Director's Report to the National Advisory Council on Drug Abuse
Comparison of Outcomes By Gender and for Fee-For-Service Versus Managed Care: A Study of Nine Community Programs
During-treatment services and 7-month post-treatment entry outcome of cocaine- or alcohol-dependent men (N = 145) and women (N = 149) Target City patients receiving either standard fee-for-services (N = 183) or managed care treatment funding (N = 111) in nine community outpatient programs were compared. No differences were found in treatment services received by the various subgroups. Regression analyses compared the four described subgroups (Gender x Type of Funding) on their seven Addiction Severity Index composite scores at 7 months post-admission controlling for the respective baseline composite score and several background variables on which the groups differed. Surprisingly few outcome differences were revealed between men and women patients and patients receiving the two forms of treatment funding. The only difference noted was that patients treated via managed care showed more improvement in the drug area. The need for further evaluation of the effects of managed care is emphasized. Alterman, A.I., Randall, M., McLellan, A.T. J Subst Abuse Treatment, 19(2), pp. 127-134, 2000.
Generalizability of the Clinical Dimensions of the Addiction Severity Index To Nonopioid-Dependent Patients
Clinical dimensions (CDs) for the Addiction Severity Index recently have been established for application among opioid-dependent patients in methadone treatment. The generalizability of CDs to other substance-dependent patients was examined in a sample of 2,027 adult nonopioid-dependent patients, comprised of 581 primarily cocaine-dependent, 544 primarily alcohol-dependent, 803 polydrug-dependent patients, and 99 patients dependent on other varied drugs. Generality of dimensions was assessed through confirmatory components analysis, structural congruence, internal consistency, and variance partitioning in higher order factoring. The CDs were found generalizable overall and to specific nonopioid-dependent subgroups, and across patient gender and age, and to African American and White patients. Preliminary concurrent and predictive validity data supported the CD structure. Alterman, A.I., McDermott, P.A., Cook, T.G., Cacciola, J.S., McKay, J.R., McLellan, A.T., Rutherford, M.J. Psychology of Addictive Behaviors, 14(3), pp. 287-294, 2000.
History of the Methamphetamine Problem
Methamphetamine (MA), called meth, crystal, or speed, is a central nervous system stimulant that can be injected, smoked, snorted, or ingested orally. Until the late 1980s, illicit use and manufacture of MA was endemic to California, but the MA user population has recently broadened in nature and in regional distribution, with increased use occurring in Midwestern states. An estimated 4.7 million Americans (2.1% of the U.S. population) have tried MA at some time in their lives. Short-and long-term health effects of MA use include stroke, cardiac arrhythmia, stomach cramps, shaking, anxiety, insomnia, paranoia, hallucinations, and structural changes to the brain. Prolonged use at high levels results in dependence. Children of MA abusers are at risk of neglect and abuse, and the use of MA by pregnant women can cause growth retardation, premature birth, and developmental disorders in neonates and enduring cognitive deficits in children. MA-related deaths and admissions to hospital emergency rooms are increasing. Although inpatient hospitalization may be indicated to treat severe cases of long-term MA dependence, optimum treatment for MA abusers appears to be an intensive outpatient setting with three to five visits per week of comprehensive counseling for at least the first three months. Anglin, M.D., Burke, C., Perrochet, B., Stamper, E., Dawud-Noursi, S. J Psychoactive Drugs, 32(2), pp. 137-141, 2000.
Risk and Prevalence of Treatable Sexually Transmitted Diseases at a Birmingham Substance Abuse Treatment Facility
The prevalence of sexually transmitted disease (STD) was evaluated in patients entering residential drug treatment. Of 311 patients, crack cocaine use was reported by 67% and multi-substance use was reported by 71%. STD risk behaviors were common. The prevalence of infection was as follows: Chlamydia trachomatis, 2.3%; Neisseria gonorrhoeae, 1.6%; trichomoniasis, 43%; and syphilis, 6%. STD counseling and screening may be a useful adjunct to inpatient drug treatment. Bachmann, L.H., Lewis, I., Allen, R., Schwebke, J.R., Leviton, L.C., Siegal, H.A., Hook, E.W. Am J Public Health Oct; 90(10), pp. 1615-1618, 2000.
