IUPHAR Review: New strategies for medications to treat substance use disorders

Substance use disorders (SUDs) and drug overdose are a public health emergency and safe and effective treatments are urgently needed. Developing new medications to treat them is expensive, time-consuming, and the probability of a compound progressing to clinical trials and obtaining FDA-approval is low. The small number of FDA-approved medications for SUDs reflects the low interest of pharmaceutical companies to invest in this area due to market forces, characteristics of the population (e.g., stigma, and socio-economic and legal disadvantages), and the high bar regulatory agencies set for new medication approval. In consequence, most research on medications is funded by government agencies, such as the National Institute on Drug Abuse (NIDA). Multiple scientific opportunities are emerging that can accelerate the discovery and development of new medications for SUDs. These include fast and efficient tools to screen new molecules, discover new medication targets, use of big data to explore large clinical data sets and artificial intelligence (AI) applications to make predictions, and precision medicine tools to individualize and optimize treatments. This review provides a general description of these new research strategies for the development of medications to treat SUDs with emphasis on the gaps and scientific opportunities. It includes a brief overview of the rising public health toll of SUDs; the justification, challenges, and opportunities to develop new medications; and a discussion of medications and treatment endpoints that are being evaluated with support from NIDA.

Evaluation of the New England Office Based Addiction Treatment ECHO: A Tool for Strengthening the Addiction Workforce

INTRODUCTION

Reducing substance-related morbidity requires an educated and well-supported workforce. The New England Office Based Addiction Treatment Extension for Community Healthcare Outcomes (NE OBAT ECHO) began in 2019 to support community-based addiction care teams through virtual mentoring and case-based learning. We sought to characterize the program's impact on the knowledge and attitudes of NE OBAT ECHO participants.

METHODS

We conducted an 18-month prospective evaluation of the NE OBAT ECHO. Participants registered for 1 of 2 successive ECHO clinics. Each 5-month clinic included ten 1.5-hour sessions involving brief didactic lectures and de-identified patient case presentations. Participants completed surveys at Month-0, -6, -12, and -18 to assess attitudes about working with patients who use drugs and evidence based practices (EBPs), stigma toward people who use drugs, and addiction treatment knowledge. We compared outcomes using 2 approaches: (i) between-groups, which involved comparing the first intervention group to the delayed intervention (comparison) group, and (ii) within-groups, which involved comparing outcomes at different time points for all participants. In the within-group approach, each participant acted as their own control.

RESULTS

Seventy-six health professionals participated in the NE OBAT ECHO, representing various roles in addiction care teams. Approximately half (47% [36/76]) practiced primary care, internal, or family medicine. The first intervention group reported improved job satisfaction and openness toward EBPs compared to the delayed intervention group. Within-group analyses revealed that ECHO participation was associated with increased positive perceptions of role adequacy, support, legitimacy, and satisfaction 6 months following program completion. No changes were identified in willingness to adopt EBPs or treatment knowledge. Stigma toward people who use drugs was persistent in both groups across time points.

CONCLUSIONS

NE OBAT ECHO may have improved participants' confidence and satisfaction providing addiction care. ECHO is likely an effective educational tool for expanding the capacity of the addiction workforce.

Craving and opioid use disorder: A scoping review

INTRODUCTION

The subjective experience of drug craving is a prominent and common clinical phenomenon for many individuals diagnosed with opioid use disorder (OUD), and could be a valuable clinical endpoint in medication development studies. The purpose of this scoping review is to provide an overview and critical analysis of opioid craving assessments located in the published literature examining OUD.

METHOD

Studies were identified through a search of PubMed, Embase, and PsychInfo databases and included for review if opioid craving was the focus and participants were diagnosed with or in treatment for OUD.

RESULTS

Fifteen opioid craving assessment instruments were identified across the 87 studies included for review. The most common were the Visual Analog Scale (VAS, 41 studies), Desires for Drug Questionnaire (DDQ, 12 studies), Heroin Craving Questionnaire (HCQ, 10 studies), and Obsessive-Compulsive Drug Use Scale (OCDUS, 10 studies). Craving assessments varied considerably in their format, content, time frame, and underlying subscales, and only 6 of 15 had been psychometrically evaluated.

DISCUSSION

This review identified a variety of opioid craving assessments, but few had been evaluated for their psychometric properties making it difficult to ascertain whether craving is being assessed optimally in studies of OUD. Thus, the development of a reliable and valid opioid craving assessment would be worthwhile and could be guided by recently published Food and Drug Administration Clinical Outcome Assessment (COA) guidelines. Importantly, a COA focused on opioid craving could be a valuable addition to research studies designed to evaluate novel treatments for OUD.

Randomized Trial of Reduced-Nicotine Standards for Cigarettes

BACKGROUND

The Food and Drug Administration can set standards that reduce the nicotine content of cigarettes.

METHODS

We conducted a double-blind, parallel, randomized clinical trial between June 2013 and July 2014 at 10 sites. Eligibility criteria included an age of 18 years or older, smoking of five or more cigarettes per day, and no current interest in quitting smoking. Participants were randomly assigned to smoke for 6 weeks either their usual brand of cigarettes or one of six types of investigational cigarettes, provided free. The investigational cigarettes had nicotine content ranging from 15.8 mg per gram of tobacco (typical of commercial brands) to 0.4 mg per gram. The primary outcome was the number of cigarettes smoked per day during week 6.

RESULTS

A total of 840 participants underwent randomization, and 780 completed the 6-week study. During week 6, the average number of cigarettes smoked per day was lower for participants randomly assigned to cigarettes containing 2.4, 1.3, or 0.4 mg of nicotine per gram of tobacco (16.5, 16.3, and 14.9 cigarettes, respectively) than for participants randomly assigned to their usual brand or to cigarettes containing 15.8 mg per gram (22.2 and 21.3 cigarettes, respectively; P<0.001). Participants assigned to cigarettes with 5.2 mg per gram smoked an average of 20.8 cigarettes per day, which did not differ significantly from the average number among those who smoked control cigarettes. Cigarettes with lower nicotine content, as compared with control cigarettes, reduced exposure to and dependence on nicotine, as well as craving during abstinence from smoking, without significantly increasing the expired carbon monoxide level or total puff volume, suggesting minimal compensation. Adverse events were generally mild and similar among groups.

CONCLUSIONS

In this 6-week study, reduced-nicotine cigarettes versus standard-nicotine cigarettes reduced nicotine exposure and dependence and the number of cigarettes smoked. (Funded by the National Institute on Drug Abuse and the Food and Drug Administration Center for Tobacco Products; ClinicalTrials.gov number, NCT01681875.).

