miller et al-2014-drug and alcohol review

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Comparing subjective well-being and health-related quality of life of

Australian drug users in treatment in Regional and Rural Victoria

PETER G. MILLER, SHANNON HYDER, LUCY ZINKIEWICZ, NICOLAS DROSTE &JANE B. HARRIS

Faculty of Health, School of Psychology, Deakin University, Geelong, Australia

AbstractIntroduction and Aims. The aim of this study is to examine the self-reported subjective well-being and health-related qualityof life (HRQOL) of alcohol and other drug users and to examine whether subjective well-being in this sample would be predictedby either HRQOL and/or severity of dependence. Design and Methods. A cross-sectional survey was conducted of 201Victorian substance users in individual targeted outpatient treatment for a variety of types of substance use. Participantswere administered an interview, including the personal well-being index, the SF-8 health sur vey and the severity of dependence

scale, in order to assess subjective well-being, the mental health component of HRQOL and severity of drug dependencerespectively. Results. Subjective well-being was predicted by mental health aspects of HRQOL (sr2 = 0.03) and byemployment (sr2 = 0.05), rather than by severity of dependence [F(5,146)= 5.60, P


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(happiness) response to domains, such as goals, values,

accomplishments and personal situation. A more com-

plete definition of QOL should include both of these two

indicators but not conflate them [8]. Cummins proposes

that QOL is best captured by using a measure, such as

the personal well-being index [9], to measure subjective

well-being and a separate measure (e.g.the OpiateTreat-

ment Index) [10] to measure physical symptomology.

Although they tend to be independent from each other,

objective indicators (usually poor living conditions) can

drive subjective indicators down, creating a stronger

relationship between the two indicators [8]. Current

research is increasingly suggesting that QOL is multidi-

mensional [3], and this paper seeks to compare two

dimensions of QOL in a drug-using sample.This paper

adopts a health-related and psychological approach to

measuring QOL by investigating self-reported subjec-

tive well-being and HRQOL in a sample of people

receiving AOD outpatient treatment.

HRQOL

HRQOL has been defined as the perceived impact

of health status on physical, psychological and social

functioning [11]. An excellent HRQOL score would

represent an absence of self-reported pathology [5,12].

By focusing on perceptions of health symptomology,

HRQOL can be conceptualised as an objective measure

of QOL. Use of such measures is common within

health-care services [11].

Current research into HRQOL and substance users

generally shows that users have lower HRQOL than

do the general population [1317], although some

research suggests that drug users in younger age

groups, around 1835, do not have such lower levels of

HRQOL. This finding is believed to be a result of the

health effects of drug use not yet being present [13,18].

Greater severity of substance use is also associated with

worse HRQOL [13,14,17], even within younger drug

users [18].

Subjective well-being

Subjective well-being describes peoples satisfaction

with their lives as a whole or with the individualdomains of their lives [5]. Subjective well-being is a

useful tool for assessing whether a person is actually

satisfied with their lives, without focusing on ill-health,

as someone who is healthy and wealthy may still not be

satisfied [12]. Cummins and colleagues propose that

subjective well-being is under homeostatic control, and

it is controlled and maintained by psychological mecha-

nisms that function under the influence of personality

[5], meaning that subjective well-being will vary only

within a small positive range around an individuals set

point in normal life, referred to as core affect [19,20].

Ones subjective well-being may vary as a result of a

positive or negative life event, but after the situation has

been dealt with, subjective well-being will usually

return to that of the homeostatic level [5]. However, if

individuals enter a depressive state, subjective well-

being normally drops to below the lower levels of the

normal range and remains there [21].

Research into the subjective well-being of substance

users is not as common as research into the HRQOL of

such individuals. In some AOD research, subjective

well-being is referred to as subjective QOL [22] rather

than subjective well-being, and in consequence, studies

have employed various tools to measure subjective well-

being. Drug users have generally been found to have

lower subjective well-being than do those in the general

population [2325]. Subjective well-being is also lower

in alcoholic women with depressive symptoms than

those without [26]. Further, poorer family/personal

relationships in substance users are associated withpoorer subjective well-being [15,23,2628].This raises

the possibility that, if issues of family/personal relation-

ships are focused on in treatment rather than just physi-

cal symptoms, improvement in subjective well-being to

normal levels may occur [15,22,2729].

