Director's Report to Council - Research Findings Excerpts

September, 2008

Basic Behavioral Research

Menstrual Cycle Modulates Striatal Dopamine in Drug-Naive Cynomolgus Monkeys

Several studies have reported that the subjective effects of abused stimulants in women vary with the menstrual cycle. Given the role of the brain dopamine system in abused drugs, these menstrual cycle effects may be mediated by interactions between gonadal hormones and dopamine. Drs. Paul Czoty and Michael Nader and colleagues at Wake Forest University School of Medicine conducted the first non-human primate study to examine whether basal measures of DA D2 receptor availability vary with the menstrual cycle phase. They tested seven drug-naive, individually-housed female cynomolgus monkeys using the D2-like receptor ligand [18F]fluoroclebopride (FCP). Menstrual cycle phase was determined by serum progesterone levels on the day of the PET scan. In both the caudate nucleus and the putamen, D2 receptor availability was found to be lower during the follicular phase than in the luteal phase. Previous studies examining menstrual cycle effects on D2 receptor availability in female human subjects have reported mixed results, including effects consistent with the present results, opposite the present results, and a report of no effects. Drs. Czoty, Nader and colleagues note that there are several potential explanations for these discrepancies, including their use of monkeys with no drug history of any kind (other than veterinary care with ketamine) and their use of a state-of-the-art primate microPET camera with high resolution. Whether the lower D2 receptor availability observed in the follicular phase this study reflects lower D2 receptor densities or higher levels of extracellular dopamine in the follicular phase is unclear; however, the authors note that rodent studies have shown that estrogen, which is higher in the follicular phase than luteal, has been shown to increase dopamine release. Several studies have shown that D2 receptor availability is inversely related to vulnerability to the abuse-related effects of cocaine. The present data, therefore, suggest that such effects in females would be greater in the follicular phase, which is an outcome that has been observed in several studies examining the subjective effects of stimulants in humans. Also, NIDA grantee Dr. Nancy Mello of the Harvard Medical School reported in 2007 that a low dose of cocaine produced a considerably greater progressive ratio breakpoint during the follicular phase than in the luteal phase in cynomolgus monkeys (Mello, N.K., Knudson, I.M., and Mendelson, J.H.. Sex and Menstrual Cycle Effects on Progressive Ratio Measures of Cocaine Self-Administration in Cynomolgus Monkeys. Neuropsychopharmacology, 32, pp. 1956-1966, 2007). Although only females were studied in the present study, data from a prior published study by these researchers examining D2 receptor availability in individually-housed male monkeys permitted an examination of sex differences. Results from that study indicated that D2 receptor availability in both the caudate nucleus and the putamen was lower than seen in females in either the luteal or follicular phase. This research highlights the need for models of the neurobiology of addiction to incorporate sex differences and the interactions of gonadal hormones and neurotransmitter systems underlying addiction. Czoty, P.W., Riddick, N.V., Gage, H.D., Sandridge, M., Nader, S.H., Garg, S., Bounds, M., Garg, P.K., and Nader, M.A. Effect of Menstrual Cycle Phase on Dopamine D2 Receptor Availability in Female Cynomolgus Monkeys. Neuropsychopharmacology. 2008, Feb 6. [E-pub ahead of print] .

Behavioral and Brain Development Research

Fatty Acid Ethyl Esters in Meconium are Associated with Poorer Neurodevelopmental Outcomes to Two Years of Age

The aim of this study was to examine the relationship between fatty acid ethyl esters (FAEE) in meconium and neurodevelopment in infants at 6.5 months, 1 year, and 2 years of age who were exposed to alcohol in utero. The current study reports on a secondary analysis of the data collected in a prospective longitudinal study of high risk mothers and their infants. Meconium was collected from 219 newborns shortly after birth and neurodevelopment was assessed with the Bayley Scales of Infant Development (2nd edition) which included the Mental and Psychomotor scales. Increasing concentrations of FAEE were significantly correlated with poorer mental and psychomotor development at all follow-up visits even after controlling for a number of prenatal and maternal factors. The results of this study showed that elevated FAEE in meconium may be a marker in identifying newborn infants who may be at risk for mental and psychomotor delays from alcohol exposure in utero, but do not show the typical characteristic facies of FAS. Early intervention is critical in these children and the results of this study are important in that the meconium analysis described by these authors may be a reliable means of identifying these at-risk children at birth. Peterson, J., Kirchner, H., Xue, W., Minnes, S., Singer, L., and Bearer, C. Fatty Acid Ethyl Esters in Meconium are Associated with Poorer Neurodevelopmental Outcomes to Two Years of Age. Journal of Pediatrics, 152(6), pp. 788-792, June, 2008.

Meaningful Differences in Maternal Smoking Behavior during Pregnancy: Implications for Infant Behavioral Vulnerability

Dr. Laurie Wakschlag and her colleagues used the 9-month-old sweep of the Millennium Cohort Study, a cohort of over 18,000 infants born in 2000-2, to examine the effects of smoking during pregnancy on problem behavior in offspring. Prior research has shown that the prenatal exposure to maternal smoking is associated with problem behavior in infants, but it is not clear whether these effects are associated with maternal characteristics that distinguish persistent smoking from quitting or whether they are due to teratological effects. In this study, mothers were classified as pregnancy non-smokers, quitters and light or heavy smokers. The Carey Infant Temperament Scale was used to assess temperamental positive mood, receptivity to novelty and regularity. Mothers who smoked heavily during pregnancy had infants with the lowest scores of easy temperament and low positive mood. In contrast, mothers who quit smoking during their pregnancy had infants with the highest scores of easy temperament. There also appeared to be a protective effect of quitting during pregnancy in that these mothers' infants had a decreased risk of distress to novelty and irregularity in comparison to those mothers who had never smoked. The results of this study suggest that offspring behavior associated with pregnancy smoking is complex and multi-determined. Future research is needed to elucidate the differences in maternal personality characteristics between quitters and persistent smokers and how these differences help to predict early vulnerabilities and offspring behavioral patterns over time. Pickett, K., Wood, C., Adamson, J., DeSouza, L., and Wakschlag, L. Meaningful Differences in Maternal Smoking Behavior during Pregnancy: Implications for Infant Behavioral Vulnerability. Journal of Epidemiology and Community Health, 62(4), pp. 318-324, 2008.

Children's Cognitive-Behavioral Functioning at Age 6 and 7: Prenatal Drug Exposure and Caregiving Environment

This study examined the relationship of prenatal drug exposure (PDE) and caregiving environment to cognitive, academic, and behavioral performance. Participants included 111 with PDE that were part of a longitudinal randomized controlled trial of a home-based intervention among drug-using women and their infants. A total of 62 non-drug exposed children were recruited from the same community to serve as controls. At ages 6 and 7, children were administered the Stanford-Binet Intelligence Scales, Fourth Edition, the Wide Range Achievement Test and the Child Behavior Checklist. Numerous theoretically and empirically derived confounders that examined perinatal and environmental factors were included in the multivariate analyses. The results indicated that after adjustment for the confounding variables, there were no significant exposure-group differences on measures of cognitive, academic or behavior problems. Females had higher scores on overall IQ, higher reading achievement scores and fewer caregiver-reported attention and aggression problems. This gender difference was evident regardless of PDE status. The children who participated in this study were from low income families and scores obtained were well below normative expectations. Future studies examining the effects of prenatal exposure to drugs need to be aware of the influence that poverty has on cognitive and behavioral development of children so that attributions to PDE are accurate. Nair, P., Black, M., Ackerman, J., Schuler, M., and Keane, V. Children's Cognitive-Behavioral Functioning at Age 6 and 7: Prenatal Drug Exposure and Caregiving Environment. Ambulatory Pediatrics, 8(3), pp. 154-162, 2008.

Prenatal Cocaine Exposure: Drug and Environmental Effects at 9 Years

Dr. Sonia Minnes and her colleagues investigated the effects of prenatal cocaine exposure (CE) in a large sample of children with a high follow-up rate, controlling for a number of confounding variables such as polydrug exposure, blood lead levels, iron-deficiency anemia (IDA), quality of caregiving environment and foster/adoptive care. Three hundred and seventy one children in a longitudinal, prospective study from birth were assessed for IQ and school achievement at 9 years of age (192 cocaine exposure; 179 non-cocaine exposure). No effects were seen in school achievement measures. Poorer perceptual reasoning IQ was seen in CE children; the degree of impairment was linearly related to a cocaine metabolite. Effects were mediated by smaller birth head circumference, indicating a relationship with fetal brain growth. Positive effects of the home environment and negative effects of alcohol, lead, and marijuana exposure were additive. The most pervasive negative effects were associated with lead exposure, underscoring the need for stronger public health efforts. Lower lead levels and better home environments were seen in those CE children who were placed in foster/adoptive care. This study shows the importance of documenting environmental factors in behavioral teratology studies. Singer, L., Nelson, S., Short, E., Min, M., Lewis, B., Russ, S., and Minnes, S. Prenatal Cocaine Exposure: Drug and Environmental Effects at 9 years. Journal of Pediatrics, 153(1), pp. 105-111, 2008.

