Substance Use & Misuse, 46:390–397, 2011
C 2011 Informa Healthcare USA, Inc.
Copyright ISSN: 1082-6084 print / 1532-2491 online
DOI: 10.3109/10826084.2010.501675
QUALITY OF LIFE
Quality of Life, Needs, and Interest Among Cocaine Users: Differences
by Cocaine Use Intensity and Lifetime Severity of Addiction to Cocaine
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C.C. Morales-Manrique1 , A. Palepu2 , M. Castellano-Gomez3 , R. Aleixandre-Benavent4 ,
Cocaine Group Comunidad Valenciana5 and Juan Carlos Valderrama-Zurián6
1
Unidad de Información e Investigación Social y Sanitaria (UISYS) (Universitat de València-CSIC). Valencia, Spain;
Division of Internal Medicine, Department of Medicine, Faculty of Medicine, University of British Columbia,
Vancouver, British Columbia, Canada and Center for Health Outcome and Evaluation Sciences, St. Paul’s Hospital,
Vancouver, British Columbia, Canada; 3 Direccion General de Drogodependencias, Conselleria de Sanitat, Generalitat
Valenciana, Velencia, Spain; 4 Unidad de Información e Investigación Social y Sanitaria (UISYS) (Universitat de
València-CSIC). Valencia, Spain and Instituto de Historia de la Medicina y de la Ciencia López Piñero (Universitat de
Valéncia-CSIC) Valencia, Spain; 5 Direccion General de Drogodependencias, Conselleria de Sanitat, Generalitat
Valenciana, Velencia, Spain; 6 Unidad de Información e Investigación Social y Sanitaria (UISYS) (Universitat de
València-CSIC). Valencia, Spain and Centro de Investigación de Seguridad y Emergencias. IVASPE. Consellerı́a de
Gobernación. Generalitat Valenciana. Valencia, Spain
2
We examined the quality of life (QoL) of 149 patients
who were recruited in 2005 at outpatient treatment
centers for cocaine dependence in Spain. Important life
areas and life areas with potential need and interest
to change in order to improve the QoL were analyzed
in terms of patients’ cocaine use intensity within the
previous six months and lifetime severity addiction to
cocaine. The Spanish versions of the Drug User Quality of Life Scale and the Lifetime Severity Index for
Cocaine were used to measure QoL, needs and interest, and severity addiction to cocaine. The data analysis employed t-tests, linear regression, Mann–Whitney
U tests, multivariate regression, and chi-square tests.
Tailoring treatment programs to address the life areas
that are considered relevant to cocaine users considering their intensity of consumption and lifetime severity
addiction to cocaine may improve retention and treatment outcomes. Further research needs to consider patients of different ethnic backgrounds and cultural contexts. The study’s limitations are noted.
Keywords quality of life, cocaine-related disorders, needs
assessment, therapy, treatment outcome, satisfaction
INTRODUCTION
Quality of life (QoL) has become an important variable to
consider in clinical and interventions studies, particularly
as an outcome measure (Lasalvia et al., 2005; Millson et
al., 2006) in the area of mental health. However, little is
known about the effect of cocaine consumption and outpatient treatment on drug users’ QoL.
A closely related factor to QoL is patient satisfaction, or how well a patient’s perceived needs are being addressed (Lasalvia et al., 2005; Slade et al., 2004).
Some studies note that the effectiveness of substance
abuse treatment depends on the attention to these registered needs and offering services that address these issues (Butters & Erickson, 2003; Kirby, Marlowe, Lamb,
& Platt, 1997; MacMaster, 2005). In most cases, however, patients are not asked what issues are important
to them from a broad perspective that encompasses the
cultural, socioeconomic, demographic, political, and social context (Hubley, Russell, & Palepu, 2005). It is critical that the patient’s perspective is considered during
the measurement of QoL, since numerous studies have
shown that health professionals have substantially different perceptions of their patients’ QoL when compared
Participants of the Cocaine Group Comunidad Valenciana: Vicente Tomás, Mariló Temprado, Alberto Sancho, Nuria Sánchez, Carmen Ripoll, Inés
Pranes, Sebastián Monllau, Fátima Hinarejos, Agustı́n Gutiérrez, Carmen Gimeno, Marı́a Gilabert, Pilar Garzón, Rafael Forcada, Maria del Arco,
Francisca Blázquez, and Jesús Blasco.
This work was supported by CSISP, Dirección General de Salud Pública, Consellerı́a de Sanitat, Generalitat Valenciana. Dr. Anita Palepu is
supported by a Michael Smith Foundation for Health Research Senior Scholar Award. The authors would like to thank the collaboration of Jennifer
Syvertsen and the patients that were evaluated.
Address correspondence to Dr. Juan Carlos Valderrama Zurián, Unidad de Información e Investigación Social y Sanitaria (UISYS) (Universitat de
València-CSIC). Plaza Cisneros 4, 46003, Valencia, Spain; E-mail: [email protected].
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QUALITY OF LIFE, NEEDS, AND INTEREST AMONG COCAINE USERS
to their patients’ self-perceptions (Bengtsson-Tops et al.,
2005).
