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Director's Report to the National Advisory Council on Drug Abuse - February, 2004

Research Findings - Services Research

Post-Discharge Recovery Management Checkups Can Improve Outcomes for Chronic Substance Users

The majority of people presenting for publicly-funded substance abuse treatment relapse and receive multiple episodes of care before achieving long-term recovery. This Early Re-Intervention experiment evaluates the impact of a Recovery Management Checkup (RMC) protocol that includes quarterly recovery management checkups (assessments, motivational interviewing, and linkage to treatment re-entry). Data are from 448 adults (59% female, 85% African American, and 75% aged 30-49) randomly assigned to either RMC or an attention (assessment only) control group. Participants assigned to RMC were significantly more likely than those in the control group to return to treatment, to return to treatment sooner, and to spend more subsequent days in treatment; they were significantly less likely to be in need of additional treatment at 24 months. This demonstrates the importance of post-discharge recovery management checkups as a means to improve the long-term outcomes of people with chronic substance use disorders. Dennis, M., Scott, C.K., and Funk, R. An Experimental Evaluation of Recovery Management Checkups (RMC) for People With Chronic Substance Use Disorders. Evaluation and Program Planning, 26, pp. 339-352, 2003.

Case Managers Minimally Facilitate Delivery of Services in Addiction Treatment Programs

This study examined whether designated case management staff facilitated delivery of comprehensive medical and psychosocial services in substance abuse treatment programs. Researchers employed a multilevel, prospective cohort study of 2829 clients admitted to selected substance abuse treatment programs, including long-term residential, outpatient, and methadone treatment modalities. Program directors reported program use of staff specifically designated as case managers. After treatment discharge, clients reported their receipt of 9 supplemental services during the treatment episode. In multivariate models controlling for multiple program-level and client-level factors, program-level availability of designated case managers increased client-level receipt of only 2 of 9 services, and exerted no effect on service comprehensiveness, compared to programs that did not have designated case managers. These findings do not support the common practice of designating case management staff as a means to facilitate comprehensive services delivery in addiction treatment programs. Friedmann, P.D., Hendrickson, J.C., Gerstein, D.R., and Zhang, Z. Designated Case Managers as Facilitators of Medical and Psychosocial Service Delivery in Addiction Treatment Programs. The Journal of Behavioral Health Services & Research, 22(27), pp. 86-98, 2003.

Provision of Timely Addiction Treatment Up in 1990s, But Accessibility Problems Persist for Some

This study examined organization-level characteristics associated with the accessibility of outpatient addiction treatment. Program directors and clinical supervisors from a nationally representative panel of outpatient substance abuse treatment units in the United States were surveyed in 1990 (N=481), 1995 (N=387), and 2000 (N=480). Accessibility was measured from clinical supervisors' reports of whether the treatment organization provided "treatment on demand" (an average wait time of 48 hours or less for treatment entry), and of whether the program turned away any patients. In multivariable logistic models, provision of "treatment on demand" increased two-fold from 1990 to 2000 (OR, 1.95; 95 percent CI, 1.5 to 2.6), while reports of turning patients away decreased nonsignificantly. Private for-profit units were twice as likely to provide "treatment on demand" (OR, 2.2; 95 percent CI, 1.3 to 3.6), but seven times more likely to turn patients away (OR, 7.4; 95 percent CI, 3.2 to 17.5) than public programs. Conversely, units that served more indigent populations were less likely to provide "treatment on demand" or to turn patients away. Methadone maintenance programs were also less likely to offer "treatment on demand" (OR, .65; 95 percent CI, .42 to .99), but more likely to turn patients away (OR, 2.4; 95 percent CI, 1.4 to 4.3). Although the provision of timely addiction treatment appears to have increased throughout the 1990s, accessibility problems persist in programs that care for indigent patients and in methadone maintenance programs. Friedmann, P.D., Lemon, S.C., Stein, M.D., and D'Aunno, T.A. Accessibility of Addiction Treatment: Results From A National Survey of Outpatient Substance Abuse Treatment Organizations. Health Services Research, 38(3), pp. 887-903, 2003.

Smoking Cessation Does Not Negatively Affect Drug Abuse Treatment Outcome

Although cigarette smoking is endemic among illicit drug users, drug abuse treatment programs rarely encourage smoking cessation and often discourage it. The purpose of this study was to determine whether smoking cessation after entering drug abuse treatment influenced drug use 12 months after drug abuse treatment. Researchers analyzed 2,316 cigarette smokers in the Drug Abuse Treatment Outcome Study (DATOS), a national, longitudinal study of drug abuse treatment. Heckman probit selection models assessed the association of self-reported smoking cessation while in drug abuse treatment on self-reported drug abstinence in the year after treatment completion, while simultaneously accounting for possible nonparticipation bias. Controlling for multiple factors, smoking cessation was significantly associated with greater abstinence from drug use after completion of drug abuse treatment. Despite drug abuse treatment programs' hesitance to encourage smokers to quit, smoking cessation does not negatively impact drug use outcomes. Lemon, S.C., Friedmann, P.D., and Stein, M.D. The Impact of Smoking Cessation on Drug Abuse Treatment Outcome. Addictive Behaviors, 28(7), pp. 1323-1331, 2003.

