Social rehabilitation of addicts: a two-year evaluation

Factors associated with employment among a cohort of injection drug users

INTRODUCTION AND AIMS

One of the most substantial costs of drug use is lost productivity and social functioning, including holding of a regular job. However, little is known about employment patterns of injection drug users (IDU). We sought to identify factors that were associated with legal employment among IDU.

DESIGN AND METHODS

We describe the employment patterns of participants of a longitudinal cohort study of IDU in Vancouver, Canada. We then use generalised estimating equations (GEE) to determine statistical associations between legal employment and various intrinsic, acquired, behavioural and circumstantial factors.

RESULTS

From 1 June 1999 to 30 November 2003, 330 (27.7%) of 1190 participants reported having a job at some point during follow up. Employment rates remain somewhat stable throughout the study period (9-12.4%). Factors positively and significantly associated with legal employment in multivariate analysis were male gender (adjusted odds ratio [AOR] = 2.78) and living outside the Downtown Eastside (AOR = 1.85). Factors negatively and significantly associated with legal employment included older age (AOR = 0.97); Aboriginal ethnicity (AOR = 0.72); HIV-positive serostatus (AOR = 0.32); HCV-positive serostatus (AOR = 0.46); daily heroin injection (AOR = 0.73); daily crack use (AOR = 0.77); public injecting (AOR = 0.50); sex trade involvement (AOR = 0.49); recent incarceration (AOR = 0.56); and unstable housing (AOR = 0.57).

DISCUSSION AND CONCLUSIONS

Our results suggest a stabilising effect of employment for IDU and socio-demographic, drug use and risk-related barriers to employment. There is a strong case to address these barriers and to develop innovative employment programming for high-risk drug users.

Combining stepped-care approaches with behavioral reinforcement to motivate employment in opioid-dependent outpatients

Employment is associated with improved treatment outcome for opioid-dependent outpatients receiving methadone (e.g., Platt, 1995). Opioid-dependent individuals typically enter treatment unemployed and many remain unemployed despite reductions in heroin use. Additional interventions are needed to motivate employment seeking behaviors and outcome. This article reports on a promising approach to reduce the chronic unemployment commonplace in treatment-seeking, opioid-dependent patients--a "stepped care" service delivery intervention that incorporates multiple behavioral reinforcements to motivate patient participation in and adherence to the treatment plan. This therapeutic approach (Motivated Stepped Care--MSC; Brooner and Kidorf (2002) was refined and modified to motivate and support a range of positive treatment behaviors and outcomes in patients with opioid-dependence (Kidorf et al. 1999), including job-seeking and acquisition. Patients who are unemployed after one year of treatment are systematically advanced to more intensive steps of weekly counseling and remain there until employment is attained. Those who remain unemployed despite exposure to at least 4 weeks of counseling at the highest step of care (Step 3, which is 9 h weekly of counseling) are started on a methadone taper in preparation for discharge, which is reversible upon attaining a job. This article describes the MSC approach and presents rates of employment for patients who were judged capable of working (n = 228). A review of medical and billing records during August--September 2002 revealed that the great majority of these patients were employed (93%), usually in full-time positions. Employment was associated with less frequent advancement to higher intensities of weekly counseling because of drug use. Further, multiple indices of improved employment stability and functioning, including months of work, hours of work, and annualized salary, were associated with better drug use outcomes. These data suggest that the MSC intervention is an effective platform for motivating and supporting both job seeking and employment in patients with chronic and severe substance use disorder.

The role of vocational behaviors preceding and during 12-step oriented treatment

This study examined the role of vocational behaviors in the treatment of 80 crack users. The study had two general aims: (a) to predict which crack users had acquired jobs after 30 days in treatment; and (b) to examine if vocational behaviors assessed at admission and follow-up accounted for variations in recovery motivation, psychological functioning, and treatment completion. Multivariate analyses identified four predictors (race, having a polysubstance problem, 12-step sponsor, and specific job skill) of job acquisition. Multivariate analyses also indicated that past year employment was negatively related to recovery motivation but positively related to psychological functioning and treatment completion, and that job acquisition was negatively related to one measure of recovery motivation but positively related to psychological functioning. Future research should use multiple group designs to examine the effects associated with including a vocational component in treatment programs.

Retention in outpatient drug free treatment clinics

This study examined time in treatment and the percentage of clients who quit or were expelled from drug treatment clinics as dependent measures in a general model including socioecological aspects of the clinic neighborhood environment, the clinic structure (attributes, e.g., size, and services and staffing), and the client composition of the clinic (sociodemographic and deviance). In this study the clinic was the unit of analysis. The data were analyzed by means of path analysis, for (1) drug free outpatient, nonopiate orientation (DFO-N) and (2) drug free outpatient, opiate orientation (DFO-O). There were 204 DFO-N and 130 DFO-O clinics. The path analytic model proved to be useful for the explanation of clinic retention outcomes. The socioecological variables predicted the types of clients who entered treatment. These in turn along with clinic attributes were significant predictors of clinic retention. Clinic attributes also predicted clinic services and staffing. The results suggested that both clinic variables and client composition variables are important predictors of clinic retention.

Stereotyping as a negative factor in substance abuse treatment

Sixty addicts, health professionals, and counseling students were administered the Internal-External Locus of Control Test and the Multiple Affect Adjective Check List to determine if stereotypes exist between the subject groups, the nature of the stereotypes, and if educational level alters the stereotypes. The findings demonstrated gross misperception of addict clients by the health professionals and students, particularly toward psychotic and hostile dimensions. Educational level was found to improve the accuracy of the nonaddict perceptions. The study concludes with a discussion of the findings as they pertain to development of the counselor-client relationship, recidivism, and treatment of substance abuse clients.