Employment-based reinforcement interventions have been used to promote abstinence from drugs among chronically unemployed injection drug users. The current study utilized an employment-based reinforcement intervention to promote opiate and cocaine abstinence among opioid-dependent, HIV-positive participants who had recently completed a brief inpatient detoxification. Participants (n=46) were randomly assigned to an Abstinence & Work group that was required to provide negative urine samples in order to enter the workplace and earn incentives for work (n=16), a Work Only group that was permitted to enter the workplace and earn incentives independent of drug use (n=15), and a No Voucher control group that did not receive any incentives for working (n=15) over a 26-week period. The primary outcome was urinalysis-confirmed opiate, cocaine, and combined opiate/cocaine abstinence. Participants were 78% male and 89% African American. Results showed no significant between-group differences in urinalysis-verified drug abstinence or HIV risk behaviors during the 6-month intervention. The Work Only group had significantly greater workplace attendance and worked more minutes per day when compared to the No Voucher group. Several features of the study design, including the lack of an induction period, setting the threshold for entering the workplace too high by requiring immediate abstinence from several drugs, and increasing the risk of relapse by providing a brief detoxification that was not supported by any continued pharmacological intervention, likely prevented the workplace from becoming established as a reinforcer that could be used to promote drug abstinence. However, increases in workplace attendance have important implications for adult training programs.
HIV; contingency management; therapeutic workplace; incentive; injection drug use
Electronic screening and brief intervention (e-SBI) approaches for substance use have shown early promise. This trial was designed to replicate previous findings from a single 20-minute e-SBI for drug use among postpartum women. A total of 143 postpartum, primarily low-income African-American women meeting criteria for drug use, were randomly assigned to either a tailored e-SBI or a time-matched control condition. Blinded follow-up evaluation 3- and 6-months following childbirth revealed strong effects for confirmed illicit drug use abstinence at the 3-month observation (OR = 3.3, p = .01), as did hair analysis at 6 months (OR = 4.8, p = .018). Additional primary outcomes suggested small to moderate effect sizes in favor of the e-SBI, but did not reach significance. This result replicates previous findings but fails to show durable effects. Assessment reactivity, e-SBI design, and possible extension of e-SBI via tailored messaging all merit careful consideration.
Pregnancy; drug abuse screening; brief intervention; drug users; motivation; computers
Although women with Substance Use Disorders (SUD) have high rates of trauma and post-traumatic stress, many addiction programs do not offer trauma-specific treatments. One promising intervention is Pennebaker’s expressive writing, which involves daily, 20-minute writing sessions to facilitate disclosure of stressful experiences.
Women (N = 149) in residential treatment completed a randomized clinical trial comparing expressive writing to control writing. Repeated measures analysis of variance was used to document change in psychological and physical distress from baseline to 2-week and 1-month follow-ups. Analyses also examined immediate levels of negative affect following expressive writing.
Expressive writing participants showed greater reductions in post-traumatic symptom severity, depression, and anxiety scores, when compared to control writing participants at the 2-week follow-up. No group differences were found at the 1-month follow-up. Safety data were encouraging; while expressive writing participants showed increased negative affect immediately after each writing session, there were no differences in pre-writing negative affect scores between conditions the following day. By the final writing session, participants were able to write about traumatic/stressful events without having a spike in negative affect.
Results suggest expressive writing may be a brief, safe, low cost, adjunct to SUD treatment that warrants further study as a strategy for addressing post-traumatic distress in substance-abusing women.
Substance Abuse; Trauma; Expressive Writing
Poor pregnancy and birth outcomes are major problems in the United States, and maternal smoking during pregnancy has been identified as one of the most preventable risk factors associated with these outcomes. This study examines less explored risk factors of smoking among underserved African American pregnant women.
A cross-sectional survey was conducted at an outpatient obstetrics-gynecology clinic of an inner-city university hospital in Virginia from March 2009 through January 2011 in which pregnant women (N=902) were interviewed at their first prenatal care visit. Survey questions included items related to women’s sociodemographic characteristics as well as their pregnancy history; criminal history; receipt of social services; child protective services involvement; insurance status; and history of substance abuse, domestic violence, and depression. Multiple logistic regression was conducted to calculate odds ratios and 95% confidence intervals depicting the relationship between these factors and smoking during pregnancy.
