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

Research Findings - Services Research

Organizational Factors Influence Adoption of Naltrexone

Three surveys of outpatient substance abuse treatment centers in Connecticut, Massachusetts, Rhode Island, Maine, Vermont, and New Hampshire were conducted in 1997 (N-281), 1999 (N=235), and 2001 (N=246) to examine organizational characteristics that influenced the adoption of naltrexone. Structural equation modeling with manifest variables was used to assess predictors related to the use of naltrexone. Use of naltrexone increased over time from 14% in 1997 to 25% in 2001. In 1997, programs funded by managed care were more likely, and clinics that provided only substance abuse services were less likely to use psychiatric medication and naltrexone. In subsequent years, counselor education level and organization size also was associated with increased use of naltrexone. Fuller, B.E., Rieckmann, T, McCarty, D., Smith, K.W. and Levine, H. Adoption of Naltrexone to Treat Alcohol Dependence. Journal of Substance Abuse Treatment, 28, pp. 273- 280, 2005.

Emergency Departments Offer Opportunities to Identify Cocaine Abusers and Enroll Them in Treatment

This study examined 145 patients with cocaine-associated chest pain, aged 18-60 years, with low to moderate risk for acute coronary syndrome who were screened (urinalysis and/or self-report) from among 1,343 chest-pain patients presenting for emergency department (ED) treatment who agreed to be screened for cocaine (94% response rate). Responses on standardized and validated instruments were used to examine demographic and clinical characteristics. Half of the cocaine using patients met criteria for substance abuse or dependence in the past three months, primarily cocaine or alcohol dependence; on the other hand, a substantial proportion surprisingly did not meet abuse or dependence criteria and reported infrequent cocaine use. Approximately one-half of the entire chest-pain sample reported substantial symptoms of depression. Substance use frequency and consequences, depression, and psychological distress were significantly more severe among those with past three-month substance use diagnoses; however, most socio-demographic characteristics were not associated with substance use diagnoses. Findings regarding diversity in alcohol and drug involvement, current level of psychological functioning, depressive symptomatology, and interest in treatment services provide useful information for designing ED-based interventions for this population. Because cocaine-related chest-pain was shown to be manifest among patients with no history of frequent substance abuse, ER staff should consider discussing alcohol and cocaine usage with all chest-pain patients, and discourage cocaine use when mentioned. For those presenting a history of cocaine use, patients should be provided on-the-spot counseling and referral for substance abuse treatment, as their brush with myocardial infarction appears to increase in motivation to be treated. Booth, B.M., Weber, J.E., Walton, M.A., Cunningham, R.M., Massey, L., Thrush, C.R. and Maio, R.F. Characteristics of Cocaine Users Presenting to an Emergency Department Chest Pain Observation Unit. Academic Emergency Medicine, 12(4), pp. 329-37, 2005.

Modified Work-Release Therapeutic Community is Superior to Standard Work-Release

This study examined the effects of 6-month work-release transitional therapeutic community treatment on the drug use and employment rates of 945 prisoners in the Delaware corrections system. Participants were followed for up to 5 years after release. A comparison group (N=374) received standard 6-month work-release supervision. Abstinence rates were 32.2% in the treatment group and 9.9% in the no-treatment group, and the treatment group had a higher overall proportion of time free of drug use. Time-to-relapse was a mean of 28.8 months in the treatment group versus 13.2 months in the no-treatment group. Relapse was defined as any use of any drug and was confirmed by urinalysis. Positive effects were seen even for those who did not complete treatment. The treatment group had a significantly higher rate of employment after leaving work release (54.6%) than did the no-treatment group (45.4%). Treatment during the transitional period between prison and community showed substantial and persistent benefits even for a cohort marked with extensive criminal history, low rates of marital bonds, and substantial unemployment. Butzin, C.A., Martin, S.S. and Inciardi, J.A. Treatment During Transition From Prison to Community and Subsequent Illicit Drug Use. Journal of Substance Abuse Treatment, 28, pp. 351- 358, 2005.

Perceived Deterrence Related to Drug Court Outcomes

This study examined individuals' expectations that they would be rewarded or sanctioned appropriately for their participation in drug court, and the impact this expectation had on outcomes including reduction in drug use and criminal recidivism. Perceived-deterrence theory provides the conceptual framework for this study and posits that, the likelihood an offender will engage in drug use or illegal activity is influenced by the perceived certainty of being detected for infractions or recognized for accomplishments, the perceived certainty of receiving sanctions for infractions or rewards for accomplishments, and the anticipated magnitude of the sanctions and rewards. Perceived deterrence of 225 offenders participating in three different drug courts was examined. Exploratory cluster analysis on longitudinal perceived deterrence scores yielded five subtypes of drug offenders characterized either by consistently elevated perceived-deterrence scores, consistently moderate scores, consistently low scores, increasing scores, or decreasing scores. The best outcomes were associated with consistently elevated scores, whereas the worst outcomes were associated with scores that declined over time as the participants became accustomed to the drug court program. The correlational design does not permit inferences of causality; however, the results lend credence to perceived deterrence as a potential explanatory mechanism for the effects of drug courts. Marlowe, D.B., Festinger, D.S., Lee, P.A. and Patapis, N.S. Perceived Deterrence and Outcomes in Drug Court. Behavioral Sciences and the Law, 23(2), pp. 183-198, 2005.

Need-Based Syringe Dispensation May Reduce Syringe Reuse

Numerous papers about the effectiveness of syringe exchange programs (SEPs) have been published, but only a few identify operational characteristics of the SEPs they study or assess which of those characteristics are associated with optimal HIV risk reduction among clients. The objective of this study was to examine whether different syringe dispensation policies were associated with client-level injection-related HIV risk. Injection drug users (IDUs) were recruited at 23 SEPs in California in 2001 (n = 531). SEPs were classified by their executive directors as to whether they provided a strict one-for-one syringe exchange, gave a few extra syringes above the one-for-one exchange, or distributed the amount of syringes based upon need as opposed to how many syringes were turned in by the clients. Injection-related risk was compared by SEP program type. In multivariate logistic regression analysis, clients of distribution-based programs had lower odds of reusing syringes (adjusted odds ratio = 0.43; 95% CI = 0.27, 0.71) when adjusting for confounding variables. There were no statistical differences with regards to distributive or receptive syringe sharing by dispensation policy. It is concluded that SEPs that base syringe dispensation policy upon need may facilitate reductions in reuse of syringes. Kral, A.H., Anderson, R., Flynn, N.M. and Bluthenthal, R.N. Injection Risk Behaviors Among Clients of Syringe Exchange Programs With Different Syringe Dispensation Policies. Journal of Acquired Immune Deficiency Syndrome, 37(2), pp. 1307-1312, 2004.

