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National Institute on Drug Abuse

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

May, 2000

Research Findings

Services Research

Contingency Management in Outpatient Methadone Treatment: A Meta-Analysis

A meta-analysis was conducted on contingency management interventions in outpatient methadone treatment settings. The outcome was drug use during treatment, as detected through urinalysis. Significant moderators of outcomes included type of reinforcement provided, time to reinforcement delivery, the drug targeted for behavioral change, number of urine specimens collected per week, and type of subject assignment. These factors represent important considerations for the utilization of contingency management techniques for the reduction of drug use during treatment related to reduced risk behaviors. Griffith, J.D., Rowan-Szal, G.A., Roark, R.R., and Simpson, D.D. Drug and Alcohol Dependence, 58, pp. 55-66, 2000.

Office-based Methadone Prescribing: Acceptance by Inner-city Practitioners in New York

In preparation for a study of office-based methadone treatment in New York City, 71 providers from 11 sites were surveyed about their willingness to prescribe methadone in their office-based practices. In the U.S., methadone maintenance is restricted by federal and state regulations to specialized clinics that serve fewer than 20% of the heroin-dependent population. In Europe, Canada, and Australia, primary health care providers are used widely to prescribe methadone. Eighty-five percent of the respondents had methadone-maintained patients who came to their practice for other care. One-third felt knowledgeable enough to prescribe methadone, and 66% said they would if given proper training and support (88% among AIDS care providers). Half expressed concern that they might be unable to meet the multiple needs of these patients. Forty-seven respondents were willing to become methadone providers with additional training and ancillary support. These providers could serve, at 10-20 patients each, 470-940 patients, a population the size of 3 to 5 average methadone clinics. McNeely, J., Drucker, E., Hartel, D., and Tuchman, E. Journal of Urban Health-Bulletin of the New York Academy of Medicine, 77(1), pp. 96-102, 2000.

Drug Treatment and 12-Step Program Participation: The Additive Effects of Integrated Recovery Activities

This study examined the separate and combined effects of 12-step programs and drug treatment on recovery. Treatment participants with pretreatment 12-step involvement stayed in treatment longer and were more likely to complete the 24-week treatment program. Both pretreatment 12-step involvement and duration of participation in drug treatment were associated with subsequent 12-step involvement. Importantly, an additive effect was found for these recovery activities -- those who participated concurrently in both drug treatment and 12-step programs had higher rates of abstinence than those who participated only in treatment or in 12-step programs. The researchers suggest that rather than being used as recovery alternatives, drug treatment and 12-step programs are utilized by the patient as integrated recovery activities. Fiorentine, R., Hillhouse, M.P. Journal of Substance Abuse Treatment, 18, pp. 65-74, 2000.

Drug Abuse Treatment Outcome Study of Adolescents: A Comparison of Client Characteristics and Pretreatment Behaviors in Three Treatment Modalities

The sample was 3382 adolescent subjects who presented for treatment from 1993 to 1995 in 37 programs in Pittsburgh, Pennsylvania; Miami, Florida; Minneapolis, Minnesota; Chicago, Illinois; Portland, Maine; and New York City, New York. Interviewers queried subjects about their background, including education and employment; physical and mental health; use of tobacco, alcohol, and other drugs; sexual experiences; legal problems: religious beliefs; and treatment experience. The findings indicate that the long-term residential treatment modality was the least gender balanced and had the most African-American and Hispanic clients. This modality was also distinguished by the proportion of clients who were referred to treatment by the juvenile or criminal justice system. Compared with other modalities, short-term inpatient clients were more likely to be female and white and to report more indicators of psychiatric impairment. Outpatient clients were slightly younger than clients in the other modalities, had higher levels of school attendance at the time of admission to treatment, had the least criminally involved lifestyles, and the lowest rates of (regular daily or weekly) drug use were also the lowest of the three modalities for all drugs assessed, and they had the least drug treatment experience. The findings suggest that there is a need for more community-based adolescent substance abuse treatment programs and more training in substance abuse treatment programs to serve the specific needs of incarcerated youth and youth under criminal justice supervision. Finally, the researchers recommended that programs be designed to address such specialized issues as comorbid substance abuse and psychiatric problems, family dysfunction, physical and sexual abuse, gender and ethnic differences, and academic performance. Rounds-Bryant, J.L., Kristiansen, P.L., and Hubbard, R.L. Am J Drug Alcohol Abuse, 25(4), pp. 573-591, 1999.

