Elsevier

Addictive Behaviors

Volume 35, Issue 5, May 2010, Pages 499-503
Addictive Behaviors

Psychiatric distress, risk behavior, and treatment enrollment among syringe exchange participants

https://doi.org/10.1016/j.addbeh.2009.12.033Get rights and content

Abstract

The present study evaluated psychiatric distress as a predictor of treatment enrollment in out-of-treatment injection opioid users newly registered at the Baltimore Needle Exchange Program (BNEP). Study participants (n = 281) completed the Addiction Severity Index (ASI), the Risk Assessment Battery (RAB), and the Symptom Checklist-90 (SCL-90-R), and were randomly assigned to one of three different conditions for 4 months that evaluated referral strategies designed to promote treatment interest and enrollment. The Global Severity Index (GSI) of the SCL-90 was used as a measure of psychiatric distress. A logistic regression showed that higher GSI scores predicted more treatment enrollment (Adjusted OR = 2.15, CI = 1.10–4.23, p < 0.05), after controlling for study condition, demographic variables, syringe exchange site, and severity of drug use. The results suggest that the data from the assessment of psychiatric distress in syringe exchange settings can be used to support motivational strategies for encouraging syringe exchangers to seek substance abuse treatment.

Introduction

Injection drug users enrolled in community syringe exchange programs (SEPs) exhibit rates of other psychiatric disorders that are higher than reported in general population estimates (Brienza et al., 2000, Kessler et al., 2005, Kidorf et al., 2004). At least three practical concerns are associated with the high rates of psychiatric comorbidity in this subgroup of injection drug users. The first is that the psychiatric distress associated with the presence of other psychiatric disorders may further impair their already poor psychosocial functioning (e.g., Brooner, King, Kidorf, Schmidt, & Bigelow, 1997). Second, psychiatric distress and psychosocial impairment are both associated with higher rates of drug use and greater frequencies of HIV-risk behavior (Disney et al., 2006, Kidorf et al., 2004, Metzger et al., 1991). Psychiatric distress among out-of-treatment SEP participants could moderate the harm reduction efforts associated with exchanging used for new syringes by increasing drug use and related HIV-risk behaviors, thereby increasing the risk of transmitting HIV and other infectious diseases to self or others (Des Jarlais et al., 2007, Wood et al., 2002).

While psychiatric distress is often associated with increased drug use and associated problems in injection drug users, several studies have shown that distress may be associated with increased treatment-seeking (e.g., Cohen et al., 2007, Mojtabai et al., 2002. This is a particularly important issue given the low rates of treatment participation documented in community SEPs. While the policy of many SEPs is to refer participants to substance abuse treatment (Des Jarlais, McKnight, Goldblatt, & Purchase, 2009), overall rates of treatment enrollment in this population remain strikingly low. Riley et al. (2002), for example, reported that only 5% of SEP participants requested referral to substance abuse treatment over a two and a half year time period. Similarly, Kidorf et al. (2005) found that only 11% of newly enrolled SEP registrants entered substance abuse treatment within a year. This is unfortunate because the addition of substance abuse treatment in syringe exchangers may increase the harm reduction benefits of SEPs via reductions of drug use and increased access to other services (Kidorf et al., 2009, Sorensen and Copeland, 2000, Van Den Berg et al., 2007), including specialized psychiatric care.

A relationship between psychiatric distress and treatment enrollment has been suggested across a number of epidemiological studies (Mojtabai et al., 2002, Ross et al., 1999). Most recently, Cohen et al. (2007) showed that individuals with both an alcohol use disorder and a co-occurring psychiatric disorder were more likely to enroll in substance abuse treatment than those with an alcohol use disorder only. However, the impact of psychiatric distress on treatment-seeking behavior is unknown in out-of-treatment syringe exchangers, although one study did suggest a potential facilitating effect. Post-hoc analyses in a study conducted several years ago by Kidorf et al. (2005) showed that while a short-term motivational intervention failed to increase rates of treatment-seeking in syringe exchangers, participants with (vs. without) a current major depression were more likely to enroll in treatment.

In the present study, a new sample of registrants to the Baltimore Needle Exchange Program (BNEP; n = 281) completed the Addiction Severity Index (ASI; McLellan et al., 1992), the Risk Assessment Battery (RAB; Metzger et al., 1993), and a measure of psychiatric distress (Symptom Checklist 90-Revised; SCL-90-R; Derogatis, 1983) at intake, and were then randomized to one of three study conditions evaluating strategies to increase substance abuse treatment enrollment. While the main effects of these interventions showed that a combination of motivational enhancement and behavioral incentives was associated with significantly higher rates of treatment entry (Kidorf et al., 2009), the present study evaluates: 1) the relationships between psychiatric distress and both substance use and HIV-risk behaviors, and 2) psychiatric distress as a predictor of substance abuse treatment-seeking behavior across study conditions. The primary hypothesis is that while higher levels of psychiatric distress would correlate with greater drug use and HIV-risk behavior severity, psychiatric distress would also be positively associated with treatment enrollment.

Section snippets

Participants

Study participants were opioid-dependent individuals newly registered at the Baltimore Needle Exchange Program (BNEP) during a 4-year time period (5/03 to 3/07). The BNEP uses a mobile medical van as a setting for injection drug users to exchange used for sterile syringes. BNEP staff referred participants to our research van, which was parked adjacent to the BNEP van at selected sites on the east and west sides of the city. BNEP registrants who came to the research van were informed of the

Relationship between GSI scores, ASI composite scores, and RAB subscales

Table 1 shows the Pearson correlation coefficients between GSI scores and 1) ASI composite scores, and 2) BRAB subscales. GSI scores were significantly correlated with six of the seven ASI composite scores, and each of the RAB scales; in all instances higher GSI scores were associated with greater problem severity and HIV-risk behavior.

