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1.  Do college students improve their grades by using prescription stimulants nonmedically? 
Addictive behaviors  2016;65:245-249.
Introduction
Many college students engage in nonmedical use of prescription stimulants (NPS) because they believe it provides academic benefits, but studies are lacking to support or refute this belief.
Methods
Using a longitudinal design, 898 undergraduates who did not have an ADHD diagnosis were studied. Year 3 GPA (from college records) of four groups was compared: Abstainers (did not engage in NPS either year; 68.8%); Initiators (NPS in Year 3 but not Year 2; 8.7%); Desisters (NPS in Year 2 but not Year 3; 5.8%); and Persisters (NPS in both years; 16.7%). Generalized estimating equations regression was used to estimate the association between NPS and change in GPA, controlling for sex and Year 2 GPA.
Results
GPA increased significantly within Abstainers (p<.05), but did not change significantly within the other groups. Overall, the relationship between NPS pattern group and change in GPA was not statistically significant (p=.081). NPS was generally infrequent, but Persisters used more frequently than Desisters (11.7 versus 3.4 days in Year 2) and Initiators (13.6 versus 4.0 days in Year 3, both ps<.001), controlling for sex and Year 2 GPA.
Conclusions
We cannot rule out the possibility that NPS prevented declines in GPA, but we can conclude that students who engaged in NPS showed no increases in their GPAs and gained no detectable advantages over their peers. The results suggest that prevention and intervention strategies should emphasize that the promise of academic benefits from NPS is likely illusory.
doi:10.1016/j.addbeh.2016.07.016
PMCID: PMC5140739  PMID: 27469455
Academic performance; College students; drug abuse; prescription drug abuse; substance use
2.  Extended-release naltrexone for pre-release prisoners: A randomized trial of medical mobile treatment 
Contemporary clinical trials  2016;53:130-136.
Background
Extended-release naltrexone (XR-NTX), is an effective treatment for opioid use disorder but is rarely initiated in US prisons or with criminal justice populations. Mobile treatment for chronic diseases have been implemented in a variety of settings. Mobile treatment may provide an opportunity to expand outreach to parolees to surmount barriers to traditional clinic treatment.
Methods
Male and female prisoners (240) with pre-incarceration histories of opioid use disorder who are within one month of release from prison will be enrolled in this randomized clinical trial. Participants are randomized to one of two study arms: 1) [XR-NTX-OTx] One injection of long-acting naltrexone in prison, followed by 6 monthly injections post-release at a community opioid treatment program; or 2) [XR-NTX+ MMTx] One injection of long-acting naltrexone in prison followed by 6 monthly injections post-release at the patient's place of residence utilizing mobile medical treatment. The primary outcomes are: treatment adherence; opioid use; criminal activity; re-arrest; reincarceration; and HIV risk-behaviors.
Results
We describe the background and rationale for the study, its aims, hypotheses, and study design.
Conclusions
The use of long-acting injectable naltrexone may be a promising form of treatment for pre-release prisoners. Finally, as many individuals in the criminal justice system drop out of treatment, this study will assess whether treatment at their place of residence will improve adherence and positively affect treatment outcomes.
doi:10.1016/j.cct.2016.12.015
PMCID: PMC5274608  PMID: 28011389
prisoners; long-acting naltrexone; medical mobile treatment; criminal justice
3.  Energy drink use patterns among young adults: Associations with drunk driving 
Background
Highly caffeinated “energy drinks” (ED) are commonly consumed, and sometimes mixed with alcohol. Associations between ED consumption, risk-taking, and alcohol-related problems have been observed. This study examines the relationship between ED consumption—both with and without alcohol—and drunk driving.
Methods
Data were derived from a longitudinal study of college students assessed annually via personal interviews. In Year 6 (modal age 23; n=1,000), participants self-reported their past-year frequency of drunk driving, ED consumption patterns [frequency of drinking alcohol mixed with energy drinks (AmED) and drinking energy drinks without alcohol (ED)], alcohol use (frequency, quantity), and other caffeine consumption. Earlier assessments captured suspected risk factors for drunk driving. Structural equation modeling was used to develop an explanatory model for the association between ED consumption patterns and drunk driving frequency while accounting for other suspected risk factors.
Results
More than half (57%) consumed ED at least once during the past year. Among ED consumers, 71% drank AmED and 85% drank ED alone; many (56%) engaged in both styles of ED consumption while others specialized in one or the other (29% drank ED alone exclusively, while 15% drank AmED exclusively). After accounting for other risk factors, ED consumption was associated with drunk driving frequency in two ways. First, a direct path existed from ED frequency (without alcohol) to drunk driving frequency. Second, an indirect path existed from AmED frequency through alcohol quantity to drunk driving frequency.
Conclusions
Among this sample, ED consumption with and without alcohol was common, and both styles of ED consumption contributed independently to drunk driving frequency. Results call for increased attention to the impact of different patterns of ED consumption on alcohol-related consequences, such as drunk driving.
