed as higher risk, the increased use of long-term opioid therapy suggests the importance of improved understanding of the benefits and risks of opioid therapy among persons with a history of substance abuse, and the need for more careful screening for substance abuse history than is the usual practice. Weisner C, Campbell C, Ray G, et al. Trends in prescribed opioid therapy for non-cancer pain for individuals with prior substance use disorders. Pain 2009;145(3):287-293.

Interim Methadone Reduces Arrests

This study examined the frequency and severity of arrest charges among heroin addicts randomly assigned to either interim methadone (IM) maintenance or to remain on a waiting list for methadone treatment. It was hypothesized that IM participants would have a: (1) lower number of arrests at 6 and 12 months and (2) lower mean crime severity scores at 6 and 12 months post-baseline. Available official arrest data for all 319 study participants for the 2 years before and after study enrollment showed that participants randomly assigned to IM as compared to those on a waiting list had significantly fewer arrests at 6 but not at 12 months from study enrollment. Additional post hoc analyses revealed that those participants not in treatment at 4 and 10-month follow-up assessment points were significantly more likely to be arrested and to have a higher mean crime severity rating at 12 and 24 months post-baseline assessment. Schwartz R, Jaffe J, O 'Grady K, Kinlock T, Gordon M, Kelly S, Wilson M, Ahmed A. Interim methadone treatment: Impact on arrests. Drug Alcohol Depend. 2009;103(3):148-154.

HIV Patients with Psychiatric Disorders are Less Likely to Discontinue HAART

This study examined whether having a psychiatric disorder among HIV-infected individuals is associated with differential rates of discontinuation of HAART and whether the number of mental health visits impact these rates. This longitudinal study (fiscal year: 2000-2005) used discrete time survival analysis to evaluate time to discontinuation of HAART. The predictor variable was presence of a psychiatric diagnosis (serious mental illness versus depressive disorders versus none). The setting was five United States outpatient HIV sites affiliated with the HIV Research Network. The sample consisted of 4989 patients; the majority was nonwhite (74.0%) and men (71.3%); 24.8% were diagnosed with a depressive disorder, and 9% were diagnosed with serious mental illness. The main outcome measure was time to discontinuation of HAART adjusting for demographic factors, injection drug use history, and nadir CD4 cell count. Relative to those with no psychiatric disorders, the hazard probability for discontinuation of HAART was significantly lower in the first and second years among those with SMI [adjusted odds ratio: first year, 0.57 (0.47-0.69); second year, 0.68 (0.52-0.89)] and in the first year among those with depressive disorders [adjusted odds ratio: first year, 0.61 (0.54-0.69)]. The hazard probabilities did not significantly differ among diagnostic groups in subsequent years. Among those with psychiatric diagnoses, those with six or more mental health visits in a year were significantly less likely to discontinue HAART compared with patients with no mental health visits. Individuals with psychiatric disorders were significantly less likely to discontinue HAART in the first and second years of treatment. Mental health visits are associated with decreased risk of discontinuing HAART. Himelhoch S, Brown C, Walkup J, Chander G., Korthius P., Afful J., Gebo K. HIV patients with psychiatric disorders are less likely to discontinue HAART. AIDS 2009;23(13):1735-1742.

Trends in Long-Term Opioid Therapy for Chronic Non-Cancer Pain

The authors report trends and characteristics of long-term opioid use for non-cancer pain. CONSORT (CONsortium to Study Opioid Risks and Trends) data base which includes adult enrollees of two health plans serving over 1 per cent of the US population was used. Using automated data, authors constructed episodes of opioid use between 1997 and 2005. Age-sex standardized rates of opioid use episodes were estimated beginning in each year (incident) and on-going in each year (prevalent), and the per cent change in rates annualized (PCA) over the 9-year period. Long-term episodes were defined as > 90 days with 120+ days supply or 10+ opioid prescriptions in a given year. It was found that over the study period, incident long-term use increased from 8.5 to 12.1 per 1000 at Group Health (GH) (6.0% PCA), and 6.3 to 8.6 per 1000 at Kaiser Permanente of Northern California (KPNC) (5.5% PCA). Prevalent long-term use doubled from 23.9 to 46.8 per 1000 at GH (8.5% PCA), and 21.5 to 39.2 per 1000 at KPNC (8.1% PCA). Non-Schedule II opioids were the most commonly used opioid among patients engaged in long-term opioid therapy, particularly at KPNC. Long-term use of Schedule II opioids also increased substantially at both health plans. Among prevalent long-term users in 2005, 28.6% at GH and 30.2% at KPNC were also regular users of sedative hypnotics. Long-term opioid therapy for non-cancer pain is increasingly prevalent, but the benefits and risks associated with such therapy are inadequately understood. Concurrent use of opioids and sedative-hypnotics was unexpectedly common and deserves further study. Von Korff M, Boudreau D, Rutter CM, et al. Trends in long-term opioid therapy for chronic non-cancer pain. Pharmacoepi Drug Saf. 2009:1-10.

Correlates of Alcohol Use Among Methadone-Maintained Adults

This prospective study (n = 190) examined correlates of alcohol use from baseline data of a longitudinal trial conducted among moderate and heavy alcohol users receiving methadone maintenance therapy (MMT). The sample included MMT clients who were 18-55 years of age, and were receiving MMT from five large methadone maintenance clinics in the Los Angeles area. Half of the sample was heavy drinkers and nearly half (46%) reported heroin use. Using a structured questionnaire, correlates of heavy alcohol use included White and Hispanic ethnicity, and fair or poor physical health combined with older age (50 years). We also found that MMT clients who were younger than 50 years, regardless of health status, were more likely to be heavy drinkers. Compared with moderate alcohol consumers, a greater number of heavy alcohol users also experienced recent victimization. To optimize MMT, alcohol screening should be part of routine assessment and alcohol treatment should be made available within MMT programs. Moreover, special consideration should be provided to the most vulnerable clients, such as the younger user, those with a long-term and current history of heavy drug use, and those victimized and reporting fair or poor health. In addition, promoting attention to general physical and mental health problems within MMT programs may be beneficial in enhancing health outcomes of this population. Nyamathi A, Cohen A, Marfisee M, et al. Correlates of alcohol use among methadone-maintained adults. Drug Alcohol Depend. 2009;101:124-127.

