Alcohol and Substance Abuse in Women and Children

Barry Stimmel

• Publisher: Routledge
• Year: 2014
• eBook ISBN: 9781317774013
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

Here is a timely volume that examines the problems of substance abuse in women and children, with a particular emphasis on the role played by the family in the development and perpetuation of the problem.

Pathways to Heroin Abstinence: A Longitudinal Study of Urban Black Youth

Ann F. Brunswick, PhD
Peter A. Messeri, PhD

The authors are with Columbia University (Public Health, Sociomedical Services), New York, NY. To request reprints, write: A. Brunswick, PhD, 60 Haven Avenue, B-4, New York, NY 10032.

ABSTRACT. Reported here is a study of the effectiveness of treatment in reducing the duration of heroin careers, with a special focus on gender differences. The longitudinal research is based on a community representative sample of urban black youth, ages 18-23, and utilizes a recently introduced statistical methodology, event-history analysis. Simple hazard probability analysis confirmed that males and females did not differ significantly in their cumulative probabilities of abstinence from heroin. The more elaborated event-history model demonstrated, however, that treatment played a significantly different role among young men and women in attaining abstinence. While a man’s likelihood of abstinence was but marginally greater with treatment than without it, women’s likelihood of abstinence was significantly increased by entering treatment.

Introduction

Empirical research conducted over the last two decades has dispelled the belief that heroin use inevitably results in a permanent state of addiction.¹,² While precise estimates are lacking, it appears that, for many, heroin addiction is not a lifelong affliction³-⁵ and at least some portion of heroin users return to a heroin-free state without benefit of formal treatment.⁶,¹⁰ The first dramatic evidence that heroin addiction was situation-dependent and spontaneously reversible was provided by Robins¹¹,¹² in her study of drug use among returning Vietnam veterans: the great majority of military personnel who had become addicted in Vietnam discontinued use upon returning to the U.S. The cumulative results of these studies also present strong evidence that heroin users vary considerably in frequency of use and physical dependency. Many individuals have reported using heroin on a casual basis over an extended period of time without (or before) becoming addicted.³’”’¹⁴ Even the heroin careers of addicts are typically interspersed with periods of temporary abstinence.³,⁴,¹⁵

If periodic abstinence as well as lasting recovery from heroin abuse are now established phenomena, the same cannot be said for our understanding of the role of treatment in ending heroin careers within a general population of users. Research evaluating the effectiveness of treatment programs has been confined for the most part to the experiences of client populations. Data currently available to distinguish the heroin user most likely to enter treatment¹⁶ and/or to compare patterns of post-treatment abstinence and relapse with the careers of untreated users are indeed limited.

The few studies reviewed by Waldorf and Biernacki¹⁰ which systematically compare treated and untreated heroin users have reported little difference in rates of recovery between the two. Unfortunately, failure to specify clearly the relevant user population along with internal differences between treated and untreated users places severe limits on generaliz-ability from this small body of research. Athough the nonrandom character of treatment entry is well established,¹⁶,¹⁷ treated and control groups are rarely matched on salient attributes nor has multivariate analysis been employed to adjust for their differences, differences which when left uncontrolled are likely to confound inferences regarding treatment effects.

Our knowledge is similarly limited when it comes to cross group comparisons of drug treatment efficacy and termination of drug use. The antecedents and functions of heroin use are commonly postulated to differ across broad socioeconomic and demographic categories—ethnicity, sex and age—and by place and time.²,¹⁸-²² Yet, minimal attention has been paid to systematic comparison of the differential success of treatment in providing for the needs of males vs. females; whites vs. blacks and/or other minorities; inner-city vs. middle-class users. (For an exception, see Savage & Simpson.²³)

In recognition of the dearth of empirical evidence on these matters, this paper selects one particular issue—that of differences in treatment efficacy on the basis of gender. It reports findings from ongoing prospective research into heroin use and treatment behavior in a community sample of nonhis-panic black young people (see Methods). The analysis reported here focuses on members of the panel who reported nonexperimental use of heroin for some period of time up to 1976, when the oldest among them still were in their early twenties. The findings can be taken as a representation of heroin experiences of black youths who grew up in Harlem during the 1960s.

In a previous analysis²⁴ the role of sex and other factors in regulating entry into heroin treatment programs was investigated. Of particular interest, that study demonstrated that female heroin users in the sample tended to enter treatment at a later stage of their careers than males. The present study extends this research to a comparative examination of treatment outcomes: Does treatment intervention reduce the duration of heroin careers relative to the length of careers preceding natural, i.e., untreated abstinence? Retaining emphasis on specifying gender differences in drug related behavior, the question of whether young black male and female heroin users in the study sample differed in their reliance upon treatment as a means of ending their heroin careers is of particular concern. By conducting the analysis within a multivariate framework, simultaneous controls could be imposed on other factors suspected of being associated with either or both treatment entry and the length of heroin careers. Finally, a longitudinal methodology—event-history analysis²⁵—has been applied to model the complexities arising from the time varying nature of treatment entry and of certain other conditions hypothesized to influence the duration of heroin use.

