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National Institute on Drug Abuse

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

September, 1999

Research Findings

Clinical and Services Research

Therapeutic Alliance and Psychiatric Severity as Predictors of Completion of Treatment For Opioid Dependence

Information about patient characteristics and scores on the subscales of the Addiction Severity Index (ASI) were obtained for 114 patients at intake to a buprenorphine treatment program lasting 3-4 months. The strength of the therapeutic alliance was assessed by the Helping Alliance Questionnaire (HAQ). Patients with fewer psychiatric symptoms were more likely to complete treatment. Among patients with moderate to severe psychiatric symptoms, the strength of the therapeutic alliance was a significant predictor of treatment completion. The findings underscore the importance of early identification of opioid-dependent patients with moderate to severe levels of psychopathology. In this patient subgroup, a strong therapeutic alliance may be an essential condition for successful treatment. Petry, N. and Bickel, W. Psychiatric Services, 50 (2), pp. 219-227, February 1999.

Technology Transfer of Network Therapy to Community-Based Addictions Counselors

In this study Network Therapy, a drug addiction treatment that utilizes peer and family support, was disseminated to a cohort of addiction counselors located in an outpatient community-based addiction treatment center. Training methods included a didactic seminar, role-playing, use of videotaped illustrations, and clinical case supervision. The trained counselors then implemented the Network Therapy with a sample of cocaine-abusing patients; the Network Therapy patients were compared by chart review to a cohort of cocaine abusers who received treatment as usual. The two groups were similar in demographics and in the amount of standard treatment that they received. However, the Network Therapy patients had significantly fewer positive urinalyses than the standard treatment patients, though they were not significantly different in terms of treatment retention, however. These preliminary findings demonstrated the feasibility of training addiction counselors and transporting the Network Behavioral Therapy approach to counselors in a community-based treatment program. Keller, D., and Galanter, M. Journal of Substance Abuse Treatment, 16(2), pp. 183-189, March 1999.

Relative Potency of LAAM and Methadone in Humans Under Acute Dosing Conditions

This study compared the effects of acute doses of LAAM and methadone and also examined the ability of naloxone to reverse their effects. Five occasional opioid users received once weekly doses of either placebo, LAAM, or methadone (15, 30, or 60 mg/70 kg orally) in agonist exposure sessions and then received naloxone (1 mg/70kg intramuscularly) 24, 72, and 144 hours after agonist exposure. Subject-rated, observer-rated, and physiological measures were assessed regularly. Comparisons of physiological and subjective measures in agonist exposure sessions indicate that LAAM is not less potent than methadone under acute dosing conditions. For some measures LAAM was significantly more potent. Three subjects were withdrawn from the study due to greater than anticipated and clinically relevant respiratory depression after receiving 60 mg of LAAM. Acute agonist effects suggest that LAAM may be more potent than methadone and more potent than current labeling indicates. An accurate LAAM: methadone relative potency estimate will aid determination of adequate doses for opioid dependent patients inducted onto LAAM and for methadone maintenance patients who choose to switch to more convenient 3x weekly LAAM. Eissenberg, T., Stitzer, M., Bigelow, G., Buchhalter, A., and Walsh, S. J. of Pharmacology and Experimental Therapeutics, 289, pp. 936-945, 1999.

Factors Associated with Lapses to Heroin Use During Methadone Maintenance

This prospective, observational study investigated factors predicting a lapse to heroin use in 74 heroin-abstinent methadone maintenance patients, After baseline data collection, participants were assessed twice per week for 7 weeks and again at 6 months after baseline. Proportional hazards regression and logistic regression were used to investigate the effects of study predictors on heroin use. A goal of absolute heroin abstinence consistently predicted a lower risk of a lapse, whereas marijuana use was associated with a greater risk. Stress did not appear to be a predictor of a lapse in this study. The findings suggest that factors influencing lapses are similar across drug treatment populations and the role of stress in precipitating relapse remains unresolved. Wasserman, D., Weinstein, M., Havassy, B., and Hall, S. Alcohol and Drug Dependence, Vol. 1, pp. 1-10, January 1999.

Identifying Methadone Maintenance Clients at Risk for Poor Treatment Response: Pretreatment and Early Progress Indicators

This study evaluated whether early treatment response predicts treatment response 6 and 9 months later. New admissions to methadone maintenance treatment (n=59) were divided into outcome groups based on treatment retention and ongoing drug use as revealed by urinalysis results 6 and 9 months after admission. Regression analyses revealed that two early (week 2) performance measures, counseling attendance and opioid abstinence, could be used to correctly classify the outcomes of more than 80% of the sample. Of the 20 participants who neither submitted an opiate-negative sample during week 2 of treatment nor attended at least 2 scheduled counseling sessions by that time, not one achieved a superior 6-month outcome. The odds of having a superior treatment outcome increased considerably for those who submitted two opiate negative urine samples and attended two counseling sessions by the second week of treatment. These findings suggest that determining patient performance early in treatment may be used to guide subsequent treatment planning and may facilitate better patient-treatment matching. Morral, A., Belding, M., and Iguchi, M. Drug and Alcohol Dependence 55, pp. 25-33, 1999.