Relationship between GSI scores and treatment enrollment

Overall, 40% of participants (n = 115) enrolled in substance abuse treatment during the 4-month study period. As shown in Table 2, logistic regression analyses

Psychiatric distress and treatment enrollment

Psychiatric distress has been reported retrospectively as a factor motivating substance abuse treatment enrollment (Marlowe, Merikle, Kirby, Festinger, & McLellan, 2001). The present study shows that psychiatric distress is also prospectively associated with treatment enrollment in injection drug users, and dovetails with results from an earlier study of syringe exchangers that reported a similar relationship between major depression and substance abuse treatment entry (Kidorf et al., 2005).

Conclusions

The findings from the present study provide important new information for the already widely held view that psychiatric distress is a harbinger for more severe drug use and psychosocial impairment in substance users. The prospective nature of the study and its extension to variables not ordinarily included in earlier reports make a relevant and important contribution to this literature. The findings also point to an opportunity to increase participation in SEPs and improve the overall success

Role of Funding Sources

Funding for this study was provided by NIH-NIDA Grant R01-DA12347. NIH 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.

Contributors

Drs. Kidorf and Brooner designed the study. Dr. Kidorf wrote the first draft of the manuscript. Ken Kolodner conducted the statistical analyses. Drs. Van King, Jessica Pierce, Christopher Burke, and Robert Brooner provided assistance with literature searches and editing subsequent drafts of the manuscript. All of the authors contributed to and have approved the final manuscript.

Conflict of Interest

All authors declare that they have no conflicts of interest.

Acknowledgements

This study was supported by research grant RO1 DA 12347 (M. Kidorf, PI) from the National Institute on Drug Abuse. We gratefully acknowledge the support of the Baltimore City Health's Department Syringe Exchange Program and its dedicated staff. Acknowledgement and thanks are also due to our research staff whose diligence ensured the integrity of the study, especially Kori Kindbom, M.A., Jim Blucher, M.A., Karin Taylor, M.A., Michael Sklar, M.A., Rachel Burns, B.A., and Samantha DiBastiani, B.A.

References (39)

  • S.A. Strathdee et al.

    Facilitating entry into drug treatment among injection drug users referred from a needle exchange program: Results from a community-based behavioral intervention trial

    Drug and Alcohol Dependence

    (2006)
  • J.A. Tucker et al.

    Different variables are associated with help-seeking patterns and long-term outcomes among problem drinkers

    Addictive Behaviors

    (2004)
  • M. Zack et al.

    The SCL-90 factor structured in comorbid substance abusers

    Journal of Substance Abuse

    (1998)
  • M. Alegria et al.

    Disparity in depression treatment among racial and ethnic minority populations in the United States

    Psychiatric Services

    (2008)
  • W.K. Bickel et al.

    Toward a behavioral economic understanding of drug dependence: Delay discounting processes

    Addiction

    (2001)
  • R.K. Brooner et al.

    Psychiatric and substance use comorbidity among treatment-seeking opioid abusers

    Archives of General Psychiatry

    (1997)
  • L.R. Derogatis

    SCL-90-R: Administration, scoring and procedures. Manual II

    (1983)
  • L.R. Derogatis et al.

    Confirmation of the dimensional structure of the SCL-90: A study in construct validation

    Journal of Clinical Psychology

    (1977)
  • D.C. Des Jarlais et al.

    Residual injection risk behavior, HIV Infection, and the evaluation of syringe exchange programs

    AIDS Education and Prevention

    (2007)
  • Cited by (8)

    • Do DSM-5 substance use disorder criteria differ by user care settings? An item response theory analysis approach

      2021, Addictive Behaviors
      Citation Excerpt :

      In a previous study among the substance user treatment seeking subgroup, DIF and DTF by psychiatric comorbidities were found (Kervran et al., 2020). Since substance users in treatment settings showed more severe mental health disability than substance users in HR settings (Compton, Thomas, Stinson, & Grant, 2007; Kidorf et al., 2004, 2010; Metzger et al., 1990; Ross et al., 2002), future studies should explore if psychiatric comorbidities in the treatment subgroup could explain the DIF and DTF observed. These populations are different in terms of precariousness (Moracchini et al., 2012; Ross et al., 2005), which has not been fully explored in this study, and which could explain the DIF of criteria related to consequences of use that are contextually and culturally bound.

    • Benefits of concurrent syringe exchange and substance abuse treatment participation

      2011, Journal of Substance Abuse Treatment
      Citation Excerpt :

      Prior research has consistently shown that most syringe exchangers are not enrolled in substance abuse treatment (e.g., Kidorf et al., 2004). Improving the linkage between syringe exchanges and substance abuse treatment settings extends the reach of treatment to this critically important subgroup of high severity and highly impaired injection drug users (Grau et al., 2005; Huo & Ouellet, 2007; Kidorf et al., 2010; Neufeld et al., 2008). Concurrent participation in treatment and an SEP provides important harm reduction benefits for treatment-seeking patients who continue to inject drugs.

    View all citing articles on Scopus
    View full text