Exposure to Violence and Posttreatment Substance Use Among Patients With Opioid Use Disorder.

Exposure to violence can lead to a dramatic increase in the likelihood of the development of a substance use disorder (SUD). Given the overlap between the two, substance use for survivors of violence, then, can be a coping mechanism to manage the traumatic effects of abuse and persistent use can evolve into a diagnosable SUD. This study was designed to examine the posttreatment substance use among adults who have a history of exposure to violence and sought treatment for opioid use disorder. Data for this study were drawn from the Comprehensive Addiction Treatment Outcome Research system. Among the 13,105 patients included in the study, 444 (3.4%) received a formal diagnosis for opioid use disorder. Female victims of violence are at a greater risk of suffering injuries related to violence, resulting in increased levels of medical care utilization, which may prompt the initiation and prolonged use of prescription pain relief medication. Related to this important finding is another indicating that exposure to violence at multiple points in the past was associated with more severe indicators of substance use. These data show that there is a relationship between exposure to violence, SUDs, and relapse among patients seeking treatment. Not only must patients and treatment providers address these past violent experiences as important psychological factors in recovery, but in the context of opioid use disorder, physical injuries contributing to chronic pain may also trigger persistent substance use.

Exposure to Violence and Substance Use Treatment Outcomes Among Female Patients.

BACKGROUND: Many female substance use patients have experienced violence in the past, with most estimates showing the majority of patients reporting violent experiences at some point. Prior experience with violence has been linked to increased severity of substance use, and this may contribute to more challenges in the path to recovery. OBJECTIVES: Existing research has confounded the timing at which violence has occurred with the type of violence to which patients have been exposed. The current study was conducted to specify the extent to which the timing of exposure and the type of violence were associated with substance use after discharge from treatment. METHODS: Data were collected from 3,439 female patients included in the Comprehensive Assessment and Treatment Outcome Research (CATOR) system. RESULTS: With regard to the type of exposure, findings indicated female patients who were exposed to multiple forms of violence (i.e. physical and sexual) displayed the greatest severity of substance use upon treatment initiation, as well as the greatest likelihood for use following discharge from treatment. In terms of the timing, female patients who experienced violence at various time points (i.e. before and after 18 years of age) displayed the greatest severity of substance use, but patients who experienced violence after 18 years of age had the highest probability of substance use following discharge from treatment. Conclusions/Importance: Clinicians should collect information related to these important details as treatment protocols are developed, and as patients are connected to aftercare services to minimize post-treatment substance use.

The entanglement between relapse and posttreatment criminal justice involvement.

BACKGROUND: Research has established a connection between substance use and criminal activity, but much less is known about the association between posttreatment relapse and related contact with the criminal justice system. OBJECTIVE: The current study was designed to elucidate this relationship by examining the long-term effects of relapse on arrest. The study also investigated the probability of relapse into substance use as it followed an arrest. METHOD: Data from 5,822 adults who participated in the Comprehensive Assessment and Treatment Outcome Research (CATOR) system were analyzed. This prospective longitudinal research design included 0-6, 6-12, 12-18, and 18-24 month follow-up data. RESULTS: A series of logistic regression analyses indicated that relapse was associated with posttreatment arrest within the observed follow-up period, but did not significantly influence the likelihood of arrest in future follow-up periods. In comparison, posttreatment arrest in the 6-12 month follow-up period had lasting effects for relapse to substance use in the 12-18 and 18-24 month periods. Arrest in the 0-6 month posttreatment period was also associated with increased risk for relapse in the 18-24 month period. CONCLUSIONS: Given the evidence that demonstrated within follow-up period associations between relapse and arrest, relapse prevention is critical to preventing contact with the criminal justice system. In addition, the lasting impact of an arrest must be mitigated to maintain posttreatment recovery from substance use for adults who come into contact with the criminal justice system.

How well do the DSM-5 alcohol use disorder designations map to the ICD-10 disorders?