Classification and definition of misuse, abuse, and related events in clinical trials: ACTTION systematic review and recommendations

As the nontherapeutic use of prescription medications escalates, serious associated consequences have also increased. This makes it essential to estimate misuse, abuse, and related events (MAREs) in the development and postmarketing adverse event surveillance and monitoring of prescription drugs accurately. However, classifications and definitions to describe prescription drug MAREs differ depending on the purpose of the classification system, may apply to single events or ongoing patterns of inappropriate use, and are not standardized or systematically employed, thereby complicating the ability to assess MARE occurrence adequately. In a systematic review of existing prescription drug MARE terminology and definitions from consensus efforts, review articles, and major institutions and agencies, MARE terms were often defined inconsistently or idiosyncratically, or had definitions that overlapped with other MARE terms. The Analgesic, Anesthetic, and Addiction Clinical Trials, Translations, Innovations, Opportunities, and Networks (ACTTION) public-private partnership convened an expert panel to develop mutually exclusive and exhaustive consensus classifications and definitions of MAREs occurring in clinical trials of analgesic medications to increase accuracy and consistency in characterizing their occurrence and prevalence in clinical trials. The proposed ACTTION classifications and definitions are designed as a first step in a system to adjudicate MAREs that occur in analgesic clinical trials and postmarketing adverse event surveillance and monitoring, which can be used in conjunction with other methods of assessing a treatment's abuse potential.

Cigarette smoking and short-term addiction treatment outcome

Cigarette smoking is common among patients in cocaine and opioid dependence treatment, and may influence treatment outcome. We addressed this issue in a secondary analysis of data from an outpatient clinical trial of buprenorphine treatment for concurrent cocaine and opioid dependence (13 weeks, N=200). The association between cigarette smoking (lifetime cigarette smoking status, number of cigarettes smoked per day prior to study entry) and short-term treatment outcome (% of urine samples positive for cocaine or opioids, treatment retention) was evaluated with analysis of covariance, bivariate correlations, and multivariate linear regression. Nicotine-dependent smokers (66% of participants) had a significantly higher percentage of cocaine-positive urine samples than non-smokers (12% of participants) (76% vs. 62%), but did not differ in percentage of opioid-positive urine samples or treatment retention. Number of cigarettes smoked per day at baseline was positively associated with percentage of cocaine-positive urine samples, even after controlling for baseline sociodemographic and drug use characteristics, but was not significantly associated with percentage of opioid-positive urine samples or treatment retention. These results suggest that cigarette smoking is associated with poorer short-term outcome of outpatient treatment for cocaine dependence, but perhaps not of concurrent opioid dependence, and support the importance of offering smoking cessation treatment to cocaine-dependent patients.

Drugs of abuse: management of intoxication and antidotes

Illicit drug intoxications are an increasing public health problem for which, in most cases, no antidotes are clinically available. The diagnosis and treatment of these intoxications requires a trained clinician with experience in recognizing the specific signs and symptoms of intoxications to individual drugs as well as polydrug intoxications, which are more the rule than the exception. To make the diagnosis, the clinical observation and a urine toxicology test are often enough. Evaluating the blood levels of drugs is frequently not practical because the tests can be expensive and results may be delayed and unavailable to guide the establishment of a treatment plan. Other laboratory tests may be useful depending on the drug or drugs ingested and the presence of other medical complications. The treatment should be provided in a quiet, safe and reassuring environment. Vital signs should be closely monitored. Changes in blood pressure, respiratory frequency and temperature should be promptly treated, particularly respiratory depression (in cases of opiate intoxication) or hyperthermia (in cases of cocaine or amphetamine intoxication). Intravenous fluids should be administered as soon as possible. Other psychiatric and medical complication should receive appropriate symptomatic treatment. Research on immunotherapies, including vaccines, monoclonal and catalytic antibodies, seems to be a promising approach that may yield specific antidotes for drugs of abuse, helping to ameliorate the morbidity and mortality associated with illicit drug intoxications.

Treatment of tobacco dependence in mental health and addictive disorders

People with mental health and addictive (MHA) disorders smoke at high rates and require tobacco treatment as a part of their comprehensive psychiatric care. Psychiatric care providers often do not address tobacco use among people with mental illness, possibly owing to the belief that their patients will not be able to quit successfully or that even short-term abstinence will adversely influence psychiatric status. Progress in the development of treatments has been slow in part because smokers with current MHA disorders have been excluded from most smoking cessation trials. There are several smoking cessation treatment options, including psychological and pharmacological interventions, that should be offered to people with an MHA disorder who smoke. Building motivation and readiness to quit smoking is a major challenge, and therefore motivational interventions are essential. We review the treatment options for people with tobacco dependence and MHA disorders, offer recommendations on tobacco assessment and tailored treatment strategies, and provide suggestions for future research. Treatment efficacy could be enhanced through promoting smoking reduction as an initial treatment goal, extending duration of treatment, and delivering it within an integrated care model that also aims to reduce the availability of tobacco in MHA treatment settings and in the community.

Exposure to violence among substance-dependent pregnant women and their children

This study examined the prevalence of exposure to violence among drug-dependent pregnant women attending a multidisciplinary perinatal substance abuse treatment program. Participants (N = 715) completed the Violence Exposure Questionnaire within 7 days after their admission to the program. Their rates of lifetime abuse ranged from 72.7% for physical abuse to 71.3% for emotional abuse to 44.5% for sexual abuse. Their rates of abuse remained high during their current pregnancy, ranging from 40.9% for emotional abuse to 20.0% for physical abuse to 7.1% for sexual abuse. Nearly one third of the women reported having physical fights with their current partner (lifetime), and 25% of these women reported that children were present during those physical fights. A total of 30% of the women perceived a need for counseling regarding exposure to violence for themselves and 15% perceived a need for counseling for their children. Study findings confirm previous reports of high rates of abuse and violence exposure among substance-abusing pregnant women and their strong need for counseling for psychosocial sequelae. This study affirmed the value of routine screening for violence exposure in this at-risk population as well as the need to train therapists in specific strategies for helping such women address this complex array of problems.

