RESEARCH METHODOLOGY The Sample

The results presented in this article are from the study's first 144 subjects (80 from Hong Kong and 64 from the United States recruited between 1979 and 1982). Because our subjects were drawn from two different countries, it is natural that two distinct populations are represented. Also, because our populations volun-teered for aftercare. they are a unique subset of the population of addicts in treatment. The subjects averaged 31 years of age;

were 85 percent male; the Hong Kong subjects were 100 percent ethnic Chinese, the American subjects were 95 percent Caucasian and 5 percent black; the Americans were two-thirds Catholic, while the Chinese were 87 percent without religious preference. In addition, the Americans were better educated; more often employed, with higher occupational prestige; and more likely to be married than the Chinese were. All of the subjects were opiate addicts

(addicted for a mean of 6.4 years) and had relapsed an average of 4.3 times prior to entering the study.

The American subjects came mostly from methadone maintenance pro-grams (62 percent), outpatient drug-free counseling (14 percent), and detoxification programs (11 percent); the Chinese came from halfway houses (50 percent) or Shek Kwu Chau (50 percent), Hong Kong's island residential treatment center. During the month before entering the program, 82 percent did not use illicit opiates, and 18 percent used an illicit opiate at least once.

Randomization and Followup

The 144 subjects were randomized to treatment (77) or control (67) conditions at the study's six yroup sites. Control subjects were urged to make use of aftercare services available to them as part of the primary treatment program from which they were referred or other availahle community resources. Followup interviews were scheduled for 6 and 12 months after the baseline interview.

Ninety-eight percent of the first followups and 82 percent of the second followups were completed, although it took an average of 9.1 months and 19.7 months respectively to complete them. Subject

attrition at second followup was due to refusal and nonresponse (4 percent), death (3 percent), relocation (1 percent), and subjects who were not reinterviewed because of practical administrative problems (10 percent). All significance levels reported in this article are from two-tailed tests.

RESULTS

Process Evaluations

Although the meat of our evaluation was an assessment of outcomes, including illicit opiate use, employment, and crime, this section presents the results for several key process measures. They are 1) length of membership in the groups, 2) participation in group activities, and 3) the subjects' own assessments of the programs' value.

About half of the subjects were active group members for about 13 weeks (approximately 3 months), and a quarter were members for 6 months or more. In the United States during the project's fourth year (not reported here), the number of dropouts declined

dramati-cally after we adopted a mandatory 3-week attendance period before subjects were randomized. Of the last 16 experimental subjects, 69 percent remained the entire 6 months. Two of the American groups are still active and self-sustaining 7 months after the research was discontinued.

Treatment and control groups were compared in four dimensions of activities that characterize our program's self-help component

(learning about recovery, socializing with recovered addicts, trying to help others recover, and social service), and two that do not (working in a treatment program and religious activities).

In each of the four dimensions characterizing our program, the differences favored the treatment group for both first and second followup, and by the second followup all of the differences were significant. By contrast, the other two activities were not dif-ferent across experimental and control groups. A subsample of the experimental subjects were asked whether being in the study had helped them. At the first followup, 74 percent said that it had helped to some degree; at the second followup, 87 percent said so.

Thus, there was clear evidence that we were able to implement the treatment: subjects attended meetings and participated in self-help activities, and most participants thought that the program was helpful.

Relapses During a 1-Year Followup Period

The most important objective of our aftercare program was to pre-vent readdiction to illicit opiates. During the first 6-month followup period, 46 percent of the combined sample had relapsed

(10 or more days of daily use); during the second 6-month period, more than 60 percent relapsed. However, for both 6-month periods,

the experimental group had significantly more subjects who had good outcomes, defined as abstinent or having only rare "slips"

(use less than once per month). After statistical controls for baseline differences and country effects were introduced, the combined experimental groups had more subjects with good outcome than the control groups did (32 percent versus 18 percent) for the entire 12-month followup period (p < .05). Thus, as a result of aftercare, the experimental group's rate of positive outcomes was 77 percent better than the control group's.

When we examined the countries separately, we found that in Hong Kong 15 percent more of the experimental subjects had positive outcomes than the controls throughout both 6-month time periods, which is at the .1O confidence level. In the United States 17 percent more of the experimental group than the controls had posi-tive outcomes, which is at the .18 confidence level. The effect in the United States appeared to weaken over time, since it was significant at the .05 level for the first 6 months but signifi-cant only at the .1O level for the second 6 months, and at the .18 level for the entire year. The small differences in the treatment effect across countries were not statistically significant for any time period.

A quantitative measure of this outcome is the number of days on which the subjects used an illicit opiate during the 12 months. A

regression analysis of this measure found that the combined experimental group used illicit opiates on 49 fewer days than the control group did, an effect that was significant at the .O1 level. The effect in Hong Kong was 59 days (p < .05), and in the United States the effect was 37 days (p < .12).

