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

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

We evaluated the influence of psychotherapy attendance on treatment outcome in 90 dually (cocaine and heroin) dependent outpatients who completed 70 days of a controlled clinical trial of sublingual buprenorphine (16 mg, 8 mg, or 2 mg daily, or 16 mg every other day) plus weekly individual standardized interpersonal cognitive psychotherapy. Treatment outcome was evaluated by quantitative urine benzoylecgonine (BZE) and morphine levels (log-transformed), performed three times per week. Repeated-measures linear regression was used to assess the effects of psychotherapy attendance (percent of visits kept), medication group, and study week on urine drug metabolite levels. Mean psychotherapy attendance was 71% of scheduled visits. Higher psychotherapy attendance was associated with lower urine BZE levels, and this association grew more pronounced as the study progressed (p=0.04). The inverse relationship between psychotherapy attendance and urine morphine levels varied by medication group, being most pronounced for subjects receiving 16 mg every other day (p=0.02). These results suggest that psychotherapy can improve the outcome of buprenorphine maintenance treatment for patients with dual (cocaine and opioid) dependence.

We examined the effect peers have on Temporary Assistance to Needy Families (TANF) recipients' employment behavior. Nondrug using and chronic drug using TANF recipients (n=433) participating in a study funded by the National Institute on Drug Abuse were asked how many of the people they regularly spent time with over the past 4 months had jobs and how many of them encouraged the individual to look for work. Results of a path analysis showed that age, education, and chronic drug use were significantly related to the nature of peer relationships. A significant and positive association between the number of peers that worked and the number of hours worked in the following 4 months was observed. Examining the effect of peers on labor force participation by TANF recipients is necessary to assist recipients in securing and maintaining employment.

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

Objective: This study assessed the need over time for treatment of personal adjustment and substance abuse problems among chronic drug using and other recipients of Temporary Assistance for Needy Families (TANF)., Methods: Participants were administered the personal adjustment problems and substance abuse problems scales contained in the Multidimensional Addictions and Personality Profile (MAPP) at intake, one-year, and two-year interviews., Results: Most participants who were not chronic users had total scale scores that would indicate no recommended referral or a referral to outpatient treatment. Approximately one-third of chronic users had scores that would indicate referral to inpatient treatment. Many chronic users had comorbid conditions but reported receiving no psychological or substance abuse treatment., Conclusions: Many TANF recipients may be experiencing coexisting personal and substance abuse related problems that are going untreated.

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

Background: Buprenorphine is a partial mu-opiate agonist and kappa-opiate antagonist with established efficacy in the treatment of opiate dependence. Its efficacy for cocaine dependence is uncertain. This study evaluated buprenorphine for the treatment of concomitant cocaine and opiate dependence., Methods: Two hundred outpatients currently dependent on both cocaine and opiates were randomly assigned to double-blind groups receiving a sublingual solution of buprenorphine (2, 8, or 16 mg daily, or 16 mg on alternate days, or placebo), plus weekly individual drug abuse counseling, for 13 weeks. The chief outcome measures were urine concentrations of opiate and cocaine metabolites (quantitative) and proportion of urine samples positive for opiates or cocaine (qualitative). Group differences were assessed by use of mixed regression modeling., Results: The target dose of buprenorphine was achieved in 179 subjects. Subjects receiving 8 or 16 mg buprenorphine daily showed statistically significant decreases in urine morphine levels (P =.0135 for 8 mg and P <.001 for 16 mg) or benzoylecgonine concentrations (P =.0277 for 8 mg and P =.006 for 16 mg) during the maintenance phase of the study. For the 16-mg group, mean benzoylecgonine concentrations fell from 3715 ng/mL during baseline to 186 ng/mL during the withdrawal phase; mean morphine concentrations fell from 3311 ng/mL during baseline to 263 ng/mL during withdrawal. For the 8-mg group, mean benzoylecgonine concentrations fell from 6761 ng/mL during baseline to 676 ng/mL during withdrawal; mean morphine concentrations fell from 3890 ng/mL during baseline to 661 ng/mL during withdrawal. Qualitative urinalysis showed a similar pattern of results. Subjects receiving the highest dose showed concomitant decreases in both urine morphine and benzoylecgonine concentrations. There were no significant group differences in treatment retention or adverse events., Conclusions: A sublingual buprenorphine solution at 16 mg daily is well tolerated and effective in reducing concomitant opiate and cocaine use. The therapeutic effect on cocaine use appears independent of that on opiate use.