The Development of Corpus Callosum Microstructure and Associations with Bimanual Task Performance in Healthy Adolescents

Studies utilizing conventional magnetic resonance imaging studies have provided important information regarding the development of the corpus callosum (CC). This study used diffusion tensor imaging to examine the relationship of fine motor skills with white matter microstructural development of the CC in healthy children, adolescents, and young adults (ages 9 - 24 years). Fractional anisotropy (FA), which is a measure of white matter's structural organization, was the primary DTI variable. An alternating finger tapping test was used to assess interhemispheric transfer and motor speed. Relationships between behavioral performance on the tapping task and white matter microstructure, age, and gender were examined. Younger subjects performed the unilateral and bimanual finger tapping task significantly slower. Improved motor performance was correlated with increased white matter integrity in the splenium. The splenium of the CC is believed to be primarily involved in the transmission of interhemispheric signals from the posterior cortical regions. Gender differences were also noted in that males outperformed females. Decreases in alternating finger tapping time and increases in FA likely reflect increased myelination in the CC and more efficient neuronal signal transmission. The data from this study suggest that white matter integrity continues to develop until 18 years of age, which is consistent with findings from conventional MRI studies that show similar age related changes in splenium white matter volume. This study has expanded the utility of diffusion tensor imaging by using this method to demonstrate relationships between fine motor skills and underlying white matter microstructure in childhood and adolescence. Muetzel, R., Collins, P., Mueller, B., Schissel, A., Lim, K., and Luciana, M. The Development of Corpus Callosum Microstructure and Associations with Bimanual Task Performance in Healthy Adolescents. Neuroimage, 39(4), pp. 1918-1925, 2008.

Clinical Neuroscience Research

Individual Differences in Nicotine Dependence, Withdrawal Symptoms, and Sex Predict Brain Responses to Smoking Cues

McClernon and colleagues at Duke University used fMRI to study the influence of individual difference factors and withdrawal symptoms on brain cue reactivity. Multiple regression analysis was used to evaluate relations between individual difference factors and withdrawal symptoms and event-related fMRI responses to visual smoking cues in a sample of 30 smokers. Predictors were self-report nicotine dependence (Fagerstroem test of nicotine dependence, FTND), prescan withdrawal symptoms (craving and negative affect), and sex. The unique variance of each predictor was examined after controlling for each of the others. Positive associations were observed between FTND and reactivity to cues in right anterior cingulate and orbitofrontal cortex (OFC) whereas negative associations were observed between prescan craving and reactivity in ventral striatum. Higher negative affect or being male was associated with greater reactivity in left hippocampus and left OFC. Women exhibited greater cue reactivity than men in regions including the cuneus and left superior temporal gyrus. Individual difference factors and withdrawal symptoms were uniquely associated with brain reactivity to smoking cues in regions subserving reward, affect, attention, motivation, and memory. These findings provide further evidence that reactivity to conditioned drug cues is multiply determined and suggest that smoking cessation treatments designed to reduce cue reactivity focus on each of these variables. McClernon, F.J., Kozink, R.V., and Rose, J.E. Individual Differences in Nicotine Dependence, Withdrawal Symptoms, and Sex Predict Transient fMRI-BOLD Responses to Smoking Cues. Neuropsychopharmacology, 33(9), pp. 2148-2157, 2008.

Epidemiology and Etiology Research

Developmental Trajectories of Young Adult Poly-Substance Use

Despite the prominence of comorbidity among substances and the recent attention focused on trajectory-based approaches to characterizing developmental change, little research in the substance use field has simultaneously considered both course and comorbidity. Using nationally representative panel data from the Monitoring the Future Project (MTF; n = 32,087; 56% female; 82% Caucasian), authors identified developmental courses of heavy drinking, smoking, and marijuana use using 4 waves of data spanning ages 18 to 26 in a multi-cohort young adult sample. Comorbidity was examined by cross-classifying group membership in substance use trajectories. Finally, the extent to which risk factors (sex, race, alcohol expectancies, delinquency, sensation seeking, depressive affect, religiosity, academic achievement, and parent education) accounted for combinations of comorbidity that occurred at a rate greater than chance was examined. For each substance, authors identified 4 courses of substance use that were largely consistent with those found in the literature (chronic high use, late-onset use, developmentally limited use, and low-use), with a fifth moderate smoking group. Heavy drinking, smoking, and marijuana use were each highly associated, and distinct patterns of comorbidity were evident, with greatest agreement along the diagonal. All risk factors explained comorbidity to some degree, with delinquency, sensation seeking, alcohol expectancies, and religion in particular predicting combinations of comorbidity that were characterized by early onset and chronic high use. Cross-substance trajectory concordance was high, with parallel changes in substance use over emerging adulthood. This suggests similar developmental timing of use, perhaps due to the experience of developmental transitions that have a common influence on use of different substances. Prediction of combinations of comorbidity characterized by early onset and persistently high use suggests that to some extent, individuals use multiple substances because of a common vulnerability to each, rather than directional relations among substances (e.g., cross-tolerance, cueing). Jackson, K., Sher, K., and Schulenberg, J., Conjoint Developmental Trajectories of Young Adult Substance use. Alcohol Clin. Exp. Res., 32(5), pp. 723-737, 2008.

Long-term Trends in Adolescent and Young Adult Smoking in the US

The authors sought to describe long-term adolescent and young adult smoking trends and patterns by analyzing adolescent data from Monitoring the Future, 1976 to 2005, and young adult (aged 18-24 years, roughly 16,000 students per year) data from the National Health Interview Survey, 1974 to 2005 (n~1800-5600), overall and in subpopulations to identify trends in current cigarette smoking prevalence. Five metapatterns emerged (1) a large increase and subsequent decrease in overall smoking over the past 15 years, (2) a steep decline in smoking among Blacks through the early 1990s, (3) a gender gap reversal among older adolescents and young adults who smoked over the past 15 years, (4) similar trends in smoking for most subgroups since the early 1990s, and (5) a large decline in smoking among young adults with less than a high school education. Long-term patterns for adolescent and young adult cigarette smoking were decidedly nonlinear, and the authors found evidence of a cohort effect among young adults. Continued strong efforts and a long-term societal commitment to tobacco use prevention are needed, given these unprecedented declines in smoking among most subpopulations since the mid- to late 1990s. Nelson, D., Mowery, P., Asman, K., Pederson, L., O 'Malley, P., Malarcher, A., Maibach, E., and Pechacek, T. Long-Term Trends in Adolescent and Young Adult Smoking in the United States: Metapatterns and Implications. Am. J. Public Health, 98(5), pp. 905-915, 2008.

Individual, Social, and Environmental Influences Associated with HIV Infection among Injection Drug Users in Tijuana, Mexico

Researchers examined correlates of HIV infection among injection drug users (IDUs) in Tijuana, Mexico, a city bordering the United States, which is situated on major migration and drug trafficking routes. IDUs aged > or =18 years were recruited using respondent-driven sampling. Participants underwent antibody testing for HIV and syphilis and structured interviews. Weighted logistic regression identified correlates of HIV infection. Of 1056 IDUs, the median age was 37 years, 86% were male, and 76% were migrants. HIV prevalence was higher in female participants than in male participants (8% vs. 3%; P = 0.01). Most IDUs testing HIV-positive were previously unaware of their serostatus (93%). IDUs reported injecting with a median of 2 people in the prior 6 months and had been arrested for having injection stigmata (ie, 'track-marks') a median of 3 times. Factors independently associated with HIV infection were being female, syphilis titers consistent with active infection, larger numbers of recent injection partners, living in Tijuana for a shorter duration, and being arrested for having track-marks. These findings reveal the range of individual, social, and environmental factors that are independently associated with HIV infection among IDUs in Tijuana. They point to the need to intervene not solely on individual risk behaviors but on social processes that drive these behaviors, including problematic policing practices. Strathdee, S., Lozada, R., Pollini, R., Brouwer, K., Mantsios, A., Abramovitz, D., Rhodes, T., Latkin, C., Loza, O., Alvelais, J., Magis-Rodriguez, C., and Patterson, T. Individual, Social, and Environmental Influences Associated with HIV Infection among Injection Drug Users in Tijuana, Mexico. J Acquir Immune Defic Syndr, 47(3), pp. 369-376, 2008.

Predicting Hospitalization among HIV-Infected Antiretroviral Naive Patients Starting HAART: Determining Clinical Markers and Exploring Social Pathways

In the era of highly active antiretroviral therapy (HAART), hospitalization as a measure of morbidity has become of increasing interest. The objectives of this study were to determine clinical predictors of hospitalization among HIV-infected persons initiating HAART and to explore the impact of gender and drug use on hospitalization. The analysis was based on a cohort of HIV-positive individuals initiating HAART between 1996 and 2001. Information on hospitalizations was obtained through data linkage with the BC Ministry of Health. Cox-proportional hazard models were used to assess variables associated with time to hospitalization. A total of 1,605 people were eligible and 672 (42%) were hospitalized for one or more days. The final multivariate model indicated that there was an increased risk of hospitalization among those with high baseline HIV RNA (HR for > 100,000 copies/mL: 1.26; 95%CI: 1.16-1.59) or low CD4 cell counts (HR [95% CI] compared to > or = 200 cells/mm3: 1.62 [1.28-2.06] and 1.29 [1.07-1.56] for < 50 and 50-199 cells/mm(3), respectively). Other factors, including adherence, previous hospitalization, gender and injection drug use remained predictive of hospitalization. These findings highlight the importance of closely monitoring patients starting therapy with low CD4 cell counts in order to mediate or prevent outcomes requiring hospitalization. Fielden, S., Rusch, M., Levy, A., Yip, B., Wood, E., Harrigan, R., Goldstone, I., Guillemi, S., Montaner, J., and Hogg, R. Predicting Hospitalization among HIV-Infected Antiretroviral Naive Patients Starting HAART: Determining Clinical Markers and Exploring Social Pathways. AIDS Care, 20(3), pp. 297-303, 2008.

