Joseph Guydish

Smoking Prevalence in Addiction Treatment: A Review

INTRODUCTION This review explores whether smoking prevalence in addiction treatment samples exceeds that shown in epidemiological data for persons with alcohol or other drug use disorders and whether smoking may have decreased over time in the addiction treatment population as it has done in the general population. METHODS English language papers published between 1987 and 2009 were searched electronically. Forty papers reporting smoking prevalence for addiction treatment samples in the United States were identified, and key predictor variables were abstracted. Random logistic models were used to assess relationships between each individual predictor (year, treatment modality, primary drug treated, government status, and public/private funding status) and smoking prevalence. RESULTS The lowest smoking prevalence aggregated for studies reported in any single year was 65%, well above epidemiological estimates reported among those with alcohol use and drug use disorders. The odds of smoking were higher in methadone maintenance programs (odds ratio [OR] = 2.25, CI = 1.08, 4.68) as compared with outpatient programs. No other variables in the model were significant. Reanalysis omitting recent studies that may represent outliers or confounding with type of treatment showed a small but significant decrease in smoking over time (OR = 0.9891, CI = 0.9888, 0.9893). CONCLUSIONS The very high smoking rates reported in addiction treatment samples warrant significant, organized, and systemic response from addiction treatment systems, from agencies that fund and regulate those systems, and from agencies concerned with tobacco control.

Staff Smoking and Other Barriers to Nicotine Dependence Intervention in Addiction Treatment Settings : A Review

Abstract The aims of this review were to assess smoking prevalence among drug abuse treatment staff and summarize the range of barriers to provision of nicotine dependence intervention to clients receiving addictions treatment. A systematic literature search was conducted to identify publications reporting on workforce smoking prevalence, attitudes toward smoking, and perceived barriers to providing smoking cessation treatment in drug abuse treatment settings. Twenty papers met study inclusion criteria. Staff smoking prevalence estimates in the literature ranged from 14% to 40%. The most frequently reported barriers to providing nicotine dependence intervention in addiction treatment settings were lack of staff knowledge or training in this area, that smoking cessation concurrent with other drug or alcohol treatment may create a risk to sobriety, and staff are themselves smokers. Staff smoking is not uniformly elevated in the drug abuse treatment workforce. Smoking prevalence may be lower where staff are more educated or professionally trained, and may be higher in community-based drug treatment programs. Barriers to treating nicotine dependence may be addressed through staff training, policy development, and by supporting staff to quit smoking. State departments of alcohol and drug programs, and national and professional organizations, can also support treatment of nicotine dependence in drug abuse treatment settings.

Evaluating needle exchange: are there negative effects?

ObjectiveWe analyzed data on all drug-treatment admissions in San Francisco County over a 4-year period (n = 35460) to evaluate the potential negative effects of the San Francisco needle-exchange program. MethodsAdmissions in the 2 years preceding implementation of the exchange program (1987–1988) were compared with admissions in the 2 years following implementation (1989–1990). ResultsNo negative consequences of needle exchange were detected. Specifically, the presence of the exchange program was not associated with (1) increases in injection drug use, (2) increases in needle-sharing behavior, or (3) changing drug-use behavior from non-injection to injection. We also compared high-drug-use neighborhoods with and without local needle-exchange sites. Neighborhoods without needle-exchange sites showed a greater increase in proportion of admissions for injection drug use, and in frequency of injection, over time. ConclusionsBecause of methodological limitations, our findings are preliminary. Longitudinal studies comparing needle-exchange and non-exchange cohorts are needed to further evaluate effects of this intervention.

A DRUG COURT OUTCOME EVALUATION COMPARING ARRESTS IN A TWO YEAR FOLLOW-UP PERIOD

Since the first drug court in Miami in 1989, the drug court movement has spread throughout the United States, influencing how drug-involved offenders are treated in the criminal justice system. This paper reports on an outcome evaluation of a drug court in San Mateo County, California. Arrest rates were compared for drug court participants (N=618) and nonparticipants (N=75), and for graduates (N=257) and nongraduates (N=361). Factors associated with rearrest were assessed for participants in both groups. During a two-year follow-up period, there were no significant differences in rearrest rates between the participant and non-participant groups. Comparisons between graduates and nongraduates showed lower rearrest rates for graduates (19% vs. 53%, χ2(1)=73.5, p< 0.01). In a model including participants and nonparticipants, only a prior history of conviction predicted an increased likelihood of rearrest whereas being female and older decreased the likelihood of rearrest. In addition, among drug court participants only, graduating decreased the likelihood of rearrest.

Investigation of a secondary syringe exchange program for homeless young adult injection drug users in San Francisco, California, U.S.A.

This study investigated an HIV prevention program for homeless young adult injection drug users (IDUs) that combined a secondary syringe exchange program (SEP) with community‐level activities. Homeless young IDUs were recruited from street‐based settings in San Francisco, and a structured questionnaire was administered. The secondary SEP operated in a circumscribed geographic area, and for analytic purposes respondents were assigned to the intervention site group if they primarily spent time in this area (n = 67), or the comparison site group if they primarily spent time elsewhere (n = 55). Almost all (96%) intervention site youth had used the secondary SEP in the past 30 days and were significantly more likely to regularly use SEP. In bivariate analysis, comparison site IDUs were more likely to share syringes, reuse syringes, share the cotton used to filter drugs, and use condoms with casual sex partners only inconsistently. In multivariate analysis, comparison site remained positively associated with sharing syringes (adjusted odds ratio [AOR], 3.748; 95% confidence interval [CI], 1.406‐9.988), reusing syringes (AOR, 2.769; 95% CI, 1.120‐6.847), and inconsistent condom use with casual sex partners (AOR, 4.825; 95% CI, 1.392‐ 16.721). This suggests that the intervention was effective in delivering SEP services to homeless young adult IDUs, and that IDUs who frequented the intervention site had a lower HIV risk than comparison group IDUs.

