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CORK Bibliography: Treatment Outcome and Alcohol Problems

89 citations. January 2009 to present

Prepared: September 2009

Adamson SJ; Sellman JD; Frampton CMA. Patient predictors of alcohol treatment outcome: A systematic review. Journal of Substance Abuse Treatment 36(1): 75-86, 2009. (86 refs.)

Patient characteristics as predictors of alcohol use disorder treatment outcome were examined on three levels, identifying whether or not variables were significant predictors of drinking-related outcome in univariate analysis, in multivariate analysis, and in multivariate analyses limited to studies including several "key predictors." Also, a model was developed to predict total percentage of variance in treatment outcome accounted for in each study using each of the key predictors and a range of methodological factors. The most consistent Univariate predictors were baseline alcohol consumption, dependence severity, employment, gender, psychopathology rating, treatment history, neuropsychological functioning, alcohol-related self-efficacy, motivation, socioeconomic status/income, treatment goal, and religion. When these key predictors were combined into multivariate analyses, baseline alcohol consumption and gender showed substantial reductions in predictive consistency whereas the remaining variables were not greatly affected. The most consistent predictors overall were dependence severity, psychopathology ratings, alcohol-related self-efficacy, motivation, and treatment goal. The two predictor variables most associated with greater variance accounted for in predictive models, when controlling for broader methodological variables, were baseline alcohol consumption and dependence severity. Few predictor variables were examined in more than a third of studies reviewed, and few variables were found to be significant predictors in a clear majority of studies. However, a subset of variables was identified, which collectively could be considered to represent a consistent set of predictors. Too few studies controlled for other important predictor variables. Attempts to synthesize findings were often hampered by lack of agreement of the best measure for predictor variables.

Ahmadi J; Kampman K; Oslin D; Pettinati H; Dackis C; Sparkman T. Predictors of treatment outcome in outpatient cocaine and alcohol dependence treatment. American Journal on Addictions 18(1): 81-86, 2009. (22 refs.)

We examined the ability of several baseline variables to predict treatment outcome in a pharmacotherapy trial that included 164 participants who were both cocaine- and alcohol-dependent and were selected for a randomized, double-blind, placebo-controlled study. Predictor variables included results from the baseline Addiction Severity Index (ASI), initial Urine Drug Screen results, cocaine and alcohol craving and cocaine and alcohol withdrawal symptoms at the start of treatment. Successful treatment was defined as four continuous weeks of self-reported cocaine abstinence verified by urine drug screens. In respect to demographic characteristics, there were no significant differences between patients who achieved four weeks of abstinence from cocaine and those who did not. Baseline variables that most consistently predicted cocaine abstinence included initial urine drug screen (UDS) results, the initial Cocaine Selective Severity Assessment (CSSA) scores, and initial self-reported cocaine use in past 30 days, whereas cocaine craving, cocaine composite scores, alcohol craving, alcohol withdrawal symptoms, and alcohol composite scores did not. The results of this study suggest that cocaine dependence severity in general, and initial UDS results, the CSSA scores and frequency of recent cocaine use in particular, have a significant impact on treatment outcome in the treatment of cocaine-dependent patients with comorbid alcoholism. Initial UDS results and CSSA scores are very useful predictors of treatment outcome and could be used as stratifying variables in outpatient cocaine and alcohol medication trials.

Amaro H; Ahl M; Matsumoto A; Prado G; Mule C; Kemmemer A et al. Trial of the university assistance program for alcohol use among mandated students. Journal of Studies on Alcohol and Drugs Supplement 16: 45-56, 2009. (68 refs.)

Objective: The aim of this study was to investigate the effectiveness of a brief intervention for mandated students in the context of the University Assistance Program, a Student Assistance Program developed and modeled after workplace Employee Assistance Programs. Method: Participants were 265 (196 males and 69 females) judicially mandated college students enrolled in a large, urban university in the northeast United States. All participants were sanctioned by the University's judicial office for all alcohol- or drug-related violation. Participants were randomized to one of two intervention conditions (the University Assistance Program or services as usual) and were assessed at baseline and 3 and 6 months after intervention. Results: Growth curve analyses showed that relative to services as usual, the University Assistance Program was more efficacious in reducing past-90-day weekday alcohol consumption and the number of alcohol-related consequences while increasing past-90-day use of protective behaviors and coping skills No significant differences in growth trajectories were found between the two intervention conditions on past-90-day blood alcohol concentration, total alcohol consumption, or weekend consumption. Conclusions: The University Assistance Program may have a possible advantage over service as usual for mandated students.

Arndt S. Stereotyping and the treatment of missing data for drug and alcohol clinical trials. (editorial). Substance Abuse Treatment, Prevention and Policy 4: e-article 2, 2009. (7 refs.)

Stigma and stereotyping of marginalized groups often is insidious and shows up in unlikely places, for instance in how clinical trials consider dropouts in treatment research. A surprising number of studies presume that people who do not complete the study protocol relapse and code their data as if they had been observed. There is no good statistical rationale for this treatment of missing data and numerous and more defensible alternative methods are available. We need to be mindful about our attitudes and preconceptions about the people we are intending to help. There is no good reason to continue to support science built on this scientifically indefensible stereotyping, however unintentional.

Balsa AI; Homer JF; French MT; Weisner CM. Substance use, education, employment, and criminal activity outcomes of adolescents in outpatient chemical dependency programs. Journal of Behavioral Health Services & Research 36(1): 75-95, 2009. (55 refs.)

Although the primary outcome of interest in clinical evaluations of addiction treatment programs is usually abstinence, participation in these programs can have a wide range of consequences. This study evaluated the effects of treatment initiation on substance use, school attendance, employment, and involvement in criminal activity at 12 months post-admission for 419 adolescents (aged 12 to 18) enrolled in chemical dependency recovery programs in a large managed care health plan. Instrumental variables estimation methods were used to account for unobserved selection into treatment by jointly modeling the likelihood of participation in treatment and the odds of attaining a certain outcome or level of an outcome. Treatment initiation significantly increased the likelihood of attending school, promoted abstinence, and decreased the probability of adolescent employment, but it did not significantly affect participation in criminal activity at the 12-month follow-up. These findings highlight the need to address selection in a non-experimental study and demonstrate the importance of considering multiple outcomes when assessing the effectiveness of adolescent treatment.

Baltieri DA; Daro FR; Ribeiro PL; De Andrade AG. The role of alcoholic beverage preference in the severity of alcohol dependence and adherence to the treatment. Alcohol 43(3): 185-195, 2009. (61 refs.)

The severity of dependence on alcohol and the efficacy of diverse types of treatments for alcoholism have been the subject of various researches. This study focused on the types of beverages preferentially consumed by alcohol-dependent outpatients and their effects on the severity of dependence and therapeutic outcomes. Our sample comprised 153 patients, 18-60 years of age, with an International Classification of Diseases (ICD-10) diagnosis of alcohol dependence, who were randomly divided into three different groups to receive topiramate (up to 300 mg/day), naltrexone (50 mg/day), or placebo during 12 weeks of follow-up. Spirits and beer were the main beverages consumed. At the start of this research, the group of spirits drinkers showed higher severity of alcohol dependence, higher craving for alcohol, more frequent history of treatments for alcoholism, and lower income than the group of beer preference drinkers. During the study, beer preference drinkers demonstrated higher adherence to the treatment, independently of the types of medications prescribed (P = .02, odds ratio, 2.46, 95% confidence interval, 1.17-5.19). This study suggests that the severity of dependence and the adherence to the treatment can be factors that set apart beer drinkers from spirits drinkers. As the compliance with the treatment for alcoholism was lower among spirits preference drinkers, a more intensive model of treatment would be necessary.

Barber JP. Toward a working through of some core conflicts in psychotherapy research. (editorial). Psychotherapy Research 19(1): 1-12, 2009. (58 refs.)

The author discusses the evidence for six basic statements that many, but not all, psychotherapy researchers adhere to: (1) The therapeutic alliance has a causal role in outcome, (2) therapeutic techniques explain patients' outcome, (3) therapists determine outcome, (4) patients determine therapy outcome, (5) randomized controlled trials (RCTs) provide valuable data, (6) data from RCTs are almost worthless. These truths combine to form three core conflicts: Is psychotherapy about the alliance or techniques? Does the patient or therapist determine the outcome? Are RCTs a blessing or a curse? After showing that these statements oversimplify the research of the therapeutic process, the author recommends keeping both sides of the conflict in awareness and endorses a pluralistic methodological approach for the study of both efficacy and the mechanisms of psychotherapy.

Bertholet N; Horton NJ; Saitz R. Improvements in readiness to change and drinking in primary care patients with unhealthy alcohol use: a prospective study. BMC Public Health 9(article 101), 2009

Background: The course of alcohol consumption and cognitive dimensions of behavior change (readiness to change, importance of changing and confidence in ability to change) in primary care patients are not well described. The objective of the study was to determine changes in readiness, importance and confidence after a primary care visit, and 6-month improvements in both drinking and cognitive dimensions of behavior change, in patients with unhealthy alcohol use. Methods: Prospective cohort study of patients with unhealthy alcohol use visiting primary care physicians, with repeated assessments of readiness, importance, and confidence ( visual analogue scale (VAS), score range 1-10 points). Improvements 6 months later were defined as no unhealthy alcohol use or any increase in readiness, importance, or confidence. Regression models accounted for clustering by physician and adjusted for demographics, alcohol consumption and related problems, and discussion with the physician about alcohol. Results: From before to immediately after the primary care physician visit, patients (n = 173) had increases in readiness (mean +1.0 point), importance (+0.2), and confidence (+0.5) (all p < 0.002). In adjusted models, discussion with the physician about alcohol was associated with increased readiness (+0.8, p = 0.04). At 6 months, many participants had improvements in drinking or readiness (62%), drinking or importance (58%), or drinking or confidence (56%). Conclusion: Readiness, importance and confidence improve in many patients with unhealthy alcohol use immediately after a primary care visit. Six months after a visit, most patients have improvements in either drinking or these cognitive dimensions of behavior change.

Burnette ML; Schneider R; Timko C; Ilgen MA. Impact of substance-use disorder treatment on women involved in prostitution: Substance use, mental health, and prostitution one year after treatment. Journal of Studies on Alcohol and Drugs 70(1): 32-40, 2009. (30 refs.)

Objective: Prostitution is common among women with substance-use disorders (SUDs). However, little is known about the outcomes of SUD treatment for women involved in prostitution relative to their peers or the impact of SUD treatment on subsequent prostitution. Method: Participants were 1,287 women from a national study of SUD treatment sites. Women completed a baseline interview at entry to SUD treatment and a follow-up interview roughly I year after discharge. We compared the substance-related and mental health outcomes at follow-up of women involved in prostitution and women not involved in prostitution, and determined if prostitution declined significantly at follow-up. Among women reporting prostitution at baseline (n = 533), we examined whether receipt of specific ancillary services (medical, mental health, psychosocial) was associated with cessation of prostitution and whether cessation of prostitution was associated with better substance-related and mental health outcomes. Results: Women reporting prostitution at baseline had more frequent drug and alcohol use, reduced abstinence rates, and more mental health symptoms at follow-up compared with their peers. However, the rate of prostitution declined from baseline to follow-up. Receipt of more mental health and psychosocial services during treatment was associated with the cessation of prostitution at follow-up, and cessation of prostitution was associated with lower substance use, higher rates of abstinence, and fewer mental health symptoms at follow-up. Conclusions: Comprehensive services may be needed to effect significant reductions in substance use and mental health symptoms among women engaged in prostitution.

Calsyn DA; Hatch-Maillette M; Tross S; Doyle SR; Crits-Christoph P; Song YS et al. Motivational and skills training HIV/sexually transmitted infection sexual risk reduction groups for men. Journal of Substance Abuse Treatment 37(2): 138-150, 2009. (52 refs.)

The effectiveness of a motivational and skills training HIV/AIDS group intervention designed for men in substance abuse treatment was evaluated. Men in methadone maintenance (n = 288) or outpatient psychosocial treatment (n = 302) completed assessments at baseline, 2 weeks, 3 months, and 6 months postintervention. Participants were randomly assigned to attend either Real Men Are Safe (REMAS; five sessions containing information, motivational exercises, and skills training) or HIV education (HIV-Ed; one session containing HIV prevention information). REMAS participants engaged in significantly fewer unprotected vaginal and anal sexual intercourse occasions (USO) during the 90 days prior to the 3- and 6-month follow-ups than HIV-Ed participants. Completing REMAS resulted in an even stronger effect: Completers reduced their number of USO by 21% from baseline to 6-month follow-up. In contrast, HIV-Ed completers increased the number of USO by 2%. A motivational and skills training HIV prevention intervention designed for men was associated with greater sexual risk reduction over standard HIV-Ed. Substance abuse treatment programs call therefore help reduce sexual risk among their clientele by providing a more intensive intervention than what is traditionally provided.

Campbell CI; Alexander JA; Lemak CH. Organizational determinants of outpatient substance abuse treatment duration in women. Journal of Substance Abuse Treatment 37(1): 64-72, 2009. (50 refs.)

Longer treatment duration has consistently been related to improved substance use outcomes. This study examined how tailored women's programming and organizational characteristics were related to duration in outpatient substance abuse treatment in women. Data were from two waves of a national outpatient substance abuse treatment unit survey (n = 571 in 1999/2000, n = 566 in 2005). Analyses were conducted separately for methadone and nonmethadone programs. Negative binomial regressions tested associations between organizational determinants, tailored programming, and women's treatment duration. Of the tailored programming services, childcare was significantly related to longer duration in the nonmethadone programs, but few other organizational factors were. Tailored programming was not associated to treatment duration in methadone programs, but ownership, affiliation, and accreditation were related to longer duration. Study findings suggest evidence for how external relationships related to resources, treatment constraints, and legitimacy may influence women's treatment duration. Methadone programs may be more vulnerable to external influences.

Chassin L; Knight G; Vargas-Chanes D; Losoya SH; Naranjo D. Substance use treatment outcomes in a sample of male serious juvenile offenders. Journal of Substance Abuse Treatment 36(2): 183-194, 2009. (46 refs.)

This study examined drug-treatment-related reductions in alcohol and marijuana use, cigarette smoking, and nondrug offending among male adolescents who bad been adjudicated of a serious (almost exclusively felony) offense. Results indicated that the "real-world" drug treatments that these adolescents experienced had significant effects on substance use, which could not be explained solely by incarceration in controlled environments. However, effects on cigarette smoking and criminal offending were found only for treatments that included family involvement. Results suggest that involving families in adolescents' treatment may be useful for promoting desistence from criminal offending in this population.

Chi FW; Kaskutas LA; Sterling S; Campbell CI; Weisner C. Twelve-Step affiliation and 3-year substance use outcomes among adolescents: Social support and religious service attendance as potential mediators. Addiction 104(6): 927-939, 2009. (78 refs.)

