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It has been argued that people often overcome substance abuse problems without benefit of professional treatment or formal intervention (1). There is even evidence that this may be significantly more common than treatment-facilitated desistance from drugs (2). Variously referred to as spontaneous remission (3), natural recovery (4), maturing out (5), and unassisted change (6), this process is as difficult to understand as it is to define. This may be attributable, in part, to the fact that studies investigating spontaneous remission have often relied on impressionistic and qualitative measures that defy unambiguous interpretation. This review serves as a preliminary attempt to provide a quantitative analysis of the literature on spontaneous remission, cognizant of the fact that even a quantitative analysis is subject to alternate interpretation. Despite the fact that unassisted change is often neither spontaneous nor remission to a previously “healthy” state (see Ref. 6), spontaneous remission is the term used here to identify desistance from substance abuse in the absence of formal intervention because it is the term most commonly encountered in the literature.

The purpose of this review is to provide a preliminary quantitative analysis of research on spontaneous remission organized to answer three primary questions. The first question posed by this review is, Does spontaneous remission from alcohol, tobacco, and other drug abuse occur, and if so, at what rate? To test this hypothesis, the general prevalence of spontaneous remission is calculated for studies on alcohol, tobacco, and illicit drugs. The present review also questions whether self-remitting individuals are fundamentally different from people who continue misusing substances or remit through formal treatment; the preremission substance abuse histories of these groups are used for this examination. The four pre-remission measures used to compare self-remitters with nonremitters and treatment remitters were the frequency of prior use, past signs of dependency, prior drug-related problems, and previous attempts at cessation. The third and final question addressed in this review is whether the initiating and maintaining factors responsible for spontaneous remission from alcohol, tobacco, and other drug abuse can be identified and quantified.

DEFINITION ISSUES

Before addressing the three questions that form the body of this paper, the terms substance abuse, formal intervention, and spontaneous remission need to be clarified and defined. Congruent with DSM-IV (7), substance abuse is defined as usage that (a) exceeds a certain frequency and (b) creates physical, social, legal, or psychological problems for the individual. Frequency of alcohol and other drug abuse was minimally defined as weekly ingestion of an illegal substance and/or consumption of 4 ounces or more of alcohol in a single sitting for a minimum of 12 consecutive months or at least 2 alcohol binges, each of which lasted 3 or more days, over a period of 1 year (8). Averaging 10 or more cigarettes a day for a period of 1 or more years, on the other hand, served as the sole criterion for tobacco abuse. Problems were distinguished by the presence of one or more of the following negative consequences of alcohol or illicit drug abuse: withdrawal symptomatology, tolerance, medical problems, family conflict, work/ school problems, and legal difficulties.

There is no simple way to define formal intervention, although criteria introduced by Stall (9) may provide some clarification. Stall defines formal intervention as assistance “received through a generally recognized organization which has as a primary goal the resolution of alcohol (or other drug) related problems” (p. 194). As such, formal intervention can be accessed through medical, psychiatric, private, and public rehabilitative and self-help (e.g., Alcoholics Anonymous, AA) channels. Assistance received through friends, family, and religious organizations or in verbal warnings from medical or legal authorities do not constitute formal intervention under this definition. Some readers may take issue with the decision to place self-help groups like AA and Narcotics Anonymous (NA) in the same category as medical and rehabilitative services. However, the primary goal of an organization like AA is to help people resolve substance use difficulties. Consequently, self-help groups; were eliminated as possible explanations for spontaneous remission initiation, although they were retained as potential explanations for spontaneous remission maintenance.

Here, spontaneous remission is defined as cessation of alcohol, tobacco, or other drug abuse without formal intervention or a statement by the subject that formal intervention had no effect on his or her decision to desist from the abuse of one or more of these substances. Many of the studies in this area do not stipulate abstinence as a necessary condition for remission from substance abuse. Accordingly, the present review employed two different definitions of spontaneous remission. The narrow definition of spontaneous remission required total abstinence from the identified substance of abuse for a period of 6 consecutive months. The broad definition of spontaneous remission utilized in this study held that subjects had to be abstinent or have significantly reduced the amount or frequency of alcohol or illegal drug use and be free of any substance-related negative consequences for at least 6 consecutive months. In the case of tobacco, an average daily inhalation of no more than 1 cigarette was required for spontaneous remission using the broad definition of remission. It should be noted that, in studies utilizing a broad definition of remission, the proportion of subjects who were totally abstinent was 65.6%.

Drug use by women of child-bearing age has become a topic of growing concern for health policymakers and health service providers during the 1980s [1]. Among the many reasons for this is that new drug use occurs at a rate for females that is twice that of males [2]. In addition to the behavioral health implications of drug abuse by a woman who is a prospective mother, the teratological effects of some psychoactive substances, particularly alcohol [3-5], crack cocaine [6-8], PCP [9, 10], and opiates [11, 12], are known to contribute to both morphological and behavioral complications in infants born to drug-abusing women.

An Office of Substance Abuse Prevention (OSAP) demonstration project, the Pregnant Adolescent Substance Abuse Project (PASAP), was initiated in early 1988 for the purpose of identifying, educating, and referring for counseling or treatment all pregnant maternal health clinic attendees under 21 years determined to be occasional or current users of psychoactive substances. The subject pool was drawn from among the majority of the 16 Maternal Health Clinics in Prince George’s County, Maryland.