Important Sex Differences in Aberrant Prescription Drug Use Behaviors

Patients who are prescribed opioids often display one or more aberrant prescription use behaviors (e.g., requesting early refills, borrowing medication from family), which raise concern among healthcare professionals. Little is known about the sex differences in specific types of aberrant behaviors or sex-specific predictors of such behaviors. A battery of anonymous, self-report assessments was administered to 121 (49 men, 72 women) chronic pain patients enrolled in an outpatient pain management clinic. Most of the participants were white women with an average age of 51.6 years (SD=13.2). Significantly more men than women were taking a prescribed opioid (91.7% vs. 77.8%, P=0.05). Women were significantly more likely than men to hoard unused medication (67.6% vs. 47.7%, P=0.04) and to use additional medications to enhance the effectiveness of pain medication (38.8% vs. 20.0%, P=0.04). A trend toward men using alternative routes of administration (eg, crushing and snorting pills) more often than women was observed (8.9% vs. 1.5%, P=0.08). Among men, high rates of aberrant prescription use behaviors were associated with current alcohol use and the use of oxycodone and morphine. Among women, use of hydrocodone was associated with high rates of aberrant prescription use behaviors. Some aberrant prescription use behaviors are common among chronic pain patients and may be sex-specific. Predictors of aberrant prescription use behaviors may also differ by sex. The authors note that additional research may be needed to help identify aberrant prescription use behaviors that best predict sex-specific risk for developing opioid abuse or dependence. Back S, Payne R, Waldrop A, Smith A, Reeves S, Brady K. Prescription opioid aberrant behaviors: A pilot study of sex differences. Clin J Pain 2009;25(6):477-484.

Prescription Opioid Abuse and Diversion in an Urban Community

Prescription-drug diversion is a topic about which comparatively little is known, and systematic information garnered from prescription-drug abusers and dealers on the specific mechanisms of diversion is extremely limited. A pilot ultrarapid assessment was carried out in Wilmington, Delaware, during December 2006 to better understand the scope and dynamics of prescription-drug abuse and diversion. This involved focus groups with prescription-drug abusers and key informant interviews with police, regulatory officials, prescription-drug dealers, and pill brokers. The research team recruited focus group participants from the two residential substance abuse treatment programs in Wilmington reporting the highest proportions of prescription drug abusing clients. A total of six focus groups were conducted with 32 patients in these two programs. Dealers were recruited from the same treatment facilities, and three in-depth interviews were completed. In-depth interviews were also conducted with two prescription pill brokers recruited through the authors' existing contacts in the drug abusing community. Six in-depth interviews were conducted with representatives from a number of Delaware agencies-the Attorney General's Office, the Department of Professional Regulation, the State Police, the Wilmington Police Department, and the Newark Police Department. In-depth interview and focus group guides were developed for each of the target populations. The in-depth interviews with police and regulatory officials focused on the extent of prescription drug abuse and diversion in the community, the types of drugs most commonly diverted, and mechanisms being used to channel the drugs to the illicit market. The focus group areas of inquiry with prescription drug abusers included general perceptions of the prescription drug problem in Delaware, sources and mechanisms of access to prescription drugs, popularity and prices of prescription medications on the street, as well as the initiation and progression of prescription and illicit drug abuse. The primary sources of prescription drugs on the street were the elderly, patients with pain, and doctor shoppers, as well as pill brokers and dealers who work with all of the former. The popularity of prescription drugs in the street market was rooted in the abusers' perceptions of these drugs as 1) less stigmatizing; 2) less dangerous; and, 3) less subject to legal consequences than illicit drugs. For many, the abuse of prescription opioids also appeared to serve as a gateway to heroin use. The diversion of prescription opioids might be reduced through physician education focusing on 1) recognizing that a patient is misusing and/or diverting prescribed medications; 2) considering a patient's risk for opioid misuse before initiating opioid therapy; and 3) understanding the variation in the abuse potential of different opioid medications currently on the market. Patient education also appears appropriate in the areas of safeguarding medications, disposal of unused medications, and understanding the consequences of manipulating physicians and selling their medications. Inciardi J, Surratt H, Cicero T, Beard R. Prescription opioid abuse and diversion in an urban community: The results of an ultrarapid assessment. Pain Med. 2009;10(3):537-548.

Correlates of the Provision of Detoxification Services and Medication-Based Treatments for Substance Abuse in Correctional Institutions

In recent years, there has been an increased examination of organizational-level innovation adoption in substance abuse treatment organizations. However, the majority of these studies have focused on community-based treatment centers. One understudied area of the substance abuse treatment system is correctional institutions. This study uses the Criminal Justice Drug Abuse Treatment Studies (CJ-DATS) cooperative's National Criminal Justice Treatment Practices (NCJTP) survey to examine the adoption of detoxification services and pharmacotherapies for the treatment of substance abuse across a nationally representative sample of correctional institutions (n = 198). There were significant differences between jails and prisons in the percentage of organizations offering detoxification services and medications. Specifically, detoxification services were offered by 5% of prisons and 34% of jails; and, medications were offered by 6% of prisons and 32% of jails. Binary logistic regression models were used to examine the associations between these services and organizational characteristics, including context, resources, previously introduced practices, culture, and systems integration. Variables measuring organizational context and previously introduced practices were significant correlates of the provision of both detoxification services and medications. Multivariate results indicated that the differences between jails and prisons remained significant after controlling for other organizational factors. Although the adoption of detoxification services and pharmacotherapies may be a controversial topic for correctional institutions, these services have the potential to improve offender well-being and reduce public health risks associated with substance abuse. Oser CB, Knudsenb HK, Staton-Tindall M, et al. Organizational-level correlates of the provision of detoxification services and medication-based treatments for substance abuse in correctional institutions. Drug Alcohol Depend. 2009;1035:S73-S81.

Opioid Treatment Programs in the CTN are Quicker to Adopt Buprenorphine

This study was designed to assess the representativeness of opioid treatment programs (OTPs) participating in NIDA's Clinical Trials Network (CTN), and potential barriers to the effective diffusion of practices aimed at the treatment of opioid-dependent patients, specifically buprenorphine, to the general population of OTPs in the U.S. Interviews were conducted with clinical directors of the N=49 OTPs within the CTN and a sample (N=50) drawn from the population of U.S. OTPs outside the CTN. The two groups were compared on their organizational, clinical, and client characteristics, as well as their adoption of buprenorphine. The study documented significant differences between the CTN OTPs and the general population of OTPs on numerous variables, including nonprofit operations, number of employees (all staff, nurses, and Master's level counselors), annual caseflow, Medicaid coverage, client unemployment, and client criminal justice involvement - all of which were significantly higher in the CTN OTPs. As of 2006, OTPs in the CTN were more likely to have adopted buprenorphine than the general population of OTPs (42.8% vs. 24.0%, p<.05). However, involvement in the CTN's buprenorphine trials did not explain the differential uptake. In multivariate models, the CTN vs non-CTN difference in buprenorphine adoption persisted after controlling for the programs' structural characteristics (funding, staff, census), but not when controlling for clinical or client characteristics. These findings suggest that participation in the CTN, per se, did not convey a unique advantage to OTPs in preparing them to adopt buprenorphine, but rather that selection effects -specifically structural characteristics - were the key predictors of adoption. Consideration of site characteristics may be important in the development of dissemination materials and local constraints on the uptake of evidence-based practices. Ducharme LJ, Roman PM. Opioid treatment programs in the Clinical Trials Network: Representativeness and buprenorphine adoption. J Subst Abuse Treat. 2009;37:90-94.

