Contingency management for patients with dual disorders in intensive outpatient treatment for addiction.

OBJECTIVE: This quality improvement program evaluation investigated the effectiveness of contingency management for improving retention in treatment and positive outcomes among patients with dual disorders in intensive outpatient treatment for addiction. METHODS: The effect of contingency management was explored among a group of 160 patients exposed to contingency management (n = 88) and not exposed to contingency management (no contingency management, n = 72) in a six-week partial hospitalization program. Patients referred to the partial hospitalization program for treatment of substance use and comorbid psychiatric disorders received diagnoses from psychiatrists and specialist clinicians according to the Diagnostic and Statistical Manual of the American Psychiatric Association. A unique application of the contingency management "fishbowl" method was used to improve the consistency of attendance at treatment sessions, which patients attended 5 days a week. Days attending treatment and drug-free days were the main outcome variables. Other outcomes of interest were depression, anxiety and psychological stress, coping ability, and intensity of drug cravings. RESULTS: Patients in the contingency management group attended more treatment days compared to patients in the no contingency management group; M = 16.2 days (SD = 10.0) versus M = 9.9 days (SD = 8.5), respectively; t = 4.2, df = 158, p <.001. No difference was found between the treatment groups on number of drug-free days. Psychological stress and drug craving were inversely associated with drug-free days in bivariate testing (r = -.18, p <.02; r = -.31, p <.001, respectively). Treatment days attended and drug craving were associated with drug-free days in multivariate testing (B =.05, SE =.01, ß =.39, t = 4.9, p <.001; B = -.47; SE =.12, ß = -.30, t = -3.9, p <.001, respectively; Adj. R(2) =.21). Days attending treatment partially mediated the relationship between exposure to contingency management and self-reported drug-free days. CONCLUSIONS: Contingency management is a valuable adjunct for increasing retention in treatment among patients with dual disorders in partial hospitalization treatment. Exposure to contingency management increases retention in treatment, which in turn contributes to increased drug-free days. Interventions for coping with psychological stress and drug cravings should be emphasized in intensive dual diagnosis group therapy.

Alcohol outcome expectancies as socially shared and socialized beliefs.

Alcohol expectancies are important predictors of alcohol involvement in both adolescents and adults, yet little research has examined the social origins and transmission of these beliefs. This paper examined alcohol outcome expectancies collected in a cohort-sequential longitudinal study of 452 families with children followed over seven waves. Children completed interviews every 6 months, and parents completed interviews annually. Eighteen of 27 alcohol expectancies were highly consensual, being endorsed by significantly more than 67% of the mothers and fathers. These consensual expectancies were also highly stable over a 3-year period. Over the same period, children increased their adoption of both the positive and negative consensual alcohol expectancies. Unconditional latent growth modeling showed that piece-wise growth models with a transition at age 12 fit the data best. Both the positive and negative consensual expectancies were adopted at a faster rate between ages 8.5 and 11.5 than between ages 12 and 13.5. For negative expectancies, there was no further growth between ages 12 and 13.5. Taken together, these findings support the conceptualization of alcohol outcome expectancies as socially shared and transmitted beliefs.

Divalproex utility in bipolar disorder with co-occurring cocaine dependence: a pilot study.

OBJECTIVE: The aim of this open-label pilot study was to evaluate the utility of divalproex in decreasing cocaine use and stabilizing mood symptoms among patients with bipolar disorder with comorbid cocaine dependence. METHOD: Fifteen patients enrolled in the study and seven met final inclusion criteria of DSM-IV/SCID diagnoses of bipolar I disorder and comorbid cocaine dependence with active cocaine use. Patients were started on open-label divalproex. After stabilization on divalproex sodium, weekly assessments were undertaken for 8weeks. Subjects also attended dual recovery counseling. RESULTS: The results revealed significant improvement on % cocaine abstinent days, dollars spent on cocaine, ASI's drug use severity index, % alcohol abstinent days, drinks per drinking day, marijuana use and cigarettes smoking. They also had significant improvement on manic, depressive, and sleep symptoms and on functioning. There were no reported adverse events or increases in liver function tests. CONCLUSION: The results of this open-label study point to the potential utility of divalproex in patients with bipolar disorder and primary cocaine dependence. Double-blind, placebo-controlled studies to fully evaluate the efficacy of divalproex in this high risk clinical population are warranted.

Benchmarking physician performance, part 2.

