Translating research findings into practice: example of treatment services for adolescents in managed care.

An important question in the alcoholism treatment field is how research findings can be translated into real-world clinical practice. Researchers have developed a new research-practice integration (RPI) model that can both drive the formulation of studies and new research questions and promote improvements in treatment quality. The hallmark of this model is a collaborative relationship between the key stakeholders in both alcohol and other drug (AOD) treatment and research, including health plan administrators and clinicians, treatment program administrators, psychiatry and primary care departments, patients and their families, purchasers, and researchers. The issue of technology transfer is especially relevant in the realm of adolescent AOD treatment. The implementation and feasibility of the RPI model are illustrated by a case study of a managed health care plan's treatment services for adolescents with AOD dependence. In this setting, key research findings are being used to shape the plan's adolescent health services

Patient Satisfaction with Primary Care Office-Based Buprenorphine/Naloxone Treatment

BACKGROUND: Factors associated with satisfaction among patients receiving primary care–based buprenorphine/naloxone are unknown. OBJECTIVE: To identify factors related to patient satisfaction in patients receiving primary care–based buprenorphine/naloxone that varied in counseling intensity (20 vs 45 minutes) and office visit frequency (weekly vs thrice weekly). DESIGN AND PARTICIPANTS: One hundred and forty-two opioid-dependent subjects. MEASUREMENTS: Demographics, drug treatment history, and substance use status at baseline and during treatment were collected. The primary outcome was patient satisfaction at 12 weeks. RESULTS: Patients’ mean overall satisfaction score was 4.4 (out of 5). Patients were most satisfied with the medication and ancillary services and indicated strong willingness to refer a substance-abusing friend for the same treatment. Patients were least satisfied with their interactions with other opioid-dependent patients, referrals to Narcotics Anonymous, and the inconvenience of the treatment location. Female gender (β = .17, P = .04) and non-White ethnicity/race (β = .17, P = .04) independently predicted patient satisfaction. Patients who received briefer counseling and buprenorphine/naloxone dispensed weekly had greater satisfaction than those whose medication was dispensed thrice weekly (mean difference 4.9, 95% confidence interval 0.08 to 9.80, P = .03). CONCLUSIONS: Patients are satisfied with primary care office-based buprenorphine/naloxone. Providers should consider the identified barriers to patient satisfaction

Coercion and Motivation: Construct Analysis and Factor Association in Entering Treatment for Substance-Abuse

Informed by the theoretical underpinnings of Self-determination theory (SDT), we aimed to examine relationships between motivation and independent measures of external pressure and explore whether or not a directional association exists between perceived coercion and motivation. Using the Circumstance, and Motivation subscales of the CMR and availability sampling method, we surveyed 63 clients seeking substance abuse treatment under legal coercion, social coercion, and voluntarily. Results suggest that motivation to engage in substance abuse treatment is not reliably inferred from referral source. Treatment seeking groups appear to experience greater external pressures to leave treatment than to enter treatment. Results are consistent with SDT—specifically, treatment motivation appears to be a personal consideration that likely moderates the effect of coercion

Randomized Clinical Trial of Motivational Enhancement of Substance Use Treatment Among Incarcerated Adolescents: Post-Release Condom Non-Use

Evaluated impact of motivational enhancement (ME) of substance abuse treatment compared to relaxation training (RT) on sex without condoms (overall and involving substance use) 3 months following release among incarcerated adolescents. This randomized clinical trial involved 114 incarcerated adolescents from the Northeast. Regression analyses determined if treatment condition, baseline levels of depressive symptoms, and their interaction predicted condom non-use 3 months post-release, controlling for baseline condom non-use. Among those who reported fewer baseline depressive symptoms, those in ME condition reported significantly less condom non-use, in general and involving marijuana use compared with those in RT condition. Periods of incarceration represent opportunities to help juvenile detainees reduce behaviors that impact their health and the health of those with whom they interact in the community

Ethnic differences among substance using adolescents in a treatment dissemination project.