BACKGROUND: The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), and the International Statistical Classification of Diseases and Related Health Problems, 10th edition (ICD-10), both establish diagnostic criteria for alcohol use disorders. The dimensional severity perspective provided by the DSM-5 may overlap in important ways but also may diverge from the categorical harmful use versus dependence designations presented by the ICD-10. It is especially important to consider the convergence of these 2 diagnostic approaches as the DSM is widely used by clinicians, but the U.S. Centers for Medicare and Medicaid Services has recently required that providers bill for services using the ICD-10 designations. METHODS: Data from 6,871 male and 801 female admissions to a state prison system were used to compare the DSM-5 severity index for alcohol use disorder to the ICD-10 clinical and research formulations for harmful use and dependence. RESULTS: The DSM-5 and the ICD-10 were highly convergent for the most severe alcohol use disorders and also for those who did not receive a diagnosis. Most DSM-5 moderate alcohol use disorder cases were classified as dependence cases under both the clinical and research ICD criteria. In contrast, there was much more variation in the DSM mild cases. These were divided into categories of harmful use or misuse, depending on whether the clinical or research ICD criteria were applied. Results were similar among male and female inmates. CONCLUSIONS: The DSM-5 and ICD-10 exhibit a high level of agreement for cases that would not receive a diagnosis as well as the most severe cases. However, there are important distinctions to be made between the 2 approaches for mild and moderate DSM disorders in addition to harmful use/misuse cases in the ICD. The cases influenced by these discrepancies are most likely to be affected by recently implemented service provider billing practices.

Pathways to rearrest among court mandated female substance use treatment patients.

BACKGROUND AND OBJECTIVES: Many women who experience substance dependence come into contact with the criminal justice system and are mandated by the court to enter treatment. Treatment is a viable option and can have many positive outcomes, but there remains significant room for improvement. This study was designed to identify key risk factors that can be addressed to improve substance use treatment outcomes for this population. METHODS: The study sample consisted of (n) 381 women who were court mandated to enter substance use treatment. Multivariate path analyses were conducted to assess the associations between correlates of substance use treatment outcomes, risk for relapse, and rearrest. RESULTS: Women who displayed certain demographic risk factors (i.e., less educated and unmarried) and had greater levels of substance use severity prior to entering treatment experienced elevated risk for relapse. Consequently, women who relapsed were nearly three times (OR = 2.50, 95% CI = 1.26-4.93) as likely to be rearrested within 12 months of discharge from treatment compared to those who did not relapse. DISCUSSION AND CONCLUSIONS: Certain risk factors contribute to relapse, which increases risk for rearrest. SCIENTIFIC SIGNIFICANCE: Services specifically tailored to women who were court mandated to enter treatment need to consider certain demographic risk factors, clinical substance use severity, and relapse prevention as key elements to minimize subsequent criminal offending.

Detecting DSM-5 Opioid and Methamphetamine Use Disorders With the UNCOPE Screen.

BACKGROUND: The most recent wave of the opioid epidemic has contributed to record number of drug overdoses. Most fatal outcomes are associated with opioids and methamphetamine; two substances that tend to be used at high rates among criminal justice populations. Despite the steady rise in the number of overdoses in local detention centers, many correctional facilities do not conduct routine screens for opioid and methamphetamine use disorders. This study examines the utility of the UNCOPE, a 6-item brief screen, to detect probable Diagnostic and Statistical Manual for Mental Disorders, fifth edition (DSM-5) diagnoses for these 2 specific substance use disorders (SUDs). The study also examines key indicators of these specific SUDs. METHODS: Data were collected from comprehensive substance use assessments conducted with 717 adults who were recently admitted to 4 county jails. RESULTS: Findings indicate that 3 positive UNCOPE responses accurately detected 99.8% of opioid use disorder diagnoses and 98.7% of methamphetamine use disorder diagnoses. Receiver operating characteristic curve results generate an area under the curve at 0.99 for severe opioid use cases and 0.98 for severe methamphetamine use cases. Subsequent analyses indicate 2 of the 6 items on the UNCOPE function to accurately identify 100% of cases classified with opioid use disorder and 99.6% of cases classified with methamphetamine use disorder. CONCLUSIONS: Evidence suggests that UNCOPE is a practical and efficient approach to identifying opioid and methamphetamine use disorders. In addition, 2 items can serve as an ultra-brief method to detecting these conditions at the time of admission to detention centers.

