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

Research Findings - Epidemiology and Etiology Research

Lifetime Prevalence and Age-of-Onset Distributions' of DSM-IV Disorders in the National Comorbidity Survey Replication

This study estimated lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the recently completed National Comorbidity Survey Replication. This nationally representative face-to-face household survey, conducted between February 2001 and April 2003, used the fully structured World Health Organization World Mental Health Survey version of the Composite International Diagnostic Interview. Participants were 9282 English-speaking respondents aged 18 years and older. Results indicated the following lifetime prevalence estimates: anxiety disorders (28.8%), mood disorders (20.8%), impulse-control disorders (24.8%), substance use disorders (14.6%), and any disorder (46.4%). The median age of onset is much earlier for anxiety (11 years) and impulse-control (11 years) disorders than for substance use (20 years) and mood (30 years) disorders. Half of all lifetime cases start by age 14 years and three-fourths by age 24 years. Later onsets are mostly of comorbid conditions, with estimated lifetime risk of any disorder at age 75 years (50.8%) only slightly higher than observed lifetime prevalence (46.4%). Lifetime prevalence estimates are higher in recent cohorts than in earlier cohorts and have fairly stable inter-cohort differences across the life course that vary in substantively plausible ways among socio-demographic subgroups. These findings indicate that about half of Americans will meet the criteria for a DSM-IV disorder sometime in their life, with first onset usually in childhood or adolescence. Interventions aimed at prevention or early treatment need to focus on youth. Kessler, R.C., Berglund, P., Demler, O., Jin, R., and Walters, E.E. Lifetime Prevalence and Age-of-onset Distributions' of DSM-IV Disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry 62, pp. 593-602, 2005.

Prevalence and Treatment of Mental Disorders: 1990 to 2003

Although the 1990s saw enormous change in the mental health care system in the United States, little is known about changes in the prevalence or rate of treatment of mental disorders. This study examined trends in the prevalence and rate of treatment of mental disorders among people 18 to 54 years of age during the past decade. Data from the National Comorbidity Survey (NCS) were obtained in 5388 face-to-face household interviews conducted between 1990 and 1992, and data from the NCS Replication were obtained in 4319 interviews conducted between 2001 and 2003. Anxiety disorders, mood disorders, and substance-abuse disorders that were present during the 12 months before the interview were diagnosed with the use of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV). Treatment for emotional disorders was categorized according to the sector of mental health services, psychiatry services, other mental health services, general medical services, human services, and complementary-alternative medical services. Results indicated that the prevalence of mental disorders did not change during the decade (29.4 percent between 1990 and 1992 and 30.5 percent between 2001 and 2003, P=0.52), but the rate of treatment increased. Among patients with a disorder, 20.3 percent received treatment between 1990 and 1992 and 32.9 percent received treatment between 2001 and 2003 (P<0.001). Overall, 12.2 percent of the population 18 to 54 years of age received treatment for emotional disorders between 1990 and 1992 and 20.1 percent between 2001 and 2003 (P<0.001). Only about half those who received treatment had disorders that met diagnostic criteria for a mental disorder. Significant increases in the rate of treatment (49.0 percent between 1990 and 1992 and 49.9 percent between 2001 and 2003) were limited to the sectors of general medical services (2.59 times as high in 2001 to 2003 as in 1990 to 1992), psychiatry services (2.17 times as high), and other mental health services (1.59 times as high) and were independent of the severity of the disorder and of the sociodemographic characteristics of the respondents. Despite an increase in the rate of treatment, these findings indicate that most patients with a mental disorder do not receive treatment. Continued efforts are needed to obtain data on the effectiveness of treatment in order to increase the use of effective treatments. Kessler, R.C., Demler, O., Frank, R.G., Olfson, M., Pincus, H.A., Walters, E.E., Wang, P., Wells, K.B., and Zaslavsky, A.M., Prevalence and Treatment of Mental Disorders, 1990 to 2003. New England Journal of Medicine, 352, pp. 2515-2523, 2005.

Initial Treatment Contact after First Onset of Mental Disorders in the National Comorbidity Survey Replication

This study investigated patterns and predictors of failure and delay in making initial treatment contact after first onset of a mental disorder in the United States from the recently completed National Comorbidity Survey Replication. This nationally representative face-to-face household survey, conducted between February 2001 and April 2003, used the fully structured World Health Organization World Mental Health Survey version of the Composite International Diagnostic Interview. Participants were 9282 English-speaking respondents aged 18 years and older. Cumulative lifetime probability curves show that the vast majority of people with lifetime disorders eventually make treatment contact, although more so for mood (88.1%-94.2%) disorders than for anxiety (27.3%-95.3%), impulse control (33.9%-51.8%), or substance (52.7%-76.9%) disorders. Delay among those who eventually make treatment contact ranges from 6 to 8 years for mood disorders and 9 to 23 years for anxiety disorders. Failure to make initial treatment contact and delay among those who eventually make treatment contact are both associated with early age of onset, being in an older cohort, and a number of socio-demographic characteristics (male, married, poorly educated, racial/ethnic minority). These findings indicate that failure to make prompt initial treatment contact is a pervasive aspect of unmet need for mental health care in the United States. Interventions to speed initial treatment contact are likely to reduce the burdens and hazards of untreated mental disorder. Wang, P.S., Berglund, P., Olfson, M., Pincus, H.A., Wells, K.B., and Kessler, R.C. Failure and Delay in Initial Treatment Contact after First Onset of Mental Disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry 62, pp. 603-613, 2005.

Patterns and Predictors of Attention-Deficit/Hyperactivity Disorder Persistence into Adulthood: Results from the National Comorbidity Survey Replication

This study examined correlates of persistence of childhood cases into adulthood using a retrospective assessment of childhood ADHD, childhood risk factors, and a screen for adult ADHD. Participants were a sample of 3197 18-44 year old respondents from the National Comorbidity Survey Replication (NCS-R). Blinded adult ADHD clinical reappraisal interviews were administered to a sub-sample of respondents. Multiple Imputation (MI) was used to estimate adult persistence of childhood ADHD. Logistic regression was used to study retrospectively reported childhood predictors of persistence. Potential predictors included socio-demographics, childhood ADHD severity, childhood adversity, traumatic life experiences, and comorbid DSM-IV child-adolescent disorders (anxiety, mood, impulse-control, and substance disorders). The results identified 36.3% of respondents as meeting DSM-IV criteria for current ADHD. Childhood ADHD severity and childhood treatment significantly predicted persistence. Controlling for severity and excluding treatment, none of the other variables significantly predicted persistence even though they were significantly associated with childhood ADHD. These findings identified no modifiable risk factors for adult persistence of ADHD. Further research, ideally based on prospective general population samples, is needed to search for modifiable determinants of adult persistence of ADHD. Kessler, R.C., Adler, L.A., Barkley, R., Biederman, J., Conners, C.K., Faraone, S.V., Greenhill, L.L., Jaeger, S., Secnik, K., Spencer, T., Ustun, T.B., and Zaslavsky, A.M., Patterns and Predictors of Attention-Deficit/Hyperactivity Disorder Persistence into Adulthood, Results from the National Comorbidity Survey Replication. Biological Psychiatry 57, pp. 1442-1451, 2005.

Costs of Attention Deficit-Hyperactivity Disorder (ADHD) in the US

The objective of this study is to provide a comprehensive estimate of the cost of ADHD by considering the healthcare and work loss costs of persons with ADHD, as well as those costs imposed on their family members. Excess per capita healthcare (medical and prescription drug) and work loss (disability and work absence) costs of treated ADHD patients (ages 7 years-44 years) and their family members (under 65 years of age) were calculated using administrative claims data from a single large company, work loss costs are from disability data or imputed for medically related work loss days. Excess costs are the additional costs of patients and their family members over and above those of comparable control individuals. The excess costs of untreated individuals with ADHD and their family members were also estimated. All per capita costs were extrapolated using published prevalence and treatment rates and population data, the prevalence of persons with ADHD was based upon the literature. Results indicated that the total excess cost of ADHD in the US in 2000 was $31.6 billion. Of this total, $1.6 billion was for the ADHD treatment of patients, $12.1 billion was for all other healthcare costs of persons with ADHD, $14.2 billion was for all other healthcare costs of family members of persons with ADHD, and $3.7 billion was for the work loss cost of adults with ADHD and adult family members of persons with ADHD. These findings indicate that the annual cost of ADHD in the US is substantial. Both treated and untreated persons with ADHD, as well as their family members, impose considerable economic burdens on the healthcare system as a result of this condition. Birnbaum, H.G., Kessler, R.C., Lowe, S.W., Secnik, K., Greenberg, P.E., Leong, S.A., and Swensen, A.R. Costs of Attention Deficit-Hyperactivity Disorder (ADHD) in the US, Excess Costs of Persons with ADHD and their Family Members in 2000. Current Medical Research and Opinion 21, pp. 195-205, 2005.

