Substance Use & Misuse, 49:1784–1794, 2014 C 2014 Informa Healthcare USA, Inc. Copyright ISSN: 1082-6084 print / 1532-2491 online DOI: 10.3109/10826084.2014.931972
ORIGINAL ARTICLE
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Characteristics of a Treatment-Seeking Population in Outpatient Addiction Treatment Centers in Mexico 1 ˜ 1 , Angelica ´ ´ Rodrigo Mar´ın-Navarrete1 , Liliana Templos-Nunez Eliosa-Hernandez , 1 1 1 ´ ´ , Alejandro Perez-L ´ ´ on opez , Luis Villalobos-Gallegos , Jose´ Fernandez-Mondrag 1 ´ , Rosa E. Verdeja2 , Elizabeth Alonso2 , Daniel J. Feaster2 Diana Galvan-Sosa and Viviana E. Horigian2 1
Clinical Trials Unit on Addiction and Mental Health, Instituto Nacional de Psiquiatr´ıa Ram´on de la Fuente, Mexico City, Mexico; 2 Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami FL important characteristics to take into account when planning treatment as they facilitate tailoring treatment to meet patients’ needs.
Background: Baseline patients’ characteristics are critical for treatment planning, as these can be moderators of treatment effects. In Mexico, information on treatment seekers with substance use disorders is scarce and limited to demographic characteristics. Objective: This paper presents and analyses demographic characteristics, substance use related problems, clinical features, and addiction severity in a sample of treatment seekers from the first multi-site randomized clinical trial implemented in the Mexican Clinical Trials Network on Addiction and Mental Health. Methods: A total of 120 participants were assessed prior randomization. Chi square or F-tests were used to compare sites across variables. Spearman correlation was used to associate negative consequences of substance use and motivation to change. Results: The majority of participants were men, and the most prevalent substances reported were alcohol, marijuana, and cocaine. Participants were predominantly on the contemplation or action stage of change, and this was correlated with the perception of the negative consequences associated with substance use. Participants reported a high prevalence of substance use related problems. Conclusions: Substance use related problems, clinical features, and addiction severity reported by treatment seekers are
Keywords Treatment seekers, outpatient treatment, substance use disorders, addiction severity
BACKGROUND
Drug related problems in Mexico have increased in recent years, shifting from a country with low use rates to an advanced market with a continuous escalation in the number of people with substance use disorders that require help (Medina-Mora & Real, 2013). Data from the Mexican National Addiction Survey of 2011 indicates that the prevalence of substance use significantly increased in the period from 2002 to 2011; meanwhile, only a small percentage of the substance using population seeks and receives specialized treatment (Secretar´ıa de Salud [SSA], 2012). This finding is consistent with the worldwide problem of people with mental health and substance use disorders facing serious access barriers to adequate care services (Becker & Kleinman, 2013; World Health Organization, 2013). The documented access barriers and lack of adequate services in Mexico (Galvan & Mar´ın-Navarrete, 2010; Rojas, Real, Garc´ıa-Silberman & Medina-Mora, 2010)
A special acknowledgment for their institutional support in this study: Consejo Nacional Contra las Adicciones (CONADIC), Centro Nacional para la Prevenci´on y el Control de las Adicciones (CENADIC), National Institute on Drug Abuse-Clinical Trials Network (NIDA-CTN). A special acknowledgment for their institutional and active contribution in this study: Cl´ınica de Trastornos Adictivos of the INPRFM, Centros de Integraci´on Juvenil A. C. (CIJ), Consejo Estatal contra las Adicciones of Puebla (CECAP). This publication stems from the project “Development of a Clinical Trial Network on Addiction and Mental Health in Mexico” funded by a grant from the U.S. Department of State (Grant No. SINLEC11GR0015). The U.S. Department of State had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication. Clinical Trial Registration: ISRCTN registry No. ISRCTN91657311. Address correspondence to Rodrigo Mar´ın-Navarrete, PhD, Clinical Trials Unit on Addiction and Mental Health, Instituto Nacional de Psiquiatr´ıa Ram´on de la Fuente, Clz. M´exico-Xochimilco #101, Col. San Lorenzo Huipulco, Deleg. Tlalpan, Mexico City 14370, Mexico; E-mail: [email protected]
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TREATMENT-SEEKING POPULATION IN OUTPATIENT ADDICTION TREATMENT CENTERS IN MEXICO
translate into an increase in drug use related problems, such as violence, co-occurring medical and psychiatric disorders, sexually transmitted diseases and criminal behavior, which place a burden not only on the country’s public health (Mar´ın-Navarrete, Eliosa-Hern´andez et al., 2013; Ort´ız, Mart´ınez & Meza, 2012; Revuelta & Salcedo, 2013; SSA, 2012) but also on the substance user’s families (Biegel, Ishler, Katz & Johnson, 2007; Mattoo, Nebhinani, Anil Kumar, Basu & Kulhara, 2013). Mexico has addressed these increasing substance use problems with three different sources of treatment services. The first one is represented by the public sector with over 400 outpatient care centers and approximately 30 inpatient treatment units. Many of these public centers represent one of two major national addiction treatment institutions in Mexico, the Centros de Integraci´on Juvenil (CIJ) and the Centro Nacional para la Prevenci´on y el Control de las Adicciones (CENADIC) and a minority is represented by other public care institutions throughout the country. The second source of treatment services is represented by professional private health services, which are generally too expensive for the majority of the population. The last source is composed by traditional self-help groups (e.g., AA or other 12-step-programs) with almost 20,000 groups throughout the country and 2,291 mutual-aid residential centers, which are based on the 12-step philosophy where only a few have integrated medical and psychological assistance (CONADIC, CENADIC & CICAD-OEA, 2011; Mar´ın-Navarrete, Benjet et al., 2013). While there are several treatment service options available for the population, currently the substance abuse treatment field in Mexico faces many challenges, which include the strengthening of translational research to deliver effectively evidence-based practices to patients and the development of more personalized treatments that respond to patient needs and include care for co-occurring psychiatric disorders and other social problems (MedinaMora, Real, Villatoro & Natera, 2013). Information about population that attends services for treatment of substance use disorders is critical to respond to patient needs. These patient characteristics could mediate and or moderate treatment effects and therefore should play a major role in clinical decision-making and program development (Kalapatapu et al., 2013; McClure, Acquavita, Dunn, Stoller & Stitzer, 2014). However, in Mexico information available on these patients is generally limited to demographic characteristics and substance and alcohol use without taking into account related problems (mental and psychological condition and traumatic events) and clinical features (motivation to seek treatment, previous treatments, stage of change and social and personal consequences of substance use). OBJECTIVE