Twelve-Step affiliation among adolescents is little understood. We examined 12-Step affiliation and its association with substance use outcomes 3 years post-treatment intake among adolescents seeking chemical dependency (CD) treatment in a private, managed-care health plan. We also examined the effects of social support and religious service attendance on the relationship. We analyzed data for 357 adolescents, aged 13-18, who entered treatment at four Kaiser Permanente Northern California CD programs between March 2000 and May 2002 and completed both baseline and 3-year follow-up interviews. Measures at follow-up included alcohol and drug use, 12-Step affiliation, social support and frequency of religious service attendance. At 3 years, 68 adolescents (19%) reported attending any 12-Step meetings, and 49 (14%) reported involvement in at least one of seven 12-Step activities, in the previous 6 months. Multivariate logistic regression analyses indicated that after controlling individual and treatment factors, 12-Step attendance at 1 year was marginally significant, while 12-Step attendance at 3 years was associated with both alcohol and drug abstinence at 3 years [odds ratio (OR) 2.58, P < 0.05 and OR 2.53, P < 0.05, respectively]. Similarly, 12-Step activity involvement was associated significantly with 30-day alcohol and drug abstinence. There are possible mediating effects of social support and religious service attendance on the relationship between post-treatment 12-Step affiliation and 3-year outcomes. The findings suggest the importance of 12-Step affiliation in maintaining long-term recovery, and help to understand the mechanism through which it works among adolescents.

Chung T; Maisto SA. "What I got from treatment": Predictors of treatment content received and association of treatment content with 6-month outcomes in adolescents. Journal of Substance Abuse Treatment 37(2): 171-181, 2009. (44 refs.)

Some adolescents show a greater response to treatment than others. We examined the extent to which amount of treatment content received was associated with certain patient characteristics (e.g., readiness to change) and severity of substance involvement at 6-month follow-up. Adolescents (N = 107) recruited from outpatient addiction treatment reported at follow-up on the extent to which treatment addressed addictive behaviors (e.g., getting motivated to change) and other concerns (e.g., depression). Contrary to prediction, readiness to change did not predict amount of treatment content received, but greater number of inpatient days during follow-up predicted greater endorsement of addictive behaviors content. At 6 months, more addictive behaviors content received was associated with fewer alcohol symptoms. For both alcohol and marijuana, greater endorsement of treatment content related to other concerns was associated with greater substance involvement at 6 months, suggesting the importance of evaluating and addressing other concerns because youth may present with problems in multiple domains.

Coulton S; Perryman K; Bland M; Cassidy P; Crawford M; Deluca P et al. Screening and brief interventions for hazardous alcohol use in accident and emergency departments: A randomised controlled trial protocol. BMC Health Services Research 9(article 114), 2009. (34 refs.)

Background: There is a wealth of evidence regarding the detrimental impact of excessive alcohol consumption on the physical, psychological and social health of the population. There also exists a substantial evidence base for the efficacy of brief interventions aimed at reducing alcohol consumption across a range of healthcare settings. Primary research conducted in emergency departments has reinforced the current evidence regarding the potential effectiveness and cost-effectiveness. Within this body of evidence there is marked variation in the intensity of brief intervention delivered, from very minimal interventions to more intensive behavioural or lifestyle counselling approaches. Further the majority of primary research has been conducted in single centre and there is little evidence of the wider issues of generalisability and implementation of brief interventions across emergency departments. Methods/design: The study design is a prospective pragmatic factorial cluster randomised controlled trial. Individual Emergency Departments (ED) (n = 9) are randomised with equal probability to a combination of screening tool (M-SASQ vs FAST vs SIPS-PAT) and an intervention (Minimal intervention vs Brief advice vs Brief lifestyle counselling). The primary hypothesis is that brief lifestyle counselling delivered by an Alcohol Health Worker (AHW) is more effective than Brief Advice or a minimal intervention delivered by ED staff. Secondary hypotheses address whether short screening instruments are more acceptable and as efficient as longer screening instruments and the cost-effectiveness of screening and brief interventions in ED. Individual participants will be followed up at 6 and 12 months after consent. The primary outcome measure is performance using a gold-standard screening test (AUDIT). Secondary outcomes include; quantity and frequency of alcohol consumed, alcohol-related problems, motivation to change, health related quality of life and service utilisation. Discussion: This paper presents a protocol for a large multi-centre pragmatic factorial cluster randomised trial to evaluate the effectiveness and cost-effectiveness of screening and brief interventions for hazardous alcohol users attending emergency departments.

Davidson KM; Tyrer P; Tata P; Cooke D; Gumley A; Ford I. Cognitive behaviour therapy for violent men with antisocial personality disorder in the community: an exploratory randomized controlled trial. Psychological Medicine 39(4): 569-577, 2009. (29 refs.)

Background. Little information exists on treatment effectiveness in antisocial personality disorder (ASPD). We investigated the feasibility and effectiveness of carrying out a randomized controlled trial of cognitive behaviour therapy (CBT) in men with ASPD who were aggressive. Method. This was an exploratory two-centre, randomized controlled trial in a community setting. Fifty-two adult men with a diagnosis of ASPD, with acts of aggression in the 6 months prior to the study, were randomized to either treatment as usual (TAU) plus CBT, or usual treatment alone. Change over 12 months of follow-up was assessed in the occurrence of any act of aggression and also in terms of alcohol misuse, mental state, beliefs and social functioning. Results. The follow-up rate was 79%. At 12 months, both groups reported a decrease in the occurrence of any acts of verbal or physical aggression. Trends in the data, in favour of CBT, were noted for problematic drinking, social functioning and beliefs about others. Conclusions. CBT did not improve outcomes more than usual treatment for men with ASPD who are aggressive and living in the community in this exploratory study. However, the data suggest that a larger study is required to fully assess the effectiveness of CBT in reducing aggression, alcohol misuse and improving social functioning and view of others. It is feasible to carry out a rigorous randomized controlled trial in this group.

de Dios MA; Vaughan EL; Stanton CA; Niaura R. Adolescent tobacco use and substance abuse treatment outcomes. Journal of Substance Abuse Treatment 37(1): 17-24, 2009. (31 refs.)

This study investigated the relationship between cigarette-smoking status and 12-month alcohol and marijuana treatment outcomes in a sample of 1,779 adolescents from the Drug Abuse Treatment Outcomes Study for Adolescents. Participants were classified into four groups based on change in cigarette-smoking status from intake to the 12-month follow-up: persistent smokers, nonsmokers, quitters, and smoking initiators. Logistic regression was used to predict likelihood of relapse to alcohol, marijuana, and other drugs after controlling for intake levels and demographic/treatment characteristics. Results found persistent smokers and smoking initiators to have significantly greater odds of alcohol and marijuana relapse compared with quitters, Furthermore, persistent smokers and smoking initiators were also found to have distinctively shorter periods to marijuana relapse at follow-up. Implications for the implementation of tobacco cessation treatment in the context of substance abuse treatment for adolescents are discussed.

Dranitsaris G; Selby P; Negrete JC. Meta-analyses of placebo-controlled trials of acamprosate for the treatment of alcohol dependence impact of the Combined Pharmacotherapies and Behavior Interventions Study. Journal of Addiction Medicine 3(2): 74-82, 2009. (42 refs.)

Objectives: The Combined Pharmacotherapies and Behavior Interventions Study (COMBINE) reported no significant difference between acamprosate and placebo in the treatment of alcohol dependence. To evaluate the impact of COMBINE, we performed a meta-analysis of acamprosate placebo-controlled trials with the inclusion of data from COMBINE. As a secondary analysis, we added the COMBINE data to a recently published meta-analysis of naltrexone placebo-controlled trials. Methods: A structured literature search of major databases was performed from January 1990 to August 2007 for acamprosate placebo-controlled randomized trials. Mean differences in cumulative abstinent days (CAD) and abstinence rates (AR) from eligible studies were statistically combined to calculate point estimates and 95% CI for differences in CAD and AR. Results: Ten and 16 studies evaluating CAD and AR, respectively were suitable for statistical pooling. The findings revealed that acamprosate was superior to placebo in the mean number of CAD (P < 0.001) and AR (pooled AR = 1.58 P < 0.001). The pooled AR for naltrexone was also significant indicating a relative benefit over placebo (AR = 1.27; P < 0.001). The COMBINE trial results contributed a weight of less than 15% to the final pooled statistical outcomes for both agents. Conclusions: The current study confirmed that acamprosate and naltrexone are both effective agents for the treatment of patients with alcohol dependence. Systematic reviews with meta-analyses of randomized controlled trials and randomized controlled trials with adequate sample sizes are in the same (highest) level of evidence. Therefore, clinicians should use both these sources of information as their foundation for selecting optimal therapy for patients with alcohol dependence.

DuPont RL; McLellan AT; Carr G; Gendel M; Skipper GE. How are addicted physicians treated? A national survey of physician health programs. Journal of Substance Abuse Treatment 37(1): 1-7, 2009. (23 refs.)

Introduction: Physicians with substance use disorders receive care that is qualitatively different from and reputedly more effective than that offered to the general population, yet there has been no national study of this distinctive approach. To learn more about the national system of Physician Health Programs (PHPs) that manage the care of addicted physicians, we surveyed all 49 state PHP medical directors (86% responded) to characterize their treatment, support, and monitoring regimens. Results: PHPs do not provide substance abuse treatment. Under authority from state licensing boards, state laws, and contractual agreements, they promote early detection, assessment, evaluation, and referral to abstinence-oriented (usually) residential treatment for 60 to 90 days. This is followed by 12-step-oriented outpatient treatment. Physicians then receive randomly scheduled urine monitoring, with status reports issued to employers, insurers, and state licensing boards for (usually) 5 or more years. Outcomes are very positive, with only 22% of physicians testing positive at any time during the 5 years and 71% still licensed and employed at the 5-year point. Conclusion: Addicted physicians receive an intensity, duration, and quality of care that is rarely available in most standard addiction treatments: (a) intensive and prolonged residential and outpatient treatment, (b) 5 years of extended support and monitoring with significant consequences, and (c) involvement of family, colleagues, and employers in support and monitoring. Although not available to the general public now, several aspects of this continuing care model could be adapted and used for the general population.

DuPont RL; McLellan AT; White WL; Merlo LJ; Gold MS. Setting the standard for recovery: Physicians' health programs. Journal of Substance Abuse Treatment 36(2): 159-171, 2009. (62 refs.)

A sample of 904 physicians consecutively admitted to 16 state Physicians' Health Programs (PHPs) was studied for 5 years or longer to characterize the outcomes of this episode of care and to explore the elements of these programs that could improve the care of other addicted populations. The study consisted of two phases: the first characterized the PHPs and their system of care management, while the second described the outcomes of the study sample as revealed in the PHP records. The programs were abstinence-based, requiring Physicians to abstain front any use of alcohol or other drugs of abuse as assessed by frequent random tests typically lasting for 5 years. Tests rapidly identified any return to substance use, leading to swift and significant consequences. Remarkably, 78% of participants had no positive test for either alcohol or drugs over the 5-year period of intensive monitoring. At post-treatment follow-up 72% of the physicians were continuing to practice medicine. The unique PHP care management included close linkages to the 12-step programs of Alcoholics Anonymous and Narcotics Anonymous and the use of residential and outpatient treatment programs that were selected for their excellence.

Ewing SWF; LaChance HA; Bryan A; Hutchison KE. Do genetic and individual risk factors moderate the efficacy of motivational enhancement therapy? Drinking outcomes with an emerging adult sample. Addiction Biology 14(3): 356-365, 2009. (62 refs.)

Research indicates that motivational enhancement therapy (MET) helps catalyze reductions in problem drinking among emerging adults. However, moderators of this intervention remain relatively unknown. Therefore. the objectives of this study were: (1) to test whether a single session of MET increased motivation to reduce drinking and drinking outcomes; and (2) to examine whether genetic dopamine D-4 receptor L (DRD4 L) and individual personality risk factors (impulsivity and novelty seeking) moderated the effects of the MET These hypotheses were evaluated by randomly assigning a sample of emerging adult problem drinkers (n = 67) to receive a single session of MET or alcohol education. Follow-up data indicated that only individuals who were low in impulsivity, novelty seeking and/or who had the short DRD4 variable number of tandem repeats genotype evidenced differentially increased behavior change (taking steps toward reducing drinking) following the MET.

Fadardi JS; Cox WM. Reversing the sequence: Reducing alcohol consumption by overcoming alcohol attentional bias. Drug and Alcohol Dependence 101(3): 137-145, 2009. (81 refs.)

The aims of the research were to (a) compare the alcohol attentional bias (AAB) of social, hazardous, and harmful drinkers and (b) assess the effects of alcohol attention-control training on the AAB and alcohol consumption of hazardous and harmful drinkers, Participants were social drinkers (N=40), hazardous drinkers (N=89), and harmful drinkers (N=92). Paper-and-pencil measures were used to collect information about participants' socio-demographic characteristics, health status, motivational structure, drinking-related locus of control and situational self-confidence, readiness to change, affect, and alcohol consumption. Computerized classic, alcohol- and concerns-Stroop tests were administered. All participants were tested individually, with the order of tests counterbalanced across participants. After the baseline assessment, the hazardous and harmful drinkers were trained with the Alcohol Attention-Control Training Program (AACTP) for two and four sessions, respectively. Both samples completed a post-training assessment, and the harmful drinkers also completed 3-month follow-up. Results indicated that (a) the harmful drinkers had larger AAB than the hazardous and the social drinkers; (b) the attentional training reduced the hazardous and harmful drinkers' AAB; and (c) the harmful drinkers showed post-training reductions in alcohol consumption and improvements on the other drinking-related indices. The harmful drinkers' improvements were maintained at the 3-month follow-up.

Field CA; Adinoff B; Harris TR; Ball SA; Carroll KM. Construct, concurrent and predictive validity of the URICA: Data from two multi-site clinical trials. Drug and Alcohol Dependence 101(1/2): 115-123, 2009. (77 refs.)

Background: A better understanding of how to measure motivation to change and how it relates to behavior change in patients with drug and alcohol dependence would broaden our understanding of the role of motivation in addiction treatment. Methods: Two multi-site, randomized clinical trials comparing brief motivational interventions with standard care were conducted in the National Institute on Drug Abuse Clinical Trials Network. Patients with primary drug dependence and alcohol dependence entering Outpatient treatment participated in a study of either Motivational Enhancement Therapy (n = 431) or Motivational Interviewing (n = 423), The construct, concurrent, and predictive validity of two composite measures of motivation to change derived from the University of Rhode Island Change Assessment (URICA): Readiness to Change (RTC) and Committed Action (CA) were evaluated. Results: Confirmatory factor analysis confirmed the a priori factor structure of the URICA. RTC was significantly associated with measures of addiction severity at baseline (r = .12-.52, p < .05).Although statistically significant (p < .01), the correlations between treatment outcomes and RTC were low (r = - .15 and 18). Additional analyses did not support a moderating or mediating effect of motivation on treatment retention or substance use. Conclusions: The construct validity of the URICA was confirmed separately in a large sample of drug- and alcohol-dependent patients. However, evidence for the predictive validity of composite scores was very limited and there were no moderating or mediating effects of either measure on treatment outcome. Thus, increased motivation to change, as measured by the composite scores of motivation derived from the URICA, does not appear to influence treatment outcome.

