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Director's Report to the National Advisory Council on Drug Abuse - September, 2004

Research Findings - Services Research

Buprenorphine-Naloxone is Practical and Safe for Use in Diverse Community Treatment Settings

In October 2002, the U.S. Food and Drug Administration approved buprenorphine-naloxone (Suboxone) sublingual tablets as an opioid dependence treatment available for use outside traditionally licensed opioid treatment programs. The NIDA Center for Clinical Trials Network (CTN) sponsored two clinical trials assessing buprenorphine-naloxone for short-term opioid detoxification. These trials provided an unprecedented field test of its use in twelve diverse community-based treatment programs. Opioid-dependent men and women were randomized to a thirteen-day buprenorphine-naloxone taper regimen for short-term opioid detoxification. The 234 buprenorphine-naloxone patients averaged 37 years old and used mostly intravenous heroin. Direct and rapid induction onto buprenorphine-naloxone was safe and well tolerated. Most patients (83%) received 8 mg buprenorphine-2 mg naloxone on the first day and 90% successfully completed induction and reached a target dose of 16 mg buprenorphine-4 mg naloxone in three days. Medication compliance and treatment engagement was high. An average of 81% of available doses was ingested, and 68% of patients completed the detoxification. Most (80.3%) patients received some ancillary medications with an average of 2.3 withdrawal symptoms treated. The safety profile of buprenorphine-naloxone was excellent. Of eighteen serious adverse events reported, only one was possibly related to buprenorphine-naloxone. All providers successfully integrated buprenorphine-naloxone into their existing treatment milieus. Overall, data from the CTN field experience suggest that buprenorphine-naloxone is practical and safe for use in diverse community treatment settings, including those with minimal experience providing opioid-based pharmacotherapy and/or medical detoxification for opioid dependence. Amass, L., Ling, W., Freese, T.E., Reiber, C., Annon, J.J., Cohen, A.J., McCarty, D., Reid, M.S., Brown, L.S., Clark, C., Ziedonis, D.M., Krejci, J., Stine, S., Winhusen, T., Brigham, G., Babcock, D., Muir, J.A., Buchan, B.J. and Horton, T. Buprenorphine-Naloxone is Practical and Safe for Use in Diverse Community Treatment Settings. Am J Addict, 13 (1), pp. S42-66, 2004.

Training Rural Practitioners to Use Buprenorphine: Using the Change Book to Facilitate Technology Transfer

The Opiate Medication Initiative for Rural Oregon Residents trained physicians and counselors in Central and Southwestern Oregon to use buprenorphine and develop service models that supported patient participation in drug abuse counseling. The "Change Book" from Addiction Technology Transfer Centers was used to structure the change process. Fifty-one individuals (17 physicians, 4 pharmacists, 2 nurse practitioners, and 28 drug abuse counselors and administrators) from seven counties completed the training and contributed to the development of community treatment protocols. A pre-post measure of attitudes and beliefs toward the use of buprenorphine suggested significant improvements in attitude after training, especially among counselors. Eight months after training, 10 of 17 physicians trained had received waivers to use buprenorphine and 29 patients were in treatment with six of the physicians. The Change Book facilitated development of county change teams and structured the planning efforts. The initiative also demonstrated the potential to concurrently train physicians, pharmacists, and counselors on the use of buprenorphine. McCarty, D., Rieckmann, T., Green, C., Gallon, S. and Knudsen, J. Training Rural Practitioners to Use Buprenorphine: Using The Change Book to Facilitate Technology Transfer. J Subst Abuse Treat, 26(3), pp. 203-208, 2004.

Cost Effectiveness of Disulfiram for Treating Cocaine in Methadone Patients

The cost-effectiveness of providing disulfiram to methadone-maintained opioid addicts in a randomized clinical trial setting is studied. The economic evaluation is based on a double blind clinical trial in which 67 cocaine-dependent methadone-maintained opioid-dependent subjects were randomized to get the additional treatment of disulfiram or placebo in a 12-week trial. Outcome measures used are the number of days of cocaine use and grams of cocaine per week. Cost measures used are the cost of providing standard methadone treatment and the incremental cost of adding disulfiram to the standard treatment. Cost measures of standard and disulfiram-enhanced treatment were collected retrospectively from the provider. Results from this cost-effectiveness analysis imply that, even though disulfiram increases slightly the cost of methadone treatment, its increase in effectiveness may be important enough to warrant its addition for treating cocaine dependence in methadone-maintained opiate addicts. Jofre-Bonet, M., Sindelar, J.L., Petrakis, I.L., Nich, C., Frankforter, T., Rounsaville, B.J. and Carroll, K.M. Cost Effectiveness of Disulfiram: Treating Cocaine Use in Methadone-Maintained Patients. Substance Abuse Treat; 26(3), pp. 225-232, 2004.

