Peer recovery support for individuals with substance use disorders: assessing the evidence.

In recent years, peer recovery support services have become an accepted part of the treatment of substance use disorders, providing a more extensive array of services than typically associated with mutual support groups. Peer providers may help consumers set recovery goals, develop a plan, and work toward and maintain recovery. In this literature review, the last in the Assessing the Evidence Base (AEB) Series, the authors review the evidence supporting peer recovery support services, noting that more research is needed to distinguish the effects of peer recovery support from other recovery support activities.

Skill building: assessing the evidence.

OBJECTIVE: Skill building for adults involves multiple approaches to address the complex problems related to serious mental illness. Individuals with schizophrenia are often the research focus. The authors outline key skill-building approaches and describe their evidence base. METHODS: Authors searched meta-analyses, research reviews, and individual studies from 1995 through March 2013. Databases surveyed were PubMed, PsycINFO, Applied Social Sciences Index and Abstracts, Sociological Abstracts, Social Services Abstracts, Published International Literature on Traumatic Stress, ERIC, and CINAHL. Authors chose from three levels of evidence (high, moderate, and low) on the basis of benchmarks for the number of studies and quality of their methodology. They also described the evidence of service effectiveness. RESULTS: Over 100 randomized controlled trials and numerous quasi-experimental studies support rating the level of evidence as high. Outcomes indicate strong effectiveness for social skills training, social cognitive training, and cognitive remediation, especially if these interventions are delivered through integrated approaches, such as Integrated Psychological Therapy. Results are somewhat mixed for life skills training (when studied alone) and cognitive-behavioral approaches. The complexities of schizophrenia and other serious mental illnesses call for individually tailored, multimodal skill-building approaches in combination with other treatments. CONCLUSIONS: Skill building should be a foundation for rehabilitation services covered by comprehensive benefit plans that attend to the need for service packages with multiple components delivered in various combinations. Further research should demonstrate more conclusively the long-term effectiveness of skill building in real-life situations, alone and in various treatment combinations. Studies of diverse subpopulations are also needed.

Trauma-focused cognitive-behavioral therapy for children and adolescents: assessing the evidence.

OBJECTIVE: Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) is a conjoint parent-child treatment developed by Cohen, Mannarino, and Deblinger that uses cognitive-behavioral principles and exposure techniques to prevent and treat posttraumatic stress, depression, and behavioral problems. This review defined TF-CBT, differentiated it from other models, and assessed the evidence base. METHODS: Authors reviewed meta-analyses, reviews, and individual studies (1995 to 2013). Databases surveyed were PubMed, PsycINFO, Applied Social Sciences Index and Abstracts, Sociological Abstracts, Social Services Abstracts, PILOTS, the ERIC, and the CINAHL. They chose from three levels of research evidence (high, moderate, and low) on the basis of benchmarks for number of studies and quality of their methodology. They also described the evidence of effectiveness. RESULTS: The level of evidence for TF-CBT was rated as high on the basis of ten RCTs, three of which were conducted independently (not by TF-CBT developers). TF-CBT has demonstrated positive outcomes in reducing symptoms of posttraumatic stress disorder, although it is less clear whether TF-CBT is effective in reducing behavior problems or symptoms of depression. Limitations of the studies include concerns about investigator bias and exclusion of vulnerable populations. CONCLUSIONS: TF-CBT is a viable treatment for reducing trauma-related symptoms among some children who have experienced trauma and their nonoffending caregivers. Based on this evidence, TF-CBT should be available as a covered service in health plans. Ongoing research is needed to further identify best practices for TF-CBT in various settings and with individuals from various racial and ethnic backgrounds and with varied trauma histories, symptoms, and stages of intellectual, social, and emotional development.

Peer support services for individuals with serious mental illnesses: assessing the evidence.

