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National Institute on Drug Abuse

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

September, 2000

Research Findings

Services Research

Use of Antiretroviral Therapies by HIV-Infected Persons Receiving Methadone Maintenance

HIV-infected persons receiving methadone maintenance must often seek medical care at a separate site. This study examined the relationship of attitudes and beliefs about antiretroviral therapy (ART) on the decision to initiate ART among those referred off-site. HIV-infected injection drug users (n = 72) were interviewed at three methadone maintenance programs. Of those with CD4 cell counts under 500, 83% reported that they had received ART. Of these persons, 56% had used three-drug combination therapy. Beliefs about the benefits of ART included increased survival (96%), decreased viral load (87%), decreased HIV-related infections (87%), cure for HIV (29%). Physician input, CD4 count, and possible side effects were more important than friends, family, or mass media for patients who had decided to start ART. The off-site referral model for HIV care did not appear to impede access to ART for HIV-infected IDUs in methadone maintenance. Stein, M.D., Urdaneta, M.E., Clarke, J., Maksad, J., Sobota, M., Hanna, L., and Markson L.E. J Addict Dis., 19(1), pp. 85-94, 2000.

Drug Abuse, Methadone Treatment, and Health Services Use Among Injection Drug Users with AIDS

Health care use by injection drug users (IDUs) with AIDS were analyzed for methadone maintenance treatment (MMT) patients using AIDS surveillance and Medicaid health care claims data. Consistent participation in MMT was associated with a higher probability of antiretroviral use and, among antiretroviral recipients, more consistent use of antiretrovirals. Consistent MMT was more likely among women, whites, and older subjects. For AIDS-infected IDUs, consistent MMT may lower barriers to receipt of appropriate HIV-related health care and reinforce adherence to medical recommendations. Monthly total expenditures and inpatient expenditures were significantly lower for IDUs in MMT than for IDUs with claims indicative of current drug abuse. Sambamoorthi, U., Warner, L.A., Crystal, S., Walkup, J. Drug Alcohol Depend, 60(1), pp. 77-89, 2000.

Effect of Ongoing Illicit Drug Use on Adherence to Antiretroviral Therapy Among HIV-Infected Methadone Patients

HIV seropositive methadone maintenance patients receiving antiretroviral therapy had HIV RNA testing and were surveyed regarding their adherence to their treatment regimens. Adherence was measured using self-report on 4 questions relating to medication use in the last day and last month and whether the patient took "drug holidays." Over half (52%) of the patients were receiving 2-drug antiretroviral therapy and 48% were receiving triple therapy that included a protease inhibitor. Persons on triple therapy reported higher rates of adherence on all measures and were more likely to have undetectable HIV RNA levels than persons on dual therapy (60% vs. 50%). Ongoing illicit drug injection was the only factor significantly associated with multiple measure nonadherence; however, it was not associated with undetectable HIV RNA level. Levels of nonadherence were comparable to estimates from other chronic diseases. This finding has important implications for patients receiving highly active antiretroviral therapy. Stein, M.D., Rich, J.D., Maksad, J., Chen, M.H., Hu, P., Sobota, M., and Clarke, J. Am J Drug Alcohol Abuse, 26(2), pp. 195-205, 2000.

Substance Misuse and Related Infectious Diseases in a Soup Kitchen Population

Representative samples of female (N = 119) and male (N = 100) guests at two inner city soup kitchens were interviewed. By hair analysis, 75% tested positive for cocaine/crack and 25% tested positive for heroin/opiates. Only 25% of guests were in substance dependency treatment. Infectious disease rates were: 16% HIV seropositive, 21% hepatitis B exposure, 6% hepatitis B carrier, and 15% syphilis exposure. Years of injecting drug use and homelessness or marginal housing were associated with HIV infection and hepatitis B exposure. Soup kitchens should be prime locations for outreach to cocaine/crack and heroin users in need of treatment, medical care, and interventions to prevent infectious disease transmission. Magura, S., Nwakeze, P.C., Rosenblum, A., Joseph, H. Subst Use Misuse, 35(4), pp. 551-583, 2000.