Prince George’s County, Maryland, forms the eastern border of Washington, D.C., and contains elements of urban, suburban, and rural life. In the County there has been a growing proportion of infants identified as “at risk” due to maternal drug abuse. In 1986, 16% of all high risk newborn infants were so designated because of maternal drug abuse. By 1989 that figure had risen steadily to 46% (annualized N = 522 of 1,142). This represents a threefold increase in drug-related infant outcome problems identified in just 4 years. The PASAP research demonstration project was initiated to specifically reduce the number of pregnant adolescents using drugs, and in so doing decrease the number of drug-compromised infants. (*)

While the PASAP has had among its objectives a county-wide risk-reduction/prevention program and the education of area health care providers about drug use during pregnancy, the following results focus on a description of the maternal health sample characteristics.

METHODS

The PASAP progrma sampled new walk-in patients at 11 Prince George’s County Maternal Health Clinics. Young women under age 21 and pregnant were asked to participate in a confidential interview. There were four different interviewers.

The interview process proceeded to establish initial rapport through an informal discussion that addressed pregnancy, childbirth planning, and immediate needs of the young woman. The discussion was derivative of a standard intake questionnaire that the interviewee had completed. Personal and demographic information preceded questions concerning the use of legal substances (tobacco and alcohol) in the home and social support environment. These questions preceded more specific probing about the personal use of drugs, drug accessibility, and drug interest.

From the interview and the questionnaire responses, a profile of risk was determined based on the considerations noted below.

Risk Assessments

The assignment to a risk category was not strictly operational, but among the determining factors were the drug use that may have been occurring in the immediate environment of the pregnant adolescent, such as by friends and family, the stability of her circumstances, support structures, her past experience with drugs, her inclination toward further use, etc. In general, the following definitions apply.

Not at risk assumes an avowed disinterest in drug use of any kind including tobacco and having no close friends or members of the family involved in substance use.

At some risk assumes either soem noncontinuing past personal use of substances or use by a friend or family member.

At high risk is designated for those who smoke cigarettes and/or report only infrequent use of other psychoactive substances, those who stopped using upon learning they were pregnant, or who may be living with or be friends with a known drug abuser having a significant emotional connection to the patient.

Abuser is one who continues to report at least occasional use of illicit substances during her pregnancy. This low use criterion for “abuser” is regarded as appropriate for a pregnant woman. This is justified both on the basis of infant risk and historical underreporting about drug use.

On the basis of the risk assignment at the time of the interview, the young woman was referred to one of four optional interventions described below.

A retrospective reexamination of the factors correlated with risk group assignment was done at the completion of the data collection phase to categorically identify criteria associated with the composite interviewer judgment of risk.

Interventions

All pregnant patients interviewed by PASAP received education concerning the effects of alcohol, drugs, and cigarettes upon the unborn child and upon their own ability to function as a parent. Those judged to be at risk were offered counseling and/or encouraged to attend peer group sessions that explored issues of pregnancy, health, and substance use. Identified substance abusers were referred to various remediation services operating under the Prince George’s (PG) County Health Department, Directorate of Addictions.

The driver was smoking a marijuana joint while traveling down U.S. Route 1 in Maryland when his tandem dump truck struck a bridge abutment, flipped end over end, and landed in a river. Fortunately, the driver was not injured. The $51,000 truck, however, was a total loss.

That drug-related accident in 1982, says Harold C. Green, president of Chamberlain Contractors, Inc., prompted him to adopt a comprehensive safety program at his Laurel, Md., paving company and, in 1987, a drug-testing and employee-assistance program.

But Green’s 60-employee company is not typical of small firms when it comes to drug-prevention programs.

According to the U.S. Department of Labor’s Bureau of Labor Statistics, only 3 percent of small businesses have drug-testing programs, and only 12 percent have a formal policy on drug use.

In contrast, among larger companies - those with 250 or more employees - 46 percent of employers test their workers, and 74 percent have formal anti-drug policies.

The businesses that employ the majority of U.S. workers - the small and medium-sized firms - for the most part have been standing on the sidelines in the war on drugs, either because they lack the resources or the knowledge to fight the problem or because they don’t believe there is a drug problem among their workers.

The statistics, though, suggest there is a problem. According to the National Institute on Drug Abuse, part of the Department of Health and Human Services, 74 percent of the 11.7 million drug users in the country are employed either full time or part time. In addition, figures indicate, as many as 23 percent them use illegal drugs on the job.

Drug users with jobs can be found in every profession, from law firms to construction companies, according to the NIDA’s. National Household Survey on Drug Abuse. (See the chart on Page 55.)

The cost to business of such drug use, according to estimates by various drug-prevention organizations, is $75 billion to $100 billion each year in lost productivity and higher health-care and workers’ compensation costs. Also, employee drug users have higher absentee and tardiness rates than nonusers.

To combat the pervasiveness of the problem, the Partnership for a Drug-Free America and the Community Anti-Drug Coalitions of America (CADCA) have re-energized their three-year-old National DRUGS DON’T WORK Partnership campaign. A major goal is to involve small companies to a greater degree in the war on drugs.

The idea, says William J. Kaufmann, president of the partnership, is to raise the level of awareness of drug abuse among workers in small companies.

