The impact of illicit drug use and substance abuse treatment on adherence to HAART.

High levels of adherence to highly active antiretroviral therapy (HAART) are essential for virologic suppression and longer survival in patients with HIV. We examined the effects of substance abuse treatment, current versus former substance use, and hazardous/binge drinking on adherence to HAART. During 2003, 659 HIV patients on HAART in primary care were interviewed. Adherence was defined as > or =95% adherence to all antiretroviral medications. Current substance users used illicit drugs and/or hazardous/binge drinking within the past six months, while former users had not used substances for at least six months. Logistic regression analyses of adherence to HAART included demographic, clinical and substance abuse variables. Sixty-seven percent of the sample reported 95% adherence or greater. However, current users (60%) were significantly less likely to be adherent than former (68%) or never users (77%). In multivariate analysis, former users in substance abuse treatment were as adherent to HAART as never users (Adjusted Odds Ratio (AOR)=0.82; p>0.5). In contrast, former users who had not received recent substance abuse treatment were significantly less adherent than never users (AOR=0.61; p=0.05). Current substance users were significantly less adherent than never users, regardless of substance abuse treatment (p<0.01). Substance abuse treatment interacts with current versus former drug use status to affect adherence to HAART. Substance abuse treatment may improve HAART adherence for former substance users.

Addressing lesbian, gay, bisexual, and transgender issues from the inside: one federal agency's approach.

The mission of the Substance Abuse and Mental Health Services Administration (SAMHSA) is to protect and serve underserved and vulnerable populations. Congress established SAMHSA under Public Law 102-321 on October 1, 1992, to strengthen the nation's health care capacity to provide prevention, diagnosis, and treatment services for substance abuse and mental illnesses. SAMHSA works in partnership with states, communities, and private organizations to address the needs of people with substance abuse and mental illnesses as well as the community risk factors that contribute to these illnesses. As part of its efforts to address the unique needs of special populations, SAMHSA has reached out to the lesbian, gay, bisexual, and transgender (LGBT) community. SAMHSA and its centers (Center for Substance Abuse Treatment, Center for Substance Abuse Prevention, and Center for Mental Health Services) have made a concerted effort, through both policy and programs, to develop services responsive to this community.

The Addiction Severity Index: a field study of internal consistency and validity.

This study investigated whether the use of the Addiction Severity Index (ASI) in a network of inner-city alcohol and drug abuse clinics under nonideal conditions would yield internally consistent and valid data. A sample of 8,984 ASI scores was collected over a 34-month period. Construct validity was examined by computing the internal consistency of all subscales. Convergent and divergent validity of composite scores and of severity ratings were evaluated using correlation matrices. Findings demonstrated that ASI scores were internally consistent and valid, even though the recommended administration protocol may not always have been followed as faithfully as might be desirable. This robustness bodes well for the use of the ASI in on-line clinical environments. Results should be viewed with caution until the reliability of ASI administration is tested under similar nonideal conditions and until permissible deviations from standard protocol can be quantified.

The value of case management in the publicly funded substance abuse treatment system. The perspective of program directors, case managers and clients.

The many purposes of this article is to understand the role and value of case management from the perspective of program directors, case managers and clients. A survey of program directors from publicly funded substance abuse treatment programs in Boston was administered, and in-depth interviews with a sample of program directors, case managers, and clients were conducted. Case management allowed programs to serve more complex clients and increased time available for counselors to focus on the clinical needs of clients. From the perspective of case managers and clients, much of the value of case management came from educating clients about steps they could take to meet their needs and then supporting them in their efforts as they took these steps. Successful steps taken to deal with these needs helped lay the foundation necessary to confront the challenges of treatment. Program directors, case managers, and clients considered case management a valuable enhancement to substance abuse treatment.

The value of acupuncture detoxification programs in a substance abuse treatment system.

Our purpose is to compare baseline characteristics and detoxification readmission rates of clients treated at outpatient acupuncture programs and at short-term residential programs, two options available to persons seeking substance abuse detoxification. This was a retrospective cohort study using data on clients discharged from publicly funded detoxification programs in Boston between January 1993 and September 1994. Multivariate models were used to examine the effect on 6-month detoxification readmission rates of treatment at residential detoxification programs (used by 6,907 clients) versus at outpatient acupuncture programs (used by 1,104 clients) after adjusting for baseline differences. Acupuncture clients were less likely to be readmitted for detoxification within 6 months (odds ratio [OR] 0.71, 95% confidence interval [CI] 0.53-0.95). Similar results were found when the analysis was performed on a subsample of clients that were relatively similar in terms of baseline characteristics (OR 0.61, 95% CI 0.39-0.94). We determined that acupuncture detoxification programs are a useful component of a substance abuse treatment system.

HIV testing in substance abusers.

