Literature Update for CERGA May - July 2009
Contents
List of journal checked
List of agencies checked
List of references …
List of abstracts …
Alcohol
Opiate treatment
Treatment organisation and delivery
Epidemiology and demography
Co-morbidity
Psychosocial treatments
Psychostimulants
Blood borne viruses
Overdose prevention and harm reduction
Pregnancy treatment
Alcohol
Opiate treatment
Treatment organisation and delivery
Epidemiology and demography
Co-morbidity
Psychosocial treatments
Psychostimulants
Blood borne viruses
Overdose prevention and harm reduction
Pregnancy treatment
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List of Journals
Issues /
year
12
6
Addiction
Addiction Research and Theory
Addictive Behaviours
Addictive Disorders and their Treatment
Alcoholism
4
Alcoholism and Drug Abuse Weekly
Alcoholism: Clinical and Experimental Research
American Journal of Drug and Alcohol Abuse
American Journal on Addictions
British Medical Journal International
Drug and Alcohol Dependency
12
6
6
Weekly
Drug and Alcohol Review
6
Drugs and Alcohol Today
4
Drugs: Education, Prevention and Policy
Forensic Science International
International Journal of Drug Policy
6
Journal of Addictive Diseases
Journal of Alcohol and Drug Education
4
Journal of Public Health
Journal of Substance Abuse Treatment
Journal of Substance Use and Misuse
Lancet
6
6
6
Weekly
List of Agencies:
National Treatment Agency Publications
2 of 26
Volumes & issues checked and
comments
104 (5) May; 104 (6) June; 104 (7) July
17 (3) Jun; 17 (4) Aug
34 (5) May; 34 (6 & 7) Jun-July
8 (2) Jun; 8 (3) Sept
Not on UoA e-Journals catalogue : on NHS
e-lib but only 2005-2008
Not on UoA e-Journals catalogue: on NHS
e-lib
33 (5) May; 33 (6) June; 33 (7) July
35 (3) May; 35 (4) July
18 (3) May; 18 (4) July
338 (7702) – 338 (7714) 2 May-25 July
Not on UoA e-Journals catalogue nor on
NHS e-lib
Changed publisher in 2009; no ’09 issues
found on UoA e-Journals catalogue, most
recent - 2008
Not on UoA e-Journals catalogue : on NHS
e-lib
16 (3) June; 16 (4) Aug
187 (1-3) May; 188 (1-3) July; 189 (1-3) Aug
Not on UoA e-Journals catalogue; on NHS
e-lib
20 (3) May ; 20 (4) July
28 (2); 28 (3)
Not on UoA e-Journals catalogue : on NHS
e-lib
17 (3) June; 17 (4) Aug
36 (3) April; 36 (4) June; 37 (1) July
14 (3&4) June
373 (9674) Apr/May – 373 (9686) July
List of References
Note: number in [ ] after reference is page number for abstract
Alcohol
1. Alcohol-related cirrhosis—early abstinence is a key factor in prognosis, even in the most
severe cases. Addiction 2009 104 (5): 768-774. Clare Verrill, Hannah Markham, Alexa Templeton,
Norman J. Carr, Nick Sheron [p 8]
2. Twelve-Step affiliation and 3-year substance use outcomes among adolescents: social
support and religious service attendance as potential mediators. Addiction 2009 104 (6): 927939. Felicia W. Chi, Lee A. Kaskutas, Stacy Sterling, Cynthia I. Campbell, Constance Weisner [p 8]
3. How do people recover from alcohol dependence? A systematic review of the research on
mechanisms of behavior change in Alcoholics Anonymous. Addiction Research & Theory 17
(3):236 – 259. John Francis Kelly a; Molly Magill b; Robert Lauren Stout c [p 8]
4. Cognitive-behavioral therapy for panic disorder in patients being treated for alcohol
dependence: Moderating effects of alcohol outcome expectancies. Addictive Behaviours
Volume 34 (6-7): 554-560. Matt G. Kushner, Sandra Sletten, Christopher Donahue, Paul Thuras,
Eric Maurer, Antonina Schneider, Brenda Frye, Joani Van Demark [p 9]
5. Initiating acamprosate within-detoxification versus post-detoxification in the treatment of
alcohol dependence. Addictive Behaviours 34(6-7): 581-586. Kyle M. Kampman, Helen M.
Pettinati, Kevin G. Lynch, Hu Xie, Charles Dackis, David W. Oslin, Thorne Sparkman, Tiffany
Sharkoski, Charles P. O'Brien [p 10]
6. Understanding and Treating Patients With Alcoholic Cirrhosis: An Update. Alcoholism: Clinical
and Experimental Research 33 (7): 1136-1144. Giovanni Addolorato, Marcia Russell, Emanuele
Albano, Paul S. Haber, Jack R. Wands, Lorenzo Leggio [p 10]
7. GPs should get specific training on dealing with patients’ alcohol problems, MPs hear. British
Medical Journal 338 (7704): b1913. Adrian O’Dowd, London. [News] [p11]
8. The Cost Effectiveness of Naltrexone Added to Cognitive-Behavioral Therapy in the
Treatment of Alcohol Dependence. Journal of Addictive Diseases 28 (2): 137 – 144. David
Walters; Jason P. Connor; Gerald F. X. Feeney; Ross McD Young [p12]
9. Effectiveness and cost-effectiveness of policies and programmes to reduce the harm caused
by alcohol. Lancet 373 (9682): 2234-2246. Peter Anderson, Dan Chisholm, Daniela C Fuhr [p 12]
10. Engagement and Retention in Outpatient Alcoholism Treatment for Women. American Journal
on Addictions 18 (4): 277 – 288. Fiona S. Graff; Thomas J. Morgan; Elizabeth E. Epstein; Barbara
S. McCrady; Sharon M. Cook; Noelle K. Jensen; Shalonda Kelly [p 12]
Opiate Treatment
11. Retention in methadone maintenance drug treatment for prescription-type opioid primary
users compared to heroin users. Addiction 2009 104 (5): 775-783. Caleb J. Banta-Green,
Charles Maynard, Thomas D. Koepsell, Elizabeth A. Wells, Dennis M. Donovan [p 13]
12. Comparison of costs and utilization among buprenorphine and methadone patients. Addiction
2009 104 (6): 982-992. Paul G. Barnett [p13]
13. Comparing retention in treatment and mortality in people after initial entry to methadone and
buprenorphine treatment. Addiction 2009 104 (7): 1193-1200. James Bell, Lieu Trinh, Bethany
Butler, Deborah Randall, George Rubin [p 13]
3 of 26
14. Predictors of opiate agonist treatment retention among injection drug users referred from a
needle exchange program. Journal of Substance Abuse Treatment 36 (3): 306-312. Jennifer R.
Havens, Carl A. Latkin, Minya Pu, Llewellyn J. Cornelius, David Bishai, Steve Huettner, Charles
Rapp, Erin P. Ricketts, Jacqueline J. Lloyd, Steffanie A. Strathdee [p14]
15. Factors associated with the prescribing of buprenorphine or methadone for treatment of
opiate dependence. Journal of Substance Abuse Treatment 37 (1): 95-100. Gayle Ridge, Michael
Gossop, Nicholas Lintzeris, John Witton, John Strang [p14]
16. Baseline Neurocognitive Profiles Differentiate Abstainers and Non-Abstainers in a Cocaine
Clinical Trial. Journal of Addictive Diseases 28 (3): 250 – 257. Joy M. Schmitz; Marc E. Mooney;
Charles E. Green; Scott D. Lane; Joel L. Steinberg; Alan C. Swann; F. Gerard Moeller [p15]
17. Inadequate Dose of Opioid-agonist Medication is Related to Misuse of Benzodiazepines.
Addictive Disorders & Their Treatment 8 (3): 145-153. Heikman, Pertti Kalevi; Ojanpera, Ilkka
Antero [p15]
18. Prescribing Injectable Methadone: What the Addiction Specialist Needs to Know. Addictive
Disorders & Their Treatment 8 (3): 154-158. George, Sanju MRCPsych *; Dharmadhikari, Anupam
[15]
Treatment Organisation and Delivery
19. Improving substance abuse treatment enrollment in community syringe exchangers.
Addiction 2009 104 (5): p 786-795. Michael Kidorf, Van L. King, Karin Neufeld, Jessica Peirce, Ken
Kolodner, Robert K. Brooner [p16]
20. Results from two randomized clinical trials evaluating the impact of quarterly recovery
management checkups with adult chronic substance users. Addiction 2009 104 (6): p 959-971.
Christy K Scott, Michael L. Dennis [p 16]
21. Health professionals' attitudes towards AOD-related work: Moving the traditional focus from
education and training to organizational culture. Drugs: education, prevention and policy 16 (3):
232 – 249. Natalie Skinner a; Ann M. Roche a; Toby Freeman a; Anna Mckinnon a [p16]
22. User involvement in efforts to improve the quality of drug misuse services in England: A
national survey. Drugs: education, prevention and policy 16 (4): 364 – 377. Sue Patterson;
Tim Weaver; Kostas Agath; Deborah Rutter; Eliot Albert; Mike J. Crawford [p 17]
23. Does a History of Violence Influence Treatment, Self-Help, and 1-Year Outcomes in
Substance Use Disorder Patients? Journal of Addictive Diseases 28 (2): 171 – 179. Renee
Schneider; Christine Timko [p 17]
24. Relating counselor attributes to client engagement in England. Journal of Substance Abuse
Treatment 36 (3): 313-320. Dwayne Simpson, Grace A. Rowan-Szal, George W. Joe, David Best,
Ed Day, Angela Campbell [p 17]
25. Organizational determinants of outpatient substance abuse treatment duration in women.
Journal of Substance Abuse Treatment 37 (1): 64-72. Cynthia I. Campbell, Jeffrey A. Alexander,
Christy Harris Lemak [p 18]
26. The evaluation of a trial of syringe vending machines in Canberra, Australia. International
Journal of Drug Policy 20 (4): 336-339. David McDonald [p 18]
27. Secondary exchange of sterile injecting equipment in a high distribution environment: A
mixed method analysis in south east Sydney, Australia. International Journal of Drug Policy 20
(4): 324-328. Joanne Bryant, Max Hopwood [p 18]
4 of 26
Epidemiology and Demography
28. Maintenance therapy and 3-year outcome of opioid-dependent prisoners: a prospective study
in France (2003–06). Addiction 2009 104 (7): 1233-1240. Jean-Noël Marzo, Michel Rotily, Fadi
Meroueh, Marina Varastet, Catherine Hunault, Ivana Obradovic, Adeline Zin [p 19]
29. Groin injecting in injectable opioid treatment service users in South London. Addiction
Research & Theory 17 (4): 381 - . Peter G. Miller a; Luciana Forzisi b; Deborah Zador c; Nick
Lintzeris d; Nicola Metrebian b; Rob Van Der Waal e; Soraya Mayet b; John Strang b [p20]
30. Prospective Study of the Association Between Neurobehavior Disinhibition and Peer
Environment on Illegal Drug Use in Boys and Girls. American Journal of Drug and Alcohol
Abuse 35 (3): 145 – 150. Levent Kirisci; Ada C. Mezzich; Maureen Reynolds; Ralph E. Tarter;
Sema Aytaclar [p 20]
31. Factors associated with mortality in Scottish patients receiving methadone in primary care:
retrospective cohort study. BMJ 2009;338:b2225. C McCowan, B Kidd, T Fahey [p 21]
32. Sex work, substance misuse and service provision: The experiences of female sex workers in
south London. Drugs: education, prevention and policy, 16 (4): 355 – 363. Brenda Mosedale;
Christos Kouimtsidis; Martina Reynolds [p 21]
33. Epidemiological Trends in Abuse and Misuse of Prescription Opioids. Journal of Addictive
Diseases 28 (2):130 – 136. Henry Spiller; Douglas J. Lorenz; Elise J. Bailey; Richard C. Dart [p21]
34. Pathways from Adolescent Parent-Child Conflict to Substance Use Disorders in the Fourth
Decade of Life. American Journal on Addictions 18 (3): 235 – 242. Judith S. Brook; David W.
