Lifetime use of non-nicotine drugs in electronic cigarette devices among a sample of individuals in substance use disorder treatment.

Background: Limited data are available on other substance use in e-cigarettes (OSUE). The aim of this research was to determine the prevalence and predictors of OSUE among a sample of individuals in substance use disorder (SUD) treatment. Methods: In 2019, we surveyed 553 individuals from 18 residential SUD treatment programs in California, USA. Individuals reporting any lifetime use of an e-cigarette containing nicotine (n = 279) were asked about ever use of drugs other than nicotine in their e-cigarette. Those who reported use of non-nicotine drugs in their e-cigarette also reported what psychoactive drugs were used. Results: Among all the participants, 25 % (n = 139) . reported ever engaging in OSUE. The most common drugs used in vaping devices were marijuana/THC/hash, (70.5 %, n = 98) and amphetamines/methamphetamine (51.1 %, n = 71). Among those who had engaged in OSUE, 44.6 % (n = 62) had vaped drugs for which they sought treatment. Older persons (OR = 0.93, CI 0.91, 0.95) and African Americans (OR = 0.48, CI 0.24, 0.94) were less likely to have ever engaged in OSUE, while persons in treatment for opioid use were more likely (OR = 1.71, CI 1.08, 2.71). Conclusion: Among a sample of clients in SUD treatment, about 25% had ever engaged in OSUE, with THC/marijuana and amphetamines most commonly reported. Further research is needed to evaluate the OSUE to understand the reasons for use and implications among persons enrolled in SUD treatment.

Pre-implementation Assessment of Tobacco Cessation Interventions in Substance Use Disorder Residential Programs in California.

BACKGROUND: Across the United States, substance use disorder (SUD) treatment programs vary in terms of tobacco-related policies and cessation services offered. Implementation of tobacco-related policies within this setting can face several barriers. Little is known about how program leadership anticipate such barriers at the pre-implementation phase. This study used the Consolidated Framework for Implementation Research (CFIR) during the pre-implementation stage to identify factors that may influence the implementation stage of tobacco-related cessation policies and services in residential SUD programs. METHODS: We conducted semi-structured qualitative interviews with sixteen residential treatment program directors in California. The analysis was guided by a deductive approach using CFIR domains and constructs to develop codes and identify themes. ATLAS.ti software was used to facilitate thematic analysis of interview transcripts. FINDINGS: Themes that arose as anticipated facilitators for implementation included the relative advantage of the intervention vs. current practice, external policies/incentives to support tobacco-related policy, program directors' strong commitment and high self-efficacy to incorporate cessation into SUD treatment, and recognizing the importance of planning and engaging opinion leaders. Potential barriers included the SUD recovery culture, low stakeholder engagement, organizational culture, lack of workforce expertise, and lack of reimbursement for smoking cessation services. CONCLUSION: To support successful implementation of tobacco-related organizational change interventions, staff and clients of residential SUD programs require extensive education about the effectiveness of evidence-based medications and behavioral therapies for treating tobacco dependence. Publicly funded SUD treatment programs should receive support to address tobacco dependence among their clients through expanded reimbursement for tobacco cessation services.

Impacts of COVID-19 on residential treatment programs for substance use disorder.

INTRODUCTION: The COVID-19 pandemic may present special challenges for residential substance use disorder (SUD) treatment facilities, which may lack infrastructure and support to implement infection control protocols while maintaining on-site treatment services. However, little is known about how residential SUD treatment programs are impacted by the COVID-19 pandemic. METHODS: The research team conducted semi-structured interviews with 17 directors of 20 residential SUD treatment programs across California during the state's shelter-in-place order. The researchers then analyzed qualitative interview data thematically and coded them using ATLAS.ti software. FINDINGS: Thematic analyses identified six major themes: program-level impacts, staff impacts, client impacts, use of telehealth, program needs, and positive effects. "Program-level impacts" were decreased revenue from diminished client censuses and insufficient resources to implement infection control measures. "Staff impacts" included layoffs, furloughs, and increased physical and emotional fatigue. "Client impacts" were delayed treatment initiation; receipt of fewer services while in treatment; lower retention; and economic and psychosocial barriers to community re-entry. "Use of telehealth" included technical and interpersonal challenges associated with telehealth visits. "Program needs" were personal protective equipment (PPE), stimulus funding, hazard pay, and consistent public health guidance. "Positive effects" of the pandemic response included increased attention to hygiene and health, telehealth expansion, operational improvements, and official recognition of SUD treatment as an essential health care service. CONCLUSION: Study findings highlight COVID-related threats to the survival of residential SUD treatment programs; retention of the SUD treatment workforce; and clients' SUD treatment outcomes. These findings also identify opportunities to improve SUD service delivery and suggest avenues of support for residential SUD treatment facilities during and after the COVID-19 pandemic.