OBJECTIVE: This review assessed the level of evidence and effectiveness of peer support services delivered by individuals in recovery to those with serious mental illnesses or co-occurring mental and substance use disorders. METHODS: Authors searched PubMed, PsycINFO, Applied Social Sciences Index and Abstracts, Sociological Abstracts, Social Services Abstracts, Published International Literature on Traumatic Stress, the Educational Resources Information Center, and the Cumulative Index to Nursing and Allied Health Literature for outcome studies of peer support services from 1995 through 2012. They found 20 studies across three service types: peers added to traditional services, peers in existing clinical roles, and peers delivering structured curricula. Authors judged the methodological quality of the studies using three levels of evidence (high, moderate, and low). They also described the evidence of service effectiveness. RESULTS: The level of evidence for each type of peer support service was moderate. Many studies had methodological shortcomings, and outcome measures varied. The effectiveness varied by service type. Across the range of methodological rigor, a majority of studies of two service types--peers added and peers delivering curricula--showed some improvement favoring peers. Compared with professional staff, peers were better able to reduce inpatient use and improve a range of recovery outcomes, although one study found a negative impact. Effectiveness of peers in existing clinical roles was mixed. CONCLUSIONS: Peer support services have demonstrated many notable outcomes. However, studies that better differentiate the contributions of the peer role and are conducted with greater specificity, consistency, and rigor would strengthen the evidence.

Residential treatment for individuals with substance use disorders: assessing the evidence.

OBJECTIVE: Residential treatment is a commonly used direct intervention for individuals with substance use or co-occurring mental and substance use disorders who need structured care. Treatment occurs in nonhospital, licensed residential facilities. Models vary, but all provide safe housing and medical care in a 24-hour recovery environment. This article describes residential treatment and assesses the evidence base for this service. METHODS: Authors evaluated research reviews and individual studies from 1995 through 2012. They searched major databases: PubMed, PsycINFO, Applied Social Sciences Index and Abstracts, Sociological Abstracts, and Social Services Abstracts. They chose from three levels of evidence (high, moderate, and low) and described the evidence of service effectiveness. RESULTS: On the basis of eight reviews and 21 individual studies not included in prior reviews, the level of evidence for residential treatment for substance use disorders was rated as moderate. A number of randomized controlled trials were identified, but various methodological weaknesses in study designs-primarily the appropriateness of the samples and equivalence of comparison groups-decreased the level of evidence. Results for the effectiveness of residential treatment compared with other types of treatment for substance use disorders were mixed. Findings suggested either an improvement or no difference in treatment outcomes. CONCLUSIONS: Residential treatment for substance use disorders shows value and merits ongoing consideration by policy makers for inclusion as a covered benefit in public and commercially funded plans. However, research with greater specificity and consistency is needed.

Substance abuse intensive outpatient programs: assessing the evidence.

OBJECTIVE: Substance abuse intensive outpatient programs (IOPs) are direct services for people with substance use disorders or co-occurring mental and substance use disorders who do not require medical detoxification or 24-hour supervision. IOPs are alternatives to inpatient and residential treatment. They are designed to establish psychosocial supports and facilitate relapse management and coping strategies. This review assessed the evidence base for IOPs. METHODS: Authors searched major databases: PubMed, PsycINFO, Applied Social Sciences Index and Abstracts, Sociological Abstracts, Social Services Abstracts, Published International Literature on Traumatic Stress, ERIC, and CINAHL. They identified 12 individual studies and one review published between 1995 and 2012. They chose from three levels of research evidence (high, moderate, and low) based on benchmarks for the number of studies and quality of their methodology. They also described evidence of service effectiveness. RESULTS: Based on the quality of trials, diversity of settings, and consistency of outcomes, the level of evidence for IOPs was rated high. Multiple randomized trials and naturalistic analyses that compared IOPs with inpatient or residential care found comparable outcomes. All studies reported reductions in alcohol and drug use. However, substantial variability in the operationalization of IOPs and outcome measures was apparent. CONCLUSIONS: IOPs are an important part of the continuum of care for substance use disorders. They are as effective as inpatient treatment for most individuals. Public and commercial health plans should consider IOP services as a covered health benefit. Standardization of the elements included in IOPs may improve their quality and effectiveness.

Consumer and family psychoeducation: assessing the evidence.

OBJECTIVE: Psychoeducation provides adult consumers who have serious mental illness or co-occurring substance use disorders with information to support recovery. Some models also provide this service to family members. This review examined the evidence base for psychoeducation models in group and individual formats. METHODS: Authors reviewed meta-analyses, research reviews, and individual studies from 1995 through 2012. Databases surveyed were PubMed, PsycINFO, Applied Social Sciences Index and Abstracts, Sociological Abstracts, Social Services Abstracts, Published International Literature on Traumatic Stress, the Educational Resources Information Center, and the Cumulative Index to Nursing and Allied Health Literature. Authors chose from three levels of evidence (high, moderate, and low) on the basis of benchmarks for the number of studies and quality of their methodology. They also described service effectiveness. RESULTS: More than 30 randomized controlled trials (RCTs) of consumer psychoeducation and more than 100 RCTs of family psychoeducation provide a high level of evidence for the effectiveness of each model. Reviews of consumer psychoeducation found that experimental groups had reduced nonadherence (primarily with medication regimens), fewer relapses, and reduced hospitalization rates compared with control groups. Some studies found significant improvements in social and global functioning, consumer satisfaction, and quality of life. Multifamily psychoeducation groups (the focus of numerous studies) were associated with significantly improved problem-solving ability and a reduced burden on families, compared with control groups, among other strong outcome effects. CONCLUSIONS: Psychoeducation should be included in covered services. Group and family interventions are especially powerful. Future research should assess psychoeducation models with children and adolescents and with individuals from various racial and ethnic backgrounds.

