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National Institute on Drug Abuse

Director's Report to the National Advisory Council on Drug Abuse

February, 2000

Research Findings

Services Research

Gender Differences in Drug Treatment Careers Among Clients in the National Drug Abuse Treatment Outcome Study

Gender differences were examined among 7,652 individuals admitted in the Drug Abuse Treatment Outcome Study, a national multi-site prospective study. Relationships between prior drug treatment, demographic and background characteristics, addiction career, treatment career parameters, family and social relationships, criminal justice involvement, and mental health status were examined. Stepwise discriminant function analyses were conducted separately for men and women to determine both the common and unique characteristics associated with a history of prior drug treatment. More severe drug use history and criminal behavior were related to prior treatment history for both men and women. Prior drug treatment among men was associated with factors related to family opposition to drug use and support for treatment, whereas for women prior drug treatment was associated with antisocial personality disorder and self-initiation into treatment. Treatment initiation among men appears to be facilitated by social institutions, such as employment, the criminal justice system, and one's family. Treatment re-entry among women was associated with referral by a social worker. These findings suggest that different strategies for increasing treatment utilization may be needed for men and women. Grella, C.E., and Joshi, V. American Journal of Drug and Alcohol Abuse, 25(3), pp. 385-406, August 1999.

Assessing the Needs of Substance Abusing Women. Psychometric Data on the Psychosocial History

The Psychosocial History (PSH) is a comprehensive multidisciplinary interview designed to assess the status, history, and needs of women in substance abuse treatment. The PSH retains the fundamental scoring structure of the Addiction Severity Index (ASI), while adding supplemental questions considered clinically useful and relevant for predicting outcomes. The present study examined the psychometric properties and general utility of both instruments with a sample of women enrolled in substance abuse treatment. Initially, the instruments were tested independently and found to have excellent test-retest reliability and acceptable internal consistency. A reliability trial between the instruments found that the composite scores (CS) of the ASI and PSH yielded satisfactory correlations among four of the six CS domains. The PSH had higher CS scores than the ASI across domains, which may reflect the comprehensive nature of the PSH items that prompt greater disclosure of problems and needs. Validity analyses showed significant correlations of PSH and ASI psychiatric CSs with Symptom Checklist-90-Revised totals. These results suggest that the PSH yields reliable and valid assessment data similar to the ASI. Moreover, the PSH provides a more comprehensive assessment than the ASI in the area of pregnancy, family issues, and victimization. Comfort, M., Zanis, D.A., Whiteley, M.J., Kelly-Tyler, A., and Kaltenbach K.A. Journal of Substance Abuse Treatment,17(1-2), pp. 79-83, 1999.

Psychiatric Comorbidity Measures as Predictors of Retention in Drug Abuse Treatment Programs

This study examined lifetime and current psychiatric comorbidity measures as predictors of drug abuse treatment retention and tested the generalizability of results across treatment agencies in diverse settings and with varying practices in the National Drug Abuse Treatment Outcome Studies (DATOS), a longitudinal study of clients from 96 treatment agencies in 11 U.S. cities. Clinical thresholds for adequate treatment retention were 90 days for long-term residential and outpatient drug-free, and 360 days for outpatient methadone. Dimensional measures of current psychiatric symptoms emerged as better predictors than lifetime DSM-III-R diagnoses. The predictive association of hostility with retention varied significantly across treatment agencies, both in long-term residential and outpatient drug-free modalities. On-site mental health services in long-term residential programs were associated with better retention for clients with symptoms of hostility. Broome, K.M., Flynn, P.M., and Simpson, D.D. Health Services Research, 34(3), pp. 791-806, August 1999.

Help-Seeking by African American Drug Users: A Prospective Analysis

In this study, help-seeking was significantly more likely for African American drug users with more formal education and those scoring higher on both drug-related problem recognition and ethnic identity. This latter result suggests that ethnic identity, despite having no main effect on help-seeking in this sample, may nonetheless make an important contribution to help-seeking by "potentiating" the influence of drug problem recognition. Longshore, D. Addictive Behaviors, 24(5), pp. 683-686, 1999.

Methadone Maintenance and State Medicaid Managed Care Programs

Coverage for methadone services in state Medicaid plans may facilitate access to the most effective therapy for heroin dependence. State Medicaid plans were reviewed to assess coverage for methadone services, methadone benefits in managed care, and limitations on methadone treatment. Medicaid does not cover methadone maintenance medication in 25 states (59 percent). Only 12 states (24 percent) include methadone services in Medicaid managed care plans. Moreover, two of the 12 states limit coverage for counseling or medication and others permit health plans to set limits. State authorities for Medicaid and substance abuse can collaborate to ensure that appropriate medication and treatment services are available for Medicaid recipients who are dependent on opioids and to construct payment mechanisms that minimize incentives that discourage enrollment among heroin-dependent individuals. McCarty, D., Frank, R.G., and Denmead, G.C. Milbank Quarterly, 77(3), pp. 341-362, 1999.