doi:10.1111/acer.13229
PMCID: PMC5074694  PMID: 27676240
Alcohol; college students; drunk driving; energy drinks; young adults
4.  Proceedings of the 14th annual conference of INEBRIA 
Holloway, Aisha S. | Ferguson, Jennifer | Landale, Sarah | Cariola, Laura | Newbury-Birch, Dorothy | Flynn, Amy | Knight, John R. | Sherritt, Lon | Harris, Sion K. | O’Donnell, Amy J. | Kaner, Eileen | Hanratty, Barbara | Loree, Amy M. | Yonkers, Kimberly A. | Ondersma, Steven J. | Gilstead-Hayden, Kate | Martino, Steve | Adam, Angeline | Schwartz, Robert P. | Wu, Li-Tzy | Subramaniam, Geetha | Sharma, Gaurav | McNeely, Jennifer | Berman, Anne H. | Kolaas, Karoline | Petersén, Elisabeth | Bendtsen, Preben | Hedman, Erik | Linderoth, Catharina | Müssener, Ulrika | Sinadinovic, Kristina | Spak, Fredrik | Gremyr, Ida | Thurang, Anna | Mitchell, Ann M. | Finnell, Deborah | Savage, Christine L. | Mahmoud, Khadejah F. | Riordan, Benjamin C. | Conner, Tamlin S. | Flett, Jayde A. M. | Scarf, Damian | McRee, Bonnie | Vendetti, Janice | Gallucci, Karen Steinberg | Robaina, Kate | Clark, Brendan J. | Jones, Jacqueline | Reed, Kathryne D. | Hodapp, Rachel M. | Douglas, Ivor | Burnham, Ellen L. | Aagaard, Laura | Cook, Paul F. | Harris, Brett R. | Yu, Jiang | Wolff, Margaret | Rogers, Meighan | Barbosa, Carolina | Wedehase, Brendan J. | Dunlap, Laura J. | Mitchell, Shannon G. | Dusek, Kristi A. | Gryczynski, Jan | Kirk, Arethusa S. | Oros, Marla T. | Hosler, Colleen | OGrady, Kevin E. | Brown, Barry S. | Angus, Colin | Sherborne, Sidney | Gillespie, Duncan | Meier, Petra | Brennan, Alan | de Vargas, Divane | Soares, Janaina | Castelblanco, Donna | Doran, Kelly M. | Wittman, Ian | Shelley, Donna | Rotrosen, John | Gelberg, Lillian | Edelman, E. Jennifer | Maisto, Stephen A. | Hansen, Nathan B. | Cutter, Christopher J. | Deng, Yanhong | Dziura, James | Fiellin, Lynn E. | O’Connor, Patrick G. | Bedimo, Roger | Gibert, Cynthia | Marconi, Vincent C. | Rimland, David | Rodriguez-Barradas, Maria C. | Simberkoff, Michael S. | Justice, Amy C. | Bryant, Kendall J. | Fiellin, David A. | Giles, Emma L. | Coulton, Simon | Deluca, Paolo | Drummond, Colin | Howel, Denise | McColl, Elaine | McGovern, Ruth | Scott, Stephanie | Stamp, Elaine | Sumnall, Harry | Vale, Luke | Alabani, Viviana | Atkinson, Amanda | Boniface, Sadie | Frankham, Jo | Gilvarry, Eilish | Hendrie, Nadine | Howe, Nicola | McGeechan, Grant J. | Ramsey, Amy | Stanley, Grant | Clephane, Justine | Gardiner, David | Holmes, John | Martin, Neil | Shevills, Colin | Soutar, Melanie | Chi, Felicia W. | Weisner, Constance | Ross, Thekla B. | Mertens, Jennifer | Sterling, Stacy A. | Shorter, Gillian W. | Heather, Nick | Bray, Jeremy | Cohen, Hildie A. | McPherson, Tracy L. | Adam, Cyrille | López-Pelayo, Hugo | Gual, Antoni | Segura-Garcia, Lidia | Colom, Joan | Ornelas, India J. | Doyle, Suzanne | Donovan, Dennis | Duran, Bonnie | Torres, Vanessa | Gaume, Jacques | Grazioli, Véronique | Fortini, Cristiana | Paroz, Sophie | Bertholet, Nicolas | Daeppen, Jean-Bernard | Satterfield, Jason M. | Gregorich, Steven | Alvarado, Nicholas J. | Muñoz, Ricardo | Kulieva, Gozel | Vijayaraghavan, Maya | Adam, Angéline | Cunningham, John A. | Díaz, Estela | Palacio-Vieira, Jorge | Godinho, Alexandra | Kushir, Vladyslav | O’Brien, Kimberly H. M. | Aguinaldo, Laika D. | Sellers, Christina M. | Spirito, Anthony | Chang, Grace | Blake-Lamb, Tiffany | LaFave, Lea R. Ayers | Thies, Kathleen M. | Pepin, Amy L. | Sprangers, Kara E. | Bradley, Martha | Jorgensen, Shasta | Catano, Nico A. | Murray, Adelaide R. | Schachter, Deborah | Andersen, Ronald M. | Rey, Guillermina Natera | Vahidi, Mani | Rico, Melvin W. | Baumeister, Sebastian E. | Johansson, Magnus | Sinadinovic, Christina | Hermansson, Ulric | Andreasson, Sven | O’Grady, Megan A. | Kapoor, Sandeep | Akkari, Cherine | Bernal, Camila | Pappacena, Kristen | Morley, Jeanne | Auerbach, Mark | Neighbors, Charles J. | Kwon, Nancy | Conigliaro, Joseph | Morgenstern, Jon | Magill, Molly | Apodaca, Timothy R. | Borsari, Brian | Hoadley, Ariel | Scott Tonigan, J. | Moyers, Theresa | Fitzgerald, Niamh M. | Schölin, Lisa | Barticevic, Nicolas | Zuzulich, Soledad | Poblete, Fernando | Norambuena, Pablo | Sacco, Paul | Ting, Laura | Beaulieu, Michele | Wallace, Paul George | Andrews, Matthew | Daley, Kate | Shenker, Don | Gallagher, Louise | Watson, Rod | Weaver, Tim | Bruguera, Pol | Oliveras, Clara | Gavotti, Carolina | Barrio, Pablo | Braddick, Fleur | Miquel, Laia | Suárez, Montse | Bruguera, Carla | Brown, Richard L. | Capell, Julie Whelan | Paul Moberg, D. | Maslowsky, Julie | Saunders, Laura A. | McCormack, Ryan P. | Scheidell, Joy | Gonzalez, Mirelis | Bauroth, Sabrina | Liu, Weiwei | Lindsay, Dawn L. | Lincoln, Piper | Hagle, Holly | Wallhed Finn, Sara | Hammarberg, Anders | Andréasson, Sven | King, Sarah E. | Vargo, Rachael | Kameg, Brayden N. | Acquavita, Shauna