Rural drug users: factors associated with substance abuse treatment utilization

The purpose of this study is to use a modified version of Andersen's Behavioral Model of Health Services Use to identify the correlates of the number of substance abuse treatment episodes received by rural drug users. Data were collected from face-to-face interviews with 711 drug users in rural areas of Ohio, Arkansas, and Kentucky. Descriptive analyses examine rural drug users' substance use histories and retrospective substance abuse treatment service utilization patterns. A negative binomial regression model indicated that selected predisposing, historical health, and enabling factors were significantly associated with the utilization of substance abuse treatment among rural drug users. Despite high levels of recent and lifetime self-reported substance use among these rural drug users, treatment services were underutilized. Future studies are needed to examine the impact of the health care system and characteristics of the external environment associated with rural substance abuse treatment in order to increase utilization among drug users.

Intervention attendance among emergency department patients with alcohol- and drug-use disorders

OBJECTIVE

The emergency department (ED) visit provides a window of opportunity for screening and linkage to services for inner-city adults with substance-use disorders (SUDs). This article examines predictors of intervention attendance among ED patients who screen positive for an SUD (alcohol or other drug).

METHOD

As part of a large randomized control trial, medical and injured patients (ages 19-60) in an inner-city ED completed a computerized screening survey. Based on random assignment, those screening positive for an SUD either were scheduled to attend a post-discharge intervention or received a referral brochure. Interventions (brief motivational intervention vs. case management intervention) focused on linking participants to substance-use treatment. Independent variables assessed included demographics, ED visit reason, health functioning, readiness to change, self-efficacy, and substance use. Intervention attendance (yes/no) was the dependent variable.

RESULTS

Overall, 957 (62.3% male; 58.3% African-American; M(age) = 33.2 years) were randomized to interventions (brief motivational intervention/case management intervention) and are the focus of subsequent analyses. There were no differences in the pattern of predictors of intervention attendance for brief motivational intervention versus case management intervention. Bivariate analyses compared those who attended the post-ED intervention with those who did not attend. Participants who attended the intervention (50%) were significantly more likely to be older, unmarried, insured, unemployed, and in the "action" stage of change.

CONCLUSIONS

The present findings highlight the relative importance of assessing and attending to readiness to change as well as demographic factors such as insurance and employment (and potentially associated barriers) in ED-based screening, brief intervention, and referral to treatment protocols.

Longitudinal association of preference-weighted health-related quality of life measures and substance use disorder outcomes

AIM

To examine the construct validity of generic preference-weighted health-related quality of life measures in a sample of patients with a substance use disorder (SUD).

DESIGN

Longitudinal (baseline and 6-month follow-up) data from a research study that evaluated interventions to improve linkage and engagement with SUD treatment.

SETTING

A central intake unit that referred patients to seven SUD treatment centers in a Midwestern US metropolitan area.

PARTICIPANTS

A total of 495 individuals with a SUD.

MEASUREMENTS

Participants completed two preference-weighted measures: the self-administered Quality of Well-Being scale (QWB-SA) and the standard gamble weighted Medical Outcomes Study SF-12 (SF-6D). They were also administered two clinical assessments: all seven domains of the Addiction Severity Index (ASI) and a symptom checklist based on the DSM-IV. Construct validity was determined via the relationships between disease-specific SUD and generic measures.

FINDINGS

In unadjusted analyses, the QWB-SA and SF-6D change scores were correlated significantly with six ASI subscale change scores, but not with employment status. In adjusted repeated-measures analyses, three of seven ASI subscale scores were significant predictors of QWB-SA and 5/7 ASI subscale scores were significant predictors of SF-6D. Abstinence and problematic use at follow-up were significant predictors of QWB-SA and SF-6D. Effect sizes ranged from 0.352 to 0.400 for abstinence and -0.484 to -0.585 for problematic use.