Few published studies make reference to the needs of
patients in ambulatory addiction treatment1 and the therapeutic preferences of cocaine users, and these are primarily from the United States (Brown, Hill, & Giroux,
2004; Schmitz, Bordnick, Kearney, Fuller, & Breckenridge, 1997). There is lack of information to guide treatment models, highlighting the necessity for studies to examine the perceived needs among persons with cocaine
abuse or dependence. Exploring what other factors influence their QoL is relevant for tailoring these treatment
programs and services. Such studies with the Spanish population would be especially relevant, given that Spain is
among the countries with the highest prevalence of cocaine consumption among adults, as well as the greatest
increase in consumption among youth in Europe (EMCDDA, 2006).
The aims of this study are to examine the QoL, life areas that are most important, and life areas with potential
need and interest to change in order to improve the QoL
among cocaine users in outpatient treatment considering
differences by cocaine use intensity and lifetime severity
of addiction to cocaine.
MATERIALS AND METHODS
Sample
Subjects were eligible for the study if they were 18 years
of age or older, actively participating in outpatient substance user treatment for cocaine dependence, and reporting cocaine use during the previous six months. Patients
enrolled in methadone maintenance treatment were not eligible.
The sample consisted of 149 patients from substance
user outpatient treatment centers in the region of Valencia, Spain; 125 (84%) were males, with a mean age of
31.3 years (SD = 6.4, range 18–51), and average duration
of drug use of 10.2 years (SD = 6). Regarding other characteristics, 93 (62%) were employed, and 139 (93%) had
stable housing (defined as living in house or apartment).
Measures
The Drug User Quality of Life Scale, Spanish version
(DUQOL-Spanish; Morales-Manrique, ValderramaZurian, Castellano-Gomez, Aleixandre-Benavent, &
Palepu, 2007) was used to measure QoL, life areas that
are considered important for the QoL, and the need and
interest in changing these areas to improve the QoL. The
1
Treatment can be briefly and usefully defined as a planned, goal directed change process, of necessary quality, appropriateness, and conditions (endogenous and exogenous), which is bounded (culture, place,
time, etc.) and can be categorized into professional-based, traditionbased, mutual-help based (AA, NA, etc.) and self-help (“natural recovery”) models. There are no unique models or techniques used with substance users—of whatever types—which are not also used with nonsubstance users. In the West, with the relatively new ideology of “harm
reduction” and the even newer QoL treatment-driven model, there are
now a new set of goals in addition to those derived from/associated with
the older tradition of abstinence-driven models. Editor’s note
391
instrument is a cross-cultural adaptation of the Injection
Drug User Quality of Life Scale (IDUQOL; Brogly,
Mercier, Bruneau, Palepu, & Franco, 2003; Hubley et al.,
2005) in a Spanish drug-dependent population, with or
without injectable consumption. It measures the unique
and individual circumstances that determine QoL for
drug users and obtains indicators of QoL represented by
22 life areas using a 7-point Likert scale with a range
of 1 (very unsatisfied) to 7 (very satisfied), yielding an
average total score of QoL. It also included a question
of what life areas the patients perceived that affected
their QoL—to measure important life areas. To measure
needs and interest in changing, the instrument included
the questions: “Trying to look at your life objectively,
what is it necessary to change to improve your quality of
life?”; and “At this time, which of these areas do you have
interest in changing to improve your quality of life?.” The
description of each life area is shown in Table 1.
To measure addiction severity we used the Lifetime Severity Index for Cocaine (Hser, Shen, Grella,
& Anglin, 1999) validated with a Spanish population
(LSI-C-Spanish; Morales-Manrique, Valderrama-Zurian,
Castellano-Gomez, & Aleixandre-Benavent, 2007). It is a
28-item questionnaire that considers four aspects of addiction to cocaine: lifetime use, recent use, psychological
dependency, and attempts to quit using. It gives five categories for classification of severity: a severity score of less
than 2 is considered without severity, 2–3 is low severity,
4–5 is medium severity, 6–9 is high severity, and more
than 9 indicates extreme severity.
Fieldwork Procedures
Data were collected from October to December 2005.
The patients provided informed consent and were assured
of confidentiality and anonymity. Doctors, psychologists,
and nurses who had clinical experience in the drug dependency area administered the scales. An instruction
and administration manual for the DUQOL-Spanish scale
was provided in addition to regular contact with the investigator group for any further clarification required.
The average administration time of the DUQOL-Spanish
was 19 minutes (SD = 7). The LSI-C-Spanish was selfadministered, with an average administration time of 10
minutes. Demographic information, employment status,
housing situation, and frequency of consumption during
the previous six months were obtained by interview or by
the review of the patient’s clinical record.
Data Analysis
We used two independent variables related to cocaine consumption: lifetime severity of addiction to cocaine and cocaine use intensity within the previous six months (frequency of use >30 vs. ≤30 times). T-tests were used to
explore the association of QoL with the variables of cocaine use intensity, employment status (currently working/not working), housing (stable/unstable), and gender.