Part 1 of this article (January-February 2006) reviewed ways of measuring the work of physicians through methods such as data envelopment analysis (DEA) and relative value units (RVUs). These techniques provide insights into: 1. Who are the best-performing physicians? 2. Who are the underperforming physicians? 3. How can underperforming physicians improve? 4. What are the underperformers' performance targets? 5. How do you deal with full- and part-time physicians in a university setting? Part 2 compares the performance of 16 primary care physicians in the same medical specialty using DEA efficiency scores. DEA is capable of modeling multiple criteria and automatically determines the relative weights of each performance measure. This research also provides a preliminary framework for how work measurement and DEA can be used as a basis for a medical team or physician compensation system.

Benchmarking physician performance, Part 1.

The performance of 16 primary care physicians in the same medical specialty and university clinic is compared using data envelopment analysis (DEA) efficiency scores. DEA is capable of modeling multiple criteria and automatically determines the relative weights of each performance measure. In this research, the performance measures include physician work relative value units (RVUs) as an input variable and patient satisfaction and total billable charges as the two output variables. The results provide insights into: 1. Who are the best-performing physicians? 2. Who are the underperforming physicians? 3. How can underperforming physicians improve? 4. What are the underperformers' performance targets? 5. How do you deal with full- and part-time physicians in a university setting? This research also provides a preliminary framework for how work measurement and DEA analysis can be used as a basis for a medical team or physician compensation system.

Alcohol screening in young persons attending a sexually transmitted disease clinic. Comparison of AUDIT, CRAFFT, and CAGE instruments.

OBJECTIVE: To compare the ability of 3 brief alcohol screens (Alcohol Use Disorders Identification Test [AUDIT], CRAFFT, and CAGE) to identify adolescents and young adults with a current alcohol use disorder (AUD) and to determine whether there are gender-based or race-based differences in screening performance. DESIGN, PARTICIPANTS, AND SETTING: Cross-sectional study of 358 young persons (55% males; 49% blacks; age range, 15-24 years; mean age, 20.6 years) who were attending an urban clinic for sexually transmitted diseases and reported alcohol use during the past year. MEASUREMENTS: Receiver operating characteristic (ROC) curve analysis was used to determine the ability of the 3 screens to discriminate between participants with and without AUDs detected in the Structured Clinical Interview for DSM-IV (SCID). RESULTS: One third (33%) of participants met Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria for a current AUD (24% with alcohol abuse and 9% with alcohol dependence). The AUDIT performed best at a cut score of 9 (sensitivity, 0.76; specificity, 0.79), CRAFFT at a cut score of 2 (sensitivity, 0.94; specificity, 0.33), and CAGE at a cut score of 1 (sensitivity, 0.69; specificity, 0.63). The AUDIT had the best overall performance (area under the curve [AUC], 0.84), followed closely by CRAFFT (AUC, 0.79) and then CAGE (AUC, 0.70). Performance of screens did not differ by gender. The AUDIT performed slightly better in whites than blacks, but no race-based differences were observed for the CAGE or CRAFFT. CONCLUSIONS: Clinicians should use the AUDIT or CRAFFT, rather than the CAGE, to screen young persons for AUDs. The AUDIT performs best, but its length may limit its utility in this setting. The CRAFFT is a suitable alternative, with excellent sensitivity and no gender-based or race-based differences.

High-lethality status in patients with borderline personality disorder.

Recurrent suicidal behaviors in patients with Borderline Personality Disorder (BPD) are often considered communicative gestures; however, 10% complete suicide. This study seeks to identify risk factors for suicide within a BPD sample by comparing patients with High- and Low-Lethality attempts. BPD attempters (n = 113) were assessed on demographic, diagnostic, and personality variables: clinical symptoms, suicidal behaviors; childhood, family, and treatment histories; social adjustment; and recent life events. Forty-four High-Lethality attempters, defined by a score of 4 or more on Beck's Medical Lethality Scale, were compared to 69 Low-Lethality attempters. Discriminating variables were entered in a multivariate logistic regression model to define predictors of High-Lethality status. High-Lethality attempters were older, with children, less education, and lower socioeconomic class (SES) than Low-Lethality attempters. They were more likely to have Major Depressive Disorder (MDD), co-morbid Antisocial Personality Disorder (ASPD), and family histories of substance abuse. They reported greater intent to die, more lifetime attempts, hospitalizations, and time in the hospital. High-Lethality status was best predicted by low SES, co-morbid ASPD, extensive treatment histories, and greater intent to die. These characteristics resemble profiles of patients who complete suicide, are not specific for BPD, and do not include impulsivity, aggression, or severity of BPD criteria.

