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National Institute on Drug Abuse

Director's Report to the National Advisory Council on Drug Abuse

May, 1999

Research Findings

Clinical and Services Research

Moderate Versus High Dose Methadone in the Treatment of Opioid Dependence: A Randomized Trial

Drs. Strain, Bigelow, Liebson and Stitzer of the Department of Psychiatry and Behavioral Sciences at the Johns Hopkins University School of Medicine, assessed the relative efficacy of moderate (40-50 mg.) versus high (80-100 mg) oral dose methadone in the treatment of opioid dependence. Results of a 40-week, randomized, double-blind clinical trial, conducted in an outpatient substance abuse treatment research clinic, suggest the high-dose group (N=95) experienced significantly greater decreases in illicit opioid use than did the medium-dose group (N=97), although patients from both groups showed a decrease in illicit opioid use during methadone maintenance and detoxification. Strain, E.C., Bigelow, G.E., Stitzer, M.L. Journal of the American Medical Association, 281(11), pp. 1000-1005, 1999.

History of Alcohol or Drug Problems, Current Use of Alcohol or Marijuana, and Success in Quitting Smoking

Dr. Humfleet and colleagues at the University of San Francisco examined the relationship of alcohol and drug treatment history and current alcohol and marijuana consumption with success in smoking cessation treatment in a smoking clinic population. No significant differences in abstinence rates were found based on history of alcohol/drug problem or treatment. Both alcohol use at baseline and any alcohol use during treatment predicted smoking at all follow-up points. Alcohol users had significantly lower quit rates than did participants reporting no use. Neither use of marijuana at baseline nor during treatment predicted outcome. Past alcohol and drug problems do not appear to predict treatment outcome, however, even low to moderate levels of alcohol consumption during smoking cessation may decrease treatment success. Humfleet, G., Munoz, R., Sees, K., Reus, V., and Hall, S. Addictive Behaviors, 24, pp. 149-154, 1999.

Abstinence-Based Vouchers Increase Marijuana Abstinence During Outpatient Treatment for Marijuana Dependence

Dr. Alan Budney and colleagues at the University of Vermont tested the efficacy of an abstinence-based voucher program with persons seeking treatment for marijuana dependence. Participants (N=60) were randomly assigned to one of three treatments: brief motivational therapy (M), brief therapy combined with behavioral coping-skills therapy (MBT), or a combination of the brief therapy, the coping-skills therapy and voucher program (MBTV). The voucher program involved providing monetary-based incentives contingent on subjects' submitting urine specimens free of cannabinoids. A significantly greater number of subjects in the MBTV group compared with the MBT or M groups were abstinent at the end of the 14-week treatment (35% vs. 10% vs. 5%, respectively). This is the first trial to show that an abstinence-based voucher program can improve marijuana abstinence rates in the treatment of marijuana dependence. Paper presented at the 1998 conference of the American Public Health Association, Washington, D.C. and the 1998 conference of the College on Problems of Drug Dependence, Scottsdale, AZ.

Manipulation of Cigarette Craving through Rapid Smoking: Efficacy and Effects on Smoking Behavior

Drs. Stitzer and Houtsmuller at Johns Hopkins University attempted to 1) identify interventions that can reliably influence cigarette cravings, and 2) assess the relationship between cigarette craving and smoking behavior. The effects of aversive rapid smoking on self-reported craving and subsequent smoking behavior were compared to effects of self-paced smoking or no smoking. Subjects (N=14) engaged in a rapid, self-paced or no smoking procedure at the start of three separate sessions. Craving levels, measured repeatedly during the next 3 hours of no smoking, were significantly lower after rapid smoking than after either self-paced or no smoking. Measures of subsequent smoking behavior (latency to first cigarette; number of cigarettes, number of puffs) did not differ systematically across conditions. Thus craving was reliably suppressed by aversive rapid smoking, but craving scores did not predict actual smoking behavior. Houtsmuller, E.J., Stitzer, M.L. Psychopharmacology, 142, pp. 149-157, 1999.

