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Background: Spirituality is a construct encompassing a diversity of strongly held beliefs and pursuits related to life's meaning and purpose. Empirical studies in key domains of spirituality related to substance use disorder (SUD) can be valuable in guiding research, and potentially clinical care., Objectives: To conduct a scoping review of research on the psychological, biological, and cultural dimensions of spirituality and their role in relation to SUD. To identify limitations in empirical findings within these domains and identify promising areas for related research., Data Sources, Study Appraisal, and Synthesis Methods: Illustrative studies available in the empirical literature are reviewed in order to characterize these three key domains., Results: Certain areas of importance stand out: On Psychology, attribution of SUD to a spiritual outlook; spiritual awakening; the relation of spirituality to drug craving; and spirituality in the context of psychedelic-assisted psychotherapy. On Biology, heritability of traits related to shared spiritual experience; neurophysiologic correlates of spiritually related experiences; and correlates in brain imaging; On Culture, spiritual aspects of SUD in different cultural settings; distinctions between spiritual and religious phenomena; roles that international organizations play; and context of acquiring recovery capital. The need for further research in each area is defined., Conclusions: There is utility in examining the diversity of findings in the roles of psychology, biology, and culture in the SUD field. Further research, particularly applying randomization and clinical controls, would be useful in improving the effective application of the construct of spirituality in clinical care.

Background: A Zoom-based website was developed in 2020 that offers continuous access to online Narcotics Anonymous (NA) meetings for the first time. This website provides immediate access for persons with substance use disorder to support abstinence from substance-related addictive disorders. Objectives: This study is designed to characterize attendees employing this online format; to evaluate their experiences for gaining support to maintain abstinence; and to compare the 24/7 experience to face-to-face (FF) meetings they attend. Methods: An anonymous 33-item survey was made available on the 24/7 NA website that links to the 24/7 meetings. Persons accessing the site could choose to fill out the survey. Results: 530 respondents completed the survey (64.9% female/35.1% male). Most had stable prior involvement in NA. They had attended more 24/7 meetings (14.9, SD 19.7) than FF meetings (4.6, SD 7.8) in the previous month. 86% had previously attended FF meetings, 48% had served as sponsors, and 92% reported that the 24/7 meetings were more comfortable for them than the FF meetings ( p  < .001, Cohen's d = 0.65) and more supportive of abstinence ( p  < .001, Cohen's d = 0.91). Of the respondents, 8% were still using drugs, of whom 52% had previously completed some of the Twelve Steps. Conclusions: The 24/7 format provides a new and easily accessible way for NA members to gain support for abstinence and is positively rated by attendees seeking support for recovery from substance use disorders. It may serve as a valuable adjunct to the traditional FF format.

Background: The Twelve Steps described by Narcotics Anonymous (NA) and Alcoholics Anonymous denote key aspects of how members can achieve abstinence from alcohol and other drugs. However, there are limited empirical findings on what long-term members rely on to support their ongoing recovery. Method: In order to clarify the members' reliance on those latter resources, we surveyed 2,293 long-term NA members through the internet on items they rely on for their recovery. They scored nine NA-related resources (e.g., their sponsor) and three non-NA institutional ones (e.g., a professional therapist). Results: Three factors accounted for 53.6% of the variance in the respondents' scores of the 12 items. We labeled them, with the percent of variance accorded, as NA-based social (24.9%) support, spiritual (17.8%) support, and outside professional (10.9%) help. While NA-based resources ranked highest, outside resources (a house of worship, a therapist, or medications for psychological distress) were scored by 75.4% of the respondents. Analysis by subgroups of respondents reflected the diversity of resources members draw on. The use of internet-based meetings during the COVID-19 period reflected the resilience of the NA format. Conclusion: Members of Twelve Step programs can be studied to shed light on options that they rely on for support for their ongoing recovery, both within the fellowships and outside them. Long-term members can apparently rely on resources inside the fellowship and simultaneously on professional ones, as well. These findings can be helpful for researchers in considering mechanisms that underlie long-term Twelve Step-related recovery and for clinicians in employing both these fellowships and outside resources as adjuncts to their professional care.

Background : The term God, included in 5 of the 12 Steps of Narcotics Anonymous (NA) and Alcoholics Anonymous (AA), self-designated spiritual fellowships, has not been studied empirically relative to members' experiences. A greater understanding of this can be clinically useful and can shed light on the 12 Step process of recovery. Objectives : To determine how NA members understand the 12-step concept "God as we understood Him" and the relationship between their understanding of God and the intensity of their craving and depressive symptoms." Methods : 450 (59% male) NA members completed a survey related to their experiences relative to their relationship with "God." The relationship among these variables and comparisons to the general population was analyzed. Craving and depressive symptoms were assessed by self-report. Results : 98% of the NA participants believe in God explicitly or some other higher power (vs 89% of a probability sample of the US population), 67% believe that God determines what happens to them some or all of the time (vs 48%), 78% (vs 28%) report hearing God talking to them "in their mind"; and 37% report that God talks to them "out loud." Acceptance of 12 Step God-related variables inversely predicted a significant portion of the variance of scores on craving (7.5%) and depression (13.5%). Conclusions : Respondents' understanding of God in NA varied considerably and was predictive of their depressive symptoms and craving intensity. These findings can serve as a basis for research into mechanisms underlying NA/AA recovery experiences and can also aid clinicians in how to employ these programs.