Brook; Chenshu Zhang; Patricia Cohen [p 22]
35. A profile of adolescent cocaine use in Northern Ireland. International Journal of Drug Policy 20
(4): 357-364. Patrick McCrystal, Andrew Percy [p 22]
Co-morbidity
36. Co-morbidity of drug addiction: An analysis of epidemiological data and possible etiological
models. Addiction Research & Theory 17(4): 420 – 431. Author: Zsolt Demetrovics a [p 22]
37. Gender and comorbidity among individuals with opioid use disorders in the NESARC study.
Addictive Behaviours 34 (6-7): 498-504. Christine E. Grella, Mitchell P. Karno, Umme S. Warda,
Noosha Niv, Alison A. Moore [p 23]
Psychosocial Treatment
38. Social anxiety impacts willingness to participate in addiction treatment. Addictive Behaviours
34 (5): 474-476. Sarah W. Book, Suzanne E. Thomas, Jared P. Dempsey, Patrick K. Randall, Carrie
L. Randall [p 23]
39. Parenting Practices as Mediators of Treatment Effects in an Early-Intervention Trial of
Multidimensional Family Therapy. American Journal of Drug and Alcohol Abuse 35 (4): 220-226.
Craig E. Henderson; Cindy L. Rowe; Gayle A. Dakof; Sam W. Hawes; Howard A. Liddle [p 24]
40. Assessing the effectiveness of an Internet-based videoconferencing platform for delivering
intensified substance abuse counseling. Journal of Substance Abuse Treatment 36 (3): 331-338.
Van L. King, Kenneth B. Stoller, Michael Kidorf, Kori Kindbom, Steven Hursh, Thomas Brady, Robert
K. Brooner [p 24]
41. Informal discussions in substance abuse treatment sessions. Journal of Substance Abuse
Treatment 36 (4): 366-375. Steve Martino, Samuel A. Ball, Charla Nich, Tami L. Frankforter,
Kathleen M. Carroll [p 25]
5 of 26
42. Randomized trial of training and supervision in motivational interviewing with adolescent
drug treatment practitioners. Journal of Substance Abuse Treatment 37 (1): 73-78. Luke
Mitcheson, Kaanan Bhavsar, Jim McCambridge [p 25]
43. Acupuncture or counselling: outcomes and predictors of treatment choice in a non-statutory
addiction service. Journal of Substance Use 14 (3&4): 151-160. Heather Ashton; Arunima
Nodiyal; David Green; Brian Moore; Nick Heather [p 25]
Psychostimulatants
44. An audit of a stimulant clinic: changes in drug use, drug beliefs, and motivational ratings.
Journal of Substance Use 14 (3 & 4): 179 – 188. L. Ramsay; Alyson Bond; Selina Pope [p 26]
45. Pharmacogenetic Treatments for Drug Addiction: Cocaine, Amphetamine and
Methamphetamine. American Journal of Drug and Alcohol Abuse 35 (3): 161 – 177.
Colin N. Haile; Thomas R. Kosten; Therese A. Kosten [p 26]
46. General practitioners’ management of psychostimulant drug misuse: Implications for
education and training. Drugs: education, prevention and policy, 16 (4): 343 – 354. Ahmed
Alkhamis; Catriona Matheson; Christine Bond [p 26]
47. Theories of Addiction: Methamphetamine Users' Explanations for Continuing Drug Use and
Relapse. American Journal on Addictions 18 (4): 294 – 300. Thomas F. Newton; Richard De La
Garza II; Ari D. Kalechstein; Desey Tziortzis; Caitlin A. Jacobsen [p 27]
Blood Borne Viruses
48. Longitudinal community plasma HIV-1 RNA concentrations and incidence of HIV-1 among
injecting drug users: prospective cohort study. BMJ 2009;338:b1649. Evan Wood, Thomas
Kerr, Brandon D L Marshall, Kathy Li, Ruth Zhang, Robert S Hogg, P Richard Harrigan, Julio S G
Montaner [p 27]
49. Managing hepatitis C virus infection. BMJ 2009;338 (7711):b2366. Kathryn L Nash, Ian Bentley,
Gideon M Hirschfield. Clinical Review [p 28]
50. Successful treatment of chronic hepatitis C with pegylated interferon in combination with
ribavirin in a methadone maintenance treatment program. Journal of Substance Abuse
Treatment 37 (1): 32-40. Alain H. Litwin, Kenneth A. Harris Jr., Shadi Nahvi, Philippe J. Zamor,
Irene J. Soloway, Peter L. Tenore, Daniel Kaswan, Marc. N. Gourevitch, Julia H. Arnsten [p 28]
Overdose Prevention and Harm Reduction
51. Using a group approach to preventing heroin overdose in North London. Drugs: education,
prevention and policy 16 (4): 328 – 342. Peter Phillips; Chris Glover; Teresa Allan; Mary Ellen
Khoo [p 29]
52. Preventing Death Among the Recently Incarcerated: An Argument for Naloxone Prescription
Before Release. Journal of Addictive Diseases 28 (2): 124 – 129. Sarah E. Wakeman; Sarah E.
Bowman; Michelle McKenzie; Alexandra Jeronimo; Josiah D. Rich [p 29]
Pregnancy Treatment
53. Gestational Age at Enrolment and Continued Substance Use Among Pregnant Women in
Drug Treatment. Journal of Addictive Diseases 28 (2): 103 – 112. Mishka Terplan; Joanne
Garrett; Katherine Hartmann [p 30]
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Abstracts
Alcohol
1. Alcohol-related cirrhosis—early abstinence is a key factor in prognosis, even in the most severe
cases. Addiction 2009 104 (5): 768-774. Clare Verrill, Hannah Markham, Alexa Templeton, Norman J.
Carr, Nick Sheron
Aims: To determine the effect of pathological severity of cirrhosis on survival in patients with alcohol-related
cirrhosis.
Design: Liver biopsies from 100 patients were scored for Laennec score of severity of cirrhosis, and
medical notes were reviewed to determine various clinical factors, including drinking status. Up-to-date
mortality data were obtained using the National Health Service Strategic Tracing Service.
Setting: Southampton General Hospital between 1 January 1995 and 31 December 2000.
Participants A total of 100 consecutive patients with biopsy proven alcohol-induced liver cirrhosis.
Measurements Laennec score of severity of cirrhosis and mortality.
Findings: Most surprisingly, the severity of cirrhosis on biopsy had little impact on survival; indeed, early
death was more likely in patients with the least severe cirrhosis. Abstinence from alcohol at 1 month after
diagnosis of cirrhosis was the more important factor determining survival with a 7-year survival of 72% for the
abstinent patients versus 44% for the patients continuing to drink.
Conclusions: It is never too late to stop drinking, even with the most severe degrees of cirrhosis on biopsy.
Early drinking status is the most important factor determining long-term survival in alcohol-related cirrhosis.
2. Twelve-Step affiliation and 3-year substance use outcomes among adolescents: social support
and religious service attendance as potential mediators. Addiction 2009 104 (6): 927-939. Felicia W.
Chi, Lee A. Kaskutas, Stacy Sterling, Cynthia I. Campbell, Constance Weisner
KeywordsAdolescents • long-term outcomes • mediation • religious service attendance • social support • 12Step affiliation
Aims: Twelve-Step affiliation among adolescents is little understood. We examined 12-Step affiliation and
its association with substance use outcomes 3 years post-treatment intake among adolescents seeking
chemical dependency (CD) treatment in a private, managed-care health plan. We also examined the effects
of social support and religious service attendance on the relationship.
Design: We analyzed data for 357 adolescents, aged 13–18, who entered treatment at four Kaiser
Permanente Northern California CD programs between March 2000 and May 2002 and completed both
baseline and 3-year follow-up interviews.
Measures: Measures at follow-up included alcohol and drug use, 12-Step affiliation, social support and
frequency of religious service attendance.
Findings: At 3 years, 68 adolescents (19%) reported attending any 12-Step meetings, and 49 (14%)
reported involvement in at least one of seven 12-Step activities, in the previous 6 months. Multivariate
logistic regression analyses indicated that after controlling individual and treatment factors, 12-Step
attendance at 1 year was marginally significant, while 12-Step attendance at 3 years was associated with
both alcohol and drug abstinence at 3 years [odds ratio (OR) 2.58, P < 0.05 and OR 2.53, P < 0.05,
respectively]. Similarly, 12-Step activity involvement was associated significantly with 30-day alcohol and
drug abstinence. There are possible mediating effects of social support and religious service attendance on
the relationship between post-treatment 12-Step affiliation and 3-year outcomes.
Conclusions: The findings suggest the importance of 12-Step affiliation in maintaining long-term recovery,
and help to understand the mechanism through which it works among adolescents
3. How do people recover from alcohol dependence? A systematic review of the research on
mechanisms of behavior change in Alcoholics Anonymous. Addiction Research & Theory 17 (3):236 –
259. John Francis Kelly a; Molly Magill b; Robert Lauren Stout c
Keywords: Self-help; mutual-help groups; addiction; alcoholism; recovery
Rigorous reviews of the science on the effectiveness of Alcoholics Anonymous (AA) indicate that AA and
related 12-step treatment are at least as helpful as other intervention approaches. Exactly how AA achieves
7 of 26
these beneficial outcomes is less well understood, yet, greater elucidation of AA's mechanisms could inform
our understanding of addiction recovery and the timing and content of alcohol-related interventions.
Empirical studies examining AA's mechanisms were located from searches in Pubmed, Medline, PsycINFO,
Social Service Abstracts and from published reference lists. Thirteen studies completed full mediational
tests. A further six were included that had completed partial tests. Mechanisms examined fell into three
domains: (1) Common processes; (2) AA-specific practices; and (3) Social and spiritual processes. Results
suggest AA helps individuals recover through common process mechanisms associated with enhancing selfefficacy, coping skills, and motivation, and by facilitating adaptive social network changes. Little research or
support was found for AA's specific practices or spiritual mechanisms. Conclusions are limited by betweenstudy differences in sampling, measurement, and assessment time-points, and by insufficient theoretical
elaboration of recovery-related change. Similar to the common finding that theoretically-distinct professional
interventions do not result in differential patient outcomes, AA's effectiveness may not be due to its specific
content or process. Rather, its chief strength may lie in its ability to provide free, long-term, easy access and
exposure to recovery-related common therapeutic elements, the dose of which, can be adaptively selfregulated according to perceived need.
4. Cognitive-behavioral therapy for panic disorder in patients being treated for alcohol dependence:
Moderating effects of alcohol outcome expectancies. Addictive Behaviours Volume 34 (6-7): 554-560.
Matt G. Kushner, Sandra Sletten, Christopher Donahue, Paul Thuras, Eric Maurer, Antonina Schneider,
Brenda Frye, Joani Van Demark
Anxiety disorders commonly co-occur with alcohol use disorders and reliably mark a poor response to
substance abuse treatment. However, treating a co-occurring anxiety disorder does not reliably improve
substance abuse treatment outcomes. Failure to account for individual differences in the functional dynamic
between anxiety symptoms and drinking behavior might impede the progress and clarity of this research
program. For example, while both theory and research point to the moderating role of tension-reduction
alcohol outcome expectancies (TR-AOEs) in the association between anxiety symptoms and alcohol use,
relevant treatment studies have not typically modeled TR-AOE effects. We examined the impact of a hybrid
cognitive-behavioral therapy (H-CBT) treatment for panic disorder (independent variable) on response to a
community-based alcohol dependence treatment program (dependent variable) in patients with higher vs.
lower TR-AOEs (moderator). The H-CBT treatment was generally effective in relieving participants' panic
symptoms relative to controls. However, TR-AOEs interacted with study cohort (H-CBT vs. control) in
predicting response to substance abuse treatment. As expected, the H-CBT was most effective in improving
alcohol use outcomes among those with the highest TR-AOEs. The study's primary methodological
limitations are related to the quasi-experimental design employed.