HIV testing among substance abusers in the United States is a significant public and individual health issue in need of further examination. We analyzed interview data gathered over 15 months in 1992 and 1993 from 2315 patients on presentation for addiction treatment to determine the frequency of and factors associated with previous HIV testing. Among this group of alcohol, heroin, and cocaine abusers, 53% (1231) reported previous HIV testing. Although in bivariate and multivariable analyses those with identifiable risk factors for HIV were more likely to have been tested, 27% of injection drug users, 38% with multiple sexual partners, and 39% of those with a history of a sexually transmitted disease (STD) had not been HIV tested. Other factors associated with previous HIV testing included having a primary care physician, the primary care physician's awareness of the patient's substance abuse problem, and having received prior addiction care. However, 38% of substance abusers who had previously received addiction treatment beyond detoxification had not been tested. Of those tested, 10% (n = 122) reported a positive test, and 7% (n = 81) had not received the test results. Of those with positive test results, 37% were not injection drug users. Promotion of HIV testing among alcohol and other drug abusers in both medical and substance abuse treatment settings should be a priority.

The functioning and well being of persons who seek treatment for drug and alcohol use.

We assessed the reliability of the Medical Outcomes Study Short Form Health Survey (SF-20) in a heterogeneous group of persons seeking drug and alcohol treatment. Patients (n = 2688) seeking detoxification and treatment at four intake sites for Addiction Treatment in Boston, Massachusetts, received all components of the SF-20 including physical, role, and social functioning; mental health; health perception and bodily pain. The primary drugs used were alcohol 38%, cocaine 38%, heroin 24%. Reliability coefficients for the MOS scales ranged from 0.70 to 0.92. Users of these three drugs had similar profiles among the health components. Sociodemographic characteristics in combination explained 2-7% of score variance. Alcohol and other drug use had little effect on physical or role function scores. Health perception and pain subscale scores were low. We conclude the MOS survey is a reliable measure of function and well being in this population. Like other chronic diseases, alcohol and drug use have powerful effects on quality of life.

Improving publicly funded substance abuse treatment: the value of case management.

OBJECTIVES: This study evaluated the impact of case management on client retention in treatment and short-term relapse for clients in the publicly funded substance abuse treatment system. METHODS: A retrospective cohort design was used to study clients discharged from the following four modalities in 1993 and 1994: short-term residential (3112 clients), long-term residential (2888 clients), outpatient (7431 clients), and residential detox (7776 clients). Logistic regression models were used to analyze the impact of case management after controlling for baseline characteristics. RESULTS: The odds that case-managed clients reached a length of stay previously identified as associated with more successful treatment were 1.6 (outpatient programs) to 3.6 (short-term residential programs) times higher than the odds for non-case-managed clients. With the exception of outpatient clients, the odds of case-managed clients' being admitted to detox within 90 days after discharge (suggesting relapse) were about two thirds those of non-case-managed clients. The odds of case-managed detox clients' transitioning to post-detox treatment (a good outcome) were 1.7 times higher than the odds for non-case-managed clients. CONCLUSIONS: Case management is a low-cost enhancement that improves short-term outcomes of substance abuse treatment programs.

Physician unawareness of serious substance abuse.

PURPOSE: To describe and assess the prevalence of perceived physician unawareness of serious substance abuse. PATIENTS AND METHODS: We report an observational study with validation of multivariable results of data collected by interview from persons presenting for addictions treatment in the public system who reported having a physician. RESULTS: Of 3,253 patients interviewed, 87% (2,843) responded to the question about having a physician. Of 1,440 patients who stated that they had physicians, 45% (651) reported that the physician who cared for them was unaware of their substance abuse. In multivariable logistic regressions adjusting for sociodemographics, health status, and substance abuse histories, the following patient characteristics were found to be independently associated with physician unawareness of substance abuse and were confirmed in a validation analysis (OR = Odds Ratio, CI = 95% Confidence Interval); no prior episodic medical illness (OR = 1.98, CI = 1.35-2.92), no health insurance (OR = 1.89, CI = 1.33-2.70), no prior mental health treatment (OR = 1.75, CI = 1.06-2.88), no chronic medical illness (OR = 1.69, CI = 1.18-2.40), no prior substance abuse treatment (OR 1.64, CI 1.17-2.31), and no prior detoxification (OR = 1.54, CI = 1.14-2.22). CONCLUSIONS: Forty-five percent of patients with substance abuse serious enough to prompt a presentation for treatment stated that the physician who cared for them was unaware of their substance abuse. Patients without health insurance, a history of medical illness, or prior substance abuse or mental health treatment were more likely to have reported physician unawareness. Even among substance abusing patients requesting addiction treatment, many perceive that their physicians do not recognize their substance abuse.

Victimization among substance-abusing women. Worse health outcomes.

