Predicting Homelessness among Emerging Adults Aging Out of Foster Care.

This study examines risk and protective factors associated with experiencing homelessness in the year after "aging out" of foster care. Using a state-level integrated administrative database, we identified 1,202 emerging adults in Washington State who exited foster care between July 2010 and June 2012. Initial bivariate analyses were conducted to assess the association between candidate predictive factors and an indicator of homelessness in a 12-month follow-up period. After deploying a stepwise regression process, the final logistic regression model included 15 predictive factors. Youth who were parents, who had recently experienced housing instability, or who were African American had approximately twice the odds of experiencing homelessness in the year after exiting foster care. In addition, youth who had experienced disrupted adoptions, had multiple foster care placements (especially in congregate care settings), or had been involved with the juvenile justice system were more likely to become homeless. In contrast, youth were less likely to experience homelessness if they had ever been placed with a relative while in foster care or had a high cumulative grade point average relative to their peers.

Adult attention-deficit/hyperactivity disorder and nicotine withdrawal: a qualitative study of patient perceptions.

BACKGROUND: Nicotine use has been reported to ameliorate symptoms of Attention-Deficit/Hyperactivity Disorder (ADHD). Furthermore, adults with ADHD have a relatively high prevalence of cigarette smoking and greater difficulty abstaining from smoking. Overall, though, there is scant literature investigating the beliefs, perceptions and experiences of smokers with ADHD regarding smoking cessation and withdrawal. METHODS: Our participants (n = 20) fulfilling criteria for ADHD and a past or current dependence from nicotine were recruited from the in- and outpatient clinic of the Zurich University Psychiatric Hospital and the Psychiatric Services Aargau (Switzerland). We conducted in-depth interviews to explore their motivations to quit, past experiences with and expectations about quitting using a purposeful sampling plan. The sample was selected to provide diversity in relation to level of nicotine dependence, participation in a smoking-cessation program, gender, age, martial status and social class. Mayring's qualitative content analysis approach was used to evaluate findings. RESULTS: Adult smokers with ADHD had made several attempts to quit, experienced intense withdrawal symptoms, and relapsed early and often. They also often perceived a worsening of ADHD symptoms with nicotine abstinence. We identified three motives to quit smoking: 1) health concerns, 2) the feeling of being addicted, and 3) social factors. Most participants favored a smoking cessation program specifically designed for individuals with ADHD because they thought ADHD complicated their nicotine withdrawal and that an ADHD-specific smoking cessation program should address specific symptoms of this disorder. CONCLUSIONS: Since treatment initiation and adherence associate closely with perception, we hope these findings will result in better cessation interventions for the vulnerable subgroup of smokers with ADHD.

Childhood adversity and behavioral health outcomes for youth: An investigation using state administrative data.

This study aimed to measure the relative contribution of adverse experiences to adolescent behavioral health problems using administrative data. Specifically, we sought to understand the predictive value of adverse experiences on the presence of mental health and substance abuse problems for youth receiving publicly funded social and health services. Medicaid claims and other service records were analyzed for 125,123 youth age 12-17 and their biological parents. Measures from administrative records reflected presence of parental domestic violence, mental illness, substance abuse, criminal justice involvement, child abuse and/or neglect, homelessness, and death of a biological parent. Mental health and substance abuse status of adolescents were analyzed as functions of adverse experiences and other youth characteristics using logistic regression. In multivariate analyses, all predictors except parental domestic violence were statistically significant for substance abuse; parental death, parental mental illness, child abuse or neglect and homelessness were statistically significant for mental illness. Odds ratios for child abuse/neglect were particularly high in both models. The ability to identify risks during childhood using administrative data suggests the potential to target prevention and early intervention efforts for children with specific family risk factors who are at increased risk for developing behavioral health problems during adolescence. This study illustrates the utility of administrative data in understanding adverse experiences on children and the advantages and disadvantages of this approach.

A performance measure for continuity of care after detoxification: relationship with outcomes.

