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CORK Bibliography: Assessments

76 citations. January 2010 to present

Prepared: September 2011

Accornero VH; Anthony JC; Morrow CE; Xue L; Mansoor E; Johnson AL et al. Estimated effect of prenatal cocaine exposure on examiner-rated behavior at age 7 years. Neurotoxicology and Teratology 33(3): 370-378, 2011. (69 refs.)

Prenatal cocaine exposure has been linked to increased child behavior difficulties in some studies but not others. Objective: The primary aim was to estimate the relationship between in utero cocaine exposure and child behavioral functioning at age 7 years with ratings made by blinded examiners during a structured testing session. A second aim was to examine whether caregiver drug use and psychological problems might mediate suspected relationships between prenatal cocaine exposure and aspects of examiner-rated behavior. Methods: 407 children (212 cocaine-exposed, 195 non-exposed) participating in the longitudinal Miami Prenatal Cocaine Study (MPCS) were rated with regard to their behavior during a neuropsychological assessment conducted at age 7 years. Raters were trained research psychometricians blinded to drug exposure status. Individual behavioral items were summarized and the cocaine-behavior relationship was estimated within the context of latent variable modeling, using Mplus software. Results: Two latent variables, Behavioral Regulation and Sociability, were derived via exploratory latent structure analysis with promax rotation. Prenatal cocaine exposure, statistically controlling for child sex, test age, and prenatal exposure to alcohol, tobacco, and marijuana, was associated with Behavioral Regulation (estimated slope beta = -0.25; 95% CI = -0.48. -0.02; p = 0.04) but not Sociability (estimated slope beta = 0.03; 95% Cl = -0.26, 0.20; p = 0.79). Neither postnatal drug use by caregivers nor the severity of their psychological problems at age 5 follow-up predicted levels of child Behavioral Regulation or Sociability at age 7 years (p>0.10). Conclusions: Examiner ratings of child behavior at age 7 revealed less optimal behavioral regulation for prenatally cocaine-exposed compared to non-exposed children, in contrast with what had been previously found from parent-report data. This evidence highlights the potential value of trained observers in assessing behavioral outcomes of children exposed in utero to drugs and other toxicants.

Alterman AI; Cacciola JS; Dugosh KL; Ivey MA; Coviello DM. Measurement of mental health in substance use disorder outpatients. Journal of Substance Abuse Treatment 39(4): 408-414, 2010. (30 refs.)

Few studies have examined mental health (MH) attributes of patients with substance use disorder (SUD) This study examines the internal consistency, concurrent validity, and comparative level of MH attributes (i.e., optimism, life attitudes, spirituality/religiousness, social support, positive mood, hope, and vitality) in patients with SUD compared with the instrument development group The internal consistency of optimism, spirituality/religiousness positive mood, hope and vitality were similar in both groups Some subscales of the social support and life attitude measures had lower internal consistency than was found for the original samples, although internal consistency of more global constructs were comparable Patients with SUD had higher positive mood, spirituality/religiousness, and hope scores, whereas social support, life attitudes and optimism scores were lower than in the original sample Correlations between MH attributes and recent life problems of patients with SUD generally supported the concurrent validity of the MH measures.

Barrett B; Fogel SJ; Garrett J; Young MS. Assessing health care needs among street homeless and transitionally housed adults. Journal of Social Service Research 37(3): 338- 350, 2011. (56 refs.)

This study examined the health services received and needed among homeless persons in Hillsborough County, FL (N = 823). Lifetime and current need and receipt of health services were assessed with a cross-sectional survey. Participants reported extensive lifetime and current needs for physical and behavioral health care services. Nearly a third of participants reported current unaddressed health problem(s); an inability to obtain needed health care; and feelings of unaddressed mental health issue(s) as well as substance abuse problem(s) in the past year. Future research on homelessness and health should focus on identifying different pathways to health and mental health services for this vulnerable population and the outcomes of these interventions.

Bewick BM; West R; Gill J; O'May F; Mulhern B; Barkham M; Hill AJ. Providing web-based feedback and social norms information to reduce student alcohol intake: A multisite investigation. Journal of Medical Internet Research 12(5): e-article 59, 2010. (37 refs.)

Background: Unhealthy alcohol use among university students is cause for concern, yet the level of help seeking behavior for alcohol use is low within the student population. Electronic brief interventions delivered via the Internet present an alternative to traditional treatments and could enable the delivery of interventions on a population basis. Further evidence is needed of the effectiveness of Internet-delivered interventions and of their generalizability across educational institutions. Objective: Our objective was to evaluate the effectiveness across 4 UK universities of a Web-based intervention for student alcohol use. Methods: In total, 1112 participants took part. Participants were stratified by educational institution, gender, age group, year of study, and self-reported weekly consumption of alcohol and randomly assigned to either the control arm or to the immediate or delayed intervention arms. Intervention participants gained access to the intervention between weeks 1 to 7 or weeks 8 to 15, respectively. The intervention provided electronic personalized feedback and social norms information on drinking behavior accessed by logging on to a website. Participants registered interest by completing a brief screening questionnaire and were then asked to complete 4 further assessments across the 24 weeks of the study. Assessments included a retrospective weekly drinking diary, the Alcohol Use Disorders Identification Test (AUDIT), and a readiness-to-change algorithm. The outcome variable was the number of units of alcohol consumed in the last week. The effect of treatment arm and time on units consumed last week and average units consumed per drinking occasion were investigated using repeated measures multivariate analysis of covariance (MANCOVA). In addition, the data were modeled using a longitudinal regression with time points clustered within students. Results: MANCOVA revealed a main effect of time on units of alcohol consumed over the last week. A longitudinal regression model showed an effect of assessment across time predicting that participants who completed at least 2 assessments reduced their drinking. The model predicted an additional effect of being assigned to an intervention arm, an effect that increased across time. Regression analysis predicted that being male or being assigned to an intervention arm increased the odds of not completing all assessments. The number of units of alcohol consumed over the last week at registration, age, university educational institution, and readiness to change were not predictive of completion. Conclusions: Delivering an electronic personalized feedback intervention to students via the Internet can be effective in reducing weekly alcohol consumption. The effect does not appear to differ by educational institution. Our model suggested that monitoring alone is likely to reduce weekly consumption over 24 weeks but that consumption could be further reduced by providing access to a Web-based intervention. Further research is needed to understand the apparent therapeutic effect of monitoring and how this can be utilized to enhance the effectiveness of brief Web-based interventions.

Brackley MH; Williams GB; Wei CC. Substance abuse interface with intimate partner violence: What treatment programs need to know. Nursing Clinics of North America 45(4): 581-+, 2010. (18 refs.)

This article provides suggestions for skill development for substance abuse (SA) treatment agencies and providers for implementing Treatment Improvement Protocol number 25: Substance Abuse Treatment and Domestic Violence. Methods for detecting, screening, intervening, and referring victims and perpetrators of intimate partner violence enrolled in SA treatment are presented. Evidence-based brief intervention is presented. A 2-minute screen for domestic violence as well as danger assessment for lethality of abuse and the Conflict Tactics Scales 2 are reviewed. A survey of interventions aimed at establishing trust, brief intervention from best practice, guidelines for safety planning, compliance strategies for SA treatment, and community resource development are presented.

Byrne MM; Davila EP; Zhao W; Parker D; Hooper MW; Caban-Martinez A et al. Cancer screening behaviors among smokers and non-smokers. Cancer Epidemiology 34(5): 611-617, 2010. (45 refs.)

Objective: We explored whether smoking is associated with cancer screening behaviors. Methods: We used data from the 2007 Florida Behavioral Risk Factor Surveillance Systemem and the Florida Tobacco Callback Survey to examine screening behaviors related to four cancer types (breast, cervical, prostate, and colorectal). Using multiple logistic regression analyses, we examined the association between smoking status and health screening behaviors. Results: For 10 of the 11 cancer screening variables, being a current smoker was significantly associated with being less likely to ever have been screened and also less likely to be compliant with screening guidelines. For breast and cervical cancer, level of nicotine dependence was also significantly related to compliance with screening recommendations; women with higher levels of dependence were less likely to be compliant. Conclusions: Our results support the notion that individuals' actions related to their health are consistent across different types of behaviors. We found that smokers were less likely to engage in cancer screening behaviors. In addition, among smokers, individuals with greater nicotine dependence had lower compliance with some screening tests. Physicians should ensure that their patients who smoke are receiving appropriate and adequate screening for cancer.

Cacciola JS; Alterman AI; Habing B; McLellan AT. Recent status scores for version 6 of the Addiction Severity Index (ASI-6). Addiction 106(9): 1588-1602, 2011. (57 refs.)

Aims To describe the derivation of recent status scores (RSSs) for version 6 of the Addiction Severity Index (ASI-6). Design: 118 ASI-6 recent status items were subjected to nonparametric item response theory (NIRT) analyses followed by confirmatory factor analysis (CFA). Generalizability and concurrent validity of the derived scores were determined. Setting and participants: A total of 607 recent admissions to variety of substance abuse treatment programs constituted the derivation sample; a subset (n = 252) comprised the validity sample. Measurements: The ASI-6 interview and a validity battery of primarily self-report questionnaires that included at least one measure corresponding to each of the seven ASI domains were administered. Findings: Nine summary scales describing recent status that achieved or approached both high scalability and reliability were derived; one scale for each of six areas (medical, employment/finances, alcohol, drug, legal, psychiatric) and three scales for the family/social area. Intercorrelations among the RSSs also supported themulti-dimensionality of the ASI-6. Concurrent validity analyses yielded strong evidence supporting the validity of six of the RSSs (medical, alcohol, drug, employment, family/social problems, psychiatric). Evidence was weaker for the legal, family/social support and child problems RSSs. Generalizability analyses of the scales to males versus females and whites versus blacks supported the comparability of the findings, with slight exceptions. Conclusions: The psychometric analyses to derive Addiction Severity Index version 6 recent status scores support the multi-dimensionality of the Addiction Severity Index version 6 (i.e. the relative independence of different life functioning areas), consistent with research on earlier editions of the instrument. In general, the Addiction Severity Index version 6 scales demonstrate acceptable scalability, reliability and concurrent validity. While questions remain about the generalizability of some scales to population subgroups, the overall findings coupled with updated and more extensive content in the Addiction Severity Index version 6 support its use in clinical practice and research.

Cheng DA; Kettinger L; Uduhiri K; Hurt L. Alcohol consumption during pregnancy: Prevalence and provider assessment. Obstetrics and Gynecology 117(2, Part 1): 212-217, 2011. (19 refs.)

OBJECTIVE: To estimate the prevalence of prenatal alcohol consumption and the extent of provider screening and discussion about alcohol use during pregnancy. METHODS: Data were obtained from a stratified random sample of 12,611 mothers from Maryland who delivered live infants during the years 2001-2008 and completed the Maryland Pregnancy Risk Assessment Monitoring System survey. Analyses were conducted using Proc Surveyfreq in SAS 9.2. RESULTS: Nearly 8% (95% confidence interval 7.1-8.4) of mothers from Maryland reported alcohol consumption during the last 3 months of pregnancy. The highest prevalence of late-pregnancy alcohol consumption was reported by mothers who were non-Hispanic white, (10.9%, confidence interval 9.8-11.9), aged 35 years or older (13.4%, confidence interval 12.4-14.4), and college graduates (11.4%, confidence interval 10.2-12.6) (P<.001). Nineteen percent (confidence interval 17.6-21.0) of mothers reported that their prenatal care provider did not ask whether they were drinking alcoholic beverages, and 30% (confidence interval 28.3-30.8) reported that a healthcare provider did not counsel them about the consequences of alcohol use on the child. Reported screening and counseling were least prevalent among mothers who were non-Hispanic white, aged 35 years or older, and college graduates (P<.01). CONCLUSION: Despite the substantial number of women who continue to drink alcohol during pregnancy, healthcare providers do not routinely assess alcohol consumption or counsel all women about its harmful effects. Counseling was least prevalent among the same groups of women with the highest rates for drinking. Provider alcohol assessment, as recommended by the U. S. Surgeon General to prevent alcohol misuse, needs further promotion as a routine part of prenatal care.

Choo EK; Nicolaidis C; Jenkinson RH; Cox JM; McConnell KJ. Failure of intimate partner violence screening among patients with substance use disorders. Academic Emergency Medicine 17(8): 886-889d, 2010. (10 refs.)

