Association among outcomes in a naturalistic statewide assessment of substance user treatment

Substance user treatment outcome measurement is important for research and policy questions, yet little literature has addressed the relationships among outcome measures of treatment success. Ideally, treatment outcomes would correlate to at least a moderate degree. The Iowa Department of Public health requires substance user treatment programs receiving public funds to provide client information. Demographic information, "substance abuse" history, current use, arrests, and hospitalizations were ascertained at admission and a 6-month follow-up for 1374 clients (from January 1999 to December 2000). Abstinence, arrests, and hospitalizations were good outcome measures of substance user treatment success. Reduction in frequency of use was negatively associated with arrests, substance use-related hospitalizations, and increased income. Full-time employment at follow-up produced different results depending on the client's sex. However, all associations among outcomes were modest. Specificity may be reasonable in some instances; however, other situations might require a broad-spectrum approach that ideally would produce a wide range of benefits.     

The relative effectiveness of women-only and mixed-gender treatment for substance-abusing women

Following research indicating that the treatment needs of women are different from those of men, researchers and clinicians have argued that drug treatment programs for women should be designed to take their needs into account. Such programs tend to admit only women and incorporate philosophies and activities that are based on a social, peer-based model that is responsive to women's needs. To assess the relative effectiveness of women-only (WO) outpatient programs compared with mixed-gender (MG) outpatient programs, 291 study volunteers were recruited (152 WO, 139 MG), and a 1-year follow-up was completed with 259 women (135 WO, 124 MG). Using bivariate, logistic regression, and generalized estimating equation analysis, the following four outcomes were examined: drug and alcohol use, criminal activity, arrests, and employment. In both groups, women showed improvement in the four outcome measures. Comparison of the groups on outcomes yielded mixed results; women who participated in the WO treatment reported significantly less substance use and criminal activity than women in the MG treatment, but there were no differences in arrest or employment status at follow-up compared with those in the MG treatment.     

Perceived Neighborhood Safety,Recovery Capital,and Successful Outcomes Among Mothers 10 years After Substance Abuse Treatment

This study examines perceived neighborhood characteristics associated with successful outcome among mothers 10 years after being treated for substance use disorders. Data were obtained from 713 mothers first studied at admission to drug treatment in California in 2000–2002 and followed up in 2009–2011. At follow-up, 53.6% of mothers had a successful outcome (i.e., no use of illicit drugs and not involved with the criminal justice system). Perceived neighborhood safety almost doubled the odds of success. Perceived neighborhood safety interacted with social involvement, decreasing the odds of success among mothers who reported more versus less neighborhood social involvement. Perceived neighborhood climate is associated with long-term outcomes among mothers with substance use disorders independent of individual-level characteristics, underscoring the need for further efforts to understand its interaction with recovery capital in ways that promote and impede health.     

Substance use and posttraumatic stress disorders: symptom interplay and effects on outcome

This study examined concurrent and prospective associations between substance use disorder (SUD) and posttraumatic stress disorder (PTSD) diagnosis and symptoms and mechanisms underlying these associations. Participants (n = 133) were assessed at intake and 6 months following inpatient SUD treatment. Patients differed by baseline PTSD status on psychiatric comorbidity and substance use history but not on current substance use symptoms. Participants with alcohol use disorders reported a greater number of reexperiencing symptoms. Baseline PTSD status did not predict substance use outcome. However, change in PTSD status over follow-up predicted substance use outcomes; those with unremitted PTSD demonstrated poorer SUD outcome than those with remitted PTSD. General psychiatric distress at follow-up was associated with poorer outcomes, and such distress mediated the association between PTSD change status and substance use outcome. Findings suggest that clinicians should assess for PTSD among those with SUD and, during treatment, should monitor PTSD and other psychological symptoms, which may be risk factors for relapse to substance abuse.     