Menthol cigarette use in substance use disorder treatment before and after implementation of a county-wide flavoured tobacco ban.

INTRODUCTION: This study examined the impact of a San Francisco City and County ban on all flavoured tobacco products, including menthol cigarettes, among clients in residential substance use disorder (SUD) treatment. METHODS: We conducted cross-sectional surveys of clients at two residential SUD programmes before the County began enforcing the ban (n=160) and twice after enforcement began (n=102, n=120). The samples were compared on demographic characteristics, smoking status, smoking behaviours and the proportion reporting menthol as their usual cigarette. Menthol smokers were asked whether they smoked only menthol cigarettes, mostly menthol, both menthol and non-menthol or mostly non-menthol. Post-ban samples were asked about awareness of the ban and access to menthol cigarettes. RESULTS: In multivariate analyses, we found no evidence that the ban was associated with decreased number of cigarettes per day or increased readiness to quit among current smokers. However, odds were lower post-ban for reporting menthol as the usual cigarette (OR=0.80, 95% CI 0.72 to 0.90), and for smoking only menthol cigarettes (OR=0.19, 95% CI 0.18 to 0.19). Perhaps most importantly, and with the ability to influence all other findings, 50% of self-identified menthol smokers reported purchasing menthol cigarettes in San Francisco nearly 1 year after the ban was implemented. CONCLUSION: In subgroups where smoking has remained elevated, like those receiving SUD treatment, local menthol bans may have only modest impacts on smoking behaviour. Broader regional, state or national bans, that effectively restrict access to menthol products, may be needed to show stronger effects on smoking behaviour.

Sex Differences in Graphic Warning Label Ratings by Addictions Clients.

OBJECTIVES: Research on sex differences in responses to cigarette graphic warning labels (GWLs) has been limited despite tobacco-related, health disparities for women. We examined whether women had stronger responses to certain labels than to others, whether this pattern differed from men's, and whether there were overall sex ratings differences. METHODS: Smokers (N = 881) in 24, addictions treatment programs rated 3 of 9 Food and Drug Administration-developed labels on credibility, message reactance, quit motivation, and negative emotions. Participants rated one label depicting a woman and/or baby, and 2 depicting tobacco-related disease or male images. RESULTS: Women's (n = 432) ratings of labels depicting women/babies versus other labels did not differ from men's (n = 449) ratings. Women had higher ratings than men across all labels combined on credibility (p < .001), quit motivation (p = .007), and negative emotions (p < .001). Individual labels were analyzed for sex differences. Women's ratings were higher on credibility for 3 of 9 labels, and on negative emotions for 7 of 9 labels. CONCLUSIONS: Female smokers in addictions treatment had generally stronger responses to GWLs than men, supporting GWL implementation in the United States to help close the sex gap in smoking cessation.

Cigarette Smoking Cessation Intervention for Buprenorphine Treatment Patients.

Introduction: Patients receiving medication assisted therapy (MAT) for opioid use disorder have high cigarette smoking rates. Cigarette smoking interventions have had limited success. We evaluated an intervention to increase cigarette abstinence rates in patients receiving buprenorphine-assisted therapy. Methods: Cigarette smokers (N = 175; 78% male; 69% Caucasian; 20% Hispanic), recruited from a buprenorphine clinic were randomly assigned to either an extended innovative system intervention (E-ISI) or to Standard Treatment Control (STC). The E-ISI combined motivational intervention with extended treatment (long-term nicotine replacement therapy , varenicline, and extended cognitive behavioral therapy). STC received written information about quit-lines, medication, and resources. Assessments were held at baseline and 3, 6, 12, and 18 months. Seven-day biochemically verified point-prevalence cigarette abstinence was the primary outcome measure. Results: Fifty-four percent of E-ISI participants entered the extended treatment intervention; E-ISI and STC differed at 3 months on abstinence status but not at months 6, 12, and 18. E-ISI participants were more likely to attempt to quit, to have a goal of complete abstinence, and to be in a more advanced stage of change than STC participants. A higher number of cigarettes smoked and the use of cannabis in the previous 30 days predicted continued smoking. Conclusions: The E-ISI was successful in increasing motivation to quit smoking but did not result in long-term abstinence. The failure of treatments that have been efficacious in the general population to produce abstinence in patients receiving MAT of opioid use disorder suggests that harm reduction and other innovative interventions should be explored. Implications: This study demonstrates that an intervention combining motivational interviewing with an extended treatment protocol can increase cigarette quit attempts, enhance cigarette abstinence goals, and further movement through stages of change about quitting smoking in patients receiving MAT for opioid use disorder who smoke cigarettes. The intervention did not increase abstinence rates over those observed in a standard treatment control, however. The latter finding supports those of earlier investigators who also failed to find efficacy for smoking cessation in this population and who also used interventions effective in the general population. This pattern of findings suggests that patients with opioid use disorder can be motivated to change smoking behavior, but alternative and innovative approaches to cigarette smoking treatment should be studied.

