Examining substance use among rural Appalachian and urban non-Appalachian individuals participating in drug court.

The study purpose was to examine differences in substance use among individuals in drug court (N = 583) in rural Appalachian (n = 301) and urban non-Appalachian areas (n = 282). A series of logistic regression analyses suggested individuals in the rural Appalachian area were significantly more likely to report lifetime use of cocaine, illicit opiates, and illicit benzodiazepines, but they were less likely to report methamphetamine use when compared with individuals in the urban non-Appalachian area. Regarding past 30-day use, a series of logistic regression analyses suggested individuals in the rural Appalachian area were significantly more likely to use marijuana, illicit opiates, and illicit benzodiazepines, but they were less likely to report crack cocaine use when compared with individuals in the urban non-Appalachian area. Identifying differences which exist in substance use is the first step in generating evidence-based structural changes in treatment drug court programs. Future research should focus on better understanding context in terms of demographic, geographic, and economic conditions, which may be of critical influence on substance use and treatment planning.

Examining gender differences in substance use and age of first use among rural Appalachian drug users in Kentucky.

BACKGROUND: Previous research suggests gender differences exist in types of substances used and age of first use. Recent studies exploring contextual differences in substance use between rural Appalachian and urban environments show different patterns of substance use in rural environments. OBJECTIVE: This study explores whether previously established differences in gender and age of first use exist within a rural Appalachian environment. METHODS: Data are from a community-based study of drug users in rural Appalachia (N=400). Self-reported substance use was recorded using an interviewer-administered questionnaire with questions from the Addiction Severity Index (ASI). RESULTS: On average, participants were 32 years old (X=32.33; median=31.00; interquartile range (IQR)=12) and the majority were male (59%). Examining the past 30-day substance use, more males reported alcohol (adjusted odds ratio (AOR): 2.11, 95% CI: 1.36, 3.23; p=.001) and any illegal drug use (AOR: 1.85, 95% CI: 1.16, 2.95; p=.010), which included heroin, cocaine, crack cocaine, methamphetamine, marijuana, and hallucinogens, after controlling for sociodemographic characteristics. ANCOVA analyses showed that males reported the use of alcohol (p=.000), marijuana (p=.007), and hallucinogens (p=.009) at a significantly younger age than females. CONCLUSION: Findings suggest more men report the use of alcohol and "street" drugs, including heroin, crack cocaine, methamphetamine, marijuana, and hallucinogens. Furthermore, males report the use of alcohol, marijuana, and hallucinogens at a significantly younger age. SCIENTIFIC SIGNIFICANCE: Understanding gender differences in substance use as well as other differences among individuals living in rural Appalachia presents important opportunities to incorporate this knowledge into substance abuse early intervention, prevention, and treatment efforts.

Examining differences in substance use among rural and urban pregnant women.

Substance use during pregnancy is a major public health concern. This study examined differences in substance use among pregnant women from rural and urban areas. Participants were 114 pregnant women entering a hospital-based inpatient detoxification unit primarily for Opiate Dependence who voluntarily agreed to a face-to-face interview. Substance use measures were based on the Addiction Severity Index gathering information about lifetime, past 12 months, and 30 days prior to admission. Rural pregnant women had higher rates of illicit opiate use, illicit sedative/benzodiazepine use, and injection drug use (IDU) in the 30 days prior to admission. Additionally, a greater proportion of rural pregnant women reported the use of multiple illegal/illicit substances in the 30 days prior to entering detoxification. More specifically, pregnant women from rural areas were 8.4 times more likely to report illicit opiate use, 5.9 times more likely to report IDU, 3.3 times more likely to report illicit sedative/benzodiazepine use, and 2.8 times more likely to report the use of multiple illegal/illicit substances in the 30 days prior to entering inpatient detoxification, after adjustment for socio-demographic characteristics (including education and income), pregnancy characteristics, physical and mental health indicators, and criminal justice system involvement. The increased rates of prescription opiate and benzodiazepine use as well as IDU among rural pregnant women are concerning. In order to begin to understand the elevated rates of substance abuse among rural pregnant women, substance use must be considered within the context of demographic, geographic, social, and economic conditions of the region.

Examining Predisposing Factors and Program Performance Indicators Associated With Program Completion: A Comparison of Opioid and Non-Opioid-Preferring Participants in Drug Court.

