Research Findings - Services Research

Optimal Amounts of Counseling Plus Buprenorphine-Naloxone Maintenance Therapy for Opioid Dependence

In this study published in the New England Journal of Medicine, the authors determined the optimal level of counseling and frequency of clinic attendance for medication distribution in primary care practices engaged in office-based buprenorphine-naloxone treatment of opioid dependence. The study was conducted as a 24-week randomized, controlled clinical trial with 166 patients assigned to one of three treatments: standard medical management and either once-weekly or thrice-weekly medication dispensing or enhanced medical management and thrice-weekly medication dispensing. Standard medical management was brief, manual-guided, medically focused counseling; enhanced management was similar, but each session was extended. The primary outcomes were the self-reported frequency of illicit opioid use, the percentage of opioid-negative urine specimens, and the maximum number of consecutive weeks of abstinence from illicit opioids. It was found that the three treatments had similar efficacies with respect to the mean percentage of opioid-negative urine specimens (standard medical management and once-weekly medication dispensing, 44 percent; standard medical management and thrice-weekly medication dispensing, 40 percent; and enhanced medical management and thrice-weekly medication dispensing, 40 percent; P=0.82) and the maximum number of consecutive weeks during which patients were abstinent from illicit opioids. All three treatments were associated with significant reductions from baseline in the frequency of illicit opioid use, but there were no significant differences among the treatments. The proportion of patients remaining in the study at 24 weeks did not differ significantly among the patients receiving standard medical management and once-weekly medication dispensing (48 percent) or thrice-weekly medication dispensing (43 percent) or enhanced medical management and thrice-weekly medication dispensing (39 percent) (P=0.64). Adherence to buprenorphine-naloxone treatment varied; increased adherence was associated with improved treatment outcomes. Therefore, among patients receiving buprenorphine-naloxone in primary care for opioid dependence, the efficacy of brief weekly counseling and once-weekly medication dispensing did not differ significantly from that of extended weekly counseling and thrice-weekly dispensing. This study also has implications for clinical care and research. The fact that many patients can receive efficacious care in a primary care, office-based setting with weekly brief counseling and medication dispensing is important. The recent finding that the availability of buprenorphine-naloxone attracts new patients to treatment for addiction provides support for federal efforts to expand access to the treatment. The findings also show that supervised nurses can provide appropriate counseling. The finding of ongoing cocaine use among patients treated for opioid dependence is consistent with findings among patients receiving methadone maintenance and supports efforts to monitor and address this coexisting disorder. Finally, the variability in buprenorphine-naloxone adherence highlights the need both to measure adherence in future research and to monitor and encourage adherence in practice in order to reduce the potential misuse of the medication and to improve the treatment outcomes. Strategies to improve buprenorphine-naloxone adherence are needed. Fiellin, D., Pantalon, M., Chawarski, M., Moore, B., Sullivan, L., O 'Connor, P., and Schottenfeld, R. Counseling Plus Buprenorphine-Naloxone Maintenance Therapy for Opioid Dependence. N Engl J Med, 355(4), pp. 365-374, 2006.

Training Primary Care Clinicians in Maintenance Care for Moderated Alcohol Use

Despite belief in a responsibility to help their patients with alcohol problems, primary care physicians are often hesitant to accept responsibility for the management of these disorders. The authors goal in this study was to evaluate whether training primary care clinicians in maintenance care for patients who have changed (reduced) their drinking, will influence the provider behavior in the medical practice. The study randomized 15 physicians and 3 mid-level clinicians in 2 primary care offices in a 2:1 design. The 12 intervention clinicians received a total of 2 (1/4) hours of training in the maintenance care of alcohol problems in remission, a booster session, study materials and chart-based prompts at eligible patients' visits. Six controls provided usual care. Screening forms in the waiting rooms identified eligible patients, defined as those who endorsed: 1 or more items on the CAGE questionnaire or that they had an alcohol problem in the past; that they have "made a change in their drinking and are trying to keep it that way"; and that they drank <15 (men) or <10 (women) drinks per week in the past month. Exit interviews with patients evaluated the clinician's actions during the visit. Of the 164 patients, 62% saw intervention clinicians. Compared with patients of control clinicians, intervention patients were more likely to report that their clinician asked about their alcohol history (odds ratio, 2.8; 95% confidence interval, 1.3, 5.8). Intervention clinicians who asked about the alcohol history were more likely to assess prior and planned alcohol treatment, assist through offers for prescriptions and treatment referral, and receive higher satisfaction ratings for the visit. This pilot study suggests that training, and chart based prompting, can increase by nearly 3-fold the likelihood that clinicians will inquire about the alcohol history with patients who have changed their drinking behavior. The magnitude of these findings is similar to that of a primary care study of brief counseling for patients with current hazardous drinking. Systemic prompts and training in the maintenance care of alcohol use disorders in remission might increase primary care clinicians' inquiries about the alcohol history as well as appropriate assessment and intervention after an initial inquiry. Friedmann, P., Rose, J., Hayaki, J., Ramsey, S., Charuvastra, A., Dube, C., Herman, D., and Stein, M. Training Primary Care Clinicians in Maintenance Care for Moderated Alcohol Use. J Gen Intern Med, 21, pp. 1-7, 2006.