Behavioral management for children and adolescents: assessing the evidence.

OBJECTIVE: Behavioral management services for children and adolescents are important components of the mental health service system. Behavioral management is a direct service designed to help develop or maintain prosocial behaviors in the home, school, or community. This review examined evidence for the effectiveness of family-centered, school-based, and integrated interventions. METHODS: Literature reviews and individual studies published from 1995 through 2012 were identified by searching PubMed, PsycINFO, Applied Social Sciences Index and Abstracts, Sociological Abstracts, Social Services Abstracts, Published International Literature on Traumatic Stress, the Educational Resources Information Center, and the Cumulative Index to Nursing and Allied Health Literature. Authors chose from three levels of evidence (high, moderate, and low) based on benchmarks for the number of studies and quality of their methodology. They also described the evidence of service effectiveness. RESULTS: The level of evidence for behavioral management was rated as high because of the number of well-designed randomized controlled trials across settings, particularly for family-centered and integrated family- and school-based interventions. Results for the effectiveness of behavioral management interventions were strong, depending on the type of intervention and mode of implementation. Evidence for school-based interventions as an isolated service was mixed, partly because complexities of evaluating group interventions in schools resulted in somewhat less rigor. CONCLUSIONS: Behavioral management services should be considered for inclusion in covered plans. Further research addressing the mechanisms of effect and specific populations, particularly at the school level, will assist in bolstering the evidence base for this important category of clinical intervention.

Permanent supportive housing: assessing the evidence.

OBJECTIVES: Permanent supportive housing provides safe, stable housing for people with mental and substance use disorders who are homeless or disabled. This article describes permanent supportive housing and reviews research. METHODS: Authors reviewed individual studies and literature reviews from 1995 through 2012. Databases surveyed were PubMed, PsycINFO, Applied Social Sciences Index and Abstracts, Sociological Abstracts, Social Services Abstracts, Published International Literature on Traumatic Stress, the Educational Resources Information Center, and the Cumulative Index to Nursing and Allied Health Literature. The authors chose from three levels of evidence (high, moderate, and low) on the basis of benchmarks for the number of studies and quality of their methodology. They also described the evidence of service effectiveness. RESULTS: The level of evidence for permanent supportive housing was graded as moderate. Substantial literature, including seven randomized controlled trials, demonstrated that components of the model reduced homelessness, increased housing tenure, and decreased emergency room visits and hospitalization. Consumers consistently rated this model more positively than other housing models. Methodological flaws limited the ability to draw firm conclusions. Results were stronger for studies that compared permanent supportive housing with treatment as usual or no housing rather than with other models. CONCLUSIONS: The moderate level of evidence indicates that permanent supportive housing is promising, but research is needed to clarify the model and determine the most effective elements for various subpopulations. Policy makers should consider including permanent supportive housing as a covered service for individuals with mental and substance use disorders. An evaluation component is needed to continue building its evidence base.

Medication-assisted treatment with buprenorphine: assessing the evidence.

OBJECTIVE: Buprenorphine maintenance treatment (BMT) and methadone maintenance treatment (MMT) are pharmacological treatment programs for individuals with opioid use disorders. MMT is discussed in a companion article. This article describes BMT and reviews available research on its efficacy. METHODS: Authors reviewed meta-analyses, systematic reviews, and individual studies of BMT from 1995 through 2012. Databases surveyed were PubMed, PsycINFO, Applied Social Sciences Index and Abstracts, Sociological Abstracts, Social Services Abstracts, and Published International Literature on Traumatic Stress. They chose from three levels of evidence (high, moderate, and low) based on benchmarks for the number of studies and quality of their methodology. They also described the evidence of service effectiveness. RESULTS: Sixteen adequately designed randomized controlled trials of BMT indicated a high level of evidence for its positive impact on treatment retention and illicit opioid use. Seven reviews or meta-analyses were also included. When the medication was dosed adequately, BMT and MMT showed similar reduction in illicit opioid use, but BMT was associated with less risk of adverse events. Results suggested better treatment retention with MMT. BMT was associated with improved maternal and fetal outcomes in pregnancy, compared with no medication-assisted treatment. Rates of neonatal abstinence syndrome were similar for mothers treated with BMT and MMT during pregnancy, but symptoms were less severe for infants whose mothers were treated with BMT. CONCLUSIONS: BMT is associated with improved outcomes compared with placebo for individuals and pregnant women with opioid use disorders. BMT should be considered for inclusion as a covered benefit.

