Characteristics of American-Indian clients seeking inpatient treatment for substance abuse

OBJECTIVE: The current study was conducted as a preliminary examination of substance use and some of its correlates in nonreservation-residing American Indians. METHOD: A group of 522 American-Indian (AI) subjects (473 men) were compared with two sets of geographic controls: (1) an equal number of African Americans (AA) and (2) an equal number of European Americans (EA). All received treatment in the same facilities over the same time period. RESULTS: Contrary to expectations, the ethnic/racial groups were remarkably similar on a number of alcohol use variables, including the amount consumed in the 6 months prior to treatment and the number of previous treatments. Among those self-reporting as problem drinkers, there were group differences in the age of first drink (AA mean = 13.54, AI mean = 12.24 and EA mean = 11.71) and first drunk (AA mean = 15.80, AI mean = 14.23 and EA mean = 14.08) and the number of alcohol-related problems (AA mean = 7.52, AI mean = 8.49 and EA mean = 8.46). On these measures, AI and EA subjects did not differ whereas AA subjects reported a later age of onset and fewer negative consequences. EA and AI male subjects reported marijuana as their most frequently used "other" drug, whereas AA male subjects listed stimulants as their primary drugs. Regardless of ethnic/racial group, women did not differ on their drug(s) of choice, reporting stimulants as the most frequently abused drug (after accounting for alcohol use). CONCLUSIONS: This preliminary study is remarkable for the observed similarities among groups. Future studies using more rigorous sampling are needed to provide clarification of this preliminary study.     

A new highly specific buprenorphine immunoassay for monitoring buprenorphine compliance and abuse

Urine buprenorphine screening is utilized to assess buprenorphine compliance and to detect illicit use. Robust screening assays should be specific for buprenorphine without cross-reactivity with other opioids, which are frequently present in patients treated for opioid addiction and chronic pain. We evaluated the new Lin-Zhi urine buprenorphine enzyme immunoassay (EIA) as a potentially more specific alternative to the Microgenics cloned enzyme donor immunoassay (CEDIA) by using 149 urines originating from patients treated for chronic pain and opioid addiction. The EIA methodology offered specific detection of buprenorphine use (100%) (106/106) and provided superior overall agreement with liquid chromatography-tandem mass spectrometry, 95% (142/149) and 91% (135/149) using 5 ng/mL (EIA[5]) and 10 ng/mL (EIA[10]) cutoffs, respectively, compared to CEDIA, 79% (117/149). CEDIA generated 27 false positives, most of which were observed in patients positive for other opioids, providing an overall specificity of 75% (79/106). CEDIA also demonstrated interference from structurally unrelated drugs, chloroquine and hydroxychloroquine. CEDIA and EIA[5] yielded similar sensitivities, both detecting 96% (22/23) of positive samples from patients prescribed buprenorphine, and 88% (38/43) and 81% (35/43), respectively, of all positive samples (illicit and prescribed users). The EIA methodology provides highly specific and sensitive detection of buprenorphine use, without the potential for opioid cross-reactivity.     

Acceptance of HIV-antibody testing by persons seeking outpatient treatment for cocaine abuse

One hundred of 101 applicants for outpatient treatment for cocaine abuse consented to voluntary HIV-antibody testing when the testing was offered as an option within the medical assessment at intake. Twelve applicants tested HIV-antibody positive; eight of these had injected drugs parenterally with syringes and needles used by other addicts and four had never taken drugs intravenously. There were no significant differences between HIV-antibody positive and negative applicants regarding the percentages who completed the evaluation, began treatment, and completed four weeks of treatment. A subgroup of 48 patients were interviewed regarding their knowledge of HIV infection, AIDS, and risk factors associated with transmission of HIV. All 48 patients had heard of HIV, AIDS, and recommendations that they use condoms as well as clean syringes and needles. None of the 48 patients reported that they used condoms; 10 reported reduced sexual activity and number of sexual partners; and none of those who shared needles reported that they had discontinued sharing other addicts' drug paraphernalia. The authors conclude that on-site, voluntary HIV-antibody testing for drug abusing patients entering treatment appears feasible and is not a deterrent to persons entering and continuing in treatment for drug abuse. The finding that persons at risk for HIV infection have knowledge of risk factors and have not changed risk-taking behaviors associated with HIV contagion points out the urgent need for further education and counseling.     

