Director's Report to the National Advisory Council on Drug Abuse

May, 1999

Research Findings

Epidemiology, Etiology, and Prevention Research

In the Past 6 Months

• Heroin has attracted a growing number of young people, many from the suburbs, some of whom inject.

• Marijuana indicators have continued to escalate across the country.

• Cocaine indicators have generally continued to level or decline, but some increases are reported.

• Methamphetamine has been increasingly involved in medical emergencies across the country, but other indicators are mixed.

• "Club drugs," especially GHB, have increasingly resulted in adverse reactions in several areas.

The 45th biannual meeting of the Community Epidemiology Work Group (CEWG) was held in Miami, Florida on December 15-18, 1997.

The CEWG is composed of researchers from 21 metropolitan areas of the United States who meet semiannually to report on patterns and trends of drug abuse in their respective areas; emerging drugs of abuse; vulnerable populations and factors that may place people at risk of drug use and abuse; and, negative health and social consequences. Reports are based on drug abuse indicator data, such as morbidity and mortality information, treatment data, and local and State law enforcement data. Additional sources of information include criminal justice, correctional, medical and community health reports, local and State surveys, and research findings from ethnographic studies. The following are highlights from the meeting:

• Cocaine - While most cocaine indicators continue to reflect declines or stability, some increases are still reported. Cocaine mortality figures declined or appeared stable in eight cities but increased in three areas (Detroit, Phoenix, and Texas) where 1997 or partial-1998 data were available. Emergency department (ED) mentions declined significantly* in 6 of the 20 CEWG cities in the Drug Abuse Warning Network (DAWN) and increased* in 2 (Chicago and Denver). The percentage of treatment admissions for primary cocaine problems declined or remained stable in 15 of the 16 areas where trend data were available (it increased in Philadelphia). Cocaine-positive urinalysis percentages remained relatively stable (within 4 percentage points) among male adult arrestees in 16 of the 17 CEWG cities in the Arrestee Drug Abuse Monitoring (ADAM) program. Again, an increase** in Philadelphia was the exception. The cocaine-using population generally continues to age; however, younger users are still appearing in local indicators in Dallas (ED mentions), Miami, and Washington, DC (arrestee urinalysis). Austin street outreach workers report a new generation of young African-American crack addicts and an increase in crack users among Hispanic women. Injection of crack (dissolved in lemon juice, orange juice, or vinegar) is reported in Austin, Boston (usually in conjunction with heroin), New York, and Washington, DC (either alone or mixed with heroin). Some slight shifts to cocaine hydrochloride are reported: in Detroit (with increased intranasal use), in cities outside of Boston (possibly in relation to cocaine injection), and in San Francisco. In areas such as Atlanta, the crack scene is shifting to suburban and rural counties.

• Heroin - Mortality figures suggest an abatement or plateau following increases: between 1996 and 1997, heroin-related deaths increased in 8 of the 11 cities where such data were available; but partial-1998 data, available in 8 cities, suggest declines or stable levels in 6 of them. DAWN and treatment figures show more mixed trends: ED mentions increased* in four cities (Miami, New Orleans, Chicago, and Washington, DC) and declined* in three (Los Angeles, Baltimore, and New York); and primary heroin treatment percentages increased slightly in four cities (Boston, Detroit, New Orleans, and New York), declined in five (Los Angeles, Philadelphia, San Diego, San Francisco, and Seattle), and remained stable in five (Denver, Atlanta, Minneapolis/St. Paul, St. Louis, and Dallas). ADAM percentages remained generally stable, except for an increase** in Philadelphia.

  Researchers caution against complacence about the recent leveling of some indicator data because there is lag time between heroin initiation and its appearance in indicators. National concerns about the lure of "heroin-chic" trends and the "normalization" of heroin among middle-class youth appear to be borne out in some cities. San Francisco ethnographers report an increase in young middle-class users. Younger populations are also increasingly initiating heroin use in Boston, where needle exchange workers report a recent increase in younger injectors. Atlanta ethnographic reports also continue to indicate an increasing number of recently initiated snorters shifting to injection. An increase in injecting among Newark treatment admissions suggests a possible reversal of the trend toward increased snorting which started in the mid-1980s. A Chicago study identified a high percentage of suburban youth who are injectors. Suburban or rural heroin activity is also reported around the Baltimore and Boston areas. A recent surge in asthmatic reactions among young heroin snorters is under investigation in Chicago.

• Marijuana - Marijuana now accounts for more than 10 percent of total ED mentions in six cities, and it is the top-ranking primary drug treatment problem in four cities (Denver, Seattle, New Orleans, and Minneapolis/St. Paul). ED mentions increased* in six cities; no significant declines were noted. Treatment percentages increased in 10 cities and remained stable in 5. Among adult male arrestees, marijuana-positive findings exceeded cocaine-positives in nine ADAM cities; percentages declined in three cities and increased in two**. In each of the eight CEWG cities where ADAM tests juvenile males, the percentage of positive urinalyses was much higher for juveniles than for adults. Focus group findings in Boston revealed teens who, because they had grown bored with or developed tolerance for marijuana, had moved on to other drugs. Marijuana is sometimes combined with crack in Chicago (3750s), Miami (geek joints), and Philadelphia (turbos); with PCP in Chicago (wicky stick or donk), New York (high-powered blunts), Philadelphia (love boat), and St. Louis; with methamphetamine in St. Louis; with embalming fluid in Minneapolis and Seattle; and with embalming fluid laced with PCP in Houston. The World Wide Web has become a substantial source of information, including instructions on indoor growing, user group discussions, announcements about the "legal" sale of marijuana, and advertisements for marijuana seeds.

• Stimulants - Indicators of methamphetamine use are mixed. Available partial-1998 mortality figures show methamphetamine-related deaths declined in four cities and increased in two (Phoenix and St. Paul). Methamphetamine ED mentions increased* in nine cities, in all regions of the country: Atlanta, Dallas, Denver, Minneapolis/St. Paul, Philadelphia, Phoenix, San Diego, San Francisco, and Seattle; no significant declines were noted. Methamphetamine remains the number-one primary drug treatment problem in San Diego and Honolulu. Treatment percentages increased in four western cities (Denver, San Diego, San Francisco, and Seattle) and remained stable in four (Dallas, Los Angeles, Minneapolis/St. Paul, and St. Louis). Methamphetamine-positive urinalyses remained generally stable** among adult male arrestees. "Tweaking," or "crystal" use, occurs among a broad array of subcultures, including urban gay men, white working-class, bikers, the dance club scene, adolescent girls, and urban runaway street youth who follow a yearly circuit ranging from New Orleans, the Southwest, California, and the Northwest (including Vancouver, British Columbia).

• Methylenedioxymethamphetamine - MDMA (ecstasy, blue lips, blue kisses, and white dove) availability is reported, primarily as a club drug at raves and dance parties, in Atlanta, Baltimore, Boston, Chicago, Miami, New York, St. Louis, Seattle, and Washington, DC. In the Boston area, the prominence of MDMA has increased as reflected in seizure data, in focus group reports by suburban white teens, in reports by needle exchange workers, and in school survey data. MDMA has now become included in Atlanta's weekend-long gay male party circuit. In Seattle, ecstasy is mixed with other drugs, such as LSD (candy flipping), mushrooms (flower flipping), and heroin (H-bomb); a new liquid form of ecstasy in that city is of concern because its purity ranges wildly, it is cut with many different drugs, and users are uncertain of what they are getting. Similarly, in Miami, adulteration is viewed as an opportunity to try something different rather than a ripoff, a phenomenon known as "rolling" because these combinations produce seesaw stimulant and depressant effects.

• Methylphenidate (Ritalin) remains readily obtainable by Boston students in middle- and upper-middle-class communities; it is increasingly reported in Phoenix in poison control calls; and a resurgence is reported in Seattle, where it is diverted from prescribed use, especially among younger students.

• Depressants Ð Use of Gamma-hydroxybutyrate (GHB), a central nervous system depressant, continues to spread across the country with recipes for its manufacture easily accessible on the Internet. It has been involved in poisonings, overdoses, date rapes, and even fatalities in Boston, Colorado, Detroit, Miami, New York, Phoenix, Seattle, and Texas. Availability is also reported in Atlanta, Baltimore, and Minneapolis/St. Paul. It is associated with the club scene, raves, gay circuit parties, and fitness centers and gyms. It is frequently consumed with alcohol, and sometimes with marijuana, LSD, or ecstasy. In New Orleans, it is mixed with amphetamine in an alcoholic drink called "max." Only in San Francisco did ethnographers report a decline in 1998. Its names include "grievous bodily harm," "cherry meth," "easy lay," "gamma," "Georgia home boy," "G," "liquid E," "liquid ecstasy," "liquid X," "great hormones at bedtime," "everclear," "g-riffic," and "salty water." In addition, gamma butyrolactone (GBL) is contained in commercial products (Blue Nitro, RenewTrient, and ReVivarin) legally sold as health supplements; it metabolizes into GHB and produces clinical symptoms identical to GHB. Dangerous labeling may cause a critical lag time in seeking help for GBL toxicity.

