Research Findings - Services Research

Buprenorphine and Methadone Maintenance in Jail and Post-Release: A Randomized Clinical Trial

Buprenorphine has rarely been administered as an opioid agonist maintenance therapy in a correctional setting. This study introduced buprenorphine maintenance in a large urban jail, Rikers Island in New York City. Heroin-dependent men not enrolled in community methadone treatment and sentenced to 10-90 days in jail (N= 116) were voluntarily randomly assigned either to buprenorphine or methadone maintenance, the latter being the standard of care for eligible inmates at Rikers. Buprenorphine and methadone maintenance completion rates in jail were equally high, but the buprenorphine group reported for their designated post-release treatment in the community significantly more often than did the methadone group (48% vs. 14%, p < .001). Consistent with this result, prior to release from Rikers, buprenorphine patients stated an intention to continue treatment after release more often than did methadone patients (93% vs. 44%, p < .001). Buprenorphine patients were also less likely than methadone patients to withdraw voluntarily from medication while in jail (3% vs. 16%, p < .05). There were no post-release differences between the buprenorphine and methadone groups in self-reported relapse to illicit opioid use, self-reported re-arrests, self-reported severity of crime or re-incarceration in jail. From this study, it appears that after initiating opioid agonist treatment in jail, continuing buprenorphine maintenance in the community appears to be more acceptable to offenders than continuing methadone maintenance. Magura S, Lee JD, Hershberger J, Joseph H, Marsh L, Shropshire C, Rosenblum A. Buprenorphine and methadone maintenance in jail and post-release: a randomized clinical trial. Drug Alcohol Depend. 2009;99:222-30.

Racial Disparities Persist in Low-Dose Methadone Maintenance

Previous research identified a persistent pattern of low-dosing among methadone maintenance programs. It is generally accepted that a therapeutic dose for patients in the maintenance phase of treatment is at or above 80mg/day. While there is likely variation around this target level, programs whose caseloads are receiving average doses below this threshold are described by the authors as "low dose" settings. This article adds additional waves of data to a longitudinal national survey to determine whether programs have made improvements in average dosage levels. Data were collected from a nationally representative sample of methadone treatment facilities in 1988 (n=172), 1990 (n=140), 1995 (n=116), 2000 (n=150), and 2005 (n=146). In 1988, fully 94.2% of patients in sampled programs were receiving doses under 80mg/day. By 2005, this number decreased to 56.3%. Random-effects regression models found that programs serving higher percentages of African-American and Hispanic clients were more likely to be characterized as low-dose settings, as were programs whose directors endorsed a 12-step approach to recovery. The proportion of programs with an average daily dose below recommended levels remains much higher than optimal. The stigma of methadone maintenance persists even within the opioid addiction treatment community, and impedes the delivery of evidence-based care. Racial minorities appear disproportionately affected by these patterns. Pollack HA, D'Aunno T. Dosage patterns in methadone treatment: results from a national survey, 1988-2005. Health Serv Res. 2008;43(6):2143-63.

Persistence of Virologic Benefits Following Directly Administered Antiretroviral Therapy (DAART) Among Drug Users: Results from a Randomized Controlled Trial

Although directly administered antiretroviral therapy (DAART) has demonstrated impressive biological benefits compared with self-administered therapy (SAT) among drug users, the persistence of DAART after transition to SAT has not been examined. A community-based, prospective, randomized controlled trial was conducted of 6 months of DAART compared with SAT. The primary outcome was the proportion of subjects who achieved virologic success at 6 months post-intervention, defined as either a 1.0 log10 reduction from baseline or HIV-1 RNA <400 copies per milliliter. Secondary outcomes included the change from baseline in HIV-1 RNA and CD4 lymphocyte count. Of the 53 subjects in the SAT arm and 88 subjects in the DAART arm, 52 and 82, respectively, provided blood samples at 6 months post-intervention. The DAART (n = 88) and SAT (n = 53) arms did not differ on virologic success (DAART 58.0% vs. SAT 56.6%, P = 0.64), mean reduction in log10 HIV-1 RNA (-0.79 vs. -0.31 log10 copies/mL, P = 0.53), or mean change in CD4 lymphocyte count (+60.2 vs. -15.4 cells/mL, P = 0.12). In the multivariate analysis, only high levels of social support significantly predicted virologic success. This analysis, from the first randomized controlled trial of DAART among active drug users, failed to show the persistence of the DAART intervention at improving virologic outcomes. Additional strategies are needed to ensure the on-treatment benefits persist following the cessation of DAART. Maru D, Bruce R, Walton M, Springer S, Altice F. Persistence of virologic benefits following directly administered antiretroviral therapy among drug users: results from a randomized controlled trial. J Acquir Immune Defic Syndr. 2009;50(2):176-81.

Important Economic Differences Found in This Study of Male and Female Methadone Maintenance Clients

Although the number of women entering drug treatment has increased in recent years, it remains considerably lower than the estimated number of women needing such treatment. Thus, the large numbers of out-of-treatment opioid-dependent women are unable to benefit from the proven ability of drug-abuse treatment—particularly methadone maintenance treatment—to reduce drug use, HIV-risk behaviors, and crime. For this study, gender differences were explored among 355 in- and out-of-treatment opioid-addicted adults in Baltimore. Addiction Severity Index and other variables were compared among: 1) in-treatment women vs. out-of-treatment women; 2) out-of-treatment: women vs. men; and, 3) in-treatment: women vs. men. Analysis indicated that in-treatment and out-of-treatment women worked less and used more cocaine than their male counterparts (p < .01). Moreover, out-of-treatment women used heroin and cocaine more often, spent more money on drugs, earned more illegal income, and had fewer treatments than in-treatment women (p < .01). It is important to note that in the analysis of gender differences, women reported more difficulties in employment than men. Findings indicate greater severity of drug and employment problems of opioid-addicted women and underline the need for gender-specific drug-treatment services. Kelly S, Schwartz R, O 'Grady K, Mitchell S, Reisinger H, Peterson J, Agar M, Brown B. Gender differences among in- and out-of-treatment opioid-addicted individuals. Am J Drug Alcohol Abuse. 2009;35(1):38-42.

Clinicians' Attitudes Toward Evidence-Based Treatment Practices

To better understand the extent that empirically supported and promising substance abuse treatment approaches are implemented in community settings, a sample of California treatment providers were surveyed regarding their perceptions and use of several psychosocial and pharmacological treatment interventions. Program directors (n=30) and staff members (n=331) from diverse community settings rated the effectiveness and extent of use of various treatment interventions, and provided information on program and workforce characteristics via self-administered questionnaires. On average, program directors and staff rated the psychosocial treatment interventions as effective, with the exception of vouchers/motivational incentives. About half of the treatment providers did not know the effectiveness of certain pharmacological treatments, including buprenorphine and naltrexone. Respondents from the majority of programs (55%-80%) reported using Motivational Enhancement Therapy, Community Reinforcement Approach, and Supportive Expressive Psychotherapy. The extent that programs used several of the treatment interventions was related to organizational training and information resources. Variability in clinician ratings and use of these practices suggests the need for more aggressive and standardized training and research dissemination efforts. Herbeck D, Hser Y, Teruya C. Empirically supported substance abuse treatment approaches: a survey of treatment providers ' perspectives and practices. Addict Behav. 2008;33(5):699-712.

