Cigarette smoking and short-term addiction treatment outcome.

Cigarette smoking is common among patients in cocaine and opioid dependence treatment, and may influence treatment outcome. We addressed this issue in a secondary analysis of data from an outpatient clinical trial of buprenorphine treatment for concurrent cocaine and opioid dependence (13 weeks, N=200). The association between cigarette smoking (lifetime cigarette smoking status, number of cigarettes smoked per day prior to study entry) and short-term treatment outcome (% of urine samples positive for cocaine or opioids, treatment retention) was evaluated with analysis of covariance, bivariate correlations, and multivariate linear regression. Nicotine-dependent smokers (66% of participants) had a significantly higher percentage of cocaine-positive urine samples than non-smokers (12% of participants) (76% vs. 62%), but did not differ in percentage of opioid-positive urine samples or treatment retention. Number of cigarettes smoked per day at baseline was positively associated with percentage of cocaine-positive urine samples, even after controlling for baseline sociodemographic and drug use characteristics, but was not significantly associated with percentage of opioid-positive urine samples or treatment retention. These results suggest that cigarette smoking is associated with poorer short-term outcome of outpatient treatment for cocaine dependence, but perhaps not of concurrent opioid dependence, and support the importance of offering smoking cessation treatment to cocaine-dependent patients.

A comparison of psychosocial barriers among welfare recipients: implications for drug treatment.

Implementation of Temporary Assistance for Needy Families (TANF) presents welfare recipients with time-limited benefits and work requirements. However, it is estimated that over 140,000 welfare recipients meet the DSM-IV criteria for "drug dependence". In this study, samples of chronic drug using and non-drug using female TANF recipients were compared with regard to: current employment, psychological functioning, self-perceived employment skills, barriers to employment, and need for help in seeking employment. It was found that non-drug using study participants were significantly more likely to be employed and reported significantly higher self-perceived work skills than users. Chronic users reported significantly greater barriers to seeking employment.

Changes in economically disadvantaged adolescents' knowledge and beliefs about HIV/AIDS.

PURPOSE: The purpose of this study was to compare HIV/AIDS related knowledge and beliefs in two cohorts of economically disadvantaged adolescents (n = 132). Participants were between 15 and 21 years old, predominately African-American and Hispanic, and participants in a Job Training Partnership Act (JTPA) summer program. The hypothesis was that adolescent HIV/AIDS-related knowledge would be higher in 1999 than in 1994. METHODS: A cohort of sixty-six (66) adolescents were surveyed in 1994 and another cohort of 66 adolescents was surveyed again in 1999, all participating in the JTPA program. Participants' knowledge and beliefs were assessed using the National Adolescent Student Health Survey. RESULTS: A statistically significant increase in overall HIV/AIDS knowledge occurred between the two measurements. Fifty-five percent (55.6%) of the 1999 cohort believed that HIV could be contracted by donating blood, compared to 47.5% of the 1994 cohort. Belief that it is more likely to become infected with the AIDS virus through male to male sex was higher in 1999 by 2% and was 10% higher for female to female sex. CONCLUSIONS: Adolescent misconceptions/misinformation, gender-based lack of knowledge, increased perception of immunity from HIV infection, and a reported reduction in health education courses were all factors in the adolescents' continued engagement in risky sexual activities. Given these findings, and that AIDS is predicted to be one of the top five causes of death among young people, increased gender- and ethnic-specific HIV intervention programs are recommended.

Health services implications of DNA testing.

This review article summarizes the state of the art in genetic testing and discusses the many issues that new technologies have raised. A health services perspective is offered to aid in providing laboratorians with an understanding of the dilemma that society faces with the exponential advances in knowledge. Unmistakably, these new technologies are a mixed blessing: on the one hand, diagnoses can be made with greater accuracy and preventive measures implemented more fruitfully and individuals may be more conclusively identified and/or exonerated for forensic purposes. On the other hand, however, are the very real concerns that discrimination under a medical guise will be encouraged and that privacy rights may be compromised. Another important issue is how the laboratory profession will serve in moving these new technologies from research to practice. We examine the role of the CLS in moving forward to a role of patient counselor and advocate in the emerging complex world of DNA-related biotechnology.

