Buprenorphine programs in Europe, Australia, and the United States have been successful in treating opioid addiction. Expanded access to opioid treatment programs with the introduction of buprenorphine may help stem the co-occurring
epidemic of HIV and drug abuse in undertreated regions of the world, including Eastern Europe, Asia, and the former Soviet Union.

Background: Of the estimated 13 million injection drug users—primarily heroin abusers—worldwide, more than 10 million live in developing or transitional countries. These numbers reflect a dramatic increase in the number of opioid abusers in these countries between 1990 and 2000. Accompanying this increased prevalence of injection drug use (IDU) has been a rapid increase in HIV infection rates. In some parts of Asia and the former Soviet Union, HIV infection prevalence has
reached 80 to 90 percent among those addicted to opioids. Although methadone is the opioid treatment that has been available the longest worldwide, the global availability of buprenorphine has steadily increased; now both methadone and buprenorphine are included in the World Health Organization’s (WHO) Model List of Essential Medicines. However,
availability of methadone or buprenorphine treatment varies widely from country to country.

Study Design: The researchers examined the international experience with buprenorphine and attitudes of various countries toward methadone maintenance treatment (MMT) or buprenorphine maintenance treatment (BMT) when used to
combat opioid addiction and HIV transmission.

What They Found: Responses to opioid dependence vary widely in countries around the world. High-dose buprenorphine tablets are currently approved for use in 44 countries and are already being marketed in 31 of these countries. Three predominant treatment models have emerged. In the United States and France, physicians and drug abuse treatment specialists are the major prescribers; in Australia, community-based pharmacies supervise dispensing and work closely
with primary care physicians and specialty clinics; and in Italy and Germany, specialty clinics or a combination of these systems dispense and prescribe buprenorphine. Maintenance treatment is just beginning to become available in Eastern
European countries and the independent states that were part of the Soviet Union. HIV infection prevalence among injection drug users is lowest in Croatia and Slovenia, where methadone and buprenorphine treatment have been available
the longest. International data to date suggest that expanded access to opioid treatment reduces the morbidity and mortality related to IDU, improves the health and social conditions of patients, and plays a critical role in curbing the spread of HIV.

Comments from the Authors: It is important that countries learn from each other’s unique experiences in managing opioid addiction. Research from several countries shows us that BMT can be established rapidly and safely in primary health care
settings and that access to a choice of treatments has important public health implications. This is particularly true when we consider, first, that the rising heroin epidemic in some parts of the world fuels a co-occurring HIV infection epidemic
among injection drug users, and second, that treatment with either methadone or buprenorphine is an essential and proven tool in reducing the rate of HIV infection.

What’s Next: Countries that do not offer MMT or BMT should consider the findings of this report -- treatment can be effective. Countries that offer MMT should consider BMT to expand access to treatment. Flexibility of care models available
with BMT and its successful use in primary care settings increase opportunities for effective individual treatment and better regional management of the HIV epidemic. Finally, additional research must be done to evaluate the use of buprenorphine in diverse populations such as pregnant women, prison populations, HIV-infected individuals, and those with comorbid health conditions.

Publication: The overview article was written by a group of researchers from the United States, Australia, and Europe, and led by Dr. Maria Patrizia Carrieri of the Institut Nationale de la Santé et de la Recherche Médicale in Marseilles, France. It was published in volume 43 (Supplement 4), S197 (2006) of Clinical Infectious Diseases.

NIDA NewScan, August 22, 2007

Recently published data suggest that incorporating evidence-based treatments into juvenile drug courts enhances their effectiveness by decreasing subsequent rates of adolescent substance abuse and criminal behaviors, such as assault. According to the researchers, despite fewer criminal activities among youth appearing in drug court, increased surveillance of these youth may lead to greater rates of arrest. Youth in any of the drug court conditions engaged in fewer criminal activities than youth appearing in family courts. However, these relative reductions in antisocial behaviors did not translate to corresponding decreases in rearrest or incarceration. Greater surveillance of youth in drug court, compared to family court, may lead to greater arrest rates despite fewer crimes committed.

Juvenile drug courts provide continuous judicial supervision to young offenders, and also make available support assistance such as substance abuse treatment and mental health services.

In this study, which was supported in part by NIDA, 161 substance-abusing, juvenile offenders were randomly assigned to family court with community services (such as group substance-abuse treatment provided by local community-based practitioners), drug court with community services, drug court with multisystemic therapy (MST), or drug court with MST and contingency management (CM) therapy. MST is an intensive family- and community-based treatment that addresses multiple determinants of serious antisocial behavior in juvenile offenders, such as low parental monitoring, associating with drug-abusing peers, and poor school performance. CM is a form of therapy based upon a simple behavioral principle—if a behavior is reinforced or rewarded, it is more likely to occur in the future. Family court, in some states, has jurisdiction over family disputes (especially those involving children).

During a one-year assessment period, the researchers observed that drug court with MST and CM was most effective at reducing light alcohol use, binge drinking, marijuana, and polydrug abuse among youth. Results also showed that youth in drug court alone or any combination of drug court and accompanying treatment engaged in significantly fewer status offenses, such as truancy and alcohol possession, and crimes against a person.

What it means: The findings support the viability of juvenile drug courts, which are intensive treatment regimens established within and supervised by juvenile courts to provide specialized services for eligible druginvolved youth and their families. The study also supports the capacity of some evidence-based treatments of adolescent substance abuse to enhance juvenile drug court outcomes related to substance abuse.

Dr. Scott Henggeler and his colleagues at the Medical University of South Carolina published their results in the February 2006 issue of the Journal of Consulting and Clinical Psychology.

NIDA NewScan, July 24, 2006

Men and women who are addicted to heroin and awaiting entry into a comprehensive treatment program can benefit from an interim methadone maintenance program.

Dr. Robert P. Schwartz, of Friends Research Institute, Inc. and the University of Maryland School of Medicine, and his colleagues enrolled 194 heroin-addicted patients in an interim treatment program, which consisted of methadone only, and compared their progress with 120 patients assigned to a waiting list for entry into comprehensive treatment, which can include methadone and other services such as counseling, family therapy, and employment assistance.

The scientists found that only 16 percent of the patients receiving methadone on an interim basis dropped out of the program within 4 months, and that 76 percent of the patients originally assigned to the interim condition entered a comprehensive methadone treatment program. Only 21 percent of those on the waiting list entered comprehensive treatment. In addition, results from a followup interview conducted either at entry into comprehensive treatment or at 120 days from initial data collection showed that 56.6 percent of the interim treatment patients tested positive for heroin, compared with 79.2 percent of the waiting list group. The interim treatment participants also reported spending less money on drugs and receiving less illegal income than the waiting list participants.

What it means: Participation in interim methadone maintenance treatment can effectively increase the probability that a person will enter a comprehensive methadone treatment program. The results also suggest that interim methadone treatment is associated with a significant reduction in heroin use and a significant self-reported reduction in crime.