Patient characteristics and treatment implications of marijuana abuse among bipolar alcoholics: results from a double blind, placebo-controlled study.

OBJECTIVE: Marijuana abuse, primarily a disorder of adolescents and young adults, is highly prevalent among patients with severely ill psychiatric population, especially those with bipolar disorder. Additional marijuana abuse may impact on the clinical presentation of bipolar illness and may potentially act as mediator of treatment response in this population. However, the characterization of bipolar disorder patients with additional marijuana abuse and the impact of such abuse on treatment outcome has been rarely examined. The aim of this study was to characterize bipolar alcoholic patients with comorbid marijuana abuse and test the impact of marijuana abuse on alcohol and mood outcome of patients with bipolar disorder and comorbid alcohol dependence. METHOD: We conducted secondary analyses of a randomized, double blind, placebo-controlled trial testing valproate in 52 bipolar alcoholics. Subjects had a comprehensive assessment at baseline using structured diagnostic assessments, and they were then assessed every 2 weeks for 24 weeks. RESULTS: Twenty-five subjects (48%) reported marijuana abuse. Those with co-occurring marijuana abuse were younger, had fewer years of education, and had significantly higher number of additional psychiatric comorbidity. They also had more severe alcohol and other drug use and were significantly more likely to present in the manic phase. The mixed model indicated that the placebo-treated marijuana abuse group had the worst alcohol use outcome. CONCLUSIONS: Marijuana abuse among patients with bipolar disorder and alcohol dependence is associated with higher degree of severity of alcohol and other drugs of abuse and may negatively impact on alcohol treatment outcome.

Clinical predictors of treatment in a population of adolescents with alcohol use disorders.

The purpose of this paper is to identify potential predictors of treatment utilization, among both psychiatric and drug and alcohol variables. The subjects were 393 adolescents and young adults, age 12.9 to 18.11 years, who met DSM-IV criteria for a lifetime history of either alcohol abuse or alcohol dependence at baseline assessment. DSM-IV psychiatric and AUD diagnoses were obtained by semi-structure interviews (K-SADS and SCID). Other alcohol and drug variables were obtained by the Alcohol Consumption Questionnaire and other self-reports. The results of these analyses suggest that there are few potential predictors associated with substance use disorder (SUD) treatment. For mental health (MH) treatment, depression in the form of Major Depressive Disorder was relatively strong associated at baseline and follow-up, while Attention Deficit Hyperactivity Disorder and Conduct Disorder appear to be associated with MH treatment at follow-up. For SUD treatments, there are essentially no variables strongly associated with treatment. The best potential predictors of who enters treatment and how long they stay may not be related to comorbidity or other dimensional variables of clinical severity. Rather, treatment utilization appears to be related to environmental factors, which may include family factors, adolescent and parental motivation, access to treatment, or to the use of appropriate treatment modalities.

Fluoxetine in adolescents with comorbid major depression and an alcohol use disorder: a 3-year follow-up study.

The goal of this 3-year follow-up evaluation was to determine whether the decreases in drinking and in depressive symptoms that were noted during our acute phase study with fluoxetine in comorbid adolescents persisted at a 3-year follow-up evaluation. At the 3-year follow-up evaluation, the group continued to demonstrate significantly fewer DSM criteria for an AUD and fewer BDI depressive symptoms and also consumed fewer standard drinks than they had demonstrated at the baseline of the acute phase study. However, 7 of the 10 participants demonstrated MDD at the 3-year follow-up assessment, and 4 demonstrated an AUD. The presence of a MDD was significantly correlated with the presence of an AUD at both the 1-year and the 3-year follow-up assessments. Four of the participants restarted SSRI medications during the follow-up period. Half of the subjects graduated from college during the 3-year assessment period, despite their residual depressive symptoms and drinking. We conclude that the long-term therapeutic effects of an acute phase trial of fluoxetine plus psychotherapy slowly decrease but did not disappear when fluoxetine is discontinued shortly after the acute phase trial. The high rate of MDD at follow-up suggests that longer term antidepressant medication treatment may be needed for at least some comorbid adolescents.

Alcohol use disorder symptoms and risk-taking behavior as predictors of alcohol-related medical events among young adults treated in emergency departments.

