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Learning Objectives: After participating in this activity, learners should be better able to:• Assess the treatment gap for patients with substance use disorders• Evaluate treatments and models of implementation for substance use disorders ABSTRACT: Substance use disorders (SUDs) account for substantial global morbidity, mortality, and financial and social burden, yet the majority of those suffering with SUDs in both low- and middle-income (LMICs) and high-income countries (HICs) never receive SUD treatment. Evidence-based SUD treatments are available, but access to treatment is severely limited. Stigma and legal discrimination against persons with SUDs continue to hinder public understanding of SUDs as treatable health conditions, and to impede global health efforts to improve treatment access and to reduce SUD prevalence and costs. Implementing SUD treatment in LMICs and HICs requires developing workforce capacity for treatment delivery. Capacity building is optimized when clinical expertise is partnered with regional community stakeholders and government in the context of a unified strategy to expand SUD treatment services. Workforce expansion for SUD treatment delivery harnesses community stakeholders to participate actively as family and peer supports, and as trained lay health workers. Longitudinal supervision of the workforce and appropriate incentives for service are required components of a sustainable, community-based model for SUD treatment. Implementation would benefit from research investigating the most effective and culturally adaptable models that can be delivered in diverse settings.

Background: Evidence-based outpatient treatment for opioid use disorder (OUD) consists of medications that treat OUD (MOUD) and psychosocial treatments (e.g., psychotherapy or counseling, case management). Prior studies have not examined the use of these components of care in a commercially insured population., Methods: We analyzed claims data from a large national commercial insurer of enrollees age 17-64 identified with OUD (2008-2016, N = 87,877 persons and 122,708 person-years). Multinomial logistic regression models identified factors associated with receiving in a given year: 1) both MOUD and psychosocial visits, 2) MOUD without psychosocial visits, 3) psychosocial visits without MOUD, or 4) neither. We estimated predicted probabilities for key variables of interest., Results: Identification of OUD nearly tripled during the observation period (0.17% in 2008, 0.45% in 2016). Among person-years identified as having OUD, 36.3% included MOUD (8.1% both MOUD and psychosocial visits and 28.2% MOUD without psychosocial visits). In adjusted analyses, women had a lower probability of receiving either treatment alone or in combination (e.g.,MOUD plus psychosocial visits: women = 6.7% [6.5%-6.9%] vs. men = 9.2% [9.0%-9.4%]). Moderate/severe vs. mild OUD was associated with a higher probability of receiving MOUD (e.g., MOUD plus psychosocial visits: 8.7% [8.6%-8.9%] vs. 0.9% [0.7%-1.0%]). In contrast, an OUD overdose was associated with a greater probability of receiving neither treatment (78.2% [77.4%-79.0%] vs. 55.5% [55.2%-55.8%]). Over time, the probability of receiving each MOUD and psychosocial treatment category increased relative to 2008, but reached a peak and then plateaued or declined, by the end of the study period., Conclusions: A significant treatment gap exists among individuals identified with OUD in this commercially insured population, with greater risks of receiving no treatment for women and for individuals with mild versus moderate or severe OUD. Overdose is associated with receiving neither MOUD nor psychosocial treatment. While treated prevalence initially increased relative to 2008, rates of treatment subsequently plateaued. Additional study and monitoring to elucidate barriers to OUD treatment in commercially insured populations are warranted., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Opioid use disorder (OUD) in pregnant women has increased significantly in recent years. Maintaining these women on sublingual (SL) buprenorphine (BUP) is an evidence-based practice but BUP-SL is associated with several disadvantages that an extended-release (XR) BUP formulation could eliminate. The National Drug Abuse Treatment Clinical Trials Network (CTN) is conducting an intent-to-treat, two-arm, open-label, pragmatic randomized controlled trial, Medication treatment for Opioid-dependent expectant Mothers (MOMs), to compare mother and infant outcomes of pregnant women with OUD treated with BUP-XR, relative to BUP-SL. A second aim is to determine the relative economic value of utilizing BUP-XR. Approximately 300 pregnant women with an estimated gestational age (EGA) of 6-30 weeks, recruited from 12 sites, will be randomized in a 1:1 ratio to BUP-XR or BUP-SL, balancing on site, EGA, and BUP-SL status (taking/not taking) at the time of randomization. Participants will be provided with study medication and attend weekly medication visits through 12 months postpartum. Participants will be invited to participate in two sub-studies to evaluate the: 1) mechanisms by which BUP-XR may improve mother and infant outcomes; and 2) effects of prenatal exposure to BUP-XR versus BUP-SL on infant neurodevelopment. This paper describes the key design decisions for the main trial made during protocol development. This Investigational New Drug (IND) trial uniquely uses pragmatic features where feasible in order to maximize external validity, hence increasing the potential to inform clinical practice guidelines and address multiple knowledge gaps for treatment of this patient population., Competing Interests: Declaration of Competing Interest Dr. Lofwall reported receiving research funding from Braeburn Pharmaceuticals, Inc., consulting fees from Braeburn Pharmaceuticals, Inc. and Titan, and honorarium/travel expenses from Camurus. Dr. Murphy reports having consulted for Sandoz Inc. for work unrelated to the investigation reported here. Dr. Wexelblatt reported receiving consulting fees from Braeburn Pharmaceuticals, Inc. All other authors have no potential conflicts of interest to report., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Women face unique issues related to their substance use. Treatment programs that incorporate gender-specific components can to lead to enhanced outcomes for women with substance use disorders (SUDs). Nevertheless, most women receive treatment in mixed-gender SUD treatment programs that lack women-specific components. Programs cite lack of expertise and staff time as barriers to providing gender-specific care. Leveraging technology can address some of the challenges of providing gender-specific care in a mixed-gender setting by offering an accessible, cost-effective alternative to in-person services. Materials and Methods: We developed a gender-specific, web-based, psychoeducational intervention for women with SUDs as an addition to treatment as usual in a mixed-gender SUD treatment program. Next, we examined the feasibility and acceptability of this single-session intervention in a prepilot study with 30 women with SUDs. Based on these data, we refined the intervention and tested feasibility and acceptability with 60 women with SUDs. Results: Participants indicated a high level of satisfaction with the intervention. Satisfaction did not significantly differ by level of care (inpatient, partial hospitalization, or outpatient) or age, and was not associated with the number of previous treatment episodes. Participants highlighted the importance of addressing co-occurring disorders, trauma, and sexual abuse in SUD treatment for women. Conclusions: Women in this study found this web-based gender-specific intervention relevant regardless of their previous experience in treatment. Delivery of this intervention is feasible and has the potential to be a highly sustainable strategy for increasing exposure to gender-specific SUD components of care.

