The urgent need for contingency management among Tribal communities in the United States: Considerations for implementation, policy, and sovereignty

In two randomized controlled trials, culturally adapted contingency management (i.e., incentives provided for substance-negative urine samples) was associated with reduced alcohol and drug use among geographically diverse American Indian and Alaska Native (AI/AN) adults. In response to interest in contingency management from other Tribal and AI/AN communities, our research team in collaboration with AI/AN behavioral health experts, translated the research into practice with new AI/AN community partners. Tenets of community-based participatory research were applied to develop, pilot, and refine contingency management training and implementation tools, and identify implementation challenges. In partnership with the AI/AN communities, four members of the university team developed tools and identified implementation and policy strategies to increase the successful uptake of contingency management in each location. Through our collaborative work, we identified policy barriers including inadequate federal funding of contingency management incentives and a need for further clarity regarding federal anti-kickback regulations. Adoption of contingency management is feasible and can strengthen Tribal communities' capacity to deliver evidence-based substance use disorder treatments to AI/AN people. Unfortunately, non-evidence-based limits to the use of federal funding for contingency management incentives discriminate against AI/AN communities. We recommend specific federal policy reforms, as well as other practical solutions for Tribal communities interested in contingency management.

Federal legal and regulatory aspects of contingency management incentives

OBJECTIVE

Incentives are an integral part of Contingency Management (CM) Programs for substance use disorder treatment, primarily for the treatment stimulant use disorders, but because stimulant use often co-occurs with opioid use, the Substance Abuse and Mental Health Services Administration (SAMHSA) permits the use of CM incentives as a part of its State Opioid Response grant program. However, incentives implicate federal laws and could result in either financial penalties or criminal sanctions against programs that use them.

METHODS

The U.S. Department of Health and Human Services Office of Inspector General (OIG) is tasked with enforcing key federal laws that address the issues of kick-backs, inducements, and false claims. By looking at these laws and regulations, this paper seeks to create a clearer understanding of the the barriers providers face when utilizing CM, as well as the guardrails that can be put in place to alleviate those barriers.

RESULTS

This paper distills key concerns raised by the OIG and suggests critical guardrails that militate against fraud, waste and abuse.

CONCLUSION

Following the recommended guardrails should allow providers to employ CM strategies to help their patients by making clear that the intent is to help patients without engaging in kickbacks, illegal inducements or false claims.

Recovery incentives program: California's contingency management benefit

OBJECTIVE

The role of methamphetamine and cocaine use in California's drug poisoning (overdose) crisis has dramatically increased in the past five (5) years and has disproportionately affected American Indian, Alaska Native, and Black Californians. No FDA-approved medications currently exist for the treatment of individuals with stimulant use disorder (StimUD). Outside the Veteran's Administration, the Recovery Incentives Program: California's Contingency Management Benefit is the first large scale implementation of contingency management (CM). CM is the behavioral treatment with the most evidence and largest effect sizes for StimUD.

METHODS

The Program uses a CM protocol where participants can receive a maximum of $599 over a six-month period, contingent upon 36 stimulant-negative urine test results. Urine tests are conducted using a set of approved, CLIA-waived, point-of-care urine drug tests (UDTs). To ensure fidelity to the CM protocol and to prevent fraud, waste, and abuse, all aspects of incentive accounting and distribution are managed electronically via a custom-developed software system. Incentive distribution utilizes electronic gift cards. A significant innovation of the project is the conceptualization of the CM Coordinator, a designated and highly trained and supervised individual responsible for all aspects of CM operation in a specific site.

RESULTS AND CONCLUSIONS

The California Department of Health Care Services contracted with UCLA to develop and implement a robust evaluation of the Program; goals include evaluating the effectiveness of real-world implementation and facilitating quality improvement. The project will likely significantly impact the use of CM for StimUD nationally and may well reduce stimulant-related drug poisoning deaths.