Objectives: This study examined the relationship between substance use disorder (SUD) and intimate partner violence (IPV) screening and management practices in the emergency department (ED). Methods: This was a retrospective cohort study of adult ED patients presenting to an urban, tertiary care teaching hospital over a 4-month period. An automated electronic data abstraction process identified consecutive patients and retrieved visit characteristics, including results of three violence screening questions, demographic data, triage acuity, time of visit, and International Classifications of Disease, 9th revision (ICD-9), diagnosis codes. Data on management were collected using a standardized abstraction tool by two reviewers masked to the study question. Multivariate logistic regression was used to determine predictors of screening and management. Results: In 10,071 visits, 6,563 violence screens were completed. IPV screening was documented in 33.5% of patients with alcohol-related diagnoses (95% confidence interval [CI] = 27.7% to 39.3%, chi 2 = 116.78, p < 0.001) and 53.3% of patients with drug-related diagnoses (95% CI = 44.3% to 62.3%, chi 2 = 7.69, p = 0.006), compared to 66.1% of patients without these diagnoses (95% CI = 65.2% to 67.1%). In the multivariate analysis, alcohol (odds ratio [OR] = 0.30, 95% CI = 0.22 to 0.40) and drug use (OR = 0.56, 95% CI = 0.38 to 0.83) were associated with decreased odds of screening. Of completed screens, 429 (6.5%) were positive, but violence was addressed further in only 55.7% of patients. Substance abuse did not appear to affect the odds of having positive screens addressed further by providers (OR = 1.96, 95% CI = 0.39 to 10.14). Conclusions: This study found an association between SUD and decreased odds of IPV screening. Failure to screen for IPV in the setting of substance use may represent a missed opportunity to address a critical health issue and be a barrier to successful intervention.

Clark DB; Moss HB. Providing alcohol-related screening and brief interventions to adolescents through health care systems: Obstacles and solutions. PLoS Medicine 7(3): e1000214, 2010. (37 refs.)

The article identifies the problems impeding the U.S. Substance Abuse and Mental Services Administration's goal of Screening, Brief Intervention, Referral and Treatment (SBIRT). While there is a consensus that the health care system is an appropriate location for these services, most adolescents visiting health care providers do not receive them. This paper identifies the problems impeding SBIRT for adolescents and proposes some solutions. They do not take into consideration developmental changes that occur during the course of adolescence. The problems of existing screening instruments are described. In terms of brief interventions, the Amerian Academy of Pediatrics does not included these within its recommendations "because the data for such management options are not yet conclusive." While motivational interviewing is cited as promising, the training required and time involvement renders it an unlikely that it will/can be widely adopted. An alternative, using web-based interventions is presented. The reimbursements also render such interventions as unlikely. There is also discussion of treatment options and confidentiality.

Delgado MK; Acosta CD; Ginde AA; Wang NE; Strehlow MC; Khandwala YS et al. National survey of preventive health services in US emergency departments. Annals of Emergency Medicine 57(2): 104-108, 2011. (11 refs.)

Study objective: We describe the availability of preventive health services in US emergency departments (EDs), as well as ED directors' preferred service and perceptions of barriers to offering preventive services. Methods: Using the 2007 National Emergency Department Inventory (NEDI)-USA, we randomly sampled 350 (7%) of 4,874 EDs. We surveyed directors of these EDs to determine the availability of (1) screening and referral programs for alcohol, tobacco, geriatric falls, intimate partner violence, HIV, diabetes, and hypertension; (2) vaccination programs for influenza and pneumococcus; and (3) linkage programs to primary care and health insurance. ED directors were asked to select the service they would most like to implement and to rate 5 potential barriers to offering preventive services. Results: Two hundred seventy-seven EDs (80%) responded across 46 states. Availability of services ranged from 66% for intimate partner violence screening to 19% for HIV screening. ED directors wanted to implement primary care linkage most (17%) and HIV screening least (2%). ED directors "agreed/strongly agreed" that the following are barriers to ED preventive care: cost (74%), increased patient length of stay (64%), lack of follow-up (60%), resource shifting leading to worse patient outcomes (53%), and philosophical opposition (27%). Conclusion: Most US EDs offer preventive services, but availability and ED director preference for type of service vary greatly. The majority of EDs do not routinely offer Centers for Disease Control and Prevention recommended HIV screening. Most ED directors are not philosophically opposed to offering preventive services but are concerned with added costs, effects on ED operations, and potential lack of follow-up.

Delrahim-Howlett K; Chambers CD; Clapp JD; Xu RH; Duke K; Moyer RJ et al. Web-based assessment and brief intervention for alcohol use in women of childbearing potential: A report of the primary findings. Alcoholism: Clinical and Experimental Research 35(7): 1331-1338, 2011. (36 refs.)

Background: There is a need for more effective assessment and primary prevention programs aimed at accurately measuring and reducing alcohol consumption among women before conception in underserved, high-risk populations. Health information technology may serve this purpose; however, the effectiveness of such tools within this population is not known. Methods: We conducted a small-scale randomized controlled trial to test the effectiveness of an adapted web-based alcohol assessment and intervention tool among low-income, nonpregnant women of reproductive age who were receiving Women Infant and Children (WIC) services in San Diego County and who reported currently drinking at a moderate risk level. A total of 150 risky drinking participants completed a web-based assessment and were randomly assigned to either receive a personalized feedback intervention or general health information about alcohol consumption and fetal alcohol syndrome. Follow-up assessments on reported alcohol consumption were conducted via telephone at 1- and 2-months postbaseline. Participants ranged in age from 18 to 44 and were predominately Hispanic/Latina (44%). Results: At baseline, all respondents reported consuming >= 3 standard drinks on >= 1 occasion in the previous month. Outcome data were available for 131 participants. The main outcome measure was reduction in the number of risky drinking occasions, which did not differ significantly between treatment conditions (odds ratio 1.200, 95% CI 0.567 to 2.539, p = 0.634). Over 70% of the participants, however, reported a reduction in risky drinking occasions regardless of treatment condition (control 43/63, 68%; experimental 49/68, 72%). Conclusions: The results of this study demonstrate that web-based assessment of alcohol consumption among low-income women of reproductive age, as represented by WIC clients, is feasible and acceptable. The findings also suggest that detailed and interactive assessments of alcohol consumption may be sufficient for the reduction of risky drinking within this population without personalized feedback.

Demirkol A; Haber P; Conigrave K. Problem drinking: Detection and assessment in general practice. Australian Family Physician 40(8): 570-574, 2011. (27 refs.)

Background: Alcohol has long been an integral part of the social life of many Australians However, alcohol is associated with significant harm to drinkers, and also to nondrinkers. Objective: This article explores the role of the general practitioner in the detection and assessment of problem drinking. Discussion: Excessive alcohol use is a major public health problem and the majority of people who drink excessively go undetected. General practitioners are in a good position to detect excessive alcohol consumption; earlier intervention can help improve outcomes. AUDIT-C is an effective screening tool for the detection of problem drinking. National Health and Medical Research Council guidelines suggest that no more than two standard drinks on each occasion will keep lifetime risk of death from alcohol related disease or injury at a low level. Once an alcohol problem is detected it is important to assess for alcohol dependence, other substance use, motivation to change, psychiatric comorbidities and examination and investigation findings that may be associated with excessive alcohol use. A comprehensive assessment of the impact and risk of harm of the patient's drinking to themselves and others is vital, and may require several consultations.

Dom G; Francque S; Michielsen P. Risk for relapse of alcohol use after liver transplantation for alcoholic liver disease: A review and proposal of a set of risk assessment criteria. (review)18. Acta Gastro-Enterologica Belgica Acta Gastro-Enterologica Belgica(2): 247-251, 2010. (18 refs.)

Background : Liver transplantation for end stage alcoholic liver disease is becoming an increasingly frequent procedure. Within this context assessing the risk on relapse in alcohol use is a major issue. However, up to now, there is a clear lack in validated criteria that can be used to assess future relapse risk. Method : Literature review based upon Medline search identifying all new studies that have been published after the latest meta-analysis on this subject (2007-2009). Results : Five new original studies were identified. They provide new evidence for the prospective validity of different criteria; pre-transplant abstinence duration, diagnosis of alcohol dependence versus abuse, level of social support, additional psychiatric co-morbidity. Conclusions: These criteria seem promising as to the prediction of relapse in alcohol after liver transplantation. Based upon these results a new comprehensive assessment scale is proposed.

dos Santos MML; Trautmann F; Kools JP. Rapid Assessment Response (RAR) study: Drug use and health risk - Pretoria, South Africa. Harm Reduction Journal 8(e-article 14), 2011. (27 refs.)

Background: Within a ten year period South Africa has developed a substantial illicit drug market. Data on HIV risk among drug using populations clearly indicate high levels of HIV risk behaviour due to the sharing of injecting equipment and/or drug-related unprotected sex. While there is international evidence on and experience with adequate responses, limited responses addressing drug use and drug-use-related HIV and other health risks are witnessed in South Africa. This study aimed to explore the emerging problem of drug-related HIV transmission and to stimulate the development of adequate health services for the drug users, by linking international expertise and local research. Methods: A Rapid Assessment and Response (RAR) methodology was adopted for the study. For individual and focus group interviews a semi-structured questionnaire was utilised that addressed key issues. Interviews were conducted with a total of 84 key informant (KI) participants, 63 drug user KI participants (49 males, 14 females) and 21 KI service providers (8 male, 13 female). Results. and Discussion: Adverse living conditions and poor education levels were cited as making access to treatment harder, especially for those living in disadvantaged areas. Heroin was found to be the substance most available and used in a problematic way within the Pretoria area. Participants were not fully aware of the concrete health risks involved in drug use, and the vague ideas held appear not to allow for concrete measures to protect themselves. Knowledge with regards to substance related HIV/AIDS transmission is not yet widespread, with some information sources disseminating incorrect or unspecific information. Conclusions: The implementation of pragmatic harm-reduction and other evidence-based public health care policies that are designed to reduce the harmful consequences associated with substance use and HIV/AIDS should be considered. HIV testing and treatment services also need to be made available in places accessed by drug users.

Engstrom C. Social workers' ability to assess how clients experience investigation sessions: With and without the ASI. Journal of Social Work 9(3): 309-321, 2010. (28 refs.)

Two groups of social workers (n = 19, n = 13) carried out two different forms of assessment session, one involving an ASI (Addiction Severity Index) interview (n = 40) and one without (n = 43). After the sessions the social workers were requested to assess both the clients' experience and their own experience of the session. The clients also reported their own experience of the sessions. Findings: The results show that the social workers' assessment of the clients' experience differs from the clients' own assessments regarding the sub-scales of alliance and the clients' sense of own competence. However, no difference was observed between the social workers' assessment and the clients' negative experiences of the sessions. The results show the importance of asking the clients for their views when testing new ways of working. This will provide a more balanced picture as social workers are inclined to perceive the negative aspects and misjudge other experiences. The two different forms of session, with or without the ASI, did not affect the social workers' assessment of the clients' experience of the sessions.

Fahy P; Croton G; Voogt S. Embedding routine alcohol screening and brief interventions in a rural general hospital. Drug and Alcohol Review 30(1): 47-54, 2011. (25 refs.)

Issues. Alcohol screening and brief intervention approaches (SBI) are strongly supported by evidence, but few health-care facilities have successfully introduced and sustained routine SBI. Approach. This paper describes the first 2 years of implementing SBI in an Australian rural general hospital. The SBI project aims were to universally screen presentations to Northeast Health Wangaratta (NHW), to provide brief interventions to people screening at medium risk of harm from drinking and enhanced referral for persons screening at high risk. Key Findings. In 2007 and 2008, the NHW SBI project conducted 11 079 screens for alcohol use disorders using the Alcohol Use Disorders Identification Screening Test screening tool. Eighty-five per cent of persons screened at low risk of alcohol-related problems, 11% at medium risk and 4% at high risk. Implications. Policy and planning bodies and hospital management's support and the appointment of a dedicated project worker are critical to successful SBI implementation. Conclusion. It is possible to establish a SBI service in a rural general hospital setting. The NHW SBI project broadened the focus from treatment of persons with severe dependency to detection, early intervention and prevention for the larger, more easily treated, cohort of persons drinking at hazardous/harmful but non-dependent levels. The challenge for any organisation is to maintain routine SBI deployment over the long term.

Gans J; Falco M; Schackman BR; Winters KC. An in-depth survey of the screening and assessment practices of highly regarded adolescent substance abuse treatment programs. Journal of Child and Adolescent Substance Abuse 19(1): 33-47, 2010. (25 refs.)

