Research Findings - Services Research

Interim Methadone Maintenance Enhances Patient Engagement in Treatment

A total of 319 individuals meeting the criteria for current heroin dependence and methadone maintenance treatment were randomly assigned to either interim methadone maintenance, consisting of an individually determined methadone dose and emergency counseling only for up to 120 days, or referral to community-based methadone treatment programs. Significantly more participants assigned to the interim methadone maintenance condition entered comprehensive methadone maintenance treatment by the 120th day from baseline (75.9%) than those assigned to the waiting list control condition (20.8%) (P<.001). Overall, in the past 30 days at follow-up, interim participants reported significantly fewer days of heroin use (P<.001), had a significant reduction in heroin-positive drug test results (P<.001), reported spending less money on drugs (P<.001), and received less illegal income (P<.02) than the waiting list participants. Thus Interim methadone maintenance results in a substantial increase in the likelihood of entry into comprehensive treatment, and is an effective means of reducing heroin use and criminal behavior among opioid-dependent individuals awaiting entry into a comprehensive methadone treatment program. Schwatz, R.P., Brady, J.V., and Callaman, J.M. A Randomized Controlled Trial of Interim Methadone Maintenance. Arch Gen Psychiatry, 63(Jan), pp. 102-109, 2006.

Higher Syringe Coverage is Associated with Lower Odds of HIV

The purpose of this study was to determine if adequate syringe coverage - "one shot for one syringe" - among syringe exchange program (SEP) clients is associated with injection-related HIV risk behaviors and syringe disposal. HIV risk assessments with 1577 injection drug users (IDUs') recruited from 24 SEPs' in California between 2001 and 2003 were analyzed for the study. Individual syringe coverage was calculated as a proportion of syringes retained from SEP visits to total number of injections in the last 30 days. Participants were divided into four groups based on syringe coverage: <50%, 50-99%, 100-149%, and 150% or more. In multivariate logistic regression, SEP clients with less than 50% syringe coverage had significantly higher odds of reporting receptive syringe sharing in the last 30 days (adjusted odds ratio [AOR] = 2.3; 95% confidence interval [CI] = 1.4, 3.6) and those with 150% or more coverage had lower odds of reporting receptive syringe sharing (AOR= 0.5; 95%CI = 0.3, 0.8) as compared to SEP clients with adequate syringe coverage of 100-149%. Similar associations were observed for other main outcomes of distributive syringe sharing and syringe re-use. No differences in safe syringe disposal were observed by syringe coverage. Individual syringe coverage is strongly associated with safer injection behaviors without impacting syringe disposal among SEP clients. Syringe coverage is a useful measure for determining if IDUs' are obtaining sufficient syringes to lower HIV risk. Bluthenthal, R.N., Anderson, R., Flynn, N.M., and Kral, A.H. Higher Syringe Coverage Is Associated with Lower Odds of HIV. Drug Alcohol Depend, 12 pp. 1-9, 2006.

Examination of the Association Between Syringe Exchange Program (SEP)

Dispensation Policy and SEP Client-level Coverage This study explores whether syringe exchange programs' (SEPs') dispensation policy is associated with syringe coverage among SEP clients. The study used a cross-sectional sample of 24 SEPs and their injection drug using clients (IDU) (n=1546) in California, USA. Clients were classified as having adequate syringe coverage if they received at least as many syringes from the SEP as their self-reported injections in the last 30 days. SEPs' were classified based on their syringe dispensation policy. Dispensation schemes ranging from least restrictive to most are: unlimited needs-based distribution; unlimited one-for-one exchange plus a few additional syringes; per visit limited one-for-one plus a few additional syringes; unlimited one-for-one exchange; and per visit limited one-for-one exchange. Adequate syringe coverage among SEP clients by dispensation policy is as follows: unlimited needs-based distribution = 61%; unlimited one-for-one plus = 50%; limited one-for-one plus = 41%; unlimited one-for-one = 42%; and limited one-for-one = 26%. In multivariate analysis, adequate syringe coverage was significantly higher for all dispensation policies compared to per visit limited one-for-one exchange. Using propensity scoring methods, the study compared syringe coverage by dispensation policies while controlling for client-level differences. Providing additional syringes above one-for-one exchange (50% versus 38%, P = 0.009) and unlimited exchange (42% versus 27%, P = 0.05) generally resulted in more clients having adequate syringe coverage compared to one-for-one exchange and per visit limits. Providing less restrictive syringe dispensation is associated with increased prevalence of adequate syringe coverage among clients. This study suggests that SEPs' should adopt syringe dispensation policies that provide IDUs sufficient syringes to attain adequate syringe coverage. Bluthenthal, R.N., Ridgeway, G., Schell, T., Anderson, R., Flynn, N.M., and Kral, A.H. Examination of the Association between Syringe Exchange Program (SEP) and SEP Client-level. Addiction, 10, pp. 1-9, 2007.

