National Institute on Drug Abuse
Director's Report to the National Advisory Council on Drug Abuse
February, 1998
Research Findings
Clinical and Services Research
Psychosocial Predictors of Drug Abuse Among Drug Clinic-Referred Youths
In a study that examined 2582 adolescents referred to drug treatment facilities nationwide and in Ontario, Canada, who met criteria for DSM-III-Revised drug abuse or dependence of at least one psychoactive substance, Winters, Latimer and Stinchfield found the strongest predictors of drug use severity at the time of referral, as measured by the Personal Experience Inventory, to be use of illicit drugs by peers and by siblings. Less predictive were psychological distress (emotional disturbance; social isolation), declaration of nonconventional values (e.g., rejecting conventional values; absence of goals; spiritual isolation), and family distress (e.g., parent drug use; parent dysfunction; family estrangement). Results were similar for all racial/ethnic, gender, and age subgroups represented in the study sample. Journal of Pediatric Psychology. In Press.
DSM-IV Criteria for Adolescent Alcohol and Cannabis Use Disorders
In a study comparing DSM-III-Revised and DSM-IV criteria for alcohol and cannabis use disorders among 772 teenagers (63% boys; 77% white) referred to adolescent outpatient drug treatment programs in the Minneapolis, MN area, Winters, Latimer and Stinchfield found that compared to the use of the DSM-III-R criteria, the application of DSM-IV criteria for alcohol and cannabis use resulted in more "abuse" assignments and fewer "dependence" assignments. Study results indicated that the shift in diagnostic assignments when using DSM-IV compared to DSM-III-R was due to a lowering of the abuse threshold rather than a tightening of the dependence criteria. Journal of Studies on Alcohol. In Press.
Marijuana Use and Treatment Outcome Among Opioid-Dependent Patients
Dr. Alan Budney and colleagues at the University of Vermont assessed marijuana use in 107 persons enrolled in treatment for opioid dependence. The relationship between marijuana use and treatment outcome was explored in a subset of this sample who received treatment that included buprenorphine detoxification and behavior therapy (N=79). Sixty-six percent of participants were current marijuana users and almost all (94%) continued to use during treatment. Only a few markers of increased psychosocial impairment or adverse consequences associated with marijuana use were observed. Users were less likely to be married than nonusers, and more likely to report financial difficulties, be involved in drug dealing and engage in sharing of needles (p<.05). A unique effect of marijuana use on drug dealing and sharing needles was retained after statistically controlling for the influence of heroin and alcohol use and other sociodemographic variables. No significant adverse relations were observed between marijuana use and treatment outcome. These outcome findings are consistent with previous studies examining marijuana use in opioid-dependent and cocaine-dependent patients. This suggests that progress in treatment for opioid dependence can be made without mandating that patients abstain from marijuana use. Addiction, In Press.
Persistence and Clinical Significance of Hepatitis G Virus (HGV) Infections in Injecting Drug Users
To determine the prevalence of HGV infection and its association with liver disease, HGV RNA was assessed in the most recent serum sample for 246 long-term IDUs and in prior specimens for those found HGV-RNA positive. HGV RNA was detected at the most recent visit in 15%. Of those found positive, 82% also had HGV-RNA positive serum samples at all prior visits occurring a median of 6.1 years earlier. HGV-positive IDUs were younger and had fewer years duration of drug use, suggesting that HGV RNA had previously been cleared. Serial samples from 29 short-term IDUs detected HGV RNA in 9 (31%) and in 56% of those HGV infection cleared. No differences were detected in serum levels of liver-related enzymes among HGV RNA-positive vs. HGV RNA-negative IDUs (p>.20). These data indicate that HGV infection is not associated with hepatic inflammation, and that HGV clearance occurs after many acute infections but uncommonly in persons who remain RNA-positive years after exposure. Thomas, D.L., Nakatsuji, Y., Shih, J.W. et al., J Infect Dis, 176, pp. 586-592, 1997.
Cannabis Dependence, Withdrawal, and Reinforcing Effects Among Adolescents with Conduct Symptoms and Substance Use Disorders
Crowley and his colleagues from the University of Colorado assessed 209 adolescents (165 males, 64 female; 13-19 year old), who were referred for substance and conduct problems, to determine if cannabis produced dependence and withdrawal. The subjects were diagnosed with substance dependence, 100%; current conduct disorder, 82.1%; major depression, 17.5%; and attention-deficit/hyperactivity disorder, 14.8%. Most patients claimed serious problems from cannabis, and 78.6% met standard adult criteria for cannabis dependence. Two-thirds of cannabis-dependent patients reported withdrawal. Progression from first to regular cannabis use was as rapid as tobacco progression, and more rapid than that of alcohol, suggesting that cannabis is a potent reinforcer. Data indicate that for adolescents with conduct problems cannabis is not benign, and that the drug potently reinforces cannabis-taking, producing both dependence and withdrawal. However, the authors suggested that findings from this severely affected clinical population should not be generalized broadly to all other adolescents. Crowley, T.J., MacDonald, M.J., Whitmore, E.A., and Mukulich, S.K. Drug and Alcohol Dependence, In Press.
