Showing papers in "Addiction in 1998"

The efficacy of methadone maintenance interventions in reducing illicit opiate use, HIV risk behavior and criminality: a meta-analysis

Abstract: Aims. To provide empirically based evaluation data regarding the efficacy of psychopharmacological interventions in opiate substance abuse, the present study employed meta-analytic statistical procedures to determine the effectiveness of methadone hydrochloride as a pharmacotherapeutic agent . Design. Empirical research findings from 11 studies investigating the effect of methadone maintenance treatment (MMT) on illicit opiate use, and eight and 24 studies investigating the effect of MMT on HIV risk behaviors and criminal activities, respectively, by individuals in such treatment were addressed . Findings. Results demonstrate a consistent, statistically significant relationship between MMT and the reduction of illicit opiate use, HIV risk behaviors and drug and property-related criminal behaviors. The effectiveness of MMT is most apparent in its ability to reduce drug-related criminal behaviors. MMT had a moderate effect in reducing illicit opiate use and drug and property-related criminal behaviors, and a small to moderate effect in reducing HIV risk behaviors . Conclusions. Results clarify discrepancies in the literature and are useful in predicting the outcomes of individuals in treatment. The treatment's effectiveness is evident among opiate-dependent individuals across a variety of contexts, cultural and ethnic groups, and study designs.

The Maudsley Addiction Profile (MAP):A brief instrument for assessing treatment outcome.

Abstract: Aim. To develop a brief, multi-dimensional instrument for assessing treatment outcome for people with drug and/or alcohol problems. The Maudsley Addiction Profile (MAP) is the first instrument to be developed in the United Kingdom for this purpose. Design. Field testing with quota-recruitment of problem drug users and problem alcohol users in treatment with researcher and clinician-administered test-retest interviews. Setting. Two community and two inpatient services at the Bethlem Royal and Maudsley Hospital, London. Participants. Subjects (160 drug users and 80 alcohol users) interviewed by eight interviewers (four researchers and four clinicians), each of whom interviewed 30 subjects on two occasions. Measures. Sixty items across substance use, health risk physical/psychological health and personal/social functioning domains. Findings. Average completion time of the MAP was 12 minutes. The questionnaire was acceptable to a majority of subjects and performed well with both researcher and clinician interviewers. Internal reliability and feasible concurrent validity assessments of the scales and items were highly satisfactory. Test-retest reliability was good, average intraclass correlation coefficients across eight substances were 0.94 and 0.81 across health risk, health problems, relationship conflict, employment and crime measures. Conclusions. The MAP can serve as a core research instrument with additional outcome measures added as required. The collection of a set of reliable quantitative measures of problems among drug and alcohol users by research or treatment personnel for outcome evaluation purposes need not be time-consuming.

Researching the spiritual dimensions of alcohol and other drug problems

Abstract: Although religions have been far from silent on the use of psychoactive drugs, and spirituality has long been emphasized as an important factor in recovery from addiction, surprisingly little research has explored the relationships between these two phenomena. Current findings indicate that spiritual/religious involvement may be an important protective factor against alcohol/drug abuse. Individuals currently suffering from these problems are found to have a low level of religious involvement, and spiritual (re)engagement appears to be correlated with recovery. Reasons are explored for the lack of studies testing spiritual hypotheses, and promising avenues for future research are discussed. Comprehensive addictions research should include not only biomedical, psychological and socio-cultural factors but spiritual aspects of the individual as well.

Buprenorphine maintenance treatment of opiate dependence: a multicenter, randomized clinical trial.

Abstract: Aims. To evaluate the safety and ef® cacy of an 8 mg/day sublingual dose of buprenorphine in the maintenance treatment of heroin addicts by comparison with a 1 mg/day dose over a 16-week treatment period. As a secondary objective, outcomes were determined concurrently for patients treated with two other dose levels. Design. Patients were randomized to four dosage groups and treated double-blind. Setting. Twelve outpatient opiate maintenance treatment centers throughout the United States. Participants. Two hundred and thirty-nine women and 497 men who met the DSM-III-R criteria for opioid dependence and were seeking treatment. Intervention. Patients received either 1, 4, 8 or 16 mg/day of buprenorphine and were treated in the usual clinical context, including a 1-hour weekly clinical counseling session. Measurement. Retention in treatment, illicit opioid use as determined by urine toxicology, opioid craving and global ratings by patient and staff. Safety outcome measures were provided by clinical monitoring and by analysis of the reported adverse events. Findings. Outcomes in the 8 mg group were signi® cantly better than in the 1 mg group in all four ef® cacy domains. No deaths occurred in either group. The 8 mg group did not show an increase in the frequency of adverse events. Most reported adverse effects were those commonly seen in patients treated with opioids. Conclusions. The ® ndings support the safety and ef® cacy of buprenorphine and suggest that an adequate dose of buprenorphine will be a useful addition to pharmacotherapy.

