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Director's Report to the National Advisory Council on Drug Abuse
September, 1995

Research Findings

Treatment and Services Research

Treatment Research

Depression in Substance Dependent Adolescents:

Although depression is common among youths diagnosed with a Substance Use Disorder (SUD), the relationship among these two disorders is still unclear. To address this question, 99 delinquent boys, ages 13-19 years, admitted to a residential drug treatment program, were administered the adolescent form of the Comprehensive Addiction Severity Index, the Diagnostic Interview Schedule for Children, and Children's Depression Rating Scale-Revised. Results indicated that depressed boys received more Substance Dependence diagnoses than did the non-depressed boys (4.2 versus 3.0; p<.008), with differences most significant for amphetamines and opioids. However, depressed boys did not report initiating or regularly using drugs at an earlier age. Depression preceded regular drug use in 43% of the cases while regular drug use preceded or was concurrent with depression in 48% of the cases (9% did not report). The findings lend modest support to clinical reports that in those cases where signs of depression precede substance abuse, the boys may have used psychoactive substances to relieve their dysphoric feelings or more severe depressive symptomatology. (Riggs, P.D., Baker, S., Young, S.E., and Crowley, T.J. J Am Acad Child Adolesc Psychiatry, in press).

Methadone Treatment: Behavioral/Pharmacological Variables:

This study examined sexual and drug use behavior in 247 methadone maintenance patients, to explore the association of cocaine use with HIV risk behavior. In univariate analysis, cocaine use was positively associated with any drug injection, number of injections, and sexual intercourse without condoms. These relationships remained significant after controlling for other drug use and demographic factors. Heroin use also contributed to injection-related risk. It is concluded that cocaine use represents a continued source of risk for exposure to HIV in this population, and that more aggressive efforts are warranted to reduce illicit drug use, particularly of heroin and cocaine, in methadone patients. (Bux, D.A., Lamb, R.J., and Iguchi, M.Y. Cocaine Use and HIV Risk Behavior in Methadone Maintenance Patients. Drug and Alcohol Dependence, 1995, 37, 29-35).

Behavioral-Pharmacological Treatments to Reduce Drug Abuse and HIV Spread:

Intensive HIV counseling and testing programs were established at the outset of this research to examine the interrelation between abused drugs, treatment factors, medications, and consequent HIV risk behaviors. Data on HIV risk behaviors, and HIV rates were accumulated. These data indicated that lower behavioral risk was found in HIV negative cocaine users with higher levels of depressive symptomatology, and further, that the HIV negative users were more anxious than the HIV positive matched controls. The data also indicate that women report more HIV risk behaviors than men, regardless of HIV status or primary drug of dependence (heroin or cocaine). Overall, drug use, as measured by twice weekly drug screens, was not found to differ as a direct function of HIV status or primary drug of abuse. (Presented at the 57th Annual Meeting of the College on Problems of Drug Dependence, June 10-15, 1995 in Scottsdale, Arizona).

Behavior Therapy for Antisocial Opioid Abusers:

Antisocial personality is commonly detected in drug abusers, where the diagnosis is associated with a poor prognosis and increased risk of HIV transmission. In a controlled clinical trial to improve treatment outcome of antisocial opioid abusers in methadone substitution therapy, subjects were randomly assigned to either an experimental group, which incorporates a 9-step contingency management approach for reducing drug use, or a control group. Each step, in the experimental group, rapidly conveys greater or less control to patients over major aspects of treatment (e.g., number of counseling sessions, methadone dose levels) based on urine results from the prior 2-weeks. Significant outcome differences were found favoring the experimental treatment. This group had a lower rate of urine specimens positive for any substance, including opioids and cocaine. The control group also selfreported an increased severity of drug use over time. Preliminary results support the viability of reducing drug use in antisocial opioid abusers with a structured behavioral intervention using positive and negative contingencies delivered in a timely manner. (Presented at the 57th Annual Meeting of the College on Problems of Drug Dependence, June 10-15, 1995 in Scottsdale, Arizona).

