Research Findings - Services Research

Screening, Brief Intervention, and Referral to Treatment (SBIRT): Toward a Public Health Approach to the Management of Substance Abuse

Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a comprehensive and integrated approach to the delivery of early intervention and treatment services through universal screening for persons with substance use disorders and those at risk. This paper by Dr. Babor describes research on the components of SBIRT conducted during the past 25 years, including the development of screening tests, clinical trials of brief interventions and implementation research. Beginning in the 1980s, concerted efforts were made in the US and at the World Health Organization to provide an evidence base for alcohol screening and brief intervention in primary health care settings. With the development of reliable and accurate screening tests for alcohol, more than a hundred clinical trials were conducted to evaluate the efficacy and cost effectiveness of alcohol screening and brief intervention in primary care, emergency departments and trauma centers. With the accumulation of positive evidence, implementation research on alcohol SBI was begun in the 1990s, followed by trials of similar methods for other substances (e.g., illicit drugs, tobacco, prescription drugs) and by national demonstration programs in the US and other countries. The results of these efforts demonstrate the cumulative benefit of translational research on health care delivery systems and substance abuse policy. It is shown that SBIRT yields short-term improvements in individual's health, however long-term effects on population health have not yet been demonstrated, but simulation models suggest that the benefits could be substantial. Babor, T., McRee, B., Kassebaum, P., Grimaldi, P., Ahmed, K., and Bray, J. Screening, Brief Intervention, and Referral to Treatment (SBIRT): Toward a Public Health Approach to the Management of Substance Abuse. Subst. Abuse, 28(3), pp. 7-30, 2007.

Discovery of Three Distinct Life Course Trajectories for Heroin Addicts Show Delayed Treatment Results in High Morbidity and Early Mortality

This study investigates trajectories of heroin use and subsequent consequences in a sample of 471 male heroin addicts who were admitted to the California Civil Addict Program in 1964-1965 and followed over 33 years. Applying a two-part growth mixture modeling strategy to heroin use level during the first 16 years of the addiction careers since first heroin use, the authors identified three groups with distinctive profiles: stably high-level heroin users (n = 278), late decelerated users (n = 149), and early quitters (n = 44). Study findings empirically demonstrate the chronic nature of heroin addiction. Early treatment seekers are more likely to have periods of recovery, fewer medical problems, and longer survival than those delaying treatment beyond 16 years (X2=11.0, df=2, p<.004). Hser, Y., Huang, D., Chou, C., and Anglin, M. Trajectories of heroin addiction: growth mixture modeling results based on a 33-year follow-up study. Eval. Rev., 31(6), pp. 548-563, 2007.

Primary Medical Care Reduces HIV Risk Behaviors in Adults with Addictions

Human immunodeficiency virus (HIV) risk behaviors are prevalent in persons with addictions. This study assessed whether exposure to primary medical care is associated with decreases in HIV risk behaviors. This was a prospective 2-year cohort study of 298 adults with addictions. Outcomes evaluated were sex and drug-related HIV risk behaviors, measured by the Risk Assessment Battery. The predictor variables were the cumulative number of primary care visits (0, 1, > or = 2). Associations were tested using regression models for correlated data. It was found that in women, receipt of primary care was associated with less sex risk behavior (mean decrease 2.1, p < or = 0.1). Among women and men, > or = 2 primary care visits was associated with lower odds of any drug risk behavior (OR = 0.37, p = 0.03). From this study it is shown that exposure to primary care can impact HIV risk behavior favorably among adults with addictions. Takizawa, C., Cheng, D., Samet, J., Winter, M., Larson, M., and Saitz, R. Primary Medical Care and Reductions in HIV Risk Behaviors in Adults with Addictions. J. Addict. Dis., 26(3), pp. 17-25, 2007.

Methadone Maintenance at Release for Male Prisoners: 3 Month Outcomes

This study examined benefits of methadone maintenance among pre-release prison inmates. Incarcerated males with pre-incarceration heroin dependence (n = 197) were randomly assigned to (a) group educational counseling (counseling only); (b) counseling, with opportunity to begin methadone maintenance on release (counseling + transfer); or (c) counseling and methadone maintenance in prison, with opportunity to continue methadone maintenance on release (counseling +methadone). At 90-day follow-up, counseling + methadone participants were significantly more likely than counseling-only and counseling + transfer participants to attend drug treatment (p =.0001) and less likely to be reincarcerated (p =.019). Counseling + methadone and counseling +transfer participants were significantly less likely (all ps < .05) to report heroin use, cocaine use, and criminal involvement than counseling-only participants. Kinlock, T. W., Gordon, M. S., Schwartz, R. P., and O'Grady, K.E. A Study of Methadone Maintenance for Male Prisoners: 3-Month Post Release Outcomes. Crim. Just. & Beh., 35(1), pp. 34-47, 2008.

Buprenorphine-Naloxone Treatment for Prerelease Opioid-dependent Inmates in Puerto Rico

This study examined the feasibility of providing daily buprenorphine-naloxone (bup-nx) in prison and on release to 45 male inmates with histories of heroin addiction in Puerto Rico. Participants were assessed at study entry and at 1 month after release (N = 42; 93.3% follow-up rate). Treatment completers compared with non-completers had significantly greater reductions in self-reported heroin use, cocaine use, and crime and were less likely to be opioid-positive according to urine drug testing. The short-term outcomes of this study suggest that bup-nx may contribute to reductions in re-addiction to heroin and in criminal activities among re-entering male prisoners. Garcia, C.A., Correa, G.C., Hernandez, A.D., Kinlock, T.W., Gordon, M.S., Avila, C.A., Reyes, I.C., and Schwartz, P. Buprenorphine-Naloxone Treatment for Pre-Release Opioid-Dependent Inmates in Puerto Rico. J. Addiction Medicine, 1(3), pp. 126-132, 2007.

A New Tobacco Threat: Characteristics of U.S. Waterpipe Users

Waterpipe smoking, a traditional method of tobacco use, has experienced resurgence in the Middle East and Indian subcontinent in recent years. Despite growing evidence of its dependence potential and health-damaging effects, waterpipe use has spread beyond these regions to many other countries, including the United States. Because little is known about waterpipe use in the United States, the authors surveyed convenience samples of users from two U.S. cities, Richmond, Virginia (n = 109), and Memphis, Tennessee (n = 34). Respondents in both cities were primarily young adults, a majority (75%) was men, and most were college students or had a college degree. Initial and current use usually occurred in a social context, with a group of friends in a cafe or restaurant or at home. Most respondents had smoked a waterpipe for 2 or fewer years, and 67% currently smoked at least once a month (22% smoked at least once per week and 10% smoked daily). Most believed waterpipe use to be less addictive and harmful than cigarette smoking, believed they could quit use at any time, but had no plans or desire to quit. A majority of respondents used other tobacco products such as cigarettes, and 35% of those who did not smoke cigarettes said they would "probably" or "definitely" smoke one in the next year. Multivariate correlates of greater frequency of use included younger age at first use, ownership of a waterpipe, use occurring primarily with groups of friends, and the perception of being "hooked." Waterpipe users were young and educated, tended to experiment with multiple forms of tobacco, were unaware of the potentially harmful and addictive properties of waterpipe use, and planned to continue use in the future. Educational efforts are needed to increase awareness of the potential hazards of this increasingly popular form of tobacco use. Ward, K., Eissenberg, T., Gray, J., Srinivas, V., Wilson, N., and Maziak, W. Characteristics of U.S. Waterpipe Users: A Preliminary Report. Nicotine Tob. Res., 9(12), pp. 1339-1346, 2007.

Waterpipe Tobacco Smoking in the United States: Knowledge, Attitudes, Beliefs, and Behavior

Despite evidence of increasing waterpipe tobacco smoking prevalence among U.S. young adults little is known about the knowledge, attitudes, beliefs, and smoking patterns of waterpipe users in this population. To address this lack of knowledge, two convenience samples of U.S. waterpipe users were surveyed - one from a Richmond, Virginia, waterpipe cafe (n = 101), the other from an Internet forum called HookahForum.com (n = 100). Sixty percent reported first-time waterpipe use at or before age 18. Daily waterpipe use was reported by 19%, weekly use by 41%, and monthly use by 29%. Waterpipe use was more common during the weekend (75%) than during weekdays (43%). Many waterpipe users smoked the sweetened and flavored tobacco (i.e., maassel), and fruit flavors were the most popular (54%). Past month use of cigarettes, tobacco products other than cigarettes or waterpipe, and alcohol was 54%, 33%, and 80% respectively, and 36% reported past-month marijuana use. Most waterpipe users were confident about their ability to quit (96%), but only a minority (32%) intended to quit. Most waterpipe users believed waterpipe tobacco smoking was less harmful and addictive than cigarettes. More detailed study of a larger group of randomly sampled U.S. waterpipe tobacco smokers will be valuable in understanding this behavior and developing effective strategies to prevent it. Smith-Simone, S., Maziak, W., Ward, K., and Eissenberg, T. Waterpipe Tobacco Smoking: Knowledge, Attitudes, Beliefs, and Behavior in Two U.S. Samples. Nicotine Tob. Res., 10(2), pp. 393-398, 2008.

