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CORK Bibliography: Treatment Outcome, Drugs

86 citations. January 2008 to present

Prepared: September 2008

Amato L; Minozzi S; Davoli M; Vecchi S; Ferri MMF; Mayet S. Psychosocial and pharmacological treatments versus pharmacological treatments for opioid detoxification. (review). Cochrane Database of Systematic Reviews 3(article AR CD005031), 2008. (71 refs.)

Background: Different pharmacological approaches aimed at opioid detoxification are effective. Nevertheless a majority of patients relapse to heroin use, and relapses are a substantial problem in the rehabilitation of heroin users. Some studies have suggested that the sorts of symptoms which are most distressing to addicts during detoxification are psychological rather than physiological symptoms associated with the withdrawal syndrome. Objectives: To evaluate the effectiveness of any psychosocial plus any pharmacological interventions versus any pharmacological alone for opioid detoxification, in helping patients to complete the treatment, reduce the use of substances and improve health and social status. Search strategy: We searched the Cochrane Drugs and Alcohol Group trials register (27 February 2008). Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2008), PUBMED (1996 to February 2008); EMBASE (January 1980 to February 2008); CINAHL (January 2003-February 2008); PsycINFO (1985 to April 2003) and reference list of articles. Selection criteria: Randomised controlled trials which focus on any psychosocial associated with any pharmacological intervention aimed at opioid detoxification. People less than 18 years of age and pregnant women were excluded. Data collection and analysis Three reviewers independently assessed trials quality and extracted data. Main results: Nine studies involving people were included. These studies considered five different psychosocial interventions and two substitution detoxification treatments: Methadone and Buprenorphine. The results show promising benefit from adding any psychosocial treatment to any substitution detoxification treatment in terms of completion of treatment relative risk (RR) 1.68 (95% confidence interval (CI) 1.11 to 2.55), use of opiate RR 0.82 (95% CI 0.71 to 0.93), results at follow-up RR 2.43 (95% CI 1.61 to 3.66), and compliance RR 0.48 (95% CI 0.38 to 0.59). Authors' conclusions: Psychosocial treatments offered in addition to pharmacological detoxification treatments are effective in terms of completion of treatment, use of opiate, results at follow-up and compliance. Although a treatment, like detoxification, that exclusively attenuates the severity of opiate withdrawal symptoms can be at best partially effective for a chronic relapsing disorder like opiate dependence, this type of treatment is an essential step prior to longer-term drug-free treatment and it is desirable to develop adjunct psychosocial approaches that might make detoxification more effective. Limitations to this review are imposed by the heterogeneity of the assessment of outcomes. Because of lack of detailed information no meta analysis could be performed to analyse the results related to several outcomes.

Ames SC; Croghan IT; Clark MM; Patten CA; Stevens SR; Schroeder DR et al. Change in perceived stress, partner support, decisional balance, and self-efficacy following residential nicotine dependence treatment. Journal of Addictive Diseases 27(1): 73-82, 2008. (35 refs.)

The primary aim was to examine the effect of an eight day residential treatment for nicotine dependence on perceived stress, partner support, decisional balance, and self-efficacy for stopping smoking. Whether these variables predicted six months post treatment abstinence following residential treatment was also examined. Participants included 170 adult cigarette smokers. Perceived stress, partner support, decisional balance, and self-efficacy for stopping smoking were assessed on the first and last day of treatment. In addition, six month continuous tobacco abstinence was evaluated. Residential treatment was: found to produce significant (p < 0.001) treatment changes in all psychosocial factors except one aspect of decisional balance (i.e., cons of smoking). Psychosocial factors did not predict six month tobacco abstinence. Only age (p = 0.014) and history of mental illness (p = 0.012) were found to predict six month continuous abstinence following residential treatment. This study provides new information about how residential treatment impacts psychosocial factors considered to be important predictors of tobacco abstinence in outpatient settings.

Aubin HJ; Bobak A; Britton JR; Oncken C; Billing CB; Gong J et al. Varenicline versus transdermal nicotine patch for smoking cessation: results from a randomised open-label trial. Thorax 63(8): 717-724, 2008. (31 refs.)

Background: Varenicline, a new treatment for smoking cessation, has demonstrated significantly greater efficacy over placebo and sustained release bupropion ( bupropion SR). A study was undertaken to compare a 12-week standard regimen of varenicline with a 10-week standard regimen of transdermal nicotine replacement therapy (NRT) for smoking cessation. Methods: In this 52-week, open-label, randomised, multicentre, phase 3 trial conducted in Belgium, France, the Netherlands, UK and USA, participants were randomly assigned (1:1) to receive varenicline uptitrated to 1 mg twice daily for 12 weeks or transdermal NRT (21 mg/day reducing to 7 mg/day) for 10 weeks. Non-treatment follow-up continued to week 52. The primary outcome was the biochemically confirmed (exhaled carbon monoxide (<= 10 ppm) self-reported continuous abstinence rate (CAR) for the last 4 weeks of the treatment period in participants who had taken at least one dose of treatment. Secondary outcomes included CAR from the last 4 weeks of treatment through weeks 24 and 52, and measures of craving, withdrawal and smoking satisfaction. Results: A total of 376 and 370 participants assigned to varenicline and NRT, respectively, were eligible for analysis. The CAR for the last 4 weeks of treatment was significantly greater for varenicline (55.9%) than NRT (43.2%; OR 1.70, 95% CI 1.26 to 2.28, p < 0.001). The week 52 CAR (NRT, weeks 8-52; varenicline, weeks 9-52) was 26.1% for varenicline and 20.3% for NRT (OR 1.40, 95% CI 0.99 to 1.99, p = 0.056). Varenicline significantly reduced craving (p < 0.001), withdrawal symptoms (p < 0.001) and smoking satisfaction (p < 0.001) compared with NRT. The most frequent adverse event was nausea (varenicline, 37.2%; NRT, 9.7%). Conclusions: The outcomes of this trial established that abstinence from smoking was greater and craving, withdrawal symptoms and smoking satisfaction were less at the end of treatment with varenicline than with transdermal NRT.

Babor TF. Regression to the mean: elephant in the living room or the delusions of a Swedish student 'out bicycling'? (editorial). Addiction 103(1): 4-5, 2008. (6 refs.)

Blalock JA; Robinson JD; Wetter DW; Schreindorfer LS; Cinciripini PM. Nicotine withdrawal in smokers with current depressive disorders undergoing intensive smoking cessation treatment. Psychology of Addictive Behaviors 22(1): 122-128, 2008. (35 refs.)

The authors investigated withdrawal in smokers with current threshold and subthreshold depressive disorders (N = 21) who were participating in a pilot study of intensive counseling interventions for smoking cessation. The majority of participants (67%) were taking antidepressants when they entered the trial. Withdrawal symptoms were compared in prolonged abstainers versus nonabstainers across a 12-week treatment period and at the 3-month follow-up assessment visit. Prolonged abstinence was associated with an increase in positive affect and a decrease in depressive symptoms and craving over time. Nonabstinence was associated with little overall change in these variables from treatment onset to the 3-month follow-up. At the 3-month follow-up, 44% of prolonged abstainers were in complete remission of their baseline depressive disorders, compared with 0% remission among nonabstainers. Findings suggest that within the context of an intensive smoking cessation intervention, some smokers with current depressive disorders may experience significant improvement in affective and craving symptoms. Findings also suggest that abstinence may be associated with improvement in affect.

Brands B; Blake J; Marsh DC; Sproule B; Jeyapalan R; Li S. The impact of benzodiazepine use on methadone maintenance treatment outcomes. Journal of Addictive Diseases 27(3): 37-48, 2008. (31 refs.)

The purposes of this study were to examine predictors of benzodiazepine use among methadone maintenance treatment patients, to determine whether baseline benzodiazepine use influenced ongoing use during methadone maintenance treatment, and to assess the effect of ongoing benzodiazepine use on treatment outcomes (i.e., opioid and cocaine use and treatment retention). A retrospective chart review of 172 methadone maintenance treatment patients (mean age = 34.6 years; standard deviation = 8.5 years; 64% male) from January 1997 to December 1999 was conducted. At baseline, 29% were "non-users" (past year) of benzodiazepine, 36% were "occasional users," and 35% were "regular/problem users." Regular/problem users were more likely to have started opioid use with prescription opioids, experienced more overdoses, and reported psychiatric comorbidity. Being female, more years of opioid use, and a history of psychiatric treatment were significant predictors of baseline benzodiazepine use. Ongoing benzodiazepine users were more likely to have opioid-positive and cocaine-positive urine screens during methadone maintenance treatment. Only ongoing cocaine use was negatively related to retention. Benzodiazepine use by methadone maintenance treatment patients is associated with a more complex clinical picture and may negatively influence treatment outcomes.

Brown CH; Wang W; Kellam SG; Muthen BO; Petras H; Toyinbo P et al. Methods for testing theory and evaluating impact in randomized field trials: Intent-to-treat analyses for integrating the perspectives of person, place, and time. (review). Drug and Alcohol Dependence 95(Supplement 1): S74-S104, 2008. (148 refs.)

Randomized field trials provide unique opportunities to examine the effectiveness of an intervention in real world settings and to test and extend both theory of etiology and theory of intervention. These trials are designed not only to test for overall intervention impact but also to examine how impact varies as a function of individual level characteristics, context, and across time. Examination of such variation in impact requires analytical methods that take into account the trial's multiple nested structure and the evolving changes in outcomes over time. The models that we describe here merge multilevel modeling with growth modeling, allowing for variation in impact to be represented through discrete mixtures-growth mixture models-and nonparametric smooth functions-generalized additive mixed models. These methods are part of an emerging class of multilevel growth mixture models, and we illustrate these with models that examine overall impact and variation in impact. In this paper, we define intent-to-treat analyses in group-randomized multilevel field trials and discuss appropriate ways to identify, examine, and test for variation in impact without inflating the Type I error rate. We describe how to make causal inferences more robust to misspecification of covariates in such analyses and how to summarize and present these interactive intervention effects clearly. Practical strategies for reducing model complexity, checking model fit, and handling missing data are discussed using six randomized field trials to show how these methods may be used across trials randomized at different levels.

Cacciola JS; Camilleri AC; Carise D; Rikoon SH; Mckay JR; McLellan AT et al. Extending residential care through telephone counseling: Initial results from the Betty Ford Center Focused Continuing Care protocol. Addictive Behaviors 33(9): 1208-1216, 2008. (30 refs.)

There is increasing evidence that a chronic care model may be effective when treating substance use disorders. In 1996, the Betty Ford Center (BFC) began implementing a telephone-based continuing care intervention now called Focused Continuing Care (FCC) to assist and support patients in their transition from residential treatment to longer-term recovery in the "real world". This article reports on patient utilization and outcomes of FCC. FCC staff placed clinically directed telephone calls to patients (N=4094) throughout the first year after discharge. During each call, a short survey was administered to gauge patient recovery and guide the session. Patients completed an average of 5.5 (40%) of 14 scheduled calls, 58% completed 5 or more calls, and 85% were participating in FCC two months post-discharge or later. There was preliminary evidence that greater participation in FCC yielded more positive outcomes and that early post-discharge behaviors predict subsequent outcomes. FCC appears to be a feasible therapeutic option. Efforts to revise FCC to enhance its clinical and administrative value are described.

Carballo JL; Fernandez-Hermida JR; Sobell LC; Dum M; Secades-Villa R; Garcia-Rodriguez O et al. Differences among substance abusers in Spain who recovered with treatment or on their own. Addictive Behaviors 33(1): 94-105, 2008. (48 refs.)

This exploratory study compared the differences among substance abusers in Spain who recovered with treatment or on their own. Advertisements were used to recruit 58 individuals (29 self-changers and 29 treatment-changers) who had had problems with alcohol or drugs, and who had been recovered for at least one year. The groups differed significantly in severity of dependence, psychiatric treatment prior to recovery, and coping strategies to maintain recovery. Consistent with previous studies, those who had recovered through treatment had a more serious substance use history than those who changed on their own. In addition, social support was associated with maintenance of change for both groups. These findings parallel those for English-speaking populations.

Carmody TP; Duncan C; Simon JA; Solkowitz S; Huggins J; Lee S; Delucchi K. Hypnosis for smoking cessation: A randomized trial. Nicotine & Tobacco Research 10(5): 811-818, 2008. (27 refs.)

The purpose of this study was to determine whether hypnosis would be more effective in helping smokers quit than standard behavioral counseling when both interventions are combined with nicotine patches (NP). A total of 286 current smokers were enrolled in a randomized controlled smoking cessation trial at the San Francisco Veterans Affairs Medical Center. Participants in both treatment conditions were seen for two 60-min sessions, and received three follow-up phone calls and 2 months of NP. At 6 months, 29% of the hypnosis group reported 7-day point-prevalence abstinence compared with 23% of the behavioral counseling group (relative risk [RR]=1.27; 95% confidence interval, CI 0.84-1.92). Based on biochemical or proxy confirmation, 26% of the participants in the hypnosis group were abstinent at 6 months compared with 18% of the behavioral group (RR = 1.44; 95% CI 0.91-2.30). At 12 months, the self-reported 7-day point-prevalence quit rate was 24% for the hypnosis group and 16% for the behavioral group (RR = 1.47; 95% CI 0.90-2.40). Based on biochemical or proxy confirmation, 20% of the participants in the hypnosis group were abstinent at 12 months compared with 14% of the behavioral group (RR=1.40; 95% CI 0.81-2.42). Among participants with a history of depression, hypnosis yielded significantly higher validated point-prevalence quit rates at 6 and 12 months than standard treatment. It was concluded that hypnosis combined with NP compares favorably with standard behavioral counseling in generating long-term quit rates.

Chawarski MC; Mazlan M; Schottenfeld RS. Behavioral drug and HIV risk reduction counseling (BDRC) with abstinence-contingent take-home buprenorphine: A pilot randomized clinical trial. Drug and Alcohol Dependence 94(1/3): 281-284, 2008. (20 refs.)