Predictors of Relapse after Treatment for Methamphetamine Use

Using a natural history approach to interview patients treated for methamphetamine use in publicly-funded Los Angeles County programs in 1995-1997, treatment utilization and outcomes as well as relapse to drug use were studied. Results showed that in the 2 to 3 years following treatment, half of the subjects had resumed methamphetamine use, 36% within six months of the end of treatment, and 15% more within seven to 19 months. Shorter time to relapse was predicted by shorter length of treatment, older age of first substance use, involvement in selling methamphetamine, ethnicity (being Hispanic), and a higher number of prior treatment episodes. Brecht, M.L., von Mayrhauser, C., Anglin, M.D. J Psychoactive Drugs, 32(2), pp. 211-220, 2000.

Illicit Drug Use and Emergency Room Utilization

The relationship between chronic illicit drug use and emergency room (ER) utilization was studied using data from the 1994 National Household Survey on Drug Abuse. A two-stage estimation technique was used to identify chronic drug users (CDUs) and to test for the possibility of endogeneity bias in the estimation of ER utilization. After adjustments for bias, it was estimated that chronic drug use increased the probability of using an ER by more than 30 percent compared to casual users or non-drug-users. McGeary, K.A., French, M.T. Health Serv Res, 35(1), pp. 153-169, 2000.

Multisystemic Therapy, Monitoring Treatment Fidelity

The importance of insuring the fidelity of implementation of a specific intervention, multisystemic therapy (MST), was examined in relation to patient outcomes in a sample of youth treated for drug abuse. Relations between therapist adherence to MST principles and instrumental and ultimate outcome variables were also examined, as were relations between clinical supervision and therapist adherence. The findings provide modest support for the associations between MST adherence measures and instrumental and ultimate outcomes. Results also show that adherence can be altered when clinical supervision and adherence monitoring procedures are fortified. The modest associations between adherence measures and outcomes argue for further refinement and validation of the MST adherence measure, especially in light of the well-established effectiveness of MST with challenging clinical populations and the increasing dissemination of MST programs. Schoenwald, S.K., Henggeler, S.W., Brondino, M.J., and Rowland, M.D. Fam Process, 39(1), pp. 83-103, 2000.

Demographic, Individual, and Interpersonal Predictors of Adolescent Alcohol and Marijuana Use Following Treatment

A vulnerability model of adolescent substance abuse treatment outcome provided the basis for investigating demographic, individual, interpersonal, and treatment factors to predict the follow-up use of alcohol and marijuana in a sample of adolescents (N = 225) with psychoactive substance use disorders. Pretreatment levels of sibling substance use and aftercare participation predicted alcohol and marijuana use during the first 6 months posttreatment. Pretreatment levels of deviant behavior also predicted the use of marijuana at 6-month follow-up. Peer substance use at intake and 6-month posttreatment both predicted substance use frequency outcomes at 12-month follow-up. Alcohol and marijuana use frequencies at 6-month follow-up also predicted continued use for these substances throughout the remainder of the 1st posttreatment year. Shorter treatment length and being male were risk factors for alcohol use during the 2nd half of the 1st posttreatment year. Elevated psychological substance dependence at 6-month follow-up was a unique risk factor for subsequent marijuana use. Latimer, W.W., Winters, K.C., Stinchfield, R., and Traver, R.E. Psychol Addict Behav, 14(2), 162-173, 2000.

