An item response theory analysis of DSM-IV criteria for hallucinogen abuse and dependence in adolescents

Aim

This study applied both item response theory (IRT) and multiple indicators–multiple causes (MIMIC) methods to evaluate item-level psychometric properties of diagnostic questions for hallucinogen use disorders (HUDs), differential item functioning (DIF), and predictors of latent HUD.

Methods

Data were drawn from 2004–2006 National Surveys on Drug Use and Health. Analyses were based on 1548 past-year hallucinogen users aged 12–17 years. Substance use and symptoms were assessed by audio computer-assisted self-interviewing methods.

Results

Abuse and dependence criteria empirically were arrayed along a single continuum of severity. All abuse criteria indicated middle-to-high severity on the IRT-defined HUD continuum, while dependence criteria captured a wider range from the lowest (tolerance and time spent) to the highest (taking larger amounts and inability to cut down) severity levels. There was indication of DIF by hallucinogen users' age, gender, race/ethnicity, and ecstasy use status. Adjusting for DIF, ecstasy users (vs. non-ecstasy hallucinogen users), females (vs. males), and whites (vs. Hispanics) exhibited increased odds of HUD.

Conclusions

Symptoms of hallucinogen abuse and dependence empirically do not reflect two discrete conditions in adolescents. Trends and problems related to hallucinogen use among girls and whites should be examined further to inform the designs of effective gender-appropriate and culturally sensitive prevention programs.     

A Rasch analysis of the Harm Reduction Self-Efficacy Questionnaire in Portugal

Introduction

A high degree of self-efficacy is required from drug users if they are to adopt long-term abstinence-maintaining or harm-reducing behaviors. Our objective was to analyze the psychometric quality of the Harm Reduction Self-Efficacy Questionnaire (HRSEQ) with the Rating Scale Model (RSM), an extension of the Rasch Model for polytomous items.

Methods

Participants were 419 drug dependents from both harm reduction low threshold methadone program and therapeutic community programs in Portugal (84.5% male).

Results

Indicate that the original 11-category response system did not work adequately in any of the HRSEQ situations (Withdrawal, Negative emotions and Social pressure). There was no gender-related or group-related DIF and thus the findings of neither group nor gender-related difference in harm reduction self-efficacy cannot be plausibly attributed to that technical problem.

Conclusions

After recoding the rating scales by collapsing the eleven categories into four, the HRSEQ scores show good model fit and psychometric adequacy.     

The Washington circle engagement performance measures' association with adolescent treatment outcomes

Background

For adolescents, substance use disorder (SUD) treatment outcomes (e.g., abstinence, problematic behaviors) often cannot be measured soon enough to influence treatment trajectory. Although process measures (e.g., treatment engagement) can play an important role, it is essential to demonstrate their association with outcomes. This study explored the extent to which engagement in outpatient treatment was associated with outcomes and whether demographic/clinical characteristics moderated these relationships.

Methods

This is a prospective study of adolescents (N = 1491) who received outpatient treatment for SUDs at one of 28 treatment sites taking part in a national evidence-based practice implementation initiative. Information from the Global Appraisal of Individual Needs interviews at intake and six-month follow-up, as well as encounter data, were used. Adjusted hierarchical logistic models were used to estimate effects of engagement on six-month outcomes.

Results

Sixty-one percent of adolescents engaged in outpatient treatment. Adolescents engaging in treatment had significantly lower likelihoods of reporting any substance use (OR 0.60, 95% CI 0.41, 0.87), alcohol use (OR 0.63, 95% CI 0.45, 0.87), heavy alcohol use (OR 0.53, 95% CI 0.33, 0.86), and marijuana use (OR 0.64, 95% CI 0.45, 0.93). This association of engagement with abstinence outcomes was not limited to any particular group. Treatment engagement, however, was not associated with adolescents’ self-report of illegal activity or trouble controlling behavior at follow-up.

Conclusion

At the individual level, the Washington Circle engagement measure was a predictor of some positive outcomes for adolescents in outpatient treatment. Efforts to better engage adolescents in treatment could improve quality of care.     