The fourth wave of the overdose crisis: Examining the prominent role of psychomotor stimulants with and without fentanyl

The current overdose and broader public health crisis involving illicit drug use is often referred to as the "opioid" or "fentanyl" crisis. Clearly there is extensive data on the profound damage done by opioids over the past 20 years and specifically by fentanyl in the past 5 years. However, there is an extensive array of data that suggests there is more to the current crisis than opioids/fentanyl. Much recent evidence indicates that methamphetamine and cocaine are playing a substantial and increasing role in the illicit drug crisis in the US-the 4th wave. This paper reviews data that illustrate the role of psychomotor stimulants in fatal overdoses, nonfatal overdoses, and emergency department visits. Despite the major detrimental role that stimulants are having on the public health in the US in 2023, there is virtually no evidence-based treatment available in practice for people with stimulant use disorder (StimUD). Although there are no medications with FDA-approval for the treatment of StimUD, there is a behavioral treatment, contingency management (CM), with over 3 decades of robust research supporting its efficacy for individuals with StimUD. Despite the overwhelming evidence supporting CM, it is not being widely used in routine treatment outside the VA healthcare system. This paper reviews some of the (a) evidence for CM, (b) CM protocol design elements that require consideration, (c) current obstacles to the widespread implementation of CM, and (d) strategies for addressing these obstacles. Overcoming these obstacles is a priority to allow routine use of CM as a treatment for StimUD.

Contingency Management for Stimulant Use Disorder: Progress, Challenges, and Recommendations

The United States is currently in the fourth wave of the overdose crisis wherein stimulants together with fentanyl are the major drivers of overdose deaths. To date, there has been limited effort outside the US Veterans Administration Health System health system to disseminate evidence-based treatment for people with stimulant use disorder. Contingency management, a behavioral intervention in which positive reinforcement is provided for a target behavior indicating treatment progress, has decades of empirical support but limited implementation in real-world, non-US Veterans Administration Health System settings. The purpose of the report is to provide an overview of contingency management, the barriers to adoption, and recommendations for overcoming these barriers.

PTSD / substance use disorder comorbidity: Treatment options and public health needs

Purpose of Review

Posttraumatic stress disorder (PTSD) commonly co-occurs with substance use disorder (SUD) and is challenging to treat. We review all behavioral therapy models with at least one randomized controlled trial in a current PTSD/SUD population. We identify factors in selecting a model for clinical use, emphasizing a public health framework that balances the need for evidence with the need for feasibility in frontline settings.

Recent Findings

Seven published models and 6 unpublished models are reviewed. Public health considerations for choosing a model include: whether it's been studied across a broad range of SUDs and in complex SUD patients; whether it can be conducted in group modality; its appeal to patients and providers; its cost; workforce requirements; and its ability to reduce substance use in addition to PTSD.

Summary

There are two broad types of models: those that originated in the PTSD field versus the SUD field. Overall, the latter are stronger on public health factors and more feasible in SUD settings. Published models in this category include Relapse Prevention, BRENDA, and Seeking Safety. PTSD/SUD research is at an early stage and there is a need for methodology that quantifies "level of burden" (patients' socioeconomic disadvantages) across trials.

Should the United States Government Repeal Restrictions on Buprenorphine/Naloxone Treatment?

Attention must be focused on needed changes to the current United States law that restricts physicians who prescribe buprenorphine for the detoxification or treatment of Opioid Use Disorder, to accepting no more than 100 patients. The current system does not provide comprehensive treatment as defined by the American Society of Addiction Medicine (ASAM) criteria. In addition, it suffers from both fragmentation and stigma and will require a significant change to comply with ASAM's call for integrated delivery of comprehensive addiction treatment. This commentary calls for the development and implementation of "best practice," by recommending caution in lifting the 100 patient limit until substantial achievement of this goal occurs. The authors call for an increase to 200 in the patient limit to be restricted to those physicians who are Board Certified in Addiction Medicine by the American Board of Addiction Medicine (ABAM) or in Addiction Psychiatry by the American Board of Psychiatry and Neurology (ABPN), or other responsible medical organizations. Any additional restriction lifting should follow a systemic evolution that rewards and documents competency. Such a system would involve the integration of treatment, treatment systems, and recovery with prescription medication. In addition, it should monitor emotional blunting, treatment progress and initiation of genetic addiction risk testing.

Bridging the Gap between Substance Abuse Practice and Research: The National Treatment Plan Initiative

The abuse of alcohol and other drugs leads to serious health problems, criminal activity, automobile crashes, and lost productivity in the workplace. As we advocate treatment for those who suffer from alcohol or drug addiction, we must advocate treatment that is proven effective for the drug and populace involved. However, due to background, cultural, and language differences between substance abuse researchers, treatment providers, and policy makers, empirically tested treatments are not being put into widespread practice. To bridge this gap, the Center for Substance Abuse Treatment sponsored the National Treatment Plan Initiative, a two-year effort to listen to multiple segments of the treatment field. This led to the formation of the Practice Improvement Collaborative (PIC) Program, whose purpose is to foster community-based partnerships that are committed to the identification, adoption, and evaluation of evidence-based practices that address locally defined needs. The PIC and the overall goals of the National Treatment Plan are discussed.

