Cheryl Teruya

Treatment Retention among Patients Randomized to Buprenorphine/Naloxone Compared to Methadone in A Multi-site Trial

AIMS To examine patient and medication characteristics associated with retention and continued illicit opioid use in methadone (MET) versus buprenorphine/naloxone (BUP) treatment for opioid dependence. DESIGN, SETTINGS AND PARTICIPANTS This secondary analysis included 1267 opioid-dependent individuals participating in nine opioid treatment programs between 2006 and 2009 and randomized to receive open-label BUP or MET for 24 weeks. MEASUREMENTS The analyses included measures of patient characteristics at baseline (demographics; use of alcohol, cigarettes and illicit drugs; self-rated mental and physical health), medication dose and urine drug screens during treatment, and treatment completion and days in treatment during the 24-week trial. FINDINGS The treatment completion rate was 74% for MET versus 46% for BUP (P < 0.01); the rate among MET participants increased to 80% when the maximum MET dose reached or exceeded 60 mg/day. With BUP, the completion rate increased linearly with higher doses, reaching 60% with doses of 30-32 mg/day. Of those remaining in treatment, positive opioid urine results were significantly lower [odds ratio (OR) = 0.63, 95% confidence interval (CI) = 0.52-0.76, P < 0.01] among BUP relative to MET participants during the first 9 weeks of treatment. Higher medication dose was related to lower opiate use, more so among BUP patients. A Cox proportional hazards model revealed factors associated with dropout: (i) BUP [versus MET, hazard ratio (HR) = 1.61, CI = 1.20-2.15], (ii) lower medication dose (<16 mg for BUP, <60 mg for MET; HR = 3.09, CI = 2.19-4.37), (iii) the interaction of dose and treatment condition (those with higher BUP dose were 1.04 times more likely to drop out than those with lower MET dose, and (iv) being younger, Hispanic and using heroin or other substances during treatment. CONCLUSIONS Provision of methadone appears to be associated with better retention in treatment for opioid dependence than buprenorphine, as does use of provision of higher doses of both medications. Provision of buprenorphine is associated with lower continued use of illicit opioids.

Empirically supported substance abuse treatment approaches: A survey of treatment providers’ perspectives and practices

To better understand the extent that empirically supported and promising substance abuse treatment approaches are implemented in community settings, treatment providers were surveyed regarding their perceptions and use of several psychosocial and pharmacological treatment interventions. Program directors (n=30) and staff members (n=331) from diverse community settings rated the effectiveness and extent of use of various treatment interventions, and provided information on program and workforce characteristics via self-administered questionnaires. On average, program directors and staff rated the psychosocial treatment interventions as effective, with the exception of vouchers/motivational incentives. About half of the treatment providers did not know the effectiveness of certain pharmacological treatments, including buprenorphine and naltrexone. Respondents from the majority of programs (55%-80%) reported using Motivational Enhancement Therapy, Community Reinforcement Approach, and Supportive Expressive Psychotherapy. The extent that programs used several of the treatment interventions was related to organizational training and information resources. The study findings provide important information regarding training and research dissemination efforts.

Health and Health Care Disparities Among Homeless Women

While disparities in health and health care between vulnerable (e.g., minorities, low-income) and majority populations are well documented, less is known about disparities within these special populations that are large and diverse. Such knowledge is essential to determine the neediest within these generally needy populations, and to plan interventions to reduce their health and health care disparities. With data from 1,331 women residing in Los Angeles County California, in one of the largest, most comprehensive studies of the health of homeless women to date, this study examined the health and health care disparities among homeless African American, Latina, and white women. This study further explored if race/ethnicity and other factors that predispose homeless women to poor health, or enable them to obtain better health care, were associated with their unmet need for medical care. The study found that white, non-Latina women were more likely to report unmet need than African Americans and Latinas, and women suffering from drug abuse, violence, or depression were most in need of care. These findings should be considered in targeting and addressing the special needs of homeless women of different racial/ethnic groups.

