Economic evaluation of a prerelease substance abuse treatment program for repeat criminal offenders

Substance use disorders are common conditions among repeat criminal offenders. Without addressing these underlying substance use behaviors, parolees are significantly more likely to recidivate within 1 year of release. New Jersey is one of the first states to actively pursue substance abuse treatment options for inmates who are in the final stages of their sentences. Given the fiscal realities of taxpayer-supported programs, such initiatives must clearly demonstrate economic benefits for sustainability and growth. This article conducted one of the few comprehensive economic evaluations of prerelease substance abuse treatment to determine whether Community Education Centers' programs in New Jersey generated desirable outcomes, significant economic benefits, and positive net benefits. Relative to a matched comparison group of offenders who did not receive treatment, the intervention group returned an average economic benefit of $4,307 to $6,209 over the 1-year postrelease period. These economic benefits are underscored by the fact that the treatment program is housed in a separate facility, with a lower average per diem from that of the general inmate population. These results provide quantitative economic evidence that prerelease substance abuse treatment programs have the potential to reduce recidivism and save taxpayer dollars without adding to existing prison resources.     

Factors associated with lifetime history of drug treatment among substance dependent women

There is extensive research on factors related to substance use treatment retention and completion but less is known about factors related to treatment initiation, particularly for women. This paper examines factors associated with a lifetime history of substance abuse treatment among women with drug abuse or dependence. Baseline interview data, using the Addiction Severity Index (ASI) that obtained during a randomized clinical trial was analyzed comparing women with no history of drug treatment with women with a history at least one drug treatment episode. Of the 153 women, 47.4% had a lifetime history of drug treatment compared to 52.6% who have never enrolled in drug treatment. After multiple logistic regression, craving drugs at least 15 days in the past month, using cocaine at least 15 days in the past month, ASI alcohol composite score, perceived seriousness of legal problems, history of at least 3 pregnancies, and history of physical abuse by a known person, were independently associated with drug treatment.     

Using enhanced and integrated services to improve response to standard methadone treatment: Changing the clinical infrastructure of treatment networks

Outcomes are presented from opioid-dependent outpatients (N = 81) participating in a new community-based initiative designed to improve access to enhanced substance abuse and psychiatric services in a publicly supported methadone maintenance treatment network in Baltimore, MD. The initiative, entitled Community Access to Specialized Treatment (CAST), is located at the Addiction Treatment Services, a program within this network. Network programs referred patients engaged in unremitting drug use who are at risk for discharge to CAST, where they received methadone substitution, individual and group counseling within an adaptive platform, behavioral contingencies to reinforce adherence, and on-site psychiatric evaluation and care. Patients returned to their referring program after producing at least two consecutive weeks of drug-negative urine samples and full counseling adherence. CAST was well utilized by the community. Patients had high rates of adherence to scheduled individual and group counseling services (93% and 73%, respectively); 43% of referrals successfully completed the program in an average of 101 days. This community-wide service delivery approach is a novel alternative to integrating intensive substance abuse and psychiatric care at each program within a treatment network.     

Two approaches to tailoring treatment for cultural minority adolescents

At this time, compared with mainstream (Caucasian) youth, cultural minority adolescents experience more severe substance-related consequences and are less likely to receive treatment. Although several empirically supported interventions (ESIs), such as motivational interviewing (MI), have been evaluated with mainstream adolescents, fewer published studies have investigated the fit and efficacy of these interventions with cultural minority adolescents. In addition, many empirical evaluations of ESIs have not explicitly attended to issues of culture, race, and socioeconomic background in their analyses. As a result, there is some question about the external validity of ESIs, particularly in disadvantaged cultural minority populations. This review seeks to take a step toward filling this gap, by addressing how to improve the fit and efficacy of ESIs like MI with cultural minority youth. Specifically, this review presents the existing literature on MI with cultural minority groups (adult and adolescent), proposes two approaches for evaluating and adapting this (or other) behavioral interventions, and elucidates the rationale, strengths, and potential liabilities of each tailoring approach.     

Informed consent to undergo treatment for substance abuse: a recommended approach

With more than 3 million persons receiving substance abuse treatment per year in the United States and with increasing interest in treatment outcomes, there is a need for closer attention to all aspects of the treatment process. However, minimal attention has been given to informed consent as a way of enlisting client engagement and active participation in treatment. Although there is some literature on informed consent in substance abuse research, the literature on informed consent to undergo substance abuse treatment is very limited. Incorporating informed consent into substance abuse treatment is recommended as part of motivational interviewing. Standard treatment consent issues include (1) the clinical characteristics of the problem, including diagnosis; (2) treatment recommendations; (3) the risks and benefits of treatment; (4) the financial costs of the intervention; (5) alternative services or interventions should a client refuse the recommended form of care; and (6) freedom to choose or refuse treatment. This article provides a background for informed consent procedures to facilitate client engagement in substance abuse treatment and suggests needs for future research on informed consent to undergo substance abuse treatment.     

