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Correlates of heavy drinking and alcohol related problems among men and women in drug treatment programs
Drug and Alcohol Dependence,
Elsevier Scientific Publishers
32 (1993) 25 - 35 Ireland Ltd.
25
Correlates of heavy drinking and alcohol related problems among men and women in drug treatment programs Denise Herd School of Public Health, 518
Warren Hall, University
of Calvornia,
Berkeley,
CA 94720 (USA)
(Accepted August 31st, 1992)
A series of analyses were conducted to explore if there were significant differences in heavy drinking and alcohol-related problems in clients admitted to different types of drug treatment programs and whether such differences, if found, could be attributed to variation in social characteristics, drug use behavior, drinking norms, drinking contexts, or in reasons for combining alcohol and drug use. Men and women (N = 246) in four types of publicly funded treatment programs were interviewed at intake regarding drinking and drug use patterns and related problems. The results of the study showed significant differences in drinking behavior and alcohol-related problems of clients in different treatment modalities. Men in a county jail substance abuse program exhibited the highest frequency of heavy drinking and highest rates of alcohol problems; clients of methadone programs reported the lowest rates and those in therapeutic communities described intermediate rates. A series of regression analyses showed that the only significant predictors of the frequency of heavier drinking and drunkenness were drinking context and reasons for combining alcohol and drug use. In addition, age (youthfulness) was associated with the frequency of getting drunk. The most powerful predictors of alcohol-related problems were the frequency of getting drunk and drinking to enhance the effects of other drugs. Heavy drinking and drinking to prevent getting sick from drugs were also significantly associated with drinking problems. The frequency of drug use (by specific type) and most social characteristics showed no direct association with drinking patterns or problems. Key words: drinking patterns;
drinking problems; drug use frequency; treatment
modality; drinking contexts; drinking moti-
vations
Introduction A considerable body of research shows that many people admitted to drug treatment programs are heavy drinkers with relatively high rates of alcohol-related problems (Carroll et al., 1977; Barr et al., 1977; Ginzburg, 1977; Kaufman, 1982). As some studies indicate, excessive alcohol use in this population is of concern because it has been associated with high levels of psychological symptomology and with poorer treatment and mortality outcomes (Kaufman, Corresponbe to: Denise Herd, School of Public Health, 518 Warren Hall, University of California, Berkeley, CA 94720, USA. 0376-8716/93/$06.00 0 1993 Elsevier Scientific Publishers Printed and Published in Ireland
1982; Weiss et al., 1988; Roszell et al., 1986; Croughan et al., 1981). The purpose of the present study is to add to the understanding of the extent and correlates of heavy drinking and alcohol-related problems in persons admitted to several types of drug treatment programs. Most previous research has focused on the high rates of excessive drinking and related problems among clients of methadone treatment programs. Estimates of alcohol abuse in methadone patients at treatment intake range from a low of 20% to as high as 36% or even 53% (Hunt et a1.,1986) and many studies document the poorer prognosis and health outcomes of problem drinkers in this population. Very few reports have compared the drinking Ireland Ltd.
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patterns and alcohol related problems of clients in methadone programs with those in other types of treatment modalities. Two of the major studies that do make this comparison indicate that those admitted to thercommunities and or other nonapeutic methadone based programs may actually have a higher prevalence of drinking related problems than clients admitted to methadone programs. In the Treatment Outcome Prospective Study, perhaps the most extensive analysis of the relationship between treatment modality and drug and alcohol use to date, Hubbard et al. (1989) showed that clients admitted to outpatient methadone programs were substantially less likely to be classified as heavy alcohol users than those admitted to residential programs and outpatient drug free programs (25.0% vs. 41.7% and 35.7% respectively). The importance of differences in alcohol use by modality was confirmed in a series of analyses showing that even when controlling for some client characteristics (age, sex, race/ethnicity, pretreatment drug abuse patterns, number of prior treatments and source of referral) methadone patients were less likely to be heavier drinkers than residential or outpatient drug free clients in the year before treatment. Similarly, Ginzburg’s analysis (1977) of data from the Drug Abuse Reporting Program on 24 126 drug treatment clients showed that pre-treatment levels of heavy alcohol consumption (e.g. 8 ounces or more alcohol/day) were lower among methadone maintenance patients than they were for those in therapeutic communities or in in-patient detoxification facilities (42% vs. 56%). Methadone maintenance patients were also less likely to report alcohol-related problems than those in therapeutic communities (5% compared to 13%) prior to entering drug treatment. In contrast to the above findings, Barr and Cohen (1979) reported considerably higher mean alcohol consumption scores for a sample of methadone patients from 10 Philadelphia clinics (0.79 oz/day) than for a sample of clients in a therapeutic community setting (0.26 oz/day). Despite the higher intake levels of the methadone patients, their rates of alcohol-related problems were lower than rates of clients in the therapeutic community sample.
The differences in prevalence rates described within methadone treatment programs, as well as the conflicting reports on rates across treatment modalities, reflect the need for more detailed analyses and comparisons of drinking patterns and problems of clients in drug treatment programs. Many prior studies have used only limited measures of drinking practices and alcohol-related problems or have been based on highly restricted samples. In addition, little if any previous research has been conducted to explain why differences in drinking behavior and alcohol-related problems occur in different groups of drug treatment clients. Although some studies (Bar and Cohen, 1979; Hubbard et al., 1989) have suggested that these differences may stem from variation in social characteristics and levels of social instability or pathology, these assumptions have only rarely been subject to systematic analysis, In addition, researchers have pointed to differences in drug use behavior (e.g. differences in drug of abuse and intensity of use) as a possible explanation of variation in drinking behavior among clients entering different treatment modalities. For example it was reported that persons admitted to drug treatment for primary or exclusive heroin addiction were less likely to drink heavily than those entering treatment for polydrug abuse or primary addiction to amphetamines or sedatives and barbituates (Simpson, 1976; Carroll et al., 1977). However, little research exists that analyzes the simultaneous relationship between drug use, drinking behavior and treatment modality. In view of the restricted scope of prior research in this area, the following paper will examine differences in drinking patterns and alcohol-related problems among clients admitted to several types of drug treatment programs. The basic goals of the analyses are to: (1) ascertain whether there are significant differences in prevalence rates of heavy drinking and alcoholrelated problems among those entering different treatment modalities; and (2) if these differences exist, to determine if they can be explained by differences in the social characteristics of clients, by differences in the drug use behavior of clients, or by variation in
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other aspects of their drinking-related behavior (e.g. reasons for using alcohol with drugs, drinking norms and drinking contexts). Data on reasons for combining drugs and alcohol will be included since previous research (Hunt et al., 1986; Blume, 1987; Gawin and Ellinwood, 1988) suggests that heavy or problem drinking among drug users may result from drinking to achieve certain effects with drugs such as increasing the euphoria or ‘high’ from other drugs or selfmedicating to relieve negative reactions from drug use. Drinking norms and drinking contexts will be explored since general population studies (c.f. Clark, 1988) and some clinical research (Hunt et al., 1986) indicate that the social worlds of heavy or problem drinkers may differ from those with moderate or non-problem drinking patterns. For example, Hunt et al. (1988) showed that while there were few demographic differences between abusive pattern drinkers and other methadone clients, abusive drinkers were more likely than other clients to report ‘hanging out with friends drinking’ and drinking on the street with friends than drinking in bars, restaurants or at home. Analyzing differences in drinking-related behavior at the outset of drug treatment is believed to be important since it is now recognized that pre-treatment drinking patterns are one of the best predictors of drinking behavior after treatment ends (Simpson and Lloyd, 1981; Bar and Cohen, 1979). Methods
This study was implemented as part of the Community Epidemiology Laboratory by the Alcohol Research Group (Weisner, 1989) that includes parallel studies of drinking behavior and related problems of persons admitted for treatment in a range of social and health agencies. Data for the research described in this paper came from a study of alcohol and drug use patterns and problems of adults entering drug treatment programs. Sample
Data are based on responses from adults in four types of publicly funded drug treatment
programs in a northern California county. These treatment programs included all of the county’s residential drug treatment and outpatient methadone treatment facilities and consist of two residential drug-free treatment programs (N = 59), two methadone detoxification facilities (N = 127) and two methadone maintenance programs (iV = 21). In addition the sample includes men from a county jail education/counseling program for drug and alcohol abuse among incarcerated men (N = 100). Over half the men in the county jail program and five clients in other programs stated that they were mainly in treatment for alcohol problems. Since the focus of this study is on the drinking behavior of those in treatment primarily for a drug other than alcohol, clients who indicated that their main drug of abuse was alcohol were excluded from the sample. The resulting subsample consists of 44 men in the county jail program, 55 men and women from therapeutic communities and 147 men and women in methadone programs. The vast majority of those admitted to methadone programs reported being in treatment for using heroin and other opiates (97%) compared to 16% of those in residential programs and 23% of men in the county jail program. Slightly more than half of clients (54%) entering therapeutic communities and 36% of those in jail indicated that their main drug of abuse was cocaine. Another 20% of residential program participants and 25% of men in the jail program reported entering treatment for problems with amphetamines. Only 4% of clients in residential programs and 11% of those in jail stated that they were in treatment for cannabis. Comparatively few clients from all three program types indicated that they were being treated for other drugs or multiple drug use (5%, 6% and 3%, respectively for the jail, therapeutic community and methadone programs). The social composition of the sample also varied according to treatment modality. Statistically significant differences were noted by gender, age, race, marital and employment status. The county jail sample was all male, while 39% of the clients of the methadone programs and 35% of those in the residential programs were
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women. Participants in the methadone programs were significantly older than clients drawn from the residential and jail programs (the mean ages were 35,27 and 29 years, respectively). The methadone programs included a larger percentage of white clients (60% vs. 39%) and a smaller proportion of black clients (29% compared to roughly 50%) than participants in the county jail or residential settings. Hispanics comprised 14% of the jail sample, 2% of the residential sample and 4% of methadone clients. Clients of methadone programs were more likely to be married (31% compared to 20% and 9%, respectively) than those in jail or residential programs. Employment rates were somewhat higher for methadone clients (19%) than for clients in therapeutic communities (13%). Since they were incarcerated, none of the men in the jail substance abuse program were employed at the time of the interview. There were no statistically significant differences in educational or income level for clients admitted to different types of treatment programs. The average amount of schooling was slightly below 12 years for participants in each type of program and average family income levels were very similar for clients across treatment modalities (e.g. $21 510 yearly for methadone clients, $24 585 for residential program participants and $23 432 for incarcerated men). Procedures
The project was designed as an intake study. Using the official intake records of each agency, each person admitted to a program was contacted to seek their participation in the study. All clients who consented were personally interviewed as soon as possible after being admitted to a drug treatment program. The interviews generally took place within 3 days to avoid treatment bias regarding drinking and drug use behavior in the past year. The response rate for the sample was 86%. A standardized questionnaire which took approximately 75- 90 min to complete was privately administered to each respondent by a trained interviewer not affiliated with the treatment programs. The interviews took place on site in each program.
