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National Institute on Drug Abuse

Director's Report to the National Advisory Council on Drug Abuse

February, 2000

Research Findings

Research on AIDS and Other Medical Consequences of Drug Abuse

Behavioral Practices and Therapies for HIV/AIDS

A study assessed knowledge and utilization of, and adherence to, combination antiretroviral therapies including protease inhibitors among 210 low-income 18-52 year olds living with HIV/AIDS. Most (65%) had received protease inhibitors at some point, although only 54% had received them in the previous 3 months. Parents with AIDS were more likely to have taken protease inhibitors than young adults (72% vs 33%). About half of those taking combination antiretroviral therapies reported consistent adherence (55%), even among the 64% who experienced side effects. However, the reliability of these reports appears moderate. More than half of those taking combination therapies reported improvements in their health (62%) Eighty seven percent of subjects reported having their viral loads tested on average 3.7 times. More than one third reported undetectable viral loads. Subjects were moderately informed about protease inhibitors. Those who abstained from substance use were more likely to be adherent, and adherence was not related to sexual behavior. These reports suggest that persons with AIDS are at risk for developing treatment-resistant strains of HIV because half or fewer have adequate levels of adherence, and further, a substantial minority are not on approved combination therapies. Gwadz, M., De Vogli, R., Rotheram-Borus, M.J., Diaz, M.M., Cisek, T.J., Nionne B., and Tottenham, N. Behavioral Practices Regarding Combination Therapies for HIV/AIDS. Journal of Sex Education & Therapy, 24, pp. 81-88, 1999.

Coping Ability among HIV + and - Female Injection Drug Users

This study examined the psychosocial determinants of coping ability in a cohort of 249 HIV positive and HIV negative female injection drug users (IDUs), using a cross-sectional retrospective design. Information collected using a structured questionnaire included data on psychosocial risk and protective factors in the personality, family, and peer domains, HIV status, and coping ability. Coping ability was associated with conventionality, greater control of emotions, less psychopathology, and family cohesion in both HIV positive and HIV negative subjects. The psychosocial factors affected coping in HIV positive and HIV negative IDUs via two different mediational models. The interactional findings supported the influence of risk/protective interactions in both groups. The findings demonstrate the impact of the interplay between personality factors and external support on coping ability in female IDUs. Brook, D.W., Brook, J.S., Whiteman, M., Roberto, J., Masci, J.R., Amundsen, F., and de Catalogne, J. Coping Among HIV Negative and HIV Positive Female Injection Drug Users. AIDS Educ Prev, 11(3), pp. 262-273, 1999.

Coping Strategies of HIV + and HIV - Female Injection Drug Users

This study examined longitudinally the psychosocial correlates of coping strategies among 165 HIV positive and 179 HIV negative female injection drug users (IDUs). Participants were interviewed twice using a structured questionnaire, with a 6-month interval between interviews. The questionnaire included psychosocial measures as well as measures of general coping and specific HIV-related coping. Data were analyzed using logistic regression analyses. The findings indicated that favorable factors in the psychosocial domains at Time 1 were significantly associated with an increased likelihood at Time 2 of the use of general coping and specific adaptive coping strategies, such as problem solving and seeking social support, and with a decreased likelihood at Time 2 of the use of maladaptive coping strategies, such as aggression and the use of illicit drugs. These findings highlight particular areas of psychosocial functioning that can be targeted by intervention programs to promote adaptive coping and minimize maladaptive coping among HIV positive and HIV negative female IDUs. Brook, D.W., Brook, J.S., Richter, L., Whiteman, M., Win, P.T., Masci, J.R., and Roberto, J. Coping Strategies of HIV-Positive and HIV-Negative Female Injection Drug Users: A Longitudinal Study. AIDS Educ Prev, 11(5), pp. 373-388, 1999.

Preventing Adolescent Health Risk Behaviors

The purpose of this study was to examine 6-year follow-up data on adolescent health-risk from a nonrandomized controlled trial of an intervention combining teacher training, parent education, and social competency training. Two intervention conditions were studied. The full program provided intervention components in grades 1 through 6, the later intervention program was provided in only grades 5 and 6; students in the current follow-up sample were 18 years of age. Results indicate that compared to control group students, the full intervention group students reported significantly fewer violent acts, less heavy drinking, lower incidence of sexual intercourse, and fewer sexual partners. They also reported more commitment and attachment to school, better academic achievement, and less school misbehavior. The late intervention students did not differ significantly from the control group in health risk behaviors. Hawkins, J.D., Catalano, R.F., Kosterman, R., Abbott, R., and Hill, K.G. Preventing Adolescent Health-Risk Behaviors by Strengthening Protection during Childhood. Archives of Pediatric and Adolescent Medicine, 153, pp. 226-234, 1999.