Aims: To examine the quality of screening and assessment practices at some of the most highly regarded adolescent substance use treatment programs in the United States. Methods: Between March and September 2005, telephone surveys were administered to directors of highly regarded programs. Several different publications and databases were then used to measure the quality of the screening and assessment instruments described by programs. Results: For the 120 programs responding, 77 distinctly named instruments developed by outside sources were used at some point in the screening and assessment process, and the majority of programs also used instruments developed in-house. Fewer than half of these instruments were mentioned in the Substance Use Screening & Assessment Instruments Database. We were able to confirm that 87% of the instruments developed by others have a published manual, and 74% have been described in an article appearing in a peer-reviewed publication. Sixty-two percent were designed to be used with adolescents or adults and adolescents, while 19% were designed for adults only. Conclusion: Although adolescent substance abuse treatment programs recognized the importance of screening and assessment, the quality of such practices varied significantly. A large number of different tools were used by some of the most highly regarded programs in the country, and many used questionnaires developed in-house that may not have had high standards of reliability and validity. Furthermore, numerous programs were using assessment instruments that were not uniquely designed for adolescents. Encouraging the adoption of standardized assessment practices would help those involved in treatment to evaluate programs and to understand the assessment process.

Gifford AE; Farkas KJ; Jackson LW; Molteno CD; Jacobson JL; Jacobson SW et al. Assessment of benefits of a universal screen for maternal alcohol use during pregnancy. Birth Defects Research. Part A: Clinical and Molecular Teratology 88(10, special issue): 838-846, 2010. (40 refs.)

INTRODUCTION: The objective of this report is to estimate the benefits of universal meconium screening for maternal drinking during pregnancy. Fetal alcohol spectrum disorder (FASD), including its most severe manifestation fetal alcohol syndrome (FAS), is preventable and remains a public health tragedy. The incidences of FAS and FASD have been conservatively estimated to be 0.97 and 10 per 1000 births, respectively. Meconium testing has been demonstrated to be a promising at-birth method for detection of drinking during pregnancy. METHODS: The current costs of FAS and FASD, alcohol treatment programs, and meconium screening were estimated by literature review. Monetary values were converted roughly to equal dollars in 2006. RESULTS: Costs of adding meconium analysis to the current newborn screening program and of treatment for the identified mothers were estimated and compared to potential averted costs that may result from identification and intervention for mothers and affected infants. Three potential maternal treatment strategies are analyzed. Depending on the treatment type, the savings may range from $6 to $97 for every $1 spent on screening and treatment. DISCUSSION: It needs to be emphasized, however, that such screening is premature and that to be effective this screening can be implemented only if there is a societal willingness to institute prevention and intervention programs to improve both women's and children's health. Future research should be directed at improving detection and developing in-depth prevention and remedial intervention programs. A thorough consideration of the ethical issues involved in such a screening program is also needed.

Gordon AJ; Kunins HV; Rastegar DA; Tetrault JM; Walley AY. Update in addiction medicine for the generalist. Journal of General Internal Medicine 26(1): 77-82, 2011. (56 refs.)

Generalist clinicians routinely care for patients who misuse or are dependent on alcohol, nicotine, and other drugs of abuse. These problems contribute to significant morbidity, health care utilization, cost, and preventable death.The aim of this update is to identify and examine recent advances in addiction medicine that have practice implications for generalist physicians and their patients. To accomplish this, we independently selected articles in the field of addiction medicine, summarized and critically appraised, and examined the articles in the context of their implications for generalist practice using methodology we used in prior updates. During an initial review, we identified articles through an electronic MedLine search (limited to human studies and in English) using search terms for alcohol, nicotine, and other drugs of abuse from January 2008 through January 2010. From the citations, the authors selected articles for more intensive review. All authors then agreed collectively on the important articles regarding addiction medicine that have implications for practice for generalist clinicians. Topics covered in this review include prescription drug abuse, overdose deaths related to prescription drug diversion, factors influencing risk of overdose of prescribed oioids, screening in primary care, impact of intervention on health status, pharamcotherapy for smoking cessation, office-based opioid agonist therapy.

Guydish J; Tajima B; Chan M; Delucchi KL; Ziedonis D. Measuring smoking knowledge, attitudes and services (S-KAS) among clients in addiction treatment. Drug and Alcohol Dependence 114(2-3): 237- 241, 2011. (52 refs.)

Background: Addiction treatment programs are increasingly working to address prevalent and comorbid tobacco dependence in their service populations. However at present there are few published measurement tools, with known psychometric properties, that can be used to assess client-level constructs related to tobacco dependence in addiction treatment settings. Following on previous work that developed a staff-level survey instrument, this report describes the development and measurement characteristics of the smoking knowledge, attitudes and services (S-KAS) for use with clients in addiction treatment settings. Method: 250 clients enrolled in residential drug abuse treatment programs were surveyed. Summary statistics were used to characterize both the participants and their responses, and exploratory factor analysis (EFA) was used to examine the underlying factor structure. Results: Examination of the rotated factor pattern indicated that the latent structure was formed by one knowledge factor, one attitude factor, and two "service" factors reflecting program services and clinician services related to tobacco dependence. Standardized Cronbach's alpha coefficients for the four scales were, respectively, .57, .75, .82 and .82. Conclusions: The proposed scales have reasonably good psychometric characteristics, although the knowledge scale leaves room for improvement, and will allow researchers to quantify client knowledge, attitudes and services regarding tobacco dependence treatment. Researchers, program administrators, and clinicians may find the S-KAS useful in changing organizational culture and clinical practices related to tobacco addiction, help in program evaluation studies, and in tracking and improving client motivation.

Hebert KK; Cummins SE; Hernandez S; Tedeschi GJ; Zhu SH. Current major depression among smokers using a state quitline. American Journal of Preventive Medicine 40(1): 47-53, 2011. (43 refs.)

Background: Smokers seeking treatment to quit smoking are generally not assessed for current depression, yet depression among smokers may influence quitting outcome. Purpose: This study aims to formally assess current major depression among smokers calling a state tobacco quitline. Methods: A total of 844 smokers calling the California Smokers' Helpline in 2007 were screened for depression by the mood module of the Patient Health Questionnaire (PHQ-9). The Social Functioning Questionnaire (SFQ) also was administered to these callers. Two months after the screening, follow-up evaluations were conducted to assess cessation outcome. Results: In all, 24.2% of smokers met criteria for current major depression and 16.5% reported symptoms indicating mild depression. Callers with current major depression were more likely to be heavy smokers and on Medicaid. Moreover, 74.0% of smokers with current major depression had substantial social and occupational functioning deficits. Two months later, those with major depression at baseline were significantly less likely to have quit smoking (18.5% vs 28.4%). Conclusions: Almost one in four smokers who called the California Smokers' Helpline met criteria for current major depression. More than 400,000 smokers call state quitlines in the U. S. for help with quitting each year, which means that as many as 100,000 smokers with serious depressive symptoms are using these services annually. The large number of depressed smokers who seek help suggests a need to develop appropriate interventions to help them quit successfully.

Hoxmark E; Nivison M; Wynn R. Predictors of mental distress among substance abusers receiving inpatient treatment. Substance Abuse Treatment, Prevention and Policy 5: article 15, 2010. (53 refs.)

Background: Mental distress measured by the HSCL-10 is used as an indicator of psychiatric disorders in population studies, where a higher level of mental distress has been shown to be related to demographic factors such as living conditions and level of education. The first aim of the study was to explore whether mental distress could be a valuable concept in substance use treatment. The second aim of the study was to explore to what degree mental distress among substance users at admission to treatment could be explained by the same demographic factors as in population studies, or whether treatment differences or differences in substance use would be better predictors of mental distress in this population. Methods: Patients (N = 185) who received inpatient substance use treatment in five different settings in Northern Norway participated in the study. HSCL-10 was used as a measure for mental distress at admission to treatment. The self-report measures AUDIT, DUDIT and DUDIT-E were used for measuring substance use and readiness for treatment. The patients' clinicians reported demographic and treatment factors. A three-block hierarchical multiple regression analysis was conducted to determine potential predictors of mental distress. Block 1 included demographic variables, Block 2 included treatment variables, and Block 3 substance use variables. Results: Patients generally reported a high level of mental distress at admission to treatment, and 83% reported mental distress higher than the established cut-off level. Being female, having previously received psychiatric treatment, having a higher score on DUDIT and AUDIT, and using a larger number of substances all predicted a higher level of mental distress. The model explained 32% of the variance in mental distress. Conclusions: Mental distress measured by the HSCL-10 can be a valuable concept in substance use treatment. The HSCL-10 can be useful in screening for patients who are in need of further assessment for psychiatric disorders. Female gender, previous psychiatric treatment, and higher use of substances all predicted a higher level of mental distress. The study underlines the importance of assessing the mental health of patients in substance use treatment.

Ives R. Meeting professionals' needs in the United Kingdom for effective VSM intervention. Substance Use & Misuse 46(Supplement 1): 134-139, 2011. (17 refs.)

An exploratory study examined what professionals needed to support their responses to volatile substance misuse (VSM). Many respondents saw VSM as a problem of unknown dimensions and were uncertain about how to tackle it. Resources for treatment and prevention were seen as outdated. Workers were concerned that VSM was becoming more common among adults, supporting an indication found in a study of VSM-related deaths. Evidence-informed treatment protocols, information on working with clients, assessments of local needs, and the evaluation of existing approaches to VSM would improve the response. A further phase of the research will be reported in 2012.

Kalapatapu RK; Paris P; Neugroschl JA. Alcohol use disorders in geriatrics. (review). International Journal of Psychiatry in Medicine 40(3): 321-337, 2010. (68 refs.)

Alcohol use disorders cause significant morbidity and mortality in the geriatric population This review article begins with a hypothetical case for illustration, asking what the primary care physician could do for a geriatric patient with alcohol abuse over a course of four office visits. Various aspects of alcohol use disorders in the geriatric population are reviewed such as range of alcohol use, epidemiology medical/psychiatric impact, detection, comprehensive treatment planning, modalities of psychotherapy, medication management, and resources for clinicians/patients.

Keller TE; Blakeslee JE; Lemon SC; Courtney ME. Subpopulations of older foster youths with differential risk of diagnosis for alcohol abuse or dependence. Journal of Studies on Alcohol and Drugs 71(6): 819-830, 2010. (70 refs.)

Objective: Distinctive combinations of factors are likely to be associated with serious alcohol problems among adolescents about to emancipate from the foster care system and face the difficult transition to independent adulthood. This study identifies particular subpopulations of older foster youths that differ markedly in the probability of a lifetime diagnosis for alcohol abuse or dependence. Method: Classification and regression tree (CART) analysis was applied to a large, representative sample (N = 732) of individuals, 17 years of age or older, placed in the child welfare system for more than I year. CART evaluated two exploratory sets of variables for optimal splits into groups distinguished from each other on the criterion of lifetime alcohol-use disorder diagnosis. Results: Each classification tree yielded four terminal groups with different rates of lifetime alcohol-use disorder diagnosis. Notable groups in the first tree included one characterized by high levels of both delinquency and violence exposure (53% diagnosed) and another that featured lower delinquency but an independent-living placement (21% diagnosed). Notable groups in the second tree included African American adolescents (only 8% diagnosed), White adolescents not close to caregivers (40% diagnosed), and White adolescents closer to caregivers but with a history of psychological abuse (36% diagnosed). Conclusions: Analyses incorporating variables that could be comorbid with or symptomatic of alcohol problems, such as delinquency, yielded classifications potentially useful for assessment and service planning. Analyses without such variables identified other factors, such as quality of caregiving relationships and maltreatment, associated with serious alcohol problems, suggesting opportunities for prevention or intervention.

Keys VA. Alcohol withdrawal during hospitalization. American Journal of Nursing 111(1): 40-44, 2011. (10 refs.)

For a chronic drinker, sudden alcohol withdrawal because of an unexpected hospitalization can lead to escalating withdrawal symptoms and even death if unrecognized and untreated. Nurses need to be aware of the prevalence of alcohol abuse in the United States and consider the possibility of unplanned alcohol withdrawal in their patients. This article discusses the effects on the body of chronic alcohol intake, the potential symptoms of alcohol withdrawal, and ways to recognize and treat these symptoms through early assessment and consistent intervention.

Kishore V; Lynch S; Pichon J; Theall K; Johnson S; Roberson E et al. Knowledge, attitudes and practice relating to hazardous alcohol use across the continuum of care in a community healthcare centre. Drugs: Education, Prevention and Policy 18(1): 60-68, 2011. (20 refs.)