Predicting relapse among young adults: psychometric validation of the Advanced WArning of RElapse (AWARE) scale

Objective

Failure to maintain abstinence despite incurring severe harm is perhaps the key defining feature of addiction. Relapse prevention strategies have been developed to attenuate this propensity to relapse, but predicting who will, and who will not, relapse has stymied attempts to more efficiently tailor treatments according to relapse risk profile. Here we examine the psychometric properties of a promising relapse risk measure—the Advance WArning of RElapse (AWARE) scale (Miller &; Harris, 2000) in an understudied but clinically important sample of young adults.

Method

Inpatient youth (N = 303; Ages 18–24; 26% female) completed the AWARE scale and the Brief Symptom Inventory-18 (BSI) at the end of residential treatment, and at 1-, 3-, and 6-months following discharge. Internal and convergent validity was tested for each of these four timepoints using confirmatory factor analysis and correlations (with BSI scores). Predictive validity was tested for relapse 1, 3, and 6 months following discharge, as was incremental utility, where AWARE scores were used as predictors of any substance use while controlling for treatment entry substance use severity and having spent time in a controlled environment following treatment.

Results

Confirmatory factor analysis revealed a single, internally consistent, 25-item factor that demonstrated convergent validity and predicted subsequent relapse alone and when controlling for other important relapse risk predictors.

Conclusions

The AWARE scale may be a useful and efficient clinical tool for assessing short-term relapse risk among young people and, thus, could serve to enhance the effectiveness of relapse prevention efforts.     

Interim methadone treatment: Impact on arrests

Aims

This study examines the frequency and severity of arrest charges among heroin addicts randomly assigned to either interim methadone (IM) maintenance or to remain on a waiting list for methadone treatment. It was hypothesized that IM participants would have a: (1) lower number of arrests at 6 and 12 months and (2) lower mean crime severity scores at 6 and 12 months post-baseline.

Methods

Available official arrest data were obtained for all 319 study participants for a period of 2 years before and after study enrollment. Crime severity ratings of charges were made using an established measure of crime severity.

Findings

Participants randomly assigned to IM as compared to those on a waiting list had a significant reduction in number of arrests at 6 but not at 12 months from study enrollment. There were no significant differences in whether participants were arrested for a more severe crime but frequency of severe crime was relatively low in both groups. Additional post hoc analyses based on whether participants were in methadone treatment at 4 and 10 months after original random assignment to treatment condition revealed that those participants not in treatment at these follow-up assessment points were significantly more likely to be arrested and to have a higher mean crime severity rating at 12 and 24 months post-baseline assessment.

Conclusions

IM as compared to the waiting list condition, had a significant reduction in number of officially recorded arrests from baseline to 6 months post-baseline. Those who were enrolled in methadone treatment at the 4- and 10-month follow-up assessment, regardless of initial assignment, had fewer arrests at 12 and 24 months post-baseline.     

One-year outcomes of telephone case monitoring for patients with substance use disorder

Background

Many patients treated for substance use disorder (SUD) do not achieve lasting recovery from a single episode of treatment and require continuing care. The current randomized clinical trial investigated whether in-person continuing care as usual (CCAU) following intensive outpatient SUD treatment leads to better SUD outcomes when compared with telephone case monitoring (TCM).

Method

This study randomized 667 intensive SUD outpatients to telephone case monitoring versus face-to-face continuing care as usual at two sites. Patients completed data at baseline, 3 and 12 months with telephone interviews. Data of interest include self-report of substance use, psychiatric symptoms, quality of life, and treatment satisfaction. We also evaluated potential interaction effects for distance to VA provider, SUD severity, and presence of co-morbid psychiatric disorder.