Blacks and Hispanics Received Alcohol and Employment Services That Were Not Commensurate With their Greater Need

This study examined whether ethnic differences exist in access to care, receipt of services, and associated outcomes of 1,057 offenders participating in California's Proposition 36. Data are based on intake and 3-month follow-up interviews conducted as part of a multisite prospective treatment outcome study. Logistic regressions were conducted to examine ethnicity and other predictors of treatment placement and services intensity. Across ethnic groups, services intensity in several domains was inadequately matched to need, and few services besides substance abuse treatment were provided. Blacks and Hispanics received alcohol and employment services that were not commensurate with their greater need (O.R. = 0.59, p<.05). Although Blacks were more likely to be placed in residential programs, their employment status worsened from intake to follow-up (11% vs. 26% for Hispanics and 23% for Whites, p<.05). There were few other ethnic differences in outcomes. Assessing and eliminating ethnic-associated differences in health service delivery may improve program processes and outcomes. Fosados, R., Evans, E., and Hser, Y. Ethnic Differences in Utilization of Drug Treatment Services and Outcomes Among Proposition 36 Offenders in California. J. Subst. Abuse Treat., 33(4), pp. 391-399, 2007.

Trends in Opioid Prescribing by Race/Ethnicity for Patients Seeking Care in US Emergency Departments

National quality improvement initiatives implemented in the late 1990s were followed by substantial increases in opioid prescribing in the United States, but it is unknown whether opioid prescribing for treatment of pain in the emergency department has increased and whether differences in opioid prescribing by race/ethnicity have decreased. The objective of this study was to determine whether opioid prescribing in emergency departments has increased, whether non-Hispanic white patients are more likely to receive an opioid than other racial/ethnic groups, and whether differential prescribing by race/ethnicity has diminished since 2000. Pain-related visits to US emergency departments were identified using reason-for-visit and physician diagnosis codes from 13 years (1993-2005) of the National Hospital Ambulatory Medical Care Survey. Pain-related visits accounted for 156,729 of 374,891 (42%) emergency department visits. Opioid prescribing for pain-related visits increased from 23% (95% confidence interval [CI], 21%-24%) in 1993 to 37% (95% CI, 34%-39%) in 2005 (P < .001 for trend), and this trend was more pronounced in 2001-2005 (P = .02). Over all years, white patients with pain were more likely to receive an opioid (31%) than black (23%), Hispanic (24%), or Asian/other patients (28%) (P < .001 for trend), and differences did not diminish over time (P = .44), with opioid prescribing rates of 40% for white patients and 32% for all other patients in 2005. Differential prescribing by race/ethnicity was evident for all types of pain visits, was more pronounced with increasing pain severity, and was detectable for long-bone fracture and nephrolithiasis as well as among children. Statistical adjustment for pain severity and other factors did not substantially attenuate these differences, with white patients remaining significantly more likely to receive an opioid prescription than black patients (adjusted odds ratio, 0.66; 95% CI, 0.62-0.70), Hispanic patients (0.67; 95% CI, 0.63-0.72), and Asian/other patients (0.79; 95% CI, 0.67-0.93). Opioid prescribing for patients making a pain-related visit to the emergency department increased after national quality improvement initiatives in the late 1990s, but differences in opioid prescribing by race/ethnicity have not diminished. Fletcher, M., Kertesz, S., Kohn, M., and Gonzales, R. Trends in Opioid Prescribing by Race/ethnicity for Patients Seeking Care in US Emergency Departments. JAMA, 299(1), pp. 70-78, 2008.

On-Site 12-Step Meetings Are Associated With Abstinence One Year After Discharge

Rates of return to active substance use after addiction treatment tend to be high; participation in 12-step fellowships (e.g., Alcoholics Anonymous) reduces relapse rates but many clients do not attend or attend for a short period only. The authors of this quasi-experimental study used repeated measurement to explore the role of presence/absence of on-site 12-step meetings during treatment on post-treatment outcomes. Polysubstance-dependent clients (N = 219) recruited at a program with and one without 12-step on-site, were followed for one year post-treatment. On-site 12-step enhanced 12-step attendance, especially during treatment, and predicted continuous abstinence for the post-treatment year. Holding 12-step meetings on-site is a low-cost strategy that programs should consider to foster post-treatment remission maintenance. Laudet, A., Stanick, V., and Sands, B. An Exploration of the Effect of On-Site 12-Step Meetings on Post-Treatment Outcomes among Polysubstance-Dependent Outpatient Clients. Eval. Rev., 31(6), pp. 613-646, 2007.

Unprotected Sex Among Ukrainian Addicts Forecasts Escalated HIV Infection Rates

From June 2004 through November 2006, outreach workers recruited 1557 Ukrainian IDUs, including 526 from Kiev, 494 from Odessa, and 537 from Makeevka/Donesk. Participants were administered a standardized computer-assisted interview assessing HIV-related drug and sex risk behaviors, self-efficacy for practicing safe sex, and HIV knowledge. Overall, 80% of the participants were sexually active in the 30-day period before their interview. They also engaged in high-risk sex behavior with 53% reporting anal or vaginal sex without a condom, 27% having sex with more than 1 partner, 41% having an IDU sex partner, and 37% having an HIV-positive sex partner or a partner whose HIV status they did not know. Overall, serology found significantly more women (40%) compared to men (32%) were HIV-positive. Men were twice as likely to have multiple sex partners (X2 = 33.42, df =1; p< .001). The extremely high HIV prevalence rate in Ukraine and in this cohort, combined with their recent high-risk sex behaviors, forecasts not only a continuance of the AIDS epidemic in the region but an escalation. Booth, R., Lehman, W., Brewster, J., Sinitsyna, L., and Dvoryak, S. Gender Differences in Sex Risk Behaviors among Ukraine Injection Drug Users. J. Acquir. Immune Defic. Syndr., 46(1), pp. 112-117, 2007.

Long-term Drug Abstinence Is Related to Psychiatric Trajectory

This study examines psychiatric trajectories of individuals entering chemical dependency treatment in a private, managed care health plan, and estimates relationships among those trajectories, individual characteristics, and abstinence (in the 30 days prior to follow-up) from drugs over 9 years. The original sample consisted of 1,204 adult men and women who met criteria for alcohol or other drug dependence or abuse and were admitted to treatment between April 1994 and April 1996. Interview data were collected at 6 mo., and 1, 5, 7, and 9 years after intake. This study is based on the 934 clients who had at least one follow-up interview within in 1 year and another between years 1 and 9. Psychiatric outcomes were measured using the ASI Psychiatric Composite scale. Other variables included age, gender, race/ethnicity, income, education, marital status, employment status, all seven ASI composite scores, and dependence and abuse measures based on the Diagnostic Interview Schedule for Psychoactive Substance Dependence. Four discrete trajectory groups of clients with homogenous longitudinal traits based on their patterns of psychiatric status over time were identified: consistent low-severity, deteriorating, improving, and consistent high-severity. Results, reported as odds ratios (OR), indicate that compared to clients in low severity groups, those in the deteriorating (OR = 0.61, 95% CI: 0.42 - 0.87), improving (OR = 0.61, 95% CI = 0.40-0.93) and high-severity (OR = 0.43, 95% CI: 0.29-0.66) all had lower levels of abstinence at follow-up. A higher ASI Drug Composite score was also negatively associated with attaining abstinence at follow-up. Variables associated with higher follow-up abstinence rates included higher index treatment length of stay, higher ASI Medical Composite score, being female, being married at follow-up, and being employed at follow-up. Age demonstrated a non-linear effect, with those aged 30-39 years and 50 to 59 years experiencing better outcomes than those aged 40-49 years in comparison to those younger than 30 years of age. These results suggest that careful attention be paid to client's psychiatric status during treatment assessment, treatment, and aftercare. Chi, F.W., and Weisner, C.M. Nine-Year Psychiatric Trajectories and Substance Use Outcomes. Eval. Rev., 32(1), pp. 39-58, 2008.

Pain Medication Agreements are Found Useful by Internal Medicine Residents

Little is known about whether internal medicine residents find pain management agreements (PMAs) useful or whether PMA use is associated with more positive attitudes toward patients with chronic noncancer pain (CNCP). The authors surveyed all internal medicine residents at Rhode Island Hospital regarding whether they found PMAs useful, what percentage of their patients taking chronic opioids had a signed PMA, and their attitudes toward and experiences with managing CNCP. The survey response rate was 89% (110/124). Ninety percent of respondents reported finding PMAs useful. A majority of respondents reported that PMAs were at least somewhat helpful for reducing multiple prescribers (76%), reducing requests for early refills (67%), reducing calls and pages from patients (57%), making it easier to discuss potential problems associated with chronic opioid use (73%), and making it easier to identify patients who are abusing pain medications (66%). Residents who reported greater use of PMAs reported a greater sense of preparation (r=0.20, P=0.04), greater confidence (r=0.18, P=0.06), and a greater sense of reward (r=0.24, P=0.02) for managing CNCP. In a multivariate analysis, PMA use was significantly associated with a greater sense of preparation and a greater sense of reward for managing CNCP. Overall this study shows that among internal medicine residents, PMA use was associated with more positive attitudes toward CNCP management. Fagan, M., Chen, J., Diaz, J., Reinert, S., and Stein, M. Do Internal Medicine Residents Find Pain Medication Agreements Useful? Clin. J. Pain, 24(1), pp. 35-38, 2008.