Impact of research network participation on the adoption of buprenorphine for substance abuse treatment

There is a growing body of research supporting the use of buprenorphine and other medication assisted treatments (MATs) for the rapidly accelerating opioid epidemic in the United States. Despite numerous advantages of buprenorphine (accessible in primary care, no daily dosing required, minimal stigma), implementation has been slow. As the field progresses, there is a need to understand the impact of participation in practitioner–scientist research networks on acceptance and uptake of buprenorphine. This paper examines the impact of research network participation on counselor attitudes toward buprenorphine addressing both counselor-level characteristics and program-level variables using hierarchical linear modeling (HLM) to account for nesting of counselors within treatment programs. Using data from the National Treatment Center Study, this project compares privately funded treatment programs (N = 345) versus programs affiliated with the National Institute on Drug Abuse Clinical Trials Network (CTN) (N = 198). Models included 922 counselors in 172 CTN programs and 1203 counselors in 251 private programs. Results of two-level HLM logistic (Bernoulli) models revealed that counselors with higher levels of education, larger caseloads, more buprenorphine-specific training, and less preference for 12-step treatment models were more likely to perceive buprenorphine as acceptable and effective. Furthermore, buprenorphine was 50% more likely to be perceived as effective among counselors working in CTN-affiliated programs as compared to private programs. This study suggests that research network affiliation positively impacts counselors' acceptance and perceptions of buprenorphine. Thus, research network participation can be utilized as a means to promote positive attitudes toward the implementation of innovations including medication assisted treatment.     

Erectile dysfunction medication use among men seeking substance abuse treatment

Few studies of erectile dysfunction (ED) medications use among heterosexual drug using or abusing men have been conducted. The aims of this study were to provide information on ED medication use prevalence, method of acquisition, and sexual effects among men seeking substance abuse treatment. A single time point cross-sectional anonymous survey was completed by 297 men over the age of 18 seeking substance abuse treatment at an outpatient clinic at a Veterans Affairs Medical Center in the Pacific Northwest. Mean age of participants was 49.7 years and 59.4% self-identified as Caucasian. Alcohol (56.7%) and cocaine (26.1%) were the primary drugs of abuse. Lifetime use of ED medications was reported by 24% (95%CI = 8.6%, 39.4%) of men. Almost 69% of ED medication users reported obtaining ED medications from a physician. Fifty-nine percent of ED medication users reported taking the medications to enhance their sexual experience rather than to treat ED, which was marginally associated with stimulant use (OR = 3.86, 95%CI = 0.96, 15.54, p = .057). These results add to an emerging recognition of the need to address the health implications of ED medication use among heterosexual drug using populations.     

Trauma history and relapse probability among patients seeking substance abuse treatment

We estimated the prevalence of trauma history and relapse in a sample of 959 patients at two outpatient chemical dependence clinics of a managed healthcare organization. A large majority (89%) reported a history of at least one traumatic event. The most common traumatic events were serious accidents, being robbed, seeing someone killed or seriously injured, and partner violence. One third of the patients had a history of substance abuse disorder relapse. There were gender and ethnic differences in the types of traumatic events reported. There were ethnic differences in relapse rates, which were highest among African American and multicultural patients. The types of traumatic events reported differed in patients of various sexual orientations. Bisexual patients had the highest rates of relapse, even when trauma exposure was controlled. Clinical implications of the findings are discussed.     

A multi-level analysis of counselor attitudes toward the use of buprenorphine in substance abuse treatment

Despite evidence that buprenorphine is effective and safe and offers greater access as compared with methadone, implementation for treatment of opiate dependence continues to be weak. Research indicates that legal and regulatory factors, state policies, and organizational and provider variables affect adoption of buprenorphine. This study uses hierarchical linear modeling to examine National Treatment Center Study data to identify counselor characteristics (attitudes, training, and beliefs) and organizational factors (accreditation, caseload, access to buprenorphine, and other evidence-based practices) that influence implementation of buprenorphine for treatment of opiate dependence. Analyses showed that provider training about buprenorphine, higher prevalence of opiate-dependent clients, and less treatment program emphasis on a 12-step model predicted greater counselor acceptance and perceived effectiveness of buprenorphine. Results also indicate that program use of buprenorphine for any treatment purpose (detoxification, maintenance, and/or pain management) and time (calendar year in data collection) was associated with increased diffusion of knowledge about buprenorphine among counselors and with more favorable counselor attitudes toward buprenorphine.     