Objective: Violence and homicide are more prevalent in Colombia, South America, than in the United States, but the role of psychosocial factors in the violent behavior of Colombian adolescents remains unclear. The objective of the study was to identify personality, familial, peer, and ecological variables associated with violence in Colombian adolescents., Method: A survey of adolescents was conducted in 1995-1996. A standard self-report measure was adapted to ensure linguistic and cultural relevance. A total of 2,837 adolescents ages 12-17 years from various self-reported ethnic groups were randomly selected from the community in three Colombian cities: Bogota, Medellin, and Barranquilla. Eighty percent of eligible adolescents agreed to participate. Data were collected concerning the adolescent's personality attributes, family characteristics, peer characteristics, and ecological/cultural factors, including the availability of illicit drugs and the prevalence of violence in the community. The dependent variable was the adolescent's self-reported frequency of violent behavior., Results: Violence directed at the adolescent and the adolescent's own drug use were both more highly correlated with the adolescent's violent behavior than were other risk factors. Significant risk factors of less importance included tolerance of deviance, peer drug use, peer deviance, and exposure to violence on television., Conclusions: The results supported a model in which violent behavior was correlated independently with a number of risk factors from several domains. The findings point to the use of specific intervention procedures for adolescents to prevent their own subsequent acts of violent behavior.

Background: To review the reliability and validity literature and develop an understanding of these concepts as applied to managed care studies., Results: Reliability is a test of how well an instrument measures the same input at varying times and under varying conditions. Validity is a test of how accurately an instrument measures what one believes is being measured., Methods: A review of reliability and validity instructional material was conducted., Conclusions: Studies of managed care practices and programs abound. However, many of these studies utilize measurement instruments that were developed for other purposes or for a population other than the one being sampled. In other cases, instruments have been developed without any testing of the instrument's performance. The lack of reliability and validity information may limit the value of these studies. This is particularly true when data are collected for one purpose and used for another. The usefulness of certain studies without reliability and validity measures is questionable, especially in cases where the literature contradicts itself

Older racial and ethnic minorities are a rapidly growing segment of the population. HIV infection disproportionately affects minorities of all ages, presenting new challenges in research, prevention, and treatment of HIV infection. Cultural characteristics coupled with changing values and age-related beliefs can present some atypical challenges to HIV researchers and clinicians. Family relationships, language barriers, and the psychology of aging complicate these challenges even further. Older minorities also experience certain stigmas that the added burden of HIV infection only exacerbates. Effective research, prevention, and treatment must begin with sensitivity to the varied characteristics of older minorities.

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

Context: Drug use is a primary route for the transmission of the Hepatitis C virus (HCV). A substantial proportion of welfare recipients have been shown to be substance abusers. In addition, federal legislation has imposed limits on the number of months individuals may receive benefits and has mandated most recipients to participate in a 'work activity' in exchange for benefits. HCV symptoms may inhibit welfare recipients' ability to seek and maintain employment., Objective: To assess the prevalence of HCV in a sample of Temporary Assistance to Needy Families (TANF) recipients and the effects of HCV antibody seropositivity on employability., Design, Setting, and Participants: The sample for this study consisted of 380 individuals participating in a longitudinal study of employment patterns among TANF recipients in Houston, TX, funded by the National Institute on Drug Abuse (NIDA). Private interviews regarding welfare receipt, employment, and drug use were conducted at intake into the study and at 4-month intervals for one year. Participants agreed to a one-time blood test. Blood samples were tested for the presence of HCV antibodies by enzyme linked immunoassay., Main Outcome Measure: Employment status over time by HCV antibody status., Results: Overall, 12% of all participants tested positive for the presence of HCV antibodies. A significantly greater proportion of chronic drug users (31%) than non-drug users (4%) tested positive for the presence of Hepatitis C antibodies. Those who tested positive for hepatitis C had significantly lower rates of employment., Conclusions: Potential infection with Hepatitis C may constitute an employment barrier for many welfare recipients.

