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Fall 2004

Brief treatments for cannabis dependence: Findings from a randomized multisite trial.

Babor TF. Journal of Consulting and Clinical Psychology 72(3): 455-466, 2004. (31 refs.)
This study evaluated the efficacy of 2 brief interventions for cannabis-dependent adults. A multisite randomized controlled trial compared cannabis use outcomes across 3 study conditions: (a) 2 sessions of motivational enhancement therapy (MET); (b) 9 sessions of multicomponent therapy that included MET, cognitive-behavioral therapy, and case management; and (c) a delayed treatment control (DTC) condition. Participants were 450 adult marijuana smokers with a Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) diagnosis of cannabis dependence. Assessments were conducted at baseline, and at 4, 9, and 15 months postrandomization. The 9-session treatment reduced marijuana smoking and associated consequences significantly more than the 2-session treatment, which also reduced marijuana use relative to the DTC condition. Most differences between treatments were maintained over the follow-up period. Discussion focuses on the relative efficacy of these brief treatments and the clinical significance of the observed changes in marijuana use.

Can the practitioner correctly predict outcome in motivational interviewing?

Strang J; McCambridge J. Journal of Substance Abuse Treatment 27(1): 83-88, 2004. (21 refs.)
We have examined whether practitioner ratings (immediately post-intervention) or other recorded characteristics of a single-session 1-hour motivational intervention were predictive of 3-month cannabis use outcome. In the context of a cluster randomized trial involving 200 non help-seeking illegal drug users (age range 16-20), 105 were randomized to the intervention, of whom 97 (92%) were interviewed for followup at 3 months, 96 of whom were current cannabis users at study entry. Six intervention characteristics and seven practitioner ratings as well as patterns of self-motivational statements were investigated in relation to substantial change in use, (which was defined as cessation or reduction by more than 50%). Both practitioner ratings post-session, and also the subject's own elicited self-motivational statements, were found to be predictive of outcome 3 months later. The strongest predictor of substantial change, however, was simply whether change had been discussed during the session. On the basis of the above findings, it does indeed appear possible for outcome to be predicted by the motivational interviewing practitioner immediately following delivery of the intervention, on the basis of simple observations and ratings. This area warrants more specific study.

Counseling buprenorphine patients: Information and treatment approaches for counselors.

McCann MJ. Journal of Psychoactive Drugs Supplement 2: 139-146, 2004. (16 refs.)
The Drug Addiction Treatment Act of 2000 allows qualifying physicians to prescribe buprenorphine out of office-based practices to treat opioid-dependent patients, with the requirement that they have the ability to refer them to ancillary counseling services. It is likely that these patients will be seen by a wide range of counselors with varying experience in treating addictions. In order to enable the spectrum of counselors working with buprenorphine patients to receive information regarding opioids, buprenorphine, opioid dependency, and relevant counseling approaches, an online course has been developed. The information and rationale provided in this course is summarized in this article, including: background information regarding opioids and buprenorphine; general issues in counseling patients with substance abuse disorders; and approaches to counseling buprenorphine patients.

Enabling behavior in a clinical sample of alcohol-dependent clients and their partners.

Rotunda RJ; West L; O'Farrell TJ. Journal of Substance Abuse Treatment 26(4): 269-276, 2004. (37 refs.)
Substance use disorders affect not only the identified client but significant others as well. Clinical work and some research suggest that partner responses to drinking may either facilitate or hinder treatment acceptance and recovery efforts. Female partners of male alcoholics have received much of this attention, and have been labeled as codependents or enablers. We administered a clinically derived assessment tool, the Behavioral Enabling Scale, to 42 alcoholic clients and their partners enrolled in a couples counseling program to determine the extent of specific partner behaviors that might reasonably be thought to reinforce drinking or hinder recovery. Results indicated that, among other findings, the majority of both clients and partners reported the partner took over chores or duties from the alcoholic client at some point during the relationship, drank or used other drugs with the client, and lied or made excuses to others to cover for the drinker. Moreover, particular relationship beliefs were associated with higher behavioral enabling scores, providing clear direction for cognitive and behavioral interventions. It is argued that efforts to understand and treat alcohol dependence will be more productive if partner behaviors are incorporated into assessment and intervention procedures.