Patterns of Opioid Analgesic Dependence Symptoms

This study examined symptoms of dependence related to the extramedical use of opioid analgesic medications. The 2002-2003 public data-files of the National Survey on Drug Use and Health were used to identify 7810 extramedical opioid analgesic users in the past-year. Latent Class Analysis was used to empirically define classes of past-year extramedical opioid analgesic users based on observed clustering of DSM-IV defined clinical dependence features; multinomial logistic regression was used to describe differences across these groups. The best-fitting four-class model identified classes that differed quantitatively and qualitatively, with 2% of the users in Class 4 (most severe) and 84% in Class 1 (least severe). Classes 2 and 3 had parallel symptom profiles, but those in Class 3 reported additional problems. Adolescents (12-17 year olds) were at higher odds of being in Class 3 versus older age groups; females were two times as likely to be in Classes 2 and 4, and those with mental health problems were at higher odds of belonging to the more severe classes. Differences by type of past year opioid users were also detected. This study sheds light on the classification and distribution of extramedical opioid analgesic dependence symptoms in the US general population and identifies significant subgroups. Ghandour, L., Martins, S., and Chilcoat, H. Understanding the Patterns and Distribution of Opioid Analgesic Dependence Symptoms Using a Latent Empirical Approach. Int. J. Methods Psychiatr. Res., 17(2), pp. 89-103, 2008.

Substance Use among Asian Americans and Pacific Islanders Sexual Minority Adolescents: Findings from the National Longitudinal Study of Adolescent Health

Researchers assessed the prevalence, incidence, and correlates of substance use among Asian American individuals transitioning from adolescence to young adulthood. Data were obtained from the National Longitudinal Study of Adolescent Health, Wave II (1996) and Wave III (2001). Information on substance use was abstracted from a nationally representative sample of 1108 Asian Americans and Pacific Islanders (AAPIs) from both Waves. Weighted prevalence, incidence, and patterns of smoking, binge drinking, marijuana use, and other drug use were analyzed by sexual orientation and gender. Multiple logistic regression analyses were conducted to investigate the unique contribution of being a sexual minority in relation to four types of substance use by gender. A link between sexual orientation and substance use behaviors among AAPIs did not emerge until young adulthood. Significant increases in the incidence and prevalence of all four types of substance use (tobacco, binge drinking, marijuana, and other drugs) were found among sexual minority AAPIs. Specifically being an AAPI sexual minority young woman, compared with being a heterosexual young woman, a heterosexual young man, or a sexual minority young man, was significantly associated with substance use after controlling for demographic characteristics, problem behaviors, and substance use during adolescence. The highest prevalence of substance use was found among AAPI sexual minority women. These findings bring new light to the importance of sexual orientation in the design of substance abuse programs. Hahm, H., Wong, F., Huang, Z., Ozonoff, A., and Lee, J. Substance Use among Asian Americans and Pacific Islanders Sexual Minority Adolescents: Findings from the National Longitudinal Study of Adolescent Health. J. Adolesc. Health, 42(3), pp. 275-283, 2008.

The Role of Gender and Family on Long-Term Patterns of Drug Use among an Urban African-American Cohort

The current study uses longitudinal data from a community cohort of African-American inner-city males and females followed from first grade through mid-adulthood (n=1242 at baseline). It identifies the substance use patterns through mid-adulthood, including lifetime prevalence, age of onset and termination, and sequencing of substance classes, as well as the risk of initiation of substance use changes over the life course using survival analysis. It also investigates whether early family structure and process play a role in drug use initiation throughout the life course, and whether the relationship between family factors and drug initiation differs by gender. Overall, among the general trends of use, the authors find a considerable amount of abstention with over 40% of the participants never using illegal drugs by mid-adulthood, over 70% never using cocaine, and over 90% never using heroin. With respect to onset, the authors find a long-term influence of early family factors on substance use, particularly for females. Family discipline in childhood and family cohesion and parental rule setting during adolescence seem to be key factors in predicting later substance use for females. The implica-tions of these findings for future research and policy are discussed. Doherty, E., Green, K., Reisinger, H., and Ensminger, M. Long-Term Patterns of Drug Use among an Urban African-American Cohort: the Role of Gender and Family. J. Urban Health, 85(2), pp. 250-267, 2008.

Factors Related to Correctional Facility Incarceration among Active Injection Drug Users in Baltimore

The authors investigated the moderating effect of impulse control on the association between drug use and incarceration among active injection drug users (IDU). The study sample consisted of 282 IDUs aged 15-50 years from the Baltimore metropolitan region who reported injection drug use within the past 6 months and indicated that heroin or speedball was their drug of choice. Impulse control was measured using commission error standardized scores from the Test of Variables of Attention (TOVA). Incarceration was obtained using self-reported lifetime history of incarceration in correctional facilities. Findings indicated that impulse control moderated the association between years of injection drug use and incarceration in correctional facilities adjusting for ethnicity, gender, estimated pre-morbid intelligence, and age of first injection use. Specifically, among individuals who were intact in impulse control, four or more years of injection drug use was associated with incarceration (AOR=4.97, 95% CI: 2.02-12.23). This finding was not observed among individuals with impaired impulse control (AOR=0.57, 95% CI: 0.10-3.23). Furthermore, impulse control moderated the association between regular cocaine use and incarceration. Among individuals who had a history of cocaine use, individuals with low impulse control but not impaired were more likely to have reported time in a correctional facility (AOR=6.28, 95% CI: 1.68-23.60). There was no association among individuals with impaired or intact impulse control. Results highlight the importance of considering cognitive measures of impulse control in addressing negative outcomes associated with drug use. Severtson, S., and Latimer, W. Factors Related to Correctional Facility Incarceration among Active Injection Drug Users in Baltimore, MD. Drug Alcohol Depend., 94(1-3), pp. 73-81, 2008.

The MAOA Promoter Polymorphism, Disruptive Behavior Disorders, and Early Onset Substance Use Disorder: Gene-Environment Interaction

Conduct, oppositional defiant, and attention deficit hyperactivity disorders, reflecting early antisociality and behavior dysregulation, are predictive of substance use disorders. Liabilities to these disorders share genetic and environmental variance. Parenting characteristics have been shown to influence development of antisociality, moderated by variation at the MAOA gene, which has also been associated with the risk for substance use disorders. To extend these findings, the authors tested the relationships between the MAOA promoter polymorphism (variable number tandem repeat), indices of child's perception of paternal and maternal parenting, and disruptive behavior disorders and substance use disorders. A sample of 148 European-American males was assessed prospectively at ages from 10-12 to 18-19 years and genotyped for the monoamine oxidase A variable number tandem repeat. The Diagnostic and Statistical Manual of mental disorders-III-R diagnoses were obtained using standard methodology. Parenting was assessed using a scale summarizing the child's evaluation of the parenting style (parent's behavior toward him, parental emotional distance and involvement). Correlation, logistic regression, and Cox proportional hazard regression analysis were used to determine the relationships between the variables. The strength of association between parenting index and conduct and attention deficit hyperactivity disorders depended on the MAOA genotype. Unlike earlier findings, the parenting-risk relationships were observed in the 'high' rather than 'low-activity' genotypes. The strength and direction of relationships depended on the parental sex. The MAOA polymorphism's association with the risk for substance use disorders was detected when parenting was controlled for. The results are consistent with the contribution of the MAOA gene, parenting style, and their interactions to variation in the risk for early onset behavior disorders and liability to substance use disorders. Vanyukov, M., Maher, B., Devlin, B., Kirillova, G., Kirisci, L., Yu, L., and Ferrell, R. The MAOA Promoter Polymorphism, Disruptive Behavior Disorders, and Early Onset Substance Use Disorder: Gene-Environment Interaction. Psychiatr. Genet., 17(6), pp. 323-332, 2007.

Reciprocal Influence of Parent Discipline and Child's Behavior on Risk for Substance Use Disorder

This study aimed at determining the association of father's and mother's (parental) substance use disorder (SUD) and discipline styles and son's neurobehavioral disinhibition (ND) with son's SUD from childhood (age 10-12) to young adulthood (age 19). It was hypothesized that (1) parental discipline styles and son's ND mediate the association between parental SUD and son's SUD, (2) son's ND mediates the association between parental discipline styles and son's SUD, and (3) parental discipline styles mediate the association between ND and SUD in the son. Two-hundred-sixty-three families including a 10-12 year-old son and both parents participated in the study. The authors found that mother's discipline styles predicted father's discipline styles, son's ND predicted mother's instilling guilt positively and father's punishment negatively, son's ND mediated the association between father's SUD and punishment and son's SUD, and mother's SUD predicted son's ND and SUD. The reciprocal prediction between son's ND and father's punishment and prediction of father's punishment by mother's punishment point to the need for family-based interventions that take into account the quality of specific dyadic interactions pertaining to discipline behaviors that amplify the risk for SUD in male children. Mezzich, A., Tarter, R., Kirisci, L., Feske, U., Day, B., and Gao, Z. Reciprocal Influence of Parent Discipline and Child's Behavior on Risk for Substance Use Disorder: a Nine-Year Prospective Study. Am. J. Drug Alcohol Abuse, 33(6), pp. 851-867, 2007.

