Assessing men with opioid use disorder for testosterone deficiency after the development of symptoms.

OBJECTIVE: Individuals with opioid use disorder (OUD) have reduced life expectancy and inferior outcomes when treated for depression, diabetes, and fractures. Their elevated risk of testosterone deficiency may contribute to all of these relationships, however few individuals prescribed opioids are evaluated with testosterone assays. The purpose of this study is to determine whether patients with opioid use disorder are evaluated for testosterone deficiency after development of a symptom that may merit investigation, such as erectile dysfunction (ED). METHOD: We conducted a retrospective longitudinal cohort study that utilized data from a national database called TriNetX. Patients were eligible for inclusion if they were 20 to 90 years of age, male, and diagnosed with erectile dysfunction. We utilized descriptive statistics and logistic regression to address study aims. RESULTS: Testosterone testing was uncommon for all patients with ED. Among 20,658 patients, it was assessed in 11.2% with OUD and 15.1% without OUD. Among those screened, 40% individuals with OUD and ED had testosterone deficiency. Odds of screening those with OUD were lower than matched controls (RR 0.74). CONCLUSIONS: Individuals with OUD are at increased risk of testosterone deficiency than the general population, but nearly 90% are not evaluated for this condition even after development symptoms. That 40% of individuals assessed were classified as testosterone deficient suggests endocrine disorders may be contributing to increased fracture risk, chronic pain, and severe depression commonly encountered in patients with OUD. Addressing this care gap may reduce morbidity and mortality associated with opioid use disorder.

Enhancing massed prolonged exposure with cannabidiol to improve posttraumatic stress disorder: Design and methodology of a pilot randomized clinical trial.

Background: The impact of posttraumatic stress disorder (PTSD) is substantial and often results in pervasive functional impairments. Although evidence-based treatments for PTSD are established, there remains room for improvement as many individuals continue to meet diagnostic criteria even after successful treatment completion. Cannabidiol (CBD) has attracted considerable attention based on its potential to treat a myriad of health conditions. CBD may decrease anxiety and facilitate extinction learning processes, two critical targets of trauma-focused psychotherapies. We present the design and methods for a pilot randomized clinical trial to examine the combination of CBD and prolonged exposure for PTSD. Methods: Participants (n = 24) will be randomized to CBD or placebo for 18 days delivered in combination with ten daily prolonged exposure sessions over two weeks. The study medication will be Epidiolex® (250 mg BID). The PTSD Checklist for DSM-5 will be the primary outcome to assess PTSD severity at baseline, during treatment, and at 1-month follow-up. Blood, saliva, and heart rate will be collected during treatment to assess intervention effects on biological outcomes related to PTSD and the endocannabinoid system. Results: Consistent with the purpose of a pilot, our goals are to evaluate the feasibility of study procedures, safety of the intervention, and the preliminary effect of CBD to inform a larger trial. Descriptive and inferential statistics will be used to address study aims. Conclusion: Findings will inform decision making on combining CBD with behavioral interventions for PTSD to enhance outcomes and mitigate the morbidity of this debilitating condition.

Adapting and scaling a single site DEA X-waiver training program to a statewide initiative: Implementing GetWaiveredTX.

OBJECTIVES: To address the critical need for opioid use disorder (OUD) treatment by rapidly planning and implementing a statewide DEA X-waiver training initiative expanding office-based OUD treatment in Texas by: (1) facilitating access to buprenorphine waiver trainings to targeted regions and health care providers across the state; and (2) supporting completion of DEA X-waiver requirements. METHODS: We used a transdisciplinary and theory-driven approach to adapt and rapidly scale up an existing, previously successful DEA X-waiver initiative. Pre-implementation activities included a literature review to identify OUD treatment barriers and demographic analyses to identify high-need areas of the state. We used geospatial mapping methods to identify regions with highest point prevalence of opioid-overdose mortality and low access to a buprenorphine provider. The study team used the Replicating Effective Programs (REP) framework developed by the Centers for Disease Control and Prevention to support implementation of evidence-based practices. RESULTS: In six months, we trained 451 waiver eligible providers, 133 (29%) of whom received waivers by 6 months post-training. Of the 163 (36.1%) providers who completed the post-waiver evaluation, 97% reported that they were satisfied or very satisfied with the training. Our initiative delivered high quality education to providers and increased the number of waiver trainers in Texas from eight to thirteen. CONCLUSIONS: Despite recent changes to the DEA X-waiver process, barriers to treating OUD with buprenorphine remain. Lack of education and experience treating substance use disorders remains a significant factor in limiting clinician comfort in prescribing buprenorphine. The research team successfully adapted a Texas-wide initiative to increase the number of office-based providers eligible to prescribe buprenorphine for OUD from an existing single-site initiative. Attentiveness to barriers pre-implementation and to adaptations during implementation enabled moderate impact across a large network in a short time and facilitated program sustainment.