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

This study examined the relationship of alcohol/drug use history and current alcohol and marijuana use with success in smoking cessation treatment in a smoking clinic population. Of the 199 smokers who participated, 23% reported a history of alcohol or drug use problems; 12.6% reported a history of drug treatment; 78.7% reported alcohol use, and 21.3% reported marijuana use during treatment. The results indicate that a history of alcohol or drug problems does not predict smoking cessation success. However, current alcohol use, even at low levels, appears to increase the likelihood of treatment failure. In this study neither use of marijuana at baseline nor during treatment predicted outcome, which appears to be inconsistent with the limited research available indicating a negative effect of marijuana use on outcome. Differences in local cultural norms, frequency, and rate of marijuana use, and community attitudes regarding marijuana use may have influenced this finding. Humfleet, G., Munoz, R., Sees, K., Reus, V., and Hall, S. Addictive Behaviors, Vol. 24(1), pp. 149-154, 1999.

Contingent Reinforcement Sustains Post-Detoxification Abstinence for Multiple Drugs: A Preliminary Study with Methadone Patients

This study examined the efficacy of a urinalysis-based contingency management program for preventing relapse to abused drugs following a brief residential detoxification. Fourteen methadone maintenance patients who were chronic benzodiazepine users were enrolled in a 7-day inpatient benzodiazepine detoxification and randomly assigned to receive Contingency Management (N=7) or Standard Care (N=7) therapy upon return to outpatient methadone treatment. In the Contingency Management condition, a methadone take-home dose or $25 (patient's choice) could be earned for each urine submitted that was free of opiates, cocaine, and benzodiazepines. Preliminary findings from this study suggest that abstinence-based contingency management is a promising approach for preventing relapse to multiple drug abuse in a subgroup of methadone maintenance patients when abstinence has been initiated through brief detoxification treatment. Chutuape, M., Silverman, K., and Stitzer, M. Drug and Alcohol Dependence, 54, pp. 69-81, 1999.

Relationship of ADHD, Depression and Non-Tobacco Substance Use Disorders to Nicotine Dependence in Substance-Dependent Delinquents

In a study of 367 male and female behaviorally disordered juvenile delinquents, 13 - 19 years old, Dr. Riggs and colleagues, Department of Psychiatry, University of Colorado School of Medicine, found that attention deficit hyperactivity disorder (ADHD) and major depression significantly contributed to the severity of nicotine dependence in adolescents diagnosed with a non-tobacco substance use disorder (SUD). ADHD was associated with earlier onset of regular smoking in males, and the severity of non-tobacco SUD was related to nicotine dependence severity in both boys and girls. Riggs, P.D., Mikulich, S.K., Whitmore, E.A., and Crowley, T.J. Drug and Alcohol Dependence, 54, pp. 195-205, 1999.

Effects of Naltrexone on Alcohol and Cocaine Use in Dually Addicted Patients

Drs. Oslin, Pettinati, Volpicelli and colleagues from the Center for the Study of Addictions, Department of Psychiatry, University of Pennsylvania, reported the results of a small-scale study evaluating the efficacy of naltrexone in treating alcohol and cocaine dependent patients. Of 15 patients (mean age 36 years; 87% African American males) enrolled in the 12-week, open medication trial, 7 did not complete the study. Of the remaining 8, seven patients were rated as much or very much improved for alcohol and cocaine use, with two subjects achieving complete abstinence from both alcohol and cocaine for the 12-week period. Oslin, D.W., Pettinati, H.M., Volpicelli, J.R., Wolf, A.L., Kampman, K. and O'Brien, C. Journal of Substance Abuse Treatment, 16(2), pp.163-167, 1999.

An Efficient Tool for Screening for Maladaptive Family Functioning in Adolescent Drug Abusers: The Problem Oriented Screening Instrument for Teenagers (POSIT)

Dr. Santisteban and colleagues from the Center for Family Studies, University of Miami School of Medicine, reported results of a study that examined the validity of the NIDA-developed POSIT questionnaire's 11-item Family functioning (problem area) scale in terms of degree to which the scale provides useful information regarding family functioning when the POSIT is administered to youths with behavior problems. Study participants were 135 boys and girls referred for drug treatment. Family functional status was determined by use of the general scale of the Family Assessment Measure (FAM) and the family scale of the Adolescent Drug Abuse Diagnosis (ADAD). Results indicate POSIT Family area problem scores can classify families correctly in terms of their functioning. Santisteban, D.A., Tejeda, M., Dominicis, C. and Szapocznik, J. American Journal of Drug and Alcohol Abuse, 25(2), pp. 197-206, 1999.

Drug Abuse Counseling Shows Promise for Cocaine Dependence

The National Institute on Drug Abuse Collaborative Cocaine Treatment Study was a large multi-site investigation consisting of NIDA scientists, a Coordinating Center at the University of Pennsylvania, and four clinical sites at the following locations: University of Pennsylvania; Brookside Hospital in Nashua, NH; McLean Hospital and Massachussetts General Hospital; and University of Pittsburgh—Western Psychiatric Institute and Clinic. The purpose of this study was to evaluate four behavioral treatments for cocaine-dependent patients. All patients enrolled in the study received Group Drug Counseling (GDC). The three other treatment conditions consisted of a combination of Group Drug Counseling plus Individual Drug Counseling (IDC), Cognitive Therapy, or Supportive-Expressive Psychotherapy. A major finding from this study indicates that while all groups improved, patients that received the combination of Individual and Group Drug Counseling showed the greatest reduction in frequency of drug use. The combination of GDC and IDC shown to be successful in reducing drug use in this study, was an intensive, manual-guided therapy delivered by carefully selected, experienced counselors. In contrast, drug counseling performed in the community may vary widely in intensity, quality and type of interventions. However, this approach shows promise for the treatment of cocaine dependence. Crits-Christoph, P., Siqueland, L., Blaine, J., Frank, A., Luborsky, L., Onken, L.S., Muenz, L.R., Thase, M.E., Weiss, R.D., Gastfriend, D.R., Woody, G.E., Barber, J.P., Butler, S.F., Daley, D., Salloum, I., Bishop, S., Najavits, L.M., Lis, J., Mercer, D., Griffin, M.L., Moras, K. and Beck A.T. Psychosocial Treatments for Cocaine Dependence. Archives of General Psychiatry, 56, pp. 493-502, 1999.

