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

Research Findings - Services Research

Costs and Benefits of Addiction Treatment

Little information is available on the client and treatment characteristics that contribute to treatment costs and benefits. This study analyzed data from a sample of treatment clients from the Chicago Target Cities Project to develop estimation techniques and to determine predictors of treatment cost, benefit, and net benefit. The Chicago Project was a quasi-experimental evaluation study of 2,862 individuals in various addiction treatment facilities. Economic analyses were conducted in two stages. First, the authors estimated cost and benefit during the 6-month follow-up, using previously published methods, and then used these measures to compute average cost, benefit, net benefit, and benefit-cost ratio. Second, the authors statistically examined the distributions of cost, benefit, and net benefit and selected empirical models for handling non-normal data. These models were then estimated to identify the predictors of cost, benefit, and net benefit. Results indicate that the average (per client) cost of all treatment services from baseline to follow-up was $1,943. The average treatment benefit was $8,268, leading to an average net benefit of $6,325 and a benefit-cost ratio of 4.26. Findings from a robust regression suggest that (1) age, race, age at first drug use, treatment modality, and some treatment characteristics were significantly related to treatment cost, and (2) education, age at first drug use, some scores on the Addiction Severity Index, some types of treatment, and resistance to continuing care were related to treatment benefit and net benefit. In conclusion, for the average individual, the net benefit (benefit-cost ratio) of treatment was significantly greater than zero (one). Furthermore, cost and benefit were significantly related to certain client and program characteristics. Future studies may find these empirical models useful when investigating the predictors of the costs and benefits of addiction treatment. Salome, H.J., French, M.T., Scott, C., Foss, M. and Dennis, M. Investigating Variation in the Cost and Benefits of Addiction Treatment: Econometric Analysis of the Chicago Target Cities Project. Evaluation and Program Planning, 26, pp. 325-118, 2003.

Utilization and Cost Impact of Integrating Substance Abuse Treatment and Primary Care

This study examined the impact of integrating medical and substance abuse treatment on health care utilization and cost. Patients participated in a randomized clinical trial in which they were assigned to one of two treatment modalities: (1) an Integrated Care model where primary health care was provided with substance abuse treatment within the unit, and (2) an Independent Care model where medical care was provided in the HMO's primary care clinics independently from substance abuse treatment. There were no statistically significant differences between the two treatment groups over time for the full, randomized cohort. However, among the subset of patients with substance abuse related medical conditions, Integrated Care patients had statistically significant decreases in hospitalization rates, inpatient days and Emergency Room use. Total medical costs per member-month declined significantly from $431.12 to $200.03. Among Independent Care patients with substance abuse related medical conditions, there was a downward trend in inpatient days and Emergency Room costs, but no statistically significant decrease in total medical cost. Findings for the full sample suggest that integrating substance abuse treatment with primary care may not be necessary or appropriate for all patients. However, it may be beneficial to refer patients with substance abuse related medical conditions to a provider also trained in addiction medicine given that there appear to be large cost impacts of providing integrated care for such patients. Parthasarathy, S., Mertens, J., Moore, C., and Weisner, C. Utilization and Cost Impact of Integrating Substance Abuse Treatment and Primary Care. Medical Care, 41(3), pp. 357-367, 2003.

The Value of Intensive Services for High-Risk Offenders

Tests of the importance of service matching have had varying results, yet little attention has been given to testing the hypotheses about outcomes for clients based on differing risks to recidivate. The authors tested the "risk principle" (i.e., treatment services should target the specific factors that increase risk of recidivism for each client) and "responsivity principle" (i.e., treatment services should be consistent with the abilities and learning style of each individual offender) using a sample of clients from one site of a four-site randomized block experimental design study examining the effectiveness of traditional criminal justice supervision vs. a systemic case management model in which the management and organization of treatment and criminal justice supervision services are part of an integrated care plan. Findings from a preliminary examination of official and self-report data from this site suggest the importance of the risk and responsivity concepts in providing substance abuse treatment, particularly for high-risk clients. Because of the relatively low statistical power of the tests used in this exploratory analysis, many observed relationships were not statistically significant. Nonetheless, the delivery of criminal justice supervision with a continuing care intervention improves treatment participation and retention. Those in the high-risk treatment group experienced fewer overall arrests within one-year of randomization into the study. Thanner, M.H. and Taxman, F.S. Responsivity: The Value of Providing Intensive Services to High-Risk Offenders. Journal of Substance Abuse Treatment, 24(2), pp. 137-147, 2003.