  Another club drug, ketamine ("Special K" or "vitamin K"), is popular in cities such as Atlanta, Boston, Miami, Minneapolis/St. Paul, San Diego, and Seattle. It is usually snorted, but injection is reported among young users in some areas, including Boston and Minneapolis/St. Paul. In the latter city, being under the influence of ketamine is known as being "in the hole" or "in the K hole." The drug has been involved in DUI cases and poison control calls in Miami and in one death in San Diego.

• Clonazepam - (Klonopin or Rivotril) has been termed "street drug of the 90s" in Boston. Juveniles in Texas commonly use it in combination with beer. It is sold in Atlanta to enhance the effects of methadone, and it is commonly diverted in Phoenix. Alprazolam (Xanax, or "sticks") is increasingly replacing diazepam on the street in New York; it is also a common street drug in Boston. Diazepam is appearing in Atlanta crack houses. An emerging trend in Seattle involves concomitantly injecting heroin and a depressant, typically diazepam -a longtime practice in Chicago. Flunitrazepam (Rohypnol) reports continue to decline in Miami, but still appear in Minnesota and in Texas treatment and survey data. Use of this "date-rape" drug was suspected in a syphilis outbreak among white, middle-class adolescent girls in Atlanta. Trazodone (Desyrel) has been involved in numerous poisonings and one death in Detroit.

• Hallucinogens - Ethnographic, law enforcement, and survey data suggest continued low-level abuse of lysergic acid diethylamide (LSD) and phencyclidine (PCP), despite declining or stable ED and treatment indicators. For example, treatment percentages have been declining in Chicago for more than a decade, but school survey data suggest some increases in LSD. Massachusetts school surveys also show increased hallucinogen use. LSD is reportedly common among teens and young adults - often in suburban and rural settings in a number of cities, including Atlanta, Baltimore, Boston, Detroit, Minneapolis/St. Paul, New York, St. Louis, Seattle, and parts of Texas. It is frequently found at local concerts, parties, and raves. PCP availability continues in several cities, including Baltimore, Minneapolis/St. Paul, New Orleans, and New York. Ethnographers in San Francisco note a renewed interest in PCP in one predominately Hispanic neighborhood. In Washington, DC, PCP-positive screens among adult and juvenile arrestees continue their decade-long decline. Use of PCP in combination with marijuana continues to be reported in Chicago, New York, Philadelphia, and St. Louis. PCP/crack combinations are reported in Philadelphia. In Houston, marijuana cigarettes are dipped in embalming fluid containing PCP. Psilocybin mushrooms ("shrooms") are reportedly available in some cities, including Baltimore, Minneapolis/St. Paul, and Seattle.

• Other Drugs - Ten Newark teenagers were recently hospitalized for reactions to jimsonweed; the drug is also reportedly abused in Phoenix. Ingesting cough medications in Minneapolis/St. Paul is known as "robo tripping" and adolescents who use it are known as "robo cops." The practice has resulted in adverse reactions. The cough medicine guaiphenesin (Robitussin) is also reportedly abused in Phoenix and by Boston teenagers.

*DAWN comparisons are for first half 1996 versus first half 1997; changes are noted only when statistically significant at p<0.05.

**ADAM comparisons are for first half 1997 versus first half 1998; changes are noted only when they are >5 percentage points.

Posttraumatic Stress Disorder and Drug Use Disorders

This study sought to elucidate the relationships between posttraumatic stress disorder (PTSD), trauma, and drug use disorders. Although much comorbidity between PTSD and drug abuse has been observed, the causal mechanisms have remained unclear. This paper presents data on 1007 adults, ages 21-30, enrolled in a health maintenance organization in Michigan. The subjects were followed up three and five years after initial interview, and assessed for PTSD, drug use disorders, and traumatic events. While PTSD increased the risk for drug abuse or dependence, exposure to trauma in the absence of PTSD did not. Risk was particularly notable for abuse or dependence on prescription drugs. Prior drug abuse or dependence did not appear to increase the risk for trauma or PTSD in this sample. It appears that drug abuse or dependence in individuals with PTSD may be a result of self-medication, although it is also possible that there is a shared vulnerability to PTSD and drug use disorders. Chilcoat, H.D., and Breslau, N. Arch Gen Psychiatry, 55, pp. 913-917, 1998.

Preventing Adolescent Health Risk Behaviors By Strengthening Protection During Childhood

Researchers at the University of Washington examined the long-term effects of an intervention combining teacher training, parent education, and social competence training for children during the elementary grades on health-risk behaviors at age 18 years. The study employed a nonrandomized controlled trial with follow-up six years after intervention. Subjects consisted of 643 students in public elementary schools serving high-crime areas in Seattle, Washington. A full intervention condition (n=156) provided in grades 1 through 6 consisted of 5 days of teacher in-service training each intervention year, developmentally appropriate parenting classes offered to parents when children were in grades 1, 2, 3, 5, and 6, and developmentally adjusted social competence training for children in grades 1 and 6. A late intervention condition (n=267) provided in grades 5 and 6 paralleled the full intervention at these grades. A control condition (n=220) consisted of students in schools assigned to receive no intervention in grades 5 and 6 and who were not in intervention classrooms in grades 1 through 4. The follow-up at age 18, six years after the end of intervention, included 93% of the baseline sample and assessed self-reported substance use, violent and non-violent crime, sexual activity, pregnancy, bonding to school, school achievement, grade repetition and school dropout, suspension and/or expulsion, and school misbehavior. Compared to control students, fewer students receiving the full intervention reported heavy drinking (15.4% vs. 25.6%), violent delinquent acts (48.3% vs. 59.7%), sexual intercourse (72.1% vs. 83.0%), having multiple sex partners (49.7% vs. 61.5%), and pregnancy or causing pregnancy (17.1% vs. 26.4%) by age 18 years. The full-intervention student group reported more commitment and attachment to school, better academic achievement, and less school misbehavior than control students. Late intervention in grades 5 and 6 only did not significantly affect health-risk behaviors in adolescence. These findings suggest that a package of interventions with teachers, parents, and children provided throughout the elementary grades can have enduring effects in reducing heavy drinking, violent behavior, and sexual intercourse at age 18 years among multiethnic urban children. Results support efforts to reduce health-risk behaviors through universal interventions in selected communities or schools serving high-crime neighborhoods. Hawkins, J.D., Catalano, R.F., Kosterman, R., Abbott, R., Hill, K.G. Archives of Pediatrics and Adolescent Medicine, 153, pp. 226-234, 1999.

A Longitudinal Study of Children of Alcoholics: Predicting Young Adult Substance Use Disorders, Anxiety, and Depression

Investigators at Arizona State University tested the magnitude and specificity of parental alcoholism effects on young adult alcohol and drug abuse/dependence, and also tested whether adolescent symptomatology and adolescent substance use mediated the effects of parental alcoholism on these diagnoses. Participants were from an ongoing longitudinal study in which a target child was assessed in adolescence using computer-assisted interviews with both parents and the child, (N=454 families, mean age at Time 1=12.7). In young adulthood, the original target children and their full-biological siblings were assessed (mean age=21) again using computer-assisted interviewing (N=732 young adults). Results showed unique effects of parent alcoholism on young adult substance abuse and dependence, over and above the effects of other parental psychopathology, suggesting that parent alcoholism is a specific risk factor for substance abuse/dependence above and beyond the general elevation in risk that might be associated with having a dysfunctional parent. Adolescent externalizing symptoms were found to be significant mediators of these effects, suggesting that children of alcoholics are at elevated risk for substance use disorders, in part, because of their broader pattern of early adolescent antisociality and conduct problems. Drug and alcohol diagnoses were mediated somewhat differently. For drug abuse/dependence diagnoses, adolescent conduct problems completely explained the significant parent alcoholism effect, although an effect of parental antisociality remained. However, for alcohol abuse/dependence diagnoses, the effects of parental alcoholism could not be completely explained by adolescent conduct problems. Thus, greater vulnerability to the psychopharmacological properties of alcohol may account for additional risk for alcoholism among children of alcoholics, whereas parental antisociality is more important to drug abuse/dependence because drug use necessarily involves illegal behaviors. Chassin, L., Pitts, S.C., DeLucia, C., and Todd, M. Journal of Abnormal Psychology, 108, pp. 106-119, 1999.