Despite evidence of ethnic differences in substance use patterns among adolescents in community samples, clinical studies have not found ethnic differences in posttreatment outcomes. Prior clinical studies have been limited by small samples, focus on broad treatment modalities, and lack of consideration of important covariates. We investigated ethnic differences in substance use frequency and problems in a large sample of White (60%), African American (12%), and Latino (28%) adolescents prior to and following an evidence-based treatment. Participants included 4,502 adolescents (29% female), with ages 13–18 years, who received Motivational Enhancement Therapy/Cognitive Behavior Therapy 5 Sessions. At baseline, African American adolescents demonstrated less frequent use, fewer problems, and less comorbidity than Whites or Latinos. Consistent with prior research, there were no ethnic differences in substance use outcomes among assessment completers (71%) when controlling for baseline differences. However, African Americans, older adolescents, and males were less likely to complete the posttreatment assessment. Implications for clinical service and effectiveness research are discussed

Du sable dans l’engrenage : la motivation des clients sous contrainte judiciaire dans les traitements pour la toxicomanie

Le système de justice devient de plus en plus impliqué dans le processus de référence des individus criminalisés vers des programmes de traitement de la toxicomanie. Cette pratique a d’importantes retombées sur les interventions cliniques puisque ces clients sont habituellement considérés comme peu motivés au changement et qu’ils présenteraient des besoins spécifiques qui ne seraient pas facilement satisfaits à travers les approches classiques d’intervention. Ainsi, l’objectif de cet article est, à travers une recension des articles publiés au cours des dix dernières années, de discuter de la disposition au changement des participants à des traitements sous contrainte. L’analyse démontre que la coercition imposée par un ordre judiciaire peut fonctionner comme une source de motivation externe afin d’amener et de retenir les individus en traitement. Par ailleurs, l’engagement et le changement de comportement seraient plutôt reliés au développement de la motivation interne. La « théorie du bas-fond » associe la motivation interne d’un toxicomane à l’accumulation de conséquences négatives reliées à sa consommation de psychotropes. Ainsi, les individus ayant vécu le plus de problèmes seraient davantage prêts au changement et de ce fait, seraient plus susceptibles d’arriver à des résultats positifs à la suite d’un traitement. Cette « théorie » n’est toutefois que partiellement soutenue par les études scientifiques recensées, car si la gravité des problèmes semble reliée à la motivation au changement en début de traitement, celle-ci n’est pas toujours associée à un impact positif du traitement. Nous concluons que les dimensions « externe » et « interne » de la motivation entreraient en intime relation dans le contexte des traitements sous contrainte, et que le processus de développement de la motivation interne à partir des pressions externes exercées sur l’individu mériterait beaucoup plus de recherches.The justice system is becoming increasingly involved in the referral process of criminalized individuals to drug treatment programs. This practice has important implications for clinical interventions, as these people are usually considered poorly motivated to change, and present specific needs that are not easily satisfied through conventional intervention approaches. Thus, the aim of this paper is to discuss the readiness to change of coerced treatment participants through a review of articles published over the last ten years. The analysis demonstrates that the coercion generated by the justice system can function as a source of external motivation, in the sense of bringing and retaining individuals into treatment. Moreover, engagement and behavior change are rather related to the development of internal motivation. Some studies associate the internal motivation of an addict with the experience of negative consequences related to the use of psychotropic substances. Therefore, individuals who experience the most problems would be more willing to change and thus more likely to achieve positive results in treatment. This is called «hitting the bottom theory». This «theory» is only partially supported, because if the seriousness of the problems seem related to motivation to change in early treatment, it is not always associated with positive treatment outcomes. We conclude that the «external» and «internal» dimensions of motivation come into intimate relationship in the context of coerced treatment, and the process of developing internal motivation through external pressure requires much more research.El sistema judicial está cada vez más involucrado en el proceso de referencia de los individuos con condenas criminales a programas de tratamiento de la toxicomanía. Esta práctica tiene importantes consecuencias en las intervenciones clínicas, porque se considera en general que estos clientes están poco motivados para el cambio y que presentan necesidades específicas que no se pueden satisfacer fácilmente mediante los enfoques clásicos de intervención. A través de una reseña de trabajos publicados durante los últimos diez años, este artículo tiene como objetivo analizar la disposición al cambio que presentan ante los tratamientos los participantes que están bajo orden judicial. El análisis demuestra que la coerción impuesta por una orden judicial puede funcionar como fuente de motivación externa para hacer ir a los individuos al tratamiento y retenerlos. Por otra parte, el compromiso y el cambio de comportamiento estarían más bien relacionados con el desarrollo de la motivación interna. La teoría del «bajo fondo» relaciona la motivación interna de un toxicómano a la acumulación de consecuencias negativas vinculadas a su consumo de psicotrópicos. Las personas que han vivido más problemas serían más propicias al cambio y, de este modo, serían más susceptibles de lograr resultados positivos con un tratamiento. Esta «teoría» es sólo parcialmente sostenida por los estudios científicos analizados, ya que si bien la gravedad de los problemas parece estar relacionada con la motivación para el cambio al principio del tratamiento, la misma no está siempre asociada con un impacto positivo del tratamiento. Nosotros llegamos a la conclusión de que las dimensiones «externa» e «interna» de la motivación estarían en íntima relación en el contexto de los tratamientos impuestos por orden judicial y que el proceso de desarrollo de la motivación interna a partir de presiones externas ejercidas sobre el individuo merecería más investigación..