Unemployment in substance users is also strongly

associated with lower subjective well-being, with

employed users having much better subjective well-

being [24,26]. Having a job is considered to be instru-

mental in helping substance users increase their social

inclusion after and during treatment [27]. Health,

standard of living and life achievements are also lower

in those with lower subjective well-being [24]. Further,

regional differences exist as drug users living in rural

areas have lower subjective well-being than drug users

in metropolitan areas [23].

The current study

Objective and subjective measures of QOL are thought

to be independent of each other [5], suggesting that

measures of HRQOL and subjective well-being should

have little or no relation to each other. However, meas-

ures of HRQOL and subjective well-being have never

been investigated together in relation to drug and

alcohol treatment research. The aim of the present

study was, therefore, to examine these measures in

AOD users in outpatient treatment and to determine

whether subjective well-being would be predicted by

HRQOL and/or by severity of dependence.

Methods

Participants

The non-random convenience sample comprised 201

adult patients (102 men and 99 women) attending

652 P. G. Milleret al.

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urban and regional drug and alcohol outpatient treat-

ment facilities in Victoria, Australia (Barwon Health

and Western Region Alcohol and Drug Centre).

Patients were admitted for any drug or alcohol-related

problem over a one-year recruitment period and were

engaged in individual targeted treatment. Most

received a combination of case management and

substance use counselling. Opiate-dependent patients

received methadone as well.These treatments represent

a treatment as usual sample, rather than trying to

manipulate the type of treatment being received. There

were 102 men and 99 women, with ages ranging from

18 to 68 years [M= 31.96, standard deviation (SD)=10.42]. Mean years of education was 10.4 years, with

60.2% of the sample being unemployed, 15.9%

employed part time and 6.5% full time.The majority of

participants lived in urban areas of Victoria, specifically

in Geelong (80.6%), and 17.4% came from the

regional area of Warrnambool. The main substance for

which treatment was being sought was heroin (58.2%),followed by alcohol (13.4%), cannabis (10%), amphe-

tamines (4.5%) and other opiates (4%).

Materials

Demographic and general drug use information was

collected. Interviewees were asked about their primary

drug of choice and any other drugs they used.

SF-8 health survey. To measure HRQOL, the SF-8

health survey was used, which is an eight-item

response, generic short form survey of health status

[30]. Each item assesses a particular domain of health,

including general health, physical functioning, role

limitations by physical problems, bodily pain, vitality,

social functioning, general mental health and role limi-

tations resulting from emotional problems. Participants

describe their feelings about these aspects of their lives

over the preceding four weeks, using a 5 or 6-point

response scale ranging from a negative (e.g.very poor)

to positive response (e.g.excellent). The eight items are

used to calculate two separate measures, the physical

component summary (PCS), focusing on physical

health, and the mental component summary (MCS),

focusing on mental health, standardised to produce apopulation mean of 50 and SD of 10 for each measure.

The Cronbachs alpha for the current sample was high

( =0.87).

Personal well-being index. The personal well-being

index (PWI) contains seven items assessing satisfaction

with standard of living, health, achieving in life, rela-

tionships, safety, community connectedness and future

security, responded to on an 11-point scale ranging

fromcompletely dissatisfiedto completely satisfied, with the

midpoint labelled asneutral[31]. After rescaling, a total

score between 0 and 100 is produced, with higher

scores indicating greater subjective well-being [9]. The

PWI normative score for Australians is 76.2 [31]. The

Cronbachs alpha for the current sample was high

( =0.82).

Severity of dependence scale. The severity of depend-

ence scale (SDS) is a five-item scale measuring the

degree of dependence experienced by drug users

[32]. For consistency in administration, items were

responded to on an 11-point response scale, then scores

were rescaled to the original 4-point scale. Total scores

served as the measure for analysis, with a cut-off score

of 4 indicating dependence [33] and higher scores indi-

cating a higher degree of dependence. The Cronbachs

alpha for the current sample was acceptable ( =0.76).