Sex Behavior and Substance Use Among Young Adults

The relationship between substance use during adolescence and HIV risk behavior among young adults aged 19-21 years with and without a college education was examined. Subjects were part of a longitudinal study that measured drug use and other variables in 6th-10th grades. Subjects who participated in at least 3 of these data collection periods were the targeted sample for the present study (N=952). Results indicate that increased use of alcohol and marijuana at younger ages is related to riskier sexual activity and increased use of alcohol and marijuana as young adults. Staton, M., Leukefeld, C., Logan, T. K., Zimmerman, R., Lynam, D., Milich, R., Martin, C., McClanahan, K., and Clayton, R.R. Risky Sex Behavior and Substance Use Among Young Adults. Health & Social Work, 24, pp. 147-154, 1999.

The Impact of Parental AIDS on Adolescent Children

This study examines the problem of adolescent children taking on adult parenting and spousal roles in families where a parent has AIDS (PWA). In Phase 1, relationships among parental AIDS-related illness, parent drug use, parent and adolescent demographics, and parentification indicators (parental, spousal, or adult role-taking) were assessed among 183 adolescent-parent pairs (adolescents aged 11-18 yrs). Adult role-taking was associated with maternal PWAs, female adolescents, and greater parent drug use. Greater parental AIDS-related illness predicted more spousal and parental role-taking. Parent drug use predicted more parental role-taking by adolescents. In Phase 2, the impact of parentification on later adolescent psychological adjustment was examined in 152 adolescents. Adult role-taking predicted more internalized emotional distress; parental role taking predicted externalized problem behaviors such as sexual behavior, alcohol and marijuana use, and conduct problems. Given these dysfunctional outcomes, interventions to mitigate parentification among children of PWAs was discussed. Stein, J.A., Riedel, M., and Rotheram-Borus, M.J. Parentification and its Impact on Adolescent Children of Parents with AIDS. Family Process, 38, pp. 193-208, 1999.

Problem Behavior of Adolescents Whose Parents Have AIDS

Substance use, acts of sexual risk, conduct problems, and internalizing, externalizing, and somaticizing mental health symptoms were examined among 239 adolescents (aged 11-19 yrs) and their parents living with AIDS in New York City. The assessment measures administered were constructs emerging from the creation of latent variables using a structural equational modeling approach. Other factors assessed were parental illicit drug use, health status, and internalizing of emotional distress, as well as adolescent alcohol and marijuana use. Consistent with theories regarding imitative behavior, stress, and anticipatory loss, adolescents' externalizing behavior problems and somatic symptoms were related to their parents' status. Rotheram-Borus, M.J., and Stein, J. A. Problem Behavior of Adolescents whose Parents are Living with AIDS. American Journal of Orthopsychiatry, 69, pp. 228-239, 1999.

Youth Living With HIV as Peer Leaders

Community-based service providers often hire youth living with HIV (YLH) as peer leaders or facilitators for delivering HIV education to uninfected adolescents. Life narratives were collected from 44 YLH during a hypotheses-generating 2-yr ethnographic study. About 30% of the youth were employed as peer educators. While 60% of the 44 youth had lower-class backgrounds, only 23% of the peer leaders were lower class. One-fifth of the sample was female, but more than one-half of the peer leaders were female. After identifying and categorizing difficulties experienced by the peer leaders, a frequency count of each theme was conducted. Issues about professional boundaries were evident in 38.5% of the youth's narratives, indicating conflicts in their roles as peer leaders; 23% of the youth engaged in substance use and sexual behaviors that placed themselves and uninfected youth in their peer educator programs at risk; and 8% of the youth reported relapse while peer leaders. These data suggest reconsideration or restructuring of existing peer education models that employ YLH. Luna, G.C., and Rotheram-Borus, M.J. Youth Living with HIV as Peer Leaders. American Journal of Community Psychology, 27, pp. 1-23, 1999.

An Institutional Analysis of HIV Prevention Efforts by the Nation's Outpatient Drug Abuse Treatment Units

Drawing from an institutional-theory perspective on innovations in organizations, this research examines human immunodeficiency virus (HIV) prevention practices by the nation's outpatient substance abuse treatment units during the period from 1988 to 1995. An institutional perspective argues that organizations adopt new practices not only for technical reasons, but also because external actors actively promote or model the use of particular practices. The extent to which treatment units use several practices to prevent HIV infection among their clients and among drug-users not in treatment are examined. Results from random-effects regression analyses of national survey data show that treatment units significantly increased their use of HIV prevention practices from 1988 to 1995. Further, the results show that treatment units' use of prevention practices was related to clients' risk for HIV infection, unit resources available to support these practices, and organizational support for the practices. Implications are discussed for an institutional view of organizational innovation as well as for research on HIV prevention. D'Aunno T., Vaughn T.E., and McElroy P. Journal of Health and Social Behavior, 40(2), pp. 175-192, June 1999.