Linear regression was used to explore the association of
the satisfaction of each of the 22 life areas considered in
392
C. C. MORALES-MANRIQUE ET AL.
TABLE 1. DUQOL-Spanish life areas
Life areas
Being useful
Community resources
Drug and alcohol
treatment
Drugs and alcohol
Education and training
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Family
Feeling good about
yourself
Free choice
Friends
Harm reduction
Health
Health care
Housing
How others treat you
Leisure activities
Money
Neighborhood safety
Partner(s)
Sense of future
Sex
Spirituality
Transportation
a
Description
e.g., employment, volunteering, participating in the community, and helping others.
e.g., food bank, soup kitchen, shelters, outreach programs, and social service agenciesa .
e.g., detox, recovery house, residential treatment, and methadone.
e.g., marijuana, speed, alcohol, heroin, cocaine, crack, etc., and includes selling, buying, and using.
e.g., formal schooling, literacy programs, high school equivalency, life skills training, job training, certification,
pre-employment programs, language courses (e.g., ESL).
e.g., parents, children, siblings, foster and adoptive families, grandparents, cousins, aunts, and uncles (not
friends).
e.g., self-esteem and self-worth.
e.g., making your own decisions, autonomy, being able to do things on your own, and having individual rights.
Anyone you consider a friend (but not family).
Vein care, being safe when using drugs, access to, and experience with: e.g., low-threshold methadone
treatment, needle exchange.
e.g., mental and physical health including pain, HIV, AIDS, Hep. C., disability, and schizophrenia.
e.g., access to, and experience with physicians, nurses, hospitals, clinics, emergency department,
physiotherapy, and complementary health services (acupuncture).
e.g., owning, renting, house, apartment, hotel room, shelters, homeless, and staying at someone else’s place.
e.g., how you are treated by people you see on the street, your neighbors, store personnel, family, and friends.
e.g., music, sports, movies, books, and parties.
e.g., income, welfare, cash flow, meeting your needs, financial aid worker, and saving money.
Feeling safe from harm in my neighborhood, e.g., crime, violence, police harassment of self and others.
e.g., spouse, common-law partner, same sex partner, girlfriend, or boyfriend (not casual partners).
e.g., hopefulness, aspirations, dreams, and goals.
e.g., sexual intimacy, sex in exchange for money or drugs, being safe when having sex (use of condoms), birth
control, and sexual abuse.
e.g., religion, faith, belief in a higher being or spiritual world, and communion with nature.
e.g., car, taxi, public transportation, and getting to places you need to go.
In the Spanish version, services available in Spain are named.
the DUQOL-Spanish with addiction severity (as a continuous variable). The nonparametric Mann–Whitney U
test was used to examine differences in the satisfaction of
each of the 22 life areas by the variable cocaine use intensity. Two multivariate regression models were fit to examine the independent association of cocaine use intensity
and addiction severity with QoL, adjusting for age, gender, employment status, and housing. We used chi-square
tests to examine differences in the selection of life areas
identified as important for the QoL, and those needing to
change and having an interest to change to improve the
QoL by the variables cocaine use intensity and a binary
addiction severity variable (high/extreme addiction: score
≥6, vs. low addiction: scores 2–3), as well as the variables
housing, employment status, and gender. Odds ratios and
95% confidence intervals (OR; 95% CI) were calculated.
Associations were considered statically significant when
p < .05. The statistical program SPSS 14.0 was used for
the analysis.
RESULTS
Patients with lower QoL total scores were more likely to
be currently unemployed (t = −2.6; p = .008) and have
unstable housing (t = −3.9; p < .0001). No differences
in QoL were found by gender (t = −0.5; p = .604) or
age (F = 0.17; p = .895). Significant differences in the
selection of life areas with need and interest in changing
for improving the QoL by gender, employment status, and
housing are displayed in Table 2.
Significant associations in satisfaction scores, life areas selected as important, life areas with need and interest to change by the variable lifetime addiction severity to
cocaine are presented in Table 3. Patients with low addiction scores were significantly associated with higher satisfaction in the areas of family and money. A significantly
higher proportion of patients with low addiction scores
endorsed importance in the areas of health care, neighborhood safety, and drug and alcohol treatment for their
QoL. More patients with high/extreme addiction scores
endorsed a need and interest in changing the life area of
family. In the multivariate regression, the association of
lifetime addiction severity and QoL showed a nonsignificant relationship (p = .38) and unstable housing was the
only covariate associated with QoL (p = .020). The regression model showed a global significance of the equation (F = 2.7; p = 0.024) and explained 11% of the variance (R2 = 0.106).