Measures
The major variables used in the analyses are type of treatment population; drinking patterns and drinking problems; the frequency of using different types of drugs; reasons for combining alcohol and drug use; drinking norms; the social context of drinking; and criminal behavior. The time frame for all behavioral variables was 12 months before entering a treatment program or being incarcerated. The variables used to examine drinking patterns are based on questions about the frequency of drinking five or more drinks on an occasion and the frequency of drunkenness during the past 12 months (every day, nearly every day, 3-4 times weekly, 2 -3 times monthly, once a month, 6 - 11 times yearly, 1 - 5 times y-early, not during the past 12 months). The variable measuring drinking patterns was constructed by combining the following two interview items: ‘In the 12 months before you came to (this program/jail) about how often did you have 12 or more drinks, that is, any combination of cans of beer, glasses of wine, or hard liquor?; In the 12 months before you came to (this program/jail), about how often did you have five or more drinks but less than 12, that is any combination of cans of beer, glasses of wine or hard liquor at one time? This variable was considered to be a good indicator of heavier drinking since it combines criteria previously used to assess high quantity drinking in general population and clinical samples (Hilton, 1987; Weisner, 1989; Room, 1990). The response categories for both the frequency of heavier drinking and drunkenness items were converted to numerical values based on the number of times drinking or getting drunk per day, week, month or year.* Since the data were positively skewed, they were transformed into base 10 logarithms to attain a more normal distribution. The alcohol problems scale includes 27 items on alcohol dependence and adverse social, health and legal consequences of drinking that have been used in major general population surveys and in related alcohol treatment samples in the Community Epidemiology Laboratory (Clark and Midanik, 1982; Hilton, 1987; Weisner, 1989). (See Appendix for a list of items.) The
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items were summed to form a scale which was shown to have an alpha reliability score of 0.94. The frequency of drug use was measured by a series of questions on how often the respondent used each of the major drug types (heroin and opiates, amphetamines, cocaine, tranquilizers, cannabis and hallucinogens) - twice a day or more, about once a day, about 3- 5 times a week, once or twice a week, once every 2 -3 weeks, once every month or two, less often, or not at all. The response categories were converted to numerical values for use in the regression analyses. * * An index consisting of six questions on why the respondent used alcohol and drugs together (e.g. to quench thirst, to enhance the effects of another drug, to stay alert or wake up after using another drug, to stop being sick, to sleep or relax and as part of a social situation) was used as an indicator of reasons for combining drug and alcohol use. Drinking norms were measured with an index of nine interview items on the appropriateness of drinking in various social settings (e.g. when at a bar with friends, at a party, as a parent spending time with small children, during working hours, when visiting parents, when with friends at home, when getting together with friends after work, at sports events or recreation and when going to drive a car). Scores from the items were then summed and averaged. Two interview items on the frequency of drinking in bars, taverns and cocktail lounges and on the
proportion of the time that the respondent drank with family, with friends or acquaintances or alone were used as indicators of the social context of drinking. Finally, the extent of participating in illegal activities was measured using a scale consisting of responses to ten items including attempted or actual car theft, drunkenness in a public place, driving with a suspended or revoked license, check forging or illegal use of credit card, probation or parole violation, burglary or vandalism, selling drugs illegally, prostitution or prostitution-related activity and child neglect or abuse. Analysis Analysis of variance was used to examine whether there were significant differences in the frequency of heavier drinking, alcohol-related problems and other variables among respondents in different treatment modalities. Scheffe tests were used to ascertain the exact pattern of group differences when the overall ANOVA was significant. Harmonic means were used in the Scheffe procedure to adjust for unequal cell sizes in the ANOVA analyses. Multiple regression analyses were used to develop models for explaining drinking frequency and problem level when controlling for type of treatment program, social characteristics (e.g., gender, social and economic status, race, etc.), drug use behavior, criminal behavior, drinking contexts, norms and reasons for combining drug and alcohol use. Results
*Accordingly, 365 was used as the base number for computing daily frequency; 52 for weekly frequency; 12 for monthly frequency and one for yearly frequency. Midpoints for each of the original ordinal values were taken and multiplied by the daily, weekly, monthly, or yearly base number, e.g. every day = 1 x 365 = 365; 3 -4 times weekly = 3.5 x 52 = 182; 2-3 times monthly = 2.5 x 12 = 30; 6- 11 times yearly = 8.5 x 1 = 88.5, etc. **A similar approach to the one used for computing numerical values for the frequency of drinking and of drunkenness was adopted. Hence, 365 was used as the base category for daily frequency; 52 for weekly frequency; and 12 for monthly frequency. Midpoints for each of the original ordinal values were obtained and multiplied by the appropriate base number, e.g. twice a day or more = 2 x 365 = 730; once or twice a week = 1.5 x 52 = 78; once every month or two = 1 x 9 = 9, etc.
Drinking behavior by treatment modality Major differences were observed in drinking behavior according to treatment modality. Residents in the three different types of programs differed significantly in the frequency of consuming five or more drinks (F = 11.72, d.f. = 2, 245, P < O.OOOl), the frequency of being drunk (F = 11.51, d.f. = 2, 245, P < 0.0001) and rates of alcohol-related problems (F = 7.28, d.f. = 2, 245, P < 0.001). The Scheffe tests showed that clients in methadone programs were significantly less likely to consume five or more drinks at a time, or to report
30 Table I.
Reasons for use of alcohol with drugs by program type in percents.