Mental Health Conditions, Substance Use Disorders, and Jail Readmission in Four Rural Counties.

Most jails are in rural areas, and many adults who pass through these facilities experience behavioral health needs. Evidence suggests mental health conditions (MHCs) and substance use disorders (SUDs) may be linked to an increased risk for jail readmission, but most work documenting this relationship uses vague measures, outdated diagnostic information, has been conducted in large metropolitan jails, or has demonstrated significant variability between facilities. This multisite study examined the associations between specific MHCs, SUDs, and jail readmission among 675 adults from four rural jails. Descriptive statistics and multivariate analyses indicated rural jail populations are likely to present MHCs, especially major depression and PTSD, at higher rates than those found in national estimates. SUDs were also observed at rates higher than those typical of national surveys, and particular SUDs were significantly more prevalent in some facilities relative to others. MHCs were not associated with prior jail admission, but SUDs were linked to a greater probability of a previous jail stay. These results highlight the importance of increasing the availability of jail-based, substance-specific treatment programs that cater to individual facilities' most pressing needs to ultimately reduce jail readmission.

An assessment of the compatibility of DSM-IV and proposed DSM-5 criteria in the diagnosis of cannabis use disorders.

The current study used an automated version of the substance use disorder diagnostic schedule-IV (SUDDS-IV) to assess DSM-IV (fourth edition of the Diagnostic and statistical manual of mental disorders) and two sets of proposed DSM-5 (fifth edition of the Diagnostic and statistical manual of mental disorders) cannabis use disorder criteria among adult prison inmates in the Minnesota Department of Corrections state prison system from 2000 to 2003. Initially proposed DSM-5 criteria had only two diagnostic designations (moderate and severe). A subsequent revision added a mild designation and required a greater number of positive findings for the severe diagnosis. The sample was composed of 7,672 (89.6% male) inmates. Inmates with no DSM-IV diagnoses and most who currently received a cannabis dependence diagnosis according to the DSM-IV guidelines will fit into corresponding DSM-5 categories (i.e., no diagnosis and severe cannabis use disorder, respectively). Some diagnostic criteria, in addition to those proposed for the DSM-5, emerged as cardinal indicators of moderate cannabis use disorder. The study's limitations are noted.

A brief alternative for identifying alcohol use disorders.

This study sought to evaluate the clinical utility of a brief assessment interview in accurately classifying inmates manifesting an alcohol use disorder (AUD) based on a structured diagnostic assessment interview. Data were derived from routine clinical assessments of 7,672 inmates (89.6% male) incarcerated in the Minnesota Department of Corrections state prison system. An automated version of the Substance Use Disorder Diagnostic Schedule-IV (SUDDS-IV), which included a subset of the items comprising the Triage Assessment for Addictive Disorders (TAAD), was administered to all inmates from 2000 to 2003. Approximately 99% of the DSM-IV dependence and no diagnosis cases were appropriately classified by the TAAD. Although the TAAD identified nearly all cases with any diagnosis, 20%-24% of cases classified as abuse by the TAAD were found to be dependent by the longer instrument. Similar findings were noted when DSM-5 criteria were applied. The TAAD has the potential to provide a more clinically defensible means of identifying AUDs than brief screens when time constraints may preclude a comprehensive assessment. Limitations and implications for routine clinical practice are discussed.

