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Director's Report to the National Advisory Council on Drug Abuse
September, 2001

Research Findings

Services Research

A Comparison of the Predictive Validity of Four Sets of Baseline ASI Summary Indices

This study compared the long-term predictive validity of original and new baseline Addiction Severity Index summary scores in methadone patients. The indices included the original Interviewer Severity Ratings (ISRs) and the new Clinical Indices (CIs), which use both lifetime and recent problem information, and the original Composite Scores (CSs) and Evaluation Indices (EIs), based on recent problems only. Outcomes were medical hospitalization, employment, alcohol intoxication, drug hospitalization, and psychiatric hospitalization in Months 7-24 post study entry and criminal charges in Months 0-24. Hierarchical logistic regression analyses were used in which 1 index was entered first and the other in the 2nd step. The reverse order of entry was used in a 2nd analysis. A final analysis set compared the best predictor from each of the 2 prior analysis sets. The CIs were superior to the other indices in predicting 3 of 6 outcomes (psychiatric hospitalization, drug hospitalization, and criminal charges); the EI was the best predictor of alcohol intoxication, and the CS the best predictor of unemployment. Alterman, A.I., Bovasso, G.B., Cacciola, J.S., and McDermott, P.A. A Comparison of the Predictive Validity of Four Sets of Baseline ASI Summary Indices. Psychol Addict Behav., 15(2), pp. 159-162, June 2001.

Factors Associated with Frequency of 12-Step Attendance by Drug Abuse Clients

Comparison was made of treatment clients attending Narcotics Anonymous and/or Alcoholics Anonymous meetings less than weekly (n = 41) with treatment clients attending meetings at least three times a week (n = 30). The frequent attendees (attending an average of 30.6 meetings monthly) differed from non- and infrequent attendees (attending an average of 0.4 meetings monthly) in terms of histories of greater lifetime drug use, greater incidence of arrests and treatment experiences, and an earlier age of first use of alcohol. Although those who attended more frequently were also older, age was not found to influence the differences found between groups. Measures of religiosity, use of community services, and support from others for recovery and psychological functioning, other than ratings of the helpfulness of 12-Step, were not differentiated among groups. The findings suggest that 12-Step groups are more likely to be selected by clients with more severe histories of drug use and criminal activity, i.e., those most in need of the support to behavior change those groups provide. The role of treatment programs in facilitating the use of 12-Step groups is discussed. Brown, B.S., O'Grady, K.E., Farrell, E.V., Flechner, I.S., and Nurco, D.N. Factors Associated with Frequency of 12-Step Attendance by Drug Abuse Clients. Am J Drug Alcohol Abuse. 27(1), pp. 147-160, Feb 2001.

Initial Validation of a Computer-Administered Addiction Severity Index: The ASI-MV

The Addiction Severity Index--Multimedia Version (ASI-MV) is a CD-ROM-based simulation of the interview-administered Addiction Severity Index (ASI). Clients in treatment (N = 202) self-administered the ASI-MV to examine the test-retest reliability, criterion validity, and convergent-discriminant validity of the ASI-MV. Excellent test-retest reliability was observed for composite scores and severity ratings. Criterion validity, tested against the interviewer-administered ASI, was good for the composite scores. For severity ratings, variable agreement was observed between the ASI-MV and each interviewer, suggesting poor interrater reliability among interviewers. This conclusion was bolstered by a finding of superior convergent-discriminant validity for both composite scores and severity ratings compared to the standard ASI. The ASI-MV is a viable alternative to the expensive and potentially unreliable interviewer-administered version. Butler, S.F., Budman, S.H., Goldman, R.J., Newman, F.J., Beckley, K.E., Trottier, D., and Cacciola, J.S. Initial Validation of a Computer-Administered Addiction Severity Index: The ASI-MV. Psychology of Addictive Behaviors. 15(1), pp. 4-12, Mar 2001.

