Literature Update for CERGA (Abstracts)

Literature Update for CERGA

The following journals were reviewed for June-end August 2008 [Search conducted between 24/07/08 and 30/07/08]

Addiction British Medical Journal Drug and Alcohol Review Journal of Substance Abuse Treatment Drugs: Education, Prevention and Policy Journal of Public Health National Treatment Agency for Substance Misuse Drug and Alcohol Dependency International Journal of Drug Policy Addiction Research and Theory Addictive Disorders and their Treatment Addictive Behaviours Alcoholism American Journal on Addictions Drugs and Alcohol Today

The titles of potential interest are listed below under topic headings:  Epidemiology and Demography  Opiate Treatment  Treatment Organisation  Psychostimulants  Co-morbidity  Harm Reduction  Alcohol  Cannabis  Blood Borne Viruses (BBVs)

Titles are listed then the corresponding abstracts are in the second part of this document.

Epidemiology and Patient Demography

2. Degenhardt L, Kinner S A, Roxburgh A, Black E Bruno R, Fetherston J, Fry C L. Drug use and risk among regular injecting drug users in Australia: does age make a difference? Drug and Alcohol Review 2008; 27(4): 357-60

3. Larm P, Hodgins S, Larsson A, Samuelson Y M, Tengström. Long-term outcomes of adolescents treated for substance misuse. Drug and Alcohol Dependency 2008; 96(1-2): 79-89 4. Buchanan A S, Latkin C A. Drug use in the social networks of heroin and cocaine users before and after drug cessation. Drug and Alcohol Dependency 2008; 96(3): 286-89

5. Neufeld K, King V, Peirce J, Kolodner K, Brooner R, Kidorf M. A comparison of 1-year substance abuse treatment outcomes in community syringe exchange participants versus other referrals. Drug and Alcohol Dependency 2008; 97(1-2): 122-129

6. Deutscher M, Perlman D C. Why some injection drug users lick their needles: A preliminary survey. Int J of Drug Policy 2008; 19(4): 342-45

7. Wu L, Blazer D G, Stitzer M L, Patkar A A, Blaine J D. Infrequent illicit methadone use of among stimulant-using patients in methadone maintence treatment programs: A National Drug Abuse Treatment Clinical Trials Network Study. American Journal on Addictions 2008; 17(4): 304-311

8. Bloor M et al. Contribution of problem drug users’ deaths to excess mortality in Scotland: secondary analysis of cohort study BMJ 2008;337 a478

Opiate treatment

9. Gordon M S, Kinlock T W, Schwartz R P, O’Grady K E. A randomized clinical trial of methadone maintenance for prisoners: findings at 6 months post-release. Addiction 2008; 103(8): 1333-42

10. Roose R J, Kunins H V, Sohler N L, Elam R T, Cunningham C O. Nurse practitioner and physician assistant interest in prescribing buprenorphine. Journal of Substance Abuse Treatment 2008; 34(4): 456-59

12. Wittchen H, Apelt S M, Soyka M, Gastpar M, Backmund M, Gölz J, Kraus M R, Tretter F, Schäfer M, Siegert J, Scherbaum N, Rehm J, Bühringer G. Feasibility and outcome of substitution treatment of heroin-dependent patients in specialized substitution centers and primary care facilities in Germany: A naturalistic study in 2694 patients. Drug and Alcohol Dependency 2008; 95(3): 245-57

13. Bell J R, Ryan A, Mutch C, Batey R. Optimising the benefits of unobserved dose administration for stable opioid maintenance patients: Follow-up of a randomised trial. Drug and Alcohol Dependency 2008; 96(1-2) 183-86

14. Mooney M E, Poling J, Gonzalez G, Gonsai K, Kosten T, Sofuoglu M. Preliminary study of Buprenorphine and Bupropion for Opioid- Dependent Smokers. American Journal on Addictions 2008; 17(4): 287-292 15. Prosser J M, Steinfield M, Cohen L J, Derbyshire S, Eisenberg D P, Cruciani R A, Galynker I I. Abnormal heat and pain perception in remitted heroin dependence months after detoxification from methadone-maintenance. Drug and Alcohol Dependency 2008; 95(3): 237-44

16. Businelle M S, Parker J D, May R K, Kendzor D E, Burke R S. Effects of contingency management on substance abuse continuing care participation. Addiction Disorders and their Treatment 2008; 7(2); 99-108

19. Green T C, Heimer R, Grau L E. Distinguishing signs of opioid overdose and indication for naloxone: an evaluation of six overdose training and naloxone distribution programs in the United States. Addiction 2008; 103(6): 979-89

Treatment Organisation

21. Frost N, Griffiths P, Fanelli R. Peering into dirty waters: the potential and implications of a new approach to monitoring drug consumption [Editorial]. Addiction 2008; 103(8): 1239-41

Psychostimulants

22. McGregor C, Srisurapanont M, Mitchell A, Longo M C, Cahill S, White J M. Psychometric evaluation of the Amphetamine Cessation Symptom assessment. Journal of Substance Abuse Treatment 2008; 34(4): 443-49

Co-morbidity

23. Winstock A R, Lea T, Sheridan J. Patients’ help-seeking behaviours for health problems associated with methadone and buprenorphine treatment. Drug and Alcohol Review 2008; 27(4): 393-97

Harm reduction 24. Wong F L, Rotheram-Borus M J, Lightfoot M, Pequegnat W, Comulada W S, Cumberland W, Weinhardt L S, Remien R H, Chesney M, Johnson M. Effects of behavioral intervention on substance use among people living with HIV: the Healthy Living Project randomized controlled study. Addiction 2008; 103(7): 1206-14

25. Hanson T, Alessi S M, Petry N M. Contingency management reduces drug-related human immunodeficiency virus risk behaviors in cocaine- abusing methadone patients. Addiction 2008; 103(7): 1187-97

26. Vallejo F, Toros C, Fuente L de la, Brugal M T, Barrio G, Soriano V, Ballesta R, Bravo M J and Project Itinere Group. Hepatitis B vaccination: An unmet challenge in the era of harm reduction programs. Journal of Substance Abuse Treatment 2008; 34(4): 398-406

28. Matheson C, Anthony G B, Bond C, Rossi M K. Assessing and prioritizing the preferences of injecting drug users in needle and syringe exchange service development. Journal of Public Health 2008; 30(2): 133-38

29. Davis P, Abou-Saleh M T. Developing an enhanced counselling intervention for the primary prevention of Hepatitis C among injecting drug users. Addiction Disorders and their Treatment 2008; 7(2): 65-76

Alcohol

30. Richardson K, Baillie A, Reid S, Morley K, Teesson M, Sannibale C, Weltman M, Haber P. Do acamprosate or naltrexone have an effect on daily drinking by reducing craving for alcohol? Addiction 2008; 103 (6): 953-59

31. Barbor T F, Caetano R. The trouble with alcohol abuse: what are we trying to measure, diagnose, count and prevent? (Editorial) Addiction 2008; 103(7): 1057-59

32. Hickman M, Lingford-Hughes A, Bailey C, Macleod J, Nutt D, Henderson G. Does alcohol increase the risk of overdose death: the need for a translational approach. Addiction 2008; 103(7): 1060-62

33. Soyka M. Alcohol and the risk of overdose death from heroin [Commentary]. Addiction 2008; 103(7): 1064-65

34. Rose H L, Miller P M, Nemeth L S, Jenkins R G, Nietert P J, Wessell A M. Alcohol screening and brief counselling in a primary care hypertensive population: a quality improvement intervention. Addiction 2008; 103(8): 1271-80

35. Mulia N, Schmidt L, Bond J, Jacobs L, Korcha R. Stress, social support and problem drinking among women in poverty. Addiction 2008; 103(8): 1283- 93

36. Sheridan J, Wheeler A, Chen L J, Huang A C, Leung I N, Tien K Y. Screening and brief interventions for alcohol: attitudes, knowledge and experience of community pharmacists in Auckland, New Zealand. Drug and Alcohol Review 2008; 27(4): 380-87

37. Dundon W D, Pettinati H M, Lynch K G, Xie H, Varillo K M, Makadon C, Oslin D W. The therapeutic alliance in medical-based interventions impacts outcome in treating alcohol dependence. Drug and Alcohol Dependency 2008; 95(3) 230-36

38. McCambridge J, Jenkins R J. Do brief interventions which target alcohol consumption also reduce cigarette smoking?: Systematic review and meta-analysis. Drug and Alcohol Dependency 2008; 96(3): 263-270

39. Bewick B M, Trusler K, Mulhern B, Barkham M. The feasibility and effectiveness of a web-based personalised feedback and social norms alcohol intervention in UK university students: A randomised controlled trial. Addictive Behaviours 2008; 33(9) 1192-98

