Dual Diagnosis Patients Research Articles

Neuropsychological Aspects of Dual Diagnosis

Dual diagnosis (DD) has been described as the coexistence of a severe mental health condition and a drug abuse and/or dependence disorder. In the last decades, there has been a growing interest in the prevalence and characteristics of dual diagnosis, since it has been argued that DD patients show more clinical treatment difficulties and higher morbidity. Few works have studied the neuropsychological aspects of patients with DD, although neuropsychological deficits have been widely described both in patients showing a severe mental health condition and in those with a drug abuse and/or dependence disorder. Knowledge of the type and severity of potential neuropsychological deficits in patients with DD is of great relevance since it could be an interviewing factor for clinical treatment and prognosis. The present work aims to review the main data on attention, memory, and executive functions in dual diagnosis patients, from an explanatory point of view. We focus on the diagnoses of Schizophrenia and Bipolar Disorder since these have shown the highest prevalence and severity in DD and have provided a wealth of data. We describe the differences in neuropsychological performance found in these patients and the implications for clinical treatment and psychosocial functioning. Finally, we propose possible working ideas for future studies in order to improve our present knowledge of the neuropsychological aspects of DD.

Serotonin transporter polymorphism as a predictor for escitalopram treatment of major depressive disorder comorbid with alcohol dependence

The aim of this study was to determine whether the serotonin transporter gene polymorphism ( 5- HTTLPR) is associated with the treatment outcomes of escitalopram for patients with comorbid major depression and alcohol dependence. Eighty treatment-seeking patients were randomly assigned to either receive 20 mg of escitalopram or a control of 20 mg of the non-serotonergically acting memantine. Depression was measured by the Montgomery–Asberg Depression Rating Scale (MADRS) and alcoholism by the Alcohol Use Disorders Identification Test (AUDIT). Twenty-nine participants in each treatment group completed the study, and from those DNA was given by 27 in the escitalopram group and 21 in the memantine group. In the escitalopram group linear regression showed that LL genotype predicted greater decrease in MADRS scores compared with the SS/SL genotypes ( p = 0.04) after a 3 month treatment period. Moreover, each L allele associated with MADRS score decrease by 15% ( p = 0.04) in the escitalopram group. In the memantine group, however, no association between LL genotype and MADRS decrease was detected. AUDIT decrease was not associated with the 5- HTTLPR genotype for either medication. This is the first study in the treatment of depression in dual diagnosis patients to report a significant association between outcomes with escitalopram and the 5- HTTLPR gene polymorphism.

Co-morbid PTSD and suicidality in individuals with schizophrenia and substance and alcohol abuse

Suicide risk is high in schizophrenic patients and is further elevated in dual diagnosis patients. Suicide behaviour is a continuum from ideation, plans to attempts. Exposure to traumatic stress and co-morbid PTSD is elevated in schizophrenic patients. Suicide behaviour is also common in non-psychotic PTSD patients. This study aimed to investigate the effect of trauma and co-morbid PTSD on suicide behaviour in dual diagnosis patients and whether co-morbid PTSD would further elevate suicide risk. This was a cross-sectional study in which suicide behaviour was compared in those with and without co-morbid PTSD in 110 patients suffering schizophrenia and alcohol and/or substance abuse. 100 (91%) reported at least one traumatic event with an average of 4.3 events. 31 (28%) patients met criteria for full PTSD. Current suicidal ideation was reported by 39 (35%) and 23 (21%) reported plans and ideation, 69 (63%) reported at least one previous suicide attempt. Suicide behaviour was significantly associated with an increasing number of traumatic events. Suicidality was significantly associated and elevated with co-morbid PTSD. Analysis indicated that the effect of trauma on suicide behaviour appeared to be mediated by hopelessness. Suicide behaviour was not associated with exposure to trauma per se but was associated with incremental exposure to traumatic experiences. Consistent with the study hypotheses, co-morbid PTSD further adds to the risk of suicide behaviour in an already vulnerable group.