Medical and Psychiatric Conditions Prevalent among Alcohol and Drug Treatment Patients in an HMO

Prior research on health conditions related to substance abuse largely focused on alcohol and patients treated in publicly-funded programs, inpatients, and the general population. This study compares the prevalence of medical and psychiatric conditions among 747 substance abuse patients and 3,690 demographically matched controls from the same health maintenance organization, and examines whether any heightened prevalence for substance abuse patients (relative to controls) varies according to demographic subgroups and type of substance. Approximately one third of the conditions examined were more common among substance abuse patients than among matched controls, and many of these conditions were among the most costly. Researchers also found that pain-related diagnoses, including arthritis, headache, and lower back pain, were more prevalent among such patients, particularly those dependent on narcotic analgesics. These findings point to the importance of examining comorbid medical conditions and substance abuse in both primary and specialty care. Findings regarding pain-related diagnoses among patients dependent on narcotic analgesics highlight the need for linkages between primary care and substance abuse treatment. Moreover, optimal treatment of many common medical disorders may require identification, intervention, and treatment of an underlying substance abuse disorder. Mertens, J.R, Lu, Yun W., Parthasarathy, S., Moore, C. and Weisner, C.M. Medical and Psychiatric Conditions of Alcohol and Drug Treatment Patients in an HMO. Archives of Internal Medicine, 163(20), pp. 2511-2517, 2003.

Comorbid Psychiatric Disorders in Youth in Juvenile Detention

This epidemiological study seeks to estimate 6-month prevalence of comorbid psychiatric disorders among juvenile detainees by demographic subgroups including gender, race/ethnicity, and age. Participants in this longitudinal study include 1,829 youth (age 10-18 years) initially arrested and detained between 1995 and 1998 at the Cook County Juvenile Temporary Detention Center in Chicago, IL. Subjects were randomly selected to participate in the study. Results indicate significantly more females (57%) than males (46%) met the criteria for 2 or more mental health disorders represented in the DSM-III-R. Nearly 14% of the girls and 11% of the boys had both a major mental disorder (psychosis, manic episode, or major depressive episode) and a substance use disorder. Nearly 30% of the girls and 20% of the boys with substance use disorders had major mental health disorders. Rates of comorbidity were higher among non-Hispanic whites and older adolescents. Abram, K.M., Teplin, L.A., McClelland, G.M., and Dulcan, M.K. Comorbid Psychiatric Disorders in Youth in Juvenile Detention. Archives of General Psychiatry, 60, pp. 1097-1108, 2003.

Head Injury Is An Indicator of Co-Occurring Problems Among Drug Abusers

This study examined 661 drug-abusing inmates detained in a state prison, who self-reported a history of head injury, health problems, and mental health disorders. Participants included individuals who had previously participated in drug abuse treatment, were currently enrolled in prison-based drug abuse treatment, and individuals who had never participated in drug treatment. Research subjects were divided into three groups: those with no head injury; those with one head injury; and those with two or more head injuries. Results indicate inmates with head injuries had a significantly greater number of health problems, higher levels of alcohol and marijuana use, and significantly more mental health problems including depression, anxiety, suicidal thinking, difficulties concentrating, and violent behavior. The investigators suggest assessment for head injury is an important part of treatment and service planning for drug abusing offenders. Walker, R., Hiller, M., Staton, M., and Leukefeld, C. Head Injury Among Drug Abusers: An Indicator of Co-Occurring Problems. Journal of Psychoactive Drugs, 35(3), pp. 343-353, 2003.

Analytic Method Facilitates Understanding of Multiple Source Reports on Linkage to Primary Care

In studies designed to measure health outcomes, researchers often obtain data on patients' utilization of health services from multiple sources. This common practice raises key methodological challenges in data analysis, including how data should best be represented and interpreted in statistical models. In the HELP (Health Evaluation and Linkage to Primary care) study, 642 subjects without primary medical care, and who were undergoing alcohol or drug detoxification, were enrolled in a randomized controlled trial of a health evaluation intervention to link them with primary care. The outcome of interest was attendance at a primary care appointment (linkage to primary care) after discharge from the detoxification unit. Both self-report and administrative sources of linkage were collected. Researchers applied methodology developed by Fitzmaurice et al., (American Journal of Epidemiology, 1995) to fit a single regression that allowed inclusion of all multiple-source outcomes in a single multivariate regression analysis. This model allowed testing for source differences in outcome and estimation of different source effects where necessary and included data from subjects with partially observed source observations. These methods were applied to the analysis of the HELP study using correlated survival regression models to assess the magnitude and significance of the relationship between predictor variables and linkage. Researchers concluded that when multiple sources of outcome data are combined into a single model, as done in this study, comparisons between the different source reports can be made quantitatively, which can yield more precise and accurate understandings of the underlying questions of interest. Horton, N.J., Saitz, R., Laird, N.M., and Samet, J.H. A Method of Modeling Utilization Data from Multiple Sources: Application in a Study of Linkage to Primary Care. Health Services and Outcomes Research Methodology, 3, pp. 211-223, 2003.