Garbutt JC; Osborne M; Gallop R; Barkenbus J; Grace K; Cody M et al. Sweet liking phenotype, alcohol craving and response to naltrexone treatment in alcohol dependence. Alcohol and Alcoholism 44(3): 293-300, 2009. (58 refs.)

Aims: To investigate the relationship between the sweet liking/sweet disliking phenotype (a putative probe of brain opioid function), craving for alcohol and response to treatment with naltrexone in individuals with alcohol dependence. Methods: Forty individuals with alcohol dependence were enrolled in a 12-week open-label study of 50 mg of naltrexone with four sessions of motivational enhancement therapy. Prior to treatment, individuals completed a sweet preference test and the Penn Alcohol Craving Scale. Subjects were categorized as sweet liking (SL), n = 15, or sweet disliking (SDL), n = 25, via a standard sweet tasting paradigm. The sweet tasting results were blinded to the subjects and to treatment staff. SL status, pretreatment craving and their interaction were examined as predictors of frequency of abstinent days and heavy drinking days during treatment with naltrexone. Results: SL and SDL subjects achieved similar reductions in percent heavy drinking days with treatment. During treatment, SDL subjects had 48% abstinent days compared to 30% for SL subjects (P = 0.034). Pretreatment craving did not predict % heavy drinking days or % abstinent days. An interaction effect was found between the SL/SDL phenotype and pretreatment craving such that SL subjects with high craving demonstrated higher rates of percent abstinent days whereas SDL subjects with high craving demonstrated lower rates of percent abstinent days, P < 0.001. Conclusions: These findings indicate that the SL/SDL phenotype may predict variation in response to naltrexone and/or counseling treatment. Furthermore, the SL/SDL phenotype may interact with craving to provide a more robust prediction of outcome with naltrexone or counseling.

Gaume J; Gmel G; Faouzi M; Daeppen JB. Counselor skill influences outcomes of brief motivational interventions. Journal of Substance Abuse Treatment 37(2): 151-159, 2009. (38 refs.)

The aim of this study was to estimate the influence of counselor skills during brief motivational interventions (BMIs) on patient alcohol use 12 months later. Ninety-five BMIs delivered by five counselors of similar background and training were recorded and coded using the Motivational Interviewing Skills Code (MISC). Baseline alcohol measures and sociodemographics of patients did not differ across counselors, whereas MISC scores and outcome at 12 months did. Multilevel models showed that counselors with better motivational interviewing (MI) skills achieved better outcomes overall and maintained efficacy across all levels of an important predictor (patient ability to change), whereas counselors with poorer MI skills were effective mostly at high levels of ability to change. Findings indicated that avoidance of MI-inconsistent skills was more important than frequency of using MI-consistent skills and that training and selection of counselors should be based more on the overall MI-consistent gestalt than on particular MI techniques.

Gil-Rivas V; Prause J; Grella CE. Substance use after residential treatment among individuals with co-occurring disorders: The role of anxiety/depressive symptoms and trauma exposure. Psychology of Addictive Behaviors 23(2): 303-314, 2009. (80 refs.)

This longitudinal study examined the contribution of anxiety/depressive symptoms and lifetime and recent trauma exposure to substance use after residential substance abuse treatment among individuals with co-occurring disorders. Data were collected from adults at treatment entry and 6 and 12 months later. At treatment entry, nearly all participants reported lifetime trauma exposure. and over one third met criteria for posttraumatic stress disorder (PTSD). Over the follow-up, nearly one third of the participants were exposed to trauma. Lifetime trauma exposure and a diagnosis of PTSD at treatment entry were lot associated with substance use over the follow-up. Trauma exposure and anxiety/depressive symptoms over the follow-up were associated with an increased likelihood of substance use. Gender did not moderate the association between trauma exposure and anxiety/depressive symptoms and substance use. These findings highlight the importance of monitoring for trauma exposure and symptoms of anxiety/depression to better target interventions and continuing care approaches to reduce the likelihood of posttreatment substance use in this population.

Gopalakrishnan R; Ross J; O'Brien C; Oslin D. Course of late-life depression with alcoholism following combination therapy. Journal of Studies on Alcohol and Drugs 70(2): 237-241, 2009. (24 refs.)

Objective: The comorbidity of alcoholism and depression increases the complexity of treatment and is associated with severe disability and morbidity. However, long-term treatment algorithms have been understudied. Method: This study examined the natural course of 74 depressed alcoholics over 6 to 12 months following a 12-week acute-phase trial of sertraline (Zoloft), naltrexone (Revia), and compliance enhancement therapy. Subjects were monitored for long-term outcomes based on their acute-phase trial response. Results: Fifty-four subjects followed up at 6 months, and 50 subjects remained at the 12-month visit. Full responders at the end of the 12-week acute-phase trial sustained better overall outcomes (6 months: chi(2) = 19.9, 4 df, p = .001; 12 months; chi(2) = 11.7, 4 df, p = .20) as compared with partial responders and nonresponders over a 6-month and 12-month period. Conclusions: Initial full responders sustain better overall treatment outcomes at 6 and 12 months, compared with partial responders and nonresponders. The defined outcome categories incorporate meaningful and practical measures of severity and can help predict treatment outcomes in clinical practice, thereby allowing timely interventions. Future studies should focus on maintenance strategies for full responders and treatment adaptations for partial responders and nonresponders.

Grella CE; Anglin MD. Introduction to the Special Issue on Addiction Health Services. (editorial). Journal of Behavioral Health Services & Research 36(2): 131-136, 2009. (34 refs.)

This is an Introduction to a special issue in memory of Douglas Longshore, a prominent researcher in the field of addiction health services. The findings from the ten papers in this issue are summarized and discussed within the context of Doug's development as a researcher and the core themes from his work. Three core areas are addressed: (1) internal processes related to change among substance abusers, (2) processes related to ethnicity and gender, and (3) treatment effectiveness, particularly regarding interventions to reduce risk of HIV/AIDS among substance abusers. The implications for addiction health services are discussed with regard to the application of these themes to practice.

Grella CE; Needell B; Shi YF; Hser YI. Do drug treatment services predict reunification outcomes of mothers and their children in child welfare? Journal of Substance Abuse Treatment 36(3): 278-293, 2009. (67 refs.)

The effect of mothers' participation in substance abuse treatment on reunification with their children who are in out-of-home care is an important policy issue. This article examines the predictors of child reunification among mothers who participated in a statewide treatment outcome study. Data were integrated from multiple sources to determine the contributions of characteristics of mothers (n = 1, 115), their children (n = 2,299), and treatment programs (n = 43) on reunification outcomes. Hierarchical linear modeling was used to determine the fixed and random effects of mother, child, and program characteristics. Mothers with more employment and psychiatric problems were less likely to be reunified with their children; completion of 90 or more days in treatment approximately doubled their likelihood of reunification. Mothers who were treated in programs providing a "high" level of family-related or education/employment services were approximately twice as likely to reunify with their children as those who were treated in programs with "low" levels of these services.

Hawkins EH. A tale of two systems: Co-occurring mental health and substance abuse disorders treatment for adolescents. (review). Annual Review of Psychology 60: 197-227, 2009. (179 refs.)

Co-occurring disorders present serious challenges to traditional mental health and substance abuse treatment systems. Among adolescents in need of behavioral health services, co-occurring disorders are highly prevalent and difficult to treat. Without effective intervention, youth with co-occurring disorders are at increased risk of serious medical and legal problems, incarceration, suicide, school difficulties and dropout, unemployment, and poor interpersonal relationships. In general, current service systems are inadequately prepared to meet this need due to a variety of clinical, administrative, financial, and policy barriers. This article presents an overview of co-occurring disorders among adolescents, highlights general considerations for co-occurring disorders treatment, reviews selected treatment models and outcomes, and discusses recommendations and best practice strategies.

Heather N; Honekopp J; Smailes D. Progressive stage transition does mean getting better: A further test of the Transtheoretical Model in recovery from alcohol problems. Addiction 104(6): 949-958, 2009. (46 refs.)

To test two central assumptions of the Transtheoretical Model (TTM) regarding recovery from alcohol problems: (i) individuals making a forward transition from pre-action to action stages will show greater drinking improvements than those remaining in pre-action stages; and (ii) individuals remaining in pre-action stages will not demonstrate improvements in drinking outcomes. Large, multi-centre, randomized controlled trial of treatment for alcohol problems [United Kingdom Alcohol Treatment Trial (UKATT)]. Stage of change, drinks per drinking day and percentage days abstinent at baseline, 3- and 12-month follow-ups. In support of TTM assumption 1, improvements in drinking outcomes were consistently greater among clients who showed a forward stage transition (Cohen's d = 0.68) than among those who did not (d = 0.10). Two tests of assumption 2 showed a significant improvement in drinking outcomes in non-transition groups, inconsistent with the TTM; one test showed a significant deterioration and the other showed equivalent drinking outcomes across time. An explanation is offered as to why, under the relevant assumption of the TTM, clients in non-transition groups showed small changes in drinking outcomes. In contrast to a previous study by Callaghan and colleagues, our findings largely support the TTM account of recovery from alcohol problems in treatment. The discrepancy can be explained by the use in our study of a more reliable and valid method for assigning stage of change.

Hogue A; Liddle HA. Family-based treatment for adolescent substance abuse: Controlled trials and new horizons in services research. (review). Journal of Family Therapy 31(2): 126-154, 2009. (140 refs.)

This article provides an overview of controlled trials research on treatment processes and outcomes in family-based approaches for adolescent substance abuse. Outcome research on engagement and retention in therapy, clinical impacts in multiple domains of adolescent and family functioning, and durability and moderators of treatment effects is reviewed. Treatment process research on therapeutic alliance, treatment fidelity and core family therapy techniques, and change in family processes is described. Several important research issues are presented for the next generation of family-based treatment studies focusing on delivery of evidence-based treatments in routine practice settings.

Howland RH; Rush AJ; Wisniewski SR; Trivedi MH; Warden D; Fava M et al. Concurrent anxiety and substance use disorders among outpatients with major depression: Clinical features and effect on treatment outcome. Drug and Alcohol Dependence 99(1-3): 248-260, 2009. (72 refs.)

Background: Depressed patients often present with comorbid anxiety and/or substance use disorder. This report compares the four groups defined by the disorders (anxiety disorder, substance use disorder, both, and neither) in terms of baseline clinical and sociodemographic features, and in terms of outcomes following treatment with citalopram (a selective serotonin reuptake inhibitor). Methods: The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial enrolled 2838 outpatients with non-psychotic major depressive disorder (MDD) from 18 primary and 23 psychiatric care clinics. Clinical and sociodemographic features were assessed at baseline. These baseline features and the treatment outcomes following treatment with citalopram were compared among the four groups. Results: Participants with non-psychotic MDD and comorbid anxiety and/or Substance use disorder showed several distinctive baseline sociodemographic and clinical features. They also showed greater depression severity; length of illness; likelihood of anxious, atypical or melancholic features; more intolerance/attrition; and worse remission/response outcomes with treatment. Participants with either anxiety or substance use disorder showed Outcomes generally intermediate between those with both and those with neither. Conclusions: Comorbid anxiety and/or Substance use disorder are clinically identifiable, and their presence may define distinct MDD subgroups that have more problems and worse pharmacological treatment Outcomes. They may benefit from more aggressive, multi-faceted treatment and psychosocial rehabilitation targeted at reducing their psychological comorbidity and functional impairment.

Humphreys K; Harris AHS; Kivlahan DR. Performance monitoring of substance use disorder interventions in the Veterans Health Administration. American Journal of Drug and Alcohol Abuse 35(3): 123-127, 2009. (24 refs.)

Background: Measuring and improving the quality of treatment for patients with substance use disorders are enduring challenges. Methods: This article describes how the Veterans Affairs health care system is using incentivized performance measures to promote more effective delivery of interventions for nicotine, illegal drug, and alcohol disorders. Results: The monitoring and incentive system has increased the delivery of evidence-based services, including screening for alcohol use disorders. Conclusions: Further work remains to be done to strengthen the connection between process-based measures and longer-term patient outcomes.

Jansson I; Hesse M; Fridell M. Influence of personality disorder features on social functioning in substance-abusing women: Five years after compulsive residential treatment. European Addiction Research 15(1): 25-31, 2009. (21 refs.)

Background: Personality disorders (PD) are related to negative outcome in substance abuse treatment, and in the general population, personality disorders are related to negative outcome in overall functioning. Little is known about the impact of PD on adjustment following substance abuse treatment. Methods: A cohort of 132 women was followed for 5 years after their index treatment episode in compulsory treatment. During treatment, patients were assessed with the SCID-II. At follow-up, patients were administered a timeline follow-back interview covering their functioning, including employment status over the years, and linked with hospital and criminal justice registers. Results: The impact of PD on functioning varied substantially between disorders and outcome domains. Conduct disorder alone was associated with criminal justice involvement, and conduct disorder and avoidant PD features were associated with unemployment. Dependent PD and obsessive-compulsive personality disorder features were positively associated with employment. Borderline PD features were associated with hospital admissions. Discussion: We discuss how strategies associated with various PDs may foster or hinder social adjustment in general and employment patterns in particular.

Kampman KM; Pettinati HM; Lynch KG; Xie H; Dackis C; Oslin DW et al. Initiating acamprosate within-detoxification versus post-detoxification in the treatment of alcohol dependence. Addictive Behaviors 34(6-7): 581-586, 2009. (35 refs.)

Objectives: This trial compared the efficacy of acamprosate, started at the beginning of detoxification, to acamprosate started at the completion of detoxification. in the treatment of alcohol dependence. Methods: This biphasic clinical trial consisted of a randomized, double-blind, placebo-controlled Detoxification Phase (DP), followed by a 10-week open-label Rehabilitation Phase (RP). Forty alcohol dependent patients were randomly assigned to receive either 1998 mg of acamprosate daily, or matching placebo. during the DP (5-14 days). After completing cletoxification, all patients received open label acamprosate (1998 mg daily) in the RP. Outcome measures during the DP included: treatment retention, alcohol withdrawal, alcohol consumption, and oxazepam used. Outcome measures during the RP included: treatment retention and alcohol consumption. Results: There were no significant outcome differences between acamprosate and placebo-treated patients during the DP. Patients given acamprosate, compared to placebo, during the DP drank more alcohol in the RP. Conclusions: Starting acamprosate at the beginning of detoxification did not improve DP outcomes. Starting acamprosate after detoxification was completed was associated with better drinking outcomes during subsequent alcohol rehabilitation treatment.

