Psychiatric histories of drug using mothers: treatment implications

Contingency management with community reinforcement approach or twelve-step facilitation drug counseling for cocaine dependent pregnant women or women with young children

BACKGROUND

Cocaine abuse among women of child-bearing years is a significant public health problem. This study evaluated the efficacy of contingency management (CM), the community reinforcement approach (CRA), and twelve-step facilitation (TSF) for cocaine-dependent pregnant women or women with young children.

METHODS

Using a 2×2 study design, 145 cocaine dependent women were randomized to 24 weeks of CRA or TSF and to monetary vouchers provided contingent on cocaine-negative urine tests (CM) or non-contingently but yoked in value (voucher control, VC). Primary outcome measures included the longest consecutive period of documented abstinence, proportion of cocaine-negative urine tests (obtained twice-weekly), and percent days using cocaine (PDC) during treatment. Documented cocaine abstinence at baseline and 3, 6, 9 and 12 months following randomization was a secondary outcome.

FINDINGS

CM was associated with significantly greater duration of cocaine abstinence (p<.01), higher proportion of cocaine-negative urine tests (p<0.01), and higher proportion of documented abstinence across the 3-, 6-, 9- and 12-month assessments (p<0.05), compared to VC. The differences between CRA and TSF were not significant for any of these measures (all p values ≥0.75). PDC decreased significantly from baseline during treatment in all four groups (p<0.001) but did not differ significantly between CM and VC (p=0.10) or between TSF and CRA (p=0.23).

INTERPRETATION

The study findings support the efficacy of CM for cocaine dependent pregnant women and women with young children but do not support greater efficacy of CRA compared to TSF or differential efficacy of CM when paired with either CRA or TSF.

The effects of sexual abuse as a child on the risk of mothers physically abusing their children: a path analysis using systems theory

OBJECTIVE

The potential path from sexual abuse as a child to the current risk of physical abuse by mothers was assessed. Ontogenic variables including the experience of the parent's sexual abuse as a child and current depression or substance abuse were expected to have a greater impact on the risk of child abuse than microsystem and exosystem variables such as family functioning, domestic violence, income, community safety, and social support.

METHOD

A path analysis using secondary data was conducted to examine these systemic impacts. The sample consisted of 265 women, the majority of whom were African-American with a high school education or GED. The majority of these women were employed, lower socio-economic status, and over 50% of the sample had never been married.

RESULTS

Sexual abuse as a child was found to impact maternal depression. Maternal depression and locus of control impacted risk of physical abuse. These two variables accounted for 22% of the variance in the dependent variable.

CONCLUSION

These findings indicate that it may not be the experience of sexual abuse itself that has an impact on a mother's risk of physical abuse, but rather whether she is able to resolve that trauma. Her locus of control appears to be important in this resolution. The majority of these women were low-income, urban African-American women; it may be important to focus on locus of control for this population.

Collaboration between child welfare and substance-abuse fields: combined treatment programs for mothers

OBJECTIVE

To review collaboration between child welfare and drug-abuse fields in providing treatment to mothers who abuse drugs and maltreat their children.

METHODS

Literature review of studies examining effects of maternal drug abuse on parenting skills and outcomes of interventions for both maternal drug abuse and parenting skills.

RESULTS

Parenting skills differ between mothers who do and do not abuse drugs, but these studies are primarily limited to mothers of infants and preschoolers. The evidence base for interventions to address both substance use and parenting in these mothers is growing, but more well-controlled studies are needed. Opportunities for improved collaboration between fields are presented.

CONCLUSION

Progress has been made toward collaboration to address drug abuse and parenting skills of mothers who abuse drugs, but more integrated strategies are needed, especially for mothers who use drugs and maltreat their children.

Changes in quality of life for pregnant women in substance user treatment: developing a quality of life index for the addictions

Using preference weights from a community sample, items from the Addiction Severity Index (ASI) were converted into a quality of life index (QOLI) and used to compare the cost-effectiveness of five addiction treatment modalities for pregnant women.

METHODS

Interviews using the time trade-off methodology were conducted with 143 members of Massachusetts local health planning boards to determine preference weights for different health states resulting from active addiction. A multi-attribute utility formula was used to convert these seven preference weighted scores into a single QOLI. To apply the QOLI, these preference weights were combined with the number of problem days reported in each ASI domain by a sample of 439 pregnant women in MA in five treatment modalities, 1992-1996.

