The validity of the interviewer severity ratings in groups of ASI interviewers with varying training.

AIMS: This study evaluated the hypothesis that the subjective interviewer severity rating (ISR) summary indices of the intake Addiction Severity Index (ASI) of less trained interviewers are less valid than those of more highly trained interviewers. DESIGN: Baseline ASIs from three completed studies whose interviewers varied in degree of initial ASI training and subsequent quality assurance monitoring were examined. Associations between baseline ISRs and three other sets of ASI summary indices not based on interviewer ratings-composite scores, clinical indices and evaluation indices-were compared for three groups of interviewers with varying amounts of training. The assumption underlying these analyses was that more reliable ISRs, found in more trained interviewers, would be more highly associated with the other more objective indices. SETTING: Methadone maintenance patients in the Philadelphia and New York City areas. PARTICIPANTS: Thirty-five interviewers with the most intense training who administered 295 interviews; 10 interviewers with an intermediate level of training who administered 763 interviews; and eight identified (and other unidentified) least trained interviewers who administered a total of 276 interviews. Measurements and methods. Four sets of summary indices from the above ASIs. Both bivariate and multivariate analyses were performed. FINDINGS: The study found that the validity of the validity of ISRs was greater in more trained interviewers. CONCLUSIONS: Greater training and subsequent monitoring of ASI interviewers generally appears to be associated with increased ISR validity.

Predictive validity of the Addiction Severity Index's composite scores in the assessment of 2-year outcomes in a methadone maintenance population.

The current research tested the predictive validity of 6 of the 7 Composite Scores (CSs) of the Addiction Severity Index (ASI) in 310 methadone maintenance patients assessed at treatment entry using the ASI and other measures, and followed for 2 years. Logistic regression was used to estimate the sensitivity and specificity of the CSs at intake in predicting their respective validity criterion measures at follow up. Except for the Medical CS, each of the other 5 CS measures significantly predicted its validity criterion measure. The CSs measuring drug use, alcohol abuse, psychopathology, and legal problems had high specificity (88% [corrected] for the Drug CS, 91% for the Alcohol CS, 96% for the Legal CS, and 100% for the Psychological CS). The CSs measuring employment problems had high sensitivity (76%). The results support the predictive validity of most of the ASI CSs as measures of specific problems as well as the validity of the multidimensional construct on which the ASI is based.

Suggested specifications for a standardized Addiction Severity Index database.

The Addiction Severity Index (ASI) has become one of the most widely used instruments in the addictions field. As a result of its wide popularity, there are multiple versions of the instrument in use, and a wide range of computer systems used to collect and/or store ASI data. Thus, it has been difficult for different users and systems to share ASI data. This difficulty significantly reduces the value of the information for treatment providers, policy makers, and researchers. This article provides operational definitions and specifications for a "Standard ASI Database." Descriptions for standard variable names, data types, field lengths, value labels, range checks, and programming notes for all items in the fifth edition of the ASI are available electronically from the senior. Examples from the full protocol and the rationale for producing the Standard ASI Database elements are illustrated here. It is hoped that the format suggested will become the "industry standard" for ASI data storage among all users of the ASI and that, regardless of the software used or the method of data collection, there will be a single, standard format for all ASI databases. The potential applications from such a database would benefit treatment providers/clinicians and researchers as well as payers and policy makers.

A comparison of the predictive validity of four sets of baseline ASI summary indices.

This study compared the long-term predictive validity of original and new baseline Addiction Severity Index summary scores in methadone patients. The indices included the original Interviewer Severity Ratings (ISRs) and the new Clinical Indices (CIs), which use both lifetime and recent problem information, and the original Composite Scores (CSs) and Evaluation Indices (EIs), based on recent problems only. Outcomes were medical hospitalization, employment, alcohol intoxication, drug hospitalization, and psychiatric hospitalization in Months 7-24 poststudy entry and criminal charges in Months 0-24. Hierarchical logistic regression analyses were used in which 1 index was entered first and the other in the 2nd step. The reverse order of entry was used in a 2nd analysis. A final analysis set compared the best predictor from each of the 2 prior analysis sets. The CIs were superior to the other indices in predicting 3 of 6 outcomes (psychiatric hospitalization, drug hospitalization, and criminal charges); the EI was the best predictor of alcohol intoxication, and the CS the best predictor of unemployment.