40. Ray L A, Hutchinson K E, MacKillop J, Miranda R, Audette A, Swift R, Monti P M. Effects of Naltrexone during the descending limb if the blood alcohol curve. American Journal on Addictions 2008; 17(4): 257-64

Bloodborne Viruses (BBVs)

41. Werb D, Kerr T, Small W, Li K, Montaner J, Wood E. HIV risks associated with incarceration among injection drug users: implications for prison- based public health strategies. Journal of Public Health 2008; 30(2): 126-32

42. Willner-Reid J, Belendiuk K A, Epstein D H, Schmittner J, Preston K L. Hepatitis C and human immunodeficiency virus risk behaviors in polydrug users on methadone maintenance. Journal of Substance Abuse Treatment 2008; 34(5): 78-86

43. Novick N, Kreek M J. Critical issues in the treatment of hepatitis C virus infection in methadone maintenance patients. Addiction 2008; 103 (6): 905-18

44. Malta M, Strathdee S A, Monica M F, Bastos F I. Adherence to antiretroviral therapy for human immunodeficiency virus/acquired immune deficiency syndrome among drug users: a systematic review. Addiction 2008; 103(8): 1242-57 Cannabis

45. McLaren J, Swift W, Dillon P, Allsop S. Cannabis potency and contamination: a review of the literature. Addiction 2008; 103(7): 1100-09

46. Martin G, Copeland J. The adolescent cannabis check-up: Randomized trial of a brief intervention for young cannabis users. Journal of Substance Abuse Treatment 2008; 34(4) 407-14 Abstracts

Epidemiology and demography

1. Verthein U, Bonorden-Kleij K, Degkwitz P, Dilg C, Köhler W K, Passie T, Soyka M, Tanger S, Vogel M, Haassen C . Long-term effects of heroin- assisted treatment in Germany. Addiction 2008; 103(6): 960-66 Aims Trials in Switzerland, the Netherlands and Spain have found that heroin-assisted treatment (HAT) as maintenance treatment for opioid-dependent patients reduces illicit drug use. A German trial also found diamorphine treatment to be superior to methadone treatment. The present study describes the association between 2 years of heroin treatment and improvements in health and social stabilization, as well as illicit drug use. Design A prospective cohort study design. Participants A total of 515 patients were assigned to diamorphine treatment; 278 patients remained in the study treatment for the entire period of 24 months (54.8%). Measurements The results on physical (Opiate Treatment Index Health Symptoms Scale) and mental (Symptom Checklist 90–Revised Global Severity Index) health and illicit drug use (number of days with drug use within the last month—European Addiction Severity Index) were examined by repeated-measures analyses. Findings Symptoms of physical (Pillai's trace = 0.837, df = 4, P < 0.001) and mental health (Pillai's trace = 0.450, df = 4, P < 0.001) improved during treatment. Street heroin use declined rapidly (Pillai's trace = 0.836, df = 4, P < 0.001), as did cocaine use (Pillai's trace = 0.280, df = 4, P < 0.001). Conclusions HAT is associated with improvements in mental and physical health in the long term. 2. Degenhardt L, Kinner S A, Roxburgh A, Black E Bruno R, Fetherston J, Fry C L. Drug use and risk among regular injecting drug users in Australia: does age make a difference? Drug and Alcohol Review 2008; 27(4): 357-60

Introduction and Aims To examine age-related differences in drug use and risk among regular injecting drug users (IDU) in Australia. Design and Methods Cross-sectional data from the 2006 Illicit Drug Reporting System were examined for age-related differences in demographic characteristics, drug use history and current use patterns and self-reported risk behaviours. Results IDU under 25 years of age were more likely to have initiated injecting at a younger age, to identify as Aboriginal and/or Torres Strait Islander, and to be injecting daily or more often than their older counterparts. They reported more frequent heroin use in the preceding 6 months, and were more likely to report morphine as the first drug injected than were IDU aged 35 years or over. Younger IDU were also more likely to report providing used needles to others, engaging in recent property crime and drug dealing and arrest in the last year. Conclusions Younger IDU reported significantly different drug use patterns and higher rates of risk behaviours than their older counterparts. Treatment services need to ensure that harm and demand reduction services deliver messages to new cohorts of IDU, particularly given that their drug use patterns may be different to those of older users.

3. Larm P, Hodgins S, Larsson A, Samuelson Y M, Tengström. Long-term outcomes of adolescents treated for substance misuse. Drug and Alcohol Dependency 2008; 96(1-2): 79-89 Introduction Little is known about the long-term outcome of substance misuse by teenagers, this is especially true for gender specific consequences. Objectives To examine the prevalence of death, physical illnesses related to substance misuse, mental illness, substance misuse, criminality, and poverty in adulthood among two cohorts of individuals who as adolescents had consulted for substance misuse problems, to estimate the effect of sex on adverse outcomes, and to compare cohort effects. Methods Individuals who had consulted a substance misuse clinic as adolescents during 1968–1971 and 1980–1984 were followed until 2002. Adverse outcomes were documented using information from Swedish national registers. Results In the older cohort followed to age 50, only one-in-five escaped all six adverse outcomes, while over half of subjects experienced at least two or more. Sex and the severity of adolescent substance misuse and delinquency were predictors of adverse outcomes. More women than men experienced physical illness and poverty in the older cohort while more men than women were convicted of criminal offences in both cohorts and presented continued substance misuse in the younger cohort. Men in the younger as compared to the older cohort had higher rates of substance misuse and criminal convictions. Conclusions Adolescents seeking help for substance misuse problems are at elevated risk for multiple adverse outcomes later in life. Outcomes differ for women and men and by severity of adolescent misuse and delinquency. Few cohort differences in adult outcomes exist.

4. Buchanan A S, Latkin C A. Drug use in the social networks of heroin and cocaine users before and after drug cessation. Drug and Alcohol Dependency 2008; 96(3): 286-89 The present study examined social control processes in drug cessation among adults. Social control theory posits that the association between drug use and the drug use of a person's social network results from an individual seeking out similar peers. The data included 629 individuals who reported past-year heroin or cocaine use at baseline and had follow-up data in a community study in Baltimore, MD. Negative binomial regression modeling indicated that the reduction in social network drug use was significantly greater for quitters than those who did not quit. Compared to non- quitters at baseline, the incidence rate ratio (IRR) of the number of drug-using network members was 0.86 for quitters at baseline, 0.71 for non-quitters at follow-up, and 0.28 for quitters at follow-up (all p < 0.05). These findings support social control theory in adult drug use cessation. Future research should extend the length of follow- up and assess bidirectional influences.

This longitudinal cohort study of 324 consecutive admissions to methadone maintenance treatment between 08/1994 and 09/1997 compared 1-year outcomes of opioid-dependent patients referred from a syringe exchange program (SEP; n = 81) versus other sources (n = 243). All participants received stepped-based counseling. The Addiction Severity Index was completed upon admission. Treatment outcomes were assessed using weekly urine testing and days in treatment. GEE regression models were used to evaluate the association between baseline variables and treatment outcomes. SEP referrals were older, included more males and African Americans, reported greater unemployment and heavier heroin, cocaine, and injection drug use at admission. During treatment, SEP referrals used more opioids (OR 2.57; 95% CI 1.86–3.56) and cocaine (OR 2.77; 95% CI 1.93–3.95), and were less likely to complete 1 year (35%) compared to other referrals (56%; hazard ratio 1.88; 95% CI 1.35–2.62). Nevertheless, referral source was not significantly associated with outcome when adjusted for baseline characteristics. Greater baseline frequency of substance and injection drug use, and younger age were positively associated with ongoing opioid and cocaine use. African American race and baseline unemployment were also associated with ongoing cocaine use. Younger age and greater baseline cocaine use were associated with poorer retention at 1 year. The poorer treatment response of SEP referrals is likely due to higher baseline problem severity. Specialized interventions may be required to reduce drug use and improve retention in this population. 6. Deutscher M, Perlman D C. Why some injection drug users lick their needles: A preliminary survey. Int J of Drug Policy 2008; 19(4): 342-45 Background Injection drug users (IDUs) with poor hygiene practices are at risk for infection with their commensal flora. One example of a poor hygiene practice is licking the needle prior to injecting the drug. There are few published reports addressing the proportion of IDUs who lick their needles prior to injection and no prior studies evaluating the reasons for this practice. Methods We conducted face-to-face interviews with 40 IDUs admitted to the internal medicine service at our institution. We collected data regarding whether the subject licked the needle before injecting drugs, whether the subject licked the injection site before or after injecting drugs, and the reasons they report for doing so. Results Thirteen (32.5%, 95% CI, 18.6–49.1) of 40 subjects reported licking their needles prior to injecting. Reasons included ritualistic practices, cleaning the needle, enjoying the taste of the drug, checking the “quality” of the drug, and checking that the needle was in usable condition. Conclusions In our study, approximately one-third of IDUs licked their needles prior to injecting. More data are needed to demonstrate whether the practice of needle licking significantly increases a person's risk for infection with oropharyngeal flora. Medical providers should ask patients about specific practices surrounding injection drug use, and educate drug users about avoiding unhygienic injection practices. 7. Wu L, Blazer D G, Stitzer M L, Patkar A A, Blaine J D. Infrequent illicit methadone use of among stimulant-using patients in methadone maintence treatment programs: A National Drug Abuse Treatment Clinical Trials Network Study. American Journal on Addictions 2008; 17(4): 304-311

We sought to determine the prevalence, patterns, and correlates of past-month illicit methadone use and history of regular illicit use among stimulant-using methadone maintenance treatment patients. We obtained self-reported information on illicit methadone use from 383 participants recruited from six community-based methadone maintenance programs. Overall, 1.6% of participants reported illicit use in the past month, and 4.7% reported a history of regular use. Younger age and history of outpatient psychological treatment were associated with increased odds of past-month illicit use. Illicit methadone use among patients in maintenance programs is infrequent; however, a number of factors may increase risk of illicit use.