Administrative data from five states were used to examine whether continuity of specialty substance abuse treatment after detoxification predicts outcomes. We examined the influence of a 14-day continuity of care process measure on readmissions. Across multiple states, there was support that clients who received treatment for substance use disorders within 14-days after discharge from detoxification were less likely to be readmitted to detoxification. This was particularly true for reducing readmissions to another detoxification that was not followed with treatment and when continuity of care was in residential treatment. Continuity of care in outpatient treatment was related to a reduction in readmissions in some states, but not as often as when continuity of care occurred in residential treatment. A performance measure for continuity of care after detoxification is a useful tool to help providers monitor quality of care delivered and to alert them when improvement is needed.

Case studies from three states: breaking down silos between health care and criminal justice.

The jail-involved population-people with a history of arrest in the previous year-has high rates of illness, which leads to high costs for society. A significant percentage of jail-involved people are estimated to become newly eligible for coverage through the Affordable Care Act's expansion of Medicaid, including coverage of substance abuse treatment and mental health care. In this article we explore the need to break down the current policy silos between health care and criminal justice, to benefit both sectors and reduce unnecessary costs resulting from lack of coordination. To draw attention to the hidden costs of the current system, we review three case studies, from Washington State, Los Angeles County in California, and New York City. Each case study addresses different aspects of care needed by or provided to the jail-involved population, including mental health and substance abuse, emergency care, and coordination of care transitions. Ultimately, bending the cost curve for health care and criminal justice will require greater integration of the two systems.

Engagement in outpatient substance abuse treatment and employment outcomes.

This study, a collaboration between an academic research center and Washington State's health, employment, and correction departments, investigates the extent to which treatment engagement, a widely adopted performance measure, is associated with employment, an important outcome for individuals receiving treatment for substance use disorders. Two-stage Heckman probit regressions were conducted using 2008 administrative data for 7,570 adults receiving publicly funded treatment. The first stage predicted employment in the year following the first treatment visit, and three separate second-stage models predicted the number of quarters employed, wages, and hours worked. Engagement as a main effect was not significant for any of the employment outcomes. However, for clients with prior criminal justice involvement, engagement was associated with both employment and higher wages following treatment. Clients with criminal justice involvement face greater challenge regarding employment, so the identification of any actionable step which increases the likelihood of employment or wages is an important result.

Criminal justice outcomes after engagement in outpatient substance abuse treatment.

The relationship between engagement in outpatient treatment facilities in the public sector and subsequent arrest is examined for clients in Connecticut, New York, Oklahoma and Washington. Engagement is defined as receiving another treatment service within 14 days of beginning a new episode of specialty treatment and at least two additional services within the next 30 days. Data are from 2008 and survival analysis modeling is used. Survival analyses express the effects of model covariates in terms of "hazard ratios," which reflect a change in the likelihood of outcome because of the covariate. Engaged clients had a significantly lower hazard of any arrest than non-engaged in all four states. In NY and OK, engaged clients also had a lower hazard of arrest for substance-related crimes. In CT, NY, and OK engaged clients had a lower hazard of arrest for violent crime. Clients in facilities with higher engagement rates had a lower hazard of any arrest in NY and OK. Engaging clients in outpatient treatment is a promising approach to decrease their subsequent criminal justice involvement.

Self-reported alcohol and drug use six months after brief intervention: do changes in reported use vary by mental-health status?

