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Director's Report to the National Advisory Council on Drug Abuse - September, 2008

Research Findings - Research on Behavioral and Combined Treatments for Drug Abuse

Cognitive Deficits in Marijuana Users: Effects on Motivational Enhancement Therapy Plus Cognitive Behavioral Therapy Treatment Outcome

The clinical variables that affect treatment outcome for marijuana-dependent individuals are not yet well understood, including the effects of cognitive functioning. Dr. Aharonovich and colleagues from Columbia University did a study to address this by investigating the level of cognitive functioning and treatment outcome. At the beginning of treatment, 20 marijuana-dependent outpatients were given a series of tests that measure psychological functioning known to be linked to particular brain structures or pathways. All patients received 12 weekly individual sessions of combined motivational enhancement therapy and cognitive behavioral therapy. Cognitive functioning test scores were compared between those who completed and those who dropped out of treatment. Also, the proportion of urine samples that were negative for marijuana was compared between those with higher and lower scores on the cognitive tests. Marijuana abstinence was unrelated to cognitive functioning, however, dropouts scored significantly lower than completers on measures of abstract reasoning and processing accuracy. These results provide initial evidence that cognitive functioning plays a role in retaining adult marijuana-dependent patients in treatment. If supported by further studies, the findings may help inform the development of interventions made specifically for cognitively impaired marijuana-dependent patients. Aharonovich, E., Brooks, A., Nunes, E., and Hasin, D. Cognitive Deficits in Marijuana Users: Effects on Motivational Enhancement Therapy plus Cognitive Behavioral Therapy Treatment Outcome. Drug. Alcohol Depend., 95(3), pp. 279-283, 2008.

Menstrual Phase Effects on Smoking Relapse

The research on smoking cessation suggests that women have a more difficult time quitting than do men, although the reasons for this are not well understood. Some studies have found that smoking behavior fluctuates with the menstrual phase cycle, where smoking and craving is higher in the luteal than the follicular phase, making it more difficult to quit during that phase. To test this, Dr. Allen and colleagues from the University of Minnesota conducted a study to examine if menstrual phase affects relapse in 202 women who were attempting to quit smoking. The women were assigned to quit smoking in either the follicular (F) or luteal (L) menstrual phase and were followed for up to 26 weeks. They measured how many days before relapse and relapse phase to determine if those who begin a quit attempt during the F phase were more successful than those who begin during the L phase. The mean number of days to relapse after a period of continuous abstinence for the F group was 13.9 versus 21.5 days for the L group. Relapse from prolonged abstinence for the F group was 20.6 versus 39.2 days for the L group. At 14 days, 84% of the F group had relapsed compared with 65% of the L group. At 30 days, 86% of the F group relapsed, compared with 66% of the L group. These results suggest that women attempting to quit smoking in the F phase had less favorable outcomes than those attempting to quit in the L phase. This could relate to ovarian hormones, which may play a role in smoking cessation for women. Allen, S.S., Bade, T., Center, B., Finstad, D., and Hatsukami, D. Menstrual Phase Effects on Smoking Relapse. Addiction, 103(5), pp. 809-821, 2008.

Distress Tolerance Treatment for Early-Lapse Smokers: Rationale, Program Description, and Preliminary Findings

A significant percentage of individuals attempting to quit smoking have a cigarette within a matter of days, and very few are able to recover to achieve long-term abstinence. This observation suggests that many smokers may have a history exclusively of quitting only to return to smoking very soon after. Recent evidence suggests that certain individuals' reactions to, and the inability to tolerate, withdrawal symptoms (rather than withdrawal severity itself), may represent an important treatment target for developing new behavioral interventions for these individuals. In this article, Dr. Brown and colleagues from Brown Medical School describe a novel, multi-component distress-tolerance treatment for smokers who repeatedly return to smoking shortly after quit attempts that incorporates behavioral and pharmacological elements of standard smoking-cessation treatment. The theoretical rationale for the treatment is presented, drawing distress-tolerance elements from exposure-based and Acceptance and Commitment Therapy-based treatment approaches. The article also presents preliminary data from a pilot study (N = 16) and discusses the clinical implications of this approach. Brown, R., Palm, K., Strong, D., Lejuez, C., Kahler, C., Zvolensky, M., Hayes, S., Wilson, K., and Gifford, E. Distress Tolerance Treatment for Early-Lapse Smokers: Rationale, Program Description, and Preliminary Findings. Behav. Modif., 32(3), pp. 302-332, 2008.