Pregnenolone for cognition and mood in dual diagnosis patients

Mood and substance-use disorders are both associated with cognitive deficits. Patients with mood and substance-use disorders have poorer cognition than patients with only a mood disorder. Pregnenolone may have beneficial effects on mood and cognition. In a proof-of-concept investigation, 70 participants with bipolar disorder or recurrent major depressive disorder and history of substance abuse/dependence (abstinent for ≥14days prior to enrollment) were randomly assigned to receive pregnenolone (titrated to 100mg/day) or placebo for 8weeks. Participants were assessed using the Mini International Neuropsychiatric Interview, Hamilton Rating Scale for Depression (HRSD), Young Mania Rating Scale (YMRS), Rey Auditory Verbal Learning Test (RAVLT), Trail Making Test (TMT-B), and Stroop Test. Mood was assessed bi-weekly, while cognition was evaluated at baseline, and weeks 4 and 8. Groups were compared using a random regression analysis that used all of the available data. The pregnenolone group showed trends toward greater improvement, relative to placebo, on the HRSD and YMRS. A post hoc analysis of completers found a statistically significant reduction in HRSD scores with pregnenolone as compared to placebo. Pregnenolone appeared to be safe and well tolerated. Findings suggest that pregnenolone use may be associated with some improvement in manic and depressive symptoms, but not cognition in depressed patients with a history of substance use. Larger trials examining the impact of pregnenolone on mood in more narrowly defined populations may be warranted.

Service Needs and Utilization for Dual-Diagnosis Patients

The authors examined treatment patterns for two groups of dually diagnosed psychiatric inpatients, those with a) co-occurring, but independent mental and substance use disorders (IMD + PSUD); and b) substance-induced organic mental disorders (PSUD-OMD). Assessments included the Addiction Severity Index for perceived service needs, discharge records for recommended treatments, and the Quality of Life Interview for follow-up treatment utilization. As expected, the groups differed on treatment patterns. Both received fewer services than needed during the 1-year follow-up. In particular, the IMD + PSUD patients utilized few substance abuse services and the PSUD-OMD utilized few psychiatric services.

The Implementation and Evaluation of Cognitive Milieu Therapy for Dual Diagnosis Inpatients: A Pragmatic Clinical Trial

Dual diagnosis is chronic psychiatric condition involving serious mental illness and substance abuse. Experts recommend the integration of treatment for concurrent substance abuse and serious psychiatric problems. The following pragmatic trial examined the implementation and outcomes of cognitive milieu therapy (CMT) among a group of dual diagnosis inpatients. CMT is an integrated treatment for both mental illness and substance abuse based on cognitive behavioral principles and carried out within a supportive inpatient environment. A convenience sample of dual diagnosis inpatients (N = 136) was assessed pre- and post-intervention from an inpatient setting where CMT was the mode of treatment. Psychopathology was measured using the Brief Psychiatric Rating Scale and substance abuse measured with the DrugCheck scale, breath/urine samples, and the Severity of Dependence Scale. Functioning was assessed with the Global Assessment of Functioning scale. Inpatient treatment was typically 3 to 9 months long. Ratings from independent sources post-intervention revealed that inpatients showed a significant reduction in both psychiatric symptoms (p < .0001) and levels of substance abuse. Patients also reported significant reductions in levels of anxiety and depressive symptoms (p < .0001). Treatment fidelity was considered adequate, where at least 80% of patients received all the core elements of the intervention. CMT is a promising treatment for dual diagnosis populations and warrants further controlled studies to evaluate its effectiveness in a range of clinical settings.

