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Director's Report to the National Advisory Council on Drug Abuse - May, 2004

Research Findings - Services Research

Long-Term Response to Treatment is Influenced by Early Response to Treatment and Participation in Aftercare

For many individuals substance use is a chronic, relapsing condition that can last for decades and require multiple treatment episodes. The objectives of this study were to (a) explore the relationships between initial severity, participant characteristics, treatment, recovery environment and initial and long-term response to treatment and (b) illustrate the need for long-term evaluation over multiple episodes of care. Data were collected from 1,054 adults seeking publicly funded substance abuse treatment. The final path analysis fit the data well (CFI = 0.99, RMSEA = 0.043). The effects of the initial treatment on long-term outcomes were entirely mediated by the initial response to treatment, participation in aftercare and 12-step support groups. This suggests the importance of evaluating outcomes in the context of (a) multiple episodes of care and (b) the extent to which a given episode of care produces initial changes in behavior and participation in a supportive recovery environment. Scott, C.K., Foss, M.A., and Dennis, M.L. Factors Influencing Initial and Longer-term Responses to Substance Abuse Treatment: A Path Analysis. Evaluation and Program Planning, 26, pp. 287-295, 2003.

Response to Substance Abuse Treatment Can Predict Subsequent Substance Use and Criminal Activity

Changes in criminal activity following substance abuse treatment were examined among 941 individuals. The estimated cost to society of crimes committed in the 6 months prior to intake was used to classify participants into three groups: no-, low-, and high-cost. Logistic regression was used to predict criminal activity at 6 and 24 months following intake as a function of (a) intake status, (b) treatment, and (c) outcome status and changes. The three groups varied significantly at intake and what predicted subsequent criminal activity. Treatment effects on criminal activity were mediated by the extent to which treatment reduced substance use. Outcomes were also predicted by other factors (e.g. housing, employment, medical problems, psychological distress, and social support). The results support the need for multidimensional assessments for predicting the risk of illegal activity, the need for reassessments following treatment, and the value of addressing other problems in reducing subsequent criminal activity. Scott, C.K., Foss, M.A., Lurigio, A.J., and Dennis, M.L. Pathways to Recovery after Substance Abuse Treatment: Leaving a Life of Crime Behind. Evaluation and Program Planning, 26, pp. 403-412, 2003.

Recovery Management Checkups Can Improve Long-term Outcomes of Chronic Substance Users

The majority of people presenting for publicly-funded substance abuse treatment relapse and receive multiple episodes of care before achieving long-term recovery. This Early Re-Intervention experiment evaluates the impact of a Recovery Management Checkup (RMC) protocol that includes quarterly recovery management checkups (assessments, motivational interviewing, and linkage to treatment re-entry). Data are from 448 adults who were randomly assigned to either RMC or an attention (assessment only) control group. Participants were 59% female, 85% African American, and 75% aged 30-49. Participants assigned to RMC were significantly more likely than those in the control group to return to treatment, to return to treatment sooner, and to spend more subsequent days in treatment; they were significantly less likely to be in need of additional treatment at 24 months. This demonstrates the importance of post-discharge recovery management checkups as a means to improve the long-term outcomes of people with chronic substance use disorders. Dennis, M., Scott, C.K. and Funk, R. An Experimental Evaluation of Recovery Management Checkups (RMC) for People with Chronic Substance Use Disorders. Evaluation and Program Planning, 26, pp. 339-352, 2003.