To quench thirst when using another drug To enhance the effects of another drug To help you stay alert or wake up after using another drug To stop being sick or control bad feelings from using another drug To help you relax or sleep after using another drug As part of a social situation when using another drug aNumbers in parentheses
Jail (44Y
Residential (55)
Methadone (1471
X2
P
77
67
34
34.62
0.000
32
33
26
0.98
0.614
18
7
2
15.58
0.001
48
29
29
5.65
0.059
61
64
26
31.9
0.000
70
66
33
28.25
0.000
are numbers of respondents.
being drunk in the past 12 months than participants in the other types of treatment programs (P <: 0.05). In addition, methadone patients reported substantially lower mean rates of alcohol-related problems than clients in the residential or jail substance abuse programs (3.6 vs. 6.4 and 7.3, respectively) and were shown by the Scheffe tests to have significantly lower problem rates than those in the jail substance abuse program (P < 0.05). Clients admitted to different types of treatment programs also differed in the degree of permissiveness of their drinking norms (F = 6.33, d.f. = 2, 242, P c 0.002) and in how often they attended bars (F = 4.70, d.f. = 2, 245, P c 0.01). The Scheffe tests showed that men admitted to the jail substance abuse program espoused more liberal drinking norms and reported attending bars more frequently than participants in therapeutic communities and methadone programs (P < 0.05). Clients in different types of treatment settings differed significantly in whether they did more than half of their drinking with family or friends. Of those admitted to the jail and methadone programs, 25% and 31%, respectively reported that half or more of their drinking oc-
curred with family members while only 7% of those admitted to therapeutic communities described this pattern. Clients entering the jail and residential programs were more likely than clients entering methadone programs to do at least half of their drinking with friends (75% and 73%, respectively compared to 55%). However, there were no significant differences in the proportion of clients in different treatment modalities who reported doing at least half of their drinking alone. The percentages for drinking alone were 27% for persons in the jail and residential programs and 21% for those in methadone programs. Considerably lower percentages of clients in methadone programs than those in therapeutic communities or in jail indicated that they have used alcohol in conjunction with drugs to quench thirst, to help stay alert on drugs, to relax or sleep after using drugs, or as part of a social situation (see Table I). However, similar proportions of participants from each type of program stated that they used alcohol to enhance the effect of another drug. Incarcerated men were more likely than other drug treatment clients to use alcohol to control sickness or bad feelings when using other drugs.
31 Table II. problems.
Regression models for predicting frequency of drinking 5 + drinks, frequency of drunkenness
Variables
Methadone program Therapeutic community Female Age Black Hispanic Married Divorced Income Education Employed Unemployed Frequency heroin use Frequency cocaine use Frequency speed use Frequency cannabis use Crime index Drinking norms Frequency going to bars Drinking alone Drinking with friends Drinking with family Drinking to enhance drug affects Drinking to stay alert after drugs Drinking in social situation with drugs
Frequency of 5+ drinks
Frequency of drunkenness
and alcohol-related
Alcohol problems
b
Beta
b
Beta
b
Beta
- 0.33 (0.396)a - 0.07 (0.366) -0.43 (0.229) 0.00 (0.018) - 0.20 (0.240) 0.32 (0.380) - 0.31 (0.237) -0.19 (0.223) 0.00 (0.000) 0.08 (0.053) 0.19 (0.337) 0.32 (0.260) -0.00 (0.090) -0.04 (0.106) 0.20 (0.193) 0.01 (0.152) 0.05 (0.044) 0.42 (0.230) 0.73 (0.775) 0.58 (0.222) 0.54 (0.202) -0.09 (0.224) 0.37 (0.243) 0.11 (0.404) -0.23 (0.236)
-0.08
-0.24 (0.374) 0.10 (0.346) 0.34 (0.216) - 0.04 (0.017) - 0.25 (0.227) -0.13 (0.359) - 0.30 (0.224) -0.05 (0.210) 0.00 (0.000) 0.04 (0.050) 0.22 (0.318) 0.34 (0.245) 0.04 (0.085) -0.05 (0.100) 0.02 (0.182) 0.15 (0.144) 0.04 (0.042) 0.13 (0.218) 0.88 (0.732) 0.43 (0.210) 0.37 (0.190) 0.32 (0.212) 0.54 (0.229) 0.21 (0.381) -0.13 (0.223)
- 0.07
- 0.23 (1.228) 0.07 (1.134) 0.05 (0.716) 0.06 (0.567) -0.08 (0.747) 0.80 (1.181) - 1.27 (0.738) -0.76 (0.691) -0.00 (0.000) 0.20 (0.166) -0.87 (1.045) 0.18 (0.810) -0.20 (0.279) 0.22 (0.330) 0.24 (0.600) -0.20 (0.472) 0.15 (0.137) 0.06 (0.720) -0.43 (2.410) 1.26 (0.700) - 1.08 (0.636) -0.28 (0.700) 3.30 (0.763) 1.11 (1.252) -0.06 (0.733)
- 0.02
- 0.02 -0.11 0.01 - 0.05 0.04 - 0.07 -0.05 0.01 0.08 0.04 0.08 -0.00 - 0.02 0.06 0.00 0.07 0.10 0.05 0.13** 0.14** -0.02 0.09 0.01 - 0.06
-0.02 -0.09 -0.17’ -0.07 -0.02 -0.08 -0.02 0.02 0.04 0.04 0.10 0.03 - 0.03 0.00 0.06 0.05 0.04 0.06 0.11* 0.11” 0.08 0.15* 0.03 - 0.04
0.00 0.00 0.06 -0.01 0.03 -0.08 -0.05 -0.05 0.05 - 0.04 0.01 -0.04 0.03 0.02 -0.02 0.05 0.00 -0.01 0.08 -0.08 -0.02 0.22*** 0.04 - 0.00
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Table II (co&d.) Variables
Frequency of 5+ drinks b
Drinking to stop being sick from drugs Drinking to relax after drug use Drinking to quench thirst from drugs
Frequency of drunkenness Beta
0.80 (0.264) 0.73 (0.255) 0.71 (0.255)
b
0.20** 0.19** 0.19**
Beta
0.74 (0.249) 0.41 (0.241) 0.40 (0.241)
Frequency of drinking 5 + -
Frequency of drunkeness R2 = 0.49
Alcohol problems
R2 = 0.40
0.21** 0.12 0.12
b
Beta
2.43 (0.840) 0.54 (0.807) 0.02 (0.806) 0.75 (0.234) 1.26 (0.248)
0.17*+ 0.04 0.00 0.21** 0.31***
R2 = 0.61
=Standard Errors for b are in parentheses. *P < 0.05. **P < 0.01. *f*P<
0.001.
Correlates and predictors and problems
of drinking patterns
The previous section described differences in the prevalence of alcohol consumption and in rates of drinking problems across treatment modalities. In addition, it showed that clients admitted to different types of programs varied in their drinking contexts and in reasons for combining drug and alcohol use. Given these differences, a series of regression analyses were performed to explain variation in drinking and problem rates among drug treatment clients. The purpose of these analyses was to address the simultaneous impact of program type, demographic characteristics, frequency of using different types of drugs, drinking norms, drinking contexts, reasons for using alcohol with drugs and criminal behavior on the frequency of consuming five or more drinks and the frequency of drunkenness. These variables were then used to develop a model for explaining alcohol problems. The results displayed in Table II indicate that differences in drinking patterns and problems among clients admitted to different types of treatment programs are no longer significant when controlling for other variables. The findings show that the only significant predictors
of drinking five or more drinks were reasons for having used alcohol with drugs and drinking contexts. Clients who reported using alcohol to stop being sick from drugs, to relax or sleep after drugs, and to quench thirst were more likely to drink five or more drinks than others. In addition those who stated that they did at least half of their drinking alone or with friends drank more heavily than those not reporting these patterns. This model accounted for nearly half the variance in consumption patterns (R2 = 0.49). A similar model emerged for predicting the frequency of drunkenness. Drug treatment clients who reported drinking to control being sick from drugs and to enhance the effects of drugs; as well as those who did at least half of their drinking alone or with friends were significantly more likely to get drunk than other clients. In addition, younger clients were more likely to get drunk than older ones. This model accounted for two-fifths of the variance (R2 = 0.40) in drunkenness rates. The most important predictors of alcohol-related problems were the frequency of being drunk and having used alcohol to enhance the effect of another drug. In addition, the frequency of drinking five or more drinks and using alcohol to stop being
33
sick from drug use were significantly associated with problems. This model explained alcohol problems quite well as illustrated by its R2 value of 0.61. Discussion The findings from the ANOVA analyses revealed that clients admitted to different types of drug treatment programs exhibit different levels of alcohol consumption and alcoholrelated problems. Clients entering methadone programs were less likely to drink heavily or to experience alcohol-related problems than those entering other types of drug treatment programs. These results are consistent with the findings of previous research (Ginzburg, 19’77; Hubbard et al., 1989), which also showed that drinking and alcohol-related problem rates were lower for methadone clients than for persons in other treatment modalities. However, the relationship between treatment modality and drinking behavior disappeared in the regression analyses. These analyses showed that type of treatment program, most demographic characteristics and drug use behavior were not significant predictors of drinking behavior when the social context of drinking and reasons for having used drugs and alcohol together were taken into account. The association between age level and drunkenness was the only significant relationship between drinking behavior and social status to emerge in these analyses. The frequency of drunkenness was the best predictor of experiencing alcohol-related problems, but some reasons for having used drugs and alcohol together and the frequency of heavier drinking were also important. These findings suggest that rates of alcoholrelated problems among clients of methadone programs in this study were lower than those in other drug treatment settings primarily because they were less likely to get drunk or drink heavily. Rates of drunkenness and of heavier consumption among these clients may be lower because the population is older and they are less likely than clients in other types of programs to drink in contexts (with friends) or for reasons (to
relax after drugs, to quench thirst) associated with heavier drinking. This analysis has raised important questions about the explanation of drinking behavior and alcohol-related in drug treatment samples. First, the data presented suggest that when other variables are considered, the frequency of using specific types of drugs is not related to drinking behavior in this population. The association between high levels of opiate use and low rates of drinking reported in other studies may be due to other factors such as the fact that heroin users are generally an older population subgroup. Second, these results indicate, as does other research (Hunt et al., 1986; Gawin and Ellinwood, 1988), that using alcohol with drugs for specific effects such as ‘boosting a high’ or controlling negative drug reactions may result in heavy or problem drinking. In addition, the findings confirm results from prior research illustrating the association between heavier drinking and drinking in particular contexts among drug treatment clients (Hunt et al., 1986). In summary, this study has shown that heavier and problem drinking in persons admitted to drug treatment agencies appears strongly related to reasons for combining alcohol and drug use and drinking contexts. Further research is needed to explore the relationships between social characteristics and drinking motivations and contexts in this population. This will help provide insight into the nature of groups who are likely to use alcohol for specific reasons or in particular settings that appear to result in heavy drinking, high rates of drunkenness and alcohol-related problems. Acknowledgements Data for this paper were collected under a National Alcohol Research Center Grant A-A05595 to the Alcohol Research Group, Medical Research Institute of San Francisco. The author wishes to acknowledge the invaluable assistance of Joel Grube for statistical advice and John Rogers for computer programming.
