A 24-year follow-up of California narcotics addicts.

OBJECTIVE: This study examined longitudinal patterns of narcotics use, other substance use, criminal involvement, morbidity, and mortality among narcotics addicts. DESIGN: A 24-year follow-up study. Data were obtained from admission records and two face-to-face interviews conducted in 1974-1975 and 1985-1986. PARTICIPANTS: Five hundred eighty-one narcotics addicts admitted to the California Civil Addict Program during the years 1962 through 1964. RESULTS: Most of this sample initiated narcotics use before age 20 years and had a mean age at program admission of 25.4 years. In 1974-1975, 13.8% of the sample died and 28.6% tested negative for opiates. Corresponding rates in 1985-1986 were 27.7% and 25.0%, respectively. Substance use and criminal involvement remained high among this sample into their late 40s. In any given year during the 10 years prior to the 1985-1986 interview, less than 10% of the sample participated in community-based treatment programs such as methadone maintenance. Disability, long periods of heavy alcohol use, heavy criminal involvement, and tobacco use were among the strongest correlates of mortality. CONCLUSIONS: The results suggest that the eventual cessation of narcotics use is a very slow process, unlikely to occur for some addicts, especially if they have not ceased use by their late 30s.

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.

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.

Gender differences in mortality among treated opioid dependent patients.

AIMS: To assess gender differences in characteristics, mortality rates, and the causes and predictors of death among treated opioid-dependent individuals. METHODS: Linked vital statistics data were obtained for all individuals first enrolled in publicly funded pharmacological treatment for opioid dependence in California from 2006 to 2010. Standardized mortality ratios (SMR) were calculated by gender. Cox proportional hazards models with time-varying covariates were fitted to determine the effect of gender on the hazard of all-cause mortality, controlling for covariates. RESULTS: Over a median 2.6 years (interquartile range: 1.4-3.7), 1.031 deaths were observed, including 2.2% (259/11,564) of women and 3.7% (772/20,758) of men. Women had a greater increased risk of mortality compared to the general population (SMR 5.1 95% CI: 4.5, 5.7) than men (SMR 4.3 95% CI: 4.0, 4.6). The relative risk of death for women compared with men was 1.18 (95% CI: 1.02, 1.36). Women had a lower instantaneous hazard of all-cause mortality than men (HR 0.58, 95% CI 0.50, 0.68), controlling for other factors. Significant interaction effects indicated that among men, mortality risk was decreased by full-time employment and increased by non-daily heroin use (relative to daily use) and medical problems. Concurrent opioid and methamphetamine/cocaine use increased mortality risk among women and decreased it among men. CONCLUSIONS: Treatment for opioid dependence is likely to reduce mortality risk among men by addressing employment and medical problems, and via interventions to reduce overdose risk after heroin abstinence, and among women by attending to the concurrent use of methamphetamine/cocaine and opioids.

Short term health-related quality of life improvement during opioid agonist treatment.

BACKGROUND: Opioid dependence is associated with high levels of morbidity, yet sparse data exists regarding the health-related quality of life (HRQoL) of individuals with opioid dependence, particularly following treatment initiation. To inform cost-effectiveness analyses of treatment modalities, this study investigates short-term changes in HRQoL following enrollment into opioid agonist treatment (OAT), across treatment modalities and patient subgroups. METHODS: Data was analyzed from the Starting Treatment with Agonist Replacement Therapies (START) and Prescription Opioid Addiction Treatment Studies (POATS) randomized controlled trials. Participants included individuals dependent on prescription opioids (POs) or heroin, receiving limited-term or time-unlimited treatment. PO- or heroin-users in START received buprenorphine/naloxone (BUP/NX) or methadone (MET) over 24 weeks. PO-users in POATS received psychosocial care and short-term (4-week) taper with BUP/NX, with non-responders offered subsequent extended (12-week) stabilization and taper. HRQoL was assessed using the short-form SF-6D while in and out of OAT, with distinction between MMT and BUP/NX in START. Linear mixed effects regression models were fitted to determine the independent effects of OAT on HRQoL and characterize HRQoL trajectories. RESULTS: Treatment had a similar immediate and modest positive association with HRQoL in each patient subgroup. The association of OAT on HRQoL was statistically significant in each model, with effect sizes between 0.039 (heroin-users receiving BUP/NX) and 0.071 (PO-users receiving MET). After initial improvement, HRQoL decreased slightly, or increased at a diminished rate. CONCLUSIONS: OAT, whether delivered in time-limited or unlimited form, using BUP/NX or MET, is associated with modest immediate HRQoL improvements, with diminishing benefits thereafter.

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.

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.

Comparative treatment effectiveness. Effects of program modality and client drug dependence history on drug use reduction.