Marijuana Use Among American Indian Adolescents

Researchers at the University of Colorado Health Sciences Center report two studies of marijuana use among American Indian adolescents. The first study examined the characteristics of marijuana (MJ) users in a survey of 1464 9th-12th-grade adolescents from four Indian tribal groups. Forty percent of these American Indian subjects had used MJ at least once in the last month. The prevalence of MJ use varied across the 4 tribes. Low- and high-frequency marijuana use (1-3 times in the past month, and 11 or more times in that period, respectively) were modeled as outcome variables. The factors associated with MJ use varied with the frequency of use and by gender. Males were no more likely than females to use MJ at a low frequency, but were more likely to use at high frequency. In the final multivariate models, low-frequency MJ use among females was associated with reporting that peers encouraged alcohol use as well as use of alcohol and stimulants. Among males, low-frequency use was associated with greater positive alcohol expectancies, lower grades in school, and alcohol use. While high-frequency MJ use was associated with use of alcohol, stimulants and cocaine among females, such use was associated with higher scores on the antisocial behavior scale as well as the use of alcohol, stimulants and cocaine among males. Overall, the strongest associations were with the use of alcohol and other illicit substances. Novins, D.K. and Mitchell, C.M. Factors Associated With Marijuana Use Among American Indian Adolescents. Addiction. 93(11), pp. 1693-1702, Nov 1998. The second study examined the developmental course of marijuana use among 1766 American Indian adolescents 14-20 years old across three cultural groups. Three annual ascertainments of 30-day marijuana use and 5 age cohorts were linked and hierarchical linear modeling was used to assess the trajectory of marijuana use, taking account of gender and community group differences as well. Use of marijuana increased in middle adolescence, peaked in later adolescence, and began to decrease in early adulthood, supporting a non-linear maturational model. Both gender and community differences were observed in the trajectories, with girls and boys similar in frequency of use at age 14 but diverging by age 20; in all three communities, males showed a sharper increase in use. The authors conclude that growth curve analysis provides an additional tool for studying effects of interventions that may not be apparent in traditional evaluation design. Mitchell, C.M., Novins, D.K., and Holmes, T. Marijuana Use Among American Indian Adolescents: A Growth Curve analysis from Ages 14 Through 20 Years. Journal of the American Academy of Child and Adolescent Psychiatry, 38(1), pp. 72-78, 1999.

Stress-Coping Factors in Adolescent Substance Use: Test of Ethnic and Gender Differences in Samples of Urban Adolescents

Addressing the question of whether and how the etiology of drug use differs for adolescents in various ethnic groups, researchers investigated group differences in the relationship between stress-coping variables and substance use with samples of inner-city students in 6th-8th grades (N = 1,289) and metropolitan-area students in 7th-9th grades (N = 1,702). Use of cigarettes, alcohol, and marijuana were considered, and measures of psychosocial predictor domains focused on affect, life events, parental support, and coping patterns. African-American adolescents had the lowest rate of substance use, Hispanics were intermediate, and Whites had the highest rate; there was no gender difference in overall substance use. Multiple regression analysis showed that the strength of predictive relationships for stress-coping variables was lower for African Americans and was greatest for Whites; methodological tests showed that these differences were not attributable to statistical artifacts. Hispanic adolescents showed greater vulnerability than did Whites at younger ages but this effect was reversed at later ages. Implications of the study include the importance of incorporating stress-coping components in the design of prevention programs for all ethnic groups. As affective factors were less predictive of substance use among African-American adolescents, programs should give greater attention to other domains when targeting programs to these adolescents. Earlier prevention efforts (before age 12) are likely to be most critical for Hispanic youth. Vaccaro, D. and Wills, T.A. Journal of Drug Education. Vol. 28(3), pp. 257-280, 1998.

Illicit Substance Use Among Adolescents: A Matrix of Prospective Predictors

A research team led by Dr. John Petraitis reviewed findings from 58 prospective studies of illicit substance use (ISU) among adolescents. In addition to including only longitudinal studies, the review considered both significant and nonsignificant findings, focused on relationships for which cross-study validation was possible, and attempted to cover the full range of predictors. Traditional review techniques were used rather than meta-analysis because of the number and range of predictors. The review identified 384 findings and classified them according to three types of influence (social, attitudinal, and intrapersonal) and four levels of influence (ultimate, distal, proximal, and immediate). The bulk of evidence reconfirmed the importance of several predictors of ISU (e.g., intentions and prior substance-related behavior, friendship patterns and peer behaviors, absence of supportive parents, psychological temperament), revealed that a few variables thought to be well-established predictors may not be (e.g., parental behaviors, parental permissiveness, depression, low self-esteem), and uncovered several variables where findings were either sparse or inconsistent (e.g., the role of public policies concerning ISU, mass media depictions of ISU, certain parenting styles, affective states, perceptions of parental disapproval for ISU, and substance-specific refusal skills). Among the well-established findings: (1) ISU rarely is the first problem occurring among adolescents but more often follows other problem behaviors; (2) adolescents usually are prepared cognitively for ISU, usually believing that potential benefits exceed potential costs, etc; (3) ISU usually occurs after exposure to other substance users; (4) ISU is closely related to deviant peer bonding and, to a lesser extent, to detachment from and rebellion against religion, school, and family; (5) ISU occurs more frequently among adolescents who do not control their emotion, when they are extraverted and socially disinhibited, and when they are aggressive around other people -- not among those who are anxious, depressed, or low in self-esteem; and (6) though parental permissiveness seems to have little effect on ISU, absence of parental emotional support or absence of an intact family may lay the foundations for ISU. Petraitis, J., Flay, B.R., Miller, T.Q., Torpy, E.J., Greiner, B. Substance Use & Misuse. 33(13), pp. 2561-2604, Nov 1998.

Familial Backgrounds and Risk Behaviors of Youth with Thrownaway Experiences

Some homeless youth have been characterized as "thrownaway" in that they have specifically been told to leave home. In this study conducted by Research Triangle Institute, thrownaway experiences among homeless youth are examined in two national samples: a nationally representative sample of youth residing in youth shelters, and a purposive sample of street youth in 10 cities. Prevalence of thrownaway experiences for the total samples and for demographic subgroups is provided along with comparisons of the familial backgrounds and high-risk behaviors of youth with and without such experiences. Youth with thrownaway experiences constituted nearly half of each sample. In both samples, these youth were more likely than youth without such experiences to report: (1) that they had attempted suicide, used marijuana and other drugs (excluding cocaine), and had been involved in the drug trade and carried hidden weapons; (2) that other family members had used illicit drugs during the 30 days before the youth left home; and (3) that they had spent at least 1 night away from home due to physical and/or emotional abuse or neglect, familial conflict, and familial substance use. Results indicate that thrownaway youth constitute a particularly vulnerable subpopulation of homeless youth and suggest that a greater recognition and understanding of such youth will facilitate design of services that better address their needs. Ringwalt, C., Greene, J., Robertson, M. Journal of Adolescence. 21(3) 241-252, 1998.

Comorbidity of Substance Use Disorders with Mood and Anxiety Disorders: Results of the International Consortium in Psychiatric Epidemiology

This study is a cross-national investigation of patterns of comorbidity between substance use and psychiatric disorders in six research sites in five countries. All sites used comparable measures of substance use, and substance and mental disorders. The investigators report that there was a strong association between mood and anxiety disorders, as well as conduct and antisocial personality disorder, with substance disorders at all sites. The results also suggest that there is a continuum in the magnitude of comorbidity as a function of the spectrum of substance use category (use, problems, dependence) as well as a direct relationship between the number of comorbid disorders and increasing levels of severity of substance use disorders. This relationship was particularly pronounced for drugs. Whereas there was no specific temporal pattern of onset for mood disorders in relation to substance disorders, the onset of anxiety disorders was more likely to precede that of substance disorders in all countries. Results illustrate the contribution of cross-national data to understanding the patterns and risk factors for psychopathology and substance use disorders. Comorbidity of Substance Use Disorders with Mood and Anxiety Disorders: Results of the International Consortium in Psychiatric Epidemiology. Merikangas, K., Mehta, R., Molnar, B., Walters, E., Swendsen, J., Aguilar-Gaziola, S., Bijl, R., Borges, G., Caraveo-Anduaga, J., Dewitt, D., Kolody, B., Vega, W., Wittchen, H., and Kessler, R. Addictive Behaviors, 23(6), pp. 893-907, 1998.

Eight-fold Increased Risk of Drug Disorders among Relatives of Probands with Drug Disorders

Merikangas and her colleagues at Yale Genetics Research Unit performed a controlled family study of probands (N=231 probands; N=61 control probands; and N=1267 adult first-degree relatives) with several different predominant drugs of abuse, including opioids, cocaine, cannabis, and/or alcohol. Diagnostic estimates were based on semistructured diagnostic interviews and/or structured family history interviews regarding each proband, spouse, and adult first-degree relative. Interview data were reviewed blindly and independently by clinicians with extensive experience in the evaluation and treatment of substance use disorders. There was an 8-fold increased risk of drug disorders among the relatives of probands with drug disorders across a wide range of specific substances, including opioids, cocaine, cannabis, and alcohol, which is largely independent from the familial aggregation of both alcoholism and antisocial personality disorder. There was also evidence of specificity of familial aggregation of the predominant drug of abuse. Elevation in risk of this magnitude places a family history of drug disorder as one of the most potent risk factors for the development of drug disorders. Results suggest that there may be risk factors that are specific to particular classes of drugs as well as risk factors that underlie substance disorders in general. Merikangas, K.R., Stolar, M., Stevens, D.E., Goulet, J., Presisig, M.A., Fenton, B., Zhang, H., O'Malley, S.S., Rounsaville, B.J. Familial Transmission of Substance Use Disorders. Archives of General Psychiatry, 55, pp. 973-979, 1998.

