A randomized comparison of extended-release naltrexone with or without patient navigation vs enhanced treatment-as-usual for incarcerated adults with opioid use disorder.

The high prevalence of opioid use among justice-involved adults make jails an exceptional setting to initiate opioid use disorder (OUD) treatment, but optimal strategies for delivering these interventions are still not well understood. The objective of this study was to conduct a randomized controlled trial to assess the effectiveness of extended-release naltrexone (XR-NTX, Vivitrol®; Alkermes Inc) alone or in conjunction with patient navigation (XR-NTX + PN) for jail inmates with OUD. We randomized a sample of 135 sentenced jail inmates with moderate to severe OUD to (1) XR-NTX only; (2) XR-NTX + PN; or (3) enhanced treatment-as-usual (ETAU) with drug education, each initiated prior to release from jail. We scheduled follow-up data assessments at 1, 3, 6, and 12 months post-release. Primary outcomes were opioid use (based on Timeline Followback Interview and Addiction Severity Index) and meeting CIDI DSM-5 criteria for OUD 6 months postrelease. We also measured treatment adherence, HIV risk, and recidivism. XR-NTX participants received a mean of 2.26 of 7 possible injections compared to XR-NTX + PN participants, who received a mean of 2.93 injections (Cohen's d = 0.33, 95% CI: -0.09 to 0.74). Thirty-six percent of patients in XR-NTX + PN attended at least one postrelease PN session. We found no significant differences by study condition six months after release from jail for the primary outcomes of any opioid use (ETAU: 17%, XR-NTX: 16%, XR-NTX + PN: 29%) and past 30-day OUD (ETAU: 8%, XR-NTX: 11%, XR-NTX + PN: 10%). Secondary outcomes of rearrest and HIV risk also were similar across groups, with the exception of lower sex-related HIV risk among those in the XR-NTX condition at 12 months. This study did not show superior outcomes of XR-NTX or XR-NTX + PN with regard to opioid use or recidivism outcomes, relative to ETAU. It did, however, highlight the difficulties with adherence to XR-NTX and PN interventions in OUD patients initiating treatment in jail.

A clinical instrument to guide brief interventions for adolescents with substance use concerns.

BACKGROUND: Adolescent substance use is an important public health problem in New Mexico and the United States. The New Mexico Department of Health school-based health centers (SBHCs) universally administer a validated screen, the CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble), for adolescent substance use concerns; however, quality assurance efforts revealed that SBHC providers needed more information at the point of screening to initiate brief interventions for students with positive CRAFFT screens. The CHISPA (Cocaine, Heroin, IV drugs, Synthetic pot, Pot, Alcohol) was developed to gather specific information on recent substance use experience to guide brief interventions. This paper describes the development and initial reliability and validity of data obtained using the CHISPA instrument. METHODS: In 2015, 99 high school-aged SBHC users in Albuquerque, New Mexico, completed the CRAFFT and CHISPA twice over 2 weeks using standard test-retest methods. Using the CHISPA, students reported for the prior 3 months substances used, frequency of use, and signs of addiction or acute danger (adverse events). RESULTS: Retest reliability for the CRAFFT score was 0.82. CHISPA retest reliabilities were 0.75 for alcohol use; 0.91 for having used any substances; 0.92 for number of substances used; 0.81 for frequency of substance use; and 0.79 for number of adverse events. CRAFFT scores correlated with CHISPA measures of number of substances used at 0.62; with frequency of substance use at 0.58; and with number of adverse events at 0.64. CONCLUSIONS: CHISPA measures show preliminary evidence of reliability and validity. SBHC providers and other providers in primary care settings who use the CRAFFT screen may benefit from using the CHISPA to define recent substance use experience to guide brief interventions for adolescents with substance use concerns. The CHISPA instrument is currently being tested in electronic form in selected SBHCs in the state of New Mexico.

Adolescent substance use: Assessing the knowledge, attitudes, and practices of a school-based health center workforce.

BACKGROUND: Recent attention has focused on the potential for school-based health centers (SBHCs) to provide access points for adolescent substance use care. In 2015, the University of New Mexico began screening, brief intervention, and referral to treatment (SBIRT) training for providers at New Mexico Department of Health (NMDOH)-funded SBHCs across the state. This study assesses baseline knowledge, attitudes, and practices of the New Mexico SBHC provider workforce regarding adolescent substance use and provision of services. METHODS: In early 2015, the NMDOH administered an SBHC provider workforce survey (N = 118) and achieved a 44.9% response rate. This descriptive analysis includes all survey respondents who self-identified as a primary care or behavioral health provider in an SBHC serving middle or high school students (n = 52). RESULTS: Among respondents, the majority (57.7%) were primary care providers, including nurse practitioners, physicians, and physician assistants. The remaining 42.3% of respondents were master's-level behavioral health providers. Only 44.2% of providers reported practicing the full SBIRT model at their SBHC, and 21.2% reported having received continuing education on SBIRT within the previous 3 years. Most respondents, 84.6%, agreed that it is the responsibility of SBHC providers to screen students for substance use using a standardized tool, and 96.2% agreed that it is the responsibility of the SBHC provider to assess for students' readiness to change. A majority reported self-efficacy in helping students achieve change in their alcohol use, illicit drug use, and prescription drug misuse: 73.1%, 65.4%, and 63.5%, respectively. CONCLUSIONS: These results suggest that SBIRT training for New Mexico SBHC providers is timely. The authors identified gaps between recommended SBIRT practices and SBIRT delivery as well as discrepancies between reported provider self-efficacy and actual implementation of the SBIRT model. Further study will determine the effectiveness of efforts to address substance use and implement SBIRT in SBHCs.

