Measuring interstate variations in drug problems.

This article describes the Drug Problem Index (DPI), a composite index measuring the interstate severity of drug abuse problems. The DPI's components (drug-coded mortality, drug-defined arrest, and drug-treatment client rates) were selected because they were linked closely with drug abuse, data were available for all states, and there was published evidence of their validity. The variables were reliable, and their convergent validity was estimated in a multi-trait, multi-method matrix. We found evidence consistent with the DPI's construct validity in its relations with other consequences of drug abuse. The DPI correlated significantly with the Block Grant drug need index but not with model estimates of drug dependence based on the National Household Survey.

Statewide substance abuse prevention planning.

The State of Rhode Island contracted with the authors to prepare a statewide, comprehensive substance abuse prevention plan. The literature review revealed a lack of research on statewide planning for prevention services. To obtain data for Rhode Island's plan, the authors conducted a family of studies including synthetic estimation, key informant interviews, a telephone survey of agency directors, program budget analysis, construction of a statistical index for estimating the optimal geographic allocation of prevention dollars, and a review of General Laws regarding tobacco, alcohol, and other drugs. Their recommendations include the increased funding and coordination of prevention services, allocating services according to need rather than population size, greater use of social policy as a prevention tool, and a shift in primary prevention programming from senior high to lower grades and in program emphasis from information-education to psychosocial programs.

Implementation issues and techniques in randomized trials of outpatient psychosocial treatments for drug abusers. II. Clinical and administrative issues.

This paper focuses on implementation problems in randomized trials of outpatient psychosocial treatments for drug abusers. The authors examined these problems in nine clinical trial studies and drew on published literature and their own research experiences. Common problems faced by principal investigators include the need for midstream treatment protocol and research design modifications based on the response of both clients and clinical staff, tension between research and clinical requirements, and the need to administer a large, complex organization over a substantial period of time. Solutions include conducting a pilot study, employing advanced research and analysis methods that can incorporate complex design variations, fostering a team spirit between diverse staffs, and employing special management structures.

Implementation issues and techniques in randomized trials of outpatient psychosocial treatments for drug abusers: recruitment of subjects.

We reviewed nine randomized clinical trials of outpatient psychosocial treatments for drug abuse to ascertain implementation problems and solutions that the researchers developed. The most common problem was subject recruitment. Inadequate recruitment can disrupt a project's timetable, preoccupy its staff, reduce the trial's ability to detect treatment differences, and perhaps result in the trial's abandonment. The causes of recruitment problems include the need for large samples and multiple eligibility criteria, subject reluctance to be a "guinea pig," low client treatment motivation, client dislike of research procedures, clinicians' distrust of research, and difficulties collaborating with treatment agencies. Solutions include realistic assessment of the target population's size, use of mass media, statistical adjustments to minimize unnecessary sample exclusions, variable treatment assignment ratios, and prevention of common collaboration difficulties.

Assessment of drug abuser treatment needs in Rhode Island.

BACKGROUND: Rhode Island's Division of Substance Abuse asked us to assess the State's drug treatment needs and make recommendations regarding its treatment system for the next three years. METHODS: We used a statewide telephone drug use survey of 5,176 households supplemented by drug-related hospital discharges, Division of Drug Control statistics, and interviews with providers, state officials, and out-of-state experts. Drug abuse was measured with items from the Diagnostic Interview Schedule. Abusers were asked if they were receiving or wanted to receive treatment. RESULTS: Survey responses, used to estimate the unmet need for drug treatment, indicated a need to triple drug treatment services. Regression models using survey data indicated that the treatment network was overly centralized in the Providence area. Interviews with state officials, clinicians, and out-of-state experts provided material for recommendations on reimbursement policy, treatment mix, quality assurance, and cost containment. CONCLUSIONS: The RI Department of Health's certificate-of-need program adopted our overall recommendation for tripling the drug treatment system as its guideline in evaluating proposals for new treatment facilities. With State funding of a new adolescent center and expansion of outpatient slots in the private sector, this recommendation has now been fully implemented.

Alcohol use and abuse in random samples of physicians and medical students.

BACKGROUND: This study sought to resolve conflicting views about whether physicians are especially prone to alcohol abuse. METHODS: Using an anonymous, mailed questionnaire on substance use, we surveyed 500 physicians, 510 pharmacists, and 974 of their students. The physicians and pharmacists were selected randomly from the state society's membership lists, and students selected were from local school lists. Follow-up surveys were sent to nonresponders at two-week intervals. RESULTS: The physicians and medical students did not drink especially heavily and were no more vulnerable to alcoholism than were their counterparts in pharmacy and other professions. Physicians differed from pharmacists in their style of drinking (greater frequency, smaller quantity), but not in total amount of alcohol consumed. Drinking habits among physicians were not associated with medical specialty or type of practice, but were positively related to gender (males drank more than females) and to age (older doctors were more apt to qualify as heavy drinkers than were younger doctors). CONCLUSIONS: Physicians were no more likely to abuse substances nonmedically than were other professionals. Any group in which alcohol use is nearly universal incurs a risk of abuse and impairment that cannot be ignored.