The Epidemiology of Physical Attack and Rape Among Crack-Using Women

This prospective study examines the epidemiology of physical attack and rape among a sample of 171 not-in-treatment, crack-cocaine using women. Since initiating crack use, 62% of the women reported suffering a physical attack. The annual rate of victimization by physical attack was 45%. Overall, more than half of the victims sought medical care subsequent to an attack. The prevalence of rape since crack use was initiated was 32%, and the annual rate was 11%. Among those women having been raped since they initiated crack use, 83% reported they were high on crack when the crime occurred as were an estimated 57% of the perpetrators. Logistic regression analyses showed that duration of crack use, arrest for prostitution, and some college education were predictors of having experienced a physical attack. Duration of crack use and a history of prostitution were predictors of suffering a rape. Drug abuse treatment programs must be sensitive to high levels of violence victimization experienced by crack-cocaine using women. Screening women for victimization, and treating the problems that emanate from it, may help make drug abuse treatment more effective. Falck, R.S., Wang, J., Carlson, R.G., and Siegal, H.A. The Epidemiology of Physical Attack and Rape among Crack-Using Women. Violence. Vict.,16(1), pp. 79-89, Feb 2001.

An Evaluation of Drug Treatments for Adolescents in 4 US Cities

Little is known about outcomes of community-based treatment programs for adolescents with drug problems. This study evaluated the treatment outcomes of 1,167 adolescents (age range, 11-18 years; 368 females, 799 males) from 4 US cities (Pittsburgh, Pa; Minneapolis, Minn; Chicago, Ill; and Portland, Ore) using a naturalistic, non- experimental evaluation design. These adolescents were consecutive admissions between 1993 and 1995 in one of 23 community-based treatment programs in the Drug Abuse Treatment Outcome Studies for Adolescents. Included were 418 admissions to 8 residential programs, 292 admissions to 9 outpatient drug-free programs, and 457 admissions to 6 short-term inpatient programs. Adolescents in treatment typically had multiple problems (e.g., 58.4% of them were involved in the legal system, and 63.0% met diagnostic criteria for a mental disorder). Nevertheless, less than half (43.8%) of all patients reported weekly marijuana use in the year following treatment (dropping from 80.4% in the year before admission). Similarly, there were decreases in heavy drinking (dropping from 33.8% to 20.3%), use of other illicit drugs (dropping from 48.0% to 42.2%), and criminal involvement (dropping from 75.6% to 52.8%). Additionally, patients reported better psychological adjustment and school performance after treatment. Longer stays in treatment were positively associated with several favorable outcomes, although length of time in treatment was generally short. These findings suggest that substance abuse treatment for adolescents is effective in achieving many important behavioral and psychological improvements. Strategies specific to adolescents to improve their treatment retention and completion are needed to maximize the therapeutic benefits of drug treatment. Hser, Y.I., Grella, C.E., Hubbard, R.L., Hsieh, S-C., Fletcher, B.W., Brown, B.S., and Anglin, M.D. An Evaluation of Drug Treatments for Adolescents in 4 US Cities. Arch Gen Psychiatry. 58, pp. 689-695, 2001.

Drug Treatment Outcomes for Adolescents with Comorbid Mental and Substance Use Disorders

This study compared the pretreatment characteristics and post treatment outcomes of substance-abusing adolescents with and without comorbid mental disorders in the Drug Abuse Treatment Outcome Studies for Adolescents. Subjects (N = 992) were sampled from 23 adolescent drug treatment programs across three modalities (residential, short-term inpatient, outpatient drug-free). Nearly two thirds (64%) of the sample had at least one comorbid mental disorder, most often conduct disorder. Comorbid youth were more likely to be drug or alcohol dependent and had more problems with family, school, and criminal involvement. Although comorbid youth reduced their drug use and other problem behaviors after treatment, they were more likely to use marijuana and hallucinogens, and to engage in illegal acts in the 12 months after treatment, as compared with the noncomorbid adolescents. Integrated treatment protocols need to be implemented within drug treatment programs in order to improve the outcomes of adolescents with comorbid substance use and mental disorders. Grella, C.E., Hser, Y.I., Joshi, V, and Rounds-Bryant, J. Drug Treatment Outcomes for Adolescents with Comorbid Mental and Substance Use Disorders. J Nerv Ment Dis.,189(6), pp. 384-392, June 2001.

