Indiana University-Purdue University Indianapolis (IUPUI) / Deaths due to prescription painkillers and heroin have quickly become national, state, and local public health concerns. Studies using data from Medical Examiners or Coroner Offices throughout the United States have been conducted and are contributing to the understanding of this epidemic. However, the analysis of these fatalities are specific to the communities where the study was conducted and cannot be assumed that the decedents in one community are similar to decedents in another community. Many local governments and agencies throughout the U.S. are aware that this problem exists in their communities, but are not prepared to adequately respond to and intervene in these fatalities as an analysis of those who have died has rarely been conducted. This dissertation is a replication study of longitudinal epidemiological analyses of opiate related fatalities that was implemented in a location where an analysis of opiate-related fatalities had not been conducted, Marion County, Indiana. The purpose of the dissertation was twofold: (1) to describe the demographic characteristics of the decedents using publicly available data from the Marion County Coroner’s Office to be used in informing future preventative efforts to decrease opiate-related fatalities in Marion County and (2) to inform other communities on how to conduct a similar analysis in their own community. This dissertation describes the methods of the replication study, provides descriptive results of the people who died from opiate-related overdoses, and: (a) Report the types of opiates identified in blood toxicology reports and (b) Present the histories of opiate-related decedents as reported in the Deputy Coroner Field Officer’s Reports (DCFOR). Additionally, analysis was conducted to determine if decedent characteristics deferred depending on the type of opiate fatality based on the toxicology in 1) heroin alone, 2) painkillers alone, and 3) heroin and painkillers combined.

