Abstract
MORE was a mobile outreach drug abuse prevention and HIV harm reduction program primarily for ex-offenders who are active drug users. Through case management, clients were provided substance abuse education, counseling, and referral. Long term goals of these services were to reduce their drug use and re-incarceration for drug related crimes. From January 2002 to May 2006, 487 unduplicated clients were recruited in year long cohorts and offered services. The program evaluation tool was the Federal Office of Budget and Management Government Performance and Results Act questionnaire. Government Performance and Results Act interviews were conducted at in-take into the program, approximately six months later and again approximately 12 months after their initial in-take.
By the six and 12 month follow-up interviews, active drug using clients reported significant reductions in their use of alcohol, cocaine/crack, heroin, and fewer sex partners and crimes. Program completers reported significantly reduced cocaine/crack and heroin use as well as fewer days in jail and crimes than non-completers (p < .01 to .001). Six program components account for these reductions: case management, day-treatment, outpatient services, outreach, HIV/AIDS, and substance abuse education. The differences in program service intensity, income, and employment for program completers and non-completers were analyzed using logistic regression. The intensity of case management and all services received along with having higher income by month six were the most significant predictors of program completion.
Introduction
A fundamental assumption of drug treatment in the U.S. is that clients must have the ability and willingness to completely abstain from illegal drug use. This is an absolute pre-condition for effective treatment. Having insurance, personal identification, access to treatment, and stable personal-families relationships are some other pre-conditions for effective treatment (CitationAppel, Ellison, Jansky, & Oldak, 2004). One cannot enter a program if the abstinence pre-condition is unmet (CitationClapp & Burke, 2006). Random drug testing is used to monitor clients' compliance and if one is found to have used illegal drugs while in treatment, it is necessary to start the program over or to be dropped as a client. A related belief of many in the treatment community is that illegal drug use is a uniformly flawed state with no degrees of abuse or intermediate phases of any consequence between absolutely compulsive and anti-social drug abuse and abstinence from drug use.
While absolute sobriety may be necessary for recovering addicts to remain “clean” and “sober,” health outreach workers, who work with out-of-treatment drug users, know that there are many ups and downs in addiction related to seeking treatment. Some of their clients can use illegal drugs regularly without becoming more intensely addicted to them while others can decrease their use or stop their drug use altogether for periods of time. One of the great mysteries of drug abuse is still spontaneous recovery, where a long-time drug user loses interest and the need to use drugs, and then stops using on their own without treatment (CitationLatkin, Knowlton, Hoover, & Mandell, 1999). More importantly, some drug users have brief periods where they are willing to go into treatment, go through withdrawal, and achieve abstinence (CitationGuydish, Moore, Gleghorn, et al., 2000; CitationStaff, 2002). This is the phase in drug use that makes treatment-on-demand so important; when a drug user is ready and willing to go into treatment, a program opening must be available before the user's willingness to recover passes.
A disconnect exists between the dictum of abstinence as a precondition for treatment and the actual reality of varied drug use among out-of-treatment addicts. To go from drug use to treatment is similar to expecting an individual to levitate into a second store window because there are no stairs or other ways to gradually reach such heights from the street. Very few active drug users manage to “levitate” into treatment and, interestingly, there is very little research done on treatment initiation (CitationWalton-Moss & McCaul, 2006). Even legal referral and/or social network pressures to quit, cut down, and/or enter treatment does not affect client initiation of treatment (CitationWild, Cunningham, & Ryan, 2006). It is generally believed that their addiction must become so bad (“hit bottom”) that treatment is their only alternative. A consequence of this disconnect is that even if treatment is available on-demand, it is unlikely that it would significantly reduce the numbers of active drug users because of the abstinence first pre-conditions to treatment (CitationReuter & Pollack, 2006).