Contingent Reinforcement Sustains Post-detoxification Abstinence From Multiple Drugs: A Preliminary Study with Methadone Patients

In a study examining the efficacy of a urinalysis-based contingency management program for preventing relapse to abused drugs following brief residential detoxification, 14 chronic benzodiazepine abusing methadone-maintained patients enrolled in a 7-day residential detox were randomly assigned to receive either Contingency Management or Standard Care upon return to outpatient methadone treatment. The contingency management condition was either a take-home dose of methadone or a $25 voucher (patient choice) for each urine that was free of opiates, cocaine, and benzodiazepines. Preliminary data analysis showed that the Contingency Management patients submitted more drug-free urine samples during the behavioral intervention compared to pre-detoxification, whereas no significant changes were observed from pre-to post-detoxification in the Standard Care patients. Abstinence-based contingency management may be a promising strategy for preventing relapse to multiple drugs of abuse in a subpopulation of methadone maintenance patients when abstinence has been initiated through brief residential detoxification. Chutuape, M., Silverman, K., and Stitzer, M., Drug and Alcohol Dependence, 54, pp. 69-81, 1999.

Disulfiram Effects on Acute Cocaine Administration

This randomized, double-blind, placebo-controlled within subjects study was conducted ( in 7 subjects meeting DSM-IV criteria for cocaine dependence and alcohol abuse) to determine whether disulfiram ( 250 or 500mg/day or placebo ) alters responses to acute intranasal cocaine ( 1 or 2mg/kg , placebo ) administration. Effects of disulfiram on cocaine pharmacokinetics, physiological, and behavioral responses were determined. Disulfiram treatment increased plasma cocaine concentrations three to six times and significantly increased cocaine-associated cardiovascular responses, but did not alter the behavioral responses to cocaine. This study provides evidence of a significant interaction between cocaine and disulfiram which should be considered in the decision regarding disulfiram treatment in cocaine dependent patients. McCance-Katz, E., Kosten, T., and Jatlow, P. Drug and Alcohol Dependence (52), pp. 27-39, 1998.

A Nicotine Antagonist, Mecamylamine, Reduces Cue-Induced Craving in Cocaine-Dependent Subjects

Dr. Malcolm S. Reid and colleagues at the New York Veterans Affairs Medical Center and at the San Francisco Veterans Affairs Medical Center reported that mecamylamine, a nicotine antagonist, attenuated cue-induced cocaine craving. Twenty-three cocaine-dependent subjects who were also cigarette smokers were randomly assigned to either mecamylamine or placebo in a single-dose, placebo controlled, cross-over, double blind study. Various measures of craving and anxiety were recorded before and during cocaine cues. While all subjects reported an increase in craving, anxiety, skin conductance and skin temperature in response to cocaine cues, the cue-induced increase in cocaine craving was reduced, while skin conductance and skin temperature were unaffected for subjects on mecamylamine. This suggests that mecamylamine, in reducing cue-induced cocaine craving, may have potential as a cocaine pharmacotherapy. Reid, M.S., Mickalian, J.D., Delucci, K.L. and Berger, K.S. A Nicotine Antagonist, Mecamylamine, Reduces Cue-Induced Craving in Cocaine-Dependent Subjects. Neurophsychopharmacology, 20, pp. 297-307, 1999.

Concurrent Use of Cocaine and Alcohol is More Potent and Potentially More Toxic Than the Use of Either Alone

In this double-blind, randomized within subjects study, 8 volunteers meeting DSM-IV criteria for cocaine dependence and alcohol abuse participated in 3 drug administration sessions: four doses of intranasal cocaine (1mg/kg every 30 min.) with oral alcohol (1 g/kg) administered following the initial cocaine dose and a second dose (120mg/kg) at 60 minutes calculated to maintain plasma alcohol concentration at approximately 100mg/dL during the cocaine administration; four doses of cocaine/placebo alcohol; four doses of cocaine placebo/alcohol. Pharmacokinetic, physiological, and behavioral effects were followed over 8 hours. Simultaneous administration of cocaine and alcohol produced greater euphoria and increased perception of well-being relative to cocaine alone. In addition, heart rate significantly increased following the cocaine and alcohol administration relative to either drug alone. The enhanced psychological effects may encourage ingestion of larger amounts of these substances over time placing users at increased risk for greater toxicity than with either drug alone. McCance-Katz, E., Kosten, T., and Jatlow, P., Biological Psychiatry, (44) pp. 250-259, 1998.

