Substance use and the puzzle of adherence.

AIDS: The issues of HIV resistance and its relation to patient adherence to treatment are discussed. Non-compliance or misuse of combination therapy fears are usually directed at a single group, substance abusers. There are differences in the availability and use of HIV treatment by race, gender, and injection drug use status. Those most affected by injection-drug-related HIV disease, and thus from treatment, are Hispanics and African-Americans. Complying with HIV drug treatment regimens can be difficult but it is important since non-adherence to drug therapy, once started, can develop a new strain of HIV that may be resistant to a particular antiviral drug. Unfortunately, twelve years of studies have found non-adherence to be the norm in general medical treatment. Many reasons exist, including the patient's decision to non-comply. Researchers have found that while short-term adherence can be increased with some simple actions, long-term compliance is more difficult and labor intensive. To help long-term compliance, practitioners must understand their patients' belief systems, deliver accurate information to influence beliefs, and in cases when competing demands are compelling, help to reduce distractions. For injection drug users, withdrawal is the chief distraction, and addressing that distraction is a primary negative influence on adherence. Since research cannot identify who will or will not adhere, it is suggested that generic judgments be avoided and HIV treatment be available to all in need.^ieng

An introduction to ethnic and cultural diversity.

Ethnic and cultural diversity are important determinants of alcohol and drug use patterns and consequences. Cultural differences constitute proximal determinants of alcoholism and imply certain differences in attitudes, values, and perceptual constructs as a result of different culturally based experiences. Thus, all children and adolescents are not equal clinically; transcultural communication is necessary for effective identification, diagnosis, and management of substance use disorders. Health status antecedents to, and consequences of, substance use disorders in ethnic groups of color are examined. Drinking is explored in biological, cultural, and social contexts.

Interventions/Wilmer: a continuum of care for substance abusers in the criminal justice system.

This article describes a 300-bed substance abuse treatment program that is part of a continuum of care focused on preventing drug and criminal recidivism in substance abusing criminals incarcerated in Dallas County, Texas. It is the product of a joint effort of the judiciary, the Dallas County Supervision and Corrections Department, the State of Texas Criminal Justice Division, and Interventions Co., a not-for-profit treatment provider. The program is rooted in over 25 years of treatment experience and incorporates therapeutic community (TC) technology combined with 12-Step programming, behavior modification, job training (having a job is required for graduation), educational, and medical/psychiatric elements. Treatment is conceived as part of a continuum of care to provide substantial and sustained support for the inmate in the difficult process of adapting to the community post incarceration. Treatment plans are individualized and are based on an extended workup in which the individual's status in a number of domains is assessed. Specialized services, such as transportation and childcare, facilitate recovery. Once in the community, urine monitoring, groups, and counseling continue. The program is beginning its fourth year of operation and approximately 600 inmates have started the program. A formal evaluation is in process.

Alcoholism in the family. A multicultural exploration.

The initial focus is on defining race, culture, and ethnicity, followed by a review of the extent of alcohol and alcohol use consequences among African-Americans and Native Americans. Cultural specificity in an historical context is provided. A brief overview of gaps in the incident and prevalence data is presented. The biosociocultural context of drinking among African-American women with specific emphasis on cultural disruption, socialization, and social class is explored. A triracial infant girl (African-American/Native American/German-Irish-American), whose family genogram documents, by the case study method, six generations back to slavery, is presented. The alcohol use patterns within this family are somewhat illustrative of historical patterns and of racial and ethnic import. An absence of religiosity/spirituality is noted. The family genogram is followed by a discussion of the limitations of the case study method of family genograms. The final section relates the findings of the family genogram back to the extant data and the gaps in the collection of data regarding the epidemiology of alcoholism across groups. It highlights the recent findings and questions raised by those findings from cross-cultural and racial studies of alcoholism among women of color.

Medical maintenance: an interim report.

In a pilot study, 130 methadone maintained subjects with a six-month history of good treatment performance were assigned randomly, for a one-year study period, to an experimental condition (once per month non-random urine screen, counseling session and doctor visit, two times per month methadone pick up, a quarterly true random urine screen, and participation in a diversion control program), or they were assigned to a control condition of staying under standard conditions for six months and then being transferred to the experimental condition for six months. Three out of four subjects (73%) completed the year in good standing with no differences between control and experimental conditions. Subject satisfaction was such that the Institutional Review Board judged that return to standard conditions would be a hardship. A Study of Medical Maintenance (SMM) continues and extends the pilot study with two protocols: (1) for new subjects and (2) for subjects entered from the pilot study. SMM requires a once per month random urine screen and extends the experimental condition to two years but is otherwise identical to the pilot study; 71 of 107 S's (66%) entered protocol 1 and are in good standing. Pilot subjects (N = 75) are holding their good performance, some for over four years. The reduced levels of services in these studies free up resources which can be applied to entering IDU's into treatment thereby contributing to a slowing of the HIV epidemic.

Medical maintenance: a pilot study.

In a one year study, 130 methadone maintained subjects with a six month history of good treatment performance were assigned randomly to an experimental condition of one monthly non-random urine screen, one monthly counseling session, one monthly doctor visit, two times per month methadone pick up, a quarterly true random urine screen and participation in a diversion control program or to a control condition of staying under standard conditions for six months and then being transferred to the experimental condition for six months. Results of urine screens and scores on the Addiction Severity Index (ASI) at entrance and six month intervals showed no differences between groups. Three out of four subjects completed the year in good standing. Subject satisfaction was such that the IRB judged that return to standard conditions would be a hardship. Experimental conditions were cheaper such that resources freed up could be applied to the HIV epidemic.