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Director's Report to the National Advisory Council on Drug Abuse - May, 2005

Research Findings - Services Research

Multiple Episodes Of Care Over Several Years Are Norm For Addicts

Interview data were collected at 6, 18, 24, 36, 48, and 60 months post-intake from 1,271 of 1,326 (96%) people recruited from a stratified sequential sample of admissions to publicly funded treatment programs in a large metropolitan area. The most common dependence diagnoses were for cocaine (64%), alcohol (44%), opioids (41%), and/or marijuana (14%). Survival analysis of patient histories was used to estimate the time from first use and first treatment until people reported 12 months of abstinence or died. During the three years after intake, 47% reached at least 12 months of abstinence. The median time from first to last use was 27 years. The median time from first treatment episode to last use was 9 years. Years to recovery were significantly longer for males, people starting use under the age of 21 (particularly those starting under the age of 15), people who had participated in treatment 3 or more times, and for people high in mental distress. These exploratory results suggest that multiple episodes of care over several years are the norm and that rather than thinking of multiple episodes in terms of "cumulative dosage," it might be better thought of as further evidence of chronicity and that we need to develop and evaluate models of longer term recovery management. Dennis, M.L., Scott, C.K, Funk, R.R., and Foss, M.A. The Duration and Correlates of Addiction and Treatment. Journal of Substance Abuse Treatment 28(4), pp. 9-60, 2005.

New Information Increases Understanding Of Addiction Relapse

This study replicates earlier work, by documenting transition patterns during a 3-year period within the relapse cycle, and identifies variables that predict transitions across pathways between one of four states: (1) in the community using, (2) incarcerated, (3) in treatment, or (4) in the community not using. Data are from 1,326 adults recruited from sequential admissions to 12 substance abuse treatment facilities in Chicago, IL, between 1996 and 1998. Participants were predominantly female (60%) and African American (88%) adults. Participants were interviewed at intake, and at 6, 24, and 36 months post-intake and follow-up rates ranged from 94% to 98% per wave. Over 83% of the participants transitioned from one point in the cycle to another during the 3 years (including 36% two times, 14% three times). Results examining follow-up data also showed that the longer a person stayed abstinent the greater the odds that she would remain abstinent. However, the percentage of addicts who maintained abstinence over the 3-year cycle studied was only 10.6%. Factors predicting transition within the cycle varied depending upon in which of the four paths a subject was at each follow-up period. Results help demonstrate the need to adopt a chronic vs. acute care model for addiction. While exploratory and observational, several of the predictors are time-dependent and identify promising targets for interventions designed to shorten the cycle and increase the long-term effectiveness of treatment. Scott, C.K., Foss, M.A., and Dennis, M.L. Pathways to Relapse, Treatment, and Recovery Cycle Over Three Years. Journal of Substance Abuse Treatment 28, pp. 61-70, 2005.

Average Substance Abuse Care Costs Higher For Co-Occurring Alcohol And Drug Disorders Than For Alcohol Or Drug Disorders Alone

The study investigated the relationship of substance use disorders, concurrent psychiatric disorders, and patient demographics to patterns of treatment use and spending in behavioral health and medical treatment sectors. Researchers examined insurance claims (data on costs and use of services) for 1899 individuals who received treatment for substance use disorders in 1997. Medical and pharmacy spending was assessed for 590 individuals. The most prevalent services were outpatient, intensive outpatient, residential, and detoxification. Average mental health/substance abuse care spending conditional on use was highest for those with concurrent alcohol and drug disorders ($5235) compared to those with alcohol ($2507) or drugs ($3360) alone; other psychiatric illness ($4463) compared to those without ($1837); and employees' dependents ($4138) compared to employees ($2875) or their spouses ($2744). A significant minority of individuals also sought mental health/substance abuse services in the medical sector. Understanding services use and associated costs can best be achieved by examining services use across treatment sectors. Greenfield, S.F., Azzone, V., Huskamp, H., Cuffel, B., Croghan, T., Goldman, W. and Frank, R.G. Treatment for Substance Use Disorders in a Privately Insured Population Under Managed Care Costs and Services Use. Journal of Substance Abuse Treatment 27(4), pp. 265-275, 2004.

Drug Court Has Positive Net Economic Benefits

This study conducted a cost-benefit analysis of three drug court programs in Kentucky for two groups of drug court participants: program graduates (n=222) and program terminators (n=371). Economic cost data were collected using the Drug Abuse Treatment Cost Analysis Program (DATCAP). Data related to economic benefits of the drug court programs were assessed by calculating the reduction in costs associated with criminal justice system, domestic violence, mental health services, motor vehicle accidents, and by considering increased child support payments and earnings from employment. Economic benefits of the drug court programs were estimated relative to a comparison group of individuals who were assessed for the drug court programs, but did not enter the programs. Cost per treatment episode was estimated to be $3,178 per drug court participant. Findings indicate that, particularly for graduates, drug court involvement was associated with reductions in incarceration, mental health services, and legal costs, as well as increases in earnings and child support payments. There is an economic benefit of $8,624 over 12 months and a net savings of $5,446. Logan, T.K., Hoyt, W.H., McCollister, K.E., French, M.T., Leukefeld, C. and Minton, L. Economic Evaluation of Drug Court: Methodology, Results, and Policy Implications. Evaluation and Program Planning 27(4), pp. 381-396, 2004.