ProcedureEthics approval was obtained from the Deakin Univer-

sity Human Research Ethics Committee and Barwon

Health, for the study to be conducted. Eligible partici-

pants (over 18 years old, not heavily intoxicated, not

suicidal and receiving treatment from a provider) were

recruited in treatment service waiting rooms by staff

and research staff, and via posters placed in treatment

services. Participants were given a plain language state-

ment detailing the survey and their involvement in the

project.This information was read aloud to participants

by the researchers prior to commencement of inter-

views. After signing an informed consent receipt, par-ticipants were administered the study questionnaire by

a researcher at a convenient time for each participant

and inside treatment facilities. Participants received$10

compensation for participation.

Results

Participants scale scores

Descriptives for all scales are detailed inTable 1. Partici-

pants scores for PWI were significantly lower than the

mean of 76.20 for the Australian population in general

[T(197)= 20.24,P< 0.001]. Mean scores for the SF-8MCS and SF-8 PCS were 36.98 and 45.07,respectively,

significantly lower than the normative figure of 50

[T(191)= 14.80, P< 0.001; T(191)= 7.74, P< 0.001].

Correlations and relationships between key variables and

demographic factors

A range of key variables did not show any significant

impact on the outcome variables in either bivariate or

multivariate analyses and were not included in any

Well-being of drug users in treatment 653



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subsequent analyses. These include variables, such as

number of dependent children, relationship status,

housing status, blood-borne virus status (i.e. hepatitis C

virus, human immunodeficiency virus), currently use of

any drugs, polydrug use, treatment modality or time in

treatment.Table 2 shows correlations between key vari-

ables, revealing significant correlations between scores

on the two SF-8 measures and PWI scores. In line with

subjective well-being research, relationships between

PWI scores and various demographic variables were

assessed. Independent groupsttests showed no signifi-

cant difference on PWI scores by gender [T(196)=1.58, P= 0.21] or geographical region [T(42.27)=1.08,P= 0.28]. Two one-way ANOVA were then con-ducted to determine whether scores on the PWI dif-

fered by type of drug for which in treatment or by

employment status. There was no significant effect

for the type of drug participants were in treatment

for [F(4, 174)= 0.47, P= 0.76]. However, a signi-

ficant effect of employment status was observed[F(2, 161)= 5.30, P< 0.01], with those who wereemployed having a higher PWI score than those who

were unemployed, and full-time participants having

the highest score. Tukeys HSD post hoc analyses

revealed significant differences (P< 0.05) betweenunemployed (M= 45.51; SD= 18.07; n= 130) andpart-time employed (M= 55.82; SD= 17.45; n= 31)participants in PWI score but no difference between

those in full-time (M= 55.82; SD= 18.39;n = 13) andpart-time employment.

Predictors of subjective well-being

Multiple regression analyses were conducted to deter-

mine the relative contribution of severity of dependence

and HRQOL to the subjective well-being of substance

users in treatment. Given the significant differences in

PWI score by employment, it was decided to include

employment, and SF-8 PCS, SF-8 MCS and SDS

scores as predictors of PWI score. Employment was

dummy variable coded into two variables: full-time

employment (yes/no) and part-time employment (yes/

no). Overall, the regression model predicting PWI score

was significant [F(5, 146)= 5.60,P< 0.001,R2 =0.14,adjusted R2 =0.13]. As shown in Table 3, SF-8 MCSscore and part-time employment were significant inde-

pendent predictors of PWI score. Severity of depend-

ence (as measured by SDS) was not a significant

predictor of PWI score, whereas the mental health-

related aspects of HRQOL was a significant predictor.

