Faculty Bibliography

Substance abuse treatment programs are an important platform for delivery of services for infectious diseases associated with drug and alcohol use. However, important components of infectious disease care are not universally provided. Clinician training often focuses on information about infectious diseases and less attention is paid to provider opinions and attitudes that may be barriers to providing infectious diseases services. In a national multi-site trial conducted by the National Drug Abuse Treatment Clinical Trials Network (CTN), we investigated the relationship between clinician opinions and the delivery of services for human immunodeficiency virus, hepatitis C virus, and sexually transmitted infections in substance abuse treatment settings. Survey data were collected from 1,723 clinicians at 269 CTN treatment programs. Clinician opinion was found to be significantly related to infectious disease service delivery. Implications for training are discussed

Background: Relapse among patients in substance abuse treatment has generated interest in identifying attitudinal factors that sustain recovery. Objective: To assess the relationship of attitudes toward approaches to motivation for treatment and Twelve Step beliefs. Methods: Dually diagnosed patients (N = 100) completed a survey assessing treatment attitudes, motivation, and Twelve Step beliefs. Results: Endorsement of medical services was positively correlated with motivation but unrelated to Twelve Step beliefs. Endorsement of religious services was unrelated to motivation but was associated with Twelve Step beliefs. Conclusions: Patients may have differing perceptions regarding routes to recovery based on preferences for professional services or spiritual resources

CONTEXT: The usual treatment for opioid-addicted youth is detoxification and counseling. Extended medication-assisted therapy may be more helpful. OBJECTIVE: To evaluate the efficacy of continuing buprenorphine-naloxone for 12 weeks vs detoxification for opioid-addicted youth. DESIGN, SETTING, AND PATIENTS: Clinical trial at 6 community programs from July 2003 to December 2006 including 152 patients aged 15 to 21 years who were randomized to 12 weeks of buprenorphine-naloxone or a 14-day taper (detox). INTERVENTIONS: Patients in the 12-week buprenorphine-naloxone group were prescribed up to 24 mg per day for 9 weeks and then tapered to week 12; patients in the detox group were prescribed up to 14 mg per day and then tapered to day 14. All were offered weekly individual and group counseling. MAIN OUTCOME MEASURE: Opioid-positive urine test result at weeks 4, 8, and 12. RESULTS: The number of patients younger than 18 years was too small to analyze separately, but overall, patients in the detox group had higher proportions of opioid-positive urine test results at weeks 4 and 8 but not at week 12 (chi(2)(2) = 4.93, P = .09). At week 4, 59 detox patients had positive results (61%; 95% confidence interval [CI] = 47%-75%) vs 58 12-week buprenorphine-naloxone patients (26%; 95% CI = 14%-38%). At week 8, 53 detox patients had positive results (54%; 95% CI = 38%-70%) vs 52 12-week buprenorphine-naloxone patients (23%; 95% CI = 11%-35%). At week 12, 53 detox patients had positive results (51%; 95% CI = 35%-67%) vs 49 12-week buprenorphine-naloxone patients (43%; 95% CI = 29%-57%). By week 12, 16 of 78 detox patients (20.5%) remained in treatment vs 52 of 74 12-week buprenorphine-naloxone patients (70%; chi(2)(1) = 32.90, P < .001). During weeks 1 through 12, patients in the 12-week buprenorphine-naloxone group reported less opioid use (chi(2)(1) = 18.45, P < .001), less injecting (chi(2)(1) = 6.00, P = .01), and less nonstudy addiction treatment (chi(2)(1) = 25.82, P < .001). High levels of opioid use occurred in both groups at follow-up. Four of 83 patients who tested negative for hepatitis C at baseline were positive for hepatitis C at week 12. CONCLUSIONS: Continuing treatment with buprenorphine-naloxone improved outcome compared with short-term detoxification. Further research is necessary to assess the efficacy and safety of longer-term treatment with buprenorphine for young individuals with opioid dependence. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00078130.

OBJECTIVES: We intend to review the importance of appropriately recognizing and managing attention deficit/attention deficit hyperactivity disorder (ADD/ADHD) in the acute psychiatric hospital setting. METHODS: We demonstrate the management of three patients with associated ADD/ADHD diagnosis in the hospital setting. This case series is followed by a review of the literature on the treatment of ADD/ADHD with particular focus on inpatient treatment. RESULTS: Given that the core symptoms of ADD/ADHD are inattention, hyperactivity, poor concentration, impulsivity, poor organization and emotional instability, it follows that a comprehensive inpatient treatment plan should address these issues in order to obtain sustained, focused participation on the part of the patient. Suppression of ADD/ADHD symptoms with stimulants greatly enhanced our patients' ability to more productively and actively participate in the treatment of the acute psychiatric problems which led to their admission. CONCLUSIONS: Currently, no published data exist on prevalence of ADD/ADHD in psychiatric hospitals, rates of treatment and outcome of treatment with regard to recovery and quality of aftercare. Nonetheless, the benefits of treating ADD/ADHD among psychiatric inpatients may be seen in case examples and are also apparent in the data concerning treatment of ADD/ADHD in the dually diagnosed

BACKGROUND: Despite growing concern about illicit methadone use in the US and other countries, there is little data about the prevalence and correlates of methadone use in large urban areas. We assessed the prevalence and examined correlates of lifetime and recent illicit methadone use in New York City (NYC). METHODS: 1,415 heroin, crack, and cocaine users aged 15-40 years were recruited in NYC between 2000 and 2004 to complete interviewer-administered questionnaires. RESULTS: In multivariable logistic regression, non-injection drug users who used illicit methadone were more likely to be heroin dependent, less than daily methamphetamine users and to have a heroin using sex partner in the last two months. Injection drug users who used illicit methadone were more likely to use heroin daily, share injection paraphernalia and less likely to have been in a detoxification program and to have not used marijuana in the last six months. CONCLUSION: The results overall suggest that illicit (or street) methadone use is likely not a primary drug of choice, but is instead more common in concert with other illicit drug use.