Pragmatic determination and correlates of victimization among female adolescents presenting for residential addictions treatment.

This study sought to determine whether a structured diagnostic interview using a direct questioning strategy administered at admission to a residential addictions treatment program could identify the nature and extent of victimization and relationships of victimization to co-occurring mental health conditions relatively early in the treatment process. Interview data from 198 consecutive admissions of female adolescents were analyzed. Results revealed that 85% of participants reported victimization (i.e., physical, sexual, or emotional abuse) at intake. Prevalence rates for mood, anxiety, and behavioral disorders were positively related to the extent of victimization. Early exploration of victimization using direct questioning at admission appears both feasible and clinically relevant. Clinical implications for the standard residential addictions treatment intake assessment procedures are discussed.

An Ultra-Brief 2-Item Depression Screening Tool for Correctional Populations.

Although a number of depression screening instruments exist for use primarily in community mental health and medical settings, few have been validated on correctional populations. This study sought to examine the clinical utility of six different 2-item pairs in identifying risk for DSM-5 major depressive episode among a sample of county jail inmates. Data for the current report were derived from routine clinical assessments of 283 inmates recently admitted to a county jail. All inmates were administered the depression screening items as part of a structured diagnostic assessment interview to identify mental health needs. Results revealed that the best performing 2-item screen involved the combination of "difficulty concentrating" and "lack of energy," which represented the best balance of sensitivity (85.5%) and specificity (76.6%). Screening for major depression using as few as two items can be a valid and efficient strategy in identifying risk for major depressive episode among jail inmates.

A PTSD Screen for Forensic Populations.

Posttraumatic stress disorder (PTSD) has been observed in a sizable proportion of the U.S. adult correctional population. Jail administrators must pay particularly close attention to inmates with PTSD symptoms, considering these facilities serve as the gateway to the criminal justice system and inmates with PTSD may pose a risk to themselves, other inmates, and staff. The reality of conducting behavioral health assessments in a jail environment is wrought with significant challenges, including limited time. The current study examined prior research on PTSD screening tools to establish an empirical basis for a practical screen to be used among adults recently booked into local jails. Data from a random sample of 283 adults assessed specificity and sensitivity rates of different combinations of criteria. Results indicated a two-item screen achieved an 86.4% sensitivity rate as well as an 80.4% specificity rate. This evidence demonstrates a practical and clinically relevant approach to conducting PTSD screens among adult jail inmates.

Substance Use Risk Indicators and Offending Patterns Among Local Jail Inmates.

This study examined clinical indicators of adult jail inmates' substance use severity and offending patterns. Clinical assessment and booking data were gathered from a random sample of 283 adult inmates using the Comprehensive Addiction and Psychological Evaluation-5, which is consistent with diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Greater substance use risk was associated with increased likelihood of detention for property-related offenses, nonviolent offenses, and multiple jail admissions. Inmates with greater substance use risk were also significantly less likely to be detained for violent offenses. The assessment and coordination of care for jail inmates in local detention centers is paramount to reducing jail bookings, especially for nonviolent offenses.

A prospective study of behavioral health indicators and repeat jail admissions among rural inmates.