Maternal buprenorphine treatment and infant outcome.

BACKGROUND AND OBJECTIVES: Maternal buprenorphine maintenance predisposes the infant to exhibit neonatal abstinence syndrome (NAS), but there is insufficient published information regarding the nature of NAS and factors that contribute to its severity in buprenorphine-exposed infants. METHODS: The present study evaluated forty-one infants of buprenorphine-maintained women in comprehensive substance use disorder treatment who participated in an open-label study examining the effects of maternal buprenorphine maintenance on infant outcomes. Modifiers of the infant outcomes, including maternal treatment and substance use disorder parameters, were also evaluated. RESULTS: Fifty-nine percent of offspring exhibited NAS that required pharmacologic management. Both maternal buprenorphine dose as well as prenatal polysubstance exposure to illicit substance use/licit substance misuse were independently associated with NAS expression. Polysubstance exposure was associated with more severe NAS expression after controlling for the effects of buprenorphine dose. Other exposures, including cigarette smoking and SRI use, were not related to outcomes. Maternal buprenorphine dose was positively associated with lower birth weight and length. CONCLUSIONS: Polysubstance exposure was the most potent predictor of NAS severity in this sample of buprenorphine-exposed neonates. This finding suggests the need for interventions that reduce maternal polysubstance use during medication assisted treatment for opioid use disorder, and highlights the necessity of a comprehensive approach, beyond buprenorphine treatment alone, for the optimal care for pregnant women with opioid use disorders.

Incentivizing attendance to prolonged exposure for PTSD with opioid use disorder patients: A randomized controlled trial.

OBJECTIVE: To determine whether contingent monetary incentives increase opioid use disorder patients' attendance to Prolonged Exposure (PE) therapy and whether attendance is associated with improvement in posttraumatic stress disorder (PTSD) and substance use disorder (SUD) outcomes. METHOD: Patients (N = 58) with PTSD were offered PE or PE with incentives (PE + I; max $480) to attend PE sessions. Participants were assessed at baseline and weeks 6, 12, and 24 postrandomization. RESULTS: Participants were mostly women (79%) and Caucasian (71%); mean age 37.43 years (SD = 11.33). PE + I participants attended a median of 9 (of 12) sessions compared to 1 session for PE participants (p < .001), which included more exposure sessions (PE + I mdn = 6; PE mdn = 0; p < .001). A Time × treatment condition interaction indicated that PE + I participants exhibited a greater decrease in PTSD severity over time than PE participants (OR = 3.1; 95% CI = 0.4-5.7; p = .024). PE + I participants remained in substance use treatment longer than PE participants (mdn days = 262 vs. 192; p = .039). There were no group differences in drug use. CONCLUSIONS: Monetary incentives increased SUD patients' attendance to an otherwise poorly attended treatment for PTSD. Better attendance in the incentivized group was associated with greater PTSD improvement, better SUD treatment retention, and no increased drug use. Incentives are well supported for improving adherence to substance use treatment goals and promising as a means to improve therapy attendance, which may improve the effectiveness of existing psychotherapies in difficult-to-treat populations. (PsycINFO Database Record

Maternal buprenorphine treatment and fetal neurobehavioral development.