Increased Recidivism Among Offenders Treated Under California's Proposition 36

In November 2000, California voters approved the Substance Abuse and Crime Prevention Act (SACPA), also known as "Proposition 36," which offered adults convicted of non-violent drug possession offenses the option of participating in drug treatment in lieu of incarceration. The investigators compared data collected from a sub-sample of 3,748 offenders in 13 California counties admitted to drug treatment during the first six months of SACPA (July-December, 2001) to 1,178 offenders referred to treatment under criminal justice pressure other than SACPA, and 1,882 patients admitted without legal pressure. Relative to non-SACPA patients, SACPA patients with severe drug problems were significantly less likely to be treated in residential programs. Subsequent analyses further revealed a significant severity by modality interaction, with high-severity/outpatient clients being most likely to be rearrested on a drug-related charge in the 12 months after treatment admission. Although the prevalence of arrests decreased for all three groups after treatment admission, SACPA clients were more likely to be re-arrested for a drug crime even after controlling for the interaction between drug use severity and treatment modality. These findings underscore the role of client-treatment matching (based on addiction severity) and of actively applying legal pressure to increase treatment retention and maximize potential treatment benefits. Farabee, D., Hser, T., Anglin, M.D. and Huang, Y. Recidivism Among an Early Cohort of California's Proposition 36 Offenders. Criminology and Public Policy 3(4), pp. 563-584, 2004.

Psychological Distress Is A Significant Indicator of Drug Abuse Relapse

This study examined the background characteristics and psychological distress of 180 drug abuse patients in relationship to drug use and drinking. Distress was measured by the 24-item Brief Symptoms Inventory Hopkins Checklist. A modified linear scale for drug use and drinking was derived from retrospective self-reports using the Time Line Follow Back (TLFB) and Lifetime Drinking History (LDH). Structural equation modeling found that psychological distress at baseline and follow-up were direct, robust predictors of reuse of alcohol, and to a lesser extent reuse of illicit drugs, 2 years following substance user treatment. Described as negative emotional states or depressive symptomatology --psychological distress'' may constitute a common and costly proximal high-risk situation and a marker of return to substance use among patients with substance use problems. Regardless of causal origin, for practical purposes, assessment of psychological distress during substance user treatment, preferably after a --reasonable'' detoxification period, may provide a marker for further investigation for risk for resumed substance use or relapse. Flynn, H.A., Walton, M.A., Curran, G.M., Blow, F.C. and Knudtzen, S. Psychological Distress and Return to Substance Use Two Years Following Treatment. Substance Use and Misuse 39, pp. 885-910, 2004.

New Analytic Method for Evaluating Causal Effects in Observational Studies

Causal effect modeling with naturalistic rather than experimental data is challenging. In observational studies participants in different treatment conditions may also differ on pre-treatment characteristics that influence outcomes. Propensity score methods can theoretically eliminate these confounds for all observed covariates, but accurate estimation of propensity scores is impeded by large numbers of covariates, uncertain functional forms for their associations with treatment selection, and other problems. This article demonstrates that boosting, a modern statistical technique, can overcome many of these obstacles. The authors illustrate this approach with a study of 449 adolescent probationers in substance abuse treatment programs. Propensity score weights estimated using boosting eliminate most pre-treatment group differences and substantially alter the apparent relative effects of adolescent substance abuse treatment. McCaffrey, D.F., Ridgeway, G. and Morral, A.R. Propensity Score Estimation with Boosted Regression for Evaluating Causal Effects in Observational Studies. Psychological Methods 9(4), pp. 403-425, December 2004.

California Women Benefit More Than Men From Treatment Of Methamphetamine Abuse

A prospective longitudinal study examined treatment outcomes among 1073 methamphetamine-abusing patients (567 women, 506 men) from 32 community-based outpatient and residential programs in 13 California counties. Data were collected at intake and at 3 months and 9 months after admission. With one exception, improvements from baseline to follow-up were observed in all areas measured by the Addiction Severity Index (ASI) for both women and men in either modality. However, compared to men, women demonstrated greater improvement in family relationships and resolution of medical problems, while maintaining the same level of improvement as men in all other areas. These results showed gains for women despite higher unemployment, greater childcare responsibilities, cohabitation with someone who also used alcohol or drugs, relatively more reports of physical or sexual abuse and more psychiatric symptoms. Hser, Y., Evans, E., and Huang, Y. Treatment Outcomes Among Women and Men Methamphetamine Abusers In California. Journal of Substance Abuse Treatment 28(1), pp. 77-85, 2005.

