Linking female sex workers with substance abuse treatment

Transcription

1 Journal of Substance Abuse Treatment 27 (2004) Linking female sex workers with substance abuse treatment Larry A. Nuttbrock, (Ph.D.) a, *, Andrew Rosenblum, (Ph.D.) a, Stephen Magura, (Ph.D.) a, Cherie Villano, (Psy.D.) a, Joyce Wallace, (M.D.) b a National Development and Research Institutes (NDRI), New York, NY, USA. b Foundation for Research on Sexually Transmitted Diseases (FROST D), New York, NY, USA. Received 17 November 2003; received in revised form 8 July 2004; accepted 12 August 2004 Abstract We evaluated mobile street-based outreach as a modality for linking street-walking female sex workers with substance abuse treatment in New York City. Sex workers (N = 179) approaching an existing outreach facility were randomly assigned to receive usually provided services, or to receive an enhanced version of these services. Among the 144 women successfully followed for 6 months, 35.0% were detoxified; 43.1% of the 78 current heroin users received methadone maintenance; and 35.4% of the followed-up clients received some other type of treatment. Intervention group differences in these outcomes were not significant. Detoxification during followup was associated with heroin dependence and lifetime detoxification. Methadone maintenance (among heroin users) was associated with Hispanic ethnicity and legally mandated treatment. Other types of treatments were negatively associated with the degree of involvement in the sex trade. We conclude that a variety of factors affect motivation for substance abuse treatment among female sex workers, and that street-based outreach is a highly effective modality for linking this population with much needed treatment. D 2004 Elsevier Inc. All rights reserved. Keywords: Sex workers; Street outreach; Substance abuse treatment 1. Introduction Substance use is endemic among female street-based sex workers in large metropolitan areas (Goldstein, 1979; Plant, 1990). In Atlanta in 1997, for example, 92.5% of the women arrested for prostitution were tested as positive for illegal drugs (National Institute of Justice, 1998). High levels of alcohol, marijuana, cocaine and heroin use, in particular, have been observed in this population, with a significant minority using amounts of these substances indicative of dependence (Gossop, Griffiths, Powis, & Strang, 1992; Gossop, Powis, Griffiths, & Strang 1994; Gossop et al., 1995). Substance use is interwoven into the sex work life-style in multiple respects. The use of cocaine, in particular, may cause some women to drift into the sex trade (Inciardi & Surratt, * Corresponding author. 71 W. 23rd St., 8th Fl., New York, NY 10010, USA. Tel.: ; fax: address: [email protected] (L.A. Nuttbrock). 2001) and involvement in the sex trade, in turn, may cause some sex workers to use substances (Kuhns, Heide, & Silverman, 1992). Sex work occurs in venues where alcohol and others drugs are readily available (Grella, Anglin, & Wugalter, 1997) and where norms regarding the virtues of abstinence may be diminished (Inciardi & McElrath, 1998). Substance use may also be a coping mechanism for dealing with the everyday hazards of sex work on the streets (Marshall & Hendtlass, 1986). High levels of alcohol and other drug consumption and their effects on health, especially HIV, among female sex workers make the treatment of substance abuse in this population a public health priority. But the illegal status and alienation of sex workers, according to several accounts, remain as barriers to treatment in traditional delivery systems (Clements, 1996; Sion, 1977). Sex workers are said to be reluctant to approach medical clinics and drug treatment providers for fear of being stigmatized as a prostitute (Weiner, 1996). According to some reports, substance abusing sex workers typically come into contact with the treatment system only incidentally as a result of /04/$ see front matter D 2004 Elsevier Inc. All rights reserved. doi: /j.jsat

2 234 L.A. Nuttbrock et al. / Journal of Substance Abuse Treatment 27 (2004) contacts with emergency rooms or the jail system (Arnold, Stewart, & McNeece, 2000). In New York City, barriers to engaging this highly impaired population in the context of the traditional substance abuse treatment system prompted a unique mobile outreach modality: FROST D (Foundation for Research on Sexually Transmitted Diseases, aka From Our Streets with Dignity). Since 1992, using a large mobile RV, FROST D has been delivering outreach services at various sites in New York City where sex workers congregate (strolls) and drug activity is common. In 1999, the National Development and Research Institute (NDRI) was awarded a grant from the Center for Substance Abuse Treatment to: (1) evaluate the efficacy of FROST D s services in linking female sex workers with substance abuse treatment; (2) compare the efficacy of this approach to an enhanced version of it using an experimental research design; and (3) identify client characteristics associated