Validity of self-report of drug use among STD patients, ER patients, and arrestees

Substance Use Disorder

Substance use disorders (SUDs) present a challenge in the emergency department (ED) setting. This article provides an overview of SUDs, their clinical assessment, legal considerations in drug testing, diagnosis, and treatment approaches. SUDs are prevalent and coexist with mental health disorders, necessitating comprehensive evaluation and management. Clinical assessment involves screening tools, substance use history, and identification of comorbidities. Diagnosis relies on a thorough evaluation of substance abuse patterns and associated medical conditions. Treatment approaches encompass a multidisciplinary approach, incorporating counseling, medications, and social support. Effective management of SUDs in the ED requires a comprehensive understanding of these complex disorders.

Assessing the Validity of Self-Reports of Marijuana Use among Adolescents Entering the Juvenile Justice System: Gender Differences

Objective: Scant research exists on the validity of self-reported marijuana use using biological assays among adolescents involved in the juvenile justice system. This exploratory study examined gender (sex) differences in underreporting of marijuana use and the impact of age, race/ethnicity, living situation, depression, family problems, sexual risk behaviors, previous drug treatment, and juvenile justice placement. Methods: Self-reports of past year marijuana use were validated with urinalysis, and those testing positive for marijuana use were selected for study. The sample was 256 females and 885 males, aged 12 to 18, entering an urban juvenile assessment center in a southeastern U.S. state between 2017 and 2019. Results: Results indicated significant differences in marijuana underreporting (tested positive but self-reported no use), with 37% of females and 55% of males underreporting use. For males, Hispanic ethnicity, African American race, sexually transmitted infection (STI), and secure detention placement increased the odds of underreporting, while having an incarcerate parent and previous drug treatment decreased the odds. For females, number of sexual partners decreased the odds of underreporting of marijuana use. Conclusion: These findings imply use of collateral information, such as urine tests, as a recommendation for juvenile justice intake to corroborate self-reports and guide risk assessment.

Lost in Transition: The Behavioral Health Needs of Veterans in Eight County Jails

The behavioral health needs, service utilization, and discharge planning provision of veterans in jails have been understudied, yet practitioners must understand each component to ensure veterans' behavioral health needs are met through linkage to culturally-appropriate services. Thus, this study asked: How do veterans differ from non-veterans regarding behavioral health needs, jail-based service engagement, and discharge planning within jails? How do jails identify veterans and are they referred to culturally-appropriate services? In a booking sample across eight jails, this evaluative, cross-sectional study compared veterans to non-veterans by demographics, criminal/legal outcomes, behavioral health needs, and receipt of jail-based behavioral health and discharge planning services. Additionally, the process by which booking officers and jail-based clinicians identify veterans was assessed. Veterans were more likely to be male, older, to have received mental health services prior to their jail stay, and to misuse alcohol. They are less likely to have insecure housing and misuse drugs. No differences existed for length of stay in jail nor recidivism. Veterans were equally likely to receive jail-based behavioral health services, but less likely to receive discharge planning services. While many veterans identified their military status at booking, just over one-third who received services from clinicians were identified as veterans. Of those identified by clinicians, few were referred to culturally-appropriate services as part of their discharge planning. Practitioners in the criminal/legal and mental health systems need to collaborate and develop processes that successfully identify and link veterans to culturally-appropriate services.

Opioid abuse surveillance in patients with endocarditis

BACKGROUND

Opioid abuse is a significant cause of morbidity and mortality in the United States, and injection drug use (IDU) is a common form of opioid abuse. IDU is a major risk factor for infections including infective endocarditis (IE).

OBJECTIVES

To determine the prevalence of opioid abuse among patients with IE in both patient problem lists and diagnostic codes and describe underlying patient characteristics.

METHODS

A retrospective chart review from 1-1-2010 to 11-19-2018 of a large academic medical center's patients with documented IE was performed. Demographic, comorbidity, opioid prescription data and records of drug abuse in both the patient's problem list and ICD9/10 codes were recorded.

RESULTS

Of the 796 patients with documented IE, 105 patients (13.2%) had opioid abuse or related IDU in their problem list, but only 22 received an ICD-9/10 code associated with drug abuse. IE patients with opioid abuse were generally younger (43.6 vs 61.7 years [P < 0.001]), had fewer chronic comorbidities, and were prescribed opioids more often (86.7% vs 53.8% [P < 0.001]).

CONCLUSIONS

Opioid abuse and IDU are commonly recorded in the problem list of patients with IE, but opioid abuse is frequently not listed as a diagnosis in administrative billing codes.

Subtle scales: An avenue for identification of prescription drug abuse

Prescription drug abuse and diversion behavior is sustained by overprescribing of abuse-liable substances. Individuals who intend to abuse or divert prescriptions can feign symptoms easily and effectively. Efforts to identify such faking behavior have been lacking because most drug abuse screening tools and self-reported symptom inventories are known to have poor sensitivities to faking. This paper makes the case for the potential of subtle scales in the identification of faking behavior. Subtlety in scale development is the degree to which the psychopathological meaning of an item can be determined in an a priori fashion. Scales containing subtle items, such as the Minnesota Multiphasic Personality Inventory and the Substance Abuse Subtle Screening Inventory, have traditionally shown only moderate sensitivity to faking due to the lack of a tailored and focused approach. This paper provides a guide for the development of a subtle scale that is tailored to a specific condition and using sound measurement theory, a theoretical framework, and knowledge derived from literature. The Accuracy of Knowledge framework proposed by Lanyon is presented along with its application to the development of a subtle scale. Further, specific recommendations have been provided for the various steps involved in the development of a subtle scale including item development, sample selection, item refinement, and scale scoring. Use of well-developed subtle scales can present opportunities to reduce overprescribing, over-diagnosis, and help in the early identification of abuse behavior for targeted interventions. We conclude by presenting opportunities, scope, and possible avenues for research within the cultural context of the United States.

Under-reporting of Risky Drug Use Among Primary Care Patients in Federally Qualified Health Centers

OBJECTIVE

The Affordable Care Act encourages integration of behavioral health into primary care. We aim to estimate the level of under-reporting of drug use in federally qualified health centers (FQHCs) among self-reported risky drug users.

METHODS

Adult patients in the waiting rooms of 4 FQHCs who self-reported risky drug use on the screening instrument World Health Organization's Alcohol, Smoking and Substance Involvement Screening Test (score 4-26), who participated in the "Quit Using Drugs Intervention Trial," submitted urine samples for drug testing. Under-reporters were defined as patients who denied use of a specific drug via questionnaire, but whose urine drug test was positive for that drug. Descriptive statistics, Pearson chi-square test, and logistic regression were used for analysis.