Treatment Retention Increased in Oregon and Washington, 1994-1998

This study examined individual and system characteristics associated with retention in methadone maintenance treatment among Medicaid-eligible adults (aged 18-64 years) in publicly funded treatment for opiate use in Oregon (N=3557) and Washington (N=5308), 1994-1998. Logistic regression was used to examine the contributions of predisposing, need, and enabling characteristics on 365-day retention in methadone maintenance treatment. Older patients, patients with a history of methadone maintenance treatment, and persons with stable Medicaid eligibility had higher rates of retention than did patients with disabilities, polysubstance users, and those with an arrest record. In Oregon, which delivers methadone maintenance treatment through managed care, retention rose sharply from 28% to 51% between 1994 and 1998 and then leveled off. During the same time period, retention in Washington State grew from 28% to 34%. The higher rates of retention in Oregon can be explained in part by differences in service delivery influenced by financing. Faced with long waiting lists, Washington providers were more than twice as likely as their Oregon counterparts to discharge patients for rule violations. Given the importance of retention, policies and practices that influence retention should be carefully considered. Because Medicaid eligibility has a dramatic impact on retention, policies that help extend eligibility or stabilize eligibility among individuals actively engaged in treatment should be carefully considered. Deck, D. and Carlson, M.J. Retention in Publicly Funded Methadone Maintenance Treatment in two Western States. Journal of Behavioral Health Services Research, 32(1), pp. 43-60, 2005.

Relationship Between Drug Treatment Services, Retention and Outcomes

This longitudinal study examined the relationships between treatment processes and outcomes among 1939 patients in 36 outpatient and residential community-based drug treatment programs in 13 California counties who were assessed at intake, discharge, three months after admission, and nine months after admission. Path analyses related the quantity and quality of services received in the first three months of treatment to retention in treatment and outcomes at the nine-month follow-up. Patients were determined to have a favorable outcome if for at least 30 days before the follow-up assessment they did not use drugs, were not involved in criminal activity, and lived in the community. Analyses controlled for patients' baseline characteristics. Greater service intensity and satisfaction were positively related to either treatment completion or longer treatment retention, which in turn was related to favorable treatment outcomes. Patients with greater problem severity received more services and were more likely to be satisfied with treatment. These patterns were similar for patients regardless of whether they were treated in outpatient drug-free programs or residential programs. Hser, Y., Evans, E., Huang, Y., and Anglin, M.D. Relationship Between Drug Treatment Services, Retention and Outcomes. Psychiatric Services 55(7), pp. 767-774, 2004.

Transitions During Effective Treatment For Cocaine-Abusing Homeless

Seventy-two cocaine dependent homeless persons receiving day treatment, which included abstinence-contingent housing and employment; established abstinence, maintained abstinence for longer durations, and were significantly less likely to relapse than 69 similar patients in a day treatment-only condition. This random controlled study indicated that day treatment with abstinence-contingent housing and employment was more effective in maintaining complete abstinence once it was established, and patients who relapsed returned more quickly to abstinence than those day treatment patients not in abstinence-contingent situations. Milby, J.B., Schumacher, J.E., Vuchinich, R.E. and Wallace, D. Transitions During Effective Treatment for Cocaine-abusing Homeless Persons: Establishing Abstinence, Lapse, and Relapse, and Reestablishing Abstinence. Psychology of Addictive Behaviors 18(3), pp. 250-256, 2004.

Psychiatric Services for Patients with Chemical Dependency Enhance Treatment Outcomes

This study examined the relationship between use of psychiatric services and alcohol and drug treatment outcomes five years after such treatment. It was anticipated that receipt of psychiatric services would predict long-term abstinence. A sample of 604 outpatients from a managed care organization's chemical dependency program was interviewed about substance use and severity of psychiatric symptoms at baseline and at five years. Patients were required to have at least three years of membership in the health plan during the five years after intake. Severity of psychiatric symptoms was categorized as zero, low, middle, or high. Use of psychiatric services was ascertained on the basis of administrative data from the health plan. Logistic regression analysis was used to assess the relationship between receipt of psychiatric services during the five years after intake and abstinence at five years. Results were adjusted for individual, treatment, and extra-treatment characteristics; severity of psychiatric symptoms at baseline; and other contacts with the health system. Results revealed that patients who received a threshold level of psychiatric services (an average of at least 2.1 hours a year) were significantly more likely to be abstinent at five years than patients who received less than 2.1 hours a year. The use of psychiatric services among patients with chemical dependency is associated with enhanced long-term outcomes. Ray, G.T., Mertens, J. and Weisner, C. Relationship Between Use of Psychiatric Services and Five-year Alcohol and Drug Treatment Outcomes. Psychiatric Services 56(2), pp. 164-171, 2005.

New Screener and Assessment Measure For Patients With Chronic Pain

Under a small business innovation research grant a self-administered screening tool (Screener and Opioid Assessment for Patients with Pain (SOAPP) was developed and validated for chronic pain patients considered for long-term opioid therapy. A consensus of 26 pain and addiction experts was obtained on important characteristics of chronic pain patients that predict future medication misuse using concept mapping. A 24-item SOAPP (version 1.0) was developed based on this consensus and was administered to 175 patients who were taking opioids for chronic pain. After 6 months, 95 of these patients were re-evaluated. Validation of the SOAPP was conducted. Of the original 24 items, 14 SOAPP items reliably (alpha = .74) predicted subsequent aberrant behaviors (a positive score on the Prescription Drug Use Questionnaire (PDUQ) interview, positive urine toxicology screen, and/or ratings by staff). Receiver operating characteristics curve analysis yielded an area under the curve of 0.881 (P<0.001), suggesting adequate sensitivity and specificity for a screening device. Butler, S.F., Budman, S.H., Fernandez, K. and Jamison, R.N. Validation of a Screener and Opioid Assessment Measure for Patients with Chronic Pain. Pain 112, pp. 65—75, 2004.

