Substance use disorders and treatment utilization among MDMA users: Results from The National Epidemiologic Survey on Alcohol and Related Conditions.

The study examined the prevalence and correlates of substance use disorders and treatment utilization among lifetime MDMA users. Secondary analyses were conducted on data from the 2001-2002 NESARC, a nationally representative survey of adults in the United States. Lifetime MDMA use was assessed, and MDMA users (n = 562) were compared to a matched sample of non-MDMA users. Substance use diagnoses were made using the AUDADIS - DSM-IV, and data on treatment utilization were collected. MDMA use was significantly related to lifetime and past year substance use disorders as well as treatment utilization in bivariate analyses. Multivariate analysis, however, showed that MDMA use was not related to lifetime substance use diagnosis or to treatment utilization. MDMA use still had the strongest association with past year substance use disorders.

An evaluation of drug treatments for adolescents in 4 US cities.

BACKGROUND: Little is known about outcomes of community-based treatment programs for adolescents with drug problems. METHODS: We studied 1167 adolescents (age range, 11-18 years; 368 females, 799 males) from 4 US cities (Pittsburgh, Pa; Minneapolis, Minn; Chicago, Ill; and Portland, Ore) using a naturalistic, nonexperimental evaluation design. These adolescents were consecutive admissions during the period from 1993 to 1995 at 23 community-based treatment programs in the Drug Abuse Treatment Outcome Studies for Adolescents. Included were 418 admissions to 8 residential programs, 292 admissions to 9 outpatient drug-free programs, and 457 admissions to 6 short-term inpatient programs. RESULTS: Adolescents in treatment typically had multiple problems (eg, 58.4% of them were involved in the legal system, and 63.0% met diagnostic criteria for a mental disorder). Nevertheless, less than half (43.8%) of all patients reported weekly marijuana use in the year following treatment (dropping from 80.4% in the year before admission). Similarly, there were decreases in heavy drinking (dropping from 33.8% to 20.3%), use of other illicit drugs (dropping from 48.0% to 42.2%), and criminal involvement (dropping from 75.6% to 52.8%). Additionally, patients reported better psychological adjustment and school performance after treatment. Longer stays in treatment were positively associated with several favorable outcomes, although length of time in treatment was generally short. CONCLUSIONS: Substance abuse treatment for adolescents is effective in achieving many important behavioral and psychological improvements. Strategies specific to adolescents to improve their treatment retention and completion are needed to maximize the therapeutic benefits of drug treatment.

Drug treatment outcomes for adolescents with comorbid mental and substance use disorders.

This study compared the pretreatment characteristics and posttreatment outcomes of substance-abusing adolescents with and without comorbid mental disorders in the Drug Abuse Treatment Outcome Studies for Adolescents. Subjects (N = 992) were sampled from 23 adolescent drug treatment programs across three modalities (residential, short-term inpatient, outpatient drug-free). Nearly two thirds (64%) of the sample had at least one comorbid mental disorder, most often conduct disorder. Comorbid youth were more likely to be drug or alcohol dependent and had more problems with family, school, and criminal involvement. Although comorbid youth reduced their drug use and other problem behaviors after treatment, they were more likely to use marijuana and hallucinogens, and to engage in illegal acts in the 12 months after treatment, as compared with the noncomorbid adolescents. Integrated treatment protocols need to be implemented within drug treatment programs in order to improve the outcomes of adolescents with comorbid substance use and mental disorders.

A 33-year follow-up of narcotics addicts.

BACKGROUND: This study examined longitudinal patterns of heroin use, other substance use, health, mental health, employment, criminal involvement, and mortality among heroin addicts. METHODS: The sample was composed of 581 male heroin addicts admitted to the California Civil Addict Program (CAP) during the years 1962 through 1964; CAP was a compulsory drug treatment program for heroin-dependent criminal offenders. This 33-year follow-up study updates information previously obtained from admission records and 2 face-to-face interviews conducted in 1974-1975 and 1985-1986; in 1996-1997, at the latest follow-up, 284 were dead and 242 were interviewed. RESULTS: In 1996-1997, the mean age of the 242 interviewed subjects was 57.4 years. Age, disability, years since first heroin use, and heavy alcohol use were significant correlates of mortality. Of the 242 interviewed subjects, 20.7% tested positive for heroin (with additional 9.5% urine refusal and 14.0% incarceration, for whom urinalyses were unavailable), 66.9% reported tobacco use, 22.1% were daily alcohol drinkers, and many reported illicit drug use (eg, past-year heroin use was 40.5%; marijuana, 35.5%; cocaine, 19.4%; crack, 10.3%; amphetamine, 11.6%). The group also reported high rates of health problems, mental health problems, and criminal justice system involvement. Long-term heroin abstinence was associated with less criminality, morbidity, psychological distress, and higher employment. CONCLUSIONS: While the number of deaths increased steadily over time, heroin use patterns were remarkably stable for the group as a whole. For some, heroin addiction has been a lifelong condition associated with severe health and social consequences.