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References Barr, H.L. and Cohen, A. (1979) The Problem-Drinking Drug Addict. Services Research Reports and Monograph Series. Rockville, Maryland, National Institute on Drug Abuse. DHEW Publication No. ADM 79 - 893. Barr, H.L., Cohen, A., Hannigan, P. and Steinberger, H. (1977) Problem drinking by drug addicts and its implications. In: Currents in Alcoholism, Vol. 2 (Seixas, F., ed.), pp. 269-284. Grune and Stratton, New York. Blume, S.B. (1987) Alcohol problems in cocaine abusers. In: Cocaine: A Clinicians Handbook (Washton, A. and Gold, MS., eds.), pp. 202-207. Carroll, J.F.X., Malloy, T.E., Kenrick, F.M. (1977) Alcohol abuse by drug dependent persons: A literature review and evaluation. Am. J. Drug Alcohol Abuse 4, 293-314. Clark, W. (1988) Places of drinking: A comparative analysis. Contemp. Drug Prob. 15, 399-446. Clark, W. and Midanik, L. (1982) Alcohol use and alcohol problems among U.S. adults: Results of the 1979 national survey. In: Alcohol and Health Monograph 1. DHHS Publication no.(ADM)82-1190: Alcohol Consumption and Related Problems, pp. 3-52. Washington, D.C.: U.S. Government Printing Office. Croughan, J.L., Miller, J.P., Whitman, B.Y. and Schober, J.G. (1981) Alcoholism and alcohol dependence in narcotic addicts: A prospective study with a five year follow-up. Am. J. Drug Alcohol Abuse 8, 85 - 94. Gawin, F.H. and Ellinwood, E.H. Jr. (1988) Cocaine and other stimulants: Actions, abuse and treatment. New Engl. J. Med. 318, 1173- 1182. Ginzburg, H.M. (1977) Substance substitution: Do methadone maintenance patients become alcoholics?. In: Currents in Alcoholism, Vol. 2 (Seixas, F., ed.), pp. 253-267. Grune and Stratton, New York. Hilton, M.E. (1987) Demographic characteristics and the frequency of heavy drinking as predictors of self-reported drinking problems. Br. J. Addict. 8, 913-925. Hubbard, R.L., Mardsen, M.E., Rachal, J.V., Harwood, H.J.,
APPENDIX
Alcohol
4.
related
I. Alcohol
Cavanaugh, E.R., Ginzburg, H.M. (1989) Drug Abuse Treatment: A National Study of Effectiveness, University of North Carolina Press, Chapel Hill and London. Hunt, D.E., Strug, D.L., Goldsmith, D.D., Lipton, D.S., Robertson, K. and Truitt, L. (1986) Alcohol Use and Abuse: Heavy Drinking Among Methadone Clients. Am. J. Drug Alcohol Abuse, 12, 147 - 164. Kaufman, E. (1982) The relationship of alcoholism and alcohol abuse to the abuse of other drugs. Am. J. Drug Alcohol Abuse 9, 1- 17. Room, R. (1990) Measuring alcohol consumption in the U.S.: Methods and rationales. In Research Advances in Alcohol and Drug Problems, Vol. 10 (Kozolowski, L. et al., eds.), pp. 39-80. Plenum Press, New York. Roszell, D.K. Calsyn, D.A. and Chaney, E.F. (1986) Alcohol use and psychopathology in opioid addicts on methadone maintenance, Am. J. Drug Alcohol Abuse 12, 269-278. Simpson, D.D. (1976) Pretreatment drug use by patients entering drug treatment programs during 1971- 73. J. Drug Educ. 6, 53-71. Simpson, D.D. (1981) Treatment for drug abuse: Followup outcomes and length of time spent. Arch. Gen. Psychiatry 38, 875-880. Simpson, D.D. and Lloyd, M.R. (1981) Alcohol use following treatment for drug addiction. J. Stud. Alcohol 42, 323 - 335. Weisner, C., The role of alcohol-related problematic events in treatment entry, presented at the 116th Annual Meeting of the American Public Health Association, Boston, November, 1988. Weisner, C., Drinking patterns and problems in health and social service agencies: Results from comparable epidemiological studies, presented at the 15th Annual Alcohol Epidemiology Symposium, Kettil Bruun Society for Social and Epidemiological Research on Alcohol, Maastricht, the Netherlands, June 11- 16, 1989. Weiss, R.D.. Mirin, S.M., Griffin, M.L. and Michael, J.L. (1988) A comparison of alcoholic and nonalcoholic drug abusers. J. Stud. Alcohol 49, 510-515.
problems
dependence
scale items
related
items
In the 12 months before you came to this program/jail have you: 1. Felt that you should cut down on your drinking or stop altogether? 2. Tried to cut down on your drinking but were unable to do so? 3. Gotten drunk when there was an important reason to stay sober?
5.
6. 7. 8. 9.
Awakened the next day not being able to remember some of the things you had done while drinking? Taken a drink first thing when you got up in the morning? Had your hands shake a lot in the morning after drinking? Stayed intoxicated for several days at a time? Been told to leave a place because of your drinking? Gotten into a physical fight because of your drinking?
35
10. Been sick because of drinking (nausea, vomiting, severe headache, etc.)? In the 12 months before you came to this program/jail: 11. Did you find that you needed more alcohol than you used to, to get the same effect as before? 12. Did you take a drink intending to have just one or two and end up drunk? 13. Did your drinking interfere with your spare time activities or hobbies? 14. Did you try to limit your drinking to certain places and times so that you could keep it under control? 15. Did you feel you needed a drink so badly that you could not think of anything else? 16. Did you awaken during the night or early in the morning sweating all over because of drinking? II. Social, Legal and Health Consequences of Drinking In the 12 months before you came to this program/jail, did your drinking cause you difficulties with:
17. 18. 19. 20. 21.
Personal relationships? Your work? The police or other authorities? Your physical health? Your psychological health or mental well-being?
In the 12 months before you came to this program/jail: 22. Were you arrested for drunk driving? 23. Did the police pick you up for public drunkenness? 24. Did you have any serious arguments with family members or others close to you about your drinking or the effect your drinking was having on those around you? 25. Did your drinking cause any work problems that your boss complained about like missing work, making mistakes, or any other job problems? 26. Did a doctor or health worker tell you that you had serious problems connected with your drinking? 27. Have any of your friends, relatives or acquaintances said anything about your drinking or suggested you cut down?
