Search

s / Drug and Alcohol Dependence 146 (2015) e202–e284 e273 Results: Students in the program condition showed greater increase of knowledge regarding tobacco (5.92%; p 0 to 21 joint equivalents/wk in the CD group (CDG); >5 heroin bag equivs/wk in the OD group (ODG)); there was no significant difference between the number of high users in each group (p=0.66). The mean age of the ODG was 22.6 years (SD=1.8) vs. 22.2 years (SD=2.1) in the CDG. The ODG was 32.7% female and the CDG was 24.6% female. The distribution of race was significantly different between the groups (p

naltrexone in opioid dependent patients, including both datadriven and addressing commonly asked topics on safety (e.g., hepatic health, anhedonia/depression, post treatment overdose risk). Methods: Per-subject urine data was solicited from all RCT authors and subjected to statistical analysis in accordance with Cochrane requirements. Subjective measures of opioid agonist use and other substances were also analyzed. For safety outcomes, a qualitative assessment was conducted of all relevant RCT and non-RCT contributions. Seven databases were searched, producing n=1104 abstracts, of which n=43 were relevant articles and n=6 were RCTs. Risk of bias was assessed for all studies in accordance with Cochrane principles. Results: Meta-analysis found a main effect of sustained release naltrexone on illicit opioid use (Z=5.2, p< .01) on both urine and subjective measures. On safety outcomes, sustained release naltrexone was generally well tolerated with some variations in site reactions due to the type of administration method used. Risk of biaswas generally consideredmoderate to high, especially for nonrandomized studies. Conclusions: Sustained releasenaltrexone increases abstinence from opioids in opioid dependent patients who volunteered for this type of medication-assisted abstinence and was generally safe in use. While no larger studies have yet compared sustained release naltrexone to maintenance treatment with methadone or buprenorphine, this review indicates that sustained release naltrexone can be considered an effective an safe treatment option for opioid dependence. Note: Results & Conclusions are subject to final approval by the Cochrane Drugs & Alcohol Group editorial review board Financial Support: The University of Oslo The Research Council of Norway.

Objectives. California’s Proposition 36 offers nonviolent drug offenders community-based treatment as an alternative to incarceration or probation without treatment. We examined how treatment capacity changed to accommodate Proposition 36 clients and whether displacement of other clients was an unintended consequence. Methods. Treatment admissions were compared for the year before and 2 years after the law was enacted. Surveys of county administrators and treatment providers were conducted in Kern, Riverside, Sacramento, San Diego, and San Francisco counties. Results. The number of Proposition 36 offenders admitted to treatment continued to increase in the state (approximately 32000 in Year 1 and 48000 in Year 2) and in the 5 counties; total treatment admissions stabilized in Year 2 after increasing in Year 1. Voluntary clients decreased by 8000 each year statewide, but the change varied across counties. One third of treatment providers reported decreased treatment availability for non–Proposition 36 clients in Year 2. Conclusion. Despite expanded treatment capacity (mostly in outpatient treatment), indirect evidence suggests that displacement of voluntary clients may have occurred in part because of the demand for treatment by Proposition 36 clients.

This study computed the life expectancy of a cohort of male narcotics addicts followed for 33 years and assessed the productivity lost as a result of premature mortality. The future life expectancy was constructed for the narcotics addicts and for a comparable cohort from the general U.S. population. The average future life expectancy of the cohort was 18.84 years compared to 33.48 years for comparable U.S. males (t = 49.49, p < .00001). As a result of this premature mortality, the estimated monetary value of lost productivity was greater than 174 million dollars. The lives of heroin addicts were severely truncated at productive ages resulting in a loss of potential productivity that increases social and economic burdens.

This study examined tooth retention, tooth loss and use of dental care among aging male narcotics abusers being followed-up for more than 33 years. The cohort of 581 male narcotics addicts admitted to California Civil Addict Program in 1962-1964 was tracked until 1996-1997. As of 1997, 284 (48.9%) were confirmed to be dead. A total of 108 surviving participants completed the oral examination and survey of use of dental services. African American addicts showed the least number of remaining teeth; and African Americans and Hispanics were less likely to utilize dental services compare to Whites. Factors significantly related to tooth retention were abusers’ age (p = 0.0006), ethnicity (p = 0.01), income (p < 0.0001), smoking status (p = 0.03), and dental visits during the 12 months prior to the survey (p < 0.0001). These findings suggest that settings such as prisons and drug treatment programs that include dental care referral and follow-up would be expected to enhance oral and general health among narcotics-addicted individuals.

The objectives of this study were to examine differences in substance abuse treatment needs, treatment utilization, and outcomes between Asian Americans/Pacific Islanders (AAPI) and others. Data were collected from 452 AAPI and a matched sample of 403 non-AAPI who were admitted to 43 drug treatment programs across California. A subset of these participants was assessed at 3 months (n = 112) and 9 months (n = 140) after treatment admission. Differences in pretreatment characteristics, treatment retention and completion, services received, and treatment outcomes were examined. AAPI presented to treatment with lower alcohol and drug severity lower than the comparison group and similar problem severity in other domains. There were no group differences in treatment retention, but AAPI received a greater number of legal services and fewer medical and psychiatric services than the comparison group. AAPI also received fewer total services within their treatment program. Treatment outcomes were similar between the two groups, with one exception: AAPI demonstrated better alcohol outcomes than those in the comparison group.