Organizational Absorptive Capacity Affects the Pace of Innovation in Privately-Funded Substance Abuse Treatment Clinics

Few studies have identified the organizational characteristics that are associated with the transfer of research-based treatment techniques into practice. One potentially fruitful concept is absorptive capacity, referring to an organization's ability to seek and utilize information, which may be positively associated with the use of innovative treatment techniques. Data from a nationally representative sample of 322 privately funded substance abuse treatment centers indicate that treatment organizations use a greater number of innovations when they scored high on absorptive capacity, which is defined as engaging in more environmental scanning, surveying referral sources, and third party payers for satisfaction, and having more professionals in their workforce. Knudsen, H.K. and Roman, P.M. Organizational Absorptive Capacity Affects the Pace of Innovation in Privately Funded Substance Abuse Treatment Clinics. Journal of Substance Abuse Treatment, 26(1), pp. 353-361, 2004.

Many Adults Do Not Link with Primary Medical Care after Alcohol or Drug Detoxification

This prospective cohort study—conducted in the context of a randomized trial of a linkage intervention and an expansion of Medicaid benefits—identified patient characteristics and health care experiences associated with primary care linkage after alcohol or drug detoxification. Researchers collected primary interview data over two years from 400 adults without primary medical care, in an urban residential detoxification program. Linkage was defined as self-report of at least one visit with a primary care clinician during follow-up. Of 400 subjects, 63% linked with primary medical care. In a multivariable model adjusting for randomization assignment, predisposing, enabling and illness variables, women, those with no recent incarceration, those with support for abstinence by family or friends, and those who had visited a medical clinic or physician recently were significantly more likely to link with primary care. Those with health insurance during follow-up were also more likely to link. Recent mental health or addictions treatment utilization and health status were not associated with linkage. Researchers conclude that a substantial proportion of adults with addictions do not link with primary medical care. These data suggest that efforts could be focused on those least likely to link, that contacts with mental health and addictions treatment providers are underutilized opportunities for these efforts, and that health policy changes such as expanding health insurance benefits may improve entry of substance dependent patients into primary medical care. Saitz, R., Larson, M.J., Horton, N.J., Winter, M., and Samet, J.H. Linkage with Primary Medical Care in a Prospective Cohort of Adults with Addictions in Inpatient Detoxification: Room for Improvement. Health Services Research, 39(3), pp. 587-606, 2004.

Woman-Focused HIV Intervention with African American Crack Abusers Out-of-drug-treatment

African American women (n = 620) who use crack participated in a comparison randomized trial comparing a women-focused HIV intervention, a revised National Institute on Drug Abuse standard intervention, and a control group. Risk behavior, employment, and housing status were assessed with linear and logistic regression. All groups significantly reduced crack use and high-risk sex at each 3 and 6 month follow-up, but only woman-focused intervention participants consistently improved employment and housing status. Compared with control subjects at 6 months, woman-focused intervention participants were least likely to engage in unprotected sex; revised standard intervention women reported greatest reductions in crack use. A woman-focused intervention can successfully reduce risk and facilitate employment and housing and may effectively reduce the frequency of unprotected sex in the longer term. Wechsberg, W.M., Lam, W.K., Zule, W.A. and Bobashev, G. Efficacy of a Woman-Focused Intervention to Reduce HIV Risk and Increase Self-Sufficiency Among African American Crack Abusers. Am J Public Health, 94(7), pp. 1165-1173, 2004.

Family-Based Therapy was Shown to be More Effective Than Peer-Group Therapy in Treating Urban Adolescent Substance Abuse

A randomized clinical trial evaluated a family-based therapy (Multidimensional Family Therapy, MDFT; Liddle 2002a) and a peer group therapy with 80 urban, low-income, and ethnically diverse young adolescents (11 to 15 years) referred for substance abuse and behavioral problems. Both treatments were outpatient, relatively brief, manual-guided, equal in intervention dose, and delivered by community drug treatment therapists. Results indicated that the family-based treatment (MDFT, an intervention that targets teen and parent functioning within and across multiple systems on a variety of risk and protective factors) was significantly more effective than peer group therapy in reducing risk and promoting protective processes in the individual, family, peer, and school domains, as well as in reducing substance use over the course of treatment. Liddle, H.A., Rowe, C.L., Dakof, G.A., Ungaro, R.A. and Henderson, C.E. Family-based Therapy was Shown to be More Effective than Peer-group Therapy in Treating Urban Adolescent Substance Abuse. Journal of Psychoactive Drugs, 36(1), pp. 49-63, 2004.

