Selection of a substance use disorder diagnostic instrument by the National Drug Abuse Treatment Clinical Trials Network

Evidence-Based Assessment of Substance Use Disorder

The current review describes updated information on the evidence-based assessment of substance use disorder. We offer an overview of the state of the science for substance-related assessment targets, instruments (screening, diagnosis, outcome and treatment monitoring, and psychosocial functioning and wellbeing) and processes (relational and technical) as well as recommendations for each of these three components. We encourage assessors to reflect on their own biases, beliefs, and values, including how those relate to people that use substances, and to view the individual as a whole person. It is important to consider a person's profile of symptoms and functioning inclusive of strengths, comorbidities, and social and cultural determinants. Collaborating with the patient to select the assessment target that best fits their goals and integration of assessment information in a holistic manner is critical. We conclude by providing recommendations for assessment targets, instruments, and processes as well as recommendations for comprehensive substance use disorder assessment, and describe future directions for research.

The Spanish language version of the TAPS tool: protocol for a validation and implementation study in primary care

BACKGROUND

The TAPS Tool ("Tobacco, Alcohol, Prescription drug, and illicit Substance use") is a screening and brief assessment for detecting unhealthy substance use in healthcare settings that was developed by the National Institute on Drug Abuse Clinical Trials Network and validated in a multisite study. Our team developed a Spanish language version of the TAPS Tool that supports provider- and self-administration screening using a mobile/web-based platform, the TAPS Electronic Spanish Platform (TAPS-ESP).

METHODS

This article describes the protocol and rationale for a study to validate the TAPS-ESP in a sample of Spanish-speaking primary care patients recruited from a network of community-based clinics in Texas (target N = 1,000). The TAPS-ESP will be validated against established substance use disorder diagnostic measures, alternative screening tools, and substance use biomarkers. The study will subsequently examine barriers and facilitators to screening with the TAPS-ESP from a provider workflow perspective using qualitative interviews with providers.

DISCUSSION

Validating a Spanish language version of the TAPS Tool could expand access to evidence-based, linguistically accurate, and culturally relevant substance use screening and brief assessment for an underserved health disparity population.

TRIAL REGISTRATION

The study was registered with www.

CLINICALTRIALS

gov : NCT05476588, 07/22/2022.

Validation of Two Diagnostic Assessments for Opioid and Stimulant Use Disorder for Use by Non-Clinicians

Objective

The United States is in the fourth wave of the opioid epidemic marked by the increase in fentanyl and co-occurring stimulant use related overdose deaths. Measures are needed to quickly diagnose opioid and stimulant use disorders, yet current traditional diagnostic assessments pose barriers to providing rapid diagnoses.

Methods

This study aimed to (1) validate an updated version of the Rapid Opioid Dependence Screen (RODS) from DSM-IV criteria for opioid dependence to the now DSM-5 moderate-to-severe opioid use disorder, the Rapid Opioid Use Disorder Assessment (ROUDA); and (2) create and validate the Rapid Stimulant Use Disorder Assessment to DSM-5 stimulant use disorder (RSUDA) when compared to the substance use disorder module from the DSM-5 version of the Mini International Neuropsychiatric Interview.

Results

One-hundred and fifty adults completed study assessments, 122 reported opioid misuse and 140 reported stimulant misuse within their lifetime. The ROUDA had a sensitivity of 82.5% (95% confidence interval [CI] 75.7, 89.2), specificity of 100.0% (95% CI: 100, 100), and strong internal consistency α = 0.94. The RSUDA had similarly high sensitivity (83.8%, 95% CI: 77.7, 89.9), specificity (91.4%, 95% CI: 86.8, 96.1), and internal consistency α = 0.87. The ROUDA and RSUDA are efficient and valid measures that can be administered in various settings by non-clinical staff to rapidly diagnose opioid and stimulant use disorders and allow for immediate treatment and harm reduction interventions.

Conclusions

The ROUDA and RSUDA are efficient and valid measures that can be administered by non-clinicians to rapidly diagnose opioid and stimulant use disorders.

Assessing self-stigma levels and associated factors among substance use disorder patients at two selected psychiatric hospitals in Egypt: a cross-sectional study

BACKGROUND

Substance use disorder is a growing problem worldwide, and the stigma associated with it remains a significant barrier to treatment and recovery. This study aimed to assess the perceived stigma among individuals with substance use disorders and its correlation with their socio-demographic characteristics and clinical history Parameters.

METHODS

A cross-sectional study was conducted among 552 patients with substance use disorders admitted to the outpatient clinics of Mansoura University Hospital, Addiction Treatment Unit of the Psychiatry Department, and Port Said Mental Hospital, Addiction Department. Participants completed a self-administered questionnaire, which included demographic information, clinical history parameters, and the Perceived Stigma of Substance Abuse Scale (PSAS).

RESULTS

The study found that almost half of the participants were aged 29 or younger, married, and had a median stigma score of 20. The vast majority of participants were male, had no previous legal problems, and had a median stigma score of 19. The most common type of substance used was opioids, and more than half of the participants were still using drugs. The highest mean stigma scores were for the items "Most people think less of a person who has been in treatment for substance use" and "Most employers will pass over the application of someone who has been treated for substance use in favor of another applicant." The perceived stigma score was significantly correlated with the severity of use but not with age or duration of use.

CONCLUSION

Our study investigates self-stigma in substance use disorder (SUD), revealing its variance across demographics and clinical groups. We found that self-stigma correlates with use severity and possibly decreases with abstinence. Notably, societal bias contributes significantly to self-stigma, necessitating societal interventions. The impact of self-stigma on patient well-being highlights the need for personalized treatments and stigma reduction strategies.

Psychometric Performance of a Substance Use Symptom Checklist to Help Clinicians Assess Substance Use Disorder in Primary Care

Importance

Substance use disorders (SUDs) are underrecognized in primary care, where structured clinical interviews are often infeasible. A brief, standardized substance use symptom checklist could help clinicians assess SUD.

Objective

To evaluate the psychometric properties of the Substance Use Symptom Checklist (hereafter symptom checklist) used in primary care among patients reporting daily cannabis use and/or other drug use as part of population-based screening and assessment.

Design, Setting, and Participants

This cross-sectional study was conducted among adult primary care patients who completed the symptom checklist during routine care between March 1, 2015, and March 1, 2020, at an integrated health care system. Data analysis was conducted from June 1, 2021, to May 1, 2022.

Main Outcomes and Measures

The symptom checklist included 11 items corresponding to SUD criteria in the Diagnostic and Statistical Manual for Mental Disorders (Fifth Edition) (DSM-5). Item response theory (IRT) analyses tested whether the symptom checklist was unidimensional and reflected a continuum of SUD severity and evaluated item characteristics (discrimination and severity). Differential item functioning analyses examined whether the symptom checklist performed similarly across age, sex, race, and ethnicity. Analyses were stratified by cannabis and/or other drug use.

Results

A total of 23 304 screens were included (mean [SD] age, 38.2 [5.6] years; 12 554 [53.9%] male patients; 17 439 [78.8%] White patients; 20 393 [87.5%] non-Hispanic patients). Overall, 16 140 patients reported daily cannabis use only, 4791 patients reported other drug use only, and 2373 patients reported both daily cannabis and other drug use. Among patients with daily cannabis use only, other drug use only, or both daily cannabis and other drug use, 4242 (26.3%), 1446 (30.2%), and 1229 (51.8%), respectively, endorsed 2 or more items on the symptom checklist, consistent with DSM-5 SUD. For all cannabis and drug subsamples, IRT models supported the unidimensionality of the symptom checklist, and all items discriminated between higher and lower levels of SUD severity. Differential item functioning was observed for some items across sociodemographic subgroups but did not result in meaningful change (<1 point difference) in the overall score (0-11).

Conclusions and Relevance

In this cross-sectional study, a symptom checklist, administered to primary care patients who reported daily cannabis and/or other drug use during routine screening, discriminated SUD severity as expected and performed well across subgroups. Findings support the clinical utility of the symptom checklist for standardized and more complete SUD symptom assessment to help clinicians make diagnostic and treatment decisions in primary care.

Trajectories of non-prescribed buprenorphine and other opioid use: A multi-trajectory latent class growth analysis

INTRODUCTION

With the increasing use of non-prescribed buprenorphine (NPB), we need more data to identify the longitudinal patterns of NPB use. The goal of this natural history study is to characterize heterogeneity in trajectories of NPB, other opioid use, and participation in medication for opioid disorder (MOUD) treatment among a community-recruited sample of individuals with current opioid use disorder (OUD).