Elsevier Scientific Publishers
32 (1993) 25 - 35 Ireland Ltd.
25
Correlates of heavy drinking and alcohol related problems among men and women in drug treatment programs Denise Herd School of Public Health, 518
Warren Hall, University
of Calvornia,
Berkeley,
CA 94720 (USA)
(Accepted August 31st, 1992)
A series of analyses were conducted to explore if there were significant differences in heavy drinking and alcohol-related problems in clients admitted to different types of drug treatment programs and whether such differences, if found, could be attributed to variation in social characteristics, drug use behavior, drinking norms, drinking contexts, or in reasons for combining alcohol and drug use. Men and women (N = 246) in four types of publicly funded treatment programs were interviewed at intake regarding drinking and drug use patterns and related problems. The results of the study showed significant differences in drinking behavior and alcohol-related problems of clients in different treatment modalities. Men in a county jail substance abuse program exhibited the highest frequency of heavy drinking and highest rates of alcohol problems; clients of methadone programs reported the lowest rates and those in therapeutic communities described intermediate rates. A series of regression analyses showed that the only significant predictors of the frequency of heavier drinking and drunkenness were drinking context and reasons for combining alcohol and drug use. In addition, age (youthfulness) was associated with the frequency of getting drunk. The most powerful predictors of alcohol-related problems were the frequency of getting drunk and drinking to enhance the effects of other drugs. Heavy drinking and drinking to prevent getting sick from drugs were also significantly associated with drinking problems. The frequency of drug use (by specific type) and most social characteristics showed no direct association with drinking patterns or problems. Key words: drinking patterns;
drinking problems; drug use frequency; treatment
modality; drinking contexts; drinking moti-
vations
Introduction A considerable body of research shows that many people admitted to drug treatment programs are heavy drinkers with relatively high rates of alcohol-related problems (Carroll et al., 1977; Barr et al., 1977; Ginzburg, 1977; Kaufman, 1982). As some studies indicate, excessive alcohol use in this population is of concern because it has been associated with high levels of psychological symptomology and with poorer treatment and mortality outcomes (Kaufman, Corresponbe to: Denise Herd, School of Public Health, 518 Warren Hall, University of California, Berkeley, CA 94720, USA. 0376-8716/93/$06.00 0 1993 Elsevier Scientific Publishers Printed and Published in Ireland
1982; Weiss et al., 1988; Roszell et al., 1986; Croughan et al., 1981). The purpose of the present study is to add to the understanding of the extent and correlates of heavy drinking and alcohol-related problems in persons admitted to several types of drug treatment programs. Most previous research has focused on the high rates of excessive drinking and related problems among clients of methadone treatment programs. Estimates of alcohol abuse in methadone patients at treatment intake range from a low of 20% to as high as 36% or even 53% (Hunt et a1.,1986) and many studies document the poorer prognosis and health outcomes of problem drinkers in this population. Very few reports have compared the drinking Ireland Ltd.
26
patterns and alcohol related problems of clients in methadone programs with those in other types of treatment modalities. Two of the major studies that do make this comparison indicate that those admitted to thercommunities and or other nonapeutic methadone based programs may actually have a higher prevalence of drinking related problems than clients admitted to methadone programs. In the Treatment Outcome Prospective Study, perhaps the most extensive analysis of the relationship between treatment modality and drug and alcohol use to date, Hubbard et al. (1989) showed that clients admitted to outpatient methadone programs were substantially less likely to be classified as heavy alcohol users than those admitted to residential programs and outpatient drug free programs (25.0% vs. 41.7% and 35.7% respectively). The importance of differences in alcohol use by modality was confirmed in a series of analyses showing that even when controlling for some client characteristics (age, sex, race/ethnicity, pretreatment drug abuse patterns, number of prior treatments and source of referral) methadone patients were less likely to be heavier drinkers than residential or outpatient drug free clients in the year before treatment. Similarly, Ginzburg’s analysis (1977) of data from the Drug Abuse Reporting Program on 24 126 drug treatment clients showed that pre-treatment levels of heavy alcohol consumption (e.g. 8 ounces or more alcohol/day) were lower among methadone maintenance patients than they were for those in therapeutic communities or in in-patient detoxification facilities (42% vs. 56%). Methadone maintenance patients were also less likely to report alcohol-related problems than those in therapeutic communities (5% compared to 13%) prior to entering drug treatment. In contrast to the above findings, Barr and Cohen (1979) reported considerably higher mean alcohol consumption scores for a sample of methadone patients from 10 Philadelphia clinics (0.79 oz/day) than for a sample of clients in a therapeutic community setting (0.26 oz/day). Despite the higher intake levels of the methadone patients, their rates of alcohol-related problems were lower than rates of clients in the therapeutic community sample.
The differences in prevalence rates described within methadone treatment programs, as well as the conflicting reports on rates across treatment modalities, reflect the need for more detailed analyses and comparisons of drinking patterns and problems of clients in drug treatment programs. Many prior studies have used only limited measures of drinking practices and alcohol-related problems or have been based on highly restricted samples. In addition, little if any previous research has been conducted to explain why differences in drinking behavior and alcohol-related problems occur in different groups of drug treatment clients. Although some studies (Bar and Cohen, 1979; Hubbard et al., 1989) have suggested that these differences may stem from variation in social characteristics and levels of social instability or pathology, these assumptions have only rarely been subject to systematic analysis, In addition, researchers have pointed to differences in drug use behavior (e.g. differences in drug of abuse and intensity of use) as a possible explanation of variation in drinking behavior among clients entering different treatment modalities. For example it was reported that persons admitted to drug treatment for primary or exclusive heroin addiction were less likely to drink heavily than those entering treatment for polydrug abuse or primary addiction to amphetamines or sedatives and barbituates (Simpson, 1976; Carroll et al., 1977). However, little research exists that analyzes the simultaneous relationship between drug use, drinking behavior and treatment modality. In view of the restricted scope of prior research in this area, the following paper will examine differences in drinking patterns and alcohol-related problems among clients admitted to several types of drug treatment programs. The basic goals of the analyses are to: (1) ascertain whether there are significant differences in prevalence rates of heavy drinking and alcoholrelated problems among those entering different treatment modalities; and (2) if these differences exist, to determine if they can be explained by differences in the social characteristics of clients, by differences in the drug use behavior of clients, or by variation in
27
other aspects of their drinking-related behavior (e.g. reasons for using alcohol with drugs, drinking norms and drinking contexts). Data on reasons for combining drugs and alcohol will be included since previous research (Hunt et al., 1986; Blume, 1987; Gawin and Ellinwood, 1988) suggests that heavy or problem drinking among drug users may result from drinking to achieve certain effects with drugs such as increasing the euphoria or ‘high’ from other drugs or selfmedicating to relieve negative reactions from drug use. Drinking norms and drinking contexts will be explored since general population studies (c.f. Clark, 1988) and some clinical research (Hunt et al., 1986) indicate that the social worlds of heavy or problem drinkers may differ from those with moderate or non-problem drinking patterns. For example, Hunt et al. (1988) showed that while there were few demographic differences between abusive pattern drinkers and other methadone clients, abusive drinkers were more likely than other clients to report ‘hanging out with friends drinking’ and drinking on the street with friends than drinking in bars, restaurants or at home. Analyzing differences in drinking-related behavior at the outset of drug treatment is believed to be important since it is now recognized that pre-treatment drinking patterns are one of the best predictors of drinking behavior after treatment ends (Simpson and Lloyd, 1981; Bar and Cohen, 1979). Methods
This study was implemented as part of the Community Epidemiology Laboratory by the Alcohol Research Group (Weisner, 1989) that includes parallel studies of drinking behavior and related problems of persons admitted for treatment in a range of social and health agencies. Data for the research described in this paper came from a study of alcohol and drug use patterns and problems of adults entering drug treatment programs. Sample
Data are based on responses from adults in four types of publicly funded drug treatment
programs in a northern California county. These treatment programs included all of the county’s residential drug treatment and outpatient methadone treatment facilities and consist of two residential drug-free treatment programs (N = 59), two methadone detoxification facilities (N = 127) and two methadone maintenance programs (iV = 21). In addition the sample includes men from a county jail education/counseling program for drug and alcohol abuse among incarcerated men (N = 100). Over half the men in the county jail program and five clients in other programs stated that they were mainly in treatment for alcohol problems. Since the focus of this study is on the drinking behavior of those in treatment primarily for a drug other than alcohol, clients who indicated that their main drug of abuse was alcohol were excluded from the sample. The resulting subsample consists of 44 men in the county jail program, 55 men and women from therapeutic communities and 147 men and women in methadone programs. The vast majority of those admitted to methadone programs reported being in treatment for using heroin and other opiates (97%) compared to 16% of those in residential programs and 23% of men in the county jail program. Slightly more than half of clients (54%) entering therapeutic communities and 36% of those in jail indicated that their main drug of abuse was cocaine. Another 20% of residential program participants and 25% of men in the jail program reported entering treatment for problems with amphetamines. Only 4% of clients in residential programs and 11% of those in jail stated that they were in treatment for cannabis. Comparatively few clients from all three program types indicated that they were being treated for other drugs or multiple drug use (5%, 6% and 3%, respectively for the jail, therapeutic community and methadone programs). The social composition of the sample also varied according to treatment modality. Statistically significant differences were noted by gender, age, race, marital and employment status. The county jail sample was all male, while 39% of the clients of the methadone programs and 35% of those in the residential programs were
28
women. Participants in the methadone programs were significantly older than clients drawn from the residential and jail programs (the mean ages were 35,27 and 29 years, respectively). The methadone programs included a larger percentage of white clients (60% vs. 39%) and a smaller proportion of black clients (29% compared to roughly 50%) than participants in the county jail or residential settings. Hispanics comprised 14% of the jail sample, 2% of the residential sample and 4% of methadone clients. Clients of methadone programs were more likely to be married (31% compared to 20% and 9%, respectively) than those in jail or residential programs. Employment rates were somewhat higher for methadone clients (19%) than for clients in therapeutic communities (13%). Since they were incarcerated, none of the men in the jail substance abuse program were employed at the time of the interview. There were no statistically significant differences in educational or income level for clients admitted to different types of treatment programs. The average amount of schooling was slightly below 12 years for participants in each type of program and average family income levels were very similar for clients across treatment modalities (e.g. $21 510 yearly for methadone clients, $24 585 for residential program participants and $23 432 for incarcerated men). Procedures
The project was designed as an intake study. Using the official intake records of each agency, each person admitted to a program was contacted to seek their participation in the study. All clients who consented were personally interviewed as soon as possible after being admitted to a drug treatment program. The interviews generally took place within 3 days to avoid treatment bias regarding drinking and drug use behavior in the past year. The response rate for the sample was 86%. A standardized questionnaire which took approximately 75- 90 min to complete was privately administered to each respondent by a trained interviewer not affiliated with the treatment programs. The interviews took place on site in each program.