Chemically Dependent Youth Benefit from Psychiatric Services

Many adolescents with alcohol and drug problems have mental health co-morbidities. The literature suggests that patients entering chemical dependency (CD) treatment with co-occurring problems have less successful outcomes, including treatment dropout and relapse. Researchers examine the impact of psychiatric services on treatment initiation, retention, and alcohol and drug abstinence outcomes for adolescents in CD treatment. Participants were 419 adolescents aged 12-18 years who were seeking treatment at four CD programs of a nonprofit, managed care, group model health system. A parent or guardian for each adolescent also participated. Participants were surveyed at intake and at 6 months and the researchers were exposed to clinical and administrative data pertaining to their diagnoses for CD and psychiatric utilization. Six-month response rates were 91% for adolescents and 93% for parents. Fifty-five percent of the patients with treatment intakes had at least one psychiatric diagnosis in addition to a substance use disorder. Compared with matched controls, patients with CD intakes had higher rates of depression, anxiety, eating disorders, attention deficit hyperactivity disorder, conduct disorder, and conduct disorder including oppositional defiant disorder. Thirty-one percent of the full sample had psychiatric visits in the 6 months after intake; among those with a psychiatric diagnosis, 54% had a psychiatric visit. Girls and those with higher Youth Self-Report internalizing scores were more likely to have a psychiatric visit (OR = 2.27, p < 0.001 and OR = 1.05, p < 0.0001, respectively). Adolescents receiving psychiatric services were more likely to be abstinent from both alcohol and drugs than those not receiving these services (OR = 1.57, 95% CI = 0.98-2.5) and more likely to be alcohol abstinent (OR = 1.68, 95% CI = 1.00-2.85). Those adolescents at co-located clinics had higher odds of abstinence from both alcohol and drugs (OR = 1.57, 95% CI = 1.03-2.39) and drugs (OR = 1.84, 95% CI = 1.87-2.85) and of returning after intake to initiate CD treatment (OR = 2.28, 95% CI = 1.44-3.61, p < 0.001) than others. The results demonstrate the need for psychiatric treatment of adolescents in CD treatment and highlight the importance of their receiving such services. Sterling, S. and Weisner, C. Chemical Dependency and Psychiatric Services for Adolescents in Private Managed Care: Implications for Outcomes. Alcoholism: Clinical and Experimental Research, 25(5), pp. 801-809, 2005.

Effectiveness of Post-Discharge Monitoring in Sustaining Addiction Recovery

Using data from quarterly interviews conducted over a 2-year period in which 448 post-discharge recovering addicts were randomly assigned to either an assessment only condition or to a Recovery Management Checkup (RMC) condition, investigators looked at the frequency, type, and predictors of transitions between points in the relapse, treatment reentry, and recovery cycle. The results indicated that about one-third of the participants transitioned from one point in the cycle to another each quarter; 82% transitioned at least once, 62% multiple times. People assigned to RMC were significantly more likely to return to treatment sooner and receive more treatment. The probability of transitioning to recovery was related to drug use severity, problem orientation, desire for help, self-efficacy, self-help involvement, and recovery environment at the beginning of the quarter and the amount of treatment received during the quarter. These findings support the conceptualization of addiction as a chronic condition and demonstrate the need for and effectiveness of post-discharge monitoring and checkups. The methods in this study also provide a simple but replicable method for learning more about the multiple pathways that individuals travel along before achieving a prolonged state of recovery. Scott, C.K., Dennis, M.L. and Foss, M.A. Utilizing Recovery Management Checkups to Shorten the Cycle of Relapse, Treatment Reentry, and Recovery. Drug & Alcohol Dependence, 78(3), pp. 325-338, 2005.

Discussion Groups Facilitate Recruitment into Treatment for MSMs

Drug-using men who have sex with men (MSM) are at high risk of acquiring or transmitting HIV infection. Efforts to change behaviors in this population have been hampered by difficulties in recruiting drug-using MSM into behavioral interventions. This study sought to develop an effective strategy for recruiting drug-using MSM into behavioral interventions that consist of motivational interviewing alone or motivational interviewing plus contingency management. MSM were recruited through advertising and community outreach into groups to discuss party drugs, party burnout, and sexual behavior, with the intervention subsequently described and enrollment offered in the group setting. Many more eligible MSM responded to advertisements for the discussion groups than advertisements for the interventions, and 58% of those who participated in the discussion groups volunteered for counseling. Men who entered counseling reported high levels of drug use and sexual activity and were racially and ethnically diverse. Only 35% were willing to accept drug treatment. Results demonstrate that a two-stage strategy in which drug-using MSM are first recruited into discussion groups before they are offered a behavioral intervention can be an effective way to induce voluntary acceptance of an intervention employing a behavioral risk-reduction approach. Kanouse, D.E., Bluthenthal, R.N., Bogart, L., Iguchi, M.Y., Perry, S., Sand, K. and Shoptaw, S. Recruiting Drug-using Men Who Have Sex With Men into Behavioral Interventions: A Two-Stage Approach. Journal of Urban Health, 82 (1 Suppl 1), pp. i109-i119, 2005; Epub 2005.