METHODS

The study recruited a community-based sample of 357 individuals with OUD who used NPB in the past 6 months in Ohio, United States, for baseline and follow-up assessments (every 6 months for 2 years) of drug use, treatment participation, and other health and psychosocial characteristics. The study used multiple imputation to handle missing data. We used a multi-trajectory latent class growth analysis (MT-LCGA) to find salient groupings of participants based on the trajectories of NPB, other opioid use, and treatment participation.

RESULTS

Over time, NPB use frequency declined from a mean of 14.6 % of days at baseline to 3.6 % of days at 24-month follow-up along with declines in heroin/fentanyl (56.4 % to 23.6 % of days) and non-prescribed pharmaceutical opioid (NPPO) use (11.6 % to 1.5 % of days). Participation in MOUD treatment increased from a mean of 17.0 % of days at baseline to 52.4 % of days at 24 months. MT-LCGA identified a 6-class model. All six classes showed declines in NPB use. Class 1 (28 %) was characterized by high and increasing MOUD treatment utilization. Class 2 (21 %) showed sustained high levels of heroin/fentanyl use and had the lowest levels of NPB use (2.2 % of days) at baseline. Class 3 (3 %) was characterized as the primary NPPO use group. Class 4 (5 %) transitioned from high levels of NPB use to increased MOUD treatment utilization. It had the highest levels of NPB use at baseline (average of 80.7 % of days) that decreased to an average of 12.9 % of days at 24 months. Class 5 (16 %) showed transition from high levels of heroin/fentanyl use to increased MOUD treatment utilization. Class 6 (27 %) showed decreased heroin/fentanyl use over time and low MOUD treatment utilization. Classes showed varying levels of improvement in psychosocial functioning, polydrug use, and overdose risks.

CONCLUSION

Overall, our findings suggest that NPB use was generally self-limiting with individuals reducing their use over time as some engage in greater utilization of MOUD treatment. A need exists for continuing improvements in MOUD treatment access and retention.

Characteristics of women with alcohol use disorders who benefit from intensive motivational interviewing

BACKGROUND

Women with alcohol disorders have more severe problems related to their drinking than men. They have higher mortality from alcohol-related accidents and enter treatment with more serious medical, psychiatric, and social consequences.

Objective: This study assessed the effects of Intensive Motivational Interviewing (IMI), a new, 9-session counseling intervention for women with drinking problems.

Methods: A randomized clinical trial was conducted with 215 women. Most were white (83%), college educated (61%), and older (mean age 51). Half received IMI and half a standard single session of MI (SMI) along with an attention control (nutritional education).

Results: Generalized estimating equations models showed women who were heavy drinkers at baseline in the IMI condition reduced heavy drinking more than those in the SMI condition at 2-, 6-, and 12-month follow-up. Analyses of disaggregated subgroups showed IMI was most effective for women with low psychiatric severity, more severe physical and impulse control consequences associated with drinking, and higher motivation. However, formal 3-way interaction models (condition by moderator by time) showed significant effects primarily at 2 months.

Conclusions: Improvements associated with IMI were limited to heavy drinking and varied among subgroups of women. Studies of women with more diverse characteristics are needed.

Personality change during substance use disorder treatment is associated with improvements in abstinence self-efficacy post-treatment among U.S. military veterans

Prior research suggests that personality traits change during substance use disorder (SUD) treatment. However, the extent to which changes in traits during SUD treatment are associated with subsequent improvements in treatment outcomes remains untested. Among U.S. military veterans (n = 200) enrolled in SUD residential treatment, we examined whether changes in the personality factors of positive emotionality (PEM), negative emotionality (NEM), and constraint (CON) during treatment were associated with subsequent changes in abstinence self-efficacy and SUD symptoms. We analyzed data at treatment entry, discharge, and 12-months post-discharge via univariate and bivariate latent change score models. During treatment, PEM, CON, and abstinence self-efficacy increased, while NEM decreased, on average. Changes in NEM and CON were largely sustained, whereas PEM and abstinence self-efficacy significantly decreased post-treatment. SUD symptoms decreased from pre- to post-treatment. In bivariate models, higher levels of NEM at baseline were associated with less improvement in both abstinence self-efficacy during treatment and SUD symptoms pre- to post-treatment. Higher levels of CON at baseline were associated with greater improvement in SUD symptoms pre- to post-treatment, and increases in CON during treatment were associated with greater retention of treatment gains in abstinence self-efficacy post-treatment. Greater improvements in CON during treatment were also associated with greater improvements in SUD symptoms pre- to post-treatment in unadjusted (p = 0.041) but not adjusted models (p = 0.089). Our findings suggest that personality changes marked by improvements in impulse control over the course of SUD treatment may be linked to subsequent improvements in treatment outcomes and may have value as a proximal treatment target among SUD patients during residential care.

Criminal recidivism among justice-involved veterans following substance use disorder residential treatment

Veterans in treatment for substance use disorders (SUD) often report past criminal offending. However, the rate of criminal recidivism in this population is unknown. Further, prior research in veterans has not examined personality factors as predictors of recidivism, despite the prominence of such factors in leading models of recidivism risk management. We examined these issues in a secondary data analysis of 197 military veterans with a history of criminal offending who were enrolled in an SUD residential treatment program. Participants were interviewed using several measurement instruments at treatment entry, one month into treatment, treatment discharge, and 12 months post-discharge. Most veterans (94%) had a history of multiple charges, and 53% had recent involvement in the criminal justice system at the time of treatment entry. In the 12 months post-discharge, 22% reported reoffending. In addition, 30% of patients who had been recently involved in the criminal justice system at treatment entry reoffended during follow-up. Higher friend relationship quality (OR = 2.32, 95% CI [1.03, 5.21]) at treatment entry and higher staff ratings of patients' relationship quality with other residents during treatment (OR = 2.76, 95% CI [1.40, 5.41]) predicted lower odds of recidivism post-discharge. After accounting for these factors, smaller reductions during treatment in the personality trait of Negative Emotionality predicted an increased risk for criminal recidivism post-discharge (OR = 1.13, 95% CI [1.01, 1.26]). Results support augmenting the curriculum of SUD programs for veterans with services aimed at reducing risk for criminal recidivism, with a focus on interventions that directly target patients' social support networks and tendencies towards negative emotionality.

Unintentional drug overdose: Is more frequent use of non-prescribed buprenorphine associated with lower risk of overdose?

BACKGROUND

Unintentional drug overdoses have reached epidemic levels in the U.S. This study tests the hypothesis that people who have used non-prescribed buprenorphine more frequently in the past six months were less likely to experience a drug overdose during that same time period.

METHODS

Participants age 18 years or older with opioid use disorder who reported use of non-prescribed buprenorphine in the last six months were recruited from the Dayton, Ohio, area using a combination of targeted and modified respondent-driven sampling. Participants completed a structured interview, including six-month timeline follow-back, after informed consent. Logistic regression was used to test the association between (log-transformed) frequency of non-prescribed buprenorphine use and overdose in the previous six months, adjusted for confounding due to sex, homelessness, incarceration, substance use treatment, previous overdose, heroin/fentanyl injection, psychiatric comorbidity, and (log-transformed) frequencies of other (non-opioid) drug use.

RESULTS

Almost 89% of 356 participants were white, 50.3% were male, and 78.1% had high school or greater education. Over 27% (n = 98) reported experiencing an overdose in the past six months. After adjusting for confounding, greater frequency of non-prescribed buprenorphine use was significantly associated with lower risk of overdose (AOR = 0.81, 95% CI = 0.66, 0.98; p = .0286). Experiencing an overdose more than six months ago (AOR = 2.19, 95% CI = 1.24, 3.97); injection as the most common route of administration of heroin/fentanyl (AOR = 2.49, 95% CI = 1.36, 4.71); and frequency of methamphetamine use (AOR = 1.13, 95% CI = 1.02, 1.27) were strongly associated with increased risk of recent overdose in multivariable analysis.

DISCUSSION

The findings support our hypothesis that higher frequency of non-prescribed buprenorphine use is associated with lower risk of drug overdose, a potential harm reduction consequence of diversion. Improving the availability of buprenorphine though standard substance use disorder treatment, primary care, and other innovative methods is urgently needed.

Assessing Mothers' Postpartum Depression From Their Infants' Cry Vocalizations

Postpartum Depression (PPD), a condition that affects up to 15% of mothers in high-income countries, reduces attention to the needs of the child and is among the first causes of infanticide. PPD is usually identified using self-report measures and therefore it is possible that mothers are unwilling to report PPD because of a social desirability bias. Previous studies have highlighted the presence of significant differences in the acoustical properties of the vocalizations of infants of depressed and healthy mothers, suggesting that the mothers’ behavior can induce changes in infants’ vocalizations. In this study, cry episodes of infants (N = 56, 157.4 days ± 8.5, 62% firstborn) of depressed (N = 29) and non-depressed (N = 27) mothers (mean age = 31.1 years ± 3.9) are analyzed to investigate the possibility that a cloud-based machine learning model can identify PPD in mothers from the acoustical properties of their infants’ vocalizations. Acoustic features (fundamental frequency, first four formants, and intensity) are first extracted from recordings of crying infants, then cloud-based artificial intelligence models are employed to identify maternal depression versus non-depression from estimated features. The trained model shows that commonly adopted acoustical features can be successfully used to identify postpartum depressed mothers with high accuracy (89.5%).