This study examined treatment outcome as a function of program modality, clients' lifetime patterns of drug dependence, and their interaction, controlling for current level of drug use at treatment intake. Data were based on 2,966 clients who were interviewed at intake and at 1-year follow-up as part of the Drug Abuse Treatment Outcome Study (DATOS), which included programs of four major modalities. Subjects' lifetime patterns of drug dependence were classified into nine groups according to Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R; American Psychiatric Association; 1987) diagnostic criteria and time of onset of drug use career. Outcome measure was the reduction of heroin use or cocaine use at follow-up from levels at intake. The results showed that rates of lifetime drug dependence and current drug use at DATOS admission were highest among methadone maintenance clients and lowest among outpatient drug-free clients. Drug use reduction was observed for all modalities. The presence of dependence diagnosis was associated with less improvement when current use level at intake was controlled. Clients dependent on heroin but not currently daily users benefited most from inpatient and residential programs. Methadone programs were also relatively ineffective in reducing cocaine use. Characteristics of the client's drug dependence history, in addition to the current or presenting drug problem, should be assessed to guide treatment planning. The high rate of cocaine dependence among methadone clients, most of whom were dependent on heroin, poses considerable challenge to contemporary opiate substitution treatments.

Matching clients' needs with drug treatment services.

This paper reports results of a study that investigated whether matching drug treatment services with client needs improved outcomes for a sample of 171 clients who participated in community-based drug treatment programs. Clients were initially assessed on multiple problem areas (alcohol use, drug use, medical, psychological, family/social, legal, employment, housing) and on areas of special needs or stated preferences for services (e.g., transportation, child care, language). A 6-month follow-up interview reassessed clients' problems/needs in all areas and collected information on the services received. The results showed that some services significantly improved client outcome for those who had expressed needs for such services. Notably, services meeting the need for vocational training, child care, transportation, and housing showed beneficial effects. A higher level of needs and services matching (defined either by the ratio of services received to services desired, or by the total level of met versus unmet needs in the eight problem areas) significantly predicted longer treatment retention.

Predicting drug treatment entry among treatment-seeking individuals.

This study examined factors related to drug treatment program entry among 276 drug abusers seeking treatment referral. Six-month follow-up interviews determined that 171 (62.0%) followed through with the treatment referral. The analyses indicated that treatment-entry and non-entry subjects did not differ in predisposing factors (age, gender, race/ethnicity, education), type of drug use, or years of use. A logistic regression analysis indicated that characteristics at baseline predicting subsequent treatment entry include legal pressure, lower levels of psychological distress and family or social problems, and prior successful treatment experience. Legal coercion was an effective factor promoting treatment entry. Drug abusers having prior successful treatment experience were also more likely to reenter treatment. However, those with more severe problems (drug related and others) seemed less likely to enter treatment, indicating that psychological distress and family problems may undermine motivation to follow through on treatment referral.

Drug treatment careers. A conceptual framework and existing research findings.

While outcomes for any single intervention are important to determine, the long term evaluation of multiple, sequential interventions is at least equally important. One strategy for examining this process is that of the treatment career. A treatment careers perspective applies a longitudinal dynamic approach to identify and understand key factors influencing the development of, and transitions in the course of, drug dependence and its treatment. After presenting an overview of the treatment careers perspective, this paper reviews and discusses relevant research issues and findings on treatment seeking, utilization and resistance, entry and reentry, engagement and retention, client treatment matching, and outcomes. Key findings include high resistance to entering treatment by many drug users, late development of treatment careers relative to addiction and criminal careers, short durations of most treatment episodes, cumulative and facilitative effects of treatment experiences, and beneficial effects of matching clients to treatment. The treatment careers perspective provides a useful framework within which findings on drug treatment can be better integrated and critical issues can be identified for further research, leading to a better understanding of drug dependence and its treatment.

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.

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.

Individual change amid stable smoking patterns in polydrug users over 3 years.

The pattern of stability/change in smoking status was examined annually in 254 community-dwelling polydrug users over 3 years. Respondents' smoking status was classified as nonsmoker, intermittent smoker, or "everyday" smoker. Results showed that the typical probability of retaining the same smoking status across any two consecutive assessments was: 0.77 for nonsmokers (never smokers and former smokers combined), 0.82 for everyday smokers, and 0.16 for intermittent smokers. The transition matrix proved stable across three observations; the predicted equilibrium distribution matched well with observed distributions. Fifty-five percent of intermittent smokers converted to everyday smoking within a year, but 29% converted to former-smoker status in the same period. No other transition exceeded 12%. Considerable flux in individual smoking status, particularly among intermittent smokers, was observed despite stable prevalence of smoking status in this population. Intermittent smoking status appeared to be a temporary "way station" between the two more stable everyday smoker and nonsmoker classifications. Results challenge current assumptions about "occasional" or "chipper" smokers.