5. Initiating acamprosate within-detoxification versus post-detoxification in the treatment of alcohol
dependence. Addictive Behaviours 34(6-7): 581-586. Kyle M. Kampman, Helen M. Pettinati, Kevin G.
Lynch, Hu Xie, Charles Dackis, David W. Oslin, Thorne Sparkman, Tiffany Sharkoski, Charles P. O'Brien
Objectives
This trial compared the efficacy of acamprosate, started at the beginning of detoxification, to acamprosate
started at the completion of detoxification, in the treatment of alcohol dependence.
Methods
This biphasic clinical trial consisted of a randomized, double-blind, placebo-controlled Detoxification Phase
(DP), followed by a 10-week open-label Rehabilitation Phase (RP). Forty alcohol dependent patients were
randomly assigned to receive either 1998 mg of acamprosate daily, or matching placebo, during the DP (5–
14 days). After completing detoxification, all patients received open label acamprosate (1998 mg daily) in the
RP. Outcome measures during the DP included: treatment retention, alcohol withdrawal, alcohol
consumption, and oxazepam used. Outcome measures during the RP included: treatment retention and
alcohol consumption.
Results
There were no significant outcome differences between acamprosate and placebo-treated patients during
the DP. Patients given acamprosate, compared to placebo, during the DP drank more alcohol in the RP.
Conclusions
Starting acamprosate at the beginning of detoxification did not improve DP outcomes. Starting acamprosate
after detoxification was completed was associated with better drinking outcomes during subsequent alcohol
rehabilitation treatment.
8 of 26
6. Understanding and Treating Patients With Alcoholic Cirrhosis: An Update. Alcoholism: Clinical and
Experimental Research 33 (7): 1136-1144. Giovanni Addolorato, Marcia Russell, Emanuele Albano, Paul S.
Haber, Jack R. Wands, Lorenzo Leggio
Keywords
Alcoholic Cirrhosis • Oxidative Stress • Pentoxifylline • Corticosteroids • Alcohol Relapse • Baclofen
Alcoholic cirrhosis represents the terminal stage of alcoholic liver disease (ALD) and one of the main causes
of death among alcohol abusers. The aim of this review was to provide an update on alcoholic cirrhosis, with
an emphasis on recent findings. Increased alcohol consumption in developing countries is expected to
increase cirrhosis mortality. There is a need, therefore, to develop new approaches to the prevention of ALD,
including more attention to co-factors that may increase risk of ALD (i.e., obesity and diabetes, chronic HCV
infection, and smoking). Furthermore, a better understanding of the pathological mechanisms on the basis of
alcohol cirrhosis represents a cornerstone in order to develop new pharmacological treatments. Inflammatory
and immune responses along with oxidative stress and alterations in adipokine secretion might contribute in
different ways to the evolution of alcohol-induced fibrosis/cirrhosis. As of this date, patients with severe
alcoholic hepatitis with a Maddrey Discriminant Factor (MDF) 32 should be offered pentoxifylline and/or
corticosteroids unless contraindications exist. For ambulatory patients, S-adenosylmethionine (SAMe) may
be considered in a motivated patient with nutritional support. Current studies do not support use of anti-tumor
necrosis factor (TNF)-alpha antibody. Finally, achieving total alcohol abstinence should represent the main
aim in the management of patients affected by any stage of cirrhosis. In the last decades, several drugs able
to increase abstinence and prevent alcohol relapse have been evaluated and some of them have obtained
approval for alcohol dependence. Patients with alcoholic cirrhosis; however, are usually excluded from such
treatments. A recent study demonstrated the efficacy and safety of baclofen in inducing and maintaining
alcohol abstinence in cirrhotic alcohol-dependent patients with cirrhosis. All together the information
available suggests the need of a multimodal approach in the clinical management of these patients.
7. GPs should get specific training on dealing with patients’ alcohol problems, MPs hear. British
Medical Journal 338 (7704): b1913. Adrian O’Dowd, London
News
With the right training and support, doctors could take on the role of preventing the overuse of alcohol by
their patients as part of routine care, MPs were told earlier this month.
At an evidence session as part of the parliamentary health select committee’s inquiry into alcohol, expert
witnesses said that primary care could do more to help patients with alcohol problems.
MPs asked clinicians what more the NHS could do to prevent the development of alcohol related problems.
Mike Kelly, director of the Centre for Public Health Excellence at the National Institute for Health and Clinical
Excellence, said that the institute was currently undertaking three related reviews: prevention of alcohol
misuse, management and treatment of people with alcohol problems, and dealing with alcohol dependency.
"The NHS has to recognise alcohol as a major priority," said Professor Kelly. "We have seen changes over
the last 30 years in patterns of alcohol consumption . . . and alcohol related disease which are the
consequence of cultural and other kinds of changes. That means you can change it back. It’s not an
inevitable juggernaut."
Interventions and screening tools that were known to work need to be implemented effectively, he added.
"Any direct interventions in an NHS setting have to be done in a non-judgmental way. The evidence that we
have looked at suggests that you can embed this in routine care.
"However, if doctors and nurses are to do this routinely, that needs to be backed up with appropriate training,
and we mustn’t give GPs and nurses too much overload and yet more things to be done in a general practice
consultation."
MPs asked about the effectiveness of brief interventions in which a doctor might spend between 5 and 10
minutes with a patient in a focused discussion on alcohol and asked whether such sessions involved "scare
tactics."
Professor Kelly said: "Those brief interventions are effective in reducing alcohol consumption, injury,
mortality, morbidity, and the social consequences." Paul Cassidy, a GP in Gateshead and research assistant
at University of Newcastle working in alcohol studies, also giving evidence, said, "These interventions are not
scare tactics. It’s an educational and a motivational approach to public health."
The witnesses said there was currently too much focus on cases of alcohol dependency and not enough on
the less severe types of drink related health problem that affect much more of the patient population.
Dr Cassidy said: "GPs often think about alcohol dependents, and these are the patients who seem to give us
the biggest problem, but it’s the non-dependent drinkers, of whom there are a lot, that are seen in everyday
practice.
"The impact is often felt more on the dependent end, but it’s the more subtle effect on raising people’s blood
pressure, leading to strokes and small injuries, that affect the normal patient."
9 of 26
Another witness, Lynn Owens, nurse consultant and alcohol clinical lead at Liverpool Primary Care Trust,
said, "We need to provide good, sound, and clear advice to individuals about their drinking at the earliest
opportunity.
"That should start as early as health in schools [and] when you visit your GP for routine vaccinations," she
said. She added that GPs need to help people recognise the role that alcohol may have in their illnesses.
The inquiry continues.
8. The Cost Effectiveness of Naltrexone Added to Cognitive-Behavioral Therapy in the Treatment of
Alcohol Dependence. Journal of Addictive Diseases 28 (2): 137 – 144. David Walters; Jason P. Connor;
Gerald F. X. Feeney; Ross McD Young
Keywords: Cost-effectiveness; CBT; alcohol treatment; naltrexone
The purpose of this study was to evaluate the comparative cost of treating alcohol dependence with either
cognitive behavioral therapy (CBT) alone or CBT combined with naltrexone (CBT+naltrexone). Two hundred
ninety-eight outpatients dependent on alcohol who were consecutively treated for alcohol dependence
participated in this study. One hundred seven (36%) patients received adjunctive pharmacotherapy
(CBT+naltrexone). The Drug Abuse Treatment Cost Analysis Program was used to estimate treatment costs.
Adjunctive pharmacotherapy (CBT+naltrexone) introduced an additional treatment cost and was 54% more
expensive than CBT alone. When treatment abstinence rates (36.1% CBT; 62.6% CBT+naltrexone) were
applied to cost effectiveness ratios, CBT+naltrexone demonstrated an advantage over CBT alone. There
were no differences between groups on a preference-based health measure (SF-6D). In this treatment
center, to achieve 100 abstainers over a 12-week program, 280 patients require CBT compared with 160
CBT+naltrexone. The dominant choice was CBT+naltrexone based on modest economic advantages and
significant efficiencies in the numbers needed to treat.
9. Effectiveness and cost-effectiveness of policies and programmes to reduce the harm caused by
alcohol. Lancet 373 (9682): 2234-2246. Peter Anderson, Dan Chisholm, Daniela C Fuhr
This paper reviews the evidence for the effectiveness and cost-effectiveness of policies and programmes to
reduce the harm caused by alcohol, in the areas of education and information, the health sector, community
action, driving while under the influence of alcohol (drink-driving), availability, marketing, pricing, harm
reduction, and illegally and informally produced alcohol. Systematic reviews and meta-analyses show that
policies regulating the environment in which alcohol is marketed (particularly its price and availability) are
effective in reducing alcohol-related harm. Enforced legislative measures to reduce drink-driving and
individually directed interventions to already at-risk drinkers are also effective. However, school-based
education does not reduce alcohol-related harm, although public information and education-type
programmes have a role in providing information and in increasing attention and acceptance of alcohol on
political and public agendas. Making alcohol more expensive and less available, and banning alcohol
advertising, are highly cost-effective strategies to reduce harm. In settings with high amounts of unrecorded
production and consumption, increasing the proportion of alcohol that is taxed could be a more effective
pricing policy than a simple increase in tax.
10. Engagement and Retention in Outpatient Alcoholism Treatment for Women. American Journal on
Addictions 18 (4): 277 – 288. Fiona S. Graff; Thomas J. Morgan; Elizabeth E. Epstein; Barbara S.
McCrady; Sharon M. Cook; Noelle K. Jensen; Shalonda Kelly
Reviews of the dropout literature note significant attrition from addiction treatment. However, consistent
predictors have not been identified and few studies have examined factors related to retention and
engagement for women in gender-specific treatment. The current study consisted of 102 women and their
partners randomized to individual or couples outpatient alcoholism treatment. Women attended more
treatment sessions if they were assigned to individual treatment, older, had fewer symptoms of alcohol
dependence, had more satisfying marital relationships, had spouses who drank, and had matched
preference for treatment condition. Women were more engaged in treatment (ie, completed more assigned
homework) if they had fewer children at home, fewer alcohol dependence symptoms, later age of onset of
alcohol diagnosis, more satisfying marital relationships, and spouses who accepted or encouraged their
drinking. Results highlight important associations of treatment and relationship variables with treatment
retention and engagement.
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Opiate Treatment
11. Retention in methadone maintenance drug treatment for prescription-type opioid primary users
compared to heroin users. Addiction 2009 104 (5): 775-783. Caleb J. Banta-Green, Charles Maynard,
Thomas D. Koepsell, Elizabeth A. Wells, Dennis M. Donovan
Keywords
Heroin • methadone maintenance treatment • prescription-type opioid • public assistance • substance abuse
• treatment retention
Aims: To assess retention in methadone maintenance treatment for prescription-type opioid primary
(PTOP) users compared to heroin users.
Design and participants: A retrospective cohort study was carried out to examine the association between
opiate types used on 12-month retention. The study population consisted of adults admitted to one of 11 notfor-profit methadone maintenance clinics in 2004 and 2005 throughout Washington State (n = 2308). Logistic
regression analyses with fixed effects for treatment agencies were conducted.
Measurements: Opiate use type in past 30 days: any heroin use or primary prescription opioid without
heroin use. Demographics, other drugs used, self-reported medical and psychiatric concerns, social, familial
and legal issues, public assistance type and housing stability were documented at intake using a
comprehensive biopsychosocial instrument, the Treatment and Assessment Reports Generation Tool.