Identification and treatment of patients with nicotine problems in routine clinical psychiatry practice

The aim of this study is to assess the rates of nicotine problems diagnosed by psychiatrists, the characteristics of psychiatric patients who smoke, and the services provided to them in routine psychiatric practice. Data were obtained by asking psychiatrists participating in the American Psychiatric Institute for Psychiatric Research and Education's Practice Research Network to complete a self-administered questionnaire to provide detailed sociodemographic, clinical, and health plan information on three of their patients seen during routine clinical practice. A total of 615 psychiatrists provided information on 1,843 patients, of which 280 (16.6%) were reported to have a current nicotine problem. Of these, 9.1% were reported to receive treatment for nicotine dependence. Patients with nicotine problems were significantly more likely to be males, divorced or separated, disabled, and uninsured, and have fewer years of education. They also had significantly more co-morbid psychiatric disorders, particularly schizophrenia or alcohol/substance use disorders; a lower Global Assessment Functioning score; and poorer treatment compliance than their counterparts. The results suggest a very low rate of identification and treatment of nicotine problems among patients treated by psychiatrists, even though psychiatric patients who smoke seem to have more clinical and psychosocial stressors and more severe psychiatric problems than those who do not smoke. Programs should be developed to raise the awareness and ability of psychiatrists to diagnose and treat patients with nicotine problems, with a particular emphasis on the increased medical and psychosocial needs of psychiatric patients who smoke.

Treatment compliance in patients with comorbid psychiatric and substance use disorders

This study examines clinical and non-clinical factors associated with treatment compliance problems in 342 patients with substance use disorders (SUD) seen in routine psychiatric practice. Weighted Wald-X(2) and multivariate logistic regression assessed sociodemographic, clinical, treatment, and health plan characteristics associated with treatment compliance problems. Among patients with SUD, 40.5% were reported to currently have treatment compliance problems. Patients with treatment compliance problems were significantly more likely to have personality disorders, lower global assessment of functioning scores, and medication side effects than those without treatment compliance problems. Patients seen by psychiatrists who were reimbursed by discounted rather than undiscounted fee-for-service were five times more likely to be reported to have treatment compliance problems. Both clinical and non-clinical factors appear to be associated with treatment compliance problems. Understanding these factors and targeting treatment interventions may improve treatment compliance and patient outcomes.

Parenting knowledge among substance abusing women in treatment

The purpose of this study was to assess parenting knowledge and beliefs among drug abusing pregnant and recently postpartum women engaged in a comprehensive substance abuse treatment program. The effects of a parenting skills training program for this population were evaluated. A Parenting Skills Questionnaire was developed and administered to a sample of 73 pregnant and drug-dependent women during their first week of substance abuse treatment and again approximately 7 weeks later, following parenting skills training. The questionnaire was designed to assess whether group and individual parenting sessions changed the subjects' knowledge and beliefs in four parenting domains: newborn care, feeding practices, child development and drug abuse during pregnancy. Pre-intervention scores for all parenting domains were low. Post- vs. pre-intervention comparisons showed significant increases in all domain scores after individual and group parenting skills training. Preliminary results obtained from this clinic-based sample suggest that these substance abusing mothers lacked important parenting knowledge and that this knowledge improved after comprehensive substance abuse treatment that included parenting training.

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

Several instruments for diagnosing substance use disorders (SUD) have been developed, but to date none has emerged as the standard for community-based clinical studies. To select the most suitable SUD diagnostic instrument for its clinical trials, the National Drug Abuse Treatment Clinical Trials Network (CTN) implemented a procedure in which 36 university-based addiction researchers and 62 community-based addiction treatment providers evaluated and ranked five widely recognized diagnostic instruments: (1) the SUD section of the Structured Clinical Interview for DSM-IV (SCID); (2) the SUD section of the Composite International Diagnostic Interview, 2nd ed. (CIDI-2); (3) the SUD section of the Diagnostic Interview Schedule for DSM-IV Diagnosis (DIS-IV); (4) the Diagnostic Statistical Manual-IV Checklist (DSM-IV Checklist); and (5) the Substance Dependence Severity Scale (SDSS). To assist the evaluation and ranking process, key characteristics of each instrument were presented in tabular and narrative formats. Participants ranked each instrument from 1 (most preferred) to 5 (least preferred). The SCID received the best overall mean score (2.24) followed by the CIDI-2 (2.59), DIS (2.94), DSM Checklist (3.40) and the SDSS (3.83). After discussing the pragmatic and scientific advantages and disadvantages of each instrument, the CTN Steering Committee selected the CIDI-2. The selection of the CIDI-2 standardizes the collection of diagnostic data and provides a common diagnostic tool for practitioners and clinical researchers in the CTN. Implications for practice/research collaboration and initiatives are explored.

Randomized trial of buprenorphine for treatment of concurrent opiate and cocaine dependence

BACKGROUND

Buprenorphine is a partial mu-opiate agonist and kappa-opiate antagonist with established efficacy in the treatment of opiate dependence. Its efficacy for cocaine dependence is uncertain. This study evaluated buprenorphine for the treatment of concomitant cocaine and opiate dependence.

METHODS

Two hundred outpatients currently dependent on both cocaine and opiates were randomly assigned to double-blind groups receiving a sublingual solution of buprenorphine (2, 8, or 16 mg daily, or 16 mg on alternate days, or placebo), plus weekly individual drug abuse counseling, for 13 weeks. The chief outcome measures were urine concentrations of opiate and cocaine metabolites (quantitative) and proportion of urine samples positive for opiates or cocaine (qualitative). Group differences were assessed by use of mixed regression modeling.

RESULTS

The target dose of buprenorphine was achieved in 179 subjects. Subjects receiving 8 or 16 mg buprenorphine daily showed statistically significant decreases in urine morphine levels (P =.0135 for 8 mg and P <.001 for 16 mg) or benzoylecgonine concentrations (P =.0277 for 8 mg and P =.006 for 16 mg) during the maintenance phase of the study. For the 16-mg group, mean benzoylecgonine concentrations fell from 3715 ng/mL during baseline to 186 ng/mL during the withdrawal phase; mean morphine concentrations fell from 3311 ng/mL during baseline to 263 ng/mL during withdrawal. For the 8-mg group, mean benzoylecgonine concentrations fell from 6761 ng/mL during baseline to 676 ng/mL during withdrawal; mean morphine concentrations fell from 3890 ng/mL during baseline to 661 ng/mL during withdrawal. Qualitative urinalysis showed a similar pattern of results. Subjects receiving the highest dose showed concomitant decreases in both urine morphine and benzoylecgonine concentrations. There were no significant group differences in treatment retention or adverse events.

CONCLUSIONS

A sublingual buprenorphine solution at 16 mg daily is well tolerated and effective in reducing concomitant opiate and cocaine use. The therapeutic effect on cocaine use appears independent of that on opiate use.