Ethnic disparities in the availability and quality of substance abuse treatment are of interest to both policy makers and treatment service providers. While there have been a number of studies indicating greater unmet needs for health services and poorer health outcomes for ethnic minorities across a range of disease areas (including cardiovascular disease, mental health, diabetes, and other chronic and infectious diseases) (IOM 2003), there has been little research on the service needs and treatment outcomes of Hispanics in substance abuse treatment. The lack of relevant data is particularly true for Hispanic methamphetamine (meth) abusers. Rates of meth abuse in California are among the highest in the country and continue to increase. Hispanics represent about 32 percent of the California population (California Department of Finance 2001). Yet we have limited information regarding service utilization and outcomes among Hispanic meth abusers receiving community-based drug treatment. In the present article, we use the term Hispanic to include Mexican Americans, Puerto Ricans, Cubans, and South and Central Americans living in California. Although there are little published data regarding ethnic disparities specifically among meth abusers, we review literature on drug treatment utilization and outcomes among Hispanics who abused other types of drugs that has relevance to the present study. Earlier studies reported opposing findings documenting both the underutilization of drug treatment services by ethnic minorities and an overrepresentation of Hispanics in drug abuse programs (Little 1981; De La Rosa, Khalsa, and Rouse 1990). However, more recent studies showed that among individuals with a perceived or clinical need for psychiatric or substance abuse services, Hispanics were less likely to be receiving services and less satisfied with the services they did receive as compared with whites (Wells et al. 2001). Among drug using arrestees, fewer Hispanics than whites reported receiving prior drug treatment, and Hispanics were more likely to believe that they had no need for treatment (Longshore et al. 1992). Hispanics have also been shown to have less access to speciality mental health care services than non-Hispanic whites (Padgett et al. 1994; Alegria et al. 2002). Few studies have examined the service needs of Hispanics in substance abuse treatment. Some studies have indicated more severe substance use and employment problems for Hispanics than blacks and whites in drug treatment (Kosten, Rounsaville, and Kleber 1985). Hispanics also entered treatment with a greater number of prior arrests and more time in jail than had whites (Anglin et al. 1988a, b). However, Morgenstern and Bux (2003) reported no ethnic differences in severity of legal problems between Hispanics and whites upon admission into treatment. An examination of mental health differences revealed that Hispanics who abused narcotics showed less psychopathology as compared to whites based on their multiphasic personality inventory (MMPI) scores (Penk et al. 1981). Clearly, additional research is needed to improve our understanding of Hispanic patients' clinical and psychosocial functioning upon entry into treatment so that improved care can be developed. The findings regarding substance abuse treatment retention among Hispanics are also inconsistent. In studies of outpatient cocaine abusers, some have reported that Hispanics are more likely to drop out of treatment than whites (Agosti, Nunes, and Ocepeck-Welikson 1996), while others have found no differences between Hispanics and whites (Kleinman et al. 1992). The latter study reported that Hispanics did not differ from whites in drug treatment retention but were more likely to be retained than blacks. Studies of narcotic-dependent individuals have consistently shown poor drug and legal outcomes for Hispanics. Following discharge from methadone maintenance, for example, Hispanics were less likely to be abstinent and were more likely to report daily drug use than whites (Anglin et al. 1988a, b). Approximately 12 years after entry into the California Civil Addict Program, more Hispanics (49 percent) than whites (31 percent) reported daily heroin use in the past 3 years (Brecht et al. 1987). An examination of legal outcomes showed that Hispanics in a methadone maintenance program were arrested more often and spent more time in jail than did whites during the year following treatment admission (Long and Demaree 1975). In a longitudinal study following narcotic-dependent men, Hispanics were more likely to be incarcerated or deceased than whites and had a more persistent and severe course of drug addiction (Prendergast, Hser, and Gil-Rivas 1998). Few studies have examined ethnic differences in outcomes of individuals who abuse drugs other than narcotics. Morgenstern and Bux (2003) reported no ethnic differences in alcohol, drug, legal, or psychiatric outcomes of 252 patients receiving community-based substance abuse treatment. However, a study of meth users found that being Hispanic (compared with white) was a significant predictor of time to relapse following treatment (Brecht, von Mayrhauser, and Anglin 2000). There is a notable lack of recent research examining Hispanic substance abuse outcomes generally and among meth abusers specifically. Based on a large treatment outcome study completed in California, we examined ethnic differences in service needs, treatment utilization, satisfaction, and outcomes between Hispanic and non-Hispanic white meth abusers. We hypothesized that Hispanics would receive fewer services, be less satisfied with the services they did receive, and have poor drug and psychiatric outcomes compared to whites. We also explored ethnic differences in alcohol, employment, family/social, medical, and legal outcomes because difficulties in these domains can be significant impediments to recovery. Our study objective was to contribute empirical data on how ethnicity is related to drug and psychosocial outcomes, and in turn, whether treatments need to be adapted to improve outcomes among different ethnicities.

This study compared characteristics of pregnant women treated in women-only (WO) and mixed-gender (MG) substance abuse treatment programs and compared services provided by these two types of programs. Participants were 407 pregnant women who were admitted to 7 WO programs and 29 MG programs in 13 counties across California during 2000–2002. Pregnant women treated in WO programs demonstrated greater severity in drug use, legal problems, and psychiatric problems than those treated in the MG programs. They were also less likely to be employed and more likely to be homeless. Women-only programs were more likely to offer child care, children’s psychological services, and HIV testing. The greater problem severity of pregnant women treated in WO programs suggests that these specialized services are filling an important gap in addiction services, although further expansion is warranted in psychiatric, legal, and employment services.