Background: Depression is highly prevalent among individuals with substance use disorders (SUDs), especially women, and has been noted to improve during SUD treatment. Perceived stress is independently related to severity of depression and substance use disorders (SUDs) as well as recurrence of symptoms and relapse following treatment. The aim of this study was to investigate among adults enrolled in SUD treatment whether levels of perceived stress and substance use over the course of treatment were related to reduction in depression., Methods: This is a secondary analysis of data from the Women's Recovery Group Study. Women (n = 100) were randomized to either single- or mixed-gender group therapy and men (n = 58) received mixed-gender group therapy. Measures of substance use, perceived stress and depressive symptoms were collected for 6 months following treatment completion. In this study, we used lagged mixed models to investigate whether levels of substance use and perceived stress at each time point were associated with changes in depression at the subsequent time point., Results: Results indicated that depressive symptoms significantly improved over time. Both substance use and perceived stress were associated with subsequent depressive symptoms. Importantly, stress was associated with symptoms when controlling for substance use, suggesting that changes in depressive symptoms were not solely attributable to levels of substance use., Conclusions: These results suggest that both stress and substance use are associated with improvements in depressive symptoms in substance use disorder treatment. Although preliminary, these results provide further support for the importance of targeting stress reduction in people with substance use disorders., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Despite the high rate of co-occurring eating disorders (EDs) and substance use disorders (SUDs) in women, there is a lack of integrated treatment. This study implemented the Women's Recovery Group (WRG), a gender-specific group therapy for women with SUDs, in an ED residential treatment program to assess the feasibility and satisfaction of the WRG for women with co-occurring SUDs and EDs. Women (N = 24) were enrolled in the study if they were aged 18 years or older and engaged in the WRG as part of their treatment. Patient and therapist satisfaction with the WRG were assessed post-treatment, and craving to use substances was measured at enrollment and post-treatment. Participants reported moderate satisfaction with the WRG, and therapists reported above average satisfaction with the WRG. Craving to use substances in the environment in which one previously used significantly decreased from enrollment to post-treatment. In its current form, the WRG was feasible to implement in ED residential treatment. Participants indicated that they would have liked more information on co-occurring EDs, self-image/self-esteem, shame and guilt, and maintaining sobriety at college. These results support the need for modifications to the WRG to better integrate treatment for women with co-occurring EDs and SUDs., Competing Interests: Declarations of interest: None

Background : Smoking is highly prevalent in people with opioid use disorder (OUD) and is a significant contributor to morbidity and mortality in this population. However, little is known about the differences between those with OUD who do and do not smoke cigarettes. Objectives : Our aim was to investigate differences between treatment-seeking adults with OUD who did and did not smoke. Methods: Participants ( N  = 568; 30% female) completed a battery of self-report questionnaires including measures of current smoking status and number of cigarettes smoked per day as well as measures of clinical characteristics (e.g. craving, anxiety). Results : Of the total sample, 77% were current smokers. Multivariable logistic regression identified heroin use (OR = 2.20, 95% CI = 1.38, 3.53) and younger age (OR = 0.97, 95% CI = 0.95, 0.997) as strong correlates of smoking status; other characteristics were not significant. Older age and opioid craving were associated with more cigarettes smoked per day. Notably, these patterns differed for males and females; opioid craving ( B  = 0.62, SE B = 0.24) was associated with the number of cigarettes smoked among men, and anxiety ( B  = 0.39, SE B = 0.19) was associated with the number of cigarettes smoked among women. Conclusion : Adults with OUD who used heroin in the past month were more likely to be current smokers. No sex differences were observed in likelihood of smoking; however, the predictors of smoking status and severity differed between men and women.

Objectives: To advance our understanding of medication treatments for opioid use disorders (OUDs), identification of distinct subgroups and factors associated with differential treatment response is critical. We examined trajectories of opioid use for patients with OUD who were randomized to (but not in all cases inducted onto) buprenorphine-naloxone (BUP-NX) or extended-release naltrexone (XR-NTX), and identified characteristics associated with each trajectory., Methods: Growth mixture models (GMMs) were run to identify distinct trajectories of days of opioid use among a subsample of 535 individuals with OUD who participated in a 24-week randomized controlled trial (RCT; 2014-2016) of BUP-NX (n = 281) or XR-NTX (n = 254)., Results: Four distinct opioid use trajectory classes were identified for BUP-NX (near abstinent/no use (59%); low use (13.2%); low use, increasing over time (15%); and moderate use, increasing over time (12.8%)). Three distinct opioid use trajectory classes were found for XR-NTX (near abstinent/no use (59.1%); low use (14.6%); and moderate use, increasing over time (26.4%)). Across both BUP-NX and XR-NTX, the near abstinent/no use class had the highest number of medical management visits. Within BUP-NX, the low use class had a greater proportion of individuals with a previous successful treatment history compared with other classes. Within XR-NTX, the moderate use, increasing over time class had the highest proportion of Hispanic participants compared with other classes., Conclusions: Findings highlight the significant heterogeneity of opioid use during a RCT of BUP-NX and XR-NTX and factors associated with opioid use patterns including medical management visits and history of treatment success., (Copyright © 2019 Elsevier B.V. All rights reserved.)

This report uses an enhanced conceptualisation of self-injury mortality (SIM), which comprised registered or known suicides by any method and estimated non-suicide deaths from opioid and other drug self-intoxication. SIM surpassed diabetes as a cause of death in the USA in 2015. The gap expanded in 2016 with respective rates of 29.1 and 24.8 per 100 000 population. Facing similar social and psychologically complex health problems to SIM, the USA has initiated and sustained successful broad-based prevention efforts that have reduced deaths from cardiovascular diseases, smoking-related lung cancer, HIV and motor vehicular injury-given both necessary epidemiological understanding to define the problem and sufficient political will to address it. Development of strategies to prevent SIM will be facilitated by focusing on factors that are common risks for diverse outcomes. Like premature mortality frequently associated with diabetes, deaths from self-injurious behaviours are preventable., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The gender gap in substance use disorders (SUDs), characterized by greater prevalence in men, is narrowing, highlighting the importance of understanding sex and gender differences in SUD etiology and maintenance. In this critical review, we provide an overview of sex/gender differences in the biology, epidemiology and treatment of SUDs. Biological sex differences are evident across an array of systems, including brain structure and function, endocrine function, and metabolic function. Gender (i.e., environmentally and socioculturally defined roles for men and women) also contributes to the initiation and course of substance use and SUDs. Adverse medical, psychiatric, and functional consequences associated with SUDs are often more severe in women. However, men and women do not substantively differ with respect to SUD treatment outcomes. Although several trends are beginning to emerge in the literature, findings on sex and gender differences in SUDs are complicated by the interacting contributions of biological and environmental factors. Future research is needed to further elucidate sex and gender differences, especially focusing on hormonal factors in SUD course and treatment outcomes; research translating findings between animal and human models; and gender differences in understudied populations, such as those with co-occurring psychiatric disorders and gender-specific populations, such as pregnant women., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