The analysis reported that maternal age [OR= 1.08, 95%CI=1.05–1.12], less than high school education [OR=4.30, 95%CI=2.27–8.14], unemployed [OR=2.33, 95%CI=1.35–4.04], criminal history [OR=1.66, 95%CI=1.05–2.63], receipt of social services [OR=2.26, 95%CI=1.35–3.79] alcohol use [OR=2.73, 95%CI=1.65–4.51] and illicit drug use [OR=1.97, 95%CI=1.04–3.74] during pregnancy were statistically significant risk factors associated with smoking during pregnancy.
In addition to the well known risk factors, public health professionals should be aware that criminal history and receipt of social services are important factors associated with smoking during pregnancy. Social service providers such as WIC and prisons and jails may offer a unique opportunity for education and cessation interventions during the preconception or interconception period.
Smoking during pregnancy; Correlates of smoking; Criminal history; Social Services; Preconception health
This study examined the ability of the Drug Abuse Screening Test (DAST-10) to identify prenatal drug use using hair and urine samples as criterion variables. In addition, this study was the first to use “best practices,” such as anonymity, ACASI technology, and a written screener, to facilitate disclosure in this vulnerable population. 300 low-income, post-partum women (90.3% African-American) were recruited from their hospital rooms after giving birth. Participation involved (a) completing a computerized assessment battery that contained the DAST-10 and (b) providing urine and hair samples. Twenty-four percent of the sample had a positive drug screen. The sensitivity of the DAST-10 was only .47. Nineteen percent of the sample had a positive toxicology screen but denied drug use on the DAST-10. Findings suggest that brief drug use screeners may have limited utility for pregnant women and that efforts to facilitate disclosure via reassurance and anonymity are unlikely to be sufficient in this population.
DAST-10; pregnancy; drug use; screening
This study sought to develop and begin validation of an indirect screener for identification of drug use during pregnancy, without reliance on direct disclosure.
Women were recruited from their hospital rooms after giving birth. Participation involved (a) completing a computerized assessment battery containing three types of items: direct (asking directly about drug use), semi-indirect (asking only about drug use prior to pregnancy) and indirect (with no mention of drug use), and (b) providing urine and hair samples. An optimal subset of indirect items was developed and cross-validated based on ability to predict urine/hair test results.
Obstetric unit of a university-affiliated hospital in Detroit.
400 low-income, African American, post-partum women (300 in the developmental sample and 100 in the cross-validation sample); all available women were recruited without consideration of substance abuse risk or other characteristics.
Women first completed the series of direct and indirect items using a Tablet PC; they were then asked for separate consent to obtain urine and hair samples that were tested for evidence of illicit drug use.
In the cross-validation sample, the brief screener consisting of 6 indirect items predicted toxicology results more accurately than direct questions about drug use (area under the ROC curve = .74, p < .001). Traditional direct screening questions were highly specific but identified only a small minority of women who used drugs during the last trimester of pregnancy.
Indirect screening may increase the accuracy of mothers’ self-reports of prenatal drug use.
Computer-based brief motivational interventions may be able to reach a high proportion of at-risk individuals and thus have potential for significant population impact. The present studies were conducted to determine the acceptability and preliminary efficacy of a computer-based brief motivational intervention (the motivation enhancement system, or MES). In Study 1, quantitative and qualitative feedback from 30 postpartum women and 17 women in treatment for drug use were used to modify the software. In Study 2, 50 urban postpartum women who reported drug use in the month before pregnancy completed the intervention and provided repeated within-session ratings of state motivation. In Study 3, 30 women were randomly assigned to intervention or control conditions with 1-month follow-up. Overall, women rated the MES as highly acceptable and easy to use and reported significant increases in state motivation at postintervention and at 1-month follow-up (d = .49). These preliminary results are encouraging and suggest that further work in this area is warranted.
