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Director's Report to the National Advisory Council on Drug Abuse - May, 2003

Research Findings - Services Research

The Effect of Primary Medical Care on Addiction and Medical Severity in Substance Abuse Treatment Programs

Researchers performed secondary analysis of data from a prospective cohort study of patients admitted to a purposive national sample of substance abuse treatment programs to examine whether the availability of primary medical care on-site at addiction treatment programs or off-site by referral improves patients' addiction severity and medical outcomes, compared to programs that offer no primary care. After controlling for treatment modality, geographic region, and multiple patient-level characteristics, patients who attended programs with on-site primary medical care experienced significantly less addiction severity at 12-month follow-up, compared with patients who attended programs with no primary medical care. However, on-site care did not significantly influence medical severity at follow-up. Referral to off-site primary care exerted no detectable effects on either addiction severity or medical severity. These findings indicate that on-site primary medical care improves substance abuse treatment patients' addiction-related outcomes, but not necessarily their health-related outcomes. Friedmann, P.D., Zhang, Z., Hendrickson, J., Stein, M.D., and Gerstein, D.R. The Effect of Primary Medical Care on Addiction and Medical Severity in Substance Abuse Treatment Programs. Journal of General Internal Medicine, 18, pp. 1-8, 2003.

Effects of Management Practices on Retaining Counseling Staff at Substance Abuse Treatment Centers

The annual turnover rate for drug abuse treatment counselors in a national study of 345 private treatment organizations was 18.5%. Significantly higher than such high-turnover occupations as teachers (13%) and nurses (12%), employee withdrawal presents a significant disruptive factor to continuity of care in drug abuse treatment. Results indicated that increasing counselor autonomy, providing rewards for strong job performance, and establishing a creative and innovative work environment can reduce counselor turnover. Knudsen, H.K., Johnson, J.A., and Roman, P.M. Retaining Counseling Staff at Substance Abuse Treatment Centers: Effects of Management Practices. Journal of Substance Abuse Treatment, 24, pp. 1-7, 2003.

Role of Treatment Completion and Length of Stay on Employment and Crime in Outpatient Drug-free Treatment

Length of stay in treatment has been found to be a significant predictor of positive post-treatment outcomes, such as decreases in unemployment and crime. However, length of stay may be an incomplete predictor of successful treatment. The objective of this study was to examine the effect that treatment completion and length of stay have on post-treatment employment and crime for patients in outpatient drug-free treatment, the largest treatment modality in the United States. Data are from the National Treatment Improvement Evaluation Study and include 986 adults enrolled in outpatient drug-free programs across the United States. Findings suggest that treatment completion and length of stay are significantly related to post-treatment employment. Holding length of stay constant, the occurrence of employment at follow-up among patients who complete their planned treatment is almost 2 times that of patients who do not complete treatment. However, treatment completion did not have a statistically significant effect on the probability of post-treatment crime. Although the results of this study are mixed, the findings suggest that greater attention should be placed on evaluating the importance of both length of stay and treatment completion in treatment outcome studies. Zarkin G.A., Dunlap L.J., Bray J.W. and Wechsberg W.M. The Effect of Treatment Completion and Length of Stay on Employment and Crime in Outpatient Drug-free Treatment. Journal of Substance Abuse Treatment, 23(4), pp. 261-271, 2002.

Effects of HIV Prevention Services in Correctional Drug Treatment Programs

This study evaluated receipt of HIV prevention services in correctional substance abuse treatment programs and examined their impact on short-term risk behaviors. The authors performed a secondary analysis of the National Treatment Improvement Evaluation Study, a prospective cohort study conducted during 1993 to 1995. The sample included 1,223 adult non-HIV-positive inmates, enrolled in nine correctional substance abuse treatment programs. A composite index modeled after the validated Risk Assessment Battery measured HIV risk behavior at treatment entry and at 12-month follow-up. Overall, most inmates received HIV prevention services while in treatment. Controlling for potential confounders, HIV prevention services were significantly associated with reduced risk behavior among inmates who were out of custody at follow-up, but no such association was observed among those still in custody. Analyses suggest that HIV prevention services are beneficial in reducing risk behavior among incarcerated individuals whose discharge is expected in the near future. Ballard Lubelczyk, R.A., Friedmann, P.D., Lemon, S.C., Stein, M.D., and Gerstein, D. The Effects of HIV Prevention Services in Correctional Drug Treatment Programs: Do They Change Risk Behaviors? AIDS Education and Prevention, 14, pp. 117-125, 2002.