Chronic Severe Pain Plays A Role In Heroin Use Among Methadone Patients

Recent studies indicate that severe chronic pain is common among patients in methadone maintenance treatment (MMT). This study used qualitative methods to explore the experiences of 12 MMT patients with chronic pain as measured on the Brief Pain Inventory. Results suggest that chronic severe pain may be linked to illegal drug use, social isolation, and role failure. A variety of barriers limited access to effective pain treatment due to providers' perceived lack of concern or inability to "listen." These preliminary results suggest that more research is needed to guide the development of effective treatment strategies. Karasz, A., Zallman, L., Berg, K., Gourevitch, M., Selwyn, P., and Arnstein, J. The Experience of Chronic Severe Pain in Patients Undergoing Methadone Maintenance Treatment. Journal of Pain Symptom Management 28, pp. 517—525, 2004.

Brief Family-Based Treatment for Adolescent Substance Abuse Superior to Peer Group Therapy In Clinical Trial

A randomized clinical trial compared a family-based therapy (Multidimensional Family Therapy, MDFT) and a peer group therapy with 80 urban, low-income, and ethnically diverse young adolescents (between the ages of 11 and 15). Both treatments were outpatient, relatively brief, manual-guided, equal in intervention dose, and delivered by community drug treatment therapists. Results indicated that the family-based treatment was significantly more effective than peer group therapy in reducing risk and promoting protective processes in the individual, family, peer, and school domains, as well as in reducing substance use over the course of treatment. These results support the clinical effectiveness of MDFT with young adolescents and also supports the dissemination potential of this family-based, multi-system, developmentally-oriented intervention. Liddle, H.A., Rowe, C.L., Dakof, G.A., Ungaro, R.A. and Henderson, C.E. Early Intervention for Adolescent Sbstance Ause: Petreatment to Post-treatment Outcomes of a Randomized Clinical Trial Comparing Multidimensional Family Therapy and Peer Group Treatment. Journal of Psychoactive Drugs 36(1), pp. 49-63, 2004.

Treatment Fidelity For Multidimensional Family Prevention (MDFP) Demonstrated

Multi-dimensional family prevention (MDFP) is a new family-based prevention counseling model for adolescents at high risk for substance abuse and related behavior problems which emerged from Multi-dimensional family therapy (MDFT). Fidelity was assessed by comparing and contrasting MDFP to both MDFT and a second empirically-based intervention used for adolescent substance abusers, cognitive-behavioral therapy (CBT). Randomly-selected videotapes of 109 MDFP sessions, 57 MDFT sessions, and 31 CBT sessions were observationally-rated along two key dimensions of implementation: intervention parameters and intervention techniques. Overall, MDFP was similar to MDFT and different from CBT in a manner congruent with its theoretical principles of interactional, systemic intervention. Hogue, A., Liddle, H.A., Singer, A., and Leckrone, J. Intervention Fidelity in Family-based Prevention Counseling for Adolescent Problem Behaviors. Journal of Community Psychology 33, pp. 191-211, 2005.

Family Focus Predicts Post-treatment Improvement For Adolescent Substance Abusers

The relationship between specific therapy techniques and treatment outcome was examined for two empirically-supported treatments for adolescent substance abuse: individual cognitive-behavioral therapy and multi-dimensional family therapy. Participants were 51 inner-city, substance abusing adolescents receiving outpatient psychotherapy within a larger randomized trial. One session per case was evaluated using a 17-item observational measure of model-specific techniques and therapeutic foci. Exploratory factor analysis identified two subscales, Adolescent Focus and Family Focus, with strong inter-rater reliability and internal consistency. Process-outcome analyses revealed that family focus, but not adolescent focus, predicted post-treatment improvement in drug use, externalizing, and internalizing symptoms within both study conditions. Hogue, A., Liddle, H.A., Dauber, S., and Samuolis, J. Linking Session Focus to Treatment Outcome in Evidence-based Treatments for Adolescent Substance Abuse. Psychotherapy: Theory, Research, Practice, and Training, 41, pp. 83-96, 2004.

Patients Increasingly Referred Outside Substance Abuse Treatment Program for Psychiatric Care

Face-to-face interviews were conducted with a nationally representative panel of 450 privately-funded centers in 1995-1996, 1997-1998, and 2000-2001. Over the study period, the percentage of centers that referred clients with serious mental illness to external providers increased from 57% to 67%. For-profit centers and hospital-based programs, however, were significantly less likely to refer these dually diagnosed clients to external agencies. These data demonstrate that integrated care for clients with co-occurring drug abuse and mental health disorders has become less available over time, despite the consensus that such care is evidence-based treatment for this population. Knudsen, H.K., Roman, P.M., and Ducharme, L.J. The Availability of Psychiatric Programs in Private Substance Abuse Treatment Centers, 1995-2001. Psychiatric Services, 55, pp. 270-273, 2004.

