Faculty Bibliography

INTRODUCTION: Screening and delivery of evidence-based interventions by dentists is an effective way to reduce tobacco use. However, dental visits remain an underutilized opportunity for the treatment of tobacco dependence. This is, in part, because the current reimbursement structure does not support expansion of dental providers' role in this arena. The purpose of this study was to interview dental insurers to assess attitudes toward tobacco use treatment in dental practice, pros and cons of offering dental provider reimbursement, and barriers to instituting a tobacco use treatment-related payment policy for dental providers. METHODS: Semi-structured interviews were conducted with 11 dental insurance company executives. Participants were identified using a targeted sampling method and represented viewpoints from a significant share of companies within the dental insurance industry. RESULTS: All insurers believed that screening and intervention for tobacco use was an appropriate part of routine care during a dental visit. Several indicated a need for more evidence of clinical and cost-effectiveness before reimbursement for these services could be actualized. Lack of purchaser demand, questionable returns on investment, and segregation of the medical and dental insurance markets were cited as additional barriers to coverage. Conclusions: Dissemination of findings on efficacy and additional research on financial returns could help to promote uptake of coverage by insurers. Wider issues of integration between dental and medical care and payment systems must be addressed in order to expand opportunities for preventive services in dental care settings.

BACKGROUND: In opioid dependent youth there is substantial attrition from medication-assisted treatment. If youth at risk for attrition can be identified at treatment entry or early in treatment, they can be targeted for interventions to help retain them in treatment. METHODS: Opioid dependent adolescents and young adults (n=152), aged 15-21, were randomized to 12 weeks (BUP, n=74) or 2 weeks of detoxification (DETOX, n=78) with buprenorphine/naloxone (Bup/Nal), both in combination with 12 weeks of psychosocial treatment. Baseline and early treatment related predictors of treatment attrition were identified in each group using bivariate and multivariate logistic regression. RESULTS: In the DETOX group 36% left between weeks 2 and 4, at the end of the dose taper, while in the BUP group only 8% left by week 4. In the BUP group, early adherence to Bup/Nal, early opioid negative urines, use of any medications in the month prior to treatment entry, and lifetime non-heroin opioid use were associated with retention while prior 30-day hallucinogen use was associated with attrition. In the DETOX group, only use of sleep medications was associated with retention although not an independent predictor. A broad range of other pre-treatment characteristics was unrelated to attrition. CONCLUSIONS: Prompt attention to those with early non-adherence to medication or an early opioid positive urine, markers available in the first 2 weeks of treatment, may improve treatment retention. Extended Bup/Nal treatment appeared effective in improving treatment retention for youth with opioid dependence across a wide range of demographics, and pre-treatment clinical characteristics.

BACKGROUND: Screening, brief intervention, and referral to treatment (SBIRT) approaches to reducing hazardous alcohol and illicit drug use have been assessed in a variety of health care settings, including primary care, trauma centers, and emergency departments. A major methodological concern in these trials, however, is "assessment reactivity," the hypothesized impact of intensive research assessments to reduce alcohol and drug use and thus mask the purported efficacy of the interventions under scrutiny. Thus, it has been recommended that prospective research designs take assessment reactivity into account. The present article describes the design of the National Institute on Drug Abuse Clinical Trials Network protocol, Screening, Motivational Assessment, Referral, and Treatment in Emergency Departments (SMART-ED), which addresses the potential bias of assessment reactivity. METHODS/DESIGN: The protocol employs a 3-arm design. Following an initial brief screening, individuals identified as positive cases are consented, asked to provide demographic and locator information, and randomly assigned to one of the three conditions: minimal screening only, screening + assessment, or screening + assessment + brief intervention. In a two-stage process, the randomization procedure first reveals whether or not the participant will be in the minimal-screening-only condition. Participants in the other two groups receive a more extensive baseline assessment before it is revealed whether they have been randomized to also receive a brief intervention. Comparing the screening only and screening + assessment conditions will allow determination of the incremental effect of assessment reactivity. DISCUSSION: Assessment reactivity is a potential source of bias that may reduce and/or lead to an underestimation of the purported effectiveness of brief interventions. From a methodological perspective, it needs to be accounted for in research designs. The SMART-ED design offers an approach to minimize assessment reactivity as a potential source of bias. Elucidating the role of assessment reactivity may offer insights into the mechanisms underlying SBIRT as well as suggest clinical options incorporating assessment reactivity as a treatment adjunct. CLINICALTRIALS.GOV IDENTIFIER: NCT01207791.

ABSTRACT: Psychosis and substance abuse are intimately related. Psychotic spectrum illnesses commonly co-occur with substance use disorders (SUDs), and many substances of abuse can cause or exacerbate psychotic symptoms along a temporal spectrum from acute to chronic presentations. Despite the common co-occurrence between psychotic spectrum illnesses and SUDs, they are often under-recognized and undertreated, leading to poor treatment outcomes. Accurate detection and diagnosis of individuals with psychotic illness co-occurring with addictive disorders is key to properly treat such disorders. This article will review the nature of the relationship between psychosis and substance abuse by examining prevalence rates of each disorder alone and their rates of co-occurrence, the neurobiological basis for substance abuse comorbidity in schizophrenia spectrum disorders, key and salient aspects related to accurate diagnosis along a continuum from acute to subacute to chronic conditions, and pitfalls associated with diagnostic dilemmas. A case example will be used to highlight key points related to diagnostic challenges.