Early risk factors for violence in Colombian adolescents

OBJECTIVE

Violence and homicide are more prevalent in Colombia, South America, than in the United States, but the role of psychosocial factors in the violent behavior of Colombian adolescents remains unclear. The objective of the study was to identify personality, familial, peer, and ecological variables associated with violence in Colombian adolescents.

METHOD

A survey of adolescents was conducted in 1995-1996. A standard self-report measure was adapted to ensure linguistic and cultural relevance. A total of 2,837 adolescents ages 12-17 years from various self-reported ethnic groups were randomly selected from the community in three Colombian cities: Bogota, Medellin, and Barranquilla. Eighty percent of eligible adolescents agreed to participate. Data were collected concerning the adolescent's personality attributes, family characteristics, peer characteristics, and ecological/cultural factors, including the availability of illicit drugs and the prevalence of violence in the community. The dependent variable was the adolescent's self-reported frequency of violent behavior.

RESULTS

Violence directed at the adolescent and the adolescent's own drug use were both more highly correlated with the adolescent's violent behavior than were other risk factors. Significant risk factors of less importance included tolerance of deviance, peer drug use, peer deviance, and exposure to violence on television.

CONCLUSIONS

The results supported a model in which violent behavior was correlated independently with a number of risk factors from several domains. The findings point to the use of specific intervention procedures for adolescents to prevent their own subsequent acts of violent behavior.

Demographic and practice characteristics of psychiatrists who primarily treat patients with substance use disorders

This study examined the sociodemographic and practice characteristics of psychiatrists whose caseloads consist primarily of patients with Substance Use Disorders (SUD). A survey instrument was completed by a random sample of 865 psychiatrists. Study groups were defined as high-SUD providers if psychiatrists reported having 51% or more patients with SUD (n=92) and non-SUD providers as those who reported not having any patients with SUD (n=128). High-SUD providers tended to be younger, more likely to graduate from international medical schools, have larger caseloads, work more hours per week, and have a higher proportion of inpatients and publicly funded patients than non-SUD providers. Results suggest that psychiatrists who primarily treat patients with SUD are in their early careers and treat patients with more clinical, psychosocial, and economic disadvantages. The implications of these findings for psychiatry training programs and policy makers will be discussed.

Heroin detoxification with buprenorphine on an inpatient psychiatric unit

The purpose of this open-label, uncontrolled study was to evaluate the feasibility of administering off-label buprenorphine in combination with ancillary medications for inpatient short-term detoxification of heroin-dependent patients at a psychiatric facility. A sample of 20 heroin-dependent patients admitted to an urban psychiatric hospital was administered buprenorphine 6, 4, and 2 mg/day during the first, second, and third day of detoxification, respectively, and then observed during the fourth and fifth day. Eighty-five percent of the subjects abused other substances, 75% reported cocaine abuse/dependence, 75% had comorbid mood disorders. All subjects completed the medication phase of the study. No clinically significant adverse events were reported. There was a significant decrease in the Clinical Investigation Narcotic Assessment (CINA) total score between baseline and days 2 through 5. The results suggest that buprenorphine is well tolerated and may be beneficial for medically supervised short-term withdrawal from heroin for hospitalized psychiatric patients.

Health services implications of DNA testing

This review article summarizes the state of the art in genetic testing and discusses the many issues that new technologies have raised. A health services perspective is offered to aid in providing laboratorians with an understanding of the dilemma that society faces with the exponential advances in knowledge. Unmistakably, these new technologies are a mixed blessing: on the one hand, diagnoses can be made with greater accuracy and preventive measures implemented more fruitfully and individuals may be more conclusively identified and/or exonerated for forensic purposes. On the other hand, however, are the very real concerns that discrimination under a medical guise will be encouraged and that privacy rights may be compromised. Another important issue is how the laboratory profession will serve in moving these new technologies from research to practice. We examine the role of the CLS in moving forward to a role of patient counselor and advocate in the emerging complex world of DNA-related biotechnology.

Open-label pilot study of bupropion plus bromocriptine for treatment of cocaine dependence

Combinations of medications are often used in neuropsychiatry to enhance treatment efficacy. This 8-week, open-label study tested the combination of bupropion (< or =300 mg) and bromocriptine (< or =7.5 mg) daily in 34 cocaine-dependent (DSM-IIIR) outpatients also receiving weekly individual counseling. The first 18 subjects spent one week at maximum dose; the next 16 spent three weeks. Both groups showed significant reductions in self-reported cocaine use, with no significant change in proportion of urine toxicology tests positive for cocaine. There were no significant differences in outcome between groups. These results suggest that the combination of bupropion and bromocriptine is safe in cocaine addicts, but provide ambiguous evidence of its efficacy.

Changes in economically disadvantaged adolescents' knowledge and beliefs about HIV/AIDS

PURPOSE

The purpose of this study was to compare HIV/AIDS related knowledge and beliefs in two cohorts of economically disadvantaged adolescents (n = 132). Participants were between 15 and 21 years old, predominately African-American and Hispanic, and participants in a Job Training Partnership Act (JTPA) summer program. The hypothesis was that adolescent HIV/AIDS-related knowledge would be higher in 1999 than in 1994.

METHODS

A cohort of sixty-six (66) adolescents were surveyed in 1994 and another cohort of 66 adolescents was surveyed again in 1999, all participating in the JTPA program. Participants' knowledge and beliefs were assessed using the National Adolescent Student Health Survey.

RESULTS

A statistically significant increase in overall HIV/AIDS knowledge occurred between the two measurements. Fifty-five percent (55.6%) of the 1999 cohort believed that HIV could be contracted by donating blood, compared to 47.5% of the 1994 cohort. Belief that it is more likely to become infected with the AIDS virus through male to male sex was higher in 1999 by 2% and was 10% higher for female to female sex.

CONCLUSIONS

Adolescent misconceptions/misinformation, gender-based lack of knowledge, increased perception of immunity from HIV infection, and a reported reduction in health education courses were all factors in the adolescents' continued engagement in risky sexual activities. Given these findings, and that AIDS is predicted to be one of the top five causes of death among young people, increased gender- and ethnic-specific HIV intervention programs are recommended.

A comparison of psychosocial barriers among welfare recipients: implications for drug treatment

Implementation of Temporary Assistance for Needy Families (TANF) presents welfare recipients with time-limited benefits and work requirements. However, it is estimated that over 140,000 welfare recipients meet the DSM-IV criteria for "drug dependence". In this study, samples of chronic drug using and non-drug using female TANF recipients were compared with regard to: current employment, psychological functioning, self-perceived employment skills, barriers to employment, and need for help in seeking employment. It was found that non-drug using study participants were significantly more likely to be employed and reported significantly higher self-perceived work skills than users. Chronic users reported significantly greater barriers to seeking employment.