Adolescent tobacco use and substance abuse treatment outcomes

This study investigated the relationship between cigarette-smoking status and 12-month alcohol and marijuana treatment outcomes in a sample of 1,779 adolescents from the Drug Abuse Treatment Outcomes Study for Adolescents. Participants were classified into four groups based on change in cigarette-smoking status from intake to the 12-month follow-up: persistent smokers, nonsmokers, quitters, and smoking initiators. Logistic regression was used to predict likelihood of relapse to alcohol, marijuana, and other drugs after controlling for intake levels and demographic/treatment characteristics. Results found persistent smokers and smoking initiators to have significantly greater odds of alcohol and marijuana relapse compared with quitters. Furthermore, persistent smokers and smoking initiators were also found to have distinctively shorter periods to marijuana relapse at follow-up. Implications for the implementation of tobacco cessation treatment in the context of substance abuse treatment for adolescents are discussed.     

Consumer perceptions of trauma assessment and intervention in substance abuse treatment

Substance abuse treatment programs are increasing their use of integrated interventions for trauma and substance abuse. While positive behavioral outcomes have been associated with this model, the purpose of this study was to determine consumers' satisfaction with it. Participants were 51 men and 102 women who received trauma assessments and interventions through a drug treatment court. Satisfaction with treatment was measured through the Consumer Perception of Care (CPC). Participants were generally satisfied with the trauma assessments and interventions they received. Number of traumatic experiences, measured by the Adverse Childhood Experiences (ACE) scale, and level of distress, as assessed on the Trauma Symptom Inventory (TSI), were significantly associated with assessment and treatment satisfaction. Gender differences were noted, with men reporting fewer traumatic experiences and trauma-symptoms and less satisfaction with trauma assessment. Implications for the integration of trauma and substance abuse interventions in drug treatment courts and other programs are discussed.     

The impact of impulsivity on cocaine use and retention in treatment

To determine whether impulsivity was related to severity of drug use and treatment outcome, 50 cocaine dependent subjects underwent baseline measures of severity of current cocaine use and the Barratt Impulsiveness Scale (BIS-11). The hypothesis of the study was that there would be a significant correlation between impulsivity and cocaine use severity. As predicted, there was a significant correlation between BIS-11 total scores and self-reported average daily cocaine use as well as cocaine withdrawal symptoms. A subset of 35 patients underwent a 12-week double-blind placebo controlled trial of buspirone and group therapy. Subjects with high baseline impulsivity remained in the study a significantly shorter period than did subjects with lower baseline impulsivity. This study shows that impulsivity is a significant predictor of cocaine use and treatment retention, and suggests the need for targeting impulsivity in cocaine dependence treatment.     

Substance use and treatment seeking in young offenders on community orders

Both international and Australian studies reveal very low rates of treatment utilization for substance abuse among young offenders despite very high problematic rates of substance abuse among this group. The current study reports on substance use patterns of a representative sample of 712 young offenders serving community orders with the New South Wales Department of Juvenile Justice (Australia) and their history of and attitudes toward treatment. Most (87%) young offenders had used marijuana, and 47% had used amphetamines in the last 12 months. One third of the sample reported problematic use of alcohol (being drunk at least weekly, on average). Forty-three percent reported that they engaged in crime to maintain their substance use. On the substance abuse scale of the Adolescent Psychopathology Scale—Short Form, 36.4% of the sample fell into the moderate to severe problem range. Despite such problems, treatment motivation was poor: 10% reported willingness to access treatment for their drug problems. Eighteen percent reported accessing some form of treatment in the past; the most common form of help seeking was approaching their family (12%). Self-reported access to other drug treatments was even lower, with the more intensive treatments revealing low rates of treatment completion. Despite almost 40% of the sample revealing significant substance abuse problems, referral for treatment was also low, with only 18% of the sample being offered an appointment with juvenile justice drug and alcohol workers. This study reveals the gap between awareness of problematic drug use and treatment-seeking behavior, and has implications for improving outreach to young offenders with substance abuse problems.     