Resistance To Drug Abuse Treatment: A Comparison of Drug Users Who Accept Or Decline Treatment Referral Assessment
For largely unknown reasons, many drug abusers do not seek formal treatment. Treatment referral assessment was offered to a sample of 283 drug users. Only 58 subjects (20.5%) accepted this offer. Differences were examined between those who accepted the treatment referral assessment and those who declined. Predictors of acceptance included higher levels of severity in drug use and higher scores on a motivation and readiness scale. Among those who declined the assessment, 43.1% denied drug use, 37.3% thought their drug use was not a problem, and 16.4% expressed no interest in treatment. Further analysis showed that scores on motivation and readiness were positively related to a higher level of severity in employment problems, family problems, drug use, and to having a history of prior treatment. Boyle, K., Polinsky, M.L., Hser, Y.I. Journal of Drug Issues, 30(3), pp. 555-574, 2000.
Program Variation in Treatment Outcomes Among Women in Residential Drug Treatment
Multilevel modeling was used to assess the program characteristics associated with treatment retention among 637 women in 16 residential drug treatment programs in the Drug Abuse Treatment Outcome Study. Women who were pregnant or had dependent children had higher rates of retention in programs in which there were higher percentages of other such women. Programs with higher proportions of pregnant and parenting women provided more services related to women's needs. Longer retention was associated with higher rates of post-treatment abstinence. The findings support provision of specialized services and programs for pregnant and parenting women. Grella, C.E., Joshi, V., Hser, Y.I. Eval Review, 24(4), pp. 364-383, 2000.
A Search for Strategies To Engage Women in Substance Abuse Treatment
In order to remain in treatment, patients must initially engage in the treatment process, and clinicians seek motivational strategies to draw each patient into the treatment process. This study found that outpatient clients who received engagement services during the intake period showed increased use of these services, relative to a comparison group, throughout the treatment process. Tangible engagement services provided to women during the intake period for outpatient substance abuse treatment had no significant effect on the rates of admission, discharge, and service utilization. Comfort, M., Loverro, J., Kaltenbach, K. Social Work in Health Care, 31(4), pp. 59-70, 2000.
Access to Substance Abuse Treatment Services Under the Oregon Health Plan
The 1995 implementation of a capitated substance abuse benefit within the Oregon Health Plan, a Medicaid managed care plan, provided an opportunity to study the impact of funding mechanisms on access to publicly funded substance abuse treatment. Statewide treatment data for all Medicaid-eligible persons aged 12 to 64 years enrolled in the Oregon Health Plan before (1994) and after (1997) implementation of the capitated benefit were analyzed. An increase was found in access to substance abuse treatment for Medicaid-eligible persons in Oregon after a shift to managed care. Results show that the percentage of Medicaid-eligible persons admitted to substance abuse treatment programs during a calendar year increased from 5.5% of the average number of enrolled members per month in 1994 to 7.7% in 1997, following managed care. After case mix adjustment, access rates varied considerably among the 7 largest prepaid health plans. Operating characteristics of these health plans, such as the method of reimbursing treatment providers, were significant predictors of access. Deck, D.D., McFarland, B.H., Titus, J.M., et al. J Am Med Assoc, 284(16), pp. 2093-2099, 2000.