Epidemiological evidence indicates that prenatal nutritional deprivation may increase the risk of schizophrenia. The goal of these studies was to use an animal model to examine the effects of prenatal protein deprivation on behaviors and receptor binding with relevance to schizophrenia. We report that prenatally protein deprived (PD) female rats showed an increased stereotypic response to apomorphine and an increased locomotor response to amphetamine in adulthood. These differences were not observed during puberty. No changes in haloperidol-induced catalepsy or MK-801-induced locomotion were seen following PD. In addition, PD female rats showed increased (3)H-MK-801 binding in the striatum and hippocampus, but not in the cortex. PD female rats also showed increased (3)H-haloperidol binding and decreased dopamine transporter binding in striatum. No statistically significant changes in behavior or receptor binding were found in PD males with the exception of increased (3)H-MK-801 binding in cortex. This animal model may be useful to explore the mechanisms by which prenatal nutritional deficiency enhances risk for schizophrenia in humans and may also have implications for developmental processes leading to differential sensitivity to drugs of abuse

Heroin addiction is a chronic complex disease with a substantial genetic contribution. This study was designed to identify genetic variants that are associated with susceptibility to develop heroin addiction by analyzing 1350 variants in 130 candidate genes. All subjects had Caucasian ancestry. The sample consisted of 412 former severe heroin addicts in methadone treatment, and 184 healthy controls with no history of drug abuse. Nine variants, in six genes, showed the lowest nominal P values in the association tests (P < 0.01). These variants were in noncoding regions of the genes encoding the mu (OPRM1; rs510769 and rs3778151), kappa (OPRK1; rs6473797) and delta (OPRD1; rs2236861, rs2236857 and rs3766951) opioid receptors; the neuropeptide galanin (GAL; rs694066); the serotonin receptor subtype 3B (HTR3B; rs3758987) and the casein kinase 1 isoform epsilon (CSNK1E; rs1534891). Several haplotypes and multilocus genotype patterns showed nominally significant associations (e.g. OPRM1; P = 0.0006 and CSNK1E; P = 0.0007). Analysis of a combined effect of OPRM1 and OPRD1 showed that rs510769 and rs2236861 increase the risk of heroin addiction (P = 0.0005). None of these associations remained significant after adjustment for multiple testing. This study suggests the involvement of several genes and variants in heroin addiction, which is worthy of future study.

Nicotine dependence is highly prevalent among drug- and alcohol-dependent patients. A multisite clinical trial of smoking cessation (SC) treatment was performed at outpatient community-based substance abuse rehabilitation programs affiliated with the National Drug Abuse Treatment, Clinical Trials Network. Cigarette smokers (N=225) from five methadone maintenance programs and two drug and alcohol dependence treatment programs were randomly assigned in a 2:1 ratio to receive either (1) SC treatment as an adjunct to substance abuse treatment-as-usual (TAU) or (2) substance abuse TAU. Smoking cessation treatment consisted of 1 week of group counseling before the target quit date and 8 weeks of group counseling plus transdermal nicotine patch treatment (21 mg/day for Weeks 1-6 and 14 mg/day for Weeks 7 and 8) after the target quit date. Smoking abstinence rates in SC, 10%-11% during treatment and 5%-6% at the 13- and 26-week follow-up visits, were significantly better than those in TAU during treatment (p< .01). In addition, SC was associated with significantly greater reductions as compared with TAU in cigarettes smoked per day (75% reduction, p< .001), exhaled carbon monoxide levels (p< .001), cigarette craving (p< .05), and nicotine withdrawal (p< .05). Smoking cessation did not differ from TAU on rates of retention in substance abuse treatment, abstinence from primary substance of abuse, and craving for primary substance of abuse. Compliance with SC treatment, moderate at best, was positively associated with smoking abstinence rates. Smoking cessation treatment resulted in significant reductions in daily smoking and modest smoking abstinence rates without having an adverse impact on substance abuse rehabilitation when given concurrently with outpatient substance abuse treatment. Substance abuse treatment programs should not hesitate to implement SC for established patients

UNLABELLED: Hepatitis B (HBV) vaccination coverage remains low among drug users. In 1997, ACIP made hepatitis B vaccine available for persons aged 0-18 years and many states began requiring HBV vaccination for entry into middle school; these programs might affect HBV vaccination and infection rates in younger DUs. We were interested in determining correlates of immunization among younger (<25 years) and older (25 and older) DUs. METHODS: A community-based sample of 1,211 heroin, crack, and cocaine users 18 or older was recruited from Harlem and the Bronx. We assessed previous HBV vaccination and infection and correlates using bivariate analyses. RESULTS: The sample was predominantly male (74.0%), aged > or =25 years (67.1%) and Hispanic (59.9%). In terms of socioeconomic status, 57.1% had less than a high school education, 84.5% had been homeless in their lifetime, and 48.0% had an illegal main income source. Among 399 DUs younger than 25 years of age, 30% demonstrated serological evidence of previous vaccination, 49.9% were susceptible to HBV at baseline, and 20% showed evidence of infection. In our model, previous HBV infection and vaccination status were associated with being 22 years old or younger (AOR = 1.40 and 1.66). Compared to susceptible individuals, those vaccinated were significantly less likely to be born in other countries (AOR = 0.50). Among 812 DUs 25 and older, 10.6% demonstrated serological evidence of previous vaccination, 59.2% were susceptible to HBV at baseline, and 30.2% showed evidence of infection. CONCLUSION: Existing interventions to increase HBV vaccination among adolescents should target high risk groups.