The Effectiveness of the Minnesota Model Approach in the Treatment of Adolescent Drug Abusers

Outcomes of drug-abusing adolescents treated with a 12-Step "Minnesota Model" approach (inpatient and outpatient) were examined at 6 and 12 months post-treatment among three groups of adolescents: those who completed treatment, those who did not, and those on a waiting list. Subjects were 245 clinic-referred adolescents (12-18 years old) who met at least one DSM-III-R substance dependence disorder. Analyzed from both relative and absolute perspectives, it was found that completing treatment was associated with far superior outcome compared to either not completing or not receiving treatment. In the year after treatment, 53% of treatment completers reported either abstinence or a minor lapse, compared to 15% for the non-completers and 28% for the waiting list group. Favorable drug abuse treatment outcomes were about two to three times more likely if treatment was completed. There were no outcome differences between residential and outpatient groups. Alcohol was the most common drug used during the follow-up period, despite cannabis being the preferred drug at intake. Winters, K.C., Stinchfield, R.D., Opland, E., Weller, C., and Latimer, W.W. Addiction, 95(4), pp. 601-612, 2000.

Managed Care and Unmet Need for Mental Health and Substance Abuse Care

Unmet needs were analyzed in the 1998 Health Care for the Communities national survey. Need for help with emotional, mental health, alcohol, or drug problems was reported by 1,059 privately insured individuals during the past 12 months. Of those, 12% reported receiving little care or delayed care and 9.5% reported receiving no care. Enrollment in a managed care program did not predict differences in self-reported unmet need. The rate of unmet need associated with no care was lower under managed care, but the rate for less care or delayed care was higher. Sturm, R., and Sherbourne, C.D. Psychiatric Services, 51(2), p. 177, 2000.

Trends in Psychiatric Care Expenditures and Length of Stay in Industrial Countries

International trends in inpatient psychiatric care and length of stay were examined from 1980 to 1995 using data from the Organization for Economic Cooperation and Development. Psychiatric care as a proportion of total inpatient expenditures was found to have a strong downward trend. The average length of stay for mental health and substance abuse disorders showed a small increase in Australia and Switzerland, while the U.S. and the Netherlands had a small decrease. The international phenomena of decreasing inpatient expenditures for psychiatric disorders may result from treatment advances such as medications that reduce the need for inpatient care. Sturm, R., and Bao, Y. Psychiatric Services, 51(3), p. 295, 2000.

The Impact of Prior Authorization on Outpatient Utilization in Managed Behavioral Health Plans

The effect of preauthorization on outpatient behavioral health utilization under managed care was examined by comparing plans with similar benefits, but differing in the number of visits authorized. Plans primarily authorizing in increments of 5 visits were compared to plans authorizing in increments of 10 visits. The likelihood of terminating outpatient service between the two groups was analyzed using conditional logistic regression. Results suggest that patients whose treatment is authorized in increments of 5 sessions are nearly 3 times more likely to terminate treatment at exactly the fifth visit than if their treatment is authorized in increments of 10 sessions conditional on being in treatment until the 5th visit. The likelihood of termination peaks in both the 5- and 10-session authorization at the 10th visit, but the difference is not statistically significant. The authorization effect differs by provider type and is weaker among psychiatrists than among nonphysician providers. Liu, X., Sturm, R., and Cuffel, B.J. Med Care Res Rev, 57(2), pp. 182-195, 2000.

Services Provided During Methadone Treatment, A Gender Comparison

Greater improvement in post-treatment outcomes has been shown in programs that tailor frequency and type of services to unique client needs. Using a sample of 635 clients (199 females and 436 males) admitted to three community-based methadone treatment programs, this study examined gender differences in services needed and provided during the first 3 months of treatment. Results revealed that compared to males, women entered treatment with more psychological symptoms and AIDS/HIV-risky behaviors. They also presented with less criminal activity, less alcohol use, and higher motivation. Counselors addressed psychological and crisis issues more frequently with women, and counseling strategies were more often directed toward developing problem-solving and communication skills. Counselors also made more medical referrals and reported having better rapport with females. Attention to employment issues and HIV/AIDS sexual-risk behaviors did not differ by gender, even though women had more needs in these areas. Rowan-Szal, G.A., Chatham, L.R., Joe, G.W., and Simpson, D.D. Journal of Substance Abuse Treatment, 19(1), pp. 7-14, 2000.

