Assessing Feasibility and Barriers to Implementing a Family-Based Intervention in Opioid Treatment Programs.

Families Facing the Future (FFF) is an intervention designed specifically for families with a parent in methadone treatment. FFF is unique because it addresses prevention for children and recovery for parents in a single intervention. The primary goals of the program are to prevent parents' relapse, help them cope with relapse if it occurs, and teach parenting skills in order to reduce the likelihood of substance use among their children. FFF has been implemented as an adjunct to treatment in several Opioid Treatment Programs, but has not been widely adopted due to various implementation barriers. The aims of this study, therefore, were to (1) assess the perceived feasibility of implementing FFF and (2) identify/describe barriers to implementing FFF. An online survey was used to assess implementation feasibility, while individual qualitative interviews were conducted to explore specific barriers to implementation. Data collection from a total of 40 participants (20 patients and 20 providers) was conducted from August 2022 to October 2022 at two Opioid Treatment Programs in Florida. Analyses revealed high feasibility scores, indicating that FFF was viewed by both patients and providers as a practical intervention to implement. Despite strong perceived feasibility of the intervention, qualitative findings identified several implementation barriers with respect to difficulty attending parent training sessions, aversion to in-home visits, and lack of funding (inability to provide patient incentives/bill insurance). This study provides evidence that while patients and providers view FFF as having high feasibility, significant implementation barriers exist. This paper fills a void in the literature by informing if and which modifications might be necessary to facilitate wider adoption of FFF in real-world Opioid Treatment Program settings.

Acceptability and Usability of a Reward-Based Mobile App for Opioid Treatment Settings: Mixed Methods Pilot Study.

BACKGROUND: Contingency management is an evidence-based yet underutilized approach for opioid use disorder (OUD). Reasons for limited adoption in real-world practice include ethical, moral, and philosophical concerns regarding use of monetary incentives, and lack of technological innovation. In light of surging opioid overdose deaths, there is a need for development of technology-enabled solutions leveraging the power of contingency management in a way that is viewed by both patients and providers as acceptable and feasible. OBJECTIVE: This mixed methods pilot study sought to determine the perceived acceptability and usability of PROCare Recovery, a reward-based, technology-enabled recovery monitoring smartphone app designed to automate contingency management by immediately delivering micropayments to patients for achieving recovery goals via smart debit card with blocking capabilities. METHODS: Participants included patients receiving buprenorphine for OUD (n=10) and licensed prescribers (n=5). Qualitative interviews were conducted by 2 PhD-level researchers via video conferencing to explore a priori hypotheses. Thematic analysis of interviews was conducted and synthesized into major themes. RESULTS: Participants were overwhelmingly in favor of microrewards (eg, US $1) to incentivize treatment participation (up to US $150 monthly). Participants reported high acceptability of the planned debit card spending restrictions (blocking cash withdrawals and purchases at bars or liquor stores, casinos or online gambling). Quantitative data revealed a high level of perceived usability of the PROCare Recovery app. CONCLUSIONS: Patients and providers alike appear receptive to microfinancial incentives in standard OUD treatment practices. Further pilot testing of PROCare is underway to determine acceptability, feasibility, and preliminary effectiveness in a rigorous randomized controlled trial.

Rewarding recovery: the time is now for contingency management for opioid use disorder.

Contingency management (i.e. rewarding people, often with money, for achieving their recovery goals) is backed by decades of empirical support yet remains highly underutilized. Rewards are rarely used in real-world clinical practice due to a number of concerns, including most notably, the apparent lack of innovation, as well as moral, philosophical, ethical, and economic concerns, and even federal rules meant to prevent illegal inducements in health care. Still, other opponents argue that some patients will try to "game" the system by simply doing whatever it takes to earn monetary rewards. This paper provides a succinct, up-to-date overview of the current evidence base for contingency management for opioid use disorder. Common barriers and solutions to implementation, as well as implications for future research and clinical practice are discussed. Although important, greater uptake of contingency management interventions is about more than legislation and regulations; it's about recognizing stigma, shaping attitudes, and increasing awareness. Provider involvement in advocacy efforts at all levels and collaboration involving academic-industry partnerships is necessary to advance the burgeoning digital health care space and improve outcomes for people with opioid use disorder. Key MessagesContingency management is highly effective but highly underutilized.Low uptake is largely attributed to a lack of innovation and moral, ethical, and economic concerns, among other barriers.Technology-enabled solutions and academic-industry partnerships are critical to advance opioid use disorder care.

