The NODS-CLiP: a rapid screen for adult pathological and problem gambling.

OBJECTIVES: To describe and evaluate tests of the performance of the NODS-CLiP, an efficient standardized diagnostic interview instrument for adult pathological and problem gambling. SETTING AND SAMPLES: Identical batteries of diagnostic questions about gambling behavior, motives, and thoughts were administered to participants in eight general adult population field studies conducted in the United States between 1999 and 2003, including six state-level random-digit-dial (RDD) telephone surveys, one national RDD survey, and one in-person systematic random sample survey of commercial gambling patrons in eight states. Total survey N = 17,180. Response rates ranged from 24 to 71%. MEASURES: Data from all experienced gamblers (N = 8,867) were re-analyzed to compare diagnostic status derived from the 17-item NORC Diagnostic Screen for Gambling Disorders (NODS), a validated DSM-IV-based instrument, with results from all 2- to 4-item subsets of NODS items. RESULTS: Three NODS questions pertaining to loss of Control, Lying, and Preoccupation (the "CLiP"), requiring one minute to administer, identified virtually all pathological gamblers and most problem gamblers diagnosed by the complete NODS. The CLiP has excellent sensitivity and specificity for NODS constructs. CONCLUSIONS: A two-stage NODS-CLiP procedure appears quite promising as an efficient epidemiological instrument for general population research and clinical triage for gambling disorders.

Patient satisfaction and sustained outcomes of drug abuse treatment.

The authors investigated the relationship between patients' self-rated satisfaction with treatment services during and shortly after treatment with their drug use outcomes at one year follow-up, using a US national panel survey of patients in 62 methadone, outpatient, short-term residential, and long-term residential programs. A favorable evaluation of treatment near the time of discharge had a significant positive relationship with drug use improvement outcomes approximately one year later, independent of the separately measured effects of treatment duration, counseling intensity, patient adherence to treatment protocols, pre-treatment drug use patterns, and other characteristics of patients and treatment programs.

Do mechanisms that link addiction treatment patients to primary care influence subsequent utilization of emergency and hospital care?

BACKGROUND: Patients with drug use disorders are heavy users of emergency department (ED) and inpatient hospital care. This study examines whether formal mechanisms to link addiction treatment patients to primary medical care, either directly on site or by off-site referral-when compared with an absence of said mechanisms-might reduce these patients' use of ED and hospital services after substance abuse treatment. METHODS: We used longitudinal data from 6 methadone maintenance programs with 232 patients, 24 outpatient nonmethadone programs with 1202 patients, and 14 long-term residential programs with 679 patients in the National Treatment Improvement Evaluation Study. Multivariate logistic models controlling for health status and medical service utilization before treatment examined whether provision of medical services on- or off-site during treatment linkage led to reduced use of ED and hospital services in the year after treatment compared with no such provision. RESULTS: On-site delivery of primary care reduced subsequent ED and hospital use among patients in methadone maintenance and long-term residential compared with the nonlinkage condition but not in outpatient nonmethadone programs. Off-site referral for medical care reduced subsequent ED visits but not hospitalizations in long-term residential programs. CONCLUSIONS: These findings suggest that for some treatment modalities, stronger primary care linkage mechanisms decrease subsequent utilization of expensive ED and hospital services. Future study should examine the cost implications of these strong linkage mechanisms and ways to strengthen linkages to off-site medical care.

Criminal involvement among young male ecstasy users.

Ecstasy (MDMA) use increased rapidly in the U.S. between about 1995 and 2001. Most research on the drug focused on its psychopharmacological and public health contexts. Previous research on drugs-crime linkages suggests that there may have been a concommitant rise in ecstasy-related crimes. We explore this dimension here using data from 7794 arrested men, age 16 to 25, in the 2001 Arrestee Drug Abuse Monitoring (ADAM) sample and 9764 male respondents of similar age in the 2001 National Household Survey on Drug Abuse (NHSDA). Our results using a variety of bivariate and regression methods indicate that ecstasy use is less prevalent among young male arrestees than young men in general and that ecstasy use among arrestees is positively associated with various measures of drug market participation but negatively related to violent and property offenses. We recommend further investigation of ecstasy use in drug-oriented data sets and longitudinal studies to evaluate the link between ecstasy use and overall drug marketing.

The effect of matching comprehensive services to patients' needs on drug use improvement in addiction treatment.

