Emergent Issues in the Field of Drug Abuse: Volume 7

The drug abuse prevention research and practice community has recognized only in the past two decades the important relationship between findings from epidemiologic studies and the development of effective preventive interventions. Epidemiologic studies show what drugs are being used, in what ways, and by whom. They show the age at which most drug users initiate the use of illicit drugs and what characteristics and factors are most likely to be associated with increased risk to initiate drug use. This information and advances in understanding behavior change have had significant impact on the design of effective interventions to prevent drug abuse. This chapter discusses the relationship between epidemiologic and prevention intervention research in five section: (1) a brief history of drug abuse epidemiologic and prevention intervention research; (2) an overview of the epidemiology of drug abuse with an emphasis on the initiation of drug use among children and adolescents; (3) a discussion of the implications of epidemiologic findings for the design of prevention interventions; (4) a review of recent positive findings from prevention intervention research; and (5) a summary of gaps in our knowledge base requiring additional research.

The intuitively appealing hypothesized relationship between drug use and physical health status is reexamined critically in a longitudinal perspective. Individuals who were first surveyed in Houston junior high schools in 1971 are followed up through personal interviews in the fourth decade of life. In addition to focusing on the baseline effect of drug use on health, we include latent constructs reflecting deviance and psychological maladjustment as theoretically relevant antecedent and mediating variables. Using structural equation models, we found a positive, significant relationship between adolescent substance use and poor physical health in adulthood. Controlling for the spurious effects of adolescent psychological health, the baseline relationship is reduced, but remains significant. However, including a latent construct for adolescent deviance in the models attenuates the baseline relationship to insignificance. On the assumption that deviance is a cause, rather than a consequence of drug use, we conclude that the general deviant lifestyle, rather than drug use per se, adversely effects physical health, even into middle adulthood.

The objective of this study is to examine the relationship between depression and drug use and potential ramifications of that relationship on the health services needs, utilization, and costs of chronic and injecting drug abusers. A network-based sample of 1,330 injecting and other chronic drug users, as well as non-drug using neighborhood controls, was obtained within Dade County, Florida. Using the Health Services Research Model as an analytical framework, results show that drug users had significantly higher levels of depression than non-drug users from similar neighborhoods. In addition, it was found that depression was significantly associated with perceptions of poor health, increased health problems, and perceived limitations on even light physical activity among both drug users and non-users. Among drug users, depression was also significantly related to not receiving needed care, lack of treatment adherence, use of the emergency room for primary care or any reason, hospital admissions, and any use of outpatient or private clinic services. Results from logistical regression analysis show that even when controlling for relevant issues such as sociodemographic, economic, and drug use variables, depression retains an independent and significant relationship with health services need and utilization. Differences in the cost of health care utilization between depressed and non-depressed samples are also estimated. Implications of this study point to the need to consider screening and treatment for depression within health system structures in order to improve cost-effective access to needed services among drug using populations.

This chapter summarizes findings and conclusions from recent studies exploring the role of motivation-readiness factors in drug abuse treatment. The research focuses on populations entering drug treatment, particularly therapeutic community programs in community- and prison-based settings. However, findings from studies in other modalities and from samples not entering treatment are also discussed. Issues addressed include (1) the nature of the motivational concept in recovery, (2) motivation as a variable affecting treatment retention and outcomes, (3) motivation in the treatment process, (4) differences in motivation across treatment populations and modalities, (5) client correlates of motivation, and (6) motivational enhancement. Conclusions highlight the critical role of motivation-readiness factors in understanding treatment-seeking, retention, and outcomes. Key implications are discussed for research, theory, treatment practice, and health care policy. These implications underscore issues relating to the interaction of motivation and treatment processes, the interaction of motivation and treatment demands, differences in motivation among special populations, client correlates of motivation, and self-selection and study designs.

The substance abuse treatment system is currently confronted with not only more clients but also clients with a complex array of health and human service needs. Existing systems often lack both resources and the institutional structure needed to manage clients with multiple and often chronic needs. Presented in this chapter is a review of a federally funded demonstration project designed to address these client management requirements in the treatment system. The project, Target Cities, focused a variety of interventions designed to improve access to assessments and treatment, client-treatment matching procedures, linkages and referrals to other health and human service providers, and client tracking. Discussed are the history, rationale, implementation, and findings produced by these system changes in one main metropolitan area. The results indicated that centralized intake improved access to treatment while maintaining client satisfaction with the intake process.