Modified Therapeutic Community for Homeless Mentally Ill Chemical Abusers: Emerging Subtypes

This paper is one of a series reporting on a clinical field trial evaluating the efficacy of the modified therapeutic community (TC) approach for the treatment of homeless mentally ill chemical abusers (MICAs). The social and psychological characteristics of the treatment sample were described in an earlier paper; the purpose of the present report was to categorize subtypes of homeless MICA clients to predict with greater accuracy their treatability in modified TCs. An index that consistently correlated with treatment-relevant variables was identified for each of three dimensions; Homelessness (residential instability), Mental Illness (current severity), and Substance Abuse (current substance abuse/dependence diagnosis). These indices yielded distributions that captured the variability in the sample with respect to a number of variables, including drug use, criminality, human immunodeficiency virus (HIV) risk (sexual behavior), psychological status, and motivation. Bivariate and multivariate analyses showed that the indices were not strongly related to demographic variables such as race/ethnicity, age, or gender, but were significantly associated with baseline drug use, criminal activity, HIV risk (sexual behavior), psychological symptoms, and motivation and readiness. These findings indicate that, even among those admitted to residential treatment for substance abuse, homeless MICA clients are not homogeneous; rather, subgroup differences emerge among the indices of homelessness, mental illness, and substance abuse. The efficacy of treatment in modified TCs for these subgroups will be assessed in subsequent papers examining the relationships among the three indices, client retention, and outcomes during and subsequent to residential treatment. De Leon, G., Sacks, S., Staines, G., and McKendrick K. Am J Drug Alc Abuse, 25(3), pp. 495-515, 1999.

The Relationship of Counseling and Self-Help Participation To Patient Outcomes in DATOS

Using a sample of 927 cocaine patients enrolled in programs in three modalities included in the national Drug Abuse Treatment Outcome Studies (DATOS), this investigation examined the relationship of three dimensions of treatment process on after-treatment cocaine use, heavy alcohol use, and predatory illegal activity. Logistic regression revealed significant reductions in all three outcomes and strong effects of treatment duration and after-treatment self-help, conditional on the modality. Results did not support the hypothesized relationship between treatment outcomes and amounts of counseling and during-treatment self-help. Findings support the robustness of duration effects and after-treatment self-help and contribute to the measurement methodology for calibrating treatment intensity. The strong after-treatment self-help effect in the two residential and inpatient modalities suggests these programs can improve treatment outcomes by making referral to after-treatment self-help participation a standard practice and installing mechanisms to increase the likelihood of attendance at least twice weekly during the year after treatment. Etheridge, R.M., Craddock, S.G., Hubbard, R.L., and Rounds-Bryant, J.L. Drug and Alcohol Dependence, 57(2), pp. 99-112, 1999.

Retention and Patient Engagement Models for Different Treatment Modalities in DATOS

Using data from the Drug Abuse Treatment Outcomes Studies (DATOS), structural equation models tested the relationship between session attributes (e.g., relative frequency that addiction was discussed relative to health and other topics, number of sessions attended) and therapeutic involvement (e.g., rapport with counselor, confidence in treatment) during the first month of treatment as they related to patient retention in treatment for 90 or more days. Confirmatory results were replicated across different treatment approaches; outpatient drug free, long-term residential, and outpatient methadone maintenance. Session attributes were related to patient therapeutic involvement, and in turn to retention in treatment. In addition, session attributes and therapeutic involvement were demonstrated to be significant mediators of the relationship between pre-treatment motivation levels and treatment retention. Joe, G.W., Simpson, D.D., and Broome, K.M. Drug and Alcohol Dependence, 57, pp. 113-125, 1999.

Patient and Program Attributes Related to Treatment Process Indicators in DATOS

Using data from the Drug Abuse Treatment Outcomes Studies (DATOS), hierarchical linear modeling was used to examine the relationship between patient and drug abuse treatment program attributes and retention in treatment. Results showed that both patient and program attributes affected retention in treatment. High-patient retention programs were those that used more social and public health services, maintained more consistent attendance at counseling sessions, and that served patients who had more similar kinds of needs. High-treatment retention patients were those who possessed high levels of intrinsic motivation to participate in treatment, who expressed confidence that treatment will reduce their drug abuse, and expressing high levels of commitment to complete treatment. Broome, K.M., Simpson, D.D., and Joe, G.W. Drug and Alcohol Dependence, 57, pp. 127-135, 1999.

Prior Treatment Experience Related to Process and Outcomes in DATOS

Data collected as part of the Drug Abuse Treatment Outcomes Studies (DATOS) were used to examine the role of prior treatment history in affecting drug treatment outcomes among cocaine abusers. The focus of this study was to identify factors related to improved outcomes for the prior-treatment population. Patients with histories of prior treatment had less favorable post-treatment outcomes. Participation in aftercare self-help and living in an environment with few drug abusers was a significant factor in reducing drug abuse for patients with prior-treatment histories. Hser, Y-I, Grella, C.E., Hsieh, S-H., Anglin, M.D., and Brown, B.S. Drug and Alc Dep, 57, pp. 137-150, 1999.