8. Bloor M et al. Contribution of problem drug users’ deaths to excess mortality in Scotland: secondary analysis of cohort study BMJ 2008;337 a478

Objectives To examine the "Scottish effect"—namely, the growing divergence between mortality in Scotland and England that is not explained by national differences in levels of deprivation—and, more specifically, to examine the extent to which the Scottish effect is explained by cross national differences in the prevalence of problem drug use. Design Secondary analysis of cohort study (the DORIS study). Participants 1033 Scottish drug users recruited to the cohort study in 33 drug treatment facilities across Scotland in 2001-2 and followed up 33 months later in 2004-5. Results 38 deaths occurred in the cohort, giving a standardised mortality ratio for the cohort of 1244 (95% credible interval 876 to 1678). Only 22 of the 38 deaths in drug users were classified as drug related deaths. From estimates of the size of the problem drug using populations in both England and Scotland, the contribution of deaths in drug users to national death rates can be estimated: the attributable risk fraction for Scotland is 17.3% (12.3% to 22.8%) and that for England is 11.1% (7.8% to 14.8%). Excluding estimated numbers of deaths in drug users would bring down age standardised mortality at ages 15-54 years from 196 to 162 per 100 000 in Scotland and from 138 to 122 per 100 000 in England; 32.0% (22.3% to 43.0%) of the excess mortality in Scotland is due to drug use. Conclusion Although problem drug use is a low prevalence risk behaviour, it carries a high mortality; the standardised mortality ratio for Scottish drug users is 12 times as high as for the general population. The higher prevalence of problem drug use in Scotland than in England accounts for a third of Scotland’s excess mortality over England. Successful public health efforts to reduce the prevalence of problem drug use in Scotland or deaths in Scottish drug users would have a dramatic impact on overall mortality in Scotland. Opiate Treatment 9. Gordon M S, Kinlock T W, Schwartz R P, O’Grady K E. A randomized clinical trial of methadone maintenance for prisoners: findings at 6 months post-release. Addiction 2008; 103(8 ): 1333-42

Aims This study examined the effectiveness of methadone maintenance initiated prior to or just after release from prison at 6 months post-release. Design A three-group randomized controlled trial was conducted between September 2003 and June 2005. Setting A Baltimore pre-release prison. Participants Two hundred and eleven adult pre-release inmates who were heroin- dependent during the year prior to incarceration. Intervention Participants were assigned randomly to the following: counseling only: counseling in prison, with passive referral to treatment upon release (n = 70); counseling + transfer: counseling in prison with transfer to methadone maintenance treatment upon release (n = 70); and counseling + methadone: methadone maintenance and counseling in prison, continued in a community-based methadone maintenance program upon release (n = 71). Measurements Addiction Severity Index at study entry and follow-up. Additional assessments at 6 months post-release were treatment record review; urine drug testing for opioids, cocaine and other illicit drugs. Findings Counseling + methadone participants were significantly more likely than both counseling only and counseling + transfer participants to be retained in drug abuse treatment (P = 0.0001) and significantly less likely to have an opioid-positive urine specimen compared to counseling only (P = 0.002). Furthermore, counseling + methadone participants reported significantly fewer days of involvement in self-reported heroin use and criminal activity than counseling only participants. Conclusions Methadone maintenance, initiated prior to or immediately after release from prison, increases treatment entry and reduces heroin use at 6 months post-release compared to counseling only. This intervention may be able to fill an urgent treatment need for prisoners with heroin addiction histories. 10. Roose R J, Kunins H V, Sohler N L, Elam R T, Cunningham C O. Nurse practitioner and physician assistant interest in prescribing buprenorphine. Journal of Substance Abuse Treatment 2008; 34(4): 456- 59 Office-based buprenorphine places health care providers in a unique position to combine HIV and drug treatment in the primary care setting. However, federal legislation restricts nurse practitioners (NPs) and physician assistants (PAs) from prescribing buprenorphine, which may limit its potential for uptake and inhibit the role of these nonphysician providers in delivering drug addiction treatment to patients with HIV. This study aimed to examine the level of interest in prescribing buprenorphine among nonphysician providers. We anonymously surveyed providers attending HIV educational conferences in six large U.S. cities about their interest in prescribing buprenorphine. Overall, 48.6% (n = 92) of nonphysician providers were interested in prescribing buprenorphine. Compared to infectious disease specialists, nonphysician providers (adjusted odds ratio [AOR] = 2.89, 95% confidence interval [CI] = 1.22–6.83) and generalist physicians (AOR = 2.04, 95% CI = 1.09–3.84) were significantly more likely to be interested in prescribing buprenorphine. NPs and PAs are interested in prescribing buprenorphine. To improve uptake of buprenorphine in HIV settings, the implications of permitting nonphysician providers to prescribe buprenorphine should be further explored.

11. D’Amico E J, Miles J N V, Stern S A, Meredith L S. Brief motivational interviewing for teens at risk of substance use consequences: A randomized pilot study in a primary care clinic. Journal of Substance Abuse Treatment 2008; 34(5): 53-61 The current study examined the impact of a brief motivational interviewing (MI) intervention (Project CHAT) on alcohol consumption and drug use for high-risk teens in a primary care clinic that provides health care for underserved populations. Youth (N = 42, 48% male) were screened, and those eligible completed a baseline survey. Baseline survey completers were randomly assigned to usual care or to an MI intervention and completed a 3-month follow-up survey. The sample (age 12 to 18 years) was 85.7% Hispanic or Latino, 9.5% African American, and 4.8% White. At the 3-month follow-up, Project CHAT teens reported less marijuana use, lower perceived prevalence of marijuana use, fewer friends who used marijuana, and lower intentions to use marijuana in the next 6 months, as compared to teens assigned to usual care. Providing this type of brief intervention is a viable approach to working with high-risk teens to decrease substance use. 12. Wittchen H, Apelt S M, Soyka M, Gastpar M, Backmund M, Gölz J, Kraus M R, Tretter F, Schäfer M, Siegert J, Scherbaum N, Rehm J, Bühringer G. Feasibility and outcome of substitution treatment of heroin- dependent patients in specialized substitution centers and primary care facilities in Germany: A naturalistic study in 2694 patients. Drug and Alcohol Dependency 2008; 95(3): 245-57

Background In many countries, buprenorphine and methadone are licensed for the maintenance treatment (MT) of opioid dependence. Despite many short-term studies, little is known about the long-term (12-month) effects of these treatments in different settings, i.e. primary care-based (PMC) and specialized substitution centers (SSCs). Objectives To describe over a period of 12 months: (1) mortality, retention and abstinence rates; (2) changes in concomitant drug use, somatic and mental health; and (3) to explore differences between different types of provider settings. Methods 12-Month prospective-longitudinal naturalistic study with four waves of assessment in a prevalence sample of N = 2694 maintenance patients, recruited from a nationally representative sample of N = 223 substitution physicians. Results The 12-month retention rate was 75%; the mortality rate 1.1%. 4.1% of patients became “abstinent” during follow-up. 7% were referred to drug-free addiction treatment. Concomitant drug use decreased and somatic health status improved. No significant improvements were observed for mental health and quality of life. When controlling for initial severity, small PMC settings revealed better retention, abstinence and concomitant drug use rates. Conclusion The study underlines the overall 12-month effectiveness of various forms of agonist MT. Findings reveal relatively high retention rates, low mortality rates, and improvements in most 12-month outcome domains, except for mental health and quality of life. PMC settings appear to be a good additional option to improve access to MTs. 13. Bell J R, Ryan A, Mutch C, Batey R. Optimising the benefits of unobserved dose administration for stable opioid maintenance patients: Follow-up of a randomised trial. Drug and Alcohol Dependency 2008; 96(1-2) 183-86