Alcohol screening and intervention in community health settings places a great time demand on practitioners. Thus, implementation of practitioner-delivered intervention is challenging. Aims: The aim of this study was to assess the feasibility of incorporating a brief alcohol intervention into daily practices of a community health care centre by utilizing assistance from non-practitioners and administrative staff. Methods: In regard to alcohol use, the knowledge, attitudes and practice (KAP) of the staff of a health care centre were assessed using a self-administered survey. The 57-item survey consisted of alcohol-relevant questions in four domains: clinical practice, knowledge and self-assessment of skills and available resources. Findings: The sample consisted of 70 individuals-23 practitioners, 21 medical assistants and 26 administrative staff from two New Orleans' clinics. Practitioners were observed to be most confident in assessing alcoholism as well as in implementing interventions for alcohol abuse. Medical assistants exhibited high self-rated scores, second to practitioners, in survey items regarding attitudes towards patients, alcohol knowledge and alcohol-related clinical skills. Conclusions: Based on KAP, it appears that healthcare workers other than practitioners, particularly medical assistants, may serve as a useful resource to practitioners in providing alcohol screening and prevention services. Educationation and empowerment of medical assistants will however be needed to achieve this goal.

Klingemann H; Gomez V. Masculinity issues in addiction treatment in Swiss inpatient alcohol programs: Bringing men's treatment needs back to the research agenda. Journal of Men's Health 7(3): 211-220, 2010. (27 refs.)

Background" Various types of risk behaviors, including alcohol and drug consumption, are by far more frequent among men than among women. Men represent the majority of patients in addiction programs. However the relationship between male gender role orientations and the treatment response is under-researched. This paper sheds light on the relative importance of masculinity concepts within both the general population and a clinical sample the perception of specific treatment needs by male alcohol patients and the response to masculinity topics in treatment practice. Methods: The study was conducted among 200 men in two Swiss alcohol inpatient programs representative for the total patient load in the Swiss alcohol treatment system and included a matched population control group (n = 200). The Bem Sex Role Inventory the Male Role Norm Scale and the Masculine Gender Role Stress Scale were included in the group comparison. Results: Patients show significantly lower values on the masculinity subscale and lower values on the femininity subscale than the control group, the undifferentiated man is typical for the clinical setting . Patients who acknowledge men-specific treatment needs suffer significantly more from gender role stress and problems with sexuality and fatherhood than patients who are not aware of masculinity issues. For both topics patients prefer a non-therapeutic setting. Group and individual therapy do not address sexuality and fatherhood issues. Conclusions: These findings suggest that for specific subgroups of men an appropriate diagnosis should first check on sensitive masculinity issues then assess gender role orientations and masculinity stress and provide adequate treatment modalities.

Klosa K; Wiltfang J; Wenz HJ; Koller M; Hertrampf K. Dentists' opinions and practices in oral cancer prevention and early detection in Northern Germany. European Journal of Cancer Prevention 20(4): 313- 319, 2011. (27 refs.)

The objective of this study was to evaluate opinions and practices, related to oral cancer prevention and early detection, of dentists in Northern Germany, with focus on risk assessment and routine oral examination by means of a standardized questionnaire. In November 2007, a self-administered validated questionnaire was mailed to all dentists in Schleswig-Holstein (n = 2233), followed by two reminders, after 3 and 6 weeks. The survey was composed of 41 items and was divided into sections on several aspects of oral cancer. For this study, self-reported information about the assessment of the patients' health history and the dentists' activities with regard to the initial and recall appointments of younger compared with older patients were evaluated. The dentists' evaluation of the health history showed a clear focus on tobacco in contrast to alcohol. Dentists' opinions and practices in routine oral examination showed interesting discrepancies. Sixty-five percent, 94%, of the dentists agreed that this examination for younger (18-39 years) and older patients (>= 40 years) should be provided annually. But, only 25%, 30%, of the dentists always examined their younger and older patients at the initial appointment. Approximately 20%, less than 30% always investigated younger and older patients at the recall appointment. The results emphasized a discrepancy in the dentists' assessments of the health history. Dentists' opinions about the routine examination differed considerably from the actual integration in the daily work. These findings underline the need for the implementation of targeted educational programmes with focus on primary and secondary prevention.

Krank MD; Schoenfeld T; Frigon AP. Self-coded indirect memory associations and alcohol and marijuana use in college students. Behavior Research Methods 42(3): 733-738, 2010. (32 refs.)

Indirect memory associations for substance use predict both the concurrent and prospective levels of substance use. These methods assess spontaneous, possibly implicit, and easily accessible associations that predict substance use over direct (explicit) methods of assessment (e. g., outcome expectancies). The present study tested and expanded the application of a coding method for alcohol and marijuana associations on the basis of self-coding of indirect responses (Frigon & Krank, 2009). College students generated free associates to (1) ambiguous words (e. g., draft or weed), (2) situations (e. g., at a party, hanging out with friends), and (3) emotions (having fun, feeling dreamy). Later, participants were shown their responses and were asked to code their responses according to both nonrisk and risk activities, such as alcohol and marijuana use. Self-coded scores were higher than researcher-coded scores, captured the same variance, and improved the prediction of substance use. Self-coding of indirect memory associations provides accurate and efficient prediction of the level of alcohol and marijuana. Self-coding is efficient and may be useful for reducing ambiguities in coding of many different kinds of open-ended responses.

Lapham SC; Skipper BJ. Does screening classification predict long-term outcomes of DWI offenders? American Journal of Health Behavior 34(6, special issue): 737-749, 2010. (44 refs.)

Objectives: To determine the usefulness of a screening classification system in predicting treatment use, current substance abuse disorders (SUD), and driving over the alcohol limit (DOL) at 15-year follow-up. Methods: Interviewed 583 driving while imparied (DWI) first offenders with SUDs. Univariate and multivariate statistics were used to determine predictors of long-term outcomes. Results: Screening classification defined groups with different treatment histories and 15-year outcomes. Current SUDs were reported by 21% and DOL by 10%, of subjects. Conclusions: Group differences suggest that screening data could be used more effectively to triage and treat DWI offenders.

Looman J; Abracen J. Substance abuse among high-risk sexual offenders: Do measures of lifetime history of substance abuse add to the prediction of recidivism over actuarial risk assessment instruments? Journal of Interpersonal Violence 26(4): 683-700, 2011. (45 refs.)

There has been relatively little research on the degree to which measures of lifetime history of substance abuse add to the prediction of risk based on actuarial measures alone among sexual offenders. This issue is of relevance in that a history of substance abuse is related to relapse to substance using behavior. Furthermore, substance use has been found to be related to recidivism among sexual offenders. To investigate whether lifetime history of substance abuse adds to prediction over and above actuarial instruments alone, several measures of substance abuse were administered in conjunction with the Sex Offender Risk Appraisal Guide (SORAG). The SORAG was found to be the most accurate actuarial instrument for the prediction of serious recidivism (i.e., sexual or violent) among the sample included in the present investigation. Complete information, including follow-up data, were available for 250 offenders who attended the Regional Treatment Centre Sex Offender Treatment Program (RTCSOTP). The Michigan Alcohol Screening Test (MAST) and the Drug Abuse Screening Test (DAST) were used to assess lifetime history of substance abuse. The results of logistic regression procedures indicated that both the SORAG and the MAST independently added to the prediction of serious recidivism. The DAST did not add to prediction over the use of the SORAG alone. Implications for both the assessment and treatment of sexual offenders are discussed.

Martin RA; MacKinnon SM; Johnson JE; Myers MG; Cook TAR; Rohsenow DJ. The Alcohol Relapse Situation Appraisal Questionnaire: Development and validation. Drug and Alcohol Dependence 116(1-3): 45-51, 2011. (36 refs.)

Background: The role of cognitive appraisal of the threat of alcohol relapse has received little attention. A previous instrument, the Relapse Situation Appraisal Questionnaire (RSAQ), was developed to assess cocaine users' primary appraisal of the threat of situations posing a high risk for cocaine relapse. The purpose of the present study was to modify the RSAQ in order to measure primary appraisal in situations involving a high risk for alcohol relapse. Methods: The development and psychometric properties of this instrument, the Alcohol Relapse Situation Appraisal Questionnaire (A-RSAQ), were examined with two samples of abstinent adults with alcohol abuse or dependence. Factor structure and validity were examined in Study 1 (N=104). Confirmation of the factor structure and predictive validity was assessed in Study 2 (N=159). Results: Results demonstrated construct, discriminant and predictive validity and reliability of the A-RSAQ. Discussion: Results support the important role of primary appraisal of degree of risk in alcohol relapse situations.

McAuley A; Goodall CA; Ogden GR; Shepherd S; Cruikshank K. Delivering alcohol screening and alcohol brief interventions within general dental practice: Rationale and overview of the evidence. (review). British Dental Journal 210(9): e15, 2011. (53 refs.)

Alcohol consumption and affordability in the UK has increased over the last 50 years and is associated with a range of adverse oral health outcomes, the most serious of which, oral cancer, is also increasing in incidence. Despite this, routine screening and intervention relating to alcohol consumption within general dental practice remains uncommon. This review of the literature describes the background and outlines the evidence base for undertaking alcohol screening and delivering brief interventions in general dental practice. Consideration will be given to the rationale for, and range of issues related to, introducing this into general dental practice.

Mills K; Knight T. Offering substance misuse services to Accession Eight migrants in London: Findings from a qualitative study. Drugs: Education, Prevention and Policy 17(6): 853-869, 2010. (41 refs.)

This article reports findings from a study undertaken in two parts between November 2006 and May 2008, investigating the drug treatment needs of new migrants to the UK. The study explored the eligibility and treatment needs of new communities in London. This article reports findings in relation to EU Accession Eight (A8) nationals' entitlement and access to drug treatment. For this part of the study 20, in depth interviews were conducted with staff of Drug and Alcohol Action Teams and treatment services in seven London boroughs to identify levels of service provision, along with practitioners' interpretations of entitlement to services, perceptions of local need and gaps in treatment. Additionally, 19 interviews were conducted with related service providers. Six service users were interviewed. Findings show professionals are eager to address the needs of A8 migrants but services are providing limited treatment to A8 nationals. However, entitlements vary between boroughs and decisions are pragmatic, based upon assessments of clinical necessity but also financial constraints. Decisions made on this footing can lead to services being denied despite intense need and resulting in reduced opportunities for planning. The article concludes with observations as to how provision might develop to meet a changing context.

Minugh PA; Lomuto N; Janke S. Projecting adolescent prevention and treatment need: A novel application utilizing the Communities that Care data in the state of Kansas. Journal of Drug Issues 40(3): 627-651, 2010. (45 refs.)

This study projects substance abuse and dependence prevalence rates based on the number of early problem behaviors (tobacco alcohol and marijuana use and arrests prior to age 15) reported by youth who have taken part in eleven administrations of the annual Kansas Communities That Care survey following a model developed by McGue and Iacono (2005) The probability of males and females developing a substance abuse or dependence disorder at age 17 and 20 was assigned to each respondent Projections were mapped to show county and statewide dispersions for planning purposes. Projected numbers were much higher than expected In addition to young adult treatment need, the implications for prevention service planning became readily apparent. The findings highlight missed opportunities for indicated prevention and early intervention services and are further discussed in the context of how early intervention might alleviate demand on the treatment system as adolescents progress into young adulthood

Neblett RC; Hutton HE; Lau B; McCaul ME; Moore RD; Chander G. Alcohol consumption among HIV-infected women: Impact on time to antiretroviral therapy and survival. Journal of Women's Health 20(2): 279-286, 2011. (46 refs.)

Objective: Alcohol use is prevalent among HIV-infected people and is associated with lower antiretroviral adherence and high-risk sexual and injection behaviors. We sought to determine factors associated with alcohol use among HIV-infected women engaged in clinical care and if baseline alcohol use was associated with time to combination antiretroviral therapy (cART) and death in this population. Methods: In an observational clinical cohort, alcohol consumption at the initial medical visit was examined and categorized as heavy, occasional, past, or no use. We used multinomial logistic regression to test preselected covariates and their association with baseline alcohol consumption. We then examined the association between alcohol use and time to cART and time to death using Kaplan-Meier statistics and Cox proportional hazards regression. Results: Between 1997 and 2006, 1030 HIV-infected women enrolled in the cohort. Assessment of alcohol use revealed occasional and hazardous consumption in 29% and 17% of the cohort, respectively; 13% were past drinkers. In multivariate regression, heavy drinkers were more likely to be infected with hepatitis C than nondrinkers (relative risk ratios [RRR] 2.06, 95% confidence interval [CI] 1.29-3.44) and endorse current drug (RRR 3.51, 95% CI 2.09-5.91) and tobacco use (RRR 3.85 95% CI 1.81-8.19). Multivariable Cox regression adjusting for all clinical covariates demonstrated an increased mortality risk (hazard ratio [HR] 1.40, 95% CI 1.00-1.97, p < 0.05) among heavy drinkers compared to nondrinkers but no delays in cART initiation (1.04 95% CI 0.81-1.34) Conclusions: Among this cohort of HIV-infected women, heavy alcohol consumption was independently associated with earlier death. Baseline factors associated with heavy alcohol use included tobacco use, hepatitis C, and illicit drug use. Alcohol is a modifiable risk factor for adverse HIV-related outcomes. Providers should consistently screen for alcohol consumption and refer HIV-infected women with heavy alcohol use for treatment.