Trends in Suicide Ideation, Plans, Gestures, and Attempts in the United States: 1990-1992 to 2001-2003

This study provides nationally representative trend data on suicidal ideation, plans, gestures, attempts, and their treatment. Data came from the 1990-1992 National Comorbidity Survey and the 2001-2003 National Comorbidity Survey Replication. These surveys asked identical questions to 9708 people aged 18 to 54 years about the past year's occurrence of suicidal ideation, plans, gestures, attempts, and treatment. Trends were evaluated by using pooled logistic regression analysis. Face-to-face interviews were administered in the homes of respondents, who were nationally representative samples of US English-speaking residents. Results indicated no significant changes occurred between 1990-1992 and 2001-2003 in suicidal ideation (2.8% vs 3.3%, P=.43), plans (0.7% vs 1.0%, P=.15), gestures (0.3% vs 0.2%, P=.24), or attempts (0.4%-0.6%, P=.45), whereas conditional prevalence of plans among ideators increased significantly (from 19.6% to 28.6%, P=.04), and conditional prevalence of gestures among planners decreased significantly (from 21.4% to 6.4%, P=.003). Treatment increased dramatically among ideators who made a gesture (40.3% vs 92.8%) and among ideators who made an attempt (49.6% vs 79.0%). These findings indicate a dramatic increase in treatment, but no significant decrease occurred in suicidal thoughts, plans, gestures, or attempts in the United States during the 1990s. Continued efforts are needed to increase outreach to untreated individuals with suicidal ideation before the occurrence of attempts and to improve treatment effectiveness for such cases. Kessler, R.C., Berglund, P., Borges, G., Nock, M., and Wang, P.S., Trends in Suicide Ideation, Plans, Gestures, and Attempts in the United States, 1990-1992 to 2001-2003. JAMA 293, pp. 2487-2495, 2005.

Prevalence, Severity, and Comorbidity of 12-month DSM-IV Disorders in the National Comorbidity Survey Replication

This study estimated the 12-month prevalence, severity, and comorbidity of DSM-IV anxiety, mood, impulse control, and substance disorders in the recently completed US National Comorbidity Survey Replication. This nationally representative face-to-face household survey, conducted between February 2001 and April 2003, used the fully structured World Health Organization World Mental Health Survey version of the Composite International Diagnostic Interview. Participants were 9282 English-speaking respondents aged 18 years and older. Results indicated the following 12-month prevalence estimates: anxiety (18.1%), mood (9.5%), impulse control (8.9%), substance (3.8%), and any disorder (26.2%). Of 12-month cases, 22.3% were classified as serious, 37.3% moderate, and 40.4% mild. Fifty-five percent carried only a single diagnosis, 22% had 2 diagnoses, and 23% had 3 or more diagnoses. Latent class analysis detected 7 multivariate disorder classes, including 3 highly comorbid classes representing 7% of the population. These findings indicate that mental disorders are widespread, and that serious cases are concentrated among a relatively small proportion of cases with high comorbidity. Kessler, R.C., Chiu, W.T., Demler, O. and Walters, E.E. Prevalence, Severity, and Comorbidity of 12-month DSM-IV Disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry 62, pp. 617-627, 2005.

Twelve-month Use of Mental Health Services in the United States: Results from the National Comorbidity Survey Replication

This study provided data on patterns and predictors of 12-month mental health treatment in the United States from the recently completed National Comorbidity Survey Replication. Of the 12-month cases, 41.1% received some treatment in the past 12 months, including 12.3% treated by a psychiatrist, 16.0% treated by a nonpsychiatrist mental health specialist, 22.8% treated by a general medical provider, 8.1% treated by a human services provider, and 6.8% treated by a complementary and alternative medical provider (treatment could be received by > 1 source). Overall, cases treated in the mental health specialty sector received more visits (median, 7.4) than those treated in the general medical sector (median, 1.7). More patients in specialty than general medical treatment also received treatment that exceeded a minimal threshold of adequacy (48.3% vs 12.7%). Unmet need for treatment is greatest in traditionally underserved groups, including elderly persons, racial-ethnic minorities, those with low incomes, those without insurance, and residents of rural areas. These findings indicate that most people with mental disorders in the United States remain either untreated or poorly treated. Interventions are needed to enhance treatment initiation and quality. Wang, P.S., Lane, M., Olfson, M., Pincus, H.A., Wells, K.B., and Kessler, R.C. Twelve-month Use of Mental Health Services in the United States - Results from the National Comorbidity Survey Replication. Archives of General Psychiatry 62, pp. 629-640, 2005.

Epidemiological Risk Estimates of Cocaine Dependence for the United States, 2000-2001

This paper presents new estimates for the risk of becoming cocaine dependent within 24 months after first use of the drug, and study subgroup variation in this risk. The study estimates are based on the National Household Survey on Drug Abuse conducted during 2000-2001, with a representative sample of U.S. residents aged 12 years and older (n = 114,241). A total of 1081 respondents were found to have used cocaine for the first time within 24 months prior to assessment. Between 5 and 6% of these recent-onset users had become cocaine dependent since onset of use. Excess risk of recent cocaine dependence soon after onset of cocaine use was found for female subjects, young adults aged 21-25 years, and non-Hispanic Black/African-Americans. The use of crack-cocaine and taking cocaine by injection was associated with having become cocaine dependent soon after onset of use. These epidemiologic findings help to quantify the continuing public health burden associated with new onsets of cocaine use in the 21st century. O'Brien, M.S. and Anthony, J.C. Risk of Becoming Cocaine Dependent, Epidemiological Estimates for the United States, 2000-2001. Neuropsychopharmacology 30, pp. 1006-1018, 2005.

Developmental Trajectories of Offending Predict Alcohol Use, Drug Use, and Depressive Symptoms

This longitudinal study examined the validity of differing offending pathways and the prediction from the pathways to substance use and depressive symptoms for 204 young men. Findings from this study indicated good external validity of the offending trajectories. Further, substance use and depressive symptoms in young adulthood (i.e., ages 23-24 through 25-26 years) varied depending on different trajectories of offending from early adolescence to young adulthood (i.e., ages 12-13 through 23-24 years), even after controlling for antisocial propensity, parental criminality, demographic factors, and prior levels of each outcome. Specifically, chronic high-level offenders had higher levels of depressive symptoms and engaged more often in drug use compared with very rare, decreasing low-level, and decreasing high-level offenders. Chronic low-level offenders, in contrast, displayed fewer systematic differences compared with the two decreasing offender groups and the chronic high-level offenders. The findings supported the contention that varying courses of offending may have plausible causal effects on young adult outcomes beyond the effects of an underlying propensity for crime. Wiesner, M., Kim, H.K. and Capaldi, D.M. Developmental Trajectories of Offending, Validation and Prediction to Young Adult Alcohol Use, Drug Use and Depressive Symptoms. Development and Psychopathology 17, pp. 251-270, 2005.

Cocaine Use and the Occurrence of Panic Attacks

This study uses the case-crossover method to estimate the magnitude of excess occurrence of panic attacks during months of cocaine use vs. months of no cocaine use, motivated by a prior estimate that cocaine users have three-fold excess risk of panic attack. The epidemiologic case-crossover method is a powerful tool for research on suspected hazards of illegal drug use, the advantage being a subject-as-own-control approach that constrains stable individual-level susceptibility traits. The self-report data on cocaine and panic are from assessments of a nationally representative sample of 1071 recent panic cases age 18 years or older identified as part of the National Household Surveys on Drug Abuse conducted in the United States during 1994-1997. Based on case-crossover estimates, cocaine use is associated with a three- to- four-fold excess occurrence of panic attack (estimated relative risk (RR) = 3.3, p = 0.049, 95% confidence interval, 1.0, 13.7). Year-by-year, the RR estimates from four independent yearly replicates (1994-1997) are 5.0, 2.0, 3.0, and 3.0. While there are several important limitations, this study adds new evidence about a previously reported suspected causal association linking cocaine use to occurrence of panic attacks, and illustrates advantages of the epidemiologic case-crossover approach and new directions in research on hazards of illegal drug use. O'Brien, M.S., Wu, L.T. and Anthony, J.C. Cocaine Use and the Occurrence of Panic Attacks in the Community: A Case-crossover Approach. Substance Use & Misuse 40, pp. 285-297, 2005.

Early Onset Inhalant Use and Risk for Opiate Initiation

This study examined a hypothesized link from early onset inhalant use to later use of opiates by young adulthood, with data from an epidemiological sample of 2311 first graders who entered an urban mid-Atlantic public school system in 1985 or 1986 (49.8% male, 67.1% ethnic minority), and who were studied longitudinally to young adulthood. An estimated 9% had initiated inhalant use before the age of 14 and at follow-up in young adulthood an estimated 3% (n = 66) of the sample had tried opiates at least once. Youth who used inhalants prior to age 14 were twice as likely to initiate opiate use, as compared to those who had never tried. Statistical adjustment for other covariates attenuated but did not dissolve this relationship. These findings help confirm previously reported evidence that the use of inhalants might be an early marker of vulnerability for future involvement with illegal drugs such as heroin, but an exploratory analysis suggests that there may be no direct inhalants-opiate link once a general early onset susceptibility trait is taken into account. Storr, C.L., Westergaard, R. and Anthony, J.C., Early Onset Inhalant Use and Risk for Opiate Initiation by Young Adulthood. Drug and Alcohol Dependence, 78, pp. 253-261, 2005.