When Seeking Care From Free-Standing Drug Abuse Treatment Clinics, Patients Are Less Likely to be Medicated for Their Clinical Depression

This research considers the public-private distinction, organizational compatibility, and inter-organizational referral relationships in the use of selective serotonin reuptake inhibitors (SSRIs) medication for depression, by substance abuse treatment organizations. Using data from nationally representative samples of 363 publicly funded and 403 privately funded substance abuse treatment centers, a four-category typology of public and private organizations initially predicted variation in SSRI use. Controlling for government-ownership and not-for-profit status, results indicate that compared to free-standing drug abuse treatment programs, those affiliated with mental health centers were almost 3 times more likely to offer SSRIs (I.R = 2.97, p<,001). Those affiliated with hospitals were almost 2 times more likely to offer SSRIs (O.R. = 1.85, p<.05). Other factors included program access to contract physicians (O.R. = 2.18, P<.01) or full-time staff physicians (O.R. = 3.94, p<.001). These and other findings indicate that patients with co-morbid conditions do not have an equal likelihood of treatment with psychiatric medication. When seeking care from free-standing clinics, patients are less likely to be medicated for their clinical depression. Knudsen, H., Ducharme, L., and Roman, P. The Use of Anti-depressant Medications in Substance Abuse Treatment: The Public-Private Distinction, Organizational Compatibility, and the Environment. J. Health Soc. Behav., 48(2), pp. 195-210, 2007.

For-Profit Organizations More Likely To Implement New Treatments or Services Than Non-Profit Organizations

This study used a structured interview survey of directors of a large national sample (n = 200) of mental health service organizations treating children to examine the governance, financing, staffing, services, and implementation practices of these organizations. Descriptive analyses showed private organizations financing services with public (particularly Medicaid) funds are prevalent and that employment of professional staff, clinical supervision and training, productivity requirements, and outcomes monitoring are common. Results of random effects regression models (RRMs) evaluating associations between governance, financing, and organizational characteristics and the use of new treatments and services showed for-profit organizations more likely to implement such treatments, and organizations with more licensed clinical staff and weekly clinical supervision in place less likely to do so. Results of RRMs evaluating relations between director ratings of the importance to new treatment and service implementation of three factors-fit with existing implementation practices, infrastructure support, and organizational mission and support-suggest greater importance to public than private organizations of these factors. Schoenwald, S., Chapman, J., Kelleher, K., Hoagwood, K., Landsverk, J., Stevens, J., Glisson, C., Rolls-Reutz, J., and Rolls-Reutz, J. A Survey of The Infrastructure for Children's Mental Health Services: Implications for The Implementation of Empirically Supported Treatments (ESTs). Adm. Policy Ment. Health, 35(1-2), pp. 84-97, 2008.

Longer Stay in Mutual Help Recovery Homes Associated with Lower Levels of Anxiety and Alcohol Use

Anxiety often co-occurs with alcohol abuse and predicts both the initial development of alcohol abuse problems and relapse among individuals in recovery. Individuals with comorbid substance abuse and anxiety symptoms may benefit from mutual-help environments, as these settings offer an increased amount of social support for individuals in recovery. Because symptoms of anxiety predict higher rates of relapse, mutually-supportive environments that potentially buffer anxiety might be beneficial recovery settings. This study examined anxiety symptoms and alcohol use over a one-year period among a sample of adults in self-governed, communal-living recovery homes for substance abuse (n=163). The authors explored whether staying in a supportive recovery environment for six months or longer was associated with lower levels of anxiety and alcohol use over time. Findings indicated that individuals who remained for at least six months had significantly lower anxiety symptoms and rates of alcohol use over time. The implications of these findings are discussed. Aase, D.M., Jason, L.A., Ferrari, J.R., Groh, D.R., Alvarez, J., Olson, B.D., and Davis, M.I. Anxiety Symptoms and Alcohol Use: A Longitudinal Analysis of Length-of-Time in Mutual-Help Recovery Homes. International Journal of Self Help & Self Care, 4 pp. 19-33, 2007.

Particulate Emissions from Waterpipe-Smoking

Waterpipe tobacco smoking is increasingly common worldwide, and evidence about its harmful effects to smokers is emerging. However, no studies have investigated the potential exposure of nonsmokers to waterpipe smoke. The authors measured particulate matter (PM) emissions (PM(2.5), PM(10)) before and during laboratory sessions in which 20 individuals used a waterpipe to smoke tobacco and 20 individuals smoked a cigarette (10 for each particle-size/smoking-method), as well as 10 waterpipe and 10 cigarette smoldering sessions (i.e., without a smoker). For the waterpipe smoking method, the indoor air levels of particulate matter build gradually, reaching high levels compared with background. Higher levels of PM are reached during waterpipe use compared with cigarette smoking, likely because of cumulative, yet slower buildup during the longer waterpipe use sessions. Smoldering of waterpipe, however, did not seem to contribute to indoor particulate matter, in sharp contrast to what is witnessed with cigarette smoking, where smoldering can be a substantial source of hazardous PM emissions. Policymakers considering clean air regulations should include waterpipe tobacco smoking, and the public should be warned about this source of smoke exposure. Maziak, W., Rastam, S., Ibrahim, I., Ward, K., and Eissenberg, T. Particulate Emissions from Waterpipe-Smoking. Nicotine Tob. Res., 10(3), pp. 519-523, 2008.

Individual and System Factors Influence Waiting Time for Addition Treatment

The authors of this study assessed waiting time preceding clinical assessment at a centralized intake unit and during the period after the assessment but before treatment entry. The analysis included 577 substance abusers who were enrolled in a large clinical trial of two brief treatment interventions in a midsize metropolitan area in Ohio. Bivariate analyses identified individual and system factors that influenced pre-assessment and post-assessment waiting time, as well as total wait to treatment services. Multivariate analyses demonstrated that longer wait time for an assessment is influenced by being court referred, less belief in having a substance abuse problem, and less desire for change. A shorter wait to actually enter treatment is predicted by having a case manager, being more ready for treatment, and having less severe employment and alcohol problems. The different influences present during the two waiting periods suggest that assessment and treatment programs need to implement system changes and entry enhancement interventions that are specific to the needs of substance abusers at each waiting period. Carr, C.J., Jiangmin, X.U., Redko, C., Lane, T., and Rapp, R. Individual and System Influences on Waiting Time for Substance Abuse Treatment. J. Subst. Abuse Treat., E-Published 2007.

The Ecology of Adolescent Substance Abuse Service Utilization

This paper presents an ecological-community model toward the explanation of variation in patterns of substance abuse (SA) service utilization among adolescents who are enrolled in Tennessee's Medicaid program (TennCare). Guided by a theoretical framework that draws from the social ecology work of Bronfenbrenner and health services utilization models promoted by Aday and Andersen, the researchers applied a social indicators approach toward explaining the impact of community ecology on identification of SA and treatment engagement. Both county-level rates and individual-level treatment utilization are examined and hierarchical linear modeling is incorporated to examine the individual-in-community phenomenon. This study is an expansion of previous service utilization research and suggests that explanations of youth's service utilization must necessarily include not only individual, familial, and service system characteristics, but community factors, as well. Jones, D.L., and Heflinger, C.A. The Ecology of Adolescent Substance Abuse Service Utilization. Am. J. Community Psychol., 40 pp. 345-358, 2007.

Crack Cocaine Trajectories Among Users In a Midwestern American City

Although crack cocaine first appeared in cities in the United States in the mid-1980s, little is known about its use over long periods of time. This study identified crack cocaine user groups on the basis of long-term trajectories. Following a natural history approach, data were collected periodically from 1996 to 2005. Group-based modeling assessed the probability of a crack smoker becoming abstinent during the observation period. A targeted sampling plan guided the recruitment of a community sample of crack cocaine users in Dayton, Ohio. Subjects on this study were crack smokers (n = 430) 18 years or older whose urine tested positive for cocaine metabolites at the baseline interview. Interviewer-administered and audio computer self-administered, structured questionnaires were used to collect data on a range of variables, including frequency of crack use. Abstinence was defined as not having used crack for at least 6 consecutive months during the study. Three trajectory-based groups were identified: (1) No Change, characterized by a very low probability of abstinence; (2) Some Change, characterized by a low to moderate probability of abstinence; and (3) Dramatic Change, characterized by a high probability of abstinence. The authors also found African Americans and men were significantly less likely to become abstinent. For the majority of the people (63.6%), crack use was uninterrupted by extended periods of abstinence during the study. From this study it appears that crack cocaine use that persists for a decade or longer may well be the norm for a large proportion of people who have experience with the drug. Falck, R., Wang, J., and Carlson, R. Crack Cocaine Trajectories among Users in a Midwestern American City. Addiction, 102(9), pp. 1421-1431, 2007.