with substance abuse treatment in the context of these approaches to outreach in this population. The basic findings of this intervention study are reported here. 2. Materials and methods 2.1. Participants Study participants were 179 sex workers who presented for FROST DTs outreach services between January of 2000 and March of Inclusion criteria were female gender, age (18 or older), self-identification as a sex worker, and a willingness to participate in a longitudinal research study involving random assignment to study groups. Intoxicated clients, or those who were currently enrolled in substance abuse treatment, were excluded. The Institutional Review Board of NDRI approved the research protocols Data collection Clients meeting the study s eligibility criteria were randomly assigned to continue receiving FROST D services, or to receive an enhanced version of these services (described below). During periods when the counselor delivering the experimental intervention was unavailable (e.g., engaged with a client), FROSTTD clients were deliberately assigned to the control condition. Therefore, slightly more controls than experimentals (n = 96, 83 respectively) were recruited for the study. A total of 144 clients (81%) were successfully followed, and reinterviewed after 6 months or longer; 76 had been assigned to the control group and 68 had been assigned to the experimental group. Despite random assignment, the study groups were statistically different with regard to ethnicity. Respondents assigned to the experimental group were less likely to be white (odds ratio =.29; p =.05) and more likely to be Hispanic (odds ratio = 1.98; p =.05). Other than ethnicity there were no baseline differences between the two groups. Although past 6-month treatment history was assessed on all followup interviews, the average duration of time between the baseline and followup interviews was 9.19 months. This was primarily due to the loss of some data on September 11, 2001 (our office was located in the World Trade Center at that time), which required a readministration of 71 followup interviews. Even though, at followup, the duration of time since the baseline sometimes exceeded 6 months, measurements of substance abuse treatment were based on the prior 6 months. The participants were paid $40 for completing a baseline and followup interviews (with additional compensation for intermediate interviews and HIV testing) Description of the outreach programs The existing modality FROSTTD has been conducting outreach with female sex workers for more than two decades. The Off-The-Streets Mobile Unit (OTSMU) delivers services in New York City at various sites where sex workers congregate and drug activity is common. During the time of this study, the areas, all of which are characterized by low socioeconomic status and racial/ethnic diversity, included East Harlem in Manhattan, Hunts Point in the Bronx, and Coney Island in Brooklyn. Encounters with the women are designed to engender trust and confidence in the outreach staff. The OTSMU, staffed by a driver, an intern, and senior and intraining counselors, provides amenities (bathroom facilities; a bag lunch; and a warm and friendly environment), HIV prevention (condoms and literature), brief on-site counseling, and with the assistance of an office-based social worker, agency referrals for medical, psychiatric, and substance abuse treatment. Referrals for substance abuse treatment require detailed knowledge of the complex and changing requirements for admissions to these facilities, and are made in the context of the network of services provided in the New York Metropolitan Area. A review of FROST D records indicated that contacts with the OTSMU van average about 475 per month (contacts can include repeated visits by the same client) The enhanced modality The experimental intervention entailed an additional mobile unit, the Treatment Linkage Van, which operated in tandem with the OTSMU van, and featured three program enhancements designed to increase the number of successful referrals to substance abuse treatment: (1) a weekly scheduling of counseling for a minimum of 6 weeks (not required by FROST D); (2) on-site substance abuse counseling conducted by an experienced treatment specialist (rather than a counselor in collaboration with an office-based social worker) and (3) direct access to an array of programs designed specifically for women, including substance abuse