Inadequate Documentation of Opioid Dependence and Methadone Maintenance Treatment (MMT) in the Medical Record

Opioid-dependent patients often have co-occurring chronic illnesses requiring medications that interact with methadone. Methadone maintenance treatment (MMT) is typically provided separately from medical care. Hence, coordination of medical care and substance use treatment is important to preserve patient safety. The authors reviewed medical records to identify potential safety risks among MMT patients engaged in medical care by evaluating the frequency that opioid dependence and MMT documentation are missing in medical records and characterizing potential medication-methadone interactions. Among patients from a methadone clinic who received primary care from an affiliated, but separate, medical center, electronic medical records were reviewed for documentation of methadone, opioid dependence, and potential drug-methadone interactions. The proportions of medical records without opioid dependence and methadone documentation were estimated and potential medication-methadone interactions were identified. Among the study subjects (n = 84), opioid dependence documentation was missing from the medical record in 30% (95% CI, 20%-41%) and MMT documentation was missing from either the last primary care note or the last hospital discharge summary in 11% (95% CI, 5%-19%). Sixty-nine percent of the study subjects had at least 1 medication that potentially interacted with methadone; 19% had 3 or more potentially interacting medications. This study shows that among patients receiving MMT and medical care at different sites, documentation of opioid dependence and MMT in the medical record occurs for the majority, but is missing in a substantial number of patients. This is despite the use of electronic medical records. Most of these patients are prescribed medications that potentially interact with methadone. This study highlights opportunities for improved coordination between medical care and MMT. Walley A, Farrar D, Cheng D, Alford D, Samet J. Inadequate documentation of opioid dependence and methadone maintenance treatment (MMT) in the medical record. J Gen Intern Med. 2009;24(9):1007-1011.

Workplace Mandates Statistically Associated with Longer Stays in Addiction Treatment

A sample of 448 employed members of a private U.S. managed care plan were followed to determine whether those mandated to addiction treatment by their employers (n=75) had different outcomes from those who entered treatment without a mandate (n=373). Multivariate analyses, including control variables such as Addiction Severity Index intake scores, psychiatric diagnoses and services, and motivation were estimated to assess the statistical association between being mandated to treatment and length of stay, abstinence, psychiatric severity, and employment problem severity. Those with a workplace mandate stayed in treatment an average of 58 days longer in treatment (p <0.001). Workplace mandates were not independently associated with other outcomes at 1 year in models that included length of stay. However, longer stays were associated with higher odds of abstinence (0R = 1.01 CI=1.01-1.01), and lower levels of employment problem severity (β=-0.124, p =0.009). To the extent that workplace mandates actually caused the longer stays, they were associated with improved outcomes. Weisner C, Lu Y, Hinman A, et al. Substance use, symptom, and employment outcomes of persons with a workplace mandate for chemical dependency treatment. Psychiatr Serv. 2009;60(5):646-654.

TC Prison Programs Provide a Modest Cost-Offset

This study set out to examine whether there were any reductions in administrative costs from prison-based TC programs. The incremental economic costs of two therapeutic community (TC) yards in a California prison and their associated benefit in terms of saved administrative costs due to reduced disruptive prisoner behavior compared with the regular prison yard were estimated. A multivariate general linear model including race/ethnicity, prior incarceration, principal commitment offence, recidivism risk and a propensity score for TC assignment revealed that the TC yards were associated with an average reduction of $122,990 in administrative costs per yard, in 2005 dollars, over a two year period compared with the regular yard. This suggests that there is at least a small costs offset that can be applied to the approximately $2,000,000 average incremental cost of a TC yard. Zhang SX, Roberts RE. An economic analysis of the in-prison therapeutic community model on prison management costs. Journal of Criminal Justice 2009;37:388-395.

The Relationship Between Neighborhood Criminal Behavior and Oxford Houses

The present study investigated crime rates in areas surrounding 42 Oxford Houses and 42 control houses in a large city in the Northwestern United States. A city-run Global Information Systems' (GIS) website was used to gather crime data including assault, arson, burglary, larceny, robbery, sexual assault, homicide, and vehicle theft over a calendar year. Findings indicated that there were no significant differences between the crime rates around Oxford Houses and the control houses. These results suggest that well-managed and governed recovery homes pose minimal risks to neighbors in terms of criminal behavior. Deaner J, Jason LA, Aase DM, Mueller D. The Relationship between neighborhood criminal behavior and Oxford Houses. Therapeutic Communities 2009:3089-3093.

HIV-related Health Services in Adolescent Substance Abuse Treatment Programs

Given that alcohol and drug abuse heightens the risk of adolescents acquiring HIV, substance abuse treatment programs for youths may represent an important site of HIV prevention. In this research, the authorsn explored the adoption of three HIV-related health services: risk assessment during intake, HIV prevention programming, and HIV testing. Data were collection through telephone interviews with 149 managers of adolescent-only substance abuse treatment programs in the USA. About half of these programs had adopted HIV risk assessment and HIV prevention. On-site HIV testing was less widely adopted, with only one in four programs offering this service. At the bi-variate level, the availability of on-site primary medical care and the availability of an overnight level of care were positively associated with these three types of services. The association for the measure of an overnight level of care was no longer significant once medical services were controlled. However, in a separate analysis, it was found that programs offering an overnight level of care were much more likely to offer on-site medical care than outpatient-only facilities. There was also evidence that publicly funded treatment programs were more likely to offer HIV prevention and on-site HIV testing, after controlling for other organizational characteristics. Much more research about the adoption of HIV-related services in adolescent substance abuse treatment is needed, particularly to offer greater insight into why certain types of organizations are more likely to adopt these health services. Knudsen HK, Oser CB. Availability of HIV-related health services in adolescent substance abuse treatment programs. AIDS Care 2009;21(10):1238-1246.