Payer-Level Care Coordination and Re-admission to Acute Mental Health Care for Uninsured Individuals.

This study determined the short- and long-term outcomes associated with payer-level care coordination, compared with care-as-usual in "high-utilizers" of acute care services in a large, publicly funded safety net system. Administrative claims data (2016-2020) were analyzed. All patients were "high-utilizers," defined by the State of Florida as either (a) 3 + more acute care episodes in a 6-month period or (b) 1 + acute care episodes in the past 6 months lasting 16 + days. Patients enrolled in care coordination (n = 178) were compared to usual care (n = 1,127) on rates of re-admission and post-discharge engagement in outpatient/residential services. Care coordination was associated with reduced rates of re-admission, significant cost savings, and enhanced engagement in post-discharge non-crisis services. In light of the observed clinical and economic benefits associated with care coordination, payers, policymakers, and administrators of acute care settings should consider potential return on investment for allocation of resources to support specialty care coordination programs.

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.

The Eleventh Judicial Circuit Criminal Mental Health Project: Improving Access to Mental Health Treatment in Miami-Dade County.

The Eleventh Judicial Circuit Criminal Mental Health Project (CMHP), a court-based jail diversion program, was established to divert individuals with serious mental illness from the criminal justice system into treatment and support services. The CMHP's success is built on collaboration among a diverse array of community stakeholders. This column describes the establishment and maintenance of these partnerships. CMHP's success is the result of several factors, including motivated local champions, acquisition of grant funding, formalized communication support, and use of the sequential intercept model. As the CMHP grows, system science methods will be useful for supporting optimization and sustainment.

Medication Treatment With Methadone or Buprenorphine: Differential Reasons for Premature Discharge.

OBJECTIVES: Medication treatment with methadone or buprenorphine has shown demonstrated effectiveness for opioid dependence; while premature discharge is associated with adverse outcomes. Specific reasons for premature discharge generally fall into 2 broad categories (ie, patient- and program-initiated). Previous studies have typically failed to distinguish between different types of discharge reasons among patients who leave treatment early. This study sought to determine whether type of medication was associated with differential discharge reasons among medication treatment patients who were prematurely discharged. METHODS: Data were derived from electronic health records for 5486 patients prematurely discharged from 41 for-profit licensed opioid treatment programs in the United States from 2012 to 2013. All patients were treated with methadone or buprenorphine. Patients were studied through retrospective chart review until premature discharge. RESULTS: Buprenorphine patients who left treatment prematurely were 2.18 times (95% confidence interval [CI] 1.89-2.53) more likely to be discharged against medical advice relative to methadone patients after controlling for intake differences. Methadone patients were 1.76 times (95% CI 1.47-2.10) more likely to be administratively discharged after adjustment for covariates. CONCLUSIONS: Further research is warranted to determine whether individually-tailored strategies may improve retention for certain patients based on medication. Ongoing review of program rules and policies may benefit methadone patients, who are nearly twice as likely to be discharged for an administrative, program-initiated reason. Strategies including contingency management, motivational incentives, and psychoeducation regarding the advantages of retention may benefit buprenorphine patients who are over 2 times more likely to leave treatment early due to a patient-initiated reason.

The Role of Patient Payment Method in Premature Discharge from Methadone Maintenance Treatment.

