A controlled trial of methadone treatment combined with directly observed isoniazid for tuberculosis prevention in injection drug users

Substance abuse is associated with high risk for tuberculosis (TB) and poor adherence to medication regimens. This study compared completion rates for isoniazid (INH) preventive therapy for injection drug users (IDUs) randomly assigned to methadone treatment combined with directly observed preventive treatment (DOPT) versus those assigned to routine TB clinic referral without methadone treatment. One hundred and eleven opioid-dependent patients with latent TB were assigned to one of three 6-month treatment conditions: standard methadone treatment including substance abuse counseling combined with daily INH DOPT (n=37); minimal methadone treatment without counseling, also combined with daily INH DOPT (n=35); or routine care referral to TB clinic for monthly INH supplies without DOPT and without methadone treatment (n=39). INH completion rates were 77.1% for minimal methadone and 59.5% for standard methadone, as compared with only 13.5% for routine care (P<0.0001). Mean duration of INH treatment retention was 5.7, 5.0 and 1.6 months, respectively (P<0.0001). TB incidence at 4-year follow-up was 0 of 54 subjects who completed preventive therapy versus 2 of 57 who failed to complete. One of these two had been assigned to routine care, and the other to minimal methadone. In conclusion, INH retention time and completion rates were significantly improved by methadone treatment combined with observed INH, whether or not substance abuse counseling was provided. The results of this study indicate that methadone treatment offers clear public health benefits when it is used to deliver preventive medical services.     

Reinforcing integrated psychiatric service attendance in an opioid-agonist program: A randomized and controlled trial

Background

The benefits of integrating substance abuse and psychiatric care may be limited by poor service utilization. This randomized clinical trial evaluated the efficacy of using contingency management to improve utilization of psychiatric services co-located and integrated within a community-based methadone maintenance treatment program.

Methods

Opioid-dependent outpatients (n = 125) with any current psychiatric disorder were randomly assigned to: (1) reinforced on-site integrated care (ROIC), with vouchers (worth $25.00) contingent on full adherence to each week of scheduled psychiatric services; or (2) standard on-site integrated care (SOIC). All participants received access to the same schedule of psychiatrist and mental health counseling sessions for 12-weeks.

Results

ROIC participants attended more overall psychiatric sessions at month 1 (M = 7.53 vs. 3.97, p < .001), month 2 (M = 6.31 vs. 2.81, p < .001), and month 3 (M = 5.71 vs. 2.44, p < .001). Both conditions evidenced reductions in psychiatric distress (p < .001) and similar rates of drug-positive urine samples. No differences in study retention were observed.

Conclusions

These findings suggest that contingency management can improve utilization of psychiatric services scheduled within an on-site and integrated treatment model. Delivering evidenced-based mental health counseling, or modifying the contingency plan to include illicit drug use, may be required to facilitate greater changes in psychiatric and substance abuse outcomes.     

Hepatitis B virus and hepatitis C virus services offered by substance abuse treatment programs in the United States

Although substance abuse treatment programs are important contact points for providing health services for hepatitis B virus (HBV) and hepatitis C virus (HCV) infections, availability of services in these programs has not been well characterized. This study evaluated the spectrum of HBV and HCV services offered by substance abuse treatment programs within the National Drug Abuse Treatment Clinical Trials Network. Our survey of substance abuse treatment program administrators covered availability of testing for HBV and HCV; hepatitis A virus (HAV) and HBV immunization; and HCV medical and nonmedical services. There were also questions covering clarity of guidelines for HBV and HCV testing and HAV and HBV immunization. Differences between methadone and nonmethadone programs were examined. Despite the importance of substance abuse in sustaining the hepatitis epidemics, few programs offer comprehensive HBV and HCV testing or HCV health care services. Interventions to improve access to hepatitis services for substance-abusing patients are needed.     

Predictors of Dually Diagnosed Patients' Psychiatric Symptom Exacerbation During Acute Substance Use Disorder Treatment

ABSTRACT

Objectives: This study identified intake risk factors that predicted dual diagnosis patients' exacerbation of psychiatric symptoms during acute substance use disorder care; and examined whether receipt of recommended services for dual diagnosis patients reduced the likelihood of exacerbation, and whether additional help post-discharge was associated with improved symptoms at a 1-year follow-up.

Methods: Dual diagnosis patients (N = 230) who received treatment in one of 14 residential substance abuse programs were evaluated at in-take, discharge (98%), and 1-year follow-up (80%).