Use of pharmacotherapies in the treatment of alcohol use disorders and opioid dependence in primary care

Substance-related and addictive disorders are chronic relapsing conditions that substantially impact public health. Effective treatments for these disorders require addressing substance use/dependence comprehensively as well as other associated comorbidities. Comprehensive addressing of substance use in a medical setting involves screening for substance use, addressing substance use directly with the patient, and formulating an appropriate intervention. For alcohol dependence and opioid dependence, pharmacotherapies are available that are safe and effective when utilized in a comprehensive treatment paradigm, such as medication assisted treatment. In primary care, substance use disorders involving alcohol, illicit opioids, and prescription opioid abuse are common among patients who seek primary care services. Primary care providers report low levels of preparedness and confidence in identifying substance-related and addictive disorders and providing appropriate care and treatment. However, new models of service delivery in primary care for individuals with substance-related and addictive disorders are being developed to promote screening, care and treatment, and relapse prevention. The education and training of primary care providers utilizing approved medications for the treatment of alcohol use disorders and opioid dependence in a primary care setting would have important public health impact and reduce the burden of alcohol abuse and opioid dependence.

The need and opportunity to expand substance use disorder treatment in school-based settings

In this paper, we explore the unmet need for substance use disorder (SUD) treatment among youth, its consequences, and the opportunity to address this gap due to the expansion of behavioral health services to school-based settings under the Parity and Affordable Care Acts. We discuss the importance of using evidence-based approaches to assessment and treatment to ensure effectiveness and cost-effectiveness and show how the severity of SUD is related to a wide range of school, substance, mental, health, and health care utilization problems. Next, we introduce the other three articles in the special issue that further demonstrate the feasibility and impact of using these evidence-based practices in school-based settings, the challenges of identifying and interviewing with youth, and the need for a full continuum of interventions. In each of these areas we try to draw out the policy implication of these trends and papers.

Meaningful use of electronic behavioral health data in primary health care

In August 2011, scientists and policy-makers held a conference entitled "Using IT to Improve Community Health: How Health Care Reform Supports Innovation." One of the conference sessions was entitled "Electronic health records: Meaningful use implementation challenges, innovation, and regulations." This Meeting Report discusses the meaningful use of behavioral health data for the treatment of mental health and substance abuse conditions and optimization of behavioral wellness by primary care physicians.

Electronic health records: essential tools in integrating substance abuse treatment with primary care

While substance use problems are considered to be common in medical settings, they are not systematically assessed and diagnosed for treatment management. Research data suggest that the majority of individuals with a substance use disorder either do not use treatment or delay treatment-seeking for over a decade. The separation of substance abuse services from mainstream medical care and a lack of preventive services for substance abuse in primary care can contribute to under-detection of substance use problems. When fully enacted in 2014, the Patient Protection and Affordable Care Act 2010 will address these barriers by supporting preventive services for substance abuse (screening, counseling) and integration of substance abuse care with primary care. One key factor that can help to achieve this goal is to incorporate the standardized screeners or common data elements for substance use and related disorders into the electronic health records (EHR) system in the health care setting. Incentives for care providers to adopt an EHR system for meaningful use are part of the Health Information Technology for Economic and Clinical Health Act 2009. This commentary focuses on recent evidence about routine screening and intervention for alcohol/drug use and related disorders in primary care. Federal efforts in developing common data elements for use as screeners for substance use and related disorders are described. A pressing need for empirical data on screening, brief intervention, and referral to treatment (SBIRT) for drug-related disorders to inform SBIRT and related EHR efforts is highlighted.