Cocaine Stimulates the Human Cardiovascular System via a Central Mechanism of Action

Cocaine is thought to stimulate the cardiovascular system by blocking the peripheral norepinephrine reuptake. Now Victor and his colleagues' research shows that cocaine also stimulates central sympathetic outflow. This central sympathetic activation appears to be targeted not only to the cutaneous circulation promoting peripheral vasoconstriction but also to the heart promoting tachycardia. The investigators measured blood pressure, heart rate, and skin sympathetic nerve activity in 14 healthy volunteers before, during and for 90 minutes after intranasal cocaine (2 mg/kg, n=7) or lidocaine (2 mg/kg, n=7). Cocaine caused >3-fold increase in skin sympathetic nerve activity and this was accompanied by decreased skin blood flow, increased skin vascular resistance, and increased heart rate. Intranasal lidocaine caused only a small transient increase in SNA due to local nasal irritation. In 11 additional subjects, cocaine-induced increase in heart rate was eliminated by beta-blockade (propranolol) but was unaffected by muscarininc receptor blocakade (atropine), indicating sympathetic mediation of cocaine effects. Vongpatanasin, W., Mansour, Y., Chavoshan, B., Arbique, D., and Victor, R.G. Circulation, 100, pp. 497-502, 1999.

Inhibitory Control Involves the Right Side of the Brain

Dr. Eliot Stein and his colleagues at the Milwaukee College of Medicine used an advanced brain imaging technique, event-related functional magnetic resonance imaging (fMRI), to determine what parts of the brain are active when a normal person withholds a pre-potent response in a laboratory task. Past attempts to determine what areas of the brain are associated with behavioral inhibition have been hampered by the inability to separate brain activity associated with correct withholding responses from brain activity associated with incorrect responses. With event-related fMRI, brain activity can be imaged during a single behavioral response trial. It was expected that the ventral portions of the frontal lobe of the brain would be activated when a person successfully withheld a response to the second target letter. Contrary to this expectation, response inhibition was most strongly associated with activation of brain regions distributed across the right hemisphere, including areas in the dorsal prefrontal cortex, frontal limbic areas, and the parietal lobe. As relapse of drug-taking after a period of abstinence can be seen as a failure to inhibit drug-seeking and drug-taking, these results suggest the possibility that dysfunction in these brain areas contributes to the difficulty drug abusers have in refraining from drug use. Garavan et al., Proc Natl. Acad. Sci., 96, pp. 8301-8306, 1999.

Association of Methylphenidate-Induced Craving with Changes in Brain Metabolism in Cocaine Abusers

Dr. Nora Volkow and colleagues previously have shown that decreases in dopamine D2 receptors in cocaine abusers were associated with decreased metabolic activity in the prefrontal cortex, cingulate gyrus, and orbitofrontal cortex. Because it was also shown that the orbitofrontal cortex and the striatum had increased metabolic activity in active cocaine abusers reporting intense craving, it was postulated that during cocaine intoxication, the increase in dopamine facilitates activation of these brain regions, which in turn, leads to craving and subsequent impulsive and compulsive drug-taking, characteristic of the addicted individual. To test this hypothesis, the effects of two sequential doses of methylphenidate (a drug very similar to cocaine) on regional glucose metabolism in detoxified cocaine abusers was measured using positron emission tomography (PET). Results showed that methylphenidate induced variable changes in brain metabolism. Subjects with higher D2 measures tended to have increased metabolism, whereas subjects with lower D2 measures tended to have decreased metabolism. Methylphenidate's effects were significant for increases in metabolism in the superior cingulate, right thalamus, and cerebellum. Methylphenidate-induced changes in the right orbitofrontal cortex and right striatum were associated with craving, and those changes in the prefrontal cortex were associated with mood. Given these results, this study indicates that dopamine enhancement is not sufficient to increase metabolism in the frontal regions. Activation of the right orbitofrontal cortex and right striatum, which are regions found to be abnormal in compulsive disorders, in subjects reporting craving may be one of the mechanisms underlying compulsive drug administration in addicted persons. The finding of a predominant correlation of craving with the right brain regions and not left suggests laterality of reinforcing responses. Volkow, N.D. et al., Association of Methylphenidate-Induced Craving with Changes in Right Striato-orbitofrontal Metabolism in Cocaine Abusers: Implications in Addiction. Am. J. Psychiatry, 156, pp. 19-26, 1999.

