EVALUATION OF PROGRAMS FOR THE TREATMENT OF BENZODIAZEPINE DEPENDENCY

Programs for the treatment of benzodiazepine dependency differ in a number of ways. Their outcome goals, for example, vary. In some of the programs the reduction or the elimination of benzodiazepine use is the main objective. In others a reduction in anxiety and depression among patients is regarded as much more important than decreasing benzodiazepine use. These differences in goals make comparative evaluations difficult. Further, the type of clients recruited to the programs are often dissimilar. However, it is still possible and valuable to make comparative evaluations of the numerous programs. The aims of published evaluations differ. Most evaluations are directed towards outcome data. Only in a few studies has the aim been to analyze the dynamic treatment process. To achieve more reliable and valid evaluations it is necessary to get data which describe the process and the results from both the clients' and the therapists' perspectives and combining different research strategies. [Translations are provided in the International Abstracts Section of this issue.]     

Evaluation of Drug Use Prevention Programs Directed at Adolescents

The aim of this article is to present a theoretical model of how to undertake evaluations of prevention programs directed at adolescents. Based on the results from metaanalyses of outcome studies of school-based programs, this article concludes that interactive programs tend to be more effective than not only those mainly intended to increase factual knowledge about tobacco, alcohol, and illegal drugs, but also those initiatives aimed at influencing adolescents’ attitudes toward those substances. The interactive strategy corresponds to problem-based learning or the interactive educational approach, now widely popular in educational circles. These outcome studies have provided us with important knowledge. However, there are relatively few evaluation investigations that analyze in substantive detail the process by which adolescents change their alcohol, tobacco, and illegal drug-use behavior, and alter their perceptions about these substances. In an ongoing intervention study based on an interaction framework, involving all youngsters in the ninth grade (15–16 year olds, n = 300, undertaken in year 2001–2002) in the Aland Islands, Finland, the students’ perceptions regarding the risks involved in illegal drug use could not be altered. Neither was it possible to decrease the alcohol or tobacco consumption during this school year. However, what did occur was that a number of expectations regarding alcohol were changed, which, in turn, might influence the patterns of alcohol use by the target group. The ways students in the Alands celebrate the end of junior high school are culturally embedded, and this may explain the lack of success in decreasing their alcohol consumption and tobacco use at the end of the ninth grade. Based on the analysis, a combination of outcome and process evaluations is recommended in order to reach a better understanding of how school prevention programs may achieve the desired goals.     

Evaluation of drug use prevention programs directed at adolescents

The aim of this article is to present a theoretical model of how to undertake evaluations of prevention programs directed at adolescents. Based on the results from metaanalyses of outcome studies of school-based programs, this article concludes that interactive programs tend to be more effective than not only those mainly intended to increase factual knowledge about tobacco, alcohol, and illegal drugs, but also those initiatives aimed at influencing adolescents' attitudes toward those substances. The interactive strategy corresponds to problem-based learning or the interactive educational approach, now widely popular in educational circles. These outcome studies have provided us with important knowledge. However, there are relatively few evaluation investigations that analyze in substantive detail the process by which adolescents change their alcohol, tobacco, and illegal drug-use behavior, and alter their perceptions about these substances. In an ongoing intervention study based on an interaction framework, involving all youngsters in the ninth grade (15-16 year olds, n = 300, undertaken in year 2001-2002) in the Aland Islands, Finland, the students' perceptions regarding the risks involved in illegal drug use could not be altered. Neither was it possible to decrease the alcohol or tobacco consumption during this school year. However, what did occur was that a number of expectations regarding alcohol were changed, which, in turn, might influence the patterns of alcohol use by the target group. The ways students in the Alands celebrate the end of junior high school are culturally embedded, and this may explain the lack of success in decreasing their alcohol consumption and tobacco use at the end of the ninth grade. Based on the analysis, a combination of outcome and process evaluations is recommended in order to reach a better understanding of how school prevention programs may achieve the desired goals.     