Substance Abuse Treatment Cost Offsets Vary with Gender, Age, and Abstinence

Likelihood The cost-offset effect has been promoted as a way for substance abuse treatment to pay for itself by generating reductions in health care utilization in other areas. Clients (n = 5,434) that were abstinent for 24 months following substance abuse treatment had lower post-treatment utilization than clients that had relapsed. An examination of cost offsets revealed a complex interplay between gender, age, and type of utilization (medical versus psychiatric). Cost offsets were larger for women over 40 years old. Zywiak, W.H., Hoffmann, N.G., Stout, R.L., Hagberg, S., Floyd, A.S., and DeHart, S.S. J Health Care Finance, 26(1), pp. 33-39, 1999.

Client Engagement in Drug Treatment

This study investigates why some clients are more likely to engage in treatment. Findings indicate that the predictors of treatment engagement are generally confined to current treatment experiences. For both women and men, the perceived utility of treatment, ancillary services, and the client-counselor relationship are the strongest predictors of client engagement in treatment. Client characteristics are generally not strong predictors of treatment engagement. Concerning the client-counselor relationship, the findings suggest that women may respond more favorably to an empathic counseling style, whereas men may respond to a more utilitarian style. The findings contradict popular stereotypes about the treatment-receptive client, identify possible directions for treatment improvement, and highlight the need for more research examining the treatment experience of the client. Fiorentine, R., Nakashima, J., and Anglin, M.D. Journal of Substance Abuse Treatment, 17(3), pp. 199-206, 1999.

Psychiatric Comorbidity and the 16-month Trajectory of Substance-Abusing and Substance-Dependent Juvenile Offenders

This study examines correlates of internalizing and externalizing disorders among substance-abusing and substance-dependent juvenile offenders to determine the association between psychiatric comorbidity and psychosocial functioning of the youths 16 months later. Participants were 118 juvenile offenders meeting DSM-III-R criteria for substance abuse or dependence and their families. Comorbidity for externalizing disorders was associated with high rates of antisocial behavior and predicted worse 16-month outcomes than substance abuse alone or substance abuse with comorbid internalizing disorders. For criminal activity and drug use, the presence of internalizing disorders buffered the deleterious effect of externalizing disorders on substance-abusing and substance-dependent juvenile offenders. Even in substance-abusing delinquents, a population already extreme in antisocial behavior, the presence of externalizing disorders indicates high risk for deterioration. Randall, J., Henggeler S.W., Pickrel S.G., and Brondino M.J. J. Am. Acad. Child Adolesc. Psychiatry, 38(9), pp. 1118-1124, 1999.

Victims as Victimizers: Physical Aggression by Persons with a History of Childhood Abuse

Substance abuse has been called the dominant characteristic of families involved in child abuse cases, but the frequency with which childhood victims become adult victimizers is uncertain. This study examines whether a history of childhood sexual or physical abuse is associated with becoming a victimizer (i.e., abusing or assaulting others) as an adult. Interview data from 439 intravenous drug users found a history of sexual or physical abuse before 16 years of age was reported by 51% of women and 31% of men. Seventeen percent of the subjects reported being victimizers. Among childhood victims of physical or sexual abuse, 28% victimized others; among those who denied childhood abuse, 10% victimized others. Two thirds of victimizers reported being under the influence while assaulting others. Controlling for gender, having children, education, race, and history of incarceration, childhood abuse was significantly associated with becoming a victimizer (odds ratio, 3.6). This study confirms a high rate of childhood abuse among intravenous drug users suggesting that treatment programs should both assess and program for treating the adult for past abuse and preventing future victimization. Clarke, J., Stein, M.D., Sobota, M., Marisi, M., and Hanna, L. Arch Intern Med, 159(16), pp. 1920-1924, 1999.

