The Hang Up.

Over the past year, our ethics service has had numerous consultations involving patients who use the emergency department for regular dialysis. Sometimes, they have access to outpatient hemodialysis that they forgo; other times, they've been "fired" from this kind of outpatient facility, and so the ED is their last option. In most of these cases, we're called because the patient is disruptive once admitted to the ICU and behavior plans haven't helped. But the call from a resident this March 2020 morning was different, the patient had end-stage renal disease and often missed hemodialysis, but he wasn't disruptive. "It's just that he comes in after using cocaine, and given scarcity with the coronavirus and ICU beds…." I have come to think that this is one of the more insidious effects of the pandemic: that there will be a resurgence of the view that some patients deserve health care by virtue of their compliant behavior and that those who are nonadherent don't.

Mortality Risk among Cocaine Users before and after the Economic Recession: Results of a Longitudinal Study.

BACKGROUND: Studies have highlighted 2 different groups of cocaine users (CUs): "socially integrated" (stable living conditions, regular employment, use cocaine alone or in combination with other psychoactive substances) and "socially marginalized" (socioeconomic and health problems, former or current heroin users, many injecting cocaine). These differences are also found in the elevated mortality risk for CUs, higher among subjects with cocaine and heroin use. This study targeted residents in Northern Italy who turned to a public treatment center for drug addiction following problems caused by primary cocaine use between 1982 and 2016. OBJECTIVES: To estimate mortality risk for subjects who have never used heroin (CUs) compared to that of subjects who have used heroin (HCUs). METHOD: Retrospective cohort study. We selected 1,993 subjects; 18,015 Person Years (PY). RESULTS: Over time, the quota of subjects injecting cocaine and using heroin decreased, while patients not using heroin increased. Both new patients and crude mortality rates (CMR) decreased during the years 2009-2012 and increased in the following period. CMRs were 5.55 per 1,000 PY, higher for HCUs, men and subjects aged over 44 years. Standardized mortality rates were 3.49, higher for women, injecting cocaine and HCUS. Among CUs, most of the deaths were from injury excluding drug related and tumors; among HCUs, from drug-related causes and diseases of the cardiovascular system. CONCLUSION: The study results show a change in the characteristics of SERD clients being treated for primary cocaine use, which are reflected both in mortality risk and causes of death. After a long period of a decrease, mortality risk increased in the period after the economic recession. Aspects concerning the effects of the economic recession on the problematic consumption of cocaine and on the risk of death are discussed.

Predictors of mental health and substance use disorder treatment use over 3 years among rural adults using stimulants.

Background: Persons using substances, living in rural communities, tend to underutilize mental health (MH) and substance use disorder (SUD) treatment compared with their urban peers. However, no studies have examined longitudinal predictors of MH and SUD treatment use among rural persons using stimulants. Methods: Data were collected through interviews conducted between 2002 and 2008 from a natural history study of 710 adults using stimulants and living in rural counties of Arkansas, Kentucky, and Ohio. Each study site recruited participants using respondent-driven sampling (RDS). Participants were adults, not in drug treatment, and reporting past-30-day use of methamphetamine, crack cocaine, or powder cocaine. Study participants completed face-to-face baseline assessments and follow-up interviews using computer-assisted personal interviews. Follow-up interviews were conducted at 6-month intervals for 3 years. Results: Our results show that being male, nonwhite, and having a prior lifetime history of MH or SUD treatment use were associated with lower odds of using MH and SUD treatment over time; having medical insurance and living in a state with potentially greater availability of MH and SUD treatment were associated with higher odds of using MH and SUD treatment over the 3-year period. Further, reporting greater legal problems and alcohol severity were associated with greater odds of using MH and SUD care, whereas greater employment problems was associated with higher odds of SUD but not MH treatment use. Conclusions: Findings from this study could be used to inform clinical and public health strategies for improving linkage to MH and SUD care in this population. Our findings also highlight the importance of having medical insurance as a potential facilitator to utilizing SUD care in this population and support the need for health care policies that increase the ability of rural adults who use stimulants to pay for such services.