The Waterpipe: A Rapidly Developing Public Health Threat

This is a commentary by the author, a world authority on nicotine and tobacco, and a NIDA international grantee. The waterpipe, known in many cultures under different shapes and names (e.g. hookah, shisha, narghile), is a centuries-old tobacco use method that is witnessing a world-wide surge in popularity. This popularity is most noticeable among youths, and is surpassing cigarette smoking among this group in some societies. Many factors may have contributed to the recent waterpipe spread, including the introduction of sweetened/flavored waterpipe tobacco (known as Maassel), its reduced-harm perception, the thriving cafŽ culture, mass media and the internet. The passage of smoke through water on its way to the smoker underlies much of the common misperception that waterpipe use is less harmful than cigarettes. The health/addictive profile of waterpipe compared to cigarettes is largely un-researched and is likely to be influenced by the properties of smoke, duration and frequency of use, type of tobacco used, volume of smoke inhaled and the contribution of charcoal. However, the accumulation of evidence about the harmful and addictive potential of waterpipe use is outpacing the public health response to this health risk. A timely public health and policy action is needed in order to curb the emerging waterpipe smoking epidemic. Maziak W. The waterpipe: time for action. Addiction. 2008;103(11):1763-7.

First Study of Prevalence and Correlates of Illicit Methadone Use in New York City

Despite growing concern about illicit methadone use in the US and other countries, there is little data about the prevalence and correlates of methadone use in large urban areas. The authors assessed the prevalence and examined correlates of lifetime and recent illicit methadone use in New York City (NYC). 1,415 heroin, crack, and cocaine users aged 15-40 years were recruited in NYC between 2000 and 2004 to complete interviewer-administered questionnaires. The researchers found that in multivariable logistic regression, non-injection drug users who used illicit methadone were more likely to be heroin dependent, less than daily methamphet-amine users and to have a heroin using sex partner in the last two months. Injection drug users who used illicit methadone were more likely to use heroin daily, share injection paraphernalia and less likely to have been in a detoxification program and to have not used marijuana in the last six months. The results overall suggest that illicit (or street) methadone use is likely not a primary drug of choice, but is instead more common in concert with other illicit drug use. Ompad D, Fuller C, Chan C, Frye V, Vlahov D, Galea S. Correlates of illicit methadone use in New York City: a cross-sectional study. BMC Public Health. 2008;8:375-81.

Psychiatric Disorders and Repeat Incarcerations: The Revolving Prison Door

Although numerous investigations have reported substantially elevated rates of psychiatric disorders among prison inmates compared with the general population, it is unclear whether mental illness is a risk factor for multiple episodes of incarceration. The authors examined this association in a retrospective cohort study of the nation's largest state prison system. The study population included 79,211 inmates who began serving a sentence between September 1, 2006, and August 31, 2007. Data on psychiatric disorders, demographic characteristics, and history of incarceration for the preceding 6-year period were obtained from statewide medical information systems and analyzed. Inmates with major psychiatric disorders (major depressive disorder, bipolar disorders, schizophrenia, and non-schizophrenic psychotic disorders) had substantially increased risks of multiple incarcerations over the 6-year study period. The greatest increase in risk was observed among inmates with bipolar disorders, who were 3.3 times more likely to have had four or more previous incarcerations compared with inmates who had no major psychiatric disorder. Prison inmates with major psychiatric disorders are more likely than those without to have had previous incarcerations. The authors recommend expanding interventions to reduce recidivism among mentally ill inmates. They discuss the potential benefits of continuity of care reentry programs to help mentally ill inmates connect with community-based mental health programs at the time of their release, as well as a greater role for mental health courts and other diversion strategies. Baillargeon J, Binswanger I, Penn J, Williams B, Murray O. Psychiatric disorders and repeat incarcerations: the revolving prison door. Am J Psychiatry. 2009;166(1):103-9.

Impact of Patient Race on Patient Experiences of Access and Communication in HIV Care

Patient-centered care--including the domains of access and communication--is an important determinant of positive clinical outcomes. The purpose of this study was to explore associations between race and HIV-infected patients' experiences of access and communication. This was a cross-sectional survey. Nine hundred and fifteen HIV-infected adults receiving care at 14 U.S. HIV clinics participated in the study. Dependent variables included patients' reports of travel time to their HIV care site and waiting time to see their HIV provider (access) and ratings of their HIV providers on always listening, explaining, showing respect, and spending enough time with them (communication). Multivariate logistic regression was used to estimate associations between patient race and dependent variables, and random effects models to estimate site-level contributions. Patients traveled a median 30 minutes (range 1-180) and waited a median 20 minutes (range 0-210) to see their provider. On average, blacks and Hispanics reported longer travel and wait times compared with whites. Adjusting for HIV care site attenuated this association. HIV care sites that provide services to a greater proportion of blacks and Hispanics may be more difficult to access for all patients. The majority of patients rated provider communication favorably. Compared to whites, blacks reported more positive experiences with provider communication. Racial disparities were observed in patients' experience of access to care but not in patient-provider communication. Disparities were explained by poor access at minority-serving clinics. Efforts to make care more patient-centered for minority HIV-infected patients should focus more on improving access to HIV care in minority communities than on improving cross-cultural patient-provider interactions. Korthuis P, Saha S, Fleishman J, McGrath M, Josephs J, Moore R, Gebo K, Hellinger J, Beach M, Beach, M. Impact of patient race on patient experiences of access and communication in HIV care. J Gen Intern Med. 2008;23(12):2046-52.

Psychiatric Disorders, Particularly Alcohol Use Disorders, Are Common in College-Aged Populations

Although young adulthood is often characterized by rapid intellectual and social development, college-aged individuals are also commonly exposed to circumstances that place them at risk for psychiatric disorders. The objectives of this study are to assess the 12-month prevalence of psychiatric disorders, sociodemographic correlates, and rates of treatment among individuals attending college and their non-college-attending peers in the United States. Face-to-face interviews were conducted in the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (N = 43,093). Analyses were done for the subsample of college-aged individuals, defined as those aged 19 to 25 years who were both attending (n = 2188) and not attending (n = 2904) college in the previous year. The main measures were sociodemographic correlates and prevalence of 12-month DSM-IV psychiatric disorders, substance use, and treatment seeking among college-attending individuals and their non-college-attending peers. The investigators found that almost half of college-aged individuals had a psychiatric disorder in the past year. The overall rate of psychiatric disorders was not different between college-attending individuals and their non-college-attending peers. However, the unadjusted risk of alcohol use disorders was significantly greater for college students than for their non-college-attending peers (odds ratio = 1.25; 95% confidence interval, 1.04-1.50), although not after adjusting for background sociodemographic characteristics (adjusted odds ratio = 1.19; 95% confidence interval, 0.98-1.44). College students were significantly less likely (unadjusted and adjusted) to have a diagnosis of drug use disorder or nicotine dependence or to have used tobacco than their non-college-attending peers. Bipolar disorder was less common in individuals attending college. College students were significantly less likely to receive past-year treatment for alcohol or drug use disorders than their non-college-attending peers. Psychiatric disorders, particularly alcohol use disorders, are common in the college-aged population. Although treatment rates varied across disorders, overall fewer than 25% of individuals with a mental disorder sought treatment in the year prior to the survey. These findings underscore the importance of treatment and prevention interventions among college-aged individuals. Blanco C, Okuda M, Wright C, Hasin D, Grant B, Liu S, Olfson M. Mental health of college students and their non-college-attending peers: results from the National Epidemiologic Study on Alcohol and Related Conditions. Arch Gen Psychiatry. 2008; 65(12):1429-37.