Changes in needle sharing behavior among intravenous drug users: San Francisco, 1986-88.

We analyzed data for San Francisco intravenous drug users entering treatment, April 1986-September 1988 (N = 7,660). The proportion of cases reporting any needle sharing in the month preceding treatment decreased from 50 percent in 1986 to 28 percent in 1988. Similar decreases were reported by two longitudinal cohorts (needle sharing by the same individuals) admitted in 1986 and 1987 (n = 303), and in 1986 and 1988 (n = 205). In a multiple logistic regression model four variables predicted needle sharing: earlier time of admission, cocaine use, younger age, and being White rather than Black.

An international systematic review of smoking prevalence in addiction treatment.

AIMS Smoking prevalence is higher among people enrolled in addiction treatment compared with the general population, and very high rates of smoking are associated with opiate drug use and receipt of opiate replacement therapy (ORT). We assessed whether these findings are observed internationally. METHODS PubMed, PsycINFO and the Alcohol and Alcohol Problems Science Database were searched for papers reporting smoking prevalence among addiction treatment samples, published in English, from 1987 to 2013. Search terms included tobacco use, cessation and substance use disorders using and/or Boolean connectors. For 4549 papers identified, abstracts were reviewed by multiple raters; 239 abstracts met inclusion criteria and these full papers were reviewed for exclusion. Fifty-four studies, collectively comprising 37,364 participants, were included. For each paper we extracted country, author, year, sample size and gender, treatment modality, primary drug treated and smoking prevalence. RESULTS The random-effect pooled estimate of smoking across people in addiction treatment was 84% [confidence interval (CI) = 79, 88%], while the pooled estimate of smoking prevalence across matched population samples was 31% (CI = 29, 33%). The difference in the pooled estimates was 52% (CI = 48%, 57%, P < .0001). Smoking rates were higher in programs treating opiate use compared with alcohol use [odds ratio (OR) = 2.52, CI = 2.00, 3.17], and higher in ORT compared to out-patient programs (OR = 1.42, CI = 1.19, 1.68). CONCLUSIONS Smoking rates among people in addiction treatment are more than double those of people with similar demographic characteristics. Smoking rates are also higher in people being treated for opiate dependence compared with people being treated for alcohol use disorder.

Injection Risk Behavior among Women Syringe Exchangers in San Francisco

Women who inject drugs in cities where syringe exchange programs (SEPs) are well established may have different risks for HIV infection. In 1997, we interviewed 149 female syringe exchangers in San Francisco, CA, a city with high rates of injection drug use that is home to one of the largest and oldest SEPs in the United States. In this report, we describe their sociodemographics, health, and risk behavior, and we examine factors associated with recent syringe sharing. Fifty percent of respondents were women of color and the median age was 38 years. Most (86%) injected heroin and nearly half were currently homeless or had recently been incarcerated. One-third of all women reported needle sharing in the prior month. This was higher than the rate of needle sharing reported by a mixed gender sample of San Francisco exchangers in 1993, although it resembled the rate reported by a mixed gender sample in 1992. In a multivariate analysis, syringe sharing was associated with age, housing status, and sexual partnerships. Syringe sharers were more likely to be young, homeless, or have a sexual partner who was also an injection drug user. While wide access to sterile syringes is an important strategy to reduce HIV transmission among injection drug users (IDU), syringe exchange alone cannot eradicate risky injection by female IDU. Additional efforts to reduce risky injection practices should focus on younger and homeless female IDU, as well as address selective risk taking between sexual partners.

Preventing AIDS in drug users and their sexual partners

Part I: Aids and Drug Use. Sorensen, Introduction: The AIDS-Drug Connection. Wermuth, Case: Implication for AIDS Prevention. Guydish, Golden, Hembry, Needle Sharing, Needle Cleaning, and Risk Behavior Change Among Injection Drug Users. Choi, Wermuth, Unsafe Sex and Behavior Change. Gibson, Catania, Peterson, Theoretical Background. Part II: Preventative Interventions With Drug Abusers and Sexual Partners. Batki, London, Drug Abuse Treatment for HIV Infected Drug Abusers. Sorensen, London, Morales, Group Counseling. Gibson, Lovelle-Drache,Individual Counseling. Wermuth, Robbins, Choi, Eversley, Reaching and and Counseling Women Sexual Partners. Part III: Social Implications. Sorensen, Guydish, Adopting Effective Interventions. Wermuth, Sorensen, Franks, People, Programs, and Policies. Appendix: Where to Get Help or Information.

Addressing tobacco use through organizational change: a case study of an addiction treatment organization.

Abstract Compared to the general population, persons entering addiction treatment are three to four times more likely to be tobacco dependent and even addiction treatment staff members are two to three times more likely to be tobacco dependent. In these settings, tobacco use continues to be the norm; however addiction treatment programs are increasingly aware of the need to assess for and treat tobacco dependence. The problem is a cultural issue that is so ingrained that assumptions about tobacco use and dependence in addiction treatment are rarely questioned. Denial, minimization, and rationalization are common barriers to recovery from other addictions; now is the time to recognize how tobacco use and dependence must be similarly approached. This article describes the Addressing Tobacco through Organizational Change (ATTOC) model which has successfully helped many addiction treatment programs to more effectively address tobacco use. The article will review the six core strategies used to implement the ATTOC intervention, the 12-Step approach guiding the model, and describe a case study where the intervention was implemented in one clinic setting. Other treatment programs may use the experience and lessons learned from using the ATTOC organizational change model to better address tobacco use in the context of drug abuse treatment.