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...on Clinical Aspects

www.ProjectCork.org

Winter 2010

Fostering interdependent versus independent living in youth aging out of care through healthy relationships.

Antle BF; Johnson L; Barbee A; Sullivan D. Families in Society90(3): 309-315, 2009. (47 refs.)
Although the child welfare system has historically provided "independent living" services, youth aging out of foster care are at increased risk of negative outcomes such as poverty, substance abuse, and homelessness. This manuscript builds upon the recent shift to "interdependent livings" approaches by describing skills for various stages of relationships, including the youth's relationship with their caseworker and foster family, centering around the need to define clear expectations and model healthy relationship skills. Youth must recognize their risk patterns and need for professional support, and develop educational/vocational goals for mentoring. Future relationships often include reconnecting with birth families and dating/romantic relationships, requiring an exploration of physical and emotional safety and establishment of healthy patterns for life-long relationships.

Health conditions in methamphetamine-dependent adults 3 years after treatment.

Mooney LJ; Glasner-Edwards S; Marinelli-Casey P; Hillhouse M; Ang A; Hunter J et al. Journal of Addiction Medicine3(3): 155-163, 2009. (59 refs.)
Objectives: Medical conditions in methamphetamine (MA) users have not been well characterized. Using both self-report and physical examination data, the aims of this study were to (1) describe the frequency of medical conditions in a sample of MA users 3 years posttreatment; (2) evaluate the association between medical conditions and MA use frequency; and (3) examine the relationship of route of administration with medical outcomes. Methods: MA-dependent adults (N = 301) who participated in the Methamphetamine Treatment Project were interviewed and examined 3 years after treatment. Medical, demographic, and substance use characteristics were assessed using the Addiction Severity Index and Life Experiences Timeline. Current and lifetime medical conditions, electrocardiogram characteristics, and physical examination abnormalities were assessed. Results: Among the most frequently reported lifetime conditions were wounds and burns (40.5%, N = 122) and severe dental problems (33%, N = 99), and a significant proportion of the sample evidenced prolonged corrected QT interval (19.6%, N = 43). Although health conditions were not associated with MA use frequency during follow-up, intravenous MA use was significantly associated with missing teeth (odds ratio = 2.4; 95% confidence interval, 1.2-4.7) and hepatitis C antibodies (odds ratio = 13.1; confidence interval, 5.6-30.1). Conclusion: In this sample of MA users, dental problems and corrected QT prolongation were observed at elevated rates. Although posttreatment MA use frequency was not associated with a majority of medical outcomes, intravenous MA use exacerbated risk for dental pathology and hepatitis C. Longer term follow-up research is needed to elucidate health trajectories of MA users.

A conceptual model predicting internalizing problems in middle childhood among children of alcoholic and nonalcoholic fathers: The role of marital aggression.

Eiden RD; Molnar DS; Colder C; Edwards EP; Leonard KE. Journal of Studies on Alcohol and Drugs 70(5): 741-750, 2009. (43 refs.)
Objective: The purpose of this study was to test a conceptual model predicting children's anxiety/depression in middle childhood in a community sample of children with parents who had alcohol problems (n = 112) and those without alcohol problems (n = 101). The conceptual model examined the role of parents' alcohol diagnoses, depression, and antisocial behavior among parents of children ages 12 months to kindergarten age in predicting marital aggression and parental aggravation. Higher levels of marital aggression and parental aggravation were hypothesized to predict children's depression/anxiety within time (18 months to kindergarten age and, prospectively, to age during fourth grade). Method: The sample was recruited front New York State birth records when the children were 12 months old. Assessments were conducted at 12, 18, 24, and 36 months; at kindergarten age; and during fourth grade, Results: Children with alcoholic fathers had higher depression/anxiety scores according to parental reports but not self-reports. Structural equations modeling was largely supportive of the conceptual model. Fathers' alcoholism was associated with higher child anxiety via greater levels of marital aggression among families with alcohol problems. Results also indicated that there was a significant indirect association between parents' depression symptoms and child anxiety via marital aggression. Conclusions: The results highlight the nested nature of risk characteristics in alcoholic families and the important role of marital aggression in predicting children's anxiety/depression. Interventions targeting both parents' alcohol problems and associated marital aggression are likely to provide the dual benefits of improving family interactions and lowering risk of children's internalizing behavior problems.

