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Publications (33)71.44 Total impact

  • [Show abstract] [Hide abstract] ABSTRACT: Among the nearly 750,000 inmates in U.S. jails, 12% report using opioids regularly, 8% report use in the month prior to their offense, and 4% report use at the time of their offense. Although ample evidence exists that medications effectively treat Opiate Use Disorder (OUD) in the community, strong evidence is lacking in jail settings. The general lack of medications for OUD in jail settings may place persons suffering from OUD at high risk for relapse to drug use and overdose following release from jail.
    No preview · Article · May 2016
  • No preview · Article · Nov 2015
  • No preview · Article · Nov 2015
  • [Show abstract] [Hide abstract] ABSTRACT: This paper reviews research conducted in Baltimore over the past 15 years that examined: (1) what factors differentiate heroin-addicted individuals who enter methadone treatment from those who do not enter? (2) how difficult is gaining access to methadone treatment? (3) what are effective ways to overcome barriers to treatment entry? (4) why do so many methadone patients drop out of treatment prematurely? (5) what are the added benefits of counseling when coupled with methadone or buprenorphine treatment? and (6) Does increasing access to treatment have an impact on overdose deaths? Specific recommendations are made for policymakers concerned with addressing heroin addiction.
    No preview · Article · Jun 2015 · Journal of Addictive Diseases
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    [Show abstract] [Hide abstract] ABSTRACT: This secondary analysis compared outcomes of African-American adults newly-admitted to buprenorphine treatment who were on parole and probation to patients who were not under criminal justice supervision. Buprenorphine patients (N=300) were randomly assigned to receive either Intensive Outpatient Treatment (IOP) or Standard Outpatient Treatment (OP) treatment and were assessed at baseline, 3- and 6-months. There were no differences between groups in treatment retention. Among probationers/parolees, IOP was associated with lower 3-month treatment retention compared to OP, but among participants not on probation/parole the relationship was reversed (p=.004). Both conditions showed significant declines in heroin and cocaine use, illegal activity, and in meeting DSM-IV criteria for opioid and cocaine dependence. Probationers/parolees reported lower frequency of illegal activities at 3-months compared to non-probationers/parolees (p=.007). Buprenorphine treatment should be made more widely available to individuals on parole/probation as they respond as well to treatment as patients not supervised by the criminal justice system.
    Full-text · Article · Nov 2014 · Journal of drug issues
  • [Show abstract] [Hide abstract] ABSTRACT: The World Health Organization's Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) has strong support as a clinical screening tool and research instrument, but has only been validated with adults. This study evaluated the ASSIST and ASSIST-Lite in an adolescent population. Internal consistency, concurrent validity, discriminant validity and diagnostic accuracy were examined for tobacco, alcohol and cannabis ASSIST scores. An abbreviated version (the ASSIST-Lite) was evaluated for cannabis. Three community health centers in Baltimore, MD, USA. A total of 525 primary care patients, ages 12–17 years. Measures included the ASSIST, the CRAFFT screening tool and items from the Composite International Diagnostic Interview (CIDI) corresponding to substance use disorder criteria in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition. The ASSIST had good internal consistency (α = 0.68–0.88), good concurrent validity with the CRAFFT (r = 0.41–0.76; P < 0.001), and was able to discriminate between gradations of cannabis problem severity. In receiver operating characteristics analysis of optimal clinical cut-points, the ASSIST accurately identified tobacco, alcohol and cannabis use disorders (sensitivities = 95–100%; specificities = 79–93%; area under the curve [AUC] = 0.90–0.94), but did so at minimally low cut-points (indicative of any use in the past 3 months). The ASSIST-Lite performed similarly to the ASSIST in identifying cannabis use disorders (sensitivity = 96%; specificity = 88%; AUC = 0.92), also at a minimally low cut-point. However, confirmatory factor analysis of the ASSIST indicated poor model fit. The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) is promising as a research and screening/brief assessment tool with adolescents, but revisions to clinical risk thresholds are warranted. The ASSIST-Lite is sufficiently informative for rapid clinical screening of adolescents for cannabis use disorders.
    No preview · Article · Oct 2014 · Addiction
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    [Show abstract] [Hide abstract] ABSTRACT: Background: The CRAFFT, previously validated against DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) diagnostic criteria, is the most widely used screening instrument for alcohol and other substance misuse in adolescents. The present secondary analysis study sought to compare the CRAFFT with the new DSM-5 diagnostic criteria in order to assess the CRAFFT's psychometric properties and determine the optimal cut-point for identifying adolescents in need of further assessment.
