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Director's Report to the National Advisory Council on Drug Abuse - February, 2003

Research Findings - Services Research

Differences Between Ecstasy-Using and Non-using Methamphetamine Users

The researchers considered ecstasy use within its common poly-drug context (specifically with methamphetamine [MA]), examining differences between Ecstasy-using and non-using subgroups of clients treated for MA use, and exploring the relationship of Ecstasy use to selected treatment outcomes. Ecstasy+MA users differed from those using MA alone, in that those who have not used Ecstasy primarily in terms of socio-demographics (higher income, fewer children), substance abuse behaviors and motivators (lifetime history of more types of drugs, more likely to report use of Ecstasy to enhance sex, more drug-related problems), lifestyle (more likely to have had same-sex sex partners), and treatment characteristics (younger at admission, less likely to complete treatment). Subjects using ecstasy had significantly lower rates of treatment completion, but the actual time to relapse did not differ from the MA using population. These results suggest that using ecstasy compounds the deleterious effects of methamphetamine and compromises access to and adherence to treatment. Brecht, M.L., and von Mayrhauser, C. Journal of Psychoactive Drugs, 34(2), pp. 215-223, April-June 2002.

Mental Health Problems and Sexual Abuse among Adolescents in Foster Care: Relationship to IV Risk Behaviors and Intentions

Although adolescents in foster care present with multiple psychosocial and mental health problems that individually are associated with increased risk for HIV, few studies have examined the interrelationships among these factors. These authors examined sexual abuse histories and mental health problems among 343 youths in foster care to determine associations with HIV-risk behaviors and behavioral intentions. Of the sample, 25% reported internalizing behaviors (withdrawal, somatic complaints, depression), 28% reported externalizing behaviors (delinquency, aggression), and 37% reported prior sexual abuse. Multivariate analyses using simultaneous entry of variables, and controlling for demographic variables and behavioral intentions, showed externalizing behaviors as having the strongest relationship with both HIV risk behaviors and behavioral intentions. Moreover, there was a significant race by gender interaction, with Caucasian females engaging in more risky behaviors than their male counterparts and youths of color. This study begins to address the comparatively understudied issue of the empirical interrelationships among psychosocial problems and HIV risk behaviors in foster care children. Auslander, W.F., McMillen, J.C., Elze, D., Thompson, R., Jonson-Reid, M., and Stiffman, A. AIDS & Behavior, 6(4), pp. 351-359, December 2002.

Factors Associated with Completion of a Drug Treatment Court Diversion Program

Drug Treatment Courts are a relatively new effort to provide treatment instead of punitive incarceration for certain drug offenders. The researchers analyzed initial data from a longitudinal study of drug court outcomes in Delaware to identify factors associated with successful completion of a drug treatment program for first-time offenders. The strongest predictors of success were factors associated with social stakeholder values, especially those involving employment. Factors associated with program completion included race, education, and frequency of drug use. While the overall success of drug courts continues to be documented, these data suggest that success varies with individual characteristics. This study is an initial step toward understanding the influence of individual offender characteristics on the outcomes of Delaware's drug court system. This knowledge is essential for determining appropriate candidacy for drug court substance abuse treatment and developing effective treatment interventions and resources for offenders. Butzin, C.A., Saum, C.A., and Scarpitti, F.R., Substance Use and Misuse, Fall 2002.

Pathways to Long-term Recovery: A Preliminary Investigation

Recovery from addiction is a lifelong process. A large body of empirical data exists on the short-term effectiveness (one to two years) of various treatment modalities, yet little is known about recovery processes over time. This is unfortunate because treatment gains are often short-lived and even multiple treatment episodes do not always succeed in breaking the addiction cycle. Further, treatment represents only one path to recovery. This article reports on a study of individuals in long-term recovery from substance abuse (median = 12 years) and examines the factors they cite as important in establishing and maintaining their recovery status. Key factors reported were social and community support, affiliation with 12-Step organizations and negative consequences of substance use. This study points to the importance of prosocial networks in supporting continued abstinence in the community. Laudet, A.B., Savage, R., and Mahmood, D. J Psychoactive Drugs, 34(3), pp. 305-311, July-September 2002.