Modified Therapeutic Community for Homeless Mentally Ill Chemical Abusers: Treatment Outcomes
Two modified therapeutic community programs (TC1 and TC2) were compared with treatment as usual (TAU) for 342 homeless mentally ill chemical abusers (MICA). Follow-up interviews were obtained at 12 months post-baseline and at an average of about 2 years post-baseline. Outcome measures assessed drug use, crime, HIV risk behavior, psychological symptoms, and employment. Individuals in both modified TC groups showed significantly greater behavioral improvement than TAU at both follow-up time intervals. TC2, with lower demands and more staff guidance, was superior to TC1. Completers of modified TC programs showed significantly greater improvement than either TC dropouts or a subgroup of TAU clients with high exposure (i.e., more than 8 months) to other treatment protocols. The findings support the effectiveness and longer-term stability of effects of modified TC programs for treating homeless MICA clients. De Leon, G., Sacks, S., Staines, G., McKendrick, K. American J Drug Alcohol Abuse, 26(3), pp. 461-480, 2000.
To Thine Own Self Be True: Self-Concept and Motivation for Abstinence Among Substance Abusers
Individuals on a wait-list to enter public-sector addiction treatment were interviewed regarding their reasons for attempting abstinence. Follow-up interviews were completed 3 to 6 months after participants' removal from county-controlled treatment wait-lists. Rates of continuous self-reported abstinence for 90 days preceding follow-up were positively associated with motivation linked to discrepancies between substance use and self-standards. Characteristics associated with high identity-linked motivation were cocaine preference, a history of reducing self-dissatisfaction through substance use, low rewards and high costs associated with using, and low support for the user identity among significant others. The perception of discrepancies between substance use and self-standards was an effective motivator of abstinence even among those who reported previous use of substances to dampen self-dissatisfaction. Downey, L., Rosengren, D.B., Donovan, D.M. Addictive Behaviors, 25(5), pp. 743-757, 2000.
Benefit-Cost Analysis of Residential and Outpatient Addiction Treatment in the State of Washington
A benefit-cost analysis of full continuum (FC) residential and partial continuum (PC) outpatient care was conducted on a sample of substance abusers from the State of Washington. Economic benefits were derived from client self-reported information at treatment entry and at 9 months postadmission using an augmented version of the Addiction Severity Index. Results strongly indicate that both treatment options generate positive and significant net benefits to society. Average per client economic benefits of treatment from baseline to follow-up were statistically significant for both FC and PC for most variables and in the aggregate. The overall difference in average economic benefit between FC and PC was positive ($8,053) and statistically significant, favoring FC over PC. The average cost of treatment amounted to $2,530 for FC and $1,138 for PC. Average net benefits were estimated to be $17,833 for FC and $11,173 for PC, a statistically significant difference. French, M.T., Salome, H.J., Krupski, A., McKay, J.R., Donovan, D.M., McLellan, A.T., Durell, J. Evaluation Review, 24(6), pp. 609-634, 2000.
Measuring Client Clinical Progress in Therapeutic Community Treatment: The Therapeutic Community Client Assessment Inventory, Client Assessment Summary, and Staff Assessment Summary
Measuring changes in the individual during treatment is a first step in the effort to understand the change process and what can be done to improve treatment effectiveness. The development of the therapeutic community (TC) Client Assessment Inventory (CAI), Client Assessment Summary (CAS), and Staff Assessment Summary (SAS) is described. These instruments, derived from a comprehensive theory of TC treatment and recovery, measure client self-report and staff evaluation of client progress along 14 domains of behavior, attitude, and cognitive change. Analyses of scale properties indicate that both client and staff instruments reliably differentiate clinical changes during treatment. Client self-ratings are initially consistently higher than staff ratings. Kressel, D., De Leon, G., Palij, M., Rubin, G. J Substance Abuse Treatment, 19(3), pp. 267-272, 2000.
Support, Mutual Aid and Recovery from Dual Diagnosis
In recovery from substance abuse and mental health disorders (dual-diagnosis), social support can have a buffering role in stressful situations. The associations among social support (including dual-recovery mutual aid), recovery status, and personal well-being were investigated in dually-diagnosed individuals (N = 310) using cross-sectional self-report data. Persons with higher levels of support and greater participation in dual-recovery mutual aid reported less substance use and mental health distress and higher levels of well-being. Participation in mutual aid was indirectly associated with recovery through perceived levels of support. The association between mutual aid and recovery held for dual-recovery groups but not for traditional, single-focus self-help groups. Laudet, A.B., Magura, S., Vogel, H.S., Knight, E. Community Mental Health Journal, 36(5), pp. 457-476, 2000.