Research versus " Real World" Patients: Representativeness of Participants in Clinical Trials of Treatments for Cocaine Dependence

To assess the representativeness of subjects participating in clinical trials, 243 research subjects participating in clinical trials of treatments for cocaine dependence were compared to a sub-sample of 213 individuals being treated for cocaine dependence in outpatient clinical settings from a large national database. The findings from this study suggest that research patients participating in clinical trials are similar to, if not more severe than, individuals with cocaine problems in regular clinical and community-based treatment settings. Carroll, K., Nich, C., Mclellan, T., McKay, J., and Rounsaville, B. Drug and Alcohol Dependence (54), pp. 171-177, 1999.

Persistence of Viremia and the Importance of Long-Term Follow-up After Acute Hepatitis C Infection

The purpose of this investigation was to prospectively characterize acute hepatitis C virus (HCV) infections and to evaluate the hypothesis the outcome is affected by identifiable clinical or viral factors. In a study of 142 IDUs who were HCV antibody negative in 1988 and who were followed semi-annually through 1996, HCV seroconversion was observed in 43 (30%). HCV RNA was detected and quantified in a median of 10 specimens per participant and showed two distinct patterns of viremia: viral clearance was noted in 6 (14%) and viral persistence was observed in 37 (86%) participants. Subjects with viral clearance were more likely to be white (p=.004), have jaundice (p=.03), and have lower peak viral titer (p=.003). However, the outcome for a given person could not be predicted by clinical features, RNA level, or HCV subtype. No acute infections were recognized by health care workers. At the time of seroconversion, HCV RNA was detectable in 81% of participants, and recombinant immunoblot assay was positive in 85%. The authors conclude that approximately 85% of those with acute hepatitis C develop persistent viremia; however, acute infections are uncommonly recognized clinically, underscoring the importance of screening those at risk. Long-term follow-up, but no single lab test, is necessary to ascertain the outcome and in some cases make the diagnosis of acute HCV infection. Villano, S.A., Vlahov, D., Nelson, K.E., Cohn, S., and Thomas, D.L. Persistence of Viremia and the Importance of Long-Term Follow-Up after Acute Hepatitis C Infection. Hepatology, 29, pp. 908-914, 1999.

Ambient Temperature and Mortality From Unintentional Cocaine Overdose

The Cornell University Medical College researchers, Marzuk, Tardiff and colleagues conducted a retrospective medical examiner surveillance study to assess the association of hot weather with mortality from unintentional cocaine overdose. All cases of fatal unintentional drug overdoses in New York City from 1990 through 1995 were identified through manual review of all medical files at the Office of Chief Medical Examiner of New York. The study population consisted of all fatal unintentional cocaine overdoses from 1993 through 1995 (n=2008). The contemporaneous comparison groups included fatal unintentional opiate overdoses (n=793), all other fatal unintentional overdoses (n=85) and a subset of homicides (n=4638) and fatalities from motor vehicle crashes (n=815). A temperature threshold of 31.1C (88F) was identified, above which the mean daily number of fatal cocaine overdoses increased steadily. On days with a maximum daily temperature of 31.1C or higher ("hot days"), the mean daily number of cocaine overdose deaths was 2.34 (SD=1.68), which was 33% higher than the mean on days with a maximum temperature of <31.1C (mean=1.76 [SD=1.37], p<0.001). In contrast, the opiate overdose deaths/day was 0.81 on hot days and 0.71 on other days. The proportions with a positive cocaine toxicology among homicides and traffic fatalities did not differ significantly on hot days from those on other days. The investigators concluded that high ambient temperature is associated with a significant increase in mortality from cocaine overdose. The increase was not explained by changes in cocaine use among the general population. They stated that although cocaine use is dangerous on all days, it appears to be even more dangerous on hot days. Marzuk, P., Tardiff, K., Leon, A., Hirsch, C.S., Portera, L., Iqbal, M.I., Nock, M.K., and Hartwell, N. Ambient Temperature and Mortality From Unintentional Cocaine Overdose. JAMA, 279, pp. 1795-1800, 1998.