Findings: Patients who, at intake, were anxious, untroubled by their psychiatric problems, using more than one substance, had less severe alcohol problems, lived with a problem drinker, and had no close friends were at greater risk of exacerbation of psychiatric symptoms at discharge. Patients who received, during acute treatment, recommended services (e.g., individual counseling, vocational counseling, discharge planning) were more likely to improve, even when intake risk was controlled. Additional outpatient treatment post-discharge was associated with fewer psychiatric symptoms at 1 year.

Conclusions: Substance abuse treatment staff should be vigilant about identifying and preventing dual diagnosis patients' psychiatric symptom exacerbation. Attending to changes in psychiatric symptoms and tailoring interventions to patients at greatest risk could help reduce the likelihood of in-treatment increases in psychiatric symptoms.     

Assessing the effectiveness of an Internet-based videoconferencing platform for delivering intensified substance abuse counseling

Enhanced schedules of counseling can improve response to routine opioid-agonist treatment, although it is associated with increased time demands that enhance patient resistance and nonadherence. Internet-based counseling can reduce these concerns by allowing patients to participate from home. This study assesses treatment satisfaction and response to Internet-based (CRC Health Group's e-Getgoing) group counseling for partial responders to methadone maintenance treatment. Patients testing positive for an illicit substance (n = 37) were randomly assigned to e-Getgoing or onsite group counseling and followed for 6 weeks. Patients in both conditions responded favorably to intensified treatment by achieving at least 2 consecutive weeks of abstinence and 100% attendance to return to less-intensive care (e-Getgoing: 70% vs. routine: 71%, ns). Treatment satisfaction was good and comparable across conditions. E-Getgoing patients expressed a preference for the Internet-based service, reporting convenience and increased confidentiality as major reasons. Integrating Internet-based group counseling with on-site treatment services could help expand the continuum of care in methadone maintenance clinics.     

State policies matter: the case of outpatient drug treatment program practices

This study examined relationships between state policy requirements governing outpatient substance abuse treatment services and reported outpatient treatment program practices. State policies effective as of February 1, 2003, and February 1, 2004, were collected and analyzed via primary legal research; data were validated by state officials (88% response rate; >90% validation rate). Treatment practice data were obtained from the National Survey of Substance Abuse Treatment Services for the years 2003 and 2004. Multivariate analyses clustered by state were conducted, controlling for state, program, and state-aggregated client admission characteristics. Results indicated that treatment programs located in states with requirements for comprehensive substance abuse assessment, family counseling, substance abuse and infectious disease/sexually transmitted disease testing services, HIV/AIDS education, and aftercare services had significantly higher odds of offering such services (p values ranging from < .05 to < .001). This study presents new information regarding the potential role that state policy context may play in understanding treatment program practices.     

Preliminary evidence of good treatment response in antisocial drug abusers

Antisocial personality disorder (APD) is a chronic debilitating condition strongly associated with the development and maintenance of severe drug and alcohol use disorder. The overlap of these problems is associated with high rates of personal and social suffering. Available literature consistently point to this as a population in need of effective clinical services. The present study reports preliminary data from a controlled clinical trial aimed at improving the treatment outcomes of antisocial drug abusers using an intensive behavioral approach relying upon a highly structured contingency management intervention. Drug abusers in methadone substitution therapy (n=40) were assessed for APD and other psychiatric and substance use problems. Patients were randomly assigned to an experimental (n=20) or control (n=20) condition following stratification on demographic and selected clinical variables (baseline drug use, evidence of other non-substance use psychiatric diagnoses). Treatment outcome data are presented for the first 17 weeks of participation in the study (4 weeks baseline and 13 weeks randomized treatment), including results of weekly urine drug testing and monthly self-reports of drug use and other psychosocial problems. Patients in both study conditions attained generally good outcomes. These early results suggest that antisocial drug abusers can respond positively to drug abuse treatments with a behavioral focus, but fail to support superior effectiveness for the more intensive intervention used in the experimental condition.     

Treatment services in two national studies of community-based drug abuse treatment programs

Findings from a number of sources over the past decade have documented a decline in the resources available for drug abuse treatment and the services being provided to clients in community-based drug abuse treatment programs. We compared client reports of services received and unmet service needs in a national crossmodality sample of clients in two studies of drug abuse treatment: the Treatment Outcome Prospective Study (TOPS), 1979–1981, and the Drug Abuse Treatment Outcome Study (DATOS), 1991–1993. Findings showed a marked decrease over the past decade in the number and variety of services clients reported receiving. Most striking was the large increase in self-reported unmet service needs in the DATOS investigation. Although most clients reported having received at least some sessions of drug abuse counseling during treatment and the level of satisfaction with treatment and services was generally high across modalities, client reports indicated that drug abuse counseling alone did not address their wider ranging service needs. Programs in the methadone modality generally reflected the lowest level of drug abuse counseling and services.     