Delivery of HIV risk-reduction services in drug treatment programs.

This study examined services received for HIV risk reduction among individuals in drug treatment. Analyses were conducted using data from 4,412 participants in the national Drug Abuse Treatment Outcome Study (DATOS), a prospective multisite study of drug treatment effectiveness. A higher percentage of individuals in long-term residential programs received HIV-related services, compared with clients in short-term inpatient, methadone maintenance, and outpatient drug-free programs. More men than women, and individuals at higher sex-risk as compared with those at lower sex-risk, received HIV services. Logistic regression analyses indicated that individuals who engaged in sex work had a higher likelihood than those who did not, of receiving HIV-related services, although individuals with high-risk or multiple sexual partners were no more likely than others to receive HIV services. More comprehensive service delivery is needed in order to reduce the risk for HIV among clients in drug treatment.

Program variation in treatment outcomes among women in residential drug treatment.

Multilevel modeling was used to assess the program characteristics associated with treatment retention among 637 women in 16 residential drug treatment programs in the Drug Abuse Treatment Outcome Study. Women who were pregnant or had dependent children had higher rates of retention in programs in which there were higher percentages of other such women. Longer retention was associated with higher rates of posttreatment abstinence. Bivariate analyses showed that programs with higher proportions of pregnant and parenting women provided more services related to women's needs. The findings support the provision of specialized services and programs for women in order to improve outcomes of drug abuse treatment.

Gender differences in drug treatment careers among clients in the national Drug Abuse Treatment Outcome Study.

Gender differences in the factors associated with having a history of drug treatment were examined among 7,652 individuals admitted into the Drug Abuse Treatment Outcome Study (DATOS), a national multisite prospective study. Bivariate relationships were examined between a history of prior drug treatment and variables measuring demographic and background characteristics, addiction career, treatment career parameters, family and social relationships, criminal justice involvement, and mental health status. Stepwise discriminant function analyses (DFAs) were conducted separately for men and women to determine both the common and unique characteristics associated with a history of prior drug treatment. More severe drug use history and criminal behavior were related to prior treatment history for both men and women. Prior drug treatment among men was associated with factors related to family opposition to drug use and support for treatment, whereas for women prior drug treatment was associated with antisocial personality disorder and self-initiation into treatment. Moreover, treatment initiation among men appears to be facilitated by social institutions, such as employment, the criminal justice system, and one's family. In contrast, treatment reentry among women was associated with referral by a social worker, suggesting that contact with family service agencies can facilitate women's treatment entry. The findings suggest that different strategies for increasing treatment utilization may be appropriate for men and women.

Characteristics of women-only and mixed-gender drug abuse treatment programs.

Specialized substance abuse treatment programs have been developed for women within the past two decades. This article presents the results of a secondary analysis of a regional database of drug abuse treatment programs that compared the characteristics of women-only (WO) and mixed-gender (MG) programs across three treatment modalities. In general, WO programs differed from MG programs in their policies regarding fees, sources of payment, special populations served, services offered, and treatment capacity, process, and duration. The differences in program characteristics reflect broader societal gender differences, including women's generally lower economic status and primary responsibility for child-rearing.

Women in residential drug treatment: differences by program type and pregnancy.

This study compared the characteristics of 4,117 women treated in publicly funded residential drug treatment programs in Los Angeles County between 1987 and 1994 by pregnancy status and program gender composition, that is, women-only and mixed-gender programs. A logistic regression analysis determined the predictors of program completion. Women in women-only programs were more likely than women in mixed-gender programs to be pregnant, homeless, or on probation; to use methamphetamines; to use alcohol; and have prior drug treatment. Pregnant women were younger, more likely to be homeless, had fewer years of drug use, were more often referred by other service providers, and were less likely to have injected drugs or have prior drug treatment than non-pregnant women. Although women in women-only programs had more problems, they spent more time in treatment and were more than twice as likely to complete treatment as compared with women in mixed-gender programs.

Prior treatment experience related to process and outcomes in DATOS.