Medical personnel and outreach workers who are familiar with the chasm between treatment and the reality of drug users have addressed it with “harm reduction.” When drug abuse continues, advocates of harm reduction believe it is important to work towards reducing the harm addicts pose to themselves and to society (CitationLenton & Single, 1998). Street outreach has brought directly to active drug users HIV/AIDS education, medical care, and bleach and condoms to prevent the transition of HIV through needle sharing and sexual contact. Outreach workers and volunteers have also exchanged clean and sterile needles for ones that are potentially contaminated with HIV. All of these measures are done as ad-hoc and stop-gap actions. They are not funded by the federal government and do not exist on a large enough scale to reach more than a small percent of all active drug users. Furthermore, although harm reduction is not value neutral, it can be justified as the lesser of two evils (CitationFry, Treloar, & Maher, 2005). It is assumed that the overriding value of harm reduction measures is to reduce health risks and anti-social behavior among out-of-treatment addicts. Advocates of harm reduction believe that the value exceeds any harm to society and other individuals caused by advocates' support of active drug abusers' addictions and use of illegal drugs.
Prior research has documented the effectiveness of harm reduction measures and suggests potential bridges exist between treatment and the majority of active drug users. For example, methadone maintenance patients who relapsed and received case management were six times more likely to re-enter a methadone program than peers who received passive referrals (CitationCoviello, Zanis, Wesnoski, & Alterman, 2006). Active drug users can conduct an effective HIV prevention intervention among their peers that results in referrals to treatment (CitationDickson-Gomez, Weeks, Martinez, & Convey, 2006). Syringe exchanges may be very important for removing HIV contaminated needles from circulation; but of equal importance is that they are often the only source of medical and preventive care that injection drug users have access to (CitationHeinzerling, 2006). Interventions found to be effective in reducing sex workers drug use and HIV risks include peer education, training in condom negotiation, training in using male and female condoms, and occupational health training (CitationRekart, 2005). A needle exchange program demonstrated that it was an important bridge to treatment. It had dedicated treatment slots available to it and used case management and transportation-on-demand to get willing clients to treatment. Forty percent of the referrals successfully made it to treatment compared to 26% of non-program referred drug users (CitationStrathdee, Ricketss, Huettner, et al., 2006).
The above sample of prior research suggests that a great deal can be done to both access and bridge out-of-treatment drug users to eventual treatment. Bridges to treatment can increase the numbers who seek to end their addiction and may even affect their potential for relapse after treatment. What all of the above efforts have in common is the willingness to work with active drug users without making abstinence a pre-condition. Directly providing them with health and social services and making effective referrals made it possible for a significant number to bridge the chasm between their reality and abstinence-based treatment. This study reports the outcome of one such harm reduction demonstration. Ex-offenders are a particularly difficult sub-population among active drug users to work with (CitationFreudenberg, Daniels, Crum, Perkins, & Richie, 2005). Men and women who are on probation and who have histories of drug use are particularly difficult to work with in treatment because their criminal records and prior drug use disqualify them from most jobs, housing, voting in many states, and even student loans to get an education and job training. They are also difficult to work with in outreach; if their drug use is discovered by the authorities, their probation can be revoked and they can be sent back to jail. Participation in street outreach or a harm reduction program is potential evidence of drug usage.
The Intervention
The California Prevent Education Project (Cal-Pep) in Oakland, California, started a mobile van based outreach program funded by the Center for Substance Abuse Treatment (CSAT). The program was called MORE and its purpose was to provide drug abuse prevention and HIV risk reduction programs primarily to ex-offenders. Through case management, clients were provided assistance with medical care and social services, counseling, and referral at the time and places where they congregated. Two primary goals of these services were to reduce their drug use and re-incarceration for drug related crimes. The initial MORE clients were recruited in January 2002 and a new cohort was recruited each year until the program ended December 2006. The program evaluation tool was the Federal Office of Budget and Management Office's Government Performance and Results Act (GPRA) questionnaire which asks for general demographics, the kind and extent of their drugs used, number of times arrested, days in jail, and crimes committed. Clients were asked to recall the answers to these questions within the 30 days prior to their interviews. Staff also recorded what kinds of services each client used and how often, measuring each client's program service intensity over 12 months.
GPRA interviews were conducted at in-take into the program, approximately six months later and again approximately 12 months after their initial in-take. It is presumed that during this period some program impacts would be evident. It was anticipated that client drug use might decline in some way, their integration into general society might improve, their HIV sexual and drug abuse risks might also decline, and their living and work circumstances might also improve. These would be the desired outcomes of the primary intervention tool, case management. This evaluation compared the results of interviews conducted at in-take, and the six and 12 month follow-ups. The results for 468 unduplicated clients were analyzed who entered the MORE project from January 2002 through September 2006.