Brain Dopamine Receptor Levels Predict Reinforcing Responses to Drugs in Humans

The dopamine system is involved in the reinforcing properties of all drugs of abuse. It has been hypothesized that low levels of dopamine D2 receptors may predispose individuals to use drugs in order to compensate for the decrease in activation of 'reward' circuits stimulated by this receptor system. Using PET neuroimaging techniques, Dr. Nora Volkow and colleagues at the Brookhaven National Laboratory and SUNY-Stony Brook have correlated concentrations of brain dopamine D2 receptors to measures of subjective responses to the drug methylphenidate (a psychostimulant drug that acts like cocaine in that it blocks brain dopamine transporters, thereby amplifying dopamine's effect in the brain). Using [11C]raclopride, a molecule that specifically attaches to D2 dopamine receptors to indicate concentrations of receptor sites, it was shown that those individuals with relatively lower levels of brain dopamine D2 receptors found the drug methylphenidate to elicit "pleasant" effects, whereas those individuals with relatively higher levels of brain D2 dopamine receptors found the drug methylphenidate to be "unpleasant." Most cocaine abusers report methylphenidate as pleasant, and individuals that reported methylphenidate as pleasant had D2 dopamine levels similar to those previously shown for cocaine abusers. These results are highly suggestive of a dopamine D2 involvement in the perception of reinforcing effects of psychostimulant drugs and are consistent with findings in animals that D2 dopamine receptors mediate the reinforcing responses to drugs. The findings in this study are the first evidence in humans revealing a direct association between D2 dopamine receptor levels in brain and the reinforcing effects of psychostimulants. These data have significant implications for individual differences in drug liking and may represent a critical component in the neurobiological basis for drug abuse and addiction vulnerability. Volkow, N.D. et al., Brain Dopamine D2 Receptor Levels Predict Reinforcing Responses to Psychostimulants in Humans. American Journal of Psychiatry, September 1999.

Treatment Outcome Prediction Based in Quantitative EEG Profiles

Dr. Leslie Prichep at the New York University School of Medicine and Nathan S. Kline Institute for Psychiatric Research and her colleagues have investigated the existence of outcome-related neurophysiological subtypes within a population of abstinent cocaine-dependent adults. This group has demonstrated a distinctive quantitative EEG (QEEG) profile in abstinent cocaine abusers showing abnormalities in specific wave activity that persists up to six months. In this study, a group of 35 adult, abstinent, male, cocaine abusers were evaluated, and two neurophysiological subtypes were identified: Cluster 1 characterized by significant deficits of delta and theta activity, significant excess of alpha activity and more normal amounts of beta activity, and Cluster 2 characterized by deficits of delta, more normal amounts of theta and anterior excess of alpha and beta activity. No significant relationship was found between QEEG subtype and length of exposure to cocaine, time since last use, demographic characteristics, or comorbid clinical features of depression and anxiety for either cluster. A significant relationship, however, was shown between QEEG subtype grouping and length of stay in treatment; Cluster 2 individuals remained in treatment significantly longer (approximately 62 weeks) than Cluster 1 individuals (approximately 18 weeks). These data point to a possible neurobiological marker or predictor of treatment outcome. Prichep, L.S. et al., Prediction of Treatment Outcome in Cocaine Dependent Males Using Quantitative EEG. Drug and Alcohol Dependence, 54, pp. 35-43, 1999.

Increases in Provoked Aggression during Marijuana Withdrawal

Dr. Harrison Pope, Jr. of McLean Hospital/Harvard Medical School and associates found that during withdrawal from long-term marijuana use there is an increase in aggressive responding in a laboratory task. Little is known about aggressive behavior associated with extended abstinence from marijuana as most studies in the literature have addressed the effects of acute marijuana administration on aggression. Long-term marijuana users (> 10 years) were tested immediately prior to stopping marijuana use and repeatedly up to 28 days of abstinence (verified by daily urines). Subjects were tested on a computerized task in which they had the choice of pushing one button to accumulate points and pushing a second button to subtract points from an opponent. The subjects were informed that they were competing with other subjects, but in fact were playing against the computer. Aggressive behavior was defined as responding on the point subtraction button. Aggressive behavior was provoked by subtracting points from the subject on a random basis, which would be attributed to actions of the fictitious opponent. Furthermore, aggressive behavior was encouraged by providing a provocation-free interval if the subject engaged in responding on the button that resulted in points being subtracted by the fictitious opponent. Aggressive responding increased markedly on the third day of abstinence and peaked on the seventh day of abstinence. Aggressive responding returned to baseline by the 28th day of abstinence. There was no change in non-aggressive responding during the entire abstinence period. The increase in aggressive responding paralleled increases in scores on the Hamilton Depression and Anxiety Scales. The results suggest that increased susceptibility to aggressive responses to provocation may be a component of an abstinence syndrome associated with chronic marijuana use. Kouri, E.M., Pope, H.G., Lukas, S.E., Psychopharmacology, 143, pp. 302-308, 1999.

Abnormalities in Human Post-Mortem Striatal Dopaminergic Terminal Markers

Dr. Karley Little and associates at the University of Michigan assayed dopamine transporter binding and vesicular monoamine transporter binding in post-mortem tissue from cocaine-using subjects and matched controls. The vesicular monoamine transporter binding assayed with (+)-[3H]dihydrotetrabenazine (DTBZ) was used to distinguish alterations in binding associated adaptive changes in the dopamine transporter from changes in the number of dopamine terminals. The investigators report that cocaine abusers exhibited abnormally high levels of WIN 35428 binding to the dopamine transporter in striatal tissue from cocaine users relative to controls. On the other hand, DTBZ binding was lower in cocaine users compared to controls. The results indicate that cocaine users exhibit upregulation of the dopamine transporter with concomitant reductions in the apparent number of dopamine terminals. Little, K.Y. et al., American Journal of Psychiatry, 156, pp. 238-245, 1999.

