Design of the NIDA clinical trials network validation study of tobacco, alcohol, prescription medications, and substance use/misuse (TAPS) tool

BACKGROUND

Substance use and its associated use disorders are under-detected and under-treated in primary care. There is a need for a clinically useful brief screening and assessment instrument to identify primary care patients with substance use, sub-threshold substance use disorder (SUD), and SUD to facilitate brief intervention and treatment.

METHODS

We describe the design of the recently completed National Drug Abuse Treatment Clinical Trials Network's tobacco, alcohol, prescription medications, and substance use/misuse screen and brief assessment tool validation study. Study aims included to: develop a 2-stage screening and brief assessment tool (TAPS Tool) to detect substance use, problem use, and SUD among adult primary care patients; examine the validity of both the screen component and the TAPS Tool by comparing them to reference standard screening and assessment measures of no use, problem use, and SUD; and determine the feasibility and acceptability of the self-administration and interviewer-administration of the tool. The design included a pilot testing phase (n=30) and the main study of 2000 adult primary care participants who were randomly assigned in counter-balanced order to have the interviewer-administration or the self-administration of the TAPS Tool followed by the other administration format. Participants' views of feasibility, acceptability and preference for format of self-administration versus interviewer-administration of the TAPS Tool were assessed. Criterion measures of use and DSM-5 SUDs were administered.

DISCUSSION

The TAPS Tool study builds on prior work to develop a 2-stage clinical tool for facilitating the adoption of screening, brief assessment and treatment for SUDs in primary care.

Developing effective interorganizational relationships between community corrections and community treatment providers

Weak service coordination between community corrections and community treatment agencies is a significant barrier in the diffusion of pharmacotherapy for treating opioid and alcohol use disorders. This analysis draws on qualitative interviews (n=141) collected in a multisite randomized trial to explore what probation/parole officers and treatment staff believe are the most critical influences on developing positive interorganizational relationships (IORs) between their respective agencies. Officers and treatment staff highlighted factors at both the individual and organizational level, with issues related to communication surfacing as pivotal. Findings suggest that future interventions consider developing shared interagency goals with input at all staff levels.

Interim methadone and patient navigation in jail: Rationale and design of a randomized clinical trial

BACKGROUND

Methadone maintenance is an effective treatment for opioid dependence but is rarely initiated in US jails. Patient navigation is a promising approach to improve continuity of care but has not been tested in bridging the gap between jail- and community-based drug treatment programs.

METHODS

This is an open-label randomized clinical trial among 300 adult opioid dependent newly-arrested detainees that will compare three treatment conditions: methadone maintenance without routine counseling (termed Interim Methadone; IM) initiated in jail v. IM and patient navigation v. enhanced treatment-as-usual. The two primary outcomes will be: (1) the rate of entry into treatment for opioid use disorder within 30days from release and (2) frequency of opioid positive urine tests over the 12-month follow-up period. An economic analysis will examine the costs, cost-effectiveness, and cost-benefit ratio of the study interventions.

RESULTS

We describe the background and rationale for the study, its aims, hypotheses, and study design.

CONCLUSIONS

Given the large number of opioid dependent detainees in the US and elsewhere, initiating IM at the time of incarceration could be a significant public health and clinical approach to reducing relapse, recidivism, HIV-risk behavior, and criminal behavior. An economic analysis will be conducted to assist policy makers in determining the utility of adopting this approach. ClinicalTrials.gov: NCT02334215.

The SOMATICS collaborative: Introduction to a National Institute on Drug Abuse cooperative study of pharmacotherapy for opioid treatment in criminal justice settings

BACKGROUND

Among the nearly 750,000 inmates in U.S. jails, 12% report using opioids regularly, 8% report use in the month prior to their offense, and 4% report use at the time of their offense. Although ample evidence exists that medications effectively treat Opiate Use Disorder (OUD) in the community, strong evidence is lacking in jail settings. The general lack of medications for OUD in jail settings may place persons suffering from OUD at high risk for relapse to drug use and overdose following release from jail.

METHODS

The three study sites in this collaborative are pooling data for secondary analyses from three open-label randomized effectiveness trials comparing: (1) the initiation of extended-release naltrexone [XR-NTX] in Sites 1 and 2 and interim methadone in Site 3 with enhanced treatment-as usual (ETAU); (2) the additional benefit of patient navigation plus medications at Sites 2 and 3 vs. medication alone vs. ETAU. Participants are adults with OUD incarcerated in jail and transitioning to the community.