Using data collected from cocaine-abusing patients who participated in the Drug Abuse Treatment Outcome Studies (DATOS), we contrasted patients in treatment for the first time and patients having extensive histories of prior treatment to identify factors associated with better outcomes in each group. Compared with first-timers, treatment-experienced patients had less favorable post-treatment outcomes. Indicators of early engagement in DATOS treatment predicted post-treatment abstinence for both groups. Importantly, the interaction of treatment history and several process measures affected post-treatment abstinence. For example, individual counseling and program compliance had greater impacts on abstinence among treatment repeaters in outpatient drug-free programs than for first-timers. Social support and environmental context were significantly related to abstinence. These findings confirm the importance of considering treatment process and aftercare in developing and implementing strategies to optimize treatment for patients with different treatment histories.

Patient histories, retention, and outcome models for younger and older adults in DATOS.

Structural equation modeling with multiple groups was used to examine relationships among pretreatment patient characteristics, treatment retention, and treatment outcomes among younger and older adults in the Drug Abuse Treatment Outcome Studies. Separate models were tested for 551 patients treated in long-term residential (LTR) programs and 571 patients treated in outpatient drug-free (ODF) programs. There was a stronger positive relationship between treatment retention and abstinence at follow-up for younger adults in both treatment modalities. Prior treatment history had a negative effect on self-efficacy to resist drug use for older adults in LTR. Negative reference group influence was reduced for all groups following treatment, however, it was more strongly related to abstinence for younger adults in LTR and for older adults in ODF. Clinical implications of age-related differences in these relationships are discussed.

Relationship of HIV testing and high-risk behaviors among clients in methadone maintenance treatment.

This article reports on the association between frequency of HIV testing and high-risk behaviors among 339 individuals in the Los Angeles Enhanced Methadone Maintenance Project. Individuals who reported taking three or more HIV tests prior to entering treatment (45% of the sample) were more likely to know someone who was HIV positive, to engage in illegal activity, to perceive their risk for HIV as high, and to use condoms; they were less likely to disinfect injection equipment; and they scored higher on measures of HIV knowledge and depression as compared with less frequent testers. The strongest predictor of frequent HIV testing (three or more tests) after treatment entry, reported by 43% of the sample, was having a high number of injection-sharing partners. Although a substantial number of individuals in methadone maintenance treatment continued to take HIV tests, test taking was more strongly related to high-risk injection behavior than to sexual behavior.

Consideration of special populations in the drug treatment system of a large metropolitan area.

This article provides a descriptive overview of the characteristics of a large metropolitan drug treatment system in relation to special populations of substance abusers enrolled in the system and the services provided. The findings are based on self-report responses to a comprehensive survey of 294 drug treatment programs in Los Angeles County. The special populations are grouped by health status, ethnic background, language needs, and gender-related needs. The groups are not mutually exclusive. Survey results indicated a generally high proportion of programs capable of meeting the unique needs of a variety of special population clients and most programs having some mix of special population clients in their current caseload. The types of services offered varied by modality and by special populations being served. Implications for program planning and service delivery include consideration of whether or not to offer specialized programs for unique client types.

Mental health and substance abuse treatment services for dually diagnosed clients: results of a statewide survey of county administrators.

Finding are presented from a survey of administrators of county departments of mental health and alcohol and drug programs in California regarding services for individuals with co-occurring mental and substance abuse disorders. A total of 47 counties responded (84% response rate). The survey findings indicate that collaboration across county mental health and alcohol and drug services primarily occurs through information sharing, coordination of services, and joint projects. Fewer than one-half of the counties responding provide integrated programs, and the most frequently provided services are outpatient counseling and case management. Administrators cited historical differences between the two service systems and societal stigma as the greatest barriers to service delivery. Two opposing strategies for state action were suggested, either establishing specific funding set-asides or blending funding for services. Counties varied widely in their ability to estimate unmet service needs. Implications for policy development related to the dually diagnosed are discussed.

A county survey of mental health services in drug treatment programs.

Forty-five administrators of drug treatment programs in Los Angeles County were surveyed about the adequacy of mental health services within their program and the drug treatment system. Approximately half agreed that dually diagnosed clients are not served within the system, and the majority noted that their programs restrict admission of such clients. Administrators of outpatient drug-free programs and methadone maintenance programs were more likely to characterize their mental health services as inadequate or unavailable than were administrators of other types of programs. The findings suggest the need to increase awareness of the treatment needs of dually diagnosed clients in drug treatment programs.

Patterns and predictors of cocaine and crack use by clients in standard and enhanced methadone maintenance treatment.