Mental Health Problems and Sexual Abuse Among Adolescents in Foster Care: Relationship to HIV Risk Behaviors and Intentions

Adolescents in foster care present with multiple psychosocial and mental health problems that individually are associated with increased risk for HIV infection. However, few studies have examined the interrelationships among these problems and HIV risk behaviors in this population. This study examined the sexual abuse histories and mental health problems among 343 youths in foster care to determine their association with HIV-risk behaviors and behavioral intentions. Results indicated that 25% reported internalizing behaviors (withdrawn, somatic complaints, depressed), and 28.3% reported externalizing behaviors (delinquent and aggressive behaviors). Of the sample, 37% reported some form of prior sexual abuse. Multivariate analyses using simultaneous entry of variables indicated that controlling for demographic variables and behavioral intentions, externalizing behaviors showed the strongest relationship with HIV risk behaviors. Likewise, in the multivariate model, it was most strongly associated with behavioral intentions. Moreover, there was a significant race by gender interaction with Caucasian females engaging in more risky behaviors than their male counterparts, and youths of color. Auslander, W.F., McMillen, J.C., Elze, D., Thompson, R., Jonson-Reid, M., and Stiffman, A. Mental Health Problems and Sexual Abuse Among Adolescents in Foster Care: Relationship to HIV Risk Behaviors and Intentions. AIDS & Behavior, 6(4), pp. 351-359, 2002.

Mental Health and Addiction Problems Among American Indian Youth

This study examined the addiction and mental health service use of American Indian adolescents. The Diagnostic Interview Schedule and the Service Assessment for Children and Adolescents were used to ask Southwestern American Indian youth about their mental health needs, substance use, and service configurations. Seventy-nine percent had mental health or addiction problems, with half meeting criteria for at least one diagnosis. One in 4 youth met criteria for drug dependence/abuse or conduct disorder, 1 in 5 for depression, and 1 in 8 for alcohol dependence/abuse. Most youth received treatment services from a combination of providers. Youth meeting more diagnostic criteria were increasingly likely to use service configurations with adults, nonspecialist professionals, and specialists, respectively. Regardless of disorder, youth were least likely to use configurations with traditional healers or specialists, and there was little difference in rates of use between the two. The lack of services from specialist providers was potentially offset by use of an extensive range of informal adults, nonspecialist professionals, and peers. Since informal helpers, peers, and nonspecialist providers, but not specialists, are providing the bulk of services to these adolescents, they must be given support and skills so they can function effectively. Stiffman, A.R., Striley, C.W., Brown, E., Limb, G., and Ostmann, E. American Indian Youth: Who Southwestern Urban and Reservation Youth Turn To for Help with Mental Health or Addictions. Journal of Child & Family Studies, 12, pp. 319-333, 2003.

Cost Sharing by Managed Care Plans for Substance Abuse and Mental Health Treatment

Recent initiatives to improve private insurance coverage for substance abuse and mental health in the United States have mostly focused on equalizing coverage limits to those found in general medical care. Federal law does not address cost sharing (co-payments and coinsurance), which may also deter needed care or impose significant financial burdens on enrollees. This article reports on cost sharing requirements for outpatient care in a nationally representative sample of managed care plans in 1999. Levels of cost sharing are substantial, with around 40 percent of products requiring co-payments of $20 or more and another 15 percent requiring coinsurance of 50 percent. Cost sharing for outpatient substance abuse treatment is very similar to that for mental health. Compared to general medical care, at least 30 percent of products impose higher cost sharing for substance abuse and mental health treatment. Future parity initiatives should be examined for how they address differences in cost sharing as well as limits. Hodgkin, D., Horgan, C.M., Garnick, D.W., and Merrick, E.L. Cost Sharing for Substance Abuse and Mental Health Services in Managed Care Plans. Medical Care Research and Review, 60(1), pp. 101-116, 2003.

Behavioral Health Quality Management Activities within Managed Care Organizations

This study analyzes managed care organizations' (MCOs') use of behavioral health quality management activities using nationally representative survey data. Four hundred and thirty four MCOs in 60 market areas were surveyed regarding their use of four behavioral health quality management activities: patient satisfaction surveys, clinical outcomes assessment, performance indicators, and practice guidelines. Chi(2) tests and logistic regression were used to determine effects of product type (HMO, PPO, point-of-service) and behavioral health contracting arrangement (specialty contract, comprehensive contract including general medical and behavioral health, internal provision). Three-quarters of products used patient satisfaction surveys (70.1%), performance indicators (72.7%), and practice guidelines (73.8%) for behavioral health. Under half (48.9%) assessed clinical outcomes. Most commercial managed care products use patient satisfaction surveys, performance indicators, and practice guidelines for behavioral health, whereas clinical outcomes assessment is less common. Product type and contracting arrangements significantly affect use of these activities. Merrick, E.L., Garnick, D.W., Horgan, C.M., and Hodgkin, D. Quality Measurement and Accountability for Substance Abuse and Mental Health Services in Managed Care Organizations. Medical Care, 40(12), pp. 1238-1248, 2002.