Drug Treatment Effectiveness and Client-Counselor Empathy. Exploring the Effects of Gender and Ethnic Congruency

This study examined the effects of gender and ethnic congruency between patients and counselors on perceived counselor empathy, client engagement in treatment, and abstinence during and after outpatient drug treatment. The findings indicate that client-counselor gender and ethnic congruence were significantly associated with higher levels of perceived counselor empathy for all gender, ethnic, and age groups. However, client-counselor gender and ethnic congruence were not consistently associated with higher levels of treatment engagement and abstinence for all gender, ethnic, and age groups. The findings support a recommendation of paying closer attention to matching clients to counselors. This may be especially important for women, Latinos, and clients 35 years or older. With some female patients it may also be important to match with respect to ethnicity. Also with Latino clients, routinely matching a client to an empathic counselor regardless of gender or ethnicity of the counselor would lead to more favorable treatment outcomes than matching clients solely to gender and ethnically-congruent counselors. Fiorentine, R., Hillhouse, M.P. Journal of Drug Issues, 29(1), pp. 59-74, 1999.

Integrative Modeling of Client Engagement and Outcomes during the First 6 Months of Methadone Treatment

Integrative models containing client and treatment components were tested in a sample of 396 daily opioid users from three methadone maintenance treatment sites. Measures included client motivation at intake as well as repeated assessments of therapeutic engagement (relationships between clients and their counselors, session attendance, and results of urine testing) during the first 6 months of treatment. There was a positive effect of pretreatment motivation on engagement and a reciprocal positive relationship between components of engagement and their effects on lowering drug use throughout treatment. Further analyses addressed differential effects of group versus individual counseling and showed that group session attendance was associated with higher rates of drug-negative urines. Joe, G.W., Simpson, D.D., Greener, J.M., and Rowan-Szal, G.A. Addictive Behaviors, 24(5), 1999.

Biopsychosocial Characteristics and Treatment Outcomes of Pregnant Cocaine-dependent Women in Residential and Outpatient Substance Abuse Treatment

This study compared treatment outcomes of pregnant cocaine-dependent women and their infants enrolled in residential (N=32) and outpatient (N=32) treatments. No significant differences between treatment programs were found in retention or infant birth outcomes, but abstinence and patterns of attrition showed differences favoring residential treatment. Comfort, M., Kaltenbach, K.A. J. Psychoactive Drugs, 31(3), pp. 279-289, 1999.

New Directions in Alcohol and Drug Treatment under Managed Care

Studies on managed care and substance abuse were reviewed to explore potential effects of the introduction and expansion of managed care on the financing and organization of public and private alcohol and drug abuse treatment systems. Managed care will continue to have major effects on the organization of service delivery, the workforce, and the provision of services, especially in its impact on links between treatment agencies and the medical community, and other health and social service agencies. The impact of a new emphasis on treatment accountability through the mechanisms of outcomes monitoring and performance indicators has yet to be determined. Weisner, C., McCarty, D., Schmidt, L. Am. J. Manag. Care, 5 Spec No, SP 57-69, 1999.

Prison-based Substance Abuse Treatment, Residential Aftercare and Recidivism

The impact of residential aftercare on recidivism following prison-based treatment was examined. Data were collected from male inmates (293 treated, 103 untreated) in a 9-month in-prison therapeutic community (ITC) and several community-based transitional therapeutic communities (TTCs). Post-release recidivism was based on state criminal history records. ITC treatment, especially when followed by residential aftercare, was effective for reducing post-release recidivism rates, supporting a recommendation for a continuum of care model (from institution to community) with high quality programs and services. Hiller, M.L., Knight, K., and Simpson, D.D. Addiction, 94(6), pp. 833-842, 1999.

The Effect of Copayments on Drug and Alcohol Treatment following Inpatient Detoxification under Managed Care

The study examined the rates and duration of outpatient substance abuse treatment following inpatient detoxification under managed care. Seven years of claims data from a large behavioral health care carve-out plan were used to identify patients. Seventy-nine percent of the detoxification patients received formal substance abuse treatment, the majority within the week following discharge. Formal follow-up care lasted an average of ten weeks, with visits occurring on average about once a week. When other variables likely to influence participation in substance abuse treatment were controlled for, the level of outpatient copayments significantly affected the rate of participation in treatment. The results suggest that reducing copayment levels is one mechanism for increasing the likelihood that individuals with severe drug and alcohol problems will receive subsequent treatment. Stein, B., Orlando, M., Sturm, R. Psychiatric Services, 51(2), pp. 195-198, 2000.