Hallucinogens and Residual Neuropsychological Toxicity

Halperin and Pope searched the Medline database between 1964 and 1998 and reviewed the published articles on hallucinogens (LSD, Mescaline, Psilocybin, Psilocin, DMT, and MDMA). Of the several hundred citations in the literature, a total of 42 investigations were found where neuropsychological tests had been administered to the subjects. After applying various inclusion and exclusion criteria, only nine qualifying studies were found where the subjects were administered the appropriate neuropsychological tests to assess the residual, but not the acute effects of hallucinogens. The authors conclude that interpretation of the studies was limited by various confounding variables, such as subjects' premorbid cognitive and personality function and prior use of other substances. The literature tentatively suggests that there are few, if any, long-term neuropsychological deficits attributable to hallucinogen use. To better resolve this issue, it will be important to study larger samples of chronic, frequent hallucinogen users who have not often used other types of drugs Halperin, J. and Pope, H. Do Hallucinogens Cause Residual Neuropsychological Toxicity? Drug and Alcohol Dependence, 53, pp. 247-256, 1999.

Dynorphin Lowers Dopaminergic Tone Acting through Opioid Receptor Mechanisms

Dr. Mary Jeanne Kreek and associates demonstrated that administration of dynorphin increased prolactin levels suggesting a reduction of dopaminergic tone that modulates that system. It was further demonstrated that this action likely occurred through kappa and possibly mu opioid receptors. Furthermore, females were more responsive than males. These results suggest that a dynorphin-like compound might be useful in managing cocaine addiction. (Kreek, M.J., Schluger, J., Borg, L., Bunduz, M., and Ho, A. The Journal of Pharmacology and Experimental Therapeutics, 288(1), pp. 260-269, 1999) Dynorphin was also administered as a possible treatment for opioid withdrawal. Opiate-dependent subjects who had been stabilized on morphine received a single dose of dynorphin A(1-13) with positive results. There was some reduction in symptomatology at the higher doses (500 micrograms), but these were not dose-dependent. Specker, S., Wananukul, W., Hatsukami, D., Nolin, K., Hooke, L., Kreek, M.J., and Pentel, P.R. Psychopharmacology, 137, pp. 326-332, 1998.

Regional Brain Metabolic Activation During Craving

Dr. Nora Volkow and colleagues at the Brookhaven National Laboratory investigated cerebral circuits involved in cue-elicited craving. Thirteen cocaine abusers were scanned using positron emission tomography (PET). Craving was induced during an interactive interview about neutral versus cocaine themes. In addition to the PET scans, behavioral and cardiovascular responses were recorded. During the cocaine theme interview, subjects reported higher self reports for cocaine craving and had higher heart rates, systolic and diastolic blood pressures than during the neutral theme interview. Metabolic (both absolute and relative) values were higher during the cocaine theme than the neutral theme in the orbitofrontal and left insular cortex, and relative values were higher in the cerebellum. Relative metabolic values in the right insular region were correlated significantly with self reports of cocaine craving. The activation during the cocaine theme of the temporal insula, a brain region implicated in autonomic control, and of the orbitofrontal cortex, a brain region involved in expectancy and reinforcing salience of stimuli, support their involvement with craving in chronic cocaine users. Wang, J.G., Volkow, N.D., Fowler, J.S., Cervany, P., Hitzemann, R.J., Pappas, N.R., Wong, C.T., and Felder, C. Regional Brain Metabolic Activation During Craving Elicited by Recall of Previous Drug Experiences. Life Sci, 64(9), pp. 775-784, 1999.

