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1999 March

Improving Substance Abuse Treatment Utilization: A Motivational Interviewing Approach

John S. Baer, PhD
Research Associate Professor

Psychology

Description: Incarceration represents a unique opportunity for substance abuse intervention. Substance abuse is common among those with criminal justice involvement, and often is a factor in criminal recidivism. Incarcerated individuals also are often available for service delivery, and frequently are interested in information and/or programs that may reduce their likelihood of recidivism. As a result, several current substance abuse treatment efforts now take place within prison systems during incarceration. However, most jail incarcerations are brief, and potentially beneficial community treatment services are underutilized. Methods to enhance initial treatment engagement in both incarcerated and more general populations are understudied.

The aim of the proposed study is to test the efficacy of a motivational enhancement feedback intervention to enhance post-incarceration utilization of substance abuse services outside the jail system. This effort is consistent with recent use of brief intervention to facilitate treatment utilization, as well as with Veterans Affairs efforts to expand services to underserved veterans who might benefit from services. Thus, incarcerated veterans with a substance use disorder diagnosis (based on preliminary assessment) will be invited to participate in the proposed study. Veterans volunteering to participate will be randomly assigned to one of two conditions: 1) Assessment session only, or 2) Assessment session and motivational enhancement feedback interview. These sessions will take place in the King County Jail system within the week prior to release dates. In-person follow-up assessments will be arranged two months subsequent to release date. All contacts will be made by trained research staff.

Results of this study will be used first to estimate the effect size of motivational interventions for facilitating and increasing addiction service utilization among incarcerated veterans, and secondly to provide data to develop a proposal for a full clinical trial to evaluate the effectiveness of such an intervention across a range of settings and patient types.

Investigation of Social Communication Skills in School-age Children with Alcohol Related Disabilities

Lesley B. Olswang, PhD
Professor and Associate Chair

Speech and Hearing Sciences

Description: Since the identification of Fetal Alcohol Syndrome (FAS) over 25 years ago, anecdotal reports provided by caregivers of these children cite pervasive social communication deficits within this population. Similar deficits have been reported in many of the children who do not have the syndrome of FAS, but receive a diagnosis of other alcohol related disabilities (e.g. Fetal Alcohol Effects, Alcohol Related Neurodevelopmental Disorder, Atypical Fetal Alcohol Syndrome). Despite the overwhelming evidence from caregiver reports, to date, no systematic investigations of social communication deficits have been conducted with the affected children themselves. The purpose of this exploratory study is to investigate social communication skills of children with alcohol related disabilities during peer conflict tasks. The participants will include 20 children with alcohol related disabilities and 20 typically developing children similar to the experimental group in chronological age, socioeconomic status, gender and verbal mental age. Two experimental procedures, an open-ended response task and a forced-choice response task, will be administered to elicit children's goals and strategies as they attempt to resolve peer conflict vignettes. In addition, caregiver and teacher judgments of the children's peer related social skills will be obtained. The results of this study will further define the deficits associated with alcohol related disabilities and assist in the development of social communication interventions for this population of children.

Genetics of Opiate Dependence: Predisposing Functional Polymorphisms in the Gene for the Cannabinoid (CNR1) Receptor

Carl C. Ton, PhD
Acting Assistant Professor

Human Genome Center, Division of Medical Genetics

Description: There is now significant evidence that substance abuse disorders are familial and that genetic factors account for a substantial degree of their familial aggregation. Individual (pharmacogenetic) differences in the initial sensitivity of affected neuronal systems, or in their propensity to adapt, may predispose to the development of opiate dependence. Hitherto, research on possible candidate genes underlying genetic vulnerability to opiate addiction has focused primarily on the opioid and dopamine receptor (brain reward) systems. However, recent studies in animal models have pointed to a significant involvement of the central cannabinoid receptor (CNR1) in mediating the motivational properties of opiates, and in the development of physical dependence to these drugs. These observations are consistent with the view of opiate dependence as a complex genetic trait, where variance in the heritable component of relative risk derives from the contributions of multiple genetic loci. This study proposes to investigate the possible contribution from one such source: genetic polymorphisms at the CNR1 locus. Specifically, we seek to: (1) discover, by means of direct genomic sequencing, coding DNA sequence variations in the gene for the cannabinoid receptor (CNR1); and (2) to score for their allelic frequencies in the general human population vs. a test population of documented opiate dependent patients. Clinical importance: This study attempts to determine whether there is an association between specific coding polymorphisms of CNR1 and vulnerability to opiate dependence. A positive outcome from this pilot investigation would lay the groundwork for future genetic analyses aimed at evaluating the possible additive or epistatic interactions between CNR1 alleles and polymorphic variants already known to exist within the opioid and dopaminergic systems. An understanding of the interplay between these predisposing genetic variants would inform attempts at developing more rational and effective therapeutic modalities.