Early Violent Death among Delinquent Youth

This study compared mortality rates for delinquent youth with those for the general population, controlling for differences in gender, race/ethnicity, and age. This prospective longitudinal study examined mortality rates among 1829 youth (1172 male and 657 female) enrolled in the Northwestern Juvenile Project, a study of health needs and outcomes of delinquent youth. Participants, 10 to 18 years of age, were sampled randomly from intake at the Cook County Juvenile Temporary Detention Center in Chicago, Illinois, between 1995 and 1998. The sample was stratified according to gender, race/ethnicity (African American, non-Hispanic white, Hispanic, or other), age (10-13 or >= 14 years), and legal status (processed as a juvenile or as an adult), to obtain enough participants for examination of key subgroups. The sample included 1005 African American (54.9%), 296 non-Hispanic white (16.2%), 524 Hispanic (28.17%), and 4 other-race/ethnicity (0.2%) subjects. Data on deaths and causes of death were obtained from family reports or records and were then verified by the local medical examiner or the National Death Index. For comparisons of mortality rates for delinquents and the general population, all data were weighted according to the racial/ethnic, gender, and age characteristics of the detention center, these weighted standardized populations were used to calculate reported percentages and mortality ratios. Mortality ratios were calculated by comparing the sample's mortality rates with those for the general population of Cook County, controlling for differences in gender, race/ethnicity, and age. Results indicated that sixty-five youth died during the follow-up period. All deaths were from external causes. As determined by using the weighted percentages to estimate causes of death, 95.5% of deaths were homicides or legal interventions (90.1% homicides and 5.4% legal interventions), 1.1% of all deaths were suicides, 1.3% were from motor vehicle accidents, 0.5% were from other accidents, and 1.6% were from other external causes. Among homicides, 93.0% were from gunshot wounds. The overall mortality rate was greater than 4 times the general-population rate. The mortality rate among female youth was nearly 8 times the general-population rate. African American male youth had the highest mortality rate (887 deaths per 100 000 person-years). These findings indicate that early violent death among delinquent and general-population youth affects racial/ethnic minorities disproportionately and should be addressed, as are other health disparities. Future studies should identify the most promising modifiable risk factors and preventive interventions, explore the causes of death among delinquent female youth, and examine whether minority youth express suicidal intent by putting themselves at risk for homicide. Teplin, L.A., McClelland, G.M., Abram, K.M., and Mileusnic, D. Early Violent Death among Delinquent Youth: A Prospective Longitudinal Study. Pediatrics 115, pp. 1586-1593, 2005.

Early Parenting Practices and Subsequent Risk of Trying Cannabis

This study estimated the extent to which parental monitoring, parental involvement and reinforcement, and coercive parental discipline during primary school might exert a durable influence on the risk of transitioning into an early stage of youthful cannabis onset. Data come from a prospective study of first-graders who entered an urban public school system in the middle 1980s. Parenting was assessed in fourth grade, and cannabis experiences were evaluated during periodic assessments from middle childhood through young adulthood. Results indicated that the estimated risk of the first chance to try cannabis peaked around 16 to 18 years of age. Lower parental involvement and reinforcement and higher coercive parental discipline were associated modestly with a greater risk of cannabis exposure opportunity through the years of adolescence and into early adulthood (parental involvement and reinforcement, adjusted relative risk, 1.4, 95% confidence interval, 1.1-1.7, parental discipline, adjusted relative risk, 1.3, 95% confidence interval, 1.1-1.5). These findings indicate that certain parenting practices in the mid-primary school years may have a durable impact, perhaps helping to shield youths from having a chance to try cannabis throughout adolescence and into young adulthood. Chen, C.Y., Storr, C.L., and Anthony, J.C. Influences of Parenting Practices on the Risk of Having a Chance to Try Cannabis. Pediatrics 115, pp. 1631-1639, 2005.

Gender/Racial Differences in "Jock" Identity, Dating, and Adolescent Sexual Risk

Despite recent declines in overall sexual activity, sexual risk-taking remains a substantial danger to US youth. Existing research points to athletic participation as a promising venue for reducing these risks. Linear regressions and multiple analyses of covariance were performed on a longitudinal sample of nearly 600 Western New York adolescents in order to examine gender- and race-specific relationships between "jock" identity and adolescent sexual risk-taking, including age of sexual onset, past-year and lifetime frequency of sexual intercourse, and number of sexual partners. After controlling for age, race, socioeconomic status, and family cohesion, male jocks reported more frequent dating than nonjocks but female jocks did not. For both genders, athletic activity was associated with lower levels of sexual risk-taking, however, jock identity was associated with higher levels of sexual risk-taking, particularly among African American adolescents. Future research should distinguish between subjective and objective dimensions of athletic involvement as factors in adolescent sexual risk. Miller, K.E., Farrell, M.P., Barnes, G.M., Melnick, M.J. and Sabo, D. Gender/racial Differences in Jock Identity, Dating, and Adolescent Sexual Risk. Journal of Youth and Adolescence 34, pp. 123-136, 2005.

Nicotine Phenotypes based on Withdrawal Discomfort, Response to Smoking, and Ability to Abstain

Smoking is often viewed as a comprehensive phenotype rather than a complex set of traits involving intermediate phenotypes. To explore this issue in a laboratory setting, researchers tested 69 smokers stratified on depression, nicotine dependence, and gender. On the third day of an initial withdrawal period, participants were tested for differences in uncued and cued craving and withdrawal. On the fourth day, participants were exposed to a controlled dose of smoke and assessed for physiological and hedonic effects and reduction of craving and withdrawal. Following resumption of smoking for at least a week, participants were then tested on their ability to abstain for an 11-day interval. During the withdrawal test, high-depressed smokers and men exhibited elevated craving and withdrawal scores overall, whereas no differences emerged for dependence. Cue exposure produced significant increases in craving but not withdrawal. During the smoke-exposure test, men were significantly more likely than women, and high-depressed smokers more likely than low-depressed smokers, to show evidence of experiencing pleasurable "buzzes." High-dependent smokers showed significant increases in diastolic blood pressure, possibly suggestive of greater sensitivity to nicotine. During the quit test, high-dependent smokers had more difficulty abstaining than low-dependent smokers, and women more than men, no differences emerged based on depression. Independently of group membership, inability to abstain was predicted by increased anxiety, depression, and difficulty concentrating in response to cue exposure. These findings provide support for the existence of phenotypes that can be distinguished by withdrawal symptomatology (primarily driven by depression) and ability to remain abstinent (primarily driven by dependence). Pomerleau, O.F., Pomerleau, C.S., Mehringer, A.M., Snedecor, S.M., Ninowski, R. and Sen, A. Nicotine Dependence, Depression, and Gender: Characterizing Phenotypes Based On Withdrawal Discomfort, Response to Smoking and Ability to Abstain. Nicotine & Tobacco Research 7, pp. 91-102, 2005.

Accuracy of Offspring Assessment Based on Parental Smoking Status

This study investigated the accuracy of offspring assessments of parental smoking status among 116 parents and 151 adult children (276 parent-child dyads) who provided data on both their own and their parents' smoking status. All currently smoking and all ex-smoking parents were correctly classified as ever-smokers by their offspring (n = 79 and 100, respectively). Of the 97 offspring who reported on never-smoking parents, 88 correctly classified their parents as never-smokers. Thus, sensitivity for detecting ever-smoking in parents was 100%, and specificity, 91%. Because all incorrect classifications involved never-smoking parents, further analyses focused on this group. Too few parents were misclassified to permit testing of parental characteristics. Offspring who misclassified their parents were significantly older than those who did not, neither sex nor smoking status of the offspring was associated with the increased likelihood of misclassification. No significant differences were discovered for dyadic factors (concordance/discordance for sex, parent-offspring age difference). Overall, these results support the utility of proxy reports of parental smoking phenotype by adult informants when self-report is unavailable. Pomerleau, C.S., Snedecor, S., Ninowski, R., Gaulrapp, S., Pomerleau, O.F. and Kardia, S.L.R. Differences in Accuracy of Offspring Assessment Based On Parental Smoking Status. Addictive Behaviors 30, pp. 437-441, 2005.

Validation of Retrospective Reports of Early Smoking Experiences

Initial sensitivity to the pharmacological effects of a drug may affect patterns of future use and dependence for a wide variety of drugs. Retrospective reports of sensations experienced upon early experimentation, however, may be limited by recall bias based on time elapsed and subsequent experiences. To validate reports of early experiences with nicotine, this study investigated 34 smokers who had contributed retrospective data on early experiences with smoking. Half had reported experiencing a buzz from smoking their first cigarette (the "yes" group), the other half had not (the "no" group). To simulate initial sensitivity to nicotine, participants were asked to remain abstinent from smoking for 5 days to allow for the dissipation of tolerance. They then participated in a laboratory session in which they were re-exposed to nicotine in an unfamiliar form (nicotine nasal spray) and asked to indicate pleasurable responses by depressing a foot pedal if and when they experienced a "pleasurable buzz." Smokers in the "yes" group were marginally more likely to be male. The two groups did not differ significantly on age or race. The "yes" group smoked significantly more cigarettes/day than the "no" group. When the two groups were compared for response to nasal spray following 5 days' abstinence, smokers in the "yes" group were marginally more likely to have signaled experiencing at least one pleasurable buzz and rated "pleasurable sensation from spray" on a 100-mm visual analogue scale administered 10 min after nicotine dosing significantly higher than were those in the "no" group. To the extent that several days' abstinence can serve as a model for initial sensitivity to nicotine, our findings validate retrospective reports of pleasurable sensations upon early smoking experimentation. Pomerleau, O.F., Pomerleau, C.S., Mehringer, A.M., Snedecor, S.A. and Cameron, O.G. Validation of Retrospective Reports of Early Experiences with Smoking. Addictive Behaviors 30, pp. 607-611, 2005.