Background The registration of combination buprenorphine/naloxone, a formulation designed to reduce risk of diversion, has led some Australian jurisdictional authorities to allow treatment without direct observation of dosing for stable, opioid-dependent patients. Aim To compare two approaches (1) initiating treatment with observed dosing, then allowing patients who demonstrate stability to change to unobserved dosing; or (2) initiating patients with unobserved dosing, subsequently requiring those who fail to stabilize to change to observed treatment. Methods This study builds on an RCT comparing efficacy of observed and unobserved treatment at 3 months. At the conclusion of the RCT, clinically “stable” subjects were allocated to continue without observed dosing, while those who did not demonstrate stability were allocated to observed dosing. Subjects were followed for a further 3 months. Primary end-point was retention in treatment. Results Of 119 subjects randomised, 70 were retained in treatment to 3 months. Forty-five stable subjects were allocated to unobserved dosing, 25 to observation. Unstable subjects allocated to observed treatment were more likely to drop out thereafter (OR 2.14, 95% CI 1.09–4.19). There was a non- significant trend for people initiated with observed dosing to be better retained during the allocation phase; at 6 months, 13 subjects (22%) from the original unobserved group, and 22 (34%) from the observed group, were retained in treatment (χ2 = 2.10, 1 df, p = 0.15). Conclusions Withdrawal of unobserved doses led to marked attrition from treatment. If access to unobserved dosing is to be restricted to stable patients, it appears preferable to initiate dosing with observation and allow unobserved doses for people who successfully stabilize, than to initiate with unobserved doses and transfer unstable patients to observation. 14. Mooney M E, Poling J, Gonzalez G, Gonsai K, Kosten T, Sofuoglu M. Preliminary study of Buprenorphine and Bupropion for Opioid- Dependent Smokers. American Journal on Addictions 2008; 17(4): 287- 292

In this double-blind, placebo-controlled trial, bupropion (BUPRO, 300 mg/day) was compared to placebo (PBO) for the concurrent treatment of opioid and tobacco addiction in 40 opioid-dependent smokers stabilized on buprenorphine (BUPRE, 24 mg/day). Participants received contingent, monetary reinforcement for abstinence from smoking, illicit opioids, and cocaine. Significant differences in treatment retention were observed (BUPRE+BUPRO, 58%; BUPRE+PBO, 90%). BUPRO treatment was not more effective than placebo for abstinence from tobacco, opioids, or cocaine in BUPRE-stabilized patients. These preliminary findings do not support the efficacy of BUPRO, in combination with BUPRE, for the concurrent treatment of opioid and tobacco addiction.

15. Prosser J M, Steinfield M, Cohen L J, Derbyshire S, Eisenberg D P, Cruciani R A, Galynker I I. Abnormal heat and pain perception in remitted heroin dependence months after detoxification from methadone- maintenance. Drug and Alcohol Dependency 2008; 95(3): 237-44

Patients receiving methadone maintenance therapy (MMT) for opiate dependence have altered nociception, complicating analgesic treatment. Increasing numbers of patients are choosing opiate-free treatment programs, yet data on the course of this abnormality months after detoxification from methadone is contradictory and based exclusively on cold pressor experiments. Heat and pain thresholds were measured by quantitative sensory testing (QST) in 23 subjects with heroin dependence in full, sustained remission months after detoxification from methadone and 27 healthy non- drug using controls. Self reports of pain intensity and unpleasantness were also collected. Test scores were compared across groups and correlated with measures of drug use history. There were significant differences between remitted opiate- dependent subjects and controls on the measures of heat threshold (38.83 vs. 35.96; Mann–Whitney U = 177.5, p = 0.006), and the measure of pain threshold (48.73 vs. 47.62; Mann–Whitney U = 217.5, p = 0.043). There was no correlation of any measure of drug use history with the heat or pain experience. Abstinent, formerly opioid-dependent patients continue to demonstrate abnormal noxious perception months after detoxification from methadone. 16. Businelle M S, Parker J D, May R K, Kendzor D E, Burke R S. Effects of contingency management on substance abuse continuing care participation. Addiction Disorders and their Treatment 2008; 7(2); 99-108 Objectives The purpose of the present study was to evaluate the effectiveness and feasibility of adding a contingency management (CM) component to the standard substance abuse treatment program available to substance-dependent veterans. Methods Participants included 36 substance-dependent male veterans who completed the Veterans Affairs Medical Center residential or day treatment program. Participants were enrolled in either the CM or standard treatment program. The CM group included 6 substance-dependent male veterans who agreed to participate in a 6- month CM program. In this program, veterans were rewarded with vouchers for attending aftercare sessions and submitting breath and urine samples that were negative for alcohol and other drugs. The standard treatment group included 30 substance-dependent male veterans who completed the residential or day treatment program immediately before the initiation of the CM program. Results Veterans who participated in the adjunctive CM program attended significantly more aftercare sessions than those in the standard treatment group during both the 6-month CM program and the 6 months after the discontinuation of the program. Conclusions Initial findings indicate that CM may be a useful means of increasing treatment attendance among veterans with substance use disorders. The difficulties encountered during the process of integrating the CM component into the standard treatment program are discussed.

17. Weinstock J, Barry D, Petry N M. Exercise-related activities are associated with positive outcome in contingency management treatment for substance use disorders. Addictive Behaviours 2008; 33(8): 1072-75 Exercise has been proposed as an adjunct intervention for substance use disorders due to its many benefits in terms of mental and physical health. This study investigated the association between completion of exercise-related activities and substance use disorders treatment outcome in a sample of 187 participants undergoing intensive outpatient treatment with contingency management. The sample was divided into two groups based upon whether or not an individual completed an exercise-related activity. Individuals who engaged in exercise-related activities (n = 45) were found to achieve longer durations of abstinence during treatment than individuals who did not complete an exercise-related activity (n = 142). Overall, these findings suggest that exercise may be of benefit to individuals undergoing substance use disorders treatment. Methods for implementing an exercise intervention within substance use disorders treatment are discussed.

18. Godley S H, Godley M D, Wright K L, Funk R R, Petry N M. Contingent reinforcement of personal goal activities for adolescents with substance use disorders during post-residential continuing care. American Journal on Addictions 2008; 17(4): 278-86 Contingency management (CM) is efficacious in improving outcomes of substance- abusing patients, but CM studies are relatively rare in adolescents. CM approaches can reinforce both abstinence and adherence to treatment-related goal areas. This paper describes 1,739 different activities in 10 goal areas (e.g., education, family/friends, and social/recreational) chosen by 86 adolescents who were participating in a multiple week CM study that reinforced both abstinence and adherence with goal-related activities. The mean activities selected was 20, and the mean completed was 13. Overall, 1,114 or 64% of chosen activities were completed. The clinical feasibility of activity incentive programs for adolescents is discussed.

Aims This study assessed overdose and naloxone administration knowledge among current or former opioid abusers trained and untrained in overdose–response in the United States. Design and participants Ten individuals, divided equally between those trained or not trained in overdose recognition and response, were recruited from each of six sites (n = 62). Setting US-based overdose training and naloxone distribution programs in Baltimore, San Francisco, Chicago, New York and New Mexico. Measurements Participants completed a brief questionnaire on overdose knowledge that included the task of rating 16 putative overdose scenarios for: (i) whether an overdose was occurring and (ii) if naloxone was indicated. Bivariate and multivariable analyses compared results for those trained to untrained. Responses were also compared to those of 11 medical experts using weighted and unweighted kappa statistics. Findings Respondents were primarily male (72.6%); 45.8% had experienced an overdose and 72% had ever witnessed an overdose. Trained participants recognized more opioid overdose scenarios accurately (t60 = 3.76, P < 0.001) and instances where naloxone was indicated (t59 = 2.2, P < 0.05) than did untrained participants. Receipt of training and higher perceived competency in recognizing signs of an opioid overdose were associated independently with higher overdose recognition scores. Trained respondents were as skilled as medical experts in recognizing opioid overdose situations (weighted kappa = 0.85) and when naloxone was indicated (kappa = 1.0). Conclusions Results suggest that naloxone training programs in the United States improve participants' ability to recognize and respond to opioid overdoses in the community. Drug users with overdose training and confidence in their abilities to respond may effectively prevent overdose mortality.