Drug Treatment Instrumental in Reducing Homelessness

The course of homelessness was examined among adult substance abusers entering treatment in the Chicago Target Cities treatment sample. The research objectives were to: (1) examine client movement in and out of homelessness over 2 years post entry into the index treatment episode, and (2) determine the treatment and non-treatment factors that predict achieving and sustaining residential stability. The sample, recruited from treatment programs on Chicago's West Side, was 59% female and predominantly African-American (87%), unemployed (86%), and unmarried (90%). Approximately one-third self-presented as homeless. Descriptive results showed that 73% of initially homeless clients had improved their residential status at 6 months, and 60% were stably housed at 24 months. By contrast, 28% of initially housed clients were not stably housed at 6 months (the majority of these had gone into residential treatment), and only 16% were homeless at 24 months. Sample-wide, homelessness was reduced by 37% between baseline and the 2-year follow-up. The high percentage of homeless substance abusers that achieved and maintained stable housing is consistent with a conclusion that treatment reduced homelessness in the Chicago Target Cities sample. Alternative explanations cannot be entirely ruled out, but are insufficient to nullify the general conclusion. Factors discriminating homeless and housed clients at baseline were consistent with prior literature. Several treatment and non-treatment factors predicted 6- and 24-month housing outcomes in conditional logistic regression models, although the significance and direction of effect estimates varied across conditions. The most consistent predictors were crack as the primary substance, which appears to be a persistent risk factor for becoming and remaining homeless, and whether or not the participant reported that persons were dependent on him/her for food/shelter, which appears to be a persistent protective factor for achieving housing and preventing homelessness. Orwin, RG., Scott, C.K., and Arieira, C.R. Transitions Through Homelessness and Factors that Predict Them: Residential Outcomes in the Chicago Target Cities Treatment Sample. Evaluation and Program Planning, 26, pp. 379-392, 2003.

Workplace Drug Testing Programs Can Discourage Employee Drug Use

Despite resistance among labor and consumer groups and a lack of rigorous empirical evidence regarding effectiveness, drug testing programs have remained popular with employers throughout the 1990s and into the current century. This study analyzed nationally representative data on over 15,000 US households to determine whether various types of workplace drug testing programs influenced the probability of drug use by workers. The study estimated several empirical specifications using both univariate and bivariate probit techniques, and specification tests favored the bivariate probit model. Estimated marginal effects of drug testing on any drug use were negative, significant, and relatively large, indicating that drug testing programs are achieving one of the desired effects. The results were similar when any drug use was replaced with chronic drug use in the models. These results have important policy implications regarding the effectiveness and economic viability of workplace anti-drug programs. French, M.T., Roebuck, M.C. and Alexandre, P.K. To Test or Not to Test: Do Workplace Drug Testing Programs Discourage Employee Drug Use? Social Science Research, 33(1), pp. 45-63, 2004.

Factors Supporting Innovation in Private Treatment Organizations

A study of 322 privately-funded substance abuse treatment centers participating in the University of Georgia National Treatment Center Study, found that provider organizations high in their capacity to absorb external knowledge via such activities as journal reading, participation in external seminars, staff professional association involvement, and various career development activities; as well as engaging in "environmental scanning" activities such as regularly seeking satisfaction input from patients and associated service support organizations were most likely to adopt therapeutic innovations. Larger provider organizations were significantly more likely to be high in absorptive capacity and environmental scanning. Knudsen, H.K., and Roman, P.M. Modeling the Use of Innovations in Private Treatment Organizations: The Role of Absorptive Capacity. Journal of Substance Abuse Treatment, 26, pp. 353-361, 2004.

Management Practices Have Potential to Reduce Turnover in Substance Abuse Counselors

A study of 1,107 substance abuse treatment counselors from 345 privately-funded substance abuse treatment centers participating in the University of Georgia National Treatment Center Study found that in clinics where management provided high job autonomy, supported counselor creativity, and rewarded good job performance counselors expressed higher levels of commitment to the organization and high levels of intent to remain in the organization. Results demonstrate that management practices in substance abuse treatment clinics have potential to reduce job turnover, thereby avoiding personnel costs associated with job turnover (recruiting, hiring, and training replacements) and lost treatment resources due to disruption of continuity of care for patients. Knudsen, H.K., Johnson, J.A. and Roman, P.M. Retaining Counseling Staff at Substance Abuse Treatment Centers: Effects of Management Practices. Journal of Substance Abuse Treatment, 24, pp. 129-135, 2003.