RESULTS

We describe the rationale, specific aims, and designs of three separate studies harmonized to enhance their scientific yield to investigate how to best prevent jail inmates from relapsing to opioid use and associated problems as they transition back to the community.

CONCLUSIONS

Conducting drug abuse research during incarceration is challenging and study designs with data harmonization across different sites can increase the potential value of research to develop effective treatments for individuals in jail with OUD.

Pharmacotherapy for opioid dependence in jails and prisons: research review update and future directions

Purpose

The World Health Organization recommends the initiation of opioid agonists prior to release from incarceration to prevent relapse or overdose. Many countries in the world employ these strategies. This paper considers the evidence to support these recommendations and the factors that have slowed their adoption in the US.

Methods

We reviewed randomized controlled trials (RCTs) and longitudinal/observational studies that examine participant outcomes associated with the initiation or continuation of opioid agonists (methadone, buprenorphine) or antagonists (naltrexone) during incarceration. Papers were identified through a literature search of PubMed with an examination of their references and were included if they reported outcomes for methadone, buprenorphine, or naltrexone continued during incarceration or initiated prior to release in a correctional institution.

Results

Fourteen studies were identified, including eight RCTs and six observational studies. One RCT found that patients treated with methadone who were continued on versus tapered off methadone during brief incarceration were more likely to return to treatment upon release. A second RCT found that the group starting methadone treatment in prison versus a waiting list was less likely to report using heroin and sharing syringes during incarceration. A third RCT found no differences in postrelease heroin use or reincarceration between individuals initiating treatment with methadone versus those initiating treatment with buprenorphine during relatively brief incarcerations. Findings from four additional RCTs indicate that starting opioid agonist treatment during incarceration versus after release was associated with higher rates of entry into community treatment and reduced heroin use. Finally, one pilot RCT showed that providing extended-release naltrexone prior to discharge resulted in significantly lower rates of opioid relapse compared to no medication.

Conclusion

Reasons why uptake of these pharmacotherapies is limited in the US and relatively widespread in Europe are discussed. Recommendations for future research are outlined.

Confirmatory factor analysis of the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) in community health center patients

BACKGROUND AND OBJECTIVES

To investigate the factor structure of the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST).

METHODS

Secondary analysis on an adult primary care sample (N = 2,599).

RESULTS AND DISCUSSION

Factor analysis of the tobacco, alcohol, and cannabis items did not yield an acceptable oblique, three-factor solution, due in part to floor effects and limited variability. A short form comprises three items (past-3-month frequency of use, urge to use, and whether others have expressed concern for use), that showed good psychometrics.

SCIENTIFIC SIGNIFICANCE

Supports the need for further investigation of the ASSIST factor structure and a short form. (Am J Addict 2016;25:259-263).

Two Models of Integrating Buprenorphine Treatment and Medical Staff within Formerly "Drug-Free" Outpatient Programs

"Drug-free" outpatient programs deliver treatment to the largest number of patients of all treatment modalities in the U.S., providing a significant opportunity to expand access to medication treatments for substance use disorders. This analysis examined staff perceptions of organizational dynamics associated with the delivery of buprenorphine maintenance within three formerly "drug-free" outpatient treatment programs. Semi-structured interviews (N = 15) were conducted with counseling and medical staff, and respondents were predominantly African American (n = 11) and female (n = 12). Themes and concepts related to medical staff integration emerged through an inductive and iterative coding process using Atlas.ti qualitative analysis software. Two treatment clinics incorporated buprenorphine maintenance into their programs using a co-located model of care. Their staff generally reported greater intra-organizational discord regarding the best ways to combine medication and counseling compared to the clinic using an integrated model of care. Co-located program staff reported less communication between medical and clinical staff, which contributed to some uncertainty about proper dosing and concerns about the potential for medication diversion. Clinics that shift from "drug-free" to incorporating buprenorphine maintenance should consider which model of care they wish to adapt and how to train staff and structure staff communication.