Context: Treating high-risk substance abusers who are members of minority groups may require varied protocols depending on differences among minority groups., Objectives: To explore cocaine abuse (CA)/ dependence with physiological dependence (CDPD) and posttraumatic stress disorder (PTSD) diagnosis differences between out-of-treatment Hispanic and African American adults, in order to identify cultural differences in how experiences and attitudes affect cocaine use behaviors., Design, Setting, and Participants: This study uses data collected between February and November 2000, as part of a three-year longitudinal study. A cohort of 347 out-of-treatment, Hispanic and African American cocaine-using adults from the Houston metropolitan area were interviewed to measure differences between cocaine users who are dually diagnosed and those that are not., Main Outcome Measures: Meeting the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. criteria for dual diagnoses of CA/PTSD or CDPD/PTSD., Results: For the dual diagnoses categories, 102 (29%) participants met the requirements for CA/PTSD or CDPD/PTSD. Logistic regression models were used, with CA/PTSD and CDPD/PTSD as the dependent variables. Age, race, gender, and income were used as the independent variables. Results indicate that individuals with higher income have a greater probability of developing CA/PTSD (beta = 0.919, p < 0.05). For both dual diagnoses categories of CA/PTSD and CDPD/ PTSD, results indicate that being female increases the likelihood of developing both of these dual diagnoses, (beta = 2.106, p < 0.05) or (beta = 2.510, p < 0.05). However, being an older female decreases the probability that an individual would develop these dual diagnoses (beta = -2.227, p < 0.05) (beta = -2.577, p < 0.05)., Conclusions: No differences were found for race/ethnicity among the dually diagnosed Hispanics and African Americans, however, gender differences were found. Being female increases an individual's probability of developing a dual diagnosis of CA/PTSD or CDPD/PTSD. In addition to being female, being a young female further increases an individual's probability of being dually diagnosed.

The purpose of this open-label, uncontrolled study was to evaluate the feasibility of administering off-label buprenorphine in combination with ancillary medications for inpatient short-term detoxification of heroin-dependent patients at a psychiatric facility. A sample of 20 heroin-dependent patients admitted to an urban psychiatric hospital was administered buprenorphine 6, 4, and 2 mg/day during the first, second, and third day of detoxification, respectively, and then observed during the fourth and fifth day. Eighty-five percent of the subjects abused other substances, 75% reported cocaine abuse/dependence, 75% had comorbid mood disorders. All subjects completed the medication phase of the study. No clinically significant adverse events were reported. There was a significant decrease in the Clinical Investigation Narcotic Assessment (CINA) total score between baseline and days 2 through 5. The results suggest that buprenorphine is well tolerated and may be beneficial for medically supervised short-term withdrawal from heroin for hospitalized psychiatric patients., (Copyright 2002 Elsevier Science Inc.)

This study is an initial effort to use network data to forecast the spread of HIV in a large U.S. city. Data were collected from a sample of drug users and sociodemographically matched nonusers in low-income areas of Houston, Texas. Two sample-based HIV prevalence models and two sociological models were combined with three published biological models to yield forecasts of the growth of HIV seroprevalence. The forecasts predict a compounded annual growth in HIV of between 2.4% and 16.5% among low-income residents of Houston's inner city. These results suggest that forecasts are most sensitive to the nature of the sociological model used. A random mixing model showed about a threefold overestimate of 20-year projected seroprevalence compared with the empiric network data. Thus, the collection of additional social network data is probably the most important requirement for more accurate projections.

This study examines the effects of drug use and work requirements on psychological distress and employment among chronic drug-using and non-drug-using welfare recipients. Using a natural history design, 442 female Temporary Assistance for Needy Families (TANF) recipients (including 251 with chronic drug use problems) were interviewed every 4 months in order to assess changes in psychological functioning, employment status, and wages. Data from the first year (four waves) indicate that employment and wages increased substantially, though less so for drug users than non-drug users. Psychological distress decreased only slightly over the study period. Growth curve analyses show that drug use had no direct effect on wages; however, drug use did significantly increase psychological distress. Both the work mandate and psychological distress contributed to wages. The authors consider the implications of these trends for the mental health service needs of drug-using TANF recipients.

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

Objectives: The purpose of this study was to provide an overview of welfare reform and its impact on the substance-abusing recipient., Methods: The data for this paper were derived from sources including the US Department of Health and Human Services and the National Institute on Drug Abuse., Results: The number of individuals on public assistance has decreased in the years following implementation of welfare reform legislation. Factors relevant to transitioning welfare recipients into the workplace, such as transportation and childcare, have special ramifications for the drug-using population. Additionally, these individuals require treatment for their addictions in order to become employable. The issue of concern is that recipients may be deterred from seeking benefits by various provisions of welfare reform legislation and turn instead to other sources (including illicit activities) for sustenance., Conclusions: Welfare caseloads have been dropping over the past two years. However, the number of substance abusers continues to rise. It is not known in what ways welfare reform will affect substance abusers who are welfare recipients. Important policy issues arise from this nexus; it is argued that these issues will require careful investigation.