In terms of cocaine use intensity, QoL was significantly
lower in patients who consumed cocaine more than 30
times compared to those who consumed less (t = −3.27;
p < .001). In the multivariate regression cocaine use intensity showed a significant association with QoL (p =
.022) and unstable housing was the only covariate that was
393
QUALITY OF LIFE, NEEDS, AND INTEREST AMONG COCAINE USERS
TABLE 2. Life areas with need and interest to change to improve QoL by gender, employment status, and housing
Variables
Masculine gender (yes/no)
Currently unemployeda (yes/no)
Unstable housinga,b (yes/no)
Life area with need
to change
X2 (p); OR (95% CI)
Partner(s)
Family
Being useful
Leisure activities
Sense of future
DAT
Housing
Free choice
Money
Sense of future
5.4(.020); 4.1(1.2–14.5)
8.2(.004); 2.7(1.4–5.5)
17.0(.000); 4.3(2.1–8.8)
5.9(.015); 2.3(1.2–4.5)
14.5(.000); 3.9(1.9–7.6)
6.4(.031); 5.2(1.3–21.1)
10(.003); 8.9(1.8–43.8)
6.0(.020); 5.9(1.2–29.0)
5.5(.022); 8.4(1.0–67.9)
6.8(.016); 6.5(1.3–31.7)
Life area with
interest to change
X2 (p); OR (95% CI)
NS
Being useful
Free choice
Sense of future
5.2(.220); 2.21(1.1–4.4)
5.6(.018); 2.28(1.1–4.5)
12.1(.001); 3.33(1.7–6.7)
DAT
Housing
Free choice
Partner(s)
5.1(.034); 4.1(1.2–15.5)
10.4(.003); 9.2(1.9–45.4)
8.9(.005); 8.1(1.7–39.7)
5.5(.035); 4.7(1.2–19.1)
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a
Within the previous six months.
Stable housing defined as living in a house or apartment.
NS: nonsignificant value found; DAT: drug and alcohol treatment.
b
independently associated with QoL (p = .005). The regression model showed a global significance of the equation (F = 4.94; p = .0001) and explained 15% of the variance (R2 = 0.149).
Significant differences in the satisfaction of each life
area and in the selection of life areas with the need and
interest to change by cocaine use within the previous six
months are presented in Table 4. Patients who consumed
cocaine more than 30 times had lower satisfaction in eight
(36%) of the life areas considered, specifically in the areas of education and training, family, friends, how others
treat you, neighborhood safety, partner(s), community resources, and sex. Those who consumed cocaine more than
30 times reported the need to change nine (41%) and more
interest to change seven (32%) life areas in order to improve their QoL. There were no significant differences regarding the selection of life areas considered important for
the QoL.
DISCUSSION
Our findings illustrate that cocaine use is significantly associated with the overall perceived QoL, as well as many
diverse life areas that are relevant to the needs and interests of cocaine users. The life area family is one that stands
out in our study. Among the 22 life areas considered, the
area of family was identified as important for the majority
of patients (93.3%), and was among the areas that more
patients with higher addiction scores endorsed as having
a need and interest in changing in order to improve their
QoL. Also, other life areas pertaining to significant interpersonal relationships were adversely affected—e.g.,
friends and partner(s)—with greater dissatisfaction and
necessity of changing them among those with high
intensity cocaine use. This is consistent with previous
studies that have shown the importance of obtaining help
and support from family and friends as a specific strategy
to stop the cocaine use (Brown et al., 2004), and that recovery without treatment of alcohol and drug use-related
problems is often related to the support of the individual’s
family and/or a significant other (Sobell, Ellingstad, &
Sobell, 2000). Also, a positive family context or social
support has been found to be the factor most notably associated with favorable responses to drug user’s treatment
(Higgins, Budney, Bickel, & Badger, 1994; Longabaugh,
Beattie, Noel, Stout, & Malloy, 1993). Furthermore, this
TABLE 3. Significant results of satisfaction in life areas, and life areas selected as important, with need and interest to change by
addiction severity as a continuous and dichotomous variable
Life areas
Satisfaction
Money
Family
Selected has important for QoL
Health care
Neighborhood safety
Drug and alcohol treatment
With need to changeb
Family
With interest to changec
Family
a
Addiction severity to cocaine
F (p)
5.3 (.024)
10.7 (.001)
X2 (p)a
9.4 (.002)
6.4 (.011)
8.7 (.005)
X2 (p)
9.9 (.002)
X2 (p)
11.5 (.001)
Direction of the relationship
> in low addiction
> in low addiction
OR (95% CI)
5.7 (1.8–18.7)
3.9 (1.3–11.7)
14.4 (1.6–12.6)
OR (95% CI)
5.6 (1.8–17.2)∗
OR (95% CI)
6.6 (2.1–20.9)∗
> in low addiction
> in low addiction
> in low addiction
> in high/extreme addiction
> in high/extreme addiction
Subjects with high /extreme vs. low addiction selecting the life area.
As answer to the question “Trying to look at your life objectively, what is it necessary to change to improve your quality of life?”
c
As answer to the question “At this time, which of these areas do you have interest in changing to improve your quality of life?”