Patient Engagement in Treatment is Enhanced When Staff Beliefs and Associated Practices are Widely Shared

Two nonspecific organizational factors--consensus, defined as agreement within staff and client groups about treatment and other practices, and concordance, defined as agreement between staff and client groups--were shown to influence client engagement in treatment in a national sample of 80 residential substance abuse treatment programs including 595 staff and 3,732 clients. Agreement was tested using a combined therapeutic community, cognitive-behavioral therapy, and 12-step treatment scale completed by staff and clients. Treatment engagement was measured by the combined scores on the three scales completed by the clients addressing engagement, rapport with the counseling process, and confidence in treatment. Within-group consensus was measured by the standard deviations of the mean scores, whereas between-groups concordance was measured by the standard error of the difference between staff and client mean scores. Regression analyses showed that staff consensus was a significant independent predictor of client treatment engagement (p < .05), whereas client consensus approached significance (p < .10). Concordance was also a significant predictor of client engagement (p < .002) after controlling for staff and client consensus. Melnick, G., Wexler, H.K., Chaple, M., and Banks, S. The Contribution of Consensus within Staff and Client Groups as well as Concordance between Staff and Clients to Treatment Engagement. J Subst Abuse Treat, 31(3), pp. 277-285, 2006.

Public Sector Managed Care Did Not Result in Poorer Care for Most Clients

This study of publicly funded substance abuse treatment systems compared Mid-State, a county that reorganized its treatment system using managed care principles, to two other California counties that took different approaches, North-State and South-State. It was hypothesized that Mid-State would have better outcomes due to its emphasis on quality of care. This natural experiment compared the ''experimental'' county, Mid-State, to two ''control '' counties, assessing client outcomes following treatment. Administrative and historical exigencies that may affect system differences were explored in interviews with treatment program managers and staff. Comparison counties were selected using treatment system and county census data, maximizing similarities to enhance internal validity. The study participants consisted of adult clients (n = 681) who were interviewed when beginning treatment and 12 months later (81% response rate). In addition, 50 treatment program managers and staff members across the three counties were interviewed during the year of client recruitment. Outcome was assessed using client interviews that assessed functioning in the seven Addiction Severity Index domains-alcohol, drug, psychiatric, legal, employment, medical and family/social. It was found that the outcomes (differences between baseline and 12 month composite scores) did not differ between counties in six of seven domains; in the seventh, psychiatric functioning, South-State had better outcomes than Mid-State. Staff interviews indicated generally similar treatment strategies across counties, with Mid-State supplying greater oversight and performance standards. In this study managed care in public sector treatment generally did not result in poorer outcomes. The authors suggested that future attention in Mid-State to the barriers to successful implementation of individualized treatment, and to dual diagnosis treatment, might bring more positive results. Beattie, M., McDaniel, P., and Bond, J. Public Sector Managed Care: A Comparative Evaluation of Substance Abuse Treatment in Three Counties. Addiction, 101(6), pp. 857-872, 2006.

Impact of Enhanced Services on Virologic Outcomes for HIV-Infected Drug Users

Directly administered antiretroviral therapy (DAART) is a promising intervention for improving HIV outcomes among active drug users, but the elements associated with successful DAART programs remain largely unknown. This study aimed to assess the impact of co-located medical, case management, and referral to substance abuse services (DAART-Plus) among the subjects receiving DAART as part of a larger randomized controlled trial comparing DAART with self-administered therapy. The health services utilization of 72 subjects receiving DAART was analyzed for its impact on changes in HIV-1 RNA levels at 6 months. The primary outcome was virologic success, defined as achieving an HIV-1 RNA level 400 copies/mL or a 1.0 log10 reduction in HIV-1 RNA level. A second analysis consisted of linear regression assessing the effect of covariates on log10 HIV-1 RNA reduction from baseline to 6 months. In multivariate analyses, achieving virologic success at 6 months was associated with high medical services utilization [adjusted odds ratio [AOR] = 10.0 (1.4, 73.9); P = 0.02] and with the use of case management services [AOR = 5.8 (1.1, 30.5); P = 0.04]. Both services resulted in a larger reduction in log10 HIV-1 RNA from baseline (difference in slopes: 20.9 and 21.0, respectively; P = 0.02 for both). Referral to off-site substance abuse services treatment did not significantly predict either virologic outcome. Among individuals who receive DAART, the utilization of on-site medical and case management services was independently associated with improved virologic outcomes. These results suggest the potential utility of integrating these services into DAART interventions (DAART-Plus) targeting HIV-infected drug users with problematic adherence. Smith-Rohrberg, D., Mezger, J., Walton, M., Bruce, D., and Altice, F. Impact of Enhanced Services on Virologic Outcomes in a Directly Administered Antiretroviral Therapy Trial for HIV-Infected Drug Users. J Acquir Immune Defic Syndr, 43(S1), pp. S48-S53, 2006.