Contributions to a social conditioning model of cocaine recovery.

This article describes recent developments in a theory of recovery from drug addiction and in the adaptation of Recovery Training and Self Help (RTSH) to cocaine addiction. RTSH is an example of a new element of treatment known as "relapse prevention" (RP), which is an application of the discovery that addiction follows the laws of operant conditioning. We learned, however, that to understand and to treat cocaine addiction, we had to expand upon the conditioning paradigm to include a sociological analysis of the deviant lifestyle from which cocaine addiction stems. The theory presented here postulates three stages of recovery from cocaine addiction. Cocaine addicts can recover as outpatients by (1) initially building "walls" against drug triggers and supplies, (2) extinguishing addiction in the protective community of recovering persons, and (3) gradually lowering the walls and expanding beyond the recovering community to function more fully in conventional society. We have developed an outpatient group treatment system based on this recovery model. The Cocaine Recovery System includes a month-long cessation program, followed by a six-month recovery program, and active participation in the recovering community. A professional and a recovering person colead both the cessation and recovery programs, which feature Recovery Training sessions designed to help cocaine addicts achieve treatment goals and avoid or cope with threats to recovery. Clients in the recovery program also meet weekly for a support session, a weekend recreational activity, and individual counseling. The program also encourages group members to attend 12-step fellowship meetings. Clients achieve difficult lifestyle changes by taking a series of "commitment steps," which increasingly engage the clients in a recovering lifestyle and make relapse more difficult.

A randomized controlled trial of recovery training and self-help for opioid addicts in New England and Hong Kong.

The efficacy of a group relapse prevention program, Recovery Training and Self-help (RTSH), was investigated experimentally with opioid addicts in New England and Hong Kong. The experimental program featured weekly attendance at a professionally led recovery-training session, a peer-led self-help style meeting and a weekend recreational activity. Researchers randomly assigned newly recovering opioid addicts (N = 168) to experimental and control conditions, and followed them to assess their outcomes; 98% provided follow-up data. The intervention significantly reduced the probability and extent of relapse and helped unemployed subjects find work. RTSH also significantly reduced self-reported criminality. These findings suggest that relapse prevention programs can be effective in helping opioid addicts achieve long-term recovery.

Health care policy issues in the drug abuser treatment field.

As we enter the 1990s drug abuse has once again become a major health concern, and for the first time the drug treatment field has had to address many of the policy, regulation, and planning issues resulting from cost inflation that have become commonplace in other parts of the health care field. To avoid serious errors and confusion, drug abuse health policies must recognize the very different needs of the public and private sectors. The public sector, where poor addicts receive drug treatment provided or purchased by the government, has long suffered from chronically inadequate funding. Although responses to several epidemics (heroin, crack, and AIDS) have produced periods of increased allocations for drug abuse treatment, more often than not long waiting lists at programs have rationed treatment to lower-income addicts seeking care. Low salary levels have limited the quality of public treatment services, and the absence of resources has hindered the development of programs that respond to new technical developments and drug abuse problems, such as the crack epidemic. Despite severe resource shortages, the public drug treatment system has sometimes used resources inefficiently, with little attention to appropriateness of admissions, lengths of stay, ambulatory treatment modalities, or varying levels of care. Public sector goals for the 1990s should include filling current shortages in drug treatment services, developing adequate long-term funding for treating addicts who lack third-party coverage, modernizing the treatment system, developing new patterns of practice that use existing resources more efficiently, and developing a plan for treating intravenous drug users infected with the AIDS virus. In the private sector, the advent of working- and middle-class demand for drug treatment in the 1970s and 1980s has produced a new drug treatment system that suffers from many of the policy problems common to the rest of health care. Drug abuse in the workplace has resulted in much wider coverage of substance abuse services by insurance companies and HMOs. The availability of third-party funds has spawned a for-profit chemical dependency treatment industry. The high cost of private residential treatment services has caused significant cost inflation. Cost-containment measures, which are a new phenomenon for this field and are inappropriate for the public sector, have led to the same confusion and debates that they have produced in other areas of health care.(ABSTRACT TRUNCATED AT 400 WORDS)

Risk factors of drug impairment in random samples of physicians and medical students.