A case study in collaborating with Atlanta-based African-American churches: a promising means for reaching inner-city substance users with rapid HIV testing

This case study examined programmatic data from a federally funded faith-based rapid HIV testing initiative. In 2004, Recovery Consultants of Atlanta, Inc. (RCA, Inc.) began providing rapid HIV testing in collaboration with six Atlanta-based African-American churches. Of the 1,947 persons tested from January 2004 to July 2005, 1,872 (96.1%) were African-American, 1,247 (64%) were male, and 1,612 (82.8%) were between the age of 26 and 56. A total of 85 HIV-infected individuals were identified and 72 were identified as previously undiagnosed cases (positivity rate of 3.7%). This case study highlights and promotes rapid HIV testing offered in partnership with African American churches as a strategy for raising HIV awareness among inner-city substance users.

Structural characterisation of ligand-binding determinants in human lung surfactant protein D: influence of Asp325

The crystal structures of a biologically and therapeutically active recombinant homotrimeric fragment of human lung surfactant protein D with a series of bound ligands have been determined. While the structures reveal various different binding modes, all utilise a similarly positioned pair of mannose-type O3' and O4' hydroxyls with no direct interaction between any non-terminal sugar and protein. The orientation, position, and interactions of the bound terminal sugar depend on the sugar itself, the presence and form of glycosidic linkage, and the environment in the crystal, which, via Asp325, places stereochemical and electronic constraints, different for the three different subunits in the homotrimer, on the ligand-binding site. As a direct consequence of this influence, the other binding-pocket flanking residue, Arg343, exhibits variable conformation and variable interactions with bound ligand and leaves open to question which orientation of terminal mannobiose, and of other terminal disaccharides, may be present in extended physiological ligands. The combined structural evidence shows that there is significant flexibility in recognition; that Asp325, in addition to Arg343, is an important determinant of ligand selectivity, recognition, and binding; and that differences in crystal contact interfaces exert, through Asp325, significant influence on preferred binding modes.

Integration of viral hepatitis services into opioid treatment programs

Opioid treatment programs (OTPs) dispense methadone and buprenorphine under specific federal regulations to individuals diagnosed with opioid dependence. OTPs can provide a comprehensive therapeutic milieu, often including primary medical care, psychosocial counseling, vocational rehabilitation, ongoing performance monitoring, and other vital services. Because of the high prevalence of infectious diseases, particularly hepatitis C virus infection, model OTPs are developing comprehensive care and treatment programs that integrate general medical and infectious disease-related medical care with substance abuse and mental health services. Integrating hepatitis care services in the substance abuse treatment settings fosters access to care for patients with multiple comorbidities, many who otherwise would not receive needed care. Improving health related outcomes for this patient population with complex medical problems requires an advanced integrated model of care for OTPs that can be exemplified through establishing resources needed to prevent hepatitis infection as standard of care. Outcomes management becomes possible through enhancing current capability of existing dispensing programs. This may serve as a national model for highly cost-efficient healthcare that has a measurable outcome of improved health.

Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: comparison at intake and 6 months later

OBJECTIVES

Alcohol screening and brief interventions in medical settings can significantly reduce alcohol use. Corresponding data for illicit drug use is sparse. A Federally funded screening, brief interventions, referral to treatment (SBIRT) service program, the largest of its kind to date, was initiated by the Substance Abuse and Mental Health Services Administration (SAMHSA) in a wide variety of medical settings. We compared illicit drug use at intake and 6 months after drug screening and interventions were administered.

DESIGN

SBIRT services were implemented in a range of medical settings across six states. A diverse patient population (Alaska Natives, American Indians, African-Americans, Caucasians, Hispanics), was screened and offered score-based progressive levels of intervention (brief intervention, brief treatment, referral to specialty treatment). In this secondary analysis of the SBIRT service program, drug use data was compared at intake and at a 6-month follow-up, in a sample of a randomly selected population (10%) that screened positive at baseline.

RESULTS

Of 459,599 patients screened, 22.7% screened positive for a spectrum of use (risky/problematic, abuse/addiction). The majority were recommended for a brief intervention (15.9%), with a smaller percentage recommended for brief treatment (3.2%) or referral to specialty treatment (3.7%). Among those reporting baseline illicit drug use, rates of drug use at 6-month follow-up (4 of 6 sites), were 67.7% lower (p<0.001) and heavy alcohol use was 38.6% lower (p<0.001), with comparable findings across sites, gender, race/ethnic, age subgroups. Among persons recommended for brief treatment or referral to specialty treatment, self-reported improvements in general health (p<0.001), mental health (p<0.001), employment (p<0.001), housing status (p<0.001), and criminal behavior (p<0.001) were found.