Timing of Entry into Fatherhood in Young, At-Risk Men

The timing of first fatherhood was examined in a sample of 206 at-risk, predominantly White men, followed prospectively for 17 years. An event history analysis was used to test a model wherein antisocial behavior, the contextual and familial factors that may contribute to the development of antisocial behavior, and common correlates of such behavior, including academic failure, substance use, and early initiation of sexual behaviors, lead both directly and indirectly to an early transition to fatherhood. Having a mother who was younger at first birth, low family socioeconomic status, poor academic skills, failure to use condoms, and being in a cohabitating or marital relationship predicted entry into fatherhood. Pears, K.C., Pierce, S.L., Kim, H.K., Capaldi, D.M. and Owen, L.D. The Timing of Entry into Fatherhood in Young, At-risk Men. Journal of Marriage and the Family 67, pp. 429-447, 2005.

Personality Factors Contributing to Comorbidity

The authors investigated the role of personality traits in accounting for comorbidity in common psychiatric and substance use disorders. 7588 participants in a population-based twin registry in Virginia were interviewed with the SCID to determine lifetime diagnoses of common psychiatric and substance use disorders, and completed self-report questionnaires to determine dimensions of neuroticism, extraversion, and novelty seeking. Of note, neuroticism accounted for the highest proportion of comorbidity within internalizing (mood and anxiety) disorders (20-45%) and between internalizing and externalizing (antisocial and substance use) disorders (19-88%). Variation in neuroticism and novelty seeking each accounted for a modest proportion (10-12% and 7-14%, respectively) of the comorbidity within externalizing disorders. Extraversion contributed negligibly. Although rates of disorders differed among the genders, the patterns of comorbidity accounted for by personality were similar in males and females. These findings extend previous research on personality and psychiatric disorder by using a population-based sample and by quantifying the proportion of comorbidity explained by personality dimension. Given that comorbidity among psychiatric and substance use disorders is extremely common, these findings can help refine our understanding of those underlying traits that put individuals at risk for multiple later disorders, regardless of gender, particularly the role of neuroticism. Khan, A.A., Jacobson, K.C., Gardner, C.O., Prescott, C.A. and Kendler, K.S. Personality and Comorbidity of Common Psychiatric Disorders. British Journal of Psychiatry, 186, pp. 190-196, 2005.

Association of Early Adolescent Problem Behavior with Adult Psychopathology

The authors investigated whether the association between adolescent problem behavior and adult substance use and mental health disorders was general, such that adolescent problem behavior elevates the risk for a variety of adult disorders, or outcome-specific, such that each problem behavior is associated specifically with an increased risk for disorders clinically linked to that behavior (e.g., early alcohol use with adult alcohol abuse). A population-based group of 578 male and 674 female twins reported whether they had ever engaged in, and the age of initiation of, five adolescent problem behaviors: smoking, alcohol use, illicit drug use, police trouble, and sexual intercourse. Participants also completed a structured clinical interview at both ages 17 and 20 covering substance use disorders, major depressive disorder, and antisocial personality disorder. Each problem behavior was significantly related with each clinical diagnosis. The association was especially marked for those who had engaged in multiple problem behaviors before age 15. Among those with four or more problem behaviors before age 15, the lifetime rates of substance use disorders, antisocial personality disorder, and major depressive disorder exceeded 90%, 90%, and 30% in males and 60%, 35%, and 55% in females, respectively. The association between the clinical diagnoses and adolescent problem behavior was largely accounted for by two highly correlated factors. This study suggests that early adolescent problem behavior identifies a subset of youth who are at an especially high and generalized risk for developing adult psychopathology. McGue, M. and Iacono, W.G. The Association Of Early Adolescent Problem Behavior With Adult Psychopathology. American Journal of Psychiatry. 162(6), pp. 1118-1124, 2005.

Coping Factors Mediating the Association between Childhood ADHD and Adolescent Cigarette Use

The authors sought to examine the possible role of coping factors in the relationship between childhood attention deficit hyperactivity disorder (ADHD) and higher rates of later cigarette use. Subjects were 142 adolescents who had been diagnosed with ADHD in childhood, and 100 adolescent controls without ADHD. Adolescents were interviewed regarding cigarette use and parental support, while parents were interviewed regarding coping skills; both parents and adolescents were interviewed with standardized instruments to determine psychiatric diagnoses (ADHD and CD). Results indicated that subjects with childhood ADHD smoked more frequently, had fewer adaptive coping skills, and lower parental support compared with controls. Reduced coping and support partially mediated the association between ADHD and smoking. Persistence of ADHD (which could be related to reduced coping skills) and adolescent conduct disorder (which often relates to poor parental support) were also important in the model. As noted by the authors, the model accounted for 30% of the variance in smoking, and other variables need to be included to explicate these relationships further. However, if confirmed, these findings point to coping behaviors as possible targets for preventive intervention with ADHD youth at risk for cigarette use. Molina, B.S., Marshal, M.P., Pelham, W.E. Jr. and Wirth, R.J. Coping Skills and Parent Support Mediate The Association Between Childhood Attention-Deficit/Hyperactivity Disorder And Adolescent Cigarette Use. Journal of Pediatric Psychology 30(4), pp. 345-357, 2005.

Child Psychopathology and Early Substance Use

This study examined the relationships between childhood externalizing and internalizing disorders and early substance use and abuse, in a large community-based sample of twins of both genders, at ages 11 and 14. The sample was composed of twins participating in the Minnesota Twin Family Study, an epidemiological sample of twins and their families representative of the largely-Caucasian population of Minnesota. A total of 699 twin girls and 665 twin boys participated at both time-points. Twins participated in in-person, life-time diagnostic assessments of the following childhood DSM III-R externalizing and internalizing disorders at age 11: conduct disorder, oppositional defiant disorder, attention deficit hyperactivity disorder, major depressive disorder and in addition, for girls only, overanxious disorder and separation anxiety disorder. At ages 11 and 14, substance use and abuse were assessed. Consistent with the literature, externalizing disorders at age 11, particularly conduct and oppositional disorders, were related to substance use and abuse in both boys and girls, at ages 11 and 14. Among the internalizing disorders, only major depression among girls at age 11 showed a relationship to substance use and abuse at age 14. These findings can help refine populations that may benefit from interventions for early substance abuse. King, S.M., Iacono, W.G. and McGue, M. Childhood Externalizing and Internalizing Psychopathology in the Prediction of Early Substance Use. Addiction, 99, pp. 1548-1559, 2004.

Heritability of Cigarette Smoking and Family Dysfunction in Women

Previous studies using adoption samples have found that the impact of genetic risk factors on alcoholism in women have a stronger influence when there is a history of conflict in the family. The authors of this study investigated a similar impact on cigarette smoking in a population-based twin sample. A sample of 1676 female twins from a population-based registry provided data on maximum lifetime cigarette smoking and family dysfunction assessed as the mean report of up to four informants (twin, co-twin, mother, father). Using a variety of statistical approaches and models, the hypothesis was not confirmed; on the contrary, the heritability (proportion of variance due to genetic factors) of cigarette smoking was reduced at higher levels of family dysfunction, and unique environmental factors became more significant. Further work, with different populations and substances, is needed; in the meantime, the authors caution against a broad assumption that adverse childhood environments always increase heritability. Kendler, K.S., Aggen, S.H., Prescott, C.A., Jacobson, K.C. and Neale, M.C. Level of Family Dysfunction and Genetic Influences on Smoking in Women. Psychological Medicine, 34, pp. 1263-1269, 2004.

Partitioning Common and Specific Influences on Drug Use and Abuse

Previous studies of the genetic epidemiology of drug abuse have generally modeled drug use and drug abuse and dependence separately. However, the authors of this paper note that drug use disorders are contingent on drug use (one cannot develop the disorder without first using the drug) and so they apply a model that can partition the genetic and environmental influences into those that are common to both stages and those that are stage-specific. Using the SCID, data on use and abuse/dependence of cannabis, cocaine, sedatives, stimulants and any illicit drug were obtained from 1191 male and 934 female Caucasian twin pairs in the Mid-Atlantic Twin Registry. Results provide evidence for both genetic, shared environmental and unique environmental influences that are common to illicit drug use and abuse/dependence, and factors that are specific to abuse/dependence. Similarities among different types of drugs and between both sexes were noted in the patterns of risk influences. Thus, it is likely that there are some genetic and environmental factors that influence both drug use and abuse/dependence regardless of the drugs used or gender of the user, and that there are other factors that operate specifically to predispose to abuse and dependence once use has onset. Agrawal, A., Neale, M.C., Jacobson, K.C., Prescott, C.A. and Kendler, KS. Illicit Drug Use and Abuse/Dependence: Modeling of Two-Stage Variables Using the CCC Approach. Addictive Behaviors 30(5), pp. 1043-1048, 2005.