P. | Van Loon, Ruth Anne | Smith, Rachel | Brehm, Bonnie J. | Diers, Tiffiny | Kim, Karissa | Barker, Andrea | Jones, Ashley L. | Skinner, Asheley C. | Hinman, Agatha | Svikis, Dace S. | Thacker, Casey L. | Resnicow, Ken | Beatty, Jessica R. | Janisse, James | Puder, Karoline | Bakshi, Ann-Sofie | Milward, Joanna M. | Kimergard, Andreas | Garnett, Claire V. | Crane, David | Brown, Jamie | West, Robert | Michie, Susan | Rosendahl, Ingvar | Andersson, Claes | Gajecki, Mikael | Blankers, Matthijs | Donoghue, Kim | Lynch, Ellen | Maconochie, Ian | Phillips, Ceri | Pockett, Rhys | Phillips, Tom | Patton, R. | Russell, Ian | Strang, John | Stewart, Maureen T. | Quinn, Amity E. | Brolin, Mary | Evans, Brooke | Horgan, Constance M. | Liu, Junqing | McCree, Fern | Kanovsky, Doug | Oberlander, Tyler | Zhang, Huan | Hamlin, Ben | Saunders, Robert | Barton, Mary B. | Scholle, Sarah H. | Santora, Patricia | Bhatt, Chirag | Ahmed, Kazi | Hodgkin, Dominic | Gao, Wenwu | Merrick, Elizabeth L. | Drebing, Charles E. | Larson, Mary Jo | Sharma, Monica | Petry, Nancy M. | Saitz, Richard | Weisner, Constance M. | Young-Wolff, Kelly C. | Lu, Wendy Y. | Blosnich, John R. | Lehavot, Keren | Glass, Joseph E. | Williams, Emily C. | Bensley, Kara M. | Chan, Gary | Dombrowski, Julie | Fortney, John | Rubinsky, Anna D. | Lapham, Gwen T. | Forray, Ariadna | Olmstead, Todd A. | Gilstad-Hayden, Kathryn | Kershaw, Trace | Dillon, Pamela | Weaver, Michael F. | Grekin, Emily R. | Ellis, Jennifer D. | McGoron, Lucy | McGoron, Lucy
doi:10.1186/s13722-017-0087-8
PMCID: PMC5606215
6.  Immediate vs. delayed computerized brief intervention for illicit drug misuse 
Journal of addiction medicine  2016;10(5):344-351.
Objective
Computerized brief interventions are a promising approach for integrating substance use interventions into primary care settings. We sought to examine the effectiveness of a computerized brief intervention for illicit drug misuse, which prior research showed performed no worse than a traditional in-person brief intervention.
Methods
Community health center patients were screened for eligibility using the World Health Organization Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST). Participants were adult patients (ages 18-62; 53% female) with moderate-risk illicit drug use (N=80), randomized to receive the computerized brief intervention either immediately, or at their 3-month follow-up. Assessments were conducted at baseline, 3-, and 6-month follow-up, and included the ASSIST and drug hair testing.
Results
Most participants in the sample (90%) reported moderate-risk marijuana use. Although the sample as a whole reported significant decreases in ASSIST Global Drug Risk scores and ASSIST marijuana-specific scores, no significant differences were detected between Immediate and Delayed conditions on either of these measures. Likewise, no significant differences were detected between conditions in drug-positive hair test results at either follow-up.
Conclusions
This study did not find differences between immediate vs. delayed computerized brief intervention in reducing drug use or associated risks, suggesting potential regression to the mean or reactivity to the consent, screening, or assessment process. The findings are discussed in light of the study's limitations and directions for future research.
doi:10.1097/ADM.0000000000000248
PMCID: PMC5042843  PMID: 27504925
brief intervention; computerized brief intervention; marijuana; primary care
7.  Buprenorphine treatment and 12-step meeting attendance: Conflicts, compatibilities, and patient outcomes 
This analysis examines patient experiences and outcomes with 12-step recovery group attendance during buprenorphine maintenance treatment (BMT), two approaches with traditionally divergent philosophies regarding opioid medications for treatment of opioid use disorder. Using quantitative (n=300) and qualitative (n=20) data collected during a randomized trial of counseling services in buprenorphine treatment, this mixed-methods analysis of African Americans in BMT finds the number of NA meetings attended in the prior 6 months was associated with a higher rate of retention in BMT (p<.001) and heroin/cocaine abstinence at 6 month follow-up (p=.005). However, patients whose counselors required them to attend 12-step meetings did not have better outcomes than patients not required to attend such meetings. Qualitative narratives highlighted patients’ strategies for managing dissonant viewpoints on BMT and disclosing BMT status in community 12-step meetings. Twelve-step meeting attendance is associated with better outcomes for BMT patients over the first 6 months of treatment. However, there is no benefit to requiring meeting attendance as a condition of treatment, and clinicians should be aware of potential philosophical conflicts between 12-step and BMT approaches.