A qualitative study on the initiation into injection drug use: Necessary and background processes.

Khobzi N; Strike C; Cavalieri W; Bright R; Myers T; Calzavara L et al. Addiction Research & Theory17(5): 546-559, 2009. (16 refs.)
Previous literature has identified several factors associated with the initiation of injection drug use; we add to this literature by focussing on the biological, psychosocial, socio-cultural and socio-structural processes that play a role in injection initiation. We identified three necessary processes. Firstly, one must already have developed a conception of drugs as creating desired effects. Secondly, initiation is born out of a social context through interaction with injection drug users. Lastly, the medical mismanagement of pain was a necessary process for a small number of participants. This article also sheds some light on how and why such necessary processes develop. In general, the majority of the participants indicated backgrounds of intense psychosocial and socio-structural hardship. An unstable family life, childhood abuse and environments where drug use is prominent all helped to reinforce a sense of inevitability in some participants.

A randomized clinical trial of methadone maintenance for prisoners: Results at 12 months post-release.

Kinlock TW; Gordon MS; Schwartz RP; Fitzgerald TT; O'Grady KE. Journal of Substance Abuse Treatment 37(3): 277-285, 2009. (63 refs.)
This study examined the impact of prison-initiated methadone maintenance at 12 months postrelease. Males with preincarceration heroin dependence (N = 204) were randomly assigned to (a) Counseling Only: counseling in prison, with passive referral to treatment upon release; (b) Counseling + Transfer: counseling in prison with transfer to methadone maintenance treatment upon release; and (c) Counseling + Methadone: counseling and methadone maintenance in prison, continued in the community upon release. The mean number of days in community-based drug abuse treatment were, respectively, Counseling Only, 23.1; Counseling + Transfer, 91.3; and Counseling + Methadone, 166.0 (p < .01); all pairwise comparisons were statistically significant (all ps < .01). Counseling + Methadone participants were also significantly less likely than participants in each of the other two groups to be opioid-positive or cocaine-positive according to urine drug testing. These results support the effectiveness of prison-initiated methadone for males in the United States. Further study is required to confirm the findings for women.

Alcohol biomarkers in patients admitted for trauma.

Fleming M; Bhamb B; Schurr M; Mundt M; Williams A. Alcoholism: Clinical and Experimental Research 33(10): 1777-1781, 2009. (23 refs.)
Background: To assess the value of blood alcohol levels (BAL) and carbohydrate-deficient transferrin (CDT) in trauma patients. Methods: A prospective study was conducted among 213 patients admitted to a university hospital after trauma. Outcomes of interest included the development of alcohol withdrawal, infections, respiratory problems, cardiac events, thromboembolism, and length of stay. Results : The majority (78%) of the trauma patients in the study was males over the age of 18. Seventy-five percent were reported drinking an alcohol-containing beverage in the previous 30 days, 34% had >= 5 heavy drinking days, and 18.7% met current DSM-IV criteria for alcohol abuse and 13.1% current criteria for dependence. Twenty-two percent (n = 48) had a positive BAL and 14% (n = 30) a CDT level > 2.5%. Twelve percent (n = 27) of the sample developed alcohol withdrawal and 55% (n = 113) had one or more adverse health events during their hospitalization. The development of alcohol withdrawal was associated with an admission CDT > 2.5% (KH2: 4.77, p < 0.029) and/or a positive BAL (KH2: 54.01, p < 0.001). The alcohol biomarkers identified 13 male and 3 female high-risk patients (7.4% of the total sample) who denied excessive alcohol use, and who would have been missed if these markers were not used. A composite morbidity trauma score composed of 25 adverse health events was associated with a positive BAL (p < 0.022). Conclusion: The study provides additional empirical evidence that supports the use of BAL in all patients admitted for trauma. The usefulness of CDT in trauma patients remains unclear and will require larger samples in more critically ill patients.