Hazardous drinkers in the accident and emergency department: Who accepts advice?

Patton R M; Touquet R. Emergency Medicine Journal 21(4): 491-492, 2004. (5 refs.)
Aims: To identify factors that predict acceptance of brief advice among people consuming excessive alcohol in an accident and emergency (A&E) department. Methods: Patients presenting to an A&E department were screened using the Paddington Alcohol Test. All patients identified as hazardous drinkers were offered advice about their drinking. Data were collected on patients' age, sex, presenting condition, and alcohol consumption. Binary logistic regression was used to identify variables that predicted acceptance of the offer of advice. Results: The presenting condition, together with the total number of units consumed on a single occasion, predict the uptake of an offer of help. Conclusions: Patients identified as hazardous drinkers who present after a fall, head injury, or other accident are less likely to accept help. Clinicians should emphasise the potential relation between alcohol consumption and health related consequences to encourage the uptake of advice for these patients.

Lack of relationship between long-term use of benzodiazepines and escalation to high dosages.

Soumerai SB; Simoni-Wastila L; Singer C; Mah C; Gao XM; Salzman C; Ross-Degnan D. Psychiatric Services 54(7): 1006-1011, 2003. (31 refs.)
Objective: The objective of this study was to determine whether long-term benzodiazepine use is associated with dose escalation. Methods: The authors examined changes in dose and the frequency of dose escalation among new and continuing (at least two years) recipients of benzodiazepines identified from a database containing drug-dispensing and health care use data for all New Jersey Medicaid patients for 39 months. Independent variables included age; Medicaid eligibility category; gender; race or ethnicity; neighborhood socioeconomic variables; chronic illnesses, such as schizophrenia, bipolar illness, panic disorder, and seizure disorder; and predominant benzodiazepine received. Logistic regression analyses were conducted to determine the association between the independent variables and escalation to a high dosage (at least 20 diazepam milligram equivalents [DMEs] per day for elderly patients and at least 40 DMEs per day for younger patients). Results: A total of 2,440 patients were identified, comprising 460 new and 1,980 continuing recipients. Seventy-one percent of continuing recipients had a permanent disability. Among all groups of continuing recipients, the median daily dosage remained constant at 10 DMEs during two years of continuous use. No clinically or statistically significant changes in dosage were observed over time. The incidence of escalation to a high dosage was 1.6 percent. Subgroups with a higher risk of dose escalation included antidepressant recipients and patients who filled duplicate prescriptions for benzodiazepines at different pharmacies within seven days. Elderly and disabled persons had a lower risk of dose escalation than younger patients. Conclusion: The results of this study did not support the hypothesis that long-term use of benzodiazepines frequently results in notable dose escalation.

The association between cannabis and alcohol use and the development of mental disorder.

Byrne P; Jones S; Williams R. Current Opinion in Psychiatry 17(4): 255-261, 2004. (53 refs.)
Purpose of review: The purpose of this review was to examine recent evidence on the possible associations between cannabis and alcohol misuse and the development of mental disorders, particularly among young people. Recent findings The authors concluded that although a wide body of research has demonstrated the existence of such associations, the natures of the relationships involved are highly complex in character, and in all probability involve the mediation of a variety of additional factors. It is surmised that many of these additional factors relate to the experience of social exclusion. Summary: The authors call for further research to be carried out to extend existing knowledge of the nature of these associations and the way in which the experience of social exclusion impact upon them. Such research should be UK specific, population based and longitudinal in nature, and have at its heart an understanding of the nature of social exclusion and the bearing it has on both the misuse of substances and the risk of developing mental disorders.

The association of race and ethnicity with rates of drug and alcohol testing among US trauma patients.