CONCLUSIONS

SBIRT was feasible to implement and the self-reported patient status at 6 months indicated significant improvements over baseline, for illicit drug use and heavy alcohol use, with functional domains improved, across a range of health care settings and a range of patients.

Hepatitis infection in the treatment of opioid dependence and abuse

Many new and existing cases of viral hepatitis infections are related to injection drug use. Transmission of these infections can result directly from the use of injection equipment that is contaminated with blood containing the hepatitis B or C virus or through sexual contact with an infected individual. In the latter case, drug use can indirectly contribute to hepatitis transmission through the dis-inhibited at-risk behavior, that is, unprotected sex with an infected partner. Individuals who inject drugs are at-risk for infection from different hepatitis viruses, hepatitis A, B, or C. Those with chronic hepatitis B virus infection also face additional risk should they become co-infected with hepatitis D virus. Protection from the transmission of hepatitis viruses A and B is best achieved by vaccination. For those with a history of or who currently inject drugs, the medical management of viral hepatitis infection comprising screening, testing, counseling and providing care and treatment is evolving. Components of the medical management of hepatitis infection, for persons considering, initiating, or receiving pharmacologic therapy for opioid addiction include: testing for hepatitis B and C infections; education and counseling regarding at-risk behavior and hepatitis transmission, acute and chronic hepatitis infection, liver disease and its care and treatment; vaccination against hepatitis A and B infection; and integrative primary care as part of the comprehensive treatment approach for recovery from opioid abuse and dependence. In addition, participation in a peer support group as part of integrated medical care enhances treatment outcomes. Liver disease is highly prevalent in patient populations seeking recovery from opioid addiction or who are currently receiving pharmacotherapy for opioid addiction. Pharmacotherapy for opioid addiction is not a contraindication to evaluation, care, or treatment of liver disease due to hepatitis virus infection. Successful pharmacotherapy for opioid addiction stabilizes patients and improves patient compliance to care and treatment regimens as well as promotes good patient outcomes. Implementation and integration of effective hepatitis prevention programs, care programs, and treatment regimens in concert with the pharmacological therapy of opioid addiction can reduce the public health burdens of hepatitis and injection drug use.

Policy and practice implications of epidemiological surveys on co-occurring mental and substance use disorders

This article describes factors that influence national policy and practice, with particular focus on the implications of epidemiological survey research. Examples of areas of concern to policymakers include treatment-seeking patterns, access to care at points of service in public health and social service systems, evidence-based practices, workforce development, and the complexities of reimbursement. In responding to data on systemic barriers to care, the Substance Abuse and Mental Health Services Administration (SAMHSA) has sought to promote a no wrong door strategy to address the needs of persons with co-occurring disorders (CODs) involving their mental health and substance use. Examples of SAMHSA programs and policies addressing CODs discussed in this article include targeted partnerships with the states, mechanisms to enhance system infrastructure, technical assistance, and initiatives with special populations.

IDENTIFICATION OF MYCOPLASMATACEAE BY THE FLUORESCENT ANTIBODY METHOD

Clark, Harold W. (The George Washington University, Washington, D.C.), Jack S. Bailey, Richard C. Fowler, and Thomas McP. Brown. Identification of Mycoplasmataceae by the fluorescent antibody method. J. Bacteriol. 85:111-118. 1963.-The conditions of the fluorescent antibody reactions were studied in relation to their application to Mycoplasmataceae or pleuropneumonia-like organisms (PPLO). Mycoplasma hominis type 1 and 2 antigens and their homologous antisera were used to determine the activity and specificity of these and other strains. Fluorescein isothiocyanate conjugated antiserum globulin preparations were used in both the direct and indirect fluorescent antibody methods. A direct tube technique was used for the detection and measurement of growth in broth cultures by the addition of conjugated antiserum. The specific fluorescent staining and recognition of hot water fixed M. hominis colonies was presented as a suitable identification standard. The antigenic activity was found to remain in the insoluble residue after exposure of M. hominis strains to sonic vibration (9 kc) for 30 min and centrifugation. Brief 2-min exposures of tissue cells to vibration (9 kc) caused the disruption of tissues, with the release of viable and "bound" nonwashable strains that reacted specifically with fluorescent antibody. It is proposed to apply both the sonic vibration and the fluorescent antibody techniques for the identification of Mycoplasmataceae in human tissues.