RESULTS
compares the interviews of clients at intake (N = 468), at the six month follow-up interview (N = 327), and at the 12 month follow-up interview (N = 281). Sixty percent of clients were retained for a full year of service and cohorts of clients received services across five years of outreach. When all clients were compared across interview periods by age, years of education, total income from all sources, gender and race, there were no statistically significant differences (analysis not shown). Other researchers have found racial differences in participation in treatment (CitationDay, Eggen, Ison, Copello, & Fazil, 2006). The only significant demographic factor across interview periods was employment (p < .001). At intake only 13% of clients were employed, but by the six and 12 month follow-up interviews client employment increased to 21% and then 31% respectively. Analysis across interview periods suggests that MORE clients who completed 12 months of the program were not demographically different from the larger group who started at intake. Whatever impact MORE had on clients was not due to self- or other-selection of clients based upon age, schooling, race, or gender. Having progressively more employment was the only way clients may have differed across interview periods.
TABLE 1 Characteristics of Out-of-Treatment MORE Clients by Interview Period and Program Status
further divides interview periods by program completion status. Clients who completed the program (completers) are compared with those who were either terminated or who dropped out (non-completers). One completed the program by utilizing services and participating in follow-up interviews. In contrast, some clients were terminated by staff because they had moved away from the Cal-Pep service area, returned to jail, or were institutionalized. Drop-outs were clients who interviewed at intake, received some services but could not be found again. Drop-outs also consisted of those who did not avail themselves to any services. In both instances clients were considered drop-outs when they were unable or unwilling to use services and be further interviewed. In those terminated and who dropped out were combined and appear in the table as “non-completers.”
The average age of completers and non-completers at intake was 42 years old. Their average years of schooling were 11.1 to 11.8 years. Only at the six month follow-up were program completers statistically different from non-completers; they had 11.7 years of schooling and non-completers had 11.1 (p < .05). Only in income did completers and non-completers significantly differ across more than one period. Completers had an average income of $648 at the six month follow-up in comparison to non-completers' $202. At the 12 month interview the difference was $752 (p < .001) compared to $114 (p < .001). The final significant relationship in was between completers and non-completers at the 12 month follow-up interview. Thirty-three percent of completers were employed in comparison to only 7% of non-completers who could be interviewed (p < .05).
reports the ways in which it is believed that the MORE project impacted clients who completed the three interviews. The GPRA follow-up questionnaire enabled staff to ask clients about their drug use and criminal activities. In the first part of client responses were analyzed across interview periods. In the 30 days prior to their follow-up interviews clients' reported that their alcohol use declined on average from 7.4 days of use at intake to 5.4 days after 12 months (p < .003). Crack and cocaine use declined on average from 4.4 days of use prior to intake to 2.2 days by month 12 (p < .001). There was no significant change in clients' use of marijuana and hashish. Those who used heroin reported a decline in use from 10.2 days to 4.6 by month 12 (p < .001). The number of crimes clients reported committing in the 30 days prior to their interviews declined on average from 13.1 prior to intake to 7.6 prior to their second follow-up interview (p < .005). A surprise is that clients' reported spending 0.7 days in jail on average at their intake interview but their days in jail increased to 1.3 after a year (p < .010). The second half of repeats the same measures but divides each interview period by completers and non-completers. In doing so, provides another look at the MORE program impact.
TABLE 2 Drug Use, Jail/Crime, Sex Partners, Stress and Health by Interview Period and Program Status
In at intake, those who later completed the program already differed in one way from those who did not finish the program. Program non-completers reported committing on average twice as many crimes (14.7 vs. 7.1) in the 30 days prior to intake when compared with completers (p < .05). This might partly explain why non-completers later dropped out or were terminated; they ended up back in jail. By the six month interview, program completers had diverged from non-completers on two other points. They had significantly fewer days on average in jail (1.2 vs. 5.3) (p < .001) and used heroin for half the days (4.5 vs. 9.1) non-completers did (p < .05). By the month 12 follow-up, program completers' days in jail were significantly down to on average less than one day in jail in the 30 days prior to their interview but non-completers were up to six days. Program completers used cocaine and crack on average less than half as many days (2 vs. 5.5) as did non-completers (p < .05).