This chapter reports findings on two studies that culminated in the development of a multilevel intervention to improve access to health care among chronic drug users. The first two studies began with an investigation of the health care delivery system serving chronic drug users in Miami-Dade County, Florida from the perspectives of both consumers and providers. These studies documented the health care needs and use patterns of chronic drug users as well as the practices and perspectives of the providers who served them. Findings indicated that (1) chronic drug users demonstrated greater health care needs than nondrug users; (2) chronic drug users were less likely to receive appropriate health care services; and (3) the gap between services needed and services actually provided can be ameliorated. By participating in our multilevel intervention, both health care providers and health care consumers changed attitudes and behaviors resulting in the provision of appropriate, accessible, and acceptable health care.

This study examines the relationship between conventional moral belief and drug problem recognition in African-American, Hispanic-American, and non-Hispanic white drug users. After adjustment for demographic, psychosocial, and drug use severity factors that might have confounded this relationship, conventional moral belief was significantly associated with drug problem recognition among African-Americans and Hispanic-Americans but not among whites. The particular relevance of conventional moral belief among nonwhites may reflect cultural values emphasizing collective identity and/or religiosity. Nonwhites may be more inclined than whites to view recovery as a process of claiming or reclaiming moral standing in a community of conventional others.

Much of the literature on drug treatment for women demonstrates a need for gender-oriented, family-centered treatment. Based on observations of a treatment program for Latina women and life histories of female Puerto Rican substance abusers, we expand this argument by describing a trajectory of recovery for female Puerto Rican drug abusers that emphasizes their relationships with children, family, kin and treatment staff. We also identify dilemmas that arise when incorporating these trajectories of recovery into treatment programs. They include (1) the need to balance the interests of mothers with the interests of children; (2) the need to mediate kin and family dynamics that may be counter-productive to recovery, and (3) the importance of establishing treatment contexts that facilitate trust and personal connections without compromising professional distance.

On December 31, 1996, the U.S. Congress officially ended its funding of the Social Security Administration's program of supplemental security income (SSI) and social security disability income (SSDI) cash and Medicaid benefits for drug addiction and alcoholism (DA&A). This social policy change is part of the U.S. Congress welfare reform, which will impact more than 26,000 Illinois residents, thousands in Cook County alone. Our study seeks to illuminate the meaning of these benefits to a group of approximately 40 former Cook County recipients. We explored the utility and meaning of the cash and Medicaid benefits to at least three types of recipients (Good Citizens, Hustlers, and Lost Souls) that emerged from a series of focus groups. Our paper studies the differences between the three types of recipients in their use of cash (e.g., from paying for housing and living essentials to purchasing drugs) and Medicaid (e.g., medications and drug treatment) benefits. Findings and conclusions also generate important insights into how recent social policy changes impact the drug-using community and produce new health and social problems for both the former recipients and society-at-large.

This chapter explores the impact of the National Institute on Drug Abuse (NIDA) funded by Cooperative Agreement AIDS education and prevention program on crack users and drug injectors. Data on the 5,789 participants were drawn from eight cities throughout the United States. Subjects were classified into three user groups: injectors only, crack smokers only, and crack-smoking injectors. They were interviewed at baseline and six months later at follow-up about their HIV risk behaviors which included needle-related behaviors, drug use patterns, and sexual behaviors. At baseline, subjects were assigned either to a two-session NIDA developed standard intervention or to a more elaborate and prolonged enhanced intervention which was independently developed in each of the sites. Analyses were conducted for the cities individually. Three major findings emerged from the analyses: (1) there is a relative lack of post intervention differences between the standard and enhanced interventions; (2) statistically significant and substantively meaningful changes occurred between pretest and posttest; and (3) despite meaningful reductions in risk behaviors among some users, a large percentage of these drug users continue to engage in all types of risky behaviors. Implications of these findings are discussed in the chapter.