The study was published in the January 2006 issue of the Archives of General Psychiatry.

NIDA NewScan, May 19, 2006

A recently developed mathematical model that simulates the chronic nature of heroin abuse shows that methadone treatment for heroin abusers generates economic benefits that are more than seven times greater than what has been shown by previous models.

The NIDA-funded research is the first to present lifetime estimates of the costs and benefits associated with drug abuse and its treatment. Previous studies examining drug treatment costs and benefits typically have focused on a single treatment episode, treating drug abuse as an acute problem that can be cured in a single episode of therapy, rather than as a chronic disease.

The goal of the scientists was to develop a realistic simulation model that represents the progression of heroin abuse in individuals aged 18 to 60 years with respect to drug treatment, criminal behavior, employment, and healthcare use. Their model demonstrates that increasing a heroin user’s access to treatment over that person’s lifetime decreases the likelihood of engaging in extended drug abuse, increases employment opportunities, and lessens the probability of committing future crimes and seeking care for addiction-related medical consequences. The study further suggests that the individual and society together reap $38 in economic benefits for each dollar spent on methadone treatment.

What it means: Research seeking to conduct cost–benefit analyses of drug treatment regimens need to take the chronic nature of the disease into account. Such models represent a more realistic view of the recurring nature of drug abuse and addiction, and offer a more accurate picture of the social and economic consequences of the disease and its therapies.

Dr. Gary Zarkin, of RTI International, and his colleagues published their research in the November 2005 issue of Health Economics.

NIDA NewScan, May 19, 2006

Preliminary results of a new study, supported in part by NIDA, suggest that buprenorphine is comparable to methadone for treatment of neonatal abstinence syndrome (NAS), a term for a group of health problems experienced by infants when withdrawing from exposure to narcotics.

Of the 20 pregnant, opioid-addicted women recruited into the study, 11 received methadone and 9 received buprenorphine during their second trimester. The study results showed no significant differences between the two groups regarding NAS scores or the total number of morphine drops administered to the infants to alleviate distress.

Twenty percent of the buprenorphine-exposed newborns were treated for NAS, compared with more than 45 percent of the methadone-exposed infants, though this difference was also not statistically significant. However, the scientists did observe that buprenorphine-exposed newborns were discharged from the hospital 1.3 days earlier than methadone-exposed newborns.

What it means: This is the first study to compare the effects of buprenorphine and methadone on NAS under rigorous scientific conditions. Although effects on the newborns were similar in some respects, the significant difference seen in neonatal length of stay suggest the economic benefits of using buprenorphine to treat pregnant opiate-addicted women could amount to an annual savings of $7-$11 million in the United States. The scientists say these results support the need for larger studies to detect potential differences between the two medications.

The study, led by Dr. Hendree Jones of The Johns Hopkins Medical Institutions, was published in the July 2005 issue of Drug and Alcohol Dependence.

NIDA NewScan, September 7, 2005

NIDA scientists have shown that JHW007, a chemical structurally similar to benztropine - a drug used to treat people with Parkinson's disease - can block the behavioral stimulant effects of cocaine in mice, and may one day serve as a treatment for cocaine abuse.

The researchers showed that JHW007 actively and effectively competes with cocaine for binding sites on the dopamine transporter, a protein that removes and therefore terminates the actions of dopamine, a brain chemical associated with pleasure and reward. The scientists also found that while occupying these binding sites, JHW007 produced little of the hallmark stimulant effects produced by cocaine.

The prevailing thought among researchers has been that all substances that bind to the dopamine transporter will have effects similar to those of cocaine. But this study shows that binding to the dopamine transporter does not invariably result in cocaine-like effects, and that some drugs that act at that site may block the effects of cocaine.

What it means: These findings suggest that chemical analogs of cocaine that attach to the same binding site can block the cascade of effects that ultimately result in addiction and compulsive drug-seeking behavior. Some of these compounds prevent the effects of cocaine and therefore show promise for development as treatments for cocaine abuse.

The study, led by Dr. Jonathan Katz of NIDA's Intramural Research Program, was published in the February 23, 2005 issue of the Journal of Neuroscience.

NIDA NewScan, August 23, 2005

NIDA scientists hypothesize that the use of compounds that promote the production of myelin—the protective sheath that surrounds the axons of nerve cells—may prevent nerve damage from cocaine or methamphetamine abuse.

Some studies have suggested that cocaine and methamphetamine can damage the myelin sheath. This sheath, an insulating layer of protein and fatty substances, allows impulses to travel rapidly and efficiently between cells. If the myelin is damaged through drug abuse or a disease process such as multiple sclerosis, the impulses are disrupted.

Through a series of experiments on rat nerve cells, NIDA scientists have determined that proteins called sigma- 1 receptors are involved in promoting the development of myelin.

Because myelination continues in humans until about the age of 20, using very selective, pure sigma-1 receptor agonists to stimulate the process may protect against nerve damage in young substance abusers.

What it means:Compounds that promote the production of sigma-1 receptors may act as shields against myelin degeneration processes related to cocaine and methamphetamine abuse. Future research will help clarify the mechanisms involved in these processes.

Dr. Tsung-Ping Su and Dr. Teruo Hayashi published their findings in the October 12, 2004 issue of the Proceedings of the National Academy of Sciences.

NIDA NewScan, March 9, 2005

Scientists have developed a new computerized screening tool that allows primary care practitioners to detect older substance-abusing adults.

Results of a study that tested the diagnostic capabilities of the Drug Abuse Problem Assessment for Primary Care (DAPA-PC) showed that older adults and younger adults had similar rates of alcohol and drug abuse. The study, which involved 266 adults aged 18–54 and 61 adults aged 55–86, also showed that older adults were less likely than younger adults to view their drug use as problematic. Older adults were less likely to report that they felt their use of alcohol and/or drugs was excessive. When compared with younger respondents, older adults also were less likely to report that they had tried to quit, control, or reduce their drinking and/or other drug abuse during the past 6 months.

The scientists at Danya International, Inc. who developed the DAPA-PC, predict that the number of older adults who abuse alcohol and other drugs will greatly increase over the next several decades. Because virtually all of today’s alcohol and drug screening devices have been developed and validated with younger adults, they say there is a need for tools to help identify older substance abusers.

Users of the DAPA-PC, which was developed via a Small Business Innovation Research Grant from NIDA, first answer a brief series of questions about trauma, and then progress to a brief questionnaire about alcohol and drug use. Asking about trauma, the researchers say, is a predictive yet nonthreatening way to determine a person’s level of drug and alcohol use or abuse.

What it means: Computerized screening instruments for drug and alcohol abuse can help identify substance abuse in older adult patients who may not report substance-related problems and appear to be less likely than younger adults to seek help for them.

Dr. Susanna Nemes and her colleagues published the study in the October 12, 2004 issue of The American Journal of Drug and Alcohol Abuse.