Long-term follow-up of people with co-existing psychiatric and substance use disorders: patterns of use and outcomes

The aims of this study were to document long-term patterns of substance use among people with co-existing psychiatric and substance use disorders and to explore differences in psychosocial outcomes for groups with different substance use outcome profiles (persistent hazardous, intermittent hazardous and non-hazardous users). An opportunistic long-term (4 - 6 years) follow-up interview was conducted with participants from a previous study who were recruited during their inpatient admission at a public psychiatric hospital in Newcastle, New South Wales, Australia. Follow-up data were obtained from 47 people from the original study and combined with their existing baseline, 6-month and 12-month data. The follow-up interview included demographic variables and measures of substance use, psychiatric symptomatology and a range of psychosocial variables. Alcohol, cannabis and amphetamines were the most commonly misused substances. Persistent hazardous users experienced poorer outcomes in the domains of social functioning and psychiatric symptomatology, including depression, than intermittently hazardous or non-hazardous users. An unusually high mortality rate of 10% among the males in the original sample (12/120) was an unexpected finding, particularly as this was likely to be an underestimate. Given the differences in outcomes between groups with varied gradations of substance use, a harm minimisation approach for research and practice among people with co-existing psychiatric and substance use disorders is endorsed. [Greig RL, Baker A, Lewin TJ, Webster RA, Carr VJ. Long-term follow-up of people with co-existing psychiatric and substance use disorders: patterns of use and outcomes. Drug Alcohol Rev 2006;25:249 - 258]     

Patient Pre-Treatment Expectations Do Not Predict Cocaine Use Outcomes: Data From Four Clinical Trials

Background: There are very few data regarding the extent to which patients' initial expectations regarding treatment are associated with substance use treatment outcomes. Objective: This study sought to determine how patients' treatment expectations were associated with treatment outcomes. Methods: This study explored patient pre-treatment expectations and substance use treatment outcomes for 387 individuals participating in treatment for cocaine use within the United States (68.2% male, mean age 36 years old, 54.8% Caucasian). Results: Participants' expectations regarding abstinence were not strongly associated with post-treatment or follow-up cocaine use outcome measures. There was a significant association between the expected timeframe of receiving a positive treatment effect (i.e., outcome efficiency expectations) and days of cocaine use at the 1-month follow-up point (F = 3.45, p =.009). Post-hoc comparisons revealed that participants that expected positive effects of treatment within 0–1 week reported fewer days of cocaine use than those that expected results in 1–2 months. Also, those that expected positive effects of treatment in 1–2 months reported more cocaine use than those who expected positive results within two weeks to one month. Further, there was a significant effect of outcome efficiency expectations on a proxy measure of achieving a good treatment outcome at the three-month follow-up point (F = 11.13, p =.025). Conclusions/Importance: Results suggest that treatment outcomes are not associated with patients' treatment outcome expectations, but that some outcomes are associated with treatment outcome efficiency expectations.     

Gender-Sensitive Substance Abuse Treatment and Arrest Outcomes for Women

The present study links an empirically-developed quantitative measure of gender-sensitive (GS) substance abuse treatment to arrest outcomes among 5109 substance abusing women in mixed-gender short-term residential programs in Washington State. Frailty models of survival analysis and three-level hierarchical linear models were conducted to test the beneficial effects of GS treatment on decreasing criminal justice involvement. Propensity scores were used to control for the pre-existing differences among women due to the quasi-experimental nature of the study. Men's arrest outcomes were used to control for confounding at the program level. Results show that women in more GS treatment programs had a lower risk of drug-related arrests, and women in more GS treatment programs who also completed treatment had a significant reduction in overall arrests from 2 years before- to 2 years after treatment, above and beyond the reduction in arrests due to treatment alone. Implications and directions for future research are discussed.     

Treatment outcomes: first time versus treatment-experienced clients

A sample of treatment seeking clients was assessed at intake and 6, 12, 24 and 30 months later. Treatment-naive and treatment-experienced clients were compared in terms of baseline characteristics, 6-month outcomes, and predictors of these outcomes. Long-term outcomes of clients achieving an initially successful outcome were compared for the two groups. Results revealed significant short-term improvement for both groups, although treatment-experienced clients reported more serious drug use. The most consistent significant predictors of substance use outcomes were baseline severity of substance use and self-help participation. Outcome predictors unique to each group were also identified. Long-term outcomes for clients with an initial successful outcome tended to be better for treatment-experienced than treatment-naive clients. Both groups tended to have poorer outcomes as the follow-up duration increased. The results suggest that common and unique predictors of outcomes be considered in treating these two groups of clients. Additionally, treatment-naive clients may be at increased risk for poor outcomes even when initial success is achieved.     