Hepatitis C: Critical Treatment Target Among Offenders in Correctional Facilities

Chronic infection with hepatitis C virus (HCV) is the most common blood-borne illness in the United States, affecting nearly 2 percent of all Americans, or an estimated 4-5 million individuals. Although most individuals with chronic infection are not expected to progress to end-stage liver disease or death, hepatitis C is the most common indication for liver transplantation in the U.S., and it is responsible for 10,000 deaths annually. HCV can be transmitted through blood and blood product transfusions, hemodialysis and high-risk sexual practices, but the leading risk factor for HCV infection is injection drug use (IDU). While the hepatitis C epidemic is substantial in the country as a whole, it has become a major concern in correctional settings. Prevalence of HCV infection in prisons is 8- to 20-fold higher than in the community, with infection rates between 16 and 41 percent and evidence of chronic infection in 12-35 percent. An estimated one out of three Americans with chronic hepatitis C infection rotates through correctional facilities annually. Despite the slow progression of most infections, illness and death within correctional systems is already substantial, likely explained by a large number of infections acquired decades ago. Hepatitis C infection is a leading cause of illness and death among in-custody inmates in some correctional facilities and an emerging cause in others. Allen, S.A., Rich, J.D., Schwartzapfel, B., and Friedmann, P.D. Hepatitis C Among Offenders--Correctional Challenge and Public Health Opportunity. Federal Probation, 67(2), pp. 22-26, 2003.

Short-term Alcohol and Drug Treatment Outcomes Predict Long-term Outcome

Although addiction is recognized as a chronic, relapsing condition, few treatment studies, and none in a commercially insured managed care population, have measured long-term outcomes. The authors examined the relationship of 6-month treatment outcomes to abstinence 5 years post-treatment, and whether the predictors of abstinence at 5 years were different for those who were, and were not, abstinent at 6 months. The sample (N = 784) is from an outpatient (day hospital and traditional outpatient) managed care chemical dependency program. Subjects were interviewed at baseline, 6 months, and 5 years. Logistic regression analysis was used to assess which individual, treatment and extra-treatment characteristics predicted alcohol and drug abstinence at 5 years. Abstinence at 6 months was an important predictor of abstinence at 5 years. Among those abstinent at 6 months, predictors of abstinence at 5 years were older age, being female, 12-step meeting attendance, and recovery-oriented social networks. Among those not abstinent at 6 months, being alcohol dependent rather than drug dependent, 12-step meeting attendance, treatment readmission, and recovery-oriented social networks predicted abstinence at 5 years. Findings of this study demonstrate a clear association between short-term and long-term treatment success. In addition, these results strongly support the importance of recovery-oriented social networks for those with good short-term outcomes, and the beneficial impact of readmission for those not initially successful in treatment. Weisner, C., Ray, G.T., Mertens, J.R., Satre, D.D., and Moore, C. Short-term Alcohol and Drug Treatment Outcomes Predict Long-term Outcome. Drug and Alcohol Dependence, 71(3), pp. 281-294, 2003.

Best Characteristics of Adolescent Gateway Drug Prevention Programs Identified

This paper identifies the best characteristics of gateway prevention programs that prevent or reduce adolescents' use of alcohol, tobacco, and marijuana. A comprehensive literature review of the performance of school-, family-, and community-based drug prevention programs covering the last 20 years was conducted to identify the best characteristics of successful drug prevention programs: involving parents; teaching life and resistance skills and normative education; enacting laws and policies against adolescent drug use; encouraging peer participation; conducting a media campaign; and retaining program participants. School administrators, parents, and community leaders can use the knowledge in this paper to design drug prevention programs that accommodate specific risk factors and types of gateway drug use by adolescents. Montoya, I.D., Atkinson, J., and McFaden, W.C. Best Characteristics of Adolescent Gateway Drug Prevention Programs. Journal of Addictions Nursing, 14, pp. 75-83, 2003.

Gaps in the Drug-free and Methadone Treatment Program Response to Hepatitis C

Drug treatment programs are potential sites for the delivery of Hepatitis C prevention and care services to drug users. Using data collected from a random sample (N=595) of drug treatment programs in the United States, this study compares the provision of HCV services by drug-free and methadone maintenance treatment programs (MMTPs). It then examines and compares perceived inadequacies in this service provision from the perspective of the managers in the two types of programs. Findings indicate that MMTPs are providing more HCV services than drug-free programs, and that a greater proportion of MMTPs compared to drug-free programs are dissatisfied with their current level of HCV service provision. Managers of drug-free programs would like to offer patients more HCV education, while MMTP mangers would like to provide more HCV testing to their patients, and more support and care for patients who are HCV+. Strauss, S., Astone, J., Vassilev, Z., Des Jarlais, D., and Hagan, H. Gaps in the Drug-free and Methadone Ttreatment Program Response to Hepatitis C. Journal of Substance Abuse Treatment, 24, pp. 291-297, 2003.