Initial validation of a computer-administered Addiction Severity Index: the ASI-MV.

The Addiction Severity Index--Multimedia Version (ASI-MV) is a CD-ROM-based simulation of the interviewer-administered Addiction Severity Index (ASI). Clients in treatment (N = 202) self-administered the ASI-MV to examine the test-retest reliability, criterion validity, and convergent-discriminant validity of the ASI-MV. Excellent test-retest reliability was observed for composite scores and severity ratings. Criterion validity, tested against the interviewer-administered ASI, was good for the composite scores. For severity ratings, variable agreement was observed between the ASI-MV and each interviewer, suggesting poor interrater reliability among interviewers. This conclusion was bolstered by a finding of superior convergent-discriminant validity for both composite scores and severity ratings compared to the standard ASI. The ASI-MV is a viable alternative to the expensive and potentially unreliable interviewer-administered version.

Discovery of 1-[3-(aminomethyl)phenyl]-N-3-fluoro-2'-(methylsulfonyl)-[1,1'-biphenyl]-4-yl]-3-(trifluoromethyl)-1H-pyrazole-5-carboxamide (DPC423), a highly potent, selective, and orally bioavailable inhibitor of blood coagulation factor Xa.

Factor Xa (fXa) plays a critical role in the coagulation cascade, serving as the point of convergence of the intrinsic and extrinsic pathways. Together with nonenzymatic cofactor Va and Ca2+ on the phospholipid surface of platelets or endothelial cells, factor Xa forms the prothrombinase complex, which is responsible for the proteolysis of prothrombin to catalytically active thrombin. Thrombin, in turn, catalyzes the cleavage of fibrinogen to fibrin, thus initiating a process that ultimately leads to clot formation. Recently, we reported on a series of isoxazoline and isoxazole monobasic noncovalent inhibitors of factor Xa which show good potency in animal models of thrombosis. In this paper, we wish to report on the optimization of the heterocyclic core, which ultimately led to the discovery of a novel pyrazole SN429 (2b; fXa K(i) = 13 pM). We also report on our efforts to improve the oral bioavailability and pharmacokinetic profile of this series while maintaining subnanomolar potency and in vitro selectivity. This was achieved by replacing the highly basic benzamidine P1 with a less basic benzylamine moiety. Further optimization of the pyrazole core substitution and the biphenyl P4 culminated in the discovery of DPC423 (17h), a highly potent, selective, and orally active factor Xa inhibitor which was chosen for clinical development.

The relationship of psychiatric comorbidity to treatment outcomes in methadone maintained patients.

The authors examined the relationship of comorbid non-substance use psychiatric disorders to preadmission problem status and treatment outcomes in 278 methadone maintenance patients. Recent admissions were assigned DSM-III-R Axis I and II diagnoses according to structured diagnostic interviews. The Addiction Severity Index was administered at admission to assess past and current substance use and psychosocial problems and again 7 months later. Treatment retention and month 7 drug urinalysis results were also obtained. Across substance use and psychosocial domains, participants showed significant and comparable levels of improvement regardless of comorbidity. Comorbid participants received more concurrent psychiatric treatment which may have accounted for the lack of differential improvement among groups. Nevertheless, psychiatric comorbidity was associated with poorer psychosocial and medical status at admission and follow-up and participants with the combination of Axis I and II comorbidity had the most severe problems. Admission and month 7 substance use were, for the most part, not related to psychiatric comorbidity, although there was a trend indicating more treatment attrition for participants with personality disorders.

The effectiveness of two intensities of psychosocial treatment for cocaine dependence.