BACKGROUND: Premature discharge is a pervasive problem in methadone maintenance treatment (MMT), and is associated with numerous adverse outcomes. Although a number of demographic variables have consistently been found to impact MMT retention, method of payment has received considerably less attention. A notable limitation of prior work is that most studies classify all patients who leave treatment early, irrespective of reason, as treatment dropouts and fail to account for specific reasons. OBJECTIVE: This study sought to determine whether method of payment for MMT services was associated with differential reasons for premature discharge. METHODS: The sample was comprised of 4158 patients prematurely discharged from 33 MMT facilities located throughout the U.S. from 2009 to 2012. Patients were classified into two groups based on their method of payment: self-pay and insurance (largely Medicaid). Patients were studied through retrospective electronic chart review. RESULTS: Binary logistic regression indicated that insurance patients who were prematurely discharged were significantly more likely to be discharged due to a program-initiated reason (administrative), while self-pay patients were more likely to be discharged due to a patient-initiated reason (against medical advice) after controlling for significant intake demographic and clinical covariates. CONCLUSIONS: Further research is needed to determine whether insurance patients may require different supports in place compared to self-pay patients in order to improve compliance with program guidelines (e.g. behavioral contracts providing a detailed description of rules both at admission and throughout treatment with an emphasis on the potential consequences of noncompliance), and whether self-pay patients may benefit from motivational incentives and interventions to remain engaged in treatment.

Patient adherence to multi-component continuing care discharge plans.

Intuitively, it is assumed that greater patient adherence to treatment recommendations in substance use disorder (SUD) treatment is associated with favorable outcomes, but surprisingly, there is limited research systematically examining the adherence-outcome relationship in the context of the continuing care phase post-discharge from residential treatment. This study sought to determine the effect of adherence to multi-component continuing care plans on long-term outcomes among patients following the primary treatment episode. Data were abstracted from electronic medical records for 271 patients (59.0% male) discharged from a U.S. residential program between 2013 and 2015. Patients were categorized based on their level of adherence to their individualized continuing care discharge plan, and studied through retrospective record review for 12months post-discharge. 12-month outcomes included past 30-day and continuous abstinence, re-admission, and quality of life. With the exception of re-admission rate, fully adherent patients demonstrated significantly better results on all study outcomes at 12months compared to patients who were partially or non-adherent. Fully adherent patients were 9.46 times (95% CI: 5.07-17.62) more likely to be continuously abstinent through 12months relative to the other adherence groups. Fully adherent patients were 7.53 times (95% CI: 2.41-23.50) more likely to report a positive quality of life at 12months relative to the other adherence groups. The findings support the widely held contention that greater adherence to continuing care discharge plans is associated with favorable long-term outcomes, and provide insight into realistic outcomes expectations for patients who are adherent to their multi-component continuing care discharge plans.

Importance of short-term continuing care plan adherence on long-term outcomes among patients discharged from residential substance use treatment.

BACKGROUND: Patients adherent to their recommended treatment regimen demonstrate favorable outcomes. However, it is unclear whether there are specific short-term continuing care performance variables indicative of better long-term prognosis. OBJECTIVE: This study determined the impact of attendance at an outpatient appointment within 7 days post-discharge from residential treatment on 12-month outcomes. METHOD: Data were abstracted from electronic medical records for 275 patients (58.9% male) discharged from a single residential treatment program. All discharge plans included a 7-day outpatient appointment with a provider in their home community. Patients were dichotomized based on their attendance at the initial appointment to yield a re-engagement variable. Twelve-month outcomes included past 30-day and continuous abstinence rates, quality of life, and long-term adherence to continuing care plans. RESULTS: Patients attending their initial outpatient appointment within 7 days of discharge evidenced better long-term outcomes relative to patients who did not with respect to continuous abstinence (75.4% vs. 37.3%), past-30-day abstinence (92.0% vs. 70.6%), quality of life (94.2% vs. 78.4%), and adherence (66.4% vs. 9.8%). Re-engagement remained a significant predictor of continuous abstinence and quality of life at 12 months after controlling for 12-month adherence and relevant demographic characteristics. CONCLUSION: Treatment providers are encouraged to emphasize the relative importance of attending initial post-discharge appointments in achieving successful long-term outcomes. Allocation of resources to enhance engagement during residential treatment may be justified in that there may be value in actively encouraging patients to participate in continuing care activities, particularly shortly following discharge.