Findings: The odds of being retained in treatment for PTOP compared to heroin users not adjusting for
other factors was 1.33 (95% confidence interval [CI], 1.03, 1.71). In the final logistic regression model the
odds of retention for PTOP compared to heroin users was 1.25 (95% CI, 0.93, 1.67), indicating that there
was no statistically significant difference in treatment retention by opiate type after adjusting for
demographics, treatment agencies, other drug use, public assistance type, medical, psychiatric, social, legal
and familial factors.
Conclusion: The findings of this study suggest that PTOP can be treated at methadone maintenance
treatment facilities at least as effectively as heroin users in terms of treatment retention.
12. Comparison of costs and utilization among buprenorphine and methadone patients. Addiction
2009 104 (6): 982-992. Paul G. Barnett
Keywords
Buprenorphine • cost and cost analysis • economics • health care cost • methadone • opioid-related
disorders/rehabilitation • substance abuse treatment • veterans
Aims: Buprenorphine is an effective alternative to methadone for treatment of opioid dependence, but
economic concerns represent a barrier to implementation. The economic impacts of buprenorphine adoption
by the US Veterans Health Administration (VHA) were examined.
Design: Prescriptions of buprenorphine, methadone treatment visits, health-care utilization and cost, and
diagnostic data were obtained for 2005.
Findings: VHA dispensed buprenorphine to 606 patients and methadone to 8191 other patients during the
study year. An analysis that controlled for age and diagnosis found that the mean cost of care for the 6
months after treatment initiation was $11 597 for buprenorphine and $14 921 for methadone (P < 0.001).
Cost was not significantly different in subsequent months. The first 6 months of buprenorphine treatment
included an average of 66 ambulatory care visits, significantly fewer than the 137 visits in methadone
treatment (P < 0.001). In subsequent months, buprenorphine patients had 8.4 visits, significantly fewer than
the 21.0 visits of methadone patients (P < 0.001). Compared to new methadone episodes, new
buprenorphine episodes had 0.634 times the risk of ending [95% confidence interval 0.547–0.736].
Implementation of buprenorphine treatment was not associated with an influx of new opioid-dependent
patients.
Conclusion: Despite the higher cost of medication, buprenorphine treatment was no more expensive than
methadone treatment. VHA methadone treatment costs were higher than reported by other providers.
Although new buprenorphine treatment episodes lasted longer than new methadone episodes,
buprenorphine is recommended for more adherent patients.
13. Comparing retention in treatment and mortality in people after initial entry to methadone and
buprenorphine treatment. Addiction 2009 104 (7): 1193-1200. James Bell, Lieu Trinh, Bethany Butler,
Deborah Randall, George Rubin
Keywords
Buprenorphine • heroin • methadone • mortality • overdose • retention
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Aim: To compare retention in treatment and mortality among people entering methadone and
buprenorphine treatment for opioid dependence.
Data sources: The Pharmaceutical Drugs of Abuse System (PHDAS) database records start- and enddates of all episodes of methadone and buprenorphine treatment in New South Wales, and the National
Death Index (NDI) records all reported deaths.
Methods: Data linkage study. First entrants to treatment between June 2002 and June 2006 were identified
from the PHDAS database. Retention in treatment was compared between methadone and buprenorphine.
Names were linked to the NDI database, and 'good matches' were identified. Deaths were classified as
occurring during induction, maintenance and either post-methadone or post-buprenorphine, depending on
the latest episode of treatment prior to death. The numbers of inductions into treatment, of total person-years
spent in each treatment, and person-years post-methadone or buprenorphine, were calculated. Risk of death
in different periods, and different treatments, was analysed using Poisson regression.
Results: A total of 5992 people entered their first episode of treatment—3349 (56%) on buprenorphine,
2643 on methadone. Median retention was significantly longer in methadone (271 days) than buprenorphine
(40 days). During induction, the risk of death was lower for buprenorphine (relative risk = 0.114, 95%
confidence interval = 0.002–0.938, P = 0.02, Fisher's exact test). Risk of death was lowest during treatment,
significantly higher in the first 12 months after leaving both methadone and buprenorphine. Beyond 12
months after leaving treatment, risk of death was non-significantly higher than during treatment.
Conclusions: Buprenorphine was safer during induction. Despite shorter retention in treatment,
buprenorphine maintenance was not associated with higher risk of death.
14. Predictors of opiate agonist treatment retention among injection drug users referred from a
needle exchange program. Journal of Substance Abuse Treatment 36 (3): 306-312. Jennifer R. Havens,
Carl A. Latkin, Minya Pu, Llewellyn J. Cornelius, David Bishai, Steve Huettner, Charles Rapp, Erin P.
Ricketts, Jacqueline J. Lloyd, Steffanie A. Strathdee
Aims: The aim of this study was to examine the effect of a case management intervention on retention in
opiate agonist therapy among injection drug users (IDUs) referred from a needle exchange program (NEP).
Design, intervention, participants, and setting: A randomized trial of a strengths-based case
management intervention versus passive referral (control) was conducted among NEP attendees requesting
and receiving referrals to subsidized, publicly funded opiate agonist treatment programs in Baltimore, MD.
Measurements: Multivariable Cox regression models were used to identify predictors of treatment retention
using an ecological model approach, taking into account factors at the individual, social, and environmental
level.
Findings: Of 245 IDUs, 127 (51.8%) entered opiate agonist treatment, for whom median retention was 7.9
months. The intervention was not associated with longer retention (p = .91). Individual-level factors predictive
of shorter retention included being employed and greater levels of psychiatric distress. Participants who had
prior treatment experience and multiple treatment requests were retained significantly longer. Social factors
adversely affecting treatment retention included unstable housing and buying drugs for others. Living further
away from the treatment site was an environmental barrier that negatively affected treatment retention.
Conclusions: Multilevel interventions that address individual, social, and environmental factors are
necessary to improve substance abuse treatment retention and treatment outcomes among IDUs referred
from NEP.
15. Factors associated with the prescribing of buprenorphine or methadone for treatment of opiate
dependence. Journal of Substance Abuse Treatment 37 (1): 95-100. Gayle Ridge, Michael Gossop,
Nicholas Lintzeris, John Witton, John Strang
The study investigates patient preferences and beliefs and treatment program factors related to the decision
to prescribe either buprenorphine or methadone to opiate-dependent patients. The sample (N = 192) was
recruited from 10 addiction treatment services in London. Data were collected by means of a single
structured interview conducted with patients commencing a treatment episode at the participating agencies.
Data on patient demographics, beliefs, attitudes, and preferences were collected using a structured
interview. Data regarding treatment goals and prescribed medication were collected from interviews with
clinical staff. Oral methadone had a higher preference rating than buprenorphine. Clinical prescribing
practices were influenced by patient preferences (both positive and negative), by prior treatment
experiences, and by current treatment goals. Patient preferences and beliefs about opioid agonist
medications served as an important influence upon clinical prescribing practices. The odds of being
prescribed buprenorphine were three times greater among those patients who reported a preference for
buprenorphine. The odds of receiving a prescription for methadone were about twice as great among those
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for whom methadone was the more preferred medication. Preferences were related to previous treatment
experiences with these opioid agonists, and for patients in both groups, personal experience was the most
important source of information about the treatment options. Buprenorphine was more likely to be prescribed
for short-term detoxification and methadone for maintenance treatment.
16. Baseline Neurocognitive Profiles Differentiate Abstainers and Non-Abstainers in a Cocaine
Clinical Trial. Journal of Addictive Diseases 28 (3): 250 – 257. Joy M. Schmitz; Marc E. Mooney; Charles
E. Green; Scott D. Lane; Joel L. Steinberg; Alan C. Swann; F. Gerard Moeller
Keywords: Impulsivity; decision making; cocaine; cognitive behavioral therapy; contingency management;
citalopram; profile analysis
Previous studies have shown that cocaine users have higher levels of impulsivity and impaired decision
making; however, few have examined these factors as predictors of treatment success. We obtained
baseline neurocognitive measures from 75 cocaine-dependent individuals participating in a 12-week clinical
trial targeting impulsivity with behavioral therapies and pharmacotherapy. Participants treated with citalopram
had higher cocaine abstinence rates compared to placebo-treated participants. The aim of this secondary
analysis study was to determine whether profiles of performance on neurocognitive measures administered
at baseline discriminated among patients who achieved abstinence and those who did not. Participants
completed the Immediate and Delayed Memory Task, Barratt Impulsiveness Scale-11, and Iowa Gambling
Task. Profile analysis results showed different patterns of performance on these baseline measures as a
function of outcome. Compared with non-abstinent participants, abstinent participants had higher scores on
the Barratt Impulsiveness Scale-11 Non-Planning subscale and better performance on the Iowa Gambling
Task. Profile differences for the two outcome groups did not vary as a function of treatment condition.
Results suggest that cocaine-dependent patients entering treatment with higher impulsivity and less impaired
decision-making abilities may respond favorably to targeted behavioral interventions. Neurocognitive profiles
may be useful in understanding population heterogeneity and predicting differential outcomes in subgroups
of cocaine abusers.
17. Inadequate Dose of Opioid-agonist Medication is Related to Misuse of Benzodiazepines.
Addictive Disorders & Their Treatment 8 (3): 145-153. Heikman, Pertti Kalevi; Ojanpera, Ilkka Antero
Objectives: To evaluate whether misuse of nonprescribed substances is related to dose-adequacy of
opioid-agonist medication (OAM) in opioid substitution treatment.
Methods: Opioid-dependent patients undergoing a substitution treatment program of the Helsinki University
Central Hospital. Opioid-dependent patients evaluated their dose of OAM (methadone or buprenorphine
combined with naloxone) as either too low (group 1) or adequate (group 2). Instead of being limited to the
main drug classes detectable by standard immunoassay techniques, this study systematically investigated
the incidental use of a very broad spectrum of therapeutic and illicit drugs both from blood and urine
samples.
Results: Of the 65 participating patients 21 (32%) completed the study. Their doses and blood
concentrations of OAM showed no differences between the 2 groups. The group 1 patients, however,
showed more positive laboratory findings for nonprescribed benzodiazepines (7/10 vs. 1/11, P=0.008).
Diazepam was present in all positive samples of nonprescribed benzodiazepines, alprazolam in 4,
clonazepam in 3, and midazolam in 2 samples. There was no difference in misuse of opiates, amphetamine,
cannabis, barbiturates, designer drugs, or psychotropic drugs between groups 1 and 2.
Conclusions: The inadequate dose of OAM in opioid substitution treatment for opioid-dependent patients
seems to be related to the misuse of benzodiazepines.
18. Prescribing Injectable Methadone: What the Addiction Specialist Needs to Know. Addictive
Disorders & Their Treatment 8 (3): 154-158. George, Sanju MRCPsych *; Dharmadhikari, Anupam
Although injectable methadone is prescribed for maintenance treatment to opioid addicts, this has not so far
been systematically evaluated. Neither is there consensus on its effectiveness or any clear guidance on
prescribing. In this paper, we offer a synthesis of the evidence base for injectable methadone treatment in
opioid addiction and also discuss the theoretical and practical aspects of prescribing it in opioid dependence.
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Treatment Organisation and delivery
19. Improving substance abuse treatment enrollment in community syringe exchangers. Addiction
2009 104 (5): p 786-795. Michael Kidorf, Van L. King, Karin Neufeld, Jessica Peirce, Ken Kolodner, Robert
K. Brooner
Keywords
Harm reduction • injection drug users • syringe exchange • treatment enrolment
Aims: The present study evaluated the effectiveness of an intervention combining motivational
enhancement and treatment readiness groups, with and without monetary incentives for attendance and
treatment enrollment, on enhancing rates of substance abuse treatment entry among new registrants at the
Baltimore Needle Exchange Program (BNEP).
