Scott F. Grey

The Adolescent Substance Abuse Prevention Study: A randomized field trial of a universal substance abuse prevention program

OBJECTIVES The purpose of the study was to determine whether a universal school-based substance abuse prevention program, Take Charge of Your Life (TCYL), prevents or reduces the use of tobacco, alcohol, or marijuana. METHODS Eighty-three school clusters (representing school districts) from six metropolitan areas were randomized to treatment (41) or control (42) conditions. Using active consenting procedures, 19,529 seventh graders were enrolled in the 5-year study. Self-administered surveys were completed by the students annually. Trained Drug Abuse Resistance Education (D.A.R.E.) police officers presented TCYL in seventh and ninth grades in treatment schools. Analyses were conducted with data from 17,320 students who completed a baseline survey. Intervention outcomes were measured using self-reported past-month and past-year use of tobacco, alcohol, and marijuana when students were in the 11th grade. RESULTS Main effect analyses show a negative program effect for use of alcohol and cigarettes and no effect for marijuana use. Subgroup analyses indicated that the negative effect occurred among nonusers at baseline, and mostly among white students of both genders. A positive program effect was found for students who used marijuana at baseline. Two complementary papers explore the relationship of the targeted program mediators to the use of alcohol, tobacco, and marijuana and specifically for students who were substance-free or who used substances at baseline. CONCLUSIONS The negative impact of the program on baseline nonusers of alcohol and tobacco indicate that TCYL should not be delivered as a universal prevention intervention. The finding of a beneficial effect for baseline marijuana users further supports this conclusion. The programmatic and methodological challenges faced by the Adolescent Substance Abuse Prevention Study (ASAPS) and lessons learned offer insights for prevention researchers who will be designing similar randomized field trials in the future.

Predictors of surgical site infection after open lower extremity revascularization

Objective: Surgical site infection (SSI) after open lower extremity bypass (LEB) is a serious complication leading to an increased rate of graft failure, hospital readmission, and health care costs. This study sought to identify predictors of SSI after LEB for arterial occlusive disease and also potential modifiable factors to improve outcomes. Methods: Data from a statewide cardiovascular consortium of 35 hospitals were used to obtain demographic, procedural, and hospital risk factors for patients undergoing elective or urgent open LEB between January 2012 and June 2015. Bivariate comparisons and targeted maximum likelihood estimation were used to identify independent risk factors of SSI. Adjusted odds ratios (ORs) were calculated for patient demographics, comorbidities, operative details, and hospital‐level factors. Results: Our study population included 3033 patients who underwent 703 femoral‐femoral bypasses, 1431 femoral‐popliteal bypasses, and 899 femoral‐distal vessel bypasses. An SSI was diagnosed in 320 patients (10.6%) ≤30 days after the index operation. Adjusted patient and procedural predictors of SSI included renal failure currently requiring dialysis (OR, 4.35; 95% confidence interval [CI], 3.45‐5.47; P < .001), hypertension (OR, 4.29; 95% CI, 2.74‐6.72; P < .001), body mass index ≥25 kg/m2 (OR, 1.78; 95% CI, 1.23‐2.57; P = .002), procedural time >240 minutes (OR, 2.95; 95% CI, 1.89‐4.62; P < .001), and iodine‐only skin preparation (OR, 1.73; 95% CI, 1.02‐2.91; P = .04). Hospital factors associated with increased SSI included hospital size <500 beds (OR, 2.22; 95% CI, 1.09‐4.55; P = .028) and major teaching hospital (OR, 1.66; 95% CI, 1.07‐2.58; P = .024). SSI resulted in increased risk of major amputation and surgical reoperation (P < .01), but did not affect 30‐day mortality. Conclusions: SSI after LEB is associated with an increase in rate of amputation and reoperation. Several patient, operative, and hospital‐related risk factors that predict postoperative SSI were identified, suggesting that targeted improvements in perioperative care may decrease complications and improve vascular patient outcomes.

Methods for Synthesizing Findings on Moderation Effects Across Multiple Randomized Trials

This paper presents new methods for synthesizing results from subgroup and moderation analyses across different randomized trials. We demonstrate that such a synthesis generally results in additional power to detect significant moderation findings above what one would find in a single trial. Three general methods for conducting synthesis analyses are discussed, with two methods, integrative data analysis and parallel analyses, sharing a large advantage over traditional methods available in meta-analysis. We present a broad class of analytic models to examine moderation effects across trials that can be used to assess their overall effect and explain sources of heterogeneity, and present ways to disentangle differences across trials due to individual differences, contextual level differences, intervention, and trial design.