Nejtek VA; Kaiser K; Vo H; Hilburn C; Lea J; Vishwanatha J. Are there racial/ethnic differences in indigent inner-city clients with dual diagnoses? Journal of Dual Diagnosis 7(1-2): 26- 38, 2011. (12 refs.)

Objective: This is an exploratory, cross-sectional study that examined personal, clinical, and treatment characteristics among non-Hispanic Caucasian, non-Hispanic African American, and Hispanic indigent inner-city clients with co-occurring disorders. Methods: Men and women aged 20 to 50 years who met DSM-IV criteria for concurrent mood and substance use disorders were eligible. Inpatients, persons in detoxification programs, and incarcerated inmates were excluded. Assessments covered sociodemographic characteristics, clinical diagnoses, substance use, psychosocial variables, health care utilization and treatment history. Results: Two hundred volunteers were screened, and 145 were eligible to enroll. Racial/ethnic group differences in the distribution of mood and substance use disorders and medical diseases were evident. Receiving psychiatric treatment and psychiatric medications significantly differed among racial/ethnic groups, with Caucasians more likely to receive these services than African Americans or Hispanics. African Americans and Hispanics were also more likely than Caucasians to have positive screening results for their drug of choice and for other drugs as well. Serious medical illnesses were evident in about half of the sample, and the distributions of these illnesses significantly differed among racial/ethnic groups. There were no significant differences in hospitalization or emergency department visits among racial/ethnic groups. Conclusions: Indigent inner-city clients have multiple psychiatric and medical problems that warrant continuity of care. However, few doctor's visits for medical illnesses, lack of psychotropic medications, staggering unemployment, and homelessness were common in our sample. These results present health care and social service professionals with potentially serious treatment challenges. Better recognition and understanding of racial/ethnic needs in those with co-occurring disorders are needed.

Nettleman MD; Brewer J; Stafford M. Scheduling the first prenatal visit: office-based delays. American Journal of Obstetrics and Gynecology 203(3): article 207.e1, 2010. (15 refs.)

OBJECTIVE: The purpose of this study was to evaluate the office-based component of delayed entry into prenatal care. STUDY DESIGN: Phone numbers for all obstetrics offices in a single state were obtained from a commercial list. A research assistant who posed as a newly pregnant, fully insured woman asked each clinic when she should come in for her first prenatal visit. RESULTS: Information was provided by 239 of the 279 (86%) offices. The recommended appointment times ranged from immediately (4 weeks of gestation) to 10.6 weeks, which averaged 6.37 weeks. Twenty-five percent of clinics recommended a first appointment at >= 8 weeks. Scheduling calls were not a source of prenatal advice: <5% of clinics asked about smoking, alcohol, or medical condition; 88% of clinics did not mention vitamins. CONCLUSION: Office-based delays in scheduling the first prenatal visit occur in a substantial proportion of clinics, even for fully insured women. There is a need for a standard source of advice in early pregnancy.

North CS. A tale of two studies of two disasters: Comparing psychosocial responses to disaster among Oklahoma City bombing survivors and Hurricane Katrina evacuees. Rehabilitation Psychology 55(3): 241-246, 2010. (34 refs.)

An accumulation of disaster mental health research literature in the last few decades has contributed knowledge to direct disaster mental health interventions. However, no single set of principles can necessarily outline all anticipated mental health needs to be encountered in a particular disaster. Methods: To illustrate how different disaster scenarios may yield a divergence of mental health needs, this article compares mental health findings from two distinctly different studies of two very different populations affected by two very different disasters: directly exposed survivors the Oklahoma City bombing and sheltered evacuees from Hurricane Katrina. Results: Research on the two disasters reviewed illustrates many facets and complexities of postdisaster mental health needs in different populations in different settings after different types of disasters. The major findings of the Oklahoma City bombing study related to posttraumatic stress disorder and the main findings of the Hurricane Katrina study involved need for treatment of preexisting chronic mental health and substance abuse problems. Conclusion: The disaster studies in this review diverged in type of disaster, affected populations, setting, and timing of the study, and these studies yielded a divergence of findings. One disaster mental health model clearly cannot adequately describe all postdisaster scenarios.

Nystrom S; Andren A; Zingmark D; Bergman H. The reliability of the Swedish version of the Addiction Severity Index (ASI). Journal of Substance Use 15(5): 330-339, 2010. (25 refs.)

A test-retest was carried out to test the stability of composite scores (CS) and the interviewers' and clients' assessments. The reliability study included 39 alcohol dependant Swedish-speaking detoxified patients at the Centre for Dependency Disorders in Stockholm. Of these, 75% were outpatients and 25% inpatients. Alcohol was the chief substance. The result shows the overall reliability of all the indices-composite scores, interviewers' ratings and clients' assessments-were satisfactory. For composite scores (CS), the intraclass correlations varied from 0.77 (physical health) to 0.99 (employment) for all the scales except the family and relations scale (0.66) and the legal scale (0.66). For interviewers' assessments, the intraclass correlations were between 0.74 and 0.96 for all the scales except family and relations (0.69). Clients' assessments of problems and needs were also satisfactory but for the intra class correlation for the 30 day measurement of physical health (0.24).

O'Brien CP; Gastfriend DR; Forman RF; Schweizer E; Pettinati HM. Long-term opioid blockade and hedonic response: Preliminary data from two open-label extension studies with extended-release naltrexone. American Journal on Addictions 20(2): 106-112, 2011. (36 refs.)

The emergence of extended-release naltrexone (XR-NTX) raises the opportunity to explore the role of endorphin blockade on hedonic response during long-term alcohol dependence treatment. A hedonic survey was administered to 74 alcohol dependent patients treated for an average of 3.5 years with nearly continuous month-long intramuscular XR-NTX. The paper-and-pencil, one-time survey asked patients about the degree of pleasure they experienced in the past 90 days with drinking alcohol, sex, exercise and other daily activities. The data revealed lower pleasure ratings for alcohol than for sex, exercise and 10 other common activities. Mean responses to drinking alcohol and gambling were significantly lower than to listening to music, sex, reading, being with friends, eating good food, eating spicy food, and playing video/card games. This effect was independent of XR-NTX dose or duration. Although this exploratory study lacked baseline data, a comparison group or control for the impact of patient discontinuation, the data indicate the feasibility of examining long-term hedonic response in recovery. The differential hedonic ratings suggest that, in patients who persist with long-term continuous therapy, XR-NTX may selectively inhibit the pleasure associated with drinking alcohol, compared to a variety of other activities.

Omole OB; Ngobale KNW; Ayo-Yusuf OA. Missed opportunities for tobacco use screening and brief cessation advice in South African primary health care: a cross-sectional study. BMC Family Practice 11: e-article 94, 2010. (34 refs.)

Background: Primary health care (PHC) settings offer opportunities for tobacco use screening and brief cessation advice, but data on such activities in South Africa are limited. The aim of this study was to determine the extent to which participants were screened for and advised against tobacco use during consultations. Methods: This cross-sectional study involved 500 participants, 18 years and older, attended by doctors or PHC nurses. Using an exit-interview questionnaire, information was obtained on participants' tobacco use status, reason (s) for seeking medical care, whether participants had been screened for and advised about their tobacco use and patients' level of comfort about being asked about and advised to quit tobacco use. Main outcome measures included patients' self-reports on having been screened and advised about tobacco use during their current clinic visit and/or any other visit within the last year. Data analysis included the use of chi-square statistics, t-tests and multiple logistic regression analysis. Results: Of the 500 participants, 14.9% were current smokers and 12.1% were smokeless tobacco users. Only 12.9% of the participants were screened for tobacco use during their current visit, indicating the vast majority were not screened. Among the 134 tobacco users, 11.9% reported being advised against tobacco use during the current visit and 35.1% during any other visit within the last year. Of the participants not screened, 88% indicated they would be 'very comfortable' with being screened. A pregnancy-related clinic visit was the single most significant predictor for being screened during the current clinic visit (OR = 4.59; 95% CI = 2.13-9.88). Conclusion: Opportunities for tobacco use screening and brief cessation advice were largely missed by clinicians. Incorporating tobacco use status into the clinical vital signs as is done for pregnant patients during antenatal care visits in South Africa has the potential to improve tobacco use screening rates and subsequent cessation.

Oral R; Bayman L; Assad A; Wibbenmeyer L; Buhrow J; Austin A et al. Illicit drug exposure in patients evaluated for alleged child abuse and neglect. Pediatric Emergency Care 27(6): 490-495, 2011. (32 refs.)

Background: Substantiation of drug exposure in cases with alleged maltreatment is important to provide proper treatment and services to these children and their families. A study performed at University of Iowa Hospitals and Clinics showed that 30% of pediatric patients with burn injuries, which were due to child maltreatment, were also exposed to illicit drugs. Objective: The children presenting to the University of Iowa Hospitals and Clinics with alleged maltreatment have been tested for illicit substances since 2004. The objective of this study was to analyze the presence of illicit drug exposure in the pediatric subpopulation admitted to pediatric inpatient and outpatient units for an evaluation for abuse/neglect. Design and Methods: The study design is a retrospective chart review. Using hospital databases, every pediatric chart with a child abuse/neglect allegation was retrieved. The association between risk factors and clinical presentation and illicit drug test result was assessed. Excel and SAS were used for statistical analysis. Institutional review board approval was obtained to conduct this study. Results: Six hundred sixty-five charts met study inclusion criteria for child abuse/neglect allegation. Of those, 232 cases were tested for illicit drugs between 2004 and 2008 per the testing protocol. Thirty-four cases (14.7%) tested positive on a drug test. Positive test rates based on clinical presentation were 28.6% (18/63) in neglect cases, 16.1% (5/31) in cases with soft tissue injuries, 14.3% (4/28) in burn injuries, 10.0% (2/20) in cases with sexual abuse, 7.1% (2/28) in cases with fractures, and 4.8% (3/62) in abusive head trauma cases. There were long-term abuse findings in 129 children (55.6%). Logistic regression analysis revealed that positive drug testing was most significantly associated with clinical symptoms suggesting physical abuse or neglect versus sexual abuse (odds ratio [OR] = 6.70; 95% confidence interval [CI], 1.26-35.49; P = 0.026), no or public health insurance versus those with private insurance (OR = 4.49; 95% CI, 1.47-13.66; P = 0.008), history of parental drug abuse versus those without parental history of drug abuse (OR = 3.42; 95% CI, 1.38-8.46; P = 0.008), and history of domestic violence versus those without a history of domestic violence (OR = 2.81; 95% CI, 1.08-7.30; P = 0.034). Conclusions: The results of this study showed that an illicit drug screening protocol used in the assessment of children evaluated for child abuse identified almost 15% of the population of allegedly abused and neglected children who were tested according to a protocol being exposed to illicit drugs. Thus, routine drug testing of at least children assessed for neglect and nonaccidental burn and soft tissue injuries, children with a history of either parental drug use or domestic violence is recommended.

Orford J; Templeton L; Velleman R; Copello A. Methods of assessment for affected family members. Drugs: Education, Prevention and Policy 17(special issue): 75-85, 2010. (16 refs.)

The article begins by making the point that a good assessment of the needs and circumstances of family members is important if previous neglect of affected family members is to be reversed. The methods we have used in research studies are then described. They include a lengthy semi-structured interview covering seven topic areas and standard questionnaires for assessing the impact of substance misuse on the family member and whole family, and the family member's symptoms of psychological and physical ill health and ways of coping. Also described are two methods for assessing social support ( SS) available to a family member: drawing a SS network diagram; and a recently developed family member social support scale. The remainder of the article discusses the challenge of introducing standard family assessment and outcome monitoring into routine service practice, including the need for shorter versions of those assessments that have been used in research.

Ozechowski TJ; Waldron HB. Assertive outreach strategies for narrowing the adolescent substance abuse treatment gap: Implications for research, practice, and policy. (review). Journal of Behavioral Health Services & Research 37(1): 40-63, 2010. (206 refs.)

In any given year, only about 10% of the nearly two million adolescents exhibiting substance abuse or dependence in the United States receive substance abuse treatment. Given this state of affairs, it is unlikely that the massive effort and expenditure of resources over the past decade on developing, testing, and disseminating effective treatments for adolescent substance abuse will have an appreciable impact on the prevalence of substance use disorders among the adolescent population. In order to substantially diminish the pervasive gap between levels of need for and utilization of adolescent substance abuse treatment, specialized assertive outreach strategies may be needed. This paper outlines a framework for assertive outreach for adolescents with substance use disorders and proposes specific types of strategies for identifying and enrolling such adolescents into treatment. Implications for practice and policy pertaining to adolescent substance abuse treatment service delivery are considered.