Impact of Behavioral Contingency Management Intervention on Coping Behaviors and PTSD Symptom Reduction in Cocaine-addicted Homeless

The purpose of this study was to examine changes in post-trauma symptoms among 118 homeless cocaine-dependent adults participating in a randomly controlled trial studying effective treatments for dually diagnosed homeless individuals. Among those with trauma exposure and PTSD symptoms, the group receiving more behaviorally intensive, contingency management treatment had significantly greater reductions in PTSD symptomatology than did the group receiving less-intensive treatment. Regression analyses revealed that greater positive distraction coping and lower negative avoidance coping at baseline, in addition to changes in avoidance coping over the 6-month study period, were significantly related to greater symptom and severity reductions. The study provides some initial evidence of important treatment outcomes other than abstinence in addiction-related interventions. Lester, K., Milby, J., Schumacher, J., Vuchinich, R., Person, S., and Clay, O. Impact of Behavioral Contingency Management Intervention on Coping Behaviors and PTSD Symptom Reduction in Cocaine-addicted Homeless. J Trauma Stress, 20(4), pp. 565-575, 2007.

Toward Cost-Effective Initial Care for Substance-Abusing Homeless

In a randomized controlled trial, behavioral day treatment, including contingency management (CM (+)), was compared to contingency management components alone (CM). All 206 cocaine-dependent homeless participants received a furnished apartment with food and work training/employment contingent on drug-negative urine tests. CM (+) also received cognitive-behavioral therapy, therapeutic goal management, and other intervention components. Results revealed that CM (+) treatment attendance and abstinence were not significantly different from CM during 24 weeks of treatment. After treatment and contingencies ended, however, CM (+) showed more abstinence than CM, indicating a delayed effect of treatment from 6 to 18 months. CM (+) had more consecutive weeks abstinent across 52 weeks, but not during active treatment. The researchers concluded that 1) CM alone may be viable as initial care for cocaine-dependent homeless persons; 2) since CM(+) yields more durable abstinence, it may be appropriate as stepped-up care for clients not responding to CM. Milby, J., Schumacher, J., Vuchinich, R., Freedman, M., Kertesz, S., and Wallace, D. Toward Cost-effective Initial Care for Substance-abusing Homeless. J. Subst. Abuse Treat., 34(2), pp. 180-191, 2008.

Provider-Level Effects on Psychiatric Inpatient Length of Stay for Youth with Mental Health and Substance Abuse Disorders

Previous research on inpatient care for children and adolescents with emotional or behavioral problems indicates that patient-level factors predict length of stay (LOS) poorly. This analysis examines whether patient-level factors are poor predictors of LOS, because LOS is primarily determined by facilities rather than patients. This study uses Tennessee Medicaid claims data from 1996 to 2001. The data include information on 14,162 observations related to 8,400 patients (age 12-21) from 163 hospitals. The researchers estimate log LOS using a cross-classified model. Covariates include admission-level characteristics (age, diagnosis, qualification for Medicaid, year), patient-level characteristics (gender, race), and facility characteristics (facility type). Results suggest that variation in LOS is attributable to facility-level factors (51%), time-invariance patient-level factors (5%), factors that vary across admissions (42%), and a correlation between patient-level and facility-level factors (5%). About half of the variation in LOS is explained by facility-level factors. Given the vulnerable nature of youth who are in need of inpatient psychiatric care, it may be particularly important to monitor provider-level processes and outcomes. Gifford, E. J., and Foster, E. M. Provider-level Effects on Psychiatric Inpatient Length of Stay for Youth with Mental Health and Substance Abuse Disorders. Med Care, 46 pp. 240-246, 2008.

Substance Abuse Treatment Provider Views of "Culture": Implications for Behavioral Health Care in Rural Settings

Mandates for culturally competent substance abuse and mental health services call for behavioral health providers to recognize and engage cultural issues. These efforts to incorporate culture typically focus on client culture, but provider views of culture can also influence the provision of services. Analysis of 42 semi-structured interviews with behavioral health providers suggests that culture is considered by many to be an obstacle to help seeking and treatment of substance-abusing youth. Although some providers do not highlight cultural issues, others conceptualize culture in terms of (a) generalized Hispanic cultural attributes, (b) male-dominant gender roles, and (c) the culture of poverty. Quintero, G.A., and Lilliott, E. Substance Abuse Treatment Provider Views of "Culture": Implications for Behavioral Health Care in Rural Settings. Qual. Health Res., 17(9), pp. 1256-1267, 2007.

Exposure to Secondhand Smoke At Home and in Public Places in Syria: A Developing Country's Perspective

This study employs sensitive methods to address the issue of exposure to secondhand smoke among children and women in an understudied developing country setting (Syria). The study combines data collected by the Syrian Center for Tobacco Studies as part of two international studies conducted in 2006: by Johns Hopkins and the Roswell Park Cancer Institute. The authors employed objective measures (hair nicotine, and ambient household nicotine assessed by passive monitors) to assess children's and mother's exposure to secondhand smoke at home, and used the TSI SidePak personal aerosol monitor to sample respirable suspended particles less than 2.5 micron diameter (PM(2.5)) in the air in public places (40 restaurants/cafes in Aleppo). Mean level of hair nicotine was 11.8 ng/mg among children (n = 54), and was higher if the mother was a smoker (19.4 +/- 23.6 ng/mg) than nonsmoker (5.2 +/- 6.9 ng/mg) (p < .05). Children's hair nicotine level was strongly correlated with ambient household nicotine and number of cigarettes smoked daily in the house (r = .54 and r = .50, respectively, p < .001), and also was related to having a father who smoked in the children's presence. In public places, average PM(2.5) in the monitored 40 hospitality venues was 464 microg/m(3) and correlated with smoker density measured as cigarettes-waterpipes/100 m(3) (r = .31, p = 0.049). Thus, children in Syria are exposed to high levels of secondhand smoke at home, in which mothers smoking plays a major role. Also, levels of respirable hazardous particles are high in public hospitality venues, putting customers and workers at serious health risks. Maziak, W., Ali, R., Fouad, M., Rastam, S., Wipfl, H., Travers, M., Ward, K., and Eissenberg, T. Exposure to Secondhand Smoke at Home and in Public Places in Syria: A Developing Country 's Perspective. Inhal. Toxicol., 20(1), pp. 17-24, 2008.

Exploring Drug Users Attitudes and Decisions Regarding Hepatitis C (HCV) Treatment in the U.S.

Individuals with a history of injecting drugs are at the highest risk of becoming infected with the hepatitis C virus (HCV), with studies of patients in methadone maintenance treatment programmes (MMTP's) reporting that 60-90 percent of intravenous drug users (IDUs) have the virus. Fortunately, HCV therapy has been shown to be effective in 42-82 percent of all patients with chronic HCV infection, including IDUs. While the decision to start HCV therapy requires significant consideration, little research exists that explores the attitudes of drug users toward HCV therapy. Therefore, this paper examines how drug users perceive the treatment, as well as the processes by which HCV-positive individuals examined the advantages and disadvantages of starting the HCV medications. Interviews were conducted with 164 patients from 14 drug treatment programs throughout the United States, and both uninfected and HCV-positive drug users described a pipeline of communication among their peers that conveys largely negative messages about the medications that are available to treat HCV. Although many of the HCV-positive individuals said that these messages heightened their anxiety about the side effects and difficulties of treatment, some patients said that their peers helped them to consider, initiate HCV treatment or both. Gaining a better understanding of drug users' perceptions of HCV treatment is important, because so many of them, particularly IDUs, are already infected with HCV and may benefit from support in addressing their HCV treatment needs. In addition, currently uninfected drug users will likely remain at high risk for contracting HCV and may need to make decisions about whether or not to start the HCV medical regimen in the future. Munoz-Plaza, C.E., Astone-Twerell, J., Des Jarlais, D., Gwadz, M., Hagan, H., Osborne, A., and Rosenblum, A. Exploring Drug Users Attitudes and Decisions Regarding Hepatitis C (HCV) Treatment in the U.S. Int. J. Drug Policy, 19 pp. 71-78, 2008.

A Behavioral Treatment for Opioid-dependent Patients with Antisocial Personality

Antisocial personality disorder (APD) is associated with increased problem severity in treatment-seeking opioid-dependent patients. Treatment studies have reported mixed results but generally show that patients with APD make progress that is often comparable to drug dependent patients without the personality disorder. Much of this work is based on secondary analyses of studies evaluating responses to a variety of drug abuse treatment interventions. This study reports on a randomized prospective trial evaluating a behavioral approach for managing opioid-dependent patients with APD. Subjects (N = 100) met Diagnostic and Statistical Manual of Mental Disorders criteria for opioid dependence and APD using a structured clinical interview and were randomly assigned to either an experimental condition (n = 51), which used a highly structured contingency management intervention, or a control condition (n = 49), which reflected standard methadone treatment. Subjects in the experimental group had significantly better counseling attendance and some indication of lower psychosocial impairment compared to the control group. The experimental intervention increased attendance in subjects with low and high levels of psychopathy and with and without other psychiatric comorbidity. These findings support the development of interventions more tailored to drug-dependent patients with APD. Neufeld, K.J., Kidorf, M.S., Kolodner, K., King, V.L., Clark, M., and Brooner, R.K. A Behavioral Treatment for Opioid-dependent Patients with Antisocial Personality. J. Subst. Abuse Treat., 34, pp. 101-111, 2008.