Design: Opioid-dependent study participants (n = 281) referred by the BNEP were assigned randomly to
one of three referral interventions: (i) eight individual motivational enhancement sessions and 16 treatment
readiness group sessions (motivated referral condition—MRC); (ii) the MRC intervention with monetary
incentives for attending sessions and enrolling in treatment—MRC+I); or (iii) a standard referral condition
which directed participants back to the BNEP for referral (standard referral—SRC). Participants were
followed for 4 months.
Findings: MRC+I participants were more likely to enroll in any type of treatment than MRC or SRC
participants (52.1% versus 31.9% versus 35.5%; χ2 = 9.12, P = 0.01), and more likely to enroll in treatment
including methadone than MRC or SRC participants (40.4% versus 20.2% versus 16.1%; χ 2 = 16.65,
P < 0.001). MRC+I participants also reported less heroin and injection use than MRC and SRC participants.
Conclusions: Syringe exchange sites can be effective platforms to motivate opioid users to enroll in
substance abuse treatment and ultimately reduce drug use and number of drug injections.
20. Results from two randomized clinical trials evaluating the impact of quarterly recovery
management checkups with adult chronic substance users. Addiction 2009 104 (6): p 959-971.
Christy K Scott, Michael L. Dennis
Keywords
Chronic dependence • controlled clinical trial • effectiveness • longitudinal • recovery management •
substance abuse treatment
Aims: Post-discharge monitoring and early reintervention have become standard practice when managing
numerous chronic conditions. These two experiments tested the effectiveness of recovery management
checkup (RMC) protocols for adult chronic substance users.
Intervention: RMC included quarterly monitoring; motivational interviewing to provide personalized
feedback and to resolve ambivalence about substance use; treatment linkage, engagement and retention
protocols to increase the amount of treatment received.
Participants and setting: Recruited from sequential addiction treatment admissions, participants in the two
experiments were, on average, 36 and 38 years of age, mainly female (59% versus 46%), African American
(85% versus 80%) and met past-year criteria for dependence (87% versus 76%).
Design: Participants in both experiments were assigned randomly to the RMC or control condition and
interviewed quarterly for 2 years.
Measurement: The Global Appraisal of Individual Needs (GAIN) was the main assessment instrument.
Findings: RMC participant outcomes were better than control participants in both experiments. Effect sizes
were larger in the second experiment in terms of reducing days to readmission (Cohen's d = 0.41 versus
d = 0.22), successive quarters in the community using substances (d = −0.32 versus −0.19), past-month
symptoms of abuse/dependence (d = −0.23 versus −0.02) and increasing the days of abstinence over 2
years (d = +0.29 versus 0.04).
Conclusion: RMC, which provided ongoing monitoring and linkage, is feasible to conduct and is effective
for adults with chronic substance dependence.
21. Health professionals' attitudes towards AOD-related work: Moving the traditional focus from
education and training to organizational culture. Drugs: education, prevention and policy 16 (3): 232 –
249. Natalie Skinner a; Ann M. Roche a; Toby Freeman a; Anna Mckinnon a
Aim: This article presents a critical review of research on health professionals' attitudes towards alcohol and
other drug (AOD)-related work relevant to both researchers and practitioners. It moves beyond education
and training programs to examine the relevance of organizational culture in influencing attitudes.
Method: A review of research conducted on health professionals' attitudes towards AOD-related work, and
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strategies to develop positive attitudes was undertaken.
Findings: 12 evidence-based tenets were identified in regard to attitudes towards AOD-related work. Key
findings include the importance of professional attitudes related to confidence and perceived legitimacy of
responding, and personal attitudes related to social justice concerns. Education/training and role support
were identified as important evidence-based strategies to develop and support positive attitudes.
Conclusion: To foster development of positive attitudes and effective responses in regard to AOD-related
work a focus that extends beyond the individual worker is required. Education and training are a necessary,
but not sufficient, condition to ensure health professionals' capacity and willingness to respond to AOD
issues. Research on organizational culture provides valuable insight into the types of organizational and
systems factors likely to influence AOD-related attitudes and work practice. Key strategies to develop an
organizational culture supportive of AOD-related work and future research areas are highlighted.
22. User involvement in efforts to improve the quality of drug misuse services in England: A national
survey. Drugs: education, prevention and policy 16 (4): 364 – 377. Sue Patterson; Tim Weaver;
Kostas Agath; Deborah Rutter; Eliot Albert; Mike J. Crawford
Aim: To examine the extent of user involvement (UI) in efforts to improve the quality of drug misuse services
in England, to identify outcomes of involvement, and explore factors that promote and hinder this process.
Methods: Cross-sectional survey of service commissioners, providers and members of user groups in a
representative sample of 50 of the 149 English Drug Action Teams (DATs) in England.
Findings: We found wide variation in the degree to which systems for involving users had been
implemented. Thirty-nine (84.7%) of the 46 DATs that responded reported working with service users, but
only 22 (47.8%) involved them directly in commissioning services. User groups had generally been set up
with the support of service providers, and had been running for an average of three years. Most stakeholders
were able to identify changes to the organization and delivery of services resulting from user involvement,
but the impact of these changes on engagement and retention in services has not been examined.
Stakeholders reported that cultural, organizational, and individual variables hindered UI, including staff
resistance and limited numbers of users willing to be involved.
Conclusions: Our findings suggest that most commissioners and providers of drug services in England
involve users in efforts to improve service quality. Direct payments to users, effective systems for delivering
feedback, and a better understanding of the impact of the outcomes of involvement may help to sustain this
process.
23. Does a History of Violence Influence Treatment, Self-Help, and 1-Year Outcomes in Substance
Use Disorder Patients? Journal of Addictive Diseases 28 (2): 171 – 179. Renee Schneider; Christine
Timko
Keywords: Self-help; substance use disorder treatment; 12-step programs; violence
Rates of violence perpetration are high among patients with substance use disorder, but the impact of
violence on substance use disorder treatment outcomes has received little attention. Patients with (n = 155)
or without (n = 190) a history of difficulty controlling violent behavior were interviewed at entry to substance
use disorder treatment and 1 year later. Substance use disorder severity, amount of treatment, and extent of
participation in 12-step self-help groups were assessed to examine potential differences in treatment
outcomes between violent and non-violent patients. After adjusting for baseline differences, no differences in
substance use disorder severity were found at 1 year. However, over the year, violent patients received
more treatment and participated more in 12-step groups compared to non-violent patients. In addition, violent
patients benefited more from 12-step group participation than non-violent patients did. Referral to 12-step
self-help groups may enhance the likelihood of recovery from a substance use disorder for patients with a
history of violence.
24. Relating counselor attributes to client engagement in England. Journal of Substance Abuse
Treatment 36 (3): 313-320. Dwayne Simpson, Grace A. Rowan-Szal, George W. Joe, David Best, Ed Day,
Angela Campbell
Client functioning and treatment engagement were examined in relation to staff attributes and organizational
climate across a diverse sample of drug treatment and outreach programs in England. Self-rating
assessments were obtained from 1,539 clients and 439 counselors representing 44 programs, and results
were interpreted using comparable data from studies of treatment programs in the United States. Client
scores on treatment participation and counseling rapport in England were directly related to their higher
levels of motivation and psychosocial functioning, as well as to staff ratings of professional attributes and
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program atmosphere. By linking records from English clients with their counselors in each program, findings
also indicate these relationships are rooted in the personal interactions between clients and their counselor.
Standardized assessments of treatment structure, process, and performance used across therapeutic
settings and national boundaries show there is generalizability in the pattern of clinical dynamics, including
the relationships between organizational functioning and quality of services.
25. Organizational determinants of outpatient substance abuse treatment duration in women.
Journal of Substance Abuse Treatment 37 (1): 64-72. Cynthia I. Campbell, Jeffrey A. Alexander, Christy
Harris Lemak
Longer treatment duration has consistently been related to improved substance use outcomes. This study
examined how tailored women's programming and organizational characteristics were related to duration in
outpatient substance abuse treatment in women. Data were from two waves of a national outpatient
substance abuse treatment unit survey (n = 571 in 1999/2000, n = 566 in 2005). Analyses were conducted
separately for methadone and nonmethadone programs. Negative binomial regressions tested associations
between organizational determinants, tailored programming, and women's treatment duration. Of the tailored
programming services, childcare was significantly related to longer duration in the nonmethadone programs,
but few other organizational factors were. Tailored programming was not associated to treatment duration in
methadone programs, but ownership, affiliation, and accreditation were related to longer duration. Study
findings suggest evidence for how external relationships related to resources, treatment constraints, and
legitimacy may influence women's treatment duration. Methadone programs may be more vulnerable to
external influences.
26. The evaluation of a trial of syringe vending machines in Canberra, Australia. International Journal
of Drug Policy 20 (4): 336-339. David McDonald
Background: Syringe vending machines (SVMs) have been trialled in Canberra, Australian Capital Territory,
Australia, as an intervention aiming to increase the availability of sterile injecting equipment for use by IDUs.
This study evaluated the 12-month trial.
Methods: A utilisation-focused evaluation model, with both formative and summative components, was
employed. Four SVMs were installed, each dispensing packs containing four 1 mL syringes and associated
injecting paraphernalia. The trial participants were the clients of the SVMs and other key informants. The
core measurements used were the number of syringes dispensed in Canberra by SVMs and other outlets,
SVM clients’ demographics and experiences of and attitudes towards SVMs, perceived impacts of SVMs on
needle sharing, unsafe disposal of used syringes in the vicinity of SVMs, and community and stakeholder
attitudes.
Results: The trial was implemented successfully, with no adverse consequences identified. The SVMs
appear to be serving both the usual clients of the other outlets for sterile injecting equipment (community
pharmacies and the Needle Syringe Program outlets) and others who are reluctant to use such outlets or
find them inconvenient. The out-of-business-hours provision of syringes through the SVMs was particularly
welcomed by both SVM clients and other stakeholders. The continuing operation of the initial four SVMs is
widely supported, and additional machines are requested by clients and others.
Conclusions: Owing to the success of the trial in terms of feasibility and outcomes for both IDUs and for the
broader community, it is desirable that providing sterile injecting equipment through SVMs continues and be
expanded as an integral component of harm reduction strategies.
27. Secondary exchange of sterile injecting equipment in a high distribution environment: A mixed
method analysis in south east Sydney, Australia. International Journal of Drug Policy 20 (4): 324-328.
Joanne Bryant, Max Hopwood
Background: In Australia, sterile needles are distributed to people who inject drugs through formal services
for the purposes of limiting the transmission of blood borne viruses (BBV). Secondary exchange (SE)
involves people acquiring needles from formal services and redistributing them to others. This paper
describes the extent, patterns and contexts of SE in south east Sydney, Australia and examines whether SE
is independently associated with BBV risk practices.
Methods: Quantitative and qualitative data were collected through a cross-sectional study using surveys and
in-depth interviews. Respondents were people using community-based pharmacies to obtain sterile needles
and syringes.
Results: Data were collected from 229 survey respondents, over half of whom (54%) reported SE in the
previous month. Of these, 40% engaged in distribution only, 25% in receipt only and 36% in both.
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Respondents reported passing on 21.7% of their needles to others in the last month, most commonly to
friends (51.6%) and partners (27.4%). Recipients of SE were four times more likely than non-secondary
exchangers to report borrowing used syringes in the last month. Respondents reported supplying sterile
equipment to others to prevent reuse and to reduce risks associated with unplanned drug use.
Conclusion: SE is a common activity in south east Sydney but does not appear to be highly organised,
usually taking place in small networks of friends and/or partners for altruistic reasons. Harm reduction
programs could capitalise on the prevalence of SE to reach injecting drug users who do not use formal
distribution services.
