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...on clinical issues
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www.ProjectCork.org
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Spring 2007
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Associations between spirituality and substance abuse symptoms in the Baltimore Epidemiologic Catchment Area follow-up, 1993-1996.
Coyle C; Crum RM; Ford DE. Journal of Addictive Diseases 25(4): 125-132, 2006. (36 refs.)
Prior studies on substance abuse treatment programs have provided some evidence that participants who embrace some facet of spirituality during recovery may have greater success in maintaining sobriety. Several plausible associations exist between spirituality and sobriety; this paper posits that spirituality has consistently negative associations with substance abuse symptoms in models with 'substance abuse symptoms' as the outcome. The data come from the Baltimore Epidemiologic Catchment Area (ECA) study. In 1993, ECA researchers surveyed 1,920 of the original 3,841 participants, all household residents in East Baltimore. Multiple logistic regression analyses show that strong spiritual beliefs within this population are negatively associated with current substance abuse symptoms [OR = 0.53; 95 % CI = 0.35-0.80, p = 0.002]. Homeownership is also negatively associated, while positively associated characteristics include suffering from income-related stress and having a history of substance abuse treatment. This population-based study confirms findings from clinical studies, and the results support continued emphases on spirituality in substance abuse recovery programs. Copyright 2006, Haworth Press, Inc.
Attitudes toward the integration of smoking cessation treatment into drug abuse clinics.
Fuller BE; Guydish J; Tsoh J; Reid MS; Resnick M; Zammarelli L et al. Journal of Substance Abuse Treatment 32(1): 53-60, 2007. (44 refs.)
This article examines the variables associated with the presence of smoking cessation interventions in drug abuse treatment units, as well as staff attitudes toward the integration of smoking cessation services as a component of care. Surveys were administered to 106 organizations, 348 treatment clinics, and 3,786 employees in agencies that participated in the National Drug Abuse Treatment Clinical Trials Network. Organizational factors, attributes of the treatment setting, and staff attitudes toward smoking cessation treatment were assessed. Use of smoking cessation interventions was associated with the number of additional services offered at clinics, residential detoxification services, and attitudes of the staff toward smoking cessation treatment. Staff attitudes toward integrating smoking cessation services in drug treatment were influenced by the number of pregnant women admitted, the number of ancillary services provided, the attitudes of staff toward evidence-based practices, and whether smoking cessation treatment was offered as a component of care. Copyright 2007, Elsevier Science.
Do parents' marital circumstances predict young adults' DSM-IV cannabis use disorders? A prospective study.
Hayatbakhsh MR; Najman JM; Jamrozik K; Mamun AA; Alati R. Addiction 101(12): 1778-1786, 2006. (46 refs.)
Aims To determine whether parental marital status and marital quality in adolescence are associated with cannabis use disorders in young adults. Design Prospective birth cohort study. Setting A 21-year follow-up of 4815 mothers and their children who participated at 14 years after the child's birth in Queensland, Australia. Participants Cohort of 2303 young adults who completed the life-time version of the Composite International Diagnostic Interview-computerized version (CIDI-Auto) at the 21-year follow-up. Measurements Young adults' cannabis use disorders were assessed using the CIDI-Auto. Marital status and quality (marital circumstances) and potential confounding factors such as socio-economic status (SES), maternal mental health and maternal substance use were measured when the child was 14 years of age. Findings: Marital circumstances of the mother when child was aged 14 years predicted risk of cannabis use disorders in their offspring. After adjustment for potential confounding factors, adolescents who grew up in step-father families were more likely to have cannabis use disorders in early adulthood and a moderate association was found for those children who experienced maternal marital disagreement [odds ratio (OR) = 1.7; 95% confidence interval (CI): 1.0, 2.9]. There was no significant increase in subsequent risk of cannabis use disorders for children whose mothers were unpartnered at 14 years. Conclusions: Maternal marital status and marital quality are associated with young adults' subsequent cannabis use disorders. This association is independent of suspected confounding factors measured at 14 years. However, at least part of the association is explained by changes in marital status before 14 years. Copyright 2006, Society for the Study of Addiction to Alcohol and Other Drugs.