CONCLUSIONS

Generic preference-weighted health-related quality of life measures show moderate to good associations with substance-use specific measures and in certain circumstances can be used in their stead. This study provides further support for the use of the Quality of Well-Being scale and Medical Outcomes Study SF-12 in clinical and economic evaluations of substance use disorder interventions.

Stimulant use by young adult African Americans in a rural community: a pipeline to prison?

The association between stimulant use and legal outcomes was examined in rural adults aged 18-21 years (n = 98) in the Mississippi River Delta of Arkansas from 2003 through 2008. Participants were interviewed at baseline and every 6 months for 2 years, using the Substance Abuse Outcomes Module, Addiction Severity Index, Short-Form 8 Health Survey, Brief Symptom Inventory, Patient Health Questionnaire depression screen, and an abbreviated antisocial personality disorder measure. More than three quarters were arrested before baseline; 47 were arrested over the next 2 years. Early arrest but not substance use was related to subsequent arrest. Limitations and implications for interventions are discussed.

Predictors of depressive symptomatology among rural stimulant users

This study examined sociodemographic and drug-related predictors of depressive symptoms among a rural, multistate sample of not-in-treatment stimulant drug users (n=710). Participants were recruited using respondent-driven sampling in Ohio, Arkansas, and Kentucky. The Patient Health Questionnaire (PHQ-9) was used to measure symptoms of depression. Moderate to severe depressive symptomatology was reported by 43.0% of the sample. Cumulative logistic regression analysis showed that daily and nondaily crack use as well as the daily use of cocaine HCl increased the odds of depressive symptoms. Methamphetamine use had no significant association with depression. The daily use of marijuana, the illicit use of tranquilizers, light/moderate cigarette smoking, and injection drug use also increased the risk of depressive symptoms. Living in Kentucky or Ohio (compared to Arkansas), having unstable living arrangements, and being White, female, and older were related to higher odds of depressive symptoms. These results suggest that a host of drug and nondrug factors need to be considered when addressing depressive symptoms in stimulant users.

"Tweaking and geeking, just having some fun": an analysis of methamphetamine poems

There is a body of methamphetamine-themed poetry that speaks regretfully of the highly negative experiences of those in recovery from methamphetamine (MA) addiction or who feel trapped in an MA-using lifestyle. During ethnographic research in western Kentucky, the author collected two MA-themed poems from active MA users that differ from other MA poetry. They describe misadventures that occur during MA "binges." However, the text and tone of the poems are comically ironic and represent optimism rather than regret toward MA use. Analyzing these poems provides valuable insights into local patterns of MA use, related terminology, and attitudes toward MA use.

Religiousness among at-risk drinkers: is it prospectively associated with the development or maintenance of an alcohol-use disorder?

OBJECTIVE

This study examined whether particular dimensions of religiousness are prospectively associated with the development or maintenance of an alcohol-use disorder (AUD) among at-risk drinkers or persons with a history of problem drinking.

METHOD

A prospective cohort study was conducted among at-risk drinkers identified through a population-based telephone survey of adults residing in the southeastern United States. The cohort was stratified by baseline AUD status to determine how several dimensions of religiousness (organized religious attendance, religious self-ranking, religious influence on one's life, coping through prayer, and talking with a religious leader) were associated with the development and, separately, the maintenance or remission of an AUD over 6 months. Multiple logistic regression analyses were conducted to estimate the odds of developing versus not developing an AUD and maintaining versus remitting from an AUD while adjusting for measures of social support and other covariates.

RESULTS

Among persons without an AUD at baseline, more frequent organized religious attendance, adjusted odds ratio (OR(adj)) = 0.73, 95% CI [0.55, 0.96], and coping through prayer, OR(adj) = 0.63, 95% CI [0.45, 0.87], were associated with lower adjusted odds of developing an AUD. In contrast, among persons with an AUD at baseline, no dimension of religiousness was associated with the maintenance or remission of an AUD.

CONCLUSIONS

The findings of this study suggest that religious attendance and coping through prayer may protect against the development of an AUD among at-risk drinkers. Further research is warranted to ascertain whether these or other religious activities and practices should be promoted among at-risk drinkers.