Adolescent Health Care Utilization and Costs Do Not Diminish Following 1 Year of CD Treatment

This paper examined utilization and cost in the 1 year pre- and post-intake among a sample of adolescents (N = 419) entering chemical dependency (CD) treatment in a private, not-for-profit HMO. Multivariate analyses showed that these youth used significantly more medical services than a demographically matched sample of members without substance use (SU) problems. Their utilization and costs were higher than matched members, and they did not show the same reductions in post-treatment costs that adults do. This is of concern since it would appear that the medical and mental health problems of adolescents entering CD treatment may be so severe that there are no short-term reductions in post-treatment cost, including ER and hospitalizations. Parthasarathy, S., and Weisner, C. Health Care Services Use by Adolescents with Intakes into an Outpatient Alcohol and Drug Treatment Program. Am J Addict, 15 Suppl 1, pp. 113-121, 2006.

Teenage Marijuana and Hard Drug Use Increases in a Weak Economy

This research examines how teenage drug and alcohol use responds to changes in the economy. In contrast to the recent literature confirming pro-cyclical alcohol use among adults, this research offers strong evidence that a weaker economy leads to greater teenage marijuana and hard-drug use and some evidence that a weaker economy also leads to higher teenage alcohol use. The findings are based on logistic models with state and year fixed effects, using teenagers from the NLSY-1997. The evidence also indicates that teenagers are more likely to sell drugs in weaker economies. This suggests one mechanism for counter-cyclical drug use - that access to illicit drugs is easier when the economy is weaker. These results also suggest that the strengthening economy in the 1990s mitigated what would otherwise have been much larger increases in teenage drug use. Arkes, J. Does the Economy Affect Teenage Substance Use? Health Econ, 16 pp. 19-36, 2007.

Economic Evaluations Done Alongside RTCs Could be Improved

This article evaluates the statistical methods used for economic evaluations of medical interventions based on patient level data collected during randomized controlled trials. Only 42 (37%) of the 115 economic evaluations presented a cost-effectiveness ratio or estimated net benefits and 24 (57%) of these reported the uncertainty of this statistic. A comparison of costs alone was more common with 92 (80%) of the 115 studies statistically comparing costs between treatment groups. Of these, about two-thirds (62; 68%) used at least one statistical test appropriate for drawing inferences for arithmetic means. Incomplete cost data were reported in 67 (58%) studies with only two using a published statistical approach for handling censored cost data. The quality of statistical methods used in economic evaluations conducted alongside randomized controlled trials was poor in the majority of studies published in 2003. Adoption of appropriate statistical methods is required before the results from such studies can consistently provide valid information to decision-makers. Doshi, J., Glick, H., and Polsky, D. Analyses of Cost Data in Economic Evaluations Conducted alongside Randomized Controlled Trials. Value Health, 9(5), pp. 334-340, 2006.

Medical Conditions of Adolescents in AOD Treatment

This study compares the prevalence of medical conditions among 417 adolescent alcohol and drug treatment patients with 2082 demographically matched controls from the same managed care health plan and examines whether comparisons vary among substance-type subgroups. Approximately one-fourth of the comorbid conditions examined were more common among adolescent alcohol and drug patients than among matched controls, and several were highly costly conditions (e.g., asthma, injury). Pain-related diagnoses, including headache and abdominal pain, were more prevalent among these alcohol and drug patients. These findings point to the importance of examining comorbid medical and chemical dependency in both adolescent primary care and specialty care. Moreover, optimal treatment of many common medical disorders may require identification, intervention, and treatment of a substance use problem. Mertens, J., Flisher, A., Fleming, M., and Weisner, C. Medical Conditions of Adolescents in Alcohol and Drug Treatment: Comparison with Matched Controls. J Adolesc Health, 40(2), pp. 173-179, 2007. Payee Assignment Does Not Reduce Substance Abuse among Those with Serious Mental Illness Approximately 700,000 Social Security beneficiaries in the U.S. with psychiatric disabilities have been assigned a representative payee to manage their funds but it is unclear how those judged to need a payee differ from others and whether payee assignment improves clinical outcomes, especially substance abuse. Participants in this observational 12-month cohort study (n=1457) received SSI or SSDI and had serious mental illness. They were subsequently enrolled at eighteen community-based sites that provided Assertive Community Treatment. Social Security administrative records were used to determine whether a payee had been assigned. At baseline, participants who were assigned a payee were more likely to have schizophrenia and had more severe clinician-rated drug and alcohol use than those not assigned a payee. In GEE models that adjusted for these and other potentially confounding covariates, participants assigned a payee between 4 and 12 months after program entry subsequently used significantly more psychiatric services than participant's not assigned payees but showed no greater reduction in substance use. Although substance use is associated with being assigned a payee, substance use does not decline substantially following payee assignment. Participants assigned payees made greater subsequent use of psychiatric services, suggesting the potential for benefit from payee assignment. Rosen, M., McMahon, T., and Rosenheck, R. Does Assigning a Representative Payee Reduce Substance Abuse? Drug Alcohol Depend, 86(2-3), pp. 115-122, 2007.

