Pathways to treatment retention for individuals legally coerced to substance use treatment: the interaction of hope and treatment motivation.

BACKGROUND: Although several states have adopted policies diverting individuals convicted of non-violent drug offenses to substance use treatment, in lieu of incarceration or as a condition of probation, previous research has produced inconsistent findings on the effectiveness of such programs when comparing outcomes for legally coerced individuals to more voluntary entrants. Less studied in these populations is within group variation in treatment expectations and motivation influences, which have been shown to affect retention as well. METHODS: As motivation has traditionally been viewed as contributing to treatment retention and higher levels of hope (the perception that goals can be met) are viewed as an asset in treatment, the role of these factors in predicting better retention between legally coerced and more voluntary clients were examined in a sample of 289 treatment admissions in California. RESULTS: Results found that motivation mediates the relationship between hope and retention for participants in general. Although the differences in mediation between the legally coerced and the non-legally coerced were not significant, when examining the groups separately, there was a significant mediation of the relationship between hope and retention by motivation only for those individuals who were not legally coerced into treatment (p<.05). CONCLUSION: The findings imply that while being legally coerced may lead to different pathways to treatment retention, for individuals who were not legally coerced, higher levels of hope may play an important role in determining treatment retention.

Health and health care disparities among homeless women.

While disparities in health and health care between vulnerable (e.g., minorities, low-income) and majority populations are well documented, less is known about disparities within these special populations that are large and diverse. Such knowledge is essential to determine the neediest within these generally needy populations, and to plan interventions to reduce their health and health care disparities. With data from 1,331 women residing in Los Angeles County California, in one of the largest, most comprehensive studies of the health of homeless women to date, this study examined the health and health care disparities among homeless African American, Latina, and white women. This study further explored if race/ethnicity and other factors that predispose homeless women to poor health, or enable them to obtain better health care, were associated with their unmet need for medical care. The study found that white, non-Latina women were more likely to report unmet need than African Americans and Latinas, and women suffering from drug abuse, violence, or depression were most in need of care. These findings should be considered in targeting and addressing the special needs of homeless women of different racial/ethnic groups.

Hospitalizations among homeless women: are there ethnic and drug abuse disparities?

This paper explores associations among the vulnerabilities of being female, being a member of a minority group, and being a drug abuser in homeless women's hospitalizations. It uses a 1997 probability survey of 974 homeless females age 15-44 in Los Angeles. In unadjusted analyses, whites were more likely than other ethnic minority groups to be hospitalized, and drug abusers were more likely to be hospitalized than non-drug abusers. Multiple logistic regression analyses indicated that factors associated with hospitalization differed considerably among the ethnic and drug-abuse subgroups. For example, ethnic disparities in inpatient health care were found for drug-abusing women, but not for those who did not abuse drugs. Pregnancy was the only important determinant of hospitalization in all subgroups (OR, 2.9-17.4). Preventing unintended pregnancy appears to be the most inclusive means of reducing hospitalization and attendant costs among homeless women.

Seeing the trees despite the forest: applying recursive partitioning to the evaluation of drug treatment retention.

AIMS: The aim of this study is to demonstrate the utility of recursive partitioning (RP) for analyzing process and outcome data in drug treatment research. The basic methodology of RP is introduced and applied to the prediction of treatment retention. METHODS: A total of 315 individuals randomly assigned to one of two treatment conditions; 289 (91.7%) completed a comprehensive baseline assessment battery. Treatment retention was assessed at a 52-week follow-up interview. FINDINGS: The RP approach was successful in generating a parsimonious decision tree that predicted drug treatment retention from the 195 input variables. Severity of drug use (as indicated by length of time speedballing), criminal behavior (as indicated by history of property crimes), level of insight, social network, and age at intake were predictive of treatment retention. The model is estimated to explain 32% of the variability in the population. CONCLUSIONS: RP supports the notion that there are early indicators of treatment retention and that specific approaches that are tailored to individuals' needs will be potentially more successful in treatment engagement and retention than the typical "one size fits all" approach. The results also demonstrate the utility of RP for the detection of complex relationships between diverse and interdependent predictors.