BACKGROUND: Gestational opioid use/misuse is escalating in the United States; however, little is understood about the fetal effects of medications used to treat maternal opioid use disorders. OBJECTIVE: The purpose of this study was to determine the effect of maternal buprenorphine administration on longitudinal fetal neurobehavioral development. STUDY DESIGN: Forty-nine buprenorphine-maintained women who attended a substance use disorder treatment facility with generally uncomplicated pregnancies underwent fetal monitoring for 60 minutes at times of trough and peak maternal buprenorphine levels. Data were collected at 24, 28, 32, and 36 weeks gestation. Fetal neurobehavioral indicators (ie, heart rate, motor activity, and their integration [fetal movement-fetal heart rate coupling]) were collected via an actocardiograph, digitized and quantified. Longitudinal data analysis relied on hierarchic linear modeling. RESULTS: Fetal heart rate, heart rate variability, and heart rate accelerations were significantly reduced at peak vs trough maternal buprenorphine levels. Effects were significant either by or after 28 weeks gestation and tended to intensify with advancing gestation. Fetal motor activity and fetal movement-fetal heart rate coupling were depressed from peak to trough at 36 weeks gestation. Polysubstance exposure did not significantly affect fetal neurobehavioral parameters, with the exception that fetuses of heavier smokers moved significantly less than those of lighter smokers at 36 weeks gestation. By the end of gestation, higher maternal buprenorphine dose was related to depression of baseline fetal cardiac measures at trough. CONCLUSION: Maternal buprenorphine administration has acute suppressive effects on fetal heart rate and movement, and the magnitude of these effects increases as gestation progresses. Higher dose (≥13 mg) appears to exert greater depressive effects on measures of fetal heart rate and variability. These findings should be balanced against comparisons to gestational methadone effects, relatively good outcomes of buprenorphine-exposed infants, and recognition of the benefits of medication-assisted treatment for pregnant women with opioid use disorders in optimizing pregnancy outcomes.

Criminal Charges Prior to and After Enrollment in Opioid Agonist Treatment: A Comparison of Methadone Maintenance and Office-based Buprenorphine.

BACKGROUND: Entry into methadone maintenance is associated with a reduction in criminal activity; less is known about the effects of office-based buprenorphine. OBJECTIVE: To compare criminal charges before and after enrollment in methadone maintenance or office-based buprenorphine. METHODS: Subjects were opioid-dependent adults who initiated either methadone maintenance (n = 252) or office-based buprenorphine (n = 252) between 2003 and 2007. Medical records were reviewed to gather demographic data and a state-maintained web-based database to collect data on criminal charges. Overall charges and drug charges in the 2 years prior to and after treatment enrollment were compared. Multivariable analysis was used to examine risk factors for charges after treatment enrollment. RESULTS: In the 2 years after enrolling in treatment, subjects receiving methadone had a significant decline in the proportion of subjects with any charges (49.6% vs. 32.5%, p < .001) or drug charges (25.0% vs. 17.5%, p = .015), as well as the mean number of cases (0.97 vs. 0.63, p = .002) and drug cases (0.38 vs. 0.23, p = .008), while those who initiated buprenorphine did not have significant changes in any of these measures. On multivariable analysis, the strongest predictor of criminal charges in the 2 years after treatment enrollment was prior charges (adjusted odds ratio 3.35, 95% confidence interval, 2.24-5.01). CONCLUSIONS: Enrollment in office-based buprenorphine treatment did not appear to have the same beneficial effect on subsequent criminal charges as methadone maintenance. If this observation is replicated in other settings, it may have implications for matching individuals to these treatment options.

Comparison of methods to assess psychiatric medication adherence in methadone-maintained patients with co-occurring psychiatric disorder.

BACKGROUND: Adherence with psychiatric medication is a critical issue that has serious individual and public health implications. This is a secondary analysis of a large-scale clinical treatment trial of co-occurring substance use and psychiatric disorder. METHOD: Participants (n=153) who received a clinically-indicated psychiatric medication ≥30 days during the 12-month study and provided corresponding data from Medication Event Monitoring System (MEMS) and Morisky Medication Taking Adherence Scale (MMAS) self-report adherence ratings were included in the analyses. Accuracy in MEMS caps openings was customized to each participant's unique required dosing schedule. RESULTS: Consistent with expectations, MEMS-based adherence declined slowly over time, though MMAS scores of forgetting medication remained high and did not change over the 12-month study. MEMS caps openings were not significantly impacted by any baseline or treatment level variables, whereas MMAS scores were significantly associated with younger age and presence of an Axis I disorder and antisocial personality disorder, or any cluster B diagnoses. CONCLUSIONS: Results suggest that MEMS caps may be a more objective method for monitoring adherence in patients with co-occurring substance use and psychiatric disorder relative to the MMAS self-report. Participants in this study were able to successfully use the MEMS caps for a 12-month period with <1% lost or broken caps, suggesting this comorbid population is able to use the MEMS successfully. Ultimately, these data suggest that an objective method for monitoring adherence in this treatment population yield more accurate outcomes relative to self-report.