Welfare Reform, Employment, and Alcohol and Drug Use among Low-Income Women

In 1996 welfare reform legislation transformed income assistance for needy families by imposing work requirements, time-limited benefits, and explicit provisions allowing states to sanction recipients who fail to meet program requirements. Though they represent a minority of the welfare population, women with substance use disorders (SUDs) experience multiple, and more severe, employment barriers than other Temporary Assistance to Needy Families (TANF) recipients. This review of welfare reform, substance abuse, and employment documents the evidence to date regarding the employment patterns of women with SUDs before and after welfare reform, and proposes several topics for further research. Based on higher rates of unemployment, less work experience, and lower earnings when working, women with SUDs have worse employment records than other TANF recipients. Despite elevated employment barriers, women with SUDs left TANF after 1996 as fast as, or faster than, other women. Since the 1996 welfare reform, women with SUDs have increased their employment and earnings, but by less than similar women without SUDs. Future research should describe how specific state welfare policies relate to employment of low-income women with SUDs, how the well-being of these women and their children changes with employment, and how welfare and employment interact to affect access to health insurance among this population. Meara, E. Welfare Reform, Employment, and Drug and Alcohol Use Among Low-Income Women. Harv Rev Psychiatry, 14(4), pp. 223-232, 2006.

Negative Reinforcement: A Behavioral Paradigm to Inform Services Research in the Criminal Justice System

This article is part of a series of conceptual papers examining a proposal to offer depot naltrexone to certain nonviolent opiate-addicted criminal offenders in exchange for release from incarceration or diversion from prosecution. Operant conditioning paradigms of behavioral change suggest the application of negative-reinforcement has a better chance of impacting offender drug use and associated criminal activity than what has heretofore been attempted with drug-abusing offenders. Traditional correctional efforts have been largely unsuccessful due to the complexities of implementation and the side effects of punishment. Although positive reinforcement can be more efficacious, it has often been strenuously resisted on the ground that it is inequitable to reward antisocial individuals for doing what is minimally expected of most citizens. Negative reinforcement steers between these hurdles by avoiding the iatrogenic effects of punishment, while also being palatable to stakeholders. More research is needed to identify the effects, costs, and side effects of negative-reinforcement arrangements for drug offenders. The current proposal provides an excellent platform for conducting this research because the target intervention (depot naltrexone) is demonstrably efficacious, nonpsychoactive, and has few, if any, side effects. Therefore, use of this medication would be unlikely to invoke the same types of legal and ethical objections that have traditionally been levied against the use of psychoactive medications with vulnerable populations of institutionalized offenders. Specific recommendations are offered for questions that must be addressed in future research studies. Marlowe, D. Depot Naltrexone in Lieu of Incarceration: a Behavioral Analysis of Coerced Treatment for Addicted Offenders. J Subst Abuse Treat, 31(2), pp. 131-139, 2006.

Private As Opposed to Public Sector Providers Differ in Ways that Affect Types of Patients Treated, As Well As Therapeutic and Business Practices

As an organizational field, substance abuse treatment clearly includes a remarkable range of organizations. This study summarizes findings from an ongoing research program by examining the organizational structure, service delivery, and patterns of innovation adoption in two large samples of substance abuse treatment programs in the United States (N= 403 private- and 363 publicly-funded). Among highlighted findings, there are notable differences between the public and private sectors in structural and staffing characteristics, as well as in the characteristics of clients receiving substance abuse treatment. With regard to the use of evidence-based practices, findings suggest that pharmacotherapies are more likely to be adopted in private centers, whereas notably effective voucher approaches are more common in public centers. Also found was that private treatment centers had stronger financial performance when they were embedded within larger organizations yet maintained decentralization with regard to their staff; private centers were more likely to treat co-morbid patients (65% vs 50%) and patients with other addictions (eating & gambling); whereas public centers more often helped patients with transportation to care (71% vs 53%). Roman, P.M., Ducharme, L.J., and Knudsen, H.K. Patterns of Organization and Management in Private and Public Substance Abuse Treatment Programs. J Subst Abuse Treat, 31(3), pp. 235-243, 2006.