A recombinant fragment of human SP-D reduces allergic responses in mice sensitized to house dust mite allergens

C57Bl6 mice sensitized to Dermatophagoides pteronyssinus and challenged with D. pteronyssinus allergen extract given intranasally followed by treatment with intranasal applications of a 60-kDa truncated, trimeric recombinant form of human SP-D (rfhSP-D) showed a significant reduction in serum IgE, IgG1, peripheral blood eosinophilia and airway hyperresponsiveness compared to saline or bovine serum albumin-treated controls. Intracellular cytokine staining of lung and spleen homogenates showed increases in interleukin (IL)-12 production in lung tissue and normalization of IL-12 and interferon (IFN)-gamma in spleen tissue. In previous studies we demonstrated the effectiveness of native SP-D and rfhSP-D in down-regulating allergic responses to allergens of Aspergillus fumigatus. The results reported here indicate that rfhSP-D can suppress the development of allergic symptoms in sensitized mice challenged with allergens of the common house dust mite.

Moving from research to practice just in time: the treatment of cannabis use disorders comes of age

This supplement issue on the treatment of marijuana use disorders describes two large multi-site field experiments: the Cannabis Youth Treatment (CYT) study with adolescents and the Marijuana Treatment Project (MTP) with adults. The papers cover multiple aspects of the treatment of cannabis users, including the rationale for studying cannabis use disorders, descriptions of the CYT and MTP studies,characteristics of adolescents and adults presenting for treatment of cannabis use disorders, court diversion issues, economic evaluation and confirmation of self-reported cannabis use, among other topics. This Introduction provides background information and an overview of the papers from the perspective of the funding agency.

Legal issues facing physicians: substance abuse in the workplace

This chapter addresses key Department of Transportation (DOT) rules for drug testing employees working in industries regulated by the DOT. It also discusses the issue of substance abuse and the Americans with Disabilities Act. Finally, it reviews the iss e of confidentiality. It is important for the reader to recognize that this chapter is but a review of critical and crucial material. The reader is encouraged to pursue additional information if greater clarity and understanding are required.

Residential substance abuse treatment for pregnant and postpartum women and their children: treatment and policy implications

In FY 1993 and FY 1995, the federal government awarded 27 five-year grants that supported 35 residential treatment projects for substance-abusing pregnant and postpartum women and their children. These projects provided comprehensive culturally and gender-specific treatment. Preliminary aggregated data collected in a national cross-site evaluation of 24 of these projects are encouraging with respect to infant mortality and morbidity, treatment retention and completion rates, and behavioral changes in the participating mothers at six months postdischarge. Local evaluations reflect other benefits of treatment. Cost data are expected to demonstrate the efficiencies and benefits of these projects compared to no treatment.

Violent traumatic events and drug abuse severity

We examined the occurrence of violent traumatic events, DSM-III-R diagnosis of posttraumatic stress disorder (PTSD), and PTSD symptoms, and the relationship of these variables to drug abuse severity. One-hundred fifty opioid-dependent drug abusers who were participants in a randomized trial of two methadone treatment interventions were interviewed using the Diagnostic Interview Schedule, the Addiction Severity Index, and the Beck Depression Inventory. Twenty-nine percent met diagnostic criteria for PTSD. With the exception of rape, no gender differences in the prevalence of violent traumatic events were observed. The occurrence of PTSD-related symptoms was associated with greater drug abuse severity after controlling for gender, depression, and lifetime diagnosis of PTSD. The high rate of PTSD among these methadone patients, the nature of the traumatic events to which they are exposed, and subsequent violence-related psychiatric sequelae have important implications for identification and treatment of PTSD among those seeking drug abuse treatment.

Methadone maintenance vs 180-day psychosocially enriched detoxification for treatment of opioid dependence: a randomized controlled trial

CONTEXT

Despite evidence that methadone maintenance treatment (MMT) is effective for opioid dependence, it remains a controversial therapy because of its indefinite provision of a dependence-producing medication.

OBJECTIVE

To compare outcomes of patients with opioid dependence treated with MMT vs an alternative treatment, psychosocially enriched 180-day methadone-assisted detoxification.

DESIGN

Randomized controlled trial conducted from May 1995 to April 1999.

SETTING

Research clinic in an established drug treatment service.

PATIENTS

Of 858 volunteers screened, 179 adults with diagnosed opioid dependence were randomized into the study; 154 completed 12 weeks of follow-up.