Pandya A; Katz CL; Smith R; Ng AT; Tafoya M; Holmes A et al. Services provided by volunteer psychiatrists after 9/11 at the New York City Family Assistance Center: September 12-November 20, 2001. Journal of Psychiatric Practice 16(3): 193-199, 2010. (6 refs.)

To characterize the experience of volunteer disaster psychiatrists who provided pro bono psychiatric services to 9/11 survivors in New York City, from September 12, 2001 to November 20, 2001. Method. Disaster Psychiatry Outreach (DPO) is a non-profit organization founded in 1998 to provide volunteer psychiatric care to people affected by disasters and to promote education and research in support of this mission. Data for this study were collected from one-page clinical encounter forms completed by 268 DPO psychiatrists for 2 months after 9/11 concerning 848 patients served by the DPO 9/11 response program at the New York City Family Assistance Center. Results. In this endeavor, 268 psychiatrist volunteers evaluated 848 individuals and provided appropriate interventions. The most commonly recorded clinical impressions indicated stress-related and adjustment disorders, but other conditions such as bereavement, major depression, and substance abuse/dependence were also observed. Free samples were available for one sedative and one anxiolytic agent; not surprisingly, these were the most commonly prescribed medications. Nearly half of those evaluated received psychotropic medications. Conclusions. In the acute aftermath of the attacks of September 11, 2001, volunteer psychiatrists were able to provide services in a disaster response setting, in which they were co-located with other disaster responders. These services included psychiatric assessment, provision of medication, psychological first aid, and referrals for ongoing care. Although systematic diagnoses could not be confirmed, the fact that most patients were perceived to have a psychiatric diagnosis and a substantial proportion received psychotropic medication suggests potential specific roles for psychiatrists that are unique and different from roles of other mental health professionals in the early post-disaster setting. In addition to further characterizing post-disaster mental health needs and patterns of service provision, future research should focus on the short-and long-term effects of psychiatric interventions, such as providing acute psychotropic medication services and assessing the effectiveness of traditional acute post-disaster interventions including crisis counseling and psychological first aid.

Passik SD; Lowery A. Psychological variables potentially implicated in opioid-related mortality as observed in clinical practice. Pain Medicine 12(2): S36-S42, 2011. (49 refs.)

Opioid-related deaths in the United States have become a public health problem, with accidental and unintended overdoses being especially troubling. Screening for psychological risk factors is an important first step in safeguarding against nonadherence practices and identifying patients who may be vulnerable to the risks associated with opioid therapy. Validated screening instruments can aid in this attempt as a complementary tool to clinicians' assessments. A structured screening is imperative as part of an assessment, as clinician judgment is not the most reliable method of identifying nonadherence. As a complement to formal screening, we present for discussion and possible future study certain psychological variables observed during years of clinical practice that may be linked to medication nonadherence and accidental overdose. These variables include catastrophizing, fear, impulsivity, attention deficit disorders, existential distress, and certain personality disorders. In our experience, chronic pain patients with dual diagnoses may become "chemical copers" as a way of coping with their negative emotion. For these patients, times of stress could lead to accidental overdose. Behavioral, cognitive-behavioral (acceptance and commitment, dialectical behavior), existential (meaning-centered, dignity), and psychotropic therapies have been effective in treating these high-risk comorbidities, while managing expectations of pain relief appears key to preventing accidental overdose.

Pecora PJ. Why current and former recipients of foster care need high quality mental health services. Administration and Policy in Mental Health and Mental Health Services Research 37(1-2, special issue): 185-190, 2010. (36 refs.)

This commentary presents data about the emotional, behavioral, and substance abuse disorders of youth in foster care and former recipients of foster care ("alumni") in the United States to underscore the reasons why high quality mental health services are essential.

Pinxten WJL; De Jong C; Hidayat T; Istiqomah AN; Achmad YM; Raya RP et al. Developing a competence-based addiction medicine curriculum in Indonesia: The training needs assessment. Substance Abuse 32(2, special issue): 101- 107, 2011. (23 refs.)

Indonesia has one of the fastest growing, injecting drugs user-driven, human immunodeficiency virus (HIV) epidemics in Asia. Coverage of needle and syringe programs (NSPs), opioid substitution therapy (OST), and antiretroviral treatment (ART) is increasing, but is still low, whereas professional training in addiction medicine is not yet established. Urgent development and scaling-up of professional capacity in comprehensive, evidence-based addiction medicine is needed. In this article the results of the first step is presented, being the training needs assessment (TNA) and the process of further developing a national evidence- and competence-based addiction medicine curriculum in Indonesia.

Piper ME; Smith SS; Schlam TR; Fleming MF; Bittrich AA; Brown JL et al. Psychiatric disorders in smokers seeking treatment for tobacco dependence: Relations with tobacco dependence and cessation. Journal of Consulting and Clinical Psychology 78(1): 13-23, 2010. (72 refs.)

Objective: The present research examined the relation of psychiatric disorders to tobacco dependence and cessation outcomes. Method. Data were collected from 1,504 smokers (58.2% women; 83.9% White; mean age = 44.67 years, SD = 11.08) making an aided smoking cessation attempt as part of a clinical trial. Psychiatric diagnoses were determined with the Composite International Diagnostic Interview structured clinical interview. Tobacco dependence was assessed with the Fagerstrom Test of Nicotine Dependence (FTND) and the Wisconsin Inventory of Smoking Dependence Motives (WISDM). Results: Diagnostic groups included those who were never diagnosed, those who had ever been diagnosed (at any time, including in the past year), and those with past-year diagnoses (with or without prior diagnosis). Some diagnostic groups had lower follow-up abstinence rates than did the never diagnosed group (ps < .05). At 8 weeks after quitting, strong associations were found between cessation outcome and both past-year mood disorder and ever diagnosed anxiety disorder. At 6 months after quitting, those ever diagnosed with an anxiety disorder (OR = .72, p = .02) and those ever diagnosed with more than one psychiatric diagnosis (OR = .74, p = .03) had lower abstinence rates. The diagnostic categories did not differ in smoking heaviness or the FTND, but they did differ in dependence motives assessed with the WISDM. Conclusion: Information on recent or lifetime psychiatric disorders may help clinicians gauge relapse risk and may suggest dependence motives that are particularly relevant to affected patients. These findings also illustrate the importance of using multidimensional tobacco dependence assessments.

Potter JS; Prather K; Kropp F; Byrne M; Sullivan CR; Mohamedi N et al. A method to diagnose opioid dependence resulting from heroin versus prescription opioids using the Composite International Diagnostic Interview. Contemporary Clinical Trials 31(2): 185-188, 2010. (15 refs.)

Treatment research with opioid-dependent populations has not traditionally distinguished between those dependent on prescription opioids versus dependent upon heroin. Evidence suggests there is a substantial subpopulation of individuals with opioid dependence resulting largely or exclusively from prescription opioid use. Because this subpopulation may respond to treatment differently from heroin users, a method for discriminating DSM-IV opioid dependence due to prescription opioid use would provide more precision when examining this population. This paper describes an innovative method using a currently available diagnostic instrument, to diagnose DSM-IV opioid dependence and distinguish between dependence resulting from prescription opioids versus dependence upon heroin.

Raes V; De Jong CAJ; De Bacquer D; Broekaert E; De Maeseneer J. The effect of using assessment instruments on substance-abuse outpatients' adherence to treatment: A multi-centre randomised controlled trial. BMC Health Services Research 11(e-article 123), 2011. (46 refs.)

Background: Drop-out is an important problem in the treatment of substance use disorder. The focus of this study was to investigate the effectiveness of within treatment assessment with feedback directly to patients with multiple substance use disorder on outpatient individual treatment adherence. Feedback consisted of personal resources' and readiness to change status and progress that facilitate or hinder change, thereby using graphical representation. Methods: Informed consent was obtained from both the control and experimental groups to be involved in research and follow-up. Following Zelen's single consent design, baseline participants (n = 280) were randomised (sample-size-estimation: 80%power, p=.05, 2-sided) and treatment consent was obtained from those allocated to the experiment (n = 142). In both groups, equal numbers of patients did not attend sessions after allocation. So, 227 persons were analyzed according to intention-to-treat analysis (ITT: experiment n = 116; control n = 111). Excluding refusals 211 participants remained for per-protocol analysis (PP: experiment n = 100; control n = 111), The study was conducted in five outpatient treatment-centres of a large network (De Sleutel) in Belgium. Participants were people with multiple substance use disorder -abuse and dependence-who had asked for treatment and who had been advised to start individual treatment after a standardised admission assessment with the European Addiction Severity Index. The experimental condition consisted of informing the patient about the intervention and of subsequent assessments plus feedback following a protocol within the first seven sessions. Assessments were made with the Readiness to Change Questionnaire and the Personal Resources Diagnostic System. The control group received the usual treatment without within treatment assessment with feedback. The most important outcome measure in this analysis of the study was the level of adherence to treatment at and beyond eight sessions. Results: Individual treatment that included assessment with feedback increased adherence to treatment at and beyond eight sessions (RR = 1.6,95%CI:1.2-2.2). Benefit was also found at and beyond twelve sessions, which was the number of sessions required to complete 90% of the assessments with feedback in practice (RR = 1.6,95% CI:1.2-2.5). Conclusions: Assessment with feedback in routine practice improved adherence to treatment. More research is needed to evaluate progress in social functioning and motivation to change in outpatient treatment of substance use disorder, thereby using objective measures

Roberts SCM; Nuru-Jeter A. Women's perspectives on screening for alcohol and drug use in prenatal care. Women's Health Issues 20(3): 193-200, 2010. (39 refs.)

Background. Screening for alcohol and drug use in prenatal care is widely promoted in the United States as a public health strategy for reducing alcohol and drug use during pregnancy. However, the published literature does not consider women's perspectives or the potential negative ramifications of screening. Methods. Twenty semistructured interviews and two focus groups (n = 38) were conducted with a racially/ethnically diverse sample of low-income pregnant and parenting women using alcohol and/or drugs in a northern California county. Results. Most women were averse to having drug but not alcohol use identified and were mistrustful of providers' often inconspicuous efforts to discover drug use. Women expected psychological, social, and legal consequences from being identified, including feelings of maternal failure, judgment by providers, and reports to Child Protective Services. Women did not trust providers to protect them from these consequences. Rather, they took steps to protect themselves. They avoided and emotionally disengaged from prenatal care, attempted to stop using substances that could be detected by urine tests before prenatal care visits, and shared strategies within social networks for gaining the benefits of prenatal care while avoiding its negative consequences. Conclusion. Considerations of the public health impact of screening for drug use in prenatal care should account for the implications of women's physical avoidance of and emotional disengagement from prenatal care, specifically the direct effects of late, limited, and no prenatal care on pregnancy outcomes and missed opportunities for health promoting interventions.

Robinson JD; Lam CY; Carter BL; Minnix JA; Cui Y; Versace F et al. A multimodal approach to assessing the impact of nicotine dependence, nicotine abstinence, and craving on negative affect in smokers. Experimental and Clinical Psychopharmacology 19(1): 40-52, 2011. (72 refs.)

We used multimodal measurement to evaluate whether (a) nicotine dependence is associated with baseline and postquit negative affect and craving, (b) smoking relapse is associated with greater negative affect and craving than abstinence, and (c) craving is associated with negative affect. Treatment-seeking smokers were randomly assigned to either a brief behaviorally based smoking-cessation treatment condition or to a delayed treatment control condition. Participants in the treatment condition attended four assessment sessions, 4-5 days prequit (baseline), 1-2 days postquit, 3-5 days postquit, and 10-14 days postquit, while controls attended four sessions spaced over the same intervals. Retrospective questionnaires were collected at the beginning of each session, and corrugator EMG and in-session ratings were collected during viewing of affective and cigarette-related slides. The multimodal measures indicated that more dependent smokers experienced greater negative affect and craving at baseline and postquit, regardless of abstinence status. The self-report measures indicated that both relapsed and abstinent smokers reported greater negative affect and craving than control smokers. Craving was associated with negative affect across measurement modalities. These results highlight the benefits of using multimodal measures to study the impact of nicotine dependence and withdrawal on negative affect and craving.

Room R; Rehm J; Parry C. Alcohol and non-communicable diseases (NCDs): Time for a serious international public health effort. (commentary). Addiction 106(9): 1547-1548, 2011. (16 refs.)