Universal school-based substance abuse prevention programs: Modeling targeted mediators and outcomes for adolescent cigarette, alcohol and marijuana use

OBJECTIVE We examined the relationships among targeted constructs of social influences and competence enhancement prevention curricula and cigarette, alcohol and marijuana use outcomes in a diverse sample of high school students. We tested the causal relationships of normative beliefs, perceptions of harm, attitudes toward use of these substances and refusal, communication, and decision-making skills predicting the self-reported use of each substance. In addition, we modeled the meditation of these constructs through the intentions to use each substance and tested the moderating effects of the skills variables on the relationships between intentions to use and self-reported use of each of these substances. METHODS Logistic regression path models were constructed for each of the drug use outcomes. Models were run using the Mplus 5.0 statistical application using the complex sample function to control for the sampling design of students nested within schools; full information maximum likelihood estimates (FIML) were utilized to address missing data. RESULTS Relationships among targeted constructs and outcomes differed for each of the drugs with communication skills having a potentially iatrogenic effect on alcohol use. Program targets were mediated through the intentions to use these substances. Finally, we found evidence of a moderating effect of decision-making skills on perceptions of harm and attitudes toward use, depending upon the outcome. CONCLUSIONS Prevention curricula may need to target specific drugs. In addition to normative beliefs, perceptions of harm, and refusal and decision-making skills, programs should directly target constructs proximal to behavioral outcomes such as attitudes and intentions. Finally, more research on the effects of communication skills on adolescent substance use should be examined.

Tramadol versus buprenorphine for the management of acute heroin withdrawal: a retrospective matched cohort controlled study.

Many medications have been used over the past thirty years for the treatment of opioid withdrawal, including propoxyphene, methadone, clonidine, parenteral buprenorphine, and, more recently, sublingual buprenorphine. Each has been found to have clinical strengths and limitations. Tramadol is a centrally acting synthetic analgesic with opiate activity primarily due to the binding of a metabolite to the micro receptor. Despite this micro receptor activity, tramadol appears to have low abuse potential and is a non-scheduled analgesic. The pharmacologic profile of tramadol makes it a candidate for opiate withdrawal treatment. A chart review was undertaken to retrospectively compare treatment outcomes of heroin-dependent patients when detoxified with parenteral buprenorphine (1996-1997) versus tramadol (1999-2000). Inclusion criteria for this study were heroin as drug of choice, current opioid physical dependence (ie, withdrawal symptoms), no current abuse of oral opioid analgesics, and no alcohol or benzodiazepine withdrawal symptoms. Patient cases that met inclusion criteria were group-matched between buprenorphine and tramadol on the basis of age, sex, and amount of heroin used (bags/day). Charts were audited for patient demographics, daily heroin use at admission, withdrawal symptoms, and discharge status. In total, 129 patient charts were reviewed, and 115 met all inclusion criteria and were group-matched (45 patients in the buprenorphine group, seventy in the tramadol group). There were no differences in demographics between the two groups of patients. Fifty-six percent of the buprenorphine group and 71% of the tramadol group completed detoxification; tramadol-treated patients had significantly higher average withdrawal symptoms when compared to the buprenorphine group and a greater reduction in withdrawal symptoms over time. Finally, the number of side effects was small and did not differ between the groups. The results of this study are consistent with previous pilot reports that indicated few clinical differences between parenteral buprenorphine and oral tramadol protocols when used in the management of acute heroin withdrawal. As a consequence, tramadol shows some promise as an opioid withdrawal management medication.

The influence of program mediators on eleventh grade outcomes for seventh grade substance users and nonusers

OBJECTIVES In their work examining the effects of the Take Charge of Your Life (TCYL) program, Sloboda and colleagues (This Issue) found that the TCYL program had significant positive effects on baseline marijuana users and significant negative effects on baseline nonusers of cigarettes and alcohol. METHODS Mediational analyses were used to understand why the program had these differential impacts on baseline users and nonusers. RESULTS Path models for binary outcomes revealed significant program impacts on marijuana normative beliefs and refusal skills. The treatment impacts were between 1.5 and 3 times larger for the baseline users than for nonusers. These direct effects of the program on normative beliefs and refusal skills mediated the treatment impact on use for baseline marijuana users. In contrast, the negative treatment effects on alcohol and cigarette use could not be explained by the programs targeted mediators (normative beliefs, refusal skills, consequences, attitudes and intentions). The direct effects of treatment on use for the baseline nonusers of cigarettes and alcohol remain unexplained. CONCLUSIONS Possible explanations for this pattern and implications for strengthening universal prevention programs that are delivered to both users and nonusers are discussed. The importance of mediational analyses for programs that show negative impacts, as well as for those that show positive impacts is stressed.

