Ethical issues in informed consent with substance abusers

Barriers and motivators to participation and retention in HIV/HCV cohort studies among people who inject drugs: a community consultation in Iran

BACKGROUND

The lack of robust estimates of HIV/HCV incidence among people who inject drugs (PWID) in Iran calls for well-designed prospective cohort studies. Successful recruitment and follow-up of PWID in cohort studies may require formative assessment of barriers PWID are faced with in participation and retention in cohort studies and factors they think may facilitate their engagement in such studies. Using a focus group discussion (FGD) format, we conducted a consultation with PWID in southeast Iran to recognize those barriers and motivators.

METHODS

Using targeted sampling and through snowball referrals, we recruited PWID (aged≥18, injected in last 6 months) from community-based drop-in centers (DICs), homeless shelters, and through outreach efforts to participate in four FGDs (one women-only). Socio-demographic characteristics, injection behaviors and self-reported HCV/HIV testing and diagnosis history were obtained. Then, a semi-structured FGD guide was applied to explore barriers and motivators to participation and retention in cohort studies among study participants. All FGD sessions were recorded and transcribed verbatim, removing any identifying information. The content of FGDs were analyzed by thematic analysis using an inductive approach.

RESULTS

In total, 30 individuals (10 women) participated in the study. The median age of participants was 35 (IQR 31-40), with majority (73.3%) reporting injecting drug use within the last month. Only 40.0% reported ever being tested for HCV whereas a larger proportion (63.4%) reported ever being tested for HIV. While the majority were willing to participate in cohort studies, breach of confidentiality, fear of positive test results, perceived required commitment, and marginalization were reported as barriers to participation and retention in such studies. Monetary incentive, the thought of a better life, protection from police interventions and trust between health workers and PWID were addressed as motivators of engagement in cohort studies among PWID.

CONCLUSIONS

Strategies to enhance data security and reduce stigma associated with injecting drug use along with involving peer workers in research, providing pre and post-test counselling and education and addressing the needs of more marginalized groups potentially through integrated healthcare programs and housing support are among few approaches that may help address barriers and strengthen the motivators for successful cohort studies among this population.

Guidelines and Recommendations for Training Ethical Alcohol Researchers

Research on alcohol use presents several ethical challenges, and therefore, training of ethical alcohol researchers is particularly important. While the Helsinki Declaration (World Medical Association, 2001), Belmont Report (National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, 1978), and American Psychological Association's (APA) Ethics Code (2002) provide ethical guidelines and aspirational principles for researchers, there are a number of areas in which these principles allow for judgment. For trainees in particular, this ambiguity may be disconcerting. Along with these broader principles, there are also specific considerations for training alcohol researchers in the responsible conduct of research, which may further complicate matters for trainees. Although alcohol research is an important avenue for understanding a large public health concern and investigating risk and protective factors associated with use, it also presents a number of ethical and legal challenges for researchers. Working with high-risk drinking populations presents unique ethical and legal challenges in the areas of informed consent, confidentiality, compensation, and risk-benefit ratios. Additionally, alcohol administration studies present challenges for those supervising, as well as conducting, such experiments. New technology, such as the use of ecological momentary assessment (EMA) or other ambulatory assessment methods to examine risky and illegal behaviors, also presents new ethical challenges that are likely to continue to evolve in the coming years for trainees. Specific recommendations for handling a variety of concerns that may arise when conducting alcohol research are provided. Additionally, suggestions for improving the training of ethical alcohol researchers are discussed.

Challenges to Studying Illicit Drug Users

PURPOSE

Throughout the world, illicit drug use continues to pose a significant risk to public health. The opioid crisis in North America, the diversion of the prescription drug tramadol throughout Africa, and the increasing supply of methamphetamines in East and South Asia all contribute to increasing risks to individual and societal health. Furthermore, the violation of human rights in efforts to enforce prohibitionist values poses significant threats to many individuals worldwide. With these evolving situations, it is imperative that researchers direct their attention to the various populations of illicit drug users. However, the inclusion of illicit drug users, often considered a vulnerable population, as participants in research studies presents several increased risks that must be addressed in study protocols. Researchers are required to provide "additional safeguards" to all study protocols involving illicit drug users, but there is often substantial variability and inconsistency in how these safeguards are applied. Additional safeguards can be timely, costly, and unduly burdensome for researchers, ethical review boards, and research participants.