AiRCare: A naturalistic evaluation of the effectiveness of a protracted telephone-based recovery assistance program on continuing care outcomes.

BACKGROUND & OBJECTIVE: Substance use disorder treatments are increasingly being contextualized within a disease management framework. Within this context, there is an identified need to maintain patients in treatment for longer periods of time in order to help them learn how to manage their disease. One way to meet this need is through telephone-based interventions that engage patients, and include more active outreach attempts and involvement of the patient's family. This study sought to evaluate the effectiveness of three formats of an intensive 12-month post-discharge telephone-based case management approach (AiRCare) on adherence to continuing care plans and substance use outcomes. METHODS: Data were abstracted from electronic medical records for 379 patients (59.9% male) discharged from a residential treatment program located in the southwestern U.S. from 2013 to 2015. Patients were categorized into one of three groups and received telephone contacts based on their self-selection upon admission to residential treatment (i.e., patient only, family only, and both patient and family). Outcome variables included re-engagement and re-admission rates, quality of life, abstinence rates at 6 and 12 months, and compliance with continuing care plans. RESULTS & CONCLUSIONS: Favorable short- and long-term outcomes were found for the majority of patients, irrespective of case management group. There appeared to be some value in the addition of family contacts to patient contacts with respect to reducing risk for 12-month re-admission to residential care. These positive but preliminary indications of the effectiveness of AiRCare require replication in a well-powered, randomized controlled trial.

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.

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.

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.

Do positive alcohol expectancies have a critical developmental period in pre-adolescents?

OBJECTIVE: Positive outcome expectancies have been shown to predict initiation of alcohol use in children and to mediate and moderate the relationship between dispositional variables and drinking behavior. Negative outcome expectancies for alcohol appear to weaken as children progress to middle adolescence, but positive expectancies tend to increase during this time. Positive alcohol expectancies have been found to increase in children in third and fourth grades, indicating what some investigators have termed a possible critical period for the development of positive expectancies. METHOD: In the present study, we assessed alcohol expectancies at baseline, 6, 12, and 18 months in 277 second-through sixth-grade students. Children completed the Alcohol Expectancy Questionnaire-Adolescent. Univariate analyses of covariance were conducted. RESULTS: There were significant main effects for grade on positive alcohol-expectancy change for Global Positive Transformations at 12 and 18 months, Social Behavior Enhancement or Impediment at 6 and 12 months, and Relaxation/Tension Reduction at 6 and 18 months, whereby a consistent pattern emerged in that lower grades did not differ from each other, but they differed significantly from the higher grades. CONCLUSIONS: Data support a critical developmental period for positive alcohol expectancies, with the greatest change observed between third and fourth grade and between fourth and fifth grade, and only in those expectancies clearly describing positive outcomes (e.g., Relaxation/Tension Reduction) via positive or negative reinforcement versus those with either combined or ambiguous outcomes (e.g., Social Behavior Enhancement or Impediment).

A naturalistic comparison of the effectiveness of methadone and two sublingual formulations of buprenorphine on maintenance treatment outcomes: findings from a retrospective multisite study.

OBJECTIVE: This study sought to compare the effectiveness of the 3 most commonly prescribed maintenance medications in the United States indicated for the treatment of opioid dependence in reducing illicit drug use and retaining patients in treatment. METHOD: Data were abstracted from electronic medical records for 3,233 patients admitted to 34 maintenance treatment facilities located throughout the United States during the period of July 1, 2012, through July 1, 2013. Patients were grouped into 1 of 3 medication categories based on their selection at intake (methadone [n = 2,738; M dosage = 64.64 mg/d, SD = 25.58], Suboxone [n = 102; M dosage = 9.75 mg/d, SD = 4.04], or Subutex [n = 393; M dosage = 12.21 mg/d, SD = 5.31]) and were studied through retrospective chart review for 6 months or until treatment discharge. Two measures of patient retention in treatment and urinalysis drug screen (UDS) findings for both opioids and various nonopioid substances comprised the study outcomes. RESULTS: The average length of stay (LOS) in terms of days in treatment for the methadone group (M = 169.86, SE = 5.02) was significantly longer than both the Subutex (M = 69.34, SE = 23.43) and Suboxone (M = 119.35, SE = 20.82) groups. The Suboxone group evinced a significantly longer average LOS relative to the Subutex group. After adjustment for relevant covariates, patients maintained on methadone were 3.73 times (95% confidence interval [CI]= 2.82-4.92) and 2.48 times (95% CI = 1.57-3.92) more likely to be retained in treatment at 6 months than patients prescribed Subutex and Suboxone, respectively. The 6-month prevalence rates of positive UDS findings for both opioids and nonopioid substances were similar across medication groups. CONCLUSIONS: Comparable rates of illicit drug use at 6 months may be expected irrespective of maintenance medication, while increased retention may be expected for patients maintained on methadone relative to those maintained on Suboxone or Subutex.