Predictors of attrition from a national sample of methadone maintenance patients

BACKGROUND

Methadone substitution therapy is an effective harm reduction treatment method for opioid dependent persons. Ability to retain patients in methadone treatment is an accepted predictor of treatment outcomes.

OBJECTIVES

The current study evaluates the roles of psychiatric comorbidity, medical comorbidity, and sociodemographic characteristics as predictors of retention in methadone treatment utilizing retrospective analysis of data from a nationwide sample of patients in methadone treatment in the VA.

METHODS

Data were gathered using the VA's national health services use database. A cohort of veterans with a new episode of "opiate substitution" in fiscal year 1999 was identified, and their continuous service use was tracked through fiscal year 2002. The sample included a total of 2,363 patients in 23 VA medical centers. Survival analysis was used to explore factors associated with retention in methadone treatment.

RESULTS

Younger age, having a serious mental illness, being African American, or having race recorded as unknown were associated with lower rates of retention in methadone treatment programs in this population of veterans (controlling for site).

CONCLUSION

Given that extended methadone treatment is associated with improved outcomes while patients remain in treatment, more longitudinal studies using primary data collection are needed to fully explore factors related to retention. For the VA population specifically, further research is necessary to fully understand the relationship between race/ethnicity and treatment retention.

SCIENTIFIC SIGNIFICANCE

This is the first retention study the authors are aware of that utilizes data from a nationwide, multisite, population of participants in methadone treatment.

Two-year trajectory of stimulant use in 18- to 21-year-old rural African Americans

Little is known about stimulant use trajectories of rural African American youth. The purpose of the present study is to explore substance use over 24 months in 98 African Americans, ages 18 to 21, who used cocaine or methamphetamine 30 days prior to baseline. The majority was male, unemployed, and had not graduated from high school. At baseline, almost half of the participants met criteria for abuse/dependence of cocaine--the primary stimulant used--which decreased to 25% by the final follow-up. Similar decreases were noted in rates of alcohol and marijuana abuse/dependence, although monthly use remained high. Participants reported minimal utilization of mental health or substance abuse services, but demonstrated significant improvements on physical and mental health measures. In summary, cocaine use declined, but other substances were used at high rates, suggesting a significant need for intervention services that address multisubstance use in rural areas.

Pain interference in individuals in driver intervention programs for driving under the influence offenders

Pain-related problems among individuals in court-mandated Driver Intervention Programs (DIPs) for "driving under the influence" (DUI) offenders have not been well studied. This project examines 3,189 individuals from a DIP in Dayton, Ohio. Over 11% of participants reported significant pain-related interference in the past 4 weeks. Pain was significantly more likely in those with depression, more childhood conduct problems, and recent use of multiple illicit drugs. Many individuals seen in court-mandated DIP programs for DUI offenders also report difficulties with pain. DIP programming should address pain in relation to substance use and mental health issues.

Correlates of intimate partner violence among men and women in an inner city emergency department

The current study surveyed medical or injured patients (men and women) in an inner city emergency department to examine the rates and correlates of intimate partner violence, including substance use patterns. Over a 2-year period, participants (n = 10,744) self-administered a computerized health survey during their emergency department visit that included screening items regarding past year history of intimate partner violence (including victimization and aggression). Overall, rates of any intimate partner violence involvement in past year were 8.7% (7.3% victimization and 4.4% aggression); however, women were more likely than men to report intimate partner violence. When examining participants' substance use patterns, participants who reported using both alcohol and cocaine were most likely to report intimate partner violence. Predictors of partner aggression and victimization were remarkably similar. This article provides unique data regarding correlates of past year intimate partner violence history among a comprehensive sample of male and female emergency department patients presenting for medical complaints or injury.

Longitudinal relationship between psychological distress and multiple substance use: results from a three-year multisite natural-history study of rural stimulant users

OBJECTIVE

Substance use is associated with poor mental health, but little is known regarding how use of multiple substances is associated with mental health, particularly longitudinally, in community studies. This article examines this issue in a large (N = 710), natural-history study of rural stimulant (cocaine and/or methamphetamine) users in three states.

