Drug Abuse Treatment

Research Findings from February, 1998 Director's Report

This section lists selected summaries from NIDA funded research projects that investigate the child and adolescent drug abuse treatment. The summaries provided were selected from recent issues of the Director's Report to the National Advisory Council on Drug Abuse. For a more comprehensive listing of NIDA funded projects see the Director's Report.

Psychosocial Predictors of Drug Abuse Among Drug Clinic-Referred Youths

In a study that examined 2582 adolescents referred to drug treatment facilities nationwide and in Ontario, Canada, who met criteria for DSM-III-Revised drug abuse or dependence of at least one psychoactive substance, Winters, Latimer and Stinchfield found the strongest predictors of drug use severity at the time of referral, as measured by the Personal Experience Inventory, to be use of illicit drugs by peers and by siblings. Less predictive were psychological distress (emotional disturbance; social isolation), declaration of nonconventional values (e.g., rejecting conventional values; absence of goals; spiritual isolation), and family distress (e.g., parent drug use; parent dysfunction; family estrangement). Results were similar for all racial/ethnic, gender, and age subgroups represented in the study sample. Journal of Pediatric Psychology. In Press.

DSM-IV Criteria for Adolescent Alcohol and Cannabis Use Disorders

In a study comparing DSM-III-Revised and DSM-IV criteria for alcohol and cannabis use disorders among 772 teenagers (63% boys; 77% white) referred to adolescent outpatient drug treatment programs in the Minneapolis, MN area, Winters, Latimer and Stinchfield found that compared to the use of the DSM-III-R criteria, the application of DSM-IV criteria for alcohol and cannabis use resulted in more "abuse" assignments and fewer "dependence" assignments. Study results indicated that the shift in diagnostic assignments when using DSM-IV compared to DSM-III-R was due to a lowering of the abuse threshold rather than a tightening of the dependence criteria. Journal of Studies on Alcohol. In Press.

Cannabis Dependence, Withdrawal, and Reinforcing Effects Among Adolescents with Conduct Symptoms and Substance Use Disorders

Crowley and his colleagues from the University of Colorado assessed 209 adolescents (165 males, 64 female; 13-19 year old), who were referred for substance and conduct problems, to determine if cannabis produced dependence and withdrawal. The subjects were diagnosed with substance dependence, 100%; current conduct disorder, 82.1%; major depression, 17.5%; and attention-deficit/hyperactivity disorder, 14.8%. Most patients claimed serious problems from cannabis, and 78.6% met standard adult criteria for cannabis dependence. Two-thirds of cannabis-dependent patients reported withdrawal. Progression from first to regular cannabis use was as rapid as tobacco progression, and more rapid than that of alcohol, suggesting that cannabis is a potent reinforcer. Data indicate that for adolescents with conduct problems cannabis is not benign, and that the drug potently reinforces cannabis-taking, producing both dependence and withdrawal. However, the authors suggested that findings from this severely affected clinical population should not be generalized broadly to all other adolescents. Crowley, T.J., MacDonald, M.J., Whitmore, E.A., and Mukulich, S.K. Drug and Alcohol Dependence, In Press.

Fluoxitine in Drug-Dependent Delinquents with Major Depression: An Open Trial

Riggs et al. treated, in an open trial for > 7 weeks with a fixed dose of 20 mg of fluoxitine, a group of adolescents, who had been referred to residential treatment for substance use disorder. A >50% improvement was observed in mean scores on the 10-point depression scale. Of the 8 adolescents, 7 showed marked improvement and wished to continue fluoxitine after trial. Side effects were mild and transient. No subject required dosage reduction or discontinuation of medication because of side effects. Fluoxitine appeared useful in treating substance-dependent delinquents whose major depressions persisted or emerged after 4 weeks of abstinence. These preliminary findings justify a controlled trial in such youths. Riggs, P.D., Mikulich, S.K., Coffman, L.M., Crowley, T.J. J. Child and Adolescent Psychopharmacol, 7(2), pp. 87-95, 1997.

Potential for Child Abuse

Falkin and Strauss found average scores on the Child Abuse Potential Inventory (CAP) among women substance-abusing offenders with minor children (N=300) were in the same range as scores for individuals convicted of child abuse. These scores were significantly higher for women with psychological problems and those who had experienced physical abuse as children. The children of these women may be at high risk for abuse if the women do not receive appropriate interventions after treatment. Falkin, G. and Strauss, S., The Potential for Child Abuse Among Women Offenders Who Abuse Substances, paper presented at the 7th International Conference on Family Violence, Durham, New Hampshire, June 1997.