This study examined utilization of mental health services and treatment outcomes among 1,091 patients with mental health problems recruited from 39 treatment programs in 13 California counties. We compared three groups: one that received dual treatment from drug and mental health programs (N = 294), one that received mental health services only within drug treatment programs (N = 578), and one that received no mental health services (N = 219). Individuals who received dual treatment had more severe substance use and mental health problems, followed in severity by those who received mental health services within drug treatment, and those who received no services. All groups significantly reduced their psychiatric severity at the follow-up, although there were no group differences in treatment retention and drug use outcomes. These findings suggest that individuals with mental health problems can be successfully treated within drug treatment programs and/or in conjunction with mental health providers.

Objective. To examine premature mortality in terms of years of potential life lost (YPLL) among a cohort of long-term heroin addicts. Method. This longitudinal, prospective study followed a cohort of 581 male heroin addicts in California for more than 33 years. In the latest follow-up conducted in 1996/97, 282 subjects (48.5%) were confirmed as deceased by death certificates. YPLL before age 65 years was calculated by causes of death. Ethnic differences in YPLL were assessed among Whites, Hispanics, and African Americans. Results. On average, addicts in this cohort lost 18.3 years (SD = 10.7) of potential life before age 65. Of the total YPLL for the cohort, 22.3% of the years lost was due to heroin overdose, 14.0% due to chronic liver disease, and 10.2% to accidents. The total YPLL and YPLL by death cause in addict cohort were significantly higher than that of US population. The YPLL among African Americans was significantly lower than that among Whites or Hispanics. Conclusion. The YPLL among addicts was much higher than that in the national population; within the cohort, premature mortality was higher among Whites and Hispanics compared to African American addicts.

This prospective longitudinal study examines patterns of psychiatric symptomatology among men admitted to treatment for cocaine dependence in 1988–1989. Study participants were interviewed at treatment intake, and at 1 year, 2 years and 12 years after treatment. The Hopkins Symptom Checklist-58 (SCL) and Natural History Interview were administered at the 4 time points. Of the 266 study participants interviewed at the 12-year follow-up, 138 (52%) had been cocaine abstinent for 5 years or more. Repeated measures ANOVA assessed changes in SCL scores over time for cocaine-abstinent and non-abstinent men. Both groups had similarly high mean SCL scores at treatment intake, and reductions in symptom severity 1 year after treatment. By 12-year follow-up, the abstinent group reported significantly lower SCL scores than the non-abstinent group on 4 of the 5 symptom measures. Additionally, cocaine-abstinent men reported lower rates of depressive and psychotic disorders, and lower use of psychopharmacologic and inpatient treatment than non-abstinent men. These findings suggest that severe psychiatric symptomatology persists among individuals unable to achieve a stable recovery from cocaine dependence.

The study examined long-term outcomes (mortality, substance use, mental health, employment, criminal involvement) among a cocaine-dependent sample. This 12-year follow-up study, conducted in 2002-2003, updates information obtained at intake and two face-to-face interviews conducted in 1990-1991 and 1991-1992 among 321 male cocaine-dependent veterans admitted to drug treatment in 1988-1989. At the 2002-2003 follow-up, 28 had died and 266 were interviewed. A mixed model examining the longitudinal relationships demonstrated that treatment was associated with lower levels of cocaine use over the 12-year follow-up period after entry into the index treatment and more stable recovery (i.e., continuously abstinent from cocaine for at least 5 years). Few measures at intake predicted stable recovery at follow-up: only being White (vs. being African American) and having greater confidence in ability to avoid cocaine use in high-risk situations. Individuals achieving stable recovery reported less psychiatric symptoms, criminal involvement, and unemployment during the year prior to the interview. Adverse outcomes were apparent for a significant number of cocaine-dependent users who continued to use cocaine for a long period.

The study examined health conditions among an aging cohort of male narcotics addicts. This prospective cohort study (1964–1998) included interviews and medical testing for 108 surviving subjects who had been admitted to the California Civil Addict Program during the years 1962 through 1964. Medical testing results were: 51.9% had high blood pressure, 22.4% showed hyperlipidemia, 13.3% had elevated levels of blood glucose, 33.6% had abnormal pulmonary function, half of the sample had abnormal liver function, and 94.2% tested positive for hepatitis C, 85.6% for hepatitis B, 3.8% for syphilis, and 27.3% for TB. The study empirically demonstrated poor health conditions and high morbidity among surviving narcotics addicts.

Timely information provided by an effective outcome monitoring system (OMS) is key to making improvements in treatment program effectiveness, service provision, and client outcomes. The California Treatment Outcome Project (CalTOP) developed and pilot-tested an automated outcome monitoring system for California's alcohol and other drug (AOD) system of care. CalTOP was designed to track client movement through treatment programs, measure standardized assessment of client service needs, record service utilization, assess treatment outcomes and client satisfaction, and determine the extent to which treatment produces cost-offsets in other health and social service systems. Information collected by CalTOP revealed that client problem severity at admission was high, services needed were diverse, and treatment services were generally not well matched to the level of problem severity or needs of clients. Also, client retention and length of stay in treatment were generally insufficient to maximize the potential benefits associated with treatment. This article presents the type of information on client demographics and treatment retention that was provided by CalTOP and outlines recommendations for implementing an AOD outcome monitoring system statewide.