APPROACH

Through synthesis of the current literature, this article addresses the barriers to studying illicit drug users and the methods researchers can utilize to minimize risk. A case study is provided to illustrate the high level of scrutiny of study protocols involving the participation of illicit drug users and the effect of such scrutiny on recruitment of participants. The article concludes with a discussion of the effects of the current political climate on the recruitment of illicit drug users in research.

CONCLUSIONS

Individuals who participate in criminal or illegal behaviors such as illicit drug use, prostitution, illegal entry into a country, and human trafficking are susceptible to multiple physical, mental, and social health risks, as well as criminal prosecution. The importance of research on the health of marginalized populations cannot be overstated. This work must continue, and at the same time, we must continue to protect these individuals to the best of our ability through diligent attention to sound research methods.

CLINICAL RELEVANCE

The use of illicit drugs continues to pose a substantial threat to global health. Individuals who use illicit drugs are susceptible to multiple physical, mental, and social health risks, as well as criminal prosecution. It is imperative that researchers study these vulnerable populations in order to develop interventions to minimize individual and societal harm. There are several barriers to the study of illicit drug users that must be addressed through rigorous methodology and the addition of safeguards.

Assessing informed consent in an opioid relapse prevention study with adults under current or recent criminal justice supervision

Concerns persist that individuals with substance use disorders who are under community criminal justice supervision experience circumstances that might compromise their provision of valid, informed consent for research participation. These concerns include the possibilities that desire to obtain access to treatment might lead individuals to ignore important information about research participation, including information about risks, or that cognitive impairment associated with substance use might interfere with attending to important information. We report results from a consent quiz (CQ) administered in a multisite randomized clinical trial of long-acting naltrexone to prevent relapse to opioid use disorder among adults under community criminal justice supervision-a treatment option difficult to access by this population of individuals. Participants were required to answer all 11 items correctly before randomization. On average, participants answered 9.8 items correctly (89%) at baseline first attempt (n=306). At week 21 (n=212), participants scored 87% (9.5 items correct) without review. Performance was equivalent to, or better than, published results from other populations on a basic consent quiz instrument across multiple content domains. The consent quiz is an efficient method to screen for adequate knowledge of consent information as part of the informed consent process. Clinical researchers who are concerned about these issues should consider using a consent quiz with corrected feedback to enhance the informed consent process. Overall, while primarily useful as an educational tool, employing a CQ as part of the gateway to participation in research may be particularly important as the field continues to advance and tests novel experimental treatments with significant risks and uncertain potential for benefit.

Informed Assent Recall Among Adolescents in Substance Use Disorder Treatment Research

Evidence suggests that vulnerable populations such as substance users, those involved in the criminal justice system, and those with cognitive deficits often fail to recall information regarding the informed assent process. This study investigated correlates of assent quiz errors (AQE) among adolescents enrolling in a substance use disorder treatment study.

METHOD

Adolescents (age 13-19) entering substance use treatment completed a standard informed consent procedure to participate in a longitudinal research study, followed by a brief 6-item assent quiz.

RESULTS

Informed assent quiz errors were lower in this study relative to those observed in the adult literature. Being male and having lower treatment resistance was associated with making an AQE. Both days of marijuana use and days spent in the criminal justice system were associated with AQE. Hyperactivity-impulsivity approached significance (p = .057) but was not a correlate of AQE.

CONCLUSION

Those collecting assent should be aware that heavily-using males involved in the criminal justice system are prone to make more errors, and should use procedures such as assent quizzes to enhance their understanding of study procedures. Future research should investigate the impact of motivation and consider using experimental designs to test adolescent recall of study procedures under various assenting conditions.

The Ethics of Paying Drug Users Who Participate in Research: A Review and Practical Recommendations

The payment of research participants raises ethical and empirical questions that have special importance in addictions research involving drug-dependent participants. Despite a now large literature on human subjects payment, what is still needed is practical guidance for investigators and ethics committees. This paper reviews the literature on: Current payment practices and guidelines; defining features of undue and due incentives and fair reimbursement; and the significance of risks and harms that may arise from paying drug using participants. We conclude that research payments are ethically acceptable in most circumstances of addictions research, but should be closely scrutinized in situations where these may exacerbate existing harms or create additional risks for participants and investigators. General principles, key questions and procedural options are highlighted for an applied approach to ethical research payments. Future research directions are identified.

