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CORK Bibliography: Confidentiality

52 citations. January 1997 to present

Prepared: March 2008

Ambrose PJ. Doping control in sports: A perspective from the 1996 Olympic Games. American Journal of Health-System Pharmacy 54(9): 1053-1057, 1997

Doping-control (DC) procedures, particularly as used at the 1996 Olympic Games, ate described, and the role of pharmacists in DC is discussed. DC procedures must be strict and precisely followed to avoid contamination of samples, the appearance of bias, and breaches in security and confidentiality. The process of selecting athletes for testing can be random, nonrandom, or a combination of the two. Escorts are used to notify athletes of their selection, verify their identity, and accompany them to the DC station. When urine specimens are obtained for DC, the voiding process must be directly observed. The specimen is checked for pH and specific gravity and then processed for shipping to a laboratory to be analyzed for banned substances. Medication histories are also obtained, giving athletes the opportunity to declare any substance that has been taken for legitimate medical purposes. Laboratory analysis involves screening and confirmation phases. During the Atlanta Games, roughly 50 pharmacists participated in the DC program as escorts or technical officers. It is logical to involve pharmacists in DC programs because they can develop and conduct drug-testing protocols; educate athletes, coaches, and trainers about drug use and abuse; and help ensure the safe and effective use of medications. Sophisticated doping-control procedures have been developed for athletic competitions, and pharmacists have much to offer DC programs.

American Society of Addiction Medicine. Public policy statement on confidentiality in physician illness. Journal of Addictive Diseases 19(2): 123-125, 2000. (0 refs.)

This policy statement sets forth recommendations adopted by the American Society of Addiction Medicine in respect to confidentiality of the medical records of physician patients. It is the position of the Society that recent discussion in some quarters to promote physician disclosure to patients and potential patients of conditions that "might potentially" affect the ability to practice, violates right to privacy and would deter early diagnosis and impede Physician Health Programs that address physician impairment. Seven recommendations are set forth, all of which in essence state that physicians should be treated as are other patients in terms of reporting to governmental or other agencies, and should have the same level of confidentiality of medical records.

American Society of Addiction Medicine, Board of Directors. Public policy statement on centralized credentialing systems and the physician in recovery. (editorial). Journal of Addictive Diseases 19(2): 121-123, 2000. (0 refs.)

This is a policy statement adopted by the Board of the American Society of Addiction Medicine (ASAM) April 1999. There has been a rapid increase in the number of bodies involved in the credentialing and accreditation of physicians. Multiple systems can be both time consuming and costly. The American Medical Association has initiated efforts to create a unified system, and developed the American Medical Accreditation Program to accomplish this.; a group that is a member of the Performance Measurement Coordinating Council along with two other groups (National Committee of Quality Assurance to accredit health plans, health care networks, and care systems and also the Joint Commission on Accreditation of Healthcare Organizations to accredit single healthcare provider organization and health care networks. ASAM is sensitive to the value of a unified system but also sensitive to the circumstances posed by the physician in treatment or recovery, who may be unfairly excluded by credentialing. It therefore sets forth three recommendations -- the need to address the issues of recovering physicians; the need to consider conditions that may be related to the illness that would be the basis for denial of accreditation; and the need for confidentiality in such proceedings, to prevent personal medial histories from being accessible to the public or other medical/governmental organizations.

American Society of Addiction Medicine, Board of Directors. Public policy statement on reporting of patient information related to fitness for driving or other potentially dangerous activities. Journal of Addictive Diseases 19(2): 125-127, 2000. (0 refs.)

This policy statement by the American Society of Addiction Medicine was adopted in April 1999 and pertains to reporting of patients who may engage in dangerous behavior secondary to substance use. The Association believes it is important to distinguish between imminent danger (which needs to be acted upon) and longer range potential danger. The statement includes six recommendations: (1) that assessment of potential likelihood of harm, including driving be assessed; (2) dangers of engaging in driving or other potentially dangerous behaviors should be discussed with patients; (3) Voluntary hospitalization or emergency room evaluation should be considered when the patient presents substantial risk to self or others, which does not breech confidentiality; (4) the Association supports the development of state laws that provide for mechanisms for involuntary treatment in the event the patient is incapacitated by acute intoxication and represents an imminent danger to self or others; (5) Physicians should not be required to report all patients to a state motor vehicle licensing agency; and (6) reporting to authorities should be reserved only for unusual circumstances in which the substance-dependent patient poses an immediate threat to public safety; acting in accordance with federal confidentiality regulations is required, so that an individual's receipt of treatment is not revealed without patient consent.

Audrain J; Tercyak KP; Goldman P; Bush A. Recruiting adolescents into genetic studies of smoking behavior. Cancer Epidemiology, Biomarkers & Prevention 11(3): 249-252, 2002. (16 refs.)

The goal of this study is to describe the process of establishing a longitudinal cohort to study genetic, psychological, and social predictors of adolescent smoking. Parents of eligible adolescents were approached for their consent via mail. Seventy-two percent of parents (n = 1533 of 2120) provided a response regarding their teens' participation. Among those who provided a response, 75% (1151) agreed to allow their teen to participate in the research yielding an overall parental consent rate of 54%. Compared with parents who consented to their teens' participation, parents who declined were less educated (89% had greater than a high school education compared with 69% of those who did not provide consent), less likely to be Caucasian (68 versus 48%), and less likely to report having ever even experimented with smoking (71 versus 60%). The most frequently reported reasons parents gave for declining consent included lack of interest and confidentiality concerns. A logistic regression model predicting consent to participate revealed a significant race by education interaction, indicating that among Caucasian parents, those with an education beyond high school were over two times more likely to provide consent compared with Caucasian parents with a high school education or less (odds ratio = 2.43; confidence interval = 1.37- 4.32, P = 0.003).

Babcock M. More than just one way: Teaching complex thinking in addictions work. Journal of Teaching in the Addictions 1(1): 19-31, 2002. (38 refs.)