Managed Care and Outpatient Substance Abuse Treatment Intensity

This study examines the extent to which managed care behavioral controls are associated with treatment intensity in outpatient substance abuse treatment facilities. Data are from the 1995 National Drug Abuse Treatment System Survey, a nationally representative survey that includes over 600 provider organizations with a response rate of 86%. Treatment intensity is measured in three ways: (1) the number of months clients spend in outpatient drug treatment, (2) the number of individual treatment sessions clients receive over the course of treatment, and (3) the number of group treatment sessions clients receive over the course of treatment. After accounting for selection bias and controlling for market, organization, and client characteristics, there was no significant relationship between the scope of managed care oversight and treatment intensity. However, the stringency of managed care oversight activities was negatively associated with the number of individual and group treatment sessions received over the course of treatment. The study provides evidence that managed care influences outpatient substance abuse treatment through the process by which units are selected by managed care firms or choose to participate in managed care programs. The process by which treatment organizations chose to participate or are chosen for managed care programs appears not to be random. Lemak, C.H., and Alexander, J.A. Managed Care and Outpatient Substance Abuse Treatment Intensity. Journal of Behavioral Health Services & Research, 28(1), pp. 12-29, Feb 2001.

Multidimensional Assessment of Perceived Treatment-Entry Pressures Among Substance Abusers

Motivational assessment instruments typically measure clients' attributions about their readiness to change problem behaviors. They do not indicate why a client may be motivated to change, or provide guidance on how to retain an unmotivated client in treatment. The authors interviewed 415 substance abuse clients about their reasons for entering treatment and scored their responses along the dimensions of (a) negative versus positive treatment-entry pressures, (b) internal versus external sources of those pressures, and (c) the life domain from which the pressures emanated. Exploratory cluster analysis yielded 5 types of clients characterized by different profiles of perceived treatment-entry pressures. Cluster membership was predictive of treatment outcomes, and the clusters differed by demographic variables. The results of this study indicate that there are multiple types of pressures on clients to enter treatment. These data support the discriminative and predictive utility of performing a multidimensional assessment of pressures to enter treatment. Marlowe, D.B., Merikle, E.P., Kirby, K.C., Festinger, D.S., and McLellan, A.T. Multidimensional Assessment of Perceived Treatment-Entry Pressures among Substance Abusers. Psychol Addict Behav., 15(2), pp. 97-108, June 2001.

Public Sector Managed Care for Substance Abuse Treatment: Opportunities for Health Services Research

Observations of reduced utilization of alcohol and drug abuse treatment following the introduction of managed behavioral health care suggest that substance abuse services may be especially responsive to managed care restrictions and limits. In publicly funded treatment systems, patient attributes, system and provider characteristics, and financing mechanisms may heighten susceptibility to unintended effects. The State Substance Abuse and Mental Health Treatment Managed Care Evaluation Program reviewed state managed care programs for publicly funded alcohol and drug treatment services and is evaluating programs in Arizona, Iowa, Maryland, and Nebraska. This article describes initiatives and outlines evaluation activities. It discusses the opportunities and challenges of assessing public managed care plans. McCarty, D., Argeriou, M., Denmead, G., and Dilonardo, J. Public Sector Managed Care for Substance Abuse Treatment: Opportunities for Health Services Research. J Behav Health Serv Res., 28(2), pp.143-154, May 2001.

Prevalence of Nonpsychotic Mental Disorders Does Not Affect Treatment Outcome in a Homeless Cocaine-Dependent Sample

This study presents the prevalence and treatment outcome of DUAL diagnoses (psychoactive substance use disorders [PSUD] plus other nonpsychotic mental disorders) among a population of homeless persons participating in a behavioral day treatment and contingency management drug abuse treatment programs. Participants were 128 persons: 76.6% male, 23.4% female; 82.2% African-American, 17.2% Caucasian. There were 46 (35.9%) PSUDs and 82 (64.1%) DUAL participants. Cocaine (96.9%) and alcohol disorders (57.8%) were most prevalent overall, and 60.2% of participants had two or more psychoactive substance use disorders. DUAL participants had significantly more alcohol disorders than PSUDs (62.2% versus 50.0%). The most prevalent mental disorders (other than substance use) for the total and DUAL samples were, respectively, mood (51.6% and 80.5%) and anxiety (35.9% and 56.1%), and 31.3% and 48.8% had more than two mental disorders. The DUAL group had more severe problems than the PSUD group at baseline in alcohol, medical condition, employment/support, and psychiatric status areas on the ASI. Both groups showed treatment improvements at 6-months follow-up with the DUAL group showing greater mean changes than the PSUD group in five of the seven ASI areas. These findings are discussed in terms of effect of dual diagnoses on treatment outcome and study limitations related to a retrospective design and select sample of nonpsychotic mental disorders. McNamara, C., Schumacher, J.E., Milby, J.B., Wallace, D., and Usdan, S. Prevalence of Nonpsychotic Mental Disorders Does Not Affect Treatment Outcome in a Homeless Cocaine-Dependent Sample. Am J Drug Alcohol Abuse, 27(1), pp. 91-106, Feb 2001.