Process evaluation of a technology-delivered screening and brief intervention for substance use in primary care

Psychotherapy process research examines the content of treatment sessions and their association with outcomes in an attempt to better understand the interactions between therapists and clients, and to elucidate mechanisms of behavior change. A similar approach is possible in technology-delivered interventions, which have an interaction process that is always perfectly preserved and rigorously definable. The present study sought to examine the process of participants' interactions with a computer-delivered brief intervention for drug use, from a study comparing computer- and therapist-delivered brief interventions among adults at two primary health care centers in New Mexico. Specifically, we sought to describe the pattern of participants' (N=178) choices and reactions throughout the computer-delivered brief intervention, and to examine associations between that process and intervention response at 3-month follow-up. Participants were most likely to choose marijuana as the first substance they wished to discuss (n = 114, 64.0%). Most participants indicated that they had not experienced any problems as a result of their drug use (n = 108, 60.7%), but nearly a third of these (n = 32, 29.6%) nevertheless indicated a desire to stop or reduce its use; participants who did report negative consequences were most likely to endorse financial or relationship concerns. However, participant ratings of the importance of change or of the helpfulness of personalized normed feedback were unrelated to changes in substance use frequency. Design of future e-interventions should consider emphasizing possible benefits of quitting rather than the negative consequences of drug use, and-when addressing consequences-should consider focusing on the impacts of substance use on relationship and financial aspects. These findings are an early but important step toward using process evaluation to optimize e-intervention content.

Community correctional agents' views of medication-assisted treatment: Examining their influence on treatment referrals and community supervision practices

BACKGROUND

Alcohol and opioid use disorders are common among adults under community supervision. Although several medications (medication-assisted treatment or MAT) are Food and Drug Administration (FDA)-approved to treat such disorders, they are underutilized with this population despite established effectiveness at decreasing substance use. This paper examines how community correctional agents' understanding of addiction and views of MAT influence their professional actions regarding addiction medications.

METHODS

A total of 118 semistructured qualitative interviews were conducted with community correctional agents taking part in the CJ-DATS MATICCE implementation study across 20 parole/probation offices in 9 US states. Using grounded theory methodology and an iterative analytic approach, issues of role perception, views of MAT, current treatment referral, and community supervision practices were explored.

RESULTS

Agents often had limited autonomy to make direct treatment referrals, regardless of their views of MAT, as they were required to follow court orders and their organization's policies and procedures. Within some organizations, community correctional agents held sufficient autonomy to make direct treatment referrals, with agents struggling to reconcile their desire to support their clients who needed MAT with concerns about the abuse potential of opioid agonist medications. Viewing MAT as a "treatment of last resort" was counterbalanced by the view that it was an effective evidence-based practice. Agents described how MAT impacted their ability to supervise clients and how their knowledge and understanding of MAT was directly influenced by watching their clients who were successful or unsuccessful on MAT. Even those agents who were more accepting of MAT were largely unsupportive of it long-term use.

CONCLUSIONS

Community correctional agents' views of MAT were influenced by their understanding of addiction as well as their experiences supervising clients receiving treatment with medications, but whether or not MAT referrals were made was not always within their control.

Meyer A, Hruska B, Ochalek T, Rose G, Badger GJ, Brooklyn JR, Heil SH, Higgins ST, Moore BA, Schwartz RP. Bridging waitlist delays with interim buprenorphine treatment: initial feasibility

Despite the effectiveness of agonist maintenance for opioid dependence, individuals can remain on waitlists for months, during which they are at significant risk for morbidity and mortality. Interim dosing, consisting of daily medication without counseling, can reduce these risks. In this pilot study, we examined the initial feasibility of a novel technology-assisted interim buprenorphine treatment for waitlisted opioid-dependent adults. Following buprenorphine induction during Week 1, participants (n=10) visited the clinic at Weeks 2, 4, 6, 8, 10 and 12 to ingest their medication under staff observation, provide a urine specimen and receive their remaining doses via a computerized Med-O-Wheel Secure device. They also received daily monitoring via an Interactive Voice Response (IVR) platform, as well as random call-backs for urinalysis and medication adherence checks. The primary outcome was percent of participants negative for illicit opioids at each 2-week visit, with secondary outcomes of past-month drug use, adherence and acceptability. Participants achieved high levels of illicit opioid abstinence, with 90% abstinent at the Week 2 and 4 visits and 60% at Week 12. Significant reductions were observed in self-reported past-month illicit opioid use (p<.001), opioid withdrawal (p<.001), opioid craving (p<.001) and ASI Drug composite score (p=.008). Finally, adherence with buprenorphine administration (99%), daily IVR calls (97%) and random call-backs (82%) was high. Interim buprenorphine treatment shows promise for reducing patient and societal risks during delays to conventional treatment. A larger-scale, randomized clinical trial is underway to more rigorously examine the efficacy of this treatment approach.