Limbic Activation During Cue-Induced Cocaine Craving

Dr. Anna Rose Childress and colleagues at the University of Pennsylvania School of Medicine tested whether limbic activation occurs during cue-induced craving in humans. Using positron emission tomography (PET), relative regional cerebral blood flow (CBF) was measured in limbic and comparison brain regions in detoxified and cocaine-nave subjects during exposure to cocaine-related and neutral, nondrug-related videos. Results revealed that during the cocaine video, the cocaine users experienced craving and showed a pattern of CBF increases in the amygdala and anterior cingulate, with concomitant decreases in the basal ganglia relative to the responses to the nondrug video. Drug-nave subjects did not show this pattern of CBF change, and the two groups did not differ in their responses in the comparison regions. It was concluded that limbic activation is one component of cue-induced cocaine craving. Childress, A.R., Mozley, D.P., McElgin, W., Fitzgerald, J., Reivich, M., and O'Brien, C.P. Limbic Activation During Cue-Induced Cocaine Craving. Am. J. Psychiatry, 156, pp. 11-18, 1999.

How Are Women Who Enter Substance Abuse Treatment Different than Men?: A Gender Comparison from the Drug Abuse Treatment Outcome Study

Gender differences at admission to treatment were examined in a large sample (N=10,010) of men and women entering four major substance abuse treatment modalities in the Drug Abuse Treatment Outcome Study (DATOS). Women were younger and less educated than men and had been employed less. Although some drug use patterns were similar, men reported more alcohol use while women reported greater daily use of cocaine. Women reported more problems related to health and mental health. In addition, women reported higher levels of past and current physical and sexual abuse. Both men and women who had custody of children showed concern that drug treatment might affect their custody, but most other issues related to children are still primarily women's issues. Wechsberg, W.M., Craddock, S.G., & Hubbard, R.L. Drugs and Society, 13(1/2), pp. 97-115, 1998.

Women in Residential Drug Treatment: Differences by Program Type and Pregnancy Attitudes

This study compared the characteristics of 4,117 women treated in publicly-funded residential drug treatment programs in Los Angeles County between 1987-1994 by pregnancy status and program gender composition, i.e., women-only and mixed gender programs. A logistic regression analysis determined the predictors of program completion. Patients in women-only programs were more likely than women in mixed-gender programs to be pregnant, homeless, on probation, to use methamphetamines, to use alcohol, and to have prior drug treatment. Pregnant women were younger, more likely to be homeless, had fewer years of drug use, were more often referred to treatment by other services providers, and were less likely to have injected drugs or have prior drug treatment than non-pregnant women. Patients in women-only programs spent more time in treatment and were over twice as likely to complete treatment as women in mixed gender programs. Grella, C.E., Journal of Health Care for the Poor and Underserved, 10(2), May 1999.

Substance Use, Mental Disorders, Abuse and Crime: Gender Comparisons Among a National Sample of Adolescent Drug Treatment Clients

This paper describes important gender comparisons in drug and alcohol use, illegal activity, physical and sexual abuse, and mental health problems among a large sample of adolescents (N=3,382) who were treated from 1993 to 1995 in adolescent-oriented drug programs that participated in the Drug Abuse Treatment Outcome Study of Adolescents. Most of the adolescents reported regular use of marijuana and alcohol. Males had higher rates of illegal activity and involvement with the juvenile justice system. Females reported more sexual abuse, while males reported more physical abuse. Males and females had equal rates of conduct disorder and attention deficit hyperactivity disorder. Rounds-Bryant, J. L., Kristiansen, P.L., Fairbank, J.A., & Hubbard, R.L. Journal of Child & Adolescent Substance Abuse, 7(4), pp. 19-34, 1998.