Review of Adolescent Opioid Dependence: No Quick Fix - Despite Short Duration of Opioid Use

This review reports the results of an NIH-funded multisite randomized clinical trial of 2-week vs. 12-week buprenorphine-naloxone treatment of opioid-dependent patients aged 15 to 21 years (mean age, 19 years), in which both groups had their medication tapered at the end of their respective treatments. Nearly half reported injection use, and one-fifth had evidence of hepatitis C infection. The median duration of their opioid use was 1 year. The primary finding is that the 12-week treatment with buprenorphine-naloxone was associated with greater treatment retention and decreased illicit opioid use—but only during the period that medication was provided. The study used a multisite design, appropriate eligibility criteria, rigorous methods, and cogent outcomes and provided long-term follow-up. The study had a number of methodological limitations, including the trial was too small to make strong conclusions regarding the safety of buprenorphine-naloxone in this population. Despite these concerns, it is apparent that adolescent opioid-dependent patients have greater abstinence while receiving buprenorphine-naloxone. The most important finding of this study is the rate of relapse in both treatment groups following the medication taper. Past-week opioid use did not differ by treatment condition at 12 weeks or 12 months and was reported by 38% to 55% and 53% to 72% of participants, respectively. This finding is of concern given the young age of the participants and their relatively short duration of opioid use. The implication is that adolescent opioid-dependent patients, like their adult counterparts, will likely need long-term, rather than short-term, opioid agonist treatment. This is consistent with trials in adults that have compared brief methadone and buprenorphine tapers with long-term treatment (6 months to 1 year) and have consistently demonstrated better outcomes with long-term treatment. Abstinence rates and retention in treatment are uniformly improved with provision of medication over longer periods of time. These trials, conducted in adults with longer durations of opioid dependence (e.g., 5-10 years), were not previously thought to be generalizable to adolescents. The unique finding of the study by Woody et al., that young opioid-dependent patients with relatively short durations of opioid use have high rates of relapse when provided with either brief or longer tapers of agonist medications, is sobering. The results of this trial should prompt clinicians to use caution when tapering buprenorphine-naloxone in adolescent patients who receive this medication. Supportive counseling; close monitoring for relapse; and, in some cases, naltrexone should be offered following buprenorphine tapers. From a research perspective, additional efforts are needed to provide a stronger evidence base from which to make recommendations for adolescents who use opioids. There is limited research on prevention of opioid experimentation and effective strategies to identify experimentation and intercede to disrupt the transition from opioid use to abuse and dependence. No information is available regarding the efficacy of treatment with medications such as methadone or buprenorphine-naloxone compared with non-agonist approaches (e.g., naltrexone) or non-pharmacologic approaches such as short-term rehabilitation or partial hospitalization programs. The high rate of relapse seen with both medication taper protocols in the current trial involving opioid-dependent adolescents, combined with the adverse social, legal, and infectious consequences of opioid dependence—and the risk for overdose with relapse—makes the need for rigorous evidence in this area urgent. These findings are another important reminder that there are no quick fixes for opioid dependence. Fiellin D. Treatment of adolescent opioid dependence: no quick fix. JAMA. 2008;300(17):2057-9.

Analysis of NSDUH Data Suggests Link between Ecstasy Use and Poor Academic Achievement

Data on 65,294 adolescents from the 2002-2005 National Survey on Drug Use and Health were used to examine the academic achievement of adolescents who reported using ecstasy (n=1,743) compared with those who did not use drugs (n=33,497), only used alcohol and/or tobacco (n=17,015), or used marijuana but did not use ecstasy. Multinomial regressions adjusting for demographics and survey year revealed that ecstasy users were four times the odds of reporting moderate grades as non-drug users to and 12 times the odds of reporting low grades (average grade of D or lower). This compares with marijuana users who had three and six times the odds of reporting moderate and low grades and alcohol/tobacco users who had less than 2 times the odds of reporting either. Although this analysis did not establish causality, it does suggest that further research into the causal relationship between ecstasy use and academic achievement be investigated. Martins S, Alexandre P. The association of ecstasy use and academic achievement among adolescents in two U.S. national surveys. Addict Behav. 2009;34(1):9-16.

Barriers to Participation in Criminally-Mandated Treatment

This study addresses why some California Proposition 36 offenders did not enter drug treatment. Self-reported and administrative data were analyzed to compare the characteristics, perceptions, and re-arrest rates of 124 untreated and 1,335 treated offenders assessed by 30 sites in five California counties. Offenders were comparable in many domains at assessment; however, untreated offenders were younger, not employed, more criminally severe, and less motivated for treatment. Avoiding incarceration was the primary reason for choosing Proposition 36, but there were fewer untreated offenders who felt ready for treatment (12.9% vs. 35.7%) . Reasons for not entering treatment included re-arrest (31.6%), no desire for treatment (23.9%), and assignment to a program that was too far away (11.1%). Both groups had fewer total arrests after assessment, but recidivism was higher among untreated offenders. Evans E, Li L, Hser Y. Treatment entry barriers among California's Proposition 36 offenders. J Subst Abuse Treat. 2008;35:410-8.

Gender Differences in Generalized Anxiety Disorder: Results from a National Survey

The goals of this study were to assess gender differences in the epidemiology, comorbidity, and treatment-seeking patterns of DSM-IV generalized anxiety disorder (GAD) in the United States. The authors analyzed data derived from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions, a large cross-sectional survey of a representative sample (N = 43,093) of the U.S. population. The lifetime and 12-month male:female prevalence ratios of DSM-IV GAD were 1:1.9 and 1:2.2, respectively. Men with GAD had significantly higher rates of comorbid alcohol and drug use disorders, nicotine dependence, and antisocial personality disorder. Women with GAD had significantly higher rates of comorbid mood disorders (except bipolar disorder) and anxiety disorders (except social anxiety disorder). Men with GAD reported greater use of alcohol and drugs to help relieve GAD symptoms. GAD in women was associated with higher rates of family history of depression. Disability associated with GAD was greater in women than in men. Rates of treatment seeking for DSM-IV GAD were low for both genders, but particularly low among men. There are significant gender differences in the prevalence, comorbidity pattern, sociodemographic and clinical correlates, course, and treatment-seeking rates of persons with DSM-IV GAD. Increased recognition and treatment of GAD, particularly among men, could lead to substantial reductions in the societal and personal burden and improve the quality of life of those afflicted with this disorder. Vesga-L—pe O, Schneier F, Wang S, Heimberg R, Liu S, Hasin D, Blanco C. Gender differences in generalized anxiety disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). J Clin Psychiatry. 2008;69(10):1606-16.

Integrating Buprenorphine Treatment Into Office-Based Practice: A Qualitative Study

Despite the availability and demonstrated effectiveness of office-based buprenorphine maintenance treatment (BMT), the systematic examination of physicians' attitudes towards this new medical practice has been largely neglected. To study this, the authors identified facilitators and barriers to the potential or actual implementation of BMT by office-based medical providers. To accomplish this, a qualitative study using individual and group semi-structured interviews was undertaken. Twenty-three practicing office-based physicians in New England were studied. Interviews of these physicians were audiotaped, transcribed, and entered into a qualitative software program. The transcripts were thematically coded using the constant comparative method by a multidisciplinary team. It was found that: eighty percent of the physicians were white; 55% were women. The mean number of years since graduating medical school was 14 (SD = 10). The primary areas of clinical specialization were internal medicine (50%), infectious disease (20%), and addiction medicine (15%). Physicians identified physician, patient, and logistical factors that would either facilitate or serve as a barrier to their integration of BMT into clinical practice. Physician facilitators included promoting continuity of patient care, positive perceptions of BMT, and viewing BMT as a positive alternative to methadone maintenance. Physician barriers included competing activities, lack of interest, and lack of expertise in addiction treatment. Physicians' perceptions of patient-related barriers included concerns about confidentiality and cost, and low motivation for treatment. Perceived logistical barriers included lack of remuneration for BMT, limited ancillary support for physicians, not enough time, and a perceived low prevalence of opioid dependence in physicians' practices. It was concluded that addressing physicians' perceptions of facilitators and barriers to BMT is crucial to supporting the further expansion of BMT into primary care and office-based practices. Barry D, Irwin K, Fiellin D. Integrating buprenorphine treatment into office-based practice: a qualitative study. J Gen Intern Med. 2009;24(2):218-25.