A Ten-Year Analysis of the Incidence and Risk Factors for Acute Pancreatitis Requiring Hospitalization in an Urban HIV Clinical Cohort

To assess the incidence of and risk factors for acute pancreatitis in HIV-infected patients in the contemporary highly active antiretroviral therapy (HAART) era, the researchers evaluated all cases of acute pancreatitis requiring hospitalization between 1996 and 2006 in patients followed at Johns Hopkins Hospital's HIV clinic. A nested, case-control analysis was employed for initial episodes of acute pancreatitis, and conditional logistic regression was used to assess risk factors. Of 5,970 patients followed for 23,460 person-years (PYs), there were 85 episodes of acute pancreatitis (incidence: 3.6 events/1000 PYs). The incidence of pancreatitis from 1996 to 2000 was 2.6 events/1000 PYs; the incidence from 2001 to 2006 was 5.1 events/1000 PYs (p= 0.0014, comparing rates in two time periods). In multivariate regression, factors associated with pancreatitis included female gender (adjusted odds ratio [AOR] 2.96 [1.69, 5.19]; p< 0.001); stavudine use (AOR 2.19 [1.16, 4.15]; p 0.016); aerosolized pentamidine use (OR 6.27; 1.42, 27.63]; p 0.015); and CD4 count less than 50 cells/mm3 (AOR 10.47 [3.33, 32.90]; p<0.001). Race/ethnicity, HIV risk factor, HIV-1 RNA, and newer non-nucleoside reverse transcriptase inhibitors (NNRTI) - and protease inhibitor (PI)-based HAART regimens were not associated with an increased risk of pancreatitis after adjustment for the above factors. Pancreatitis remains a significant cause of morbidity in the HIV population in the HAART era. Acute pancreatitis is associated with female gender, severe immunosuppression, and stavudine and aerosolized pentamidine usage. Newer anti-retrovirals, articularlyatazanavir, lopinivir/ritonavir, tenofovir, abacavir, and efavirenz, were not associated with an increased risk of pancreatitis. Riedel, D.J., Gebo, K.A., Moore, R.D., and Lucas, G.M. A Ten-Year Analysis of the Incidence and Risk Factors for Acute Pancreatitis Requiring Hospitalization in an Urban HIV Clinical Cohort. AIDS Patient Care STDS, 22(2), pp. 113-121, 2008.

Uncovering Patterns of HIV Risk Through Multiple Housing Measures

Understanding the relationships between housing and HIV has been limited by reliance on a single housing indicator based on current living arrangements (e.g., stable, unstable, or homeless). This paper examines the cross-sectional and longitudinal relationships between five housing indicators (objective housing stability, subjective housing stability, supportive housing, number of residences in the last 6 months, and housing services needs) and four HIV risk behaviors (hard drug use, needle sharing, sex exchange, and unprotected intercourse) among women at-risk for HIV and with recent criminal justice system involvement (n = 493). In cross-sectional analyses, each risk behavior was associated with multiple indicators of poor housing, and the patterns of association varied by risk behavior. In the longitudinal analyses, changes in risk behavior were associated with changes in housing status since the previous assessment. These indicators reflect different aspects of housing and are uniquely associated with different risk behaviors. The relationships between housing and HIV risk are complex, and both constructs must be recognized as multidimensional. Weir, B.W., Bard, R.S., O'Brien, K., Casciato, C.J., and Stark, M.J. Uncovering Patterns of HIV Risk Through Multiple Housing Measures. AIDS Behav., 11 pp. S31-S44, 2007.

It is More Than the Money: Adolescents with Substance Use Problems Have Many Reasons for Participating in Research

The authors of this paper examined reasons why adolescents with substance use problems continued to participate in follow-up interviews. The sample consisted of 145 adolescents between the ages of 12 and 18, who completed an outcome study following outpatient treatment for substance use. Participants were asked to report on 18 possible reasons for continued participation. Adolescents' top reason for continued participation was financial compensation; however, a high percentage of adolescents responded favorably to several other attitudinal questions concerning their follow-up participation, suggesting that the adolescents had a primarily positive view of their research experience and that reasons for research participation are multidimensional. Reasons other than financial compensation that were reported include fulfillment of a commitment, wanting to help others, and the perception that the research was important and credible. Garner, B.R., Passetti, L.L., Orndorff, M.G., and Godley, S.H. Reasons for and Attitudes Toward Follow-Up Research Participation Among Adolescents Enrolled in an Outpatient Substance Abuse Treatment Program. Journal of Child and Adolescent Substance Abuse, 164(4), pp. 45-58, 2007.

Decline in Availability of Tailored Outpatient Care for Women from 1995 to 2005

Tailoring substance abuse treatment to women often leads to better outcomes. This investigation sought to depict recent changes in outpatient substance abuse treatment (OSAT) tailoring to women. Data were from 2 waves of a national OSAT unit survey (N = 618 in 1995, N = 566 in 2005). Multiple logistic regressions with generalized estimating equations test associations between unit and contextual attributes and tailoring to women. Two measures of tailoring to women declined significantly between 1995 and 2005: availability of single sex therapy (from 66% to 44% of units) and percent of staff trained to work with women (from 42% to 32% of units). No aspect of tailoring to women became more common. Methadone treatment (O.R. =2.3; p<.001), and private for-profit status (O.R. = .23 to .49; p<.01) and government managed care financing (O.R. = 3.64; p<.001) were associated with higher odds of tailoring to women. Campbell, C., Wells, R., Alexander, J., Jiang, L., Nahra, T., and Lemak, C. Tailoring of Outpatient Substance Abuse Treatment To Women, 1995-2005. Med. Care, 45(8), pp. 775-780, 2007.

Psychometrics of the Inmate Prerelease Assessment for Reentry Planning

The Inmate Prerelease Assessment (IPASS) was developed specifically as a measure of post-release risk for prison-based treatment graduates. By taking into account historical drug use and criminal activity of inmates as well as their performance during prison-based treatment, the IPASS provides a "priority" score indicating the relative need for more (versus less) intensive treatment services on release. The present study used data from offenders paroling from prisons in a southwest (N = 127) and Midwest (N = 75) state to examine the psychometric properties of the IPASS subscales. With regard to construct validity, psychometric properties ranged from good to excellent. The IPASS scales also showed strong internal consistency, with coefficient alphas greater than .80 for the Texas Christian University Drug Screen, Client Evaluation of Treatment, and Counselor Evaluation of Client scales. Further research will explore alternatives on how the Client and Counselor scales are optimally incorporated into the IPASS priority score and will examine the score in relation to aftercare participation and post-release outcomes Farabee, D., Knight, K., Garner, B. R., and Calhoun, S. The Inmate Prerelease Assessment for Reentry Planning. Criminal Justice and Behavior, 34(9), pp. 1188-1197, 2007.

A Validation Study of the Co-Occurring Disorders Screening Instrument For Mental Disorders Developed Under the Criminal Justice Drug Abuse Treatment Studies

Three standardized screening instruments--the Global Appraisal of Individual Needs Short Screener, the Mini-International Neuropsychiatric Interview-Modified, and the Mental Health Screening Form (MHSF)--were compared to two shorter instruments, the 6-item Co-Occurring Disorders Screening Instrument for Mental Disorders (CODSI-MD) and the 3-item CODSI for Severe Mental Disorders (CODSI-SMD) for use with offenders in prison substance abuse treatment programs, which was developed as part of the Criminal Justice Drug Abuse Treatment Studies (CJDATS). Results showed that the CODSI screening instruments were comparable to the longer instruments in overall accuracy and that all of the instruments performed reasonably well. The CODSI instruments showed sufficient value to justify their use in prison substance abuse treatment programs and to warrant validation testing in other criminal justice populations and settings. Sacks, S., Melnick, G., Coen, C., Banks, S., Friedmann, P.D., Grella, C., Knight, K., and Zlotnick, C. CJDATS Co-Occurring Disorders Screening Instrument For Mental Disorders: A Validation Study. Criminal Justice and Behavior, 34(9), pp. 1198-1215, 2007.