Alcoholics with a history of heroin consumption: Clinical features and chronology of substance abuse.

Ceccanti M; Vitali M. Heroin Addiction and Related Clinical Problems11(3): 35-38, 2009. (6 refs.)
In our clinical experience, when alcohol is used as a surrogate for heroin, social adjustment improves, although the metabolic destiny does not change, and the medical outcome is worsened to some extent by alcoholism itself. Alcohol abusers with a history of heroin use engage in alcohol use in a more intensive way. Alcohol consumption is higher right from the start, and reaches higher maximum levels, whereas heroin use dwindles, in some cases to extinction. The results of our studies support the hypothesis that alcohol replaces opiate craving in former heroin consumers who break away from heroin, and often become alcohol abusers or at least increase their use of alcohol.

Are opioid dependence and methadone maintenance treatment (MMT) documented in the medical record? A patient safety issue.

Walley AY; Farrar D; Cheng DM; Alford DP; Samet JH. Journal of General Internal Medicine24(9): 1007-1011, 2009. (24 refs.)
BACKGROUND: Opioid-dependent patients often have co-occurring chronic illnesses requiring medications that interact with methadone. Methadone maintenance treatment (MMT) is typically provided separately from medical care. Hence, coordination of medical care and substance use treatment is important to preserve patient safety. OBJECTIVE: To identify potential safety risks among MMT patients engaged in medical care by evaluating the frequency that opioid dependence and MMT documentation are missing in medical records and characterizing potential medication-methadone interactions. METHODS: Among patients from a methadone clinic who received primary care from an affiliated, but separate, medical center, we reviewed electronic medical records for documentation of methadone, opioid dependence, and potential drug-methadone interactions. The proportions of medical records without opioid dependence and methadone documentation were estimated and potential medication-methadone interactions were identified. RESULTS: Among the study subjects (n=84), opioid dependence documentation was missing from the medical record in 30% (95% CI, 20%-41%) and MMT documentation was missing from either the last primary care note or the last hospital discharge summary in 11% (95% CI, 5%-19%). Sixty-nine percent of the study subjects had at least 1 medication that potentially interacted with methadone; 19% had 3 or more potentially interacting medications. CONCLUSION: Among patients receiving MMT and medical care at different sites, documentation of opioid dependence and MMT in the medical record occurs for the majority, but is missing in a substantial number of patients. Most of these patients are prescribed medications that potentially interact with methadone. This study highlights opportunities for improved coordination between medical care and MMT.

Assessing non-injecting heroin use in Birmingham, UK: A comparison of characteristics and reasons for non-injecting in samples of never-injected and formerly-injecting heroin users in contact with adult drug treatment.

Smith AC; Best D; Day E. Journal of Drug Issues 39(3): 477-493, 2009. (25 refs.)
Aims: To explore reasons why individuals who prefer to use heroin by routes other than injection have abstained from injecting despite entrenched heroin use. Methods: A cross-sectional interview using structured and semi-structured questions was carried out with 40 non-injecting heroin users (20 former injectors and 20 who had never injected) recruited at two Community Drug Team sites in Birmingham, UK. Results: The most endorsed reason for non-injection was worry about appearance. Additional reasons included identity issues and stigmatized status of injecting. 'Never injectors' were younger, more likely to have an educational qualification, had higher measured heroin dependence, and lower prior exposure to injecting than former injectors. (Each of these measures was statistically significant.) There was no difference between the groups in estimated prevalence of injection among peers. Conclusions: This study points to continuity between injecting and non-injecting cultures, challenges the concept of injection as a natural progression from non-injecting heroin use, and highlights personal addiction career factors in injection transitions.

Circumstances and witness characteristics associated with overdose fatality.