AIMS: To examine whether need-service matching in addiction treatment leads to improvements in drug use, and whether treatment duration mediates those improvements. DESIGN, PARTICIPANTS, MEASUREMENTS: This analysis utilizes prospective data from a US cohort of addiction treatment patients who reported service needs beyond core rehabilitative services (n = 3103). 'Drug use improvement' is the difference between the patient's peak drug use frequency (in days per month) in the year before intake and in the year after treatment. Overall and primary use of the major illicit drugs (heroin, powder or crack cocaine and marijuana) are considered separately. 'Need-service match' means that a patient rated a service as important at intake and reported its receipt during treatment. 'Percentage of needs matched' indicates the proportion of five service domains (medical, mental health, family, vocational and housing) so matched. FINDINGS: In mixed regression models controlling for multiple factors, a greater percentage of needs matched tended to improve primary (beta = 0.028, P = 0.09) and overall (beta = 0.049, P = 0.05) drug use in the follow-up year. Exclusion of treatment duration as a covariate doubled the magnitude of these coefficients. The benefits of matching were concentrated among the half of patients reporting needs in four to five rather than one to three domains, and were strongest among patients in long-term residential facilities. Addressing vocational and housing needs exerted the greatest effects. CONCLUSIONS: Matching comprehensive services to needs is a useful addiction treatment practice, especially for high-need patients. Treatment duration might partially mediate its effect.

Designated case managers as facilitators of medical and psychosocial service delivery in addiction treatment programs.

This study examines whether having designated case management staff facilitates delivery of comprehensive medical and psychosocial services in substance abuse treatment programs. A multilevel, prospective cohort study of 2829 clients admitted to selected substance abuse treatment programs was used to study clients from long-term residential, outpatient, and methadone treatment modalities. Program directors reported whether the program had staff designated as case managers. After treatment discharge, clients reported their receipt of 9 supplemental services during the treatment episode. In multivariate models controlling for multiple program-level and client-level factors, program-level availability of designated case managers increased client-level receipt of only 2 of 9 services, and exerted no effect on service comprehensiveness, compared to programs that did not have designated case managers. These findings do not support the common practice of designating case management staff as a means to facilitate comprehensive services delivery in addiction treatment programs.

A hierarchy of gambling disorders in the community.

AIMS: To help refine the definition and diagnosis of gambling disorders, we investigated the distribution among US gamblers of the 10 DSM-IV criteria for Pathological Gambling. DESIGN: We drew data from two stratified random surveys (n = 2417, n= 530) of gambling behavior and consequences among community-based samples of US adults. A fully structured questionnaire, administered by trained lay interviewers, screened for the life-time prevalence of problem and Pathological Gambling. Per DSM-IV definitions, anyone meeting five or more of 10 itemized criteria was considered a pathological gambler. We analyzed these criteria among all gamblers who met one or more criteria (n = 399). FINDINGS: Most gamblers who met only one or two criteria reported 'chasing their losses'. At subclinical levels (three to four criteria), gamblers also reported elevated rates of gambling-related fantasy: lying, gambling to escape and preoccupation. Pathological gamblers with five to seven criteria reported marked elevations of loss of control, withdrawal symptoms and tolerance (internalizing dimensions of dependence); risking their social relationships and needing to be bailed out financially (externalizing dimensions). Most of the highest-level pathological gamblers (eight to 10 criteria) reported committing illegal acts to support gambling. CONCLUSION: Dependence in a biobehavioral sense appears to be a hallmark of Pathological Gambling, but it marks only one threshold in a qualitative hierarchy of disorders beginning with a common subclinical behavior, 'chasing'. Epidemiological assessments and future DSM revisions might consider explicit recognition of a problem gambling disorder, identifying people presenting some cognitive symptoms of Pathological Gambling but not clear signs of dependence. Pathological gamblers in turn appear to have two distinct levels of severity.

A qualitative investigation of antiretroviral therapy among injection drug users.

Recent advances in antiretroviral therapy for HIV/AIDS have improved the quality of life and life expectancies of many with this fatal disease. Nevertheless, a significant proportion of individuals from disadvantaged groups, which traditionally have had difficulty accessing high-quality health care in the United States, have not benefited from these treatments. For example, injection drug users (IDUs), now a principal source of new cases of AIDS, have received antiretroviral therapy at significantly lower rates than other groups. Whereas numerous studies have described this group quantitatively, few studies have examined in depth the influences that lead to IDUs' problematic relationship with HIV/AIDS treatment. The study described here is based on a longitudinal survey of 516 IDUs. A quantitative analysis was conducted with 103 HIV-positive IDUs and an in-depth qualitative analysis was performed with a subsample of 34 HIV-positive IDUs. This paper presents findings on the consequences of antiretroviral therapy use and nonuse among these individuals, focusing on their perspectives regarding this treatment regimen. Findings suggest that problematic access to, and usage of, antiretroviral therapy is related to wider societal problems of drug abuse, access to health care and housing, and the social and historical divisions that impact the lives of IDUs and their communities. Efforts to improve the availability and the adherence to antiretroviral therapy among IDUs should involve these individuals as a critical component in the design of culturally appropriate and supportive health care services.

Does retention matter? Treatment duration and improvement in drug use.