doi:10.1016/j.jsat.2015.05.005
PMCID: PMC4560966  PMID: 25986647
Buprenorphine; 12-step; Narcotics Anonymous; Opioid Dependence
8.  Implementation and Evaluation of an Intervention for Children in Afghanistan at Risk for Substance Use or Actively Using Psychoactive Substances 
The present study examined the impact of a novel intervention for children at risk for substance use or actively using substances that was provided to 783 children between 4 and 18 years of age in Afghanistan. They received the Child Intervention for Living Drug-free (CHILD) protocol while in outpatient or residential treatment. CHILD included age-appropriate literacy and numeracy, drug education, basic living safety, and communication and trauma coping skills. A battery of measures examined multiple child health domains at treatment's start and end and 12 weeks later. For younger children, there were no significant Gender or Gender X Time effects (all p's > .16 and .35, resp.). The time main effect was significant for all outcomes (all p's < .00192, the prespecified per-comparison error rate). Post hoc testing showed significant improvements from residential treatment entry to completion for all scales. For older children, a time main effect was significant for (all p's < .00192, the prespecified per-comparison error rate) all but one outcome. Community follow-up means were significantly lower than residential treatment entry means. CHILD had a positive impact on children, and treatment impact endured from posttreatment to follow-up assessment.
doi:10.1155/2017/2382951
PMCID: PMC5591973  PMID: 28932246
9.  Interim Methadone and Patient Navigation in Jail: Rationale and Design of a Randomized Clinical Trial 
Background
Methadone maintenance is an effective treatment for opioid dependence but is rarely initiated in US jails. Patient navigation is a promising approach to improve continuity of care but has not been tested in bridging the gap between jail- and community-based drug treatment programs.
Methods
This is an open-label randomized clinical trial among 300 adult opioid dependent newly-arrested detainees that will compare three treatment conditions: methadone maintenance without routine counseling (termed Interim Methadone; IM) initiated in jail v. IM and patient navigation v. enhanced treatment-as-usual. The two primary outcomes will be: (1) the rate of entry into treatment for opioid use disorder within 30 days from release and (2) frequency of opioid positive urine tests over the 12-month follow-up period.
An economic analysis will examine the costs, cost-effectiveness, and cost-benefit ratio of the study interventions.
Results
We describe the background and rationale for the study, its aims, hypotheses, and study design.
Conclusions
Given the large number of opioid dependent detainees in the US and elsewhere, initiating IM at the time of incarceration could be a significant public health and clinical approach to reducing relapse, recidivism, HIV-risk behavior, and criminal behavior. An economic analysis will be conducted to assist policy makers in determining the utility of adopting this approach.
doi:10.1016/j.cct.2016.06.002
PMCID: PMC4969178  PMID: 27282117
methadone treatment; interim methadone; patient navigation; criminal justice; jail
10.  The SOMATICS collaborative: Introduction to a National Institute on Drug Abuse cooperative study of pharmacotherapy for opioid treatment in criminal justice settings 
Contemporary clinical trials  2016;48:166-172.
Background
Among the nearly 750,000 inmates in U.S. jails, 12% report using opioids regularly, 8% report use in the month prior to their offense, and 4% report use at the time of their offense. Although ample evidence exists that medications effectively treat Opiate Use Disorder (OUD) in the community, strong evidence is lacking in jail settings. The general lack of medications for OUD in jail settings may place persons suffering from OUD at high risk for relapse to drug use and overdose following release from jail.
Methods
The three study sites in this collaborative are pooling data for secondary analyses from three open-label randomized effectiveness trials comparing: (1) the initiation of extended-release naltrexone [XR-NTX] in Sites 1 and 2 and interim methadone in Site 3 with enhanced treatment-as usual (ETAU); (2) the additional benefit of patient navigation plus medications at Sites 2 and 3 vs. medication alone vs. ETAU. Participants are adults with OUD incarcerated in jail and transitioning to the community.
Results
We describe the rationale, specific aims, and designs of three separate studies harmonized to enhance their scientific yield to investigate how to best prevent jail inmates from relapsing to opioid use and associated problems as they transition back to the community.
Conclusions
Conducting drug abuse research during incarceration is challenging and study designs with data harmonization across different sites can increase the potential value of research to develop effective treatments for individuals in jail with OUD.
doi:10.1016/j.cct.2016.05.003
PMCID: PMC5454801  PMID: 27180088
Interim methadone; Extended-release naltrexone; Opioid relapse prevention; Jail; Criminal justice
11.  Performance of the Tobacco, Alcohol, Prescription medication, and other Substance use (TAPS) Tool for substance use screening in primary care patients 
Annals of internal medicine  2016;165(10):690-699.
Background
Substance use is a leading cause of morbidity and mortality that is under-identified in medical practice.
Objective
The Tobacco, Alcohol, Prescription medication, and other Substance use (TAPS) Tool was developed to address the need for a brief screening and assessment instrument that includes all commonly used substances, and fits into clinical workflows. The goal of this study was to assess the performance of the TAPS Tool in primary care patients.
Design
Multi-site study conducted within the National Drug Abuse Treatment Clinical Trials Network, comparing the TAPS Tool against a reference standard measure.
Setting
Five adult primary care clinics.
Participants
2,000 adult patients were consecutively recruited from clinic waiting areas.
Measurements
Interviewer- and self-administered versions of the TAPS Tool were compared to the reference standard modified Composite International Diagnostic Interview (CIDI), which measures problem use and substance use disorders (SUD).
Results
Interviewer- and self-administered versions of the TAPS Tool had similar diagnostic characteristics. For identifying problem use (at a cutoff of 1+), the TAPS Tool had sensitivity 0.93 (95% CI 0.90–0.95) and specificity 0.87 (95% CI 0.85–0.89) for tobacco, and sensitivity 0.74 (95% CI 0.70–0.78), specificity 0.79 (95% CI 0.76–0.81) for alcohol. For problem use of illicit and prescription drugs, sensitivity ranged from 0.82 (95% CI 0.76–0.87) for marijuana to 0.63 (95% CI 0.47–0.78) for sedatives, and specificity was 0.93 or higher. For identifying any SUD, sensitivity was lower, but a score of 2+ greatly increased the likelihood of having a SUD.