Kon AA; Pretzlaff RK; Marcin JP. Health Policy 69(2): 159-167, 2004. (31 refs.)
Background: Racial and ethnic minority patients often receive differential medical care compared to Caucasians. The aim of this study was to evaluate the association of race and ethnicity with rates of alcohol and drug testing among adult US trauma patients. Methods: Data for 79,246 adults admitted to 58 institutions participating in the US National Trauma Data Bank were evaluated using multivariable, hierarchical, mixed-effects analyses to determine the odds of receiving alcohol and drug testing among different racial/ethnic groups. The primary outcome variable was whether an alcohol or drug test was performed. The secondary outcome variable was the results of those tests. Participants were stratified by injury severity using the Injury Severity Score. Additional case-mix variables included: gender, age, Glasgow Coma Scale, day and time of arrival, and payment source. Results: Black and Hispanic males in all injury severity groups were tested for alcohol more frequently than Caucasian males (odds ratio for Black men 1.31, 95% confidence interval 1.16-1.47; and for Hispanic men 1.45, 95% confidence interval 1.19-1.77, in the moderate injury group). Hispanic males in the moderate injury group were also tested for drugs more frequently then Caucasian males (odds ratio 1.33, 95% confidence interval 1.09-1.63). Conclusion: Racial and ethnic minority trauma patients in the US are tested for alcohol and drugs at higher rates after adjusting for potential confounders. Because having a positive alcohol or drug test can adversely affect a patient's medical care, differential testing that is racially or ethnically biased may place minority patients at risk of receiving disparate care.

Predicting suicide ideation for substance users: The role of self-esteem, abstinence, and attendance at 12-step meetings.

Wilke DJ. Addiction Research & Theory 12(3): 231-240, 2004. (16 refs.)
This study tested if a three-way interaction between gender, abstinence, and self-esteem could predict the occurrence of suicidal thoughts in a sample of drug users who are one year post-treatment. It was expected that those who resolved their drug and alcohol problems and had higher self-esteem would have a lower risk of suicide ideation than those who had resolved their drug and alcohol problems (e.g. were abstinent) and had lower self-esteem, and that this effect would be stronger for women than men. Using a 3-step hierarchical logistic regression, results indicated a significant 2-way interaction between self-esteem and abstinence in the predicted direction, and no effect for gender. However, it was also found that those who had lower levels of self-esteem, regardless of abstinence or continued use, had virtually identical odds of suicidal ideation. Further, increased frequency of attendance at AA/NA meetings also predicted a higher risk of suicide ideation. This suggests that careful assessment of depression symptoms or suicidal ideation for drug users seeking assistance be completed before automatically urging attendance at 12-step meetings. Implications for clinical work with clients are presented.

Treatment of patients with schizophrenia and substance abuse disorders. (review).

Tsuang J; Fong TW. Current Pharmaceutical Design 10(18): 2249-2261, 2004. (187 refs.)
Approximately half of patients with schizophrenia have a lifetime diagnosis of substance abuse disorders. These dual diagnosis patients are more likely to have poorer outcomes, including more severe psychiatric symptoms with increased hospitalizations, higher utilization of services and frequent homelessness. Assessment and treatment of dually diagnosed patients has evolved over the last twenty years. To date, the strongest evidence for effective management of dual diagnosis patients has been utilization of integrated treatment services, which combines both mental health and substance abuse treatments concurrently. Strategies commonly used include a combination of pharmacological treatment, intensive case management, motivational interviewing, individual and group psychotherapy, and family participation. This chapter summarizes the treatment options available for this population.

Predicting retention of adolescents in substance abuse treatment.

Battjes RJ; Gordon MS; O'Grady KE; Kinlock TW. Addictive Behaviors 29(5): 1021-1027, 2004. (7 refs.)
Because retention of adolescents in substance abuse treatment is critical to treatment effectiveness, factors that predict length of time in treatment were examined among youth (N = 173) admitted to five outpatient clinics. At admission, youth received a comprehensive psychosocial assessment. Relevant predictors of length of treatment were determined using Poisson regression analyses. Factors positively associated with treatment duration included use of drugs in addition to alcohol and marijuana, having less deviant peers, absence of substance-caused emotional problems, and viewing counselor's skills more positively. In contrast, pressure to enter treatment was unrelated to treatment duration. Results suggest that the counselor-client relationship and peer influences be explicitly considered in treatment.

Relapse prevention for alcohol and drug problems: That was Zen, this is Tao. (review).