Despite the multiplicity of factors creating the phenomena seen in addictions treatment, addictions workers usually assume that only one factor is significant. This simplistic thinking is fostered by recovery insecurities of many workers, and by an intellectual tradition of simplistics in the addictions field. This paper describes several topics common in additions work that illustrate how univariate thinking distorts professional practice. The teacher or supervisor must model intellectual integrity and humility to persuade workers in the field to adopt more sophisticated thinking. Section headings in this journal article include: (1) the rock; (2) three waves of addictions work; (3) case studies -- attitudes toward drug and alcohol use; (4) decriminalization; (5) addictions confidentiality laws; (6) family matters; (7) adult children of alcoholics (ACOA); (8) AOD-related birth defects; (9) class and addiction; (10) failure is the patient's fault; (11) only Twelve-Step; and (12) changing.

Barton A; Quinn C. Risk management of groups or respect for the individual? Issues for information sharing and confidentiality in Drug Treatment and Testing Orders. Drugs: Education, Prevention and Policy 9(1): 35-43, 2002. (25 refs.)

Drug Treatment and Testing Orders (DTTOs) are generating huge amounts of debate in the field of drug work. It may not be too misplaced to argue that the impact of the DTTOs could be such as to change the nature of drug services in the UK. As to be expected with such far- reaching legislation there are numerous areas of concern. This paper begins to explore one of those area: the nature and problem of information sharing and client confidentiality. To achieve this, the paper examines the growth of the concept and practice of risk management within the criminal justice system and contrasts that model's concern with the control of groups, to health's traditional focus on the individual.

Bendtsen P; Timpka T. Acceptability of computerized self-report of alcohol habits: A patient perspective. Alcohol and Alcoholism 34(4): 575-580, 1999. (18 refs.)

The acceptability of computerized assessment of alcohol habits was explored in 57 consecutive out-patients over a 6-month period. Altogether, 46 men and 11 women agreed to complete a paper and pencil questionnaire exploring their opinion about computerized assessment. The study focused on the patients' acceptance of computerized testing and also on whether some sub-groups had reservations. The participants indicated that they had no general anxiety towards computers and did not mind being assessed by their use. Nearly half of the men were not convinced of the usefulness of computers as a means of asking about alcohol habits. The same level of confidence was recorded with regard to whether doctors would make better assessments using computers. Around one-quarter of both men and women were worried that computers might cause doctors to spend less time with the patients and that staff might lose the personal contact with patients. Because of the small sample size, we conclude tentatively that a computerized lifestyle test appears to be an acceptable method both to men and women with different educational backgrounds. However, two important issues need to be further addressed, namely concerns about confidentiality and loss of personal contact.

Bjarnason T; Adalbjarnardottir S. Anonymity and confidentiality in school surveys on alcohol, tobacco, and cannabis use. Journal of Drug Issues 30(2): 335-343, 2000. (20 refs.)

School surveys are currently the most important method of collecting data on alcohol and drug use among youth. Although methodological studies suggest that school surveys yield reliable and valid estimates of substance use among youth, it has been argued that results will be affected by the level of perceived anonymity. Longitudinal research designs raise an important question in this respect since follow-up makes complete anonymity impossible. In fact responses to such surveys should be regarded as confidential rather than anonymous. This study compares the reported use of cigarettes alcohol and cannabis between an anonymous, cross-sectional survey and a confidential, longitudinal survey. Both females and males in the confidential survey have a slightly higher rate of nonresponse for lifetime cannabis use. Furthermore, females tend to be slightly less likely to admit to any use of alcohol and cannabis in the confidential survey, and those who do admit to having used cigarettes and alcohol, report slightly fewer occasions. The correlations between use of cigarettes, alcohol, and cannabis are not affected by this bias. These results add further support to earlier research that has found school surveys to be a robust method of data collection, and suggests that the bias introduced by identification numbers in longitudinal research has limited practical significance.

Breslow RE; Erickson BJ; Cavanaugh KC. The psychiatric emergency service: Where we've been and where we're going. Psychiatric Quarterly 71(2): 101-121, 2000. (25 refs.)

The Psychiatric Emergency Service (PES) has evolved into a separate service with its own space and staff specialized for the handling of psychiatric emergencies. A study of trends in our PES reveals increased need for children's services, issues with managed care and an expansion in the use of the PES as a filter for the mental health system in dealing with substance abuse. Education and research have been added to the missions of the PES and there is strong potential for future development in this area. PESs of the future may be very different, with advances in communication, safety, computerized records and databases. New dilemmas in balancing the patient's right to confidentiality and autonomy against the potential of these advances are bound to occur.

Brodey BB; McMullin D; Winters KC; Rosen CS; Downing DR; Koble JM. Adolescent substance use assessment in a primary care setting. American Journal of Drug and Alcohol Abuse 33(3): 447-454, 2007. (17 refs.)

Health initiatives suggest that adolescent substance use assessment may be beneficial as part of primary care to screen for early problematic behaviors. To examine the accuracy of such reporting, we compared the anonymous and confidential self-reports of 180 adolescents in a primary care setting. Matching samples to control for demographic variables, we found that adolescents were more likely to report marijuana use and substance use behaviors, such as selling drugs, when reporting anonymously vs. reporting confidentially. These results challenge the accuracy of confidential self-reports within this setting, and suggest further research is needed.

Brody JL; Waldron HB. Ethical issues in research on the treatment of adolescent substance abuse disorders. Addictive Behaviors 25(2): 217-228, 2000. (34 refs.)

Treatment research on adolescent substance use disorders raises a number of important ethical and legal concerns which have not been widely acknowledged. This paper explores these concerns as they relate to fundamental ethical principles in the conduct of human research. The issues discussed include tensions between conflicting regulations governing informed consent for research and treatment of adolescents, the capacity of adolescents to give informed consent, potentially coercive elements related to research on substance use treatment. problems associated with confidentiality and release of information, research vulnerability associated with substance use, and ethical implications of distinctions between effectiveness and efficacy research. Suggestions for ways investigators may address these concerns are provided.