BACKGROUND: Although brief intervention (BI) for alcohol and other drug problems has been associated with subsequent decreased levels of self-reported substance use, there is little information in the extant literature as to whether individuals with co-occurring hazardous substance use and mental illness would benefit from BI to the same extent as those without mental illness. This is an important question, as mental illness is estimated to co-occur in 37% of individuals with an alcohol use disorder and in more than 50% of individuals with a drug use disorder. The goal of this study was to explore differences in self-reported alcohol and/or drug use in patients with and without mental illness diagnoses six months after receiving BI in a hospital emergency department (ED). METHODS: This study took advantage of a naturalistic situation where a screening, brief intervention, and referral to treatment (SBIRT) program had been implemented in nine large EDs in the US state of Washington as part of a national SBIRT initiative. A subset of patients who received BI was interviewed six months later about current alcohol and drug use. Linear regression was used to assess whether change in substance use measures differed among patients with a mental illness diagnosis compared with those without. Data were analyzed for both a statewide (n = 828) and single-hospital (n = 536) sample. RESULTS: No significant differences were found between mentally ill and non-mentally ill subgroups in either sample with regard to self-reported hazardous substance use at six-month follow-up. CONCLUSION: These results suggest that BI may not have a differing impact based on the presence of a mental illness diagnosis. Given the high prevalence of mental illness among individuals with alcohol and other drug problems, this finding may have important public health implications.

Evaluation of an innovative Medicaid health policy initiative to expand substance abuse treatment in Washington State.

State health policy making is rarely based on evidence derived from empirical analysis. An exception is an innovative policy established in 2005 in Washington State (Senate Bill [SB] 5763) to provide funding (approximately $30 million) to expand access to substance abuse (SA) treatment for Medicaid beneficiaries. The authors analyzed Medicaid claims data and other administrative data over a 7-year period, July 2001 through June 2008, for three cohorts of welfare clients (n ≈ 44,000) to assess the effect of SA treatment on health care expenditures. Regression analysis showed SA treatment to be associated (p < .001) with per member per month expenditure savings of approximately $160 to $385 depending on the welfare cohort. The aggregate annualized estimated saving ($16.8 million) equaled the cost-saving goal of SB 5763. While it may be tempting for policy makers to cut funding for SA treatment, this may be counterproductive and in the long-run increase Medicaid costs.

Impact of sexual orientation and co-occurring disorders on chemical dependency treatment outcomes.

OBJECTIVE: The aims of this study were to compare client characteristics at admission to chemical dependency (CD) treatment by sexual orientation, examine sexual orientation as a predictor of co-occurring CD and mental health problems (hereafter referred to as co-occurring disorders [COD]), and to examine the effect of sexual orientation and COD on 1-year CD treatment outcomes (treatment completion, treatment reentry, and arrest) among men and women. METHOD: This retrospective cohort study used 2004-2008 data from publicly funded CD treatment programs in Washington State (n = 69,525 clients). Bivariate comparisons were made using chi-square tests; logistic and Cox regressions were to estimate risk in multivariate analyses. RESULTS: Risk factors associated with sexual minority status (lesbian/gay/bisexual) included COD, primary drug (vs. alcohol) use, and greater substance use. In multivariate analyses, sexual minority clients were more than twice as likely as their heterosexual counterparts to have COD. COD, but not sexual orientation, negatively predicted treatment completion and arrest overall in the year following treatment among male and female clients and positively predicted treatment reentry and intimate partner violence-related arrest among women. COD moderated the effect of sexual orientation on arrest; gay men with COD were less likely to be arrested, particularly for substance use and other violence-related crimes. CONCLUSIONS: These findings highlight the importance of assessing mental health among sexual minority clients in treatment settings and addressing issues specific to both female and male sexual minorities.

Review of risk and protective factors of substance use and problem use in emerging adulthood.

This review examines the evidence for longitudinal predictors of substance use and abuse in emerging adulthood. Nationally representative data from the 2007 National Survey on Drug use and Health suggest that many substance use problems reach their peak prevalence during emerging adulthood (usually defined as the period from age 18 to age 26). This stage of development is characterized by rapid transitions into new social contexts that involve greater freedom and less social control than experienced during adolescence. Concurrent with this newfound independence is an increase in rates of substance use and abuse. Understanding the risk and protective factors associated with emerging adult substance use problems is an important step in developing interventions targeting those problems. While multiple reviews have examined risk and protective factors for substance use during adolescence, and many of these earlier predictors may predict emerging adult substance use, few studies have focused primarily on the emerging adult outcomes examining predictors from both adolescence and emerging adulthood. This review used the databases PubMed and PsycInfo to identify articles pertaining to longitudinal predictors of substance use problems in emerging adulthood, building from the conceptual framework presented in a review on risk and protective factors for adolescent substance abuse by Hawkins and colleagues (Hawkins, Catalano, & Miller, 1992). Predictors identified as predictors of substance use in adolescence, sometimes decreased in strength and in one case reversed direction. Unique predictors in emerging adulthood were also identified. Implications for prevention science during adolescence and emerging adulthood are discussed as well as suggestions for future research.