Limitations
Low prevalence of some drug classes led to poor precision in some estimates. Research assistants were not blinded to the participant’s TAPS Tool responses when they administered the CIDI.
Conclusions
In a diverse population of adult primary care patients, the TAPS Tool detected clinically relevant problem substance use. While it may also detect tobacco, alcohol, and marijuana use disorders, further refinement is needed before the TAPS Tool can be broadly recommended as a screener for SUD.
doi:10.7326/M16-0317
PMCID: PMC5291717  PMID: 27595276
12.  Process evaluation of a technology-delivered screening and brief intervention for substance use in primary care 
Psychotherapy process research examines the content of treatment sessions and their association with outcomes in an attempt to better understand the interactions between therapists and clients, and to elucidate mechanisms of behavior change. A similar approach is possible in technology-delivered interventions, which have an interaction process that is always perfectly preserved and rigorously definable. The present study sought to examine the process of participants’ interactions with a computer-delivered brief intervention for drug use, from a study comparing computer- and therapist-delivered brief interventions among adults at two primary health care centers in New Mexico. Specifically, we sought to describe the pattern of participants’ (N=178) choices and reactions throughout the computer-delivered brief intervention, and to examine associations between that process and intervention response at 3-month follow-up. Participants were most likely to choose marijuana as the first substance they wished to discuss (n = 114, 64.0%). Most participants indicated that they had not experienced any problems as a result of their drug use (n = 108, 60.7%), but nearly a third of these (n = 32, 29.6%) nevertheless indicated a desire to stop or reduce its use; participants who did report negative consequences were most likely to endorse financial or relationship concerns. However, participant ratings of the importance of change or of the helpfulness of personalized normed feedback were unrelated to changes in substance use frequency. Design of future e-interventions should consider emphasizing possible benefits of quitting rather than the negative consequences of drug use, and—when addressing consequences—should consider focusing on the impacts of substance use on relationship and financial aspects. These findings are an early but important step toward using process evaluation to optimize e-intervention content.
doi:10.1016/j.invent.2016.01.004
PMCID: PMC4836054  PMID: 27110494
e-Health; brief intervention; substance abuse; process research; adults
13.  Two models of integrating buprenorphine treatment and medical staff within formerly “drug-free” outpatient programs 
Journal of psychoactive drugs  2016;48(2):101-108.
“Drug-free” outpatient programs deliver treatment to the largest number of patients of all treatment modalities in the US, providing a significant opportunity to expand access to medication treatments for substance use disorders. This analysis examined staff perceptions of organizational dynamics associated with the delivery of buprenorphine maintenance within three formerly “drug-free” outpatient treatment programs. Semi-structured interviews (N=15) were conducted with counseling and medical staff, and respondents were predominantly African American (n=11) and female (n=12). Themes and concepts related to medical staff integration emerged through an inductive and iterative coding process using Atlas.ti qualitative analysis software. Two treatment clinics incorporated buprenorphine maintenance into their programs using a co-located model of care. Their staff generally reported greater intra-organizational discord regarding the best ways to combine medication and counseling compared to the clinic using an integrated model of care. Co-located program staff reported less communication between medical and clinical staff, which contributed to some uncertainty about proper dosing and concerns about the potential for medication diversion. Clinics that shift from “drug-free” to incorporating buprenorphine maintenance should consider which model of care they wish to adapt and how to train staff and structure staff communication.
doi:10.1080/02791072.2015.1130884
PMCID: PMC4956482  PMID: 26940870
buprenorphine; outpatient treatment; treatment staff; team care model; integration
14.  Drinking like an adult? Trajectories of alcohol use patterns before and after college graduation 
Background
College students who engage in high-risk drinking patterns are thought to “mature out” of these patterns as they transition to adult roles. College graduation is an important milestone demarcating this transition. We examine longitudinal changes in quantity and frequency of alcohol consumption between the college years and the four years after graduation; and explore variation in these changes by gender and race/ethnicity.
Methods
Participants were 1128 college graduates enrolled in a longitudinal prospective study of health-risk behaviors. Standard measures of alcohol consumption were gathered during eight annual personal interviews (76% to 91% annual follow-up). Graduation dates were culled from administrative data and self-report. Spline models, in which separate trajectories were modeled before and after the “knot” of college graduation, were fit to eight annual observations of past-year alcohol use frequency and quantity (typical number of drinks/drinking day).
Results
Frequency increased linearly pre-graduation, slightly decreased post-graduation, and then rebounded to pre-graduation levels. Pre-graduation frequency increased more steeply among individuals who drank more heavily at college entry. Quantity decreased linearly during college, followed by quadratic decreases after graduation.
Conclusions
Results suggest that the post-college “maturing out” phenomenon might be attributable to decreases in alcohol quantity but not frequency. High-frequency drinking patterns that develop during college appear to persist several years post-graduation.
doi:10.1111/acer.12973
PMCID: PMC4775364  PMID: 26893253
Alcohol use trajectories; college graduation; college students; longitudinal research; maturing out
15.  Marijuana use trajectories during college predict health outcomes nine years post-matriculation 
Drug and alcohol dependence  2015;159:158-165.
Background
Several studies have linked marijuana use with a variety of health outcomes among young adults. Information about marijuana’s long-term health effects is critically needed.