Health Literacy: Depression, Mental Health, Quality Adjusted Life Years and Addictions

The researchers hypothesized that low literacy would be associated with higher addiction severity, higher levels of depressive symptoms, and worse mental health functioning compared with those with higher literacy in adults with alcohol and drug dependence. The association of literacy with multiple mental health outcomes was assessed using multivariable analyses. Measurement instruments included the Rapid Estimate of Adult Literacy in Medicine (REALM), the Center for Epidemiologic Studies-Depression (CES-D) scale, the Mental Component Summary scale of the Short Form Health Survey, and the Addiction Severity Index for drug and alcohol addiction. Subjects included 380 adults recruited during detoxification treatment and followed prospectively at 6-month intervals for 2 years. Based on the REALM, subjects were classified as having either low (< or = 8th grade) or higher (> or = 9th grade) literacy levels. In longitudinal analyses, low literacy was associated with more depressive symptoms. The adjusted mean difference in CES-D scores between low and high literacy levels was 4 (P<.01). Literacy was not significantly associated with mental health-related quality of life or addiction severity. In people with alcohol and drug dependence, low literacy is associated with worse depressive symptoms. The mechanisms underlying the relationship between literacy and mental health outcomes should be explored to inform future intervention efforts. Lincoln, A., Paasche-Orlow, M., Cheng, D., Lloyd-Travaglini, C., Caruso, C., Saitz, R., and Samet, J. Impact of Health Literacy on Depressive Symptoms and Mental Health-Related: Quality of Life Among Adults with Addiction. J Gen Intern Med, 21(8), pp. 818-822, 2006.

Adoption of Buprenorphine for Addiction Treatment is More Common Among Accredited Service Providers that Include Physician Services and Detoxification

The recent approval of buprenorphine for the treatment of opiate dependence offers an opportunity to analyze innovation adoption in community-based treatment. Using data collected from national samples of 299 privately funded and 277 publicly funded treatment centers, research examined buprenorphine adoption using baseline data collected between 2002 and 2004 as well as follow-up data collected 12 months later. Private centers were significantly more likely than public centers to report current use of buprenorphine. The baseline data indicated that early adoption was positively associated with center accreditation, physician services, availability of detoxification services, current use of naltrexone, and the percentage of opiate-dependent clients. Multivariate analyses of follow-up data suggest that adoption was greater in accredited centers, for-profit facilities, organizations offering detoxification services, and naltrexone-using centers. Future research should continue to monitor the extent to which buprenorphine is adopted in these settings. Knudsen, H.K., Ducharme, L.J., and Roman, P.M. Early Adoption of Buprenorphine in Substance Abuse Treatment Centers: Data from the Private and Public Sectors. J Subst Abuse Treat, 30, pp. 363-373, 2006.

Retention in Methadone Treatment is Highest for Patients Receiving Both Case Management and Voucher Reinforcement

A clinical trial contrasted two interventions designed to link opioid-dependent hospital patients to drug abuse treatment. The 126 out-of-treatment participants were randomly assigned to (a) case management, (b) voucher for free methadone maintenance treatment (MMT), (c) case management plus voucher, or (d) usual care. Participants were heroin dependent, 75% male, between 18 and 65 years of age, were receiving medical treatment at San Francisco General Hospital (inpatient or outpatient), were eligible fore methadone treatment under California law, and had at least two prior treatment failures. Services were provided for 6 months. MMT enrollment at 3 months was 47% (case management), 89% (voucher), 93% (case management plus voucher), and 11% (usual care); at 6 months enrollment was 48%, 68%, 79%, and 21%, respectively. Case management and vouchers can be valuable in health settings to link substance abusers with medical problems to drug abuse treatment. Sorensen, J.M., Barnett, P.G., Mitsuishi, F., Lin, C., Song, Y., Chen, T., Hall, S.M., and Mason, C.L. Randomized Trial of Drug Abuse Treatment-Linkage Strategies. J Consult Clin Psychol, 73(6), pp. 1026-1035, 2006.

Attitudes Towards Spending for Drug Rehabilitation

Although a large body of literature clearly demonstrates the clinical and economic benefits of addiction treatment for many clients and in most settings, the general public has a somewhat ambivalent attitude toward treatment expansion and taxpayer financing. This study uses data from the General Social Survey (GSS), a nationally representative repeated cross-section survey of the English-speaking U.S. adult population (aged 18 years and older) living in noninstitutionalized settings, to examine trends in attitudes towards spending on drug rehabilitation between 1984 and 2004. Analyses were conducted on N=11,094, respondents which represents 84.9% of all those eligible. Respondents were asked whether they believed the country spent too little, about the right amount, or too much on drug rehabilitation. Averaging across the years, 57.6 % of respondents said the country spent too little 32.1% said about right, and 10.3% too much on drug rehabilitation, although public support for more spending has been declining in recent years. Age, gender, marital status, education, religion, and political affiliation all were associated with attitudes. The authors describe a comprehensive social strategy to translate public opinion and the knowledge base on substance abuse treatment into political will and policy. French, M., Homer, J., and Nielsen, A. Does America Spend Enough on Addiction Treatment? Results From Public Opinion Surveys. J Subst Abuse Treat, 31(3), pp. 245-254, 2006.