Motivational interviewing to improve treatment engagement and outcome in individuals seeking treatment for substance abuse: a multisite effectiveness study

Despite recent emphasis on integrating empirically validated treatment into clinical practice, there are little data on whether manual-guided behavioral therapies can be implemented in standard clinical practice and whether incorporation of such techniques is associated with improved outcomes. The effectiveness of integrating motivational interviewing (MI) techniques into the initial contact and evaluation session was evaluated in a multisite randomized clinical trial. Participants were 423 substance users entering outpatient treatment in five community-based treatment settings, who were randomized to receive either the standard intake/evaluation session at each site or the same session in which MI techniques and strategies were integrated. Clinicians were drawn from the staff of the participating programs and were randomized either to learn and implement MI or to deliver the standard intake/evaluation session. Independent analyses of 315 session audiotapes suggested the two forms of treatment were highly discriminable and that clinicians trained to implement MI tended to have higher skill ratings. Regarding outcomes, for the sample as a whole, participants assigned to MI had significantly better retention through the 28-day follow-up than those assigned to the standard intervention. There were no significant effects of MI on substance use outcomes at either the 28-day or 84-day follow-up. Results suggest that community-based clinicians can effectively implement MI when provided training and supervision, and that integrating MI techniques in the earliest phases of treatment may have positive effects on retention early in the course of treatment.     

Validity of self-reports and drug use among young people seeking treatment for substance abuse or dependence

The present study assessed drug use and the validity of self-reports of drug use among young people seeking treatment. On admission the participants (n = 316), 215 males and 101 females, were interviewed about their drug use. Urine samples were collected to screen for alcohol, amphetamine, benzodiazepines, cannabis, cocaine, methylenedioxymethamphetamine (MDMA) and opiate use. Self-reports of substance use were compared with urinalysis results. Seventy-three percent of the participants reported use of two or more substances. Single substance users were primarily alcohol users. Kappa agreement between self-report and urinalysis results was of acceptable concordance (> or = 0.65) except for alcohol (kappa = 0.19). Conditional kappa values were good (> or = 0.85) with exception of opiates (cond. kappa = 0.57). The self-reports were generally reliable among young people seeking treatment. No significant differences (p > or = 0.54) were found in the validity of self-reports between the genders.     

Prevalence of mood and substance use disorders among patients seeking primary care office-based buprenorphine/naloxone treatment

BackgroundPsychiatric comorbidity can adversely affect opioid dependence treatment outcomes. While the prevalence of psychiatric comorbidity among patients seeking methadone maintenance treatment has been documented, the extent to which these findings extend to patients seeking primary care office-based buprenorphine/naloxone treatment is unclear.AimsTo determine the prevalence of mood and substance use disorders among patients seeking primary care office-based buprenorphine/naloxone treatment, via cross sectional survey.Methods237 consecutive patients seeking primary care office-based buprenorphine/naloxone treatment were evaluated using modules from the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I). Current (past 30 days) and past diagnoses were cataloged separately.ResultsPatients ranged in age from 18 to 62 years old (M = 33.9, SD = 9.9); 173 (73%) were men; 197 (83%) were white. Major depression was the most prevalent mood disorder (19% current, 24% past). A minority of patients met criteria for current dysthymia (6%), past mania (1%), or past hypomania (2%). While 37 patients (16%) met criteria for current abuse of or dependence on at least one non-opioid substance (7% cocaine, 4% alcohol, 4% cannabis, 2% sedatives, 0.4% stimulants, 0.4% polydrug), 168 patients (70%) percent met criteria for past abuse of or dependence on at least one non-opioid substance (43% alcohol, 38% cannabis, 30% cocaine, 9% sedatives, 8% hallucinogens, 4% stimulants, 1% polydrug, and 0.4% other substances).ConclusionMood and substance use comorbidity is prevalent among patients seeking primary care office-based buprenorphine/naloxone treatment. The findings support the need for clinicians to assess and address these conditions.     

Early adoption of buprenorphine in substance abuse treatment centers: data from the private and public sectors

The recent approval of buprenorphine for the treatment of opiate dependence offers an opportunity to analyze innovation adoption in community-based treatment. Using data collected from national samples of 299 privately funded and 277 publicly funded treatment centers, this research examines buprenorphine adoption using baseline data collected between 2002 and 2004 as well as follow-up data collected 12 months later. Private centers were significantly more likely than public centers to report current use of buprenorphine. The baseline data indicated that early adoption was positively associated with center accreditation, physician services, availability of detoxification services, current use of naltrexone, and the percentage of opiate-dependent clients. Multivariate analyses of follow-up data suggest that adoption was greater in accredited centers, for-profit facilities, organizations offering detoxification services, and naltrexone-using centers. Future research should continue to monitor the extent to which buprenorphine is adopted in these settings.     