Methods
Data are from a ten-year study of 1,253 young adults originally recruited as first-year college students and assessed annually thereafter. Six trajectories of marijuana use during college (Non-Use, Low-Stable, Early-Decline, College-Peak, Late-Increase, Chronic) were previously derived using latent variable growth mixture modeling. Nine health outcomes assessed in Year 10 (modal age 27) were regressed on a group membership variable for the six group trajectories, holding constant demographics, baseline health status, and alcohol and tobacco trajectory group membership.
Results
Marijuana trajectory groups differed significantly on seven of the nine outcomes (functional impairment due to injury, illness, or emotional problems; psychological distress; subjective well-being; and mental and physical health service utilization; all ps<.001), but not on general health rating or body mass index. Non-Users fared better than the Late-Increase and Chronic groups on most physical and mental health outcomes. The declining groups (Early-Decline, College-Peak) fared better than the Chronic group on mental health outcomes. The Late-Increase group fared significantly worse than the stable groups (Non-Use, Low-Stable, Chronic) on both physical and mental health outcomes.
Conclusions
Even occasional or time-limited marijuana use might have adverse effects on physical and mental health, perhaps enduring after several years of moderation or abstinence. Reducing marijuana use frequency might mitigate such effects. Individuals who escalate their marijuana use in their early twenties might be at especially high risk for adverse outcomes.
doi:10.1016/j.drugalcdep.2015.12.009
PMCID: PMC4724514  PMID: 26778758
Cannabis; health care utilization; health outcomes; longitudinal studies; mental health; physical health
16.  The Roles of Maternal Depression, Serotonin Reuptake Inhibitor Treatment, and Concomitant Benzodiazepine Use on Infant Neurobehavioral Functioning Over the First Postnatal Month 
The American journal of psychiatry  2015;173(2):147-157.
Objective
The purpose of this article was to systematically compare the developmental trajectory of neurobehavior over the first postnatal month for infants with prenatal exposure to pharmacologically untreated maternal depression, selective serotonin reuptake inhibitors or serotonin and norepinephrine reuptake inhibitors (collectively: SSRIs), SSRIs with concomitant benzodiazepines (SSRI plus benzodiazepine), and no maternal depression or drug treatment (no exposure).
Method
Women (N=184) were assessed at two prenatal time points to determine psychiatric diagnoses, symptom severity, and prenatal medication usage. Infants were examined with a structured neurobehavioral assessment (Neonatal Intensive Care Unit Network Neurobehavioral Scale) at multiple time points across the first postnatal month. SSRI exposure was confirmed in a subset of participants with plasma SSRI levels. General linear-mixed models were used to examine group differences in neurobehavioral scores over time with adjustment for demographic variables and depression severity.
Results
Infants in the SSRI and SSRI plus benzodiazepine groups had lower motor scores and more CNS stress signs across the first postnatal month, as well as lower self-regulation and higher arousal at day 14. Infants in the depression group had low arousal throughout the newborn period. Infants in all three clinical groups had a widening gap in scores from the no-exposure group at day 30 in their response to visual and auditory stimuli while asleep and awake. Infants in the SSRI plus benzodiazepine group had the least favorable scores on the Neonatal Intensive Care Unit Network Neurobehavioral Scale.
Conclusions
Neonatal adaptation syndrome was not limited to the first 2 weeks postbirth. The profile of neurobehavioral development was different for SSRI exposure than depression alone. Concomitant benzodiazepine use may exacerbate adverse behavioral effects.
doi:10.1176/appi.ajp.2015.14080989
PMCID: PMC4742381  PMID: 26514656
17.  Understanding Patterns Of High-Cost Health Care Use Across Different Substance User Groups 
Health affairs (Project Hope)  2016;35(1):12-19.
Substance use contributes to significant societal burdens, including high-cost health care use. However, these burdens may vary by type of substance and level of involvement. Using the 2009–13 National Surveys on Drug Use and Health, we examined all-cause hospitalizations and estimated costs across substance use profiles for alcohol, marijuana, and other illicit drugs. For each substance, we characterized differences between abstainers, nondiagnostic users (people who used the substance but did not meet diagnostic criteria for substance use disorder), and people with substance use disorders. In a multivariate analysis, we found that the odds of hospitalization were 16 percent lower for nondiagnostic marijuana users and 11 percent lower for nondiagnostic alcohol users, compared to abstainers. Neither alcohol- nor marijuana-specific substance use disorders were associated with hospitalization. In contrast, substance use disorders for other illicit drugs were strongly associated with hospitalization: People with those disorders had 2.2 times higher odds of hospitalization relative to abstainers. A more detailed understanding of health care use in different substance user groups could inform the ongoing expansion of substance use services in the United States.
doi:10.1377/hlthaff.2015.0618
PMCID: PMC4936480  PMID: 26733696
18.  SBIRT Implementation for Adolescents in Urban Federally Qualified Health Centers 
Background
Alcohol, tobacco, and other drug use remains highly prevalent among US adolescents and is a threat to their well-being and to the public health. Clinical trials and meta-analyses evidence supports the effectiveness of Screening, Brief Intervention and Referral to Treatment (SBIRT) for adolescents with substance misuse but primary care providers have been slow to adopt this evidence-based approach. The purpose of this paper is to describe the theoretically informed methodology of an on-going implementation study.
Methods
This study protocol is a multi-site, cluster randomized trial (N = 7) guided by Proctor’s conceptual model of implementation research and comparing two principal approaches to SBIRT delivery within adolescent medicine: Generalist vs. Specialist. In the Generalist Approach, the primary care provider delivers brief intervention (BI) for substance misuse. In the Specialist Approach, BIs are delivered by behavioral health counselors. The study will also examine the effectiveness of integrating HIV risk screening within an SBIRT model. Implementation Strategies employed include: integrated team development of the service delivery model, modifications to the electronic medical record, regular performance feedback and supervision. Implementation outcomes, include: Acceptability, Appropriateness, Adoption, Feasibility, Fidelity, Costs/Cost-Effectiveness, Penetration, and Sustainability.