NIDA NewScan, March 9, 2005

People who continue to abuse cocaine while undergoing methadone therapy for opiate addiction may benefit from long-term abstinence reinforcement that incorporates the use of vouchers, new research reports.

A total of 78 methadone patients who used cocaine during their methadone treatment were randomly assigned to either an abstinence reinforcement group that included take-home doses of methadone, an abstinence reinforcement group that included take-home doses of methadone and monetary vouchers, or a usual care control group that included daily methadone in a clinic setting. All participants also received individual and group counseling.

When the scientists analyzed the results of the 52-week intervention, they found that the take-home plus voucher group had significantly longer durations of sustained abstinence from cocaine and opiates than either of the other groups. Members of this group sustained about 19 weeks of continuous abstinence compared to 6.3 weeks for the take-home only group and 2.3 weeks for the usual care group.

What it means: Persistent cocaine use has been a serious problem in individuals receiving methadone treatment for opiate addiction. However, no drug treatment and few psychosocial therapies have proven effective in reducing cocaine use. These results point to the potential efficacy of long-term, voucher-based reinforcement to achieve and maintain drug abstinence in this population, and suggest the need to develop practical vehicles to deliver such interventions on a wide scale.

Dr. Kenneth Silverman, of the Johns Hopkins University School of Medicine, and his colleagues published the study in the October 2004 issue of the Journal of Consulting and Clinical Psychology.

NIDA NewScan, March 9, 2005

Scientists at the U.S. Department of Energy’s Brookhaven National Laboratory have found that the anticonvulsant drug vigabatrin (also known as gamma vinyl-GABA or GVG) may block the addictive effects of toluene, a substance found in many household products that are abused as inhalants.

In the study, rats learned that one of three chambers contained toluene vapors, and they would spend more of their time in that chamber than the others. On the final day of the study, the rats received either saline or vigabatrin one hour prior to testing. When the rats were given access to the three chambers, those that had been previously treated with vigabatrin spent only 80 seconds in the toluene-containing chamber. The rats pretreated with saline spent 349 seconds in that chamber.

Human abuse of inhalants remains a health concern in the United States, where many young people attempt to get high by inhaling vapors from common household products that contain volatile solvents or aerosols. National surveys indicate that more than 22.9 million Americans have abused inhalants at least once in their lives. Results from the annual Monitoring the Future (MTF) survey of 8th-, 10th-, and 12th-grade students in U.S. schools show that lifetime inhalant use for 8th-graders increased significantly during 2004.

What it means: Vigabatrin appears to block toluene-seeking behavior in rats. Further research that explores the value of this drug as a treatment for inhalant abuse in humans may prove useful.

Dr. Stephen Dewey and his colleagues published this study, which was funded in part by NIDA, in the December 1, 2004 issue of the journal Synapse.

NIDA NewScan, March 9, 2005

A study that estimates the prevalence of injection drug use in 96 U.S. metropolitan areas places the lowest rate of this practice in Ann Arbor, Michigan, and the highest in Fresno, California.

Dr. Samuel Friedman and his colleagues at the National Development and Research Institutes in New York City analyzed data from 96 U.S. metropolitan statistical areas (which include the central urban area and the surrounding suburbs) that had populations greater than 500,000 in 1996. They found that the number of injection drug users per 10,000 persons in each metropolitan area varied from 19 to 173.

What it means: Knowing the approximate number of injection drug users within a specific geographic area can help policymakers and health officials assess the adequacy of existing services and policies and make more informed decisions about allocating funds for services.

This NIDA-funded study was published in the September 2004 issue of the Journal of Urban Health.

NIDA NewScan, March 9, 2005

People who have major mental illnesses often have co-occurring substance abuse disorders. Conversely, individuals with substance abuse disorders often have co-occurring psychiatric disorders. But are the substance abuse problems of patients with major mental illnesses less severe than those of patients in substance abuse treatment?

Are the psychiatric disorders of patients receiving substance abuse treatment less severe than those of psychiatric patients? Scientists at the University of California–San Francisco conducted a study that addressed these questions. They compared, at treatment entry, 120 substance abuse patients who had co-occurring psychiatric disorders with 106 psychiatric patients who had co-occurring substance abuse disorders. Both patient groups were in public, acute-crisis, residential treatment programs, within either the mental health or substance abuse treatment systems. The researchers speculated that the relative absence of differences between the two patient groups would suggest that the prevalent practice of specialized treatments in separate systems of care for comorbid patients was not clinically indicated.

Dr. Barbara Havassy and her colleagues determined patients’ DSM-IV (the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) psychiatric and substance abuse diagnoses and assessed severity of drug abuse and psychiatric symptoms. Few differences

between the comorbid groups emerged. There were no diagnostic differences except for those with schizophrenia spectrum disorders. These disorders were slightly more common among psychiatric than substance abuse patients; nevertheless, nearly one-third of substance abuse patients were diagnosed with this disorder. Furthermore, although more substance abuse than psychiatric patients reported recent drug abuse, the average days of drug abuse, among those in each group who reported drug abuse, was not different.

What it means: Health care providers should recognize the associative nature of drug abuse and mental illness. Substance abuse treatment providers should be prepared to treat patients with severe mental illness. Likewise, mental health treatment providers should be prepared for patients with severe drug problems and long histories of abuse. Other providers and programs, independent of the treatment system, should be aware of the potential for co-occurring disorders and be prepared to offer interventions to their patients.

The researchers published this study in the January 2004 issue of the American Journal of Psychiatry.

NIDA NewScan, April 30, 2004

Results of a small pilot study suggest that combining the drug bupropion with brief counseling sessions may help teens reduce or stop smoking, even those with attention deficit hyperactivity disorder (ADHD). Evidence suggests that people with ADHD have more difficulty quitting smoking than people who do not have the disorder.

Bupropion is known commonly as Zyban or Wellbutrin.

Researchers at the Medical University of S. Carolina in Charleston enrolled 16 adolescents, aged 12 to 19 years, in the study. Participants took the drug at the maximum dosage of 300 mg daily for 6 weeks. They also took part in two 30-minute smoking cessation counseling sessions. Eleven of the 16 youths had co-occurring ADHD.

The scientists say that the number of cigarettes the participants smoked daily decreased significantly from an average of more than 18 at the start of the study to less than 1 when the study ended. Five participants, one of whom had ADHD, quit smoking by the fourth week of the study.

The researchers also assessed levels of carbon monoxide (CO) in expired breath to gauge the efficacy of the program. Levels of CO decreased significantly, falling

from a baseline of about 18 parts per million (ppm) to about 7.2 ppm by the end of the study. CO, a component of cigarette smoke, reduces the capacity of blood to carry oxygen, forcing the heart to work harder to supply the body with the oxygen it needs. Decreased levels of CO may signify the efficacy of a smoking cessation program.