This pilot randomized clinical trial evaluated whether the efficacy of office-based buprenorphine maintenance treatment (BMT), provided with limited counseling or oversight of medication adherence is improved by the addition of individual drug counseling and abstinence-contingent take-home doses of buprenorphine. After a 2-week buprenorphine and stabilization period, heroin dependent individuals (n = 24) in Muar, Malaysia were randomly assigned to Standard Services BMT (physician administered advice and support, and weekly, non-contingent medication pick-up) or Enhanced Services (nurse-delivered manual-guided behavioral drug and HIV risk reduction counseling (BDRC) and abstinence-contingent take-home buprenorphine (ACB), 7 day supply maximum). Outcomes included retention, proportion of opioid-negative urine tests, self-reported drug use, and self-reported HIV risk behaviors. 12/12 (100%) of Enhanced Services and 11/12 (92%) of Standard Services participants completed the entire protocol. The proportion of opioid-negative urine tests increased significantly over time for both groups (p < 0.001), and the reductions were significantly greater in the Enhanced Services group (p < 0.05); Enhanced Services group achieved higher overall proportions of opiate negative urine toxicology tests (87% vs. 69%, p = 0.04) and longer periods of consecutive abstinence from opiates (10.3 weeks vs. 7.8 weeks, p = 0.154). Both groups significantly reduced HIV risk behaviors during treatment (p < 0.05), but the difference between Enhanced and Standard Services (26% vs. 17% reductions from the baseline levels, respectively) was not statistically significant (p = 0.9). Manual-guided behavioral drug and HIV risk reduction counseling and abstinence-contingent take-home buprenorphine appear promising for adding to the efficacy of office-based BMT provided with limited drug counseling and medication oversight.

Chi FW; Weisner CM. Nine-year psychiatric trajectories and substance use outcomes - An application of the group-based modeling approach. Evaluation Review 32(1): 39-58, 2008. (48 refs.)

This study identifies longitudinal psychiatric trajectories of 934 adult individuals entering chemical dependency treatment in a private, managed care health plan and examines the relationship of these trajectories with substance use (SU) outcomes. The authors apply a group-based modeling approach to identify trajectory groups based on repeated measures of psychiatric severity for 9 years and identify four distinct groups. Results of multivariate logistic generalized estimating equation models find an association between psychiatric trajectories and long-term SU. Older cohorts and life course measures of marital status and employment status as individuals changed over time are related to drug and some alcohol outcomes.

Clark C; Young MS; Jackson E; Graeber C; Mazelis R; Kammerer N et al. Consumer perceptions of integrated trauma-informed services among women with co-occurring disorders. Journal of Behavioral Health Services & Research 35(1): 71-90, 2008. (48 refs.)

As part of a national, multi-site treatment outcome study, an instrument was designed to assess consumers' perceptions of key services integrating trauma, mental health, and substance abuse issues, the Consumer Perceptions of Care (CPC). This study evaluates the psychometric properties of this instrument and analyzes consumers' perceptions of the services they received. The results suggest that the measure has four factors: services integration, choice in services, trauma-informed assessment, and respect for cultural identity. These factors demonstrated adequate reliability, and the overall results suggested that the measure is a reliable, sensitive, and valid reflection of consumers' perceptions of their services and their providers for diverse racial and ethnic groups. Women in the intervention programs perceived their services as more highly integrated for trauma, mental health, and substance use than women in the services as usual or comparison programs, supporting its utility as a measure of programs designed to provide integrated services.

Cropley M; Theadom A; Pravettoni G; Webb G. The effectiveness of smoking cessation interventions prior to surgery: A systematic review. Nicotine & Tobacco Research 10(3): 407-412, 2008. (17 refs.)

The objective of this review was to evaluate the effectiveness of smoking cessation interventions prior to surgery and examine smoking cessation rates at 6 months follow-up. The Cochrane Library Database, PsycINFO, EMBASE, Medline, and Cinahl databases were searched using the terms: smok$, smoking cessation, tobacco, cigar$, preop$, operati$, surg$, randomi*ed control$ trial, intervention, program$, cessation, abstinen$, quit. Further articles were obtained from reference lists. The search was limited to articles on adults, written in English and published up to December 2006. Only randomized control trials (RCTs) that incorporated smoking cessation interventions to patients awaiting elective surgery were included. Seven studies met the inclusion criteria. Methodological quality was assessed by all the authors. The findings revealed that short-term quit rates (or a reduction by more than half of normal daily rate) ranged from 18% to 93% in patients receiving a smoking intervention (mean 55%), compared with a range of 2%-65% of controls (mean=27.7%). Two studies examined smoking status at 6 months but these revealed no significant difference in abstinence rates between patients who had received an intervention and those that had not. Studies that incorporated counseling in addition to nicotine replacement therapy appeared to show greater benefits. It is concluded that smoking cessation interventions prior to surgery are effective in helping patients to quit smoking. However, such effects appear to be short-lived. Future research needs to examine intervention and patient factors to see whether tailoring the smoking cessation intervention specifically to the patient improves overall abstinence rates.

D'Amico E; Miles JNV; Stern SA; Meredith LS. Brief motivational interviewing for teens at risk of substance use consequences: A randomized pilot study in a primary care clinic. Journal of Substance Abuse Treatment 35(1): 53-61, 2008. (31 refs.)

The current study examined the impact of a brief motivational interviewing (MI) intervention (Project CHAT) on alcohol consumption and drug use for high-risk teens in a primary care clinic that provides health care for underserved populations. Youth (N = 42, 48% male) were screened, and those eligible completed a baseline survey. Baseline survey completers were randomly assigned to usual care or to an MI intervention and completed a 3-month follow-up survey. The sample (age 12 to 18 years) was 85.7% Hispanic or Latino, 9.5% African American, and 4.8% White. At the 3-month follow-up, Project CHAT teens reported less marijuana use, lower perceived prevalence of marijuana use, fewer friends who used marijuana, and lower intentions to use marijuana in the next 6 months, as compared to teens assigned to usual care. Providing this type of brief intervention is a viable approach to working with high-risk teens to decrease substance use.

Darke S; Ross J; Williamson A; Mills KL; Havard A; Teesson M. Injecting and noninjecting heroin administration: Transitions and treatment outcomes across 36 months. Journal of Drug Issues 38(2): 543-557, 2008. (29 refs.)

To examine long-term stability in route of administration and treatment outcomes for noninjecting (NIHU) and injecting (IHU) heroin users, a cohort of 429 heroin users were followed over 36 months. Across follow-up, 35.3% of NIHU injected heroin and a transition to primary heroin injecting was made by 8.5%. Amongst IHU, 11.1% smoked heroin and a transition to primary heroin smoking was made by 2.3%. While NIHU were less likely to be in treatment at 36 months, there were no differences in overall treatment exposure. At 36 months, there were no differences in heroin use, polydrug use, crime, physical health, or psychopathology, NIHU were, however, less likely to be injecting and to have injection-related health problems. It is concluded that there is a substantial risk of injecting occurring amongst NIHU and that route of administration does not differentially predict long-term treatment response.

Davey-Rothwell MA; Kuramoto SJ; Latkin CA. Social networks, norms, and 12-step group participation. American Journal of Drug and Alcohol Abuse 34(2): 185-193, 2008. (22 refs.)

In a sample of active drug users, we assessed the associations between frequency of attending a 12-step program, perceived social norms, and social network structure. Participants who reported that most or all of their drug partners attended 12-step groups were over ten times more likely to be frequent attenders compared to individuals who did not go to Narcotics Anonymous (NA). While social network structure of number of cocaine and heroin users and number of members in treatment was associated with frequent attendance, there was no association among individuals who infrequently went to a 12-step program. Individuals who are trying to control their drug use should be encouraged to affiliate with others in recovery or attending a 12-step program.

Davoli M. Improving research to evaluate the effects of psychological treatments for addiction. (editorial). Addiction 103(6): 888-889, 2008. (15 refs.)

De Leon G; Melnick G; Cleland CM. Client matching: A severity-treatment intensity paradigm. Journal of Addictive Diseases 27(3): 99-113, 2008. (34 refs.)

Despite considerable effort to develop matching strategies and client placement protocols, research studies fail to yield compelling results regarding the benefits of matching to treatment. The most consistent findings suggest a matching paradigm, which defines a successful placement as the least treatment intensity required addressing the severity of the disorder. The purpose of the present study is to provide further empirical support for the validity of a severity-intensity paradigm utilizing data from the Drug Abuse Treatment Outcome Studies. A "passive match" approach employed the Client Matching Protocol decision algorithm, which recommended clients to long-term residential or outpatient drug-free treatment. One-year outcomes for clients matched to long-term residential treatment were better on all outcome variables compared to those undertreated in outpatient drug-free treatment. Findings supported the validity of the severity-intensity paradigm in that undertreated clients showed less improvement compared to matched and overtreated clients.

Dennis ML; Ives ML; White MK; Muck RD. The Strengthening Communities for Youth (SCY) initiative: A cluster analysis of the services received, their, correlates and how they are associated with outcomes. Journal of Psychoactive Drugs 40(1): 3-16, 2008. (35 refs.)

This article describes the Strengthening Communities for Youth (SCY) initiative using data from 1,297 adolescents in eight U.S. cities (Oakland, CA; Tucson, AZ; Iowa City, IA; Bloomington, IL; St. Louis, MO; Cleveland, OH; Louisville, KY, New York, NY) to better understand the pattern of services they received, how these services varied by need, and how services were associated with initial treatment outcomes. Data include adolescent reports collected with the Global Assessment of Individual Needs (GAIN) at treatment intake and 90 days post-intake, information on early therapeutic alliance using a modified Working Alliance Inventory (WAI), and staff reports from service logs. Cluster analysis identified four patterns of treatment received: (1) substance abuse and mental health treatment, (2) primarily residential treatment, (3) interrupted treatment, and (4) primarily outpatient treatment. Outcomes examined included changes in substance use, substance abuse/dependence problems, recovery environment risk, as well as risk from social peers, illegal activity and emotional problems. Overall and for most groups, treatment was associated with reduced or unchanged problems in each of these areas. The exception was for cluster 1, for whom emotional problems actually increased. Implications for placement, treatment planning and future research are discussed.

Dolan SL; Martin RA; RohsenoW DJ. Self-efficacy for cocaine abstinence: Pretreatment correlates and relationship to outcomes. Addictive Behaviors 33(5): 675-688, 2008. (62 refs.)

Little research has been conducted on the relationship of self-efficacy at treatment entry to individual differences or to treatment outcome for patients with cocaine dependence. Those relationships were examined in 163 cocaine-dependent patients in a residential treatment program using two measures of self-efficacy administered in the first week of treatment: beliefs about success in quitting in general and confidence about not using in 11 cocaine-specific high-risk situations. The most robust correlates of self-efficacy were greater desire to stop using and lower urge to use in high-risk situations. Age, depressive symptoms, cognitive functioning, recent substance use, and past success with quitting also correlated with self-efficacy. Both measures of self-efficacy predicted quantity and frequency of cocaine use and abstinence at 3 but not 6 months after treatment after controlling pretreatment cocaine use. Results suggest that treatments should target self-efficacy in cocaine-dependent patients.

Driessen M; Schulte S; Luedecke C; Schaefer I; Sutmann F; Ohlmeier M et al. Trauma and PTSD in patients with alcohol, drug, or dual dependence: A multi-center study. Alcoholism: Clinical and Experimental Research 32(3): 481-488, 2008. (22 refs.)

Background: We investigated (1) the prevalence of posttraumatic stress disorder (PTSD) in treatment-seeking subjects with substance use dependence (SUD), (2) the association between comorbid PTSD and the severity and course of addiction and psychopathology, and (3) this association in patients with subsyndromal PTSD, and in trauma exposure without PTSD. Methods: In this cross-sectional study, 459 subjects in 14 German addiction treatment centers participated with alcohol-dependence (A) in 39.7%, drug-dependence (D) in 33.6%, or both (AD) 26.8%. The diagnostic measures included the International Diagnostic Checklists (IDCL), Posttraumatic Diagnostic Scale (PDS), Addiction Severity Index (ASI), and the Brief Psychiatric Rating Scale (BPRS). Associations between independent characteristics and outcomes were analysed by univariate and multivariate statistics. Results: 25.3% of the subjects had PTSD confirmed by both IDCL and PDS with higher rates in the AD (34.1%) and D (29.9%) groups compared with group A (15.4%, p < 0.001). In 22.8%, PTSD was subsyndromal (either IDCL or PDS positive) without significant differences between SUD groups, and 18.3% met PTSD trauma criteria A without PTSD (exposure). After controlling for SUD and gender, trauma subgroups significantly differed regarding the onset of alcohol-related symptoms (p < 0.02), numbers of previous admissions (p < 0.03), severity of SUD (p < 0.001), current craving (p < 0.02), and psychopathology (p < 0.001). We observed the worst outcome in PTSD, while trauma exposure had no effects. Conclusions: The prevalence of PTSD is higher in drug than in alcohol dependence. The more strictly PTSD is diagnosed (by interviewer and questionnaire) the more clearly are associations with characteristics of SUD. PTSD seems to be an independent risk factor for an unfavorable outcome of SUD.

Farren CK; Mc Elroy S. Treatment response of bipolar and unipolar alcoholics to an inpatient dual diagnosis program. Journal of Affective Disorders 106(3): 265-272, 2008. (33 refs.)