Does assigning a representative payee reduce substance abuse?
Rosen MI; McMahon TJ; Rosenheck R. Drug and Alcohol Dependence 86(2/3): 115-122, 2007. (34 refs.)
Background: Approximately 700,000 Social Security beneficiaries in the U.S. with psychiatric disabilities have been assigned a representative payee to manage their funds but it is unclear how those judged to need a payee differ from others and whether payee assignment improves clinical outcomes, especially substance abuse. Methods: Participants in this observational 12-month cohort Study (n = 1457) received SSI or SSDI and had serious mental illness. They were subsequently enrolled at eighteen community-based sites that provided Assertive Community Treatment. Social Security administrative records were used to determine whether a payee had been assigned. Results: At baseline, participants who were assigned a payee were more likely to have schizophrenia and had more severe clinician-rated drug and alcohol use than those not assigned a payee. In GEE models that adjusted for these and other potentially confounding covariates, participants assigned a payee between 4 and 12 months after program entry subsequently used significantly more psychiatric services than participants not assigned payees but showed no greater reduction in substance use. Conclusions: Although substance use is associated with being assigned a payee, substance use does not decline substantially following payee assignment. Participants assigned payees made greater subsequent use of psychiatric services, suggesting the potential for benefit from payee assignment. Copyright 2007, Elsevier Science.
DSM-IV alcohol dependence and abuse: Further evidence of validity in the general population.
Grant BF; Harford TC; Muthen BO; Yi HY; Hasin DS; Stinson FS. Drug and Alcohol Dependence 86(2/3): 154-166, 2007. (53 refs.)
Background: In order to understand the validity of the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) alcohol abuse and dependence diagnoses, studies are needed in both clinical and general population samples. The purpose of this study was to examine the construct and criterion-oriented validity of DSM-IV alcohol dependence and abuse in the general population with respect to factor structure and their relationship to family history of alcoholism, treatment utilization, and psychiatric comorbidity. Methods: This analysis is based on data from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), in which nationally representative data were collected in personal interviews conducted with one randomly selected adult in each sample household or group quarters. A subset (n=26,946) of the NESARC sample (total n=43,093) who reported drinking one or more drinks during the year preceding the interview formed the basis of analyses. Latent variable modeling was used to assess the concurrent validity of DSM-IV alcohol abuse and dependence symptom items. Results: The latent variable modeling yielded one major factor related to alcohol dependence, a second factor related to alcohol abuse and a third smaller factor defined by tolerance. The validity of alcohol dependence in general population samples was further supported by statistically significant associations with family history of alcoholism, treatment utilization, and psychiatric and medical comorbidities. Conclusions: The factor structure and relationship to external criterion variables observed in the study provide support for the further validity of DSM-IV alcohol dependence in the general population, whereas support for the validity of DSM-IV abuse was equivocal. Copyright 2007, Elsevier Science.
Encouraging posttreatment self-help group involvement to reduce demand for continuing care services: Two-year clinical and utilization outcomes.
Humphreys K; Moos RH. Alcoholism: Clinical and Experimental Research 31(1): 64-68, 2007. (20 refs.)