Predictors of intention to change HIV sexual and injection risk behaviors among heterosexual methamphetamine-using offenders in drug treatment: a test of the AIDS Risk Reduction Model.

This study tested components of the acquired immunodeficiency syndrome (AIDS) Risk Reduction Model (ARRM) for a sample of methamphetamine-using offenders in drug treatment. Analyses included the first two stages of the ARRM, problem recognition and intention to reduce risk (potential precursors to later possible behavior change), assessing predictors of intentions to increase condom use, reduce other sexual risk, and disinfect needles. Path analysis results showed potential applicability of the ARRM as a basis for intervention development for this population. There was a consistent effect of self-efficacy for risk reduction strategies, as well as direct or indirect effects of problem recognition factors (AIDS knowledge, peer norms), on the three intention indicators. Prior sex risk behavior (condom use) was directly negatively related to intention to use condoms; prior needle use was indirectly negatively related to intention to disinfect. Intention to use condoms was lower for women. Results can help identify areas for intervention development.

Modeling attitude towards drug treament: the role of internal motivation, external pressure, and dramatic relief.

Motivation for change has historically been viewed as the crucial element affecting responsiveness to drug treatment. Various external pressures, such as legal coercion, may engender motivation in an individual previously resistant to change. Dramatic relief may be the change process that is most salient as individuals internalize such external pressures. Results of structural equation modeling on data from 465 drug users (58.9% male; 21.3% Black, 34.2% Hispanic/Latino, and 35.1% White) entering drug treatment indicated that internal motivation and external pressure significantly and positively predicted dramatic relief and that dramatic relief significantly predicted attitudes towards drug treatment: chi (2) = 142.20, df = 100, p < 0.01; Robust Comparative Fit Index = 0.97, Root Mean Squared Error of Approximation = 0.03. These results indicate that when external pressure and internal motivation are high, dramatic relief is also likely to be high. When dramatic relief is high, attitudes towards drug treatment are likely to be positive. The findings indicate that interventions to get individuals into drug treatment should include processes that promote Dramatic Relief. Implications for addictions health services are discussed.

Substance use and intimate partner violence: clarifying the relevance of women's use and partners' use.

Research has shown that, when women and/or their partners are involved in substance use, women's risk for intimate partner violence (IPV) is higher. Prior research has not examined whether substance use by both women and their partners contributes independently or interactively to women's risk of victimization and has not identified factors moderating the effect of substance use by victim or partner. Mental health and social support are explored as moderators of the association between women's victimization and substance use by victim or partner in a study of 590 impoverished women residing in the Los Angeles area. This study found that substance use by both the woman and her partner independently predicted IPV and that social support moderated the effect of women's substance use. These findings clarify the relevance of substance use in the context of intimate relationships and that of social support as a buffer against IPV among impoverished women.

Examining self-control as a multidimensional predictor of crime and drug use in adolescents with criminal histories.

The general theory of crime posits that variability in propensities to engage in crime and deviance is partly a function of individual differences in low self-control (LSC). LSC is hypothesized to comprise of six subdomains: impulsiveness, preference for physical activities, risk seeking, self-centeredness, preference for simple tasks, and volatile temper. Using structural equation modeling, LSC was examined to determine if a global self-control measure or a multidimensional measure of its subdomains was a more salient predictor of violent and property crimes and drug use among adolescent male offenders (n = 317). Only the multidimensional model adequately fit the data. Risk seeking predicted violent and property crimes, whereas volatile temper predicted violent crimes and drug use. The general theory of crime may obscure differences in the explanatory power of self-control subfactors for specific types of crime, especially within at-risk youth. Findings have implications for effective interventions among adolescent males with criminal histories.