Attention Deficit Disorder and Substance Abuse

Timothy Wilens, M.D. and his colleagues at Harvard Medical School have shown that boys with attention deficit hyperactivity disorder (ADHD) who are treated with stimulants such as Ritalin are 84 percent less likely to abuse drugs and alcohol when they get older. Research showed that 75 percent of the non-medicated ADHD boys had at least one substance use disorder, compared to 25 percent of the medicated ADHD boys and 18 percent of the boys without ADHD. Researchers calculated that treating ADHD with stimulants was associated with an 84 percent reduction in risk of developing a substance use disorder. Rather than being concerned that boys with ADHD might be prescribed stimulant medication, scientists are now concerned when they are not. Appropriate treatment of ADHD appears to be quite helpful in preventing the later emergence of substance abuse in these vulnerable individuals with ADHD. The use of interventions in childhood to prevent the later emergence of substance abuse is a promising avenue for future research investigations. Biederman et al., Pediatrics, Vol 104(2), August 1999.

Susceptibility Genes Identified for Further Study in Possible Linkage for Nicotine Dependence

It has been clear from twin and other studies that there is a significant genetic component for smoking. However, as yet no gene has been identified as related to either smoking initiation or dependence on nicotine. Now, Straub, Kendler and colleagues have identified several suggestive regions on 6 chromosomes that may have critical genes. These were determined by a whole genome scan using 451 markers in 343 genotyped individuals (308 of whom were nicotine dependent). Regions yielding a large lod score of linkage were examined more closely in the original and in a second sample. The results pointed to regions on Chromosomes 2,4, 10, 16, 17, and 18 that merit further study. It is cautioned that although these results are suggestive, further study may show the linkage to be due to chance. Straub, R.E. et al., Molecular Psychiatry, 4, pp. 129-144, 1999.

On-Site Primary Care and Mental Health Services in Outpatient Drug Abuse Treatment Units

Providing primary care and mental health services to substance abuse clients has been shown to improve retention and substance abuse outcomes. This article examines the relationship between the organizational features of 597 outpatient drug abuse treatment units and the degree to which they provide on-site primary care and mental health services. In two-stage models, Joint Commission on Accreditation of Healthcare Organizations-certified and methadone programs delivered more on-site primary care services. Units affiliated with mental health centers provided more on-site mental health services but less direct medical care. Units with dual-diagnosis clients provided more on-site mental health but fewer on-site HIV/AIDS treatment services. These findings suggest that organizational features influence the degree to which health services are incorporated into drug abuse treatment. Fully integrated care might be an unattainable ideal for many such organizations, but quality improvement across the treatment system might increase the reliability of clients' access to health services. Friedmann, P., Alexander, J., Jin, L., D'Aunno, T. Journal of Behavioral Health Services & Research, Vol. 26 (1), February, pp. 80-94, 1999.

Modified Therapeutic Community for Mentally Ill Chemical Abusers: Outcomes and Costs

Several studies have established that the personal and social consequences of substance abuse are extensive and costly. These consequences are frequently compounded by mental illness. Although interventions that target mentally ill chemical abusers (MICAs) present several challenges, the potential benefits of successful interventions are significant. This article presents outcomes and costs of a modified therapeutic community (TC) intervention for homeless MICAs. Outcomes at follow-up are compared with those for a control group of homeless MICAs receiving standard services in a "treatment-as-usual" (TAU) condition. Annual economic costs for the modified TC and the average weekly cost of treating a single client are estimated. Treatment and other health service costs at 12 months postbaseline are compared for modified TC and TAU clients. The results of this study indicate that, suitably modified, the TC approach is an effective treatment alternative for homeless MICAs, with the potential to be highly cost-effective relative to standard services. French, M.T., Sacks, S., De Leon, G., Staines, G., and McKendrick, K. Evaluation Health Professional, 22(1), pp. 60-85, March 1999.

Program Quality Effects on Patient Outcomes During Methadone Maintenance: A Study of 17 Clinics

This study was designed to replicate Ball and Ross' benchmark research, which was the first to identify a set of program quality factors for methadone maintenance programs and relate them to patient outcomes. Ball and Ross' treatment domain variables were measured in a new and larger sample of methadone clinics, and eight candidate program quality factors were derived. Both studies found that program factors defined by more frequent counseling contacts, higher director involvement with treatment, and more director experience were associated with lower drug use by patients during treatment. Several patient and counselor characteristics also were associated with drug use outcomes. Magura, S., Nwakeze, P.C., Kang, S.Y., and Demsky, S. Substance Use and Misuse, 34(9), pp. 1299-1324, July 1999.

Effects of Culturally Congruent Intervention on Cognitive Factors Related to Drug-Use Recovery

This paper describes a culturally congruent intervention to promote recovery from illegal drug use among African Americans and reports initial outcomes. The intervention was based on the transtheoretical stages-of-change model and on techniques of focused dyadic counseling and motivational interviewing. Subjects were randomly assigned to the culturally congruent intervention or to a control condition. Each condition featured a single counseling session during which drug-related and other needs were assessed and appropriate referrals offered. Posttest data indicated that subjects in the culturally congruent condition were more involved in the counseling session, more willing to self-disclose, more motivated to seek help for drug use associated problems, and higher for preparation for change. Longshore, D., Grills, C., Annon, K. Substance Use and Misuse. 34(9), pp. 1223-1241, July 1999.