Perceptions of research risk and undue influence: Implications for ethics of research conducted with cocaine users

BACKGROUND

Despite the prominence of human laboratory and clinical trial research in the development of interventions for substance use disorders, this research presents numerous ethical challenges. Ethical principles outlined in the Belmont Report, including respect for persons, beneficence, and justice, have traditionally guided research conduct. Few empirical studies exist examining substance abuse research ethics. The present study examined perceptions of beneficence and respect for persons in substance use research, including relative risk and desired monetary compensation, using an online sample of cocaine users.

METHODS

The study was conducted on Amazon.com's Mechanical Turk (mTurk), a crowdsourcing website used for survey-based research. Of 1764 individuals screened, 138 reported past year cocaine use. These respondents completed a battery of standardized and experimenter-designed questionnaires used to characterize each respondent's self-reported attitudes, beliefs, and behaviors about drug use and the relative risks and desired monetary compensation associated with research participation.

RESULTS

Ratings of relative risk revealed that most respondents found common research practices as less than or equal to the relative risk of everyday life. Receiving experimental medication outside the hospital was rated as the most risky research activity, but on average was not rated as presenting more risk than everyday life. Desired compensation for research participation was associated with the perceived risk of research activities. Increases in desired compensation for participation were only observed for research perceived as much more risky than everyday activities.

CONCLUSIONS

These findings indicate that cocaine users assess risk in a way that is consistent with standard research practice.

Increased hepatitis C virus vaccine clinical trial literacy following a brief intervention among people who inject drugs

INTRODUCTION AND AIMS

While people who inject drugs are at high risk of hepatitis C virus (HCV) infection and will be the target population for future HCV vaccine trials, little is known about clinical trial literacy (CTL) in this group. We assessed the impact of a brief intervention (BI) designed to improve HCV vaccine CTL among people who inject drugs in Sydney, Australia.

DESIGN AND METHODS

People who inject drugs enrolled in a community-based prospective observational study between November 2008 and September 2010 (n = 102) completed a CTL assessment followed immediately by the BI. Post-test assessment was conducted at 24 weeks.

RESULTS

The median age of the sample was 27 years, 73% were male and 60% had 10 or less years of schooling. The median time since first injection was 5 years and 20% reported daily or more frequent injecting. The mean number of correct responses increased from 5.3 to 6.3/10 (t = -4.2; 101df, P < 0.001) 24 weeks post-intervention. Statistically significant differences were observed for three knowledge items with higher proportions of participants correctly answering questions related to randomisation (P = 0.002), blinding (P = 0.005) and vaccine-induced seropositivity (P = 0.003) post-intervention.

DISCUSSION AND CONCLUSIONS

A significant increase in HCV vaccine CTL was observed, suggesting that new and relatively novel concepts can be learned and recalled in this group. These findings support the feasibility of future trials among this population. [Correction added on 21 November 2012, after first online publication: T-score for mean number of correct responses was corrected to '-4.2' in the Results section.]

Good intentions and dangerous assumptions: Research ethics committees and illicit drug use research

Illicit drug users are frequently identified as a ‘vulnerable population’ requiring ‘special protection’ and ‘additional safeguards’ in research. However, without specific guidance on how to enact these special protections and safeguards, research ethics committee (REC) members sometimes fall back on untested assumptions about the ethics of illicit drug use research. In light of growing calls for ‘evidence-based research ethics’, this commentary examines three common assumptions amongst REC members about what constitutes ethical research with drug users, and whether such assumptions are borne out by a growing body of empirical data. The assumptions that form the focus of this commentary are as follows: (i) drug users do not have the capacity to provide informed consent to research; (ii) it is ethically problematic to provide financial incentives to drug users to participate in research; and (iii) asking drug users about their experiences ‘re-traumatizes’ and ‘re-victimizes’ them.