High-Cost Health Services Utilization Among Drug Using Prisoners Re-entering Community

The use of health services by prisoners during their incarceration and after their return to the community impacts the U.S. health care system and health care costs associated with this system. These health care costs are expected to increase over the next decade as more prisoners return to their communities. The current study prospectively examined the use of high-cost health care services-emergency room visits and hospitalizations-among 565 male drug-abusing prisoners one year after prison release. A series of structural equation models were used to examine predisposing factors, including health status and drug use, and to estimate the frequency of high-cost health service utilization. As expected, health status was the most robust predictor of high-cost health services. However, the finding that drug abuse had nonsignificant relationships with high-cost health services utilization was not expected. Leukefeld, C., Hiller, M., Webster, J., Tindall, M., Martin, S., Duvall, J., Tolbert, V., and Garrity, T. A Prospective Examination of High-Cost Health Services Utilization Among Drug Using Prisoners Reentering the Community. J Behav Health Serv Res, 33(1), pp. 73-85, 2006.

Few Racial Differences Were Found on Most Health Indicators for Cocaine-abusing Veterans

Racial minorities generally exhibit worse health status than do whites. To assess the presence of similar phenomena among long-term cocaine-using veterans, this study examined racial variations in mortality and health status among cocaine-dependent men who were originally recruited at their admissions to cocaine treatment in 1988-1989 and were interviewed approximately 12 years later in 2002-2003. Mortality was higher among whites (15%) than blacks (6%), particularly due to drug overdose. Controlling for socioeconomic factors, cocaine severity, and depression, the racial difference was still significant in the survival analysis. Racial differences were examined in the health status of those interviewed in the 12-year follow-up study (178 blacks and 65 whites), after confirmation of their comparable socioeconomic backgrounds and levels of healthcare access and utilization. Contrary to expectations, few racial differences were found on most health indicators, although the level of cocaine use was higher among blacks. Furthermore, fewer blacks reported having hepatitis or sexually transmitted diseases than did whites. The study results suggest that black cocaine-dependent veterans do not have worse health status when compared with white veterans on most health indicators. Yang, J. C., Huang, D., and Hser, Y. Long-Term Morbidity and Mortality among a Sample of Cocaine-Dependent Black and White Veterans . J Urban Health, 83(5), pp. 926-940, 2006.

Organizational and Management Factors Influence Use of EBPs

This study overviews data from several national longitudinal studies (N > 1000 clinics) of substance abuse treatment practices conducted by the University of Chicago and the University of Michigan via the National Drug Abuse Treatment System Survey to develop an understanding as to why there exists a seemingly wide gap between research and practice in the field of substance abuse treatment. Data collected in the 1980s reported marked reductions in the nature and number of primary health care, mental health care, and social services provided within substance abuse treatment. Data colleted in the 1990s indicate that reductions have stopped, yet 2005 data show services remain below 1980-s levels. Several organizational characteristics are related to the availability of health care, mental health, and social services. For example, clinics affiliated with hospitals and mental health centers are significantly more likely to have medical care (physical exams and routine primary care) and mental health services available for clients. Organizational characteristics also affect therapeutic practices. Clinics that treat higher percentages of African American clients are more likely to provide methadone doses that are too low tobe effective. Clinics with JCAHO accreditation were more likely to provide higher methadone doses. The 2005 NDATSS sample showed that clinics whose directors held a strong 12-step orientation but weak support for HIV prevention practice were more likely to give low doses. Finally, methadone clinics with managed care arrangements requiring prior authorization for treatment also provided lower doses. D'Aunno, T. The Role of Organization and Management in Substance Abuse Treatment: Review and Roadmap. J Subst Abuse Treat, 31(3), pp. 221-233, 2006.

ED and Hopsital Utilization Among Alcohol and Drug Dependent Detox

Utilization of emergency department (ED) services and hospitalization among a cohort of substance abusers are described based on structured research interviews with 470 adults without primary care admitted to an urban residential detoxification program. Cross-sectional analysis of baseline data of subjects found nearly 19% of subjects went to an ED on 2 or more occasions in the 6 months prior to detoxification and 14% were admitted for an overnight hospitalization. Upon further analysis of past 6-month ED utilization, the following factors were independently associated with increased odds of ED use: White race; at least one month homeless in the past 5 years; chronic health condition; injury in past 6 months; and subject perception that their substance abuse interfered with seeking care from a regular doctor. Subjects with cocaine as a primary problem had lower odds of ED utilization than a reference group with alcohol as a primary problem. Access to primary care is apparently needed to lower ED and hospital utilization episodes. Larson, M., Saitz, R., Horton, N., Lloyd-Travaglini, C., and Samet, J. Emergency Department and Hospital Utilization Among Alcohol and Drug-Dependent Detoxification Patients Without Primary Medical Care. Am J Drug Alcohol Abuse, 32(3), pp. 435-452, 2006.