In-session affiliation among members is a hypothesized mechanism of action of group therapy for women with substance use disorders (SUDs). We evaluated group affiliation as an independent predictor of SUD treatment outcome in women (n = 100), 18 years or older diagnosed with substance dependence, who were randomized to the single-gender Women's Recovery Group (WRG) or mixed-gender group therapy (Group Drug Counseling; GDC). Affiliative statements made by members in both groups were measured for 39 women in each treatment arm. We studied the relationship between frequency of affiliative statements categorized in quintiles and the trajectory of days of any drug use during 3 months treatment and 6 months post-treatment using a Poisson regression model with estimation via generalized estimating equations. Furthermore, we investigated whether the effect of affiliation on substance use was moderated by group therapy type. The relationship between amount of affiliation and substance use reduction was non-linear. At the end of the treatment phase (3 months), women who experienced the highest level of affiliation (>65 affiliative statements on average) were found to reduce substance use by about 1.75 days more (p-value = 0.02) than women who experienced the lowest level of affiliation (<26). The effects of affiliation persisted 6 months post-treatment and were moderated by therapy group, whereby women enrolled in the single-gender WRG appeared to benefit more from affiliation post-treatment. Training therapists to facilitate verbal affiliation may provide added therapeutic benefit to group therapy for women with SUDs., (Copyright © 2018. Published by Elsevier Inc.)

Background & Objectives: We investigated gender differences in individuals with opioid use disorder (OUD) receiving inpatient services and entering a randomized controlled trial comparing extended-release naltrexone to buprenorphine., Methods: Participants (N = 570) provided demographic, substance use, and psychiatric information., Results: Women were significantly younger, more likely to identify as bisexual, live with a sexual partner, be financially dependent, and less likely employed. Women reported significantly greater psychiatric comorbidity and risk behaviors, shorter duration but similar age of onset of opioid use., Discussion/conclusions: Findings underscore economic, psychiatric, and infection vulnerability among women with OUD., Scientific Significance: Interventions targeting these disparities should be explored, as women may face complicated treatment initiation, retention, and recovery. (Am J Addict 2018;27:465-470)., (© 2018 American Academy of Addiction Psychiatry.)

This study explores the content family members find helpful in family meetings that occur while patients are in short-term treatment for substance use disorders. Three focus groups were conducted; two with 23 family members and one with 10 patients who were asked to identify those topics that are helpful or unhelpful for families with and without prior treatment experiences. Families identified education about substance use disorders and an overview of treatment options as useful for family members new to treatment, and an emphasis on response to relapse and family supports as important for those with prior treatment experiences.

Objectives: The Alternative Quality Contract (AQC) implemented in 2009 by Blue Cross Blue Shield of Massachusetts (BCBSMA) is intended to improve quality and control costs by putting providers at risk for total medical spending and tying payment to performance on specified quality measures. We examined the AQC's early effects on use of and spending on medication treatment (MT) for addiction among individuals with alcohol use disorders (AUDs) and opioid use disorders (OUDs), conditions not subject to any performance measurement in the AQC., Methods: Using data from 2006 to 2011, we use difference-in-difference estimation of the effect of the AQC on MT using a comparison group of enrollees in BCBSMA whose providers did not participate in the AQC. We compared AQC and non-AQC enrollees with AUDs (n = 37,113 person-years) and/or OUDs (n = 12,727 person-years) on any use of MT, number of prescriptions filled, and MT spending adjusting for demographic and health status characteristics., Results: There was no difference in MT use among AQC enrollees with OUD (38.7%) relative to the comparison group (39.1%) (adjusted difference = -0.4%, 95% confidence interval -3.8% to 3.0%, P = 0.82). Likewise, there was no difference in MT use for AUD between the AQC (6.3%) and comparison group (6.5%) (P = 0.64). Similarly, we detected no differences in number of prescriptions or spending., Conclusions: Despite incentives for improved integration and quality of care under a global payment contract, the initial 3 years of the AQC showed no impact on MT use for AUD or OUD among privately insured enrollees with behavioral health benefits.

In 2009, Blue Cross-Blue Shield of Massachusetts (BCBSMA) implemented the alternative quality contract (AQC), which pays provider organizations a global payment for all services used by enrollees. BCBSMA claims for 2006-2011 were used to compare youths enrolled in provider organizations participating in the AQC (7,407 person-years [PYs]) with those not participating (45,398 PYs). Difference-in-differences models estimated changes in mental health and substance abuse treatment service utilization and spending attributable to the AQC. The AQC was associated with small increases in the probability of any outpatient visits and in the probability and number of medication management visits among children with attention-deficit hyperactivity disorder (ADHD). Spending did not change, and there was no evidence of reductions in service utilization or spending for children with ADHD in the first three years of AQC implementation.

Background and Objectives: We assessed the safety, tolerability, and preliminary efficacy of nabilone, a cannabinoid agonist, to treat cannabis dependence., Methods: Eighteen adults with DSM-IV cannabis dependence were randomized to receive either 2 mg/day of nabilone (n = 10) or placebo (n = 8) for 10 weeks in addition to medication management. Twelve participants, six in each group, completed treatment. The safety and tolerability of nabilone was assessed at each visit. Any side effects from nabilone or the placebo were documented. Cannabis use outcomes were assessed via self-report of days of use and twice-weekly urine cannabinoid tests; secondary outcomes included cannabis craving and anxiety., Results: We assessed safety and tolerability at each study visit. A total of eight adverse events, all mild or moderate, were reported in two participants in the nabilone group, and six events were reported in four participants in the placebo group during study treatment. A total of eight adverse events were reported in two participants in the nabilone group and six events were reported in four participants in the placebo group during study treatment. All reported adverse events were rated mild-to-moderate. There were no side effects deemed serious enough to be classified as an FDA-defined serious adverse event. In general, participants in both groups reported reduced cannabis use according to self-report over the course of the study, although these reductions were not statistically discernible. Moreover, there was no difference in cannabis use between the nabilone group and the placebo group as measured by self-report., Discussion and Conclusions: Nabilone pharmacotherapy was safe and well-tolerated in participants with cannabis dependence. Future studies might evaluate a higher dose of nabilone to determine its effects on cannabis use outcomes in participants with cannabis dependence., Scientific Significance: There remains a clear need for additional pharmacotherapy trials for cannabis dependence, and nabilone remains a candidate for such trials. (Am J Addict 2017;26:795-801)., (© 2017 American Academy of Addiction Psychiatry.)