Effect of traumatic event reexposure and PTSD on substance use disorder treatment response.

BACKGROUND: A remarkably high rate of traumatic event reexposure has been demonstrated in community-based substance users which negatively impacts their substance use disorder (SUD). The rate and effect of such reexposure in treatment is unknown. Despite increasing evidence that a diagnosis of posttraumatic stress disorder (PTSD) has little influence on long-term SUD treatment outcomes, it is possible that PTSD symptom fluctuations could have effects. METHODS: This prospective longitudinal study examined the rate and effect of traumatic event reexposure and PTSD symptoms in 169 male and female methadone maintenance patients with a comorbid psychiatric disorder who were participating in a parent study. Traumatic events and PTSD symptoms were tested for association with drug use, treatment interruption, and counseling adherence in the same month, one month later, and two months later. RESULTS: Approximately 18% of patients were reexposed to a traumatic event each month during the 12-month study. Reexposure was associated with about twice the risk of treatment interruption in the same month and one month later. Every 10% increase in PTSD symptom severity was associated with a 36% increased risk of treatment interruption two months later. No effects were seen on drug use or counseling adherence. CONCLUSIONS: SUD patients have a relatively high rate of traumatic event reexposure. Both traumatic events and PTSD symptoms are associated with increased risk of treatment interruption, resulting in SUD patients leaving treatment at precisely the time they could benefit from treatment support.

Substance use and response to psychiatric treatment in methadone-treated outpatients with comorbid psychiatric disorder.

The psychiatric care of opioid users receiving agonist therapies is often complicated by high rates of illicit drug use (Brooner et al., 2013). The present study evaluates if illicit drug use (i.e., opioids, cocaine, sedatives) detected at the start of psychiatric care affects treatment response. Methadone maintenance patients (n = 125) with at least one current psychiatric disorder completed a 3-month randomized clinical trial evaluating the efficacy of financial incentives on attendance to on-site integrated substance abuse and psychiatric services (Kidorf et al., 2013). The present study re-analyzes the data set by grouping participants into one of two conditions based on the 4-week baseline observation: (1) no illicit drug use (baseline negative; n = 50), or (2) any illicit drug use (baseline positive; n = 75). All participants received a similar schedule of psychiatric services, and had good access to prescribed psychiatric medications. The Global Severity Index (GSI) of the Hopkins Symptom Checklist-Revised was administered monthly to evaluate changes in psychiatric distress. Results showed that while both conditions evidenced similar utilization of on-site psychiatric services, baseline negative participants remained in treatment somewhat longer (80.7 vs. 74.8 days, p = .04) and demonstrated greater reductions in GSI scores than baseline positive participants at month 3 (p = .004). These results have implications for interpreting previous studies that have shown inconsistent efficacy of pharmacotherapy and other psychiatric treatments, and for providing clinical care for patients with co-occurring substance use and psychiatric disorders.

Challenges and outcomes of parallel care for patients with co-occurring psychiatric disorder in methadone maintenance treatment.