The Partnership for a Drug-Free America, formed in 1986, is a coalition of volunteers from the communications industry that has donated time and talent in a public-service campaign against drug abuse. CADCA, an organization of activists in 3,800 communities, and the DRUGS DON’T WORK partnership were established by then - President Bush’s Drug Advisory Council to provide high-level leadership to private-sector anti-drug efforts.

The DRUGS DON’T WORK program can provide business with low-cost services and products to set up drug-free-workplace programs, such as a how-to manual, a model drug-testing program and information on the U.S. Department of Transportation’s drug-testing requirements. Programs in 26 states are affiliated with the DRUGS DON’T WORK initiative, with many run by state and local chambers of commerce.

The U.S. Chamber of Commerce, through a nonprofit affiliate, the Center for Workforce Preparation, is supporting the national effort. The center is serving as a clearinghouse for information on state and local chambers’ drug-free-workplace programs and is urging employers to pledge that they will strive for a drug-free workplace.

A DRUGS DON’T WORK campaign to receive written pledges from 80,000 businesses by the end of 1997 kicks off in February. (See the pledge card.)

Establishing a drug-free-workplace program is the quickest and most effective way for businesses to have an impact on the country’s drug problem, Kaufmann says. But such programs also have a positive effect on a company’s bottom line, he notes.

Chamberlain Contractors’ green says he has seen “a substantial reduction in insurance costs from what they would have been if I hadn’t put the [drug] program in place.” His premiums for workers’ compensation and general liability insurance, including auto insurance, dropped to $132,000 last year from $252,000 in 1987, the year he instituted the drug program.

Alabama, Florida, and Georgia have laws that provide companies that establish drug-free-workplace programs with a 5 percent discount on workers’ comp premiums. Among other states considering such measures are Arizona, New Jersey, North Carolina and Washington.

And drug-free-workplace program don’t just save employers money - they can save people’s lives, says Mark Goodson, president of Goodson Electric, an electrical contractor in Palmetto, Fla.

Because of the drug program is company set up with the help of the Manatee County Chamber of Commerce, “we were able to intervene in a young man’s life, to help him,” says Goodson referring to an employee who was having family and job problems related to drug use. “I had a good man, and I saved a good employee.”

Women represent a fast-growing segment of the criminal justice system. The number of women incarcerated increased by 202% nationwide from 1980 to 1989, compared to a 112% increase for men during the same period (1). Among the reasons for this escalation is the widespread increase in crack cocaine use among women. A 1991 survey of New York State inmates found that 51% of female inmates used crack cocaine prior to entry, 28% used heroin, and 4% used other drugs not including marijuana (2). A study conducted by the Bureau of Justice Statistics compared inmates who had used crack cocaine a month before their arrest with inmates who had used other drugs (3). Crack cocaine users were more likely than users of other drugs to be female, black non-Hispanic, and unemployed; they were also three times more likely to have committed their current offense in order to obtain money for drugs, and more likely to have had a previous criminal history. Beyond these demographic differences, little is known about psychosocial characteristics that may discriminate crack cocaine users from other drug users among incarcerated women.

The widespread practice of exchanging sex for money or crack cocaine, now documented by many studies (4-7), has evolved into a particularly degrading and dangerous form of prostitution. Fullilove’s ethnographic research documented multiple psychological traumas (e.g., homelessness, loss of child custody, domestic abuse, and sexual and physical abuse) that both predate and occur concomitantly with the exchange of sex for money or drugs among crack-using women (8). Wallace found that two-thirds of a sample of 66 crack-using patients in detoxification were children of alcoholics, and many also suffered from physical and sexual abuse as children (9). Another study of 146 indigent women who had a current or past history of using crack cocaine found that sexual abuse was associated with severity of drug use and with other traumatic experiences (10). Although methodologically limited (i.e., lack of comparison group and failure to adjust for potentially confounding variables), these studies suggest that psychological trauma may be a useful construct in understanding how crack-using women may differ from other drug-addicted women. Psychological trauma refers to a set of responses to extraordinary, emotionally overwhelming events that are beyond the individual’s ability to control (11-13). These events may be ongoing and chronic, such as physical abuse, or they may be discrete and clearly bounded, such as loss of child custody (11-13).

The association among psychological trauma, substance abuse, and the symptomatology of posttraumatic stress disorder (PTSD) has been hypothesized as a complex interaction between external factors (severity, duration, and frequency of trauma experienced) and inter/intrapersonal factors (coping strategies, availability of social support, personality factors, prior stress, early deprivation) (14-16). Previous studies that have documented deficiencies in social support and social competence among crack cocaine users, particularly among women, suggest that crack cocaine users may be more prone to exhibit PTSD following a traumatic experience (17,18). The intent of this study was to depict childhood and adult psychological trauma variables (childhood sexual abuse history, childhood physical abuse history, history of parental alcohol abuse, domestic abuse, loss of custody of children, exchanging sex for money or drugs) associated with regular crack use (three or more times per week). Based on previous research findings (8-10), we hypothesized that after adjusting for social support, coping, demographic/ criminal history variables, women who report childhood and adult psychological traumas are more likely than other women to be classified as regular crack users. To test this hypothesis, we used two separate logistic equations: one in which adult trauma variables were entered first, followed by social support and coping variables, and demographic/criminal history indicators; and another in which past trauma variables were entered first, followed by social support and coping variables, and demographic indicators.