Case Management as a Therapeutic Enhancement: Impact on Post-treatment Criminality

The researchers examined proximal (aftercare participation) and distal (severity of legal problems) measures of treatment outcomes among 453 veterans who received substance abuse treatment and were randomly assigned to case management and non-case management. The results of multivariate analyses showed that case-managed subjects stayed longer in aftercare services than non-case managed clients, and the longer these clients stayed in post-treatment aftercare, the less they participated in criminal activity. The length of aftercare participation was also positively associated with employment and initial readiness for treatment. This study adds to the evidence that motivation for treatment and case management services are essential components to standards of care leading to positive client outcomes. Siegal, H.A., Li, L., and Rapp, R.C. J Addictive Disorders, 21(4), pp. 37-46, 2002.

UpDate: State Report-Integration and Its Discontents: Substance Abuse Treatment in the Oregon Health Plan

With the creation of the Oregon Health Plan (OHP) in 1994, Oregon placed its Medicaid program under a managed care system. This paper examines the managed care practices of seven health plans serving OHP enrollees between 1996 and 1998. Results indicated that the original plan to integrate substance abuse treatment services with physical care for OHP enrollees evolved into a multi-layered, carved-out approach. Factors working against integration included changes in the administration and management of the chemical dependency benefit, financial losses by health plans, and lack of training and incentives for physicians to refer clients to substance abuse treatment. This research provides important information related to the impact of managed care practices on substance abuse treatment services for Medicaid recipients. Laws, K.E., Gabriel, R.M., and McFarland, B., Health Affairs, 21(4), pp. 284-289, Jul-Aug, 2002.

Coping Among Individuals Seeking Private Chemical Dependence Treatment: Gender Differences and Impact on Length of Stay in Treatment

Length of stay in treatment and coping skills predict chemical dependence and abuse treatment outcomes. The researchers explored the interaction of coping strategies and length-of-stay in treatment, while paying particular attention to the effect of gender among 747 (433 men, 314 women) individuals who entered chemical dependence and abuse treatment in a private, managed care facility. Women reported using more emotional discharge (behavioral attempts to reduce tension by expressing negative feelings), cognitive avoidance (cognitive attempts to avoid thinking realistically about problems), resigned acceptance (cognitive attempts to react to problems by accepting them), and seeking support/guidance (behavioral attempts to seek information, guidance, or support) than men. The gender differences for emotional discharge disappeared after the variables of depressive symptom and drug problem severities were controlled. Greater use of seeking alternative rewards (behavioral attempts to participate in substitute activities and create new sources of satisfaction), less use of emotional discharge, and older age were significant predictors of longer length of stay, with no gender differences found. This study provides evidence for identifying and decreasing the use of emotional discharge early in treatment, possibly through the use of intervention strategies such as anger management, cognitive restructuring, or motivational interviewing, as well as encouraging participation in alternative activities. Kohn, C.S., Mertens, J.R., and Weisner, C.M. Alcoholism-Clinical and Experimental Research, 26(8), pp. 1228-1233, 2002.

Selecting Data Sources for Substance Abuse Services Research

In this article, researchers discuss the strengths and weaknesses of using different sources of data in the conduct of alcohol and drug abuse services research. Four different data sources commonly used in substance abuse services research are described: surveys of organizations, medical records, claim and encounter data, and program-level administrative data. For each, information is provided on where to obtain data, how each type has been used, and the advantages and challenges of each. This overview can help investigators to think more critically about the datasets they now use; providers to understand the types of data sources most appropriate for specific research questions so as to participate more fully in research; and policy makers to interpret correctly the study results based on different types of data. Moreover, it should foster better communication among these stakeholders in collaborative projects to improve the effectiveness of services for people with addictions. Garnick, D.W., Hodgkin, D., and Horgan, C.M. J Subst Abuse Treat, 22(1), pp. 11-22, 2002.