Epidemiology, clinical features and management of patients presenting to European emergency departments with acute cocaine toxicity: comparison between powder cocaine and crack cocaine cases.

Objective: To analyse the epidemiology, clinical picture and emergency department (ED) management of a large series of patients who presented to European EDs after cocaine consumption, comparing data from powder (C1 group) and crack (C2 group) consumers. Methods: Between October 2013 and December 2016, the Euro-DEN Plus Registry recorded 17,371 consecutive acute recreational drug toxicity presentations to 22 EDs in 14 European countries. Epidemiological and demographic data, co-ingestion of alcohol and other drugs, clinical features, ED management and outcome (death) were analysed for cocaine cases, and comparison of clinical picture in C1 and C2 patients were performed adjusting for alcohol and other drug co-ingestion. Results: We included 3002 cases (C1: 2600; C2: 376; mixed consumption: 26): mean age 32(9) years, 23% female. The proportion of presentations involving cocaine varied significantly between countries (>30% in Malta, Spain, France, Denmark) and only centres in France, United Kingdom, Poland, Ireland and Malta recorded crack-related cases. Cocaine was frequently used with ethanol (74.3%, C1>C2) and other drugs (56.8%, C2>C1), the most frequent amphetamine (19.4%, C1>C2) and opioids (18.9%, C2>C1). C2 patients were more likely to have clinically significant episodes of hypotension (adjusted OR = 2.35; 95%CI = 1.42-3.89), and bradypnea (1.81; 1.03-3.16) and systolic blood pressure >180 mmHg on ED arrival (2.59; 1.28-5.25); while less likely anxiety (0.51; 0.38-0.70), chest pain (0.47; 0.31-0.70), palpitations (0.57; 0.38-0.84), vomiting (0.54; 0.32-0.90), and tachycardia on ED arrival (0.52; 0.39-0.67). Sedative drugs were given in 29.3%. The median length of hospital stay was 4:02 h, 22.1% patients were hospitalized, and 0.4% (n = 12) died. Conclusion: Cocaine is commonly involved in European ED presentations with acute recreational drug toxicity, but there is variation across Europe not just in the involvement of cocaine but in the proportion related to powder versus crack. Some differences in clinical picture and ED management exist between powder cocaine and crack consumers.

Childhood Physical and Sexual Abuse Predicts Suicide Risk in a Large Cohort of Veterans.

OBJECTIVE: To examine whether childhood physical and sexual abuse is a significant predictor of suicide risk in veterans. METHODS: This study was a retrospective chart review of 4,709 patients admitted to a psychiatric ward (August 2004 through July 2014) at the Atlanta Veterans Affairs Medical Center (VAMC). Sociodemographic and clinical data and history of childhood (aged ≤ 18 years) physical and sexual abuse were obtained from the patients' electronic health records. Suicide risk data of patients who attempted and completed suicide were obtained from the Atlanta VAMC suicide high-risk team. Binary logistic regressions with maximum likelihood estimation method were used to examine the association of demographic (age, sex, marital status, race, service) and clinical (psychiatric diagnoses, number of hospital admissions, and length of stay) variables and childhood physical and sexual abuse and type with suicide behavior. RESULTS: The combination of childhood physical and sexual abuse, number of admissions to a psychiatric inpatient unit, and major depressive disorder (MDD) were the best predictors of enhanced suicide risk (P < .001). This combination accounted for 9.9% variance in suicide risk and correctly classified 83% of cases into respective suicide versus nonsuicide risk groups. Additional significant predictors were bipolar disorder (P < .001) and cocaine use disorder (P = .02). Surprisingly, diagnosis of schizophrenia predicted a reduced risk. CONCLUSIONS: To our knowledge, this study is the first to shed light on the interaction of childhood physical and sexual abuse and suicide risk in a large cohort of veterans. In the final model, childhood physical and sexual abuse, number of psychiatric admissions, and MDD were the best predictors of increased suicide risk. Schizophrenia was a protective factor in this veteran cohort.