This paper addresses this problem analyzing the baseline data: demographic characteristics, substance use characteristics, related problems, clinical features, and addic-
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tion severity of participants from a multi-site randomized clinical trial that tested an adaptation of CTN 0021: Motivational Enhancement Treatment for Spanish Speakers (METS; Carroll et al., 2009) for the Mexican population (Intervenci´on de Incremento Motivacional or IIM). This was the first trial implemented in the Mexican Clinical Trials Network on Addiction and Mental Health (REC-INPRFM, acronym for the Spanish name; Mar´ınNavarrete, 2012; Horigian et al., unpublished results). Also this paper identifies possible priorities for future research and treatment program design. METHOD Participants and Sites
The trial was conducted in three outpatient addiction treatment centers, two of which were located in Mexico City and a third in the city of Puebla. This study analyzed the baseline characteristics of the 120 participants that were randomized in the trial. Inclusion criteria were: age between 18 and 65 years, seeking outpatient treatment for any substance use, any substance within the 28 days prior to treatment admission, having a stable living arrangement and planning to live near the treatment center during the duration of trial participation. Exclusion criteria were: dementia or other organic brain syndromes, suicidal or homicidal ideation or behavior, legal status that could result in incarceration, seeking detoxification, opioid maintenance treatment or residential inpatient treatment. The Ethics and Research committee of participating institutions approved the trial, and subjects were consented prior participation. Measures
A trained and certified research assistant performed all trial assessments at each of the participating sites. The following self-report and interview measures were administered at baseline, prior to randomization and treatment exposure. Composite International Diagnostic Interview (CIDI). The CIDI is a standardized interview that assesses mental disorders in adults according to ICD-10 and DSM-IV criteria. It provides diagnoses as reported by the patient (lifetime, 12 months and 30 days prior the interview). For this trial, only the substance use disorders module was used ¨ un, (Haro et al., 2006; Kessler et al., 2004; Kessler & Ust¨ 2004). Addiction Severity Index Lite (ASI-Lite). The ASI is a semi-structured face-to-face interview conducted by clinicians and researchers. The ASI covers the following areas: medical, employment/support, drug and alcohol use, legal, family/social, and psychiatric. The ASI obtains lifetime information about problem behaviors, as well as problems within the previous 30 days (McLellan et al., 1992). The ASI-Lite is a research version based on ASI 5th edition, and has 59 less questions. Composite scores were calculated following the ASI scoring manual (McGahan, Griffith, Parente, & McLellan, 1986). In the ASI, each composite score is the sum of answers to several questions
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R. MAR´IN-NAVARRETE ET AL.
within a problem area, and equal weighting is attributed to all questions within a composite score. Possible values on the composite score range from zero to one. Treatment Attitudes and Expectation Form (AEQ). The AEQ is a 36-item scale that inquires about reasons for entering treatment and preferences in counseling (Elkin, Parloff, Hadley & Autry, 1985). The version that was used for the study was adapted from the MATCH project (Project MATCH Research Group, 1997) and a CSAT Methamphetamine Treatment Project (Huber et al., 2000). Short Inventory of Problems Revised (SIP-R). The SIPR is a 17-item modified scale taken from the Drinker Inventory of Consequences (DrINC) (Miller et al., 1992). This measure assesses the patient’s perception of adverse consequences of his/her substance use in a period of 3 months prior to the assessment date. This scale has a good internal consistency (alpha = 0.96) and showed to have construct validity through correlations with scores from the ASI (Kiluk et al., 2013). Scores higher than mean for each negative consequence were classified as “problem” in this study. All other scores (lower than mean) were classified as “no problem.” University of Rhode Island Change Assessment Scale (URICA). The URICA is a 32-item scale assessing client readiness to change substance use behavior. It is composed by 4 subscales measuring stages of change according to the transtheoretical model: precontemplation, contemplation, action, and maintenance (McConnaughty et al., 1983). These subscales account for 58% of the variance and Cronbach’s coefficient alphas range from 0.88 to 0.89 (McConnaughty et al., 1983). The URICA readiness score was determined by summing the scores on contemplation, action, and maintenance subscales, and subtracting the precontemplation subscale score from that sum (Blanchard, Morgenstern, Morgan, Labouvie & Bux, 2003). Statistical Analysis
We used either χ 2 or F tests to compare sites across variables. A P-value of less than 0.05 was considered significant. Spearman correlation was used to associate negative consequences of substance use and motivation to change. Analyses were conducted using SPSS version 19. RESULTS Demographic Characteristics
The baseline demographic characteristics show varied significant differences among sites, particularly on years of education and employment pattern. Most participants reported having full time employment during the past three years but fewer reported full time employment in the 30day period prior the interview (see Table 1). Substance Use Characteristics
According to CIDI criteria, half of the participants had alcohol dependence (50%) while almost half of the sample had drug dependence (45.8%). There were significant sta-
tistical differences in drug abuse and dependence across sites; the highest rate of drug dependence was found in Site 1 while Site 2 had the highest percentage of drug abuse (see Table 2). Participant main substance of use and years of use varied significantly among sites. For Site 3 the most reported main substance of use was alcohol while for Site 1 was alcohol as well as cocaine and for Site 2, it was cannabis. There were statistical differences across sites in the number of years using heroin, cocaine, cannabis, alcohol to intoxication and more than one substance per day. Regarding substance use during lifetime, cannabis (42.5%) was most reported. There was a statistical difference between the routes of administration of cocaine (χ 2 = 24.900, gl = 6; p ≤ 0.001). The principal routes of administration in the three sites were smoking (34.2%) and intranasal (16.7%), but in Site 3 there was a participant that had reported an injecting route of administration of cocaine. Related Problems