Effectiveness of Highly Active Antiretroviral

Therapy among IDU with Late-Stage HIV Highly active antiretroviral therapy (HAART) has been shown to be effective in different populations, but data among injection drug users are limited. HIV-infected IDUs recruited into the Acquired Immunodeficiency Syndrome Link to Intravenous Experiences (ALIVE) Study as early as 1988 were tested semiannually to identify their first CD4-positive T-lymphocyte cell count below 200/ll; they were followed for mortality through 2002. Visits were categorized into the pre-HAART (before mid-1996) and the HAART eras and further categorized by HAART use. Survival analysis with staggered entry was used to evaluate the effect of HAART on AIDS-related mortality, adjusting for other medications and demographic, clinical, and behavioral factors. Among 665 participants, 258 died during 2,402 person-years of follow-up. Compared with survival in the pre-HAART era, survival in the HAART era was shown by multivariate analysis to be improved for both those who did and did not receive HAART (relative hazards .25, 0.06 and 0.33, respectively; p < 0.001). Inferences were unchanged after restricting analyses to data starting with 1993 and considerations of lead time bias and human immunodeficiency viral load. The annual CD4-positive T-lymphocyte cell decline was less in untreated HAART-era participants than in pre-HAART-era participants as well, suggesting that changing indications for treatment may have contributed to improved survival and that analyses restricted to the HAART era probably underestimate HAART effectiveness. These findings suggest that treatment can work in this and other populations where reduced access may have occurred from a general reluctance by clinicians to provide treatment due to concerns about adherence and the potential development of resistant virus that might be transmitted to others. Research is needed to develop and improve approaches for reaching HIV-infected IDUs to offer and monitor effective antiretroviral treatment. Vlahov, D., Galai, N., Safaeian, M., Galea, S., Kirk, G., Lucas, G. and Sterling, T. Effectiveness of Highly Active Antiretroviral Therapy among Injection Drug Users with Late-Stage Human Immunodeficiency Virus Infection. Amer J Epidemiol, 161, pp. 999-1012, 2005.

The Effect of HIV Infection on Overdose Mortality

This prospective cohort study sought to quantify the association of HIV infection with overdose mortality and explore the potential mechanisms. A total of 1927 active IDUs who were HIV seronegative at baseline, of whom 308 later HIV seroconverted, were followed semi-annually for death from 1988 to 2001. Survival analyses using marginal structural and standard Cox models were used to evaluate the effect of HIV infection on the risk of overdose mortality. The study found that overdose death rates were higher in HIV-seropositive than HIV-seronegative drug users: 13.9 and 5.6 per 1000 person-years, respectively (P < 0.01). The hazard ratio (HR) was 2.54 [95% confidence interval (CI) 1.47, 4.38] for the marginal structural model and 2.06 (95% CI 1.25, 3.38) for the standard Cox model, both adjusted for demographics, drug injection characteristics, alcohol abuse, substance abuse treatment, and sexual orientation. Adjusting for possible time-varying mediators (i.e. drug use, medical conditions and healthcare access) in extended marginal structural models reduced the effect of HIV on overdose mortality by 30% (HR 1.82, 95% CI 1.01, 3.30). Abnormal liver function was associated with a higher risk of overdose mortality (HR 2.00, 95% CI 1.05, 3.84); adjustment for this further reduced the effect of HIV on overdose mortality. These findings indicate that HIV infection is associated with a higher risk of overdose mortality. Drug use behavior, systematic disease and liver damage associated with HIV infection appeared to account for a substantial portion of this association. Wang, C., Vlahov, D., Galaia, N., Colea, S., Bareta, J., Pollinia, R., Mehtaa, S., Nelson, K. and Galea, S. The Effect of HIV Infection on Overdose Mortality. AIDS, 19, pp. 935-942, 2005.

Prospective Evaluation of Community-Acquired Acute-Phase Hepatitis C Virus Infection

More than two-thirds of hepatitis C virus (HCV) infections in Western countries are caused by injection drug use, but prospective clinical data regarding the most common mode of HCV acquisition are rare, in part because acute-phase HCV infection is usually asymptomatic. To characterize acute-phase HCV infection, 179 HCV antibody negative injection drug users were prospectively evaluated; 62 (34%) of these patients had seroconverted. Twenty of the participants who seroconverted had long-term follow-up with consistent monthly sampling before and after seroconversion, allowing detailed study. The first indication of HCV infection was the presence of HCV RNA in serum, which preceded elevation of alanine transaminase levels and total bilirubin levels to more than or equal to 2 times baseline in 45% and 77% of patients, respectively. No subjects had jaundice. The median time from initial viremia to seroconversion was 36 days (range, 32 46 days). In one instance, viremia was detected 434 days before seroconversion. However, in no other case was HCV RNA detected >63 days before seroconversion. In subjects with viral persistence, a stable level of HCV RNA in the blood was noted in some subjects within 60 days after the initial detection of viremia, but in others, it was not apparent until >1 year later. In subjects with long-term viral clearance, HCV became persistently undetectable as early as 94 and as late as 620 days after initial viremia. These data underscore the importance of nucleic acid screening of blood donations to prevent HCV transmission and of long-term follow-up to ascertain whether there is viral persistence, at least among injection drug users. Cox, A., Netski, D., Mosbruger, T., Sherman, S., Strathdee, S., Ompad, D., Vlahov, D., Chien D., Shyamala, V., Ray, S. and Thomas, D. Prospective Evaluation of Community-Acquired Acute-Phase Hepatitis C Virus Infection. Clin Infectious Diseases, 40, pp. 951-958, 2005.

Drug Use and HIV Risk Practices of Secondary and Primary Needle Exchange Users

This study examined HIV risk practices associated with secondary needle exchange, obtaining needles from a needle exchange program (NEP) through others who attend in person. Data were analyzed from NEP logs, a survey and HIV testing from 901 drug injectors who (a) always visited NEPs themselves to get needles (primary-only NEP users), (b) obtained at least some NEP needles by having others exchange for them (mixed/secondary NEP users), and (c) obtained no needles from an NEP. About 22% of 40,000 NEP visits involved secondary exchanges, and these accounted for over half of all needles exchanged. In multiple logistic regression analyses, primary-only needle exchange was significantly associated with lower levels of receptive needle sharing, backloading, sharing other injection equipment and lending used needles, and positively associated with obtaining drug treatment. Mixed/secondary needle exchange was associated with less receptive needle sharing and a greater likelihood of drug treatment. Secondary exchange facilitated HIV risk reduction but the salutary effects of NEPs were attenuated in mixed/ secondary exchangers. Huo, D., Bailey, S., Hershow, R. and Ouellet, L. Drug Use and HIV Risk Practices of Secondary and Primary Needle Exchange Users. AIDS Educ Prev. (2), pp. 170-184, April 7, 2005.

Attitudes of Emergency Medical Service Providers Towards Naloxone Distribution Programs

Training and distributing naloxone to drug users is a promising method for reducing deaths associated with heroin overdose. Emergency Medical Service (EMS) providers have experience responding to overdose, administering naloxone, and performing clinical management of the patient. Little is known about the attitudes of EMS providers toward training drug users to use naloxone. An anonymous survey was conducted of 327 EMS providers to assess their attitudes toward a pilot naloxone program. Of 176 who completed the survey, the majority were male (79%) and Caucasian (75%). The average number of years working as an EMS provider was 7 (SD = 6). Overall attitudes toward training drug users to administer naloxone were negative, with 56% responding that this training would not be effective in reducing overdose deaths. Differences in attitudes did not vary by gender, level of training, or age. Providers with greater number of years working in EMS were more likely to view naloxone trainings as effective in reducing overdose death. Provider concerns included drug users' inability to properly administer the drug, program condoning and promoting drug use, and unsafe disposal of used needles. The study concludes that incorporating information about substance abuse and harm reduction approaches in continuing education classes may improve the attitudes of providers toward naloxone training programs. Tobin, K., Gaasch, W., Clarke, C., MacKenzie, E. and Latkin, C. Attitudes of Emergency Medical Service Providers Towards Naloxone Distribution Programs. J Urban Health, 82(2), pp. 296-302, 2005.

The Effect of Serostatus on HIV Risk Behavior Change Among Women

Sex Workers in Miami, Florida HIV prevention and risk reduction are especially salient and timely issues for women, particularly among those who are drug-involved or who exchange sex for drugs or money. Studies suggest that HIV-prevention measures can be effective with highly vulnerable women, and have the potential to produce significant reductions in risk behaviors among both HIV-negative and HIV-positive women. Within this context, this paper examines risk behaviors and HIV serostatus among 407 drug-involved women sex workers in Miami, Florida, and investigates the effects of participation in HIV testing, counseling, and a risk-reduction intervention on subsequent behavioral change among this population. Overall, at follow-up, the HIV-positive women were 2.4 times more likely than the HIV-negative women to have entered residential treatment for drug abuse, 2.2 times more likely to have decreased the number of their sex partners, 1.9 times more likely to have decreased the frequency of unprotected sex, 1.9 times more likely to have reduced their levels of alcohol use, and 2.3 time more likely to have decreased their crack use. These data support the importance of HIV testing and risk-reduction programs for drug-involved women sex workers. Inciardi, J., Surratt, H., Kurtz, S. and Weaver, J. The Effect of Serostatus on HIV Risk Behavior Change Among Women Sex Workers in Miami, Florida. AIDS Care, 17 (Supplement 1): S88-S101, June 2005.