The implications of cocaine use and associated behaviors on adverse cardiovascular outcomes among veterans: Insights from the VA Clinical Assessment, Reporting, and Tracking (CART) Program.

BACKGROUND: Cocaine use has been associated with adverse cardiovascular outcomes in patients with coronary artery disease (CAD). It is unclear whether this is due to direct effects of cocaine or other factors. HYPOTHESIS: Cocaine use is associated with worse outcomes in patients undergoing cardiac catheterization METHODS: We used the Veterans Affairs database to identify veterans undergoing coronary catheterization between 2007 and 2014. We analyzed association between cocaine use and 1-year all-cause mortality, myocardial infarction (MI), and cerebrovascular accident (CVA) among veterans with obstructive CAD (N = 122 035). To explore factors contributing to these associations, we sequentially adjusted for cardiac risk factors, risky behaviors, and clinical conditions directly affected by cocaine. RESULTS: 3082 (2.5%) veterans were cocaine users. Cocaine users were younger (median 58.2 vs 65.3 years; P < 0.001), more likely to be African American (58.9% vs 10.6%; P < 0.001), and had fewer traditional cardiac risk factors. After adjustment for cardiac risk factors, cocaine was associated with increased risk of mortality (HR: 1.23, 95% CI: 1.08-1.39), MI (HR: 1.40, 95% CI: 1.07-1.83), and CVA (HR: 1.88, 95% CI: 1.38-2.57). With continued adjustment, increased CVA risk remained significantly associated with cocaine use, whereas MI risk was mediated by risky behaviors and mortality was fully explained by conditions directly affected by cocaine. CONCLUSIONS: Cocaine use is associated with adverse cardiac events in veterans with CAD. Contributors to this association are multifaceted and specific to individual cardiovascular outcomes, including associated risky behaviors and direct effects of cocaine. Effective intervention programs to reduce cardiac events in this population will require multiple components addressing these factors.

Cocaine and HIV are independently associated with neural activation in response to gain and loss valuation during economic risky choice.

Stimulant abuse is disproportionately common in HIV-positive persons. Both HIV and stimulants are independently associated with deficits in reward-based decision making, but their interactive and/or additive effects are poorly understood despite their prevalent co-morbidity. Here, we examined the effects of cocaine dependence and HIV infection in 69 adults who underwent functional magnetic resonance imaging while completing an economic loss aversion task. We identified two neural networks that correlated with the evaluation of the favorable characteristics of the gamble (i.e. higher gains/lower losses: ventromedial prefrontal cortex, anterior cingulate, anterior and posterior precuneus and visual cortex) versus unfavorable characteristics of the gamble (i.e. lower gains/higher losses: dorsal prefrontal, lateral orbitofrontal, posterior parietal cortex, anterior insula and dorsal caudate). Behaviorally, cocaine and HIV had additive effects on loss aversion scores, with HIV-positive cocaine users being the least loss averse. Cocaine users had greater activation in brain regions that tracked the favorability of gamble characteristics (i.e. increased activation to gains, but decreased activation to losses). In contrast, HIV infection was independently associated with lesser activation in regions that tracked the unfavorability of gamble characteristics. These results suggest that cocaine is associated with an overactive reward-seeking system, while HIV is associated with an underactive cognitive control system. Together, these alterations may leave HIV-positive cocaine users particularly vulnerable to making unfavorable decisions when outcomes are uncertain.

Questionnaire of core beliefs related to drug use and craving for assessment of relapse risk. / Cuestionario de creencias nucleares relacionadas con el consumo de drogas y el craving, para la valoración del riesgo de recaída.