Drugs; Computer-based; Perinatal; Motivation; Brief intervention
To examine the relative prevalence of marijuana and tobacco use among low-income post-partum women, using self-report, urine, and hair testing data; and to further explore perceptions of the substances among postpartum women by evaluating perceived risk and monetary cost of prenatal marijuana versus tobacco use.
Data from two studies were available for a total of 100 (Study 1) and 50 (Study 2) low-income, primarily African-American post-partum women. Study 1 participants completed brief self-report measures of substance use as well as urine and hair samples; study 2 participants completed a brief opinion survey regarding the risks and monetary costs of prenatal marijuana use.
In Study 1, the self-reported prevalence of any tobacco or marijuana use in the past three months was 17% and 11%, respectively. However, objectively-defined marijuana use was more prevalent than self-reported tobacco use: 14% tested positive for marijuana by urinalysis, and 28% by hair analysis. Study 2 participants were more likely to believe that there is a safe level of marijuana use during pregnancy, and nearly half believed that using marijuana during pregnancy was less expensive than smoking cigarettes.
Marijuana use may be as or more prevalent than tobacco use among low-income, African-American pregnant women. These findings may in part be attributable to perceptions of roughly equivalent cost and the lack of a clear public health message regarding prenatal marijuana use, combined with growing pro-marijuana advocacy. A broader public health response to address prenatal marijuana use, along with other substances of abuse, is needed.
Substance use; Marijuana; Tobacco; Pregnancy; Public health policy
Posttraumatic stress disorder (PTSD) and other Axis I comorbidity among women with substance use disorders (SUD) appear similarly prevalent and are associated with comparable negative clinical profiles and treatment outcomes. The relative contribution of comorbid PTSD versus other Axis I psychiatric disorders to clinical characteristics is largely unexamined, however, despite theory and empirical data indicating that PTSD and substance use disorders may have a unique relationship that confers specific risk for clinical severity and poor treatment outcome. In a sample of pregnant, opioid and/or cocaine dependent women entering substance abuse treatment, women with PTSD (SUD-PTSD; n=23) were compared to those with other Axis I comorbidity (SUD-PSY; n=45) and those without Axis I comorbidity (SUD-Only; n=37). Data were collected via face-to-face interviews and urinalysis drug assays. While the study groups had similar substance use severity, the SUD-PTSD group was more likely to report suicidality, aggression and psychosocial impairment than both the SUD-PSY and SUD-Only groups. Findings indicate treatment considerations for substance dependent women with PTSD are broader and more severe than those with other Axis I conditions or substance dependence alone.
posttraumatic stress disorder; women; substance use disorders; dual diagnosis; treatment indicators
Implementation of evidence-based interventions for smoking during pregnancy is challenging. We developed 2 highly replicable interventions for smoking during pregnancy: (a) a computer-delivered 5As-based brief intervention (CD-5As) and (b) a computer-assisted, simplified, and low-intensity contingency management (CM-Lite).
A sample of 110 primarily Black pregnant women reporting smoking in the past week were recruited from prenatal care clinics and randomly assigned to CD-5As (n = 26), CM-Lite (n = 28), CD-5As plus CM-Lite (n = 30), or treatment as usual (n = 26). Self-report of smoking, urine cotinine, and breath CO were measured 10 weeks following randomization.
Participants rated both interventions highly (e.g., 87.5% of CD-5As participants reported increases in likelihood of quitting), but most CM-Lite participants did not initiate reinforcement sessions and did not show increased abstinence. CD-5As led to increased abstinence as measured by cotinine (43.5% cotinine negative vs. 17.4%; odds ratio [OR] = 10.1, p = .02) but not for CO-confirmed 7-day point prevalence (30.4% abstinent vs. 8.7%; OR = 5.7, p = .06). Collapsing across CM-Lite status, participants receiving the CD-5As intervention were more likely to talk to a doctor or nurse about their smoking (60.5% vs. 30.8%; OR = 3.0, p = .02).
Low-intensity participant-initiated CM did not affect smoking in this sample, but the CD-5As intervention was successful in increasing abstinence during pregnancy. Further research should seek to replicate these results in larger and more diverse samples. Should CD-5As continue to prove efficacious, it could greatly increase the proportion of pregnant smokers who receive an evidence-based brief intervention.