Levels of perceived mental and psychological conditions were quite high in the overall sample. Although differences in depressive symptoms across the three sites were marginal, there were statistically significant differences in lifetime anxiety, hallucinations, suicide attempts, and prescribed medications for emotional or psychological problems, with Site 1 showing the highest prevalence of these conditions in comparison with the other two sites (see Table 3). Physical abuse during lifetime was very common (39.2%) in the study sample, with 9.2% reporting physical abuse in the past 30 days. Site 3 showed significantly higher lifetime sexual abuse than other sites (see Table 4). Clinical Features
In general, the main motivation for seeking treatment was family (82.5%), followed by emotional (80%) and medical reasons (64.2%). Comparisons between sites in economic problems as a reason to seek treatment displayed significant differences (χ 2 = 6.593, p = .037); also participants of Site 2 had legal reasons to seek treatment more often compared with Site 1 and 3 (χ 2 = 8.089, p = .018) (see Table 5). Participants in Site 3 reported significantly more hospitalizations for emotional or psychological problems in the 30-day period prior the assessment than participants in the other two sites (see Table 6). According to URICA scores, most participants were in the contemplation stage (57.3%) followed by the action stage (36.8%). Only 6% of participants in all three sites were in the pre-contemplation stage. Taking into account percentages by site, most participants in Sites 1 and 3 were in the contemplation stage (52.3% and 76.3%, respectively) while in Site 2 most were in the action stage (45.7%). According to SIP-R scale, at least 69.2% of participants perceived negative consequences of their substance use. Most of the participants reported interpersonal problems
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TREATMENT-SEEKING POPULATION IN OUTPATIENT ADDICTION TREATMENT CENTERS IN MEXICO
TABLE 1. Demographic characteristics by site Site 1 n = 44
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Mean or %
Site 2 n = 38
SD
Age 31.4 9.8 Years of Education 10.8 3.6 Gender Male 86.4 Female 13.6 Marital Status Married/Cohabiting 27.3 Separated/Divorced 18.2 Never Married 54.5 Usual Employment Pattern (Past 3 Years) Full time (35 hrs/wk) 56.8 Part time (regular hours) 11.4 Part time (irregular, day 13.6 work) Student 18.2 Homemaker 0 Unemployed 0 Usual Employment Pattern (Past 30 Days) Full time (35 hr/wk) 29.5 Part time (regular hours) 9.1 Part time (irregular, day 9.1 work) Student 13.6 Retired/Disability 0 Homemaker 0 Unemployed 38.6
Site 3 n = 38
Total N = 120
Mean or %
SD
Mean or %
SD
Mean or %
SD
28.5 11.5
9.05 2.44
30.1 9.6
8.6 2.5
30.1 10.6
9.2 3.0
89.5 10.5
71.1 28.9
Significance between groups F(2,118) = 1.02, p = .36 F(2,118) = 4.04, p = .02 χ 2 (2) = 5.18, p = .08
82.5 17.5 χ 2 (8) = 4.67, p = .79
21.1 21.1 57.9
23.7 18.4 57.9
24.2 19.2 56.7 χ 2 (10) = 23.37, p = .009
39.5 18.4 7.9
50 15.8 5.3
49.2 15 9.2
31.6 0 2.6
7.9 7.9 13.2
19.2 2.5 5 χ2
26.3 15.8 18.4
28.9 15.8 10.5
28.3 13.3 12.5
21.1 2.6 0 15.8
10.5 0 2.6 31.6
15 0.8 0.8 29.2
(62.5%), followed by social and physical ones (52.5% and 51.7%, respectively). The proportion of participants who perceived negative consequences of substance use was similar between sites. The Spearman correlation showed a positive association between all negative consequences of substance use and motivation to change. Intrapersonal, social and interpersonal consequence sub-scales from SIP-R showed a moderate association with motivation to change stage scores in the URICA (see Table 7). Addiction Severity Index (ASI-lite)
Through one-way ANOVA analysis, conducted between all sites, areas that showed to have higher levels of severity were employment, family/social, and psychiatric. But the areas that showed significant differences between sites were drug, legal, and psychiatric composite scores (see Table 8). DISCUSSION
This analysis presents relevant information on demographic characteristics, substance use characteristics, clinical features, related problems and addiction severity of treatment-seeking patients from three centers for treatment of substance use disorders. As expected, overall,
(12)
= 12.18, p = .43
there were more men than women in the sample in concordance with Mexican epidemiological reports that point out that more men attend treatment than women (SSA, 2012). This continues to be of concern as the Mexican National Survey on Addiction (SSA, 2012) revealed an increase in the prevalence of substance use in women, underscoring the need for better outreach strategies to engage women into treatment, and to provide gender specific treatment opportunities (Galvan & Mar´ın-Navarrete, 2010). Results on main substance of abuse were also concordant with literature, having alcohol, marijuana, and cocaine the most reported main substance in that order; which are also the most reported substances in the National Addiction Survey (SSA, 2012). Differences across sites were relevant, with alcohol being the most reported substance in Site 3, which was a primary care addiction center; whereas in Site 2, which included the youngest patients, marijuana was the most reported; and cocaine and alcohol in Site 1, which also had the patients with highest percentage of mental health problems and more severity of addiction. These findings indicate meaningful differences in population characteristics and drug of choice across treatment settings. In the overall sample, we found that 27.5% patients didn’t present any diagnostic criteria for drug abuse or dependence; and 16.7% had no alcohol abuse or
R. MAR´IN-NAVARRETE ET AL.
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TABLE 2. Substance Use characteristics by site Site 1 n = 44
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Mean or % SUD Diagnostics (from CIDI) Alcohol Abuse 36.36 Alcohol Dependence 56.82 Drug Abuse 20.45 Drug Dependence 63.64 Main Substance of use Alcohol 31.8 Cannabis 29.5 Cocaine 31.8 Inhalants 4.5 Others 2.3 Substance use (Years) Alcohol (Any Use) 13.11 Alcohol (to 7.41 intoxication) Heroin 0 Methadone 0 (prescribed) Methadone (illicit) 0 Other 0.02 opiates/Analgesic Barbiturates 0 Other Sedatives/ 0.59 Hypnotics/ Tranquilizers Cocaine 4.91 Amphetamines/ 0.5 Methamphetamines Cannabis 6.45 Hallucinogens 0.91 Inhalants 0.89 More than 1 Substance 5.86 per day Nicotine 10.07 Substance Use (Lifetime) Heroin 15.9 Methadone 0 (prescribed) Methadone (illicit) 0 Other 9.1 opiates/Analgesic Barbiturates 0 Other Sedatives/ 25 Hypnotics/ Tranquilizers Cocaine 18.2 Amphetamines/ 31.8 Methamphetamines Cannabis 25 Hallucinogens 38.6 Inhalants 34.1 Nicotine 4.5
Site 2 n = 38
SD
8.2 7.75
Mean or %
Site 3 n = 38
SD
Mean or %
Total N = 120
SD
Mean or %
39.47 34.21 44.74 36.84