BACKGROUND: Approximately three quarters of a million adults are detained in US jails, and rural detention centers are responsible for the largest recent increases in this population. It is estimated that two thirds of jail inmates meet criteria for a substance use disorder (SUD), nearly half present symptoms consistent with a mental health condition (MHC), and the vast majority of adults in jails have been arrested and booked into these facilities in the past. It is critical to examine the link between SUDs, MHCs, and readmissions to help inform better approaches. METHODS: This prospective study examined the associations between SUDs, MHCs, and jail readmissions in a random sample of 224 adults collected from a rural correctional facility in North Carolina. The Comprehensive Addiction and Psychological Evaluation-5 (CAAPE-5) was administered to participants within 24 to 96 h of admission to the jail. Information consistent with DSM-5 designations for SUDs and several MHCs was evaluated in conjunction with 12-month jail readmission data. RESULTS: Bivariate analyses demonstrated the disproportionality of SUDs and several MHCs (including depressive episode, posttraumatic stress, and antisocial personality) among adults who were readmitted to the jail. Binary multivariate logistic regression analyses showed SUDs nor MHCs to be associated with any jail readmissions, but multinomial regression results indicated SUDs were the most robust indicator of multiple 12-month jail readmissions. CONCLUSIONS: Local jails need to implement systems capable of conducting behavioral health assessments, with a special focus on SUDs as one of the strongest indicators of readmission. This information will allow jail administrators to better manage detainees while they are incarcerated, but it can also enhance the ability to connect adults with appropriate programming options to address the condition and reduce the likelihood of reentering the detention center.

Posttraumatic stress, panic disorder, violence, and recidivism among local jail detainees.

PURPOSE: Most research on posttraumatic stress disorder (PTSD) and offending has been conducted with special populations (e.g. veterans and female inmates) and generally overlooks the additive effect of panic disorder (PD) in offending patterns. The purpose of this paper is to assess the prevalence of PTSD and PD among jail inmates, while simultaneously examining the relationships between these disorders, offending types and frequency. DESIGN/METHODOLOGY/APPROACH: A random sample of adults recently booked into a local county jail participated in the Comprehensive Addictions and Psychological Evaluation-5 (CAAPE-5), a structured psychological assessment. The study sample was comprised of 200 male and 83 female inmates. FINDINGS: Indications of PTSD were observed among 44.0 percent of male inmates and 57.8 percent of female inmates. Most male inmates (78.4 percent) with positive PTSD indications also met criteria for PD, with a similar proportion (78.1 percent) of female inmates also meeting criteria for both. The combination of PTSD and PD was not associated with offending frequency, but inmates presenting indications of both PTSD and PD were more likely to be charged with a violent offense relative to those with only PTSD. PRACTICAL IMPLICATIONS: Inmates with PTSD who also have panic attacks may have a more severe condition with possible implications for other risks. Observations of these conditions among adults recently booked into local jails should coincide with each other. ORIGINALITY/VALUE: Few studies have examined mental health conditions among local jail detainees, despite the ever-present need to address them. The current study considers this important population and investigates the prevalence of co-occurring conditions.

The UNCOPE: An effective brief screen for DSM-5 substance use disorders in correctional settings.

This study examines the clinical utility of the UNCOPE (Hoffmann, Hunt, Rhodes, & Riley, 2003), a brief 6-item screen that has been validated on a number of criminal justice involved populations (i.e., state prison and county jail inmates, recent arrestees, and juvenile offenders), in identifying risk for DSM-5 substance use disorders (SUDs) among a large sample of state prison inmates. Although the UNCOPE has demonstrated relatively good accuracy in identifying DSM-IV substance dependence, its utility for DSM-5 SUDs warrants investigation. The current study explored substance-specific UNCOPE screening for identifying DSM-5 diagnoses for alcohol, cocaine, and cannabis. Data for the present report were derived from routine consecutive clinical assessments of 6,871 male and 801 female inmates recently admitted to a state prison system. All inmates were administered the UNCOPE as part of a computer-prompted structured diagnostic interview conducted by certified addiction counselors during routine clinical assessments to identify SUDs. Results revealed that a cut-score of 3 positive responses yielded reasonable sensitivity estimates for a severe DSM-5 diagnosis ranging from 85% to 97%, depending on substance class and gender. Specificity findings for those without a severe diagnosis were very high and ranged from 97% to 99%. Cronbach's alphas were .90 or greater, and the item intercorrelations were generally high. Observed findings suggest screening for specific substances using the UNCOPE is a potentially valid strategy for the identification of specific DSM-5 SUDs among inmates. (PsycINFO Database Record

Diagnostic Concordance between DSM-5 and ICD-10 Cannabis Use Disorders.