This study was aimed at designing a questionnaire for the assessment of addiction-related core beliefs and craving. The sample comprised 215 patients (85.8% males and 14.2% females) in treatment for dependence to alcohol (40%), cocaine (36.3%) and cannabis (23.7%). Descriptive statistics were used to characterize the sample. Variance, regression and factorial analyses were conducted to study the questionnaire structure and its relation with variables such as abstinence and craving. Items about drug-related beliefs yielded a four-factor structure: what patient think that they could not do without drug use, lack of withdrawal, conditions required to use drugs again, and use of drugs as the only way to feel good. Items related to craving yielded three factors: negative emotions as precipitants of drug use, positive emotions, and difficulties attributed to coping with craving. Furthermore, beliefs were more important to predict craving than abstinence time. The present questionnaire allows to assess a set of significant factors to design prevention relapse programs.

El objetivo de la investigación fue diseñar un cuestionario para la evaluación de creencias nucleares en torno al consumo de drogas y el craving. La muestra estuvo compuesta por 215 pacientes, de los que el 85.8% eran hombres y el 14.2% mujeres en tratamiento por su adicción al alcohol (40%), cocaína (36.3%) y cánnabis (23.7%). Se realizó un análisis descriptivo de la muestra, análisis de varianza, de regresión y análisis factorial con la finalidad de indagar en la estructura del cuestionario y su relación con variables como la abstinencia o deseo de consumo. El apartado de creencias relacionadas con las drogas mostró una estructura de cuatro factores: lo que la persona cree que no podrá realizar en ausencia del consumo de drogas, la falta de renuncia al consumo, las condiciones que deben darse para volver a consumir y el consumo como única vía para sentirse bien. El apartado relacionado con el craving mostró tres factores: las emociones negativas como precipitantes del consumo, las emociones positivas y las dificultades atribuidas al afrontamiento del deseo. A su vez, se constata que las creencias tienen más peso en la predicción del deseo en comparación al tiempo de abstinencia. El cuestionario permite evaluar un conjunto de creencias que muestras factores significativos para el diseño de programas de prevención de recaídas.

Oral health assessment for users of marijuana and cocaine/crack substances.

The objective of this study was to assess the oral health status of users of illicit drugs such as marijuana and cocaine/crack and compare it with individuals not using these chemical substances. Questionnaires were applied to 35 illicit drugs users to gather information on demographic status, general health, and use of drugs. Then, a clinical assessment of the oral health condition was performed to collect data on decayed, missing and filled teeth (DMFT) index, salivary flow rate (SFR), and mucosal lesions. The control group was composed of 35 non-illicit drug users. In the experimental group, 91.43% were males, 80% were smokers, and 42.85% were alcoholics. Cocaine was the most common drug used (77.15%), followed by marijuana (68.6%), and crack (51.4%). The average DMFT index was 9.8 and the SFR was reduced in 60% of subjects. Mucosal alterations were detected, but no potentially malignant disorders or oral cancer were diagnosed. Compared to control group, significantly higher values for gender (40%, p = 0.0001), smoking (22.86%) and heavy drinking (5.7%) habits (p = 0.0001), SFR (31.4%; p = 0.0308), and oral lesions (p = 0.0488) were found for the experimental group, although significantly higher values were found in the control group for DMFT index (p = 0.0148). It can be concluded that the use of illicit drugs contributed to an increased prevalence of oral mucosa lesions. In addition, a decline on SFR and a reduced DMFT index was observed for illicit drug users.

The Quest to Extend Health Services to Vulnerable Substance Users in Rio de Janeiro, Brazil in the Context of an Unfolding Economic Crisis.

Calls to address crack-cocaine use in Brazil among homeless and street-frequenting populations who are in urgent need of health services have questioned the capacity of the Brazilian Unified Health System to attend to the nation's most marginalized citizens. In recent years, Brazil has launched several actions to escalate care for substance users, yet many obstacles hindering accessibility and effectiveness of services remain. Paradoxically, these actions have been implemented in the context of a growing economic crisis, and expanding services for a population of poor and stigmatized substance users while cutting other government programs tends to elicit harsh criticism from citizens. In consequence of such prospects, this commentary aims to discuss barriers marginalized substance users face in accessing health services that are at risk of worsening with government cutbacks. Using Rio de Janeiro as an example, we explore two primary issues: the resource-strained, under-staffed and decentralized nature of the Brazilian Unified Health System and the pervading stigma that bars vulnerable citizens from official structures and services. Abandoning initiated government efforts to increase access to health services would risk maintaining vulnerable citizens at the margins of public structures, inhibiting the opportunity to offer this population humane and urgently needed treatment and care.