Managed Care Plans' Requirements for Screening for Alcohol, Drug, and Mental Health Problems in Primary Care

Researchers sought to determine managed care organizations' (MCOs) requirements for screening for alcohol, drug, or mental health problems in primary care settings. A telephone survey was used to gather information on the three largest commercial products offered by MCOs. Products included health maintenance organizations, preferred provider organizations, and point-of-service plans. Managed care organizations were asked whether their products required screening for alcohol, drug, or mental health problems in primary care settings. Chi-square tests were performed to ascertain whether screening requirements, the distribution of practice guidelines, and the topics addressed in those guidelines varied by product type and contracting with specialty behavioral health vendors. The data were weighted to produce national estimates. Only about 15% of the products surveyed required any alcohol, drug, or mental health screening by primary care practitioners. Slightly more than half of all the products surveyed distributed practice guidelines that addressed mental illness, and about one third distributed substance abuse practice guidelines. Although the feasibility, utility, and effectiveness of screening are increasingly recognized, few MCOs currently require alcohol, drug, or mental health screening by primary care physicians in any of their product types. Garnick, D.W., Horgan, C.M., Merrick, E.L., Hodgkin, D., Faulkner, D., and Bryson, S. Am J Manage Care, 8(10), pp. 879-88, August 2002.

Program Retention and Perceived Coercion in Three Models of Mandatory Drug Treatment

Despite the proliferation of drug courts and other mandatory treatment models, few studies have compared the impact of different program features. This study compared three groups of clients (N = 330) mandated to the same long-term residential treatment facilities. Study participants were referred from two highly structured programs or from more conventional legal sources, such as probation or parole agents. Analyses showed that these clients varied substantially in their perceptions of legal pressure, and these perceptions generally corresponded to the programs' different coercive policies and practices. Retention analyses confirmed that the odds of staying in treatment for six months or more were nearly three times greater for clients in the most coercive program compared to clients in the third group. Results support the use of structured protocols for informing clients about legal contingencies of participation and how participation will be monitored, and developing the capacity to enforce threatened consequences for failure. Young, D., and Belenko, S. Journal of Drug Issues, 32(1), pp. 297-328, Winter 2002.

Improving Service Delivery to the Dually Diagnosed in Los Angeles County

Service delivery to dually diagnosed individuals remains problematic in many communities because of entrenched administrative structures that maintain the separation of mental health and substance abuse treatment systems. This article describes efforts to improve service delivery to dually diagnosed individuals in Los Angeles County by increasing communication, coordination, and collaboration across the two treatment systems. Findings are presented on the relationships among program models of service delivery, treatment orientations of programs, and interactions with other service providers to the dually diagnosed. Results showed that drug treatment programs that adhered more closely to an integrated model of service delivery received more patient referrals from case management outreach teams and that programs with a stronger counseling approach to treatment had more linkages with other service providers. Knowledge gained from research on these differing models of service delivery can be combined with new clinical advances to improve service delivery to the dually diagnosed. Grella, C.E., and Gilmore, J. Journal of Substance Abuse Treatment, 23(2), pp. 115-122, 2002.

Predictors of Drug Abuse Treatment Entry Among Crack-cocaine Smokers

The goal of this study was to identify factors that predict drug abuse treatment program entry among a community sample of 430 crack-cocaine users. Subjects were recruited using a targeted sampling method, and they responded to interviewer-administered questionnaires at 6 month intervals over a 3-year period. At baseline, 41% (n = 174) reported they had never been in a drug abuse treatment program. During the observation period, 38% (n = 162) reported they had entered a program. Of these, 44% (n = 71) reported that their treatment was court-ordered. Slightly more than 25% (n = 44) entered treatment for the first time. A host of variables, including individual characteristics, frequency and duration of crack use, frequency of drunkenness, Addiction Severity Index (ASI) family/social, medical, and psychiatric status composite scores, perceived need for treatment, history of treatment, and medical insurance coverage, were explored. The results of Cox proportional hazards model suggested that younger people, users with more severe legal problems, people who perceived a need for treatment, and individuals with prior treatment experience had a greater likelihood of entering treatment. Developing a strategy to practically apply these findings may facilitate treatment entry for a population involved with a dangerous and debilitating drug. Siegal, H.A., Falck, R.S., Wang, J.C., and Carlson, R.G. Drug and Alcohol Dependence, 68(2), pp. 159-166, 2002.