Community Epidemiology Work Group (CEWG)

The 43rd biannual meeting of the CEWG was held in Phoenix, Arizona on December 9-12, 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 data, local and State survey information, and research findings from ethnographic studies. The following are highlights from the meetings:

• Cocaine - Crack cocaine continues to dominate as the Nation's primary illicit drug problem, but indicator data show a leveling off in many urban areas: cocaine-related deaths were stable or up slightly in 6 of the 8 areas where such information was reported; emergency department (ED) mentions increased* in only 3 of the 20 CEWG cities in the Drug Abuse Warning Network (DAWN); the percentage of treatment admissions for primary cocaine problems declined slightly or remained stable in 13 of the 15 areas where data were available; and prices remained stable or declined slightly in most areas. Supplies remain abundant in nearly every city. Cocaine continues to be frequently used in combination with other drugs in some cities, including heroin and marijuana in Atlanta and Philadelphia, and methamphetamine in Denver. Demographic data continue to show most cocaine users as older, inner-city crack addicts; only in Miami were any new using populations reported this period. [* DAWN comparisons are for 1994 versus 1996; they are included only when they are reliable at p<0.05.]

• Heroin - Heroin overshadows cocaine in some indicators: it was the top-ranking ED mention in three cities, and it was the most common primary drug of abuse among treatment admissions in six areas. The rate of ED mentions per 100,000 increased significantly* in eight cities. Mortality, treatment, arrestee urinalysis, and price/purity figures were mixed, with increases in some cities, declines in others, and stable trends in others. In six CEWG cities, noteworthy percentages (˜10 percent) of arrestees, both male and female, tested heroin-positive in the Alcohol and Drug Abuse Monitoring (ADAM) program.

  Injecting remains the most common route of heroin administrationÑparticularly in the West, but also in some eastern and midwestern cities. However, it is declining sharply in some cities. Snorting predominates in several eastern and midwestern cities. Smoking is increasing among treatment admissions in Hawaii, San Diego, San Francisco, Atlanta, and Denver. Younger heroin users tend to snort or smoke the drug. Overall, heroin users tend to be males, older than 35, but in some cities, qualitative and quantitative dataÐincluding mortality figures in Miami--indicate increases among those age 18Ð25. Those age 17 and younger still account for relatively few ED mentions or treatment admissions, but even the low numbers, in areas such as Dallas, Minneapolis/St. Paul, San Francisco, and Texas, are a cause for serious concern.

• Marijuana - Continuing the upward trend in many cities since 1992, marijuana ED rates increased significantly* in 9 CEWG cities and primary marijuana abuse as a percentage of treatment admissions increased slightly to moderately in at least 10 reporting areas since the previous reporting period. Marijuana is now the top-ranking primary drug in at least four areas, and it accounts for substantial proportions (>20 percent) of nonalcohol admissions in at least three others. Among adult male arrestees, marijuana now exceeds cocaine as the most frequently detected drug in eight of the CEWG cities in ADAM; moreover, in each of the seven CEWG cities where ADAM tests juvenile males, the percentage of positive urinalyses is much higher for juveniles than for adults. Treatment demographics have similarly become increasingly youth dominated: the <17 age group now accounts for the largest percentages of marijuana admissions in at least eight areas. That age group also accounted for 20 percent or more of marijuana ED mentions in seven of the CEWG cities in 1996. All age groups, however, are substantially represented in all indicators, both qualitative and quantitative. Youth often consume marijuana with malt liquor. In some cities, joints or blunts are also dipped in PCP, codeine cough syrup, or embalming fluid; sometimes they contain crack or cocaine HCl, or they are laced with heroin.

• Stimulants - Except for ED mentions, methamphetamine indicators--mortality, treatment, and arrestee urinalysis--and ethnographic research show increases in the West, where the problem has been historically centered. Recent ADAM data show increases** in all the western CEWG cities. San Diego mortality figures also show increases, as do treatment figures in Denver, Los Angeles, and San Francisco. Methamphetamine is the most common primary drug among treatment admissions in San Diego and Hawaii, and it equals heroin as the number-one drug in Arizona. By contrast, ED rates declined significantly by 30-40 percent* throughout the West. They also declined* in Philadelphia, but the numbers are much lower there. The only city with a significant increase* was Minneapolis/St. Paul, but, again, the numbers are sharply lower than in the West. Smoking has recently overtaken inhalation as the primary route of administration in San Diego and Los Angeles. "Ice" smoking also predominates in Hawaii, and it is increasing in Denver and San Francisco. Injecting, however, still predominates in Denver, San Francisco, and Texas. In San Francisco, methamphetamine remains widespread among the gay and club scenes. Denver drug dealers sometimes cut crack or heroin with methamphetamine. Elsewhere in the country, methamphetamine appears in indicators in Minneapolis/St. Paul and in the rural areas surrounding St. Louis; availability is reported in Atlanta and New Orleans; and it is associated with the club or rave scenes in Boston, Baltimore, Miami, and New York City. [**ADAM comparisons are for first half of 1996 versus first half of 1997.]