Injectable pharmacotherapy for opioid use disorders (IPOD).

BACKGROUND: Despite the growing prevalence of opioid use among offenders, pharmacotherapy remains an underused treatment approach in correctional settings. The aim of this 4-year trial is to assess the clinical utility, effectiveness, and cost implications of extended-release naltrexone (XR-NTX, Vivitrol®; Alkermes Inc.) alone and in conjunction with patient navigation for jail inmates with opioid use disorder (OUD). METHODS: Opioid-dependent inmates will be randomly assigned to one of three treatment conditions before being released to the community to include: 1) XR-NTX only; 2) XR-NTX plus patient navigation (PN), and 3) enhanced treatment-as-usual (ETAU) with drug education and a community treatment referral. Before release from jail, participants in the XR-NTX and XR-NTX plus PN conditions will receive their first XR-NTX injection. Those in the XR-NTX plus PN condition also will meet with a patient navigator. Participants in both XR-NTX conditions will be scheduled for medical management sessions twice monthly for months 1-3, monthly medical management sessions for months 4-6, with monthly injections for 5months post-release (which, given the pre-release injection, results in a 6-month medication phase). Follow-up data collection will occur at 1, 3, 6, and 12months post release. RESULTS: We discuss the study's rationale, aims, methods, and anticipated findings. The primary outcome is the presence of a DSM 5 OUD diagnosis 1year after randomization (6months after the end of the active treatment phase). DISCUSSION: We hypothesize that providing XR-NTX prior to release from jail will be particularly beneficial for this extremely high-risk population by reducing opioid use, associated criminal behavior, and injection-related disease risk. ClinicalTrials.Gov: NCT02110264.

The SOMATICS collaborative: Introduction to a National Institute on Drug Abuse cooperative study of pharmacotherapy for opioid treatment in criminal justice settings.

BACKGROUND: Among the nearly 750,000 inmates in U.S. jails, 12% report using opioids regularly, 8% report use in the month prior to their offense, and 4% report use at the time of their offense. Although ample evidence exists that medications effectively treat Opiate Use Disorder (OUD) in the community, strong evidence is lacking in jail settings. The general lack of medications for OUD in jail settings may place persons suffering from OUD at high risk for relapse to drug use and overdose following release from jail. METHODS: The three study sites in this collaborative are pooling data for secondary analyses from three open-label randomized effectiveness trials comparing: (1) the initiation of extended-release naltrexone [XR-NTX] in Sites 1 and 2 and interim methadone in Site 3 with enhanced treatment-as usual (ETAU); (2) the additional benefit of patient navigation plus medications at Sites 2 and 3 vs. medication alone vs. ETAU. Participants are adults with OUD incarcerated in jail and transitioning to the community. RESULTS: We describe the rationale, specific aims, and designs of three separate studies harmonized to enhance their scientific yield to investigate how to best prevent jail inmates from relapsing to opioid use and associated problems as they transition back to the community. CONCLUSIONS: Conducting drug abuse research during incarceration is challenging and study designs with data harmonization across different sites can increase the potential value of research to develop effective treatments for individuals in jail with OUD.

Informatics students across the globe learn to collaborate in second life.

In preparing healthcare professionals to work in the field of informatics, there are many online programs of study. These programs of students include a variety of educational tools. This poster describes the experiences of four student located across the globe learning how to work as a collaborative team. The team used Second Life as a platform to participate in a system life cycle course. The benefits and challenges of the Virtual Clinic environment are highlighted.

Patient relapse in the context of drug abuse treatment.

How do addiction treatment programs integrate the expectation of relapse into drug abuse treatment? This article serves as a thought piece to pose questions rather than definitive solutions. It reflects a distillation of discussions that occurred at the National Institute on Drug Abuse meeting titled "Program Response to Patient Relapse," held on July 15, 2009, along with quantitative and qualitative information about the patterns and types of discharge policies, which factors influence them, and how the culture of drug abuse treatment and the personnel interact with this issue. Some existing data on the discharging of relapsed patients are identified. A program's response to relapse is usually guided by its setting (level of care), philosophy (abstinence vs risk behavior reduction), and associated patient behavior ("benign" vs program disruptive). Key questions examined in this context include the following: Can different discharge policies impact a patient's access to treatment, and what are the implications of incorporating a medical model of addiction into discharge policies?