The GPRA questionnaire also asked about injection drug use. Across the three interview periods, the percentage of clients who injected drugs went from 32.5% at intake down to 22.3% after one year (p < .003) (analysis not shown here). But within interview periods, there were no significant differences in injection between completers and non-completers. The GPRA also asks a series of questions about the personal effect drug use has on clients. One of these questions asked how much stress clients experienced in the 30 days prior to their interview due to their drug use. They were also asked to rate their physical health. Across interview periods, clients reported significant declines in stress due to drug use over the three interview periods (p < .001) and significant improvements in their health self-ratings (p < .001). Within each interview period, however, there was a significant difference at the six month health ratings of those who went on to complete the program compared to those who did not. A higher percent of completers rated their health as good to excellent (78%) than did non-completers (63%) (p < .05). In prior research, active drug users were found to be highly motivated to maintain good health (CitationDrumm, Mcbridge, Metsch, Neufeld, & Sawatsky, 2005).
Significant differences in drug use, crime, and personal morale across interview periods in suggest that the MORE program has had the desired impact on clients who used the service. It is assumed that the significant differences across interview periods and among clients within interview periods in were due to the MORE program's core interventions: case management, day treatment, health outreach, substance abuse and HIV/AIDS education and referrals to other services.
shows MORE client service utilization of core interventions. Staff recorded client attendance at each MORE service and the days or sessions clients spent in related services they were referred to. The total of each service was calculated when clients completed the program, were terminated or dropped out; this total was aggregated at the end for 12-month interviews. Of the 468 clients who were initially interviewed at intake, 365 (74.5%) had sessions in eight core services across 12 months. Of these 365 clients, 302 completed the program and 63 either dropped out or were terminated after intake or after the six month interview. The remaining 122 clients were also drop-outs. They were interviewed at intake and several were interviewed at the six month follow-up. What distinguishes them from other program drop-outs is that they never availed themselves to services and therefore had no service sessions to count. They are not included in and the total of drop-outs whose service utilization can be analyzed. Separate analyses (as in and ) were done to see if there were any significant demographic and drug use differences between program completers and the remaining 122 drop-out clients. Based on the intake interviews, there were no significant demographic and drug use differences; program completers and the remaining 122 drop-out clients are not distinct sub-groups within the sample population at intake.
For those who utilized the MORE program, clients who completed the program met with staff in case management sessions regularly and one-on-one on average 148 times; those who did not complete the program met on average less than half that time (62) (p < .000). Program completers attended five times as many day treatment sessions (56 to 11) as non-completers, three times as many outpatient sessions, twice as many outreach and HIV education sessions, and 3.5 times as many substance education sessions. All of these differences were statistically significant.
TABLE 3 MORE Service Sessions by Program Completion Status
Of 18 potential services reported by the GPRA questionnaire, less than 4% of all MORE clients used 12 other services (not shown here) in numbers too low for statistical analyses. The last row of (No. 7) consists of the average of all service sessions clients received and includes any service sessions they may have received from the twelve unlisted services. Program completers used 2.7 times more total services than non-completers (p < .000). It can be expected that clients who completed the program had significantly more sessions or days of service than did clients who either dropped out or were terminated. The essential finding in suggests the following: the more actively using drug abusers participated in MORE services, the more likely they reduced their drug use and stress, and also improved their physical health ().
shows the effect of each service on program status. What specific non-service factors were the most important or accounted most for program completion? From and , three factors may have also impacted program completion; they were income, employment, and number of crimes committed, all by the six month interview. By this point, program completers may have had to begin with or gained more income than those who did not finish the MORE program. Possibly, other clients succeeded because of new employment rather than because of MORE services—employment is an important pre-condition to successful drug treatment (CitationPlatt, 1995). Still other clients may have not completed the program because they lacked employment as an incentive. Finally, some clients may have not completed the program because of arrests; police departments vary in the timing and intensity with which they pursue drug related crimes. The more intensely they pursue addicts, the more inaccessible they are even to outreach (CitationCooper, Moore, Gruskin, & Krieger, 2005). Non-completers committed on average twice as many crimes as those who completed the MORE program.