Racial/Ethnic Disparities in Injection Drug Use in Large US Metropolitan Areas

Because Blacks and Latinos bear a disproportionate burden of injection-related health problems compared with whites, this investigation sought to examine and describe black/white and Latino/white disparities in injecting drugs in 94 US metropolitan statistical areas (MSAs) in 1998. Using US Census data and three databases documenting injectors' use of different healthcare services (drug treatment, HIV counseling and testing, and AIDS diagnoses), researchers calculated database-specific black/white and Latino/white disparities in injecting in each MSA and created an index of black/white and Latino/white disparities by averaging data across the three databases. They found that the median black/white injecting disparity in the MSAs ranged from 1.4 to 3.7 across the three databases; corresponding median Latino/white injecting disparities ranged from 1.0 to 1.1. Median black/white and Latino/white index disparity values were 2.6 and 1.0, respectively. The findings suggest that, although whites were the majority of injectors in most MSAs, database-specific and index black/white disparity scores indicate that blacks were more likely to inject than whites. While database-specific and index disparity scores indicate that Latinos and whites had similar injecting rates, they also revealed considerable variation in disparities across MSAs. Future research would help to understand the causes of these disparities, including racial/ethnic inequality and discrimination, and to identify their contributions to the disproportionate burden of injection-related health problems borne by blacks and Latinos. Cooper, H., Friedman, S., Tempalski, B., Friedman, R. and Keem, M. Racial/Ethnic Disparities in Injection Drug Use in Large US Metropolitan Areas. Ann Epidemiol, 15, pp. 326-334, 2005.

Respondent-Driven Sampling to Recruit MDMA Users: A Methodological Assessment

Recruiting samples that are more representative of illicit drug users is an on-going challenge in substance abuse research. Respondent-driven sampling (RDS), a new form of chain-referral sampling, is designed to eliminate the bias caused by the non-random selection of the initial recruits and reduce other sources of bias (e.g. bias due to volunteerism and masking) that are usually associated with regular chain-referral sampling. This study provides a methodological assessment of the application of RDS among young adult MDMA/ecstasy users in Ohio. The results show that the sample compositions converged to equilibrium within a limited number of recruitment waves, independent of the characteristics of the initial recruits (i.e. seeds). The sample compositions approximated the theoretical equilibrium compositions, and were not significantly different from the estimated population compositions-with the exception that White respondents were over-sampled and Black respondents were under-sampled. The effect of volunteerism and masking on the sampling process was found not to be significant. Though identifying productive seeds and improving the referral rate are significant challenges when implementing RDS, the findings demonstrate that RDS is a flexible and robust sampling method. RDS has the potential to be widely employed in studies of illicit drug-using populations. Wang, J., Carlson, R., Falck, R., Siegal, H., Rahman, A. and Li, L. Respondent-Driven Sampling to Recruit MDMA Users: A Methodological Assessment. Drug and Alcohol Depend, 78, pp. 147-157, 2005.

Drug Sharing Among Heroin Networks: Implications for HIV and Hepatitis B and C Prevention

Qualitative and quantitative findings from the baseline survey of a longitudinal, socially focused blood-borne disease intervention study among 611 heroin IDUs in Denver indicate that high risk injection practices-the sharing of contaminated drug solution in particular-often occur as a consequence of how heroin is obtained, the quantity obtained and the setting where it is injected. Contamination occurs if a contaminated syringe is used to liquefy and apportion the shared drug. In a cohort of 304 heroin injecting networks, there was at least one member who, when asked to describe their last injection, reported dividing the drug as a liquid (82%), using a reservoir of water that syringes had been rinsed in to mix drugs (67%), using a common cooker (86%)-a proxy for drug sharing-and beating a shared cotton filter (58%). In contrast, only 22% reported syringe sharing. Variables associated with various injection practices included location of the last injection episode, quantity of drug injected, dope sickness, and years injecting. When compared to those who injected in a safe setting, those in an unsafe location had almost three times the odds (OR = 2.9; 95% CI: 1.9, 4.6) of being part of an injection episode where there was cooker sharing; and the smaller the quantity of heroin (≤1/4 gram v. >1/4 gram) present at the episode, the greater the odds that cooker sharing occurred (OR = 1.8; 95% CI: 1.2, 2.6). Use of a used, unbleached syringe to prepare shared drugs had twice the odds of occurring in "unsafe" v. safe settings (OR = 2.2; 95% CI: 1.3, 4.0) and in episodes in which a participant was dopesick (OR = 2.1; 95% CI: 1.2, 3.6). In summary, this study found that risky injection practices occur within an injection process that is, in part, a response to a structurally imposed risk environment. The findings indicate that reducing the blood-borne disease risks embedded within this process requires interventions designed to mitigate the environmental factors that influence it, including syringe accessibility, law enforcement strategies and the settings where IDUs inject drugs. Koester, S., Glanz, J. and Baron, A. Drug Sharing Among Heroin Networks: Implications for HIV and Hepatitis B and C Prevention. AIDS and Behavior, 9(1), pp. 27-39, 2005.

"Long-Term" and "New" IDUs in a Declining HIV/AIDS Epidemic in Rio de Janeiro, Brazil

A substantial decline of HIV prevalence has been observed in injection drug users (IDUs) from Rio de Janeiro, in recent years. Differential characteristics and behaviors of new (injecting for <6 years) and long-term (>= 6 years) injectors may help to understand recent changes and to implement appropriate prevention strategies. Between October 1999 and December 2001, 609 active/ex-IDUs were recruited from different communities, interviewed, and tested for HIV. Contingency table analysis and t-tests were used to assess differences between new and long-term injectors. Multiple Logistic Regression was used to identify independent predictors of HIV serostatus for long-term and new injectors. HIV prevalence was found to be 11.7% for 309 long-term injectors (95% CI 8.1- 15.3) and 4.3% for 300 new injectors (95% CI 2.0-6.6). New injectors reported having engaged in treatment and having received syringes from needle exchange programs (NEPs) more frequently than long-term injectors in the last 6 months, but sharing behaviors remained frequent and even increased vis-a`-vis long-term injectors. For male new injectors, "sexual intercourse with another man" was found to be the sole significant risk factor for HIV infection (Adj OR=8.03; 95% CI 1.52-42.48). Among male long-term injectors, ‘‘to have ever injected with anyone infected with HIV'' (Adj OR=3.91; 95% CI 1.09-14.06) and to have ‘‘ever been in prison'' (Adj OR=2.56; 95% CI 1.05-6.24) were found to be significantly associated with HIV infection. New injectors are seeking help in drug treatment centers or needle exchange programs. They differ from long-term injectors in terms of their risk factors for HIV infection and have lower prevalence levels for HIV. Such differences may help to understand the recent dynamics of HIV/AIDS in this population and highlight the need to reinforce new injectors' help-seeking behavior and to reduce current unacceptably high levels of unprotected sex and syringe sharing in new injectors despite attendance of prevention/treatment programs. Hacker, M., Friedman, S., Telles, P., Teixeira, S., Bongertz, V., Morgado, M. and Bastosi, F. The Roles of "Long-Term" and "New" IDUs in a Declining HIV/AIDS Epidemic in Rio de Janeiro, Brazil. Subst Use & Misuse, 40, pp. 99-123, 2005.

Challenges to Research on HIV/AIDS Among Migrant and Immigrant Hispanic Populations in the U.S.

Migrant populations in the U.S. have been found to be at risk for HIV/AIDS. The growth in immigrant and migrant Hispanic populations increases the need to enhance understanding of influences on their HIV-risk behaviors. Four challenges to conducting research among these populations have been identified: (1) the need to use multilevel theoretical frameworks; (2) the need to differentiate between Hispanic subgroups; (3) challenges to recruitment and data collection; and (4) ethical issues. This article describes how two studies of Hispanic immigrants and migrants in the New York area addressed these challenges. One study focused on new immigrants from Mexico, the Dominican Republic, El Salvador, Honduras and Guatemala, and a second study focused on Puerto Rican drug users. Both studies incorporated qualitative and quantitative methods to study these hard-to-reach populations. Continued research to understand socio-cultural and contextual factors affecting drug abuse and HIV risk among mobile and migrant populations is crucial to developing sustainable and effective intervention programs. Deren, S., Shedlin, M., Decena, C. and Mino, M. Challenges to Research on HIV/AIDS Among Migrant and Immigrant Hispanic Populations in the U.S. J Urban Health, 82(2), Spplt 3: 13-25, 2005.