What women who use drugs have to say about ethical research: findings of an exploratory qualitative study

Drug users are generally seen as a vulnerable population requiring special protection in research; however, to date there has been little empirical research into the ethics of research with illicit drug users. Moreover, the available research has tended to treat "drug users" as a homogeneous category, and has failed to consider potential gender differences in users' experiences. Drawing on focus groups with twenty-seven female drug users in Vancouver, Canada, this study examines women's experiences of research and what they see as ethical and respectful engagement. Many study participants talked about feeling dehumanized as a result of prior research participation. Women were critical of the assumption that drug users lack the capacity to take part in research, and affirmed the appropriateness of financial incentives. A variety of motivations for research participation were identified, including a desire for financial gain and altruistic concerns such as a desire to help others. These findings suggest that women drug users' views on ethical research differ from prevailing assumptions among institutional review boards about how research with such populations should proceed.

The decision making control instrument to assess voluntary consent

BACKGROUND

The decision to participate in a research intervention or to undergo medical treatment should be both informed and voluntary.

OBJECTIVE

The aim of the present study was to develop an instrument to measure the perceived voluntariness of parents making decisions for their seriously ill children.

METHODS

A total of 219 parents completed questionnaires within 10 days of making such a decision at a large, urban tertiary care hospital for children. Parents were presented with an experimental form of the Decision Making Control Instrument (DMCI), a measure of the perception of voluntariness. Data obtained from the 28-item form were analyzed using a combination of both exploratory and confirmatory factor analytic techniques.

RESULTS

The 28 items were reduced to 9 items representing 3 oblique dimensions: Self-Control, Absence of Control, and Others' Control. The hypothesis that the 3-factor covariance structure of our model was consistent with that of the data was supported. Internal consistency for the scale as a whole was high (0.83); internal consistency for the subscales ranged from 0.68 to 0.87. DMCI scores were associated with measures of affect, trust, and decision self-efficacy, supporting the construct validity of the new instrument.

CONCLUSION

The DMCI is an important new tool that can be used to inform our understanding of the voluntariness of treatment and research decisions in medical settings.

Subjects agree to participate in environmental health studies without fully comprehending the associated risk

Recent advances in environmental health research have greatly improved our ability to measure and quantify how individuals are exposed. These advances, however, bring bioethical uncertainties and potential risks that individuals should be aware of before consenting to participate. This study assessed how well participants from two environmental health studies comprehended consent form material. After signing the consent form, participants were asked to complete a comprehension assessment tool. The tool measured whether participants could recognize or recall six elements of the consent form they had just reviewed. Additional data were collected to look for differences in comprehension by gender, age, race, and the time spent reading the original consent form. Seventy-three participants completed a comprehension assessment tool. Scores ranged from 1.91 to 6.00 (mean = 4.66); only three people had perfect comprehension scores. Among the least comprehended material were questions on study-related risks. Overall, 53% of participants were not aware of two or more study-related risks. As environmental public health studies pose uncertainties and potential risks, researchers need to do more to assess participants’ understanding before assuming that individuals have given their ‘informed’ consent.

Enhancing HIV vaccine trial consent preparedness among street drug users

This research used open-ended and true-false questions to assess the preparedness of 96 ethnically diverse, economically and socially marginalized adult street drug users to consent to participate in HIV vaccine trials (HVT). Specific areas of consent vulnerability included misconceptions about: (1) the recuperative value and risk of vaccines in general; (2) the presence of the HIV virus within the vaccine and the possibility of contracting or transmitting HIV as a consequence of participation; (3) inclusion criteria and experimental blinds; and (4) distrust in the medical and research establishments. A brief HVT lesson administered to 30 participants was effective in correcting specific HVT knowledge misperceptions and increasing certain, but not all areas of HVT trust. Assessment of post-lesson responses to ethics-relevant questions provides information on respondents' attitudes toward AIDS safe behavior, research risks and benefits, monetary compensation, and willingness to participate. Implications for enhancing informed consent for HVT involving active drug users are discussed.

Alcohol abuse and acute lung injury: can we target therapy?