METHODS

Sample Recruitment and Selection

At Rikers Island, the major jail facility in New York City, female drug users were recruited to participate in the study. Eligible participants were aged 18-55, convicted and serving a sentence between 3 months and I year, scheduled for release within 10 weeks, and reported using drugs-other than marijuana or alcohol-three or more times a week within the 3 months prior to arrest. The latter data were corroborated by review of prison medical or intake records indicating use of drugs other than alcohol or marijuana prior to arrest. Among 194 women recruited, 170 met eligibility criteria and 159 agreed to participate in the 90-minute interview process. Data on drug use were missing for one woman; consequently, analyses were performed on 158 subjects.

During the past several decades, significant changes in the drug abuse treatment system and the clients admitted to treatment programs have influenced the provision of treatment services and therapeutic results of the various modalities represented in the treatment system. A turning point for the current system during these decades occurred with the Omnibus Budget Reconciliation Act of 1981, which legislated the conveyance of funding authority from the federal government to the states in the form of block grants. With this transition, the role of the National Institute on Drug Abuse (NIDA) shifted toward research, the states assumed more responsibility for treatment allocation decisions (1), and funding for community-based treatment evolved toward heterogeneous packaging of finances accumulated from various public and private sources. The advent of widespread cocaine use and the epidemic of the acquired immune deficiency syndrome (AIDS) among injection drug users further complicate the picture. Another issue receiving attention is that of dual diagnosis among substance abuse treatment clients. The increasing complexity of issues having an impact on the delivery of treatment requires more sophistication in treatment approaches and consequently in client assessment and outcome research.

Three comprehensive national evaluation studies of drug treatment were conducted during the past 25 years: the Drug Abuse Reporting Program (DARP: 1969-1973) (2-5), the Treatment Outcome Prospective Study (TOPS; 1979-1981) (6), and the Drug Abuse Treatment Outcome Study (DATOS; 1991-1993) (7). These three databases provide comprehensive data sources on clients admitted to publicly funded community-based drug abuse treatment programs from the late 1960s to the early 1990s. In comparing client intake characteristics and behaviors in the year before treatment admission, including drug use, social background characteristics, and diagnostic indicators of the various treatment populations, it is apparent that these variables underwent significant change consistent with societal changes in the past 25 years.

This paper first provides a summary of the differences in characteristics between DARP and TOPS clients. It then describes the characteristics of DATOS clients who sought drug abuse treatment from 1991 to 1993 and compares these characteristics and behaviors to those of the TOPS clients who sought treatment from 1979 to 1981. In addition to describing trends in client characteristics data, this paper discusses implications for subsequent analyses and correlates of outcomes. This overview primarily gives a historical context from which the major evolving issues in drug treatment may be understood.

METHODS

DARP was conducted by the Institute for Behavioral Research of Texas Christian University and collected over 44,000 admission records from 52 federally supported community agencies between 1969 and 1973 (2-5). TOPS was conducted by Research Triangle Institute (RTI) and collected data from personal interviews with 11,750 clients entering 41 different drug abuse treatment programs from 1979 to 1981 before the transition to block grant funding (6). DATOS, also conducted by RTI, involved 10,010 clients who entered treatment in 96 programs from 1991 to 1993. By 1994, DATOS intake and in-treatment data collection phases had been completed, and the first follow-up (1-year post treatment, which started in 1993) was completed in 1995.

Both TOPS and DATOS used a similar methodology and data collection instruments.The studies relied on a longitudinal prospective cohort design that focused on providing descriptive information on the characteristics and behaviors of clients as they entered and progressed through treatment (6). In TOPS and DATOS, cities and programs were purposively (not randomly) chosen for participation; they were representative at the time of their selection of typical, stable drug treatment programs in large and medium-sized U.S. cities.

TOPS subjects were both adolescent and adult clients of substance abuse treatment programs that participated in the study. Representing a broad geographical distribution, the nine cities in TOPS were Chicago, Des Moines, Detroit, Miami, New Orleans, New York, Philadelphia, Portland, and San Francisco. For the three modalities in the TOPS subset under consideration, there were 9,989 clients admitted to 37 drug treatment programs. Subjects in DATOS were clients age 18 or older recruited from programs in 11 major cities across the United States: Chicago, Houston, Miami. Minneapolis, New Orleans, Newark, New York, Phoenix, Pittsburgh, Portland, and San Jose.

DATOS was a comprehensive multisite prospective study of drug abuse treatment effectiveness. For DATOS, the DARP and TOPS modalities were expanded to reflect the current treatment system and included short-term inpatient in addition to outpatient methadone, outpatient drug-free, and long-term residential. Because no modality in the previous studies was equivalent to the DATOS short-term inpatient modality, it is omitted from consideration here (see Table 1).

DRUG ABUSE BEHAVIORS ASSOCIATED WITH AIDS

Drug abuse, and particularly intravenous drug abuse (IVDA), is an important factor in transmission of the human immunodeficiency virus (HIV). Since HIV is transmitted via infected blood and other body fluids, the common practice among IVDAs of sharing needles facilities the transfer of the virus. High risk sexual activity, too, increases the chance of drug abusers becoming infected with HIV and subsequently infecting others.

In order to fully delineate the connection between drug abuse and HIV, it is necessary to examine scientific information from both disciplines. Therefore, this article will review the status of epidemiologic studies concerning both the acquired immunodeficiency syndrome (AIDS) and drug abuse (focusing on IVDA). We will review reported AIDS cases, HIV seroprevalence studies of IVDAs, and surveys of drug abuse. We will critique several ongoing studies and suggest additional opportunities for epidemiologic research.