Clinical and cerebral blood flow changes in catatonic patients treated with ECT

OBJECTIVE

To determine changes in clinical manifestations and cerebral blood flow (CBF) before and after administration of ECT to patients with catatonia due to schizophrenia or mood disorders.

METHODS

A sample of nine patients who met DSM-IV criteria for catatonia was studied. Patients received between 5 and 15 sessions (thrice per week) of ECT. Severity of catatonia was measured with the Modified Rogers Scale (MRS). Changes in CBF were measured with a brain single positron emission computer tomography (SPECT) that was performed 1 week before the first ECT and 1 week after the last ECT.

RESULTS

Catatonia was due to schizophrenia in five patients and mood disorders in four patients. There were no significant clinical and brain SPECT differences between these two groups before treatment. Pre- vs. post-ECT comparisons showed significant reduction of catatonic symptoms in both groups. However, patients with mood disorders needed less ECT sessions and showed greater clinical improvement. Brain SPECT showed significant increase in CBF in parietal, temporal, and occipital regions in patients with mood disorder and no significant changes in patients with schizophrenia.

CONCLUSIONS

These results support the efficacy of ECT for treatment of catatonic patients, especially secondary to mood disorders, which seem to be correlated with improvements in CBF.

Partner concordance in reports of joint risk behaviors

OBJECTIVE

To evaluate the accuracy of self reports on sexual and drug use behaviors.

METHODS

Data from a network study of HIV transmission among a sample of drug users and nonusers are used to compare reports of sexual and drug use behaviors by partners who engaged in those behaviors. Partner concordance (self-report agreement between two people) was used as an estimate of validity.

RESULTS

Results showed that persons are able to recall and report about 85% of their recent partners (15%-20% less for recent drug use partners). For relationships that were reported by both partners, a high degree of concordance existed about recent behaviors (83%-96%) and variable agreement about frequency (0.48 </= r </= 0.86). When the time between interviews was longer, then recall, behavioral concordance, and agreement about frequency were lower.

CONCLUSIONS

Underreporting of sex and drug partners may make HIV prevention and intervention efforts more difficult if risk partners cannot be identified. The ability to reach out to all affected partners is critical in the effort to contain any epidemic. Underreporting may also skew epidemiologic projections on which many policy decisions are made.

Psychiatric care of patients with depression and comorbid substance use disorders

BACKGROUND

The goal of this study was to describe the sociodemographic and clinical characteristics and routine psychiatric care of depressed patients with or without substance use disorders (SUDs) and to assess the association between the presence of comorbid SUD and the psychiatric management of patients with depression.

METHOD

Each of a sample of 531 psychiatrists participating in the Practice Research Network (PRN) of the American Psychiatric Institute for Research and Education was asked to provide information about 3 randomly chosen patients. Data were collected using a self-administered questionnaire, which generated detailed diagnostic and clinical data on 1228 psychiatric patients. Weighted data were analyzed using the SUDAAN software package. Multivariate logistic regression was used to compare depressed patients with and without SUD.

RESULTS

A total of 595 patients (48.4%) were diagnosed with depression (DSM-IV criteria). The prevalence of SUD (excluding nicotine dependence) in this group was 18.1%. The group with SUD had a significantly larger proportion of males, young adults, patients seen in public general hospitals, and non-managed care public plans. No significant group differences were found for primary payer, locus of care, length of treatment, type of current or past treatment, and prescription of medications. Only 2.2% of SUD patients were prescribed with an anti-SUD medication (i.e., disulfiram and naltrexone).

CONCLUSION

Concomitant SUDs have little effect on the routine psychiatric care of depressed patients. Efforts should be made to improve the identification and management of depressed patients with SUD.

Labor force participation in a sample of substance users

This paper reviews the microeconomic theory underlying the work/leisure tradeoff and how this tradeoff may be manifested among substance users. The effects of drug use, demographic factors, and income factors on the probability of labor force participation are analyzed in a sample of 687 male and 327 female drug users. The decision not to seek employment appears to be associated primarily with non-job-related sources of income (including illegal sources).

Age and HIV risk in a national sample of injection drug and crack cocaine users

A national sample of 25,106 out-of-treatment crack cocaine and injection drug users was examined to determine the effect of aging on HIV risk behavior. Injectors and crack cocaine users aged 55 and over were compared to those who were aged 18 to 54 years of age. Results showed that the behavior risk of older persons did not differ substantially from those reported by other age groups, and that injection risk rose steadily along with age for all ages represented in the sample. The authors conclude that older persons who use illegal drugs remain at elevated risk for HIV compared to the general population, and may be in need of more targeted intervention strategies.

Normative influence on condom use in the personal networks of female cocaine smokers

Attitudes-norms research (the theories of planned behavior and reasoned action) has been successful in accounting for many types of behavior change. One of the strengths of this approach has been to combine individual beliefs and normative influences in the explanation of behavior change. However, the conceptualization of normative influence in these theories makes very strong assumptions about self-awareness in the selection of normative referents. These assumptions are particularly problematic when applied to female cocaine smokers, who report frequent sex while under duress or while cognitively impaired. In this study the original conceptualization of normative influence and two alternatives (assuming emotion-based and interaction-based selection of normative referents) are operationalized to evaluate stage of change for condom use among women who are heavy crack cocaine users with multiple sex partners. Results show that stage of change for use of condoms with nonmain partners is best accounted for by interaction-based selection of normative referents.

Pathological gambling among cocaine-dependent outpatients

OBJECTIVE

The authors investigated the occurrence of pathological gambling among cocaine-dependent outpatients, its influence on short-term outcome of treatment, and comparative characteristics of patients with and without pathological gambling.

METHOD

The subjects were 313 cocaine-dependent (200 also opiate-dependent) outpatients in clinical trials of medication for cocaine dependence. Pathological gambling (DSM-III-R criteria) was assessed with the Diagnostic Interview Schedule, and sociodemographic and socioeconomic characteristics were determined with the Addiction Severity Index. Outcome was defined as time in treatment (proportion of maximum scheduled time) and proportion of cocaine-positive urine samples during treatment.