There was no change in ADHD symptom scores among the participants who completed the study.

What it means: These results suggest that bupropion might have a role in treating nicotine dependence in adolescents. In light of the limited options available for treating nicotine dependence in youth, future studies of the efficacy of bupropion that are randomized, double-blinded, and placebo-controlled may be warranted.

Dr. Himanshu Upadhyaya and his colleagues published this study in the February 2004 issue of Journal of the American Academy of Child and Adolescent Psychiatry.

NIDA NewScan, April 30, 2004

Depression is common among opiate users and may serve as a trigger for high-risk drug injection practices, continued drug use, and relapse. Research has shown that individuals with co-occurring depression and substance use are less likely to complete treatment and have poorer prognoses after traditional treatment. However, scientists at the Brown University School of Medicine demonstrated that multisession, combination antidepressant therapy successfully reduced depression in active injection drug users.

Dr. Michael Stein and colleagues recruited 109 out-of-treatment injection drug users diagnosed with depression to participate in the study. Fifty-three participants received combined psychotherapy and pharmacotherapy for their depression during a 3-month period. These participants were scheduled to receive eight individual cognitive behavioral therapy (CBT) sessions and three pharmacotherapy visits. Fifty-six participants did not receive treatment. At the end of 3 months, adherence to treatment was assessed, and all study members participated in follow-up interviews designed to assess their heroin use and severity of depression.

Forty-three percent of participants receiving the combined treatment were considered to be fully adherent to their treatment schedules (receiving more than 75 percent of either psychotherapy or pharmacotherapy). At follow-up, significant reductions in depression were observed. Participants receiving the combined

treatment were about 2.5 times more likely than those not receiving treatment to be in depression remission. Nearly 40 percent of participants who were fully adherent to treatment were in remission at 3 months, while only about 12 percent of those not receiving treatment were in remission at this time. Among all participants, depression status was associated with frequency of heroin use. Participants in remission at 3 months reported fewer than 8 days of heroin use during that time compared with roughly 13 days of heroin use among those not in remission.

What it means: These findings indicate that depressed drug abusers are able to successfully participate in conventional treatment for depression, and for those who are adherent, depression remission is not uncommon. However, most mental health and drug treatment programs do not provide integrated treatment for their dually diagnosed patients. Developing and improving programs for patients with co-occurring depression and substance abuse disorders who do not seek drug treatment may be important as a potential prelude to entry into drug treatment.

The study was published in the February 2004 issue of the Archives of General Psychiatry. It was funded in part by NIDA.

NIDA NewScan, April 30, 2004

A study designed to assess the usefulness of a single session of motivational interviewing in drug abuse treatment showed that the single session of the psychotherapy technique had no effect on drug use outcomes. However, results of a subsequent analysis suggest that the therapist may have pressed for change before the individual was ready.

Motivational interviewing is designed to strengthen a person’s commitment to changing their behavior by focusing on such factors as desire, self-efficacy, need, readiness, and reasons. In the original study, University of New Mexico researchers randomly assigned 152 outpatients and 56 inpatients to receive or not receive a single session of motivational interviewing as part of their drug abuse therapy. The researchers assessed drug use at the pretreatment baseline and at 3, 6, 9, and 12 months following study entry. They found that adding a single session of motivational interviewing failed to have a positive effect on abstinence.

In a follow-up study, a psycholinguist watched videotapes of 84 persons undergoing motivational interviewing— representing a subset of individuals from the earlier study—and their therapists to analyze the language they used.

For the psycholinguistic analysis, each session was broken into four parts: motivational interviewing, assessment feedback, additional motivational

interviewing, and developing a change plan. The researchers found that during the motivational interviewing segments, the study participants used language that showed a strong commitment to drug abstinence. However, the analysis also revealed that individuals began “resisting,” or using weaker language, when the therapist switched to giving assessment feedback. There was also a precipitous decline in commitment language when the therapist pressed for a plan to initiate behavior changes.

What it means: The finding from the first study—the failure of motivational interviewing to have a positive impact on drug use behaviors—was unexpected because previous assessments had shown that the technique improved treatment retention, adherence, and outcome. Results of the second study suggest that therapists should modify manual-guided motivational interviewing techniques when faced with individuals whose language, especially during assessment feedback, begins to reflect a decline in their initial desire to reduce drug use. By pressing for change before a person is ready, the therapist can undermine the existing motivation for behavior change.

Dr. William Miller and his colleagues published these NIDA-funded studies in the August 2003 and October 2003 issues of the Journal of Consulting and Clinical Psychology.

NIDA NewScan, April 30, 2004

Study results suggest that encouraging patients to adopt the “12-step” philosophy and its associated behaviors may be responsible in part for the therapeutic success of combined individual and group counseling for cocaine addiction. The researchers who conducted these studies also found that counseling may affect a drug abuser’s beliefs about drug abuse.

The 12-step philosophy includes believing in a “higher power” to help someone remain drug-free, and believing that recovery from addiction is a life-long process. Other recommended behaviors include attending meetings, obtaining a sponsor, and staying away from the people, places, and things that trigger substance abuse.

The study, conducted by Dr. Paul Crits-Christoph, of the University of Pennsylvania, and his colleagues, focused on 487 patients who were randomly assigned to receive 6 months of group drug counseling, either alone or in combination with individual drug counseling (IDC), supportive-expressive psychotherapy (SEP), or cognitive psychotherapy (CT). The researchers then analyzed outcomes using the Addiction Recovery Scale to assess the effectiveness of the 12-step program among people receiving group and individual drug counseling. They also used other scales to examine how IDC, SEP, and CT achieved their effects.

The researchers found a statistical correlation between the adoption of the 12-step philosophy and behaviors and drug counseling outcomes.

In what was an unexpected finding, the scientists also found that the combination of individual and group drug counseling may have influenced patients’ beliefs about substance abuse. Negative beliefs about substance abuse (e.g., “Life without using drugs is boring,” or “I don’t deserve to recover from drug abuse”) may help maintain usage. When patients’ beliefs became less negative, there were more reductions in drug use. In fact, changing beliefs about addiction was more highly correlated with reduced drug use than was adopting the 12-step philosophy. A possible explanation, the scientists suggest, is that beliefs about substance abuse change in response to changes in drug use.

What it means: Although the 12-step philosophy and associated behaviors are linked with the positive effects seen with group and individual counseling for cocaine addiction, the inability to show a sequential process—first adopting the 12-step philosophy and then undergoing counseling—means the mechanism that drives these affirming results remains unknown. The authors also say that changing beliefs about addiction may play an important part in successful treatment.

The NIDA-funded study was published in the October 2003 issue of the Journal of Consulting and Clinical Psychology.

NIDA NewScan, April 30, 2004

A team of NIDA-funded researchers from the University of Chicago, Brown University, and Rhode Island Hospital has found that, in general, the more time a person spends in treatment for addiction, the better.