Disparities in Access to Care Among Children in the Child Welfare System

This study examined health service access among children of different racial/ethnic groups in the child welfare system in an attempt to identify and explain disparities. Data were from the National Survey of Child and Adolescent Well-Being (n=2,505). Measures reflected child health services need, access, and enabling factors. Chi-square and t tests were used to compare across racial/ethnic groups. A logistic regression model further explored the greatest disparity identified, that between non-Latino/ Black and White children in caseworker-reported access to counseling. In general, caseworker reports of health care service receipt did not differ across racial/ethnic groups. However, Latino children had better reported access to vision services than non-Latino/ White children, and counseling access was lower for non-Latino/ Black children than non-Latino/ White children. Caseworkers' self-reported efforts to facilitate service access did not vary by race/ethnicity for any type of health care. In the multiple regression model, both private health insurance and a lack of insurance were negatively associated with counseling access, while a history of sexual abuse, adolescence, and greater caseworker effort to secure services were positively associated with access. Race was just barely non-significant after controlling for other factors expected to affect access. One possible reason why Black children are less likely to be identified as needing counseling is the fact that they are less likely than White children to have reports of sexual abuse, which strongly predicts counseling access. First, child welfare practice may be more equitable than many believe, with generally comparable health service access reported across children's racial/ethnic groups. Second, caseworkers may be under-identifying need for counseling services among Black children, although this might reflect less frequent reports of sexual abuse for Black children. Third, both privately insured and uninsured children were less likely to receive needed mental health counseling than those with public insurance. This suggests that policy makers should focus on increasing the numbers of children enrolled in public health insurance programs such as Medicaid and the State Children's Health Insurance Program (SCHIP). Wells R, Hillemeier M, Bai Y, Belue R. Health Service Access across racial/ethnic groups of children in the child welfare system. Child Abuse Negl. 2009;33(5):282-292.

Adherence to Scheduled Sessions in a Randomized Field Trial of Case Management: The Criminal Justice Drug Abuse Treatment Studies Transitional Case Management Study

The Transitional Case Management (TCM) study, one of the projects of the Criminal Justice Drug Abuse Treatment Studies (CJ-DATS) cooperative, was a multi-site randomized test of whether a strengths-based case management intervention provided during an inmate's transition from incarceration to the community increases participation in community substance abuse treatment, enhances access to needed social services, and improves drug use and crime outcomes. As in many intervention studies, TCM experienced a relatively large percentage of treatment group participants who attended few or no scheduled sessions. The paper discusses issues with regard to participation in community case management sessions, examines patterns of session attendance among TCM participants (n=382), and analyzes client and case manager characteristics that are associated with number of sessions attended and with patterns of attendance. The average number of sessions (out of 12) attended was 5.7. Few client or case manager characteristics were found to be significantly related to session attendance. Prendergast M, Greenwell L, Cartier J, et al. Adherence to scheduled sessions in a randomized field trial of case management: The criminal justice drug abuse treatment studies transitional case management study. J Experimental Criminology. 2009:5273-5297.

The Drugs-Violence Nexus Among Rural Felony Probationers

Little research has focused on the drugs-violence nexus in rural areas. As such, the purpose of this study is to use Goldstein's tripartite conceptual framework to examine the relationship between drugs and violence among felony probationers in rural Appalachian Kentucky (n = 799). Data on demographics, substance use criminal history, and violence were collected between 2001 and 2004 using an interviewer-administered questionnaire. Rural probationers are partitioned into four groups based on lifetime violent victimization/perpetration experiences: (a) neither a perpetrator nor a victim, (b) perpetrator only, (c) victim only, and (d) both a perpetrator and a victim. Chi-square analyses indicate substance use, and criminal history varies across the four groups. Binary logistic regression analyses are used to explore the significant correlates of both perpetration and victimization. Multivariate analyses support both the psychopharmacological model and the economic compulsive models of perpetration and victimization. Oser CB, Mooney JL, Staton-Tindall M, Leukefeld CG. The drugs-violence nexus among rural felony probationers. J Interpers Violence 2009;24(8):1285-1303.

Clinical Supervision Provided to Therapists in Randomized Treatment Trials Can be Provided to Mental Health Professionals in the Workplace

This observational study used mixed-effects regression models to examine relations among supervisor adherence to a clinical supervision protocol, therapist adherence, and changes in the behavior and functioning of youths with serious antisocial behavior. The youths were treated with an empirically supported treatment, multi-systemic therapy. Participants were 1,979 youths and families treated by 429 clinicians across 45 provider organizations in North America. The mean age for youth was 14.0, and most were male (65.0%) and Caucasian (59.5%), with 19.3% of youth identified as African American, and 6.4% Asian or Pacific Islander. Four dimensions of clinical supervision were examined. Mixed-effects regression model results showed that one dimension, supervisor focus on adherence to treatment principles, predicted greater therapist adherence. Two supervision dimensions, Adherence to the Structure and Process of Supervision and focus on Clinician Development, predicted changes in youth behavior. Conditions required to test hypothesized mediation by therapist adherence of supervisor adherence effects on youth outcomes were not met. However, direct effects of supervisor and therapist adherence were observed in models including both of these variables. The results reported here suggest that the training and clinical supervision provided to therapists in successful randomized treatment trials can be provided to mental health professionals in the workplace as part of a multi-component treatment transport strategy. To support the effective transport and implementation of empirically supported treatments in practice contexts, additional research is needed to evaluate the viability, implementation, and effects on client outcomes in usual care settings of the training and supervision protocols used in treatment trials. Schoenwald S, Sheidow A, Chapman J. Clinical supervision in treatment transport: Effects on adherence and outcomes. J Consult Clin Psychol. 2009;77(3):410-421.

Wraparound Services Among Substance Abuse Treatment Organizations Serving Criminal Offenders

Women's substance abuse treatment outcomes are improved when women-specific needs are addressed through wraparound services, such as the provision of child care, employment assistance, or mental health counseling. Despite a higher prevalence of pre-incarceration drug use, women in prison report receiving fewer services than their male counterparts, suggesting they likely have greater service needs upon release. It is unknown whether community-based treatment organizations with a women-specific program offer more wraparound services than programs without a focus on women. This study uses data from the Criminal Justice Drug Abuse Treatment Studies (CJ-DATS) research cooperative's National Criminal Justice Treatment Practices Survey (NCJTPS), a nationally representative sample of community-based treatment programs serving predominantly criminal offenders (n = 217). First, bivariate analyses identified differences between organizations with and without a women-specific program on the number of wraparound services adopted as well as organizational-level characteristics (i.e., organizational structure, personnel characteristics, culture, sources of information, and systems integration) related to their adoption. Second, Poisson regression was used to identify the organizational characteristics associated with the number of adopted wraparound services, with having a women-specific program being the primary covariate of interest. Results indicate larger organizations that utilized a greater number of treatment approaches and believed that treatment could reduce crime were more likely to offer a greater assortment of wraparound services. In an effort to improve behavioral treatment outcomes, it is imperative to examine organizational-level contextual factors that shape the availability of wraparound services for female offenders in community-based substance abuse treatment settings. Oser CB, Knudsen H, Staton-Tindall M, Leukefeld C. The adoption of wraparound services among substance abuse treatment organizations serving criminal offenders: The role of a women-specific program. Drug Alcohol Depend. 2009;1035:S82-S90.