Kavanagh D; Connolly JM. Mailed treatment to augment primary care for alcohol disorders: A randomised controlled trial. Drug and Alcohol Review 28(1): 73-80, 2009. (26 refs.)

Introduction and Aims. Remote delivery of interventions is needed to address large numbers of people with alcohol use disorders who are spread over large areas. Previous correspondence trials typically examined its effects as stand-alone treatment. This study aimed to test whether adding postal treatment to general practitioner (GP) support would lower alcohol use more than GP intervention alone. Design and Methods. A single-blind, randomised controlled trial with a crossover design was conducted over 12 months on 204 people with alcohol use disorders. Participants in an immediate correspondence condition received treatment over the first 3 months; those receiving delayed treatment received it in months 3-6. Results. Few participants were referred from GPs, and little intervention was offered by them. At 3 months, 78% of participants remained in the study. Those in immediate treatment showed greater reductions in alcohol per week, drinking days, anxiety, depression and distress than those in the delayed condition. However, post-treatment and follow-up outcomes still showed elevated alcohol use, depression, anxiety and distress. Greater baseline anxiety predicted better alcohol outcomes, although more mental distress at baseline predicted dropout. Discussion and Conclusions. The study gave consistent results with those from previous research on correspondence treatments, and showed that high levels of participant engagement over 3 months can be obtained. Substantial reductions in alcohol use are seen, with indications that they are well maintained. However, many participants continue to show high-risk alcohol use and psychological distress.

Kelly JF; Magill M; Stout RL. How do people recover from alcohol dependence? A systematic review of the research on mechanisms of behavior change in Alcoholics Anonymous. (review). Addiction Research & Theory 17(3): 236-259, 2009. (133 refs.)

Rigorous reviews of the science on the effectiveness of Alcoholics Anonymous (AA) indicate that AA and related 12-step treatment are at least as helpful as other intervention approaches. Exactly how AA achieves these beneficial outcomes is less well understood, yet, greater elucidation of AA's mechanisms could inform our understanding of addiction recovery and the timing and content of alcohol-related interventions. Empirical studies examining AA's mechanisms were located from searches in Pubmed, Medline, PsycINFO, Social Service Abstracts and from published reference lists. Thirteen studies completed full mediational tests. A further six were included that had completed partial tests. Mechanisms examined fell into three domains: (1) Common processes; (2) AA-specific practices; and (3) Social and spiritual processes. Results suggest AA helps individuals recover through common process mechanisms associated with enhancing self-efficacy, coping skills, and motivation, and by facilitating adaptive social network changes. Little research?? or support was found for AA's specific practices or spiritual mechanisms. Conclusions are limited by between-study differences in sampling, measurement, and assessment time-points, and by insufficient theoretical elaboration of recovery-related change. Similar to the common finding that theoretically-distinct professional interventions do not result in differential patient outcomes, AA's effectiveness may not be due to its specific content or process. Rather, its chief strength may lie in its ability to provide free, long-term, easy access and exposure to recovery-related common therapeutic elements, the dose of which, can be adaptively self-regulated according to perceived need.

King A; Cao D; Vanier C; Wilcox T. Naltrexone decreases heavy drinking rates in smoking cessation treatment: An exploratory study. Alcoholism: Clinical and Experimental Research 33(6): 1044-1050, 2009. (48 refs.)

There is mixed support for the efficacy of the opioid antagonist naltrexone in the treatment of nicotine dependence. One potential unexplored mechanism underlying naltrexone's effects in smoking cessation may be in its ability to reduce alcohol consumption. Alcohol consumption and liver enzyme levels (aspartate aminotransferase and alanine transaminase) were examined in a sample of 78 nonalcoholic social drinking smokers (34 naltrexone, 44 placebo) enrolled in a double-blind randomized clinical trial of naltrexone in smoking cessation. Naltrexone or placebo began 3 days prior to the quit date (25 mg daily) and continued for 8 weeks (50 mg daily). All participants received nicotine patches and behavioral counseling up through 4 weeks after the quit date. Naltrexone significantly reduced weekly heavy drinking rates. This effect was associated with greater nausea and pill taking adherence within the naltrexone group. Within heavy drinkers, naltrexone also directionally improved smoking quit rates compared with placebo. Liver enzyme levels did not differ during treatment with naltrexone compared with placebo. Naltrexone may reduce the frequency of heavy drinking in nonalcoholics attempting to quit smoking. Further, naltrexone may preferentially improve smoking quit rates within heavy drinkers who smoke, and further investigation in larger sample sizes is warranted.

Kranzler HR; Tennen H; Armeli S; Chan G; Covault J; Arias A et al. Targeted naltrexone for problem drinkers. Journal of Clinical Psychopharmacology 29(4): 350-357, 2009. (23 refs.)

This study aimed to replicate and extend prior research showing that the targeted use of naltrexone is a useful strategy to reduce heavy drinking. We compared the effects of naltrexone with those of placebo in a sample of 163 individuals (58.3% male) whose goal was to reduce their drinking to safe limits. Patients received study medication (ie, naltrexone 50 mg or placebo) and were instructed to use it daily or targeted to situations identified by them as being high risk for heavy drinking. An interactive voice response system was used to obtain daily reports of drinking and medication use during the 12-week trial. Analyses were conducted using hierarchical linear modeling, with sex as a potential moderator variable. On the primary outcome measure, mean drinks per day., at week 12, men in the targeted naltrexone group drank significantly less than patients in the other groups did. On a secondary outcome measure, drinks per drinking day, during week 12, the targeted naltrexone group drank significantly less than the other groups did, with no moderating effect of sex. These results support the use of a targeted approach to reduce drinking among heavy drinkers, particularly men), but argue for the use of additional strategies or more efficacious medications than naltrexone to increase the effects of such an intervention.

Kushner MG; Sletten S; Donahue C; Thuras P; Maurer E; Schneider A et al. Cognitive-behavioral therapy for panic disorder in patients being treated for alcohol dependence: Moderating effects of alcohol outcome expectancies. Addictive Behaviors 34(6-7): 554-560, 2009. (37 refs.)

Anxiety disorders commonly co-occur with alcohol use disorders and reliably mark a poor response to substance abuse treatment. However, treating a co-occurring anxiety disorder does not reliably improve substance abuse treatment outcomes. Failure to account for individual differences in the functional dynamic between anxiety symptoms and drinking behavior might impede the progress and clarity of this research program. For example, while both theory and research point to the moderating role of tension-reduction alcohol outcome expectancies (TR-AOEs) in the association between anxiety symptoms and alcohol use, relevant treatment studies have not typically modeled TR-AOE effects. We examined the impact: of a hybrid cognitive-behavioral therapy (H-CBT) treatment for panic disorder (independent variable) on response to a community-based alcohol dependence treatment program (dependent variable) in patients with higher vs. lower TR-AOEs (moderator). The H-CBT treatment was generally effective in relieving participants' panic symptoms relative to controls. However, TR-AOEs interacted with study cohort (H-CBT vs. control) in predicting response to substance abuse treatment. As expected, the H-CBT was most effective in improving alcohol use outcomes among those with the highest TR-AOEs. The study's primary methodological limitations are related to the quasi-experimental design employed.

LaBrie JW; Huchting KK; Lac A; Tawalbeh S; Thompson AD; Larimer ME. Preventing risky drinking in first-year college women: Further validation of a female-specific motivational-enhancement group intervention. Journal of Studies on Alcohol and Drugs Supplement 16: 77-85, 2009. (33 refs.)

Objective: Female college students have increased their alcohol consumption rates. The current study sought to replicate the effectiveness of a female-specific motivational-enhancement group intervention and extended previous work by adding a 6-month follow-Lip. The intervention included several motivational-enhancement components delivered in a group setting and included a group discussion of female-specific reasons for drinking. Method: Participants were 285 first-year college women. Data collection consisted of an online pi-c-intervention questionnaire, 10 weeks of online follow-up assessment, and a 6-month online follow-tip. Using a randomized design, participants chose a group session, blind to treatment status. Held during the first weeks of the first semester. 159 participants received the intervention and 126 participants received an assessment-only control. Results: Using a repeated-measures analysis of covariance, intervention participants consumed significantly less than control participants on drinks per week (F = 11.86, 1/252 df. p < .001), maximum drinks (F = 11.90. 1/252 df, p <.001), and heavy episodic drinking events (F = 20.14, 1/252 df, p < .001) across 10 weeks of follow-tip. However, these effects did not persist at the 6-month follow-up. Moderation effects were found for social motives on all drinking variables, such that the intervention was most effective for those women with higher social motives for drinking. Conclusions: Efficacy was found for a female-specific motivational group intervention in creating less risky drinking patterns among first-year women, especially women with social motives for drinking. The effect dissipated by the second semester, suggesting the need for maintenance or booster sessions.

Lafave L; Desportes L; McBride C. Treatment outcomes and perceived benefits: A qualitative and quantitative assessment of a women's substance abuse treatment program. Women & Therapy 32(1): 51-68, 2009. (33 refs.)

This study examines outcomes of a women's substance abuse treatment program based on empowerment, choice, and client/therapist collaboration. The program was assessed through qualitative and quantitative research methods. The article includes extensive quotes from six client interviews as well as data from pre-post surveys of 50 women in the treatment program. Results show that the women felt they benefited from the collaborative treatment approach. Benefits to the women included feeling more empowered and learning to take responsibility for their lives. The importance of taking a broad view of recovery that includes ongoing evaluation of positive changes in various areas of the clients' lives is discussed.

Lapham S; Forman R; Alexander M; Illeperuma A; Bohn MJ; Bohn Michael J. The effects of extended-release naltrexone on holiday drinking in alcohol-dependent patients. Journal of Substance Abuse Treatment 36(1): 1-6, 2009. (25 refs.)

A post hoc analysis examined the effect of extended-release naltrexone (XR-NTX) treatment combined with psychosocial support on alcohol consumption during holiday and nonholiday periods in a cohort of alcohol-dependent patients who had maintained at least 4 days of continuous abstinence before receiving their first treatment. Three parameters of drinking behavior were examined: percentage of drinking days, percentage of heavy drinking days, and the number of drinks per day. Patients receiving XR-NTX 380 mg reported significantly lower median percentages of drinking days, heavy drinking days, and the number of drinks per day compared with the placebo group. Patients treated with XR-NTX 190 mg reported similar results overall. The results suggest that treatment with XR-NTX 380 mg in combination with psychosocial intervention leads to significant reductions in alcohol consumption, with some measures indicating abstinence in alcohol-dependent patients with initial abstinence during holiday periods.

Laudet AB; Becker JB; White WL. Don't wanna go through that madness no more: Quality of life satisfaction as predictor of sustained remission from illicit drug misuse. (review). Substance Use & Misuse 44(2): 227-252, 2009. (103 refs.)

Individuals who have developed a clinical dependence on drugs and/or alcohol often report that they sought help because they were sick and tired of being sick and tired. Quality of life (QOL) remains the missing measurement in the addictions arena. The few studies conducted to date show that QOL is typically poor during active addiction and improves as a function of remission. An intriguing question bears on the role of QOL in subsequent remission status. Reasoning that higher life satisfaction may increase the price of future use and thus enhance the likelihood of sustained remission, this exploratory study tests the hypotheses that QOL satisfaction prospectively predicts sustained remission, and that motivational constructs mediate the association. Inner city residents (N = 289, 53.6% male, mean age 43) remitting from chronic and severe histories of dependence to crack and/or heroin were interviewed three times at yearly interval beginning in April 2003. Logistic regression findings generally support our hypotheses: Controlling for other relevant variables, baseline life satisfaction predicted remission status 1 and 2 years later and the association was partially mediated by motivation (commitment to abstinence) although the indirect effect did not reach statistical significance. Findings underline the importance of examining the role of QOL satisfaction in remission processes. Limitations of this exploratory study are discussed, including the use of a single-item global life satisfaction rating; suggestions for future studies are discussed including the need to embrace QOL as a bona fide clinical outcome and to use comprehensive standardized QOL measures that speak to individual dimensions of functioning. Implications are noted, especially the need for the addiction field to continue moving away from the pathology-focused model of care toward a broader model that embraces multiple dimensions of positive health as a key outcome.

Lewandowski CA; Hill TJ. The impact of emotional and material social support on women's drug treatment completion. Health and Social Work 34(3): 213-221, 2009. (41 refs.)

This study assessed how women's perceptions of emotional and material social support affect their completion of residential drug treatment. Although previous research has examined how social support affects recovery, few studies, if any, have examined both the types and the sources of social support. The study hypothesized that women's perceptions of the emotional and material social support they receive from family, friends, partners, drug treatment, child welfare, and welfare agencies will affect treatment completion. The sample consisted of 117 women who were enrolled in a women's residential treatment program. Data were collected in semistructured initial and follow-up interviews using a life history calendar; the Scale of Perceived Social Support, which was adapted for this study; and women's treatment records. The results support the hypothesis. Social support can have both positive and negative effects on treatment completion, depending on the type and source of support provided.

Litt MD; Kadden RM; Kabela-Cormier E; Petry NM. Changing network support for drinking: network support project 2-year follow-up. Journal of Consulting and Clinical Psychology 77(2): 229-242, 2009. (59 refs.)

Network Support Project was designed to determine whether a treatment could lead patients to change their social network from one that supports drinking to one that supports sobriety. This study reports 2-year posttreatment outcomes. Alcohol-dependent men and women (N = 210) were randomly assigned to 1 of 3 outpatient treatment conditions: network support (NS), network support + contingency management (NS + CM), or case management (CaseM, a control condition). Analysis of drinking rates indicated that the NS condition yielded up to 20% more days abstinent than the other conditions at 2 years posttreatment. NS treatment also resulted in greater increases at 15 months in social network support for abstinence, as well as in AA attendance and AA involvement than did the other conditions. Latent growth modeling suggested that social network changes were accompanied by increases in self-efficacy and coping that were strongly predictive of long-term drinking outcomes. The findings indicate that a network support treatment can effect long-term adaptive changes in drinkers' social networks and that these changes contribute to improved drinking outcomes in the long term.

LoCastro JS; Youngblood M; Cisler RA; Mattson ME; Zweben A; Anton RF et al. Alcohol areatment effects on secondary nondrinking outcomes and quality of life: The COMBINE Study. Journal of Studies on Alcohol and Drugs 70(2): 186-196, 2009. (49 refs.)