The CRAFFT cut-points and DSM-5 criteria for alcohol and other drugs: a reevaluation and reexamination

BACKGROUND

The CRAFFT, previously validated against DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) diagnostic criteria, is the most widely used screening instrument for alcohol and other substance misuse in adolescents. The present secondary analysis study sought to compare the CRAFFT with the new DSM-5 diagnostic criteria in order to assess the CRAFFT's psychometric properties and determine the optimal cut-point for identifying adolescents in need of further assessment.

METHODS

Participants were primary care patients aged 12-17 (N = 525) who were recruited while waiting for a medical appointment in an urban federally qualified health center in Baltimore, Maryland, USA. Participants were administered the CRAFFT and the Composite International Diagnostic Interview, second edition, modified to include the new DSM-5 craving item. The authors examined the performance of the CRAFFT in identifying any problem use (defined as 1 or more DSM-5 criteria) and any DSM-5 substance use disorder (2 or more DSM-5 criteria) for alcohol or drugs other than tobacco. The authors examined sensitivity, specificity, and receiver operating characteristic areas under the curve (AUC) to determine the optimal CRAFFT cut-point(s) for predicting any problem use and any DSM-5 substance use disorder (SUD).

RESULTS

Examining the CRAFFT as a continuous measure, AUC values were 0.93 for problem use or higher and 0.97 for DSM-5 SUD. Consistent with previously recommended cut-points for the CRAFFT, the cut-point of 2 performed optimally for identifying adolescents both exhibiting problem use of alcohol or drugs and meeting DSM-5 SUD criteria for alcohol or other drugs.

CONCLUSIONS

Despite changes in the DSM substance use diagnostic criteria, the CRAFFT continues to demonstrate excellent sensitivity and specificity at its established cut-point of 2. Additional studies examining the CRAFFT in light of the new DSM-5 diagnostic criteria with more diverse populations are warranted.

Reference periods in retrospective behavioral self-report: A qualitative investigation

BACKGROUND

Self-report questions in substance use research and clinical screening often ask individuals to reflect on behaviors, symptoms, or events over a specified time period. However, there are different ways of phrasing conceptually similar time frames (eg, past year vs. past 12 months).

METHODS

We conducted focused, abbreviated cognitive interviews with a sample of community health center patients (N = 50) to learn how they perceived and interpreted questions with alternative phrasing of similar time frames (past year vs. past 12 months; past month vs. past 30 days; past week vs. past 7 days).

RESULTS

Most participants perceived the alternative time frames as identical. However, 28% suggested that the "past year" and "past 12 months" phrasings would elicit different responses by evoking distinct time periods and/or calling for different levels of recall precision. Different start and end dates for "past year" and "past 12 months" were reported by 20% of the sample. There were fewer discrepancies for shorter time frames.

CONCLUSIONS

Use of "past 12 months" rather than "past year" as a time frame in self-report questions could yield more precise responses for a substantial minority of adult respondents.

SCIENTIFIC SIGNIFICANCE

Subtle differences in wording of conceptually similar time frames can affect the interpretation of self-report questions and the precision of responses.

Buprenorphine dose induction in non-opioid-tolerant pre-release prisoners

BACKGROUND

In a previously reported randomized controlled trial, formerly opioid-dependent prisoners were more likely to enter community drug abuse treatment when they were inducted in prison onto buprenorphine/naloxone (hereafter called buprenorphine) than when they received counseling without buprenorphine in prison (47.5% vs. 33.7%, p=0.012) (Gordon et al., 2014). In this communication we report on the results of the induction schedule and the adverse event profile seen in pre-release prisoners inducted onto buprenorphine.

METHOD

This paper examines the dose induction procedure, a comparison of the proposed versus actual doses given per week, and side effects reported for 104 adult participants who were randomized to buprenorphine treatment in prison. Self-reported side effects were analyzed using generalized estimated equations to determine changes over time in side effects.

RESULTS

Study participants were inducted onto buprenorphine at a rate faster than the induction schedule. Of the 104 (72 males, 32 females) buprenorphine recipients, 64 (37 males, 27 females) remained on medication at release from prison. Nine participants (8.6%) discontinued buprenorphine because of unpleasant opioid side effects. There were no serious adverse events reported during the in-prison phase of the study. Constipation was the most frequent symptom reported (69 percent).

CONCLUSION

Our findings suggest that buprenorphine administered to non-opioid-tolerant adults should be started at a lower, individualized dose than customarily used for adults actively using opioids, and that non-opioid-tolerant pre-release prisoners can be successfully inducted onto therapeutic doses prior to release.