Opioid use disorder is a highly disabling psychiatric disorder, and is associated with both significant functional disruption and risk for negative health outcomes such as infectious disease and fatal overdose. Even among those who receive evidence-based pharmacotherapy for opioid use disorder, many drop out of treatment or relapse, highlighting the importance of novel treatment strategies for this population. Over 60% of those with opioid use disorder also meet diagnostic criteria for an anxiety disorder; however, efficacious treatments for this common co-occurrence have not be established. This manuscript describes the rationale and methods for a behavioral treatment development study designed to develop and test an integrated cognitive-behavioral therapy for those with co-occurring opioid use disorder and anxiety disorders. The aims of the study are (1) to develop and pilot test a new manualized cognitive behavioral therapy for co-occurring opioid use disorder and anxiety disorders, (2) to test the efficacy of this treatment relative to an active comparison treatment that targets opioid use disorder alone, and (3) to investigate the role of stress reactivity in both prognosis and recovery from opioid use disorder and anxiety disorders. Our overarching aim is to investigate whether this new treatment improves both anxiety and opioid use disorder outcomes relative to standard treatment. Identifying optimal treatment strategies for this population are needed to improve outcomes among those with this highly disabling and life-threatening disorder., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Many individuals in clinical samples with borderline personality disorder (BPD) experience high levels of functional impairment. However, little is known about the levels of functional impairment experienced by individuals with BPD in the general community. To address this issue, we compared overall and domain-specific (educational/occupational; social; recreational) functioning in a sample of community-based individuals with BPD (n = 164); community-based individuals without BPD (n = 901); and clinically-ascertained individuals with BPD (n = 61). BPD diagnoses and functional outcomes were based on well-accepted, semi-structured interviews. Community-based individuals with BPD were significantly less likely to experience good overall functioning (steady, consistent employment and ≥1 good relationship) compared to community-based individuals without BPD (BPD: 47.4%; Non- BPD: 74.5%; risk difference -27.1%; p < 0.001), even when compared directly to their own non-BPD siblings (risk difference -35.5%; p < 0.001). Community-based individuals with BPD versus those without BPD did not differ significantly on most domain-specific outcomes, but the former group experienced poorer educational/occupational performance and lower quality relationships with parents, partners, and friends. However, community-based individuals with BPD were significantly more likely to experience good overall functioning than clinically-based individuals with BPD (risk difference -35.2%; p < 0.001), with the latter group more likely to experience reduced employment status, very poor quality relationships with partners, and social isolation. In conclusion, community-based individuals with BPD experienced marked functional impairment, especially in the social domain, but were less likely to experience the more extreme occupational and social impairments seen among patients with BPD., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Among individuals with substance use disorders (SUDs), comorbidity with other psychiatric disorders is common and often noted as the rule rather than the exception. Standard care that provides integrated treatment for comorbid diagnoses simultaneously has been shown to be effective. Technology-based interventions (TBIs) have the potential to provide a cost-effective platform for, and greater accessibility to, integrated treatments. For the purposes of this review, we defined TBIs as interventions in which the primary targeted aim was delivered by automated computer, Internet, or mobile system with minimal to no live therapist involvement. A search of the literature identified nine distinct TBIs for SUDs and comorbid disorders. An examination of this limited research showed promise, particularly for TBIs that address problematic alcohol use, depression, or anxiety. Additional randomized, controlled trials of TBIs for comorbid SUDs and for anxiety and depression are needed, as is future research developing TBIs that address SUDs and comorbid eating disorders and psychotic disorders. Ways of leveraging the full capabilities of what technology can offer should also be further explored.

Background and Aims: Global payment and accountable care reform efforts in the United States may connect more individuals with substance use disorders (SUD) to treatment. We tested whether such changes instituted under an Alternative Quality Contract (AQC) model within the Blue Cross Blue Shield of Massachusetts' (BCBSMA) insurer increased care for individuals with SUD., Design: Difference-in-differences design comparing enrollees in AQC organizations with a comparison group of enrollees in organizations not participating in the AQC., Setting: Massachusetts, USA., Participants: BCBSMA enrollees aged 13-64 years from 2006 to 2011 (3 years prior to and after implementation) representing 1 333 534 enrollees and 42 801 SUD service users., Measurements: Outcomes were SUD service use and spending and SUD performance metrics. Primary exposures were enrollment into an AQC provider organization and whether the AQC organization did or did not face risk for behavioral health costs., Findings: Enrollees in AQC organizations facing behavioral health risk experienced no change in the probability of using SUD services (1.64 versus 1.66%; P = 0.63), SUD spending ($2807 versus $2700; P = 0.34) or total spending ($12 631 versus $12 849; P = 0.53), or SUD performance metrics (identification: 1.73 versus 1.76%, P = 0.57; initiation: 27.86 versus 27.02%, P = 0.50; engagement: 11.19 versus 10.97%, P = 0.79). Enrollees in AQC organizations not at risk for behavioral health spending experienced a small increase in the probability of using SUD services (1.83 versus 1.66%; P = 0.003) and the identification performance metric (1.92 versus 1.76%; P = 0.007) and a reduction in SUD medication use (11.84 versus 14.03%; P = 0.03) and the initiation performance metric (23.76 versus 27.02%; P = 0.005)., Conclusions: A global payment and accountable care model introduced in Massachusetts, USA (in which a health insurer provided care providers with fixed prepayments to cover most or all of their patients' care during a specified time-period, incentivizing providers to keep their patients healthy and reduce costs) did not lead to sizable changes in substance use disorder service use during the first 3 years following its implementation., Competing Interests: Mr. Mechanic is a Trustee at Atrius Health, one of the medical groups participating in the AQC. Kenneth Duckworth is an employee at Blue Cross Blue Shield of Massachusetts., (© 2016 Society for the Study of Addiction.)