Evidence-Based Effectiveness of a Private Practice Intensive Outpatient Program With Dual Diagnosis Patients

The purpose of this study is to demonstrate the effectiveness of a freestanding intensive outpatient program (IOP) in a private practice setting for the treatment of dual diagnosis substance-abusing patients. Pre- and post-treatment Symptom Checklist 90–Revised, Global Assessment of Functioning, and patient functional rating scales were analyzed. Reliable change indices and clinically significant change measures were utilized. Trajectories of change for depression and number of days substances were used were analyzed, based on weekly Brief Symptom Inventory and substance use data reported by patients. Client satisfaction was also assessed at the end of treatment. Although patients started treatment with psychiatric symptoms comparable to those found in inpatient settings and 56% presented with suicidal or homicidal ideation, all symptom scales, functional impairments, and number of days used were significantly reduced by the end of treatment. Effect size statistics, reliable change indices, and statistically significant results indicated that 56% to 74% of patients treated in this program may be expected to improve, depending on the stringency of the criteria utilized. It is clear that dual diagnosis substance-abusing patients can be safely and effectively treated in a private practice IOP setting.

A Pilot Study of Quetiapine in Patients With Bipolar Disorder and Cocaine Dependence

Bipolar disorder is associated with high rates of substance use disorders. However, few treatment trials are reported in this population. The goal of this pilot study was to obtain randomized, placebo-controlled data on quetiapine in bipolar disorder and cocaine dependence. Twelve outpatients with bipolar disorder and cocaine dependence were randomized to 12 weeks of quetiapine or placebo as add-on therapy. Participants were titrated within one week to 400 mg/day with flexible titration to a maximum of 800 mg/day. Cocaine and other substance use, craving, mood symptoms, and safety/tolerability were assessed. No significant between-group differences were observed in cocaine use or craving. The quetiapine group had significantly fewer heavy drinking days than the placebo group and showed a trend toward longer treatment retention. Significant between-group differences in mood measures were not observed, although differences in depression scores, favoring quetiapine, showed a large effect size. Other than constipation, which was more common with quetiapine, side effects did not show significant between-group differences. Quetiapine was not associated with reduction in cocaine use, but was associated with reduction in alcohol use and longer time in treatment and was generally well-tolerated. Larger trials of quetiapine in dual diagnosis patients seem warranted.

Patients With Dual Diagnoses or Substance Use Disorders Only: 12-Step Group Participation and 1-Year Outcomes

We compared outpatients (regional facility) with substance use and psychiatric (N == 199) or only substance use (N == 146) disorders on baseline and one-year symptoms (93%% follow-up), and treatment and 12-step group participation over the year (2005). We examined whether diagnostic status moderated associations between participation and outcomes (Addiction Severity Index) with regressions. At follow-up, dual diagnosis patients had more severe symptoms, despite comparable treatment. The groups were comparable on 12-step participation, which was associated with better outcomes. However, associations of participation with better outcomes were weaker for dual diagnosis patients. Study (VA HSR&D-funded) implications and limitations are noted and research suggested.

Mood Stabilizers in the Treatment of Substance Use Disorders

Individuals suffering from drug addiction may also manifest features of bipolar spectrum disorders. Hyperthymic and cyclothymic temperaments may render individuals vulnerable to later development of substance abuse. Bipolar disorders themselves may be altered or precipitated by substance use, most notably by stimulants (amphetamines), alcohol, and cannabinoids. The clinical usefulness of mood stabilizers, particularly antiepileptics, has been established as safe and effective in substance abusers with and without comorbid mood disorders. Most studies on this issue have been of short duration and focused on the resolution of a currently manifest period of illness. Few studies have been conducted on the usefulness of these drugs on the long-term longitudinal course of these diseases, such as frequently encountered recurrent relapses into states of agitation, impulsivity, and/or dissatisfaction. As opposed to the clinical experience with traditional antidepressants and neuroleptics, antiepileptics do not induce counter-polar states (depressed patients abruptly turning manic or hypomanic; nor patients currently hypomanic or manic turning abruptly depressed). Many clinicians consider antiepileptic mood stabilizers to be the preferred category of medications for the treatment of such patients. Valproate appears to be a potentially fruitful medication to study in these dual diagnosis patients due to preliminary evidence demonstrating its anticraving efficacy.