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

Purpose: The purpose of this study was to compare HIV/AIDS related knowledge and beliefs in two cohorts of economically disadvantaged adolescents (n = 132). Participants were between 15 and 21 years old, predominately African-American and Hispanic, and participants in a Job Training Partnership Act (JTPA) summer program. The hypothesis was that adolescent HIV/AIDS-related knowledge would be higher in 1999 than in 1994., Methods: A cohort of sixty-six (66) adolescents were surveyed in 1994 and another cohort of 66 adolescents was surveyed again in 1999, all participating in the JTPA program. Participants' knowledge and beliefs were assessed using the National Adolescent Student Health Survey., Results: A statistically significant increase in overall HIV/AIDS knowledge occurred between the two measurements. Fifty-five percent (55.6%) of the 1999 cohort believed that HIV could be contracted by donating blood, compared to 47.5% of the 1994 cohort. Belief that it is more likely to become infected with the AIDS virus through male to male sex was higher in 1999 by 2% and was 10% higher for female to female sex., Conclusions: Adolescent misconceptions/misinformation, gender-based lack of knowledge, increased perception of immunity from HIV infection, and a reported reduction in health education courses were all factors in the adolescents' continued engagement in risky sexual activities. Given these findings, and that AIDS is predicted to be one of the top five causes of death among young people, increased gender- and ethnic-specific HIV intervention programs are recommended.

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

Objective: To determine changes in clinical manifestations and cerebral blood flow (CBF) before and after administration of ECT to patients with catatonia due to schizophrenia or mood disorders., Methods: A sample of nine patients who met DSM-IV criteria for catatonia was studied. Patients received between 5 and 15 sessions (thrice per week) of ECT. Severity of catatonia was measured with the Modified Rogers Scale (MRS). Changes in CBF were measured with a brain single positron emission computer tomography (SPECT) that was performed 1 week before the first ECT and 1 week after the last ECT., Results: Catatonia was due to schizophrenia in five patients and mood disorders in four patients. There were no significant clinical and brain SPECT differences between these two groups before treatment. Pre- vs. post-ECT comparisons showed significant reduction of catatonic symptoms in both groups. However, patients with mood disorders needed less ECT sessions and showed greater clinical improvement. Brain SPECT showed significant increase in CBF in parietal, temporal, and occipital regions in patients with mood disorder and no significant changes in patients with schizophrenia., Conclusions: These results support the efficacy of ECT for treatment of catatonic patients, especially secondary to mood disorders, which seem to be correlated with improvements in CBF.

Objective: To evaluate the accuracy of self reports on sexual and drug use behaviors., Methods: Data from a network study of HIV transmission among a sample of drug users and nonusers are used to compare reports of sexual and drug use behaviors by partners who engaged in those behaviors. Partner concordance (self-report agreement between two people) was used as an estimate of validity., Results: Results showed that persons are able to recall and report about 85% of their recent partners (15%-20% less for recent drug use partners). For relationships that were reported by both partners, a high degree of concordance existed about recent behaviors (83%-96%) and variable agreement about frequency (0.48

Background: The goal of this study was to describe the sociodemographic and clinical characteristics and routine psychiatric care of depressed patients with or without substance use disorders (SUDs) and to assess the association between the presence of comorbid SUD and the psychiatric management of patients with depression., Method: Each of a sample of 531 psychiatrists participating in the Practice Research Network (PRN) of the American Psychiatric Institute for Research and Education was asked to provide information about 3 randomly chosen patients. Data were collected using a self-administered questionnaire, which generated detailed diagnostic and clinical data on 1228 psychiatric patients. Weighted data were analyzed using the SUDAAN software package. Multivariate logistic regression was used to compare depressed patients with and without SUD., Results: A total of 595 patients (48.4%) were diagnosed with depression (DSM-IV criteria). The prevalence of SUD (excluding nicotine dependence) in this group was 18.1%. The group with SUD had a significantly larger proportion of males, young adults, patients seen in public general hospitals, and non-managed care public plans. No significant group differences were found for primary payer, locus of care, length of treatment, type of current or past treatment, and prescription of medications. Only 2.2% of SUD patients were prescribed with an anti-SUD medication (i.e., disulfiram and naltrexone)., Conclusion: Concomitant SUDs have little effect on the routine psychiatric care of depressed patients. Efforts should be made to improve the identification and management of depressed patients with SUD.