20. Roux P, Villes V, Blanche J, Bry D, Spire B, Feroni I, Carrieri M P. Buprenorphine in primary care: Risk factors for treatment injection and implications for clinical management. Drug and Alcohol Dependency 2008; 97(1-2): 105-113 Aims Though the introduction of office-based buprenorphine has greatly contributed to stem the HIV epidemic since 1995, concerns have been raised about the intravenous use of buprenorphine even in patients on substitution treatment. The aim of this study was to identify which factors are predictive of buprenorphine injection in patients receiving office-based buprenorphine. Design and setting Subazur is a survey consisting of two longitudinal assessments of 111 stabilized patients receiving office-based buprenorphine in southeastern France. Measurements Patients were interviewed by phone at enrolment and 6 months later about social characteristics, addictive behaviors, treatment experiences, overdoses and suicide ideation or attempt. A logistic regression based on generalized estimating equations (GEE) was used to identify factors associated with buprenorphine injection at any interview. Findings Among the 111 patients (32% women, mean age 38 years), 36 reported buprenorphine injection after having started treatment initiation in 40 interviews. After adjustment for time since first injection, individuals perceiving their prescribed dosage as inadequate (OR = 2.6 95%CI[1.2–5.7]) and those reporting a history of suicide ideation or attempt (OR = 2.7 95%CI[1.1–7.0]) had approximately a three-fold higher risk of injecting buprenorphine. Conclusions Providing adequate care for both drug dependence and psychiatric comorbidities in primary care is a major issue. Like heroin use during methadone treatment, buprenorphine injection should be regarded more as a response to inadequate care than simply as a “misuse”. A re-assessment of the treatment efficacy through a possible dosage increase or a switch to methadone could potentially reduce diversion and assure sustained adherence to OST. Treatment Organisation

21. Frost N, Griffiths P, Fanelli R. Peering into dirty waters: the potential and implications of a new approach to monitoring drug consumption [Editorial]. Addiction 2008; 103(8): 1239-41

No abstract available Psychostimulants 22. McGregor C, Srisurapanont M, Mitchell A, Longo M C, Cahill S, White J M. Psychometric evaluation of the Amphetamine Cessation Symptom assessment. Journal of Substance Abuse Treatment 2008; 34(4): 443-49

Testing of a new scale, the Amphetamine Cessation Symptom Assessment (ACSA), in a sample of treatment-seeking amphetamine users (N = 133) showed satisfactory reliability, while factor analysis identified three components explaining 64.7% of the variance in scores. Scores were inversely related to subjective general well-being (r = −.33, p < .01) and directly related to the Beck Depression Inventory (r = .59, p < .01). There were positive relationships between the ACSA and measures of amphetamine dependence (r = .36, p < .01) and the intensity of recent amphetamine use (r = .24, p < .01). The ACSA discriminated between “low-dose” and “high-dose” users, indicating discriminant validity. In inpatients (n = 63), ACSA scores declined significantly over time, while higher scores in inpatient treatment dropouts indicated predictive validity. The ACSA showed satisfactory reliability and validity, with a three-factor solution providing the best fit to the data. The ACSA could play an important role in providing clinical outcome data, particularly in outcome evaluation of new treatment protocols. Co-Morbidity 23. Winstock A R, Lea T, Sheridan J. Patients’ help-seeking behaviours for health problems associated with methadone and buprenorphine treatment. Drug and Alcohol Review 2008; 27(4): 393-97

Introduction and Aims Clients in opioid substitution therapy often have considerable unmet health-care needs. The current study aimed to explore health problems related to opioid substitution therapy among clients on methadone and buprenorphine treatment. Design and Methods A self-complete, cross-sectional survey conducted among 508 patients receiving methadone and buprenorphine treatment at community pharmacies in New South Wales (NSW), Australia. Results. The most common problems for which participants had ever sought help were dental (29.9%), constipation (25.0%) and headache (24.0%). The most common problems for which participants would currently like help were dental (41.1%), sweating (26.4%) and reduced sexual enjoyment (24.2%). There were no significant differences between those currently on methadone and those currently on buprenorphine for any of the health problems explored, nor differences for gender or treatment duration. Participants on methadone doses 100 mg or above were significantly more likely to want help currently for sedation. Discussion and Conclusions. The considerable unmet health care needs among participants in this study suggest that treatment providers should consider improving the detection and response to common health problems related to opioid substitution therapy. Harm Reduction 24. Wong F L, Rotheram-Borus M J, Lightfoot M, Pequegnat W, Comulada W S, Cumberland W, Weinhardt L S, Remien R H, Chesney M, Johnson M. Effects of behavioral intervention on substance use among people living with HIV: the Healthy Living Project randomized controlled study. Addiction 2008; 103(7): 1206-14

Aim Reductions in substance use were examined in response to an intensive intervention with people living with human immunodeficiency virus (HIV) (PLH). Design, setting and participants A randomized controlled trial was conducted with 936 PLH who had recently engaged in unprotected sexual risk acts recruited from four US cities: Milwaukee, San Francisco, New York and Los Angeles. Substance use was assessed as the number of days of use of 19 substances recently (over the last 90 days), evaluated at 5-month intervals over 25 months. Intervention A 15-session case management intervention was delivered to PLH in the intervention condition; the control condition received usual care. Measurements An intention-to-treat analysis was conducted examining reductions on multiple indices of recent substance use calculated as the number of days of use. Findings Reductions in recent substance use were significantly greater for intervention PLH compared to control PLH: alcohol and/or marijuana use, any substance use, hard drug use and a weighted index adjusting for seriousness of the drug. While the intervention-related reductions in substance use were larger among women than men, men also reduced their use. Compared to controls, gay and heterosexual men in the intervention reduced significantly their use of alcohol and marijuana, any substance, stimulants and the drug severity-weighted frequency of use index. Gay men also reduced their hard drug use significantly in the intervention compared to the control condition. Conclusions A case management intervention model, delivered individually, is likely to result in significant and sustained reductions in substance use among PLH. 25. Hanson T, Alessi S M, Petry N M. Contingency management reduces drug-related human immunodeficiency virus risk behaviors in cocaine- abusing methadone patients. Addiction 2008; 103(7): 1187-97

Aim Contingency management (CM) is efficacious in reducing drug use. This study examined whether CM also reduces human immunodeficiency virus (HIV) risk behaviors and if these effects are mediated by longest duration of abstinence achieved during treatment. Design Data were analyzed from a subset of participants in a combined data set of three published randomized controlled trials of CM treatments. Setting A community-based methadone maintenance clinic. Participants One-hundred and sixty-five cocaine-abusing methadone maintenance patients. Intervention Participants received either standard methadone treatment or standard methadone treatment with CM for 3 months. Measurements The HIV Risk Behavior Scale (HRBS) was administered prior to randomization to a study condition and 3 months after the study treatments ended. The primary objective indicator of drug use was longest duration of cocaine and opioid abstinence achieved during treatment. Findings Relative to those assigned to standard care, participants receiving CM significantly decreased overall HIV risk behaviors and injection drug use risk behaviors. CM participants also achieved longer durations of consecutive cocaine and opioid abstinence during treatment. Duration of abstinence achieved mediated the relationship between treatment condition and HRBS difference scores. Conclusions These results suggest that CM treatment reduces HIV drug use risk behaviors in cocaine-abusing methadone maintenance patients. 26. Vallejo F, Toros C, Fuente L de la, Brugal M T, Barrio G, Soriano V, Ballesta R, Bravo M J and Project Itinere Group. Hepatitis B vaccination: An unmet challenge in the era of harm reduction programs. Journal of Substance Abuse Treatment 2008; 34(4): 398-406

The prevalence of vaccination against hepatitis B virus (HBV), factors associated with vaccination, and missed opportunities for vaccination were assessed among 949 street-recruited young injecting heroin users (IHUs) and noninjecting HUs (NIHUs). A cross-sectional study was carried out in Madrid, Barcelona, and Seville. Face-to- face interviews were held using a structured questionnaire with computer-assisted personal interviewing. Dried blood spot samples were tested for anti-HBV core antigen and HBV surface antigen. Bivariate and logistic regression analyses were performed. The prevalence of HBV vaccination was 21.7%, with significant differences among the cities (13.3% in Madrid, 18.4% in Seville, and 33.2% in Barcelona) and between IHUs (23.8%) and NIHUs (17.9%). In the logistic regression analysis, living in Barcelona and being aged 25 years or younger were associated with HBV vaccination in IHUs and NIHUs; in IHUs, vaccination was also associated with living in the street or in institutions for most of the last 12 months. Practically all those susceptible to HBV infection had missed at least one opportunity for vaccination, and most of them had missed such an opportunity in the last year. The proportion of vaccinated HUs remains very low despite efforts to set up harm reduction programs. New and more active strategies must be incorporated in these programs.