The use of administrative data as a substitute for individual screening scores in observational studies related to problematic alcohol or drug use.

Administrative data provide a rich resource for improving our understanding of individuals with substance use disorders. The validation of administrative proxies for moderate or high risk alcohol or drug (AOD) use could enhance the ability to carry out rigorous observational research (for example, for use in the construction of comparison groups). This study used receiver operating characteristic (ROC) curve techniques to assess how well AOD-related administrative indicators predicted self-reported AOD use obtained from AUDIT/DAST screening scores. An administrative AOD indicator, derived from a combination of medical encounter and billing data, arrest records, and publicly funded AOD-related services data, demonstrated discrimination in the acceptable range (AUC: 0.72-0.78) for identifying self-reported AOD use consistent with potential need for either (1) any AOD-related intervention, or (2) intensive AOD-related intervention or treatment. These findings held up in two distinct samples: a statewide Medicaid-only sample and a single-site mixed-payer sample that included the uninsured. Our findings suggest that indicators of AOD-related problems derived from administrative data can be useful for identifying moderate or high risk AOD use in a research context. The findings further suggest that proxies for substance use disorders, such as those evaluated here, can enhance future observational studies intended to improve health care for this population.

Impact of brief interventions and brief treatment on admissions to chemical dependency treatment.

This study examined two issues. One, whether individuals with possible substance use disorders were more likely to be admitted to specialized chemical dependency (CD) treatment after receiving a brief intervention (BI) - either alone or in combination with other services - than similar individuals who did not receive a BI. Two, whether participation in brief treatment (BT) following a BI was helpful in facilitating admission to CD treatment. The study took place in the emergency department (ED) of a large urban safety-net hospital where CD professionals screened patients for alcohol/drug problems and provided BI, BT, and referral to specialized CD treatment when appropriate (SBIRT). Substance use disorders were indicated by alcohol/drug problems noted in administrative records. Hospital records were used to match patients with likely substance use disorders who received BI with similar ED patients who had not been screened. Admission to publicly funded CD treatment was determined by matching patient identifiers to state administrative records of CD treatment. Results indicated that individuals with a likely substance use disorder who received a BI (regardless of subsequent participation in BT) were significantly more likely to enter specialized CD treatment in the subsequent year than similar individuals who did not receive a BI. This result was particularly pronounced for patients with no CD treatment in the past two years. Results also indicated that participation in BT facilitated admission into CD treatment. The results suggest that SBIRT programs could serve an important role in increasing entry to specialized treatment for individuals with substance use disorders.

Effect of co-occurring disorders and intimate partner violence on substance abuse treatment outcomes.

This retrospective cohort study examined risk factors for co-occurring substance use and mental disorders (COD) and the effect of COD and intimate partner violence (IPV) victimization among women and IPV-related arrest among men on 1-year substance abuse treatment outcomes. The study sample included clients admitted to Washington State publicly funded substance abuse treatment facilities in 2004-2007. COD was associated with a high substance use and IPV risk profile at admission. Having a COD decreased the odds of completing treatment by 30% among men and women and increased the risk of treatment reentry by 9% and 12% among men and women, respectively. IPV also decreased the odds of completing treatment among women and increased the risk of treatment reentry among men. Men with COD were less likely than those without COD to be arrested for substance-related crimes but more likely to be arrested for violence-related crimes in the follow-up period. Implications of these findings are discussed.