Parity for Mental Health and Substance Abuse Care under Managed Care

Most health care plans restrict benefits for behavioral treatment, especially mental health and substance abuse care, to limit their financial risk of paying for costly long-term illnesses. These benefit restrictions have been criticized as unfair and unnecessary by many who seek parity between medical care and behavioral health care coverage. However, benefit restrictions have become less important in allocating health care resources and controlling costs due to the impact of managed care. The implication of managed care for policies aimed at achieving parity in insurance coverage was examined using a theoretical approach to examine adverse selection, moral hazard (over-utilization of benefits), and other insurance issues. The researchers found that due to the control of managed care on cost and utilization, parity in benefit design no longer implies equal access to or quality of mental health and substance abuse care. Similarly, parity has less value in avoiding adverse selection, the enrollment of high-cost members in a health plan with a comparatively lenient benefit structure. Frank, R.G. and McGuire, T.G. Journal of Mental Health Policy and Economics, 1(4), pp. 153-159, 1998.

Mental Health and Substance Abuse Parity: A Case Study of Ohio's State Employee Program

In the United States, insurance benefits for treating alcohol, drug abuse and mental health (ADM) problems have been much more limited than medical care benefits. This study documents the experience of the State of Ohio with adopting full parity for ADM care for its state employee program under managed care. In contrast to the emerging inflation anxiety regarding overall healthcare costs, managed care can provide long-run cost containment for ADM care when patient copayments are reduced and coverage limits are lifted. This may differentiate ADM care from medical care and reasons may include the state of management techniques (much higher technology utilization in medical care) and demographic factors (medical, but not behavioral health costs increase as the population ages). This study indicates that a parity level benefit for ADM care is affordable under managed care. Sturm, R., Goldman, W. and McCullugh, J. Journal of Mental Health Policy and Economics, 1(4), pp. 129-134, 1998.

Legal Pressure and Treatment Retention in a National Sample of Long-Term Residential Programs

This study examined the association between legal pressure and treatment retention in a national sample of 2,605 clients admitted to 18 long-term facilities that participated in the Drug Abuse Treatment Outcome Study (DATOS). Hierarchical linear models were used to assess the relationship of background factors and legal pressure with treatment participation for 90 days or longer. Two thirds of the sample entered residential treatment with moderate to high pressure from legal authorities, and they were significantly more likely than the low-pressure clients to stay 90 days or more. Moreover, the difference in retention between moderate-to-high and low-pressure clients was even greater in programs with proportionally larger caseloads under legal surveillance. The criminal justice system (CJS) can influence treatment participation and retention, and it appears essential for the CJS and treatment programs to maintain an open and constructive relationship to maximize their potential combined impact. Hiller, M.L., Knight, K., Broome, K.M., Simpson, D.D., Criminal Justice and Behavior, 25(4), pp. 463-481, 1998.

Effects of Readiness for Drug Abuse Treatment on Client Retention and Assessment of Process

This study examined client motivation as a predictor of retention and therapeutic engagement across the major types of treatment settings represented in the third national drug abuse treatment outcome study (DATOS) conducted in the United States. Sequential admissions during 1991-1993 to 37 programs provided representative samples of community-based treatment populations. Based on this naturalistic non-experimental evaluation design, hierarchical linear model (HLM) analysis for nested data was used to control for systematic variations in retention rates and client attributes among program within modalities. The data were collected from long-term residential (LTR), outpatient methadone (OMT), and outpatient drug free (ODF) programs located in 11 large cities. A total of 2265 clients in 18 LTR, 981 clients in 13 OMT and 1, 791 clients in 16 ODF programs were studied. Pre-treatment variables included problem recognition and treatment readiness (two stages of motivation), sociodemographic indicators, drug use history and dependence, criminality, co-morbid psychiatric diagnosis and previous treatment. Retention and engagement (based on ratings of client and counselor relationships) served as outcome criteria. Pre-treatment motivation was related to retention in all three modalities, and the treatment readiness scale was the strongest predictor in LTR and OMT. Higher treatment readiness also was significantly related to early therapeutic engagement in each modality. Indicators of intrinsic motivation-especially readiness for treatment-were not only significant predictors of engagement and retention, but were more important than sociodemographic, drug use, and other background variables. Joe, G.W., Simpson, D.D., Broome, K.M., Addiction, 93(8), pp. 1177-1190, 1998.