Abstinent-Contingent Housing and Treatment Retention Among Crack-Cocaine-Dependent Homeless

Attendance in Behavioral Day Treatment was studied with regard to treatment outcome among homeless persons dependent on crack-cocaine. Participants (N = 141) were 72.3% male and 82.7% African American. Days attended, activities attended, and follow-up rates over a 12-month period were positively affected by the more attractive treatment of providing immediate, rent-free, abstinent-contingent housing during a 2-month Behavioral Day Treatment program. Results replicated previous findings that abstinence is a function of treatment attendance and more treatment is associated with greater abstinence. Analytical techniques used in this study allow for the planning, predictability, and measurement of drug abuse treatment success as a function of service utilization. Schumacher, J.E., Usdan, S., Milby, J.B., Wallace, D., and McNamara, C. J of Substance Abuse Treatment, 19(1), pp. 81-88, 2000.

Depression Among Needle Exchange Program and Methadone Mintenance Cients

The prevalence of major depression was compared in two cohorts of injection drug users in Rhode Island, those enrolled in a methadone maintenance treatment program (MMTP) and those enrolled in a needle exchange program (NEP). Symptomatic and duration criteria for major depression in the last 6 months were identified using the Structured Clinical Interview for DSM-III-R. Among 528 persons interviewed, 54% of those in NEP and 42% of those in MMTP met criteria for major depression. Women (odds ratio [OR] 2.5, 95% confidence interval [CI] 1.7-3.7), persons with alcohol use disorders (OR 1.7, 95% CI 1.1-2.7), and persons without a current partner (OR 1.8, 95% CI 1.2-2.6) were more likely to be depressed. Persons enrolled in MMTP were less likely to be depressed (OR 0.6, 95% CI 0.4-0.8) than NEP. Higher rates of depression were found among NEP attendees than among those enrolled in MMTP. Mental health referrals should be part of the growing number of needle exchanges in the United States. Brienza, R.S., Stein, M.D., Chen, M., Gogineni, A., Sobota, M., Maksad, J., Hu, P., and Clarke, J. J Subst Abuse Treat,18(4), pp. 331-337, 2000.

Effectiveness of Communication and Relationship Skills Training For Men in Substance Abuse Treatment

Although the importance of gender-sensitive programming for women has been acknowledged, few studies have examined outcomes from male-centered interventions in substance abuse treatment programs. Data were collected from 122 male clients in a court-mandated residential treatment program who participated in a study of a psychoeducational group intervention for men. The intervention (Time Out! For Men) addressed communication skills, sexuality, gender socialization, and intimacy. Participation in the training resulted in significant increases in knowledge and social conformity, along with reductions in attitudes that may be associated with rigid socialization and gender-role conflict. The results provide support for the utility of male targeted programming in substance abuse treatment settings. Bartholomew, N.G., Hiller, M.L., Knight, K., Nucatola, D.C., Simpson, D.D. J Subst Abuse Treat,18(3), pp. 217-225, 2000.

Chronic Illicit Drug Use, Health Services Utilization and the Cost of Medical Care

Differences in health services utilization and the cost of medical care were studied for chronic drug users (CDUs), chronic injecting drug users (IDUs), and non-drug users (NDUs) in a community-based (out of treatment) sample. Annual differences between CDUs, IDUs, and NDUs were estimated for three measures: number of times admitted to a hospital, number of outpatient visits, and number of emergency room episodes. CDUs and IDUs were found to consume significantly more inpatient and emergency care, but less outpatient services relative to NDUs. Analyses of total health care costs showed that CDUs and IDUs each generated about $1000 in excess services utilization per individual relative to NDUs. This research is the first study to compare differences in health services utilization and cost among out-of-treatment drug users relative to a matched group of non-users in a community-based setting. Strategies are needed that promote more ambulatory care and discourage emergency room and inpatient care among drug users. French, M.T., McGeary, K.A., Chitwood, D.D., and McCoy, C.B. Soc Sci Med, 50(12), pp. 1703-1713, 2000.