Screening for Substance Abuse Lags Behind Screening for Mental Health Disorders in Private Managed Care Health Plans

Epidemiological data suggest that mental health and substance use conditions are under-recognized and under-treated. There are several strategies that private health plans can use in their managed care products to increase screening rates for these conditions, and this study examines the extent to which selected strategies were used by health plans in 2003. Data are from a survey of a nationally-representative sample of health plans representing 812 products. Results were weighted to produce national estimates. Plans were asked about whether or not they verify health care providers' screening for these conditions or distribute practice guidelines. (Plans were also asked about their use of screening outside of primary care, for example through member surveys, but the results were not given separately for substance abuse). The study found relatively lower rates of use of these strategies for substance abuse compared with mental health. Overall, 52.4% of the products used no strategies to screen for substance abuse conditions, compared with only 19.2% that used no strategies for mental health screening. Only eight percent of products verify primary care providers' screening for substance abuse, while 34% of products verify it for mental health. Only 33% distributed practice guidelines for substance abuse compared with 78% for mental health. Increases in the use of these strategies may lead to higher rates of identification of these disorders, which may lead to higher rates of entry into treatment, and ultimately, higher rates of recovery. Garnick, D., Horgan, C., Merrick, E., and Hoyt, A. Identification and Treatment of Mental and Substance Use Conditions: Health Plans Strategies. Med. Care, 45(11), pp. 1060-1067, 2007.

Evidence that the Dimensions of Change Instrument (DCI) is Valid for Monitoring Adult Progress in Therapeutic Communities

The Dimensions of Change Instrument (DCI) measures treatment process in residential therapeutic community (TC) settings. It summarizes eight factors of treatment process from a client perspective. Results present evidence of the reliability of the DCI for assessing both adult (N = 519) and adolescent (N = 474) client perceptions of treatment process. The DCI factors significantly increased over time, with increases consistently seen across all DCI factors for adults. Findings show that clinicians can use the DCI to evaluate adult client progress and target areas for improving quality of care in TC settings. Paddock, S., Edelen, M., Wenzel, S., Ebener, P., Mandell, W., and Dahl, J. Measuring Changes in Client-Level Treatment Process in The Therapeutic Community (TC) with The Dimensions of Change Instrument (DCI). Am. J. Drug Alcohol Abuse, 33(4), pp. 537-546, 2007.

Health Plans Place More Restrictions on Buprenorphine Coverage than on the Coverage of Prescription Drugs for Alcohol Disorders

This paper describes results from a nationally-representative telephone survey of health plan managers (including medical directors) that assessed restrictions on plan member access to prescription medications for substance abuse disorders, including buprenorphine. These restrictions included formulary exclusions, prior authorization requirements, and placing these medications on higher cost-sharing tiers. Information was collected in 2003 on 347 health plans (83% response rate) representing 812 distinct insurance products. Weights were used to generate national estimates. The results reveal that buprenorphine was excluded from the formularies of 31% of health products, although this varied by product type. For example 45% of point of service plans (POS) excluded buprenorphine from their formularies, compared with 38% of health maintenance organizations (HMOs) and 5.9% of preferred provider organizations (PPO's). These proportions also varied by whether or not the health product used a pharmacy benefits manager - only 9.5% of products with a pharmacy benefits manager excluded these prescription drugs from the formulary compared with 55.2% of products without one. The overall rate of formulary exclusion of buprenorphine is much higher than the exclusion rates of disulfiram (1.3%), generic naltrexone (6.2%), and branded naltrexone (6.4%). Among products that include these drugs in their formularies, 79.5% of the products restricted buprenorphine to the most costly cost-sharing tier, compared with 28% for disulfiram, 1.6% for generic naltrexone, and 44% for branded naltrexone (44.2%). Prior authorization was also higher for buprenorphine. Approximately 7% of products covering buprenorphine required prior authorization, compared with 0.4-2.7% of plans covering prescription drugs for alcohol disorders. The authors speculate that coverage of buprenorphine may be restricted either because it is a relatively new drug, having been approved by the FDA only a year before the data were collected, or because the demand for the drug by health plan purchasers and enrollees is low, making restrictions less risky for health plans. Horgan, C., Reif, S., Hodgkin, D., Garnick, D., and Merrick, E. Availability of Addiction Medications in Private Health Plans. J. Subst. Abuse Treat., 34(2), pp. 147-156, 2008.

The Latent Structure of Substance Use Disorders: National Data

To better understand the underlying concepts of substance dependence and abuse, the authors examine the factor structure of DSM-IV lifetime criteria for cannabis and cocaine use disorders. Data for this study were drawn from the National Longitudinal Alcohol Epidemiologic Survey (NLAES), a large nationally representative U.S. sample aged 18 years and older. Exploratory factor analysis (EFA) examined the factor structure for each substance and the factors were related to background covariates using latent variable modeling techniques. Separate analyses were conducted for lifetime marijuana and cocaine users. A two-factor solution was identified for each substance and was similar to DSM-IV abuse and dependence. The factors were highly correlated for both cannabis (r = 0.73) and cocaine (r = 0.77). Background variables accounted only for a modest amount of factor variance. In conjunction with the findings in alcohol use disorders, these results support the use of consistent criteria across substances in DSM-IV and ICD-10, and suggest that the consistent finding of two correlated factors across substances needs to be better understood. Blanco, C. Harford, T.C., Nunes, E., et al. The Latent Structure of Marijuana and Cocaine Use Disorders: Results from the National Longitudinal Alcohol Epidemiologic Survey (NLAES). Drug and Alcohol Dependence, 91, pp. 91-96, 2007.

Factors Associated with Sustained Recovery, Higher Quality of Life, and Lower Stress

Many recovering persons report quitting their drug use because they are "sick and tired" of the drug life. Recovery is the path to a better life, but that path is often challenging and stressful. There has been little research on the millions of recovering persons in the United States, and most research has focused on substance use outcomes rather than on broader functioning domains. This study builds on the authors' previous cross-sectional findings that recovery capital (social supports, spirituality, religiousness, life meaning, and 12-step affiliation) enhances the ability to cope with stress and enhances life satisfaction. This study (a) tests the hypothesis that higher levels of recovery capital prospectively predict sustained recovery, higher quality of life, and lower stress one year later, and (b) examines the differential effects of recovery capital on outcomes across the stages of recovery. Recovering persons (N = 312), mostly inner-city ethnic minority members whose primary substance had been crack or heroin, were interviewed twice at a one year interval in New York City between April 2003 and April 2005. Participants were classified into one of four baseline recovery stages: under 6 months, 6-18 months, 18-36 months, and over 3 years. Multiple regression findings generally supported the central hypothesis and suggested that different domains of recovery capital were salient at different recovery stages. The study's limitations are noted and implications of findings for clinical practice and for future research are discussed, including the need for a theoretical framework to elucidate the recovery process. Laudet, A.B., and White, W. Recovery Capital as Prospective Predictor of Sustained Recovery, Life Satisfaction, and Stress among Former Poly-Substance Users. Substance Use & Misuse, 43, pp. 27-54, 2008.

Improving Linkage to Addiction Treatment: Case Management Superior to Motivational Interviewing

Poor linkage with substance abuse treatment remains a problem, negating the benefits that can accrue to both substance abusers and the larger society. Numerous behavioral interventions have been tested to determine their potential role in improving linkage. This study reports the results of a randomized clinical trial of 678 substance abusers that compared the linkage effect of two brief interventions with the referral standard of care (SOC) at a centralized intake unit (CIU). Interventions included five sessions of strengths-based case management (SBCM) or one session of motivational interviewing (MI). A priori hypotheses predicted that both interventions would be better than the standard of care in predicting linkage and that SBCM would be more effective than MI. The authors analyzed the effect of the two interventions on overall treatment linkage rates and by treatment modality. Logistic regression analysis examined predictors of treatment linkage for the sample and each group. Two hypotheses were confirmed in that SBCM (n=222) was effective in improving linkage compared to the SOC (n=230), 55.0% vs. 38.7% (p<.01). SBCM improved linkage more than MI (55.0% vs. 44.7%, p<.05). Motivational interviewing (n=226) was not significantly more effective in improving linkage than the standard of care (44.7% vs. 38.7%; p>.05). The three trial groups differed only slightly on the client characteristics that predicted linkage with treatment. The results of this study confirm a body of literature that supports the effectiveness of case management in improving linkage with treatment. The role of motivational interviewing in improving linkage was not supported. Results are discussed in the context of other case management and motivational interviewing linkage studies. Rapp, R., Otto, A., Lane, D., Redko, C., McGatha, S., and Carlson, R. Improving Linkage with Substance Abuse Treatment Using Brief Case Management and Motivational Interviewing. Drug Alcohol Depend., 94(1-3), pp. 172-182, 2008.

Substance Abuse Treatment May Be Sufficient for Those with Mild Mental Health Symptoms

This article reviews the literature on the prevalence of co-occurring disorders in the substance abuse treatment system, and on the effects of single and integrated treatments on that population. It suggests that although prevalence of mental disorders is likely substantially higher in the substance abuse treatment population than in the general population, it is not clear that requiring that each individual with a co-occurring disorder receive integrated treatment is necessary, and in fact may not be possible given current funding constraints and scarcity of highly-educated treatment professions who are able to provide integrated treatment. It does suggest that screening for mental health disorders by substance abuse treatment providers may be useful, after clients have become abstinent, so that tailored treatments can be targeted to the more severely mentally ill, which research shows can benefit from the addition of psychotherapy to substance abuse counseling. Screening might also be useful in discharge planning, as those with co-occurring disorders appear to have much higher rates of relapse and may be especially able to benefit from follow-up care that addresses the chronicity of the disorder. Flynn, P.M., and Brown, B.S. Co-occurring Disorders in Substance Abuse Treatment: Issues and Prospects. J Subst. Abuse Treat., 34, pp. 36-47, 2008.