Children, Particularly Sons, of Opiate Addicts with Major Depression at Increased Risk for Conduct Disorder and Global, Social, and Intellectual Impairment

Children (N=114, age 6 to 17 years) of 69 white methadone maintenance patients with (N=30) and without (N=39) major depression were evaluated for DSM-III-R diagnoses by the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Epidemiologic version and best estimate, and by measures of functioning (Children's Global Assessment Scale, Social Adjustment Inventory for Children and Adolescents, WISC, and Peabody Picture Vocabulary Test), and compared with children of historical controls without substance abuse history. Sons of opiate addicts with major depression were at increased risk for conduct disorder and global, social, and intellectual impairment compared with sons of opiate addicts without major depression and/or sons of controls with neither drug dependence nor depression. Sons of opiate addicts without major depression differed little from controls. Daughters of opiate addicts did not differ from controls in rates of disorders but had poorer social adjustment and nonverbal intelligence. Treatment settings such as methadone maintenance might afford an opportunity for primary and secondary prevention, both through early detection of childhood disorders and treatment of parental drug dependence and psychopathology. Nunes, E.V., Weissman, M.M., Goldstein, R.B., McAvay, G., Seracini, A.M., Verdeli, H., Wickramaratne, P.J. Psychopathology in Children of Parents with Opiate Dependence and/or Major Depression. Journal of the American Academy of Child and Adolescent Psychiatry, 37(11), pp. 1142-1151, 1998.

Ethnic Identity Is Mediated by Family Factors In Protecting Against Drug Use

This study examined the multiple components of ethnic identity, the place of this ethnic identity set in the mediational model of the path to drug use predicted by a family interactional framework, and the protective role of each component of ethnic identity. The participants were 259 male and 368 female African Americans in late adolescence. They responded to a structured questionnaire in individual interviews. Few of the specific components of ethnic identity were significantly related as main effects to drug use, and most of the effect of ethnic identity was mediated by the family set of variables. Each of the components of ethnic identity offset risks or enhanced protective factors from the ecology, family, personality, and peer domains, thereby lessening drug use. This pattern highlights the importance of incorporating ethnic identity into drug prevention programs which serve African-American youth. Brook, J.S., Balka, E.B., Brook, D.W., et al. Drug Use Among African Americans: Ethnic Identity as a Protective Factor. Psychol Rep, 83(3 Pt 2): pp. 1427-1446, 1998.

Young Adult Drug Use May Be Reduced by Early Interventions, Stronger Parent-Child Bonds

This study examined young adult drug use stemming from childhood aggression, the parent-child mutual attachment relationship, and the effect of unconventionality. Youngsters and their mothers were interviewed when the youngsters were early adolescents, late adolescents, and young adults. Additional data were collected from the mothers when their youngsters were children. The analysis was conducted on youngsters who had complete data at all 4 points in time. The findings were in accord with the family interactional model; that is, the parent-child mutual attachment relationship affects unconventionality in the youngster, which, in turn, affects young adult drug use. The results indicate that the parent-child mutual attachment relationship does so through the stability of : (a) the attachment relationship from childhood to young adulthood, (b) unconventional personality and behavioral attributes from early adolescence to young adulthood, and (c) drug use from early adolescence to young adulthood. The findings imply that early intervention with respect to aggression, inter-ventions that focus on strengthening the parent-child bond and conventional behavior, and interventions aimed at early drug use should be most effective in reducing young adult drug use. Brook, J.S., Whiteman, M., Finch, S., and Cohen, P. Mutual Attachment, Personality, and Drug Use: Pathways from Childhood to Young Adulthood. Gen Soc Gen Psy Monogr, 124(4), pp. 492-510, 1998.

Drug Use Among School Dropouts Is Influenced by Association With Drug Using Peers

A sample of 910 Mexican-American and white non-Hispanic school dropouts were surveyed regarding their alcohol, marijuana, and other drugs, and socialization characteristics that have previously been shown to be predictive of adolescent substance use. A structural equation model based on peer cluster theory was evaluated for goodness of fit and for differences in model characteristics by ethnicity and gender. Results partially confirmed peer cluster theory among school dropouts in that association with drug-using peers was the most powerful direct predictor of substance use. The effects of other socializing influences were indirect, mediated through association with drug-using peers. Some differences were present between Mexican-American and white non-Hispanic subgroups. Results were similar to those obtained from previous tests of this model among youth who remain in school, suggesting that social influences on drug use are similar across students and school dropouts. Association with drug-using peers dominates the prediction of substance abuse among school dropouts. Family communication of drug use sanctions helps to both limit substance use and strengthen family bonds. Prior school adjustment is likely to be an important protective factor limiting substance use among Mexican-American dropouts. Swaim, R.C., Bates, M.S., and Chevez, E. Structural Equation Socialization Model of Substance Use Among Mexican-American and White Non-Hispanic School Dropouts. J Adolesc Health, 23, pp. 128-138, 1998.

Effects of Drug Testing High School Athletes

Data from numerous studies have shown that high school athletes initiate hazardous drug use behaviors at rates similar to non-athletic peers, with the added risk of anabolic steroids and other ergogenic drug use. Some investigators have found higher use of alcohol and other high risk behaviors among those engaged in aggressive contact sports. Currently, schools from many states have initiated drug testing of adolescent athletes using urinalysis. The use of drug surveillance as a deterrent was upheld by the US Supreme Court in 1995 and 1998. However, the acceptability of the technique and its impact on future drug use by adolescents have never been studied. To assess the use of alcohol and other drugs in athletes, (n=1506) male high school football players and adolescent females (n=2085) were surveyed. Results included lifetime use of alcohol (76.2% male, 65.3% female), marijuana (29.4% male, 14.8% female) and amphetamines (8.4% male, 7.8% female). Participants were also surveyed by confidential questionnaire (1299 students from 28 high schools) to determine potential deterrent effects and acceptability of drug testing. Of those surveyed, only a small minority (<9%) said they would use drugs or alcohol (12%) if random drug testing were school policy. Importantly, drug testing received broad student support. Goldberg, L., Elliot, D., Moe, E., Kuehl, K., and Clarke, G. Acceptability and Potential Deterrent Effects of Drug Testing. Medicine and Science in Sports and Exercise, 31(5)S, 1999. Gender Differences in Use of Prescribed Psychotropic Drugs Data from the 1989 National Ambulatory Medical Care Survey (NAMCS) was used to examine gender differences in aggregate psychotropic drug use and use of specific therapeutic categories--anxiolytics, sedative-hypnotics, antidepressants, and antipsychotics. Logistic regression analysis was used to estimate the probability of psychotropic drug use in aggregate. For equations where gender was statistically significant, separate logistic regression equations were estimated to determine the explanatory variables that vary by gender. The probability of receiving any psychotropic drug is 55% greater in office visits by women than by men, all else constant. Further, gender is a positive and significant predictor of anxiolytic and antidepressant use. Variables estimating anxiolytic and antidepressant use that differ by gender include diagnosis, physician specialty, and payment source for the office visit. Findings confirm research that has demonstrated that women are more likely than men to receive anxiolytics and antidepressants in office-based care. In addition, there were significant differences in the predictors of drug use for women and men. Simoni-Wastila, L. Gender and Psychotropic Drug Use. Medical Care 36(1), pp. 88-94, 1998.

Clusters Of Marijuana Use In The United States

To assess the extent of clustering of marijuana use within United States neighborhoods, researchers at Johns Hopkins University analyzed data from the annual National Household Survey on Drug Abuse conducted during the period 1990-1995 using alternating logistic regression, a recently developed statistical method. Estimates of pairwise odds ratios ranged from 1.3 (95% confidence interval 1.22-1.42) for the lifetime history of marijuana use to 2.0 (95% confidence interval 1.6-2.6) for recent sharing of marijuana from one person to another. This is approximately the same order of magnitude as the clustering of diarrheal disease in villages of the less developed nations of the world. The extent of clustering of marijuana use was not very dependent upon either neighborhood-level or individual-level characteristics measured in the survey (e.g., age, sex, race, income levels). The more recent and intensive the marijuana use, the greater the clustering within neighborhoods. In addition, the practice of sharing marijuana with other persons also occurs in clusters within neighborhoods. This sharing may be one of the fundamental interpersonal and social processes that accounts for clustering of marijuana use; it is a potential target for future community- and school-oriented prevention programs to curb the increasing prevalence of youthful marijuana use. Bobashev, G.V., and Anthony, J.C. American Journal of Epidemiology, 148(12), pp. 1168-1174, Dec. 1998.

Substance Abuse And Associated Psychosocial Problems Among Argentina Adolescents: Sex Heterogeneity And Familial Transmission

Researchers from the University of Pittsburgh collaborated with researchers in Argentina on a study to clarify the effects of sex and familial transmission in the psychosocial concomitants of substance abuse problems among adolescents. Male (N=956) and female (N=303) adolescents in school, and male adolescents in a drug treatment program (N=51) in Buenos Aires Province, Argentina were administered a translated version of the Drug Use Screening Inventory. Use of substances, familial substance abuse and associations between psychosocial problem domains and substance abuse problems were examined. Substance abuse and psychosocial problems varied broadly by sex. Female adolescents in the school-based sample were found to generally report higher levels of psychosocial problems and greater use of minor tranquilizers than school boys or boys in treatment for substance abuse. Conduct deviancy was associated with substance abuse problems only in males, while health problems were associated only in females. However, among all youth, substance abuse problems were found to be associated with older age, greater social competency, problems in school performance, and involvement with deviant peers. Familial substance abuse was associated with substance abuse problems among all adolescents, but the pattern of associations with other psychosocial problems differed between males and females. Heterogeneity in socioeconomic status was found in the associations between psychosocial problems, adolescent substance abuse, and familial substance abuse. The results are consistent with a syndrome of problem behaviors and demonstrate the cross-cultural consistency of sex heterogeneity in adolescent substance abuse and its consequences. Moss, H.B., Bonicatto, S., Kirisci, L., Girardelli, A.M., Murrelle, L. Drug and Alcohol Dependence 52(3), pp. 221-230, 1998.