Data Set License: CC-BY-NC

Methamphetamine Use and Its Correlates among Individuals with Opioid Use Disorder in a Midwestern U.S. City

Background: U.S. is experiencing a surging trend of methamphetamine use among individuals who use opioids. More research is needed to characterize this emerging "twin epidemic." Objectives: The study aims to identify social and behavioral characteristics associated with methamphetamine use among individuals with opioid use disorder (OUD) in the Dayton, Ohio, area, an epicenter of the opioid crisis and an emerging frontier of methamphetamine epidemic. Methods: 357 adult individuals with current OUD were recruited using targeted and respondent-driven sampling. Structured interviews collected information on social and drug use characteristics. Multivariable Logistic Regression was used to identify characteristics associated with the past 6-month use of methamphetamine. Results: 49.7% were female, and 88.8% were non-Hispanic whites. 55.6% used methamphetamine in the past 6-months, and 84.9% reported first use of methamphetamine after initiation of illicit opioids. Methamphetamine use was associated with homelessness (aOR = 2.46, p = .0001), lifetime history of diverted pharmaceutical stimulant use (aOR = 2.97, p < .001), injection route of heroin/fentanyl use (aOR = 1.89, p = .03), preference for fentanyl over heroin (aOR = 1.82, p = .048), lifetime history of extended-release injectable naltrexone (Vivitrol)-based treatment (aOR = 2.89, p = .003), and more frequent marijuana use (aOR = 1.26, p = .04). Discussion: The findings point to the complexity of motivational and behavioral pathways associated with methamphetamine and opioid co-use, ranging from self-treatment and substitution behaviors, attempts to endure homelessness, and greater risk taking to experience euphoria. More research is needed to understand the causal relationships and the association between methamphetamine and Vivitrol use. Public health responses to the opioid crisis need to be urgently expanded to address the growing epidemic of methamphetamine use.

Patterns of non-prescribed buprenorphine and other opioid use among individuals with opioid use disorder: A latent class analysis

AIM

Non-prescribed buprenorphine (NPB) use increased in the US. This study aims to characterize heterogeneity in patterns of NPB and other opioid use among individuals with current opioid use disorder.

METHODS

The study recruited 356 participants in Dayton (Montgomery County), Ohio, area in 2017-2018 using targeted and Respondent Driven Sampling. Participants met the following criteria: 1) 18 years or older, 2) current moderate/severe opioid use disorder (DSM-5), 3) past 6-month NPB use. Latent class analysis (LCA) was conducted to identify subgroups based on past 6-month (days of NPB and heroin/fentanyl use; use of NPB to get high; use of non-prescribed and prescribed pharmaceutical opioids; participation in formal treatment) and lifetime (years since first NPB and other illicit opioid use) characteristics. Selected auxiliary variables were compared across classes using Asparouhov and Muthén's 3-step approach.

RESULTS

49.7% were female, and 88.8% were non-Hispanic whites. 89% used NPB to self-treat withdrawal. LCA resulted in three classes: "Heavy Heroin/Fentanyl Use" (61%), "More Formal Treatment Use" (29%) and "Intense NPB Use" (10%). After adjusting for multiple testing, the following past 6-month variables differed significantly between classes: injection as a primary route of heroin/fentanyl administration (p < 0.001), cocaine use (p = 0.044), unintentional drug overdose (p = 0.023), and homelessness (p = 0.044), with the "Intense NPB Use" class having the lowest prevalences.

CONCLUSION

Predominance of self-treatment goals and the association between more intense NPB use and lower risks of adverse consequences suggest potential harm minimization benefits of NPB use. More research is needed to understand consequences of NPB use over time.

Heavy Drinking among Women Receiving Intensive Motivational Interviewing: 6-Month Outcomes

Compared to men, women with alcohol use disorders experience more severe consequences related to drinking. Intensive Motivational Interviewing (IMI) is a new 9-session version of Motivational Interviewing (MI) designed for women with alcohol use disorders. The current study reports outcomes from a randomized clinical trial of IMI compared to a single session of MI. Data were collected at baseline, 2-month, and 6-month follow-up. In addition to a standard "intent-to-treat" (ITT) analysis, we conducted disaggregated subgroup analyses of women who were heavy drinkers and a "per protocol" (PP) analysis of women in the IMI condition who attended 7-9 sessions (80% of the IMI sample). Women in both study conditions made large reductions in drinking between baseline and 2 months that were maintained at 6 months. Generalized estimating equation (GEE) models using the full sample (N = 215) did not show time by condition differences, but heavy drinkers(n = 153) receiving IMI showed significantly larger reductions in drinking at 2- and 6-month follow-up than the comparison condition. Assessment of heavy drinkers using the PP sample showed larger between condition differences favoring IMI at both follow-up time points. Results support the efficacy of IMI in terms of reducing drinking, particularly among women who are heavy drinkers.

Beneficial effects of motivational interviewing case management: A latent class analysis of recovery capital among sober living residents with criminal justice involvement

BACKGROUND

This secondary analysis uses data from a recent clinical trial conducted with probationers and parolees with substance use disorders (N = 330) residing in Sober Living Houses (SLHs). The treatment condition received Motivational Interviewing Case Management (MICM), while controls received usual care SLH residency. Both conditions improved on multiple domains, though residents randomized to MICM improved significantly more than usual care controls on criminal justice outcomes. Because MICM is designed to help ex-offenders attain more recovery capital (RC) in multiple domains, we hypothesized MICM participants that already possessed higher RC would show significantly greater improvement at follow-up than usual SLH residents with higher RC. Moreover, MICM and usual SLH residents with low RC would show no differences at 1-year follow-up.

METHODS

A latent class analysis (LCA) grouped participants into two patterns of RC: those with low RC and those with high RC. These classes were interacted with study condition to predict change on six Addiction Severity Indices (ASI) at follow-up.

RESULTS

MICM was more effective for the higher RC class, with greater improvement in drug, legal, and psychiatric outcomes for those who attended at least three MICM sessions. MICM was no more beneficial than usual care for those in a low RC class.

CONCLUSIONS

SLH operators should consider implementation of MICM for residents with more RC resources. Those with fewer recovery resources, such as a history of psychiatric problems or physical/sexual abuse, would benefit from a more intensive intervention to assist them with improving the amount and quality of their RC.

Intensive Motivational Interviewing for Heavy Drinking among Women

Objectives

Women suffer more severe consequences related to heavy drinking than men. Relative to men, women who are heavy drinkers experience higher severity of medical, psychiatric, and social problems, even when they have fewer years drinking. Currently there are few gender-specific, evidence-based interventions for heavy drinking among women.

Methods

A randomized clinical trial was conducted with 215 women with alcohol problems. Half were randomly assigned to receive a 9-session, "Intensive Motivational Interviewing" (IMI) intervention (N=107) and half were randomly assigned to a standard single session of MI (SMI) along with 8 sessions of nutritional education (N=108) to achieve time equivalence. Both conditions received weekly outpatient group counseling. Follow-up interviews were conducted at 2 months. Primary outcomes included percent drinking days (PDD), percent heavy drinking days (PHDD, 4+ drinks), and the Addiction Severity Index (ASI) Alcohol scale. Longitudinal changes were assessed using generalized estimating equations (GEE).

Results

The sample was predominantly white (83.3%), college educated (61.4%), and married (53.5%). The mean age was 50.9 (sd = 11.3). Relative to baseline, both study conditions showed significant reductions in PDD, PHDD, and ASI alcohol severity (p<.001). Among heavy drinkers, defined as women drinking 14+ days to the point of intoxication over the past 30 days at baseline (N=153), those assigned to IMI (n=67) showed larger reductions in PDD (p<.01) and PHDD (p<.05) at 2-months compared to women receiving SMI.

Conclusions

Findings support the efficacy of IMI for heavy drinking among women. Additional studies are needed that assess drinking over longer time periods.

Prevalence of substance use disorder comorbidity among individuals with eating disorders: A systematic review and meta-analysis

OBJECTIVE

Although prior meta-analyses have significantly enriched the available literature on the comorbidity of substance use disorders (SUD) among individuals with eating disorders (ED), there have been few, recent, comprehensive reviews, and limited meta-analyses that include a range of SUDs.