Results

Participants randomized to the telephone case monitoring condition substantially engaged with face-to-face continuing care resulting in cross-over contamination. We addressed this issue by using randomization as an instrumental variable to evaluate the impact of telephone case monitoring (contamination adjusted, intent to treat analysis). Instrumental variable analyses indicated significant benefit of telephone case monitoring for drug and alcohol percent days abstinent and psychiatric symptom outcomes at 3-months follow-up, but not at 12-month follow-up. No interaction analyses were significant.

Discussion

Participants receiving telephone case monitoring achieved better short term outcomes in terms of substance use and psychiatric symptoms. The “on treatment” effects suggests the need for future studies to investigate consumer (patient) perspectives on the optimal duration of telephone case monitoring and use of alternative monitoring methods such as text messaging.     

Participation in Alcoholics Anonymous and post-treatment abstinence from alcohol and other drugs

Background

This study examined associations between two types of AA participation (i.e., meeting attendance, having a sponsor) and two types of post-treatment abstinence (i.e., abstinence from alcohol, abstinence from drugs).

Method

Respondents completed measures that assessed their demographic characteristics, the severity of their substance use, and their motivation to change when they enrolled in treatment (T1). They completed measures of AA participation at T1 and a 3 month follow-up assessment (T2), and measures of recent abstinence at T1 and a 6 month follow-up assessment (T3).

Results

T2 sponsor was associated prospectively with T3 abstinence from alcohol.

Conclusions

Having a sponsor served as a marker for subsequent abstinence. Future research can examine factors that may mediate or moderate the associations between having a sponsor and subsequent abstinence.     

Television-supported self-help for problem drinkers: A randomized pragmatic trial

Objectives

To test the effectiveness of a television-supported self-help intervention for problem drinking.

Methods

Dutch television viewers (N = 181) drinking in excess of the guidelines for low-risk alcohol use were randomly assigned either to the Drinking Less TV self-help course (consisting of five televised sessions supplemented by a self-help manual and a self-help website) or to a waitlisted control group. To ensure trial integrity, intervention delivery was mimicked beforehand by sending intervention participants weekly DVDs in advance of the actual telecasts in 2006. Pre-post assessments were carried out on both groups, as well as a 3-month follow-up assessment on the intervention group to study effect maintenance. The primary outcome measure was low-risk drinking.

Results

The intervention group was more successful than the waitlist group in achieving low-risk drinking at post-intervention (OR = 9.4); the effects were maintained in the intervention group at 3-month follow-up.

Conclusions

The low-threshold television-based course Drinking Less appears effective in reducing problem drinking.     

Sober living houses for alcohol and drug dependence: 18-Month outcomes

Objective

A major challenge facing many individuals attempting to abstain from substances is finding a stable living environment that supports sustained recovery. Sober living houses (SLHs) are alcohol- and drug-free living environments that support abstinence by emphasizing involvement in 12-step groups and social support for recovery. Among a number of advantages, they are financially self-sustaining and residents can stay as long as they wish. Although SLHs can be used as housing referrals after inpatient treatment, while clients attend outpatient treatment, after incarceration, or as an alternative to treatment, they have been understudied and underutilized.

Method

To describe outcomes of SLH residents, we interviewed 245 individuals within 1week of entering SLHs and at 6-, 12-, and 18-month follow-up. Eighty-nine percent completed at least one follow-up interview. Outcomes included the Addiction Severity Index (ASI), Brief Symptom Inventory (BSI), and measures of alcohol and drug use. Covariates included demographic characteristics, 12-step involvement, and substance use in the social network.

Results

Regardless of referral source, improvements were noted on ASI scales (alcohol, drug, and employment), psychiatric severity on the BSI, arrests, and alcohol and drug use. Substance use in the social network predicted nearly all outcome measures. Involvement in 12-step groups predicted fewer arrests and lower alcohol and drug use.

Conclusion

Residents of SLHs made improvements in a variety of areas. Additional studies should use randomized designs to establish causal effects of SLHs. Results support the importance of key components of the recovery model used by SLHs: (a) involvement in 12-step groups and (b) developing social support systems with fewer alcohol and drug users.     

Gender differences in high-risk situations for drinking: Are they mediated by depressive symptoms?