This prospective longitudinal study examined treatment outcomes among 1,073 methamphetamine-abusing patients (567 women, 506 men) from 32 community-based outpatient and residential programs in 13 California counties. Data were collected at intake and at 3 months and 9 months after admission. With one exception, improvements from baseline to follow-up were observed in all areas measured by the Addiction Severity Index for both women and men in either modality. Compared to men, women demonstrated greater improvement in family relationships and medical problems, and similar improvement in all other areas, despite the fact that more women were unemployed, had childcare responsibilities, were living with someone who also used alcohol or drugs, had been physically or sexually abused, and reported more psychiatric symptoms. Implications for service improvement are discussed.

Many drug abusers have repeated exposure to treatment, yet little is known about the reasons some individuals re-enter treatment following relapse to drug use. This paper examines the predictors of treatment re-entry among cocaine abusers who relapsed to cocaine use (N = 347) within 5 years following their index treatment episode. In-depth assessments were conducted at treatment intake in 1991-93 and at 1 and 5 years following treatment discharge. About 44% of the sample returned to treatment, at an average of 2.6 years following discharge. A logistic regression analysis demonstrated that individuals who were African American, were previously married, used cocaine at least weekly after treatment discharge, and had more service needs at the time of index treatment were more likely to re-enter treatment. The findings suggest that a longer-term perspective on treatment utilization is needed to more fully address chronic substance abuse and the problems typically associated with it.

Five counties (Kern, Riverside, Sacramento, San Diego, San Francisco) that demonstrate both variations and similarities in their implementation of Proposition 36 (e.g., treatment approaches, urine testing) and patient mix have been selected to participate in a study assessing how California's Proposition 36 is affecting the drug treatment system and patient outcomes. Except for San Francisco, treatment admissions increased during the first year of Proposition 36 implementation over the prior year (27% in Kern, 21% in Riverside, 17% in Sacramento, and 16% in San Diego), mostly in outpatient drug-free programs. Compared to non-Proposition 36 patients, Proposition 36 patients were more likely to be men, first-time admissions, treated in outpatient drug-free programs, employed full-time, and users of methamphetamine or marijuana. They were less likely to be treated in residential programs or methadone maintenance programs and fewer reported heroin use or injection drug use. Guided by the multilevel open systems framework, the study examines key issues of Proposition 36 that influence treatment systems and outcomes and empirically identifies “best practice” approaches in treating drug-abusing offenders.

This study investigated effects of drug-use initiation and conduct disorder (CD) among 1031 adolescents who participated in the Drug Abuse Treatment Outcomes Studies for Adolescents (DATOS-A) sponsored by the National Institute on Drug Abuse (NIDA). The mean age of first drug use was 12.7 (S.D.=2.2), 57% met DSM-III-R criteria for CD, and earlier initiators were more likely to have CD. About 78% of the adolescents with CD reported that their first CD symptom occurred prior to drug-use initiation. The proportions of adolescents who had prior treatment were similar (about 28%) across all groups, but earlier initiators reported a greater number of treatment episodes and younger ages at their first treatment. Conduct disordered adolescents revealed greater problems prior to DATOS-A treatment, but they appeared to be more motivated and ready for treatment. Although adolescents with CD still showed worse outcomes after treatment, the impact of CD appeared to lessen when pretreatment differences were controlled. To a lesser extent, adolescents who began using drugs at earlier ages had greater alcohol and drug use and other problems at intake, but their treatment outcomes appeared to be similar to later initiators. There were few significant interaction effects of initiation and CD. Findings from this study highlight the importance of better understanding the progression of drug use, treatment utilization, and psychiatric comorbidity among adolescents with substance abuse problems.

Weighted linear regression (WLR) is computationally efficient for generating parametric images in dynamic PET studies. However, due to high noise level of pixel kinetics, parametric images estimated by WLR usually have high variability. The authors have shown earlier that, for image-wise model fitting, the incorporation of simple ridge regression and spatial constraint (SRRSC) can improve the stability and signal-to-noise ratio of the estimated parametric images. In this study, the authors investigate the use of generalized ridge regression with spatial constraint (GRRSC) instead of SRRSC, and evaluate the amount of further improvement due to GRRSC. Computer simulation of O-15 water kinetics in a Hoffman brain phantom and human PET study were used as the data for evaluation. Results showed that both GRRSC and SRRSC improved parametric images quality for studies with high or middle noise level of dynamic images. GRRSC provide no significantly different parametric images compared with SRRSC. For its lower computational burden and its simplicity, SRRSC is suggested to be the choice method for generating parametric images for O-15 dynamic studies.