Benefits in Behavioral Health Carve-Out Plans of Fortune 500 Firms

This study examined the prevalence and nature of behavioral health carve-out contracts among Fortune 500 firms in 1997. A survey was conducted of 498 companies that were listed as Fortune 500 firms in 1994 or 1995. A total of 336 firms (68 percent) responded to the survey. Univariate analyses were used to analyze prevalence, types, and amounts of covered services, cost sharing, and benefit limits. A total of 132 firms reported contracting with managed behavioral health organizations; 124 firms answered benefits questions about covered services, cost-sharing levels, and annual and lifetime limits. Findings indicate that most of the plans covered a broad range of services. Cost sharing was typically required, and for inpatient care it was often substantial. Fifteen percent of the firms offered mental health benefits that were below the limits defined in this study as minimal benefit levels, and 34 percent offered substance abuse treatment benefits that fell below minimal levels. The most generous mental health benefits and substance abuse treatment benefits, defined as no limits or a lifetime limit only of $1 million or more, were offered by 31 percent and 20 percent of the firms, respectively. The carve-out contracts of the Fortune 500 firms in this study typically covered a wide range of services, and the benefits appeared generous relative to those reported for other integrated and carve-out plans. However, these benefits generally did not reach the level of parity with typical medical benefits, nor did they fully protect enrollees from the risk of catastrophic expenditures. Merrick, E.L., Garnick, D.W., Horgan, C.M., Goldin, D., Hodgkin, D., and Sciegaj, M. Benefits in Behavioral Health Carve-Out Plans of Fortune 500 Firms. Psychiatr Serv., 52(7), pp. 943-948, July 2001.

Service Outcomes of Peer Consumer Advocacy for Soup Kitchen Guests

This study determined client outcomes for two "linkage and coordination" models of case management-an individual case manager model and a team model consisting of a case manager and a peer helper-in an inner-city meal program. Soup kitchen guests seeking social services were voluntarily randomly assigned to one of two conditions-linkage and Coordination (WC) plus Peer Consumer Advocacy (PCA) [N = 57] or Linkage and Coordination (L/C) only [N = 53]. The PCAs provided guests with social and instrumental support to help them implement their case plans. Almost all study participants were unemployed and reported drug or alcohol misuse. Participants who received WC plus PCA, compared with those receiving WC only, met more often with the case manager, kept more service referral appointments, and received more entitlements and community services. Other significant predictors of appointments kept were older age and limitations in activities of daily living. The WC plus PCA participants also showed better outcomes for cocaine/crack use, but not for heavy alcohol or other drug use. Nwakeze, P.C., Magura, S., Rosenblum, A., et al. Service Outcomes of Peer Consumer Advocacy for Soup Kitchen Guests. J Soc Serv Res, 27(2), pp. 19-38, 2000.

Association of Outpatient Alcohol and Drug Treatment with Health Care Utilization and Cost: Revisiting the Offset Hypothesis