Logistic regression was used to assess the relative importance of each core service with income, employment, and reported crimes at the six month interview. Program completion status was the dependent variable. Since it is dichotomous, logistic regression is the most appropriate multivariate statistical procedure. The six core program session totals were the independent covariates along with the six month income, number of crimes reported and employment status as a categorical variable. Statistical significance was tested for between covariates to identify potential multicollinearity. Where covariates were found to be significantly related to one another, they were entered into separate regressions in groups that were not significantly related to each other. The numbers of crimes was the only variable that had to be dropped altogether. It was significantly related to key service session covariates and to employment. When it was entered into the logistic regression, the resulting models lacked statistical significance. shows the capacity of key covariates to predict client outcomes of program completion or non-completion.
TABLE 4 Logistic Regression Analyses of Program Completion and Termination-Drop-Out Status by Harm Reduction Services, Income and Employment Covariates
In model 1, having higher income by the 6-month interview and total day treatment sessions were significant predictors but showed that these factors gave program completers only a slight advantage over program drop-outs. The total of substance abuse and AIDS education sessions was not a significant predictor in relation with the other two factors. In Model 2, employment by the 6-month interview and total AIDS education sessions were not significant predictors in analysis with total case management sessions. The only significant factor was the total of case management sessions, but it gave program completers only a slight advantage other program drop-outs like the findings in Model 1. In Model 3, substance abuse education was a significant predictor (p < .016) when paired in a regression model with the total of all services. But having high total service intensity was more significant (p < .000) and replicates findings from prior research (CitationHser, Evans, Huang, & Anglin, 2004). Case management and the total of substance abuse education sessions were the only significant predictors that slightly distinguished program completers from drop-outs.
DISCUSSION
Our regression analysis results suggest that case management and the total of substance abuse education sessions clients received are mutually exclusive and more important than income and employment; in actuality, they are not. Part of the work of MORE case managers was to help clients find employment, which is also emphasized in substance abuse education. Case managers also work with clients to receive whatever financial supports they qualified for. Therefore, the more intensely clients worked with their case manager and attended substance abuse education sessions, the more likely they found employment, improved their income, and completed the program. Clients who did not avail themselves to case management missed this potential benefit and were more likely to not complete the program. Case management and drug abuse education sessions are in fact closely related to each other in distinguishing program completers from non-completers although the distinctive was slight.
The surprise in is that days in jail increasing on average between intake and the six month interview. This is also a program effect. Case managers encouraged clients to settle outstanding warrants because this is essential to legal participation in society and necessary for work. One must have a driver's license, be able to use one's social security number, and complete applications without legal barriers. As a result, clients who availed themselves to case management and addressed warrants ended up spending more time in jail between the intake and six month interview than clients who did not benefit from case management. Addressing warrants also ended up distinguishing program completers from non-completers. By the 12 month interview, the jail time of clients who eventually completed the program dropped to almost zero in contrast to those who did not address warrants and who did not complete the program.
The number of crimes committed by clients was a factor that may have distinguished program completers and non-completers independent of outreach services. Those who did not complete the MORE program started out at intake reporting higher numbers of crimes committed in the 30 days prior to their intake interview than those who eventually completed the program. This pattern held through the six month interview. It is difficult to determine from this data or from staff interviews whether the consistency in committing crimes was due to more severe and expensive drug habits, greater ambition, a higher need for excitement, or for another reason. The intensity of policing is also a factor in the extent to which addicts who commit crimes are arrested, go back to jail and only return to the streets more addicted and more marginalized from society than before (CitationBluthenthal, Heinzerling, Martinez, & Kral, 2005). The number of crimes reported was the clearest basis in bivariate analysis for distinguishing program completers from non-completers.
Overall, the main MORE program goals were successfully demonstrated and achieved. This project showed that active drug users could be engaged in outreach and work successfully with case managers. During the process, they could reduce their drug use, reduce the stress associated with it and improve their sense of health. They were also able to increase their income and employment, without an absolute commitment to sobriety. It is our presumption that active drug users like the MORE program completers are more likely and better able to enter formal abstinence-based treatment than they were prior to entering the program. If federal policy barriers to harm reduction were removed, more attention may be paid to demonstrations such as the MORE project to addressing the needs of out-of-treatment drug users (CitationFriedman, Jarlais & Sterk, 1990). Potentially, extensive case management of active drug users may significantly increase the numbers going into treatment and effectively address relapse after treatment (CitationCoviello et al., 2006). A clear limitation is that the evaluation did not permit a third follow-up of former program completers to see how many of them entered treatment. Prior research on case management of ex-offenders found that they did enter treatment (CitationNeedels, James-Burdumy, & Burghardt, 2005). Another limitation is that our regression analyses were able to only slightly distinguish program completers from drop-outs by program components.