Objective: To evaluate the full range of alcohol treatment effectiveness, it is important to assess secondary nondrinking outcome dimensions in addition to primary alcohol consumption outcomes. Method: We used a large sample (n = 1,226) of alcohol-dependent participants entering the National Institute on Alcohol Abuse and Alcohol ism-sponsored COMBINE (Combining Medications and Behavioral Interventions) Study, a multisite clinical trial of pharmacological (naltrexone [ReVia] and acamprosate [Campral]) and behavioral interventions, to examine the effects of specific treatment combinations on nondrinking functional outcomes. We assessed the outcomes at baseline and at the end of 16 weeks of alcohol treatment and again at the 26-week and/or 52-week postrandomization follow-ups. Results: (1) Drinking and secondary outcomes were significantly related, especially at the follow-up periods. A higher percentage of heavy drinking days, more drinks per drinking day, and lower percentage of days abstinent were associated with lower quality-of-life measures. (2) All nondrinking outcomes showed improvement at the end of 16 weeks of treatment and most maintained improvement over the 26-week and 52-week follow-ups. Only two measures returned to pretreatment levels at 52 weeks: percentage of days paid for work and physical health. Improvements of nondrinking outcomes remained even after adjusting for post-treatment heavy drinking status. (3) Although nondrinking outcomes showed overall improvement, specific pharmacological and behavioral treatment combinations were not differentially effective on specific secondary outcomes. Conclusions: In the current study, changes that resulted from treatment were multidimensional, and improvements in nondrinking outcomes reflected the overall significant improvement in drinking but they were not differentiated between treatment combination groups. Findings from this study support the importance of including secondary nondrinking outcomes in clinical alcohol-treatment trials.

Madras BK; Compton WA; Avula D; Stegbauer T; Stein JB; Clark HW. Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: Comparison at intake and 6 months later. Drug and Alcohol Dependence 99(1-3): 280-295, 2009. (82 refs.)

Objectives: Alcohol screening and brief interventions in medical settings can significantly reduce alcohol use. Corresponding data for illicit drug use is sparse. A Federally funded screening, brief interventions, referral to treatment (SBIRT) service program, the largest of its kind to date, was initiated by the Substance Abuse and Mental Health Services Administration (SAMHSA) in a wide variety of medical settings. We compared illicit drug use at intake and 6 months after drug screening and interventions were administered. Design: SBIRT services were implemented in a range of medical settings across six states. A diverse patient population (Alaska Natives, American Indians, African-Americans. Caucasians, Hispanics), was screened and offered score-based progressive levels of intervention (brief intervention, brief treatment, referral to specialty treatment). In this secondary analysis of the SBIRT service program, drug use data was compared at intake and at a 6-month follow-up, in a sample of a randomly selected population (10%) that screened positive at baseline. Results: Of 459,599 patients screened, 22.7% screened positive for a spectrum of use (risky/problematic, abuse/addiction). The majority were recommended for a brief intervention (15.9%), with a smaller percentage recommended for brief treatment (3.2%) or referral to specialty treatment (3.7%). Among those reporting baseline illicit drug use, rates of drug use at 6-month follow-up (4 of 6 sites), were 67.7% lower (p < 0.001) and heavy alcohol use was 38.6% lower (p < 0.001), with comparable findings across sites, gender, race/ethnic, age subgroups. Among persons recommended for brief treatment or referral to specialty treatment, self-reported improvements in general health (p < 0.001), mental health (p < 0.001), employment (p < 0.001), housing status (p < 0.001), and criminal behavior (P < 0.001) were found. Conclusions: SBIRT was feasible to implement and the self-reported patient status at 6 months indicated significant improvements over baseline, for illicit drug use and heavy alcohol use, with functional domains improved, across a range of health care settings and a range of patients.

Magill M; Barnett NP; Apodaca TR; Rohsenow DJ; Monti PM. The role of marijuana use in brief motivational intervention with young adult drinkers treated in an emergency department. Journal of Studies on Alcohol and Drugs 70(3): 409-413, 2009. (22 refs.)

Objective: The aim of this research was to study marijuana use, associated risks, and response to brief motivational intervention among young adult drinkers treated in an emergency department. Method: Study participants (N = 215; ages 18-24) were in a randomized controlled trial for alcohol use that compared motivational interviewing with personalized feedback (MI) with personalized feedback only. Past-month marijuana users were compared with nonusers on demographics, readiness, self-efficacy, and behavioral risk variables. Marijuana use was examined as a potential moderator of alcohol outcomes. Whether marijuana use alone or combined marijuana and alcohol use would be reduced as a result of brief intervention for alcohol was examined at 6 and 12 months. Results: Current marijuana users were younger, were more likely to be white, and reported more alcohol use, other illicit drug use, and more alcohol-related consequences than nonmarijuana users. Marijuana use at baseline did not moderate response to brief alcohol treatment. Marijuana use declined from baseline to 6 months for both treatment groups, but only MI participants continued to reduce their use of marijuana from 6- to 12-month follow-up. Reductions in number of days of use of marijuana with alcohol appeared to be primarily a function of decreased alcohol use. Conclusions: Young adult drinkers reporting current marijuana use are at generally higher risk but responded to brief alcohol treatment by reducing alcohol and marijuana use.

Magill M; Ray LA. Cognitive-behavioral treatment with adult alcohol and illicit drug users: A meta-analysis of randomized controlled trials. (review). Journal of Studies on Alcohol and Drugs 70(4): 516-527, 2009. (112 refs.)

Objective: This meta-analysis examined 53 controlled trials of cognitive-behavioral treatment (CBT) for adults diagnosed with alcohol- or illicit-drug-use disorders. The aims were to provide an overall picture of CBT treatment efficacy and to identify client or treatment factors predictive of CBT effect magnitude. Method: The inverse variance weighted effect size (Hedges'g) was calculated for each study and pooled using fixed and random effects methods. Potential study-level moderators were assessed in subgroup analyses by primary drug, type of CBT, and type of comparison condition. In addition, seven client and treatment variables were examined in meta-regression analyses. Results: Across studies, CBT produced a small but statistically significant treatment effect (g = 0. 154, p <.005). The pooled effect was somewhat lower at 6-9 months (g = 0.115, p < .005) and continued to diminish at 12-month follow-up (g = 0.096, p < .05). The effect of CBT was largest in marijuana studies (g = 0.513, p < .005) and in studies with a no-treatment control as the comparison condition (g = 0.796, p < .005). Metaregression analyses indicated that the percentage of female participants was positively associated and the number of treatment sessions was negatively associated with effect size. Conclusions: The findings demonstrate the utility of CBT across a large and diverse sample of studies and under rigorous conditions for establishing efficacy. CBT effects were strongest with marijuana users, when CBT was compared with no treatment, and may be larger with women than with men and when delivered in a brief format.

Malet L; Reynaud M; Llorca PM; Chakroun N; Blanc O; Falissard B. Outcomes from primary care management of alcohol dependence in France. Journal of Substance Abuse Treatment 36(4): 457-462, 2009

A prospective study assessed the outcome in a sample of 122 Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition alcohol-dependent patients in primary care. Standardized questionnaires collected clinical, social, and m,management data during 875 visits over an 18-month follow-up. A time-event analysis identified outcome predictors. Forty-three percent of patients attempted at least one detoxification during tallow-up, one out of three in a hospital. Despite a very high relapse rate (83%), only 14%, of the patients attempted a repeated abstinence. Longest and cumulative durations of abstinence appeared to be very close, corresponding to 29% of the follow-up time. The frequency of visits (risk ratio [RR] = 1.08) and visits addressing alcohol consumption (RR = 1.73) significantly lead to detoxification. In this French sample, management by the general practitioners appears to be a positive predictor of outcome in alcohol dependence. Future research could (a) enlighten the relationship between detoxification and frequency or circumstances of the visits and (b) tell whether formal planned follow-up by general practice physicians could improve outcome in alcohol dependence.

Mason M. Social network characteristics of urban adolescents in brief substance abuse treatment. Journal of Child & Adolescent Substance Abuse 18(1): 72-84, 2009. (37 refs.)

In this study, the social network characteristics of 102 urban adolescents in brief substance abuse treatment are described and analyzed longitudinally to examine risk and protective mechanisms. The treatment intervention had one session devoted to social support and networks. Social networks were conceptualized and measured along two dimensions (a risk and a protective dimension) with four categories within each dimension. Results indicate a reduction in risk and an increase in protective characteristics at 12-month follow-up and point to specific characteristics that increase risk for and protection against substance use and psychiatric problems. These findings support a social network approach in understanding adolescent health behaviors.

Mazza M; Mandelli L; Di Nicola M; Harnic D; Catalano V; Tedeschi D et al. Clinical features, response to treatment and functional outcome of bipolar disorder patients with and without co-occurring substance use disorder: 1-year follow-up. Journal of Affective Disorders 115(1/2): 27-35, 2009. (34 refs.)

Introduction: Bipolar disorder patients (BP) with comorbid Substance Use Disorder (SUD) may present clinical features that could compromise adherence and response to pharmacological treatment. The purpose of this study was to examine clinical and psychopathological features of BP with and without comorbid SUD in a real-world setting. Methods: The sample was composed by 131 affective patients. Sixty-five patients were affected by Bipolar Disorder I (BP-I, 49.2%), 29 by Bipolar Disorder II (BP-II, 22.3%) and 37 by Cyclothymic Disorder (CtD, 28.5%), according to DSM-IV Sixty-six patients were diagnosed for a comorbid SUD. All patients have been submitted to psychometric assessment with Hamilton Depression Rating Scale (HDRS), Hamilton Anxiety Rating Scale (HARS), Young Mania Rating Scale (YMRS), Global Assessment Scale (GAS), Social Adjustment Self-reported Scale (SASS), Quality of Life Scale (QoL), at baseline and repeated follow-up periods (1, 3, 6, 12 months). Results: BP comorbid for SUD were more likely diagnosed as BP-II and CID and were less likely to present a moderate-severe manic symptomatology. Furthermore, personality disorders were more frequent in SUD patients than in non-comorbid BP. BP with SUD were not different for primary outcome measure (HDRS, HARS, YMRS, GAS) from non-comorbid BP; however, BP with SUD were significantly more impaired in social functioning (SASS) at any stage of the follow-tip and poor functioning increased the risk of relapse in substance use during treatment. Finally, SUD comorbidity did not represent a risk factor for treatment drop-out, while in our sample young age, low treatment dosage and BP-I diagnosis were significantly associated with drop-out. Discussion: The primary finding of this work is that BP with comorbid SUD are significantly more compromised in social functioning. Second, these patients were less likely to be diagnosed for BP-I and to present a severe manic symptomatology. Finally, we found that the diagnosis of SUD, but young age, low treatment dosage and BP-I diagnosis to be risk factors for treatment drop-out. Physicians should be alert to these differences in their clinical practice.

Mckay JR; Carise D; Dennis ML; Dupont R; Humphreys K; Kemp J et al. Extending the benefits of addiction treatment: Practical strategies for continuing care and recovery. (editorial). Journal of Substance Abuse Treatment 36(2): 127-130, 2009. (0 refs.)

Melnick G; Wexler HK; Chaple M; Cleland CM. Constructive conflict and staff consensus in substance abuse treatment. Journal of Substance Abuse Treatment 36(2): 174-182, 2009. (58 refs.)

Previous studies demonstrated the relationship between consensus among both staff and clients with client engagement in treatment and between client consensus and 1-year treatment outcomes. The present article explores the correlates of staff consensus, defined as the level of agreement among staff as to the importance of treatment activities in their program, using a national sample of 80 residential substance abuse treatment programs. Constructive conflict resolution had the largest effect on consensus. Low client-to-staff ratios, staff education, and staff experience in substance abuse treatment were also significantly related to consensus. Frequency of training, an expected correlate of consensus, was negatively associated with consensus, whereas frequency of supervision was not a significant correlate. The implications of the findings for future research and program improvement are discussed.

Morgenstern J; Neighbors CJ; Kuerbis A; Riordan A; Blanchard KA; McVeigh KH et al. Improving 24-month abstinence and employment outcomes for substance-dependent women receiving Temporary Assistance for Needy Families with intensive case management. American Journal of Public Health 99(2): 328-333, 2009. (34 refs.)

Objective. We examined abstinence rates among substance-dependent women receiving Temporary Assistance for Needy Families (TANF) in intensive case management (ICM) over 24 months and whether ICM yielded significantly better employment outcomes compared with a screen-and-refer program (i.e., usual care). Methods. Substance-dependent (n=302) and non-substance dependent (n = 150) TANF applicants in Essex County, New Jersey, were recruited. We randomly assigned substance-dependent women to ICM or usual care. We interviewed all women at 3, 9, 15, and 24 months. Results. Abstinence rates were higher for the ICM group than for the usual care group through 24 months of follow-up (odds ratio [OR]=2.11; 95% confidence interval [CI] = 1.36, 3.29). A statistically significant interaction between time and group on number of days employed indicated that the rate of improvement over time in employment was greater for the ICM group than for the usual care group (incidence rate ratio=1.03; 95% CI=1.02, 1.04). Additionally, there were greater odds of being employed full time for those in the ICM group (OR=1.68; 95% CI=11.12, 2.51). Conclusions. ICM is a promising intervention for managing substance dependence among women receiving TANF and for improving employment rates among this vulnerable population.

Nagel T; Robinson G; Condon J; Trauer T. Approach to treatment of mental illness and substance dependence in remote Indigenous communities: Results of a mixed methods study. Australian Journal of Rural Health 17(4): 174-182, 2009. (45 refs.)

Objective: To develop and evaluate a culturally adapted brief intervention for Indigenous people with chronic mental illness. Design: A mixed methods design in which an exploratory phase of qualitative research was followed by a nested randomised controlled trial. Setting: Psycho-education resources and a brief intervention, motivational care planning (MCP), were developed and tested in collaboration with aboriginal mental health workers in three remote communities in northern Australia. Participants: A total of 49 patients with mental illness and 37 carers were recruited to a randomised controlled trial that compared MCP (n = 24) with a clinical control condition (treatment as usual, n = 25). Intervention: The early treatment group received MCP at baseline and the late treatment group received delayed treatment at six months. Main outcome measures: The primary outcome was mental health problem severity as measured by the health of the nation outcome scales. Secondary measures of well-being (Kessler 10), life skills, self-management and substance dependence were chosen. Outcome assessments were performed at baseline, six-month, 12-month and 18-month follow up. Results: Random effects regression analyses showed significant advantage for the treatment condition in terms of well-being with changes in health of the nation outcome scales (P < 0.001) and Kessler 10 (P = 0.001), which were sustained over time. There was also significant advantage for treatment for alcohol dependence (P = 0.05), with response also evident in cannabis dependence (P = 0.064) and with changes in substance dependence sustained over time. Conclusions: These results suggest that MCP is an effective treatment for Indigenous people with mental illness and provide insight into the experience of mental illness in remote communities.

Orford J; Hodgson R; Copello A; Wilton S; Slegg G. To what factors do clients attribute change? Content analysis of follow-up interviews with clients of the UK Alcohol Treatment Trial. Journal of Substance Abuse Treatment 36(1): 49-58, 2009. (27 refs.)