Cost-Effectiveness of Post-Release Substance Abuse Treatment For Criminal Offenders

A study of Delaware's CREST Outreach Center, a work release therapeutic community (TC) and aftercare program for criminal offenders estimated the cost-effectiveness over an 18-month post-release follow-up for four study groups: CREST work release TC completers, CREST work release TC noncompleters, CREST work release completers who also participated in aftercare treatment, and a comparison group of standard work release participants. The 6-month CREST program cost $1,937 for the average participant, and led to 30 fewer days incarcerated (29% less) than the average participant in a standard work release program. This implies that the CREST program reduced incarceration for criminal offenders at an average cost of $65 per day. The additional investment of $935 per client to provide aftercare services led to 49 fewer days incarcerated (43% less) than CREST work release-only participants. This suggests that by adding an aftercare component to the CREST work release program, a day of incarceration is avoided at an average cost of $19 per day. These results indicated that completing the CREST work release TC program and participating in aftercare were cost-effective treatment strategies. McCollister, K.E., French, M.T., Inciardi, J.A., Butzin, C.A., Martin, S.S. and Hooper, R.M. A Cost-Effectiveness Analysis of Post-release Substance Abuse Treatment for Criminal Offenders. Journal of Quantitative Criminology, 19(4), pp. 389-407, 2003.

Cost-Effectiveness of Addiction Treatment: Paradoxes of Multiple Outcomes

This paper identifies and illustrates the challenges of conducting cost-effectiveness analysis of addiction treatments given the multiple important outcomes of substance abuse treatment. Potential problems arise because cost-effectiveness analysis is intended primarily for single outcome programs, yet addiction treatment results in a variety of outcomes such as reduced drug use and crime and increased employment. Methodological principles, empirical examples, and practical advice are offered on how to conduct an economic evaluation given multiple outcomes. An empirical example is provided to illustrate some of the conflicts in cost-effectiveness ratios that may arise across the range of outcomes. The data are from the Philadelphia Target Cities quasi-experimental field study of standard versus "enhanced" (e.g. case management and added social services) drug treatment. Outcomes are derived from the Addiction Severity Index, while cost data were collected and analyzed using the Drug Abuse Treatment Cost Analysis Program. While the results are illustrative only, they indicate that cost-effectiveness ratios for each of several different outcomes can produce conflicting implications. These findings suggest that multiple outcomes should be considered in any economic analysis of addiction treatments because focusing on a single outcome may lead to inadequate and possibly incorrect policy inferences. However, incorporating multiple outcomes into a cost-effectiveness analysis of addiction treatment is difficult. Cost-benefit analysis may be a preferable and more appropriate approach in some cases. Sindelar, J.L., Jofre-Bonet, M., French, M.T., and McLellan, A.T. Cost-Effectiveness Analysis of Addiction Treatment: Paradoxes of Multiple Outcomes. Drug and Alcohol Dependence, 73(1), pp. 41-50, 2004.

Adolescent Substance Abuse: Under-reported or Under-detected by Health Plans?

This article examines whether health plans are adequately identifying adolescents with substance use problems. Three measures developed by the Washington Circle, a group focused on the development of substance use performance measures, have been adapted for the 2004 Health Plan Employer Data and Information Set. One measure-the identification rate-can be used to examine the extent to which private health plans are able to identify adolescent enrollees with substance abuse problems. Using MarketScan, a database of private health plan claims for selected employers maintained by the MEDSTAT Group, researchers calculated a 0.5 percent rate of adolescents (ages 12-18 years) identified with substance abuse problems among those enrolled in 1997. This rate is low compared to the 6.8 percent rate of substance dependence reported by a subset of adolescents covered by commercial insurance who were included in the 1998 National Household Survey on Drug Abuse. Researchers detected no meaningful variation across health plan type. Researchers suggest that the low identification rate may be due to (a) providers' reluctance to record substance abuse diagnoses due to stigma or legal issues, or (b) providers' failure to identify substance abuse because they lack adequate training in or incentives for screening and diagnosis. Lee, M.T., Garnick, D.W., Miller, K. and Horgan, C.M. Adolescents with Substance Abuse: Are Health Plans Missing Them? Psychiatric Services, 55(2), p. 116, 2004.

