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Remission From Drug Dependence Symptoms and Drug Use Cessation Among Women Drug Users in Puerto Rico
Lynn A. Warner, PhD;
Margarita Alegría, PhD;
Glorisa Canino, PhD
Arch Gen Psychiatry. 2004;61:1034-1041.
ABSTRACT
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Background Studies of remission from drug dependence have most often been based on treatment samples, with limited generalizability to persons who may benefit from but never seek substance abuse treatment. Little is known about remission patterns among drug users in the community.
Objective To identify patterns and predictors of remission in a community sample of drug users followed up prospectively.
Design Three waves of data on a range of individual and interpersonal correlates of drug abuse and health care service use were collected between April 1997 and October 2000.
Setting Areas of metropolitan San Juan where drug sales were known to occur.
Participants Two hundred seventy-five women aged 18 to 35 who were crack cocaine or injecting drug users.
Main Outcome Measures Self-reported drug use validated with urine screens and drug use dependence criteria based on the DSM-IV.
Results Most (86.9%) of the women were drug dependent at baseline. By wave 3, fewer than half (42.6%) of the women were dependent, 13.8% had subthreshold disorder, and 17.8% used substances but did not endorse any dependence criteria. Cessation of use and decreases in the number of dependence criteria endorsed were significantly less likely for women with depressive symptoms (odds ratio [OR], 0.92; 95% confidence interval [CI], 0.88-0.96; and OR, 0.88; 95% CI, 0.86-0.90; respectively), with a partner who engaged in criminal activities (OR, 0.30; 95% CI, 0.16-0.58; and OR, 0.63; 95% CI, 0.46-0.85; respectively), and who traded sex for money or drugs (OR, 0.12; 95% CI, 0.05-0.29; and OR, 0.26; 95% CI, 0.19-0.35; respectively).
Conclusions Drug use patterns and rates of dependence fluctuated substantially over time among drug users recruited from the community. Findings regarding the characteristics that impede remission suggest that mental health practitioners have an important role to play in community-based outreach and interventions designed to support women’s efforts to stop using drugs.
INTRODUCTION
Compared with the amount of research on the development of substance use disorders, there has been less emphasis on patterns of remission once drug use disorders are established. Available data on remission are primarily from treatment-based samples or from community-based samples that represent populations who are dependent on alcohol rather than illicit substances. The generalizability of these studies to community samples of persons who abuse illicit substances is not known; however, their lower degree of "recovery capital"1 is likely to yield different remission patterns. Moreover, respondents in longitudinal community studies that speak to remission from alcoholism have been almost exclusively male2-4 or predominately European American,5-9 and longitudinal studies of remission from heroin tend to be based on convenience10 or treatment samples, also predominately male.11-12 Consequently, our understanding of remission from drug dependence among ethnic minority women is limited.
According to data from longitudinal community-based studies,2-3,5 most persons with alcoholism do not receive treatment for their condition. Rather, people with alcohol problems often "age out" of substance use behaviors8-9,13-15 or remit from alcoholism without substance abuse treatment (ie, "spontaneously"),6-7,16-18 especially if the drinking problems are less serious.19 Modest evidence about remission from other substances also suggests that high rates of cessation occur without treatment,20 although data on respondents’ drug abuse or dependence were not reported. The earliest empirical evidence that "hard" drug users can achieve remission, despite never receiving treatment, was based on a sample of male soldiers who had been opiate users in Vietnam and then decreased or stopped their use on return to the United States.10 More recent research supports the argument that remission from heroin use most likely occurs without treatment,21 although treatment-related remission may be more likely than spontaneous remission for users who are dependent on heroin.22
Insofar as posttreatment factors that support sustained remission are independent of the treatment experience, studies of relapse following treatment were used to identify relevant predictors of remission in this community sample, along with cross-sectional studies of the correlates of substance abuse among ethnic minority women. Three main categories were identified: individual (sexual abuse history, psychiatric symptoms, and levels of social status attainment), interpersonal (relationship with a partner and social support from family and friends), and institutional (contact with social, health, and criminal justice systems). Low socioeconomic status, comorbid psychiatric conditions, and lack of family and social supports are consistent markers of noncompliance with treatment and relapse following treatment completion.23 For women in particular, symptoms of depression are believed to play an important role in persistence of substance abuse.24-26 Relationships with a partner are associated with treatment retention,27 posttreatment drug use continuation,28-29 and drug use persistence.30 Childhood experience of sexual abuse is a significant predictor of drug use disorder, as well as a risk factor for unsuccessful treatment.31 Health services research suggests that remission among the most serious substance users tends to be associated with the use of health services rather than addiction or mental health treatment.32-35