Employment Intervention for Drug Abusing Offenders

An examination of 500 participants at drug court entry who consented to participate in the Kentucky project revealed that less than half worked full-time before entering Drug Court; participants averaged 3.7 jobs in the five years before entering drug court; and the longest full-time job held averaged 4.3 years with 80.4 days of employment at a legal job in the six months before entering Drug Court. Most participants reported their last or usual occupation as a service worker or as a laborer. Participants reported transportation, job placement and job training as the types of employment help they most needed, which reinforced the finding that almost half (41%) reported employment problems in the six months before entering Drug Court. These findings highlight the importance of developing employment interventions that can assist drug abusers involved in the criminal justice system. Future project studies will examine differences in participants who are randomized into the enhanced employment intervention when compared with those who are randomized into Drug Court as usual. Leukefeld, C., Smiley McDonald, H., Staton, M., Mateyoke-Scrivner, A., Hopper, H., Webster, J.M., Logan, T.K., Hiller, M. and Garrity, T. An Employment Intervention for Drug Abusing Offenders. Federal Probation, April 2003.

Psychological Distress, Employment, and Drug Use among Female Welfare Recipients

In this study, the authors examined the relationship over time among work experience, psychological distress, and illegal substance use in a sample of 534 women receiving Temporary Assistance for Needy Families. Study participants were interviewed at intake and at 4-month intervals for a period of 2 years. Each interview recorded the number of hours worked in the previous 4 months and the use of powder cocaine, crack cocaine, heroin, or methamphetamines during the same period. To measure the extent of psychological distress, participants completed the personal adjustment problems subscales of the Multidimensional Addictions and Personality Profile at intake and at 1-year intervals. A path model was analyzed to assess the temporal effects of employment, drug use, and emotional and psychological distress. Results suggest a cycle in which employment at one time period can reduce the likelihood of drug use in the following period, which, in turn, can lead to improvement in levels of distress. This improvement can lead to an increase in the number of hours worked and further improvement in distress levels. Atkinson, J.S., Montoya, I.D., Whitsett, D.D., Bell, D.C. and Nagy, C.W. The Relationship Among Psychological Distress, Employment, and Drug Use Over Time in a Sample of Female Welfare Recipients. Journal Of Community Psychology, 31(3), pp. 223-234, 2003.

Little Change During 1990s in Availability of Comprehensive Services in Outpatient Drug Abuse Treatment

Research suggests that comprehensive medical and psychosocial services that are essential to high quality addiction treatment, declined in the 1980s. To determine whether this downward trend in the availability of comprehensive services continued in the 1990s, the researchers analyzed data from a national panel study of outpatient substance abuse treatment units in 1990 (n=481), 1995 (n=618), and 2000 (n=745). Response rates exceeded 85%. Regarding the availability of comprehensive services, including physical examinations, routine medical care, mental health services, financial counseling, and employment counseling, administrators reported whether any substance abuse treatment client received the service in the past year. The reported availability of comprehensive services changed little during the 1990s, with the exception of physical examinations (reported availability increased from 1990 to 1995) and financial counseling (reported availability decreased from 1990 to 1995). These findings highlight the continuing need to monitor access to comprehensive services and other markers of program quality in addiction treatment over time. Friedmann, P.D., Lemon, S.C., Durkin, E.M., and D'Aunno, T.A. Trends in Comprehensive Service Availability in Outpatient Drug Abuse Treatment. Journal of Substance Abuse Treatment, 24(1), pp. 81-88, 2003.

