Faculty Bibliography

This study examined commuting patterns among 23,141 methadone patients enrolling in 84 opioid treatment programs (OTPs) in the United States. Patients completed an anonymous one-page survey. A linear mixed model analysis was used to predict distance traveled to the OTP. More than half (60%) the patients traveled < 10 miles and 6% travelled between 50 and 200 miles to attend an OTP; 8% travelled across a state border to attend an OTP. In the multivariate model (n = 17,792), factors significantly (P < .05) associated with distance were, residing in the Southeast or Midwest, low urbanicity, area of the patient's ZIP code, younger age, non-Hispanic white race/ethnicity, prescription opioid abuse, and no heroin use. A significant number of OTP patients travel considerable distances to access treatment. To reduce obstacles to OTP access, policy makers and treatment providers should be alert to patients' commuting patterns and to factors associated with them.

Buprenorphine has rarely been administered as an opioid agonist maintenance therapy in a correctional setting. This study introduced buprenorphine maintenance in a large urban jail, Rikers Island in New York City. Heroin-dependent men not enrolled in community methadone treatment and sentenced to 10-90 days in jail (N=116) were voluntarily randomly assigned either to buprenorphine or methadone maintenance, the latter being the standard of care for eligible inmates at Rikers. Buprenorphine and methadone maintenance completion rates in jail were equally high, but the buprenorphine group reported for their designated post-release treatment in the community significantly more often than did the methadone group (48% vs. 14%, p<.001). Consistent with this result, prior to release from Rikers, buprenorphine patients stated an intention to continue treatment after release more often than did methadone patients (93% vs. 44%, p<.001). Buprenorphine patients were also less likely than methadone patients to withdraw voluntarily from medication while in jail (3% vs. 16%, p<.05). There were no post-release differences between the buprenorphine and methadone groups in self-reported relapse to illicit opioid use, self-reported re-arrests, self-reported severity of crime or re-incarceration in jail. After initiating opioid agonist treatment in jail, continuing buprenorphine maintenance in the community appears to be more acceptable to offenders than continuing methadone maintenance

Given the high prevalence of hepatitis C virus (HCV) infection among drug users, HCV testing is critical in this population. While many drug treatment programs offer HCV testing, patients often do not utilize this essential program-facilitated service. Summarizing date collected in semi-structured interviews and surveys with patients in 25 programs, this paper identifies barriers and facilitators to being tested for HCV through the program. Barriers include the patient's belief that she/he is not HCV infected, fear of needles, fear of obtaining a positive HCV test result, fear of disclosure of such a result, and fear of inappropriate or disrespectful treatment during the testing process. In addition, 38% of HCV sero-unaware or sero-negative patients completing the survey did not know that HCV testing was offered through their programs. Salient facilitators for those tested through their programs include support from staff in explaining the importance of testing and help in understanding and coping with test results.

A multi-state survey of 5663 opioid dependent persons enrolling in 72 methadone maintenance treatment programs (MMTPs) was conducted to determine the prevalence of prescription opioid (PO) abuse, factors associated with PO abuse and sources for POs. Regions where PO abuse was believed to be prevalent were oversampled; primary opioid was defined as the drug used the most before coming to the MMTP. Among primary heroin abusers, 69% reported abusing POs. Opioid abuse frequencies among primary PO abusers were oxycodone (79%), hydrocodone (67%), methadone (40%), morphine (29%), heroin (13%), hydromorphone (16%), fentanyl (9%) and buprenorphine (1%). Correlates (p < or = .01) of PO abuse, using general estimating equations, were: low urbanicity (MMTPs located in comparatively low population density counties), white ethnicity, no history of injecting primary drug, no previous methadone treatment, younger age, chronic pain, and pain as a reason for enrollment. The most frequent sources of POs were dealer, friend or relative, and doctor's prescription; least frequent were Internet and forged prescription. One-third of PO abusers reported a history of injecting their primary drug. PO abuse is highly prevalent among MMTP patients. Future studies should describe HIV/HCV needle injection practices, characteristics that predict treatment outcomes, and factors that contribute to higher prevalence of persistent pain among PO abusers.