23.68 57.89 15.79 34.21
33.33 50 26.67 45.83
21.8 39.5 34.2 5.3 0
60.5 15.8 5.3 7.9 10.5
37.5 28.3 24.2 5.8 4.2
11.34 2.11
8.69 4.2
SD
Significance between groups χ 2 (2) χ 2 (2) χ 2 (2) χ 2 (2) χ 2 (8)
= 2.419, p = .298 = 5.555, p = .062 = 9.512, p = .009 = 8.922, p = .012 = 26.64, p < .001
11.84 4.37
8.17 6.26
12.15 4.77
8.31 6.66
F(2,118) = 0.497, p = .610 F(2,118) = 7.266, p = .001
0 0
0 0
0 0
0.47 0.11
1.7 0.65
0.15 0.03
0.98 0.37
F(2,118) = 3.171, p = .046 F(2,118) = 1.080, p = .343
0 0.15
0 0.42
0 2.6
0 0
0 0
0 0.14
0 1.46
—— F(2,118) = 1.017, p = .365
0 1.52
0 0.68
0 2.62
0 0.21
0 0.99
0 0.5
0 1.82
—— F(2,118) = 0.727, p = .485
6.43 1.37
3.89 0.08
5.93 0.36
0.87 0.11
2.71 0.52
3.31 0.24
5.58 0.92
F(2,118) = 6.141, p = .003 F(2,118) = 2.800, p = .065
7.53 3.05 4.59 6.52
4.16 0.42 1.45 5.34
5.98 1.98 3.6 7.03
2.66 0.16 0.42 1.95
5.48 0.68 1.15 3.5
4.53 0.52 0.92 4.46
6.59 2.2 3.5 6.13
F(2,118) F(2,118) F(2,118) F(2,118)
7.42
8.66
9.06
8.87
9.25
9.24
8.51
F(2,118) = 0.330, p = .720
= 3.619, p = .030 = 1.251, p = .290 = 0.818, p = .444 = 5.070, p = .008
5.3 0
21.1 2.6
14.2 0.8
χ 2 (2) = 4.069, p = .131 χ 2 (2) = 2.176, p = .337
0 7.9
2.6 5.3
0.8 7.5
χ 2 (2) = 2.176, p = .337 χ 2 (2) = 0.443, p = .801
0 7.9
0 23.7
0 19.2
—– χ 2 (2) = 4.583, p = .101
31.6 21.1
47.4 15.8
31.7 23.3
χ 2 (2) = 8.027, p = .018 χ 2 (2) = 3.090, p = .213
36.8 44.7 21.1 2.6
68.4 21.1 23.7 60.5
42.5 35 26.7 21.7
χ 2 (2) = 16.460, p = .000 χ 2 (2) = 5.089, p = .079 χ 2 (2) = 2.025, p = .363 χ 2 (2) = 49.522, p = .000
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TREATMENT-SEEKING POPULATION IN OUTPATIENT ADDICTION TREATMENT CENTERS IN MEXICO
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TABLE 3. Mental and Psychological condition in the past 30-days and Lifetime (from ASI-lite) Site 1 n = 44 %
Site 2 n = 38 %
Site 3 n = 38 %
Total N = 120 %
43.2 70.5 2.3 77.3
52.6 57.9 0.0 57.9
39.5 68.4 2.6 55.3
45.0 65.8 1.7 64.2
34.1 9.1 0.0 54.5
21.1 0.0 0.0 5.3
31.6 13.2 0.0 18.4
29.2 7.5 0.0 27.5
χ 2 (2) = 1.83, p = .40 χ 2 (2) = 4.10, p = .08 ——— χ 2 (2) = 27.14, p ≤ .001
84.1 88.6 13.6 84.1
71.1 55.3 2.6 44.7
73.7 73.7 0.0 50
76.7 73.3 5.8 60.8
χ 2 (2) = 2.21, p = .33 χ 2 (2) = 11.62, p = .003 χ 2 (2) = 7.94, p = .02 χ 2 (2) = 15.99, p ≤ .001
59.1 40.9 31.8 40.9
34.2 21.1 7.9 7.9
39.5 60.5 31.6 34.2
45.0 40.8 24.2 28.3
χ 2 (2) = 5.79, p = .055 χ 2 (2) = 12.25, p = .002 χ 2 (2) = 8.04, p = .018 χ 2 (2) = 11.89, p = .003
Past 30 days Depression Anxiety Hallucinations Trouble understanding, concentrating, or remembering Trouble controlling violent behavior Serious thoughts of suicide Attempted suicide Prescribed medication for any psychological/emotional problems Lifetime Depression Anxiety Hallucinations Trouble understanding, concentrating, or remembering Trouble controlling violent behavior Serious thoughts of suicide Attempted suicide Prescribed medication for any psychological/emotional problems
dependence. This allows us to think that a percentage of treatment seekers in this study were experimental users. Regarding employment, the decrease in percentages of full-time employment leading up to treatment initiation, the relatively high percentage of unemployment in the 30days prior the interview and ASI scores in the employment composite measure suggest that job loss may be related to
Significance between groups χ 2 (2) χ 2 (2) χ 2 (2) χ 2 (2)
= 1.42, p = .49 = 1.60, p = .45 = 0.96, p = .62 = 5.25, p = .07
substance use, and also may have had an impact on seeking treatment. Substance use has an impact on productivity, access to work opportunities, and capacity to keep a stable job, which in turn impacts the economy of the patients (Kessler & Frank, 1997; WHO, 2012; WHO, 2013). This may point towards the need to implement interventions aimed at the development of employment skills.
TABLE 4. Traumatic Events in the 30 days and Lifetime (from ASI-lite)
Physical abuse past 30 days Physical abuse lifetime Sexual abuse past 30 days Sexual abuse lifetime
Site 1 n = 44 %
Site 2 n = 38 %
Site 3 n = 38 %
Total N = 120 %
Significance between sites
6.8 40.9 4.5 11.4
10.5 34.2 0.0 0.0
10.5 42.1 2.6 23.7
9.2 39.2 2.5 11.7
χ 2 (2) = 0.46, p = .79 χ 2 (2) = 0.59, p = .75 χ 2 (2) = 1.73, p = .42 χ 2 (2) = 10.35, p = .006
TABLE 5. Motivation to seek treatment (from ASI-lite)
Emotional Social Family Legal Money Job Medical / Health Another person Other
Site 1 n = 44 %
Site 2 n = 38 %
Site 3 n = 38 %
Total N = 120 %
86.4 45.5 79.5 0 27.9 30.2 63.6 27.3 29.5
78.9 39.5 81.6 13.2 28.9 26.3 60.5 28.9 34.3
73.7 26.3 86.8 2.6 52.6 34.2 68.4 44.7 15.8
80 37.5 82.5 5 36.1 30.3 64.2 33.3 26.5
Significance between sites χ 2 (2) χ 2 (2) χ 2 (2) χ 2 (2) χ 2 (2) χ 2 (2) χ 2 (2) χ 2 (2) χ 2 (2)
= 2.087, p = .352 = 3.279, p = .194 = 0.785, p = .675 = 8.089, p = .018 = 6.593, p = .037 = 0.561, p = .755 = 0.524, p = .770 = 3.280, p = .194 = 3.537, p = .171
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1790 TABLE 6. Previous treatments (from ASI-lite) Site 1 n = 44
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Mean Days in a controlled environment Lifetime hospitalization for medical problems Times in alcohol abuse treatment Times in alcohol detox treatment Times in drug abuse treatment Times in drug detox treatment Days in outpatient treatment for any substance in the past month Hospitalizations for any psychological or emotional condition Outpatient treatment for any psychological or emotional condition
SD
Site 2 n = 38
Total N = 120
Mean
SD
Mean
SD
Mean
SD
Significance between groups
0.05 1.34
0.30 2.83
0.16 1.79
0.50 2.84
0.58 1.00
3.57 1.19
0.25 1.38
2.03 2.44
F(2,118) = 0.76, p = .47 F(2,118) = 1.01, p = .37
1.32 0.39 1.45 0.52 2.80
2.53 0.97 2.44 1.09 5.530
0.39 0.08 0.89 0.11 0.92
1.15 0.36 1.67 0.39 1.81
0.97 0.37 1.26 0.68 1.18
1.67 1.00 2.45 1.60 4.30
0.92 0.28 1.22 0.44 1.69
1.93 0.84 2.22 1.51 4.31
F(2,118) = 2.40, p = .10 F(2,118) = 1.66, p = .19 F(2,118) = 0.66, p = .522 F(2,118) = 2.65, p = .08 F(2,118) = 2.37, p = .10
0.16
0.57
0.03
0.16
0.66
1.94
0.28
1.17
F(2,118) = 3.24, p = .04
2.95
9.03
0.37
0.94
2.13
5.35
1.88
6.31
F(2,118) = 1.78, p = .17
TABLE 7. Correlation between SIP-R and URICA Motivation to change
Perceived problems Interpersonal Physical Social Impulse Intrapersonal Total
Site 3 n = 38
P
p
0.49 0.34 0.50 0.36 0.41 0.50
ORIGINAL ARTICLE
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Characteristics of a Treatment-Seeking Population in Outpatient Addiction Treatment Centers in Mexico 1 ˜ 1 , Angelica ´ ´ Rodrigo Mar´ın-Navarrete1 , Liliana Templos-Nunez Eliosa-Hernandez , 1 1 1 ´ ´ , Alejandro Perez-L ´ ´ on opez , Luis Villalobos-Gallegos , Jose´ Fernandez-Mondrag 1 ´ , Rosa E. Verdeja2 , Elizabeth Alonso2 , Daniel J. Feaster2 Diana Galvan-Sosa and Viviana E. Horigian2 1
Clinical Trials Unit on Addiction and Mental Health, Instituto Nacional de Psiquiatr´ıa Ram´on de la Fuente, Mexico City, Mexico; 2 Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami FL important characteristics to take into account when planning treatment as they facilitate tailoring treatment to meet patients’ needs.