3 L.A. Nuttbrock et al. / Journal of Substance Abuse Treatment 27 (2004) treatment. The treatment specialists, associated with the enhanced Treatment Linkage Model, was an employee of Project Return (now known as Palladia), a multi-service agency that has been providing services to the women of New York City since the 1970s. The programs focus on problems of substance use, but an array of additional support services is also provided, tailored to the needs of women Hypotheses Intervention Effect: The above enhancements were hypothesized to result in a greater number of clients placed in substance abuse treatment in the enhanced (treatment linkage) as compared to the existing (FROST D) street outreach modalities. Client Effects: Reflecting previous literature (Arnold et al., 2000; Galanter & Kleber, 1999), living arrangements, degree of involvement in the sex trade, involvement in the criminal justice system, motivation for substance abuse treatment, lifetime substance use, and severity of substance dependence were hypothesized to be associated with accepting substance abuse treatment Measures Demographic Characteristics: age; ethnicity, coded as Hispanic, non-hispanic Black, and non-hispanic White; marital status (ever married vs. never married); education (years completed); number of children. Living Arrangements: living in one s own apartment or living quarters (one or more days) during the prior months, coded as yes or no. Living on the streets or some other place not meant for sleeping (one or more days) during the prior month, coded as yes or no. Involvement in the Sex Trade: age (in years) of entry into the sex trade; degree of involvement in the sex trade (coded as some of the time; most of the time; or all of the time); number of btricksq during the prior month; income from sex work during the prior month. Involvement with the Criminal Justice System: Current legal status, coded as no involvement in the criminal justice system vs. some type of involvement (on parole or probation; out on bail; or outstanding warrants); selfreported legal requirement to be in substance abuse treatment, coded from strongly disagree (1) to strongly agree (5). Motivation for Substance Abuse Treatment: The Drug Abuse Treatment Awareness and Readiness Scale (DATAR) which consists of (1) an acknowledgment of alcohol/drug use problems, e.g. drug/alcohol use is ba problem for youq (nine items); (2) an awareness that change is needed and help is wanted, e.g. byou need help in dealing with your drug/alcohol useq (seven items); and (3) a commitment to active change through participation in a treatment program, e.g. btreatment could be your last chance to solve your drug/alcohol problemsq (eight items; Simpson & Joe, 1993). Response categories range from bstrongly disagreeq (coded as 1) to bstrongly agreeq (coded as 5) (Knight & Hacom, 1994). This widely used instrument has shown good reliability, and predicted treatment retention, in a previous study by Simpson, Joe, Rowan-Szal, and Greene (1995). Unstandardized scoring is used in this study of female sex workers. Substance Use and Severity of Dependence: The lifetime and prior-month histories of using alcohol (four or more drinks/day) and specific classes of other drugs (marijuana; benzodiazepines or other depressants, such as barbiturates; powder and crack cocaine; and heroin), coded as positive or negative. The recent use of cocaine and opiates was also assessed biologically using radioimmunoassays of hair. A hair sample of about 50 strands, 1.3 cm in length (1 month of typical growth), measured from the root end, was obtained to test for intake of cocaine and opiates during the prior 30 days. Following laboratory protocols (Psychemedics Corporation, Culver City, CA), 5 or more nanograms of cocaine and 2 or more nanograms of opiate metabolites per 10 mg of hair were coded as positive. Severity of dependence on alcohol and other drugs is evaluated with protocols developed and validated by Gossop et al. (1992), Gossop, Best, Marsden, and Strang (1997), and Kaye and Drake (2002) in previous studies of female sex workers. The scaling is based on five items: (1) perception that use of a particular drug is bout of controlq; (2) being anxious or worried about the prospect of missing a fix (or drink); (3) worrying about the use of a particular drug; (4) wishing to stop using it; and (5) difficulty in going without or stopping its use. Scores for each of the items ranges from 0 to 3; coded from 0 (never) to 3 (often) for the first four items and 0 (not difficult) to 3 (impossible) for the last item. Severity of dependence on particular types of drugs is computed by adding the scores for the five items (range of 0 to 15). Using the non-use of a particular substance during the prior month as a reference category, this consists of (a) substance use associated with a low level of dependence (scores at or below the mean for a given substance) and (b) substance use associated with a high level of dependence (scores above the mean for a given substance). Substance Abuse Treatment: At baseline, life-time history of substance abuse treatment is coded (yes or no), including: a prior detoxification from alcohol or other drugs; prior enrollment in a methadone maintenance program; and prior enrollment in any other type of treatment or intervention (12-step program; 21- or 28-day rehab; outpatient counseling; therapeutic community or TC; or any other type of treatment). For followup data an identical coding scheme is used but is restricted to substance abuse treatment in the past 6 months. Treatments received in a jail/ prison or hospital emergency room are not included in the lifetime or followup measures of substance abuse treatment Statistical analysis Logistic regression analysis is used to examine the effects of client characteristics and type of outreach