Health Providers' Descriptions of the Significance of the Therapeutic Relationship in Treatment of Patients with Dual Diagnoses

Dual diagnosis of substance abuse and severe psychiatric illness is frequent, and the building of therapeutic relationships with this group of patients seems to be both important and difficult. An integrated treatment model has been claimed to be the preferred treatment for dual diagnosis patients. This study explores how providers in an integrated treatment model, and a substance abuse treatment model with less emphasis on psychiatric co-morbidity, handle relationship building. Two focus groups included providers working in a Therapeutic Community (TC) and a Dual Diagnosis (DD) ward. Participants were given a short case history and asked to describe how they would approach the case. The analysis was based on a phenomenological method. All providers perceived a good relationship to be central to the treatment. Providers in the DD ward were more ready to build close relationships with the patients, and described their relationship with the patients as more crucial to treatment. The providers in the TC ascr...

Predictors of completing treatment and achieving abstinence during inpatient dual diagnosis treatment

Background: Little is known about predictors of successful inpatient treatment of dual diagnosis patients. Methods: In a naturalistic prospective study, consecutive patients admitted to a dual diagnosis inpatient cognitive milieu therapy program were evaluated at intake to treatment with the Brief Psychiatric Rating Scale (BPRS), the Beck Depression Inventory (BDI), the Beck Anxiety Inventory (BAI), and the Severity of Dependence Scale (SDS). Logistic regression was used to determine predictors of confirmed abstinence during community linkage and completing treatment with medical advice. Results: No significant predictors were found of completing treatment. High thought disturbance, anxiety and severity of dependence were associated with drug or alcohol use during community linkage. A diagnosis of alcohol dependence was associated with abstinence during community linkage. Discussion: Dual diagnosis patients with severe substance dependence, as well as patients with elevated thought disturbance and anxiety...

Developing a service for people with dual diagnosis

Background: Comorbid severe mental illness and substance misuse occur in 15% of patients attending community mental health teams. Although these patients have poorer outcomes than those without comorbidity, historically they have been inadequately provided for by existing addiction and mental health services. Development: In Richmond, UK, a new service was developed for people with dual diagnosis without extra staffing or financial resources. The model comprised three components: a link worker from the community drug and alcohol team who works with individual mental health teams to offer advice and attend multidisciplinary meetings; a five-day training in dual diagnosis for staff; and a protocol for joint working of patients by both mental health and substance misuse teams. Discussion: The major issue in implementing the model was engaging staff, but overall referral pathways between teams have improved. In addition, the majority of dual diagnosis patients attend joint appointments, and 80 members of staf...

Reprint of “Treatment of cannabis use disorders in people with schizophrenia spectrum disorders — A systematic review”

Background Cannabis use disorders (CUD) are prevalent among people with schizophrenia spectrum disorders (SSD), with a range of detrimental effects, e.g. reduced compliance to medication and psychosocial interventions, and increased level of psychotic-dimension symptoms. The aim of this study was to review literature on treatments of CUD in SSD-patients. Methods PubMed, PsycINFO, EMBASE, and The Cochrane Central Register of Controlled Trials were searched. Results 41 articles were selected, 11 treating cannabis as a separate outcome. Contingency management was only effective while active. Pharmacological interventions appeared effective, but lacked randomized controlled trials (RCTs). Psychosocial interventions, e.g. motivational interviewing and cognitive behavior therapy (CBT), were ineffective in most studies with cannabis as a separate outcome, but effective in studies that grouped cannabis together with other substance use disorders. Conclusions Insufficient evidence exists on treating this form of dual-diagnosis patients. Studies grouping several types of substances as a single outcome may overlook differential effects. Future RCTs should investigate combinations of psychosocial, pharmacological, and contingency management.

