Chunki Fong

Prevalence and Correlates of Posttraumatic Stress Disorder and Chronic Severe Pain in Psychiatric Outpatients

This cross-sectional study reports the prevalence and correlates of posttraumatic stress disorder (PTSD) and chronic severe pain in psychiatric outpatients (n = 295), a sample that has not previously been examined for the co-occurrence of these two disorders. Nearly half the participants (46%) met the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition criteria for PTSD; 40% reported chronic severe pain; and 24% had both disorders. We compared four groups of subjects who had either both disorders, PTSD only, chronic severe pain only, or neither disorder for variables previously found to be associated with both disorders or either disorder alone (e.g., psychiatric distress, substance use, stressful life events, physical/sexual abuse). Multiple pairwise comparisons indicated that persons with both disorders were significantly different from persons with neither disorder for all dependent variables and that they had greater physical and psychosocial stressors. Persons with either PTSD or chronic severe pain alone were more likely to have a chronic medical condition, higher ratings of psychiatric distress, and more stressful life events than persons with neither disorder. Mental health treatment providers should be aware of the potential for the co-occurrence of PTSD and chronic severe pain and of the many related factors in psychiatric outpatients.

Prevalence and Characteristics of Chronic Pain in Patients Admitted to an Outpatient Drug and Alcohol Treatment Program

OBJECTIVES To evaluate the prevalence, characteristics, and correlates of chronic pain in a population of predominantly employed, alcoholic patients attending an outpatient drug and alcohol treatment program. METHODS A pain survey was administered to 79 patients attending an outpatient drug and alcohol treatment program situated in a suburban community outside of New York City. Chronic severe pain was defined as pain that 1) had persisted for at least 6 months; and 2) was either moderate to severe in intensity or significantly interfered with daily activities. RESULTS Seventy-six percent of patients experienced pain during the past week. Chronic severe pain was experienced by 29.1% of patients. High levels of pain interference with physical and psychosocial functioning were reported by 26.1%. Patients with chronic severe pain were more likely to have significant comorbidity, to cite physical pain as the impetus for alcohol or drug abuse, to have abused a prescription drug or used an illicit drug to treat pain during the prior 3 months, and to have used illicitly obtained opioids. Only 13% of patients with chronic severe pain were currently receiving pain treatment and 72% expressed interest in receiving treatment. DISCUSSION Chronic severe pain was prevalent in this predominantly employed, alcoholic population attending an outpatient drug and alcohol treatment program. Pain was associated with significant functional impairment, medical and psychiatric comorbidities, and abuse behaviors. Few patients accessed adequate pain treatment. Efforts should be made to better address the pain problems in this patient population.

Medication assisted treatment in US drug courts: Results from a nationwide survey of availability, barriers and attitudes

Drug treatment courts are an increasingly important tool in reducing the census of those incarcerated for non-violent drug offenses; medication assisted treatment (MAT) is proven to be an effective treatment for opioid addiction. However, little is known about the availability of and barriers to MAT provision for opioid-addicted people under drug court jurisdiction. Using an online survey, we assessed availability, barriers, and need for MAT (especially agonist medication) for opioid addiction in drug courts. Ninety-eight percent reported opioid-addicted participants, and 47% offered agonist medication (56% for all MAT including naltrexone). Barriers included cost and court policy. Responses revealed significant uncertainty, especially among non-MAT providing courts. Political, judicial and administrative opposition appear to affect MATs inconsistent use and availability in drug court settings. These data suggest that a substantial, targeted educational initiative is needed to increase awareness of the treatment and criminal justice benefits of MAT in the drug courts.

Psychometric Utility of the Childhood Trauma Questionnaire with Female Street-Based Sex Workers

ABSTRACT The present study examines the psychometric properties of a verbal, face-to-face administration of the Childhood Trauma Questionnaire (CTQ) with female street-based sex workers (N = 171). Confirmatory Factor Analysis (CFA) indicated a poor fit between our data and the instruments established 5-factor structure. Exploratory Factor Analysis (EFA) yielded four stable and usable factors corresponding to the Emotional Abuse, Emotional Neglect, Physical Abuse, and Sexual Abuse subscales of the CTQ; the Physical Neglect subscale did not emerge as a stable factor. Cross loading of many CTQ items onto more than one factor most likely produced the poor CFA fit, and indicated that abuse/neglect constructs were not conceptually distinct for our sample. Mean trauma scores did not differ significantly from published scores for female substance abusers. According to the CTQ Minimization/Denial scale, 42% of participants minimized their childhood maltreatment experiences. A combination of qualitative and quantitative methods may be optimal for the acquisition of sensitive trauma information with wary and vulnerable street populations.