Objective

The purpose of the present study was to examine gender differences in the frequency of high-risk drinking situations and to investigate the extent to which depressive symptoms mediate the relationship.

Method

Participants were 143 outpatient alcohol treatment seekers. Each participant completed the Beck Depression Inventory-II and Inventory of Drug-Taking Situations (IDTS) at baseline prior to treatment. Results: Multivariate analysis of variance was used to examine gender differences in drinking across eight categories of situations assessed on the IDTS. Mediational analyses tested whether gender differences on these IDTS subscales may be mediated by depressive symptoms. We found support for the hypothesis that women report drinking more than men in response to unpleasant emotions and conflict with others, and that these associations are significantly mediated by depression severity.

Conclusions

The current findings have important implications for appropriate treatment for alcohol-dependent women. In particular, such treatment should include training in affect regulation and interpersonal skills, as well as treatment for depression, when appropriate.     

Pathological gambling subtypes: A comparison of treatment-seeking and non-treatment-seeking samples from Brazil and Canada

Background

Pathological gambling (PG) is a heterogeneous disorder. The identification and characterization of PG subtypes could lead to tailored treatment approaches, which may, in turn, improve treatment outcomes.

Objective

To investigate PG subtypes based on personality traits across two different cultural and clinical settings. Consistent with the Pathways Model, we hypothesized the presence of three subtypes (behaviorally conditioned — BC, emotionally vulnerable — EV, and antisocial impulsivist — AI).

Methods

140 PG adults from São Paulo, Brazil (SP sample) and 352 adults with PG (n = 214) or sub-clinical PG (n = 138) from Toronto, Canada (TO sample) completed the Temperament and Character Inventory (TCI). Latent-class analysis was used to investigate subtypes.

Results

A 2-class solution was the best model for the pooled SP and TO samples. Class 1 presented a normative personality profile and was composed exclusively of participants from Toronto (BC subtype). Class 2 was characterized by high novelty seeking, high harm avoidance, and low self-directedness, and included participants from both SP and TO (EV subtype). When sub-clinical PGs were excluded from the analysis, a single-class solution better characterized the SP and TO samples.

Conclusions

Our results suggest that PG severity, rather than community or clinical settings, may have an effect on PG subtypes. The generalizability of the results is limited by the demographic and clinical features of the selected samples. Future neurobiological studies may contribute to the categorization of subjects into PG subtypes based on different underlying biological pathways.     

How are addicted physicians treated? A national survey of physician health programs

Introduction

Physicians with substance use disorders receive care that is qualitatively different from and reputedly more effective than that offered to the general population, yet there has been no national study of this distinctive approach. To learn more about the national system of Physician Health Programs (PHPs) that manage the care of addicted physicians, we surveyed all 49 state PHP medical directors (86% responded) to characterize their treatment, support, and monitoring regimens.

Results

PHPs do not provide substance abuse treatment. Under authority from state licensing boards, state laws, and contractual agreements, they promote early detection, assessment, evaluation, and referral to abstinence-oriented (usually) residential treatment for 60 to 90 days. This is followed by 12-step–oriented outpatient treatment. Physicians then receive randomly scheduled urine monitoring, with status reports issued to employers, insurers, and state licensing boards for (usually) 5 or more years. Outcomes are very positive, with only 22% of physicians testing positive at any time during the 5 years and 71% still licensed and employed at the 5-year point.

Conclusion

Addicted physicians receive an intensity, duration, and quality of care that is rarely available in most standard addiction treatments: (a) intensive and prolonged residential and outpatient treatment, (b) 5 years of extended support and monitoring with significant consequences, and (c) involvement of family, colleagues, and employers in support and monitoring. Although not available to the general public now, several aspects of this continuing care model could be adapted and used for the general population.     

Long-term outcomes of office-based buprenorphine/naloxone maintenance therapy

Background

Buprenorphine/naloxone was approved by the FDA for office-based opioid maintenance therapy (OMT), with little long-term follow-up data from actual office-based practice. 18-Month outcome data on the office-based use of buprenorphine/naloxone (bup/nx) and the impact of socioeconomic status and other patient characteristics on the duration and clinical effects of bup/nx are reported.