Behavioral Drug and HIV Risk Reduction Counseling (BDRC) with Abstinence-Contingent Take-Home Buprenorphine: A Pilot Randomized Clinical Trial

Office-based buprenorphine maintenance treatment (BMT) is usually provided with limited counseling or oversight of medication adherence. Dr. Chawarski and colleagues from Yale University evaluated whether the efficacy of BMT is improved by adding individual drug counseling and take-home doses of buprenorphine that are given contingent on being drug-free. After a 2-week buprenorphine and stabilization period, heroin dependent individuals (n=24) in Muar, Malaysia were randomly assigned to Standard Services BMT (physician administered advice and support, and weekly, non-contingent medication pick-up) or Enhanced Services (nurse-delivered manual-guided behavioral drug and HIV risk reduction counseling (BDRC) and abstinence-contingent take-home buprenorphine (ACB), 7 day supply maximum). Outcomes included retention, proportion of opioid-negative urine tests, self-reported drug use, and self-reported HIV risk behaviors. 12/12 (100%) of Enhanced Services and 11/12 (92%) of Standard Services participants completed the entire study. The proportion of opioid-negative urine tests increased significantly over time for both groups, and the reductions were significantly greater in the Enhanced Services group. Enhanced Services group gave significantly higher overall proportions of opiate negative urine tests (87% vs. 69%), and tended to have longer periods of consecutive abstinence from opiates (10.3 weeks vs. 7.8 weeks). Both groups significantly reduced HIV risk behaviors to a similar degree during treatment (26% vs. 17% reductions from the baseline levels for Enhanced and Standard Services, respectively). These results suggest that manual-guided behavioral drug and HIV risk reduction counseling and abstinence-contingent take-home buprenorphine may improve office-based BMT provided with limited drug counseling and medication oversight. Chawarski, M., Mazlan, M., and Schottenfeld, R. Behavioral Drug and HIV Risk Reduction Counseling (Bdrc) with Abstinence-Contingent Take-Home Buprenorphine: A Pilot Randomized Clinical Trial Drug. Alcohol Depend, 94(1-3), pp. 281-284, 2008.

Evaluation of Ongoing Oxycodone Abuse among Methadone-Maintained Patients

Prevalence of prescription opioid abuse has increased dramatically in recent years in the United States generally, and a similar pattern of increasing prescription opioid use has also been noted among patients seeking treatment for opioid dependence. Drs. Dunn and Higgins and colleagues from the University of Vermont evaluated 100 patients in outpatient methadone maintenance (MM) treatment and examined the extent of ongoing oxycodone abuse that might be going undetected with current urinalysis-testing methods. Urine samples were collected from these patients over a 6-week period and analyzed using the clinic's usual enzyme multiplied immunoassay test (EMIT) opiate assay (300 ng/ml opiate cutpoint), and a supplemental oxycodone test strip (100 ng/ml oxycodone cutpoint). The EMIT assay identified only 6% (20/437) of samples as positive for oxycodone, whereas the oxycodone test strip indicated that 19% (83/437) tested positive for recent oxycodone use. Oxycodone users were more likely to report a prescription opioid as their primary drug at intake, be in MM treatment for a significantly shorter duration, and provide significantly more opioid- and cocaine-positive urine samples. Overall, these data illustrate the potential importance of monitoring for ongoing oxycodone use in MM clinics. Although future efforts should examine this question using more rigorous experimental methods, findings from this initial project have implications for clinical issues such as evaluating patient stability in treatment, making medication-dosing decisions, and determining patient eligibility for methadone take-home privileges. Dunn, K., Sigmon, S., McGee, M., Heil, S., and Higgins, S. Evaluation of Ongoing Oxycodone Abuse among Methadone-Maintained Patients. J. Subst. Abuse Treat., 2008 Feb 21 [E-pub ahead of print].