Estimating the Client Costs of Addiction Treatment

The costs of addiction treatment services are an important determinant of a program's cost-effectiveness, and therefore, of its relevance to addiction treatment providers, insurance companies, and patients. This article introduces the Client DATCAP (Drug Abuse Treatment Cost Analysis Program) and presents process, survey-specific, and quantitative findings from a pilot study to estimate the client costs of attending outpatient and inpatient treatment. The preliminary findings suggest that the self-administered Client DATCAP is a feasible and practical instrument for estimating costs incurred by clients in treatment, with completion time amounting to less than 10 minutes. Furthermore, client costs had a considerable range across respondents, with time costs consistently accounting for the largest cost component. Findings from the pilot study led to the development and release of edition 2 of the outpatient and inpatient modules of the Client DATCAP. Salome, H.J., French, M.T., Miller, M., McLellan, A.T. Estimating the Client Costs of Addiction Treatment: First Findings From the Client Drug Abuse Treatment Cost Analysis Program (Client DATCAP). Drug Alcohol Depend, 71(2), pp. 195-206, 2003.

Cost of Residential Addiction Treatment in Public Housing

The cost of providing addiction treatment services in a variety of settings is useful information for program administrators, policy makers, and researchers. This study estimates the economic costs of providing substance abuse treatment services at Safeport, a three-phase residential treatment program serving addicted women living in public housing. Economic (opportunity) costs are estimated for each phase separately and for the complete program. Results indicate that the total cost of providing treatment services at Safeport in 2001 was $1,325,235. This total cost comprises $549,737 for stabilization or early abstinence (Phase I), $400,098 for relapse prevention and self-sufficiency (Phase II), and $375,400 for independent living preparation and long-term recovery (Phase III). Average daily census (number of clients/families on a typical day) was just over 11 clients/families in each phase or 34 clients/families for the entire program. The average length of stay was 12 weeks for Phase I, 20 weeks for Phase II, 18 weeks for Phase III, and 50 weeks overall. The average weekly cost per client amounted to $930 for Phase I, $677 for Phase II, $635 for Phase III, and $748 over the full program. The average cost per treatment episode amounted to $11,163 for Phase I, $13,541 for Phase II, $11,435 for Phase III, and $36,136 for the complete program. Future research should compare these cost estimates with corresponding outcome data from Safeport to perform a comprehensive economic evaluation. Alexandre, P.K., Roebuck, M.C., French, M.T., Barry, M. The Cost of Residential Addiction Treatment in Public Housing. Journal of Substance Abuse Treatment, 24(4), pp. 285-290, 2003.

Cost-Effectiveness of Prison-Based Treatment and Aftercare Services

This study performed a cost-effectiveness analysis of the Amity in-prison therapeutic community and Vista aftercare programs for criminal offenders in California. For the average treatment participant, the cost of treatment was $4,112, which led to approximately fifty-one fewer days incarcerated (36% less) than the average individual in the control group. For the average offender, treatment reduced recidivism at a cost of $80 per incarceration day. For participants who received both in-prison treatment and aftercare services, an additional day of incarceration was avoided at a cost of $51 per day relative to those that received in-prison treatment only. Results show that offering a continuum of treatment has the potential to reduce re-incarceration among substance-abusing offenders. McCollister, K.E., French, M.T., Prendergast, M., Wexler, H., Sacks, S. and Hall, E. Is In-Prison Treatment Enough? A Cost-Effectiveness Analysis of Prison-Based Treatment and Aftercare Services for Substance-Abusing Offenders. Law & Policy, 25(1), pp. 63-82, 2003.

Providers' Views on Treating the Dually Diagnosed

Service delivery to dually diagnosed individuals is often impeded by the divergent treatment approaches used by mental health and substance misuse treatment providers. This paper describes findings from a survey of mental health and substance misuse treatment program administrators and staff in Los Angeles County (n = 275) on their views about treating the dually diagnosed. All groups agreed about the challenges of treating dually diagnosed patients; however, there were differences both between and within providers in the two treatment systems on other aspects of treatment. The study is limited as a nonrepresentative sample of programs within a large urban county, but programs were selected because of their participation in county-sponsored activities to improve service delivery to the dually diagnosed. Substance misuse administrators and staff-as opposed to mental health counterparts-strongly endorsed strict adherence to abstinence and use of confrontational approaches. Grella, C.E. Contrasting the Views of Substance Misuse and Mental Health Treatment Providers on Treating the Dually Diagnosed. Substance Use and Misuse, 38(10), pp. 1433-1446, 2003.