Clients Smoking Five Years After Alcohol and Drug Abuse Treatment Have Worse Long-Term Treatment Outcomes

This prospective study examined the relationship between cigarette smoking and five-year substance abuse treatment outcomes. Of 749 individuals who began private outpatient treatment, 598 (80%) were re-interviewed by telephone at five years. At five-year follow-up, 53% reported smoking cigarettes in the prior 30 days. Those smoking at that time were less likely to be abstinent from alcohol and drugs in the prior 30 days (48.3% vs. 64.0%), and had higher Addiction Severity Index (ASI) scores in employment, alcohol, drug, psychiatric, and family-social problems; worse self-reported health; and greater self-reported depression. Satre, D.D., Kohn, C.S., and Weisner, C. Cigarette Smoking and Long-Term Alcohol and Drug Treatment Outcomes: A Telephone Follow-Up at Five Years. Am J Addict, 16, pp. 32-37, 2007.

Higher Contingency Management Payouts are More Cost Effective

Contingency management has been shown to be effective in improving treatment outcomes. This paper assesses the relative cost-effectiveness of lower versus higher cost prize-based contingency management (CM) treatments for cocaine abuse as implemented in two community-based treatment centers. One hundred twenty patients who enrolled in out-patient treatment for cocaine abuse were randomly assigned to one of three 12-week treatment conditions: standard treatment (STD) alone or two variants of STD combined with prize based CM. In CM, drawing for prizes was available to those submitting drug-free urine samples and completing goal-related activities. There were two levels of pay-out (referred to as $80 versus $240) based on the potential value of prizes won. The higher magnitude CM produced outcomes at a lower per unit cost than did the lower magnitude prize CM treatment. This was the case for all three outcome measures examined (longest duration of consecutive abstinence, percentage completing treatment, and percentage of samples drug-free) and held across various assumptions in the sensitivity analysis. Sindelar, J., Elbel, B., and Petry, N. What Do We Get for Our Money? Cost-Effectiveness of Adding Contingency Management. Addiction, 102(2), pp. 309-316, 2007.

Buprenorphine Use: The International Experience

The confluence of the heroin injection epidemic and the human immunodeficiency virus (HIV) infection epidemic has increased the call for expanded access to effective treatments for both conditions. Buprenorphine and methadone are now listed on the World Health Organization's Model Essential Drugs List. In France, which has the most extensive experience, buprenorphine has been associated with a dramatic decrease in deaths due to overdose, and buprenorphine diversion appears to be associated with inadequate dosage, social vulnerability, and prescriptions from multiple providers. Other treatment models (in the United States, Australia, Germany, and Italy) and buprenorphine use in specific populations are also reviewed in the present article. In countries experiencing a dual epidemic of heroin use and HIV infection, such as former states of the Soviet Union and other eastern European and Asian countries, access to buprenorphine and methadone may be one potential tool for reducing the spread of HIV infection among injection drug users and for better engaging them in medical care. Carrieri, M. P., Amass, L., Lucas, G. M., Vlahov, D., Wodak, A., and Woody, G. E. Buprenorphine Use: The International Experience. Clin Infect Dis, 43, pp. S197-S215, 2006.

Limited Effectiveness of Antiviral Treatment for Hepatitis C in an Urban HIV Clinic

This study evaluated predictors and trends of referral for hepatitis C virus (HCV) care, clinic attendance and treatment in an urban HIV clinic. A retrospective cohort analysis in which 845 of 1318 co-infected adults who attended the Johns Hopkins HIV clinic between 1998 and 2003 after an onsite viral hepatitis clinic was opened attended regularly (1 visit/year for 2 years). Logistic regression was used to examine predictors of referral. A total of 277 (33%) of 845 were referred for HCV care. Independent predictors of referral included percentage elevated alanine minotransferase levels [adjusted odds ratio (AOR) for 10% increase, 1.16; 95% confidence interval (CI), 1.10-1.22] and CD4 cell count >350 cells/ml (AOR, 3.20; 95% CI, 2.10-4.90), while injection drug use was a barrier to referral (AOR, 0.26; 95% CI, 0.11-0.64). Overall referral rate increased from <1% in 1998 to 28% in 2003; however, even in 2003, 65% of those with CD4 cell count >200 cells/ml were not referred. One hundred and eighty-five (67%) of 277 referred kept their appointment, of whom 32% failed to complete a pre-treatment evaluation. Of the remaining 125, only 69 (55%) were medically eligible for treatment, and 29 (42%) underwent HCV treatment. Ninety percent of 29 were infected with genotype 1 and 70% were African American; six (21%) achieved sustained virologic response (SVR). Only 0.7% of the full cohort achieved SVR. Although the potential for SVR and the recent marked increase in access to HCV care are encouraging, overall effectiveness of anti-HCV treatment in this urban, chiefly African American, HCV genotype 1 HIV clinic is extremely low. New therapies and treatment strategies are an urgent medical need. Mehta, S.H., Lucas, G.M., Mirel, L.B., Torbenson, M., Higgins, Y., Moore, R.D., Thomas, D.L., and Sulkowski, M.S. Limited Effectiveness of Antiviral Treatment for Hepatitis C in an Urban HIV Clinic. AIDS, 20(18), pp. 2361-2369, 2006.