Background and Objectives: A Stage II, two-site randomized clinical trial compared the manualized, single-gender Women's Recovery Group (WRG) to mixed-gender group therapy (Group Drug Counseling; GDC) and demonstrated efficacy. Enhanced affiliation and support in the WRG is a hypothesized mechanism of efficacy. This study sought to extend results of the previous small Stage I trial that showed the rate of supportive affiliative statements occurred more frequently in WRG than GDC., Methods: Participants (N = 158; 100 women, 58 men) were 18 years or older, substance dependent, and had used substances within the past 60 days. Women were randomized to WRG (n = 52) or GDC (n = 48). Group therapy videos were coded by two independent raters; Rater 1 coded 20% of videos (n = 74); Rater 2 coded 25% of videos coded by Rater 1 (n = 19)., Results: The number of affiliative statements made in WRG was 66% higher than in GDC. Three of eight affiliative statement categories occurred more frequently in WRG than GDC: supportive, shared experience, and strategy statements., Discussion and Conclusions: This larger Stage II trial provided a greater number of group therapy tapes available for analysis. Results extended our previous findings, demonstrating both greater frequency of all affiliative statements, as well as specific categories of statements, made in single-gender WRG than mixed-gender GDC., Scientific Significance: Greater frequency of affiliative statements among group members may be one mechanism of enhanced support and efficacy in women-only WRG compared with standard mixed-gender group therapy for substance use disorders. (Am J Addict 2016;25:573-580)., Competing Interests: Declaration of Interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this paper., (© 2016 American Academy of Addiction Psychiatry.)

Background: Tobacco use is the leading cause of preventable death and disability. New payment and delivery system models including global payment and accountable care have the potential to increase use of cost-effective tobacco cessation services., Objective: To examine how the Alternative Quality Contract (AQC) established in 2009 by Blue Cross Blue Shield of Massachusetts (BCBSMA) has affected tobacco cessation service use., Design: We used 2006-2011 BCBSMA claims and enrollment data to compare adults 18-64 years in AQC provider organizations to adults in non-AQC provider organizations. We examined the AQC's effects on all enrollees; a subset at high risk of tobacco-related complications due to certain medical conditions; and behavioral health service users., Main Measures: We examined use of: (1) any cessation treatment (pharmacotherapy or counseling); (2) varenicline or bupropion; (3) nicotine replacement therapies (NRTs); (4) cessation counseling; and (4) combination therapy (pharmacotherapy plus counseling). We also examined duration of pharmacotherapy use and number of counseling visits among users., Key Results: Rates of tobacco cessation treatment use were higher following implementation of the AQC relative to the comparison group overall (2.02 vs. 1.87 %, p < 0.0001), among enrollees at risk for tobacco-related complications (4.97 vs. 4.66 %, p < 0.0001), and among behavioral health service users (3.67 vs. 3.25 %, p < 0.0001). Statistically significant increases were found for use of varenicline or bupropion alone, counseling alone, and combination therapy, but not for NRT use, pharmacotherapy duration, or number of counseling visits among users., Conclusions: In its initial three years, the AQC was associated with increases in use of tobacco cessation services., Competing Interests: Compliance with Ethical Standards Funders We gratefully acknowledge funding support from the National Institute on Drug Abuse (R01 DA035214; multi-PI Barry and Huskamp; K24DA019855, Greenfield) and the National Institute on Aging (F30-AG039175, Song). Conflict of Interest Those acknowledged received no compensation for their contributions to the study. Dr. Duckworth is an employee of BCBSMA. All other authors declare no conflicts of interest.

Russian Federation's (RF) HIV epidemic is the fastest growing of any country. This study explores factors associated with high HIV risk behavior in tuberculosis (TB) patients with alcohol use disorders in Tomsk, RF. This analysis was nested within the Integrated Management of Physician-delivered Alcohol Care for TB Patients (IMPACT, trial number NCT00675961) randomized controlled study of integrating alcohol treatment into TB treatment in Tomsk. Demographics, HIV risk behavior (defined as participant report of high-risk intravenous drug use and/or multiple sexual partners with inconsistent condom use in the last six months), clinical data, alcohol use, depression and psychosocial factors were collected from 196 participants (161 male and 35 female) at baseline. Forty-six participants (23.5%) endorsed HIV risk behavior at baseline. Incarceration history(Odds Ratio (OR)3.93, 95% confidence interval (CI) 1.95, 7.95), age under 41 (OR:2.97, CI:1.46, 6.04), drug addiction(OR: 3.60 CI:1.10, 11.77), history of a sexually transmitted disease(STD)(OR 2.00 CI:1.02, 3.90), low social capital (OR:2.81 CI:0.99, 8.03) and heavier alcohol use (OR:2.56 CI: 1.02, 6.46) were significantly more likely to be associated with HIV risk behavior at baseline. In adjusted analysis, age under 41(OR: 4.93, CI: 2.10, 11.58), incarceration history(OR: 3.56 CI:1.55, 8.17) and STD history (OR: 3.48, CI: 1.5, 8.10) continued to be significantly associated with HIV risk behavior. Understanding HIV transmission dynamics in Russia remains an urgent priority to inform strategies to address the epidemic. Larger studies addressing sex differences in risks and barriers to protective behavior are needed.

Accountable care using global payment with performance bonuses has shown promise in controlling spending growth and improving care. This study examined how an early model, the Alternative Quality Contract (AQC) established in 2009 by Blue Cross Blue Shield of Massachusetts (BCBSMA), has affected care for mental illness. We compared spending and use for enrollees in AQC organizations that did and did not accept financial risk for mental health with enrollees not participating in the contract. Compared with BCBSMA enrollees in organizations not participating in the AQC, we found that enrollees in participating organizations were slightly less likely to use mental health services and, among mental health services users, small declines were detected in total health care spending, but no change was found in mental health spending. The declines in probability of use of mental health services and in total health spending among mental health service users attributable to the AQC were concentrated among enrollees in organizations that accepted financial risk for behavioral health. Interviews with AQC organization leaders suggested that the contractual arrangements did not meaningfully affect mental health care delivery in the program's initial years, but organizations are now at varying stages of efforts to improve mental health integration., (Project HOPE—The People-to-People Health Foundation, Inc.)