INTERVENTIONS

Patients were randomized to MMT (n = 91), which required 2 hours of psychosocial therapy per week during the first 6 months; or detoxification (n = 88), which required 3 hours of psychosocial therapy per week, 14 education sessions, and 1 hour of cocaine group therapy, if appropriate, for 6 months, and 6 months of (nonmethadone) aftercare services.

MAIN OUTCOME MEASURES

Treatment retention, heroin and cocaine abstinence (by self-report and monthly urinalysis), human immunodeficiency virus (HIV) risk behaviors (Risk of AIDS Behavior scale score), and function in 5 problem areas: employment, family, psychiatric, legal, and alcohol use (Addiction Severity Index), compared by intervention group.

RESULTS

Methadone maintenance therapy resulted in greater treatment retention (median, 438.5 vs 174.0 days) and lower heroin use rates than did detoxification. Cocaine use was more closely related to study dropout in detoxification than in MMT. Methadone maintenance therapy resulted in a lower rate of drug-related (mean [SD] at 12 months, 2.17 [3.88] vs 3.73 [6.86]) but not sex-related HIV risk behaviors and in a lower severity score for legal status (mean [SD] at 12 months, 0.05 [0.13] vs 0.13 [0.19]). There were no differences between groups in employment or family functioning or alcohol use. In both groups, monthly heroin use rates were 50% or greater, but days of use per month dropped markedly from baseline.

CONCLUSIONS

Our results confirm the usefulness of MMT in reducing heroin use and HIV risk behaviors. Illicit opioid use continued in both groups, but frequency was reduced. Results do not provide support for diverting resources from MMT into long-term detoxification.

Collectins and innate immunity in the lung

Evidence from both in vitro and in vivo studies suggests that the collectins are important elements in host innate immune defences against infectious agents. Study of the collectins in specific disease settings now raises the prospects of developing therapies exploiting these mechanisms of innate immunity.

Needle exchange programs and social policy

The specter of AIDS will continue to dominate the concerns of clinicians, policy-makers, and social scientists into the next century. In addition to being a biological issue, HIV disease is a political issue. As a result of this, interest groups have mobilized to restrict certain interventions aimed at stopping the spread of HIV. Among those restricted interventions is the exchange of sterile needles and syringes for "dirty" needles and syringes with injection drug users (IDUs). Increasing the availability of clean equipment by removing the laws restricting their availability, and/or by funding needle exchange programs, would appear to be a much needed and rational public health policy. However, needle exchange programs have been viewed as fostering drug addiction or enabling drug addicts, thus marginalizing it as an early stage of treatment for addicts and as a demonstrated public health intervention. There is no empirical evidence to support this conclusion. In the absence of better knowledge about how to prevent the use of illicit injection drugs and how to effectively treat IDUs, we believe that needle exchange programs (NEPs) need to be implemented for several key reasons. First, they can help slow the spread of HIV infection. Second, they can be cost-effective when compared to the higher health care costs that result without needle exchange programs. Third, they can act as a precursor to treatment, or recovery, for addicts.

Antigenic properties of pleuropneumonia-like organisms from tissue cell cultures and the human genital area

Bailey, Jack S. (George Washington University, Washington, D. C.), Harold W. Clark, William R. Felts, Richard C. Fowler, and Thomas McP. Brown. Antigenic properties of pleuropneumonia-like organisms from tissue cell cultures and the human genital area. J. Bacteriol. 82:542-547. 1961.-Antigens were prepared from several tissue culture and human genital strains of pleuropneumonia-like organisms (PPLO) by a method utilizing continuous agitation of the incubating cultures. Antisera were produced in rabbits by intravenous injection of suspensions of these organisms standardized turbidimetrically. The antigenic properties of the selected strains were compared by agglutination techniques supplemented by a test based upon the inhibition of growth of PPLO by specific antisera.The majority of tissue culture strains of PPLO studied, including contaminants from several HeLa cell lines, appeared to be antigenically similar to the human type 1 strains. However, one strain (Sp-1) from a HeLa cell line was found to be related to the human type 2 PPLO.