The Black Box of Prescription Drug Diversion

A variety of surveys and studies are examined in an effort to better understand the scope of prescription drug diversion and to determine whether there are consistent patterns of diversion among various populations of prescription drug abusers. Data are drawn from the RADARS System, the National Survey of Drug Use and Health, the Delaware School Survey, and a series of quantitative and qualitative studies conducted in Miami, Florida. The data suggest that the major sources of diversion include drug dealers, friends and relatives, smugglers, pain patients, and the elderly, but these vary by the population being targeted. In all of the studies examined, the use of the Internet as a source for prescription drugs is insignificant. Little is known about where drug dealers are obtaining their supplies, and as such, prescription drug diversion is a "black box" requiring concentrated, systematic study. Inciardi JA, Surratt HL, Cicero T, Kurtz SP, Martin SS, Parrino MW. The black box of prescription drug diversion. J Addict Dis. 2009; 28: 332-347.

Adoption of New Medications Takes Considerable Time as Clinics Adapt to Change

The National Drug Abuse Treatment Clinical Trials Network (CTN), a collaborative federal research initiative that brings together universities and community-based treatment programs (CTPs), conducted multiple clinical trials of buprenorphine for opioid dependence. Part of the CTN's mission is to promote the adoption of evidence-based treatment technologies. Drawing on a data collected during face-to-face interviews with administrators from a panel of 206 CTPs, this research examined the adoption of buprenorphine over a 2-year period. Results indicated that the adoption of buprenorphine doubled between the baseline and 24-month follow-up interviews. Involvement in a buprenorphine protocol continued to be a strong predictor of adoption at the 2-year follow-up. Adoption of buprenorphine tripled among those CTPs without buprenorphine-specific protocol experience. For-profit CTPs and those offering inpatient detoxification services were more likely to adopt buprenorphine over time. A small percentage of programs discontinued using buprenorphine. These findings point to the dynamic nature of service delivery in community-based addiction treatment and the continued need for longitudinal studies of organizational change. Knudsen HK, Abraham AJ, Johnson JA, Roman PM. Buprenorphine adoption in the National Drug Abuse Treatment Clinical Trials Network . J Subst Abuse Treat. 2009; 37:307-312.

Personal Versus Home Environmental Effects on Prenatal Care

Nearly one-fourth of African-American women receive no prenatal care during the first trimester of pregnancy. The aim of the current study is to identify factors that underlie inadequate prenatal care among African-American women. Maternal alcohol abuse has been examined as one risk factor for inadequate prenatal care, but findings have been inconsistent, perhaps because (a) alcohol use during pregnancy is substantially under-reported and (b) studies have not considered the wider social network in which maternal alcohol use takes place. The current study attempts to clarify relationships between personal alcohol use, alcohol use in the home environment, and prenatal care in a sample of post-partum women. Participants were 107 low-income, primarily African-American women. All participants completed a computer-based screening which assessed personal and environmental alcohol use, prenatal care and mental health. Environmental alcohol use was related to delayed prenatal care while personal alcohol use was not. More specifically, after controlling for demographic variables, the presence of more than three person-episodes of binge drinking in a woman's home environment increased the odds of seriously compromised prenatal care by a factor of seven. Findings suggest the need to further assess environmental alcohol use and to examine the reliability of personal alcohol use measures. Grekin ER, Ondersma SJ. The relationship between prenatal care, personal alcohol abuse and alcohol abuse in the home environment. Prenatal Care 2009;16(5):463-470.

Motivation Enhancement Therapy with Pregnant Substance-abusing Women

Some evidence suggests that motivational approaches are less efficacious - or even counter-productive - with persons who are relatively motivated at baseline. The present study was conducted to examine whether disordinal moderation by baseline motivation could partially explain negative findings in a previous study (Winhusen T, Kropp F, Babcock D, Hague D, Erickson SJ, Renz C, Rau L, Lewis D, Leimberger J, Somoza E. Motivational enhancement therapy to improve treatment utilization and outcome in pregnant substance users. J. Subst. Abuse Treat. 2008;35: 161-173). Analyses also focused on the relative utility of the University of Rhode Island Change Assessment (URICA) scale, vs. a single goal question as potential moderators of Motivation Enhancement Therapy (MET). Participants were 200 pregnant women presenting for substance abuse treatment at one of four sites. Women were randomly assigned to either a three-session MET condition or treatment as usual (TAU). Generalized Estimating Equations (GEE) revealed no significant moderation effects on drug use at post-treatment. At follow-up, contrary to expectations, participants who had not set a clear quit goal at baseline were less likely to be drug-free if randomized to MET (OR = 0.48); participants who did set a clear quit goalwere more likely to be drug-free if randomized to MET (OR = 2.53). No moderating effects were identified via the URICA. Disordinal moderation of MET efficacy by baseline motivation may have contributed somewhat to the negative results of the Winhusen, et al., 2008. study, but in the opposite direction expected. A simple question regarding intent to quit may be useful in identifying persons who may differentially respond to motivational interventions. However, moderation effects are unstable, may be best identified with alternate methodologies, and may operate differently among pregnant women. Ondersma SJ, Winhusen T, Erickson SJ, Stine S M, Wang Y. Motivation enhancement therapy with pregnant substance-abusing women: Does baseline motivation moderate efficacy? Drug Alcohol Depend. 2009;101:74-79.

Mortality Among Injection Drug Users in Chennai, India

Injection drug users (IDUs) have estimated mortality rates over 10 times higher than the general population; much of this excess mortality is HIV-associated. Few mortality estimates among IDUs from developing countries, including India, exist. IDUs (1158) were recruited in Chennai from April 2005 to May 2006; 293 were HIV positive. Information on deaths and causes was obtained through outreach workers and family/network members. Mortality rates and standardized mortality ratios were calculated; multivariate Poisson regression was used to identify predictors of mortality. We observed 85 deaths over 1998 person-years (p-y) of follow-up [mortality rate (MR) 4.25 per 100 p-y; 95% confidence interval (CI) = 3.41-5.23]. The overall standardized mortality ratio was 11.1; for HIV-positive IDUs, the standardized mortality ratio was 23.9. Mortality risk among HIV-positive IDUs (MR: 8.88 per 100 p-y) was nearly three times that of negative IDUs (MR: 3.03 per 100 p-y) and increased with declining immune status (CD4 cells>350: 5.44 per 100 p-y vs. CD4 cells200: 34.5 per 100 p-y). This association persisted after adjustment for confounders. The leading causes of mortality in both HIV negative and positive IDUs were overdose (n=22), AIDS (n=14), tuberculosis (n=8) and accident/trauma (n=9). Substantial mortality was observed in this cohort with the highest rates among HIV-positive IDUs with CD4 counts of less than 350 cells/ml. Although, in these 2 years, non-AIDS deaths outnumbered AIDS-related deaths, the relative contribution of AIDS-associated mortality is likely to increase with advancing HIV disease progression. These data reinforce the need for interventions to reduce the harms associated with drug use and increase HAART access among IDUs in Chennai. Solomon SS, Celentano DD, Srikrishnan A, et al. Mortality among injection drug users in Chennai, India (2005-2008). AIDS 2009;23:997-1004.