Tennessee Serves More Youth with Fewer Services through Medicaid Managed Care

This study assessed trends in access to and use of behavioral health services for school-aged children in Tennessee's Medicaid managed care program (TennCare), between 1995 and 2000. Researchers used data from the Bureau of TennCare on claims, encounters, and enrollment in analyses of enrollment periods for children and adolescents who were 4-17 years old at the time of service or enrollment. Measures were calculated in four areas: overall access to behavioral health services; use of inpatient services; use of outpatient specialty treatment services; and use of supportive services like case management and medication management. Study results showed that the number of youths receiving a behavioral service increased by nearly half between 1995 and 2000. At the same time, the number of youths enrolled in TennCare increased by 19 percent. The annual access rate increased from about 72 youths per 1,000 enrollees to about 92. However, the volume of services for children fell, and access rates were low relative to estimated need. The system made less use of inpatient services and relied more on outpatient services, particularly case management and medication management services. Researchers concluded that children's access rates for behavioral health services improved even as the TennCare program expanded to cover more children. However, the system served more youths in part by reducing the volume of services for children receiving treatment and substituting more supportive services. Saunders, R.C. and Heflinger, C.A. Tennessee Serves More Youth with Fewer Services through State's Medicaid Managed Care Program. Psychiatric Services, 54, pp. 1364-1371, 2003.

Treating Drug-Abusing Offenders Under California Proposition 36

This study summarizes initial differences in the way five California counties are implementing California Proposition 36, which allows drug abuse offenders to receive treatment rather than jail time. Using first year data, investigators examined variations and similarities in implementation, such as treatment approaches, urine testing, and patient mix. Except for San Francisco, treatment admissions increased during the first year of Proposition 36 over the previous year (up 27% in Kern, 21% in Riverside, 17% in Sacramento, and 16% in San Diego). Most increases were in outpatient drug-free programs. Results are consistent with Proposition 36 aims that emphasize referral of nonviolent drug offenders to community-based treatment. Results suggest that Proposition 36 is bringing previously untreated drug abusers to treatment. Compared to non-Proposition 36 patients, Proposition 36 patients were more likely to be employed males being treated for the first time in outpatient abstinence-oriented programs for methamphetamine or marijuana use. Non-Prop 36 patients were more likely to be treated in residential programs or methadone maintenance programs, and were more likely to report heroin use or injection drug use. Hser, Y., Teruya, C., Evans, E., Longshore, D., Grella, C., and Farabee, D. Treating Drug-abusing Offenders: Initial Findings from a Five-County Study on the Impact of California's Proposition 36 on the Treatment System and Patient Outcomes. Evaluation Review, 27(5), pp. 479-504, 2003.

Changes in Smoking Status Among Substance Abusers

Impact of change in smoking status on 12-month substance abuse treatment outcomes was examined among 749 HMO participants. At follow-up, 13% of the 395 smokers quit and 12% of the 254 nonsmokers started/relapsed back to smoking. At treatment entry, quitters were less likely to be diagnosed alcohol dependent compared to smokers; starters/resumers were more likely to be diagnosed as alcohol and drug dependent compared to all groups. Total days abstinent was greatest for quitters and nonsmokers. Self-initiated smoking cessation appears nondetrimental and may be beneficial to substance abuse treatment. Individuals who start/resume smoking after entry into substance abuse treatment may be at greater risk of relapse and are understudied. Kohn, C.S., Tosh, J.Y. and Weisner, C.M. Changes in Smoking Status among Substance Abusers: Baseline Characteristics and Abstinence from Alcohol and Drugs at 12-month Follow-up. Drug and Alcohol Dependence, 69(1), pp. 61-71, 2003.

Clinical Characteristics Differ by Age, Suggesting Age Variation in Treatment Needs

At baseline, older adults showed higher levels of DSM-IV alcohol dependence, lower rates of drug dependence, and fewer psychiatric symptoms, relative to younger individuals. Source of suggestions to enter treatment differed by age. Older and middle-aged patients were more likely to have an abstinence goal and to stay in treatment longer than younger adults. Improvement in ASI severity scores differed by age. Lower rates of dependence and hostility, and greater motivation and length of stay in treatment, which were all associated with greater age, positively affect prognosis of older adults in treatment. Baseline differences by age group in clinical characteristics suggest variation in treatment needs. Satre, D.D., Mertens, J., Arean, P., and Weisner, C. Contrasting Outcomes of Older, Middle-aged, and Younger Adult Chemical Dependency Patients in a Managed Care Program. Journal of Studies on Alcohol, 64(4), pp. 520-530, 2003.

