The data of this study were collected as part of a community-based HIV prevention project in San Antonio, Texas. Outreach workers distributed bleach, condoms, and educational material to IDUs on the street. However, their primary focus was to reduce HIV transmission by encouraging drug users to enter drug abuse treatment and by facilitating their entry into treatment. A semi-structured questionnaire consisting of 60 questions was administrated by outreach workers to 1100 IDUs between February 1993 and May 1995. The questionnaire included section on socio-demographics, drug use history, current drug use, treatment history, injection-related HIV risk behavior, sexual behavior, and previous contact related to HIV prevention. In this report we focus on one key item from the questionnaire: "Does the respondent want treatment?"

The sample was 67% male. Sixty-eight percent were Hispanic, 18% African-American, and 14% non- Hispanic white. Seventy-eight percent were unemployed and 56% had less than a high school education. Sixty-seven percent wanted treatment, 64% were eligible for methadone maintenance, and 43% had never been in treatment. Only 2% were HIV positive.

The following characteristics of IDUs who wanted treatment have implications for policy makers. Less than 10% reported full-time employment and fifty-four percent had less than a high school education. Thirty-eight percent were women, and 54% of these had at least one dependent child. Seventy-six percent were primary heroin users, and 77% were eligible for methadone maintenance. Almost two-thirds of those who wanted treatment and were eligible for methadone maintenance reported using cocaine in the past 30 days. These findings reinforce previous studies and emphasize the need for methadone maintenance programs to develop effective strategies for reducing cocaine use among their patients.3,4

Additional statistical analysis identified four independent predictors of wanting treatment. These included injecting at least 30 times a month, being eligible for methadone maintenance, a history of at least two previous treatment admissions, and being enrolled after the first year of the project. The association being eligible for methadone maintenance and wanting to enter treatment suggests that substance abuse treatment as an HIV prevention strategy may be most appropriate in cities where a majority of IDUs are dependent on heroin. The independent association between frequency of injection and wanting treatment suggests that, regardless of the specific drug used, IDUs who inject more frequently are more likely to want treatment than IDUs who inject less frequently. These two findings are important because studies have shown that methadone maintenance is effective in reducing HIV risk behaviors, and studies have identified frequency of injecting as a risk factor for HIV infection.

The independent association between two or more previous treatment admissions and wanting to enter treatment is not surprising. It illustrates the chronic, relapsing nature of addiction, and it emphasizes the need to augment efforts to get IDUs into treatment with interventions and program policies designed to increase retention.

William A. Zule, Dr.P.H.

David P. Desmond, M.S.W.

Kenneth N. Vogtsberger, M.D.

Department of Psychiatry
University of Texas Health Science Center at San Antonio

1. Hubbard RL, Marsden ME, Cavanaugh E, Rachal JV and Ginzburg HM: "Role of drug abuse treatment in limiting the spread of AIDS." Rev Infect Dis. 10:377-384 (1988).
2. Sisk JE, Hatziandreu EJ, and Hughes R: The effectiveness of drug abuse treatment: Implications for controlling AIDS/HIV infection. Background Paper 6, September, 1990. Office of Technology Assessment, Congress of the United States, 1990.
3. Rawson RA, McCann MJ, Hasson AJ, and Ling W: "Cocaine abuse among methadone maintenance patients: are these effective treatment strategies." J Psychoactive Drugs. 26:129-136 (1994).
4. Condelli WS, Fairbank JA, Dennis ML, and Rachal JV: "Cocaine use by clients in methadone programs: significance, scope, and behavioral interventions." J Subst Abuse Treat. 8:203-212 (1991).

During alcohol withdrawal, the HPA axis is stimulated, and glucocorticoid levels dramatically increase. It appears that increased levels of the glucocorticoids can worsen alcohol withdrawal. For instance, if a rat is given alcohol for several days and the alcohol is then removed, the animal will experience more severe withdrawal if corticosterone is also given. Conversely, if corticosterone release during withdrawal is suppressed, the animal's withdrawal symptoms are not as severe.

The administration of a synthetic glucocorticoid may therefore be effective in decreasing HPA axis stimulation during withdrawal. By activitating the negative feedback loop, the synthetic glucocorticoid would decrease the body's release of cortisol. Over the past 50 years, a number of reports have suggested that glucocorticoids have lessened alcohol withdrawal severity. In the late 1940s and early 1950s, clinicians reported that the administration of adrenal cortical extract (which contained cortisol) brought "quick and complete relief" from withdrawal symptoms and that the "torturing drying-out period is practically eliminated."1,2 More recently, patients experiencing severe withdrawal and not responding to traditional drug therapy were successfully treated with intravenous dexamethasone, a synthetic glucocorticoid.3