This study aims to advance our understanding of remission using data from the Inner-City Latina Drug Use Study (ICLDUS),36 a community-based longitudinal study of women who live in the extended metropolitan area of San Juan. First, we describe patterns of remission in terms of reductions in the number of DSM-IV drug dependence criteria and total cessation of drug use. Both types of remission are considered because a sole focus on cessation of all drug use would overlook the chronic relapsing nature of drug and alcohol addictions, which is underscored by a literature review that reported that 40% to 60% of samples return to substance use within a year of treatment and that a smaller proportion (15% to 30%) returns to dependent use.37
Second, individual, interpersonal, and institutional predictors were analyzed separately and together to identify the characteristics that remain significant in the context of risk factors from other domains. By identifying key predictors, and the type of remission for which they are most salient, the results may be useful for program planners and clinicians who seek to support women’s efforts to stop using drugs.
METHODS
STUDY DESIGN
The ICLDUS is a 3-wave longitudinal research project funded by the National Institute on Drug Abuse, fielded between April 1997 and October 2000, in San Juan, to study drug use patterns and correlates among low-income, inner-city women, aged 18 to 35. Two groups of women were recruited: crack cocaine and injecting drug users from drug sale areas and non–drug users who lived within a 1.6-km radius of these areas. Because the research question focuses on remission from substance use and dependence, only respondents from the first sample were included in the analysis.
A 2-stage sampling procedure was used. First, research staff visited locations that had constituted the sampling frame of a prior study38 and updated the list, including new areas and excluding areas that had closed down, only operated at night, or did not service female clients. Sixty areas were identified and ordered by random assignment for the purpose of recruitment.
During the first year of the study, 316 women were approached at the drug sale areas. Three women refused to participate, and 38 were ineligible because of the age criteria, yielding 275 female drug users in the baseline sample (time 1 response rate, 98.8%). On average, 16.5 months elapsed between times 1 and 2, and 10.1 months between times 2 and 3. Ten percent could not be located at times 2 and 3 for interviews, 4.4% were not reinterviewed at time 2, and 6.6% were not reinterviewed at time 3, but they provided information for the other data collection periods. Substance use patterns did not differ significantly between the women with complete and incomplete data according to analyses of variance adjusted for multiple comparisons, with a mean of 4.7 drug dependence symptoms experienced at time 1 by women with complete information, 4.5 among women missing at time 2 only, 5.3 among women missing at time 3 only, and 5.1 among women missing at times 2 and 3.
Urine and hair samples for drug assays, as well as serum for human immunodeficiency virus (HIV) testing, were obtained from consenting participants. Data from urine tests are particularly important for this sample, who may underreport drug use because of a strong stigma associated with illicit drug use among Latino groups39 and because women may face greater consequences for reporting drug use than their male counterparts.40
The women were offered HIV and sexually transmitted disease precounseling and were given a directory of sexually transmitted disease and drug treatment facilities. All recruitment and follow-up procedures were consistent with the study protocol approved by the Institutional Review Board of the University of Puerto Rico Medical Sciences Campus.
MEASURES
Substance Use, Dependence, and Remission
Respondents reported on their use of 8 illicit substances (crack cocaine, cannabis, opiates, sedatives, amphetamines, hallucinogens, inhalants, and phencyclidine [phenylcyclohexyl piperidine]), as well as alcohol. Results of urine tests for crack cocaine and heroin, the most prevalent drugs in this sample, were included to improve the accuracy of drug use estimates. The urine tests were conducted with a rapid on-site protocol that has shown a sensitivity of 100%, specificity of 90%, and efficiency of 95.1% for detection of cocaine and heroin use.41
Substance dependence was measured with the Spanish version of the substance abuse and dependence module of the Composite International Diagnostic Interview (CIDI).42 Past-year dependence was defined by DSM-IV criteria,43 and women who endorsed 3 or more of the criteria for a given drug within the year before interview were counted as substance dependent.