Are Rates of Psychiatric Disorders in the Homeless Population Changing?

The objective is to examine the prevalence of psychiatric illness among 3 homeless populations in St. Louis, MO, in approximately 1980, 1990, and 2000. Selected demographics and lifetime substance abuse and dependence and other mental illness among the 3 populations are compared. Among the homeless populations, the prevalence of mood and substance use disorders dramatically increased, and the number of minorities within these populations has increased. The prevalence of drug use disorder increased dramatically among both men and women over the past 2 decades, and among women, the increase was higher than the prevalence of alcohol use disorder. In 2000, 84% of men and 58% of women had an alcohol or other drug use disorder. Also in 2000, substance use disorders accounted for the vast majority of psychopathology (prevalence of any psychiatric disorder was 88% among men and 69% among women). In 1980, the abused drug of choice was cannabis, but it was surpassed over the next 2 decades by cocaine, which had not been found among homeless men or women in 1980. The popularity of amphetamine and sedative-hypnotic abuse decreased after 1980. Opioid abuse remained relatively unchanged over the 2 decades and was the third most prevalent abused drug of choice in 2000. The prevalence of psychiatric illness, including substance abuse and dependence, is not static in the homeless population. Service systems need to be aware of potential prevalence changes and the impact of these changes on service needs. North, C.S., Eyrich, K.M., Pollio, D.E., and Spitznagel, E.L Are Rates of Psychiatric Disorders in the Homeless Population Changing? Am J Public Health, 94, pp. 103-108, 2004.

Are Health Plans Adequately Identifying Adolescents With Substance Use Problems?

Three measures developed by the Washington Circle, a group focused on the development of substance abuse performance measures, have been adapted for the 2004 Health Plan Employer Data and Information Set. One measure—the identification rate—can be used to examine the extent to which private health plans are able to identify adolescent enrollees with substance use problems. The researchers calculated this rate for adolescents using MarketScan, a database of private health plan claims for selected employers maintained by the MEDSTAT Group. About a quarter million adolescents were covered in 1997. The number of adolescents with any primary or secondary substance abuse claims during the year was divided by the member-years for adolescents aged 12 to 18. For enrolled adolescents, the overall identification rate was .5 percent and .7 percent for males and .4 percent for females. The researchers compared these results to the 6.8 percent rate of alcohol dependence or drug dependence—or both—obtained from a special analysis of a subset of adolescents covered by commercial insurance who were included in the 1998 National Household Survey on Drug Abuse. No meaningful variation was observed across health plan type. The low rate points to the urgent need to close the gap between the number of adolescents who need treatment and those who receive it. Lee, T.M., Garnick, D.W., Miller, K., and Horgan, C.M. Are Health Plans Adequately Identifying Adolescents With Substance Use Problems? Psychiatric Services, 55(2), pp. 116, 2004.

Family and Peers Influence Severity of Alcohol and Drug Problems in Adolescents

To examine how parental limit setting, family conflict, and perception of family experience influence severity of alcohol and drug problems, and important gender differences in these relationships, the researchers interviewed consecutive intakes, aged 12 to 18 years, at 4 chemical dependency programs of a large group-model nonprofit health maintenance organization (HMO) (n=419). The Family Conflict, Limit Setting, and Positive Family Experience scales correlated with substance dependence (p<0.01, p<0.01, p<0.05, respectively). Depression also correlated with family conflict (p<0.01), absence of limit setting (p<0.01), poor family experience (p<0.01) and dependence symptoms (p<0.01). Number of substance-using friends correlated with number of dependence symptoms (p<0.01). Gender differences included the following: (1) girls scoring higher in family conflict (p=0.0002), negative perceptions of family experience (p<0.0017), and lower in absence of limit setting (p<0.0001); (2) how family environment predicted problem severity: absence of limit setting was significant for boys and girls but family conflict for boys only; (3) girls had more dependence symptoms (p=<0.0001), psychiatric diagnoses (e.g., depression (p<0.0003), anxiety (p<0.0002), conduct disorder (p=0.07)), and substance-abusing family members (53 % versus 39%; p=0.006). To conclude, family and peers influence severity of alcohol and drug problems in adolescents. Wu, N., Lu, Y., Sterling, S., and Weisner, C. Family Environment Factors and Substance Abuse Severity in an HMO Adolescent Treatment Population. Clinical Pediatrics, 43(4), pp. 323-333, 2004.