RESULTS

Of the 192 eligible participants, 189 (96%) provided urine samples. Fifty-four samples were negative or indeterminate, yielding 135 participants with positive urine drug tests for this analysis: 6 tested positive for amphetamines, 18 opiates, 21 cocaine, 97 marijuana. Thirty patients (22%) under-reported drug use and 105 (78%) reported drug use accurately. Under-reporting by specific substances was: amphetamines 66%, opiates 45%, cocaine 14%, and marijuana 7%. Logistic regression revealed that under-reporting of any drug was associated with history of incarceration and older age (odds ratios 2.6 and 3.3, respectively; P < 0.05).

CONCLUSIONS

Under-reporting of drug use is prevalent even among self-reported drug users in primary care patients of FQHCs (22%), but varied considerably based on the substance used. Further research is indicated to assess the extent of under-reporting among all primary care patients, regardless of their self-reported drug use status.

Understanding and learning from the diversification of cannabis supply laws

BACKGROUND AND AIMS

Prohibitions on producing, distributing and selling cannabis are loosening in various jurisdictions around the world. This paper describes the diversification of cannabis supply laws and discusses the challenges to and opportunities for learning from these changes.

METHODS

We document changes in cannabis supply laws that de jure legalized cannabis production for medical and/or non-medical purposes (excluding industrial hemp) in Australasia, Europe, North America and South America. We also highlight challenges to evaluating these legal changes based on our experiences studying cannabis laws and policies in the United States.

FINDINGS

As of August 2016, two countries have passed laws to legalize large-scale cannabis production for non-medical purposes at the national (Uruguay) or subnational level (four US states). At least nine other countries legally allow (or will soon allow) cannabis to be supplied for medicinal purposes. Most of the changes in cannabis supply laws have occurred since 2010. The data available in most countries are inadequate for rigorously evaluating the changes in cannabis supply laws.

CONCLUSION

The evidence base for assessing changes in cannabis supply laws remains weak. Efforts should focus upon collecting information about quantities consumed and market transactions as well as validating self-report surveys.

Does Cigarette Smoking Affect Drug Abuse Treatment?

Does quitting cigarette smoking help or hurt the polydrug user in treatment for drug use? Data were obtained from 407 polydrug users in 15 treatment centers in Los Angeles at baseline and one-year follow-up. Measures: Smoking status, reported drug use, urine test results, SF-36 scores, Hopkins SCL, ASI-alcohol use, -drug use, -psychiatric problems, and ad hoc employment-related problems. Results: Most respondents (95%) reported some lifetime smoking. Over one-year follow-up, 29% reported a change in smoking status. At follow-up, stable former smokers reported fewer psychiatric problems than stable current smokers. Change in smoking status was associated with reduced heroin use, but with increased psychiatric problems and employment-related problems. Stable former smokers consistently reported healthier outcomes than either stable regular smokers or status changers, as reflected in somatization, obsessive/compulsive behavior, depression, and anxiety scores. Conclusions: Long-term but not short-term abstinence from tobacco use in polydrug users undergoing treatment is associated with consistently more favorable health outcomes.

CADS: Two Short Screeners for Cocaine and Heroin Dependence among Arrestees

In view of the prevalence of drug use among criminals, the assessment of drug dependence is a valuable responsibility of the criminal justice system. Obtaining accurate and expeditious assessments, however, has traditionally been a difficult goal to achieve because of limited time and resources. While several scales have been developed to screen for drug dependence, none have been developed for specific drugs of abuse within criminal populations. We used data from the Substance Abuse Need for Treatment among Arrestees (SANTA) study in Baltimore to develop screening instruments for cocaine and heroin dependence. The SANTA interview is a module of questions that diagnoses alcohol and other drug (AOD) abuse and dependence according to the Diagnostic and Statistical Manual of Mental Disorders, third edition-revised (DSM-III-R) criteria. Extensive inquiries about AOD-using behaviors are made using a computer-assisted module of the Diagnostic Interview Schedule, Version III-Revised (DIS-III-R), a structured interview that operationalizes the nine DSM-III criteria to diagnose substance abuse and dependence and estimate treatment need based on interview responses. The Center for Substance Abuse Research (CESAR) Arrestee Drug Screener (CADS) developed in the current study utilizes two sets of three questions each from the DIS-III-R for the purpose of identifying cocaine and heroin dependence among arrestees. The high sensitivities and negative predictive values of the CADS make them especially useful for identifying those arrestees most likely to be diagnosed dependent on the respective drug. Implications for using the screeners with criminal populations are discussed.

Correlates of Mandrax use and condom beliefs in preventing sexually transmitted infections among a cohort of South African prison inmates

BACKGROUND

This study was designed to identify the extent to which self-reported Mandrax use impacts condom-use beliefs amongst South African prison inmates.

METHODS

Participants were inmates from four prisons in the provinces of KwaZulu-Natal and Mpumalanga. In total, 357 inmates participated in the parent study of which 121 are included in this analysis based on their self-reported use of Mandrax. The questionnaire was developed in English, translated into Zulu, and back translated into English. Age significantly predicted the use of Mandrax: younger prison inmates reported higher use. Linear regression analysis was conducted to determine whether the use of Mandrax was associated with length of incarceration and other demographic variables, as well as participants' self-reported condom use beliefs behavior.

RESULTS

Regression results indicated that two factors operationalizing condom-use beliefs were impacted by Mandrax use: 1) it is important to use condoms every time you have sex (p<0.01); 2) condoms work well to prevent the spread of HIV (p<0.02). Both factors were also inversely related to Mandrax use.

CONCLUSION

STI prevention programs among prison inmates that seek to promote safer sex behaviors among men must address attitudes to condom use, specifically consistent and correct use of latex condoms and reducing substance misuse.

Telling the Truth About Drug Use

The gap between what people admit about their behavior and what is actually true has plagued social scientists and survey methodologists for decades. This gap would not matter if it did not play an important role in estimation of the extent of the consumption of illegal drugs and/or changing trends in illegal use, both data critical for developing public policy and determining the effects of intervention programming and policy changes. The Arrestee Drug Abuse Monitoring (ADAM) survey matches anonymous self-reported interview information to a urine test for nine drugs in a probability-based sample of adult male arrestees conducted within 48 hr of their arrest. Using data from 2000-2003 and 2007-2011 collected in 10 U.S. counties, this article looks at how the gap between the truth and reality in self-report varies by the drug reported, by the region of the country, over time, and by characteristics of the user, and discusses the relevance of these findings to policy.

Substance use among victimized women on probation and parole

Victimized women within the criminal justice system are an important group and understanding their substance use is critical. Substance use was examined among 406 victimized women on probation and parole in an urban community from 2010 to 2013. Ninety-three percent reported lifetime use of an illicit substance, whereas 58% and 45% reported use of at least one illicit substance in the past 2 years and 12 months, respectively. Among probationers, having been in a controlled environment was associated with a higher prevalence of illicit substance use as compared to parolees. Implications for practice, policy, and future research are discussed.