Recent studies have revealed an important but previously unrecognized association between alcohol abuse and the risk of acute respiratory distress syndrome (ARDS). This devastating form of lung injury strikes individuals of any age following insults, such as major trauma or sepsis, and even with state-of-the-art medical care it has a mortality as high as 50%. Although the precise incidence is unknown, it is estimated that 200,000 individuals develop ARDS each year in the USA alone. Alcohol abuse independently increases the risk approximately two- to fourfold and, therefore, causes tens of thousands of excess deaths annually. When one couples these grim estimates with the well-recognized association between alcohol abuse and severe lung infections, such as bacterial pneumonia and tuberculosis, it is apparent that alcohol-related lung diseases are a major public health problem. Exciting new studies reveal that the alcoholic lung is characterized by discrete changes in cellular function within the lower airways, mediated via oxidant stress and altered signaling pathways and, in experimental models, is highly amenable to targeted therapies. Furthermore, these therapies are already used clinically for other conditions and could readily be tested in clinical studies of alcoholics at high risk for ARDS and/or with severe lung infections. This article focuses on the epidemiology and pathophysiology of alcohol-induced lung dysfunction and discusses potential new treatments that are suggested by recent experimental findings.

Measuring coercion to participate in research within a doubly vulnerable population: initial development of the coercion assessment scale

Despite many efforts aimed to ensure that research participation is autonomous and not coerced, there exists no reliable and valid measure of perceived coercion for the doubly vulnerable population of substance-abusing offenders. The current study describes the development and initial validation of an instrument measuring perceived coercion to participate in research among substance-abusing offenders. The results indicated that a substantial number of individuals report feeling coerced to participate in the study. In addition, the instrument has adequate levels of internal consistency, a one-dimensional factor structure, and evidence of discriminative validity. This study provides initial support for the instrument's validity and clinical utility.

Corrected Feedback: A Procedure to Enhance Recall of Informed Consent to Research among Substance Abusing Offenders

This study examined the efficacy of corrected feedback for improving consent recall throughout the course of an ongoing longitudinal study. Participants (N = 135) were randomly assigned to either a corrected feedback or a no-feedback control condition. Participants completed a consent quiz 2-weeks after consenting to the host study and at months 1, 2, and 3. The corrected feedback group received corrections to erroneous responses and the no-feedback control group did not. The feedback group displayed significantly greater recall overall and in specific content areas (i.e., procedures, protections, risks/benefits). Results support the use of corrected feedback for improving consent recall.

Effective Strategies for Maintaining Research Participation in Clinical Trials

Achieving high protocol adherence is essential for ensuring the overall success and scientific merit of clinical trials. Strategies for maximizing recruitment and treatment adherence have been previously explored in the literature. There has been less focus, however, on effective methods for maintaining participants in research follow-up. This article examines factors associated with poor follow-up rates as well as strategies for facilitating research commitment and addressing sources of nonadherence. Special attention is devoted to alcohol- and substance-dependent populations, groups known to have poor adherence rates. Examples are drawn from the COMBINE Study, an NIAAA-funded, nationwide, multisite, combined behavioral and pharmacotherapy trial for alcohol problems that achieved high one-year follow-up rates. The important role of coordinating centers in facilitating research retention is also discussed.

Ethics in substance use disorder treatment

The coming decades will see exciting breakthroughs in the treatment of SUDs, such as further elucidation of the genetic mechanisms of addiction. Yet if the past is any guide to the future, each new discovery will bring with it new challenges to the core ethical obligations of honoring informed consent, protecting confidentiality, and respecting justice, while also protecting the public from harm and ensuring the good of the individual patient. For the emerging scientific shift to a biobehavioral model of addiction to transform cultural attitudes and enhance treatment and research will require the scientifically rigorous and ethically sound agency of ethicists and addiction professionals to influence public policy. The growing body of neurobiologic evidence that contests traditional assumptions about free will and responsibility will evoke more deliberate and nuanced approaches to informed consent and treatment participation and dispute the forensic orientation in drug policy. If this unprecedented paradigm change can influence health care decision making in a reasoned and balanced fashion, there is real hope that the cultural stigma, which has warranted highly stringent confidentiality protections, and the disenfranchisement underlying health disparities in addiction treatment may move in the direction of compassionate and competent care for all those who suffer from addiction.