OBJECTIVE: Most opioid users seeking treatment in community-based substance abuse treatment programs have at least one co-occurring psychiatric disorder, and the presence of psychiatric comorbidity in this population is associated with increased psychological distress, poorer quality of life, and reduced response to substance abuse treatment. This observational study describes clinical outcomes of referring patients receiving methadone maintenance with at least one co-occurring psychiatric disorder to a community psychiatry program located on the same hospital campus. METHODS: Participants (n = 156) were offered priority referrals to a community psychiatry program that included regularly scheduled psychiatrist appointments, individual and group therapy, and enhanced access to psychiatric medications for 1 year. Psychiatric distress was measured with the Symptom Checklist (SCL-90-R), which participants completed monthly. RESULTS: While about 80% of the sample (n = 124) initiated psychiatric care, the average length of treatment was only 128.2 days (SD = 122.8), participants attended only 33% of all scheduled appointments (M = 14.9 sessions, SD = 14.1), and 84% (n = 104) did not complete a full year of care. Of those who did not complete a full year, over half (55%, n = 68) left psychiatric care while still receiving substance abuse treatment. Exploratory negative binomial regression showed that baseline cocaine and alcohol use disorder (p = .002 and .022, respectively) and current employment (p = .034) were associated with worse psychiatric treatment retention. Modest reductions in psychiatric distress over time were observed (SCL-90-R Global Severity Index change score = 2.5; paired t = 3.54, df = 121, p = .001). CONCLUSIONS: Referral of patients with co-occurring psychiatric disorders receiving methadone maintenance to a community psychiatry program is often ineffective, even after reducing common barriers to care. Service delivery models designed to improve attendance and retention, such as integrated care models, should be evaluated. This study is part of a larger clinical trial, registered at www.clinicaltrials.gov under #NCT00787735.

A comparison of characteristics and outcomes of opioid-dependent patients initiating office-based buprenorphine or methadone maintenance treatment.

BACKGROUND: The purpose of this study was to compare demographic factors and 1-year treatment outcomes of patients treated with buprenorphine or methadone. METHODS: The study included 252 subjects who received a prescription for buprenorphine in an academic internal medicine practice and 252 subjects who enrolled in a methadone maintenance program located on the same campus over the same time frame. Data were collected retrospectively. Patients were classified as "opioid-positive" or "opioid-negative" each month for a year based on urine drug testing and provider assessment. Successful treatment was defined as remaining in treatment after 1 year and achieving 6 or more opioid-negative months. RESULTS: Buprenorphine patients were more likely to be male, have health insurance, be employed, abuse prescription opioids, and be human immunodeficiency virus (HIV) infected; they were less likely to abuse benzodiazepines. At 12 months, 140 (55.6%) of buprenorphine patients and 156 (61.9%) of methadone patients remained in treatment (P =.148). Patients on methadone had a higher mean number of opioid-negative months (6.96 vs. 5.43; P <.001) and mean number of months in treatment (9.38 vs. 8.59; P <.001). On multivariable analysis, methadone maintenance was significantly associated with successful treatment (adjusted odds ratio: 2.10; 95% confidence interval: 1.43-3.07). CONCLUSIONS: Office-based buprenorphine and methadone maintenance programs serve very different populations. Both are effective, but patients on methadone had mildly better treatment outcomes.

Prospective risk factors for traumatic event reexposure in community syringe exchange participants.

BACKGROUND: Traumatic event reexposure in injecting drug users is associated with increased drug use and potential for psychiatric symptoms. This is the first study to examine fixed and time-varying factors that are prospectively associated with new traumatic event reexposure in injecting drug users. METHODS: Injecting drug users registered in a syringe exchange program were enrolled in a 16-month parent study comparing strategies to increase drug abuse treatment enrollment. Participants (N=162) completed baseline measures of demographics, psychiatric treatment history, and lifetime traumatic event exposure. Monthly follow-ups assessed past-month traumatic event exposure, days of heroin and cocaine use, criminal activity, and drug abuse treatment participation. Generalized estimating equations models tested the influence of fixed baseline and time-varying factors on traumatic event reexposure in the same month, the following month, and two months later. RESULTS: Significant fixed risk factors for traumatic event reexposure include female gender and past psychiatric treatment. In addition, each past traumatic event exposure was associated with an increased likelihood of reexposure. After accounting for all other factors, each day of cocaine use was associated with a small but persistent increased risk of traumatic event reexposure. Reexposure to a traumatic event in the prior month more than doubled the risk of subsequent reexposure. CONCLUSIONS: Injecting drug users experience a pattern in which drug use is associated with increased risk of subsequent traumatic event reexposure, and traumatic event reexposure is associated with further drug use and continued reexposure. Implications for addressing these concerns in injecting drug users are presented.

A randomized trial of Web-based videoconferencing for substance abuse counseling.