Partner concordance in reports of joint risk behaviors.

OBJECTIVE: To evaluate the accuracy of self reports on sexual and drug use behaviors. METHODS: Data from a network study of HIV transmission among a sample of drug users and nonusers are used to compare reports of sexual and drug use behaviors by partners who engaged in those behaviors. Partner concordance (self-report agreement between two people) was used as an estimate of validity. RESULTS: Results showed that persons are able to recall and report about 85% of their recent partners (15%-20% less for recent drug use partners). For relationships that were reported by both partners, a high degree of concordance existed about recent behaviors (83%-96%) and variable agreement about frequency (0.48

Psychiatric care of patients with depression and comorbid substance use disorders.

BACKGROUND: The goal of this study was to describe the sociodemographic and clinical characteristics and routine psychiatric care of depressed patients with or without substance use disorders (SUDs) and to assess the association between the presence of comorbid SUD and the psychiatric management of patients with depression. METHOD: Each of a sample of 531 psychiatrists participating in the Practice Research Network (PRN) of the American Psychiatric Institute for Research and Education was asked to provide information about 3 randomly chosen patients. Data were collected using a self-administered questionnaire, which generated detailed diagnostic and clinical data on 1228 psychiatric patients. Weighted data were analyzed using the SUDAAN software package. Multivariate logistic regression was used to compare depressed patients with and without SUD. RESULTS: A total of 595 patients (48.4%) were diagnosed with depression (DSM-IV criteria). The prevalence of SUD (excluding nicotine dependence) in this group was 18.1%. The group with SUD had a significantly larger proportion of males, young adults, patients seen in public general hospitals, and non-managed care public plans. No significant group differences were found for primary payer, locus of care, length of treatment, type of current or past treatment, and prescription of medications. Only 2.2% of SUD patients were prescribed with an anti-SUD medication (i.e., disulfiram and naltrexone). CONCLUSION: Concomitant SUDs have little effect on the routine psychiatric care of depressed patients. Efforts should be made to improve the identification and management of depressed patients with SUD.

Labor force participation in a sample of substance users.

This paper reviews the microeconomic theory underlying the work/leisure tradeoff and how this tradeoff may be manifested among substance users. The effects of drug use, demographic factors, and income factors on the probability of labor force participation are analyzed in a sample of 687 male and 327 female drug users. The decision not to seek employment appears to be associated primarily with non-job-related sources of income (including illegal sources).

Access as a managed care marketing outcomes measure.

As their position in the health care market diminishes, HMOs are feeling the pinch from the competition. Purchasers of health plans have many more options available today than in the past. Employers can select from single or consolidated health plans, plans offered by coalitions, or plans offered by provider systems. Following closely behind the withstanding issue of controlling costs is quality of care and customer satisfaction. The bad press surrounding managed care is making employers demand assurances that employees will receive the best quality of care their money can buy. To assist in this endeavor managed care companies are focusing more on their customers. To this end marketers use report cards to assess purchaser and enrollee satisfactions, with the hope that if they have a happy customer, s/he will be a loyal one. This paper reviews current marketing strategies of managed care companies and their level of usefulness with respect to sustaining customers and hence market share.

Normative influence on condom use in the personal networks of female cocaine smokers.

Attitudes-norms research (the theories of planned behavior and reasoned action) has been successful in accounting for many types of behavior change. One of the strengths of this approach has been to combine individual beliefs and normative influences in the explanation of behavior change. However, the conceptualization of normative influence in these theories makes very strong assumptions about self-awareness in the selection of normative referents. These assumptions are particularly problematic when applied to female cocaine smokers, who report frequent sex while under duress or while cognitively impaired. In this study the original conceptualization of normative influence and two alternatives (assuming emotion-based and interaction-based selection of normative referents) are operationalized to evaluate stage of change for condom use among women who are heavy crack cocaine users with multiple sex partners. Results show that stage of change for use of condoms with nonmain partners is best accounted for by interaction-based selection of normative referents.

