Douglas Longshore

Drug Treatment Careers A Conceptual Framework and Existing Research Findings

While outcomes for any single intervention are important to determine, the long term evaluation of multiple, sequential interventions is at least equally important. One strategy for examining this process is that of the treatment career. A treatment careers perspective applies a longitudinal dynamic approach to identify and understand key factors influencing the development of, and transitions in the course of, drug dependence and its treatment. After presenting an overview of the treatment careers perspective, this paper reviews and discusses relevant research issues and findings on treatment seeking, utilization and resistance, entry and reentry, engagement and retention, client treatment matching, and outcomes. Key findings include high resistance to entering treatment by many drug users, late development of treatment careers relative to addiction and criminal careers, short durations of most treatment episodes, cumulative and facilitative effects of treatment experiences, and beneficial effects of matching clients to treatment. The treatment careers perspective provides a useful framework within which findings on drug treatment can be better integrated and critical issues can be identified for further research, leading to a better understanding of drug dependence and its treatment.

Drug Use and Medication Adherence among HIV-1 Infected Individuals

This longitudinal study examined the impact of drug use and abuse on medication adherence among 150 HIV-infected individuals, 102 who tested urinalysis positive for recent illicit drug use. Medication adherence was tracked over a 6-month period using an electronic monitoring device (MEMS caps). Over the 6-month study drug-positive participants demonstrated significantly worse medication adherence than did drug-negative participants (63 vs. 79%, respectively). Logistic regression revealed that drug use was associated with over a fourfold greater risk of adherence failure. Stimulant users were at greatest risk for poor adherence. Based upon within-participants analyses comparing 3-day adherence rates when actively using versus not using drugs, this appears to be more a function of state rather than trait. These data suggest that it is the acute effects of intoxication, rather than stable features that may be characteristic of the drug-using populace, which leads to difficulties with medication adherence.

New Inroads in Preventing Adolescent Drug Use: Results From a Large-Scale Trial of Project ALERT in Middle Schools

OBJECTIVES We evaluated the revised Project ALERT drug prevention program across a wide variety of Midwestern schools and communities. METHODS Fifty-five South Dakota middle schools were randomly assigned to program or control conditions. Treatment group students received 11 lessons in 7th grade and 3 more in 8th grade. Program effects for 4276 8th-graders were assessed 18 months after baseline. RESULTS The revised Project ALERT curriculum curbed cigarette and marijuana use initiation, current and regular cigarette use, and alcohol misuse. Reductions ranged from 19% to 39%. Program effects were not significant for initial and current drinking or for current and regular marijuana use. CONCLUSIONS School-based drug prevention programs can prevent occasional and more serious drug use, help low- to high-risk adolescents, and be effective in diverse school environments.

The life course perspective on drug use: a conceptual framework for understanding drug use trajectories.

This article discusses the life course perspective on drug use, including conceptual and analytic issues involved in developing the life course framework to explain how drug use trajectories develop during an individuals lifetime and how this knowledge can guide new research and approaches to management of drug dependence. Central concepts include trajectories marked by transitions and social capital and turning points influencing changes. The life course perspective offers an organizing framework for classifying varying drug use trajectories, identifying critical events and factors contributing to the persistence or change in drug use, analytically ordering events that occur during the life span, and determining contributory relationships.

Self-Control and Criminal Opportunity: A Prospective Test of the General Theory of Crime

The general theory of crime (Gottfredson and Hirschi 1990) proposes that self-control is the primary individual-level cause of crime and that its effect is contingent on criminal opportunity. This study conducted a prospective test of self-control and opportunity as predictors of property crime and personal crime among drug-using offenders. Each predictor had a main effect; property crimes and personal crimes were more frequent among offenders lower on self-control and those with higher opportunity. A significant interaction between these predictors was also detected. About four percent of the variance in each type of crime was explained by these predictors. Results support the proposition that self-control is a causal factor in criminal behavior and suggest that its effect is partially contingent on opportunity, but self-control and opportunity, as measured here, had very modest explanatory power.

The efficacy of an integrated risk reduction intervention for HIV-positive women with child sexual abuse histories.

Child sexual abuse (CSA) is associated with HIV risk behaviors [Bensley, L., Van Eenwyk, J., and Simmons, K. W., 2003.] and more prevalent among women living with HIV than in the general population [Koenig, L. J., and Clark, H., 2004]. This randomized Phase~I clinical trial tested the impact of a culturally congruent psychoeducational intervention designed to reduce sexual risks and increase HIV medication adherence for HIV-positive women with CSA histories. An ethnically diverse sample of 147 women were randomized to two conditions: an 11-session Enhanced Sexual Health Intervention (ESHI) or an attention control. Results based on “intent to treat’’ analysesof pre–post changes are reported here. Additional analyses explored whether theobserved effects might depend on “intervention dose,’’ i.e., number of sessions attended. Women in the ESHI condition reported greater sexual risk reduction than women in the control condition. Although there were no differences between women in the ESHI and control groups on medication adherence, women in the ESHI condition who attended 8 or more sessions reported greater medication adherence at posttest than control women. The findings provide initial support for this culturally and gender-congruent psychoeducational intervention for HIV-positive women with CSA, and highlight the importance of addressing the effects of CSA on sexual risk reduction and medicationadherence in preventive interventions for women.