Background: Digital technologies show promise for increasing treatment accessibility and improving quality of care, but little is known about gender differences. This secondary analysis uses data from a multi-site effectiveness trial of a computer-assisted behavioral intervention, conducted within NIDA's National Drug Abuse Clinical Trials Network, to explore gender differences in intervention acceptability and treatment outcomes., Methods: Men (n=314) and women (n=192) were randomly assigned to 12-weeks of treatment-as-usual (TAU) or modified TAU+Therapeutic Education System (TES), whereby TES substituted for 2hours of TAU per week. TES is composed of 62 Web-delivered, multimedia modules, covering skills for achieving and maintaining abstinence plus prize-based incentives contingent on abstinence and treatment adherence. Outcomes were: (1) abstinence from drugs and heavy drinking in the last 4weeks of treatment, (2) retention, (3) social functioning, and (4) drug and alcohol craving. Acceptability was the mean score across five indicators (i.e., interesting, useful, novel, easy to understand, and satisfaction)., Results: Gender did not moderate the effect of treatment on any outcome. Women reported higher acceptability scores at week 4 (p=.02), but no gender differences were detected at weeks 8 or 12. Acceptability was positively associated with abstinence, but only among women (p=.01)., Conclusions: Findings suggest that men and women derive similar benefits from participating in a computer-assisted intervention, a promising outcome as technology-based treatments expand. Acceptability was associated with abstinence outcomes among women. Future research should explore characteristics of women who report less satisfaction with this modality of treatment and ways to improve overall acceptability., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Co-occurring drug use disorders are under-detected in psychiatrically ill populations highlighting the need for more efficient screening tools., Objectives: This study compares a single-item screening tool, previously validated in a primary care setting, to the 10-item Drug Abuse Screening Test (DAST-10) for identifying co-occurring drug use disorders among patients with severe psychiatric illness., Methods: A total of 395 patients attending a psychiatric partial hospital program completed both the single-item screen and DAST-10. A subsample of consecutive patients (n = 67) was also administered the Structure Clinical Interview for DSM-IV (SCID-IV) as a diagnostic reference standard., Results: Concordance between screening measures was moderate (κ = 0.4, p < 0.01). Sensitivity and specificity of the single-item screen and DAST-10 as compared to the SCID-IV were comparable, while area under the receiver operating curve showed better discriminatory power for the identification of drug use disorders with the single-item screen., Conclusions: In comparison to the DAST-10, the single-item screen appears to be a more efficient tool to identify co-occurring drug use disorders in a psychiatric treatment setting among patients with a range of psychiatric diagnoses.

Objective: Insurance coverage for young adults has increased since 2010, when the Affordable Care Act (ACA) required insurers to permit children to remain on parental policies until age 26 as dependents. This study estimated the association between the dependent coverage provision and changes in young adults' use of hospital-based services for substance use disorders and non-substance use psychiatric disorders., Method: The authors conducted a quasi-experimental comparison of a national sample of non-childbirth-related inpatient admissions to general hospitals (a total of 2,670,463 admissions, 430,583 of which had primary psychiatric diagnoses) and California emergency department visits with psychiatric diagnoses (N=11,139,689), using data spanning 2005 to 2011. Analyses compared young adults who were targeted by the ACA dependent coverage provision (19- to 25-year-olds) and those who were not (26- to 29-year-olds), estimating changes in utilization before and after implementation of the dependent coverage provision. Primary outcome measures included quarterly inpatient admissions for primary diagnoses of any psychiatric disorder per 1,000 population; emergency department visits with any psychiatric diagnosis per 1,000 population; and payer source., Results: Dependent coverage expansion was associated with 0.14 more inpatient admissions for psychiatric diagnoses per 1,000 for 19- to 25-year-olds (targeted by the ACA) than for 26- to 29-year-olds (not targeted by the ACA). The coverage expansion was associated with 0.45 fewer psychiatric emergency department visits per 1,000 in California. The probability that inpatient admissions nationally and emergency department visits in California were uninsured decreased significantly., Conclusions: ACA dependent coverage provisions produced modest increases in general hospital psychiatric inpatient admissions and higher rates of insurance coverage for young adults nationally. Lower rates of emergency department visits were observed in California.

Background: This Stage II trial builds on a Stage I trial comparing the single-gender Women's Recovery Group (WRG) to mixed-gender Group Drug Counseling (GDC) that demonstrated preliminary support for the WRG in treating women with substance use disorders. The Stage II trial aims were to (1) investigate effectiveness of the WRG relative to GDC in a sample of women heterogeneous with respect to substance of abuse and co-occurring psychiatric disorders, and (2) demonstrate the feasibility of implementing WRG in an open-enrollment group format at two sites., Method: In this randomized clinical trial, participants were included if they were substance dependent and had used substances within the past 60 days (n=158). Women were randomized to WRG (n=52) or GDC (n=48); men were assigned to GDC (n=58). Substance use outcomes were assessed at months 1-6 and 9., Results: Women in both the WRG and GDC had reductions in mean number of substance use days during treatment (12.7 vs 13.7 day reductions for WRG and GDC, respectively) and 6 months post-treatment (10.3 vs 12.7 day reductions); however, there were no significant differences between groups., Conclusions: The WRG demonstrated comparable effectiveness to standard mixed-gender treatment (i.e., GDC) and is feasibly delivered in an open-group format typical of community treatment. It provides a manual-based group therapy with women-focused content that can be implemented in a variety of clinical settings for women who are heterogeneous with respect to their substance of abuse, other co-occurring psychiatric disorders, and life-stage., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

The goals of the present study were to examine: (a) putative dysfunctions in reward responsiveness in a sample of adolescents ( n = 40) with co-occurring depressive and substance use disorders; (b) possible links between reward responsiveness and symptoms of depression, anhedonia, anxiety, and motivation for change in relation to alcohol and drug use; and (c) potential gender differences in findings. Before and after a 2-week residential treatment, adolescents completed self-report assessments of depression, anhedonia, anxiety symptoms, and motivation for change in relation to substance use. In addition, participants completed a computer-based Probabilistic Reward Task (PRT) to examine reward responsiveness (i.e., participants' ability to modulate behavior as a function of reinforcement history). Results indicated that depression and anhedonia symptoms decreased, and motivation for change in relation to drug use increased. Improved reward responsiveness over the course of residential treatment emerged in female, but not male, participants.

A significant number of women of reproductive age in the United States use addictive substances. In 2012 more than 50% reported current use of alcohol, 20% used tobacco products, and approximately 13% used other drugs. Among women, use of these substances is associated with several significant medical, psychiatric, and social consequences, and the course of illness may progress more rapidly in women than in men. The prevalence of substance use and evidence of accelerated illness progression in women highlight the importance of universal substance use screening in women in primary care settings., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background and Objectives: Open-enrollment group therapy research is challenged by the participant recruitment necessary to ensure continuous group enrollment. We present successful strategies to overcome the following barriers during the Women's Recovery Group (WRG) two-site clinical trial (N = 158): maintenance of sample size and balanced gender randomization during continuous enrollment, maintenance of group attendance, and training and retention of therapists over the 24-month continuous group enrollment., Methods: To increase recruitment, we targeted referral sources yielding the highest enrollment conversion at each site. Group sessions were consistently held regardless of group size. Therapists were trained in two teams allowing for coverage and uninterrupted treatment over 24 months., Results: At both sites recruitment and enrollment increased with each successive quarter. Sample size and end date targets were met without disruptions in treatment. Group therapists reported high satisfaction with their training and treatment experiences., Discussion and Conclusions: These strategies supported targeted enrollment and study duration, stability of open-enrollment group therapy frame, and therapist retention and satisfaction., Scientific Significance: Applying these strategies can aid in providing evidence-based group therapy in both clinical and research settings., (© American Academy of Addiction Psychiatry.)