    Preview · Article · Jul 2014 · Substance Abuse
  • [Show abstract] [Hide abstract] ABSTRACT: Background The recently published Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) includes several major revisions to substance use diagnoses. Studies have evaluated the impact of these changes among adult samples but research with adolescent samples is lacking. Methods 525 adolescents (93% African American) awaiting primary care appointments in Baltimore, Maryland were recruited for a study evaluating a substance use screening instrument. Participants were assessed for DSM-5 nicotine, alcohol, and cannabis use disorder, DSM-IV alcohol and cannabis abuse, and DSM-IV dependence for all three substances during the past year using the modified Composite International Diagnostic Interview-2, Substance Abuse Module. Contingency tables examining DSM-5 vs. DSM-IV joint frequency distributions were examined for each substance. Results Diagnoses were more prevalent using DSM-5 criteria compared with DSM-IV for nicotine (4.0% vs. 2.7%), alcohol (4.6% vs. 3.8%), and cannabis (10.7% vs. 8.2%). Cohen's κ, Somer's d, and Cramer's V ranged from 0.70-0.99 for all three substances. Of the adolescents categorized as “diagnostic orphans” under DSM-IV, 7/16 (43.8%), 9/29 (31.0%), and 13/36 (36.1%) met criteria for DSM-5 disorder for nicotine, alcohol, and cannabis, respectively. Additionally, 5/17 (29.4%) and 1/21 (4.8%) adolescents who met criteria for DSM-IV abuse did not meet criteria for a DSM-5 diagnosis for alcohol and cannabis, respectively. Conclusions Categorizing adolescents using DSM-5 criteria may result in diagnostic net widening-particularly for cannabis use disorders-by capturing adolescents who were considered diagnostic orphans using DSM-IV criteria. Future research examining the validity of DSM-5 substance use disorders with larger and more diverse adolescent samples is needed.
    No preview · Article · Jul 2014 · Drug and alcohol dependence
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    [Show abstract] [Hide abstract] ABSTRACT: The National Institute on Alcohol Abuse and Alcoholism developed an alcohol screening instrument for youth based on epidemiologic data. This study examines the concurrent validity of this instrument, expanded to include tobacco and drugs, among pediatric patients, as well as the acceptability of its self-administration on an iPad. Five hundred and twenty-five patients (54.5% female; 92.8% African American) aged 12 to 17 completed the Brief Screener for Tobacco, Alcohol, and other Drugs (BSTAD) via interviewer-administration or self-administration using an iPad. Diagnostic and Statistical Manual, Fifth Edition substance use disorders (SUDs) were identified using a modified Composite International Diagnostic Interview-2 Substance Abuse Module. Receiver operating characteristic curves, sensitivities, and specificities were obtained to determine optimal cut points on the BSTAD in relation to SUDs. One hundred fifty-nine (30.3%) adolescents reported past-year use of ≥1 substances on the BSTAD: 113 (21.5%) used alcohol, 84 (16.0%) used marijuana, and 50 (9.5%) used tobacco. Optimal cut points for past-year frequency of use items on the BSTAD to identify SUDs were ≥6 days of tobacco use (sensitivity = 0.95; specificity = 0.97); ≥2 days of alcohol use (sensitivity = 0.96; specificity = 0.85); and ≥2 days of marijuana use (sensitivity = 0.80; specificity = 0.93). iPad self-administration was preferred over interviewer administration (z = 5.8; P < .001). The BSTAD is a promising screening tool for identifying problematic tobacco, alcohol, and marijuana use in pediatric settings. Even low frequency of substance use among adolescents may indicate need for intervention.
    Preview · Article · Apr 2014 · PEDIATRICS
  • [Show abstract] [Hide abstract] ABSTRACT: A benefit-cost analysis was conducted as part of a clinical trial in which newly-admitted methadone patients were randomly assigned to interim methadone (IM; methadone without counseling) for the first 4months of 12months of methadone treatment or 12months of methadone with one of two counseling conditions. Health, residential drug treatment, criminal justice costs, and income data in 2010 dollars were obtained at treatment entry, and 4- and 12-month follow-up from 200 participants and program costs were obtained. The net benefits of treatment were greater for the IM condition but controlling for the baseline variables noted above, the difference between conditions in net monetary benefits was not significant. For the combined sample, there was a pre- to post-treatment net benefit of $1470 (95% CI: -$625; $3584) and a benefit-cost ratio of 1.5 (95% CI: 0.8, 2.3), but using our conservative approach to calculating benefits, these values were not significant.
