Barbara E. Havassy

Characteristics of recent violence among entrants to acute mental health and substance abuse services

ObjectiveThe aim of this study was to describe the characteristics of recent interpersonal violence perpetrated and experienced by individuals recruited from acute crisis mental health and substance abuse treatment settings and to examine differences among incidents involving individuals with mental disorders only (MDO), substance use disorders only (SDO), and co-occurring mental and substance use disorders (COD).MethodParticipants (N = 419) were interviewed about their involvement in specific acts of violence in the past 30 days. Participants were also asked about where each incident took place, who was involved, whether individuals were injured, and whether alcohol or drugs were used before the incident. We examined distributions of violence characteristics for the full sample and used logistic regression analyses to test differences among incidents involving participants with MDO, SDO, and COD.ResultsApproximately 41% (n = 171) of the sample was involved in at least one incident of violence as a perpetrator or a victim, generating a total of 379 incidents. Far more incidents of violence involved victimization (62%) than perpetration (38%). Most incidents were isolated and involved only perpetration or only victimization. However, a total of 98 (26%) incidents occurred with another incident and constituted 49 episodes of violence that included incidents of perpetration and victimization. Characteristics of perpetration and victimization incidents were similar, except that victimization incidents involved more serious types of violence. The majority of incidents took place outdoors and did not result in injuries. Participants used drugs or alcohol prior to over 40% of incidents. Most incidents of perpetration (70%) targeted someone known to the participant. Diagnostic group was the strongest predictor of type of injury, location of incident, and use of alcohol and drugs before the incident. Individuals with substance use disorders, either alone or co-occurring with mental disorders, were more likely to report that violent incidents took place outdoors. Individuals with mental disorders, either alone or co-occurring with substance use disorders, were less likely to report alcohol and drug use prior to involvement in violence.ConclusionsViolence is common among individuals entering acute crisis mental health and substance abuse treatment. We found that such persons are more likely to report being victims of violence than perpetrators of violence. In contrast to prior studies, we found that most incidents took place outdoors. Although individuals in different diagnostic groups were no more or less likely to perpetrate or experience violence, they perpetrated and experienced violence under different circumstances. Implications and directions for future research and practice are discussed.

Self-regulation of dose in methadone maintenance with contingent privileges

Abstract The effect of giving methadone maintenance clients the opportunity to regulate their dosage and of offering take-home doses as an incentive for dose reduction was studied. Subjects (116) were randomly assigned to one of three conditions: self-regulation ofdose (SR-1); self-regulation of dose with incentive for reduction (SR-2) and standard treatment (control). Dependent variables were dosage and use of illicit drugs (measured by urinalyses). Results for the first four months show SR-1 subjects increased dose and maintained themselves at dosages significantly greater than the SR-2 or control groups while having significantly less use of illicit opiates during certain time periods. SR-2 subjects were not different from controls. Findings indicate subjects behaved responsibly under self-regulation and that this regimen is clinically feasible. Nevertheless, an increase in take-home privileges was an insufficient incentive to yield major reductions in dosage in SR-2 as a group.

Detection of Illicit Opioid and Cocaine Use in Methadone Maintenance Treatment

Urine toxicology is the gold standard for estimating the prevalence of illicit drug use in methadone maintenance treatment (MMT). The frequency of urine testing may be crucial for establishing accurate use rates. Infrequent testing may lead programs to undercount active drug users and to target interventions too narrowly. This study compared results from frequent testing (twice per week) versus less frequent testing of 166 patients at four MMT programs. As part of a research study, all patients were tested by research staff for opioid and cocaine use twice per week on a fixed schedule for 10 weeks. During the same period, the four MMT programs tested the patients according to their standard protocols, approximately weekly (one program) or every 3-4 weeks (three programs). The research tests identified approximately 50% more illicit opioid users and 70% more cocaine users than the less frequent program tests. Patients who were drug positive according to the research tests but drug negative according to the program tests tended to be infrequent users. The data suggest that standard urine testing practices in MMT programs may result in underestimates of the prevalence of opioid and cocaine use. More frequent testing, even for time-limited periods, should produce more accurate depictions of drug use prevalence and help indicate the direction of interventions.

Racial Distribution of Dual-Diagnosis Clients in Public Sector Mental Health and Drug Treatment Settings

This study examined the racial distribution of dual-diagnosis clients in public sector residential mental health and drug treatment settings. In a sample of 179 dual-diagnosis clients, there was a significantly larger proportion of blacks in the drug treatment cohort than the mental health cohort. There were black-white differences in the types of substance use disorders found, but not in the types of mental health disorders. Diagnostic and drug use pattern differences did not account for the differential racial distribution in the two settings. However, the racial distribution was explained by the recent history of service use in the two treatment sectors. In the 2 years after study entry, blacks were less likely than whites to receive mental health treatment and whites were less likely than blacks to receive drug treatment. The implications of these findings regarding the appropriate treatment for dual-diagnosis blacks and whites in the public sector are discussed.

Leaving a cardiology service against medical advice.

In an exploratory retrospective study of 64 hospitalized patients, we examined the demographic, medical, and psychologic correlates in patients who left our Cardiology Service against medical advice (AMA). Based on a medical chart review, the AMA and control groups were found to be significantly different regarding prior cardiac disability level, physical signs of chronic alcohol abuse on admission, cardiac complications, and requirement of antihypertensive/diuretic medications while hospitalized. The two groups were also significantly different with regard to somatic complaints, apparent anxiety and use of psychotropic medication on the day before leaving against medical advice. This study indicates that a multifactorial assessment of patients hospitalized on a cardiology service can enhance identification of those at risk to leave the hospital against medical advice.