Latinos and HIV/AIDS: Examining Factors Related to Disparity and Identifying Opportunities for Psychosocial Intervention Research

Latinos maintain an AIDS case rate more than 3 times higher than whites, a greater rate of progression to AIDS, and a higher rate of HIV/AIDS-related deaths. Dr. Gonzalez and colleagues from Massachusetts General Hospital reviewed three broad areas related to these disparities: (1) relevant demographic, socioeconomic, and socio-cultural factors among Latinos; (2) drug abuse and mental health problems in Latinos relevant to HIV/AIDS outcomes; and (3) opportunities for psychosocial intervention. Latinos living with HIV are a rapidly growing group, are more severely impacted by HIV than whites, and confront unique challenges in coping with HIV/AIDS. A body of research suggests that depression, substance abuse, treatment adherence, health literacy, and access to healthcare may be fruitful targets for intervention research in this population. Though limited, the current literature suggests that psychosocial interventions that target these factors could help reduce HIV/AIDS disparities between Latinos and whites and could have important public health value. Gonzalez, J., Hendriksen, E., Collins, E., Duran, R., and Safren, S. Latinos and HIV/AIDS: Examining Factors Related to Disparity and Identifying Opportunities for Psychosocial Intervention Research. AIDS Behav., 2008 [E-pub ahead of print].

Therapeutic Education System (TES) to Augment Office Based Buprenorphine

Office based buprenorphine offers a novel way to treat opioid abuse which may reduce barriers to care because patients can receive opioid maintenance pharmacotherapy via a physician without having to attend treatment at a methadone clinic. Drs. Bickel, Marsch, and colleagues have developed a web based computerized therapeutic education system (TES) based on a promising behavioral treatment called the Community Reinforcement Approach (CRA) to provide skills training and psycho-education and abstinence reinforcement which are not typically a focus of physician training but which are thought to influence pharmacotherapy outcomes. Researchers conducted a randomized clinical trial of buprenorphine maintained patients comparing opioid and cocaine using patients randomized to (1) TES plus Voucher Reinforcement plus in person therapy every other week vs. (2) Completely in-person therapist delivered CRA treatment plus Voucher Reinforcement therapy, vs. (3) Standard Treatment (buprenorphine alone). Both the computerized augmented treatment plus Vouchers and the therapist delivered CRA plus Vouchers conditions produced more weeks of cocaine and opioid abstinence than usual care indicating the novel behavioral treatments did indeed augment the pharmacotherapy. Additionally, although durations of abstinence were similar in the computer augmented and therapist only delivered conditions, participants in the computer augmented conditions spent 934 minutes less on average with their therapists than did those in the non-computerized condition. Results suggest that computer augmented treatment may be a useful way to reduce staff and patient time for behavioral treatment while still improving treatment over standard medication alone. Further studies are needed to examine what effect the TES contributes beyond the Abstinent Contingent Voucher Component of the behavioral treatment. Bickel, W., Marsch, L., Buchhalter, A., and Badger, G. Computerized Behavior Therapy for Opioid-dependent Outpatients: A Randomized Controlled Trial. Exp. Clin. Psychopharm., 16(2), pp.132-143, 2008.