Organizational determinants of outpatient substance abuse treatment duration in women

Longer treatment duration has consistently been related to improved substance use outcomes. This study examined how tailored women's programming and organizational characteristics were related to duration in outpatient substance abuse treatment in women. Data were from two waves of a national outpatient substance abuse treatment unit survey (n = 571 in 1999/2000, n = 566 in 2005). Analyses were conducted separately for methadone and nonmethadone programs. Negative binomial regressions tested associations between organizational determinants, tailored programming, and women's treatment duration. Of the tailored programming services, childcare was significantly related to longer duration in the nonmethadone programs, but few other organizational factors were. Tailored programming was not associated to treatment duration in methadone programs, but ownership, affiliation, and accreditation were related to longer duration. Study findings suggest evidence for how external relationships related to resources, treatment constraints, and legitimacy may influence women's treatment duration. Methadone programs may be more vulnerable to external influences.     

Prevalence and characteristics of substance abuse treatment utilization by U.S. adolescents: national data from 1987 to 2008

Objective

Although many adolescents use and abuse illicit drugs, few of those who could benefit from substance abuse treatment ever receive these services. The present study examines the prevalence of utilization of substance abuse treatment in national samples of adolescents over the past 22 years and identifies characteristics associated with receipt of these services.

Method

Monitoring the Future data on lifetime utilization of substance abuse treatment was available for 12th grade students who reported any lifetime illicit drug use from 1987 to 2008 (N = 25,537). After describing the prevalence of treatment utilization over this time period, logistic regression was used to examine potential predictors of treatment utilization.

Results

The overall prevalence of treatment utilization has remained relatively unchanged over the past 22 years. In multivariable models, adolescents reporting a greater frequency of lifetime use of marijuana or cocaine were more likely to receive substance abuse treatment. Additionally, substance abuse treatment utilization was more likely in those who received other mental health services.

Conclusion

Despite increased evidence for the effectiveness of substance abuse treatment, utilization of these services by adolescents has remained low and relatively stable over the past 22 years. Attempts to increase utilization of substance abuse treatment services would likely benefit from building on existing connections with mental health treatment.     

Engaging resistant adolescents in drug abuse treatment

In the first phase of a two-part treatment development study, families with a treatment-resistant drug-abusing adolescent (n = 42) were offered 12 sessions of Community Reinforcement and Family Training (CRAFT). This parent-focused intervention was designed to help parents facilitate their adolescents' entry into treatment, to support adolescents' subsequent behavior change, and to improve parent and family functioning. In the second phase, successfully engaged adolescents (n = 30) were offered 12 sessions of a multicomponent individual cognitive-behavioral therapy (CBT) targeting substance use and related problem behaviors. For parents and adolescents, measures were collected on pretreatment and posttreatment, with an additional follow-up assessment for parents at 3 months after treatment. Parents on CRAFT intervention experienced a significant reduction in negative symptoms, and 71% of parents were successful in engaging their resistant youths in treatment. The CBT intervention for engaged youths was associated with a statistically significant, but not clinically significant, reduction in marijuana use.     

Clinical decision making in chemical dependence treatment: A programmatic model

Chemical dependence treatment has traditionally been based on either an inpatient or outpatient model. With the current emphasis on cost effectiveness, these separate approaches are being intensively scrutinized. Recent studies suggest that not all chemically dependent patients can be treated with the same model and that patient characteristics other than chemical of abuse are significant factors in retention and outcome. A program model is presented which takes into consideration clinical decision making based on patient characteristics, intensity of care and treatment modalities.     

Substance use treatment outcomes for youth: integrating personal and environmental predictors

This investigation examined personal and environmental predictors of substance treatment outcomes in youth. A 424 adolescents (M=15.9 years, S.D.=1.3) completed comprehensive assessments, including substance use, environmental factors (e.g., family history, social supports), and person-centered variables (e.g., Axis I diagnosis, motivation, self-esteem), at study intake and throughout the year following inpatient treatment. Youth treatment outcomes were assessed by relapse status (abstaining, minor relapse, major relapse) and DSM-IV dependence symptoms at 1 year. Relapse status was predicted by demographic (age), environmental (social supports), and person-centered factors (diagnosis) while dependence symptoms were best predicted by substance use variables alone. Consideration of the general and specific nature of risk and protection within the adolescent developmental context were explored.     

Substance use treatment outcomes in a sample of male serious juvenile offenders

This study examined drug-treatment-related reductions in alcohol and marijuana use, cigarette smoking, and nondrug offending among male adolescents who had been adjudicated of a serious (almost exclusively felony) offense. Results indicated that the "real-world" drug treatments that these adolescents experienced had significant effects on substance use, which could not be explained solely by incarceration in controlled environments. However, effects on cigarette smoking and criminal offending were found only for treatments that included family involvement. Results suggest that involving families in adolescents' treatment may be useful for promoting desistence from criminal offending in this population.     