Outcomes in Syria's First Smoking Cessation Trial

This study was undertaken to determine the feasibility of implementing cessation interventions in Syria. The authors randomized 50 smokers to either a brief or intensive behavioral cessation intervention. Adherence to treatment and cessation through 3 months post-cessation were calculated. It was found that adherence in the intensive group was only moderate and was associated with smoking for more years and higher self-efficacy. Cessation rates in the brief and intensive intervention groups were 16% and 4%, respectively. Nicotine dependence predicted abstinence at 3 months. This study shows that important barriers to cessation included perceived dependence, lack of access to pharmacotherapy, poor social support, and water pipe smoking. Asfar, T., Weg, M., Maziak, W., Hammal, F., Eissenberg, T., and Ward, K. Outcomes in Syria's First Smoking Cessation Trial. Am. J. Health Behav., 32(2), pp. 146-156, 2008.

Results of RCTs May Be Externally Valid

This study compared abstinence rates at 6 and 12 months for 4 groups of treatment seeking commercially-insured HMO members meeting most or all of the criteria for ASAM Level III treatment: Those randomized to day hospital (n=154) or community residential treatment (n=139); those self-selected into day hospital (n=321); and those directed to residential treatment because of high environmental risks (n=82). A multivariate random-effects logistic regression model, which included group dummies, group x time interactions, baseline ASI scores and other measures, yielded no difference in abstinence rates by group. Variables that were significantly associated with lower abstinence rates included ASI drug severity scores and number of lifetime treatment episodes, while age, number of index episode treatment days, and number of 12-step meeting days were associated with higher abstinence rates. These results suggest that concerns in the literature about the external validity of trials that randomize clients to different treatment settings requiring different levels of treatment intensity (e.g. clients who agree to be randomized may have different prognoses than the average client in treatment; having a say in the treatment decisions may affect prognosis) may not be valid for this specific population of clients. Witbrodt, J., Bond, J., Kaskutas, L., Weisner, C., Jaeger, G., Pating, D., and Moore, C. Day Hospital and Residential Addiction Treatment: Randomized and Nonrandomized Managed Care Clients. J. Consult. Clin. Psychol., 75(6), pp. 947-959, 2007.

Co-occurring Mental Health Problems are Common for Both Adolescents and Adults in Addiction Treatment

As the field follows recommendations to introduce standardized assessments on substance, mental and behavioral problems, a consistent picture has emerged that co-occurring disorders are common, that there is heterogeneity in the type of disorder, and that the pattern varies by age. This paper examines the prevalence of self-reported substance use and mental health problems, the pattern of comorbidity, and how both vary by age among people presenting to substance abuse treatment. The authors analyzed data from a sample of 4,939 adolescents and 1,958 adults presenting to substance abuse treatment in multi-site studies who were assessed with the Global Appraisal of Individual Needs (GAIN) and categorized into five age groups: age <15, 15-17, 18-25, 26-39, and 40+. Two thirds of clients had a co-occurring mental problem in the year prior to treatment admission. Across all ages, clients self-reporting criteria for past-year substance dependence were more likely than those who did not to have other co-occurring mental health problems (odd ratios of 2.9 to 8.8). The prevalence and patterns of co-occurring mental health problems however, varied by age. Young adults (age 18-25) were found to be most vulnerable to co-occurring problems. Chan, Y., Dennis, M.L., and Funk, R.R. Prevalence and Comorbidity of Major Internalizing and Externalizing Problems among Adolescents and Adults Presenting to Substance Abuse Treatment. J. Subst. Abuse Treat., 34(1), pp. 14-24, 2008.

Using Mediational Models to Explore the Nature of Tobacco Motivation and Tobacco Treatment Effects

Various theories have proposed mechanisms for drug motivation and relapse. For instance, negative reinforcement theories focus on the alleviation of withdrawal. However, other theories and some data cast doubt on the importance of withdrawal as a motivator of addictive drug use. Using data from a randomized double-blind placebo-controlled smoking cessation treatment study (N=608), this research examined the impact of withdrawal on drug motivation and the ability to maintain abstinence. Withdrawal was experimentally manipulated by randomly assigning participants to receive active bupropion versus placebo. Mediation analyses revealed that active bupropion reduced the amount of withdrawal and craving that individuals reported in the 1st week post quit; modest support was also found for smaller declines in positive affect. These effects, in turn, were all positively associated with post-treatment abstinence. These results implicate withdrawal as an important factor in motivating persistent tobacco use. Piper, M., Federmen, E., McCarthy, D., Bolt, D., Smith, S., Fiore, M., and Baker, T. Using Mediational Models to Explore The Nature of Tobacco Motivation and Tobacco Treatment Effects. J. Abnorm. Psychol., 117(1), pp. 94-105, 2008.

State Level Factors Related to Establishing Tobacco Cessation Quit Line

Quit line services are an effective population-wide tobacco cessation strategy adopted widely in the United States as part of state comprehensive tobacco control efforts. Despite widespread evidence supporting quit lines' effectiveness, many states lack sufficient financial resources to adequately fund and promote this service. Efforts to augment state tobacco control efforts might be fostered by greater knowledge of state level factors associated with the funding and implementation of those efforts. The authors analyzed data from the 2004 North American Quitline Consortium survey and from publicly available sources to identify state level factors related to quitline implementation and funding. Factors included in the analyses were state demographic characteristics, tobacco use variables, state tobacco control spending, and economic and political climate variables. Univariate and multivariate regression analyses were conducted. It was found that the best fitting multivariate model that significantly predicted the presence or absence of a state quitline included only cigarette excise tax rate (p = 0.020). In terms of funding levels, states with high rates of cigarette consumption (p = 0.047) and with higher per capita expenditures for tobacco control programs (p = 0 .0.004) were most likely to spend more on per capita operations budget for quitlines. From this study it is shown that state level factors appear to play a part in whether states had established quitlines by mid-2004 and the amount of per capita quitline funding. It was also shown that only cigarette excise tax predicted the presence or absence of a quitline in a state. Keller, P., Koss, K., Baker, T., Bailey, L., and Fiore, M. Do State Characteristics Matter? State Level Factors Related to Tobacco Cessation Quitlines. Tob. Control, 16 Suppl 1, pp. i75-i80, 2007.

Predictors of Bacterial Infections Among HCV-Negative Injection Drug Users in Rhode Island

The prevalence and risk factors for treated bacterial infections (i.e., skin abscess or cellulitis, osteomyelitis, or endocarditis) were investigated among a community sample of drug users with a history of injection drug use (IDU) who tested negative for Hepatitis C (HCV). Participants were IDUs in an HCV reduction intervention trial followed for 24 months. Among 109 participants, 9.2% reported a bacterial infection during follow-up. Non-Caucasian participants and those who had injected for longer periods at baseline were less likely to experience a bacterial infection at follow-up. IDUs with no history of HCV infection experience bacterial infections, but at lower rates than other IDU cohorts. This paper shows that behavioral interventions should target bacterial infections as well as HCV or HIV prevention outcomes. Phillips, K., Anderson, B., and Stein, M. Predictors of Bacterial Infections Among HCV-Negative Injection Drug Users in Rhode Island. Am. J. Drug Alcohol Abuse, 34(2), pp. 203-210, 2008.

A Rasch Model Analysis of Evidence-Based Treatment Practices Used in the Criminal Justice System

This study used item response theory (IRT) to examine the extent to which criminal justice facilities and community-based agencies are using evidence-based substance abuse treatment practices (EBP's), which EBPs are most commonly used, and how EBP's cluster together. The study used data collected from wardens, justice administrators, and treatment directors as part of the National Criminal Justice Treatment Practices survey (NCJTP), and includes both adult criminal and juvenile justice samples. Results of Rasch modeling demonstrated that a reliable measure can be formed reflecting the extent to which juvenile and adult correctional facilities, and community treatment agencies serving offenders, have adopted various treatment practices supported by research. Results also demonstrated the concurrent validity of the measure by showing that features of the facilities' organizational contexts were associated with the extent to which facilities were using EBP's, and which EBP's they were using. Researchers, clinicians, and program administrators may find these results interesting not only because they show the program factors most strongly related to EBP use, but the results also suggest that certain treatment practices cluster together, which may help stakeholders plan and prioritize the adoption of new EBP's in their facilities. Henderson, C.E., Taxman, F.S., and Young, D.W. A Rasch Model Analysis of Evidence-Based Treatment Practices Used in the Criminal Justice System. Drug Alcohol Depend., 93 pp. 163-175, 2008.