The UK Alcohol Treatment Trial compared outcomes after a social treatment (Social Behavior and Network Therapy) and a motivational treatment (Motivational Enhancement Therapy). As part of the process element of the trial, a subsample of clients were interviewed 3 months after treatment allocation and another subsample 12 months after allocation (N = 397) to explore the factors to which clients attributed positive changes that might have occurred in their drinking. Postinterview reports were content analyzed using three types of code: social, motivational, and general. At 3 months, Social Behavior and Network Therapy clients made significantly more social attributions and Motivational Enhancement Therapy clients more motivational attributions, and the difference for motivational attributions was maintained at 12 months (with a trend for social attributions). Overall, the factors to which change was most frequently attributed were involvement of others in supporting behavior change (a social factor), awareness of the consequences of drinking (a motivational Factor), and three general factors-determination, commitment, and decision; detoxification or medication; and feeling comfortable talking. Change was more frequently attributed to general factors than it was to either social or motivational ones. Some of the difficulties in eliciting and coding attribution material are referred to. The results may help understand the absence of between-treatment type outcome differences in UK Alcohol Treatment Trial and other trials.

Orford J; Hodgson R; Copello A; Krishnan M; de Madariaga M; Coulton S. What was useful about that session? Clients' and therapists' comments after sessions in the UK Alcohol Treatment Trial (UKATT). Alcohol and Alcoholism 44(3): 306-313, 2009. (16 refs.)

Aim: The aim of this study was to report and contrast the aspects of two therapies considered by clients and therapists to be most and least useful. Method: In the UK Alcohol Treatment Trial (UKATT), 742 clients were treated by 49 therapists with up to three sessions of motivational enhancement therapy (MET) or up to eight sessions of social behaviour and network therapy (SBNT). After each treatment session, clients and therapists were asked to independently complete two sentences, one inviting a statement about the 'most useful' and the other about the 'least useful' thing that had happened during the session. Results: The proportion of 'most useful' sentences completed was greater than the proportion of 'least useful' and equally so for MET and SBNT. The content of comments was significantly different for the two treatments: more comments on social aspects followed SBNT and more motivational comments followed MET, with larger numbers of comments following both treatments that were more general. Clients more often completed 'most useful' sentences than therapists and less often completed 'least useful' sentences. There were a number of differences in the content of their comments: notably more 'most useful' client comments about talking to their therapists, and more therapist comments about client engagement. Conclusions: MET and SBNT left distinct impressions on the participants immediately following treatment sessions, adding to the evidence that they are different treatments, and hence deepening the mystery about why outcomes following the two treatments were so similar.

Oroszi G; Anton RF; O'Malley S; Swift R; Pettinati H; Couper D et al. OPRM1 Asn40Asp predicts response to naltrexone treatment: A haplotype-based approach. Alcoholism: Clinical and Experimental Research 33(3): 383-393, 2009. (53 refs.)

Individualized pharmacotherapy requires identification of genetic variants predictive of treatment response. In OPRM1, Asn40Asp has been reported to be predictive of response to naltrexone treatment. Nevertheless, the in vitro function of the polymorphism remains elusive and over 300 OPRM1 sequence variants have been identified to date. Therefore we used a haplotype-based approach to capture information of other genetic variants that might predict treatment response to naltrexone in the COMBINE Study. 5' nuclease genotyping assays (TaqMan((R))) were applied for 10 SNPs. Five-locus haplotypes in 2 OPRM1 haplotype blocks were assigned to Caucasian participants. The relationship of the haplotypes to medication reflected by "good clinical outcome" was analyzed in 306 Caucasians treated without Combined Behavioral Intervention and with either naltrexone or placebo. A significant haplotype by medication interaction (p = 0.03) was found in OPRM1 block 1. Naltrexone-treated alcoholics with haplotype AGCCC, the single haplotype carrying the Asp40 allele had the highest percent of good clinical outcome. When interaction of genotypes at each of the 5 loci comprising block 1 with medication was examined, only the Asn40/Asp40 and Asp40/Asp40 genotypes were found to significantly interact with naltrexone treatment. No haplotype by medication interaction was documented in OPRM1 block 2. Our haplotype-based approach confirms that the single OPRM1 locus predictive of response to naltrexone treatment is Asn40Asp in exon 1. A substantial contribution of any other OPRM1 genetic variant to interindividual variations in response to naltrexone treatment (at least in terms of good clinical outcome) is not supported by our findings.

Petersen CB; Gronbaek MN; Rask MB; Nielsen B; Nielsen AS. Suicidal behaviour among alcohol-dependent Danes attending outpatient treatment. Nordic Journal of Psychiatry 63(3): 209-216, 2009

The association between alcohol dependence and suicidal behaviour is well established and patients with suicidal behaviour in treatment for alcohol dependence present a considerable challenge for clinical services. The aim of this study is to identify risk factors for suicide attempts and to evaluate the outcome of treatment in patients in treatment for alcohol dependence. Semistructured, detailed interviews were administered at baseline and at three sequential follow-up interviews with a large sample of 1692 patients at an outpatient treatment centre in the county of Funen in Denmark. Characteristics of, predictors for and outcome among suicidal patients were studied. Alcohol-dependent patients with a history of suicide attempts were found to constitute a highly selected group in alcohol abuse treatment as they often had a more severe course of alcohol dependence, were unemployed, younger, were more often lowly educated, and had more physical and psychiatric problems. Traumatic childhood experience related to physical or sexual abuse was found as a major predictor for suicidal behaviour among alcohol-dependent patients. We found no significant difference in the effect of treatment in patients with and without suicidal behaviour. These results support the hypothesis that alcohol-dependent patients with a history of suicide attempts are a selected group in respect to a number of demographical and psychosocial factors, but we found no difference in the outcome of treatment. This may imply that suicidal patients in treatment for alcohol abuse are treated effectively within the present treatment settings.

Pettinati HM; Gastfriend DR; Dong QM; Kranzler HR; O'Malley SS. Effect of extended-release naltrexone (XR-NTX) on quality of life in alcohol-dependent patients. Alcoholism: Clinical and Experimental Research 33(2): 350-356, 2009. (38 refs.)

Background: Extended-release naltrexone (XR-NTX) is a once-a-month injectable formulation for the treatment of alcohol dependence previously shown to reduce drinking and heavy drinking relative to placebo (Garbutt et al., 2005). A 24-week, randomized, double-blind, placebo-controlled study established the efficacy and safety of XR-NTX in this patient population. In this report, the effect of XR-NTX on quality of life (QOL) was examined. Methods: Alcohol-dependent patients were randomly assigned to receive XR-NTX 380 mg (N = 205), XR-NTX 190 mg (N = 210), or placebo (N = 209), combined with a standardized psychosocial intervention. QOL was assessed using the Medical Outcomes Study 36-item short-form health survey, administered at baseline and at 4-week intervals during 24 weeks of treatment. Results: Compared with U.S. population norms, patients showed initial impairment in the health-related QOL domains of mental health, social functioning, and problems with work or other daily activities due to emotional problems. Adherence to all 6 injections was 65% for XR-NTX 190 mg, 63% for XR-NTX 380 mg, and 64% for placebo. Generalized estimating equations analyses using an intention-to-treat sample revealed that XR-NTX 380 mg was associated with significantly greater improvements from baseline in mental health (p = 0.0496), social functioning (p = 0.010), general health (p = 0.048), and physical functioning (p = 0.028), compared with placebo. Linear regression analyses revealed that reductions from baseline in drinking (percentage of drinking days and percentage of heavy drinking days in the last 30 days) were significantly (p < 0.05) correlated with improvements in quality of life. Conclusion: Extended-release naltrexone 380 mg in combination with psychosocial intervention was associated with improvements in QOL, specifically in the domains of mental health, social functioning, general health, and physical functioning.

Riper H; van Straten A; Keuken M; Smit F; Schippers G; Cuijpers P. Curbing problem drinking with personalized-feedback interventions: A meta-analysis. (review). American Journal of Preventive Medicine 36(3): 247-255, 2009. (84 refs.)

Context: The effectiveness of personalized-feedback interventions to reduce problem drinking has been evaluated in several RCTs and systematic reviews. A meta-analysis was performed to examine the overall effectiveness of brief, single-session personalized-feedback interventions without therapeutic guidance. Evidence acquisition: The selection and analyses of studies were conducted in 2008. Fourteen RCTs of single-session personalized-feedback interventions without therapeutic guidance were identified, and their combined effectiveness on the reduction of problematic alcohol consumption was evaluated in a meta-analysis. Alcohol consumption was the primary outcome measure. Evidence synthesis: The pooled standardized-effect size (14 studies, 15 comparisons) for reduced alcohol consumption at post-intervention was d=0.22 (95% CI=0.16, 0.29; the number needed to treat=8.06; areas under the curve=0.562). No heterogeneity existed among the studies (Q=10.962; p=0.69; I-2=0). Conclusions: The use of single-session personalized-feedback interventions without therapeutic guidance appears to be a viable and probably cost-effective option for reducing problem drinking in student and general populations. The Internet offers ample opportunities to deliver personalized-feedback interventions on a broad scale, and problem drinkers are known to be amenable to Internet-based interventions. More research is needed on the long-term effectiveness of personalized-feedback interventions for problem drinking, on its potential as a first step in a stepped-care approach, and on its effectiveness with other groups (such as youth obliged to use judicial service programs because of violations of minimum-age drinking laws) and in other settings (such as primary care).

Roberts-Lewis AC; Parker S; Welch C; Wall A; Wiggins P. Evaluating the cognitive and behavioral outcomes of incarcerated adolescent females receiving substance abuse treatment: A pilot study. Journal of Child & Adolescent Substance Abuse 18(2): 157-171, 2009. (26 refs.)

The purpose of this pilot study was to evaluate the effectiveness of a cognitive-behavioral approach in changing the behavioral and cognitive skills of incarcerated girls participating in a substance abuse treatment program. A repeated measures design was used. The findings of this study revealed that the behaviors (i.e., self-monitoring, self-control, etc.) and cognitive skills (i.e., cognitive concentration, consequential thinking, etc.) of participants improved significantly. Research and practice implications are discussed.

Roudsari B; Caetano R; Frankowski R; Field C. Do minority or white patients respond to brief alcohol intervention in trauma centers? A randomized trial. Annals of Emergency Medicine 54(2): 285-293, 2009. (389 refs.)

Study objective: The current study evaluates whether the effectiveness of brief alcohol intervention in reducing 6-and 12-month risk of injuries in a large Level I urban trauma center varies according to trauma patients' ethnicity. Methods: Eligible white, Hispanic, and black trauma patients aged 18 years or older were randomized to brief alcohol intervention or treatment as usual. The intervention was a "non-confrontational, patient-centered conversation" focused on patients' drinking pattern, with the purpose of encouraging them to change risky drinking. Study outcomes were patient-reported 6-and 12-month incidence of all-type injuries, alcohol-related injuries, and serious injuries (ie, injuries requiring emergency department visit or hospital admission). Results: A total of 1,493 trauma patients (668 whites, 537 Hispanics, 288 blacks) participated in this study. After 1 year of follow-up, we were not able to detect any important association between brief intervention and the risk of all-type injuries, alcohol-related injuries, or serious injuries among study participants. In addition, the association between brief intervention and the outcomes of interest was not modified by patients' ethnicity. Conclusion: Our study, congruent with some recent publications, implies that there are some patient-and provider-related impediments that could restrict the effectiveness of brief intervention programs in trauma centers, regardless of patient ethnicity. Unless those impediments are identified and eliminated, assuming that brief intervention will be an effective strategy for controlling future alcohol-related injuries among trauma patients and should be provided under any circumstances might not be reasonable.

Saitz R; Palfai TP; Cheng DM; Horton NJ; Dukes K; Kraemer KL et al. Some medical inpatients with unhealthy alcohol use may benefit from brief intervention. Journal of Studies on Alcohol and Drugs 70(3): 426-435, 2009. (47 refs.)

Objective: Studies of alcohol brief intervention for medical inpatients have mixed results. We explored potential moderators of the effectiveness of brief intervention for unhealthy alcohol use among medical inpatients. Method: This is a secondary analysis of a randomized controlled trial of brief motivational counseling among 341 urban-hospital medical inpatients (99 women) with unhealthy alcohol use. Self-reported main outcomes were receipt of alcohol treatment by 3 months in subjects with dependence and change in the mean number of drinks per day 3 and 12 months after enrollment in all subjects. Results: Among subjects with dependence, the effect of brief intervention on receipt of alcohol treatment differed significantly by gender and age (p = .02 for each interaction). In stratified analyses, brief intervention was associated with receipt of alcohol treatment in women (adjusted odds ratio [AOR] = 3.9, 95% confidence interval [CI]: 1.2-12.7), and younger (<44 years) subjects (AOR = 3.6, 95% CI: 1.3-10.1). Among subjects with nondependent, unhealthy alcohol use, brief intervention was significantly associated with fewer drinks per day and better physical health-related quality of life at 3 months. However, among those with dependence, intervention was associated with worse physical health-related quality of life and more hospital use, and no changes in drinking, In adjusted analyses among those with and without dependence, brief intervention was not associated with mental health-related quality of life, alcohol problems, or readiness to change. Effects of brief intervention on consumption outcomes were not consistently moderated by demographic characteristics, comorbidity/health, or readiness to change. Conclusions: Some medical inpatients with unhealthy alcohol use, particularly women, younger adults, and patients without dependence may benefit from brief intervention. Few factors that were expected to moderate brief intervention effects did so. Additional research should assess which medical inpatients, if any, can benefit from brief intervention.

Schneider R; Timko C. Does a history of violence influence treatment, self-help, and 1-year outcomes in substance use disorder patients? Journal of Addictive Diseases 28(2): 171-179, 2009. (39 refs.)

Rates of violence perpetration are high among patients with substance use disorder, but the impact of violence on substance use disorder treatment outcomes has received little attention. Patients with (n = 155) or without (n = 190) a history of difficulty controlling violent behavior were interviewed at entry to substance use disorder treatment and 1 year later. Substance use disorder severity, amount of treatment, and extent of participation in 12-step self-help groups were assessed to examine potential differences in treatment outcomes between violent and non-violent patients. After adjusting for baseline differences, no differences in substance use disorder severity were found at 1 year. However, over the year, violent patients received more treatment and participated more in 12-step groups compared to non-violent patients. In addition, violent patients benefited more from 12-step group participation than non-violent patients did. Referral to 12-step self-help groups may enhance the likelihood of recovery from a substance use disorder for patients with a history of violence.

Scott CK; Dennis ML. Results from two randomized clinical trials evaluating the impact of quarterly recovery management checkups with adult chronic substance users. Addiction 104(6): 959-971, 2009. (33 refs.)