BACKGROUND: Studies of alcohol-positive patients in emergency departments are not clear on the relationship between alcohol use disorder (AUD) symptoms and risk for injury. METHOD: Two-hundred three young adults (118 males (58%); mean age = 19.4 years) who were treated in two Level-1 emergency departments (ED) received comprehensive psychiatric interviews and completed the Alcohol Use Disorders Identification Test (AUDIT) and the Cognitive Appraisal of Risky Events (CARE). RESULTS: Males diagnosed with the AUD symptom of "drinking more or over a longer period than intended" are at greatest risk for requiring emergency care for an alcohol-related medical problem (OR = 10.8, 95% CI = 1.2,94.3, p < .04). Risk-taking behaviors increase risk for an alcohol-related medical event for both genders (OR = 2.6, 95% CI=1.1,5.6.1, p < .03). Alcohol use disorder severity related negatively to risk for experiencing an alcohol-related medical problem (OR = 0.6, 95% CI = 0.4,0.9, p < .04). CONCLUSIONS: Young adults treated for alcohol-related medical problems often exhibit DSM-IV defined symptoms of AUD and are engaging in risk-taking behaviors and should be referred for an in-depth assessment of alcohol use disorders and risk-taking activities.

Psychiatric disorders and attempted suicide among adolescents with substance use disorders.

OBJECTIVE: To determine the effects of psychiatric disorders on attempted suicide among adolescents with substance use disorders (SUD). METHODS: Age of onset for psychiatric disorders, age of first suicide attempt, and the relationship of psychiatric disorder with attempted suicide were investigated in a sample of 503 adolescents with DSM-IV defined SUD (age range: 12.2-19.0 years). RESULTS: Males who attempted suicide had a significantly earlier onset of alcohol use disorders (AUD) and significantly more mood, AUD, and disruptive behavior disorder symptoms compared to non-attempting males. Females who attempted suicide had a significantly earlier onset and higher counts of mood disorders and SUD symptoms compared to non-attempting females. Hazard analysis revealed that mood disorders represent the highest psychiatric risk for attempted suicide in both the genders. Attention deficit-hyperactivity disorder (ADHD) increased the risk for attempted suicide among males. The interaction of mood disorder and AUD increased the risk for attempted suicide among females. CONCLUSIONS: Clinicians should closely monitor SUD adolescents for suicide risk and be aware of gender differences for suicidal behavior based on course and severity of psychiatric disorder in this population.

Impulsivity, gender, and response to fenfluramine challenge in borderline personality disorder.

Behavioral impulsivity in borderline personality disorder (BPD) is associated with indices of diminished central serotonergic function, independent of suicidal behavior, depression or alcohol use disorder. Many of these studies have been conducted among males in specialized settings. Studies of BPD females, who constitute the majority of BPD patients, are generally conducted in community settings and report inconsistent findings. We studied gender differences in behavioral impulsivity and the prolactin response to D,L-fenfluramine (FEN) in BPD subjects in a community setting. A FEN challenge study was conducted with 64 BPD subjects (20 male, 44 female), and 57 controls (36 male, 21 female). Axis I and II disorders, including BPD, and suicidal histories were assessed by structured interviews. Controls were free of Axis I and II disorders. Impulsivity and aggression were assessed by the Buss-Durkee Hostility Inventory, Barratt Impulsiveness Scale, Minnesota Multiphasic Personality Inventory-Psychopathic Deviate subscale, and the Brown-Goodwin Lifetime History of Aggression. Male, but not female, BPD subjects had significantly diminished prolactin responses compared to controls. Impulsivity and aggression each predicted prolactin responses. A significant effect of BPD diagnosis on prolactin response was eliminated when impulsivity was co-varied. Impulsivity and aggression were inversely related to delta-prolactin and peak-prolactin responses among male but not female subjects. Gender differences in central serotonergic function may contribute to variations in impulsivity in BPD.

Impulsivity and prefrontal hypometabolism in borderline personality disorder.