This study examines the hypothesis that treatment reduces medical utilization and costs of patients with substance use problems. Adult patients (N = 1.011; 67% men) entering the outpatient chemical dependency recovery program at Sacramento Kaiser Permanente over a 2-year period were recruited into the study. Medical utilization and costs were examined for 18 months prior and 18 months after intake. To account for overall changes in utilization and cost, an age, gender and length-of-enrollment matched nonpatient control group (N = 4,925) was selected from health-plan members living in the same service area. Multivariate analyses controlling for age and gender were conducted using generalized estimating equation methods, allowing for correlation between repeated measures and nonnormal distributions of the outcome variable. The treatment cohort was less likely to be hospitalized (odds ratio [OR] = 0.59; p < .01) and there was a trend for having spent fewer days (rate ratio [RR] = 0.77; p < .10) in the hospital in the post treatment period compared to pretreatment period. These patients were also less likely to visit the emergency room (ER) (OR = 0.64; p < .01) and had fewer ER visits (RR = 0.81; p < .01) following treatment. Inpatient, ER and total medical costs declined by 35%, 39% and 26%, respectively (p < .01). Reductions in cost were greater for the treatment cohort when compared with the matched sample (p < .05). Among women, there were significant reductions (p < .05) in inpatient, ER and total costs for the study cohort when compared with the matched sample; among men, the reductions in inpatient and ER cost (but not total cost) were significantly larger (p < .05) for the study cohort when compared with the matched sample. For the treatment cohort, the change in medical cost was not significantly different by gender. Changes in cost were significantly different across the various age groups (p < .05) for the study cohort and the matched sample. Among those in the group aged 40-49 years, the decline in cost for study cohort was significantly larger (p < .05) than for the matched sample. For patients with substance use disorders entering treatment, there was a substantial decline in inappropriate utilization and cost (hospital and ER) in the post treatment period. The disaggregated pattern of post treatment decline in utilization and cost is suggestive of long-term reductions that warrant a longer follow-up. Parthasarathy, S.,Weisner, C., Hu, T.W., and Moore, C. Association of Outpatient Alcohol and Drug Treatment with Health Care Utilization and Cost: Revisiting the Offset Hypothesis. J Stud Alcohol., 62(1), pp. 89-97, Jan 2001.

Association of Outpatient Alcohol and Drug Treatment with Health Care Utilization and Cost: Revisiting the Offset Hypothesis

Individuals with alcohol and drug use problems may receive health care from medical, mental health, and substance abuse providers, or a combination of all three. Systems of care are often distinct and separate, and substantial opportunities for benefit to patient, provider, and payer are missed. In this article, the authors outline (1) the possible benefits of linking primary care, mental health, and substance abuse services from the perspective of the major stakeholders-medical and mental health providers, addiction clinicians, patients, and society-and (2) reasons for sub optimal linkage and opportunities for improving linkage within the current health care system. They also review published models of linked medical and substance abuse services. Given the potential benefits of creating tangible systems in which primary care, mental health, and substance abuse services are meaningfully linked, efforts to implement, examine, and measure the real impact should be a high priority. Samet, J.H., Friedmann, P., Saitz, R. Association of Outpatient Alcohol and Drug Treatment with Health Care Utilization and Cost: Revisiting the Offset Hypothesis. Arch Intern Med., 161, pp. 85-91, 2001.

Treatment Readiness Training and Probationers' Evaluation of Substance Abuse Treatment in a Criminal Justice Setting

Clients who are legally coerced into substance abuse treatment often have low intrinsic motivation to participate, are less ready for treatment, and are consequently more problematic to treat and less satisfied with their treatment than are voluntary clients. A set of readiness training activities, designed to promote early involvement in treatment, was implemented in a 4-month residential criminal justice program. Five hundred probationers were randomly assigned to receive either the readiness training developed by the authors or the approach typically used at the facility. Based on their response to an intake interview, probationers were categorized as having low, medium, or high readiness for treatment. Probationers in the readiness training group rated their counselors, groups, and community meetings higher than did probationers in the standard group. In addition, probationers in the readiness training group rated themselves as "working the program" to a greater extent than did probationers in the standard group. Probationers with higher initial levels of readiness for treatment rated their counselors, sessions, and security staff higher than did probationers with lower levels. The results suggest that the readiness training activities may help probationers become more involved in treatment and that this may lead to greater satisfaction with counselors and sessions. Sia, T.L., Dansereau, D.F., and Czuchry, M.L. Treatment Readiness Training and Probationers' Evaluation of Substance Abuse Treatment in a Criminal Justice Setting. Journal of Substance Abuse Treatment, 19(4), pp. 459-467, Dec 2000.

Are Barriers to Mental Health and Substance Abuse Care Still Rising?