Web-based videoconferencing can improve access to substance abuse treatment by allowing patients to receive counseling services in their homes. This randomized clinical trial evaluates the feasibility and acceptability of Web-based videoconferencing in community opioid treatment program (OTP) participants. Participants that reported computer and Internet access (n=85) were randomly assigned to receive 12weeks of weekly individual counseling in-person or via eGetgoing, a Web-based videoconferencing platform. Fifty-nine of these participants completed the study (eGetgoing=24; in-person=35), with most study withdrawal occurring among eGetgoing participants. Participants exposed to the study conditions had similar rates of counseling attendance and drug-positive urinalysis results, and reported similar and strong ratings of treatment satisfaction and therapeutic alliance. These results support the feasibility and acceptability of Web-based counseling as a good method to extend access to individual substance abuse counseling when compared to in-person counseling for patients that are able to maintain a computer and Internet connection for reliable communication.

Reinforcing integrated psychiatric service attendance in an opioid-agonist program: a randomized and controlled trial.

BACKGROUND: The benefits of integrating substance abuse and psychiatric care may be limited by poor service utilization. This randomized clinical trial evaluated the efficacy of using contingency management to improve utilization of psychiatric services co-located and integrated within a community-based methadone maintenance treatment program. METHODS: Opioid-dependent outpatients (n=125) with any current psychiatric disorder were randomly assigned to: (1) reinforced on-site integrated care (ROIC), with vouchers (worth $25.00) contingent on full adherence to each week of scheduled psychiatric services; or (2) standard on-site integrated care (SOIC). All participants received access to the same schedule of psychiatrist and mental health counseling sessions for 12-weeks. RESULTS: ROIC participants attended more overall psychiatric sessions at month 1 (M=7.53 vs. 3.97, p<.001), month 2 (M=6.31 vs. 2.81, p<.001), and month 3 (M=5.71 vs. 2.44, p<.001). Both conditions evidenced reductions in psychiatric distress (p<.001) and similar rates of drug-positive urine samples. No differences in study retention were observed. CONCLUSIONS: These findings suggest that contingency management can improve utilization of psychiatric services scheduled within an on-site and integrated treatment model. Delivering evidenced-based mental health counseling, or modifying the contingency plan to include illicit drug use, may be required to facilitate greater changes in psychiatric and substance abuse outcomes.

Managing psychiatric comorbidity within versus outside of methadone treatment settings: a randomized and controlled evaluation.

BACKGROUND AND AIMS: Integrating psychiatric services within substance abuse treatment settings is a promising service delivery model, but has not been evaluated using random assignment to psychiatric treatment setting and controlled delivery of psychiatric care. This study evaluates the efficacy of on-site and integrated psychiatric service delivery in an opioid-agonist treatment program on psychiatric and substance use outcomes. DESIGN: Participants at the Addiction Treatment Services (ATS) were assigned randomly to receive on-site and integrated substance abuse and psychiatric care (on-site: n = 160) versus off-site and non-integrated substance abuse and psychiatric care (off-site: n = 156), and observed for 1 year. On-site participants received all psychiatric care within the substance abuse program by the same group of treatment providers. The same type and schedule of psychiatric services were available to off-site participants at a community psychiatry program. SETTING: All participants received routine methadone maintenance at the ATS program in Baltimore, Maryland, USA. PARTICIPANTS: Participants were opioid-dependent men and women with at least one comorbid psychiatric disorder, as assessed by the Structured Clinical Interview for DSM-IV and confirmed by expert clinical reappraisal. MEASUREMENTS: Outcomes included psychiatric service utilization and retention, Hopkins Symptom Checklist Global Severity Index (GSI) change scores and urinalysis test results. FINDINGS: On-site participants were more likely to initiate psychiatric care 96.9 to 79.5%; P < 0.001), remain in treatment longer (195.9 versus 101.9 days; P < 0.001), attend more psychiatrist appointments (12.9 versus 2.7; P < 0.001) and have greater reductions in GSI scores (4.2 versus 1.7; P = 0.003) than off-site participants; no differences were observed for drug use. CONCLUSIONS: On-site and integrated psychiatric and substance misuse services in a methadone treatment setting might improve psychiatric outcomes compared with off-site and non-integrated substance misuse and psychiatric care. However, this might not translate into improved substance misuse outcomes.