Benzodiazepine use among opiate-dependent subjects in buprenorphine maintenance treatment: correlates of use, abuse and dependence

BACKGROUND: Previous studies from North America, Europe and Australia have reported high levels of benzodiazepine use among opiate-dependent patients in opiate maintenance treatment. However, to date, there are no available data on patterns of abuse and dependence on benzodiazepines according to DSM criteria among these patients. AIMS: To describe the independent correlates of use, abuse and dependence on benzodiazepines among buprenorphine patients selected from standard treatment settings. METHODS: Cross-sectional study in France between June 2001 and June 2004. Buprenorphine patients treated for over 3 months were recruited via physicians prescribing buprenorphine. Patients answered a self-administered questionnaire, the DSM-IV criteria for benzodiazepine abuse and dependence, the Beck Anxiety and Depression Inventories (BAI, BDI) and the Nottingham Health Profile (NHP). Main outcome was modalities of benzodiazepine use: no use vs. simple use vs. problematic use (abuse or dependence according to DSM-IV). RESULTS: 170 patients were recruited. 54% did not use benzodiazepines during the previous month, 15% were simple users and 31% were problematic users. Benzodiazepine use (all modalities) was associated with poly-use of psychotropics. Simple users of benzodiazepines were not statistically different from non-users for the other factors explored. Problematic users of benzodiazepines had higher depression and anxiety levels, correlated with quality of life impairment and precariousness. They used higher dosages of benzodiazepines than simple users. CONCLUSIONS: Characteristics of simple benzodiazepine users were distinct from problematic users but not from non-users in this sample of buprenorphine patients. This should be taken into account in the clinical management of benzodiazepine use among buprenorphine patients.     

Trauma treatment for veterans in buprenorphine maintenance treatment for opioid use disorder

IntroductionOpioid use disorder (OUD) rates are high among veterans. PTSD is also prevalent among veterans; those with comorbidity have worse outcomes than those without comorbidity. This study assessed buprenorphine retention rates in veterans initiating OUD treatment, comparing veterans without PTSD to veterans with PTSD who were receiving versus not receiving concurrent trauma treatment.MethodsThis retrospective chart review examined consecutive referrals to buprenorphine maintenance (N = 140). PTSD diagnosis was identified by chart review and retention was defined as continuous buprenorphine maintenance 6-months post-admission. Logistic regression analyses compared buprenorphine retention for veterans without PTSD and PTSD-diagnosed veterans who received concurrent trauma treatment to a reference group of PTSD-diagnosed veterans who did not receive trauma treatment. Models adjusted for opioid type, age, and service-connected status.ResultsSixty-seven (47.9%) buprenorphine-seeking veterans carried a PTSD diagnosis; only 31.3% (n = 21) received trauma treatment while in buprenorphine maintenance, with 11.9% (n = 8) receiving evidence-based psychotherapy for PTSD. Among PTSD-diagnosed veterans who received trauma treatment, 90.5% (n = 19/21) were in buprenorphine maintenance at 6-months, compared to 23.9% (n = 11/46) of PTSD-diagnosed veterans without trauma treatment, and 46.6% (n = 34/73) of veterans without PTSD. In the full model, veterans with trauma treatment had 43.36 times greater odds of remaining in buprenorphine treatment than the reference group.ConclusionsMost PTSD-diagnosed veterans in buprenorphine treatment were not receiving trauma treatment. Those receiving concurrent trauma treatment had better retention, suggesting OUD and trauma can be simultaneously addressed. Future clinical trials should investigate trauma-focused treatment for veterans with comorbid PTSD who are seeking buprenorphine for OUD.     

Determinants of buprenorphine treatment for opioid dependence

This study assessed the social, demographic and clinical determinants of whether an opioid-dependent patient received buprenorphine versus an alternative therapy. A retrospective cohort analysis of opioid-dependent adults enrolled in Group Health Cooperative between January 1, 2006 and December 1, 2010 was performed. Increasing the number of physicians with DATA waivers in a region and living in a relatively-populated area increased the likelihood of being treated with buprenorphine, indicating that lack of access is a potential barrier. Comorbidity also appeared to be a factor in receipt of treatment, with the effect varying by diagnosis. Finally, patients with an insurance plan allowing health services to be sought from any provider, with increased cost sharing, were significantly more likely to receive buprenorphine, implying that patient demand is a factor. Programs integrating patient education, physician training, and support from addiction specialists would be likely facilitators of increasing access to this cost-effective treatment.