METHOD

In accordance with the PRISMA guidelines, six electronic databases were searched, and a total of 1013 articles were identified using a combination of search terms to identify relevant prevalence studies: eating disorder, substance-related disorder, drug dependence, drug abuse, drug addiction, substance abuse, and prevalence. After two authors screened articles and extracted data independently, 43 articles met inclusion criteria. Data was coded, and a risk of bias assessment was conducted for each included study. Meta-analysis and moderator-analysis was carried out using random-effects modelling.

RESULTS

The pooled lifetime and current prevalence of any comorbid SUD was 21.9% (95% CI 16.7-28.0) and 7.7% (95% CI 2.0-25.8), respectively. Tobacco (36.1 ± 23.1%), caffeine (23.8 ± 12.5%), and alcohol (20.6 ± 16.0%) were the most prevalent SUD comorbidities. Higher prevalence was observed in all-female samples, primarily Caucasian samples, and binge-purge presentations. Neither lifetime nor current prevalence were associated with age.

DISCUSSION

These results suggest that individuals with eating disorders should be regularly screened and offered treatment for substance use disorders concurrently during treatment for ED.

Initiation and engagement as mechanisms for change caused by collaborative care in opioid and alcohol use disorders

BACKGROUND

To assess the mechanism by which a collaborative care (CC) intervention improves self-reported abstinence among primary care patients with opioid and alcohol use disorders (OAUD) compared to treatment as usual.

METHODS

Secondary data analysis of SUMMIT, a randomized controlled trial of CC for OAUD. Participants were 258 patients with OAUD receiving primary care at a multi-site Federally Qualified Health Center. Using a mediation analysis decomposition of a total effect into a mediated and a direct effect, we examined the effect of CC on abstinence at six months, attributable to the HEDIS treatment initiation and engagement measures for the total sample, for individuals with alcohol use disorders alone, and for those with a co-morbid opioid use disorder.

RESULTS

Although the CC intervention led to an increase in both initiation and engagement, among the full sample, only initiation mediated the effect of the intervention on abstinence (3.8%, CI=[0.4%, 8.3%]; 32% proportion of the total effect). In subgroup analyses, among individuals with comorbid alcohol and opioid use disorders, almost 100% of the total effect was mediated by engagement, but the effect was not significant. This was not observed among the alcohol use disorder only group.

CONCLUSIONS

Among primary care patients with OAUDs, treatment initiation partially mediated the effect of CC on abstinence at 6-months. The current study emphasizes the importance of primary care patients returning for a second substance-use related visit after identification. CC may work differently for people with co-morbid opioid use disorders vs. alcohol use disorders alone.

Predictors of treatment initiation for alcohol use disorders in primary care

BACKGROUND

We identified predictors of receiving treatment (brief therapy [BT] and/or extended-release injectable naltrexone [XR-NTX]) for the treatment of alcohol use disorders (AUDs) in primary care. We also examined the relationship between receiving BT and XR-NTX.

METHODS

Secondary data analysis of SUMMIT, a randomized controlled trial of collaborative care. Participants were 290 individuals with AUDs who reported no past 30-day opioid use and who were receiving primary care at a multi-site Federally Qualified Health Center. Bivariate and multivariate analyses examined predictors of BT and/or XR-NTX.

RESULTS

Thirty-two percent (N = 93) received either BT or XR-NTX, 28% (N = 82) received BT and 13% (N = 37) received XR-NTX; 9% (N = 26) received both BT and XR-NTX. Older age, white race, talking with a professional about alcohol use and having more negative consequences all predicted receipt of evidence-based treatment; being homeless was a negative predictor. The predictors of receiving BT included not being homeless and previously talking with a professional; the predictors of receiving XR-NTX included older age, white race and experiencing more negative consequences. In 80% of those who received both BT and XR-NTX, receipt of BT preceded XR-NTX.

CONCLUSIONS

Patient factors were important predictors of receiving primary-care based AUD treatment and differed by type of treatment received. Receiving BT was associated with subsequent use of XR-NTX and may be associated with a longer duration of XR-NTX treatment. Providers should consider these findings when considering ways to increase primary-care based AUD treatment.

Test characteristics of a drug CAGE questionnaire for the detection of non-alcohol substance use disorders in trauma inpatients

BACKGROUND

Non-alcohol substance use disorders (drug use disorders [DUDs]) are common in trauma patients.

OBJECTIVE

To determine the test characteristics of a 4-item drug CAGE questionnaire to detect DUDs in a cohort of adult trauma inpatients.

METHODS

Observational cross-sectional cohort of 1,115 adult patients admitted directly to a level-one trauma center between September, 1994 and November, 1996. All participants underwent both a 4-item drug CAGE questionnaire and the substance use disorder section of a structured psychiatric diagnostic clinical interview (SCID) (DSM-IIIR criteria), administered by staff unaware of their clinical status. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV), positive (LR+) and negative likelihood ratios (LR-), and the area under the receiver operating curve (AUC) were calculated for each individual question and the overall questionnaire, using SCID-generated DUD diagnoses as the standard. Performance characteristics of the screen were also compared across selected sociodemographic, injury mechanism, and diagnostic sub-groups.

RESULTS

Subjects with DUDs were common (n = 349, 31.3%), including cannabis (n = 203, 18.2%), cocaine (n = 199, 17.8%), and opioids (n = 156, 14.0%). The screen performed well overall (AUC = 0.90, 95% CI: 0.88-0.91) and across subgroups based on age, sex, race, marriage status, income, education, employment status, mechanism of injury, and current/past DUD status (AUCs 0.75-1.00). Answering any one question in the affirmative had a sensitivity = 83.4% (95% CI: 79.1-87.1), specificity = 92.3% (95% CI: 90.2-94.1), PPV = 83.1%, LR+ = 10.8.

CONCLUSIONS

The 4-item drug CAGE and its individual questions had good-to-excellent ability to detect DUDs in this adult trauma inpatient population, suggesting its usefulness as a screening tool.

Motivational Interviewing Case Management (MICM) for Persons on Probation or Parole Entering Sober Living Houses

The failure of incarceration as a response to drug offenses has resulted in new policies supporting community-based alternatives. One challenge has been finding appropriate housing for persons on probation and parole. Sober living houses (SLHs) are alcohol- and drug-free living environments that are increasingly being used as housing options for these individuals. The current study examined 6- and 12-month outcomes for 330 persons on probation or parole who entered 49 SLHs. Residents in 22 houses (n = 149 individuals) were randomly assigned to receive a "Motivational Interviewing Case Management" (MICM) intervention and residents in the other 27 houses (n = 181 individuals) received SLH residency as usual. At 6-and 12-month follow-up, both study conditions showed significant improvement relative to baseline on substance abuse, criminal justice, HIV risk, and employment outcomes. For persons who attended at least one MICM session, there were better criminal justice outcomes compared to the SLH as usual group.

Patient predictors of substance use disorder treatment initiation in primary care

INTRODUCTION

Primary care clinics are opportune settings in which to deliver substance use disorder (SUD) treatment, but little is known about which patients initiate treatment in these settings.

METHODS

Using secondary data from a RCT that aimed to integrate SUD treatment into a federally qualified health center (FQHC) using an organizational readiness and collaborative care (CC) intervention, we examined patient-level predictors of initiation of evidence-based practices for opioid and/or alcohol use disorders (OAUDs): a brief behavioral treatment (BT) based on motivational interviewing and cognitive behavioral therapy and medication-assisted treatment (MAT) (extended-release injectable naltrexone (XR-NTX) for patients with an alcohol use disorder or opioid use disorder and buprenorphine/naloxone (BUP/NX) for patients with an opioid use disorder). Using the Andersen model of health care access, we tested bivariate and multivariate logistic regression models to assess associations between patient factors and initiation of BT and MAT.

RESULTS

Twenty-three percent of all participants (N = 392) received BT and 13% received MAT. In the multivariate model examining factors associated with initiation of BT, being of "other" or "multiple" races compared with being White (OR = 0.45, CI = 0.22, 0.92), being homeless (OR = 0.45, CI = 0.21, 0.97) and having been arrested within 90 days of baseline (OR = 0.21 CI = 0.63, 0.69) were associated with significantly lower odds of initiating BT. Greater self-stigma (OR = 1.60, CI = 1.06, 2.42), receiving MAT (OR = 5.52, CI = 2.34, 12.98), and having received the CC study intervention (OR = 12.95, CI = 5.91, 28.37) were associated with higher odds of initiating BT. In the multivariate model examining patient factors associated with initiating MAT, older age (OR = 1.07, CI = 1.03, 1.11), female gender (OR = 3.05, CI = 1.25, 7.46), having a diagnosis of heroin abuse or dependence (with or without alcohol abuse or dependence compared with have a diagnosis of alcohol dependence only (OR = 3.03, CI = 1.17, 7.86), and having received at least one session of BT (OR = 6.42, CI = 2.59, 15.94), were associated with higher odds of initiating MAT.