Interest by Patients in Smoking Cessation Treatments

The authors surveyed 884 Vermont (VT) tobacco smokers by random digit dialing to determine past and future use of treatment. Among those who had recently attempted to quit, 61% had ever used a treatment, 21% had ever used a psychosocial treatment, and 57% had used a medication. Among those who planned to quit in the next month, 68% stated they would use a treatment, 35% would use a psychosocial treatment, and 62% would use a medication. The major predictors of past or future use of treatment were greater cigarettes per day, older age, being a woman, and seeing a health professional. Although this survey suggests many smokers have used or plan to use a smoking cessation treatment, program data indicate less than 10% of VT smokers who try to quit use the state quitline, counseling, or free medication provision. This study posed the follow-up question of; despite availability and awareness of their existence, why do smokers not use smoking cessation treatments, and can this be changed? Hughes J, Marcy T, Naud S. Interest in treatments to stop smoking. J Subst Abuse Treat. 2009;36(1):18-24.

Psychological Mediators of Bupropion Sustained-Release Treatment for Smoking Cessation

This study aimed to test simultaneously the understanding of the effects of bupropion sustained-release (SR) treatment on putative mediators and the understanding of determinants of post-quit abstinence, including withdrawal distress, cigarette craving, positive affect and subjective reactions to cigarettes smoked during a lapse. The specificity of bupropion SR effects was also tested in exploratory analyses. The study was performed using data from a randomized, placebo-controlled clinical trial of bupropion SR. Results were submitted to mediation analyses at the Center for Tobacco Research and Intervention, Madison, WI, USA. A total of 403 adult, daily smokers without contraindications to bupropion SR use were studied. Participants were assigned randomly to receive a 9-week course of bupropion SR or placebo pill and to receive eight brief individual counseling sessions or no counseling. Ecological momentary assessment ratings of smoking behavior and putative mediators were collected pre- and post-quit. Results of structural equation and hierarchical linear models did not support the hypothesis that bupropion SR treatment improves short-term abstinence by reducing withdrawal distress or affecting the subjective effects of a lapse cigarette, but provided partial support for mediation by cigarette craving reduction and enhanced positive affect. Bupropion SR effects on point-prevalence abstinence at 1 month post-quit were also mediated partially by enhanced motivation to quit and self-efficacy. Results of this study provide some support for models of bupropion SR treatment and relapse and suggested that motivational processes may partially account for bupropion SR efficacy. McCarthy D, Piasecki T, Lawrence D, Jorenby D, Shiffman S, Baker T. Psychological mediators of bupropion sustained-release treatment for smoking cessation. Addiction. 2008;103(9):1521-33.

Government Databases Offer Accurate and Valuable Outcomes Data for Addiction Treatment Systems of Care

Using administrative data to evaluate health care outcomes has become increasingly common, but the reliability and validity of outcome measures based on cross-system data linkage have been little scrutinized. Applying a deterministic data matching methodology, records for 6545 Californians admitted to 43 substance abuse treatment programs between 2000 and 2001 were matched to administrative data acquired from three state agency databases for motor vehicle driving incidents, criminal history, and mental health services utilization. Administrative data confirmed self-report results in some measures (e.g., percent of people using mental health services, percent ever arrested) and augmented and improved accuracy for results in others (e.g., frequency of service utilization, and frequency of arrests). Agreement statistics between self-report and administrative data ranged from a low of 72% for lifetime psychiatric admissions (inpatient and outpatient) to 96 and 98% for past month and past 6-month mental health hospitalizations. Criminal justice data ranged between a low of 79% for lifetime arrests to 92% for arrests in the past month. Similar to findings based on the interview data, the administrative data also revealed improvements in several domains 1-year post-treatment compared to 1-year pre-treatment. Findings illustrate the value of using administrative records for substance abuse treatment outcome evaluation, while highlighting areas for improvement for future cross-system data linkage efforts. Hser Y, Evans E. Cross-system data linkage for treatment outcome evaluation: lessons learned from the California Treatment Outcome Project. Eval Program Plann. 2008;31(2):125-35.

Initiation Associated with Adolescent Treatment Outcomes in Models that Adjust for Selection Bias

419 adolescents who presented for intake at one of four Kaiser Permanente Northern California intensive structured outpatient chemical dependency programs were followed for 12 months to determine the relationship between treatment initiation and drug use and other behavioral outcomes. Initiation was operationalized as two treatment visits within 60 days of intake. As has been done in studies of other medical treatments but rarely in studies of substance abuse treatment, instrumental variable techniques using distance to the treatment facility and difficulties in transportation as instruments were used to address selection bias. In multivariate models controlling for baseline measurements of outcomes, individual and family characteristics, referral sources, and community and site characteristics, initiation was significantly associated with school attendance, employment, and abstinence. Patients who had initiated had a 48 percentage point higher probability of attending school and a 56 percentage point lower probability of being employed at 12 months than those who had not initiated. Patients who initiated also had a 19 percentage point higher probability of being abstinent at 12 months. The study suggests the importance of testing for selection bias and controlling for it when necessary. Balsa AI, Homer JF, French MT, Weisner CM. Substance use, education, employment and criminal activity outcomes of adolescents in outpatient chemical dependency programs. J Behav Health Serv Res. 2009;36(1):75-95.

Correlates of HIV Testing Among South African Women with High Sexual and Substance-use Risk Behaviors

Despite its importance in raising awareness of HIV risk behavior and in linking HIV-positive individuals to care and treatment, research findings indicate that the HIV antibody testing rate in the general South African population remains relatively low, although knowledge of HIV testing services is high. The identification of important correlates of testing behavior can be used to improve HIV testing campaigns by refining messages that target individuals at highest risk for infection. This study uses data from an ongoing prevention intervention study in Pretoria, South Africa to identify factors that may have a greater influence on facilitating or hindering HIV testing among South African women who face a high risk for infection. The data for this study (n=425) are derived from the baseline interviews and HIV test results collected between June 2004 and January 2007. HIV testing for this study was significantly associated with education level, alcohol and cannabis use, sex trading, number of STI symptoms, physical abuse and number of visits to a clinic for medical treatment. Results suggest that more focused efforts need to be made to provide HIV testing to women who report substance use behavior, experience violence and report high-risk sexual behavior. Interventions also need to address denial of HIV infection and fear to test for HIV. Luseno W, Wechsberg W. Correlates of HIV testing among South African women with high sexual and substance-use risk behaviors. AIDS Care. 2009;21(2):178-84.