This prospective longitudinal study examined the influence of patients' perceptions of their counselors on their lengths of stay in treatment and subsequent treatment outcomes. Patients (N = 511) were recruited from 19 substance abuse treatment programs in Los Angeles County. While in treatment, patients rated their counselors on 14 aspects (e.g., empathy, directiveness); 1 year later they were interviewed for follow-up outcomes. Multiple regression analyses were conducted using patients' ratings of their counselors to assess the impact of these ratings on treatment retention and follow-up outcomes (i.e., severity of alcohol use, drug use, and psychiatric status as measured by the Addiction Severity Index). Results revealed that patients' positive perceptions of their counselors were significantly associated with a longer length of stay in treatment for the outpatient drug free/day treatment and residential treatment subsamples. Patients' positive perceptions were also significantly associated with better psychiatric functioning at follow-up, but had a limited relationship to severity of alcohol use and no relation to severity of drug use.

s / Drug and Alcohol Dependence 140 (2014) e86–e168 e115 Conclusions: These findings indicate that frequency of alcohol usemay aid in understanding the likelihoodof engagement in additional risky behaviors, and proposes that frequent alcohol users represent an important target population in the prevention of risky behaviors. Future research should work to further examine levels of alcohol consumption that may better predict risk for additional risky behaviors, and how these variables are related. Financial support: The study was financially supported by Dr. Sherecce Fields, faculty start-up funds. http://dx.doi.org/10.1016/j.drugalcdep.2014.02.328 Patterns of prescription and illicit drug use among young adults: the significance of housing status and injection drug use Stephen Lankenau, A. Kecojevic Community Health and Prevention, Drexel University, Philadelphia, PA, United States Aims: Over the past 25 years, misuse of prescription drugs, such as opioids, tranquilizers, and stimulants, among adolescents and young adults has become a primary public health problem. Few studies have examined the relationship between housing status and injection drug use in samples of young adults who misuse prescription drugs. The study aims are to: describe demographic and behavioral characteristics of three groups of young adults who currently misuse prescription drugs – housed non-IDU, homeless non-IDU, and homeless IDU – and report different patterns of prescription and illicit drug use among these three groups. Methods: Enrollment criteria were: between 16 and 25 years old; misuse of opioid, tranquilizer, and/or stimulant 3 times in past 90 days; and injection drug use, homeless, or polydrug use in past 90 days. A total of 596 participants (293 New York and 303 Los Angeles) were enrolled between 2009 and 2011. Independent variables included: race; sexual identity; social factors during youth; drug treatment; and infectious diseases history. Dependent variables included 90-day misuse of illicit and prescription drugs. Analysis consisted of multinomial logistic regression models comparing differences between housed non-IDU, homeless non-IDU, and homeless IDU. Results: Housed non-IDUs compared to homeless non-IDUs were significantly less likely to have recently used heroin or methamphetamine or have a history of drug treatment or an STI but more likely to have recently misused prescription stimulants. Homeless IDUs compared to homeless non-IDUswere significantly more likely to have recently used heroin ormethamphetamine and to have a history of drug treatment and a STI. Conclusions: Homeless IDUs could be characterized as themost at-risk group while also engaging in the patterns of prescription and illicit drug use that are most consistent with dependency and negative health outcomes. Heroin use is clearly an important factor in patterns of prescription drug misuse, such as opioids and tranquilizers, among homeless IDUs. Financial support: Research supported by NIDA R01 DA21299. http://dx.doi.org/10.1016/j.drugalcdep.2014.02.329 Specific maternal substance use behaviors linked to child co-occurring externalizing and internalizing symptoms H. Isabella Lanza, Y. Hser, N. Glick Semel Institute for Neuroscience and Human Behavior, UCLA, Los Angeles, CA, United States Aims: Past research indicates maternal substance use is linked to children’s poor behavioral and emotional health and that children with co-occurring externalizing and internalizing behaviors are at greater risk for maladaptive developmental outcomes. However, it is unclear what proportion of children of substance-using mothers exhibit co-occurring symptoms and what type of substance use behaviors are related to co-occurrence. Methods: Data were obtained from a follow-up study of mothers re-interviewed 10 years after admission to drug abuse treatment (2009–2011). The Addiction Severity Index measured maternal substance use behaviors and mothers reported on a target child using the Child Behavior Checklist (N=396; approx. 11 yrs, range 6–17yrs). Five oppositional defiant (externalizing) symptoms and six depressive (internalizing) symptoms (Achenbach et al., 2001) were used to identify underlying externalizing and internalizing patterns with latent class analysis (LCA). Maternal substance use behaviors were added as covariates to assess associations with classes. Results: LCA identified the 3-class model as best-fitting, characterized by a no symptoms (45%), externalizing-only (47%), and co-occurring externalizing and internalizing (9%) classes. More years of maternal amphetamine use predicted to the co-occurring (ˇ = .08, p< .05, OR=1.08) and externalizing-only (ˇ = .07, p< .01, OR=1.07) classes vs. no symptoms class.Mothers reporting greater days of marijuana use and drug problems in the last month prior to follow-up interview were more likely to have children in the co-occurring (ˇ = .05, p< .05, OR=1.05; ˇ = .12, p< .01, OR=1.12, respectively) vs. no symptoms class. Conclusions: LCA revealed a small groupof children at high-risk for co-occurring externalizing and internalizing symptoms, which may have significant implications for intervention efforts targeting children of substance-usingmothers. Mothers reporting recent marijuana use and drug problems may be particularly vulnerable to having children with co-occurring problems. Financial support: Supported by NIDA R01DA021183, P30DA016383, & K05DA017648 (PI: Hser). http://dx.doi.org/10.1016/j.drugalcdep.2014.02.330 Australian post-marketing surveillance studies, 2012 Briony Larance1, Louisa Degenhardt1, Richard Mattick1, Robert Ali 4, Nicholas Lintzeris2,3 1 National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia 2 South Eastern Sydney Local Health District, Sydney, NSW, Australia 3 University of Sydney, Sydney, NSW, Australia 4 University of Adelaide, Adelaide, SA, Australia Aims: Toexamine thediversionand injectionofbuprenorphinenaloxone film among people who inject drugs regularly (PWID) in the first year following its introduction in Australia. Methods: Cross-sectional surveys of PWID were conducted in Jan–Mar 2012 (N=450), Jun–Jul 2012 (N=900) and Oct–Nov 2012 (N=450). Additional data sources included interviews with 52 key