Predictors of Dropout from Group Therapy among Patients with Bipolar and Substance Use Disorders

Bipolar and substance use disorders frequently occur together. Group therapies that integrate treatment for both disorders can effectively reduce substance use, but no study has examined factors related to early drop out from integrated group therapy. Dr. Weiss and colleagues from Harvard Medical School identified baseline demographic and clinical characteristics that predict treatment dropout among patients with co-occurring bipolar and substance use disorders. Baseline data were analyzed from patients who took part in a randomized controlled trial of integrated group therapy for bipolar and substance use disorders. Cigarette smoking, recent mood episode, and lack of a college education were strong predictors of dropout. This was the case even after possible associations with other demographic and substance use variables were taken into account. These results suggest that, given the strength of smoking as a predictor of dropout as well as the high rate of smoking among this population, a greater focus on the relationship between smoking and bipolar disorder may be needed to potentially reduce the rate of early dropout from integrated treatment. Graff, F., Griffin, M., and Weiss, R. Predictors of Dropout from Group Therapy among Patients with Bipolar and Substance Use Disorders. Drug Alcohol Depend., 94(1-3), pp. 272-275, 2008.

Effects of Voucher-Based Incentives on Abstinence from Cigarette Smoking and Fetal Growth among Pregnant Women

Drs. Heil and Higgins and colleagues from the University of Vermont examined whether vouchers that are given contingent upon smoking abstinence during pregnancy are an effective way to decrease maternal smoking and improve fetal growth. A total of 82 smokers entering prenatal care were randomly assigned to either contingent or non-contingent voucher conditions. Vouchers exchangeable for retail items were available during pregnancy and for 12 weeks postpartum. In the contingent condition, vouchers were earned for biochemically verified smoking abstinence; in the non-contingent condition, vouchers were earned independent of smoking status. Smoking outcomes were evaluated using urine-toxicology testing and self-report. Fetal growth outcomes were evaluated using serial ultrasound examinations performed during the third trimester. Contingent vouchers significantly increased abstinence at the end-of-pregnancy (41% versus 10%) and at the 12-week postpartum point (24% versus 3%). There was significantly greater fetal growth with the contingent condition in terms of estimated weight, femur length and abdominal circumference. These results provide further evidence that abstinent-contingent vouchers can substantially decrease maternal smoking during pregnancy, and provide new evidence of positive effects on fetal health. Heil, S., Higgins, S., Bernstein, I., Solomon, L., Rogers, R., Thomas, C., Badger, and G. Lynch, M. Effects of Voucher-Based Incentives on Abstinence from Cigarette Smoking and Fetal Growth among Pregnant Women. Addiction, 103(6), pp. 1009-1018, 2008.

Attempts to Stop or Reduce Marijuana Use in Non-Treatment Seekers

Dr. Hughes and colleagues at the University of Vermont examined the short-term outcomes of individuals who intended to quit or reduce their marijuana use on their own, without seeking treatment. Daily marijuana smokers (n=19) called a phone each night for 28 nights to report marijuana use and reported intentions to change at the end of each week. Outcomes did not differ between those who initially planned to reduce vs. quit in the next month. Participants averaged three attempts to reduce and one attempt to quit during the 28 days. Participants reduced marijuana use on 11% and abstained from marijuana on 14% of days. Most were successful in reducing or abstaining on half or more of the days they attempted; however, only four participants (21%) reduced 50% or more for at least 7 consecutive days, and only two (10%) abstained for that long. Abstinence or reduction did not appear to change alcohol or caffeine use. The authors concluded that: (a) initial intentions are poor predictors of outcomes, (b) most users make multiple, short-lived attempts to change, (c) reduction was as common as abstinence, (d) many attempts to change are initially successful but few persist, and (e) other drug use does not appear to worsen with marijuana reduction or abstinence. Hughes, J., Peters, E., Callas, P., Budney, A., and Livingston, A. Attempts to Stop or Reduce Marijuana Use in Non-Treatment Seekers. Drug Alcohol Depend., 97(1-2), pp. 180-184, 2008.