Accessibility of Addiction Treatment: Results from a National Survey of Outpatient Substance Abuse Treatment Organizations

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

Prevalence of Hepatitis C in a Drug Using and Non-using Welfare Population

Drug use is a primary route for the transmission of the hepatitis C virus (HCV), and a substantial proportion of welfare recipients have been shown to be substance abusers. Despite the fact that HCV symptoms may inhibit welfare recipients' ability to seek and maintain employment, federal legislation has imposed limits on the number of months individuals may receive welfare benefits and has mandated most recipients to participate in a 'work activity' in exchange for benefits. In this study, researchers sought to assess the prevalence of HCV in recipients of Temporary Assistance to Needy Families (TANF), and the effects of HCV antibody seropositivity on employability. Participants were 380 individuals participating in a longitudinal study of employment patterns among TANF recipients in Houston, TX. Participants were interviewed about welfare receipt, employment, and drug use at intake into the study and at 4-month intervals for one year. They also received a one-time blood draw to test for the presence of HCV antibodies by enzyme-linked immunoassay. Overall, 12% of participants tested positive for the presence of HCV antibodies, with a significantly greater proportion of chronic drug users (31%) than non-drug users (4%) testing positive. Those who tested positive for hepatitis C had significantly lower rates of employment. Future research should focus more closely on the impact of HCV infection in obtaining employment for welfare recipients. Montoya, I.D., Atkinson, J.S., Lichtiger, B., and Whitsett, D.D. Prevalence of Hepatitis C in a Drug Using and Non-Using Welfare Population. Health Policy, 64(2), pp. 221-228, 2003.

Provision of Hepatitis C Education in Drug Treatment Programs

Using a nationwide sample of 434 drug treatment programs, the researchers report the results of a logistic regression analysis that differentiates programs providing HCV education to all of their patients versus programs that do not. Fifty-four percent of the programs provide HCV education to all patients. Programs are about four and a half times as likely to provide HCV education to all patients if they dispense methadone; almost four times as likely to provide this service if they educate most of their staff about HCV; twice as likely if they are residential; and almost twice as likely if they conduct HIV testing on-site. Thus, in spite of the high prevalence of hepatitis C among drug users, only about half of the drug treatment programs in the United States educate all of their patients about hepatitis C. Drug-free outpatient programs, especially those without a medical orientation, need to take proactive steps to provide critically needed HCV education to all of their patients. Astone, J., Strauss, S.M., Vassilev, Z.P., and Des Jarlais, D.C. Provision of Hepatitis C Education in a Nationwide Sample of Drug Treatment Programs. Journal of Drug Education, 33(1), pp. 107-117, 2003.

Screening for Sexually Transmitted Infections in Substance Abuse Treatment Programs

The authors evaluated the prevalence of two sexually transmitted infections (STIs)--chlamydia and gonorrhea--in clients at a methadone maintenance program and a residential detoxification program. Data collection included urine specimens for chlamydia and gonorrhea ligase chain reaction testing and assessment of sexual, substance abuse, and STI histories. Of 700 subject assessments, 490 occurred among detoxification clients and 210 in methadone maintenance clients. Chlamydia trachomatis was detected in 5/700 (0.9, 5% CI = 0.1-1.8%) and Neisseria gonorrhoeae in none. All chlamydia-infected subjects were recruited from the detoxification program. Subjects reported high risk sexual behavior: 17% reported commercial sex exchange, and 22% reported inconsistent condom use with multiple sex partners during the prior 2 months. Study results suggest that routine screening among younger substance abusers and in communities with high prevalence should be considered. Liebschutz, J.M., Finley, E.P., Braslins, P.G., Christiansen, D., Horton, N.J., and Samet, J.H. Screening for Sexually Transmitted Infections in Substance Abuse Treatment Programs. Drug and Alcohol Dependence, 70(1), pp. 93-99, 2003.

On-Site Primary Medical Care at Addiction Treatment Programs Can Improve Outcomes

This secondary data analysis examined 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. The original study involved a prospective cohort of patients admitted to a purposive national sample of substance abuse treatment programs. Administrators at 52 treatment programs and 2,878 patients completed treatment intake, discharge, and follow-up interviews. 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 addiction severity or medical severity. It appears then that on-site primary medical care can improve addiction-related outcomes but not necessarily the health --related outcomes of substance treatment patients. Friedmann P.D., Zhang Z., Hendrickson J., Stein, M.D., and Gerstein, D.R. Effect of Primary Medical Care on Addiction and Medical Severity in Substance Abuse Treatment Programs. Journal of General Internal Medicine, 18(1), pp. 1-8, 2003.