Bohnert ASB; Tracy M; Galea S. Annals of Emergency Medicine 54(4): 618-624, 2009. (40 refs.)
Study objective: Emergency physicians have an opportunity to provide overdose fatality prevention interventions to individuals at risk for experiencing or witnessing an overdose to reduce fatality. The present study uses data about the most recent overdose observed by a sample of inner-city drug users to determine the circumstances of overdose that are associated with overdose fatality. Methods: Participants (n=690) aged 18 years or older were recruited with targeted street outreach. All participants had used heroin or cocaine in the previous 2 months and had witnessed at least 1 overdose. Survey data included the circumstances of the last overdose witnessed, including actions taken, drug use behavior, the location of the event, and whether or not the overdose was fatal (the outcome measure). Results: One hundred fifty-two (21.7%) of the witnessed overdoses were fatal. Witness powdered cocaine use (adjusted odds ratio 1.6; 95% confidence interval [CI] 1.0 to 2.6) and injection drug history (adjusted odds ratio=0.5; 95% CI 0.3 to 0.9) were associated with the last witnessed overdose being fatal. Witnessed overdoses that occurred in public or abandoned buildings compared with homes were more likely to be fatal (adjusted odds ratio=1.9; 95% CI 1.0 to 3.5), as were overdoses in which witnesses sought outside medical help (adjusted odds ratio=1.5; 95% CI 1.0 to 2.1). Conclusion: Future prevention interventions may fruitfully target users of powdered cocaine, drug users without a history of injecting, and individuals who use drugs in public or abandoned buildings for brief interventions on responding when witnessing an overdose to reduce mortality.

Client and service characteristics associated with addiction treatment completion of clients with co-occurring disorders.

Mangrum LF. Addictive Behaviors 34(10, Special Issue): 898-904, 2009. (53 refs.)
The study examines client and service characteristics of addiction treatment completers and non-completers with co-occurring disorders (COD). On demographic variables, completers were more likely to be male and homeless. In the psychiatric domain, a greater proportion of completers received diagnoses of depression and generalized anxiety disorder, whereas non-completers were more often diagnosed with bipolar disorder and posttraumatic stress disorder. No group differences were found in client-reported psychiatric symptom severity; however, non-completers were rated by clinicians as having more severe symptoms in the areas of interpersonal sensitivity, depression, and hostility. In the area of substance use patterns, no differences were found in primary substance of abuse but completers reported more days of use during the month prior to treatment. Completers also had a greater history of both prior detox and non-detox treatment. At discharge, completers achieved higher rates of past month abstinence and AA attendance, but no differences were found in length of stay in treatment. Examination of recovery support services utilization revealed that completers more often received peer mentoring services. Greater proportions of the non-completer group received educational support, clothing, medical care, and employment assistance. These results suggest that future studies are needed in examining possible differential treatment response by diagnostic category and the potential role of peer mentoring in enhancing addiction treatment completion of COD clients.

Effectiveness of community treatments for heroin and crack cocaine addiction in England: A prospective, in-treatment cohort study.

Marsden J; Eastwood B; Bradbury C; Dale-Perera A; Farrell M; Hammond P et al. Lancet 374(9697): 1262-1270, 2009. (35 refs.)
Background: Addiction to heroin and crack cocaine is debilitating and persistent, but such disorders are treatable. We present the first effectiveness study of the main community interventions for addiction to heroin and crack cocaine in England, using data from the National Drug Treatment Monitoring System (NDTMS). Methods: The study cohort consisted of all adults with a heroin or crack cocaine addiction, or both, who started pharmacological treatment (n=18428 patients) or psychosocial treatment (n=2647) between Jan 1 and Nov 30, 2008, received at least 6 months' treatment or were discharged by the study endpoint (May 31, 2009), and had outcome data submitted to the NDTMS. Effectiveness was assessed from change in days of heroin or crack cocaine use, or both in the 28 days before the start of treatment and in the 28 days before review. Findings 14656 clients-74% of the cohort eligible for analysis at review with available data-were analysed at the study endpoint. During the 28 days before review, 37% (5016/13 542) of heroin users abstained from heroin and 52% (3941/7636) of crack cocaine users abstained from crack cocaine. A higher proportion of users of heroin only abstained than did users of both heroin and crack cocaine (42% [2465/5863] vs 33% [2551/7679]; OR 1.46, 95% CI 1.36-1.56), and more users of crack cocaine only abstained than did users of both drugs (57% [295/522] vs 51% [3646/7114]; 1.24, 1.03-1.48). Overall heroin use reduced by 14.5 days (95% CI 14.3-14.7) and crack cocaine use by 7.7 days (7.5-7.9). For clients given pharmacological treatment, reduction in days of heroin use was smaller for users of both heroin and crack cocaine than for users of heroin alone (p<0.0001), but this differential effectiveness was not recorded for psychosocial treatment in heroin or crack cocaine users compared with users of both drugs. Interpretation: The first 6 months of pharmacological or psychosocial treatment is associated with reduced heroin and crack cocaine use, but the effectiveness of pharmacological treatment is less pronounced for users of both drugs. New strategies are needed to treat individuals with combined heroin and crack cocaine addiction. Funding National Treatment Agency for Substance Misuse. >