Objectives: Despite growing concerns for non-medical use of prescription pain relievers (NMUPPRs), little is known about the role of comorbid, untreated depressive disorders., Methods: We examined past year rates of NMUPPRs and major depressive episode (MDE), using data between 2008 and 2014 from the National Survey on Drug Use and Health for both youths (12-17 years) and adults (18 or older). Prevalence estimates with 95% confidence intervals were computed. Stratified analyses and generalized linear models were run to examine the association between NMUPPRs and MDE, controlling for treatments received for mental health and/or substance misuse. In order to explore whether MDE effect might change by treatment received, a model with an interaction term including MDE and treatment was fit., Results: Among respondents, about 9% (youths) and 7% (adults) reported past year MDE and about 6% (youths), and 4% (adults) NMUPPRs. About 1.2% (youths) and 0.7% (adults) reported both MDE and NMUPPRs. Those with past year MDE were more likely to report NMUPPRs (RR, 95%CI: 2.60, 2.42-2.80, and 2.64, 2.47-2.82, for youths and adults). Considering the any treatment/MDE interaction on NMUPPRs, MDE risk ratio for subjects who received some treatment (youths: adjusted risk ratio (ARR) = 1.15; adults: ARR = 1.25) was about 70-80% as compared with their untreated counterpart (youths: ARR = 1.57; adults: ARR = 1.54). The likelihood of reporting NMUPPRs amongst respondents who did not receive any treatment was higher for those with past year MDE (main effect: youths ARR = 1.57, p < 0.001; adults ARR = 1.54, p < 0.001)., Conclusion: Unrecognized and untreated depressive disorders should be considered for prevention, treatment, and policy implications in order to tackle NMUPPRs epidemic.

Background: People with severe substance use disorders require long-term rehabilitative care after the initial treatment. There is, however, a deficit in the availability of such care. This may be due both to inadequate medical coverage and insufficient use of community-based Twelve-Step programs in many treatment facilities. In order to address this deficit, rehabilitative care for severe substance use disorders could be promoted through collaboration between practitioners of medically assisted treatment, employing medications, and Twelve-Step-oriented practitioners., Objective: To describe the limitations and benefits in applying biomedical approaches and Twelve-Step resources in the rehabilitation of persons with severe substance use disorders; and to assess how the two approaches can be employed together to improve clinical outcome., Method: Empirical literature focusing on clinical and manpower issues is reviewed with regard (a) to limitations in available treatment options in ambulatory and residential addiction treatment facilities for persons with severe substance use disorders, (b) problems of long-term rehabilitation particular to opioid-dependent persons, associated with the limitations of pharmacologic approaches, (c) the relative effectiveness of biomedical and Twelve-Step approaches in the clinical context, and (d) the potential for enhanced use of these approaches, singly and in combination, to address perceived deficits., Results: The biomedical and Twelve-Step-oriented approaches are based on differing theoretical and empirically grounded models. Research-based opportunities are reviewed for improving addiction rehabilitation resources with enhanced collaboration between practitioners of these two potentially complementary practice models. This can involve medications for both acute and chronic treatment for substances for which such medications are available, and Twelve-Step-based support for abstinence and long-term rehabilitation. Clinical and Scientific Significance: Criteria for developing evidence-based approaches for combined treatment should be developed, and research for evidence-based treatment on this basis can be undertaken in order to develop improved clinical outcome.

Background: Many individuals with alcohol-use disorders who had experienced alcohol craving before joining Alcoholics Anonymous (AA) report little or no craving after becoming long-term members. Their use of AA prayers may contribute to this. Neural mechanisms underlying this process have not been delineated., Objective: To define experiential and neural correlates of diminished alcohol craving following AA prayers among members with long-term abstinence., Methods: Twenty AA members with long-term abstinence participated. Self-report measures and functional magnetic resonance imaging of differential neural response to alcohol-craving-inducing images were obtained in three conditions: after reading of AA prayers, after reading irrelevant news, and with passive viewing. Random-effects robust regressions were computed for the main effect (prayer > passive + news) and for estimating the correlations between the main effect and the self-report measures., Results: Compared to the other two conditions, the prayer condition was characterized by: less self-reported craving; increased activation in left-anterior middle frontal gyrus, left superior parietal lobule, bilateral precuneus, and bilateral posterior middle temporal gyrus. Craving following prayer was inversely correlated with activation in brain areas associated with self-referential processing and the default mode network, and with characteristics reflecting AA program involvement., Conclusion: AA members' prayer was associated with a relative reduction in self-reported craving and with concomitant engagement of neural mechanisms that reflect control of attention and emotion. These findings suggest neural processes underlying the apparent effectiveness of AA prayer.

Substance use disorder, which is often comorbid with post-traumatic stress disorder (PTSD), is a problem confronted by many veterans. To determine the potential utility of Narcotics Anonymous (NA) for veterans, 508 NA attendees were studied. Veterans (n = 172) were more likely to have been referred by a professional than were non-veterans (77% vs. 27%, respectively); 70% had been hospitalized for alcohol or drug problems, and 51% had been treated for non-substance psychological problems. The 70% of veterans who reported at least 1 of 3 service-related stressful experiences were more likely to report PTSD-related symptoms. NA can serve as a recovery resource for certain veterans with substance use disorders, with or without PTSD.