Multidisciplinary Clinic Links Substance Abusers with Medical Care

In response to an increasing need for pragmatic approaches to the integration of medical care and substance abuse treatment, the authors assessed the effectiveness of a novel multidisciplinary clinic for linking patients in a residential detoxification program to primary medical care. Patients undergoing in-patient detoxification from alcohol, heroin, or cocaine, who had no primary care physician, entered into a randomized controlled trial. The intervention consisted of a clinical evaluation within the detoxification unit of the Health Evaluation and Linkage to Primary Care (HELP) clinic by a nurse, social worker, and physician, plus facilitated referral to an off-site primary care clinic. The primary outcome was attendance at a primary care appointment within 12 months. Secondary outcomes assessed over 24 months were addiction severity; health-related quality of life, utilization of medical and addiction services, and HIV risk behaviors. Of the 470 participants enrolled, 235 were randomized to the HELP clinic intervention. Linkage to primary medical care occurred in 69% of the intervention group compared to 53% in the control group, a statistically significant difference. The HELP clinic, a multidisciplinary clinic located in a detoxification program, effectively linked alcohol- and drug-dependent individuals to primary medical care. This intervention utilized a "reachable moment," the period of addiction care, as a window of opportunity for linking substance abusers to medical care. The HELP clinic did not significantly affect secondary outcomes. Samet, J.H., Larson, M.J., Horton, N.J., Doyle, K., Winter, M., and Saitz, R. Linking Alcohol- and Drug-Dependent Adults to Primary Medical Care: A Randomized Controlled Trial of a Multidisciplinary Health Intervention in a Detoxification Unit. Addiction, 98(4), pp. 509-516, 2003.

Drug-Use Initiation and Conduct Disorder among Adolescents in Drug Treatment

This study investigated effects of drug-use initiation and conduct disorder (CD) among 1,031 adolescents who participated in the Drug Abuse Treatment Outcomes Studies for Adolescents (DATOS-A) sponsored by the National Institute on Drug Abuse (NIDA). The mean age of first drug use was 12.7 (S.D.=2.2), 57% met DSM-III-R criteria for CD, and earlier initiators were more likely to have CD. About 78% of the adolescents with CD reported that their first CD symptom occurred prior to drug-use initiation. The proportions of adolescents who had prior treatment were similar (about 28%) across all groups, but earlier initiators reported a greater number of treatment episodes and younger ages at their first treatment. Conduct disordered adolescents revealed greater problems prior to DATOS-A treatment, but they appeared to be more motivated and ready for treatment. Although adolescents with CD still showed worse outcomes after treatment, the impact of CD appeared to lessen when pretreatment differences were controlled. To a lesser extent, adolescents who began using drugs at earlier ages had greater alcohol and drug use and other problems at intake, but their treatment outcomes appeared to be similar to later initiators. There were few significant interaction effects of initiation and CD. Findings from this study highlight the importance of better understanding the progression of drug use, treatment utilization, and psychiatric comorbidity among adolescents with substance abuse problems. Hser, Y.I., Grella, C.E., Collins, C., and Teruya, C. Drug-Use Initiation and Conduct Disorder Among Adolescents in Drug Treatment. Journal of Adolescence, 26(3), pp. 331-345, 2003.

Gender Identity, Ethnicity, Acculturation, and Drug Use Among Adolescents in the Southwest

This article presents the findings of a survey completed by 1,351 predominantly Mexican-American middle school students residing in a large urban center in the U.S. Southwest. The study explored associations between drug use attitudes and behaviors and biological sex, gender identity, ethnicity and acculturation status. Based on the concepts of machismo and marianismo that have been used to describe Mexican populations, four dimensions of gender identity were measured: aggressive masculinity, assertive masculinity, affective femininity and submissive femininity. In explaining a variety of indicators of drug use behaviors and anti-drug norms, biological sex alone had limited explanatory power, while gender identity--often regardless of biological sex--was a better predictor. Aggressive masculinity was generally associated with higher risk of drug use, while the other three gender identity measures had selected protective effects. However, the impact of gender identity was strongly mediated by acculturation. Less acculturated Mexican-American students reported lower aggressive masculinity scores than non-Latinos. Less acculturated Mexican-American girls reported both the lowest aggressive masculinity scores and the highest submissive femininity scores. More acculturated Mexican-American students, along with the less acculturated Mexican-American boys, did not appear to be following a polarized approach to gender identity (machismo and marianismo), as was expected. The findings suggest that some aspects of culturally prescribed gender roles can have a protective effect against drug use behaviors and attitudes, possibly for both girls and boys. Kulis, S. Marsiglia, F.F., and Hurdle, D. Gender Identity, Ethnicity, Acculturation and Drug Use: Exploring Differences among Adolescents in the Southwest. Journal of Community Psychology, 31(2), pp. 167-188, 2003.