b
394
C. C. MORALES-MANRIQUE ET AL.
TABLE 4. Significant results of satisfaction in life areas, and
life areas selected has important, with need and interest to
change by variable the variable intensity of cocaine use within
the previous six months
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Life areas
Satisfaction
Education and
training
Family
Friends
How others treat
you
Neighborhood
safety
Partners
Community
resources
Sex
With need to
changeb
Health
Drugs and
alcohol
Family
Feeling good
about yourself
Friends
Leisure activities
Neighborhood
safety
Sex
Partner(s)
With interest to
changec
Drugs and
alcohol
Education and
training
Feeling good
about yourself
Leisure activities
Neighborhood
safety
Partner(s)
Sex
Cocaine use >30 times (yes/no)a
Z (p)
−2.6 (.008)
−2.2 (.026)
−2.5 (.012)
−2.4 (.018)
−3.6 (.000)
−2.4 (.018)
−2.7 (.008)
−2.5 (.012)
0pt2,162.0pt
X2 (p)
O R (95%C I )
7.9 (.005)
12.8 (.000)
2.6 (1.3–5)
3.9 (1.8–8.6)
4.1 (.043)
4.1 (.043)
2.0 (1.0–4.0)
2.0 (1.0–3.7)
10.6 (.001)
6.5 (.011)
5.8 (.016)
3.0 (1.5–5.8)
2.3 (1.2–4.5)
2.8 (1.2–6.5)
10.4 (.001)
4.4 (.035)
X 2 (p)
3.1 (1.5–6.1)
2.1 (1.1–4.3)
O R (95%C I )
5.3 (.021)
2.4 (1.1–5)
4.6 (.033)
2.1 (1.1–4.1)
8.4 (.004)
2.6 (1.4–5.1)
4.4 (.037)
6.4 (.012)
2.0 (1.0–3.8)
3.4 (1.3–9.0)
4.1 (.043)
10.4 (.001)
2.0 (1.0–4.0)
3.1 (1.5–6.1)
Higher satisfaction in subjects with cocaine use ≤ 30 times
within the previous six months.
b
As answer to the question “Trying to look at your life objectively,
what is it necessary to change to improve your quality of life?”
c
As answer to the question “At this time, which of these areas do
you have interest in changing to improve your quality of life?”
a
support can reduce the likelihood of prostitution among
crack users (Latkin, Hua, & Forman, 2003), thereby reducing sexual risk behaviors. Conflicts in the interpersonal areas and also dissatisfaction, need and interest to
change neighborhood safety can be partly explained by
the vulnerability to cocaine-induced paranoia (an irrational, intense suspicion of others), one of the promi-
nent behavioral syndromes associated with chronic cocaine use (Kalayasiri et al., 2006). The integration of
programs that attend to the typical interpersonal conflicts
that can emerge between the patients addicted to cocaine
and their family—or other significant relationships—is
therefore highly relevant.
The sex life area was also significantly affected by cocaine use. High intensity cocaine users reported significant dissatisfaction, and more need and interest in changing it. Because the description for this life area is quite
broad in the DUQOL (see Table 1), this area can be interpreted in two ways: one could be the search for sexual
satisfaction, and the other could pertain to the reduction
of sexual risk behaviors. It is well documented that the
crack or cocaine consumption is associated with increased
sexual risk behaviors (Inciardi & Surratt, 2001), regardless of the drug use pattern being regular or recreational
(Colfax et al., 2005). Compared to the use of other illicit
drugs, cocaine use is associated with having multiple sexual partners and with the exchange of sex for money (Degenhardt, Day, Conroy, & Gilmour, 2006). On the other
hand, in persons addicted to cocaine, sexual dysfunction is
not uncommon (Cocores, Miller, Pottash, & Gold, 1988),
and longstanding cocaine use is associated with reduced
libido (Cocores, Dackis, & Gold, 1986).
Our results are consistent with studies that have found
cocaine-associated alternations in motivation, most typically depressive symptoms such as disinterest and boredom, during the phases of chronic intoxication, as well
as acute or late syndromes of abstinence (Roncero, Trasovares, Bruguera, Egido, & Casas, 2005). This may explain
why we observed that different life areas related to motivation or change are associated with addiction severity. For
example, patients with low addiction were more likely to
select the areas of drug and alcohol treatment and health
care among other areas as important for their QoL when
compared to patients with higher addiction; and patients
who used cocaine more than 30 times reported greater
need and interest to change the area of feeling good about
yourself, higher dissatisfaction and interest to change the
area of education and training, and more need and interest
to change their leisure activities. Therefore, it is important to consider the affective or motivational states of patients in treatment programs, especially among those with
higher addiction scores and/or more intense cocaine use.
Providing opportunities for employment and leisure may be relevant to treatment programs. Current
employment was positively associated with the global
QoL score and had a favorable effect in the areas of being useful and sense of future (unemployed subjects had
higher necessity and interest to change these areas). Tailoring treatment to the vocational needs of addicted patients has shown to be predictor of outpatient treatment
retention (McCaul, Svikis, & Moore, 2001). In addition,
orientation programs on employment are preferred over
psychotherapy, medical treatment, and legal attendance
among cocaine-dependent patients in treatment in the
United States (Schmitz, Oswald, Baldwin, & Grabowski,
1994). Similarly, among African-American crack users,
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QUALITY OF LIFE, NEEDS, AND INTEREST AMONG COCAINE USERS
“having work”2 is a specific strategy to stop drug use
(Brown et al., 2004). The development of interests not related to illicit drugs and changes related with work and
life in general are factors associated with abstinence and
reduced risk of relapse among persons who have recovered without treatment (Sobell et al., 2000).