Buchanan D; Khoshnood K; Stopka T; Shaw S; Santelices C; Singer M. Ethical dilemmas created by the criminalization of status behaviors: Case examples from ethnographic field research with injection drug users. Health Education & Behavior 29(1): 30-42, 2002. (36 refs.)

The criminalization of behaviors such as the ingestion of certain mood-altering drugs creates ethical dilemmas for researchers studying those behaviors. The Syringe Access, Use, and Discard (SAUD) project is designed to uncover microcontextual factors that influence HIV and hepatitis risk behaviors of injection drug users. The article presents seven ethical dilemmas encountered using ethnographic method: issues involving syringe replacement at injection locales. risks of participants' arrest, potential disruptions in participants' supply routes, risks of research staff arrest, threats to the protection of confidentiality. issues surrounding informed consent in working with addicts, and the confiscation of potentially incriminating information by police. The article concludes with a discussion of the limitations of traditional ethical frameworks. such as utilitarianism, for resolving these dilemmas and recommends instead improving public health professionals' capacity for practical reasoning (phronesis) through the greater use of case studies in public health Curricula.

Bush PJ; D'Elio MA; Peoples CD; Schell HM. Surveying and tracking urban elementary schoolchildren's use of abusable substances. Substance Use & Misuse 32(12/13): 1967-1972, 1997. (17 refs.)

Prospective research shows that substance users in an urban school population may have greater than average problems associated with mobility, reading skills, absenteeism, dropout, retention in grade, and school cooperation. Methods are described that were used in a 4-year longitudinal study beginning in the 4th and 5th grades of ill District of Columbia public schools. The methods helped meet needs for accurate tracking, accurate data collection, protection of confidentiality, and acquisition and maintenance of the population.

Clough A; Conigrave K. Managing confidentiality in illicit drugs research: ethical and legal lessons from studies in remote Aboriginal communities. Internal Medicine Journal 38(1): 60-63, 2008. (11 refs.)

Assuring participant confidentiality in illicit drugs research has raised legal questions and challenges both for researchers and ethics committees. There are similar challenges for clinicians. To study cannabis use in Aboriginal people in Arnhem Land (Northern Territory), a risk-management approach was successful. Aboriginal participants were informed in their own language that confidentiality could not be assured if they disclosed information about illegal behaviours. Researchers avoided questions of intrinsic interest to law enforcement. Relationships between researchers and study participants and the integrity of the study were preserved. These considerations have relevance for clinicians as well as researchers dealing with the influence of illicit behaviours on health.

Coleman P. Privilege and confidentiality in 12-step self-help programs: Believing the promises could be hazardous to an addict's freedom. (review). Journal of Legal Medicine 26(4): 435-474, 2005. (199 refs.)

A wide gap exists between perception and reality on the question of whether an individual can prevent others from revealing statements he or she made while dealing with addiction in a 12-step self-help group. The simple but troubling explanation for this disparity is that, although people are routinely assured whatever they say during meetings will not be repeated, neither state nor federal laws support these promises. As a variety of studies demonstrate the advantages associated with participating in peer-run programs, especially when attendance is combined with conventional treatment, researchers encourage physicians to persuade their patients to participate. These recommendations are appropriate as most people in recovery benefit from the support of others who also are struggling with sobriety and from the continual monitoring organizations like Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) provide. Traditional lengthy therapy, even if it were as effective, is not a good alternative because it has become too expensive. Thus, physicians should refer their patients to established self-help groups, but only after fully explaining the limitations on confidentiality and privilege. Failure to do so could subject physicians to both disciplinary action and civil liability. This article provides information important for people in these programs as well as their attorneys and therapists. Part I defines addiction and discusses the human and financial costs attributed to this compulsive disorder. Part II explains the law surrounding confidentiality, privilege, and the duty to report certain information. Part III briefly describes the history and evolution of self-help groups in treating people with drug and alcohol problems. It also compares and contrasts such programs to group therapy and substance abuse counseling with an eye toward determining whether the differences justify disparate protections. Part IV analyzes relevant court decisions. Part V canvasses state statutes on group therapy and points out that they do not encompass associations lacking a professional therapist or clergyman to whom confidentiality and privilege might apply. This section also reviews federal and state legislative treatment of substance abuse counselors and suggests these laws could be expanded to include self-help members. Part VI cautions physicians who refer patients to these groups that, to avoid both civil liability and licensure problems, they should alert their patients that, under exceptional circumstances, their statements made in working through the 12 steps might be disclosed. This warning will satisfy the duty to alert patients to potential risks and protect physicians from claims that they failed to obtain informed consent for the recommended treatment--namely, joining a self-help group. Finally, Part VII proposes a uniform statute that grants confidentiality and a qualified privilege to communications between and among self-help participants. The article concludes that the only way to eliminate the problem is to pass legislation that shields these conversations absent either consent to release or clear and convincing evidence of a compelling need for the information.

Crabbe T; Donmall M. The optimal size of attributor for use with the University of Manchester Drug Misuse Database. Addiction 91(10): 1547-1550, 1996. (7 refs.)

This paper describes the anonymous, attributable code which is applied to different individuals when they are reported to the regional drug misuse databases using the University of Manchester system. It then reports on the effect of removing selected data items included in the attributor on the system's ability to distinguish between different drug users reported to the database. All of the attributable codes that did not use the full set of data items were found to reduce the system's ability to distinguish between the reporting of new drug users and new episodes of drug use for users previously reported to the database.

Crome I; Ghodse H; Gilvarry E; McArdle P. Young People and Substance Misuse. London: Gaskell, 2004. (Chapter refs.)

This book is directed to professionals in the field. It covers the critical elements in dealing with this young people around substance abuse, covering definitions of substance abuse, reviewing the prevalence, attraction of substance use, assessment, and evidence-based treatment approaches, that include behavioral techniques, drug therapy, as well as family therapy. It also addresses essential issues that may be overlooked -- competence, consent, and and confidentiality. The book is organized into 14 chapters, and has 14 contributors. Following an introduction, Chapter 2 reviews prevention efforts; Chapter 3, epidemiology; Chapter 4, determinants of substance use; Chapter 5, social influences; Chapter 6, psychiatric comorbidity; Chapter 7, implications of parental substance misuse; Chapter 8, health issues; Chapter 9, smoking; Chapter 10, assessment; Chapter 11, treatment; Chapter 12, substance use by young offenders; Chapter 13, ethical and legal principles; and Chapter 14, evidence-based model for services.