In order to more carefully assess the potential effectiveness of the glucocorticoids in the treatment of alcohol withdrawal, we compared the effects of the glucocorticoid dexamethasone to no dexamethasone in a group of sixteen alcohol dependent men admitted for detoxification at the Substance Abuse Treatment Center at the VA Medical Center in Charleston, SC. Patients were heavy daily drinkers without other active substance abuse and had been drinking within the past 24 hours. The tranquilizer lorazepam was given to treat withdrawal symptoms every eight hours, as needed, for 72 hours. Lorazepam 2 mg was given only if withdrawal severity was at least mild to moderate in severity [as determined by the Clinical Instrument Withdrawal Assessment - Alcohol Revised (CIWA-AR)]. Eight patients were given 4 mg dexamethasone intravenously shortly after admission and when their breath alcohol concentration was less than 100 mg%. Eight other patients, the comparison group, were not administered dexamethasone. The effectiveness of dexamethasone was determined by (1) measuring the CIWA-AR just prior to and then one hour after dexamethasone administration, and (2) comparing the doses of lorazepam needed between the group given dexamethasone and those not given dexamethasone.

There were no significant baseline clinical differences between the group of patients given dexamethasone and those treated with lorazepam only. There was not a significant difference between the amount of lorazepam required to treat withdrawal symptoms in the dexamethasone group (meanñSD, 4.2ñ1.2 mg) compared to the control group (3.5ñ2.6 mg). Although withdrawal severity in the dexamethasone group decreased significantly one hour after dexamethasone, this change was not clinically significant.

These findings would suggest that dexamethasone, in doses expected to suppress withdrawal-associated HPA axis activation, is not effective in the treatment of the alcohol withdrawal. However, there were design problems that may have obscured a clinical effect. First, patients only showed mild to moderate symptoms of withdrawal before treatment. A clinically significant response to dexamethasone, therefore, may have not been easily apparent. On the other hand, withdrawal severity required treatment with lorazepam in all but two of the 16 patients. Second, a placebo control group was not used. Third, since plasma cortisol levels were not obtained, it cannot be certain the dose of dexamethasone was high enough to assure cortisol suppression.

These findings may suggest that the previous studies, showing that glucocorticoids were effective in treating alcohol withdrawal, was a fortuitous observation. Alternately, the effectiveness of dexamethasone may only be apparent in alcohol dependent patients experiencing severe withdrawal symptoms. Given the potential usefulness of HPA axis suppression in treating withdrawal, based on pre-clinical studies, this treatment modality deserves further evaluation.

Bryon Adinoff, M.D.
Department of Psychiatry
University of Texas Southwestern Medical Center
VA North Texas Health Care System
Dallas, TX

Birgit Pols, M.D.
The Community Project
New York, NY

1. Tintera JW, Lovell HW. Endocrine treatment of alcoholism. Geriatrics 1949;4:274-280.
2. Wilson DC, Elbirlik K. The use of adrenal cortical extract in cases of acute alcoholic intoxication. Neuropsychiatry 1953;3:56-62.
3. Fisher DK, Simpson RK, Smith KA, Mattox KL. Efficacy of dexamethasone in benzodiazepine-resistant tremens. Lancet 1988;1:1340-1341.

The current study was a prospective investigation on the use of alcohol in depressed outpatients who were in long-term pharmacologic treatment with fluoxetine. The purpose of the study was to assess the use of alcohol and its effect on patients' ability to complete a continuation/maintenance treatment study and to examine the effects of continuation treatment with fluoxetine on the consumption of alcohol.

Subjects were outpatients who met DSM-III-R criteria for Major Depressive Disorder according to the SCID-P. Patients had a Hamilton Depression Rating Scale-17 item version (HAM-D-17) 3 16 at screen and baseline. Patients who showed full response after 8 weeks of open treatment with fluoxentine 20 mg/day were enrolled into the continuation study. Extensive criteria included alcohol abuse/dependence, bipolar disorder, psychotic disorders, serious suicidal risk, and serious or unstable medical illness. Alcohol consumption was assessed in all patients at entry point of the continuation phase, as well as month 4 and month 7.

The results of this study suggest that those depressed patients, who do not abuse alcohol, but do consume alcohol at the start of the continuation phase, are less likely to complete pharmacological treatment than those who do not consume alcohol. A clinical implication of our study is that depressed patients would benefit from abstaining from alcohol intake prior to and during continuation antidepressant treatment. This is consistent with our earlier report showing that, in a research protocol of depressed outpatients, whose average alcohol intake was less than one ounce per day, the degree of alcohol consumption before starting the antidepressant was a significant predictor of poorer outcome. Methodological limitations of both studies included the fact that data on alcohol consumption was collected via patient interview and was not confirmed with blood levels. Another limitation is the possibility that fluoxentine administration itself changed the alcohol blood level, or the central nervous system effect of alcohol, thus affecting the ingested amount of alcohol by the patients. Further studies investigating the relationship between treatment of depression and subsyndromal consumption of alcohol are ongoing at our center.