Preventive Interventions for Externalizing Disorders in Adolescents

Adolescent externalizing dimensions refer to the cluster of highly co-occurring behaviors and disorders that include conduct disorders, oppositional defiant disorders, Attention Deficit Hyperactivity Disorder, substance use disorders and-more recent to the literature-problem gambling. Externalizing disorders are likely influenced by several personal (e.g., personality, attitudes, values) and environmental (e.g., peers, parenting practices, intervention or treatment experiences) factors. The emerging discipline of developmental psychopathology provides a conceptual framework that is applicable to the study of the etiology, prevention and intervention of externalizing disorders of youth. Developmental psychopathology is a macroparadigm, which emphasizes the contrast between typical and atypical development. This conceptualization allows for qualitative changes in functioning over time, and the influence by mediator and moderator variables at varying developmental stages from adolescence to young adulthood. In the past, preventive interventions for youth with externalizing disorders, many of which have focused on substance abuse, were designed as one-size-fits-all. The disappointing results have drawn attention to the complexity and multiplicity of the risk factors involved. In order to prevent the onset, maintenance and course of externalizing behaviors among adolescents, a prevention framework must include strategies crafted to respond to the unique risk profiles of various subgroups of the population. Consequently, prevention efforts that are initiated early in a child's life, adjusted with emerging developmental tasks and sustained over time, are the best possible tools available today. Winters, K.C., August, G.E., and Leitten, W. Preventive Interventions for Externalizing Disorders in Adolescents. In D. Rowe (Ed.), Reducing Adolescent Risk: Toward An Integrated Approach. Newbury Park, CA: Sage Press, 2003.

Runaway Youth's Use of Federally-Funded Crisis Services Differs by Region

This study examined national and regional differences between runaway shelter users and national census norms on demographic and high-risk characteristics. Data collected from federally-funded youth shelters nationwide (n = 16,652) were compared with U.S. adolescent populations (n = 26,735,028). Runaway youth were more likely to be female, minority and older than respective national figures; ethnicity varied greatly from one region of the U.S. to another. Proportions of youth with high-risk characteristics, such as illicit drug use and selling, suicidal behaviors, and physical and sexual abuse were strikingly different across regions. Development of policies and services that target particular issues of youth in specific regions is needed. Thompson, S., Maguin, E., and Pollio, D. National and Regional Differences Among Runaway Youth Using Federally-Funded Crisis Services. Journal of Social Services Research, 30(1), pp. 1-17, 2003.

Women More Vulnerable than Men to Relapse Because of Substance-Using Partners

Gender differences in the characteristics of individuals entering drug treatment and their post-treatment substance use were examined among 904 individuals, the majority of whom were female (63%) and predominantly African American (93%), who were admitted into the Chicago Target Cities Project. Bivariate relationships were examined in background characteristics, addiction and treatment career parameters, family and social relationships, psychosocial functioning, and treatment/social interventions received. Path analysis was used to determine the predictors of drug/alcohol use at 6- and 24-months following intake at a central referral agency, by developing separate path models for males and females. Drug/alcohol use was significantly reduced for men and women at 6- and 24-months, dropping by about 50% for both. Women had more episodes of subsequent treatment and men had higher rates of incarceration during the follow-up periods. The path analyses showed that at 6-months following intake, living with someone with a drug/alcohol problem was related to higher rates of drug/alcohol use for women, but not for men. For both men and women, psychological distress was related to higher levels of substance use at the 6-month follow-up, whereas having an improved living situation and participating in 12-step groups were related to lower levels of use at both follow-up points. The findings suggest that, although there are some similarities in the factors related to recovery for both men and women, women are more vulnerable to relapse because of having substance-using partners. Grella, C.E., Scott, C.K., Foss, M.A., Joshi, V. and Hser, Y. Gender Differences in Drug Treatment Outcomes Among Participants in the Chicago Target Cities Study. Evaluation and Program Planning, 26, pp. 297-310, 2003.