Prefrontal hypoperfusion and decreased glucose uptake in the prefrontal cortex (PFC) are found in violent criminal offenders, murderers and aggressive psychiatric patients. These abnormalities may be independent of diagnosis and associated with impulsive-aggression as a personality trait. Impulsive-aggression is a clinical characteristic of borderline personality disorder (BPD) where it is associated with assaultive and suicidal behaviors. We conducted FDG-PET studies in 13 non-depressed, impulsive female subjects with BPD and 9 healthy controls to look for abnormalities in glucose metabolism in areas of the PFC associated with regulation of impulsive behavior. Statistical Parametric Mapping-99 (SPM99) was used to analyze the PET data with Hamilton depression scores as covariate. Significant reductions in FDG uptake in BPD subjects relative to healthy controls were found bilaterally in medial orbital frontal cortex, including Brodmann's areas 9, 10 and 11. There were no significant areas of increased uptake in BPD subjects compared to control subjects. Covarying for measures of impulsivity or impulsive-aggression rendered insignificant the differences between groups. Decreased glucose uptake in medial orbital frontal cortex may be associated with diminished regulation of impulsive behavior in BPD.

Fluoxetine in depressed AUD adolescents: a 1-year follow-up evaluation.

The authors conducted the first naturalistic 1-year follow-up evaluation of 10 adolescents with comorbid major depressive disorder and an alcohol use disorder (AUD) who had previously participated in an acute phase study of open-label fluoxetine plus psychotherapy (Cornelius et al. 2001). The goal of this follow-up evaluation was to determine whether the decreases in drinking and in depressive symptoms that were noted during the acute phase study persisted at the follow-up evaluation. At the 1-year follow-up evaluation, the group continued to demonstrate significantly fewer depressive symptoms (according to the 24-item Hamilton Rating Scale for Depression) and a lower frequency of drinking (drinking days in the last 30 days) than they had demonstrated at the baseline of the acute phase study. Surprisingly, all of the subjects had chosen to discontinue their antidepressant medication by the second month of their naturalistic follow-up period. Three subjects had experienced a relapse of their major depression during the follow-up period, and three others demonstrated a persistence of their original depressive episode throughout the follow-up period. Also, the number of drinks per drinking day continued to be high (about five per day), which was not significantly different from the baseline level. Thus, the long-term therapeutic effects of an acute phase trial of fluoxetine plus psychotherapy were limited. The high rate of recurrence or persistence of major depression in our sample and in a previous sample of nonalcoholic adolescents with major depression (Emslie et al. 1998) and the significant levels of drinking of our comorbid adolescents suggest that longer term treatment may be needed for at least some adolescents with major depressive disorder and alcohol use disorder.

Childhood abuse as a risk factor for suicidal behavior in borderline personality disorder.

A childhood history of sexual or physical abuse is highly prevalent in borderline personality disorder (BPD) and is associated with self-destructive behavior in clinical and nonclinical samples. Viewing BPD as a "high risk" disorder, we asked if childhood abuse was a risk factor for adult suicidal behavior or if it was related to other known risk factors for suicide in BPD. A semistructured Abuse History was obtained in 61 criteria-defined BPD patients, who were characterized by structured interviews and self-reports for Axis I disorders, Suicide History, BPD severity, hopelessness, impulsivity, impulsive-aggression, and antisocial traits. Occurrence and severity of childhood sexual abuse, but not physical abuse, predicted adult suicidal behavior independent of other known risk factors. The odds of a sexually abused patient attempting suicide in adulthood was over 10 times that of a patient who was never sexually abused. Given a history of childhood sexual abuse, the risk of adult suicidal behavior in BPD was increased by antisocial traits, severity of BPD, hopelessness, or comorbid major depressive episode (MDE).

Psychiatric disorders among older adolescents treated in emergency departments on weekends: a comparison with a matched community sample.

OBJECTIVE: This study was undertaken to explore the characteristics of young patients treated in emergency departments (EDs) who follow through with an evaluation for psychiatric disorders as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) and to investigate differences in rates of psychiatric disorders between ED-treated adolescents and demographically similar adolescents recruited from the community. METHOD: Sixty three older adolescents (40 males) who were treated at two urban university hospital EDs were matched one-to-one on age, gender and race with 63 adolescents recruited from the community for participation in studies at an alcohol research center. Comprehensive psychiatric interviews were conducted with both groups. RESULTS: ED-treated adolescents were diagnosed with higher rates of current alcohol use disorders (AUDs), current drug use disorders and current major depression than were community controls. The ED sample had a particularly high rate of the DSM-IV "hazardous use" of alcohol symptom. ED-treated adolescents also had a higher rate of lifetime comorbid alcohol use disorders and drug use disorders, as well as a higher rate of lifetime comorbid alcohol use disorders and major depression, compared with the community controls. CONCLUSIONS: Adolescents who are treated in EDs should be routinely assessed for the presence of AUD, drug involvement and depressive disorders.