Why Carve Out? Determinants of Behavioral Health Contracting Choice Among Large U.S. Employers

Many U.S. employers have carved substance abuse and mental health services out of their medical plans. Under carve-outs, employers contract directly with specialized vendors, bypassing their general health plans. This study tested hypotheses about why purchasers carve out using data from a survey of America's Fortune 500 firms. Size was the strongest predictor of an employer's decision to carve out behavioral health once other characteristics are controlled for. Firms that value coordination are less likely to carve out, while those that value special expertise are more likely to carve out. Firms are less likely to carve out enrollees in health maintenance organizations (HMOs) than those in other types of plans. Hodgkin, D., Horgan, C.M., Garnick, D.W., Merrick, E.L., and Goldin, D. J Behav Health Serv Res, 27(2), pp.178-193, 2000.

Recovery Challenges Among Dually Diagnosed Individuals

Mental health and substance abuse service integration is relatively recent and often poorly implemented despite a high incidence of co-occurring mental and substance abuse disorders, and despite evidence for the benefits of integrated treatment services for dually diagnosed persons. Moreover, service providers and clients often hold divergent views of what constitutes appropriate and feasible treatment goals. This study interviewed an urban sample of dually diagnosed members of self-help groups (N = 310) concerning the challenges confronting them in their recovery, and the interrelations of these issues. The findings suggest that most clients struggle with emotional and socioeconomic issues which bear significantly on their ability to adequately handle other aspects of recovery. Laudet, A.B., Magura, S., Vogel, H.S., and Knight, E. Journal of Substance Abuse Treatment, 18(4), pp. 321-329, 2000.

Contrasts Between Admitters and Deniers of Drug Use

This study evaluated the agreement between self-reported drug use and urinalysis results in 232 male and 27 female opiate-dependent patients at 2, 7, and 24 months following admission to methadone maintenance treatment. Differences between deniers (those who stated no drug use but whose urinalysis results were positive) and admitters of drug use were compared on psychosocial variables, and degree of Axis I and II psychopathy were examined. Generally, more drug use was acknowledged by self-report than found in urinalyses. Evidence was limited that deniers were consistently different than admitters. However, a significant increase was found for deniers in psychopathy ratings if interview and collateral information was used, compared to use only of interview information. Rutherford, M.J., Cacciola, J.S., Alterman, A.I., McKay, J.R., and Cook, T.G. Journal of Substance Abuse Treatment, 18(4), pp. 343-348, 2000.

Initiating Abstinence in Cocaine Abusing Dually Diagnosed Homeless Persons

The effectiveness of behavioral day treatment plus abstinence contingent housing and work therapy (DT+) was compared to behavioral day treatment alone (DT). A randomized controlled trial assessed participants at baseline, 2 and 6 months. Participants met criteria for cocaine abuse or dependence, non-psychotic mental disorders, and homelessness. DT+ achieved greater abstinence at 2 and 6 months and more days housed at 6 months than DT. Effectiveness of DT+ was demonstrated, with greatest impacts on abstinence outcomes. Results replicated earlier work demonstrating effectiveness of behavioral day treatment and contingency management as an effective combination for cocaine abusing homeless persons. Milby, J.B., Schumacher, J.E., McNamara, C., Wallace, D., Usdan, S., McGill, T., and Michael, M. Drug and Alcohol Dependence, 60(1), pp. 55-67, 2000.