Shortened time horizons and insensitivity to future consequences in heroin addicts

Abstract: Aims. To investigate whether heroin addicts demonstrate shortened time horizons and decreased sensitivity to future consequences of their behavior compared to non-drug users . Design Setting and Participants. Thirty-four heroin addicts enrolled in a buprenorphine treatment clinic and 59 non-drug-using controls completed a personality questionnaire and two laboratory tasks . Measurements. The Stanford Time Perception Inventory (STPI) personality questionnaire assessed orientation to the future, and the Future Time Perspective (FTP) task elicited predictions of the timing and ordering of future events. The Bechara card task measured preferences for decks of cards that range in magnitude and probability of delayed and immediate rewards and punishers . Findings. Heroin addicts scored significantly lower than controls on the STPI scale indicative of future orientation. In the FTP, heroin addicts were less likely to predict events far into the future and less likely to systematically organize events in the future. In the card task, heroin addicts were less likely to win money than controls. They were more likely to play from a deck that contained greater immediate gains but that resulted in large, delayed punishers and overall net losses. They also made fewer selections from a deck that provided an overall net gain via relatively low immediate rewards and frequent small punishments . Conclusions. Shortened time horizons and decreased sensitivity to delayed consequences may explain drug abusers' persistent use of drugs, despite the long-term negative consequences associated with drug use.

A meta-analysis of predictors of continued drug use during and after treatment for opiate addiction.

Abstract: Buts: de nombreuses personnes soignees pour la dependance aux opiaces continuent de consommer de la drogue pendant et apres le traitement. Il est possible d'ameliorer cette partie du probleme en s'interessant aux caracteristiques des patients qui predisent un usage continu de drogues. Cette etude utilise les techniques de la meta-analyse pour identifier les facteurs de risque de la poursuite de l'usage de drogue chez les patients soignes pour abus d'opiaces. Projet et Mesures: une recherche approfondie de la litterature publiee a partir de 69 etudes qui rapportaient des informations sur l'association bivariee entre une ou plusieurs variables independantes et l'usage continu de drogues illegales pendant et apres le traitement de la dependance aux opiaces. Resultats: les auteurs notent que la plupart des variables des patients ont de faibles relations longitudinales avec l'usage continuel de drogue, bien que quelques variables fassent preuve d'associations longitudinales moderees. Dix variables montrent des relations statistiquement significatives et longitudinalement predictives (moyenne > 0.1) avec l'usage ininterrompu, dont les suivantes: un niveau eleve d'usage de drogue/ opiaces avant le traitement, un traitement anterieur de la dependance aux opiaces, pas d'abstinence anterieure d'opiaces, l'abstinence d'une faible consommation d'alcool, la depression, un niveau eleve de stress, des problemes de chomage ou des difficultes au travail, des liens avec des camarades qui abusent des opiaces, la courte duree du traitement, et l'abandon du traitement avant la fin. Quelques autres variables peuvent etre potentiellement et longitudinalement predictives. Conclusions: pour prevenir les rechutes, les interventions therapeutiques doivent s'interesser a plusieurs variables parce qu'aucune variable seule ne peut predire vraiment un usage ininterrompu de drogue.

Effects of readiness for drug abuse treatment on client retention and assessment of process

Abstract: Aims. This study examined client motivation as a predictor of retention and therapeutic engagement across the major types of treatment settings represented in the third national drug abuse treatment outcome study (DATOS) conducted in the United States. Design. Sequential admissions during 1991-93 to 37 programs provided representative samples of community-based treatment populations. Based on this naturalistic non-experimental evaluation design, hierarchical linear model (HLM) analysis for nested data was used to control for systematic variations in retention rates and client attributes among programs within modalities. Setting. The data were collected from long-term residential (LTR), outpatient methadone (OMT) and outpatient drug-free (ODF) programs located in 11 large cities. Participants. A total of 2265 clients in 18 LTR, 981 clients in 13 OMT and 1791 clients in 16 ODF programs were studied. Measurements. Pre-treatment variables included problem recognition and treatment readiness (two stages of motivation), socio-demographic indicators, drug use history and dependence, criminality, co-morbid psychiatric diagnosis and previous treatment. Retention and engagement (based on ratings of client and counselor relationships) served as outcome criteria. Findings. Pre-treatment motivation was related to retention in all three modalities, and the treatment readiness scale was the strongest predictor in LTR and OMT. Higher treatment readiness also was significantly related to early therapeutic engagement in each modality. Conclusions. Indicators of intrinsic motivation-especially readiness for treatment-were not only significant predictors of engagement and retention, but were more important than socio-demographic, drug use and other background variables. Improved assessments and planning of interventions that focus on stages of readiness for change and recovery should help improve treatment systems.

Treatment of cocaine and alcohol dependence with psychotherapy and disulfiram.