De Rosa CJ; Montgomery SB; Kipke MD; Iverson E; Ma JL; Unger JB. Service utilization among homeless and runaway youth in Los Angeles, California: Rates and reasons. Journal of Adolescent Health 24(3): 190-200, 1999. (16 refs.)

Purpose: To describe the service utilization patterns of homeless and runaway youth in a "service-rich" area (Los Angeles, California); identify demographic and other correlates of utilization; and contextualize the findings with qualitative data. Method: During Phase 1 of this study, survey data were collected from an ethnically diverse sample of 296 youth aged 13-23 years, recruited from both service and natural "hang-out" sites using systematic sampling methods. During Phase 2, qualitative data were collected from 46 youth of varying ethnicities and lengths of time homeless. Results: Drop-in centers and shelters were the most commonly used services (reported by 78% and 40%, respectively). Other services were used less frequently [e.g., medical services (28%) and substance abuse treatment (10%) and mental health services (9%)]. Utilization rates differed by ethnicity, length of time in Los Angeles, and city of first homeless episode (Los Angeles vs. all others). Shelter use was strongly associated with use-of all other services. Despite youths' generally positive reactions to services, barriers were described including restrictive rules, confidentiality and reporting problems, and negative interactions with staff members. Youth suggested improvements including more targeted services, more long- term services, revised age restrictions, and mote and/or better job training and transitional services to get them off the streets. Conclusions: Because shelters and drop-in centers act as gateways to other services and offer intervention potential for these hard-to- reach youth, it is vital that barriers to use of these services are eliminated.

Dias PJ. Adolescent substance abuse: Assessment in the office. Pediatric Clinics of North America 49(2): 269-300, 2002. (78 refs.)

This article discusses in depth the screening of an adolescent for substance abuse and evaluation of the adolescent identified with substance abuse that includes negotiating a confidentiality policy with the parents. A bio-psychosocial-spiritual developmental approach that briefly outlines clinical clues and laboratory assessment is described. Reviews of individual, family, and environmental risk factors with legal issues in assessment are considered. Easy-to- remember mnemonics and screening tools are presented to assist the busy pediatrician in the comprehensive office assessment of the adolescent using or suspected of using/abusing substances.

Erlich LB. A Textbook of Forensic Addiction, Medicine and Psychiatry. Springfield IL: Charles C Thomas Publisher, 2001

This volume assembles information from medicine, law, and psychiatry. Following an introduction to key legal constructs, and the role of the expert witness, it turns to the history of the legal regulation of addicting substances as well as summarizing drugs of abuse and mechanisms of their actions . It then proceeds to discuss the relationship of addiction to both civil and criminal law, how addiction influences the determination of competence, and confidentiality and privilege. The next chapters deal with topics closely related to addiction: HIV/AIDS, ADHD, obesity, pain management, and behaviorial addictions; special populations (impaired physicians, the military, prisoners, and athletes); the relationship of addiction to psychiatric issues (mental retardation, dual diagnosis) and the emergence of drug courts, and also the drug-free workplace. Prescription drug abuse is discussed. Following attention to malpractice in reference to substance use, the book concludes with a chapter on developing a forensic practice.

Fazzone PA; Hotlin JK; Reed BG. Substance Abuse Treatment and Domestic Violence. Treatment Improvement Protocol (TIP) Series 25. Rockville MD: Center for Substance Abuse Treatment, 1997. (208 refs.)

This protocol was developed by a consensus panal established to provide the substance abuse field with an overview of domestic violence in order to understand the needs and behaviors of batterers and victims, and define appropriate treatment, and to work with domestic violence experts. (Research has indicated that one-quarter of men who commit acts of domestic violence also have substance abuse problems.) Chapter 1 establishes the connections between substance abuse and domestic violence. The Panel recommends that those in substance abuse treatment be screened for domestic violence issues. Chapters 2 and 3 provide overviews of survivor clients and batterer clients. Chapter 4 focuses upon screening and referral. Chapter 5 examines attendant legal issues, with special attention to the 1994 Violence Against Women Act (VAWA). Chapter 6 makes recommendations in respect to linkages between the domestic violence programs and substance abuse treatment. The volume also includes further information on special resources; the application of Federal confidentiality regulations; instruments to screen for domestic violence and to assess a batterer's dangerousness; a model safety plan for work with survivor clients; and a directory of national programs and hotlines concerning domestic violence.

Ferri CP; Gossop M; Rabe-Hesketh S; Laranjeira RR. Differences in factors associated with first treatment entry and treatment re-entry among cocaine users. Addiction 97(7): 825-832, 2002. (33 refs.)

Aims: To investigate factors associated with first entry to treatment and with treatment re-entry among cocaine users. Design: Cross-sectional study. Setting, participants Cocaine users (n = 313) recruited from community and treatment settings in Brazil. Measurements: Structured questionnaire including selected items from the addiction severity index (ASI), general health questionnaire, version 28 (GHQ-28), CAGE and the severity of dependence scale (SDS). Findings: Higher dose use, being a problematic drinker and increased awareness of their problem were associated with increased odds of making first contact with an agency. Greater severity of dependence, being involved in acquisitive crime and social support increased the chance of treatment re-entry. Being involved in acquisitive crimes and concerns about confidentiality were associated with decreased odds of first treatment contact. Being a problematic drinker was associated with decreased odds of re-entry treatment. Conclusions: These findings suggest that the distinction between first treatment contact and subsequent entry to treatment is useful, clinically relevant and deserving of further investigation.