Epidemiology of Substance Use Disorders in Women

This article reviews the current epidemiology and patterns of substance use, abuse, and dependence, and the course, medical consequences, and treatment-related issues of substance disorders in women of all ages. There are approximately 15.1 million individuals who abuse or depend on alcohol in the United States; approximately 4.6 million (nearly one third) of these individuals are women. In 2001, an estimated 15.9 million Americans aged 12 years or older were current illicit drug users, and more than a third were women. In 1999, almost 4% of pregnant women were past-month users of illicit drugs. Research suggests that women are more susceptible than men to substance-related interpersonal difficulties, trauma, and medical consequences, heightening their risk of morbidity and mortality. In an early study of 100 alcohol-dependent women, 31% were dead at the 11-year follow-up, with most deceased from alcohol-related causes. The lifespan of these alcohol-dependent women was shortened by an average of more than 15 years. In a more recent study, heavily drinking women (> 4 standard alcoholic drinks/day) died significantly earlier compared with non-alcohol-dependent women (consume <4 standard alcoholic drinks/day), and there was also a trend toward earlier mortality rates compared with the heavily drinking men (>8 standard alcoholic drinks/day). In addition to these data on alcohol disorders, other studies indicate a broad range of health-related consequences in women with substance use disorders. For example, in 1986, mortality for lung cancer in women surpassed breast cancer mortality to become the leading cause of cancer death for women in the United States. These and other illnesses and accidents that can be attributed to substance use and abuse in women accounted for $68 billion in health care costs in 1995 (12.3% of the total health care expenditure for women). Despite these statistics, women are underrepresented in traditional substance abuse treatment settings. This may be partly because women tend to pursue avenues of treatment other than traditional substance abuse programs, such as mental health or primary care services. One study of obstetrics and gynecology practices found that 12% to 16% of patients had an alcohol disorder. The obstetrician gynecologist (OB-GYN) may be the only clinician and primary care provider for many women through the life cycle. Many of these women come for a myriad of problems that may or may not be related to their substance abuse, including routine physical examinations, prenatal care, and sexual problems. Discussions about infertility, pregnancy, or birth control provide the OB-GYN with an opportunity to assess and advise patients about their alcohol or drug use. From a public health and clinical perspective, this presents an enormous opportunity to detect and counsel these patients and refer them to appropriate treatment as indicated. Greenfield, S.F., Manwani, S.G. and Nargiso, J.E. Epidemiology of Substance Use Disorders in Women. Obstetrics and Gynecology Clinics of North America, 30(3), pp. 413, 2003.

Methamphetamine Use Behaviors and Gender Difference

This analysis describes methamphetamine (MA) use behaviors in a broad cross-section of (N = 350) former clients from a large publicly funded treatment system and examines differences between males and females in drug use history, MA initiation and motivators, MA-related problems, acquisition, distribution, manufacture, and treatment characteristics. Results describe the prevalence of polydrug use, prolonged MA use before treatment, initiation primarily through friends, common sensation-seeking motivators (to have fun, get high, and experiment), numerous problems related to MA use (including paranoia, violent behavior, hallucinations, financial problems, and legal and work problems), and a majority who have sold MA. Gender differences appear in selected aspects of motivators and routes of initiation, access to MA, use patterns, and MA-related problems. Males were more likely than females to report work problems (70% vs. 48%) and high blood pressure (31% vs. 16%), and females were more likely to report skin problems (47% vs. 27%). Such description of behaviors and gender differences can provide a basis for development of treatment strategies and points of departure for future research. Brecht, M.L., O'Brien, A., von Mayrhauser, C. and Anglin, M.D. Addictive Behaviors, 29(1), pp. 89-106, 2004.

Burden of Medical Illness in Drug and Alcohol Dependent Persons without Primary Care

Little is known about the frequency, severity and risk factors for disease in drug and alcohol dependent persons without primary medical care. This article assesses the burden of medical illness and identifies patient and substance dependence characteristics associated with worse physical health in order to compare measures of illness burden in this population. Researchers conducted a cross-sectional study among alcohol, heroin or cocaine dependent persons without primary medical care admitted to an urban inpatient detoxification unit (mean age = 35.7 years; 76% male; 46% Black). Forty-five percent reported being diagnosed with a chronic illness, and 80% had prior medical hospitalizations. The mean age-adjusted SF-36 Physical Component Summary (PCS) score was significantly lower than the general U.S. population norm (44.1 vs. 50.1). In multivariable analysis, the following factors were associated with worse health: female gender, problem use of hallucinogens, heroin, other opiates, living alone, having medical insurance, and older age. Alcohol and drug dependent persons without primary medical care have a substantial burden of medical illness compared to age and gender matched U.S. population controls. While the optimal measure of medical illness burden in this population is unclear, a variety of health measures document this medical illness burden in addicted persons. De Alba, I., Samet, J.H. and Saitz, R. Burden of Medical Illness in Drug and Alcohol Dependent Persons without Primary Ccare. American Journal of Addiction, 13, pp. 33-45, 2004.