Effectiveness of Making Alcoholics Anonymous easier: A group format 12-step facilitation approach.

Kaskutas LA; Subbaraman MS; Witbrodt J; Zemore SE. Journal of Substance Abuse Treatment 37(3): 228-239, 2009. (52 refs.)
Most treatment programs recommend clients attend 12-step groups, but many drop out posttreatment. The effectiveness of Making Alcoholics Anonymous [AA] Easier (MAAEZ), a manual-guided intervention designed to help clients connect with individuals encountered in AA, was tested using an "OFF/ON" design (n = 508). MAAEZ effectiveness was determined by comparing abstinence rates of participants recruited during ON and OFF conditions and by studying the effect of the number of MAAEZ sessions attended. At 12 months, more clients in the ON condition (vs. OFF) reported past 30-day abstinence from alcohol (p = .012), drugs (p = .009), and both alcohol and drugs (p = .045). In multivariate analyses, ON condition participants had significantly increased odds of abstinence from alcohol (odds ratio [OR] = 1.85) and from drugs (OR = 2.21); abstinence odds also increased significantly for each additional MAAEZ session received. MAAEZ appeared especially effective for those with more prior AA exposure, severe psychiatric problems, and atheists/agnostics. MAAEZ represents an evidence-based intervention that is easily implemented in existing treatment programs.

Increased drinking in a trial of treatments for marijuana dependence: Substance substitution?

Kadden RM; Litt MD; Kabela-Cormier E; Petry NM. Drug and Alcohol Dependence 105(1/2): 168-171, 2009. (16 refs.)
This report examines whether participants in a study of treatments for marijuana dependence may have increased their use of alcohol when they reduced or ceased marijuana use. Participants were randomly assigned to one of four psychosocial treatments and followed at 3-month intervals for 1 year. Findings are from 207 cases with data at posttreatment and at least one other follow-up. 73% of cases reported an increase of at least 10% in drinking days over their level at intake, and 65% reported an increase of at least 10% in drinks per drinking day. Drinking increases were not related to treatment condition nor to change in marijuana use, but were related to baseline drinking: those with less baseline drinking tended to increase their drinking during treatment and those with more baseline drinking reported less drinking during treatment. Thereafter, drinking levels remained fairly stable throughout the follow-up year. The results are most likely reflective of a regression to the mean effect, and indicate that use of alcohol and marijuana are independent of one another.

Medical Classics. Alcoholics Anonymous: "The Big Book" (editorial).

Loder E. British Medical Journal 339(b4387), 2009. (0 refs.)
This editorial is a response to the 60the anniversary of the Alcoholics Anonymous' classic publication known as "The Big Book." The editor notes that the initial response of the medical community to AA, as witnessed by the editorial in the Journal of the American Medical Association , was dismissive. The editorial in JAMA described "the AA method as a 'curious combination of organizing propaganda and religious exhortation' and decried it as among the 'considerable number of other forms of quack treatment' that had 'sprung up' to treat alcoholism." While the JAMA reviewer opined, however, that the one valid element "is the recognition of the seriousness of addiction to alcohol", but other than this the book was said to be of "no scientific interest." In this editorial it is noted that AA has become a commonly used treatment approach, and might well be seen as among the very early "lifestyle" interventions, meaning that changes in personal habits are advocated rather than procedures or drugs.

Rapid cognitive screening of patients with substance use disorders.