OBJECTIVES: With the recent federal mandate that all U.S. health care settings transition to ICD-10 billing codes, empirical evidence is necessary to determine if the DSM-5 designations map to their respective ICD-10 diagnostic categories/billing codes. The present study examined the concordance between DSM-5 and ICD-10 cannabis use disorder diagnoses. METHOD: Data were derived from routine clinical assessments of 6871 male and 801 female inmates recently admitted to a state prison system from 2000 to 2003. DSM-5 and ICD-10 diagnostic determinations were made from algorithms corresponding to the respective diagnostic formulations. RESULTS: Past 12-month prevalence rates of cannabis use disorders were comparable across classification systems. The vast majority of inmates with no DSM-5 diagnosis continued to have no diagnosis per the ICD-10, and a similar proportion with a DSM-5 severe diagnosis received an ICD-10 dependence diagnosis. Most of the variation in diagnostic classifications was accounted for by those with a DSM-5 moderate diagnosis in that approximately half of these cases received an ICD-10 dependence diagnosis while the remaining cases received a harmful use diagnosis. CONCLUSIONS: Although there appears to be a generally high level of agreement between diagnostic classification systems for those with no diagnosis or those evincing symptoms of a more severe condition, concordance between DSM-5 moderate and ICD-10 dependence diagnoses was poor. Additional research is warranted to determine the appropriateness and implications of the current DSM-5 coding guidelines regarding the assignment of an ICD-10 dependence code for those with a DSM-5 moderate diagnosis.

Psychobehavioral risk factors, substance treatment engagement and clinical outcomes as predictors of emergency department use and medical hospitalization.

OBJECTIVE: Prior research on health care utilization after treatment for substance misuse disorders has not accounted for posttreatment clinical outcomes as well as putative confounds associated with both substance use and health care. This study examined the association of posttreatment health care utilization with treatment factors (program type and time in treatment) and baseline psychological/behavioral risk factors (smoking status and level of depressive, alcohol and drug dependence symptoms). The study also examined whether posttreatment clinical outcomes-participation in aftercare, Alcoholic Anonymous (AA) attendance, substance use, depressive symptoms and smoking- were associated with subsequent health care utilization. METHOD: We analyzed predictors of posttreatment medical hospitalizations and emergency department (ED) use among 15,041 participants in a multistate treatment evaluation project conducted from 1987 to 1995. RESULTS: Greater time in treatment reduced the likelihood of future hospitalizations and ED use, whereas clients in outpatient treatment were less likely to be hospitalized. Baseline measures of depressive, alcohol and drug dependence symptoms were each independently associated with subsequent health care use. Posttreatment aftercare participation reduced the likelihood of future hospitalization and ED use, whereas AA attendance also reduced the likelihood of hospitalization. In addition, posttreatment counts of depressive symptoms increased the likelihood of future hospitalization and ED use. Substance relapse increased the likelihood of subsequent ED use. CONCLUSIONS: The study supports the public health importance of substance misuse disorders treatment, with greater treatment involvement associated with lower high-cost medical utilization. Treatment clinical outcomes-posttreatment relapse and depressive symptoms-partially mediate the effect of treatment on health care utilization.

Prevalence of co-occurring disorders among juveniles committed to detention centers.

The Practical Adolescent Diagnostic Interview (PADDI), a structured diagnostic interview designed to gather basic information about substance use disorders, mental health conditions, and related experiences, was used in routine evaluation of all adolescents committed to two juvenile detention centers. Anonymous data from 252 consecutively admitted adolescents were analyzed to assess the prevalence and severity of problem areas and to provide a preliminary exploration of interrelationships among those problems. Results demonstrated that a majority of adolescents manifested multiple problems. Whereas prevalence rates were high across gender, females displayed significantly greater mental health problems and maltreatment histories.

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.