Post-discharge monitoring and early reintervention have become standard practice when managing numerous chronic conditions. These two experiments tested the effectiveness of recovery management checkup (RMC) protocols for adult chronic substance users. RMC included quarterly monitoring; motivational interviewing to provide personalized feedback and to resolve ambivalence about substance use; treatment linkage, engagement and retention protocols to increase the amount of treatment received. Recruited from sequential addiction treatment admissions, participants in the two experiments were, on average, 36 and 38 years of age, mainly female (59% versus 46%), African American (85% versus 80%) and met past-year criteria for dependence (87% versus 76%). Participants in both experiments were assigned randomly to the RMC or control condition and interviewed quarterly for 2 years. The Global Appraisal of Individual Needs (GAIN) was the main assessment instrument. RMC participant outcomes were better than control participants in both experiments. Effect sizes were larger in the second experiment in terms of reducing days to readmission (Cohen's d = 0.41 versus d = 0.22), successive quarters in the community using substances (d = -0.32 versus -0.19), past-month symptoms of abuse/dependence (d = -0.23 versus -0.02) and increasing the days of abstinence over 2 years (d = +0.29 versus 0.04). RMC, which provided ongoing monitoring and linkage, is feasible to conduct and is effective for adults with chronic substance dependence.

Simpson D; Rowan-Szal GA; Joe GW; Best D; Day E; Campbell A. Relating counselor attributes to client engagement in England. Journal of Substance Abuse Treatment 36(3): 313-320, 2009. (39 refs.)

Client functioning and treatment engagement were examined in relation to staff attributes and organizational climate across a diverse sample of drug treatment and outreach programs in England. Self-rating assessments were obtained from 1,539 clients and 439 counselors representing 44 programs, and results were interpreted using comparable data from studies of treatment programs in the United States. Client scores on treatment participation and counseling rapport in England were directly related to their higher levels of motivation and psychosocial functioning, as well as to staff ratings of professional attributes and program atmosphere. By linking records from English clients with their counselors in each program, findings also indicate these relationships are rooted in the personal interactions between clients and their counselor. Standardized assessments of treatment structure, process, and performance used across therapeutic settings and national boundaries show there is generalizability in the pattern of clinical dynamics, including the relationships between organizational functioning and quality of services.

Snyder CMJ; Anderson SA. An examination of mandated versus voluntary referral as a determinant of clinical outcome. (review). Journal of Marital and Family Therapy 35(3): 278-292, 2009. (109 refs.)

A literature review was undertaken to examine evidence for the effectiveness of psychotherapy with mandated clients. The primary question addressed was whether or not clients mandated to therapy, whether by court order or by order of their employers, show poorer outcomes than clients who enter therapy voluntarily. To this end, research on client resistance and motivational readiness to change was reviewed. This was followed by an examination of research on the effectiveness of mandated treatment. The question of the potential influence of relationship factors such as the therapeutic alliance was also addressed. The literature review was followed by suggestions for future research on the effectiveness of treatment for clients with mandated or voluntary referral status.

Soyka M; Schmidt P. Outpatient alcoholism treatment: 24-month outcome and predictors of outcome. Substance Abuse Treatment, Prevention and Policy 4(article 15), 2009. (46 refs.)

Objectives: To study the value of demographic and alcohol-related variables for predicting 24-month treatment outcome in an outpatient setting. Methods: Prospective observational study with 92 alcohol-dependent patients. Assessments were made by personal interviews at the beginning and end of therapy, and at the 24-month follow-up. Univariate and logistic regression analyses were performed. Results: The mean age was 46.0 (SD = 9.9) years. There were 58 males (65.2%) and 31 females (34.8%). Of the 67 patients interviewed at 2-year follow-up, 58% were abstinent and 79% improved. Differences between abstainers and non-abstainers were found for number of previous detoxifications, and number of patients attempted suicides. In addition, female gender and a higher number of prior treatments predicted negative treatment outcome. Conclusion: Matching patients to different types of treatment by means of empirically based characteristics may help to improve outcome but research has failed to establish reliable predictors in that area. Data from this follow-up study confirm the role of certain clinical outcome predictors. Additionally, results give further evidence for outpatient treatment as an effective setting for alcohol-dependent patients as indicated by a favourable retention rate (84%) and outcome (minimum abstinence rate 44%).

Spence R; Bohman T; Waters V; Velasquez M; Von Sternberg K; Wallisch L et al. SBIRT outcomes in Houston: Final report on InSight, a hospital district-based program for patients at risk for alcohol or drug use problems. Alcoholism: Clinical and Experimental Research 33(8): 1374-1381, 2009. (26 refs.)

Background: Screening, Brief Intervention, and Referral to Treatment (SBIRT) services have been implemented as the standard of care for patients in the Harris County Hospital District (HCHD). The present analysis addresses alcohol and drug use for patients admitted over a 39-month period from July 1, 2005 through September 30, 2008. Methods: Patients were screened for alcohol and drug use at medical admission. Those who were positive received further assessment and were transitioned to receive services as appropriate. A sample of consenting patients who were positive and received services was contacted at 6 months for a follow-up interview. Using an intent-to-treat (ITT) protocol, the analysis included all patients who were assigned for follow-up, including those with completed follow-ups as well as those who could not be contacted at follow-up. Patients not contacted at follow-up were assumed to have maintained their baseline drug and alcohol consumption levels. Results: Of 59,760 patients who were screened by generalists (primarily nurses, physicians, and medical care technicians), 15,241 (26%) were positive and received further assessment and services. The 6-month follow-up interview completion rate was 66%. The ITT sample consisted of all 1,937 patients who were assigned for follow-up. There was an overall reduction in the number of patients reporting any days of heavy drinking from 70% at intake to 37% at 6-month follow-up and a reduction in the mean number of days of heavy drinking from 7.8 days at intake to 4.1 days at follow-up. The number of patients reporting any days of drug use was 82% at intake versus 33% at follow-up, and the mean number of days of drug use declined from 8.3 days at intake to 4.2 days at follow-up. Conclusions: The results were consistent with but of greater magnitude than most other studies reporting positive outcomes for SBIRT patients. Drug use and heavy alcohol use were found to decrease substantially from admission to follow-up. This finding holds good for all levels of drug or alcohol misuse severity, with the highest severity patients showing the largest decreases. Future studies are needed to control for potential regression to the mean effects and to develop improved understanding of differences in outcomes by race/ethnicity.

Stade BC; Bailey C; Dzendoletas D; Sgro M; Dowswell T; Bennett D. Psychological and/or educational interventions for reducing alcohol consumption in pregnant women and women planning pregnancy. (review). Cochrane Database of Systemic Reviews 2009(2): article CD004228, 2009. (91 refs.)

Background: It is estimated that more than 20% of pregnant women worldwide consume alcohol. Current research suggests that alcohol intake of seven or more standard drinks (one standard drink = 13.6 grams of absolute alcohol) per week during pregnancy places the baby at risk of serious, lifelong developmental and cognitive disabilities. Psychological and educational interventions may help women to reduce their alcohol intake during pregnancy. Objectives: To determine the effectiveness of psychological and educational interventions to reduce alcohol consumption during pregnancy in pregnant women or women planning pregnancy. Search strategy: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (August 2008), CENTRAL (The Cochrane Library 2007, Issue 4), MEDLINE (1966 to November 2007), EMBASE (1980 to November 2007), CINAHL (1982 to November 2007), Counsel. Lit (1980 to November 2007), PsycLIT (1974 to November 2007) and PsycINFO (1967 to November 2007) and checked cited references from retrieved articles. Selection criteria: Randomized controlled trials examining the effectiveness of psychological and educational interventions for reducing consumption of alcohol among pregnant women, or women planning for pregnancy. Data collection and analysis At least two review authors independently extracted information from the results sections of the included studies. Main results: Four studies met the inclusion criteria (715 pregnant women), and reported on at least one of the outcomes of interest. We performed no meta-analyses as the interventions and outcomes measured in the studies were not sufficiently similar. For most outcomes there were no significant differences between groups; and results relating to abstaining or reducing alcohol consumption were mixed. Results from individual studies suggest that interventions may encourage women to abstain from alcohol in pregnancy. There was very little information provided on the effects of interventions on the health of mothers and babies. Authors' conclusions: The evidence from the limited number of studies suggests that psychological and educational interventions may result in increased abstinence from alcohol, and a reduction in alcohol consumption among pregnant women. However, results were not consistent, and the paucity of studies, the number of total participants, the high risk of bias of some of the studies, and the complexity of interventions limits our ability to determine the type of intervention which would be most effective in increasing abstinence from, or reducing the consumption of, alcohol among pregnant women.

Stein LAR; Minugh PA; Longabaugh R; Wirtz P; Baird J; Nirenberg TD et al. Readiness to change as a mediator of the effect of a brief motivational intervention on posttreatment alcohol-related consequences of injured emergency department hazardous drinkers. Psychology of Addictive Behaviors 23(2): 185-195, 2009. (52 refs.)

Brief motivational interventions (BMIs) are usually effective for reducing alcohol use and consequences in primary care settings. We examined readiness to change drinking as a mediator of the effects of BMI on alcohol-related consequences. Participants were randomized into three conditions: (a) standard care plus assessment (SC), (b) SC plus BMI (BI), and (c) BI plus a booster session (BIB). At 12-month follow-tip BIB patients had significantly reduced alcohol consequences more than had SC patients. Patients receiving BI or BIB maintained higher readiness scores 3 months after treatment than did patients receiving SC. However, readiness mediated treatment effects only for those highly motivated to change prior to the intervention but not for those with low pre-intervention motivation. BI and BIB for these patients decreased alcohol consequences in part because they enhanced and maintained readiness for those highly motivated prior to the intervention, but not for those with low motivation. Results are opposite of what would be expected from MI theory. An alternative explanation is offered as to why this finding occurred with this opportunistically recruited Emergency Department patient population.

Sterling S; Chi F; Campbell C; Weisner C. Three-year chemical dependency and mental health treatment outcomes among adolescents: The role of continuing care. Alcoholism: Clinical and Experimental Research 33(8): 1417-1429, 2009. (92 refs.)

Background: Few studies have examined the effects of treatment factors, including the types of services [chemical dependency (CD), psychiatric, or both], on long-term outcomes among adolescents following CD treatment, and whether receiving continuing care may contribute to better outcomes. This study examines the effect of the index CD and ongoing CD and psychiatric treatment episodes, 12-step participation, and individual characteristics such as CD and mental health (MH) severity and gender, age, and ethnicity, on 3-year CD and MH outcomes. Methods: Participants were 296 adolescents aged 13 to 18 seeking treatment at 4 CD programs of a nonprofit, managed care, integrated health system. We surveyed participants at intake, 1 year, and 3 years, and examined survey and administrative data, and CD and psychiatric utilization. Results: At 3 years, 29.7% of the sample reported total abstinence from both alcohol and drugs (excluding tobacco). Compared with girls, boys had only half the odds of being abstinent (OR = 0.46, p = 0.0204). Gender also predicted Externalizing severity at 3 years (coefficients 18.42 vs. 14.77, p < 0.01). CD treatment readmission in the second and third follow-up years was related to abstinence at 3 years (OR = 0.24, p = 0.0066 and OR = 3.33, p = 0.0207, respectively). Abstinence at 1 year predicted abstinence at 3 years (OR = 4.11, p < 0.0001). Those who were abstinent at 1 year also had better MH outcomes (both lower Internalizing and Externalizing scores) than those who were not (11.75 vs. 15.55, p = 0.0012 and 15.13 vs. 18.06, p = 0.0179, respectively). Conclusions: A CD treatment episode resulting in good 1-year CD outcomes may contribute significantly to both CD and MH outcomes 3 years later. The findings also point to the value of providing a continuing care model of treatment for adolescents.

Terplan M; Garrett J; Hartmann K. Gestational age at enrollment and continued substance use among pregnant women in drug treatment. Journal of Addictive Diseases 28(2): 103-112, 2009. (46 refs.)

Substance use during pregnancy is associated with poor obstetrical and neonatal outcomes. Although intervention for substance use including alcohol improves pregnancy outcomes, a substantial number of women continue to use drugs or consume alcohol during treatment. To determine whether gestational age at entry into treatment (specifically first trimester enrollment) was associated with lower risk of continued substance use, we analyzed the North Carolina Treatment Outcomes and Program Performance System, an administrative database of drug treatment clinics, between 2000 and 2004. There were 847 pregnant women using substances who met our inclusion criteria. Demographic and other risk factor data were collected. We conducted logistic regression and a Generalized Estimating Equation analysis. Gestational age at enrollment was not associated with continued substance use (odds ratio [OR] = 0.88; 95% confidence interval [CI] = 0.51, 1.51). Women who had child care provided, were less likely to continue substance use (OR = 0.64; 95% CI = 0.48, 0.84), whereas those referred from the criminal justice system were more likely to continue (OR = 1.53; 95% CI = 1.01, 2.30). Although earlier gestational age at enrollment in treatment does not predict greater abstinence at any time point, this data does suggest that the provision of childcare may improve treatment success.

Tikkanen R; Sjoberg RL; Ducci F; Goldman D; Holi M; Tiihonen J; Virkkunen M. Effects of MAOA-genotype, alcohol consumption, and aging on violent behavior. Alcoholism: Clinical and Experimental Research 33(3): 428-434, 2009. (75 refs.)

Environmental factors appear to interact with a functional polymorphism (MAOA-LPR) in the promoter region of the monoamine oxidase A gene (MAOA) in determining some forms of antisocial behavior. However, how MAOA-LPR modulates the effects of other factors such as alcohol consumption related to antisocial behavior is not completely understood. This study examines the conjunct effect of MAOA-LPR, alcohol consumption, and aging on the risk for violent behavior. Recidivism in severe impulsive violent behavior was assessed after 7 to 15 years in a sample of 174 Finnish alcoholic offenders, the majority of whom exhibited antisocial or borderline personality disorder or both, and featured impulsive temperament traits. The risk for committing new acts of violence increased by 2.3% for each kilogram of increase in yearly mean alcohol consumption (p = 0.004) and decreased by 7.3% for every year among offenders carrying the high activity MAOA genotype. In contrast, alcohol consumption and aging failed to affect violent behavior in the low activity MAOA genotyped offenders. MAOA-LPR showed no main effect on the risk for recidivistic violence. Violent offenders carrying the high activity MAOA genotype differ in several ways from carriers with the low activity MAOA risk allele previously associated with antisocial behavior. Finnish high activity MAOA genotyped risk alcoholics exhibiting antisocial behavior, high alcohol consumption, and abnormal alcohol-related impulsive and uncontrolled violence might represent an etiologically distinct alcohol dependence subtype.

Ting L; Jordan-Green L; Murphy CM; Pitts SC. Substance use problems, treatment engagement, and outcomes in partner violent men. Research on Social Work Practice 19(4): 395-406, 2009. (58 refs.)