Effects of Drug Abuse and Mental Disorders on Use and Type of Antiretroviral Therapy in HIV-infected Persons

AbstractOBJECTIVE: To distinguish the effects of drug abuse, mental disorders, and problem drinking on antiretroviral therapy (ART) and highly active ART (HAART) use. DESIGN: Prospective population-based probability sample of 2,267 (representing 213,308) HIV-infected persons in care in the United States in early 1996. MEASUREMENTS: Self-reported ART from first (January 1997–July 1997) to second (August 1997–January 1998) follow-up interviews. Drug abuse/dependence, severity of abuse, alcohol use, and probable mental disorders assessed in the first follow-up interview. Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) estimated from weighted models for 1) receipt of any ART, and 2) receipt of HAART among those on ART. RESULTS: Of our study population, ART was reported by 90% and HAART by 61%. Over one third had a probable mental disorder and nearly half had abused any drugs, but drug dependence (9%) or severe abuse (10%) was infrequent. Any ART was less likely for persons with dysthymia (AOR, 0.74; CI, 0.58 to 0.95) but only before adjustment for drug abuse. After full adjustment with mental health and drug abuse variables, any ART was less likely for drug dependence (AOR, 0.58; CI, 0.34 to 0.97), severe drug abuse (AOR, 0.52; CI, 0.32 to 0.87), and HIV risk from injection drug use (AOR, 0.55; CI, 0.39 to 0.79). Among drug users on ART, only mental health treatment was associated with HAART (AOR, 1.57; CI, 1.11 to 2.08). CONCLUSIONS: Drug abuse-related factors were greater barriers to ART use in this national sample than mental disorders but once on ART, these factors were unrelated to type of therapy.

Self-Control and Social Bonds: A Combined Control Perspective on Deviance

With longitudinal data from a sample of adult male drug offenders, this study tested 4 aspects of social bonding (attachment, involvement, religious commitment, and moral belief) and association with substance-using peers as outcomes of low self-control and as mediators of the relationship between low self-control and drug use. Low self-control was negatively related to social bonds and positively related to drug use and association with substance-using peers. The relationship between low self-control and drug use was fully mediated by moral belief and association with substance-using peers. These results support the utility of integrating self-control and social bonding perspectives on deviance.

Self-Control and Criminal Opportunity: Cross-Sectional Test of the General Theory of Crime

In this study, the authors tested two hypotheses drawn from the general theory of crime. The first hypothesis is that low self-control is a major individual-level cause of crime. The second, that the effect of self-control is contingent on criminal opportunity. The measure of self-control used was a 23-item self-report index. To measure criminal opportunity, two proxy variables were used: gender and crime-involved friends. Crime measures included number of criminal acts of force and number of criminal acts of fraud reported in a 6-month recall period by a sample of 522 criminal offenders. Self-control was lower among offenders reporting more crimes of force and fraud, but the variance explained by self-control was low in each case. The relationship between self-control and fraud crimes was contingent on criminal opportunity, but the relationship between self-control and force crimes was not. Implications of these findings for the general theory of crime are reviewed.

Risk factors for hepatitis C virus infection among homeless adults

OBJECTIVE: To describe the prevalence of hepatitis C virus (HCV) infection in a sample of homeless and impoverished adults and examine risk factors for HCV infection in the overall sample and as a function of injection drug use.DESIGN: Assays were conducted on stored sera. Socio-demographic characteristics and risky sexual activity were measured by content-specific items. Substance use was measured by a structured questionnaire. HCV antibodies were tested by enzyme-linked immunosorbent assay; a confirmatory level was defined by recombinant immunoblot assay.SETTINGS: Shelters (N=36) and outdoor locations in Los Angeles.PARTICIPANTS: Eight hundred eighty-four homeless women and/or partners or friends.RESULTS: Among this sample of 884 homeless and impoverished adults, 22% were found to be HCV infected. Lifetime injection drug users (IDUs) (cocaine, crack, and methamphetamine) and recent daily users of crack were more likely than nonusers or less-frequent users of these drugs to be HCV-infected. Similar results were found for those who had been hospitalized for a mental health problem. Among non-injection drug users and persons in the total sample, those who reported lifetime alcohol abuse were more likely than those who did not to be HCV infected. Controlling for socio-demographic characteristics, multiple logistic regression analyses revealed IDUs have over 25 times greater odds of having HCV infection than non-IDUs. HCV infection was also predicted by older age, having started living on one’s own before the age of 18, and recent chronic alcohol use. Males and recent crack users had about one and a half times greater odds of HCV infection when compared to females and non-chronic crack users.CONCLUSIONS: Targeted outreach for homeless women and their partners, including HCV testing coupled with referrals to HCV and substance abuse treatments, may be helpful.