Programmatic,Counselor, and Client-Level Comparison of Rural Versus Urban Drug Court1 Treatment

Despite a number of recent evaluations demonstrating the effectiveness of “drug court” programs for reducing both substance abuse and criminal behavior, some authors have recently called for more thorough process evaluations (inside the “black box” of treatment) of these programs. Specifically, this article describes the need for thorough process evaluation to examine differences in program implementation across rural and urban drug courts. The delivery of substance-user treatment and allied social services is examined in a sample of four adult drug courts (two urban and two rural), using a direct observation methodology, as well as traditional surveys and interviews of treatment staff and administrators. Results reveal that there are, in fact, differences in implementation, and staff and client characteristics between courts in each type of geographic region and suggest that these differences may impact the effectiveness of the court programs in meeting their goals of reduced substance use and criminal behavior.     

Programmatic, counselor, and client-level comparison of rural versus urban drug court treatment

Despite a number of recent evaluations demonstrating the effectiveness of "drug court" programs for reducing both substance abuse and criminal behavior, some authors have recently called for more thorough process evaluations (inside the "black box" of treatment) of these programs. Specifically, this article describes the need for thorough process evaluation to examine differences in program implementation across rural and urban drug courts. The delivery of substance-user treatment and allied social services is examined in a sample of four adult drug courts (two urban and two rural), using a direct observation methodology, as well as traditional surveys and interviews of treatment staff and administrators. Results reveal that there are, in fact, differences in implementation, and staff and client characteristics between courts in each type of geographic region and suggest that these differences may impact the effectiveness of the court programs in meeting their goals of reduced substance use and criminal behavior.     

Anticonvulsant drugs in the treatment of substance withdrawal

Although detoxification cannot, in itself, be considered a treatment for addiction, it is one of the most pivotal phases. In order to facilitate entry into recovery and/or rehabilitation programs, a detoxification treatment has to be experienced as easy and safe by the patient. In consideration of the many inconveniences related to standard withdrawal treatments, there is an interest in developing alternative pharmacological strategies. The main rationales for using anticonvulsants in substance-abuse patients are their lack of addiction potential, evidence support a role of kindling mechanisms in withdrawal syndromes and their efficacy in comorbid psychiatric disorders. The available data currently support the utilization of carbamazepine as a treatment for detoxification from benzodiazepines, alcohol and opiates, and as a useful agent to reduce cocaine consumption. The use of valproate is well corroborated for alcohol detoxification and it seems to be a promising treatment for the reduction of cocaine use; however, it has been found to be ineffective against benzodiazepine withdrawal symptoms. Some preliminary data suggest that lamotrigine could be useful in opiate and cocaine dependence. Gabapentin shows potential as a treatment for cocaine dependence, and some case reports have stimulated interest in this agent for alcohol and benzodiazepine detoxification. Due to its particular pharmacological profile, topiramate is one of the most interesting newer anticonvulsants. It has been found to be efficacious in opiate and possibly benzodiazepine detoxification and also has theoretical potential as a preventive therapy.     

Enhancing substance abuse treatment evaluations: Examining mediators and moderators of treatment effects

This article considers ways in which the basic, comparative approach to evaluating treatment for substance abuse is sometimes enhanced. The general strategy has been to make treatment evaluation projects explanatory by embedding them in a theoretical framework. Using either a theory of the treatment process or of patient- treatment matching as a guide, the typical approaches for enhancing comparative treatment evaluations are to identify either mediators or moderators of treatment effects. In addition to addressing the basic question of “Does the treatment work or not work?” one can also ask in more explanatory evaluations: “How or why does the treatment work or not work?” and/or “For whom do treatments work or not work?” Variations of these questions that can be addressed in treatment process and patient-treatment interaction effect analyses are discussed. Particular attention is given to explaining (identifying mediators of) patient-treatment interaction effects. Some advantages of making treatment evaluations more explanatory are discussed.     