HIV-specific Health Maintenance in Middle Aged and Older Patients

Given the increased prevalence of HIV infection in older individuals, the investigators evaluated the adequacy of HIV-specific health maintenance, age-appropriate cancer screening, and diabetes management in an urban HIV clinic. They randomly selected 222 HIV-positive patients 40 years or older followed at the Johns Hopkins University Moore Clinic between 1999 and 2002. Demographic, clinical, and pharmaceutical data were abstracted from clinic charts. Outcomes of interest were vaccinations, annual rapid plasmin reagin (RPR) testing, and Papanicoloau smears and mammography in women. Logistic regression analyses were performed to identify variables significantly associated with being up to date on vaccinations. The sample was 56% female and 82% African American with a mean age of 50.9 years. Sixty-five percent used tobacco, 10% used alcohol, and 13% used illicit drugs daily. At the time of evaluation, 87% had received the pneumococcal vaccine. Of nonimmune patients, 66% were vaccinated for hepatitis B and 28% for hepatitis A. Eighty-two percent of women were referred for Papanicoloau smears and 56% for mammography. Only 59% completed the Papanicoloau smear, and 31% had mammography. Forty-two percent of patients with diabetes underwent quarterly foot examinations, and 33% had microalbuminuria screening. Risk factors for missed vaccinations include prior AIDS diagnosis (odds ratio [OR] 1.82, 95% confidence interval [CI] 1.55, 3.13), CD4+ cell count less than 50 cells/mm(3) at the time of visit (OR 6.31, 95% CI 1.74, 22.9), and a history of chronic obstructive pulmonary disease (COPD) or asthma (OR 2.54, 95% CI 1.03, 6.28). In summary, HIV-positive patients are more likely to receive HIV-specific primary care interventions, especially vaccinations that can be given in clinic, than routine health maintenance screening that required referral and evaluation elsewhere. This suggests that if health maintenance screening can be delivered in the same clinic, usage rates are likely to increase. Sheth, A., Moore, R., and Gebo, K.. Provision of General and HIV-Specific Health Maintenance in Middle Aged and Older Patients in an Urban HIV Clinic. AIDS Patient Care STDS, 20(5), pp. 318-325, 2006.

Mental Health Problems and Criminal Justice Involvement Among Female Street-Based Sex Workers

This paper examines the connections of mental health, victimization, and criminal justice involvement among a sample of 343 street-based female sex workers in Miami, Florida. Using targeted sampling strategies, drug-using sex workers were recruited into an HIV prevention intervention and research program. Data were collected by trained interviewers using standardized questionnaires that focused on drug use, childhood abuse, recent victimization, mental health, and criminal justice involvement. More than half of the participants reported histories of physical (54.5%) or sexual (54.2%) abuse as children, and more than one-third reported violent victimization in the past year. Nearly 32% were classified with moderate or severe anxiety symptoms, 46.2% had symptoms of moderate or severe depression, and 64.6% had symptoms of acute traumatic stress. In addition, 81.9% had prior arrest histories. The intersection of these factors suggests that police and law enforcement agencies must play a substantial role in managing an offender population with impaired mental health functioning. The policy implications of these findings are discussed. Surratt, H. Mental Health Problems and Criminal Justice Involvement Among Female Street-Based Sex Workers. Law Enforcement Executive Forum, 6, pp. 121-134, 2006.

Validation of a New Screener for Pain Patients at Risk of Opioid Addiction

The Screener and Opioid Assessment for Patients with Pain (SOAPP) is a brief, self-administered screening instrument used to assess suitability of long-term opioid therapy for chronic pain patients. This study examined the reliability and validity of the SOAPP as a measure of risk of opioid abuse for patients on opioid medication. Patients taking opioids for noncancer pain (N=396) from two pain centers completed the SOAPP prior to being placed on opioids for pain. Demographic data, SOAPP scores, and results of urine toxicology screens from the patients' medical records were examined. Patients were divided into two groups of high and low risk of opioid abuse potential based on cutoff scores of 8 and higher on the SOAPP. Results showed that patients in the high-risk group were younger, more likely to be asked to give a urine screen, and had more abnormal urine screens compared with those in the low-risk group (P < 0.05). A combined factor analysis of the SOAPP revealed five factors labeled 1) history of substance abuse, 2) legal problems, 3) craving medication, 4) heavy smoking, and 5) mood swings. Preliminary support was found for the internal reliability and predictive validity of the SOAPP. Akbik, H., Butler, S.F., Budman, S.H., Fernandez, K., Katz, N.P., and Jamison, R.N. Validation and Clinical Application of the Screener and Opioid Assessment for Patients with Pain (SOAPP). Journal of Pain & Symptom Management, 32(3), pp. 287-293, 2006.

Validation of the ASI to Screen for Mental Disorders Among Drug Abusers

This study, used data from the Drug Evaluation Network System and a study conducted through the Center for Studies on Addiction of the University of Pennsylvania/Philadelphia Veterans Administration Medical Center (N=2,813) to determine the potential of the Addiction Severity Index (ASI) to serve as a screening instrument for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) substance dependence. A significant positive correlation was found between ASI composite scores (CSs) and DSM-IV diagnoses of dependence in both the alcohol (r =.7) and drug (r =.5) domains ( p < .01). Receiver operating characteristic analyses were run to predict DSM-IV alcohol and drug dependence diagnoses from the respective ASI CSs. Results showed good to strong prediction; ASI CSs identified dependent clients with approximately 85% sensitivity and 80% specificity. Rikoon, S.H., Cacciola, J.S., Carise, D., Alterman, A.I., and McLellan, A.T. Predicting DSM-IV Dependence Diagnoses from Addiction Severity Index Composite Scores. J Subst Abuse Treat, 31(1), pp. 17-24, 2006.