Background: Depressed and bipolar alcoholics represent a significant affective subgroup that has a poorer prognosis than either diagnosis alone. To date few systematic treatment programs have been developed to treat dual diagnosis. Methods: An inpatient treatment program was developed at St Patrick's Hospital Dublin to treat dual diagnosis clients with alcohol dependence and either unipolar or bipolar affective disorder. Clients (N=232) were assessed for depression, anxiety, elation, cravings, drink and drug intake on admission, discharge, 3 and 6 months post-discharge from the program. Results: In the overall group there was a reduction in number of drinking days and units per drinking day over the study (P <.01). There was a 71.8% complete abstinent rate at 3 months and 55.8% at 6 months in the depression group, non-significantly greater than for the bipolar group at 64.7% and 54.1% respectively. Gamma GT, MCV and craving scores were significantly reduced over time (p <.01). Mania, depression and anxiety inventory scores fell over time in both groups (p <.01). 15-21-year olds were more severely anxious, had higher illicit drug use, and were more likely to relapse to drug use than older clients. Bipolar 1 clients were significantly more likely than bipolar 2 clients to be on mood stabilisers at all follow-up stages (p <.001). Limitations: No control group was used. Conclusions: There is evidence for efficacy of a specifically designed dual diagnosis inpatient treatment prograrn as both depressed and bipolar alcoholics had significant reductions in all measurements of mood, craving, and alcohol/drug consumption by self report and biological markers, suggesting both diagnoses can be effectively treated together.

Fiellin DA; Moore BA; Sullivan LE; Becker WC; Pantalon MV; Chawarski MC et al. Long-term treatment with buprenorphine/naloxone in primary care: Results at 2-5 years. American Journal on Addictions 17(2): 116-120, 2008. (31 refs.)

To examine long-term outcomes with primary care office-based buprenorphine/naloxone treatment, we followed 53 opioid-dependent patients who had already demonstrated six months of documented clinical stability for 2-5 years. Primary outcomes were retention, illicit drug use, dose, satisfaction, serum transaminases. and adverse events. Thirty-eight percent of enrolled subjects were retained for two years. Ninety-one percent of urine samples had no evidence of opioid use, and patient satisfaction was high. Serum transaminases remained stable from baseline. No serious adverse events related to treatment occurred. We conclude that select opioid-dependent patients exhibit moderate levels of retention in primary care office-based treatment.

Finney JW. Regression to the mean in substance use disorder treatment research. Addiction 103(1): 42-52, 2008. (38 refs.)

Aims: Regression to the mean (RTM) refers to the tendency for a group of cases that differ from the population mean to move (regress) towards the mean, on average, when re-assessed, if scores at the two points are less than perfectly correlated. This paper considers factors that affect the magnitude of RTM and how RTM may impact findings from primary studies and reviews of substance use disorder (SUD) treatment. Design and methods The paper is guided largely by A Primer on Regression Artifacts by Campbell and Kenny. It reviews potential RTM effects in three areas of SUD treatment research. One is the extent to which within-group improvement in comparative treatment trials, including 'placebo effects', is a function of RTM. The second is the vulnerability of treatment evaluations employing non-equivalent control group designs to RTM and biased estimates of treatment effects when matching, or statistical equating is used to adjust for pre-existing group differences. The final issue is the impact of RTM in syntheses of research findings on SUD treatments. In particular, the tendency for later studies of a particular intervention to have smaller treatment effect sizes relative to earlier studies is considered as an RTM phenomenon. Findings: RTM is a pervasive, but often unrecognized phenomenon that can bias findings in SUD treatment studies and in systematic reviews of that research. Conclusion: SUD treatment researchers should be aware of RTM, take any available steps to reduce it, and try to diagnose whether it is still affecting research findings.

Fothergill KE; Ensminger ME; Green KA; Crum RA; Robertson J; Juon HS. The impact of early school behavior and educational achievement on adult drug use disorders: A prospective study. Drug and Alcohol Dependence 92(1/3): 191-199, 2008. (81 refs.)

Few longitudinal studies have examined the effects of education on drug use disorders among community populations of African Americans. This study explores the impact of multiple early education indicators on later problem drug use in an African American population followed for more than 35 years. The initial cohort comprised all 1st graders (N = 1242, 51% female) living in the Woodlawn community of Chicago in 1966. Follow-up assessments were conducted in adolescence (1975-76), early adulthood (1992-93), and mid adulthood (2002-03). One or both adult interviews were completed by 1053 individuals providing information for identifying lifetime drug use disorders. Logistic regression with multiple imputation revealed several important relationships between early education indicators and DSM-III-R/DSM-IV drug use disorders. Specifically, the risk for adult problem drug use was related to: underachievement in 1st grade; low 7th and 8th grade standardized math scores; both suspension from and skipping school in adolescence; not having a high school diploma (compared to having a college degree), and having a diploma or GED (compared to having a college degree). Also, 1st graders characterized as shy by their teachers were less likely to develop problem drug use in adulthood. Results indicate potential opportunities for targeted intervention at multiple life stages.

Fu SS; Kodl M; Willenbring M; Nelson DB; Nugent S; Gravely AA et al. Ethnic differences in alcohol treatment outcomes and the effect of concurrent smoking cessation treatment. Drug and Alcohol Dependence 92(1/3): 61-68, 2008. (46 refs.)

The Timing of Alcohol and Smoking Cessation (TASC) Study tested the optimal timing of smoking cessation treatment in an alcohol-dependent population. Previously reported results suggest that providing concurrent smoking cessation treatment adversely affects alcohol outcomes. The purpose of this analysis was to investigate whether there are ethnic differences in alcohol and tobacco outcomes among a diverse sample of alcohol-dependent smokers using data from the TASC trial in which 499 participants were randomized to either concurrent (during alcohol treatment) or delayed (6 months later) smoking intervention. This analysis focused on smokers of Caucasian (n = 381) and African American (n = 78) ethnicity. Alcohol outcomes included 6 months sustained alcohol abstinence rates and time to first use of alcohol post-treatment. Tobacco outcomes included 7-day point prevalence smoking abstinence. Random effects logistic regression analysis was used to investigate intervention group and ethnic differences in the longitudinally assessed alcohol outcomes. Alcohol abstinence outcomes were consistently worse in the concurrent group than the delayed group among Caucasians, but this was not the case for African Americans. No significant ethnic differences were observed in smoking cessation outcomes. Findings from this analysis suggest that concurrent smoking cessation treatment adversely affects alcohol outcomes for Caucasians but not necessarily for African Americans.

Garner BR; Godley SH; Funk RR. Predictors of early therapeutic alliance among adolescents in substance abuse treatment. Journal of Psychoactive Drugs 40(1): 55-65, 2008. (62 refs.)

Given the importance of the therapeutic alliance in achieving positive treatment outcomes, research is needed to illuminate the factors that contribute to the development of this important relationship. The aim of the current study was to expand upon the existing literature by examining predictors of the early therapeutic alliance among adolescents treated in two outpatient programs. Use of multilevel modeling techniques revealed that the majority of the variance in adolescents' ratings of the therapeutic alliance was due to adolescent factors (91%), while the variance in therapist ratings of alliance were nearly equally divided between adolescent and therapist factors (52% vs. 48%). Participant age was found to be the only significant predictor of therapist-rated alliance, with therapists reporting higher alliances with older adolescents. Adolescents reporting higher levels of social support, greater problem recognition, and more reasons for quitting also reported higher therapeutic alliance ratings. Future research is needed to examine if early identification of adolescents with low social support and problem recognition combined with brief treatment readiness interventions can be a promising approach to help improve therapeutic engagement and post-treatment substance use outcomes.

Gaudiano BA; Uebelacker LA; Miller IW. Impact of remitted substance use disorders on the future course of bipolar I disorder: Findings from a clinical trial. Psychiatry Research 160(1): 63-71, 2008. (44 refs.)

Given the high lifetime prevalence rates of bipolar disorder and comorbid substance use disorders (SUDS), the aim of the study was to examine the effect of a remitted SUD on the future course of bipolar I disorder in patients taking part in a clinical trial. Patients with bipolar I disorder were enrolled in a larger study examining the effects of pharmacotherapy plus family interventions. These patients were recruited during an acute mood episode and their mood symptoms and substance abuse were assessed longitudinally for up to 28 months. Patients with a remitted SUD showed a poorer acute treatment response, a longer time to remission of their acute mood episode, and a greater percentage of time with subthreshold but clinically significant depression and manic symptoms over follow-up compared to those without this comorbidity pattern. Subsequent substance abuse during follow-up could not fully account for the poorer course of illness. As remitted SUDS appear to negatively predict treatment outcome, current findings have implications for both clinical trials of bipolar patients as well as clinical practice.

Gossop M; Stewart D; Marsden J. Attendance at Narcotics Anonymous and Alcoholics Anonymous meetings, frequency of attendance and substance use outcomes after residential treatment for drug dependence: a 5-year follow-up study. Addiction 103(1): 119-125, 2008. (44 refs.)

Aims This study investigates the relationship between frequency of attendance at Narcotics Anonymous and Alcoholics Anonymous (NA/AA) meetings and substance use outcomes after residential treatment of drug dependence. It was predicted that post-treatment NA/AA attendance would be related to improved substance use outcomes. Methods Using a longitudinal, prospective cohort design, interviews were conducted with drug-dependent clients (n = 142) at intake to residential treatment, and at 1 year, 2 years and 4-5 years follow-up. Data were collected by structured interviews. All follow-up interviews were carried out by independent professional interviewers. Findings Abstinence from opiates was increased throughout the 5-year follow-up period compared to pre-treatment levels. Clients who attended NA/AA after treatment were more likely to be abstinent from opiates at follow-up. Abstinence from stimulants increased at follow-up but (except at 1-year follow-up) no additional benefit was found for NA/AA attendance. There was no overall change in alcohol abstinence after treatment but clients who attended NA/AA were more likely to be abstinent from alcohol at all follow-up points. More frequent NA/AA attenders were more likely to be abstinent from opiates and alcohol when compared both to non-attenders and to infrequent (less than weekly) attenders. Conclusions: NA/AA can support and supplement residential addiction treatment as an aftercare resource. In view of the generally poor alcohol use outcomes achieved by drug-dependent patients after treatment, the improved alcohol outcomes of NA/AA attenders suggests that the effectiveness of existing treatment services may be improved by initiatives that lead to increased involvement and engagement with such groups.

Green JP; Lynn SJ; Montgomery GH. Gender-related differences in hypnosis-based treatments for smoking: A follow-up meta-analysis. American Journal of Clinical Hypnosis 50(3): 259-271, 2008. (52 refs.)

In an earlier meta-analysis of 12 studies using hypnosis-based treatments for smoking cessation, we provided preliminary evidence that males fare better than females when trying to quit smoking (Green, Lynn, & Montgomery, 2006). By excluding studies that reported no gender differences, but failed to report final outcome-statistics-by-gender, our previous conclusion may have overestimated the role of gender in hypnosis-based smoking cessation treatment. In the present analysis, we included 12 additional studies that reported no gender differences, but failed to report final outcome-by-gender statistics. Across each of these studies, we calculated identical success rates for male and female participants and then added these results to our database. Among all 24 groups of participants who completed hypnosis-based treatment for smoking, we found a small but significant effect for male participants being more successful in quitting smoking relative to females. Specific suggestions for tailoring hypnosis smoking cessation programs to take gender differences into account are discussed.

Gwadz MV; Leonard NR; Cleland CM; Riedel M; Arredondo GN; Wolfe H et al. Behavioral interventions for HIV infected and uninfected mothers with problem drinking. Addiction Research & Theory 16(1): 47-65, 2008. (65 refs.)

This article evaluates the efficacy of a 14-session social-cognitive behavioral intervention on problem drinking (and where applicable, drug use) among urban HIV-infected and uninfected mothers, in comparison to a single-session social/motivational intervention, and explores the relationships of initial substance use problem severity and HIV status to efficacy. A randomized controlled trial design was used. Participants (N = 118) were mothers with problem drinking, both HIV-infected (55%) and uninfected, and primarily from racial/ethnic minority and low socioeconomic status backgrounds. Participants were interviewed five times over 18 months. Both intervention arms yielded reductions in alcohol and drug use frequency, alcohol quantity, and alcohol/drug problems, with moderate effect sizes. Those with greater initial substance use maintained reductions over a longer period of time in response to the more intensive social-cognitive intervention. Treatment efficacy did not vary by HIV status. The utility of targeting intervention intensity to the level of substance use is supported.

Hall JA; Smith DC; Easton SD; An H; Williams JK; Godley SH et al. Substance abuse treatment with rural adolescents: Issues and outcomes. Journal of Psychoactive Drugs 40(1): 109-120, 2008. (57 refs.)

This study compared the characteristics and treatment outcomes of rural adolescents with urban adolescents in substance abuse treatment programs in CSAT's Strengthening Communities for Youth (SCY) initiative. Using data from ten SCY programs nationally, the authors classified adolescents as rural or urban using Rural-Urban Commuting Area (RUCA) codes. We then evaluated changes in substance use frequency and substance-related problems at three, six, and 12 months after baseline assessments for the two sites that treated rural (n = 59) and urban (n = 345) youth in outpatient settings. Data were analyzed using a two-part mixed effects model for zero-saturated dependent variables. At treatment intake, rural youth exhibited greater problem severity on a number of substance abuse and mental health indices. From intake to the 12-month follow-up point, the percentages of both urban and rural youth who reported abstinence increased significantly. Both rural and urban youth also reported fewer problems due to substance use over time, but differences between groups were not consistent. Overall, treatment appears equally effective for both rural and urban adolescents. As few rural youth obtained treatment, we encourage funding agencies and treatment providers to consider innovative ways for providing services in rural areas and addressing gaps in primary prevention, early identification, and continuing care.

Hall WD; Mattick RP. Oral substitution treatments for opioid dependence. (editorial). Lancet 371(9631): 2150-2151, 2008. (13 refs.)

Hanson T; Alessi SM; Petry NM. Contingency management reduces drug-related human immunodeficiency virus risk behaviors in cocaine-abusing methadone patients. Addiction 103(7): 1187-1197, 2008. (46 refs.)