Unstable housing is another outstanding factor to consider in treatment programs. It was the only variable independently associated with total DUQOL score in both
multivariate regression models. This is consistent with the
fact that significantly more patients with unstable housing
in our study endorsed a need and interest in changing their
current drug and alcohol treatment, which may reflect a
shortcoming in their treatment program where important
life areas to their QoL remain unaddressed. Previous studies with cocaine-addicted patients have reported that the
assistance of needs related to housing is a critically important strategy to stop or reduce the use of drugs (Brown
et al., 2004).
Study’s Limitations
Limitations of our study include the cross-sectional design
and that we recruited only cocaine-dependent persons participating in outpatient treatment. Our sample size is relatively small and may not be representative of cocaine users
of the area. We were unable to better characterize our sample, particularly not capturing important attributes such as
their skills, abilities, values, and educational level. Finally,
we did not consider differences by concurrent psychiatric
diagnoses or by other types of illicit drugs used.
CONCLUSIONS
Overall, QoL is affected by the intensity of cocaine consumption controlling for other variables. Patients who
consumed cocaine more than 30 times within the previous six months reported lower satisfaction in several life
areas, especially those related to interpersonal relationships. Similarly, higher lifetime addiction severity was associated with less satisfaction in the family and money
areas. Life areas related to motivation or change of substance misuse are affected in the way they are considered important for the QoL. Our findings support prioritizing therapeutic programs that address family conflicts,
especially among patients with higher addiction scores,
and providing assistance to patients with unstable housing to improve their housing situation is also critically
important. Tailoring treatment programs to address the
life areas that are considered relevant to cocaine users
according to their intensity of consumption and lifetime
addiction severity may improve retention and treatment
outcomes. Qualitative studies would be useful for an indepth exploration of the nature of the needs and interests
2
The reader is reminded of the need to distinguish between work and
employment. Whereas many drug users, who represent a heterogeneous
population, are not employed (salary, hours, delineated roles, opportunities for advancement or being fired, tasks, sites, etc.) being an active
drug users is work with its own range of “demands,” very often being
more than a full time “job.” Editor’s note.
395
revealed—for example, studies that examine the type of
family conflicts that tend to characterize cocaine users
with higher addiction severity scores. Likewise, similar
studies need to consider other ethnic populations and patients within different cultural contexts, and also persons
dependent on other substances as well as poly-substance
users.
Declaration of Interest
The authors report no conflict of interest. The authors
alone are responsible for the content and writing of this
paper.
RÉSUMÉ
Nous examinons la qualité de vie (QV) de 149 patients en traitement ambulatoire pour une dépendance à
la cocaı̈ne en Espagne. Pour cela, nous avons analysé
certains domaines de vie considérés comme importants
et aussi des domaines de vie avec une nécessité ou un
intérêt de changer pour améliorer la QV. Toujours en termes d’intensité d’usage de la cocaı̈ne pendant les 6 mois
préalables et la sévérité de l’addiction à la cocaı̈ne au long
de la vie. Le DUQOL-Spanish fût utilisé pour mesurer la
QV, domaines de vie importants, nécessités et intérêts ; et
le LSI-C-Spanish pour mesurer la sévérité de l’addiction à
la cocaı̈ne. Pour l’analyse de données on utilisât l’épreuve
T-Student, la régression linéale, l’épreuve de U MannWhitney, la régression multi variable et le Test du χ 2 .
Lorsque l’on conçoit des programmes de traitement qui
assistent les domaines de vie qui sont perçus par les
patients comme relevants pour sa qualité de vie, l’on
considère l’intensité de la consommation et la sévérité
de l’addiction à la cocaı̈ne, améliore la rétention et la
réponse au traitement. Des futures études devraient considérer des patients d’autres groupes ethniques et d’autres
contextes culturels. Les limitations de l’étude sont
indiquées.
RESUMEN
Examinamos la Calidad de Vida (CV) de 149 pacientes
en tratamiento ambulatorio por dependencia a la cocaı́na
en España. Áreas de vida consideradas importantes, y
áreas de vida con necesidad e interés de cambiar para
mejorar la CV se analizaron en términos de la frecuencia de uso de la cocaı́na durante los seis meses previos y
severidad de la adicción a la cocaı́na a lo largo de la
vida. El DUQOL-Spanish se usó para medir la CV, áreas
de vida importantes, y necesidades e intereses; y el LSIC-Spanish para medir la severidad de la adicción a la
cocaı́na. En el análisis de datos se empleó la prueba TStudent, regresión lineal, prueba de U Mann-Whitney, regresión multivariable y prueba Chi cuadrado. Al diseñar
programas de tratamiento que asisten las áreas de vida que
son percibidas por el paciente como relevantes para su calidad de vida, considerando su frecuencia de consumo y
severidad de la adicción a la cocaı́na, mejora la adherencia y respuesta al tratamiento. Futuros estudios necesitan
396
C. C. MORALES-MANRIQUE ET AL.
considerar pacientes de otros grupos étnicos y contextos
culturales. Se señalan las limitaciones del estudio.
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THE AUTHORS
Claudia Cristina Morales
Manrique. PhD Psychologist
researcher. Completed her
studies of psychology at
the Universidad Rafael
Urdaneta (Venezuela); obtained
postgraduate diplomas in
Clinical Psychology at the
Universitat de Barcelona
(Spain), and in Design and
Statistics in Health Sciences,
at the Universitat Autònoma
de Barcelona (Spain). Her PhD
degree in psychology was obtained at the Universitat de València.