Psychological distress and substance use among community-recruited women currently victimized by intimate partners: a latent class analysis and examination of between-class differences

Latent class analysis was used to examine patterns of victimization among a community sample of 212 women experiencing intimate partner violence (IPV). Results identified three classes of women characterized by victimization history (recent IPV, childhood victimization); classes were further differentiated by IPV-related posttraumatic stress disorder symptoms, other indicators of psychological distress, and substance use. Differentiating levels of victimization and their associated patterns of psychosocial functioning can be used to develop intervention strategies targeting the needs of different subgroups of women so that mental health and substance use problems can be reduced or prevented altogether. Implications for treatment and future research are presented here.

Illicit drug use, hypertension, and chronic kidney disease in the US adult population

Illicit drug use has been associated with chronic kidney disease (CKD) in select populations, but it is unknown whether the same association exists in the general population. By using data from the National Health and Nutrition Examination Survey 2005-2008, we conducted a cross-sectional analysis of 5861 adults who were questioned about illicit drug use, including cocaine, methamphetamines, and heroin, during their lifetime. The primary outcome was CKD as defined by an estimated glomerular filtration rate ≤60 mL/min/1.73 m(2) using the Chronic Kidney Disease Epidemiology Collaboration equation or by microalbuminuria. We also examined the association between illicit drug use and blood pressure (BP) ≥120/80, ≥130/85, and ≥140/90 mm Hg. Logistic regression was used to examine the association between illicit drug use and CKD and BP. Mean estimated glomerular filtration rate was similar between illicit drug users and nonusers (100.7 vs 101.4 mL/min/1.73 m(2), P = 0.4), as was albuminuria (5.7 vs 6.0 mg/g creatinine, P = 0.5). Accordingly, illicit drug use was not significantly associated with CKD in logistic regression models (odds ratio [OR], 0.98; confidence interval [CI], 0.75-1.27) after adjusting for other important factors. However, illicit drug users had higher systolic (120 vs 118 mm Hg, P = 0.04) and diastolic BP (73 vs 71 mm Hg, P = 0.0003) compared with nonusers. Cocaine use was independently associated with BP ≥130/85 mm Hg (OR, 1.24; CI, 1.00-1.54), especially when used more during a lifetime (6-49 times; OR, 1.42; CI, 1.06-1.91). In a representative sample of the US population, illicit drug use was not associated with CKD, but cocaine users were more likely to have elevated BP.

Testing for amphetamine-type stimulant (ATS) use to ascertain validity of self-reported ATS use among young female sex workers in Cambodia

Objective

To assess concordance between self-reported amphetamine-type stimulant (ATS) use and toxicology results among young female sex workers (FSW) in Phnom Penh, Cambodia.

Methods

Cross-sectional data from the Young Women’s Health Study-2 (YWHS-2), a prospective study of HIV and ATS use among young (15 to 29 years) FSW in Phnom Penh, Cambodia, was analyzed. The YWHS-2 assessed sociodemographic characteristics, HIV serology, HIV risk, and ATS use by self-report and urine toxicology testing at each quarterly visit, the second of which provided data for this assessment. Outcomes include sensitivity, specificity, positive- and negative predictive values (overall and stratified by age), sex-work setting, and HIV status.

Results

Among 200 women, prevalence of positive toxicology screening for ATS use was 14% (95% confidence interval [CI], 9.2, 18.9%) and concurrent prevalence of self-reported ATS was 15.5% (95% CI, 10.4, 20.6%). The sensitivity and specificity of self-reported ATS use compared to positive toxicology test results was 89.3% (25/28), and 96.5% (166/172), respectively. The positive predictive value of self-reported ATS use was 80.6% (25/31); the negative predictive value was 98.2% (166/169). Some differences in concordance between self-report and urine toxicology results were noted in analyses stratified by age group and sex-work setting but not by HIV status.

Conclusion

Results indicate a high prevalence of ATS use among FSW in Phnom Penh, Cambodia, and high concordance between self-reported and toxicology-test confirmed ATS use.

The Effectiveness of Substance Use Measures in the Detection of Full and Partial Denial of Drug Use

Appraisals of substance abuse often constitute a key component of psychological assessments affecting both diagnostic and treatment issues. Because of negative consequences, many substance users engage in outright denials and marked minimization regarding their drug use. Psychological measures, especially those with transparent items, are highly vulnerable to this denial. To address this response style, indirect items are often included on substance use measures to identify those who deny their use. The purpose of this study was to examine the effects of complete and partial denial on the Drug Abuse Screening Test–20, Substance Abuse Subtle Screening Inventory–3, and Drug Use Screening Inventory–Revised. Partial denial refers to the disacknowledgement of drug-related impairment interfering in multiple domains of a client’s functioning. The study used a mixed within- and between-subjects design with 102 inpatient substance users. Each participant completed the study under two conditions: a disclosing condition and an experimental condition (either complete denial or partial denial). Results show partial denial is distinctly different from complete denial across three self-report substance use measures. Importantly, substance users engaging in these denial conditions were often undetected by these measures. Contrary to expectations, subtle scales with indirect item content were only minimally more effective than the face valid scales alone for the assessment of denied drug use.

Substance-related disorders among juvenile offenders: what role do psychopathic traits play?

Substance use disorders are associated with psychopathy, a personality disorder that is heterogeneous in both adults and youth; secondary variants of psychopathy with comorbid psychopathology and primary variants without comorbidity show distinct correlates and outcomes. In adult criminal populations, secondary variants report greater substance abuse compared with primary variants. The primary aim of this study is to replicate and extend these findings to a juvenile offender population. Compared with primary variants of juvenile psychopathy, secondary variants (a) reported significantly more frequent substance use--particularly alcohol--within the 6 months prior to incarceration (d = .43), (b) were almost twice as likely to abuse substances while incarcerated, and (c) were more likely to be diagnosed with a current Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV; American Psychiatric Association, 2000) substance use disorder. Practical implications for working with justice-involved youth are discussed.

Hair and urine testing to assess drugs of abuse consumption in couples undergoing assisted reproductive technology (ART)

For the first time in Europe hair and urine testing have been applied to assess drugs of abuse consumption in couples undergoing assisted reproductive technology and the eventual association of toxic habits with other lifestyle, health status and sociodemographic factors was also investigated. Couples attending five assisted reproduction centers in Rome were invited to join the study. When they presented at the Centre for the visit, they were asked to answer a structured questionnaire concerning sociodemographic characteristics and lifestyle habits, and at the same time to provide hair and urine samples. Hair and urine testing for drugs of abuse, urinary profile of principal endogenous steroids involved in fertility process (testosterone, epitestosterone, androsterone, etiocholanolone and dehydroepiandrosterone) and of alcohol and tobacco smoke biomarkers were performed with validated methodologies. Of the 594 enrolled individuals (297 couples), 352 (164 couples and 24 single individuals from the couple) completed the questionnaire and gave both hair and urine samples, apart from 3 bald men, who only gave urine samples. Urine testing showed an overall 4.8% (17 individuals) positivity to drugs of abuse: 4.2% to cannabinoids, 1.4% to cocaine and 0.85% to both drugs. Results of 4cm segment hair samples testing matched those from urine samples. Thus, taking together, results of urine and hair testing confirmed repeated use of cannabis, cocaine and both drugs in 3.7, 0.85 and 0.57% examined individuals, respectively. Drug consumers were in a statistically higher percentage active smokers and alcohol drinkers, less prone to physical activity and with a trend towards higher weight than non consumers. Finally, repeated drug consumption was associated with significant lower concentration of urinary testosterone in males and of urinary dehydroepiandrosterone in females. The findings of the present study confirm the suitability of urine testing to disclose recent drugs of abuse consumption and of hair analysis to verify repeated consumption. Association between different toxic habits and sedentary lifestyle is also substantiated by the obtained results in our cohort of couples attending assisted reproduction centers.