Abstract: Aims. To evaluate disulfiram and three forms of manual guided psychotherapy for individuals with cocaine dependence and concurrent alcohol abuse or dependence. Design. Randomized controlled trial. Setting. Urban substance abuse treatment center. Participants. One hundred and twenty-two cocaine/alcohol abusers (27% female; 61% African-American or Hispanic). Interventions. One of five treatments delivered over 12 weeks: cognitive behavioral treatment (CBT) plus disulfiram; Twelve Step facilitation (TSF) plus disulfiram; clinical management (CM) plus disulfiram; CBT plus no medication; TSF plus no medication. Measurements. Duration of continuous abstinence from cocaine or alcohol; frequency and quantity of cocaine and alcohol use by week, verified by urine toxicology and breathalyzer screens. Findings. Disulfiram treatment was associated with significantly better retention in treatment, as well as longer duration of abstinence from alcohol and cocaine use. The two active psychotherapies (CBT and TSF) were associated with reduced cocaine use over time compared with supportive psychotherapy (CM). Cocaine and alcohol use were strongly related throughout treatment, particularly for subjects treated with disulfiram. Conclusions. For the large proportion of cocaine-dependent individuals who also abuse alcohol, disulfiram combined with outpatient psychotherapy may be a promising treatment strategy. This study underlines (a) the significance of alcohol use among treatment-seeking cocaine abusers, (b) the promise of the strategy of treating co-morbid disorders among drug-dependent individuals, and (c) the importance of combining psychotherapy and pharmacotherapy in the treatment of drug use disorders.

Impulsivity, personality disorders and pathological gambling severity

Abstract: Aims. The present study seeks to replicate and expand ® ndings from earlier studies that pathological gamblers manifest elevated traits of impulsivity. Secondly, the study aims to elucidate the relationship between impulsivity, indices reecting severity of pathological gambling and other measures of psychopathology and personality dysfunction. Design. Case series. Participants. Eighty-two consecutive gamblers seeking treatment for problem gambling. Setting. Impulse Disorders Research Unit, School of Psychiatry, University of New South Wales, Australia. Measurements. Semi-structured interview designed to obtain demo- graphic information and gambling history, the South Oaks Gambling Screen, the Eysenck Impulsivity Scale, the Personality Disorder Questionnaire-Revised, the Beck Depression Inventory and the Beck Anxiety Inventory. Findings. Results show elevated traits of impulsivity among clinic samples of pathological gamblers compared to normative data and show that impulsivity is related to the severity of gambling behaviour as measured by the South Oaks Gambling Questionnaire. A principal component analysis of the Eysenck Impulsivity Scale and the Personality Disorder Questionnaire± Revised, demonstrated that the concept of the a antisocial± impulsivisto identi® ed by Blaszczynski, Steel & McConaghy (1997) is not only characterized by impulsivity and antisocial personality disorder but also by high loadings from other cluster B and cluster C personality disorders. Conclusion. This research supports the role of the construct of impulsivity in mediating the severity of gambling behaviour and associated behavioural and psychological disturbance among pathological gamblers presenting for treatment. Impulsivity is best understood as part of a general personality disorder structure characterized primarily by DSM-III-R Axis II cluster B and some cluster C personality disorders.

Network support for drinking, Alcoholics Anonymous and long‐term matching effects

Abstract: Aims. (1) To examine the matching hypothesis that Twelve Step Facilitation Therapy (TSF) is more effective than Motivational Enhancement Therapy (MET) for alcohol-dependent clients with networks highly supportive of drinking 3 years following treatment; (2) to test a causal chain providing the rationale for this effect. Design. Outpatients were re-interviewed 3 years following treatment. ANCOVAs tested the matching hypothesis. Setting. Outpatients from five clinical research units distributed across the United States. Participants: Eight hundred and six alcohol-dependent clients. Intervention. Clients were randomly assigned to one of three 12-week, manually-guided, individual treatments: TSF, MET or Cognitive Behavioral Coping Skills Therapy (CBT). Measurements. Network support for drinking prior to treatment, Alcoholics Anonymous (AA) involvement during and following treatment, percentage of days abstinent and drinks per drinking day during months 37-39. Findings. (1) The a priori matching hypothesis that TSF is more effective than MET for clients with networks supportive of drinking was supported at the 3 year follow-up; (2) AA involvement was a partial mediator of this effect; clients with networks supportive of drinking assigned to TSF were more likely to be involved in AA; AA involvement was associated with better 3-year drinking outcomes for such clients. Conclusions. (1) In the long-term TSF may be the treatment of choice for alcohol-dependent clients with networks supportive of drinking; (2) involvement in AA should be given special consideration for clients with networks supportive of drinking, irrespective of the therapy they will receive.