Cash Benefits Associated with Lower Risk Behavior Among Homeless and Marginally Housed

To address the widespread debate about the role of public assistance to the urban poor, this study identified characteristics of individuals receiving cash assistance and explored the link between cash subsidies and risk behavior. From 1999 to 2000, a representative sample of homeless and marginally housed (HMH) adults living in San Francisco was recruited and interviewed about subsidies, shelter, jail, and drug use. Among 1,156 adults, 87% were ever homeless, 22% currently injected drugs, and 14% were HIV positive. Sixty percent of participants reported that most of their income came from subsidies [mostly subsidized (MS)]. The MS had lower odds of receiving any income from selling drugs or trading sex. Adjusting for HIV infection, the MS had higher odds of sleeping in a hotel [odds ratio (OR) =_2.39] or shelter (OR =_1.61) compared to the street. The MS had lower odds of injection drug use (OR =_0.69) and recent incarceration (OR=_O.77). Among San Francisco's homeless, being MS was positively associated with having shelter and negatively associated with injection drug use and incarceration. These data suggest that government subsidies are associated with positive health behaviors among the urban poor. Riley, E.D., Moss, A.R., Clark, R.A., Monk, M.L. and Bangsberg, D.R. Cash Benefits are Associated with Lower Risk Behavior Among the Homeless and Marginally Housed in San Francisco. Journal of Urban Health, 82(1), pp. 142-150, 2005.

Brief Motivational Intervention May Facilitate Abstinence From Heroin and Cocaine

Brief intervention is effective for alcohol misuse, but not adequately tested in the clinical setting with drug using patients. This study tested the impact of a single, structured encounter targeting cessation of drug use, conducted by peer educators with out-of-treatment cocaine and heroin users screened in the context of a routine medical visit. A randomized, controlled trial was conducted in inner-city teaching hospital outpatient clinics with 3- and 6-month follow-up by blinded observers. Drug abstinence was documented by hair testing. Analysis was limited to enrollees with drug-positive hair at baseline. Among 23,669 patients screened from May 1998 to November 2000, 1,232 (5%) were eligible, and 1,175 enrolled. Enrollees (mean age 38 years) were 29% female, 62% were non-Hispanic Black, 23% were Hispanic, and 46% were homeless. Among those with positive hair test at entry, the follow-up rate was 82%. The intervention group was more likely to be abstinent than the control group for cocaine alone (22.3% vs. 16.9%), heroin alone (40.2% vs. 30.6%), and both drugs (17.4% vs. 12.8%), with adjusted OR of 1.51-1.57. Cocaine levels in hair were reduced by 29% for the intervention group and only 4% for the control group. Reductions in opiate levels were similar (29% vs. 25%). The authors conclude that brief motivational intervention may help patients achieve abstinence from heroin and cocaine. Bernstein, J., Bernstein, E., Tassiopoulos, K., Heeren, T., Levenson, S. and Hingson, R. Brief Motivational Intervention at a Clinic Visit Reduces Cocaine and Heroin Use. Drug and Alcohol Dependence, 77, pp. 49-59, 2005.

Low-cost Contingent Rewards Effective in Reducing Cocaine Use By Methadone Clients

Both behavioral (low-cost contingency rewards) and cognitive (relapse prevention counseling) interventions have shown promise in helping engage opiate-dependent clients in treatment. In this study, researchers examined the effectiveness of combining contingent rewards with a cocaine-specific relapse prevention counseling module. Sixty-one cocaine-using methadone clients (60% male, 74% Hispanic/20% Caucasian) were randomly assigned to one of four treatment conditions to participate in the eight-week intervention and eight-week follow-up period. Conditions included specialized counseling on cocaine abuse (COCA) with or without contingent rewards (stars for clean urines, attending sessions, etc. redeemable for prizes valued to $25); methadone treatment as usual with or without contingent rewards. Using analysis of variance (ANOVA), differences in cocaine use and treatment retention were examined. Both contingent reward conditions were significantly related to reductions in cocaine use during and upon completion of treatment. The COCA intervention also showed substantial reductions in use even without rewards when compared to the no-COCA/no-Reward group. Moreover, the COCA counseling module was positively related to six-month retention rates regardless of reward contingency. Though results support the value of low-cost contingent rewards for changing the behavior of methadone clients. Though encouraging, the power for this study was limited. Rowan-Szal, G.A., Bartholomew, N.G., Chatham, L.R. and Simpson, D.D. A Combined Cognitive and Behavioral Intervention for Cocaine-Using Methadone Clients. Journal of Psychoactive Drugs, 37(1) pp. 75-84, 2005.

Compromises to Cultural/Ethical Issues and Maintenance of Research Integrity

A study of American Indian youth illustrates competing pressures between research and ethics. A stakeholder/researcher team developed three plans to protect subjects. The first allowed youths to skip potentially upsetting interview sections. The second called for those flagged for abuse or suicidality to receive referrals, emergency 24-hour clinical backup, or both. The third, based on the community's desire to promote service access, included giving youths a list of service resources. Interviewers gave referrals to those flagged as having mild problems, and reported ones with serious problems to supervisors for clinical backup. The youths seldom chose to skip sections, so data integrity was not compromised. They did have more problems than expected (e.g., one in three had thought about suicide, one in five had attempted, and one in four reported abuse), so service agencies were not equipped to respond. Researchers must accept the competing pressures and find ethically appropriate compromises that will not undermine research integrity. Stiffman, A.R., Striley, C.W., Brown, E., Limb, G. and Ostmann, E. Cultural and Ethical Issues Concerning Research on American Indian Youth. Ethics and Behavior, 15(1), pp. 1-14, 2005.

High Lifetime Benefit-Cost Ratio For Chronic Disease Model of Drug Abuse Treatment

Several studies have examined the benefits and costs of drug treatment; however, they have typically focused on the benefits and costs of a single treatment episode. Although beneficial for certain analyses, the results are limited because they implicitly treat drug abuse as an acute problem that can be treated in one episode. Researchers developed a Monte Carlo simulation model that incorporates the chronic nature of drug abuse. The model represents the progression of individuals from the general population aged 18-60 with respect to their heroin use, treatment for heroin use, criminal behavior, employment, and health care use. Three model scenarios are presented for an increase in the probability of going to treatment, an increase in the treatment length of stay, and a scenario in which drug treatment is not available so that the impact on results may be examined. The benefit-cost ratio of treatment from the chronic disease model (37.72) exceeds the benefit-cost ratio from the acute care model (4.86). The chronic care model characterizes the dynamics of heroin use and captures the notion of heroin use as a chronic recurring condition. Similar models can be developed for other chronic diseases, such as diabetes, mental illness, or cardiovascular disease. Zarkin, G.A., Dunlap, L.J., Hicks, K.A. and Mamo, D. Benefits and Cost Of Methadone Treatment: Results From A Lifetime Simulation Model. Health Economics. Published on line May 5, 2005.