Matching Clients' Needs with Drug Treatment Services

This study reports results of a study that investigated whether matching drug treatment services with client needs improved outcomes for a sample of 171 clients who participated in community-based drug treatment programs. Clients were initially assessed on multiple problem areas (alcohol use, drug use, medical, psychological, family/social, legal, employment, housing) and on areas of special needs or stated preferences for services (e.g., transportation, child care, language) A 6-month follow-up interview reassessed clients' problems/needs in all areas and collected information on the services received. The results showed that some services significantly improved client outcome for those who had expressed needs for such services. Notably, services meeting the need for vocational training, child care, transportation and housing showed beneficial effects. A higher level of needs and services matching (defined either by the ratio of services received to services desired, or by the total level of met versus unmet needs in the eight problem areas) significantly predicted longer treatment retention. Journal of Substance Abuse Treatment, 16(4), pp. 299-305, June 1999.

Predicting Posttreatment Cocaine Abstinence for First-Time Admissions and Treatment Repeaters

This study examined client and program characteristics that predict posttreatment cocaine abstinence among cocaine abusers (n=507) with different treatment histories. Client and program data were collected as part of the recently completed nationwide Drug Abuse Treatment Outcome Study (DATOS). Cocaine abusers (n=507) treated in 18 residential programs were interviewed at intake and 1-year follow-up. Program directors provided program level data. Results indicate that no prior treatment and longer retention in DATOS programs were positive predictors of posttreatment abstinence. The interactive effect of these two variables was also significantly positive. Programs that offered legal services and included recovering staff increased their clients' likelihood of cocaine abstinence. Crack use at both the client and program level predicted negative impact. None of the program variables assessed differentially affected the outcomes of first-timers and repeaters. Although treatment repeaters were difficult to treat, their likelihood of achieving abstinence was similar to first timers if they were retained in treatment for a sufficient time. Both repeaters and first-timers responded similarly to the treatment program characteristics examined. Hser, Y.I., Joshi, V., Anglin, M.D., and Fletcher, B. American Journal of Public Health, 89 (5), pp. 666-671, May 1999.

Sequences of Powder Cocaine and Crack Use Among Arrestees in Los Angeles County

This paper examines the sequence or progression of use between powder cocaine and crack using arrestee data collected from county jails in Los Angeles County. Four sequences are identified and examined each in terms of user characteristics, history of use, dependence, contact with the criminal justice system, and concomitant use of other drugs. Findings confirm some already established observations, but also offer new knowledge on powder cocaine and crack abuse. For instance, powder cocaine-initiated users are more likely to progress to crack than to restrict their use to powder cocaine only, whereas crack-initiated users tend more often to use crack only than to progress to powder cocaine. This study provides additional support to the notion that powder cocaine and crack, when used interchangeably, can interact and reinforce each other, resulting in a higher level of use and dependence on both forms of the substance. In addition to contributing to the understanding of powder cocaine and crack use among criminal offenders, in particular, and across the adult population, in general, this article sheds light on prevention, treatment, and social control policies of both cocaine abuse and overall illicit drug use. Shaw, V.N., Hser, Y.I., Anglin, M.D., and Boyle, K. American Journal of Drug and Alcohol Abuse, 25(1), pp. 47-66, February 1999.

Interaction Effects of Client and Treatment Program Characteristic on Retention: An Exploratory Analysis Using Hierarchical Linear Models

This study examined the interaction effects of treatment program and client characteristics on client retention in treatment for drug users. Program characteristics included services provision, funding source, staff-client gender congruence, and client characteristics included gender, age at admission, and drug use level prior to admission. The same model was applied separately to residential methadone maintenance and outpatient drug-free programs. Data were obtained from 59 treatment programs and 3,764 patients who had discharge records. A noteworthy significant interaction effect was the program's funding source and patient's gender on treatment retention in the outpatient drug-free modality. Female clients stayed in the programs that accepted only public funding for shorter periods than in programs that accepted both public and private funding. Male patients remained in treatment an average of 25.3 fewer days than female patients in programs that only accepted public funds, but stayed about the same time as females if the programs received mixed funding. Chou, C., Hser, Y., & Anglin, M.D. Substance Use & Misuse, 33(11), pp. 2281-2301, 1998.

Managed Care and Technical Efficiency in Outpatient Substance Abuse Treatment Units

This study examined the extent to which managed care participation was associated with technical efficiency in outpatient substance abuse treatment organizations as well as the contribution of specific managed care practices and other organizational, financial, and environmental attributes to technical efficiency in these organizations. Technical efficiency is a mechanism by which cost savings may be gained or lost under managed care. As used here it is the use of specific input resources (e.g. staff hours and expenses) to provide specific outputs (e.g. therapy hours). Managed care was defined as a set of public or private programs designed to control access to care, types of care delivered, or the amount and/or costs of care. Data are from a nationally representative sample survey of substance abuse treatment organizations conducted in 1995 (n=618). Overall, analyses indicate that managed care participation is not significantly related to the level of efficiency. Only one managed care oversight procedure, the imposition of sanctions by managed care firms, was significantly associated with relative efficiency of these provider organizations. However, several organizational factors were associated with the relative level of efficiency, including hospital affiliation, mental health center affiliation, JCAHA accreditation, receipt of lump sum revenues, methadone treatment modality, percent clients unemployed, and percent clients who abuse multiple drugs. Alexander, J., Wheeler, J., Nahra, T., and Lemak, C. Journal of Behavioral Health Services and Research, 25(4), November 1998.