Racial Differences in Marijuana-users Risk of Arrest in the United States

A recent study of arrest data shows that African Americans are 2.5 times more likely to be arrested for marijuana possession offences than Whites, even though general prevalence estimates show that they are no more likely to be using. The current study investigates the purchase patterns of marijuana users from the 2002 National Survey on Drug Use and Health (NSDUH) to evaluate whether differences in purchasing behaviors exist across racial groups. Although in general people who purchase marijuana are more likely to buy in private settings and from someone they know, this analysis shows that African Americans are statistically more likely to engage in risky purchasing behaviors that increase their likelihood of arrest. Using trivariate probit regression with demographic, drug use, and drug market covariates, analyses reveal that African Americans are nearly twice as likely to buy outdoors (0.31 versus 0.14), three times more likely to buy from a stranger (0.30 versus 0.09), and significantly more likely to buy away from their homes (0.61 versus 0.48). These results provide an additional explanation for the differential in arrest rates between African Americans and Whites. Ramchand, R., Pacula, R., and Iguchi, M. Racial Differences in Marijuana-Users ' Risk of Arrest in the United States. Drug Alcohol Depend, 84(3), pp. 264-272, 2006.

Factor Structure of the Comprehensive Severity Inventory (CASI)

This article describes the results of psychometric work conducted on the Comprehensive Adolescent Severity Inventory (CASI) among 205 in-treatment substance-abusing adolescents. Four dimensions, each composed of component subscales, resulted from standard psychometric analyses: Chemical Dependency, Psychosocial Functioning, Delinquency, and Risk Behavior. Each dimension had high internal consistency (alpha coefficients for the component subscales comprising each clinical dimension range from .78 to .96) and test-retest reliability (intraclass correlation coefficients range from .88 to .96 and all are significant at p < .0001.). Concurrent validity and specificity of the CASI dimensions also were found: significant and substantial variance in NIMH Diagnostic Interview Schedule for Children-Revised (DISC-IV) and Brief Symptom Inventory (BSI) scores was associated with relevant CASI dimensions; CASI dimensions that theoretically should show no significant relationship with divergent pathology were not associated. The dimensions forecasted substantial variance in adolescent functioning post treatment discharge, supporting predictive validity. Finally, the dimensional clinical structure was found to be generalizable over male and female adolescents, younger and older adolescents, and adolescents from different ethnic groups. These results provide further evidence for the CASI's promise in research and practice as an adolescent-specific assessment instrument that comprehensively assesses multidimensional areas of functioning within a developmental context of measurement. Meyers, K., Hagan, T., McDermott, P., Webb, A., Randall, M., and Frantz, J. Factor Structure of the Comprehensive Adolescent Severity Inventory (CASI): Results of Reliability, Validity, and Generalizability Analyses. Am J Drug Alcohol Abuse, 32(3), pp. 287-310, 2006.

Co-morbid "Spill Over" Among Cocaine-dependent Homeless Persons

Data from an addiction treatment trial for 95 cocaine-dependent homeless persons (1996-1998) were used to profile psychiatric diagnoses at baseline and 6 months, including mood-related disorders (e.g. depression) and anxiety-related disorders (e.g. post-traumatic stress disorder). Treatment interventions, including systematic reinforcement for goal attainment, were behavioral in orientation. There was a 32% reduction in the prevalence of comorbid nonaddiction psychiatric disorder from baseline to 6 months, with similar reductions in the prevalence of mood (-32%) and anxiety-related disorders (-20%) (p=0.12). Among cocaine-dependent homeless persons with psychiatric comorbidity undergoing behavioral addiction treatment, a reduction in comorbid psychiatric disorder prevalence was observed over 6 months. Not all participants improved, suggesting that even evidence-based behavioral addiction treatment will prove insufficient for a meaningful proportion of the dually diagnosed homeless population. Kertesz, S. G., Madan, A., Wallace, D., Schumacher, J.E., and Milby, J.B. Substance Abuse Treatment and Psychiatric Comorbidity: Do Benefits Spill Over? Analysis of Data from a Prospective Trial Among Cocaine-Dependent Homeless Persons. Subst Abuse Treat Prev Policy, 1(1), pp. 27-27, 2006.