Measures
The major variables used in the analyses are type of treatment population; drinking patterns and drinking problems; the frequency of using different types of drugs; reasons for combining alcohol and drug use; drinking norms; the social context of drinking; and criminal behavior. The time frame for all behavioral variables was 12 months before entering a treatment program or being incarcerated. The variables used to examine drinking patterns are based on questions about the frequency of drinking five or more drinks on an occasion and the frequency of drunkenness during the past 12 months (every day, nearly every day, 3-4 times weekly, 2 -3 times monthly, once a month, 6 - 11 times yearly, 1 - 5 times y-early, not during the past 12 months). The variable measuring drinking patterns was constructed by combining the following two interview items: ‘In the 12 months before you came to (this program/jail) about how often did you have 12 or more drinks, that is, any combination of cans of beer, glasses of wine, or hard liquor?; In the 12 months before you came to (this program/jail), about how often did you have five or more drinks but less than 12, that is any combination of cans of beer, glasses of wine or hard liquor at one time? This variable was considered to be a good indicator of heavier drinking since it combines criteria previously used to assess high quantity drinking in general population and clinical samples (Hilton, 1987; Weisner, 1989; Room, 1990). The response categories for both the frequency of heavier drinking and drunkenness items were converted to numerical values based on the number of times drinking or getting drunk per day, week, month or year.* Since the data were positively skewed, they were transformed into base 10 logarithms to attain a more normal distribution. The alcohol problems scale includes 27 items on alcohol dependence and adverse social, health and legal consequences of drinking that have been used in major general population surveys and in related alcohol treatment samples in the Community Epidemiology Laboratory (Clark and Midanik, 1982; Hilton, 1987; Weisner, 1989). (See Appendix for a list of items.) The
29
items were summed to form a scale which was shown to have an alpha reliability score of 0.94. The frequency of drug use was measured by a series of questions on how often the respondent used each of the major drug types (heroin and opiates, amphetamines, cocaine, tranquilizers, cannabis and hallucinogens) - twice a day or more, about once a day, about 3- 5 times a week, once or twice a week, once every 2 -3 weeks, once every month or two, less often, or not at all. The response categories were converted to numerical values for use in the regression analyses. * * An index consisting of six questions on why the respondent used alcohol and drugs together (e.g. to quench thirst, to enhance the effects of another drug, to stay alert or wake up after using another drug, to stop being sick, to sleep or relax and as part of a social situation) was used as an indicator of reasons for combining drug and alcohol use. Drinking norms were measured with an index of nine interview items on the appropriateness of drinking in various social settings (e.g. when at a bar with friends, at a party, as a parent spending time with small children, during working hours, when visiting parents, when with friends at home, when getting together with friends after work, at sports events or recreation and when going to drive a car). Scores from the items were then summed and averaged. Two interview items on the frequency of drinking in bars, taverns and cocktail lounges and on the
proportion of the time that the respondent drank with family, with friends or acquaintances or alone were used as indicators of the social context of drinking. Finally, the extent of participating in illegal activities was measured using a scale consisting of responses to ten items including attempted or actual car theft, drunkenness in a public place, driving with a suspended or revoked license, check forging or illegal use of credit card, probation or parole violation, burglary or vandalism, selling drugs illegally, prostitution or prostitution-related activity and child neglect or abuse. Analysis Analysis of variance was used to examine whether there were significant differences in the frequency of heavier drinking, alcohol-related problems and other variables among respondents in different treatment modalities. Scheffe tests were used to ascertain the exact pattern of group differences when the overall ANOVA was significant. Harmonic means were used in the Scheffe procedure to adjust for unequal cell sizes in the ANOVA analyses. Multiple regression analyses were used to develop models for explaining drinking frequency and problem level when controlling for type of treatment program, social characteristics (e.g., gender, social and economic status, race, etc.), drug use behavior, criminal behavior, drinking contexts, norms and reasons for combining drug and alcohol use. Results
*Accordingly, 365 was used as the base number for computing daily frequency; 52 for weekly frequency; 12 for monthly frequency and one for yearly frequency. Midpoints for each of the original ordinal values were taken and multiplied by the daily, weekly, monthly, or yearly base number, e.g. every day = 1 x 365 = 365; 3 -4 times weekly = 3.5 x 52 = 182; 2-3 times monthly = 2.5 x 12 = 30; 6- 11 times yearly = 8.5 x 1 = 88.5, etc. **A similar approach to the one used for computing numerical values for the frequency of drinking and of drunkenness was adopted. Hence, 365 was used as the base category for daily frequency; 52 for weekly frequency; and 12 for monthly frequency. Midpoints for each of the original ordinal values were obtained and multiplied by the appropriate base number, e.g. twice a day or more = 2 x 365 = 730; once or twice a week = 1.5 x 52 = 78; once every month or two = 1 x 9 = 9, etc.
Drinking behavior by treatment modality Major differences were observed in drinking behavior according to treatment modality. Residents in the three different types of programs differed significantly in the frequency of consuming five or more drinks (F = 11.72, d.f. = 2, 245, P < O.OOOl), the frequency of being drunk (F = 11.51, d.f. = 2, 245, P < 0.0001) and rates of alcohol-related problems (F = 7.28, d.f. = 2, 245, P < 0.001). The Scheffe tests showed that clients in methadone programs were significantly less likely to consume five or more drinks at a time, or to report
30 Table I.
Reasons for use of alcohol with drugs by program type in percents.