High Rate of Cigarette and Waterpipe Smoking Among Medical Students in Syria: A Cross-sectional Study

This study was performed to investigate tobacco use, beliefs and attitudes among medical students in Syria. Specifically, a cross-sectional study of a random sample of 570 medical students (first and fifth year) registered at the Damascus University Faculty of Medicine in 2006-2007 were given a self-administered questionnaire for demographic information, smoking behavior (cigarette, waterpipe), family and peer smoking, attitudes and beliefs about smoking and future role in advising patients to quit smoking. The authors found that the overall prevalence of tobacco use was 10.9% for cigarettes (15.8% men, 3.3% women), 23.5% for waterpipe (30.3% men, 13.4% women) and 7.3% for both (10.1% men, 3.1% women). Both smoking methods were more popular among the fifth year students (15.4% and 27%) compared to their younger counterparts (6.6% and 19.7%). Regular smoking patterns predominated for cigarettes (62%), while occasional use patterns predominated for waterpipes (83%). More than two thirds of students (69%) thought they might not address or would have difficulty addressing smoking in their future patients. From these findings, it was concluded that the level of tobacco use among Syrian medical students is alarming and highlights the rapidly changing patterns of waterpipe use, especially among female students. It was further suggested that medical schools should highlight this phenomenon and address it more efficiently in their curricula. Almerie M, Matar H, Salam M, Morad A, Abdulaal M, Koudsi A, Maziak W. Cigarettes and waterpipe smoking among medical students in Syria: a cross-sectional study. Int J Tuberc Lung Dis. 2008;12(9):1085-91. Benefit Limits in Health Insurance Plans in 2003 Provide Baseline against Which to Measure Success of Parity Data from a nationally-representative sample of health insurance plans (n=368) were used to determine the state of behavioral health care benefit limits and cost sharing in 2003. The survey revealed that among the plans 62% of plans that imposed day limits, 50% imposed a 60 day limit on care for all behavioral health care combined, while 50% imposed day limits below that amount. Among the 16% that imposed separate day limits on substance abuse treatment, approximately 9% had limits of 60 days, 40% had limits of 30 days while 50% had limits of less than 30 days. Data from the survey also revealed that the average out-of-pocket costs of 20 substance abuse treatment limits was $400, the costs for 50 visits were $2,400. Hodgkin D, Horgan C, Garnick D, Merrick E. Benefit limits for behavioral health care in private health plans. Adm Policy Ment Health. 2009;36(1):15-23.

Health-related Quality of Life in HIV-infected Patients: The Role of Substance Use

HIV infection and substance use disorders are chronic diseases with complex contributions to health-related quality of life (HRQOL). A cross-sectional survey was conducted of 951 HIV-infected adults receiving care at 14 HIV Research Network sites in 2003 to estimate associations between HRQOL and specific substance use among HIV-infected patients. HRQOL was assessed by multi-item measures of physical and role functioning, general health, pain, energy, positive affect, anxiety, and depression. Mental and physical summary scales were developed by factor analysis. Linear regression was used to estimate adjusted associations between HRQOL and current illicit use of marijuana, analgesics, heroin, amphetamines, cocaine, sedatives, inhalants, hazardous/binge alcohol, and drug use severity. Current illicit drug use was reported by 37% of subjects. Mental HRQOL was reduced for current users [adjusted beta coefficient -9.66, 95% confidence interval [(CI]) -13.4, -5.94] but not former users compared with never users. Amphetamines and sedatives were associated with large decreases in mental (amphetamines: beta = -22.8 [95% CI -33.5, -12.0], sedatives: beta = -18.6 [95% CI -26.2, -11.0]), and physical HRQOL (amphetamines: beta = -11.5 [95% CI -22.6, -0.43], sedatives: beta = -13.2 [95% CI -21.0, -5.36]). All illicit drugs were associated with decreased mental HRQOL: marijuana (beta = -7.72 [95% CI -12.0, -3.48]), non-prescription analgesics (beta = -13.4 [95% CI -20.8, -6.07]), cocaine (beta = -10.5 [95% CI -16.4, -4.67]), and inhalants (beta = -14.0 [95% CI -24.1, -3.83]). Facilitating sobriety for patients with attention to specific illicit drugs represents an important avenue for elevating HRQOL in patients living with HIV. Korthuis P, Zephyrin L, Fleishman J, Saha S, Josephs J, McGrath M, Hellinger J, Gebo K, for the HIV Research Network. Health-related quality of life in HIV-infected patients: the role of substance use. AIDS Patient Care STDs. 2008;22(11):859-67.

The Dynamic Assessment and Referral System for Substance Abuse (DARSSA): Computer System to Screen and Refer Patients to Treatment

The Dynamic Assessment and Referral System for Substance Abuse (DARSSA) conducts a computerized substance abuse assessment; prints personalized summary reports that include tailored substance abuse treatment referral lists; and, for individuals who provide authorization, automatically faxes their contact information to a "best match" substance abuse treatment provider (dynamic referral). After piloting the program, the authors enrolled a sample of 85 medical patients. The DARSSA identified 48 (56%) participants who were risky substance users, many of whom had not been identified during their routine medical assessment. Mean satisfaction scores for all domains ranged between "Good" to "Excellent" across patients, nurses, doctors, and substance abuse treatment providers. The median completion time was 13min. Of the 48 risky substance using participants, 20 (42%) chose to receive a dynamic referral. These findings show that DARSSA provides a user-friendly, desirable service for patients and providers. It has the potential to improve identification of substance abuse in medical settings and to provide referrals that would not routinely be provided. Future studies are planned to establish its efficacy at promoting treatment initiation and abstinence. Boudreaux E, Bedek K, Gilles D, Baumann B, Hollenberg S, Lord S, Grissom G. The dynamic assessment and referral system for substance abuse (DARSSA): development, functionality, and end-user satisfaction. Drug Alcohol Depend. 2009;99(1-3):37-46.

Emergency Department Initiated Treatments for Tobacco (EDITT): A Pilot Study

Emergency departments (EDs) have strong potential to initiate tobacco interventions with economically disadvantaged populations. The authors piloted three ED-initiated tobacco interventions and derived parameter estimates for future trials. The study enrolled adult patients being treated in an urban ED who were daily smokers. Exclusion criteria included severe illness or pain, isolation (for contagion), altered mental status, an insurmountable language barrier, temporary residence, and lack of telephone access. Subjects in the Bedside + Booster group received motivational counseling by a trained counselor at the bedside, up to three telephone sessions post-visit, and a self-help guide. Subjects in the Faxed Referral group had their personal contact information faxed to the hospital's tobacco dependence clinic, whereupon they received identical treatment as the Bedside + Booster group, but all sessions occurred over the telephone (i.e., no bedside counseling). The Standard Referral group received the self-help guide and a referral to the hospital's tobacco dependence clinic. A 2:2:1 randomization schedule was used to maximize the experience with the motivational interventions. Outcomes were assessed at 1 and 3 months. The study enrolled 90 subjects. Of the 36 subjects assigned to the Bedside + Booster condition, 31 (87%) completed bedside counseling and at least one booster session, while 22 (61%) completed the maximum four sessions. Of the 37 subjects assigned to the Faxed Referral group, 28 (76%) completed at least one telephone session, while 19 (51%) completed the maximum four sessions. Quit attempts over the 3 months ranged from 18% (Standard Referral) to 57% (Faxed Referral). Seven-day abstinence was attained by 8% (Bedside + Booster), 14% (Faxed Referral), and 6% (Standard Referral) at 3 months. These preliminary findings show Motivational cessation counseling can be feasibly initiated during the ED encounter with minimal medical staff involvement. Adequately powered trials are needed to study ED-initiated interventions that include post-visit follow-up. Boudreaux E, Baumann B, Perry J, Marks D, Francies S, Camargo C, Ziedonis D. Emergency department initiated treatments for tobacco (EDITT): a pilot study. Ann Behav Med. 2008;36(3):314-25.

Training Physicians to Treat Substance Use Disorders

The importance of training physicians to effectively assess and manage substance use disorders has become increasingly recognized. The authors highlight published studies that enhance medical curricula and common teaching practices are identified. Preferable curricula incorporate interactive teaching methods along with experiential and didactic components. Addiction specialists serve an important role in training programs designed for medical students and residents (i.e., role models) and practicing physicians (i.e., clinical support). Further integration of online training into current programs may expand and enhance training opportunities. Polydorou S, Gunderson E, Levin F. Training physicians to treat substance use disorders. Curr Psychiatry Rep. 2008;10(5):399-404.

