Association of MDMA/ecstasy and other substance use with self-reported sexually transmitted diseases among college-aged adults: a national study.

OBJECTIVES: MDMA/ecstasy use among college students has increased and reportedly leads to risky sexual behaviours. However, little is known about its association with sexually transmitted diseases (STDs). To evaluate this public health concern, this study examined the association between substance use (particularly MDMA) and self-reported STDs (chlamydia, gonorrhoea, herpes and syphilis) among college students and non-students aged 18-22 years (n=20,858). STUDY DESIGN: A cross-sectional data analysis of a national survey. METHODS: Data were drawn from the 2005-2006 National Surveys on Drug Use and Health; a nationally representative survey of non-institutionalized Americans. Self-reported STDs and substance use were assessed by the audio computer-assisted self-interviewing method. The association between MDMA use and STDs was determined while taking into account young adults' use of other substances, healthcare utilization and sociodemographic characteristics. RESULTS: Overall, 2.1% of college students and 2.5% of non-students reported contracting an STD in the past year. MDMA use in the past year was not associated with STDs. Among non-students, onset of MDMA use before 18 years of age increased the odds of past-year STDs. In both groups, alcohol use, marijuana use, female gender and African American race increased the odds of both past-year and lifetime STDs. Additional analyses indicated that, regardless of college-attending status, greater odds of past-year STDs were noted among users of alcohol and drugs, and users of alcohol alone, but not among users of drugs alone. CONCLUSIONS: Alcohol use is a robust correlate of STDs. Irrespective of college-attending status, young women and African Americans have a higher rate of STDs than young men and Whites.

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.

Conceptualizing and assessing treatment structure and process in community-based drug dependency treatment programs.

Having established the effectiveness of drug dependency treatment, the next generation of research will necessitate a focus on treatment structure and process and the systems within which programs operate. As a foundation for a process conceptualization, we constructed a grounded theory definition of treatment consisting of core elements and related comprehensive services. We then presented the multilevel conceptual framework that guided the Drug Abuse Treatment Outcome Study (DATOS) treatment structure and process study design and instrumentation, anchored by supporting empirical literature. The framework emphasizes seven critical levels of process measurement that future research should consider in order to avoid potential spurious findings.

Drug abuse treatment outcome study of adolescents: a comparison of client characteristics and pretreatment behaviors in three treatment modalities.

OBJECTIVES: The present study presents background and pretreatment characteristics of adolescent substance abuse treatment clients, and it provides a mechanism for describing perhaps the largest research sample of adolescents who were in drug treatment in this decade. METHODS: The sample was 3382 subjects who presented for treatment from 1993 to 1995 in 37 programs in Pittsburgh. Pennsylvania: Miami, Florida; Minneapolis, Minnesota; Chicago, Illinois; Portland, Maine; and New York City, New York. Informed permission for the youth to participate was obtained from the subject's custodial parent/guardian, and both the youth and the youth's parents or guardians provided informed assent if they agreed to participate as subjects. Adolescents then were interviewed privately and confidentially by a trained professional interviewer who was independent of the treatment programs. The interviews queried subjects about their background, including education and employment; physical and mental health; use of tobacco, alcohol, and other drugs; sexual experiences; legal problems: religious beliefs; and treatment experience. RESULTS: The long-term residential treatment modality was the least gender balanced of the modalities and had the most African-American and Hispanic clients. This modality was distinguished by the proportion of clients who were referred to treatment by the juvenile or criminal justice system. Compared with other clients in other modalities, short-term inpatient clients were more likely to be female and white. Inpatient clients also reported more indicators of psychiatric impairment. Outpatient clients were slightly younger than clients in the other modalities, and more of them were attending school at the time of admission to treatment. Outpatient clients had the least criminally involved lifestyles, their rates of (regular daily or weekly) drug use were also the lowest of the three modalities for all drugs assessed, and they had the least drug treatment experience. CONCLUSIONS: These results merit several recommendations. One is the need for more community-based adolescent substance abuse treatment programs. An additional recommendation is for more substance abuse treatment programs in facilities that serve incarcerated youth. Finally, and perhaps most critically, it is recommended that programs be designed to address such specialized issues as comorbid substance abuse and psychiatric problems, family dysfunction, physical and sexual abuse, gender and ethnic differences, and academic performance.

A national evaluation of treatment outcomes for cocaine dependence.