Executive Cognitive Functioning, Temperament, and Antisocial Behavior in Conduct-Disordered Adolescent Females

Investigators from CEDAR assessed whether low executive cognitive functioning (ECF) and a difficult temperament are related to aggressive and nonaggressive forms of antisocial behavior (ASB) in 249, 14-18-year-old, conduct-disordered females and controls. ECF was measured using neuropsychological tests; temperament was measured using the Dimensions of Temperament Survey--Revised; and ASB was assessed using psychiatric symptom counts for conduct disorder. The conduct-disordered females exhibited lower ECF capacity and greater difficult temperament compared with controls. The combined influence of low ECF and difficult temperament was significantly related to both forms of ASB. In comparison with low ECF, difficult temperament was more strongly related to nonaggressive ASB, whereas in comparison with difficult temperament, low ECF was more strongly related to aggressive ASB. Last, ECF mediated the relation between difficult temperament and aggressive ASB. Giancola, P.R., Mezzich, A.C., and Tarter, R.E. Journal of Abnormal Psychology. 107(4), pp. 629-641, Nov 1998.

Comorbidity of Alcoholism with Anxiety and Depressive Disorders in Four Geographic Communities

The comorbidity of alcoholism with anxiety and depressive disorders was examined in four epidemiologic investigations from diverse geographic sites. Despite variability in lifetime prevalence rates for these disorders, a strong cross-site consistency in magnitude and specific patterns of comorbidty existed. Individuals with alcohol abuse or dependence generally experienced a two- to threefold increased risk of anxiety and depressive disorders. Phobic conditions typically preceded the onset of alcoholism, but no systematic pattern was observed for panic or depressive disorders. Considerable heterogeneity was observed concerning the impact of comorbid conditions on symptoms of the index disorder. While the presence of comorbid anxiety or depressive disorders was consistently associated with moderate increase in the symptoms of alcohol abuse or dependence, alcoholism was associated with large increases in the number of depressive symptoms and little or no increase in phobic symptoms. Findings are discussed in terms of the self-medication hypothesis and the etiologic heterogeneity of these forms of comorbidity in the general population. Swendsen, J.D., Merikangas, K.R., Canino, G.J., Kessler, R.C., Rubio-Stipec, M., and Angst, J. The Comorbidity of Alcoholism with Anxiety and Depressive Disorders in Four Geographic Communities. Comprehensive Psychiatry 39, 4, pp. 176-184, (July/August), 1998.

Co-morbidity between Panic Disorder and Alcoholism May Not Be a Consequence of Self-medication of Panic Symptoms

This study examines the patterns of familial aggregation and co-morbidity of alcoholism and anxiety disorders in the relatives of 165 probands selected for alcoholism and/or anxiety disorders compared to those of 61 unaffected controls. Probands were either selected from treatment settings or at random from the community. DSM-III-R diagnoses were obtained for all probands and their 1,053 first-degree relatives, based on direct interview or family history information. Findings indicate (1) alcoholism was associated with anxiety disorders in the relatives, particularly among females; (2) both alcoholism and anxiety disorders were highly familial; (3) familial aggregation of alcoholism was attributable to alcohol dependence rather than to alcohol abuse, particularly among male relatives; and (4) the pattern of co-aggregation of alcohol dependence and anxiety disorders in families differed according to the subtype of anxiety disorder; there was evidence of a partly shared diathesis underlying panic and alcoholism whereas social phobia and alcoholism tended to aggregate independently. The finding that the onset of social phobia tended to precede that of alcoholism, when taken together with the independence of familial aggregation of social phobia and alcoholism, supports a self-medication hypothesis for the co-occurrence of social phobia and alcoholism. In contrast, the lack of a systematic pattern in the order of onset of panic and alcoholism among subjects with both disorders as well as evidence for shared underlying familial risk factors suggest that co-morbidity between panic disorder and alcoholism is not a consequence of self-medication of panic symptoms. The study emphasizes the importance of examining co-morbid disorders and subtypes thereof in identifying sources of heterogeneity in the pathogenesis of alcoholism. Merikangas, K.R., Stevens, D.E., Fenton, B., Stolar, F.M., O'Malley, S., Woods, S.W., and Risch, N. Co-morbidity and Familial Aggregation of Alcoholism and Anxiety Disorders. Psychological Medicine 28, pp. 773-788, 1998.

Cigarette Use Increases Following Drug Abuse Treatment

To test the hypothesis that participation in drug treatment and risk-behavior bias predict greater cigarette use, researchers at UCLA analyzed data from a 3-wave survey of 346 drug abusers to assess the influence of risk-behavior bias, drug use, prior cigarette use, and prior and current participation in drug treatment on subsequent cigarette use. After controlling for prior levels of cigarette use with a longitudinal path model, it was found that participation in drug treatment at Wave 2 significantly predicted increased cigarette use at Wave 2. There were similar results at Wave 3. Additional analyses indicated that reduced heroin use was especially associated with more smoking. Risk-behavior bias predicted more drug and cigarette use and predicted less participation in drug treatment at Wave 3. These results suggest that drug treatment, reduced heroin use, and a tendency toward risky behavior may lead to increased cigarette use, which may represent a form of substance replacement. Conner, B.T., Stein, J.A., Longshore, D., and Stacy, A.W. Associations Between Drug Abuse Treatment and Cigarette Use: Evidence of Substance Replacement. Experimental and Clinical Psychopharmacology 7, pp. 64-71, 1999.

The Etiology of Adult and Adolescent Substance Use May Differ--Substance Use Patterns in Milwaukee Gangs

A study of the patterns of substance use by male and female gang members in Milwaukee, Wisconsin, from their teenage years in the 1980s into adulthood indicate that the gangs started out as one form of neighborhood-based drug-using peer groups. Variation existed in drug use but family variables explained little of the variation. Male gang members raised in families with a history of gang involvement and drug use were more likely than other gang members to use cocaine and to use it seriously. On the other hand, severe family distress was not related to onset, duration, nor seriousness of cocaine use in either males or females. Cocaine use for both males and females increased in adulthood. It appears that the etiology of adult and adolescent drug use may differ. Neither social control theory nor differential association theory is well suited to explain the variations in gang drug use by age or gender. Hagedorn, J.M., Torres, J., and Giglio, G. Cocaine, Kicks, and Strain: Patterns of Substance Use in Milwaukee Gangs. Contemporary Drug Problems 25, Spring, pp. 113-145, 1998.

Characteristics of Inconsistent Respondents Who Have "Ever Used" Drugs in a School-Based Sample

Inconsistency of reporting of lifetime drug use has been recognized in numerous longitudinal surveys, and some researchers have coined the term "recanting" to describe denial of ever-use at follow-up when use has been acknowledged at an earlier contact. Investigators at the University of Illinois at Chicago examined the predictors of inconsistent responses from adolescents to questions about whether they ever used alcohol, cigarettes, and marijuana. Male adolescents had significantly higher rates of inconsistent responses than female adolescents. Black and Hispanic adolescents had significantly higher rates of inconsistent responses regarding ever using alcohol and cigarettes (only for Black) than White adolescents. The subjects' living status and academic achievements were significant predictors of inconsistent responses regarding ever using marijuana. Thus, these results are consistent with the notion that inconsistent responses may bias the estimation of the prevalence of ever using drugs in multivariate analyses. Siddiqui, O., Mott, J.A., Anderson, T.L., and Flay, B.R. Measurements, Instruments, Scales, and Tests -- Characteristics of Inconsistent Respondents who have "Ever Used" Drugs in a School-Based Sample. Substance Use & Misuse, 34(2), pp. 269-295, 1999.

Stressful Life Events and Adolescent Substance Use and Depression: Conditional and Gender Differentiated Effects

Stressful life circumstances have myriad influences on human health and behavior. Early research focused on the variable distribution of stress and its effects by socioeconomic status, race, and gender. More recent research indicates that variation by age is also an important consideration. For example, adolescent reactions to stressful life events are often inconsistent with adult reactions to similar life situations and transitions. Moreover, since most studies assess only a single outcome-usually depression-they risk classification bias since analyses exclude other potential stress-related outcomes. This paper assesses the gender distinct effects of stressful life events on two outcomes among adolescents, substance use and depressive symptoms. The results of a second-order regression model indicate that life events affect female, but not male, depressive symptoms, especially when self-esteem is low or mastery is high. Furthermore, life events affect substance use when peer drug use is high, or when parental support is low, but this latter effect is limited to female adolescents. Hoffmann, J.P., and Su, S.S. Substance Use & Misuse 33(11), pp. 2219-2262, 1998.

