Jack Blaine

WHO Study on the reliability and validity of the alcohol and drug use disorder instruments: overview of methods and results

The WHO Study on the reliability and validity of the alcohol and drug use disorder instruments in an international study which has taken place in centres in ten countries, aiming to test the reliability and validity of three diagnostic instruments for alcohol and drug use disorders: the Composite International Diagnostic Interview (CIDI), the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) and a special version of the Alcohol Use Disorder and Associated Disabilities Interview schedule-alcohol/drug-revised (AUDADIS-ADR). The purpose of the reliability and validity (R&V) study is to further develop the alcohol and drug sections of these instruments so that a range of substance-related diagnoses can be made in a systematic, consistent, and reliable way. The study focuses on new criteria proposed in the tenth revision of the International Classification of Diseases (ICD-10) and the fourth revision of the diagnostic and statistical manual of mental disorders (DSM-IV) for dependence, harmful use and abuse categories for alcohol and psychoactive substance use disorders. A systematic study including a scientifically rigorous measure of reliability (i.e. 1 week test-retest reliability) and validity (i.e. comparison between clinical and non-clinical measures) has been undertaken. Results have yielded useful information on reliability and validity of these instruments at diagnosis, criteria and question level. Overall the diagnostic concordance coefficients (kappa, kappa) were very good for dependence disorders (0.7-0.9), but were somewhat lower for the abuse and harmful use categories. The comparisons among instruments and independent clinical evaluations and debriefing interviews gave important information about possible sources of unreliability, and provided useful clues on the applicability and consistency of nosological concepts across cultures.

Concordance of DSM-IV alcohol and drug use disorder criteria and diagnoses as measured by AUDADIS-ADR, CIDI and SCAN.

This study was designed to examine the agreement of DSM-IV alcohol and drug use disorder diagnoses generated by three WHO/NIH diagnostic instruments, the AUDADIS-ADR, the CIDI, and the SCAN. This substudy, conducted in three countries, Greece, Luxembourg, and the United States, was part of the larger joint project on diagnosis and classification of mental disorders and alcohol and drug-related problems, which was initiated to evaluate the cross-cultural applicability of the instruments and the criteria. Overall, concordance among the three assessments was good for alcohol and opiate dependence, fair to good for cocaine and sedative dependence, and low for amphetamine dependence. Cannabis dependence concordance was significantly more discrepant than any other substance. Agreement on abuse was low for all substances examined. In addition, the concordance of DSM-IV criteria for each substance was examined. Finally, reasons for discrepancies in responses among assessments were examined, based on discrepancy interview protocol methodology. Further investigation will help to refine these instruments in order to provide a more thorough understanding of alcohol and drug abuse diagnoses.

Extended vs short-term buprenorphine-naloxone for treatment of opioid-addicted youth: a randomized trial.

CONTEXT The usual treatment for opioid-addicted youth is detoxification and counseling. Extended medication-assisted therapy may be more helpful. OBJECTIVE To evaluate the efficacy of continuing buprenorphine-naloxone for 12 weeks vs detoxification for opioid-addicted youth. DESIGN, SETTING, AND PATIENTS Clinical trial at 6 community programs from July 2003 to December 2006 including 152 patients aged 15 to 21 years who were randomized to 12 weeks of buprenorphine-naloxone or a 14-day taper (detox). INTERVENTIONS Patients in the 12-week buprenorphine-naloxone group were prescribed up to 24 mg per day for 9 weeks and then tapered to week 12; patients in the detox group were prescribed up to 14 mg per day and then tapered to day 14. All were offered weekly individual and group counseling. MAIN OUTCOME MEASURE Opioid-positive urine test result at weeks 4, 8, and 12. RESULTS The number of patients younger than 18 years was too small to analyze separately, but overall, patients in the detox group had higher proportions of opioid-positive urine test results at weeks 4 and 8 but not at week 12 (chi(2)(2) = 4.93, P = .09). At week 4, 59 detox patients had positive results (61%; 95% confidence interval [CI] = 47%-75%) vs 58 12-week buprenorphine-naloxone patients (26%; 95% CI = 14%-38%). At week 8, 53 detox patients had positive results (54%; 95% CI = 38%-70%) vs 52 12-week buprenorphine-naloxone patients (23%; 95% CI = 11%-35%). At week 12, 53 detox patients had positive results (51%; 95% CI = 35%-67%) vs 49 12-week buprenorphine-naloxone patients (43%; 95% CI = 29%-57%). By week 12, 16 of 78 detox patients (20.5%) remained in treatment vs 52 of 74 12-week buprenorphine-naloxone patients (70%; chi(2)(1) = 32.90, P < .001). During weeks 1 through 12, patients in the 12-week buprenorphine-naloxone group reported less opioid use (chi(2)(1) = 18.45, P < .001), less injecting (chi(2)(1) = 6.00, P = .01), and less nonstudy addiction treatment (chi(2)(1) = 25.82, P < .001). High levels of opioid use occurred in both groups at follow-up. Four of 83 patients who tested negative for hepatitis C at baseline were positive for hepatitis C at week 12. CONCLUSIONS Continuing treatment with buprenorphine-naloxone improved outcome compared with short-term detoxification. Further research is necessary to assess the efficacy and safety of longer-term treatment with buprenorphine for young individuals with opioid dependence. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00078130.