Multidisciplinary Health Clinic to Evaluate Patients During Detoxification Can Link Patients to Primary Medical Care

Researchers evaluated the feasibility of establishing a multidisciplinary Health Evaluation and Linkage to Primary care (HELP) clinic at an urban residential detoxification unit. Patients received a clinical evaluation and facilitated linkage to primary medical care including personalized referral, reminders, and appointment rescheduling. Of 235 adults reporting alcohol, cocaine or heroin as first or second drug of choice and without a primary care physician, 178 (76%) received a full HELP clinic evaluation, 35 (15%) some clinic components, and 7 (3%) only a primary care appointment. Of those with a full evaluation, 28% received pneumococcal vaccination, and most received health behavior counseling. Over the subsequent 2 years, 131 (60%) of the 220 patients who had any contact with the HELP clinic had at least one primary care visit. A multidisciplinary health clinic to evaluate patients during detoxification is feasible and can link patients with substance dependence to primary medical care. Sweeney, L.P., Samet, J.H., Larson, M.J. and Saitz, R. Establishment of a Multidisciplinary Health Evaluation and Linkage to Primary Care (HELP) Clinic in a Detoxification Unit. Journal of Addictive Diseases, 23(3), pp. 33-45, 2004.

DSM-IV Criterion for Cannabis Tolerance is Limited as an Indicator of Dependence in Adolescents

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

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

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

Chronic Marijuana Use Associated With Dropping Out of School

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

Activity Based Costing of Probation With and Without Substance Abuse Treatment: A Case Study

Since many offenders have drug problems, investigators have proposed that drug testing and treatment should be an integral part of probation. In 1994, the Office of National Drug Control Policy (ONDCP) funded a demonstration project designed to integrate drug treatment with traditional supervision services. As part of this demonstration a new procedure called 'seamless' probation was set up in which treatment providers were co-located with probation officers and probation officers coordinated offenders' participation in treatment. This study examines the cost of providing substance abuse treatment coordination through probation agencies. Activity Based Costing (ABC) is used to examine the cost of probation with and without treatment coordination in one probation agency. The agency budget was analyzed and allocated to various programs. A questionnaire was developed to assess probation officers' activities. The cost of coordinating treatment for one offender was calculated by dividing the total cost of the program by units of various activities done by the probation officers. Preliminary test of reliability of the instrument showed that it accurately portrayed the probation officers' time allocation. Probation officers spent 6.9% of their time in seamless supervision and 83.3% time in traditional supervision (83.83%). The seamless probation officers had more group meetings and more phone contact with their offenders than traditional probation officers. The average cost per offender per day was 12 dollars for seamless probation and 7 dollars for traditional probation. Comparison of seamless and traditional supervision activities showed major differences in terms of the probation officers' activities and costs. There are significant costs associated with asking probation officers to coordinate treatment. Alemi, F., Taxman, F., Doyon, V., Thanner, M. and Baghi, H. Activity Based Costing of Probation with and without Substance Abuse Treatment: A Case Study. Journal of Mental Health Policy Econ, 7(2), pp. 51-57, 2004.

Self-Help Organizations for Alcohol and Drug Problems: Toward Evidence-Based Practice and Policy

This expert consensus statement reviews evidence on the effectiveness of drug and alcohol self-help groups and presents potential implications for clinicians, treatment program managers and policymakers. Because longitudinal studies associate self-help group involvement with reduced substance use, improved psychosocial functioning, and lessened health care costs, there are humane and practical reasons to develop self-help group supportive policies. Policies described here that could be implemented by clinicians and program managers include making greater use of empirically-validated self-help group referral methods in both specialty and non-specialty treatment settings and developing a menu of locally available self-help group options that are responsive to clients' needs, preferences, and cultural background. The workgroup also offered possible self-help supportive policy options (e.g., supporting self-help clearinghouses) for state and federal decision makers. Implementing such policies could strengthen alcohol and drug self-help organizations, and thereby enhance the national response to the serious public health problem of substance abuse. Humphreys, K., Wing, S., McCarty, D., Chappel, J., Gallant, L., Haberle, B., Horvath, A.T., Kaskutas, L.A., Kirk, T., Kivlahan, D., Laudet, A., McCrady, B.S., McLellan, A.T., Morgenstern, J., Townsend, M. and Weiss, R. Self-Help Organizations for Alcohol and Drug Problems: Toward Evidence-Based Practice and Policy. J Subst Abuse Treat, 26(3), pp. 151-158; discussion pp. 159-165, 2004.