Fitzgerald JL; Hamilton M. Confidentiality, disseminated regulation and ethico-legal liabilities in research with hidden populations of illicit drug users. Addiction 92(9): 1099-1107, 1997. (32 refs.)

An assurance of confidentiality is at the core of trusting relationships in outreach, ethnographic research and patient/client encounters. In the past, centralized State health care services have provided assurances of confidentiality to those engaged in health- related research either through common law or by statute. However, unless specific confidentiality legislation is in place, no assurances of confidentiality can now be made to research subjects involved in either longitudinal, interview-based or ethnographic research. The consequences of this situation become move serious given the recent emergence of the use of peer and community outreach. A significant problem with the outreach model is the failure to provide adequate legal and ethical support for those in outreach roles. Additionally, unless research subjects can be granted assurances of confidentiality, they will not engage in research for fear of later prosecution. At this time when outreach models are the modus operandi, the lack of a fundamental commitment to sustain confidentiality may seriously undermine further research. This paper will draw on the experiences of some Australian qualitative research and will review some of the ethical and legal liabilities for research that arise when an assurance of confidentiality cannot be given to those participating in research.

Forman RF; Bovasso G; Woody G; McNicholas L; Clark C; Royer-Malvestuto C; Weinstein S. Staff beliefs about drug abuse clinical trials. Journal of Substance Abuse Treatment 23(1): 55-60, 2002. (18 refs.)

Staff from 10 community-based addiction treatment organizations in the National Drug Abuse Clinical Trials Network participated in an educational session about addiction research practices and human subject protections. This 1.5-hour presentation addressed "informed consent," "confidentiality of research information," "inclusion and exclusion criteria," "random assignment," "patient protections," and "patient payments." Pre- and post-session surveys were administered to 115 staff members measuring their beliefs about clinical trials. At baseline, 52% of staff believed patients could transfer out of a study even if they were doing poorly, and 55% believed staff had this right; 44% agreed that patients could participate in a clinical trial without understanding what would take place in the study. After the educational session, staff beliefs about patient protections were significantly increased in five of the seven items. A fourth of staff continued to believe patient payments were harmful, and 37% did not believe participation in a clinical trial would increase a patient's chances at recovery.

Fortunati FG; Zonana HV. Legal considerations in the child psychiatric emergency department. Child and Adolescent Psychiatric Clinics of North America 12(4): 745-+, 2003. (22 refs.)

Psychiatry is regulated more than any other field of medicine. All mental health clinicians must be familiar with the unique regulations that govern their practice. Nowhere is this truer than in the child psychiatric emergency department. In this article, the authors provide an overview of some of the relevant legal issues that clinicians in the emergency department must understand. These issues include consent for mental health and substance abuse treatment, confidentiality, hospitalization, mandated reporting of suspected child abuse, and the Tarasoff duty to warn. The regulation of psychiatric practice varies greatly from state to state, and the reader is urged to consult his or her own state's statutes, regulations, and case law for definitive resolution of specific topics.

Glaser FB; Warren DG. Legal and ethical issues. IN: McCrady BS; Epstein EE, eds. Addictions: A Comprehensive Guidebook. New York: Oxford University Press, 1999. pp. 399-413. (22 refs.)

This chapter provides a basis for clinicians and counselors in considering and working through the ethical, legal, and moral dilemmas raised by patients in a therapeutic situation. One of the legal issues facing practitioners is confidentiality. There are two components of the principle of privacy, which underpins the laws and regulations governing patient confidentiality in the therapeutic environment. First, the principle of privacy as it relates to the body and, second, the principle of privacy as it relates to the patient's background. A discussion is presented concerning federal regulations that apply concerning confidentiality in substance abuse treatment. Some of the legal issues facing clients include the legality of the use of alcohol by underage youth, workplace laws and regulations, drug testing in the workplace, and possession of drug "paraphernalia." Important ethical issues facing practitioners often concern the extent of care expected from therapists and the responsibilities of the client. A "pragmatic model" for resolving ethical concerns in clinical practice suggests that there are five "decision bases" or sources of information regarding right conduct that therapists should consult: (1) theories of ethics, (2) professional codes of ethics, (3) professional theoretical premises, (4) the sociolegal context, and (5) the personal/professional identity.

Howard J. Substance Abuse Treatment for Persons with Child Abuse and Neglect Issues. Treatment Improvement Protocol (TIP) Series 36. Rockville MD: Center for Substance Abuse Treatment, 2000. (476 refs.)

This Treatment Improvement Protocol considers treatment issues for two populations -- adults in treatment who may be abusing or neglecting their children and also adult survivors of child abuse or neglect. The first three chapters primarily consider adult survivors. Chapter 1 defines abuse and neglect, the epidemiology and rates in the general population as well as among those in substance abuse treatment, and provides a review of the literature on links between childhood abuse and subsequent substance abuse. Chapter 2 describes screening and assessment tools to assist in evaluating a childhood history of abuse or neglect. Chapter 3 provides guidelines on treating clients with histories of abuse or neglect and considering the need for referral to mental health care clinics. Chapter 4 considers the issues that may be generated within clinicians when working with this client population, and discusses means of addressing these counter-transference issues. Chapters 5 and 6 shifts attention to adults who may be abusing or neglecting their own children. The first of these considers techniques for identifying adults at risk or who have abused/neglected their children. It also considers issues of working with child protective service agencies. Chapter 6 provides an overview of the legal issues of which counselors need to be aware as mandated reporters. The final, concluding chapter (7) addresses emerging issues in this field which will have a bearing on future practice, such as fast-track adoptions and welfare reform. There are seven appendices that include an extensive bibliography, rules pertaining to client confidentiality, description of screening and assessment instruments; and resources related to childhood trauma among adults.

Klein JD; McNulty M; Flatau CN. Adolescents' access to care: Teenagers' self-reported use of services and perceived access to confidential care. Archives of Pediatrics & Adolescent Medicine 152(7): 676-682, 1998. (35 refs.)