Age and HIV risk in a national sample of injection drug and crack cocaine users.

A national sample of 25,106 out-of-treatment crack cocaine and injection drug users was examined to determine the effect of aging on HIV risk behavior. Injectors and crack cocaine users aged 55 and over were compared to those who were aged 18 to 54 years of age. Results showed that the behavior risk of older persons did not differ substantially from those reported by other age groups, and that injection risk rose steadily along with age for all ages represented in the sample. The authors conclude that older persons who use illegal drugs remain at elevated risk for HIV compared to the general population, and may be in need of more targeted intervention strategies.

Pathological gambling among cocaine-dependent outpatients.

OBJECTIVE: The authors investigated the occurrence of pathological gambling among cocaine-dependent outpatients, its influence on short-term outcome of treatment, and comparative characteristics of patients with and without pathological gambling. METHOD: The subjects were 313 cocaine-dependent (200 also opiate-dependent) outpatients in clinical trials of medication for cocaine dependence. Pathological gambling (DSM-III-R criteria) was assessed with the Diagnostic Interview Schedule, and sociodemographic and socioeconomic characteristics were determined with the Addiction Severity Index. Outcome was defined as time in treatment (proportion of maximum scheduled time) and proportion of cocaine-positive urine samples during treatment. RESULTS: Pathological gambling had a lifetime occurrence rate of 8.0% and a current (past month) occurrence of 3.8%. Onset preceded the onset of cocaine dependence in 72.0% of the patients (and preceded onset of opiate dependence in 44.4%). Patients with pathological gambling (lifetime or current) did not differ significantly from other patients in length of treatment or proportion of cocaine-positive urine samples. Those with lifetime pathological gambling were significantly more likely to have tobacco dependence (84.0% versus 61.1%) and antisocial personality disorder (56.0% versus 19.8%), to be unemployed (84.0% versus 49.3%), to have recently engaged in illegal activity for profit (64.0% versus 38.5%), and to have been incarcerated (62.5% versus 33.9%). CONCLUSIONS: Pathological gambling is substantially more prevalent among cocaine-dependent outpatients than in the general population. Patients with pathological gambling differ from other cocaine-dependent outpatients in some sociodemographic characteristics but not in short-term outcome of treatment for cocaine dependence.

Economics as a factor in models of behavioral motivation and change.

This note first presents a summary of four main behavioral models that are used to explain behavioral motivation and change. Three models are based on psychosocial theory. They are: 1) the Theory of Reasoned Action, 2) the Theory of Planned Behavior, and 3) the Theory of Stages-of-Change. The fourth model is based on economic theory and is known as the Rational Addiction Model. Each model is analyzed for its strengths and weaknesses. The note concludes by arguing for the usefulness of integrating the economic and the psychosocial models to study drug use. Specific examples and suggestions are presented.

Clinical and cerebral blood flow changes in catatonic patients treated with ECT.

OBJECTIVE: To determine changes in clinical manifestations and cerebral blood flow (CBF) before and after administration of ECT to patients with catatonia due to schizophrenia or mood disorders. METHODS: A sample of nine patients who met DSM-IV criteria for catatonia was studied. Patients received between 5 and 15 sessions (thrice per week) of ECT. Severity of catatonia was measured with the Modified Rogers Scale (MRS). Changes in CBF were measured with a brain single positron emission computer tomography (SPECT) that was performed 1 week before the first ECT and 1 week after the last ECT. RESULTS: Catatonia was due to schizophrenia in five patients and mood disorders in four patients. There were no significant clinical and brain SPECT differences between these two groups before treatment. Pre- vs. post-ECT comparisons showed significant reduction of catatonic symptoms in both groups. However, patients with mood disorders needed less ECT sessions and showed greater clinical improvement. Brain SPECT showed significant increase in CBF in parietal, temporal, and occipital regions in patients with mood disorder and no significant changes in patients with schizophrenia. CONCLUSIONS: These results support the efficacy of ECT for treatment of catatonic patients, especially secondary to mood disorders, which seem to be correlated with improvements in CBF.