Educating young people about drugs: a systematic review

Abstract: Aims. To assess the effectiveness of interventions directed at the prevention or reduction of use of illicit substances by young people or those directed at reducing harm caused by continuing use. Design. A systematic review was conducted. Reports were identified through electronic and hand searching and contact with known workers in the area. Studies were included if they reported evaluations of interventions targeting illicit drug use and provided sufficient detail of the intervention and design of the evaluation to allow judgements to be made of their methodological soundness. Meta-analyses were conducted combining the data of the methodologically sound studies. Participants and settings targeted by interventions. Evaluations of interventions were included if their targeted audience included young people aged between 8 and 25 years. Identified evaluations were delivered in a range of settings including: schools and colleges; community settings; the family; medical/therapeutic settings; mass media. Measurements. Data extracted from each report included details of design, content and theoretical orientation of intervention, setting of the intervention, target audience, methods, population size, subject refusal rates, rates of attrition, outcome measures, length of follow-up and findings, including statistical power. Findings. The majority of studies identified were evaluations of interventions introduced in schools and targeting alcohol, tobacco and marijuana simultaneously. These studies were methodologically stronger than interventions targeting other drugs and implemented outside schools. Meta-analyses showed that the impact of evaluated interventions was small with dissipation of programme gains over time. Interventions targeting hard to reach groups have not been evaluated adequately. Conclusions. Effort needs to be directed towards the development of improved evaluative solutions to the problems posed by these groups. There is still insufficient evidence to assess the effectiveness of the range of approaches to drugs education; more methodologically sound evaluations are required. There is also a need to target interventions to reflect the specific needs and experiences of recipients.

A comparison of two alcohol craving questionnaires.

Abstract: Aim To compare two multi-dimensional questionnaires to measure cravings and urges for alcohol: the Alcohol Craving Questionnaire (ACQ: Singleton, Henningfield & Tiffany, 1994a) and the Desires for Alcohol Questionnaire (DAQ: Clark et al , 1996) Design, setting and participants Both questionnaires were administered, in a counterbalanced order, to a total of 380 recreational drinkers In a further study, a shortened version of the DAQ was administered to a sample of 131 drinkers attending AA or a treatment centre Exploratory factor analyses were carried out on the data and relationships between questionnaire score and other variables were assessed Findings In recreational drinkers both instruments appeared to have a three-factor structure The DAQ appeared superior to the ACQ in a number of respects: it produced more reliable factors; its structure accounted for a higher proportion of the variance; the factor inter-correlations were somewhat lower; in a combined analysis of both instruments most of the factors retained came from the DAQ; and the DAQ discriminated better between binge and non-binge drinkers and excessive and moderate drinkers A similar factor structure was found for the DAQ in the alcoholic subjects with addition of a factor of "controllability" Conclusions The results support a multifactorial account of alcohol craving, and indicate that the DAQ has some advantages over the ACQ as a research tool

Illicit drug use among Mexicans and Mexican Americans in California: the effects of gender and acculturation

Abstract: Aims. To examine the effects of gender and acculturation on illicit drug use among the Mexican-origin population in California. Design. The 3012 subjects between 18 and 59 years of age were selected under a stratified, multi-stage cluster sampling method. Setting. Fresno County in California is primarily agricultural, with only one metropolitan area. Over 30% of the total population of 764 800, are Hispanics, of Mexican origin. Measurements. A modified version of the World Health Organization's Composite International Diagnostic Instrument (WHO-CIDI) was used to ascertain drug use. Respondents were considered drug users if they had ever used marijuana, cocaine, hallucinogens, heroin or inhalants. Acculturation was measured with a Likert scale, assessing English vs. Spanish language preference. Other covariates of interest were nativity and place of residence. Findings. Men had higher rates of use than women for every drug (men = 46.3%, women = 23.2%). Urban rates were higher than rural rates, for both women (urban = 32.8% vs. rural = 16.6%) and men (urban = 57.0% vs. rural = 36.8%). In logistic regression models, men were more likely than women to have ever used illicit drugs or inhalants (adjusted OR = 4.8), cocaine (adjusted OR = 5.3) or marijuana (OR = 4.3). However, the combined effect of United States nativity and acculturation, on drug use, was greater among women (adjusted OR = 29.3) than among men (adjusted OR = 7.4). The effect of acculturation was stronger among urban, than among town or rural residents. Conclusions. Acculturation and United States nativity are risk factors for illicit drug use among Mexican origin men and women. However, women have increased vulnerability compared with men. Findings reinforce the need for culturally based public health interventions.

Familial influences on gambling behavior: an analysis of 3359 twin pairs.

Abstract: ackground. Pathological gambling is becoming an increasing problem in the United States as the number of legalized gambling establishments grows. To examine vulnerability to pathological gambling, we estimated the familial contributions (i.e. inherited factors and/or experiences shared by twin siblings during childhood) to DSM-III-R pathological gambling symptoms and disorder. Methods. Data were obtained from a telephone interview performed in 1991-92 utilizing the Diagnostic Interview Schedule Version III-Revised. Interviews were administered to 6718 members of the nationally distributed Vietnam Era Twin Registry of male-male monozygotic and dizygotic twin pairs who served in the military during the Vietnam era. Results. Inherited factors explain between 35% (95% CI: 28%, 42%) and 54% (95% CI: 39%, 67%) of the liability for the five individual symptoms of pathological gambling behavior that could be estimated statistically. In addition, familial factors explain 56% (95% CI: 36%, 71%) of the report of three or more symptoms of pathological gambling and 62% (95% CI: 40%, 79%) of the diagnosis of pathological gambling disorder (four or more symptoms). Conclusions. Familial factors have an important influence on risk for pathological gambling behavior. The increasing access to legalized gambling is likely to result in a higher prevalence of pathological gambling behavior among individuals who are more vulnerable because of familial factors.