27. Sullivan L E, Moore B A, Chawarski M C, Pantalon M V, Barry D, O’Connor P G, Schottenfeld R S, Fiellin D A. Buprenorphine/naloxone treatment in primary care is associated with decreased human immunodeficiency virus risk behaviors. Journal of Substance Abuse Treatment 2008; 34(5): 87-92 Methadone treatment reduces human immunodeficiency virus (HIV) risk, but the effects of primary-care-based buprenorphine/naloxone on HIV risk are unknown. The purpose of this study was to determine whether primary-care-based buprenorphine/naloxone was associated with decreased HIV risk behavior. We conducted a longitudinal analysis of 166 opioid-dependent persons (129 men and 37 women) receiving buprenorphine/naloxone treatment in a primary care clinic. We compared baseline and 12- and 24-week overall, drug-related, and sex-related HIV risk behaviors using the AIDS/HIV Risk Inventory (ARI). Buprenorphine/naloxone treatment was associated with significant reductions in overall and drug-related ARI scores from baseline to 12 and 24 weeks. Intravenous drug use in the past 3 months was endorsed by 37%, 12%, and 7% of patients at baseline and at 12 and 24 weeks, respectively (p < .001). Sex while you or your partner were “high” was endorsed by 64%, 13%, and 15% of patients at baseline and at 12 and 24 weeks, respectively (p < . 001). Inconsistent condom use during sex with a steady partner was high at baseline and did not change over time. We conclude that primary-care-based buprenorphine/naloxone treatment is associated with decreased drug-related HIV risk, but additional efforts may be needed to address sex-related HIV risk when present. 28. Matheson C, Anthony G B, Bond C, Rossi M K. Assessing and prioritizing the preferences of injecting drug users in needle and syringe exchange service development. Journal of Public Health 2008; 30(2): 133- 38 Background Needle exchange services are vital for the distribution of clean injecting equipment and disposal of equipment used for intravenous drug users. From the number of clean needles and syringes distributed and the estimated number of injecting drug users (IDUs), there may be insufficient use of needle exchange services. This highlighted the need to consider how services could be improved to encourage the use. Methods A structured, short, anonymous questionnaire was distributed to IDUs through a wide range of agencies and services in North East Scotland. A form of snowball sampling was also used. Results A total of 370 individuals responded. Respondents noted the following in their two prioritized preferred options: ‘Provision of paraphernalia’ (citric acid, water and filters; 54%), ‘weekend opening hours’ (24%) and ‘antibiotic prescribing’ (23%). Other service developments noted were: ‘friendly, approachable staff’ (16%), ‘family planning’ (10.4%), ‘dressings for wounds/sores’ (9%), ‘leaflets on safer injecting’ (7.0%), ‘advice from staff on safer injecting’ (3.0%) and ‘evening opening hours’ (0.8%). Geographical gaps in current needle exchange services were identified. There was homogeneity of responses across demographic groups. Conclusion IDUs were willing to participate and suggested more provision of paraphernalia. 29. Davis P, Abou-Saleh M T. Developing an enhanced counselling intervention for the primary prevention of Hepatitis C among injecting drug users. Addiction Disorders and their Treatment 2008; 7(2): 65-76 Background Transmission of the hepatitis C virus (HCV) is known to be high among drug users who share injections and the prevention of infection is currently only by changing high-risk behaviors; vaccination against infection is not an option. Prevention programs such as through needle exchange schemes and methadone maintenance prescribing as a substitute to injecting drugs do not seem to be effective in reducing spread of infection. Providing an effective behavioral prevention aimed at changing high-risk behaviors could potentially provide significant health and economic gains. Yet there are no randomized controlled trials of approaches known to be successful in other aspects of disease prevention. Objective To develop an enhanced counseling program based on evidence-based approaches in related behavioral change areas that routine drug clinic staff can be trained to deliver. This needs to be appropriate for and acceptable to this patient group and to enhance therapeutic alliance to increase the likelihood of behavioral change. Method A treatment program was devised based on what is known to be effective in other areas of behavior change where there is ambivalence about change or problems due to the addictive nature of the behavior. This was modified after feedback from service users and piloting within the patient group. It was then delivered to 2 groups of randomly allocated injection drug users. One group received the enhanced counseling therapy, the other a simple educational intervention. Measures were taken of the acceptability of the interventions and their effects on therapeutic alliance. Results Patients receiving the enhanced counseling intervention found the intervention significantly more acceptable and helpful for changing high-risk behaviors associated with HCV transmission. Moreover, these patients developed significantly higher levels of therapeutic alliance that is associated with better treatment outcomes. Conclusions An enhanced counseling program that is likely to be effective in reducing HCV transmission can be delivered by routine clinic staff to patients who inject drugs. This program has been shown to be acceptable to patients and is effective in enhancing therapeutic alliance in this hard to engage population. Alcohol 30. Richardson K, Baillie A, Reid S, Morley K, Teesson M, Sannibale C, Weltman M, Haber P. Do acamprosate or naltrexone have an effect on daily drinking by reducing craving for alcohol? Addiction 2008; 103 (6): 953-59 Aim To explore the effect of acamprosate and naltrexone on craving and alcohol consumption in the treatment of alcohol dependence. Design A randomized, double-blind, single-dummy, placebo-controlled trial. Setting Three treatment centres in Sydney, Australia. Participants A total of 169 alcohol-dependent subjects were given naltrexone (50 mg/day), acamprosate (1998 mg/day) or placebo for 12 weeks, in conjunction with manualized medication compliance therapy. Intervention During the course of the trial, participants kept a daily diary which included the number of standard drinks they consumed and their peak craving for alcohol that day rated on a 0–10 scale. Measurements Subjective ratings of daily craving and daily drinking for the first 6 weeks of treatment. Findings Mixed/hierarchical linear models were employed on an intention-to-treat basis. Analyses revealed that craving was a significant predictor of daily drinking and baseline levels of depression were the best predictor of daily craving. There was no significant improvement in model fit when treatment group was added both in models of daily craving and daily drinking. Daily alcohol consumption was best predicted by a model incorporating baseline dependence and depression scores, and daily craving, entered as a time-varying covariate. However, there was a significant craving × time × treatment interaction (t = −3.365, df = 4413.712, P < 0.001), suggesting that at higher levels of craving drinking was reduced at a significantly greater rate with naltrexone compared to acamprosate. Conclusions Naltrexone had a greater effect on drinking when craving was high. These results support the role of naltrexone in reducing craving when that craving is highly salient. The role of acamprosate in reducing craving was not supported by these findings.

31. Barbor T F, Caetano R. The trouble with alcohol abuse: what are we trying to measure, diagnose, count and prevent? (Editorial) Addiction 2008; 103(7): 1057-59

No abstract available

32. Hickman M, Lingford-Hughes A, Bailey C, Macleod J, Nutt D, Henderson G. Does alcohol increase the risk of overdose death: the need for a translational approach . Addiction 2008; 103(7): 1060-62

Background We argue for a translational approach to addiction science, using an important current research question as a case study. Case study What is the evidence in support of the hypothesis that alcohol increases the risk of a heroin/opiate overdose through a pharmacological interaction? Findings The positive epidemiological evidence shows that opiate overdose deaths rarely involve a single drug; that alcohol is the most common other drug involved; that there is a negative association between alcohol and morphine concentration at post mortem; and that post-mortem levels of morphine are often below the levels expected of highly tolerant individuals. The evidence is consistent with the hypothesis that heroin users who drink may require less heroin to overdose than those who do not drink (all other factors being equal) because of a pharmacological interaction. However, the evidence is consistent with, and does not rule out, other causal (and non-causal) pathways. Alcohol could be associated negatively with tolerance, or confounded by other factors. Experimental evidence is required which is unlikely to be obtained through further epidemiological study or through randomized clinical trials. Conclusions We believe that animal models could provide the key evidence to test the hypothesis for a 'pharmacodynamic' or 'pharmacokinetic' interaction, which could be corroborated in clinical challenge studies and epidemiological studies. Such a translational approach demands greater collaboration between addiction scientists from basic to applied science and from neuroscience to social science, and would be able to address other key research questions and hypotheses in addiction.