"I Already Stopped": Abstinence Prior To Treatment

Pre-treatment abstinence and its relation to subsequent outcome was investigated using data collected for a randomized experimental design immediately after assessment for publicly funded substance abuse treatment at the King County Assessment Center (KCAC) in Seattle. Participants (N = 565), who had illicit drug use in the 90 days prior to KCAC referral to treatment, waited a median of 12 days (range = 0-108 days) until either treatment entry or waiting list dropout. Forty-five percent of participants reported abstinence from initial assessment to when they entered or failed to enter treatment. Higher rates of abstinence were associated with shorter waiting periods, less substance use prior to initial assessment, and higher readiness to change. Pre-treatment abstinence was not associated with either treatment entry or completion. Findings suggest that individuals can become abstinent prior to treatment, but this is not a good predictor of treatment entry, completion, or outcome. Rosengren, D.B., Downey, L., Donovan, D.M. Addiction, 95(1), pp. 65-76, 2000.

Effectiveness of Comprehensive Services for Crack-Dependent Mothers with Newborns and Young Children

The Family Rehabilitation Program (FRP) is a network of community-based programs providing comprehensive services to families, including prenatally cocaine-exposed newborns, with drug-dependent parents in New York City. An admission sample of 173 mothers in 17 FRP sites was studied for one year. Average retention was 10 months; half the clients were still active in the program at follow-up. Mothers completing or still active in FRP had higher rates of abstinence and substantially lower average levels of cocaine use (by hair analysis) at follow-up than those exiting prematurely. The percent of families with children removed from homes did not increase significantly between admission and follow-up, and completing or remaining active in the program were associated with less out-of-home placement at follow-up. Magura, S., Laudet, A., Kang, S.Y., Whitney, S.A. Journal of Psychoactive Drugs, 31(4), pp. 321-338, 1999.

The Addiction Severity Index: A Field Study of Internal Consistency and Validity

The validity and internal consistency of the Addiction Severity Index (ASI) was tested in a network of inner-city alcohol and drug abuse clinics. A sample of 8,984 ASI scores was collected over a 34-month period. Construct validity was examined by computing the internal consistency of all subscales. Convergent and divergent validity of composite scores and of severity ratings were evaluated using correlation matrices. ASI scores were found to be internally consistent and valid under non-ideal conditions, even though the recommended administration protocol may not always have been followed as faithfully as might be desirable. This robustness bodes well for the use of the ASI in on-line clinical environments. Leonhard, C., Mulvey, K., Gastfriend, D.R., and Schwartz, M. Journal of Substance Abuse Treatment, 18(2), pp. 129-135, 2000.

Exploring the Additive Effects of Drug Misuse Treatment and 12-Step Involvement: Does 12-Step Ideology Matter?

This study examines the effects of 12-Step ideology on 12-Step program participation and abstinence from drug use. Acceptance of 12-Step ideology, particularly strong agreement with the need for frequent, lifelong attendance at 12-Step meetings, and the need to surrender to a "higher power" were found to be significant predictors of weekly or more frequent attendance at 12-Step meetings independent of other mediating variables. Acceptance of the notion that controlled or nonproblematic drug use is not possible predicted abstinence independent from 12-Step participation and other potentially mediating variables. These findings have implications for group process and recovery from drug misuse. Fiorentine, R., Hillhouse, M.P. Subst. Use Misuse, 35(3), pp. 367-397, 2000.

Crack-Cocaine Users as Victims of Physical Attack

A retrospective and prospective natural history design was used to study correlates of physical attack among 440 not-in-treatment crack-cocaine users in Dayton, Ohio. Physical attack was found to be widespread among these crack cocaine users. Between baseline and 12-month follow-up, the odds of men being attacked were significantly less than those for women. The findings did not vary by ethnicity. Injuries often resulted in the need for medical care. These findings point to the need for accessible and effective drug abuse treatment to diminish harm to this population. Siegal, H.A., Falck, R.S., Wang, J., and Carlson, R. J National Medical Association, 92, pp. 76-82, 2000.