Prevalence of alcohol and other substances of abuse among injured patients in a Norwegian emergency department

BACKGROUND

Studies have found a high prevalence of both alcohol and other impairing psychoactive drugs in injured patient populations. The aim of this study was to assess the prevalence of potentially impairing psychoactive substances in all patients admitted to a hospital emergency department with injuries from accidents, assault or deliberate self harm.

METHODS

A total of 1272 patients over 18 years of age, admitted to the hospital within 12h of injury, were included. Presence of alcohol was determined by an enzymatic method and other drugs by liquid chromatography-mass spectrometry (LC-MS) or gas chromatography-mass spectrometry (GC-MS), both highly specific analytical methods for determining recent intake.

RESULTS

There were 510 (40%) women in the sample. Of the patients, 38% of the women and 48% of the men had a positive blood sample for psychoactive substances on admission. The most prevalent psychoactive substance was alcohol (27%) with an average concentration of 1.5 g/kg. A further 21% of patients tested showed use of medicinal drugs, and 9% showed use of illicit substances. Cannabis was the most prevalent illicit drug (6.2%). Diazepam (7.4%) and zopiclone (5.3%) were the most prevalent medicinal drugs. In road traffic accidents, 25% of the car drivers had positive findings, about half of them for alcohol.

CONCLUSION

Psychoactive substances were found in nearly half the patients admitted with injuries. The most common substance was alcohol. Alcohol was particularly related to violence, whereas medicinal drugs were most prevalent in accidents at home.

Exploring the Impact of Medical Marijuana Laws on the Validity of Self-Reported Marijuana Use Among Juvenile Arrestees Over Time

Past studies have found that underreporting of marijuana use is particularly high. The present study extends previous research that examined the temporal validity of self-reported marijuana use among juvenile arrestees. Furthermore, the present study explores whether the passage of medical marijuana laws in some states have affected the validity of self-reported marijuana use among juvenile arrestees. Using existing juvenile offender interview and urinalysis data from the Arrestee Drug Abuse Monitoring Program (ADAM) for the years 1998 to 2002, we find that the validity of self-reported marijuana use was low, but quite stable, over time even after the threshold for a positive test was changed. However, study sites in states that had passed medical marijuana laws had significantly higher validity levels than states that had not, suggesting that the passage of medical marijuana laws may affect validity of self-reported marijuana use.

Cumulative victimization, psychological distress, and high-risk behavior among substance-involved women

This research addressed two questions: (a) What is the relationship between different patterns of cumulative victimization and psychological distress? And (b) How does the pattern of cumulative victimization and psychological distress influence women's engagement in substance- and sex-related risk behavior? Data were analyzed from interviews with 149 sexually active, crack-using women who completed a follow-up interview after participating in the Kentucky National Institute on Drug Abuse (NIDA) AIDS Cooperative Agreement. Findings from the multivariate analyses indicated that victimization accounted for 5% and 39% of the variance in psychological distress and high-risk behavior, respectively; cumulative victimization and psychological distress accounted for 6% to 11% of the variance in the high-risk behaviors. Results highlight the affects of childhood and adult victimization on psychological distress and the associations between different types of psychological distress and risk behavior.

Effects of receiving additional off-site services on abstinence from illicit drug use among men on methadone: a longitudinal study

Health and psychosocial service needs that may be co-morbid with opioid addiction may impede the success of drug treatment among patients attending methadone maintenance treatment programs (MMTPs). This longitudinal panel study investigates whether receipt of services from one or more helping professionals outside of the MMTP confers a benefit for drug treatment outcomes among a random sample of male MMTP patients (N=356). Each participant was interviewed 3 times, with 6 months between each interview. Since this observational study did not employ random assignment, propensity score matching was employed to strengthen causal validity of effect estimates. Results support hypotheses that receiving additional off-site services has significant beneficial effects in increasing the likelihood of abstaining from cocaine, heroin, and any illicit drug use over both the ensuing 6- and 12-month time periods. These findings indicate that receipt of additional medical and/or psychosocial services enhances the efficacy of methadone treatment in increasing abstinence from illicit drug use.

Factors related to injection drug use among female prisoners

Female inmates (N = 655) of a large prison facility in the southeastern United States were surveyed about their substance use, social histories, and demographics. Multinomial logistic regression was used to identify predictors of injection drug use. The sample was primarily young (M = 34 +/- 9 years), and evenly split on race (45.3% White and 44.6% Black). Four predictors were identified as significant risk factors for injection drug use: being White, having a prior history of substance user treatment, having a prior drug-related charge, and being a problem drinker. Implications, limitations, and future directions are discussed.

Childhood conduct problems and other early risk factors in rural adult stimulant users

CONTEXT

Understanding childhood risk factors associated with adult substance use and legal problems is important for treatment and prevention.

PURPOSE

To examine the relationship of early substance use, conduct problems before age 15, and family history of substance abuse on adult outcomes in rural, stimulant users.

METHODS

Adult cocaine and methamphetamine users (N = 544) in rural Arkansas and Kentucky were interviewed. Data were analyzed using both bivariate analyses and multiple logistic and log-linear regression models, with dependent variables being any substance abuse/dependence, stimulant abuse/dependence, total number of arrests since age 18 and days incarcerated since age 18.

FINDINGS

One third reported 3 or more conduct disorder problems prior to age 15; half reported initiation of substances (excluding alcohol) before age 15; and 60% reported family history of substance problems. All 3 variables were associated with adult substance abuse/dependence but only the latter two were associated with stimulant abuse/dependence.

CONCLUSIONS

This study highlights early risk factors for adult substance abuse/dependence among rural stimulant users.

Brain mu-opioid receptor binding: relationship to relapse to cocaine use after monitored abstinence

RATIONALE

Cocaine users have increased regional brain mu-opioid receptor (mOR) binding which correlates with cocaine craving. The relationship of mOR binding to relapse is unknown.

OBJECTIVE

To evaluate regional brain mOR binding as a predictor of relapse to cocaine use is the objective of the study.

MATERIALS AND METHODS

Fifteen nontreatment-seeking, adult cocaine users were housed on a closed research ward for 12 weeks of monitored abstinence and then followed for up to 1 year after discharge. Regional brain mOR binding was measured after 1 and 12 weeks using positron emission tomography (PET) with [11C]carfentanil (a selective mOR agonist). Time to first cocaine use (lapse) and to first two consecutive days of cocaine use (relapse) after discharge was based on self-report and urine toxicology.

