Factors predicting entry of injecting drug users into substance abuse treatment.

A prospective study of 823 injecting drug users (IDUs) was made to identify baseline variables differentiating those who entered treatment during the study from those who did not enter. Variables independently associated with entering treatment in a multiple logistic regression model included (a) expressed desire for treatment, (b) being eligible for methadone maintenance, (c) two or more previous treatment admissions, (d) frequency of injection, (e) heroin use in the past 30 days, (e) being human immunodeficiency virus (HIV) positive, (f) giving money or drugs for sex, and (g) level of injection-related risk for HIV infection.

Histories of childhood trauma and the effects on risky HIV behaviors in a sample of women drug users.

A cross-sectional study was conducted to examine the association between childhood trauma and current human immunodeficiency virus (HIV) risk behaviors of 181 active illicit-drug-using women in San Antonio, Texas. We found very few statistically significant associations, which could he explained by (a) childhood trauma subtypes not being mutually exclusive, (b) clustering of mild-to-severe forms of abuse. and (c) childhood trauma having an indirect, rather than direct, effect on HIV risk behavior. Public health implications from this study are that prevention programs need to consider past and current individual and environmental factors that influence HIV sexual risk behaviors in women drug users.

Prevalence of childhood trauma in a community sample of substance-abusing women.

The purpose of this study was to estimate the prevalence of positive trauma histories in a community sample of intravenous drug using (IVDU) women for five subsets of childhood trauma (emotional abuse or neglect, physical abuse or neglect, and sexual abuse) and to compare demographic variables between the abused versus nonabused groups. Of the 181 women who completed the Childhood Trauma Questionnaire (CTQ), 109 (60.2%) were sexually abused, 100 (55.2%) were physically abused, 83 (45.9%) were emotionally abused, 151 (83.4%) were emotionally neglected, and 108 (59.7%) were physically neglected. There were no statistically significant findings for age, ethnicity, and educational level. Those subjects that were physically neglected were more likely not to be in a current relationship compared to those subjects that were not abused (p = .036). The findings suggest that the prevalence of all five childhood traumas was higher than what has been reported in the general population, and that physical neglect of individuals may predict lack of current significant relationships.

Reaching and enrolling drug users for HIV prevention: a multi-site analysis.

Since 1994, several sites have participated in a NIDA Cooperative Agreement for AIDS Community-based Outreach/Intervention Research Program to examine rates of HIV risk behaviors and evaluate HIV risk reduction interventions among out-of-treatment drug injection and crack cocaine and heroin smokers. We studied the process and outcome of community outreach for recruitment of drug users in AIDS research and education projects in three metropolitan areas: St. Louis, MO; San Antonio, TX, and Durham and Wake Counties, NC. There were two primary areas of focus: (1) the level of accuracy among community health outreach workers (CHOWs) in identifying potentially eligible persons for HIV prevention, and (2) overall effectiveness in recruiting and enrolling persons in formal assessment and intervention studies. We found cross-site and within-site differences in levels of accuracy and in recruitment and enrollment yields. Drug users who had never been in treatment and drug users who had never been tested for HIV infection were underrepresented at all sites. We discuss the factors which may have contributed to cross-site and within-site differences. The findings suggest a need for continued study, refinement, and evaluation of community outreach strategies in order to enroll a broad spectrum of vulnerable groups in HIV prevention activities.

An ethnographic comparison of HIV risk behaviors among heroin and methamphetamine injectors.

Drug injection and other practices affecting the risk of human immunodeficiency virus (HIV) infection were studied among 154 heroin users and 45 methamphetamine users in San Antonio, Texas. Amphetamine users were younger, mostly white, and had less-severe drug dependence. Heroin users had significantly higher levels of needle risk, as indicated by frequency of injection, number of persons sharing equipment, and place of injection. Methamphetamine users tended to buy syringes in lots of 10 or more from pharmacies and to use a syringe less than 5 times before discarding it. Heroin users tended to buy 1 needle at a time from an illicit source and to use it more than 20 times. Of methamphetamine users, 71% had more than one sex partner, compared to 39% of heroin users. Partners of methamphetamine users were more likely to be drug injectors than were partners of heroin users. Fewer methamphetamine users reported a behavior change in response to the acquired immunodeficiency syndrome (AIDS) epidemic, and fewer had been contacted by AIDS Education/Outreach. We suggest that efforts to promote risk reduction among methamphetamine users be stepped up because this population has been underserved and because less-sweeping behavior changes are needed to reduce needle-related risks to acceptable levels.

Attitudes toward methadone maintenance: implications for HIV prevention.