Medical Provider Referrals of Adolescents to Substance Abuse and Mental Health Treatment

This study examines the factors related to referrals of adolescents with substance use disorders to substance abuse or mental health treatment by their medical providers. Administrative and chart review data from the membership of a large private health maintenance organization (HMO) were collected from a probability sample of 400 adolescents, ages 13-18, who were diagnosed with a substance use disorder in 1999. Logistic regression analyses examined referral to substance abuse treatment and referral to mental health treatment in the aggregate and stratified by gender. Documented use of both alcohol and another illicit drug, and legal problems increased likelihood of referral to substance abuse and mental health treatment, whereas diagnoses of alcohol and marijuana use disorders decreased likelihood of referral to substance abuse treatment. Mental health diagnoses played a limited role in both types of referrals, although specific psychosocial problems were associated with increased likelihood of referrals. Treatment history and location of first mention of problem were significant predictors of referral. There were no gender differences in referral rates to either substance abuse or mental health treatment; however predictors of referral differed by gender. These findings extend our knowledge about factors that influence clinicians' treatment referrals of adolescents with substance abuse diagnoses and have implications for influencing clinician referral behavior within health plans. Scott, M., Parthasarathy, S., Kohn, C., Hinman, A., Sterling, S. and Weisner, C. Medical Provider Referrals of Adolescents to Substance Abuse and Mental Health Treatment. Ment Health Serv Res, 6(1), pp. 47-60, March 2004.

Depression and Hostility as Predictors of Long-term Outcomes Among Opiate Users

Researchers investigated associations that pre-treatment depression and hostility have with drug use and criminal behavior at 1-year and 5-year follow-up in patients with and without additional treatment involvement in the year prior to each follow-up. Using data from an analytic sample of 727 patients at 1-year follow-up and 432 patients at 5-year follow-up, from 18 programs included in the national Drug Abuse Treatment Outcome Studies (DATOS), the researchers followed a naturalistic, non-experimental evaluation design. Multiple logistic regression analyses revealed that greater depression predicted less drug use in the year preceding each follow-up, whereas greater hostility predicted increased drug use and more arrests at each follow-up. These predictive relationships appeared only among individuals not involved in additional treatment. Depression and hostility showed opposite associations with outcomes, underscoring the need to assess these psychological conditions separately and to tailor treatment plans appropriately. Rao, S.R., Broome, K.M., and Simpson, D.D. Depression and Hostility as Predictors of Long-Term Outcomes Among Opiate Users. Addiction, 99(5), pp. 579-589, 2004. Predicting Adolescent Drug Abuse Treatment Outcome with the Personal Experience Inventory This study examined the clinical utility of the Personal Experience Inventory (PEI) Psychosocial scales to predict adolescent drug abuse treatment outcome. The role of psychosocial risk factors in predicting treatment outcome also has theoretical interest given that such factors have been associated with the development of drug abuse. The sample consisted of 138 male and 105 female adolescents recruited at a hospital-based adolescent drug abuse treatment program. Clients were assessed at intake, discharge, and 6 and 12 months after discharge. Intake PEI Psychosocial scales were modestly predictive of outcome; the magnitude of the predictions was higher for boys than girls. Three PEI Psychosocial domains of deviance, family dysfunction, and peer drug use were predictive of boys' outcome; sibling and peer drug use were predictive of girls' outcome. The strength of these predictive relationships was similar to those found in other treatment outcome prediction research. There was limited support for the predictive validity of the PEI. These PEI Psychosocial scales that show predictive associations with outcome may be helpful in treatment planning. Stinchfield, R.D. and Winters, K.C. Predicting Adolescent Drug Abuse Treatment Outcome with the Personal Experience Inventory (PEI). Journal of Child and Adolescent Substance Abuse, 13, pp. 103-120, 2003.

Elevated Post Treatment Relapse Rates Among Recovering Youth with ADHD

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

Suicidal Behavior In Urban American Indian Adolescents

The majority of American Indians do not live on reservations, yet research on suicidal behavior in this population overwhelmingly focuses on reservation Indians. This exploratory study uses a sample of 144 urban and 170 reservation American Indian adolescents to compare rates and correlates of suicidal behavior. One-fifth of urban youth and one-third of reservation youth reported lifetime suicidal ideation, although similar numbers (14%-18%) reported an attempt. Urban youth had fewer psychosocial problems, and in multivariate analyses, the two groups shared no common correlate of attempted suicide. The results suggest that different prevention measures may be warranted for urban Indian youth. Freedenthal, S. and Stiffman, A.R. Suicidal Behavior in Urban American Indian Adolescents: A Comparison with Reservation Youth in a Southwestern State. Suicide and Life-threatening Behavior, 34, pp. 160-171, 2004.