RESULTS

A shorter interval before relapse was associated with increased mOR binding in frontal and temporal cortical regions at 1 and 12 weeks of abstinence (Ps < 0.001) and with a lesser decrease in binding between 1 and 12 weeks (Ps < 0.0008). There were significant positive correlations between mOR binding at 12 weeks and percent days of cocaine use during first month after relapse (Ps < 0.002). In multiple linear regression analysis, mOR binding contributed significantly to the prediction of time to relapse (R2= 0.79, P < 0.001), even after accounting for clinical variables.

CONCLUSIONS

Increased brain mOR binding in frontal and temporal cortical regions is a significant independent predictor of time to relapse to cocaine use, suggesting an important role for the brain endogenous opioid system in cocaine addiction.

Prevalent cocaine use and myocardial infarction

Studies have reported a possible link between cocaine use and risk for cardiovascular events. The aim of this study was to examine the association between self-reported cocaine use and physician-diagnosed myocardial infarction (MI) in the Third National Health and Nutrition Examination Survey (NHANES III), conducted from 1988 to 1994. Odds ratios (ORs) were estimated using logistic regression models adjusted for age and additionally for gender, race, and other MI risk factors, which accounted for the complex sampling design. In the group aged 18 to 59 years, there was no statistically significant association between any exposure to cocaine and MI (age-adjusted OR 1.56, 95% confidence interval [CI] 0.44 to 5.50, p = 0.48; multivariate-adjusted OR 1.06, 95% CI 0.30 to 3.73, p = 0.92). Participants who reported using cocaine >10 times had a nonsignificant higher prevalence of MI (age-adjusted OR 3.13, 95% CI 0.80 to 12.25, p = 0.10; multivariate-adjusted OR 1.84, 95% CI 0.46 to 7.29, p = 0.40). However, participants aged 18 to 45 years who reported >10 occasions of cocaine use had a significantly elevated prevalence of MI in age-adjusted models (OR 4.60, 95% CI 1.12 to 18.88, p = 0.035). The association was attenuated in multivariate-adjusted models (OR 3.84, 95% CI 0.98 to 15.07, p = 0.054). The lifetime prevalence of cocaine use increased from 14% in NHANES III to 19% in NHANES 2005-2006. In conclusion, these data support a substantial association between cocaine use and MI; the temporal trend in cocaine use may increase the occurrence of MI, particularly in younger populations.

Longitudinal Substance Use following an Emergency Department Visit for Cocaine-Associated Chest Pain

Substance abuse is a chronic, relapsing condition, yet some individuals over time seem to cease use for factors that are largely unclear. A life threatening episode of cocaine-associated chest pain requiring an emergency department (ED) visit may influence subsequent use. A consecutive cohort (n = 219) of patients who presented to a large, urban ED with cocaine-associated chest pain was interviewed at baseline, three months, six months, and 12 months to evaluate longitudinal rates of subsequent drug use. Overall, there was a significant decrease in cocaine use over time (baseline = 100.0%, three months = 56.5%, six months = 54.2%, and 12 months = 51.7%, p < .05 for baseline versus each follow-up interval). Findings suggest that substance use declines following an ED visit for cocaine-related chest pain. However, about half of the subjects were still using cocaine one year later. Future studies examining the potential impact of brief interventions or case management to intervene with this not-in-treatment ED population are warranted.

One-year medical outcomes and emergency department recidivism after emergency department observation for cocaine-associated chest pain

STUDY OBJECTIVE

Chest pain is the most common complaint among cocaine users who present to the emergency department (ED) seeking care, and many hospital resources are applied to stratify cocaine users in regard to future cardiac morbidity and mortality. Little is known about the longitudinal cardiac and noncardiac medical outcomes of cocaine users who have been stratified to an ED observation period after their ED visit. We examine 1-year cardiac outcomes in a low- to intermediate-risk sample of patients with cocaine-associated chest pain in an urban ED, as well as examine ED recidivism at 1 year for cardiac and noncardiac complaints.

METHODS

Prospective consecutive cohort study of patients (18 to 60 years) who presented to an urban Level I ED with cocaine-associated chest pain and were risk stratified to low to intermediate cardiac risk. Exclusion criteria were ECG suggestive of acute myocardial infarction, increased serum cardiac markers, history of acute myocardial infarction or coronary artery bypass graft, hemodynamic instability, or unstable angina. Baseline interviews using validated measures of health functioning and substance use were conducted during chest pain observation unit stay and at 3, 6, and 12 months. ED utilization during the study year was abstracted from the medical chart. Zero-inflated Poisson regression analyses were conducted to predict recurrent ED visits.

RESULTS

Two hundred nineteen participants (73%) were enrolled, 65% returned to the ED post-index visit, and 23% returned for chest pain; of these, 66% had a positive cocaine urine screening result. No patient had an acute myocardial infarction within the 1-year follow-up period. Patients with continued cocaine use were more likely to have a recurrent ED visit (P<.001), but these repeated visits were most often related to musculoskeletal pain (21%) and injury (30%), rather than potential cardiac complaints.

CONCLUSION

Patients with cocaine-associated chest pain who have low to intermediate cardiac risk and complete a chest pain observation unit protocol have a less than 1% rate of myocardial infarction in the subsequent 12 months.

Tracking inner city substance users from the emergency department: how many contacts does it take?

BACKGROUND

Longitudinal studies of substance users report difficulty in locating and completing 12-month interviews, which may compromise study validity.

OBJECTIVES

This study examined rates and predictors of contact difficulty and in-person follow-up completion among patients presenting with cocaine-related chest pain to an inner-city emergency department (ED). The authors hypothesize that less staff effort in contacting patients and lower follow-up rates would bias subsequent substance use analysis by missing those with heavier substance misuse.

METHODS

A total of 219 patients aged 19 to 60 years (65% males; 78% African American) with cocaine-related chest pain were interviewed in the ED and then in person at 3, 6, and 12 months. Demographics, substance use measures, and amount/type of research staff contacts (telephone, letters, home visits, and locating patient during return ED visits) were recorded. Poisson and negative binomial regression analyses were conducted to predict quantity of patient contacts for the 12-month follow-up.

RESULTS

Interview completion rates at 3, 6, and 12 months were 78, 82, and 80%, respectively. Average contact attempts to obtain each interview were 10 at 3 months (range 3-44), 8 at 6 months (1-31), and 8 at 12 months (1-49); 13% of patients required a home visit to complete the 12-month interview. Participants requiring more contact attempts by staff were younger and reported more frequent binge drinking at baseline (p < 0.05), but were less likely to meet criteria for substance abuse or dependence (p < 0.5), or to report prior mental health treatment (p < 0.05). Comparisons of parallel regressions predicting contact difficulty based on the entire sample, the low-effort group, and the difficult-to-reach group showed variation in findings.

CONCLUSIONS

This study demonstrates that substantial staff effort is required to achieve adequate retention over 12 months of patients with substance misuse. Without these extensive efforts at follow-up, longitudinal analyses may be biased.