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

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

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

Objective: The authors investigated the occurrence of pathological gambling among cocaine-dependent outpatients, its influence on short-term outcome of treatment, and comparative characteristics of patients with and without pathological gambling., Method: The subjects were 313 cocaine-dependent (200 also opiate-dependent) outpatients in clinical trials of medication for cocaine dependence. Pathological gambling (DSM-III-R criteria) was assessed with the Diagnostic Interview Schedule, and sociodemographic and socioeconomic characteristics were determined with the Addiction Severity Index. Outcome was defined as time in treatment (proportion of maximum scheduled time) and proportion of cocaine-positive urine samples during treatment., Results: Pathological gambling had a lifetime occurrence rate of 8.0% and a current (past month) occurrence of 3.8%. Onset preceded the onset of cocaine dependence in 72.0% of the patients (and preceded onset of opiate dependence in 44.4%). Patients with pathological gambling (lifetime or current) did not differ significantly from other patients in length of treatment or proportion of cocaine-positive urine samples. Those with lifetime pathological gambling were significantly more likely to have tobacco dependence (84.0% versus 61.1%) and antisocial personality disorder (56.0% versus 19.8%), to be unemployed (84.0% versus 49.3%), to have recently engaged in illegal activity for profit (64.0% versus 38.5%), and to have been incarcerated (62.5% versus 33.9%)., Conclusions: Pathological gambling is substantially more prevalent among cocaine-dependent outpatients than in the general population. Patients with pathological gambling differ from other cocaine-dependent outpatients in some sociodemographic characteristics but not in short-term outcome of treatment for cocaine dependence.

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

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

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

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

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

Objective: To evaluate the effectiveness, efficiency, and equity of behavioral healthcare and to guide an assessment of the current state of the art of behavioral health-oriented health services research., Study Design: The framework is grounded in previous conceptual work by the authors in defining a prevention- and outcomes-oriented continuum of healthcare and in identifying and integrating the concepts and methods of health services research and policy analysis for assessing healthcare system performance., Patients and Methods: The defining assumptions are that (1) the denominator for behavioral healthcare services must encompass a look at the population, not just the patients, who manifest behavioral health risks; and (2) the delivery system to address these needs must extend beyond acute, treatment-oriented services to include both primary prevention and aftercare services for chronic relapsing conditions., Results: Current policy and practice in behavioral healthcare reveal the absence of a comprehensive, coordinated continuum of care; substantial variation in policy and financial incentives to encourage such development; and poorly defined or articulated outcome goals and objectives. The current state of the art of research in this area reflects considerable imprecision in conceptualizing and measuring the effectiveness, efficiency, and equity criteria. Further, these 3 criteria have not been examined together in evaluating system performance., Conclusions: The first era of behavioral healthcare focused on cost savings in managed care alternatives; the second is focusing on quality and outcomes; a third must consider the issues of equity and access to behavioral healthcare, especially for the most seriously ill and vulnerable, in an increasingly managed care-dominated public and private policy environment.

Objective: To estimate and compare the HIV risks among three Hispanic subpopulations., Methods: Chronic drug users participating in a nationwide intervention study on drug use were interviewed with regard to drug use and sexual behavior. HIV risk was estimated using information about individuals' HIV-relevant behaviors, the social context (i.e., city) in which such behaviors occur, and published estimates of HIV transmission for various risk behaviors. Multiple linear regression analysis was used to investigate differences in estimated HIV risk between Puerto Rican, Mexican-American, and Mexican drug users, accounting for sociodemographic factors, sexual preference, and geographic region., Results: Puerto Ricans had significantly greater estimated overall HIV risk, estimated injection risk, and in general, significantly greater estimated sexual risk than Mexican Americans and Mexicans. No significant differences were found in any estimated risk between Mexican Americans and Mexicans in this sample. No significant differences were found among any of the subgroups for estimated risk from having anal sex while using a condom, or from having receptive anal sex without using a condom., Conclusions: These findings suggest that Puerto Ricans who use drugs experience a higher risk of HIV infection than other Hispanic drug users. Research is needed to identify which economic, social, and cultural components account for this increased risk.