Background: Baseline patients’ characteristics are critical for treatment planning, as these can be moderators of treatment effects. In Mexico, information on treatment seekers with substance use disorders is scarce and limited to demographic characteristics. Objective: This paper presents and analyses demographic characteristics, substance use related problems, clinical features, and addiction severity in a sample of treatment seekers from the first multi-site randomized clinical trial implemented in the Mexican Clinical Trials Network on Addiction and Mental Health. Methods: A total of 120 participants were assessed prior randomization. Chi square or F-tests were used to compare sites across variables. Spearman correlation was used to associate negative consequences of substance use and motivation to change. Results: The majority of participants were men, and the most prevalent substances reported were alcohol, marijuana, and cocaine. Participants were predominantly on the contemplation or action stage of change, and this was correlated with the perception of the negative consequences associated with substance use. Participants reported a high prevalence of substance use related problems. Conclusions: Substance use related problems, clinical features, and addiction severity reported by treatment seekers are
Keywords Treatment seekers, outpatient treatment, substance use disorders, addiction severity
BACKGROUND
Drug related problems in Mexico have increased in recent years, shifting from a country with low use rates to an advanced market with a continuous escalation in the number of people with substance use disorders that require help (Medina-Mora & Real, 2013). Data from the Mexican National Addiction Survey of 2011 indicates that the prevalence of substance use significantly increased in the period from 2002 to 2011; meanwhile, only a small percentage of the substance using population seeks and receives specialized treatment (Secretar´ıa de Salud [SSA], 2012). This finding is consistent with the worldwide problem of people with mental health and substance use disorders facing serious access barriers to adequate care services (Becker & Kleinman, 2013; World Health Organization, 2013). The documented access barriers and lack of adequate services in Mexico (Galvan & Mar´ın-Navarrete, 2010; Rojas, Real, Garc´ıa-Silberman & Medina-Mora, 2010)
A special acknowledgment for their institutional support in this study: Consejo Nacional Contra las Adicciones (CONADIC), Centro Nacional para la Prevenci´on y el Control de las Adicciones (CENADIC), National Institute on Drug Abuse-Clinical Trials Network (NIDA-CTN). A special acknowledgment for their institutional and active contribution in this study: Cl´ınica de Trastornos Adictivos of the INPRFM, Centros de Integraci´on Juvenil A. C. (CIJ), Consejo Estatal contra las Adicciones of Puebla (CECAP). This publication stems from the project “Development of a Clinical Trial Network on Addiction and Mental Health in Mexico” funded by a grant from the U.S. Department of State (Grant No. SINLEC11GR0015). The U.S. Department of State had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication. Clinical Trial Registration: ISRCTN registry No. ISRCTN91657311. Address correspondence to Rodrigo Mar´ın-Navarrete, PhD, Clinical Trials Unit on Addiction and Mental Health, Instituto Nacional de Psiquiatr´ıa Ram´on de la Fuente, Clz. M´exico-Xochimilco #101, Col. San Lorenzo Huipulco, Deleg. Tlalpan, Mexico City 14370, Mexico; E-mail: [email protected]
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TREATMENT-SEEKING POPULATION IN OUTPATIENT ADDICTION TREATMENT CENTERS IN MEXICO
translate into an increase in drug use related problems, such as violence, co-occurring medical and psychiatric disorders, sexually transmitted diseases and criminal behavior, which place a burden not only on the country’s public health (Mar´ın-Navarrete, Eliosa-Hern´andez et al., 2013; Ort´ız, Mart´ınez & Meza, 2012; Revuelta & Salcedo, 2013; SSA, 2012) but also on the substance user’s families (Biegel, Ishler, Katz & Johnson, 2007; Mattoo, Nebhinani, Anil Kumar, Basu & Kulhara, 2013). Mexico has addressed these increasing substance use problems with three different sources of treatment services. The first one is represented by the public sector with over 400 outpatient care centers and approximately 30 inpatient treatment units. Many of these public centers represent one of two major national addiction treatment institutions in Mexico, the Centros de Integraci´on Juvenil (CIJ) and the Centro Nacional para la Prevenci´on y el Control de las Adicciones (CENADIC) and a minority is represented by other public care institutions throughout the country. The second source of treatment services is represented by professional private health services, which are generally too expensive for the majority of the population. The last source is composed by traditional self-help groups (e.g., AA or other 12-step-programs) with almost 20,000 groups throughout the country and 2,291 mutual-aid residential centers, which are based on the 12-step philosophy where only a few have integrated medical and psychological assistance (CONADIC, CENADIC & CICAD-OEA, 2011; Mar´ın-Navarrete, Benjet et al., 2013). While there are several treatment service options available for the population, currently the substance abuse treatment field in Mexico faces many challenges, which include the strengthening of translational research to deliver effectively evidence-based practices to patients and the development of more personalized treatments that respond to patient needs and include care for co-occurring psychiatric disorders and other social problems (MedinaMora, Real, Villatoro & Natera, 2013). Information about population that attends services for treatment of substance use disorders is critical to respond to patient needs. These patient characteristics could mediate and or moderate treatment effects and therefore should play a major role in clinical decision-making and program development (Kalapatapu et al., 2013; McClure, Acquavita, Dunn, Stoller & Stitzer, 2014). However, in Mexico information available on these patients is generally limited to demographic characteristics and substance and alcohol use without taking into account related problems (mental and psychological condition and traumatic events) and clinical features (motivation to seek treatment, previous treatments, stage of change and social and personal consequences of substance use). OBJECTIVE