Drug Use Trajectory Patterns among Older Drug Users

To better understand patterns of drug use trajectories over time, it is essential to have standard measures of change. Our goal here is to introduce measures we developed to quantify change in drug use behaviors. A secondary goal is to provide effective visualizations of these trajectories for applied use. We analyzed data from a sample of 92 older drug users (ages 45 to 65) to identify transition patterns in drug use trajectories across the life course. Data were collected for every year since birth using a mixed methods design. The community-drawn sample of active and former users were 40% female, 50% African American, and 60% reporting some college or greater. Their life histories provided retrospective longitudinal data on the diversity of paths taken throughout the life course and changes in drug use patterns that occurred over time. Bayesian analysis was used to model drug trajectories displayed by innovative computer graphics. The mathematical techniques and visualizations presented here provide the foundation for future models using Bayesian analysis. In this paper we introduce the concepts of transition counts, transition rates and relapse/remission rates, and we describe how these measures can help us better understand drug use trajectories. Depicted through these visual tools, measurements of discontinuous patterns provide a succinct view of individual drug use trajectories. The measures we use on drug use data will be further developed to incorporate contextual influences on the drug trajectory and build predictive models that inform rehabilitation efforts for drug users. Although the measures developed here were conceived to better examine drug use trajectories, the applications of these measures can be used with other longitudinal datasets

A Brief Introduction to Four National Health Databases in the United States

Health and medical care pervade every aspect of our lives. As the world population ages, an entirely new demographic stress will be put on healthcare systems. Some estimates project healthcare costs in the United States to account for 20% of GDP in the next few years. In comparison, China’s total expenditure on health as a percentage of GDP has risen steadily and it is currently below 6%. However, with the rise of life expectancy, an aging population and higher living standards, health expenditure in China will continue to rise.  Another challenge China faces is healthcare system reform to ensure equity and to reduce health disparity. To solve these challenges, accurate collection of health statistics at the national level is needed. In this article, we introduce and compare four national health databases in United States, which are pillars for evaluating national health profile and for formulating national health policies. The four databases are National Health Interview Survey (NHIS), Medical Expenditure Panel Survey (MEPS), National Health and Nutrition Examination Survey (NHANES) and Behavioral Risk Factor Surveillance System (BRFSS). As an example, we illustrate how to derive the prevalence of cholesterol screening from the four databases. Despite differences, the overall distributions follow similar patterns across four datasets. These databases can be linked with other data sources to answer more complicated questions in health and healthcare. We hope that this article can draw the attention of Chinese health researchers and policymakers on the importance of health surveillance and can lead to more discussions and interest on how China can benefit from the U.S. experience in conducting health surveillance at the national level