Discussion

The aim of the present study was to examine the self-

reported subjective well-being and HRQOL of AOD

users in outpatient treatment and to examine the pre-

dictors of subjective well-being in this sample. Consist-

ent with previous research, the sample reported lower

levels of subjective well-being (measured by PWI) [9]

and HRQOL (measured by the SF-8 health survey)

Table 1. Descriptive data for PWI, SDS, SF-8 PCS and SF-8 MCS

Variable Mean (SD) Range Population norms

PWI 49.12 (18.83) 0100 0.82 76.20SDS 8.21 (3.67) 015 0.76 a

SF-8 MCS 36.98 (12.19) 0100 0.87 50.00

SF-8 PCS 45.07 (8.81) 0100 0.87 50.00

aAs the current sample was comprised of a heterogeneous group of AOD users, no appropriate norm exists. MCS, mental healthcomponent summary; PCS, physical health component summary; PWI, personal well-being index; SD, standard deviation; SDS,severity of dependence scale.

Table 2. Correlations between key variables

Variable PWI SDS SF-8 MCS SF-8 PCS

PWI 1 0.05 0.33** 0.28**SDS 1 0.21** 0.01SF-8 MCS 1 0.21**SF-8 PCS 1

**P< 0.01 (two-tailed). MCS, mental health componentsummary; PCS, physical health component summary; PWI,personal well-being index; SDS, severity of dependence scale.

Table 3. Multiple regression analysis predicting PWI

Predictor r sr2

SF-8 PCS 0.21 0.15 0.02SF-8 MCS 0.26* 0.19* 0.03SDS 0.06 0.09 0.00Full-time work 0.14 0.15 0.02Part-time work 0.21* 0.24* 0.05

*P< 0.05. MCS, mental health component summary; PCS,physical health component summary; PWI, personal well-being index; SDS, severity of dependence scale.




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than in the general Australian population [24], but sub-

jective well-being was predicted only by the mental

health aspects of HRQOL and part-time employment

and not by severity of dependence.

Subjective well-being and QOL

HRQOL was quite poor in the current sample of sub-

stance users in treatment. Both the mean score for the

physical health component of the SF-8 (M= 45.07)and the mental health component of the SF-8

(M= 36.98) were substantially lower than the popula-tion norm of 50. These results build upon similar find-

ings in existing studies that have investigated the

HRQOL of substance users in treatment, with Borders

et al. [13] also finding that drug users in treatment had

a lower mean score on the SF-8 PCS (M= 48) than thenorm of 50.

Participants had lower scores on the PWI than the

general Australian population norm of 76.2 [9].Notably, the drug users in the current study scored

below 60 on the PWI, which is the lower limit for a

healthy rating [34]. These results are consistent with

the sole prior study that had measured the PWI of

substance users [24], which found that Australian-

injecting drug users had a profoundly lower subjective

well-being (M= 55.4) than did the general Australianpopulation, and the present study found an even lower

average. The lower scores in the current study may be

because of participants in the current study being in

outpatient treatment. This sample is likely to be less

happy with their drug use than a sample not in treat-

ment [24] and therefore have even lower PWI scores.

Another potential reason for the lower PWI in the

current sample concerns the type of participants used.

Although Dietzeet al. [24] included only injecting drug

users, the current study included a range of different

types of alcohol and drug users, and the lower PWI

scores in the current sample may be because of lower

scores from some of this more heterogeneous group.

Finally, the lower subjective well-being of this sample is

consistent with previous research which reported lower

subjective well-being in rural and regional drug users

[23]. Indeed, rurality is predictive of a range of AOD

problems [3537], and issues such as lack of access totreatment services, higher rates of unemployment and

social isolation, these factors may account for some of

the differences observed in this group compared with

those accessed in previous research.

Predictors of subjective well-being

Subjective well-being was not predicted by severity of

dependence but was predicted by the mental health

component of HRQOL. On the surface, these results

are inconsistent with the belief that subjective and

objective measures of QOL are somewhat independent

of each other [8] and that subjective well-being is not

related to health symptoms. However, a closer scrutiny

of the items in the SF-8 MCS reveals that they assess

more subjective aspects of mental functioning and

health. Specifically, several items ask about perceptions

of vitality, mental health, and social and emotional

problems as opposed to physical health, for example,

asking how much did personal or emotional problems

limit your usual work?The validity of using the overall

SF-8 measure as an objective HRQOL measure is

therefore questionable. Consistent with the current

findings, other studies have also found that substance

users subjective well-being appears to be related to

their mental health [22,2426,29].