Striking racial disparities in infant mortality exist in the United States, with rates of infant death among African Americans (AA) nearly twice the national average. Community-based participatory research (CBPR) approaches have been successful in fostering collaborative relationships between communities and researchers focused on developing effective and sustainable interventions and programs targeting needs of the community. The current paper details use of the Perinatal Period of Risk (PPOR) model as a method to engage communities by identifying factors influencing racial disparities in infant mortality and examining changes in those factors over a ten year period.
Infant Mortality; Perinatal Periods of Risk; Community Based Participatory Research
Unemployment is associated with negative outcomes both during and after drug abuse treatment. Interventions designed to increase rates of employment may also improve drug abuse treatment outcomes. The purpose of this multi-site clinical trial was to evaluate the Job Seekers’ Workshop (JSW), a three session, manualized program designed to train patients in the skills needed to find and secure a job.
Study participants were recruited through the NIDA Clinical Trials Network (CTN) from six psychosocial counseling (n=327) and five methadone maintenance (n=301) drug treatment programs. Participants were randomly assigned to either standard care (program-specific services plus brochure with local employment resources) (SC) or standard care plus JSW. Three 4-hr small group JSW sessions were offered weekly by trained JSW facilitators with ongoing fidelity monitoring.
JSW and SC participants had similar 12- and 24-week results for the primary outcome measure (i.e., obtaining a new taxed job or enrollment in a training program), Specifically, one-fifth of participants at 12 weeks (20.1 – 24.3%) and nearly one-third at 24 weeks (31.4–31.9%) had positive outcomes, with “obtaining a new taxed job” accounting for the majority of cases.
JSW group participants did not have higher rates of employment/training than SC controls. Rates of job acquisition were modest for both groups, suggesting more intensive interventions may be needed. Alternate targets (e.g., enhancing patient motivation, training in job-specific skills) warrant further study as well.
Substance Use Disorders; Vocational Rehabilitation; Treatment; Translational Research; Employment
Alcohol and drug dependent women are at increased risk for HIV/STDs. This paper discusses how a prevention curriculum, “Safer Sex Skill Building” (SSB), designed to reduce the contraction of HIV/STDs among drug-abusing women, could be modified to fit the needs of alcohol-abusing women in a residential treatment program. Authors modified the SSB by incorporating feedback from expert consultants as well as by engaging study participants in revising the therapy manual in order to create a curriculum that speaks to participants’ experiences. Specific steps to assist those who would want to adapt an empirically-based manual-driven treatment intervention are provided.
HIV/STDs prevention curriculum; sexual risk behaviors; women; alcohol problems; curriculum adaptation
Aims: To assess the efficacy of the Therapeutic Workplace, a substance abuse intervention that promotes abstinence while simultaneously addressing the issues of poverty and lack of job skills, in promoting abstinence from alcohol among homeless alcoholics. Methods: Participants (n = 124) were randomly assigned to conditions either requiring abstinence from alcohol to engage in paid job skills training (Contingent Paid Training group), offering paid job skills training with no abstinence contingencies (Paid Training group) or offering unpaid job skill training with no abstinence contingencies (Unpaid Training group). Results: Participants in the Contingent Paid Training group had significantly fewer positive (blood alcohol level ≥ 0.004 g/dl) breath samples than the Paid Training group in both randomly scheduled breath samples collected in the community and breath samples collected during monthly assessments. The breath sample results from the Unpaid Training group were similar in absolute terms to the Contingent Paid Training group, which may have been influenced by a lower breath sample collection rate in this group and fewer reported drinks per day consumed at intake. Conclusion: Overall, the results support the utility of the Therapeutic Workplace intervention to promote abstinence from alcohol among homeless alcoholics, and support paid training as a way of increasing engagement in training programs.
This paper has two aims. First, we provide an overview of the potential of technology in the area of brief interventions for substance use, and describe recent projects from our lab that are illustrative of that potential. Second, we present data from a study of during-session predictors of brief intervention response. In a sample of post-partum women (N = 39), several variables showed promise as predictors of later drug use, and a brief index derived from them predicted abstinence with a sensitivity of .7 and a specificity of .89. This promising approach and initial study findings support the importance of future research in this area.