Bridges and barriers to recovery: Clinical observations from an opiate recovery project

Clinical issues are described in opiate addicts attempting to taper off methadone maintenance, and techniques are suggested to help this patient population. The observations were generated in an experimental “Tapering Network” project, in which opiate addicts on methadone maintenance had the opportunity to receive individual and group counseling, relapse prevention training, self-help groups, and other services. Vignettes illustrate clinical problems with intimacy and social isolation, identity as a former addict, and a “post methadone syndrome” characterized by vulnerability, dramatic swings in mood, and disordered thinking for a period of up to six months after detoxification. To counteract these barriers to recovery, a program model is suggested that uses curricula available in the emerging literature on treatment of substance abuse. These techniques can provide bridges to recovery.     

An holistic approach to substance abuse treatment

The purpose of this article is to describe a model outpatient substance abuse treatment program. This program is designed to provide patients with not only traditional modalities of treatment such as individual, group, and family therapy, but also to provide an opportunity for patients to express thoughts and feelings through holistic modalities. These modalities include dance/movement therapy, Tai Chi, art therapy, leisure and recreational skills, spiritual growth and development, cultural awareness and appreciation, vocational services, psychiatric care and physical health. The authors describe features of this program that they believe to be unique and that focus on ways to help patients develop a stronger sense of self-identity, self-esteem and self-confidence.     

Cost-utility analysis of methadone maintenance treatment: a methodological approach

Economic considerations influence the substance user treatment system. These considerations influence who gets treatment and for how long, as well as determining what services they receive and in what setting. Current medical literature argues that maintenance treatment reduces risk-taking behavior, such as injection drug use and needle sharing. Treatment also reduces the mortality associated with abuse of opiates by injection and can cause decreases in costs incurred by the criminal justice system and social services agencies. This suggests the need for complex economic evaluations of a maintenance treatment to find out the optimum treatment program. This paper describes methods of economic evaluation in health care and reviews the methodology of cost-utility analysis in economic evaluations of methadone maintenance treatment.     

Alcohol detoxification completion,acceptance of referral to substance abuse treatment,and entry into substance abuse treatment among Alaska Native people

BackgroundLittle is known about factors associated with detoxification treatment completion and the transition to substance abuse treatment following detoxification among Alaska Native people. This study examined 3 critical points on the substance abuse continuum of care (alcohol detoxification completion, acceptance of referral to substance abuse treatment, entry into substance abuse treatment following detoxification).MethodsThe retrospective cohort included 383 adult Alaska Native patients admitted to a tribally owned and managed inpatient detoxification unit. Three multiple logistic regression models estimated the adjusted associations of each outcome separately with demographic/psychosocial characteristics, clinical characteristics, use related behaviors, and health care utilization.ResultsSeventy-five percent completed detoxification treatment. Higher global assessment functioning scores, longer lengths of stay, and older ages of first alcohol use were associated with completing detoxification. A secondary drug diagnosis was associated with not completing detoxification. Thirty-six percent accepted a referral to substance abuse treatment following detoxification. Men, those with legal problems, and those with a longer length of stay were more likely to accept a referral to substance abuse treatment. Fifty-eight percent had a confirmed entry into a substance abuse treatment program at discharge. Length of stay was the only variable associated with substance abuse treatment entry.ConclusionsServices like motivational interviewing, counseling, development of therapeutic alliance, monetary incentives, and contingency management are effective in linking patients to services after detoxification. These should be considered, along with the factors associated with each point on the continuum of care when linking patients to follow-up services.     

Assessing the effectiveness of community-based substance abuse treatment for adolescents

The Adolescent Treatment Models initiative, a 10-site, multimodality, prospective study, was designed to evaluate adolescent substance abuse treatment outcomes and to assess the relative efficacy of different treatment models. Based upon longitudinal data gathered at multiple assessment points using a standardized instrument, treatment outcome trajectories were determined for a cohort of 1,057 adolescents from entry into substance abuse treatment until 12 months post-intake. Client outcomes on substance use and program effectiveness were explored across individual treatment programs and levels of care. Strong treatment effects, defined as a significant reduction in alcohol and other drug use at three months post-intake, were found. The reductions of greatest magnitude in relation to pretreatment use occurred among adolescents in residential treatment. Within level of care, few significant differences in treatment effects were found between programs. Relapse effects, defined as an increase in substance use at 12 months relative to three months, were observed across nearly all programs, but varied in relation to treatment modality. This is most evident among those entering residential treatment, with the highest rate of relapse occurring among adolescents in long-term residential treatment care. Despite strong evidence of treatment effectiveness, continuing care is vital to maintenance of treatment benefit.     