Attitudes of opioid users toward methadone maintenance were studied using semi-structured field interviews. One hundred and sixty-one heroin and speedball users in San Antonio, Texas, were interviewed between 1989 and 1992. Users were classified according to whether or not they had ever been on methadone maintenance. Opioid users who had never been on methadone maintenance were more likely to express a negative attitude toward methadone maintenance than users who had been on it (50% versus 30%). Sources of negative attitudes fell into the following categories: (1) general societal disapproval of addictive drugs, including methadone; (2) prior experience with 12 Step groups or abstinence-based treatment programs; (3) previous forced rapid detoxification from methadone in jail; and (4) observation of methadone maintained peers who continued to use drugs. Very few respondents reported adverse effects from methadone itself as a source of negative attitudes. Sources of positive attitudes included: (1) prior successful treatment with methadone; and (2) observation of methadone patients who stopped using drugs.

Injecting drug users who want treatment.

This study examined characteristics of injecting drug users (IDUs) who want treatment and the features that differentiate them from IDUs who do not want treatment. Data were collected as part of a community-based HIV prevention project in San Antonio, Texas. Interviews were administered to 1,100 IDUs between February 1993 and May 1995. Interview topics included sociodemographics, drug use history, current drug use, treatment history, injection-related HIV risk behavior, sexual behavior, and previous contact related to HIV prevention. Multiple logistic regression analysis identified four factors independently associated with wanting treatment in the multivariate model. These were: (1) 30 or more injections per month; (2) being eligible for methadone maintenance; (3) 2 or more previous treatment admissions; and (4) being recruited after the first year of the project. Implications of these findings are discussed.

The intravenous injection of illicit drugs and needle sharing: an historical perspective.

This study reviewed the literature on the history of needle sharing and intravenous drug abuse. Reports suggest that needle sharing was practiced by drug abusers as early as 1902 in China and 1914 in the United States. Intravenous drug abuse was first mentioned in the literature in 1925. However other references suggest that some opioid users were injecting intravenously prior to 1920. Outbreaks of malaria in Egypt, the United States, and China between 1929 and 1937 were attributed to needle sharing and intravenous injection of opioids. These reports suggest that both needle sharing and intravenous drug use were common by 1937. Factors such as medical use of intravenous injections, enactment and zealous enforcement of antinarcotic laws, and interactions among drug users in institutional settings such as regional hospitals and prisons may have contributed to the spread of both needle sharing and the intravenous technique among drug abusers.

Ethnic matching of caseworker and patient in methadone maintenance.

The relation of ethnic matching of caseworker and patient to treatment outcomes was evaluated in a cohort of 610 opioid users admitted to methadone maintenance. At admission, the subjects were assigned to caseworkers in rotation. Thirty-seven percent of the Anglo subjects, 11% of the African-American subjects, and 60% of the Hispanic subjects were matched with caseworkers of their own ethnic group. In all ethnic groups, the matched and nonmatched subgroups did not differ significantly on 11 pretreatment characteristics. The subgroups also did not differ significantly on 3 treatment variables, with the exception of methadone dose in the Anglo group. The Anglo-matched subgroup had a slightly higher mean dose (61 mg) than did the not matched subgroup (52 mg). In all ethnic groups, the matched and nonmatched subgroups did not differ significantly on 12 outcome variables. No relation was found between ethnic matching and treatment outcomes.

Compulsory supervision and methadone maintenance.

Treatment outcomes of 296 subjects admitted to methadone maintenance while on probation or parole are compared to those of 314 subjects admitted without such compulsory supervision. Equivalent treatment services were offered to both groups. The pretreatment differences between groups were small except for time incarcerated. All subjects were followed for one year. The compulsory supervision group had worse outcomes with respect to retention, productive activity, and incarceration. The differences were small except for incarceration. The mean number of months incarcerated was 2.1 for the compulsory supervision group and 0.7 for the voluntary group. Of subjects discharged from treatment, a higher percentage of the compulsory supervision group was discharged because of incarceration, but a higher percentage of the voluntary group was discharged for noncompliance with program requirements. The findings do not support a policy of exclusion of opioid users from methadone maintenance because they are on probation or parole.

Rapid admission and retention on methadone.

An open clinical trial was conducted to compare the effects of rapid (1-day) admission with slow (14-day) admission to methadone maintenance on pretreatment attrition, retention during treatment, and other outcomes. One hundred eighty-six illicit opioid users eligible for methadone maintenance were randomly assigned to rapid admission or slow admission, with 93 subjects assigned to each group. The random assignment produced two groups that were similar on 22 personal variables. All subjects admitted to treatment were followed for 1 year. Follow-up interviews were obtained with 155 (98%) of the 158 subjects admitted to treatment. During the period from initial contact to medication, only 4% of the rapid admission subjects but 26% of the slow admission subjects dropped out. The risk of dropout during slow admission was 6 times that during rapid admission. A higher percentage of rapid admission subjects, 43%, than of slow admission subjects, 39%, remained continuously in treatment for 1 year, but the difference was not significant. The two subgroups that remained in treatment for 1 year did about equally well on measures of illicit drug use and social performance. The findings indicate that pretreatment attrition can be markedly reduced by prompt medication, and the prompt medication does not adversely affect retention during treatment or other outcomes.