RESULTS

Starting at 10 years with an addiction problem, board members indicated that they would give up between 0.83 and 3.96 years to avoid the problems in one domain caused by addiction. The average QOLI was 0.68 at intake but increased by 0.19 points by 6-month follow-up to 0.87. All five treatment groups showed notable improvement in their quality of life. Mean improvements ranged from a high of 0.23 QOLIs for clients who received both residential and outpatient treatment to a low of 0.16 for clients who received only detoxification. Treatment costs ranged from 10,187 dollars for residential and outpatient combined to 2535 dollars for detoxification only, with costs per QOLI ranging from 14,912 dollars to 44,291 dollars.

CONCLUSIONS

Although this QOLI could benefit from further refinement and development, it showed promise as a single outcome measure for CEAs in the chemical dependency field. This QOLI was sensitive enough to distinguish between the treatment groups, it correlated well with other outcome measures and can be easily converted from the ASI using spreadsheet software and a simple formula.

Treatment readiness among out-of-treatment African-American crack users

Crack cocaine use is linked to high rates of HIV and other sexually transmitted infections, as well as violence and criminal activity. Substance abuse treatment can play an important role in reducing drug use and related problems. However, many crack users do not want treatment, and those who do often encounter significant obstacles to access. This study compares 216 out-of-treatment African-American crack users who reported wanting to enter treatment with 129 who did not want treatment. In bivariate analyses, participants wanting treatment in the next 30 days were more likely to report needing help with medical care, daily crack use, physical abuse, transportation issues, and legal pressure to enter treatment. Predictors of treatment readiness in multiple logistic regression analysis included gender, daily crack use, legal pressure, depression, and problem recognition. Fear of physical abuse and previous treatment admissions were associated with decreased odds of wanting treatment. The many unmet needs reported by crack users motivated for treatment suggest that treatment entry and retention could be facilitated by pretreatment and more comprehensive and ancillary treatment services.

Methamphetamine use behaviors and gender differences

This analysis describes methamphetamine (MA) use behaviors in a broad cross-section of (N=350) former clients from a large publicly funded treatment system and examines differences between males and females in drug use history, MA initiation and motivators, MA-related problems, acquisition, distribution, manufacture, and treatment characteristics. Results show polydrug use, prolonged MA use before treatment, initiation primarily through friends, common sensation-seeking motivators (to have fun, get high, and experiment), numerous problems related to MA use (including paranoia, violent behavior, hallucinations, financial problems, and legal and work problems), and a majority who have sold MA. Gender differences appear in selected aspects of motivators and routes of initiation, access to MA, use patterns, and MA-related problems. Such description of behaviors and gender differences can provide a basis for development of treatment strategies and points of departure for future research.

Severity of substance abuse and psychiatric problems among perinatal drug-dependent women

The present study assessed 108 women enrolled in a residential treatment program for perinatal substance abusers in order to examine possible subtypes based on current alcohol, other drug and psychiatric problem severity. Most participants were African-American (81%), unmarried (91%), unemployed (97%), high school graduates (63%) with a mean age of 30 years. The primary substances of abuse were cocaine/crack (87%) and opiates (9%). The majority (79%) of subjects were also nicotine dependent. Drug severity did not distinguish between these groups; however, when cluster analysis was applied to ASI alcohol and psychiatric composite scores, three clusters emerged: (1) high alcohol, drug, and psychiatric problem severity (57%); (2) high drug and psychiatric problem severity (20%); and (3) high drug severity only (23%). Neither current nor childhood demographic characteristics differed among the three groups. However, significant differences were found among selected childhood risk factors, including perceived quality of relationships with family, age of onset of substance use, childhood abuse history, and family history of mental illness. These results emphasize the need for careful assessment and treatment planning that addresses the unique needs of these women.