The scientists found that treatment for up to 18 months in residential settings, or almost 14 months in outpatient nonmethadone treatment, yielded the greatest reductions in illicit drug use. Both overall and primary drug use declined after 18 months in long-term residential programs, at which point peak use measured about one-tenth the pretreatment level. After 18 months in this setting, the amount of improvement began to wane. A similar effect was seen in people treated in nonmethadone outpatient settings. Individuals in nonmethadone programs who reduced drug use on their own before entering a treatment program were better able to remain in recovery.

The 4,005 patients in the study were treated for addiction to cocaine, heroin, or marijuana in 62 drug treatment units throughout the United States. As part of the National Treatment Improvement Evaluation Study, they were interviewed at admission, discharge, and one year after therapy ended between 1993 and 1995.

Treatment programs included methadone maintenance programs, outpatient nonmethadone programs, short-term residential programs, and long-term residential programs.

There was no significant relationship between treatment duration and overall drug use improvement for individuals in methadone maintenance and short-term residential programs.

What it means: Remaining in treatment for an extended time has beneficial outcomes for people in residential or outpatient drug treatment programs. Insurers may consider changing their policies to include a longer length of stay so people can be more effectively treated for their addictions.

Lead author Dr. Zhiwei Zhang of the National Opinion Research Center (NORC), a national organization for research at the University of Chicago, and his colleagues published this analytic study in the May issue of Addiction.

NIDA NewScan, December 12, 2003

During contingency management (CM) treatment, drug abusers are given vouchers for goods and services when they refrain from using drugs for a given amount of time. With sustained abstinence, the value of the vouchers is increased. Earlier research showed that this escalation in voucher values helped maintain abstinence, but when only fixed-value vouchers were given for abstinence, sustained, continuous abstinence appeared to decrease. In some CM programs, the length of time abusers are required to abstain from drug use to receive a voucher also may increase at certain intervals. NIDA-funded researchers have found that although CM remained effective when voucher values became fixed, effectiveness was reduced when abusers were required to abstain from drug use for longer periods before receiving a voucher.

Dr. Thomas Kosten and coworkers at the Yale University School of Medicine recruited 75 individuals who abused cocaine and heroin simultaneously. They participated in a 24-week study where they received buprenorphine combined with the antidepressant desipramine and escalating CM vouchers during the first 12 weeks. (Combining CM with some medications for the treatment of cocaine and heroin dependence has shown to be more effective than either treatment alone.) During the second 12 weeks, participants continued to receive the medications and to participate in CM, but escalating CM values were eliminated

so that the participants received a voucher worth a fixed amount for each submitted drug-free urine sample (samples were taken 3 times per week). During weeks 13 to 16, participants remained continuously abstinent, despite getting fixed-value vouchers. At 17 to 20 weeks, participants had to submit two consecutive drug-free urine samples to receive a voucher. At 21 to 24 weeks, three consecutive drug-free samples were required. The researchers found the fixed-value vouchers had little effect on abstinence from drug use in weeks 16 to 20. However, abstinence decreased in weeks 17 to 24, as participants were required to submit more drug-free samples to earn a voucher.

What it means: These findings suggest that to sustain the effects of CM, treatment programs need to focus on both broader psychosocial changes and reduction in drug use. Vouchers alone are not enough to maintain abstinence during treatment.

This study was published in the May issue of the journal Addiction.

NIDA NewScan, December 12, 2003

Researchers examining the impact of integrating medical and substance abuse treatment services found that for substance abuse patients as a whole, integrating the two services had little effect on health care utilization or cost. However, among those patients with substance abuse-related medical conditions, integrating medical and substance abuse treatment services resulted in decreases in hospitalization rates, fewer days of inpatient treatment, and fewer emergency room visits. Also, total medical costs per patient per month were halved, from $431.12 to $200.03.

Adult patients entering treatment at the Kaiser Permanente Outpatient Chemical Dependency Recovery Program in Sacramento were randomly assigned to one of two treatment modalities: an integrated care model where medical care was provided with substance abuse treatment and an independent care model where medical care was provided in primary care clinics, independent from substance abuse treatment.

The investigators tracked medical utilization and costs of the 654 patients for 12 months pretreatment and for 12 months following treatment entry. They found that for the full group, there were no statistically significant differences between the two treatment groups over time. However, for those patients with substance

abuse-related medical conditions, such as depression, hypertension, asthma, psychoses, pneumonia, cirrhosis, or hepatitis C, integrated care produced significant benefits. They had significant decreases in hospitalization rates, inpatient days, emergency room use, and total medical costs. Patients with substance abuse-related medical conditions who received independent care had a slight reduction in inpatient days and emergency room costs but incurred no significant decrease in total medical cost.

What it means: Integrating substance abuse treatment with primary care may be cost-beneficial and provide a better quality of care for substance abuse patients with medically related problems.

The study was published in the February 2003 issue of the journal Medical Care by a research team headed by Dr. Sujaya Parthasarathy from Kaiser Permanente.

NIDA NewScan, July 30, 2003

A survey of 434 managed care plans in 60 market areas found that patients receiving substance abuse and mental health services often had to make a higher copayment or pay a higher share of allowed charges than did patients receiving general medical care.

Researchers from Brandeis University found that at least 30 percent of the managed care service providers surveyed imposed higher cost sharing requirements for outpatient substance abuse and mental health treatment than for medical services. Among the plans using copayments (a fixed dollar amount per visit), the mean copayment for medical care was $11.73 compared to mean copayments of $17.39 for substance abuse treatment and $18 for mental health services. Similarly, among plans using co-insurance (a preset percentage of allowed charges), the mean co-insurance rate was significantly lower for medical care (19.1 percent) compared to 34.9 percent for substance abuse treatment and 35.9 percent for mental health services.

What it means: These findings imply that to achieve parity in behavioral health benefits, attention needs to be paid to cost sharing as well as to limits on benefits.

Dr. Dominic Hodgkin and colleagues from Brandeis University published this study in the March 2003 issue of the journal Medical Care Research and Review. The research was supported by grants from the National Institute on Drug Abuse, the National Institute on Alcohol Abuse and Alcoholism, and the Substance Abuse and Mental Health Services Administration.

NIDA NewScan, July 30, 2003

Lobeline, a drug with a long history of use in smoking cessation programs, may be a potential treatment for methamphetamine abuse. In a previous study using rats, researchers from the University of Kentucky found that lobeline decreased the animals' self-administration of d-methamphetamine (METH). They concluded that lobeline acted by decreasing the animal's perception of METH- induced pleasure (reward).

The researchers conducted a series of experiments with male rats that were trained to self-administer METH by pressing a lever. In a group of rats that consistently self-administered METH, the researchers exchanged METH with lobeline to determine whether lobeline would serve as a substitute for METH. When METH was exchanged with lobeline, the number of times the rats pressed the lever decreased daily over the course of the experiment, indicating that lobeline did not serve as substitute for METH.