Assessing the Region's Readiness to Participate in a Clinical Trials Network

Elizabeth A. Wells, PhD
Research Associate Professor

School of Social Work

Description: The National Institute on Drug Abuse (NIDA) is seeking to establish a national Clinical Trials Network (CTN) in order to bridge gaps between addiction treatment research and addiction treatment practice as it exists in community-based programs. This network will be composed of regional nodes each comprised of a Regional Research and Training Center (RRTC) and a number of community-based treatment programs (CTPs). RRTCs will generally be University-based, and it will be the RRTC's responsibility to recruit community programs. In order to build a partnership between community-based programs and university researchers so that a node can be formed, significant gaps in communication, practice, philosophy and trust must begin to be addressed. We hope to apply to become a node of the CTN, not in the first, but in the second round of NIDA CTN funding. This proposal is a first step on the part of University of Washington researchers to determine CTP interest in participating in such a network and to assess specific barriers to researcher-clinic collaboration.

Investigators will mail a survey to 578 addiction treatment programs listed in the "Directory of Certified Chemical Dependency Treatment Services in Washington State" (DASA, 1998). This survey will assess interest in network participation, ideas about clinical problems that should be addressed in network research, willingness to be involved in randomized studies, potential incentives for network participation, barriers to participation, and clinic characteristics. Surveys not returned will be followed by phone calls and a second mailing. Monetary incentives and continuing education opportunities will be offered for survey completion. Results will be used to identify potential CTPs, characteristics of interested CTPs, and to identify incentives and barriers to network participation.

1999 October

Utilities for Mental Health Outcomes Among Individuals with Co-occurring Substance Use Disorders and Schizophrenia

Dan Kivlahan, PhD
Associate Professor

Psychiatry & Behavioral Sciences

Description: Substance use disorders are a significant problem among individuals with schizophrenia, and are associated with deleterious consequences including poor treatment adherence, high institutionalization costs, poor psychosocial functioning and treatment outcome. Because this population is so difficult and expensive to treat, it is important to identify treatments that are cost-effective. Cost-utility analysis (CUA) is a widely used method that incorporates measures of effectiveness and importance of different outcomes. To conduct CUA studies, health utilities must be measured. Preliminary literature indicates that it is feasible to measure mental health utilities among individuals with schizophrenia, however, no studies have tested the feasibility of this methodology with individuals with co-occurring schizophrenia and substance use disorders.

The objective of this study is to determine the feasibility of measuring mental health outcome utilities among individuals with co-occurring substance use disorders and schizophrenia. This effort is consistent with Veterans Affairs efforts to identify cost-effective, patient-centered care. Veterans who have a diagnosis of schizophrenia and substance use disorders will be invited to participate in this study. We will determine whether it is feasible for participants to complete the measurement of utilities using a state-of-the-science multi-media computerized assessment. We will identify inconsistencies in responses, and whether symptom severity (schizophrenia and substance use) is associated with frequency of making inconsistent responses and repairing inconsistent responses. If this method is shown to be feasible with this sample, we will report the variability of utility values obtained, in preparation for future studies. If this approach is not feasible, we will better understand the limitations of this methodology and identify the limits of generalizing utility weightings derived from individuals with these co-occurring conditions.

Barriers to Care and the Impact of Delaying Treatment for Injection Drug Use-Related Soft-Tissue Infections

Joseph O. Merrill, MD, MPH
Acting Instructor, Research Scientist

Medicine, Alcohol and Drug Abuse Institute

Traci A. Takahashi, PhD

Description: Background: Soft tissue infections are common medical complications in injection drug users and result in significant morbidity and medical costs. Injection drug users' delay in seeking care may alter the natural history of soft tissue infections and lead to adverse health outcomes and increased health care utilization. While previous studies have identified a number of barriers to care in this population, none has evaluated how these barriers impact the natural history and health outcomes of soft tissue infections.