Pharmacological research on addictions: a framework for ethical and policy considerations

Findings from neuroscience research hold promise for improved treatments for and prevention of substance use disorders (SUD), but ethical concerns about psychopharmacological research involving SUD may potentially undermine scientific progress. This article reviews the literature pertaining to seven ethical requirements that elucidate a coherent framework for evaluating the ethics of clinical SUD research protocols. Those requirements are social or scientific value, scientific validity, fair subject selection, favorable risk-benefit ratio, independent review, informed consent, and respect for potential or enrolled subjects. An evidence-based analysis suggests that sound pharmacological research in SUD can safeguard the welfare of research participants while collecting valuable scientific data and benefiting society.

Regulatory Issues Encountered when Conducting Longitudinal Substance Abuse Research

OBJECTIVE: To summarize challenges unique to obtaining Institutional Review Board (IRB) approval for longitudinal substance abuse research, focusing on solutions and lessons learned. METHODS: Thirteen senior Principal Investigators with experience conducting research on substance abuse treatment and health services outcomes recalled instances from the prior 5 years when obtaining UCLA and non-UCLA IRB approval was hampered by differences in the interpretation of regulatory guidelines and how those differences were resolved. PRINCIPAL FINDINGS: Comprehensive yet flexible research protocols regarding (1) informed and voluntary consent, (2) participant payment, and (3) re-contact efforts are essential for securing IRB approval of longitudinal substance abuse studies. Specific examples of lessons learned are provided. CONCLUSIONS: Experiences can help researchers to provide appropriate and explicit justification for longitudinal substance abuse research protocols, thereby minimizing the burden and cost associated with meeting regulatory requirements as well as enhancing the efficiency, quantity, and quality of data collected.

Informed consent to opioid agonist maintenance treatment: recommended ethical guidelines

BACKGROUND

Some bioethicists have questioned whether opioid addicted individuals are able to provide free and informed consent to opioid agonist maintenance treatment. Conflicting motives for providing such treatment (e.g. improving the personal health of addicts and protecting public health and order) can also influence what individuals are required to consent to, and how that consent is obtained. We discuss both issues and attempt to specify the conditions for obtaining informed consent to agonist maintenance treatment for opioid addiction.

METHODS

We briefly review the neuroscientific literature on the effects of addiction on the autonomy and decision-making capacity of opioid dependent individuals, and ascertain how informed consent to the treatment of opioid addiction should be obtained. We also provide an ethical analysis of the competing social and medical forces that influence the consent process and make some recommendations on how to ensure that individuals enter maintenance treatment that is provided in an effective and ethical way.

RESULTS

Our analysis shows that whilst the autonomy of opioid dependent individuals is impaired by their addiction, they do retain the ability to consent to treatment provided they are not in acute withdrawal or intoxication. These symptoms should have abated, either by supervised withdrawal or stabilisation on agonist maintenance, before they are asked to consent to a detailed treatment contract. Once stabilised, individuals should be provided with detailed information about the risks and benefits of all treatments, and restrictions and regulations under which they are provided.

CONCLUSION

Informed consent is an important part of the treatment process that should be obtained in ways that increase the autonomy and decision-making capacity in opioid addicts.

Researching the intoxicated: informed consent implications for alcohol and drug research

This article considers the informed consent process in relation to carrying out research with intoxicated participants in 'field' research settings. There is little discussion in the literature of the potential problems that the intoxication of research participants may pose to research. Intoxication is a potential problem for all researchers but is heightened in field research that takes place in settings where participants are likely to be intoxicated, such as licensed venues, in drug consumption rooms, or police custody suites. The risks to research participants that intoxication poses should not be resolved by electing not to do research with intoxicated participants; it is argued that these risks can be managed to some extent, and are offset by the benefits of such research. Moreover, intoxication (and the impairment of cognitive functions relevant to valid informed consent) may not always be identifiable through behavioural or biochemical methods of detection. The search for accurate and field-practical methods for identifying intoxication amongst participants is useful, but not the only strategy for researchers who want to ensure the validity of the consent process. Suggestions are provided for devising research protocols that acknowledge and accept intoxication of research participants and attempt to protect them. One solution is to side-step identification of intoxication per se as a strategic objective in the consent process, and turn instead to established methods for ensuring that information has been understood by potential research participants.