Changes in HIV-related Risk Behaviors Following Drug Abuse Treatment

This study measures changes in HIV-related injection drug and sexual risk behaviors following drug treatment in a therapeutic community program. A prospective cohort study of 261 drug users, randomly assigned to day or residential treatment, were interviewed 2 weeks after entering treatment and 6, 12, and 18 months later (follow-up rate: 83%). Drug abuse treatment was associated with a decrease in HIV-related risk behavior. Greater reductions in injection risk behaviors were associated with more time in treatment and being in the later waves of interviews. Interview wave was also associated with greater reductions in sexual risk behavior. Woods, W.J., Guydish, J.R., Sorensen, J.L., Coutts, A., Bostrom, A., and Acampora, A. AIDS, 13, pp. 2151-2155, 1999.

HIV Testing in Substance Abusers

Which drug abuse treatment patients are HIV tested is a significant public and individual health issues in need of further examination. Over 15 months in 1992 and 1993, interview data gathered from 2315 patients at entry to treatment were analyzed to examine factors associated with previous HIV testing. Among this group of alcohol, heroin, and cocaine abusers, 53% (1231) reported previous HIV testing. Although those with identifiable HIV risk factors were more likely to have been tested, 27% of injection drug users, 38% with multiple sexual partners, 39% of those with a history of a sexually transmitted disease, and 38% of those with previous drug treatment had not been HIV tested. Other factors associated with previous HIV testing included having a primary care physician, the primary care physician's awareness of the patient's substance abuse problem, and having received prior addiction care. Of those tested, 10% (n = 122) reported a positive test, and 7% (n = 81) had not received the test results. Of those with positive test results, 37% were not injection drug users. Promotion of HIV testing among alcohol and other drug abusers in both medical and substance abuse treatment settings should be a priority. Samet, J.H., Mulvey, K.P., Zaremba, N., and Plough, A. Am J Drug Alcohol Abuse, 25(2), pp. 269-280, May 1999.

Differential Access to HIV Services Linked to HIV Transmission Mode in Urban Poor

Researchers examined the effect of HIV-health status and HIV transmission mode on access to HIV-related services among African American, Hispanic, and White HIV+ persons in Houston. Data were collected from 169 African Americans, 72 Hispanics, and 253 White HIV+ persons seeking social and medical services at community-based organizations. A total of 42 logistic regressions were estimated for each HIV service and ethnic group. The results showed significant differences in access to HIV social services based on HIV transmission mode among the three racial/ethnic groups. However, no differences were found in access to HIV medical services based on either HIV status or HIV-transmission mode among the three racial/ethnic groups. Montoya, I., Trevino, R., and Kreitz, D. Access to HIV Services by the Urban Poor. J Community Health, 24(5), pp. 331-346, 1999.

Heating Drug Solutions May Inactivate HIV-1

An ethnographic research study was conducted in response to concerns about risk of HIV-1 transmission from drug injection paraphernalia such as cookers. Specifically, ethnographic methods were used to develop a descriptive typology of the paraphernalia and practices used to prepare and inject illegal drugs. Observational data were then applied in laboratory studies in which a quantitative HIV-1 micro culture assay was used to measure the recovery of infectious HIV-1 in cookers. HIV-1 survival inside cookers was a function of the temperature achieved during preparation of drug solution; HIV-1 was inactivated once temperature exceeded, on average, 65 degrees centigrade. Although different types of cookers, volumes, and heat sources affected survival times, heating cookers 15 seconds or longer reduced viable HIV-1 below detectable levels. Clatts, M., Heimer, R., Abdala, N., Goldsamt, L., Sotheran, J., Anderson, K., Gallo, T., Luciano, P., and Kyriakides, T. HIV-1 Transmission in Injection Paraphernalia: Heating Drug Solutions May Inactivate HIV-1. JAIDS, 22(2), pp. 194-199, 1999.

Nitrites and Kaposi's Sarcoma in AIDS Subjects

This group has been studying the effects of nitrites on immune processes. In a correlative study, they have associated nitrite exposure with tumor production in mice. Epidemiological studies have correlated the incidence of Kaposi's sarcoma (KS) in AIDS with a history of abuse of nitrite inhalants. To determine if exposure to nitrite inhalants could alter tumor growth, syngeneic PYB6 tumor cells were injected into groups of mice. Exposure of these mice to inhaled isobutyl nitrite increased both the tumor incidence and the tumor growth rate by almost 4-fold. Following only five daily exposures to the inhalant, the induction of specific T cell mediated cytotoxicity was inhibited by 36%. Similar inhalation exposures inhibited the tumoricidal activity of activated macrophages by 86%. The data suggest that exposure to abused levels of a nitrite inhalant compromised tumor surveillance mechanisms. Soderberg, L.S.F., Toxicology Letters, 104, pp. 35-41, 1999.