The finding that severity of dependence was not

related to subjective well-being is inconsistent with

Dietzeet al. [24], who found higher frequency of inject-

ing drug use was associated with lower subjective well-being, as measured by the PWI. However, frequency of

injecting does not necessarily reflect dependence and

may therefore have a different relationship with subjec-

tive well-being. This finding suggests that the relation-

ship between severity of dependence and subjective

well-being is not as simple as it first appears and that

other factors, such as employment, are more important

than severity of dependence in predicting subjective

well-being. The current finding is also in contrast with

other studies showing lower levels of QOL, as measured

using HRQOL, in those with more severe addictions

[13,14,17].

Although gender, geographical region and drug in

treatment for did not predict subjective well-being, a

significant relationship was found between subjective

well-being and employment status. Full-time employed

participants had the highest subjective well-being, with

part-time employees a little lower in subjective well-

being, and those who were unemployed had signifi-

cantly lower subjective well-being than both. These

findings are similar to those of Dietze et al. [24] who

also found that drug users who were employed had a

higher subjective well-being than those who were not.

These results provide further evidence for the impor-

tance of employment or some other meaningful activity(e.g. volunteering) for subjective well-being. Employ-

ment may keep recovering substance users busy and

provide more meaningful or rewarding alternatives to

drug use. De Maeyeret al. [27] found that employment

led those who were in substance treatment feel as if they

were included in the social world. This is consistent

with recent findings that engaging in job-related activ-

ities is associated with reductions in employment prob-

lems and improvements in QOL in substance-addicted

patients [38].




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These findings suggest that treatment services should

consider their service users mental health as a key

variable for treatment planning, if they do not already

do so. More interestingly, the findings suggest that pro-

grams which address the employment needs of drug

users in treatment may be effective in improving their

subjective well-being and, potentially, their long term

recovery.This aligns with a body of research that shows

the importance of paid work and the central role that it

plays in terms of social recognition and self-esteem, in

particular, that people assign great value to having

status as workers and to being integrated into a work-

place on a regular basis [39].

Limitations

The generalisability of the current findings is limited by

both the nature and size of the sample.The sample was

drawn from urban and regional towns, and as such, the

findings may reflect differences compared with samples

from capital cities. Additionally, the sample was fairly

heterogeneous in comparison with other studies. Most

other QOL studies focus on only one drug used or in

treatment for, whereas the present study included

several substance use types, reflecting the treatment

population of the services in question. However, the

present sample was dominated by people who identi-

fied heroin as their main drug of choice, with smaller

proportions of cannabis, alcohol, amphetamine and

other opiate users, and the lack of findings in relation to

substance use and demographic factors may reflect

trends combined across this range of substance users.In addition, when conducting analyses related to drug

dependence, we used a cut-off score of 4 on the SDS

based on previous research [33,40]; however, this may

not be reflective of dependence on all drugs covered in

this study. Future studies should attempt to recruit

participants seeking treatment for use of a broader

range of substances.

Conclusion

The present study showed that substance users in out-

patient treatment have lower subjective well-being andpoorer HRQOL than the general Australian popula-

tion. Subjective well-being was predicted by mental

aspects of HRQOL and not by severity of drug depend-

ence or by physical aspects of HRQOL. The findings

highlight the importance of mental health interventions

in AOD treatment settings as well as the role of

employment as a facilitator of recovery and well-being.

Treatment which aims to improve substance users

well-being should include mental health interventions

and pathways to employment.

Acknowledgements

We would like to thank the staff at Barwon Health Drug

and Alcohol Services for all of their support conducting

the research, especially Prof Tom Callaly, Amy

Langbein and Marjan Geertsma. A very special thanks

to Wendy Doppler for all of her support. Similarly, we

would like to the Western Regional Alcohol and Drug

Centre, Dawn Bermingham and Geoff Soma. This

research was supported by an National Health and

Medical Research Council Howard Florey fellowship.

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