Availability and Capacity of Substance Abuse Programs in Correctional Settings: A Classification and Regression Tree Analysis

The purpose of this study was to investigate the structural and organizational factors that contribute to the availability and increased capacity for substance abuse treatment programs in correctional settings. The authors used classification and regression tree statistical procedures to identify how multi-level data can explain the variability in availability and capacity of substance abuse treatment programs in jails and probation/parole offices. The data for this study combined the National Criminal Justice Treatment Practices (NCJTP) Survey and the 2000 Census. The NCJTP survey was a nationally representative sample of correctional administrators for jails and probation/parole agencies. The sample size included 295 substance abuse treatment programs that were classified according to the intensity of their services: high, medium, and low. The independent variables included jurisdictional-level structural variables, attributes of the correctional administrators, and program and service delivery characteristics of the correctional agency. The two most important variables in predicting the availability of all three types of services were stronger working relationships with other organizations and the adoption of a standardized substance abuse screening tool by correctional agencies. For high and medium intensive programs, the capacity increased when an organizational learning strategy was used by administrators and the organization used a substance abuse screening tool. This study presents the first phase of understanding capacity-related issues regarding treatment programs offered in correctional settings. Taxman FS, Kitsantas P. Availability and capacity of substance abuse programs in correctional settings: A classification and regression tree analysis. Drug Alcohol Depend. 2009;103S (S43-S53):1-11.

Associations Among State and Local Organizational Contexts: Use of Evidence-Based Practices in the Criminal Justice System

This study used hierarchical linear modeling (HLM) to examine the extent to which the organizational characteristics of state corrections agencies and local criminal justice facilities interacted in their associations with the extent to which local facilities are using evidence-based substance abuse treatment practices (EBPs). The study used data collected from two nationally representative surveys - one of state executives and the other of local prison wardens, justice administrators, and treatment directors - which were conducted as part of the National Criminal Justice Treatment Practices survey, as part of the Criminal Justice Drug Abuse Treatment Studies cooperative research program, and includes both adult criminal and juvenile justice samples. The sample consisted of correctional executives and criminal and juvenile justice (ns=100 and 70, respectively), criminal and juvenile justice administrators (ns = 289; 141), and treatment directors providing services for adult and juvenile offenders (ns = 142; 75). Results indicated that several state organizational characteristics were either associated with more EBP use or interacted with local organizational characteristics in associations with EBP use, including: (1) systems integration at the state level was associated with greater EBP use; (2) state staffing adequacy and stability accentuated the association between local training and resources for new programs and EBP use (i.e., in states with better staffing, the relationship between training/resources and EBP use in local facilities was stronger); and (3) state executives' attitudes regarding the missions and goals of corrections tended to diminish the extent to which corresponding local administrator attitudes were associated with EBP use. The study has implications for future research focused on EBP diffusion and implementation in correctional environments, particularly attempts to influence EBP use by working through state agencies. Henderson CE, Young DW, Farrell J, Taxman FS. Associations among state and local organizational contexts: Use of evidence-based practices in the criminal justice system. Drug Alcohol Depend. 2009;103S:S23-S32.

More Counselor Training is Needed in Medication Assisted Treatment

Addiction treatment counselors play a central role in the dissemination of information about new treatment techniques to their patients, making them key players in the implementation of new treatment technologies. This study examines counselors' perceptions of the effectiveness and acceptability of pharmacotherapies for the treatment of alcohol dependence. Mail questionnaires were received from 1,140 counselors employed in a nationally representative sample of public-sector addiction treatment programs in 2006 (61% response rate). Counselors answered a series of questions about three FDA-approved medica-tions used in the treatment of alcohol dependence (disulfiram, tablet naltrexone, and acamprosate), indicating their extent of familiarity with each medication, its perceived effectiveness in the treatment of alcohol dependence, and its acceptability for use with alcohol-dependent patients. While most (71.8%) counselors were familiar with disulfiram, less than half (41.9%) were familiar with tablet naltrexone, and very few (23.9%) were familiar with acamprosate. Those who were familiar with each medication rated it at the midpoint of the provided scale for perceived effectiveness, and just above the midpoint of the provided scale for perceived acceptability for use in alcohol treatment. However, counselors reported having received little or no training about any of these medications. Moreover, with less than 20% of participating treatment facilities having adopted any of these medications, counselors have had little first-hand exposure to this treatment approach. Multivariate models showed that the receipt of medication specific training as well as indirect observation of the medication's use in the treatment program were significantly associated with diffusion counselors' awareness and perceptions of the effectiveness and acceptability of the medications for use in addiction treatment When exposed to information about medications to treat alcohol dependence, counseling staff appear quite receptive. More efforts are needed to disseminate information about medication-assisted treatment to front-line addiction treatment staff. Abraham AJ, Ducharme LJ, Roman PM. Counselor attitudes toward pharmacotherapies for alcohol dependence. J Stud Alcohol Drugs 2009;70:628-635.

Research on the Diffusion of Evidence-Based Treatments Within Substance Abuse Treatment: A Systematic Review

This article provides a comprehensive meta-analysis of research studies that have examined the diffusion of evidence-based treatments (EBTs) within the field of substance abuse treatment. Sixty-five research studies were identified and were grouped into one of three major classifications: attitudes toward EBTs, adoption of EBTs, and implementation of EBTs. Results suggests significant progress has been made with regard to the advancement of the fields' knowledge about attitudes toward and the extent to which specific EBTs have been adopted in practice, as well as with regard to the identification of organizational factors related to EBT adoption. In an effort to advance the substance abuse treatment field toward evidence-based diffusion practices, recommendations are made for greater use of scientifically rigorous experimental or quasi-experimental research designs, psychometrically sound instruments, and integration of quantitative and qualitative data collection when studying EBT implementation. Garner BR. Research on the diffusion of evidence-based treatments within substance abuse treatment: A systematic review. J Subst Abuse Treat. 2009;36:376-399.

Treatment Engagement is Influenced by Organizational Factors Regardless of Culture

Client functioning and treatment engagement were examined in relation to staff attributes and organizational climate across a diverse sample of drug treatment and outreach programs in England. Self-rating assessments were obtained from 1,539 clients and 439 counselors representing 44 programs, and results were interpreted using comparable data from studies of treatment programs in the United States. Client scores on treatment participation and counseling rapport in England were directly related to their higher levels of motivation and psychosocial functioning, as well as to staff ratings of professional attributes and program atmosphere. By linking records from English clients with their counselors in each program, findings also indicate these relationships are rooted in the personal interactions between clients and their counselor. Standardized assessments of treatment structure, process, and performance used across therapeutic settings and national boundaries show there is generalizability in the pattern of clinical dynamics, including the relationships between organizational functioning and quality of services. Simpson D, Rowan-Szal GA, Joe GW, Best D, Day E, Campbell A. Relating counselor attributes to client engagement in England. J Subst Abuse Treat. 2009;36; 313-320.