Implication for social theory: There is a need to understand the theoretic implication of our findings (CitationFriedman & Touze, 2006). There is nothing inherent in substance abuse and HIV/AIDS education, day treatment, or outpatient services that will dispose an active drug user to reduce his or her drug use. All of these program components were necessary to make a difference in the lives of clients by the 12th month of service. Case management was distinct from the other program components in two ways. It addressed the individual needs of each client and afforded regular meetings with someone dedicated to improving the clients' lives. Together the outreach services and case management served to better integrate clients into general society. Illegal drug users are generally individuals who were alienated from society, presumably because of their drug use. There is a flip-side to drug users lacking access to care: it is their belief that even if care is available, it is not for them (CitationHeinzerling et al., 2006).
The following is suggested: short of complete abstinence from drugs, any intervention that better integrates active drug users into general society will reduce their drug use and better integrate them into general society. The first and most important objective should not be abstinence from drug use. The primary objective should be reintegrating drug users into the workforce, reducing the stigma of drug addiction, and combating their dependency on crime, and the criminal justice system as the only social institution devoted to them. Reintegration will then reduce, if not eliminate, their drug use. Our findings theoretically suggest that drug abuse is a social and personal marker of alienation from society and a medicalization of alienation. The greater the alienation, the greater the dependency is on drugs. Active drug users who are beyond street outreach and case management are probably the most alienated sub-population. Other ways will have to be devised to address users such as the ones who dropped out of the Cal-Pep MORE outreach effort.
Notes
This project was carried out with funding from a Substance Abuse and Mental Health Administration (SAMHSA), Center for Substance Abuse Treatment (CSAT) grant from the Targeted Capacity Expansion Program for Substance Abuse Treatment and HIV/AIDS Services (TCE/HIV). The views and opinions contained in the publication do not necessarily reflect those of the Center for Substance Abuse Treatment, the Substance Abuse and Mental Health Services Administration, or the U.S. Department of Health and Human Services, and should not be construed as such.
Note. *p < .05
**p < .001.
Note. *p < .05
**p < .001.
REFERENCES
- Appel , P. , Ellison , A. A. , Jansky , H. K. and Oldak , R. 2004 . Barriers to enrollment in drug abuse treatment and suggestions for reducing them: Opinions of drug injecting street outreach clients and other system stakeholders. . The American Journal of Drug and Alcohol Abuse , 30 ( 1 ) : 129 – 153 .
- Bluthenthal , R. N. , Heinzerling , K. , Martinez , A. and Kral , A. H. 2005 . Police crackdowns, societal cost, and the need for alternative approaches. . International Journal of Drug Policy , 16 ( 3 ) : 137 – 138 .
- Clapp , J. D. and Burke , A. C. 2006 . Discriminant analysis of factors differentiating among substance abuse treatment units in their provision of HIV/AIDS harm reduction services. . Social Work Research , 23 ( 2 ) : 69 – 76 .
- Cooper , H. , Moore , L. , Gruskin , S. and Krieger , N. 2005 . The impact of a police drug crackdown on drug injectors' ability to practice harm reduction: A qualitative study. . Social Science & Medicine , 61 ( 3 ) : 673 – 684 .
- Coviello , D. M. , Zanis , D. A. , Wesnoski , S. A. and Alterman , A. I. 2006 . The effectiveness of outreach case management in re-enrolling discharged methadone patients. . Drug and Alcohol Dependence , 85 ( 1 ) : 56 – 65 .
- Day , E. , Eggen , J. , Ison , J. , Copello , A. and Fazil , Q. 2006 . Ethnicity and attempts at self-detoxification from opioid drugs. . Drugs: Education, Prevention & Policy , 13 ( 1 ) : 93 – 103 .
- Dickson-Gomez , J. , Weeks , M. , Martinez , M. and Convey , M. 2006 . Times and places: Process evaluation of a peer-led HIV prevention intervention. . Substance Use & Misuse , 41 ( 5 ) : 669 – 690 .