Cost Analysis of Cannabis Youth Treatment Approaches

The present study conducted an economic cost analysis of several outpatient adolescent treatment approaches. The Cannabis Youth Treatment (CYT) study evaluated five structured treatments for cannabis-using adolescents. Using the Drug Abuse Treatment Cost Analysis Program (DATCAP), the economic cost of each site-specific treatment was determined. The average economic costs of the five types of outpatient treatments ranged from $837 to $3334 per episode, and varied by both direct factors (e.g. hours of treatment, treatment retention) and indirect factors (e.g. cost of living, staff level, case-load variation). These adolescent treatment cost estimates are examined in terms of their calculation, variability by condition, variability by site within condition and comparability with previous DATCAP results from outpatient drug-free programs for adults. Future research will integrate treatment outcomes and costs to complete cost-effectiveness and benefit-cost analyses of the five therapies. French, M.T., Roebuck, M.C., Dennis, M.L., Diamond, G., Godley, S.H., Tims, F., Webb, C. and Herrell, J.M. The Economic Cost of Outpatient Marijuana Treatment for Adolescents: Findings from a Multi-site Field Experiment. Addiction. 97, Suppl 1, pp. 84-97, 2002.

Costs and Benefits of Methadone Treatment: Crime Cost Savings

Longer lengths of stay in methadone treatment have been associated with greater treatment benefits such as reductions in heroin use and criminal activity. This paper examines monetary returns from investments in longer-term methadone treatment for opioid users who participated in NIDA's Drug Abuse Treatment Outcome Studies (DATOS). Part 1 focuses on crime cost savings for discharged patients (patients who left their index DATOS treatment program before completing 1 year of treatment) and continuing patients (those who continued in treatment for 1 year or longer). Subjects were 394 methadone patients from 8 medium to large cities and 16 programs; overall 37% were women, 33% African American, with an average age of 37.2. Greater lengths of stay in methadone treatment were associated with greater crime cost savings. Results showed that methadone treatment provides significant returns on treatment investments for both continuing and discharged patients. However, greater net economic benefits were realized from continuing patients. Flynn, P.M., Porto, J.V., Rounds-Bryant, J.L., and Kristiansen, P.L. Costs and Benefits of Methadone Treatment in DATOS - Part 1: Discharged Versus Continuing Patients. Journal of Maintenance in the Addictions, 2(1/2), pp. 129-149, 2003.

Costs and Benefits of Methadone Treatment: Gender Differences

This paper examines the role played by patient gender in affecting the cost savings of outpatient methadone treatment (OMT) in NIDA's Drug Abuse Treatment Outcome Studies (DATOS). Subjects were 144 women and 250 men from 8 cities and 16 programs. Female subjects were 30% African American, 43% Caucasian, and 26% Hispanic with an average age of 35.5 years. Male subjects were 35% African American, 40% Caucasian, and 24% Hispanic with an average age of 38 years. Women had greater reductions in crime costs than men. Greater net economic benefits to society were accrued by women than men. Results suggest that males might benefit from longer stays in methadone treatment. Flynn, P.M., Porto, J.V., Rounds-Bryant, J.L., and Kristiansen, P.L. Costs and Benefits of Methadone Treatment: Gender Differences for Discharged and Continuing Patients. Journal of Maintenance in the Addictions, 2(1/2), pp. 151-169, 2003.

Building Bridges Between Research and Practice in Drug Abuse Treatment

The slowness with which most treatment innovations enter the field of drug abuse treatment has been a long and persistent complaint in the field. Dr. James Sorensen and his co-authors recently published an edited book of papers addressing ways to promote and exemplify collaboration in the substance abuse field. Chapter authors examine what field-developed treatments have attracted research attention, what research-developed treatments have been readily adopted into the field, and what is needed to bring researchers and practitioners into accord. By working together, researchers and practitioners can identify and develop promising scientific protocols, use the most rigorous standards to test them, and put into practice treatments that prove to be most effective. Drug Abuse Treatment through Collaboration: Practice and Research Partnerships that Work. Sorensen, James L., Rawson, Richard A. , Guydish, Joseph, and Zweben, Joan E. (Eds). Ways to Build Bridges Between Research and Practice in Drug Abuse Treatment. Washington, DC, US: American Psychological Association. xxii, 326 pp., 2003.


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