AIM: This study examines whether there is a minimum threshold, continuous or non-linear relationship between the duration of addiction treatment and improvements in drug use. DESIGN: Longitudinal cohort study of 62 drug treatment units and 4005 clients in the US National Treatment Improvement Evaluation Study, fielded from 1993 to 1995. SUBJECTS: Baseline and 1-year follow-up interviews with clients in methadone maintenance, out-patient non-methadone, short-term residential and long-term residential treatment programs. MEASURES: Improvement in drug use is the difference between the client-reported peak frequency of drug use (in days per month) in the year prior to the baseline interview minus the peak frequency in the year after discharge. Primary drug, and overall use of the major illicit drugs (heroin, cocaine powder, crack cocaine, and marijuana) are considered separately. RESULTS: Controlling for multiple factors, treatment duration had a positive linear relationship with primary drug use improvement among methadone clients and an inverted-U-shaped relationship with overall and primary drug use improvements among out-patient and long-term residential clients. Improvement with longer duration is greatest for long-term residential clients. CONCLUSIONS: Contrary to previous arguments for a sharp retention threshold for onset of treatment effects, we find smooth curves relating treatment duration to drug use improvements in methadone maintenance, out-patient non-methadone and long-term residential modalities. These relationships are effectively linear for durations typically observed in single treatment episodes, but unusually long retention in out-patient non-methadone and long-term residential units appear steadily less predictive of improvement.

Effect of primary medical care on addiction and medical severity in substance abuse treatment programs.

OBJECTIVE: To examine whether the availability of primary medical care on-site at addiction treatment programs or off-site by referral improves patients' addiction severity and medical outcomes, compared to programs that offer no primary care. DESIGN: Secondary analysis of a prospective cohort study of patients admitted to a purposive national sample of substance abuse treatment programs. SETTING: Substance abuse treatment programs in major U.S. metropolitan areas eligible for demonstration grant funding from the federal Substance Abuse and Mental Health Services Administration. RESPONDENTS: Administrators at 52 substance abuse treatment programs, and 2,878 of their patients who completed treatment intake, discharge, and follow-up interviews. MEASUREMENTS: Program administrators reported whether the program had primary medical care available on-site, only off-site, or not at all. Patients responded to multiple questions regarding their addiction and medical status in intake and 12-month follow-up interviews. These items were combined into multi-item composite scores of addiction and medical severity. The addiction severity score includes items measuring alcohol and drug use, employment, illegal activities, legal supervision, family and other social support, housing, physical conditions, and psychiatric status. The medical severity score includes measures of perceived health, functional limitations, and comorbid physical conditions. MAIN RESULTS: After controlling for treatment modality, geographic region, and multiple patient-level characteristics, patients who attended programs with on-site primary medical care experienced significantly less addiction severity at 12-month follow-up (regression coefficient, -25.9; 95% confidence interval [95% CI], -43.2 to -8.5), compared with patients who attended programs with no primary medical care. However, on-site care did not significantly influence medical severity at follow-up (coefficient, -0.28; 95% CI, -0.69 to 0.14). Referral to off-site primary care exerted no detectable effects on either addiction severity (coefficient, -9.0; 95% CI, -26.5 to 8.5) or medical severity (coefficient, -0.03; 95% CI, -0.37 to 0.44). CONCLUSIONS: On-site primary medical care improves substance abuse treatment patients' addiction-related outcomes, but not necessarily their health-related outcomes. Further study is needed to discern the mechanism through which on-site primary care might improve the addiction-related outcomes of substance abuse treatment.

HIV risk behaviors in African-American drug injector networks: implications of injection-partner mixing and partnership characteristics.

AIMS: We explore the mechanisms by which 'partnership-level' variables--the mix of characteristics of individuals who inject drugs together--affect the incidence of HIV risk behaviors, including receptive syringe sharing, and facilitate or impede the spread of HIV. DESIGN: We apply multivariate analysis techniques to data on injection partnerships (pairs of individuals who inject drugs together) collected using a network sample of 401 African-American IDUs in Washington, DC. FINDINGS: Drug injectors tended to select injection partners of the same gender and similar age, but risk behaviors were most common in partnerships between individuals who are dissimilar in both gender and age. Partners who had a sexual relationship, injected drugs frequently together, smoked crack-cocaine regularly, injected speedball (heroin mixed with cocaine) regularly and/or had close social ties were more likely to engage in risky injection practices than otherwise similar partners. These factors account largely for the association between the gender-age mix of the partnership and injection risk behavior. CONCLUSIONS: Among African-American IDUs in Washington DC, partnership-level variables appear critical in the transmission of HIV.

HIV prevention services in correctional drug treatment programs: do they change risk behaviors?

This study evaluated receipt of HIV prevention services in correctional substance abuse treatment programs and examined their impact on short-term risk behaviors. The authors performed a secondary analysis of the National Treatment Improvement Evaluation Study (NTIES), a prospective cohort study conducted during 1993 to 1995. The sample included 1,223 adult non-HIV-positive inmates, enrolled in nine correctional substance abuse treatment programs. A composite index modeled after the validated Risk Assessment Battery measured HIV risk behavior at treatment entry and at 12-month follow-up. Overall, most inmates received HIV prevention services while in treatment. Controlling for potential confounders, HIV prevention services were significantly associated with reduced risk behavior among inmates who were out of custody at follow-up, but no such association was observed among those still in custody. This analysis suggests that HIV prevention services are beneficial in reducing risk behavior among incarcerated individuals whose discharge is expected in the near future.