BACKGROUND: This national study focused on posttreatment outcomes of community treatments of cocaine dependence. Relapse to weekly (or more frequent) cocaine use in the first year after discharge from 3 major treatment modalities was examined in relation to patient problem severity at admission to the treatment program and length of stay. METHODS: We studied 1605 cocaine-dependent patients from 11 cities located throughout the United States using a naturalistic, nonexperimental evaluation design. They were sequentially admitted from November 1991 to December 1993 to 55 community-based treatment programs in the national Drug Abuse Treatment Outcome Studies. Included were 542 patients admitted to 19 long-term residential programs, 458 patients admitted to 24 outpatient drug-free programs, and 605 patients admitted to 12 short-term inpatient programs. RESULTS: Of 1605 patients, 377 (23.5%) reported weekly cocaine use in the year following treatment (dropping from 73.1% in the year before admission). An additional 18.0% had returned to another drug treatment program. Higher severity of patient problems at program intake and shorter stays in treatment (<90 days) were related to higher cocaine relapse rates. CONCLUSIONS: Patients with the most severe problems were more likely to enter long-term residential programs, and better outcomes were reported by those treated 90 days or longer. Dimensions of psychosocial problem severity and length of stay are, therefore, important considerations in the treatment of cocaine dependence. Cocaine relapse rates for patients with few problems at program intake were most favorable across all treatment conditions, but better outcomes for patients with medium- to high-level problems were dependent on longer treatment stays.

The relationship of counseling and self-help participation to patient outcomes in DATOS.

Using a sample of 927 cocaine patients enrolled in programs in three modalities included in the national Drug Abuse Treatment Outcome Studies (DATOS), this investigation examined the relationship of three dimensions of treatment process on after-treatment cocaine and heavy alcohol use and predatory illegal activity. Logistic regression revealed significant reductions in all three outcomes and strong effects of treatment duration and after-treatment self-help, conditional on the modality. Results did not support the hypothesized relationship between treatment outcomes and amounts of counseling and during-treatment self-help. Findings support the robustness of duration effects and after-treatment self-help and contribute to the measurement methodology for calibrating treatment intensity. The strong after-treatment self-help effect in the two residential and inpatient modalities suggests these programs can improve treatment outcomes by making referral to after-treatment self-help participation a standard practice and installing mechanisms to increase the likelihood of attendance at least twice weekly during the year after treatment.

Costs and benefits of treatment for cocaine addiction in DATOS.

Our objective was to examine the cost of long-term residential (LTR) and outpatient drug-free (ODF) treatments for cocaine-dependent patients participating in the Drug Abuse Treatment Outcome Studies (DATOS), calculate the tangible cost of crime to society, and determine treatment benefits. Subjects were 502 cocaine-dependent patients selected from a national and naturalistic nonexperimental evaluation of community-based treatment. Financial data were available for programs from 10 US cities where the subjects received treatment between 1991 and 1993. Treatment costs were estimated from the 1992 National Drug Abuse Treatment Unit Survey (NDATUS), and tangible costs of crime were estimated from reports of illegal acts committed before, during, and after treatment. Sensitivity analyses examined results for three methods of estimating the costs of crime and cost-benefit ratios. Results showed that cocaine-dependent patients treated in both LTR and ODF programs had reductions in costs of crime from before to after treatment. LTR patients had the highest levels and costs of crime before treatment, had the greatest amount of crime cost reductions in the year after treatment, and yielded the greatest net benefits. Cost-benefit ratios for both treatment modalities provided evidence of significant returns on treatment investments for cocaine addiction.

Characteristics and pretreatment behaviors of clients entering drug abuse treatment: 1969 to 1993.

This study summarizes historical changes among clients entering drug treatment in their sociodemographic characteristics and important pretreatment behaviors, such as work activity, criminal behavior, drug use, prior drug treatment, and health insurance. Data are drawn from three major studies of drug abuse treatment clients: the Drug Abuse Reporting Program (DARP), 1969-1972; the Treatment Outcome Prospective Study (TOPS), 1979-1981; and the Drug Abuse Treatment Outcome Study (DATOS), 1991-1993. The mix of drug treatment clients and their interaction with the drug treatment system changed substantially over the past three decades. Because data items are most directly comparable between TOPS and DATOS, the focus of this paper is on changes within the past decade. The most conspicuous change is in types and numbers of drugs used by clients entering treatment. Multiple drug use declined since the late 1970s, while reports of cocaine use since TOPS more than doubled among clients in the long-term residential and outpatient treatment modalities, and increased 1 1/2 times among methadone clients. Other differences in treatment populations include decreases in clients' working full-time and in reports of suicidal ideation and attempts and predatory crime. Data from such studies as DARP, TOPS, and DATOS are valuable in historical, contextual, policy, and evaluative frameworks. The changing nature of the drug treatment client population--from sociodemographics to drug use and multiple treatment problem severities--highlights the complexity of issues and difficulties encountered by those attempting to treat clients or plan treatment strategies.