Client-service matching in substance abuse treatment for women with children

This article addresses the relation between services matched to client-identified needs and substance abuse treatment outcomes for women with children. The study uses data collected for a program evaluation of an enhanced substance abuse services program for mothers involved with the child welfare system. In-person surveys were conducted with 183 women who were currently attending, or had recently completed substance abuse treatment. Bivariate tests and multivariate logistic regression models were conducted to assess the association between matched client-identified service needs and two treatment outcomes: substance use and satisfaction with treatment. Matched counseling services (domestic violence services, family counseling) were associated with reports of reduced substance use; matched ancillary services (housing, job training, legal services) were associated with clients' satisfaction with treatment. However, the total number of services clients received had a stronger relationship to treatment outcomes than did services matched to client-identified needs.     

Injection drug users' experience with and attitudes toward methadone clinics in Denver, CO

Clients' perceptions and attitudes toward methadone treatment programs are frequently overlooked in substance abuse research. Given the importance of methadone maintenance as a harm-reduction strategy and clients' concerns about treatment, it is essential to understand perceptions and attitudes toward existing programs. Using data from the 2009 National HIV Behavioral Surveillance system with injection drug users in Denver, CO, we evaluated participants' experiences with methadone clinics and examined predictive factors associated with ever being a client of a methadone clinic. Costs of services, perceptions of staff not caring about the client, and attitudes toward the counseling services seemed to be the major barriers to program retention. Besides heroin use, previous attempt at self-detoxification and being infected with hepatitis C were the strongest predictors of ever being on methadone treatment. Addressing the barriers to program retention and encouraging treatment engagement are essential to embracing methadone maintenance as a harm-reduction strategy for injection drug users.     

Challenges and Outcomes of Parallel Care for Patients With Co-Occurring Psychiatric Disorder in Methadone Maintenance Treatment

Objective: Most opioid users seeking treatment in community-based substance abuse treatment programs have at least one co-occurring psychiatric disorder, and the presence of psychiatric comorbidity in this population is associated with increased psychological distress, poorer quality of life, and reduced response to substance abuse treatment. This observational study describes clinical outcomes of referring patients receiving methadone maintenance with at least one co-occurring psychiatric disorder to a community psychiatry program located on the same hospital campus. Methods: Participants (n = 156) were offered priority referrals to a community psychiatry program that included regularly scheduled psychiatrist appointments, individual and group therapy, and enhanced access to psychiatric medications for 1 year. Psychiatric distress was measured with the Symptom Checklist (SCL-90-R), which participants completed monthly. Results: While about 80% of the sample (n = 124) initiated psychiatric care, the average length of treatment was only 128.2 days (SD = 122.8), participants attended only 33% of all scheduled appointments (M = 14.9 sessions, SD = 14.1), and 84% (n = 104) did not complete a full year of care. Of those who did not complete a full year, over half (55%, n = 68) left psychiatric care while still receiving substance abuse treatment. Exploratory negative binomial regression showed that baseline cocaine and alcohol use disorder (p =.002 and.022, respectively) and current employment (p =.034) were associated with worse psychiatric treatment retention. Modest reductions in psychiatric distress over time were observed (SCL-90-R Global Severity Index change score = 2.5; paired t = 3.54, df = 121, p =.001). Conclusions: Referral of patients with co-occurring psychiatric disorders receiving methadone maintenance to a community psychiatry program is often ineffective, even after reducing common barriers to care. Service delivery models designed to improve attendance and retention, such as integrated care models, should be evaluated. This study is part of a larger clinical trial, registered at www.clinicaltrials.gov under #NCT00787735.     

Engaging hospitalized heroin-dependent patients into substance abuse treatment.