The Use of Tramadol for Acute Heroin Withdrawal: A Comparison to Clonidine.

Abstract Using a retrospective chart review, 59 patients detoxified with tramadol were compared to 85 patients detoxified with clonidine on rates of leaving against medical advice (AMA) and control of withdrawal symptoms. Patients detoxified with tramadol had 23% (95% CI, 0.09–0.59; P < .01) the risk of leaving AMA and scored an average of 0.24 points lower (95% CI, 0.08–0.41; P < .01) on a 0-3 point withdrawal symptom scale compared to patients detoxified with clonidine. This preliminary study indicates that tramadol is more effective in managing withdrawal than clonidine, and may be especially useful in outpatient detoxification.

The proportion and characteristics of adolescents who return for anonymous HIV test results

Background Theproportion of adolescents who return for HIV test results varies widely, andknowledge of what characteristics affect their return islimited. Goal Toquantify the proportion of adolescents who return for results of anonymous HIVtests, and to identify the characteristics that predict theirreturn. StudyDesign This retrospective study evaluated 285 adolescentsconsenting to anonymous HIV tests in an urban clinic that provides medicalservices free of charge without eligibility requirements to a mostly working,uninsuredpopulation. Results Ofthe adolescents studied, 42% returned for test results. Three characteristicsindependently predicted their return: (1) coming to the clinic only for HIVtesting, (2) having private health insurance, and (3) engaging in unprotectedsex while using drugs oralcohol. Conclusions Exceptfor having unprotected sex while using drugs or alcohol, the characteristicsthat placed adolescents at risk for HIV infection did not predict their returnfor test results. Given the low return rate for anonymous testing in thissetting, confidential testing, which permits follow-up evaluation of thosefailing to return for test results, should beconsidered.

Integrating Substance Abuse Content into an HIV Risk-Reduction Intervention: A Pilot Study with Middle School-Aged Hispanic Students

A pilot study of a school‐based HIV/AIDS risk reduction program with integrated components on substance abuse was conducted to determine: 1) its effectiveness in Hispanic, middle school‐aged children and 2) if differences in effectiveness are found in students who report risky behaviors. Activity‐oriented training on decision‐making, HIV/AIDS illness, risky behaviors, and abstinence was provided to 125 students. Participants were classified into risk groups, based on reported sexual and alcohol/drug (AOD) activity. Effectiveness was analyzed by comparing the risk groups knowledge, beliefs, and perceived‐risk scores pre/post‐program in sexual activity, AOD use, disease course, and casual contact categories. This program improved some knowledge, few beliefs, and few perceived risks. The perceived‐risk scores of the high‐risk group did not reflect their higher risk for HIV/AIDS‐ School‐based programs should measure actual HIV/AIDS risks, including AOD, to identify participants who need focused interventions. Further research is needed to understand how AOD influences risky sexual behaviors, and what content and interventions are useful.

Workplace Hand Hygiene and Wellness A Survey of Knowledge, Beliefs, and Practices

Community hand hygiene interventions have reduced the spread of infectious disease in elementary schools, daycare centers, and private homes. Despite this success, and the potential for reducing workplace absenteeism and presenteeism, few peer-reviewed hand hygiene intervention studies among workers have been published. This research used the Theory of Planned Behavior (TPB) to guide the development of a model to understand and predict motivations for performing hand hygiene, and to examine related illness, absenteeism, and presenteeism among employees from 39 bank branches in Ohio. Although the TPB has been used extensively to elucidate hand hygiene practices among employees in the health care and food industries, little is known about the ability of the TPB to predict hand hygiene practices among workers in public settings. These survey findings indicate a need for hand hygiene improvement, and support the use of attitudinal beliefs and social norms to guide multimodal approaches for workplace hand hygiene interventions.