Gender Differences in Treatment Outcomes over a Three-Year Period: A Path Model Analysis

Gender differences in longitudinal patterns of treatment utilization and outcomes over three yearly time points were examined among a sample of 511 patients recruited from drug treatment programs across Los Angeles County. Face-to-face interviews were conducted at baseline and one-year follow-up. Retrospectively recalled natural history data were collected at the follow-up interview. Over the three observational years, compared to men, women generally reported greater involvement in drug abuse treatment, lower levels of drug use and employment, and higher levels of drug use by their spouses. The path model showed that womens drug use and criminality were negatively related to formal treatment and self-help group participation, but positively related to their spouses drug use. Fewer factors significantly impacted mens drug use and crime over time. Implications of these gender differences are discussed.

Treating drug-abusing offenders. Initial findings from a five-county study on the impact of California's Proposition 36 on the treatment system and patient outcomes.

Five counties (Kern, Riverside, Sacramento, San Diego, San Francisco) that demonstrate both variations and similarities in their implementation of Proposition 36 (e.g., treatment approaches, urine testing) and patient mix have been selected to participate in a study assessing how Californias Proposition 36 is affecting the drug treatment system and patient outcomes. Except for San Francisco, treatment admissions increased during the first year of Proposition 36 implementation over the prior year (27% in Kern, 21% in Riverside, 17% in Sacramento, and 16% in San Diego), mostly in outpatient drug-free programs. Compared to non-Proposition 36 patients, Proposition 36 patients were more likely to be men, first-time admissions, treated in outpatient drug-free programs, employed full-time, and users of methamphetamine or marijuana. They were less likely to be treated in residential programs or methadone maintenance programs and fewer reported heroin use or injection drug use. Guided by the multilevel open systems framework, the study examines key issues of Proposition 36 that influence treatment systems and outcomes and empirically identifies “best practice” approaches in treating drug-abusing offenders.

Impact of California’s Proposition 36 on the Drug Treatment System: Treatment Capacity and Displacement

OBJECTIVES Californias Proposition 36 offers nonviolent drug offenders community-based treatment as an alternative to incarceration or probation without treatment. We examined how treatment capacity changed to accommodate Proposition 36 clients and whether displacement of other clients was an unintended consequence. METHODS Treatment admissions were compared for the year before and 2 years after the law was enacted. Surveys of county administrators and treatment providers were conducted in Kern, Riverside, Sacramento, San Diego, and San Francisco counties. RESULTS The number of Proposition 36 offenders admitted to treatment continued to increase in the state (approximately 32000 in Year 1 and 48000 in Year 2) and in the 5 counties; total treatment admissions stabilized in Year 2 after increasing in Year 1. Voluntary clients decreased by 8000 each year statewide, but the change varied across counties. One third of treatment providers reported decreased treatment availability for non-Proposition 36 clients in Year 2. CONCLUSION Despite expanded treatment capacity (mostly in outpatient treatment), indirect evidence suggests that displacement of voluntary clients may have occurred in part because of the demand for treatment by Proposition 36 clients.

Turning Points in the Life Course: Current Findings and Future Directions in Drug Use Research

Turning point, a key concept in the developmental life course approach, is currently understudied in the field of substance abuse, but merits further research. A turning point often involves a particular event, experience, or awareness that results in changes in the direction of a pathway or persistent trajectory over the long-term. This article (1) provides an overview of the relevant literature on the concept of turning points from the life course and developmental criminology perspectives, (2) reviews literature on turning points in substance use, (3) discusses methodological considerations, and (4) suggests areas for future research on turning points in drug use. The influence of life course concepts related to drug use trajectories and turning points (including, for example, timing and sequencing of life events, individual characteristics, human agency, and social and historical context) offers a potentially fruitful area of investigation that may increase our understanding of why and how drug users stop and resume using over the long-term. Further research on turning points may be particularly valuable in unpacking the multifaceted and complex underlying mechanisms and factors involved in lasting changes in drug use.

Drug-Use Initiation and Conduct Disorder among Adolescents in Drug Treatment.