Family Drug Court has Higher Engagement and Completion Rates than Other Court Assisted Treatment Services

A geographical comparison-group design was used to examine the effectiveness of the Pima County (Arizona) Court Assisted Treatment Services (CATS) program and its drug court intervention. The study compared summary statistics for the volunteers to family drug court (n=33) with a treatment-refusal group (n=42) and a treatment-as-usual group (n=45) from a matched geographical area. The family drug court group had higher engagement and completion rates of residential treatment than the comparison groups. In addition, the family drug court group had fewer parental rights severed, a higher percentage of permanency decisions reached within one year, earlier permanency decisions, and a higher percentage of children placed with their parents. The results suggest that further study of family court as a treatment of choice is warranted. Ashford, Josˇ B., Treating Substance-abusing Parents: A Study of the Pima County Family Drug Court Approach, Juvenile and Family Court Journal, Fall. pp. 27-33, 2004.

Drug Treatment Services as Providers of Hepatitis C Virus Treatment

(HCV) is the most prevalent blood-borne infectious disease in the U.S., especially among drug users, and co-infection with HIV is common. Because drug users are often medically underserved, drug treatment units are important sites of opportunity for providing services for these infectious diseases. Given the commonalities in the routes of transmission of HIV and HCV, and the fact that many drug treatment units have established an infrastructure to provide HIV services, some have suggested integrating HCV services into those already established for HIV. Using data collected in a telephone survey with 89 drug treatment units throughout the U.S., the researchers examined the extent to which drug treatment units have expanded their HIV services to include those for HCV, and the extent to which this expansion was facilitated by having HIV services in place. Overall, a greater proportion of methadone maintenance than drug-free treatment units provided services for HIV and HCV. The majority of units in both modalities that provided HIV and HCV-related services expanded their HIV service delivery to include similar HCV services, and one third expanded all of their HIV services. A large number with an HIV service infrastructure, however, did not facilitate this expansion, often because the units wanted to emphasize differences in the two viral infections. Policy makers and individual treatment units need to develop strategies that capitalize on existing infrastructures while maintaining the distinction between HIV and HCV primary and secondary prevention efforts. Strauss, S.M., Astone, J.M., DesJarlais, D.C. and Hagan, H. Integrating Hepatitis C Services Into Existing HIV Services: The Experiences of a Sample of U.S. Drug Treatment Units, AIDS Patient Care STDS, 19(2), pp. 78-88, 2005.

Interagency Collaboration in Developing Opioid Agonist Programs for Inmates

This paper briefly reviews the empirical literature and describes the development of a unique inter-agency collaboration between community treatment providers, researchers, and the criminal justice system to implement treatment and research on opioid agonist treatment for inmates leaving prison and returning to their community. The authors clearly articulate the problem of inadequate treatment and relapse to drug use for individuals with heroin addiction prior to incarceration. They suggest prisons provide an opportunity to engage individuals with heroin addiction histories in treatment, including opioid agonist programs. They describe the steps necessary for the development of an opioid agonist program within a prison setting followed by on-going treatment in the community. In addition, they detail logistical issues related to conducting research in a prison-based setting and offer recommendations for developing and implementing opioid agonist programs in other prison-based settings and conducting research. Kinlock, T.W., Schwartz, R.P. and Gordon, M.S. The Significance of Interagency Collaboration in Developing Opioid Agonist Programs for Inmates. Corrections Compendium, pp. 6-30.

Juvenile Offenders at Increased Risk for HIV Infection

The purpose of this study was to examine the prevalence, multiple correlates, and gender differences in chlamydia and gonorrhea infections among adolescents incarcerated in a youth detention center in the southern region of the United States. STD screening was conducted on 1816 youth, ages 10-18, as they entered the facility. Rates of undiagnosed chlamydia were 24.7% for incarcerated girls and 8.1% for boys. Gonorrhea was detected in 7.3% of the girls and 1.5% of the boys. Only youth 13 years or older were asked to complete a survey: 763 assented to participate, and 690 gave permission to link their STD test results to their survey responses. The majority of the juveniles who participated in the study were African American (89%) and male (67%). Predictors of STD positivity differed for boys and girls. Demographic characteristics (gender, race, and age) account for 52% of the total variance in STD infections; youths' behavior (alcohol use, sex under the influence of alcohol, history of STD and sexual risk reduction strategy) accounts for about one-third of the total variance, psychological (sexual abuse, alcohol and drug expectancies) and family variables (family structure/living arrangements, supervision and monitoring, parental involvement, family communication) account for 8.6% (boys) and 7.2% (girls) of the total variance. An approach that considers psychological and social influences on adolescent sexual behavior is useful for identifying potential risk and protective factors of adolescent STD/HIV risk that are amenable to intervention. Robertson, A.A., Baird-Thomas, C., St. Lawrence, J.S. and Pack, R. Predictors of Infection with Chlamydia or Gonorrhea in Incarcerated Adolescents. Sexually Transmitted Diseases, 32(2), pp. 115-122, 2005.

Managed Care Delivers Outpatient Treatment for Adolescent Substance Abuse

This study assessed the impact of managed care on publicly funded adolescent substance abuse treatment by comparing differences in service utilization and outcomes across prospective samples from two states: Oregon, which uses managed care practices in service financing and delivery, and Washington, which does not. One hundred and six adolescents from Washington and 94 from Oregon, who entered outpatient substance abuse treatment in 1998 and 1999, completed self-report surveys about their substance use before and after receiving treatment (follow-up rate = 75 percent). In addition, clinical chart reviews conducted at the 6-month follow-up assessed the type and amount of treatment these adolescents received during the study period. Results showed that service utilization and treatment outcomes were comparable across the two state samples, suggesting that managed care is capable of delivering substance abuse treatment services of comparable quality to state-administered substance abuse treatment services. Carlson, M.J., Gabriel, R.M., Deck, D.D., Laws, K.E. and D'Ambrosio, R. The Impact Of Treatment: Service Use And Six-Month Outcomes In Oregon and Washington. Medical Care Research Review, 62(3), pp. 320-38, 2005.