Effects of Ethnic Pride and Biculturalism on Drug Use Norms of Urban American Indian Adolescents

This study examined how strength of ethnic identity, multiethnic identity, and other indicators of biculturalism relate to the drug use norms of urban American Indian middle school students. Following the focus theory of norms, different categories of norms that may impact drug use are distinguished. Regression analysis of self-reports by 434 American Indian 7th graders attending middle schools in a large southwestern U.S. city show that those with a more intense sense of ethnic pride adhere more strongly to certain anti-drug norms, while those with negative feelings toward their ethnic or racial heritage have more permissive norms toward drug use. Compared to multi-ethnic American Indian students, those claiming only an American Indian identity report less certainty that they would refuse potential drug offers. Those who speak a language other than English with family and friends at least occasionally report that fewer of their friends are drug users. While American Indian students with better grades in school hold consistently stronger anti-drug norms, there are few differences by gender, socioeconomic status, or age. Kulis, S., Napoli, M. and Marsiglia, F.F. Ethnic Pride, Biculturalism, and Drug Use Norms of Urban American Indian Adolescents in the Southwest. Social Work Research, 26(2), pp. 101-112, 2002.

Self-Reported Health Status Among Treated Methamphetamine Users

Little research has examined how drug abuse is related to general health status over the long term among young and middle-aged adults. The authors investigated how self-reported health status is related to prolonged methamphetamine use in a diverse sample of 350 methamphetamine users, ages 18 to 52, who have been treated for drug abuse. Using retrospective data, the authors investigated how prolonged methamphetamine use in younger and older age groups is related to two self-reported measures of current health status: overall health, and presence of a health condition that began after starting illegal drug use. The authors controlled for the effects of drug use history, social and demographic factors, and other early experiences (e.g., early sexual abuse) that might pose obstacles to good health later in life. They found that having a current health condition is predicted by greater age and by more prolonged methamphetamine use, especially among younger adults. Early sexual abuse predicts both measures of poor health. Current health status is predicted by several measures of drug use history and early experiences, but by fewer social and demographic factors. The results suggest that reduction of methamphetamine use among younger people is important in promoting their later health and that methamphetamine treatment services could be improved by a greater understanding of how early experiences influence later health. Greenwell, L., and Brecht, M.L. Self-Reported Health Status Among Treated Methamphetamine Users. American Journal Of Drug And Alcohol Abuse, 29(1), pp. 75-104, 2003.

The Role of Chronic Drug Use in Serious Injuries and Trauma

The authors estimated the differential risks of serious injury or trauma for a community-based sample of 926 chronic drug users (CDU) and a matched comparison group of 553 nondrug users (NDUs). The authors also estimated whether CDUs and NDUs differed in their utilization of health care services for serious injury or trauma. Data were collected in 1996 and 1997 through community outreach activities in Miami-Dade County, Florida. Analyses estimated the effects of drug use on (1) any lifetime serious injury or trauma, (2) any serious injury or trauma during the past 12 months, and (3) utilization of health care services for serious injury or trauma. All analyses were gender specific and the models were estimated with a measure of problematic alcohol use in addition to CDU. Female CDUs experienced significantly more serious injury, trauma, or both (both lifetime and past year) than nonusers, but drug use status did not predict serious injury or trauma (lifetime and past year) for males. Regardless of gender, conditional on experiencing any serious injury or trauma during the past year, CDUs and NDUs did not differ in their utilization of health care services. The elevated risk for serious injury or trauma for female CDUs renders these individuals vulnerable to severe medical problems. Specific training in substance abuse issues may be necessary if health care providers are to identify, engage, knowledgeably serve, and refer CDUs for appropriate services. Zavala, S.K., and French, M.T. Dangerous to Your Health - The Role of Chronic Drug Use in Serious Injuries and Trauma. Medical Care, 41(2), pp. 309-322, 2003.