A validation of self-reported substance use with biochemical testing among patients presenting to the emergency department seeking treatment for backache, headache, and toothache

PURPOSE

This study tests the validity of self-reported illicit substance use against biochemical testing among Emergency Department (ED) patients seeking treatment with narcotics for backache, headache, and toothache and to characterize patients who provide false reports.

METHODS

Retrospective chart review comparing the self-reported drug use history obtained during an ED visit during a six-year period (1995-2001) with the results of a biochemical drug screen obtained the same day.

RESULTS

248 patients met screening criteria, 79 (32%) of whom tested positive for unclaimed "drugs of abuse." Patients with a history of "drug abuse" and chronic pain were significantly more likely to test positive for unclaimed drugs than were their counterparts (p=.05 and p<.0001, respectively). No significant difference was found in comparing those with and without multiple ED visits or those requesting a specific narcotic.

CONCLUSION

Self-reported drug use is unreliable in this ED subpopulation. When this knowledge is critical for patient care, biochemical testing may be indicated.

Outcomes of a prospective trial of student-athlete drug testing: the Student Athlete Testing Using Random Notification (SATURN) study

PURPOSE

To assess the effects of random drug and alcohol testing (DAT) among high school athletes.

METHODS

This was a 2-year prospective randomized controlled study of a single cohort among five intervention high schools with a DAT policy and six schools with a deferred policy, serially assessed by voluntary, confidential questionnaires. DAT school athletes were at risk for random testing during the full academic year. Positive test results were reported to parents or guardians, with mandatory counseling. Indices of illicit drug use, with and without alcohol use, were assessed at the beginning and end of each school year for the past month and prior year. Potential mediating variables were evaluated.

RESULTS

Student-athletes from intervention and control schools did not differ in past 1-month use of illicit drug or a combination of drug and alcohol use at any of the four follow-up periods. At the end of the initial school year and after 2 full school years, student-athletes at DAT schools reported less drug use during the past year (p < .01) compared to athletes at the deferred policy schools. Combining past year drug and alcohol use together, student-athletes at DAT schools reported less use at the second and third follow-up assessments (p < .05). Paradoxically, DAT athletes across all assessments reported less athletic competence (p < .001), less belief authorities were opposed to drug use (p < .01), and indicated greater risk-taking (p < .05). At the final assessment, DAT athletes believed less in testing benefits (p < .05) and less that testing was a reason not to use drugs (p < .01).

CONCLUSIONS

No DAT deterrent effects were evident for past month use during any of four follow-up periods. Prior-year drug use was reduced in two of four follow-up self-reports, and a combination of drug and alcohol use was reduced at two assessments as well. Overall, drug testing was accompanied by an increase in some risk factors for future substance use. More research is needed before DAT is considered an effective deterrent for school-based athletes.

Effects of cannabis on pulmonary structure, function and symptoms

BACKGROUND

Cannabis is the most widely used illegal drug worldwide. Long-term use of cannabis is known to cause chronic bronchitis and airflow obstruction, but the prevalence of macroscopic emphysema, the dose-response relationship and the dose equivalence of cannabis with tobacco has not been determined.

METHODS

A convenience sample of adults from the Greater Wellington region was recruited into four smoking groups: cannabis only, tobacco only, combined cannabis and tobacco and non-smokers of either substance. Their respiratory status was assessed using high-resolution CT (HRCT) scanning, pulmonary function tests and a respiratory and smoking questionnaire. Associations between respiratory status and cannabis use were examined by analysis of covariance and logistic regression.

RESULTS

339 subjects were recruited into the four groups. A dose-response relationship was found between cannabis smoking and reduced forced expiratory volume in 1 s to forced vital capacity ratio and specific airways conductance, and increased total lung capacity. For measures of airflow obstruction, one cannabis joint had a similar effect to 2.5-5 tobacco cigarettes. Cannabis smoking was associated with decreased lung density on HRCT scans. Macroscopic emphysema was detected in 1/75 (1.3%), 15/92 (16.3%), 17/91 (18.9%) and 0/81 subjects in the cannabis only, combined cannabis and tobacco, tobacco alone and non-smoking groups, respectively.

CONCLUSIONS

Smoking cannabis was associated with a dose-related impairment of large airways function resulting in airflow obstruction and hyperinflation. In contrast, cannabis smoking was seldom associated with macroscopic emphysema. The 1:2.5-5 dose equivalence between cannabis joints and tobacco cigarettes for adverse effects on lung function is of major public health significance.

Correlates and predictors of women's sex trading over time among a sample of out-of-treatment drugs abusers

This research addressed two research questions: (a) controlling for crack use, what are the factors associated with women's engagement in ever having traded sex? and (b) controlling for crack use, what are the factors associated with women's engagement in sex trading in the past 90 days? The sample included 149 sexually active, crack using women selected from a subsample of participants in the Kentucky NIDA AIDS Cooperative Agreement. Bivariate analyses indicated that in addition to the pattern of crack use, 13 of the candidate variables were significantly related to sex trading, ever and 11 related to sex trading in the past 90 days. The multivariate models accounted for more than 40% of the variance in sex trading, ever and almost 59% of the variance in sex trading over the past 90 days. Suggestions for HIV/AIDS prevention and intervention among drug-involved women are discussed; implications for future research are suggested.

Predicting in-treatment performance and post-treatment outcomes in methamphetamine users

AIMS

This study examines the utility of individual drug use and treatment characteristics for predicting in-treatment performance and post-treatment outcomes over a 1-year period.

DESIGN, SETTING AND PARTICIPANTS

Data were collected from 420 adults who participated in the Methamphetamine Treatment Project (MTP), a multi-site study of randomly assigned treatment for methamphetamine dependence. Interviews were conducted at baseline, during treatment and during three follow-up time-points: treatment discharge and at 6 and 12 months following admission.

MEASUREMENTS

The Addiction Severity Index (ASI); the Craving, Frequency, Intensity and Duration Estimate (CFIDE); and laboratory urinalysis results were used in the current study.

FINDINGS

Analyses addressed both in-treatment performance and post-treatment outcomes. The most consistent finding is that pre-treatment methamphetamine use predicts in-treatment performance and post-treatment outcomes. No one variable predicted all in-treatment performance measures; however, gender, route of administration and pre-treatment methamphetamine use were significant predictors. Similarly, post-treatment outcomes were predicted by a range of variables, although pre-treatment methamphetamine use was significantly associated with each post-treatment outcome.

CONCLUSIONS

These findings provide useful empirical information about treatment outcomes for methamphetamine abusers, and highlight the utility of assessing individual and in-treatment characteristics in the development of appropriate treatment plans.