Some Substance Abuse Interventions for Adolescents Reduce Social Costs

An economic evaluation of five outpatient adolescent treatment approaches (12 total site-by-conditions) was conducted. The economic cost of each of the 12 site-specific treatment conditions was determined by the Drug Abuse Treatment Cost Analysis Program (DATCAP). Economic benefits of treatment were estimated by first monetizing a series of treatment outcomes and then analyzing the magnitude of these monetized outcomes from baseline through the 12-month follow-up. The average economic costs of treatment ranged from $90 to $313 per week and from $839 to $3,279 per episode. Relative to the quarter before intake, the average quarterly cost to society for the next 12 months (including treatment costs) significantly declined in 4 of the 12 site-by-treatment conditions, remained unchanged in 6 conditions, and increased in 2 treatment conditions (both in the same site). These results suggest that some types of substance-abuse intervention for adolescents can reduce social costs immediately after treatment. French, M.T., Roebuck, M.C., Dennis, M.L., Godley, S.H., Liddle, H.A., and Tims, F.M. Outpatient Marijuana Treatment for Adolescents: Economic Evaluation of a Multisite Field Experiment. Evaluation Review, 27(4), pp. 421-459, 2003.

Treatment of Sleep Disturbance in Alcohol Recovery

Sleep disturbance is common during recovery from alcoholism and can precipitate relapse. Although sleep complaints are commonly managed with medication, little is known about their management among recovering alcoholic patients. Researchers surveyed a self-weighted, random systematic sample of 503 members of the American Society of Addiction Medicine (ASAM) to examine addiction medicine physicians' medical management of sleep disturbance among patients in early recovery from alcoholism. After 3 mailings, 311 (62%) responded. Of respondents, 64% had offered pharmacological treatment to an insomniac, alcoholic patient in the first 3 months after detoxification, but only 22% offered medication to more than half of such patients. Trazodone was the preferred therapy, chosen first by 38% of respondents, followed by other sedating antidepressants (12%), and antihistamines (12%). The mean duration of therapy for trazodone and other sedating antidepressants exceeded one month. Experts in addiction medicine appear reluctant to prescribe medication to sleep-disturbed patients in early recovery from alcoholism. When they do prescribe, trazodone, other sedating antidepressants, and antihistamines are favored, despite limited evidence for or against this indication. Although the treatment of disordered sleep among alcoholic patients in early recovery may have merit to prevent relapse, controlled studies of these sleep agents are needed. Friedmann, P.D., Herman, D.S., Freedman, S., Lemon, S.C., Ramsey S., and Stein, M.D. Treatment of Sleep Disturbance in Alcohol Recovery: A National Survey of Addiction Medicine Physicians. Journal of Addictive Diseases, 22(2), pp. 91-103, 2003.

Voluntary, Community-Based Alcohol Screening is Feasible and Can Benefit Drinkers

Researchers assessed the feasibility of the 1999 voluntary, community-based National Alcohol Screening Day (NASD) by determining 1) the extent to which community and college sites were registered to hold screenings and the extent to which the subjects came to participate, 2) the demographic and clinical characteristics of participants at screening sites, and 3) the extent to which individuals who were referred for evaluation and treatment adhered to follow-up recommendations. Registered community and college sites were documented. Screening forms returned by the participants were analyzed. A subgroup of randomly selected participants from community and college sites was contacted by telephone. A total of 1,218 community sites and 499 college sites participated in NASD. At the 1,089 sites that reported results, 32,876 people participated, 18,043 were screened, and 5,959 were referred for treatment. Forty-three percent of those screened had a score of 8 or more on the Alcohol Use Disorders Identification Test (AUDIT), indicating harmful or hazardous drinking. Only 13% of those screened had previous alcohol treatment. In the subgroup that participated in the follow-up survey (N=704), community participants (N=337) had higher mean scores on the AUDIT than the college participants (N=337). Approximately 50% of the community participants and 20% of the college participants adhered to the recommendation to pursue follow-up. The researchers conclude that voluntary, community-based screening for alcohol problems is feasible and provides education, screening, and referral for many individuals with harmful or hazardous drinking behavior. Greenfield, S.F., Keliher, A., Sugarman, D., Kozloff, R., Reizes, J.M., Kopans, B., and Jacobs, D. Who Comes to Voluntary, Community-Based Alcohol Screening? Results of the First Annual National Alcohol Screening Day, 1999. American Journal of Psychiatry, 160(9), pp. 1677-1683, 2003.

DATStats: Drug Abuse Treatment Cost Analysis

The Drug Abuse Treatment Cost Analysis Program (DATCAP) was developed and launched in the early 1990s to help addiction researchers and administrators estimate the economic costs of substance abuse interventions. This paper presents summary results from 85 DATCAPs completed over the past 10 years. After first grouping the DATCAPs into 9 treatment modalities, cost measures (normalized to 2001 dollars) are reported along with client caseload information. Additionally, the distribution of costs across 6 resource categories is presented for each of the treatment modalities. The average weekly economic cost per client ranged from 82 US dollars per week for outpatient drug court interventions to 1,138 US dollars per week for adolescent residential treatment. As expected, labor was overwhelmingly the most utilized resource across all modalities, ranging from 48% to 88% of total economic cost. Addiction researchers, program administrators, and policymakers now have cost estimates and resource distribution information for various treatment modalities serving diverse populations. Roebuck, M.C., French, M.T., and McLellan, A.T. DATStats: Results From 85 Studies Using the Drug Abuse Treatment Cost Analysis Program. Journal of Substance Abuse Treatment, 25(1), pp. 51-57, 2003.