Since 2003 she has collaborated with her mentor Dr. Juan Carlos
Valderrama Zurián, at the Universitat de València, doing research
in the area of drug dependence. She worked in many projects
related to risk and protective factors for alcohol and other drugs
consumption in immigrant population (ej. latinoamerican), and in
the validation of some questionnaires. Currently she has special
interest in doing research on Subjective Quality of Life in drug
users, immigrants, and ethnic minorities.
Anita Palepu, MD, MPH,
FRCPC, is an Associate
Professor, Division of Internal
Medicine, UBC, and a Michael
Smith Foundation for Health
Research Senior Scholar. She
has been actively involved with
the launch of an independent,
open access general medical
journal Open Medicine and is
currently the Co-Editor. Her
research program falls under
the broad umbrella of urban
health research with particular interest in vulnerable populations
such as drug users, HIV-infected persons, and homeless persons.
She is the Organizing Conference Chair of the 7th International
Conference on Urban Health held in Vancouver in October 2008.
Juan Carlos Valderrama
Zurián MD, PhD in Medicine
from the University of
Valencia and Professor in the
University of Valencia, Spain.
He has published over 60
journal articles and chapters
in the areas of drug abuse
research. His research has
been supported by grants from
the Delegación del Gobierno
para el Plan Nacional sobre
Drogas, Dirección General de
Drogodependencias and Dirección General de Salud Pública
of the Generalitat Valenciana, and from the Plan Municipal
de Drogodependencias y otros Trastornos Adictivos of the
Ayuntamiento de Valencia. Dr. Valderrama Zurián has been
recognized for his contributions and has received the first
Research Award from the Generalitat Valenciana/Bancaja
for his research in risk behaviors, psychopathology, and
HIV.
Rafael Aleixandre Benavent,
MD, PhD, is a tenured scientist
at the Spanish Research CouncilCSIC. His PhD is in Information
Science from the University of
Valencia. Associated professor
at the Instituto de Historia de la
medićina de la Ciencia López
Piñero at the University of
Valencia. His research has been
funded by competitive sources
such as the Spanish National
R&D Plans and the Autonomous
Region of Valencia R&D Plans. He is member of the Unidad de
Información e Investigación Social y Sanitaria UISYS (Universitat
de Valèncı́a-CISIC) and serves on the Advisory Board of several
journals. His areas of experience include research evaluation,
bibliometric indicators, comparative studies on R&D outputs at
the European and Spanish level, journals evaluation, information
sources in S&T, and research in drug dependence.
Miguel Castellano Gómez,
MD, is Chief of Studies and
Research Service of Plan
of Drug Dependence of the
region of Valencia. He has
coordinated several clinical
and epidemiological studies and
he has participated in European
Twinning Programmes which
consist in offering a practical
advise to the institutions and
administrations of the Eastern
European countries. He is
working on several aspects related to psychoactive substances,
mainly in the areas of epidemiological studies related to the
patterns of alcohol and drug use in several settings, developing
policies, preventive programs, and treatment services.
REFERENCES
Bengtsson-Tops, A., Hansson, L., Sandlund, M., Bjarnason, O., Korkeila, J., Merinder, L., et al. (2005). Subjective versus interviewer assessment of global quality of life among persons with
schizophrenia living in the community: a Nordic multicentre
study. Quality of Life Research, 14, 221–229.
Brogly, S., Mercier, C., Bruneau, J., Palepu, A., & Franco, E.
(2003). Towards more effective public health programming
for injection drug users: development and evaluation of the
Subst Use Misuse Downloaded from informahealthcare.com by SIIS Ctro de Docume Estudios on 04/14/11
For personal use only.
QUALITY OF LIFE, NEEDS, AND INTEREST AMONG COCAINE USERS
injection drug user quality of life scale. Substance Use and Misuse, 38, 965–992.
Brown, E. J., Hill, M. A., & Giroux, S. A. (2004). “A 28-day program ain’t helping the crack smoker”—perceptions of effective drug abuse prevention interventions by north central Florida
African Americans who use cocaine. Journal of Rural Health,
20, 286–295.
Butters, J., & Erickson, P. G. (2003). Meeting the health care needs
of female crack users: a Canadian example. Women and Health,
37, 1–17.
Cocores, J. A., Dackis, C. A., & Gold, M. S. (1986). Sexual dysfunction secondary to cocaine abuse in two patients. Journal of
Clinical Psychiatry, 47, 384–385.
Cocores, J. A., Miller, N. S., Pottash, A. C., & Gold, M. S. (1988).
Sexual dysfunction in abusers of cocaine and alcohol. American
Journal of Drug and Alcohol Abuse, 14, 169–173.
Colfax, G., Coates, T. J., Husnik, M. J., Huang, Y., Buchbinder, S.,
& Koblin, B., et al. (2005). Longitudinal patterns of methamphetamine, popper (amyl nitrite), and cocaine use and high-risk
sexual behavior among a cohort of San Francisco men who have
sex with men. Journal of Urban Health, 82, 62–70.