Predictors of High Rates of Suicidal Ideation Among Drug Users

Several studies have attempted to understand the link among substance abuse, depression, and suicidal ideation (SI). Assessment of this link is important to develop specific interventions for persons in substance abuse treatment. This association was tested among 990 drug users in and out of treatment with significant criminal justice histories from two NIDA-sponsored studies. The Diagnostic Interview Schedule and Substance Abuse Module assessed DSM-III-R depression, number of depression criteria met, antisocial personality disorder (ASPD), and substance use disorders. Compared with men, women were twice as likely to report depression (24% vs. 12%), whereas men were nearly twice as likely to report ASPD (42% vs. 24%). High rates of SI were found, with women more likely than men to report thoughts of death (50% vs. 31%), wanting to die (39% vs. 21%), thoughts of committing suicide (47% vs. 33%), or attempting suicide (33% vs. 11%); 63% of women and 47% of men reported at least one of these suicidal thoughts or behaviors. Male and female ideators were more likely than nonideators to report depressed mood and to meet criteria for depression, ASPD, and alcohol use disorders. Male ideators were more likely than male nonideators to meet criteria for cocaine use disorders. Using logistic regression, SI among men was predicted by alcohol use disorder (OR - 1.60), ASPD (OR - 1.59), and number of depression criteria (OR _ 9.38 for five criteria). Among women, SI was predicted by older age, marital status, alcohol use disorder (OR - 2.77), and number of depression criteria (OR - 9.12 for five criteria). These original findings point out the need to discuss suicidal thoughts among depressed drug users for early treatment and prevention. Cottler, L., Campbell, W., Krishna, V., Cunningham-Williams, R. and Abdallah, A. Predictors of High Rates of Suicidal Ideation Among Drug Users. J Nerv Ment Dis,193, pp. 431-437, 2005.

Knowledge of Hepatitis among Active Drug Injectors at a SEP

IDUs are at high risk for contracting and spreading viral hepatitis through nonsterile injection practices, unprotected sexual contact, and unsanitary living conditions. This study sought to characterize hepatitis knowledge, prior testing, and vaccination history among IDUs at a New York City syringe exchange program (SEP). IDU subjects generally had a poor understanding of viral hepatitis transmission and prevention. They also had low vaccination rates: only 8% reported receiving hepatitis A vaccine and 11% hepatitis B vaccine. These findings suggest that educating IDUs about risky behaviors and medical preventive interventions, such as vaccines for hepatitis A and B and treatment for hepatitis C, may help prevent disease and reduce transmission. Stronger linkages between health-care centers and SEPs, drug treatment programs, and other service delivery centers where IDUs are encountered may promote hepatitis education and vaccination. Carey, J., Perlman, D., Friedmann, P., Kaplan, W., Nugent, A., Deutscher, M., Masson, C. and Des Jarlais, D. Knowledge of Hepatitis among Active Drug Injectors at a SEP. J Subst Abuse Treat, 29, pp. 47- 53, 2005.

Use of Electronic Debit Cards in Longitudinal Data Collection with Geographically Mobile Drug Users

This study sought to assess the use of electronic debit (ATM) cards in conducting longitudinal research with geographically mobile ("urban nomad") drug users. Young illicit drug users with recent travel history were street-recruited from the Lower East Side area of New York City. Multiple efforts were made to develop rapport and positive relationships between participants and the study. Honoraria were paid through electronic debit cards usable at ATMs countrywide. Participants were encouraged to complete follow-up interviews in person if they were in New York City, or by telephone if elsewhere. Follow-up rates from two other recent cohort studies of young drug users in New York were used to compare with those from this study. 139 participants were recruited between 2001-2002. They had traveled extensively, averaging 31 trips per participant to different cities during the prior 3 years. Telephone follow-up interviews were obtained from participants in over 200 different cities/towns. The follow-up rates were 81% at 6 months and 71% at 12 months, substantially higher than corresponding rates in the comparison studies. The use of electronic debit cards, combined with other efforts to develop positive relationships and rapport with participants, led to high rates of continued study participation. Debit cards appear to be a useful and promising approach to conduct longitudinal research with geographically mobile populations. Des Jarlais, D., Perlis, T. and Settembrino, J. The Use of Electronic Debit Cards in Longitudinal Data Collection with Geographically Mobile Drug Users. Drug and Alcohol Depend, 77, pp. 1-5, 2005.

Barriers to Health and Social Services for Street-Based Sex Workers

Homelessness, poverty, drug abuse and violent victimization faced by street-based women sex workers create needs for a variety of health and social services, yet simultaneously serve as barriers to accessing these very services. Researchers utilized interview (n = 586) and focus group (n = 25) data to examine the service needs and associated barriers to access among women sex workers in Miami, Florida. Women most often reported acute service needs for shelter, fresh water, transportation, crisis intervention, and drug detoxification, as well as long-term needs for mental and physical health care, drug treatment, and legal and employment services. Barriers included both structural (e.g., program target population, travel costs, office hours, and social stigma) and individual (e.g., drug use, mental stability, and fear) factors. Bridging these gaps is tremendously important from a public health perspective given the disease burden among this population. The findings support additional efforts to improve service staff training and outreach and to reduce marginalization and stigma in this population through peer education, empowerment, and accessing care and treatment. Kurtz, S., Surratt, H., Kiley, M. and Inciardi, J. Barriers to Health and Social Services for Street-Based Sex Workers. J Health Care for the Poor and Underserved, 16, pp. 345-361, 2005.

Post-Circuit Blues: Motivations and Consequences of Crystal Meth Use among Gay Men in Miami

Miami, Florida was at the vanguard of the rise of circuit parties and attendant club drug use--especially ecstasy, GHB, and ketamine-in the 1990s. Crystal methamphetamine, a drug of abuse among gay men for some years on the West coast, gradually moved east toward the end of the decade and recently became prevalent in Miami. This paper reports the results of focus group research into the motivations and consequences of crystal use among gay men in this new setting. Loneliness, fears about physical attractiveness due to aging and illness, and desires to lose sexual inhibitions were common motivations for using the drug. Continued use of crystal was often described as the cause of lost friendships, employment and long-term relationships, as well as sexual behaviors that put men at risk for HIV and other sexually transmitted infections. Implications for drug and sexual risk prevention interventions are discussed. Kurtz, S. Post-Circuit Blues: Motivations and Consequences of Crystal Meth Use Among Gay Men in Miami. AIDS Behav., 9(1), pp. 63-72, 2005.

The Social Structural Production of HIV Risk among IDUs

In this paper, researchers discuss the increasing appreciation for and need to understand how social and structural factors shape HIV risk. Drawing on a review of recently published literature, they describe the social structural production of HIV risk associated with injecting drug use. They use an inclusive definition of the HIV ‘risk environment' as the space, whether social or physical, in which a variety of factors exogenous to the individual interact to increase vulnerability to HIV. Factors identified as critical in the social structural production of HIV risk associated with drug injecting include cross-border trade and transport links; population movement and mixing; urban or neighborhood deprivation and disadvantage; specific injecting environments (including shooting galleries and prisons); the role of peer groups and social networks; the relevance of ‘social capital' at the level of networks, communities and neighborhoods; the role of macro-social change and political or economic transition; political, social and economic inequities in relation to ethnicity, gender and sexuality; the role of social stigma and discrimination in reproducing inequity and vulnerability; the role of policies, laws and policing; and the role of complex emergencies such as armed conflict and natural disasters. The researchers argue that the HIV risk environment is a product of interplay in which social and structural factors intermingle but where political-economic factors may play a predominant role; moreover, ‘structural HIV prevention' implies community actions and structural changes within a broad framework concerned to alleviate inequity in health, welfare and human rights. Rhodes, T., Singer, M., Bourgois, P., Friedman, S. and Strathdee, S. The Social Structural Production of HIV Risk among IDUs. Social Science and Medicine, 61, pp. 1026-1044, 2005.

Herpes Simplex Virus 2 and Syphilis Among Young Drug Users in Baltimore, Maryland

To examine the sex specific seroprevalence and correlates of herpes simplex virus 2 (HSV-2) and syphilis among a cohort of young drug users, researchers recruited drug users aged 15-30 years old who used heroin, cocaine, or crack between October 1999 and August 2002. Baseline interviews gathered information on socio-demographics, drug use and sexual behaviors. Serum was tested at baseline for HSV-2 and syphilis seroreactivity. For each sexually transmitted infection (STI), infected and non-infected participants were stratified by sex and compared using x2, Mann-Whitney tests, and logistic regression. The study found that, of the 543 participants recruited, 42.4% were female and 39.3% were African-American. The seroprevalence of STIs among females and males, respectively, were HSV-2: 58.7% and 22.0%; syphilis: 4.3% and 0.3%. In multivariate models, older age, African-American race, having over 30 lifetime sex partners, current HIV infection and previous incarceration were independently associated with HSV-2 infection among males. For females, older age, African-American race, sex trade, and daily heroin use were independently associated with HSV-2. For females, only a self reported previous syphilis diagnosis was associated with current syphilis seroreactivity in multivariate analyses. Examination of this cohort revealed a particularly high seroprevalence of HSV-2 and syphilis, especially among female drug users. Few infected participants had been previously diagnosed with these infections. Plitt, S., Sherman, S., Strathdee, S. and Taha, T. Herpes Simplex Virus 2 and Syphilis Among Young Drug Users in Baltimore, Maryland. Sex Transm Inf., 81, pp. 248-253, 2005.