Biometric Measures were Frequently Less Sensitive to the Severity of Other Problems

This study examined the need, feasibility, and validity of combining two biometric (urine and saliva) and three self-report (recency, peak quantity, and frequency) measures of substance use for marijuana, cocaine, opioids, and other substances (including alcohol and other drugs). Using data from 337 adults with substance dependence, the investigators used structural equation modeling to demonstrate that these multiple measures are driven by the same underlying factor (substance use) and that no single measure is without error. Individual measures and several possible combinations of them (including one based on the latent factors and another based on the Global Appraisal of Individual Needs (GAIN) Substance Frequency Scale) were compared to examine how well each predicted a wide range of substance-related problems. The measure with the highest construct validity in these analyses varied by drug and problem. Despite their advantages for detection, biometric measures were frequently less sensitive to the severity of other problems. Composite measures based on the substance-specific latent factors performed better than simple combinations of the biometric and psychometric measures. The Substance Frequency Scale from the GAIN performed as well as or better than all measures across problem areas, including the latent factor for any use. While the research was limited in some ways, it has important implications for the ongoing debate about the proper way to combine biometric and psychometric data. Lennox, R., Dennis, M.L., Scott, C.K., and Funk, R. Combining Psychometric and Biometric Measures of Substance Use. Drug Alcohol Depend, 83, pp. 95-108, 2006.

Organizational Characteristics are Associated with Providing Psychiatric Care for Co-morbid Substance Abuse Patients

This study examines the prevalence and key correlates of the availability of integrated care for co-occurring conditions within public and private-sector addiction treatment programs (N>400 private and >360 public). Overall, 57.5% of centers offered concurrent or co-located care for co-occurring psychiatric disorders. These tend to be larger, accredited, hospital affiliated, high percentages of adolescent patients, and which offer psychiatric services to non substance abusing patients. Private/public support did not distinguish centers that provided care for co-occurring disorders in this study. Ducharme, L.J., Knudsen, H.K., and Roman, P.M. Availability of Integrated Care for Co-occurring Substance Abuse and Psychiatric Conditions. Community Ment Health J, 42(4), pp. 363-375, 2006.

Patterns of Hepatitis-C Service Provision in Drug-Free Treatment Programs

Hepatitis C virus (HCV) infection is a global health problem, and in many countries (including the U.S.), illicit drug users constitute the group at greatest risk for contracting and transmitting HCV. Drug treatment programs are therefore unique sites of opportunity for providing medical care and support for many HCV infected individuals. This paper determines subtypes of a large sample of U.S. drug-free treatment programs (N=333) according to services they provide to patients with HCV infection, and examines the organizational and aggregate patient characteristics of programs in these subtypes. A latent class analysis identified four subtypes of HCV service provision: a "Most Comprehensive Services" class (13% of the sample), a "Comprehensive Off-Site Medical Services" class (54%), a "Medical Monitoring Services" class (8%) and a "Minimal Services" class (25%). "Comprehensive" services class programs were less likely to be outpatient and private for profit than those in the other two classes. It is of concern that so many programs belong to the "Minimal Services" class, especially because some of these programs serve many injection drug users. "Minimal Services" class programs in the U.S. need to innovate services so that their HCV infected patients can get the medical and support care they need. Similar analyses in other countries can inform their policy makers about the capacity of their drug treatment programs to provide support to their HCV infected patients. Strauss, S., Rindskopf, D., Astone-Twerell, J., Des Jarlais, D., and Hagan, H. Using Latent Class Analysis to Identify Patterns of Hepatitis C Service Provision in Drug-Free Treatment Programs in the U.S. Drug Alcohol Depend, 83(1), pp. 15-24, 2006.

Nicotine Replacement Therapy: Patterns of Use After a Quit Attempt Among Methadone-Maintained Smokers

This is the first study offering a detailed description of the use of transdermal nicotine replacement and its relationship with daily cigarette smoking in a population of heavy smokers. The authors also determined predictors of greater NRT use among methadone-maintained smokers. Three hundred and eighty three methadone-maintained smokers from 5 methadone maintenance centers enrolled in this 2 arm RCT, where assignment was either to a group given free nicotine patches (8 to 12 weeks) plus either (1) a baseline-tailored brief motivational intervention, a quit date behavioral skills counseling session, and a relapse prevention follow-up session (max), or (2) brief advice using NCI's 4 A's model (min). Of the study participants; 309 (80.6%) set a specific quit date (received NRT) and were located for assessments. Participants were 51.8% male, 78.6% Caucasian, and smoked 26.6 (SD=12.2) cigarettes/day. The outcome measured was the use of NRT and smoking behaviors during the 180-day follow-up period assessed by the Timeline follow-back method. On the day following their quit day, 86.4% of participants used NRT. The percentage of participants using NRT was 52.3%, 27.1%, and 10.4% on day 30, day 60, and day 90, respectively. Participants used NRT on 44.1% of the days through the 90 days of the treatment protocol. The estimated odds of smoking abstinence was 7.1 (P<.001) times higher on days when NRT was used than on days when NRT was not used, and cigarettes/day was also significantly lower on NRT days (14.93 vs. 4.65; P<.001). Despite being given free NRT and counseling, participants who set quit dates used NRT on only 44% of treatment period days. It is therefore apparent that nicotine replacement therapy use was inconsistent following an initial quit attempt among methadone-maintained smokers. However, on days when NRT was used, individuals were likely to smoke at reduced levels or not at all. Reasons for inconsistent patch use were postulated by the authors; and a greater understanding of expectancies and the reasons for nonadherence with NRT use is felt to be necessary to promote optimal pharmacological care and improve smoking cessation outcomes. Stein, M., Anderson, B., and Niaura, R. Nicotine Replacement Therapy: Patterns of Use After a Quit Attempt Among Methadone-Maintained Smokers. J Gen Intern Med, 21(7), pp. 753-757, 2006.

