A new brief screen for adolescent substance abuse.

OBJECTIVE: To develop a brief alcohol and other drug (AOD) screening test for adolescents. METHODS: A 9-item test was constructed by combining and modifying items from several AOD assessments, and administered concurrently with the Personal Involvement With Chemicals Scale (PICS), the criterion standard. SETTING: A hospital-based adolescent clinic. SUBJECTS: Fourteen- to 18-year-old patients consecutively arriving for routine medical care who were known to have used AOD. MEASURES: Internal consistency of the 9 items was calculated using the Cronbach alpha. The relationship between the brief screen and PICS raw score was determined by stepwise linear regression analysis. The PICS T score has been shown to correctly classify substance abuse treatment need as no treatment (T<35), brief office intervention (T = 35-40), outpatient or short-term treatment (T = 41-54), and inpatient or long-term treatment (T> or =55). Sensitivity and specificity rates for predicting a PICS T score of 55 or higher were calculated from 2 x 2 tables. RESULTS: Ninety-nine adolescents were tested (70.7% female, 36.4% black, 32.3% white, 19.2% Hispanic, mean age, 16.3 years). The 9 items had good internal consistency (Cronbach alpha = .79). Stepwise linear regression analysis identified 6 items whose total combined score was highly correlated with PICS (Pearson r = 0.84, P<.01). This model correctly classified 86% of subjects according to the PICS criteria. Two or more yes answers had a sensitivity of 92.3% and specificity of 82.1% for intensive AOD treatment need. The 6 items were arranged into a mnemonic (CRAFFT). CONCLUSIONS: Further research must confirm the test's psychometric properties in a general clinic population. However, CRAFFT seems promising as a brief AOD screening test.

Assessment of addictive disorders. The use of clinical reflection and hypotheses testing.

This article examines how a multidimensional conceptual schema (biologic, sociologic, psychodynamic, and behavioral) can be applied directly to clinical practice methods during the assessment of addictive disorders. This practice is offered to minimize some of the conceptual problems often associated with the diagnostic process. Clinical reflection and hypotheses testing are considered as meta-models that can effectively guide the conduct of clinical assessment. The purpose of this approach is to provide a parsimonious means of organizing and verifying clinical information, thus making the assessment process both manageable and teachable. The ability to manage and teach clinical methods is considered as an essential step toward the development of a practice theory in the addictions.

Conceptual crises and the addictions: a philosophy of science perspective.

This article examines the field of addictions and suggests that it is in the midst of a conceptual crisis. As a result of its immaturity, the addiction's field evidences energy, naivete, curiosity, intensely conflicting and polarized explanations of its identity and purpose, anomalous research findings, and few "facts." From a philosophy of science perspective, these characteristics are considered as indicators of the developmental stages that are associated with the evolution of scientific disciplines. A philosophy of science perspective is applied to the history of the substance abuse field and the consequent implications examined. A discussion of normal science, language, the role of paradigms, and scientific reductionism is included.

The epistemology of "addictive disease": the Lincoln-Douglas debate.

This research was conducted to examine the social perception of "addictive disease." This study provided an opportunity to gain insight into a representative sample of terms and phrases that were denotative of disease and then factor analyzed how these items clustered to reveal a spectrum of underlying factors that contribute to the perception of disease. It was expected and confirmed that subjects could discriminate between behavioral and biological disorders. In addition, the results support the view that the addictive "disease" model is a symbolic substitute for the moral turpitude model which it replaced. Finally, the findings support the view that non-physicians are capable of making fine distinctions among a number of biologically related "diseases." These results suggest that it may be important for health care providers to carefully and instrumentally apply their language to facilitate patient compliance with treatment protocols.

On smokeless tobacco, addictive behavior and warning labels.

This article will offer three primary positions: First, it will support the use of a warning label on containers of smokeless tobacco and second, suggest that an alternative to the present warning statement be considered. The Massachusetts Department of Public Health--presently the first state to consider a warning label for smokeless tobacco--proposes a label that would read as follows: WARNING: Use of snuff is addictive and may cause mouth cancer and other mouth disorders. Third, this article will suggest that a warning label will not have any notable impact on the public health. In order to support these positions, the following discussion will briefly examine the relationship between chemical dependency, addictive behavior, tobacco smoking, and the use of warning labels as a deterrant to the use of smokeless tobacco.