This study estimates unmet need and barriers to alcohol, drug, and mental health (ADM) services in 1997 to 1998 using data from a national household survey (n = 9,585). In 1997 to 1998, 10.9% of the population perceived a need for ADM services, with 15% obtaining no treatment and 11% experiencing delays or obtaining less care than needed. The rate of unmet need due to no treatment is similar to earlier studies, but the group experiencing delays/less care is almost as large. This finding emphasizes the importance of defining access to care more broadly by including timeliness and intensity of care. Economic barriers are highest for the uninsured, but also are high among the privately insured. Individuals with unmet need are significantly more likely to use complementary and alternative medicine (CAM). Those with no conventional mental health care rely on self-administered treatment, while those with delayed/insufficient conventional care use CAM providers and self-administered treatment. Sturm, R., and Sherburne, C.D. Are Barriers to Mental Health and Substance Abuse Care Still Rising? Journal of Behavioral Health Services & Research, 28(1), pp. 81-88, Feb 2001.

The First Week after Drug Treatment: The Influence of Treatment on Drug Use Among Women Offenders

Over the last decade, there has been a dramatic rise in the number of women arrested for drug offenses, and many have serious drug abuse problems. Increasingly, these women have been mandated to drug treatment, often in community-based settings. This article examines the impact of the treatment programs on the short-term post treatment drug use of women offenders (N = 165) leaving two community-based treatment programs in Portland, Oregon. Women who abstained from drug use during the first week after treatment were more likely than those who used drugs during this time to have remained in treatment longer, received a plan to make a successful transition out of treatment, avoided associations with other drug users after leaving treatment, and obtained encouragement from individuals and groups in support of abstinence. In addition, the research identified the importance of community referrals in the short-term for women to maintain sobriety after leaving treatment. The results suggest that community referrals be provided early in the treatment process since many women offenders do not complete treatment. Strauss, S.M., and Falkin, G.P. The First Week after Drug Treatment: The Influence of Treatment on Drug Use among Women Offenders. Am J Drug Alcohol Abuse, 27(2), pp. 241-264, May 2001.

Treatment Compliance in the Trajectory of Treatment Progress Among Offenders

Research on drug treatment process has been limited, with most studies centering on individual and program factors associated with successful treatment completion. Recent literature has begun highlighting the salience of treatment engagement in reducing drug dependence among criminal offenders. This study descriptively analyzes incidents of treatment noncompliance identified in monthly progress reports for 150 criminal justice-mandated clients in residential treatment. The researchers identify seven problem types and seven dimensions of noncompliance in the trajectory of treatment engagement. The latter are prevalence, frequency, types, specialization, temporal distribution, paths, and correlates. Incidents of rule violations are common among criminal justice participants of residential treatment. Although for most clients these troubles do not appear to evolve into serious obstacles to recovery, a few clients with a high frequency of noncompliant behavior never engage in treatment. Clinical implications for improving treatment engagement and retention are discussed. Sung, H., Belenko, S. and Feng, L. Treatment Compliance in the Trajectory of Treatment Progress Among Offenders. Journal of Substance Abuse Treatment, 20(2), pp. 153-162, March 2001.

Diversity in Relapse Prevention Needs: Gender and Race

Comparisons among Substance Abuse Treatment Patients Attempts to address high relapse rates following substance abuse treatment have focused on identifying relapse prevention needs and development of subsequent relapse prevention programs. Few studies have examined whether women and African-Americans have unique relapse prevention needs. Research in this area could provide an initial basis for the development of alternative relapse prevention approaches that could be more appropriate for this population. This study examined gender and race differences in psychosocial concerns among patients recruited from substance abuse treatment as potential indicators of relapse prevention needs. Participants (N = 331) completed several questionnaires during their first month of substance abuse treatment. Assessment packets included measures of coping, self-efficacy, resource needs, cravings, social influences, exposure, and leisure activities. Analyses focused on gender and race differences in these variables before and after controlling for background characteristics (i.e., age, marital status, income, polysubstance use, treatment type, and problem severity). Gender differences found were that men reported poorer coping skills and more negative social influences and exposure to substances than women; these differences remained significant when controlling for background characteristics. Significant race differences were found on all scales except negative social influences. After controlling for background characteristics, African-Americans reported significantly greater coping skills and self-efficacy than did Caucasians; however, African-Americans also reported greater resource needs in comparison to Caucasians. Results highlight the diversity in psychosocial issues among substance abusers in treatment, particularly between Caucasians and African-Americans. Implications for developing alternative relapse prevention approaches to address this diversity are discussed. Walton, M.A., Blow, F.C., and Booth, B.M. Diversity in Relapse Prevention Needs: Gender and Race Comparisons Among Substance Abuse Treatment Patients. Am J Drug Alcohol Abuse., 27(2), pp. 225-240, May 2001.