Epidemiology and Demography
28. Maintenance therapy and 3-year outcome of opioid-dependent prisoners: a prospective study in
France (2003–06). Addiction 2009 104 (7): 1233-1240. Jean-Noël Marzo, Michel Rotily, Fadi Meroueh,
Marina Varastet, Catherine Hunault, Ivana Obradovic, Adeline Zin
Keywords
Buprenorphine • cohort study • methadone • opioid addiction • prison
Aims: To describe the profile of imprisoned opioid-dependent patients, prescriptions of maintenance
therapy at imprisonment and 3-year outcome in terms of re-incarceration and mortality.
Design: Prospective, observational study (France, 2003–06).
Setting: Health units of 47 remand prisons.
Participants: A total of 507 opioid-dependent patients included within the first week of imprisonment
between June 2003 and September 2004, inclusive.
Measurements Physicians collected socio-demographic data, penal history, history of addiction,
maintenance therapy and psychoactive agent use, general health status and comorbidities. Prescriptions at
imprisonment were recorded by the prison pharmacist. Re-incarceration data were retrieved from the
National Register of Inmates, survival data and causes of death from the National Registers of vital status
and death causes.
Findings: Prison maintenance therapy was delivered at imprisonment to 394/507 (77.7%) patients. These
patients had poorer health status, heavier opioid use and prison history and were less socially integrated
than the remaining 113 patients. Over 3 years, 238/478 patients were re-incarcerated [51.3 re-incarcerations
per 100 patient-years, 95% confidence interval (CI) 46.4–56.2]. Factors associated independently with reincarceration were prior imprisonment and benzodiazepine use. After adjustment for confounders,
maintenance therapy was not associated with a reduced rate of re-incarceration (adjusted relative risk 1.28,
95% CI 0.89–1.85). The all-cause mortality rate was eight per 1000 patient-years (n = 10, 95% CI 4–13).
Conclusions: Prescription of maintenance therapy has increased sharply in French prisons since its
introduction in the mid-1990s. However, the risk of re-imprisonment or death remains high among opioiddependent prisoners. Substantial efforts are needed to implement more effective preventive policies.
29. Groin injecting in injectable opioid treatment service users in South London. Addiction Research
& Theory (4): 381 - . Peter G. Miller a; Luciana Forzisi b; Deborah Zador c; Nick Lintzeris d; Nicola
Metrebian b; Rob Van Der Waal e; Soraya Mayet b; John Strang b
Keywords: Femoral; groin; injecting; prescription heroin; addiction; treatment
Femoral (or groin) injecting is an emerging public health challenge to all drug-related services within the UK.
Recent work in the area has proposed that groin injecting in the UK has moved from being a 'risk boundary'
to an 'acceptable behaviour'. This article uses data from 10 in-depth qualitative interviews with service users
from a supervised injectable opiate treatment service in South London to report on pathways to, and reasons
for, groin injecting. Our findings indicate that even though groin injecting constitutes a risk boundary for some
injectors, the practice is no longer heavily stigmatised and is perceived by some to be an acceptable risk.
Narratives also pointed to the importance of peers in the initiation of groin injecting. Interviewees described
the groin as a site of 'last resort' in contrast to 'convenience' groin injectors described in some previous
research. We conclude that it might be helpful to distinguish between convenience and last resort groin
injectors and support the call for innovative interventions which aim to reduce modelling of groin injection and
which promote social norms supportive of using peripheral injecting sites.
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30. Cocaine Dependence and Concurrent Marijuana Use: A Comparison of Clinical Characteristics.
American Journal of Drug and Alcohol Abuse 35 (3):193 – 198. Jan A. Lindsay; Angela L. Stotts; Charles
E. Green; David V. Herin; Joy M. Schmitz
Keywords: Clinical treatment trial; cocaine dependence; dual substance abuse; marijuana
Background/Objectives: Marijuana is the most commonly used illicit substance, yet among the least
studied in medication development research. Cocaine-dependent individuals frequently also use marijuana;
however, little is known about the effect of this combined use on treatment presentation.
Methods: Marijuana use was assessed in 1183 individuals seeking outpatient treatment for cocaine
dependence. Based on past 30 days of use, the sample was divided into three groups: (1) patients reporting
no recent marijuana use (n = 634); (2) occasional use (n = 403); (3) and frequent concurrent marijuana use
(n = 146). Differences on baseline measures of substance use, addiction severity (ASI), psychopathology,
and sociodemographic characteristics were examined as a function of level of marijuana use.
Results: Frequent marijuana users were more likely to be female, Caucasian, and younger than other
groups. Cocaine-dependent patients with frequent marijuana use also used more cocaine and alcohol, and
reported more medical, legal, and psychiatric problems, including antisocial personality disorder.
Conclusion and Scientific Significance: Cocaine-dependent patients with frequent marijuana use present
for treatment with more severe impairment. Accounting for this heterogeneity among participants may
improve treatment outcome.
31. Factors associated with mortality in Scottish patients receiving methadone in primary care:
retrospective cohort study. BMJ 2009;338:b2225. C McCowan, B Kidd, T Fahey
Objective:To assess predictors of mortality in a population of people prescribed methadone.
Design: Retrospective cohort study.
Setting: Geographically defined population in Tayside, Scotland.
Participants: 2378 people prescribed and dispensed liquid methadone between January 1993 and February
2004.
Main outcome measures: All cause mortality (primary outcome) and drug dependent cause specific
mortality (secondary outcome) by means of Cox proportional hazards models during 12 years of follow-up.
Results: Overall, 181 (8%) people died. Overuse of methadone (adjusted hazard ratio 1.67, 95% confidence
interval 1.05 to 2.67), history of psychiatric admission (2.47, 1.67 to 3.66), and increasing comorbidity
measured as Charlson index 3 (1.20, 1.15 to 1.26) were all associated with an increase in all cause
mortality. Longer duration of use (adjusted hazard ratio 0.95, 0.94 to 0.96), history of having urine tested
(0.33, 0.22 to 0.49), and increasing time since last filled prescription were protective in relation to all cause
mortality. Drug dependence was identified as the principal cause of death in 60 (33%) people. History of
psychiatric admission was significantly associated with drug dependent death (adjusted hazard ratio 2.41,
1.25 to 4.64), as was history of prescription of benzodiazepines (4.35, 1.32 to 14.30).
Conclusions: Important elements of care in provision of methadone maintenance treatment are likely to
influence, or be a marker for, a person’s risk of death.
32. Sex work, substance misuse and service provision: The experiences of female sex workers in
south London. Drugs: education, prevention and policy, 16 (4): 355 – 363. Brenda Mosedale; Christos
Kouimtsidis; Martina Reynolds
Background: Observations suggest that patterns of drug use may be changing among sex workers and that
service provision may be failing this group. The aim of this study was to investigate life, substance-related,
and service-provision experiences of women who are both substance users and involved in sex work.
Methods: The study was carried out using unstructured recorded confidential interviews and analysis of the
themes arising from them.
Results: Twelve women were interviewed. Most of them came from an abusive background. There is a
vicious circle between sex working and taking drugs—sex work generates funds and drugs facilitate
continuation of work. The emergence of crack cocaine was consistently significant.
Conclusion: Experiences of the women discussed here are not new and confirm existing knowledge.
Important issues related to service provision were discussed. Flexible services are necessary to attract,
engage and support this vulnerable group.
33. Epidemiological Trends in Abuse and Misuse of Prescription Opioids. Journal of Addictive
Diseases 28 (2):130 – 136. Henry Spiller; Douglas J. Lorenz; Elise J. Bailey; Richard C. Dart
18 of 26
Keywords: Prescription drug diversion; opioid; misuse; abuse; epidemiology
The authors evaluated trends between social, geographic, and demographic factors and cases of select
scheduled drugs (buprenorphine, fentanyl, hydrocodone, hydromorphone, morphine, methadone, and
oxycodone) using the Researched Abuse, Diversion and Addiction-Related Surveillance System poison
center data and census data. Spontaneous calls from the public and healthcare professionals are recorded
by poison centers using a standardized, electronic data collection system. We compared the annual
incidence of total prescription opioid drug cases to annual data from the U.S. Department of Labor and U.S.
Census Bureau by year and by state for unemployment rate, poverty rate, population density, high school
graduation rate, and bachelor's degree proportion using the best least square fit in an evaluation for trends
for 2003 to 2006. Two strong positive trends were found between poverty rate, unemployment rate, and
prescription opioid drug rates, with prescription opioid drug rates increasing as poverty rate and
unemployment rate increased. This trend was consistent over the 4 years of study and strongly influenced by
the hydrocodone and methadone rates, with less influence from oxycodone rates. The high school
graduation rate trend was consistent over the 4 years and was strongly influenced by the hydrocodone and
methadone rate. No consistent trend was identified with population density and prescription opioid drug
rates. Understanding trends may help guide distribution of scarce resources and prevention efforts to where
they may have their greatest impact.
34. Pathways from Adolescent Parent-Child Conflict to Substance Use Disorders in the Fourth
Decade of Life. American Journal on Addictions 18 (3): 235 – 242. Judith S. Brook; David W. Brook;
Chenshu Zhang; Patricia Cohen
This 24-year community longitudinal study provides important information regarding parent-child conflict in
adolescence (mean ages 14-16), vulnerable personality attributes and peer deviance in the twenties (mean
age 22), and marital conflict and partner's illicit drug use in the late twenties and early thirties (mean ages 2732) as related to a later diagnosis of substance use disorders (SUDs) in the thirties (mean ages 32-37). A
community-based sample was interviewed between 1975 and 2007. Results based in structural equation
modeling indicated that a weak parent-child bond was related to the development of drug-conducive
personality traits, which was associated with the selection of drug-using peers and partners, which in turn,
predicted SUDs. Both peer deviance and partner's illicit drug use had the greatest effects on SUDs. The
findings should aid in formulating prevention and treatment programs targeting specific risk factors in
adolescents, young adults, and adults.
35. A profile of adolescent cocaine use in Northern Ireland. International Journal of Drug Policy 20 (4):
357-364. Patrick McCrystal, Andrew Percy
Background: The image of cocaine as a ‘party’ drug used by more affluent members of society has begun
to change as the levels of use of the drug rise amongst school aged young people.
Methods: Cocaine use patterns amongst young people aged 13–16 years who were participating in the
Belfast Youth Development Study, a longitudinal study of adolescent drug use was explored. Data was
collected through an annual datasweep in participating schools. This paper includes data collected in years
3, 4 and 5 of the study.
Results: The results show higher levels of cocaine use amongst this age group than reported in much of the
existing harm reduction literature. Lifetime use was 3.8% at age 13–14 years, rising to 7.5% at 15–16 years.
The profile indicated that adolescent cocaine users were more likely to be female, live in disrupted families
and experience social deprivation which is similar to existing adolescent drug use profiles. There was also
some evidence of experimental cocaine use amongst the sample.
Conclusions: These findings provide further evidence for the development of age appropriate school
focused harm reduction initiatives and continued monitoring of contemporary trends of use of cocaine
amongst school aged young people.
Co-morbidity
36. Co-morbidity of drug addiction: An analysis of epidemiological data and possible etiological
models. Addiction Research & Theory 17(4): 420 – 431. Author: Zsolt Demetrovics a
Keywords: Substance use disorder; co-morbidity; models of co-morbidity; self-medication
19 of 26
This review summarizes the literature on psychiatric co-morbidity of substance use. The author overviews
general population epidemiological surveys as well as clinical studies, and discusses both DSM axis I and
axis II disorders. After presenting epidemiological data the author analyzes the nature of relationship
between psychoactive substance use and other mental disorders, and-through examples-four possible
models of this relationship are examined. Despite the lack of precisely determined prevalence rates, some
definite tendencies could be observed along the consistent results of the studies. Due to methodological
problems, however, many questions remain unanswered. Although there are relatively comprehensive
studies on psychiatric disorders associated with drug use and drug addiction, the question of causality is
relatively unresolved. Theoretically possible relations regarding causality seem to overlap in practice, and in
most cases linear type connection is unlikely. It can be concluded that general questions, such as which
disorders have a great significance in connection to drug use, can be answered. Additional research is
needed, however, to examine the effects of different drug types, race, and gender. Understanding causality
also requires further research.