Oral health assessment for users of marijuana and cocaine/crack substances

Abstract: The objective of this study was to assess the oral health status of users of illicit drugs such as marijuana and cocaine/crack and compare it with individuals not using these chemical substances. Questionnaires were applied to 35 illicit drugs users to gather information on demographic status, general health, and use of drugs. Then, a clinical assessment of the oral health condition was performed to collect data on decayed, missing and filled teeth (DMFT) index, salivary flow rate (SFR), and mucosal lesions. The control group was composed of 35 non-illicit drug users. In the experimental group, 91.43% were males, 80% were smokers, and 42.85% were alcoholics. Cocaine was the most common drug used (77.15%), followed by marijuana (68.6%), and crack (51.4%). The average DMFT index was 9.8 and the SFR was reduced in 60% of subjects. Mucosal alterations were detected, but no potentially malignant disorders or oral cancer were diagnosed. Compared to control group, significantly higher values for gender (40%, p = 0.0001), smoking (22.86%) and heavy drinking (5.7%) habits (p = 0.0001), SFR (31.4%; p = 0.0308), and oral lesions (p = 0.0488) were found for the experimental group, although significantly higher values were found in the control group for DMFT index (p = 0.0148). It can be concluded that the use of illicit drugs contributed to an increased prevalence of oral mucosa lesions. In addition, a decline on SFR and a reduced DMFT index was observed for illicit drug users.

Real-time assessment of alcohol drinking and drug use in opioid-dependent polydrug users.

We investigated relationships between drinking, other drug use, and drug craving, using ecological momentary assessment (EMA), in a sample of polydrug users who were not heavy drinkers. In a prospective longitudinal cohort study, 114 heroin and cocaine users on methadone-maintenance treatment carried handheld electronic diaries during waking hours and were screened for drug and alcohol use for up to 25 weeks. Individuals who fulfilled the Diagnostic and Statistical Manual of Mental Disorders criteria for alcohol abuse or dependence were excluded. Participants responded to 2-5 random prompts per day to report on their moods, cravings, and activities and initiated entries when they used or acutely craved heroin or cocaine. Drinking alcohol was assessed in both types of entries. Breath alcohol was measured three times weekly. Participants reported drinking alcohol in 1.6% of random-prompt entries, 3.7% of event-contingent entries when craving cocaine and/or heroin, and 11.6% of event-contingent entries when using cocaine and/or heroin. Alcohol drinking was also associated with higher craving ratings and prestudy alcohol use. More drinking was detected by ambulatory self-report than by in-clinic breath testing. Even though we had screened out heavy drinkers from our sample of polydrug users, drinking was associated with heroin and cocaine craving and actual use.

Essential/precursor chemicals and drug consumption: impacts of US sodium permanganate and Mexico pseudoephedrine controls on the numbers of US cocaine and methamphetamine users.