In a different experiment, the researchers investigated whether lobeline would cause rats to resume drug-seeking behavior after a period of abstinence or if it alters METH-induced reinstatement of drug-seeking behavior. They found that lobeline did not restore drug-seeking behavior nor did it alter METH-induced reinstatement. These findings indicate that lobeline appears to alter the mechanisms mediating METH reward, but not the mechanisms mediating the reinstatement of drug-seeking behavior.

In another experiment, the effects of lobeline on dopamine levels in the brains of rats were examined. It was found that lobeline had no effect on dopamine levels, the brain chemical that regulates feelings of pleasure. This finding indicates that lobeline does not induce the same feelings of reward as METH and that lobeline did not act as a substitute reinforcer. This finding would indicate that lobeline, unlike some other pharmacological agents used to treat addiction, does not itself pose a risk for abuse.

What it means: The ability of lobeline to decrease METH self-administration without inducing reward itself suggests that lobeline may be a useful pharmacological treatment without risk of abuse.

Dr. Steven Harrod and colleagues published the study in the February 23 issue of the journal Psychopharmacology.

NIDA NewScan, May 2, 2003

Researchers from the University of Pittsburgh found that women smokers who experienced an increase in depressive symptoms during smoking-cessation treatment may be more likely to relapse. However, a history of major depressive disorder (MDD) before treatment was not predictive of failure to quit smoking.

The researchers recruited 219 women smokers who were highly motivated to quit. Their history of depression was assessed and they were classified as being positive (MDD+) or negative (MDD-) for major depressive disorder. All the women received a standard group-based smoking cessation treatment consisting of 10 90-minute sessions over a seven-week period. At each treatment session, the women reported their symptoms of depression and the number of cigarettes they had smoked since the previous session. Their depression was also assessed one, three, six and 12 months after the treatment period.

Overall, about 85 percent of the women relapsed to smoking within one year following treatment. There were no differences in the overall relapse rate among women with or without a history of depression; however, MDD+ women were more likely to relapse prior to the end of the 7-week treatment. Of those that relapsed, about 60 percent of the MDD+ women relapsed during treatment compared to 40 percent of MDD- women. Additionally, MDD+ women were more likely to drop out of treatment before the quit date compared to MDD- women.

Women who successfully quit smoking reported significant decreases in depressive symptoms from pre- to posttreatment, while those who had relapsed reported an increase in depressive symptoms. However, this change in depressive symptoms during treatment was not predictive of continuous abstinence three, six or 12 months after quitting.

What it means: Women smokers who are depressed have more difficulties getting through treatment. They may require different treatment approaches that address their depression. Drs. Michele Levine, Kenneth Perkins, and colleagues published this study in the February 2003 issue of Nicotine and Tobacco Research. It was funded by the National Institute on Drug Abuse.

NIDA NewScan, April 9, 2003

Women who are chronic drug users are almost 70 percent more likely to have experienced serious injury or trauma during the past year and almost 20 percent more likely to have experienced injury or trauma during their lifetime than women who do not use drugs. Injuries incurred and related trauma include broken bones, concussion, gunshot or knife wounds, or sexual assault.

These findings are based on data collected in 1996 and 1997 in Miami-Dade County, Florida, from 926 chronic drug users and from 553 people who did not use drugs. The sample included both men and women. Investigators analyzed the data to ascertain the effects of drug use on serious injury or trauma experienced any time in the past, within the past 12 months, and when individuals utilized health care services for serious injury or trauma.

Among women, 67 percent of the chronic drug users reported having a serious injury or traumatic event sometime in their life, compared with 55 percent of the women who did not use drugs. Twenty-nine percent of the women who abused drugs reported having experienced serious injury or a traumatic event within the past 12 months, compared with 16 percent of the women not using drugs.

Women in both groups, however, were very similar in their propensity to see a doctor or other health care provider for treatment of injury or trauma. Fifty percent of the women using drugs received treatment, compared with 57 percent among those who did not use drugs.

No statistically significant differences were found between the past year and lifetime prevalence of serious injury or trauma between male chronic drug users and non-users.

What it means: Because both female and male drug users reported high use of health care services for serious injuries or trauma, health care providers who work in community-based settings and acute care clinics should be aware that individuals seeking treatment for such injuries could be abusing drugs. Training in substance abuse issues would enable health care providers to better identify and treat drug abusers or refer them to appropriate treatment. Silvana K. Zavala, M.P.H., University of Miami, and Michael T. French, Ph.D., Medical University of South Carolina, published the study in the February 2003 issue of Medical Care.

NIDA NewScan, March 5, 2003

A study by researchers at Harvard University has provided more evidence that using stimulant medications such as methylphenidate to treat children with attentiondeficit/ hyperactivity disorder (ADHD) may reduce their risk of developing drug and alcohol use disorders later in life.

Dr. Timothy Wilens, lead investigator, and colleagues used a statistical method called metaanalysis (an examination of whether data compiled from multiple scientific studies provides evidence for statistical significance) to evaluate the relationship between stimulant therapy and subsequent substance use disorders (SUD) in youths with ADHD. After searching the literature for studies of children, adolescents, and adults with ADHD that had information on childhood exposure to stimulant therapy and later SUD outcomes, the researchers applied meta-analyses to six long-term studies. Two studies followed patients into adolescence and four followed patients into young adulthood. These studies comprised data from 674 youths receiving medication therapy for ADHD and 360 unmedicated youths with ADHD. Of those receiving medications, 97 percent were taking the stimulants methylphenidate or amphetamine.

From the compiled data, researchers found that youths with ADHD who were treated with stimulants had an almost two-fold reduction in the risk for developing SUD when compared with youths with ADHD who did not receive stimulants. Examination of each study individually suggested that stimulant medications might have a protective effect against the development of SUD.

Analysis of studies that reported follow-up into adolescence revealed that youths treated with stimulants were 5.8 times less likely to develop SUD than those not treated. However, analysis of studies that followed subjects into adulthood found that those treated with stimulants were about 1.5 times less likely to develop SUD. The researchers say that the less robust effect during adulthood may have occurred because the patients discontinued stimulant treatment when they reached a certain age or that parents may closely monitor the medications of youths with ADHD.

What it means: Overall, treating ADHD pharmacologically appears to reduce the risk of substance abuse by half. Untreated, ADHD is associated with a two-fold increased risk for developing a substance abuse disorder. Hence, while not truly immunizing against substance abuse, treating ADHD pharmacologically reduces the risk for drug and alcohol abuse and addiction to the level of risk faced by the general population. The report’s findings are among the most robust in child psychiatry demonstrating a protective effect of pharmacological
treatment on reducing the risk for later substance abuse. The study, funded by the National Institute on Drug Abuse (NIDA), is published in the January 6, 2002, issue of Pediatrics.