This paper addresses this problem analyzing the baseline data: demographic characteristics, substance use characteristics, related problems, clinical features, and addic-
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tion severity of participants from a multi-site randomized clinical trial that tested an adaptation of CTN 0021: Motivational Enhancement Treatment for Spanish Speakers (METS; Carroll et al., 2009) for the Mexican population (Intervenci´on de Incremento Motivacional or IIM). This was the first trial implemented in the Mexican Clinical Trials Network on Addiction and Mental Health (REC-INPRFM, acronym for the Spanish name; Mar´ınNavarrete, 2012; Horigian et al., unpublished results). Also this paper identifies possible priorities for future research and treatment program design. METHOD Participants and Sites
The trial was conducted in three outpatient addiction treatment centers, two of which were located in Mexico City and a third in the city of Puebla. This study analyzed the baseline characteristics of the 120 participants that were randomized in the trial. Inclusion criteria were: age between 18 and 65 years, seeking outpatient treatment for any substance use, any substance within the 28 days prior to treatment admission, having a stable living arrangement and planning to live near the treatment center during the duration of trial participation. Exclusion criteria were: dementia or other organic brain syndromes, suicidal or homicidal ideation or behavior, legal status that could result in incarceration, seeking detoxification, opioid maintenance treatment or residential inpatient treatment. The Ethics and Research committee of participating institutions approved the trial, and subjects were consented prior participation. Measures
A trained and certified research assistant performed all trial assessments at each of the participating sites. The following self-report and interview measures were administered at baseline, prior to randomization and treatment exposure. Composite International Diagnostic Interview (CIDI). The CIDI is a standardized interview that assesses mental disorders in adults according to ICD-10 and DSM-IV criteria. It provides diagnoses as reported by the patient (lifetime, 12 months and 30 days prior the interview). For this trial, only the substance use disorders module was used ¨ un, (Haro et al., 2006; Kessler et al., 2004; Kessler & Ust¨ 2004). Addiction Severity Index Lite (ASI-Lite). The ASI is a semi-structured face-to-face interview conducted by clinicians and researchers. The ASI covers the following areas: medical, employment/support, drug and alcohol use, legal, family/social, and psychiatric. The ASI obtains lifetime information about problem behaviors, as well as problems within the previous 30 days (McLellan et al., 1992). The ASI-Lite is a research version based on ASI 5th edition, and has 59 less questions. Composite scores were calculated following the ASI scoring manual (McGahan, Griffith, Parente, & McLellan, 1986). In the ASI, each composite score is the sum of answers to several questions
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R. MAR´IN-NAVARRETE ET AL.
within a problem area, and equal weighting is attributed to all questions within a composite score. Possible values on the composite score range from zero to one. Treatment Attitudes and Expectation Form (AEQ). The AEQ is a 36-item scale that inquires about reasons for entering treatment and preferences in counseling (Elkin, Parloff, Hadley & Autry, 1985). The version that was used for the study was adapted from the MATCH project (Project MATCH Research Group, 1997) and a CSAT Methamphetamine Treatment Project (Huber et al., 2000). Short Inventory of Problems Revised (SIP-R). The SIPR is a 17-item modified scale taken from the Drinker Inventory of Consequences (DrINC) (Miller et al., 1992). This measure assesses the patient’s perception of adverse consequences of his/her substance use in a period of 3 months prior to the assessment date. This scale has a good internal consistency (alpha = 0.96) and showed to have construct validity through correlations with scores from the ASI (Kiluk et al., 2013). Scores higher than mean for each negative consequence were classified as “problem” in this study. All other scores (lower than mean) were classified as “no problem.” University of Rhode Island Change Assessment Scale (URICA). The URICA is a 32-item scale assessing client readiness to change substance use behavior. It is composed by 4 subscales measuring stages of change according to the transtheoretical model: precontemplation, contemplation, action, and maintenance (McConnaughty et al., 1983). These subscales account for 58% of the variance and Cronbach’s coefficient alphas range from 0.88 to 0.89 (McConnaughty et al., 1983). The URICA readiness score was determined by summing the scores on contemplation, action, and maintenance subscales, and subtracting the precontemplation subscale score from that sum (Blanchard, Morgenstern, Morgan, Labouvie & Bux, 2003). Statistical Analysis
We used either χ 2 or F tests to compare sites across variables. A P-value of less than 0.05 was considered significant. Spearman correlation was used to associate negative consequences of substance use and motivation to change. Analyses were conducted using SPSS version 19. RESULTS Demographic Characteristics
The baseline demographic characteristics show varied significant differences among sites, particularly on years of education and employment pattern. Most participants reported having full time employment during the past three years but fewer reported full time employment in the 30day period prior the interview (see Table 1). Substance Use Characteristics
According to CIDI criteria, half of the participants had alcohol dependence (50%) while almost half of the sample had drug dependence (45.8%). There were significant sta-
tistical differences in drug abuse and dependence across sites; the highest rate of drug dependence was found in Site 1 while Site 2 had the highest percentage of drug abuse (see Table 2). Participant main substance of use and years of use varied significantly among sites. For Site 3 the most reported main substance of use was alcohol while for Site 1 was alcohol as well as cocaine and for Site 2, it was cannabis. There were statistical differences across sites in the number of years using heroin, cocaine, cannabis, alcohol to intoxication and more than one substance per day. Regarding substance use during lifetime, cannabis (42.5%) was most reported. There was a statistical difference between the routes of administration of cocaine (χ 2 = 24.900, gl = 6; p ≤ 0.001). The principal routes of administration in the three sites were smoking (34.2%) and intranasal (16.7%), but in Site 3 there was a participant that had reported an injecting route of administration of cocaine. Related Problems
