Research has shown that patients seeking detoxification report a pervasive need for a variety of desired aftercare services (eg, employment services, self-help meetings, transportation, housing, individual or group counseling, education, medical treatment, social services, vocational training, supportive medicine, psychiatric treatment, relationship counseling, or legal assistance).22
However, many opioid-dependent patients receive detoxification only, and repeated admissions for detoxification treatment are common.14
This multisite national study of patients seeking opioid detoxification identifies differential treatment needs for various groups, and the results are useful for informing aftercare and need-service matching interventions to improve care for the growing, diverse opioid-dependent population, and for possibly reducing emergency room and other high-cost medical services by tailoring treatment to specific patient needs.
Clinical studies of gender differences have focused mainly on cocaine-dependent patients or patients with different drug dependences.24
Generalizability of results from these studies to opioid-dependent patients is limited and complicated by small sample sizes, descriptive results, or a different drug-use focus. These studies show mixed results in pattern of drug use, but generally suggest greater drug-related problems in women than in men. The present study adds new data to the literature of opioid dependence by examining a geographically diverse sample recruited from 12 sites and by applying adjusted procedures to make direct comparisons between genders and racial/ethnic groups for multiple clinical indicators. Our results revealed that women used more nonheroin opioids and had more psychiatric and family/social relationship problems, while men used more heroin and reported more problems related to alcohol use and criminal activities. Additionally, women resembled men in HIV risk scores, but women reported poorer quality of life.
These discrete patterns emphasize the need for gender-specific psychosocial interventions in addition to standard treatment for opioid dependence to improve treatment retention and response.28
For example, relationship or mental health problems, as well as childcare or transportation concerns, may be more likely to interfere with women’s treatment use than that for men; thus, women can benefit from ancillary services tailored to address these issues.29
For men, treatment could incorporate motivational interviewing to address alcohol use problems or legal services to assist with legal problems. Of note, recent research has shown the benefits of male-targeted interventions in addressing motivation, communication skills, sexuality, or HIV risk.32
Clearly, this understudied area warrants more research to develop male-specific interventions tailored to men’s unique areas of concern. Furthermore, quality of life has increasingly been considered a crucial outcome measure in addiction treatment trials.5
The finding of poor quality of life in women indicates that baseline measures of quality of life should be included as a control variable in the analysis of treatment response to mitigate its confounding effects.
The results also highlight significant public health concerns for whites and Hispanics. Whites not only had a greater likelihood of using prescription drugs (than African Americans) and cannabis (than Hispanics) and of engaging in more risky injection drug use (than African Americans), but they also showed more psychiatric and family/social relationship problems (than African Americans) and poorer quality of life (than African Americans and Hispanics). Although African Americans used more heroin and cocaine than whites and experienced greater employment problems than whites, they reported lower levels of risky injection drug use (than whites and Hispanics) and exhibited better mental health and social functioning (than whites). Thus, whites show more psychopathology and HIV risk than African Americans. Our additional analyses did not find the impact of psychiatric severity on HIV risk scores,21
suggesting that the association between race/ethnicity and HIV risk behaviors is robust.
These findings of an elevated level of HIV-related injection drug use risk among whites are worrisome because recent evidence has suggested a growing rate of injection drug use in young white adults,11
and young injection drug users generally engage in a high level of risky injection and sexual behaviors.34
Further, opioid addiction and drug-related problems may be more detrimental to whites’ social support, family functioning, and mental health than to those of African Americans. Bourgois et al35
have reported that, although African American heroin users generally have a more pervasive history of incarceration than white users, they often have maintained long-term ties with their families. In contrast, white heroin users are more likely than African American users to be expelled from their families and to perceive themselves as being defeated by addiction as their problems escalate. This study also reveals a better quality of life and family/social functioning among African Americans than among whites.
Taken together, whites may benefit from interventions tailored not only to their risky injection drug use, but also to issues related to psychiatric problems, social support, and family problems. For African Americans, their higher level of employment problems than whites may be related in part to earlier or prevalent involvement with illicit drugs (heroin or cocaine) and the criminal justice system, thereby potentially hindering educational attainment.35
This distinct pattern of greater employment problems and cocaine use among African Americans has important implications for intervention. For instance, greater addiction severity, employment problems, cocaine use, and African American race have been found to be associated with an increased rate of attrition from methadone maintenance treatment programs.37
Therefore, the provision of additional vocational services or supportive employment counseling, in addition to standard treatment for opioid dependence, can be useful in improving both employment and substance use problems.39
The last issue concerns Hispanics’ elevated level of HIV risk behaviors in both risky injection drug use (greater than African Americans) and unprotected sexual behaviors (greater than whites). Regardless of gender, the rate of new HIV infections among Hispanics in the US is about 2–4 times higher than that of whites.41
HIV obviously has become a serious threat to Hispanics in the US. Unfortunately, HIV-related interventions have faced many unique challenges because Hispanics as a group in the US are considerably diverse in their cultural backgrounds. Their comparatively high rates of poverty, low education, and lack of insurance, along with language barriers, immigration issues, and diverse cultural beliefs about sexuality, have further impeded HIV prevention and treatment efforts.42
Consequently, Hispanics have a comparatively low rate of HIV testing and a high rate of late HIV diagnosis.43
These findings clearly highlight the need for research to monitor and discern patterns of HIV risk behaviors continuously and to develop culturally and linguistically appropriate HIV risk reduction interventions to meet the diverse needs of Hispanics.
This study has some limitations. The results are based on treatment-seeking opioid-dependent adults who participated in Clinical Trials Network studies. The sample is not necessarily representative of all opioid-dependent patients. Another limitation is reliance on patients’ self-reports, which are subject to recall or reporting bias. Nonetheless, studies have found that self-reported drug use patterns and HIV-related injection and sexual behaviors among drug users are generally reliable.19
In addition, due to confidentiality concerns, information on study sites was removed from the deidentified data files used for this research, and was not included in the analysis. Lastly, the small sample size of the “other” racial/ethnic group constrains the power to compare clinical characteristics of this group with those of whites, African Americans, or Hispanics.
Nonetheless, the multisite studies of the Clinical Trials Network also have noteworthy strengths not available from studies of participants from a single site. The participants were recruited from 12 major treatment programs at two treatment modalities across the nation, making them more generalizable than those found in single-site studies. All participants were assessed by an identical set of standardized instruments (Addiction Severity Index, HIV Risk Behavior Scale, SF-36) with demonstrated reliability and validity in clinical samples to allow for comparisons across treatment settings.