33. Soyka M. Alcohol and the risk of overdose death from heroin [Commentary]. Addiction 2008; 103(7) : 1064-65

No abstract available 34. Rose H L, Miller P M, Nemeth L S, Jenkins R G, Nietert P J, Wessell A M. Alcohol screening and brief counselling in a primary care hypertensive population: a quality improvement intervention. Addiction 2008; 103(8): 1271-80

Aims To determine the effect of an intervention to improve alcohol screening and brief counseling for hypertensive patients in primary care. Design Two-year randomized, controlled trial. Setting/participants Twenty-one primary care practices across the United States with a common electronic medical record. Intervention To promote alcohol screening and brief counseling. Intervention practices received site visits from study personnel and were invited to annual network meetings to review the progress of the project and share improvement strategies. Measurements Main outcome measures included rates of documented alcohol screening in hypertensive patients and brief counseling administered in those diagnosed with high-risk drinking, alcohol abuse or alcohol dependence. Secondary outcomes included change in blood pressure among patients with these diagnoses. Findings Hypertensive patients in intervention practices were significantly more likely to have been screened after 2 years than hypertensive patients in control practices [64.5% versus 23.5%; adjusted odds ratio (OR) = 8.1; 95% confidence interval (CI) 1.7–38.2; P < 0.0087]. Patients in intervention practices diagnosed with high-risk drinking, alcohol abuse or alcohol dependence were more likely than those in control practices to have had alcohol counseling documented (50.5% versus 29.6%; adjusted OR = 5.5, 95% CI 1.3–23.3). Systolic (adjusted mean decline = 4.2 mmHg, P = 0.036) and diastolic (adjusted mean decline = 3.3 mmHg, P = 0.006) blood pressure decreased significantly among hypertensive patients receiving alcohol counseling. Conclusions Primary care practices receiving an alcohol-focused intervention over 2 years improved rates of alcohol screening for their hypertensive population. Implementation of alcohol counseling for high-risk drinking, alcohol abuse or alcohol dependence also improved and led to changes in patient blood pressures. 35. Mulia N, Schmidt L, Bond J, Jacobs L, Korcha R. Stress, social support and problem drinking among women in poverty . Addiction 2008; 103(8): 1283-93

Aims Previous studies have found that stress contributes to problem drinking, while social support can buffer its effects. However, these studies are confined largely to middle-class and general populations. We extend what is known by examining how the unique stressors and forms of social support experienced by women in poverty impact alcohol problems over a 4-year time-period. Design, setting and participants This prospective study used generalized estimating equations (GEE) transition modeling and four annual waves of survey data from 392 American mothers receiving Temporary Assistance for Needy Families (TANF) in a large Northern California county. Measurements We examined the effects of neighborhood disorder, stressful life events and economic hardship on psychological distress and problem drinking over time, and whether social support moderated these relationships for women in poverty. Findings Neighborhood disorder and stressful life events increased significantly the risk for problem drinking, largely through their effect on psychological distress. We found little evidence, however, that social support buffers poor women from the effects of these stressors. Conclusions Women in poverty are exposed to severe, chronic stressors within their communities and immediate social networks which increase vulnerability to psychological distress and problem drinking. The finding that social support does not buffer stress among these women may reflect their high level of exposure to stressors, as well as the hardships and scarce resources within their networks. If the 'private safety net' of the social network fails to provide a strong buffer, more effective environmental interventions that reduce exposure to stressors may be needed to prevent alcohol problems in poor women's lives. 36. Sheridan J, Wheeler A, Chen L J, Huang A C, Leung I N, Tien K Y. Screening and brief interventions for alcohol: attitudes, knowledge and experience of community pharmacists in Auckland, New Zealand. Drug and Alcohol Review 2008; 27(4): 380-87

Introduction Screening and brief intervention (SBI) for alcohol consumption in primary care have been shown to be effective in reducing drinking. This role has not been taken up by community pharmacists. This study aimed to explore attitudes, knowledge, barriers and incentives towards involvement of community pharmacists in New Zealand with problem drinkers.

Method A postal survey (three mailshots) of community pharmacies was undertaken in Auckland, New Zealand, followed by a 10% random sample non-responder-follow- up.

Results A response rate of 39.1% to the postal survey was obtained. In general, knowledge of alcohol content of drinks and recommended safe drinking limits was poor. Respondents were generally well motivated towards undertaking this role, but lacked knowledge, skills and confidence. On follow-up, non-responders were found to be less knowledgeable, but had similar attitudes to respondents, indicating potential for extrapolation with regard to beliefs and views on this subject.

Discussion This novel study has found that there is potential for involvement of community pharmacists in New Zealand in SBI for problem drinkers. Lack of knowledge can be remedied relatively easily; greater hurdles such as lack of skills, and lack of confidence may be offset by the high level of motivation of this group. This is an area where community pharmacists can further their professional scope of practice by being in an essential position to provide this service.

This study examined the relationship of the therapeutic alliance and treatment outcomes for alcohol-dependent patients receiving naltrexone or placebo and one of three different types of clinical interventions, including two medical-based (non- specialty) treatments. This is a secondary analysis of a 24-week randomized, placebo- controlled, clinical trial of 100 mg/day of naltrexone or placebo for patients with DSM-IV alcohol dependence. Patients were also randomized to one of three interventions: (1) medication clinic only, (2) medication clinic plus BRENDA (an intervention promoting pharmacotherapy), or (3) medication clinic plus cognitive behavioral therapy (CBT). Early in treatment, patients and clinicians completed the working alliance inventory (WAI). Regression analyses were conducted to determine the predictive validity of the WAI on percent days abstinent and percent of sessions attended over the clinical trial. In the medication clinic only condition, the clinicians’ WAI total score was marginally correlated to percent of visits attended (p = .057) but not percent days abstinent. In the medication clinic plus BRENDA condition, clinicians’ WAI total score was positively correlated with percent days abstinent (p = .013) but not percent visits attended. No significant relationships were found between the WAI scores and either outcome measure in the CBT condition or for any of the patient rated assessments. To our knowledge, this is the first published report providing some support for the importance of the therapeutic alliance in medical interventions for alcohol dependence but only in the context of the clinicians’ ratings. The absence of other effects underscores the need for further research.

Brief interventions are known to be effective in changing both substance use and other health-compromising behaviors. It is unknown whether they may have secondary effects on behaviors which are not specifically targeted. The literature on brief alcohol interventions was selected to explore this possibility, with a study focus on secondary impact on cigarette smoking. The CINAHL, EMBASE, MEDLINE and PSYCINFO bibliographic databases were searched for reviews of brief alcohol intervention studies published in English language, peer-reviewed journals between 1995 and 2005. Authors of primary studies identified in the reviews were contacted to ascertain whether or not their studies had collected cigarette smoking data and, if available, to obtain data. Random effect models were used to pool data for meta- analysis. Eleven review papers reported the results of 41 individual primary studies which were included in this systematic review. Fourteen of these studies collected cigarette smoking outcome data, of which 7 studies still had information available and provided these data for meta-analysis. There were no between-group differences in smoking cessation or reduction across these studies. High levels of smoking cessation were detected in both brief intervention and control groups with much heterogeneity between studies. Brief alcohol interventions do not also reduce cigarette smoking, and it appears unlikely that there exist other important secondary effects. The behavioral consequences of brief intervention study participation itself warrant further study. 39. Bewick B M, Trusler K, Mulhern B, Barkham M. The feasibility and effectiveness of a web-based personalised feedback and social norms alcohol intervention in UK university students: A randomised controlled trial. Addictive Behaviours 2008; 33(9) 1192-98 Objective Alcohol misuse amongst University students is a serious concern, and research has started to investigate the feasibility of using e-health interventions. This study aimed to establish the effectiveness of an electronic web-based personalised feedback intervention through the use of a randomised control trial (RCT). Methods 506 participants were stratified by gender, age group, year of study, self- reported weekly consumption of alcohol and randomly assigned to either a control or intervention condition. Intervention participants received electronic personalised feedback and social norms information on their drinking behaviour which they could access by logging onto the website at any time during the 12-week period. CAGE score, average number of alcoholic drinks consumed per drinking occasion, and alcohol consumption over the last week were collected from participants at pre- and post-survey. Results A significant difference in pre- to post-survey mean difference of alcohol consumed per occasion was found, with those in the intervention condition displaying a larger mean decrease when compared to controls. No intervention effect was found for units of alcohol consumed per week or for CAGE scores. Sixty-three percent of intervention participants agreed that the feedback provided was useful. Those intervention participants who were above the CAGE cut off were more likely to report that the website would make them think more about the amount they drank. Conclusions Delivering an electronic personalised feedback intervention to students via the World Wide Web is a feasible and potentially effective method of reducing student alcohol intake. Further research is needed to replicate this outcome, evaluate maintenance of any changes, and investigate the process of interaction with web- based interventions. 40. Ray L A, Hutchinson K E, MacKillop J, Miranda R, Audette A, Swift R, Monti P M. Effects of Naltrexone during the descending limb if the blood alcohol curve. American Journal on Addictions 2008; 17(4): 257-64