Marijuana Withdrawal Among Adults Seeking Treatment for Marijuana Dependence

The clinical relevance of marijuana withdrawal has not been established. Budney et al. has documented for the first time, the incidence and severity of perceived marijuana withdrawal symptoms in a clinical sample of 54 marijuana-dependent adults (average age, 33.8+8 years; 15% women) seeking outpatient treatment for marijuana dependence. Eighty-two percent of the subjects smoked marijuana 4+ times daily, and approximately 54% smoked 26+ cigarettes daily. The subjects completed a 22-item Marijuana Withdrawal Symptom checklist based on their most recent period of marijuana abstinence. The majority (57%) indicated that they had experienced > six symptoms of at least moderate severity and 47% experienced > four severe symptoms. Withdrawal severity was greater in those with psychiatric symptomatology and more frequent marijuana use. The authors concluded that this study further provides support for a cluster of withdrawal symptoms experienced following cessation of regular marijuana use and that the effective and behavioral symptoms were consistent with those observed in previous laboratory and interview studies. Furthermore, since withdrawal symptoms are frequently a target for clinical intervention with other substances of abuse, this may also be appropriate for marijuana. Budney, A.J., Novy, P.L., and Hughes, J.R. Marijuana Withdrawal Among Adults Seeking Treatment for Marijuana Dependence, Addiction, 94(9), pp. 1311-1321, 1999.

Marijuana Smoking and Risk of Cancer

Zhang et al. from UCLA conducted a case-control study of 173 previously untreated cases of squamous cell carcinoma of the head and neck; and 176 cancer-free controls at Sloan-Memorial Kettering Cancer Center, New York, between 1992 and 1994. They collected epidemiological data by using a structured questionnaire, which included history of tobacco smoking, alcohol use, and marijuana use. The overall prevalence of lifetime marijuana use was 9.7% in controls and 13.9% in cases. The highest prevalence of marijuana use was found in cases with squamous cell carcinoma of the larynx (n=48; 22.9%) and tongue (n=52; 19.2%). Controlling for age, sex, race, education, alcohol use, and pack-years of cigarette smoking, the risk of head and neck cancer was increased with marijuana use [OR comparing ever with never users, 2.6;95% CI,1.1-6.6] with a dose-response relationships for frequency of marijuana use/day and years of marijuana use (P for trend <0.05). The associations were stronger for subjects who were 55 years of age and younger (OR,3.1;95% CI,1.0-9.7). These data suggest that marijuana use may increase the risk of head and neck cancer with a strong dose-response pattern, and that marijuana use may interact with mutagen sensitivity and other risk factors (cigarette smoking, alcohol use) to increase the risk of head and neck cancer. The researchers stated that these results need to be interpreted with some caution in drawing causal inferences because of certain methodological limitations, especially with regard to interactions mentioned above. Zhang, Z.F., Morgenstern, H., Spitz, M.R., Tashkin, D.P., et al. Marijuana Use and Increased Risk of Squamous Cell Carcinoma of the Head and Neck. Cancer Epidemiology, Biomarkers and Prevention, 8(12), pp. 1071-1078, 1999.

Level of In Utero Cocaine Exposure and Neonatal CNS Ultrasound Findings

Researchers in Boston report ultrasound findings suggestive of an association between vascular injury of the neonatal CNS and level of prenatal cocaine exposure. Three cocaine exposure groups were studied based on maternal report and infant meconium testing: unexposed, heavier cocaine exposure (>75th percentile self-reported days of use or meconium benzoylecognine concentration), and lighter cocaine exposure (all others). Analyses involved neonatal ultrasounds from 241 well, term infants. Infants with lighter cocaine exposure and unexposed infants did not differ on any of the ultrasound results. Infants with heavier cocaine exposure were more likely than unexposed infants to show subependymal hemorrhage in the caudo-thalamic groove (odds ratio of 3.88 with control for gender, gestational age, birth weight, maternal parity, blood pressure in labor, ethnicity, and use of cigarettes, alcohol, and marijuana during pregnancy). The researchers suggest that the inconsistency between these findings and others reported in the literature may reflect previous lack of consideration of possible dose effects. The long-term functional implications of these findings remain to be determined. Children represented in this report continue to be studied as part of an ongoing longitudinal study of development relative to illicit drug exposure in utero. Frank, D.A., McCarten, K.M., Robson, C.D., Mirochnick, M., Cabral, H., Park, H., and Zuckerman, B. Level of In Utero Cocaine Exposure and Neonatal Ultrasound Findings. Pediatrics, 104, pp. 1101-1105, 1999.

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