This study investigated effects of drug-use initiation and conduct disorder (CD) among 1031 adolescents who participated in the Drug Abuse Treatment Outcomes Studies for Adolescents (DATOS-A) sponsored by the National Institute on Drug Abuse (NIDA). The mean age of first drug use was 12.7 (S.D.=2.2), 57% met DSM-III-R criteria for CD, and earlier initiators were more likely to have CD. About 78% of the adolescents with CD reported that their first CD symptom occurred prior to drug-use initiation. The proportions of adolescents who had prior treatment were similar (about 28%) across all groups, but earlier initiators reported a greater number of treatment episodes and younger ages at their first treatment. Conduct disordered adolescents revealed greater problems prior to DATOS-A treatment, but they appeared to be more motivated and ready for treatment. Although adolescents with CD still showed worse outcomes after treatment, the impact of CD appeared to lessen when pretreatment differences were controlled. To a lesser extent, adolescents who began using drugs at earlier ages had greater alcohol and drug use and other problems at intake, but their treatment outcomes appeared to be similar to later initiators. There were few significant interaction effects of initiation and CD. Findings from this study highlight the importance of better understanding the progression of drug use, treatment utilization, and psychiatric comorbidity among adolescents with substance abuse problems.

Utilizing drumming for American Indians/Alaska Natives with substance use disorders: a focus group study.

Background: Drumming has been utilized among American Indian/Alaska Native (AI/AN) tribes for centuries to promote healing and self-expression. Drum-Assisted Recovery Therapy for Native Americans (DARTNA), currently under development, is a substance abuse treatment utilizing drumming as a core component. Objectives: Focus groups were conducted to assist in the development of the DARTNA protocol. Feedback obtained from these focus groups will inform a subsequent pretest of DARTNA and an empirical study analyzing its effectiveness. Methods: Three focus groups were conducted among AIs/ANs with substance use disorders (n = 6), substance abuse treatment providers (n = 8), and a community advisory board (n = 4) to solicit feedback prior to a pretest of the DARTNA protocol. Results: Overall, participants indicated that DARTNA could be beneficial for AIs/ANs with substance use disorders. Four overarching conceptual themes emerged across the focus groups: (1) benefits of drumming, (2) importance of a culture-based focus, (3) addressing gender roles in drumming activities, and (4) providing a foundation of common AI/AN traditions. Conclusions: The DARTNA protocol is a potentially beneficial and culturally appropriate substance abuse treatment strategy for AIs/ANs. In order to optimize the potential benefits of a substance abuse treatment protocol utilizing drumming for AIs/ANs, adequate attention to tribal diversity and gender roles is needed. Scientific Significance: Due to the shortage of substance abuse treatments utilizing traditional healing activities for AIs/ANs, including drumming, results from this study provide an opportunity to develop an intervention that may meet the unique treatment needs of AIs/ANs.

Patient Perspectives on Buprenorphine/Naloxone: A Qualitative Study of Retention During the Starting Treatment with Agonist Replacement Therapies (START) Study

Abstract This study examines the barriers and facilitators of retention among patients receiving buprenorphine/naloxone at eight community-based opioid treatment programs across the United States. Participants (n = 105) were recruited up to three and a half years after having participated in a randomized clinical trial comparing the effect of buprenorphine/naloxone and methadone on liver function. Semi-structured interviews were conducted with 67 patients provided with buprenorphine/naloxone who had terminated early and 38 patients who had completed at least 24 weeks of the trial. Qualitative data were analyzed using the constant comparison method. Barriers to buprenorphine/naloxone retention that emerged included factors associated with: (1) the design of the clinical trial; (2) negative medication or treatment experience; and (3) personal circumstances. The facilitators comprised: (1) positive experience with the medication; (2) personal determination and commitment to complete; and (3) staff encouragement and support. The themes drawn from interviews highlight the importance of considering patients’ prior experience with buprenorphine/naloxone and methadone, medication preference, personal circumstances, and motivation to abstain from illicit use or misuse of opioids, as these may influence retention. Ongoing education of patients and staff regarding buprenorphine/naloxone, especially in comparison to methadone, and support from staff and peers are essential.