Correlates of Outpatient Drug Treatment Drop-Out Among Methamphetamine Users
California Alcohol and Drug Data System (CADDS) data were used to provide information on retention and drop-out for 2,337 methamphetamine users entering public outpatient treatment programs in California from 1994 - 1997. Overall, 23.3% of methamphetamine users completed 180 or more days of treatment, a rate similar to that for users of other drugs throughout California. Methamphetamine users who were older (40 years or over), had less severe drug use patterns (used less than daily or did not inject), or who were under coerced treatment were significantly more likely to complete treatment that other methamphetamine users. Men were significantly more likely to drop out of treatment before 180 days. Maglione, M., Chao, B., Anglin, M.D. J Psychoactive Drugs, 32(2), pp. 221-228, 2000.
Detoxification Centers: Who's in the Revolving Door?
Data from 443,812 admissions to publicly funded detoxification centers in Massachusetts from 1984 to 1996 were analyzed to assess changes in the population served. Substantial increases in admissions of women, African Americans, and Hispanics were apparent. Mean age at admission declined and unemployment increased. A 25% decline in admissions reporting alcohol use was coupled with a twofold increase in reported cocaine use and a fourfold increase in heroin use. Detoxification services have evolved. The older, white, male alcoholic is no longer the primary consumer. Policy initiatives (e.g., increased services for women) and the changing epidemiology of drugs abuse (e.g., increased access to heroin) contributed to the changing population served in detoxification centers. McCarty, D., Caspi, Y., Panas, L., Krakow, M., Mulligan, D.H. J Behav Health Serv Res, 27(3), pp. 245-256, 2000.
Predictors of Substance Abuse Treatment Retention Among Women and Men in an HMO
Although research has examined treatment retention in public drug treatment programs, little is known about factors that influence treatment retention in an insured outpatient population. All eligible intakes to a health maintenance organization's outpatient alcohol and drug treatment programs (abstinence based day hospital and traditional outpatient modalities) were recruited during a 2-year period, for a sample of 317 women and 599 men. One general pattern of predictors of increased retention was shared by women and men -- fewer and less severe drug problems. Most other predictors were gender-specific. Among women, higher retention was predicted by having higher incomes, belonging to ethnic categories other than African American, being unemployed, being married, and having lower levels of psychiatric severity. Among men, predictors of higher retention included being older, receiving employer suggestions to enter treatment, and having abstinence goals. These findings suggest treatment factors that may enhance retention among insured populations, including employer referrals, psychiatric services, and drug-related services. Mertens, J.R., Weisner, C.M. Alcohol Clin Exp Res, 24(10), pp. 1525-1533, 2000.
Managed Care Risk Contracts and Substance Abuse Treatment
This study estimates how one managed care arrangement, shifting risk to the organization managing care, affects substance abuse treatment. Full risk plans do not differ in access rates to any substance abuse treatments or inpatient treatment, but they significantly lower costs per user (by about $470, or 17%). Sturm, R. Inquiry - The Journal of Health Care Organization Provision and Financing, 37(2), pp. 219-225, 2000.