Levels of perceived mental and psychological conditions were quite high in the overall sample. Although differences in depressive symptoms across the three sites were marginal, there were statistically significant differences in lifetime anxiety, hallucinations, suicide attempts, and prescribed medications for emotional or psychological problems, with Site 1 showing the highest prevalence of these conditions in comparison with the other two sites (see Table 3). Physical abuse during lifetime was very common (39.2%) in the study sample, with 9.2% reporting physical abuse in the past 30 days. Site 3 showed significantly higher lifetime sexual abuse than other sites (see Table 4). Clinical Features
In general, the main motivation for seeking treatment was family (82.5%), followed by emotional (80%) and medical reasons (64.2%). Comparisons between sites in economic problems as a reason to seek treatment displayed significant differences (χ 2 = 6.593, p = .037); also participants of Site 2 had legal reasons to seek treatment more often compared with Site 1 and 3 (χ 2 = 8.089, p = .018) (see Table 5). Participants in Site 3 reported significantly more hospitalizations for emotional or psychological problems in the 30-day period prior the assessment than participants in the other two sites (see Table 6). According to URICA scores, most participants were in the contemplation stage (57.3%) followed by the action stage (36.8%). Only 6% of participants in all three sites were in the pre-contemplation stage. Taking into account percentages by site, most participants in Sites 1 and 3 were in the contemplation stage (52.3% and 76.3%, respectively) while in Site 2 most were in the action stage (45.7%). According to SIP-R scale, at least 69.2% of participants perceived negative consequences of their substance use. Most of the participants reported interpersonal problems
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TABLE 1. Demographic characteristics by site Site 1 n = 44
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Mean or %
Site 2 n = 38
SD
Age 31.4 9.8 Years of Education 10.8 3.6 Gender Male 86.4 Female 13.6 Marital Status Married/Cohabiting 27.3 Separated/Divorced 18.2 Never Married 54.5 Usual Employment Pattern (Past 3 Years) Full time (35 hrs/wk) 56.8 Part time (regular hours) 11.4 Part time (irregular, day 13.6 work) Student 18.2 Homemaker 0 Unemployed 0 Usual Employment Pattern (Past 30 Days) Full time (35 hr/wk) 29.5 Part time (regular hours) 9.1 Part time (irregular, day 9.1 work) Student 13.6 Retired/Disability 0 Homemaker 0 Unemployed 38.6
Site 3 n = 38
Total N = 120
Mean or %
SD
Mean or %
SD
Mean or %
SD
28.5 11.5
9.05 2.44
30.1 9.6
8.6 2.5
30.1 10.6
9.2 3.0
89.5 10.5
71.1 28.9
Significance between groups F(2,118) = 1.02, p = .36 F(2,118) = 4.04, p = .02 χ 2 (2) = 5.18, p = .08
82.5 17.5 χ 2 (8) = 4.67, p = .79
21.1 21.1 57.9
23.7 18.4 57.9
24.2 19.2 56.7 χ 2 (10) = 23.37, p = .009
39.5 18.4 7.9
50 15.8 5.3
49.2 15 9.2
31.6 0 2.6
7.9 7.9 13.2
19.2 2.5 5 χ2
26.3 15.8 18.4
28.9 15.8 10.5
28.3 13.3 12.5
21.1 2.6 0 15.8
10.5 0 2.6 31.6
15 0.8 0.8 29.2
(62.5%), followed by social and physical ones (52.5% and 51.7%, respectively). The proportion of participants who perceived negative consequences of substance use was similar between sites. The Spearman correlation showed a positive association between all negative consequences of substance use and motivation to change. Intrapersonal, social and interpersonal consequence sub-scales from SIP-R showed a moderate association with motivation to change stage scores in the URICA (see Table 7). Addiction Severity Index (ASI-lite)
Through one-way ANOVA analysis, conducted between all sites, areas that showed to have higher levels of severity were employment, family/social, and psychiatric. But the areas that showed significant differences between sites were drug, legal, and psychiatric composite scores (see Table 8). DISCUSSION
This analysis presents relevant information on demographic characteristics, substance use characteristics, clinical features, related problems and addiction severity of treatment-seeking patients from three centers for treatment of substance use disorders. As expected, overall,
(12)
= 12.18, p = .43
there were more men than women in the sample in concordance with Mexican epidemiological reports that point out that more men attend treatment than women (SSA, 2012). This continues to be of concern as the Mexican National Survey on Addiction (SSA, 2012) revealed an increase in the prevalence of substance use in women, underscoring the need for better outreach strategies to engage women into treatment, and to provide gender specific treatment opportunities (Galvan & Mar´ın-Navarrete, 2010). Results on main substance of abuse were also concordant with literature, having alcohol, marijuana, and cocaine the most reported main substance in that order; which are also the most reported substances in the National Addiction Survey (SSA, 2012). Differences across sites were relevant, with alcohol being the most reported substance in Site 3, which was a primary care addiction center; whereas in Site 2, which included the youngest patients, marijuana was the most reported; and cocaine and alcohol in Site 1, which also had the patients with highest percentage of mental health problems and more severity of addiction. These findings indicate meaningful differences in population characteristics and drug of choice across treatment settings. In the overall sample, we found that 27.5% patients didn’t present any diagnostic criteria for drug abuse or dependence; and 16.7% had no alcohol abuse or
R. MAR´IN-NAVARRETE ET AL.
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TABLE 2. Substance Use characteristics by site Site 1 n = 44
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Mean or % SUD Diagnostics (from CIDI) Alcohol Abuse 36.36 Alcohol Dependence 56.82 Drug Abuse 20.45 Drug Dependence 63.64 Main Substance of use Alcohol 31.8 Cannabis 29.5 Cocaine 31.8 Inhalants 4.5 Others 2.3 Substance use (Years) Alcohol (Any Use) 13.11 Alcohol (to 7.41 intoxication) Heroin 0 Methadone 0 (prescribed) Methadone (illicit) 0 Other 0.02 opiates/Analgesic Barbiturates 0 Other Sedatives/ 0.59 Hypnotics/ Tranquilizers Cocaine 4.91 Amphetamines/ 0.5 Methamphetamines Cannabis 6.45 Hallucinogens 0.91 Inhalants 0.89 More than 1 Substance 5.86 per day Nicotine 10.07 Substance Use (Lifetime) Heroin 15.9 Methadone 0 (prescribed) Methadone (illicit) 0 Other 9.1 opiates/Analgesic Barbiturates 0 Other Sedatives/ 25 Hypnotics/ Tranquilizers Cocaine 18.2 Amphetamines/ 31.8 Methamphetamines Cannabis 25 Hallucinogens 38.6 Inhalants 34.1 Nicotine 4.5