Copersino ML; Fals-Stewart W; Fitzmaurice G; Schretlen DJ; Sokoloff J; Weiss RD. Experimental and Clinical Psychopharmacology 17(5): 337-344, 2009. (64 refs.)
To date, there has not been a time-efficient and resource-conscious way to identify cognitive impairment in patients with substance use disorders (SUDs). In this study, we assessed the validity, accuracy, and clinical utility of a brief (10-min) screening instrument, the Montreal Cognitive Assessment (MoCA), in identifying cognitive impairment among patients with SUDs. The Neuropsychological Assessment Battery-Screening Module, a 45-min battery with known sensitivity to the mild to moderate deficits observed in patients with SUDs, was used as the reference criterion for determining agreement, rates of correct and incorrect decision classifications, and criterion-related validity for the MoCA. Classification accuracy of the MoCA, based on receiver operating characteristic (ROC) analysis, was strong, with an area under the ROC curve of 0.86, 95% confidence interval [0.75, 0.97]. The MoCA also showed acceptable sensitivity (83.3%) and specificity (72.9%) for the identification of cognitive impairment. Using a cutoff of 25 on the MoCA, the overall agreement was 75.0%; chance-corrected agreement (kappa) was 41.9%. These findings indicate that the MoCA provides a time-efficient and resource-conscious way to identify patients with SUDs and neuropsychological impairment, thus addressing a critical need in the addiction treatment research community.

Severity of baseline alcohol use as a moderator of brief interventions in the emergency department.

Blow FC; Ilgen MA; Walton MA; Czyz EK; McCammon R; Chermack ST et al. Alcohol and Alcoholism 44(5): 486-490, 2009. (30 refs.)
Aims: This study examines whether the severity of baseline alcohol consumption/consequences moderates the effect of an alcohol brief intervention (BI) in the emergency department (ED). Methods: Injured patients (N = 494) were recruited from an ED, randomly assigned to receive brief advice or not and completed a 12-month follow-up interview. Results: A significant interaction was found between severity of baseline alcohol consumption (i.e. average weekly, binge drinking) and receipt of a BI on alcohol consumption at 12 months. The form of this interaction indicates that the BI group tended to report lower alcohol consumption at follow-up than the untreated group especially in those who had reported high baseline consumption. Severity of alcohol consequences at baseline did not significantly impact the effect of the BI on 12-month outcomes. Conclusion: ED patients with higher alcohol consumption benefit from BI. In some cases, the BI's effects may be enhanced for patients who are heavier drinkers, perhaps due to a greater opportunity to develop a discrepancy between current behavior and future goals.

Social status, gender and alcohol-related problems: The Black young adult experience.

Godette DC; Edwards E; Ford CL; Strunin L; Heeren T; Kawachi I. Ethnicity & Health 14(5): 479-496, 2009. (52 refs.)
Objectives. Using data from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions, this study examined prevalence of drinking and related problems among five racial/ethnic groups aged 18-30. Design. Logistic regression analyses examined influences of gender and social status on alcohol-related problems among blacks, controlling for demographics. Results. Black drinkers were significantly less likely to be high-risk or risky/heavy episodic drinkers than all groups except Asians; and experienced lower prevalence of alcohol-related problems than whites and American Indians. Controlling for drinking, prevalence of alcohol-related problems among blacks was similar to other groups, except native Americans. Analyses of blacks revealed males, unemployed, and heaviest drinkers had highest prevalence of problems. Strong associations between drinking and problems remained consistent across black sub-groups defined by social status and gender. Conclusion. While blacks are not as engaged in risky/heavy drinking, they are not shielded from problems conditional on drinking patterns. Focus on alcohol-related problems among black males and unemployed is indicated.

The neurocircuitry of impaired insight in drug addiction. (review).