A 12-year follow-up of a methadone medical maintenance program.

Methadone Medical Maintenance (MDM) is an alternative for treatment of stable methadone maintained individuals. It involves a monthly physician's visit, at which methadone take-home doses are dispensed to last until the next appointment. The safety and efficacy of this treatment modality is currently under investigation. The purpose of this study was to evaluate the long-term safety and efficacy of MDM in a methadone program in Baltimore. A sample of 21 patients was enrolled in the study and followed for 12 years. They were evaluated once a month by a primary care physician affiliated with a methadone clinic who collected urine toxicology samples and dispensed the monthly methadone dose. The results showed that only 6 (28.6%) patients dropped out during the 12 years of the study. Twelve (0.5%) of 2,290 urine samples collected were positive for drugs. No methadone overdose or diversion was observed. Participants reported significant improvement in their quality of life. The results of this study support the safety and efficacy of medical maintenance of stable methadone maintained individuals.

Access to HIV services by the urban poor.

This paper examines the effect of HIV-health status and HIV-transmission mode on access to HIV-related services among African Americans, Hispanics and White HIV+ individuals. Data were collected from 169 African Americans, 72 Hispanics and 253 White HIV+ individuals seeking 8 social and 6 medical HIV services at 29 public and community-based organizations in Houston, Texas. A total of 42 separate logistic regressions were estimated for each HIV service and for each race/ethnic group. The results showed significant differences in access to HIV social services based on HIV-transmission mode among the three race/ethnic groups, but no significant differences were found in access to medical services based on either HIV status or HIV-transmission mode among the three race/ethnic groups.

A framework for assessing the effectiveness, efficiency, and equity of behavioral healthcare.

OBJECTIVE: To evaluate the effectiveness, efficiency, and equity of behavioral healthcare and to guide an assessment of the current state of the art of behavioral health-oriented health services research. STUDY DESIGN: The framework is grounded in previous conceptual work by the authors in defining a prevention- and outcomes-oriented continuum of healthcare and in identifying and integrating the concepts and methods of health services research and policy analysis for assessing healthcare system performance. PATIENTS AND METHODS: The defining assumptions are that (1) the denominator for behavioral healthcare services must encompass a look at the population, not just the patients, who manifest behavioral health risks; and (2) the delivery system to address these needs must extend beyond acute, treatment-oriented services to include both primary prevention and aftercare services for chronic relapsing conditions. RESULTS: Current policy and practice in behavioral healthcare reveal the absence of a comprehensive, coordinated continuum of care; substantial variation in policy and financial incentives to encourage such development; and poorly defined or articulated outcome goals and objectives. The current state of the art of research in this area reflects considerable imprecision in conceptualizing and measuring the effectiveness, efficiency, and equity criteria. Further, these 3 criteria have not been examined together in evaluating system performance. CONCLUSIONS: The first era of behavioral healthcare focused on cost savings in managed care alternatives; the second is focusing on quality and outcomes; a third must consider the issues of equity and access to behavioral healthcare, especially for the most seriously ill and vulnerable, in an increasingly managed care-dominated public and private policy environment.

Naltrexone shortened opioid detoxification with buprenorphine.