Cognitive impairment in dual diagnosis inpatients with schizophrenia and alcohol use disorder

Cognitive impairment has been found independently among individuals with schizophrenia and individuals with alcohol use disorders. Less is known about the nature and severity of cognitive impairment in patients with a dual diagnosis, though the co-occurrence of these disorders may further exacerbate cognitive impairment. The study investigates the possible additive effect of alcohol use disorder and schizophrenia on cognitive impairment among patients diagnosed with schizophrenia. Participants were inpatients with schizophrenia ( n = 30), inpatients with a dual diagnosis of schizophrenia and alcohol use disorder ( n = 30), and matched controls ( n = 30): all completed a comprehensive neuropsychological battery. Both patient groups were significantly impaired, relative to controls, across the battery. Dual diagnosis patients were significantly more impaired than schizophrenia patients on delayed verbal memory, and executive functioning, primarily set-shifting, working memory, and planning, and had higher psychiatric morbidity scores. The findings provide support for an additive effect of the two disorders on cognitive impairment. These cognitive deficits may affect capacity to engage in treatment, increase risk of relapse, and adversely affect treatment outcomes. An understanding of the cognitive profile of people with dual diagnosis may help to tailor treatment delivery to meet their specific needs, enhance cognitive strengths, accommodate deficits and improve treatment outcomes.

Treatment of cannabis use disorders in people with schizophrenia spectrum disorders — A systematic review

Background Cannabis use disorders (CUD) are prevalent among people with schizophrenia spectrum disorders (SSD), with a range of detrimental effects, e.g. reduced compliance to medication and psychosocial interventions, and increased level of psychotic-dimension symptoms. The aim of this study was to review literature on treatments of CUD in SSD-patients. Methods PubMed, PsycINFO, EMBASE, and The Cochrane Central Register of Controlled Trials were searched. Results 41 articles were selected, 11 treating cannabis as a separate outcome. Contingency management was only effective while active. Pharmacological interventions appeared effective, but lacked randomized controlled trials (RCTs). Psychosocial interventions, e.g. motivational interviewing and cognitive behavior therapy (CBT), were ineffective in most studies with cannabis as a separate outcome, but effective in studies that grouped cannabis together with other substance use disorders. Conclusions Insufficient evidence exists on treating this form of dual-diagnosis patients. Studies grouping several types of substances as a single outcome may overlook differential effects. Future RCTs should investigate combinations of psychosocial, pharmacological, and contingency management.

P01-49 The use of the free recall method in the analysis of verbal memory deficits in dual diagnosis patients

In schizophrenia there are specific cognitive deficits including verbal memory deficits. The objective of this study was to examine short-term verbal memory differences between subjects with and without a dual diagnosis.A group of 80 patients with a diagnose of schizophrenia were examined. 40 of them never used illicit drugs, the other 40 also received a diagnose of addiction to psychoactive substances. The Free Recall Method was used to compare two examined groups. The results of addicted and not addicted schizophrenic patients were analyzed in all trials of the 5 stages of the examination with the use of Free Recall Method. Persons suffering from schizophrenia can usually repeat much fewer words in all five stages of the examination with Free Recall Method. This deficiency of short-term memory in this group of subjects is present from the very beginning of information coding.As it was expected a deficiency in short-term verbal memory was found in all examined patients. However when comparing both groups no statistical differences concerning verbal memory deficits were found between the group of patients suffering from schizophrenia addicted and not addicted to psychoactive substances.The fact that no significant differences concerning short-term verbal memory between two examined groups were found, which is consistent with some of the studies found in the literature, may be a good predictor for this group in terms of their possible chances of successful rehabilitation.