Methods

This retrospective chart review and cross-sectional telephone interview provide treatment retention of opioid-dependent patients receiving bup/nx-OMT in an office-based setting. 176 opioid-dependent patients from two different socioeconomic groups (high and low SES) were begun on bup/nx, started intensive outpatient treatment, and followed-up after a minimum of 18 months (18–42 months) by telephone interview to assess treatment outcome.

Results

110 subjects (67%) completed the interview, 77% remained on bup/nx with no difference in retention between high and low SES groups. Those on bup/nx at follow-up were more likely to report abstinence, to be affiliated with 12-step recovery, to be employed and to have improved functional status.

Conclusions

Bup/nx-OMT is a viable treatment option and when coupled with a required abstinence oriented addiction counseling program is effective in promoting abstinence, self-help group attendance, occupational stability, and improved psychosocial outcomes in both low SES and high SES patient populations over an 18–42-month period.     

A multidimensional assessment of the validity and utility of alcohol use disorder severity as determined by item response theory models

Background

The relative severity of the 11 DSM-IV alcohol use disorder (AUD) criteria are represented by their severity threshold scores, an item response theory (IRT) model parameter inversely proportional to their prevalence. These scores can be used to create a continuous severity measure comprising the total number of criteria endorsed, each weighted by its relative severity.

Methods

This paper assesses the validity of the severity ranking of the 11 criteria and the overall severity score with respect to known AUD correlates, including alcohol consumption, psychological functioning, family history, antisociality, and early initiation of drinking, in a representative population sample of U.S. past-year drinkers (n = 26,946).

Results

The unadjusted mean values for all validating measures increased steadily with the severity threshold score, except that legal problems, the criterion with the highest score, was associated with lower values than expected. After adjusting for the total number of criteria endorsed, this direct relationship was no longer evident. The overall severity score was no more highly correlated with the validating measures than a simple count of criteria endorsed, nor did the two measures yield different risk curves. This reflects both within-criterion variation in severity and the fact that the number of criteria endorsed and their severity are so highly correlated that severity is essentially redundant.

Conclusions

Attempts to formulate a scalar measure of AUD will do as well by relying on simple counts of criteria or symptom items as by using scales weighted by IRT measures of severity.     

Stimulant abuser groups to engage in 12-Step: A multisite trial in the National Institute on Drug Abuse Clinical Trials Network

Aims

The study evaluated the effectiveness of an 8-week combined group plus individual 12-step facilitative intervention on stimulant drug use and 12-step meeting attendance and service.

Design

Multisite randomized controlled trial, with assessments at baseline, mid-treatment, end of treatment, and 3- and 6-month post-randomization follow-ups (FUs).

Setting

Intensive outpatient substance treatment programs.

Participants

Individuals with stimulant use disorders (n = 471) randomly assigned to treatment as usual (TAU) or TAU into which the Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) intervention was integrated.

Measurements

Urinalysis and self-reports of substance use and 12-step attendance and activities.

Intervention

Group sessions focused on increasing acceptance of 12-step principles; individual sessions incorporated an intensive referral procedure connecting participants to 12-step volunteers.

Findings

Compared with TAU, STAGE-12 participants had significantly greater odds of self-reported stimulant abstinence during the active 8-week treatment phase; however, among those who had not achieved abstinence during this period, STAGE-12 participants had more days of use. STAGE-12 participants had lower Addiction Severity Index Drug Composite scores at and a significant reduction from baseline to the 3-month FU, attended 12-step meetings on a greater number of days during the early phase of active treatment, engaged in more other types of 12-step activities throughout the active treatment phase and the entire FU period, and had more days of self-reported service at meetings from mid-treatment through the 6-month FU.