Current directions in research on understanding and preventing intoxicated aggression

Abstract: The present paper describes promising research directions that emerged from a recent international conference on intoxication and aggression and from the scientific literature generally. In this overview, intoxicated aggression is seen as arising from an interactional process involving multiple contributing factors or causes. This model helps to define research directions that can further understanding and prevention. First, the societal/cultural framing of intoxication and aggression exerts a powerful influence on drinking behaviour and needs to be better understood. Another important area for research is the moderating role on alcohol-related aggression of personal factors such as predisposition to aggression and individual differences in expectations about alcohol and aggression. Research on the role of basic pharmacological effects of alcohol in increasing the likelihood of aggressive behaviour is also a critical aspect of understanding intoxicated aggression. Drinking contexts and environments play a considerable role in the relationship between intoxication and aggressive behaviour and need to be better understood. Another critical direction for future research is the study of intoxicated aggression as a process involving the interaction of the person, the situation and the effects of alcohol in natural and experimental settings. Finally, the paper highlights promising directions for research on interventions to prevent intoxicated aggression and violence.

Supplemental social services improve outcomes in public addiction treatment

Abstract: Aims. To evaluate the effectiveness and value of social services added to standard addiction rehabilitation. Design. A controlled, quasi-experimental, field study with repeated measures. Setting. Conducted in two groups of publicly supported outpatient addiction treatment programs. Control programs provided standard, twice-weekly, outpatient group counseling. "Enhanced" programs provided standard counseling but also case managers to coordinate and expedite use of pre-contracted medical screenings, housing assistance, parenting classes and employment services. Measurements. The Addiction Severity Index was used to record the nature and severity of patient problems in seven areas at treatment admission and at 6-month follow-up. Services provided during treatment were measured with the Treatment Services Review. Measures were taken on consecutive samples of patients admitted to all programs-before enhancements (wave 1, N = 431)-and at 12 months (wave 2, N = 710); and 26 months following enhancements (wave 3, N = 187). Findings. There were no significant differences in patient characteristics, treatment services or 6-month outcomes of the two sets of programs in wave 1. Wave 2 and especially wave 3 enhanced programs provided significantly more social and medical services than control programs. Patients treated in enhanced programs showed significantly less substance use, fewer physical and mental health problems and better social function at 6-months than Controls. Conclusions. Adding social services to public sector programs substantially improved the outcomes of addiction treatment. Changes in "real world" systems require time to implement; early evaluations may fail to capture the full impact of those changes.

The economic costs of alcohol, tobacco and illicit drugs in Canada, 1992

Abstract: Aims, design and setting. The economic costs of alcohol, tobacco and illicit drugs to Canadian society in 1992 are estimated utilizing a cost-of-illness framework and recently developed international guidelines. Measurements. For causes of disease or death (using ICD-9 categories), pooled relative risk estimates from meta-analyses are combined with prevalence data by age, gender and province to derive the proportion attributable to alcohol, tobacco and/or illicit drugs. The resulting estimates of attributable deaths and hospitalizations are used to calculate associated health care, law enforcement, productivity and other costs. The results are compared with other studies, and sensitivity analyses are conducted on alternative measures of alcohol consumption, alternative discount rates for productivity costs and the use of diagnostic-specific hospitalization costs. Findings. The misuse of alcohol, tobacco and illicit drugs cost more than $18.4 billion in Canada in 1992, representing $649 per capita or 2.7% of GDP. Alcohol accounts for approximately $7.52 billion in costs, including $4.14 billion for lost productivity, $1.36 billion for law enforcement and $1.30 billion in direct health care costs. Tobacco accounts for approximately $9.56 billion in costs, including $6.82 billion for lost productivity and $2.68 billion for direct health care costs. The economic costs of illicit drugs are estimated at $1.4 billion. Conclusions. Substance abuse exacts a considerable toll to Canadian society in terms of illness, injury, death and economic costs.