Longitudinal effects of LAAM and methadone maintenance on heroin addict behavior.

Levo-alpha-acetylmethadol maintenance (LAAM) was compared to methadone maintenance (MM) on the behavioral performance of 315 heroin addicts before, during, and after 12 months of fully subsidized treatment. Assessments of drug use, criminal behavior, HIV risk behaviors, and employment and residential status were obtained at treatment intake and at 6, 12, and 18 months after admission. Treatment retention and in-treatment suppression of heroin use were significantly better for the LAAM group than for the MM group. Improvements were also noted during treatment in criminal behavior, criminal justice involvement, and employment status, and there were reductions in injection HIV risk and number of sexual partners. Most significant effects were primarily related to active participation in maintenance treatment. Under subsidized treatment, retention rates were two to four times that of similar clients in local community programs during the same period. LAAM was a useful and a potentially important addition to treatment options for opiate addiction, conferring greater retention and opiate suppression benefits. Its removal from application provides a historical lesson concerning the introduction of new medications into addiction health services.

Are religiosity and spirituality useful constructs in drug treatment research?

Religiosity and spirituality (R/S) have been shown to be related to better outcomes in many health service areas, including drug abuse treatment. The latter area, however, lacks a fully emergent empirical framework to guide further study. Moreover, although scientists have tested isolated hypotheses, no comprehensive process model has been designed and validated, limiting conceptual development as well. This paper reviews the relevant R/S and health research literature with a primary focus on drug treatment processes. Then a conceptual model is suggested to guide future incremental study of R/S assessment and intervention development. Implications for addiction health services include increased efforts to empirically validate R/S interventions, to increase practitioner competencies in this area, and to disseminate relevant research findings.

Effect of religiosity and spirituality on drug treatment outcomes.

This study empirically tested one component of a comprehensive model of the role of religiosity and spirituality (R/S) in drug treatment that is presented as a companion article in this special issue. Data collected from individuals dependent on heroin receiving narcotic replacement therapy were used to assess the effects of R/S on drug treatment outcomes. Based on their R and S scores, participants were assigned to one of four groups: those whose scores remained consistently high across the 12-month study period were compared to those whose scores were consistently low, increased, or decreased across the same period. Results indicated that at both study completion (12 months after admission) and 6 months after that participants in the consistently high and increasing spirituality groups self-reported significantly fewer days of heroin and cocaine/crack use than those in the consistently low group (p < 0.05). There were no significant differences among the religiosity groups on self-reported heroin or cocaine/crack use. Results from chi(2) analyses indicated that at 12 months the results of urinalysis for the presence of opiates, but not cocaine/crack, were dependent on spirituality group membership (p < 0.01) but not religiosity group membership. Results also indicated that at the 6-month follow-up, there were significantly more participants in the decreasing group who were not in maintenance treatment who had a positive urinalysis and fewer in the increasing group than would be expected if the two variables were independent (p < 0.05). Implications for addictions health services are discussed.

Ethnic identity, spirituality, and self-efficacy influences on treatment outcomes among Hispanic American methadone maintenance clients.

There is increasing concern over whether standard health care services, such as substance abuse treatment, adequately account for important cultural influences, yet studies focusing on the impact of cultural influences on substance abuse treatment continue to be limited. The current study prospectively examined the effects of two cultural factors (ethnic identity and spirituality) on substance abuse treatment outcomes among Hispanic American clients (N=114) enrolled in methadone maintenance treatment. In addition, this study examined whether a commonly studied treatment factor (i.e., self-efficacy) significantly influenced treatment outcomes. Higher levels of self-efficacy at intake were related to increased odds of reported heroin abstinence and a lower number of drugs used at 1-year follow-up. Greater levels of ethnic identity were related to a greater number of drugs used at follow-up. No significant effects were found for spirituality.

The life course perspective on drug use: a conceptual framework for understanding drug use trajectories.