Background and Objectives: This prospective study uses path analytic models to examine baseline characteristics associated with both functioning and drinking outcomes 12 months after inpatient alcohol treatment., Methods: Alcohol-dependent participants (N = 101) were recruited during inpatient alcohol treatment and assessed monthly 1 year after discharge., Results: Alcohol severity was negatively associated with education and self-efficacy; marital status was positively associated with self-efficacy; and education and self-efficacy were negatively associated with drinking outcomes. Low alcohol severity, not having a depression diagnosis, and being married were associated with less social support impairment, which was in turn associated with better drinking outcomes. Having a history of sexual abuse did not influence drinking outcomes. However, having a history of sexual abuse was negatively associated with global functioning., Conclusions and Scientific Significance: Drinking outcomes were associated with education, self-efficacy, social support, and diagnosis of depression at baseline; however, global functioning 1 year following treatment was primarily and negatively associated with sexual abuse history. Future treatment research should include measures of both functioning and drinking behavior outcomes., (© American Academy of Addiction Psychiatry.)

Importance: Young adults have high levels of behavioral health needs but often lack health insurance. Recent health reforms have increased coverage, but it is unclear how use of hospital-based care changed after expanding insurance. OBJECTIVE To evaluate the association between health insurance coverage expansions and use of hospital-based care among young adults with behavioral health diagnoses., Design, Setting, and Participants: Quasi-experimental analyses of community hospital inpatient and emergency department use from 2003-2009 based on hospital discharge data, comparing differential changes in service use among young adults with behavioral health diagnoses in Massachusetts vs other states before and after Massachusetts' 2006 health reform. This population-based sample included inpatient admissions (n = 2,533,307, representing 12,821,746 weighted admissions across 7 years) nationwide and emergency department visits (n = 6,817,855 across 7 years) from Maryland and Massachusetts for 12- to 25-year-old patients., Main Outcomes and Measures: Inpatient admission rates per 1000 population for primary diagnosis of any behavioral health disorder by diagnosis; emergency department visit rates per 1000 population by behavioral health diagnosis; and insurance coverage for hospital discharges., Results: After 2006, uninsurance among 19- to 25-year-old individuals in Massachusetts decreased from 26% to 10% (16 percentage points; 95% CI, 13-20). Young adults experienced relative declines in inpatient admission rates of 2.0 per 1000 for primary diagnoses of any behavioral health disorder (95% CI, 0.95-3.2), 0.38 for depression (95% CI, 0.18-0.58), and 1.3 for substance use disorder (95% CI, 0.68-1.8). The increase in emergency department visits with any behavioral health diagnosis after 2006 was lower among young adults in Massachusetts compared with Maryland (16.5 per 1000; 95% CI, 11.4-21.6). Among young adults in Massachusetts, the percentage of behavioral health discharges that were uninsured decreased by 5.0 (95% CI, 3.0-7.2) percentage points in inpatient settings and 5.0 (95% CI, 1.7-7.8) percentage points in emergency departments relative to other states., Conclusions and Relevance: Expanded health insurance coverage for young adults was not associated with large increases in hospital-based care for behavioral health, but it increased financial protection for young adults with behavioral health diagnoses and for the hospitals that care for them.

Objective: Self-report measures of alcohol misuse and alcohol use disorders are valuable assessment tools for both research and clinical practice settings. However, readability is often overlooked when establishing the validity of these measures, which may result in measures written at a reading-grade level that is higher than the ability level of many potential respondents. The aim of the current study was to estimate the reading-grade level of validated measures of alcohol misuse and associated problems., Method: A total of 45 measures were identified, and reading-grade level was calculated using three validated readability formulas., Results: The majority of measures were written above the recommended reading-grade level for patient materials (5th-6th grade), with particularly poor readability for measure instructions., Conclusions: Given that many self-report alcohol misuse measures are written at a high reading-grade level, the consideration of readability is important when selecting measures for use in research and practice settings. Moreover, the development or modification of measures to target low-literacy populations may facilitate the broader applicability of these instruments.

Aims: To test the feasibility and effectiveness of brief counseling intervention (BCI) and naltrexone integrated into tuberculosis (TB) care in Tomsk, Russia., Design: Using a factorial randomized controlled trial design, patients were randomized into: naltrexone (NTX), brief behavioral compliance enhancement therapy (BBCET), treatment as usual (TAU) and BCI., Setting and Participants: In the Tomsk Oblast, hospitalized TB patients diagnosed with alcohol use disorders (AUDs) by the DSM-IV were referred at the start of TB treatment. Of the 196 participants, the mean age was 41 years and 82% were male. Severe TB (84.7% had cavitary disease) and smoking (92.9%) were common. The majority had a diagnosis of an AUD (63.0%); 27.6% reported nearly daily drinking and consumed a median of 16 standard drinks per day., Measurements: Primary outcomes were 'favorable' TB outcome (cured, completed treatment) and change in mean number of abstinent days in the last month of study compared with baseline. Change in mean number of heavy drinking days, defined as four drinks per day and five drinks per day for women and men, respectively, and TB adherence, measured as percentage of doses taken as prescribed under direct observation, were secondary outcomes. Analysis based on 'intention-to-treat' was performed for multivariable analysis., Findings: Primary TB and alcohol end-points between naltrexone and no-naltrexone or BCI and no-BCI groups did not differ significantly. TB treatment adherence and change in number of heavy drinking days also did not differ significantly among treatment arms. Among individuals with a prior quitting attempt (n = 111), naltrexone use was associated with an increased likelihood of favorable TB outcomes (92.3% versus 75.9%, P = 0.02)., Conclusions: In Tomsk Oblast, Russia, tuberculosis patients with severe alcohol use disorders who were not seeking alcohol treatment did not respond to naltrexone or behavioral counselling integrated into tuberculosis care; however, those patients with past attempts to quit drinking had improved tuberculosis outcomes., (© 2013 The Authors, Addiction © 2013 Society for the Study of Addiction.)