The purpose of this study was to evaluate a 6-month outpatient program developed to improve abstinence and other health and social problems of heroin-addicted persons hospitalized in an urban academic medical center's medical or surgical unit and referred from the Substance Abuse Consult Service. Treatment intervention consisted of methadone therapy, daily group therapy, individual case management, medical and psychiatric consultation, and social services. The first 67 patients referred were followed for 6 months. Outcome measures were retention in treatment, urine drug screens, and health and social indicators. Patients averaged 19 weeks in treatment, with 52% of patients completing the 6-month program. Urine toxicology screens showed a reduction of illicit drug use. Patients improved deficits in health and social indicators by obtaining medical coverage, keeping outpatient medical appointments, and improving their housing conditions. Findings suggest that this combination of intensive psychosocial treatment with opioid substitution following an acute illness substantially impacts treatment outcomes. Implications for service delivery and health-care economics are discussed.     

Substance abuse treatment and receipt of liver specialty care among persons coinfected with HIV/HCV who have alcohol problems

We examined the association of substance abuse treatment with access to liver specialty care among 231 persons coinfected with HIV and hepatitis C virus (HCV) with a history of alcohol problems who were recruited and followed up in the HIV-Longitudinal Interrelationships of Viruses and Ethanol cohort study from 2001 to 2004. Variables regarding demographics, substance use, health service use, clinical variables, and substance abuse treatment were from a standardized research questionnaire administered biannually. We defined substance abuse treatment services as any of the following in the previous 6 months: 12 weeks in a halfway house or residential facility, 12 visits to a substance abuse counselor or mental health professional, day treatment for at least 30 days, or any participation in a methadone maintenance program. Liver specialty care was defined as a visit to a liver doctor, a hepatologist, or a specialist in treating hepatitis C in the past 6 months. At study entry, most of the 231 subjects (89%, n = 205) had seen a primary care physician, 50% had been exposed to substance abuse treatment, and 50 subjects (22%) had received liver specialty care. An additional 33 subjects (14%) reported receiving liver specialty care during the follow-up period. In the multivariable model, we observed a clinically important although not statistically significant association between having been in substance abuse treatment and receiving liver specialty care (adjusted odds ratio = 1.38; 95% confidence interval = 0.9–2.11). Substance abuse treatment systems should give attention to the need of patients to receive care for prevalent treatable diseases such as HIV/HCV coinfection and facilitate its medical care to improve the quality of care for individuals with substance use disorders. The data illustrate the need for clinical care models that give explicit attention to the coordination of primary health care with addiction and hepatitis C specialty care while providing ongoing support to engage and retain these patients with complex health needs.     

Efficacy of ecologically-based treatment with substance-abusing homeless mothers: Substance use and housing outcomes

This randomized pilot study tested the efficacy of an integrative treatment targeting homeless substance abusing mothers with young children in their care. Sixty mothers with 2–6 year old children were recruited from a local family shelter. The mothers were randomly assigned to Ecologically-Based Treatment (n = 30) or treatment as usual (n = 30). The intervention group received 3 months of rental and utility assistance up to $600 per month, case management services, and substance abuse counseling (referred to as supportive services). The treatment as usual group received housing and services through the family shelter and community housing programs. All participants completed follow-up assessments at 3, 6, and 9 months post-baseline. Mothers receiving Ecologically-Based Treatment showed a quicker decline in alcohol frequency and a quicker increase in housing stability. Furthermore, with supportive services, two-thirds of women were successful in maintaining their apartments 6 months after rental assistance ended.     

Predictors of engagement in vocational counseling for methadone treatment patients

Employment enhances the outcomes of substance dependency treatment. Unfortunately, although unemployed methadone treatment patients frequently state they are interested in a job, many fail to participate in vocational services when available. Unless patients become engaged, vocational services do not have an opportunity to be effective. This is the first study to explore a broad array of factors that may be associated with differential engagement in vocational services among methadone patients. The study was conducted in two methadone programs in New York City during 2001-2004. Unemployed methadone patients (n = 211) were voluntarily randomly assigned to either of two vocational counseling programs (standard vs. experimental) and followed for 6 months. The sample was 59% male, 75% minority group, aged 45 years on average, and in methadone treatment for 5 years on average. Being engaged in the vocational counseling programs was defined as five or more sessions with the counselor in the first 6 months after study entry. In multivariate analysis, the factors associated with higher engagement in vocational counseling were being non-Hispanic, having more education, a drug injection history, a crack use history, having chronic emotional/mental problems, better work attitudes, and assignment to the experimental vocational program. The results indicate that it is often the most "needy" unemployed methadone patients who become more engaged in vocational counseling. A vocational counseling model which emphasizes assertive outreach and attends to nonvocational clinical issues as well is more likely to engage patients.