Similarities and Differences in Rural and Urban Substance Abuse Treatment

Using three waves of longitudinal data from a nationally representative sample of 450 privately-funded substance abuse treatment centers, this research found that rural and urban centers were similar in their increasing provision of inpatient psychiatric levels of care and their decreasing provision of more intensive services for chemical dependency between 1995 and 2001. Rural and urban centers were increasingly likely to offer specialty treatment tracks for women, adolescents, clients with HIV/AIDS, and relapsing clients over time, but rural centers were less likely to offer a treatment track tailored to substance-abusing women. The use of treatment innovations was similar at rural and urban treatment centers with the exception of lesser use of acupuncture at rural centers. Rural and urban centers did not differ in their average charges for treatment services. Knudsen, H.K., Johnson, J.A., Roman, P.M. and Oser, C.B. Rural and Urban Similarities and Differences in Private Substance Abuse Treatment Centers. Journal of Psychoactive Drugs, 35, pp. 511-518, 2003.

Medical and Psychiatric Conditions of Alcohol and Drug Treatment Patients in an HMO

This study compares the prevalence of medical and psychiatric conditions among 747 substance-abuse patients with 3,690 demographically-matched controls from the same health maintenance organization (HMO), and examines whether comparisons vary among demographic and substance-type subgroups. Approximately one-third of these comorbid conditions were more common among alcohol and drug patients than among matched controls, and many of these were among the most costly conditions. Researchers also found that pain-related diagnoses, including arthritis, headache, and lower back pain, were more prevalent among alcohol and drug patients, and particularly among those dependent upon narcotic analgesics. Findings point to the importance of examining comorbid medical and substance abuse in both primary care and specialty care. Findings regarding pain-related diagnoses among those dependent upon narcotic analgesics highlight the need for linkages between primary care and substance abuse treatment. Mertens, J.R., Lu, Y.W., Parthasarathy, S., Moore, C. and Weisner, C.M. Medical and Psychiatric Conditions of Alcohol and Drug Treatment Patients in an HMO: Comparison to Matched Controls. Archives of Internal Medicine, 163(20), pp. 2511-2517, 2003.

Perceived Accessibility and Coordination of Service for Persons With Co-Occurring Substance Abuse and Mental Disorders

Several initiatives in the past 20 years have been implemented in Los Angeles County to improve service delivery across the mental health and substance abuse treatment systems, with the goal of increasing access to and coordination of services for individuals with co-occurring substance abuse and mental disorders. To examine the current status of service delivery to this population, a survey was conducted with administrators of mental health and substance abuse programs that provide services to dually diagnosed patients and with the treatment staff in those programs. Administrators (n = 15) and staff (n = 99) in substance abuse programs rated the accessibility and coordination of services to dually diagnosed patients significantly lower than the mental health administrators (n = 10) and staff (n = 136). Efforts to coordinate service delivery across the two systems need to address these divergent perceptions between staff in programs that are increasingly called upon to work together to jointly deliver services. Grella, C.E., Gil-Rivas, V. and Cooper, L.J. Perceptions of Mental Health and Substance Abuse Program Administrators and Staff on Service Delivery to Persons with Co-occurring Substance Abuse and Mental Disorders. Behavioral Health Services Research, 31(1), pp. 38-49, 2004.

Increased Prevalence of Psychiatric Illness Among Homeless, 1980-2000

Researchers examined the prevalence of psychiatric illness among 3 homeless populations in St. Louis, MO, in approximately 1980, 1990, and 2000. The prevalence of mood and substance use disorders and the number of minorities within these populations has increased over the two decades. Service systems need to be aware of potential prevalence changes, the increasing severity of their clientele's care needs and the growing health disparities that impact treatment service needs. North, C.S., Eyrich, K.M., Pollio, D.E. and Spitznagel, E. A Comparison of Psychiatric Prevalence of Homelessness Across Three Decades. American Journal of Public Health, 94(1), pp. 103-108, 2004.