This double-blind, randomized, placebo-controlled clinical trial evaluated the impact on withdrawal symptoms of (i) combining naltrexone with a 4-day buprenorphine taper for short opioid detoxification (NB Group), compared to (ii) using a 4-day buprenorphine taper alone, followed by naltrexone on day 8 (PB Group). Sublingual buprenorphine was administered on days 1-4 (26 mg total). For the NB Group (n = 32) escalating doses of oral naltrexone were given on days 2-8 (placebo day 1). For the PB Group (n = 28) placebo was given on days 1-7 and naltrexone on day 8. Main outcome measures were Observed Opioid Withdrawal scores (OOW, 0-30) and use of medications to treat opioid withdrawal. Of 32 patients in the NB group, 59% experienced clinically relevant withdrawal (defined as OOW > or = 5) on day 2, but, after day 5, none experienced withdrawal. In the PB group, the number of patients experiencing withdrawal increased over time. The first naltrexone dose induced comparable withdrawal in both groups: peak OOW scores were (mean +/- SD) 5.2 +/- 3.3 on day 2 for the NB group, and 4.0 +/- 3.9 on day 8 for the PB group (NS), though, on day 2, 7 patients dropped out in the NB group and none in the PB group, while only one patient dropped out in the PB group on day 8. Throughout the 8-day study, patients in both groups received similar amount of adjunct medication: 0.64 +/- 0.07 mg (NB group) of clonidine vs 0.73 +/- 0.15 mg (PB group; NS). Only 25% of patients required use of sedatives (up to 20 mg diazepam). Starting naltrexone on day 2 appeared to abolish withdrawal symptoms after day 5 and, thus, to shorten the duration of withdrawal symptoms. Peak withdrawal symptoms after naltrexone were of moderate intensity, suggesting that naltrexone combined with buprenorphine is an acceptable and safe treatment for shortened opioid detoxification and induction of naltrexone maintenance.

Estimated HIV risk among Hispanics in a national sample of drug users.

OBJECTIVE: To estimate and compare the HIV risks among three Hispanic subpopulations. METHODS: Chronic drug users participating in a nationwide intervention study on drug use were interviewed with regard to drug use and sexual behavior. HIV risk was estimated using information about individuals' HIV-relevant behaviors, the social context (i.e., city) in which such behaviors occur, and published estimates of HIV transmission for various risk behaviors. Multiple linear regression analysis was used to investigate differences in estimated HIV risk between Puerto Rican, Mexican-American, and Mexican drug users, accounting for sociodemographic factors, sexual preference, and geographic region. RESULTS: Puerto Ricans had significantly greater estimated overall HIV risk, estimated injection risk, and in general, significantly greater estimated sexual risk than Mexican Americans and Mexicans. No significant differences were found in any estimated risk between Mexican Americans and Mexicans in this sample. No significant differences were found among any of the subgroups for estimated risk from having anal sex while using a condom, or from having receptive anal sex without using a condom. CONCLUSIONS: These findings suggest that Puerto Ricans who use drugs experience a higher risk of HIV infection than other Hispanic drug users. Research is needed to identify which economic, social, and cultural components account for this increased risk.

The role of parents in protecting Colombian adolescents from delinquency and marijuana use.

OBJECTIVES: To identify general and differentiating risk and protective factors from domains of culture and ecology, peer, family, and personality, related to adolescent delinquency and marijuana use, and to study the protective role of the parent-child mutual attachment in offsetting cultural and ecological risk factors, leading to less delinquency and marijuana use. DESIGN: Cross-sectional analyses of interview data collected in Colombia. PARTICIPANTS: A total of 2837 Colombian adolescents, 12 to 17 years of age. SETTING: Adolescents were interviewed in their homes. MAIN MEASURES: Independent variables included measures from 4 domains: culture and ecology, peer, family, and personality. The dependent variables were delinquency and marijuana use. RESULTS: Several risk factors, such as tolerance of deviance and sensation seeking, were similarly related to both delinquency and marijuana use, suggesting that a common cause underlies the propensity to engage in different deviant behaviors. Some risk factors were more involved in delinquency and other risk factors were more highly related to the adolescent's marijuana use. Finally, when violence is endemic and illegal drugs are readily available, a close parent-child bond was capable of mitigating these risk factors, leading to less marijuana use and delinquency. CONCLUSIONS: The findings have implications for public health policy related to interventions in countries in which violence and drug use are prevalent. The results point to interventional procedures aimed at adolescents vulnerable to marijuana use and delinquency as well as efforts aimed at specific vulnerabilities in these areas. For example, reducing the risk factors and enhancing the protective factors for marijuana use and delinquency may result in less adolescent marijuana use and delinquency.