Managerial Practices Result In More Evidence-Based Innovation In Private Substance Abuse Treatment Organizations

Widespread concern about the slow rate of adoption of evidence-based drug abuse treatment technologies has resulted in an emerging literature on the organizational characteristics that are associated with the adoption of innovations. Most research has considered the adoption of specific innovations rather than aggregate measures of innovation adoption. This paper examines "absorptive capacity," a concept from the management literature that refers to such business practices as hiring professionally-trained staff, scanning the competitive environment, and the collection of satisfaction data from third-party payers and referral sources. This research draws upon data from 322 privately-funded substance abuse treatment centers. The three managerial practices reflecting absorptive capacity: the hiring of professionally-trained staff; scanning the competitive environment; and the collection of satisfaction data were significantly associated with the adoption of evidence-based practices, suggesting that that center leadership can play an important role in closing the research-to-practice gap. Knudsen, H.K. and Roman, P.M. Modeling the Use of Innovations in Private Treatment Organizations: The Role of Absorptive Capacity. Journal of Substance Abuse Treatment 26, pp. 51-59, 2004.

Housing Offers Protective Function For Substance Abuse and Violence in Indigent Women

A study examining retrospective self-reports of stratified random samples of women residing in shelters (N = 460) and low-income housing (N = 438) in Los Angeles County, California found that sheltered women were more likely than housed women to report physical and sexual violence, substance use and disorder, HIV risk behavior, and the co-occurrence of these problems in the past year. Differences remained when propensity weights were used to equate the groups on demographic and background characteristics. Wenzel, S.L., Tucker, J.S., Elliott, M.V., Hambarsoomians, K., Perlman, J., Becker, K., Kollross, C. and Golinelli, D. Prevalence and Co-occurrence of Violence, Substance Use and Disorder, and HIV Risk Behavior: A Comparison of Sheltered and Low-income Housed Women in Los Angeles County. Preventive Medicine 39, pp. 617-624, 2004.

Men and Women Similar In Recovery Rates But Different In Psychosocial Functioning

Gender differences were examined at 36 months following residential or outpatient drug-free treatment among 951 participants in the Chicago Target Cities Project, the majority of whom were female (62%) and African American (93%). There were no differences in the proportion of men and women who reported any alcohol or drug use at the 36-month follow-up, with an overall reduction of 41% from intake. Greater proportions of men were incarcerated or employed, whereas greater proportions of women had returned to treatment, lived with their children, lived with a substance user, or had interpersonal problems. Women, as a group, had greater increases over time in self-help participation, free time spent with family, non-using family/friends, and employment. Although both men and women showed significant improvements following treatment, gender differences persisted in several areas of psychosocial functioning related to recovery. Grella, C.E., Scott, C.K, and Foss, M.A. Gender Differences in Long-term Drug Treatment Outcomes in Chicago PETS. Journal of Substance Abuse Treatment, 28, pp. 3-12, 2005.

Using Client Characteristics to Understand Treatment Process in the Therapeutic Community

Therapeutic communities (TCs) improve post-treatment outcomes for substance abusers, but little is known about the in-treatment experience for clients with different backgrounds, experiences, and needs. This study examined the in-treatment experience of TC participants and examined the relationships between treatment process and client characteristics. Research participants included 447 adults and 148 adolescents receiving treatment in community-based TC programs in New York, California, and Texas. Data related to treatment process were collected using the Therapeutic Community Treatment Process: Dimensions of Change Instrument. Data on demographic characteristics, substance use and treatment history, and client risk factors were extracted from intake interviews and analyzed separately for adolescent and adult residents. Multivariate general linear models were used to examine the effect of client variables on treatment process, after controlling for treatment duration and program effects. Adult clients in the study were on average 36 years old, over half were male, and 57% were African American. The average age of adolescent clients was 17, with 73% being male, and 43 % Hispanic. Adult program participants who were 25 years or older, female, and had prior drug treatment were more positive about their experiences in the TC as indicated in their higher Community Environment scores. Adolescents with one or more arrests within the past 2 years were more negative about both their experiences in the TC and their self-concept as indicated in lower scores on process dimensions of the Community Environment and Personal Development and Change scales. Results from this study indicate how differences in client characteristics affect important treatment process variables including readiness for change and motivation for treatment. Chan, K.S., Wenzel, S., Orlando, M., Montagnet, C., Mandell, W., Becker, K. and Ebener, P. How Important are Client Characteristics to Understanding Treatment Process in the Therapeutic Community? The American Journal of Drug and Alcohol Abuse, 30(4), pp. 871—891, 2004.