Cocaine psychosis and AIDS: a contemporary diagnostic dilemma.

This article examines some of the differential diagnostic considerations associated with the interaction between advanced cocaine psychosis and the neuropsychiatric manifestations of AIDS-Spectrum Disorders. A clinical case is presented to illustrate the potential for institutional countertransference in the treatment of substance abusing patients. The role of a multi-dimensional hypotheses testing model in cocaine related cases is discussed.

Narcotic and other drug use: a spectrum.

Zinberg and Lewis foresaw developments in the substance abuse field in particular and in human services in general with the development of a "Spectrum of a Difficult Medical Problem." We believe this spectrum has far reaching implications and value for researchers, theoreticians, planners and practitioners currently in the substance abuse field both in conceptualizing drug involvement with its diversity of potential concerns, as well as planning treatment for drug involved clients. The application of a spectrum need not be limited to the category of drugs known as narcotics; this concept can also be applied to involvement with drugs from other categories, e.g., stimulants, sedative/hypnotics, hallucinogens, etc.

Patterns of substance use among methadone maintenance patients. Indicators of outcome.

Critics often cite the use of illicit drugs among methadone maintenance patients as evidence of this treatment modality's failure. The fact that methadone maintenance treatment does not lead quickly to abstinence in most clients can be a disappointment to treatment professionals and the public. By studying a cohort of 41 patients for their first year in a methadone maintenance program, this study revealed significant trends of diminished narcotic and cocaine use. However, increased benzodiazepine use was also identified. More importantly, this study patterns of drug using that predicted less drug use at the end of one year of treatment. These findings reflect the need for additional research to clarify the meaning of illicit drug use by methadone maintenance patients. In addition, the implications for providing, stopping, and determining effective drug treatment are discussed.

Reducing resistance and denial by exercising ambivalence during the treatment of addiction.

Stage change models and motivational enhancement therapies have significantly influenced the therapeutic tactics clinicians employ in the treatment of addictive behaviors. While motivational enhancement strategies have addressed client ambivalence to increase motivation to change, this article suggests that focusing on ambivalence during treatment has even wider clinical utility than previously thought. Resistance reduction concentrates on exercising ambivalence without an investment in clients changing, thereby strengthening client tolerance for ambivalent thoughts and feelings. Exercising ambivalence reduces resistance to treatment and change by validating a wide array of possible outcomes through detailed exploration of how a behavior pattern works for a client. Since resistance reduction does not require clients to want to change for therapy to progress, exploring the decision-making process becomes paramount. A general discussion of the resistance reduction model, ambivalence, and how clients present for treatment precedes clinical case examples.

Change intolerance to shifts in methadone formulation: a preliminary investigation.

Some patients in methadone maintenance treatment programs have substantial difficulty adjusting to changes in methadone formulation and shifts in other program policies. Clinicians can benefit from the ability to identify individuals who are "at risk" for methadone formulation and other change intolerance. By studying a cohort of 177 patients who were receiving methadone maintenance in a program that changed methadone dispensing formulations, this study revealed significant differences between two underlying patient groups (i.e., change tolerant or intolerant). These patients were distinguished by personal characteristics prior to the formulation change and methadone dose level shifts after the formulation change. Change-intolerant patients experienced formulation-related narcotic withdrawal whereas change-tolerant patients adapted to the new medication format. Gender, treatment history, and methadone abuse were three sociodemographic variables that significantly predicted patients who were intolerant to a methadone formulation change. These findings suggest the need for more research, including plasma and metabolic studies, to clarify the potential biological effects of changes in methadone formulations. In addition, the treatment implications for patients who experience change intolerance are discussed.

Two cases of misdiagnosis: some essentials of intake.

This article traces the history of two clinical cases. The first case describes a substance abusing patient who enacted the part of a narcotics addict. This enactment was affirmed by both alcohol and narcotic treatment programs, leading to a misdiagnosis. The second case describes a substance using client misdiagnosed as a result of assumptions made by the referral source. Biases inherent in the assessment of drug involved patients are illustrated and the utility of the hypotheses testing approach as a method of diagnostic error reduction and correction is discussed.

Assessing substance abuse treatment provider training needs: screening skills.