Prevalence of Psychiatric and Substance Use Disorders in Opioid Abusers in a Community Syringe Exchange Program

The present study evaluates the prevalence of psychiatric and substance use disorders in male and female intravenous opioid abusers participating at a community needle exchange program (NEP). All participants (n = 422) were administered the Structured clinical Interview for the DSM-IV (SCID) for Axis I disorders and antisocial personality disorder (APD). Psychiatric and substance abuse comorbidity were highly prevalent. Major depression was the most common current and lifetime Axis I non-substance use disorder (6 and 21% of the sample, respectively); 37% were diagnosed with APD. Over 50% of the sample was diagnosed with at least one non-substance use Axis I disorder or APD. In addition to opioid dependence, cocaine dependence was the most prevalent current and lifetime substance use disorder (68 and 78% of the sample, respectively), followed by alcohol and cannabis dependence. Overall, participants reported a mean of over one current and over three lifetime substance use disorders in addition to opioid dependence. Women reported higher rates of post-traumatic stress disorder (PTSD), while men were more likely diagnosed with APD. Presence of a psychiatric disorder was associated with increased prevalence of substance use disorder for all drug classes. The high rates of comorbidity observed in this sample suggest that the harm reduction efforts of NEPs can be significantly enhanced through referral of participants to programs that treat substance use and/or other psychiatric disorders. Kidorf, M., Disney, E.R., King, V.L., Neufeld, K., Beilenson, P.L. and Brooner, R.K. Prevalence of Psychiatric and Substance Use Disorders in Opioid Abusers in a Community Syringe Exchange Program. Drug and Alcohol Dependence, 74, pp. 115—122, 2004.

Effects of Drug Treatment for Heroin Sniffers: A Factor Against Moving to Injection?

This article explores the relationship between contact with treatment and transition to injection for heroin sniffers. The primary research question is: Does contact with treatment delay onset of injection for heroin sniffers? A stratified network-based sample was recruited from multiple communities in South Florida, which were known for high drug use. Three categories of respondents were recruited based on injection outcome: long-term injectors, short-term injectors, and sniffers (n = 900). The research question was answered in two steps. First, the prevalence of drug treatment for heroin sniffers and injectors was investigated using case-control methods. Second, the relationship was further examined by attempting to identify the causal factors that delay initial injection for a subgroup of current injectors using survival regression procedures. A positive relationship was found between contact with treatment and injection status outcome. Drug treatment significantly reduced the likelihood of heroin sniffers transitioning to injection. Delaying or preventing transition to injection could significantly decrease risk of HIV transmission by reducing or eliminating risky injecting behaviors. Reaching users, either sniffers or smokers, before they transition to injection is crucial, but continuing efforts to intervene early in an injection career is also crucial for reducing physical and social risks to injection drug users. Kelley, M.S. and Chitwood, D.D. Effects of Drug Treatment for Heroin Sniffers: A Factor Against Moving to Injection? Social Science and Medicine, 58, pp. 2083-2092, 2004.

Higher Methadone Dose, Free Treatment, and a Cooperative Orientation Are Associated With Higher Retention in Treatment

This study examined factors associated with methadone maintenance retention, defined as remaining in treatment for a minimum of 90 days, among street recruited injection drug users (IDUs). A total of 577 IDUs were randomly assigned to either a risk reduction intervention, focusing on safer injection and sex behaviors, or motivational interviewing, addressing more sweeping lifestyle changes including drug treatment. All subjects who wanted treatment were provided transportation, rapid intake and a waiver of the intake fee. In addition, 50% were randomly assigned a coupon for 90 days of free treatment. Overall, 33% entered treatment and of these, 60% remained for at least 90 days. Factors associated with retention included higher methadone dose, free treatment, greater contacts with the clinic and counselor rating of patient cooperation. Although desire for treatment, or motivation, was associated in univariate analyses with greater retention, there were no differences observed between the motivational interviewing and risk reduction interventions. Booth, R.E., Corsi, K.F. and Mikulich-Gilbertson, S.K. Higher Methadone Dose, Free Treatment, and a Cooperative Orientation are Associated with Higher Retention in Treatment. Drug Alcohol Depend, 74(2), pp. 177-185, May 2004.