Rural-Urban Differences in Substance Use and Treatment Utilization Among Prisoners

Surveys of incarcerated offenders and arrestees consistently report high rates of both drug use and alcohol in this population. This drug-crime connection has highlighted the need to learn more not only about drug treatment effectiveness, but also about drug treatment utilization. While studies have begun to examine drug treatment utilization, most of these studies have been based on urban substance abusers. Little is known about the extent to which urban and rural substance abusers may be different in terms of treatment utilization. This study, therefore, examines differences between urban and rural drug use patterns and treatment utilization among chronic drug abusers to determine whether, and in what ways, rurality may affect substance abuse and treatment seeking. The study examines these issues in a group of chronic drug users who were incarcerated at the time of the study. Findings show significant differences in drug use and treatment utilization of urban and rural offenders. Chronic drug abusers from rural and very rural areas have significantly higher rates of lifetime drug use, as well as higher rates of drug use in the 30 days prior to their current incarceration than chronic drug abusers from urban areas. Nonetheless, being from a very rural area decreased the likelihood of having ever been in treatment after controlling for the number of years using and race. While problem recognition appears to explain much of the effect of very rural residence on treatment utilization for alcohol abuse, the effects of being from a very rural area on seeking treatment for drug abuse remain statistically significant even after controlling for several other variables. The findings point to the importance of providing culturally appropriate education to very rural communities on the benefits of substance abuse treatment and of providing substance abuse treatment within the criminal justice system. Warner, B.D., and Leukefeld, C.G. Rural-Urban Differences in Substance Use and Treatment Utilization Among Prisoners. Am J Drug Alcohol Abuse., 27(2), pp. 265-280, May 2001.

Factors Affecting the Initiation of Substance Abuse Treatment in Managed Care

A long-standing concern of clinicians in addiction treatment is that a large number of individuals who are admitted to treatment do not return to actually begin the program. Authors of the study identified characteristics that predict treatment initiation. In-person structured interviews were conducted with consecutive admissions to a large outpatient program (N = 1204), and the health plan's automated registration data were used to determine treatment attendance. Those who returned to begin treatment were compared with those who did not. The study was conducted at the Chemical Dependency program of a large group model health maintenance organization (HMO). Study subjects were individuals age 18 or over admitted to the program. Study variables included DSM-IV alcohol and drug dependence and abuse, Addiction Severity Index problem severity, motivation and treatment entry measures. Findings indicate that those who were drug-dependent were less likely to begin treatment than those dependent only on alcohol. Measures of motivation, such as work-place pressures and the patient's perception of the importance of alcohol treatment, predicted starting treatment for individuals who were alcohol-dependent only or alcohol- and drug-dependent. Among patients who were dependent only on alcohol, women were more likely than men to start treatment, and for those who were drug-dependent, being employed and having higher drug severity scores predicted starting treatment. In summary, screening at intake may identify those at risk of not returning after admission to start treatment. Clinicians may consider making additional efforts during the intake process to engage individuals who are unemployed and have drug (as opposed to alcohol) disorders and less motivation. Weisner, C., Mertens, J., Tam, T., and Moore, C. Factors Affecting the Initiation of Substance Abuse Treatment in Managed Care. Addiction., 96(5), pp. 705-716, May 2001.

Gender Differences in Cocaine Craving Among Non-Treatment-Seeking Individuals with Cocaine Dependence