Spending of remuneration by subjects in non-treatment drug abuse research studies

BACKGROUND

This study examines remuneration spending by drug-using participants in residential drug abuse research.

METHODS

Ninety-four adult males who participated in residential, non-treatment drug abuse research studies earned remuneration based on length of stay and specific research procedures. Remuneration could be in cash after discharge or for in-kind purchases and bill payments. Spending of remuneration was extracted from charts and evaluated with multivariate analyses.

RESULTS

Participants received average remuneration of 1,454 dollars, taking 59% in cash. Other categories included cigarettes (60.6% of subjects), toiletries (60.6%), clothing (54.3%), and housing (52.1%). Primary drug of abuse, total remuneration, monthly income, length of stay on the residential research unit, age, and education were significantly associated with in-kind remuneration choices. Less total remuneration, intoxication in the month prior to study, higher IQ, and non-white race were associated with taking more in cash.

CONCLUSION

Residential drug abuse research participants prefer cash to in-kind research remuneration, and their choices reflected drug use and economic status.

Research note: ethics of drug treatment research with court-supervised subjects

The last two decades have seen an acceleration of clinical research on, and treatment advances in, addictive illness. Much important research in this area requires the participation of subjects who themselves suffer from drug dependence and have a strong likelihood of becoming involved in the criminal justice system at some point. However, using court-supervised persons with addictive disorders in drug research raises a number of significant ethical issues. These include, among others, worries about the individual's ability to provide capable, voluntary, informed consent and the obligation of researchers to safeguard sensitive clinical information. A variety of potentially coercive factors can influence court-supervised persons in their decision whether to enter research and can compromise their ability to provide informed consent. In this paper, we explore the ethical issues arising in this research and offer some suggestions for approaches to address these concerns.

Informed consent to undergo treatment for substance abuse: a recommended approach

With more than 3 million persons receiving substance abuse treatment per year in the United States and with increasing interest in treatment outcomes, there is a need for closer attention to all aspects of the treatment process. However, minimal attention has been given to informed consent as a way of enlisting client engagement and active participation in treatment. Although there is some literature on informed consent in substance abuse research, the literature on informed consent to undergo substance abuse treatment is very limited. Incorporating informed consent into substance abuse treatment is recommended as part of motivational interviewing. Standard treatment consent issues include (1) the clinical characteristics of the problem, including diagnosis; (2) treatment recommendations; (3) the risks and benefits of treatment; (4) the financial costs of the intervention; (5) alternative services or interventions should a client refuse the recommended form of care; and (6) freedom to choose or refuse treatment. This article provides a background for informed consent procedures to facilitate client engagement in substance abuse treatment and suggests needs for future research on informed consent to undergo substance abuse treatment.

Ethical issues in the conduct of longitudinal studies of addiction treatment

Many complex ethical issues arise in the day-to-day conduct of longitudinal studies of addiction treatment. These issues are rooted, in part, in the sustained and potentially ambiguous relationship between research staff and study participants, the frequently changing clinical and legal status of study participants, the assertive methods required to generate high follow-up rates, and the numerous systems of care and control in which participants are involved. To identify common ethical issues that arise in such studies, the authors conducted individual and group interviews with seasoned members (case trackers, field trackers, interviewers, and supervisors) of the research team. The ethical dilemmas identified through these interviews fell into seven broad arenas: (1) informed consent for research participation, (2) confidentiality and information disclosure, (3) relationship boundaries between study participants and research staff, (4) duty to warn/report responsibilities, (5) questions of autonomy and privacy, (6) issues related to compensation for research participation, and (7) data integrity. Case studies that illustrate common ethical dilemmas within each of these seven areas are presented and discussed. Ethical dilemmas in the study of addiction treatment can be effectively managed via ethically informed research protocols, staff training in ethical decision-making, monitoring and supervision, and collective debriefing of critical events.

Adolescent and parent perspectives on ethical issues in youth drug use and suicide survey research

The contribution of adolescent and parent perspectives to ethical planning of survey research on youth drug use and suicide behaviors are highlighted through an empirical examination of 322 7th-12th graders' and 160 parents' opinions on questions related to 4 ethical dimensions of survey research practice: (a) evaluating research risks and benefits, (b) establishing guardian permission requirements, (c) developing confidentiality and disclosure policies, and (d) using cash incentives for recruitment. Generational and ethnic variation in response to questionnaire items developed from discussions within adolescent and parent focus groups are described. The article concludes with a discussion of the potential contributions and challenges of adolescent and parent perspectives for planning scientifically valid and ethically responsible youth risk survey research.