Sex Work and HIV Status among Transgender Women: Systematic Review and Meta-Analysis

Transgender women are a key risk group for HIV, and epidemiologic studies have attributed high rates of HIV infection to behaviors associated with sex work in this population. This systematic review compared HIV prevalence among transgender female sex workers (TFSWs) with prevalence among transgender women who do not engage in sex work, male sex workers, and biologically female sex workers. The researchers conducted systematic searches of six electronic databases. They extracted data, appraised methodologic quality, assessed hetero-geneity, and organized meta-analyses by comparison groups. They identified 25 studies among 6405 participants recruited from 14 countries. The overall crude HIV prevalence was 27.3% in TFSWs, 14.7% in transgender women not engaging in sex work, 15.1% in male sex workers, and 4.5% in female sex workers. Meta-analysis indicated that TFSWs experienced significantly higher risk for HIV infection in comparison to all other groups, and particularly in comparison to female sex workers. Significant heterogeneity was found among the included studies, along with methodologic limitations and imprecise definitions of sex work and gender. This study suggests that TFSWs could benefit from targeted HIV prevention interventions, HIV testing, and interventions to help reduce the risk of contracting or transmitting HIV. Operario, D., Soma, T., and Underhill, K. Sex Work and HIV Status among Transgender Women: Systematic Review and Meta-Analysis. J. Acquir. Imm. Defic. Syndr., 48(1), pp. 97-103, 2008.

Defining Risk Heterogeneity for Internalizing Symptoms among Children of Alcoholic Parents

Adopting a developmental epidemiology perspective, the current study examines sources of risk heterogeneity for internalizing symptomatology among children of alcoholic parents (COAs). Parent-based factors, including comorbid diagnoses and the number of alcoholic parents in the family, as well as child-based factors, namely child gender, formed the indicators of heterogeneity. Following a novel approach to cross-study methods, the authors present a three-stage analysis involving measurement development using item response theory, examination of study effects on latent trajectories over time using latent curve modeling, and prediction of these latent trajectories testing our theoretically derived hypotheses in two longitudinal investigations across both mother- and self-reported symptomatology. Data used were the Michigan Longitudinal Study (596 children from 338 families) and the Adolescent/Adult Family Development Project (454 adolescents and their families). Authors replicated previous findings that parent alcoholism has a unique effect on child internalizing symptoms, above and beyond those of both parent depression and antisocial personality disorder. However, they also found important subgroup differences, explaining heterogeneity within COAs risk profile in terms of the number of alcoholic parents in the family, comorbid diagnoses for the alcoholic parent and, for self-reported symptoms, child gender. Such factors serve to refine the definition of risk among COAs, suggesting a more severely impaired target group for preventive interventions, identifying the significance of familial alcoholism in individual differences underlying internalizing symptoms over time, and further specifying the distal risk matrix for an internalizing pathway to alcohol involvement. Hussong, A., Flora, D., Curran, P., Chassin, L., and Zucker, R. Defining Risk Heterogeneity for Internalizing Symptoms among Children of Alcoholic Parents. Dev. Psychopathol., 20(1), pp. 165-193, 2008.

Disaggregating the Distal, Proximal, and Time-Varying Effects of Parent Alcoholism on Children's Internalizing Symptoms

The authors tested whether children show greater internalizing symptoms when their parents are actively abusing alcohol by combining observations over ages 2 through 17 from two longitudinal studies of children of alcoholic parents and matched controls recruited from the community. This integrative analysis included data from the Michigan Longitudinal Study (n=596 children from 338 families) and the Adolescent/Adult Family Development Project (454 adolescents and their parents). Using a mixed modeling approach, investigators tested whether children showed elevated mother- and child-reported internalizing symptoms (a) at the same time that parents showed alcohol-related consequences (time-varying effects), (b) if parents showed greater alcohol-related consequences during the study period (proximal effects), and (c) if parents had a lifetime diagnosis of alcoholism that predated the study period (distal effects). No support for time-varying effects was found; proximal effects of mothers' alcohol-related consequences on child-reported internalizing symptoms were found and distal effects of mother and father alcoholism predicted greater internalizing symptoms among children of alcoholic parents. Hussong, A., Cai, L., Curran, P., Flora, D., Chassin, L., and Zucker, R. Disaggregating the Distal, Proximal, and Time-Varying Effects of Parent Alcoholism on Children's Internalizing Symptoms. J. Abnorm. Child Psychol., 36(3), pp. 335-346, 2008.

The Relationship among Cardiovascular Risk Factors, Diet Patterns, Alcohol Consumption, and Ethnicity among Women Aged 50 Years and Older

This study used cluster analysis to examine diet patterns and the association between diet patterns and the presence of major cardiovascular disease (CVD) risk factors among women over 50 years of age. Data from the cross-sectional National Health and Nutrition Examination Survey (NHANES) 2001-2002 were used. Women 50 years and older were included (n=1,313), and the following major CVD risk factors were examined: being overweight or obese (body mass index >24.9), having elevated systolic blood pressure (>120 mm Hg), and having low levels of high-density lipoprotein cholesterol (<50 mg/dL [<1.30 mmol/L]). Dietary patterns were derived by cluster analysis using data from a 24-hour dietary recall. Odds Ratios (ORs) and 95% confidence intervals (CIs) were calculated using logistic regression to determine the probability of having a risk factor according to diet pattern while accounting for race/ethnicity, physical activity, age, and smoking. Cluster analysis generated six nonoverlapping diet patterns labeled: Pasta and Yellow Vegetables; Sweets; Beef, Starches, Fruits, and Milk; Frozen Meals, Burritos, and Pizza; Meat Dishes; and Soft Drinks and Poultry. The majority of the women were grouped in the Sweets diet pattern. Factors associated with adequate levels of high-density lipoprotein cholesterol included being non-Hispanic African American (OR 0.59, 95% CI 0.44 to 0.81; P<0.0001), alcohol consumption (OR 0.76, 95% CI 0.69 to 0.84; P<0.0001), and being assigned to the Sweets diet pattern (OR 0.27, 95% CI 0.14 to 0.50; P<0.0001) or Meat dishes diet pattern (OR 0.94, 95% CI 0.54 to 1.65; P<0.0075). The Sweets pattern was also associated with having normal systolic blood pressure levels (OR 0.51, 95% CI 0.34 to 0.76; P<0.0001). Individuals grouped in the Beef, Starches, and Milk diet pattern were more likely to have an adequate body mass index (OR 0.42, 95% CI 0.23 to 0.77; P<0.0032). Significant associations between dietary patterns and major CVD risk factors were observed. Food and nutrition professionals can use this information to assess unhealthful food choices observed in the dietary patterns to guide nutrition recommendations and help reduce the incidence of CVD risk factors. Future research should aim to evaluate dietary intake via complementary methods (ie, dietary patterns and nutrient assessment) to better understand diet-disease relationships. Lopez, E., Rice, C., Weddle, D., and Rahill, G. The Relationship among Cardiovascular Risk Factors, Diet Patterns, Alcohol Consumption, and Ethnicity among Women Aged 50 Years and Older. J. Am. Diet. Assoc., 108(2), pp. 248-256, 2008.

Substance Use in Marital Dyads: Premarital Assortment and Change over Time

The purpose of this study was to examine change in substance use with marriage, premarriage similarity in substance use between spouses, and the role of spouse use in predicting changes in use with marriage. Nationally representative samples of high school seniors were followed longitudinally through age 35. The sample consisted of 2,169 adults from eight senior-year cohorts (1977-1984) from the Monitoring the Future study who completed a questionnaire at least once before their first marriage and at 2-year intervals at four consecutive points in time after marriage. Results indicate significant reductions in use with marriage for cigarette smoking, heavy drinking, and marijuana use. Both men and women reported reductions in all three substances following marriage. Changes in women's use followed a linear pattern. Although men's decreases in cigarette smoking and heavy drinking were initially rapid and then decelerated, their decrease in marijuana use accelerated over time. Declines in use for both genders were associated with getting married to individuals who also decreased their use. Those with higher premarriage levels of substance use experienced greater reductions in use. A significant association between respondent and spouse premarital use suggests assortative mating takes place for all three substances. This study affirms and further qualifies the presence of a marriage effect on substance use using multiwave and multicohort national data. Results suggest that the effects of marriage on smoking, heavy drinking, and marijuana use are related to one's own initial levels of use and the direction of change in the spouse's use. These findings have important implications for life span theoretical advances as well as interventions aimed at the marital dyad. Merline, A., Schulenberg, J., O'Malley, P., Bachman, J., and Johnston, L. Substance Use in Marital Dyads: Premarital Assortment and Change over Time. J. Stud. Alcohol Drugs, 69(3), pp. 352-361, 2008.