Pregnancy; substance abuse; motivational interviewing; technology; prediction
The current retrospective study compared the psychiatric and lifestyle characteristics of two groups of treatment-seeking pregnant, opiate and/or cocaine dependent women admitted to the Center for Addiction and Pregnancy (CAP). Women reporting past and/or current suicidal ideation (SI) (46%; n = 35) were compared to women who did not report thoughts of suicidal ideation (NSI) (54%; n = 41). SI women were more likely to be homeless (p = .020), to report histories of emotional (p = .022), physical (p < 001), sexual abuse (p = .002) and psychiatric treatment (p < .001), and less likely to be married (p = .024) than NSI women. Psychiatrically, SI women were more likely to have co-morbid current and lifetime disorders than NSI women. These findings highlight the need to identify women with histories of suicidal ideation, recognize the potential relapse risk imposed by emotional distress, and confront these issues in treatment.
Drug abuse; pregnancy; suicide; treatment; gender
This study examined the sociodemographic and practice characteristics of psychiatrists whose caseloads consist primarily of patients with Substance Use Disorders (SUD). A. survey instrument was completed by a random sample of 865 psychiatrists. Study groups were defined as high-SUD providers if psychiatrists reported having 51% or more patients with SUD (n = 92) and non-SUD providers as those who reported not having any patients with SUD (n = 128). High-SUD providers tended to be younger, more likely to graduate from international medical schools, have larger caseloads, work more hours per week, and have a higher proportion of inpatients and publicly funded patients than non-SUD providers. Results suggest that psychiatrists who primarily treat patients with SUD are in their early careers and treat patients with more clinical, psychosocial, and economic disadvantages. The implications of these findings for psychiatry training programs and policy makers will be discussed.
Several instruments for diagnosing substance use disorders (SUD) have been developed, but to date none has emerged as the standard for community-based clinical studies. To select the most suitable SUD diagnostic instrument for its clinical trials, the National Drug Abuse Treatment Clinical Trials Network (CTN) implemented a procedure in which 36 university-based addiction researchers and 62 community-based addiction treatment providers evaluated and ranked five widely recognized diagnostic instruments: (1) the SUD section of the Structured Clinical Interview for DSM-IV (SCID); (2) the SUD section of the Composite International Diagnostic Interview, 2nd ed. (CIDI-2); (3) the SUD section of the Diagnostic Interview Schedule for DSM-IV Diagnosis (DIS-IV); (4) the Diagnostic Statistical Manual-IV Checklist (DSM-IV Checklist); and (5) the Substance Dependence Severity Scale (SDSS). To assist the evaluation and ranking process, key characteristics of each instrument were presented in tabular and narrative formats. Participants ranked each instrument from 1 (most preferred) to 5 (least preferred). The SCID received the best overall mean score (2.24) followed by the CIDI-2 (2.59), DIS (2.94), DSM Checklist (3.40) and the SDSS (3.83). After discussing the pragmatic and scientific advantages and disadvantages of each instrument, the CTN Steering Committee selected the CIDI-2. The selection of the CIDI-2 standardizes the collection of diagnostic data and provides a common diagnostic tool for practitioners and clinical researchers in the CTN. Implications for practice/research collaboration and initiatives are explored.