Patient Histories, Retention, and Outcome Models for Younger and Older Adults in DATOS

Using data from the Drug Abuse Treatment Outcomes Studies (DATOS), structural equation models examined the role of age on treatment retention and post-treatment abstinence for outpatient drug free (ODF) and long-term residential (LTR) patients. Results showed a significant path between retention and abstinence, but retention had a greater impact on abstinence for younger patients. Regardless of age and treatment type, patient confidence in staying abstinent was related to post treatment abstinence. However, for LTR patients, social reference group (drug abusers/non-abusers) at follow-up had a significant relationship with patient confidence in staying abstinent and actual abstinence for young patients, but not older ones. For ODF patients social reference group at follow-up was shown to have a relatively greater impact on confidence in staying abstinent for older patients. Grella, C. E., Hser, Y-I., Vandana, J., and Anglin, M.D. Drug and Alcohol Dependence, 57, pp. 151-166, 1999.

Costs and Benefits of Treatment for Cocaine Addiction in DATOS

Data from the Drug Abuse Treatment Outcomes Studies (DATOS) were used to examine the economic benefits associated with treating cocaine addiction. Three methods were used to estimate the costs of crimes before, during, and after completing either outpatient drug free (ODF) or long-term residential (LTR) treatment. Results showed that cocaine treatment was economically beneficial to society. The savings due to reduced criminality far exceeded the cost of treatment. Treatment cost to criminal cost/benefit ratios ranged between 1.68 and 2.73 for LTR and between 1.33 and 3.26 for ODF patients depending on estimation methods used. Flynn, P.M., Kristiansen, P.L., Porto, J.V., and Hubbard, R.L. Drug and Alcohol Dependence, 57, pp. 167-174, 1999.

Feasibility of Multidimensional Substance Abuse Treatment Matching: Automating the ASAM Patient Placement Criteria

The Patient Placement Criteria published by the American Society of Addiction Medicine (ASAM Criteria) established a standard for matching substance use disorder patients to treatment settings. Data from 593 substance dependent adults were assessed using a computerized implementation of the ASAM Criteria to determine whether the level of care assignments showed significant differences on clinical measures. The algorithm showed acceptable discrimination between each of three ASAM levels of care across several clinical subscales. Findings suggest that it is feasible to implement complex, multidimensional criteria for substance abuse treatment placement. Turner, W.M., Turner, K.H., Reif, S., Gutowski, W.E., and Gastfriend, D.R. Drug and Alcohol Dependence, 55(1-2), pp 35-43, June 1, 1999.

Detection of Illicit Opioid and Cocaine Use in Methadone Maintenance Treatment

Urine toxicology is the gold standard for estimating the prevalence of illicit drug use in methadone maintenance treatment (MMT). Infrequent urine testing may lead programs to undercount active drug users and to target interventions too narrowly. This study compared results from frequent testing (twice per week) versus less frequent testing of 166 patients at four MMT programs. As part of a research study, all patients were tested by research staff for opioid and cocaine use twice per week on a fixed schedule for 10 weeks. During the same period, the four MMT programs tested the patients according to their standard protocols, approximately weekly (one program) or every 3-4 weeks (three programs). The research tests identified approximately 50% more illicit opioid users and 70% more cocaine users than the less frequent program tests. Patients who were drug positive according to the research tests but drug negative according to the program tests tended to be infrequent users. The data suggest that standard urine testing practices in MMT programs may result in underestimates of the prevalence of opioid and cocaine use. More frequent testing, even for time-limited periods, should produce more accurate depictions of drug use prevalence and help indicate the direction of interventions. Wasserman, D.A., Korcha, R., Havassy, B.E., and Hall S.M. Am J Drug Alc Abuse, 25(3), pp. 561-571, 1999.

Day Treatment Versus Enhanced Standard Methadone Services for Opioid-Dependent Patients: A Comparison of Clinical Efficacy and Cost

This study examined the differential efficacy and relative costs of two intensities of adjunctive psychosocial services -- a day treatment program and enhanced standard care -- for the treatment of opioid-dependent patients in methadone maintenance treatment. Both interventions were 12 weeks in duration, manual-guided, and provided by master's-level clinicians. The day treatment was an intensive, 25-hour-per-week program. The enhanced standard care was standard methadone maintenance plus a weekly skills training group and referral to on- and off-site services. Although the cost of the day treatment program was significantly higher, there was no significant difference in the two groups' use of either opiates or cocaine. Over the course of treatment, drug use, drug-related problems, and HIV risk behaviors decreased significantly for patients assigned to both treatment intensities. Improvements were maintained at a 6 month follow-up. Providing an intensive day treatment program to unemployed, inner-city methadone patients was not cost-effective relative to a program of enhanced methadone maintenance services, which produced comparable outcomes at less than half the cost. Avants, S.K., Margolin, A., Sindelar, J.L., Rounsaville, B.J., Schottenfeld, R., Stine, S., Cooney, N.L., Rosenheck, R.A., Li, S.H., and Kosten T.R. Am J Psychiatry, 156(1), pp. 27-33, January 1999.

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