Antisocial Tendency Among Drug-Addicted Adults: Potential Long-Term Effects of Parental Absence, Support, and Conflict During Childhood

This study examined the relationship between perceptions of parent-child relations in the family of origin and antisocial tendency in a sample of drug-addicted adults. Data included retrospective accounts of childhood family factors, adolescent antisocial tendency and self-reported hostility and risk-taking prior to treatment entry. A developmental model was tested that included adolescent antisocial tendency as a mediator of the relationship between childhood parenting factors and adulthood antisocial tendency. The effects of parental support and conflict were found to operate primarily through adolescent measures of antisocial tendency. Specifically, lower levels of parental support and higher levels of conflict with parents predicted greater adolescent antisocial tendency, which in turn predicted more hostility and risk-taking in adulthood. Thus, parental support appears to serve as a buffer against deviant behavior and drug use. Knight, D.K., Broome, K.M., Cross, D.R., Simpson, D.D., American Journal of Drug and Alcohol Abuse, 24(3), pp. 361-375, 1998.

Residential Drug Abuse Treatment for Probationers: Use of Node-Link Mapping to Enhance Participation and Progress

Node-link mapping, a tool to improve communication between patients and counselors using visual representation of the relationships between behaviors, was used to enhance substance-abuse treatment in a 4-month residential criminal justice program. Twelve communities of 30 to 35 probationers ("residents") were randomly assigned to either mapping-enhanced or standard counseling. During group sessions, counselors and residents in the mapping communities collaborated to develop node-link maps representing critical behavioral issues. Counselors in standard communities used their own methods. Treatment motivation (i.e., desire for help) was assessed at intake and was used to categorize residents into three levels. Treatment involvement was measured at the middle and at the end of the program. Residents, as well as their counselors, rated those in mapping communities as participating more in group sessions than those in standard communities. Mapping residents also reported better personal progress toward treatment goals, more positive affective responses to treatment, and greater treatment engagement. Residents with higher motivation at intake had higher treatment involvement scores regardless of type of counseling received. Piter, U., Dansereau, D.F., Newbern, D. and Simpson, D.D. Journal of Substance Abuse Treatment, 15(6), pp. 535-543, 1998.

A Comparison of Two Methods for Estimating the Costs of Drug Abuse Treatment

A consistent method has not been used to estimate the costs of providing substance abuse treatment. Most previous studies used direct "out-of-pocket" expenditures as an approximation of the total value of treatment services. The risk of this method is to ignore the value of resources that are partially subsidized or used without cost to the program. This paper compares the accounting and economic approach utilizing two outpatient methadone clinics and two residential treatment programs. The study finds that economic costs are from 4 to 15 percent higher than accounting costs. Dunlap, L.J. and French, M.T. Journal of Maintenance in the Addictions, 1(3), pp. 29-44, 1998.

The Development and Validation of a Simpatia Scale for Hispanics Entering Drug Treatment

A 17-item simpatia scale was developed for use with Hispanic substance abusers using confirmatory factor analytic techniques in a sample of 144 daily opioid users. The overall scale had good internal consistency and demonstrated convergent and discriminant validity. The simpatia scale was constructed to examine social attributes reflecting agreeableness, respect of others, and politeness. The Agreeableness subscale addressed issues related to agreeing with others, similarity of opinions between self and others, and if clients openly disagreed with others. The Respect subscale addressed issues related to saying good things about others, trusting others, and treating others with respect. The Politeness subscale addressed issues related to avoiding conflict with others, doing favors, and treating others as equals. A cross-validation study demonstrated that simpatia was positively related to social support, social conformity, treatment service satisfaction, and client rating of counselor skills, whereas it was negatively related to hostility. Griffith, J.D., Joe, G.W., Chatham, L.R., Simpson, D.D. Hispanic Journal of Behavioral Sciences, 20(4), pp. 468-482, 1998.

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