Influences on Adolescent Substance Dependence: Conduct Disorder, Depression, Attention Deficit Hyperactivity Disorder, and Gender
Whitmore and his colleagues from the University of Colorado conducted a study to determine if prevalence and severity of conduct disorder (CD), major depression and ADHD would differ by gender, and that these conditions would associate differentially with severity of substance disorder (SD) in males and females. The subjects were 285 male and 82 female adolescents referred for treatment for comorbid CD and SD. The investigators found that males and females did not differ significantly in severity of substance involvement, major depression, or ADHD, but males had more severe CD. Major depression was the only variable significantly associated with SD severity for females, while for males, severity of CD combined with major depression and ADHD was significantly associated with SD severity. The authors concluded that among referred adolescents, CD, major depression, and ADHD may all be important concomitants of SD in males, while in females, depression may be the primary variable related to SD. Whitmore, E.A., Mikulich, S.K., Thompson, L.L., Riggs, P.D., Aarons, G.A., and Crowley, T.J., Drug and Alcohol Dependence, 47, pp. 87-97, 1997.
Fluoxitine in Drug-Dependent Delinquents with Major Depression: An Open Trial
Riggs et al. treated, in an open trial for > 7 weeks with a fixed dose of 20 mg of fluoxitine, a group of adolescents, who had been referred to residential treatment for substance use disorder. A >50% improvement was observed in mean scores on the 10-point depression scale. Of the 8 adolescents, 7 showed marked improvement and wished to continue fluoxitine after trial. Side effects were mild and transient. No subject required dosage reduction or discontinuation of medication because of side effects. Fluoxitine appeared useful in treating substance-dependent delinquents whose major depressions persisted or emerged after 4 weeks of abstinence. These preliminary findings justify a controlled trial in such youths. Riggs, P.D., Mikulich, S.K., Coffman, L.M., Crowley, T.J. J. Child and Adolescent Psychopharmacol, 7(2), pp. 87-95, 1997.
Risk Factors for Disruption of Primary Caregiving of Substance-Abusing Mothers
Researchers at the University of Maryland School of Medicine have identified perinatal factors (i.e., postpartum hospital stay and 2-week visit) that are predictive of disruption of primary infant caregiving among high-risk, substance-abusing mothers. Disruption of primary caregiving was defined as the infant receiving substitute care during the first 18 months of life because of the mother's inability to care for her infant due to neglect/abuse, incarceration, continued drug abuse, or homelessness (includes voluntary placement with a relative as well as protective service referral). All women in the study were at high risk for disruption based on histories of drug abuse, poverty, limited education, and other social problems. All had a history of heroin and/or cocaine use during pregnancy. Analyses were based on 152 mother-infant dyads from a larger, ongoing longitudinal study. Forty-three percent of the sample had disruption in primary caregiving. Bivariate analyses compared the disruptive care group with the non-disruptive care group on maternal and neonatal factors. Results of a multiple logistic regression showed that younger maternal age, two or more other children, positive heroin tox at delivery, and reported depressive symptoms were significantly associated with disruption of caregiving. The investigators discuss possible processes underlying these relationships, and implications of the findings for screening and service delivery. Nair, P., Black, M.M., Schuler, M., et al. Child Abuse & Neglect, 21, pp. 1039-1051, 1997.