Opioid use and abuse, as well as criminal justice involvement, have increased dramatically in the past two decades. Drug court is a community-based rehabilitation program for individuals with substance abuse issues involved in the criminal justice system. Given unique treatment needs associated with opioids, the current study examined predisposing factors and program performance indicators associated with drug court completion based on individuals' opioid preference. Secondary data (i.e., participant assessment and drug court Management Information System) as well as conviction information from a statewide database were examined for a sample of drug court participants (N = 534). Data analyses compared opioid-preferring (n = 267) and non-opioid-preferring (n = 267) program participants. For non-opioid-preferring participants, a combination of predisposing characteristics, including both social/demographic characteristics and substance use (i.e., education, drug court site, lifetime benzodiazepine use), as well as program performance indicators (i.e., number of days in drug court, number of positive drug tests, and sanctions/therapeutic responses) influenced drug court completion. For opioid-preferring participants, only program performance indicators emerged as important for program completion, specifically number of days in drug court, number of positive drug tests, and sanctions/therapeutic responses. Findings for non-opioid-preferring participants are consistent with past research, suggesting that individual predisposing characteristics and program performance indicators are influential on program completion. However, findings suggesting that only program performance indicators are influential for opioid-preferring participants adds a unique contribution to the literature. This information may help provide more individualized program planning and ultimately more programmatic success.

Contextual differences in substance use for rural Appalachian treatment-seeking women.

OBJECTIVE: To examine differences in substance use among a sample of women entering treatment from rural Appalachian and non-Appalachian areas. PARTICIPANTS: A total of 2,786 women participating in state-funded substance abuse treatment programs statewide. MEASURES: Substance use measures were based on the SAMHSA CSAT Government Performance and Results Act (GPRA) gathering information on lifetime and past 12-month use of alcohol, marijuana, opiates, sedatives/tranquilizers, cocaine, and stimulants. RESULTS: Women entering treatment in rural Appalachia had disproportionately high rates of opiate and sedative/tranquilizer use while methamphetamine, cocaine, marijuana, and alcohol were more prevalent for women in non-Appalachian areas. CONCLUSIONS: Women entering treatment in rural Appalachia were significantly more likely to report opiate and sedative/tranquilizer use compared to non-Appalachian women. In order to begin to understand the elevated rates of prescription drug abuse in rural Appalachian Kentucky, substance use must be considered within the context of demographic, geographic, social, and economic conditions of the region.

Examining the Impact of Prior Criminal Justice History on 2-Year Recidivism Rates: A Comparison of Drug Court Participants and Program Referrals.

Drug courts seek to break the cycle of substance use and crime by providing a community-based intervention to individuals with criminal justice involvement and substance-related issues. This study examined recidivism over a 2-year follow-up period as well as factors associated with recidivism for a sample of drug court participants (i.e., graduates and terminators) and a non-equivalent comparison group (i.e., individuals referred/assessed for the program who did not enter). In the 2-year follow-up window, fewer drug court graduates had any convictions compared with program terminators and referrals; specifically, fewer drug court graduates had drug trafficking convictions compared with program terminators and referrals. Fewer graduates were arrested and incarcerated in jail and/or prison in the 2-year follow-up; furthermore, graduates had spent less time incarcerated compared with program terminators and referrals. Demographics (i.e., age, race, marital status) and prior criminal justice system involvement were associated with recidivism; however, these factors had differential impacts for the three groups (i.e., graduates, terminators, and referrals). Drug court shows promise as a community-based intervention that helps keep individuals out of the criminal justice system during a 2-year follow-up period.

Examining Individual Characteristics and Program Performance to Understand Two-Year Recidivism Rates Among Drug Court Participants: Comparing Graduates and Terminators.

Drug courts strive to break the cycle of substance use and crime by providing community-based treatment and rehabilitation. The purpose of the present study was to (a) identify significantly different factors between program participants (i.e., graduates/terminators) that may affect recidivism and (b) examine these significant individual and program performance factors associated with two-year recidivism. Secondary data were examined for a stratified random sample of drug court participants ( N = 534). Examining any two-year post-program recidivism (defined as an arrest, conviction, or incarceration), over one third (37.6%) of graduates and almost all program terminators (95.3%) had two-year post-program recidivism ( p < .001). For the overall sample, age, outpatient treatment, marital status, number of times treated for a psychiatric problem in a hospital, substance use (i.e., past-30-day cocaine use and intravenous opiate use), number of positive drug tests, and receiving any sanction/therapeutic response were associated with two-year post-program recidivism. Further analyses suggested age and outpatient treatment were particularly important for program graduates. Findings provide information for early targeting of resources to drug court participants most at risk of poorer post-program outcomes by identifying factors known at program entry and indicators during program participation.

Examining implementation and preliminary performance indicators of veterans treatment courts: The Kentucky experience.