AIDS AMONG INTRAVENOUS DRUG ABUSERS

Between June 1981 and September 30, 1990, 152,126 cases of AIDS were reported to the Centers for Disease Control (CDC). In the last year (October 1989-September 1990), about 120 new cases of AIDS were reported to the CDC each day. This represents a 25% increase over the previous year (October 1988-September 1989). Approximately 29% of the AIDS cases in adults are among IVDA. Heterosexual IVDA accounts for 22% of all AIDS cases, whereas homosexual and bisexual IVDA account for an additional 7% of all cases. Twenty percent of all male cases were heterosexuals who reported using needles for self-injection of drugs not prescribed by a physician at least once prior to developing AIDS. Fifty percent of all females with AIDS reported such a drug abuse history.

The risk for AIDS in the drug-abusing community is not limited to those individuals who personally inject drugs illegally. Fifty-one percent of heterosexual AIDS cases were attributed solely to heterosexual contact with an IVDA. HIV infection among IVDA and their sexual partners is an important reservoir of infection and provides a conduit for infection for others in the heterosexual community. Children of drug abusers are also becoming infected with HIV during pregnancy and in the perinatal period. Fifty-one percent of the mothers of children with perinatally acquired AIDS reported a history of IVDA, and another 20% reported heterosexual contact with an IVDA [1].

As high as these figures are, they do not fully reflect the connection among heterosexual contact, drug abuse, and AIDS. For surveillance purposes, AIDS cases are categorized according to a hierarchy of risk factors. An AIDS patient reporting any intravenous drug use since 1977 is categorized as an intravenous drug abuser whether or not needles were shared. Some patients may have acquired the virus via heterosexual contact rather than through the use of contaminated injection paraphernalia.

In addition, many cases now listed as “undetermined” may actually be linked with HIV transmission to heterosexuals via sexual contact with IVDUs. For example, many male AIDS patients with “undetermined” risk admit to sexual contact with prostitutes or with a wide variety of heterosexual partners. If a patient does not know whether any sexual partner was an intravenous drug abuser and does not fall into other categories, the case is classified as “undetermined” rather than “heterosexual.”

SEROPREVALENCE STUDIES AMONG INTRAVENOUS DRUG ABUSERS

The number of AIDS cases does not adequately describe the extent of the problem of HIV among IVDUs. Because of the long latency period from infection with HIV to diagnosis of AIDS [2,3], and the persistence of infectivity of HIV-antibody positive individuals [4], the number of infected individuals would be a better measure of the extent of the epidemic among IVDA. However, social and political concerns preclude comprehensive HIV antibody testing at this time, thus limiting its utility for surveillance purposes in the United States.

A few general statements about HIV seroprevalence rates can be extrapolated from selected studies. Some caveats in regard to interpretation of the data are in order, however. Seroconversion rates may not always be reliable indicators of seroincidence. Most studies do not address possible changes in their study populations over time. Rates of refusal to participate in a study should be calculated and reported. Nevertheless, the following studies are reported as probably indicative of trends in seroprevalence among IVDAs.

The seroprevalence of HIV infection in a population of IVDA increases over time once infection has been introduced. This was illustrated by Des Jarlais et al. [5] who examined seroprevalence trends among IVDAs entering drug abuse treatment programs in Manhattan. In sera collected in 1978, 1/11 (9%) were HIV positive. This rose to 13/50 (26%) in 1979, 8/21 (38%) in 1980, and 14/28 (50%) between 1981 and 1983. From 1984 through 1987, seropositivity rates seemed to stabilize between 55 and 60%. In another, earlier study, Novick and colleagues [6] studied heterosexual men and women in New York City who were current or former IV heroin abusers, were on methadone maintenance, and were enrolled in a study of chronic liver disease. Stored sera from participants were tested for HIV antibody. In 1978, 0/7 sera were HIV positive; for 1979, 14/49 (29%); for 1980, 8/18 (44%); for 1981-83, 14/27 (52%); and 56% (numerator and denominator not included in report) in 1984.

As fiscal constraints limit the amount of research and treatment dollars, better methods of showing cost-effectiveness and positive net benefits are necessary. Treatment evaluators must devise methodologies so that easy, reliable measures of cost-effectiveness and net benefits can be made on a routine basis. At a basic level, policymakers and treatment practitioners need guidance in formulating and investing in treatment strategies. Policymakers want information on the types of clients that are most costly to treat and the client types that benefit most from treatment. They also need to know what benefits or outcomes should be emphasized in treatment and how long before a treatment investment “pays off” for a typical client. Treatment practitioners require a different level of information. They are more concerned with questions such as, what is the total and per-client costs of providing treatment? What are the primary funding sources for treatment services? How do benefits compare to costs? Policymakers and practitioners alike need more treatment evaluation research to help answer these questions. By determining cost effective and efficient ways of delivering treatment services to specific clients, economic analysis plays an important role in evaluating existing treatment regimens, designing new treatment methods, and revising established ones.