A Comparison of Substance Abuse Patients' and Counselors' Perceptions of Relapse Risk: Relationship To Actual Relapse
This study compared substance abuse patients' and their counselors' perceptions of relapse risk during treatment and evaluated whether these perceptions predict actual relapse 2 years later. Participants (N = 240) completed the Relapse Risk Index (RRI), which assesses confidence in abilities and need for services across four domains: coping skills, social support, resources, and leisure activities. Participants reported greater confidence and greater needs than counselors reported. Determinants of counselors' relapse risk perceptions included income, whereas participants' perceptions were related to polysubstance use. Counselors' ratings of coping skills predicted alcohol relapse; counselors' ratings did not predict drug relapse. Participants' ratings of coping skills and leisure activities predicted alcohol relapse; social support predicted drug relapse. When including background characteristics, counselors' ratings did not predict alcohol or drug relapse; participants' ratings predicted alcohol relapse but not drug relapse. Findings suggest the potential utility of considering patient perceptions to understand and possibly prevent relapse. Walton, M.A., Blow, F.C., Booth, B.M. J Substance Abuse Treatment, 19(2), pp. 161-169, 2000.
Addiction Severity Index Data from General Membership and Treatment Samples of HMO Members: One Case of Norming the ASI
The purpose of this study was to enhance the value of the Addiction Severity Index (ASI), a widely used drug abuse treatment planning and evaluation tool, by obtaining comparative data from nonclinical samples. The study included four ASI scales collected on samples of adult subscribers to a large health maintenance organization (HMO) in northern California, as well as an adult clinical sample from the same geographic region with the same HMO insurance. Interviews (N = 9,398) of non-alcohol-dependent or abuse adults from a random sample of members of a large HMO were analyzed. Complete ASI data were collected on the alcohol, drug, medical, and psychiatric composite scales and partial data on the employment scale. A sample of 327 adult members of the same HMO from one of the counties included in the survey, who were admitted to treatment for alcohol and/or drug addiction, was administered the same ASI items at treatment admission. Analyses compare problem severities in the two samples by age and gender. The general membership reported some problems in most of the ASI problem areas, although at levels of severity that were typically far below those seen in the clinical sample. General membership and clinical samples were somewhat similar in medical status and in employment. Alcohol, drug, and psychiatric status were much more severe in the clinical sample. The data from the HMO general membership sample provide one potential comparison group against which to judge the severity of problems presented by drug- and alcohol-dependent patients at treatment admission and at post-treatment follow-up. One implication of this study is that treatment-seeking substance dependent individuals may need a wider range of services than those focused simply on alcohol and drug use. Weisner, C., McLellan, A.T., Hunkeler, E.M. J Substance Abuse Treatment, 19(2), pp. 103-109, 2000.
The Outcome and Cost of Alcohol and Drug Treatment in an HMO: Day Hospital Versus Traditional Outpatient Regimens
Outcome and cost-effectiveness of two primary addiction treatment options, day hospitals (DH) and traditional outpatient programs (OP), were compared in a managed care organization. New admissions to a large HMO's chemical dependency program in California were interviewed between April 1994 and April 1996, with follow-up interviews eight months later. Admissions were randomly assigned to DH or OP; those who refused random assignment were also studied to determine the impact of self selection to treatment. Among randomized subjects, both treatment options showed significant improvement in all drug and alcohol measures. There were no differences overall in outcomes between DH and OP, but DH subjects with midlevel psychiatric severity had significantly better outcomes, particularly for alcohol abstinence (OR = 2.4; 95% CI = 1.2, 4.9). The average treatment costs were $1,640 and $895 for DH and OP programs, respectively. In the midlevel psychiatric severity group, the marginal cost of obtaining abstinence from alcohol in the DH cohort was approximately $5,464. Among the 405 self-selected subjects, DH was related to abstinence (OR = 2.1; 95% CI = 1.3, 3.5). Although significant benefits of the DH program were not found in the randomized study, DH treatment was associated with better outcomes in the self-selected group. For subjects with midlevel psychiatric severity in both the randomized and self-selected samples, the DH program produced higher rates of abstention and was more cost-effective. Understanding self-selection effects in studies that randomize patients to services requiring very different levels of commitment may be important in interpreting findings for clinical practice. Weisner, C., Mertens, J., Parthasarathy, S., Moore, C., Hunkeler, E.M., Hu, T., Selby, J.V. Health Service Research, 35(4), pp. 791-812, 2000.
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