Goldstein RZ; Craig AD; Bechara A; Garavan H; Childress AR; Paulus MP et al. Trends In Cognitive Sciences13(9): 372-380, 2009. (80 refs.)
More than 80% of addicted individuals fail to seek treatment, which might reflect impairments in recognition of severity of disorder. Considered by some as intentional deception, such 'denial' might instead reflect dysfunction of brain networks subserving insight and self-awareness. Here we review the scant literature on insight in addiction and integrate this perspective with the role of: (l) the insula in interoception, self-awareness and drug craving; (ii) the anterior cingulate in behavioral monitoring and response selection (relevant to disadvantageous choices in addiction); (iii) the dorsal striatum in automatic habit formation; and (iv) drug-related stimuli that predict emotional behavior in addicted individuals, even without conscious awareness. We discuss implications for clinical treatment including the design of interventions to improve insight into illness severity in addiction.

Treatment philosophy and service delivery in a network of faith-based substance abuse treatment.

Sung HE; Chu D; Richter L; Shlosberg A. Families in Society 90(4): 390-398, 2009. (54 refs.)
This research examines how the treatment philosophy and clinical practice of the Teen Challenge USA (TC) -- a national network of faith-based recovery services -- differ from secular substance abuse treatment programs. Using survey data from 80 TC administrators and counselors and 68 non-TC counterparts randomly selected from secular providers of substance abuse treatment, TC and non-TC providers were compared on these dimensions: views on human nature and morality perspectives on substance abuse and its treatment, structural capacity of the program and facilities, characteristics of the treatment population, service availability and utilization, and staff profiles. Findings revealed important differences as well as interesting similarities between TC and non-TC programs. Recommendations based on these findings are offered to both faith-based and secular service providers.

Treatment, Alcoholics Anonymous, and 16-year changes in impulsivity and legal problems among men and women with alcohol use disorders.

Blonigen DM; Timko C; Moos BS; Moos RH. Journal of Studies on Alcohol and Drugs 70(5): 714-725, 2009. (76 refs.)
Objective: The link between impulsive personality traits and alcohol use disorders (AUDs) is well established. No studies, however, have investigated whether receipt of help for AUDs predicts change in impulsivity or whether such change is associated with relevant outcomes such as legal problems. The present study examined predictive associations between the duration of help for AUDs (Alcoholics Anonymous [AA], professional treatment) and impulsivity and legal problems over 16 years in men and women with AUDs. Method: Participants who were initially untreated for their AUDs (n(men) = 332 n(women) = 296) completed follow-up telephone interviews at 1 and 16 years after their baseline assessment. Results: Impulsivity and legal problems declined between baseline and the I-year and 16-year follow-ups among both women and men. A longer duration of participation in AA predicted a decline in impulsivity at both follow-up assessments, and, in turn, a decline in impulsivity predicted a decline in legal problems at Years 1 and 16. In addition, a longer duration of participation in AA predicted fewer legal problems at Year 1, and this association was moderated by gender (significant in men) and impulsivity (significant for individuals with higher baseline scores). Conclusions: The results highlight the potential for AA and professional treatment to reduce the expression of impulsivity and related disinhibitory traits and legal problems in individuals with AUDs.

Vocational rehabilitation and job accommodations for individuals with substance abuse disorders.

Walls RT; Moore LC; Batiste LC; Loy B. Journal of Rehabilitation 75(4): 35-44, 2009. (25 refs.)
In the present investigation, employment variables and workplace accommodation issues are examined for individuals with substance abuse disorders. In 1996, 2000, and 2004, there were 29,063 clients, 36,529 clients, and 35,473 clients, respectively, with substance abuse disorders served by the Vocational Rehabilitation (State-Federal) program. There were about 38,000 individuals with alcoholism and about 63,000 with drug addiction. During this same period (1996 to 2005), the Job Accommodation Network (JAN) handled cases for 475 employees, 806 employers, and 87 rehabilitation professionals, all involving alcoholism (715 cases), drug addiction (333 cases), or both (320 cases). Overall, the analyses compared and contrasted data for (a) disability, (b) gender, (c) education, (d) referral source, (e) accommodation inquiry source, (f) types of services, (g) job accommodations, (h) case service costs, (i) rehabilitation closure status, (j) occupational outcomes, (k) industries, (I) ADA, and (m) primary issues. The literature reviewed and the present findings affirm the value of a strong employment orientation in successful substance abuse treatment.