Objectives: This study examined predictive associations of substance abuse with treatment engagement variables and partner abuse outcomes and explored the extent to which treatment engagement and ongoing alcohol consumption mediated the association between pretreatment substance use and posttreatment abuse. Method: Data were collected from 145 partner abusive men in treatment and partners using standardized measures of violence, alcohol and drug use at baseline, posttreatment, and follow-up assessments. Results: Men who screened positive for alcohol or drug problems at baseline had significantly lower treatment engagement and higher self-reports of partner abuse before and during treatment. Partial support was found for the mediation model. Conclusions: The implications for social work practitioners who work in interdisciplinary settings with intimate partner violence perpetrators and survivors are discussed.

Toneatto T; Brands B; Selby P. A randomized, double-blind, placebo-controlled trial of naltrexone in the treatment of concurrent alcohol use disorder and pathological gambling. American Journal on Addictions 18(3): 219-225, 2009. (26 refs.)

The efficacy of naltrexone as a treatment for concurrent alcohol abuse or dependence and pathological gambling was evaluated in a randomized, double-blind, placebo-controlled trial. Fifty-two, mostly male, subjects were recruited from the community and received 11 weeks of medication during which cognitive-behavioral counseling was also provided. No significant group differences were found on any alcohol or gambling variable (ie, frequency, quantity, expenditures) at post-treatment or at the one year follow-up. However, a strong time effect was found suggesting that treatment, in general, was effective. The use of naltrexone to treat concurrent alcohol use and gambling problems was not supported.

Tucker JA; Roth DL; Vignolo MJ; Westfall AO. A behavioral economic reward index predicts drinking resolutions: Moderation revisited and compared with other outcomes. Journal of Consulting and Clinical Psychology 77(2): 219-228, 2009. (42 refs.)

Data were pooled from 3 studies of recently resolved community-dwelling problem drinkers to determine whether a behavioral economic index of the value of rewards available over different time horizons distinguished among moderation (n = 30), abstinent (n = 95), and unresolved (n = 77) outcomes. Moderation over 1- to 2-year prospective follow-up intervals was hypothesized to involve longer term behavior regulation processes than abstinence or relapse and to be predicted by more balanced preresolution monetary allocations between short-term and longer term objectives (i.e., drinking and saving for the future). Standardized odds ratios (ORs) based on changes in standard deviation units from a multinomial logistic regression indicated that increases on this "Alcohol-Savings Discretionary Expenditure" index predicted higher rates of abstinence (OR = 1.93, p = .004) and relapse (OR = 2.89, p < .0001) compared with moderation outcomes. The index had incremental utility in predicting moderation in complex models that included other established predictors. The study adds to evidence supporting a behavioral economic analysis of drinking resolutions and shows that a systematic analysis of preresolution spending patterns aids in predicting moderation.

Udo T; Clifford PR; Davis CM; Maisto SA. Alcohol use post AUD treatment initiation as a predictor of later functioning. American Journal of Drug and Alcohol Abuse 35(3): 128-132, 2009. (20 refs.)

Objective: To replicate and extend the earlier work of Maisto and colleagues showing an association between early post-treatment alcohol use and later functioning (1, 2, 3). Methods: The present study classified adults presenting for alcohol use disorders (AUD) treatment (n = 114) into one of three drinker groups (i.e., abstainer, moderate drinker, or heavy drinker) based upon alcohol use during the first 6-months following outpatient AUD treatment initiation, and examined the associations between drinker group classification and later alcohol use and psychosocial functioning. Results: Study results showed that individuals classified within the heavy drinker group tended to have the poorest outcomes (i.e., greater alcohol use and poorer psychosocial functioning) relative to individuals classified within the abstainer or moderate drinker groups. Conclusions: Study findings are consistent with the prior work of Maisto and colleagues. In addition, it appears that alcohol use, particularly heavy alcohol consumption, during the early post-treatment initiation period may serve as a marker for later alcohol related problems and poorer overall psychosocial functioning.

Walitzer KS; Dermen KH; Barrick C. Facilitating involvement in Alcoholics Anonymous during out-patient treatment: a randomized clinical trial. Addiction 104(3): 391-401, 2009. (37 refs.)

This study evaluated two strategies to facilitate involvement in Alcoholics Anonymous (AA)-a 12-Step-based directive approach and a motivational enhancement approach-during skills-focused individual treatment. Randomized controlled trial with assessments at baseline, end of treatment and 3, 6, 9 and 12 months after treatment. A total of 169 alcoholic out-patients (57 women) assigned randomly to one of three conditions: a directive approach to facilitating AA, a motivational enhancement approach to facilitating AA or treatment as usual, with no special emphasis on AA. Self-report of AA meeting attendance and involvement, alcohol consumption (percentage of days abstinent, percentage of days heavy drinking) and negative alcohol consequences. Participants exposed to the 12-Step directive condition for facilitating AA involvement reported more AA meeting attendance, more evidence of active involvement in AA and a higher percentage of days abstinent relative to participants in the treatment-as-usual comparison group. Evidence also suggested that the effect of the directive strategy on abstinent days was mediated partially through AA involvement. The motivational enhancement approach to facilitating AA had no effect on outcome measures. These results suggest that treatment providers can use a 12-Step-based directive approach to effectively facilitate involvement in AA and thereby improve client outcome.

Wartberg L; Sack PM; Thoms E; Moller C; Stolle M; Thomasius R. Inpatient child and adolescent psychiatry and psychotherapy for substance-addicted boys and girls. Results of a follow-up study. (German). Psychotherapeut 54(3): 193-198, 2009. (24 refs.)

This study examines post-treatment out-comes (6 and 12 months post-release) of a multimodal child and adolescent psychiatric and psychotherapeutic inpatient treatment program for boys and girls diagnosed with substance use disorders (n=71) in 2 centres. Up to now there has been a lack of outcome research in this field of Germany. Outcome measures included drug use patterns and psychopathology. The greatest reduction in prevalence at 1 year follow-up occurred for cannabis, methamphetamine, cocaine and heroin use. Additionally the patients and their parents also reported significant improvements in adolescent's psychopathology at the 1 year follow-up. The results underline the importance of disorder-specific, multimodal inpatient programs for the treatment of children and adolescents with substance use disorders.

Webb G; Shakeshaft A; Sanson-Fisher R; Havard A. A systematic review of work-place interventions for alcohol-related problems. (review). Addiction 104(3): 365-377, 2009. (28 refs.)

The aims of this study were to (1) gauge any improvement in methodological quality of work-place interventions addressing alcohol problems; and (2) to determine which interventions most effectively reduce work-place-related alcohol problems. A literature search was undertaken of the data bases, Ovid Medline, PsychINFO, Web of Science, Scopus, HSELINE, OSHLINE and NIOSHTIC-2 for papers published between January 1995 and September 2007 (inclusive). Search terms varied, depending on the database. Papers were included for analysis if they reported on interventions conducted at work-places with the aim of reducing alcohol problems. Methodological adequacy of the studies was assessed using a method derived from the Cochrane Collaboration guidelines. Ten papers reporting on work-place alcohol interventions were located. Only four studies employed randomized controlled trials (RCT), but all these had methodological problems. Weaknesses in all studies related to representativeness of samples, consent and participation rates, blinding, post-test time-frames, contamination and reliability, and validity of measures used. All except one study reported statistically significant differences in measures such as reduced alcohol consumption, binge drinking and alcohol problems. The literature review revealed few methodologically adequate studies of work-place alcohol interventions. Study designs, types of interventions, measures employed and types of work-places varied considerably, making comparison of results difficult. However, it appears from the evidence that brief interventions, interventions contained within health and life-style checks, psychosocial skills training and peer referral have potential to produce beneficial results.

Weisner C; Lu Y; Hinman A; Monahan J; Bonnie RJ; Moore CD et al. Substance use, symptom, and employment outcomes of persons with a workplace mandate for chemical dependency treatment. Psychiatric Services 60(5): 646-654, 2009. (42 refs.)

Objective: This study examined the role of workplace mandates to chemical dependency treatment in treatment adherence, alcohol and drug abstinence, severity of employment problems, and severity of psychiatric problems. Methods: The sample included 448 employed members of a private, nonprofit U. S. managed care health plan who entered chemical dependency treatment with a workplace mandate (N=75) or without one (N=373); 405 of these individuals were followed up at one year (N=70 and N=335, respectively), and 362 participated in a five-year follow up (N=60 and N=302, respectively). Propensity scores predicting receipt of a workplace mandate were calculated. Logistic regression and ordinary least-squares regression were used to predict length of stay in chemical dependency treatment, alcohol and drug abstinence, and psychiatric and employment problem severity at one and five years. Results: Overall, participants with a workplace mandate had one- and five-year outcomes similar to those without such a mandate. Having a workplace mandate also predicted longer treatment stays and improvement in employment problems. When other factors related to outcomes were controlled for, having a workplace mandate predicted abstinence at one year, with length of stay as a mediating variable. Conclusions: Workplace mandates can be an effective mechanism for improving work performance and other outcomes. Study participants who had a workplace mandate were more likely than those who did not have a workplace mandate to be abstinent at follow-up, and they did as well in treatment, both short and long term. Pressure from the workplace likely gets people to treatment earlier and provides incentives for treatment adherence.

Wojnar M; Brower KJ; Strobbe S; Ilgen M; Matsumoto H; Nowosad I. Association between Val66Met brain-derived neurotrophic factor (BDNF) gene polymorphism and post-treatment relapse in alcohol dependence. Alcoholism: Clinical and Experimental Research 33(4): 693-702, 2009. (86 refs.)

The purpose of this study was to examine relationships between genetic markers of central serotonin (5-HT) and dopamine function, and risk for post-treatment relapse, in a sample of alcohol-dependent patients. The study included 154 patients from addiction treatment programs in Poland, who met DSM-IV criteria for alcohol dependence. After assessing demographics, severity of alcohol use, suicidality, impulsivity, depression, hopelessness, and severity of alcohol use at baseline, patients were followed for approximately 1 year to evaluate treatment outcomes. Genetic polymorphisms in several genes (TPH2, SLC6A4, HTR1A, HTR2A, COMT, and BDNF) were tested as predictors of relapse (defined as any drinking during follow-up) while controlling for baseline measures. Of 154 eligible patients, 123 (80%) completed follow-up and 48% (n = 59) of these individuals relapsed. Patients with the Val allele in the Val66Met BDNF polymorphism and the Met allele in the Val158Met COMT polymorphism were more likely to relapse. Only the BDNF Val/Val genotype predicted post-treatment relapse [odds ratio (OR) = 2.62; p = 0.019], and time to relapse (OR = 2.57; p = 0.002), after adjusting for baseline measures and other significant genetic markers. When the analysis was restricted to patients with a family history of alcohol dependence (n = 73), the associations between the BDNF Val/Val genotype and relapse (OR = 5.76, p = 0.0045) and time to relapse (hazard ratio = 4.93, p = 0.001) were even stronger. The Val66Met BDNF gene polymorphism was associated with a higher risk and earlier occurrence of relapse among patients treated for alcohol dependence. The study suggests a relationship between genetic markers and treatment outcomes in alcohol dependence. Because a large number of statistical tests were conducted for this study and the literature on genetics and relapse is so novel, the results should be considered as hypothesis generating and need to be replicated in independent studies.

Ye Y; Kaskutas LA. Using propensity scores to adjust for selection bias when assessing the effectiveness of Alcoholics Anonymous in observational studies. Drug and Alcohol Dependence 104(1-2): 56-64, 2009. (60 refs.)

Background: The effectiveness of Alcoholics Anonymous (AA) is difficult to establish. Observational studies consistently find strong dose-response relationships between AA meeting attendance and abstinence, and the only experimental studies favoring AA have been of 12-step facilitation treatment rather than of AA per se. Pending future randomized trials, this paper uses propensity score (PS) method to address the selection bias that potentially confounds the effect of AA in observational studies. Method: The study followed a treatment sample for 1 year to assess post-treatment AA attendance and abstinence (n = 569). Propensity scores were constructed based on known confounders including motivation, problem severity, and prior help-seeking. AA attendance during the 12-month follow-up period was studied as a predictor of alcohol abstinence for 30 days prior to the follow-up interview. PS stratification and PS matching techniques were used to adjust for the self-select bias associated with respondents' propensity to attend AA. Results: The overall advantage in abstinence initially observed narrowed when adjusted. The odds ratio associated with AA attendance reduced from 3.6 to 3.0 after PS stratification and 2.6 after PS matching to AA-attenders. Support for AA effectiveness was strengthened in the quintile with lower propensity scores and when AA-nonattenders were matched as the target group, but was weakened among those in the higher PS quintiles and when matching to AA-attenders. Discussion: These results confirm the robustness of AA effectiveness overall, because the results for higher abstinence associated with AA attendance following propensity score adjustment remained significant, and the reduction in the magnitude of AA's effect was moderate. However, the effect modification by propensity scores in both PS stratification and PS matching approaches seems to suggest that AA may be most helpful, or matter more, for those with a lower propensity to attend AA. Conversely, for those with a high propensity to go to AA (operationalized as higher motivation, greater problem severity, more prior AA and treatment exposure, etc.), attending AA may not make as much of a difference. It will be important that future studies replicate our results, as this is the first paper to use propensity score adjustment in this context.

Ziedonis DM; Amass L; Steinberg M; Woody G; Krejci J; Annon JJ et al. Predictors of outcome for short-term medically supervised opioid withdrawal during a randomized, multicenter trial of buprenorphine-naloxone and clonidine in the NIDA clinical trials network drug and alcohol dependence. Drug and Alcohol Dependence 99(1-3): 28-36, 2009. (37 refs.)

Few studies in community settings have evaluated predictors, mediators, and moderators of treatment success for medically supervised opioid withdrawal treatment. This report presents new findings about these factors from a study of 344 opioid-dependent men and women prospectively randomized to either buprenorphine-naloxone or clonidine in an open-label 13-day medically Supervised withdrawal study. Subjects were either inpatient or Outpatient in Community treatment settings, however not randomized by treatment setting. Medication type (buprenorphine-naloxone versus clonidine) was the single best predictor of treatment retention and treatment success, regardless of treatment setting. Compared to the outpatient setting, the inpatient setting was associated with higher abstinence rates but similar retention rates when adjusting for medication type. Early opioid withdrawal severity mediated the relationship between medication type and treatment outcome with buprenorphine-naloxone being Superior to clonidine at relieving early withdrawal symptoms. Inpatient subjects on clonidine with lower withdrawal scores at baseline did better than those with higher withdrawal scores; inpatient subjects receiving buprenorphine-naloxone did better with higher withdrawal scores at baseline than those with lower withdrawal scores. No relationship was found between treatment outcome and age, gender, race, education. employment, marital status, legal problems, baseline depression, or length/severity of drug use. Tobacco use was associated with worse opioid treatment outcomes. Severe baseline anxiety symptoms doubled treatment Success. Medication type (buprenorphine-naloxone) was the most important predictor of positive outcome; however the paper also considers other clinical and policy implications of other results, including that inpatient setting predicted better outcomes and moderated medication outcomes.