Maternal cocaine use: estimated effects on mother-child play interactions in the preschool period

The study objective was to evaluate the quality of parent-child interactions in preschool-aged children exposed prenatally to cocaine. African-American mothers and their full-term newborns (n = 343) were enrolled prospectively at birth and classified as either prenatally cocaine-exposed (n = 157) or non-cocaine-exposed (n = 186) on the basis of maternal self-report and bioassays. Follow-up evaluations at 3 years of age (mean age, 40 mo) included a videotaped dyadic play session and maternal interviews to assess ongoing drug use and maternal psychological distress. Play interactions were coded using a modified version of Egeland et al's Teaching Task coding scheme. Regression analyses indicated cocaine-associated deficits in mother-child interaction, even with statistical adjustment for multiple suspected influences on interaction dynamics. Mother-child interactions were most impaired in cocaine-exposed dyads when the mother continued to report cocaine use at the 3-year follow-up. Multivariate profile analysis of the Egeland interaction subscales indicated greater maternal intrusiveness and hostility, poorer quality of instruction, lower maternal confidence, and diminished child persistence in the cocaine-exposed dyads.

Screening for substance use in pregnancy: a practical approach for the primary care physician

Our goal was to identify risk factors for substance use during pregnancy for primary care physicians so that we could assess a woman's risk of alcohol or illicit drug use. Participants were 2002 Medicaid-eligible pregnant women with < or =2 visits to prenatal care clinics in South Carolina and Washington State. Structured interviews were used to collect data. Logistic regressions and classification and regression trees identified predictors for pregnant women at high risk for substance use. Approximately 9% of the sample reported current use of either drugs or alcohol or both. Past use of alcohol or cigarettes, including during the month before pregnancy, most differentiated current drug or alcohol users from current nonusers. Our analysis suggests that primary care physicians can ask 3 questions in the context of a prenatal health evaluation to target women for referral to a full clinical assessment for drug and alcohol use.

Substance use during pregnancy in the state of California, USA

Most analyses of prenatal substance use focus on individual level correlates and ignore community level variables and the effect of the dependency of respondents within communities. This analysis uses multilevel logistic regression models to more accurately assess the correlates of perinatal substance use in California. Statistical results indicate that a significant portion of substance use can be attributed to neighborhood heterogeneity, and that traditional models of substance use may inaccurately attribute this variation to individual level regression coefficients. Substantive results indicate that levels of neighborhood public assistance had an independent, significant effect on the prevalence of all substances tested for except alcohol. Black women had higher predicted prevalence risks for alcohol and cocaine while White women had higher predicted risks for tobacco, marijuana and amphetamines. Racial contrasts were non-significant for the overall illicit drug category and opiates, after controlling for neighborhood public assistance. Finally, individual level variables, with the exception of age, were not moderated by levels of neighborhood public assistance.

I Didn't Know: Discoveries and Identity Transformation of Women Addicts in Treatment

The purpose of this research was to study the efficacy of gender-sensitive substance abuse treatment programs with a focus on the perceptions of women addicts. Based on semi-structured in-depth interviews and observation of treatment groups, an analysis of the women's stories about their lives revealed transformations in their identities. These identity transformations were based on self-discoveries made during treatment that included realizations about their addiction, emotional well-being, and parenting. An analysis of their discoveries shows compliance and resistance to institutional socialization. Just as surely as the women addicts accepted the institutional socialization, they also resisted, pushed, and pulled at it, reminding us that they are not automatons of social and institutional forces.

Domestic violence and childhood sexual abuse in HIV-infected women and women at risk for HIV

OBJECTIVES

The purpose of this study was to determine the prevalence and effect of domestic violence and childhood sexual abuse in women with HIV or at risk for HIV infection.

METHODS

Participants with HIV or at risk for HIV infection enrolled in the Women's Interagency HIV Study. Childhood sexual abuse; all physical, sexual, and coercive violence by a partner; HIV serostatus; demographic data; and substance use and sexual habits were assessed.

RESULTS

The lifetime prevalence of domestic violence was 66% and 67%, respectively, in 1288 women with HIV and 357 uninfected women. One quarter of the women reported recent abuse, and 31% of the HIV-seropositive women and 27% of the HIV-seronegative women reported childhood sexual abuse. Childhood sexual abuse was strongly associated with a lifetime history of domestic violence and high-risk behaviors, including using drugs, having more than 10 male sexual partners and having male partners at risk for HIV infection, and exchanging sex for drugs, money, or shelter.

CONCLUSIONS

Our data support the hypothesis of a continuum of risk, with early childhood abuse leading to later domestic violence, which may increase the risk of behaviors leading to HIV infection.