Categorical and continuous measures were used to describe substance use remission patterns. The categorical measure of substance use had 4 levels: (1) no substance use, (2) substance use but no dependence criteria or diagnosis, (3) substance dependence criteria but no dependence diagnosis, and (4) fulfills substance dependence diagnosis. Women who self-reported no substance use but tested positive for drug use on the basis of a urine test were included in the level 2 category. The number of DSM-IV criteria (range, 0-7) relevant to a specific drug at each time point was used as the continuous measure of substance use. For the multivariate analyses, a shift from any use (level 2, 3, or 4) at time 1 to no use (level 1) at time 2 was counted as a yes answer for the dichotomous substance use cessation variable, otherwise as a no. The same assessment was made for changes in substance use between times 2 and 3. A decrease in the number of substance dependence criteria from one time point to the next was considered symptom reduction in multivariate analyses based on the continuous measure.
Predictors of Remission
The model underlying the ICLDUS study design assumes that substance abuse is a multidimensional phenomenon, and information was collected on a wide range of known drug abuse correlates and risk factors, many of which had been used in previous studies36, 44-45 of similar populations. Guided by results of these studies, specific variables from the data set were selected to represent individual, interpersonal, and institutional domains. The distribution of these variables at baseline is presented in Table 1. To minimize multicollinearity in the predictive models, correlational analyses were performed using the time 1 variables, before other data reduction or recoding occurred; variables that were highly correlated with one another (P<.001) were combined into aggregated measures or prioritized for inclusion based on the extent to which they could be targets for intervention.
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Table 1. Characteristics of 275 Women in the Inner-City Latina Drug Use Study at Time 1
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The individual domain included 3 distal and 5 current predictors. Education was a continuous variable based on number of years of education completed, the continuous "substance use problem onset age" was based on the youngest age the respondent reported for any CIDI DSM-IV substance use disorder criteria, and sexual abuse before the age of 18 was indicated if the respondent endorsed any of 4 items regarding sexual relations with someone at least 5 years older than the respondent or with a family member.46 Current predictors from this domain included trading sex for money or drugs in the past year (based on a yes or no question), number of depressive symptoms in the past year from the CIDI depression module,42 physical functioning in the past month based on summed responses to Medical Outcomes Study 36-Item Short-Form Health Survey items (with a high score indicating better physical functioning),47 HIV status (counted as positive if the respondent reported an age at onset of HIV or had a positive HIV blood test result, otherwise not), and religiosity (respondents who answered that religion is "somewhat" or "very important" to them were counted as religious, otherwise not). Interpersonal domain variables addressed the partner’s criminal activity (dichotomized into an indicator variable, with 1 assigned if the total number of 14 possible activities in the past year summed to 1 SD above the mean), social support (a composite measure of family social support and friend social support, each of which was based on 4 items assessing the frequency of behaviors such as expressing interest in the respondent’s well-being, Cronbach  for the items is.87), and drug use among family and friends (coded yes [1] if a family member was identified as a drug user or the number of friends using drugs was >1). The institutional domain included dichotomous measures reflecting past-year contact in the following 5 settings: substance abuse treatment (ie, outpatient, detoxification, methadone, residential, and drug treatment in jail), criminal justice (arrested for any of 12 reasons, including robbery and drug possession or sales), social services, medical services (ie, a physician’s office, health care center, or group practice), and hospitals (ie, admitted for  1 day for a physical health problem).
STATISTICAL ANALYSIS
To control for repeated observations on the same individual, multivariate analyses were based on general estimating equations methods. These methods are based on the assumption that dropout cases are missing completely at random.48 To evaluate if this assumption was satisfied, dropout status was regressed on the variables identified for inclusion in the analyses. The results (data not shown) indicated that dropout status was associated with depressive symptoms (Wald  2 = 3.98, P = .046; means for women with complete and incomplete data are 8.2 and 10.2, respectively) and positive HIV status (Wald 2 = 7.24, P = .007; percentages positive among women with complete and incomplete data are 22.4% and 38.2%, respectively). Given the violation of the assumption about the nature of the missing data, we ran the analyses in 2 ways.49 First, we deleted all women who did not provide data at time 2 or time 3 and ran the analysis on the women who responded at all time points (ie, the complete cases). We also imputed data, guided by the results of the attrition analysis. Specifically, for women who were missing at time 2 or time 3, the number of depressive symptoms was set to 10.2, and HIV status was set to 1, indicating yes. Mean values for the other predictor variables were estimated based on the women who provided data at time 2 and replaced the missing values for women who were not observed at time 2. The same procedure was used to impute missing values at time 3. The multivariate results presented are based on imputed data.