RESULTS

Pathological gambling had a lifetime occurrence rate of 8.0% and a current (past month) occurrence of 3.8%. Onset preceded the onset of cocaine dependence in 72.0% of the patients (and preceded onset of opiate dependence in 44.4%). Patients with pathological gambling (lifetime or current) did not differ significantly from other patients in length of treatment or proportion of cocaine-positive urine samples. Those with lifetime pathological gambling were significantly more likely to have tobacco dependence (84.0% versus 61.1%) and antisocial personality disorder (56.0% versus 19.8%), to be unemployed (84.0% versus 49.3%), to have recently engaged in illegal activity for profit (64.0% versus 38.5%), and to have been incarcerated (62.5% versus 33.9%).

CONCLUSIONS

Pathological gambling is substantially more prevalent among cocaine-dependent outpatients than in the general population. Patients with pathological gambling differ from other cocaine-dependent outpatients in some sociodemographic characteristics but not in short-term outcome of treatment for cocaine dependence.

Economics as a factor in models of behavioral motivation and change

This note first presents a summary of four main behavioral models that are used to explain behavioral motivation and change. Three models are based on psychosocial theory. They are: 1) the Theory of Reasoned Action, 2) the Theory of Planned Behavior, and 3) the Theory of Stages-of-Change. The fourth model is based on economic theory and is known as the Rational Addiction Model. Each model is analyzed for its strengths and weaknesses. The note concludes by arguing for the usefulness of integrating the economic and the psychosocial models to study drug use. Specific examples and suggestions are presented.

Access as a managed care marketing outcomes measure

As their position in the health care market diminishes, HMOs are feeling the pinch from the competition. Purchasers of health plans have many more options available today than in the past. Employers can select from single or consolidated health plans, plans offered by coalitions, or plans offered by provider systems. Following closely behind the withstanding issue of controlling costs is quality of care and customer satisfaction. The bad press surrounding managed care is making employers demand assurances that employees will receive the best quality of care their money can buy. To assist in this endeavor managed care companies are focusing more on their customers. To this end marketers use report cards to assess purchaser and enrollee satisfactions, with the hope that if they have a happy customer, s/he will be a loyal one. This paper reviews current marketing strategies of managed care companies and their level of usefulness with respect to sustaining customers and hence market share.

A 12-year follow-up of a methadone medical maintenance program

Methadone Medical Maintenance (MDM) is an alternative for treatment of stable methadone maintained individuals. It involves a monthly physician's visit, at which methadone take-home doses are dispensed to last until the next appointment. The safety and efficacy of this treatment modality is currently under investigation. The purpose of this study was to evaluate the long-term safety and efficacy of MDM in a methadone program in Baltimore. A sample of 21 patients was enrolled in the study and followed for 12 years. They were evaluated once a month by a primary care physician affiliated with a methadone clinic who collected urine toxicology samples and dispensed the monthly methadone dose. The results showed that only 6 (28.6%) patients dropped out during the 12 years of the study. Twelve (0.5%) of 2,290 urine samples collected were positive for drugs. No methadone overdose or diversion was observed. Participants reported significant improvement in their quality of life. The results of this study support the safety and efficacy of medical maintenance of stable methadone maintained individuals.

Naltrexone shortened opioid detoxification with buprenorphine

This double-blind, randomized, placebo-controlled clinical trial evaluated the impact on withdrawal symptoms of (i) combining naltrexone with a 4-day buprenorphine taper for short opioid detoxification (NB Group), compared to (ii) using a 4-day buprenorphine taper alone, followed by naltrexone on day 8 (PB Group). Sublingual buprenorphine was administered on days 1-4 (26 mg total). For the NB Group (n = 32) escalating doses of oral naltrexone were given on days 2-8 (placebo day 1). For the PB Group (n = 28) placebo was given on days 1-7 and naltrexone on day 8. Main outcome measures were Observed Opioid Withdrawal scores (OOW, 0-30) and use of medications to treat opioid withdrawal. Of 32 patients in the NB group, 59% experienced clinically relevant withdrawal (defined as OOW > or = 5) on day 2, but, after day 5, none experienced withdrawal. In the PB group, the number of patients experiencing withdrawal increased over time. The first naltrexone dose induced comparable withdrawal in both groups: peak OOW scores were (mean +/- SD) 5.2 +/- 3.3 on day 2 for the NB group, and 4.0 +/- 3.9 on day 8 for the PB group (NS), though, on day 2, 7 patients dropped out in the NB group and none in the PB group, while only one patient dropped out in the PB group on day 8. Throughout the 8-day study, patients in both groups received similar amount of adjunct medication: 0.64 +/- 0.07 mg (NB group) of clonidine vs 0.73 +/- 0.15 mg (PB group; NS). Only 25% of patients required use of sedatives (up to 20 mg diazepam). Starting naltrexone on day 2 appeared to abolish withdrawal symptoms after day 5 and, thus, to shorten the duration of withdrawal symptoms. Peak withdrawal symptoms after naltrexone were of moderate intensity, suggesting that naltrexone combined with buprenorphine is an acceptable and safe treatment for shortened opioid detoxification and induction of naltrexone maintenance.

Access to HIV services by the urban poor

This paper examines the effect of HIV-health status and HIV-transmission mode on access to HIV-related services among African Americans, Hispanics and White HIV+ individuals. Data were collected from 169 African Americans, 72 Hispanics and 253 White HIV+ individuals seeking 8 social and 6 medical HIV services at 29 public and community-based organizations in Houston, Texas. A total of 42 separate logistic regressions were estimated for each HIV service and for each race/ethnic group. The results showed significant differences in access to HIV social services based on HIV-transmission mode among the three race/ethnic groups, but no significant differences were found in access to medical services based on either HIV status or HIV-transmission mode among the three race/ethnic groups.

A framework for assessing the effectiveness, efficiency, and equity of behavioral healthcare

OBJECTIVE

To evaluate the effectiveness, efficiency, and equity of behavioral healthcare and to guide an assessment of the current state of the art of behavioral health-oriented health services research.

STUDY DESIGN

The framework is grounded in previous conceptual work by the authors in defining a prevention- and outcomes-oriented continuum of healthcare and in identifying and integrating the concepts and methods of health services research and policy analysis for assessing healthcare system performance.

PATIENTS AND METHODS

The defining assumptions are that (1) the denominator for behavioral healthcare services must encompass a look at the population, not just the patients, who manifest behavioral health risks; and (2) the delivery system to address these needs must extend beyond acute, treatment-oriented services to include both primary prevention and aftercare services for chronic relapsing conditions.

RESULTS

Current policy and practice in behavioral healthcare reveal the absence of a comprehensive, coordinated continuum of care; substantial variation in policy and financial incentives to encourage such development; and poorly defined or articulated outcome goals and objectives. The current state of the art of research in this area reflects considerable imprecision in conceptualizing and measuring the effectiveness, efficiency, and equity criteria. Further, these 3 criteria have not been examined together in evaluating system performance.