Predictors of Treatment Retention for Drug Court Participants

Factors distinguishing clients who complete drug court treatment from those who do not complete drug court have been documented, but differences between urban and rural drug court participants have not been examined. The present study seeks to determine predictors of treatment retention for drug court participants in urban and rural settings. Mental health, drug use, criminal activity, and education/employment and their association with treatment retention are examined. Research subjects included 250 participants from an urban drug court and 250 participants in a rural drug court, both located in Kentucky. Most subjects were male (69%), average age of 30, white (59%), never married (56%) with 1 child. Data collection methods included interviews and record reviews of drug court participants. Study findings indicate that retention in treatment for urban drug court participants could be predicted by examining marital status, employment, drug use, and criminal activity. For the rural drug court, however, retention was only predicted by age and juvenile incarceration. Findings from this study suggest there are different factors associated with drug court retention between urban and rural drug court settings. These findings may be useful to drug court administrators and community treatment providers seeking to tailor drug abuse treatment and services to match client needs. Mateyoke-Scrivner, A., Webster, J.M., Staton, M. and Leukefeld, C. Treatment Retention Predictors of Drug Court Participants in a Rural State. The American Journal of Drug and Alcohol Abuse 30(3), pp. 605—625, 2004.

Ethical Dilemmas in Longitudinal Studies Can Be Addressed with Planning, Training, and Supervision

Many complex ethical issues arise in the day-to-day conduct of longitudinal studies of addiction treatment. These issues are rooted, in part, in the sustained and potentially ambiguous relationship between research staff and study participants; the frequently changing clinical and legal status of study participants; the assertive methods required to generate high follow-up rates and the numerous systems of care and control in which participants are involved. To identify common ethical issues that arise in such studies, the authors conducted individual and group interviews with seasoned members (case trackers, field trackers, interviewers, and supervisors) of the research team. The ethical dilemmas identified through these interviews fell into seven broad arenas: (1) informed consent for research participation; (2) confidentiality and information disclosure; (3) relationship boundaries between study participants and research staff; (4) duty to warn/report responsibilities; (5) questions of autonomy and privacy; (6) issues related to compensation for research participation and (7) data integrity. Case studies illustrate these common ethical dilemmas can be effectively managed via ethically informed research protocols, staff training in ethical decision-making, monitoring and supervision, and collective debriefing of critical events. Scott, C.K. and White, W.L. Ethical Issues in the Conduct of Longitudinal Studies. Journal of Substance Abuse Treatment, 28, pp. 89-99, 2005.

Women's Perception of Therapeutic Communities

A comprehensive measure of treatment was administered to 447 adults and 148 adolescents receiving treatment at community-based TC programs in New York, California, and Texas. Data on demographic characteristics, substance use and treatment history, and client risk factors were extracted from intake interviews and analyzed separately for adult and adolescent residents. Controlling for treatment duration and program effects, female clients over 25 who had prior drug treatment experience reported more positive perceptions of the therapeutic community environment and expressed more willingness to change in contrast to younger males with no prior treatment experience or with one or more arrests within the past 2 years. Chan, K.S., Wenzel, S., Orlando, M., Montagnet, C., Mandell, W., Becker, K., and Ebener, P. How Important Are Client Characteristics to Understanding Treatment Process in the Therapeutic Community? The American Journal of Drug and Alcohol Abuse 30(4), pp. 871-891, 2004.

Physical Violence Against Impoverished Women: Risk and Protective Factors

Violence represents a significant threat to the health of impoverished women. Few studies have attempted to identify risk and protective factors associated with violence directed at these women, although this information might be useful for violence prevention. In a representative probability sample of impoverished women, this study prospectively examined multiple risk and protective factors to understand their relative importance to physical victimization. Study participants included 810 women in Los Angeles County, 402 living in shelters and 408 living in Section 8 low-income housing, who completed structured interviews at baseline and 6-month follow-up. Significant (p < .05) multivariate predictors of physical violence experienced during the 6 months prior to the follow-up interview included physical or sexual violence experienced as a child, physical violence experienced during the 6 months prior to baseline interview, having multiple sexual partners, psychological distress, and poor social support. Results highlight the persistence of physical violence in the lives of impoverished women and prospective risk factors for this violence. Findings also highlight opportunities to reduce women's risk of experiencing violence through enhancing social support and mental health. Wenzel, S.L., Tucker, J.S., Elliott, M.N., Marshall, G.N. and Williamson, S.L. Physical Violence Against Impoverished Women: A Longitudinal Analysis of Risk and Protective Factors. Women's Health Issues 14(5), pp. 144-154, 2004.