HIV Testing For Homeless Women Indicated

This study describes the prevalence and predictors of HIV testing in a probability cluster sample of urban homeless women. Researchers analyzed data from the University of California Los Angeles-RAND Access to Health Care for Homeless Women of Reproductive Age Study, a survey conducted in six waves from January 1997 through November 1997 at shelters and soup kitchens in Los Angeles (LA) County. The sampling unit consists of homeless woman-visits, and data were collected using structured face-to-face interviews for which respondents were paid $10. Each sampling unit was weighted to account for the frequency with which respondents used shelters or meal programs. The main outcome measure was receipt of HIV test in the past year. With a response rate of 83%, the final sample size was 970. Sixty-eight percent reported receiving an HIV test in the past year, and 1.6% reported ever being diagnosed with HIV. HIV testing in the past year was most strongly associated with pregnancy in the past year and with having a regular source of care. Approximately 25% of homeless women with indications for HIV testing had not been tested in the past year. The reported HIV seroprevalence of greater than 1% suggests that providers should offer and encourage HIV testing for all homeless women in LA County. These data, which show a high rate of testing and few statistically significant independent predictors, indicate that this may be what is happening in practice. Herndon, B., Asch, S.M., Kilbourne, A.M., Wang, M., Lee, M., Wenzel, S.L., Andersen, R. and Gelberg, L. Prevalence and Predictors of HIV Testing Among a Probability Sample of Homeless Women in Los Angeles County. Public Health Rep., 118(3), pp. 261-269, 2003.

Posttraumatic Stress Disorder Among Minority Drug Users

This study explores cocaine abuse/dependence with physiological dependence and posttraumatic stress disorder diagnosis differences between out-of-treatment Hispanic and African American adults, in order to identify cultural differences in how experiences and attitudes affect cocaine use behaviors. Data was collected between February and November 2000, as part of a three-year longitudinal study. A cohort of 347 out-of-treatment, Hispanic and African American cocaine-using adults from the Houston metropolitan area were interviewed to measure differences between cocaine users who are dually diagnosed and those that are not. For the dual diagnoses categories, 102 (29%) participants met the requirements. Logistic regression models were used with age, race, gender, and income as the independent variables. Results indicate that individuals with higher income have a greater probability of developing a diagnosis. Results also indicate that being female increases the likelihood of developing both types of dual diagnoses. However, being an older female decreases the probability that an individual would develop these dual diagnoses. No differences were found for race/ethnicity among the dually diagnosed Hispanics and African Americans, however, gender differences were found. Treating high-risk substance abusers who are members of minority groups may require varied protocols depending on differences among minority groups. Montoya, I.D., Covarrubias, L.D., Patek, J.A., and Graves, J.A. Posttraumatic Stress Disorder among Hispanic and African-American Drug Users. American Journal of Drug and Alcohol Abuse, 29 (4), pp. 729-741, 2003.

HCV Antibody Testing in Drug-Free and Methadone Maintenance Treatment Programs

Drug treatment programs are uniquely situated to screen patients for antibodies for hepatitis C virus (HCV), an infectious disease that has reached epidemic proportions among drug users. The researchers compare the accessibility of and patients' use of opportunities for HCV antibody testing in a large sample of methadone and drug-free treatment programs (N=256) in the U.S. The researchers found that almost all methadone and about 2/3 of drug-free programs in the sample provided HCV antibody screening to at least some patients in 2001. While about 2/3 of the methadone and close to 1/3 of the drug-free programs offered this service to all patients, these programs report that only about 3/5 of their patients actually provided specimens for testing for HCV antibodies. These results can inform policymakers who advocate for increased HCV antibody screening in drug treatment programs about the current level and future plans for implementing these services, illuminating where resources and motivational efforts need to be targeted. Strauss, S.M., Astone, J.M., Des Jarlais, D.C. and Hagan, H. A Comparison of HCV Antibody Testing in Drug-free and Methadone Maintenance Treatment Programs in the United States. Drug and Alcohol Dependence, 73(3), pp. 227-236, 2004.