Movie Smoking Exposure and Smoking Onset: A Longitudinal Study of Mediation Processes in a Representative Sample of U.S. Adolescents

The authors tested 2 mechanisms for the relation of movie smoking exposure with onset of cigarette smoking in adolescence. Longitudinal data with 8-month follow-up were obtained from a representative sample of 6,522 U.S. adolescents, ages 10-14 years. Structural modeling analysis based on initial nonsmokers, which controlled for 10 covariates associated with movie exposure, showed that viewing more smoking in movies was related to increases in positive expectancies about smoking and increases in affiliation with smoking peers, and these variables were both related to smoking onset. A direct effect of movie exposure on smoking onset was also noted. Mediation findings were replicated across cross-sectional and longitudinal analyses. Tests for gender differences indicated that girls showed larger effects of movie exposure for some variables. Wills, T., Sargent, J., Stoolmiller, M., Gibbons, F., and Gerrard, M. Movie Smoking Exposure and Smoking Onset: A Longitudinal Study of Mediation Processes in a Representative Sample of U.S. Adolescents. Psychol. Addict. Behav., 22(2), pp. 269-277, 2008.

The Drinking Culture of Alcohol Use

Binge drinking is a substantial health problem. Community norms about drinking may influence individual drinking problems. This study examined the relation between aspects of the neighborhood drinking culture and individual alcohol use by using data from the New York Social Environment Study conducted in 2005. The sample consisted of 4,000 New York City residents greater than 18 year of age. Methods to address social stratification and social selection, both of which are challenges to interpreting neighborhood research were applied. In adjusted models, permissive neighborhood drinking norms were associated with moderate drinking (odds ratio (OR) = 1.28, 95% confidence interval (CI): 1.05, 1.55) but not binge drinking; however, social network and individual drinking norms accounted for this association. By contrast, permissive neighborhood drunkenness norms were associated with more moderate drinking (OR = 1.20, 95% CI: 1.03, 1.39) and binge drinking (OR = 1.92, 95% CI: 1.44, 2.56); the binge drinking association remained after adjustment for social network and individual drunkenness norms (OR = 1.58, 95% CI: 1.20, 2.08). Drunkenness norms were more strongly associated with binge drinking for women than for men (p(interaction) = 0.006). Propensity distributions and adjustment for drinking history suggested that social stratification and social selection, respectively, were not plausible explanations for the observed results. Results suggest that further epidemiologic studies investigating the social and structural factors that shape harmful drinking may inform efforts targeting the problematic aspects of alcohol consumption. Ahern, J., Galea, S., Hubbard, A., Midanik, L., and Syme, S. Culture of Drinking and Individual Problems with Alcohol Use. Am. J. Epidemiol., 167(9), pp. 1041-1049, 2008.

Prevention Research

Universal Childhood Prevention Effects Developmental Course of Antisocial Personality Disorder and Violent and Criminal Behavior

Antisocial personality disorder (ASPD), violent and criminal behavior, and drug abuse disorders often share the common antecedent of early aggressive, disruptive behavior. In the 1985-1986 school year teachers implemented the Good Behavior Game (GBG), a classroom behavior management strategy targeting aggressive, disruptive behavior and socializing children to the student role. From first through seventh grade the developmental trajectories of 2311 students from 19 Baltimore City Public Schools were examined. GBG impact on these trajectories and ASPD and violent and criminal behavior by age 19-21 is reported. In five urban, poor to lower middle class predominately African-American areas, three to four schools were matched and within each set randomly assigned to one of three conditions: (1) GBG, (2) a reading achievement program, or (3) the standard program. Classrooms and teachers were randomly assigned to intervention or control. Measures at 19-21 included self reports and juvenile court and adult incarceration records. GBG impact was assessed via General Growth Mixture Modeling based on repeated measures of aggressive, disruptive behavior. Three trajectories of aggressive, disruptive behavior were identified. By young adulthood, GBG significantly reduced the rates of ASPD and violent and criminal behavior among males in the persistent high aggressive, disruptive trajectory. A replication was implemented with the following cohort of first-grade children using the same teachers, but with diminished mentoring and monitoring. Beneficial impact was found among persistent high males through seventh grade. By young adulthood GBG effects on ASPD and violent and criminal behavior were non-significant, but generally in the hypothesized direction. This study demonstrated strongest effects on high risk males, suggesting the need to understand the shared and non-shared developmental processes within and across genders. Petras, H., Kellam, S.G., Brown, C.H., Muthen, B., Ialongo, N., and Poduska, J. Developmental Epidemiological Courses Leading to Antisocial Personality Disorder and Violent and Criminal Behavior: Effects By Young Adulthood of a Universal Preventive Intervention in First- and Second-Grade Classrooms. Drug Alcohol Depend., 95S1 pp. S45-S59, 2008.

A Randomized Evaluation of Multidimensional Treatment Foster Care: Effects on School Attendance and Homework Completion in Juvenile Justice Girls

Despite growing evidence that child welfare youth are at increased risk for juvenile delinquency, little is known about gender-specific processes and effective treatment programs for girls. Multidimensional Treatment Foster Care (MTFC), an empirically validated intervention for child welfare and juvenile justice populations, has demonstrated efficacy in reducing arrest rates in delinquent boys and girls. In this study, the efficacy of MTFC on school attendance and homework completion was examined in juvenile justice girls who were referred to out-of-home care (N = 81). Results from this randomized intervention trial suggest that MTFC was more effective than group care in increasing girls' school attendance and homework completion while in treatment and at 12 months post baseline. In addition, the previously reported effect of MTFC on reducing girls' days in locked settings was mediated by homework completion while girls were enrolled in the intervention setting. Implications for policy and practice are described. Leve, L.D., and Chamberlain, P. A Randomized Evaluation of Multidimensional Treatment Foster Care: Effects on School Attendance and Homework Completion in Juvenile Justice Girls. Res. Soc. Work Pract., 17(6), pp. 657-663, 2007.

A New Statistical Procedure to Examine Behavioral Transitions

The set of statistical methods available to researchers is continually being expanded, allowing for questions about change over time to be addressed in new, informative ways. Indeed, new developments in methods to model change over time create the possibility for new research questions to be posed. Latent transition analysis, a longitudinal extension of latent class analysis, is a method that can be used to model development in discrete latent variables, for example, stage processes, over 2 or more times. The current article illustrates this approach using a new SAS procedure, PROC LTA, to model change over time in adolescent and young adult dating and sexual risk behavior. Gender differences are examined, and substance use behaviors are included as predictors of initial status in dating and sexual risk behavior and transitions over time. Lanza, S., and Collins, L. A New SAS Procedure for Latent Transition Analysis: Transitions in Dating and Sexual Risk Behavior. Dev. Psychol., 44(2), pp. 446-456, 2008.

Substance Abuse is Associated with HCV Viremia and HCV Transmission Potential

Co-infection with hepatitis C virus (HCV) is common among HIV-infected women. To further the understanding of risk factors for HCV viremia and the predictors of HCV viral load among women, sociodemographic, immunologic, and virologic factors associated with presence and level of HCV viremia were investigated among 1049 HCV-seropositive women, 882 of whom were HIV-infected and 167 HIV-uninfected at their entry into the Women's Interagency HIV Study. Plasma HCV RNA was detected in 852 (81%) of these 1049 women (range: 1.2-7.8 log(10)copies/ml). HCV-viremic women were more likely to have an HIV RNA level >100,000 copies/ml (p = 0.0004), to have reported smoking (p =0.01), or to be Black (p = 0.005). They were less likely to have current or resolved hepatitis B infection. HCV RNA levels were higher in women who were >35 years old, or HIV-infected. Current smoking and history of drug use (crack/freebase cocaine, marijuana, amphetamines, or heroin) were each associated with both presence and level of viremia. Substance abuse counseling aimed at eliminating ongoing use of illicit drugs and tobacco may reduce clinical progression, improve response to treatment, and decrease HCV transmission by lowering levels of HCV viremia in women. Operskalski, E., Mack, W., Strickler, H., French, A., Augenbraun, M., Tien, P., Villacres, M., Spencer, L., Degiacomo, M., and Kovacs, A. Factors Associated With Hepatitis C Viremia in a Large Cohort of HIV-Infected and -Uninfected Women. J. Clin. Virol., 41(4), pp. 255-263, 2008.

The Use of Harmful Legal Products among Pre-adolescent Alaskan Students

This study examined pre-adolescent use of harmful but legally obtainable products (HLPs) "in order to get high" in 4 communities in northwest and southeast Alaska. These products include inhalants, over-the-counter medications, prescription medications taken without a doctor ''s prescription and common household products. A student survey was administered to the 447 students whose parents consented and who agreed to participate. The lifetime overall use of HLPs among fifth, sixth and seventh grade students in 4 Alaskan communities was 17.4%. The lifetime use of inhalants (6.8%) and prescription medications taken without a doctor's prescription (8.0%) appear to be comparable to use rates from other studies. The use of over-the-counter medications (5.7%) appears to be slightly higher than in other U.S. surveys. The use of common household products was 6.1%. No significant differences in the lifetime or 30-day use were found correlated to region, gender, and ethnicity or student grade. There was a strong association between 30-day or lifetime use of some HLPs and the (30-day or lifetime) use of alcohol, cigarettes and smokeless tobacco. The use of harmful everyday legal products by fifth, sixth and seventh graders in Alaska appears to be similar to data collected in other parts of the country. The possibility that there may be a link between the use of available legal substances and alcohol, tobacco and marijuana deserves additional attention. Saylor, B., Fair, M., Deike-Sims, S., Johnson, K., Ogilvie, K., and Collins, D. The Use of Harmful Legal Products among Pre-Adolescent Alaskan Students. Int. J. Circumpolar Health, 66(5), pp. 425-436, 2007.