Blood Pressure Levels May Vary in Population because of Genetic, Ethnic and Body Size Factors

Blood pressure data of 2278 Indian boys and 2930 Indian girls in the age group of 3-18 years were analyzed to study the distribution pattern of systolic blood pressure and diastolic blood pressure and to develop reference values to define hypertension. Blood pressure was measured using standardized techniques in all. The first and fifth phases of Korotkoff sounds were taken as indicative of systolic blood pressure and diastolic blood pressure respectively. Height percentiles were computed for each one-year age group. According to percentiles of height 50th, 90th, 95th and 99th percentiles of systolic blood pressure and diastolic blood pressure were estimated for every one-year age. Results indicated that the blood pressure (both systolic and diastolic) tends to increase with age. The stepwise regression analysis revealed that the age and height but not gender, are important determinants of blood pressure. Age and height specific, 50th, 90th and 95th and 99th percentiles of systolic and diastolic blood pressure were derived and are presented in tabular form. Authors concluded that the blood pressure of children and adolescents can be evaluated using the reference table according to body size. The table provided helps to classify blood pressure as 'normal' or 'pre hypertension' and to define different stages of 'hypertension'. Pushpa, K., KumanPrasanna, K.M., Nagaraj, D., and Thennarasu, K. Blood Pressure Reference Tables for Children and Adolescents of Karnataka. Indian Pediatrics, 43 (June), pp. 491-501, 2006.

New Challenges and Opportunities in Managing Substance Abuse in Malaysia

Prior to mid-year 2005, the portfolio for drug addiction treatment was under the Ministry of Internal Security, which emphasized long-term incarceration and drug-free after-care as the primary approach. This approach has been viewed a failure, and Malaysia has lagged behind in the treatment of drug addiction and related disorders, despite experiencing severe drug problems. For example, by the end of 2004, 234,000 heroin users or heroin-dependent individuals had been registered in the official government registry out of 24 million persons. However, other estimates exceed 500,000 for heroin abusers in this population. Because of this situation, the Prime Minister instructed the national narcotic agency to review its existing policy on treatment of drug addiction, and as a result, the Ministry of Health now has authority for providing medical treatment for heroin dependence. This shift signals a remarkable change in Malaysian policies and approaches to addiction and an important opportunity to develop, implement and disseminate effective treatments. Amphetamine-type stimulant abuse is also increasing and of considerable public and government concern. Among the population of drug users, HIV and other infectious diseases rates are very high. In the Western Pacific regions, Malaysia has the second highest HIV prevalence (after Vietnam) among adult populations (0.62%) and the highest proportion of HIV cases resulting from injection drug use (76.3%). Drug use and related disorders exert a heavy burden on the country's health care and legal systems. Naltrexone was introduced in 1999; buprenorphine was introduced in 2001 and methadone in 2003. Agonist maintenance programs were embraced rapidly by the medical community in Malaysia. Currently, over 30,000 opiate-dependent patients are treated with agonist maintenance treatments by more than 500 medical practitioners in Malaysia. Despite these recent advances, treatments for amphetamine-type stimulant abuse or dependence are underdeveloped, and diversion of agonist medications is an emerging concern. Malaysia is addressing these problems, continues to improve treatment for heroin dependence, and act as a model for other countries in the region. Mazlan, M., Schottenfeld, R., and Chawarski, M. New Challenges and Opportunities in Managing Substance Abuse in Malaysia. Drug Alcohol Rev, 25(5), pp. 473-478, 2006.

Organizational Characteristics of Italian Substance Abuse Clinics Found to be Similar to Those in the USA

The Texas Christian University (TCU) organizational functioning and readiness for change instrument (ORC) was translated into Italian and administered to 405 substance abuse treatment program directors and staff from both public and private sectors in the Veneto Region of Northern Italy. Results indicated that the psychometric properties of the ORC in the USA and Italy are consistent. Some general differences in staff attributes were found between USA and Italian programs with US staff having more training but fewer resources such as internet and email access than Italian staff. However, organizational climates were found to be remarkably similar. Rampazzo, L., De Angeli, M., Serpelloni, G., Simpson, D.D., and Flynn, P. M. Italian Survey of Organizational Functioning and Readiness for Change: A Cross-Cultural Transfer of Treatment Assessment Strategies. European Addiction Research, 12, pp. 176-181, 2006.