Exercise as an Adjunct to Nicotine Gum in Treating Tobacco Dependence among Women

The acute effects of exercise on reducing withdrawal from and craving for cigarettes has suggested that exercise may be a useful adjunct for smoking cessation treatment. Dr. Kinnunen and colleagues from Harvard conducted the first randomized controlled trial assessing the efficacy of an exercise intervention as an adjunct to nicotine gum therapy. They compared the exercise intervention with both an equal contact control and a standard care control condition. Sedentary female smokers (N = 182) aged 18-55 years were provided with nicotine gum treatment along with brief behavioral counseling and were randomized into one of these three behavioral adjunct conditions. At the end of treatment and at 1-year follow-up, there were clear trends showing that both the exercise and equal contact control conditions had higher rates of abstinence than the standard care control, although the effect was not statistically significant. However, the equal contact condition had a significantly lower likelihood of relapse after 1 week compared with the standard care condition and there was a near significant trend in which exercise offered an advantage over standard care as well. While these findings suggest a slightly improved likelihood of abstinence with exercise compared with standard care, exercise did not differ from equal contact control in its efficacy. Potential explanations for these equivalent levels of efficacy and implications for the findings are discussed. Kinnunen, T., Leeman, R., Korhonen, T., Quiles, Z., Terwal, D., Garvey, A., and Hartley, H. Exercise as an Adjunct to Nicotine Gum in Treating Tobacco Dependence among Women. Nicotine Tob. Res., 10(4), pp. 689-703, 2008.

Smoking in Help-Seeking Veterans with PTSD Returning from Afghanistan and Iraq

Past research has shown that veterans and individuals with posttraumatic stress disorder (PTSD) have increased rates of smoking. However, the rates of smoking in younger help-seeking veterans returning from Afghanistan and Iraq, and possible correlates of smoking among this population are unknown. In this study, Dr. Kirby and colleagues from Duke University evaluated the rate of lifetime and current smoking among a sample of 90 returning male veterans diagnosed with PTSD. Fifty-nine percent reported a lifetime history of smoking including 32% that were current smokers. Current smokers were significantly younger than non-smokers. Current smokers (mean age=31) reported a mean age of smoking onset as 15.86 with a history of smoking a pack per day of 8.89 years. These smokers reported on average five previous quit attempts. According to a stages of change model, which characterizes individuals' readiness to quit, one-half of the smokers were in the contemplation phase of stopping smoking (50%), 29% were in the pre-contemplation phase and 21% were in the preparation phase. The results are placed in the context of non-psychiatric and psychiatric smokers. Kirby, A., Hertzberg, B., Collie, C., Yeatts, B., Dennis, M., McDonald, S., Calhoun, P., and Beckham, J. Smoking in Help-Seeking Veterans with PTSD Returning from Afghanistan and Iraq. Addict. Behav., 2008 [E-pub ahead of print].

A Randomized Clinical Trial of Community-Based Directly Observed Therapy as an Adherence Intervention for HAART among Substance Users

Interventions aimed to improve adherence to highly active antiretroviral therapy (HAART) can impact challenging populations, such as active substance users. Dr. Macalino and colleagues from Brown University evaluated a promising community-based approach called modified directly observed therapy (MDOT). HIV seropositive substance users were randomized to either standard of care (SOC) or MDOT (experience with HAART was taken into account during random assignment procedures). All participants were placed on a once-daily regimen and were met by an outreach worker for all 7 days during the first 3 months. They evaluated differences in viral load suppression [> 2 log drop in plasma viral load (PVL) or PVL < 50] and changes in PVL and CD4 cell count from baseline to 3 months. A total of 87 participants were enrolled (43 in SOC, 44 in MDOT). MDOT participants were more than twice as likely to achieve PVL suppression. This effect was more dramatic among those who were HAART-experienced; they were almost three times more likely to achieve PVL suppression. CD4 cell count was also significantly higher in the MDOT group. The rates of undetectable PVL did not differ between the groups. This study provides evidence that MDOT is an effective strategy to reduce viral load and increase CD4 cell counts in HAART experienced substance users. MDOT should be included in the spectrum of options to enhance adherence in this population. Macalino, G.E., Hogan, J.W., Mitty, J.A., Bazerman, L.B., Delong, A.K., Loewenthal, H., Caliendo, A.M., and Flanigan, T.P. A Randomized Clinical Trial of Community-Based Directly Observed Therapy as an Adherence Intervention for HAART among Substance Users. AIDS, 21(11), pp. 1473-1477, 2007.