The person-level data were transformed so that each woman was represented in the data set by 3 data points for each variable (825 observations with imputed data and 767 observations for complete cases). The PROC GENMOD procedure in SAS50 software was used to estimate the multivariate models. Logistic models were run to predict substance use cessation at time t, and multivariate proportional odds models were estimated to predict the probability of reduction in symptoms by time t. For comparability across models, the parameter estimates and corresponding 95% confidence intervals were exponentiated, and odds ratios (ORs) are reported. Each domain was first analyzed separately to identify the variables that were associated with the outcomes, and then the domains were entered together to identify the predictors that remained significant when controlling for other domains.
RESULTS
Table 2 shows the longitudinal aggregate patterns of substance use. All of the women reported some level of drug use at time 1, and 86.9% qualified for past-year substance dependence, with a mean number of 4.9 criteria. Most of the women were dependent on heroin or cocaine, and about one quarter of the women had co-occurring alcohol dependence. One tenth (10.6%) were not dependent but endorsed 1 or 2 DSM-IV criteria as assessed by the CIDI, and 2.6% reported substance use but did not endorse any diagnostic criteria. Over time, the rate of dependence declined significantly (F = 17.65, P<.001), as did the mean number of symptoms experienced (F = 7.97, P<.001), while the rates of substance use increased (F = 4.65, P = .01). At time 2, no substance abuse was reported by 9.1%, but about 40% of these women tested positive for cocaine or heroin. Incorporating this information into the prevalence estimate results in only 5.1% of the women with no substance use and in 9.5% of the women with substance use but no report of dependence symptoms. At time 3, fewer than half (42.6%) of the women were dependent, and 13.8% reported symptoms only. Based on adjustments because of positive urine screens for women who had self-reported no substance use, 17.8% of the women used substances without reporting symptoms at time 3.
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Table 2. Substance Use and Dependence Among 275 Women in the Inner-City Latina Drug Use Study by Time Point*
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Individual-level patterns of substance use among women who were interviewed at each time point show that 86.2% of women were persistent users, 3.2% did not use substances at either of the follow-ups, and the remainder fluctuated from use to no use or the reverse (data not shown). The patterns of symptom reduction are more complicated. About one third (33.7%) of the women followed pathways that suggest continued improvement (eg, no symptoms at time 2 or time 3, fewer symptoms at time 2 than time 1, and no symptoms at time 3).
Results from the models predicting cessation from substance use are presented separately for each domain in the "Partial Models" columns of Table 3. In the first model, 2 elements of the individual domain (ie, engaging in sex work and physical functioning) are significantly associated with cessation of substance use. Women who trade sex for money or drugs are substantially less likely (OR, 0.07) to stop using substances compared with women who do not, and women with positive physical functioning are more likely to stop drug use. In the interpersonal domain, partner criminality reduces the probability of cessation by close to 75%; on the other hand, women with high levels of social support are close to twice as likely to stop substance use compared with women with low levels of social support. Only substance abuse treatment in the institutional domain predicts cessation; women who had contact with any substance abuse service in the past year were less likely to stop using substances (OR, 0.42).
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Table 3. Predictors of Drug Use Cessation Among Women in the Inner-City Latina Drug Use Study*
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When all the domains are analyzed together (Table 3, "Full Model" columns), the relationships between several of the variables in the individual domain and cessation shift modestly. For example, depressive symptoms, which had been significant at the margin (P = .059) in the partial model, significantly reduce the odds of cessation in the full model (OR, 0.92), whereas positive feelings about religion increase the odds of cessation (OR, 1.64). A partner’s criminality persists as an interpersonal correlate of cessation in the full model, and none of the institutional variables are significant. There was little difference between these results and the results of the models that used data on complete cases only; the same parameters were significant, but at P<.05 rather than more conservative levels of significance.