Background: Most surveys on adolescents' use of health services rely on parental report, and this may underestimate adolescents' use of confidential services. Objective: To investigate adolescents' report of their own use of health services, access to care, and knowledge and use of confidential services. Method: A random digit-dialed survey of 14- to 19-year-old adolescents was conducted in Monroe County, New York. We screened 11 800 numbers and identified 4449 households (40%) of which 393 families (8.8%) had eligible adolescents. Of these, 259 (66%) consented and completed an interviewer-administered survey. Results: Almost all adolescents (92%) rated their health as excellent or good and 90% had visited a health care provider within the year. Most (88%) identified a source of primary care. As many as 27% of adolescents had used more than one source of care. Many youth identify school personnel as important resources for health and counseling needs. Only 8.4% of respondents have used services confidentially, but nearly half of all youth did not know where they could obtain confidential care if they needed to. Adolescents were least likely to know where to obtain mental health or substance abuse and reproductive services. Conclusions: While most youth have used primary care, a substantial minority have not. Many teenagers depend on multiple sources of care, and they rely on school personnel as important sources of health information. Many do not know where they could go to review confidential services or for other services that they may need. Managed care insurance and public health policies should recognize adolescents' access needs to meet them appropriately.

Lahn M; Gallagher EJ; Li SF; Touger M; Olmedo R. Prospective confirmation of low arrest rates among intoxicated drivers in motor vehicle crashes. Academic Emergency Medicine 7(3): 260-263, 2000. (22 refs.)

Objective: Several states have legally sanctioned or mandated physician reporting of drivers who were driving while intoxicated (DWI). Valid prospective evidence demonstrating extremely poor performance of the criminal justice system seems ethically and scientifically essential if overriding public health considerations are to abrogate the fundamental principles of patient-physician confidentiality. No such evidence is available. The authors reasoned that poor performance of the judicial system would be most evident if drivers who were DWI were not arrested under conditions selected to optimize legal intervention. The authors therefore wished to estimate the unbiased proportion of DWI drivers brought to an emergency department (ED) under these optimized conditions who escape detection by law enforcement officials. Methods: Prospective, consecutive cohort of drivers transported to an urban ED following a motor vehicle crash (MVC). Conditions selected to optimize legal intervention included: police at scene; inebriation of driver clinically evident to out-of-hospital personnel; and confirmatory blood ethanol level greater than or equal to 100 mg/dL (greater than or equal to 22 mmol/L). Main outcome measure was arrest for DWI. Results: Of 294 drivers in MVCs, 270 had ethanol levels, of whom 18 met criteria for optimum likelihood of legal intervention. Of these, 22% were arrested for DWI (95% CI = 6% to 48%). Adjustment for missing data, under assumptions designed to maximize arrest frequency for DWI, did not materially alter these findings. No patients were lost to follow-up. Conclusion: These findings prospectively confirm that, even under conditions selected to optimize detection by law enforcement officials, only about one of every five drivers who were DWI and were brought to an ED following an MVC -- and almost certainly no more than a minority -- comes to the attention of the criminal justice system.

Legal Action Center. Checklist for Monitoring Alcohol and Other Drug Confidentiality Compliance. Technical Assistance Publication (TAP) Series 18. Rockville MD: Substance Abuse and Mental Health Services Administration, 1996. (0 refs.)

This report, part of a series of technical assistance publications, addresses the issue of disclosure of information relating to alcohol and other drug diagnosis and treatment. The report provides a checklist and two appendices; one a copy of the confidentiality law and the other presents some of the issues related to managed care and confidentiality.

McCrady BS; Bux DA Jr. Ethical issues in informed consent with substance abusers. Journal of Consulting and Clinical Psychology 67(2): 186-193, 1999. (18 refs.)

Alcohol and drug abusers present issues that complicate the informed consent process. The present study examined the practices of federally funded clinical investigators in obtaining informed consent from alcohol and drug abusers. Ninety-one (51%) researchers completed a 27-item survey on informed consent issues. The majority of investigators (57%) recruited participants susceptible to coercion: most used procedures to minimize coercion. Two thirds of researchers used objective means to determine competence to give consent and comprehension of consent forms. Virtually all investigators had policies to deal with suicidality, homicidality, or reports of child abuse: less than 1/2 informed participants of these limits to confidentiality. Almost 50% of investigators had dealt with intoxicated or suicidal participants; 12% had encountered homicidal participants; and 23% had encountered child abuse or neglect. Half of the sample used collateral data sources; about 1/2 of these obtained written informed consent from collaterals. Guidelines for informed consent with substance abusers are suggested.

Moore ML. Ethical issues for nurses providing perinatal care in community settings. Journal of Perinatal and Neonatal Nursing 14(2): 25-35, 2000. (30 refs.)

Ethical issues in perinatal nursing are complex in that two patients- mother and fetus-are considered. This work considers six areas of potential ethical conflict: conflict between the mother and fetus, informed consent, confidentiality, cultural conflicts, conflicts associated with managed care, and conflicts in childbirth education. Ethical principles of autonomy, beneficence, and justice are included. Strategies for resolving ethical conflicts in community practice settings are suggested.

Newburn T. Drug prevention and youth justice: Issues of philosophy, practice and policy. British Journal of Criminology 39(4 Special Issue): 609-624, 1999. (62 refs.)

One aspect of the arrival of 'New Labour" in forming the British government in 1997 there have been changes in drug policy. This paper examines what is known about drug use among one of the vulnerable groups -- young offenders -- and then, via research on two innovative pilot projects in youth justice, outlines some of the central philosophical, practical, and policy issues raised. Among the issues addressed is the tension between diversion versus drugs prevention; 'holism' versus 'compartimentalism'; issues of communication and confidentiality; leadership and management tensions; and the absence of systems integration. The authors conclude that young offenders appear to have the highest prevalence of drug use in a population with rising levels of use. There are difficulties to integrating drug prevention and treatment within the youth justice arena, and the need to convince social workers and others working with youth, that while more intrusive drug treatment is 'benign.' The problems on interagency cooperation are significant despite good intentions.