Promoting Substance Use Education Among Generalist Physicians: An Evaluation of the Chief Resident Immersion Training (CRIT) Program

Education about substance use (SU) disorders remains inadequate in medical training. The purpose of this paper is to describe the Chief Resident Immersion Training (CRIT) program in addiction medicine and to evaluate its impact on chief resident (CR) physicians' substance use knowledge, skills, clinical practice, and teaching. The authors conducted a controlled educational study of CRIT programs (2003, 2004, and 2005) for incoming CRs in generalist disciplines. Intervention CRs were trained to diagnose, manage, and teach about SU. The control CRs sought but did not receive the intervention. The study group consisted of eighty-six CR applicants to the CRIT program. The program was evaluated by baseline and 6-month questionnaires assessing substance use knowledge, skills, clinical practice, and teaching. Outcomes were compared within groups from baseline to follow-up and between groups at follow-up. It was found that the intervention (n = 64) and control (n = 22) CRs were similar demographically. At 6-month follow-up, the intervention CRs reported a significant increase in SU knowledge, confidence, and preparedness to diagnose, manage, and teach and an increase in SU clinical and teaching practices compared to their baseline and control CRs. This study shows that intensive training for chief residents (CRs) improved knowledge, confidence, and preparedness to diagnose, manage, and teach about substance use (SU), affecting both the CRs' SU clinical and teaching practices. The CRIT program was an effective model for dissemination of SU knowledge and skills to educators in a key position to share this training with a broader audience of medical trainees. This model holds potential to address other high priority medical, yet under-addressed, content areas as well. Alford D, Bridden C, Jackson A, Saitz R, Amodeo M, Barnes H, Samet J. Promoting substance use education among generalist physicians: an evaluation of the Chief Resident Immersion Training (CRIT) Program. J Gen Intern Med. 2009;24(1):40-7.

Latent Class Pattern Mixture Models Offer a Superior Method for Analyzing Therapeutic Groups With Rolling Attendance

Historically, difficulties in analyzing treatment outcome data from open-enrollment groups have led to their avoidance in use in federally funded treatment trials despite the fact that 79% of treatment programs use open-enrollment groups. Latent class pattern mixture models (LCPMM) have shown promise as a defensible approach for making overall (and attendance-class-specific) inferences from open-enrollment groups with membership turnover. A statistical simulation study was conducted that compared LCPMMs to the commonly used longitudinal growth model (LGM) to understand when both frameworks are likely to produce conflicting inferences concerning overall treatment efficacy. LCPMMs performed well under all conditions examined; meanwhile, LGMs produced problematic levels of bias and Type I errors under two joint conditions: moderate to high dropout (30%-50%) and treatment by attendance class interactions exceeding Cohen's d approximately .2. This study highlights key concerns about using LGM for open-enrollment data: treatment effect overestimation and advocacy for treatments that may be ineffective in reality. Morgan Lopez AA, Fals-Stewart W. Consequences of mis-specifying the number of latent treatment attendance classes in modeling group membership turnover within ecologically valid behavioral treatment trials. J Subst Abuse Treat. 2008;35:396-409.

Long-term Strategic Planning Buffers Job Stress For Clinic Directors

Performance demands and pressure to make decisions via a centralized vertical chain of command were shown to cause emotional exhaustion and subsequent intent to quit among a large randomly-selected, national sample of 766 directors of drug abuse treatment provider organizations. Structural equation modeling showed that directors who engaged in long-term strategic planning were less likely to show emotional exhaustion and turnover intention than those who did not strategically plan (RMSEA=.04, SRMR=.041, CFI=.95, TLI=.94, BIC=47919.14). Knudsen HK, Ducharme LJ, Roman PM. Turnover intention and emotional exhaustion at the top: adapting the job demands resources model to leaders of addiction treatment organizations. Journal of Occupational Health Psychology. 2009;14(1):84-95.

Labor Outcomes For An Intensive Case Management Program Targeting TANF Applicants With Substance Use Disorders

The authors examined abstinence rates among substance-dependent women receiving Temporary Assistance for Needy Families (TANF) in intensive case management (ICM) over 24 months and whether ICM yielded significantly better employment outcomes compared with a screen-and-refer program (i.e., usual care). Substance-dependent (n = 302) and non-substance dependent (n = 150) TANF applicants in Essex County, New Jersey, were recruited. The study procedure randomly assigned substance-dependent women to ICM or usual care and interviewed women at 3, 9, 15, and 24 months. Abstinence rates were higher for the ICM group than for the usual care group through 24 months of follow-up (odds ratio [OR] = 2.11; 95% confidence interval [CI] = 1.36, 3.29). A statistically significant interaction between time and group on number of days employed indicated that the rate of improvement over time in employment was greater for the ICM group than for the usual care group (incidence rate ratio = 1.03; 95% CI = 1.02, 1.04). Additionally, there were greater odds of being employed full time for those in the ICM group (OR = 1.68; 95% CI = 1.12, 2.51). ICM is a promising intervention for managing substance dependence among women receiving TANF and for improving employment rates among this vulnerable population. Morgenstern J, Neighbors C, Kuerbis A. Abstinence and employment outcomes for substance-dependent women receiving temporary assistance for needy families with intensive case management. Am J Public Health. 2009;99(2):328-33.

Trends in Use of Prescription Opioid Medication by the Type of Noncancer Pain, From 2000-2005, Among Arkansas Medicaid and Health-Core Enrollees: Results From the TROUP Study

Use of prescription opioids for noncancer pain has increased significantly in recent years, but it is not known if trends differ among the most common noncancer pain conditions. The researchers examined trends in opioid prescribing for the years 2000 through 2005 for individuals with arthritis/joint pain, back pain, neck pain, and headaches by type and number of pain diagnoses, using data from claims records from 2 health insurers: HealthCore commercially insured members (N = 3,768,223) and Arkansas Medicaid (N = 127,866). Rates of headache, back pain, and neck pain diagnoses increased significantly in Arkansas Medicaid enrollees but more modestly among HealthCore enrollees. Rates of opioid use increased in both groups, with long-term use (>90 days '' supply per year) increasing at twice the rate of any use. It was found that rates of opioid use did not differ widely between noncancer pain conditions, but long-term opioid use rates doubled with each additional pain diagnosis. Mean days supply and cumulative yearly dose increased between 2000 and 2005 for all pain types and with increasing number of pain diagnoses, but dose per day supply remained relatively stable. The greatest increases in dose among all the pain conditions were seen in short-acting DEA Schedule II opioids. This study demonstrates increased use of opioids, particularly long-term use, in noncancer pain over a 6-year period among those with multiple pain types. These results appear to reflect a general increase in use of prescription opioids for noncancer pain rather than a condition-specific change in prescribing practices. Braden J, Fan M, Edlund M, Martin B, DeVries A, Sullivan M. Trends in use of opioids by noncancer pain type 2000-2005 among Arkansas Medicaid and Health-Core enrollees: results from the TROUP study. J Pain. 2008;9(11):1026-35.