Invasive Pneumococcal Disease in a Cohort of HIV-Infected Adults: Incidence and Risk Factors, 1990-2003

This study investigated the association between the introduction of HAART and invasive pneumococcal disease (IPD) in HIV-infected patients. Incidence of IPD was determined from 1990 to 2003 in a cohort of HIV infected individuals and a nested case-control study assessed risk factors of IPD. There were 72 cases over 19,020 person-years of follow-up (overall IPD rate, 379/100 000 person-years). In the calendar periods 1990-1995, 1995-1998, and 1998-2003, the IPD incidence per 100,000 person-years was 279 [95% confidence interval (CI), 150-519], 377 (95% CI, 227-625) and 410 (95% CI, 308-545), respectively (P _ 0.516). CD4 cell count < 200 cells/ml [odds ratio (OR), 3.0; 95% CI, 1.2-7.6), HIV RNA > 50 000 copies/ml (OR, 2.8; 95% CI, 1.2-6.5), hepatitis C (OR, 4.9; 95% CI, 1.7-14.9), serum albumin (OR, 0.1; 95% CI, 0.04-0.5), injection drug use in women (OR, 3.8; 95% CI, 1.6-8.8), and education beyond high school (OR, 0.2; 95% CI, 0.05- 0.8) were significantly associated with IPD in multivariate analysis. No treatment factor, including HAART (OR, 0.7; 95% CI, 0.3-1.5) and pneumococcal vaccination (OR, 0.9; 95% CI, 0.5-1.6), was associated with IPD. IPD incidence did not change significantly during the widespread dissemination of HAART in this cohort. IPD risk was associated with several socio-demographic and clinical factors. Barry, P.M., Zetola, N., Keruly, J.C., Moore, R.D., Gebo, K.A., and Lucas, G.M. Invasive Pneumococcal Disease in a Cohort of HIV-Infected Adults: Incidence and Risk Factors,1990-2003. AIDS, 20, pp. 437-444, 2006.

Substance Abuse Treatment Prevention and Policy

It has been proposed that the substance abuse treatment delivery system cut across different components of the criminal justice continuum in order to reduce criminal recidivism and drug use. Arrest, at the front end of this continuum, may represent a critical moment to motivate people with substance use disorders (SUD) to seek treatment but is often over looked as an intervention point. Data from the 2002 National Survey on Drug Use and Health (NSDUH) were used to compare treatment need and recent treatment admission for participants with no criminal justice (CJ) involvement in the past year, past-year arrest, and CJ supervision (i.e., probation or parole status). Of those arrested, 44.8% met criteria for an SUD. However, only 14% of those arrested with an SUD received treatment in the year of their arrest. In multivariate modeling, arrest was an independent predictor of treatment admission (odds ratio (OR) = 8.74) similar in magnitude to meeting criteria for an SUD (OR = 8.22). Those further along the continuum - under supervision - were most likely to receive treatment (OR = 22.62). Arrest involves the largest number of individuals entering the criminal justice system. The NSDUH suggests that nearly 6 million individuals in the US experience an arrest annually and that nearly half meet criteria for an SUD. Although arrest involves the largest number of individuals entering the criminal justice system, it is also the most fleeting point as individuals can move in and out rather quickly. Minimally, arrest imposes contact between the individual and a law enforcement person and can be an opportunity for early intervention strategies such as pre-arraignment diversion into treatment or brief intervention strategies. Using brief intervention at this early point in the continuum may motivate a greater number of individuals to seek treatment or decrease drug and alcohol use. Training and procedural shifts at this point of contact could have important policy implications in reducing the number of subsequent arrests or preventing individuals moving further along the criminal justice continuum, as well as decreasing the fiscal and resource burdens associated with criminal justice processing and confinement. Pimlott Kubiak, S., Arfken, C.L., Swartz, J.A., and Koch, A.L. Substance Abuse Treatment Prevention, and Policy. BioMed Central, 1(20), pp. 1-10, 2006.