A model for pharmacological research—treatment of cocaine dependence

Major problems for research on pharmacological treatments for cocaine dependence are lack of comparability of results from different treatment research programs and poor validity and/or reliability of results. Double-blind, placebo-controlled, random assignment, experimental designs, using standard intake and assessment procedures help to reduce these problems. Cessation or reduction of drug use and/or craving, retention in treatment, and medical and psychosocial improvement are some of the outcome variables collected in treatment research programs. A model to be followed across different outpatient clinical trials for pharmacological treatment of cocaine dependence is presented here. This model represents an effort to standardize data collection to make results more valid and comparable.     

Outcomes after methadone maintenance and methadone reduction treatments: two-year follow-up results from the National Treatment Outcome Research Study

This paper provides a detailed analysis of the 2-year outcomes for 351 drug misusers allocated on an intention-to-treat basis to methadone maintenance or methadone reduction treatments. Both groups showed substantial reductions in their use of illicit drugs and in other outcome areas. However, whereas most methadone maintenance patients received maintenance, only about one third of those allocated to methadone reduction received methadone reduction, and many actually received a form of methadone maintenance. Reduction patients were more likely to receive low doses of methadone, and were less likely to remain in treatment. For maintenance patients, higher doses and retention in treatment were both associated with improvements in illicit heroin use at 2 years. For the reduction patients, the more rapidly the methadone was reduced, the worse the heroin use outcomes. For patients in both treatment conditions, reductions in heroin use were associated with improvements in other outcome areas. The more severely dependent patients showed better outcomes in methadone maintenance. Methadone reduction treatment processes were associated with poor outcomes, and many patients who were allocated to methadone reduction treatment did not receive reduction treatment as intended. This calls into question the appropriateness of either the initial treatment planning process or the treatment delivery process, or both. A clearer distinction should be made between methadone maintenance and methadone reduction. Treatment goals should be made explicit both to the patient and to the clinical staff at the start of treatment. We suggest the need for a reappraisal of the goals and procedures of methadone reduction treatment.     

The impact of ongoing illicit drug use on methadone adherence in illicit drug users receiving treatment for HIV in a directly observed therapy program

INTRODUCTION: Studies evaluating the effectiveness of opioid agonist therapy programs typically evaluate drug abstinence or treatment retention as their primary outcomes. However, in many circumstances (e.g. directly observed therapy (DOT) programs within methadone maintenance programs), methadone adherence is an extremely relevant clinical outcome. We sought to evaluate the impact of ongoing illicit drug use on methadone adherence within a DOT program for the treatment of HIV-infection. METHODS: Patients were enrolled in a DOT program, where methadone and HIV medication are co-administered by a community pharmacist. Drug use (amphetamines, benzodiazepines, cocaine, and opiates) was assessed by repeated urinalysis results. Methadone adherence was calculated as the fraction of days methadone was administered. RESULTS: Ongoing drug use, and poly-substance use was common, with only 4 of 60 patients abstaining from all illicit drug use. Overall methadone adherence was 84.5%. Amphetamine use (without benzodiazepine and cocaine use), benzodiazepine use (without amphetamines) and higher methadone doses were associated with higher methadone adherence. When patients used benzodiazepines or cocaine, any positive effect associated with amphetamine use was negated. In addition, opiate use was associated with decreased methadone adherence. DISCUSSION: The effect of many illicit drugs on methadone adherence may differ from reports using other treatment outcomes.     

Client outcomes from rural substance abuse treatment

Several national evaluations have been conducted since the late 1960s that have assessed the effectiveness of publicly-funded substance abuse treatment in the United States. These studies, however, have focused principally on urban-based treatment programs, and it is unclear whether findings from urban programs can be replicated in outcome studies of programs in rural areas. The current study, therefore, examined the treatment outcomes of clients admitted to one of several short-term inpatient or outpatient drug-free treatment agencies in rural Kentucky. Findings showed that treatment was associated with reductions in drug use and criminality during a six-month follow-up interval. Employment status also improved significantly, and health services utilization was reduced. The similarity between the current findings and findings from national outcome studies of urban-based treatment programs is discussed.     