Aim Contingency management (CM) is efficacious in reducing drug use. This study examined whether CM also reduces human immunodeficiency virus (HIV) risk behaviors and if these effects are mediated by longest duration of abstinence achieved during treatment. Design Data were analyzed from a subset of participants in a combined data set of three published randomized controlled trials of CM treatments. Setting A community-based methadone maintenance clinic. Participants One-hundred and sixty-five cocaine-abusing methadone maintenance patients. Intervention Participants received either standard methadone treatment or standard methadone treatment with CM for 3 months. Measurements The HIV Risk Behavior Scale (HRBS) was administered prior to randomization to a study condition and 3 months after the study treatments ended. The primary objective indicator of drug use was longest duration of cocaine and opioid abstinence achieved during treatment. Findings Relative to those assigned to standard care, participants receiving CM significantly decreased overall HIV risk behaviors and injection drug use risk behaviors. CM participants also achieved longer durations of consecutive cocaine and opioid abstinence during treatment. Duration of abstinence achieved mediated the relationship between treatment condition and HRBS difference scores. Conclusions These results suggest that CM treatment reduces HIV drug use risk behaviors in cocaine-abusing methadone maintenance patients.

Harris KM; Griffin BA; McCaffrey DF; Morral AR. Inconsistencies in self-reported drug use by adolescents in substance abuse treatment: Implications for outcome and performance measurements. Journal of Substance Abuse Treatment 34(3): 347-355, 2008. (34 refs.)

This article presents an analysis of logical inconsistencies in adolescents' reporting of recent substance use to assess the potential effect of inaccurate reporting on measures of treatment outcomes and program performance. We used data on 1,463 clients from 10 adolescent treatment programs to assess the relationship between inconsistent reports and various factors that contribute to program assignment and treatment outcomes. Our results suggest that inconsistencies do not arise at random. Instead, inconsistencies are associated with program assignment and factors widely considered to influence treatment outcomes, including age at first use, living situation, race/ethnicity, and mental distress. We also found a positive relationship between level of inconsistent reporting of drug use and self-reports of improvement over time on several well-established treatment outcome measures. Our study highlights the need for greater awareness on the potential impact of inaccuracies in the reporting of substance use on outcome and performance measurements and that for the development of methodologies to improve accuracy.

Humphreys K; Trafton JA; Oliva EA. Does following research-derived practice guidelines improve opiate-dependent patients' outcomes under everyday practice conditions? Results of the Multisite Opiate Substitution Treatment study. Journal of Substance Abuse Treatment 34(2): 173-179, 2008. (19 refs.)

The Multisite Opiate Substitution Treatment study evaluated whether adhering to clinical-trial-derived practice guidelines improves treatment outcomes of unselected opiate-dependent patients seen in everyday practice. Clinics that were relatively concordant (n = 4) or nonconcordant (n = 4) with guidelines concerning medication dose levels and psychosocial service provision were identified. Staff interviewed 256 patients at intake and 6-month follow-up regarding past month heroin use, criminal activities, and mental health. To represent real-world practice conditions, clinics provided care in accordance with their usual approach, and no patient exclusion criteria were employed. Patients in each type of clinic were similar at baseline, but by follow-up, heroin use and mental health outcomes were significantly better in guideline-concordant clinics than in guideline-discordant clinics. Notably, 60.6% of patients in concordant clinics had urinalysis-confirmed heroin abstinence versus only 40.0% in nonconcordant clinics. Following research-derived practice guidelines seems to increase opiate substitution treatment effectiveness for opiate-dependent patients in the real world.

Kalant H. Drug treatment: Not as useless as it seems. (editorial). Addiction 103(5): 707-708, 2008. (6 refs.)

Killen JD; Fortmann SP; Schatzberg AF; Arredondo C; Murphy G; Hayward C et al. Extended cognitive behavior therapy for cigarette smoking cessation. Addiction 103(8): 1381-1390, 2008. (39 refs.)

Primary aim: Examine the effectiveness of extended cognitive behavior therapy (CBT) in promoting longer-term smoking abstinence. Design Open-label treatment phase followed by extended treatment phase. Randomization conducted prior to entry into open-label treatment phase; analysis based on intention-to-treat to avoid threat of selection bias. Setting: Community smoking cessation clinic. Participants: A total of 304 adult smokers (>= 18 years of age; >= 10 cigarettes/day). Intervention Open-label (8 weeks): all participants received bupropion SR, nicotine patch, CBT. Extended treatment (12 weeks): participants received either CBT + voicemail monitoring and telephone counseling or telephone-based general support. Measurements Seven-day point prevalence abstinence, expired-air carbon monoxide. Results At week 20 follow-up, CBT produced a higher 7-day point prevalence abstinence rate: 45% versus 29%, P = 0.006; at 52 weeks the difference in abstinence rates (31% versus 27%) was not significant. History of depression was a moderator of treatment. Those with a positive history had a better treatment response at 20 weeks when assigned to the less intensive telephone support therapy (P < 0.05). Conclusion: The superiority of CBT to 20 weeks suggests that continued emphasis on the development of cognitive and behavioral strategies for maintaining non-smoking during an extended treatment phase may help smokers to maintain abstinence in the longer term. At present, the minimum duration of therapy is unknown.

Laffaye C; McKellar JD; Ilgen MA; Moos RH. Predictors of 4-year outcome of community residential treatment for patients with substance use disorders. Addiction 103(4): 671-680, 2008. (61 refs.)

Aims: This study examined systematically how predictors of substance use disorder (SUD) treatment outcome worked together over time and identified mediators and moderators of outcome. Design: The MacArthur model was applied in this naturalistic study to identify how baseline, discharge and 1-year follow-up factors worked together to predict 4-year improvement in substance-related problems. Setting Eighty-eight community residential facilities were selected based on geographic representativeness, number of patient referrals and type of treatment orientation. Participants Of 2796 male patients who completed intake assessments, 2324 were assessed at the 1-year follow-up and 2023 at the 4-year follow-up. Measurements: Self-report measures of symptom severity, functioning, social resources and coping, treatment and involvement in Alcoholics Anonymous (AA) were collected at baseline and at 1- and 4-year follow-ups. Provider-rated treatment participation measures were obtained at discharge. Findings Greater substance use severity, more psychiatric symptoms, more prior arrests and stronger belief in AA-related philosophy at treatment entry predicted improvement significantly in substance-related problems 4 years later. At the 1-year follow-up, being employed and greater use of AA-related coping predicted outcome significantly. AA-related coping at 1 year mediated the relationship partially between belief in AA philosophy at treatment entry and 4-year outcome. Conclusions The findings highlight the unique and positive impact of AA involvement on long-term SUD treatment outcome and extend understanding of why AA is beneficial for patients.

Larm P; Hodgins S; Larsson A; Samuelson YM; Tengstrom A. Long-term outcomes of adolescents treated for substance misuse. Drug and Alcohol Dependence 96(1-2): 79-89, 2008. (62 refs.)

Introduction: Little is known about the long-term outcome of substance misuse by teenagers, this is especially true for gender specific consequences. Objectives: To examine the prevalence of death, physical illnesses related to substance misuse, mental illness, substance misuse, criminality, and poverty in adulthood among two cohorts of individuals who as adolescents had consulted for substance misuse problems, to estimate the effect of sex on adverse outcomes, and to compare cohort effects. Methods: Individuals who had consulted a substance misuse clinic as adolescents during 1968-1971 and 1980-1984 were followed until 2002. Adverse outcomes were documented using information from Swedish national registers. Results: In the older cohort followed to age 50, only one-in-five escaped all six adverse outcomes, while over half of subjects experienced at least two or more. Sex and the severity of adolescent substance misuse and delinquency were predictors of adverse outcomes. More women than men experienced physical illness and poverty in the older cohort while more men than women were convicted of criminal offences in both cohorts and presented continued substance misuse in the younger cohort. Men in the younger as compared to the older cohort had higher rates of substance misuse and criminal convictions. Conclusions: Adolescents seeking help for substance misuse problems are at elevated risk for multiple adverse outcomes later in life. Outcomes differ for women and men and by severity of adolescent misuse and delinquency. Few cohort differences in adult outcomes exist.

Lawrinson P; Ali R; Buavirat A; Chiamwongpaet S; Dvoryak S; Habrat B et al. Key findings from the WHO collaborative study on substitution therapy for opioid dependence and HIV/AIDS. Addiction 103(9): 1484-1492, 2008. (24 refs.)

Aims: Opioid substitution treatment has been studied extensively in industrialized countries, but there are relatively few studies in developing/transitional countries. The aim of this study was to examine the effectiveness of opioid substitution treatment (OST) in less resourced countries. Design: Longitudinal cohort study. Setting Purposively selected OST sites in Asia (China, Indonesia, Thailand), Eastern Europe (Lithuania, Poland, Ukraine), the Middle East (Iran) and Australia. Participants: Seven hundred and twenty-six OST entrants. Measurements Participants were interviewed at treatment entry, 3 and 6 months. Standardized instruments assessed drug use, treatment history, physical and psychological health, quality of life, criminal involvement, blood-borne virus (BBV) risk behaviours and prevalence of human immunodeficiency virus (HIV) and hepatitis C. Findings: Participants were predominantly male, aged in their early 30s and had attained similar levels of education. Seroprevalence rates for HIV were highest in Thailand (52%), followed by Indonesia (28%) and Iran (26%), and lowest in Australia (2.6%). Treatment retention at 6 months was uniformly high, averaging approximately 70%. All countries demonstrated significant and marked reductions in reported heroin and other illicit opioid use; HIV (and other BBV) exposure risk behaviours associated with injection drug users (IDU) and criminal activity, and demonstrated substantial improvement in their physical and mental health and general wellbeing over the course of the study. Conclusions: OST can achieve similar outcomes consistently in a culturally diverse range of settings in low- and middle-income countries to those reported widely in high-income countries. It is associated with a substantial reduction in HIV exposure risk associated with IDU across nearly all the countries. Results support the expansion of opioid substitution treatment.

Leeman RF; Palmer RS; Corbin WR; Romano DM; Meandzija B; O'Malley SS. A pilot study of naltrexone and BASICS for heavy drinking young adults. Addictive Behaviors 33(8): 1048-1054, 2008. (29 refs.)

Heavy drinking young adults often have limited motivation to change their drinking behavior. Adding pharmacotherapy to brief counseling is a novel approach to treating this population. A small open-label pilot study was conducted to assess the feasibility of offering eight weeks of daily and targeted (i.e., taken as needed in anticipation of drinking) naltrexone with BASICS (brief motivational) counseling to heavy drinking young adults; to assess the tolerability of the medication in this population and to obtain preliminary efficacy data. The sample (N = 14) showed strong adherence to study appointments and medication taking, supporting the feasibility of this approach. Overall, the medication was well-tolerated. Significant reductions from baseline were observed in drinks per drinking day and in percent heavy drinking days and these gains were maintained one month after treatment ended. A significant decrease in alcohol-related consequences was also observed. Findings from this small pilot study suggest that naltrexone in combination with BASICS represents a promising strategy to reduce heavy drinking among young adults.

Levin FR; Kleber HD. Use of dronabinol for cannabis dependence: Two case reports and review. American Journal on Addictions 17(2): 161-164, 2008. (27 refs.)

Marijuana is the most commonly used illicit drug in the United States and throughout the world. Despite this, the number of laboratory studies that have assessed pharmacologic agents to target cannabis withdrawal symptoms or reduce the reinforcing effects of marijuana has been modest. Unlike alcohol, cocaine, opiates, or nicotine, there has been a minimal number of clinical pharmacologic treatment trials that have targeted marijuana use. Based on recent laboratory studies, dronabinol (delta -9- tetrahydrocannabinol) has been shown to reduce cannabis withdrawal symptoms and the subjective effects of marijuana. Given that agonist agents have been found to be effective for opiate and nicotine dependence, the clinical utility of dronabinol for cannabis dependence is a reasonable approach. Two case reports using dronabinol are presented. The potential benefit, as well as questions that arise from the use of this medication in cannabis-abusing populations, is presented. Also,future areas of research that might be explored are discussed.

Litt MD; Kadden RM; Kabela-Cormier E; Petry NM. Coping skills training and contingency management treatments for marijuana dependence: Exploring mechanisms of behavior change. Addiction 103(4): 638-648, 2008. (48 refs.)

Aims Achieving abstinence in the treatment of marijuana dependence has been difficult. To date the most successful treatments have included combinations of motivation enhancement treatment (MET) plus cognitive-behavioral coping skills training (CBT) and/or contingency management (ContM) approaches. Although these treatment approaches are theoretically based, their mechanisms of action have not been explored fully. The purpose of the present study was to explore mechanisms of behavior change from a marijuana treatment trial in which CBT and ContM were evaluated separately and in combination. Design A dismantling design was used in the context of a randomized clinical trial. Setting: The setting was an out-patient treatment research facility located in a university medical center. Participants: Participants were 240 adult marijuana smokers, meeting criteria for cannabis dependence. Interventions: Participants were assigned to one of four 9-week treatment conditions: a case management control condition, MET/CBT coping skills training, ContM and MET/CBT + ContM. Measurements: Outcome measures were total 90-day abstinence, recorded every 90 days for 12 months post-treatment. Findings: Regardless of treatment condition, abstinence in near-term follow-ups was predicted most clearly by abstinence during treatment, but long-term abstinence was predicted by use of coping skills and especially by post-treatment self-efficacy for abstinence. Conclusions It was concluded that the most efficacious treatments for marijuana dependence are likely to be those that increase self-efficacy.

Lutsenko H; Doran CM; Hall WD. Australian smokers' use of bupropion and nicotine replacement therapies and their relation to reimbursement, Australia 2001-05. Drug and Alcohol Review 27(2): 160-164, 2008. (23 refs.)