Background: Accumulating evidence indicates that addiction and psychiatric treatment programs that actively promote self-help group involvement can reduce their patients' health care costs in the first year after treatment, but such initially impressive effects may wane over time. This paper examines whether the positive clinical outcomes and reduced health care costs evident 1 year after treatment among substance-dependent patients who were strongly encouraged to attend 12-step self-help groups were sustained at 2-year follow-up. Methods: A 2-year quasi-experimental analysis of matched samples of male substance-dependent patients who were treated in either 12-step-based (n = 887 patients) or cognitive-behavioral (CB, n = 887 patients) treatment programs. The 12-step-based programs placed substantially more emphasis on 12-step concepts, had more staff members "in recovery," had a more spiritually oriented treatment environment, and promoted self-help group involvement much more extensively than did the CB programs. The 2-year follow-up assessed patients' substance use, psychiatric functioning, self-help group affiliation, and mental health care utilization and costs. Results: As had been the case in the 1-year follow-up of this sample, the only difference in clinical outcomes was a substantially higher abstinence rate among patients treated in 12-step (49.5%) versus CB (37.0%) programs. Twelve-step treatment patients had 50 to 100% higher scores on indices of 12-step self-help group involvement than did patients from CB programs. In contrast, patients from CB programs relied significantly more on outpatient and inpatient mental health services, leading to 30% lower costs in the 12-step treatment programs. This was smaller than the difference in cost identified at 1 year, but still significant ($2,440 per patient, p = 0.01). Conclusions: Promoting self-help group involvement appears to improve posttreatment outcomes while reducing the costs of continuing care. Even cost offsets that somewhat diminish over the long term can yield substantial savings. Actively promoting self-help group involvement may therefore be a useful clinical practice for helping addicted patients recover in a time of constrained fiscal resources. Copyright 2007, Research Society on Alcoholism.
Counselor incentives to improve client retention in an outpatient substance abuse aftercare program.
Shepard DS; Calabro JAB; Love CT; McKay JR; Tetreault J; Yeom HS. Administration and Policy in Mental Health Services Research 33(6): 629-635, 2006. (32 refs.)
Pay for performance, the provision of financial incentives for favorable performance, is increasingly under study as an evidence-based practice. This study estimated the improvement in client retention from offering incentives to 11 substance abuse counselors providing outpatient aftercare treatment. During the incentive period, a counselor could earn a bonus of $100, in addition to his regular compensation, for each client who completed at least five aftercare sessions (the "milestone" which we considered the minimum adequate dose of the aftercare curriculum). We evaluated this and a similar, 12-session incentive using a logistic regression in which the retention "milestone" was the dependent variable and the proportion of time in the incentive condition was the independent variable. Among the 123 clients offered this aftercare program, their probability of completing at least 5 sessions was 59% with the incentive compared to 33% beforehand (odds ratio 4.1, P <.01). These findings suggest that counselor incentives are an effective strategy to improve client retention in substance abuse treatment. Copyright 2006, Springer.
Overdose prevention for injection drug users: Lessons learned from naloxone training and distribution programs in New York City.
Piper TM; Rudenstine S; Stancliff S; Sherman S; Nandi V; Clear A et al. Harm Reduction Journal 4(article 3), 2007. (24 refs.)
Background: Fatal heroin overdose is a significant cause of mortality for injection drug users (IDUs). Many of these deaths are preventable because opiate overdoses can be quickly and safely reversed through the injection of Naloxone [brand name Narcan], a prescription drug used to revive persons who have overdosed on heroin or other opioids. Currently, in several cities in the United States, drug users are being trained in naloxone administration and given naloxone for immediate and successful reversals of opiate overdoses. There has been very little formal description of the challenges faced in the development and implementation of large-scale IDU naloxone administration training and distribution programs and the lessons learned during this process. Methods: During a one year period, over 1,000 participants were trained in SKOOP (Skills and Knowledge on Opiate Prevention) and received a prescription for naloxone by a medical doctor on site at a syringe exchange program (SEP) in New York City. Participants in SKOOP were over the age of 18, current participants of SEPs, and current or former drug users. We present details about program design and lessons learned during the development and implementation of SKOOP. Lessons learned described in the manuscript are collectively articulated by the evaluators and implementers of the project. Results: There were six primary challenges and lessons learned in developing, implementing, and evaluating SKOOP. These include a) political climate surrounding naloxone distribution; b) extant prescription drug laws; c) initial low levels of recruitment into the program; d) development of participant appropriate training methodology; e) challenges in the design of a suitable formal evaluation; and f) evolution of program response to naloxone. Conclusions: Other naloxone distribution programs may anticipate similar challenges to SKOOP and we identify mechanisms to address them. Strategies include being flexible in program planning and implementation, developing evaluation instruments for feasibility and simplicity, and responding to and incorporating feedback from participants. Copyright 2007, BioMed Central.