BACKGROUND AND AIMS: In December 2006 the United States regulated sodium permanganate, a cocaine essential chemical. In March 2007 Mexico, the United States' primary source for methamphetamine, closed a chemical company accused of illicitly importing 60+ tons of pseudoephedrine, a methamphetamine precursor chemical. US cocaine availability and methamphetamine availability, respectively, decreased in association. This study tested whether the controls had impacts upon the numbers of US cocaine users and methamphetamine users. DESIGN: Auto-regressive integrated moving average (ARIMA) intervention time-series analysis. Comparison series-heroin and marijuana users-were used. SETTING: United States, 2002-14. PARTICIPANTS: The National Survey on Drug Use and Health (n = 723 283), a complex sample survey of the US civilian, non-institutionalized population. MEASUREMENTS: Estimates of the numbers of (1) past-year users and (2) past-month users were constructed for each calendar quarter from 2002 to 2014, providing each series with 52 time-periods. FINDINGS: Downward shifts in cocaine users started at the time of the cocaine regulation. Past-year and past-month cocaine users series levels decreased by approximately 1 946 271 (-32%) (P < 0.05) and 694 770 (-29%) (P < 0.01), respectively-no apparent recovery occurred through 2014. Downward shifts in methamphetamine users started at the time of the chemical company closure. Past-year and past-month methamphetamine series levels decreased by 494 440 (-35%) [P < 0.01; 95% confidence interval (CI) = -771 897, -216 982] and 277 380 (-45%) (P < 0.05; CI = -554 073, -686), respectively-partial recovery possibly occurred in 2013. The comparison series changed little at the intervention times. CONCLUSIONS: Essential/precursor chemical controls in the United States (2006) and Mexico (2007) were associated with large, extended (7+ years) reductions in cocaine users and methamphetamine users in the United States.

Income inequality, drug-related arrests, and the health of people who inject drugs: Reflections on seventeen years of research.

This paper reviews and then discusses selected findings from a seventeen year study about the population prevalence of people who inject drugs (PWID) and of HIV prevalence and mortality among PWID in 96 large US metropolitan areas. Unlike most research, this study was conducted with the metropolitan area as the level of analysis. It found that metropolitan area measures of income inequality and of structural racism predicted all of these outcomes, and that rates of arrest for heroin and/or cocaine predicted HIV prevalence and mortality but did not predict changes in PWID population prevalence. Income inequality and measures of structural racism were associated with hard drug arrests or other properties of policing. These findings, whose limitations and implications for further research are discussed, suggest that efforts to respond to HIV and to drug injection should include supra-individual efforts to reduce both income inequality and racism. At a time when major social movements in many countries are trying to reduce inequality, racism and oppression (including reforming drug laws), these macro-social issues in public health should be both addressable and a priority in both research and action.

Injecting drugs in tight spaces: HIV, cocaine and collinearity in the Downtown Eastside, Vancouver, Canada.

This commentary revisits the political turmoil and scientific controversy over epidemiological study findings linking high HIV seroincidence to syringe exchange attendance in Vancouver in the mid-1990s. The association was mobilized polemically by US politicians and hard-line drug warriors to attack needle exchange policies and funding. In turn, program restrictions limiting access to syringes at the Vancouver exchange may have interfaced with a complex conjunction of historical, geographic, political economic and cultural forces and physiological vulnerabilities to create an extraordinary HIV risk environment: (1) ghettoization of services for indigent populations in a rapidly gentrifying, post-industrial city; (2) rural-urban migration of vulnerable populations subject to historical colonization and current patterns of racism; and (3) the flooding of North America with inexpensive powder cocaine and heroin, and the popularity of crack. In fact, we will never know with certainty the precise cause for the extreme seroincidence rates in Vancouver in the early to mid-1990s. The tendency for modern social epidemiology to decontextualize research subjects and assign excessive importance to discrete, "magic bullet" variables resulted in a counterproductive scientific and political debate in the late 1990s that has obfuscated potentially useful practical lessons for organizing the logistics of harm reduction services - especially syringe exchange - to better serve the needs of vulnerable populations and to mitigate the effects of political-economically imposed HIV risk environments. We would benefit from humbly acknowledging the limits of public health science and learn to recognize the unintended consequences of well-intentioned interventions rather than sweep embarrassing histories under the rug.

Characteristics of clients using a community-based drug treatment service ('CAPS-AD') in Brazil: An exploratory study.