In a randomized clinical pilot study, 40 concerned significant others (CSOs) of treatment-refusing alcohol- and drug-using individuals were randomized to either Community Reinforcement and Family Training (CRAFT) conducted in a group format (Group CRAFT) or a Self-Directed CRAFT condition. Although results indicated no significant between-group difference in engaging treatment-refusing substance-using individuals (referred to as identified patients or IPs) into treatment, the engagement rate in Group CRAFT was similar to rates previously reported with individual CRAFT. For the intent-to-treat analysis, 60% of Group CRAFT CSOs engaged their loved one into treatment, as compared with 40% in Self-Directed CRAFT. Of CSOs in the Group condition who received at least one session of group therapy, 71% engaged their IP into treatment. CSOs in both conditions reported improvements in family cohesion and conflict at the 3- and 6-month follow-up, replicating prior CRAFT findings.

OBJECTIVES: To determine support of in-pharmacy human immunodeficiency virus (HIV) testing among pharmacy staff and the individual-level characteristics associated with in-pharmacy HIV testing support. DESIGN: Descriptive, nonexperimental, cross-sectional study. SETTING: New York City (NYC) from January 2008 to March 2009. PARTICIPANTS: 480 pharmacy staff, including pharmacists, owners/managers, and technicians/clerks. INTERVENTION: 131 pharmacies registered in the Expanded Syringe Access Program (ESAP) completed a survey. MAIN OUTCOME MEASURE: Support of in-pharmacy HIV testing. RESULTS: Support of in-pharmacy HIV testing is high among pharmacy staff (79.4%). Pharmacy staff who supported in-pharmacy vaccinations were significantly more likely to support in-pharmacy HIV testing. Pharmacy staff who thought that selling syringes to injection drug users (IDUs) caused the community to be littered with dirty syringes were significantly less likely to support in-pharmacy HIV testing. CONCLUSION: Support for in-pharmacy HIV testing was high among our sample of ESAP pharmacy staff actively involved in nonprescription syringe sales. These findings suggest that active ESAP pharmacy staff may be amenable to providing HIV counseling and testing to IDUs and warrants further investigation.

RATIONALE: Previous studies indicate that the rewarding effect of D-1 dopamine receptor stimulation in nucleus accumbens (NAc) shell is greater in food-restricted (FR) than in ad libitum fed (AL) rats. The D-1 receptor is positively coupled to adenylyl cyclase and activates protein kinase A (PKA). OBJECTIVES: The purpose of this study was to determine whether PKA is involved in the rewarding effect of D-1 receptor stimulation and, if so, whether it is involved in the enhanced response of FR rats. MATERIALS AND METHODS: Rats were stereotaxically implanted with microinjection cannulae in NAc shell and a stimulating electrode in lateral hypothalamus. The rewarding effects of SKF-82958 (1.5 or 3.0 mug, bilaterally) in the presence and absence of PKA inhibitor, Rp-cAMPS (8.9 mug), and PKA activator, Sp-cAMPS (8.9 mug), were assessed using the curve-shift method of intracranial self-stimulation (ICSS). Basal NAc levels of DARPP-32 phosphorylated on Thr34 and Thr75 were measured. RESULTS: Rp-cAMPS increased the rewarding effect of SKF-82958 in AL but not FR rats, doubling the ICSS threshold-lowering effect of the 3.0-mug dose. Sp-cAMPS decreased the rewarding effect of SKF-82958 in FR but not AL rats. Levels of phospho-DARPP-32 (Thr75), which inhibits PKA, were higher in FR than AL rats. CONCLUSIONS: Results indicate that inhibition of PKA enhances the unconditioned rewarding effect of D-1 receptor stimulation and that decreased PKA may be involved in the effect of FR on drug reward. Evidence for involvement of D-2 receptor-expressing neurons in the enhancing effect of PKA inhibition is discussed.

Although substance abuse treatment programs are important contact points for providing health services for hepatitis B virus (HBV) and hepatitis C virus (HCV) infections, availability of services in these programs has not been well characterized. This study evaluated the spectrum of HBV and HCV services offered by substance abuse treatment programs within the National Drug Abuse Treatment Clinical Trials Network. Our survey of substance abuse treatment program administrators covered availability of testing for HBV and HCV; hepatitis A virus (HAV) and HBV immunization; and HCV medical and nonmedical services. There were also questions covering clarity of guidelines for HBV and HCV testing and HAV and HBV immunization. Differences between methadone and nonmethadone programs were examined. Despite the importance of substance abuse in sustaining the hepatitis epidemics, few programs offer comprehensive HBV and HCV testing or HCV health care services. Interventions to improve access to hepatitis services for substance-abusing patients are needed.

This article, based on ethnographic fieldwork including twelve months of participant observation and 428 interviews with 84 converts and leaders in Pentecostal ministries founded and run by former addicts in Puerto Rico, describes redefined masculinity as a treatment for addiction. Industrial disinvestment and resulting unemployment and drug trade in urban North and Latin America have led to narcotic addiction among Latino and African American men and attendant homicide, infection, and incarceration. Pentecostal-evangelical street ministries are prevalent in these regions. Their alternative vision of masculine honor and power addresses a cultural crisis of men's social space. They replace the unachievable ideal of the male breadwinner with an image of male spiritual power. In place of the violence of the drug trade, they cultivate male domesticity and responsibility for the home. In place of a deleterious drug economy, they offer the social and cultural capital of ministry networks and biblical knowledge. Yet the trajectories of ministry converts reveal the limits, as well as the promise, of evangelist masculinity as a treatment for addiction. In the course of building leadership among their converts, the ministries create their own, internal hierarchies, fall short of the spiritual democracy they espouse, and lead to relapse among those left at the bottom