Objectives: To identify general and differentiating risk and protective factors from domains of culture and ecology, peer, family, and personality, related to adolescent delinquency and marijuana use, and to study the protective role of the parent-child mutual attachment in offsetting cultural and ecological risk factors, leading to less delinquency and marijuana use., Design: Cross-sectional analyses of interview data collected in Colombia., Participants: A total of 2837 Colombian adolescents, 12 to 17 years of age., Setting: Adolescents were interviewed in their homes., Main Measures: Independent variables included measures from 4 domains: culture and ecology, peer, family, and personality. The dependent variables were delinquency and marijuana use., Results: Several risk factors, such as tolerance of deviance and sensation seeking, were similarly related to both delinquency and marijuana use, suggesting that a common cause underlies the propensity to engage in different deviant behaviors. Some risk factors were more involved in delinquency and other risk factors were more highly related to the adolescent's marijuana use. Finally, when violence is endemic and illegal drugs are readily available, a close parent-child bond was capable of mitigating these risk factors, leading to less marijuana use and delinquency., Conclusions: The findings have implications for public health policy related to interventions in countries in which violence and drug use are prevalent. The results point to interventional procedures aimed at adolescents vulnerable to marijuana use and delinquency as well as efforts aimed at specific vulnerabilities in these areas. For example, reducing the risk factors and enhancing the protective factors for marijuana use and delinquency may result in less adolescent marijuana use and delinquency.

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

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

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

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

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

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

Objective: To understand how the prevalence of anemia, human immunodeficiency virus (HIV), and syphilis in a sample of out-of-treatment drug users affected delivery of care in a managed care model., Study Design: A snowball sampling design with multiple zero order contacts was used in targeted census tracts with a high incidence of illicit drug use and sexually transmitted diseases., Patients and Methods: Out-of-treatment drug users were recruited as part of a national multisite study of HIV risk behaviors in this population. Subjects were recruited using targeted community-based sampling., Results: The rate of individuals who tested positive for both syphilis and HIV was 2.5 times greater than those who tested positive for syphilis only and 2.8 times greater than those who tested positive for HIV only. Of the men, 16.1% were anemic, and 33.3% of women were anemic. Rates of HIV (10.7%) and syphilis (19.8%) were found to be high among both male and female drug users. These statistics, coupled with the prevalence of anemia, indicate that drug users have many more problems other than drug use, a conclusion which can have an impact on how managed care plans approach drug users., Conclusion: A multipronged interdisciplinary approach may be warranted for both the patient and the managed care organization.

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

Objective: To examine the linkages, cultural/ecological factors, and major psychosocial risk factors as they relate to drug use in a sample from Colombia, South America., Method: The participants were 1.687 adolescents living in mixed urban-rural communities in Colombia, South America. An individual interview was administered to youths in their homes by Colombian interviewers. The scales used were based on item intercorrelations grouped into the following risk categories: (1) adolescent personality, (2) family traits, (3) peer factors, and (4) cultural/ecological variables., Results: Pearson correlations were computed for each variable and the frequency of marijuana use. Results show that each of the domains was related to adolescent marijuana use, with some notable gender differences. As regards the interrelation of domains, a mediational model was operative., Conclusions: Findings support a family interactional theory. The domains of family, personality, and peer factors had a direct effect on the adolescents' marijuana use. Implications for prevention are also addressed.

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

This study evaluated: (1) the reporting of sociodemographic characteristics of research subjects in published outpatient studies of cocaine abuse pharmacotherapy; (2) the association of study characteristics with such reporting and with the distribution of characteristics; and (3) the comparison of sociodemographic characteristics in the research subjects with those of a community-based sample of cocaine abusers who had sought treatment. Medline search identified 68 articles on cocaine abuse outpatient pharmacotherapy published from 1983 to 1993 in an English language, peer-reviewed journal. Sociodemographic characteristics of research subjects (n = 1802) were compared with those of respondents (weighted n = 135) to the National Comorbidity Survey (1990-1992), who reported at least one cocaine-related problem and had sought substance abuse treatment. Only three (4.4%) articles reported all six of the following sociodemographic characteristics of their subjects: 82.4%, reported mean age; 58.8%, race/ethnicity; 85.3%, sex; 22.1%, employment status; 13.2%, educational status; and 5.9%, socioeconomic status/income. Compared to survey respondents, research subjects were significantly more likely to be African-American and live in the Northeast region of the US and marginally more likely to be male and currently unemployed. These findings indicate that many published articles do not follow currently recommended guidelines for describing sociodemographic characteristics of research subjects and that, aside from race/ethnicity and geographic location, research subjects are fairly comparable in basic sociodemographic characteristics to the larger population of treatment-seeking individuals with cocaine-related problems.