Premorbid brain size is a determinant of functional reserve in abstinent crack-cocaine and crack-cocaine-alcohol-dependent adults

Studies of Alzheimer's disease patients show that individuals with larger premorbid brains have a later onset of disease, or a lessened severity of cognitive impairment, or both. This may be due to a "functional reserve" associated with the greater number of neurons and synapses available in larger brains. We used magnetic resonance imaging and the MicroCog Assessment of Cognitive Functioning to examine the association between intracranial volume (premorbid brain size) and neuropsychological function in abstinent crack-cocaine and crack-cocaine-alcohol dependent individuals. There were no significant differences between the crack-only and the crack-alcohol dependent participants in neuropsychological performance or in intracranial volume. The abstinent cocaine-dependent individuals (both crack-only and crack-alcohol) were significantly impaired in many neuropsychological domains. Intracranial volume accounted for a significant proportion of the variance in neuropsychological performance. This result is consistent with the finding in the Alzheimer's literature that larger brains can maintain function to a greater degree, or for a longer period of time, in the face of cerebral disease or insult. Functional reserve may be a heretofore little recognized protective mechanism of the brain that has consequences for the severity of expression of cerebral disease or insult throughout life.

Antigenic properties of pleuropneumonia-like organisms from tissue cell cultures and the human genital area

Bailey, Jack S. (George Washington University, Washington, D. C.), Harold W. Clark, William R. Felts, Richard C. Fowler, and Thomas McP. Brown. Antigenic properties of pleuropneumonia-like organisms from tissue cell cultures and the human genital area. J. Bacteriol. 82:542-547. 1961.-Antigens were prepared from several tissue culture and human genital strains of pleuropneumonia-like organisms (PPLO) by a method utilizing continuous agitation of the incubating cultures. Antisera were produced in rabbits by intravenous injection of suspensions of these organisms standardized turbidimetrically. The antigenic properties of the selected strains were compared by agglutination techniques supplemented by a test based upon the inhibition of growth of PPLO by specific antisera.The majority of tissue culture strains of PPLO studied, including contaminants from several HeLa cell lines, appeared to be antigenically similar to the human type 1 strains. However, one strain (Sp-1) from a HeLa cell line was found to be related to the human type 2 PPLO.

Self-efficacy and illicit opioid use in a 180-day methadone detoxification treatment

Self-efficacy ratings coincided with illicit opioid use across the 3 phases of a 180-day methadone detoxification treatment. Efficacy ratings increased after patients received their first dose of methadone, did not change while they were maintained on a stable dose of methadone, and declined during the taper as they attempted to face high-risk situations without the full benefit of methadone. Efficacy ratings measured at a point before a phase of treatment predicted illicit opioid use across that phase. For clarification of the relation between self-efficacy and illicit opioid use, 3 conceptual models proposed by J.S. Baer, C.S. Holt, and E. Lichtenstein (1986) were tested. Self-efficacy influenced subsequent drug use in parallel with previous behavior, but this influence was found only at the start of the stabilization phase and immediately before the start of the taper phase. These findings highlight the usefulness of the self-efficacy concept for the treatment of opioid addiction.

Self-efficacy and illicit opioid use in a 180-day methadone detoxification treatment

Self-efficacy ratings coincided with illicit opioid use across the 3 phases of a 180-day methadone detoxification treatment. Efficacy ratings increased after patients received their first dose of methadone, did not change while they were maintained on a stable dose of methadone, and declined during the taper as they attempted to face high-risk situations without the full benefit of methadone. Efficacy ratings measured at a point before a phase of treatment predicted illicit opioid use across that phase. For clarification of the relation between self-efficacy and illicit opioid use, 3 conceptual models proposed by J.S. Baer, C.S. Holt, and E. Lichtenstein (1986) were tested. Self-efficacy influenced subsequent drug use in parallel with previous behavior, but this influence was found only at the start of the stabilization phase and immediately before the start of the taper phase. These findings highlight the usefulness of the self-efficacy concept for the treatment of opioid addiction.

Treatment research with crack-cocaine-dependent male veterans: the efficacy of different recruitment strategies

Crack cocaine dependence rapidly leads to physical deterioration and severe social consequences. There is no widely accepted standard of treatment. As such, it is important to attract broad samples of patients into treatment research to improve efficacy and to establish generalizability. Better understanding of what attracts different subgroups of cocaine users into treatment, particularly research-based treatment, is needed. This article assesses the efficacy of six different recruitment strategies for attracting different populations of male veterans into treatment for crack cocaine dependence. New directions are outlined for the examination of recruitment strategies.