The neuropharmacological effects of alcohol are known to vary by limb of the blood alcohol curve, yet human laboratory studies of alcoholism pharmacotherapies have largely failed to consider limb of intoxication when examining medication effects on subjective responses to alcohol. This study examined the effects of naltrexone compared to placebo on subjective responses to alcohol at the descending limb of the blood alcohol curve following a controlled intravenous (IV) alcohol administration. Non-treatment-seeking hazardous drinkers (n = 38) completed two double-blind counterbalanced IV alcohol challenge sessions, one after taking naltrexone (50 mg) for three days and one after taking a placebo for three days. During each session, participants reported on subjective responses to alcohol during the descending limb of the blood alcohol curve. Analyses revealed significant main effects of naltrexone, reflecting significantly decreased alcohol-induced stimulation, craving, vigor, positive mood, and alcohol “high” and increased tension as compared to placebo. These findings suggest that naltrexone may exert some of its therapeutic effects via alterations to experiential aspects of intoxication during the descending limb of alcohol intoxication. Additionally, these results highlight the potential utility of considering limb of blood alcohol curve when examining the mechanisms of action of pharmacotherapies thought to alter subjective responses to alcohol. Blood Borne Viruses (BBVs) 41. Werb D, Kerr T, Small W, Li K, Montaner J, Wood E. HIV risks associated with incarceration among injection drug users: implications for prison-based public health strategies . Journal of Public Health 2008; 30(2): 126-32 Background Recent policy announcements in Canada and the United States may potentially affect the risk environment for HIV transmission among incarcerated injection drug users (IDU). We sought to evaluate the potential impact of incarceration on HIV risk behaviour among the IDU enrolled in a prospective cohort study. Methods We examined patterns of incarceration among 1247 IDU participants enrolled in a 6-year prospective cohort study in Vancouver, Canada, and tested for potential associations between HIV risk behaviour and incarceration. Correlates of incarceration were identified using generalized estimating equations (GEE). Results At baseline, factors significantly associated with incarceration included daily injection heroin and injection cocaine use and inconsistent condom use with casual sexual partners. In a GEE analysis, factors independently associated with incarceration included: used syringe borrowing (adjusted odds ratio [AOR] = 1.36; [95% CI: 1.16– 1.60]), used syringe lending (AOR = 1.31; [95% CI: 1.12–1.55]) and inconsistent condom use with casual sexual partners (AOR = 1.16; [1.02–1.33]). All variables P < 0.05. Conclusion In our study, incarceration was independently associated with HIV transmission and acquisition behaviours. These findings suggest that increased rates of incarceration of IDU may be associated with increased HIV transmission among this group. 42. Willner-Reid J, Belendiuk K A, Epstein D H, Schmittner J, Preston K L. Hepatitis C and human immunodeficiency virus risk behaviors in polydrug users on methadone maintenance. Journal of Substance Abuse Treatment 2008; 34(5): 78-86 We examined the impact of methadone maintenance treatment (MMT) on risk behaviors for transmission of blood-borne diseases in polydrug users who had tested positive or negative for hepatitis C virus (HCV). At intake, HCV-positive participants (n = 362) engaged in more human immunodeficiency virus (HIV) risk behaviors (as measured by the HIV Risk-Taking Behavior Scale) than HCV-negative participants (n = 297; p < .001). This difference was specific to injection-related behaviors and decreased significantly within the first few weeks of MMT (p < .0001). Where needles continued to be used, HCV-positive participants became more likely over time to engage in safer injecting practices. Furthermore, HCV-positive participants became more likely to use condoms than HCV-negative participants. These findings demonstrate that both drug- and sex-related risk behaviors decrease during MMT and emphasize the benefits of methadone programs for public health and HIV/HCV prevention. 43. Novick N, Kreek M J. Critical issues in the treatment of hepatitis C virus infection in methadone maintenance patients. Addiction 2008; 103 (6): 905-18

Aims Hepatitis C virus (HCV) infection is a common chronic complication of injection drug use. Methadone maintenance programs contain large numbers of patients infected with HCV. This paper reviews HCV infection with emphasis on the medical care of HCV-infected, or HCV and human immunodeficiency virus co- infected, patients on methadone or buprenorphine maintenance. Methods Literature searches using PubMed, PsycINFO and SocINDEX were used to identify papers from 1990–present on antiviral therapy for HCV in methadone maintenance patients and on liver transplantation in methadone maintenance patients. Results Injection drug use is the most significant risk factor for HCV infection in most western countries. The prevalence of HCV antibody is high in injection drug users (53–96%) and in patients enrolled in methadone maintenance programs (67– 96%). Studies of antiviral therapy for HCV in methadone maintenance patients show rates of sustained virological response (SVR), defined as negative HCV-RNA 24 weeks after the end of treatment, of 28–94%. In studies with contrast groups, no significant differences in SVR between methadone and contrast groups were found. Excellent completion rates of antiviral therapy (72–100%) were found in five of six studies. There are many barriers to methadone maintenance patients' receiving antiviral therapy, and research on overcoming barriers is discussed. Liver transplantation has been successful in methadone maintenance patients but has not been utilized widely. Conclusion High quality medical care for all aspects of HCV infection can be provided to methadone maintenance patients. The literature supports the effectiveness of such services, but the reality is that most patients do not receive them. 44. Malta M, Strathdee S A, Monica M F, Bastos F I. Adherence to antiretroviral therapy for human immunodeficiency virus/acquired immune deficiency syndrome among drug users: a systematic review. Addiction 2008; 103(8): 1242-57

Aims Adherence to highly active antiretroviral therapy (HAART) is a key predictor of survival for human immunodeficiency virus (HIV)-infected people. Suboptimal adherence among marginalized populations such as HIV-positive drug users could be associated with clinical failure and the emergence of viral resistance. Objective To conduct a systematic review of studies assessing adherence to HAART among HIV-positive drug users (DU) and identify factors associated with non- adherence to HIV treatment. Data sources Seven electronic databases were searched for peer-reviewed papers published in English, French, Spanish or Portuguese, from 1996 to 2007. Study selection and data abstraction Studies were excluded if they presented only qualitative data, were reviews themselves or assessed other populations without disaggregating data on DU. Findings on adherence were extracted and summarized. Data synthesis Forty-one studies were considered, which studied a total of 15 194 patients, the majority of whom were HIV-positive DU (n = 11 628, 76.5%). Twenty- two studies assessed adherence using patient self-reports, eight used pharmacy records, three used electronic monitoring [i.e. Medication Event Monitoring Systems (MEMS) caps], six studies used a combination of patient self-report, clinical data and MEMS-caps, and two analyzed secondary data. Overall, active substance use was associated with poor adherence, as well as depression and low social support. Higher adherence was found in patents receiving care in structured settings (e.g. directly observed therapy) and/or drug addiction treatment (especially substitution therapy). Conclusion While lower than other populations—especially among users of stimulants, incarcerated DU and patients with psychiatric comorbidities—adherence to HAART among HIV-positive DU can be achieved. Better adherence was identified among those engaged in comprehensive services providing HIV and addiction treatment with psychosocial support. Cannabis 45. McLaren J, Swift W, Dillon P, Allsop S. Cannabis potency and contamination: a review of the literature. Addiction 2008; 103(7): 1100-09

Aims Increased potency and contamination of cannabis have been linked in the public domain to adverse mental health outcomes. This paper reviews the available international evidence on patterns of cannabis potency and contamination and potential associated harms, and discusses their implications for prevention and harm reduction measures. Methods A systematic literature search on cannabis potency and contamination was conducted. Results Cannabis samples tested in the United States, the Netherlands, United Kingdom and Italy have shown increases in potency over the last 10 years. Some countries have not shown significant increases in potency, while other countries have not monitored potency over time. While there are some grounds to be concerned about potential contaminants in cannabis, there has been no systematic monitoring. Conclusion Increased potency has been observed in some countries, but there is enormous variation between samples, meaning that cannabis users may be exposed to greater variation in a single year than over years or decades. Claims made in the public domain about a 20- or 30-fold increase in cannabis potency and about the adverse mental health effects of cannabis contamination are not supported currently by the evidence. Systematic scientific testing of cannabis is needed to monitor current and ongoing trends in cannabis potency, and to determine whether cannabis is contaminated. Additionally, more research is needed to determine whether increased potency and contamination translates to harm for users, who need to be provided with accurate and credible information to prevent and reduce harms associated with cannabis use. 46. Martin G, Copeland J. The adolescent cannabis check-up: Randomized trial of a brief intervention for young cannabis users. Journal of Substance Abuse Treatment 2008; 34(4) 407-14

The aim of this study was to evaluate the efficacy of a brief motivational enhancement therapy in reducing cannabis use and cannabis-related problems in a population of non-treatment-seeking adolescent cannabis users. In a randomized controlled trial, 40 young people (aged 14–19 years) were randomly assigned to either a two-session brief intervention or a 3-month delayed-treatment control condition. The intervention consisted of a detailed assessment and a session of motivational enhancement therapy. An additional optional discussion of skills for reducing or quitting cannabis use was offered if a participant was interested in discussing these issues. Primary outcome measures were changes in days of cannabis use, mean quantity of cannabis used weekly, and number of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition dependence symptoms reported. Significantly greater reductions on these measures were found in the Adolescent Cannabis Check-up group at 3-month follow-up. Between-group effect sizes were moderate. The approach is acceptable to participants and merits further evaluation with this difficult to reach population.