Initial Strategies for Integrating Buprenorphine into HIV Care Settings in the United States

The Centers for Disease Control and Prevention's HIV Prevention Strategic Plan through 2005 advocated for increasing the proportion of persons with human immunodeficiency virus (HIV) infection and in need of substance abuse treatment who are successfully linked to services for these 2 conditions. There is evidence that integrating care for HIV infection and substance abuse optimizes outcomes for patients with both disorders. Buprenorphine, a recently approved medication for the treatment of opioid dependence in physicians' offices, provides the opportunity to integrate the treatment of HIV infection and substance abuse in one clinical setting, yet little information exists on the models of care that will most successfully facilitate this integration. To promote the uptake of this type of integrated care, the current review provides a description of 4 recently implemented models for combining buprenorphine treatment with HIV primary care: (1) an on-site addiction/HIV specialist treatment model; (2) a HIV primary care physician model; (3) a nonphysician health professional model; and (4) a community outreach model. Sullivan, L.E., Bruce, R.D., Haltiwanger, D., Lucas, G.M., Eldred, L., Finkelstein, R., and Fiellin, D.A. Initial Strategies for Integrating Buprenorphine into HIV Care Settings in the United States. Clin Infect Dis, 43, pp. S191-S196, 2006.

Reasons for Condom Use or Non-use Among Drug Users

In this study, Rosengard, Anderson, and Stein, interviewed two hundred and seventy-seven drug using adults regarding details of their most recent sexual encounter. Demographic, attitudinal, and context variables were associated with condom use and non-use. Greater perceived risk of STDs/HIV and positive attitudes toward condoms' effect on sexual pleasure were associated with greater likelihood of reporting condom use. Common reasons for not using condoms included lower perceived risk of contracting HIV/STDs, negative attitudes toward condoms' effect on pleasure, and lack of condom availability. Tailoring messages to modifiable perceptions of risk and condom attitudes may be useful in reducing sexual risk among drug-using individuals. Rosengard, C., Anderson, B., and Stein, M. Correlates of Condom Use and Reasons for Condom Non-use Among Drug Users. Am J Drug Alcohol Abuse, 32(4), pp. 637-1441, 2006.

DSM-III-R and DSM-V Diagnoses are Generally Concordant in Drug Users with Chronic and Severe Problems

This study determined the rates of concordance between the Diagnostic and Statistical Manual of Mental Disorders Version III-R (DSM-III-R) and the next version (DSM-IV) lifetime diagnoses for Substance Abuse and Dependence in a population (N=900) homogeneous for chronic and severe substance use disorder. The substance use disorder sections of the Structured Clinical Interview for DSM-III-R and DSM-IV were combined into a single interview and administered by trained clinical research interviewers. Analysis for each drug class was restricted to patients who reported prior use of the substance. Kappa values indicated excellent agreement between the 2 classification systems for Dependence diagnoses and fair to excellent concordance for Abuse diagnoses. However for cannabis the DSM-IV nosology resulted in lower rates of Dependence and higher rates of Abuse diagnoses. Stoller, K. B., King, V.L., Kidorf, M.S., Neufeld, K.S., and Brooner, R.K. DSM-III-R Versus DSM-IV Substance Use Disorders: Concordance in Drug Users Homogeneous for Chronic and Severe Problems. Addictive Disorders & Their Treatment, 5(4), pp. 165-171, 2006.

Research is Needed to Overcome Policy and Financing Barriers to Integrated Buprenorphine and HIV Primary Care

Treatment for substance abuse and human immunodeficiency virus (HIV) infection historically have come from different providers, often in separate locations, and have been reimbursed through separate funding streams. This paper describes policy and financing challenges faced by health care providers seeking to integrate buprenorphine, a new treatment for opioid dependence, into HIV primary care. Regulatory challenges include licensing and training restrictions imposed by the Drug Addiction Treatment Act of 2000 and confidentiality regulations for alcohol and drug treatment records. Potential responses include the development of local training programs and electronic medical records. Addressing the complexity of funding sources for integrated care will require administrative support, up-front investments, and federal and state leadership. A policy and financing research agenda should address evidence gaps in the rationales for regulatory restrictions and should include cost-effectiveness studies that quantify the "value for money" of investments in integrated care to improve health outcomes for HIV-infected patients with opioid dependence. Schackman, B.R., Merrill, J.O., McCarty, D., Levi, J., and Lubinski, C. Overcoming Policy and Financing Barriers to Integrated Buprenorphine and HIV Primary Care. Clin Infect Dis, 43, pp. S247-S253, 2006.

If You Build It, They Will Come: Practitioner Interest in CM for Youth

This publication addresses the science-service gap by examining the amenability of a large heterogeneous sample of community-based therapists in state mental health and substance abuse treatment sectors to learn about an evidence-based practice (EBP) for adolescent substance abuse (i.e., contingency management [CM]) when such learning was supported administratively and logistically. Leadership in most (44 of 50) public sector agencies supported practitioner recruitment, and 432 of 543 eligible practitioners subsequently attended a 1-day workshop in CM. Workshop attendance was predicted by organizational factors but not by practitioner demographic characteristics, professional background, attitudes toward EBPs, or service sector. Moreover, the primary reason for workshop attendance was to improve services for adolescent clients; the primary barriers to attendance, for those who did not attend, were practical in nature and not due to theoretical incompatibility. The findings demonstrate a considerable amount of interest practitioners showed in both the substance abuse and mental health sectors in learning about an EBP. Henggeler, S., Chapman, J., Rowland, M., Halliday-Boykins, C., Randall, J., Shackelford, J., and Schoenwald, S. If You Build It, They Will Come: Statewide Practitioner Interest in Contingency Management for Youths. J Subst Abuse Treat, 32(2), pp. 121-131, 2007.