- Drumm , R. D. , Mcbride , D. , Metsch , L. , Neufeld , M. and Sawatsky , A. 2005 . “I'm a health nut!” street drug users' accounts of self-care strategies. . Journal of Drug Issues , 35 ( 3 ) : 607 – 630 .
- Freudenberg , N. , Daniels , J. , Crum , M. , Perkins , T. and Richie , B. E. 2005 . Coming home from jail: The social and health consequences of community reentry for women, male adolescents, and their families and communities. . American Journal of Public Health , 95 ( 10 ) : 1725 – 1736 .
- Friedman , S. , Jarlais , D. and Sterk , C. 1990 . AIDS and the social relations of intravenous drug users . The Milbank Quarterly , 60 ( Suppl. 1 ) : 85 – 110 .
- Friedman , S. R. and Touze , G. 2006 . Response policy bereft of research or theory: A failure of harm reduction science . International Journal of Drug Policy , 17 : 133 – 135 .
- Fry , C. L. , Treloar , C. and Maher , L. 2005 . Ethical challenges and responses in harm reduction research: Promoting applied communitarian ethics. . Drug & Alcohol Review , 24 ( 5 ) : 449 – 459 .
- Guydish , J. , Moore , L. , Gleghorn , A. , Davis , T. , Sears , C. and Harcourt , J. 2000 . Drug abuse treatment on demand in San Francisco: Preliminary findings. . Journal Of Psychoactive Drugs , 32 ( 4 ) : 363 – 370 .
- Heinzerling , K. G. , Kral , A. H. , Flynn , N. M. , Anderson , R. L. , Scott , A. , Gilbert , M. L. , Asch , S. M. and Bluthenthal , R. N. 2006 . Unmet need for recommended preventive health services among clients of California syringe exchange programs: Implications for quality improvement. . Drug and Alcohol Dependence , 81 ( 2 ) : 167 – 178 .
- Hser , Y.-I. , Evans , E. , Huang , D. and Anglin , D. 2004 . Relationship between drug treatment services, retention, and outcomes. . Psychiatric Services (Washington, D.C.) , 55 ( 7 ) : 767 – 774 .
- Latkin , C. , Knowlton , A. , Hoover , D. and Mandell , W. 1999 . Drug network characteristics as a predictor of cessation of drug use among adult injection drug. . American Journal of Drug & Alcohol Abuse , 25 ( 3 ) : 463 – 473 .
- Lenton , S. and Single , E. 1998 . The definition of harm reduction. . Drug and Alcohol Review , 17 ( 2 ) : 213 – 219 .
- Needels , K. , James-Burdumy , S. and Burghardt , J. 2005 . Community case management for former jail inmates: its impacts on rearrest, drug use, and HIV risk. . Journal of Urban Health: Bulletin of The New York Academy of Medicine , 82 ( 3 ) : 420 – 433 .
- Platt , J. J. 1995 . Vocational rehabilitation of drug abusers. . Psychological Bulletin , 117 ( 3 ) : 416 – 433 .
- Rekart , M. L. 2005 . Sex-work harm reduction. . Lancet , 366 ( 9503 ) : 2123 – 2134 .
- Reuter , P. and Pollack , H. 2006 . How much can treatment reduce national drug problems? . Addiction , 101 ( 3 ) : 341 – 347 .
- Staff . 2002 . City study shows move toward treatment on demand working . Alcoholism & Drug Abuse Weekly , 14 ( 5 ) : 1 (Cover story)
- Strathdee , S. A. , Ricketts , E. P. , Huettner , S. , Cornelius , L. , Bishai , D. , Havens , J. and Beilenson , P. 2006 . 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 , 83 ( 3 ) : 225 – 232 . et al
- Walton-Moss , B. and McCaul , M. 2006 . Factors associated with lifetime history of drug treatment among substance dependent women. . Addictive Behaviors , 31 ( 2 ) : 246 – 253 .
- Wild , T. C. , Cunningham , J. A. and Ryan , R. 2006 . Social pressure, coercion, and client engagement at treatment entry: A self-determination theory perspective. . Addictive Behaviors , 31 ( 10 ) : 1858 – 1872 .