Completing substance abuse treatment in child welfare: the role of co-occurring problems and primary drug of choice

A significant number of substance-abusing parents in the child welfare system do not complete substance abuse treatments. Consequently, their children experience longer stays in substitute care settings, and the risk of the termination of parental rights is increased. This study identifies and determines the specific factors that explain the completion of substance abuse treatment for substance-abusing caregivers in child welfare. The sample includes 871 caregivers enrolled in the Illinois Alcohol and Other Drug Abuse waiver demonstration. Approximately 22% of these caregivers successfully completed all required levels of substance abuse treatment. The multivariate models indicate that age, employment status, and legal involvement were significantly associated with the likelihood of completing substance abuse treatment. Heroin users were significantly less likely to complete treatment as compared with alcohol, cocaine, and marijuana users. The findings are discussed in terms of policy and practice implications for public child welfare systems.

Declared and undeclared substance use among emergency department patients: a population-based study

AIMS

To estimate both self-reported and corrected prevalences of substance use in a population-based study of general hospital emergency department (ED) patients and predict undeclared use.

DESIGN

A state-wide cross-sectional, two-stage probability sample survey that incorporates toxicological screening.

SETTING

Seven Tennessee EDs in acute care, adult, civilian, non-psychiatric hospitals.

PARTICIPANTS

A total of 1502 Tennessee residents, 18 years of age and older, possessing intact cognition, able to give informed consent and not in police custody. Measurements Prevalence of self-reported current substance use by age, sex and type with correction for under-reporting based on toxicological screening. Covariates in the multivariate analysis of undeclared use were socio-demographics, ED visit circumstances, health-care coverage, prior health status and treatment history and tobacco addiction.

FINDINGS

Declared current use was highest for alcohol (females 26%, males 47%), marijuana (males 11%, females 6%) and benzodiazepines (females 10%, males 7%). After correction for under-reporting, overall use for any of the eight targeted substances rose from 44% to 56% for females and 61% to 69% for males. Largest absolute changes involved opioids, benzodiazepines, marijuana, amphetamines and/or methamphetamine, with little change for alcohol. Patients aged 65 years and older manifested excess undeclared use relative to patients aged 18-24 years, as did patients not reporting tobacco addiction or receiving substance abuse treatment.

CONCLUSION

Adjustment for under-reporting produced minimal change in the estimated prevalence of alcohol use. However, toxicological screening markedly increased estimates of other drug use, especially for the elderly, who may under-report medication use. Screening tests are useful tools for detecting undeclared substance use.

Educational attainment but not literacy is associated with HIV risk behavior among incarcerated women

PURPOSE

To identify the educational factors associated with HIV risk behaviors among incarcerated women.

METHODS

We evaluated a cohort of female detainees at The Rhode Island Adult Correctional Institute between July and September 2004. Among the 423 women who participated in the study, 55% did not have a high school diploma, 29% had < or = 8th grade reading capacity, 32% had a learning disability, 37% had problem drinking, and 61% (257/423) reported HIV risk behavior.

RESULTS

In multiple logistic regression, participants who had completed high school had the lowest likelihood of HIV risk behavior (adjusted odds ratio [OR] 0.35, 95% confidence interval [CI] 0.12-1.00). There was no association between participants? literacy level and HIV risk behavior (adjusted OR 2.02, 95% CI 0.83-4.92).

CONCLUSIONS

Correctional education programs to reduce HIV risk behavior should focus on those with low educational attainment irrespective of literacy skills.

EPIDEMIOLOGY OF SUBSTANCE USE IN A REPRESENTATIVE SAMPLE OF 18-YEAR-OLD MALES

AIMS

To assess recent drug use through urine testing as well as the prevalence of tobacco and alcohol dependence among young males and to analyse the associations between tobacco dependence and cannabis use (delta-9-tetrahydrocannabinol, THC), tobacco dependence, and alcohol dependence as well as between THC use and other illicit drug use.

METHODS

Urine samples were collected, and nicotine and alcohol questionnaires were administered. Carbon monoxide was assessed in exhaled air. Data from young males from representative, selected districts of Lower Austria were recorded during the annual physical examination for mandatory military service. Out of all 18-year-old males in Austria 3.8% (n = 1902) were included in the study. Prevalence of recent illicit drug use, tobacco dependence (heavy smoking index, HSI), alcohol dependence (The 4-item cutting down, annoyance by criticism, guilty feeling, and eye-openers (CAGE) questionnaire), and associations between substance categories by means of logistic regression analyses were calculated.

RESULTS

Alcohol abuse was found in 15.1% and alcohol dependence was found in 3.2%. According to the HSI 51.5% of males reported daily smoking, of whom 43.7% showed a mild level, and 7.8% a high level, of nicotine dependence. About 5.1% of the sample evidenced THC in urine. Opiates were identified in 2.7% of urine samples. Smokers showed a higher risk of THC use. THC users had a tendency to use cocaine and amphetamines more frequently than THC abstainers.

CONCLUSION

Nicotine and alcohol dependence is common among young males. Biological assessment of illicit drug use seems to confirm previous questionnaire-based findings of associations between THC use and other illicit drugs. Urine testing seems to be an adequate method to analyse associations of THC use and other illicit drugs. In combination with questionnaires urine testing may be used for the assessment of associations of tobacco dependence and recent illicit drug use based on epidemiological surveys.

A CASE-CONTROL STUDY OF ALCOHOL AND SUBSTANCE USE DISORDERS AS RISK FACTORS FOR NON-FATAL INJURY

AIMS

While alcohol use is thought to be a major risk factor for both fatal and non-fatal injuries, the association of substance use disorders (alcohol use disorders, AUD and substance use disorders, SUD) with occurrence of injury has not received the same attention. To report the association of AUD and SUD, according to diagnostic and statistics manual of mental disorders-IV (DSM-IV) and international classification of diseases 10 (ICD-10) criteria, and the risk of non-fatal injuries.

METHODS

A case-control study: Cases included 653 injured patients, 18-65-years-old, who attended one emergency department (ED). Controls included 1131 subjects from a representative sample of residents of Mexico City, of the same age group. Information on drug and alcohol use was obtained by interview using the world mental health version of the composite international diagnostic interview (WMH-CIDI).

RESULTS

Among injured patients, the prevalence of substance abuse or dependence within the last 12 months was 12.3% for alcohol and 2.5% for other substances (marijuana, cocaine, tranquilizers, amphetamines, others). Among residents of Mexico City, these prevalences were 1.8 and 0.3%, respectively. Adjusted odds ratios (OR) of injury according to alcohol and substance use were 4.95 (95% confidence interval (CI): 2.87-8.52) for alcohol and 2.58 (0.73-9.17) for other substances. An important level of comorbid alcohol and substance use disorders was also found.

CONCLUSIONS

Efforts in the ED should be carried out to treat and/or refer patients with alcohol and substance use disorders, and special care should be taken to address comorbid cases.

Hepatitis C and HIV in incarcerated populations: fights, bites, searches, and syringes!