Reliability of two brief questionnaires for drug abuse treatment evaluation.

The authors report the inter-interviewer reliability of two brief questionnaires developed to measure the effects of innovations in methadone maintenance. The instruments were designed to answer the research questions, but to intrude only minimally into the clinical assessment and treatment processes. The Initial Interview, completed at the time of admission, yielded information on 23 variables, and the Followup Interview, completed as soon as possible after the first anniversary of admission, yielded information on 20 variables. To assess reliability, a repeat interview was conducted by a different interviewer immediately after the first interview was completed. Repeat interviews were conducted with 19 subjects who completed the Initial Interview and 30 who completed the Followup Interview. Exact agreement was found in all the pairs of responses from the Initial Interview for 5 of the 6 categorical variables and 6 of the 17 quantitative variables. For the remaining 11 quantitative variables, the intraclass correlation coefficients ranged from .700 to .999. Exact agreement was found in all pairs of responses from the Followup Interview for 2 of the 4 categorical variables and 8 of the 16 quantitative variables. For each of the remaining categorical variables, the kappa statistic was significant (.73 and .49). For the remaining 8 quantitative variables, the intraclass correlation coefficients ranged from .750 to .999. The findings signify satisfactory interviewer reliability of the instruments. These brief instruments could easily be adapted for use in other treatment evaluation studies where brevity in data collection is considered desirable.

Obtaining follow-up interviews for treatment evaluation.

Studies of the outcomes of substance abuse treatment are often handicapped because of subjects lost to follow-up. While follow-up data may be obtained from several sources, the follow-up interview often serves as the principal source of data. Difficulties are regularly encountered in locating and interviewing subjects not in treatment. From review of the literature on follow-up methodology and our own experience, we identified 10 procedures for effective follow-up. Application of these procedures is illustrated in a follow-up study of illicit opioid users treated in a methadone maintenance program. Follow-up interviews were obtained with 98% of the subjects. We recommend use of the 10 procedures by follow-up researchers, and we also recommend review of several previous publications on follow-up methodology.

Illicit drug injectors in three Texas cities.

In three Texas cities illicit drug injectors not in treatment were located by outreach and interviewed with a standard questionnaire. In all the cities the drug injectors were predominantly undereducated and unemployed young men from minority groups. In Dallas and Houston most were Black, while in San Antonio most were Hispanic. The most frequently reported primary drug in Houston was cocaine, but in Dallas and San Antonio it was heroin. The high needle risk for AIDS and the low rates of positive HIV antibody tests in these samples present a special window of opportunity for prevention of AIDS.

Ten-year follow-up after admission to methadone maintenance.

To assess the long-term effects of methadone maintenance, we compared the 10-year outcomes of 95 chronic opioid users who spent at least one cumulative year on methadone with those of 77 chronic opioid users who spent less than one cumulative year on methadone. All subjects were men and 90% were Mexican-American. The two groups were similar on 12 of 15 background variables. During the 10-year period, the methadone group had a cumulative mean of 54 months on methadone, while the comparison group had a cumulative mean of only 2 months on methadone. On social performance, as measured by months employed and months institutionalized, the methadone group did significantly better than did the comparison group. On months of voluntary abstinence, however, the comparison group did significantly better than did the methadone group. The mean of the comparison group, 36 months, was three times greater than that, 12 months, of the methadone group. At the end of the 10-year period, 26% of the comparison group but only 7% of the methadone group had been in continuous voluntary abstinence for 3 years or longer. Methadone maintenance for 1 year or longer was inversely related to abstinence during and at the end of the 10 years. This finding seems consistent with the hypothesis that methadone maintenance for 1 year or longer impedes eventual recovery from opioid dependence. For many patients, however, the benefits of prolonged maintenance could outweigh the possible cost of diminished likelihood of eventual recovery.

Methadone maintenance and recovery from opioid dependence.

While maintained on methadone, heroin users reduce their heroin use and related criminal activity and increase their legitimate employment. These benefits are obtained at the cost of continued opioid dependence. Furthermore, as a consequence of neural adaptation and conditioning, methadone maintenance may impede eventual recovery from opioid dependence. The authors attempt to assess such a possible effect by comparing long-term outcomes after methadone maintenance with those after drug-free treatment. In five long-term follow-up studies of methadone maintenance, the percentages found voluntarily abstinent ranged from 9 to 21. In six long-term follow-up studies of drug-free treatment, the percentages found voluntarily abstinent ranged from 10 to 19. These rates seem remarkably similar. They do not suggest that methadone maintenance impedes eventual recovery from opioid dependence, but they do not clearly exclude such an effect.