Witkiewitz K; Marlatt GA. American Psychologist 59(4): 224-235, 2004. (138 refs.)
Relapse prevention, based on the cognitive-behavioral model of relapse, has become an adjunct to the treatment of numerous psychological problems, including (but not limited to) substance abuse, depression, sexual offending, and schizophrenia. This article provides an overview of the efficacy and effectiveness of relapse prevention in the treatment of addictive disorders, an update on recent empirical support for the elements of the cognitive-behavioral model of relapse, and a review of the criticisms of relapse prevention. In response to the criticisms, a reconceptualized cognitive-behavioral model of relapse that focuses on the dynamic interactions between multiple risk factors and situational determinants is proposed. Empirical support for this reconceptualization of relapse, the future of relapse prevention, and the limitations of the new model are discussed.

Smoking cessation efforts among substance abusers with and without psychiatric comorbidity.

Unrod M; Cook T; Myers MG; Brown SA. Addictive Behaviors 29(5): 1009-1013, 2004. (13 refs.)
Little is known about the natural course of smoking behaviors following substance use treatment, particularly among individuals with comorbid substance use and psychiatric disorders. This study examined smoking cessation efforts among 120 substance abusers with and without psychiatric comorbidity. Participants completed assessments of smoking prior to and 6 months following treatment for substance abuse. Comorbidity predicted quit attempts such that a larger proportion of psychiatrically comorbid individuals made quit attempts (54%) relative to those with substance use disorders (SUDs) only (35%). The presence of a psychiatric disorder, in conjunction with a substance use disorder, does not appear to deter smoking cessation efforts in early recovery.

The role of victim and perpetrator intoxication on sexual assault outcomes.

Testa M; Vanzile-Tamsen C; Livingston JA. Journal of Studies on Alcohol 65(3): 320-329, 2004. (44 refs.)
Objective: The current study was designed to examine the impact of perpetrator and victim substance use on the sexual assault outcomes of penetration and victim injury. Method: Women, ages 1830 (n = 1,014), were recruited from households using random digit dialing. They completed computer-assisted measures, including the Sexual Experiences Survey (Koss et al., 1987). Women who reported sexual assault since age 14 (n = 359) were interviewed face-to-face regarding their most recent sexual assault incident. Results: As hypothesized, high levels of perpetrator intoxication decreased the likelihood of penetration occurring. When the victim was highly intoxicated, however, penetration was more likely. Victim injury was more likely in assaults involving penetration. Higher levels of perpetrator intoxication in assaults involving a sober victim were also associated with greater odds of victim injury Conclusions: Perpetrator intoxication effects are consistent with the presumption that intoxication at high levels impairs male sexual function but increases male physical aggression. Victim intoxication increases vulnerability to penetration but does not reduce odds of injury.

Women in detoxification: Loss of guardianship of their children.

Schilling R; Mares A; El-Bassel N. Children and Youth Services Review 26(5): 463-480, 2004. (69 refs.)
Conducted in hospital-based clinics in New York City, this study is the first to depict the living circumstances of children of women in detoxification. Structured interviews were conducted with 160 African American and 96 Latina female patients who had at least one child under age 18. Virtually, all participants had used heroin or crack cocaine in the 30 days prior to entry into detox. High-risk drug use was common, including injection, frequenting crack houses, overdosing and trading sex for drugs. Fewer than half of the mothers had a high school education, and few received income from wages or child support. Mothers, with a mean age of 36, reported an average of 2.84 minor children. Only 34% of children were in the guardianship care of their mothers alone or mothers and their partners. Only 21% of mothers indicated that they were the guardians of all of their minor children. Rates of guardianship and custody were somewhat higher for Latina mothers compared to African American mothers. The most important sources of care for the children were grandparents, other relatives and foster parents. Of the children of detoxifying mothers, 21% were living with a non-relative, whereas in a national comparison sample of African American and Latino households, only 2% of children were living with non-relatives. A logistic equation determined that women who did not live in their own home, had less education and used multiple drugs were more likely to have lost guardianship of one or more children. Study findings expand understanding of the detrimental effects of parental drug abuse on children's life opportunities.

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