Introduction to the Special Issue on the Studies on the Implementation of Integrated Models of Alcohol, Tobacco, and/or Drug Use Interventions and Medical Care

National efforts are underway to integrate medical care and behavioral health treatment. This special issue of the Journal of Substance Abuse Treatment presents 13 papers that examine the integration of substance use interventions and medical care. In this introduction, the guest editors first describe the need to examine the integration of substance use treatment into medical care settings. Next, an overview of the emerging field of implementation science and its applicability to substance use intervention integration is presented. Preview summaries of each of the articles included in this special issue are given. Articles include empirical studies of various integration models, study protocol papers that describe currently funded implementation research, and one review/commentary piece that discusses federal research priorities, integration support activities and remaining research gaps. These articles provide important information about how to guide future health system integration efforts to treat the millions of medical patients with substance use problems.

Buprenorphine Treatment and 12-step Meeting Attendance: Conflicts, Compatibilities, and Patient Outcomes

This analysis examines patient experiences and outcomes with 12-step recovery group attendance during buprenorphine maintenance treatment (BMT), two approaches with traditionally divergent philosophies regarding opioid medications for treatment of opioid use disorder. Using quantitative (n = 300) and qualitative (n = 20) data collected during a randomized trial of counseling services in buprenorphine treatment, this mixed-methods analysis of African Americans in BMT finds the number of NA meetings attended in the prior 6 months was associated with a higher rate of retention in BMT (p < .001) and heroin/cocaine abstinence at 6 month follow-up (p = .005). However, patients whose counselors required them to attend 12-step meetings did not have better outcomes than patients not required to attend such meetings. Qualitative narratives highlighted patients' strategies for managing dissonant viewpoints on BMT and disclosing BMT status in community 12-step meetings. Twelve-step meeting attendance is associated with better outcomes for BMT patients over the first 6 months of treatment. However, there is no benefit to requiring meeting attendance as a condition of treatment, and clinicians should be aware of potential philosophical conflicts between 12-step and BMT approaches.

Defining Success: Insights From a Random Assignment, Multisite Study of Implementing HIV Prevention, Testing, and Linkage to Care in U.S. Jails and Prisons

In the emerging field of implementation science, measuring the extent to which a new or modified healthcare program or practice is successfully implemented following an intervention is a critical component in understanding how evidence-based treatments become part of regular practice. This paper is intended to expand our understanding of factors that influence the successful adoption of new or modified HIV services in correctional settings. The nine-site project developed and directed an organization-level intervention designed to implement improvements in preventing, detecting, and treating HIV for persons under correctional supervision. Using semi-structured interviews to elicit perceptions from Senior Researchers and Executive Sponsors at each of the nine sites, this paper presents their views and observations regarding the success of the experimental intervention in their criminal justice setting. Within the areas of focus for implementation (either HIV prevention, testing, or linkage to community treatment) the complexity of programmatic needs was very influential with regards to perceptions of success. An organization's pre-existing characteristics, staffing, funding, and interorganizational relationships contributed to either the ease or difficulty of programmatic implementation. Results are discussed pertaining to furthering our understanding of why new or modified healthcare interventions achieve success, including whether the intervention is a modification of existing practice or is a new intervention, and the choice of implementation strategy.

Staff Views of Acceptability and Appropriateness of a Computer-Delivered Brief Intervention for Moderate Drug and Alcohol Use

The use of computers for identifying and intervening with stigmatized behaviors, such as drug use, offers promise for underserved, rural areas; however, the acceptability and appropriateness of using computerized brief intervention (CBIs) must be taken into consideration. In the present study, 12 staff members representing a range of clinic roles in two rural, federally qualified health centers completed semi-structured interviews in a qualitative investigation of CBI vs. counselor-delivered individual brief intervention (IBI). Thematic content analysis was conducted using a constant comparative method, examining the range of responses within each interview as well as data across interview respondents. Overall, staff found the idea of providing CBIs both acceptable and appropriate for their patient population. Acceptability by clinic staff centered on the ready availability of the CBI. Staff also believed that patients might be more forthcoming in response to a computer program than a personal interview. However, some staff voiced reservations concerning the appropriateness of CBIs for subsets of patients, including older patients, illiterate individuals, or those unfamiliar with computers. Findings support the potential suitability and potential benefits of providing CBIs to patients in rural health centers.