Legal Pressure Negatively Affects Methamphetamine Treatment Outcomes

With the increase in the prevalence of methamphetamine (MA) use and the associated social costs (such as crime and child abuse and neglect), a growing number of MA users are mandated to substance abuse treatment via the criminal justice system (CJS) and/or child protective service (CPS) agencies. Empirical evidence remains sparse about treatment outcomes, specifically for MA users who report that their treatment admission occurred under such pressures. This analysis uses natural history interview data from 350 clients treated for MA use in Los Angeles County to examine clients' self-reported CJS/CPS pressure to enter treatment, comparing background and treatment characteristics and selected treatment outcomes across groups defined by existence of such perceived pressure and source of pressure. Approximately half the clients reported legal pressure to enter the index (used for sampling) treatment episode. Those reporting pressure were younger, less likely to have received residential treatment, and had longer treatment episodes than those not reporting pressure. Outcomes (treatment completion, relapse within 6 months, time to relapse, and percentage of days with MA use in 24 months following treatment) did not differ significantly in simple comparisons between the pressured and nonpressured groups; however, when client and treatment characteristics were controlled, the short term outcome of relapse within 6 months was worse for those reporting legal pressure. Outcomes did not differ by source of pressure. Brecht, M. L., Anglin, M. D. and Dylan, M. Coerced Treatment for Methamphetamine Abuse: Differential Patient Characteristics and Outcomes. American Journal of Drug and Alcohol Abuse, 31, pp. 337-356, 2005.

Role of Dental Professionals and Tobacco Treatment

This review article discusses tobacco use and dependence, effective treatments, and the role of the dental professional. Tobacco dependence is discussed as a chronic condition characterized by a vulnerability to relapse that persists for years. The need for ongoing rather than acute care is highlighted. Effective treatments for tobacco exist, and a brief clinical intervention can make a difference. Dental professionals are favorably positioned to encourage tobacco cessation treatments since more than 50 percent of smokers see a dentist during the year. It is recommended that every dental patient who uses tobacco be offered at least one of the effective treatments available. In so doing, dental professionals can play an important role in primary prevention of adverse health effects and can have an important public health impact by helping to counter tobacco use. Walsh, M.M. and Ellison, J.A. Treatment of Tobacco Use and Dependence: The Role of the Dental Professional. Journal of Dental Education, 69(5), pp. 522-537, 2005.

Medical Outreach Improves Regular Use of Medical Care Among Unstably-Housed HIV-Infected Individuals

One hundred sixty-one cross-sectional interviews were conducted prior to and after establishing a medical outreach program in single room occupancy hotels. Participants' mean age was 42 years; 58% were men, 95% minority, and 59% active substance users. The postintervention group was more likely to have a regular health care provider (p = 0.02), and to take Pneumocystis carinii pneumonia prophylaxis (p = 0.03) and antiretroviral medication (p = 0.02) than the pre-intervention group. Quality of care was more positively perceived in the postintervention group (p = 0.001). On multivariate analysis, the postintervention group remained more likely to have a regular provider (OR = 5.3, p = 0.02), take antiretroviral medication (OR = 5.7, p = 0.02), and have a better perception of quality of care (OR = 4.9, p = 0.003). A medical outreach program targeting unstably housed HIV-infected individuals was associated with increased use of regular medical care and improved perceived quality of care. Cunningham, C.O., Shapiro, S., Berg, K.M., Sacajiu G. and Paccione J. An Evaluation of a Medical Outreach Program Targeting Unstably Housed HIV Infected Individuals. Journal of Health Care for the Poor and Underserved, 16, pp. 127-138, 2005.

Treatment for HCV-Infected Patients Complicated by Substance Abuse and Psychiatric Comorbidity

Despite the high prevalence of hepatitis C virus (HCV) infection among drug users enrolled in methadone maintenance treatment programs, few drug users are being treated with combination therapy. Researchers developed a pilot program to integrate care for HCV infection with substance abuse treatment in a setting of maintenance treatment with methadone. This on-site, multidisciplinary model of care includes comprehensive screening and treatment for HCV infection, assessment of eligibility, counseling with regard to substance abuse, psychiatric services, HCV support groups, directly observed therapy, and enhanced linkages to a tertiary care system for diagnostic procedures. This approach has led to high levels of adherence with liver biopsy, and substantial rates of initiation of antiviral therapy. Two cases illustrate the successful application of this model to patients with HCV infection complicated by active substance abuse and psychiatric comorbidity. Litwin, A.H., Soloway, I. and Gourevitch, M.N. Integrating Hepatitis C Services with Methadone Maintenance Treatment: Challenges and Opportunities. Clinical Infectious Diseases, 40, pp. 339-345 2005.

Medical Service Use among Patients with HIV and Substance Abuse Disorders

HIV-infected persons with a substance abuse disorder enrolled in a randomized trial of a case management intervention (N=190) were interviewed about their backgrounds, housing status, income, alcohol and drug use problems, health status and depressive symptoms at study entry. Electronic medical records were used to assess medical service use. During a two-year period, 71% were treated in the emergency department, 64% had been hospitalized and the sample averaged 12.9 ambulatory care visits. Homelessness was associated with high utilization of emergency department and inpatient services; drug use severity was associated with higher inpatient and ambulatory care service use; and alcohol use severity was associated with greater use of emergency medical services. Homelessness and substance abuse exacerbate the health care needs of HIV-infected persons and result in increased use of emergency department and inpatient services. Interventions are needed that target HIV-infected persons with substance abuse disorders particularly those that increase entry and retention in outpatient health care and thus decrease reliance on acute hospital-based services. Masson, C.L., Sorensen, J.L., Phibbs, C.S. and Okin, R.L. Predictors of Medical Service Utilization Among Individuals with Co-occurring HIV Infection and Substance Abuse Disorders. AIDS Care, 16(6), pp. 744-755, 2004.