Drinking Restraint and Alcohol Outcomes Among COAs

A subsample from a longitudinal study on children of alcoholics (COAs) (COAs, n= 189; controls, n=192), including participants with complete data from two relevant collection periods (Time 3, Mean age = 15.1 and Time 4, Mean age = 20.3), was included in this study on associations among parent alcoholism, early drinking restraint, and alcohol-related outcomes. Findings replicate and extend previous cross-sectional literature by replicating the main effects of drinking restraint as a risk factor for subsequent drinking for controls. However, for COAs, drinking restraint was protective against subsequent alcohol use. Furthermore, participants at the extreme levels of drinking restraint were least likely to develop alcohol dependence. Trim, R.S. and Chassin, L. Drinking Restraint, Alcohol Consumption, and Alcohol Dependence Among Children of Alcoholics. Stud Alcohol, 65, pp. 122-125, 2004.

Resilience, Internalizing Symptomology, and Positive Affect in a Community Sample of Children of Alcoholics

This sample was part of a larger longitudinal study of non-Hispanic Caucasian and Hispanic adolescents and their families (N=216 children of alcoholics [COAs], N=201 non COAs] recruited through court records, HMO well being evaluations, and community telephone surveys. Computer assisted interviews were conducted three times at yearly interviews. A subset of COAs performing at high and average levels of competence levels in multiple domains were identified. However, in comparison to matched controls, fewer COAs performed in a highly competent manner, and more performed in a low-competent manner for both the conduct/rule-abiding and academic competence domains. No significant differences were found between COAs and controls in the domain of social competence. For both COAs and controls, high competence was associated with fewer internalizing symptoms and the endorsement of positive affect. These findings suggest that behavioral resilience is not associated with psychological costs but is associated with decreased internalizing and increased positive affect. The authors conclude that efforts to encourage competent performance in COAs should be associated with decreased internalizing symptomatology and increased positive affect, serving to increase positive mental health for COAs. Carle, A.C. and Chassin L. Resilience in a Community Sample of Children of Alcoholics: Its Prevalence and Relation to Internalizing Symptomatology and Positive Affect. Applied Developmental Psychology, 25, pp. 577-595, 2005.

Homogeneity and Heterogeneity of Drug Use Patterns Within and Between Hispanic Students in the U.S

Data from the Monitoring the Future study were used to compare trends in and correlates of marijuana use, cocaine use, and heavy alcohol use for adolescents of Mexican American, Puerto Rican, Cuban, and other Latin American heritage in the United States. Data from nationally representative samples of eighth-grade Hispanic students who participated in the Monitoring the Future study during the years 1991-2002 (n=24,235) were analyzed. This study found that drug use differed considerably according to ethnic group on language first spoken, parental education, urbanicity, and region. In addition, drug use was significantly higher among boys and adolescents of almost all Hispanic ethnicities who did not live with both parents. The study findings suggest that the heterogeneity in drug use patterns among adolescents of different Hispanic ethnicities should be considered in the development and targeting of prevention programs. Delva, J., Wallace, J.M., O'Malley, P.M., Bachman, J.G., Johnston, L.D. and Schulenberg, J.E. American Journal of Public Health, 95(4), pp. 696-702, April 2005.

The Relationship Between College Fraternity/Sorority Membership and Substance Use

Nationally representative probability samples of US high school seniors (modal age 18 years) were followed longitudinally across two follow-up waves during college (modal ages 19/20 and 21/22). The longitudinal sample consisted of 10 cohorts (senior years of 1988 97) made up of 5883 full-time undergraduate students, of whom 58% were women and 17% were active members of fraternities or sororities. Analysis of the longitudinal data revealed that active members of fraternities and sororities had higher levels of heavy episodic drinking, annual marijuana use and current cigarette smoking than non-members at all three waves. Although members of fraternities reported higher levels than non-members of annual illicit drug use other than marijuana, no such differences existed between sorority members and non-members. Heavy episodic drinking and annual marijuana use increased significantly with age among members of fraternities or sororities relative to non-members, but there were no such differential changes for current cigarette use or annual illicit drug use other than marijuana. These findings indicate that the higher rates of substance use among US college students who join fraternities and sororities predate their college attendance, and that membership in a fraternity or sorority is associated with considerably greater than average increases in heavy episodic drinking and annual marijuana use during college. These findings have important implications for prevention and intervention efforts aimed toward college students, especially members of fraternities and sororities. McCabe, S.E., Schulenberg, J.E., Johnston, L.D., O'Malley, P.M., Backman, J.G. and Kloska, D.D. Selection and Socialization Effects of Fraternities and Sororities on US College Student Substance Use: A Multi-cohort National Longitudinal Study, Addiction, 100, pp. 512-524, 2005.

Substance Use Disorders Among Adolescents Who Use Marijuana and Inhalants

This study examined the association between the use of inhalants, marijuana, and other drugs and recent DSM-IV substance use disorders among adolescents aged 12-17 years. Data were drawn from 2000 to 2001 National Household Surveys on Drug Abuse. Adolescents aged 12-17 years who reported having ever used an illicit drug in their lifetime were categorized into four mutually exclusive groups: inhalant users (16%), marijuana users (53%), inhalant and marijuana users (16%), and other drug users (15%). Logistic regression models were used to estimate associations with recent substance use diagnoses among lifetime adolescent drug users (N= 10,180). Analyses revealed that 31% of lifetime drug users reported having never used marijuana. One half of these atypical drug users were predominantly nonmedical users of pain relievers. Adolescents who used inhalants or other drugs but not marijuana were least likely to report multidrug use. Adolescents who reported using both inhalants and marijuana were most likely to use three or more classes of drugs (73%) and to receive a diagnosis of past year alcohol (35%) and drug (39%) abuse or dependence. These findings suggest that among lifetime adolescent drug users, those who use both inhalants and marijuana are at very high risk for alcohol and drug use disorders, underscoring the importance of early-targeted interventions. Wu, L.T., Pilowsky, D.J. and Schlenger, E.W. High Prevalence of Substance Use Disorders Among Adolescents Who Use Marijuana and Inhalants. Drug and Alcohol Dependence, 78(1), pp. 23-32, April 2005.

Parent Occupation, Education, and Smoking and Adult Offspring Smoking

This study includes 603 families that have been followed for a period of 25 years (86.7% and 81.7% of the children's mothers and fathers, respectively, had an educational level of 12th grade or higher; 77.5% of the youth had a mother and/or father belonging to the white-collar occupational class. The two objectives include: (1) examining the independent associations between two components of parental SES (educational attainment and blue-collar/white-collar occupational status) and adult offspring smoking; and (2) examining the intervening factors between parental educational achievement, parental occupational status, and prenatal smoking, and smoking in their adult offspring. Findings suggest that parental blue-collar status, low parental educational achievement, and parental smoking were related to adult offspring smoking. This link was mediated by parent - child relationship, which in turn was mediated by smoking in late adolescence with respect to adult offspring smoking. Both components of parental SES (low educational achievement and blue-collar status) predict smoking in their adult offspring, although the respective pathways were somewhat different. Specifically, parental education showed a direct pathway to adult offspring smoking, whereas the parental occupation pathway was mediated by smoking in late adolescence. Parental blue-collar (versus white-collar) occupational status was associated with less parent-child mutual attachment (e.g., greater parent-child conflict, less identification with the parent), and lower parental educational aspirations for their children. Interestingly, weaker parent-child bond was associated with smoking in late adolescence, which was the most powerful predictor of adult offspring smoking. Fagan, P., Brook, J.S., Rubenstone, E. and Zhang, C. Parental Occupational, Education, and Smoking as Predictors of Offspring Tobacco Use in Adulthood: A Longitudinal Study. Addictive Behaviors, 30, pp. 517-529, 2005.

Coping Styles and Stress from Adolescence to Adulthood Among COAs

This study used a longitudinal design to examine the development of coping styles over adolescence, continuity in these coping styles, the impact of coping on adult stress and substance use, and differences in coping between children of alcoholics and their peers. The sample of 340 adolescents were followed from 11 to 23 years of age. Small to moderate effect sizes suggested inter-individual continuity in coping over time, such that those higher than their peers in planful or cognitive-avoidant coping at one point in time were likely to be higher than their peers at another point in time as well. Significant intra-individual change over time was found in the normative trends in coping, as well as inter-individual differences among adolescents in their coping trajectories. Individual trajectories of both planful and cognitive-avoidant coping showed mean decrements over time, suggesting an average decrease over adolescence. Adolescent coping continued to modestly predict coping styles in young adulthood. Adolescent planful coping predicted greater active coping in adulthood, whereas adolescent avoidant cognitive coping predicted greater avoidant coping in adulthood. The relation between transition-related stress that may be somewhat controllable and alcohol use was exacerbated by greater avoidant coping. However, a marginally significant interaction between major life events, which tend to be uncontrollable, and drug use was buffered by greater avoidant coping. This suggests that avoidant coping may be more useful for uncontrollable as opposed to controllable stressors. COAs reported less planful coping and more cognitive-avoidant coping in adolescence as well as less active coping in young adulthood. Hussong, A.M. and Chassin, L. Stress and Coping Among Children of Alcoholic Parents through the Young Adult Transition. Development and Pyschopathology, 16, pp. 985-1006, 2004.


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