Empirical findings characterizing long-term, committed Alcoholics Anonymous (AA) members are limited, particularly among younger members. The authors studied a sample of 266 highly committed attendees (mean age, 27 years) at an annual conference of Young People in Alcoholics Anonymous (YPAA), whose first encounter with AA was 6 years previously. Most (72%) had abused drugs and alcohol, and 36% had never received substance abuse treatment. They now reported a mean duration of abstinence of 44 months and had attended an average of 233 AA meetings in the previous year; 66% had served as AA sponsors, and 92% reported experiencing an AA "spiritual awakening," itself associated with a decreased likelihood of alcohol craving. Scores on AA beliefs, affiliation to other members, and the experience of spiritual awakening were associated with lower depression scores. These findings are discussed to clarify the nature of long-term AA membership.

The purpose of this study was to determine the extent to which spiritual orientation was associated with adaptation to therapeutic community treatment. Spiritual orientation was assessed by the Spirituality Self-Rating Scale, a measure consistent with the conceptualization of spirituality typically reflected in Alcoholics Anonymous members' views. Spiritual orientation was positively correlated with acceptance of therapeutic community principles and clinical progress. Further assessment of spirituality related characteristics and their relation to treatment outcomes is important in informing the design of interventions aimed at improving progress in the therapeutic community, particularly those aspects involving the relative value of integrating the 12-Step group approach in therapeutic community programs.

Background: Relapse among patients in substance abuse treatment has generated interest in identifying attitudinal factors that sustain recovery., Objective: To assess the relationship of attitudes toward approaches to motivation for treatment and Twelve Step beliefs., Methods: Dually diagnosed patients (N = 100) completed a survey assessing treatment attitudes, motivation, and Twelve Step beliefs., Results: Endorsement of medical services was positively correlated with motivation but unrelated to Twelve Step beliefs. Endorsement of religious services was unrelated to motivation but was associated with Twelve Step beliefs., Conclusions: Patients may have differing perceptions regarding routes to recovery based on preferences for professional services or spiritual resources.

This study assesses medical students' use of and attitudes towards club drugs, classified as "Generation I" (i.e., cocaine and lysergic acid diethylamide), and "Generation II" (i.e., methylenedioxymethamphetamine [MDMA], ketamine, gamma hydroxybutyrate, methamphetamine, rohypnol, dextromethorphan) club drugs based on their initial widespread use in club settings. An anonymous questionnaire was administered to 340 medical students. The prevalence of any club drug use was 16.8%, with MDMA (11.8%) and cocaine (5.9%) the most commonly used. Results discussed also include the relationship of age and gender to having ever used club drugs and to their attitudes regarding use. Additionally, the study identifies differences in patterns of use and attitudes toward Generation I versus Generation II club drugs based on age, gender, and participants' prior club drug use. Findings are compared to those of earlier studies about medical students and those in a similar age group in the general population.

Co-occurring mental illness and addiction is very common and results in worse treatment outcomes compared to singly diagnosed addicted individuals. Integrated treatment for co-occurring disorders is associated with better treatment outcomes; however there is a wide range of what is included in integrated treatment. Due to patient and staff interests, integrated treatment often includes complementary and alternative therapies, including music and art therapy. There is a need to study how these approaches effect treatment engagement, retention, and outcome. This study was a prospective naturalistic non-randomized pilot study without a control group that sought to evaluate how participation in a music therapy program affected treatment outcomes for individuals with co-occurring mental illness and addiction. In summary, music therapy appears to be a novel motivational tool in a severely impaired inpatient sample of patients with co-occurring disorders. Future studies of music therapy in integrated co-occurring disorder setting should include a control group.

The present study evaluated a model program at Bellevue Hospital Center incorporating a peer-led self-help (PLSH) approach which can be applied to bring about systems-level change in a variety of settings where persons with dual diagnosis are encountered. A total of 461 consecutive MICA inpatient admissions were evaluated to compare the PLSH unit with two standard psychiatric units. The PLSH program was associated with a higher rate of acceptance of aftercare referral (93% vs. 74%) and aftercare attendance (52% vs. 30%) among patients with no prior psychiatric hospitalizations (N = 111). In addition, the PLSH program appeared to benefit chronically impaired MICA patients (N = 350) or those with a history of prior psychiatric hospitalizations, as they were more likely to accept referral to aftercare treatment than were chronic patients discharged from the standard psychiatric units (96% vs. 81%). Such a program, when more widely applied, could yield decreased recidivism and considerably lower medical, psychiatric, and economic cost.

This study sought to determine which adolescents being treated for substance use in a residential Therapeutic Community (TC) would endorse spirituality and Twelve Step oriented approaches as part of their treatment. By identifying individual difference characteristics associated with preference for spirituality and Twelve Step oriented approaches, integrated substance abuse treatments can be targeted to appropriate subgroups of adolescents. A total of 181 adolescents completed a survey assessing their substance use and attitudes toward spirituality and Twelve Step oriented approaches that was similar to a survey completed by 322 adults in the same residential TC program. In the adolescent sample, three spirituality related characteristics: perceived connectedness to others, frequency of prayer, and spiritual orientation to life were associated with preference for both spirituality and twelve step oriented approaches being featured more in TC treatment. Adolescents were less likely than adults to express a preference that both approaches be featured more in TC treatment.

Introduction: Alcoholics Anonymous is not yet fully employed by the medical community as a means to enhance patient outcome. The purpose of this study was to evaluate visitors' use of an Internet course on Alcoholics Anonymous, and to compare how various disciplines learned about, gained access to and participated in the course., Methods: Demographic information was collected from 414 visitors to the course., Results: 64% of the 414 respondents received their last educational degree within the last 10 years, and had an interest in the topic of addiction prior to their accessing the site. 294 (71%) of those who accessed the course completed it, and those who accessed it learned about it from various sources other than print advertisement in professional journals. Within the 230 physician respondents, 143 (62%) were psychiatrists, 82 (78%) of whom learned about the Internet course via professional journal., Discussion: Given the need for further training among physicians in the use of Alcoholics Anonymous, the Internet can be utilized to make information available to a large number of people. Because it allows the user to access information outside the traditional means, the barriers to its use are minimal, and it has the potential to effectively convey useful clinical information.