Psychiatric and substance use disorders as risk factors for attempted suicide among adolescents: a case control study.

The objective of this research was to test substance-related and non-substance-related psychiatric disorders as predictors of attempted suicide among adolescents. Ninety-six psychiatrically disordered suicide attempters were matched one-to-one to 96 psychiatrically disordered non-attempters on age, race, gender, and the presence/absence of major depression. Conditional logistic regression was used to test psychiatric risk factors for their power to predict attempted suicide among adolescents. Bipolar disorder, cocaine use disorders, and conduct disorder were found to be predictive of attempted suicide in univariate testing. Bipolar disorder, inhalant use disorders, cocaine use disorders, and hallucinogen use disorders were found to be predictive of attempted suicide, after adjusting for all other covariates. Loglinear analyses revealed high odds ratios associated with the comorbidities of alcohol use disorder with conduct disorder and drug use disorders with conduct disorder in both groups. Higher rates of cocaine use disorder/conduct disorder, hallucinogen use disorder/conduct disorder, and alcohol use disorder/ conduct disorder were found among suicide attempters. Evaluation of these particular comorbid conditions should be part of the adolescent suicide risk assessment.

Predictors of problem drinking among older adolescent emergency department patients.

This study investigated consumption patterns, alcohol-related problems and predictors of problematic drinking among older adolescents. Two-hundred eighty older adolescents (148 males, mean +/- SD age = 18.5 [1.8] years) treated in two Emergency Departments (ED) completed the Alcohol Use Disorders Inventory Test (AUDIT) to identify problem drinkers. Logistic regression was used to determine predictors of problem drinker status. Higher rates of problem drinking were found among participants who were treated for physical assaults or for acute alcohol intoxication than were found among participants treated for medical illness. Being alcohol-positive in the ED, increasing frequency of drunkenness, and being treated for physical assault were predictive of problematic drinking after controlling for demographic variables. In conclusion, older adolescents who present for treatment of an assault-related injury or acute alcohol intoxication, who are alcohol-positive in the ED, and who report getting intoxicated once a month or more are likely to have a severe drinking problem.

A randomized trial of concurrent smoking-cessation and substance use disorder treatment in stimulant-dependent smokers.

OBJECTIVE: To evaluate the impact of concurrent treatments for substance use disorder and nicotine-dependence for stimulant-dependent patients. METHOD: A randomized, 10-week trial with follow-up at 3 and 6 months after smoking quit date conducted at 12 substance use disorder treatment programs between February 2010 and July 2012. Adults meeting DSM-IV-TR criteria for cocaine and/or methamphetamine dependence and interested in quitting smoking were randomized to treatment as usual (n = 271) or treatment as usual with smoking-cessation treatment (n = 267). All participants received treatment as usual for substance use disorder treatment. Participants assigned to treatment as usual with concurrent smoking-cessation treatment received weekly individual smoking cessation counseling and extended-release bupropion (300 mg/d) during weeks 1-10. During post-quit treatment (weeks 4-10), participants assigned to treatment as usual with smoking-cessation treatment received a nicotine inhaler and contingency management for smoking abstinence. Weekly proportion of stimulant-abstinent participants during the treatment phase, as assessed by urine drug screens and self-report, was the primary outcome. Secondary measures included other substance/nicotine use outcomes and treatment attendance. RESULTS: There were no significant treatment effects on stimulant-use outcomes, as measured by the primary outcome and stimulant-free days, on drug-abstinence, or on attendance. Participants assigned to treatment as usual with smoking-cessation treatment, relative to those assigned to treatment as usual, had significantly better outcomes for drug-free days at 6-month follow-up (χ(2)(1) = 4.09, P <.05), with a decrease in drug-free days from baseline of -1.3% in treatment as usual with smoking-cessation treatment and of -7.6% in treatment as usual. Participants receiving treatment as usual with smoking-cessation treatment, relative to those receiving treatment as usual, had significantly better outcomes on smoking point-prevalence abstinence (25.5% vs 2.2%; χ(2)(1) = 44.69, P < .001; OR =18.2). CONCLUSIONS: These results suggest that providing smoking-cessation treatment to illicit stimulant-dependent patients in outpatient substance use disorder treatment will not worsen, and may enhance, abstinence from nonnicotine substance use. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01077024.