    No preview · Article · Oct 2013 · Journal of substance abuse treatment
  • [Show abstract] [Hide abstract] ABSTRACT: Methadone has been the most commonly used pharmacotherapy for the treatment of opioid dependence in U.S. public sector treatment, but availability of buprenorphine as an alternative medication continues to increase. Drawing data from two community-based clinical trials that were conducted nearly contemporaneously, this study examined retention in methadone versus buprenorphine treatment over 6months among urban African Americans receiving treatment in one of four publicly-funded programs (N=478; 178 methadone; 300 buprenorphine). Adjusting for confounds related to medication selection, survival analysis revealed that buprenorphine patients are at substantially higher risk of dropout compared to methadone patients (HR=2.43; p<.001). Buprenorphine's retention disadvantage appears to be concentrated in the earlier phases of treatment (approximately the first 50days), after which risk of subsequent dropout becomes similar for the two medications. These findings confirm a retention disparity between methadone and buprenorphine in this population, and suggest potential avenues for future research to enhance retention in buprenorphine treatment.
    No preview · Article · Apr 2013 · Journal of substance abuse treatment
  • [Show abstract] [Hide abstract] ABSTRACT: Objective: This secondary data analysis examined the association between criminal justice (CJ) status and outcomes over 12 months of methadone maintenance treatment. Methods: In the parent study, 230 newly admitted patients were randomly assigned to methadone either with or without counseling for 4 months followed by standard methadone with counseling. Participants completed the ASI and urine drug testing at baseline and 4- and 12-month follow-up and the Treatment Readiness (TR) scale at baseline. The relationship between baseline CJ status (whether participants were on probation or parole), CJ status by study counseling condition, and CJ status by TR with heroin and cocaine use, illegal activity, days in treatment and treatment retention, arrests, and the number of days incarcerated or hospitalized during follow-up was examined. Results: Compared with participants not on probation/parole, probationers/parolees showed significant reductions in cocaine-positive tests from baseline to 12 months (P < 0.001). Probationers/parolees additionally reported significantly fewer days of illegal activity than nonprobationers/parolees at 12 months (P = 0.02). There was no relationship between CJ status and counseling condition for any outcomes. The relationship between CJ status and TR was significant only for cocaine-positive tests assessed over time (P = 0.017). Conclusions: Findings suggest that methadone participants on probation/parole showed improvements in outcomes in comparison with participants not on probation/parole, regardless of whether they received counseling during the first 4 months of treatment.
    No preview · Article · Feb 2013 · Journal of Addiction Medicine
  • [Show abstract] [Hide abstract] ABSTRACT: Background: Relatively limited empirical evidence exists comparing the impact on HIV sex risk behavior for patients admitted to methadone treatment programs (MTPs) as compared with nontreatment seekers. Methods: This longitudinal cohort study examined HIV sex-risk behavior among 164 out-of-treatment heroin-dependent adults recruited from the street and 351 newly admitted MTP patients. The AIDS Risk Assessment was administered at baseline, 6 months, and 12 months. Generalized linear mixed model and generalized estimating equation analyses were used to examine the changes in sex risk behavior over time. Results: The participants mean age was 41.5 years, 74.8% were African-American, 24.3% were White, and 54.4% were men. There were no significant differences between the groups in age, race, or gender. At baseline, the out-of-treatment group compared with the in-treatment group reported more sex partners (p < .001) and higher frequency of sex (p = .001). There was a group x time interaction for three of the sex-risk items and the out-of-treatment group reported having significantly more sex partners at both follow-up time points and having significantly more frequent unprotected sex while high at 6 months (all values of p < .01). Conclusions: Nontreatment seekers are at higher HIV risk than those entering MTPs and should be a focus of sex-risk reduction interventions, even if they are not interested in treatment at that time.