Predictors of sexual risk-taking among new drug users.
Elifson KW; Klein H; Sterk CE. Journal of Sex Research 43(4): 318-327, 2006. (78 refs.)
We studied predictors of HIV-related sexual risk-taking among individuals who initiated the use of heroin or methamphetamine during the past 5 years. Many studies have linked drug use to HTV risk, but most research has been based on samples of users with long-established drug careers. We conducted face-to-face interviews with 153 adult new drug users in Atlanta, GA. Drug use was not a statistically significant predictor of sexual risk, but gender, age, race, homelessness status, childhood neglect, level of paranoia, and level of (dys)functionality in handling disagreements were associated with frequency of sexual risk-taking. We discuss the need to incorporate new drug users in HIV/AIDS and other health-related prevention and intervention programs. Copyright 2006, Society for the Scientific Study of Sex.
Residential rehabilitation for the treatment of heroin dependence: Sustained heroin abstinence and drug-related problems 2 years after treatment entrance.
Darke S; Williamson A; Ross J; Teesson M. Addictive Disorders and their Treatment 5(1): 9-18, 2006. (27 refs.)
To determine levels of sustained heroin abstinence, current drug use, and drug-related problems of residential rehabilitation (RR) admissions 24 months after entering treatment. Longitudinal cohort study of 100 heroin users admitted to short-term (1 month) or long-term (3-6 months or longer) RR. Separation in the first week was uncommon in both short-term (7%) and long-term (16%) programs. Eighteen percent successfully graduated, 47% self-discharged, and 30% were expelled. Postindex treatment exposure was widespread (82%), with additional RR the most common treatment. At 24 months, 71% were heroin abstinent over the month preceding interview, and 18% reported heroin abstinence over the entire follow-up period. There had been large declines in levels of recent needle borrowing, crime, psychopathology, and improvements in global and injection-related health. Independent predictors of continuous heroin abstinent were female sex (odds ratio [OR] 5.00), successful graduation from the index program (OR 9.05), and post-treatment MT exposure (OR 0.08). The study confirms the effectiveness of RR and highlights and the impact of program graduation. Copyright 2006, Lippincott Williams & Wilkins.
Social functioning, treatment dropout, and recidivism of probationers mandated to a modified therapeutic community.
Hiller ML; Knight K; Saum CA; Simpson DD. Criminal Justice and Behavior 33(6): 738-759, 2006. (61 refs.)
Few studies have examined the impact of corrections-based drug abuse treatment programs on changes in social functioning. The current study, therefore, examines social functioning (i.e., hostility, risk taking, and social conformity) among 406 probationers in a modified therapeutic community. Data are collected prospectively and include intake, during treatment, and posttreatment information. Findings show that social functioning changes modestly during the first 90 days of treatment. Specifically, risk taking decreases with time, social conformity increases, and unexpectedly, hostility increases across time in treatment. Hostility is the only social functioning factor that predicts treatment dropout. Findings show there are no associations between social functioning indicators and recidivism both I and 2 years after treatment. However, recidivism within I year of treatment release is associated with criminal history, and recidivism within 2 years is associated with age. Copyright 2006, Sage Publications.
The effectiveness of a tailored intervention for excessive alcohol consumption prior to elective surgery.
Shourie S; Conigrave KM; Proude EM; Ward JE; Wutzke SE; Haber PS. Alcohol and Alcoholism 41(6): 643-649, 2006. (29 refs.)