Site 2 n = 38
SD
8.2 7.75
Mean or %
Site 3 n = 38
SD
Mean or %
Total N = 120
SD
Mean or %
39.47 34.21 44.74 36.84
23.68 57.89 15.79 34.21
33.33 50 26.67 45.83
21.8 39.5 34.2 5.3 0
60.5 15.8 5.3 7.9 10.5
37.5 28.3 24.2 5.8 4.2
11.34 2.11
8.69 4.2
SD
Significance between groups χ 2 (2) χ 2 (2) χ 2 (2) χ 2 (2) χ 2 (8)
= 2.419, p = .298 = 5.555, p = .062 = 9.512, p = .009 = 8.922, p = .012 = 26.64, p < .001
11.84 4.37
8.17 6.26
12.15 4.77
8.31 6.66
F(2,118) = 0.497, p = .610 F(2,118) = 7.266, p = .001
0 0
0 0
0 0
0.47 0.11
1.7 0.65
0.15 0.03
0.98 0.37
F(2,118) = 3.171, p = .046 F(2,118) = 1.080, p = .343
0 0.15
0 0.42
0 2.6
0 0
0 0
0 0.14
0 1.46
—— F(2,118) = 1.017, p = .365
0 1.52
0 0.68
0 2.62
0 0.21
0 0.99
0 0.5
0 1.82
—— F(2,118) = 0.727, p = .485
6.43 1.37
3.89 0.08
5.93 0.36
0.87 0.11
2.71 0.52
3.31 0.24
5.58 0.92
F(2,118) = 6.141, p = .003 F(2,118) = 2.800, p = .065
7.53 3.05 4.59 6.52
4.16 0.42 1.45 5.34
5.98 1.98 3.6 7.03
2.66 0.16 0.42 1.95
5.48 0.68 1.15 3.5
4.53 0.52 0.92 4.46
6.59 2.2 3.5 6.13
F(2,118) F(2,118) F(2,118) F(2,118)
7.42
8.66
9.06
8.87
9.25
9.24
8.51
F(2,118) = 0.330, p = .720
= 3.619, p = .030 = 1.251, p = .290 = 0.818, p = .444 = 5.070, p = .008
5.3 0
21.1 2.6
14.2 0.8
χ 2 (2) = 4.069, p = .131 χ 2 (2) = 2.176, p = .337
0 7.9
2.6 5.3
0.8 7.5
χ 2 (2) = 2.176, p = .337 χ 2 (2) = 0.443, p = .801
0 7.9
0 23.7
0 19.2
—– χ 2 (2) = 4.583, p = .101
31.6 21.1
47.4 15.8
31.7 23.3
χ 2 (2) = 8.027, p = .018 χ 2 (2) = 3.090, p = .213
36.8 44.7 21.1 2.6
68.4 21.1 23.7 60.5
42.5 35 26.7 21.7
χ 2 (2) = 16.460, p = .000 χ 2 (2) = 5.089, p = .079 χ 2 (2) = 2.025, p = .363 χ 2 (2) = 49.522, p = .000
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TABLE 3. Mental and Psychological condition in the past 30-days and Lifetime (from ASI-lite) Site 1 n = 44 %
Site 2 n = 38 %
Site 3 n = 38 %
Total N = 120 %
43.2 70.5 2.3 77.3
52.6 57.9 0.0 57.9
39.5 68.4 2.6 55.3
45.0 65.8 1.7 64.2
34.1 9.1 0.0 54.5
21.1 0.0 0.0 5.3
31.6 13.2 0.0 18.4
29.2 7.5 0.0 27.5
χ 2 (2) = 1.83, p = .40 χ 2 (2) = 4.10, p = .08 ——— χ 2 (2) = 27.14, p ≤ .001
84.1 88.6 13.6 84.1
71.1 55.3 2.6 44.7
73.7 73.7 0.0 50
76.7 73.3 5.8 60.8
χ 2 (2) = 2.21, p = .33 χ 2 (2) = 11.62, p = .003 χ 2 (2) = 7.94, p = .02 χ 2 (2) = 15.99, p ≤ .001
59.1 40.9 31.8 40.9
34.2 21.1 7.9 7.9
39.5 60.5 31.6 34.2
45.0 40.8 24.2 28.3
χ 2 (2) = 5.79, p = .055 χ 2 (2) = 12.25, p = .002 χ 2 (2) = 8.04, p = .018 χ 2 (2) = 11.89, p = .003
Past 30 days Depression Anxiety Hallucinations Trouble understanding, concentrating, or remembering Trouble controlling violent behavior Serious thoughts of suicide Attempted suicide Prescribed medication for any psychological/emotional problems Lifetime Depression Anxiety Hallucinations Trouble understanding, concentrating, or remembering Trouble controlling violent behavior Serious thoughts of suicide Attempted suicide Prescribed medication for any psychological/emotional problems
dependence. This allows us to think that a percentage of treatment seekers in this study were experimental users. Regarding employment, the decrease in percentages of full-time employment leading up to treatment initiation, the relatively high percentage of unemployment in the 30days prior the interview and ASI scores in the employment composite measure suggest that job loss may be related to
Significance between groups χ 2 (2) χ 2 (2) χ 2 (2) χ 2 (2)
= 1.42, p = .49 = 1.60, p = .45 = 0.96, p = .62 = 5.25, p = .07
substance use, and also may have had an impact on seeking treatment. Substance use has an impact on productivity, access to work opportunities, and capacity to keep a stable job, which in turn impacts the economy of the patients (Kessler & Frank, 1997; WHO, 2012; WHO, 2013). This may point towards the need to implement interventions aimed at the development of employment skills.
TABLE 4. Traumatic Events in the 30 days and Lifetime (from ASI-lite)
Physical abuse past 30 days Physical abuse lifetime Sexual abuse past 30 days Sexual abuse lifetime
Site 1 n = 44 %
Site 2 n = 38 %
Site 3 n = 38 %
Total N = 120 %
Significance between sites
6.8 40.9 4.5 11.4
10.5 34.2 0.0 0.0
10.5 42.1 2.6 23.7
9.2 39.2 2.5 11.7
χ 2 (2) = 0.46, p = .79 χ 2 (2) = 0.59, p = .75 χ 2 (2) = 1.73, p = .42 χ 2 (2) = 10.35, p = .006
TABLE 5. Motivation to seek treatment (from ASI-lite)
Emotional Social Family Legal Money Job Medical / Health Another person Other
Site 1 n = 44 %
Site 2 n = 38 %
Site 3 n = 38 %
Total N = 120 %
86.4 45.5 79.5 0 27.9 30.2 63.6 27.3 29.5
78.9 39.5 81.6 13.2 28.9 26.3 60.5 28.9 34.3
73.7 26.3 86.8 2.6 52.6 34.2 68.4 44.7 15.8
80 37.5 82.5 5 36.1 30.3 64.2 33.3 26.5
Significance between sites χ 2 (2) χ 2 (2) χ 2 (2) χ 2 (2) χ 2 (2) χ 2 (2) χ 2 (2) χ 2 (2) χ 2 (2)
= 2.087, p = .352 = 3.279, p = .194 = 0.785, p = .675 = 8.089, p = .018 = 6.593, p = .037 = 0.561, p = .755 = 0.524, p = .770 = 3.280, p = .194 = 3.537, p = .171
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1790 TABLE 6. Previous treatments (from ASI-lite) Site 1 n = 44
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Mean Days in a controlled environment Lifetime hospitalization for medical problems Times in alcohol abuse treatment Times in alcohol detox treatment Times in drug abuse treatment Times in drug detox treatment Days in outpatient treatment for any substance in the past month Hospitalizations for any psychological or emotional condition Outpatient treatment for any psychological or emotional condition
SD
Site 2 n = 38
Total N = 120
Mean
SD
Mean
SD
Mean
SD
Significance between groups
0.05 1.34
0.30 2.83
0.16 1.79
0.50 2.84
0.58 1.00
3.57 1.19
0.25 1.38
2.03 2.44
F(2,118) = 0.76, p = .47 F(2,118) = 1.01, p = .37
1.32 0.39 1.45 0.52 2.80
2.53 0.97 2.44 1.09 5.530
0.39 0.08 0.89 0.11 0.92
1.15 0.36 1.67 0.39 1.81
0.97 0.37 1.26 0.68 1.18
1.67 1.00 2.45 1.60 4.30
0.92 0.28 1.22 0.44 1.69
1.93 0.84 2.22 1.51 4.31
F(2,118) = 2.40, p = .10 F(2,118) = 1.66, p = .19 F(2,118) = 0.66, p = .522 F(2,118) = 2.65, p = .08 F(2,118) = 2.37, p = .10
0.16
0.57
0.03
0.16
0.66
1.94
0.28
1.17
F(2,118) = 3.24, p = .04
2.95
9.03
0.37
0.94
2.13
5.35
1.88
6.31
F(2,118) = 1.78, p = .17
TABLE 7. Correlation between SIP-R and URICA Motivation to change
Perceived problems Interpersonal Physical Social Impulse Intrapersonal Total
Site 3 n = 38
P
p
0.49 0.34 0.50 0.36 0.41 0.50