Degenhardt, L., Day, C., Conroy, E., & Gilmour, S. (2006). Examining links between cocaine use and street-based sex work
in New South Wales, Australia. Journal of Sex Research, 43:
107–114.
EMCDDA. (2006). Informe anual 2006: el estado del problema
de las drogas en Europa. Retrieved November 20, 2007, from
the European Monitoring Centre for Drugs and Drug Addiction. Web site: http://ar2006.emcdda.europa.eu/es/page022-es.
html
Higgins, S. T., Budney, A. J., Bickel, W. K., & Badger, G. J. (1994).
Participation of significant others in outpatient behavioral treatment predicts greater cocaine abstinence. American Journal of
Drug and Alcohol Abuse, 20, 47–56.
Hser, Y., Shen, H., Grella, C., & Anglin, M. D. (1999). Lifetime
severity index for cocaine use disorder (LSI-Cocaine): a predictor of treatment outcomes. Journal of Nervous and Mental Disease, 187, 742–750.
Hubley, A. M., Russell, L. B., & Palepu, A. (2005). Injection drug
use quality of life scale (IDUQOL): a validation study. Health
and Quality of Life Outcomes, 3, 43.
Inciardi, J. A., Surratt, H. L. (2001). Drug use, street crime, and
sex-trading among cocaine-dependent women: implications for
public health and criminal justice policy. Journal of Psychoactive Drugs, 33, 379–389.
Kalayasiri, R., Sughondhabirom, A., Gueorguieva, R., Coric, V.,
Lynch, W. J., Morgan, P. T., et al. (2006). Self-reported
paranoia during laboratory “binge” cocaine self-administration
in humans. Pharmacology, Biochemistry, and Behavior, 83:
249–256.
Kirby, K. C., Marlowe, D. B., Lamb, R. J., & Platt, J. J. (1997). Behavioral treatments of cocaine addiction: assessing patient needs
397
and improving treatment entry and outcome. Journal of Drug Issues, 27, 417–429.
Lasalvia, A., Bonetto, C., Malchiodi, F., Salvi, G., Parabiaghi, A.,
Tansella, M., et al. (2005). Listening to patients’ needs to improve their subjective quality of life. Psychological Medicine,
35, 1655–1665.
Latkin, C. A., Hua, W., & Forman, V. L. (2003). The relationship
between social network characteristics and exchanging sex for
drugs or money among drug users in Baltimore, MD, USA. International Journal of STD and AIDS, 14, 770–775.
Longabaugh, R., Beattie, M., Noel, N., Stout, R., & Malloy, P.
(1993). The effect of social investment on treatment outcome.
Journal of Studies on Alcohol, 54, 465–478.
MacMaster, S. A. (2005). Experiences with and perceptions of, barriers to substance abuse and HIV services among African American women who use crack cocaine. Journal of Ethnicity in Substance Abuse, 4, 53–75.
McCaul, M. E., Svikis, D. S., & Moore, R. D. (2001). Predictors
of outpatient treatment retention: patient versus substance use
characteristics. Drug and Alcohol Dependence, 62, 9–17.
Millson, P., Challacombe, L., Villeneuve, P. J., Strike, C. J., Fischer,
B., Myers, T., et al. (2006). Determinants of health-related quality of life of opiate users at entry to low-threshold methadone
programs. European Addiction Research, 12, 74–82.
Morales-Manrique, C. C., Valderrama-Zurian, J. C., CastellanoGomez, M., Aleixandre-Benavent, R., & Palepu, A. (2007).
Cross cultural adaptation of the Injection Drug User Quality
of Life Scale (IDUQOL) in Spanish drug dependent population, with or without injectable consumption: Drug User Quality
of Life Scale-Spanish (DUQOL-Spanish). Addictive Behaviors,
32, 1913–1921.
Morales-Manrique, C. C., Valderrama-Zurian, J. C., CastellanoGomez, M., & Aleixandre-Benavent, R. (2007). Exploratory
factor analysis and validation study of the lifetime severity index
for cocaine, Spanish version (LSI-C-Spanish). Journal of Nervous and Mental Disease, 195, 532–536.
Roncero, C., Trasovares, M. V., Bruguera, E., Egido, A., & Casas,
M. (2005). Consumo de cocaina y psicopatologia. In Plan
Municipal de Drogodependencias. Concejalı́a de Sanidad y
Consumo. Ayuntamiento de Valencia (Ed.), La cocaı́na a debate. Valencia, Spain: Gorcrea, S.L.
Schmitz, J. M., Bordnick, P. S., Kearney, M. L., Fuller, S. M.,
& Breckenridge, J. K. (1997). Treatment outcome of cocainealcohol dependent patients. Drug and Alcohol Dependence, 47,
55–61.
Schmitz, J. M., Oswald, L. M., Baldwin, L., & Grabowski, J. (1994).
A survey of posthospitalization treatment needs and preferences
in cocaine abusers. American Journal on Addictions, 3, 227–
235.
Slade, M., Leese, M., Ruggeri, M., Kuipers, E., Tansella, M., &
Thornicroft, G. (2004). Does meeting needs improve quality of
life? Psychotherapy and Psychosomatics, 73, 183–189.