Although Alcoholics Anonymous and other Twelve-Step interventions are among the most widely utilized self-help options by persons with chemical dependency, little is known concerning whether this approach should be integrated with non-spirituality based self-help approaches. The purpose of this study was to assess the extent to which clients receiving inpatient treatment in a residential therapeutic community (TC) felt that spirituality based interventions should be featured in TC treatment. Three hundred twenty-two members of the Daytop TC completed a survey assessing personal orientation to spirituality and attitudes towards spirituality based treatments. The majority of clients believed that the TC program should feature spirituality more in treatment. Nearly half agreed that the Twelve-Step (AA) approach should be more a part of TC treatment. Preference for Twelve-Step meeting interventions was positively correlated with past attendance at Twelve-Step meetings. Personal spiritual orientation to life was positively correlated with endorsement of spirituality based interventions in TC treatment. These findings highlight the importance of integrating treatment approaches which address the spiritual needs of TC residents.

Unlabelled: The presence of a personality disorder (PD) has been associated with certain types of poor treatment outcomes in patients with substance use disorders (SUDs). The purpose of this study was to determine the prevalence of comorbid PDs in psychiatrically hospitalized adults with both non-SUD Axis I disorders and SUDs, and to assess the relationship between Axis II psychopathology and degree of pretreatment addiction severity and treatment outcome., Method: One hundred consecutive inpatients admitted to a mixed dual diagnosis inpatient unit were assessed using semistructured interviews for SUDs, non-SUD Axis I disorders, and PDs. Pretreatment severity was assessed using a modified version of the Addiction Severity Index (ASI). Outcome measures were assessed both during hospitalization and at an initial follow-up appointment after discharge. Statistical analyses were performed comparing dually diagnosed patients with and without Axis II psychopathology., Results: A significant number (53%) of the patients met criteria for at least one personality disorder. Of the PDs, Cluster B PDs were the most prevalent, particularly borderline personality disorder (74%) and antisocial personality disorder (66%). Dually diagnosed patients without an Axis II diagnosis had less severe pretreatment severity measures. During hospitalization, patients with Axis II disorders had higher levels of psychopathology on the Brief Symptom Inventory (BSI) subscales of sensitivity and hostility. However, there was no difference in overall degree of global improvement during hospitalization. During follow-up, patients with Axis II disorders were significantly less likely to be compliant in attending their initial follow-up appointment., Conclusions: Dual diagnosis inpatients with PDs appear to improve as much as patients without PDs during their inpatient hospitalizations; however, they appear to be less likely to be compliant with attending their initial follow-up appointment.

Fifty-two heroin addicts were inducted onto buprenorphine under the care of psychiatric residents in a setting modeled on office practice. Subjects were maintained on a protocol of six weeks of 16 mg daily dosing, then tapered to zero dose up to week 16, and maintained on placebo through week 18. Of 44 subjects who continued after the first induction dose, 11 terminated during maintenance, 17 during taper; and 16 while on zero dose. Twice weekly urine toxicologies showed significant successive declines in samples positive for heroin use across these three periods: 70%, 41%, and 20%, respectively. Among historical variables, only prior AA attendance distinguished subjects who achieved zero dose from those who did not. A comparison with recent studies suggests that relatively inexperienced office-based physicians can maintain patients on buprenorphine at a level comparable to that reported for research clinic settings, but with comparable rates of heroin abstinence. These findings are discussed in light of potential options for office-based opioid maintenance.

This study examined the characteristics of gay men attending circuit parties and their drug use. In particular, the role of methylenediomethamphetamine (MDMA, "ecstasy") was considered in relation to other drug use and sexual behavior. A one-page survey was distributed to 173 men attending a circuit party. Respondents were generally gay men, Caucasian, employed, and well-educated. Twenty-five percent self-identified as HIV-positive. Eighty-six percent reported using at least one substance on the day of the party; polydrug use was frequent. The most common substances were MDMA, ketamine, and methamphetamine. MDMA use was highly associated with ketamine, methamphetamine, and cocaine use. MDMA use was also associated with significantly more receptive anal intercourse. Circuit parties are settings of increased drug use and associated high-risk sexual behavior. A better understanding of these issues is needed to develop interventions aimed at reducing drug use and sexual risk taking among gay men who attend circuit parties.

An adaptation of the drug-free therapeutic community (TC) model to homeless men with comorbid mental illness and chemical addiction (MICA) was evaluated with respect to change in psychological status over the course of a six-month residential treatment. Psychological status was assessed by: the Symptom Checklist-90-R (SCL90-R), Beck Depression Inventory (BDI), Shortened Manifest Anxiety Scale (SMAS), and Tennessee Self-Concept Scale (TSCS). A total of 52 out of an original study cohort of 124 residents were followed in longitudinal analyses to treatment midpoint, with a subset of 34 assessed through treatment completion. Significant, widespread psychological improvements were found during both the first and second half of treatment; it would appear that distress reduction was ongoing throughout treatment, with intrapersonal preceding interpersonal relief. The premise of applying a socially-based treatment to this population is discussed in light of these findings.