37. Gender and comorbidity among individuals with opioid use disorders in the NESARC study.
Addictive Behaviours 34 (6-7): 498-504. Christine E. Grella, Mitchell P. Karno, Umme S. Warda, Noosha
Niv, Alison A. Moore
Keywords: Heroin; Opioids; Gender differences; Psychiatric comorbidity; NESARC
This study examines gender differences in the association of lifetime mental and substance use disorders
among individuals with opioid use disorders in the United States. The sample (N = 578) is from the National
Epidemiologic Survey on Alcohol and Related Conditions (NESARC), which is a representative household
survey. Bivariate analyses and logistic regression modeling were conducted. About 70% of the sample had a
lifetime non-substance use Axis I disorder; women were about twice as likely as men to have either a mood
or anxiety disorder. About half of the sample had a personality disorder, with women more likely to have
paranoid disorder and men more likely to have antisocial personality disorder. Individuals with a lifetime
mental disorder were about three times more likely than others to be dependent on other substances,
independent of gender. The study demonstrated an inverse relationship between lifetime mental and other
substance use disorders, with women having significantly higher odds for several of the mental disorders
and men having greater odds of other substance use disorders.
Psychosocial Treatment
38. Social anxiety impacts willingness to participate in addiction treatment. Addictive Behaviours 34
(5): 474-476. Sarah W. Book, Suzanne E. Thomas, Jared P. Dempsey, Patrick K. Randall, Carrie L. Randall
Individuals with social anxiety have difficulty participating in group settings. Although it makes intuitive sense
that social anxiety could present a challenge in addiction treatment settings, which often involve small groups
and encouragement to participate in self-help groups like Alcoholics Anonymous (AA) and Narcotics
Anonymous (NA), to our knowledge no study has yet assessed the impact of shyness on the treatment
experience. Assessment surveys were given to 110 individuals seeking intensive outpatient substance
abuse treatment at three community treatment programs. Established cut-offs for presence of clinicallysignificant social anxiety indicated a prevalence of 37%. Controlling for depression and worry, social anxiety
was a unique predictor of endorsement that shyness interfered with willingness to talk to a therapist, speak
up in group therapy, attend AA/NA, and ask somebody to be a sponsor. Socially anxious substance abusers
were 4–8 times more likely to endorse that shyness interfered with addiction treatment activities. These
findings have clinical and research implications.
39. Parenting Practices as Mediators of Treatment Effects in an Early-Intervention Trial of
Multidimensional Family Therapy. American Journal of Drug and Alcohol Abuse 35 (4): 220-226. Craig E.
Henderson; Cindy L. Rowe; Gayle A. Dakof; Sam W. Hawes; Howard A. Liddle
Keywords: Adolescent substance abuse; mediation; multidimensional family therapy; young adolescents
Background: Contemporary intervention models use research about the determinants of adolescent
problems and their course of symptom development to design targeted interventions. Because
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developmental detours begin frequently during early-mid adolescence, specialized interventions that target
known risk and protective factors in this period are needed.
Methods: This study (n = 83) examined parenting practices as mediators of treatment effects in an earlyintervention trial comparing Multidimensional Family Therapy (MDFT), and a peer group intervention.
Participants were clinically referred, low-income, predominantly ethnic minority adolescents (average age
14). Assessments were conducted at intake, and six weeks after intake, discharge, and at 6 and 12 months
following intake.
Results: Previous studies demonstrated that MDFT was more effective than active treatments as well as
services as usual in decreasing substance use and improving abstinence rates. The current study
demonstrated that MDFT improves parental monitoring—a fundamental treatment target—to a greater extent
than group therapy, and these improvements occur during the period of active intervention, satisfying stateof-the-science criteria for assessing mediation in randomized clinical trials.
Conclusions and Scientific Significance: Findings indicate that change in MDFT occurs through
improvements in parenting practices. These results set the foundation for examining family factors as
mediators in other samples.
40. Assessing the effectiveness of an Internet-based videoconferencing platform for delivering
intensified substance abuse counselling. Journal of Substance Abuse Treatment 36 (3): 331-338. Van
L. King, Kenneth B. Stoller, Michael Kidorf, Kori Kindbom, Steven Hursh, Thomas Brady, Robert K. Brooner
Enhanced schedules of counselling can improve response to routine opioid-agonist treatment, although it is
associated with increased time demands that enhance patient resistance and nonadherence. Internet-based
counseling can reduce these concerns by allowing patients to participate from home. This study assesses
treatment satisfaction and response to Internet-based (CRC Health Group's e-Getgoing) group counseling
for partial responders to methadone maintenance treatment. Patients testing positive for an illicit substance
(n = 37) were randomly assigned to e-Getgoing or onsite group counseling and followed for 6 weeks.
Patients in both conditions responded favorably to intensified treatment by achieving at least 2 consecutive
weeks of abstinence and 100% attendance to return to less-intensive care (e-Getgoing: 70% vs. routine:
71%, ns). Treatment satisfaction was good and comparable across conditions. E-Getgoing patients
expressed a preference for the Internet-based service, reporting convenience and increased confidentiality
as major reasons. Integrating Internet-based group counseling with on-site treatment services could help
expand the continuum of care in methadone maintenance clinics.
41. Informal discussions in substance abuse treatment sessions. Journal of Substance Abuse
Treatment 36 (4): 366-375. Steve Martino, Samuel A. Ball, Charla Nich, Tami L. Frankforter, Kathleen M.
Carroll
This study evaluated the extent to which counselors initiated informal discussions (i.e., general discussions
and self-disclosures about matters unrelated to treatment) with their clients during treatment sessions within
two National Institute on Drug Abuse Clinical Trial Network protocols involving adaptations of motivational
interviewing (MI). Sixty counselors across the two protocols had 736 sessions independently rated for
counselor treatment fidelity and the occurrence of informal discussions. The results showed that 88% of the
counselors initiated informal discussions in their sessions and that most of these discussions involved
counselors sharing personal information or experiences they had in common with their clients. The major
finding was that counselor training in MI was associated with significantly less informal discussion across
sessions. A higher frequency of informal discussion was related to less counselor MI proficiency and less insession change in client motivation, although unrelated to client program retention and substance use
outcomes. The findings suggest that although some informal discussions may help build an alliance between
counselors and clients, too much of it may hinder counselors' proficient implementation of MI treatment
strategies and the clients' motivational enhancement process.
42. Randomized trial of training and supervision in motivational interviewing with adolescent drug
treatment practitioners. Journal of Substance Abuse Treatment 37 (1): 73-78. Luke Mitcheson, Kaanan
Bhavsar, Jim McCambridge
Motivational interviewing is an empirically supported treatment for drug and alcohol problems. Training in this
approach is very popular, although previous studies have identified that the acquisition of key skills is
challenging and that postworkshop supervision inputs are helpful. This pilot trial investigated the training of
adolescent drug treatment practitioners, comparing a group who received immediate training against a
delayed training study condition. Training and supervision were found to have no impact upon skill levels as
21 of 26
measured by the Motivational Interviewing Treatment Integrity Version 2, with the exception of a very specific
effect on motivational interviewing spirit. Motivational interviewing was not easy to learn for these
practitioners. Progress made indicates the importance of ongoing supervision, and for high level skill
acquisition to occur requires more intensive support of learning from ongoing practice than was used here.
43. Acupuncture or counselling: outcomes and predictors of treatment choice in a non-statutory
addiction service. Journal of Substance Use 14 (3&4): 151-160. Heather Ashton; Arunima Nodiyal; David
Green; Brian Moore; Nick Heather
Keywords: Auricular acupuncture; counselling; alcohol dependence; drug dependence
Aims: To describe the characteristics of clients choosing auricular acupuncture or counselling to treat
dependence at a UK self-referral centre and the short-term outcome for each group.
Methods: Assessments made at entry, and at 2 months and 6 months included a range of psychometric
variables (anxiety, depression, dependence severity, readiness to change), and alcohol and drug
consumption. These variables were used to predict treatment choice in logistic regression analyses and to
describe treatment outcome.
Results: Of 162 clients, 36 chose acupuncture and 126 chose counselling. Alcohol was the main preferred
drug in both groups but preference for heroin was the only independent variable determining choice for
acupuncture vs. counselling. Six-month follow-up rate was 44% in the counselling group and 25% in the
acupuncture group. There were significant improvements in psychological variables which correlated with a
decrease in alcohol consumption at 2 and 6 months. Improvements were greatest in those who attended for
6 months.
Conclusions: Acupuncture was preferred by clients whose main drug of choice was heroin. Across both
treatments clients with alcohol problems who attended the 2 and 6 months follow-up assessments showed a
significant decrease in psychological distress and reduction of alcohol consumption.
44. An audit of a stimulant clinic: changes in drug use, drug beliefs, and motivational ratings.
Journal of Substance Use 14 (3 & 4): 179 – 188. L. Ramsay; Alyson Bond; Selina Pope
Keywords: Stimulant dependence; treatment outcomes; psychological interventions
Aim: To evaluate the effectiveness of a specialist stimulant clinic in terms of changes in stimulant use,
motivation, and drug beliefs at post-treatment, and describe patients' experience of the clinic.
Design and participants: A retrospective review of 122 past patients' case files and a cross-sectional semistructured interview with five current patients.
Measurements: Data was collected on demographic characteristics; stimulant and other drug use history,
drug belief scores, motivational ratings, and patients' experience of the treatment service.
Findings: On exit from treatment, patients reduced their drug use, were more motivated to change their
drug-related behaviours and had less dysfunctional drug beliefs. All five current patients reported a positive
experience of the treatment service.
Conclusion: This study provides the first direct evidence for the effectiveness of the specialist stimulant
clinic in terms of positive treatment outcomes. These findings are very encouraging and demonstrate that
stimulant services, which provide psychological interventions, can be effective in 'typical' clinical settings.
Psychostimulants
45. Pharmacogenetic Treatments for Drug Addiction: Cocaine, Amphetamine and Methamphetamine.
American Journal of Drug and Alcohol Abuse 35 (3): 161 – 177.
Colin N. Haile; Thomas R. Kosten; Therese A. Kosten
Keywords: Gene variants; pharmacotherapies; drug therapy; stimulants; individualized therapy; gene-based
therapeutics; polymorphisms; genetic variation; subjective effects; drug dependence; addiction psychiatry
Background: Pharmacogenetics uses genetic variation to predict individual differences in response to
medications and holds much promise to improve treatment of addictive disorders. Objectives: To review
how genetic variation affects responses to cocaine, amphetamine, and methamphetamine and how this
information may guide pharmacotherapy.
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Methods: We performed a cross-referenced literature search on pharmacogenetics, cocaine, amphetamine,
and methamphetamine.
Results: We describe functional genetic variants for enzymes dopamine-beta-hydroxylase (DβH), catecholO-methyltransferase (COMT), and dopamine transporter (DAT1), dopamine D4 receptor, and brain-derived
neurotrophic factor (BDNF). A single nucleotide polymorphism (SNP; C-1021T) in the DβH gene is relevant
to paranoia associated with disulfiram pharmacotherapy for cocaine addiction. Individuals with variable
number tandem repeats (VNTR) of the SLC6A3 gene 3'-untranslated region polymorphism of DAT1 have
altered responses to drugs. The 10/10 repeat respond poorly to methylphenidate pharmacotherapy and the
9/9 DAT1 variant show blunted euphoria and physiological response to amphetamine. COMT, D4 receptor,
and BDNF polymorphisms are linked to methamphetamine abuse and psychosis.
Conclusions: Disulfiram and methylphenidate pharmacotherapies for cocaine addiction are optimized by
considering polymorphisms affecting DβH and DAT1 respectively. Altered subjective effects for
amphetamine in DAT1 VNTR variants suggest a 'protected' phenotype. Scientific Significance:
Pharmacogenetic-based treatments for psychostimulant addiction are critical for successful treatment.