METHOD

Respondent-driven sampling recruited recent (past-30-day) stimulant users in three counties each in Arkansas, Kentucky, and Ohio. Participants were interviewed every 6 months for 3 years. Mental health was measured by the Brief Symptom Inventory, and prior 6 months' substance use was measured for 17 possible substances. Data analysis used generalized estimating equations for longitudinal data with the Global Severity Index of the Brief Symptom Inventory as the dependent variable at each interview and substance use as predictor variables measured by number of substances used in the past 6 months and, separately, the 17 individual substances, adjusting for use of substance-use treatment, demographics, and recruitment site.

RESULTS

On average, both Global Severity Index score and use of many substances declined over the course of study. Global Severity Index score was significantly associated with (a) greater number of substances used in the past 6 months (p < .0001) and (b) use of crack cocaine, methamphetamine, and nonprescription use of prescription painkillers and tranquilizers.

CONCLUSIONS

Multiple and specific substances appear to incrementally increase psychological distress. Users of cocaine and methamphetamine are present in rural areas; these associations with poor psychological health raise concerns regarding availability of local treatment services for individuals with mental-health problems, as well as substance abuse.

Perceived need for treatment for alcohol use disorders: results from two national surveys

OBJECTIVES

Most individuals with alcohol use disorders receive no treatment for their disorder. Past research suggests that a major reason for this is that individuals with alcohol use disorders do not perceive a need for treatment. The research presented here had two objectives. First, to provide updated estimates of the percentage of individuals with alcohol use disorders who perceive a need for treatment, and among those, the percentage who receive any treatment for alcohol use disorders. And second, to investigate the determinants of perceived need for and utilization of treatment for alcohol use disorders.

METHODS

Secondary data analyses were performed for two national surveys, the National Epidemiologic Survey on Alcohol and Related Conditions (3,305 individuals with alcohol use disorders) and the National Survey on Drug Use and Health (7,009 individuals with alcohol use disorders).

RESULTS

In both surveys fewer than one in nine individuals with an alcohol use disorder perceived a need for treatment. In predicting perceived need, the explanatory power of diagnostic variables was much greater than that of demographic variables. Among those with perceived need, two out of every three persons reported receiving treatment in the past year.

CONCLUSIONS

Our results suggest that failure to perceive need continues to be the major reason that individuals with alcohol use disorders do not receive treatment. On the other hand, among those who perceived a need, a majority received treatment. It is likely that high levels of unmet need for treatment services for alcohol use disorders will persist as long as perceived need is low. Efforts are needed to increase levels of perceived need among those with alcohol use disorders.

Stages of change, decisional balance, and self-efficacy in condom use among rural African-American stimulant users

This pilot study (a) examined the stages of change (SOC) for condom use with primary and casual partners among rural heterosexual African American stimulant users, (b) identified gender differences in variables associated with SOC, and (c) assessed the association of SOC with decisional balance and self-efficacy. A total of 72 participants completed the study. SOC with a primary partner were much lower than with a casual partner, indicating more consistent condom use with casual partners. Significant gender differences existed in decisional balance for condom use for both primary (p = .02) and casual partners (p =.03), with women having higher decisional balance scores than men. Women also reported higher self-efficacy scores for condom use with casual partners than men. In regression models, age, decisional balance, and self-efficacy were significantly associated with SOC for condom use with a primary partner; however, only self-efficacy was significantly associated with SOC with casual partners. The results provide support for the development of interventions that promote the advantages of and increase self-efficacy for condom use.