John J. Worthington III, M.D.
Clinical Psychopharmacology
Massachusetts General Hospital

1. Kessler RC, McGonagle KA, Zhao S, Nelson CB, Hughes M, Eshleman S, Wittchen HO, Kendler KS: Lifetime and 12-month relevance of DSM-III-R psychiatric disorders in the United States. Arch Gen Psychiatry 1994; 51:8-19.
2. Fava M, Kaji J: Continuation and maintenance treatments of major depressive disorder. Psychiatric Annals 1994; 24/6:281-290.
3. Coryell W, Winokur G, Keller M, Scheftner W, Endicott J: Alcoholism and primary major deprrexisting disorders. J Aff Dis 1992; 24:93-99.

We examined data on women IDUs encountered in outreach during the National AIDS Demonstration Research (NADR) in four cities as well as data from the Methadone Enhanced Treatment (MET) study in the same four cities. Respondents were interviewed when they were first encountered in outreach or as they entered the methadone program. To minimize the effect of any differences caused by the initial interviews being conducted at different times, only data from the time periods when both the outreach and treatment programs in a site were conducting interviews were compared. The data collection period varied slightly by site, but the overall time period was from November 1989 to December 1991.

Respondents in both the outreach and treatment programs were interviewed using the AIDS Initial Assessment (AIA) instrument (National Institute on Drug Abuse [NIDA], 1988). These structured interviews were designed to assess the patterns, frequency, and route of drug use as well as risk for contracting or spreading HIV through drug use and sexual behavior. Assessment of these variables allows for identification of differences between out-of-treatment women injectors (NADR) and those enrolled in methadone treatment (MET).

For purposes of ongoing analysis, the sample consists of respondents for whom both intake and follow-up data is available; however, this study is cross-sectional only. The methadone treatment sample consists of 204 women IDUs drawn from four methadone treatment programs, one in each of four cites. Similarly, the outreach sample consists of 394 women IDUs drawn from four outreach programs, on in each of the same four cities. The data from the AIA are largely categorical with discrete variables such as drug patterns, frequently of use, and descriptive data presented in proportions. Therefore analysis was typically performed with chisquares for testing differences between the two groups of women.

The results indicate significant differences in race, drugs used (both injecting and non-injecting), injecting risk behavior, and treatment history. However, the two groups of women shared similar histories of first injecting use and sexual risk. Women who entered methadone treatment reported higher frequencies of injecting drug use and HIV risk behaviors, both direct (sharing needles) and indirect (sharing cookers, cotton, and water); yet they were also more likely to clean needles and to use new needles than the women encountered through outreach. The outreach women were more likely to be African American, to inject less than daily, and to use alcohol, crack and non-injecting cocaine daily.

The results suggest that women injectors entering treatment and those encountered in outreach are very different in their injecting intensity and HIV risk behaviors. However, both groups are still at risk for HIV infection, particularly as a result of multiple sexual partners and little reported condom use. The need of identify the risk, reinforce risk reduction maintenance, and further develop HIV prevention strategies that successfully address both the needs of these women and the differences that exist between them will be essential to stopping the spread of HIV.

Wendee M. Wechsberg, Ph.D.

Elizabeth R. Cavanaugh, B.A.

Research Triangle Institute
Research Triangle Park, NC

Editor's Note: This article is from the abstract for "Differences Found Between Women Injectors In and Out of Treatment: Implications for Intervention," co-published simultaneously in Drug & Society, The Hawthorne Press, Inc., Vol. 13. Nos 1/2, 1998, and Women and Substance Abuse, ed: Sally J. Stevens and Harry K. Wexler, The Hawthorne Press, Inc., 1998.

What is revealed is that numerous studies have now documented that significantly lower rates of drug use and related risk behaviors are practiced by injection drug users who are in treatment. Importantly, these behavioral differences, based primarily on self-report, are consistent with studies that have examined HIV seroprevalence and seroincidence among drug users.

The underlying mechanism of action suggested by the collective findings of the available literature is rather simple-individuals who enter and remain in treatment reduce their drug use which leads to fewer instances of drug related risk behavior. This lower rate of exposure results in fewer infections with HIV.

The protective effects of treatment, however, can only be achieved when programs are accessible and responsive to the changing needs of drug users. Future research needs to be directed at developing a better understanding of the factors that enhance treatment entry and retention.

David S. Metzger, Ph.D.
Director, Opiate/AIDS Research Division
Center for Studies of Addiction
University of Pennsylvania/VA Medical Center

Helen Navaline, B.A.
Research Coordinator, Opiate/AIDS Research Division
Center for Studies of Addiction
University of Pennsylvania/VA Medical Center

George E. Woody, M.D.
Director, Drug Dependence Treatment Unit and Opiate/AIDS Research Division
Center for Studies of Addiction
University of Pennsylvania/VA Medical Center

Editor's Note: The complete article is scheduled to be published in the June issue of PUBLIC HEALTH REPORTS.