s / Drug and Alcohol Dependence 140 (2014) e86–e168 e95 Medical marijuana cardholders seen in the emergency department Mark A. Ilgen1,2, Amy S. Bohnert1,2, K. Barry1,2, S. Chermack1,2, R.M. Cunningham3, M.A. Walton2, F.C. Blow1,2 1 VA Serious Mental Illness Treatment Research and Evaluation Center, Department of Veterans Affairs Healthcare System, Ann Arbor, MI, United States 2 Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States 3 Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, United States Aims: Although the number of individuals who participate in statemedical marijuana programs continues to increase, very little is knownabout how these individuals interactwith other aspects of the healthcare system. The present study examines a large sample of Emergency Department (ED) patients to describe the prevalence and characteristics of adults who report participation in statemedical marijuana programs. Methods: Research staff screened a representative sample of 2049 ED patients in Michigan for participation in a larger brief alcohol intervention trial between February and August 2012. The present study focuses on the self-report by participants that they have ever been issued a medical marijuana card. Results: Approximately 4.3% (n=89) of the sample of ED patients reported that theywere participants in statemedical marijuana programs. The vast majority of these patients (77.5%; n=69) reported that their medical marijuana card was obtained for the managementof chronicpain.Onaverage, patientswhoparticipated in state medical marijuana programs reported use of marijuana 12.9 (SD=12.7) days out of the past month. Close to 12% medical marijuanapatients reported that a physicianhad refused toprovide them with an opioid within the past year. Conclusions: Adultswhoparticipate in statemedicalmarijuana programs represent a small but importantminority of patients seen in the ED. It is critical to better characterize the types and quality of care provided to these individual within traditional medical settings. Financial support: This project was supported by NIAAA, R01AA018659. http://dx.doi.org/10.1016/j.drugalcdep.2014.02.275 Not ashamed anymore: Longitudinal changes in barriers to treatment entry for online treatment seekers Adi Jaffe1,2, D. Murphy1, Tariq Shaheed2, A. Coleman2, Y. Hser1 1 Integrated Substance Abuse Programs, University of California, Los Angeles, Los Angeles, CA, United States 2 California Treatment Services, LLC, Beverly Hills

Background Little is known about outcomes of community-based treatment programs for adolescents with drug problems. Methods We studied 1167 adolescents (age range, 11-18 years; 368 females, 799 males) from 4 US cities (Pittsburgh, Pa; Minneapolis, Minn; Chicago, Ill; and Portland, Ore) using a naturalistic, nonexperimental evaluation design. These adolescents were consecutive admissions during the period from 1993 to 1995 at 23 community-based treatment programs in the Drug Abuse Treatment Outcome Studies for Adolescents. Included were 418 admissions to 8 residential programs, 292 admissions to 9 outpatient drug-free programs, and 457 admissions to 6 short-term inpatient programs. Results Adolescents in treatment typically had multiple problems (eg, 58.4% of them were involved in the legal system, and 63.0% met diagnostic criteria for a mental disorder). Nevertheless, less than half (43.8%) of all patients reported weekly marijuana use in the year following treatment (dropping from 80.4% in the year before admission). Similarly, there were decreases in heavy drinking (dropping from 33.8% to 20.3%), use of other illicit drugs (dropping from 48.0% to 42.2%), and criminal involvement (dropping from 75.6% to 52.8%). Additionally, patients reported better psychological adjustment and school performance after treatment. Longer stays in treatment were positively associated with several favorable outcomes, although length of time in treatment was generally short. Conclusions Substance abuse treatment for adolescents is effective in achieving many important behavioral and psychological improvements. Strategies specific to adolescents to improve their treatment retention and completion are needed to maximize the therapeutic benefits of drug treatment.

This study compared the pretreatment characteristics and posttreatment outcomes of substance-abusing adolescents with and without comorbid mental disorders in the Drug Abuse Treatment Outcome Studies for Adolescents. Subjects (N = 992) were sampled from 23 adolescent drug treatment programs across three modalities (residential, short-term inpatient, outpatient drug-free). Nearly two thirds (64%) of the sample had at least one comorbid mental disorder, most often conduct disorder. Comorbid youth were more likely to be drug or alcohol dependent and had more problems with family, school, and criminal involvement. Although comorbid youth reduced their drug use and other problem behaviors after treatment, they were more likely to use marijuana and hallucinogens, and to engage in illegal acts in the 12 months after treatment, as compared with the noncomorbid adolescents. Integrated treatment protocols need to be implemented within drug treatment programs in order to improve the outcomes of adolescents with comorbid substance use and mental disorders.