Stabilization Programs Reduce Homeless Persons' Substance Use After Detoxification

This study examined whether homelessness predicted earlier resumption of substance use after detoxification, and sought evidence concerning the impact of post-detoxification stabilization programs among homeless and non-homeless individuals. Kaplan-Meier plots and proportional hazards models were used to determine association between homelessness, stabilization program use, and recurrent substance use in a prospective cohort of 470 persons entering inpatient detoxification. Among the 254 persons available at 6 months, 76% reported recurrent substance use. Homeless persons not using stabilization programs experienced the highest hazard of return to substance use after detoxification, Hazard Ratio (HR) 1.26, 95% CI (0.88,1.80). Homeless persons using these programs had the lowest rate of return to substance use HR 0.61, 95% CI (0.40,0.94). A similar impact of stabilization programs was not seen among non-homeless participants. Post-detoxification stabilization programs may slow the "revolving door" phenomenon of relapse after detoxification among homeless persons. Kertesz, S.G., Horton, N. J., Friedmann, P.D., Saitz, R., and Samet, J.H. Slowing the Revolving Door: Stabilization Programs Reduce Homeless Persons' Substance Use After Detoxification. Journal of Substance Abuse Treatment, 24(3), pp. 197-207, 2003.

Community Referral Sources and Entry of Treatment-Naive Clients into Outpatient Addiction Treatment

This study assessed the association of sources of client referral with enrollment of treatment-naive clients. Data from the 1995 (n=618) and 2000 (n=745) waves of the National Drug Abuse Treatment Survey, a panel study of outpatient substance abuse treatment units (OSAT), were analyzed. Enrollment of treatment-naive clients was defined as the percentage of OSAT clients who entered treatment in the past 30 days with no prior treatment for substance abuse. A generalized estimating equation model simultaneously assessed the association of each referral source with the dependent variable, while controlling for potential confounding and accounting for correlation of unit-level responses over time. In the multivariable model, OSAT units with a greater proportion of treatment-naive clients had received more referrals from employee assistance programs and the criminal justice system, and fewer referrals from mental health agencies. No effect of referral from medical or social service agencies was observed. These results highlight the role of coercive community institutions in treatment outreach efforts to persons in earlier phases of the "addiction career." Friedmann, P.D., Lemon, S.C., Stein, M.D., and D'Aunno, T.A. Community Referral Sources and Entry of Treatment-Naive Clients into Outpatient Addiction Treatment. The American Journal of Drug and Alcohol Abuse, 29(1), pp.105--115, 2003.

General Psychiatrists Consult Addiction Psychiatrists for Diagnostic Information and Aftercare Recommendations

Researchers reviewed the records of 381 consecutive substance abuse consultations completed by the Substance Abuse Consultation Service (SACS) of McLean Hospital to ascertain the most frequent reasons why general psychiatrists consulted the SACS, and the clinical characteristics of patients for whom consultation was sought. The most frequent reasons for consultation were to make aftercare recommendations (66%) or to make (20%) or clarify (6%) a diagnosis of substance use disorder. Mood disorders were the most prevalent co-occurring psychiatric disorder, and alcohol use disorders were the most prevalent substance use disorder. Findings indicate the potential utility of a substance abuse consultation service in a psychiatric hospital. Greenfield, S.F., Hennessy, G., Sugarman, D.E. and Weiss, R.D. What General Psychiatrists Ask Addiction Psychiatrists: A Review of 381 Substance Abuse Consultations in a Psychiatric Hospital. American Journal on Addictions, 12(1), pp. 18-28, 2003.