  Methylenedioxymethamphetamine (MDMA or "ecstasy") availability is reported in 12 CEWG areas, primarily as a club drug at raves and dance parties. Increases are reported in Boston and Miami. Ephedrine-based products remain a major concern, with products such as "herbal ecstasy" widely available at convenience stores and truck stops in many CEWG areas, including Minneapolis/St. Paul and Arizona. Methylphenidate (Ritalin) abuse is reported among school-aged adolescents in Boston and Washington, DC, and it is the drug of choice for some stimulant users in Chicago. Seizures of khat, a flowering evergreen shrub also known as "qat" or "Somali tea," continue in Minneapolis/St. Paul.

• Depressants - Gamma-hydroxybutyrate (GHB) has been involved in poison control cases in Boston, Miami, and Texas, and is suspected in deaths in Miami; it is also part of the club scene (but not reported as a significant problem) in Baltimore, Honolulu, New York City, and areas of New Jersey; in Atlanta, it has become common as a synthetic steroid. Another club drug, ketamine ("Special K" or "Vitamin K"), is available in Boston (where youth both smoke and inject it), Honolulu, Miami, Minneapolis/St. Paul (where adolescents and young adults snort it and sometimes sprinkle it on tobacco or marijuana), New York City (where recent legislation has classified it as a controlled substance), and Washington, DC. Flunetrazepam (Rohypnol) availability has been sharply curtailed in Miami since State and Federal legislative measures were enacted. In Texas, however, it continues to be reported by treatment admissions, especially youth, in border areas. It continues to be reported in "date rape" incidents in Atlanta, Minnesota (where large quantities have been seized), and the Washington, DC, area; and it is used as a club drug in Atlanta and Honolulu. It has received media attention in some cities, such as San Diego and Seattle, but is not a widespread problem there. Clonazepam (marketed as Klonopin in the United States and Rivotril in Mexico), is sold and abused as flunetrazepam in Miami; on the Texas-Mexico border, juveniles widely use it in combination with beer, just as they had used flunetrazepam before the import ban. Opiate addicts use it to enhance the effects of methadone in Atlanta, Boston, and Minneapolis/St. Paul (where availability has declined).

• Hallucinogens - Lysergic acid diethylamide (LSD) is reportedly available in many CEWG cities and prices have become somewhat lower. However, indicators are declining in most areas. Rates of LSD-related ED mentions declined* in every CEWG area with the exception of San Diego and New Orleans. Similarly, phencyclidine (PCP)-related ED mentions declined* in six CEWG cities, but rose slightly in three. Primary hallucinogen users generally continue to constitute small percentages of total treatment admissions. Most hallucinogen users are young, suburban and middle class. In numerous areas, such as Chicago, Philadelphia, St. Louis and Texas, PCP is frequently used in combination with other drugs, primarily marijuana. In Boston and Seattle, LSD and other hallucinogens are often regarded as club drugs and used in the rave scene.

Cigarette Smoking in Young Adults: Childhood and Adolescent Personality, Familial and Peer Antecedents

Prior research has demonstrated a complex interplay of a number of distinct psychosocial risk factors as they relate to cigarette smoking in young adults. In addressing the risk factors associated with tobacco use by young adults, this study examined: (1) the identification of the specific childhood and adolescent risk factors; (2) the interrelation of personality, family, and peer factors and (3) the extent to which the behaviors related to tobacco use vary by developmental stage. Three models (independent, mediational, and interdependent) were hypothesized to examine the interrelation of these variables and their effects on young adult cigarette smoking. At initial data collection, mothers were interviewed about their children when they were between the ages of 1 and 10. Three subsequent interviews were conducted with the children when they reached adolescence and young adulthood. Results show support for the mediational model and are in accord with the family interactional framework conceptions, developed to examine the pathways that lead to adolescent legal and illegal drug use and other problem behavior. There was a sequence in patterning from parenting during early adolescence to personality and peer factors extending to late adolescent smoking, and culminating in adult smoking. More specifically, difficulty in the parent-child relationship was related to tobacco-prone personality characteristics. Using a developmental approach, a number of psychosocial measures were found to be related in both younger and older children. Nevertheless, some interesting developmental differences emerged. The findings suggest at least four possible targets for therapeutic or preventive intervention: the parent, the child, the adolescent, and the peer group. Brook, J.S., Whiteman, M., Czeisler, L.J., Shapiro, J., Cohen, P. The Journal of Genetic Psychology, 158 (2), pp. 172-188, 1997.