HIV Disclosure among Adults Living with HIV

Research on disclosure among heterosexual adult person(s) living with HIV (PLH) was reviewed, omitting disclosure of parental HIV to children. Disclosure has been studied within five additional relational contexts: with partners, family members, friends, healthcare professionals and in work settings. Disclosure is higher among women than men, among Latino and white compared to African-American families, and among younger compared to older HIV-positive adults. Most PLH disclose to their sexual partners and family members, yet there is a significant minority who do not disclose. Similarly, rates of disclosure to employers range from 27-68%, suggesting broad variability in perceived consequences of employment disclosures. Of concern, 40% of PLH do not consistently disclose to their healthcare professionals. Rather than examine HIV disclosures in the context of relationships, it is possible to understand disclosures around personal identity. Disclosure decisions are often made to tell everyone (making HIV status a central attribute of one's identity), no one (requiring strategies for securing social support while remaining anonymous) or some people (requiring strategic decisions based on context). Given that disclosure decisions are central to personal identity, future data on disclosure and interventions designed to increase disclosure or comfort with disclosure must focus on communication strategies adopted by PLH to present a coherent identity. Arnold, E.M., Arnold, E.M.E.R., Flannery, D., and Rotheram-Borus, M.J. HIV Disclosure among Adults Living with HIV. AIDS Care, 20(1), pp. 80-92, 2008.

Research on Behavioral & Combined Treatments for Drug Abuse

Menstrual Phase Effects on Smoking Relapse

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

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

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

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

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

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

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

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

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

Research on Pharmacotherapies for Drug Abuse

Rural Opioid-using Pregnant Women Appear to Have Some Characteristics Associated With Better Treatment Outcomes

Historically, research on opioid use during pregnancy has occurred in urban settings and it is unclear how urban and rural populations compare. This study examined socio-demographic and other variables in opioid-using pregnant women seeking treatment and screened for participation in a multi-site randomized controlled trial. Women screened in rural Burlington, Vermont (n=54), were compared to those screened in urban Baltimore, Maryland (n=305). Rural opioid-using pregnant women appear to have some characteristics associated with better treatment outcomes (e.g., less severe drug use, greater employment). However, they may face additional barriers in accessing treatment (e.g., greater distance from treatment clinic). Heil, S.H., Sigmon, S.C., Jones, H.E., and Wagner, M. Comparison of Characteristics of Opioid-using Pregnant Women in Rural and Urban Settings. Am. J. Drug Alcohol Abuse, 34(4), pp. 463-471, 2008.

Gender Differences with High-dose Naltrexone in Patients with Co-occurring Cocaine and Alcohol Dependence

This is a randomized, double-blind, placebo-controlled clinical trial that evaluated the efficacy of a higher-than-typical daily dose of naltrexone (150 mg/day), taken for 12 weeks, in 164 patients (n = 116 men and n = 48 women) with co-occurring cocaine and alcohol dependence. Patients were stratified by gender and then randomly assigned to either naltrexone or placebo, and to either cognitive-behavioral therapy or a type of medical management. The two primary outcomes were cocaine use and alcohol use. Significant Gender x Medication interactions were found for cocaine use via urine drug screens (three way, with time) and self-reports (two way) for drug severity (two way) and alcohol use (two way). The type of psychosocial treatment did not affect outcomes. Thus, 150 mg/day naltrexone added to a psychosocial treatment resulted in reductions in cocaine and alcohol use and drug severity in men, compared to higher rates of cocaine and alcohol use and drug severity in women. Pettinati, H.M., Kampman, K.M., Lynch, K.G., Suh, J.J., Dackis, C.A., Oslin, D.W., and O'Brien, C.P. Gender Differences with High-dose Naltrexone in Patients with Co-occurring Cocaine and Alcohol Dependence. J. Subst. Abuse Treat., 34, pp. 378-390, 2008.

Predictors of Cardiovascular Response to Methamphetamine Administration in Methamphetamine-dependent Individuals May Help in the Prevention and Treatment of Cardiovascular Events in a Population at High Risk

The goal of this study was to determine predictors of cardiovascular response to methamphetamine administrated in the laboratory. Heart rate (HR) and blood pressure (BP) were measured at baseline and at several time points following the administration of methamphetamine or saline placebo. One-way ANOVA was used to determine the differences between female and male subjects in their cardiovascular response. In male subjects, linear regression and one-way ANOVA were used to determine the influence of potential predictors on cardiovascular response, including age, weight, drug use indicators, concurrent use of other substances, route of administration, and race. Methamphetamine administration provoked significant increases in HR and BP, as compared to placebo. Female gender was associated with larger peak change in diastolic BP following administration. Baseline HR and BP were found to be strong predictors of cardiovascular response to methamphetamine administration in male subjects. Lifetime use and recent use of methamphetamine and nicotine did not predict cardiovascular response to methamphetamine. Recent alcohol use was associated with increased peak change in diastolic BP. Also, current use of cannabis was negatively correlated with peak HR change. Male cannabis users show lower peak change in HR as compared to non-cannabis users. As compared to methamphetamine smokers, intravenous users demonstrated higher peak change in diastolic BP following drug administration. Race did not have a significant effect on cardiovascular response. Taken together, these findings may help in the prevention and treatment of cardiovascular events in a population at high risk of premature morbidity and mortality. Fleury, G., DeLaGarza, R., Mahoney, J.J., Evans, S.E., and Newton, T.F. Predictors of Cardiovascular Response to Methamphetamine Administration in Methamphetamine-dependent Individuals. Am. J. Addict. Mar-Apr;17(2) pp. 103-110, 2008.

Sex and Opioid Maintenance Dose Influence Response to Naloxone in Opioid-dependent Humans

Pooled self-report and physiological data from 32 male and 15 female methadone or LAAM maintained volunteers were retrospectively analyzed for individual differences in response to naloxone (0.15 mg/70 kg, IM) and placebo at 20 and 40 minutes post-injection. Males and females were each divided by the median split methadone maintenance dose (MMD, in mg/kg body weight) into high and low MMD groups and MMD was used as a factor in the analysis, along with sex, drug, and time post-drug. Females in the low, but not high, MMD group showed naloxone-induced increases in ratings on the Antagonist and Mixed-Action subscales of the Adjective Rating Scale, and the LSD sub-scale of the Addiction Research Center Inventory at 20 minutes post-injection. Males in the high MMD group showed significant naloxone-induced increases in scores of these measures at both post-injection time points. In addition, low MMD subjects showed more short-lived naloxone-induced increases on Visual Analogue Scale Bad and Any drug effects ratings than high MMD subjects. These results suggest that those on a lower MMD, especially women, experience a more intense, but short-lived, response to naloxone, whereas those on a higher MMD experience a more modest, but long lasting effect. Chopra, M.P., Feldman, Z., Mancino, M.J., and Oliveto, A. Sex and Opioid Maintenance Dose Influence Response to Naloxone in Opioid-dependent Humans. Pharm. Biochem. Behav., 2008 (E-pub ahead of print).

Changes in Mood, Cognitive Performance and Appetite in the Late Luteal and Follicular Phases of the Menstrual Cycle in Women With and Without PMDD (Premenstrual Dysphoric Disorder)

Although it's been reported that women with premenstrual dysphoric disorder (PMDD) have increased negative mood, appetite (food cravings and food intake), alcohol intake and cognitive deficits premenstrually, few studies have examined these changes concurrently within the same group of women or compared to women without PMDD. Thus, to date, there is not a clear understanding of the full range of PMDD symptoms. The present study concurrently assessed mood and performance tasks in 29 normally cycling women (14 women who met DSM-IV criteria for PMDD and 15 women without PMDD). Women had a total of ten sessions: two practice sessions, 4 sessions during the follicular phase and 4 sessions during the late luteal phase of the menstrual cycle. Each session, participants completed mood and food-related questionnaires, a motor coordination task, performed various cognitive tasks and ate lunch. There was a significant increase in dysphoric mood during the luteal phase in women with PMDD compared to their follicular phase and compared to Control women. Further, during the luteal phase, women with PMDD showed impaired performance on the Immediate and Delayed Word Recall Task, the Immeate and Delayed Digit Recall Task and the Digit Symbol Substitution Test compared to Control women. Women with PMDD, but not Control women, also showed increased desire for food items high in fat during the luteal phase compared to the follicular phase and correspondingly, women with PMDD consumed more calories during the luteal phase (mostly derived from fat) compared to the follicular phase. In summary, women with PMDD experience dysphoric mood, a greater desire and actual intake of certain foods and show impaired cognitive performance during the luteal phase. An altered serotonergic system in women with PMDD may be the underlying mechanism for the observed symptoms; correspondingly, treatment with specific serotonin reuptake inhibitors (SSRIs) remains the preferred treatment at this time. Reed, S.C., Levin, F.R., and Evans, S.M. Changes in Mood, Cognitive Performance and Appetite in the Late Luteal and Follicular Phases of the Menstrual Cycle in Women With and Without PMDD (Premenstrual Dysphoric Disorder). Horm. Behav., 54, pp. 185-193, 2008.