    No preview · Article · Jan 2012 · The American Journal of Drug and Alcohol Abuse
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    [Show abstract] [Hide abstract] ABSTRACT: Obtaining data on attitudes toward buprenorphine and methadone of opioid-dependent individuals in the United States may help fashion approaches to increase treatment entry and improve patient outcomes. This secondary analysis study compared attitudes toward methadone and buprenorphine of opioid-dependent adults entering short-term buprenorphine treatment (BT) with opioid-dependent adults who are either entering methadone maintenance treatment or not entering treatment. The 417 participants included 132 individuals entering short-term BT, 191 individuals entering methadone maintenance, and 94 individuals not seeking treatment. Participants were administered an Attitudes toward Methadone scale and its companion Attitudes toward Buprenorphine scale. Demographic characteristics for the three groups were compared using χ(2) tests of independence and one-way analysis of variance. A repeated-measures multivariate analysis of variance with planned contrasts was used to compare mean attitude scores among the groups. Participants entering BT had significantly more positive attitudes toward buprenorphine than toward methadone (p < .001) and more positive attitudes toward BT than methadone-treatment (MT) participants and out-of-treatment (OT) participants (p < .001). In addition, BT participants had less positive attitudes toward methadone than participants entering MT (p < .001). Participants had a clear preference for a particular medication. Offering a choice of medications to OT individuals might enhance their likelihood of entering treatment. Treatment programs should offer a choice of medications when possible to new patients, and future comparative effectiveness research should incorporate patient preferences into clinical trials. These data contribute to our understanding of why people seek or do not seek effective pharmacotherapy for opioid addiction.
    Full-text · Article · Jan 2012 · The American Journal of Drug and Alcohol Abuse
  • [Show abstract] [Hide abstract] ABSTRACT: This study examined outcomes and their predictors among 181 probationers enrolling in opioid agonist maintenance with methadone or levo-alpha-acetylmethadol (LAAM). Participants were interviewed at treatment entry and 2-, 6-, and 12-month follow-ups. Treatment retention and frequency of heroin use, cocaine use, and income-generating criminal activity were examined using survival and longitudinal analyses. Participants reported marked reductions in drug use and crime relative to treatment entry. A number of patient characteristics associated with various outcomes were identified. The findings support engaging probationers in treatment and highlight patient factors that might influence outcomes.
    No preview · Article · Jan 2012 · Substance Abuse
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    [Show abstract] [Hide abstract] ABSTRACT: : Human immunodeficiency virus (HIV)-risk behaviors were examined at 4- and 12-month follow-up for 230 newly admitted methadone patients randomly assigned to receive either methadone only (n = 99) or methadone with drug abuse counseling (n = 131) in the first 4 months of treatment. : The AIDS Risk Assessment was administered at baseline (treatment entry) and at 4- and 12-month follow-up. Linear mixed model analysis examined changes in HIV drug- and sex-risk behaviors over the 12 months in the total sample, drug-risk behaviors in the subsample that reported injecting drugs at baseline (n = 110), and sex-risk behaviors in the subsample that reported engaging in unprotected sex at baseline (n = 130). : Significant decreases over time were found in the frequencies of injecting, injecting with other injectors, and sharing cooker, cotton, or rinse water in the total sample and the injector subsample (P < 0.05). Decreases were also found in the frequencies of having sex without a condom either with someone who was not a spouse or primary partner or while high (P < 0.05) in the total sample and the frequencies of having sex without a condom and having sex without a condom while high in the unprotected-sex subsample (P < 0.05). No significant treatment group main effects or Treatment Group × Time interaction effects were found in any of the HIV-risk behaviors in the total sample or either subsample (P > 0.05). : During the first 12 months of treatment, providing drug abuse counseling with methadone compared with providing methadone alone was not associated with significant changes in HIV-risk behaviors for methadone maintenance patients.
    Full-text · Article · Nov 2011 · Journal of Addiction Medicine
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    [Show abstract] [Hide abstract] ABSTRACT: This study aimed to determine the relative effectiveness of 12 months of interim methadone (IM; supervised methadone with emergency counseling only for the first 4 months of treatment), standard methadone treatment (SM; with routine counseling) and restored methadone treatment (RM: routine counseling with smaller case-loads). A randomized controlled trial was conducted comparing IM, SM and RM treatment. IM lasted for 4 months, after which participants were transferred to SM. The study was conducted in two methadone treatment programs in Baltimore, MD, USA. The study included 230 adult methadone patients newly admitted through waiting-lists. We administered the Addiction Severity Index and a supplemental questionnaire at baseline, 4 and 12 months post- baseline. Measurements included retention in treatment, self-reported days of heroin and cocaine use, criminal behavior and arrests and urine tests for heroin and cocaine metabolites. At 12 months, on an intent-to-treat basis, there were no significant differences in retention in treatment among the IM, SM and RM groups (60.6%, 54.8% and 37.0%, respectively). Positive urine tests for the three groups declined significantly from baseline (Ps < 0.001 and 0.003, for heroin and cocaine metabolites, respectively) but there were no significant group x time interactions for these measures. At least one arrest was reported by 30.6% of the sample during the year, but there were no significant between-group effects. Limited availability of drug counseling services should not be a barrier to providing supervised methadone to adults dependent on heroin--at least for the first 4 months of treatment.