Implications of hepatitis C (HCV) infection in corrections settings and learning needs of nurses whose primary expertise is care of HIV-infected individuals will be presented. This target group of nurses who provide care for HCV-infected patients includes nurses working in corrections settings, and community settings, whose clients have been or will be incarcerated, and advanced practice nurses working in a variety of settings. For nurses who work in the community setting, background information is presented on characteristics of the incarcerated and the environments of some different settings where incarceration occurs, such as county, state, juvenile, and federal institutions. Barriers to HCV prevention, testing, and treatment for incarcerated people are unique and different than for those living in the community. These distinctions are an important area of knowledge for nurses caring for patients who are HCV positive or at risk, whether they are practicing in a community or correctional setting.

Accuracy of self-report and toxicological assays to detect substance misuse disorders in parasuicide patients

OBJECTIVE

To assess the accuracy of self-reported substance use and toxicological assays in subjects admitted for Intentional Drug Overdose (IDO), using as a reference diagnosis of substance use disorder.

METHOD

Self-reported substance use was collected and toxicological assays were carried out in urine samples in 507 patients with IDO. A standardized psychiatric evaluation was performed in 100 randomly selected subjects.

RESULTS

In routine practice, the emergency department staff did not investigate substance use in nearly one of two patients. Patients' statements and toxicological assays were more specific than sensitive, with lower scores for toxicological assays. Patients' statements made it possible to detect nearly 80% of subjects with substance use disorder.

CONCLUSION

Identification of substance use disorder in subjects with IDO has strong clinical consequences regarding treatment and prevention of suicidal behaviour. Thus, emergency department staff should be made aware of the value of more systematically exploring self-reported substance use.

Why extensive participation in treatment and twelve-step programs is associated with the cessation of addictive behaviors: an application of the addicted-self model of recovery

Applying the Addicted-Self Model of recovery to explain why extensive participation in recovery activities predicts abstinence, it was hypothesized that high levels of participation in treatment and Twelve-step programs promote abstinence because these activities reinforce the notion that controlled use is not possible for dependent alcohol and drug users. Findings from a prospective treatment outcomes study (n = 356) indicate general support for this hypothesis. Yet the cognitive transformation described by the Addicted-Self Model involving acknowledgement of loss of control over alcohol and other drugs is only a partial explanation of why extensive participation in recovery activities promotes recovery. Reiterating the conclusion that "more is better," frequent counseling participation, treatment completion, and weekly or more frequent participation in Twelve-Step programs promote absti- nence independently from their influence on controlled use self-efficacy. Theoretical and clinical implications, and directions for future research are discussed.

Imprisoned drug offenders in Taiwan: a gender-based analysis

Using data collected from a 1999 nationwide survey of 700 incarcerated drug users in Taiwan, this article compares gender differences with respect to childhood experiences, family characteristics, drug use patterns, and criminal histories. The results from both bivariate and logistic regression analyses document some gender differences and offer tentative support for feminist views. Overall, female drug offenders in Taiwan were more likely to have spouses with alcohol or drug use-associated problems, experience physical or sexual abuse, grow up in non-two-parent households, and hold temporary and stereotypical female jobs, including prostitution. Compared to men, although female drug offenders reported earlier involvement in criminal activities, they were less violent and had fewer prior arrests. As for sources, women relied on friends or acquaintances to procure their drugs. No gender differences were identified with respect to illicit drug type or duration and frequency of use.

To smoke or not to smoke: impact on disability, quality of life, and illicit drug use in baseline polydrug users

Does tobacco use in polydrug users relate to future daily functioning (SF-36) and disability? To answer this question, community-living polydrug users (n = 254) were interviewed at baseline, 1-year and 2-year follow-up. Measures included: smoking status and self-reported disability at each assessment, and SF-36 measures collected at the final assessment. Urine samples permitted validation of reported drug use status. Results revealed that baseline disability rates were high but fell nearly 50% over two years. Disabilities named were similar to those reported in the general population. Change in smoking status was associated with decreased disability and improvements in general health and vitality. Respondents reporting disability reported lower daily functioning (SF-36). Stable everyday smoking was strongly associated with increased probability of positive urine tests for illicit drug use. Illicit drug use did not affect SF-36 ratings. Findings suggest that tobacco use by polydrug users is related to disability rates, to illicit drug use and to variations in daily functioning.

Urine drug screening in adolescents

The urine drug screen is an important tool in adolescent medicine. Several ethical, and numerous technical, issues are associated with the use of this tool. The nature and limitations of the specific tests of which the screen is composed must be known to the physician. Two-way communication with the laboratory, both before the test is ordered and after the results are reported, can be very helpful. Laboratory testing cannot substitute for an ongoing therapeutic alliance with the patient. Testing is an important element of the substance use assessment, but is only one element, is not required in every case, and is not sufficient alone in any case.

Counseling frequency and the effectiveness of outpatient drug treatment: revisiting the conclusion that "more is better."

Replicating and extending previous research, findings from a prospective investigation of outpatient drug treatment (n = 356) indicate that higher frequency of participation in group counseling during treatment predicts higher rates of alcohol and drug abstinence even for those who complete the 6-month treatment program and maintain weekly or more frequent attendance of 12-step meetings during and after treatment. Greater length of group and individual counseling sessions, however, is not associated with higher rates of abstinence, and contrary to previous research, the modest but statistically significant association between the frequency of individual counseling and abstinence was not replicated. With respect to treatment completion, regular attendance at 12- step meetings, and frequent participation in group counseling while in treatment, the evidence suggests that "more is better."

The validity of adult arrestee self-reports of crack cocaine use

Despite the many problems associated with crack use, little validated empirical evidence about the prevalence of crack cocaine exists. Researchers that track crack cocaine use have relied on self-reports to differentiate crack and powder cocaine. Prior research suggests that the accuracy of self-reports for the use of a variety of illicit substances is relatively low. To examine the validity of self-reports of crack use, this article employs a newly developed technology to detect specifically the presence of markers of crack cocaine in urine specimens. With a sample of 2327 arrestees from six cities that participate in the Arrestee Drug Abuse Monitoring (ADAM) Program, both face-to-face interview and urinalysis data were examined. Using a positive urinalysis result as the validity standard, we assessed the extent to which arrestees underreport crack cocaine use as compared to the use of marijuana, opiates,and methamphetamine. Logistic regression models were also de veloped to predict the factors that relate to underreporting. The results showed a considerable amount of underreporting for all the drug measures. In most cases, only about half the people who had a positive urinalysis test for drugs admitted using drugs. Overall, the least amount of underreporting occurred for the use of marijuana (63.6% told the "truth"), followed by methamphetamine (56.1% told the truth), crack (48.2% told the truth), and opiate (45.9% told the truth). Female crack users, as compared to male crack users, were more likely to admit using crack. Black arrestees were more likely to admit using crack than white or Hispanic arrestees. Arrestees with a history of prior drug treatment or a prior arrest, as compared to those without such histories, were more likely to admit using crack. The older the arrestee was, the more likely the arrestee would admit using crack. The more money an arrestee spent on drugs, the more likely the arrestee would admit using crack. Differences in underreporting were also observed across the six cities in this study. The implications of these findings for the monitoring of crack use are discussed.