BACKGROUND: Substance use is common in Brazil. In order to improve availability of substance misuse care services, over 400 Psycho-Social Care Centres for Alcohol and Drugs (CAPS-AD) - providing community-based care - have been established following mental health care reform (2001). Information on CAPS-AD clients and outcomes is limited. The present study examined select characteristics of local CAPS-AD clients. METHODS: N=143 adult CAPS-AD clients in Ceilândia (suburb of Brasília, Federal District) participated in a 1-week 'snapshot' assessment of service users (February 2015). Following consent, descriptive data were collected by a brief, anonymous interviewer-administered questionnaire that included socio-demographic, drug use, treatment history and needs/barriers information. RESULTS: Participants were predominantly male; middle-aged; unemployed; married; with middle-school education; primary problem drugs indicated were alcohol and cocaine/crack; half had prior treatment histories and indicated that treatment was externally motivated; 60% reported ways to improve treatment and possible reasons for treatment discontinuation; in multi-variate analyses, the latter was associated with employment and education status (both p<.05). CONCLUSION: CAPS-AD services appear to have increased low-barrier substance misuse treatment availability in Brazil, as well as attract individuals new to the treatment system. Various potential barriers to continuing in treatment should be addressed and more research on CAPS-AD clients and outcomes is needed.

Perceptions of research risk and undue influence: Implications for ethics of research conducted with cocaine users.

BACKGROUND: Despite the prominence of human laboratory and clinical trial research in the development of interventions for substance use disorders, this research presents numerous ethical challenges. Ethical principles outlined in the Belmont Report, including respect for persons, beneficence, and justice, have traditionally guided research conduct. Few empirical studies exist examining substance abuse research ethics. The present study examined perceptions of beneficence and respect for persons in substance use research, including relative risk and desired monetary compensation, using an online sample of cocaine users. METHODS: The study was conducted on Amazon.com's Mechanical Turk (mTurk), a crowdsourcing website used for survey-based research. Of 1764 individuals screened, 138 reported past year cocaine use. These respondents completed a battery of standardized and experimenter-designed questionnaires used to characterize each respondent's self-reported attitudes, beliefs, and behaviors about drug use and the relative risks and desired monetary compensation associated with research participation. RESULTS: Ratings of relative risk revealed that most respondents found common research practices as less than or equal to the relative risk of everyday life. Receiving experimental medication outside the hospital was rated as the most risky research activity, but on average was not rated as presenting more risk than everyday life. Desired compensation for research participation was associated with the perceived risk of research activities. Increases in desired compensation for participation were only observed for research perceived as much more risky than everyday activities. CONCLUSIONS: These findings indicate that cocaine users assess risk in a way that is consistent with standard research practice.

Predictors of patient retention in methadone maintenance treatment.

This study sought to determine whether select pretreatment demographic and in-treatment clinical variables predict premature treatment discharge at 6 and 12 months among patients receiving methadone maintenance treatment (MMT). Data were abstracted from electronic medical records for 1,644 patients with an average age of 34.7 years (SD = 11.06) admitted to 26 MMT programs located throughout the United States from 2009 to 2011. Patients were studied through retrospective chart review for 12 months or until treatment discharge. Premature discharge at 6- and 12-month intervals were the dependent variables, analyzed in logistic regressions. Clinical predictor variables included average methadone dosage (mg/d) and urinalysis drug screen (UDS) findings for opioids and various nonopioid substances at intake and 6 months. Pretreatment demographic variables included gender, race/ethnicity, employment status, marital status, payment method, and age at admission. UDS findings positive (UDS+) for cocaine at intake and 6 months were found to be independent predictors of premature discharge at 12 months. UDS+ for opioids at 6 months was also an independent predictor of premature discharge at 12 months. Higher average daily methadone dosages were found to predict retention at both 6 and 12 months. Significant demographic predictors of premature discharge at 6 months included Hispanic ethnicity, unemployment, and marital status. At 12 months, male gender, younger age, and self-pay were found to predict premature discharge. Select demographic characteristics may be less important as predictors of outcome after patients have been in treatment beyond a minimum period of time, while others may become more important later on in treatment.