Methamphetamine users entering treatment: characteristics of the methamphetamine treatment project sample.

The Center for Substance Abuse Treatment funded the Metamphetamine Treatment Project to evaluate and compare treatment approaches for methamphetamine users. As part of this study, drug use patterns, history of physical or sexual abuse, history of suicidality, and psychopathology were assessed in 1,016 methamphetamine-dependent outpatients entering treatment between 1999 and 2001 at eight sites across the western United States. The sample was predominately female and racially diverse. The mean age of the participants was 32.8 years. Most were methamphetamine smokers, but there were marked regional variations. Suicidality and physical or sexual abuse were common and measures of current psychopathology were high. These clinical issues were associated with more frequent use of methamphetamine and, more strongly, with concurrent use of other drugs. Therefore, the relationship between polydrug use and psychopathology in methamphetamine users warrants further investigation.

Pharmacokinetics of buprenorphine: a comparison of sublingual tablet versus liquid after chronic dosing.

Although buprenorphine is approved for use in the outpatient treatment of opioid addiction in 2 tablet formulations, a monoproduct containing buprenorphine only (Subutex) and a buprenorphine/naloxone combination product (Suboxone), much of the clinical data that support the approval by the U.S. Food and Drug Administration were generated by using a sublingual liquid. To interpret the literature in prescribing parameters for tablet buprenorphine, this study was designed to determine steady state buprenorphine plasma levels for the 2 formulations and to assess the relative bioavailability of each. A randomized, double-blind, crossover study with dose increases was conducted during a 12-week period at an outpatient treatment clinic. Of the 184 subjects initially randomized to treatment, 133 (72.3%) were evaluated for the steady-state trough plasma concentration, 16 (8.7%) for relative bioavailability, and 31 (16.8%) for dose proportionality. At steady state, differences in the trough plasma concentrations of buprenorphine between the 2 formulations were found across all the dose levels. Average plasma concentration (Cavg) of the tablet at twice the milligram dose of the liquid was twice that of the liquid; intersubject variability was greater for the tablet. At double the dose of tablet, there is no difference in steady state plasma concentrations. The bioavailability seems equivalent for the 2 formulations across all the dose levels.

Randomized, placebo-controlled trial of sertraline and contingency management for the treatment of methamphetamine dependence.

BACKGROUND: Methamphetamine dependence and associated medical and psychiatric concerns are significant public health issues. This project evaluated the efficacy of sertraline (50mg bid) and contingency management (CM) for the treatment of methamphetamine dependence. METHOD: In this randomized, placebo-controlled, double-blind trial, participants completed a 2-week non-medication baseline and were randomized to one of four conditions for 12 weeks: sertraline plus CM (n=61), sertraline-only (n=59), matching placebo plus CM (n=54), or matching placebo-only (n=55). All participants attended clinic thrice-weekly for data collection, medication dispensing, and relapse prevention groups. Outcomes included methamphetamine use (urine drug screening and self-reported days of use), retention (length of stay), drug craving (visual analogue scale), and mood symptoms (Beck Depression Inventory). RESULTS: No statistically significant main or interaction effects for sertraline or CM in reducing methamphetamine use were observed using a generalized estimating equation (GEE), although post hoc analyses showed the sertraline-only condition had significantly poorer retention than other conditions (chi(2) (3)=8.40, p<0.05). Sertraline conditions produced significantly more adverse events than placebo conditions. A significantly higher proportion of participants in CM conditions achieved three consecutive weeks of methamphetamine abstinence than those in non-CM conditions. CONCLUSIONS: These data do not demonstrate improved outcomes for sertraline versus placebo for treatment of methamphetamine dependence; indeed, they suggest sertraline is contraindicated for methamphetamine dependence. Findings provide support for the use of contingency management for treatment of methamphetamine dependence.

A multi-site comparison of psychosocial approaches for the treatment of methamphetamine dependence.