Office of Applied Studies. The DASIS Report. Protecting Confidentiality in TEDS. Issue, December 10, 2003. Rockville MD: Substance Abuse and Mental Health Services Administration, 2003. (7 refs.)

This brief report describes the methods used to protect data and maintain confidentiality of persons whose admissions are included in the Treatment Episode Data Set (TEDS). This is an annual survey conducted by the Substance Abuse and Mental Health Services Administration on the demographic characteristics of those who enter substance abuse treatment, primarily in facilities that receive some public funding. The routine methods for entering data are described. Any direct identifiying information such as social security number or date of birth are not included, thus unique identifiers are not included. In some instances, data is assigned to a group, e.g. income between the a specific range. Other statistical procedures such as "data swapping" are described

Petersen T. Working effectively with substance misusers. IN: Petersen T; McBride A, eds. Working with Substance Misusers. London: Routledge, 2002. pp. 43-72. (32 refs.)

The skills, knowledge, and attitudes necessary to work effectively with substance abusing clients and elements of maintaining good practice are discussed. The chapter includes the Competency Assessment Tool (CAT) questionnaire, which has been developed to enable identification of learning needs. Topics addressed include: (1) existing training and educational provision; (2) nursing; (3) medicine; (4) non-statutory sector; (5) levels of training and educational needs of practitioners; (6) attitudes; (7) empathy; (8) exploring attitudes and encouraging positive attitudes amongst others; (9) knowledge; (10) knowledge of commonly used substances of misuse; (11) contextual knowledge; (12) basic health knowledge; (13) training; (14) evidence-based practice and clinical effectiveness; (15) skills, including interpersonal skills, effects of substances on body, interpretation of communication, language, and boundary setting; (16) confidentiality; (17) working with "difficult" behavior; (18) specific task orientated skills; (19) stress, burnout and self-management; (20) reflective substance misuse practitioner; (21) clinical supervision; (22) lifelong learning; and (23) reviewing and sharing practice. It is concluded that effective substance misuse practice involves knowledge, skills and attitudes. Good practice is dynamic, including both theoretical and practical aspects and a variety of treatment approaches.

Rivara FP; Tollefson S; Tesh E; Gentilello LM. Screening trauma patients for alcohol problems: Are insurance companies barriers? Journal of Trauma 48(1): 115-118, 2000. (22 refs.)

Background: Impairment caused by alcohol is the leading risk factor for trauma. However, many physicians do not screen for alcohol use because of concerns about confidentiality and denial of insurance coverage. The purpose of this study was to examine objectively the confidentiality issues and insurance statutes affecting alcohol screening in trauma centers. Methods: We conducted a survey of insurance commissioners in all 50 states to determine the prevalence of statutes allowing denial of coverage for injuries sustained while impaired due to alcohol, reviewed state insurance laws, and reviewed federal regulations protecting the confidentiality of alcohol information in patients seeking alcohol treatment. Results: Special federal regulations protecting confidentiality of alcohol screening data depend on how such information is acquired and do not routinely cover trauma patients. Concerns about screening on insurance coverage are valid in 38 states. Conclusion: Segregating information about alcohol use in the medical record and assigning designated chemical dependency counselors to screen all trauma patients would provide confidentiality of alcohol information under current federal regulations, allowing denial of release of such information, except under subpoena.

Roback HB; Moore RF; Waterhouse GJ; Martin PR. Confidentiality dilemmas in group psychotherapy with substance-dependent physicians. American Journal of Psychiatry 153(10 :): 1250-1260, 1996. (30 refs.)

OBJECTIVE: The purposes of this article are 1) to review federal and state laws relevant to confidentiality in group therapy with impaired physicians and 2) to provide empirical data concerning the actual confidentiality practices and experiences of group therapists treating chemically impaired physicians. METHOD: In the clinical research phase, 25 state medical societies identified 45 rehabilitation centers as those to which the societies preferentially referred chemically impaired physicians. Fifty-one group leaders from of these rehabilitation centers completed the survey questionnaire employed in this project. RESULTS: Because of the risk of potentially irreversible social and professional injury, physician patients were exceedingly concerned about breaches of confidentiality. Co-members' infractions most often involved the violator sharing with close friends and family members the name and abuse history of a fellow physician. In contrast, transgressors rarely leaked information about a co-member's drug-related illegal behavior. CONCLUSIONS: Chemically impaired physicians would feel safer in sharing secrets in group therapy if more jurisdictions adopted legislation making co-members liable for violating confidentiality. Currently the pertinent body of law is confusing and inconsistent and provides little protection to impaired physicians who enter group therapy. The authors propose ideas for model legislation

Roberts LW; Warner TD; Trumpower D. Medical students' evolving perspectives on their personal health care: Clinical and educational implications of a longitudinal study. Comprehensive Psychiatry 41(4): 303-314, 2000. (34 refs.)

The mental and physical health care issues of medical students are increasingly recognized as both prevalent and complex. Emotional distress, symptoms of mental illness, and maladaptive substance use are widespread and may often be driven by training-related stressors, The data suggest that nearly all medical students identify physical health concerns as well. The care of medical students as patients is complex because of problems associated with the stigma of various illnesses and the dual role of trainee and patient in medical school. A written confidential survey assessed students longitudinally near the end of their first and third years of training regarding their perceived health care needs, health concerns, attitudes toward care, access to services, and care-seeking practices (161 items). A subset of students (n = 33) were reassessed 1 month after the second survey to measure reliability. McNemar's chi-square (chi(2)) tests, repeated- measures multivariate analysis of variance (MANOVA), and kappa and Pearson correlations were used to evaluate outcomes. Almost all students reported health care needs during both training phases, and their mental and physical health concerns were stable over time. However, the preference for obtaining health care at a site other than their training institution and concerns about confidentiality increased, although students were marginally more likely to obtain care at their medical school during clinical versus preclinical training. The students' tendency to seek informal care from colleagues remained consistent, as did their high level of concern about professional jeopardy relating to personal health issues. Their tendency to accept the dual patient-student role depended on the particular health care issue; they expressed a strong tendency to protect other students' confidentiality, even in cases of potential significant impairment. Responses were reliable across a 1-month retest interval. We conclude that medical students' perspectives on their mental and physical health care across the transition from preclinical to clinical training reveal the importance of pursuing, not neglecting, a number of clinical and educational initiatives. Through their specialized expertise, psychiatrists may help to ensure sound mental and physical health care for the more than 69,000 medical students in training in this country.