"Core group" para identificar universitários em risco para infecções sexualmente transmissíveis

OBJECTIVE: To analyze the core group for sexually transmitted infections (STI) among college students. METHODS: Cross-sectional study carried out in a convenience sample comprising 711 college students of the public university of Morelos, Mexico, between 2001 and 2003. Sociodemographic and sexual behavior information were collected using self-applied questionnaires. Herpes simplex 2 (HSV-2) infection was tested in the blood. The number of sexual partners in the last year and cocaine consumption were used as indicators to construct the dependent variable "level of STI risk" in three categories: low, medium and high risk (core group). A multinomial analysis was conducted to evaluate whether different sex behaviors were associated with the variable "level of STI risk". RESULTS: There was significant association between HSV-2 seroprevalence and the variable "level of STI risk": 13%, 5.6% and 3.8% were found in high (core group), medium and low categories, respectively. There were gender differences regarding the core group. Men started having sexual intercourse earlier, had more sex partners, higher alcohol and drug consumption, higher frequency of sex intercourse with sex workers, exchanging sex for money, occasional and concurrent partners compared to women. CONCLUSIONS: The study findings suggest existing contextual characteristics in the study population that affect their sex behavior. In Mexico, the cultural conception of sexuality is determined mainly by gender differences where men engage in higher risky sexual behavior than women.OBJETIVO: Identificar al grupo core de infecciones de transmisión sexual (ITS) en una población de estudiantes universitarios mexicanos. MÉTODOS: Se realizó un estudio transversal en una muestra por conveniencia que incluyó 711 estudiantes de una universidad pública de Morelos, México, entre 2001 y 2003. Las características sociodemográficas y de comportamiento sexual se obtuvieron mediante un cuestionario auto-aplicado. La infección por el Virus del herpes simple tipo 2 (VHS-2) se determinó en pruebas de sangre. El número de parejas sexuales durante el último año y el consumo de cocaína, fueron indicadores utilizados para construir la variable dependiente "nivel de riesgo para adquirir ITS" que tuvo tres categorías: bajo, medio y alto riesgo (grupo core). Mediante un análisis multinomial se evaluó si las características sociodemográficas y de comportamiento sexual estuvieron relacionadas con la variable dependiente. RESULTADOS: Se encontró una relación significativa entre la seroprevalencia de VHS-2 y la variable dependiente encontrando frecuencias de 13%, 5.6% y 3.8% en las categorías de alto, medio y bajo riesgo, respectivamente. Los resultados mostraron diferencias de género en la constitución del grupo core. En comparación con las mujeres, los hombres iniciaron su vida sexual a más temprana edad, reportaron mayor número de parejas sexuales, mayores niveles de consumo de alcohol y drogas, mayor frecuencia de contacto sexual con trabajadoras sexuales, intercambio de sexo por dinero, relaciones con parejas ocasionales y concurrentes. CONCLUSIONES: Los resultados sugieren que existen características contextuales que influyen en el comportamiento sexual. En México la concepción cultural de la sexualidad está conformada por diferencias marcadas entre hombres y mujeres, donde los primeros tienen un comportamiento sexual de riesgo mayor que las mujeres.OBJETIVO: Analisar o core group em estudantes universitários em risco de adquirir infecções sexualmente transmissíveis (IST). MÉTODOS: Estudo transversal com amostra de conveniência composta por 711 estudantes de universidade pública de Morelos, no México, 2001-2003. Informações sociodemográficas e de comportamento sexual foram coletadas por meio de questionário auto-aplicável. Presença de infecção por Herpes simplex 2 foi diagnosticada por exame de sangue. O número de parceiros sexuais durante o último ano anterior à pesquisa e o consumo de cocaína foram indicadores utilizados para construir a variável dependente "nível de risco para adquirir IST" e definir três categorias: baixo, médio e alto risco (core group). Foi utilizada análise multinominal para avaliar se diferentes comportamentos sexuais estavam associados à variável "nível de risco para adquirir IST". RESULTADOS: Houve associação significativa entre a soroprevalência de HSV-2 e a variável "nível de risco para adquirir IST" nas categorias de alto (13%), médio (5,6%) e baixo (3,8%) risco. Foram encontradas diferenças entre os sexos em relação ao core group. Em comparação às mulheres, os homens começaram a ter relações sexuais mais cedo, tiveram maior número de parceiras sexuais, níveis mais elevados de consumo de álcool e drogas, maior freqüência de sexo com profissionais do sexo, prática de sexo por dinheiro, parceiras ocasionais e concomitantes. CONCLUSÕES: Os resultados sugerem a existência de características contextuais da população que influenciam o comportamento sexual. No México, a concepção cultural de sexualidade é caracterizada por diferenças marcantes entre homens e mulheres, nas quais os homens têm comportamento sexual de maior risco que as mulheres