Cigarette Smoking Reduced Among Opioid-Dependent Clients in a Therapeutic Community

This study examines smoking behavior in a sample of 231 opioid-dependent clients entering therapeutic community treatment, and investigates the relationship between smoking behavior and drug treatment outcomes. Regression analyses for selected Addiction Severity Index composites (alcohol, drug, medical, psychiatric), including factors for smoking (number of cigarettes per day, expired-air carbon monoxide level, nicotine dependence), time (baseline, 6 and 12-month), and smoking-by-time interaction confirmed a high smoking prevalence (95%) among opioid users. Among participants interviewed at all time points (n =206), 13% shifted from smoking to non-smoking status at some time after admission. Participants who reported a greater number of cigarettes were more likely to report higher drug severity at any time point. Chun J, Haug NA, Guydish JR, et al. Cigarette smoking among opioid-dependent clients in a therapeutic community. Am J Addict. 2009;18:316-320.

Filling Service Gaps: Providing Intensive Treatment Services for Offenders

This study explores conditions and factors that may underlie the wide variation among states in the provision of intensive treatment for offenders in criminal justice settings, used multilevel modeling techniques with data from the National Criminal Justice Treatment Practices (NCJTP) survey, conducted as part of NIDA's Criminal Justice Drug Abuse Treatment Studies (CJDATS) cooperative research program. The NCJTP survey is a nationally representative multilevel survey designed to assess substance abuse service provision, and organizational factors associated with service provision, in adult and juvenile justice systems throughout the U.S. The samples consisted of state correctional executives in the adult criminal and juvenile justice systems, and a sample of administrators of adult criminal and juvenile justice administrators who run local facilities and justice agencies. The correctional facilities are nested at the local level within jurisdictions, which served as our sampling unit. The final sample employed in this analysis consisted of 426 correctional facility administrators and 97 executive administrators of state-level agencies from 41 states. The correctional facilities consisted of 287 adult facilities (66.7%) and 139 juvenile facilities (33.3%). Overall, these included 176 community corrections facilities or offices (41.3%), 147 adult prisons or juvenile institutions (34.5%), and 103 local jails or detention facilities (24.2%). Results indicate that states' overall rates of substance abuse and dependence, funding resources, and the state governor's political party affiliation were significantly associated with intensive treatment provision. Numerous factors that have been implicated in recent studies of evidence-based practice adoption, including state agency executives' views regarding rehabilitation, agency culture and climate, and other state-level measures (e.g., household income, crime rates, and expenditures on treatment for the general population) were not associated with treatment provision. Future research should examine further variations in offenders' service needs, the role of legislators' political affiliations, and how other factors may interact with administrator characteristics in the adoption and expansion of intensive treatment services for offenders. Young DW, Farrell JL, Henderson CE, Taxman FS. Filling service gaps: Providing intensive treatment services for offenders. Drug Alcohol Depend. 2009;103S:S33-S42.

Director Leadership Quality Important in Addiction Counselor Job Satisfaction

Five-hundred and fifty counseling staff and directors from 94 outpatient "drug-free" programs in six states were interviewed to assess job satisfaction, burnout, and the quality of director leadership. Composite measures of each of these constructs were derived and assessed using confirmatory factor analysis and Rasch modeling. Separate multivariate hierarchical linear models were used to estimate the effect of a variety of organizational and counselor factors on each of these composite measures and only a few variables were significantly related to these measures. Counselor burnout overall was relatively low among these programs (24.07 on a 1 to 50 scale) and was associated only with director leadership quality. Counselors in programs with higher average director leadership ratings had slightly lower burnout ratings (-0.33, p < 0.05). Job satisfaction, with a mean score of 40.28 on a 1 to 50 scale, was lower for counselors with a caseload of more than 30 clients (-1.59, p < 0.05), and higher among those in programs with higher director leadership ratings (0.53, p < 0.01) and those in programs that provided more than one level of treatment (1.77, p <0.05). Director leadership measures, with a mean rating of 37.92 on a one to 50 scale, were lower in programs that operated under a parent organization than stand-alone programs (-2.19, p <0.05). Broome K, Knight D, Edwards J, Flynn P. Leadership, burnout, and job satisfaction in outpatient drug-free treatment programs. J Subst Abuse Treat. 2009;37(2):160-170.

Obstacles to Retention in Outpatient Treatment: Program- and Individual-Level Factors from the Clients' Perspective

Attrition from treatment for substance abuse disorders is a persistent challenge that severely limits the effectiveness of services. Although a large body of research has sought to identify predictors of retention, the perspective of clients of services is rarely examined. This exploratory qualitative study presents clients' stated reasons for leaving outpatient treatment (n = 135) and their views of what could have been done differently to keep them engaged in services. Participants were 57.2% male, with an average age of 39 years; most were from ethnic minority groups (62% African American, and 36.1% reported being Hispanic); 73.7% reported government assistance as their primary income source. Obstacles to retention fell into program- and individual-level factors. Program-level barriers include dissatisfaction with the program, especially counselors; unmet social services needs; and lack of flexibility in scheduling. Individual-level barriers to retention were low problem recognition and substance use. Study limitations are noted, including the small sample size and recruitment of research subjects from only two treatment programs in one city. The implications of findings for research and practice are discussed, emphasizing the need to understand and address clients' needs and expectations to maximize treatment retention and the likelihood of positive outcomes. Substance use disorder clients in clinical settings present an opportunity for engagement in the change process including enhancing motivation for change. Laudet A, Stanick V, Sands B. What could the program have done differently? A qualitative examination of reasons for leaving outpatient treatment. J Subst Abuse Treat. 2009;37(2):182-190.

Adaptive Interventions May Optimize Outcomes in Drug Courts: A Pilot Study

Adaptive interventions apply a priori decision rules for adjusting treatment services in response to participants' clinical presentation or performance in treatment. This pilot study (n = 30) experimentally examined an adaptive intervention in a misdemeanor drug court. The participants were primarily charged with possession of marijuana (73%) or possession of drug paraphernalia (23%). Results revealed that participants in the adaptive condition had higher graduation rates and required significantly less time to graduate from the program and achieve a final resolution of the case. It took an average of nearly 4 fewer months for participants in the adaptive intervention to resolve their cases compared with those participating in drug court as usual. Participants in the adaptive condition also reported equivalent satisfaction with the program and therapeutic alliances with their counselors. These data suggest that adaptive interventions may enhance the efficiency and effectiveness of drug courts and justify examining adaptive interventions in large-scale drug court studies. Marlowe DB, Festinger DS, Arabia PL, et al. Adaptive interventions may optimize outcomes in drug courts: A pilot study. Curr Psychiatry Rep. 2009;11:370-376.

