High risk sexual behaviours among heroin sniffers who have no history of injection drug use: implications for HIV risk reduction.

The purpose of this paper is to assess sexual behaviours which place heroin sniffers (HSs) at high risk for HIV infection. A stratified network-based sample was used to recruit HSs who had no history of injection drug use was recruited from the streets of South Florida, USA. HSs displayed a high HIV seroprevalence rate of 12.1%; women (18.1%) were more likely than men (8.7%) to test positive for HIV. Both men and women HSs engaged in considerable high risk sex behaviour, including high risk sex-exchange behaviour. The use of crack cocaine was associated with increased sex exchange behaviour among women. The need for intervention programs targeted toward HSs is discussed.

Drug use and barriers to use of health care services.

This paper examines barriers to health care utilization and the correlates associated with these barriers. As part of a larger study of health services utilization, the study sample of 1085 including injection drug users, other chronic users of heroin or cocaine, and a demographically similar group who had used neither heroin nor cocaine, was selected based on the criterion of not having received health care for at least one health problem within the previous 12 months. Both categories of chronic drug users were more likely than non-users not to want health care treatment and to put off seeking needed health care.

Primary preventive health care among injection drug users, other sustained drug users, and non-users.

The primary objective of this paper is to investigate the relationship between sustained illicit drug use and the utilization of primary preventive health care. Data from 1254 African-American, Hispanic/Latino, and non-Hispanic/Latino white men and women collected in 1996-1997 were analyzed to determine independent risk factors for the utilization of primary preventive health care that was not received as a result of seeking treatment for a specific health condition. When several demographic, health, and drug use variables were assessed in a logistic regression model, gender, ethnicity, health insurance status, drug use, and alcohol use were independently associated with primary preventive care. Women, Hispanic/Latinos, and persons who had health insurance were more likely to have received primary preventive health care while injection drug users, other sustained drug users, and "heavy" alcohol users were less likely to have used primary preventive health care services in the past year.

Using the drug abuse screening test (DAST-10) to analyze health services utilization and cost for substance users in a community-based setting.

The dual purpose of this study was to: (1) determine whether problematic drug users, defined through the Drug Abuse Screening Test (DAST-10), exhibited differences in health services utilization and cost relative to a combined group of non-problematic drug users and non-drug users; and (2) assess whether the findings were similar to those for chronic drug users (CDUs) and injecting drug users (IDUs). Results showed that health services utilization and total cost were very similar for problematic drug users defined through quantity-frequency (i.e., CDU, IDU) and diagnostic (i.e., DAST-10) criteria. Findings suggest that quantity/frequency criteria for problematic drug use were reasonable approximations for diagnostic-based measures.

Gender differences in the processes of change for condom use: patterns across stages of change in crack cocaine users.

Interventions to increase condom use in crack users have had mixed results. For interventions to achieve greater success, the mechanisms of behavior change in this population need to be understood. One mechanism, the processes of change, was examined across stages of change for condom use. Results from the analysis of variance for males and females revealed that stage of change was associated with different levels of three experiential processes: consciousness raising, social liberation and self-reevaluation. However, these analyses found that male and females seem to have different patterns of behavioral process use. Specifically, females in the preparation stage were different from those in precontemplation, whereas this difference was not pronounced in males. In general, people had high levels of experimental processes in every stage of change. The patterns of behavior process use mimicked patterns found for other behaviors with a linear increase across the stages of change. This may indicate that for maintaining condom use, more emotional and behavioral activities are required throughout the process of acquisition and maintenance than are necessary for other health-related activities. Implications of this research are that interventions for increasing condom use in drug users may target behavioral steps differently for males and females.

Crack smokers' intention to use condoms with loved partners: intervention development using the theory of reasoned action, condom beliefs, and processes of change.