4 236 L.A. Nuttbrock et al. / Journal of Substance Abuse Treatment 27 (2004) (FROST D outreach/counseling vs. enhanced counseling) on three types of substance abuse treatment during 6 months of followup. The analysis was conducted using Version 6.1 of SPSS. 3. Results 3.1. Analysis of attrition Based on variables contained in the baseline interview, the 144 clients who were successfully followed, with one exception, were similar to the 35 clients who were not followed up. The successfully followed clients reported a later age of entree in the sex trade (odds ratio = 1.07; p =.01). This variable was not associated with the treatment outcomes under analysis Participant characteristics The 144 female sex workers who were successfully followed reported a mean age of with an average of 11.4 years of education. They were typically never married (58.0%) and non-white (29.2% Hispanic; 52.8% non-hispanic Black) with an average of 2.3 children. About one fourth (28.2%) resided (one or more days) in their apartment or living quarters during the prior month; 32.4% spent one or more days sleeping on the streets, or some other place not meant for sleeping, during the prior month. About one fourth of them (25.4%) had been arrested one or more times during the prior month. Most of them (72.2%) indicated no current involvement with the criminal justice system. However, about one fifth (19.7%) bstrongly agreedq that they could be sent to prison if they were not in substance abuse treatment. This reflects the legal practice, in New York City and other large metropolitan areas, of criminal justice leniency (e.g. parole) conditional upon being in some type of substance abuse treatment. The typical respondent first became involved with the sex trade at 27 years of age, with 26.4% being involved in the sex trade bmost of the timeq (25.5%) or ball of the timeq (16.0%) since then. The typical women reported 13.5 btricksq during the past week, with a reported sex work income of $1406 during the prior month. Scores on the 24-item treatment motivation scale (DATAR) ranged from 65 to 124 with a mean score of 105 SD = 14.53, alpha reliability =.83). Of the 111 women biologically tested for HIV, 24 (21.6%) were determined to be HIV positive Prior substance abuse treatment Most of the successfully followed female sex workers had previously been in detoxification (65.3%), or some form of conventional treatment, including 21- or 28-day rehab, outpatient counseling, or a 12-step program (66.2%). About one third (30.6%) of the lifetime heroin users had been in methadone maintenance previously Substance use and severity of dependence As summarized in Table 1, epidemic high levels of substance use and dependence were observed in this population. Lifetime use of substances ranged from 40.3% for benzodiazepines and other depressants to 95.1% for crack cocaine. Use of substances during the prior month ranged from 12.5% for benzodiazepines to 85.1% for crack cocaine (91.9% for any form of cocaine use). Results are not shown for those substances that were used by less than 10% of the sample during the prior month. According to the hair assays, 92.7% and 44.4% of the women had used cocaine and opiates, respectively, during the prior month. The severity of dependence scores (0 to 15 scale) ranged from a mean of 2.63 for marijuana to for heroin Substance abuse treatment during followup As shown in Table 2, in both study groups, a high percentage of the women were successfully enrolled in substance abuse treatment during the prior 6 months at followup. During the 6 months prior to the followup interview, 31.2% of those assigned to the control group (FROST D), and 39.4% of those assigned to the experimental group (enhanced outreach) received detoxification (study group differences were not statistically significant). After detoxification, about one half of the respondents (56.0% of the controls and 50.0% of the experimentals) enrolled in other types of substance abuse treatment. Among subjects who had received detoxification services but did not continue with additional treatment, 50% indicated that such treatment was not desired; 25% indicated that they were unaware of other treatment options. Among those who reported use of heroin during the prior 30 days (n = 78), 43.9% of the control group and Table 1 Substance use and severity of dependence Severity of Substance use dependence a Lifetime % Prior Month % Prior Month Mean Heroin Crack cocaine Alcohol b Powder cocaine Benzodiazepines c Marijuana/hashish Base N = 144; the n for severity of dependence is based on those respondents who used a given substance during the prior month. a Based on the Severity of Dependence scale; score could range from 0 to 15. b Four or more drinks/day. c Also includes barbiturates and other depressants.