Rothrauff TC; Abraham AJ; Bride BE; Roman PM. Substance abuse treatment for older adults in private centers. Substance Abuse 32(1): 7-15, 2011. (20 refs.)

By 2020, an estimated 4.4 million older adults will require substance abuse treatment compared to 1.7 million in 2000-01. This study examined the availability of special services for older adults, adoption of recommended treatment approaches, and organizational characteristics of centers that offer special services. Data were collected via face-to-face interviews with administrators and/or clinical directors from a nationally representative sample of 346 private treatment centers participating in the 2006-07 National Treatment Center Study. Results indicated that only 18% provided special services for older adults; age-specific recommendations were generally adopted; more older adult-specialty centers offered prescription drug addiction treatment, primary medical care, and housing assistance. The proportion of patients with Medicare payment predicted availability of special services. As more older adults will seek help with a myriad of substance use disorders (SUDs) over the next decade, treatment centers need to get ready for a plethora of challenges as well as unique opportunities for growth.

Sarff M; Gold JA. Alcohol withdrawal syndromes in the intensive care unit. (review). Critical Care Medicine 8(9, supplement): S494-S501, 2010. (100 refs.)

This article reviews the pathophysiology, diagnosis, and treatment of alcohol withdrawal syndromes in the intensive care unit as well as the literature on the optimal pharmacologic strategies for treatment of alcohol withdrawal syndromes in the critically ill. Treatment of alcohol withdrawal in the intensive care unit mirrors that of the general acute care wards and detoxification centers. In addition to adequate supportive care, benzodiazepines administered in a symptom-triggered fashion, guided by the Clinical Institute Withdrawal Assessment of Alcohol scale, revised (CIWA-Ar), still seem to be the optimal strategy in the intensive care unit. In cases of benzodiazepine resistance, numerous options are available, including high individual doses of benzodiazepines, barbiturates, and propofol. Intensivists should be familiar with the diagnosis and treatment strategies for alcohol withdrawal syndromes in the intensive care unit.

Secora AM; Eddie D; Wyman BJ; Brooks DJ; Mariani JJ; Levin FR. A comparison of psychosocial and cognitive functioning between depressed and non-depressed patients with cannabis dependence. Journal of Addictive Diseases 29(3): 325-337, 2010. (53 refs.)

Cannabis use and depressive disorders are thought to impair cognitive performance and psychosocial functioning. Both disorders co-occurring may compound the negative effects of these diagnoses. In this study, the authors used the California Computerized Assessment Package as the cognitive performance measure and the Addiction Severity Index as the psychosocial functioning measure to compare individuals who were cannabis dependent and either depressed or not depressed (N= 108: 54 cannabis dependent only, 54 cannabis dependent and depressed or dysthymic). As predicted, cannabis dependent individuals with comorbid depression showed more psychosocial impairment than individuals with cannabis dependence alone. However, contrary to the authors' hypothesis, individuals who were cannabis dependent with comorbid depression showed less cognitive impairment in some California Computerized Assessment Package modules than individuals with cannabis dependence alone. Based on the authors' results, they concluded that the additive effects of cannabis dependency and depression may only be limited to psychosocial domains and may not extend to cognitive functioning.

Shamblen SR; Dwivedi P. Is some data better than no data at all? Evaluating the utility of secondary needs assessment data26. Drugs: Education, Prevention and Policy 17(6): 835-852, 2010. (26 refs.)

Needs assessments in substance abuse prevention often rely on secondary data measures of consumption and consequences to determine what population subgroup and geographic areas should receive a portion of limited resources. Although these secondary data measures have some benefits (e.g. large sample sizes, lack of survey response biases and cost), statistical tests on these data may not actually answer our underlying research questions. The present study sought to examine the reliability and validity of a set of alcohol consumption and consequence proxy measures as predictors of actual criterion data on youth alcohol use collected using a sampling design. The results of this study suggest that measures of more excessive alcohol use or problem behaviour occurrence are more likely to be related to criterion measures of youth alcohol use, as these secondary data tend to be more time invariant. Furthermore, the measures of less-excessive alcohol use or problem behaviour occurrence, while more normally distributed, tend to be more time variant and will typically lead policy makers to incorrect needs assessment allocation decisions. These findings suggest that policy makers should focus on secondary data measures that reflect extreme alcohol use problems, such that geographic areas that are most in need of help receive limited resources.

Silva RR; Skimming JW; Muniz R. Cardiovascular safety of stimulant medications for pediatric attention-deficit hyperactivity disorder. Clinical Pediatrics 49(9): 840-851, 2010. (62 refs.)

Attention-deficit hyperactivity disorder (ADHD) is a common neurobehavioral disorder that is often treated with stimulants such as methylphenidate and mixed amphetamine salts. Despite their efficacy and long history of use, there is concern about their potential for adverse cardiovascular effects in children and adolescents. Data from placebo-controlled and open-label extension trials published after 2000 were reviewed, and cardiovascular adverse event data were compared. Both placebo-controlled and open-label extension trials have repeatedly shown stimulant-induced increases in mean blood pressure, heart rate, and QT interval in children, adolescents, and adults. Although these increases seem relatively minor, their existence raises questions regarding whether stimulants could influence the likelihood of sudden death or other serious cardiovascular consequences, especially in patients with underlying heart problems. Moreover, questions have been raised regarding the necessity of screening patients for occult or unrecognized heart problems that are felt to be adversely affected by stimulant use. Obtaining a baseline electrocardiogram for any patient starting stimulant treatment is reasonable if access to such screening is readily available and not too costly.

Skurtveit S; Furu K; Bramness J; Selmer R; Tverdal A. Benzodiazepines predict use of opioids: A follow-up study of 17,074 men and women. Pain Medicine 11(6): 805-814, 2010. (39 refs.)

Objective. To evaluate the effect of the use of benzodiazepines on prescription of opioids 4-7 years later in patients with noncancer pain. Design. A cohort of 7,991 men and 9,083 women aged 40, 45 and 60 years who reported no use of opioids in health surveys in 2000-2001 was linked to the nationwide Norwegian Prescription Database, and their prescriptions of opioids during 2004-2007 were analyzed. Moderate-high prescription frequency of opioids was defined as at least 12 prescriptions during the period January 2004-December 2007. Results. The unadjusted odds ratio for moderate-high prescription frequency of opioids for individuals who had previously used benzodiazepines was 7.7 (95% confidence interval 5.6-10.5) as compared with previous nonusers. After adjustment for musculoskeletal pain, alcohol, smoking habits, and socioeconomic variables, the odds ratio was lowered to 3.1 (2.1-4.6). The analysis of the effect of benzodiazepines and chronic pain individually and in combination suggest that use of benzodiazepines is an even stronger predictor of later opioid use than self-reported chronic pain. Conclusions. Our study suggests that earlier use of benzodiazepines may predict repeated use of opioids. Before starting pain treatment with opioids, clinicians should take into consideration the possibility of substance abuse and mental health disorders. A central issue when prescribing opioids for chronic noncancer pain is to balance the risk of problematic use of these drugs with the benefits of pain relief.

Smedslund G; Berg RC; Hammerstrom KT; Steiro A; Leiknes KA; Dahl HM et al. Motivational interviewing for substance abuse. (review). Cochrane Database of Systematic Reviews 5: CD008063, 2011. (292 refs.)

Background: There are 76.3 million people with alcohol use disorders worldwide and 15.3 million with drug use disorders. Motivational interviewing (MI) is a client-centred, semi-directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence. The intervention is used widely, and therefore it is important to find out whether it helps, harms or is ineffective. Objectives: To assess the effectiveness of motivational interviewing for substance abuse on drug use, retention in treatment, readiness to change, and number of repeat convictions. Search strategy: We searched 18 electronic databases, 5 web sites, 4 mailing lists, and reference lists from included studies and reviews. Search dates were November 30, 2010 for Cochrane Library, Medline, Embase and PsychINFO. Selection criteria Randomized controlled trials with persons dependent or abusing substance. Interventions were MI or motivational enhancement therapy. The outcomes were extent of substance abuse, retention in treatment, motivation for change, repeat conviction. Data collection and analysis: Three authors independently assessed studies for inclusion, and two authors extracted data. Results were categorized into (1) MI versus no-treatment control, (2) MI versus treatment as usual, (3) MI versus assessment and feedback, and (4) MI versus other active treatment. Within each category, we computed meta-analyses separately for post-intervention, short, medium and long follow-ups. Main results: We included 59 studies with a total of 13,342 participants. Compared to no treatment control MI showed a significant effect on substance use which was strongest at post-intervention SMD 0.79, (95% CI 0.48 to 1.09) and weaker at short SMD 0.17 (95% CI 0.09 to 0.26], and medium follow-up SMD 0.15 (95% CI 0.04 to 0.25]). For long follow-up, the effect was not significant SMD 0.06 (95% CI-0.16 to 0.28). There were no significant differences between MI and treatment as usual for either follow-up post-intervention, short and medium follow up. MI did better than assessment and feedback for medium follow-up SMD 0.38 (95% CI 0.10 to 0.66). For short follow-up, there was no significant effect. For other active intervention there were no significant effects for either follow-up. There was not enough data to conclude about effects of MI on the secondary outcomes. Authors' conclusions: MI can reduce the extent of substance abuse compared to no intervention. The evidence is mostly of low quality, so further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.

Staiger PK; Thomas AC; Ricciardelli LA; McCabe MP. Identifying depression and anxiety disorders in people presenting for substance use treatment. Medical Journal of Australia 195(3, supplement): S60-S63, 2011. (18 refs.)

Objective: To identify the type and proportion of depressive and related mental health disorders in a group of individuals seeking outpatient treatment at an alcohol and other drug (AOD) service. Design, setting and participants: A cross-sectional study using diagnostic interviews with 95 participants (56 men, 39 women) seeking treatment from an AOD service. Main outcome measures: Mental health and substance disorders were measured using the Composite International Diagnostic Interview, Posttraumatic Stress Disorder Checklist, Beck Depression Inventory, and State Trait Anxiety Inventory (Trait Version). Results: This was a complex group with addiction, mental health and physical health conditions; 76% had a depressive disorder and 71% had an anxiety disorder. Most were diagnosed with at least two mental health disorders and 25% were diagnosed with four or more different disorders. Alcohol and cannabis use were the most commonly diagnosed AOD disorders. Further, those diagnosed with a drug use disorder reported significantly higher levels of depression compared with those with an alcohol-only disorder. Finally, 60% of the sample reported chronic health conditions, with over one-third taking medication for a physical condition on a regular basis. Conclusions: Primary care providers such as general practitioners are likely to be increasingly called on to assess, treat and/or coordinate care of patients with AOD disorders. We show that this group will likely present to their GP with more than one mental health disorder in addition to acute and chronic physical health conditions.

Stillman FA. Capacity building and human resource development for tobacco control in Latin America. Salud Publica de Mexico 52(Supplement 2): S340-S346, 2010. (13 refs.)

Objective. To assess capacity and human resources in Latin America countries and compare with other countries. Material and Methods. Data were gathered through needs assessments that were conducted at the 2009 World Conference on Tobacco or Health, and the 2(nd) Society for Research on Nicotine and Tobacco-International American Heart Foundation, Latin America Tobacco Control Conference held in Mexico City in 2009. Results. In comparing Latin America respondents to respondents from other countries, we found that the average number of years in tobacco control was higher and the majority of respondents reported higher levels of educational attainment. Respondents reported lack of funding and other resources as their number one challenge, as well as, tobacco industry interference and lack of political will to implement tobacco control policies. Conclusions. In Latin America there are some countries that have made significant progress in building their capacity and human resources to address their tobacco epidemics, but much still needs to be done.

Truncali A; Lee JD; Ark TK; Gillespie C; Triola M; Hanley K et al. Teaching physicians to address unhealthy alcohol use: A randomized controlled trial assessing the effect of a Web-based module on medical student performance. Journal of Substance Abuse Treatment 40(2): 203-213, 2011. (40 refs.)

Background: The authors developed and evaluated an interactive, Web-based module to train medical students in screening and brief intervention (SBI) for unhealthy alcohol use. Methods: First-year students were randomized to module versus lecture. Change in knowledge, attitudes, and confidence were compared. Performance was assessed by objective structured clinical examination (OSCE) and analyzed by intention to treat and treatment received. Results: Of 141 consenting students, 64% (n = 90) completed an intervention (54% lecture vs. 70% Web assigned). Knowledge, confidence, and attitudes improved in both groups, with more improvement in Advise Assist knowledge for Web students (14% vs. -3%, p = .003). Web students outperformed their lecture peers in both general communication (65% vs. 51% items well done, p = .004);and alcohol-specific tasks (54% vs. 41%, p = .021) on OSCE. Analysis by treatment received enhanced between-group differences. Conclusion: Use of a Web-based module to teach SBI is associated with greater knowledge gain and skills performance compared with a lecture covering similar content. The module provides an efficient means for training in this area.