Recent Injection Drug Use With a Shared Needle Predicted HIV Infection Among Drug Injectors in Ukraine, But Risky Sex Behavior Did Not, Has Needle Sharers Engaged in Sex Less

From June through August 2002, 100 IDUs from sites in IDUs from Kiev, Odessa, and Makeevka/Donetsk, Ukraine were recruited through street outreach, including 212 who had previously been tested for HIV and knew their sero status. Subjects were administered a standardized computer-assisted interview assessing HIV-related drug and sex risk behaviors and history of HIV testing. Twenty six percent of the 212 participants reported they were HIV-positive. Univariate followed by multiple logistic regression analyses identified factors associated with HIV infection. In the 30-day period before their interview, HIV-infected IDUs were significantly more likely to have injected with a needle previously used by another injector without disinfecting, frontloaded and/or back loaded, and shared the drug solution from a common container. In addition, they had higher prevalence rates for hepatitis B virus and hepatitis C virus than those not infected with HIV. On the other hand, they were more likely to have reported no sex partners and, if sexually active, more likely to have used a condom. Booth, R.E., Mikulich-Gilbertson, S.K., Brewster, J.T., Salomonsen-Sautel, S. and Semerik, O. Recent Injection Drug Use with a Shared Needle Predicted HIV Infection Among Drug Injectors in Ukraine, but Risky Sex Behavior Did Not, Has Needle Sharers Engaged in Sex Less. J Acquir Immune Defic Synd., 35(1), pp. 82-88, January 2004.

Integrated Care for Substance Abuse Patient With Severe Mental Illness is Becoming Less Common, Especially Among Publicly-Funded Providers

Survey data from a nationally representative sample of privately funded substance abuse treatment centers, were used to identify the proportion of centers that offered psychiatric programs in 1995-1996, 1997-1998, and 2000-2001. Centers reported whether they treated clients with severe mental illness on-site or referred them to external providers. Repeated-measures general linear models were used to test for significant changes over time and to assess mean differences in service availability by profit status and hospital status. About 59 percent of private centers offered a psychiatric program, and this proportion did not significantly change over time. The proportion of centers that referred clients with severe mental illness to external providers increased significantly from 57 percent to 67 percent. For-profit centers and hospital-based centers were significantly more likely to offer psychiatric programs and were less likely to refer severe cases to other providers. Although the importance of integrated care for clients with dual diagnoses is widely accepted, data suggested that this pattern of service delivery is becoming less available. Knudsen, H.K., Roman, P.M. and Ducharme, L.J. Integrated Care for Substance Abuse Patient with Severe Mental Illness is Becoming Less Common, Especially Among Publicly-funded Providers. Psychiatric Services, 55(3), pp. 270-273, March 2004.

Psychological Distress Predicted Relapse Among Drug and Alcohol Abusers

Participants (n=180) completed a baseline interview within their first month of substance user treatment (conducted in 1995/1996) and follow-up interview 2 years following the baseline interview (conducted in 1997/1998). Structural equation modeling analyses were used to examine the relationship among client background characteristics and problem severity indicators, measured during treatment, in relation to alcohol and illicit drug use 2 years post treatment. Psychological distress directly predicted alcohol and illicit drug use during follow-up and appeared to mediate the relationship between client background characteristics (such as gender, race, and marital status) and substance use consequences on post treatment substance use. Income directly predicted alcohol use and age directly predicted illicit drug use, regardless of problem severity (including psychological distress and substance use consequences). Results support long-term clinical monitoring of psychological distress as a marker for return to drug or alcohol use. Flynn, H.A., Walton, M.A., Curran, G.M., Blow, F.C. and Knutzen, S. Psychological Distress Predicted Relapse Among Drug and Alcohol Abusers. Substance Use & Misuse. 39(6), pp. 885-910, May 2004.

Abstinence From Illicit Drugs is Related to Self-Efficacy and Self-Mastery for Oxford House Residents

The relationship between optimism, abstinence self-efficacy, and self-mastery was examined by investigating levels of these cognitive resources among two samples of recovering substance abusers: Oxford House residents who attended twelve-step groups and twelve-step members who had never lived in an Oxford House. Participants' levels of optimism were significantly and positively related to both abstinence self-efficacy and self-mastery scores, as abstinence self-efficacy was significantly and positively related to participants' number of days abstinent. Oxford House residents reported significantly higher levels of abstinence self-efficacy than twelve-step members. Overall, findings suggest that cognitive resources facilitate substance abusers' recovery and that the Oxford House model might provide high levels of support in their ongoing abstinence. Majer, J.M., Jason, L.A. and Olson, B.D. Abstinence from Illicit Drugs is Related to Self-Efficacy and Self-Mastery for Oxford House Residents. Assessment, 11(1), pp. 57-63, March 2004.