Space prevents presentation of the several other measures of relapse we obtained in this study, including measures of legal methadone use. The conclusions in each case were basically the Same: there is a significant positive treatment effect for both the first and second followup periods when the combined sample is employed. Although the treatment effects are in the right direc-tion in both Hong Kong and the United States, the small sample size, especially in the United States, often makes it difficult for these effects to achieve significance. For most of these opiate-use measures, the treatment effects were greater in Hong Kong than in the United States, but the differences between coun-tries (interactions) were not significant. Finally, in Hong Kong the effect remained virtually constant throughout the followup period, but in the United States it appeared to fade somewhat after the first 6 months. One possible explanation for this dif-ference is that after a 1-year period the Chinese subjects could join the 1,500-member self-help organization of ex-addicts in Hong Kong, whereas no such parent organization existed in the United States.

Employment

Although employment is a key outcome measure for almost any opiate drug treatment program, it is somewhat less central for our after-care program because a majority of our subjects in the United States had jobs or were effectively out of the labor force

(mothers with several small children) when they joined the groups, and a majority of addicts in Hong Kong work even when they are actively addicted. Our program's employment objectives vary.

Depending on the subject's employment status at entry, the objective is 1) to help the unemployed find jobs or 2) to prevent job loss and improve careers of the employed.

Our results show that the experimental group members had better employment outcomes than the controls at 6 and 12 months, but the effect is significant only at 12 months for the combined United States and Hong Kong sample. At 12 months 65 percent of the combined experimental group were employed, compared to 46 percent of the combined control group. When we examined the number of months employed during the year-long followup period, the differ-ences between experimental and control yroups were favorable, but not significant.

Almost all of the employment treatment effect was in helping unemployed subjects find jobs. Relatively few of the initially employed subjects, either experimental or controls, lost their jobs, and the experimental condition made no apparent difference.

By contrast, for initially unemployed outpatients (N=39) there were large, significant differences in employment rates between experimental and control groups at 6 months (61 percent vs. 30 percent) and 12 months (64 percent vs. 18 percent), and for ini-tially unemployed inpatients (N=40) there was a significant difference (75 percent vs. 35 percent) between the experimental and control subjects at 12 months. The difference in treatment effect between the initially employed and unemployed outpatients was statistically significant. This pattern of results was

repeated when we examined the number of months of fulltime employ-ment during the year, with the treatemploy-ment effect for initially employed subjects significant at the .05 level duriny the second 6-month period in the combined sample and the United States sample.

Thus, the aftercare program had significantly positive effects on helping unemployed subjects find and keep jobs, especially during the second 6 months followiny baseline.

Criminality

The usual indicators of criminality, such as arrest or incarcera-tion, did not occur with great frequency in this population during the entire followup period (15 months in the United States and 22 months in Hong Kong) and revealed no significant differences be-tween treatment and control. However, in examining self-reported

criminality, we found that the Hong Kong experimental group had significantly fewer members with indications of criminality than the control group did (49 percent vs. 79 percent) during the second followup period. The effect in the United States was in the right direction (58 percent vs. 77 percent) but not signifi-cant during the first followup period, and it virtually

disappeared (67 percent vs. 72 percent) by the end of the second followup period.

DISCUSSION

In sum, the research showed that our mixed self-help and profes-sional aftercare program was implemented satisfactorily in both Hong Kong and the United States. The program was received favorably by the subjects themselves, and it had statistically significant effects on preventing relapse and getting unemployed ex-addicts back to work. It also significantly reduced self-reported crime in Hong Kong and reduced crime in the United States, but not enough to be statistically significant.

Implementation Issues

Since many of the usual questions about initiating our program and handling a group once underway have been addressed elsewhere by Nurco et al. (1981) and by ourselves (Zackon et al. 1984), we will confine our discussion in this article to a few broad implemen-tation issues.

Starting our groups was hard. The greatest amounts of effort were required in developing a suitable structure and curriculum materi-als, getting real support from referral sources, getting members to participate fully, maintaining regular attendance, and prevent-iny attrition. Because our handbook provides a proven structure and curriculum materials, the major problems for a new group will be finding enough interested and appropriate clients and hiring leaders who will faithfully implement the model and keep members participating in the program long enough and actively enough to reap its benefits.

Although we believe that the training and the self-help structure ultimately set this program apart from other aftercare groups, starting the group requires leaders with skill, energy, charisma, patience, and time. The professional may need to work almost fulltime for a month or two to get the ball rolling. Once the group is established, the professional and peer leader are needed for 8 to 10 hours per week. The budget for one of our free-standing groups is now approximately $20,000 per year for the yroup leaders and incidentals. An agency-based program is

estimated to cost $12,000 per year. The estimated weekly time is 10 hours for a professional and 5 hours for a peer leader.