Research on Medical Consequences of Drug Abuse & Co-Occurring Infections (HIV/AIDS, HCV)

HIV/AIDS

C-reactive Protein: A Poor Marker of Cardiovascular Disease Risk in HIV+ Populations with a High Prevalence of Elevated Serum Transaminases

Blood lipids and high-sensitivity C-reactive protein (hsCRP) are used to assess cardiovascular disease (CVD) risk. The authors evaluated in a cross-sectional design the relationship of hsCRP to markers of liver function (aspartate and alanine transaminases [AST and ALT, respectively]), CVD risk factors and HIV-disease progression markers in 226 HIV-1 sero-positive drug users. hsCRP showed a significant inverse relationship with ALT and high-density lipoprotein, independent of age, gender, viral load, CD4 cell-count and antiretroviral (ARV) use, and was not significantly associated with HIV-disease progression markers. Serum markers of liver damage, AST and ALT, were associated with lower hsCRP, total cholesterol, low-density lipoproteins and triglycerides. Elevated liver enzymes (> or =40 IU/L) were predictive of hsCRP levels that are considered a low risk for CVD. In conclusion, hsCRP may not be a reliable marker of CVD risk in populations with HIV at-risk for elevated liver enzymes due to high hepatitis B virus/hepatitis C virus prevalence and ARV use. Baum, M.K., Rafie, C., Sales, S., Lai, S., Duan, R., Jayaweera, D.T., Page, J.B., Campa, A. Int. J. STD AIDS. 19(6), pp. 410-413, 2008.

A Pilot Survey of Attitudes and Knowledge about Opioid Substitution Therapy for HIV-Infected Prisoners

A majority of inmates in the state of Connecticut Department of Corrections use opioids or are opioid dependent before incarceration. None of the state's prisons offer opioid substitution therapy other than for detoxification or maintenance therapy for women during pregnancy. On release to the community, most prisoners relapse to drug use and this has been associated with higher recidivism rates, and less adherence to antiretroviral medications for HIV-infected persons. Nationally and internationally, methadone (METH) and buprenorphine (BUP) have been found to decrease relapse to drug use, decrease recidivism rates, improve adherence to antiretroviral medications, decrease HIV-risk taking behaviors, and improve mortality. However, the general knowledge about opioid substitution therapy among correctional facility staff has been reported as substandard. This pilot study compiled results of answers to anonymous surveys from 27 individuals who work directly with inmates in a patient-care capacity for the Connecticut Department of Corrections (CT DOC) and CT DOC case-management referral program (Project TLC) in the year 2006. The surveys included questions regarding current attitudes and knowledge about opioid substitution therapy for prisoners. A minority of respondents refer released prisoners with a history of opioid dependency to METH or BUP treatment. The majority of correctional workers and case-management referral workers did not have knowledge about BUP or METH's ability to improve health and decrease HIV risk taking behaviors. This study found that more education of individuals treating and caring for HIV-infected opioid dependent prisoners is needed. Springer, S.A., and Bruce, R.D. J. Opioid Manag. 4(2), pp. 81-86, 2008.

Non-Infection Drug Abuse Medical Consequences

Trends in Methamphetamine Use in Young Injection Drug Users in San Francisco from 1998 to 2004: the UFO Study

Secondary analysis of cross-sectional baseline data collected for a longitudinal study of young IDU from 1998 to 2004 were examined to describe temporal trends in methamphetamine use among young injection drug users (IDU) in San Francisco. Median age was 22 years [interquartile range (IQR) 20-25], 30.3% were women and median duration of injecting was 4.4 years (IQR 2-7). Prevalence of methamphetamine use was high, with 50.1% reporting recent injection, but overall there were no temporal increases in reported 'ever' injected use. Recent methamphetamine injection (past 30 days) increased significantly, and peaked at 60% in 2003. MSM-IDU had higher methamphetamine injection ever (92.3%) and recently (59.5%) compared to heterosexual male (non-MSM) IDU (81.6% and 47.3%, respectively) and to female IDU (78.4% and 46.1%, respectively). Findings disclosed that despite reports of ubiquitous increases in methamphetamine use, there were no significant increases in 6 years in ever injecting methamphetamine overall among young IDU. Further, the methamphetamine 'epidemic' appeared to have been under way among young IDU earlier than in other populations. Inglez-Dias, A., Hahn, J.A., Lum, P.J., Evans, J., Davidson, P., and Page-Shafer, K. Drug Alcohol Rev. 27(3), pp. 286-291, 2008.

Services Research

Smoking Trends May Underly Increasing Education Level Differences in Health Status Relying on Data from the Multiple Cause of Death File and the National Longitudinal Mortality Study

This study examines educational disparities in mortality and life expectancy among non-Hispanic blacks and whites in the 1980s and 1990s. Age-standardized death rates per 100,000 Americans were estimated by education, race, sex and cause between 1990 and 2000. Differences in life expectancies between those with a high school diploma and those with some college education were significant. In 2000, a 25 year old with a high-school diploma could expect to live less than 50 years, until age 75, while a 25 year old with some college could expect to live 7 years longer. This gap had increased by about 30 percent over the study time period. Lung cancer and COPD, two diseases attributable largely to tobacco use, accounted for 21 percent of this widening gap overall, and 25 percent of the gap for less-educated white women over the age of 45, who have shown more modest declines in smoking rates. The gaps are increasing because, for most groups, longevity for more highly-educated individuals is increasing while that for less-educated groups is remaining the same. Meara, E., Richards, S., and Cutler, D. The Gap Gets Bigger: Changes In Mortality and Life Expectancy By Education, 1981-2000. Health Aff (Millwood), 27(2), pp. 350-360, 2008.

Special Gender-Specific Addiction Treatment Programs Had Superior Outcomes to Mixed-Gender Progams

This quasi-experimental, retrospective study reports on the continuity of care for women with children who were admitted to long-term residential substance abuse treatment. Women were admitted to seven agencies offering specialized, women's only treatment (SP, n = 747) or to nine agencies that provided standard mixed-gender treatment (ST, n = 823). Client and treatment data were gathered from administrative sources. Multivariate analyses revealed that SP clients who completed treatment with longer stays were most likely to continue care. Women in SP programs (37%) were more likely than those in ST programs (14%) to continue care. The findings show that specialized treatment for women promotes continuing care and demonstrate the importance of treatment completion. Orwin, R., Claus, R., Kissin, W., Krupski, A., Campbell, K., and Stark, K. Does Gender-Specific Substance Abuse Treatment for Women Promote Continuity of Care? J. Subst. Abuse Treat., 32, pp. 27-39, 2007.

HIV Risk Behaviors among Rural Stimulant Users: Variation by Gender and Race/Ethnicity

The researchers examined data from a community sample of rural stimulant users (n = 691) in three diverse states to identify gender and racial/ethnic differences in HIV risk behaviors. Bivariate and logistic regression analyses were conducted with six risk behaviors as dependent variables: injecting drugs, trading sex to obtain money or drugs, trading money or drugs to obtain sex, inconsistent condom use, multiple sex partners, and using drugs with sex. Controlling for state, income, age, heavy drinking, and type of stimulant used, men had lower odds than women for trading sex to obtain money or drugs (adjusted odds ratio [AOR] =0.4, confidence interval [CI] = 0.28-0.59; p < .0001), greater odds than women for trading money or drugs to obtain sex (AOR = 44.4, CI = 20.30-97.09; p < .0001), greater odds than women of injecting drugs (adjusted odds ratio (AOR =1.6, CI = 1.11-2.42; p = .01), and lower odds than women of using condoms inconsistently (AOR = 0.6, CI = 0.35-0.92; p = .02); African Americans had lower odds than Whites of injecting drugs (AOR = .08, CI = 0.04-0.16; p < .0001), greater odds than Whites for trading sex to obtain money or drugs (AOR = 1.7, CI = 1.01-2.85; p = .04) and for trading money or drugs to obtain sex (AOR = 2.9,CI = 1.53-5.59; p = .001), and greater odds than Whites of using drugs with sex (AOR = 3.9, CI = 1.47-10.09; p = .006). These findings indicate HIV prevention efforts should be tailored to address gender and racial/ethnic differences in risk behaviors among rural stimulant users. Wright, P., Stewart, K., Fischer, E., Carlson, R., Falck, R., Wang, J., Leukefeld, C., and Booth, B. HIV Risk Behaviors among Rural Stimulant Users: Variation by Gender and Race/Ethnicity. AIDS Educ. Prev., 19(2), pp. 137-150, 2007.