Changes in Methadone Treatment Practices: Results from a Panel Study, 1988-1995

This paper examines the extent to which key methadone treatment practices (dose levels, treatment duration, and client influence in dose decisions) changed from 1988 to 1995 using panel data from a random national sample of methadone maintenance units. Results from studies conducted in the late 1980's and early 1990's showed that most methadone treatment units did not use the most effective treatment practices. Results reported in this paper indicate that treatment practices concerning dose level, client influence in dose decisions, and treatment duration improved significantly in the most recent period. However, the average dose level of 59 mg/d is still below the level found to be optimally effective and average treatment duration increased only one month. Several characteristics of client (race, age) and treatment units (staff, ownership, geographic location) are associated with effective treatment practices. D'Aunno, T., Folz-Murphy, N., and Lin, X. American Journal of Drug and Alcohol Abuse, June 1999.

Health Care Need and Utilization: A Preliminary Comparison of Injection Drug Users, Other Illicit Drug Users, and Nonusers

This paper investigates the relationship between chronic drug use and the health care system. Data from 536 African-American, Hispanic, and non-Hispanic White men and women were analyzed to determine independent risk factors for three outcome variables: 1) Need for health care treatment, 2) Utilization of health care treatment, and 3) Failure to receive needed treatment. Nine independent demographic, health, and drug-use history variables were assessed in logistic regression models. Analysis of the data shows that chronic drug users were more likely in the past year to need health care treatment, were as likely to receive some health care treatment, and were more likely not to receive needed treatment than were nonusers. Chitwood, D.D., McBride, D.C., French, M.T., and Comerford, M. Substance Use and Misuse, 34(4-5), pp. 727-746, March-April 1999.

Cost of Employee Assistance Programs: Comparison of National Estimates from 1993 and 1995

The cost and financing of mental health services is gaining increasing importance with the spread of managed care and cost-cutting measures throughout the health care system. The delivery of mental health services through structured employee assistance programs (EAPs) could be undermined by revised health insurance contracts and cutbacks in employer-provided benefits at the workplace. This study uses two recently completed national surveys of EAPs to estimate the costs of providing EAP services during 1993 and 1995. EAP costs are determined by program type, worksite size, industry, and region. In addition, information on program services is reported to determine the most common types and categories of services and whether service delivery changes have occurred between 1993 and 1995. The results of this study will be useful to EAP managers, mental health administrators, and mental health services researchers who are interested in the delivery and costs of EAP services. French, M.T., Zarkin, G.A., Bray, J.W., Hartwell, T.D. Journal of Behavioral Health Services Research, 26(1), pp. 95-103, February 1999.

Characteristics of Women-Only and Mixed-Gender Drug Abuse Treatment Programs

Specialized substance abuse treatment programs have been developed for women within the past two decades. This article presents the results of a secondary analysis of a regional database of drug abuse treatment programs that compared the characteristics of women-only (WO) and mixed-gender (MG) programs across three treatment modalities. In general, WO programs differed from MG programs in their policies regarding fees, sources of payment, special populations served, services offered, and treatment capacity, process, and duration. The differences in program characteristics reflect broader societal gender differences, including women's generally lower economic status and primary responsibility for child-rearing. Grella, C.E., Polinsky, M.L., Hser, Y.I., Perry, S.M. Journal of Substance Abuse Treatment. 17(1-2), pp. 37-44, July-September 1999.

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

This study compared the characteristics of 4,117 women treated in publicly funded residential drug treatment programs in Los Angeles County between 1987 and 1994 by pregnancy status and program gender composition, that is, women-only and mixed-gender programs. A logistic regression analysis determined the predictors of program completion. Women in women-only programs were more likely than women in mixed-gender programs to be pregnant, homeless, or on probation; to use methamphetamines; to use alcohol; and have prior drug treatment. Pregnant women were younger, more likely to be homeless, had fewer years of drug use, were more often referred by other service providers, and were less likely to have injected drugs or have prior drug treatment than non-pregnant women. Although women in women-only programs had more problems, they spent more time in treatment and were more than twice as likely to complete treatment as compared with women in mixed-gender programs. Grella, C.E. Journal of Health Care for the Poor and Underserved, 10(2), pp. 216-229, May 1999.

A National Evaluation of Treatment Outcomes for Cocaine Dependence

This national study focused on posttreatment outcomes of community treatments of cocaine dependence. Relapse to weekly (or more frequent) cocaine use in the first year after discharge from 3 major treatment modalities was examined in relation to patient problem severity at admission to the treatment program and length of stay. Cocaine-dependent patients (N =1605) from 11 cities located throughout the United States were studied using a naturalistic, nonexperimental evaluation design. They were sequentially admitted from November 1991 to December 1993 to 55 community-based treatment programs in the national Drug Abuse Treatment Outcome Studies (DATOS). Included were 542 patients admitted to 19 long-term residential programs, 458 patients admitted to 24 outpatient drug-free programs, and 605 patients admitted to 12 short-term inpatient programs. Of the 1605 patients, 377 (23.5%) reported weekly cocaine use in the year following treatment (dropping from 73.1% in the year before admission). An additional 18.0% had returned to another drug treatment program. Higher severity of patient problems at program intake and shorter stays in treatment (<90 days) were related to higher cocaine relapse rates. Patients with the most severe problems were more likely to enter long-term residential programs, and better outcomes were reported by those treated 90 days or longer. These findings suggest that dimensions of psychosocial problem severity and length of stay are, therefore, important considerations in the treatment of cocaine dependence. Cocaine relapse rates for patients with few problems at program intake were most favorable across all treatment conditions, but better outcomes for patients with medium- to high-level problems were dependent on longer treatment stays. Simpson, D.D., Joe, G.W., Fletcher, B.W., Hubbard, R.L., and Anglin, M.D. Archives of General Psychiatry, 56(6), pp. 507-514, June 1999.