Reporting ethical practices in journal articles

Little attention has focused on the reporting of ethical research practices in journal articles. In Study 1, published articles in 2 psychopathology journals were reviewed to ascertain the types of ethical research information that were reported. In Study 2, a survey was sent to authors in Study 1 to determine which ethical practices they engaged in, if they reported this information, and reasons for not including this information in their article. In general, there is a great variability regarding the types of ethical research practices reported in journal articles. Commonly cited reasons for not including ethical research practice information in the articles included the need for brevity, belief that it was common practice, and lack of relevance for the project. These results suggest that there is no standard practice for reporting research practices in journal articles and great variability in the implementation of procedures that are generally considered standard.

Empirically supported ethical research practice: the costs and benefits of research from the participants' view

Researchers and institutional review boards are routinely called upon to evaluate the cost-benefit status of proposed research protocols that involve human participants. Often these assessments are based on subjective judgments in the absence of empirical data. This reliance on subjective judgments is of particular concern for studies involving clinical samples where unfounded assumptions may adversely affect research progress or clinical outcomes. The Reactions to Research Participation Questionnaire (RRPQ) was designed to address this shortcoming and to help promote ethical decision making about research practice. The present study describes development of the RRPQ and presents a series of exploratory and confirmatory analyses investigating its structure. Based on these findings, a revised version of the instrument and suggestions for future research are presented. This approach provides a foundation for scientifically informed protection of human subjects.

Methodological, practical, and ethical challenges to inner-city health research

Inner-city health research can be challenging because it deals with vulnerable populations and sometimes puts investigators in difficult situations. Some challenges are methodological, including selecting the optimal research design, implementing effective methods of recruitment and retention, and determining the best approach to data analysis. Other issues are practical, including addressing potential biases in social research; dealing with conflicting research agendas among investigators, community agencies, and funding agencies; and disseminating research findings effectively. Another set of issues relates to the ethical conduct of research, including ensuring privacy, maintaining confidentiality, and obtaining consent that is informed, not coerced, and not influenced by undue inducements. Throughout the research endeavor, the inner-city health researcher must carefully balance the roles of investigator, advocate, activist, and caregiver.

Magdalena Pilot Project: motivational outreach to substance abusing women street sex workers

The Magdalena Pilot Project provided outreach to Albuquerque women sex workers who were also using illicit drugs, primarily cocaine and heroin. This initial uncontrolled trial evaluated the feasibility and potential impact of motivational interviewing (MI) on change in drug use and HIV risk behaviors. Twenty-seven women were enrolled and interviewed about their substance use, health risk behaviors, and plans for change, using the client-centered, directive method of MI. Four months later, 25 women (93%) were interviewed again to assess their drug use and health risk behaviors. Large reductions were reported in frequency (days) of drug use and sex work, with a corresponding increase in days of lawful employment. In identifying problems that most needed to be addressed in order to help them live healthier lives, the women prioritized (1) basic needs including decent housing, (2) mental health care, and (3) treatment for substance use disorders.

Staff beliefs about drug abuse clinical trials

Staff from 10 community-based addiction treatment organizations in the National Drug Abuse Clinical Trials Network participated in an educational session about addiction research practices and human subject protections. This 1.5-hour presentation addressed "informed consent," "confidentiality of research information," "inclusion and exclusion criteria," "random assignment," "patient protections," and "patient payments." Pre- and postsession surveys were administered to 115 staff members measuring their beliefs about clinical trials. At baseline, 52% of staff believed patients could transfer out of a study even if they were doing poorly, and 55% believed staff had this right; 44% agreed that patients could participate in a clinical trial without understanding what would take place in the study. After the educational session, staff beliefs about patient protections were significantly increased in five of the seven items. A fourth of staff continued to believe patient payments were harmful, and 37% did not believe participation in a clinical trial would increase a patient's chances at recovery.