Predictors of substance abuse treatment entry among rural illicit stimulant users in Ohio, Arkansas, and Kentucky

Illicit drug use in the rural United States is increasingly common, yet little is known about drug users' treatment-seeking behaviors. This study identifies predictors of substance abuse treatment entry over 24 months among 710 illicit stimulant users in rural areas of Ohio, Arkansas, and Kentucky. Active users of powdered cocaine, crack cocaine, and/or methamphetamine (MA) were recruited using respondent-driven sampling. Participants completed structured interviews at baseline and follow-up questionnaires every 6 months for 24 months. Data were analyzed using the Cox proportional hazards model. The paper is informed by the Anderson-Newman Model. Overall, 18.7% of the sample entered treatment. Ohio or Kentucky residence, perceived need for substance abuse treatment, higher Addiction Severity Index (ASI) legal problem composite scores, prior substance abuse treatment, and tranquilizer use were positively associated with treatment entry. Nondaily crack cocaine users and marijuana users were less likely to enter treatment. The findings can help inform rural substance abuse treatment program development and outreach.

Examining factorial structure and measurement invariance of the Brief Symptom Inventory (BSI)-18 among drug users

The purpose of this study is to examine the factorial structure of the Brief Symptom Inventory 18 (BSI-18) and test its measurement invariance among different drug using populations. A total sample of 710 drug users was recruited using respondent-drive sampling (RDS) from three states: Ohio (n=248), Arkansas (n=237), and Kentucky (n=225). The results of confirmatory factor analysis (CFA) show: 1) the BSI-18 has a three-factor structure (somatization, depression, and anxiety) with an underlying second-order factor (global severity index of distress); and 2) its factorial structure and metric (factor loadings) are invariant across populations under study. However, the scalars (intercepts) of the BSI-18 items are not invariant, and the means of the latent factors also varied across populations. Our findings provide evidence of a valid factorial structure of the BSI-18 that can be readily applied to studying drug using populations.

Perceived need for treatment for alcohol use disorders: results from two national surveys

OBJECTIVES

Most individuals with alcohol use disorders receive no treatment for their disorder. Past research suggests that a major reason for this is that individuals with alcohol use disorders do not perceive a need for treatment. The research presented here had two objectives. First, to provide updated estimates of the percentage of individuals with alcohol use disorders who perceive a need for treatment, and among those, the percentage who receive any treatment for alcohol use disorders. And second, to investigate the determinants of perceived need for and utilization of treatment for alcohol use disorders.

METHODS

Secondary data analyses were performed for two national surveys, the National Epidemiologic Survey on Alcohol and Related Conditions (3,305 individuals with alcohol use disorders) and the National Survey on Drug Use and Health (7,009 individuals with alcohol use disorders).

RESULTS

In both surveys fewer than one in nine individuals with an alcohol use disorder perceived a need for treatment. In predicting perceived need, the explanatory power of diagnostic variables was much greater than that of demographic variables. Among those with perceived need, two out of every three persons reported receiving treatment in the past year.

CONCLUSIONS

Our results suggest that failure to perceive need continues to be the major reason that individuals with alcohol use disorders do not receive treatment. On the other hand, among those who perceived a need, a majority received treatment. It is likely that high levels of unmet need for treatment services for alcohol use disorders will persist as long as perceived need is low. Efforts are needed to increase levels of perceived need among those with alcohol use disorders.

Mixed state discrimination using optimal control

We present theory and experiment for the task of discriminating two nonorthogonal states, given multiple copies. We implement several local measurement schemes, on both pure states and states mixed by depolarizing noise. We find that schemes which are optimal (or have optimal scaling) without noise perform worse with noise than simply repeating the optimal single-copy measurement. Applying optimal control theory, we derive the globally optimal local measurement strategy, which outperforms all other local schemes, and experimentally implement it for various levels of noise.