Overall, more of the estimates of remission from symptoms are significant than estimates of cessation of use (Table 4). Significant predictors in the partial models include education, sex work, depressive symptoms, and physical functioning (individual domain). Women who trade sex for money or drugs are about one fourth less likely (OR, 0.25) to improve (ie, experience fewer symptoms) as women who do not, and with each additional CIDI depressive symptom, the probability of symptom reduction decreases by approximately 10% (OR, 0.87). On the other hand, women with positive physical functioning are more likely to report a reduction in drug symptoms. All of the interpersonal predictors in the partial model are significantly associated with symptom remission. Partner criminality and drug use among family or friends are associated with lower odds of remission (OR, 0.57 and 0.54, respectively), while social support significantly increases the odds of remission (OR, 1.22).
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Table 4. Predictors of Drug Dependence Symptom Remission Among Women in the Inner-City Latina Drug Use Study*
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All of the institutional predictors, with the exception of social service contact, significantly predict remission. However, the association is positive only for women who received medical care in the prior year; the probability of remission increases by about 70% when women receive medical care compared with when they do not. Hospitalization, arrest, and substance abuse treatment are predictive of lower odds of remission.
Results of the full model for symptom remission are consistent with those of the partial models. Seven of the 11 significant predictors from the partial models are also significant in the final model, but drug use among family or friends, social support, being arrested, and hospitalization are not significant in the full model. When the models were rerun for cases with complete data, the estimates for education and physical functioning were no longer significant.
COMMENT
Most women in this community sample were dependent on substances or had problems associated with substance use when they were recruited. Although there was a significant reduction in substance dependence and number of symptoms over time, most women continued to use substances during the subsequent 2 years, often with some accompanying substance dependence symptoms. Although caution should be exercised when comparing the ICLDUS and other longitudinal community-based studies because of substantial differences in sample characteristics or the type of substances studied, it is notable that the rates of persistence and numbers of dependence symptoms tend to be substantially higher in the ICLDUS. An exception comes from a prospective study51 of older, predominately white male problem drinkers, in which only approximately 10% resolved their drinking problems. On the other hand, studies such as a 1-year follow-up of long-term cannabis users in Australia found that half of the persons who remitted from dependence reported no drug use whatsoever,52 and in a rural, predominately white sample, alcohol dependence decreased from 41% to 16% in 18 months.53 Self-reports in these studies were not supplemented with urine tests, however. Other studies54-55 of persons with severe alcohol dependence report that abstinence is more likely than controlled drinking, with the implication that controlled drinking without relapse is difficult to sustain for formerly dependent persons. Additional data are needed to determine the extent to which the persistence of substance use in the absence of meeting diagnostic criteria is a predictor of recurrent disorder or an expected stage in the achievement of complete abstinence.
The trading of sex for money or drugs is the most consistent predictor from the individual domain, significantly decreasing the odds of symptom reduction and use cessation in partial and full models. Depressive symptoms also appear to be an important individual factor in both remission outcomes, as does physical functioning. Religiosity is the sole characteristic to be significant in only one model (ie, the full model predicting drug use cessation). A partner’s criminality is a robust negative predictor in the partial and full models for symptom remission and substance use cessation, whereas other interpersonal variables are not significant in the full models. When all domains are considered jointly, none of the institutional domain variables are significantly associated with drug use cessation, but medical care and substance abuse treatment are significantly associated with symptom remission.
Sexual abuse history was not a significant predictor of either outcome, possibly because the measure did not assess severity or duration. Moreover, the measure was designed to capture the distal experience of sexual abuse during childhood, and as such its effect on substance use may be mediated by recent experiences of physical attack or rape56 or ongoing psychosocial responses to the abuse.57-58 Together with other research that shows more effective outcomes when substance abuse treatment providers address issues related to sexual abuse,59-60 these results suggest that a history of abuse may be important to address once women are involved in treatment. Substance abuse interventions that seek to engage women in treatment may need to attend to current partner issues, especially those related to the criminal activity of the partner, and to the economic and psychosocial mechanisms that support trading sex for money or drugs.