Improving Assessments and Service Referrals Utilizing A Software Program

Knowledge of service resources and lower burdens for referral have been shown to be directly associated with an increase in problems identified and with services provided. Non-substance abuse professionals, such as child welfare workers often are the first gatekeepers of mental health and addiction services for young people. A newly developed software, IMPROVE (Intervention for Multisector Health Provider Enhancement-child welfare), enables child welfare workers to assess child and adolescent mental health and substance abuse needs and to then find the best fit for them among over 1200 potential mental health and substance abuse referral resources. These findings are based on focus groups of 46 workers and supervisors and a pilot evaluation of the program involved 19 workers, 8 of whom were given the hand-held computers. The IMPROVE decision support software allows a worker to record a youth's mental health symptoms, behaviors, and addictions by checking items on an assessment screen. A keyword checklist also allows workers to note peer problems, environmental stress, strengths and talents in order to find mental health services, foster care availability, and alternatives to formal treatment options (sports, the arts, and skill building) as well as traditional social welfare programs (housing, clothing and food). The software then matches assessments or keywords indicating client need with resource names, program descriptions, and contact information. Stiffman, A.R., Foster, K., Hamburg, and Dore, P. IMPROVE: A Software Program to Improve Assessments and Multisector Referrals. In C.J. Liberton, K. Kutash and R.M. Friedman (Eds.), Conference Proceedings: A System of Care for Children's Mental Health, Expanding the Research Base. Tampa, FL: Research and Training Center for Children's Mental Health, pp. 449-452, 2005.

Organizational Factors Associated With Provision Of Hepatitis C Care In Drug Treatment

Substance abusers are at high risk for hepatitis C (HCV) infection, are medically underserved, and are hard to reach. Researchers conducted a nationwide survey with 445 randomly selected drug treatment units in the U.S. to determine unit and patient characteristics associated with the provision of on-site medical services for HCV-infected drug users. Eighty-four percent of the 322 units that estimated having at least one HCV-infected patient reported that they provided patients with HCV-related medical care. Drug treatment units were more likely to provide at least some of this care on site if they were residential, part of a network, or affiliated with a hospital, had medical staff, and required that their patients undergo a medical examination before entering treatment. Vassilev, Z.P., Strauss, S.M., Astone, J.M., Friedmann, P.D. and Des Jarlais, D.C. Provision of On-site Medical Care to Patients with Hepatitis C in Drug Treatment Units. Journal of Health Care for the Poor and Underserved, 15(4), pp. 663-671, Nov. 2004.

Organizational Characteristics Influence Length Of Stay In Detoxification Centers

Admissions to 20 publicly-funded alcohol and drug detoxification centers in Massachusetts were examined to identify program and patient variables that influenced length of stay. The last admission during fiscal year 1996 was abstracted for patients 18 years of age and older seeking alcohol, cocaine, or heroin detoxification (n = 21,311; 29% women). A hierarchical, generalized linear model examined the effects of patient and program characteristics on variation in length of stay and tested case-mix adjustments. Program size had the most influence on mean adjusted length of stay; stays were more than 40% longer in detoxification centers with 35 or more beds (7.69 days) than in centers with less than 35 beds (5.42 days). The study highlights the contribution of program size to treatment processes and suggests the need for more attention to program attributes in studies of patient outcomes and treatment processes. Jonkman, J.N., McCarty, D., Harwood, H.J., Normand, S.L. and Caspi, Y. Practice Variation and Length of Stay in Alcohol and Drug Detoxification Centers. Journal of Substance Abuse Treatment, 28, pp. 11-18, 2005.

Lifelong Addiction Leads To Health Problems In Elder Years

This study examined health conditions among an aging cohort of male narcotics addicts for the period 1964 to 1998. Data included interviews and medical testing for 108 surviving subjects who had been admitted to the California Civil Addict Program during the years 1962 through 1964. The study empirically demonstrated poor health conditions and high morbidity among surviving narcotics addicts. Medical results indicated that: 51.9% had high blood pressure; 22.4% showed hyperlipidemia; 13.3% had elevated levels of blood glucose and 33.6% had abnormal pulmonary function. Half of the sample had abnormal liver function; 94.2% tested positive for hepatitis C; 85.6% for hepatitis B; 3.8% for syphilis and 27.3% for TB. Hser, Y., Gelberg, L., Hoffman, V., Grella, C.E., McCarthy, W. and Anglin, M.D. Health Conditions Among Aging Narcotics Addicts: Medical Examination Results. Journal of Behavioral Medicine 27(6), pp. 607-622, 2004.

Rural Drinkers More Problematic than Urban Drinkers

A study to examine predictors of changes in drinking and drinking consequences in untreated at-risk drinkers in a community sample used telephone interviews at 6-month intervals over a 2-year period. A probability sample of at-risk drinkers in both rural and urban South localities was used (initial N = 733). Individuals reporting receiving services for drinking (n = 69) were excluded from the analyses. Illegal drug use and social consequences of drinking were associated with worse outcomes. Rural residents maintained higher drinking quantity and were less likely to be safe drinkers than urban residents. Participants scoring high on religiosity experienced better living outcomes. Psychiatric comorbidity was significantly associated only with drinking quantity. Results suggest that targeted interventions to encourage problem drinkers to enter treatment might improve their health and well-being. Booth, B.M., Curran, G.M., and Han, X. Predictors of Short-term Course of Drinking Among Untreated At-risk Drinkers. Journal of Studies on Alcohol 65, pp. 63-73, 2004.