Baseline Health Status and Psychiatric Symptoms Predict Subsequent Health Status of Patients in Substance Abuse Treatment

This study examined the predictors of self-reported health status at follow-up in the Drug Abuse Treatment Outcomes Study (DATOS), a longitudinal study of drug abuse treatment programs and patients in 1991-1993. Baseline and follow-up interviews of 2,966 patients in 75 programs were performed. Follow-up assessment was targeted to occur 12 months after treatment terminated; longterm methadone patients in treatment for the entire 12-month period were interviewed 24 months after intake. A composite measure, developed through principal component analysis, assessed health status. A multivariate hierarchical linear regression model adjusted for independent identified baseline predictors of health status at follow-up. Poor physical health status (including the composite measure, comorbid conditions, and pain) and greater severity of psychiatric symptoms at baseline were the strongest predictors of poor health status at follow-up. Other predictors of worse health status included older age, public insurance coverage, and employment. The authors conclude that baseline health status and psychiatric symptoms predict the subsequent health status of patients in substance abuse treatment as in other clinical populations. Future research should examine whether early identification and treatment of physical and mental health problems among patients in addiction treatment programs might remediate their adverse effects on longterm health status outcomes. Friedmann, P.D., Lemon, S.C., Anderson, B.J., and Stein, M. D. Predictors of Follow-up Health Status in the Drug Abuse Treatment Outcome Study (DATOS). Drug and Alcohol Dependence, 69(3), pp. 243-251, 2003.

Change in Smoking Status Following Substance Abuse Treatment

The impact of change in smoking status on 12-month substance abuse treatment outcomes was examined among an HMO population seeking substance abuse treatment. Of the 749 participants who entered the study at baseline, 87% (649) were retained at the 12-month follow-up. At treatment entry, 395 participants were smokers, and 254 were nonsmokers. At follow-up, 13% of the 395 baseline smokers reported quitting smoking; 12% of the 254 baseline nonsmokers reported starting/relapsing to smoking. Those who quit smoking were less likely to be diagnosed as alcohol dependent compared to those who remained smokers. Those who started/resumed smoking were more likely to be diagnosed as both alcohol and drug dependent at treatment entry compared to all other groups. Total days abstinent from alcohol and illicit drugs was greatest for individuals who quit smoking (adjusted M = 310.6) or who were nonsmokers (adjusted M = 294.7) and lowest for those who started/resumed smoking (adjusted M = 246.6) or remained smokers (adjusted M = 258.2), even after controlling for demographic (i.e. age, income), psychosocial (ASI psychiatric severity), and other treatment characteristics (length of treatment stay, prescribed bupropion) that were associated with days abstinent at 12 months. Self-initiated smoking cessation does not appear to be detrimental to substance abuse treatment outcomes, and may be beneficial. Starting/resuming smoking after entering substance abuse treatment may be a clinical marker for individuals at greater risk of relapse. Future studies may want to measure the smoking status of all participants at all time points in order to include this higher-risk group of substance using smokers. Kohn, C.S., Tsoh, J.Y., and Weisner, C.M. Changes in Smoking Status among Substance Abusers: Baseline Characteristics and Abstinence from Alcohol and Drugs at 12-month Follow-Up. Drug And Alcohol Dependence, 69(1), pp. 61-71, 2003.

A New Look at Treatment Duration and Outcomes

Researchers used longitudinal data from the National Treatment Improvement Evaluation Study to examine whether there is a minimum retention threshold, continuous, or non-linear relationship between the duration of addiction treatment and improvement in drug use. Researchers conducted baseline and one-year follow-up interviews with 4,005 clients in 62 treatment units representing four different treatment modalities: methadone maintenance, outpatient non-methadone, short-term residential, and longterm residential. Controlling for multiple factors, treatment duration had a positive linear relationship with improved primary drug use among methadone clients and an inverted-U-shaped relationship with improved overall and primary drug use for outpatient and longterm residential clients. Improvement with longer duration was greatest for long-term residential clients. This finding contradicts previous arguments for a sharp retention threshold for onset of treatment effects, showing instead smooth curves relating treatment duration to improvements in methadone maintenance, outpatient non-methadone, and long-term residential modalities. The relationships were linear for treatment durations typically observed in single treatment episodes. However, unusually long retention in outpatient non-methadone and longterm residential units appeared steadily less predictive of improvement. Zhang, Z., Friedmann, P.D., and Gerstein, D. R. Does Retention Matter? Treatment Duration and Improvement in Drug Use. Addiction, 98(5), pp. 673-684, 2003.


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