Lifetime Severity Index for Cocaine Use Disorder (LSI-Cocaine): A Predictor of Treatment Outcomes

The validity of a lifetime severity index for cocaine use disorder was developed and tested for its ability to predict post treatment outcome using data from the national Drug Abuse Treatment Outcome Study. The index, based on 28 items, considered frequency of use, recency, dependency, and attempt to quit. A higher value of the index, indicating greater severity, predicted a greater likelihood of relapse. The odds ratios were 5.7 for high severity and 4.4 for medium severity, relative to low severity and shorter time to relapse. Similarly, the polytomous logistic analysis indicated that the index predicted levels of post treatment cocaine use. Odds ratios of daily use were 47.8 for the high severity and 18.8 for medium severity; the corresponding odds ratios of weekly use were 6.75 and 5.10 and for less-than-weekly use were 3.35 and 3.57. The index can be a useful measure for both clinical and research purposes. Hser, Y., Shen, H., Grella, C., and Anglin, M.D. J. Nerv. Ment. Dis., 187(12), pp. 742-750, 2000.

Shorter Hospital Stays and More Rapid Improvement Among Patients With Schizophrenia and Substance Abuse

Length of stay and treatment response of inpatients with acute schizophrenia were examined to determine whether differences existed between those with and without comorbid substance-related problems. In a sample of 608 patients with a diagnosis of schizophrenia or schizoaffective disorder and substance abuse treated on hospital units with integrated dual diagnosis treatment researchers found that dually diagnosed patients were found to have improved markedly faster compared with patients without a dual diagnosis (30 percent shorter stays on both voluntary and involuntary units). They also showed somewhat greater symptomatic improvement and no increase in 18-month readmission rates. Dually diagnosed patients with schizophrenia appear to stabilize faster during acute hospitalization than those without a dual diagnosis. The authors hypothesize that substance abuse may temporarily amplify symptoms or that these patients may have a higher prevalence of better-prognosis schizophrenia. The availability of integrated dual-focus inpatient treatment and a well-developed outpatient system may also have helped these patients recover more rapidly. Ries, R.K., Russo, J., Wingerson, D., Snowden, M., Comtois, K.A., Srebnik, D., and Roy-Byrne, R. Psychiatric Services, 51, pp. 210-215, 2000.

Episodes Of Mental Health and Substance Abuse Treatment Under a Managed Behavioral Health Care Carve-Out

A growing number of payers of mental health and substance abuse services, including private employers and state governments, have adopted managed behavioral health care "carve-out" programs. Such payers seek to control rising metal health services and substance abuse (MHSA) benefit costs and to address adverse selection, while insuring needed services. The study found that adoption of a carve-out for Massachusetts state employees was associated with a dramatic drop in total MHSA costs per episode (particularly for individuals with severe MHSA conditions). The carve-out also was associated with a shift away from the use of facility care toward the use of outpatient care for enrollees with a diagnosis of unipolar depression. Huskamp, H. Inquiry, 36, pp. 147-161, 1999.

Impacts of Insurance on the Demand and Utilization of Drug Abuse Treatment: Implications for Insurance Mandates

The demand for, utilization of, and utilization costs for drug abuse treatment were estimated using an insurance claims database from self-insured employers. Approximately three-quarters of the increase in in-patient usage attributable to fractional co-insurance was due to increased usage per person (the other one-quarter was from to increased numbers of users). About half of the increase in outpatient usage was due to increased usage per person. These estimates may provide useful measurements of the potential impacts of improved drug abuse treatment coverage. Although the potential induced in-patient expenditures and dead-weight losses are substantial compared to co-insurance rates of 0.5, losses can be trimmed by adjusting co-insurance, even at rates of approximately 0.1. Goodman, A.C., Hanken, J.R., Nishura, E., and Sloan, J.J. International Journal of the Economics of Business, 6(3), pp. 331-348, 1999.

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