Measuring program performance in methadone treatment using in-treatment outcomes: an illustration.

Quality measurement and quality assurance in substance abuse treatment have, over the past few years, become a major policy issue. In addition, there is interest in the degree to which client outcomes can play a role in measuring treatment program performance. This article discusses the movement toward outcome-based performance measurement in substance abuse treatment. Examples of the products that such a performance measurement system might produce are provided. Why outcomes must be case-mix adjusted is discussed. In addition, using data from 18 methadone programs and more than 2,000 methadone clients from the Treatment Outcome Prospective Study, an illustration of case-mix-adjusted performance measurement is provided.

Quality of alcohol use histories collected at intake to substance user treatment.

Many survey questions on alcohol require complex cognitive tasks, such as long-term recall, shifting reference periods, and numeric calculation. Moreover, alcohol-related impairment is known to affect cognitive ability. To assess the quality of data on self-reported alcohol use, internal consistency analyses were conducted as part of a comprehensive multisite prospective study of drug user treatment outcome undertaken in 11 cities throughout the United States (DATOS). Contrary to expectation, analyses found high levels of internal consistency. For questions on age of initiation of different types of alcohol use, over 99% of respondents (N = 2,842) reported consistent answers for each pair of logically related questions. Reports of being drunk and of quantity of alcohol consumed were similarly consistent.

Relationship between drug preference and indicators of psychiatric impairment.

This study was conducted to investigate the relationship between the indicators of psychiatric disorders of individuals and their choice of either cocaine or heroin, drugs that differ markedly in their pharmacological effects. Cocaine acts as an intense stimulant, and heroin has profound sedative effects. This investigation examined the relationship between preference for heroin or cocaine and indicators of psychiatric impairment. Data from 282 subjects were grouped according to drug of choice and analyzed. Ninety-three percent of these subjects were African-American, 32% were female, and the average age was 34. Univariate and multivariate statistical analyses, such as discriminant analyses, were used to determine group differences. The results are evaluated and interpreted in relation to both the current empirical findings and to the hypotheses and theories postulated as a result of earlier clinical observations on drug of choice and psychopathology. Discriminant analysis yielded an overall correct classification rate of 75%. The discriminant function suggests that members in the cocaine drug of choice group as contrasted with members in the heroin preference group can be characterized as more socially inhibited and more self-defeating after adjusting for differences in age, duration of use of illicit substances, and marital status. Those who favored cocaine as contrasted with those who favored heroin were more likely to have never married, be younger, and have used illicit substances for a shorter period of time.

Individual Assessment Profile (IAP). Standardizing the assessment of substance abusers.

The Individual Assessment Profile (IAP), a structured intake assessment interview instrument in the public domain, was designed for use with substance-abusing populations in several large-scale and community-based drug abuse treatment projects underway in the United States. Background information is presented, including the content-based item-selection process used during the pretests and pilot testing. Validity and test-retest reliability data are also presented, along with descriptions of studies using the IAP for clinical, research, and management information purposes. Concordance between biological measures and self-reports of recent drug use, measures of internal consistency, and test-retest reliability coefficients were generally good. A computer-assisted personal interview version of the IAP and an automated reporting system were subsequently developed for clinical and management reporting purposes and used in a large-scale research demonstration project. An intreatment version of the IAP has also been developed to collect information on treatment services provided and to assess changes in behaviors after 3, 6, and 12 months of treatment. These instruments (the IAP intake and intreatment interviews) provide a comprehensive system to assess substance-abusing populations.

Treatment services in two national studies of community-based drug abuse treatment programs.

Findings from a number of sources over the past decade have documented a decline in the resources available for drug abuse treatment and the services being provided to clients in community-based drug abuse treatment programs. We compared client reports of services received and unmet service needs in a national crossmodality sample of clients in two studies of drug abuse treatment: the Treatment Outcome Prospective Study (TOPS), 1979-1981, and the Drug Abuse Treatment Outcome Study (DATOS), 1991-1993. Findings showed a marked decrease over the past decade in the number and variety of services clients reported receiving. Most striking was the large increase in self-reported unmet service needs in the DATOS investigation. Although most clients reported having received at least some sessions of drug abuse counseling during treatment and the level of satisfaction with treatment and services was generally high across modalities, client reports indicated that drug abuse counseling alone did not address their wider ranging service needs. Programs in the methadone modality generally reflected the lowest level of drug abuse counseling and services.