CONCLUSIONS

Individuals who initiate BT for OAUDs in a FQHC are less likely to be homeless and more likely to have greater self-stigma. Those who receive MAT are more likely to be of older age, female, and to have a diagnosis of heroin abuse or dependence, with or without concomitant alcohol abuse or dependence, rather than alcohol abuse or dependence alone. Receiving collaborative care (e.g., a warm handoff, and follow-up by a care coordinator) may be critical to initiating BT. Receiving at least one session of BT is associated with higher odds of receiving MAT, and receiving MAT is associated with higher odds of receiving BT. The Andersen model of health care access provides some insight into who initiates BT and MAT for OAUD treatment in FQHC-based primary care; further research is needed to explore system-level factors that may also influence treatment initiation.

Pilot Studies Examining Feasibility of Substance Use Disorder Screening and Treatment Linkage at Urban Sexually Transmitted Disease Clinics

BACKGROUND

Sexually transmitted disease (STD) clinics provide critical public health services for screening and treatment of sexually transmitted infections throughout the United States. These settings serve high-risk populations, often on a walk-in basis, and may be promising venues for integrating substance use disorder (SUD) services.

METHODS

We report findings from 2 pilot studies conducted at Baltimore City Health Department's STD clinics. The screening study characterized rates of SUDs among STD clinic patients. Patients waiting for services completed a diagnostic interview mapping to Diagnostic and Statistical Manual of Mental Disorders, 5th Edition SUD criteria (n = 100). The Treatment Linkage Feasibility study examined the feasibility of linking STD clinic patients with opioid and/or cocaine use disorders to SUD treatment in the community (n = 21), using SUD-focused Patient Navigation services for 1 month after the STD clinic visit. Assessments were conducted at baseline and 1-month follow-up.

RESULTS

In the screening study, the majority of STD clinic patients met diagnostic criteria for alcohol and/or drug SUD (57%). Substance-specific SUD rates among patients were 35% for alcohol, 31% for cannabis, 11% for opioids, and 8% for stimulants (cocaine/amphetamines). In the Treatment Linkage Feasibility study, 57% (12/21) of participants attended at least 1 SUD service, and 38% (8/21) were actively enrolled in SUD treatment by 1-month follow-up. The sample reported significant reductions in past 30-day cocaine use from baseline to follow-up (P = 0.01).

CONCLUSIONS

SUD rates are high among STD clinic patients. STD clinics are viable settings for initiating SUD treatment linkage services. Larger-scale research on integrating SUD services in these settings is needed.

Cervical dystonia and substance abuse

OBJECTIVE

To investigate the prevalence of substance abuse (SA) in patients with cervical dystonia (CD) and to correlate it with prevalence of psychiatric disorders.

METHODS

Data on anxiety, depression, dystonia severity, and substance abuse were collected from ten sites participating in the Dystonia Coalition. Patients were divided into two groups according to the presence of SA, utilizing Structured Clinical Interview for DSM-4 criteria. Wilcoxon Rank-Sum test was used to analyze the difference in median scores on the questionnaires between the groups. Chi-square test was used to analyze association between opiate and benzodiazepine use and SA. Association between TWSTRS severity and SA and medication use was assessed. A two-tailed p value of < 0.05 was considered significant. SAS 9.3 (SAS Institute Inc., Cary, NC, USA) was used for all analyses.

RESULTS

Of 208 CD patients, 23 (11%) were identified with SA; 26.3% of patients with SA were on opiates compared to 7.2% of CD patients without SA (p = 0.006). Compared to non-SA patients, those experiencing SA were more likely male (88.9%; p = 0.0007), younger (median age 55; p = 0.031), and scored worse on questionnaires assessing depression (p = 0.044, p = 0.005), anxiety (p = 0.003), and dystonia psychiatric severity (p = 0.033). The median TWSTRS motor severity scores were higher in SA patients compared to non-SA patients (20 versus 16, p = 0.0339). The median TWSTRS total disability, motor, and pain scores were higher in patients on opiates than patients who were not (12 versus 8, p = 0.0071; 18.5 versus 16, p = 0.0243; 12.4 versus 6.7, p = 0.0052, respectively).

CONCLUSIONS

Potential risk factors for SA in CD patients include younger age and male gender with comorbid anxiety, depression and other psychiatric problems. Caution should be exercised when prescribing drugs with potential for abuse in these patients.

Should alcohol screening be a routine practice in alcohol-related facial trauma care? A narrative review

The link between alcohol intoxication and Emergency Department (ED) attendance for management of alcohol-related injuries has been well documented. The acute settings such as ED and surgical wards may not be the most appropriate environment for treatment of chronic conditions, but traumatic episode presentation to ED may offer the most opportunistic time to focus on screening against harmful alcohol use in order to provide timely feedback and support. Although ED provides an opportunity to identify patients with alcohol problems, the initial challenge is finding suitable ways to identify and screen affected patients. This paper is a narrative review on methods of alcohol screening and its effectiveness and efficacy in trauma care setting. It is second part in a series on implementation of screening and brief intervention in managing trauma patients.

Collaborative Care for Opioid and Alcohol Use Disorders in Primary Care: The SUMMIT Randomized Clinical Trial

Importance

Primary care offers an important and underutilized setting to deliver treatment for opioid and/or alcohol use disorders (OAUD). Collaborative care (CC) is effective but has not been tested for OAUD.

Objective

To determine whether CC for OAUD improves delivery of evidence-based treatments for OAUD and increases self-reported abstinence compared with usual primary care.

Design, Setting, and Participants

A randomized clinical trial of 377 primary care patients with OAUD was conducted in 2 clinics in a federally qualified health center. Participants were recruited from June 3, 2014, to January 15, 2016, and followed for 6 months.

Interventions

Of the 377 participants, 187 were randomized to CC and 190 were randomized to usual care; 77 (20.4%) of the participants were female, of whom 39 (20.9%) were randomized to CC and 38 (20.0%) were randomized to UC. The mean (SD) age of all respondents at baseline was 42 (12.0) years, 41(11.7) years for the CC group, and 43 (12.2) yearsfor the UC group. Collaborative care was a system-level intervention, designed to increase the delivery of either a 6-session brief psychotherapy treatment and/or medication-assisted treatment with either sublingual buprenorphine/naloxone for opioid use disorders or long-acting injectable naltrexone for alcohol use disorders. Usual care participants were told that the clinic provided OAUD treatment and given a number for appointment scheduling and list of community referrals.

Main Outcomes and Measures

The primary outcomes were use of any evidence-based treatment for OAUD and self-reported abstinence from opioids or alcohol at 6 months. The secondary outcomes included the Healthcare Effectiveness Data and Information Set (HEDIS) initiation and engagement measures, abstinence from other substances, heavy drinking, health-related quality of life, and consequences from OAUD.

Results

At 6 months, the proportion of participants who received any OAUD treatment was higher in the CC group compared with usual care (73 [39.0%] vs 32 [16.8%]; logistic model adjusted OR, 3.97; 95% CI, 2.32-6.79; P < .001). A higher proportion of CC participants reported abstinence from opioids or alcohol at 6 months (32.8% vs 22.3%); after linear probability model adjustment for covariates (β = 0.12; 95% CI, 0.01-0.23; P = .03). In secondary analyses, the proportion meeting the HEDIS initiation and engagement measures was also higher among CC participants (initiation, 31.6% vs 13.7%; adjusted OR, 3.54; 95% CI, 2.02-6.20; P < .001; engagement, 15.5% vs 4.2%; adjusted OR, 5.89; 95% CI, 2.43-14.32; P < .001) as was abstinence from opioids, cocaine, methamphetamines, marijuana, and any alcohol (26.3% vs 15.6%; effect estimate, β = 0.13; 95% CI, 0.03-0.23; P = .01).

Conclusions and Relevance

Among adults with OAUD in primary care, the SUMMIT collaborative care intervention resulted in significantly more access to treatment and abstinence from alcohol and drugs at 6 months, than usual care.

Trial Registration

clinicaltrials.gov Identifier: NCT01810159.