Adolescent Amphetamine Users in Treatment, Client Profiles and Treatment Outcomes

The characteristics of adolescent amphetamine users admitted to residential therapeutic community treatment across the eastern United States and Canada 1992-1994 were examined. Amphetamine using adolescents were likely to be white, older, and have parents with higher education and occupational levels than nonusers. However, they also had more psychopathology, more extensive drug use and criminal histories, and engaged in more HIV-risk behaviors than nonusers. Additionally, amphetamine users tend to come from homes where one or both parents used illicit drugs, drank regularly, or had a mental illness, and they often reported histories of childhood maltreatment. At one-year follow-up, being an amphetamine user did not predict differences in treatment outcome after the client's demographic characteristics, overall drug use severity, and treatment completion were taken into account. Hawke, J.M., Jainchill, N., and De Leon, G. J Psychoactive Drugs, 32(1), pp. 95-105, 2000.

Adolescents in Therapeutic Communities, One-Year Posttreatment Outcomes

One-year post-treatment status was examined for 485 adolescents who had been in residential therapeutic communities (TCs). The majority of the sample had been mandated to treatment by the criminal or juvenile justice system. Most reported marijuana as the main drug of abuse. One year after treatment, there were significant reductions in drug use and criminal activity. The most consistent predictors of positive outcomes were completion of treatment and not associating with deviant peers post-treatment. Jainchill, N., Hawke, J., De Leon, G., Yagelka, J. J Psychoactive Drugs, 32(1), pp. 81-94, 2000.

Three-year Outcomes of Therapeutic Community Treatment for Drug-involved Offenders in Delaware

Dr. Inciardi and his colleagues at the University of Delaware note that researchers have argued for a continuum of primary (in prison), secondary (work release), and tertiary (aftercare) therapeutic community (TC) treatment for drug-involved offenders. Previous work has demonstrated significant reductions in relapse and recidivism for offenders who received primary and secondary TC treatment up to 1 year after leaving work release. However much of the effect declines significantly when the time at risk moves to 3 years after release. Further analyses reveal that program effects remain significant when their continuum model takes into account not simply exposure to the TC program, but, more importantly, program participation, program completion, and aftercare. Their outcome data clearly show that clients who complete secondary treatment do better than those with no treatment or program dropouts, and those who receive aftercare do even better in remaining drug- and arrest-free. Martin, S.S., Butzin, C.A., Saum, C.A., and Inciardi, J.A. Three-year Outcomes of Therapeutic Community Treatment for Drug-involved Offenders in Delaware: From Prison to Work Release to Aftercare. The Prison Journal, 79(3), pp. 294-320, 1999.

Do Stronger Linkages Promote Client Utilization of Medical and Psychosocial Services in Drug Abuse Treatment?

The relationship between various linkage mechanisms (on-site delivery, external arrangements, case management, and transportation assistance) and utilization of medical and psychosocial services in outpatient drug abuse treatment units was examined using data from a national survey of administrative directors and clinical supervisors in 597 outpatient drug abuse treatment units. Models were created to analyze the correlation of on-site service delivery, external arrangements (joint program/venture or contract), case management, and transportation with patient utilization of eight services: physical examinations, routine medical care, tuberculosis screening, HIV treatment, mental health care, employment counseling, housing assistance, and financial counseling services. On-site service delivery and transportation assistance were significantly associated with higher levels of client utilization of ancillary services. Referral agreements and formal arrangements had no detectable relationship to most service utilization. On-site case management was related to increased clients use of routine medical care, financial counseling, and housing assistance, but off-site case management was not correlated with utilization of most services. Conclusions were that on-site delivery appears to be the most reliable mechanism to link drug abuse treatment clients to ancillary services, while referral agreements and formal external mechanisms offer little detectable advantage over ad hoc referral. On site case management might facilitate utilization of some services, but transportation seems a more important linkage mechanism overall. Friedmann, P.D., D'Aunno, T.A., Jin, L., and Alexander, J.A. HSR, 35(2), pp. 443-466, 2000.

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