Demographic, Drug Use, and Psychosocial Characteristics of Rural Pregnant Cocaine Users
Data from a University of Florida project following the development of children exposed to cocaine in utero provide important new information on the demographics, drug use patterns, and psychosocial factors of a sample of women rarely characterized in the scientific literature, i.e., women from a generally rural population with minimal access to drug treatment, and with varying amounts of crack cocaine use during pregnancy, but with little other illicit drug use during pregnancy. The study involved 154 women in the cocaine use group, and 154 in the non-cocaine comparison group, matched on race, parity, socioeconomic status, and level of prenatal risk. Based on information collected at the time of study enrollment (i.e., the earliest contact possible after the first trimester of pregnancy) for the demographic and drug use factors, and at the time of delivery for the psychosocial variables, cocaine users were found more likely to be older, to use other drugs, to begin their drug use at an earlier age, to have more depressive symptoms, to have an external locus of control, to have lower self-esteem, to have a more simplistic understanding of child development, and to have higher positive life event impact scores. There were also similarities between the two groups, such as level of education completed (average of 11th grade for both groups) and marital status (69% never married in each group). Both groups exhibited a very low level of reading skills, a finding that led to reading the interviews and measures to each participant, and that has implications for healthcare and drug treatment programs. Behnke, M., Eyler, F.D., Woods, N.S., et al. Journal of Drug Issues, 27, pp. 501-524, 1997.
MDMA Neurotoxicity - Occurrence and Consequences
George A. Ricaurte, M.D., Ph.D. and colleagues at the Johns Hopkins School of Medicine have been studying MDMA ("Ecstasy") in a large cohort of MDMA-exposed humans. They have found that cerebrospinal fluid (CSF) measures of monoamine metabolites indicate that MDMA users have selective decreases in CSF 5-HIAA, the major metabolite of serotonin and a valid indicator of brain serotonin neurotoxicity in nonhuman primates. Also, MDMA users have been found to be more impulsive, less harm-avoidant, and more sensation seeking than control subjects. As recreational use of MDMA is increasing, it is essential to understand the possible long-term deleterious effects of MDMA on serotonin neurons in the human brain. This research delineates public health risks of recreational MDMA use and elucidates the role of brain serotonin in humans. (These findings were presented at the September 24, 1997 NIH Clinical Staff Conference and a manuscript summarizing the findings was invited by Annals of Internal Medicine).
Marijuana Intoxication and Brain Activation
Roy J. Mathew, M.D. and colleagues at the Duke University Medical Center have studied brain activation in marijuana smokers with regional cerebral blood flow (rCBF) measured with positron emission tomography (PET). He found that THC increased rCBF especially in the frontal regions bilaterally, insula and cingulate gyrus and subcortical regions with somewhat greater effects in the right hemisphere. Self ratings of THC intoxication showed significant effects and regression analysis indicated intoxication correlated most markedly with the right frontal region. Behavioral manifestations of marijuana intoxication may be associated with increased functional activity of the brain especially the frontal cortex, insula and cingulate gyrus. Mathew, R.J. et al., Life Sciences, 60 (23), 1997.
Serotonin and Aggression in Cocaine Dependence
Frederick G. Moeller, M.D. and colleagues at the University of Texas Health Sciences Center at Houston have found a significant correlation between the presence of antisocial personality disorder (ASPD) and frequency of aggressive responding. When ASPD was statistically controlled, no significant relationship was found between aggressive responding and cocaine craving, withdrawal symptoms, amount of cocaine used, or length of time since use. These preliminary results suggest that in cocaine-dependent persons seeking treatment, current aggression is most dependent upon the individual's previous history of aggressive behavior. Knowledge of the precise relationships among the variables of aggression, cocaine dependence, cocaine withdrawal, brain functioning and serotonin will enable researchers to have a firm basis upon which to construct more effective diagnostic and treatment strategies for cocaine dependent users with and without a history of violence and aggressive behavior. Moeller, F.G. et al., Drug Alcohol Depend, 44(2-3), 1997.
Concordance for ADHD Greater for Monozygotic than Dizygotic Twin Pairs
Twin concordance was assessed in a community-based sample of 194 monozygotic and 94 dizygotic male twins, aged 11-12 and with DSM-III diagnoses of ADHD from structured interviews of teachers and of mothers. Concordance rates for ADHD diagnoses were greater for monozygotic twin pairs compared to dizygotic, especially for diagnoses based on mothers' ratings; concordance rates were more similar for teachers' ratings. Thus, the magnitude of the genetic component seems to depend, in part, on the informant (of phenotype). Nevertheless, model-fitting analyses indicated strong additive genetic components, smaller non-shared environmental components and no shared environment components. These data are important because ADHD is recognized as a risk factor for development of substance abuse. Sherman, D.K., Iacono, W.G., & McGue, M.K., J Am Acad Child Adolesc Psychiatry, 36(6), 1997; Sherman, D.K., McGue, M.K., & Iacono, W.G., Am J Psychiatry, 154(4), 1997.