Prevalence of Homelessness Among Adolescents in the United States

Homeless adolescents represent one of the nation's most vulnerable groups and are believed to be at high risk for drug abuse. This study, conducted by investigators at Research Triangle Institute, reports the 12-month prevalence of homeless episodes among US adolescents. Interviews were conducted in 1992 and 1993 with a representative household sample of 6496 adolescents aged 12 to 17 as part of the Youth Risk Behavior Survey sponsored by the Centers for Disease Control and Prevention. Respondents reported whether they had spent the night in any of a variety of locations other than home during the previous 12 months. Findings indicate 7.6% of the youths questioned reported that they had spent at least 1 night in a youth or adult shelter (3.3%), public place (2.2%), an abandoned building (1.0%), outside (2.2%), underground (0.4%) or with a stranger (1.1%). Boys were much more likely than girls to report having experienced a homeless episode. This study suggests that homelessness among adolescents is not simply an urban problem and that prevention programs targeting homeless youth should be implemented nationwide. Ringwalt, C., Greene, J., Robertson, M., McPheeters, M. American Journal of Public Health, 88(9), pp. 1325-1329, 1998.

Major Depression in Children of Parents Dependent on Opiates is Associated with Increased Risk of Physical Health Problems

A study to examine the strength and specificity of the association between depression and physical health problems in children and adolescents whose parents were dependent upon opiates found the offspring to be at increased risk of physical health problems. The sample consisted of offspring ages 6-17 (mean age 11 years) of opiate addicts who had a history of MDD (N=28); other mood disorders (N=31); no history of mood disorders but other psychiatric disorders (N=92); or no history of psychiatric disorder (N=127). Detailed psychiatric assessment and medical history of the offspring by direct interview with the offspring and an informant were obtained blind to parental diagnosis. After controlling for possible confounders, there was an increased risk of dermatological disorders, headache, other neurological/neuromuscular disorders, bronchitis, other respiratory disorders and hospitalizations for nonsurgical procedures in offspring with MDD, as compared to nonpsychiatrically ill controls. The offspring with other mood disorders had a slightly elevated risk. Major depression in children and adolescents whose parents are dependent on opiates is associated with increased risk of physical health problems. This is consistent with other reports; however, the timing of the physical health problems requires further study. McAvay, G.M., Nunes, E.V., Zaider, T.I., Goldstein, R.B., Weissman, M.M. Physical Health Problems in Depressed and Non Depressed Children and Adolescents of Parents with Opiate Dependence. Depression and Anxiety, 9, 1999.

Startle Response May Be Vulnerability Marker to Discriminate among Children at Risk for Development of Anxiety Disorders and/or Alcoholism

This study examined startle reflex as a possible vulnerability marker among offspring of parents with anxiety disorders and/or alcoholism. Subjects were male and female offspring (N=66), 10 to 17 years of age, of probands who participated in a family study of comorbidity of alcoholism and anxiety disorders. Testing consisted of examining the startle reflex and its modulation by prepulse stimuli (prepulse facilitation and prepulse inhibition). Different components of the startle discriminated among children of parents with anxiety disorders and/or alcoholism, and children of normal controls. Specifically, startle magnitude was elevated in children with a parental history of an anxiety disorder whereas startle habituation and prepulse inhibition were impaired in children with a parental history of alcoholism. Findings suggest that individual differences in startle reflex may serve as a vulnerability marker for the development of anxiety disorders and alcohol problems. Grillon, C., Dierker, L., and Merikangas, K.R. Fear-Potentiated Startle in Adolescent Offspring of Parents with Anxiety Disorders. Biological Psychiatry, 44, pp. 990-997, 1998.

Sequence of Powder Cocaine and Crack Use among Arrestees in Los Angeles County

While the extent of cocaine use, characteristics of users, and consequences of dependence are well documented for both powder cocaine and crack, few studies have dealt with the sequence or progression of use between the two forms of cocaine. Drawing on arrest data from county jails in Los Angeles, investigators at UCLA identified four sequences of powder cocaine and crack use and examined each sequence in terms of user characteristics, history of use, dependence, contact with the criminal justice system, and concomitant use of other drugs. Findings indicate that (1) arrestees who initiated cocaine use with the powder form of the substance are more likely to progress to using crack than to restrict their use of cocaine to powder; (2) crack-initiated users tend more often to use crack only than to progress to powder cocaine; (3) when used interchangeably, powder cocaine and crack can interact and reinforce each other, resulting in a higher level of use and dependence on both forms of the substance. Shaw, V.N., Hser, Y.I., Anglin, M.D., and Boyle, K. American Journal of Drug and Alcohol Abuse, 25(1), pp. 47-66, 1999.

Ethnic and Gender Differences in Drug Use and Resistance

A survey was conducted to measure drug use, drug offers and drug resistance and to compare male and female members of different ethnic groups in seventh grade classes in the Phoenix metropolitan area. The survey was administered to over 4,000 students, with usable data obtained from 3,080. Significant ethnic and gender differences were described in drug use and, more importantly, in the drug offer and resistance process. Results indicate younger adolescents (12-13) do not possess large or sophisticated repertoires of strategies to resist drug offers and most offers come from acquaintances while previous studies report offers come from more intimate relationships for older adolescents. Also illustrated was that ethnicity and gender are related to drug use and how drugs are offered and resisted. This suggests that ethnic and gender specific approaches are needed in prevention curricula and refusal and life skills should be stressed. Moon, D.G., Hecht, M.L., Jackson, K.M., & Spellers, R. Ethnic and Gender Differences and Similarities in Adolescent Drug Use and the Drug Resistance Process. Substance Use and Misuse, 34, pp. 1059-1083, 1999.

Females At-Risk for Anabolic Steroid Use

Three national surveys document an increasing prevalence of young women's anabolic steroid (AS) use. Both local survey and national data indicate prevalences of AS use among young women of approximately 1%. Predictors of AS use and the relationship to disordered eating behavior (DEB) have not been defined. This study surveyed 2,090 middle and high school-aged females using a 140-item questionnaire. Tendency toward DEB and physique-altering drug use (including AS) and potential risk factors in the domains of knowledge, beliefs, psychological factors, peer/ environmental effects, demographics, drug use, and deviant behaviors were assessed. One-hundred and eleven (5.3%) subjects indicated a high intent for future AS use. Of those at high risk for DEB (24% total), 12% also were at risk for AS use. Those at risk for both DEB and AS use also indicated greater use of supplements, cocaine, alcohol and diet pills (p<0.005 for each). They also exhibited less belief in AS adverse effects, greater perceived peer AS use, and more sexual partners (p<0.005 for each). Those at risk for DEB, were also at risk and exhibited more deviant behavior. Because similar predictors are present for DEB and AS use, programs designed to prevent DEB also should address AS use. Elliot, D.L., Moe, E.L., Duncan, T., and Goldberg, L. Who Are the Young Women at Risk for Anabolic Steroid Use? Medicine and Science in Sports and Exercise, 31(5)S, 1999.

Frequency of Cigarette Use by 7th Graders is a Strong Predictor of Dropping Out of High School

This study examines the impact of early adolescent drug use on subsequent school drop out in a sample of 4,390 adolescents from California and Oregon. Participants were initially surveyed in the 7th grade and again six years later when they should have completed 12th grade. Controlling for demographics, family structure, academic orientation, early deviance, and school environment, logistic regression analyses showed that frequency of cigarette use during 7th grade predicted dropping out of high school. Separate analyses by race/ethnicity replicated this finding for Asians, Blacks, and Whites, but not for Latinos. For Latinos, early marijuana use predicted dropping out. The results suggest that preventing or reducing the incidence of early smoking and marijuana use may help reduce the probability of dropping out of high school. Ellickson, P., Khanh B., Bell, R. and McGuigan, K. Does Early Drug Use Increase the Risk of Dropping Out of High School? Journal of Drug Issues, 28(2), 1998.

Parental Monitoring

The link between parental monitoring and child problem behavior has been established in three areas: substance abuse, anti-social behavior, and safety and injury. This paper reviews the work to date on the construct and accomplishes three goals: first, to provide an empirical rationale for placing parental monitoring of children's activities as a key construct in development and prevention research; second, to stimulate more research on parental monitoring and provide an integrative framework for various research traditions as well as developmental periods of interest; third, to discuss current methodological issues that are developmentally and culturally sensitive and based on sound measurement. Possible intervention and prevention strategies that specifically target parental monitoring are discussed. Dishion, T.J., and McMahon, R.J. Parental Monitoring and the Prevention of Child and Adolescent Problem Behavior: A Conceptual and Empirical Formulation. Clinical Child and Family Psychology Review, 1, pp. 61-75, 1998.

Antecedents of Substance Use Initiation

Initiation of substance use before the age of 15-16 is a distinct risk factor for a variety of mental health problems and eventual drug abuse. Using multi-method, multi-agent measures of child, family, and peer antecedents at age 9-10, the investigators studied the longitudinal effects in an at-risk sample of 206 boys. Event history analysis was used to examine the antecedents to patterned alcohol and tobacco use, and experimentation with marijuana between age 11-16. Univariate models revealed that at Grade 4, most constructs were prognostic of boys' early substance use. Multivariate event history models clarified the risk and protective structure associated with tobacco, alcohol and marijuana use. The effects of family context, family management and peer factors were entirely mediated through characteristics of the boys at Grade 4 for alcohol initiation. Anti-social behavior was key for early onset alcohol and marijuana use. Low SES and low sociometric status were predictive of early tobacco use. Interaction effects for prediction of marijuana and tobacco onset indicated that their association with family management and boy's characteristics may vary by level of parental substance use. Dishion, T.J., Capaldi, D.M., and Yoerger, K. Middle Childhood Antecedents to Progression in Male Adolescent Substance Use: An Ecological Analysis of Risk and Protection. Journal of Adolescent Research, 14(2), pp. 175-206, 1999.