HIV Risk Behavior among Patients with Co-Occurring Bipolar and Substance Use Disorders: Associations with Mania and Drug Abuse

Bipolar and substance use disorders frequently occur together, and both are associated with impulsivity, impaired judgment, and risk-taking. Dr Weiss and colleagues from Harvard conducted this study to: (1) describe the rates of HIV sexual and drug risk behaviors among patients with co-occurring bipolar and substance use disorders, (2) test whether acute mania, psychiatric severity, and drug severity independently predict HIV risk, and (3) examine the relationship between specific substance dependencies and sexual risk behaviors. Participants (N=101) were assessed for psychiatric diagnoses, substance abuse, and HIV risk behavior using structured clinical interviews and self-report questionnaires. The majority (75%) were sexually active in the past 6 months and reported high rates of sexual risk behaviors, including unprotected intercourse (69%), multiple partners (39%), sex with prostitutes (24%, men only), and sex trading (10%). Recent manic episode, lower psychiatric severity, and greater drug severity were independent predictors of total HIV risk. Cocaine dependence was associated with increased risk of sex trading. These results suggest an important need for HIV prevention interventions for this population. Meade, C.S., Graff, F.S., Griffin, M.L., and Weiss, R.D. HIV Risk Behavior among Patients with Co-Occurring Bipolar and Substance Use Disorders: Associations with Mania and Drug Abuse. Drug Alcohol Depend., 92(1-3), pp. 296-300, 2008.

A Randomized Trial of Brief Interventions for Problem and Pathological Gamblers

Limited research exists on best methods for reducing problem gambling. Dr. Petry and colleagues from the University of Connecticut randomly assigned problem gamblers (N = 180) to an assessment only control condition, 10 min of brief advice, 1 session of motivational enhancement therapy (MET), or 1 session of MET plus 3 sessions of cognitive-behavioral therapy. Gambling was assessed at baseline, at 6 weeks, and at a 9-month follow-up. Relative to assessment only, brief advice was the only condition that significantly decreased gambling between baseline and Week 6, and it was associated with clinically significant reductions in gambling at Month 9. Between Week 6 and Month 9, MET plus cognitive-behavioral therapy significantly reduced scores on the gambling section of the Addiction Severity Index (which measures dollars wagered and days gambled in the previous month), compared with the control condition. These results suggest that a very brief intervention can reduce gambling among problem and pathological gamblers who are not actively seeking gambling treatment. Petry, N.M., Weinstock, J., Ledgerwood, D.M., and Morasco, B. A Randomized Trial of Brief Interventions for Problem and Pathological Gamblers. J. Consult. Clin. Psychol., 76(2), pp. 318-328, 2008.

When the Levee Breaks: Treating Adolescents and Families in the Aftermath of Hurricane Katrina