An exploratory attempt to distinguish subgroups among crack-abusing African-American women

Despite the significant emergence of research on female addiction over the last two decades, specific research on African-American women substance abusers, particularly crack cocaine users, is limited. The identification of meaningful subgroups of substance abusing populations, particularly minority women is important both clinically, and because of their over-representation in the epidemiological data on crack cocaine use in many urban centers across this country. An extensive battery of instruments was administered to 110 women entering treatment in an intensive outpatient substance abuse treatment program in Philadelphia, serving women who are primarily indigent, African-American, and whose primary substance of abuse is crack cocaine. Factor analysis and cluster analysis procedures were utilized to classify women into subgroups across relevant clinical, behavioral, and background concerns relevant to studying substance abusing populations. Five conceptually meaningful subgroups emerged which classified women across various indicators such as HIV sex risk factors, personality traits/Axis II dimensions, clinical syndromes, psychological symptomatology, lifetime and recent drug and alcohol use, prior physical and sexual abuse, and social context variables such as parental addiction, and whether they live with a substance abuser. Attempts to classify women into identifiable clinical subtypes is essential in order to better inform treatment initiatives designed to serve this group, as well as prevention and community outreach intervention strategies which attempt to bring them into treatment.

Gender differences in homeless persons with schizophrenia and substance abuse

The purpose of this study was to test the generalizability of previous research on gender differences between men and women with co-occurring schizophrenia and substance abuse. One hundred eight patients with schizophrenia or schizo-affective disorder involved in a study of treatment for homeless persons were interviewed for information regarding substance use, social functioning and support, comorbid disorders, victimization, medical illness, and legal troubles. We found that women had more children and were more socially connected than men. Women also had higher rates of sexual and physical victimization, comorbid anxiety and depression, and medical illness than men. We conclude that homeless women with dual disorders, like women with substance use disorders in the general population, have distinct characteristics, vulnerabilities, and treatment needs compared with men. In addition to comprehensive treatment of psychiatric and substance use disorders, gender-specific services should be developed, including prevention and treatment of victimization and related problems as well as help with accessing medical services.

Types of abuse and cocaine use in pregnant women

Previous research has found an association between childhood and adult physical and sexual abuse and substance abuse, but has not examined or compared specific dimensions of the abuse experience, such as its age of onset or the type, severity, or frequency. Women receiving perinatal care (N = 1189) at an inner-city hospital clinic were systematically questioned about their lifetime and current cocaine use and experiences of abuse. We found an association between a history of abuse in childhood and lifetime and current cocaine use, as well as physical and sexual abuse during childhood and pregnancy. There was no difference in the rates of cocaine use between women whose onset of abuse was in childhood versus adulthood. Childhood sexual abuse (alone or in combination with physical abuse) was more associated with lifetime cocaine use than was physical abuse alone. Cocaine use was related to the severity, but not the frequency of abuse.

Drug Use during Pregnancy

Prevention and intervention services for pregnant, drug-using women have often developed prior to gaining empirical data on the antecedents of prenatal drug use. These data are important to address some of the underlying factors of drug use during pregnancy. A review of the literature indentified at least six categories of psychosocial risk factors that have been investigated as relevant to drug use among women, including pregnant women. These factors include: (1) history of childhood sexual abuse, (2) family history of alcohol or drug problems, (3) male partner's alcohol or drug use, (4) current depression, (5) social support, and (6) homelessness or transiency. An examination of these psychosocial risk factors indicates that the existing literature on these factors in drug use is limited by a lack of methodological rigor, resulting in large variations in prevalence rates due to factors such as definition. This paper summarizes the existing literature and methodological iussues regarding the relation between psychosocial risk factors and drug use among women, including pregnant women. It also discusses some of the limitations and issues in assessing prenatal drug use with a particular focus on self-report and urine toxicologies.

The impact of outpatient drug services on abstinence among pregnant and parenting women

Although there is an increasing number of outpatient drug programs, there remains little consensus on which service components are most effective for pregnant and parenting women seeking treatment. In this investigation, we studied 48 women who remained in treatment for 5 consecutive months to: (1) examine differences between clients who maintained 30 to 90 days of abstinence and those who did not and (2) test the association between services and abstinence. Although we found no demographic differences between abstinent and nonabstinent women, we did find that significantly more abstinent women received family therapy services compared to nonabstinent women as they remained in treatment. Furthermore, we found that clients who were abstinent tended to receive more services overall than those who were not. Providers need to consider their population when deciding on which service components will be included: and family therapy is one service component that should be available to pregnant and parenting women.