Substance abuse in schizophrenia: Neurobiological correlates

Event Abstract Back to Event Substance abuse in schizophrenia: Neurobiological correlates Stephane Potvin1* 1 University of Montreal, Department of Psychiatry, Canada The lifetime prevalence of substance abuse among schizophrenia patients is close to 50%. The negative consequences of substance abuse in schizophrenia are well documented, but the aetiology of this comorbid condition remains unknown. According to the “affect regulation model”, schizophrenia patients abuse drugs in order to cope with their negative affects. Supporting the model, clinical studies have shown that dual diagnosis patients have less blunting of affect, but experience more negative affect. We hypothesized that patients with comorbid addiction would have increased cerebral activations in response to negative emotional stimuli, when compared to abstinent ones. Schizophrenia patients were divided into two groups: patients with (n= 12) (SCZ-ADD group) and without (n=11) (SCZ group) addiction (alcohol and/or cannabis). Using functional magnetic resonance imaging (fMRI), patients were scanned during passive viewing of emotionally negative pictures (International Affective Picture System) and of film excerpts eliciting sadness. Subjectively, the emotional experience induced by viewing the negative pictures and film excerpts was significantly higher in the SCZ-ADD group than in the SCZ group. Neurally, increased loci of activation were found in the medial prefrontal cortex (BA 10) in SCZ-ADD patients, relative to the SCZ group, and this was true for both emotional tasks. These results suggest that the functioning of the medial prefrontal cortex, thought to be impaired in patients with prominent negative symptoms, is more preserved in SCZ-ADD patients. Keywords: Addiction, Neuroimaging, Schizophrenia Conference: 3rd Mediterranean Conference of Neuroscience , Alexandria, Egypt, 13 Dec - 16 Dec, 2009. Presentation Type: Oral Presentation Topic: Symposium 16 – Neuroimaging in Paediatrics, Neurology and Psychiatry: from clinical phenomenology to neurobiological phenotypes; the Swiss Canadian Egyptian Neurodevelopemental Study (SCENS) Citation: Potvin S (2009). Substance abuse in schizophrenia: Neurobiological correlates. Front. Neurosci. Conference Abstract: 3rd Mediterranean Conference of Neuroscience . doi: 10.3389/conf.neuro.01.2009.16.066 Copyright: The abstracts in this collection have not been subject to any Frontiers peer review or checks, and are not endorsed by Frontiers. They are made available through the Frontiers publishing platform as a service to conference organizers and presenters. The copyright in the individual abstracts is owned by the author of each abstract or his/her employer unless otherwise stated. Each abstract, as well as the collection of abstracts, are published under a Creative Commons CC-BY 4.0 (attribution) licence (https://creativecommons.org/licenses/by/4.0/) and may thus be reproduced, translated, adapted and be the subject of derivative works provided the authors and Frontiers are attributed. For Frontiers’ terms and conditions please see https://www.frontiersin.org/legal/terms-and-conditions. Received: 20 Nov 2009; Published Online: 20 Nov 2009. * Correspondence: Stephane Potvin, University of Montreal, Department of Psychiatry, Montréal, Canada, stephane.potvin@usherbrooke.ca Login Required This action requires you to be registered with Frontiers and logged in. To register or login click here. Abstract Info Abstract The Authors in Frontiers Stephane Potvin Google Stephane Potvin Google Scholar Stephane Potvin PubMed Stephane Potvin Related Article in Frontiers Google Scholar PubMed Abstract Close Back to top Javascript is disabled. Please enable Javascript in your browser settings in order to see all the content on this page.

PW02-06 The use of the free recall method in the analysis of verbal memory deficits in dual diagnosis patients

In schizophrenia there are specific cognitive deficits including verbal memory deficits. The objective of this study was to examine short-term verbal memory differences between subjects with and without a dual diagnosis.A group of 80 patients with a diagnose of schizophrenia were examined. 40 of them never used illicit drugs, the other 40 also received a diagnose of addiction to psychoactive substances. The Free Recall Method was used to compare two examined groups. The results of addicted and not addicted schizophrenic patients were analyzed in all trials of the 5 stages of the examination with the use of Free Recall Method. Persons suffering from schizophrenia can usually repeat much fewer words in all five stages of the examination with Free Recall Method. This deficiency of short-term memory in this group of subjects is present from the very beginning of information coding.As it was expected a deficiency in short-term verbal memory was found in all examined patients. However when comparing both groups no statistical differences concerning verbal memory deficits were found between the group of patients suffering from schizophrenia addicted and not addicted to psychoactive substances.The fact that no significant differences concerning short-term verbal memory between two examined groups were found, which is consistent with some of the studies found in the literature, may be a good predictor for this group in terms of their possible chances of successful rehabilitation.