Structured treatments for cocaine dependence have been shown to be effective despite high attrition rates. What is unclear is what level of treatment intensity is needed to improve and sustain patient outcomes, especially among low SES urban residents. This study evaluated whether there were differences between two levels of treatment intensities for cocaine dependence in reducing substance use and improving health and social indicators. Ninety-four cocaine dependent predominantly African-American male veterans were randomly assigned to either a 12 h/week day hospital program (DH12) or a 6 h/week outpatient program (OP6) and were evaluated at baseline, during treatment and at 4 and 7 months post-treatment. Both treatments stressed abstinence, behavior change and prosocial adjustment and only differed in level of treatment intensity. During treatment measures included urine toxicologies, program attendance, treatment completion and aftercare attendance. Participants reported a 52% reduction in days of cocaine use and experienced significant improvements in employment and psychiatric functioning at seven months post-treatment. However, there was no significant difference between the DH12 and OP6 programs in terms of abstinence during treatment, treatment completion, treatment or aftercare attendance or any Addiction Severity Index (ASI)-related variable assessing level of functioning at 4 and 7 months. While future research with a larger community-based sample that includes female clients is necessary, the current findings demonstrate that a 6 h/week program is just as effective and thus has a significant cost savings compared to a 12 h/week treatment modality for cocaine dependence.

Generalizability of the clinical dimensions of the Addiction Severity Index to nonopioid-dependent patients.

Clinical dimensions (CDs) for the Addiction Severity Index recently have been established for application among opioid-dependent patients in methadone treatment (P. A. McDermott et al., 1996). This article examines the generalizability of the CDs to other substance-dependent patients. A sample of 2,027 adult nonopioid-dependent patients was identified; it comprised 581 primarily cocaine-dependent, 544 primarily alcohol-dependent, and 803 polydrug-dependent patients and 99 patients who were dependent on other varied drugs. Generality of dimensions was assessed through confirmatory components analysis, structural congruence, internal consistency, and variance partitioning in higher order factoring. The CDs were found generalizable overall and to specific nonopioid-dependent subgroups, and across patient gender and age, and to African American and White patients. Preliminary concurrent and predictive validity data supported the CD structure.

Prognostic significance of antisocial personality disorder in cocaine-dependent patients entering continuing care.

This study examined the relationship of antisocial personality disorder (APD) to response to continuing care treatments in a sample of cocaine-dependent patients. Patients (N = 127) were randomly assigned to 20-week standard group or individualized relapse prevention continuing care interventions after the completion of an initial treatment episode and followed up at 3, 6, and 12 months. APD and non-APD patients did not differ on retention in continuing care, substance use outcomes, social function outcomes, or experiences before or during cocaine relapse episodes. A diagnosis of APD was also not a predictor of differential response to the two continuing care interventions in the study. However, APD patients had worse medical and psychiatric problem severity than non-APD patients at entrance to continuing care and during follow-up. These results suggest that cocaine patients with APD who are in the continuing care phase of outpatient rehabilitation might benefit from additional medical and psychiatric treatment services.

Synthesis and activity studies of conformationally restricted alpha-ketoamide factor Xa inhibitors.

Conformationally restricted borolysine compounds containing a 2-(2-cyanophenylthio) benzoyl in the P3 position unexpectedly led to enhanced factor Xa inhibition. In an effort to improve both the potency and selectivity of this series by extending into the S' domain, we have replaced the boronic acid with alpha-ketoamides, utilizing a novel process that was developed in our labs.

Baseline prediction of 7-month cocaine abstinence for cocaine dependence patients.