5 L.A. Nuttbrock et al. / Journal of Substance Abuse Treatment 27 (2004) Table 2 Substance abuse treatment during followup Substance abuse treatment (%) Control (n = 76) Experimental (n = 68) Detoxification Methadone maintenance a Other treatments b Any of the Above Differences between control and experimental groups are not statistically significant ( p N.05). a Based only on those respondents using heroin during the previous month (42 controls and 36 experimentals). b Includes 12-step programs, 21 or 28 day rehab, outpatient counseling, therapeutic community (TC), and any other treatments or interventions. 42.9% of the experimental group enrolled in a methadone maintenance program. In the broader sample of followed-up respondents (n = 144), 35.1% of the controls and 35.8% of the experimentals were successfully enrolled in some type of substance abuse treatment. Overall, 61.7% of the entire sample had received detoxification or some other type of treatment during 6 months of followup. Study group differences in these treatment outcomes were not statistically significant Predictors of substance abuse treatment during followup To elucidate client characteristics associated with substance abuse treatment in this population, (1) living arrangements, (2) degree of involvement in the sex trade, (3) involvement in the criminal justice system, (4) motivation for substance abuse treatment, (5) prior substance use, (6) severity of substance dependence, as measured and hypothesized above, and (7) sociodemographic characteristics were used to predict detoxification, methadone maintenance, and other types of treatment during the followup. Associations statistically significant at the.05 level are shown in Table 3. Detoxification during followup was associated with prior detoxification, ethnicity (Hispanic), and heroin use/high dependence. In a multivariate logistic regression model, with all of the variables included in the equation, prior detoxification and substance use/high dependence remained statistically significant at the.05 level or less. Among the 78 women using heroin during the prior month, methadone maintenance during followup was associated with ethnicity (Hispanic) and legally required treatment. In the multivariate model, with both variables included in the equation, ethnicity (Hispanic) and legally required treatment remain statistically significant at the.05 level or less. Other types of treatment during followup (e.g., 12-step programs, 21- or 28-day rehab, outpatient counseling, or therapeutic community) were associated with age, prior treatment, and less involvement in the sex trade. In a multivariate logistic regression model, with all these variables included in the equation, involvement in the sex trade remains statistically significant at the.05 level or less. Contrary to prediction, living arrangements and motivation for substance abuse treatment (total scale or sub-scales) were not associated with substance abuse treatment during 6 months of followup time. Table 3 Predictors of substance abuse treatment during followup Bivariate Multivariate B SE OR B SE OR Detoxification (N = 144) Prior Detoxification * * Ethnicity (Hispanic) * Heroin use/dependence Use/low dependence a Use/high dependence a ** ** Methadone Maintenance (N = 78) b Ethnicity (Hispanic) * * Legally required treatment * * Other Treatment (N = 144) Age * Prior treatment * Sex trade involvement ** ** Base N = 144. a No heroin use during the prior month is the base category. b Based only on those using heroin during the prior month. * p V.05; p V.01 (two tailed).

6 238 L.A. Nuttbrock et al. / Journal of Substance Abuse Treatment 27 (2004) Discussion Consistent with previous studies of female sex workers in large metropolitan areas (Gossop et al., 1992; Gossop, Griffiths, Powis, & Strang, 1994); extremely high levels of substance use and dependence were observed in this large sample of female street walking sex workers in New York City. Crack cocaine use remains an endemic aspect of sex work on the streets of New York City, despite evidence that the use of this drug has declined in some large American cities in recent years (Golub & Johnson, 1998). The alarming prevalence of lifetime and prior-month crack cocaine use, and psychological dependence, may, in part, reflect the selection of cocaine users into the sex trade (Inciardi & Surratt, 2001); and, in part, the continuing availability of this particular drug in the inner-city areas of New York City (Nuttbrock, Rosenblum, Magura, McQuistion, & Joseph, 2000). In addition to cocaine use/dependence, extremely high levels of lifetime and prior-month heroin use, and psychological dependence, were also observed among these women. The SDS scores for dependence severity for crack, powder cocaine, and heroin dependence in this study of New York City sex workers are higher than those obtained by Gossop et al. in their study of London sex workers (Gossop, Powis, Griffiths, and Strang, 1994; Gossop et al., 1995). Greater severity of dependence with crack cocaine (7.30) compared with powder cocaine (3.84) likely reflects the difference in the addiction potential associated with the routes of administering these drugs. Crack cocaine is smoked and efficiently transmitted to the lungs and nervous system, while powder cocaine is typically ingested nasally with