Organizational Relationships Among Child Welfare Agencies and Treatment Access for Vulnerable Children

Inter-organizational relationships (IORs) between child welfare agencies and mental health service providers may facilitate mental health treatment access for vulnerable children. This study investigates whether IORs are associated with greater use of mental health services and improvement in mental health status for children served by the child welfare system. This was a longitudinal analysis of data from a 36-month period in the National Survey of Child and Adolescent Well-Being (NSCAW). The sample consisted of 1,613 children within 75 child welfare agencies who were 2 years or older and had mental health problems at baseline. IOR intensity was measured as the number of coordination approaches between each child welfare agency and mental health service providers. Separate weighted multilevel logistic regression models tested associations between IORs and service use and outcomes, respectively. Agency-level factors accounted for 9% of the variance in the probability of service use and 12% of mental health improvement. Greater intensity of IORs was associated with higher likelihood of both service use and mental health improvement. Having greater numbers of ties with mental health providers may help child welfare agencies improve children's mental health service access and outcomes. Bai, Y., Wells, R., Hillemeier, M. Coordination between child welfare agencies and mental health service providers, children's service use, and outcomes. Child Abuse Negl. 2009;33(6) 372-381.

Examination of an Interventionist-Led HIV Intervention Among Criminal Justice-Involved Female Prisoners

The purpose of this study was to examine the implementation, adherence and protocol fidelity for the Reducing Risky Relationships for HIV (RRR-HIV) study. The RRR-HIV study is a phase III trial of a randomized intervention to reduce human immunodeficiency virus (HIV) risk behaviors among incarcerated women in four US states: Connecticut, Delaware, Kentucky and Rhode Island. The intervention consists of five interventionist-led prison-based group sessions and a sixth individual community-based session. Data on adherence, implementation, acceptability and fidelity of the intervention were obtained from forms completed after the five prison-based sessions by both the interventionist and participant. Data from the sixth session were collected by the interventionist. Of the 363 women recruited to date, 173 (47.6%) have been randomly allocated to the experimental RRR intervention, of which implementation measures were available for 162 (93.6%). Almost three-quarters of women attended all five sessions, each of which lasted a median of 90 minutes, indicating successful implementation of the protocol across multiple study sites. Interventionists and participants alike reported that all of the topics for each session were discussed, suggesting adherence to the protocol. In addition, protocol interventionists indicated that more than 95% of the women were engaged/involved, interested, and understood the materials presented, indicating high levels of acceptability among the participants and fidelity to the intervention protocols. The majority of participants also answered all of the post-test questions correctly, which is another strong indicator of the fidelity to the intervention. Results suggest that the RRR-HIV study has been successfully implemented across multiple study sites. Havens JR, Leukefeld CG, Oser CB, et al. Examination of an interventionist-led HIV intervention among criminal justice-involved female prisoners. J Experimental Criminology 2009; 5:245-272.

Collaborative Behavioral Management: Integration and Intensification of Parole and Outpatient Addiction Treatment Services in the Step'n Out Study

Integration of community parole and addiction treatment holds promise for optimizing the participation of drug-involved parolees in re-entry services, but intensification of services might yield greater rates of technical violations. Collaborative behavioral management (CBM) integrates the roles of parole officers and treatment counselors to provide role induction counseling, contract for pro-social behavior, and to deliver contingent reinforcement of behaviors consistent with contracted objectives. Attendance at both parole and addiction treatment are specifically reinforced. The Step'n Out study of the Criminal Justice-Drug Abuse Treatment Studies (CJ-DATS) randomly allocated 486 drug-involved parolees to either collaborative behavioral management or traditional parole with 3-month and 9-month follow-up. Bi-variate and multivariate regression models found that, in the first 3 months, the CBM group had more parole sessions, face-to-face parole sessions, days on which parole and treatment occurred on the same day, treatment utilization and individual counseling, without an increase in parole violations. The authors conclude that CBM integrated parole and treatment as planned and intensified parolees' utilization of these services, without increasing violations. Friedmann PD, Rhodes AG, Taxman FS. Collaborative behavioral management: Integration and intensification of parole and outpatient addiction treatment services in the Step'n Out study. J Exp Criminology 2009;2009(5):227-243.

When Goals Diverge: Staff Consensus and the Organizational Climate

A sample of correctional officers and prison substance abuse treatment staff collected by the National Criminal Justice Treatment Practices Survey is used to provide an exploratory study of an aspect of organizational culture consisting of consensus (agreement) among prison personnel regarding their beliefs about rehabilitation in the presence of conflicting organizational goals and aspects of the organizational climate important to change. Findings show that among those staff members responding to the survey (n=274), the belief in rehabilitation scale mean score was associated with higher levels of organizational commitment, and interdepartmental coordination. However, an hierarchical linear modeling (HLM) analysis that used an index score derived from the standard deviation for staff consensus regarding these same beliefs about rehabilitation produced a different pattern of results, showing that high levels of consensus were associated with job frustration, cynicism towards the ability of the institution to change, and lower levels of organizational commitment. The authors conclude that, although the sample may not express the beliefs of corrections officers or prison-based treatment staff at large, within the sample, consensus appeared to play a unique role in evaluating the effect of divergent goals on organizational climate as it relates to change, and warrants consideration when considering the effects of organizational climate. Melnick G, Ulaszek WR, Lin H, Wexler H K. When goals diverge: Staff consensus and the organizational climate. Drug Alcohol Depend. 2009;103S:S17-S22.

Competing Values Among Criminal Justice Administrators: The Importance of Substance Abuse Treatment

This study applied latent class analysis (LCA) to examine heterogeneity in criminal justice administrators' attitudes toward the importance of substance abuse treatment relative to other programs and services commonly offered in criminal justice settings. The study used data collected from wardens, probation and/or parole administrators, and other justice administrators as part of the National Criminal Justice Treatment Practices survey (NCJTP), and includes both adult criminal justice (n=302) and juvenile justice (n=141) samples. Results of the LCA suggested that administrators fell into four different latent classes: (1) those who place a high importance on substance abuse treatment relative to other programs and services, (2) those who place equal importance on substance abuse treatment and other programs and services, (3) those who value other programs and services moderately more than substance abuse treatment, and (4) those who value other programs and services much more than substance abuse treatment. Latent class membership was in turn associated with the extent to which evidence-based substance abuse treatment practices were being used in the facilities, the region of the country in which the administrator worked, and attitudes toward rehabilitating drug-using offenders. The findings have implications for future research focused on the impact that administrators' attitudes have on service provision as well as the effectiveness of knowledge dissemination and diffusion models. Henderson CE, Taxman FS. Competing values among criminal justice administrators: The importance of substance abuse treatment. Drug Alcohol Depend. 2009;103S;7-16.


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