This article discusses the life course perspective on drug use, including conceptual and analytic issues involved in developing the life course framework to explain how drug use trajectories develop during an individual's lifetime and how this knowledge can guide new research and approaches to management of drug dependence. Central concepts include trajectories marked by transitions and social capital and turning points influencing changes. The life course perspective offers an organizing framework for classifying varying drug use trajectories, identifying critical events and factors contributing to the persistence or change in drug use, analytically ordering events that occur during the life span, and determining contributory relationships.

Levo-alpha-acetylmethadol (LAAM) versus methadone maintenance: 1-year treatment retention, outcomes and status.

AIMS: To compare levo-alpha-acetylmethadol (LAAM) and methadone maintenance (MM) on treatment retention, drug use during treatment and at follow-up, and abstinence. DESIGN: A two-group experimental design with patients assigned randomly (2:1) to receive fully subsidized LAAM or MM for 52 weeks. SETTING: A community clinic providing maintenance treatment in Los Angeles, California. PARTICIPANTS: A total of 315 treatment-seeking patients willing to be assigned randomly to treatment condition; 289 (91.7%) were interviewed at 52 weeks. INTERVENTION: LAAM or MM, plus ancillary services available to all patients. Medication dose varied according to clinical judgement. MEASUREMENTS: Treatment retention and status at 52-week follow-up, weekly clinical urinalysis, self-reported drug use and research urinalysis on samples collected at follow-up. FINDINGS: LAAM participants were more likely to complete the planned 52 weeks (57.4%) than MM participants (46.2%) and were less likely to be discharged for arrest/incarceration. LAAM produced fewer during treatment clinic opiate-positive samples (M = 48.8) than MM (M = 62.3). Further, 24.4% on LAAM compared to 11.8% on MM were able to sustain at least 12 weeks of abstinence during the last 24 weeks of treatment. Opiate use at follow-up was lowest (50.9%) among LAAM participants in maintenance treatment. No adverse events, cardiological or otherwise, were observed with LAAM administration. CONCLUSIONS: LAAM is an effective medication for the treatment of opiate dependence in community clinics with numerous behavioral and clinical advantages. LAAM is more effective than MM in promoting retention and extended reduction in and abstinence from opiate use while in treatment.

Processes and outcomes of substance abuse treatment between two programs for clients insured under managed care.

The purpose of this research (N = 160) was to describe and compare substance abuse treatment in two programs under managed care: one residential (RT) and one outpatient (OP). Clients in both settings improved significantly from before to after treatment in relation to substance use and quality of life. However, intensity of treatment (hours of care/week) was much greater in RT and days of sobriety were significantly higher after treatment in RT than in OP (p = .04). Intensity was negatively related to incidents of substance use during treatment (SUdT), which predicted substance use after treatment; SUdT averaged .2 for RT, and 1.6 for OP (p = .0001). Importantly, treatment was completed by 74 patients (over 90%) from RT, with 8 dropping out, and 53 (almost 70%) of those in OP completed treatment while 25 dropped out. Intensity, as seen in the RT program, rather than duration, was more effective in substance use reduction and treatment completion.

School-based drug prevention among at-risk adolescents: effects of ALERT plus.

In a recent randomized field trial, Ellickson et al. found the Project ALERT drug prevention curriculum curbed alcohol misuse and tobacco and marijuana use among eighth-grade adolescents. This article reports effects among ninth-grade at-risk adolescents. Comparisons between at-risk girls in ALERT Plus schools (basic curriculum extended to ninth grade with five booster lessons) and at-risk girls in control schools showed the program curbed weekly alcohol and marijuana use, at-risk drinking, alcohol use resulting in negative consequences, and attitudinal and perceptual factors conducive to drug use. Program-induced changes in perceived social influences, one's ability to resist those influences, and beliefs about the consequences of drug use mediated the ALERT Plus effects on drug use. No significant effects emerged for at-risk boys or at-risk adolescents in schools where the basic ALERT curriculum (covering seventh and eighth grades only) was delivered. Possible reasons for gender differences and implications for prevention programming are discussed.