The continuing care model of substance use treatment: what works, and when is "enough," "enough?".

There is little disagreement in the substance use treatment literature regarding the conceptualization of substance dependence as a cyclic, chronic condition consisting of alternating episodes of treatment and subsequent relapse. Likewise, substance use treatment efforts are increasingly being contextualized within a similar disease management framework, much like that of other chronic medical conditions (diabetes, hypertension, etc.). As such, substance use treatment has generally been viewed as a process comprised of two phases. Theoretically, the incorporation of some form of lower intensity continuing care services delivered in the context of outpatient treatment after the primary treatment phase (e.g., residential) appears to be a likely requisite if all stakeholders aspire to successful long-term clinical outcomes. Thus, the overarching objective of any continuing care model should be to sustain treatment gains attained in the primary phase in an effort to ultimately prevent relapse. Given the extant treatment literature clearly supports the contention that treatment is superior to no treatment, and longer lengths of stay is associated with a variety of positive outcomes, the more prudent question appears to be not whether treatment works, but rather what are the specific programmatic elements (e.g., duration, intensity) that comprise an adequate continuing care model. Generally speaking, it appears that the duration of continuing care should extend for a minimum of 3 to 6 months. However, continuing care over a protracted period of up to 12 months appears to be essential if a reasonable expectation of robust recovery is desired. Limitations of prior work and implications for routine clinical practice are also discussed.

Cocaine use disorder prevalence: From current DSM-IV to proposed DSM-5 diagnostic criteria with both a two and three severity level classification system.

This article presents a secondary analysis from a study investigating the compatibility of the current DSM-IV and previously proposed DSM-5 cocaine use disorder (CUD) criteria (S. L. Proctor, A. M. Kopak, & N. G. Hoffmann, 2012, Compatibility of current DSM-IV and proposed DSM-5 diagnostic criteria for cocaine use disorders. Addictive Behaviors, 37, 722-728). The current analyses examined the compatibility of the current DSM-IV and two sets of proposed DSM-5 diagnostic criteria for CUDs among adult male inmates (N = 6,871) recently admitted to the Minnesota Department of Corrections state prison system from 2000-2003. Initially proposed DSM-5 criteria (DSM-5.0) featured only two diagnostic designations (i.e., moderate and severe). A subsequent revision (DSM-5.1) included the addition of a mild designation and required a greater number of positive findings for the severe designation. A computer-prompted structured diagnostic interview was administered to all inmates as part of routine clinical assessments. The past 12-month prevalence of DSM-IV CUDs was 12.70% (Abuse, 3.78%, Dependence, 8.92%), while 10.98% met past 12-month DSM-5.1 criteria for a CUD (Mild [MiCUD], 1.72%; Moderate [MCUD], 1.12%; and Severe [SCUD], 8.14%). The vast majority of those with no diagnosis (99.6%) continued to have no diagnosis, and most of those with a dependence diagnosis (91.2%) met SCUD criteria of the proposed DSM-5.1. Most of the variation in DSM-5.1 diagnostic classifications was accounted for by those with a current abuse diagnosis. DSM-5.0 MCUD cases were most affected when DSM-5.1 criteria were applied. The proposed diagnostic changes might translate to reduced access to treatment for those individuals evincing symptoms consistent with DSM-IV cocaine abuse.