Although gender differences in substance use disorders have been identified, few studies have examined gender differences in prescription drug dependence. The aim of this study was to examine gender differences in clinical characteristics and treatment outcomes in a large clinical trial for prescription opioid dependence. Despite no pre-treatment differences in opioid dependence severity, women reported significantly greater functional impairment, greater psychiatric severity, and higher likelihood of using opioids to cope with negative affect and pain than men. Women were also more likely than men to have first obtained opioids via a legitimate prescription and to use opioids via the intended route of administration. Men reported significantly more alcohol problems than women. There were no significant gender differences in medication dose, treatment retention, or opioid outcomes. Thus, despite the presence of pre-treatment gender differences in this population, once the study treatment was initiated, women and men exhibited similar opioid use outcomes., (Copyright © 2013 Elsevier Inc. All rights reserved.)

The present study of women with substance use disorders used grounded theory to examine women's experiences in both the Women's Recovery Group (WRG) and a mixed-gender Group Drug Counseling (GDC). Semi-structured interviews were completed in 2005 by 28 women in a U.S. metropolitan area. Compared to GDC, women in WRG more frequently endorsed feeling safe, embracing all aspects of one's self, having their needs met, feeling intimacy, empathy, and honesty. In addition, group cohesion and support allowed women to focus on gender-relevant topics supporting their recovery. These advantages of single-gender group therapy can increase treatment satisfaction and improve treatment outcomes.

Background and Objectives: We assessed the feasibility of a new cognitive behavioral therapy (CBT) manual, plus transdermal patch nicotine replacement therapy (NRT), to treat co-occurring nicotine and cannabis dependence., Method: Seven of 12 (58.3%) adults with DSM-IV diagnoses of both nicotine and cannabis dependence completed 10 weeks of individual CBT and NRT., Results: Participants smoked 12.6 ± 4.9 tobacco cigarettes per day at baseline, which was reduced to 2.1 ± 4.2 at the end of treatment (F[5]  = 23.5, p < .0001). The reduction in cannabis use from 10.0 ± 5.3 inhalations per day at baseline to 8.0 ± 5.3 inhalations per day at 10 weeks was not significant (F[5]  = 1.12, p = .37). There was a significant decrease from the mean baseline Fagerstrom Test for Nicotine Dependence scores at weeks 4, 6, 8, and 10 of treatment (F[4]  = 19.8, p < .001) and mean Client Satisfaction Questionnaire scores were uniformly high (30.6 ± 1.9)., Conclusions and Scientific Significance: A CBT plus NRT treatment program significantly reduced tobacco smoking but did not significantly reduce cannabis use in individuals with co-occurring nicotine and cannabis dependence. There was no compensatory increase in cannabis use following the reduction in tobacco smoking, suggesting that clinicians can safely pursue simultaneous treatment of co-occurring nicotine and cannabis dependence. The intervention was well-liked by the 7 of the 12 enrollees who completed the study., (Copyright © American Academy of Addiction Psychiatry.)

Background: HIV infection disproportionately impacts minorities; yet research on racial/ethnic differences in the prevalence and correlates of HIV risk behaviors is limited., Objective: This study examined racial/ethnic differences in the rates of HIV risk behaviors and whether the relationship between HIV risk factors and HIV risk behaviors varies by race/ethnicity in clients participating in NIDA Clinical Trials Network trials., Results: The sample was 41% non-Hispanic White, 32% non-Hispanic Black, and 27% Hispanic (N = 2,063). HIV risk behaviors and measures of substance and psychosocial HIV risk factors in the past month were obtained. Non-Hispanic Blacks engaged in less HIV sexual risk behaviors overall than non-Hispanic Whites. While non-Hispanic Whites were the most likely to report any injection drug use, Hispanics engaged in the most HIV drug risk behaviors. Specific risk factors were differentially predictive of HIV risk behavior by race/ethnicity. Alcohol use severity was related to engaging in higher sex risk behaviors for non-Hispanic Blacks and Whites. Greater psychiatric severity was related to engaging in higher sex risk behaviors for non-Hispanic Whites. Drug use severity was associated with engaging in higher risk drug behaviors for non-Hispanic Whites and Hispanics with the magnitude of the relationship stronger for Hispanics., Conclusions: These findings highlight the need for further research testing HIV risk prevention interventions within racial/ethnic groups to identify target behaviors or risk factors that are salient to inform HIV interventions., Scientific Significance: The present study provides a systematic examination of race/ethnicity differences in the relationship between psychosocial risk factors and HIV risk behaviors., (Copyright © American Academy of Addiction Psychiatry.)

Background: For substance abuse treatment-seekers engaging in high risk sexual behavior, their inconsistent condom use may be related to their condom use attitudes and skills., Objective: This study compared treatment-seeking male and female substance abusers in their reported barriers to condom use and condom use skills., Methods: Men and women (N = 1,105) enrolled in two multi-site HIV risk reduction studies were administered the Condom Barriers Scale, Condom Use Skills, and an audio computer-assisted structured interview assessing sexual risk behavior., Results: Men endorsed more barriers to condom use, especially on the Effects on Sexual Experience factor. For both men and women, stronger endorsement of barriers to condom use was associated with less use of condoms. However, the difference between condom users and non-users in endorsement of condom barriers in general is greater for men than women, especially for those who report having casual partners., Conclusions: Findings support the need to focus on gender-specific barriers to condom use in HIV/STI prevention interventions, especially risk behavior intervention techniques that address sexual experience with condoms., Scientific Significance: Results provide additional information about the treatment and prevention needs of treatment-seeking men and women., (Copyright © American Academy of Addiction Psychiatry.)

Enhanced affiliation among members is thought to provide increased support for women in single-gender compared with mixed-gender group therapy for substance use disorders (SUDs) and to provide a potential mechanism of action for its efficacy. In a Stage I trial of single-gender versus mixed-gender group therapy for SUDs we examined affiliative statements made by members in two group treatments, single-gender Women's Recovery Group (WRG) and mixed-gender Group Drug Counseling (GDC). Twenty-eight WRG and 17 GDC group therapy tapes were coded and compared for five types of affiliative statements. Three types of affiliative statements (agreement, supportive, and completing a thought) were highly correlated and were more frequent in WRG than GDC (D=0.882, p=0.27). In GDC, women were more likely to provide an affiliative statement to a male group member than any other combination of directionality (p<0.01). Compared with mixed-gender, single-gender group therapy for SUDs may enhance support through greater frequency of affiliative statements.

The Children's Health Insurance Program (CHIP) plays a vital role in financing behavioral health services for low-income children. This study examines behavioral health benefit design and management in separate CHIP programs on the eve of federal requirements for behavioral health parity. Even before parity implementation, many state CHIP programs did not impose service limits or cost sharing for behavioral health benefits. However, a substantial share of states imposed limits or cost sharing that might hinder access to care. The majority of states use managed care to administer behavioral health benefits. It is important to monitor how states adapt their programs to comply with parity.