Outcomes of buprenorphine maintenance in office-based practice

Abstract Buprenorphine is an efficacious treatment for opioid dependence recently approved for office-based medical practice. The purpose of the study was to describe the background characteristics, treatment process, outcomes and correlates of outcomes for patients receiving buprenorphine maintenance in „real world” office-based settings in New York City, without employing the many patient exclusion criteria characterizing clinical research studies of buprenorphine, including absence of co-occurring psychiatric and non-opioid substance use disorders. A convenience sample of six physicians completed anonymous chart abstraction forms for all patients who began buprenorphine induction or who transferred to these practices during 2003-2005 (N = 86). The endpoint was the patients current status or status at discharge from the index practice, presented in an intent-to-treat analysis. The results were: male (74%); median age (38 yrs); White, non-Hispanic (82%); employed full-time, (58%); HCV+ (15%); substance use at intake: prescription opioids (50%), heroin (35%), non-opioids (49%); median length of treatment (8 months); median maintenance dose (15 mg/day); prescribed psychiatric medication (63%). The most frequent psychiatric disorders were: major depression, obsessive-compulsive and other anxiety, bipolar. At the endpoint: retained in the index practice (55%); transferred to other buprenorphine practice (6%); transferred to other treatment (7%); lost to contact or out of any treatment (32%). Outcomes were positive, in that 2/3 of patients remained in the index practice or transferred to other treatment. Patients living in their own home or misusing prescription opioids (rather than heroin) were more likely, and those employed part-time were less likely, to be retained in the index practice. At the endpoint, 24% of patients were misusing drugs or alcohol. Co-occurring psychiatric disorders and polysubstance abuse at intake were common, but received clinical attention, which may explain why their effect on outcomes was minimal

Substance use among young adolescents in hiv-affected families : Resiliency, peer deviance, and family functioning

This study examines the association of risk and protective factors with substance use among 77 early adolescents (11–15 years old) with an HIV-infected parent who were interviewed in 2000–2001 in the South Bronx, a HIV high-prevalence area of New York City. The subjects were 49% female, 53% African American, and 30% Hispanic; mean age was 13 years old. A face-to-face interview was used to administer a battery of instruments representing community, family, peer, and resiliency factors. Forty percent reported ever using tobacco, alcohol or drugs; 71% were aware of their parents HIV seropositivity. An age-adjusted path analytic model was constructed which showed : 1) family functioning predicted resiliency (a composite measure of psychological adjustment and personal competencies); 2) positive community factors and resiliency predicted less affiliation with deviant peers; and 3) poorer family functioning and affiliation with deviant peers predicted substance use. These results underscore the need for interventions that address social influence factors among vulnerable early adolescents with HIV-positive parents.

Opioid Maintenance Treatment as a Harm Reduction Tool for Opioid-Dependent Individuals in New York City: The Need to Expand Access to Buprenorphine/Naloxone in Marginalized Populations

The aim of this pilot study was to assess the effectiveness of buprenorphine/naloxone (BUP/NX) among marginalized, opioid-dependent individuals in terms of retention in and cycling into and out of a harm-reduction program. This pilot study enrolled 100 participants and followed them from November 2005 to July 2008. The overall proportion of patients retained in the program at the end of 3, 6, 9, and 12 months was 68%, 63%, 56%, and 42%, respectively. This pilot study demonstrated that BUP/NX could be successfully used to treat marginalized heroin users.

Treating cocaine-using methadone patients: predictors of outcomes in a psychosocial clinical trial.

Cocaine-using methadone patients in two clinics were assigned to 8 months of enhanced methadone treatment—primarily cognitive-behavioral therapy (CBT) for cocaine use—while similar patients in two “sibling” clinics were assigned to standard methadone treatment during 1995–1998. Cocaine use declined significantly from baseline to 4- and 12-month follow-ups. Patients receiving CBT rated the quality of their counseling relationship higher and obtained more supportive services than those receiving standard treatment. However, study treatment condition itself was not associated with outcome. Baseline measures associated with poorer outcomes across both treatment conditions were: currently enrolled in methadone treatment (in contrast to being newly enrolled), higher cocaine use frequency, greater cocaine use associated problem recognition, and an ambivalent attitude toward methadone. The results are consistent with some previous clinical trials showing that psychosocial treatments of different intensities result in similar declines in cocaine use. The findings indicate that methadone maintenance treatment can help dually-addicted patients reduce their cocaine use.

Improving treatment engagement and outcomes for cocaine-using methadone patients

A task-based behavioral contingency—the “treatment reinforcement plan” (TRP)—was implemented with cocaine-using methadone patients to increase treatment engagement and retention. Subjects (N=57) were rewarded up to

Dual-Focus Mutual Aid for Co-Occurring Disorders: A Quasi-Experimental Outcome Evaluation Study

15 per week in travel/food/entertainment vouchers for the completion of tasks related to their individual treatment needs. Eighteen types of tasks were contracted and completed with varying frequency. The largest categories of tasks were related to therapy attendance (N=272; 58% completed), obtaining public entitlements (N=165; 61% completed), medical/psychiatric appointments (N=155; 70% completed), and obtaining Medicaid (N=96; 54% completed). The highest proportion of tasks completed were related to human immunodeficiency virus (HIV) testing/education (N=19; 100% completed), managing money (N=17, 94% completed), and legal matters (N=16, 88% completed). Successful TRP involvement during months 1–2 predicted longer retention in methadone treatment, greater therapy attendance during months 3–6, and lower proportion of cocaine-positive urines at 6-month follow-up. This research supports recent findings that early treatment engagement is associated with improved therapeutic relationships, increased retention, and reduced cocaine use. Behavioral counseling techniques may be especially helpful in addressing the complex needs of high-risk methadone patients, which in turn may facilitate treatment process and positive outcomes.