In this article we describe the development and psychometric properties of a self-administered instrument for assessing drug-user treatment counselors' therapeutic approaches such as psychodynamic or interpersonal, cognitive-behavioral, family systems or dynamics, 12-step, and case management. We generated an initial pool of items corresponding to these five approaches and modified them based on expert ratings. We developed three sets of items. The first concerned the beliefs underlying each therapeutic approach. The second and third concerned the practices of each applicable approach within individual and group counseling, respectively. With the exception of case management, an approach that originated within social work and which is only applicable to individual counseling, the other four approaches are applicable, at least theoretically, to both individual and group counseling. Additionally, we included items that describe techniques used exclusively with groups (i.e., group techniques). Finally, we included some items that are not associated with any of the traditional approaches but which reflect the practical approach that drug-user treatment programs often take to both individual and group counseling (i.e., practical counseling). The initial instrument consisted of 17 subscales with a total of 76 items. This instrument was administered to 226 counselors from 45 drug-user treatment programs in Los Angeles County. Based on this data, we further refined these scales using confirmatory factor analysis to ensure both construct validity and discriminant validity. The final instrument consisted of 14 subscales with a total of 48 items.

The pattern of stability/change in smoking status was examined annually in 254 community-dwelling polydrug users over 3 years. Respondents' smoking status was classified as nonsmoker, intermittent smoker, or “everyday” smoker. Results showed that the typical probability of retaining the same smoking status across any two consecutive assessments was: 0.77 for nonsmokers (never smokers and former smokers combined), 0.82 for everyday smokers, and 0.16 for intermittent smokers. The transition matrix proved stable across three observations; the predicted equilibrium distribution matched well with observed distributions. Fifty-five percent of intermittent smokers converted to everyday smoking within a year, but 29% converted to former-smoker status in the same period. No other transition exceeded 12%. Considerable flux in individual smoking status, particularly among intermittent smokers, was observed despite stable prevalence of smoking status in this population. Intermittent smoking status appeared to be a temporary “way station” between the two more stable everyday smoker and nonsmoker classifications. Results challenge current assumptions about “occasional” or “chipper” smokers.

Multilevel modeling was used to assess the program characteristics associated with treatment retention among 637 women in 16 residential drug treatment programs in the Drug Abuse Treatment Outcome Study. Women who were pregnant or had dependent children had higher rates of retention in programs in which there were higher percentages of other such women. Longer retention was associated with higher rates of posttreatment abstinence. Bivariate analyses showed that programs with higher proportions of pregnant and parenting women provided more services related to women's needs. The findings support the provision of specialized services and programs for women in order to improve outcomes of drug abuse treatment.

We developed a lifetime severity index for cocaine use disorder and examined its predictive validity of posttreatment outcome using data from the national Drug Abuse Treatment Outcome Study. The index, based on 28 items, considered frequency of use, recency, dependency, and attempt to quit. A higher value of the index, indicating greater severity, predicted a greater likelihood of relapse (the odds ratios were 5.7 for high severity and 4.4 for medium severity, relative to low severity) and shorter time to relapse. Similarly, the polytomous logistic analysis indicated that the index predicted levels of posttreatment cocaine use (odds ratios of daily use were 47.8 for the high severity and 18.8 for medium severity; the corresponding odds ratios of weekly use were 6.75 and 5.10 and for less-than-weekly use were 3.35 and 3.57). The index can be a useful measure for both clinical and research purposes.

OBJECTIVES: This study examined client and program characteristics that predict posttreatment cocaine abstinence among cocaine abusers with different treatment histories. METHODS: Cocaine abusers (n = 507) treated in 18 residential programs were interviewed at intake and 1-year follow-up as part of the nationwide Drug Abuse Treatment Outcome Study (DATOS). Program directors provided the program-level data in a mail survey. We applied the hierarchical linear modeling approach for the analysis. RESULTS: No prior treatment and longer retention in DATOS programs were positive predictors of posttreatment abstinence. The interactive effect of these 2 variables was also significantly positive. Program that offered legal services and included recovering staff increased their clients' likelihood of cocaine abstinence. Crack use at both the client and program level predicted negative impact. None of the program variables assessed differentially affected the outcomes of first-timers and repeaters. CONCLUSIONS: Although treatment repeaters were relatively difficult to treat, their likelihood of achieving abstinence was similar to that of first-timers if they were retained in treatment for a sufficient time. First-timers and repeaters responded similarly to the treatment program characteristics examined. The treatment and policy implications of these findings are discussed.

The epidemic of cocaine abuse has led to numerous studies on the substance. While extent of use, characteristics of users, patterns of use, and consequences of dependence are well documented for both powder cocaine and crack, few studies have dealt with the sequence or progression of use between the two forms of cocaine. This paper draws on arrestee data collected from county jails in Los Angeles, California. It identifies four sequences of powder cocaine and crack use and examines each sequence in terms of user characteristics, history of use, dependence, contact with the criminal justice system, and concomitant use of other drugs. Findings not only confirm some already established observations, but also offer new knowledge on powder cocaine and crack abuse. For instance, (a) whereas powder cocaine-initiated users are more likely to progress to crack than to restrict their use to powder cocaine only, crack-initiated users tend more often to use crack only than to progress to powder cocaine; and (b) powder cocaine and crack, when used interchangeably, can interact and reinforce each other, resulting in a higher level of use and dependence on both forms of the substance. This paper contributes to the understanding of powder cocaine and crack use among criminal offenders, in particular, and across the adult population, in general. It also sheds light on prevention, treatment, and social control policies of both cocaine abuse and overall illicit drug use.