Pharmacological Treatment of Intravenous Drug Abuse

This project is looking at the most effective parameters for methadone treatment delivery, which is known to be an important HIV risk-reduction intervention. In this study the dose-related efficacy of methadone treatment was clearly demonstrated, with the highest dose tested producing the best results on all outcome measures. HIV risk behavior (i.v. drug use in particular) was shown to be inversely related to methadone dose with higher doses producing more risk reduction. In addition to conducting important controlled research that should result in improving HIV risk reduction outcomes for methadone treatment, the project has offered HIV testing, counseling and risk reduction education to over 400 opioid-dependent patients since its inception. (Strain, E.C., Stitzer, M.L., Leibson, I.A., and Bigelow, G.E. Outcome After Methadone Treatment: Influence of Prior Treatment Factors and Current Treatment Status. Drug and Alcohol Dependence, 1994, (35), 223-30).

Services Research

Treatment Services in Two National Studies of Community-Based Drug Abuse Treatment Programs.

Recently published findings suggest that drug abuse treatment programs have eroded over the past decade in terms of their ability to meet the service needs of their clients, at a time when these needs are increasing due to such factors as increasing prevalence of cocaine use, psychological problems, AIDS and other infectious diseases, and unemployment among clients.

Two national studies conducted a decade apart document a striking decline over time in the kinds of services received during treatment: the Treatment Outcome Prospective Study (TOPS) based on clients admitted to treatment during 1979-81, and the Drug Abuse Treatment Outcome Study (DATOS), based on treatment admissions 1991-93. The TOPS sample was drawn from 41 programs, and the DATOS from 99 programs. Clients in the TOPS and DATOS samples were interviewed 3 months after treatment entry and asked whether they had received services in specific problem areas similar to those (other than substance abuse) in the Addiction Severity Index (ASI): medical, psychological, family, legal, educational, vocational and financial services. A comparison of the studies indicates statistically significant declines in many of the services received by clients in the later study. The percentage having received no services (other than substance abuse counseling) in the 3 month period were:

  • in DATOS, 65% of methadone clients (vs. 49% in TOPS);
  • 23% of long-term residential clients (vs. 7% in TOPS);
  • 60% of drug-free outpatient clients (vs. 18% in TOPS).

Most commonly reported services were medical, psychological, and family. TOPS vs. DATOS comparisons of medical services showed statistically significant declines in methadone clients (33% vs. 27%) and long-term residential clients (78% vs. 55%), while drug-free outpatient clients' reports of such services were not significantly different (25% vs. 23%). Similar comparisons for psychological services showed more pronounced declines in methadone clients (16% vs. 3%), long-term residential (58% vs. 13%) and outpatient drug-free (67% vs. 9%). For family services, declines among methadone clients (9% vs. 2%), drug-free residential (33% vs. 20%), and outpatient drug-free (43% vs. 8%) were noted. With the exception of medical services for outpatient drug-free clients, all differences reported were significant beyond the .01 level.

Assessment of unmet needs was accomplished by identifying percentages of clients across programs in each modality who reported that they needed but did not receive a service during the first 3 months of treatment. Within and across modalities, the percentage reporting unmet service needs increased considerably, and by statisticaly significant amounts, over the period from TOPS to DATOS. The percentages with unmet needs increased for:

  • medical services from 18% to 40% among methadone clients, 6% to 25% in drug-free residential, and 9% to 32% in drug-free outpatient programs and

  • psychological services increased from 19% to 54% in methadone programs,10% to 57% in drug free residential, and 7% to 57% in outpatient drug free programs.

The general pattern of services provided and unmet needs suggest that programs have access to fewer services and resources with which to meet needs than was the case a decade earlier. The apparent trend that emerges from the data is cause for concern about the drug abuse treatment system nationwide. Additional data on programs is being collected to further clarify and elaborate on the observations reported here. Published in R. M. Etheridge, S.G. Craddock, G.H. Dunteman, and R.L. Hubbard (1995) "Treatment Services in Two National Studies of Community-Based Drug Abuse Treatment Programs," Journal of Substance Abuse 7, 9-26

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