Objective. To compare the usage of bupropion hydrochloride and nicotine replacement in Australia between 2001 and 2005. Design and Setting. We analysed aggregate data on the utilisation of: (1) bupropion under the Pharmaceutical Benefit Scheme (PBS) between 2001 and 2005; (2) bupropion and nicotine replacement therapy (NRT) on the Repatriation Pharmaceutical Benefit Scheme (RPBS) between 1995 and 2005; and (3) NRT aggregate sales data from GlaxoSmithKline for 2001-05. The National Drug Strategy Household Survey (NDSHS) 2004 was used to estimate the proportion of smokers who received a bupropion prescription in each year. Main Outcome Measures. Numbers of annual prescriptions for bupropion on the PBS and buproprion and NRT on the RPBS; annual sales figures on NRT patches (2001-05); and the estimated proportion of Australian smokers who used bupropion in 2003. Results. The number of bupropion prescriptions on the PBS peaked at 351 772 in 2001 (costing the PBS $83 million). This declined by 72% to 97 173 in 2005 (a cost of $12 million). The estimated percentage of smokers in Australia who used bupropion in a year fell from 11% in 2001 to 3.6% in 2005. The annual number of bupropion prescriptions on theRP BS fell from 3786 in 2001 to 1173 in 2005, while there was no change in the number of NRT prescriptions (3793 in 2001 and 3886 in 2005). Sales data from the leading market supplier of NRT also indicated that NRT use continued to grow in Australia while bupropion use declined. Conclusions. Bupropion usage has fallen by 72% since a peak in the year of first listing on the PBS, while the utilisation of NRTs appears to have increased, despite the price differential in favour of bupropion. Implications. Given the greater interest among smokers in NRT than bupropion (and evidence of the effectiveness and cost-effectiveness of NRT), the Australian government should reconsider its decision not to list NRT on the PBS.

Maremmani I; Pacini M; Lubrano S; Perugi G; Tagliamonte A; Pani PP et al. Long-term outcomes of treatment-resistant heroin addicts with and without DSM-IV axis 1 psychiatric comorbidity (dual diagnosis). European Addiction Research 14(3): 134-142, 2008. (46 refs.)

Objective: The aim of this study was to compare the long-term outcomes of treatment-resistant heroin addicts with and without DSM-IV axis I psychiatric comorbidity (dual diagnosis). Method: 129 heroin addicts who also met criteria for treatment resistance, 66 with one or more DSM-IV axis I psychiatric diagnosis (DD patients), and 63 without DSM-IV axis I psychiatric comorbidity (NDD patients) were monitored prospectively (6 years on average, min. 1, max. 9) along a methadone maintenance treatment program (MMTP). Results: The rates for survival-in-treatment were about 50% for NDD patients and about 70% for DD patients. After 4 years of treatment onwards, such rates tended to become stable. DD patients showed better outcome measures than NDD patients. A significantly higher methadone dose was needed to have DD patients stabilized. Conclusions: Contrary to expectations, treatment-resistant patients with psychiatric comorbidity showed a better long-term outcome than treatment-resistant patients without psychiatric comorbidity.

Marsden J; Farrell M; Bradbury C; Dale-Perera A; Eastwood B; Roxburgh M et al. Development of the treatment outcomes profile. Addiction 103(9): 1450-1460, 2008. (58 refs.)

Aim To develop the Treatment Outcomes Profile (TOP), a new instrument for monitoring substance misuse treatment. Design Prospective cohort, psychometric evaluation with 7-day retest and 1-month follow-up to assess inter-rater reliability, concurrent, discriminant and construct validity, and change sensitivity. Participants A sample of 1021 service users, aged 16-62 years. Recruitment from 63 treatment agencies in England, collectively providing opioid substitution treatment, psychosocial interventions, in-patient detoxification and residential rehabilitation. Measurements Thirty-eight frequency, rating scale and period prevalence measures, with 28-day recall, across substance use, health, crime and social functioning domains, administered as personal interview by 163 treatment keyworkers. Findings: Twenty outcome measures met inter-rater reliability criteria: days used alcohol, opioids, crack cocaine, cocaine powder, amphetamines, cannabis and one other named substance; days injected and period prevalence of direct or indirect needle/syringe sharing; subjective rating of physical and psychological health; days committed shop theft and drug selling, period prevalence of vehicle, property, fraud/forgery and assault/violence offences; rating of quality of life; days worked and attended for education/training; and period prevalence of acute housing problems and risk of eviction. Intraclass correlation coefficients for scale measures and Cohen's kappa for dichotomous measures reached or exceeded 0.75 and 0.61, respectively. There were satisfactory validity assessments and change sensitivity of scale items judged by effect size and smallest detectable difference. The TOP clinical tool contains an additional 10 items for individual treatment planning and review. Conclusions The TOP is a reliable and valid 20-item instrument for treatment outcomes monitoring.

Matto HC; Strolin JS; Mogro-Wilson C. A pilot study of a dual processing substance user treatment intervention with adults. Substance Use & Misuse 43(3/4): 285-294, 2008. (24 refs.)

This study responds to the identified need for evidence-based substance abuse interventions by examining the effects of an innovative dual processing substance use intervention aimed at decreasing the risk for substance relapse by targeting emotional regulation capacity. The study was completed in partnership with a Latino-serving community-based substance user treatment agency in a rural Northeastern region of the United States in 2005-2006 and was supported with pilot monies from the University at Albany School of Social Welfare NIDA-funded research center. The sample (N = 29) was comprised of adults with a diagnosis of substance dependence seeking treatment in an outpatient program. Study findings indicated that individuals who participated in the dual-processing treatment group decreased their craving with a trend toward increased self-efficacy over time in treatment and did not show treatment response differences across Latino and non-Latino clients, suggesting that treatment application was similar across these groups. The study's limitations are noted.

McIntoshi J; Bloor M; Robertson M. Drug treatment and the achievement of paid employment. Addiction Research & Theory 16(1): 37-45, 2008. (19 refs.)

The aim of this article is to identify which aspects of drug treatment are most closely associated with recovering drug users' ability to obtain paid employment. Based on a cohort study of 1033 individuals, this article reports on a logistic regression analysis of the factors associated with the achievement of paid employment 33 months after the initiation of treatment for drug dependency. While the results show a close relationship between the cessation of illegal drug use and individuals' ability to obtain paid employment, they also show that abstaining from drug use is unlikely to be successful on its own. The factor that showed the strongest independent association with the achievement of paid employment was the receipt of employment-related assistance. The study's findings are, therefore, strongly supportive of the provision of employment support programmes as the most important mechanism for helping recovering drug users to obtain employment.

McWhirter PT. Enhancing adolescent substance abuse treatment engagement. Journal of Psychoactive Drugs 40(2): 173-182, 2008. (27 refs.)

Trends in adolescent drug use are encouraging and suggest the importance of preventative programs for youth. Yet, among those who become involved with illicit substances and seek treatment, only a fraction report positive outcomes. This article describes an approach to enhance adolescent participation in substance abuse treatment. Aspects of the transtheoretical model are integrated into a treatment program designed to meet the unique developmental needs of adolescent alcohol and marijuana abusers. The result is a treatment that better engages adolescents in participation, thereby increasing the likelihood for treatment success.

Milby JB; Schumacher JE; Vuchinich RE; Freedman MJ; Kertesz S; Wallace D. Toward cost-effective initial care for substance-abusing homeless. Journal of Substance Abuse Treatment 34(2): 180-191, 2008. (40 refs.)

In a randomized controlled trial, behavioral day treatment, including contingency management (CM+), was compared to contingency management components alone (CM). All 206 cocaine-dependent homeless participants received a furnished apartment with food and work training/employment contingent on drug-negative urine tests. CM+ also received cognitive-behavioral therapy, therapeutic goal management, and other intervention components. Results revealed that CM, treatment attendance and abstinence were not significantly different from CM during 24 weeks of treatment. After treatment and contingencies ended, however, CM+ showed more abstinence than CM, indicating a delayed effect of treatment from 6 to 18 months. CM+ had more consecutive weeks abstinent across 52 weeks, but not during active treatment. We conclude that CM alone may be viable as initial care for cocaine-dependent homeless persons. That CM+ yields more durable abstinence indicates that it may be appropriate as stepped-up care for clients not responding to CM (Clinical Trials.gov, no. NCT00368524).

Moos RH. Active ingredients of substance use-focused self-help groups. (review). Addiction 103(3): 387-396, 2008. (74 refs.)

Aims and methods: This paper provides an overview of some of the probable active ingredients of self-help groups in light of four related theories that identify common social processes that appear to underlie effective psychosocial treatments for and continuing remission from these disorders. Results Social control theory specifies active ingredients such as bonding, goal direction and structure; social learning theory specifies the importance of norms and role models, behavioral economics and behavioral choice theory emphasizes involvement in rewarding activities other than substance use, and stress and coping theory highlights building self-efficacy and effective coping skills. A review of existing studies suggests that the emphasis on these active ingredients probably underlies some aspects of the effectiveness of self-help groups. Conclusions: Several issues that need to be addressed to enhance understanding of the active ingredients of action of self-help groups are discussed, including consideration of indices of Alcoholics Anonymous (AA) affiliation as active ingredients, identification of personal characteristics that may moderate the influence of active ingredients on substance use outcomes, examination of whether active ingredients of self-help groups can amplify or compensate for treatment, identification of potential detrimental effects of involvement in self-help groups and focusing on the link between active ingredients of self-help groups and other aspects of the overall recovery milieu, such as the family and social networks.

Morgenstern J; Blanchard KA; Kahler C; Barbosa KM; McCrady BS; McVeigh KH. Testing mechanisms of action for intensive case management. Addiction 103(3): 469-477, 2008. (34 refs.)

Aim: This study identified factors that predict, mediate or moderate the effects of intensive case management (ICM) on longer-term drug abstinence outcomes in women on welfare. Design In a parent study women were assigned randomly to usual care (UC) or intensive case manangement (ICM). Treatment was provided for 12 weeks and follow-up continued for 15 months after study intake. A set of hypothesized mediators was assessed at month 3 and a rigorous four-step mediational model was tested using outcomes in months 4-15. Participants Participants were 302 drug-dependent women applying and eligible for federal welfare and not currently in drug abuse treatment. Inventions ICM provided intensive treatment engagement including voucher incentives for treatment attendance and case management services; UC provided primarily referral to community treatment programs. Measurement: Substance use outcomes were assessed using the time-line follow-back interview and confirmed using biological and collateral measures. Findings Participants in ICM had more case manager contacts, better treatment engagement and more self-help attendance than did those in UC. Each of these variables predicted, and was shown to be a mediator of outcome, but case management contact was an especially robust mediator. Further, ICM effects were strongest for those who attended treatment least. Contrary to prediction, greater psychopathology and environmental stressors did not predict worse outcomes. Conclusions: Findings suggest that case management is an active intervention that may both facilitate and substitute for formal drug abuse treatment.

Murphy DA; Brecht ML; Herbeck D; Evans E; Huang D; Hser YL. Longitudinal HIV risk behavior among the Drug Abuse Treatment Outcome Studies (DATOS) adult sample. Evaluation Review 32(1): 83-112, 2008. (42 refs.)

Longitudinal trajectories for HIV risk were examined over 5 years following treatment among 1,393 patients who participated in the nationwide Drug Abuse Treatment Outcome Studies. Both injection drug use and sexual risk behavior declined over time, with most of the decline occurring between intake and the first-year follow-up. However, results of the application of growth mixture models for both sets of trajectories indicated that a subgroup of individuals reverted to a high-risk behavior over time, with a higher level of risk at the 5-year follow-up than their original risk level at intake. Of clients who were engaged in regular injection drug use at intake, 76% continued to inject drug at a moderate-stable or increased rate during the 5-year follow-up.

Ngo HTT; Tait RJ; Hulse GK. Comparing drug-related hospital morbidity following heroin dependence treatment with methadone maintenance or naltrexone implantation. Archives of General Psychiatry 65(4): 457-465, 2008. (46 refs.)

Context: Most research on heroin dependence treatments assesses short-term changes in patients' self-reported drug use. To our knowledge, long-term sustainability of changes in patients' drug use and associated hospital morbidity posttreatment have not been studied. Objectives: To evaluate drug-related hospital morbidity in heroin users at 6 months and 31/2 years after receiving naltrexone implant treatment and to compare these results with outcomes from a similar cohort treated with methadone maintenance treatment. Design: Retrospective longitudinal follow-up, using data prospectively collected via a state hospital (public and private) reporting system. Setting: Perth, Western Australia. Methadone maintenance dosage was generally dispensed daily by registered community pharmacies. Naltrexone implant treatment was performed as a day procedure at a community clinic. Participants: A total of 522 and 314 heroin-dependent persons (according to DSM-IV), first time treated with methadone maintenance or a naltrexone implant, respectively, between January 1, 2001, and December 30, 2002, were identified, using health record linkage. Main Outcome Measures: Planned outcomes included crude hospital admission rates, adjusted changes in risks (odds ratio [OR], and rates (rate ratio) of "overdose-related" and "non-overdose-related" hospital morbidity associated with opioid vs nonopioid drugs 6 months and 31/2 years posttreatment. Results: Following naltrexone implant treatment, opioid-related risk decreased for overdose (OR, 0.23; 95% confidence interval [CI], 0.11-0.48) and nonoverdose (OR, 0.64;. 95% CI, 0.46-0.89) conditions at 31/2 years. Such reductions were not observed after methadone treatment. Overdose on nonopioid drugs increased in older patients to 6 months: OR of 16.31 (95% CI, 3.07-86.53) for naltrexone and OR of 5.03 (95% CI, 1.18-21.54) for methadone. Nonoverdose (eg, dependence and withdrawal) associated with nonopioid drugs also increased for patients receiving the naltrexone implant: OR of 1.52 (95% CI, 1.04-2.23) at 31/2 years. In addition, there were 6 drug-related deaths: 5 after methadone maintenance and 1 after naltrexone implantation. Conclusions: Naltrexone implants, but not methadone maintenance, has long-term benefits in reducing opioid-related hospital morbidity. However, long-lasting and increased nonopioid drug-related morbidity following naltrexone implantation is particularly concerning. Similar studies are required to confirm these findings.