HCV Drug-Free and Methadone Maintenance Programs

Drug treatment programs are uniquely situated to screen patients for antibodies for hepatitis C virus (HCV). Almost all methadone and 2/3 of the drug-free programs in the national sample (N=256 programs) apparently offered screening for HCV, but only 60% pf the patients in these programs actually provided specimens for testing. Unfortunately, while some programs were planning to offer such testing that were not at the time of this study, many more were withdrawing this testing service due to lack of funds. This study points to the need for providing more testing resources and motivational efforts to actually use those resources provided. Strauss, S., Astone, J., Des Jarlais, D. and Hagan, H. A Comparison of HCV Antibody testing in Drug-Free and Methadone Maintenance Treatment Programs in the United States. Drug and Alcohol Dependence, 73, pp. 227-236, 2004.

The ASI Can Now be Administrated by Automated Telephone or the Internet

Two versions of the Addiction Severity Index underwent concurrent validation with the traditional clinical interview method. Eighty-eight subjects were administered all three forms yielding an average composite score inter-test correlation of .91 (range .81-.95). History items did not fare quite so well, yielding a mean kappa of .75 (.46-1.0) and mean inter-test correlation of .77 (.14-1.0). Administration times were similar for the clinical interview and internet versions, with the automated voice version taking 25% less time but also reflecting the lowest level of participant satisfaction. Brodey, B.B., Rosen, C.S., Brodey, I.S., Sheetz, B.M., Steinfeld, R.R., and Gastfriend, D.R. Validation of the Addiction Severity Index (ASI) for Internet and Automated Telephone Self-Report Administration. Journal of Substance Abuse Treatment, 26, pp. 253-259, 2004.

Estimating Episode Lengths When Some Observations are Probably Censored

This paper analyzed a case in censored failure time data problems where some observations are potentially censored. The traditional models for failure time data implicitly assume that the censoring status for each observation is deterministic. Therefore, they cannot be applied directly to the potentially censored data. The researchers propose an estimator that uses resampling techniques to approximate censoring probabilities for individual observations. A Monte Carlo simulation study shows that the proposed estimator properly corrects biases that would otherwise be present had it been assumed that either all potentially censored observations are censored or that no censoring has occurred. Finally, the researchers apply the estimator to a health insurance claims database. The resulting estimates indicate that just as ignoring the censoring problem provides estimated medians that are too low, assuming all of the potentially censored observations are censored leads to medians that are too high. The method proposed to address the probable censoring can effectively correct the biases and provide appropriate estimates of medians. From a health-care system perspective, where episode length is related to utilization and costs, this finding is most important for planning and resource allocation as it helps predict individuals' experience in the system. Goodman, A.C., Peng, Y., Hankin, J.R., Kalist, D.E. and Spurr, S.J. Estimating Episode Lengths when Some Observations are Probably Censored. Statistics in Medicine, 23, pp. 2071—2087, 2004.

Burden of Medical Illness in Drug- and Alcohol-dependent Persons Without Primary Care

Little is known about the frequency, severity, and risk factors for disease in drug- and alcohol-dependent persons without primary medical care. The aim is to assess the burden of medical illness, identify patient and substance dependence characteristics associated with worse physical health, and compare measures of illness burden in this population. This was accomplished through a cross-sectional study among alcohol-, heroin- or cocaine-dependent persons without primary medical care who were admitted to an urban inpatient detoxification unit. The mean age of these patients was 35.7 (SD 7.8) years: 76% were male and 46% were Black. Forty-five percent reported being diagnosed with a chronic illness, and 80% had prior medical hospitalizations. The mean age-adjusted SF-36 Physical Component Summary (PCS) score was lower than the general U.S. population norm (44.1 vs 50.1; p<0.001). In multivariable analysis, female gender (adjusted mean change in PCS score: _3.71 points, p=.002), problem use of hallucinogens (_3.51, p=0.013), heroin (_2.94, p=0.008), other opiates (_3.20, p=.045), living alone (_3.15, p=.023), having medical insurance (_2.26, p=0.014) and older age (_.22 points per year, p=0.001) were associated with worse health. From these data, it seems that alcohol- and drug-dependent persons without primary medical care have a substantial burden of medical illness compared to age- and gender-matched U.S. population controls. While the optimal measure of medical illness burden in this population is unclear, a variety of health measures document this medical illness burden in addicted persons. De Alba, I., Samet, J.H. and Saitz, R. Burden of Medical Illness in Drug- and Alcohol-dependent Persons without Primary Care. Am J Addict, 13, pp. 33-45, 2004.


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