Tucker JS; Wenzel SL; Golinelli D; Zhou A; Green HD. Predictors of substance abuse treatment need and receipt among homeless women. Journal of Substance Abuse Treatment 40(3): 287-294, 2011. (50 refs.)

Many homeless women do not receive needed treatment for substance abuse. This study identified social network and other predisposing factors associated with perceived need for and receipt of substance abuse treatment among 273 homeless women who screened positive for past-year substance abuse. Perceived treatment need was more likely among women with drug-using sex partners, a denser network, and an arrest history but less likely for those with a minor child and a longer history of homelessness. Receiving treatment was more likely among women who received informational support from their sex partners and who had an arrest history but less likely among those who had a more street-based social network, had a minor child, considered themselves homeless, and recently needed mental health treatment. Treatment services researchers should attend more closely to social contextual factors, as well as the more traditional individual factors, to understand access and barriers to treatment.

Venkatanarasimha N; Rock B; Riordan RD; Roobottom CA; Adams WM. Imaging of illicit drug use. (review). Clinical Radiology 65(12): 1021-1030, 2010. (23 refs.)

Illicit drug abuse is a continuing menace of epidemic proportions associated with serious medical and social problems. Drug abuse can have a wide variety of presentations some of which can be life-threatening. The clinical diagnosis can be challenging as the history is usually limited or absent. Radiologists need to be familiar with varied imaging presentations and the related complications of illicit drug abuse to ensure correct diagnosis and appropriate timely treatment. This review will illustrate the imaging spectrum of illicit drug abuse involving several organ systems and also discuss the pathophysiological consequences of drug abuse.

Verrocchio MC; Conti C; Fulcheri M. Deliberate self-harm in substance-dependent patients and relationship with alexithymia and personality disorders: A case-control study. Journal of Biological Regulators and Homeostatic Agents 24(4): 461-469, 2010. (37 refs.)

The aim of this study Is to evaluate differences in the prevalence of deliberate self-harm (DSH), alexithymia, and clinical personality patterns and syndromes between treatment-seeking substance-dependents and a comparison group, and to investigate the relationship of DSH with alexithymia, and personality disorders. One hundred and fifty-four subjects participated in the study (77 substance-dependent inpatients and 77 comparison group). DSM-IV diagnoses of substance dependence were made by the clinicians of the Addiction Services following assessment that included clinical observation. Participants were evaluated by the Deliberate Self Harm Inventory, Toronto Alexithymia Scale, and Millon Clinical Multiaxial Inventory. An Identifying Information Form was used to collect demographic information (e.g. age, educational history, marital status, and employment status). Only to the clinical sample information was added on: types of substance used, age at first substance use, age at regular substance use, and previous treatment attempts. Significant group differences were found for all measures (DSH, TAS-20, MCMI-III). Among substance-dependent patients there was a significant difference between groups with and without DSH in terms of previous treatment attempts, Hypomania and Borderline personality disorder. DSH were significantly correlated with difficulty in identifying feelings in all cases in both the comparison group and in the personality disorders group, and with difficulty describing feelings in the personality disorders group. Personality disorder and drug dependency were predictors for DSH. This study suggests that treatment of substance-dependents should involve screening for deliberate self-harm behavior, difficulty identifying and describing feelings, and personality disorders. Probably, when these problems are detected, specific psychological intervention should be integrated to usual treatment for substance-dependent patients.

Witteck A; Schmid P; Hensel-Koch K; Thurnheer MC; Bruggmann P; Vernazza P. Management of hepatitis C virus (HCV) infection in drug substitution programs Comparison of HCV treatment uptake and success rate with Swiss hepatitis C cohort study (SCCS) and Swiss HIV cohort study (SHCS) data. Swiss Medical Weekly 141: ew13193, 2011. (48 refs.)

BACKGROUND: In Switzerland, intravenous drug use (IDU) accounts for 80% of newly acquired hepatitis C virus (HCV) infections. Early HCV treatment has the potential to interrupt the transmission chain and reduce morbidity/mortality due to decompensated liver cirrhosis and hepatocellular carcinoma. Nevertheless, patients in drug substitution programs are often insufficiently screened and treated. OBJECTIVE/METHODS: With the aim to improve HCV management in IDUs, we conducted a cross sectional chart review in three opioid substitution programs in St. Gallen (125 methadone and 71 heroin recipients). Results were compared with another heroin substitution program in Bern (202 patients) and SCCS/SHCS data. RESULTS: Among the methadone/heroin recipients in St. Gallen, diagnostic workup of HCV was better than expected: HCV/HIV-status was unknown in only 1% (2/196), HCV RNA was not performed in 9% (13/146) of anti-HCV-positives and the genotype missing in 15% (12/78) of HCV RNA-positives. In those without spontaneous clearance (two thirds), HCV treatment uptake was 23% (21/91) (HIV-: 29% (20/68), HIV+: 4% (1/23)), which was lower than in methadone/heroin recipients and particularly non-IDUs within the SCCS/SHCS, but higher than in the, mainly psychiatrically focussed, heroin substitution program in Bern (8%). Sustained virological response (SVR) rates were comparable in all settings (overall: 50%, genotype 1: 35-40%, genotype 3: two thirds). In St. Gallen, the median delay from the estimated date of infection (IDU start) to first diagnosis was 10 years and to treatment was another 7.5 years. CONCLUSIONS: Future efforts need to focus on earlier HCV diagnosis and improvement of treatment uptake among patients in drug substitution programs, particularly if patients are HIV-co-infected. New potent drugs might facilitate the decision to initiate treatment.

Woods ER; Buka SL; Martin CR; Salganik M; Howard MB; Gueguen JA et al. Assessing youth risk behavior in a clinical trial setting: Lessons from the Infant Health and Development Program. Journal of Adolescent Health 46(5): 429-436, 2010. (36 refs.)

Purpose: The purpose of this article was to describe the use of the Youth Risk Behavior Surveillance System (YRBSS) with known 17-18-year-old patients in follow-up of a multisite randomized clinical trial, and to develop a new scoring algorithm indicating the degree of risk-taking behavior for between-group analyses. Methods: Seventy-five questions from the YRBSS were incorporated into the study questionnaire, with the development of safety plans to guide the disposition of participants. The YRBSS questions were grouped into two categories (with three subdomains each) named problem behaviors (conduct problems, sexual behavior, and suicide/hopelessness) and substance use (cigarettes, alcohol, and marijuana use), with scores for each subdomain indicating high, moderate, and low risk. Results: Of the 677 participants, the safety plan was activated 215 times for 199 (29.4%) of participants. Risk behaviors included binge drinking (149), alcohol/substance use and driving (41), depression (22), hopelessness (37), and suicidal ideation (13; all in the past). No emergency room evaluations were required. The subdomain scaling was analyzed by demographic characteristics, and findings were consistent with the literature; for example, higher rates of conduct problems in males, more suicidal ideation in females, greater sexual risk in African Americans, more substance use in males and whites, and more alcohol use in youth with mothers with higher levels of education. Conclusions: YRBSS can be administered in a research setting with appropriate safety precautions. These results should provide a useful guide to the application of the YRBSS to other adolescent populations in the future.

Wusthoff LE; Waal H; Ruud T; Roislien J; Grawe RW. Identifying co-occurring substance use disorders in community mental health centres. Tailored approaches are needed. Nordic Journal of Psychiatry 65(1): 58-64, 2011. (49 refs.)

Background: Increasing evidence shows that substance use disorders (SUD) and psychiatric illness co-occur, and that this co-morbidity renders treatment more difficult and results in greater use of health services. Thus, clinical routines to identify SUD amongst patients in mental healthcare should have high priority in order to provide optimal treatment. Aim: In this study, we examine whether common and well-known substance use measures are appropriate in detecting SUD in Community Mental Health Centres (CMHCs). Material and methods: The present study used a subset of data from an evaluation of the National Plan for Mental Health. Clinicians at eight CMHCs registered socio-demographic and treatment information about their patients during a 4-week period in 2007. This included diagnostic measures, the Alcohol and Drug Use Scales and the substance use item of the Health of the Nation Outcome Scales. Prevalence rates from the different substance use measures and the observed agreement between them were calculated. The prevalence rates were compared with other estimates of substance use prevalence. Results: All the different measures gave low prevalence rates of SUD, and the inter-measure agreement was poor. A combination of the measures gave prevalence rates closer to what is expected from previous epidemiological studies. Conclusion: The CMHCs participating in this study lack sufficient diagnostic routines and specific instruments to identify SUD. Clinical research that relies on methods used in this study will need combined approaches to provide reliable findings. Both clinical practice and research would benefit from valid, reliable screening methods and diagnostic procedures.

Zakletskaia L; Wilson E; Fleming MF. Alcohol use in students seeking primary care treatment at university health services. Journal of American College Health 59(3): 217-223, 2011. (18 refs.)

Objective: Given the high rate of at-risk drinking in college students, the authors examined drinking behaviors and associated factors in students being seen in student health services for primary care visits from October 30, 2004, to February 15, 2007. Methods: Analyses were based on a Health Screening Survey completed by 10,234 college students seeking general medical treatment. Results: Alcohol use was similar to other studies with 57% (n = 5,840) meeting the National Institute on Alcohol Abuse and Alcoholism criteria for at-risk drinking. Twenty-six percent of the students reported smoking at least once in the last 3 months. Risk factors for at-risk drinking included young age, white males, drinking at a fraternity/sorority house, and use of tobacco. Conclusions: These findings support the widespread implementation of alcohol screening and intervention in university health services.

Zamani N; Sanaei-Zadeh H; Mostafazadeh B. Hallmarks of opium poisoning in infants and toddlers. Tropical Doctor 40(4): 220-222, 2010. (6 refs.)

Accidental opium intoxication in children is an extremely dangerous poisoning if it remains undiagnosed and untreated. The classic triad of miosis, decreased level of consciousness and bradypnea, which are the hallmarks of opiate intoxication, are used for the diagnosis of opium poisoning in adults and children. Little attention has been paid to the signs of opium intoxication in children and no published study has explored the frequency of hallmarks of this type of poisoning in the paediatric population. We conducted a study in order to evaluate the prevalence of major signs of opium poisoning in infants and toddlers. In this study, a total of 228 infants and 82 toddlers who had been admitted to Loghman Hakim Hospital as a result of opium poisoning between 2001 and 2009 were evaluated, retrospectively. The most usual sign of opium poisoning was miosis (90%) followed by a decreased level of consciousness (88.4%), bradypnea (28.4%) and seizure (10.3%). The prevalence of the triad of miosis, bradypnea and a decreased level of consciousness was 25.2%. Miosis in association with decreased level of consciousness was detected in 82.6% of our patients. Bradypnea was present in 74 infants and 14 toddlers, which shows a statistically significant difference (P = 0.01). The mean age and weight of the patients with bradypnea were significantly less than those without bradypnea (P = 0.008 and P = 0.0001, respectively). Bradypnea and seizure were significantly more common in females (36.7% versus 26%; P = 0.05 and 15.2% versus 6.5%; P = 0.01, respectively). Miosis in association with a decreased level of consciousness is the most useful indicator of opium poisoning in infants and toddlers. Furthermore, seizure is a more common feature of this type of poisoning in infants, especially in those who are less than 1 month old.

Zwiebel MA; Hughes V. Smoking cessation efforts in one New York City HIV clinic. Journal of the Association of Nurses In AIDs Care 21(1): 11-15, 2010. (16 refs.)

In recent years, the medical management of HIV infection has become well-delineated, with established regularly updated standards of care that increasingly include health maintenance and promotion. The management of HIV infection has progressed to the point that many experts consider it a chronic disease. Health maintenance and promotion issues such as diet and exercise may have once had secondary importance or even been considered unimportant components of HIV care. But now they have become increasingly relevant, even a priority, to an HIV-infected person's immediate and long-term health status. Since 1997, mortality in PLWH from non-HIV-related disease has risen to approximately 25%. The causes of these deaths include non-HIV-related cancers, heart disease, and non-HIV-related bacterial infections. Tobacco smoking is a modifiable risk common to all of these diseases. Tobacco use by PLWH is estimated to be approximately 40% to 70%, and several studies have reported that the occurrence of non-HIV-related cancers, chronic lung disease, and heart disease is greater in smokers with HIV infection than in nonsmokers with HIV infection. The authors describe a smoking cessation effort initiated in HIV clinic. The elements included documenting smoking status in the medical record, initiating smokins cessation protocols, and providing referrals to smoking cessation programs.