Passetti F; Clark L; Mehta MA; Joyce E; King M. Neuropsychological predictors of clinical outcome in opiate addiction. Drug and Alcohol Dependence 94(1/3): 82-91, 2008. (70 refs.)

A growing literature supports a role for neurocognitive deficits such as impaired decision-making in the development and maintenance of addictive behaviour. On the basis of these findings, it has been suggested that measures of neurocognitive functioning may be applied to the task of predicting clinical outcome in drug addiction. This in turn may have relevance for differentiating treatment based on individual patient needs. To explore this hypothesis we obtained neurocognitive measures of planning, impulsivity and decision-making from 37 opiate dependent individuals within 6 weeks of starting a community drug treatment programme and we followed them up 3 months into the programme. Performance on two tests of decision-making, but not on tests of planning, motor inhibition, reflection impulsivity or delay discounting, was found to predict abstinence from illicit drugs at 3 months with high specificity and moderate sensitivity. In particular, two thirds of the participants performing normally on the Cambridge Gamble Task and the Iowa Gambling Task, but none of those impaired on both, were abstinent from illicit drugs at follow up. Other neuropsychological, psychiatric or psychosocial factors measured in this sample did not explain this finding. The results are discussed in terms of the brain circuitry involved and the potential implications for the planning of treatment services for opiate dependence.

Perkins KA; Scott J. Sex differences in long-term smoking cessation rates due to nicotine patch. Nicotine & Tobacco Research 10(7): 1245-1251, 2008. (36 refs.)

Compared to men, women may be at greater risk for smoking-related diseases and have greater difficulty quitting smoking. Sex differences in medication response could guide treatment for smoking cessation to improve women's quit rates. We conducted a meta-analysis of the 14 placebo-controlled nicotine patch trials (N=6,250) for which long-term (6 months) clinical outcome results could be determined separately by sex. This analysis updated a meta-analysis of 11 of these trials that found no significant sex differences due to nicotine patch. The increase in quitting due to the nicotine vs. placebo patch was only about half as large in women as in men. Pooled absolute quit rates at 6 months for nicotine and placebo patch, respectively, were 20.1% and 10.8% in men, and 14.7% and 10.1% in women. The odds ratio for quitting due to nicotine vs. placebo patch was lower in women (OR=1.61) than in men (OR=2.20), with an interaction odds ratio of 1.40 (95% CI=1.02-1.93, p=.04). This sex difference did not vary significantly by whether or not formal counseling was provided. Poorer outcomes in women vs. men treated with nicotine patch suggests that increasing the quit rates of women smokers may require supplementing patch treatment or use of other medications.

Pettinati HM; Kampman KM; Lynch KG; Xie H; Dackis C; Rabinowitz AR et al. A double blind, placebo-controlled trial that combines disulfiram and naltrexone for treating co-occurring cocaine and alcohol dependence. Addictive Behaviors 33(5): 651-667, 2008. (64 refs.)

Background: This is a double blind, placebo-controlled trial that evaluated the efficacy of disulfiram, naltrexone and their combination in patients with co-occurring cocaine and alcohol dependence. Methods: 208 patients were randomized to disulfiram (250 mg/day), naltrexone (100 mg/day), the combination, or placebo for 11 weeks. Outcomes were in-trial abstinence from cocaine and/or alcohol. Results: Few safety concerns were reported, although medication adherence was low in a number of patients for both medications, alone or in combination. In the primary analyses (GEE modeling), abstinence from cocaine as measured by cocaine-negative urines and days of self-reported abstinence from cocaine or alcohol did not differ between placebo and any of the medication groups. However, patients taking disulfiram (alone or in combination) were most likely to achieve combined abstinence from cocaine and alcohol. Secondary analyses revealed that patients taking the disulfiram-naltrexone combination were most likely to achieve 3 consecutive weeks of abstinence from cocaine and alcohol. Conclusion: There was an association between disulfiram treatment and abstinence from cocaine and alcohol. More patients taking the disulfiram-naltrexone combination achieved 3 consecutive weeks of abstinence in treatment than placebo-treated patients.

Pettinati HM; Kampman KM; Lynch KG; Suh JJ; Dackis CA; Oslin DW et al. Gender differences with high-dose naltrexone in patients with co-occurring cocaine and alcohol dependence. Journal of Substance Abuse Treatment 34(4): 378-390, 2008. (74 refs.)

This is a randomized, double-blind, placebo-controlled clinical trial that evaluated the efficacy of a higher-than-typical daily dose of naltrexone (150 mg/day), taken for 12 weeks, in 164 patients (n = 116 men and n = 48 women) with co-occurring cocaine and alcohol dependence. Patients were stratified by gender and then randomly assigned to either naltrexone or placebo, and to either cognitive-behavioral therapy or a type of medical management. The two primary outcomes were cocaine use and alcohol use. Significant Gender x Medication interactions were found for cocaine use via urine drug screens (three way, with time) and self-reports (two way) for drug severity (two way) and alcohol use (two way). The type of psychosocial treatment did not affect outcomes. Thus, 150 mg/day naltrexone added to a psychosocial treatment resulted in reductions in cocaine and alcohol use and drug severity in men, compared to higher rates of cocaine and alcohol use and drug severity in women.

Phillips R; Bourne H. The impact of worker values on client outcomes within a drug treatment service. International Journal of Drug Policy 19(1): 33-41, 2008. (34 refs.)

Background: Little attention has been paid to understanding the impact of values, attributes and characteristics of drugs workers on therapeutic relationships and treatment outcomes. Interaction of values with other variables is considered to be of importance since values play a role in determining attitudes and behaviours. This exploratory study investigates the impact of drug workers' personal values on client outcomes within a drug treatment service. Methods: Eight drug workers and 58 clients were recruited at a UK charity working with problematic drug users who are also socially excluded. Drug workers completed a validated questionnaire to elicit their personal values. Client outcomes were assessed using the Christo Inventory for Substance Misuse Services. The relationship between client outcomes and worker values were analysed using Spearman's rank test of association. Results: Drug workers prioritising stimulation, self-direction and hedonism value types experienced more positive client outcomes compared with those prioritising security, conformity, benevolence, tradition and universalism types. The value types associated with positive outcomes fall within Schwartz's 'openness to change' superordinate dimension, whereas those related to more negative outcomes fall within the 'conservation' dimension. Conclusion: The study suggests that drug workers' personal values may have a significant impact upon client outcomes in the treatment of substance misuse. Reasons for this finding are explored, as are limitations of this study and suggestions for future research.

Powers MB; Vedel E; Ernmelkamp PMG. Behavioral couples therapy (BCT) for alcohol and drug use disorders: A meta-analysis. (review). Clinical Psychology Review 28(6): 952-962, 2008. (47 refs.)

Narrative reviews conclude that behavioral couples therapy (BCT) produces better outcomes than individual-based treatment for alcoholism and drug abuse problems (e.g., [Epstein, E. E., & McCrady, B. S. (1998). Behavioral couples treatment of alcohol and drug use disorders: Current status and innovations. Clinical Psychology Review, 18(6), 689-711; O'Farrell, T. J., & Fals-Stewart, W. (2003). Alcohol abuse. Journal of Marital and Family Therapy, 29(1), 121-146]). However, the strength and consistency of this effect favoring BCT has not been examined because a meta-analysis of BCT studies has not been reported. This meta-analysis combines multiple well controlled studies to help clarify the overall impact of BCT in the treatment of substance use disorders. A comprehensive literature search produced 12 randomized controlled trials (n = 754) that were included in the final analyses. There was a clear overall advantage of including BCT compared to individual-based treatments (Cohen's d = 0.54). This was true across outcome domains (frequency of use d = 0.36, consequences of use d = 0.52, and relationship satisfaction d = 0.57). However the pattern of results varied as a function of time. BCT was superior to control conditions only in relationship satisfaction at posttreatment (d = 0.64). However, at follow-up BCT was superior on all three outcome domains (frequency of use d = 0.45, consequences of use d = 0.50, and relationship satisfaction d = 0.51). In addition to other control conditions, BCT also outperformed individual cognitive behavioral therapy without couples therapy (d = 0.42). Larger sample sizes were associated with higher effect sizes (p = 0.02). However, treatment dose and publication year were not related to effect size. Overall, BCT shows better outcomes than more typical individual-based treatment for married or cohabiting individuals who seek help for alcohol dependence or drug dependence problems. The benefit for BCT with low severity problem drinkers has received little attention and one study suggests its efficacy may not extend to this subgroup.

Prochaska JJ; Hall SM; Humfleet G; Munoz RF; Reus V; Gorecki J et al. Physical activity as a strategy for maintaining tobacco abstinence: A randomized trial. Preventive Medicine 47(2): 215-220, 2008. (56 refs.)

Objectives. For smoking cessation, physical activity (PA) may help manage withdrawal symptoms, mood, stress, and weight; yet studies of PA as an aid for smoking cessation have been mixed. This study examined: (I) the impact of an extended relapse prevention program on increasing moderate to vigorous PA (MVPA) in adults enrolled in a tobacco cessation treatment trial: (2) whether changes in MVPA were associated with sustained abstinence from smoking; and (3) mechanisms by which MVPA may support sustained abstinence from smoking. Methods. In a randomized controlled trial conducted from 2003-2006 in San Francisco, California, 407 adult smokers received a 12 week group-based smoking cessation treatment with bupropion and nicotine patch with the quit date set at week 3. At week 12, participants were randomized to no further treatment or to 40 weeks of bupropion or placebo with or without an 11-session relapse prevention intervention of which 2 sessions (held at weeks 16 and 20) focused on PA. Participants receiving the PA intervention (n=163) received a pedometer, counseling to increase steps 10% biweekly towards a 10,000 steps/day goal, and personalized reports graphing progress with individualized goals. The International Physical Activity Questionnaire assessed weekly minutes of MVPA at baseline and weeks 12 and 24. Sustained abstinence from tobacco at week 24 was validated with expired carbon monoxide. Results. In a repeated mixed model analysis, intervention participants significantly increased their MVPA relative to control participants, F(1,475)=3.95, p=.047. Pedometer step counts also increased significantly, t(23)=2.36,p=.027, though only 15% of intervention participants provided 6 weeks of pedometer monitoring. Controlling for treatment condition, increased MVPA predicted sustained smoking abstinence at week 24, odds ratio=1.84 (95% CI: 1.07, 3.05). Among participants with sustained abstinence, increased MVPA was associated with increased vigor (r=0.23, p=.025) and decreased perceived difficulty with staying smoke-free (r=-0.21, p=.038). Conclusion. PA promotion as an adjunct to tobacco treatment increases MVPA levels: changes in MVPA predict sustained abstinence, perhaps by improving mood and self-efficacy.

Prochaska JJ; Hall SM; Tsoh JY; Eisendrath S; Rossi JS; Redding CA et al. Treating tobacco dependence in clinically depressed smokers: Effect of smoking cessation on mental health functioning. American Journal of Public Health 983(3): 446-448, 2008. (9 refs.)

We analyzed data from a randomized trial of 322 actively depressed smokers and examined the effect of smoking cessation on their mental health functioning. Only 1 of 10 measures at 4 follow-up time points was significant: participants who successfully stopped smoking reported less alcohol use than did participants who continued smoking. Depressive symptoms declined significantly over time for participants who stopped smoking and those who continued smoking; there were no group differences. Individuals in treatment for clinical depression can be helped to stop smoking without adversely affecting their mental health functioning.

Robbins MS; Szapocznik J; Dillon FR; Turner CW; Mitrani VB; Feaster DJ. The efficacy of structural ecosystems therapy with drug-abusing/dependent African American and Hispanic American adolescents. Journal of Family Psychology 22(1): 51-61, 2008. (30 refs.)

Many family therapies for adolescent drug use include ecological interventions. The purpose of this randomized clinical trial was to establish whether ecological interventions contribute to the impact of family therapy above and beyond the contributions of family process-only interventions. A family-based ecological approach, structural ecosystems therapy (SET), was compared with family process-only condition (FAM) and community services control (CS). One hundred ninety substance-abusing or dependent African American and Hispanic adolescents were randomized to SET, FAM, or CS. Follow-up assessments were conducted at 3, 6, 12, and 18 months postrandomization. SET was significantly more efficacious than FAM and CS in reducing adolescent drug use. However, these improvements were limited to Hispanic adolescents. The study demonstrates the importance of investigating changes in adolescent drug use as a result of treatment condition across more than 1 racial/ethnic group.

Rosenthal RN; Gage A; Perhach JL; Goodman AM. Acamprosate: Safety and tolerability in the treatment of alcohol dependence. Journal of Addiction Medicine 2(1): 40-50, 2008. (48 refs.)

Acamprosate, in conjunction with psychosocial treatment, has demonstrated efficacy in maintaining abstinence in alcohol-dependent patients in multiple clinical trials. Data from 13 short-term (<=26 weeks) and long-term (>=48 weeks) clinical trials were analyzed to assess the safety and tolerability of acamprosate: 4234 patients were randomized to placebo (N = 1962), acamprosate 1332 mg/d (N = 440), 1998 mg/d (N = 1749), or 3000 mg/d (N = 83). Overall incidence of treatment-emergent adverse events (AEs) was 61% for acamprosate and 56% for placebo (P < 0.01). The majority of AEs in all groups were reported as transient and considered "mild" or "moderate" in severity, and discontinuation rates due to AEs were comparable. Most common AEs were diarrhea (16% acamprosate versus 10% placebo, P < 0.01) and flatulence (3% acamprosate versus 2% placebo, P < 0.01). Patients taking concomitant medications commonly used to treat alcohol dependence reported comparable AEs between placebo- and acamprosate-treated groups. Acamprosate was shown to be safe in patients with hepatic impairment. A dose reduction is recommended in patients with renal impairment. No clinically meaningful between-group differences were reported for clinical chemistry tests or vital sign parameters. This ad hoc analysis demonstrates that acamprosate can be used safely in alcohol-dependent patients, including those taking concomitant medications, or having renal or hepatic impairment.