Given the rapid expansion and substantial changes in drug abuse treatment, evaluating the economic merits of established and newly developed treatment options is important. Research is lacking in this area primarily because the costs and dollar benefits of treatment are difficult to conceptualize and even harder to estimate. However, administrators and policymakers must consider the costs and benefits of treatment alternatives when designing responsive treatment systems and programs. For example, if improving the health status of the drug-using population yields a significant dollar benefit, drug treatment regimens should include a health-care component. If certain populations (e.g., low-to-moderate users, first time in treatment clients) produce better outcomes than other populations (e.g., criminal justice clients), then resources should be targeted to those populations with the highest net benefits and perhaps diverted from others. By quantifying and comparing the costs and benefits of treatment in dollar units, economic analysis can improve the methods for allocating and using private and social treatment resources.

Millions of dollars are spent each year for drug abuse treatment services. In 1987 the specialized drug treatment sector had revenues of $1.3 billion (30). Despite continued investments in drug abuse treatment, an accepted methodology does not exist for analyzing the economic merits of these programs. Because society does not possess the resources to support all desirable treatment activities, we must choose which projects to support and at what level. As resource allocation becomes more important, policymakers and program administrators need decision-making tools to evaluate their options for providing and funding treatment programs. Economic analysis can play a large role in these resource allocation decisions.

More information is needed on the utilization, cost, financing, and effectiveness of drug abuse treatment (54). Some of the existing economic studies use different methods of cost accounting and evaluation (e.g., Refs. 6, 8, 24, 43, 48, 57). Any new study in this area should try to bridge this gap by first designing an economic evaluation and then implementing an economic analysis plan. To design an economic evaluation, economists must first examine key issues for the two audiences that could benefit most from the study results: policymakers and program administrators. Policymakers need broad guidelines, a decision-making framework, and evaluation techniques. Program administrators need program-specific or treatment-modality-specific information, optimal resource allocation guidelines, cost accounting rules, and methods of targeting treatment outcomes.

A carefully designed analysis plan should rely on three types of economic analysis to evaluate private and social programs: cost, cost-effectiveness, and benefit-cost.(*) Although each analysis is unique in terms of estimation procedures and policy significance, a natural progression occurs from cost to cost-effectiveness to benefit-cost analysis. Drummond et al. (12) described the components of an economic evaluation of a health care program like drug abuse treatment as illustrated in Fig. 1.

Few studies have carefully examined the full cost structure of contemporary treatment for different programs and clients. Furthermore, most of the few contemporary cost-effectiveness and benefit-cost studies of drug abuse treatment are plagued by methodological problems and data limitations. Clearly, new efforts to study the costs, effectiveness, and dollar benefits of treatment would greatly improve our understanding of “what works” at the client, program, and system level. Cost-effectiveness and benefit-cost comparisons of treatment for clients and programs could provide needed guidance for future treatment investments.

Alcohol and drug abuse continues to be an immense problem that impacts on patient health, family relationships, society, crime, and medical resources. The severity of this problem varies between subgroups identified according to certain characteristics such as gender, race, and income. Physical injury often leads to significant changes in self-image, ability to work, social interactions, and daily routine. Each of these factors alone and in various combinations can greatly impact on individual usage of alcohol and other drugs of abuse (AODA). The purpose of this article is to provide an overview of the influence of AODA in physically disabled patients. More specifically, we will review (1) the role of substance abuse in the cause of injury, (2) the average use of AODA in the physical rehabilitation population before and after injury, (3) the effects of AODA on the quality of physical rehabilitation itself, and (4) what is, and can be, done in rehabilitation programs with regard to substance abuse identification, education, and treatment. This literature review will help medical staff have a better understanding of this important problem, and stimulate thought concerning treatment, education, and future directions of investigation.

Many traumatic injuries leading to use of rehabilitation services are related to drug and alcohol use. As shown in Table 1, alcohol-related traumatic injuries accounted for up to 79% of rehabilitation patients. Alcohol usage has been reported to be involved in about 35% of automobile injuries, 55% of motor vehicle deaths, 40% of drownings, and 30% of airplane (noncommercial) crashes (1). Of those that survive injuries, many require rehabilitation services. Approximately 50% of head injury patients from car accidents occur with drivers being legally intoxicated (blood alcohol level equal to or over 100 mg/dl) at the time of injury, with as many as 72% positive for some blood alcohol (2). Other studies have found similar statistics, ranging from 29% to 58% positive blood alcohol levels (BALs) upon arrival at the emergency room (3-5).

[TABULAR DATA OMITTED]

Alcohol has been shown to be involved in over 50% of head injury (HI) patients prior to the time of accident (2,3,5). Other studies have found a preinjury prevalence of alcohol addiction in 25% to 68% of HI patients, and 29% to 58% had positive BALs at time of injury (3-7). In a study of over 400 patients, 57% of the patients with a history of alcohol abuse/dependency were intoxicated at injury, while 31% of those with no history of alcohol abuse were intoxicated at time of physical injury (8). Likewise, a large study at the University of Virginia showed a history of alcohol abuse in 34% of “moderate” and 10% of “minor” HI patients (9). The percent of those with positive BALs was 78% at the time of injury for moderately injured patients, and 53% of those with minor head injury (Table 1) (9). Gender differences may exist. Galbraith et al. (10) reported that 62% of males had positive BALs at the time of head injury, while only 27% of females had positive BALs.

