Marriage and relationship closeness as predictors of cocaine and heroin use
Introduction
Substance-use disorders are a widespread and persistent health problem in the United States, with significant social and economic consequences (Harwood et al., 1992, Office of National Drug Control Policy, 2001). The National Epidemiologic Survey on Alcohol and Related Conditions showed that approximately 2% of adult Americans experienced a drug-use disorder in the past year (2001–2002) and 10.3 experienced a drug-use disorder during their lifetimes (Compton, Thomas, Stinson, & Grant, 2007). Given the low rate of recovery among individuals with chronic drug-use disorders (e.g., Hser et al., 1993, O'Donnell, 1972), it is important to determine factors that may facilitate recovery. One such factor, social support, has been shown to predict a variety of positive treatment outcomes in substance-abuse programs, including greater treatment retention (Dobkin, De Civita, Paraherakis, & Gill, 2002), lower rates of relapse (Havassy, Wasserman, & Hall, 1995), and greater subjective well-being (Beattie & Longabaugh, 1997).
Long-term committed relationships, such as marriage, provide the primary form of social support for many individuals. Unfortunately, researchers have found that substance use is related to divorce or separation (Lex, 1994) and remaining unmarried (Kaestner, 1997). Interestingly, epidemiological data provides evidence to suggest that married individuals are much less likely to use illicit drugs. For example, Merline, O'Malley, Schulenberg, Bachman, & Johnston (2004) analyzed rates of drug use among 35-year-old adults in the Monitoring the Future study and found that married individuals were significantly less likely to use cocaine than unmarried individuals: 3.8% of married men and 2.0% of married women reported cocaine use, whereas 11.4% of unmarried men and 5.1% of unmarried women reported cocaine use.
Perhaps more important is the possibility that marriage may serve as a protective factor among those who have already initiated drug use. In an investigation of 8,427 patients who received substance-abuse treatment through the Department of Veterans Affairs, being married was significantly related to stable or improved outcomes after treatment (Moos, Nichol, & Moos, 2002). In contrast, patients who were not married were significantly more likely to experience symptom exacerbation over time. Cessation of cocaine use has also been shown to be significantly related to marital status; in a community sample, cessation of cocaine use was three times more common among married individuals than among unmarried individuals (White & Bates, 1995). As such, marital status may be a proxy for improved treatment outcome. Additionally, it may also be useful in determining which elements of the relationship contribute to the above described pattern. In turn, this knowledge may inform interventions and allow researchers to prospectively evaluate the direction of any causal relationships between drug use and marital status.
Different types and definitions of social support may be related to treatment outcomes in different ways. Structural social support represents the extent of supportive resources (Beattie, 2001) whereas functional social support is defined as the perceived or actual support received (Dobkin et al., 2002). The quality of the marital relationship (a form of functional social support) may be at least as important a predictor of treatment outcome as marital status per se (a form of structural social support). In the alcohol-research literature, low marital satisfaction has been shown to predict poor treatment outcomes (Beattie, 2001, McCrady et al., 2003), whereas marital happiness predicts optimal treatment outcomes (McCrady, Epstein, & Kahler, 2004). Promotion of marital satisfaction through couples therapy with substance abusers has been shown to reduce drug use, increase treatment retention, and promote better dyadic adjustment (e.g., Epstein and McCrady, 1998, Fals-Stewart et al., 1996, O'Farrell and Fals-Stewart, 2000, Winters et al., 2002). Thus, it appears that higher levels of extant marital satisfaction, or increases in marital satisfaction achieved through counseling, are associated with better treatment outcomes. Findings from these studies collectively warrant further exploration of the observed associations between spousal relationships and maintenance of substance use and/or recovery.
Despite the extensive body of literature on alcoholism and marriage, there is little research on the relationship between marital status and opiate and cocaine use during treatment. Several researchers (e.g., McCrady, 2004, Witkiewitz and Marlatt, 2005) posit that such relationships should be investigated at the level of the individual substance user because traditional analytical methods often fail to account for individual heterogeneity. Therefore, the goal of the current study was to test whether individual trajectories of cocaine and heroin use during treatment are predicted by marital status and by the perceived closeness (i.e., functional social support) of the marital relationship. Based on previous epidemiological data, as well as the extant literature from the alcohol field, we predicted that married individuals would have significantly better outcomes than nonmarried individuals and that closeness of the marital relationship would account for additional variance in outcome among those participants who were married. Furthermore, we examined whether being in a domestic partnership (i.e., living together, but not married) resulted in better outcomes, compared to being single or separated.
Section snippets
Participants
The current study is a secondary analysis of pooled data from three consecutively run clinical trials involving contingency management (CM) and methadone maintenance (Epstein et al., 2003, Ghitza et al., 2007, Preston et al., in press). Across the three trials, 635 cocaine-abusing, opiate-dependent individuals were enrolled in a methadone-maintenance outpatient treatment program at the National Institute on Drug Abuse in Baltimore, Maryland between the years of 2000 and 2006. Participants
Results
Participants' mean age was 41.9 (7.9), and the majority were African-American (57%) and male (54%). The mean number of days of cocaine and heroin use in the past month was 17.6 (9.8) and 29.2 (3.7), respectively. 35% of the sample was employed full time (n = 196), 43% were unemployed (n = 245), 20% reported working part-time (n = 110), and 2% were retired or on disability (n = 13). Further descriptive information for the sample is provided in Table 1. As expected, cocaine and heroin slopes were
Discussion
The primary objective of substance-abuse treatment and its associated outcome research has been to promote and maintain abstinence using various combinations of psychological and pharmacological treatments. However, given the usually chronic nature of addiction, it is also important to focus on protective factors that may facilitate lasting change. One such factor, social support, has been indicated in improved substance-use outcomes. Further, the quality of social support in a marital
Acknowledgments
This research was supported in part by the Intramural Research Program of the NIH, National Institute on Drug Abuse.
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