A study was conducted to ascertain correlates of HIV high risk behaviors and attitudes toward HIV. A questionnaire was administered to 103 men living in a modified therapeutic community (TC) for homeless, chemically addicted and mentally ill men. The psychiatric diagnoses of the sample population included psychotic disorders (48%), depressive disorders (36%), and bipolar disorders (16%). Forty-two percent reported that their primary substance of abuse was cocaine and another 40% named alcohol as the substance to which they were most addicted. Two logistic regression analyses were conducted, one with needle sharing as the outcome measure and one with endorsement of the need for lifestyle changes to reduce risk of HIV transmission. Cocaine users were 3.4 times more likely to have shared needles than the rest of the sample. Patients who had a history of sexually transmitted diseases (STDs) were 17 times more likely to endorse the need for lifestyle changes. The level of HIV transmission knowledge was unrelated to HIV risk behaviors or attitudes.

At the conclusion of a 3-year demonstration project in a medical setting in which refusal to accept methadone was an inclusion criterion, 12 subjects were unable to detoxify from buprenorphine and remained adamant in their refusal to enroll in a MMTP. In order to study the feasibility of expanding opportunities for treatment previously unavailable to this under-served population of heroin addicts, these 12 subjects plus an additional 11 subjects (N = 23) were recruited for a 12 months trial of buprenorphine treatment conducted in an office-based setting on a fee-for-service basis. An additional cohort of 40 heroin dependent subjects were entered in a protocol for detoxification only. The findings demonstrate both feasibility and patient acceptance of office based fee-for-service buprenorphine treatment, supporting the need for (1) additional studies of this population and (2) changes in government regulations to reintroduce addiction treatment under physician auspices in private practice settings.

This report examines the impact of managed care (MC) and related developments on substance abuse treatment, and evaluates how it has been associated with a decline in the availability of proper treatment for many addicted patients. A trend toward carve-out and for-profit MC organizations is associated with lower financial incentives for intensive treatment than in earlier staff-model and not-for-profit MC organizations. The value of substance abuse insurance coverage has declined by 75% between 1988 and 1998 for employees of mid-to large-size companies, compared with only an 11.5% decline for general health insurance. The shift towards MC has also been associated with a drastic reduction in frequency and duration of inpatient hospitalization, and there is no clear evidence that this reduction has been offset by a corresponding increase in outpatient support. In a survey of physicians treating addiction, the majority felt that MC had a negative impact on detoxification and rehabilitation, and on their ethical practice of addiction medicine.

We studied factors contributing to an increased risk of PPD positive status among 147 inpatients dually diagnosed for mental illness and substance abuse in a large urban hospital. Ninety-three percent (N = 137) were tested for PPD on admission. The rate of positive PPDs was 30.7%. Significant correlates of PPD positive status were the diagnosis of schizophrenia/psychosis NOS (p < .05), and crack cocaine use in the 30 days prior to admission (p < .01). A multiple logistic regression revealed a relative risk of 3.53 (p < .005) for PPD positive status for the crack using group and a relative risk of 2.16 (p < .06) for PPD positive status for the schizophrenic group. Reasons for why patients whose primary drug of abuse is crack cocaine and those whose diagnosis is schizophrenia/psychosis NOS may be at an increased risk for exposure to tuberculosis are discussed as are the implications for public health.

Mental health practitioners in the office setting are often seen as deficient in addiction treatment skills. Relevant training in often quite limited, and trainees are generally not introduced in an effective office-based modality. We studied the feasibility of teaching beginning therapists how to apply Network Therapy, a cognitive-behavioral approach to achieving abstinence and preventing relapse that augments individual therapy with support from family and friends. The therapists were 19 psychiatric residents without experience in substance abuse treatment or outpatient therapy, and the patients were 24 cocaine-dependent patients who received a 24-week course of Network treatment. The patients remained in treatment for an average of 15.4 weeks. Seventy-nine percent of their observed weekly urine toxicologies were negative for cocaine, and 42% of patients produced clean urines in the 3 weeks immediately before termination. The overall outcome compares favorably with that reported in studies on cocaine treatment where experienced therapists were employed. Our results suggest that naive mental health trainees can be taught to apply Network Therapy for effective substance abuse management. This is particularly relevant to technology transfer for general mental health trainees, who are often thought to be perceived to be refractory to learning about the outpatient management of addiction.

Substance abuse treatments are increasingly employing standardized formats. This is especially the case for approaches that utilize an individual psychotherapy format but less so for family-based approaches. Network therapy, an approach that involves family members and peers in the patient's relapse prevention efforts, is theoretically and clinically differentiated in this paper from family systems therapy for addiction. Based on these conceptual differences, a Network Therapy Rating Scale (NTRS) was developed to measure the integrity and differentiability of network therapy from other family-based approaches to addiction treatment. Seven addictions faculty and 10 third- and fourth-year psychiatry residents recently trained in the network approach used the NTRS to rate excerpts of network and family systems therapy sessions. Data revealed the NTRS had high internal consistency reliability when utilized by both groups of raters. In addition, network and nonnetwork subscales within the NTRS rated congruent therapy excerpts significantly higher than noncongruent therapy excerpts, indicating that the NTRS subscales measure what they are designed to measure. Implications for research and training are discussed.