Experience of non-fatal overdose among heroin users in Adelaide, Australia: circumstances and risk perceptions

Abstract: AIMS: To ascertain the prevalence and risk factors for non-fatal overdose among heroin users to assist in the development of an effective intervention. DESIGN: Cross-sectional design. SETTING: Community setting, principally metropolitan Adelaide. PARTICIPANTS: Current heroin users (used heroin in the previous six months). MEASUREMENTS: A structured questionnaire including the Severity of Dependence Scale. FINDING: Of 218 current South Australian heroin users interviewed in 1996, 48% had experienced at least one non-fatal overdose their life-time (median: two overdoses), and 11% had overdosed in the previous 6 months. At some time, 70% had been present at someone else's overdose (median: three overdoses). At the time of their own most recent overdose, 52% had been using central nervous system depressants in addition to heroin, principally benzodiazepines (33%) and/or alcohol (22%). The majority of overdoses occurred in a private home (81%) and in the presence of other people (88%). Unrealistic optimism regarding the risk of overdose was evident across the sample. Despite almost half the sample reporting having had an overdose, and the belief expressed by respondents that on average about 50% of regular heroin users would overdose during their life-time 73% had, during the previous 6 months, "rarely" or "never" worried about possibly overdosing. Optimism regarding the possibility of future overdose was reduced in those with recent experience of overdose in comparison to the rest of the sample. A targeted intervention aimed at the reduction of overdose among heroin users is outlined. Language: en

Pre- and in-treatment predictors of retention in methadone treatment using survival analysis

Abstract: Aims. To determine the effects of pre- and in-treatment variables on patient retention in methadone treatment. Design. Retrospective longitudinal study of an admission cohort sample for up to 3 years of treatment or until discharge. Setting. Six methadone maintenance programs operating 15 clinics in New York City. Participants. A sample of 1206 admissions to these clinics during 1989-90. Measurements. Data were abstracted from patients' medical charts. Time in treatment for up to 3 years was the dependent variable, analyzed as a survival function. Pretreatment variables were: gender, race/ethnicity, age at admission, employment, education, marital status, living arrangements, child care responsibility, criminal justice status, life-time arrests, referral source, age at first heroin use, polydrug use, route of drug administration, mental health status and methadone treatment history. In-treatment variables were: patient problems during treatment, clinic response to patient problems, patient treatment strengths, methadone dosage, heroin use and cocaine use. Findings. The estimated median treatment duration was 23 months. Cox proportional hazards modeling determined that two pretreatment variables (older age and no criminal justice involvement) were associated with longer retention in treatment. Among in-treatment variables, constructive clinic responses to patient problems, higher methadone dosage, more patient treatment strengths and less heroin and cocaine use during treatment were associated with longer retention. Conclusions. Events during treatment are crucial for patient retention in methadone treatment. Only two of 16 pretreatment variables, compared with five of six during-treatment variables, had significant effects on length of stay in a multivariate model.

Long‐term cannabis use: characteristics of users in an Australian rural area

Abstract: Aim. To investigate the characteristics and patterns of cannabis and other drug use among long-term cannabis users in an Australian rural area . Design. Cross-sectional survey of a "snowball" sample of long-term cannabis users . Setting. The North Coast of New South Wales is an area with high levels of cannabis cultivation and use, and many long-term users . Participants. The study involved 268 long-term cannabis users who had regularly used cannabis for at least 10 years . Measurements. A structured interview schedule obtained information on: demographics, social circumstances, patterns of cannabis and other drug use, contexts of use, perceptions about cannabis and legal involvement. Findings. The mean age of the sample was 36 years and 59% were male. The median length of regular cannabis use was 19 years. Most (94%) used two or more times a week and 60% used daily, with a median of two joints per day. Two-thirds (67%) used cannabis in social settings and two-thirds grew cannabis for their own use. The most common reasons for using cannabis were for relaxation or relief of tension (61%) and enjoyment or to feel good (27%). The most commonly reported negative effects were feelings of anxiety, paranoia, or depression (21%), tiredness, lack of motivation and low energy (21%) and effects of smoke on the respiratory system (18%). The majority drank alcohol (79%) and over one-third were drinking at hazardous levels. Most were current (64%) or ex-tobacco smokers (24%). One-quarter (25%) had been charged with possession of cannabis, 11% for cultivation and 6% for supply, with non-drug offences low (8% or less). Overall, three-quarters (72%) believed that the benefits of cannabis use outweighed the risks, 21% felt there was an even balance, and 7% said cannabis had done them more harm than good. Conclusions. Among long-term cannabis users in this Australian rural area, cannabis use was an integral part of everyday life and it was primarily used in social situations for the same reasons that alcohol use is used in the wider community.

Effect of smoking cessation counseling on recovery from alcoholism: findings from a randomized community intervention trial

Abstract: Aims. To assess the effects of a smoking cessation program for recovering alcoholics on use of alcohol, tobacco and illicit drugs after discharge from residential treatment. Design and Setting. A randomized community intervention trial design was employed in which 12 residential drug treatment centers in Iowa, Kansas and Nebraska were matched and then randomly assigned to the intervention or control condition. Participants. Approximately 50 adult residents (inpatients) from each site were followed for 12 months after treatment discharge. Intervention. Participating residents in the six intervention centers received a 4-part, individually tailored, smoking cessation program while those in the six control sites received usual care. Findings. Both moderate and heavy drinking rates were reduced in the intervention group. Intervention site participants were significantly more likely than controls to report alcohol abstinence at both the 6-month (OR = 1.59, 95%CI: 1.09-2.35) and 12-month assessment (OR = 1.84, 95%CI:1.28-2.92). Illicit drug use rates were comparable. Effect of the intervention on tobacco quit rates was not statistically significant. Conclusions. Counseling alcoholics in treatment to quit smoking does not jeopardize the alcohol recovery process. However, low-intensity tobacco interventions are unlikely to yield high tobacco quit rates.