Schafer G. Multiple Family Group therapy in a drug and alcohol rehabilitation centre: Residents' experiences. Australian and New Zealand Journal of Family Therapy 29(2): 88-96, 2008. (67 refs.)

This study documents how residents experience Multiple Family Group (MFG) treatment in an 18-week residential therapeutic program for people with a severe substance disorder. Individual in-depth interviews with nine residents and three ex-residents of European descent were undertaken, and analysed using a descriptive thematic analysis. Results indicate that, prior to taking part in the program, their relationships with their families were seriously damaged and their situations often appeared complex and hopeless. After attending the MFGs all of the participants of this study experienced a number of positive changes in their relationships with their family members and partners. All interviewees said that they had gained more awareness about their interactions, better communications skills and were able to integrate these skills into their relationships with their families and partners.

Schottenfeld RS; Chawarski MC; Mazlan M. Maintenance treatment with buprenorphine and naltrexone for heroin dependence in Malaysia: a randomised, double-blind, placebo-controlled trial. Lancet 371(9631): 2192-2200, 2008. (41 refs.)

Background: Expansion of access to effective treatments for heroin dependence is a worldwide health priority that will also reduce HIV transmission. We compared the efficacy of naltrexone, buprenorphine, and no additional treatment I in patients receiving detoxification and subsequent drug counselling, for maintenance of heroin abstinence, prevention of relapse, and reduction of HIV risk behaviours. Methods: 126 detoxified heroin-dependent patients, from an outpatient research clinic and detoxification programme in Malaysia, were randomly assigned by a computer-generated randomisation sequence to 24 weeks of manual-guided drug counselling and maintenance with naltrexone (n=43), buprenorphine (n=44), or placebo (n=39). Medications were administered on a double-blind and double-dummy basis. Primary outcomes, assessed by urine testing three times per week, were days to first heroin use, days to heroin relapse (three consecutive opioid-positive urine tests), maximum consecutive days of heroin abstinence, and reductions in HIV risk behaviours over 6 months. The study was terminated after 22 months of enrolment because buprenorphine was shown to have greater efficacy in an interim safety analysis. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00383045. Findings: We observed consistent, linear contrasts in days to first heroin use (p=0 . 0009), days to heroin relapse (p=0 . 009), and maximum consecutive days abstinent (p=0.0007), with all results best for buprenorphine and worst for placebo. Buprenorphine was associated with greater time to first heroin use than were naltrexone (hazard ratio 1.87 [95% CI 1.21-2.88]) or placebo (2.02 [1.29-3.16]). With buprenorphine, we also recorded significantly greater time to heroin relapse (2.7 [1.38-3.42]), and maximum consecutive days abstinent than with placebo (mean days 59 [95% CI 43-76] vs 24 [13-35]; p=0. 003); however, for these outcomes, differences between buprenorphine and naltrexone were not significant. Differences between naltrexone and placebo were not significant for any outcomes. HIV risk behaviours were significantly reduced from baseline across all three treatments (p=0.003), but the reductions did not differ significantly between the three groups. Interpretation: Our findings lend support to the widespread dissemination of maintenance treatment with buprenorphine as an effective public-health approach to reduce problems associated with heroin dependence.

Sherman SE; Aldana I; Estrada M; York L. Comparing the tolerability and effectiveness of two treatment regimens in a smoking clinic. Military Medicine 173(6): 550-554, 2008. (15 refs.)

This study compares the effectiveness and tolerability of bupropion versus bupropion plus nicotine patch for smoking cessation in a routine clinical setting. Patients at the Sepulveda Veterans Health Administration Smoking Cessation Clinic completed a baseline survey and received counseling over 2 months, along with bupropion or bupropion plus nicotine patch. Of the 227 patients randomized to treatment, 112 (49%) received bupropion only and 115 (51%) received the combination therapy. At least one side effect was noted in 55% of bupropion patients and 70% of combination therapy patients; treatment regimens were changed in 7% and 14%, respectively. Abstinence rates at 2 months were 26% for the bupropion group and 37% for the combination therapy group (p = 0.1), and at 6 months were 42% versus 35%, respectively (p = 0.4). Although 6-month abstinence rates were derived from patient self-report and should be interpreted with caution, these results suggest that most patients referred to the clinic are able to take these medications. There was no difference in the rate of switching treatments, or in long-term abstinence rates.

Shiffman S; Ferguson SG. Nicotine patch therapy prior to quitting smoking: A meta-analysis. Addiction 103(4): 557-563, 2008. (24 refs.)

Aim: To evaluate the incremental efficacy of starting nicotine patch treatment prior to quitting compared to the current regimen of starting patch treatment on the target quit day. Design and measurements Meta-analysis of four eligible studies using pre-cessation patch treatment, located by database search and contacts with cessation researchers. The studies all compared starting treatment with nicotine patch prior to the target quit date to starting active treatment at the quit date, some in the context of concurrent mecamylamine treatment. The primary end-point for the analysis was continuous abstinence for at least 28 days assessed at 6 weeks following quit day; 6-month outcomes were also examined. Findings: Compared to starting active patch treatment on quit day, pre-cessation treatment with nicotine patches was found to double the odds of quitting. This was true both at 6 weeks [pooled odds ratio (OR) = 1.96, 95% confidence interval (CI): 1.31-2.93] and 6 months (pooled OR = 2.17, 95% CI: 1.46-3.22) treatment outcomes. Mecamylamine co-treatment did not modify these effects. Keywords: Across the four studies analyzed, pre-cessation patch treatment was found to produce a robust increase in quit rates compared to current regimens starting patch at quit day. Pre-cessation patch use represents a promising innovation in smoking cessation therapy with potential beneficial implications for improved public health by further increasing quitting success.

Sias JJ; Urquidi UJ; Bristow ZM; Rodriguez JC; Ortiz M. Evaluation of smoking cessation behaviors and interventions among Latino smokers at low-income clinics in a US-Mexico border county. Addictive Behaviors 33(2): 373-380, 2008. (12 refs.)

A descriptive study of 94 Latino smokers receiving nicotine replacement therapy (NRT) in US-Mexico border clinics in El Paso County, Texas was conducted. A baseline questionnaire and two follow-up telephone surveys (8-12 weeks and 6 months) were administered to evaluate smoking habits, behaviors, and cessation interventions. Participants reported an average daily cigarette consumption of 15 cigarettes and smoked within 30 min of waking (44%). Primary motivations for quitting were personal health (95%), family's health (74%), and doctor's advice (71%). Female smokers were more likely to smoke due to being anxious (p=0.012), not being able to sleep (p=0.02), or to feel thin (p=0.002). Male smokers were more likely to smoke when drinking alcohol (p=0.005). Nearly 40% of smokers reported they had never tried to quit before. Medication use at baseline was 82% patch, 53% lozenge, 29% gum, and 24% bupropion (combination therapy permitted). At 8-12 weeks, nearly two-thirds of patients were quit and 44% remained quit at six months. Smoking habits, behaviors, and successful cessation interventions among Latinos in a US-Mexico border community were identified.

Sundblad BM; Larsson K; Nathell L. High rate of smoking abstinence in COPD patients: Smoking cessation by hospitalization. Nicotine & Tobacco Research 10(5): 883-890, 2008. (32 refs.)

Chronic obstructive pulmonary disease (COPD) is mainly caused by smoking, and smoking cessation is the single most important intervention to prevent disease progression. Most studies show that many initially successful quitters relapse within 1 year. Our aim was to study the outcome of a smoking cessation program after 1 and 3 years. Abstinence outcomes in a group of COPD patients who participated in a 1-year smoking cessation program (N=247) were compared with those of a group of COPD patients who received usual care (N=231). The smoking cessation program included a 2-week period of hospitalization. Nicotine replacement therapy and physical exercise were recommended, and education was given in group sessions. Feedback and encouraging comments by phone from the specially trained staff continued during the full year. Follow-ups were performed 1 and 3 years after the start of the smoking cessation program. In the intervention group, 52% were smoke free after 1 year and 38% after 3 years. Corresponding quit rates in the control group were 7% after 1 year and 10% after 3 years. We found no significant differences between subjects who had low or high baseline scores on the Fagerstrom Test for Nicotine Dependence in regard to their ability to stop smoking successfully. This comprehensive smoking cessation program with hospitalization and a long follow-up period resulted in high quit rates even after 3 years. Despite high costs for this aggressive smoking cessation program, beneficial economic effects are likely to be obtained in the long run.

Swan GE; Jack LM; Javitz HS; McAfee T; Mcclu JB. Predictors of 12-month outcome in smokers who received bupropion sustained-release for smoking cessation. CNS Drugs 22(3): 239-256, 2008. (55 refs.)

Aim: To examine heterogeneity in outcome at 12 months following 8 weeks of treatment for smoking cessation with bupropion sustained-release (SR) 150 or 300 mg/day combined with behavioural counselling. Design, setting, participants: Smokers were recruited from a large healthcare system and then randomized to receive either bupropion SR 150 mg/day (n = 763) or 300 mg/day (n = 761) taken for 8 weeks in combination with either proactive telephone counselling or a tailored mail approach. Measurements and findings: A comprehensive set of relevant individual pretreatment and treatment characteristics was included in the analysis. Smoking outcome at 12 months was defined as point-prevalence of any regular selfreported smoking within the 7 days prior to follow-up contact. Classification and regression tree analysis identified subgroups that varied with respect to likelihood of being nonsmokers at 12 months. Seven subgroups were identified among those receiving bupropion SR 150 mg/day (proportion of nonsmokers at 12 months ranged from 13.7% to 43.5%) and eight subgroups among those receiving bupropion SR 300 mg/day (proportion of nonsmokers at 12 months ranged from 9.6% to 51.7%). In the 150-mg/day group, those with the lowest rate reported no previous quit attempt of 1 month or more in duration while those with the highest rate all reported previous quit attempts of 1 month or longer. In the 300 mg/day group, those with the lowest rate had very high levels of dependence while those with the highest rate were more highly educated and smoked at a lower level. Across all subgroups, cost per 12-month quitter ranged from a low of $US 302 to a high of $US 2502. Conclusions: These results indicate the presence of a substantial amount of variation in outcome following treatment with both dosages of bupropion SR, with substantial cost consequences. Variation in outcome could be reduced by providing treatments tailored to subgroups of individuals who are at exceptionally high risk for smoking following a quit attempt.

Teesson M; Mills K; Ross J; Darke S; Williamson A; Havard A. The impact of treatment on 3 years' outcome for heroin dependence: findings from the Australian Treatment Outcome Study (ATOS). Addiction 103(1): 80-88, 2008. (33 refs.)

Aim: To examine the impact of treatment for heroin dependence on drug use, injection-related risk-taking, health problems, criminality and general physical and mental health over 3 years among heroin-dependent Australians. Design: Longitudinal prospective cohort study. Participants: A total of 615 heroin users enrolled in the Australian Treatment Outcome Study; 94.5% of the sample completed at least one follow-up interview over 36-month follow-up. Findings: The proportion who reported using heroin in the preceding month continued to decrease significantly from baseline to 24-month follow-up (99% versus 35%), with this rate remaining stable to 36-month follow-up. The reduction in heroin use was accompanied by reductions in other drug use. There were also substantial reductions in risk-taking, crime, injection-related health problems and improvements in general physical and mental health. Positive outcomes were associated with more time in maintenance therapies and residential rehabilitation and fewer treatment episodes. Time spent in detoxification was not associated with positive outcomes. Major depression was also associated consistently with poorer outcome. Conclusions: At 3 years, there were impressive reductions in drug use, criminality, psychopathology and injection-related health problems following treatment exposure.

Ten Wolde GB; Dijkstra A; Van Empelen P; van den Hout W; Neven AK; Zitman F. Long-term effectiveness of computer-generated tailored patient education on benzodiazepines: A randomized controlled trial. Addiction 103(4): 662-670, 2008. (38 refs.)

Aims: Chronic benzodiazepine use is highly prevalent and is associated with a variety of negative health consequences. The present study examined the long-term effectiveness of a tailored patient education intervention on benzodiazepine use. Participants A randomized controlled trial was conducted comprising three arms, comparing (i) a single tailored intervention; (ii) a multiple tailored intervention and (iii) a general practitioner letter. The post-test took place after 12 months. Participants Five hundred and eight patients using benzodiazepines were recruited by their general practitioners and assigned randomly to one of the three groups. Intervention Two tailored interventions, the single tailored intervention (patients received one tailored letter) and the multiple tailored intervention (patients received three sequential tailored letters at intervals of 1 month), were compared to a short general practitioner letter that modelled usual care. The tailored interventions not only provided different and more information than the general practitioner letter; they were also personalized and adapted to individual baseline characteristics. The information in both tailored interventions was the same, but in the multiple tailored intervention the information was provided to the participants spread over three occasions. In the multiple tailored intervention, the second and the third tailored letters were based on short and standardized telephone interviews. Measurements Benzodiazepine cessation at post-test was the outcome measure. Findings: The results showed that participants receiving the tailored interventions were twice as likely to have quit benzodiazepine use compared to the general practitioner letter. Particularly among participants with the intention to discontinue usage at baseline, both tailored interventions led to high percentages of those who actually discontinued usage (single tailored intervention 51.7%; multiple tailored intervention 35.6%; general practitioner letter 14.5%). Conclusions: It was concluded that tailored patient education can be an effective tool for reducing benzodiazepine use, and can be implemented easily.

Ten Wolde GB; Dijkstra A; Van Empelen P; Neven AK; Zitman FG. Social-cognitive predictors of intended and actual benzodiazepine cessation among chronic benzodiazepine users. Addictive Behaviors 33(9): 1091-1103, 2008. (50 refs.)