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Drug prohibition has dramatically affected countries worldwide. It fuels violence and corruption in Latin America, and Central and Southeast Asia, and is a major contributing factor behind the United States having the highest rate of incarceration in the world. Yet there is scant evidence that prohibition reduces drug use. Despite this lack of evidence, prohibition is the preferred policy stance of governments worldwide. One of the primary justifications of prohibition is that drug use causes individuals’ harm. While there is evidence of individual harms associated with drug use there is also a literature suggesting it is possible to use drugs functionally – defined here as use with minimal impairment to mental and physical health, and social roles and expectations. However, drug use is a politically charged topic and as such little research on functional drug use has come to prominence. The existence of persons who use drugs functionally would allow us to consider alternative approaches to drug control that address the harms that stem from both prohibition and individual use.In this dissertation I conducted three independent but related studies to explore the existence and drivers of functional drug use. In Chapter 1 I systematically reviewed peer-reviewed literature from Ovid MEDLINE, PsycINFO, Scopus, and Web of Knowledge databases regarding functional drug use and find robust evidence that all illegal drugs can be used functionally. Drawing on the narratives of participants across the studies the typical person who uses drugs functionally is marked by three characteristics. First, they actively avoid addiction and take steps to maintain overall good physical and mental health. Second, they are socially integrated with lives that do not revolve solely around procuring and consuming drugs; hallmarks of this included holding a job, attending school, and maintaining connections to non-drug using family and friends. Third, persons who use drugs functionally take pains to avoid negative stereotypes attached to persons who use drugs – paying for their drugs with excess income, avoiding other illegal activities and attending to important socially sanctioned activities. In Chapter 2 I used data from the Inner-City Mental Health Study Predicting HIV/AIDS, Club and Other Drug Transitions (IMPACT) study, a cross-sectional dataset of former and current persons who use drugs in New York City selected via random street intercept between 2005 and 2008, to apply the findings of our review to find participants reflective of the phenomenon of functional drug use. Using exploratory latent class analysis on questions regarding drug use behaviors I report different patterns of drug use within the IMPACT sample and regress measures of social functioning on these classes as distal outcomes to assess the functionality of each class. My solution is a 6-class model consisting of the following use patterns: former non-persons who inject drugs (PWID); former PWID; marijuana use; cocaine, crack and marijuana use; low frequency polydrug use; high frequency polydrug use. Among the classes containing persons who use drugs currently, there was a clear pattern of relative functionality based on the probability of drug related interference and having an illegal main source of income. From most functional to least functional these were: marijuana use (2% interfering use; 5% illegal main source of income), cocaine, crack and marijuana use (48%; 31%), low frequency polydrug use (58%; 38%), and high frequency polydrug use (80%; 57%); compared to 37% of the overall sample reporting interfering use and 24% reporting having an illegal main source of income. Comparing the classes to former non-PWID, marijuana use had a lower odds of drug use interference (OR = 0.07, p-value < 0.01) whereas all other classes had significantly increased odds of drug use interference with increasing odds from former PWID (OR = 1.80, p-value = 0.04), cocaine, crack and marijuana use (OR = 4.46, p-value < 0.01), low frequency polydrug use (OR = 6.48, p-value < 0.01), and high frequency polydrug use (OR = 18.66, p-value < 0.01). Regarding main source of income there was no significant difference between the marijuana use class with the former non-PWID (OR = 0.88, p-value = 0.81). The other classes however, followed a similar step-wise pattern as for drug use interference: former PWID (OR = 2.68, p-value = 0.04), cocaine, crack and marijuana use (OR = 7.21, p-value < 0.01), low frequency polydrug use (OR = 10.08, p-value < 0.01), and high frequency polydrug use (OR = 21.30, p-value < 0.01). In Chapter 3 I built on the results from Chapter 2 to test whether childhood physical abuse, sexual abuse, and neglect (CAN) was associated with membership in less compared with more functional drug use classes using multinomial logistic regression. This analysis builds on literature summarized in Chapter 1 suggesting non-functional drug use is associated with feelings of negative affect and a large body of work documenting associations between CAN and psychiatric and behavioral disorders generally, and drug use specifically. I report that childhood neglect is not associated with different patterns of drug use behaviors but is positively associated with having an illegal main source of income (OR = 1.40, 95%CI 1.02, 1.92). Participants experiencing physical abuse were 1.65 (95% CI 1.06-2.59) times more likely to engage in high frequency polydrug use compared to marijuana use but had no association with drug use interference after adjustment for drug use class. There were positive associations between all measures of sexual abuse with drug use interference and having an illegal main source of income. Adjustment for drug use class accounted for the association with drug use interference but not having an illegal main source of income. This exploration of functional drug use found a strong evidence base of qualitative work supporting its existence; however, there are few extant quantitative investigations. Applying the results of our review to an epidemiologic sample I found a hierarchy of functionality related to different patterns of drug use. Moving this body of work forward requires the development of new scales to measure functional drug use to more fully characterize the phenomenon. Replication across samples will generate much needed estimates of the prevalence of functional and non-functional drug use, key data for drug policy debates. These scales should take into account the three key dimensions outlined by participants across the studies reviewed and be applicable across various kinds of drugs and meaningful cross-culturally. I report evidence supporting an association between CAN with different patterns of drug use and reduced social functioning. Future analyses should measure other sources of childhood trauma if they are interested in the direct effect of CAN on drug use, as well as modifiers of the CAN-drug use relationship to fully characterize the phenomenon. However, it should also be noted that the model this analysis is based on, like most extant theories of use, is rooted in the moral panic over drugs that has engulfed the United States for the last 100 years. These models treat drug use as unequivocally harmful, hence an irrational activity and therefore, implicitly, the result of some trauma. Functional drug use subverts this paradigm and considers multiple reasons for and patterns of use. While there are likely negative inducements towards less functional patterns of drug use we would do well to update our models by considering pleasure and incorporating both positive and negative inducements. New models should then be tested systematically across samples.