Housing Status, Psychiatric Symptoms, and Substance Abuse Outcomes Among Sober Living House Residents over 18 Months

Studies show individuals entering sober living recovery houses (SLHs) make significant, sustained improvement on measures of substance abuse problems, employment, and arrests. The current study assessed changes in housing status among SLH residents over 18 months and the relative influences of housing status and psychiatric distress on substance abuse outcomes. Two hundred forty one men and 58 women, all age 18 and older, were interviewed within their first week of entering 20 SLHs and again at 6-, 12-, and 18-month follow-up. Between entry into the SLHs and 18-month follow-up homelessness declined from 16% to 4%, marginal housing declined from 66% to 46%, and stable housing increased from 13% to 27%. Psychiatric severity was generally mild to moderate in severity, but nevertheless showed improvement over the 18-month study period. Multivariate models showed worse substance abuse outcomes for residents with higher psychiatric distress and unstable housing. Relative to persons with stable housing, those who were homeless or marginally housed had worse outcomes and those in SLHs had better outcomes. Overall, we conclude that individuals entering SLHs show improvement in housing status and psychiatric distress, both of which are associated with better substance abuse outcomes.

Problems and Service Needs Among Ex-Offenders with HIV Risk Behaviors Entering Sober Living Recovery Homes

There is currently a nationwide effort to decrease the number of persons who are incarcerated in jails and prisons. However, many ex-offenders on probation or parole do not have access to affordable housing and larger proportions have histories of HIV risk as well as substance abuse problems. In California, sober living houses (SLHs) are becoming an increasingly popular housing option for these individuals. Based largely on the principles of Alcoholics Anonymous (AA), SLHs require abstinence from alcohol and drugs and provide peer support for recovery. The current study examined the types of problems experienced among 330 ex-offenders with lifetime risk for HIV during the six months prior to entering SLHs. Nearly three fourths (74%) of all ex-offenders entering the houses had at least one HIV risk. The importance of housing was evident in the finding that housing status and participants' perceptions of their housing situation were associated with a variety of problem areas, including substance use, HIV risk, psychiatric severity, and legal problems. SLHs represent an important housing option for ex-offenders, but many residents may need additional services to address various problems.

Performance of the Tobacco, Alcohol, Prescription Medication, and Other Substance Use (TAPS) Tool for Substance Use Screening in Primary Care Patients

BACKGROUND

Substance use, a leading cause of illness and death, is underidentified in medical practice.

OBJECTIVE

The Tobacco, Alcohol, Prescription medication, and other Substance use (TAPS) tool was developed to address the need for a brief screening and assessment instrument that includes all commonly used substances and fits into clinical workflows. The goal of this study was to assess the performance of the TAPS tool in primary care patients.

DESIGN

Multisite study, conducted within the National Drug Abuse Treatment Clinical Trials Network, comparing the TAPS tool with a reference standard measure. (ClinicalTrials.gov: NCT02110693).

SETTING

5 adult primary care clinics.

PARTICIPANTS

2000 adult patients consecutively recruited from clinic waiting areas.

MEASUREMENTS

Interviewer- and self-administered versions of the TAPS tool were compared with a reference standard, the modified World Mental Health Composite International Diagnostic Interview (CIDI), which measures problem use and substance use disorder (SUD).

RESULTS

Interviewer- and self-administered versions of the TAPS tool had similar diagnostic characteristics. For identifying problem use (at a cutoff of 1+), the TAPS tool had a sensitivity of 0.93 (95% CI, 0.90 to 0.95) and specificity of 0.87 (CI, 0.85 to 0.89) for tobacco and a sensitivity of 0.74 (CI, 0.70 to 0.78) and specificity of 0.79 (CI, 0.76 to 0.81) for alcohol. For problem use of illicit and prescription drugs, sensitivity ranged from 0.82 (CI, 0.76 to 0.87) for marijuana to 0.63 (CI, 0.47 to 0.78) for sedatives; specificity was 0.93 or higher. For identifying any SUD (at a cutoff of 2+), sensitivity was lower.

LIMITATIONS

The low prevalence of some drug classes led to poor precision in some estimates. Research assistants were not blinded to participants' TAPS tool responses when they administered the CIDI.

CONCLUSION

In a diverse population of adult primary care patients, the TAPS tool detected clinically relevant problem substance use. Although it also may detect tobacco, alcohol, and marijuana use disorders, further refinement is needed before it can be recommended broadly for SUD screening.

PRIMARY FUNDING SOURCE

National Institute on Drug Abuse.

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.

Course of Psychiatric Symptoms and Abstinence among Methamphetamine-Dependent Persons in Sober Living Recovery Homes

BACKGROUND

Although studies of co-occurring psychiatric disorders among methamphetamine (MA)-dependent persons have been conducted in treatment programs, none have examined them in service settings used to sustain long-term recovery, such as sober living houses (SLHs).

METHODS

Residents entering SLHs (N = 243) were interviewed within two weeks and at 6-, 12-, and 18-month follow-up. Measures assessed psychiatric symptoms using the Brief Symptom Inventory (BSI), past-year drug and alcohol dependence, and abstinence over six-month time periods.

RESULTS

Overall, severity of psychiatric symptoms on the BSI was similar among MA-dependent and other dependent residents. Global psychiatric severity, depression, and somatization scales on the BSI predicted abstinence for both groups. However, phobic anxiety and hostility scales were associated with abstinence for MA-dependent residents but not for those dependent on other substances.

CONCLUSION

The similarity of psychiatric symptoms among persons with and without MA dependence in SLHs is different from what studies have found in treatment programs. The association between psychiatric symptoms and abstinence for both groups suggests SLHs should consider provision of on- or off-site mental health services. Additional research is needed to understand why phobic anxiety and hostility are associated with abstinence among MA-dependent residents but not those dependent on other substances.

Predictors of transition to heroin use among initially non-opioid dependent illicit pharmaceutical opioid users: A natural history study

BACKGROUND

Increases in illicit pharmaceutical opioid (PO) use have been associated with risk for transition to heroin use. We identify predictors of transition to heroin use among young, illicit PO users with no history of opioid dependence or heroin use at baseline.

METHODS

Respondent-driven sampling recruited 383 participants; 362 returned for at least one biannual structured interview over 36 months. Cox regression was used to test for associations between lagged predictors and hazard of transition to heroin use. Potential predictors were based on those suggested in the literature. We also computed population attributable risk (PAR) and the rate of heroin transition.

RESULTS

Over 36 months, 27 (7.5%) participants initiated heroin use; all were white, and the rate of heroin initiation was 2.8% per year (95% CI=1.9%-4.1%). Mean length of PO at first reported heroin use was 6.2 years (SD=1.9). Lifetime PO dependence (AHR=2.39, 95% CI=1.07-5.48; PAR=32%, 95% CI=-2% to 64%), early age of PO initiation (AHR=3.08, 95%; CI=1.26-7.47; PAR=30%, 95% CI=2%-59%), using illicit POs to get high but not to self-medicate a health problem (AHR=4.83, 95% CI=2.11-11.0; PAR=38%, 95% CI=12%-65%), and ever using PO non-orally most often (AHR=6.57, 95% CI=2.81-17.2; PAR=63%, 95% CI=31%-86%) were significant predictors.

CONCLUSION

This is one of the first prospective studies to test observations from previous cross-sectional and retrospective research on the relationship between illicit PO use and heroin initiation among young, initially non-opioid dependent PO users. The results provide insights into targets for the design of urgently needed prevention interventions.

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.

Examining Longitudinal Stimulant Use and Treatment Attendance as Parallel Outcomes in Two Contingency Management Randomized Clinical Trials

The primary aim of this study was to examine stimulant use and longitudinal treatment attendance in one 'parallel outcomes' model in order to determine how these two outcomes are related to one another during treatment, and to quantify how the intervention impacts these two on- and off-target outcomes differently. Data came from two multi-site randomized clinical trials (RCTs) of contingency management (CM) that targeted stimulant use. We used parallel multilevel modeling to examine the impact of multiple pre-specified covariates, including selected Addiction Severity Index (ASI) scores, age and sex, in addition to CM on concurrent attendance and stimulant use in two separate analyses, i.e., one per trial. In one trial, CM was positively associated with attending treatment throughout the trial (β=0.060, p<0.05). In the second trial, CM predicted negative urinalysis ((-)UA) over the 12-week treatment period (β=0.069, p<0.05). In both trials, there was a significant, positive relationship between attendance and (-)UA submission, but in the first trial a (-)UA at both baseline and over time was related to attendance over time (r=0.117; r=0.013, respectively) and in the second trial, a (-)UA submission at baseline was associated with increased attendance over time (r=0.055). These findings indicate that stimulant use and treatment attendance over time are related but distinct outcomes that, when analyzed simultaneously, portray a more informative picture of their predictors and the separate trajectories of each. This 'indirect reinforcement' between two clinically meaningful on-target (directly reinforced behavior) and off-target (indirectly reinforced behavior) outcomes is in need of further examination in order to fully exploit the potential clinical benefits that could be realized in substance use disorder treatment trials.