NIDA NewScan, March 5, 2003

Researchers from the State University of New York Upstate Medical University in Syracuse and the University of California, San Francisco, have found evidence that methadone treatment programs are effective platforms for providing tuberculosis (TB) preventive therapy to substance abusers. In the study, methadone treatment combined with directly observed TB preventive therapy improved adherence to and completion of TB preventive therapy by injection
drug abusers.

Previous research has shown that under normal treatment conditions, substance abusers are more likely to miss doses of the TB medication isoniazid (INH) and that direct observation of preventive treatment is less effective in substance abusers than in other TB-positive individuals.

In the study conducted by Dr. Steven L. Batki at San Francisco General Hospital, 111 opioid-dependent patients with latent TB infection were randomly assigned to receive one of three treatments:

• standard methadone treatment—substance abuse counseling and directly observed daily INH;
• minimal methadone treatment—directly observed INH but with no counseling; and
• routine care—referral to TB clinic for monthly visits for 30-day supplies of INH without direct observation of medication ingestion or methadone treatment.

More than 77 percent of patients receiving minimal methadone treatment and over 59 percent of those receiving standard methadone treatment completed their INH therapy, whereas less than 14 percent of those receiving routine care completed INH therapy. On average, patients receiving both forms of methadone treatment stayed in INH therapy more than five months, while those receiving routine TB treatment stayed in treatment less than two months.

What it means: The findings from this study indicate that methadone treatment offers public health benefits when it is used to deliver preventive medical services to substance abusers.

Dr. Batki, the lead investigator for the study, reported the findings in the May 2002 issue of Drug and Alcohol Dependence. Dr. Batki is now at SUNY Upstate Medical University.

NIDA NewsScan, July 31, 2002

A NIDA-funded study in the New Haven, Connecticut area found that a mobile needle exchange program reduced emergency department use among out-of-treatment injection drug users (IDUs).

Dr. Harold A. Pollack, University of Michigan, Dr. Frederick L. Altice, Yale University School of Medicine, and colleagues from Yale University studied 373 IDUs. Of those studied, 117 had used the needle-exchange program and 256 had not.

Emergency department visits declined among the needle-exchange program users and increased among those who did not use theprogram. There

were significant reductions in emergency department use among Hispanics, men, HIV-negative IDUs, and those with mental illness.

What it means: Based on these findings, it appears that needle-exchange-based health care services can reduce emergency department use among high-risk IDUs.

The study was published in a special issue on substance abuse by the Journal of General Internal Medicine.

NIDA NewsScan, June 24, 2002

Researchers at the Johns Hopkins Medical Institutions followed the course of 120 adult patients engaged in active substance abuse and who had been hospitalized for treatment of medical conditions. To be eligible for the study, the patients had to report that they wanted to stop using drugs.

Seventy-nine of the patients were given their required medical care, integrated with intensive substance abuse treatment. Forty-one patients received only standard medical care. Upon completion of their hospitalization, more than half (50.6 percent) of the patients who had received the integrated medical/substance abuse treatment

entered outpatient substance abuse programs, compared with 2.4 percent of the comparison patients. The study was partially funded by NIDA.

What it means: Hospitals can play an important role in providing needed drug treatment services and referrals to patients with drug-related problems.

The study was published in a special issue on substance abuse by the Journal of General Internal Medicine.

NIDA NewsScan, June 24, 2002

Based on a survey of primary care physicians, Dr. Richard Saitz, Associate Professor of Medicine and Epidemiology at Boston University School of Medicine and Public Health, reports that residents and faculty physicians find less satisfaction caring for patients with alcohol or drug problems than managing patients with hypertension.

One hundred forty-four residents and faculty physicians were asked about their level of satisfaction in treating patients with substance

abuse problems and patients with hypertension.

What it means: Further understanding and responding to physician satisfaction in caring for drug abusing patients may improve their care.

The study, partially supported by NIDA, was published in a special issue on substance abuse by the Journal of General Internal Medicine.

NIDA NewsScan, June 24, 2002

Contrary to previously held views that adolescent substance abuse is exclusively an “externalizing” disorder, investigators from the University of Miami School of Medicine found that teens who abuse drugs include “internalizers,” “externalizers,” and some who are acombination of the two personality types. Teens who externalize problems tend to exhibit a general lack of control or tend to “act out” distress whereas those who internalize tend to over-control or to direct their stress inward.

The researchers found that the 236 adolescents in the study – largely inner-city, economically disadvantaged males involved with the juvenile justice system – did not represent a homogenous group. Rather, there appeared to be subtypes. The investigators concluded that treatment approaches would be most effective when tailored to the various subgroups, not to the stereotypical adolescent drug user.

The majority of the youth in the study tended to be externalizers. These adolescents were more likely to come from homes with high conflict, disorganization, and low levels of cohesion. For teens in this situation, a primary goal of therapy may be to repair strained parent-adolescent relations, and resolve conflicts that are the product of years of family dysfunction.

A smaller group in the study manifested coexisting externalizing problems and internalizing problems.

They experience many of the problems noted in the externalizing group but are marked by greater parental psychopathology. For this group, engaging the parents in the child’s treatment may be a primary concern, given that these parents may be even more disorganized, conflicted, and overwhelmed with their own problems than parents of externalizing adolescents.

A third group in the study experienced normative levels of both externalizing and internalizing problems. These adolescents are likely to use marijuana heavily but report less alcohol use and experience less preoccupation with substance abuse than the other two groups. Their substance abuse may be more socially motivated than driven bythe need to relieve psychological stress. These teens probably have the best prognosis.

What it means: Adolescent substance abusers’ personality types and family characteristics need to guidedecisions regarding treatment approaches.

Lead investigator Dr. Cynthia Rowe reported the study in the December 2001 issue of the Journal of Child andAdolescent Substance Abuse.

NIDA NewsScan, January 30, 2002

In one of the few long-term studies of drug use among Vietnam veterans, researchers at the Washington University School of Medicine in St. Louis found that many veterans who developed a drug habit during the war had substantially stopped their drug use by the time they reached their mid to late '40s. The most frequently abused drug in this study was marijuana. Of those still using drugs in their 40's, almost 20 percent of the sample reported using it.

It was found that of those still using drugs in middle age, fewer than 10 percent were receiving treatment for drug abuse. These individuals had infrequent contact with the traditional health care system, and when they did, their substance abuse problems often went untreated. Veterans with Post Traumatic Stress Disorder (PTSD) who werealso drug users were the most likely to be receiving some sort of treatment.

The researchers studied the drug use patterns of some 1200 individuals over a 25-year period. The sample included veterans whose urine tested positive for opiates, amphetamines, or barbiturates at the time they left Vietnam in 1971; veterans who weredrug free; and control civilians. The initial interviews were in 1972 and 1974. Surviving individuals were interviewed again in 1996-1997. About 10 percent of the sample had died between the interviews in the 1970's and the 1990's.

What it means: This study suggests that the treatment needs of many middle-age drug users are not being met.