Hurricane Katrina brought to the surface serious questions about the capacity of the public health system to respond to community-wide disaster. The storm and its aftermath severed developmentally protective family and community ties; thus its consequences are expected to be particularly acute for vulnerable adolescents. Research confirms that teens are at risk for a range of negative outcomes under conditions of life stress and family disorganization. Specifically, the multiple interacting risk factors for substance abuse in adolescence may be compounded when families and communities have experienced a major trauma. Further, existing service structures and treatments for working with young disaster victims may not address their risk for co-occurring substance abuse and traumatic stress reactions because they tend to be individually or peer group focused, and fail to consider the multi-systemic aspects of disaster recovery. This article proposes an innovative family-based intervention for young disaster victims, based on a model for adolescent substance abuse that has demonstrated effects, Multidimensional Family Therapy (MDFT; Liddle, 2002). The mechanisms and outcomes of the model are being investigated in a randomized clinical trial with clinically referred substance-abusing teens in a New Orleans area community impacted by Hurricane Katrina. Rowe, C.L., and Liddle, H.A. When the Levee Breaks: Treating Adolescents and Families in the Aftermath of Hurricane Katrina. J. Marital Fam. Ther., 34(2), pp. 132-48, 2008.

Is Attention Deficit Hyperactivity Disorder (ADHD) Symptom Severity Associated with Tobacco Use?

Several studies report a strong link between ADHD and tobacco use; however, the nature of this relationship is not entirely clear. Drs. Upadhyaya and Carpenter from the Medical University of South Carolina examined the relationship between attention deficit hyperactivity disorder (ADHD) symptoms and tobacco use within a sample of college students. Although tobacco use was the main focus, they also examined alcohol and marijuana use. They examined the association between the number of ADHD symptoms endorsed (severity), and tobacco, alcohol, and marijuana use in a convenience sample of 334 college students in the southeastern United States. Survey data were based on the annual Core Alcohol and Drug Survey for substance use, and the Current Symptom Scale (CSS) for ADHD, conduct disorder (CD), and antisocial personality disorder (ASPD) symptoms. Among those who had ever used a substance, the number (severity) of current ADHD symptoms, including inattentive and hyperactive symptoms, was significantly associated with the frequency of tobacco and marijuana use in the past month and past year, as well as to the frequency of alcohol use in the past month. The results suggest that the number of ADHD symptoms is proportionally associated with tobacco, alcohol, and marijuana use, and may have implications for clinical treatment. Upadhyaya, H.P., and Carpenter, M.J. Is Attention Deficit Hyperactivity Disorder (ADHD) Symptom Severity Associated with Tobacco Use? Am. J. Addict., 17(3), pp. 195-198, 2008.

Use of Brief Interventions for Drug Abusing Teenagers within a Middle and High School Setting

Promising and encouraging results have been recently reported on the use of briefer interventions for adolescent drug abusers. Because middle- and high-school-based drug abuse intervention programs have grown in popularity over the past several decades, the use of brief interventions (BIs) in school settings needs further consideration. Dr. Winters and colleagues from the University of Minnesota reviewed several clinical and school contextual issues pertaining to the scientific efficacy, feasibility, and application of BIs for students who are abusing drugs. Several advantages for employing BIs in a school setting are identified, including the relatively high base rate of students with mild-to-moderate drug involvement and the likelihood that school counselors can readily learn BI techniques. The authors describe practical, systemic, and clinical barriers that need consideration before implementing BIs. Despite these concerns, they conclude that schools are a viable setting in which to screen youth for drug abuse problems and to conduct a BI. Winters, K.C., Leitten, W., Wagner, E., and O'Leary Tevyaw, T. Use of Brief Interventions for Drug Abusing Teenagers within a Middle and High School Setting. J. Sch. Health, 77(4), pp. 196-206, 2007.

The Impact of Managed Care on Drug-Dependent Pregnant Women and their Children

Using archival data, this study examined the effects of managed care (MC) on a population of drug-dependent women and their children in a multidisciplinary, comprehensive care substance user treatment facility in pre- (1995, n=132) and post (2000, n=108)-managed care conditions. The two groups had similar birth parameters, but the MC group had more fetal and infant deaths, decreased immunization rates, and greater incidence of social services intervention. While these data are correlational and need to be interpreted with caution, they suggest that the shift from fee-for-service to managed care (MC) has resulted in poorer outcomes for drug-exposed children under MC. Jansson, L.M., Svikis, D.S., Velez, M., Fitzgerald, E., and Jones, H.E. The Impact of Managed Care on Drug-Dependent Pregnant and Postpartum Women and their Children. Subst. Use Misuse, 42(6), pp. 961-974, 2007.