Predictors of syphilis seroreactivity and prevalence of HIV among street recruited injection drug users in Los Angeles County, 1994-6

Objectives: To describe HIV prevalence and the association between syphilis incidence and sexual and drug injection risk behaviours in a cohort of street recruited injecting drug users (IDUs) in Los Angeles County, between 1994 and 1996. Methods: During the study period, 513 street recruited African-American and Latino IDUs were screened for syphilis and antibodies to HIV. Subjects were administered a risk behaviour survey at baseline and followed up at 6 month intervals for 18 months with repeated interviews and serological screening. Rate ratios were used to examine associations between syphilis incidence and demographic characteristics and risk behaviours. A proportional hazard model was used to identify predictors of syphilis incidence independent of demographic characteristics. Results: 74% of the sample were male, 70% African-American, 30% Latino; and the median age was 43 years. Overall baseline serological prevalence of HIV was 2.5% and of syphilis 5.7%. None of the participants were co-infected for HIV and syphilis at baseline or at any of the 6 month follow ups. Among 390 eligible IDUs retained for analysis of incidence data, the overall syphilis incidence was 26.0 per 1000 person years. Higher syphilis incidence was found for women compared with men (RR=2.70; 95% CI 1.60, 4.55), and for those 44 years of age or younger compared with those 45 years of age and older (RR=2.26; 95% CI 1.25, 4.08). African-Americans were more likely to be syphilis incident cases when compared with Latinos, although the difference did not reach statistical significance (RR=1.27; 95% CI 0.72, 2.23). In bivariate analysis, risk behaviours significantly associated with higher syphilis incidence included injection of cocaine, “speedball” and heroin, “crack” smoking, recency of first injection event, backloading of syringes, injecting with others, exchanging drugs or money for sex, multiple sex partners, and non-heterosexual sexual preference. Variables that significantly predicted syphilis infection at follow up in the multivariate analysis included multiple sex partners (RR=7.8; 95% CI 2.4, 25.0), exchanging money for sex (RR=3.0; 95% CI 0.9, 9.6), and recent initiation to injection drug use (RR=4.6; 95% CI 1.1, 18.8). Conclusion: Syphilis transmission among IDUs in Los Angeles County remains a serious public health concern, particularly among IDUs who engage in trading of sex for money or drugs. Although low, the prevalence of HIV observed in this study constitutes a serious concern because of the potential for expanded HIV transmission in this susceptible population of IDUs with high syphilis incidence. Enhanced case finding screening efforts and prevention of transmission of sexually transmitted infections should specifically target hard to reach IDUs and their sexual partners