Prevalence rates of HIV infection acquired through heterosexual contacts have risen steadily since 1982. Crack cocaine smokers are at particular risk of HIV infection due to heterosexual exposure. HIV risk reduction interventions seeking to increase condom use among drug users have met with minimal success, and there is a need for interventions to be strongly grounded in psychosocial models of behaviour change. This study presents the results of an investigation of predictors of intention to use condoms and related therapy processes among heterosexual drug users. Data were analyzed from 586 crack smokers recruited in Washington, DC, Miami, Florida, and Collier County, Florida who reported having both primary and casual sex partners. Participants responded to items derived from the theory of reasoned action, the theory of planned behaviour and the transtheoretical model of change. Condom use beliefs and therapy processes used to initiate and maintain condom use were assessed. Outcome expectancies and normative beliefs were the strongest predictors of intention to use condoms with a primary sexual partner. In turn, beliefs that condoms inhibit sexual romance and decrease sexual pleasure strongly predicted outcome expectancies. Therapy processes found to be associated with these constructs included: self-liberation, counter conditioning and stimulus control/reinforcement. Results suggest that HIV risk reduction interventions using a group format and targeting condom beliefs related to sexual romance and pleasure will decrease negative outcome expectancies about condom use. Also, reinforcing attempts to use condoms with intimate partners should increase positive outcome expectancies and intention to initiate or maintain condoms with a primary sexual partner.

Problem drinking, health services utilization, and the cost of medical care.

The purpose of this study was to examine the relationships between problem drinking, health services utilization, and the cost of medical care in a community-based setting. In addition to descriptive analyses, these relationships were estimated with multivariate regression models. Data were collected in 1996 and 1997 through a standardized self-administered questionnaire designed to obtain important information on demographics, health status, morbidity, health care utilization, drug and alcohol use, and related lifestyle behaviors. The survey instrument also included the 10-item Michigan Alcoholism Screening Test (MAST-10), which was used to identify problematic alcohol users (PAUs). The empirical findings indicated that PAUs had a significantly higher number of outpatient visits, more emergency room episodes, and more admissions to a hospital than a combined group of nondrinkers and nonproblematic alcohol users (NPAUs). Analyses of total health care cost showed that the estimated differential in total cost for PAUs during the past year, including the interaction effect with problematic drug use, was $367. The total cost (full effect) for PAUs was composed of a main effect ($984) and an interaction effect (-$617). These findings have implications for substance abuse interventions and health care policy.

Treating substance-using women and their children in public housing: preliminary evaluation findings.

The Key West Housing Authority created SafePort, a residential substance abuse treatment program within public housing to provide drug treatment to parenting women. All family members-women, children, and significant others-receive comprehensive assessments to determine appropriate therapeutic interventions to resolve their problems. Preliminary evaluation findings suggest that women who participate with their children are more likely to remain drug free than are those who participated without their children.

Reawakening the dragon: changing patterns of opiate use in Asia, with particular emphasis on China's Yunnan province.

Asian countries adjacent to the Golden Triangle and their neighbors have witnessed an evolution in "drug abuse" from traditional opium smoking to heroin eating, smoking, and finally heroin injection. A recent study of 630 heroin users was conducted in China's Yunnan Province, located close to the Golden Triangle. Data collected between August 1997 and February 1998 indicate injecting heroin users, in comparison to noninjectors, were more likely to have used drugs for a longer period of time, and to use drugs more frequently everyday. Other major differences existed between urban and rural subjects, especially highlighting differences between men and women. Women comprised a much higher proportion of urban subjects than rural subjects. Rural injectors were much more likely to be male, but urban injectors were almost evenly split between men and women. The emerging epidemic of heroin use in China and the continuing substance abuse problem in the United States provide an opportunity for collaborative research of mutual benefit.

The association between cigarette smoking and drug abuse in the United States.

Cigarette smoking has been identified as an independent risk factor for many human diseases. However, the association between cigarette smoking and illegal drug use has not been thoroughly investigated. We have analyzed the 1994 National Household Survey on Drug Abuse to clarify whether cigarette smoking has any effect on the initiation of illegal drug use. Data from 17,809 respondents completing the 1994 "new" (1994-B) questionnaire were analyzed. Logistic regression analyses were performed with the use of statistical package SUDAAN, taking into consideration the multistage sampling design. The results show that those who had smoked cigarettes were far more likely to use cocaine (OR = 7.5; 95% CI: 5.7-9.9), heroin (OR = 16.0; 95% CI: 6.8-37.9), crack (OR = 13.9; 95% CI: 7.9-24.5) and marijuana (OR = 7.3; 95% CI: 6.2-8.7). The associations are consistent across age-strata and remain after adjusting for race and gender. This study suggests that cigarette smoking may be a gateway drug to illegal drug use.

Adoption of injection practices in heroin users in Guangxi Province, China.