Therapist predictors of treatment delivery fidelity in a community-based trial of 12-step facilitation.

BACKGROUND AND AIMS: Therapist characteristics may be associated with variation in consistency, quality and effectiveness of treatment delivery. We examined associations between treatment fidelity and therapist education, experience, treatment orientation and perceived skills in a randomized, multi-site trial of Twelve Step Facilitation (TSF). METHODS: Raters scored audio-recorded, TSF sessions (n = 966; 97% of TSF sessions) from 32 community-based, trained therapists for adherence, competence, empathy and global session performance. RESULTS: Therapists with graduate degrees had significantly higher adherence and global performance fidelity ratings. Therapists reporting more positive attitudes toward 12-Step groups had lower adherence ratings. Being in recovery was associated with lower fidelity in univariate tests, but higher adherence in multivariate analysis. Fidelity was higher for therapists reporting self-efficacy in basic counseling skills and lower for self-efficacy in addiction-specific counseling skills. Fidelity was also superior in group relative to individual TSF sessions. CONCLUSIONS: Results have implications for therapist selection, training and supervision in community-based, effectiveness trials and community implementation of evidence-based treatments. To obtain high fidelity and improve outcomes, it may be preferable to choose masters level therapists who are open to learning new treatments and have good, general counseling skills.

Assessing fidelity of treatment delivery in group and individual 12-step facilitation.

Twelve step facilitation (TSF) is an emerging, empirically supported treatment, the study of which will be strengthened by rigorous fidelity assessment. This report describes the development, reliability and concurrent validity of the Twelve Step Facilitation Adherence Competence Empathy Scale (TSF ACES), a comprehensive fidelity rating scale for group and individual TSF treatment developed for the National Drug Abuse Treatment Clinical Trials Network study, Stimulant Abuser Groups to Engage in 12-Step. Independent raters used TSF ACES to rate treatment delivery fidelity of 966 (97% of total) TSF group and individual sessions. TSF ACES summary measures assessed therapist treatment adherence, competence, proscribed behaviors, empathy and overall session performance. TSF ACES showed fair to good overall reliability; weighted kappa coefficients for 59 co-rated sessions ranged from .31 to 1.00, with a mean of .69. Reliability ratings for session summary measures were good to excellent (.69-.91). Internal consistency for the instrument was variable (.47-.71). Relationships of the TSF ACES summary measures with each other, as well as relationships of the summary measures with a measure of therapeutic alliance provided support for concurrent and convergent validity. Implications and future directions for the use of TSF ACES in clinical trials and community treatment implementation are discussed.

Cigarette smoking among opioid-dependent clients in a therapeutic community.

This study examines smoking behavior in a sample of 231 opioid-dependent clients entering therapeutic community treatment, and investigates the relationship between smoking behavior and drug treatment outcomes. We applied regression analyses for selected Addiction Severity Index composites (alcohol, drug, medical, psychiatric), including factors for smoking (number of cigarettes per day, expired-air carbon monoxide level, nicotine dependence), time (baseline, 6 and 12-month), and smoking-by-time interaction. This study confirmed a high smoking prevalence (95%) among opioid users. Among participants interviewed at all time points (n = 206), 13% shifted from smoking to non-smoking status at some time after admission. Participants who reported a greater number of cigarettes were more likely to report higher drug severity at any time point.

Does the Presence of a Smoking Cessation Clinical Trial Affect Staff Practices Related to Smoking?

This study investigated whether organizational changes occurred when nicotine treatments were tested in specialty care clinics. Two intervention clinics (one drug treatment and one HIV-care) participated in clinical trials for nicotine treatment. Three clinics (two drug and one HIV-care) were control clinics. Staff in the intervention clinics (n=57) and in the control clinics (n=62) were surveyed at baseline and 18 months later. Staff surveys concerned nicotine-related knowledge, beliefs about treating smoking, self-efficacy in delivering such treatment, nicotine related practices, and barriers to providing nicotine treatment. Mean scale scores at 18 months were no different in clinics participating in the clinical trials from the control group for any of the five scales (knowledge, practices, barriers, efficacy, and beliefs). The presence of a smoking cessation clinical trial did not influence staff knowledge, attitudes, or practices related to smoking in these clinics. More specific organizational intervention may influence staff practices related to addressing smoking among clients in drug treatment and HIV-care clinics.