The study was published by lead investigator Dr. Rumi Kato Price in the June 28, 2001 issue of the American Journal of Public Health.

NIDA NewsScan, July 24, 2001

Researchers at the University of Pennsylvania School of Medicine found that propranolol, a beta-blocker, reduced symptoms of cocaine withdrawal and improved treatment outcomes for patients with more severe withdrawal symptoms. Propranolol showed no effect in patients suffering milder effects from withdrawal, which can includefeelings of anxiety, tremors, palpitations, and sweating.

The investigators randomly assigned 108 cocaine addicts who had volunteered for a treatment program to either propranolol (52 patients) or to placebo (56 patients).

Patients in the treatment group received propranolol for 8 weeks.

Patients with more severe cocaine withdrawal symptoms treated with propranolol fared better than those who received the placebo. Among those with severe withdrawal symptoms, the propranolol-

treated subjects had more drug-free urine screens than did those in the placebo group.

Beta-blockers are a well-established treatment for a number of anxiety states, including panic disorder, social phobia, and generalized anxiety disorder.

What it means: Clinical trials have shown that patients with severe withdrawal symptoms are more difficult to treat for cocaine addiction than are patients with milder withdrawal side effects. The fact that propranolol was most effective in patients with severe withdrawal symptoms may make it an effective adjunct therapy for these hard-to-treat patients.

This paper was published by lead investigator Dr. Kyle M. Kampman in the June 2001 issue of Drug and Alcohol Dependence.

NIDA NewsScan, July 24, 2001

Drug users are twice as likely to visit an emergency room and nearly seven times more likely to be hospitalized than comparably aged persons who do not use illicit drugs. Researchers who studied hospitalization rates for nearly 60,000 drug users––almost 20percent of whom were infected with HIV––found that hospitalization rates were lower for those receiving regular outpatient and drug abuse treatment.

The University of Pennsylvania-based researchers looked at the medical and drug treatment services received by 58,243 drug users enrolled in the New York State Medicaid program from Federal fiscal year 1996 through 1997; 11,556 were infected with HIV. Data were obtained from Medicaid claims for all ambulatory services from physicians, clinics, and drug abuse treatment providers.

Each drug user’s pattern of outpatient care based on Medicaid claims in 1996 was categorized as regular drug abuse care only, regular medical care only, both, or neither. Regular drug abuse care was defined as care from a single methadone or drug-free treatmentprogram for at least six contiguous calendar months in 1996. Approximately 40 percent of the study population had regular drug abuse care alone or with regular medical care in 1996, but a higher proportion of HIV+ drug users had regular care of both types.

A regular source of medical care was defined as a clinic or physician visited at least twice as an outpatient during 1996. Over half of the study population had regular medical care. The following year, 1997, more than half (55.6 percent) of the HIV+ group and one-third(37.5 percent) of the HIV-

group had at least one hospitalization.

Those who were hospitalized spent nearly one month as outpatients over the course of the year. In both groups, those with regular drug abuse care only, or with regular medical care, had the lowest proportions of hospitalization in 1997. For HIV+ drug users, regular drug abuse care coupled with regular medical care was associated with a nearly 25 percent reduction in their predicted rates of hospitalization. Among HIV- drug users, regular drug abuse treatment alone or with regular medical care was associated with more than a 25 percent reduction in predicted rates ofhospitalization.

In both groups, the likelihood of hospitalization was greater for persons with drug abuse or medical complications during 1996. Acute alcoholism-related complications were associated with the greatest increase in the likelihood of hospitalization.

What it means: Medical and drug abuse treatment in ambulatory services may have substantial benefits beyond reducing medical and drug-abuse related complications. Efforts to promote access to and retention in medical care and drug abuse treatment appear to be attractive strategies for improving the health of this medically complex population.

The study was published by lead investigator Dr. Barbara Turner in the May 9, 2001, issue of the Journal of the American Medical Association. The paper can be viewed online at the journal’s Web site http://jama.ama-assn.org.

NIDA NewsScan, May 21, 2001

An experimental program in Baltimore, Maryland has been successful in helping drug-abusing women stay free of drugs by paying them a salary to attend a work/training program.

In the Therapeutic Workplace, patients are hired and paid to work. To link salary to drug abstinence, patients are required to provide drug-free urine samples to gain daily access to the workplace. In the workplace, patients are paid either to perform assigned jobs or to participate in training to learn how to do those jobs.

Dr. Alan I. Leshner, NIDA director, says "This project brings into the real world the results of many years of previous research that demonstrate that reward-based treatment programs do result in decreased drug use. The barrier to general applicability of these treatment programs has been that practical funding mechanisms have not been available to sustain them. This program may provide a model solution to that problem.

"Forty heroin or cocaine abusing methadone patients enrolled in a treatment program for pregnant drug abusing women were randomly assigned to either the Therapeutic Workplace or to a no-treatment control group. The women could receive a maximum of about $4030in monetary vouchers, exchangeable for goods and services, based on their work attendance and other factors.

Each day, when a participant reported to the workplace, she was required to provide a urine sample. If the sample was drug free, she was allowed to work that day. After completing a 3-hour work shift, she received a basic pay voucher. Patients could earn additional vouchers for appropriate professional demeanor, for meeting daily learning goals, and for data entry productivity.

Participation in the workplace program nearly doubled the patients' abstinence from opiates and cocaine, as determined by urine samples collected 3 times a week during the six-month study period. Over the course of the program, 59 percent of the urine samples from the workplace women were drug-free, compared to 33 percent of the samples from the control group women. Forty percent of the Therapeutic Workplace participants had drug-free urine samples on at least 75 percent of testing occasions; in contrast, only 10 percent of the control participants did so.

What it means: This study provides some support for the notion that salary for work can be used to reinforce drug abstinence.

The study, led by Dr. Kenneth Silverman, appears in the February 2001 issue of Experimental and Clinical Psychopharmacology.

NIDA NewsScan, February, 2001

A team of researchers affiliated with Kaiser Permanente Medical Care Program in Oakland, California, has identified some gender-based differences in retention rates between men and women in outpatient programs treating alcohol and drug abuse. The researchers followed 317 women and 599 men who were admitted to the HMO program during a 2-year period. Among the findings:

Men are more likely to complete treatment for drug or alcohol abuse if they are

–– over age 40,
–– in treatment at the suggestion of an employer, rather than a family member, or
–– striving for abstinence.

Women are more likely to complete treatment if

they are

–– in the $20,000-or-higher income bracket,
–– part of an ethnic category other than black,
–– unemployed, or
–– married.

What it means: Factors that influence patients’ decisions to drop out of substance abuse treatment differ for men and women. Recognizing these differences may help clinicians identify those at risk for dropping out and help them tailor programs to improve retention and treatment outcome.

This study was published in the October issue of Alcoholism: Clinical and Experimental Research.

NIDA NewsScan, December, 2000