Supported employment: assessing the evidence.

OBJECTIVE: Supported employment is a direct service with multiple components designed to help adults with mental disorders or co-occurring mental and substance use disorders choose, acquire, and maintain competitive employment. This article describes supported employment and assesses the evidence base for this service. METHODS: Authors reviewed meta-analyses, research reviews, and individual studies from 1995 through 2012. Databases surveyed were PubMed, PsycINFO, Applied Social Sciences Index and Abstracts, Sociological Abstracts, Social Services Abstracts, Published International Literature on Traumatic Stress, the Educational Resources Information Center, and the Cumulative Index to Nursing and Allied Health Literature. Authors chose from three levels of evidence (high, moderate, and low) based on benchmarks for the number of studies and quality of their methodology. They also described the evidence for service effectiveness. RESULTS: The level of research evidence for supported employment was graded as high, based on 12 systematic reviews and 17 randomized controlled trials of the individual placement and support model. Supported employment consistently demonstrated positive outcomes for individuals with mental disorders, including higher rates of competitive employment, fewer days to the first competitive job, more hours and weeks worked, and higher wages. There was also strong evidence supporting the effectiveness of individual elements of the model. CONCLUSIONS: Substantial evidence demonstrates the effectiveness of supported employment. Policy makers should consider including it as a covered service. Future research is needed for subgroups such as young adults, older adults, people with primary substance use disorders, and those from various cultural, racial, and ethnic backgrounds.

Medication-assisted treatment with methadone: assessing the evidence.

OBJECTIVE: Detoxification followed by abstinence has shown little success in reducing illicit opioid use. Methadone maintenance treatment (MMT) helps individuals with an opioid use disorder abstain from or decrease use of illegal or nonmedical opiates. This review examined evidence for MMT's effectiveness. METHODS: Authors reviewed meta-analyses, systematic reviews, and individual studies of MMT from 1995 through 2012. Databases searched were PubMed, PsycINFO, Applied Social Sciences Index and Abstracts, Sociological Abstracts, Social Services Abstracts, and Published International Literature on Traumatic Stress. The authors rated the level of evidence (high, moderate, and low) based on benchmarks for the number of studies and quality of their methodology. They also described the evidence of service effectiveness and examined maternal and fetal results of MMT for pregnant women. RESULTS: The review included seven randomized controlled trials and two quasi-experimental studies of MMT, indicating a high level of evidence for the positive impact of MMT on treatment retention and illicit opioid use, particularly at doses greater than 60 mg. Evidence suggests positive impacts on drug-related HIV risk behaviors, mortality, and criminality. Meta-analyses were difficult to perform or yielded nonsignificant results. Studies found little association between MMT and sex-related HIV risk behaviors. MMT in pregnancy was associated with improved maternal and fetal outcomes, and rates of neonatal abstinence syndrome were similar for mothers receiving different doses. Reports of adverse events were also found. CONCLUSIONS: MMT is associated with improved outcomes for individuals and pregnant women with opioid use disorders. MMT should be a covered service available to all individuals.

Assessing the evidence base for behavioral health services: introduction to the series.

The current policy environment provides the opportunity for federal and state agencies to work with private and nonprofit sectors to transform the American health care system through development of a comprehensive set of community-based, recovery-oriented, and evidence-based services for people with mental and substance use disorders. This Assessing the Evidence Base Series (AEB Series) provides science-supported information about selected mental health and substance abuse services for health care leaders. Series authors conducted reviews of research on 14 behavioral health services: behavioral management for children and adolescents, trauma-focused cognitive-behavioral therapy for children and adolescents, recovery housing, residential treatment for individuals with substance use disorders, peer support services for individuals with serious mental illnesses, peer recovery support for individuals with substance use disorders, permanent supportive housing, supported employment, substance abuse intensive outpatient programs, skill building, intensive case management, consumer and family psychoeducation, medication-assisted treatment with methadone, and medication-assisted treatment with buprenorphine. The goal of the AEB Series is to provide a framework for decision makers to build a modern addictions and mental health service system for the people who use these services and the people who provide them. The framework is intended to support decisions about the services that are likely to be most effective. This introduction to the AEB Series explains the methods used to conduct the reviews, rate the research evidence, and describe the effectiveness of the services. The rationale underlying recommendations for implementation of the services is also discussed, and suggestions are offered for future research.