Intensive Motivational Interviewing for Women with Alcohol Problems

Motivational interviewing (MI) for the treatment of alcohol and drug problems is typically conducted over 1 to 3 sessions. This paper reports on an evaluation of an intensive 9-session version of MI (IMI) compared to a standard single MI session (SMI). Although no differences between IMI and SMI were found for methamphetamine use, there was an unexpected finding that women but not men with co-occurring alcohol problems in the IMI condition reduced the severity of their alcohol problems significantly more than those in the SMI condition at 4- and 6-month follow-up. Stronger perceived alliance with the therapist was associated with better outcome. Findings indicate that alcohol outcomes for women might be improved with the addition of more MI sessions. A current study is assessing the impact of IMI for women with more serious alcohol problems. Qualitative interviews are being conducted with women to better understand how IMI is helpful and why it appears to add benefit for women but not men.

Changes in psychiatric symptoms among persons with methamphetamine dependence predicts changes in severity of drug problems but not frequency of use

BACKGROUND

Few studies have examined how changes in psychiatric symptoms over time are associated with changes in drug use and severity of drug problems. No studies have examined these relationships among methamphetamine (MA)-dependent persons receiving motivational interviewing within the context of standard outpatient treatment.

METHODS

Two hundred seventeen individuals with MA dependence were randomly assigned to a standard single session of motivational interviewing (MI) or an intensive 9-session model of MI. Both groups received standard outpatient group treatment. The Addiction Severity Index (ASI) and timeline follow-back (TLFB) for MA use were administered at treatment entry and 2-, 4-, and 6-month follow-ups.

RESULTS

Changes in ASI psychiatric severity between baseline and 2 months predicted changes in ASI drug severity during the same time period, but not changes on measures of MA use. Item analysis of the ASI drug scale showed that psychiatric severity predicted how troubled or bothered participants were by their drug us, how important they felt it was for them to get treatment, and the number of days they experienced drug problems. However, it did not predict the number days they used drugs in the past 30 days. These associations did not differ between study conditions, and they persisted when psychiatric severity and outcomes were compared across 4- and 6-month time periods.

CONCLUSIONS

Results are among the first to track how changes in psychiatric severity over time are associated with changes in MA use and severity of drug problems. Treatment efforts targeting reduction of psychiatric symptoms among MA-dependent persons might be helpful in reducing the level of distress and problems associated with MA use but not how often it is used. There is a need for additional research describing the circumstances under which the experiences and perceptions of drug-related problems diverge from frequency of consumption.

Prophylactic efficacy of fluoxetine, escitalopram, sertraline, paroxetine, and concomitant psychotherapy in major depressive disorder: outcome after long-term follow-up

The acute efficacy of selective serotonin reuptake inhibitors (SSRIs) in the treatment of major depressive disorder (MDD) is well established; however their role in longer-term prevention of recurrence remains unconfirmed. This study aims at examining: the prophylactic efficacy of four commonly used SSRIs in MDD in a naturalistic setting with long-term follow-up, the effect of concomitant cognitive behavioral therapy (CBT), and the predictors of outcome. In a prospective cohort study, 387 patients who either remitted or responded following treatment with four different SSRIs-fluoxetine, escitalopram, sertraline and paroxetine-were followed up over several years. During an average follow-up period of 34.5 months, 76.5% of patients experienced MDD recurrence. Escitalopram and fluoxetine showed a numerically higher prophylactic efficacy than paroxetine and sertraline but the difference was statistically insignificant. The prophylactic efficacy for SSRI-only treatment was limited, with a recurrence rate of 82.0%, compared to 59.0% of patient recurrence rate in concomitant Cognitive Behavioral Therapy (CBT). The relatively small size of the CBT group and the lack of randomization may undermine the extrapolation of its findings to clinical practice. Nevertheless, the study preliminary data may help in defining the clinical utility of antidepressants and CBT in the prophylaxis from MDD recurrence.

Validation and performance of the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) among adolescent primary care patients

BACKGROUND AND AIMS

The World Health Organization's Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) has strong support as a clinical screening tool and research instrument, but has only been validated with adults. This study evaluated the ASSIST and ASSIST-Lite in an adolescent population.

DESIGN

Internal consistency, concurrent validity, discriminant validity and diagnostic accuracy were examined for tobacco, alcohol and cannabis ASSIST scores. An abbreviated version (the ASSIST-Lite) was evaluated for cannabis.

SETTING

Three community health centers in Baltimore, MD, USA.

PARTICIPANTS

A total of 525 primary care patients, ages 12-17 years.

MEASUREMENTS

Measures included the ASSIST, the CRAFFT screening tool and items from the Composite International Diagnostic Interview (CIDI) corresponding to substance use disorder criteria in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition.

FINDINGS

The ASSIST had good internal consistency (α = 0.68-0.88), good concurrent validity with the CRAFFT (r = 0.41-0.76; P < 0.001), and was able to discriminate between gradations of cannabis problem severity. In receiver operating characteristics analysis of optimal clinical cut-points, the ASSIST accurately identified tobacco, alcohol and cannabis use disorders (sensitivities = 95-100%; specificities = 79-93%; area under the curve [AUC] = 0.90-0.94), but did so at minimally low cut-points (indicative of any use in the past 3 months). The ASSIST-Lite performed similarly to the ASSIST in identifying cannabis use disorders (sensitivity = 96%; specificity = 88%; AUC = 0.92), also at a minimally low cut-point. However, confirmatory factor analysis of the ASSIST indicated poor model fit.

CONCLUSIONS

The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) is promising as a research and screening/brief assessment tool with adolescents, but revisions to clinical risk thresholds are warranted. The ASSIST-Lite is sufficiently informative for rapid clinical screening of adolescents for cannabis use disorders.

Screening for Substance Use Disorder Among Incarcerated Men with the Alcohol, Smoking, Substance Involvement Screening Test (ASSIST): A Comparative Analysis of Computer-Administered and Interviewer-Administered Modalities

Substance use disorders are overrepresented in incarcerated male populations. Cost- effective screening for alcohol and substance use problems among incarcerated populations is a necessary first step forward intervention. The Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) holds promise because it has strong psychometric properties, requires minimal training, is easy to score, is available in the public domain but, because of complicated skip patterns, cannot be self-administered. This study tests the feasibility, reliability, and validity of using computer-administered self-interviewing (CASI) versus interviewer-administered interviewing (IAI) to screen for substance use problems among incarcerated men using the ASSIST. A 2 X 2 factorial design was used to randomly assign 396 incarcerated men to screening modality. Findings indicate that computer screening was feasible. Compared to IAI, CASI produced equally reliable screening information on substance use and symptom severity, with test-retest intraclass correlations for ASSIST total and substance-specific scores ranging from 0.7 to 0.9, and ASSIST substance-specific scores and a substance abuse disorder diagnosis based on the Structured Clinical Interview (SCID) were significantly correlated for IAI and CASI. These findings indicate that data on substance use and symptom severity using the ASSIST can be reliably and validly obtained from CASI technology, increasing the efficiency by which incarcerated populations can be screened for substance use problems and, those at risk, identified for treatment.

Reliability and validity of the Spanish version of the substance dependence severity scale

PURPOSE

The purpose of this study was to estimate the reliability and provide evidence for the validity of the Spanish version of the Substance Dependence Severity Scale (SDSS).

METHODS

A total of 211 substance abusers recruited at a public center that provides treatment for substance-related disorders in an outpatient setting were assessed. Reliability was estimated by Cronbach's α and test-retest. Validity evidence was studied by analyzing the relationships with the European Addiction Severity Index (EuropASI) and Health-Related Quality of Life for Drug Abusers (HRQoLDA).

RESULTS

Adequate reliability coefficients were found for the dependence scales of all addressed substances (α = 0.737 to 0.877; test-retest r = 0.796-0.952). Low internal consistency was found for the abuse scales (α = 0.329-0.694), and adequate test-retest coefficients on alcohol, cocaine and heroin (test-retest r = 0.708-0.902). The reliability of the cannabis abuse scales was inadequate. The SDSS scores showed significant relationships with the EuropASI and HRQoLDA dimensions.

CONCLUSIONS

The psychometric analyses validate the use of the severity of dependence scales. The SDSS abuse scales must be used taking the limitations detected into consideration.

Sources of pharmaceutical opioids for non-medical use among young adults

The study uses qualitative and quantitative data to describe sources of pain pills for illicit use among young adult (18- to 23-year-old) users. Respondent-driven sampling was used to recruit 383 individuals in the Columbus, Ohio, area. The sample was almost 50% Caucasian and about 55% male. Qualitative interview participants (n = 45) were selected from the larger sample. Qualitative data suggest that pharmaceutical opioid availability was so pervasive that most individuals did not have to venture outside of their immediate social networks to find people who sold or shared pills. Participants emphasized differences between those who are actively involved in obtaining pills and those who play a more passive role. Active involvement was described as going out searching for pills and paying money to obtain them. In contrast, passive role included obtaining pills when somebody offered or shared them free of charge. Multiple logistic regression analysis indicates that a more active role in obtaining pharmaceutical opioids was related to being White, more frequent use of pharmaceutical opioids, extended-release oxycodone use, and using pharmaceutical opioids to get high, as opposed to self-treating a health problem. The study results can help inform drug use epidemiology, interventions, and policy.