Self-Reported Health Status Among Treated Methamphetamine Users

Little research has examined how drug abuse is related to general health status over the long term among young and middle-aged adults. Researchers investigate how self-reported health status is related to prolonged methamphetamine (MA) use in a diverse sample of MA users from ages 18 to 52 who have been treated for drug abuse in Los Angeles County. Using retrospective data, the researchers investigated how prolonged MA use within younger and older age groups is related to two self-reported measures of current health status: the presence of a health condition that began after starting illegal drug use, and overall health. After controlling for the effects of drug use history, social and demographic factors, and other early experiences (e.g., early sexual abuse) that might be obstacles to achieving good health later in life. The researchers found that having a current health condition is predicted by greater age and by more prolonged MA use, especially among younger people. Early sexual abuse predicts both measures of poor health. Current health status is predicted by several measures of drug use history and early experiences, but by fewer social and demographic factors. The results suggest that reduction of MA use among younger people is important in promoting their later health and that MA treatment services could be improved by a greater understanding of how early experiences influence later health. Greenwell, L. and Brecht, M.L. Self-Reported Health Status among Treated Methamphetamine Users. American Journal of Drug and Alcohol Abuse, 29(1), pp. 75-104, 2003.

Trends of Criminal Activity and Substance Use in Welfare Recipients

The Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996 instituted a compulsory work mandate for welfare recipients. However, recipients who experience difficulties finding employment may increase their involvement in criminal activities and their frequency of substance use as a means to deal with changes precipitated by PRWORA. This study used a four-wave panel design to analyze the criminal behaviors and substance-use frequency of 534 welfare recipients in Houston, Texas. Data were collected from the Attitudes, Behaviors, and Skills Assessment (ABSA) instrument designed specifically for this study. Results show that a minority of welfare recipients were involved in criminal activity. Furthermore, although participants were losing their welfare benefits, both criminal activity and substance use declined over time. Brown, V.L., Montoya, I.D., Dayton-Shotts, C.A., Carroll-Curtis, T.L., and Riley, M.A. Trends of Criminal Activity and Substance Use in a Sample of Welfare Recipients. Crime and Delinquency, 50(1), pp. 6-23, 2004.

Predictors of Self-Reported HIV Infection Among Drug Injectors in Ukraine

The spread of HIV infection in Eastern Europe has been most intense in Ukraine where the number of cases has grown from 1,500 in 1994 to over 230,000 in 2002. Much of this rise in infection has been attributed to injection drug use. Researchers interviewed 212 IDUs (mean age = 29 years; 28% female) from Makeevka/Donetsk, Kiev, and Odessa. Responses indicated that 89% had injected drugs within the past 30 days, and that most respondents engaged in unsafe needle use. No gender differences were found. HIV positive respondents reported increased safe sex behavior, but were more likely to engage in unsafe needle use. Less than 25% reported receiving information about AIDS or risk reduction. Injection with others was common regardless of HIV status. Results suggest that HIV infection in Ukraine will continue to grow fueled to a large extent by unsafe injection drug use. Booth, R.E., Mikulich-Gilbertson, S.K., Brewster, J.T., Salomonsen-Sautek, S. and Semerik, O. Predictors of Self-Reported HIV Infection Among Drug Injectors in Ukraine. Epidemiology and Social Science, 35(1), pp. 82-88, 2004.

Screening and Assessing Youth for Drug Involvement

Inclusion of this new chapter in the handbook underscores a growing recognition that the adolescent assessment literature has a significant body of research on alcoholism and drug addiction. The chapter provides an overview of several issues pertinent to evaluating adolescents for AOD use and related problems. It is organized around four major themes: Developmental issues that highlight the importance of assessing young people from a theoretical perspective and with instruments that are distinct from adult models; validity of self-report; types of instruments available for a range of assessment goals; and research needs in the field. Winters, K.C. Screening and Assessing Youth for Drug Involvement. In J. Allen and M. Colombus (Eds.), NIAAA Handbook on Assessment Instruments for Alcohol Researchers (2nd edition). Rockville, MD: National Institute on Alcohol Abuse and Alcoholism, 2003.


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