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The objective of this study is to examine the relationship between depression and drug use and potential ramifications of that relationship on the health services needs, utilization, and costs of chronic and injecting drug abusers. A network-based sample of 1,330 injecting and other chronic drug users, as well as non-drug using neighborhood controls, was obtained within Dade County, Florida. Using the Health Services Research Model as an analytical framework, results show that drug users had significantly higher levels of depression than non-drug users from similar neighborhoods. In addition, it was found that depression was significantly associated with perceptions of poor health, increased health problems, and perceived limitations on even light physical activity among both drug users and non-users. Among drug users, depression was also significantly related to not receiving needed care, lack of treatment adherence, use of the emergency room for primary care or any reason, hospital admissions, and any use of outpatient or private clinic services. Results from logistical regression analysis show that even when controlling for relevant issues such as sociodemographic, economic, and drug use variables, depression retains an independent and significant relationship with health services need and utilization. Differences in the cost of health care utilization between depressed and non-depressed samples are also estimated. Implications of this study point to the need to consider screening and treatment for depression within health system structures in order to improve cost-effective access to needed services among drug using populations.

Private alcohol problem treatment in the United States arose from a social movement that began after Prohibition and culminated in the founding of the National Institute on Alcohol Abuse and Alcoholism in 1970. Using a treatment model that incorporated much of the ideology of Alcoholics Anonymous, an isomorphic set of private treatment centers grew rapidly across the country with support and assistance from NIAAA. As this support diminished and cost containment emerged, a crisis struck the population of treatment centers, leading to many closures. Nonetheless, most of the centers have survived. This chapter uses data from a national longitudinal study of privately funded alcohol problem treatment centers to illustrate the transformation of the treatment industry during the 1990s. We argue that this transformation results from an increased difficulty in obtaining treatment funding due to the health care cost-containment practices of managed care.

On December 31, 1996, the U.S. Congress officially ended its funding of the Social Security Administration's program of supplemental security income (SSI) and social security disability income (SSDI) cash and Medicaid benefits for drug addiction and alcoholism (DA&A). This social policy change is part of the U.S. Congress welfare reform, which will impact more than 26,000 Illinois residents, thousands in Cook County alone. Our study seeks to illuminate the meaning of these benefits to a group of approximately 40 former Cook County recipients. We explored the utility and meaning of the cash and Medicaid benefits to at least three types of recipients (Good Citizens, Hustlers, and Lost Souls) that emerged from a series of focus groups. Our paper studies the differences between the three types of recipients in their use of cash (e.g., from paying for housing and living essentials to purchasing drugs) and Medicaid (e.g., medications and drug treatment) benefits. Findings and conclusions also generate important insights into how recent social policy changes impact the drug-using community and produce new health and social problems for both the former recipients and society-at-large.

The substance abuse treatment system is currently confronted with not only more clients but also clients with a complex array of health and human service needs. Existing systems often lack both resources and the institutional structure needed to manage clients with multiple and often chronic needs. Presented in this chapter is a review of a federally funded demonstration project designed to address these client management requirements in the treatment system. The project, Target Cities, focused a variety of interventions designed to improve access to assessments and treatment, client-treatment matching procedures, linkages and referrals to other health and human service providers, and client tracking. Discussed are the history, rationale, implementation, and findings produced by these system changes in one main metropolitan area. The results indicated that centralized intake improved access to treatment while maintaining client satisfaction with the intake process.

This chapter explores the impact of the National Institute on Drug Abuse (NIDA) funded by Cooperative Agreement AIDS education and prevention program on crack users and drug injectors. Data on the 5,789 participants were drawn from eight cities throughout the United States. Subjects were classified into three user groups: injectors only, crack smokers only, and crack-smoking injectors. They were interviewed at baseline and six months later at follow-up about their HIV risk behaviors which included needle-related behaviors, drug use patterns, and sexual behaviors. At baseline, subjects were assigned either to a two-session NIDA developed standard intervention or to a more elaborate and prolonged enhanced intervention which was independently developed in each of the sites. Analyses were conducted for the cities individually. Three major findings emerged from the analyses: (1) there is a relative lack of post intervention differences between the standard and enhanced interventions; (2) statistically significant and substantively meaningful changes occurred between pretest and posttest; and (3) despite meaningful reductions in risk behaviors among some users, a large percentage of these drug users continue to engage in all types of risky behaviors. Implications of these findings are discussed in the chapter.

This study examines the relationship between conventional moral belief and drug problem recognition in African-American, Hispanic-American, and non-Hispanic white drug users. After adjustment for demographic, psychosocial, and drug use severity factors that might have confounded this relationship, conventional moral belief was significantly associated with drug problem recognition among African-Americans and Hispanic-Americans but not among whites. The particular relevance of conventional moral belief among nonwhites may reflect cultural values emphasizing collective identity and/or religiosity. Nonwhites may be more inclined than whites to view recovery as a process of claiming or reclaiming moral standing in a community of conventional others.

This chapter reports findings on two studies that culminated in the development of a multilevel intervention to improve access to health care among chronic drug users. The first two studies began with an investigation of the health care delivery system serving chronic drug users in Miami-Dade County, Florida from the perspectives of both consumers and providers. These studies documented the health care needs and use patterns of chronic drug users as well as the practices and perspectives of the providers who served them. Findings indicated that (1) chronic drug users demonstrated greater health care needs than nondrug users; (2) chronic drug users were less likely to receive appropriate health care services; and (3) the gap between services needed and services actually provided can be ameliorated. By participating in our multilevel intervention, both health care providers and health care consumers changed attitudes and behaviors resulting in the provision of appropriate, accessible, and acceptable health care.