Sexual and Physical Abuse at Home Predicts Suicide Attempts by Homeless Street Youth

A study was conducted to examine the relationship between home life risk factors and suicide attempts among homeless and runaway street youth recruited from both shelters and street locations in Denver, New York City, and San Francisco. Street youth (N=775) age 12-19 years old were recruited in 1992 and 1993 by street outreach staff for interview. Cross-sectional, retrospective data were analyzed to examine the relationship between suicide attempts and antecedent home life variables. Suicide attempts were reported by 48% of the females and 27% of the males, with a mean of 6.2 times for females and 5.1 times for males. Among the females, 70% reported sexual abuse and 35% reported physical abuse; among males, 24% reported sexual abuse and 35% reported physical abuse. Sexual and physical abuse before leaving home were independent predictors of suicide attempts for both females and males. Among street youth in this study who were sexually or physically abused, the odds of attempting suicide were 1.9 to 4.3 times the odds of attempting suicide among those not sexually or physically abused. Interventions attempting to reduce risk behaviors in this population must include assessments of suicidal behaviors as well as components for assisting youth in dealing with the behavioral and emotional sequelae of sexual and physical abuse. Molnar, B.E., Shade, S.B., Kral, A., et al. Suicidal Behavior and Sexual/Physical Abuse Among Street Youth. Child Abuse and Neglect, 22 (3): pp. 213-222, 1998.

Tobacco Use and Perception of Harm Among Mexican American Youth

This study sought to understand reasons for an increase in smoking and tobacco-related diseases among the Hispanic population. It examined the relationship between gender, level of cultural identification, migrant status, and grade level and tobacco use and perception of harm among Mexican American youth. Males were more likely to use tobacco than females when grade, cultural identification, and migrant status of parents are held constant. No gender effect was found for lifetime cigarette use. The odds of using cigarettes and smokeless tobacco increased substantially across grades. Effects were found for Mexican American/Spanish and Anglo/White American cultural identification and daily cigarette use. Youths who belonged to nonmigrant families or who identified with a traditional Mexican American or Spanish culture were more likely to consider regular tobacco use as harmful. These and other findings have implications for preventing future use of tobacco among Mexican American youth. Casas, J.M., Bimbela, A., Corral, C.V., et al. Cigarette and Smokeless Tobacco Among Migrant and Nonmigrant Mexican American Youth. Hispanic J Behavioral Sciences, 22 (1), pp. 102-121, 1998.

Underreports of Drug Use More Likely in STD Patients Compared to Arrestees at Jail Sites

This paper examines the validity of self-report of drug use in several important high-risk samples by comparing survey answers with urinalysis results. The analyses include data obtained from face-to-face interviews with 1536 patients in sexually transmitted disease (STD) clinics, 1564 patients in hospital emergency rooms (ERs), and 2034 recent arrestees in jails. Using urinalysis as the criterion measure, considerable underreporting was observed, particularly among STD and ER subjects using cocaine and opiates. A logistic regression analysis on factors related to the underreporting was conducted for both cocaine and opiates. The results showed that a lower degree of underreporting was associated with subjects at jail sites (compared to STD subjects) and those who self-reported lifetime drug dependence. Hser, Y.I., Maglione, M., and Boyle, K. Validity of Self-Report of Drug Use Among STD Patients, ER Patients, and Arrestees. Am J Drug Alcohol Abuse, 25(1), pp. 81-91, 1999.

Prevention of Drug Use in Adolescent Athletes

To test the ATLAS (Adolescents Training and Learning to Avoid Steroids) program to reduce anabolic steroids (AS) and alcohol and other drugs among adolescent athletes, 31 football teams (n=3207) were assessed in a randomized controlled study. Three successive annual cohorts were entered (1994-1996). Classroom curriculum and exercise training sessions were delivered by peer leaders, facilitated by coaches and strength trainers. The program included sports nutrition and strength training, AS risks and benefits, effects of AS use in sports, drug refusal role play, and creating anti-steroid and health promotion messages. Questionnaires assessing AS use, potential risk and protective factors, and AOD use were administered before and after the intervention and up to one year later. All cohorts were combined for season's end findings and the first 2 cohorts are combined for the 1-year follow-up. At season's end, AS use was more than 50% lower among experimental subjects (p=0.035), with borderline level of significance at 1-year (p= 0.072). When alcohol and the illicit drug use index (marijuana, amphetamines and narcotics) was assessed, experimental students used fewer drugs (p=0.041). Other long-term intervention effects included fewer students reporting drinking and driving (p=0.004), lower supplement use (p=0.009), and better nutrition (p=0.015). Moe, E., Goldberg, L., Elliot, D., MacKinnon, D., and Cheong, J. Reducing Drug Use and Promoting Healthy Behaviors Among Athletes: the ATLAS Program. Medicine and Science in Sports and Exercise, 31(5)S, 1999.

Pregnancy Among Three National Samples of Runaway and Homeless Youth

Investigators at Research Triangle Institute compared estimates of the prevalence of pregnancy among runaway and homeless youth between the ages of 14 and 17 years in various settings with each other and with youth in the general population. Comparisons used three surveys of youth: (1) the first nationally representative survey of runaway and homeless youth residing in federally and non-federally funded shelter, (2) a multi-city survey of street youth, and (3) a nationally representative household survey of youth with and without recent runaway and homeless experiences. Youth living on the streets had the highest lifetime rates of pregnancy (48%), followed by youth residing in shelters (33%) and household youth (<10%). The investigators concluded that shelter and street youth were at much greater risk of having ever been pregnant than were youth in households regardless of whether they had recent runaway or homeless experiences. Such youth need comprehensive services, including pregnancy prevention, family planning, and prenatal and parenting services. Greene, J., and Ringwalt, C. Journal of Adolescent Health, 23(6), pp. 370-377, 1998.

The Female Atlanta Study (FAST): Crack Cocaine and Women

Dr. Claire Sterk explores the lives of 259 female drug users based on participant observation, close-ended interviewing, open-ended, in-depth interviewing, ethnographic mapping, and community consultants. In addition to drug copping zones in which drug selling and using were visible, women were recruited in neighborhoods in which drug use was just as prevalent but hidden. The book moves through the woman's initial drug use experimentation, controlled use, and evolution to current regular use. The various patterns of crack cocaine use and income-generating activities are organized into a typology: women who finance their use through involvement in the drug business, through illegal activities other than prostitution, through prostitution including sex for crack exchanges, and women who did not use drugs until they were in their thirties or older as they struggled to survive. Overall, the women's steady relationships with drug users were more mutually rewarding than relationships with non-users. Frequently, the women believed pregnant women should eliminate or reduce drug use; however, many women failed to learn of their pregnancy until the second trimester or later. Once aware of their pregnancy, several women shifted from smoking crack cocaine to drinking alcohol, assuming a legal substance was safer. Criminalization of drug use by pregnant women reduced their seeking prenatal care. Once pregnant, some chose abortion or drug-induced miscarriage; some elected adoption; others chose to become mothers. Many of the women had at least one experience with drug treatment and described motivators and barriers to drug treatment. The majority of the women had heard of HIV/AIDS, but many were misinformed about risk behaviors and risk reduction. Their claims to have made behavioral changes to reduce risk often referred to intentions. Among the women tested, very few felt prepared for the waiting period between test and results. At times, women increased their HIV risk-taking during this waiting period. The women who tested negative for HIV still led lives impacted by the HIV epidemic. They faced a continual challenge to remain HIV negative, basing their actions on the assumption that they or their partner was infected with HIV. Violent encounters were common--childhood and adult--and linked violence to HIV risk-taking. The women's perceptions of the past, present, their aspirations, and impact of the constantly changing drug market on their lives is interlaced with their acknowledgement that societal changes were needed to reduce racism, poverty, and sexism but they also described actions they could take themselves. Sterk, C.E. Fast Lives: Women Who Use Crack Cocaine. Philadelphia: Temple University Press, 1999.

A Test of the Social Development Model

The social development model (SDM) is a general theory of human behavior that hypothesizes that similar developmental processes can lead to either prosocial or antisocial outcomes. The current study examines the relation between family behavior and early anti-social behavior using data on 938 first and second grade students in ten suburban public elementary schools. Children were part of the longitudinal Raising Healthy Children project, which began in 1993. Child, teacher and parent reports were collected annually in the spring from 1994 through 1996. Analysis one examined the prosocial path of the SDM. The model fit well, explaining 25% of the variance in early antisocial behavior. However, the path between skills and rewards from the family was not significant. A better fit was obtained when the model included paths from skills to beliefs and skills to antisocial behavior. In analysis two, the sample was split into two groups, those whose parents modeled problem behavior (heavy drinking, illicit drug use and domestic violence) and those who did not. Two differences emerged between the two groups. First, the strength of the path between skills and problem behavior was significantly stronger for children whose parents modeled problem behaviors. Second, the belief in family values path to antisocial behavior was not significant for children whose parents modeled problem behaviors. Thus, beliefs provide a significant protective effect for children whose parents do not model problem behaviors, but not for children in families where parents model problem behaviors. Catalano, R.F., Oxford, M., Harachi, T.W., Abbott, R. D., Haggerty, K.P. Modeling the Development of Early Antisocial Behavior: A Test of the Social Development Model to Predict Problem Behavior during the During the Elementary School Period. Criminal Behavior and Mental Health, 9, pp. 40-57, 1999.