To quench thirst when using another drug To enhance the effects of another drug To help you stay alert or wake up after using another drug To stop being sick or control bad feelings from using another drug To help you relax or sleep after using another drug As part of a social situation when using another drug aNumbers in parentheses
Jail (44Y
Residential (55)
Methadone (1471
X2
P
77
67
34
34.62
0.000
32
33
26
0.98
0.614
18
7
2
15.58
0.001
48
29
29
5.65
0.059
61
64
26
31.9
0.000
70
66
33
28.25
0.000
are numbers of respondents.
being drunk in the past 12 months than participants in the other types of treatment programs (P <: 0.05). In addition, methadone patients reported substantially lower mean rates of alcohol-related problems than clients in the residential or jail substance abuse programs (3.6 vs. 6.4 and 7.3, respectively) and were shown by the Scheffe tests to have significantly lower problem rates than those in the jail substance abuse program (P < 0.05). Clients admitted to different types of treatment programs also differed in the degree of permissiveness of their drinking norms (F = 6.33, d.f. = 2, 242, P c 0.002) and in how often they attended bars (F = 4.70, d.f. = 2, 245, P c 0.01). The Scheffe tests showed that men admitted to the jail substance abuse program espoused more liberal drinking norms and reported attending bars more frequently than participants in therapeutic communities and methadone programs (P < 0.05). Clients in different types of treatment settings differed significantly in whether they did more than half of their drinking with family or friends. Of those admitted to the jail and methadone programs, 25% and 31%, respectively reported that half or more of their drinking oc-
curred with family members while only 7% of those admitted to therapeutic communities described this pattern. Clients entering the jail and residential programs were more likely than clients entering methadone programs to do at least half of their drinking with friends (75% and 73%, respectively compared to 55%). However, there were no significant differences in the proportion of clients in different treatment modalities who reported doing at least half of their drinking alone. The percentages for drinking alone were 27% for persons in the jail and residential programs and 21% for those in methadone programs. Considerably lower percentages of clients in methadone programs than those in therapeutic communities or in jail indicated that they have used alcohol in conjunction with drugs to quench thirst, to help stay alert on drugs, to relax or sleep after using drugs, or as part of a social situation (see Table I). However, similar proportions of participants from each type of program stated that they used alcohol to enhance the effect of another drug. Incarcerated men were more likely than other drug treatment clients to use alcohol to control sickness or bad feelings when using other drugs.
31 Table II. problems.
Regression models for predicting frequency of drinking 5 + drinks, frequency of drunkenness
Variables
Methadone program Therapeutic community Female Age Black Hispanic Married Divorced Income Education Employed Unemployed Frequency heroin use Frequency cocaine use Frequency speed use Frequency cannabis use Crime index Drinking norms Frequency going to bars Drinking alone Drinking with friends Drinking with family Drinking to enhance drug affects Drinking to stay alert after drugs Drinking in social situation with drugs
Frequency of 5+ drinks
Frequency of drunkenness
and alcohol-related
Alcohol problems
b
Beta
b
Beta
b
Beta
- 0.33 (0.396)a - 0.07 (0.366) -0.43 (0.229) 0.00 (0.018) - 0.20 (0.240) 0.32 (0.380) - 0.31 (0.237) -0.19 (0.223) 0.00 (0.000) 0.08 (0.053) 0.19 (0.337) 0.32 (0.260) -0.00 (0.090) -0.04 (0.106) 0.20 (0.193) 0.01 (0.152) 0.05 (0.044) 0.42 (0.230) 0.73 (0.775) 0.58 (0.222) 0.54 (0.202) -0.09 (0.224) 0.37 (0.243) 0.11 (0.404) -0.23 (0.236)
-0.08
-0.24 (0.374) 0.10 (0.346) 0.34 (0.216) - 0.04 (0.017) - 0.25 (0.227) -0.13 (0.359) - 0.30 (0.224) -0.05 (0.210) 0.00 (0.000) 0.04 (0.050) 0.22 (0.318) 0.34 (0.245) 0.04 (0.085) -0.05 (0.100) 0.02 (0.182) 0.15 (0.144) 0.04 (0.042) 0.13 (0.218) 0.88 (0.732) 0.43 (0.210) 0.37 (0.190) 0.32 (0.212) 0.54 (0.229) 0.21 (0.381) -0.13 (0.223)
- 0.07
- 0.23 (1.228) 0.07 (1.134) 0.05 (0.716) 0.06 (0.567) -0.08 (0.747) 0.80 (1.181) - 1.27 (0.738) -0.76 (0.691) -0.00 (0.000) 0.20 (0.166) -0.87 (1.045) 0.18 (0.810) -0.20 (0.279) 0.22 (0.330) 0.24 (0.600) -0.20 (0.472) 0.15 (0.137) 0.06 (0.720) -0.43 (2.410) 1.26 (0.700) - 1.08 (0.636) -0.28 (0.700) 3.30 (0.763) 1.11 (1.252) -0.06 (0.733)
- 0.02
- 0.02 -0.11 0.01 - 0.05 0.04 - 0.07 -0.05 0.01 0.08 0.04 0.08 -0.00 - 0.02 0.06 0.00 0.07 0.10 0.05 0.13** 0.14** -0.02 0.09 0.01 - 0.06
-0.02 -0.09 -0.17’ -0.07 -0.02 -0.08 -0.02 0.02 0.04 0.04 0.10 0.03 - 0.03 0.00 0.06 0.05 0.04 0.06 0.11* 0.11” 0.08 0.15* 0.03 - 0.04
0.00 0.00 0.06 -0.01 0.03 -0.08 -0.05 -0.05 0.05 - 0.04 0.01 -0.04 0.03 0.02 -0.02 0.05 0.00 -0.01 0.08 -0.08 -0.02 0.22*** 0.04 - 0.00
32
Table II (co&d.) Variables
Frequency of 5+ drinks b
Drinking to stop being sick from drugs Drinking to relax after drug use Drinking to quench thirst from drugs
Frequency of drunkenness Beta
0.80 (0.264) 0.73 (0.255) 0.71 (0.255)
b
0.20** 0.19** 0.19**
Beta
0.74 (0.249) 0.41 (0.241) 0.40 (0.241)
Frequency of drinking 5 + -
Frequency of drunkeness R2 = 0.49
Alcohol problems
R2 = 0.40
0.21** 0.12 0.12
b
Beta
2.43 (0.840) 0.54 (0.807) 0.02 (0.806) 0.75 (0.234) 1.26 (0.248)
0.17*+ 0.04 0.00 0.21** 0.31***
R2 = 0.61
=Standard Errors for b are in parentheses. *P < 0.05. **P < 0.01. *f*P<
0.001.
Correlates and predictors and problems
of drinking patterns
The previous section described differences in the prevalence of alcohol consumption and in rates of drinking problems across treatment modalities. In addition, it showed that clients admitted to different types of programs varied in their drinking contexts and in reasons for combining drug and alcohol use. Given these differences, a series of regression analyses were performed to explain variation in drinking and problem rates among drug treatment clients. The purpose of these analyses was to address the simultaneous impact of program type, demographic characteristics, frequency of using different types of drugs, drinking norms, drinking contexts, reasons for using alcohol with drugs and criminal behavior on the frequency of consuming five or more drinks and the frequency of drunkenness. These variables were then used to develop a model for explaining alcohol problems. The results displayed in Table II indicate that differences in drinking patterns and problems among clients admitted to different types of treatment programs are no longer significant when controlling for other variables. The findings show that the only significant predictors
of drinking five or more drinks were reasons for having used alcohol with drugs and drinking contexts. Clients who reported using alcohol to stop being sick from drugs, to relax or sleep after drugs, and to quench thirst were more likely to drink five or more drinks than others. In addition those who stated that they did at least half of their drinking alone or with friends drank more heavily than those not reporting these patterns. This model accounted for nearly half the variance in consumption patterns (R2 = 0.49). A similar model emerged for predicting the frequency of drunkenness. Drug treatment clients who reported drinking to control being sick from drugs and to enhance the effects of drugs; as well as those who did at least half of their drinking alone or with friends were significantly more likely to get drunk than other clients. In addition, younger clients were more likely to get drunk than older ones. This model accounted for two-fifths of the variance (R2 = 0.40) in drunkenness rates. The most important predictors of alcohol-related problems were the frequency of being drunk and having used alcohol to enhance the effect of another drug. In addition, the frequency of drinking five or more drinks and using alcohol to stop being
33
sick from drug use were significantly associated with problems. This model explained alcohol problems quite well as illustrated by its R2 value of 0.61. Discussion The findings from the ANOVA analyses revealed that clients admitted to different types of drug treatment programs exhibit different levels of alcohol consumption and alcoholrelated problems. Clients entering methadone programs were less likely to drink heavily or to experience alcohol-related problems than those entering other types of drug treatment programs. These results are consistent with the findings of previous research (Ginzburg, 19’77; Hubbard et al., 1989), which also showed that drinking and alcohol-related problem rates were lower for methadone clients than for persons in other treatment modalities. However, the relationship between treatment modality and drinking behavior disappeared in the regression analyses. These analyses showed that type of treatment program, most demographic characteristics and drug use behavior were not significant predictors of drinking behavior when the social context of drinking and reasons for having used drugs and alcohol together were taken into account. The association between age level and drunkenness was the only significant relationship between drinking behavior and social status to emerge in these analyses. The frequency of drunkenness was the best predictor of experiencing alcohol-related problems, but some reasons for having used drugs and alcohol together and the frequency of heavier drinking were also important. These findings suggest that rates of alcoholrelated problems among clients of methadone programs in this study were lower than those in other drug treatment settings primarily because they were less likely to get drunk or drink heavily. Rates of drunkenness and of heavier consumption among these clients may be lower because the population is older and they are less likely than clients in other types of programs to drink in contexts (with friends) or for reasons (to
relax after drugs, to quench thirst) associated with heavier drinking. This analysis has raised important questions about the explanation of drinking behavior and alcohol-related in drug treatment samples. First, the data presented suggest that when other variables are considered, the frequency of using specific types of drugs is not related to drinking behavior in this population. The association between high levels of opiate use and low rates of drinking reported in other studies may be due to other factors such as the fact that heroin users are generally an older population subgroup. Second, these results indicate, as does other research (Hunt et al., 1986; Gawin and Ellinwood, 1988), that using alcohol with drugs for specific effects such as ‘boosting a high’ or controlling negative drug reactions may result in heavy or problem drinking. In addition, the findings confirm results from prior research illustrating the association between heavier drinking and drinking in particular contexts among drug treatment clients (Hunt et al., 1986). In summary, this study has shown that heavier and problem drinking in persons admitted to drug treatment agencies appears strongly related to reasons for combining alcohol and drug use and drinking contexts. Further research is needed to explore the relationships between social characteristics and drinking motivations and contexts in this population. This will help provide insight into the nature of groups who are likely to use alcohol for specific reasons or in particular settings that appear to result in heavy drinking, high rates of drunkenness and alcohol-related problems. Acknowledgements Data for this paper were collected under a National Alcohol Research Center Grant A-A05595 to the Alcohol Research Group, Medical Research Institute of San Francisco. The author wishes to acknowledge the invaluable assistance of Joel Grube for statistical advice and John Rogers for computer programming.