CONCLUSIONS

The first era of behavioral healthcare focused on cost savings in managed care alternatives; the second is focusing on quality and outcomes; a third must consider the issues of equity and access to behavioral healthcare, especially for the most seriously ill and vulnerable, in an increasingly managed care-dominated public and private policy environment.

Alternative medicine as a carve-out in managed care

A major philosophical shift continues to occur in how health care is delivered in the United States. Traditional western medicine continues to develop new technologies that require new delivery systems, however, other factors are affecting this shift as well. Alternative medicine is one of these factors and is rapidly gaining attention. Alternative medicine is comprised of homeopathy, chiropractic, naturopathy, and cultural beliefs and practices such as those of the Native Americans or the Mexican Folk healers. Several managed care plans are now including alternative medicine as part of their product lines. Employers are moving from a passive role to an aggressive one in the selection of health care services available to their work force. This is in response to the changing demographics of the United States and the increased sensitivity to diversity in the work-place. Managed care companies have a marketing opportunity to increase their share of the market by looking at alternative medicine as a new product line designed to attract new subscribers. As with behavioral medicine, alternative medicine does not fit into the systems developed for delivering medical-surgical services. It, however, does not fit the systems developed for behavioral medicine either and appears to be a carve-out onto itself.

The role of parents in protecting Colombian adolescents from delinquency and marijuana use

OBJECTIVES

To identify general and differentiating risk and protective factors from domains of culture and ecology, peer, family, and personality, related to adolescent delinquency and marijuana use, and to study the protective role of the parent-child mutual attachment in offsetting cultural and ecological risk factors, leading to less delinquency and marijuana use.

DESIGN

Cross-sectional analyses of interview data collected in Colombia.

PARTICIPANTS

A total of 2837 Colombian adolescents, 12 to 17 years of age.

SETTING

Adolescents were interviewed in their homes.

MAIN MEASURES

Independent variables included measures from 4 domains: culture and ecology, peer, family, and personality. The dependent variables were delinquency and marijuana use.

RESULTS

Several risk factors, such as tolerance of deviance and sensation seeking, were similarly related to both delinquency and marijuana use, suggesting that a common cause underlies the propensity to engage in different deviant behaviors. Some risk factors were more involved in delinquency and other risk factors were more highly related to the adolescent's marijuana use. Finally, when violence is endemic and illegal drugs are readily available, a close parent-child bond was capable of mitigating these risk factors, leading to less marijuana use and delinquency.

CONCLUSIONS

The findings have implications for public health policy related to interventions in countries in which violence and drug use are prevalent. The results point to interventional procedures aimed at adolescents vulnerable to marijuana use and delinquency as well as efforts aimed at specific vulnerabilities in these areas. For example, reducing the risk factors and enhancing the protective factors for marijuana use and delinquency may result in less adolescent marijuana use and delinquency.

Estimated HIV risk among Hispanics in a national sample of drug users

OBJECTIVE

To estimate and compare the HIV risks among three Hispanic subpopulations.

METHODS

Chronic drug users participating in a nationwide intervention study on drug use were interviewed with regard to drug use and sexual behavior. HIV risk was estimated using information about individuals' HIV-relevant behaviors, the social context (i.e., city) in which such behaviors occur, and published estimates of HIV transmission for various risk behaviors. Multiple linear regression analysis was used to investigate differences in estimated HIV risk between Puerto Rican, Mexican-American, and Mexican drug users, accounting for sociodemographic factors, sexual preference, and geographic region.

RESULTS

Puerto Ricans had significantly greater estimated overall HIV risk, estimated injection risk, and in general, significantly greater estimated sexual risk than Mexican Americans and Mexicans. No significant differences were found in any estimated risk between Mexican Americans and Mexicans in this sample. No significant differences were found among any of the subgroups for estimated risk from having anal sex while using a condom, or from having receptive anal sex without using a condom.

CONCLUSIONS

These findings suggest that Puerto Ricans who use drugs experience a higher risk of HIV infection than other Hispanic drug users. Research is needed to identify which economic, social, and cultural components account for this increased risk.

Improvement in naltrexone treatment compliance with contingency management

The efficacy of a voucher-based incentive program for improving adherence to outpatient, thrice weekly naltrexone maintenance was tested in a three group, randomized, 12-week clinical trial. Voucher incentives were given as follows: contingent group (n = 19) for each consecutive naltrexone dose ingested; non-contingent group (n = 19) on unpredictable schedule independently of taking naltrexone; no-voucher group (n = 20) none. Vouchers were exchangeable for goods and services. The contingent group had significantly longer treatment retention and ingested significantly more doses of naltrexone (consecutive and total) than either control group. Voucher incentives can significantly increase adherence to naltrexone maintenance in recently detoxified opioid dependent individuals.

Broad beneficial effects of cocaine abstinence reinforcement among methadone patients

Escalating reinforcement for sustained abstinence has been effective in treating cocaine abuse. Under this schedule, patients receive vouchers for cocaine-free urine samples; vouchers have monetary values that increase with the number of consecutive cocaine-free urine samples. Cocaine-abusing methadone patients were randomly assigned to receive vouchers for 12 weeks under (a) an escalating schedule (n = 20), (b) an escalating schedule with start-up bonuses (n = 20), or (c) a noncontingent schedule (n = 19). Start-up bonuses were designed to provide added reinforcement for initiating abstinence; however, they did not improve outcomes. Both contingent interventions significantly increased cocaine abstinence. In addition, the contingent interventions increased abstinence from opiates and decreased reports of cocaine craving. These results replicate the efficacy of cocaine abstinence reinforcement and show that it can have broad beneficial effects.

An analysis of drug abuse policies in teaching hospitals

The Drug-Free Workplace Act of 1988 mandated written drug abuse policies for recipients of certain government grants and contracts. The literature has reported costly side effects of employee drug abuse such as decreased productivity and increased use of health benefits. Furthermore, litigation involving drug abuse policies has been increasingly won by employers. More than 90% of Fortune 1000 companies have adopted formal drug abuse policies. Using content analysis techniques, the current study examined the written substance abuse policies of 30 large American teaching hospitals. Results showed substantial variation in the style and content of the policies. In general, language used in the policies was vague. The study cites the potential use of strategic ambiguity in the development of the policies.