The efficacy of the drug-free therapeutic community (TC) in treating patients with chemical dependence and in rehabilitating persons with criminal histories has been extensively studied and is well established since the late 1960's. More recently, this format has been modified in order to treat individuals suffering from both addictive disorders and chronic, severe mental illness. In an indigent inner-city population, this latter group includes many patients who also have significant histories of criminal behavior. To date, there have been no systematic attempts to assess the impact of a history of criminality on the course of treatment of these patients, as they might be thought less adaptable to the milieu of a TC. In the current study, data from a sample of homeless male MICA patients were analyzed to determine if those patients with a history of criminal convictions were as likely as non-criminal patients to adjust effectively to the social milieu of a modified drug-free therapeutic community. Of 183 sequential admissions studied, 76 had never been convicted of a crime, 46 had 1 conviction, and 61 had 2 or more. No differences were observed between the groups with respect to length of stay, social adjustment on admission, and change in social adjustment during the first two months of treatment. These findings suggest that a history of criminal conduct does not compromise a dually diagnosed patient's likelihood of engaging in the social contract necessary for successful treatment in a TC.

This study compares the views on spirituality of dually diagnosed patients (diagnosed with both substance abuse and general psychiatric disorders) and medical students in order to investigate their respective orientations toward spirituality and their views of the importance of spirituality in the treatment of addiction. We administered a modified version of Feagin's "Orientation to Life and God Scale" to assess religious and spiritual orientation in both the patients and students. A second series of items was developed and administered in order to compare the patients' and students' perceptions of the relative importance of a religious and spiritual orientation in substance abuse treatment. A third series of items was also given to compare the nature of religious and health-related services on the inpatient unit that patients and students most wanted to see improved. We found that the medical students responsible for treating substance abuse are significantly less religiously and spirituality oriented than the patients they treat, and that the students do not indicate that spirituality is an important component in the care of these patients. It may be clinically relevant to train medical students in the potential importance of spirituality in addiction treatment so that they can incorporate spirituality into the treatment of addictions.

Large numbers of indigent cocaine abusers now present in center-city hospitals. Since many are also diagnosed for severe mental illness, options for their effective treatment are needed. The authors investigated the feasibility of treating these dually diagnosed patients along with the majority of abusers who were not severely impaired in a program that combines peerled treatment with psychiatric management and pharmacotherapy. Although group confrontation techniques were used, schizophrenics (N = 71) and patients with major depressive disorder (N = 50) experienced an outcome as good or better than the less impaired (N = 177) on retention, visit rates, and urinalysis results.

Treatment outcome was evaluated for perinatal cocaine addicts admitted to a hospital-based day treatment clinic, organized as a modified therapeutic community (TC) modality. The perinatal program consisted of a specialized track for women embedded within this larger coed day treatment clinic. A total of 87 perinatal women (28 pregnant at intake, the remaining 59 postpartum) were compared with cohorts of nonperinatal women (N = 63) and men (N = 158) admitted during the period of evaluation (September 1989 through December 1993). In logistic regression analysis, successful discharge urine status (last three urines prior to discharge drug-free) was associated with current child custody involvement (odds ratio = 2.80, 95% C.I. = 1.16-6.72), entering treatment when not postpartum (odds ratio = 0.15, 95% C.I. = 0.05-0.42), and taking psychiatric medication (odds ratio = 2.04, 95% C.I. = 1.11-3.72). Both pregnant and postpartum perinatal women showed a similar pattern of shorter treatment as compared with nonperinatal women and male clients, averaging 2 months of treatment as compared with 4 months for nonperinatal clients. Factoring out pregnancy and postpartum status, the women in treatment fared as well as men with respect to both retention and discharge urine standings. This finding indicates that programmatic modifications need to address specific perinatal issues and not gender issues per se. Also, a differential pattern in discharge urine status of women who enter treatment while pregnant vs. those who enter when postpartum suggests that outreach and recruitment be targeted, but not limited, to pregnant women.

Spirituality is a neglected area of study and research in the treatment of addictions. The role of spirituality in the treatment of the dually diagnosed has received particularly scant attention. One hundred and one patients on an in-patient dual-diagnosis unit, as well as the 31 members of the nursing staff who treat them were surveyed. Patients and staff were questioned about their spiritual beliefs and what was the role of spirituality in the patients' recovery from addiction. Staff were questioned about their own spirituality and what they think the patients' level of spirituality is. In addition the staff were asked what they think the patients' view of spiritually is. Results indicate that the patients and staff are equally spiritually oriented. The patients view spirituality as essential to their recovery and value spiritual programming in their treatment more than some concrete items. The nursing staff underestimated both the patients' level of spirituality and this importance placed on spiritual issues. The authors suggest that more attention should be given by staff to spirituality in the treatment of this population.

Questions have arisen about the implications of notifying drug abusers of their HIV serostatus. One major concern is that awareness of HIV infection would have a negative impact on abstinence from drug abuse. In order to ascertain the effects of serostatus notification, the authors reviewed the clinical records of 73 methadone patients who learned of their serostatus within 20 weeks after enrolling in the clinic and thereafter remained in treatment for at least 1 year. They found that, at serostatus notification, seropositive patients were more likely to be socially disadvantaged and were younger than the seronegatives at first opiate use. After serostatus notification, seropositives had more "fair hearings" for noncompliance with program norms and used more cocaine. Although the patients notified of HIV infection may have more behavioral problems, further research is needed to determine whether or not this reflects antecedent behavior patterns and drug use.