Lower Levels of Educational Attainment Predict Shorter Time to Relapse Among Alcohol-Dependent Men and Women

This study investigated the relationship between educational attainment and drinking outcomes after discharge from inpatient treatment for alcohol dependence. Researchers consecutively recruited 41 women and 60 men hospitalized for alcohol dependence between 1993 and 1996 and followed them up monthly for 1 year. Structured interviews were conducted during hospitalization and at monthly intervals after discharge for 1 year to provide data to examine the relationship between educational attainment before treatment and postdischarge drinking outcomes, including time to relapse. After covariate adjustment, educational level was a significant predictor of drinking outcomes. Lower levels of educational attainment before entry into treatment predicted shorter times to first drink and relapse in both women and men. The association of educational attainment and treatment outcome for alcohol dependence warrants further investigation. Greenfield, S.F., Sugarman, D.E., Muenz, L.R., Patterson, M.D., He, D.Y., and Weiss, R.D. The Relationship Between Educational Attainment and Relapse Among Alcohol-Dependent Men and Women: A Prospective Study. Alcoholism: Clinical and Experimental Research, 27(8), pp. 1278-1285, 2003.

Sense of Belonging in School as a Protective Factor Against Drug Abuse Among Native American Urban Adolescents

This article presents the results of a study conducted with 243 Native American students who were part of a multi-ethnic sample of adolescents attending middle school in a large urban center in the Southwest region of the United States. Native adolescents who felt a stronger sense of belonging in their school were found to report a lower lifetime use of alcohol and cigarettes, lower cigarette and marijuana use in the previous month, lower frequency of current use of these substances, fewer substances ever used, and a later age of initiation into drug use than other Native students. Research implications are discussed in relationship to school environment, culturally-grounded prevention curricula, and school social work practice. Napoli, M., Marsiglia, F.F., and Kulis, S. Sense of Belonging in School as a Protective Factor Against Drug Abuse Among Native American Urban Adolescents. Journal of Social Work Practice in the Addictions, 3(2), pp. 25-41, 2003.

Informed Consent for Laboratory Testing for Drugs of Abuse in Medical Settings

Laboratory testing for drugs of abuse is often conducted in medical settings, with little consideration of the technical limitations and the potential for legal and social harm to patients. The authors consider several technical problems associated with such testing, including the lack of chain-of-custody procedures, the possibility of false-positive results with screening immunoassays, and the infrequency of confirmatory testing. Important ethical issues arise because of the sensitive nature of drug test results, the ramifications of false-positive results, the limitations of confidentiality protection, and the practice of testing without the patient's knowledge. Taken together, these technical and ethical concerns suggest that drug testing policies in medical settings should specify which conditions require explicit informed consent and create procedures for protecting this sensitive information. Warner, E.A., Walker, R.M. and Friedmann, P.D. Should Informed Consent be Required for Laboratory Testing for Drugs of Abuse in Medical Settings? American Journal of Medicine, 115, pp. 54-58, 2003.

Client-Level Predictors of Adherence to Multi-Systemic Family Therapy

This study seeks to examine factors that facilitate or impede the adoption of an evidence-based treatment for adolescent drug abusers and their families. Specifically, investigators examined client-level correlates of therapist adherence to Multi-systemic Therapy (MST) implemented in community practice settings. MST has received empirical support as an efficacious intervention for adolescents with serious antisocial and drug abuse problems and has been transported to treatment programs in over 30 states. Data for this study were derived using a non-experimental, short-term, prospective-longitudinal design. Families were nested within therapists and family, child, and caregiver data were collected at intake. Therapist adherence to MST was measured monthly. Study participants included 233 families referred to MST by juvenile justice and social services agencies. Youth were referred because of criminal behavior and/or drug abuse. Sixty-six MST therapists from nine treatment organizations participated in the study. Regression analyses were conducted to predict therapist adherence focusing on a different domain of family characteristics: demographic characteristics, referral characteristics, and pretreatment youth functioning. Variations in therapist adherence to MST were observed in relation to demographic and functioning variables at the client level. Caregivers experiencing educational and economic disadvantage report higher therapist adherence to MST than highly educated and economically advantaged caregivers. Therapist adherence to MST was higher when there was a match between the ethnicity of the therapist and caregiver. Finally, therapist adherence to MST was higher when youth were referred for status offenses and substance abuse and lower when youth were referred for a combination of criminal and substance abuse problems and when they had more arrests pre-treatment. Overall, the investigators suggest the current study demonstrates the complexity of implementing evidence-based practice in community settings. Schoenwald, S.K., Halliday-Boykins, C. and Henggeler, S.W. Family Process, 42(3), pp. 345-359, 2003.