Background and Objectives: Crack-smoking sexually transmitted disease (STD) patients are at high-risk for contracting HIV. Goal of the Study: To examine the effects of cocaine use and other correlates on high-risk sexual behavior among STD clinic patients. Study Design: This was a cross-sectional study of 1,490 consecutive patients attending three Los Angeles County STD clinics between 1992 and 1994. Results: Logistic regression analysis found high-risk sexual activity was associated with being a male and being of younger age. Among women, high-risk sexual behavior was associated with crack cocaine use and a perceived need for help. Among the men in the study, ethnicity (being black) and having an arrest history were associated with high-risk behavior. Conclusions: Effective intervention strategies should address cocaine use among STD patients and provide them with referrals to drug treatment.

OBJECTIVES: This study sought to provide population-based estimates of drug-using arrestees in the 185 largest US cities. METHODS: A prevalence model for drug-using arrestees was developed by relating selected social indicators (from 1990 census data) and drug use rates (from Drug Use Forecasting program data) via logistic regression analysis. RESULTS: It was estimated that in 1990, across the 185 cities, about 925,000 arrestees used cocaine, 317,000 used opiates, 213,000 used amphetamines, 389,000 were drug injectors, and 1,296,000 used an illicit drug. CONCLUSIONS: This approach represents a cost-efficient method for prevalence estimation based on empirically demonstrable relationships between social indicators and drug use rates.

IntroductionIndividuals with co-occurring disorders have higher levels of psychological distress and poorer psychosocial functioning, as compared with individuals with substance dependence only. Studies identified substance abuse as a risk factor, which increases the likelihood that an individual with mental disorders may become violent.ObjectivesTo examine the gender differences in drug-related problems and predictors of recidivism among a sample of 1,444 offenders with co-morbid drug abuse and mental disorders participating in California's Proposition 36.MethodsCharacteristics and problem severity in multiple key life areas were assessed at intake using Addiction Severity Index, and drug treatment participation, mental health diagnoses and arrests were based on official records.ResultsWomen demonstrated greater problem severity than men in family relationships, health, psychological health, and sexual and physical abuse history. Men on the other hand had greater criminal history, high rates of attention disorder, and psychotic disorder. Logistic regression analyses showing that for the combined sample, male, young age, cocaine use (relative to methamphetamine), drug abuse severity, methadone treatment, arrest history and fewer prior treatment history were associated with higher recidivism at 12-month follow-up; lower education, cocaine use, and arrest history were related to women's recidivism, while young age, outpatient treatment, and arrest history were predictors of men's recidivism.ConclusionsAlthough the specific type of mental disorder did not seem to be predictive of recidivism, the high rates of mental health disorder and arrest of this population is problematic. Intervention strategies taking into consideration gender-specific problems and needs can improve outcomes for both.

Objective: This study examined longitudinal patterns of narcotics use, other substance use, criminal involvement, morbidity, and mortality among narcotics addicts. Design: A 24-year follow-up study. Data were obtained from admission records and two face-to-face interviews conducted in 1974-1975 and 1985-1986. Participants: Five hundred eighty-one narcotics addicts admitted to the California Civil Addict Program during the years 1962 through 1964. Results: Most of this sample initiated narcotics use before age 20 years and had a mean age at program admission of 25.4 years. In 1974-1975, 13.8% of the sample died and 28.6% tested negative for opiates. Correspond ing rates in 1985-1986 were 27.7% and 25.0%, respectively. Substance use and criminal involvement remained high among this sample into their late 40s. In any given year during the 10 years prior to the 1985-1986 interview, less than 10% of the sample participated in community-based treatment programs such as methadone maintenance. Disability, long periods of heavy alcohol use, heavy criminal involvement, and tobacco use were among the strongest correlates of mortality. Conclusions: The results suggest that the eventual cessation of narcotics use is a very slow process, unlikely to occur for some addicts, especially if they have not ceased use by their late 30s.

Illicit drug use has had profound economic and cultural effects on American society, contributing to sharp increases in the crime rate, accelerating the spread of AIDS, and diverting some minority groups from the economic mainstream. The primary response of government agencies has been increased effort to reduce crime rates by preventing the spread of drug use to uninitiated populations and interdicting the flow of drugs into the United States.1–3 Such approaches have been both costly and limited in effect, however,4 and alternatives, especially reducing demand for drugs by treating drug addicts, are increasingly promoted. A growing body of evidence indicates that demand reduction efforts directed toward those seriously involved represents a far more cost-effective method for reducing drug use, the user’s criminal activities, and the resulting burden on society.5–11

Survivorship analysis was applied to evaluate treatment responsiveness among four groups of heroin addicts (male and female Whites and Chicanos). Multiple outcome measures included rates of retention, incarceration, addiction, property crime, drug dealing, legal supervision, alcohol abuse, employment, and interpersonal involvement. Differential treatment responsiveness among groups was found depending on the measure in use and the time point of evaluation. Relationships between selected predictors and treatment retention were tested using the Cox proportional hazards model. Young male addicts who were using narcotics daily during treatment and who were unemployed and unmarried were at highest risk for dropping out of treatment. [Translations are provided in the International Abstracts section of this issue.]

On p. 196, the last sentence should have read: The main analyses were based on the cohort of clients entering substance abuse treatment between April 1, 2000 and May 31, 2001 who also completed a 9-month follow-up survey (N=2,567).