A broad range of baseline subject variables was evaluated to identify predictors of 7-month cocaine use for 160 lower socioeconomic cocaine dependent male veteran patients participating in either an intensive 1-month day hospital (DH; n=90) or a 1-month inpatient (INP; n=70) treatment program. The baseline measures included sociodemographic variables, the seven Addiction Severity Index composite scores, cocaine urine toxicology, craving, the SCL-90 total score, and lifetime psychiatric diagnoses. Since a proportion of subjects who reported no use at follow-up had positive urines, both liberal and conservative data estimation strategies were employed for subjects without urine toxicology data at follow-up who had reported no use (21% of subjects). Analyses were done separately for the DH and INP subjects. Under the conservative definition of cocaine abstinence/use, univariate correlations of predictor variables with 7-month cocaine use revealed no statistically significant relationships. Under the liberal definition of cocaine abstinence/use, only one variable, greater severity of alcohol problems at intake predicted cocaine abstinence at outcome. Because of the inability to predict treatment success, originally planned logistic regression analyses were not undertaken. The findings point to the difficulty of predicting long-term outcomes in cocaine dependent patients based on baseline information and to the importance of obtaining objective data on cocaine use.

Contrasts between admitters and deniers of drug use.

This study evaluated the agreement between self-reported drug use and urinalysis results in 232 men and 27 women opiate-dependent patients at 2, 7, and 24 months following admission to methadone maintenance treatment. Differences between deniers, those who stated that they had not used drugs, but whose urinalysis results were positive, and admitters of drug use on several psychosocial variables, Axis I and II pathology and degree of psychopathy were examined. Generally, more drug use was acknowledged by self-report than found in urinalyses. Evidence was limited that deniers were consistently different than admitters. Deniers had a significantly greater increase from initial psychopathy ratings made using interview only information to final psychopathy ratings made utilizing interview and collateral information.

Familial risk for alcoholism and self-reported psychopathology.

Three groups of young men varying in familial alcoholism risk (high density, high risk [HDHR]; low density, high risk [LDHR]; and low risk [LR]) were compared on the 11 clinical scales of the Personality Assessment Inventory. Significant group differences were found on 9 scales, with scores of the HDHR group exceeding those of the other 2 groups. No differences were found between the LDHR and LR groups. When the proportion with pathological scores per scale was examined, significant group differences were still revealed on 7 scales. The HDHR group exceeded the other 2 groups, but the LDHR group also exceeded the LR group on several scales. These findings support the need to more finely characterize familial alcoholism risk than is provided by the typical high-risk-low-risk dichotomy. Finally, statistically controlling for normal variations in response style reduced the number of group differences, although the same patterns persisted.

Generality of Psychopathy Checklist-Revised factors over prisoners and substance-dependent patients.

The Psychopathy Checklist-Revised (PCL-R; R. D. Hare, 1991) is an often-used device for assessment of adult antisociality. This research examined generalizability by replicating the 2-factor model for a sample of 326 male prisoners and assessing its congruence and relative reliability and specificity among 620 substance-dependent patients. Generality was assessed also across addiction subtypes (opioid, cocaine, and alcohol), age, gender, and ethnicity. The 2-factor model was found inappropriate for the substance-dependent samples, whereas a unidimensional model represented by the PCL-R total score was found generalizable across prison and substance-dependent samples.

Prior treatment history and its impact on criminal recidivism.

This study examines the hypothesis that treatment is a cumulative process; that is, treatment success is best viewed in terms of the patient's entire treatment history, rather than the index treatment episode. Three-hundred and eight patients with a primary heroin addiction were studied for 2 years posttreatment. Using posttreatment arrests as the dependent variable, the effects of prior treatment were assessed. Those with six or more prior treatment episodes and who had been in treatment for 12 or more months during the most recent episode averaged only 0.2 arrests in the 2 years posttreatment, while those with no prior treatment, but 12 or more months in the recent treatment averaged 0.88 arrests. Logistic analysis found that each prior treatment reduced the probability of a posttreatment arrest by 25%. Based on a linear regression, patients with six or more treatments prior treatments averaged half the number of posttreatment arrests as someone with no treatments before the index episode.

Comparability of telephone and In-person structured clinical interview for DSM-III-R (SCID) diagnoses.