Excess Medical Costs and Health Problems of AOD Family Members

The researchers estimate the excess medical costs and prevalence of diagnosed health conditions of family members of persons with an alcohol or drug diagnosis (AOD) compared with the family members of similar persons without an AOD, utilizing a large health plans administrative 2001-2004 databases. Using a hierarchical linear mixed model, they compared the cost and utilization of the family members of the AOD and non-AOD patients in the 2 years prior to the AOD patient's first AOD. Using logistic regression, they determined whether the family members of patients with AODs' were more likely than comparison family members to be diagnosed with medical conditions. As hypothesized, family members of patients with AODs' had greater health care costs than comparison family members in the second year before the index date (490 dollars) and in the year before the index date (433 dollars). This was the case for both adult and child family members. They also were more likely to be diagnosed with many medical conditions, especially substance abuse and depression. Ray, G., Mertens, J., and Weisner, C. The Excess Medical Cost and Health Problems of Family Members of Persons Diagnosed with Alcohol or Drug Problems. Med Care, 45(2), pp. 116-122, 2007.

Potential Role of Buprenorphine in Treatment of Opioid Dependence in HIV-Infected Individuals

Untreated opioid dependence is a major obstacle to the successful treatment and prevention of human immunodeficiency virus (HIV) infection. In this review, the authors examine the interwoven epidemics of HIV infection and opioid dependence and the emerging role of buprenorphine in improving HIV treatment outcomes among infected individuals, as well as its role in primary and secondary prevention. This article addresses some of the emerging issues about integrating buprenorphine treatment into HIV clinical care settings and the various strategies that must be considered. Specifically, it addresses the role of buprenorphine in improving HIV treatment outcomes through engagement in care, access to antiretroviral therapy and preventive therapies for opportunistic infections, and the potential benefits of and pitfalls in integrating buprenorphine into HIV clinical care settings. Authors discuss the key research questions regarding buprenorphine in the area of improving HIV treatment outcomes and prevention, including a review of published studies of buprenorphine and antiretroviral treatment and currently ongoing studies, and provide insight into and models for integrating buprenorphine into HIV clinical care settings. Dialogue among practitioners and policy makers in the HIV care and substance abuse communities will facilitate an effective expansion of buprenorphine and ensure that these beneficial outcomes are achieved. Altice, F., Sullivan, L., Smith-Rohrberg, D., Basu, S., Stancliff, S., and Eldred, L. The Potential Role of Buprenorphine in the Treatment of Opioid Dependence in HIV-Infected Individuals and in HIV Infection Prevention. Clin Infect Dis, 206:43 (S4), pp. S178-S183, 2006.

Lack of HIV Seropositivity Among a Group of Rural Probationers: Explanatory Factors

Human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) in rural America has been described as an epidemic, and the HIV prevalence rate among criminal justice populations is higher than the general population. Thus, criminally involved populations in Southern rural areas are at elevated risk for contracting HIV because of drug and sexual practices; however, little is known about HIV/AIDS in the fastest growing criminal justice population -- probationers. This study examined possible explanations for the lack of HIV seropositivity found in a purposive sample of rural probationers. Data were examined from 800 felony probationers from 30 counties in Kentucky's Appalachian region. Measures included HIV prevalence within the 30 counties, migration patterns, HIV knowledge, substance use, and sexual risk behaviors. These probationers had a high level of HIV knowledge, reported minimal injection drug use, practiced serial monogamy, and reported minimal engagement in transactional sex. However, these probationers also reported negligible condom use, and injection drug users shared needles and works. Findings suggest the importance of developing programs targeting safe sex practices in rural areas. Oser, C.B., Smiley McDonald, H.M., Havens, J.R., Leukefeld, C.G., Webster, J.M., and Cosentino-Boehm, A.L. Lack of HIV Seropositivity Among a Group of Rural Probationers: Explanatory Factors. J Rural Health, 22(3), pp. 273-275, 2006.