Pain is a leading cause of disability and the most common reason for clinical care. The field of pain research has focused on sex differences in the recent years with an expansive body of literature demonstrating sex-related differences in pain behavior and responsiveness to pharmacological interventions. Prescription opioids are potent analgesics and the mainstay for the clinical management of moderate-to-severe acute and chronic pain conditions. However, the long-term clinical use of prescription opioids for chronic pain remains controversial due to concerns about severe adverse effects, including tolerance, dependence, and addiction associated with opioid use. The non-medical use and abuse of prescription opioids has become a public health crisis, the problem even arising in a subset of chronic pain patients receiving opioid therapy. The vulnerability factors, specifically the role of pain in the propensity to prescription opioid abuse, are poorly understood. The present research project sought to investigate the propensity to opioid reward as a function of pain in male and female mice by incorporating acute (acetic acid-induced) visceral nociceptive and chronic chemotherapy (paclitaxel)-induced peripheral neuropathic pain models. Sexually dimorphic variations in the sensitivities of mice to nociceptive and allodynic behaviors were initially assessed using the two putative pain models. Following that, the two prescription opioids, morphine and oxycodone were examined under both pain contexts and the capacity of the two prescription opioids to produce reward-related behavioral effects were measured using drug discrimination, conditioned place preference, and intravenous drug self-administration procedures. The presence of acute noxious state but not chronic pain selectively attenuated the discriminative stimulus effects of the prescription opioid, morphine in male mice. The magnitude of modulation of the stimulus effects of opioids by the acute noxious state were further observed to be inversely related to the relative intrinsic antinociceptive effectiveness of the two opioids in reversing the acute noxious state and sex-specific sensitivities of mice to opioid-induced antinociception. In contrast, while no change was observed in opioid-reward as a function of the acute noxious state in both sexes, the presence of paclitaxel-induced chronic pain opioid-selectively and dose-selectively enhanced the conditioned rewarding effect of morphine (0.3 mg/kg dose), and the effect was more pronounced in male relative to female mice. These data were further supported by the self-administration results, in that the reinforcing efficacy (breakpoints under progressive ratio (PR) responding) and the incentive-motivational salience of morphine significantly increased in the presence of chronic pain in male mice, while non-selectively increasing regardless of the presence/absence of pain in female mice. Overall, the converging empirical evidence presented here suggest that these models provide preclinical tools to further understand the overlapping neurobiology of pain and opioid abuse, the behavioral effects of prescription opioids, and advance the development of novel sex-specific pain therapeutics with low addiction liability. / Pharmaceutical Sciences

Licensed substance abuse programs in the Commonwealth of Virginia are reporting turnover rates for counselors of up to 60%. Studies have indicated that low job satisfaction can be a cause for turnover in the human services professions. The entire population of substance abuse counselors certified by the Commonwealth of Virginia was surveyed by mail, using a Modified Minnesota satisfaction Questionnaire and an Individual Information Form. Of the 496 possible responses, 365 were returned for a return rate of 73.7%. The study was conducted to answer three research questions concerning the job satisfaction of these counselors and to provide insight into the possible causes of the high turnover rates. The answers to these questions sought to describe and examine the level of job satisfaction, the sources of job satisfaction and the relationship between job satisfaction and clinical supervisor and clinical supervision variables for this population. The results of the study indicate that these counselors are very satisfied with their jobs. The sources of the greatest influence on job satisfaction are represented by the scales Social service, Moral values and Creativity. The scales Advancement, Policy and practices and Compensation were the least influential on job satisfaction. A model of ten Clinical supervisor and Clinical supervision variables was regressed on job satisfaction. Four variables, Hours of supervision per week, Length of time clinical supervisor has been a clinical supervisor, Degree status of the clinical supervisor and Clinical supervisor is also the administrative supervisor were found to explain a significant amount of the variance in job satisfaction. Although these counselors indicated that they were very satisfied with their jobs, in the next five years 58.44% plan to leave their jobs, which includes 17.75% who plan to leave the substance abuse field entirely. / Ph. D.

Of the people, by the people, for the people stated in the Declaration of Independence in 1776 is what the framers of the Constitution had in mind. It was the intention to establish a framework that would create sound and just government. It held a bill of rights that provided examples for the world to follow. Unfortunately, the United States fails its own declaration when considering some of its policy and legislation. When examining drug policy, it is apparent that these laws were not of the people, by the people, or for the people, and in fact are contrary to the Constitution of the United States. This thesis will examine the history of drug policy in the United States. It will provide examples of other nation's policy on drugs to compare. In addition, a recount of the Bill of Rights and specific examples of the War on Drugs will illustrate the contradiction of U.S. drug policy to the Constitution. The thesis will end with a recommendation for the formation of new policy and a reminder of who is ultimately responsible.

Despite the fact that a lot of information exist in the literature regarding factors leading to drug abuse, consequences of drug abuse for adolescents; little exists that focuses on family support for adolescents after rehabilitation. The purpose of this study was to explore family support for adolescents after rehabilitation for drug abuse. The study was based on semi-structured interview based qualitative research. Findings during interviews was that the families have no clear understanding or are not skilled as to how to continue supporting the adolescents after they are discharged from the rehabilitation centre. What was also interesting according to the participants was that even in the rehabilitation centres families are not made part of or involved during the rehabilitation process. There is a need to make the rehabilitation centres aware that families need to be involved during the rehabilitation process of the adolescent so that it becomes easy for the families to continue supporting the adolescents after they have completed the rehabilitation process. / Health Studies / M.A. (Health Studies)