As shown in Table 1, alcohol was related to the cause of spinal cord injury (SCI) in numbers similar to those for HI (11-13). A study of over 100 SCI patients showed that 39% were intoxicated at the time of injury (11). Twenty-nine percent of SCI subjects have reported family history of alcohol problems (12). In other studies, drinking or intoxication appeared to be involved in as low as 17%, or as high as 79%, of SCI (1,14). Of note, however, is that in the study reporting only 17% intoxication, 50% of the SCI patients had been drinking (1).

Studies on cold temperature-related injuries have also shown a high incidence of alcohol-related injury (15,16). For example, 39% of 101 frostbite patients reported that their injury was related to alcohol (15). Similar results were observed in another much smaller cold injury study (16).

Alcohol abuse appears also to enhance readmission for trauma injury (17). Thus, in a recent study of 2,578 trauma patients at a level I regional trauma center, the readmission rate was increased 2.5-fold in those patients who were intoxicated (BAL > 100 mg/dl) at the time of initial treatment (17). The relative readmission risk was increased 2.2 for those with initial positive Short Michigan Alcohol Screening Tests (SMAST) and 3.5 for patients with initial admission elevated alpha-glutamyltransferase (GGT) scores (17).

WHAT IS THE RELATIONSHIP BETWEEN NON-ALCOHOL DRUG ABUSE AND CAUSE OF INJURY IN PATIENTS WITH PHYSICAL DISABILITY?

Currently there is far less data on non-alcohol, drug-related injury in rehabilitation patients than alcohol-related injury (Table 1). In an NHIF study, about 5% of rehabilitation patients listed drugs other than alcohol as a primary drug of choice (3). In a recent study of 89 head injury patients in Maryland, 18% of subjects appeared to have non-alcohol drug-related injuries (and 38% alcohol-related injuries) (18). Preliminary results of an investigation we are conducting indicate about 9% of trauma patients reported drug (non-alcohol) abuse to be directly related to the physical injury (19).

Drug Abuse in Schizophrenia and Bipolar Disorder

ABSTRACT

The incidence and type of drug abuse for 50 male schizophrenic patients and 60 male and female bipolar, manic patients were determined. Fifty percent of schizophrenic patients and 25% of bipolar patients abused one or more drugs. Alcohol, cannabis, and cocaine accounted for 82% of the drug abuse.

INTRODUCTION

In recent years the relationship between various psychiatric disorders and drug abuse has received increased attention[1-7]. Some workers have speculated that specific psychiatric disorders may predispose to specific drug abuse[8, 9]. Invariably drug abuse has been regarded as influencing negatively the course of the disease. In this study we documented the incidence and type of drug abuse in newly hospitalized bipolar, manic patients and in newly hospitalized schizophrenic patients in order to assess the similarities and differences between them.

The psychiatric inpatient records of 50 consecutively admitted male schizophrenic patients and 60 bipolar, manic patients (17 male and 43 female) were studied retrospectively. Patients were included if they met DSM-III-R Axis I criteria for schizophrenia, paranoid type or bipolar disorder, manic type, diagnosed by a senior attending psychiatrist, were at least 17 years of age and were not suffering from an Axis III diagnosis with the single exception of tardive dyskinesia.

Charts were reviewed to identify patients meeting DSM-III-R Axis I criteria for alcohol, opiate, cocaine, amphetamine, cannabis, hallucinogen, phencyclidine, sedative-hypnotic, and anxiolytic drug abuse. Data from the preadmission evaluation, the admitting office psychiatric history, the PGY II psychiatric history, the senior attending psychiatrist note, and the discharge summary were examined and correlated. In all cases the most extensive documentation of substance abuse was considered the most reliable. No patient was identified as a substance abuser by this method who had not been identified and diagnosed at the time of discharge from the index admission.

During the period of the study only 17 male patients met criteria for the DSM-III-R Axis I diagnosis of bipolar, manic type. Therefore female bipolar, manic patients were included. Age at the time of the index admission, race, marital status, employment status, number of prior psychiatric hospitalizations, and private versus public health insurance were determined for both groups.

Data were analyzed using means and SDs, and Student’s t test (two-tailed). Categorical data were analyzed using [Chi.sup.2] statistic.

RESULTS

Twenty-five of 50 male schizophrenic patients abused one or more drugs. Twelve (24%) abused alcohol, 13 (26%) abused cannabis, and 8 (16%) abused cocaine. Diazepam, psilocybin, phencyclidine, amphetamine, and codeine were each abused by one patient. Ten patients abused more than one drug. Alcohol-cannabis combinations accounted for two, cocaine-cannabis accounted for four, cocaine-amphetamine accounted for one, cocaine-cannabis-phencyclidine accounted for one, cocaine-cannabis-psilocybin accounted for one, and alcohol-cocaine-opiate accounted for one. While 25% of alcohol-abusing schizoprenic patients combined alcohol with another drug, 61% of cannabis abusers and 100% of cocaine abusers did so. These differences are significant (df = 2, [Chi.sup.2] = 11.2, p [is less than] .01).