A 12-year follow-up of a treated cocaine-dependent sample

The study examined long-term outcomes (mortality, substance use, mental health, employment, criminal involvement) among a cocaine-dependent sample. This 12-year follow-up study, conducted in 2002-2003, updates information obtained at intake and two face-to-face interviews conducted in 1990-1991 and 1991-1992 among 321 male cocaine-dependent veterans admitted to drug treatment in 1988-1989. At the 2002-2003 follow-up, 28 had died and 266 were interviewed. A mixed model examining the longitudinal relationships demonstrated that treatment was associated with lower levels of cocaine use over the 12-year follow-up period after entry into the index treatment and more stable recovery (i.e., continuously abstinent from cocaine for at least 5 years). Few measures at intake predicted stable recovery at follow-up: only being White (vs. being African American) and having greater confidence in ability to avoid cocaine use in high-risk situations. Individuals achieving stable recovery reported less psychiatric symptoms, criminal involvement, and unemployment during the year prior to the interview. Adverse outcomes were apparent for a significant number of cocaine-dependent users who continued to use cocaine for a long period.     

Explaining long-term outcomes among drug dependent mothers treated in women-only versus mixed-gender programs

Specialized substance abuse treatment for parenting women is thought to improve outcomes, but long-term impacts and how they occur are poorly understood. Utilizing a sample of 789 California mothers followed for 10 years after admission to women-only (WO) or mixed-gender (MG) drug treatment, we examine the relationship between WO treatment and outcomes and whether it is mediated by post-treatment exposures to criminal justice and health services systems. At follow-up, 48% of mothers had a successful outcome (i.e., no use of illicit drugs, not involved with the criminal justice system, alive). Controlling for patient characteristics, WO (vs. MG) treatment increased the odds of successful outcome by 44%. In the structural equation model WO treatment was associated with fewer post-treatment arrests, which was associated with better outcomes. Women-only substance abuse treatment has long-term benefits for drug-dependent mothers, a relationship that may be partially explained by post-treatment exposure to the criminal justice system. Findings underscore additional leverage points for relapse prevention and recovery-supportive efforts for drug-dependent mothers.     

Therapeutic community treatment for substance abusers with antisocial personality disorder.

This study compared treatment outcomes of substance abusers with and without antisocial personality disorder (APD) randomly assigned to two therapeutic communities, differing primarily in length of inpatient and outpatient treatment. We hypothesized that APD clients would be less likely to complete treatment, more likely to test positive for drugs and recidivate at follow-up, and that APD clients in the Standard program would have more favorable outcomes than those in the Abbreviated Inpatient program, because of the Standard program's longer inpatient treatment. Self-reports and objective measures of criminal activity and substance abuse were collected at pre- and posttreatment interviews. APD clients were as likely to complete treatment as other clients, and they exhibited the same patterns of reduced drug use and recidivism as did non-APD clients. Treatment program attended was unrelated to outcomes. Substance abusers diagnosed with APD can benefit from treatment in a therapeutic community combined with outpatient care.     

Sober living houses for alcohol and drug dependence: 18-Month outcomes

Objective

A major challenge facing many individuals attempting to abstain from substances is finding a stable living environment that supports sustained recovery. Sober living houses (SLHs) are alcohol- and drug-free living environments that support abstinence by emphasizing involvement in 12-step groups and social support for recovery. Among a number of advantages, they are financially self-sustaining and residents can stay as long as they wish. Although SLHs can be used as housing referrals after inpatient treatment, while clients attend outpatient treatment, after incarceration, or as an alternative to treatment, they have been understudied and underutilized.

Method

To describe outcomes of SLH residents, we interviewed 245 individuals within 1week of entering SLHs and at 6-, 12-, and 18-month follow-up. Eighty-nine percent completed at least one follow-up interview. Outcomes included the Addiction Severity Index (ASI), Brief Symptom Inventory (BSI), and measures of alcohol and drug use. Covariates included demographic characteristics, 12-step involvement, and substance use in the social network.

Results

Regardless of referral source, improvements were noted on ASI scales (alcohol, drug, and employment), psychiatric severity on the BSI, arrests, and alcohol and drug use. Substance use in the social network predicted nearly all outcome measures. Involvement in 12-step groups predicted fewer arrests and lower alcohol and drug use.