This preliminary study collected data from 326 heroin users in Guangxi Province, China, in 1997. Logistic regression analysis was performed to identify the risk factors for injection. Survival analysis identified factors independently associated with time from initiation of heroin use to adoption of injection. Four factors were independently associated with injection: number of friends who used heroin in the last year, duration of heroin use, dose of heroin consumed, and total number of times detoxified in drug treatment and rehabilitation centers. Only gender and duration of heroin use were independently associated with time to first injection. Median time to first injection was 11 months for males and 22 months for females. Median time to first injection varied by age. Median time to injection for those who used heroin for more than one year was 8.1 months; it was 19.1 months for on to five years of use, and 40.5 months for more than five years of use. This study's preliminary findings suggest that younger, more recent heroin users, and males are at increased risk of becoming injectors, a major risk behavior for HIV acquisition.

Chronic illicit drug use, health services utilization and the cost of medical care.

Few studies have examined the relationships between drug use, health services utilization and the cost of medical care for a community-based sample of drug users. The purpose of this study was to analyze recently collected data on chronic drug users (CDUs), CDUs who were also injecting drug users (IDUs) and non-drug users (NDUs) to determine whether these groups exhibited differences in health services utilization and cost. In addition to descriptive analyses, these relationships were estimated with multivariate regression models. Data were collected in 1996 and 1997 through a standardized self-reported questionnaire administered to individuals who were recruited through community outreach activities in the USA. Annual differences in health services utilization between CDUs, IDUs and NDUs were estimated for three measures: number of times admitted to a hospital, number of outpatient visits and number of emergency room episodes. Results of this study indicate that CDUs and IDUs consumed significantly more inpatient and emergency care, but less outpatient services relative to NDUs. Analyses of total health care costs showed that CDUs and IDUs each generated about $1000 in excess services utilization per individual relative to NDUs. This research is the first study to compare differences in health services utilization and cost among out-of-treatment drug users relative to a matched group of non-users in a community-based setting. The findings suggest that health care providers and managed care organizations should consider policies that promote more ambulatory care and discourage emergency room and inpatient care among drug users. Innovative and culturally acceptable approaches may be necessary to provide incentives without posing unusual financial hardship.

HIV-1 RNA load in needles/syringes from shooting galleries in Miami: a preliminary laboratory report.

We quantified HIV-1 RNA load in rinses from needles/syringes (N/S) obtained at shooting galleries in Miami and also analyzed the rinses for antibodies for viral proteins. In rinses from 36 N/S that contained visible blood, 14 (39%) had detectable amounts of HIV-1 RNA. Numbers of copies of HIV-1 RNA ranged from the detection limit (400 copies/ml) to 268,000 copies/ml. We also detected antibodies to HIV-1 polypeptides in 34/36 (94%) of rinses from visibly contaminated N/S using Western blots specific for the HIV-1 proteins. No antibodies were detected in laboratory rinses from six visibly clean needles. The presence of HIV-1 RNA in N/S is an important indication of the risk created by N/S sharing as well as by shared paraphernalia and wash waters by injecting drug users.

The impact of insurance status on drug abuse treatment completion.

This article discusses the impact of insurance status on drug abuse treatment completion in a not-for-profit organization, presents demographic findings, mentions financial obstacles to paying for treatment, and describes the relationship between different variables: treatment modalities versus type of drug, treatment modality versus length of stay, reason for discharge versus type of drug, and reason of discharge versus treatment status (completed/not completed). Baseline data (n = 6,539) for the period 1990-1997 was analyzed. For the insurance status analysis we randomly selected and analyzed 1,153 client entries. A statistical software package (STATA) was used for a combination of bivariate and multivariate analysis. Our results indicated, consistent with expectations, that lack of health insurance is associated significantly with not completing treatment. Therefore, new strategies and mechanisms of payment should be created to overcome these obstacles and facilitate treatment completion for clients without insurance coverage.

HIV seroprevalence across the rural/urban continuum.