T he relationship between and cigarette sm oking in depressive sym ptom s U S adolescents

Abstract: A bstract A im s. Data from the Teenage Attitudes and Practices Survey were analyzed to assess the relationship between depressive symptoms and cigarette smoking. D esigns, Setting, Participants. Nationally representative sample of adolescents interviewed in 1989 and again in 1993. M easurem ents. Prevalence rate and adjusted odds ratio for smoking at follow-up by depressive symptoms status at baseline. Findings. Adolescents with depressive symptoms were more likely than other adolescents to start smoking. C onclusions. The associations between depressive symptoms and regular smoking appears to be established by adolescence.

Effects on criminal violence of different beverage types and private and public drinking

Abstract: Aims. The purpose of the study is to analyse the relationship between homicide and assault rates on one hand, and various indicators of alcohol consumption on the other. The latter include private and public drinking with a further disaggregation into beverage-specific drinking. Measurements. The data comprise aggregate time series for Sweden during the period 1956-94. The assault rate is measured as the number of police reported assaults (at all degrees of aggravation) per 100 000 inhabitants (15 + ). The homicide rate is measured as the number of homicides (where the victim was at least one year old) per 100 000 inhabitants (15 + ). Private consumption is gauged as retail sales of alcohol, and public consumption as on-premise sales (litres 100% per inhabitant, 15 + ). These two measures are disaggregated further into beverage specific sales (beer, spirits and wine). Findings. According to the findings, there is a statistically significant relationship between the assault rate and a combined measure of on-premise sales of beer and spirits. The estimated relationship corresponds to an attributable fraction of about 40%. The homicide rate is significantly associated with retail sales of spirits; the attributable fraction is estimated at about 50%. Wine sales are not related to any of the two violence indicators. Conclusions. The findings suggest that the assault rate is related to consumption of beer and spirits in bars and restaurants, while the homicide rate is linked to consumption of spirits in private contexts. The findings, notably specific to Sweden during a certain time period, can be interpreted as the outcome of the interplay of a number of factors, including opportunity structure, social control and context of drinking, drinking patterns associated with the different beverage types and characteristics of the drinkers. (Abstract Adapted from Source: Addiction, 1998. Copyright © 1998 by Blackwell) Sweden Foreign Countries 1950s 1960s 1970s 1980s 1990s Alcohol Related Violence Alcohol Use Effects Substance Use Effects Juvenile Offender Juvenile Homicide Juvenile Substance Use Juvenile Violence Physical Assault Causes Physical Assault Offender Adult Offender Adult Homicide Adult Substance Use Adult Violence Offender Substance Use Homicide Causes Homicide Offender Violence Causes 04-01

Choosing a diagnostic cut‐off for cannabis dependence

Abstract: Aim. I While cannabis dependence has been increasingly recognized, there is little research on the measurement issues involved in operationalizing the dependence syndrome for this drug. This paper aimed to investigate the diagnostic utility and appropriate diagnostic cut-offs of three short dependence measures among long-term cannabis users. Setting and participants. Two hundred long-term, regular cannabis users were recruited and interviewed in Sydney, Australia. Measurements. Receiver Operating Characteristic analyses compared the diagnostic performance of the short University of Michigan CIDI, a measure of ICD-10 dependence and the Severity of Dependence Scale against the "gold standard" of moderate or more severe DSM-III-R cannabis dependence, as diagnosed by the Substance Abuse Module of the CIDI. Findings. The measures were of equal utility in diagnosing at least moderate DSM-III-R cannabis dependence. While the optimal diagnostic cut-offs for the short University of Michigan CIDI and the ICD-IO dependence measure remained unchanged from those conventionally applied, a more liberal cut-off was optimal for the Severity of Dependence Scale. The amended prevalence of cannabis dependence was 77% using the short University of Michigan CIDI, 72% by the ICD-IO measure and 62% by the Severity of Dependence Scale. Conclusions. The three instruments were able to diagnose cannabis dependence at levels substantially better than chance. They were generally robust in terms of the optimal diagnostic cut-off in a population of long-term cannabis users. This paper provides guidelines for choosing optimal cut-offs within different contexts.