Our experience suggests that this program could flourish in a wide range of treatment settings. Our subjects were opiate addicts

drawn from the full gamut of treatment modalities (methadone, therapeutic community, inpatient detoxification, and outpatient drug-free). We worked as a freestanding agency in the United States and as part of a large drug-treatment agency in Hong Kong.

We see no reason why the curriculum and self-help structure could not be adapted to other drugs, for the issues faced by recovering persons are often similar regardless of the drug abused. Our own future research is most likely to be on adapting the program for ex-cocaine addicts. We already have one program that has begun to use our materials with slight modification for a methadone detoxi-fication group and a cocaine addict group, and in Hong Kong the model is being used in primary treatment as well as aftercare.

Extension to primary care is another topic for future research.

At present we encourage individual clients to use other services when needed, especially individual counseling for obvious psycho-logical problems and Narcotics Anonymous (NA) for additional support and inspiration, especially during crises. Clients often have such needs, but undue attention to them can prevent an after-care group from addressing less urgent but equally important re-covery issues that are not dealt with elsewhere. One group member said, "NA is my commitment, this group is my growth." Moreover, when compared to programs that focus on primary treatment or both primary treatment and aftercare, our program offers a unique opportunity for new members to be surrounded by success, not failure. Our admission policies and program structure ensure that members, peer leaders, and ex-addict associates form a community

in which abstinence and community reintegration are the norms.

CONCLUSIONS

Finally, we want to briefly review the theoretical issues in drug treatment that this research addresses. We think we have shown that relapse rates can be reduced by an aftercare program that goes beyond the services currently available to ex-addicts. We believe that the benefits of the program will increase even further with its development and refinement.

The program's success demonstrates that professional and self-help approaches can be combined effectively to take advantage of the strengths of each. Although our outcome measures do not allow us to separate the effects of self-help from the training sessions, the addicts themselves made clear the importance they attached to the program's self-help elements. In addition, we have shown that self-help programs can be rigorously evaluated using random assignment to treatment. Our positive results, even if not as

impressive as previous findings from Ch'ien's (1979) nonrandomized evaluation, are a springboard for continued development.

Our 6-month curriculum exemplifies our conscious divergence from the usual psychotherapeutic model of drug treatment and aftercare

(Brown and Ashery 1979). We favor a structured, systematic regi-men that draws from research and clinical knowledge. Our proyram

also emphasized a hands-on, activist approach that goes beyond the therapist's office and formal group meetings. Information, plan-ning, models, motivation, and support are our therapeutic agents.

We believe that our results show this approach is cost-effective and appealing to ex-addicts.

REFERENCES

Brown, B.S., and Ashery, R.A. Aftercare in drug abuse pro-gramming. In: DuPont, R.I.; Goldstein, A.; and O'Donnell, J., eds. Handbook on Drug Abuse. National Institute on Drug Abuse.

Washington, D.C.:- Supt. of Docs., U.S. Govt. Print. Off., 1979. pp. 165-173.

Ch'ien, J.M.N. Alumni associations in Hong Kong. In: Brown, B.S., ed. Addicts and Aftercare:

Former Drug User. Beverly Hills: Sage, 1979. pp. 155-163.Community Integration of the Nurco, D.N.; Stephenson, P.; and Naesea, L. Manual for Setting Up

Drug Abuse Treatment Research Report. DHHS. Pub. No. (ADM)Self-He1p Groups of Ex-Narcotic Addicts. National Institute On 81-1087. Washington, D.C.: Supt. of Docs., U.S. Govt. Print.

Off., 1981. pp. 1-23.

Nurco, D.N.; Wegner, N.; Stephenson, P.; Makofsky, A.; and Shaffer, J.W. Ex-Addicts' Self-Help Groups. New York:

Praeger, 1983. 177 pp.

Zackon, F.; McAuliffe, W.E.; and Ch'ien, J.M.N. Addict Aftercare:

Recovery Training and Self Help. National Institute on Drug Abuse. DHHS Pub. No. (ADM) 85-1341. Washington, D.C.: Supt.

of Docs., U.S. Govt. Print. Off., 1984.

AUTHORS

William E. McAuliffe, Ph.D.

Elaine Launer, B.A.

Rob Friedman, M.A.

Barry Feldman, B.S.

Department of Behavioral Sciences Harvard University School of

Public Health 677 Huntington Avenue Boston, MA 02115

James M.N. Ch'ien, M.S.W., M.P.H., S.A.R.D.A.

Duke of Windsor Social Service Building 15 Hennessy Road, Third Floor

Hong Kong

PROJECT SKILLS: PRELIMINARY