Impact of Access to Recovery services on alcohol/drug treatment outcomes

The purpose of this study was to assess the impact of providing recovery support services to clients receiving publicly funded chemical dependency (CD) treatment through the Access to Recovery (ATR) Program in Washington State. Services included case management, transportation, housing, and medical. A comparison group composed of clients who received CD treatment only was constructed using a multistep procedure based on propensity scores and exact matching on specific variables. Outcomes were obtained from administrative data sources. Results indicated that ATR services were associated with a number of positive outcomes including increased length of stay in treatment, increased likelihood of completing treatment, and increased likelihood of becoming employed. The beneficial effects of ATR services on treatment retention were most pronounced when they were provided between 31 and 180 days after treatment began. The results reported here offer evidence for the value of ATR services.     

Exposure to Adolescent Community Reinforcement Approach treatment procedures as a mediator of the relationship between adolescent substance abuse treatment retention and outcome

Data from 399 adolescents, who participated in one of four randomly controlled trials of the Adolescent Community Reinforcement Approach (A-CRA) intervention, were used to examine the extent to which exposure to A-CRA procedures mediated the relationship between treatment retention and outcomes. Although zero-order correlations indicated that retention in treatment was a significant predictor of alcohol and other drug (AOD) use (r = -0.18, p < .001), this relationship was reduced to nonsignificance (p = .39) when exposure to A-CRA procedures was included in the model. Overall, the final model evidenced a very good fit (root mean square error of approximation = .00; comparative fit index = 1.00) and explained 29% and 43% of the variance in adolescents' posttreatment AOD use and AOD-related problems, respectively. In addition, Chi-Squared Automatic Interaction Detection analysis was used to derive a target level of A-CRA exposure, which was found to be significantly related to being in recovery at follow-up. The current findings are useful, as little research to date has identified significant mediators of the relationship between retention and treatment outcomes or identified target thresholds of treatment exposure.     

Gender differences in the impact of comprehensive services in substance abuse treatment

This study examines the impact of comprehensive services on treatment outcomes for women and men. The study uses data collected from 1992 to 1997 for the National Treatment Improvement Evaluation Study, a prospective, cohort study of substance abuse treatment programs and their clients. The analytic sample consists of 3,142 clients (1,123 women and 2,019 men) from 59 treatment facilities.

The results show that substance abuse treatment benefits both women and men. Further, both women and men benefit from comprehensive services provided as part of substance abuse treatment: specifically, the receipt of educational, housing and income support services is related to reduced post-treatment substance abuse for both women and men. Gender differences are revealed by the fact that, overall, greater proportions of women receive services and, when individual, service, and treatment organizational characteristics are controlled, 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.     

The economic costs of substance abuse treatment: updated estimates and cost bands for program assessment and reimbursement

Federal, state, and local government agencies require current and accurate cost information for publicly funded substance abuse treatment programs to guide program assessments and reimbursement decisions. The Center for Substance Abuse Treatment published a list of modality-specific cost bands for this purpose in 2002. However, the upper and lower values in these ranges are so wide that they offer little practical guidance for funding agencies. Thus, the dual purpose of this investigation was to assemble the most current and comprehensive set of economic cost estimates from the readily available literature and then use these estimates to develop updated modality-specific cost bands for more reasonable reimbursement policies. Although cost estimates were scant for some modalities, the recommended cost bands are based on the best available economic research, and we believe that these new ranges will be more useful to and pertinent for all stakeholders of publicly funded substance abuse treatment.     

Economic costs of drug abuse: financial, cost of illness, and services

This article examines costs as they relate to the financial costs of providing drug abuse treatment in private and public health plans, costs to society relating to drug abuse, and many smaller costing studies of various stakeholders in the health care system. A bibliography is developed from searches across PubMed, Web of Science, and other bibliographic sources. The review indicates that a wide collection of cost findings is available to policy makers. For example, the financial aspects of health plans have been dominated by considerations of actuarial costs of parity for drug abuse treatment. Cost-of-illness methods have been developed and extended to drug abuse costing to measure the national level of burden and are important to the economic evaluation of interventions at the program level. Costing is done in many small and focused studies, reflecting the interests of different stakeholders in the health care system. For costs in programs and health plans, as well as cost offsets of the impact of substance abuse treatment on medical expenditures, findings are surprisingly important to policy makers. Maintaining ongoing research that is highly policy relevant from the point of view of health services, more is needed on costing concepts and measurement applications.