Long-term benzodiazepine use is associated with a variety of negative health consequences. Cessation of long-term use is therefore an important health goal. In a prospective study among chronic benzodiazepinc users (N=356) social-cognitive factors of benzodiazepine cessation were examined with a nine-month follow-up. Results showed that outcome expectations, self-efficacy and disengagement beliefs predicted intention, and that intention in turn predicted benzodiazepine cessation. More specifically, benzodiazepine users reported a more positive intention to quit when they perceived more positive consequences and fewer negative consequences of cessation. In addition, a higher self-efficacy to quit and lower disengagement beliefs related to lower higher intention. Intention, in turn was the only significant psychosocial predictor of actual quitting at 9 months. The implications of these results will be discussed in terms of possible intervention strategies.

Verthein U; Bonorden-Kleij K; Degkwitz P; Dilg C; Koehler WK; Passie T et al. Long-term effects of heroin-assisted treatment in Germany. Addiction 103(6): 960-966, 2008. (19 refs.)

Aims: Trials in Switzerland, the Netherlands and Spain have found that heroin-assisted treatment (HAT) as maintenance treatment for opioid-dependent patients reduces illicit drug use. A German trial also found diamorphine treatment to be superior to methadone treatment. The present study describes the association between 2 years of heroin treatment and improvements in health and social stabilization, as well as illicit drug use. Design A prospective cohort study design. Participants A total of 515 patients were assigned to diamorphine treatment; 278 patients remained in the study treatment for the entire period of 24 months (54.8%). Measurements The results on physical (Opiate Treatment Index Health Symptoms Scale) and mental (Symptom Checklist 90-Revised Global Severity Index) health and illicit drug use (number of days with drug use within the last month-European Addiction Severity Index) were examined by repeated-measures analyses. Findings: Symptoms of physical (Pillai's trace = 0.837, df = 4, P < 0.001) and mental health (Pillai's trace = 0.450, df = 4, P < 0.001) improved during treatment. Street heroin use declined rapidly (Pillai's trace = 0.836, df = 4, P < 0.001), as did cocaine use (Pillai's trace = 0.280, df = 4, P < 0.001). Conclusions: Heroin-assisted treatment is associated with improvements in mental and physical health in the long term.

Villebro NM; Pedersen T; Moller AM; Tonnesen H. Long-term effects of a preoperative smoking cessation programme. Clinical Respiratory Journal 2(3): 175-182, 2008. (22 refs.)

Introduction: Preoperative smoking intervention programmes reduce postoperative complications in smokers. Little is known about the long-term effect upon smoking cessation. Aim: To discover long-term quit rates and the reasons behind successful cessation. Materials and Methods: 101 one of 120 smokers, randomised to smoking intervention or no intervention before hip and knee surgery, completed questionnaires concerning smoking after 1 year. We selected representative men and women for focus group interviews. Results: Significantly more patients from the intervention group abstained from smoking for 1 year post-operatively [13 in 60 patients (22%) vs; 2 in 60 (3%), P < 0.01]. Sex (mate), low nicotine dependency, non-smoking spouse and preoperative smoking intervention were related to smoking cessation. All patients gave the same reasons for smoking cessation: improved health and saving money. Follow-up for 5 years showed 17% of the controls and 8% in the intervention group (P = 0.42) had died. Conclusion: The intervention group had a significantly higher quit rate 1 year after a preoperative smoking cessation programme.

Walsh Z; Epstein A; Munisamy G; King A. The impact of depressive symptoms on the efficacy of naltrexone in smoking cessation. Journal of Addictive Diseases 27(1): 65-72, 2008. (45 refs.)

In the current double-blind study, we examined the impact of depressive symptoms on the efficacy of naltrexone as an adjunct to smoking cessation treatment. Participants were 110 adult nicotine dependent smokers interested in quitting smoking. All subjects received behavioral counseling and nicotine patches. Subjects were randomly assigned to the naltrexone or placebo group. Naltrexone was administered daily starting three days prior to the quit date (25 mg daily) and continued for 8 weeks thereafter (50 mg daily). Smoking cessation status was assessed at the end of treatment and at 24 week follow-up. The efficacy of naltrexone was moderated by depressive symptoms such that naltrexone was related to better quit rates than placebo at higher levels of depressive symptoms. These findings suggest that individual differences in depressive symptoms may be important determinants of clinical response to naltrexone, and may help to clarify discrepancies in prior studies of naltrexone and smoking cessation.

Weinstock J; Barry D; Petry NM. Exercise-related activities are associated with positive outcome in contingency management treatment for substance use disorders. Addictive Behaviors 33(8): 1072-1075, 2008. (9 refs.)

Exercise has been proposed as an adjunct intervention for substance use disorders due to its many benefits in terms of mental and physical health. This study investigated the association between completion of exercise-related activities and substance use disorders treatment outcome in a sample of 187 participants undergoing intensive outpatient treatment with contingency management. The sample was divided into two groups based upon whether or not an individual completed an exercise-related activity. Individuals who engaged in exercise-related activities (n =45) were found to achieve longer durations of abstinence during treatment than individuals who did not complete an exercise-related activity (n = 142). Overall, these findings suggest that exercise may be of benefit to individuals undergoing substance use disorders treatment. Methods for implementing an exercise intervention within substance use disorders treatment are discussed.

West R; Baker CL; Cappelleri JC; Bushmakin AG. Effect of varenicline and bupropion SR on craving, nicotine withdrawal symptoms, and rewarding effects of smoking during a quit attempt. Psychopharmacology 197(3): 371-377, 2008. (19 refs.)

Aims To examine the effect of varenicline, a selective alpha4-beta2 nicotinic acetylcholine receptor (nAChR) partial agonist, on craving and withdrawal symptoms in smokers making a quit attempt and the rewarding effects of smoking during a lapse after the target quit date (TQD). Materials and methods Pooled data were analysed from two identical double-blind, randomised trials comparing varenicline 1 mg BID, bupropion (sustained release) 150 mg BID and placebo using measures of craving and withdrawal in the first week after the TQD (in abstinent [n=612] and non-abstinent participants [n=1,155]) and of the rewarding effects of the first cigarette smoked in non-abstinent participants. Results In abstinent and non-abstinent participants combined, varenicline reduced craving more than bupropion (p < 0.01) and placebo (p <.001); the effect did not differ by whether or not subjects were abstinent; bupropion reduced craving more than placebo (p < 0.001). Among abstinent participants, both varenicline and bupropion reduced negative affect more than those receiving placebo (p < 0.005). Neither active drug reduced restlessness, insomnia or appetite vs placebo. Varenicline reduced ratings of satisfaction and psychological reward after the first cigarette smoked after the TQD vs bupropion (p < 0.005) and placebo (p < 0.001); bupropion also reduced these more than placebo (p < 0.05). Conclusions Varenicline significantly reduces craving and the rewarding effects of smoking after the TQD to a greater extent than bupropion, which may contribute to varenicline's greater efficacy for smoking cessation. Varenicline's lack of effect in reducing insomnia, restlessness and increased appetite in this analysis suggests that receptors other than the alpha4-beta2 nAChR subtype may be implicated in these withdrawal symptoms.

Williams JK; Smith DC; An H; Hall JA. Clinical outcomes of traumatized youth in adolescent substance abuse treatment: A longitudinal multisite study. Journal of Psychoactive Drugs 40(1): 77-84, 2008. (24 refs.)

The purpose of this study was to evaluate the effectiveness of outpatient substance abuse treatment for youth with high traumatic stress compared to youth without high traumatic stress in substance abuse treatment centers across the United States. The data for this study were gathered using a longitudinal survey design with purposive sampling from nine drug treatment delivery systems across the United States participating in the cooperative grant Strengthening Communities for Youth (SCY) awarded by SAMHSA's Center for Substance Abuse Treatment (CSAT) between September 2002 and June 2006. Follow-up assessments were conducted with the youth at three, six, and 12 months following intake. Traumatized youth responded to outpatient treatment in a similar pattern when compared to nontraumatized youth, although the traumatized youth had consistently higher scores on substance use frequency and substance problems scales than nontraumatized youth throughout the study. Current empirically validated treatments for adolescent substance abuse do not prepare the practitioner for trauma-informed practice or specifically address trauma-informed recovery. Based on our results, we advocate for the development and integration of trauma-informed practice within substance abuse treatment for adolescents to help them recover from trauma and substance abuse issues.

Williams JK; Smith DC; Gotman N; Sabri B; An HG; Hall JA. Traumatized youth and substance abuse treatment outcomes: A longitudinal study. Journal of Traumatic Stress 21(1): 100-108, 2008. (35 refs.)

This longitudinal study examined whether youth with high traumatic stress (HTS) respond differently to outpatient substance abuse treatment compared to youth without high traumatic stress at intake, and at 3 and 6 months following intake. Data were analyzed using a mixed-effects two-part model to fit repeated data with zero saturation. Clients in both groups significantly increased their odds of abstinence and full symptom remission of substance problems from baseline to 6 months. Of youth still using substances, the group with high traumatic stress reduced substance use significantly more than substance users without high traumatic stress. Recommendations for future research are provided.

Worley M; Gallop R; Gibbons MBC; Ring-Kurtz S; Present J; Weiss RD et al. Additional treatment services in a cocaine treatment study: Level of services obtained and impact on outcome. American Journal on Addictions 17(3): 209-217, 2008. (22 refs.)

The objective of this study was to examine the level of additional treatment services obtained by patients enrolled in the NIDA Cocaine Collaborative Study, a multi-center efficacy trial of four treatments for cocaine dependence, and to determine whether these set-vices impact treatment outcome. Cocaine-dependent patients (N = 487) were recruited at five sites and randomly assigned to six months of one of four psychosocial treatments. Assessments were made at baseline, monthly during treatment, and at follow-ups at 9, 12, 15, and 18 months post-randomization. On average, patients received little or no additional treatment services during active treatment (first six months), but the rate of obtaining most services increased during the follow-up phase (month 7 to 18). In general, the treatment groups did not differ in the rates of obtaining non-protocol services. For all treatment groups, patients with greater psychiatric severity received more medical and psychiatric services during active treatment and follow-up. Use of treatment services was unrelated to drug use outcomes during active treatment. However, during the follow-up period, increased use of psychiatric medication, twelve-step attendance, and twelve-step participation was related to less drug use. The results suggest that during uncontrolled follow-up phases, additional non-protocol services may potentially confound the interpretation of treatment group comparisons in drug use outcomes.

Yang Z; Shao YC; Li SJ; Qi JL; Zhang MJ; Hao W et al. Medication of l-tetrahydropalmatine significantly ameliorates opiate craving and increases the abstinence rate in heroin users: a pilot study. Acta Pharmacologica Sinica 29(7): 781-788, 2008. (41 refs.)

Aim: Drug addiction is a chronic brain disease with constant relapse requiring long-term treatment. New pharmacological strategies focus on the development of an effective antirelapse drug. This study examines the effects of levotetrahydropalmatine (l-THP) on reducing heroin craving and increasing the abstinence rate among heroin-dependent patients. Methods: In total, 120 heroin-dependent patients participated in the randomized, double-blinded, and placebo-controlled study using l-THP treatment. The participants remained in a ward during a 4-week period of l-THP treatment, followed by 4 weeks of observation after treatment. The patients were followed for 3 months after discharge. Outcome measures are the measured severity of the protracted abstinence withdrawal syndrome (PAWS) and the abstinence rate. Results: Four weeks of l-THP treatment significantly ameliorated the severity of PAWS, specifically, somatic syndrome, mood states, insomnia, and drug craving, in comparison to the placebo group. Based on the 3 month follow-up observation, participants who survived the initial 2 weeks of l-THP medication and remained in the trial program had a significantly higher abstinence rate of 47.8% (95% confidence interval [CI]: 33%-67%) than the 15.2% in the placebo group (95% CI: 7%-25%), according to a log-rank test (P < 0.0005). Conclusion: l-THP significantly ameliorated PAWS, especially reducing drug craving. Furthermore, it increased the abstinence rate among heroin users. These results support the potential use of l-THP for the treatment of heroin addiction.

Young JM; Girgis S; Bruce TA; Hobbs M; Ward JE. Acceptability and effectiveness of opportunistic referral of smokers to telephone cessation advice from a nurse: A randomised trial in Australian general practice. BMC Family Practice 9(e-article 16), 2008. (38 refs.)

Background: GPs often lack time to provide intensive cessation advice for patients who smoke. This study aimed to determine the effectiveness of opportunistic referral of smokers by their GP for telephone cessation counselling by a trained nurse. Methods: Adult smokers ( n = 318) attending 30 GPs in South Western Sydney, Australia were randomly allocated to usual care or referral to a telephone-based program comprising assessment and stage-based behavioural advice, written information and follow-up delivered by a nurse. Self-reported point prevalence abstinence at six and 12 months was compared between groups. Characteristics of patients who accepted and completed the intervention were investigated. Results: Of 169 smokers randomised to the intervention, 76 (45%) consented to referral. Compared with smokers in 'pre-contemplation', those further along the stage-of-change continuum were significantly more likely to consent ( p = 0.003). Those further along the continuum also were significantly more likely to complete all four calls of the intervention ( OR 2.6, 95% CI: 0.8-8.1 and OR 8.6, 95% CI: 1.7-44.4 for 'contemplation' and 'preparation' respectively). At six months, there was no significant difference between groups in point prevalence abstinence ( intention to treat) (9% versus 8%, p = 0.7). There was no evidence of differential intervention effectiveness by baseline stage-of-change ( p = 0.6) or patient sex ( p = 0.5). At 12 months, point prevalence abstinence in the intervention and control groups was 8% and 6% respectively ( p = 0.6). Conclusion: Acceptance of opportunistic referral for nurse delivered telephone cessation advice was low. This trial did not demonstrate improved quit rates following the intervention. Future research efforts might better focus support for those patients who are motivated to quit.