Schonbrun B. In the light of reason and experience: The scope of evidentiary privilege in the self-help setting. Alcoholics Anonymous examined. Cardozo Law Review 25: 1203-1242, 2004. (195 refs.)

... Cox cleaned the crime scene before departing, disposed of his bloodied clothes in an incinerator, and threw the murder weapon into a nearby body of water. ... It specifically addresses the issue that the Second Circuit left unanswered in Cox - "whether to protect the confidentiality of communications among members of AA," either by invoking the cleric-congregant privilege or by creating a distinct evidentiary privilege to protect communications in the self-help setting. ... Generally, the creation of an evidentiary privilege requires that it serve the public interest and also protect relationships where confidentiality is considered essential to the nature of the association. ... With this exposition the court attempted to elucidate the legislative intent behind the statute by extending the cleric-congregant privilege to "ministers of all religions," as "New York's test for the privilege's applicability distills to a single inquiry: whether the communication in question was made in confidence and for the purpose of obtaining spiritual guidance. ... If the privacy interest of AA members warranted the extension of a self-help privilege to AA, the brutal murder of the Chervus would have likely remained unsolved. ... Simply stated, AA is a support group of laymen that does not merit the protection of the cleric-congregant privilege or the creation of a distinct evidentiary privilege to shield its communications. ...

Scott CG. Ethical issues in addiction counseling. Rehabilitation Counseling Bulletin 43(4): 209-214, 2000. (31 refs.)

Although all counselors face ethical challenges, addictions counselors encounter ethical issues that are, in many respects, unique to their discipline. This article provides an overview of these issues, which include but are not limited to (a) the lack of communication and continuity between research and clinical practice, (b) lack of agreement over the necessary professional credentials, (c) the questionable propensity of group work in the addictions field, (d) special issues of confidentiality and privileged communication, (e) boundaries of professional practice in making treatment decisions, and (f) unusual circumstances of informed consent. In addressing these issues, addictions counselors must not only uphold the ethical standards of their profession, they must also be cognizant of any federal statutes that may supersede their state regulations and act in accordance with them.

Veit F. Ethical issues in harm reduction for adolescent illicit drug users: The Adolescent Forensic Health Service approach. Drug and Alcohol Review 19(4): 457-467, 2000. (40 refs.)

This month's column deals with ethical issues in harm reduction efforts for adolescents involved in illicit drug use. It describes the approach of the Adolescent Forensic Health Service, which is responsible for the provision of health care to adolescents in state custody. It begins with a description of use patterns common among patients seen by the Forensic Health Service, describes the services available and then discusses some of the ethical issues. The latter include lesser access to services available in the community, issues of confidentiality, and those attendant to research.

Weddle M; Kokotailo P. Adolescent substance abuse: Confidentiality and consent. Pediatric Clinics of North America 49(2): 301-316, 2002. (43 refs.)

This article describes the legal and ethical basis of adolescent confidentiality and consent. The authors review clinical applications of these principles with a focus on how they apply to diagnosis and treatment of substance abuse.

Weisleder P. The right of minors to confidentiality and informed consent. Journal of Child Neurology 19(2): 145-148, 2004. (23 refs.)

Doctor-patient confidentiality is a precept of adolescent medicine. In general, physicians honor the privacy of adolescents unless there is evidence that the youngster is engaging in dangerous activities. An otherwise healthy 16 year old was referred for headache evaluation. During the portion of the interview conducted outside the presence of his mother, the patient revealed using marijuana and cocaine regularly and LSD (lysergic acid diethylamide), hallucinogenic mushrooms, and "Ecstasy" (3,4-methylenedioxymethaniphetamine) occasionally. Given this information, and as allowed by North Carolina's General Statutes, the patient was offered confidential treatment for illegal substance abuse; he declined the offer. He also turned down the request to forgo his right to privacy so that his parents could be made aware of his addiction. As a result of the patient's drug use and disregard of its consequences, it was determined that notification of a parent was essential to his life or health; thus, confidentiality was breached. Although substance abuse is a behavior that threatens the abuser's health and life, state and federal laws vary regarding the rights of minors to confidential evaluation and treatment. For this article, laws that govern minors' rights to consent to confidential treatment for illegal substance abuse were reviewed. The aforementioned case is used as a catalyst for discussion.

Winters KC. Screening and Assessing Adolescents for Substance Use Disorders. Treatment Improvement Protocol (TIP) Series 31. Rockville MD: Center for Substance Abuse Treatment, 1999. (104 book refs.)

This volume is a companion volume to Treatment Improvement Protocol #32 which addresses adolescent treatment. [Both of these are updates of earlier versions (TIP 3 and TIP 4).] Following an executive summary and specific recommendations the volume is organized into five chapters. Chapter one provides a framework for assessment and the selection of screening and assessment tools. Chapter two deals with preliminary screening and the need for community coordination. Chapter three is concerned with the comprehensive assessment of adolescents for referral and treatment, the clinician role and skills, the setting, assessment instruments, and written reports. Chapter four focuses upon legal issues pertinent in the screening and assessment of adolescents, including federal protections of youth's right to privacy, consent to disclose information, confidentiality and exceptions to general guideline. Chapter five concerns issues of adolescents in juvenile justice settings, screening and assessment protocols, evaluation and quality management, and issues related to staff training. There are a series of Appendices. Following a Bibliography (A), there is a lengthy annotated list of a variety of instruments. These are organized as Screening Tools (8 instruments); Comprehensive Assessment Instruments (11 instruments); Instruments to measure general functioning (9 items). Within the volume are nine figures/tables that offer sample forms, checklists, or serve as summaries.