Nurse Case-Managed Intervention for Latent Tuberculosis among the Homeless

The efficacy of a nurse case-managed intervention was evaluated in subsamples of participants with one of the following characteristics: female gender, African American ethnicity, recruited from a homeless shelter, a history of military service, lifetime injection drug use, daily alcohol and drug use, poor physical health, and a history of poor mental health. The purpose of the study was to determine whether a validated nurse case managed intervention with incentives and tracking would improve adherence to latent tuberculosis infection treatment in subsamples of homeless persons with characteristics previously identified in the literature as predictive of non-adherence. A prospective 2-group site-randomized design was conducted with 520 homeless adults residing in 12 homeless shelters and residential recovery sites in the Skid Row region of Los Angeles from 1998 to 2003. Results revealed that daily drug users, participants with a history of injection drug use, daily alcohol users, and persons who were not of African American race or ethnicity had particularly poor completion rates, even in the nurse case-managed intervention program (48%, 55%, 54%, and 50%, respectively). However, the intervention achieved a 91% completion rate for homeless shelter residents and significantly improved latent tuberculosis infection treatment adherence in 9 of 12 subgroups tested (odds ratios = 2.51-10.41), including daily alcohol and drug users, when potential confounders were controlled using logistic regression analysis. It is concluded that nurse case management with incentives appears to be a good foundation for increasing adherence to 6-month isoniazid treatment in a variety of homeless subgroups and, in particular, for sheltered homeless populations. However, additional social-structural and environmental strategies are needed to address those at greatest risk of non-adherence. Nyamathi, A., Nahid, P., Berg , J., Burrage, J., Christiani, A., Aqtash, S., Morisky, D., and Leake, B. Efficacy of Nurse Case-Managed Intervention for Latent Tuberculosis among Homeless Subsamples. Nurs. Res., 57(1), pp. 33-39, 2008.

Intensive Case Management Is Associated with Improved Outcomes For Women With Substance Use Disorders

The aim of this study is to identify factors that predict, mediate or moderate the effects of intensive case management (ICM) on longer-term drug abstinence outcomes in women on welfare. In a parent study women were assigned randomly to usual care (UC) or intensive case management (ICM). Treatment was provided for 12 weeks and follow-up continued for 15 months after study intake. A set of hypothesized mediators was assessed at month 3 and a rigorous four-step mediational model was tested using outcomes in months 4-15. Participants were 302 drug-dependent women applying and eligible for federal welfare and not currently in drug abuse treatment. The ICM intervention provided intensive treatment engagement including voucher incentives for treatment attendance and case management services; UC provided primarily referral to community treatment programs. Substance use outcomes were assessed using the time-line follow-back interview and confirmed using biological and collateral measures. The authors report that participants in ICM had more case manager contacts, better treatment engagement and more self-help attendance than did those in UC. Each of these variables predicted, and was shown to be a mediator of outcome, but case management contact was an especially robust mediator. Further, ICM effects were strongest for those who attended treatment least. Contrary to prediction, greater psychopathology and environmental stressors did not predict worse outcomes. Findings suggest that case management is an active intervention that may both facilitate and substitute for formal drug abuse treatment. Morgenstern, J., Blanchard, K., Kahler, C., Barbosa, K., McCrady, B., and McVeigh, K. Testing Mechanisms of Action for Intensive Case Management. Addiction, 103(3), pp. 469-477, 2008.

Alcohol, Cannabis, and Methamphetamine Use and Other Risk Behaviors among Black and Colored South African Women

There is a pressing need for brief behavioral interventions to address the intersection of high HIV prevalence, increasing substance use, and high-risk sex practices among South African women. The primary aim of this pilot, randomized trial was to examine whether an adapted evidence-based intervention would be equally, more, or less effective at reducing HIV risk behaviors when delivered using an individual or group format. The secondary aim was to examine differences between Black and Colored South African women across pre- and post-intervention measures of alcohol and illicit drug use and sex risk behaviors. The Cape Town Women's Health Co-Op was adapted from an evidence-based intervention known as the Women's Co-Op. Study participants included Black (n=60) and Colored (n=52) women living in the township communities of Cape Town, South Africa, who reported using illicit drugs and alcohol. Colored women reported greater methamphetamine use (13 days in the past 30 days) and Black women reported mostly cannabis use (27 days in the past 30 days). Although both groups reported having unprotected sex under the influence of alcohol and/or other drugs, Black women reported greater condom use and having one partner; Colored women reported having more than one sex partner. One-month post-intervention assessments indicated significant reductions in substance use and sex risk behaviors. After controlling for baseline measures, there were no significant differences between the two intervention conditions. Significant differences in risk behaviors were observed between Black and Colored South African women. However, both ethnic groups were responsive to the adapted intervention and no differences were found by intervention assignment. These findings support the assertion that group interventions may be more cost-effective in reaching at-risk women in resource-scarce environments. Larger studies are needed to show efficacy and effectiveness of woman-focused group prevention interventions. Wechsberg, W., Luseno, W., Karg, R., Young, S., Rodman, N., Myers, B., and Parry, C. Alcohol, Cannabis, and Methamphetamine Use and Other Risk Behaviors among Black and Colored South African Women: A Small Randomized Trial in the Western Cape. Int. J. Drug Policy, 19(2), pp. 130-139, 2008.

Factors Associated with Dual Disorder Adolescent's Utilization of Mental Health Services

This study examined the rates and correlates of self-reported receipt for mental health services among 1,190 adolescents, aged 12-19, who were admitted to community-based substance abuse outpatient clinics and had a co-occurring mental health problem. Utilization of mental health service was ascertained 3 months post-intake. About one third (35%) of adolescents with a co-occurring mental health problem identified at intake received mental health service in the 3 months after treatment entry. After holding other correlates constant, history of mental health treatment, suicidal behavior, family history of mental disorder and insurance coverage at intake were associated with mental health service utilization at the 3-month follow up. Predictors of service utilization varied by gender and racial/ethnic status. The authors discuss implications for integrated substance use and mental health services. They recommend, for example, that substance abuse treatment programs provide a prompt and adequate mental health assessment for adolescents to design a treatment plan based on individual needs. In addition, youth with substance use and mental disorders have various and complex treatment needs, but may need additional insight and motivational counseling to address them. The authors also state that special attention and case management (e.g., linkage, advocacy) may be necessary for uninsured groups as they may be the least likely to obtain services without special assistance. Chan, Y., Godley, M., Godley, S., and Dennis, M. Utilization of Mental Health Services Among Adolescents in Community-Based Substance Abuse Outpatient Clinics. J. Behav. Health Serv. Res, 2007 Dec 21. E-pub ahead of print, (Special Issue), pp. 1-17, 2007.

CTN-Related Research

Adverse Events in an Integrated Trauma-focused Intervention for Women in Community Substance Abuse Treatment

A substantial number of women who enter substance abuse treatment have a history of trauma and meet criteria for posttraumatic stress disorder (PTSD). Fear regarding the extent to which PTSD treatment can evoke negative consequences remains a research question. This study explored adverse events related to the implementation of an integrated treatment for women with trauma and substance use disorder (Seeking Safety) compared with a nontrauma-focused intervention (Women's Health Education). Three hundred fifty-three women enrolled in community substance abuse treatment were randomized to 1 of the 2 study groups and monitored weekly for adverse events. There were no differences between the two intervention groups in the number of women reporting study-related adverse events (28 [9.6%] for the Seeking Safety group and 21[7.2%] for the Women's Health Education group). Implementing PTSD treatment in substance abuse treatment programs appears to be safe, with minimal impact on intervention-related adverse psychiatric and substance abuse symptoms. More research is needed on the efficacy of such interventions to improve outcomes of PTSD and substance use. Killeen, T., Hien, D., Campbell, A., Brown, C., Hansen, C., Jiang, H., Kristman--Valente, A., Neuenfeldt, C., Rocz-de la Luz, N., Sampson, R., Suarez-Morales, L., Wells, E., Brigham, G., and Nunes, E. Adverse Events in an Integrated Trauma-focused Intervention for Women in Community Substance Abuse Treatment. J. Subst. Abuse Treat. 2008 Feb 20. [E-pub ahead of print].

NIDA CTN Membership is Diverse, But Due to the Need For Large Samples, Over Represents Larger Facilities

Programs participating in the National Drug Abuse Treatment Clinical Trials Network (CTN) completed Organizational Surveys (n=106 of 112; 95% response rate) and Treatment Unit Surveys (n=348 of 384; 91% response rate) to describe the levels of care, ancillary services, patient demographics, patient drug use and co-occurring conditions. Analyses describe the corporations participating in the CTN and provide an exploratory assessment of variation in treatment philosophies. A diversity of treatment centers participates in the CTN; not for profit organizations with a primary mission of treating alcohol and drug disorders dominate. Compared to National Survey of Substance Abuse Treatment Services (N-SSATS), programs located in medical settings are over-represented and centers that are mental health clinics are under-represented. Outpatient, methadone, long-term residential and inpatient treatment units differed on patients served and services provided. Larger programs with higher counselor caseloads in residential settings reported more social model characteristics. Programs with higher social model scores were more likely to offer self-help meetings, vocational services and specialized services for women. Conversely, programs with accreditation had less social model influence. The CTN is an ambitious effort to engage community-based treatment organizations into research and more fully integrate research and practice. McCarty, D., Fuller, B., Kaskutas, L., Wendt, W., Nunes, E., Miller, M., Forman, R., Magruder, K., Arfken, C., Copersino, M., Floyd, A., Sindelar, J., and Edmundson, E. Treatment Programs in the National Drug Abuse Treatment Clinical Trials Network. Drug Alcohol Depend., 92(1-3), pp. 200-207, 2008.