Substance use disorder; Assessment; Diagnosis; Clinical trials
The aim of this study is to assess the rates of nicotine problems diagnosed by psychiatrists, the characteristics of psychiatric patients who smoke, and the services provided to them in routine psychiatric practice. Data were obtained by asking psychiatrists participating in the American Psychiatric Institute for Psychiatric Research and Education’s Practice Research Network to complete a self-administered questionnaire to provide detailed sociodemographic, clinical, and health plan information on three of their patients seen during routine clinical practice. A total of 615 psychiatrists provided information on 1,843 patients, of which 280 (16.6%) were reported to have a current nicotine problem. Of these, 9.1% were reported to receive treatment for nicotine dependence. Patients with nicotine problems were significantly more likely to be males, divorced or separated, disabled, and uninsured, and have fewer years 20 of education. They also had significantly more co-morbid psychiatric disorders, particularly schizophrenia or alcohol=substance use disorders; a lower Global Assessment Functioning score; and poorer treatment compliance than their counterparts. The results suggest a very low rate of identification and treatment of nicotine problems among patients treated by psychiatrists, even though psychiatric patients who smoke seem to have more clinical and psychosocial stressors and more severe psychiatric problems than those who do not smoke. Programs should be developed to raise the awareness and ability of psychiatrists to diagnose and treat patients with nicotine problems, with a particular emphasis on the increased medical and psychosocial needs of psychiatric patients who smoke.
This study examined the prevalence of exposure to violence among drug-dependent pregnant women attending a multidisciplinary perinatal substance abuse treatment program. Participants (N = 715) completed the Violence Exposure Questionnaire within 7 days after their admission to the program. Their rates of lifetime abuse ranged from 72.7% for physical abuse to 71.3% for emotional abuse to 44.5% for sexual abuse. Their rates of abuse remained high during their current pregnancy, ranging from 40.9% for emotional abuse to 20.0% for physical abuse to 7.1% for sexual abuse. Nearly one third of the women reported having physical fights with their current partner (lifetime), and 25% of these women reported that children were present during those physical fights. A total of 30% of the women perceived a need for counseling regarding exposure to violence for themselves and 15% perceived a need for counseling for their children. Study findings confirm previous reports of high rates of abuse and violence exposure among substance-abusing pregnant women and their strong need for counseling for psychosocial sequelae. This study affirmed the value of routine screening for violence exposure in this at-risk population as well as the need to train therapists in specific strategies for helping such women address this complex array of problems.
Violence; Sexual/physical/emotional abuse; Pregnancy; Women; Drug dependence; Children
This study examines clinical and non-clinical factors associated with treatment compliance problems in 342 patients with substance use disorders (SUD) seen in routine psychiatric practice. Weighted Wald-X2 and multivariate logistic regression assessed sociodemographic, clinical, treatment, and health plan characteristics associated with treatment compliance problems. Among patients with SUD, 40.5% were reported to currently have treatment compliance problems. Patients with treatment compliance problems were significantly more likely to have personality disorders, lower global assessment of functioning scores, and medication side effects than those without treatment compliance problems. Patients seen by psychiatrists who were reimbursed by discounted rather than undiscounted fee-for-service were five times more likely to be reported to have treatment compliance problems. Both clinical and non-clinical factors appear to be associated with treatment compliance problems. Understanding these factors and targeting treatment interventions may improve treatment compliance and patient outcomes.
Drug use among parenting women is a significant risk factor for a range of negative child outcomes, including exposure to violence, child maltreatment, and child behavior problems. Implementation of brief interventions with this population may be greatly facilitated by computer-based interventions.
Randomized clinical trial with 4-month follow-up.
Participants were 107 postpartum women recruited from an urban obstetric hospital primarily serving a low-income population. Women were randomized into assessment only versus assessment plus brief intervention conditions; 76 (71%) returned for follow-up evaluation.
A 20-minute, single-session computer-based brief motivational intervention (based on Motivational Interviewing methods) combined with two nontailored mailings and voucher-based reinforcement of attendance at an initial intake/treatment session.
Main outcome measures
Illicit drug use as measured by qualitative urinalysis and self-report.
Frequency of illicit drug use other than marijuana increased slightly for the control group, but declined among intervention group participants (p <0.05, between-groups Mann-Whitney U; d = 0.50); the magnitude of intervention effects on changes in marijuana use frequency was similar, but did not reach statistical significance. Point-prevalence analysis at follow-up did not show significant group differences in drug use. However, trends under a range of assumptions regarding participants lost to follow-up all favored the intervention group, with most effect sizes in the moderate range (ORs 1.4 to 4.7).
Results tentatively support the efficacy of this high-reach, replicable brief intervention. Further research should seek to replicate these findings and to further develop the computer as a platform for validated brief interventions.