Case Management for Substance Abusers with HIV/AIDS: Lessons from a Clinical Trial

The many problems experienced by substance abusers with HIV/AIDS have prompted development and testing of new models of service delivery. This study tested the efficacy of case management with HIV-infected substance abusers (70% male, 52% heterosexual, 42% Caucasian, 43% African American) in a general hospital setting. Ninety-two subjects were randomly assigned to treatment as usual -- hospital-based brief contact with referrals for intervention as requested; while 98 subjects were assigned to weekly case management which included both hospital-based and community visits. Regardless of SA treatment length, the duration for both conditions was 12 months. The study found negative results. The results demonstrate the need for caution in interpreting positive reports from demonstration projects that do not have a comparison condition. Taking into account the results of this study, clinicians may want to be cautious about undertaking case management with this population unless they are clearly focused on achievable outcomes and engage in this effort being fully aware of both the power of case management intervention and its limitations. Sorensen, J.L. and Masson, C.L. Case Management for Substance Abusers with HIV/AIDS: Lessons from a Clinical Trial. Directions in Rehabilitation Counseling, 15, pp. 193-201, 2004.

Unmet Adult Need For Substance Abuse Treatment

This study presents a method for estimating the size and cost of eliminating unmet need for substance abuse treatment services among adults who have clinically significant substance use disorders, and applies the approach to Massachusetts' information. Unmet treatment needs were derived using a statewide household telephone survey of 7,251 Massachusetts residents aged 19 and older conducted in 1996-1997, and an index of treatment mix and cost information from state and Medicaid financial data. The study estimates that 39,450 adult state residents (0.81% of the total sample) had a clinically significant past-year untreated substance use disorder. Providing substance abuse treatment and outreach services to them would have required an additional cost of approximately 109 million dollars (17 dollars per capita), of which the state's payer of last resort, the Massachusetts Department of Public Health Bureau of Substance Abuse Services (BSAS), would need to fund 31 million dollars (5 dollars per capita). The share paid by BSAS (28%) would represent an increase of 42% over its current spending. This paper quantifies an important but sometimes overlooked objective of managed care: to improve access for substance abusers who need but do not seek treatment. Shepard, D.S., Strickler, G.K., McAuliffe, W.E., Beaston-Blaakman, A., Rahman, M. and Anderson, T.E. Unmet Need For Substance Abuse Treatment Of Adults In Massachusetts. Administrative Policy in Mental Health. 32(4), pp. 403-26, 2005.

Reconsidering Evaluation of Addiction Treatment

Historically, addiction treatments have been delivered and evaluated under an acute-care format. Fixed amounts or durations of treatment have been provided and their effects evaluated 6-12 months after completion of care. The explicit expectation of treatment has been enduring reductions in substance use, improved personal health and social function, generally referred to as 'recovery'. In contrast, treatments for chronic illnesses such as diabetes, hypertension and asthma have been provided for indeterminate periods and their effects evaluated during the course of those treatments. Here the expectations are for most of the same results, but only during the course of continuing care and monitoring. The many similarities between addiction and mainstream chronic illnesses stand in contrast to the differences in the ways addiction is conceptualized, treated and evaluated. This paper builds upon established methods of during-treatment evaluation developed for the treatment of other chronic illnesses and suggests a parallel evaluation system for out-patient, continuing-care forms of addiction treatment. The suggested system retains traditional patient-level, behavioral outcome measures of recovery, but suggests that these outcomes should be collected and reported immediately and regularly by clinicians at the beginning of addiction treatment sessions, as a way of evaluating recovery progress and making decisions about continuing care. The researchers refer to this paradigm as 'concurrent recovery monitoring' and discuss its potential for producing more timely, efficient, clinically relevant and accountable evaluations. McLellan, A.T., McKay, J.R., Forman, R., Cacciola, J. and Kemp, J. Reconsidering the Evaluation of Addiction Treatment: From Retrospective Follow-up to Concurrent Recovery Monitoring. Addiction, 100(4), pp. 447-458, 2005.

Language Preference Effect on Program Effectiveness

This study examines whether language preference, as an indicator of acculturation, moderates the effects of a culturally-grounded substance use prevention intervention for Mexican and Mexican-American middle school students (N=2,146) in Phoenix, Arizona. The main hypothesis is that levels of program effectiveness would vary based on the language preference of the students and the specific culturally-grounded version of the intervention to which they were assigned. The researchers found that matching language preference to particular versions of the intervention did not influence substance use related program outcomes, but overall program effects (intervention versus control) did vary by language preference. English-language dominant participants, considered the most at-risk sub-group, demonstrated more desirable outcomes if they received the intervention while Spanish dominant and bilingual participants did not demonstrate significant differences between the intervention and control groups. Spanish dominant respondents had low substance use rates at baseline that remained relatively unchanged throughout the experiment. The higher initial use rates of English dominant students increased in the control group while they remained unchanged or decreased among students exposed to any version of the intervention. The program appeared to strengthen existing protective effects of Spanish language use among less acculturated students and decreased or weakened risks associated with higher acculturation among English dominant students. Marsiglia, F.F., Kulis, S., Wagstaff, D.A., Elek, E. and Dran, D. Acculturation Status and Substance Use Prevention With Mexican and Mexican American Youth. Journal of Social Work Practice in the Addictions, 5, 1/2, pp. 85-111, 2005.