Transporting a Research-based Adolescent Drug Treatment into Practice

This article describes the key ingredients and processes of transporting an empirically supported, research-developed family therapy for adolescent drug abusers, Multidimensional Family Therapy (MDFT), into an intensive day treatment program. Using the same systems change principles that guide this treatment approach, the technology transfer process is a collaborative, multidimensional, systemic intervention aimed at changing organizational structures, and attitudinal and behavioral patterns with multiple staff members at several program levels. This article describes: (1) the conceptual and empirical basis for these technology transfer efforts; (2) the technology being adapted and transferred; and (3) the critical events and processes that have shaped the transfer of MDFT into this program. The authors discuss the process and outcomes using Simpson's model of organizational change and specify the implications of this experience for the expansion of current conceptualization of technology transfer. Liddle, H.A., Rowe, C.L., Quille, T.J., Dakof, G.A., Mills, D.S., Sakran, E., and Biaggi, H. J Subst Abuse Treat, 22(4), pp. 231-243, June 2002.

Four-Year Follow-Up of Multisystemic Therapy with Substance-Abusing and Substance-Dependent Juvenile Offenders

This study addresses a gap in the adolescent substance abuse treatment literature by examining the long-term outcomes of a family-based treatment model. Eighty of 118 substance-abusing juvenile offenders provided follow-up data 4 years after participating in a randomized clinical trial comparing Multisystemic Therapy (MST) with usual community services. A multimethod (self-report, biological, and archival measures) assessment battery was used to measure the criminal behavior, illicit drug use, and psychiatric symptoms of participating young adults. Analyses demonstrated significant long-term treatment effects for aggressive criminal activity (0.15 versus 0.57 convictions per year) but not for property crimes. Findings for illicit drug use were mixed, with biological measures indicating significantly higher rates of marijuana abstinence for MST participants (55% versus 28% of young adults). Long-term treatment effects were not observed for psychiatric symptoms. These findings provide some evidence that MST can produce favorable long-term reductions in antisocial and drug using behavior of substance-abusing juvenile offenders. This information adds to the body of knowledge regarding appropriate treatment modalities for adolescent substance abusing juvenile offenders. Henggeler, S.W., Clingempeel, W.G., Brondino, M.J., and Pickrel, S.G. J Am Ac Child and Adoles Psychiatry, 41(7), pp. 868-874, 2002.

The Relationship Between Sexual and Physical Abuse and Substance Abuse Consequences

The authors examined the relation between a history of physical and sexual abuse and drug and alcohol related consequences. Cross-sectional data came from 359 male and 111 female patients recruited from an inpatient detoxification unit. The Inventory of Drug Use Consequences was used to measure negative life consequences of substance use. Eighty-one percent of women and 69% of men reported past physical/sexual abuse, starting at a median age of 13 and 11, respectively. The results of bivariate and multivariate analyses indicated that physical and sexual abuse was associated with more substance abuse consequences. For men, age 17 years or younger at first abuse was significantly associated with more substance abuse consequences than an older age at first abuse, or no abuse. For women, the association of abuse with substance use consequences was similar across all ages. Liebschutz, J., Savetsky, J.B., Saitz, R., Horton, N.J., Lloyd-Travaglini, C., and Samet, J.H. Journal of Substance Abuse Treatment, 22, pp. 121-128, 2002.

Injury Among Detoxification Patients: Alcohol Users' Greater Risk

The authors examined injury prevalence, and the impact of alcohol use on injury, among alcohol- and drug-dependent persons. Four hundred seventy (470) patients at a detoxification unit enrolled in a prospective cohort study. They were interviewed at baseline and follow-up (6, 12, 28, 24 months) to determine prevalence of injury. Overall, 24% reported at least one serious injury during the six-month period before detoxification. Similarly, about 20% had serious injury during each of the 6-month follow-up periods. Injury in the past six months was highest among the 63% of subjects who reported alcohol as a drug of choice, even after controlling for potential confounds. Analysis of 2-year follow-up data revealed a similar association, after controlling for baseline injury and alcohol consumption. The authors conclude that injury is a serious problem for a substantial proportion of patients who undergo detoxification, particularly those with alcohol dependence. This marked risk for injury persisted for 24 months after detoxification. This study suggests that patients at detoxification, particularly those with alcohol problems, represent a high-risk population for injury that may benefit from interventions to reduce these preventable complications. Rees, V.W., Horton, N.J., Hingson, R.W., Saitz, R., and Samet, J.H. Alcoholism: Clinical and Experimental Research, 26(2), pp. 212-217, February 2002.