Discussion
The study will fill a major gap in scientific knowledge regarding the best SBIRT implementation strategy at a time when SBIRT is poised to be brought to scale under health care reform. It will also provide novel data to inform the expansion of the SBIRT model to address HIV risk behaviors among adolescents. Finally, the study will generate important cost data that offers guidance to policymakers and clinic directors about the adoption of SBIRT in adolescent health care.
doi:10.1016/j.jsat.2015.06.011
PMCID: PMC4548813  PMID: 26297321
implementation; brief intervention; SBIRT; primary care; adolescents
19.  Reference periods in retrospective behavioral self-report: A qualitative investigation 
Background
Self-report questions in substance use research and clinical screening often ask individuals to reflect on behaviors, symptoms, or events over a specified time period. However, there are different ways of phrasing conceptually similar time frames (e.g., past year vs. past 12 months).
Methods
We conducted focused, abbreviated cognitive interviews with a sample of community health center patients (N=50) to learn how they perceived and interpreted questions with alternative phrasing of similar time frames (past year vs. past 12 months; past month vs. past 30 days; past week vs. past 7 days).
Results
Most participants perceived the alternative time frames as identical. However, 28% suggested that the “past year” and “past 12 months” phrasings would elicit different responses by evoking distinct time periods and/or calling for different levels of recall precision. Different start and end dates for “past year” and “past 12 months” were reported by 20% of the sample. There were fewer discrepancies for shorter time frames.
Conclusions
Use of “past 12 months” rather than “past year” as a time frame in self-report questions could yield more precise responses for a substantial minority of adult respondents.
Scientific Significance
Subtle differences in wording of conceptually similar time frames can affect the interpretation of self-report questions and the precision of responses.
doi:10.1111/ajad.12305
PMCID: PMC4902154  PMID: 26541893
20.  Buprenorphine Dose Induction in Non-Opioid-Tolerant Pre-release Prisoners 
Drug and alcohol dependence  2015;156:133-138.
Background
In a previously reported randomized controlled trial, formerly opioid-dependent prisoners were more likely to enter community drug abuse treatment when they were inducted in prison onto buprenorphine/naloxone (hereafter called buprenorphine) than when they received counseling without buprenorphine in prison (47.5% vs. 33.7%, p= 0.012) (Gordon et al., 2014). In this communication we report on the results of the induction schedule and the adverse event profile seen in pre-release prisoners inducted onto buprenorphine.
Method
This paper examines the dose induction procedure, a comparison of the proposed versus actual doses given per week, and side effects reported for 104 adult participants who were randomized to buprenorphine treatment in prison. Self-reported side effects were analyzed using generalized estimated equations to determine changes over time in side effects.
Results
Study participants were inducted onto buprenorphine at a rate faster than the induction schedule. Of the 104 (72 males, 32 females) buprenorphine recipients, 64 (37 males, 27 females) remained on medication at release from prison. Nine participants (8.6%) discontinued buprenorphine because of unpleasant opioid side effects. There were no serious adverse events reported during the in-prison phase of the study. Constipation was the most frequent symptom reported (69 percent).
Conclusion
Our findings suggest that buprenorphine administered to non-opioid-tolerant adults should be started at a lower, individualized dose than customarily used for adults actively using opioids, and that non-opioid-tolerant pre-release prisoners can be successfully inducted onto therapeutic doses prior to release.
doi:10.1016/j.drugalcdep.2015.09.001
PMCID: PMC4633333  PMID: 26409751
Buprenorphine dose; Buprenorphine induction; Opioid-dependent prisoners
21.  Prior experience with non-prescribed buprenorphine: Role in treatment entry and retention 
Buprenorphine availability continues to expand as an effective treatment for opioid dependence, but increases in availability have also been accompanied by increases in non-prescribed use of the medication. Utilizing data from a randomized clinical trial, this mixed-method study examines associations between use of non-prescribed buprenorphine and subsequent treatment entry and retention. Quantitative analyses (N=300 African American buprenorphine patients) found that patients with prior use of non-prescribed buprenorphine had significantly higher odds of remaining in treatment through 6 months than patients who were naïve to the medication upon treatment entry. Qualitative data, collected from a subsample of participants (n=20), identified three thematic explanations for this phenomenon: 1) perceived effectiveness of the medication; 2) cost of obtaining prescription buprenorphine compared to purchasing non-prescribed medication; and 3) convenience of obtaining the medication via daily-dosing or by prescription compared to non-prescribed buprenorphine. These findings suggest a dynamic relationship between non-prescribed buprenorphine use and treatment that indicates potential directions for future research into positive and negative consequences of buprenorphine diversion.
doi:10.1016/j.jsat.2015.04.010
PMCID: PMC4561018  PMID: 25980599
Buprenorphine; Buprenorphine diversion; Treatment retention; Opioid dependence
22.  The Academic Consequences of Marijuana Use during College 
Although several studies have shown that marijuana use can adversely affect academic achievement among adolescents, less research has focused on its impact on post-secondary educational outcomes. This study utilized data from a large longitudinal cohort study of college students to test the direct and indirect effects of marijuana use on college GPA and time to graduation, with skipping class as a mediator of these outcomes. A structural equation model was evaluated taking into account a variety of baseline risk and protective factors (i.e., demographics, college engagement, psychological functioning, alcohol and other drug use) thought to contribute to college academic outcomes. The results showed a significant path from baseline marijuana use frequency to skipping more classes at baseline to lower first-semester GPA to longer time to graduation. Baseline measures of other drug use and alcohol quantity exhibited similar indirect effects on GPA and graduation time. Over time, the rate of change in marijuana use was negatively associated with rate of change in GPA, but did not account for any additional variance in graduation time. Percentage of classes skipped was negatively associated with GPA at baseline and over time. Thus, even accounting for demographics and other factors, marijuana use adversely affected college academic outcomes, both directly and indirectly through poorer class attendance. Results extend prior research by showing that marijuana use during college can be a barrier to academic achievement. Prevention and early intervention might be important components of a comprehensive strategy for promoting post-secondary academic achievement.