HIV prevention among drug users continues to be a daunting challenge. Previous efforts have shown limited success. A major research question for the next generation of HIV prevention interventions for drug users is how do we design, implement, and evaluate harm reduction interventions that reach the appropriate audiences, are programmatically sustainable, maintain behavior change, and lead to meaningful changes in participants' lives. The goal of this chapter is to critique the current state of HIV prevention research and to propose using additional social science theories and methods in future approaches to behavior change. The first section of this chapter examines some of the historical and psychological factors that may have hindered progress in the field of behavioral HIV prevention. The next section presents a theoretical foundation for a social influence approach to HIV prevention interventions for drug users that considers opportunity structures within an individual's social environment. This approach emphasizes behavioral Settings, Norms, and Network Approaches to AIDS Prevention (SNNAAP). By capitalizing on naturally occurring social influence processes, promoting HIV-related behavior change among drug users may be possible. The section discusses social behavioral theories, social-oriented research methods, and individual-level factors that have been inadequately pursued in the field of HIV prevention. Examples of interventions that have incorporated social behavioral theory are presented. Next, several approaches to improving HIV prevention research methods are discussed. Finally, future directions of HIV prevention research are proposed.

This study evaluates the role of monetary incentives in the recruitment of crack-cocaine and injection drug users into an AIDS prevention program in Anchorage, Alaska. The study also looks at how seasonality impacted recruitment of this population. Data from interviews with 1,427 out-of-treatment drug users were aggregated to monthly levels. Forty-seven months of data were used in the analysis. Independent variables included monthly income, source of income, employment status, self-reported homelessness, incentive paid at intake, potential incentive at follow-up, and data on the local unemployment rate. A dummy coded variable for seasonality also was included. Regression analysis was used to develop a model using number of individuals recruited each month as the dependent variable. Only one variable, the incentive paid at intake, was significant at p < .05. A strong interaction effect was found between the amount of the incentive paid at intake and seasonality. The chapter concludes that the use of monetary incentives has a positive effect on the recruitment of hidden populations.

This paper examines the determinants of neighborhood readiness to engage in collective action for substance abuse prevention. Factors investigated include community composition (characteristics such as SES, presence of children, racial composition), community context (drug problems and police resources), and community organization (formal neighborhood association functioning, informal neighboring, collective activities). Data were obtained from 188 community leaders who reported about their neighborhood, and census data were aggregated to the neighborhood level. Community composition and context factors had opposite effects on formal and informal neighborhood organization: SES was positively associated with informal neighboring and negatively associated with formal organization, while drug problem severity was negatively associated with informal neighboring and positively associated with formal organization. Yet, formal and informal organization were positively associated with one another, and both were positively associated with perceived readiness of the neighborhood to engage in additional drug prevention activities in the future.

Private alcohol problem treatment in the United States arose from a social movement that began after Prohibition and culminated in the founding of the National Institute on Alcohol Abuse and Alcoholism in 1970. Using a treatment model that incorporated much of the ideology of Alcoholics Anonymous, an isomorphic set of private treatment centers grew rapidly across the country with support and assistance from NIAAA. As this support diminished and cost containment emerged, a crisis struck the population of treatment centers, leading to many closures. Nonetheless, most of the centers have survived. This chapter uses data from a national longitudinal study of privately funded alcohol problem treatment centers to illustrate the transformation of the treatment industry during the 1990s. We argue that this transformation results from an increased difficulty in obtaining treatment funding due to the health care cost-containment practices of managed care.

Drug abuse research has received strong and continuing support in the hope that the knowledge acquired from that research will shape the course of drug abuse treatment and prevention. However, whereas mechanisms exist to assure the sharing of knowledge within the research community, efforts to bridge the gap between research and practice have been partial and inadequate. Getting treatment and prevention programs to adopt new behaviors requires a use of strategies capable of inducing organizational change. Studies have demonstrated the importance of interpersonal contact as a part of those strategies, and the futility of relying on the professional literature. Nonetheless, reliance on the print media continues to be the strategy of choice to achieve technology transfer. To permit research findings to influence the course of drug abuse programming and policy will require new governmental initiatives in terms both of an emphasis on interpersonal contacts to achieve organizational change, and the promotion of technology transfer as a significant area for study.