Conclusion

Residents of SLHs made improvements in a variety of areas. Additional studies should use randomized designs to establish causal effects of SLHs. Results support the importance of key components of the recovery model used by SLHs: (a) involvement in 12-step groups and (b) developing social support systems with fewer alcohol and drug users.     

Prevalence of physical and sexual abuse among substance abuse patients and impact on treatment outcomes

More than half of substance abusers entering addiction treatment report a history of physical or sexual abuse. It is unclear if such a history impacts treatment outcomes. This one-year follow-up study of 700 substance abusers sought to clarify the relationship between lifetime physical and/or sexual abuse and addiction treatment outcome to help address the specific needs of this population. To achieve this goal, baseline characteristics, no-show for treatment status, post-treatment clinical outcomes, and treatment history were studied for subjects with lifetime history of abuse (47.3%) versus without. Abused subjects, predominantly women, were significantly more impaired at baseline on clinical dimensions including family/social severity and psychiatric severity as measured by the Addiction Severity Index (ASI), and general level of functioning. The two groups endorsed different drugs as primary, with the abused group less frequently endorsing heroin and cocaine in favor of alcohol and polydrug use. Abused subjects reported more prior medical and psychiatric treatments. Abuse history was not a predictor of no-show for treatment. Over the 1-year follow-up, lifetime physical and/or sexual abuse was significantly associated with worse psychiatric status and more psychiatric hospitalizations and outpatient treatment despite receiving similar intensive addiction treatment.     

Course of self-reported symptoms of attention deficit and hyperactivity in substance abusers during early treatment

Attention deficit and hyperactivity disorder has been associated with poor outcome in studies of substance use disorders. This study aimed to assess the course of self-reported symptoms of both attention deficit and hyperactivity among adults presenting for treatment for substance use disorders. A sample of 75 substance abusers were assessed after they were admitted to a centralized intake unit, and followed at 3 and 6 months after intake by independent interviewers (follow-up rate 81%). Symptoms of attention deficit and hyperactivity were assessed with the Adult Self-report Scale for ADHD (ASRS). Both types of symptoms declined significantly during follow-up, but attention symptoms had a high intraclass correlation (0.79), and hyperactivity had a moderate intraclass correlation (0.64). Both baseline attention deficit and hyperactivity symptoms were associated with worse work and social adjustment after controlling for baseline functioning. Hyperactivity was associated with poorer substance use outcomes at the trend level. In conclusion, both dimensions of ADHD contribute to worse functioning during early treatment for substance abusers, and the ASRS is a reasonably stable measure of ADHD symptoms during early recovery.     

End-of-treatment outcomes in cognitive-behavioral treatment and 12-step substance use treatment programs: Do they differ and do they predict 1-year outcomes?

This study examined changes in treatment-related proximal outcomes from intake to follow-up, associations between continuing care and maintenance of proximal outcome gains, correlations between specific proximal outcomes and substance use outcomes, and potential mediators of treatment effects for 12-step versus cognitive-behavioral (CB) substance use disorder (SUD) treatment. The participants were 1,873 male veterans seeking SUD treatment at five CB-oriented and five 12-step-oriented VA inpatient/residential SUD programs. Patterns of change in proximal outcomes were similar across the two program types. After discharge, attendance at 12-step groups, but not outpatient treatment, was associated with greater maintenance on most proximal outcomes. Only a few proximal outcomes at discharge were associated with 1-year substance use; most 1-year proximal outcomes were associated with 1-year substance use. Having a sponsor, reading 12-step materials, attending 12-step meetings, and having an abstinence goal appeared to mediate the greater effects of 12-step programs (relative to CB programs) on abstinence.     

Sense of Coherence and Tobacco Use Myths Among Adolescents as Predictors of At-Risk Youth Cigarette Use

We examined the association between a general construct of wellness beliefs, sense of coherence, and a specific measure of tobacco-related beliefs, tobacco use myths, as predictors of two smoking-related outcome measures—next year smoking expectation and last 30-day smoking. Self-report questionnaires were administered to 710 adolescents attending California continuation high schools at baseline and at 1-year follow-up between 2006 and 2008. Cross-sectionally, predictor and outcome measures were correlated. However, in longitudinal analyses, only tobacco use myths predicted change in outcome measures. We speculate that future smoking interventions among adolescents would achieve relatively efficacious outcomes by targeting specific health beliefs instead of global health beliefs. The study's limitations are noted.     