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References Barr, H.L. and Cohen, A. (1979) The Problem-Drinking Drug Addict. Services Research Reports and Monograph Series. Rockville, Maryland, National Institute on Drug Abuse. DHEW Publication No. ADM 79 - 893. Barr, H.L., Cohen, A., Hannigan, P. and Steinberger, H. (1977) Problem drinking by drug addicts and its implications. In: Currents in Alcoholism, Vol. 2 (Seixas, F., ed.), pp. 269-284. Grune and Stratton, New York. Blume, S.B. (1987) Alcohol problems in cocaine abusers. In: Cocaine: A Clinicians Handbook (Washton, A. and Gold, MS., eds.), pp. 202-207. Carroll, J.F.X., Malloy, T.E., Kenrick, F.M. (1977) Alcohol abuse by drug dependent persons: A literature review and evaluation. Am. J. Drug Alcohol Abuse 4, 293-314. Clark, W. (1988) Places of drinking: A comparative analysis. Contemp. Drug Prob. 15, 399-446. Clark, W. and Midanik, L. (1982) Alcohol use and alcohol problems among U.S. adults: Results of the 1979 national survey. In: Alcohol and Health Monograph 1. DHHS Publication no.(ADM)82-1190: Alcohol Consumption and Related Problems, pp. 3-52. Washington, D.C.: U.S. Government Printing Office. Croughan, J.L., Miller, J.P., Whitman, B.Y. and Schober, J.G. (1981) Alcoholism and alcohol dependence in narcotic addicts: A prospective study with a five year follow-up. Am. J. Drug Alcohol Abuse 8, 85 - 94. Gawin, F.H. and Ellinwood, E.H. Jr. (1988) Cocaine and other stimulants: Actions, abuse and treatment. New Engl. J. Med. 318, 1173- 1182. Ginzburg, H.M. (1977) Substance substitution: Do methadone maintenance patients become alcoholics?. In: Currents in Alcoholism, Vol. 2 (Seixas, F., ed.), pp. 253-267. Grune and Stratton, New York. Hilton, M.E. (1987) Demographic characteristics and the frequency of heavy drinking as predictors of self-reported drinking problems. Br. J. Addict. 8, 913-925. Hubbard, R.L., Mardsen, M.E., Rachal, J.V., Harwood, H.J.,
APPENDIX
Alcohol
4.
related
I. Alcohol
Cavanaugh, E.R., Ginzburg, H.M. (1989) Drug Abuse Treatment: A National Study of Effectiveness, University of North Carolina Press, Chapel Hill and London. Hunt, D.E., Strug, D.L., Goldsmith, D.D., Lipton, D.S., Robertson, K. and Truitt, L. (1986) Alcohol Use and Abuse: Heavy Drinking Among Methadone Clients. Am. J. Drug Alcohol Abuse, 12, 147 - 164. Kaufman, E. (1982) The relationship of alcoholism and alcohol abuse to the abuse of other drugs. Am. J. Drug Alcohol Abuse 9, 1- 17. Room, R. (1990) Measuring alcohol consumption in the U.S.: Methods and rationales. In Research Advances in Alcohol and Drug Problems, Vol. 10 (Kozolowski, L. et al., eds.), pp. 39-80. Plenum Press, New York. Roszell, D.K. Calsyn, D.A. and Chaney, E.F. (1986) Alcohol use and psychopathology in opioid addicts on methadone maintenance, Am. J. Drug Alcohol Abuse 12, 269-278. Simpson, D.D. (1976) Pretreatment drug use by patients entering drug treatment programs during 1971- 73. J. Drug Educ. 6, 53-71. Simpson, D.D. (1981) Treatment for drug abuse: Followup outcomes and length of time spent. Arch. Gen. Psychiatry 38, 875-880. Simpson, D.D. and Lloyd, M.R. (1981) Alcohol use following treatment for drug addiction. J. Stud. Alcohol 42, 323 - 335. Weisner, C., The role of alcohol-related problematic events in treatment entry, presented at the 116th Annual Meeting of the American Public Health Association, Boston, November, 1988. Weisner, C., Drinking patterns and problems in health and social service agencies: Results from comparable epidemiological studies, presented at the 15th Annual Alcohol Epidemiology Symposium, Kettil Bruun Society for Social and Epidemiological Research on Alcohol, Maastricht, the Netherlands, June 11- 16, 1989. Weiss, R.D.. Mirin, S.M., Griffin, M.L. and Michael, J.L. (1988) A comparison of alcoholic and nonalcoholic drug abusers. J. Stud. Alcohol 49, 510-515.
problems
dependence
scale items
related
items
In the 12 months before you came to this program/jail have you: 1. Felt that you should cut down on your drinking or stop altogether? 2. Tried to cut down on your drinking but were unable to do so? 3. Gotten drunk when there was an important reason to stay sober?
5.
6. 7. 8. 9.
Awakened the next day not being able to remember some of the things you had done while drinking? Taken a drink first thing when you got up in the morning? Had your hands shake a lot in the morning after drinking? Stayed intoxicated for several days at a time? Been told to leave a place because of your drinking? Gotten into a physical fight because of your drinking?
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10. Been sick because of drinking (nausea, vomiting, severe headache, etc.)? In the 12 months before you came to this program/jail: 11. Did you find that you needed more alcohol than you used to, to get the same effect as before? 12. Did you take a drink intending to have just one or two and end up drunk? 13. Did your drinking interfere with your spare time activities or hobbies? 14. Did you try to limit your drinking to certain places and times so that you could keep it under control? 15. Did you feel you needed a drink so badly that you could not think of anything else? 16. Did you awaken during the night or early in the morning sweating all over because of drinking? II. Social, Legal and Health Consequences of Drinking In the 12 months before you came to this program/jail, did your drinking cause you difficulties with:
17. 18. 19. 20. 21.
Personal relationships? Your work? The police or other authorities? Your physical health? Your psychological health or mental well-being?
In the 12 months before you came to this program/jail: 22. Were you arrested for drunk driving? 23. Did the police pick you up for public drunkenness? 24. Did you have any serious arguments with family members or others close to you about your drinking or the effect your drinking was having on those around you? 25. Did your drinking cause any work problems that your boss complained about like missing work, making mistakes, or any other job problems? 26. Did a doctor or health worker tell you that you had serious problems connected with your drinking? 27. Have any of your friends, relatives or acquaintances said anything about your drinking or suggested you cut down?