Integrated Care Needed for Patients With HIV, Drug Abuse, and Mental Illness

PATIENTS WHO ARE INFECTED WITH HIV and who also have simultaneous substance abuse problems and mental illness have complex medical and psychosocial needs that challenge traditional care models. But a growing body of research suggests that integrated care models may improve the quality of life for these patients and reduce further spread of the infection. As many as half of individuals with substance abuse problems are estimated to have comorbid mental illness, and these dual-diagnosis patients have a relatively high risk of becoming infected with HIV. Studies have found that between 10% and 40% of patients at HIV clinics have a “triple diagnosis” of HIV, substance abuse disorder, and psychiatric illness, said Antoine Douaihy, MD, an associate professor of psychiatry at the University of Pittsburgh School of Medicine. The interrelationship between the 3 conditions is complex. Individuals experiencing psychiatric symptoms may be more likely to engage in behaviors that put them at risk of HIV infection, and HIV infection can also contribute to poor mental health (Parry CD et al. Curr Opin Psychiatry. 2007;20[3]:235241). Patients with psychiatric disorders often develop substance abuse disorders, but substance abuse also may contribute to the emergence of mental illness. Persons with substance abuse disorders are also more likely to engage in behaviors such as sharing drug injection equipment or trading sex for drugs or money that may put them at risk of infection with HIV. All 3 of these conditions may impair judgment or cognition, which may increase risk taking, making it more difficult for them to adhere to medication regimens and contributing to psychosocial problems, said Douaihy. PREVENTION Preventing the spread of HIV, especially in particularly vulnerable populations such as individuals who inject opiates, is an important way to reduce the burden of triple diagnosis. Testing for HIV is one important component of prevention, according to Lisa R.Metsch,PhD,associateprofessor in the Department of Epidemiology and Public Health at the University of Miami Miller School of Public Health. In 2006, the US Centers for Disease Control and Prevention published a revised guideline for HIV testing (http://www.cdc.gov /mmwr/preview/mmwrhtml/rr5514a1 .htm) intended to expand identification of individuals with HIV infection, including patients in substance abuse treatment settings. About 25% of the more than 1 million individuals in the United States who are infected with HIV are unaware of their status, and the majority of new infections stem from such individuals (Marks. AIDS. 2006;20[10]:14471450), said Metsch in a presentation at the National Institute on Drug Abuse’s (NIDA’s)BlendingAddictionScienceand Treatment conference in June. “The literature shows very clearly that if someone learns their HIV-positive status, they are more likely to reduce their risk behaviors,” Metsch said in a subsequent interview. Additionally, routine testing provides an opportunity to diagnose HIV infection and link infected individuals with treatment earlier in the course of their illness, which may prolong their lives, she said. Substance abuse treatment programs are particularly well positioned to help identify patients with HIV infection, Metsch said in her presentation, because patients enrolled in these programs have a higher risk of infection. The programs also often have networks in place to refer patients for HIV care. However, less than half of such programs offer HIV testing. In some cases, the programs may not have the money orresources tooffer testing, saidMetsch, ortheymayfeeltestingconflictswiththeir philosophy. Inexpensive rapidHIVtests mayhelpremovethishurdle.Metschand colleagues are launching a clinical trial to assess the effects of rapid HIV testing, with and without counseling, in a substance abuse treatment setting.