The SCID was administered twice, once by telephone and once in person (1 week later) to 41 college age men. For major depression (lifetime k =.64, current k =.66), results indicated good agreement. The lifetime occurrence estimate based on the telephone SCID diagnosis was lower than the in-person SCID estimate. Kappas for specific diagnoses were calculable for simple phobia (lifetime k =. 47, current k = .03) and social phobia (lifetime k =.29). Base rates were less than 10% for all individual diagnoses except lifetime major depression; therefore, the kappas may be unstable. For all diagnoses where there were any positive cases, percentages of negative agreement and specificity were high, whereas percentages of positive agreement and sensitivity were lower. Overall agreement was fair for specific lifetime diagnoses but poor for current diagnoses. These results suggest caution in assuming comparability of in-person and telephone SCID diagnoses. Circumstances under which a telephone SCID may be useful and ways to improve reliability are discussed.

The 2-year test-retest reliability of the Psychopathy Checklist Revised in methadone patients.

The 2-year test-retest reliability of the Psychopathy Checklist-Revised (PCL-R) was examined in 200 men and 25 women methadone patients. Stability of the PCL-R was generally good whether it was evaluated as a dichotomous or dimensional measure. Utilizing a diagnostic cutoff score of 25 or more the intraclass correlation coefficients (ICCs) were.48 for men and.67 for women. For the Total PCL-R score ICCs were.60 and.65 for men and women, respectively. Factor 1 was more reliably measured in women compared to men (.63 vs.43). For men, Factor 1 was significantly less reliable than Factor 2 or the Total score. For women, Factor 2 was significantly less reliable than the Total PCL-R score or Factor 1.

Continuing care for cocaine dependence: comprehensive 2-year outcomes.

This report presents 2-year outcome data from an outpatient continuing care study in which cocaine-dependent patients (N = 132) were randomly assigned to either standard group counseling (STND) or individualized relapse prevention (RP). Data on cocaine outcomes during the 6-month treatment phase of the study were presented in an earlier report (J. R. McKay, A. I. Alterman, J. S. Cacciola, M. R. Rutherford, & C. P. O'Brien, 1997). In the present report, a continuing care condition main effect was obtained on only 1 of 8 outcome variables examined. However, patients who endorsed a goal of absolute abstinence on entering continuing care had better cocaine use outcomes in RP than in STND, whereas the opposite was the case for those with less stringent abstinence goals. In addition, patients with current cocaine or alcohol dependence on entering continuing care who received RP had better cocaine use outcomes in Months 1-6 and better alcohol use outcomes in Months 13-24 than those in STND.

Antisocial personality disorder and psychopathy in cocaine-dependent women.

OBJECTIVE: The goal of this study was to examine the lifetime prevalence of antisocial personality disorder according to five diagnostic systems and the prevalence of psychopathy in a study group of women. The relationship between antisocial personality disorder and psychopathy was also examined. Finally, differences in treatment admission variables based on the presence or absence of antisocial personality disorder and/or psychopathy were evaluated. METHOD: Antisocial personality disorder was diagnosed in 137 treatment-seeking, cocaine-dependent women according to the Feighner criteria, Research Diagnostic Criteria (RDC), and DSM-III, DSM-III-R, and DSM-IV criteria. Psychopathy was assessed by the Revised Psychopathy Checklist. RESULTS: Rates of antisocial personality disorder varied from 76% according to the Feighner criteria to 11% for the RDC. Nineteen percent (N = 26) of the women scored in the moderate to high range on the Revised Psychopathy Checklist. All of these women were diagnosed with antisocial personality disorder according to DSM-III and Feighner criteria, but only 15 of the 26 were diagnosed according to DSM-III-R, 12 according to DSM-IV, and six with the RDC. Moderate levels of psychopathy were associated with a history of illegal activity at treatment admission, whereas antisocial personality disorder was not. CONCLUSIONS: There was relatively little diagnostic agreement between classification systems. This study indicates that antisocial personality disorder and psychopathy are not synonymous terms for the same disorder. Findings support a need to redefine antisocial personality disorder diagnostic criteria to make them gender neutral by including behaviors associated specifically with antisociality in women.