Parents' Perceptions of Mediation vs. Pretrial Conferences in Juvenile Drug Court

Two hundred parents were randomly assigned to mediation (facilitated by master's-level social workers) or to pretrial conferences (guided by judges) to examine the effects of the dispute resolution methods on the attitudes of parents in child dependency disputes. No differences in dispute method were observed for either mediation or pretrial conferences. However, parents assigned to mediation perceived a higher degree of settlement in the case. Justice variables were more salient than trust variables in predicting parents' perceptions of the unfairness of the third parties and the degree of settlement achieved, but not in predicting dissatisfaction with the juvenile court system. Ashford, J. and Faith, R. Testing Models of Justice and Trust: A Study of Mediation in Child Dependency Disputes. Social Work Research 28(1), pp. 18-27, 2004.

TCs Offer Less Personal Freedom Yet Tolerate More Annoying Behaviors Compared to Self-Governed, Communal Living Residences

The rules and regulations from 55 self-governed, communal-living sites, managed and operated by residents called Oxford Houses in three states were compared to 14 traditional, staff-managed, therapeutic communities (TCs). Results indicated that both types of facilities prohibited self-injurious behaviors (such as physical self-harm or over medication of drugs). However, the Oxford Houses were more likely to establish policies restricting setting-destructive behaviors (e.g., disturbing, attacking, threatening, or harming others and playing loud music that annoys others), permitting residents to engage in personal liberties (e.g., staying out late or overnight and having guests stay at the sight), and to having personal possessions (e.g., own TV, stereo, and furniture) within the dwelling. Implications related to establishing social regularities that permit persons in recovery to have personal freedoms within communal-living, safe and sober settings are discussed. Ferrari, J.R., Jason, L.A., Davis, M.I., Olson, B.D. and Alvarez, J. Assessing Similarities and Differences in Governance Among Residential Recovery Programs: Self vs. Staff Rules and Regulations in Therapeutic Communities. The International Journal for Therapeutic and Supportive Organizations, 25, pp. 185-198, 2004.

Communal-Living Residents (Oxford Houses) More Confident in Ability to Remain

Abstinent from Drugs than Individuals Participating in 12-Step Self-Help Groups A study comparing 42 Oxford House communal-living members to 42 individuals participating in 12-Step self-help groups but who were not in communal living arrangements. All had less than 180 days of abstinence. Results showed that Oxford House residents reported higher levels of optimism and belief they could remain abstinent than those in the self-help groups. Findings were compelling as Oxford House members were more likely to have served time in jail (83%) compared to the 12-Step members (55%). The 12-Step members with convictions reported lower optimism and were less confident about their abstinence potential than 12-Step members without convictions; yet, for the Oxford House members there was no difference in levels of optimism and beliefs they could remain abstinent. Majer, J.M., Jason, L.A., and Olson, B.D. Optimism, Abstinence Self-efficacy and Self-mastery Among Oxford House Residents: A Comparative Analysis of Personal Resources. Assessment, 11, pp. 57-63, 2004.

Gender Differences Found in Comprehensive Services in Substance Abuse Treatment

Utilizing data from the National Treatment Improvement Evaluation Study (NTIES), collected from 1992 to 1997, researchers report noteworthy gender differences. The analytic sample consisted of 3,142 clients (1,123 women and 2,019 men) from 59 treatment facilities. Findings show that greater proportions of women receive services; and when individual, service, and treatment organizational characteristics are controlled for, women show greater reductions in post-treatment substance use. Further, women and men differ in their responsiveness to organizational characteristics. The availability of on-site services and the frequency of counseling significantly predict reduced post-treatment substance use for men, but not for women. Marsh, J.C., Cao, D. and D'Aunno, T.D. Gender Differences in the Impact of Comprehensive Services in Substance Abuse Treatment. Journal of Substance Abuse Treatment 27, pp. 289-300, 2004.

Prevalence Of HIV and Hep C Virus Among Injection Drug Users In Miami, Florida

Prevalence of HIV-1 and HCV co-infection in hard-to-reach intravenous drug users was estimated in 199 subjects from high risk inner-city locales, the so called "shooting galleries" in Miami, Florida. Positive HIV status was based on repeated reactive enzyme-linked immunosorbent assay (ELISA) and confirmatory Western Blot. Positive HCV status was based on reactive ELISA and confirmatory polymerase chain reaction techniques. Overall, 50 (25%) of participants were not infected with either virus; 61 (31%) were HIV-1/HCV co-infected; 17 (8%) were infected by HIV-1 only and 71 (36%) were infected by HCV only. The results of the multivariable analyses showed that the number of years using heroin was the only significant risk factor for HCV only infection (OR=1.15; 95% CI=1.07, 1.24) and for HIV-1/HCV (OR=1.17; 95% CI=1.09, 1.26). This study demonstrates that HIV-1/HCV co-infection is highly prevalent among so called "shooting galleries." McCoy, C.B., Metsch, L.R., Collado-Mesa, F., Arheart, K.L., Messiah, S.E., Katz, D. and Shapshak, P. The Prevalence of Human Immunodeficiency Virus Type 1 and Hepatitis C Virus among Iinjection Drug Users who use High Risk Inner-city locales in Miami, Florida. Mem Inst Oswaldo Cruz, Rio de Janeiro 99(8), pp. 789-793, 2004.


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