Higher Relapse Rate for Drug-Dependent Pregnant Women with Mood Disorders

The purpose of this study was to examine the potential treatment impact of co-occurring Axis I disorders in a sample of opiate-dependent pregnant women receiving methadone treatment. Participants were categorized into three groups according to their primary current SCID diagnosis: (1) absence of any current mood/anxiety disorder (ND, n = 29), (2) primary mood disorder (MD, n = 39), and (3) primary anxiety disorder (AD, n = 38). Demographically, the groups were similar. The MD group was significantly more likely to be positive for drugs while in treatment compared with both the ND and AD groups. The MD and AD groups had more psychosocial impairment and higher incidence of suicidal ideation compared with the ND group. Interestingly, the AD group spent more days in treatment compared with the ND or MD group. The authors conclude that the poor treatment outcomes in the MD group suggest the need for treatment that specifically targets the mood disorder in addition to the substance use disorder. While enhanced treatment resources for all substance-abusing pregnant patients with co-occurring disorders would be ideal, it may be possible to achieve improvement in treatment outcomes by recognizing the particular needs of different substance-abusing subpopulations and by tailoring treatments both at the programmatic and individual level to specifically address those needs. Fitzsimons, H.E., Tuten, M., Vaidya, V., and Jones, H.E. Mood Disorders Affect Drug Treatment Success of Drug-Dependent Pregnant Women. J. Subst. Abuse Treat., 32(1), pp. 19-25, 2007.

Secondary Family Effects of Treating Paternal Alcoholism with Learning Sobriety Together

This study examined whether Learning Sobriety Together, a treatment for substance abuse that combines behavioral couples therapy and individual counseling, had comparable secondary benefits on the internalizing and externalizing behaviors of adolescent versus preadolescent siblings living in homes with their alcoholic fathers (N = 131) and their non-substance-abusing mothers. During a 17-month assessment period, the association between parents' functioning (i.e., fathers' drinking as determined by percentage of days abstinent and parents' dyadic adjustment) and children's adjustment (as rated by mothers, fathers, and children's teachers) was stronger for preadolescents than for their adolescent siblings, particularly in terms of children's externalizing behaviors. It appears that preadolescents are at a point developmentally where their behavior is more influenced by the familial environment than by their adolescent counterparts. Furthermore, the finding that teachers reported the same patterns suggests that changes in the home environment were related to the externalizing behavior of preadolescent children in an important out-of-home context (i.e., school). In conclusion, interventions designed to reduce paternal drinking and improve couple functioning may be viable preventative interventions for preadolescents in these homes and a way to benefit children without identifying or treating children directly. Kelley, M.L., and Fals-Stewart, W. Treating Paternal Alcoholism with Learning Sobriety Together: Effects on Adolescents versus Preadolescents. J. Fam. Psychol., 21(3), pp. 435-444, 2007.

Fathering Among Drug-Dependent Men Receiving Methadone Maintenance Treatment

Using a structured research interview, this pilot study was designed to examine patterns of fathering among 50 men enrolled in methadone maintenance treatment. The men in this study reported attempts to conceive and parent children in socially responsible ways. However, their involvement in the children's lives, their relationships with the children's mothers, and their ability to provide financial support deteriorated over time as their drug abuse continued. The investigators also found that the men seemed even less involved in the lives of their non-biological children. The authors conclude that the drug abuse treatment system could provide better support for drug-abusing men interested in being effective parents. McMahon, T.J., Winkel, J.D., Suchman, N.E., and Rounsaville, B.J. Drug-Abusing Fathers: Patterns of Pair Bonding, Reproduction, and Paternal Involvement. J. Subst. Abuse Treat., 33(3), pp. 295-302, 2007.


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