Drug Use Expectancies Among Non-abstinent Community Cocaine Users

Previous research has shown that one's expectations about the effects of using a particular substance (i.e., substance use expectancies) are associated with the quantity and frequency of actual use. An extensive literature supports the importance of expectancies in predicting alcohol use, but less is known about the association between expectancies and use of other substances. The purpose of the present investigation was to examine the association between cocaine expectancies and frequency of use in a heterogeneous community sample of drug users. Participants were 157 self-identified primary cocaine users recruited from the community as part of a hepatitis prevention study. Participants completed a structured interview that assessed demographic variables, current and past drug use, and drug expectancies. Results from multivariate logistic regression analyses indicated that frequency of cocaine use was positively associated with higher expectation that drug use would increase social and physical pleasure (OR=1.67, p<0.05) and inversely associated with higher expectation that drug use would increase cognitive and physical impairment (OR=0.59, p<0.01). These findings suggest that drug use expectancies are an important correlate of cocaine use behavior in non-treatment-seeking community users. Hayaki, J., Anderson, B., and Stein, M. Drug Use Expectancies Among Non-abstinent Community Cocaine Users. Drug Alcohol Depend., 94(1-3), pp. 109-115, 2008.

Comparison of Demographic and Clinical Characteristics Between Opioid-dependent Individuals Admitted to a Community-based Treatment Setting and Those Enrolled in a Research-based Treatment Setting

Despite the significant developments in pharmacotherapy and behavioral treatments for addiction, the dissemination of new treatment methods into the community has been slow. It has been pointed out that treatments developed in research settings may be impractical in community treatment settings, which might help explain the transition lag. Screening and recruitment of participants for research studies might partially explain this, as there is evidence that substance-abusing individuals who participate in clinical research are different on a number of measures from treatment seekers. However, no study has directly compared treatment seekers with research participants drawn from similar populations using prospective methods. This study compared the demographic characteristics, drug use and psychosocial problem severity levels, and personality traits of opioid-dependent individuals seeking help in a community setting (n = 502) with those of opioid-dependent individuals in a primarily research-based drug abuse treatment setting (n = 459); both settings offered a similar set of treatment services (opioid agonist medication and counseling). Although the overall findings revealed numerous similarities between the groups, differences were also observed. Most notably, there were significantly fewer women in the research sample than in the community-based treatment sample. Other differences included a modest but statistically significant increase in psychosocial problem severity levels in the community-based treatment sample and higher drug use problem severity levels in the research sample. Interestingly, many of these differences were strongest in women as compared with men. Carroll, C.P., Kidorf, M., Strain, E.C., and Brooner, R.K. Comparison of Demographic and Clinical Characteristics Between Opioid-dependent Individuals Admitted to a Community-based Treatment Setting and Those Enrolled in a Research-based Treatment Setting. J. Subst. Abuse Treat., 33 pp. 355-361, 2007.

Perceived Need for Substance Abuse Treatment Among Illicit Stimulant Drug users in Rural Areas of Ohio, Arkansas, & Kentucky

Non-medical drug use in rural communities in the United States is a significant and growing public health threat. Understanding what motivates drug users in rural areas to seek substance abuse treatment may help in addressing the problem. Perceived need for treatment, a construct indicative of problem recognition and belief in problem solution, has been identified as an important predictor of help-seeking behavior. This cross-sectional study used data collected through face-to-face interviews to examine factors associated with perceived need for drug abuse treatment among not-intreatment, adult, illicit stimulant drug users (n = 710) in rural areas of Ohio, Kentucky, and Arkansas. More than one-quarter of the sample perceived a need for treatment. Results from a stepwise multiple regression analysis showed that white users, users with better physical and mental health status, and occasional users of methamphetamine were significantly less likely to see a need for treatment. Users with higher Addiction Severity Index composite scores for family/social problems or legal problems, and users with prior drug abuse treatment experience were significantly more likely to perceive a need for treatment. Falck, R.S., Wang, J., Carlson, R.G., Krishnan, L.L., Leukfeld, C., and Booth, B.B. Perceived Need for Substance Abuse Treatment among Illicit Stimulant Drug Users in Rural Areas of Ohio, Arkansas, and Kentucky. Drug Alcohol Depend., 91, pp. 107-114, 2007.

Crack Cocaine Trajectories Among Users in a Midwestern American City

Although crack cocaine first appeared in cities in the United States in the mid-1980s, little is known about its use over long periods of time. This study identified crack cocaine user groups on the basis of long-term trajectories. Following a natural history approach, data were collected periodically from 1996 to 2005. Group-based modeling assessed the probability of a crack smoker becoming abstinent during the observation period. A targeted sampling plan guided the recruitment of a community sample of crack cocaine users in Dayton, Ohio. Participants were crack smokers (n = 430) 18 years or older whose urine tested positive for cocaine metabolites at the baseline interview. Interviewer-administered and audio computer self-administered, structured questionnaires were used to collect data on a range of variables, including frequency of crack use. Abstinence was defined as not having used crack for at least 6 consecutive months during the study. Three trajectory-based groups were identified: (1) No Change, characterized by a very low probability of abstinence; (2) Some Change, characterized by a low to moderate probability of abstinence; and (3) Dramatic Change, characterized by a high probability of abstinence. African Americans and men were significantly less likely to become abstinent. For the majority of the people (63.6%), crack use was uninterrupted by extended periods of abstinence during the study. The authors conclude that crack cocaine use that persists for a decade or longer may well be the norm for a large proportion of people who have experience with the drug. Falck, R.S., Wang, J., and Carlson, R.G. Crack Cocaine Trajectories among Users in a Midwestern American City. Addiction, 22(1), pp. 47-54, 2007.

Important Differences Between In-Treatment and Out Of Treatment Opioid Dependent Adults

This study compared the characteristics of opioid-addicted adults seeking (n = 169) and not seeking (n = 74) methadone treatment in Baltimore, Maryland. Participants entering treatment were recruited from six methadone treatment programs, while out-of-treatment participants were recruited from the streets using targeted sampling methods. Measures included the Addiction Severity index, a Supplemental Questionnaire, and urine drug test. Data were analyzed using ANOVA, x2, and regression, holding key background variables constant. Despite the lack of differences between the samples in demographic characteristics, the out-of-treatment sample reported significantly more days of heroin, cocaine, and alcohol use and spent significantly more money on drugs and earned more illegal income at baseline. Using ASI Composite Scores, for example, the out-of-treatment group had significantly higher mean composite scores for both drug use (respectively, .34 vs. .30, p = .008) and alcohol use (.16 vs. .06, p < .001). Finally, in terms of social functioning, the out-of-treatment group had higher composite scores for both employment (.89 vs. .82, p = .002) and legal problems (.34 vs. .30, p < .001). Schwartz, R.P., Kelly, S.M., and O'Grady, K.E. In-Treatment vs. Out-of-Treatment Opioid Dependent Adults: Drug Use and Criminal History, Am. J. Drug Alcohol Abuse, 34, pp. 17-28, 2008.

A Conceptual Framework for Child and Family Mental Health Systems

This paper describes research undertaken by the MacArthur Foundation-funded Research Network on Youth Mental Health. The authors illustrate the conceptual model that provides a framework for the research network. The project is designed to understand the challenges of implementing evidence-based treatments in community-based mental health practices. This paper describes the impetus and conceptual framework underlying one cluster of the Network's activity- i.e. the Clinic Systems Project (CSP). The CSP studies examined the organizational and service system environments in a large national sample of community mental health and affiliated organizations that provide services to children. The main goal is to identify leverage points for, and barriers to, the adoption and implementation of evidence-based practices for children. Schoenwald, S., Kelleher, K., and Weisz, J. Building Bridges to Evidence-based Practice: The MacArthur Foundation Child System and Treatment Enhancement Projects (Child STEPs). Adm. Policy Ment. Health, 35(1-2), pp. 66-72, 2008.

Opioid Receptors and Legal Highs: Salvia Divinorum and Kratom

Salvia divinorum and Mitragyna speciosa ("Kratom"), two unscheduled dietary supplements whose active agents are opioid receptor agonists, have discrete psychoactive effects that have contributed to their increasing popularity. Salvia divinorum contains the highly selective kappa- opioid receptor agonist salvinorin A; this compound produces visual hallucinations and synesthesia. Mitragynine, the major alkaloid identified from Kratom, has been reported as a partial opioid agonist producing similar effects to morphine. An interesting minor alkaloid of Kratom, 7-hydroxymitragynine, has been reported to be more potent than morphine. Both Kratom alkaloids are reported to activate supraspinal mu- and delta- opioid receptors, explaining their use by chronic narcotics users to ameliorate opioid withdrawal symptoms. Despite their widespread Internet availability, use of Salvia divinorum and Kratom represents an emerging trend that escapes traditional methods of toxicological monitoring. This article elaborates on current internet trends, and provides information for toxicologists and poison control specialists with these emerging psychoactive dietary supplements. Babu, K., McCurdy, C., and Boyer, E. Opioid Receptors and Legal Highs: Salvia Divinorum and Kratom. Clin. Toxicol. (Phila), 46(2), pp. 146-152, 2008.