Smoking, Barriers to Quitting, and Smoking-Related Knowledge, Attitudes, and Patient Practices Among Male Physicians in China

Successful interventions to reduce the high rate of smoking among male physicians in China might contribute to reduction in tobacco use in the country overall. Better characterization of smoking, barriers to quitting, and smoking-related knowledge, attitudes, and patient practices in this physician population will help plan such interventions and provide baseline data to evaluate their effectiveness. The authors conducted a self-administered survey of smoking-related knowledge, attitudes, behaviors, and patient practices among health care professionals in 2 large teaching hospitals in China. It was found that of 103 male physicians, those who smoked (n = 51) had a more limited knowledge of smoking-related disease and were less likely to advise patients to quit smoking compared with nonsmoking physicians (n = 52). More than one-fourth (29%) of nonsmoking physicians accepted gift cigarettes, and these physicians were less likely to ask their patients about their smoking status than those who did not accept gift cigarettes. Seventy-five percent of smokers reported that their hospitals did not help them quit, and only 19% reported receiving training in how to help their patients quit. From this study it can be concluded that high rates of smoking, gifting of cigarettes, limited support for physician quitting, and limited training on cessation approaches may compromise the ability of male physicians in China to effectively treat their patients who smoke. Ceraso M, McElroy J, Kuang X, Vila P, Du X, Lu L, Ren H, Qian N, Jorenby D, Fiore M. Smoking, barriers to quitting, and smoking-related knowledge, attitudes, and patient practices among male physicians in China. Prev Chronic Dis. 2009; 6(1):A06-A08.

Individual and Community Risk Factors and Sexually Transmitted Diseases Among Arrested Youths: A Two-Level Analysis

High rates of infection for chlamydia and gonorrhea have been noted among youths involved in the juvenile justice system. Although both individual and community-level factors have been found to be associated with sexually transmitted disease (STD) risk, their relative importance has not been tested in this population. Study participants were newly arrested juveniles aged 12-18 processed at the Hillsborough County, FL Juvenile Assessment Center (HJAC) (a centralized intake facility) (male n = 506; female n = 442). A two-level logistic regression analysis was completed to assess the influence of individual-level and community-level predictors on STD test results among arrested youths processed at a centralized intake facility. Results from weighted two level logistic regression analyses indicated individual-level factors of gender (being female), age, race (being African American), and criminal history predicted the youths' positive STD status. Although marijuana and cocaine use, as assessed by UA, were significantly associated with STD status in bivariate analyses, these variables did not emerge as significant in multivariate analyses. For the community-level predictors, concentrated disadvantage significantly and positively predicted the youths' STD status. Implications of these findings for future research and public health policy are discussed. Dembo RSB, Childs S, Wareham J, Schmeilder J. Individual and community risk factors and sexually transmitted diseases among arrested youths: a two level analysis. J Behav Med. 2009;1-14.

Treatment Cost Analysis Tool for Directors Successfully Adapted From Research

A Microsoft¨ Excel-based workbook designed for research analysts to use in a national study was retooled for treatment program directors and financial officers to allocate, analyze, and estimate outpatient treatment costs in the U.S. This instrument can also be used as a planning and management tool to optimize resources and forecast the impact of future changes in staffing, client flow, program design, and other resources. The Treatment Cost Analysis Tool (TCAT) automatically provides feedback and generates summaries and charts using comparative data from a national sample of non-methadone outpatient providers. TCAT was used by program staff in 115 programs across 9 states to capture and allocate both economic and accounting costs, and outpatient service costs are reported for a sample of 70 programs. Costs for an average episode of treatment in regular, intensive, and mixed types of outpatient treatment were $882, $1310, and $1381 respectively (based on 20% trimmed means and 2006 dollars). An hour of counseling cost $64 in regular, $85 intensive, and $86 mixed. Group counseling hourly costs per client were $8, $11, and $10 respectively for regular, intensive, and mixed. Future directions include use of a web-based interview version, much like some of the commercially available tax preparation software tools, and extensions for use in other modalities of treatment. Flynn PM, Broome KM, Beaston-Blaackman A, Knight DK, Horgan CM, Shepard DS. Treatment cost analysis tool (TCAT) for estimating costs of outpatient treatment services. Drug Alcohol Depend. 2009;100:47-53.

Levels of Patient-Counselor Rapport Are Reflected in Topics Discussed in Therapy

Counselor ratings of rapport with 330 private, for-profit methadone clients found that topics addressed in counseling sessions were influenced by rapport. Higher rapport was associated with addressing clients with a more "supportive approach" that emphasized relapse prevention and strengths-building while lower rapport was associated with a punitive counseling style that stressed program rules and compliance. The influences of client background, counselor differences, and during-treatment positive urines were also examined. Although counselors differed in their general manner of dealing with clients, each also showed flexibility determined in part by client behavior (such as continued cocaine use). Joe GW, Simpson DD, Rowan-Szal GA. Interaction of counseling rapport and topics discussed in sessions with methadone treatment clients. Subst Use Misuse. 2009;44:3-17.

Key Informant Surveys Less Costly, Just as Accurate as Other Cost Data Collection Methods

Cost data were collected from a convenience sample of 27 methadone programs in 12 states to determine if there were any differences in information obtained via 3 methods: A key informant method, a staff time survey method, and a staff time allocation method. The key informants, the program directors, were asked to fill out the Substance Abuse Services Cost Analysis Program survey which has been used in other costing studies. The staff survey was given to primary staff including counselors, case managers, and medical, management and administrative staff. Each primary staff person was asked to allocate his or her time across the services and activities as those represented in the SASCAP based on a typical week over the past month. In the staff diary method, each primary staff was asked to record actual hours worked for 7 consecutive days and to allocate his or her time across the same service and activity categories. For most service and activity categories, the cost estimates were statistically indistinguishable from one another. However there were differences in the initial patient assessment and initial medical services activities. For these services, key informants estimated that each staff member participated in less than 6 sessions per week which lasted more than 100 minutes per session. Both staff surveys and staff diaries suggested that staff members took part in more than 20 sessions per week, spending less than 50 minutes per session. This likely is because the key informant was reporting on an entire session, while the staff members were reporting on the component parts in which they may have participated. This was not an issue for other services which were usually provided by one person. Because the key informants estimates of these issues matched the number of admissions per week the key informant method was deemed most accurate. Given that the key informant method requires far less staff time to complete, and that response rates were higher for this method than the other methods, these findings suggest that it may be the most economical way to collect accurate data. Zarkin G, Dunlap L, Wedehase B, Cowell A. The effect of alternative staff time data collection methods on drug treatment service cost estimates. Eval Program Plan. 2008;31(4):427-35.

Explaining Job Turnover Among Treatment Program Administrators

Although there is a growing literature on job stress and burnout among addiction treatment counselors, there has been no analogous research on the top administrators of addiction treatment programs. Stability in these occupations is important as administrators make key decisions about service delivery, including the adoption and implementation of evidence-based practices. Using a sample of 410 administrators of public and private sector specialty care programs, the authors estimated a structural equation model to examine the impact of job demands and job resources on emotional exhaustion and intent to leave the organization. The study's findings indicated that burnout and intent to quit were higher among administrators who were under pressure to meet financial performance targets; maintained centralized decision making structures; failed to engage in long-range strategic planning; and expressed lower tolerance for risk and innovation. Knudsen HK, Ducharme LJ, Roman PM. Turnover intention and emotional exhaustion at the top: adapting the job demands-resources model to leaders of addiction treatment organizations. J Occup Health Psychol. 2009;14:84-95.