Veterans' Treatment Courts (VTCs) are posited as a solution to offer rehabilitation for veterans involved in the criminal justice system. Despite the pervasive implementation of VTCs, there is little research focused specifically on VTC implementation and outcomes, which are based on other problem-solving court models such as drug court. The current study presents qualitative process evaluation data from key stakeholders (n=21) and veteran participants (n=4) to show accomplishments, challenges, and lessons learned during first-year implementation at two VTC sites. Quantitative performance data is also presented on veteran participants (n=19) served during the first year to show: types of services, monitoring, judicial interaction, sanctions/therapeutic responses, and rewards, as well as preliminary data on recidivism. Qualitative data, from both key stakeholders and veteran participants, suggests that offering rehabilitation via various program components, services/referrals, and accountability are critical to the success of the VTC. Data also provides valuable lessons learned for VTC implementation including communication, collaboration, information/protocols, and resources. Performance data shows that a variety of services are utilized and that frequent judicial interaction, drug testing, and sanctions are cornerstones of the VTC. Implications and future directions for research are discussed.

Implementation of an enhanced probation program: evaluating process and preliminary outcomes.

Supervision, Monitoring, Accountability, Responsibility, and Treatment (SMART) is Kentucky's enhanced probation pilot program modeled after Hawaii's Opportunity Probation with Enforcement (HOPE). SMART is proposed to decrease substance use, new violations, and incarceration-related costs for high-risk probationers by increasing and randomizing drug testing, intensifying supervision, and creating linkages with needed resources (i.e., mental health and substance use). SMART adopts a holistic approach to rehabilitation by addressing mental health and substance abuse needs as well as life skills for fostering deterrence of criminal behavior vs. punitive action only. A mixed methods evaluation was implemented to assess program implementation and effectiveness. Qualitative interviews with key stakeholders (i.e., administration, judges, attorneys, and law enforcement/corrections) suggested successful implementation and collaboration to facilitate the pilot program. Quantitative analyses of secondary Kentucky Offender Management System (KOMS) data (grant Year 1: 07/01/2012-06/30/2013) also suggested program effectiveness. Specifically, SMART probationers showed significantly fewer: violations of probation (1.2 vs. 2.3), positive drug screens (8.6% vs. 29.4%), and days incarcerated (32.5 vs. 118.1) than comparison probationers. Kentucky's SMART enhanced probation shows preliminary success in reducing violations, substance use, and incarceration. Implications for practice and policy will be discussed.

Developing a new system to measure outcomes in a service coordination program for youth with severe emotional disturbance.

This paper presents information on re-developing an outcome evaluation for a state-funded program providing service coordination utilizing wraparound to youth with severe emotional disturbance (SED) and their families. Originally funded by the Robert Wood Johnson Foundation, the Kentucky IMPACT program has existed statewide since 1990. Changing data needs and limitations of the original evaluation required revamping the program's data collection system. The new evaluation uses the extant knowledge base to improve: (1) design, (2) measures, and (3) utility. A pre-post design with multiple follow-ups provides the framework for data collection. An ecological framework provides a conceptual structure for selecting measures focusing on both the service recipients and their environment. Data collection via a personal digital assistant (PDA) ensures utility of the data for both consumers and researchers. Issues ranging from conceptualization to implementation of the project as well as lessons learned are discussed.

Factors associated with substance use during pregnancy: results from a national sample.

OBJECTIVE: To examine the prevalence and correlates of substance use during pregnancy among women in the United States. METHODS: We analyzed data from pregnant (n=1800) and non-pregnant women (n=37,527) aged 15-44 years who participated in the 2002 or 2003 National Survey on Drug Use and Health, a nationally representative epidemiologic survey. Study variables included demographics, any substance use in the prior 30 days, and possible current psychopathology. Data were analyzed using weighted chi-square and multiple logistic regressions that accounted for the complex survey design. RESULTS: The overall prevalence of any past month substance use during pregnancy was 25.8%; the prevalence rates of past month illicit drug, cigarette and alcohol use were 4.7%, 18.9% and 10%, respectively. Compared to the prevalence of substance use among women in their first trimester, use was significantly lower among women in their second or third trimesters. Women who reported using substances during pregnancy were significantly more likely to meet the criteria for possible current psychopathology and be White. Additionally, women who were employed, married, and in their second or third trimester compared to the first were significantly less likely to have used any substance during pregnancy, adjusting for age, ethnicity and income. CONCLUSIONS: Although the prevalence of substance use among pregnant women was significantly lower than non-pregnant women, some groups of women remain vulnerable to continued use, including those who are unemployed, unmarried, and experiencing possible current psychopathology. Prevention and intervention programs aimed at high-risk populations are warranted to reduce the deleterious effects of substance use on pregnancy outcomes.