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.

Longitudinal patterns of alcohol use by narcotics addicts.

Longitudinal patterns of alcohol use by narcotics addicts sampled from a drug-free treatment program and from several methadone maintenance treatment programs were examined. Overall, a high prevalence of alcohol use was found in both samples across several stages of the addicts' careers. Many addicts were also using nonnarcotic drugs and marijuana concurrently. Generally, levels of alcohol, as well as of other substances use, decreased as the narcotics addiction career began. Unlike other drug use, however, only alcohol consumption increased whenever a decrease occurred in narcotics use. Effects of ethnicity, gender, parental alcohol problems, and opiate and alcohol use onset sequence on the alcohol- and narcotics-related behavior are examined in detail. A pattern of early onset of heavy alcohol consumption before initial narcotics addiction was more common among Chicanos and was associated with a positive parental alcohol history. Women addicts typically had a much lower alcohol consumption level than their male counterparts. Among the 160 deaths of the original 581 addicts followed during the 20 years of the study, alcohol-related deaths accounted for 17.5% of the total. Treatment implications for addicts with an alcohol problem are discussed.

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.

Analytic approaches for assessing long-term treatment effects. Examples of empirical applications and findings.

Analytic approaches, including the structural equation model (autoregressive panel model), hierarchical linear model, latent growth curve model, survival/event history analysis, latent transition model, and time-series analysis (interrupted time series, multivariate time-series analysis) are discussed for their applicability to data of different structures and their utility in evaluating temporal effects of treatment. Methods are illustrated by presenting applications of the various approaches in previous studies examining temporal patterns of treatment effects. Recent advancements in these longitudinal modeling approaches and the accompanying computer software development offer tremendous flexibility in examining long-term treatment effects through longitudinal data with varying numbers and intervals of assessment and types of measures. A multimethod assessment will contribute to a more complete understanding of the complex phenomena of the long-term courses of substance use and its treatment.

Children of treated substance-abusing mothers: a 10-year prospective study.

This study examined children of substance-abusing mothers approximately 10 years after mothers' admission to drug abuse treatment, and identified maternal characteristics that may be risk factors for child behavior problems on the Child Behavior Checklist. Data were obtained from 396 mothers who were included in a sample consecutively admitted to 44 treatment programs in 13 California counties during 2000-2002. The Addiction Severity Index was administered at both intake and follow-up. Each mother reported on one child 6-17 years of age. All of the children had been exposed to drugs, either in utero or postnatally. At follow-up about 22% of the children demonstrated borderline or clinical range problem behaviors. Child behavior problems were related significantly to the mothers' ethnicity (lower among Hispanics relative to white), and problem severity in family/social relationship and mental health, marginally related to her prior medical/health problem, and not related to severity of alcohol, drug, legal and employment problems. Assisting mothers to address their family/social relationship and psychological problems may have an added value to prevent or reduce behavioral problems of their children.

Characterizing longitudinal health state transitions among heroin, cocaine, and methamphetamine users.

AIMS: Characterize longitudinal patterns of drug use careers and identify determinants of drug use frequency across cohorts of primary heroin, methamphetamine (MA) and cocaine users. DESIGN: Pooled analysis of prospective cohort studies. SETTINGS: Illicit drug users recruited from community, criminal justice and drug treatment settings in California, USA. PARTICIPANTS: We used longitudinal data on from five observational cohort studies featuring primary users of heroin (N=629), cocaine (N=694) and methamphetamine (N=474). The mean duration of follow-up was 20.9 years. MEASUREMENTS: Monthly longitudinal data was arranged according to five health states (incarceration, drug treatment, abstinence, non-daily and daily use). We fitted proportional hazards (PH) frailty models to determine independent differences in successive episode durations. We then executed multi-state Markov (MSM) models to estimate probabilities of transitioning between health states, and the determinants of these transitions. FINDINGS: Across primary drug use types, PH frailty models demonstrated durations of daily use diminished in successive episodes over time. MSM models revealed primary stimulant users had more erratic longitudinal patterns of drug use, transitioning more rapidly between periods of treatment, abstinence, non-daily and daily use. MA users exhibited relatively longer durations of high-frequency use. Criminal engagement had a destabilizing effect on health state durations across drug types. Longer incarceration histories were associated with delayed transitions toward cessation. CONCLUSIONS: PH frailty and MSM modeling techniques provided complementary information on longitudinal patterns of drug abuse. This information can inform clinical practice and policy, and otherwise be used in health economic simulation models, designed to inform resource allocation decisions.