Effects of executive function impairment on change processes and substance use outcomes in 12-step treatment

OBJECTIVE: A strong clinical rationale exists to hypothesize that neuropsychological impairment interferes with treatment-initiated change, thereby leading to poor outcome. This study examined the relationship of executive function impairment, change process factors and substance use outcomes in a sample of substance users in intensive 12-step treatment. METHOD: Participants were 118 individuals entering residential or intensive day treatment at two traditional treatment programs. Participants were assessed at entry into treatment, at discharge from treatment, and at 1 and 6 months following treatment. Participants were administered a battery of measures to assess executive function impairment, processes hypothesized to mediate change in 12-step treatment, negative prognostic indicators and substance use outcomes. RESULTS: More than half the sample showed some form of executive function impairment. Executive function impairment did not directly predict worse substance use outcomes nor difficulty acquiring or maintaining change processes. However, impairment significantly moderated the relationship between change processes and outcome. Change processes were strongly related to outcome for unimpaired individuals but weakly related for impaired individuals. CONCLUSIONS: Executive function impairment is not a significant predictor of poor treatment response in 12-step treatment. However, analyses suggest that impaired and unimpaired individuals traverse different pathways in achieving equivalent outcomes.     

“Everyone Deserves Services No Matter What”: Defining Success in Harm-Reduction-Based Substance User Treatment

This article reports qualitative interview data from a study of participant-generated outcomes of two harm reduction programs in the United States. We address the question:“What does success in harm-reduction-based substance user treatment look like?” Providers in this study understood harm reduction to adhere to notions of “any positive change,” client centeredness, and low-threshold services. Participants reported changes in demarginalization, engagement in the program, quality of life, social functioning, changes in substance use, and changes in future goals and plans. The nature of these changes is difficult to articulate within traditional notions of success (i.e., abstinence, program completion, etc.). We conclude that participants in harm reduction programs experience tangible positive changes but that legitimation of these changes calls for a reconceptualization of “outcomes” and “success” in the current context of substance user treatment and research.     

Change and stability of change after treatment of drug misuse: 2-year outcomes from the National Treatment Outcome Research Study (UK)

The National Treatment Outcome Research Study (NTORS) is a longitudinal, multisite, prospective cohort study that assesses changes in illicit drug use and other problems after treatment in national (UK) drug misuse treatment programmes. Clients were recruited from 54 residential and community-based drug treatment programmes throughout England. Four modalities were studied: inpatient drug dependence units, residential/rehabilitation programmes, methadone maintenance, and methadone reduction programmes. Data on substance use behaviours and physical and psychological health were collected by structured face-to-face interviews at intake, 1- and 2-year follow-up. Data are presented for 549 clients. A majority of clients achieved widespread improvements across a range of outcome measures after treatment in existing treatment services. For most outcomes, reductions in problem behaviours at the group level occurred within the first year and were maintained at 2 years. Considerable stability of outcomes at the individual level was also found. Abstinence from illicit drugs was substantially increased among clients from both residential and community programmes, and there were also substantial reductions in frequency of use of heroin, nonprescribed methadone, benzodiazepines, and crack cocaine. Injecting and shared use of injecting equipment was also reduced. Heavy drinking was common at intake and was not reduced at follow-up. Psychological and physical health problems were reduced on both groups at follow-up. These changes represent important clinical benefits to the individual clients, to their families, and to society.     

Psychological Distress and Return to Substance Use Two Years Following Treatment

This study examined client background characteristics, substance use severity, and psychological distress in relation to return to alcohol and drug use among men and women 2 years following substance user treatment. Participants (n = 180) completed a baseline interview within their first month of substance user treatment (conducted in 1995/1996) and follow-up interview 2 years following the baseline interview (conducted in 1997/1998). Structural equation modeling analyses were used to examine the relationship among client background characteristics and problem severity indicators, measured during treatment, in relation to alcohol and illicit drug use 2 years posttreatment. Psychological distress directly predicted alcohol and illicit drug use during follow-up and appeared to mediate the relationship between client background characteristics (such as gender, race, and marital status) and substance use consequences on posttreatment substance use. Income directly predicted alcohol use and age directly predicted illicit drug use, regardless of problem severity (including psychological distress and substance use consequences). Results support long-term clinical monitoring of psychological distress as a marker for return to drug or alcohol use.