Longitudinal changes in drug use severity and physical health-related quality of life among untreated stimulant users

The primary objective of this study was to investigate whether drug use severity is associated with physical health-related quality of life (HRQL) over time. Data are from a longitudinal, multi-state, natural history community study of users of cocaine and/or methamphetamine who were interviewed at 6-month intervals over 2 years with a 79% follow-up participation rate. Physical HRQL was assessed with the physical component summary (PCS) of the SF-8 Health Survey and drug, alcohol, and psychiatric severity were all assessed with the Addiction Severity Index (ASI). Random coefficient regression analyses were conducted to test for longitudinal associations between the independent variables and SF-8 PCS scores. Reductions in drug use severity over time were accompanied by only minor improvements in SF-8 PCS scores, underscoring the potential long-term harm of illicit drug use on physical health. Greater psychiatric severity was strongly associated with lower SF-8 PCS scores, suggesting that clinical attention to mental health issues could potentially lead to improvements in perceived physical health as well as among stimulant users.

Variations in Drinking Patterns in the Rural South: Joint Effects of Race, Gender, and Rural Residence

OBJECTIVES

To understand the relative contribution of gender, race (African-American vs. Caucasian), and rural residence on variations in drinking patterns, including past year abstinence, at-risk drinking, and recent drinking quantity and frequency for drinkers only.

METHODS

A brief health survey was administered by telephone to a probability sample of 11,529 residents of six southern states, over-sampling rural inhabitants.

RESULTS

Drinking patterns varied by gender, race, and rural residence in bivariate analysis. Gender effects were independent of rural residence, but race effects on abstinence and at-risk drinking were found only in urban residents and race differences in drinking quantity only in rural residents. Multivariate analysis, controlling for age and education, found gender and rural residence to be the strongest predictors, as well as being an African-American female.

CONCLUSIONS

Female gender, African-American race, and rural residence appear protective for at-risk drinking but rural residence dominates racial differences.

Losing All the Pieces: A Qualitative Study of HIV Risk Perception and Risk Reduction among Rural African American Women Who Use Cocaine

The purpose of this study was to examine HIV-related beliefs of rural African American women who use stimulant drugs and their perceived risk for acquiring HIV. Qualitative interviews were conducted with 15 African American women living in the Mississippi Delta region of rural Arkansas. All women in the study were active users of crack and/or powder cocaine. We used the qualitative methods of content analysis and constant comparison to analyze the transcribed interviews. Four major themes emerged from the analysis: 1) Knowledge and Beliefs, 2) Don't Ask, Don't Tell, 3) Staying Safe, and 4) Surviving in the Community. Based on participants' responses, we discuss implications for framing new risk-reduction interventions tailored to the specific needs of this high-risk population at both the individual and community levels.

An ethnographic exploration of self-reported violence among rural methamphetamine users

Baseline and follow-up qualitative interviews with methamphetamine users in rural Kentucky and Arkansas examined their involvement in drug-related violence. Twelve baseline participants reported methamphetamine-related violence, whereas 20 reported violence linked to other substances. In follow-up interviews conducted 12 to 24 months later, four participants reported methamphetamine-related violence and three reported violence associated with other substances. Violence was rarely directly attributed to methamphetamine's psychoactive effects. Rather, violence was associated with disputes over methamphetamine or its use, paranoia, ill-tempers, and hallucinations during methamphetamine "binges." Implications of the findings for additional research and interventions are discussed.

Prescription opiate misuse among rural stimulant users in a multistate community-based study

OBJECTIVES

The purpose of the current analysis was to examine the factors associated with prescription opiate misuse among stimulant users from rural counties in Arkansas, Kentucky, and Ohio (N = 714).

METHODS

Multiple logistic regression was utilized to determine the independent correlates of recent (prior 6 months) prescription opiate misuse.

RESULTS

More than half of participants (53.2%) reported prescription opiate misuse in the previous 6 months. Other drug use (heroin, cocaine, methamphetamine, and marijuana) and anxiety (Adjusted Odds Ratio: 2.04, 95% Confidence Interval: 1.60, 2.59) were independently associated with prescription opiate misuse. Chronic pain and other health indicators were not associated with prescription opiate misuse after adjustment for covariates.

CONCLUSIONS

Results indicate that illicit drug involvement and psychiatric symptoms may be driving the high rates of prescription opiate misuse among rural stimulant users. These findings have implications for the provision of treatment in resource-deprived rural areas.