BACKGROUND: Although women with a history of victimization are known to have increased somatic symptoms, health care utilization, and substance abuse, the health effects of victimization on substance-abusing women are uncertain. OBJECTIVE: To examine whether a history of victimization among substance-abusing women is associated with more medical problems or emergency department visits. METHODS: Interview data were collected from 2322 women seeking publicly funded addiction treatment from September 1992 to January 1996. We compared women with a lifetime history of physical or sexual abuse with those without such a history by bivariate and multivariable analyses. Variables included episodic medical disease, chronic medical disease, recent emergency department visits, substance abuse characteristics, and demographic data. RESULTS: The prevalence of victimization was 42%. In bivariate analyses, the following variables had significant association with victimization histories: episodic medical disease, recent emergency department visit, chronic medical disease, primary care physician's awareness of substance abuse history, ethnicity, and lower income. Alcohol and crack cocaine users had higher prevalence of victimization compared with heroin or noncrack cocaine users (P = .001). In the logistic regression, the following variables remained independently and significantly associated with victimization: episodic medical disease (odds ratio [OR], 2.15; 95% confidence interval [CI], 1.70-2.73), physician awareness of substance abuse (OR, 1.78; 95% CI, 1.42-2.23), emergency department visit (OR, 1.57; 95% CI, 1.22-2.03), chronic medical disease (OR, 1.51; 95% CI, 1.19-1.92), and lower income. CONCLUSION: Victimization in urban, poor, substance-abusing women is associated with more medical disease and health care utilization. Interventions that focus on the interconnected problems these women face may more effectively affect this challenging population.

Length of stay as an outcome in an era of managed care. An empirical study.

Longer length of stay (LOS) in substance abuse treatment, a standard measure of treatment success, conflicts with pressures from managed care. To maintain LOS as an outcome, we identified, for four modalities, LOS categories such that program completion rates were relatively constant within category and differed among categories. We validated the cutoffs by showing that future utilization over a 2-year period by clients differed by category. Clients in the long-LOS category used the system in a way consistent with more successful treatment. Thus, rather than using increase in LOS as an outcome, one can use increase in the percentage of clients reaching the long-LOS category. Categories were developed and utilization analyzed for discharges from publicly funded Boston treatment programs between 1/92 and 12/94 from the following modalities: short-term residential (5,462 discharges), long-term residential (5,086 discharges), outpatient (13,656 discharges), and detox (19,965 discharges).

Dimensions of homelessness.

Investigations of homelessness have been hampered by the lack of operational definitions sensitive enough to achieve subgroup differentiation and simple enough to permit replication. As a consequence, programming and policy development have often proceeded based on varying assessments of the composition, size, and needs of the homeless population. This paper describes the empirical use of duration of homelessness and dwelling place as elements of an operational definition of homelessness. The approach reflects a conceptualization of homelessness as a continuous variable that can be described by coordinates of time and place. A screening instrument that quantified the homeless experience was developed and evaluated in conjunction with a federally funded demonstration project for homeless substance-abusing men and women. Eight hundred and thirty-nine men and women from six public detoxification centers were screened over a two-year period that began in August 1988. Respondents were asked eight questions to assess duration (time) and location (place) of homelessness before they entered the detoxification center. A simple index was constructed retrospectively and found to differentiate the sample into homeless and near-homeless subgroups. Between-group differences were statistically significant in demographics, presenting problems, and probability for successful intervention. These data paralleled previously reported differences between homeless subgroups and support the concurrent validity of the index. Cronbach's alpha (.72) showed the index to be moderately reliable. Differentiation of homeless persons into meaningful subgroups appears possible and programmatically recommended. Homelessness is not a unitary phenomenon, and it is unlikely to respond to therapeutic interventions that fail to consider individual differences.

Late extramedullary relapse following bone marrow transplant for AML presenting as acute renal failure and leukemic ascites.

A 22-year-old woman with AML in remission for 3.5 years after BMT relapsed with extramedullary disease presenting as leukemic ascites and recurrent obstructive renal failure. The duration of remission post-transplant and the absence of bone marrow involvement may suggest an improved likelihood of response to further chemotherapy.

Use of the Addiction Severity Index with homeless substance abusers.

The Addiction Severity Index (ASI) is a widely adopted assessment instrument that provides severity ratings of the multiple problems exhibited by alcohol and drug dependent persons and allows for quantitative assessment (composite scores) of client status in these problems areas over time. ASI change scores of homeless and near homeless substance abusers, generated by contrasting ASI composite scores at two points in time, show a high level of agreement to objective relapse data from the Massachusetts Bureau of Substance Abuse Services Management Information System. Clients readmitted to a publicly funded detoxification facility exhibited significantly lower mean change scores on five of the seven problems areas measured by the ASI. These data illustrate the applicability of the ASI to homeless men and women and the utility of the ASI in measuring client improvement.

Reappraisal of temporary levodopa withdrawal ("drug holiday") in Parkinson's disease.

Transient withdrawal of therapy has been advocated as a method of dealing with the complications of long-term use of levodopa in the treatment of Parkinson's disease. We retrospectively examined the effect of a 10-day period of levodopa withdrawal, or "drug holiday," in 28 patients. We then compared the subsequent clinical course of these patients over one year with that of 30 other randomly selected, similar patients with Parkinson's disease. In both groups the disease progressed; there was no difference in disease severity, capacity for daily living activities, or total amounts of dopamine agonists eventually used. For some patients, it was possible to reduce dopamine agonists used immediately after the drug holiday without causing deterioration, but a pulmonary embolus and other complications occurred. Subsequent complications related to long-term dopamine-agonist therapy during the follow-up period were similar in the two groups. this investigation indicates that a drug holiday carries some risk and does not improve the efficacy of levodopa therapy or prevent the problems that occur with long-term administration.