46. General practitioners’ management of psychostimulant drug misuse: Implications for education
and training. Drugs: education, prevention and policy, 16 (4): 343 – 354. Ahmed Alkhamis; Catriona
Matheson; Christine Bond
Aims: To provide baseline data regarding GPs' knowledge, experience, and attitudes toward the
management of PsychoStimulant Drug Misuse (PSDM) patients to inform future education and training
initiatives.
Methods: A structured cross-sectional postal questionnaire was developed following initial content setting
interviews, piloted then sent to a sample of 250 GPs in north east Scotland.
Findings: A 52.13% response rate was achieved after two reminders. Over 42% of GPs expressed
uncertainty about their knowledge regarding PSDM. The majority were aware that some patients were using
psychostimulant drugs (61.5%), and 62.7% thought this was increasing. More than half the GPs did not have
experience in managing PSDM. Although 57% of respondents agreed that GPs should be involved over half
(54.1%) were not personally willing to do so.
Conclusion: GPs are aware of the rise in PSDM prevalence in their communities, but chose to keep their
involvement minimal. The majority thought that the most suitable way to manage PSDM patients was
primarily by specialist services with minimum input from them. A change in attitudes, education and guidance
are necessary to encourage GPs to be more involved in the management of PSDM patients.
47. Theories of Addiction: Methamphetamine Users' Explanations for Continuing Drug Use and
Relapse. American Journal on Addictions 18 (4): 294 – 300. Thomas F. Newton; Richard De La Garza II;
Ari D. Kalechstein; Desey Tziortzis; Caitlin A. Jacobsen
A variety of preclinical models have been constructed to emphasize unique aspects of addiction-like
behavior. These include Negative Reinforcement (“Pain Avoidance”), Positive Reinforcement (“Pleasure
Seeking”), Incentive Salience (“Craving”), Stimulus Response Learning (“Habits”), and Inhibitory Control
Dysfunction (“Impulsivity”). We used a survey to better understand why methamphetamine-dependent
research volunteers (N = 73) continue to use methamphetamine, or relapse to methamphetamine use after a
period of cessation of use. All participants met DSM-IV criteria for methamphetamine abuse or dependence,
and did not meet criteria for other current Axis I psychiatric disorders or dependence on other drugs of
abuse, other than nicotine. The questionnaire consisted of a series of face-valid questions regarding drug
use, which in this case referred to methamphetamine use. Examples of questions include: “Do you use drugs
mostly to make bad feelings like boredom, loneliness, or apathy go away?”, “Do you use drugs mostly
because you want to get high?”, “Do you use drugs mostly because of cravings?”, “Do you find yourself
getting ready to take drugs without thinking about it?”, and “Do you impulsively take drugs?”. The scale was
anchored at 1 (not at all) and 7 (very much). For each question, the numbers of participants rating each
question negatively (1 or 2), neither negatively or affirmatively (3-5), and affirmatively (6 or 7) were tabulated.
The greatest number of respondents (56%) affirmed that they used drugs due to “pleasure seeking.” The
next highest categories selected were “impulsivity” (27%) and “habits”(25%). Surprisingly, many participants
reported that “pain avoidance” (30%) and “craving” (30%) were not important for their drug use. Results from
this study support the contention that methamphetamine users (and probably other drug users as well) are
more heterogeneous than is often appreciated, and imply that treatment development might be more
successful if treatments targeted subtypes of patients, though a range of limitations to the approach used are
acknowledged.
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Blood Borne Viruses
48. Longitudinal community plasma HIV-1 RNA concentrations and incidence of HIV-1 among
injecting drug users: prospective cohort study. BMJ 2009;338:b1649. Evan Wood, Thomas Kerr,
Brandon D L Marshall, Kathy Li, Ruth Zhang, Robert S Hogg, P Richard Harrigan, Julio S G Montaner
Objective: To examine the relation between plasma HIV-1 RNA concentrations in the community and HIV
incidence among injecting drug users.
Design: Prospective cohort study.
Setting Inner city community in Vancouver, Canada.
Participants: Injecting drug users, with and without HIV, followed up every six months between 1 May 1996
and 30 June 2007.
Main outcome measures: Estimated community plasma HIV-1 RNA in the six months before each HIV
negative participant’s follow-up visit. Associated HIV incidence.
Results: Among 622 injecting drug users with HIV, 12 435 measurements of plasma HIV-1 RNA were
obtained. Among 1429 injecting drug users without HIV, there were 155 HIV seroconversions, resulting in an
incidence density of 2.49 (95% confidence interval 2.09 to 2.88) per 100 person years. In a Cox model that
adjusted for unsafe sexual behaviours and sharing used syringes, the estimated community plasma HIV-1
RNA concentration remained independently associated with the time to HIV seroconversion (hazard ratio
3.32 (1.82 to 6.08, P<0.001), per log10 increase). When the follow-up period was limited to observations after
1 January 1988 (when the median plasma HIV RNA concentration was <20 000 copies/ml), the median viral
load was no longer statistically associated with HIV incidence (1.70 (0.79 to 3.67, P=0.175), per log10
increase).
Conclusions: A longitudinal measure of community plasma HIV-1 RNA concentration was correlated with
the community HIV incidence rate and predicted HIV incidence independent of unsafe sexual behaviours and
sharing used syringes. If these findings are confirmed, they could help to inform both HIV prevention and
treatment interventions.
49. Managing hepatitis C virus infection. BMJ 2009;338 (7711):b2366. Kathryn L Nash, Ian Bentley,
Gideon M Hirschfield. Clinical Review


Chronic hepatitis C infection is a substantial global health problem
Strategies to prevent infection through provision of safe blood products and targeting intravenous drug
users are essential

Many people are unaware that they carry the virus and are at risk of liver disease

Complications of liver disease related to hepatitis C infection are expected to increase over the next 10
years

Sustained viral eradication and prevention of disease progression is possible through antiviral therapy

Optimal treatment is peginterferon alfa and ribavirin tailored to genotype and response to therapy

New specific targeted antiviral therapies are being developed
Chronic infection with the RNA flavivirus hepatitis C is a major cause of liver disease.1 The Department of
Health estimates that in the United Kingdom, chronic infection is present in 200 000 people—of whom 50%
are unaware that they carry the virus—with variations in prevalence between different groups (0.04% in blood
donors, 1% in …
50. Successful treatment of chronic hepatitis C with pegylated interferon in combination with
ribavirin in a methadone maintenance treatment program. Journal of Substance Abuse Treatment 37
(1): 32-40. Alain H. Litwin, Kenneth A. Harris Jr., Shadi Nahvi, Philippe J. Zamor, Irene J. Soloway, Peter L.
Tenore, Daniel Kaswan, Marc. N. Gourevitch, Julia H. Arnsten
Injection drug users constitute 60% of the more than 4 million people in the United States with hepatitis C
virus (HCV), including many methadone maintenance patients. Few data exist describing clinical outcomes
for patients receiving HCV treatment on-site in methadone maintenance settings. In this retrospective study,
we describe clinical outcomes for 73 patients receiving HCV treatment on-site in a methadone maintenance
treatment program. Fifty-five percent of patients achieved end-of-treatment response, and 45% achieved
sustained viral response. These treatment response rates are nearly equivalent to previously published HCV
treatment response rates, despite high prevalences of ongoing drug use (49%), psychiatric comorbidity
(67%), and HIV coinfection (32%). These data show that on-site HCV treatment with pegylated interferon
and ribavirin is effective in methadone-maintained patients, many of whom are active drug users,
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psychiatrically ill, or HIV coinfected, and that methadone maintenance treatment programs represent an
opportunity to safely treat chronic hepatitis C.
Overdose Prevention and Harm Reduction
51. Using a group approach to preventing heroin overdose in North London. Drugs: education,
prevention and policy 16 (4): 328 – 342. Peter Phillips; Chris Glover; Teresa Allan; Mary Ellen Khoo
Aims: This study used group psycho-education methods to assist injecting heroin users in preventing, and
responding to overdose.
Methods: An 'OD Prevention' group was advertised in a London prescribing service and associated primary
care unit. The intervention took place in a small group over one afternoon (3.5 hours), and trained
participants in recognizing, and responding to heroin overdoses (defining overdose, discussing known risk
factors and on-site instruction in cardio-pulmonary resuscitation (CPR). Participants were all injecting heroin
users in service contact with the primary care unit, drug dependence unit, or hostels for the homeless in
central London. Participants self-referred, or were referred by key workers. Participants completed pre- and
post-group questionnaires concerning their personal experience of overdose, the witnessing of others'
overdoses and fatalities, their current response in overdose situations, and their overall confidence in helping
others who have overdosed.
Findings: In total 107 people attended the group. Of these, 42% had witnessed others' overdose, and 29%
had witnessed one or more deaths as a result of overdose. Following the group intervention more
participants reported feeling 'quite or very confident' in managing an OD situation, confident in undertaking
CPR with someone who had overdosed, and were less likely to pursue 'folklore' remedies to overdose.
Conclusions: Using psycho-educational group approaches can be an effective tool in attempts to prevent
and respond to heroin overdoses, and is seen as useful by users.
52. Preventing Death Among the Recently Incarcerated: An Argument for Naloxone Prescription
Before Release. Journal of Addictive Diseases 28 (2): 124 – 129. Sarah E. Wakeman; Sarah E. Bowman;
Michelle McKenzie; Alexandra Jeronimo; Josiah D. Rich
Keywords: Naloxone; opiate; overdose; prison; incarceration
Death from opiate overdose is a tremendous source of mortality, with a heightened risk in the weeks
following incarceration. The goal of this study is to assess overdose experience and response among longterm opiate users involved in the criminal justice system. One hundred thirty-seven subjects from a project
linking opiate-dependent individuals being released from prison with methadone maintenance programs
were asked 73 questions regarding overdose. Most had experienced and witnessed multiple overdoses; 911
was often not called. The majority of personal overdoses occurred within 1 month of having been
institutionalized. Nearly all participants expressed an interest in being trained in overdose prevention with
Naloxone. The risk of death from overdose is greatly increased in the weeks following release from prison. A
pre-release program of overdose prevention education, including Naloxone prescription, for inmates with a
history of opiate addiction would likely prevent many overdose deaths.
Pregnancy Treatment
53. Gestational Age at Enrolment and Continued Substance Use Among Pregnant Women in Drug
Treatment. Journal of Addictive Diseases 28 (2): 103 – 112. Mishka Terplan; Joanne Garrett; Katherine
Hartmann
Keywords: Pregnancy; Generalized Estimating Equation Analysis; drug and alcohol treatment
Substance use during pregnancy is associated with poor obstetrical and neonatal outcomes. Although
intervention for substance use including alcohol improves pregnancy outcomes, a substantial number of
women continue to use drugs or consume alcohol during treatment. To determine whether gestational age at
entry into treatment (specifically first trimester enrollment) was associated with lower risk of continued
substance use, we analyzed the North Carolina Treatment Outcomes and Program Performance System, an
administrative database of drug treatment clinics, between 2000 and 2004. There were 847 pregnant women
using substances who met our inclusion criteria. Demographic and other risk factor data were collected. We
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conducted logistic regression and a Generalized Estimating Equation analysis. Gestational age at enrollment
was not associated with continued substance use (odds ratio [OR] = 0.88; 95% confidence interval [CI] =
0.51, 1.51). Women who had child care provided, were less likely to continue substance use (OR = 0.64;
95% CI = 0.48, 0.84), whereas those referred from the criminal justice system were more likely to continue
(OR = 1.53; 95% CI = 1.01, 2.30). Although earlier gestational age at enrollment in treatment does not
predict greater abstinence at any time point, this data does suggest that the provision of childcare may
improve treatment success
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