This paper reports on the patterns of cocaine use among subjects (N = 427) admitted to a methadone maintenance treatment demonstration project designed to reduce risk for HIV. Assessments were conducted at intake and at approximately 18-24 months after treatment admission. Self-reported data on cocaine use was compared with results of urinalysis tests at both intake and follow-up; 29 subjects who falsely reported no use were recorded as users. Over one-third used some form of cocaine at both intake and follow-up, while approximately 30% abstained at both points. Approximately 20% ceased as well as initiated cocaine use between intake and follow-up. Use of powder cocaine, either alone or combined with heroin in "speedballs," decreased at follow-up, whereas crack use increased. Discriminant function analyses were performed to determine the predictors of the different patterns of cocaine use by type. Receipt of enhanced methadone treatment compared with standard methadone treatment, treatment duration, or average duration of counselor contact appeared unrelated to cocaine use. Cocaine use at follow-up was associated with polydrug and alcohol use, illegal activity, a negative emotional state, and sex work. Crack users were more likely to be African American than nonusers; continuous users of powder cocaine were more likely to also be using heroin than were nonusers; and continuous speedball users were more likely to be women sex workers with high levels of depression. This analysis demonstrated that cessation or continuation of cocaine use after entry into methadone maintenance treatment is not uniform across different types of cocaine.

Services for perinatal women with substance abuse and mental health disorders: the unmet need.

Dual diagnosis refers to the co-occurrence of substance abuse and mental illness, which may take many forms. Women who abuse alcohol or drugs are more likely than men to be diagnosed with a psychiatric disorder, particularly depression or personality disorder. The interaction of pregnancy, addiction, and mental illness creates complex needs that often go unrecognized by treatment providers. Clinical issues concern adequate prenatal care, use of medications while pregnant and/or nursing, maternal bonding, and coordinated treatment planning among medical, addiction, and mental health treatment providers. Barriers to service delivery to perinatal substance-abusing women with a mental illness include the difficulty in diagnosing a dual disorder, child care and custody concerns, lack of health insurance or funds to pay for treatment, and the stigma associated with mental illness and addiction. Services currently available for the dually diagnosed are typically fragmented and uncoordinated and provision of those services is often hampered by philosophical differences, categorical funding, competition for scarce resources, inadequate staff training, and lack of a central administrative authority or mandate. Several models have been suggested that coordinate services for the dually diagnosed. Awareness of the service needs of dually-diagnosed perinatal women must be included within these models and integrated at all levels of the treatment system.

Background and overview of mental health and substance abuse treatment systems: meeting the needs of women who are pregnant or parenting.

Women with a psychiatric disorder who also abuse alcohol or other drugs have historically encountered barriers to integrated treatment for both disorders. Substance abuse treatment services and mental illness treatment services are usually organized independently of each other and few are designed to meet the needs of pregnant and parenting women. This chapter reviews the developmental histories of treatment systems for psychiatric and substance abuse disorders; the structural barriers that impede the delivery of services to individuals with co-occurring psychiatric and substance abuse disorders; the prevalence of dual disorders; issues related to diagnosis and assessment, types of diagnoses and addictions; treatment issues specific to women who are pregnant or parenting; models of service delivery; and initiatives directed at changing treatment systems.

What happens when a demonstration project ends. Consequences for a clinic and its clients.

The Los Angeles Enhanced Methadone Maintenance Project was a 5-year research demonstration project funded by the National Institute on Drug Abuse with the goal of reducing high-risk behavior for human immunodeficiency virus (HIV) among heroin users. A clinic was established for the purposes of the study and 500 clients with high-risk profiles were recruited into treatment. Follow-up assessments demonstrated that clients had reduced their drug use, criminal behavior, and HIV-risk behaviors after entering treatment. At the end of the project clients were given the option of continuing treatment at the clinic on a fee-for-service basis, transferring to another treatment provider, or undergoing detoxification. Clients who were eligible for Medicaid were likely to continue receiving methadone treatment, but those without Medicaid funding were not. The implications of terminating treatment among a high-risk population recruited into a research demonstration project are discussed.

HIV risk behaviors among women in methadone maintenance treatment.

This article reports on the HIV risk behaviors of a sample of 158 women heroin addicts admitted into the Los Angeles Enhanced Methadone Maintenance Project. Risk behaviors for HIV were associated with age, lack of education, ethnicity, relationship with a drug user, HIV status, and higher scores on measures of illegal activity, suicidality, depression, polydrug use, and alcohol use. Significant reductions in number of male sex partners and needle-sharing partners were reported at follow-up, although frequency of condom use was unchanged. Methadone maintenance programs need to screen women for risk factors and assist them in developing new behavioral skills in order to implement a harm reduction approach to treatment.