Concordance between ICD-10 alcohol and drug use disorder criteria and diagnoses as measured by the AUDADIS-ADR, CIDI and SCAN: results of a cross-national study

Agreement between the AUDADIS-ADR, CIDI and SCAN in case identification for ICD-10 alcohol and drug use disorders and diagnostic criteria was investigated in three countries, Luxembourg, Greece and the US. Overall, agreement for ICD-10 dependence diagnoses between the three instruments was fair to good for alcohol, opioids and cocaine, but generally lower for dependence diagnoses for other substance. In contrast, concordance between instruments for harmful use diagnoses was extremely poor for all substances. Implications of these major findings are discussed in terms of the relationship between prevalence, reliability and concordance and indications and cautions regarding cross-instrument comparisons.

Nosological comparisons of alcohol and drug diagnoses: a multisite, multi-instrument international study

International nosological research was conducted to determine cross-system agreement on alcohol and drug dependence and harmful use (abuse). ICD-10, DSM-IV and DSM-III-R diagnoses were compared in 1,811 subjects from a variety of treatment and other types of settings from 12 sites around the world. Three diagnostic instruments were used: the Alcohol Use Disorders and Associated Disabilities Interview Schedule-Alcohol/Drug-Revised (AUDADIS-ADR), the composite international diagnostic interview (CIDI), and the schedules for clinical assessment in neuropsychiatry (SCAN). At seven of the study sites, two or more of these instruments were used. Results for dependence diagnoses showed excellent cross-system agreement across sites and instruments, especially for current diagnoses. Cross-system agreement for harmless use (abuse) was much lower and less consistent. Geographic location or culture appeared to have little influence on the results for either dependence or harmful use.

Acupuncture treatment for drug abuse: A technical review

Conflicting opinions exist regarding the efficacy of acupuncture for the treatment of substance abuse. On October 23, 1991, the National Institute on Drug Abuse (NIDA) sponsored a technical review to discuss this issue. The purpose of the meeting was to review the current status of research regarding acupuncture treatment for drug abuse and to propose directions for future studies. This report represents a summary of the meeting which consisted of presentations by individuals currently involved in acupuncture treatment and discussions by a panel of experts in the field of substance abuse treatment research.

Substance Dependence Severity Scale (SDSS): reliability and validity of a clinician-administered interview for DSM-IV substance use disorders

No existing diagnostic interview assesses severity of dependence based on DSM-IV criteria across a range of substances. The Substance Dependence Severity Scale (SDSS) was designed to serve this purpose, consisting of substance-specific scales of both severity and frequency of DSM-IV criteria. This study investigated the reliability and validity of the SDSS. The test-retest reliability of the SDSS in 175 (112 male and 63 female) treated substance users ranged from good to excellent for alcohol, cocaine, heroin and sedatives (interclass correlation coefficients (ICCs)=0.75-0.88 for severity, 0.67-0.85 for frequency). Results for cannabis were lower, ranging from fair to good (ICCs=0.50-0.62). Results for joint rating and internal consistency reliability were comparable to test-retest findings. In addition to indicators of concurrent validity, scale applications are presented and discussed.

Predictors of dropout from psychosocial treatment of cocaine dependence.

The current study assessed demographic, drug and psychiatric predictors of dropout in the pilot/training phase of a large, multi-site psychotherapy outcome study for patients with cocaine dependence. The different predictors of dropout were assessed throughout the phases of the study: screening, intake, stabilization and assessment phase, and following randomization to treatment. Results showed that (1) younger patients were less likely to keep their intake appointment. (2) Of the patients who had an intake visit, those who did not complete high school and with more days of cocaine use in the previous month were less likely to complete an initial stabilization and assessment phase requiring 1 week of abstinence from all drugs. A survival analysis was used to examine time to dropout for the 286 patients randomized to individual treatment. (3) Again, younger age was associated with dropout after randomization. (4) Drug use variables did not predict time to dropout. (5) Presence of any current Axis I disorder was associated with later dropout from treatment. Minority treatment information seekers and treatment initiators were less likely to go on to complete the full treatment program.

Concurrent and predictive validity of the Substance Dependence Severity Scale (SDSS)

This study investigated the concurrent and predictive validity of the Substance Dependence Severity Scale (SDSS), a clinician-administered interview designed to assess the severity and frequency of DSM-IV dependence symptoms for a range of substances. A total of 172 (107 males and 66 females) treated substance users participated in the study. Of those, 89% (n=153) received at least one follow-up interview within 1-6 months of an initial assessment. For alcohol, cocaine and heroin, convergent and discriminant validity was supported by significant relationships between SDSS scores at baseline and other baseline measures of substance use consequences, such as the Addiction Severity Index (ASI), as well as significant relationships between SDSS change scores from baseline to follow-up and change scores of other measures of consequences. SDSS scores were significantly associated with time to first post treatment use of alcohol, cocaine and heroin, although the nature of the associations was complex. Scale applications and areas for further study are discussed.

Serious Adverse Events in Randomized Psychosocial Treatment Studies : Safety or Arbitrary Edicts?

Human subjects protection policies developed for pharmaceutical trials are now being widely applied to psychosocial intervention studies. This study examined occurrences of serious adverse events (SAEs) reported in multicenter psychosocial trials of the National Institute on Drug Abuse Clinical Trials Network. Substance-abusing participants (N = 1,687) were randomized to standard care or standard care plus either contingency management or motivational enhancement. Twelve percent of participants experienced 1 or more SAEs during the 27,198 person-weeks of follow-up. Of the 260 SAEs recorded, none were judged by the data safety monitoring board to be study related, and there were no significant differences between experimental and control conditions in SAE incidence rates. These data underscore the need to reconsider the rationale behind, and appropriate methods for, monitoring safety during psychosocial therapy trials.