DATOS
A special issue of the Psychology of Addictive Behaviors (December 1997) is devoted to findings from NIDA's Drug Abuse Treatment Outcome Study (DATOS). This issue is introduced by Dr. Alan Leshner and features 7 articles by cooperative study participants. The articles include an overview of DATOS and treatment evaluation research in the United States by Fletcher et al.; the methodology and research design of DATOS by Flynn et al.; an overview of 1-year follow-up outcomes in DATOS by Hubbard et al.; treatment retention and follow-up outcomes by Simpson et al.; DATOS treatment structure and program services by Etheridge et al.; the relationship of program diversity and retention by Simpson et al.; and a paper on the drug addiction and treatment careers of patients in DATOS by Anglin et al. DATOS is featured in an upcoming issue of NIDA NOTES.
Effectiveness of Node-Link Mapping Enhanced Counseling for Opiate Addicts: A 12- Month Posttreatment Follow-Up
A series of experimental studies at Texas Christian University has shown that a relatively low-cost visual enhancement to drug abuse counseling, called node-link mapping, leads to better during treatment outcomes than counseling-as-usual for patients in outpatient methadone treatment. "Mapping" is associated with greater patient commitment to treatment in terms of session attendance, improved relationships with the counselor, and fewer urine samples positive for opioid and cocaine metabolites. Findings show enhanced communication with patients having attention problems, minorities, and cocaine-using opioid addicts. A new posttreatment follow-up study (n=180) shows patients assigned randomly to mapping counseling reported less criminal activity and exposure to HIV risks due to the reduced use of contaminated needles in the 12 months after treatment than did patients in the standard counseling condition. It was also found that among patients staying less than 6 months in treatment, those in the mapping group had fewer urines that tested positive for opiates at follow-up and were also significantly lower in dirty needle risks than standard counseling patients. Thus, mapping-enhanced counseling may be especially beneficial for patients who leave treatment prematurely. The cumulative evidence from this and previous studies indicates that mapping represents a tool that has promise for improving the effectiveness and efficiency of drug abuse counseling programs. Joe, G.W., Dansereau, D. F., Pitre, U. and Simpson, D.D. Journal of Nervous and Mental Disease, 185, pp. 306-313, 1997.
Influences of Family and Friends on Client Progress During Drug Abuse Treatment
Relationships with family and friends reported by 439 heroin addicts during the first 3 months of drug abuse treatment were examined in relation to behavioral improvements of clients. Family conflict and peer deviance were significant predictors of injection frequency and illegal activity during treatment, and reductions in family conflict were associated with lower drug use, injection frequency, and illegal activity during treatment. These results support treatment emphasis on helping clients reduce conflict among family member and on replacing deviant friendships with others that encourage treatment participation and conformance to social norms. Knight. D.K., & Simpson, D.D. Journal of Substance Abuse Treatment, 8(4), pp. 417-429, 1996.
Managed Care of Substance Abuse Disorders
Definitive characterizations of managed care with regard to substance abuse issues are difficult given the rapidly changing landscape of both private and public health plan programs. The dynamic nature of Managed Care Organizations (MCOs) creates both problems and opportunities for generalist physicians who see substance-abusing patients. Problems include fiscal incentives that may run counter to the physician role, and more fragmented communication between physicians and other addictions providers when psychiatrists, mental health nonphysicians clinicians, and other specialty programs are carved out into separate delivery systems. Opportunities include the potential for psychiatric consultation liaison, for expanded physician intervention and case management roles, for more health plan resources focused on prevention and treatment, and profiling to achieve overall improvements in service delivery. MCOs may rely more heavily on generalist physician involvement with substance-abusing patients if potential benefits of linking substance abuse treatment and primary care can be realized. Larson, M.J., Samet, J.H., and McCarty, D. Medical Clinics of North America, 81(4), pp.1053-1069, 1997.
Estimating the Economic Cost of Substance Abuse Treatment
Few studies have estimated the economic cost and benefits of substance abuse treatment services. French and McGeary have developed a data collection instrument and method for estimating the economic cost of substance abuse treatment programs. The Drug Abuse Treatment Cost Analysis Program (DATCAP) is based on standard economic principles and the method has been tested in two drug abuse intervention studies. Findings from case studies at three treatment programs are presented to demonstrate the feasibility and reliability of the instrument. The estimation methods and results can be used by treatment programs for self-evaluation purposes and by researchers who are interested in performing cost-effectiveness or benefit-cost analyses of substance abuse services. French, M.T. and McGeary, K.A., Health Economics, Vol 5, pp. 539-544, 1997.