Professional Satisfaction Experienced When Caring for Substance-abusing Patients

This survey aimed to describe and compare the satisfaction, attitudes, and practices regarding patients with addictions among 144 resident and faculty primary care physicians. Of the sample, 40% of physicians used formal screening tools to assess substance abuse, and 24% asked patients' family history. Physicians were less likely (P<.05) to experience at least a moderate amount of professional satisfaction caring for patients with alcohol (32% of residents, 49% of faculty) or drug (residents 30%, faculty 31%) problems than when caring for patients with hypertension (residents 76%, faculty 79%). Interpersonal experience with addictions was common (85% of faculty, 72% of residents) but not associated with attitudes, practices, or satisfaction. Positive attitudes toward addiction treatment (adjusted odds ratio [AOR], 4.60; 95% confidence interval [95% CI], 1.59 to 13.29), confidence in assessment and intervention (AOR, 2.49; 95% CI, 1.09 to 5.69), and perceived responsibility for addressing substance problems (AOR, 5.59; 95% CI, 2.07 to 15.12) were associated with greater satisfaction. These results show that professional satisfaction caring for patients with substance problems is lower than that for other illnesses and suggest that addressing physician satisfaction may improve care for patients with addictions. Saitz, R., Friedmann, P.D., Sullivan, L.M., Winter, M.R., Lloyd-Travaglini, C., Moskowitz, M., and Samet, J.H. Journal of General Internal Medicine, 17, pp. 373-376, 2002.

Relationship Between Tobacco Smoking and Medical Symptoms Among Cocaine-, Alcohol- and Opiate-Dependent Patients

This study examined the relation between tobacco smoking and medical symptoms among 87 cocaine-, 98 opiate-, and 81 alcohol-dependent individuals receiving outpatient treatment. Smoking status was assessed and medical symptoms were recorded using a standardized 134-item self-report instrument (MILCOM). Almost 79% of patients were tobacco smokers. Analysis of variance revealed a main effect of tobacco smoking on medical symptoms. Smokers reported significantly more symptoms compared to non-smokers on the total scale and on the respiratory, cardiovascular, gastrointestinal, and nose/throat subscales. There was a significant interaction between tobacco smoking and substance abuse with respect to medical symptoms, such that opiate- and alcohol-dependent patients who smoked reported more medical symptoms than those who did not, but cocaine users who smoked reported fewer symptoms than those who did not smoke. The findings support the link between smoking and medical problems among substance abusers, but suggest that the effects are not uniform across substances of abuse. Patkar, A.A., Sterling, R.C., Leone, F.T., Lundy, A., and Weinstein, S.P. The American Journal on Addictions, 11, pp. 209-218, 2002.

Tobacco and Alcohol Use and Medical Symptoms Among Cocaine Dependent Patients

The authors investigated the relations between smoking and alcohol use, and medical symptoms in 125 cocaine-dependent patients. Study participants were assessed for smoking, alcohol use, and medical problems using the MILCOM, a standardized self-report instrument. Medical symptoms were compared among non-smokers, moderate smokers (<10 cigarettes/day), and heavy smokers (>10 cigarettes/day) using partial chi-square statistics. Similar comparisons of medical symptoms were made between alcohol users (>2 drinks/day) and nonusers. Contrary to expectation, there were no significant differences between non-smokers, moderate smokers, and heavy smokers across most of the 14 major medical systems assessed. However, regardless of level of cocaine use, non-smokers reported the fewest symptoms on the general subscale, while moderate smokers reported the most nose/throat and respiratory symptoms among the three groups. As expected, significant relations were observed between medical symptoms and alcohol use. Alcohol users reported more respiratory, cardiovascular, digestive, head/neck, eye, and general medical symptoms than non-users. Although the findings generally support the link between alcohol use and medical problems, the relation between medical symptoms and smoking among cocaine patients may be more complex than that observed in the general population. Patkar, A.A., Lundy, A., Leone, F.T., Weinstein, S.P., Gottheil, E, and Steinberg, M. Substance Abuse, 23, pp. 105-114, 2002.


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