Screening instruments for substance abuse can be expeditious and effective clinical tools. A training needs assessment conducted with a randomly selected sample of substance abuse treatment providers (n = 1684) in licensed facilities in New England identified the adequacy of training, interest in training, clinical skill, and training need in the use of 13 substance abuse screening instruments. The results revealed that New England substance abuse treatment providers are not skilled in the use of screening instruments and have a high level of training need in this area. Differences in screening skill were found among the New England states. In addition, women and those with less treatment experience have lower screening skill; similarly, women, those having less experience in the field, and social workers and nurses evidenced higher training need in screening. The discussion considers skill, adequacy of training, training interest, and training need. The conclusion suggests that one approach to the coexisting increased need for screening skills due to managed care requirements and the lack of interest in these skills is to study managed care marketplace demands to determine training priorities.

Smoking behavior among casino employees: self-report validation using plasma cotinine.

The veracity of behavioral self-reports is often challenged, particularly when the motivation to avoid stigma and win social approval holds potential to introduce bias into the data collected. This study employed plasma cotinine tests to validate the self-reports of tobacco use collected from 3,841 casino employees as part of a comprehensive health survey. Rates of discordance were calculated by comparing employee self-reports with results from plasma colinine tests. This study provides evidence that casino employees can provide valid self-report data. Further, discordance rates of self-reported tobacco use vary according to operational definitions of tobacco use. These findings highlight the methodological importance of recognizing the inherent heterogeneity of smoking behavior.

Comparing Hatha yoga with dynamic group psychotherapy for enhancing methadone maintenance treatment: a randomized clinical trial.

BACKGROUND: As more methadone treatment programs are funded in an attempt to curb substance abuse and HIV infection among i.v. drug users, more cost effective treatment approaches are being sought. OBJECTIVES: To investigate whether clients in outpatient methadone maintenance treatment who practice weekly Hatha yoga in a group setting experience more favorable treatment outcomes than those who receive conventional group psychodynamic therapy. METHODS: After a 5-day assessment period, 61 patients were randomly assigned to methadone maintenance enhanced by traditional group psychotherapy (ie, conventional methadone treatment) or an alternative Hatha yoga therapy (ie, alternative methadone treatment). Patients were followed for 6 months and evaluated on a variety of psychological, sociological, and biological measures. The revised Symptom Check List provided the primary psychological measures; the Addiction Severity Index provided various indices of addictive behaviors. RESULTS: The evidence revealed that there were no meaningful differences between traditional psychodynamic group therapy and Hatha yoga presented in a group setting. Both treatments contributed to a treatment regimen that significantly reduced drug use and criminal activities. Psychopathology at admission was significantly related to program participation regardless of treatment group. DISCUSSION: In addition to examining the characteristics of patients who present for treatment, this study identifies unexpected staff issues that complicate the integration of alternative and traditional treatment strategies. CONCLUSION: Alternative methadone treatment is not more effective than conventional methadone treatment, as originally hypothesized. However, some patients may benefit more from alternative methadone treatment than conventional methadone treatment. Additional research is necessary to determine characteristics that identify patients who might benefit from alternative methadone treatment.

Updating and refining prevalence estimates of disordered gambling behaviour in the United States and Canada.

BACKGROUND: This study updates prevalence estimates of gambling-related disorders in the United States and Canada, identifies differences in prevalence estimates among population segments, and identifies changes in prevalence over the past 25 years. METHOD: A meta-analytic strategy guided the synthesis of 180 estimates derived from 146 prevalence studies. RESULTS: Prevalence estimates among adolescent samples were significantly higher than estimates among adult samples for both clinical (level 3) and sub-clinical (level 2) measures of disordered gambling within both lifetime and past-year time frames. Among adults, level 3 prevalence estimates continue to increase significantly. CONCLUSIONS: Membership in youth, treatment, and prison population segments is significantly associated with experiencing gambling-related disorders. Understanding sub-clinical gamblers provides a meaningful opportunity to lower the public health burden associated with gambling disorders. Prospective studies of incidence are necessary to determine whether the prevalence of disordered gambling continues to increase among the adult general population and how adolescent gambling experiences change as this cohort ages.

"Computer addiction": a critical consideration.

Problems related to intemperate Internet use are examined within the conceptual framework of addiction. It is argued that empirical support for the construct validity of computer addiction has yet to emerge, that defining the construct as a unique psychiatric disorder is therefore premature, and that, in most cases, excessive computer use may be symptomatic of other, more primary disorders. Greater caution and rigor are urged in investigating and treating problems related to intemperate computer use.