Aim: To assess the effectiveness of a tailored pre-operative intervention for excessive alcohol consumption in reducing post-operative complications and alcohol consumption thereafter. Methods: Patients scheduled for elective surgery requiring at least overnight hospitalisation were screened for alcohol misuse. Consenting, eligible participants with >= 7 days to surgery at the time of screening were offered an intervention and those with < 7 days to surgery were provided usual care. Results: Over a period of 2 years and 10 months, 3139 patients were screened to recruit 136 participants. Baseline analysis revealed a mean age of 53 (+/- 15.8) years and a mean consumption of 71 g/day (+/- 48.1). The intervention group (n = 45) did not differ significantly from controls (n = 91) in age, consumption, and number of current smokers, but there were significantly more women in the control group. There was no difference between the groups in major or minor complications experienced, or length of stay after controlling for age, gender, and baseline consumption. At 6-month follow-up there was a significant reduction in drinking for the entire study population. Conclusion: The study did not demonstrate any beneficial effect of the pre-operative intervention on post-operative complications. The relatively short time to surgery, intervention by a non-member of the surgical team, challenges to recruitment and reduced consumption in the control group may have limited the ability of the study to detect a significant effect of the intervention. Copyright 2006, Medical Council on Alcohol.
The psychosocial benefits of Alcoholics Anonymous.
Suire JG; Bothwell RK. American Journal on Addictions 15(3): 252-255, 2006. (15 refs.)
A quasi-experimental design was implemented to evaluate the attitudes of alcoholics toward themselves and others after they had worked all twelve steps of an AA program compared to those who had not yet completed all twelve steps. One hundred individuals who were attending AA meetings were selected so that one half had completed all of the steps and the other half had not. Participants were tested in individual sessions during which they completed a series of questionnaires. Measures were taken of global self-esteem, social self-esteem, social confidence, network trust, fear of negative evaluation, need for approval, preoccupation with relationships, discomfort with closeness, relationships as secondary, and optimism. A principal components analysis of participants' responses to these measures revealed that the factors being assessed could be divided into one regarding interpersonal insecurity and another regarding social potency. The data showed that alcoholics who had been able to stay in the program and work through all twelve steps had lower levels of interpersonal insecurity than those who were just beginning to work the steps. No significant differences were found in social potency between those who had completed the steps and those who had not completed the steps. Further research is needed to clarify the specific nature of changes that occur in personality as alcoholics work through the twelve steps within community-based AA programs. Copyright 2006, American Academy of Psychiatrists in Alcoholism and Addictions.
Two-year outcomes of treatment for methamphetamine use.
Brecht ML; Greenwell L; von Mayrhauser C; Anglin MD. Journal of Psychoactive Drugs Supplement 3: 415-426, 2006. (87 refs.)
While evaluation research supports the general effectiveness of substance abuse treatment, there is not a comprehensive literature on treatment effectiveness for methamphetamine (MA) use. The authors consider three outcome measures - MA use, criminal activity, and employment-compared across three periods: 24-months pretreatment, during treatment, and 24-months post-treatment. Data are from an intensive natural history interview conducted two to three years after treatment for 349 randomly selected admissions to treatment for MA abuse in a large publicly-funded county treatment system. Through this naturalistic design, data provide a system-wide perspective on effectiveness of treatment as usual. Results showed reduction in MA use and crime during and following treatment and increased employment following treatment over pretreatment levels. Regression analyses showed higher levels of education and more time in treatment related to more positive post-treatment outcomes for all three measures. Lower percentage of post-treatment months with MA use also was related to more pretreatment MA-related problems, lower pretreatment MA use, and residential (compared to outpatient) treatment modality. Lower post-treatment criminal activity was also related to gender (being female), lower pretreatment criminal activity, and residential modality. Higher percentage of post-treatment months with employment also was related to gender (being male), ethnicity (not African-American), and higher pretreatment employment. Copyright 2006, Haight-Ashbury Publications.
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