SBIRT Implementation for Adolescents in Urban Federally Qualified Health Centers

BACKGROUND

Alcohol, tobacco, and other drug use remains highly prevalent among US adolescents and is a threat to their well-being and to the public health. Evidence from clinical trials and meta-analyses supports the effectiveness of Screening, Brief Intervention and Referral to Treatment (SBIRT) for adolescents with substance misuse but primary care providers have been slow to adopt this evidence-based approach. The purpose of this paper is to describe the theoretically informed methodology of an on-going implementation study.

METHODS

This study protocol is a multi-site, cluster randomized trial (N=7) guided by Proctor's conceptual model of implementation research and comparing two principal approaches to SBIRT delivery within adolescent medicine: Generalist vs. Specialist. In the Generalist Approach, the primary care provider delivers brief intervention (BI) for substance misuse. In the Specialist Approach, BIs are delivered by behavioral health counselors. The study will also examine the effectiveness of integrating HIV risk screening within an SBIRT model. Implementation Strategies employed include: integrated team development of the service delivery model, modifications to the electronic medical record, regular performance feedback and supervision. Implementation outcomes, include: Acceptability, Appropriateness, Adoption, Feasibility, Fidelity, Costs/Cost-Effectiveness, Penetration, and Sustainability.

DISCUSSION

The study will fill a major gap in scientific knowledge regarding the best SBIRT implementation strategy at a time when SBIRT is poised to be brought to scale under health care reform. It will also provide novel data to inform the expansion of the SBIRT model to address HIV risk behaviors among adolescents. Finally, the study will generate important cost data that offer guidance to policymakers and clinic directors about the adoption of SBIRT in adolescent health care.

Changes in Quality of Life following Buprenorphine Treatment: Relationship with Treatment Retention and Illicit Opioid Use

Studies of substance abuse treatment outcomes that give priority to cessation of all drug use may obscure other tangible benefits of treatment that are important to patients. The aim of this study was to examine the association between changes in quality of life (QoL) and: (1) retention in treatment; and (2) opioid use as measured by self-report and urine testing. Participants were 300 African American men and women starting outpatient buprenorphine treatment. Participants completed assessments at baseline, three and six months consisting of the World Health Organization's Quality of Life brief scale, Addiction Severity Index, and urine testing for opioids. There were statistically significant increases over time across all four QoL domains: physical, psychological, environmental, and social. Self-reported frequency of opioid use was negatively associated with psychological QoL, but opioid urine test results were not significantly associated with any QoL domains. Continued treatment enrollment was significantly associated with higher psychological QoL and environmental QoL. Patients entering buprenorphine treatment experience improvements in QoL, which are amplified for patients who remain in treatment. Point-prevalence opiate urine test results obtained at each assessment were not associated with any of the QoL domains and may not accurately reflect improvements perceived by patients receiving buprenorphine treatment.

Relationship of gambling with tobacco, alcohol, and illicit drug use among adolescents in the USA: Review of the literature 2000-2014

BACKGROUND AND OBJECTIVES

Adolescence is a time during which not only gambling, but also tobacco, alcohol, and illicit drug use, usually begin. The purpose of this paper is to provide an updated review of the literature on gambling and its associations with tobacco, alcohol, and illicit drug use among US youth.

METHODS

An electronic literature search of PubMed and PsycInfo was conducted for studies since 2000 using the keywords "smoking," "tobacco," "nicotine," "cigarette," "gambling," "adolescence," "adolescent," "alcohol," and "substance use." Ten articles with unique adolescent samples were located. Because the articles varied in regard to definitions of gambling, tobacco, alcohol, and drug use, we provide a qualitative review of included studies.

RESULTS

Gambling prevalence rates ranged from 44.3% to 68% in national telephone-based surveys, from 24.4% to 86% among students in school-based surveys, and from 22.5% to 47.4% in surveys of convenience samples. Significant associations were reported between gambling and tobacco use (4/7 articles), gambling and alcohol use (7/8 articles), and gambling and illicit drug use (7/8 articles).

CONCLUSIONS

The wide range in rates of gambling and problem gambling may be due in part to differences among the studies in participant samples, sampling techniques, assessment time frames, and definitions of gambling. Despite methodological differences, most studies showed significant associations of gambling with tobacco, alcohol, and other illicit drug use.

SCIENTIFIC SIGNIFICANCE

As accessibility to gambling increases, more research is needed to inform prevention efforts and identify youth at-risk for gambling and other high-risk behaviors.