Study Problem

The present study has been designed to compare annual rates of abstinence achieved through treatment relative to what is achieved without it in a general sample of young black heroin users. Abstinence is defined here as a minimum of one year without use of heroin following a history of nonexperi-mental use, and without relapse up to the time of second study, i.e., up to ages 18-23. The term “abstinence” was chosen over “cessation” because the latter suggests a more final and permanent state than could be assured at this stage in the longitudinal research. Nor were differences in effects of single and multiple treatment exposures on lengths of abstinence periods at issue in this study, given the relatively young ages and resultant limited variability in number of treatment episodes.

A comparison of treated and untreated abstinence presumes that the length of the heroin careers of untreated users is on average indicative of the duration of use for treated users had they not entered treatment. If the assumed comparability of the two populations is valid, then a higher rate of abstinence following treatment would be an indication that treatment did reduce the length of heroin careers below their average “natural” duration. The drug use patterns and practices of treated and untreated users, however, may not be identical. Because of the nonexperimental design of natural fields studies, there is no effective control over self-selection. Systematic differences between treated and untreated users thus may and probably do exist. For example, it is almost certainly true that individuals who enter treatment tend to be more deeply involved in heroin use and find it iriore difficult to withdraw than natural abstainers.⁶ In such a case observed differences in rates of treated and untreated abstinence tend to understate the true effectiveness of treatment.

Other factors, such as the comparatively longer use of heroin and older age of the user entering treatment, are also potential sources of population differences which will confound comparative analysis of rates of treated and natural abstinence. More generally, differential antecedents of the likelihood of abstinence vs. treatment entry, if not properly controlled, can bias estimates of treatment effects in an unpredictable direction. Through multiple-regression type analysis, explicit account has been taken in this study of age, frequency of use, and duration of use. These variables were found to affect treatment entry²⁴ and were considered plausible conditions for influencing the annual probability of abstinence.

A collateral interest in designing this research was to test for gender differences in treatment effects. In the past few years, investigators have begun to take note of gender differences in the psychosocial antecedents and correlates of drug use generally and of heroin use in particular.²⁰,²²-²⁶”³⁰ Treatment programs, it has been argued frequently, are inattentive to the specific needs of female addicts, particularly in regard to their maternal responsibilities.¹⁸,²¹,³¹ Moreover, female addicts may not be as well situated as their male counterparts for terminating use spontaneously, as reflected in their greater impairment of social role performance.²⁰ If heroin use is a more atypical behavior for black women than men, it may not be unreasonable to suppose that female heroin users are further removed from the intra-individual resources and informal support systems necessary for natural abstinence.

The possible mismatch between the needs of female heroin users and the provisions of treatment services, on the one hand, and their poorer access to natural means of abstinence, on the other, lead to contradictory expectations regarding gender differences in treatment outcome. A greater mismatch in services suggests that treatment would be less efficacious for females than males, whereas poorer access to natural means of abstinence suggests the opposite conclusion. While no attempt was made at this stage of research to confirm either hypothesis directly, the present study takes a first step toward resolving this issue by testing for specific gender differences in treatment outcome. These are reported and discussed below.

Methods

Source of Data

The data for this study came from the second wave of ongoing research into health and health behavior of an area representative sample of urban, nonhispanic black youth. When originally studied at ages 12-17, the panel was composed of all age appropriate adolescents residing in a cross...

Table of contents

• Cover
• Title
• Copyright
• CONTENTS
• EDITORIAL: Factors Associated With Alcohol and Substance Abuse in Women and Children
• Retrospective Analysis of Lifetime Changes in Women’s Drinking Behavior
• Substance Use Among Females in New York State: Catching Up With the Males
• The Effect of Multiple Family Therapy on Addict Family Functioning: A Pilot Study
• Adolescents’ Substance Use: Impact of Ethnicity, Income, and Availability
• Factors Associated With the Initiation of “Smoking” in Nine Year Old Children
• Onset of Adolescent Drinking: A Longitudinal Study of Intrapersonal and Interpersonal Antecedents
• Pathways to Heroin Abstinence: A Longitudinal Study of Urban Black Youth
• SELECTIVE GUIDE TO CURRENT REFERENCE SOURCES ON TOPICS DISCUSSED IN THIS ISSUE