AIMS: The Center for Substance Abuse Treatment (CSAT) Methamphetamine Treatment Project (MTP) is the largest randomized clinical trial of treatments for methamphetamine (MA) dependence to date. The objective of the study was to compare the Matrix Model, a manualized treatment method, with treatment-as-usual (TAU) in eight community out-patient settings in the Western United States. DESIGN: Over an 18-month period between 1999 and 2001, 978 treatment-seeking, MA-dependent people were randomly assigned to receive either TAU at each site or a manualized 16-week treatment (Matrix Model). SETTING: The study was conducted as an eight-site out-patient trial, with six sites located in California and one each in Montana and Hawaii. FINDINGS: In the overall sample, and in the majority of sites, those who were assigned to Matrix treatment attended more clinical sessions, stayed in treatment longer, provided more MA-free urine samples during the treatment period and had longer periods of MA abstinence than those assigned to receive TAU. Measures of drug use and functioning collected at treatment discharge and 6 months post-admission indicate significant improvement by participants in all sites and conditions when compared to baseline levels, but the superiority of the Matrix approach did not persist at these two timepoints. CONCLUSIONS: Study results demonstrate a significant initial step in documenting the efficacy of the Matrix approach. Although the superiority of the Matrix approach over TAU was not maintained at the post-treatment timepoints, the in-treatment benefit is an important demonstration of empirical support for this psychosocial treatment approach.

Opioid effects and opioid withdrawal during a 24 h dosing interval in patients maintained on buprenorphine.

In maintenance patients methadone has been shown to produce considerable changes in opioid effects and withdrawal over the dosing interval. As a partial agonist buprenorphine may be expected to produce smaller changes, but the nature and magnitude of these changes have only been described for single doses. In the present study opioid effects and withdrawal were described in patients maintained on buprenorphine. Twenty four opioid dependent subjects were administered 16 mg buprenorphine tablets sublingually for 10 days. On day 10 plasma samples were collected and physiological, subjective and observer-rated measures collected pre-dose and at 14 time points during the dosing interval. No significant respiratory depression was observed. Consistent with the partial agonist properties of buprenorphine, other physiological and subjective changes were also of small magnitude. However, even at a once daily dose of 16 mg some patients experienced significant opioid withdrawal that was maximal at the end of the dosing interval. Buprenorphine maintenance should be associated with a high level of safety and a low level of disruption caused by changing opioid effects over the dosing interval, but some patients may require high doses or other strategies to completely suppress withdrawal.

A comparison of contingency management and cognitive-behavioral approaches during methadone maintenance treatment for cocaine dependence.

BACKGROUND: This study compared 2 psychosocial approaches for the treatment of cocaine dependence: contingency management (CM) and cognitive-behavioral therapy (CBT). METHODS: Patients with cocaine dependence who were receiving methadone maintenance treatment (n = 120) were randomly assigned to 1 of 4 conditions: CM, CBT, combined CM and CBT (CBT + CM), or treatment as usual (ie, methadone maintenance treatment program only [MMTP only]) (n = 30 per cell). The CM procedures and CBT materials were comparable to those used in previously published research. The active study period was 16 weeks, requiring 3 clinic visits per week. Participants were evaluated during treatment and at 17, 26, and 52 weeks after admission. RESULTS: Urinalysis results during the 16-week treatment period show that participants assigned to the 2 groups featuring CM had significantly superior in-treatment urinalysis results, whereas urinalysis results from participants in the CBT group were not significantly different than those from the MMTP-only group. At week 17, self-reported days of cocaine use were significantly reduced from baseline levels for all 3 treatment groups but not for the MMTP-only group. At the 26-week and 52-week follow-up points, CBT participants showed substantial improvement, resulting in equivalent performance with the CM groups as indicated by both urinalysis and self-reported cocaine use data. CONCLUSIONS: Study findings provide solid evidence of efficacy for CM and CBT. Although the effect of CM is significantly greater during treatment, CBT appears to produce comparable long-term outcomes. There was no evidence of an additive effect for the 2 treatments in the CM + CBT group.