The Importance of Examining the Role of Quality of Life Satisfaction in Addiction Recovery

Quality of life (QOL) remains the missing measurement in the addictions arena and is generally underutilized as an outcome variable in addiction health services research. The few studies conducted to date show that QOL is typically poor during active addiction and improves as a function of remission. An intriguing question bears on the role of QOL in subsequent remission status. Reasoning that higher life satisfaction may "increase the price" of future use and thus enhance the likelihood of sustained remission, this exploratory study tests the hypotheses that QOL satisfaction prospectively predicts sustained remission, and that motivational constructs mediate the association. Inner city residents (N = 289, 53.6% male, mean age 43) remitting from chronic and severe histories of dependence to crack and/or heroin were interviewed three times at yearly interval beginning in April 2003. Logistic regression findings generally support the authors' hypotheses: Controlling for other relevant variables, baseline life satisfaction predicted remission status 1 and 2 years later and the association was partially mediated by motivation (commitment to abstinence) although the indirect effect did not reach statistical significance. Findings underline the importance of examining the role of QOL satisfaction in remission processes. Limitations of this exploratory study are discussed, including the use of a single-item global life satisfaction rating; suggestions for future studies are discussed including the need to embrace QOL as a bona fide clinical outcome and to use comprehensive standardized QOL measures that speak to individual dimensions of functioning. Implications are noted, especially the need for the addiction field to continue moving away from the pathology-focused model of care toward a broader model that embraces multiple dimensions of positive health as a key outcome. Laudet A, Becker J, White W. Don 'T Wanna Go Through That Madness No More: quality of life satisfaction as predictor of sustained remission from illicit drug misuse. Subst Use Misuse. 2009;44(2) 227-52.

A Method for Longitudinal Analysis of Variable and Invariant Patient Factors Improves Validity and Clarity of Results

The analysis of longitudinal data to study changes in variables measured repeatedly over time has received considerable attention in many fields. This paper proposes a two-level structural equation model for analyzing multivariate longitudinal responses that are mixed continuous and ordered categorical variables. The first-level model is defined for measures taken at each time point nested within individuals for investigating their characteristics that are changed with time. The second level is defined for individuals to assess their characteristics that are invariant with time. The proposed model accommodates fixed covariates, nonlinear terms of the latent variables, and missing data. A maximum likelihood (ML) approach was developed for the estimation of parameters and model comparison. Results of a simulation were compared to an actual longitudinal study concerning cocaine use indicate that the performance of the ML estimation is satisfactory. Song X, Lee S, Hser Y. A Two-level structural equation model approach for analyzing multivariate longitudinal responses. Stat Med. 2008;27(16):3017-41.

The Use of Recursive Partitioning in the Analysis of Addiction Treatment Retention Data

Recursive Partitioning (RP) is a statistical technique that examines all available predictors and identifies a hierarchy of variables that are, in succession, most related to the outcome measure. It is an exploratory technique, not necessarily based on conceptual or theoretical modeling. The aim of this study is to demonstrate the utility of RP for analyzing process and outcome data in drug treatment research. The authors introduce the basic methodology of RP and apply the procedure to the prediction of treatment retention. In the data analysis, a total of 315 individuals randomly were assigned to one of two treatment conditions; 289 (91.7%) completed a comprehensive baseline assessment battery. Treatment retention was assessed at a 52-week follow-up interview. The RP approach was successful in generating a parsimonious decision tree that predicted drug treatment retention from the 195 input variables. Severity of drug use (as indicated by length of time speedballing, the concurrent use of heroin and cocaine mixed and injected intravenously), criminal behavior (as indicated by history of property crimes), level of insight (an assessment of an individual's understanding of the damage that their drug use was causing), social network, and age at intake were predictive of treatment retention. The model is estimated to explain 32% of the variability in the population. RP supports the notion that there are early indicators of treatment retention and that specific approaches that are tailored to individuals' needs will be potentially more successful in treatment engagement and retention than the typical "one size fits all" approach. The results also demonstrate the utility of RP for the detection of complex relationships between diverse and interdependent predictors. Hellemann G, Conner B, Anglin M, Longshore D. Seeing the trees despite the forest: applying recursive partitioning to the evaluation of drug treatment retention. J Subst Abuse Treat. 2009;36(1);59-64.

Health Insurance Plans Change Strategies for Managing Behavioral Health Care

Survey data from nationally-representative samples of health insurance plans in 1999 (n=434) and 2003 (n=368) were used to examine changes over time in how plans provide and managed behavioral health services. Among the findings: Plans were more likely to contract with managed behavioral health organizations in 2003 than they were in 1999, moving from 58% of products to 72% of products. At the same time, the percentage of plans requiring prior authorization for outpatient detoxification, and outpatient rehabilitation declined by 15.9 and 22.8 percentage points respectively, which might increase access to care, while the percentage requiring prior authorization for intensive outpatient increased slightly by 2.8 percentage points. Cost sharing requirements for behavioral health care services, however, increased over the time period, as the percentage of plans with coinsurance requirements of greater than 20% and co-payments of greater than $20 per visit increased from 25.7% in 1999 to 42.1% in 2003. This may reduce access given that the demand for behavioral health care has been found to be quite price-sensitive. Horgan CM, Garnick DW, Merrick EL, Hodgkin D. Changes in how health plans provide behavioral health services. J Behav Health Serv Res. 2009;36(1):11-24.

Visualizations of Cognitive-Emotional Experience Is A Useful Tool for Structuring CBT

This article reviews the 20-plus year history and progress of node-link cognitive mapping as a useful strategic tool for cognitive therapists. Cognitive visualizations provided by patients can help structure more productive therapeutic sessions and also offers a useful tool for training new therapists. Mapping has been shown to enhance patient collaboration in treatment and improve engagement when used in conjunction with other approaches. Dansereau DF, Simpson, DD. A picture is worth a thousand words: the case for graphic representations. Professional Psychology: Reseach & Practice. 2009;40(1):104-110.

Criminal Thinking Style Is An Important Factor in UK Prison Addiction Treament

This study examines 199 male drug users diverted into criminal justice system treatment in Birmingham England to assess their treatment engagement and criminal thinking styles using the Texas Christian University Client Evaluation of Self and Treatment scale and the Criminal Thinking Scale. UK inmates scored similar to US norms for average desire for help and need for treatment, but slightly higher than US inmates on treatment readiness. UK inmates reported higher treatment engagement and satisfaction than US samples. An association was found between higher criminal thinking and both poorer engagement in treatment and worse client functioning (r=-.28; p<.001). The key implication is that to address offending-prone behavior as a determinant of ongoing drug use. Results indicated that criminal thinking styles are an important element in inmate engagement in addiction treatment. Best D, Day E, Campbell A, Flynn PM, Simpson DD. Relationship between drug treatment engagement and criminal thinking style among drug-using offenders. Eur Addict Res. 2009;15:71-7.

Epidemiology of Chronic Prescription Opioid Use: Results From a Major National, Population-Based Survey

Chronic pain occurs commonly and accounts for significant suffering and costs. Although use of opioids for treatment of chronic pain is increasing, little is known about patients who use opioids regularly. The researchers report data from the second wave of the Healthcare for Communities survey (2000-2001), a large, nationally representative household survey. They compared regular users of prescription opioids to nonusers of opioids and calculated the percentage of individuals within a given demographic or disease state that reported chronic opioid use. Approximately 2% of the 7,909 survey respondents reported use of opioid medications for at least a month, which the Healthcare for Communities survey defined as "regular use." It was found that opioid users were more likely than nonusers to report high levels of pain interference with their daily lives and to rate their health as fair or poor. Arthritis and back pain were the most prevalent chronic, physical health conditions among users of opioids, with 63% of regular users of opioids reporting arthritis and 59% reporting back pain. The majority of regular users of opioids had multiple pain conditions (mean=1.9 pain conditions). This study indicates that regular opioid users appear to have an overall lower level of health status and to have multiple, chronic physical health disorders. Hudson T, Edlund M, Steffick D, Tripathi S, Sullivan M. Epidemiology of regular prescribed opioid use: results from a national, population-based survey. J Pain Symptom Manage. 2008;36(3):280-8.