Observations On The Phenomenology Of Consciousness Change

Abstract

Several national evaluations have been conducted since the late 1960s that have assessed the effectiveness of publicly-funded substance abuse treatment in the United States. These studies, however, have focused principally on urban-based treatment programs, and it is unclear whether findings from urban programs can be replicated in outcome studies of programs in rural areas. The current study, therefore, examined the treatment outcomes of clients admitted to one of several short-term inpatient or outpatient drug-free treatment agencies in rural Kentucky. Findings showed that treatment was associated with reductions in drug use and criminality during a six-month follow-up interval. Employment status also improved significantly, and health services utilization was reduced. The similarity between the current findings and findings from national outcome studies of urban-based treatment programs is discussed.     

The promise of prison-based treatment for dually diagnosed inmates

The Stay'n Out therapeutic community was created 25 years ago, the first rigorously evaluated prison program that demonstrated recidivism reduction. Since then, there has been a growing appreciation for the recidivism-reducing benefit of substance abuse treatment and the general understanding has been reached that prison treatment for substance abuse is good for the public interest. A number of replicated outcome studies have led to increases in treatment capacity in most state correctional systems, primarily utilizing the therapeutic community model. In contrast, efforts to introduce treatment for offenders with co-occurring mental illness and substance abuse disorders (COD) are only beginning. This article describes developments in prison substance abuse treatment and reentry programs and offers some guiding observations from prison substance abuse treatment history that could facilitate the development of COD treatment. Lessons learned include that: public safety (i.e., recidivism reduction) is a primary goal; personal accountability as a basic treatment value facilitates cooperation between treatment and correctional staff; self-help approaches foster more ambitious treatment goals than just symptom reduction; and well-run treatment programs often ease the burden of correctional administration.     

Guideline development for office-based pharmacotherapies for opioid dependence

The success of opioid agonist maintenance has stimulated efforts to make this form of treatment more available. Methadone medical maintenance, coordination of methadone services from a physician's office, has been offered as an alternative to narcotic treatment programs for stable, recovered and socially rehabilitated opioid dependent patients. Despite the successful implementation of methadone medical maintenance programs, a number of important questions regarding the appropriate guidelines for the use of this model of care remain. The current paper reviews the process and outcome of the Medical Maintenance Consensus Panel, which was convened for the federal Center for Substance Abuse Treatment. We outline the process and describe the two guidelines that were produced by this process that are targeted at physicians, narcotic treatment programs, and policy makers.     

Cost-effectiveness analysis of four interventions for adolescents with a substance use disorder

Alcohol, tobacco, and illicit drug use among adolescents in the United States continues to be a serious public health challenge. A variety of outpatient treatments for adolescent substance use disorders have been developed and evaluated. Although no specific treatment modality is effective in all settings, a number of promising adolescent interventions have emerged. As policy makers try to prioritize which programs to fund with limited public resources, the need for systematic economic evaluations of these programs is critical. The present study attempted a cost-effectiveness analysis of four interventions, including family-based, individual, and group cognitive behavioral approaches, for adolescents with a substance use disorder. The results indicated that treatment costs varied substantially across the four interventions. Moreover, family therapy showed significantly better substance use outcome compared to group treatment at the 4-month assessment, but group treatment was similar to the other interventions for substance use outcome at the 7-month assessment and for delinquency outcome at both the 4- and 7-month assessments. These findings over a relatively short follow-up period suggest that the least expensive intervention (group) was the most cost-effective. However, this study encountered numerous data and methodological challenges in trying to supplement a completed clinical trial with an economic evaluation. These challenges are explained and recommendations are proposed to guide future economic evaluations in this area.     