Recovery housing: assessing the evidence.

OBJECTIVE: Recovery housing is a direct service with multiple components that provides supervised, short-term housing to individuals with substance use disorders or co-occurring mental and substance use disorders. It commonly is used after inpatient or residential treatment. This article describes recovery housing and assesses the evidence base for the service. METHODS: Authors searched PubMed, PsycINFO, Applied Social Sciences Index and Abstracts, Sociological Abstracts, and Social Services Abstracts. They identified six individual articles from 1995 through 2012 that reported on randomized controlled trials or quasi-experimental studies; no reviews or meta-analyses were found. They chose from three levels of evidence (high, moderate, or low) based on benchmarks for the number of studies and quality of their methodology. They also described the evidence of service effectiveness. RESULTS: The level of evidence for recovery housing was moderate. Studies consistently showed positive outcomes, but the results were tempered by research design limitations, such as lack of consistency in defining the program elements and outcome measures, small samples, and single-site evaluations, and by the limited number of studies. Results on the effectiveness of recovery housing suggested positive substance use outcomes and improvements in functioning, including employment and criminal activity. CONCLUSIONS: Recovery housing appears to be an important component in the continuum of care for some individuals. However, replication of study findings with greater specificity and in more settings is needed.

Survival and growth of foodborne pathogens during cooking and storage of oriental-style rice cakes.

Fresh cooked rice cakes for retail sale are typically held at room temperature because refrigeration dramatically reduces their quality. Room temperature, high water activity, and a pH of > 4.6 provided an environment conducive to pathogen growth. To date, no studies have been published regarding survival and growth of foodborne pathogens in fresh cooked rice cakes. This study was undertaken to investigate the effect of steam cooking on foodborne pathogens and their subsequent growth in five varieties of rice cakes made from flours of regular rice, sweet rice, white rice, tapioca, and mung bean. Bacillus cereus spores were detected in white rice, tapioca, and mung bean samples. The rice cake flours were inoculated with non-spore-forming foodborne pathogens (Escherichia coli O157:H7, Salmonella enterica serovar Typhimurium, Listeria monocytogenes, and Staphylococcus aureus) or spore-forming bacteria (Bacillus cereus) and steam cooked (100 degrees C) for 30 min. Steam cooking significantly reduced (> 6 log CFU/g) non-spore-forming foodborne pathogens in all samples and inactivated spores of B. cereus by 1 to 2 log CFU/g. Although spores of B. cereus survived steam cooking and germinated during 3 days of storage at room temperature, populations in most rice cakes remained below 106 CFU/g, which is the threshold for producing toxin. Rice cakes made from mung bean flour supported growth and germination of B. cereus spores above that critical level. In mung bean rice cakes, enterotoxin production was detected by the second day, when B cereus cell populations reached about 6.9 log CFU/g. The toxin concentration increased with storage time. However, our results suggest that rapid growth of total mesophilic microorganisms by more than 7 to 8 log CFU/ml during the first day of storage produced off flavors and spoilage before B. cereus was able to grow enough to produce toxins. Therefore, steam-cooked rice cakes made from a variety of flours including mung bean flour are safe for sale for up to 1 day after storage at room temperature and are free of B. cereus toxins.

Reducing disparity in behavioral health services: a report from the American College of Mental Health Administration.