An observation of lower rates of drug use over time in community syringe exchangers.

BACKGROUND AND OBJECTIVES: The present study evaluated changes in rates of self-reported heroin and cocaine use in opioid-dependent individuals newly registered to a syringe exchange program (SEP), and examined the effects of recovery-oriented longitudinal variables (i.e., substance abuse treatment, self-help group participation, employment) on changes in drug use. METHODS: Study participants (n = 240) were opioid-dependent and drawn from a larger study evaluating strategies to improve treatment-seeking. Mixed model analyses were used to evaluate changes in rates of heroin and cocaine use, and longitudinal correlates of change in these substances, over a one-year period. RESULTS: Results showed reductions in days of heroin and cocaine use over time, and that participation in recovery-oriented activities was strongly associated with greater changes in drug use. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: These results suggest SEPs can play a vital role in facilitating reductions in drug use through motivating participation in treatment and other recovery-oriented activities.

A collaborative approach to teaching medical students how to screen, intervene, and treat substance use disorders.

Few medical schools require a stand-alone course to develop knowledge and skills relevant to substance use disorders (SUDs). The authors successfully initiated a new course for second-year medical students that used screening, brief intervention, and referral to treatment (SBIRT) as the course foundation. The 15-hour course (39 faculty teaching hours) arose from collaboration between faculty in Departments of Medicine and Psychiatry and included 5 hours of direct patient interaction during clinical demonstrations and in small-group skills development. Pre- and post-exam results suggest that the course had a significant impact on knowledge about SUDs. The authors' experience demonstrates that collaboration between 2 clinical departments can produce a successful second-year medical student course based in SBIRT principles.

Improving treatment enrollment and re-enrollment rates of syringe exchangers: 12-month outcomes.

BACKGROUND: Developing bridges between community syringe exchange programs (SEPs) and substance abuse treatment could benefit syringe exchangers and the public health. Kidorf et al. (2009) showed that motivational approaches employed at an SEP site improved rates of treatment enrollment and reduced drug use over a 4-month observation window. The present study extends this report by evaluating rates of treatment enrollment and re-enrollment over a 12-month period. METHODS: Opioid dependent individuals (n = 281) newly registered at an SEP were randomly assigned to one of three referral interventions: (1) 8 individual motivational enhancement sessions and 16 treatment readiness group sessions designed to improve treatment interest and readiness (motivated referral condition; MRC-only); (2) MRC-only with monetary incentives for attending sessions and enrolling in treatment (MRC+I); or (3) standard referral (SRC). MRC-only and MRC+I participants discharged from treatment could attend a treatment re-engagement group designed to facilitate return to treatment (MRC+I participants received incentives for attending sessions and re-enrolling in treatment). RESULTS: The 4-month outcomes generally extended over 12 months. MRC+I participants were more likely to enroll in methadone maintenance than MRC-only or SRC participants, and to re-enroll in treatment following discharge. MRC+I participants also reported more days of treatment and less heroin and injection use. CONCLUSIONS: The good harm reduction outcomes for many SEP participants can be enhanced through strategies designed to facilitate treatment enrollment and re-enrollment.

A treatment reengagement intervention for syringe exchangers.

Poor sustained treatment engagement limits the effectiveness of all modalities of substance abuse treatment. This study evaluated the efficacy of a novel treatment reengagement intervention for a subset of syringe-exchange program (SEP) participants (N = 113) that had enrolled in treatment as part of a 4-month clinical trial (M. Kidorf et al., 2009). Three reengagement conditions for participants leaving treatment were compared. Motivational referral condition (MRC) participants (n = 31) could attend group sessions that focused on renewing treatment interest. MRC plus incentive (MRC + I) participants (n = 49) could receive modest monetary incentives for attending these sessions and reenrolling in treatment. Standard referral condition participants (n = 33) could not attend groups or receive incentives. Across a 1-year observation window, almost all study participants (86%) were discharged from treatment. MRC + I participants attended more group sessions than MRC participants and were considerably more likely to reenroll in treatment than participants in the other study conditions. Reengagement strategies can further enhance the public health benefits of SEPs by increasing rates of treatment participation over time.