Recruiting Drug-Using Men who Have Sex With Men into Behavioral Interventions: A Two-Stage Approach

Drug-using men who have sex with men (MSM) are at high risk of acquiring or transmitting HIV infection. Efforts to change behaviors in this population have been hampered by difficulties in recruiting drug-using MSM into behavioral interventions. This study sought to develop an effective strategy for recruiting drug-using MSM into behavioral interventions that consist of motivational interviewing alone or motivational interviewing plus contingency management. MSMs' were recruited through advertising and community outreach into groups to discuss party drugs, party burnout, and sexual behavior, with the intervention subsequently described and enrollment offered in the group setting. Many more eligible MSM responded to advertisements for the discussion groups than advertisements for the interventions, and 58% of those who participated in the discussion groups volunteered for counseling. Men who entered counseling reported high levels of drug use and sexual activity and were racially and ethnically diverse; only 35% were willing to accept drug treatment. Results demonstrate that a two-stage strategy in which drug-using MSM are first recruited into discussion groups before they are offered a behavioral intervention can be an effective way to induce voluntary acceptance of an intervention employing a behavioral risk-reduction approach. Kanouse, D.E., Bluthenthal , R.N., Bogart, L., Iguchi, M.Y., Perry, S., Sand, K., and Shoptaw, S. Recruiting Drug-using Men Who Have Sex with Men into Behavioral Interventions: A Two-stage Approach. J Urban Health, 2, pp. 109-119, 2005.

Buprenorphine Therapy Models for the HIV Care Setting

Buprenorphine maintenance therapy has been associated with reductions in opiate use, increased social stability, improved adherence to antiretroviral therapy, and lowered rates of injection drug use. The authors describe 4 models for the integration of buprenorphine maintenance therapy into HIV care: (1) a primary care model, in which the highly active antiretroviral therapy-administering clinician also prescribes buprenorphine; (2) a model that relies on an on-site specialist in addiction medicine or psychiatry to prescribe the buprenorphine; (3) a hybrid model, in which an on-site specialist provides the induction (with or without stabilization phases) and the HIV care provider provides the maintenance phase; and (4) a drug treatment model that provides buprenorphine maintenance therapy services with HIV services in the substance abuse clinic setting. Basu, S., Smith-Rohrberg, D., Bruce, R., and Altice, F. Models for Integrating Buprenorphine Therapy into the Primary HIV Care Setting. Clin Infect Dis, 42(5), pp. 716-721, 2006.

Buprenorphine and HIV Primary Care: New Opportunities for Integrated Treatment

NIDA, the Centers for Disease Control and Prevention, and other agencies, presented a workshop entitled "Buprenorphine in the Primary HIV Care Setting." Participants reviewed and discussed current issues, such as the introduction of and sources for the provision of buprenorphine in HIV primary care settings and strategies for integrating treatment of HIV-infected drug abusers, all of which are covered in this supplement. Data presented at this conference suggest that the most effective way to integrate the use of buprenorphine for the treatment of opioid dependence with antiretroviral therapy for HIV is to bridge two medical fiends - addiction medicine and infectious disease - and then develop supportive policies. Research is needed to develop effective ways to blend these two different medical disciplines and improve the quality of care delivered to individuals who are both HIV positive and opioid dependent. Khalsa, J., Vocci, F., Altice, F., Fiellin, D., and Miller, V. Buprenorphine and HIV Primary Care: New Opportunities for Integrated Treatment. Clin Infect Dis, 43(S4), pp. S169-S172, 2006.

Demonstration and Evaluation of a Method for Assessing Mediated Moderation

When interaction terms are correlated, the power needed to detect mediated moderation can be problematic. Mediated moderation occurs when the interaction between two variables affects a mediator, which then affects a dependent variable. In this article, authors describe the mediated moderation model and evaluate it with a statistical simulation using an adaptation of product-of-coefficients methods to assess mediation. The authors also demonstrate the use of this method with a substantive example from the adolescent tobacco literature. In the simulation, relative bias (RB) in point estimates and standard errors did not exceed problematic levels of +/- 10% although systematic variability in RB was accounted for by parameter size, sample size, and nonzero direct effects. Power to detect mediated moderation effects appears to be severely compromised under one particular combination of conditions: when the component variables that make up the interaction terms are correlated and partial mediated moderation exists. Implications for the estimation of mediated moderation effects in experimental and non-experimental research are discussed. Morgan-Lopez, A., and MacKinnon, D. Demonstration and Evaluation of a Method for Assessing Mediated Moderation. Behav Res Methods, 38(1), pp. 77-87, 2006.

Deaf Recovering Addicts Residing in Oxford Houses Have Similar Aftercare Outcomes to Hearing Residents

Deaf individuals seeking substance abuse recovery are less likely to have access to treatment and aftercare services because of a lack of culturally and linguistically specific programs and insufficient information about existing services. This study found no significant differences between 10 randomly selected Deaf and 10 hearing men, matched for age, ethnicity, and time spent living in Oxford Houses (OH) in terms of sense of community and abstinence self-efficacy. This led to the conclusion that integrating deaf recovering addicts into OH aftercare is not problematic. However, consistent with previous studies, there was a significant difference between the two groups in levels of employment, with all deaf residents being under-employed whereas all hearing residents were fully employed. Results suggest that special employment help may be needed to sustain recovery and a return to independent living. Alvarez, J., Adebanjo, A.M., Davidson, M.K., Davis, M.I., and Jason, L.A. Oxford House: Deaf-Affirmative Support. Project Muse Scholarly Journal Online, 151(4), pp. 418-422, 2006.