It is also possible that the effect of sexual trauma during childhood might be indirectly captured through current depressive symptoms among the women in the ICLDUS. This interpretation is supported by a longitudinal study61 of posttreatment drinking outcomes in which the significance of sexual abuse history disappeared when depression and other psychiatric disorders were added to the models. The strong association between depressive symptoms and lower probabilities of remission and cessation in the ICLDUS is also consistent with studies4, 62-64 that show associations between depression and relapse to drug use after treatment.
The effect of the variables in the institutional domain is important to examine further with data that provide more refined measures of temporal ordering within the year before interview. In particular, the present study indicates that substance abuse treatment is associated with lower odds of remission from drug dependence symptoms and has no significant relationship with cessation of drug use. Although conclusions regarding a causal connection are not justified, women with the most severe substance abuse at any point in the past year may be the most likely to receive treatment, and detection of a substantial change in their drug use behavior would require a longer follow-up. It is also possible that the drug abuse services available to these women do not include sex-specific programs, which have been shown to yield positive outcomes for women.59, 65 An alternative explanation is that drug treatment programs as implemented are intermittently helpful in decreasing the negative consequences that accompany women’s drug use and in improving functioning, but they do not solve the interpersonal and individual problems that influence continued drug use.
In the ICLDUS, rates of contact with drug treatment providers and health care providers are similar, but health care use resulted in significantly positive outcomes in the multivariate models (ie, symptom remission). Although these data do not allow examination of the actual services received in health care settings, the results suggest that engaging women in the recovery process may be achieved through an emphasis on health rather than drug use behavior or on collaborative service delivery between health care and substance abuse providers.51, 63, 66-67 Such an emphasis may minimize the stigma associated with drug abuse treatment. Moreover, it may offer opportunities to develop effective ways to manage symptoms of depression and to develop positive relationship skills.
The complicated missing data patterns, which are likely a reflection of the disorganized lives of the women in the study, presented some analytic challenges. Data were incomplete for about one fifth of the women in the sample, who were more depressed and more likely to be HIV positive than women with complete data. However, analyses based on complete case data and imputed data yield similar results, suggesting that the predictors identified are robust regardless of follow-up pattern.
The results should be interpreted with some caution because of the sample size. Substance use cessation is rare, and a larger sample could have resulted in a greater number of significant predictors. Similarly, the levels of significance associated with the predictors decreased when all the domains were analyzed together for substance use cessation and symptom remission models. Replication of the study with a larger sample size is needed to discern the effect of specific predictors when multiple variables are controlled for.
The urinalysis measure in addition to self-report measures of drug use provided more accurate information about drug use than would otherwise have been available, because the women who self-reported no drug use but had positive urine screens could be counted as users. However, it was not possible to determine if these women were drug dependent or experienced any drug dependence symptoms, possibly biasing downward the estimates of symptom reduction and substance dependence.
With these limitations in mind, the ICLDUS provides a unique opportunity to study longitudinal changes in substance use behavior in a high-risk community sample. The results indicate that outreach and treatment efforts may be most effective when they are coordinated with programs that address women’s socioeconomic and mental health needs, or if multimodal programs are developed. In particular, the salience of trading sex for money or drugs argues for targeted outreach to these drug users. Once engaged, positive outcomes are more likely to be achieved when program objectives include identifying and treating women’s depression, increasing women’s capacity for developing healthy relationships, and developing viable work strategies as alternatives to sex work.
AUTHOR INFORMATION
Correspondence: Lynn A. Warner, PhD, School of Social Work, Rutgers University, 536 George St, New Brunswick, NJ 08901 (lywarner{at}rci.rutgers.edu).
Submitted for Publication: November 7, 2003; final revision received April 15, 2004; accepted April 21, 2004.
Funding/Support: This study was funded by grant DA A09438-05 from the National Institute on Drug Abuse, Bethesda, Md.
Previous Presentation: This study was presented previously at the Latino Research Program Project Young Investigator’s Conference; July 3, 2001; San Juan, Puerto Rico.
Acknowledgment: We thank Patrick Shrout, PhD, for assistance with analysis in an early version of the manuscript.
Author Affiliations: School of Social Work, Rutgers University, New Brunswick, NJ (Dr Warner); Harvard University and Cambridge Health Alliance, Boston, Mass (Dr Alegría); and School of Medicine, University of Puerto Rico, San Juan (Dr Canino).
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