In this paper we report on a community based sample of heroin addicts not in addiction treatment who responded to the offer of experimental treatment (buprenorphine) for heroin addition. Comparison to a sample of methadone maintenance clients from the same geographic area reveals that on average the community sample began heroin use later, attained a higher level of education, and were most likely to have had a significant cohabitation relationship. The methadone maintenance sample, on the other hand, reported significantly greater regular use of drugs of abuse other than heroin. Each group may represent a different subgroup drawn from the heterogeneous heroin-addicted population. Implications for improved recruitment into treatment and enhanced treatment design are drawn from these findings.

The objectives of this study were to investigate HIV-1 seroprevalence and risk factors, disease progression, and awareness of HIV-1 serostatus in a population of inner city, substance using, psychiatric inpatients. To pursue these goals, we tested 118 (103 M, 15 F) dually diagnosed, acute care inpatients for HIV-1 antibodies and administered structured interviews. Twenty-seven (23%, including 24 M and 3 F) of the subjects were HIV-1 seropositive. Seropositivity was twice as great among intravenous drug users and men who had sex with other men as among patients not belonging to either of these two groups. Logistic regression analysis among male subjects revealed a significantly elevated HIV-1 risk associated with a primary diagnosis of depression (odds ratio adjusted for age, race, and presence of an AIDS risk behavior = 4.2, 95% confidence interval = 1.1, 16.5; p = 0.04). Less than half of the seropositives knew their HIV-1 status prior to this study, one had AIDS and four had two or more constitutional symptoms of AIDS. The high rate of seropositivity in this indigent, dually diagnosed population presents challenges to the health-care community. That few individuals had HIV-1 related symptoms may have implications for other treatment settings.

Rational Recovery (RR) is a new self-help movement for substance abusers, with a cognitive orientation. It has been suggested as an alternative to Alcoholics Anonymous. This study was designed to examine the nature of RR and its impact on those who join. A national sample of 433 substance-abusing people attending 63 established RR groups was evaluated, using codable self-report questionnaires completed at RR meetings. Members were mostly men with college experience who had previously attended AA. Among recruits who attended their first RR meeting in the last month, 38% were abstinent in the last month. Among members who had joined 3 or more months before, 73% were abstinent in the last month; they had attended an average of 4.1 RR meetings in that month, and carried out exercises at home based on Rational Emotive Therapy. Among those who joined 6 or more months before, 58% reported at least 6 months of abstinence. Among members with a history of heavy cocaine use, the portion reporting abstinence in the last month was not significantly different from those who had never used cocaine. The minority of members who were engaged for 3 months were still drinking, though, and did so on an average of 9.9 days in the last month. RR succeeded in engaging substance abusers and promoting abstinence among many of them while presenting a cognitive orientation that is different from the spiritual one of AA. Its utility in substance abuse treatment warrants further assessment.

The relationships between drinking history, housing history, several clinical variables and treatment retention after detoxification were evaluated in 109 inner-city alcoholics. Compared to men with a fixed abode, homeless subjects (N = 50) reported a history of alcoholism of early onset and increased severity. No differences in aftercare retention were found between homeless and non-homeless subjects.

The purpose of this project was to study women at high risk for contracting AIDS from intravenous drug use or from sexual contact with addicts. Characteristics of the population, differences between HIV+ and HIV- women, substance abuse in primary caretakers of this high risk population, and changes in drug use when learning of HIV status were investigated. Subjects were mothers at high risk for contracting HIV, whose children were referred to a pediatric AIDS clinic of a large urban hospital because of AIDS risk factors. HIV testing revealed that 27 women were HIV+ and 13 were HIV-. The most common source of infection reported by the HIV+ women was sexual contact (17 subjects), with the remainder reporting that they were unsure of the source or reported intravenous drug use as their source of infection. There were significant differences between HIV+ and HIV- mothers with regard to the presence and impact of substance abuse in their own primary caretakers before age 16. Substance abuse in the parents of subjects was apparently reflected in behaviors reflecting health risk in subsequent generations. Subjects did not report changes in AIDS risk behavior when informed of their own HIV status or that of their children.

The aim of the study was to ascertain whether there was a difference in developmental experiences between two groups of inner city postpartum patients, those who used cocaine during pregnancy and those who did not. A retrospective structured interview was administered to 80 postpartum women examining demographic characteristics, adaptive function, drug use patterns, and selected risk factors for adult substance abuse encountered before age 16. The sample was divided into two cohorts of women: 40 women identified by urine tests of their babies as using cocaine shortly before delivery and a comparison group of 40 women not identified by positive urines. Comparisons between the two cohorts revealed that the cocaine identified women had significantly higher overall past and present use of a broad range of drugs, particularly crack and other forms of cocaine, as well as lower levels of general adaptive functioning despite the fact that they were demographically comparable. When compared to the nonusers, they displayed markedly elevated scores on measures of developmental risk factors for adult substance use. This study highlights the importance of early developmental risk factors on later drug use during pregnancy and general adult adaptive functioning. Further study and intervention targeted at persons with these risk factors are warranted.

Rises in both crack cocaine use and incidence of sexually transmitted diseases have been recently reported. In this study, we investigated the relationship between crack cocaine abuse and sexual behavior in 50 psychiatric inpatients. The relationship between crack use and sexual behavior is a very complicated one, influenced by many variables such as the dose of crack used, the user's preexisting sexuality, gender, and psychiatric illness. Results indicated that while most of the subjects developed sexual disinterest and dysfunction with prolonged crack cocaine use, some of them became more sexually promiscuous and consequently contracted more sexually transmitted diseases. The implications of these findings regarding transmission of HIV among crack cocaine users are discussed.