Program Evaluation for Family-based Interventions

This article illustrates a program evaluation approach for the study of family intervention outcomes in general populations. Thirty-three rural schools were randomly assigned to 1 of 3 conditions: The Preparing for the Drug Free Years program (PDFY), the Iowa Strengthening families Program (ISFP), and a minimal-contact control group. Self-report and observational data collected from 523 families were used to develop measurement models of 3 latent parenting constructs that included measurement method effects. Analyses were conducted to ensure initial and attritional-related group equivalencies and to assess school effects. Structural equation models of the hypothesized sequence of direct and indirect effects for both PDFY and ISFP were then fit to the data. All hypothesized effects were significant for both interventions. Spoth, R., Redmond, C., Shin, C. Direct and Indirect Latent-variable Parenting Outcomes of Two Universal Family-focused Preventive Interventions: Extending a Public Health-oriented Research Base. Journal of Consulting and Clinical Psychology, 66(2), pp. 385-399, 1998.

Decreasing Drug Use in High-Risk Populations

Social-influence-based prevention programs can significantly delay the onset of tobacco, alcohol, and other drug use and slow the rate of increase in substance use prevalence among entire populations of early adolescents. Less is known about the capacity of these and other primary prevention programs to effect decreases in substance use. This is an important question since some youth have already begun to experiment with drugs by the time primary prevention programs are offered to them. In a 3.5-year follow-up of data from the Midwestern Prevention Project effects of a primary prevention program were found to decrease drug use among adolescents who were users at either sixth or seventh grade. This research suggests that social-influence-based primary prevention programs can have an impact on students who are users at baseline. The advantage of such a primary program is that it may reach and affect a "silent," not-yet-identified high-risk population of early drug users in a nonstigmatizing, nonlabeling fashion at an age when youth are more easily persuaded. Chou, P.C., et. al. Effects of a Community-Based Prevention Program on Decreasing Drug Use in High-Risk Adolescents. American Journal of Public Health, 88(6), June 1998.

A Longitudinal Perspective on Entitlement Income Among Homeless Adults

Researchers at the Alcohol Research Group of the Public Health Institute in Berkeley, California, examined sources of income in a sample of homeless adults to determine whether certain subgroups more consistently obtain entitlement income and are more likely to continue receiving it over time. From a baseline sample of 564 homeless residents of Alameda County, California, 397 were interviewed at both five-and 15-month follow-up intervals. Information was obtained on income received from public sources in the past 30 days before each interview, including general assistance, Aid to Families with Dependent Children (AFDC), Supplemental Security Income, or Social Security Disability Insurance. Data were also obtained on psychiatric diagnosis, race, marital status, education, duration of homelessness in adulthood, household status, and reported disability. At baseline, fewer than half of the respondents were receiving any entitlement income. The benefits of almost half of the AFDC and general assistance recipients were terminated during the 15-month period. Respondents who continued receiving entitlement income over the 15-month period were more likely to be black, to be women alone or with children, to have a family history of receiving welfare, and to report a disability. Respondents with dual disorders were six times more likely than others to have their benefits terminated. The investigators conclude that entitlement income is tenuous for many homeless adults, particularly those with dual diagnoses. Zlotnick, C., Robertson, M., and Lahiff, M. Psychiatric Services, 49(8), pp. 1039-1042, 1998.

Psychopathology Among Offspring of Parents with Substance Abuse and/or Anxiety Disorders

In a study with a high-risk population of children under age 18 of parents who served as probands in a family study of comorbidity of substance abuse and anxiety disorders, there was a strong degree of specificity of familial aggregation of both the anxiety disorders and substance use disorders. Rates of conduct disorder and depression were elevated among offspring of all affected parents. Inclusion of co-parent disorders in the evaluation of familial transmission in the present study strengthened the findings regarding the specificity of transmission of the anxiety disorders and the links between both parental substance abuse and antisocial personality with child conduct disorder. Merikangas, K.R., Dierker, L.C., and Szatmari, P. Psychopathology Among Offspring of Parents with Substance Abuse and/or Anxiety Disorders: A High-Risk Study. Journal of Child Psychology and Psychiatry, 39(5), pp. 711-720, 1998.

Relation between Intervention Efficacy and Cumulative Family Risk

Family risk-related variations in proximal parent and young adolescent outcomes of a universal family-focused preventive intervention were examined using a cumulative index of risk incorporating sociodemographic characteristics and social-emotional adjustment measures. Results of an initial investigation involving 209 families of young adolescents suggested that intervention efficacy was largely unrelated to cumulative family risk. These findings were replicated with a second sample of 428 families. Spoth et al., Risk Moderation of Parent and Child Outcomes in a Preventive Intervention: A Test and Replication. American Journal of Orthopsychiatry, 68(4), pp. 565-579, 1998.

Extracurricular Activities Related to School Retention Among Mexican Americans Students

With a growing Mexican American population and an increasing dropout rate predicted for this group, research is needed to examine ways of deterring this trend and increasing retention rates. The current study examined extracurricular activity, perception of school, and ethnic identification, and the association with school retention rates among Mexican American and White non-Hispanics. Individuals reporting participation in extracurricular activity were 2.30 times more likely to be enrolled in school than were those not participating in extracurricular activity. Mexican Americans reporting a higher White non-Hispanic ethnic identity level were 2.41 times more likely to be enrolled in school and had a more positive perception of school than did Mexican American individuals reporting low levels of White non-Hispanic ethnic identification. Davalos, D.B., Chavez, E.L., and Guardiola, R.J. The Effects of Extracurricular Activity, Ethnic Identification, and Perception of School on Student Dropout Rates. Hispanic J Behavioral Sciences, 21(1), pp. 61-77, 1999.

Assessing Change during Psychotherapy

This article provides an overview of methodological and conceptual issues underlying the assessment of change during psychotherapy with children and families. Three central considerations are discussed: (1) What changes do we measure? (2) When do we measure change? (3) How do we measure change? Measurement of change should be a priority of intervention research and is enhanced by: inclusion of multiple assessment points at theoretically important points during and after the intervention; use of reliable and valid measures of the change process; analysis of mediating, moderating, side effect, and clinical change variables; and protocols that assess dynamic rather than static constructs. Behaviors of interest should be measured in natural environments that are selected for their developmental relevance with regard to the age of the child and the problem behavior. Illustrations of key points are provided from the Adolescent Transitions Program, a theoretically based intervention program targeting high-risk youth. Eddy, J.M., Dishion, T.J., and Stoolmiller, M. The Analysis of Change in Children and Families: Methodological and Conceptual Issues Embedded in Intervention Studies. Journal of Abnormal Child Psychology, 26, pp. 53-69, 1998.

Comparative Perceptions of PSA Delivery

Video is a frequently used media for delivering drug prevention curriculum. Given the stress on identification, realism, and interest in curriculum development, it is important to assess the comparative perceptions of videos versus live performance. A Perception of Performance scale was developed and used to compare the two modalities for delivering drug prevention messages. The scale was developed using data from 334 undergraduate students at a large university in the southwestern United States. The age range was 17-42, median age of 19, 44% were female and 96% were European American. To validate the scale, 465 students in a single high school were randomly assigned to, either live or video performance conditions. 52% were female, 75% non-Hispanic White, 12% Hispanic, and 13% other. Participants viewed either a live performance or a video performance and then immediately completed the Perception of Performance Scale. Exploratory and Confirmatory Factor Analyses were conducted and three dimensions were identified: identification, interest, and realism with reliabilities of .86, .89, and .90 respectively. Live performance was perceived as significantly more interesting and realistic than video performance, suggesting that live performance may be a more effective medium for engaging high school aged youths. Miller, M., Hecht, M., and Stiff, J. An Exploratory Measurement of Engagement with Live and Film Media. Journal of the Illinois Speech and Theatre Association, 49, pp. 69-83, 1998.

The Lives, Motivations, and Options of Pregnant Drug Abusing Women, Their View

Extensive literature exists about the effects of drugs on the fetus but almost no information exists about the mother herself. Through interviews with 120 pregnant or recently delivered drug-using women, Dr. Sheigla Murphy and Dr. Marsha Rosenbaum examine how pregnant addicts make choices about their drug use, pregnancy, and prenatal care. To combat the stereotype of the negligent and even abusive pregnant drug user, the authors present the feelings and motivations of the women themselves. How do they decide whether to terminate their pregnancy? What options are available to them if they choose to continue the pregnancy but can't kick the drug use? Where do they get information upon which to make their decisions? They tend not to terminate pregnancy. They tend to change from one drug to another based on newspaper stories (if crack is bad, use heroin). The authors address these issues and the policy implications of their findings. Murphy, S. & Rosenbaum, M. Pregnant Women on Drugs: Combating Stereotypes and Stigma. New Brunswick, NJ: Rutgers University Press, 1999.

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