Effectiveness of Highly Regarded Adolescent Substance Abuse Treatment Programs

This study conducted the first systematic evaluation of the quality of highly regarded adolescent substance abuse treatment programs in the United States. An advisory panel of 22 experts defined 9 key elements of effective treatment for adolescent substance abuse based on a review of the literature. In-depth telephone and written surveys were conducted with 144 highly regarded adolescent substance abuse treatment programs identified by panel members and by public and private agencies. There was a 100% response rate to the initial interviews, and a 65% response rate to the follow-up surveys. The open-ended survey responses were coded by defining 5 components deemed to be crucial in addressing each of the 9 key elements, and quality scores were calculated overall and for each of the 9 key elements. Out of a possible total score of 45, the mean score was 23.8 and the median was 23. Top-quartile programs were not more likely to be accredited. The majority of programs scored at least 4 of a possible 5 on only 1 of the 9 key elements (qualified staff). The elements with the poorest-quality performance were assessment and treatment matching, engaging and retaining teens in treatment, gender and cultural competence, and treatment outcomes. Most of the highly regarded programs surveyed are not adequately addressing the key elements of effective adolescent substance abuse treatment. Expanded use of standardized assessment instruments, improved ability to engage and retain youths, greater attention to gender and cultural competence, and greater investment in scientific evaluation of treatment outcomes are among the most critical needs. Expanding awareness of effective elements in treating adolescents will lead the way to program improvement. Brannigan, R., Schackman, B.R., Falco, M. and Millman, R.B. The Quality of Highly Regarded Adolescent Substance Abuse Treatment Programs: Results of an In-depth National Survey. Archives of Pediatric Adolescence Medicine, 158, pp. 904-909, 2004.

Infectious Disease-Related Cost-Utility Analysis

The purpose of this review is to understand infectious disease-related cost-utility analyses by describing published analyses, examining growth and quality trends over time, examining factors related to quality, and summarizing standardized results. The review identified 122 cost-utility analyses and 352 cost-utility ratios. Pharmaceutical interventions were most common (47.5%); three author groups accounted for 42.8% of pharmaceutical ratios. High-volume journals (three or more published cost-utility analyses) published higher quality analyses than low-volume journals (p<0.001). Use of probabilistic sensitivity analysis and discounting at 3% were more frequently found in the years after the US Public Health Service Panel on Cost-Effectiveness in Health and Medicine recommendations (p<0.01). Median ratios varied from US$13,500/quality-adjusted life year (QALY) for immunizations to US$810,000/QALY for blood safety. Publication of infectious disease cost-utility analyses is increasing. The results of cost-utility analyses have important implications for the development of clinical guidelines and resource allocation decisions. More trained investigators and better peer-review processes are needed. Stone, P.W., Schackman, B.R., Neukermans, C.P., Olchanski, N., Greenberg, D., Rosen, A.P. and Neumann, P.J. A Synthesis of Cost-Utility Analysis Literature in Infectious Disease. Lancet Infectious Disease, 5, pp. 383-391, 2005.

Syringe Access and HIV Risk Among IDUs

This study compares syringe re-use and receptive syringe sharing among two groups of injection drug users (IDUs). They are: 1) IDUs with legal over-the-counter pharmacy access and limits on syringes that can be purchased, exchanged or possessed, and 2) IDUs without legal over-the-counter pharmacy access, but unlimited access to syringes through Syringe Exchange Programs (SEPs). Three questions are addressed: (1) Does residing in an area with no legal syringe possession increase the likelihood of police contact related to possessing drug paraphernalia? (2) Among direct SEP users, is the use of more permissive SEPs associated with less likelihood of syringe re-use and receptive syringe sharing? (3) Among non-SEP users, is residing in an area with pharmacy access associated with lower likelihood of syringe re-use and receptive syringe sharing? The study utilized a quantitative survey of IDUs recruited from SEPs, subject nomination, and outreach methods. Multivariate analyses compared police contact, syringe re-use and receptive syringe sharing among IDUs recruited in three cities. Findings revealed that police contact was associated independently with residing in the area with no legal possession of syringes. Among SEP users, those with access to SEPs without limits had lower syringe re-use but not lower syringe sharing; and among non-SEP users, no significant differences in injection risk were observed among IDUs with and without pharmacy access to syringes. Greater legal access to syringes, if accompanied by limits on the number of syringes that can be exchanged, purchased and possessed, may not have the intended impacts on injection-related infectious disease risk among IDUs. Bluthenthal, R.N., Malik, M.R., Grau, L.E., Singer, M., Marshall, P. and Heimer, R. Sterile Syringe Access Conditions and Variations in HIV Risk Among Drug Injectors in Three Cities. Addiction, 99(9), pp. 1136-1146, 2004.

Antiretroviral Therapy, Hepatitis C Virus, and AIDS Mortality Among the Homeless and Marginally Housed

Mortality has declined in most HIV-infected populations yet remains high among those with barriers to accessing antiretroviral (ARV) therapy. This study examined predictors of death in a group of HIV-infected homeless persons in San Francisco. Between 1996 and 2002, quarterly interviews and blood draws were conducted. Hazards of death were determined based on the number of months during the previous 6 months that any of the following occurred: any ARV, drug use, hepatitis C virus (HCV) status, and housing status. Among 330 participants, 65% were HCV-seropositive at baseline, 85% received ARV during the study period, and there were 57 deaths (5.3 per 100 person-years). Compared with having none of the prior 6 months on therapy, the risk of death was not significantly reduced for individuals on 1-to-5 months of therapy (hazard ratio [HR] = 0.82, 95% confidence interval [CI]: 0.43-1.57), but the risk of death was reduced 62% for those on ARV therapy for 6 months (HR = 0.38, CI: 0.19-0.76). Housing status and HCV status were not significant predictors of death. HIV is the major cause of death in this population, whereas the impact of HCV infection on death seems to be minimal. Sustained ARV treatment significantly reduces the risk of death among the homeless. Riley, E.D., Bangsberg, D.R., Guzman, R., Perry, S. and Moss, A.R. Antiretroviral Therapy, Hepatitis C Virus, and AIDS Mortality Among San Francisco's Homeless and Marginally Housed. Journal of Acquired Immune Deficiency Syndrome, 38, pp. 191-195, 2005.