An outcome study was carried out on a series of 109 highly disadvantaged alcoholics discharged from the detoxification unit of a large municipal hospital in New York City. We examined the impact of a variety of clinical and demographic factors on retention in the initial phases of outpatient and inpatient treatment following discharge. Both high school completion and a history of at least 6 months of employment in the two years preceding admission correlated with frequency of registration for continued aftercare. Measurements of cognitive flexibility correlated with frequency of aftercare completion. An association strongly approaching significance was also found between length of hospital stay and aftercare completion. Some suggestions are made as to the assessment and aftercare planning for highly disadvantaged alcoholics.

In a group of 71 inpatient schizophrenics with no other concurrent psychiatric diagnosis except for dependence on one drug, we ascertained the subjective effect their drug of abuse had on their psychiatric symptoms 2 weeks prior to hospitalization. Psychiatric symptoms were assessed by means of the Hopkins Symptom Checklist (Revised) (SCL-90R). Cocaine addicts, but not alcoholics, reported aggravation more often than improvement of symptoms. Alcoholics reported alcohol-induced symptom improvement with a similar frequency as alcohol-induced symptom aggravation.

Although homelessness in patients with combined addictive and psychiatric illness is a common problem, little has been reported about the epidemiology of homelessness in this patient population. The authors, in a study of 100 dually diagnosed patients admitted to a large metropolitan psychiatric hospital, found that a large portion of patients (N = 46) were homeless at the time of admission. Alcohol and crack/cocaine were the most frequently used drugs. Interestingly, there were no significant differences on most parameters between those who were homeless and those who were not. The authors observed that among the disadvantaged, inner-city dually diagnosed, many move in and out of the homeless state, seriously compromising their chances for recovery. Self-help treatment programs were more commonly used by homeless than domiciled patients. The homeless population may therefore be amenable to treatment in 12-step groups, as are domiciled patients.

This paper describes the historical background of the Consensus Standards for Postgraduate Medical Fellowships in Alcoholism and Drug Abuse, developed for the American Academy of Psychiatrists in Alcoholism and Addictions and the Association for Medical Education and Research in Substance Abuse. These standards were prepared by a National Advisory Committee of the Center for Medical Fellowships in Alcoholism and Drug Abuse, which includes 23 leading figures in academic medical training in the addiction field. The standards define general information, facilities and resources, the educational program, and the specific knowledge and skills appropriate to fellowship training. The standards were designed to provide a model for optimal training for residency affiliated fellowships to be used by faculty, trainees, and organizations setting training standards.

In order to ascertain the relative impact of coercion by a welfare program on retention in an ambulatory alcoholism program, records of 178 consecutive admissions to an inner-city alcoholism clinic were reviewed. Patients who came to the clinic via coerced referral from a public assistance agency were as likely to remain in treatment for at least nine sessions as self-referred patients.

This paper reports on studies designed to clarify the role of large cohesive groups in effecting diminished drug use among their members. Subjects were drawn from two contemporary religious sects and data were obtained by administering self-report questionnaires under controlled conditions, in cooperation with the sects' leadership. Data which bear directly on changes in drug use are reported here. Members of the Divine Light Mission (DLM), many of whom had been involved in the "counterculture" of the early 1970s, reported incidence of drug use prior to joining which was much above that of a nonmember comparison group. Reported levels were considerably lower after joining, and the decline was maintained over an average membership of 2 years. Unification Church (UC) members showed a similar pattern but their drug use began at a somewhat lower level and declined further still; this reflects a stricter stance toward illicit intoxicants in the UC, and relatively less openness to transcendental altered consciousness, which is an integral part of DLM meditation. Data from persons registered for UC recruitment workshops corroborated retrospective reports of the long-standing members. Changes in the consumption of tranquilizers were also considered. Data on caffeine consumption reflected less strict commitment to controls over this agent. The decline in drug use was considered in relation to feelings of social cohesiveness toward fellow group members, which was a significant predictor of change in drug use in multiple regression analysis. The findings are examined in relation to the interplay between behavioral norms in a close-knit subculture and the role of its beliefs and values in determining levels of drug use.

Recognizing the effectiveness of substance abuse treatment is made easier when there is a steady supply of newly trained medical professionals who are competent in this specialty. University-based substance abuse treatment facilities have a clear obligation to educate such professionals. This article shows how three different medical colleges were able to establish new clinical fellowships in substance abuse so that teaching activities could be fostered at preexisting treatment sites. Fellowship activities varied from one place to the next, but at all three schools important momentum was generated on behalf of substance abuse education. These experiences provide models for those academicians and administrators who face the task of integrating educational and serivce delivery missions in the substance abuse field.

This paper reviews the literature on patients presenting for general psychiatric treatment who are also substance abusers. Place of presentation, diagnosis, and treatment are considered. A considerable portion of patients seen in emergency rooms, as much as half in some settings, are substance abusers, and over a third of general psychiatry admissions have been found to have their presenting problems materially influenced or precipitated by substance abuse. Substance abuse is also frequently found among psychiatric inpatients. Diagnostically, the differentiation of general psychiatric and addictive syndromes can be difficult: primary and secondary affective disorder from consequences of long-term substance abuse; and self-medication patterns from primary general psychiatric syndromes. Treatment studies are often focused on concomitant psychotherapeutic management for patient being treated for addiction. Often, emphasis is placed on pharmacotherapy for enhancing outcome in the dually diagnosed. Qualitatively, new options tailored to this population still remain to be studied, however, as do the changes necessary in the treatment system to assure proper long-term management.