Drug treatment outcomes for persons on waiting lists.

This study examined treatment access and outcomes for persons placed on drug abuse treatment waiting lists. Participants (n = 170) were recruited when they entered either a methadone detoxification program or a day treatment program, and were waiting for methadone maintenance or residential treatment, respectively. Participants were interviewed at baseline and 2-months follow-up. Excluding the index treatment episode, 73% received some treatment during the follow-up period. Mixed effects regression was used to compare short-term outcomes for clients who did and did not enter treatment following the index episode. We found increased drug problems, over time, for all participants. Those enrolled in treatment at follow-up reported higher employment problems (collapsed across time) compared with those not in treatment. Last, participants enrolled in any subsequent treatment showed a decrease in psychiatric problems over time, while those not enrolled in subsequent treatment showed an increase in psychiatric problems. Participants who entered treatment within 60 days after being placed on a waiting list showed improvement on psychiatric measures but not on substance abuse measures.

Outcomes in a Sample of Opiod-Dependent Clients Treated Under California's Proposition 36.

This study evaluated treatment outcomes for the reduction of criminal justice involvement and substance use among opioid dependent clients in a therapeutic community setting under California's Proposition 36. We compared treatment outcomes between those mandated to treatment under Proposition 36 (n = 24) and those on probation but not involved in Proposition 36 (n = 61) over 12 months. Over time, both groups showed significant improvement on drug use and employment measures, were more likely to be involved in job training and less likely to be engaged in work activity, and had similar retention in treatment. There was no evidence that treatment outcomes were different between the two groups. These findings may be helpful in guiding policy makers and clinicians in states where similar initiatives are under consideration.

Drug treatment utilization before, during and after pregnancy.

This study retrospectively explored drug treatment utilization before, during and after pregnancy for all identified substance-using women delivering at a county hospital over a 4-year period (n=431). Drug treatment data were linked to hospital data to analyse treatment utilization. Fifty-three per cent received treatment the year before, during, or within the year after delivery, with a significantly higher proportion receiving treatment during and after pregnancy. There were significant increases in methadone and residential treatment services during pregnancy. Women spent significantly more time in treatment after delivery compared with before or during pregnancy. However, 47% of these women did not receive drug treatment. These findings support current literature suggesting that pregnancy presents an opportunity to engage women in treatment. However, there is a need to decrease the institutional, legal, and funding barriers that exist between health care and drug treatment providers. Utilizing available data to track perinatal substance use and treatment utilization are important to plan for adequate availability of treatment services for this population.

The San Francisco centralized intake unit: a description of participants and service episodes.

Using client data from the publicly-funded drug abuse treatment system in San Francisco, California, this study compared demographic characteristics of clients of a central intake unit (CIU) to those of clients who did not access the CIU, and examined characteristics of CIU episodes. The San Francisco CIU was intended to make appropriate referrals of CIU clients to treatment programs, and 47.9% of these episodes were followed by a subsequent treatment episode within 90-days of admission to the CIU. Of all individuals in the treatment system, a quarter had been to the CIU and as many as 9% of all treatment episodes were at the CIU. The majority of CIU episodes were short, consistent with the nature of assessment and referral services. These data suggest that incorporating strategies to enhance admissions to post-CIU services could increase CIU impacts. The post-CIU admission patterns were consistent with greater availability of outpatient and day treatment slots in the system. The pre-CIU admission patterns suggested that treatment agencies in the system used the CIU as a means to transition their clients into additional or longer-term treatment.

A Drug Court Outcome Evaluation Comparing Arrests in a Two Year Follow-up Period.

Since the first drug court in Miami in 1989, the drug court movement has spread throughout the United States, influencing how drug-involved offenders are treated in the criminal justice system. This paper reports on an outcome evaluation of a drug court in San Mateo County, California. Arrest rates were compared for drug court participants (N=618) and non-participants (N=75), and for graduates (N=257) and non-graduates (N=361). Factors associated with rearrest were assessed for participants in both groups. During a two-year follow-up period, there were no significant differences in rearrest rates between the participant and non-participant groups. Comparisons between graduates and non-graduates showed lower rearrest rates for graduates (19% vs. 53%, χ(2)(1)=73.5, p<0.01). In a model including participants and non-participants, only a prior history of conviction predicted an increased likelihood of rearrest whereas being female and older decreased the likelihood of rearrest. In addition, among drug court participants only, graduating decreased the likelihood of rearrest.