Buprenorphine is an efficacious treatment for opioid dependence recently approved for office-based medical practice. The purpose of the study was to describe the background characteristics, treatment process, outcomes and correlates of outcomes for patients receiving buprenorphine maintenance in 'real world' office-based settings in New York City, without employing the many patient exclusion criteria characterizing clinical research studies of buprenorphine, including absence of co-occurring psychiatric and non-opioid substance use disorders. A convenience sample of six physicians completed anonymous chart abstraction forms for all patients who began buprenorphine induction or who transferred to these practices during 2003-2005 (N = 86). The endpoint was the patient's current status or status at discharge from the index practice, presented in an intent-to-treat analysis. The results were: male (74%); median age (38 yrs); White, non-Hispanic (82%); employed full-time, (58%); HCV+ (15%); substance use at intake: prescription opioids (50%), heroin (35%), non-opioids (49%); median length of treatment (8 months); median maintenance dose (15 mg/day); prescribed psychiatric medication (63%). The most frequent psychiatric disorders were: major depression, obsessive-compulsive and other anxiety, bipolar. At the endpoint: retained in the index practice (55%); transferred to other buprenorphine practice (6%); transferred to other treatment (7%); lost to contact or out of any treatment (32%). Outcomes were positive, in that 2/3 of patients remained in the index practice or transferred to other treatment. Patients living in their own home or misusing prescription opioids (rather than heroin) were more likely, and those employed part-time were less likely, to be retained in the index practice. At the endpoint, 24% of patients were misusing drugs or alcohol. Co-occurring psychiatric disorders and polysubstance abuse at intake were common, but received clinical attention, which may explain why their effect on outcomes was minimal

This cross-sectional study reports the prevalence and correlates of posttraumatic stress disorder (PTSD) and chronic severe pain in psychiatric outpatients (n = 295), a sample that has not previously been examined for the co-occurrence of these two disorders. Nearly half the participants (46%) met the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition criteria for PTSD; 40% reported chronic severe pain; and 24% had both disorders. We compared four groups of subjects who had either both disorders, PTSD only, chronic severe pain only, or neither disorder for variables previously found to be associated with both disorders or either disorder alone (e.g., psychiatric distress, substance use, stressful life events, physical/sexual abuse). Multiple pairwise comparisons indicated that persons with both disorders were significantly different from persons with neither disorder for all dependent variables and that they had greater physical and psychosocial stressors. Persons with either PTSD or chronic severe pain alone were more likely to have a chronic medical condition, higher ratings of psychiatric distress, and more stressful life events than persons with neither disorder. Mental health treatment providers should be aware of the potential for the co-occurrence of PTSD and chronic severe pain and of the many related factors in psychiatric outpatients.

Adult substance users are known to have above average rates of Attention Deficit-Hyperactivity Disorder (ADHD), but the psychometric properties of self-report measures of ADHD symptoms for adult substance users are unknown. Subjects (206 adults with a DSM-IV substance abuse disorder) were administered the Conners Adult ADHD Rating Scales (CAARS) upon enrolling in outpatient treatment. A factor structure similar to that reported for other populations was obtained and internal consistency reliabilities for the subscales and the overall index were high. Compared with CAARS norms, substance users scored significantly above average on all subscales as well as on the overall index. The CAARS may prove useful for measuring ADHD symptomatology among substance users, but additional reliability and validity evidence is needed. The CAARS should not be used by itself to diagnose individuals for ADHD.

It is important to identify social conditions, program factors, and client characteristics that predict retention because time in substance abuse treatment is associated with improved health, mood, and social functioning. Treatment dropouts also are at high risk for serious harms, including relapse. Most opioid-dependent persons require long-term stabilization in methadone maintenance treatment (MMT) to normalize brain function and control withdrawal symptoms. The purpose of this study was to determine whether a client characteristic, namely, attitude toward methadone, was related to retention. Analysis of 14 opinion statements about methadone identified a reliable five-item scale with factorial validity. This scale (Opinions About Methadone; OAM-5) also predicted retention in MMT. Of 338 clients followed for one year after MMT enrollment, 48% dropped out of treatment; those who were more likely to remain had more favorable opinions. A supplementary qualitative study with MMT counselors demonstrated face validity for the OAM-5; counselors found the items easy to interpret and relevant to client attitudes towards MMT. The findings suggest that it would be worthwhile for MMT staff to assess client attitudes at intake, using the OAM-5. This would help them to identify and intervene promptly with those in greatest need of support for remaining in treatment.

Based on the high rates of injection drug use and infectious disease such as HIV, HCV and tuberculosis in their home country, immigrants from the Former Soviet Union (FSU) comprise a high-risk population in the United States. Yet, little is known about their drug abuse and health problems relative to other immigrant populations like Hispanics. The objectives of this exploratory study were to identify disease risk behavior, and utilization of and barriers to treatment services among drug using immigrants from the FSU. Focused interviews were conducted with 27 public officials and administrators in New York City. This study found that FSU immigrants tend to have culturally unique drug abuse patterns and behavior, such as rapid transition to injection drug use, and suspicion and avoidance of traditional drug treatment approaches. The findings of this exploratory study point to the need for further research and the need to take immediate steps to promote culturally appropriate treatment and prevention services that can address the spread of harmful behavior that threatens the public health of FSU immigrants and others.