UNLABELLED: The 2003 AMCHA Summit was an initial step. It served to provide a broad outline of the socio-political context and key issues involved in reducing disparities, and it provided some momentum for change. However, much more work remains to be done. The summit clearly demonstrated that the reduction of disparities requires a multi-level approach and multi-disciplinary leaders. As a neutral convener, AMCHA is in a unique position to help advance the debate and lead the field. The membership includes researchers, administrators, clinicians, and policy makers from all levels of the behavioral health system. As noted, a change agenda needs to include efforts at national, state, and local levels involving consumers, providers, purchasers, oversight organizations, and researchers. ACMHA is committed to advancing the field and helping the national effort to reduce disparities. Examples of potential projects include the following: Training: Much has been done to develop effective cultural-competency training modules and to guide states in its implementation. No one should reinvent the wheel at this time. Funding should be targeted to provide incentives to states for dissemination of existing training curricula and the documentation of effectiveness to all providers and administrators. DATA: Nationally, the field will benefit from data standards for the collection of and reporting on system disparities. This will facilitate interstate comparisons and provide baseline data for change efforts. Conducting surveys of providers, health plans, and public behavioral health systems on the availability and current uses of data by race and ethnicity is one example of a useful first step in this process of setting data standards. RESEARCH: Further research on the nature and causes of disparity is needed. There should be systematic research on factors influencing access, treatment, and outcomes for people of different cultures. Initially, because of the difficulties in deciding on standardized outcome measures, the encounter and claims data will provide the most useful information for analysis. Later, as standardized outcome measures are more widely utilized and the data collected, it may be possible to look for racial and ethnic differences in outcomes. The research agenda needs to be developed with a focus on services and health systems research data. Demonstrations: Demonstration efforts are urgently needed, similar to Connecticut's initiative, that integrate data on disparities with provider reporting, performance contracting, and system-wide interventions. These best practices need to be shared with the field. Coordination: The Summit showed that many are eager to learn from others in this area. As we move from further research to demonstration initiatives, AMCHA can play a role in coordinating these projects, particularly at the state and perhaps local levels. State efforts can benefit from best-practice presentations from other states and by an improved understanding of the nature and scope of the change required at a programmatic and local level. Local efforts need to clearly incorporate the views and perspectives of members of the community and consumers. The 2003 ACMHA Summit provided a foundation and a framework for work to proceed at all levels of the behavioral health delivery system. To accomplish meaningful change, we challenge SAMHSA, and the other federal agencies to provide the leadership to (1) develop common and core-performance measures focused on the reduction of disparities, (2) coordinate the research agenda, and (3) facilitate the use of new information technologies to collect and review these data. This is completely consistent with the vision of federal "leadership by example" that has been outlined by the Institute of Medicine (2003b) for the implementation of the "Crossing the Quality Chasm" report. We need to facilitate the efforts of the states and the federal government to identify and reduce disparities and provide a forum for states to share the results of their efforts, to benchmark their performance, and seek technical assistance. Over the next several years, we also expect that states will expand their efforts to implement evidence-based practices. However, we urge these states to implement existing evidence-based practices cautiously, especially with culturally diverse populations, due to the limited representation of ethnically diverse subjects in the research evidence on current practices. We strongly recommend collecting data on practice-based evidence-where effective interventions are routinely identified from existing practice and shared with the field, particularly those practices that seem effective with minority populations.

The use of chlorine dioxide to control Alicyclobacillus acidoterrestris spores in aqueous suspension and on apples.

Alicyclobacillus acidoterrestris, a thermoacidophilic, spore-forming bacterium, has been identified as a spoilage organism in commercial, pasteurized fruit juices. This study was undertaken to evaluate chlorine dioxide for reducing numbers of A. acidoterrestris spores on laboratory media and on apples. A. acidoterrestris spores in aqueous suspension and on apple surfaces of four different cultivars were treated with several concentrations of chlorine dioxide. Spores in aqueous suspension treated with 40 ppm for 5 min were reduced by more than 4 log. Treatment with 80 ppm for 1 min and 120 ppm for 30 s resulted in about 1.8 log and 4.8 log reductions of spore viability, respectively, and treatment at 80 and 120 ppm for 5 min reduced spore viability to undetectable levels (<0.7 log CFU/ml). When applied to the surfaces of four different apple cultivars ('Red Delicious', 'Golden Delicious', 'Gala', and 'Fuji'), 40 ppm free chlorine dioxide reduced A. acidoterrestris spore numbers by 1.5, 3.2, 4.5, >4.8 log after 1-, 2-, 3-, and 4-min treatments, respectively. Spore numbers were reduced by >4.8 log with 120 ppm free chlorine dioxide after only 1-min treatment. However, there was no significant difference between apple cultivars (P>0.05) on spore reduction. These results show the great effectiveness of chlorine dioxide in controlling A. acidoterrestris spores both in aqueous suspension and on apple surfaces. There was no synergistic effect on spore reduction when chlorine dioxide treatment of aqueous suspension was followed by heat.