While the first decade of the AIDS epidemic was characterized by high prevalence rates of AIDS infection in urban areas, there is increasing recognition of the spread of HIV into rural communities in the United States. Data from the Miami CARES cohort collected on 3,555 chronic drug users from 1988 to 1994 provide a unique opportunity to assess sociodemographic characteristics, drug-using behaviors and HIV risk behaviors related to HIV seropositivity in three communities across the rural-urban continuum: Miami, Florida; Belle Glade, Florida and Immokalee, Florida. The three very different communities studied demonstrate that HIV is no respecter of ecological site. The spread of HIV between areas and within areas is specifically correlated with the risk factors including injection drug use, use of crack cocaine, exchange of sex for money, and the rates for sexually transmitted diseases. All of these factors are shown to increase the risk of HIV so that the constellation of these practices helps determine the differential rates and spread of HIV in the three different areas.

Behavior changes among crack-using rural and urban women.

This study compared rural and urban crack-using women and examined their responses to two interventions. A prospective cohort study design was employed to assess the effectiveness of standard and innovative HIV prevention interventions on 541 urban and 268 rural women in Florida. Generalized estimating equation analysis, accounting for repeated measures, found that for combined urban and rural samples, the innovative intervention was more effective than the standard for a number of drug and sexual risk behaviors. However, the analysis indicated no significant differences in intervention efficacy between rural and urban women. The results imply that there is a need for similar HIV prevention services in both areas.

Crack cocaine use in rural migrant populations: living arrangements and social support.

Correlates of crack cocaine use were studied among a targeted sample of migrant workers and their sexual partners (n = 571) in rural Southern Florida. Employment among men and recent drug-user treatment among men and women are positively related to crack use, as is involvement in crime and prostitution. Among women but not men, living with children is negatively related to crack use. Drug use and HIV prevention programs should intervene with individuals and their families and social groups. Migrant workers and their sexual partners also need effective drug-user treatment with long-term relapse prevention services.

Drug treatment experiences: rural and urban comparisons.

This study sought to investigate treatment-seeking behaviors among drug users in rural populations and how they compare to their urban counterparts. Data for this analysis were drawn from the Miami and Immokalee sites of the National Institute on Drug Abuse's Cooperative Agreement Program for AIDS outreach/intervention research study targeting high-risk out-of-treatment injection drug users and crack smokers. Findings indicate that Miami subjects were 2.57 times more likely to have been in drug treatment compared to their rural counterparts. This differential may be explained in terms of the availability, accessibility, and acceptability of health care services.

Economic evaluation of breast cancer screening: A review.

PURPOSE: The authors provide a review of the economic evaluation literature of breast cancer screening and identify important trends and gaps in the literature. OVERVIEW: Healthcare resources are limited and economic evaluation plays a critical role in resource allocation, healthcare policy, and clinical decisions. Many economic evaluations of medical practice, however, are unreliable and do not use appropriate analytic techniques. Three important trends were observed. First, two economic evaluation methods are dominant. Second, a wide range of cost estimates exists across studies. Third, a lack of standardization exists across studies with regard to basic economic evaluation principles. These findings should be considered when conducting future research, analyzing economic evaluations of breast cancer screening, and developing clinical guidelines. CLINICAL IMPLICATIONS: Concerns about cost containment in healthcare make it necessary for physicians and clinical administrators to take an active role in resource allocation decisions at the clinical level. For instance, the recent debate on the proper age to begin annual mammography screening involves both resource allocation and clinical issues. Thus, it is important for physicians and clinical administrators to be familiar with the economic evaluation literature of breast cancer screening, economic evaluation methodology, and the associated shortcomings of published estimates.

Moving substance-abusing women from welfare to work.

Substance abuse and welfare reform are among the nation's highest priorities, and research that examines linkages between the two is of extreme importance to both government policy and the community. Welfare reform will have serious implications for substance abusers as well as for the various professionals who treat them and work to move their clients into functional recovery and self-sufficiency. Within the context of welfare reform and the special needs of substance-abusing populations, the present study examines current welfare status, work status, and barriers and facilitators to gaining and maintaining employment among 100 low income women who participated in a long-term residential substance-abuse treatment program in Miami, Florida. Participants completed a face-to-face interview to assess a detailed employment history and current sources of income as well as the Addiction Severity Index. Results indicate that completers of the treatment program were more likely to be working post-discharge than non-completers. Similarly, the longer the length of stay in the program, the more likely the client was to be working post-discharge. Multivariate analysis indicates a high-school education, participation in the treatment center's aftercare program, and treatment duration of more than one year were independently related to work status. These data suggest that as welfare reform becomes a reality, continuing support of various types, particularly drug treatment, is needed to assist substance-abusing women in gaining and maintaining employment.