Partnerships and pathways of dissemination: the National Institute on Drug Abuse-Substance Abuse and Mental Health Services Administration Blending Initiative in the Clinical Trials Network.

Since 2001, the National Drug Abuse Treatment Clinical Trials Network (CTN) has worked to put the results of its trials into the hands of community treatment programs, in large part through its participation in the National Institute on Drug Abuse-Substance Abuse and Mental Health Services Administration Blending Initiative and its close involvement with the Center for Substance Abuse Treatment's Addiction Technology Transfer Centers. This article describes (a) the CTN's integral role in the Blending Initiative, (b) key partnerships and dissemination pathways through which the results of CTN trials are developed into blending products and then transferred to community treatment programs, and (c) three blending initiatives involving buprenorphine, motivational incentives, and motivational interviewing. The Blending Initiative has resulted in high utilization of its products, preparation of more than 200 regional trainers, widespread training of service providers in most U.S. States, Puerto Rico, and the U.S. Virgin Islands and movement toward the development of Web-based implementation supports and technical assistance. Implications for future directions of the Blending Initiative and opportunities for research are discussed.

Blending addiction research and practice: strategies for technology transfer.

Consistent with traditional conceptions of technology transfer, efforts to translate substance abuse and addiction research into treatment practice have typically relied on the passive dissemination of research findings. The large gap between addiction research and practice, however, indicates that there are many barriers to successful technology transfer and that dissemination alone is not sufficient to produce lasting changes in addiction treatment. To accelerate the translation of research into practice, the National Institute on Drug Abuse launched the Blending Initiative in 2001. In part a collaboration with the Substance Abuse and Mental Health Services Administration/Center for Substance Abuse Treatment's Addiction Technology Transfer Center program, this initiative aims to improve the development, effectiveness, and usability of evidence-based practices and reduce the obstacles to their timely adoption and implementation.

Drugs of abuse and the aging brain.

Substance abuse among older adults has received little attention in the past, presumably because this population has traditionally accounted for only a small percentage of the drug abuse problem in the United States. The aging of the baby boomer generation (born 1946-1964), however, will soon swell the ranks of older adults and dramatically alter the demography of American society. Several observations suggest that this expansion will likely be accompanied by a precipitous increase in the abuse of drugs, including prescription medications and illicit substances, among older adults. While it is now evident that the brain changes continuously across life, how drugs of abuse interact with these age-related changes remains unclear. The dynamic nature of brain function, however, suggests that substance abuse during older age may augment the risks and require unique considerations for diagnosis and treatment. In addition to describing current and projected prevalence estimates of substance abuse among older adults, the present review discusses how aging affects brain systems involved in drug abuse, and explores the potential impact of drug abuse on the aging brain. Future directions for substance abuse research among older adults will also be considered.

Why do we need an Addiction supplement focused on methamphetamine?

Methamphetamine is a substantial public health problem in many communities in the United States and in other parts of the world. In order to bring new knowledge about methamphetamine to policy makers, clinicians and researchers, this volume has compiled a set of articles containing new information about the drug and its effects. The articles contain information presented by researchers at two special methamphetamine meetings sponsored by the National Institute on Drug Abuse in 2005.

Projecting drug use among aging baby boomers in 2020.

PURPOSE: Greater rates of lifetime drug use among the baby-boom generation, combined with the size of that generation, suggest that the number of elderly persons using drugs will increase in the next two decades. Given the potential public health demands implied by increasing numbers of elderly drug users, the goal is to project the numbers of current drug users aged 50 years and older in 2020. METHODS: Using the modeling and projection methods of Gfroerer et al (2003) applied to data from the 1999 to 2001 National Household Surveys on Drug Abuse, projections were developed for the use of marijuana, nonmedical use of any prescription-type psychotherapeutic drug, and any illicit drug use. RESULTS: From 1999 to 2001 to 2020, past-year marijuana use in persons 50 years and older is forecast to increase from 1.0% to 2.9%. The number of users is expected to increase from 719,000 to almost 3.3 million, reflecting the combined effects of the increase in rate of use and a projected 51.9% increase in the civilian noninstitutionalized population in this age group. Use of any illicit drug will increase from 2.2% (1.6 million) to 3.1% (3.5 million), and nonmedical use of psychotherapeutic drugs will increase from 1.2% (911,000) to 2.4% (almost 2.7 million). CONCLUSIONS: These projections call attention to changes to be considered in planning and to the need for improved knowledge of the biomedical and psychosocial effects of nonmedical drug use on aging and elderly individuals.