doi:10.1037/adb0000108
PMCID: PMC4586361  PMID: 26237288
alcohol; cannabis; educational achievement; GPA; illicit drugs
23.  Risk Factors for Substance Use Among Street Children Entering Treatment in India 
Background:
Although empirical studies have reported on substance use in children in India, multivariable statistical models examining risk factors in children seeking treatment for substance use are largely lacking. The goal of this study was to test a conceptual model predicting age of first use, duration of use of any psychoactive substance, and primary substance of choice from child and family characteristics in a sample of children entering substance use treatment.
Methods:
This was a single-sample cross-sectional study of 159 children entering a treatment and rehabilitation center in Delhi that provides substance use treatment and teaches children the skills to allow for their re-integration into society. De-identified data were extracted from clinical case records. Summary statistics were used to describe the sample characteristics. Regression analyses were used to examine the proposed conceptual model.
Results:
Child's age, schooling, and age at first crime were unrelated to age at first use of a psychoactive substance, duration of use of such substances, or choice of primary substance. However, parental and family factors served as risk factors for predicting one or more of these three outcomes.
Conclusions:
Findings suggest that child psychoactive substance use may have a multidimensional set of possible family and parental origins, and that child factors such as age, education, and age at first crime may play a lesser or insignificant role in a child's psychoactive substance use.
doi:10.4103/0253-7176.191375
PMCID: PMC5052954  PMID: 27833224
Cannabis; India; opium; solvents; street children; substance use treatment
24.  Potential radiating effects of misusing substances among medical patients receiving brief intervention 
Background
The societal benefits of substance use interventions are largely driven not by reducing use per se, but by the broader implications of those reductions. This encompasses “potential radiating effects of misusing substances” (PREMiS) such as utilization of high-cost hospital and emergency care, injury, productivity losses, incarceration, and driving while impaired.
Methods
This study is a secondary analysis from a randomized trial comparing in-person vs. computerized brief intervention among 360 adult community health center patients with moderate-risk illicit drug use (N= 302 with complete data through 12 months of follow-up). This study aims to examine four aspects of PREMiS outcomes in this sample: (1) their frequency; and their association with (2) type of brief intervention received (by random assignment), (3) type of drug misused, and (4) baseline drug problem severity (within the moderate risk range).
Results
12-month prevalence was 18.5% for hospitalization (399 cumulative days), 33.1% for emergency department utilization (166 cumulative visits), 39.1% for injury (1818 injury-days), and 8.3% for incarceration (278 days of detention). There were 729 missed work days among those who reported employment. Fifty percent reported driving under the influence (DUI) of substances. There were no differences in PREMiS outcomes by type of brief intervention. Participants with only marijuana misuse at baseline were not at lower risk of experiencing PREMiS events than participants with other drug misuse. Higher baseline drug problem severity was predictive of future hospitalization (p<.05) and number of hospitalization days (p<.01).
Conclusion
This community health center sample with moderate-risk illicit drug use reported considerable high-cost healthcare utilization, injury, missed work, and DUI. Interventions are needed that can reliably lower risk of negative outcomes among drug users.
doi:10.1016/j.jsat.2015.02.003
PMCID: PMC4456200  PMID: 25812927
primary care; brief intervention; drug misuse; Potential Radiating Effects of Misusing Substances (PREMiS); hospitalization; injury; productivity losses
25.  Pharmacotherapy for opioid dependence in jails and prisons: research review update and future directions 
Purpose
The World Health Organization recommends the initiation of opioid agonists prior to release from incarceration to prevent relapse or overdose. Many countries in the world employ these strategies. This paper considers the evidence to support these recommendations and the factors that have slowed their adoption in the US.
Methods
We reviewed randomized controlled trials (RCTs) and longitudinal/observational studies that examine participant outcomes associated with the initiation or continuation of opioid agonists (methadone, buprenorphine) or antagonists (naltrexone) during incarceration. Papers were identified through a literature search of PubMed with an examination of their references and were included if they reported outcomes for methadone, buprenorphine, or naltrexone continued during incarceration or initiated prior to release in a correctional institution.
Results
Fourteen studies were identified, including eight RCTs and six observational studies. One RCT found that patients treated with methadone who were continued on versus tapered off methadone during brief incarceration were more likely to return to treatment upon release. A second RCT found that the group starting methadone treatment in prison versus a waiting list was less likely to report using heroin and sharing syringes during incarceration. A third RCT found no differences in postrelease heroin use or reincarceration between individuals initiating treatment with methadone versus those initiating treatment with buprenorphine during relatively brief incarcerations. Findings from four additional RCTs indicate that starting opioid agonist treatment during incarceration versus after release was associated with higher rates of entry into community treatment and reduced heroin use. Finally, one pilot RCT showed that providing extended-release naltrexone prior to discharge resulted in significantly lower rates of opioid relapse compared to no medication.
Conclusion
Reasons why uptake of these pharmacotherapies is limited in the US and relatively widespread in Europe are discussed. Recommendations for future research are outlined.
doi:10.2147/SAR.S81602
PMCID: PMC4853155  PMID: 27217808
methadone; buprenorphine; naltrexone; heroin; corrections; incarceration

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