A Cost-Effectiveness and Cost-Benefit Analysis of Contingency Contracting-Enhanced Methadone Detoxification Treatment

The researchers examined treatment costs in an ongoing study in which 102 opioid-addicted patients had been randomly assigned to either 180-day methadone detoxification or the same treatment enhanced with contingency contracting. In the latter condition, study participants received regular reinforcers contingent on negative urine toxicology screens and breath analyses for a range of drugs and alcohol. Both conditions involved psychosocial treatment, and all participants were stabilized to a daily methadone dose of approximately 80 mg during the first 4 months, followed by a 2-month taper. Individuals participating in the enhanced condition were more likely to provide continuously drug-free urine samples and alcohol-free breath samples during the final month of treatment than were participants in the control condition. Cost of treatment was calculated individually for each participant based on actual services received. First, unit cost for each service was determined, including adjusted staff salaries for direct treatment and opportunity cost of facilities utilized during service delivery. Next, each patient's use of services during the first 120 days of the study was valued and then added the cost of methadone, laboratory work, and contingent reinforcers. A subsample (n = 45) also provided data on health care utilization during treatment, which we valued using standard Medicare unit costs. The marginal cost of enhancing the standard treatment with contingency contracting was approximately 8%. An incremental cost of $17.27 produced an additional 1% increase in the number of participants providing continuously substance-free urine and breath samples during month 4 of the study. For every additional dollar spent on treatment, a $4.87 health care cost offset was realized; however, this difference was statistically insignificant due to extreme variances and small subsample size. Hartz, D.T., Meek, P., Piotrowski, N.A., Tusel, D.J., Henke, C.J., Delucchi, K., Sees, K., Hall, S.M. American Journal of Drug and Alcohol Abuse, 25(2), pp. 207-218, May 1999.

Continuing Care for Cocaine Dependence: Comprehensive 2-Year Outcomes

This report presents 2-year outcome data from an outpatient continuing care study in which cocaine-dependent patients (N = 132) were randomly assigned to either standard group counseling (STD) or individualized relapse prevention (RP). Data on cocaine outcomes during the 6-month treatment phase of the study were presented in an earlier report. In the present report, a continuing care condition main effect was obtained on only 1 of 8 outcome variables examined. However, patients who endorsed a goal of absolute abstinence on entering continuing care had better cocaine use outcomes in RP than in STD, whereas the opposite was true for those with less stringent abstinence goals. In addition, patients with current cocaine or alcohol dependence on entering continuing care who received RP had better cocaine use outcomes in Months 1-6 and better alcohol use outcomes in Months 13-24 than those in STD. McKay, J.R., Alterman, A.I., Cacciola, J.S., O'Brien, C.P., Koppenhaver, J.M., Shepard, D.S. J Consult Clin Psychol, 67(3), pp. 420-427, June 1999.

How Expensive are Unlimited Substance Abuse Benefits under Managed Care?

Substance abuse (SA) care has been excluded from recent federal and state legislation mandating equal benefits for mental health and medical care ("parity"), largely because of cost concerns. This article studies how many patients are affected by SA coverage limits and the likely implications of limits on insurance payments, using 1996-97 claims from 25 managed care plans with unlimited SA benefits. Findings suggest that changing even stringent limits on annual SA benefits has a small absolute effect on overall insurance costs under managed care, even though a large percentage of SA patients are affected. Removing an annual limit of $10,000 per year on SA care is estimated to increase insurance payments by about 6 cents per member per year, removing a limit of $1,000 increases payments by about $3.40. As long as care is comprehensively managed, "parity" for SA in employer-sponsored health plans is not very costly. Sturm, R., Zhang, W., and Schoenbaum, M. Journal of Behavioral Health Services Research, 26(2), pp. 203-210, May 1999.

The DSM-IV Criteria for Adolescent Alcohol and Cannabis Use Disorders

The aims of this study are to compare DSM-IV criteria for alcohol and cannabis use disorders with its predecessor, DSM-III-R, and to examine the validity of the new criteria in an adolescent drug clinic sample. During evaluation, a sample of 772 adolescents (63% boys, 77% white) were administered a structured interview of diagnostic symptoms and additional problem severity measures. Independent staff ratings of problem severity and treatment referral were collected as well. Compared to its predecessor, DSM-III-R, application of the DSM-IV criteria for alcohol and cannabis users resulted in more abuse assignments and fewer dependence assignments. The shift in assignments appeared to be largely due to a lowering of the abuse threshold, rather than to a tightening of the dependence criteria. The external validity data generally supported the DSM-IV abuse and dependence distinction in adolescents, and the newer criteria were as valid as the older criteria. In contrast to DSM-III-R, the DSM-IV system yields more abuse cases and fewer dependence cases among adolescent alcohol and cannabis abusers. Validity evidence for the new criteria are defensible, yet the findings are seen as a starting point for discussing the need for tailoring substance use disorder criteria for adolescents. Winters, K.C., Latimer, W., and Stinchfield, R.D. J Stud Alcohol, 60(3), pp. 337-344, May 1999.

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