Conclusions

The present findings are mixed with respect to the impact of integrating the STAGE-12 intervention into intensive outpatient drug treatment compared with TAU on stimulant drug use. However, the results more clearly indicate that individuals in STAGE-12 had higher rates of 12-step meeting attendance and were engaged in more related activities throughout both the active treatment phase and the entire 6-month FU period than did those in TAU.     

How the states stack up: Disparities in substance abuse outpatient treatment completion rates for minorities

Background

This study was an exploratory investigation of state-level minority disparities in successfully completing outpatient treatment, a major objective for attending substance abuse treatment and a known process outcome measure.

Method

This was a retrospective analysis of state discharge and admission data from the 2006 to 2008 Treatment Episode Datasets–Discharge (TEDS-D). Data were included representing all discharges from outpatient substance abuse treatment centers across the United States. All first treatment episode clients with admission/discharge records meeting inclusion criteria who could be classified as White, Latino, or Black/African American were used (n = 940,058).

Results

States demonstrated racial and ethnic disparities in their crude and adjusted completion rates, which also varied considerably among the states. Minorities typically showed a disadvantage. A few states showed significantly higher completion rates for Blacks or Latinos.

Conclusions

Realistically, a variety of factors likely cause the state race/ethnic differences in successful completion rates. States should investigate their delivery systems to reduce completion disparities.     

The 12 Step Affiliation and Practices Scale: Development and initial validation of a measure assessing 12 step affiliation

Objective

Research on instruments designed to measure endorsement of 12 step beliefs and practices among individuals with substance use disorders is virtually nonexistent. The goal of this study was to examine the psychometric properties of a novel instrument called the 12 Step Affiliation and Practices Scale (TSAPS) using a sample of young adults receiving 12 step-based residential treatment for alcohol and drug dependence.

Method

As part of a naturalistic treatment outcome study, 300 young adults receiving residential treatment completed the TSAPS and several other assessments during and after treatment. Analyses of the TSAPS examined its factor structure, internal consistency, sensitivity to change over time, and convergent and predictive validity.

Results

A maximum likelihood estimation factor analysis using oblique rotation produced 4 factors accounting for 61.16% of the variance. Internal consistency was very high and scores on the TSAPS significantly increased across the course of treatment. Convergent validity was demonstrated by relationships with scales of treatment attitudes, twelve step expectancies and commitment to sobriety. Predictive validity was also found, as evidenced by a relationship between total TSAPS score at 3 months post-treatment and percent of abstinent days at 6 months post-treatment.

Conclusions

The TSAPS shows promise as a psychometrically sound, internally reliable measure of 12 step affiliation and practices among individuals with substance dependence.     

Daily ratings measures of alcohol craving during an inpatient stay define subtypes of alcohol addiction that predict subsequent risk for resumption of drinking

Background

Both depressive symptoms and alcohol craving have been postulated as important predictors of relapse in patients with addictive disorders. The purpose of this study was to examine the course of affective symptoms and cravings for alcohol use during the initial 25 days of residential treatment for middle aged and older adults addicted to alcohol and the relationship between these symptoms and recovery outcomes.

Methods

95 alcohol-dependent subjects were enrolled in this observational study. Participants completed a daily diary of alcohol craving, positive affect, and negative affect during residential treatment. Participants were interviewed 1 and 6 months after discharge to assess clinical symptoms of relapse and functioning.

Results

Latent class analysis identified three groups of individuals for each of the three daily measures. For alcohol craving, 17 subjects reported elevated cravings during the entire treatment stay, 37 subjects reported initially elevated but then a slight improvement in craving, and 41 subjects reported relatively low craving from the time of admission to the end of residential treatment. Alcohol craving class was associated with negative affect but not positive affect. Alcohol craving class but not affective class was predictive of time to relapse to any drinking in the 6 months after residential treatment (p < 0.05).

Conclusion

Results suggest that non-cue induced alcohol craving may define a subtype of alcohol dependence that is less responsive to treatment and may explain heterogeneity in treatment outcomes. These results also may suggest a role for differential treatment programming to address high states of craving for alcohol.