The prevalence of hypothesized risk factors of drug impairment is estimated and correlated with drug use in random samples of physicians and medical students. Substantial percentages of both physicians and medical students reported access to drugs, family histories of substance abuse, stress at work and home, emotional problems, and sensation seeking. Each of these factors correlated with drug use in physicians or medical students, and analysis suggested that in most cases the hypothesized risk factors were more likely to be causes rather than consequences of drug use.

Use and abuse of controlled substances by pharmacists and pharmacy students.

The use of controlled substances by samples of pharmacists and pharmacy students in one New England state was surveyed. A questionnaire was sent in November 1984 to a sample of 510 pharmacists randomly selected from the membership list of the state's pharmaceutical association and to a sample of 470 students from the state's pharmacy schools; 76% and 67% of the eligible pharmacists and students responded, respectively. The questionnaire elicited information about the respondents' use of controlled substances for self-treatment and recreation, as well as the instrumental use of stimulants to enhance performance. Almost half of the pharmacists (46%) and two thirds of the students (62%) reported using a controlled substance at some time without a prescription; 19% and 41%, respectively, used one within the past year. Whereas students used the drugs most often for recreation (57% ever, 36% currently), use by pharmacists was more equally divided among self-treatment (29% ever, 13% currently), recreation (29% ever, 9% currently), and instrumental purposes (21% ever). The drugs most often used were marijuana, stimulants (especially cocaine by students), tranquilizers, and opiates. Drug use was generally limited in amount, but 18% of the pharmacists and 35% of the students who ever used a drug either became dependent or were at risk of drug abuse. Current drug use was most strongly associated with age, non-attendance at religious services, student access, year in school, and citizenship. The findings of this study suggest the need for continued development of impaired pharmacist committees and drug abuse prevention programs for pharmacists and pharmacy students.

Psychoactive drug use among practicing physicians and medical students.

We surveyed random samples of 500 practicing physicians and 504 medical students in a New England state during 1984-1985; 70 percent of the physicians and 79 percent of the students responded. Fifty-nine percent of the physicians and 78 percent of the students reported that they had used psychoactive drugs at some time in their lives. In both groups, recreational use most often involved marijuana and cocaine, and self-treatment most often involved tranquilizers and opiates. In the previous year, 25 percent of the physicians had treated themselves with a psychoactive drug, and 10 percent had used one recreationally. Although most of the use was experimental or infrequent, 10 percent of the physicians reported current regular drug use (once a month or more often) and 3 percent had histories of drug dependence. More physicians and medical students had used psychoactive drugs at some time than had comparable samples of pharmacists and pharmacy students. The results suggest a need for renewed professional education about the risks of drug misuse.

Recovery training and self help: a relapse-prevention program for treated opiate addicts.

Recovery Training and Self Help (RTSH) is a new form of psychosocial treatment for drug addiction. Developed as an outpatient group aftercare modality for opiate addicts in New England and Hong Kong, it significantly reduced the probability of relapse to illicit opiates and helped unemployed subjects find work. Based on a social theory of addiction and health promotion principles, the four-part program features a weekly recovery training session, a weekly self-help style session, weekend recreational and social activities, and a support network of long-term ex-addicts. Recovery training follows a 26 week sequence of didactic presentations and exercises that systematically address predictable causes of relapse, while the other clinical components provide motivation and support for continued abstinence and social reintegration. The authors believe that RTSH should have a wide range of applicability.

Nontherapeutic opiate addiction in health professionals: a new form of impairment.

Case studies describe a new type of addicted health professional whose opiate abuse originated recreationally . Historically, health professionals have had high rates of opiate addiction, usually viewed as an occupational hazard stemming from access and from self-treatment for pain or stresses of the medical profession. Partly because addiction in health professionals was almost always therapeutic (iatrogenic) or quasi-therapeutic (stress-related), it affected them less severely than it affected heroin addicts, whose drug abuse usually began recreationally . Now, however, because recreational drug abuse has become commonplace at American colleges since the mid-1960s, a majority of young health professionals have histories of abusing drugs and some are becoming non-therapeutically addicted. Six case studies describe this new addict type, showing how the subjects went from heavy soft drug use to opiate addiction, experienced severe longterm effects, were treated by society, and responded to treatment.

Alcohol, substance use, and other risk-factors of impairment in a sample of physicians-in-training.

This article examines survey data on alcohol and drug use, stress and other risk factors of impairment in nonclinical samples of physicians and medical students. Previously unpublished data on a sample of physicians-in-training showed they were healthy nonsmokers, experiencing many feelings of job stress, but were generally light drinkers and suffered few adverse effects of drinking. Young physicians and medical students were not very different from comparable non-physician populations in their use of recreational and therapeutic drugs, although the medical professionals had slightly below average use rates. Regression analyses found that recreational drug use and drinking stemmed mainly from sensation seeking, whereas therapeutic drug use was stress-related.