The motivation for drug abuse treatment: testing cognitive and 12-step theories

The purpose of this paper is to evaluate two models of behavior change: cognitive theory and 12-step theory. Research subjects were drawn from three separate, but parallel, samples of adults. The first sample consisted of out-of-treatment chronic drug users, the second consisted of drug users who had applied for treatment at a publicly funded multiple-provider drug treatment facility, and the third consisted of drug users who had applied for treatment at an intensive outpatient program for crack cocaine users. Cognitive theory was supported. Study participants applying for drug abuse treatment reported a higher level of perceived problem severity and a higher level of cognitive functioning than out-of-treatment drug users. Two hypotheses drawn from 12-step theory were not supported. Treatment applicants had more positive emotional functioning than out-of-treatment drug users, and one treatment-seeking sample had higher self-esteem.

Hematological considerations in out-of-treatment drug users

Complete blood counts (CBCs) were performed on 215 out-of-treatment injecting and noninjecting drug users participating in a federally sponsored human immunodeficiency virus (HIV) risk-reduction program in Houston, Texas. A substantial proportion of patients/clients were found to be suffering from varying degrees of anemia and other hematological conditions. Anemia is known to affect cognitive skills such as the ability to concentrate and process information. This impairment can limit the effectiveness of drug intervention and treatment, even among those users eager to participate in intervention or treatment programs. Consideration of substance users' physical condition as manifested by hematological measures can provide an important compliment to health behavioral models that stress cognitive functioning without consideration of the underlying physical processes involved.

Broad beneficial effects of cocaine abstinence reinforcement among methadone patients

Escalating reinforcement for sustained abstinence has been effective in treating cocaine abuse. Under this schedule, patients receive vouchers for cocaine-free urine samples; vouchers have monetary values that increase with the number of consecutive cocaine-free urine samples. Cocaine-abusing methadone patients were randomly assigned to receive vouchers for 12 weeks under (a) an escalating schedule (n = 20), (b) an escalating schedule with start-up bonuses (n = 20), or (c) a noncontingent schedule (n = 19). Start-up bonuses were designed to provide added reinforcement for initiating abstinence; however, they did not improve outcomes. Both contingent interventions significantly increased cocaine abstinence. In addition, the contingent interventions increased abstinence from opiates and decreased reports of cocaine craving. These results replicate the efficacy of cocaine abstinence reinforcement and show that it can have broad beneficial effects.

Infectious diseases and anemia in a sample of out-of-treatment drug users

OBJECTIVE

To understand how the prevalence of anemia, human immunodeficiency virus (HIV), and syphilis in a sample of out-of-treatment drug users affected delivery of care in a managed care model.

STUDY DESIGN

A snowball sampling design with multiple zero order contacts was used in targeted census tracts with a high incidence of illicit drug use and sexually transmitted diseases.

PATIENTS AND METHODS

Out-of-treatment drug users were recruited as part of a national multisite study of HIV risk behaviors in this population. Subjects were recruited using targeted community-based sampling.

RESULTS

The rate of individuals who tested positive for both syphilis and HIV was 2.5 times greater than those who tested positive for syphilis only and 2.8 times greater than those who tested positive for HIV only. Of the men, 16.1% were anemic, and 33.3% of women were anemic. Rates of HIV (10.7%) and syphilis (19.8%) were found to be high among both male and female drug users. These statistics, coupled with the prevalence of anemia, indicate that drug users have many more problems other than drug use, a conclusion which can have an impact on how managed care plans approach drug users.

CONCLUSION

A multipronged interdisciplinary approach may be warranted for both the patient and the managed care organization.

Charitable care and the nonprofit paradigm

Nonprofit hospitals have begun to focus once again on serving the health needs of their communities. Governmental needs for additional revenue and for-profit hospitals' contention that tax exemptions give nonprofit hospitals an unfair competitive advantage have resulted in changes in laws and regulations and have caused a change in the role of nonprofit hospitals. As local governments become more responsive to the health needs of their communities, they are requiring nonprofit hospitals to become more responsive as well. Laws, regulations, and court decisions have begun to require nonprofit hospitals to provide charity care and services at levels equal to the amount of their exempt taxes. In response, nonprofit hospitals are developing community benefit programs and public health services.

Social network ties, self-efficacy, and condom use among women who use crack cocaine: a pilot study

So far, attempts to change the sexual risk behavior of women who use crack cocaine have been less successful than efforts to change the needle risk behavior of injection drug users. Two theoretical areas that have shown some success in predicting behavior change among of out-of-treatment drug users are Bandura's social cognitive theory (self-efficacy theory) and social network theory. According to Bandura, social networks are important sources of social support, and social support is vital to self-efficacy. Social network research also indicates that close bonds with network members may be a protective factor independently of self-efficacy. In order to test the feasibility of collecting such data, a pilot study was conducted with 60 women who used crack cocaine and who were not in treatment. Results of Pearson product-moment correlations indicated that self-efficacy (.7230) and number of very strong ties (.31252994) were positively correlated with condom use for women in the sample. In addition, the number of very strong ties (.3142) was significantly, if modestly, correlated with self-efficacy. Self-efficacy was

Barriers to social services for HIV-infected urban migrators

Anecdotal accounts suggest that residency requirements often lead to denial of services at a time when HIV positive migrators are most in need of these services. However, this suspicion has never been empirically tested. Using needs assessment data collected for Harris County, Texas, this article examines eligibility and knowledge barriers faced by HIV positive recent migrators into Harris County. Results indicated that migration into the county was a significant predictor of failure to receive government-administered basic services such as food services but was not a significant predictor of failure to receive community based organization (CBO)-administered "specialized" services targeted specifically to HIV positive individuals. Results also indicated that migration was associated with knowledge barriers for all types of services.

Pathways to marijuana use among adolescents: cultural/ecological, family, peer, and personality influences

OBJECTIVE

To examine the linkages, cultural/ecological factors, and major psychosocial risk factors as they relate to drug use in a sample from Colombia, South America.

METHOD

The participants were 1.687 adolescents living in mixed urban-rural communities in Colombia, South America. An individual interview was administered to youths in their homes by Colombian interviewers. The scales used were based on item intercorrelations grouped into the following risk categories: (1) adolescent personality, (2) family traits, (3) peer factors, and (4) cultural/ecological variables.

RESULTS

Pearson correlations were computed for each variable and the frequency of marijuana use. Results show that each of the domains was related to adolescent marijuana use, with some notable gender differences. As regards the interrelation of domains, a mediational model was operative.

CONCLUSIONS

Findings support a family interactional theory. The domains of family, personality, and peer factors had a direct effect on the adolescents' marijuana use. Implications for prevention are also addressed.