The purpose of this pilot study was to evaluate potential gender differences in cocaine craving among non-treatment seekers with cocaine dependence. Investigators examined 10 female and 11 male individuals matched by demographic characteristics and severity of drug use; we used a multidimensional questionnaire that assesses various aspects of craving: (a) current intensity, (b) projected intensity, (c) resistance to use cocaine, (d) responsiveness to drug-related conditioned stimuli, and (e) imagined likelihood of use if in a setting with access to drugs. Other instruments utilized were the Hamilton Rating Scale for Depression and Addiction Severity Index. Female subjects had higher total craving scores (p < .05), with post hoc tests showing more present desire to use cocaine and responsivity to drug-conditioned stimuli, along with lower scores on the desire not to use cocaine. In exploratory analyses, we found greater depressive symptomatology (p = .02) and severity of family/social problems (p = .02) in females than their males counterparts. These results suggest that gender may influence different aspects of cocaine craving. As estrogen is purported to modulate craving-related dopaminergic systems, further studies will be needed to confirm these observed gender differences and to investigate their possible mechanisms, particularly estrogen-dopamine interactions and their effect on craving and mood. Elman, I., Karlsgodt, K.H., and Gastfriend, D.R. Gender Differences in Cocaine Craving Among Non-Treatment-Seeking Individuals with Cocaine Dependence. Am J Drug Alcohol Abuse, 27(2), pp. 193-202, May 2001.

Can the Treatment Services Review be Used to Estimate the Costs of Addiction and Ancillary Services?

The economic costs of addiction treatment and ancillary services are of great interest to substance abuse treatment providers, researchers, and policymakers. This paper examines whether a widely used treatment evaluation instrument, the Treatment Services Review (TSR), can be used to estimate the costs of addiction and ancillary services. The fifth edition of the TSR (TSR-5) is carefully reviewed and critiqued for cost estimation purposes. Unit cost estimates and sources are presented for most of the service delivery units on the TSR-5, and important missing service measures are identified. A cost analysis method is proposed that is based on data from the TSR. A variety of unit cost estimates are offered so that researchers and practitioners will understand how this financial information is compiled. However, the investigation determined that the TSR-5 is not currently structured for a comprehensive cost analysis of treatment services. The potential benefits and limitations of the TSR-5 as a cost analysis tool are identified and explained. In addition, recommended changes to the TSR-5 are suggested and described. Although not originally developed for economic evaluation purposes, with some modifications and enhancements, the TSR is an instrument that is capable of facilitating an economic cost analysis of addiction treatment and ancillary services. By combining service utilization information from a revised TSR (i.e., TSR-6) with reliable unit cost estimates for those services, future evaluation studies will be able to provide more standardized estimates of the costs of addiction and ancillary services for different types of treatment clients. When joined with outcome data, the TSR-6, along with the proposed cost module, can also be used to determine cost-effectiveness and benefit-cost ratios for subgroups of patients and treatment components. French, M.T., Roebuck, M.C., McLellan, A.T., and Sindelar, J.L. Can the Treatment Services Review be Used to Estimate the Costs of Addiction and Ancillary Services? J Subst Abuse, 12(4), pp. 341-361, 2000.

The Cost and Cost-Effectiveness of an Enhanced Intervention for People with Substance Abuse Problems at Risk for HIV

This study attempted to estimate the costs, effectiveness, and cost-effectiveness of prevention interventions for out-of-treatment substance abusers at risk for HIV. This is the first cost-effectiveness study of an AIDS intervention that focuses on drug use as an outcome. The researchers examined data from the North Carolina Cooperative Agreement site (NC CoOp). All individuals in the study were given the revised NIDA standard intervention and randomly assigned to either a longer, more personalized enhanced intervention or no additional intervention. The cost of each intervention was estimated and, using simple means analysis and multiple regression models, estimated the incremental effectiveness of the enhanced intervention relative to the standard intervention. Finally, the researchers computed cost-effectiveness ratios for several drug use outcomes and compared them to a "back-of-the-envelope" estimate of the benefit of reducing drug use. The estimated cost of implementing the standard intervention is $187.52, and the additional cost of the enhanced intervention is $124.17. Cost-effectiveness ratios range from $35.68 to $139.52 per reduced day of drug use, which are less than an estimate of the benefit per reduced drug day. The additional cost of implementing the enhanced intervention is relatively small and compares favorably to a rough estimate of the benefits of reduced days of drug use. Thus, the enhanced intervention should be considered an important additional component of an AIDS prevention strategy for out-of-treatment substance abusers. Zarkin, G.A., Lindrooth, R.C., Demiralp, B., and Wechsberg, W. The Cost and Cost-Effectiveness of an Enhanced Intervention for People with Substance Abuse Problems at Risk for HIV. Health Serv Res., 36(2), pp. 335-355, June 2001.

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