Drug use and medication adherence among HIV-1 infected individuals.

This longitudinal study examined the impact of drug use and abuse on medication adherence among 150 HIV-infected individuals, 102 who tested urinalysis positive for recent illicit drug use. Medication adherence was tracked over a 6-month period using an electronic monitoring device (MEMS caps). Over the 6-month study drug-positive participants demonstrated significantly worse medication adherence than did drug-negative participants (63 vs. 79%, respectively). Logistic regression revealed that drug use was associated with over a fourfold greater risk of adherence failure. Stimulant users were at greatest risk for poor adherence. Based upon within-participants analyses comparing 3-day adherence rates when actively using versus not using drugs, this appears to be more a function of state rather than trait. These data suggest that it is the acute effects of intoxication, rather than stable features that may be characteristic of the drug-using populace, which leads to difficulties with medication adherence.

Criminal justice itreatment admissions for methamphetamine use in California: a focus on Proposition 36.

Methamphetamine (MA) use is considered as one of the nation's most pressing drug problems. In California, MA use has outstripped all other drugs in epidemiological extent, law enforcement activities, and treatment services demand. An opportunity for further study of MA use and its treatment emerged from a change in offender sentencing options introduced by California's Substance Abuse and Crime Prevention Act of 2000 (SACPA). Results indicate that statewide admissions for MA rose from 8.4% in FY 1992/1993 to 34.6% in FY 2004/2005, a four-fold increase over the 13 years. From the year before SACPA implementation to the year after, the percentage of treatment admissions due to MA use increased from 18.8% to 25.6%, an increase largely due to the fact that SACPA admissions were over 50% MA users. With the exception of alcohol, MA users entering treatment through SACPA had higher completion rates (about one third) from community based treatment than users of other primary drugs. This result held true for demographic and other subgroups of MA users. Multivariate regression results illuminate the relative importance of the variables examined. Implication of the findings for policy, intervention services, and research are discussed.

Adherence to antiretroviral medications in HIV: differences in data collected via self-report and electronic monitoring.

Controversy remains regarding the reliability of methods used to determine adherence to antiretroviral medication in HIV. In this study the authors compared adherence rates of 119 HIV-positive participants during a 6-month study, as estimated via electronic monitoring (EM) and self-report (SR). Adherence for both short (4-day) and long (4-week, or intervisit) periods was examined, as well as factors that underlie discrepancies between EM and SR. Results showed that intervisit EM estimates were consistently lower than those of SR. SR estimates based on shorter periods (4 days) were closer to those of EM. Higher discrepancies between EM and SR estimates were associated with lower cognitive functioning and externalized locus of control. These findings lend support for using both EM and SR methods; however, study design (e.g., length) and other factors (e.g., cognitive status, cost) should be considered.

Severity of child sexual abuse, post- traumatic stress and risky sexual behaviors among HIV-positive women.

Child sexual abuse (CSA) has been shown to enhance risk for HIV infection and other adverse outcomes. However, most studies examine the effects of a single incident of CSA rather than the full burden of abuse over the life span in predicting these adverse outcomes. A multi-dimensional approach was used in this study to examine the severity of abuse as a predictor of post-traumatic stress, depression, sexual symptoms, and risky sexual behaviors in a multi-ethnic sample of 147 HIV-positive women. Multivariate models indicated that experiencing both intrafamilial and extrafamilial CSA, adult sexual abuse (ASA) and Latina ethnicity predicted PTSD symptoms. ASA also predicted sexual trauma symptoms. Also, CSA and adult re-victimization contributed independently to risk for PTSD and sexual trauma symptoms, but not for risky sexual behaviors. The results support the need for interventions for HIV-positive women that address the full burden of abuse experienced and its sequelae.