Fifteen of 60 bipolar manic patients (4 of 17 males and 11 of 43 females) abused one or more drugs. Eleven (18%) abused alcohol, five (8%) abused cannabis, six (10%) abused cocaine, and three (5%) abused opiates. Benzodiazepines and phencyclidine were each abused by two patients. Six patients abused more than one drug. Alcohol-cocaine-cannabis combinations accounted for two, opiate-cocaine-cannabis-phencyclidine accounted for one, alcohol-cocaine-opiate-benzodiazepine accounted for one, alcohol-cocaine-cannabis-phencyclidine accounted for one, and alcohol-cocaine-benzodiazepine accounted for one. While 45% of alcohol-abusing bipolar patients combined alcohol with another drug, 80% of cannabis abusers and 100% of cocaine abusers did so. These differences approached significance (df = 2, [Chi.sup.2] = 5.74, p [is less than] .06). When the alcohol use data for schizophrenic and bipolar patients was pooled, the tendency for alcohol to be used alone was evident. While 33% of alcohol-abusing schizophrenic and bipolar patients combined alcohol with other drugs, 66% of cannabis abusers and 100% of cocaine abusers did so. These differences are significant (df = 2, [Chi.sup.2] = 16, p [is less than] .001).

Although apparent, differences in drug use between the schizophrenic and bipolar cohorts were not analyzed. Examination of demographic and clinical variables revealed that the cohorts were significantly different on measures of age, gender, and marital and employment status (Table 1), and, therefore, not comparable.

DISCUSSION

There are several methodological limitations in the design of this study which should be noted. The study is retrospective and naturalistic, and depends upon observations made by clinicians and not by researchers employing standardized diagnostic assessment instruments. The sensitivity, validity, and reliability of retrospective substance abuse diagnoses are difficult to assess. The most extensive documentation of substance abuse was presumed the most reliable, but the possibility remains that the patient or interviewer provided an exaggerated report.

Education and outreach are becoming major parts of establishing a more effective program to keep drug abuse out of the workplace.

In August 1991, a Manhattan subway accident killed five people and injured 170 others. Investigators discovered a vial of crack cocaine in the motorman’s cab, but no motorman. He was caught later, drunk.

The incident brought support for random drug and alcohol testing from transit authorities as well as unions. Last year, the U.S. Department of Transportation (DOT) added alcohol testing to its requirements. Though many businesses now fall under the DOT regulations and most others have voluntary testing, substance abuse at work persists. Companies are discovering they must do more than weed out abusers with testing; they must also educate the majority nonabusers in the workforce to help manage the problem.

Managing the problem

A good way to begin dealing with a drug abuse problem is to give employees the resources to control their environment and claim ownership of the policy on no drug abuse. Companies are finding that effective workplace programs to prevent drug abuse have front-end support of company leaders such as union representatives, influential supervisors, and other respected employees. These leaders can be key contributors to discussions and decisions about the program, and their involvement encourages support from the rest of the workforce. At Pennsylvania Precision Cast Parts, a steel producer in Lebanon, Pa., the company’s president, Richard Miller, sought input through preliminary discussions with key hourly and management employees. “I got opinions from my staff first. That group went directly to the shop floor and talked to a sampling of employees whom they knew would respond honestly about their feelings,” Miller says.

The discussions revealed that a majority of people wanted a drug-testing and employee assistance program. According to Miller, employees welcomed the idea of random drug tests to ensure “their own safety” and to keep from being exposed to impaired employees. Because workers produce molten steel at temperatures of 3,000 degrees and transport it by forklift, even a slight impairment could create tragic circumstances.

The next step was to establish goals and procedures for putting the policies in place. Decision makers focused on three objectives: identifying drug abusers, providing rehabilitation and educating the workforce to prevent drug abuse. A crucial decision was made to go ahead with the policy–not to simply try it–and to manage any ensuing conflict with honest communication.

Keeping it simple

Nalco Chemical Co. in Naperville, Ill., provides its 6,700 employees a clear policy on substance abuse. According to Ellen De Lordo, manager of employee relations, the policy is that the “use, possession and distribution in the workplace will not be tolerated and is absolutely, strictly prohibited.” The company’s drug-free workplace program combines random testing with manager/supervisor training and drug awareness sessions for employees.

De Lordo says it’s particularly important to address employees’ personal concerns about safety and job security, because employees deserve to know the facts about how substance abuse puts the workforce at risk. In the drug awareness sessions, employees learn about the physiological and psychological impact of drugs and alcohol. Newsletters, handouts and reports also inform them that alcohol and drug abusers cost American business billions of dollars a year–costs that all employees bear if companies must close or lay off workers. According to the National Institute on Drug Abuse, at least 66 percent of the nation’s illicit drug users are employed. Studies show abusers are late to work three times more often than nonabusers, ask for time off at least twice as often, are absent two and one-half times as often or at least eight days, use three times the average amount of health-care benefits, file five times as many workers’ compensation claims, and have accidents more than three and one-half times as often.

Substance abuse also damages America’s competitive position worldwide. Our nation’s businesses are competing overseas where the competition has a much lower incidence of drug abuse. The United States has only six percent of the world’s population, but consumes 60 percent of the world’s illegal drug supply. Moving into the home

One company has taken its drug-free efforts beyond the workplace and into employees’ homes. At Champion International Corp., a pulp and paper manufacturing company in Roanoke Rapids, N.C., any of the 711 employees may participate in classes on parenting to help them manage the threat of drug abuse in their families. The company offers workshops during the lunch break and in the evening.

According to program coordinator Heather Caillet, the training enables employees to take control of drug abuse prevention at home and to help the community create an environment free of drug abuse. When employees have taken steps to ensure their family’s safety and well-being, they gain confidence. The new information and skills helps them to actively support drug policies and testing at work and to confront substance abuse instead of ignoring it.