Validity of brief screening instrument for adolescent tobacco, alcohol, and drug use

BACKGROUND AND OBJECTIVE

The National Institute on Alcohol Abuse and Alcoholism developed an alcohol screening instrument for youth based on epidemiologic data. This study examines the concurrent validity of this instrument, expanded to include tobacco and drugs, among pediatric patients, as well as the acceptability of its self-administration on an iPad.

METHODS

Five hundred and twenty-five patients (54.5% female; 92.8% African American) aged 12 to 17 completed the Brief Screener for Tobacco, Alcohol, and other Drugs (BSTAD) via interviewer-administration or self-administration using an iPad. Diagnostic and Statistical Manual, Fifth Edition substance use disorders (SUDs) were identified using a modified Composite International Diagnostic Interview-2 Substance Abuse Module. Receiver operating characteristic curves, sensitivities, and specificities were obtained to determine optimal cut points on the BSTAD in relation to SUDs.

RESULTS

One hundred fifty-nine (30.3%) adolescents reported past-year use of ≥1 substances on the BSTAD: 113 (21.5%) used alcohol, 84 (16.0%) used marijuana, and 50 (9.5%) used tobacco. Optimal cut points for past-year frequency of use items on the BSTAD to identify SUDs were ≥6 days of tobacco use (sensitivity = 0.95; specificity = 0.97); ≥2 days of alcohol use (sensitivity = 0.96; specificity = 0.85); and ≥2 days of marijuana use (sensitivity = 0.80; specificity = 0.93). iPad self-administration was preferred over interviewer administration (z = 5.8; P < .001).

CONCLUSIONS

The BSTAD is a promising screening tool for identifying problematic tobacco, alcohol, and marijuana use in pediatric settings. Even low frequency of substance use among adolescents may indicate need for intervention.

Latent class analysis of non-opioid dependent illegal pharmaceutical opioid users in Ohio

BACKGROUND

Increases in non-medical use of pharmaceutical opioids in the U.S. have resulted in increases in opioid dependence and unintentional overdose deaths. We characterize heterogeneity in opioid use patterns among a community-based sample of 18-23 year-olds who use non-medical pharmaceutical opioids, yet are not opioid dependent.

METHODS

Respondent-driven sampling recruited 390 participants. Latent class analysis stratified by racial/ethnic group identified subgroups of non-medical opioid users based on: six-month frequency of use; number of opioid disorder criteria; oral vs. non-oral administration; number of types of opioids used; use of CNS depressants while under using opioids; and reason for opioid use. Multinomial logistic regression estimated the significance of covariates in predicting class membership.

RESULTS

Within whites and non-white groups, three classes emerged that were, generally, hierarchically ordered with respect to negative characteristics associated with non-medical opioid use. Within each group, the class with the least negative characteristics also had the highest proportion of individuals who use opioids only to self-medicate a health problem. Within each group's three classes, a larger proportion who had ≥ 2 opioid abuse and dependence disorder criteria always coincided with a larger proportion who use opioids ≥ 3 days per week, a larger proportion who used CNS depressants while under the influence of opioids, and a smaller proportion who used opioids only to self-medicate.

CONCLUSION

Differences in patterns of opioid use within each racial/ethnic group of young people who are not opioid dependent suggest the need for tailored interventions designed to reduce the risk of transition to opioid dependence.

Randomized trial of intensive motivational interviewing for methamphetamine dependence

An intensive, 9-session motivational interviewing (IMI) intervention was assessed using a randomized clinical trial of 217 methamphetamine (MA) dependent individuals. Intensive motivational interviewing (IMI) was compared with a single standard session of MI (SMI) combined with eight nutrition education sessions. Interventions were delivered weekly over 2 months. All study participants also received standard outpatient group treatment three times per week. Both study groups showed significant decreases in MA use and Addiction Severity Index drug scores, but there were no significant differences between the two groups. However, reductions in Addiction Severity Index psychiatric severity scores and days of psychiatric problems during the past 30 days were found for clients in the IMI group but not the SMI group. SMI may be equally beneficial to IMI in reducing MA use and problem severity, but IMI may help alleviate co-occurring psychiatric problems that are unaffected by shorter MI interventions. Additional studies are needed to assess the problems, populations, and contexts for which IMI is effective.

Treatment Outcomes of African American Buprenorphine Patients by Parole and Probation Status

This secondary analysis compared outcomes of African-American adults newly-admitted to buprenorphine treatment who were on parole and probation to patients who were not under criminal justice supervision. Buprenorphine patients (N=300) were randomly assigned to receive either Intensive Outpatient Treatment (IOP) or Standard Outpatient Treatment (OP) treatment and were assessed at baseline, 3- and 6-months. There were no differences between groups in treatment retention. Among probationers/parolees, IOP was associated with lower 3-month treatment retention compared to OP, but among participants not on probation/parole the relationship was reversed (p=.004). Both conditions showed significant declines in heroin and cocaine use, illegal activity, and in meeting DSM-IV criteria for opioid and cocaine dependence. Probationers/parolees reported lower frequency of illegal activities at 3-months compared to non-probationers/parolees (p=.007). Buprenorphine treatment should be made more widely available to individuals on parole/probation as they respond as well to treatment as patients not supervised by the criminal justice system.

Intensive motivational interviewing for women with concurrent alcohol problems and methamphetamine dependence

Motivational interviewing (MI) for the treatment of alcohol and drug problems is typically conducted over 1 to 3 sessions. The current work evaluates an intensive 9-session version of MI (Intensive MI) compared to a standard single MI session (Standard MI) using 163 methamphetamine (MA) dependent individuals. The primary purpose of this paper is to report the unexpected finding that women with co-occurring alcohol problems in the Intensive MI condition reduced the severity of their alcohol problems significantly more than women in the Standard MI condition at the 6-month follow-up. Stronger perceived alliance with the therapist was inversely associated with alcohol problem severity scores. Findings indicate that Intensive MI is a beneficial treatment for alcohol problems among women with MA dependence.

A randomized trial of intensive outpatient (IOP) vs. standard outpatient (OP) buprenorphine treatment for African Americans

BACKGROUND

Buprenorphine is increasingly being used in community-based treatment programs, but little is known about the optimal level of psychosocial counseling in these settings. The aim of this study was to compare the effectiveness of OP and IOP level counseling when provided as part of buprenorphine treatment for opioid-dependent African Americans.

METHODS

Participants were African American men and women starting buprenorphine treatment at one of two community-based clinics (N=300). Participants were randomly assigned to OP or IOP. Measures at baseline, 3- and 6-month included the primary outcome of DSM-IV opioid and cocaine dependence criteria, as well as additional outcomes of illicit opioid and cocaine use (urine test and self-report), criminal activity, retention in treatment, Quality of Life, Addiction Severity Index composite scores, and HIV risk behaviors.

RESULTS

Participants assigned to OP received, on average, 3.67 (SD=1.30)h of counseling per active week in treatment. IOP participants received an average of 5.23 (SD=1.68)h of counseling per active week (less than the anticipated 9h per week of counseling). Both groups showed substantial improvement over a 6-month period on nearly all measures considered. There were no significant differences between groups in meeting diagnostic criteria for opioid (p=.67) or cocaine dependence (p=.63). There were no significant between group differences on any of the other outcomes. A secondary analysis restricting the sample to participants meeting DSM-IV criteria for baseline cocaine dependence also revealed no significant between-group differences (all ps>.05).

CONCLUSIONS

Buprenorphine patients receiving OP and IOP levels of care both show short-term improvements.

SBIRT for adolescent drug and alcohol use: current status and future directions

Adolescence is a period of rapid biological, psychological, and social development in the human life cycle. Drug and alcohol misuse during this critical period poses substantial problems for individual and public health, yet is highly prevalent in the United States and elsewhere. The screening, brief interventions, and referral to treatment (SBIRT) model may be well-suited for identifying and intervening with adolescents who are at-risk of developing substance use disorders and those adolescents whose substance use puts them at risk for injury or illness. This article reviews the literature on SBIRT for adolescent populations, focusing on findings from randomized controlled trials. The limited evidence suggests that brief interventions may be effective with adolescents, but a number of gaps in the literature were identified. Considerations for implementing SBIRT with adolescent populations are discussed. Randomized trials are needed that have adequate statistical power, employ longer-term follow-ups, and test the effectiveness of SBIRT for adolescents in various service delivery settings.