Hair Testing and Self-Report of Cocaine Use

This study identified predictors of non-disclosure of cocaine use among individuals who self-reported heroin use during a medical care encounter. The study design was a prospective comparison of self-report of cocaine use among heroin users and hair analysis for cocaine. Participants were patients presenting for a health care visit who were willing to self-report use of heroin and were not engaged in any form of drug treatment. They were selected from four health care clinics at an academic, inner-city hospital. Measures included: 1) Self-report using standardized instruments: the Drug Addiction Severity Test (DAST), the Addiction Severity Index (ASI), and quantity/frequency questions for heroin and cocaine use; 2) biochemical evidence: analysis of hair for cocaine and opiate levels. Among 336 heroin users who tested positive for cocaine in hair, 34.2% did not report their recent cocaine use. The mean cocaine level for discordant individuals was significantly lower than for concordant individuals (109.6 ng/10 mg vs. 470.57 ng/10 mg; p <0.0001). Multivariate predictors of disclosure included opiate and cocaine levels in hair, and the ASI drug severity subscore. Although self-report has been validated for treatment system patients, almost one-third of the out-of-treatment heroin users in this medical clinic study failed to disclose concomitant cocaine use. The likelihood of non-disclosure was greatest for heavy users of heroin and light users of cocaine. Confirmation of self-report with biochemical analysis may be necessary in the medical setting to improve both clinical care and research validity. Tassiopoulos, K., Bernstein, J., Heeren, T., Levenson, S., Hingson, R. and Bernstein, E. Hair Testing and Self-Report of Cocaine Use by Heroin Users. Addiction, 99, pp. 590-597, 2004.

Testable Gateway Provider Model for Youth Service Access

Enhancing the functioning of parents, teachers, juvenile justice authorities, and other health and mental health professionals who direct children and adolescents to services is a major mental health services concern. The Gateway Provider Model is an elaborated testable subset of the Network-Episode Model (NEM; B. A. Pescosolido and C. A. Boyer, 1999) that synthesizes it with Decision (D. H. Gustafson, et al., 1999) and organizational theory (C. Glisson, 2002; C. Glisson and L. James, 1992, 2002). The Gateway Provider Model focuses on central influences that affect youth's access to treatment, i.e., the individual who first identifies a problem and sends a youth to treatment (the "gateway provider"); and the need those individuals have for information on youth problems and relevant potential resources. Preliminary studies by the authors show that providers' perception of need, their knowledge of resources, and their environment are related to the decision to offer or refer to services, supporting key aspects of the Model. Stiffman A.R., Pescosolido B. and Cabassa L. Building a Model to Understand Youth Service Access: The Gateway Provider Model. Mental Health Services Research, 6(4), pp. 189-198, 2004.

Mental Health and Environmental Factors' Association with American Indian Youth Tobacco Use

The present study merged problem behavior and social ecological theories to examine how mental health and environmental factors, including culture, were associated with American Indian youth tobacco use. A stratified random sample of 205 reservation-based and 196 urban-based American Indian adolescents were interviewed in 2001. Two-thirds of the reservation youth and half of the urban youth reported lifetime tobacco use. Logistic regression showed that, when controlling for age and location, a mental health factor (substance abuse/dependence) and environmental factors (e.g., family members' mental health problems and peer misbehavior) were significant predictors of American Indian adolescent tobacco use. Cultural factors and location (reservation vs. urban) were not significant predictors of their tobacco use. Therefore, environmental and mental health factors should be assessed for and incorporated into tobacco use intervention and prevention plans for American Indian youths in both reservation and urban areas. Yu, M., Stiffman, A.R. and Freedenthal, S. Factors Affecting American Indian Adolescent Tobacco Use. Addictive Behaviors, 30(5), pp. 889-904, 2004.

Reconciling Ideal Research Requirements with Fieldwork and Cultural Factors

The realities of doing field research with high risk, minority, or indigenous populations may be quite different than the guidelines presented in research training. There are overlapping and competing demands created by human subjects, cultural, and research imperatives. A NIDA funded study of American Indian youths illustrates competing pressures between research objectives and cultural sensitivity. This account of the problems confronted, solutions, or lack of them, fills a gap in the research literature and serves as thought-provoking examples for other researchers. In this study, cross-cultural bridges were built; the stakeholder/researcher team modified extant instruments and methods to achieve cultural appropriateness, and the researchers agreed to the communities' demands for increased service access and rights of refusal for all publications and presentations. Data indicate that these compromises did not substantially harm the data completeness, well being of the youths or later waves of the longitudinal study. To the contrary, it enhanced the ability to disseminate results to those with the most vested interests. The conflicts between ideal research requirements and cultural demands confronted by the researchers and interviewers in the American Indian community were not necessarily different from issues faced by researchers in other communities. Researchers conclude that there are no easy answers to such issues within research. Stiffman, A.R., Freedenthal S., Brown E., Ostmann E. and Hibbeler P. Addictions Field Research with Underserved Minorities: the Ideal and the Real. Journal of Urban Health, 82(2), Supplement 3, pp. iii56-iii66, 2005.

Methadone Maintenance Treatment Retention Among Street-Recruited Injection Drug Users

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). Targeted sampling methods were used to establish recruitment quotas in Denver census tracks. A total of 577 IDUs were randomly assigned to either a risk reduction intervention, focusing on safer injection and sex behaviors, or to 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 the desire for treatment, or motivation, was associated in univariate analyses with retention, there were no differences observed between the motivational interviewing and risk reduction interventions. Booth, R.E., Corsi, K.F., Mikulich-Gilbertson, S.K. Factors Associated With Methadone Maintenance Treatment Retention Among Street-recruited Injection Drug Users. Drug and Alcohol Dependence, 74, pp. 177-185, 2004.

Quality of Social Support Affects Employment Outcomes

This study examined social support and its association with employment, income, and drug use in a sample of 534 low-income women. Social support was operationalized as two distinct categories. Functional support was defined as the perceived quality of one's interactions with others, considered as either actual or perceived assistance from others. Structural support was defined as the number of individuals within a network as well as the social ties or links within the network. Such networks as social, employment, drug, and emergency are characterized by size and density. Over the two-year study period, significant increases attributable to the quality of these relationships were observed in hours-worked, income from work, income from other sources, and total income. There was also a significant decrease in welfare income. Results suggest that the perceived quality of support received is an important factor in achieving positive employment outcomes. Simply using a quantitative measure of social support was not sufficient in this analysis. For welfare populations a beneficial change in the quality of functional support could lead to improvements in work hours. Brown, V.L. and Riley, M.A. Social Support, Drug Use, and Employment Among Low-Income Women. American Journal of Drug and Alcohol Abuse, 31, pp. 203-223, 2005.


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