Six deaths linked to concomitant use of buprenorphine and benzodiazepines

Abstract: Aims. Buprenorphine at high dosage became available in 1996 for substitution treatment in France. This drug is considered particulary safe and has become widely available in general medical practice. We investigated the possible implication of a buprenorphine-benzodiazepine association in six deaths of known abusers. Design. Full investigation of cause of death was conducted for six drug abusers. Setting. The deaths occurred in two regions of France (Auvergne and Lorraine). Assays were carried out by the Institut de Medecine Legale at Strasbourg, France, one of the few French laboratories equipped to assay buprenorphine. Measurement. First, the blood and urine underwent triple exhaustive screening. Secondly, buprenorphine and norbuprenorphine were analysed in all the autopsy samples by HPLC/MS. Findings. Benzodiazepine-buprenorphine associations were found in every case; no other substances that could account for the death were found. The tissue concentrations were markedly higher than the blood levels. Conclusion. If the number of deaths linked to such drug misuse proves high, it may be necessary to review how buprenorphine is dispensed.

Alcohol consumption and mortality. I. Characteristics of drinking groups.

Abstract: Aims. This is the first of a set of three papers evaluating drinking status and mortality risk. Analyses of multiple studies describe associations of drinking patterns with characteristics hypothesized to confound the relationships between drinking status and mortality. Characteristics which both significantly differentiate drinking groups and are consistent across studies would suggest that mortality studies not controlling for them may be compromised. Design and participants. Associations are evaluated from the raw data of 10 general population studies which contained mortality data. Long-term abstainers are compared to former drinkers, long-term abstainers and former drinkers are compared to light drinkers (by quantity, frequency and volume in separate analyses) and moderate to heavy drinkers are compared to light drinkers. Tetrachoric correlation coefficients assess statistical significance; meta-analysis determines if associations are homogeneous across studies. Measurements. Measures of alcohol consumption are quantity, frequency and volume; long-term abstainers are differentiated from former drinkers. Multiple measures of health, social position, social integration and mental health characteristics are evaluated. Findings. Across studies, adult male former drinkers are consistently more likely to be heavier smokers, depressed, unemployed, lower SES and to have used marijuana than long-term abstainers. Adult female former drinkers are consistently more likely to be heavier smokers, in poorer health, not religious, and unmarried than long-term abstainers. Both types of abstainers tend to be of lower SES than light drinkers and report poorer health (not consistent). Female abstainers are more likely to be of normal or overweight than light drinkers. Conclusions. Characteristics of two groups of abstainers, other than their non-use of alcohol, may confound the associations found between drinking and mortality risk.

Should alcohol consumption measures be adjusted for gender differences

Abstract: Because of biological differences between men and women, the same quantity of alcohol consumed over the same time period produces higher blood alcohol levels (BALs) in women than in men. Some alcohol researchers have proposed that quantity and volume measures of alcohol consumption (e.g. usual number of drinks per drinking day and overall amount of alcohol consumed) should be adjusted to reflect these biological differences. To date, no standard adjustment for biological gender differences has been adopted. In this paper, we review the literature on biological and behavioral differences related to alcohol consumption and effects and discuss the implications of these differences in terms of adjusting alcohol consumption measures. Our review suggests that adjusting measures of alcohol consumption to compensate for biological sex differences is most appropriate for research or policy applications involving the short and long-term physiological effects of alcohol in contexts where gender differences in how alcohol is consumed can be assumed to be minimal. In other circumstances, non-biological gender differences relating to alcohol use, such as pace of drinking, may moderate the relationship between alcohol consumption and biological gender differences, making an adjustment less defensible. We also identify areas where more knowledge is needed not only to address the issue of adjusting alcohol measures for gender differences but also to understand better the relationship between alcohol consumption and effects.

Impact of liking for advertising and brand allegiance on drinking and alcohol‐related aggression: a longitudinal study

Abstract: Aims. To test a hypothesized model of the effect of televised alcohol advertising and allegiance to specific brands of beer on subsequent beer consumption and self-reports of aggressive behaviour linked with drinking. Design. Structural equation modelling was used to assess the fit between data collected as part of a longitudinal study of young people's health and development and a hypothesized model based on theoretical perspectives and previous research. Setting. A birth cohort has been assessed every few years, most of them in their home city of Dunedin, New Zealand. The questions about alcohol are asked as part of the day-long assessment. Participants. Members of a longitudinal survey cohort at ages 18 and 21 years. Data from 630 beer drinking participants were analysed in this study. Measurements. Responses to questions about beer consumption, liking for advertising, favourite brand of beer and self-reports of alcohol-related aggressive behaviour. Findings. Our hypothesized model assumed a positive impact of liking of alcohol advertising and brand allegiance at age 18 on the volume of beer consumed at age 21 and self-reports of alcohol-related aggressive behaviour. This was found to be a good fit to the data from the longitudinal study. Conclusion. This measurable impact of alcohol advertising occurred during a time of decline in aggregate alcohol in New Zealand. While this effect was not large enough to halt the decline in aggregate alcohol consumption it does indicate a measurable, specific impact of broadcast alcohol advertising on alcohol consumption and related behaviour which is of relevance for public health policy.