    Full-text · Article · Oct 2011 · Addiction
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    [Show abstract] [Hide abstract] ABSTRACT: To expand its public-sector treatment capacity, Baltimore City made buprenorphine treatment accessible to low-income, largely African American residents. This study compares the characteristics of patients entering methadone treatment vs. buprenorphine treatment to determine whether BT was attracting different types of patients. Participants consisted of two samples of adult heroin-dependent African Americans. The first sample was newly admitted to a health center or a mental health center providing buprenorphine (N=200), and the second sample was newly admitted to one of two hospital-based methadone programs (N=178). The Addiction Severity Index (ASI) and the Friends Supplemental Questionnaire were administered at treatment entry and data were analyzed with logistic regression. BT participants were more likely to be female (p=.017) and less likely to inject (p=.001). Participants with only prior buprenorphine treatment experience were nearly five time more likely to enter buprenorphine than methadone treatment (p<.001). Those with experience with both treatments were more than twice as likely to enter BT (OR=2.7, 95% CI=1.11-6.62; p=.028). In the 30 days prior to treatment entry, BT participants reported more days of medical problems (p=.002) and depression (p=.044), and were more likely to endorse a lifetime history of depression (p<.001). Methadone and buprenorphine treatment provided in the public sector may attract different patient subpopulations. Providing buprenorphine treatment through drug treatment programs co-located with a health and mental health center may have accounted for their higher rates of medical and psychiatric problems and appears to be useful in attracting a diverse group of patients into public-sector funded treatment.
    Full-text · Article · Sep 2011 · Drug and alcohol dependence
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    [Show abstract] [Hide abstract] ABSTRACT: This study examines the process of discharge and treatment reentry for six participants who entered treatment voluntarily but were administratively discharged from methadone treatment programs. The participants completed semistructured interviews at treatment entry and at four, eight and 12 months post-treatment entry. Grounded theory methodology was used to examine the phenomenon of treatment reentry from the perspective of the patients, who often viewed their recovery as an accumulation of positive changes. Differences in terms of the patients' goals and motivations for seeking treatment from those of the treatment programs, combined with difficulties encountered during the treatment process eventually led to discharge. However, these patients were then able to navigate their way through the treatment system in different ways in order to remain in treatment. The authors conclude that failure to abide by treatment clinic rules do not necessary constitute "treatment failure" from the perspective of patients, who often wish to remain in treatment even if it is not progressing optimally from the program's perspective. As a result, the recovery process can be more fragmented and is often characterized by a series of cyclical treatment episodes rather than continuous time in treatment, thereby impeding their progress towards recovery.
    Full-text · Article · Apr 2011 · Journal of psychoactive drugs
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    [Show abstract] [Hide abstract] ABSTRACT: Longer tenure in methadone treatment has been associated with positive outcomes such as reductions in drug use and crime, HIV seroconversion, and overdose death. Retention in treatment was examined for 351 opioid-dependent individuals who had been newly admitted to one of six methadone programs in Baltimore, Maryland. Cox proportional hazards regression was used to predict number of days retained in treatment to 90 days from baseline ASI Composite scores and Treatment Motivation scales. A second analysis predicted days in treatment to 365 days using the same baseline variables plus 3-month Motivation scales, Patient Satisfaction scales, and methadone dose in the 248 individuals who had remained in treatment at least 3 months. Analyses held constant gender, race, age, whether participants had a history of regularly smoking cocaine, whether participants were on parole/probation, and program site. Retention at 90 days was predicted by female gender, and greater baseline Treatment Readiness (p=.005) but lower Desire for Help (p=.010). Retention at 365 days was predicted by higher baseline ASI Medical Composite scores (p=.037) and lower Legal Composite scores (p=.039), higher 3-month Treatment Satisfaction scores (p=.008), and higher dose (p=.046). Greater satisfaction with treatment at 3 months was a significant predictor of retention at 12 months, indicating the importance of understanding the role satisfaction plays in determining retention. Greater severity of legal problems was associated with shorter retention, suggesting that program efforts to increase services to criminal justice patients (e.g., legal counseling) may constitute a useful addition to treatment.
    Full-text · Article · Feb 2011 · Drug and alcohol dependence