Posttreatment Victimization and Violence Among Adolescents Following Residential Drug Treatment

This article examines the relationships among experiences of childhood abuse, psychiatric disorders, self-reported victimization, and violent behavior, with a focus on gender differences. Data were obtained from interviews at treatment entry and 5-year post-treatment for 446 adolescent clients in therapeutic community (TC) drug treatment programs throughout the United States and Canada. Fifty-eight percent of the sample indicated that they engaged in serious violent behaviors (e.g., beatings, threatening or using weapons against other people, or violent crimes such as assaults, rapes, murders) in the 5 years following their separation from TC treatment. Multivariate logistic regression analyses revealed that victimization in the posttreatment period was the most significant factor associated with violent behavior, and pretreatment childhood abuse experiences and psychiatric disorders were not significantly related to the odds of violent behavior. There were significant gender differences in self-reported victimization and violent behavior. The findings suggest that violence in young adulthood for males is related to increasing involvement in violent lifestyles that include drug trafficking, while violence among females is associated with the social and psychological consequences of drug involvement and victimization. High rates of violent involvement and victimization among former adolescent clients suggests the utility of incorporating interventions such as safety-oriented strategies for females or interventions that address involvement in the drug use lifestyles (i.e., use and dealing) for both males and females into residential treatment to reduce the likelihood of future violence. Hawke, J.M., Jainchill, N. and De Leon, G. Posttreatment Victimization and Violence Among Adolescents Following Residential Drug Treatment. Child Maltreatment, 8(1), pp. 58-71, 2003.

Growth Curve Modeling Shows Longer Treatment Retention Related to Initial Reduction in Cocaine Use But Not to Later Changes in Use

This study examined longitudinal treatment effects among cocaine users. The study examined a sample of 371 cocaine users screened from arrestees in jails and from patients in sexually transmitted disease clinics and emergency rooms, all in Los Angeles County during 1992-1994. Of the 371 subjects, 121 had never been in treatment, and 250 reported a history of participation in drug user treatment (145 subjects' first treatment was for cocaine use; 105 were treated for a drug other than cocaine). Data were collected during face-to-face interviews using a natural history interview instrument. Researchers used a series of growth curve models to investigate treatment effects on cocaine use. For those who had been in treatment for cocaine use, use of cocaine decreased from approximately 70% before treatment to 12% after treatment entry, while no such changes were observed among those who had never been in treatment or those in treatment for other drugs. Relative to non-treated users, cocaine-treated participants showed a greater likelihood of pretreatment use for both initial status (OR = 3.58) and growth rate (OR = 1.05). After treatment entry, cocaine-treated participants as compared to nontreated participants had a lower likelihood of use (OR = 0.27), although their cocaine use after the initial status increased at a greater rate (OR = 1.03). Treated users were five times less likely to use when they were in treatment than when they were out of treatment. Longer treatment retention was related to initially reduced use but not to later rates of change in cocaine use. The study findings support that treatment for cocaine use is effective in reducing cocaine use. Longitudinal models provide opportunities to demonstrate the dynamic relationships between treatment and outcome. Chou, C.P., Hser, Y.I. and Anglin, M.D. Longitudinal Treatment Effects Among Cocaine Users: A Growth Curve Modeling Approach. Substance Use & Misuse, 38(9), pp. 1323-1343, 2003.

Deriving Service Costs for a Clubhouse Psychosocial Rehabilitation Program

This article (a) discusses "function cost," a concept to estimate costs where consumers are involved both in delivery and receipt of services; (b) develops a methodology for costing service units for psychosocial rehabilitation clubhouses; and (c) presents a case study of a clubhouse program. Using function cost to estimate the value of member time results in costs being on average about 10% higher than when using opportunity cost. Because the case-study clubhouse is typical in key dimensions, the methods used here appear generalizable to other programs and should have utility for other rehabilitation-based services for individuals with mental illness. Cowell, A.J., Pollio, D.E., North, C.S., Stewart, A.M., McCabe, M.M. and Anderson, D.W. Deriving Service Costs for a Clubhouse Psychosocial Rehabilitation Program. Administration and Policy in Mental Health, 30(4), pp. 323-340, 2003.

Gender Differences and Treatment Outcomes Among Methadone Patients in the Drug Abuse Treatment Outcome Study

This study examined gender differences among 727 individuals in 21 methadone treatment programs. At treatment entry, a greater proportion of men abused alcohol, lived with their parents, were under legal supervision, and were employed; a greater proportion of women received public assistance, were depressed, had a substance abusing spouse, and engaged in high-risk sexual behavior. Cocaine use was associated with continued heroin use for both men and women, regardless of treatment participation. Using alcohol, living with one's parents, and having a negative reference group were associated with poorer treatment outcomes among women who received methadone treatment during the follow-up period; criminal justice pressure was associated with abstinence for men who were not in treatment. Grella, C.E., Joshi, V. and Anglin, M.D. Gender Differences and Treatment Outcomes Among Methadone Patients in the Drug Abuse Treatment Outcome Study. Journal of Maintenance in the Addictions, 2(1/2), pp. 103-128, 2003.


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