Parental history of substance abuse as a risk factor in predicting crack smokers' substance use, illegal activities, and psychiatric status.

The purpose of this investigation was to determine if parental substance abuse places children at a higher risk regarding their own substance abuse, illegal activities, and psychological functioning. An intake assessment was conducted with 299 crack smokers currently undergoing treatment. It revealed that clients with a parental history of substance abuse were at over twice the risk for antisocial personality disorders, had been arrested significantly more times as an adult, were more likely to report illicit drug use in the past year, and had received prior treatment more often than clients without a parental history of substance abuse. Surprisingly, no relationship was observed between parental history of substance abuse and preadult behaviors including age-of-onset of drug use, childhood conduct disorders, age at first antisocial behavior, or number of arrests before age 18. Future prevention and treatment efforts with similar populations should recognize the strong influence of the family in the development of substance abuse.

Comparative cocaine abuse treatment strategies: enhancing client retention and treatment exposure.

The current investigation explores the clinical utility in providing a series of enhanced clinical services to a sample of 303 cocaine-abusing clients (primarily crack smokers) relative to a standard group therapy treatment program. In addition to examining the comparative impact of six varying psychosocial treatment approaches for cocaine abuse on client retention and treatment exposure rates, an additional emphasis has been to examine the ability of fixed and dynamic client variables in predicting client outcome in this regard. No fixed (e.g., sex, income, marital status, income level, or employment status) or dynamic (e.g., recent alcohol use, antisocial personality disorder diagnoses, or motivational variables) client characteristics were useful in predicting client retention or treatment exposure rates. Program characteristics, however, or the frequency, intensity, and/or type of treatment services offered, were related to client retention and treatment exposure. Treatment exposure and retention were significantly enhanced by providing clients with more frequent and intensive group therapy, or by adding individual treatment services to a standard group therapy treatment regimen. With a population such as cocaine abusers, who typically have an extremely high treatment dropout rate, an obvious strategy is to focus efforts on engaging and retaining clients in treatment, and maximizing levels of treatment exposure. The current findings suggest that one successful approach towards enhancing psychosocial treatments for cocaine abuse is to increase the frequency, intensity, and/or types of treatment services offered.

Relationship between time spent in treatment and client outcomes from therapeutic communities.

Research found that therapeutic communities and other types of residential programs are effective in reducing drug use, unemployment, and criminal behavior and that length of time spent in treatment is an important predictor of client outcomes from programs. Studies vary considerably, however, in terms of the amount of time they found clients need to stay in treatment to produce those outcomes. Data collected for the Treatment Outcome Prospective Study (TOPS) were analyzed to explore the relationship between time spent in treatment and client outcomes from therapeutic communities and other types of residential drug treatment programs. The analysis took into account client characteristics and whether clients received drug treatment during the follow-up year. The results indicate there is a stronger relationship between time spent in treatment and client outcomes from therapeutic communities than was suggested in earlier analysis of TOPS data.

The effects of time in drug abuse treatment and employment on posttreatment drug use and criminal activity.

The impact of length of stay in drug abuse treatment on follow-up drug use and criminal behavior has important clinical and policy implications. In this paper we use longitudinal data from the Treatment Outcome Prospective Study to estimate the simultaneous effects of time in treatment and employment outcomes--weeks worked and total earnings--on posttreatment drug use and criminal activity. The drug use/criminal activity variables include four indexes measuring the severity of use, drug-related problems, predatory illegal acts, and overall criminal behavior. The results show that time in treatment had a negative and statistically significant impact on these outcome variables for every modality with residential clients experiencing the largest relative impact. The time-in-treatment effect was robust even when employment outcomes were modeled jointly with drug use and criminal activity outcomes. These findings highlight the importance of length of stay in treatment in the recovery and rehabilitation of drug abusers.

Effects of drug misuse treatment on symptoms of depression and suicide.

In this longitudinal study of 9,904 clients who were treated at methadone, outpatient drug-free (OPDF), and residential treatment facilities, at intake more than half of all clients reported symptoms of depression or suicide. Females and multiple nonnarcotics users were at highest risk for suicide attempts. Despite a dramatic drop in the level of symptomatology by 4 weeks in treatment, many clients remained suicidal throughout the study period. Suicidal tendencies at both intake and 4 weeks were strongly related to suicidal tendencies at 12 months post-treatment; even more strongly related was the return to weekly or more frequent use of narcotics or nonnarcotics for residential and OPDF clients.