A Structured Instrument for Estimating the Economic Cost of Drug Abuse Treatment,the Drug Abuse Treatment Cost Analysis Program (DATCAP)
Drug abuse treatment programs need to know the cost of the services they provide since public and private funding is now being linked to cost and performance measures, and since programs can use financial data to improve efficiency. However, most program staff lack the knowledge to perform a cost analysis, and little user-friendly assistance is available. Furthermore, not all cost methods are consistent, which can lead to noncomparable estimates that are difficult to use for policy or planning purposes. This study reports on a cost methodology developed to provide treatment programs with a needed technical assistance tool. The Drug Abuse Treatment Cost Analysis Program (DATCAP), a structured and scientifically-based instrument for estimating the economic cost of treatment services, is discussed, as is a companion instrument to analyze treatment financing: the Drug abuse Treatment Financing Analysis Program (DATFin). The DATCAP User's Manual, which will enable individual programs to begin collecting the necessary data and estimating economic costs at their own clinics, is described. French, M.T. Dunlap, L.J., Zarkin, G.A., McGeary, K.A., McLellan, A.T. Journal of Substance Abuse Treatment, 14(4), pp. 1-11, 1997.
Modeling Missing Data
In a paper presented at the American Society of Criminology, in November, 1997, Strauss and Falkin discussed early findings of a new methodological approach to examine non-ignorable nonresponse in a sample of (approx. 330) women offenders in drug treatment in New York City. In their sample, about 17 percent self-reported HIV infection. An analysis taking missing data into account increased the upper bound estimate of seroprevalence to 35 percent. Strauss, S. & Falkin, G. Modeling the Missing Data Mechanism: An Exploration into the Unknown, Presented at the Annual Meeting of the American Society of Criminology, San Diego, November 1997.
A Bi-Costal Comparison of Criminal Activity and Drug Use
In November 1997, Falkin and Strauss presented findings from Project WORTH (Women's Options for Recovery Treatment and Health), a large scale evaluation of treatment programs that serve women mandated into treatment in New York City and Portland, Oregon. They found that three-quarters of the women in New York City used crack, while methamphetamine was the most commonly used drug in the Portland sample (reported by over 50% of women). Over three quarters of the women in both cities reported use of stimulants, including cocaine, crack, methamphetamine, and other amphetamines. Injection drug use was more prevalent in the Portland sample. Falkin, G. & Strauss, S., East Coast Meets West Coast: A Comparison of Criminal Activity and Drug Use Among Women in New York City and Portland, Oregon. Presented at the Annual Meeting of the American Society of Criminology, San Diego, November 1997.
Health Needs of Women in Drug Treatment
In a study of 500 women who entered drug treatment programs through the criminal justice system in New York, Falkin and Strauss found that nearly half rated their health as only fair or poor. This is an unfavorable comparison with women in the general population. The most frequently cited health problems were lung problems, gynecological problems, excessive undesired weight loss, night sweats, and HIV/AIDS. Almost one third of the women perceived no connection between their drug use and physical health, and only 20% recognized a close connection between their drug use and health. Health status was poorest among long-time drug users. Falkin, G. and Strauss, S., Emotional and Physical Health Problems and Needs of Women in Drug Treatment, paper presented at the American Public Health Association, Indianapolis, November 1997.
Potential for Child Abuse
Falkin and Strauss found average scores on the Child Abuse Potential Inventory (CAP) among women substance-abusing offenders with minor children (N=300) were in the same range as scores for individuals convicted of child abuse. These scores were significantly higher for women with psychological problems and those who had experienced physical abuse as children. The children of these women may be at high risk for abuse if the women do not receive appropriate interventions after treatment. Falkin, G. and Strauss, S., The Potential for Child Abuse Among Women Offenders Who Abuse Substances, paper presented at the 7th International Conference on Family Violence, Durham, New Hampshire, June 1997.
Predicting Treatment Outcomes for Felony Drug Offenders
In a study of 150 treatment admissions to the Drug Treatment Alternative Program (DTAP), Belenko examined factors that predict length of treatment and treatment outcomes for felony drug offenders diverted into residential treatment. He found that 70 percent of the DTAP clients were still in treatment after one year. Those that did drop out tended to have more extensive involvement in drug dealing and earned more from dealing than those that stayed in treatment. Dropouts were also younger, scored higher on various measures of risk-taking, had higher psychological impairment scores, greater involvement with marijuana and less alcohol involvement, had a lower perceived level of legal pressure to remain in treatment, and perceived prison as less aversive than those who remained in treatment. Belenko, S., Sufian, M, and Young, D. Predictors of Treatment Outcomes for Felony Drug Offenders: Individual Risk Factors and Legal Pressures. Presented at the Annual Conference of the American Society of Criminology, San Diego, November 1997.
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