A Critique of Project Evaluations

In recent years an increased stress has been placed on the evaluation of mental health, education, and welfare service programs. The majority of studies readily available to most evaluators represent local project evaluations which usually contain diverse references to different aspects of the evaluative process. For evaluative results to be even minimally useful to other projects, however, certain requirements must be met. These are: (1) internal validity, (2) external validity, (3) specification of the population and treatment being implemented, and (4) standardization of indicators of treatment impact. To determine the extent to which published project impact evaluations meet these criteria, a study was undertaken to “evaluate the evaluations” themselves within heroin addiction treatment programs. Six high-yield journals and 100 random sources were systematically searched for reports of evaluations which provided measures of success in terms of the consumer. Articles were analyzed in regard to our four prerequisites for cross-project comparisons regarding process variables, impact variables, and methodologies. It became clear, however, that our original objectives in evaluating either the usefulness of published project evaluations or testing any specific impact hypotheses were not achievable due to the state of evaluative measurement and reporting practices at this time. The major problems we encountered in our inability to complete a necessary and potentially fruitful comparative assessment of project evaluations are discussed in detail with recommendations for future work.     

Predictors of Benzodiazepine Discontinuation in Subjects Manifesting Complicated Dependence

We described characteristics of subjects with benzodiazepine dependence that was typically complicated by harmful and hazardous alcohol use or high benzodiazepine doses, and assessed predictors of successful discontinuation of benzodiazepines for this group. Seventy-six patients who participated in a randomized clinical trial of two different gradual withdrawal treatment approaches were assessed. The trial was conducted between February 1995 and July 1999. The mean age ±SD of subjects was 40.0±9.6 years, 55% were male, 38% were married or cohabiting, and 70% had received more than nine years of education. The median benzodiazepine dose was 35 mg /day (range 2.5–180) in diazepam equivalents. The median duration of benzodiazepine use was 84 (range 8–360) months. Subjects with lower benzodiazepine doses and no previous withdrawal attempts were more successful at benzodiazepine discontinuation. Cluster B personality/borderline personality disorder was associated with an inability to stop benzodiazepine use and with “dropping out” of treatment. Alcohol use–related disorders or other psychiatric diagnoses were not associated with outcome. Further studies on predictors of successful benzodiazepine discontinuation in different populations are required. Patients manifesting cluster B personality/borderline personality disorder and benzodiazepine dependence may need concomitant treatment for their personality disorders to benefit from benzodiazepine discontinuation treatment.     

Predictors of benzodiazepine discontinuation in subjects manifesting complicated dependence

We described characteristics of subjects with benzodiazepine dependence that was typically complicated by harmful and hazardous alcohol use or high benzodiazepine doses, and assessed predictors of successful discontinuation of benzodiazepines for this group. Seventy-six patients who participated in a randomized clinical trial of two different gradual withdrawal treatment approaches were assessed. The trial was conducted between February 1995 and July 1999. The mean age +/- SD of subjects was 40.0 +/- 9.6 years, 55% were male, 38% were married or cohabiting, and 70% had received more than nine years of education. The median benzodiazepine dose was 35 mg/day (range 2.5-180) in diazepam equivalents. The median duration of benzodiazepine use was 84 (range 8-360) months. Subjects with lower benzodiazepine doses and no previous withdrawal attempts were more successful at benzodiazepine discontinuation. Cluster B personality/borderline personality disorder was associated with an inability to stop benzodiazepine use and with "dropping out" of treatment. Alcohol use-related disorders or other psychiatric diagnoses were not associated with outcome. Further studies on predictors of successful benzodiazepine discontinuation in different populations are required. Patients manifesting cluster B personality/borderline personality disorder and benzodiazepine dependence may need concomitant treatment for their personality disorders to benefit from benzodiazepine discontinuation treatment.