a less efficient transmission to the nervous system (Brick & Erickson, 1998). In contrast with some previous literature, which suggests that this population is seldom engaged by the traditional substance abuse treatment system (Arnold et al., 2000), significant numbers of the sex workers in this study had previously been in detoxification, methadone maintenance, and some other type of treatment. This is, perhaps, not surprising, given the levels of substance use/dependence among these women, and the availability of certain types of (Medicaid covered) treatments in New York City, such as detoxification and methadone maintenance. Cities where low/no cost treatment slots are less available may have substance-dependent populations with lower lifetime rates of substance abuse treatment. In conjunction with street-based outreach, a large proportion of these women had enrolled in some type of treatment modality during a 6-month period of time. Given the on-going debate about detoxification as a form of substance abuse treatment (Amato, Davoli, Ferri, & Ali, 2002), and the use of Medicaid to pay for it (Lehman & Danziger, 2003), the placement of about one third of these women in a detoxification program during the course of the study may not be seen as a highly successful outcome. Nevertheless, detoxification from alcohol or other drugs is often a necessary first step toward other types of treatment; and, indeed, about one half of the women receiving detoxification subsequently enrolled in such treatment. At the same time, because about one half of the women undergoing detoxification did not transfer to another treatment, the use of detoxification as an entree to such treatment clearly needs to be improved. Contrary to expectation, an enhancement of the streetbased outreach provided by FROST D did not result in an additional number of these women being placed in substance abuse treatment. This may reflect the fact that: (1) this basic model of street outreach provided by FROST D is highly effective (and difficult to improve upon); (2) that treatments are readily accessible in New York City; or (3) that the particular enhancements to this outreach (a minimum level of substance abuse counseling and on-site counseling from a substance abuse treatment specialist) are not significant components of street-based outreach. The existence of a basic model of street outreach, as exemplified by FROST D, not the intensity of this outreach (as operationalized in this study), would appear to be critical. Although this study did not include a control group that did not receive outreach services, the findings suggest that the street-based outreach offered by FROST D (especially as it was implemented in this study) is an effective modality for linking this highly addicted population with needed substance abuse treatment. Analysis of client characteristics associated with substance abuse treatment during the course of the study pointed to several background and situational factors. Previously detoxified respondents were more than twice as likely to be detoxified during the course of the study (odds ratio = 2.53). This is not a surprising finding given the chronicity of substance use disorders (especially opioid dependence; Hser, Hoffman, Grella, & Anglin, 2001) and the frequency of detoxification in highly addicted populations (Isralowitz, 2002). Respondents with a high level of heroin dependence were almost three times more likely to be detoxified (odds ratio = 2.79). Previous history of detoxification and the experience of psychological substance dependence, rather than a broadly defined motivation for substance abuse treatment (measured by the DATAR), appear to be the key predictors for detoxification. Among the subset of respondents using heroin during the prior month, Hispanic ethnicity and a self-reported legal requirement to be in treatment were significant predictors of methadone maintenance during the followup. Legal demands, as indicated above, point to the influence of external motivation as a factor for enrollment in substance abuse treatment. The degree of involvement in the sex trade was a highly significant negative predictor of other types of substance abuse treatment during the course of the study. Being highly enmeshed in the sex work life style, as suggested by Arnold et al. (2000), is indeed a barrier to certain types

7 L.A. Nuttbrock et al. / Journal of Substance Abuse Treatment 27 (2004) of substance abuse treatment in this population. In conjunction with street-based outreach, despite these barriers, it is apparent that a large proportion of these women can be successfully placed in some type of treatment. Acknowledgments This study was supported by a grant from the Center for Substance Abuse Treatment (KD1 TI12049; A. Rosenblum, Principal Investigator). We thank Diane Bonovoto of Project Return (now known as Palladia), Priscella Alexander and the outreach workers at FROSTTD, and the Treatment Linkage field staff (Marie Marthol, Sarah Farkas, and Deborah Tucker) for their invaluable assistance. References Amato, L., Davoli, M., Ferri, M., & Ali, R. (2002). Methadone at tapered doses for the management of opioid withdrawal. Cochrane Database Syst Rev, 2, CD003409, Arnold, E. M., Stewart, J. C., & McNeece, C. A. (2000). 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