Purpose: The aims of the proposed study are to determine the clinical features and natural history of soft tissue infections and evaluate reasons for delay in seeking care among injection drug users. We will also evaluate the impact of delaying care on health outcomes and health care utilization.

Method: The proposed study will use cross-sectional interviews and medical record reviews of injection drug users with soft tissue infections who seek care at the Harborview Medical Center Emergency Department. Descriptive statistics will be used to characterize the clinical features and natural history of soft tissue infections. Linear regression will be used to evaluate the association of potential barriers to care with a delay in seeking care. Logistic regression will be used to identify factors, including delay in seeking care, that predict hospitalization in this setting.

Significance: Identification of barriers to care that result in delayed treatment and adverse health outcomes for injection drug users will allow development of rational programs to improve the medical care of this underserved population. This study will also provide pilot study data for a future randomized control trial to study interventions that reduce barriers to care and ultimately improve the health status of injection drug users.

Resulting articles & projects:

  • The preliminary findings from this grant were used in a successful application by Dr. Takahashi for a NIDA R03 Small Grant (R03DA14518).
  • Binswanger IA, Takahashi TA, Bradley K, Dellit TH, Benton KL, Merrill JO. Drug users seeking emergency care for soft tissue infection at high risk for subsequent hospitalization and death. J Stud Alcohol Drugs 2008;69(6):924-32. [PubMed abstract | Free online]
  • Takahashi TA, Baernstein A, Binswanger I, Bradley K, Merrill JO. Predictors of hospitalization for injection drug users seeking care for soft tissue infections. J Gen Intern Med 2007;22(3):382-8. [PubMed abstract | Free online]

Relationship of Substance Use, Psychiatric Symptoms, and Social Networks in Persons with Severe Mental Illness at High Risk for Violence

Richard Ries, MD
Professor, Medical Director

Psychiatry & Behavioral Sciences, Outpatient Psychiatry and Dual Disorders Program, Harborview Medical Center

Description: Co-morbid alcohol and drug disorders occur in 40-80% of the severely mentally ill (SMI). Use of substances by this population can result in homicidal violence as evidenced by several high profile cases headlined in the media. Although tragic, these relatively uncommon events overshadow the more customary violence associated with addiction in this population, which includes the focus of this proposal: nonlethal physical assaults, verbal threats, and victimization. Numerous publications document the strong relationship between substance use and violence in the severely mentally ill, yet the almost exclusive reliance on cross-sectional and epidemiologic approaches makes it difficult to understand the complex relationships between substance use and violence.

To date there have been no longitudinal prospective investigations examining 1) how alcohol and drug use affects the recurrence of violence in high-risk SMI individuals; 2) how substance use influences psychiatric symptoms and violence in the SMI; and 3) how factors, such as social network composition, influence substance use and violence in these individuals. Such studies are necessary before more focused preventive and treatment initiatives can be developed for this high risk population. However, before a larger study can be undertaken to examine these questions, a small pilot project is needed to evaluate some key issues including the 1) enrollment and longitudinal retention rates in this difficult to engage population; 2) enrollment and longitudinal retention rates of significant others; and 3) concordance in key risk factors for violence gathered from subjects, significant others, and clinical case managers. Building on experience from our NIDA funded representative payee study of a dually diagnosed SMI population, this project will provide in-depth information about effective ways to engage these high-risk individuals that can be used in future clinical research studies.

Additional Endogenous Agonists for the Cannabinoid Receptor in Brain

Nephi Stella, PhD
Assistant Professor

Pharmacology

Description: Marijuana and hashish are prevalent drugs of abuse in western society. Delta-9 tetrahydrocannabinol (the active ingredient) activates cannabinoid receptors, producing both psychotropic and therapeutic effects. A current line of research in molecular pharmacology is focused on the mechanism of action of delta-9 tetrahydrocannabinol, with the objective of identifying a new generation of cannabinoid based medicines that lack side effects, tolerance and/or addiction properties.

Cannabinoid receptors are normally engaged by endogenous agonists, the endocannabinoids. To date, one substance found in brain fulfills the necessary criteria to be considered an endocannabinoid. The aim of this proposal is to identify and characterize additional endocannabinoids in brain, results that would be pivotal in designing efficient cannabinoid-based medicines.