Chronic heroin use during methadone treatment: A test of the efficacy of high maintenance doses☆

A pilot study was conducted at two maintenance programs to test the effect of increasing the methadone dose of clients who continue chronic heroin use after stabilization on methadone. Program 1 subjects (Group 1) received substantial dose increases for a 14-week period; Program 2 subjects (Group 2) received no dose modifications during the same period. Results show Group 1 reported an alleviation of physical and psychological complaints but did not decrease illicit opiate use. Group 2 maintained the low level of complaints reported at baseline and, unexpectedly, decreased opiate abuse. Because the two maintenance programs differed in clinical practices and in enforcement of rules, it was concluded that clients who continue chronic heroin use need not only long-term dosage increases, but also clear, consistently applied program policies.

Allowing methadone clients control over dosage: A 48-week controlled trial☆

Abstract Two strategies for client self-regulation of dosage in methadone maintenance were examined in a 48-week randomized clinical trial. Subjects assigned to the two experimental conditions (SR-1 and SR-2) were able to regulate their dosage weekly. In addition, SR-2 subjects could earn additional take-home dose privileges by reducing dosage. A total of 85 subjects were randomly assigned to either SR-1 (n = 28), SR-2 (n = 31), or a standard treatment control condition (n = 26). An anomalous trend for female control subjects to lower their dosage was observed, but otherwise dosage trends over time were similar in all treatments. Nevertheless, control subjects showed more illicit opiate use than either self-regulation group. Results confirm that methadone maintenance clients act responsibly when given the ability to regulate their own dosage. The opportunity for an increased number of take-home doses and the convenience of less frequent clinic visits seems not to be an adequate incentive to induce clients to significantly decrease their ongoing maintenance dosage.

Recent Violence Among Persons Entering Short-Term Residential Mental Health and Substance Abuse Treatment.

Objective: Large-scale epidemiologic studies have consistently found that co-occurring mental health and substance use disorders are associated with increased risk of involvement in violence. Individuals with co-occurring mental and substance use disorders can present either in mental health or substance abuse treatment systems, and both systems must be able to respond to their needs. This study examined the prevalence and correlates of recent violence (both perpetration and victimization) among adults (N = 419) entering short-term residential mental health and substance abuse treatment. Methods: Approximately 41% (n = 171) of participants reported having any involvement in violence, and for the majority of them (n = 144; 84%) that included victimization. For analytic purposes, we classified participants with involvement in violence as any perpetration (n = 87) or only victimization (n = 84) and conducted bivariate and multivariate logistic regression analyses examining potential correlates of these different types of violence. Results: Homelessness (adjusted odds ratio [AOR] = 1.6, 95% confidence interval [CI] [1.0–2.4], p < .04), alcohol use disorder (AOR = 1.8, 95% CI [1.1–2.9], p < .03), and the interaction of comorbidity and substance abuse treatment system (AOR = 2.8, 95% CI [1.0–7.6], p < .05) were associated with an increased likelihood of any violence. Alcohol use disorder (AOR = 1.8, 95% CI [1.0–3.3], p < .05) increased the likelihood of perpetration. Homelessness (AOR = 1.9, 95% CI [1.1–3.2], p < .02) and the interaction of comorbidity and being recruited from substance abuse treatment (AOR = 5.1, 95% CI [1.8–14.2], p < .003) increased the likelihood of involvement in only victimization. Conclusions: Victimization was far more prevalent than perpetration. Comorbidity was not a significant predictor of violence, but individuals with comorbidity recruited from the substance abuse treatment system were more likely to be involved in violence.

Severely mentally ill consumers' perspectives on drug use.

Abstract Substance use disorders have serious negative consequences for severely mentally ill (SMI) adults, but many do not receive adequate substance abuse treatment. As part of a larger project on access barriers to substance abuse treatment for SMI clients, this qualitative study examined two potential client-level barriers to treatment: minimization of drug problems and perceived acceptability of drug use to reduce psychiatric symptoms. Open-ended interviews about drug use were conducted with 24 SMI adults with substance use problems. The majority of respondents identified drug use as a major problem in their lives. Respondents were aware of the impact of drugs on psychiatric symptoms, and most believed that the negative effects of drug use outweighed any short-term benefits. Nearly all respondents believed it was not acceptable for SMI adults to use drugs except marijuana. Contrary to findings in the literature that SMI adults deny or minimize drug problems, most respondents acknowledged the seriousness of their drug use, were aware of the negative effects of drug use on their psychiatric symptoms, and endorsed abstinence as the optimal treatment goal. These findings have implications for substance abuse treatment for SMI clients, particularly interventions that emphasize education about drug use as a way to increase motivation for treatment.

Relapse to Cocaine Use

Publisher Summary Relapse denotes at least one episode of drug use following a period of no use. Some authors differentiate a lapse from a relapse. Usually, a lapse is defined as a brief episode of drug use quickly followed by a resumption of abstinence. Definitions of relapse are also complicated by emerging definitions of positive cocaine treatment outcomes. Development of definitions of cocaine relapse is hampered by the lack of descriptive data on relapse episodes. There are several models of drug use and relapse, including the conditioning models, many of which have a neurobiological underpinning. Numerous biological, psychological, social, and situational factors may influence relapse to cocaine. Research on most of these factors is still sparse. Epidemiological studies suggest a high prevalence of psychiatric disorders among cocaine patients compared to the general population. This chapter reiterates that most drug abuse treatments, both psychological and pharmacological, strive to help patients achieve abstinence. Relapse Prevention (RP) is a relatively recent technology for promoting abstinence from drugs of abuse as well as cessation of nondrug problematic behaviors.